Columbia Sflnitier^ttp College of ^fj^siciansJ anb burgeons Hifararp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/contributionstooOOsimp CONTRIBUTIONS TO OBSTETRICS AND GYNECOLOGY, CONTRIBUTIONS TO Obstetrics and Gynecology BY ALEXANDER RUSSELL SIMPSON, M.D., PROFESSOR OF MEDICINE AND MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF EDINBURGH. EDINBURGH : ADAM AND CHARLES BLACK. 1880. Printed by Frank Murray, // Young Street, Edinburgh. TO THE MEMORY OF HIS FATHER ALEXANDEE SIMPSON, AND HIS UNCLE Sir JAMES YOUNG SIMPSON, Baet., THESE PAGES ARE REVERENTLY DEDICATED THE AUTHOR PREFACE. The Contributions brought together in this volume have appeared at different times in different periodicals. In this form they will be more accessible to my fellow- workers, and also to my Students, who will find here some subjects expounded and illustrated more fully than their teacher has time for in a single session. It will be seen from the Table of Contents that the several papers are arranged in the order in which the subjects may be handled in a systematic course. I hoped to have seen the work issued some months ago. Delay has arisen chiefly from the time required for the preparation of a series of Woodcuts, which I had not thought of introducing when the earlier pages went to press. I do not regret the delay, however, since it has given me the opportunity of adding, as an Appendix, an Essay on a subject of great practical importance, which has just been written. The chief intention of this Prefatory Note is to let me express my grateful acknowledgments, first, to Mr. David B. Hart, M.B., my First Assistant, for the help in collect- viii Preface. ing and arranging the papers, which has made it possible for me to carry through the volume ; second, to Mr. Francis M. Caird, M.B., for drawing on the wood many of the original Engravings with which it is illustrated; and third, to Mr. Alexander Hugh Barbour, M.B., my Second Assistant, for aid in the preparation of the Index, which will facilitate reference to the varied themes its pages treat of. ALEX^ E. SIMPSON. 52 Queen Street, Edineuegh, March 1880. CONTENTS. ^art Jfirst — ©^©t^triral. Emmenologia— Inaugural Address as President of the Edinburgh Obstetrical Page Society, 8th Dec. 1875 ..... 3 Intra-uterine and Congenital Conditions of F(etu.s — The Aeardiac Fojtus ...... 23 Intra-uterine Small-Pox ...... 30 Inti'a-uterine Peritonitis ...... 34 Congenital Melanotic Tumour ..... 36 Congenital Goitre ...... 36 Hydronephrosis ....... 52 The Umbilical Cord — Disease of the Umbilical Vein ..... 66 Torsion of Cord ....... 66 Knot on the Umbilical Cord, formed during Pregnancy . . 68 The Placenta — Dimidiate Placenta ...... 71 Placenta Preevia ....... 72 Post-Partum Haemorrhage ..... 88 Morbid Conditions of Pregnancy — Hydramnios ....... 92 Extra-Uterine Pregnancy ...... 98 Notes of a Fatal Case of Chorea Gravidarum . . . 101 On the Complete Evacuation of the Uterus after Abortion . 104 Mechanism of Labour — The Head-Flexion in Labour ..... 116 Head Markings ....... 128 Morbid Conditions of Labour — On Dystocia with Dorsal Displacement of the Arm . . 130 Notes of a Complicated Case of Labour, with Ptemarks on tbe Postui'al Treatment of Prolapsus Funis . . . 137 Spontaneous Rupture of the Uterus During Labour . . 150 Turning versus Forceps . . . . . .164 Contents. The Use of the Volsella in Gynecology Vaoina — Atresia Vaginae ....... Fibroma Vaginai ....... Sarcoma Vaginte ....... Carcinoma Vaginre in a Pregnant Female .... Uterus — The Treatment of Fibroid Tumours of the Uterus Sarcoma Uteri ....... Carcinoma Uteri — 1. On the Removal of Portions of the Diseased Tissues in Cases of Carcinoma Uteri 2. Encephaloma Uteri in a Child 3. Carcinoma Cervicis Uteri et Orificii Urethra*, terminating fatally by Rupture of the Uterus . 4. Amputation of the Cervix Uteri for Cancroid Degeneration 5. Cauliflower Excrescence of the Cervix Uteri removed by means of the Galvano-Caustic Wire 6. Epitheloma of the Cervix Uteri 7. Secondary Cancer in a Patient who had been subjected to Amputation of the Cervix Uteri On Amputation of the Cervix Uteri in Cases of Elongation Forms of Sterility ...... Notice of an Anteversion Pessary .... Ovary — Cystic Tumours of the Ovary containing Hairs Case of Double Oophorectomy, or Battey's Operation : with Remarks ..... Ovariotomy Cases . . Pelvic Hematocele .... Method of Case-Taking in Gynecology BaSI LYSIS ..... Page 183 195 •201 204 205 207 240 261 273 274 276 279 281 281 283 284 291 294 296 314 315 317 323 LIST OF ILLUSTKATIONS. Fig. Page 1. Acardiac Fcetus (half size) ..... 24 2. Acardiac Fcetus (full size) ..... 29 3. Convolution of the Umbilical Cord round the neck and left thigh, leading to death of Fcetus ..... 70 4. Vertical Section of Pelvis, showing relations when Uterus is hauled down ....... 112 5. Foetus showing Head Mouldings in Extreme Flexion . . 120 6. Diagram of angles formed by fcetal head and maternal canals — Lahs . .122 7. Vertical Mesial Section of parturient passages of a woman during labour — after Braune . . . . . . 124 8. Diagram of forces produced by resiliency of elastic canals acting on foetal head — Lahs . . . . .126 9. Fcetus with head-markings . . . . .128 10. Dorsal displacement of the arm ..... 132 11. „ ,, ,, —Sir J. Y. Simpson . . 134 12. Eeplacing of arm in dorsal displacement . . . .136 13. Inclination of the Uterus in the Dorsal Posture . . . 143 14. ,, ,, ,, Knee-elbow Posture . . 143 15. Over-distension of Cervix — Bandl .... 163 16. Normal Brim . . . . . . .164 17. Justo Minor Brim . . . . . . .165 18. Rickety Brim ....... 165 19. Extreme Head-Flexion in Pelvis Justo Minor . . . 166 20. Head-Moulding in Extreme Flexion .... 166 21. Long Forceps grasp of Head in Normal Pelvis — Sir J. Y. Simpson 167 22. Head at Brim of Eickety Pelvis . . . . .168 23. Position and Presentation of Head in Pdckety Brim . . 169 24. Head- Moulding after ti-ansit through a Flat Pelvis . . 170 25. Wedge-shape of Foetal Head in vertical section— Sir J. Y. Simpson 171 26. „ ,, as seen from above— Sir J. Y. Simpson 171 27. Co7npression in narrowest transverse diameter of Head — Sir J. Y. Simpson . . . . . • .171 xii List of Illustrations. Fig. Page 28. Moulding of Head from below upwards iu Head-last Labours — Sir J. Y. Simpson ...... 171 29. The Uterus hauled down to bring a vesico-vaginal fistula within reach — Jobert de Lamballe . . . . .185 30. Volsella for seizure of Intra-uterine Fibroids (tAvo-tliirds size) . 189 31. Ordinary Volsella (full size) . . . . .189 32. Vertical Section of Pelvis, showing relation when Uterus is hauled down ........ 190 33. Unstriped Muscular Fibres from Uterus undergoing Fatty Dege- neration — Sir J. Y. Simpson .... 209 34. Uterus laid open, showing Intra-uterine Polypus — Sir J. Y. Simpson 213 35. Nail Curette (half size) ...... 224 36. Uterine Myoma becoming pediculated, and in process of extrusion 239 37. Sarcoma Uteri seen on section, showing Fibroid Nodules . 243 38. Intra-uterine Sarcoma invading the Fallopian Tubes . . 249 39. Intra-uterine Cancer — Sir J. Y. Simpson .... 270 40. Cauliflower Excrescence of the Cervix Uteri — Sir J. Y. Simpson 271 41. Carcinoma Cervicis Uteri et Orificii Urethra;, leading to Occlusion of Os Uteri, Dilatation of Uterus, and Perforation . . 276 42. Cervix Uteri drawn down by Volsell;i?, and Ecraseur applied . 278 43. Front View of Abdominal Surface, showing Ptcgions . . 322 44. Outline Vertical Section of Female Pelvis . . . 322 45. Outline View of Pelvic Brim, seen from above— after Schultze . 322 46. Baudelocque's Cephalotribe ..... 324 47. Kilian's Cephalotribe applied to the Fa-tal Head in a Pelvis con- tracted at the Brim (Kilian) .... 325 48. Scanzoni's Cephalotribe ...... 326 49. Simpson's Cephalotribe ...... 327 50. Simpson's Cranioclast ...... 328 51. Braun's Cranioclast ...... 329 52. Simpson's Perforator ...... 330 53. Guyon's Apparatus for Intra-cranial Cephalotripsy . . 335 54. Side View of Head crushed by Guyon's Apparatus . . 336 55. Front View of Head crushed by Guyon's Apparatus . . 336 56. Basilyst ........ 337 57. Section of Deformed Pelvis and Head of Fo.tus, with point of Basilyst entering Basis Crauii .... 338 f ^rt Jirsi OBSTETEICAL. OBSTETRICS. EMMENOLOGIA. Inaugural Address as President of the Edinburgh Obstetrical Society, 8th Dec. 1875.^ TISr entering on the occupation of the honourable position to which you have called me, I do not attempt to express in words mj grateful sense of your kindness, and my high appreciation of the honour you have conferred upon me. Words would fail me worthily to thank you ; and instead of hearing me dilate upon the dignity of the office, it will please you better to see me bend myself to the fulfilment of its duties. In casting about, in the too brief time allowed me, for a subject on which I might venture to address you, it seemed to me that it would not be inappropriate, and might be some- what interesting, if I asked you to look for a little at the phenomena which bring the members of the female sex within the sphere of our observation as Fellows of this Society, and consider what insight we have gained into the meaning of Menstruation. puberty m THE TWO SEXES. It is the occurrence of menstruation, I say, which first renders the female an object of interest to an Obstetrical Society. Perhaps some would add, that were there no men- struation, our occupation would be gone. If one of the sexes rather than the other has a claim on the interest of the obstet- ^ Transactiotis of Edinhurcjh Obstetrical Society, iv. 176. Emmenologia. rician when lie meets tliem on their exit from their intra- uterine home, it is the male. For his larger head makes his transit through the parturient passages more difficult and dangerous, not only to his mother, but also to himself, than the birth of his smaller sister ; and though the number of boys born be in excess of that of girls, the extra mortality among the males, which is greatly due to the effects of their more prolonged delivery, serves ere long to bring the sexes to a numerical equality. Differences in the sex do not specially attract us then. The one is so like the other, that it requires careful investigation to distinguish between them. I once travelled in the same compartment with a gentleman who was bringing home his wife and baby from a visit the lady had gone to pay her parents on convalescence after her first con- finement. She was fond of a joke ; and she told me that when her husband arrived, she had another child dressed in her baby's clothes and put into the arms of the unsuspecting father, who admired its growth, and might have kissed it often, but that he was told that he was caressing, not his own girl, but a stranger boy. So like they are in infancy. And much alike they remain in their external appearance, in their men- tal characteristics, and in their relative proclivity to disease and death, not only during the first septennary and first den- tition, but during the second also, when nutrition and growth of the entire system are in active progress, until, with the arrival of the third septennary, the new set of evolutionary changes set in which mark the age of puberty, and which, when completed, leave the boy transformed through the youth into the man, and the girl through the maiden into the woman. Without dwelling on the diversity of features that now appears in the physical frame and in the psycldcal manifestations of the two sexes, we may note the remarkable difference they exhibit in their capability of resisting morbific influences. Till now the mortality between the sexes has been nearly equal, boys dying almost cent, per cent, with girls. Between the ages of 14 and 18, however, statistics show that for every 100 youths as many as 128 maidens die. And this higher Date of First Menstruation. mortality continues through all this third septennary, though not so markedly in the later as in the earlier section of it. From 18 to 21 or 22, the relative mortality is 105 women to the 100 men. It is at some time during these years, so fatal to her sex, that the girl becomes the subject of the change, of which to her the most striking feature is the escape of a bloody dis- charge from the genital orifice. FIKST APPEARANCE OF MENSTRUATIOISr. The date of its first appearance varies considerably in different individuals. Statistics have been collected with great assiduity by many emmenologists, and collated with the view of determining the mean date of the first discharge of the menstrual fluid. "When we look at the tabulated result, we notice that the year opposite to which stands the heaviest figure in the total column is the age of 15. Closely following it, and of nearly equal value, are the figures op- posite the ages 16 and 14. Considerably behind these are the figures opposite the years 17 and 13. Still lower are those at 18 or 12. The figures become very low opposite 19 and 11 ; still lower at 20. There is still an appreciable pro- portion at 21 ; but the figures oj)posite the years beyond this are so small, that the non-appearance of menstruation in any individual who has passed this age may well give rise to grave apprehension regarding her general health, or the condition of her sexual organs ; and although now^ and again cases are met with of its outburst at the age of 10, or earlier, we regard the occurrence as quite exceptional, and we may sometimes find the genital haemorrhages of childliood to be something quite other than a menstrual discharge. The causes of the great range of date in the first appearance of the flow are not easily determined, any more than the diversity in the dates of the evolutions of the teeth in infancy and childhood. The causes may sometimes be due to individual peculiarities of constitution or hereditary influence. But Emmenologia . there are some conditions that have been distinctly shown to have a modifying influence. 1. The effect of Climate appears in a comparison of the statistics gathered from countries under different degrees of temperature. The tables I looked at in citing the figures above, are drawn from information gathered at different points within the temperate zone, between 33° and 54° of N. latitude. If we look at tables showing the mean date of commencement of menstruation in warm climates — between 33° and tlie equator — we see the heaviest figures in the total column opposite the years, not 14 to 18, but from 11 to 15. The heaviest are opposite 12 and 13, at which ages a nearly equal number begin to menstruate. Then follow, at a marked distance, those opposite 14 and 11. At 15 and 16 a con- siderable proportion begin to menstruate ; but the retardation beyond the age of 17 is extremely rare ; whilst many begin as early as 10, some as early as 9, and a few even at 8 years of aue. On the other hand, a reference to the tables of the first eruption of the menses in colder climates — between 54° N. and the pole — informs us that the mean date is somewhat later. The heavy figures here run from 15 to 20. The heaviest is at 16, though 15 is almost equal, and 17 not far behind. Opposite 18 and 19 the figures are still large, and even opposite 20. At 21 they become distinctly less; but there remains a notable proportion in whom menstruation is delayed till the 22d or 23d year of life. The figures opposite the years of 14 and 13 are nearly the same as at 21. At 12, however, there is a decided diminution, and the appearance at an earlier age in these colder climates is almost unknown. But, however well marked the influence of climate may be in the acceleration of menstruation in warm, and its retardation in cold countries, there is good warrant for believing that — 2. llacc exerts a distinct influence in determining the date of its first appearance. We know, for example, that Anglo- Indians retain in this respect the habit of their race, and instead of beginning to menstruate, like the Hindu women, at 12 or 13, first menstruate, like their relatives at home, Influence of Race and Climate. between 15 and 16. Among different races in Hungary, one observer has noted these diversities in the mean age of the first onset of menstruation. Among Steyerians it began chiefly between the ages of 13 and 14; among Jewesses, between the ages of 14 and 15 ; among Magyars, between the ages of 15 and 16 ; and among Slavas, between the ages of 16 and 17. 3. A third element that exerts a notable influence on the date of the first menstrual discharge, is the Social Condition of the female. Thus, where the mean period of commence- ment was 15 years and 4 months in all classes of the community, the mean date among the richer classes was 14 years and 8 months, and among the poorer, 16 years ; so that, ceteris paribus, we may expect the menstrual discharge to begin earlier in a maiden well nourished and m easy circumstances, than in one who leads a life of privation, toil, and care. Other conditions have been looked to as modifiers of the date of commencing menstruation, but these are the chief; and, passing from this, it is time to inquire. What is this discharge that is taking place ? Is it a simple hsemorrhage ? NATUEE OF THE DISCHAEGE. Some physiologists correctly take note of three stages in the flow. 1st, a stage of Invasion ; Id, a stage of Per- sistence ; and od, a stage of Decline. In the first brief stage of Invasion, the discharged fluid is pale and scanty, not unlike the discharge that escapes from the genitals of some of the lower animals at the period of rut, and usually having a peculiar odour, more marked in some individuals than in others. It is like a leucorrhoeal mucous discharge faintly tinged with blood, and contains many epithelial cells derived from the different mucous membranes lining the genital canals and their follicles, quantities of mucous corpuscles or wander- ing cells, and a few red blood-globules. This preliminary pale discharge has not lasted long when it is followed by the brijoht red discharge which continues throuoh the several Emmenologia. days' stage of Persistence. The fluid that now escapes presents all the peculiarities of blood drawn from a wounded surface, except that it has little tendency to coagulate. But it is known that the admixture of a small proportion of pus or mucus to fresh-drawn blood prevents coagulation. And when we examine the menstrual discharge chemically and microscopically, it is found to consist mainly of blood mixed with cells and fragments of epithelium from the walls of the vagina and vaginal portion of the cervix, cylindrical epithelium from the canal of the cervix and from the cavity of the uterus and the uterine follicles, many rounded nucleated cells like pus and mucous globules, and compound granular corpuscles. In the third stage of Decline or Cessation, the fluid gets less in quantity, becomes first darker, less arterial in colour, then pale and turbid, and then more clear, till it returns to the condition in which it was before the Invasion. During the day or two of the decline, the fluid is found to contain chiefly mucus and pus, with many cells in various stages of fatty disintegration. QUANTITY. The amount of blood that thus escapes it is very diffi- cult to estimate. The statement that we may count an ounce for each cloth that the patient wears during a period, must be received with considerable qualification. The sense of comfort and propriety in different women differs too widely to render such a standard available, and to estimate the loss of blood at an ounce per diaper would certainly give an exaggeration in the ordinary run of cases. The difficulty of determining this point has led writers to give quite different statements as to what we are to consider as the normal loss — some giving it at 2 or 3 oz. ; others at double that amount, or more. There is certainly such considerable diversity in different women as to make it impossible to say that every woman who loses 7 or 8 oz. of menstrual blood is menstruat- ing too freely, or that one who loses less than 2 oz. is amenorrhoiic ; and, in dealing with individual cases, the im- Duration of Menstmial Flow. portant point to be ascertained is the patient's own habitual loss. For though at the first appearance of menstruation the amount may vary from much to little for a few months, it soon steadies to a quantity which the woman will regard as her natural standard — whether it be free, as 53'5 per cent. express it, or moderate, as in 16'5 per cent., or small, as in 30 per cent, is said to be the case. The habitual loss once established, should persist throughout the reproductive period; and its modification in any marked degree, either in the direction of plus or minus, we properly regard with suspicion as an indication of disease. DUEATION OF THE DISCHARGE. Closely connected with the question as to the amount of the discharge at each menstrual period, is that as to the duration of the flow. In this matter, also, there is great variation. But most women tell us that the discharge lasts with them month after month for the same length of time. With only some hours of more or less, the flow lasts for the same number of days. Some 92 or 93 per cent, thus report the duration of the discharge to be steady. In the remain- ing 7 or 8 per cent., it lasts a variable length of time, some- times for 3 days, sometimes for 6 or 8, so that they cannot tell how long the courses will run. Of those with steady duration of flow, some — and these number fully 26 per cent. — menstruate for 8 days each time; some (21 per cent.) 3 days ; some (17 per cent.) 4 days ; fewer (12 per cent.) 5 days ; still fewer (10 per cent.) 6 days ; and a very few (4 per cent.) 7 or 2 days. Duration of less than 2, or more than 8, may be regarded as abnormal, or should at least call for special inquiry as to the general or local condition of the individual case. It has been observed that there subsists this relation between the quantity of menstrual fluid that escapes, and the duration of its flow ; that when the blood is paler and scantier, the duration is shorter, and the longer the duration of the discharge, the more profuse is the amount of lo Eminenologia, blood discharged, and the greater tendency does it show to be mixed with clots. FEEQUENCY OF THE FLOW. But we have still to note another feature, in connection with this htemorrhage, that to us as obstetricians is the most important, and that is the frequency of its appearance, and the regularity of its return. It is this periodicity of the haemorrhage which has given to it in different languages its common designations — " catamenia," " menses," " monthlies," " periods," " les regies," " les epoques," etc. ; for, once it has become established, it regularly recurs at somewhat definite periods. In something like 87 per cent, of women, at least, the type of menstruation is reported to be regular. In the remainder, the menstrual cycle is of indeterminate length : the interval between the commencement of one period and the recurrence of the next is so uncertain, that the woman does not know when to expect it. Among other women, in whom the cycle is constantly, or nearly constantly, of the same duration, we find it presenting different types. Thus some, and these by far the largest number ( — 71 per cent.), have menstruation of the 28-day type, 28 days intervening between the commencement of two successive menstruations. The next most common is ( — 14 per cent.) the 30-day type. More rare are ( — 2 per cent.) the 21-day or (-f- 1 per cent.) the 27-day types. Figures such as these, gathered as they are by inquiries made of patients, are not to be received as altogether exact ; and there is good ground for doubting whether in almost any woman we should regard the type as absolutely constant, and the menstrual cycle unvarying ; but they are sufficiently correct to guide us in our deductions from their physiological or pathological interruptions. What we have to rememlier is that the menstrual month, while it may correspond with the solar of 30^ days, or the lunar of 29| days, or with the calendar month of from 28 to 31 days, may be distinct from all, but in general retains in each indi- vidual woman its own individual type. Nature and Source of the Dischai^ge. 1 1 ANCIENT THEOKIES. It is, however, time we were inquiring. What is the meaning of this menstrual discharge ? You know the theories with which the fathers of medicine were fain to satisfy themselves regarding it. It was held by some to de- pend on the elimination of some noxious material from the female economy; and this chemical theory met such wide acceptance, that among many communities menstruating females were doomed to segregation during their periods, as though there was issuing from them some exhalation that could defile their neighbours, damage fruit-trees, poison bees, turn the milk, etc. ; and this theory we trace in the Hippo- cratic designation " Katharsis," our " Cleansings," and the German " Eeinigung." Again, by many it was held to be due to plethora. In the developed female, it was supposed, a surplus quantity of blood was formed, ready to furnish mate- rial for the growth of an embryo, but no conception occurring, the system got relieved by the periodical loss. Some were even so precise as to allege that the weight of an infant corresponded to the weight of the blood that would have escaped during its gestation had it not been present to appro- priate it. Yet again it was argued that it was an unnatural occurrence — superinduced by the irregularities of civilization, said one — resulting from the non-satisfaction of the repro- ductive instinct, said another — due, said a third, to the erect posture of the human female as compared with the lower animals, one of the drawbacks of the " vultus erectus ad sidera" of the human race. SOUKCE OF THE DISCHAEGE. But I do not require to remind you that modern re- search has traced the discharge to its proper seat, and has shown it to be associated with changes that certainly exert a modifying influence on tlie general system, but that have their immediate source and spring in the sexual organs themselves. 1 2 Emmenologia. Wlien we come to search for the exact seat of the haemorrhage, it is easy to exchide the vaginal walls and vaginal portion of the cervix uteri. There is no good evidence to show that it ever comes from the canal of the cervix below, or from the Fallopian tubes above ; but there is the clearest evidence that it takes place in the cavity of the uterus itself. There was a time when the word matrix was used to designate all the hollow organs opening at the genital orifice. By-and-by the vagina was differentiated from the body which we designate the uterus. But we cannot rest here ; for the uterus proper, marked off by the os internum within and the isthmus on the surface, must be held to be a distinct organ from its cervix, anatomically, physiologically, and pathologically — very inti- mately connected with it, indeed, in all these respects, but yet perfectly distinct, as comes out very clearly when we examine more carefully the LOCAL CHANGES ASSOCIATED WITH MEIS! STKUATION. There is at the period increased vascularity and hyperse- cretion in the canal of the cervix, with intumescence through all its walls, as in a less degree there is in the vaginal tube. But in the uterus proper there are these and more. If we look at the uterine mucosa some ten days before a menstrual epoch, we notice that the almost smooth surface is beginning to be interrupted by the elevation of patches with furrows between, marking them out into irregular fields ; the orifices of the uterine follicles, before hardly discernible, become now easily visible ; and the pale reddish gray tint gives place to a darker red as the deeply injected capillaries are seen running in lozenged-shaped loops around the follicular openings. This tumefaction of the mucosa affects all its elements. There is a proliferation of the epithelial cells lying on its free expand- ing surface, and lining its many follicles ; the interglandular connective tissue shows also increase in number and size of its corpuscles, with infiltration of its intercelkilar substance, and even the capillary tubes seem to sprout and multiply. Relation of Ovidation and Menstruation. 1 3 This liyperplasa of the mucosa, which causes it to wrinkle up within its limited cavity, reaches its height when the return of the catemenia is due ; but for the preceding week it has already been so great that, in the lower part of the cavity at least, the anterior and posterior walls of the uterus get crushed together, and the transmission of any fluid along it then must be regarded as exceedingly improbable. When the day has come, the mucosa is in a condition of what has been fitly described as acute catarrh ; the cellular elements on the surface and nearest to it become the seat of cloudy swelling ; it is but a step further, and that passes over into fatty degeneration ; the disintegrated elements break down as the period of Invasion sets in ; the capillary tubes get broken open, and the extravasated blood, with its admixture of mucus, begins to trickle away, and then to flow more freely through the stage of Persistence, until it is succeeded by the mucous or muco-purulent discharge of the stage of Decline. At this time it is found that a distinct layer of the uterine mucosa has moulted or been shed off, for instead of the smooth sur- face covered with ciliated epithelium, continuous with that of the cervix, there may be seen from the sharply-defined line of the OS internum upward a somewhat fretted surface, in which it requires close examination to detect the follicles with a fine gelatinous layer of connective tissue around them, through which may be sometimes seen the fibrous bundles of what has been shrewdly described as the muscularis mucosae, i.e., the innermost layer of the muscular walls of the uterus, in which the blind extremities of the follicles are deeply and firmly embedded. On the layer of mucous membrane that is left there begins at once a process of repair, and in a few days its restoration is complete. But we have yet to find the impulse to this cycle of changes in the uterus and its mucosa in particular. To discover it we must look elsewhere. Ere we leave the uterus, how^ever, let us note, that the changes in it we have looked at point it out as an organ marvellously adapted for the function of serving as the nest in which a fertile egg might be incubated. Its 1 4 Enimenologia soft and succulent mucosa will furnish an easy soil in which a body capable of self-development may root itself ; its capa- city for growth will enable it to expand with the increase of its growing contents ; and when the embryo has reached ma- turity, its muscular fibres will be ready to effect its delivery. Hence the preparation in the mucosa for the reception of such an egg has been called its nidation, and the partial exfoliation that takes place at the period of the flow has been called the denidation of the uterus. OVULATION. It is when we search for the development of the Q,gg, and the conditions under which it is laid, that we find the key to the explanation of the changes which take place in its well-adapted nest. These we find, of course, in the egg- bearers — the ovaries. In the deep layer of their parenchyma- tous zone, we find a fertilizable ovulum. According to some physiologists, it takes nine months from the period when the ovulum begins to ripen until its ovisac reaches the surface of the ovary. However this may be, a time arrives when the nutritional impulse inherent in it starts it on a new stage of more active growth. As the ovisac expands, it produces irri- tation of the ovarian nerves, which is transmitted to the central ganglia, and is reflected thence in such a manner to the whole of the sexual apparatus, that hypersemia results, perhaps at first but as a faint and transient blush, but increasincf with each new wave until the well-known changes take place which lead to the dehiscence of the ovicapsule. The ovum thus ex- pelled has great potentialities within it, but these are all dependent on the access to it — and probably at this point — and the amalgamation with it, of spermatozoa. Let the sper- matozoa fail the ovum here or in the oviduct into which it is received, and it will move along whithersoever it may be car- ried, exerting no further influence on its surroundings than any epithelial cell by which it may be accompanied. So it will drift through the Fallopian tube and on into tlie cavity of tlie uterus, where already, it may be, the surface has begun Physiological Arrest of Menstruation. 1 5 to melt down, and with tlie menstrual discharge it will be washed away. Not, perhaps, with such perfect adaptation, but with some such close relationship in time and function, will the ovary- discharge its ovisac, and the uterus shed its surface, period after period, as each new follicle takes on more active growth and rises to maturity, on the disappearance of its predecessor. And when we are looking thus closely at the central point in the phenomena of menstruation, we can easily comprehend how, apart from climatic, and racial, and other general con- ditions, the rate of rapidity with which each Graafian follicle ripens and bursts, will depend on individual and special con- ditions in the ovaries themselves. The regular evolution of successive ova, once fairly started, might go on for long. It might be too long to render the young lady in whom we have traced the establishment of the function an object of interest to us. So, as we have come within sight of a leap year, let us wish her a happy new year, and a husband before it runs out. Then let us hope that one of us will be called in to interpret for her the non-appearance of the usual menstrual discharge. CONCEPTION. We will take it for granted that an ovum has been fertilized. But it may be questioned. At what epoch did the ovum escape from its capside ? Was it the ovum from the period when last a catamenial discharge took place ? or was it an ovum that was shed when the next discharge was due ? Up till a recent date, the almost universal answer would have been, that it was the ovum separated at the time when a uterine discharge occurred that became impregnated ; and hence it was supposed the sooner, subsequently to a menstrual epoch, that connexion was accomphshed, the more chance there was of the ovum being fertilized. It was even averred that there was an agenetic period, dating from twelve or fourteen days after one catamenia till the next was due, during which semen might be discharged into the vagina 1 6 Emmenologia. without interrupting the menstrual cycle, because the ovum of the last epoch had by that time perished, and spermatozoa could not have access to another ovum till after the following epoch, and the rupture of a fresh ovisac. Such a period of agenesis, however, cannot in the face of well-known facts be admitted ; and if a single coitus practised within a week of the commencement of a menstrual epoch be less likely to prove fruitful than a single coitus of an earlier week, the circumstance is susceptible of another explanation. For during the pre-menstrual week, as we have seen, the uterine mucosa has swelled to such a degree as to block up the uterine cavity, and prevent the upward migration of the spermatozoa; whereas, during the two post-menstrual weeks, the whole canal is more easily permeable for them. It may even be that there is special facility for their transit during the first post-menstrual days, ere the uterine mucosa has become regenerated, and its epithelial cilia begin to cause a down- ward current, as they are believed to do from fundus towards OS. If we be correct in speaking of each ordinary menstrual discharge as the accompaniment of the birth of an unfecun- dated ovum, as many observations seem to indicate, then we are forced to the conclusion, and I am quite disposed to believe it is correct, that the fecundated ovum of a normal pregnancy is a product of the period that had become due, and that has duly come, though it be not distinguished by the occurrence of a uterine haemorrhage. The interruption to menstruation we trace to the presence of spermatozoa in the genital canals, and we have to inquire at what plane they come into contact with the ovum. We have seen how easily they have access to the higher planes during the early part of the inter-menstrual interval, and there is no reason to doubt that, when the generative mucosae of the female are in a healthy condition, the spermatozoa will retain their vitality in their mucus for a considerable period. That they meet the ovum in the cavity of the uterus itself, we can hardly conceive. We may conjecture that they meet in the Fallopian tubes \ but we know that they do sometimes Changes in Uterus after Conception. 1 7 meet on the surface of the ovary. In this situation, in fact, we sometimes find the ovum undergo its further development. For though the uterus be its usual and most ap]n^opriate nest, it may get lodged and incubated in some other cavity. In most of these extra-uterine gestations, the nest fails to meet all the requirements of the growing ovum. Either there is not a soil in which the chorionic villi can take root, or the walls of the nest give way u.nder the bursting pressure of the expanding ovum, or the fully-developed product is imprisoned, till it dies. But whatever the ultimate history of these ill- lodged ova, their occurrence teaches us that the spermatozoa traverse all the mucous canals sometimes, and warrant us in believing that when a menstrual era has arrived, they may have found, in ordinary cases, their way to the surface of the ovary, so as to fertilize the ovum at the moment of its escaping from its ovisac. The ovum thus fertilized is no uninfluential, passive, perishing cell like its unfertilized pre- decessor of the foregoing epoch. It has within itself a new life power, a power of self-development. Evolutionary changes are set up in it, and in virtue of these it wHl at once begin to exercise a potent influence upon the structures with which it comes into relationship. By the time it has passed into the cavity of the uterus its chorionic villi are ready to lay hold of the soft and swollen surface of its Iming membrane ; that mucous membrane, which was in a state of growth verging on decay, receives a new impulse which leads to active proliferation of its elements, so that it grows up around the body that has got engrafted on its surface, till it surrounds it with a distinct capsule — the decidua reflexa. At the spot where the ovum became rooted in it (decidua serotina) a mutual intergrowth takes place between the villi on the chorionic surface and the structm-es in the mucosa, until the vascularized villi are hanging free into blood-pools channelled in its tissues. Throughout the rest of the cavity the mucosa (decidua vera) goes on developing until, as the ovum expands within its new capsule, the outer surface of the latter becomes amalgamated with the free surface with which B Emmenologia. it is in opposition. In this way the disintegration of the uterine mucosa is for that period arrested, and there occurs no menstrual discharge from what has now begun to be a gravid uterus. UTERO-GESTATION. But we may be sure our patient will be less curious to know the cause of the non-appearance of the menses, than anxious to be told the probable term of their re- turn ; or rather, as the question will present itself to her, what is the probable date of her confinement. Shall we attempt to fix a given date as women's standard term of utero- gestation ? You know how piously Harvey has fixed it at the 275 days, which, as he states it, run "from the festival of the Annunciation in the month of March, to the day of the blessed Nativity, which we celebrate in December." But when we seek authority for the dates we do not find them in the only book which could have told us, for it was given to tell us of other things. The dates are derived only from the teachers of the Eoman Catholic Church, and when their true meaning is investigated, it is found that the 25th of March was held as Lady-day in pagan Eome in honour of Cybele, the mother of the Babylonian Messiah, long before the era of our Lord ; while the 25th of December was kept among many Gentile peoples as the birth-day of the son of that " Queen of Heaven." They would thus carry back to remote ages the observation that this length of time was looked on as the usual period of human gestation. Statistics meritoriously compiled have shown that what was true then is near the truth still. But the patient who has asked for our opinion as to her probable term, is not likely to be able to give us a definite day to count from ; and if she did, and we were to refer her to the standard measure, we should be as likely to set her wrong as right. If we are to make the closest possible approach to the calculation of the probable date of her confinement, we must al)ove all liave regard to her own individual menstrual type, and ascertain what is with Return of Menstruation after Parturition. 1 9 her the usual length of a menstrual cycle. The ovum which took nine months of so many days to ripen within its ovisac, will, after it has become impregnated, take the same number of months to undergo its development within the uterus. We have therefore to find out the number of days between the commencements of the two menstruations that pre- ceded conception, and multiply the figure by ten; and, within a range of five days earlier or later, the birth of the impregnated ovum will probably take place. In the round and rough, we are safe in following the usual calculation of counting nine calendar months from the date of the com- mencement of last catamenia, and adding a week, because the greater proportion of women have the 28-day type of men- struation, which closely answers to this calculation. But where we are specially anxious to avoid error and to attain the nearest approach to accuracy, we must, I repeat, ascertain the individual menstrual cycle and expect the delivery on some day in the decade, the central day of which corresponds to the date when the tenth menstruation should be due. For, by the return of this tenth menstrual epoch, the fcetus has become fully developed; the once greatly hypertrophied mucous membrane of the uterus has become stretched and thinned, and its superficial portion has undergone in great part of its extent a marked degree of fatty degeneration, while, according to some recent observations, the necks of its follicles have become dilated till there are mere threads of intervening connective tissue left between. As a result of the changes going on in the lining membrane of the uterus, leading to partial desquamation of its surface, the sensory nerves are irritated. The irritation conveyed to the centres is reflected to the sexual organs, where it is manifested first in an increased mucous secretion, corresponding, though in an exaggerated form, to what we see in the Invasion stage of an ordinary menstruation ; and, secondly, in contractions set up in the muscular walls of the uterus, at first so slight as to be hardly appreciable, but increasing in intensity and continuing imtil the ovum has been expelled noii sine Idbore. The 20 Emmenologia. expulsion is also attended, as was the non-laborious birth of its predecessor, with a hsemorrhage (the red lochia) such as goes on during the Persistence stage of ordinary menstruation, and afterwards a paler mucous discharge (the white lochia) as in the stage of Decline, The internal surface of the uterus, when examined at such a time, presents appearances similar to those which we found immediately after the cessation of the catamenia, only on a greater scale, as the whole organ has undergone an enormous degree of hypertrophy during its gestation of the ovum. In a short time the disintegrated surface of the mucosa is regenerated, and the worn-out muscular fibres have melted down and have been replaced by younger cells and corpuscles, and the uterus is ready to resume once more its nine months interrupted series of changes. LACTATION. The date of the resumption of these changes will depend, however, on the condition of the ovaries, for, as we have already seen, they take place in concert with the dehiscence of an ovisac. Now there is no evidence to show that ovula- tion goes on, for example, during utero-gestation. Eather we must believe that whilst the nutritional energy of the female is demanded for the evolution and growth of one fertile ovum, there are no fresh ovisacs ripening and bursting; and hence we look upon menstruation during pregnancy as an altogether abnormal occurrence. But the woman is not done with the claims of the ovum whose history we have traced down to its expulsion from her womb. Turther changes of growth and development in the child are to take place which demand constant nutritive supplies, and for these it will be dependent on the mother's ndlk ; and this demand on her nutritional energy will again run on for an average duration of nine more months. It is certain that during the period of lactation, in a large proportion of women, the ovaries have already begun to resume their functional activity. Still we are to regard the non-appearance of the menses during lactation as the rule, and it is only after the infant is Changes at the Menopause. 2 r weaned and the nutritional energy — whatever that may involve, not only of blood-supply, but of nervous influence — is free to be directed once more to the ripening of ova within their ovisacs that we are to expect the normal re-establish- ment of menstruation. THE MENOPAUSE. I will not weary you further by dwelling on the patho- logical conditions under which menstruation may be modi- fied, so that the discharge becomes too profuse, or painful, or perv'erted, or suppressed. I fear I have already drawn too long upon your kind attention ; and, after all, some one may rightly charge me with having treated all too cursorily the great subjects of emmenology. Let the suddenness with which the intimation came upon me, that an address was expected from the new President to-night, be some apology ; and let me hasten to add, in conclusion, that in following out the history of our interesting patient, whom at several safe confinements we shall suppose ourselves, during a series of years, to have assisted, there comes a time when the menstrual discharge will cease to flow. Her married life may be running on its happy course, till, sometimes slowly, the discharge lessening month by month — sometimes suddenly, without any premonitory change in its character — sometimes, again, after a sudden increase in the quantity, or some change in the quahty, or brief repeated interruptions of its regularity, there comes a time when it finally disappears. A very variable time the date of its cessation is, haAong a far -wider range than the date of its first appearance. In some cases the menopause has already arrived at an age when the menses often first appear in other women, at the age of 21 ; and, at the other extreme, we find it running on till the age of 65 or 70. The usual range which we may regard as normal, however, runs between 35 and 55, the larger proportion falling within the central decade. In nearly a half, menstruation ceases between the ages of 45 and 50 ; in fully a quarter, between 40 and 45 ; in rather more than one-eighth, between 50 and 55 ; and in the remainder between 35 and 40. It 22 Emmenologia. has been noted that women whose menstruation is late in making its first appearance have a tendency to early meno- pause — the duration of the reproductive life in them being thus shortened at either end. On the other hand, the early menstruation is not so likely to be associated with delayed cessation. At least, in hot countries, where the early menstruation is the rule, the menopause comes on at a much earlier period than in temperate climates, and the duration of the reproductive life of the female becomes so curtailed as to have led to the remark, that the three or four wives of an Abyssinian only equal in fertility the single wife of a European. If now we examine the condition of the sexual organs, to discover the cause of this cessation of the haemorr- hage which for thirty years or more has been continuing with such regular periodicity, we find that in the ovaries the relatively few ovisacs that remain unruptured show little tendency to further evolution; and if there were the attempt at development in one, it would find its expansion impeded by the density which has settled down on the surrounding stroma, and its dehiscence prevented by the interposition of firm fibrous layers between it and the surface. It is quite possible that this state of matters obtains for some time in the ovaries, before the discharge finally disappears from the uterus. But more or less consentaneously, and in some cases apparently at an even earlier date, changes set in in the uterus also which destroy the power in its mucous membrane of periodic proliferation, desquamation, and repair. Then many of the peculiar attributes of mind and body of the female become modified, so that again she comes to bear external likeness to her male companion — a likeness in some instances so striking that a stranger meeting her and her husband casually will say, " How like these two people are ; they must be sister and brother." In any case, her name now dis- appears from the list of our midwifery engagements, and the happiest meeting we are likely henceforth to have with lier is in circumstances where none can render such efficient help as she — at the confinements of her daughters, or other women of a younger generation. Morbid Conditions of FGet2ts. INTEA-UTERINE AND CONGENITAL CONDITIONS OF FOETUS. THE ACAEDIAC FCETUS.i ^T^HE monster which I have to bring under the notice of the Society was brought to me by a midwife who is in the habit of attending parturient women of the poorer classes, with the following history : — Mrs. C, aged 20, gave birth to her first child, a girl, on 25th December 1873, being then 16| years of age, and to a second girl on 14th June 1875. The labours on both occasions were easy ; the children, well-formed and healthy, were nursed by the mother. She fell in labour at the full term of her third pregnancy on 17th March 1877, and, as usual, after a labour which was not attended with any notable escape of liquor amnii or other special feature, a healthy, well-developed, but small-sized girl was born. The umbilical cord was tied in two places, and divided between the ligatures. The cliild was laid aside, and the nurse was holding the cord, without, she avers, making any traction on it, when the mother gave a sudden movement to the side, and the umbilical cord, to the length of six or eight inches, came away in the nurse's hand. She felt anxious as to the escape of the afterbirth, but had not long to bethink herself what to do when the placental mass came down the vagina, and along with it the mis-shapen twin. She cannot tell how or when this body got detached from the ^ Transactions of the Edinburgh Obstetrical Society, iv. 384. 24 Intra-titerine Conditions of Foshis. placenta. It was placed at once in the water in which the child already born had first been washed by another woman ; Fig. 1. AcAEDiAC FcETUs. (Half size.) and, as blood was escaping, the navel was tied with a piece of tape. As is customary among people of their class, the j)la- centa, which had only a fragment of one cord attached to it, was burnt. The strange body was first buried in some out- of-the-way place, but was exhumed and brouglit to me on the sixth day afterwards. It was still in a state of good preservation, and presented in a very marked degree the features of the so-called Retus Acardiacus, or Heartless Foetus (fig. 1). It consists of the lower part of the trunk and two inferior extremities. It measures 5^ inches in length, 5| inches in breadth, and 2f inches in thickness from before backwards. The limbs are of unequal size, the right measuring at the broadest part of the fcetus 3 inches, and the left 1\ inches in breadth. They each have the appearance as of a thick fieshy thigh, with a dimple deeper in the right than in the left at the knee, and terminating abruptly Description of an Acardiac Fa^hts. 25 witli only a stumpy constricted intervening leg in a mis-shaiDen foot. The right foot is turned so that the sole looks upwards and presents two digits which have rudimentary nails, and may stand for the great and little toes, with a sjjace between them. The left lies folded in front of the other, with the sole turned inward and upwards. Two digits united together, but having each indications of nails, may represent the first and second toes ; a small toe with a less marked nail grows a few lines apart at the outer side. The trunk is very short, and measures only 1\ inches from the summit to the junction between the limbs. On the ventral aspect at its lower part, and slightly to the left of the middle line, can be seen the pro- jecting umbilicus, open and with some coils of small intestines protruding from the opening. A fringe of membranes which has been torn off the placenta is still attached to the right and lower margin of it, and in this lower portion a blood-vessel of crow-quill size is to be seen. On the posterior aspect, a small fold of dark red skin is found in the fork between the limbs, attached to the right, but close to the fissure between them. It is evidently the indication of the attempted development of a genital organ ; and, as the co-twin is a female, it probably represents the right labium or nympha. There is a small depression immediately behind it, which may represent either the vulva or the anus, but which admits a fine probe only to the depth of a line or two. Through the kindness of Pro- fessor Turner, the foetus has been injected for me by Mr. Stirling of the Anatomical Museum. The fluid introduced through the vessel already referred to passed freely into the body till all the cutaneous vessels became deeply injected, and also those in the walls of the protruded intestinal coils. The central portion and the right limb only have been dis- sected, the left leg being left intact to show its original ap- pearance. The skeleton of the trunk is represented by an imperfect pelvis, in which the sacrum and coccyx are absent. The innominate bones are fixed together along the surface that corresponds to their usual sacro-iliac joint and the rough surface behind. The several sections of the bone are still 26 Intra-tderine Conditions of Foetus. distinct one from tlie other ; tlie pubic portions being in the most rudimentary condition, and their bodies united by a broad intervening band of tendinous tissue. The neck of the thigh-bone is very short ; otherwise the femur is well formed and articulates with the tibia at a knee-joint, of which the only marked peculiarity is the absence of the patella. The tibia and fibula are fixedly flexed to the femur at an angle of about 55°. In the foot we find the calcaneum proportionally large and fixed with the navicular bone ; otherwise the tarsus and metatarsus are normal. The central metatarsal bone, however, terminates in a blunt point without articulating extremity. The first and second have articulated to them a single set of phalangeal bones; but these are broad, as if composed of two sets fixed together. The same arrangement obtains in regard to the fourth and fifth. The subcutaneous cellular tissue was remarkably cedema- tous, so that in maldng the dissection it was constantly neces- sary to wipe the cut surface with a sponge ; and the limb, which before being cut into seemed plump and tense, became shrunk and shrivelled afterwards. The gluteal muscles, and most of the muscles of the thigh and leg, can be recognised and dissected, but they all present a striking peculiarity — a peculiarity which I have not found noticed in other cases of this kind. For, whilst their outline and arrangement sufficiently indicate their nature, instead of presenting the usual red, soft, fleshy appearance of muscular masses, they are of a dull yellow colour and firm consistence, and look as if made up of solid pieces of fat. On examina- tion witli the microscope, the usual outline of muscular fibres can be seen in them ; but the transverse lines are absent, and on the a})plication of ether the substance melts almost com- pletely away. The only viscera in the body are some portions of the intestinal canal. A piece of gut, four inches in thickness, which is clearly recognisable as the rectum, occupies the pelvis. It is closed inferiorly, and does not communicate witli the depression observed in the cleft between the nates Vascular Arrangements in Acardiac Fcetus. 27 though it can be traced close down to it. The upper ex- tremity reaches up to the umbilical canal, within which it tapers somewhat suddenly to a thickness of only one inch. Here a bend takes place, which reminds one of the sigmoid flexure of the colon; and the rest of the intestinal tube, which protrudes through the umbilicus, is folded in convolu- tions, and ends in a blind extremity, which adheres by cellidar tissue to the margin of the orifice. The upper part of the rectum and the narrow coils are invested with a serous membrane, which also lines the umbilical canal; but there is no distinct shut sac. Nowhere is there any trace of urinary or generative organs, with the exception of the fold of very vascular skin already noticed on the inner posterior aspect of the root of the right thigh, and beneath this the cellular tissue is very deeply injected, and reminds one of the aspect of an erectile tissue. The vascular arrangement is of the simplest. The blood- vessel into which the injection was thrown, and which I may speak of as the afferent vessel, and which opens at the lower margin of the umbilical ring, nms down the left side of the umbilical canal accompanied by a shghtly smaller and here empty efferent vessel, till it comes close to the middle of the left ilio-pectineal line. Here it throws off a branch to the left limb, and then travels round behind the bowel till it reaches the posterior part of the imperfect pelvic brim, when it turns abruptly downwards and forwards. As it travels along the right ileo-pectineal line, it dips under the efferent vessel to pass out of the pelvis towards the inner side of that vessel. This relation of these blood-vessels leads me to regard what I have called the afferent vessel as the vein, and the other as the representative of the arterial system, and the further distribution in the thigh confirms this idea. For at the groin the afi'erent vessel, which, as I have said, lies to the inner side of its companion tube, gives off a division which corresponds precisely in its distribution and relations with the external saphena, while the other portion goes down among the muscular masses along with the efferent vessel, to wliich 2 8 Intra-uterine Conditions of Foetus. it presents the ordinary relations of the internal saphena with the femoral artery. These venous tubes, indeed, are so far unlike the saphenous vessels that they are destitute of valves ; but, on the other hand, the imperfectly-filled vessel which runs in the course of the femoral artery has thin walls, which more resemble those of the venous than the arterial system. This efferent vessel after crossing over the vein, as has been described, about the middle of the right side of the pelvis, sends a branch to supply the rudimentary intestines which have been very deeply injected through it. This branch enters the intestinal tube at its posterior aspect, and just beyond it the main division is joined by the corresponding vessel from the left side, whence the short common trunk passes up the umbilical canal towards the umbilical aperture, in which it lies inferiorly to the larger and fully-injected afferent vessel. In this arrested body, also, we thus find the blood, such as it is, making its entrance by a vein, and escap- ing through an ill-developed artery. The history and structure of this fcetus quite bear out the ingenious theory of Claudius^ that, in this variety of mons- trosity, we have to do with the arrested development of a twin whose umbilical vessels had acquired an anastomosis with the corresponding vessels of its more completely- developed neighbour. According to this theory, the twins are developed from a single ovum. Soon after the formation of the allantois, a blood-vessel of the one fcetus inosculates with a blood-vessel of the other. The streams of blood from the two hearts meet ; that which comes from the twin with the stronger heart first arrests the course of blood in the other, and then causes a reflux of it towards the weaker heart. There coagulation of the blood and atrophy of this unused lieart takes place, and, w^hilst the heart of the stronger foetus continues to send on the main current of its l)lood towards the placental villi, it sends also a side stream back into the ^ Die Entwickclung dcr herzlosen Missgcburlcn, Kiel, 1859. Cf. Forstei-, Die Misshildxmgen des Mciischcn, p. 58. Varieties of A cardiac Foehis. 29 body of its co-twin. This stream travels most easily through pelvic and femoral vessels ; and hence it is that most of these acardiac bodies are more perfectly developed inferiorly than superiorly. This common imperfection of the upper part of the body has led to their being spoken of by some as Acephalous, or Headless. But the designation is not by any means satisfactory, seeing that, as in this in- stance, not only the head, but the whole upper part of the trunk, may be want- ing; and, on the other hand, there are several instances recorded where the acardiac foetus had little more than a rudimentary head, and was Acormous or Trunk- less. Whatever be the form assumed by the arrested twin, the blood that circu- lates through it, entering by a single vein and escap- ing by a single artery, is blood that has already passed through the body of the better-growing foe- tus. The nutrition is thus extremely imperfect; but few organs show traces of development, and even in these the tissues present a low embryonic type of structure. I might have added that such monsters are sometimes expelled along with the better developed but dead twin prematurely. In such cases the acardiac foetus is not plump and fresh, but meagre and shrivelled, as seen in this Fig. 2. Acardiac FcETUs. (Full size.) Intra-uterine Conditions of Foetus. woodcut (fig. 2) of a preparation from Sir James Simpson's museum. I possess another preparation, wliicli was kindly sent me by Mr. Gibb, of Airdrie, where, along with a foetus of about the fifth month, there is a three-limbed acardiac foetus which has very much the appearance of the three legs on a Manx coin. INTEA-UTEEINE SMALL-POX.i Cases of intra-uterine small-pox are not so rare but that most of the Fellows of this Society have met with one in their own practice, or have seen them when exhibited here by others. It is but very rarely, however, that we have an opportunity of tracing out the progress of the intra-uterine disease so precisely as I was enabled to do in the case I have now to record. Mrs. M'L., aged 22, and married for five years, miscarried on Friday, the 1st of July 1858. She had had six miscar- riages previously, and had usually gone to about the seventh month of gestation before the foetus was expelled. One foetus only was retained till the eighth month, and lived up till the time of its birth. She was generally in the enjoy- ment of good health ; began to menstruate when only twelve years of age, and menstruated regularly every fortnight. After the occurrence of the miscarriage in the beginning of July 1858, already referred to, she menstruated once — in the end of the same month ; but before the time for the recur- rence of another catamenial period arrived, she had become impregnated ; and when I saw the patient for the first time, in the end of October, she presented all the appearance of a person in the third month of utero-gestation. She was then ordered to take ten grains of chlorate of potash three times a-day, as all the facts that could be furnished in regard to the ^ Edinburgh MedicalJoumal, vi. 448. Small-Pox m Utero. 3 1 repeated miscarriages seemed to point to some atrophic disease of tlie placenta as the cause of the death of the suc- cessive infants. The patient continued to do well until the beginning of February 1859. On the 7th of that month, I was sent for to see her ; and, on my arrival, I was told that on the 5th she had been out walking, when she found herself so poorly that she was obliged to hurry home. She had had some shivering fits that same morning, a good deal of sick- ness, and a feeling of soreness all over the body ; and she was then labouring under a high degree of fever, while the skin was covered with a multitude of rough red spots ; evidently the commencement of some eruptive disease. On the follow- ing day, it became quite clear that the patient had got an attack of modified small-pox. A number of discrete pustules broke out all over the body, most abundantly on the face, hands, and arms. They ran the usual course, and began to fade away after the ninth day ; so that on the 23d of the month, eighteen days from the date of the onset of the disease, the patient was able to walk out of the house. Up to this time the foetal movements continued active as usual ; but a few days afterwards, on the 25th or 26th of the month, they began to be feebler and less frequent. The patient took no heed of this circumstance for a day or two ; but having at last become alarmed about it, she came to me. This was on Monday, the 28th of February. I found the sounds of the fcetal heart to be then very faint, feeble, and indistinct ; but on visiting the patient at her own house on the following Friday (March 4th), I heard "them again quite distinct, thougli less forcible than natural. I did not see her again till the forenoon of the Monday following; and, on then listening through the stethoscope over the womb, found that the foetal heart had ceased to beat, or, at least, that its sounds were no longer audible. On the preceding day, the patient had been out walking, when, as she averred, she became rather sud- denly sensible of a feeling of weight, or falling down, in the womb, which compelled her speedily to return home. That, in the sensation thus experienced by the patient, we have an I ntra-itterine Coiiditions of Fcetiis. indication of the time when the foetus died, it is of course im- possible to determine ; but there can be but little doubt that the probable date of its death was the 5th or 6th of March. On the 8th, the patient met with an accident; for, while voiding her urine early in the morning, the utensil on which she was seated broke beneath her, and a number of cuts and scratches were inflicted on the hips and thighs. Fortunately, however, the genital organs were uninjured, and the patient speedily recovered from the effects of her mishap. I did not again see the patient till about two o'clock in the morning of Friday, the 2 2d of March, when I was summoned to deliver her. She had been suffering more or less from occasional pains, referred to the region of the womb, for two days pre- viously ; but the true labour pains had only set in about two hours before I arrived at her bedside, and by that time they had already succeeded in expelling the feet and body of the child. The head was soon delivered, and the placenta and membranes followed in due course. As had been fully anticipated, the child at birth presented evidences of having been in utero the subject of an attack of variola ; for a number of pustules, umbilicated in the centre, were found scattered here and there on the back, the head, and the thighs. The cuticle was separated, or easily separ- able, over great part of the body, and the foetus altogether was in the state of decay which we always expect to see in the case of a child that has lain for two weeks dead in the maternal womb. The pustules were but few in number, and but sparingly distributed over different parts of the body; and, in consequence of the degree to which decomposition had gone on, several of them, as the members of the Society could observe, had fallen out at points where the cuticle was scaled off, and had left only cup-like depressions in the cutis vera. But enough were still left of a character sufficiently distinc- tive to show that the foetus had suffered from smallpox, and that it had died at that period of the disease when the pustules had existed for seven or eight days — supposing always that the development of variolar pustules follows the same course Small- Pox 111 Utero. '^2) in an intra-uterine subject, that it does in a new-born child. The death of the fcetus in this instance, however, was not to be attributed to the attack of small-pox alone, or even to that chiefly. On the contrary, the attack, to judge from the small amount of eruption that had taken place, seems to have been, on the whole, rather a mild one ; for the appear- ance of the pustules indicated the attainment of a stage of the disease too far advanced to allow it to be supposed that the intensity of the fever caused the infant's death before the eruption had time to be developed. It seems probable, indeed, that it would have survived that disease, and it might have been carried to the full time, and have been born alive, had there not been at hand another source of danger in the morbid condition of the placenta. As the members of the Society could perceive, the placenta was unusually small, pale, hard, and fibrous-looking, having undergone a change which has sometimes been described as fibrous degeneration, or cirr- hosis of the placenta, — a morbid condition of that organ which is well known to be an occasional cause of intra- uterine mortality. But although the foetus died, in all probability, of the de- fective nutrition and impeded oxygenation consequent on the diseased state of its placenta, and not of the attack of small- pox, of which it showed such distinct traces ; yet the history of the case is interesting, as showing very exactly the date of the onset of the disease in the foetus, and the length of time during which the mother suffered before the progeny in her womb became affected. We have, first, the mother attacked with the disease on Saturday, February 5th; the eruption appearing on the 7th, and beginning to fade on the 16th or 17th ; and the patient so far recovered as to be able to be out of the house on the 23d of the month. She had fairly re- covered, and the eruption had faded away, and left only its yet vascular scars behind, when, secondly, on the 25th or 26tli of the month, twenty or twenty-one days from the time of the com- mencement of her own attack, she began to miss the foetal move- ments ; and this marks the date of the onset of the disease in c 34 Intra-uterine Conditions of Foetus. the foetus. On the 4th March, six or seven days after the foetus thus seemed to have become affected, its heart-sounds were still distinct and clear ; but on the third day afterwards, they were no longer to be detected. On the seventh or eighth day from the date of the commencement of its disease, the foetus had died. In short, after the disease had run a course of three weeks' duration in the mother, and had ex- pended itself in her constitution, the foetus became affected by it, and died on the seventh or eighth day afterwards, although it was not expelled from the uterus till the end of another fortnii^ht. INTEA-UTEEINE PEEITONITIS.^ On December 13, 1876, I showed to the Obstetrical Society a preparation illustrative of Intra-uterine Peritonitis in the Foetus. The patient who had borne the child had the fol- lowing history, as drawn up by Dr. Mackay, house-sur- geon to the Maternity Hospital: — "A. B., 25 years of age, second pregnancy, was, after a normal labour, delivered on 4th December (4.45 a.m.) of a female child weighing 6 lbs., which only lived an hour. The patient, a pale emaciated woman, was fovmd to have several discrete condylomata on the light labium, one on the left nympha, and a cluster of large ones on the perineum and right verge of the anus. The inguinal, especially on the right side, and nuchal glands, were enlarged and indurated. She had a male child on lOtli February 1874, which died when 1 year and 9 months of age — said to have been born with hemiplegia, and died in con\n.dsions. Patient has been mostly a factory hand, but more lately a domestic. "Present Pregnancy. — She last menstruated in the beginning of April, and about the same time, as she avers, had sexual ^ Transactions of Edinlurfjh Obstetrical Society, iv. 293. Peritonitis in Utero. 35 connection for the last time, and with the father of the present cliilcl. Since then she has been from place to place until she left a Magdalene asylum for the Poorhouse at the end of August. Not until a fortnight after admission there did she feel anything the matter with her. She then com- plained of pain on micturition, and discovered, so she says, several elevated ' blister like ' spots on the labia, and a swelling within the right one, which gradually increased to the size of a small egg, suppurated, burst, and healed along with the spots ; no trace, however, can be found of any such abscess. About the same time appeared the condylomata on the perineum, which have persisted ever since. Her throat and palate also about that period were sore and inflamed, so that she had difficulty in speaking and swallowing ; the particular character, however, of the throat affection cannot be clearly ascertained. She does not remember having felt the inguinal glands enlarge, though she felt some uneasiness there about a month ago, when also the condylomata reappeared on the labia which are now there. About two months ago the inside of her ears ' broke out into little sores, and ran matter,' and several papular spots, the size of a sixpence, appeared on the forehead. These lasted three weeks or a month, and have left no trace. She denies having had any other skin eruption, and her hair never came out. Apart from the history of the syphilitic attack, patient states that ever since the beginning of September she has had more or less abdominal pain, accompanied by constipation and some tympanitis ; and Dr. Williamson, Leith, who had her under his care in the Poorhouse, says that he suspected and treated her for some degree of deep-seated peritonitis. These symptoms have now disappeared. With the exception of the local affections, she has had now no indications of disease, and has been making a satisfactory recovery from her labour." The foetus presented an enlargement of the abdomen, the cavity of which was found on section to be distended with fluid of a reddish tint. There were traces of inflammatory 36 Intra-uterine Conditions of FcbIils. action over the whole peritoneal surface — flakes of lymph lying on the surfaces of the liver, spleen, and several of the other viscera. It was interesting to note that bands of adhe- sive matter passed from the fundus uteri to the abdominal walls and the lower intestinal coils, which might easily have led to permanent displacement if the infant had survived. CONGENITAL MELANOTIC TUMOUE.1 At the meeting of the Obstetrical Society on March 19, 1862, I showed a preparation of a Melanotic Tumour from the shoulder of an infant, which had died a few days previously. The child had been very fretful for the first day after birth, crying whenever it was moved. When dressing it the follow- ing morning the nurse observed a swelling on the shoulder. It had a diameter of about an inch and a half, was flattened on the surface, and slightly depressed in the centre where it was firmest, and was very tender to touch. The application of a plaster round the arm kept it protected, and the infant became quiet. No change occurred in the tumour. The child, though weak and puny, seemed to be doing well enough tiU it was a fortnight old, when it became affected with sclerema, specially of the head and face, which rendered all the features rigid, so that it had not been able to suck for many hours before death. On examination the tumour was found to be of a melanotic type, and was developed from the deeper surface of the true skin. The father, an old man, was affected with constitutional syphilis ; the mother was healthy. ^ Edinhurgh Medical Journal, viii. 475. Congenital Goitre. CONGENITAL GOITEE.i Congenital Goitre has been descriljed and discussed of late years, by various foreign writers, under the designation of Struma Neonatorum {Kropf der Neugehoreiun, Goitre cles nouveau-nh) , or, from one of its most prominent symptoms. Asthma Thyroideum. But, in English literature, except in a short article in the Obstetric Memoirs of Sir J. Y. Simpson,^ and in another, still more brief, by Dr. Crighton,^ of Chapel- en-le-Erith, Derbyshire, I have not met with any special notice of the affection ; perhaps, from the circumstance that it more rarely comes under observation here than on the Continent, It may, therefore, not be uninteresting if I Ijring before this Society the history of a case which I recently witnessed, and state some of the points in connection with the disease which have been recorded by other observers. A lady, in excellent general health, had had two abortions at early periods, and a miscarriage at the seventh month. Wlien she again fell in the family way, she was put upon chlorate of potash, which she continued to take regularly, three times a day, up till the time of her delivery, wliich took place at the full term. Labour was tedious throughout, but most markedly so during the second stage ; for, although the passages were wide, flaccid, and dilatable, the anterior fontanelle came too easily within reach of the finger, and the head descended in a state of imperfect flexion.^ I had great fear lest the perineum should give way during its emergence through the outlet; but, except that the mucous membrane inside the vulva, at the posterior extremity of the right nympha, got torn on the prominent tuber parietale, there ^ Glasgow Medical Journal, i. 181. - Vol. ii., p. 392 ; and Edinburgh Montlthj Medical Jmirnaliox K\}V\\ 1855, XX. 350. •^ Edinburgh Monthly Medical Journal for August 1856, 149. •* This has been pointed out specially by Sir J. Y. Simpson, who compares the effect of the tumour to that produced by the presence of the child's hand or arm in the neck. o 8 Intra-titerine Conditions of FceUls. was nothing else noteworthy in the delivery. Immediately on the birth of the child, which was a male, when it was laid on its back I noticed that there was a swelling of some sort on the front of the neck, and delayed the ligatnrmg of the cord for a short space, as respiration seemed to be effected only with the greatest difficulty, and with strong convulsive movements of the muscles of the head and upper extremities. After the cord had been tied and divided, and the child handed over to the nurse, whilst I was attending to the labour in its third stage, I could hear the rough, hoarse, crackling sound of the laboured breathing, which gave an impression as if there was some fluid in the narrowed larynx. On examination, it was at once evident that the swelling, which projected to the level of the chin, and occupied nearly all the space between the dim and the sternum, was due to an enlargement of the thyroid gland. The isthmus could be felt passing in front of the trachea, and terminating in the two lateral lobes, all in their natural relation, and retaining their normal configura- tion ; only all greatly increased in size, the right lobe slightly more hypertrophied than the left. "Wliilst being moved about, during the process of dressing, the infant had in some posi- tions increased difficulty of breathing, more particularly when it was placed in somewhat of a sitting posture, so as to let the chin press upon the tumour ; and, whenever it attempted to cry, the swelling became more prominent. For the first eight hours the quantity of fluid in the trachea continued un- diminished, but the secretion then began to clear away, and, after twenty-four hours, there was no longer any crackling ; although the hoarse, laboured breathing continued so loud for some days afterwards as to attract tlie notice of any one entering the room. Attempts at deglutition during the fii'st twenty-four hours greatly aggravated the difficulty of respira- tion, but after that period both functions were performed with progressively increasing ease. During the first fortnight, whilst I had the child under frequent observation, there was no very marked change in the size of the swelling. Tliere had been a certain degree of congestion at the date of birth Pathological Varieties of Goitre. which, during this period, had subsided, so as to leave the neck of somewhat diminished circumference ; Lut the tumour remained firm, and by its protrusion attracted the attention of any one in whose arms the child was placed. But when, about four months afterwards, I again had an opportunity of seeing it, the tumour was diminished in size to about half its original bulk ; and, as the infant had thriven extremely well, and grown very fat and plump, he simply presented the ap- pearance of having an extra layer of fat in the roll of flesh beneath his chin. Such being the history of this case, let me offer some remarks on the disease of which it forms a specimen, under the heads of — I. Pathological Anatomy ; II. Etiology ; III. Prognosis ; IV. Symptoms and Diagnosis ; V. Treatment. I. PATHOLOGICAL ANATOMY. Of the various systems according to which it has been attempted to classify the different forms of goitre, or simple hypertrophy of the thyroid gland, probably the best is that which groups them into three orders, according as the enlargement affects its three structural elements — viz., the glandular substance, the blood-vessels, or the fibrous stroma. This is the classification adopted by Dr. Eulenberg,^ of Coblentz, who has had many opportunities of enquiring into the nature of the disease, and who designates the three forms as 1. Struma Glandulosa ; 2. Struma Vasculosa; 3. Struma Fibrosa ; and, as all the cases of congenital goitre of which we have an anatomical description can be ranged in one or other of these divisions, I follow in this short sketch his classification. 1. Struma glandulosa (str. lymphatica of some authors). — Congenital goitres, with but few exceptions, aU belong to this class. Eulenberg, indeed, would confine them to one of its 1 Pathological researches regarding the thyi-oid glaud. See British and Foreign Medico-Chirurgical Beviciv, xxvi. 540. 40 Intra-uterine Conditions of Foetus. varieties which he designates struma glandulosa parenchy- matosa, in which the surface of the thyroid is uneven, nodous projections alternating with softer surfaces, and in which " we find on section an irregular conformation of the parenchyma, some parts being hard and some soft ; the cut surface has a pale, dirty yellow and exsanguious appearance ; the softened parts show a tendency to disintegration. The acini may be of normal size, reduced, or enlarged, but their contour is always determined with difficulty ; the peculiar arrangement of the disintegrated cells and of the free granules in the form of an acinus alone determines the outline." But, though some of the cases may fall under this description, assuredly others of the intra-uterine goitres, such, e.g., as that figured by Albers,^ belong rather to the group which he describes as the struma glandulosa hypertrophica, " This is characterized," according to Eulenberg, "by a uniform enlargement of the thyroid, without any prominence or nodes ; the right lobe is usually more affected than the left. A section shows the acini to be uniformly and largely developed ; the surface of the section looks uniformly granular, and generally very red and vascular. This variety consists in a dilatation of the pre-existing acini, and in a new growth of acini." Sometimes the gland is equally enlarged throughout, so as to retain somewhat of its normal configuration. In other cases the isthmus is chiefly affected. More frequently the two lobes are s^Decially impli- cated, and may meet in front with almost no isthmus between, in which case they are apt to pass in behind the trachea at the same time so as to encircle it, and in some instances both trachea and oesophagus have been cauglit in its fatal embrace. In the rarest form only one of the lobes is enlarged, and if it then grows downwards among the structures of the neck, the nature of the case may not be easily recognised. Occasionally there are found to be one^ or more^ small additional goitres, ^ Atlas clcr Pathologischen Anatomic. Tab. xxv., fig. 8. * Sir J. Y. Simpson's case. ' Albers — Erlaiiterungen zu dcvi Atlasse dcr Fathologischen Anatomie, 308. Bonn, 1832. Pathological Varieties of Goitre. 4 1 or supplementary portions of the thyroidal structure lying in apposition with the main mass of the tumour, or separated from it and extending forward under the tongue. There is another variety of this class of goitres characterized by the development of cysts of much larger size, filled with contents of a more fluid description. These cysts seem to be due sometimes to the enlargement of a single acinus ; but in other cases, more particularly where they have attained un- usual dimensions, their size results from the destruction of the interlocular dissepiments and the fusion of several small cysts into one large cavity. Of this struma glandulosa cystica, or cystic bronchocele, although it is extremely common in the adult, I find reference to only one congenital case.^ 2. Struma vasculosa. We have but very few cases on record of this form of congenital goitre, probably from the circumstance of its being of a more transitory character. Bach^ describes the appearances seen in a case where the foetus was born dead, in consequence of delivery being too long delayed, and terminated at last by the aid of the forceps. "The thyroid gland had a deep brown appearance; it was more glistening and more elastic than usual, and had almost the consistence of a placenta which is removed when a cord is tied before being cut. The thyroid arteries and veins were gorged with blood. On incision of the tumour there flowed out a quantity of blood ; it resembled, up to a certain point, a piece of hepatised lung, or rather the pathological condition which Laennec describes in speaking of pulmonary apoplexy. A section of this gland was submitted to microscopic examina- tion before being macerated, but it was impossible to trace the glandular elements. After a maceration of two days, the blood had almost disappeared, and all the constituent parts of the gland could then be traced. A certain quantity of blood, however, remained in the vascular canals." Although occur- ring only with comparative rarity as a separate affection, we ^ Herniig — LehrbiicJi der Krankhcitcn dcs Kindes. S. 206. Leipzig, 1855. ^ Memoires de V Academic do Midccinc, xix. 347. 1855. 42 Intra-tUerine Conditions of FoettLs. not mfreqiiently see this vascular variety — at least in its stage of excessive congestion — complicating the more common form of congenital goitre. Such, I doubt not, was the case with the infant whose history I have narrated ; and such was shown by post-mortem examination to have occurred in a fatal case related by Dr. Maurer,^ who found both lobes enlarged and of a brown red colour, and the veins passing down from the gland greatly swollen, some of the vessels being distended with dark blood to the thickness of a goose quill. 3. Struma fibrosa — characterized by a hard and commonly uniform tumour, ordinarily occupies only one lobe of the thyroid body, and has not, so far as I am aware, been met with as a congenital affection. ir. ETIOLOGY. Without entering on the wide and much debated question, as to the cause or causes of the prevalence of goitre in certain districts, I remark, first, that, in the writings of those who are treating of the endemic relations of the disease, there is occasional reference to its occurrence in the congenital form. Fodere^ was furnished with several exam- ples by the clergymen of the different Swiss valleys which he visited, and had himself an opportunity of seeing three. In Strasburg, where the disease is endemic. Professor Tourdes^ found at one time that, in the Maternite and the Creches, out of thirty-one infants there were three with congenital hyper- trophy of the thyroid gland. In a report^ on the health of the population of the Eussian empire, during the year 1855, it is noted that, in Kirensk, a district where goitre prevails, the disease is sometimes met with in new-born infants, and occasionally causes death by suffocation. Bach's^ observa- ^ Journal fiir Kindcrkrankhcitai xxii. 357. 1854. 2 TraiU du Gotlre ct du Crctinismc, 1808, p. 68. ^ Gazette dc Strasburg, 7. 1854. Schmidt's Jahrbiichcr, 85, 1855, p. 225. * Schmidt's Jahrbuchcr, 94, 1857, p. 368. •'"' Loco cit. , p. .373. Etiology of Congenital Goitj^c. 43 tions lead liim, with P. Frank, Bauer, and Eappe, to believe congenital goitre to be very frequent in countries where it is endemic ; and the same remark has been made by some of our own countrymen who have had an opportunity of study- ing the disease in the goitrous districts on the sides of the Himalayas, Thus, Mr. Bramley, in an essay on the Bron- chocele of Mpfd^ says: "No period of life is exempt from the disease. Children are sometimes born with it, as are also animals. Several instances of the latter occurred during my residence at Nipal ; on one occasion a goat brought forth a kid with a goitre as large as its head." Then, secondly, some of these authors speak of congenital goitre, as occurring not only endemically, but as if, at the same time, it were always hereditary. And Betz, after relating the history of a fatal case,^ adds "the mother had likewise a considerable struma lymphatica (goitre), which was always the case wherever I have met with goitre in new-born children." In his more complete essay on the subject,^ he tells of a family in which a mother, who was herself affected with goitre, gave birth to two infants who died in succession of the congenital disease. That it is largely due to hereditary constitution, there can, therefore, be no reasonable doubt. But, thirdly, in some instances it is quite impossible to trace any influence either of a hereditary or endemic nature. In the case which I have here recorded, both parents were healthy and perfectl}' free from any trace of thyroid enlarge- ment; and the infant presented the only instance of the disease which I have yet witnessed in this locality. In Dr. Keiller's case,* the mother of the cliild was born and brought up in the county of Cumberland, where goitre is not un- ^ Transactions of the Medical and Physical Society of Calcutta, vi. 195. 1833. 2 Journal fur Kindcrkranlcheitcn, xxv. 125. 1855. '^ Henle und Pfcnfcr's Zeitschrift fur rationcUe Medicine, ix. {erste Rcihc), 236. 1850. ^ Edinburgh Monthly Journal of Medical Science, 350. 1855. 44 Intra-iUerine Conditions of Foetus. common; but, although she had been affected to a slight degree at the time when she began to menstruate, it had soon passed away and left no trace. This was her first child, and she has since liorne two others, who showed no trace of thyroidal disease. In Sir J. Y. Simpson's case it was equally impossible to trace any endemic or hereditary influence. In this case, as in mine, however, I remark that the mother of the goitrous infant had been taking chlorate of potash through- out her pregnancy ; not that there is any probable relation- ship of cause and effect between the use of the medicine m the parent and the production of the disease in the child — for many infants have been born under the same con- ditions in whom the gland appeared perfectly normal — but, because every individual fact in connection with a form of disease so rarely observable among us seems to be worthy of note. Sex, as is well known, exerts a remarkable influence in the proclivity to disease of the thyroid, in individuals who are approaching the age of puberty. This comes out very clearly, e.g., in the report of the children's hospital at Dresden by Dr. Kiittner,^ who shows that out of the whole number of goitrous children under fifteen years of age, three-fourths were girls. Up till the eighth year of age the number of boys and girls is nearly equal (15 b., 17 g.), but from that date onwards the proportion changes, so that in the aggregate there are nearly four times as many girls as boys affected with the disease between the ages of eight and fifteen. The cases of intra-uterine goitre in which the sex has been noted, are too few to draw any definite conclusion from them ; but, so far as they go, they show that as in the case of children under eight years of age, sex does not materially influence the liability to the disease. For out of ten cases tabulated on p. 46, six of the infants were males, and four females. It is to be remarked that in the excessive development of the tliyroid glands in girls at puberty, we see simply morbid ^ Journal fi'ir Kimlrrkranlclicitcn, xxv. 3. 1855. Sex of Goitrous Infants. 45 exaggeration of a physiological phenomenon ; and perhaps we might be able to trace out a parallel history in the develop- ment of intra-uterine goitre if we had a more perfect history of the normal development of the gland. It would be inter- esting in this way to ascertain some of the congenital goitres to represent merely a permanence, perhaps in an exaggerated degree, of a condition that is perfectly normal in the intra- uterine foetus ; and this, I am inclined to think, is probably the true history of the disease in the more transitory cases. The thyroid gland, instead of presenting the size which is usually seen in the perfectly developed infant, retains the relative size proper to it in an earlier stage of growth ; and, as the circulation in the neck is greatly interfered with by the flexion of the head during its transit through the maternal passages, the gland becomes the subject of such a degree of turgescence as to give it a truly goitrous character. We should require to be more fully acquainted, however, with the normal course of development of this body before dogma- tising on its pathological degenerations ; for, whilst it is some- what vaguely stated (Bach) that it attains its largest size as the period of birth approaches, we know that in a foetus, about the eighth month, a goitre may already be developed of such a size as to cause great deformity (Mondini), or, if the child be born alive, to cause its death within a few hours after de- livery (Sir J. Y. Simpson). III. PEOGNOSIS. The enlargement of the thyroid gland, which, in the adult, is simply an object of dislike from its deformity, becomes in the new-born infant an object of dread from its fatality. The high degree of its mortality will be at once evident from a reference to the following Table of Cases of Congenital Goitre, showing the proportion of deaths and recoveries : — 46 Intra-uterine Conditions of Foetus. Sex. Repoeters. No. of Cases. Deaths. Recoveries. Male. Female. Albers («) . 1 1 Bach (a) 3 2 1 2 Betz («.) 3 3 3 Ci'igliton («) 3 2 1 FeiTus (6) 1 Frbbelius (c) 1 1 Hedenus (rf) 1 Keiller («) 1 1 Kiittncr (c) 1 1 Maurer («) 1 1 Simpson, A. R. (/) 1 1 Simpson, Sir J. Y. («) 1 1 Spiegelberg {g) 3 2 1 Weber (7t) . 1 1 22 6 4 15 7 Such a Table will not, of course, afford us an absolutely correct idea of the relative proportion of cases in which con- genital goitre proves fatal to the subjects of it ; for, in countries where thyroid disease is endemic, many infants may be born with goitres which are of so trifling a nature as not to come under medical observation at all. But it shows at the same time clearly enough that the congenital affection may prove highly formidable ; and it becomes, therefore, a matter of some moment to inquire Wliat are the causes of tlie fatality of this disease ? When the thyroid gland begins to take on a morbid degree of deve- (a) Loco citato. (h) Dictionnaire de Medicine, x. 283. Paris, 1824. (c) Petersburger Mul. Zcitschrift, 1865, ii. 175 ; and Centrcdblatt fiir die Medicinische Wissenschaften, 1866, iv. 128. ((•/) Hassc's Pathological A natomy. (Sydenham Soc), 386. (c) Journal fiir Kinderlrankheiten, 1865, xxv. 2. (/) Page .38. (;/) WUrzhurrjcr Mai. Zlschr, v. 160; and CcntridUatt f. a. Mai. Wis.. 1804, ii. SiU. (/i) licitrdgc turn, Pathologischen Anatomic der Netigcborencn. Simpson's Obstetric Wovk.s. Fatality of Congenital Goitre. 47 lopment at the age of puberty or at any more advanced period of life, its growth, at least in the mass of cases that ulti- mately prove fatal, is extremely slow, and the cartilages of the larynx and trachea have already become sufficiently consolidated to fortify the rigid tube against the immediate effects of pressure. But in the foetus in utero the enlarging gland finds no such resistance from the tender walls of the air-tube ; and as the functions of that organ are not called into play during intra-uterine existence its caliber may be encroached upon to any extent without the least danger to fcetal life. The instant, however, that the foetus is de- tached from the mother, and compelled to respire by the lungs instead of the placenta, the hitherto innocuous tumour presents a fatal barrier to the accomplishment of the earliest function of its independent existence. Eespiration can only be imperfectly effected through the compressed trachea, and every convulsive movement of the infant only aug- ments the difficulty, by leading to increased congestion of the thyroid gland, and so to increased compression of the tube that lies in its embrace. I speak of its embrace, because, in a large proportion of the fatal cases, the tumour encircled, more or less completely, the trachea ; and, in some of the instances, the danger to life was rendered all the greater from the compression exerted at the same time on the oesophagus. In this way the infants, that escaped the immediate dangers of suffocation, became exposed to further risk from the impediments offered to the function of degluti- tion (Albers). The degree of danger is not always commen- surate with the size of the growth, for a tolerably large goitre may cause but little difficulty of respiration if it be confined to the isthmus (Betz) ; while a tumour so small as almost to escape the observation of the physician, may become the cause of death (Bach). Betz^ avers, I may add, that the point where respiration gets impeded is not the larynx nor the upper part of the trachea, but the entrance into the ^ Journal far Kindcrkranklidtcii, xxi. 162. 48 I ntra-uterine Conditions of Foetus. laryngeal cavity wiiicli becomes narrowed by the projection of the thyroid into the mouth : while Bednar^ attributes the obstruction to paralysis of the muscles that dilate the rima glottidis. But, whatever be the explanation, this much is certain, that some infants, born with goitre, die immediately from the impossibility of respiration ; others perish within a quarter of an hour or an hour after birth from the imperfect fulfilment of the function ; and even when they have breathed somewhat more fully, and have survived for four, eight, or thirty-six hours, or even for three (Spiegelberg) or foui- days (Betz), they have eventually died in consequence of the im- peded respiration. In the non-fatal cases, the congestion, which seems to exist to a greater or less degree in all at the moment of birth, begins gradually to subside as respiration becomes established, so that after a few days the tumour is sensibly diminished in size, and, in those cases where the enlargement depends on an excessive turgescence of the vessels alone, the tumour may during that period have entirely disappeared. Even where there has been some glandular hypertrophy as well, the gland in most instances becomes diminished in six or eight weeks to its normal dimensions. In some cases, however, absorption does not set in till a later period. Thus (Bach) tells of one in which the tumour, two months after birth, remained to all appear- ance unchanged : the infant had a habitually impeded respira- tion, slightly blowing in character, and becoming stertorous when he cried. I had an opportunity lately of examining Dr. Keiller's former patient, who is now upwards of eleven years of age, and in whom no one, without having attention specially directed to it, would notice anything peculiar. He has, however, a slender, lady-like neck, and, when he throws back the head between the shoulders, an abnormal projection of the thyroid becomes apparent, and to the touch the body still feels somewhat larger than it ought to be. 1 Lchrhuch dcr Kindcrkranklwitcn, 290. 1856. Symptoms of Congenital Goitre. 49 SYMPTOMS AND DIAGNOSIS. Before labour sets in there is no symptom that could lead us to suspect an enlargement of the foetal thyroid gland ; but the moment a goitrous infant is expelled from the maternal passages, the existence of the tumour is mani- fested. 1. Sioclling of the Neck. — A rounded swelling of variable thickness is seen running across the windpipe, and filling up more or less completely the space between the chin and sternum. In the least-developed cases it gives an appear- ance as if it were a double chin, of which the lower fold had rolled a little way down the neck ; and from this it may give rise to varying degrees of deformity, according to the increase of its size, and the extent to which one or other of the lobes becomes specially affected. Perhaps the greatest degree of deformity was produced in the case of an eight months' foetus, which had been alive to a very short time before its birth, and was born with a bronchocele, regarding which Pro- fessor Mondini^ records that, " Commencing above at the margin of the lower eyelid, and hideously pushing up the nose and the mouth, it extended laterally, and, protruding the lips, descended of an enormous size down to the lower apex of the sternum, constantly tending more to the left than to the right." 2. Impeded Res-piration. — Even in the cases where the en- largement of the thyroid is least indicated by its superficial prominence, the peculiar character of the respiration speedily betokens the presence of the abnormality. Sometimes, as I have said, the function is so utterly in abeyance that the infant perishes at once. Or, if air does reach the lungs, it is only at the expense of violent inspiratory efforts, during which the facial muscles, as well as those of the extremities, are thrown into convulsive action ; and the air passes in and out with a short, harsh, rushing sound, which may be audible a British and Foreign Mcdiccd Journal, Tiii. 229. 1841. D 50 Intra-titerine Conditions of Foetus. long way off. This impediment to breathing is such a con- stant attendant on enlargement of the thyroid body, that, as I have already stated, it is often the first phenomenon that strikes the observer. Hence, as in treating of disease of the thymus gland, writers have spoken of thymic asthma; so, here, the disease in question has sometimes been denominated simply thyroid asthma. This harshness and difficulty of breathing never altogether intermits, though, during sleep, it may remit to a certain extent. Another point of interest in connection with the breathing is, that there is always a crackling or gurgling sound superadded to that from the rush of air through the constricted canal. In many children at birth a rattle in the throat gives evidence that some viscid fluid has become lodged in the cavity of the larynx, and in a few minutes it has all cleared away. But, in the goitrous infant, the imbibed fluid has not had time to pass off ere its place is taken up by a fresh, frothy secretion, which renders respiration still more difficult, and which comes to form of itself almost a distinctive feature of the disease. This foam sometimes fills the mouth and escapes at the angles (Bach, Betz); and is supposed by Bach to be due to the pressure exerted on the pneumogastric by the hypertrophied gland, because of its resemblance to the excessive bronchial secre- tion that is seen in animals which have been subjected to section of that nerve. It seems to contri1)ute in no incon- siderable degree, as I should have before remarked, to the fatal issue of the malady, from its accumulation at the glottis (Bach), or in the trachea below the point of constriction (Maurer). But, in addition to the interference with respira- tion, there has also occasionally been noticed a marked de- gree of 3. Difficulty of Deglutition. — Tliis is not by any means such a constant and formidable symptom as the interference with respiration ; yet in some cases the power of suction is alto- gether destroyed, and when fluid is introduced into the mouth of the child, the imperfect attempts to swallow it greatly aggravate the respiratory troubles. Deglutition becomes Diagnosis of Congenital Goitre. 5 1 utterly impossible in those cases where the two horns of the enlarged thyroid pass round behind the cesophagus and meet together between that tvibe and the spinal column ; and if in such a case the infant were to survive the impediment to respiration, it must infallibly die of inanition. Such a con- dition of matters is rare enough, but, even in the simpler cases, it is worthy of remark, that it is only after repeated attempts at swallowing the milk passes the point of con- striction. Of the cyanotic colour and coldness of the hands, feet, and lips, and the anxious expression of countenance, I do not s^Deak particularly, because those and other similar symptoms will at once suggest themselves to the mind as being neces- sarily associated with the imperfect fulfilment of the respira- tory function. Nor do I now detain you with a discussion as to the differential diagnosis of the fatty tumours, ranulse, hygromata,^ enlargements of the lymphatic glands, abscesses, or other swellings of the neck with which goitre may be confounded ; but remark merely that, having in view the special symptoms which I have just described, a short exami- nation of the tumour, in almost any case that may come be- fore us, will be sufficient to establish a correct diagnosis. The skin over the growth is of normal colour, and moves freely over it ; the tumour is felt exactly in the site of the thyroid gland, and, even when it grows more towards one or other side it can always be traced back to its primitive rela- tionship, and can be felt moving more or less distinctly in accordance with the movements of the larynx. TKEATMENT. There might be much room for discussion as to the treat- ment of bronchocele in the adult, but with regard to the treatment of the congenital affection I fear there is not much to be said. Wliere respiration is at all possible, it will cer- ^ Storch. Uchcr das Angeborcnc Hygrom des Halses, in the Journal f. Kmdc7'kraiikheitcn, xxxvii. 68. 1861. 52 Intra-uterine Conditions of Foetus. tainly be facilitated to some degree by extending the head, and so putting the infant in a more favourable position for breathing than when the chin is allowed to press on the tumour. In the non-fatal cases iodine has been administered and applied in various forms and combinations internally and externally, but it may be questioned how far its use has con- tributed to the cure, and it admits of no doubt that in some instances the goitre has entirely disappeared where the remedy had never been employed at all. In the more alarming cases, leeches have been applied with the view of relieving the con- gestion, emetics have been given because they are useful in other respiratory troubles, and a tube has been passed through the narrowed canal so as to permit the entrance of air to the hmg. But none of these measures have served to avert, or even greatly to retard the fatal issue. In short, the sum of all our observations in regard to the treatment of congenital goitre amounts pretty nearly to this — that in the desperate cases we can do nothing, and in the milder instances nothing needs to be done. HYDEONEPHEOSIS.i The urinary organs of the foetus in utero are subject to three varieties of morbid change, either of which may produce such an enlargement of the trunk of the child as to complicate, in a greater or less degree, the process of parturition. 1. The kidneys may be hypertrophied 2. They may have under- gone cystic degeneration. 3. Their excretory canals may be dilated in consequence of an obstruction in some part of their course. I. — SIMPLE HYPERTROPHY OF FCETAL KIDNEYS — MAKRONEPHRIA — seems to be extremely rare. A very interesting case is Glasrjoio Medical Journal, New Series, ii. 332. Makronephi'ia and Renal Cystoma. 5 3 related by Hecker and BuliP wliere this condition of the kidneys was found associated with hypertrophy of the tongue, and umbilical hernia. There were no cysts or hetero - logons degenerations of any kind in the kidneys : but an excessive development of the Malpighian pyramids, each of which seemed to be formed of groups of little pyramids, separated from each other by a fine connective tissue. The only other instance of the disease with which I am acquainted occurred in the practice of Dr. Key, of Arbroath, who kindly sent me one of the kidneys, which I showed to the Obstetrical Society of Edinburgh.^ This foetal kidney was more than twice the average size of the organ in the adult ; and this enlarge- ment seemed to depend on a simple hyperplasy, affecting chiefly the intertubular connective tissue. In neither of these cases did the ureters or bladder present any peculiarity. II. — CYSTIC DEGENERATION OF THE ECETAL KIDNEYS is not SO uncommon, for, though cases are not of very frequent occurrence, they find mention in many obstetric works, and in most of the recent treatises on renal diseases ; and their patho- logical anatomy has been very satisfactorily worked out by Virchow^ and the late Dr. Beckmann,^ whose observations and deductions have been confirmed and adopted by Drs. Erichsen,^ South,'' etc. The whole of both organs in the typical cases become converted into a mass of cysts, which are developed partly from occlusions of the tubuli uriniferi, leading to the accumulation of fluids in small loculaments ; and partly from the development of cysts in the connective tissue of the 1 Klinik cler Gchurtskundc, 127, 322. 1861. ^ Edinburgh Medical Journal, viii. 89. 1862. •^ Gesammeltc Ahlmndhmgcn, 833 and 860. See also his Vorlcsungcn ilhcr die Krankhaften Geschtvillste, 270. ■* Virchoid's Archiv fur Pathologischc Anatomic und Physiologic, ix. 221. 1856. xi. 121. 1857. ^ Virchovfs Archiv, xxxi. 371. 1864. ^ St. Bartholomew'' s Hospital Ecjjorts, ii. 12. 1866. 54 Inti'a-uterine Conditions of Foetus. organs. As the iuclividual cysts grow and press upon each other, the septa between get broken down so as to form larger cavities. The renal pelvis and the ureter are ordinarily free in such cases ; but the secreting power of the organs is for the most part destroyed, so that the foetus is incapable of extra- uterine existence. III. — HYDEONEPHEOSIS. The third variety of congenital enlargement of the glands is that which results from such obstruction to the escape of their secretion as leads to dilatation of the kidneys themselves, their cavities and canals. For this morbid condition, as studied primarily in the adult, the designation " Hydronephrosis," first applied by Eayer,^ is generally adopted in preference to the other appellations " Physconia renalis " (Sauvages^), "Hydrops renalis" (Eudolphi and Franz^), "Expansio renum" (Euysch^), " Hydrorenal distension" (Johnson*), or "the Encysted Kidney" (Roberts^). It presents itself in different degrees, according as one or both organs are implicated, and the occlusion occurs at a point more or less remote from the renal pelvis. (1.) One, Kidney alone affeetcd — Cases have been related by Billard,*^ Dehn,^ Horne,^ Glass,'' Forster,^*' Cruveilhier,^^ Yrolik,^'^ and others, wliere the hydroneplirosis was single ; the obstruc- tion occurring only in one of the ureters and the distension ^ Maladies des Ecins, iii. 476. " Nosologia Mcthodica, ii. 480. ^ Roseiistein. Die Patholoejie und Tlierapie dor Nicrcnkranlchcitcn, 351. * Meclico-Chirurgical Journal, ii. 10. 1816. •^ American Journal of the Medical Sciences, ii. 388. 1841. <* TraitH des Maladies des Enfans, 431. Paris, 1833. ' Monatsschrift fUr Gchurtskumlc, xxiv. 184. 1864. ^ Bonelus Se^mlclirctum, ii. 290. ^ Philosophical Transactions, xliv. 337. ^'^ Die Misshildungcn des Menschcn, 127. Atlas. Taf., xxiii. 19. " Train d' Anatomic Patholorjiqur, ii. 341 ; iii. 871. Atlas, livr. vi. ;>^. 4: M- 3. ^- Talulac ad lllustrandam Embryofjenesin, alarmed the patient, and made lier feel faint. The whole uterus had now settled down a little into the pelvic brim. The foetal heart was active, and the foetus was still in the right occipito-posterior position, with the head presenting. The soft canals were more relaxed, and undergoing vital dilatation. The cervix was easily permeable to the finger, which found its upper extremity entirely occupied by placental tissue. The uterus had begun to act, but the pains were feeble and the intervals prolonged. But when, with stronger pains, there began between seven and eight a new flow of blood, though of slight extent, I introduced the largest size of Barnes's dilators into the vagina, and distended it to its utmost with warm water. The contractions became more vigorous and frequent, and no blood flowed past the tam23on. Between nine and ten Dr. Hart came to assist me, and to take my place while I went to lecture. At this time I removed the large vaginal dilator. Its removal was followed by the escape of some clots and a quantity of serum. The cervix had become more expanded, and a bare portion of the membranes could be felt towards the right side, corresponding to about a third of the dilated orifice. Five grains of ergotin were now injected hypodermically. The second largest of the Barnes's dilators was carried through the os internum. During the introduction some hsemorrhage occurred from partial detach- ment of the placenta. The bag was quickly distended to an extent suiScient to make it fill and stretch the canal. From time to time more water was thrown into it, and when I returned after lecture, soon after noon, finding it dilated to its utmost capacity, we removed and replaced it with the largest sized one. The foetal heart was still beating normally, though the mother's pulse had already become frequent and weak. The large bag having been distended to its utmost, the uterine action being regular, though not very strong, and the parturient canals sufficiently dilated and relaxed to allow of the active interference which was demanded by the tendency to recurrence of the haemorrhage, the patient, who had 74 The Placenta. already breathed some chloroform to relieve the pain caused by the introduction and pressure of the hydrostatic dilators, was now more completely narcotized. Judging, whilst the mother lay on her left side, and the face of the child was turned in the same direction, that the right hand would most naturally pass along the anterior aspect of the child, I chose it for internal manipulation. In passing into the cavity of the ovum, I made my way partly through membranes and partly through the placenta, the 1\ inches deep rent in the margin of which still remains. There was no difficulty in seizing and bringing down the left leg, and effecting the version of the child. Considerable tractile force, however, required to be applied to bring down the breech, with the right leg folded on the abdomen through the passages. The cord was still pulsating, but feebly, when the trunk was exposed. The arms had gone up by the sides of the head. As the child was making attempts at inspiration, the arms were quickly freed, and the head easily followed, steady pressure being kept up on the fundus uteri by Dr. Hart. When fairly born the child seemed to be quite still, and the heart-beat was slow and weak. Under friction of the chest it at last made a feeble effort at inspiration, but no air entered the tubes. It was suspended by the heels, and whilst the throat was being cleared out in this position it made another and more successful effort. The head and heels were alternately elevated and depressed until it had made inspirations enough to make us feel sure that the blood was getting aerated. It was laid on its back, and allowed to breathe quietly, until of itself it began to cry. All this at the edge of the bed before its complete separation from the mother. The cord was now tied and divided. Meantime another subcutaneous injection of five grains of ergotin had been administered to the mother, as the uterine walls remained flaccid, and a slight but continuous escape of blood was going on. Some fifteen minutes or more had elapsed since the birth of the child, and it was disappointing to find that no progress was making witli the third stage. Primiparal Placenta Pr(^via. 75 Powerful compression of the uterus through the abdominal walls, which so rarely fails to give us the placenta, failed here, so that the hand had to be once more introduced into the uterus to detach it. I was surprised to find the placental area so extensive that the upper border of it reached high up the left side and posterior wall of the uterus, and remarked that to this wide extent of the placenta it was probably owing that the vitality of the fcetus had been sustained. After I got the placental mass lying loose in the right hand, I still kept it for a considerable time in the interior of the uterus, and continued to compress the fundus with the left hand until the uterus began to contract steadily and strongly enough to expel all its contents. A third subcutaneous dose of five grains of ergotin was administered during this time, and after the uterus was emptied it contracted firmly, and there was no further notable haemorrhage. It was now seen that the perineum had been torn back close, but not in to the anus." There was also a trifling laceration, or rather two, in the cervix uteri, but not more than we may see in any first labour, and less than we often meet with in natural labours. Two metallic stitches were introduced pretty deeply through the perineum, and secured at the skin surface. It was now two o'clock when the patient was tidied and left to rest. She was quite blanched, and very prostrate, and the pulse rapid and weak, but quite steady. Tlie ^uerperium : — IWi Decemher, VesjJ- — Pulse 120; temp. 101°. Has taken milk and beef-tea. Urine drawn of with catheter. 22d December.— Vxjlse 120; temp. 102°. Vesp.—TvUse 120 ; temp. 103°. Some tenderness over abdomen. To get turpentine stupes, and 1 mm. aconite every hour. 2od Deccmher. — Marked tympanitis, but no great pain. Pulse 120; temp. 103°. To have local treatment continued, and to take 8 mm. of turpentine thrice daily in milk. Milk and beef-tea to be continued, and a tablespoonful of brandy given every hour. Vesp. — Pulse 120 ; temp. 104°. Ten grains of qiiinine given. 76 The Placenta. "lUh to 2Wi. — Same as 23d. Evening temperature still 104°, and unaffected by quinine. Some diarrhoea on 27th; checked by lead and opium pills. To get aconite instead of quinine. IWi, Vesjh — Seems easier, and temperature now 102" ; pulse 108. Tympanitis continues. Stitches removed. Partial union. SOth December to od January. — Improvement now steady, and temperature falling. During the first three or four days morphia was given at night. On the 24th the amount of brandy was doubled. Quinine seemed to have little effect on the temperature. Aconite was much more useful, as seen by record of 29th. There was never any pulmonary nor cardiac disturbance. Urine was made freely, but generally with pain. From this point on, the patient had a rapid convalescence. The only drawback was that on 1st January, the day when she first was taken into the dining-room, she had pain in the calf of the left leg, and a wooden feeling in all the muscles, which made me apprehensive of phlegmasia. Under careful massage, however, and the administration of tincture of the muriate of iron, the threatening passed off', and she is now quite well. As for the infant, it ought to be recorded, that the day after its birth its left leg was found to be greatly swollen ; there were abrasions of the skin above the malleoli ; and the limb hung stiffly from the pelvis. I was satisfied that there was no injury in bone or joint ; but I believe that laceration of some of the structures in the upper third of the thigh had taken place. The swelling was there very great, so that the skin became quite tense, and it looked blue, as from ecchy- inosis underneath. For a week the limb remained swollen and straight, but the swelling gTadually subsided. The muscular power of the limb was restored, and now the infant, which is thriving on the milk of a wet nurse, moves the legs as naturally as if no damage had ever been sustained. Pri7iiiparal Placenta Prcevia. yy SECOND CASE OF PRIMIPAKAL PLACENTA PILEVIA.^ The history of the next patient I give in the words of Dr. Hart. Mrs. B, set. 37, married in January 1878, was first seen and treated by Dr. Simpson for endometritis and left perioophoritis in the end of the same month. Under suitable treatment the inflammation subsided. She was seen again in ]\Iay, when she was found to be two months pregnant. During her pregnancy there was nothing unusual unless occasional attacks of acute bronchitis. On 10th December I was sent for, and found that a day or so before she had passed some blood per vaginam, owing, as she thought, to the violence of her cough. External palpation showed that the liead was at the brim, with back to rifrht side. No foetal heart sound was audible. On vaginal examination the cervix was touched with difficulty, the os was found small, and the head could not be felt. She was ordered to take rest, and sedatives were given to allay the violence of the cough. i\.fter that she was seen every day, but no more bleeding occurred until the loth, when slie suddenly lost a considerable quantity. I saw her soon after, and found the vagina full of clots. There were no irregularities in the uterine wall, but the cervix was susjoiciously boggy. A sponge-tent was intro- duced with difficulty into the os, which was only about the size of a pea. Dr. Simpson saw her then, but was unable to pass his finger into the os owing to the presence of the tent. He remarked on the bogginess of the lower segment of the uterus and other features in the case as pointing to placenta prsevia. The sponge-tent was left in for twelve hours, and when removed the os easily admitted three fingers. The ])lacenta was then found lying partially over the os internum at the left side. Barnes's dilators were now used, and at four o'clock on Monday afternoon I turned by the bipolar method and brought down a leg. Ptepeated auscultations had failed to catch the fcetal heart, and I therefore did not extract at once, but left the case under Dr. M'Watt's charge so as to ^ Edinhurgli Medical Journal, xxiv. ^larch 1879. y8 The Placenta. allow the parts to dilate well. At eleven o'clock no pro- gress had been made in the labour, and therefore, while the patient was under chloroform, I passed up my hand and found that the other leg had become doubled up in the brim and thus caused the delay. It was brought down, and the child extracted with difficulty. After waiting for about fifteen minutes, and employing manual compression to the uterus, the placenta did not descend. On examination I found it adherent in about its upper two-thirds, and accordingly had to separate it manually. After this there was no bleed- ing, and the patient made a good recovery, delayed somewhat, however, by her bronchitis. Remarks on foregoing Cases. THE RELATIONS OF PLACENTA PRyEVLV AND PRIMIPARITY.^ Sir James Simpson ^ has directed special attention to the rarity of placenta prsevia in cases of first labours, and the statistics he has collected show a proportion of only 1 1 primi- parous to 136 multiparous patients suffering from this com- plication. This gives a proportion of 1 to 12|. Kuhn^ gives the proportion of 6 primiparae to 40 multiparse with placenta proevia, or a ratio of 1 to 6§. In the extensive series of cases tabulated by Dr. Eead in his work on Placenta Prmvia,^ I find 428 where the number of the pregnancy is given. Of these 65 were primiparte and 363 multiparse, which gives us a pro- portion of 1 to 5i. Ludwig Miiller, in the most recent trea- tise ^ on this subject, finds among 1574 cases of placenta prsevia, 227 in primiparte, or 1 in 5^^. This comparative rarity in primiparous patients may well indicate, as Sir 1 Edinhurgh Medical Journal, xxiv. March 1879. - Selected Obstetrical Works, 282. •' Quoted in Sclirocder's Gchurtshiilfe, 558. •» Placenta Pra:via : Its History and Treatment. ?>y William Kead, M.D. Philadelphia, 1861. ^ Placenta Pravia, die vorliegende Nachgchurt : ihre Entwickelung und Bcliandlung, 151. Stuttgart, 1877. Rarity of Placenta PrcBvia in Primipara;. 79 James,^ with his usual richness of suggestion, has hinted, that it has to do with " the cause or causes leading to the origin or production of that deviation in the site of the de- velopment of the placenta which constitutes placenta prsevia," Let us inquire into 1. The Cause of this Rarity. — From one of the conditions which favour the prtevial implantation of the placenta, the primiparous patient is entirely free. I refer, of course, first, to the dilatation of the uterine cavity and diminished tonicity of the uterine walls, that are apt to remain after a previous pregnancy, the deleterious influence of which is more marked when the new conception follows quickly on the preceding labour, or when some degree of sub-involution has remained. But, secondly, the primigravid female is less likely than one who has already borne children to have been the subject of the chronic inflammatory affections of the endometrium, that not only lead to change in the form of the uterine cavity, but impair the functions of the mucosa at various parts, and unfit it for the easy engrafting of the ovum in the most favourable zones. Again, thirdly, as we have seen that retroflexion of the uterus is rarely met with as a primary cause of sterility, whilst it is a not infre- quent affection among women who had given birth to a fer- tilised ovum, so we can see that its tendency to modify favourably the site of the placenta will be less marked among primiparous than among multiparous women. And, fourthly, the injurious influences of organic disease of the uterus on the' placental implantation will be less likely to be met with in first than in subsequent pregnancies. Probably the age at which women usually conceive for the first time protects them from the conditions which favour the- production of placenta ])reevia, and a point which is worthy of very special note is — The Age of Primiparm affected with Placenta Prcevia. — This is a subject which, so far as I know, has not been looked at hitherto. In the tables of Dr. Eead, from wliicli I have Loco citato, 283. So The Placenta. already drawn, I find the ages of 33 of the primiparous cases of placenta prtevia are given. If to their nnited ages we add that of the patients whose cases I have recorded above, we get 28| years as the average age of the women who were affected with placenta prsevia in their first labours. Five of the thirty-five were 40 years old and upwards, only four were 20 and under. How are we to interpret this marked partiality of placenta previa in primiparous women for those whose first labour comes on at an advanced age ? It may mean that m a young married woman some morbid condition has arisen which has delayed conception for some years, until the usual dates of primiparity were passed ; and continued to exert a prejudicial influence upon the progress of the pregnancy, par- turition, and the puerperium. I have seen illustrations of all these. But it may be read another way. The longer a woman lives before being married the more chances she has of becom- ing the subject of some morbid condition which, now that she does marry, either prevents conception, or mars the normal development of the ovum, or lays the foundation for some anomalous labour, Tlie cases of the two patients, whose his- tory I here record, points to an explanation in this direction for Mrs. A was 31 years of age before she was married, and Mrs. B was 35. 2. Fatality of Primvparal Placenta Prmvia. — As in natural labour, and indeed in all varieties of labour, so here primi- parity tells injuriously on the prospects both of the mother and the child. \8t, Mortality among the Mothers. — We can easily under- stand how the less easily dilatable canals of any primiparous woman will make the delivery in placenta prtevia both more; difficult for the practitioner and more dangerous for herself. The diliiculty and the danger only become more obvious when we remember tlie advanced age at which we find it so fre- <|uently occurring. The general maternal mortality in all the cases of placenta pra'via collected by liead^ amounts to 1 in 1 Loco citiit,,, 12. Fatality of PjHmiparal Placenta Prcsvia. 8 1 4|. There are 1628 cases altogether, with a mortality of 380, or 23'3 per cent. Among primiparous cases the mortality rises to 1 in 3|-. Of the 65 cases, 18 died, or 27'7 per cent. 2d. Mortality among the Children. — The proportion of the children that are lost in placenta prsevia cases is startlingly high. From Bead's statistics we gather, in taking all the cases where the result to the child is given, that the deaths exceed the survivals by nearly twenty per cent. In 854 cases there were 508 dead children, giving an infantile mortality of 59*5 per cent. The proportion of fatal cases among the in- fants also becomes much greater when the mother is primi- parous. In 56 first labours, where the result is given, 39 of the children were dead, giving a mortality of 6 9 "8 per cent. The record is all the darker when we note in the column of " remarks," that in three of the cases the children died within " a few hours," " next day," and " in three days ;" and, if we transfer these from the survival column to the black list, we get a mortality among the infants of 75 per cent. This mortality among the infants is partly due to the circumstance that the labour so often comes on prematurely; most of the first-born children that survived, so far as we can learn from Bead's statistics, having been carried till the 8th or 9th month : only one was born at 71 months. I would only add with respect to the injury of the in- fant's leg, that it was new to me to observe the lacera- tions of the muscles and vessels that had obviously taken place. But then the infants brought into the world under similar circumstances are most frequently dead as we have just seen. Hence, though such injuries may have been inflicted on them, we have no vital reaction to betray the mischief. PECULIARITIES OF THE THIRD STAGE IN PLACENTA PRiEVIA LABOURS. I may be allowed, in passing, to make some observations on F 82 The Placenta. the peculiarities in the third stage of labours complicated with placenta pnevia. These observations hold good for placenta praevia cases in general as well as for primiparal placenta prsevia cases, although I am led to make them from the cir- cumstance that in both our cases it was found necessary to extract the placenta artificially. 1. Common Necessity for Sliortening the Tliird Stage. — To begin with, we can rarely afford to allow any lengthened in- terval to elapse in such cases between the birth of the child and the complete evacuation of the uterus. The loss of blood which the patient has sustained during the first stage of the labour may have proceeded just so far that she could survive it, but a slight additional drain would prove fatal. Unless the uterus be contracting with even more than usual vigour, it is likely that there will take place additional loss of blood, owing to the partial detachment of the placenta that has been produced. In ordinary cases, where the patient has lost no blood previously and where the placenta lies high and per- haps either unseparated or else completely separated in the uterine cavity, we may wait for half-an-hour or more without seeing any htemorrhage to call for interference. But where the patient is already largely drained, and some degree of haemorrhage is necessarily progressing, as takes place so com- monly in placenta preevia cases, the indication for artificial shortening of the third stage becomes very urgent and immediate. 2. Inertia of the Uterus. — Again, even if delay were safe, it would in these cases require to be unusually prolonged. For, first, the placenta, or what remains of it still adherent to the uterine walls, is attached low down in the cavity where the muscular walls are thinnest and weakest, and where but a limited set of the muscular bundles can come to bear on it for its detachment and extrusion. And, secondly, the rapid withdrawal from the uterus of the main mass of its contents, leaves it with a tendency to inertia, which can only be over- come by active pressure and the use of ergot. The muscular conditions of the uterus thus form a second indication for Remote Restdts of Hcsmorrhage. 83 interference in the third stage, of which we have an illustra- tion in Mrs. A. 3. Adhesion of the Placenta. — But in Mrs B we get an illus- tration of yet another difficulty, which we may be prepared to meet in such cases. There the placenta was so firmly ad- herent to the uterine walls in consequence of inflammatory changes in the maternal portions of it, that its separation re- quired extreme care and caused some difficulty. It is just such an adhesion as may require similar interference after an otherwise normal labour. Only, here the inflammatory changes in the uterus, to which in this case the prsevial com- plication was due, asserted their mischievous influence further by leading to this firm adhesion between the uterus and the badly-placed placenta. Such a, double evil result is easily intelligible, REMOTE RESULTS OF HAEMORRHAGE. It has always seemed to me that whilst the immediate dangers of haemorrhage are well understood and set forth in text-books, its more remote risks have received less attention than they deserve. I have now so often seen insanity, or phlegmasia, or pelvic infiammations, or general peritonitis arise in patients whose labours had been complicated with a flooding, that I was not surprised when the dreaded rise in temperature took place in our patient, and the abdomen began to be tympanitic. All precautions were taken to prevent any septic poisoning in this case, and if we are to assume such a poisoning, I do not know where to find its source. Seats of absorption, of course, there were plenty; but the patient's own discharges were not unhealthy, her canals being regu- larly syringed with an antiseptic lotion, and the hands, instru- ments, and sponges that were applied to her were all carefully cleaned. The case appears to me to illustrate the special proclivity to inflammatory affections of a woman who had suffered from an extensive loss of blood. 84 The Placenta. TREATMENT BY ARTIFICIAL SEPARATION OF PLACENTA.^ During a debate on a communication on Placenta Prsevia, I stated that I could not follow the discussion into all the points which had been raised on this important theme, but begged to be allowed one or two remarks on the subject of treatment. One of the Fellows seemed to have homologated in all points the theories enunciated by Dr. Matthews Duncan, and had also followed that author in his rejection of artificial separation of the placenta in any case of haemorr- hage associated with placenta prtevia. But no amount of hypothetical argumentation could convince me that I had not seen good effects in the way of temporarily arresting the haemorrhage by detaching the placenta with the finger, in anticipation of the spontaneous detachment that must have occurred whilst the lower segment of the uterus was being dilated into a tube of sufficient width to allow the transit of the foetus. Now, whilst the observations of Duncan were of the highest value in throwing light on some points in connection both with the mode of production and the mode of arrest of the hemorrhage, I believed that Duncan erred in attributing the escape too absolutely to the already bared uterine surface, and so failing to appreciate the haemorrhage that takes place where blood-channels are partially torn,^ and that must cease when the same vessels are completely divided. We had only to consider the relation of the maternal vessels to the individual cotyledons of the placenta to understand how htemorrhage would go on whilst a cotyledon was in process of detachment, and would cease when the detachment was accomplished. As Hyrtl had shown that the foetal portion of each cotyledon was vascularised by its own special umbilical artery or arteries, which had little anastomosis with the vessels of the neigh- 1 Tra-iisadions of tlic Edinburgh Obstetrical Society, v. 93. ^ See Article by me on Death from Riqitiirc of Varicose Veitis in the Lotvcr Extremities, in Edinburgh Medical Journal, x. 724. 1865. Treatment of Place7ita Prcsvia. 85 boiiring territories, so Professor Turner had demonstrated to the Society the tendency to independence of the maternal blood-supply in each individual cotyledon. If we thought of the haemorrhage taking place, for example, as Duncan admitted that it sometimes did, from the tearing open at some point of the sinus of Meckel, then it was clear that, if that sinus really ran in an unbroken circle round the margin of the placenta, the blood would continue to flow from the torn vessel as long as any part of the placenta continued to receive blood from the uterine walls. This important vessel, how- ever, was not a circular sinus in the sense that it formed a continuous channel round the placental border, but was interrupted at short intervals, especially where it met the edges of the thick inter-cotyledonary trabeculse. Wlien the sinus at the border of a special cotyledon lying close to the OS uteri was torn open, blood must necessarily flow from it so long as the curling artery of the uterus feeding that cotyledon poured its contents into the caverns which were in communication with the lacerated portion of the Meckelian sinus ; and the haemorrhage could only cease when that arterial stream was cut off, perhaps only after all the exit veins of that special cotyledon had their connection with the veins in the muscular wall of the uterus completely severed. There were, therefore, the most satisfactory theoretical grounds for continuing, in appropriate cases, a line of practice which I had myself seen useful, and which I was sure other Fellows of the Society must have found to stand them in good stead in lessening the dangers of this formidable com- plication. I was far from advocating artificial separation of the placenta as the proper treatment in every case of placenta prsevia ; but I was not prepared, on the other hand, to regard it as universally inappropriate, and could even quite well conceive a case, though I had not j^et met with one, where the conditions were such as to render the com- plete separation, according to the restrictions advocated by Sir James Simpson, the safest line of treatment for the patient. In the general run of cases, the most efficient aid 86 The Placenta. to labour was afforded by the early employment of the dilating indiarubber bags, which I always used, of the fiddle- shaped pattern, according to Barnes; but each individual case demanded special treatment, and in the same patient it was often necessary to carry out one line of treatment one hour, and to follow it up the next by some other kind of operative procedure. CASE TREATED BY PARTIAL SEPARATION.^ At the meeting of the Obstetrical Society on December 11, 1861, I exhibited the secundines from a case of placenta prsevia, and stated that the patient from whom the pre- paration had been derived was forty-one years of age, and had now borne fourteen children. She averred that her last menstruation took place towards the end of the month of January 1861 ; but about the end of February there escaped a quantity of greenish fluid tinged with blood, and she had come in the end of March to consult me in con- sequence of a slight amount of haemorrhage, which went on from time to time, for about five weeks, ere it finally ceased. She had had three miscarriages at an early period of pregnancy, and feared that on this occasion she was going to abort. In her former pregnancies she had usually quickened at the beginning of the fourth month : on this occasion she quickened in the end of June. In the middle of October she was threatened with a recurrence of the haemorrhage, for she then passed a decolorized clot along with a quantity of newly extravasated blood. Under the use of the ordinary calmative measures, the bleeding soon ceased, and she had no further threatening of it till five o'clock a.m., of November 7th, when there was a considerable escape of blood, and the pa- tient began to suffer from slight labour pains. The pains went on, and blood continued to be discharged for five or six hours, when I was called to see her, and found the os ^ Edinburgh Medical Journal, viii. 383. 1862-63. Placenta Pj^cEvia t7^eated by Partial Separation. 87 dilated to the size of a shilling, and the parts all soft and relaxed. The exposed edge of the placenta was found to be lying over the left side of the os, and somewhat in front. The pains and the bleeding ceased, and the patient kej^t at rest all day, passed a quiet night, and had some sleep. On the morning of the 8th there was a recurrence of the pains and of the hsemorrhage, the flow of blood being always most abundant just as the pains were passing off. The os was gradually becoming dilated, but there were no active contrac- tions going on during the day, nor any great gushes of blood ; but as the patient was becoming reduced by the occasional slight discharges which might be described as, during some hours, an almost continual sanious oozing, I proceeded at eleven p.m. to expedite matters by rupturing the membranes. In half an hour the uterine contractions came on more vifror- ously, but with the pains the hcemorrhage returned. Believ- ing that in such cases the flow of blood took place, as Sir James Simpson had latterly taught, from the open vessels along the line where the separated surfaces of uterus and placenta are continuous with their still adherent portions, and where the tendency of each recurring pain to increase the separation has the effect of putting the torn vessels on the stretch, and so permitting the escape of blood, I passed the finger between the surfaces of the uterus and placenta so as to anticipate the detachment that should have been produced by the succeeding pains. Two strong contractions passed over without the escape of any blood ; with a third the head began to press through the os, and by one o'clock the child was safely delivered. The lobe of the placenta at the margin next to the rupture in the membranes, was flat- tened and compressed, and close by this there was, in the border of the organ, a white fibrous mass, which was in all probability an obliterated and degenerated lobule. 88 The Placenta. POST-PAETUM HvEMOPtKHAGE. PERCHLORIDE OF IRON IN POST-PARTUM H^MORRHAGE.^ In a discussion on a communication by Dr. Connel of Peebles, in which the question was raised of the value of this remedy, I gave it as my opinion that, on the evidence hitherto pubhshed, the use of perchloride of iron should not be set aside. I would be sorry to think that we should not be justified in using it in a suitable case. I had once used it in a case I was called to in considtation, but too late, as the patient was just sinking ; but I was glad to believe that the perchloride might possibly have arrested the flooding, if applied a little sooner. I did not consider the theoretical reasoning against it sound, because the stimulant action would tend to make the uterus contract, and thus the styptic power of the remedy would be appKed to a smaller placental surface, and to smaller orifices. Moreover, it is a grand antiseptic. There is a great tendency to septic absorption in these cases, but least of all in cases where the perchloride has been used ; hence, though my own experience had not furnished proof of its value, I would like to see further trial made of it in suital)le cases. In estimating the worth of the remedy, the difficulty lay in knowing whether the patient whom it seemed to save would have died had it not been used. Dr. Connel's case showed that it did arrest luemorrhage for a time, which was just what Barnes claimed for it. The death was probably caused Ijy the hcTmorrhage, slight though it was, which had occurred. INFLUENCE OF PLACENTAL SITE ON POST-PARTUM H^MORRHAGE.^ In a discussion in the Obstetrical Society, I remarked that I had met with several cases in consultation where patients ^ Transactions of tlic Edinburgh Obstetrical Society, iv. 21. 1874-75. "* Ibid., iv. 286. 1876-77. Relation of Placental Site to Hcsmorrhage. 89 had died of hsemorrhage after delivery. I had lately seen a case with Dr. Groom, in which the patient was delivered of twins, and serious haemorrhage followed ; ergot, ergotine in- jections, and all the usual means, had been tried without a satisfactory result. After the uterus had been held half an hour the bleeding stopped ; but the patient never rallied, and died in forty-eight hours. As to causation, besides the question of blood-pressure, some importance attaches to the site of the insertion of the placenta. Wlien the placenta is situated flat on the anterior or posterior wall, the mere weight of the uterus acted in assisting to restrain haemorrhage; in cases of placenta succenturiata, and in lateral or low insertion, there was more likelihood of bleeding. DEATH AFTER LABOUR.^ I stated at a meeting of the Edinburgh Obstetrical Society, on April 24, 1861, that I had that morning made an autopsy, the results of which I thought were calculated to throw some light on cases of post-partum syncope associated with haemorr- hage. The body I had dissected was that of a lady under forty years of age, the mother of seven children, whom I had been called to see six weeks before, in my uncle's absence, in consequence of an escape of blood which had taken place from the vagina on her raising herself to get out of bed. She was then supposed, but without much certainty, to be at the close of the seventh month of her eighth pregnancy. Only a small firm clot had escaped; the os was quite closed, and there were no pains ; but the patient was very nervous and anxious. She had got over her fright, and had moved to another house, and was making arrangements for going for a little to the country, when she suffered another slight loss of blood, fifteen days subsequently to the first. Three weeks afterwards, another small clot was expelled, and on the pre- ceding Thursday (April 18th), Sir James Simpson was sent for ^ Edinhurcjh Medical Journal, vii. 989. 1861-62. go The Placenta. to see her early in the morning, as a considerable gush of blood had taken place. The os nteri was then sufficiently- dilated to enable Sir James to feel the margin of the jDlacenta slightly overlapping it. No more hemorrhage took place at that time, and when he went to visit her on the following Saturday evening, she was quiet and well, although she was very anxious, and declared her conviction that she would never " get over it." On the following morning, he was again at her bedside, and as she had been losing more blood, he ruptured the membranes so as to allow the liquor amnii to escape and induce full uterine contraction. Up till this time the loss of blood altogether had been but slight, and no more haemorrhage had occurred till the time of the delivery. Labour pains set in shortly after eight p.m. of the same day (the 21st) ; shortly after which time Sir James was again in attendance, and having found matters progressing quite well and naturally, he withdrew to wait in another room. At midnight he was again summoned to his patient's bedside; and although the pains were going on very regu- larly, and no hsemorrhage was taking place, the pulse was so alarmingly quick, and feeble and intermitting, that he sent to request the assistance of Dr. Moir, who was intimate with the patient, and was present with him till the last. After Dr. Moir's arrival, chloroform was administered to the patient, and, as she was brought rmder its influence, they were both much struck with finding the pulse become slower, steadier, and more regular ; and in about half an hour a living child was born, and the placenta was soon expelled without more than the usual escape of blood. The effects of the chloroform passed off speedily after the birth of the child. The uterus contracted naturally ; but as the patient was very faint and weak, a sponge dipped in perchloride of iron was applied to the cervix, lest any oozing of blood should take place from its surface. Not another drop of blood had escaped ; stimulants had been freely administered, but the patient never rallied, and, two hours subsequent to her deli- very, slie died. Case of Death after Delivery. 9 1 At the post-mortem examination, which was made fifty- two hours afterwards, the abdominal organs were found to be all normal and healthy ; and the uterus, though it had then become soft and flabby, seemed to have been completely con- tracted, and presented no indication of having been the seat of haemorrhage. There was no blood, either fluid or clotted, in its cavity. The lungs were also healthy ; but the heart was in such a morbid condition as to have led us to conclude that the patient had died from failure of its action. It was pale and soft, and freely overlaid with fat, and contained a quantity of loosely coagulated blood. Its walls were un- usually thin, particularly on the right side, where the wall of the right ventricle was as thin as the coats of the vena cava. On careful microscopical examination, I found that the muscular fibres of the heart had undergone fatty de- generation very extensively, and to a degree very remarkable in so young a woman. So that, from all the circumstances of the case, it appeared that, while the patient's strength might have been somewhat impaired by the repeated slight losses of blood, and also, perhaps, by the restraint imposed on her during the last six weeks of her life, with a view to prevent their recurrence ; yet her death was due not to anaemia, but to the exhaustion attendant on the process of delivery, and the consequent failure in the action of a feeble, fatty heart. For, during the progress of delivery, the parturient female really was subjected to such hard labour, and underwent such an amount of fatigue as no one suffering from any cardiac affection could with safety be exposed to, and which it was not surprising to see ending fatally in one whose heart had undergone extensive fatty degeneration. 9 2 Morbid Conditions of Pregnancy. MOEBID CONDITIONS OF PEEGNANCY. HYDEAMNIOS.i rpHE object of this article is to bring under the notice of the Society the products of conception obtained from three patients who had been the subject of hydramnios, and to offer one or two remarks relating to this complication. CASE OF HYDRAMNIOS WITH TWINS. The first preparation consists of the ovum discharged by a poor patient, who came from the country to see Sir James Simpson, on account of an enormous dropsical distension of the abdomen. The seat and source of this watery collection liad been a subject of discussion between various medical men who saw her in her own home, some of whom thought it ovarian, whilst others seem to have regarded it as ascitic. The patient had suffered from severe pains in the abdomen from time to time; and when I saw her the diagnosis had become easy in consequence of dilatation having already set in in the os uteri so far as just to admit readily the finger, and to permit the protrusion through the orifice of the bag of membranes. Her menstrual history then showed that she was between five and six months pregnant, and that her large size was due to the excessive secretion of the liquor amnii. The membranes were punctured ; basinfuls of water evacuated ; and some hours afterwards the preparation before ^Edinburgh Medical Journal, x. 913. 1864-65. Hydr amnios in Twin Pi^'egnancies. 93 the Society was expelled. It is seen to consist of an unusually large bag of membranes, which can be distended with air or liquids so as to assume the ovoid or pyramidal form of the uterus, and when thus distended measures sixteen inches in length, and twelve and a-half inches across its broadest part. Doubtless, when this sac formed the lining membrane of the uterus and was supported by its strong parietes, it had been capable of much greater distension, and the measurements of the cavity of the organ before the escape of the contained fluid must have been considerably greater than is represented by these figures. In what corresponds to the back wall of the uterus the sac presents the large placental mass of eleven by eight inches in diameter; and, through the transparent walls, two foetuses are seen lying in the common cavity, and having their respective cords running into the placenta towards opposite margins. It is no uncommon thing to have hydramnios associated with the birth of twins, Kilian,^ for example, in treating of this complication, notes it among " the very striking facts that so frequently twin-children are associated with drojDsy of the ovum ;" and Hatin^ goes so far as to say that " dropsy of the amnion is more frequent in double pregnancies than in those with a single foetus." Dr. M'Clintock,^ in his masterly and only too short memoir on this subject, speaks of as many as eleven instances of twin-birth among thirty-three cases of hydramnios that have come under his observation. But the present case differs from any of those noted by Dr. M'Clintock, in that both twins are contained in one common distended cavity, whereas, ordinarily, the foetuses are located in separate compartments, only one of which became affected with dropsy. The patient made a good recovery, and there was only one other noteworthy feature in connection with her delivery to which reference will be made anon. ^ Die Geburtslehre, ii. 456. ^ Cours complet d' AccoucJiemejits et de Maladies des Femmcs ct dcs Enfans, 426. 1835. 3 Clinical Memoirs on Diseases of Women, 376. 1863. 94 Morbid Conditions of Pregnancy. CASE OF HYDRAMNIOS WITH AN ANENCEPHALOUS FOETUS. On the evening of 20tli December I was sent for to attend the wife of a medical practitioner in her labour. She had previously given birth to two well-developed healthy children. She had ceased to menstruate in May 1863, and had gone on well up till about six weeks before the date of her confine- ment, when she had accompanied her husband on a visit to Shetland, where she had had frequent occasion to make lengthened journeys in carts, — sometimes furnished with springs, sometimes without. She had suffered great incon- venience from the jolting of the vehicles on the rough roads, and had often been obliged to double herself together in con- sequence of the distressing sensations experienced in the lower part of the abdomen. From this date she began to increase in size with uncommon rapidity, and during the last two weeks began to suffer great discomfort from the increasing bulk. Spurious pains, too, set in from time to time in differ- ent parts of the uterine parietes, and added much to her discomfort. These became tolerably severe and constant on the evening of the 19th, but remitted sufficiently afterwards to allow the patient to get a night's rest. In the course of the forenoon of the 20th they again recurred, and towards evening became tolerably constant and severe, so that when I saw the patient about eleven o'clock p.m., the os uteri was dilated to more than the size of a crown piece, and was occu- pied by a firm bag of membranes which projected from it in a somewhat conical form. The fcetal presentation could not be made out, for it was with difficulty it could be reached, and when touched it at once receded from the exploring finger. The foetal heart-sounds could occasionally be heard on auscul- tation over the uterus, but the great mobility of the foetus prevented them from being easily detected. Wlien the os uteri had become a little more relaxed and dilated, the mem- branes were ruptured artificially ; and, after the escape of large quantities of fluid, the orifice became filled up with a presentation which was altogether abnormal, and which, as I Hydramnios with an Anencephalous Child. 95 stated at the time to tlie patient's husband, I could diagnose to be nothing else but the deformed head of an anencephalic child, A few vigorous pains sufficed for the expulsion of the child through the pelvic canal, and the delivery of the after- birth speedily followed. So far the case had gone on most satisfactorily in all respects as regarded the mother. But now there supervened a symptom to which I must ask your special attention, and which would have been a source of the greatest apprehension and alarm, had I not been prepared for its occurrence by having already witnessed it in the patient whose case I first related. The symptom referred to was the supervention of a very severe and prolonged shivering fit. In the first of the two patients, this rigor came on in the interval between the birth of the two foetuses, and was of such a character that the whole bed shook from the violence of the patient's tremblings. It continued for some length of time, too, in spite of the exhi- bition of hot drinks and stimulants, and finally passed off by leaving her perspiring profusely from every pore in head, body, and limbs, till all her clothes were soaked with wet. There was another but barely noticeable rigor experienced after the extrusion of the second fcetus. The darkest results were anticipated from the occurrence of a symptom so alarming, but the patient made an excellent and speedy recovery. And now, in the second case, after the patient had been fully delivered, and she was wakened up from the effects of chloro- form, when she began to yawn and comjDlain of cold, I was quite prepared to witness without alarm the onset of a rigor. The rigor did supervene, very much modified, however, by the use of a hot drink, which induced vomiting ; and it terminated in a hot stage, which was sufficiently distinct, though not marked by the very profuse perspiration witnessed in the other case. It was succeeded after short intervals by two other similar but slighter sliivering fits, but was attended mth no imtoward results, and the patient made a fair recovery. As regards the cause of the hydramnios in this second in- stance, I think we can have no hesitation in referring it to the 96 Morbid Conditions of Pregnancy. morbid condition of the foetus with which it was associated. The foetus presented a perfect specimen of the most complete form of anencephalous monster, for not only was the entire brain and vault of the cranium absent, and replaced simply by the red fleshy substance covered with serous membrane so common in such cases, but the ears were approximated to the shoulders in consequence of the shortening of the cervical vertebrse and the patency of the spinal canal. This canal was open in all its extent down to the lowest lumbar vertebra ; there was no trace of spinal marrow, and the groove, which had an average breadth of about 1|- inch, was covered with a serous membrane, in which the spinal nerves could be seen running outwards to either side between the several vertebrae. In cases of hydrocephalus and hydrorachitis, we know that the same membrane which in this case lies exposed on the surface becomes the seat of such a morbid change as leads to the effusion from it of an abnormal quantity of fluid into the closed cavity of which it forms the lining membrane. Wlien this morbid secretion goes on for some length of time, it may cause the foetal head to be enormously enlarged, or may lead to the formation in some part of the spinal column of a bulky cyst sufficient to present a very serious obstruction to the birth of the child. AVhen such active secretion can go on in a cavity surrounded by unyielding walls, it is easy to see that if the disease had set in at an early period of intra-uterine life, these same cavities would more readily give way and burst ; and so leave their lining membrane free to pour its excessive secretion into the more easily distensible cavity of the amniotic sac. The possibility of such an occurrence has been indicated by Vrolik, who gives, in his work on monsters,^ a description of an hydrencephalous foetus, in which part of the contents of the skull have come to be protruded through a small opening in the upper aspect of it, so as to form a large cyst on the 1 Tahuloe ad illustrandam Emhryogenesin Hominis et Mammalium. Tabula xliv. Hydi'amnios with Hydrocephahis & Spina Bifida. 9 7 summit of the head, which appeared as if it were ready soon to give way and pour its fluid into the general amniotic cavity. The whole morbid process with its result has been fully traced out and illustrated by Yirchow, in his work on morbid growths.^ But I have yet another preparation to show, which exhibits still more strikingly the relation that may subsist between disease of the cerebro-spinal system of the foetus and dropsy of its amnion. The child was born at the Lying-in Hospital here, under the following circumstances, as related to me by Mr. Taylor, the excellent house-surgeon : — CASE III. Mrs. B. was brought into the Lying-in Hospital, after she had been suffering from the presence of labour pains, attended with severe vomiting for four days. The patient was very weak and feverish, and the abdomen unusually large. The os was widely dilated and relaxed, and through it the foetus could be easily felt ; but the presenting part receded very readily into the roomy cavity of the uterus. The pains having ceased for some time, a catheter was introduced between the membrane and the uterine wall, by the advice of Dr. Keiller, and when the pains returned, and the waters, which escaped in enormous quantities, were evacuated, the foetus was found presenting by the breech. Delivery was completed in two hours thereafter. The child was born asphyxiated, but the attempt at its resuscitation was so far crowned with success that it began to respire, and lived for eight or ten hours. Its breathing, however, was never at all satisfactory. The mother recovered well, and was discharged, at her own request, on the ninth day after her delivery. The child, a female, measm-es Vl\ inches in length. The head measures 5-| inches in its longitudinal or occipito-f rental diameter, and 4| inches in its transverse or biparietal. The spinal canal was incomplete in the lower lumbar and in the ^ Bit Krankhaftcn Gcschwiilste, i. Ncuntc Vorlcsung, 169. G 98 Morbid Conditions of Pregnancy. sacral vertebrae, wliicli were cleft posteriorly ; and over these bones the skin was supplanted by the thin, semi-transparent, serous-looking walls of the collapsed sac of a spina bifida, which measured an inch in its transverse, by an inch and a-half in its longitudinal direction, and presented at its upper extremity a small valvular opening, through which the fluid contents had found egress. It was easy to perceive the con- nection of the spina bifida with the cavity of the skull ; for on compressing the head the contained hydrocephalic fluid could be seen, first distending the walls of the sac, and then escaping by the opening at the upper angle. On the other hand, fluids injected into the cavity of the spinal canal ran along it, and distended the head ; and on dissection it was found that the sac contained in its walls the nerves into which the lower end of the spinal cord was breaking up, and that the cavity was continuous with the central canal of the cord, which was dilated in all its extent, so as easily to admit the ordinary blow-pipe of a dissecting case, and was continuous at the upper extremity with the distended ventricles of the brain. It formed thus an uncommonly beautiful example of the hydrorrachis interna cystica, described by Forster^ and others ; but is chiefly interesting to us in regard to our present subject of observation, as showing how the quantity of fluid in the cavity of the amnios is liable to become augmented from the presence of dropsical affections of the foetal cerebro- spinal system. EXTEA-UTEKINE PREGNANCY.^ At the meeting of the Obstetrical Society on May 10, 1876, I exhibited two preparations illustrative of the sub- ject of Extra-uterine Pregnancy. The first I owe to the kindness of Dr. Will of Aberdeen, who had published the 1 Die Misshildungen dcs Menschen, 1861. Taf. xvi. Fig. 6. ' Trmisactions of the Edinhxirgh Obstetrical Society, iv. 265. 1876-77. Exh^a-Uterine Gestatio7i. 99 liistoiy of tlie case in tlie Edinhurgh Monthly Journal for 1855. The patient, aged 39, had conceived shortly after her marriage in 1844. Two months subsequently she had symp- toms of pelvic inflammation and threatened abortion. From this she rallied and went on to her full time, when labour pains came on, but passed off again. Thereafter the tumour, which had steadily increased in size till then, shrank, and the patient's health was re-established. Seven years later, in January 1851, Dr. Will attended her in her delivery, after a natural gestation and labour, of a female child, and felt then the firm and partially moveable tumour lying to the left side. In February 1854, the lady gave birth to a second full-time child, a male, after an easy labour. On the third day after, a rigor set in, followed by peritoneal inflammation ; and, after a prolonged illness, attended with hectic and diarr- hoea, the patient died in May. At the dissection of the body, the foetus now exhibited was discovered lying in a cyst, the walls of which were adhering to all the surrounding parts, and in the cavity of which some faecal matter was found that had got access through three different orifices in the bowels. It was an illustration of an extra-uterine foetus carried for many years in a patient who gave birth to other children, and at last leading to her death under the efforts of nature to effect its elimination. The second preparation was one of a macerated foetus of about the third month of pregnancy, measuring three inches in length. I had only once seen the patient from whom it was removed, along with Dr. David Gordon, who was present, and could supplement the history of the case. The woman had an obscure history of having conceived and aborted, and at the time when I saw her, she seemed to be dying of extravasation of blood into the peritoneal cavity. She was pale and pulseless, with a fluctuating swelling reach- ing half-way up the abdomen, and the propriety of making an incision to give an outlet for the blood through the vaginal roof was discussed. It was, however, set aside, chiefly because of the seemingly moribund condition of the lOO Morbid Conditions of Pregnancy. patient, who was treated by applications of ice to the abdomen, and opiates and stimulants internally. She rallied, and for a time seemed to recover satisfactorily, but died some months later from an attack of acute peritonitis. At the post-mortem examination made by Dr. Wyllie, pathologist to the Eoyal Infirmary, the peritoneal surface was seen to be pigmented in the lower part of the abdominal cavity as high as the level of the umbilicus. There were evidences of active inflammation among the coils of the intestines above the pelvic brim, and in the pelvic cavity amidst a ftecal and putrilaginous mass was found the preparation now exhibited. It lay in the space of Douglas, at the bottom of which it was discovered that perforation into the rectum had taken place. Through this orifice liquid fa3ces had escaped into the serous cavity, and seemed to have set up the fatal peritonitis. I also referred to another case of extra-uterine gestation which had been kept for the College of Surgeons Museum by the then Pathologist of the Infirmary, where the patient had died. The woman had first come into my ward suffering from some pelvic distress, which was associated with a swelling rising above the pubes toward the left side. I satisfied myself that the foetal heart was to be faintly heard through the stetho- scope, and thought it a case of pregnancy complicated with a uterine or ovarian tumour. Dr. Slavjansky and some others who saw the case doubted the existence of pregnancy ; and as, after a few days' rest, the patient, a married woman, with other children, felt ratlier easier, she was allowed to go home under promise to return in two months. She did return, but not for ten months. The swelling had grown steadily, she felt foetal movements, and at the full term liad symptoms as of labour beginning. Wlien these passed she missed the move- ments, and three months after began to suffer from pain in the abdomen, which induced her to come again to the ward. The tumour was now felt occupying the abdominal cavity ; but the patient was suffering from so much peritonitic tender- ness, that a satisfactory exploration of its relations could not be made out. I thought I could feel the outline of a foetus, Extra-Uterine Pregnancy. loi and a small aspiratoiy tapping brought away an ounce of fluid resembling liquor amnii, only darker than usual, and with much cholesterine. The peritonitic symptoms increased in severity till the patient died. At the autopsy there was found to be very extensive peritonitis, flakes of lymph lying among all the abdominal viscera up to the diaphragm. The walls of the tumour were matted to the abdominal parietes and to all the viscera which lay around it. On being opened into, it was seen to be one of those rare cases where the gesta- tion of the ovum had occurred in a Fallopian tube (the left), and where the tube had gone on developing to the close of the ordinary gestation. The question of operative interfer- ence had been discussed before the University Clinical Class, to which the case had been demonstrated as one of probable extra-uterine gestation, but decided in the negative, as experience showed that, after gestation was ended, operative measures were likely to be satisfactory only in cases like that of Dr. Macdougall, which had led to these remarks — cases, viz., where nature had already commenced, and to some extent €arried on, the process of elimination. NOTES OF A FATAL CASE OF CHOREA GRAYIDAEUM.i The case which I have to bring under the notice of the Society occurred at Bathgate, in the practice of my friend, Dr. Longmuir, to whom I am indebted for the following history : — M. Y., aged twenty, a dairymaid, began to menstruate at the age of sixteen. Menstruation was always regidar, but moderate in amount. She had had measles and whooping- cough in her early years ; and, about eight years ago, had an attack of rheumatism which lasted, according to her mother's ^ Transadioiis of the Edinburgh Obstetrical Society, iv. 238, 1876-77 ; Th<: Obstetrical Jour7ial of Great Britain and Ireland, iv. 80. 1876-77. I02 Morbid Conditions of Pregnancy. statement, for some weeks. In the middle of last July she menstruated as iisual, and in the end of the month was laid down with a smart attack of scarlatina, which was at that time very prevalent in a malign form in the district. During her convalescence from scarlatina she had again a slight attack of rheumatism, but was only off work six weeks in all. It was observed by her friends that ever after she was very easily agitated. From the date of the menstrual discharge in the month of July there was no uterine hemorrhage till the 18th of September, when the catamenia returned. She menstruated again towards the end of October. At this time, in all probability, conception took place, though the existence of pregnancy was not suspected till afterwards. It was in the first week of January — in the beginning, therefore, of the third month of gestation — that the first choreic symp- toms manifested themselves in occasional slight tossings of the head. Then there was a gradual feeling of weakness in the left side, more especially in the left arm, so that on several occasions she let fall her milk-pitchers. On the 4th of February she had a severe fall on the point of the elbow, after which her symptoms became gradually more distressing. Irregular movements took place in the muscles on both sides of the body, and by the beginning of March these became so violent that the patient was kept in a state of constant agita- tion. Even when she was kept asleep by ansesthetics or narcotics, movements, of the lower limbs more particularly, still went on. Only once when she was kept asleep for three hours with chloroform was there any cessation. Bromide of potassium was given freely, l)ut without producing any modi- fication of her distress. By and by a marked degree of de- lirium was superadded to her other symptoms, so that she kept up a frequent screaming until pulmonary congestion set in, and she sank very rapidly on 9th March. On the 11th ]VIr. A. H. Young, one of my pupils, was good enough to go to Bathgate to make the dissection along with Dr. Longmuir. In the vagina there was found a dead foetus, 8| inches in length, with the feet towards the vulva and the Chorea Gravidarum. 103 head towards the os ; the cord ran up through the cervix towards the placenta, which was still adherent to the back wall of the flaccid uterus. The uterus has been put into Professor Turner's hands for examination, as he has made and continues to make important observations in regard to the structure of the placenta and changes in the lining mem- brane of the gravid uterus. It has been carefully injected, and as it lies in the jar the Fellows can see that it presents all the characters of a uterus in the fifth month of gestation ; the cervix, which is sharply marked off from the uterus proper, not having begun to undergo any degree of shortening, but rather having up to this point shared in the general enlarge- ment of the organ. There was slight hypergemia of the pelvic and abdominal peritoneum, but the abdominal viscera were healthy. Only the kidneys were deeply injected, esjDccially in their pyra- midal portion, where some small capillary embolisms were found in a section. In the thorax the heart and large blood- vessels seemed to be healthy. The lungs were in a state of very extensive and deep congestion. On removing the calvarium, the dura mater was found to be very firmly adherent to the bone. At a point correspond- ing to the anterior fontanelle it was thickened and roughened to a distance of three-quarters of an inch to each side of the middle line. An inch and a half backwards there was a similar transverse roughening not quite so extensive. The central line between the ridges and a line entering a short way in front and behind them presented the same aj^pear- ance ; and there was a curved line on either side running from the extremities of the transverse ridges, and meeting in a point at the posterior extremity of the roughened median line. In all this area there was great vascularity, more es- pecially along the rough lines and ridges, and the dura mater had throughout this surface acquired adhesions with the pia mater. At this place there was some lymph exudation in the subarachnoid space ; and there was some slight hypersemia and very great effusion in the right ventricle. I04 Morbid Conditions of Pregnancy. The case thus presents various points of interest. It illustrates Eomberg's remark,^ that the chorea of pregnant females is almost always bi-lateral. It goes to increase the sum of the fatal cases which Barnes's- valuable table, supple- mented by WenzeP shows to be very high in such women. Of Wenzel's 66 cases 18 proved fatal = 27'3 per cent. Notwithstanding the presence of capillary emboli in the kidneys, it does not go to confirm Dr. Hughlings Jackson's theory that chorea is due to capillary embolism in the brain. The intercranial mischief which was discovered was not of embolic character, and the changes in the kidney had in all probability occurred in the last days, if not hours, of the patient's life, as it was difficult to see any cloudy change in the parenchyma of the organ. But it is wortliy of remark that we had in this patient a combination of the conditions that have severally been notably associated with the development of chorea. For, \8t, she had been the subject of an attack of rheumatism, which in a milder form had recurred shortly before the chorea appeared; 2d, she had been the subject of a recent attack of scarlatina ; and, Zd, she was pregnant. OF THE COMPLETE EVACUATION OF THE UTEEUS AFTEE AB0ETI0N.4 It is my pvirpose in this article to draw attention to our means of securing the complete evacuation of the uterus, in cases of abortion and miscarriage. Interruptions of gestation in the early months are very common; but while the authors of our obstetric text-books are careful 1 Lclirhuch der Nervenkrankheiten des Menchcn, 520. Berlin, 1857. - Transnctio'iis of the Obstetrical Society of London, x. 186. 1869. '^ Schmidt's Jahrhiiclier der gesammtcn Medicin, clxi. 200. 1874. * Edinburgh Medical Journal, xxi. 961, 1875-76; and Transactions of tlic Edinburgh Obstetrical Society. March 1876. Frequency of Abortion. 105 to point out the evils that may result from the detention of fragments of ova within the uterus, they fail to explain how we can best clear out the cavity. It is extremely difficult to determine the frequency with which abortions occur. Not to speak of the cases of wilful provocation and concealment of them, they may take place in the early weeks in patients who suppose they have merely a delayed and perhaps profuse menstruation. Even when women have supposed they were pregnant, they may think lightly of it when hsemorrhage sets in, and may cast the fruit of the womb at an early stage, without desisting from their ordinary pursuits, or, at least, without calling to their aid a medical practitioner. Hence the diversity, in the estimate given by different writers, as to their relative fre- quency; Hegar^ reckoning at least one abortion to every eight or ten full-time deliveries, while Devilliers ^ sets them down in the proportion of one to three or four. The statistics of Whitehead ^ show a proportion of about one to seven. He takes care, however, to draw attention to the fact that the average age of the women whose history he had ascertained, was a year and a half below the middle of the child-bearing period; and that while thirty-seven out of every hundred mothers experience abortion before they attain the age of thirty, the percentage of those living on in wedlock till the menopause, who are subject to this accident, rises as high as eighty-seven. The evil effects of an incomplete abortion are either immediate or more remote. The great immediate risk is the occurrence of excessive haemorrhage, which, though but rarely fatal, is sometimes very alarming, and always leaves the patient in a state of deteriorated health. Then apart from the chances of decomposition of the retained fragments or of the discharges that attend it, and the possibility of 1 Monatsschrift fur GchurtsTcunde, xxi. (Supplement), 34. 1863. - Nouveau DicUonnairc dc iUdccinc et de Chirurgie, iv. 305. 1866. 3 071 the Causes and Treatment of Abortion and Sterility, 245. io6 Morbid Conditions of Pregnancy. septic absorption from the surface where separation may be taking place, the uterus which contains a foreign body remains decidedly hypertrophied, so that when it finally be- comes evacuated, the walls may remain permanently thickened and the cavity enlarged. In a patient with the uterus in such a condition, dislocations of the organ easily occur. Such imperfect involution may easily be the starting-point of other morbid changes ; and thus it comes about that many of the women who come under observation suffering from uterine affections, can trace back the commencement of their distress to an abortion in the early months of gestation. When we have to do with a case of abortion in which the stage of expectancy is clearly over, and the patency of the OS internum, or the persistence of the pains, or the haemorr- hage long continued or profusely flowing, call for active interference, there are two main indications to be fulfilled — viz., Is;;, to restrain the haemorrhage ; and, "Id, to procure the perfect removal of the ovum. I. — RESTEAINT OF HEMORRHAGE. In treating of the fulfilment of the former of these indica- tions most of our manual writers are satisfactory enough, though even under this head there is some room for improve- ment. In a typical case we place little reliance on rest, cold, styptics, and so on, for we know that we can only effectually restrain the haemorrhage either {\d) by compelhng the uterus to more energetic contractions, or (2f?) by blocking up the channel through which it escapes. In most cases we pursue both objects simultaneously. \st. The uterus must be compelled to steady action by the administration of ergot, introduced in the form of a strong solution of ergotin^ into tlie subcutaneous cellular ^ I use for hypodermic injection a solution of one part of ergotin in three of water, with ten or twelve grains of chloral in each half-ounce bottle of the mixture. Ten drops of this fluid gives the action of the drug with great cei'tainty, and I have seen no ill eH'ects from it. Treatment of Abortion. 107 tissue — a mode of administration of the drug which is destined, I believe, to supersede those with which we have so long been familiar; for the subcutaneous injection of ergotin sets up the uterine contractions with such speed, such certainty, and such safety, that the hypodermic syringe will be found an indispensable part of the furnishing of every obstetric bag. 2d. Pending the onset of effective pains, and with the view of at once hastening them, and preventing the escape of the blood, we plug the genital canal. For the most part, and as if it were the best in all cases, authors recommend the use of the vaginal tampon. Now, the plugging of the vagina, by whatever material, is sometimes the only ex- pedient to which we can have recourse, and we may rely on it with much certainty for averting the immediate danger of excessive hsemorrhage. But it seems to me that, where we have our choice, its application ought to be restricted to those cases where there is still some hope that, if we succeed in arresting the haemorrhage, we shall at the same time succeed in averting the impending abortion. Otherwise we have a means of controlling the bleeding more directly, at once less irksome to the patient, and less troublesome of apphcation by the practitioner, in the cervical plug. For this purpose there is nothing so efficient as a good sized sponge-tent, prepared, as Messrs. Duncan, Flockhart, & Co. now always prepare them, by being dipped in a disinfectant solution before being compressed by the whipcord. In my judgment, nothing can take the place of the sponge-tent for rapid, kindly, and complete dilatation of the cervical canal. And when we have introduced a sponge-tent through the cervix uteri in a case of unavoidable abortion, we may count upon a threefold effect. First, The bleeding is arrested im- mediately and effectively ; for if there be any escape into the uterine cavity, it has simply the effect of swelling up more rapidly the sponge, which blocks up its canal of exit. Second, The uterus is stimulated to more rapid and more energetic action, as it always is when a foreign body is introduced io8 Morbid Conditions of Pregnancy. witliin its cavity. Tliird, The cervical canal is being effec- tually expanded during the lodgment of the sponge within it; and where a sponge-tent of good size has been well planted, it secures, as no other tent that I know of does, the expansion of the sphincter of the os internum. Wlien, by the adoption of these measures, we have fulfilled the first indication, we have at the same time prepared the way for the carrying out of the next — viz., II. — THE COMPLETE EVACUATION OF THE UTERUS. It is in describing the methods of securing this object that I find systematic writers particularly defective. For the most part, they tell us that when the uterus fails to expel its con- tents, these must be extracted with the finger or fingers passed through the cervix, and hooked round the ovum or placenta, or whatever fragment may stiU be in utero ; and that, when it cannot be reached with the fingers, cautious use should be made of some forceps or other instrument. But then the methods by which the uterine cavity can be reached through the vagina are harddy more than hinted at, with a few excep- tions, as by Cazeaux, who, in a single line, speaks of " strong pressure upon the hypogastrium to depress the womb ;" and Schroeder, who, somewhat more fully, describes the bi-manual manij)ulation. If, e.g., we open the latest work, the deservedly popular " System of Midwifery" by Professor Leishman, we read^ — " The finger is to be cautiously passed round the pro- truding portion, and, if necessary, another finger may be intro- duced into the os. If we can thus succeed in getting a hold of the placenta upon which we can rely, it may be extracted entire ; but a rude or unskilful mode of manipulation may entirely frustrate our efforts by leaving behind a portion of what we wish to extract whole. It is impossible to lay down rules for the skilful performance of this manoeuvre, which can only be taught by experience; but we have no doubt 1 Second edition, 433. 1876. Treat^nent of Abortion. 109 that more reliance is to l3e placed upon the fingers than upon instruments, as a general rule." It is little wonder if, a page further on, we find him speaking on the after-treatment (p. 434) of fragments of placenta giving rise again to haemorr- hage; and all that is said of the treatment in that case is, that " the patient must not be permitted to rise until all trace of this has ceased !" Why, the abortion in that case is unfinished, and we have no right to expect a cessation of the haemorrhage until the delivery has been complete. It always seems to me that there are few obstetric ma- noeuvres capable of clearer exposition than the manipulations that we employ for emptying the uterus in the last stage of an abortion. Let us first have a clear idea as to what is required to be done. We have to pass one or more fingers into the cavity of the uterus to explore the entire cavity, to separate from its walls any adherent portion of the ovum, and then to extract the separated mass. I say at once, and simply, that it is the fingers of the operator that are to do the intra-uterine work, for I am quite at one with those who deprecate the use of instruments, such as curettes, wire-loops, crotchets, and abortion forceps, for the detachment of retained ova or their fragments. When the adhesions have been all separated by the finger, it may sometimes facilitate the re- moval of the loosened body to seize it with such instruments, and, in that case, a pair of long dressing forceps, or polypus forceps, suits as well as any special implement; but the detaching of the adherent portions of the placenta should in no case be entrusted to these, or attempted with them, seeing that it can always be effected by the use of the sense- guided finger. But how are we, with the finger or fingers, to reach so high in the cavity of the uterus as completely to surround the ovum ? To begin with, the patient should, as a rule, be anesthetized. The manipulations necessary to secure a satis- factory result cause suffering, though not to a great degree, which we can always save the patient by bringing her under the influence of chloroform. And at the same time that her no Morbid Conditions of Pregnancy . sense of pain is abolished, her voluntary muscles are com- pletely relaxed, and it becomes easy for the practitioner to press down the uterus through the abdominal parietes. Once and again I have found myself baffled in the effort to reach the fundus uteri in such a patient until I had chloroformed her ; for, however willing the woman may be to further your efforts for her delivery, involuntarily she contracts the recti abdominis when you make pressure on the hypogastrium, or withdraws herself when you press the other hand against the perineum. The patient, then, having been anesthetized, we may render the uterine cavity accessible to the exploring finger in one or other of two different ways. l.s^. We can push down the fundus uteri from above. The patient may lie either supine or in the ordinary obstetric position on her left side, with the knees drawn up ; most frequently the right hand will be used for internal manipu- lation, while the left is applied to the abdominal surface. It rarely suffices to pass one finger alone into the vagina. In most cases the index and middle fingers are passed into the vagina, and while the middle finger is folded in the fornix to steady the uterus there, the forefinger is passed through the cervix. Or the middle finger can sometimes be more satis- factorily employed for the intra-uterine digitation ; or, better still, both fingers may be passed into the uterine cavity. In the last case it may become necessary to have the other two fingers carried into the canal of the vagina, the thumb alone remaining external to the vulva. It is usually only in patients who have miscarried at the fourth month, or beyond it, that the hand requires to enter so far for the separation of the placenta, and then the vaginal cavity is relaxed and roomy enough easily to permit of it. "Wliilst the fingers of the right hand are thus seeking their way up to the recesses of the uterus, the left hand, applied above the brim of the pelvis, is pressing the uterus forcibly and steadily downwards into the pelvic cavity. In this way, in the great proportion of cases, we obtain perfect command of the uterine contents. The fingejs of the two hands recognise each otlier through the Treatment of Abortion. 1 1 1 double thickness of the abdominal and uterine parietes ; and, while the left hand keeps the fundus fixed firmly downwards, the forefinger of the right peels off the adherent mass and forces it through the cervical canal. In the great proportion of cases, I repeat, we can in this manner compel the evacua- tion of the uterus, and when it fails us our resources are not yet at an end ; for, 2cl. We can drag down the cervix from below. The first is the method that has most frequently been employed, and it has this in favour of its common employment, that abortions are more frequent in multigravid than in primigravid women ; in women, therefore, in whom there is usually a degree of abdominal relaxation, which greatly favours its execution. But where the walls are more resistant, or the patient is so fat that the combined external and internal manipulation fails us, then we must seize one or other of the lips of the uterus — usually the anterior — with a volsella, double or triple pronged, and slightly curved. One of the blades grasps the vaginal aspect of the front wall of the cervix as high up as the roof of the vagina, the other at a corresponding level within the cervical canal. The uterus is capable of being dragged far down without any injury to its ligaments or laceration in the bite of the volsella. It may be pulled down with the right hand and kept fixed with it, wliilst the fingers of the left pass into the cavity and explore and eva- cuate it. Or the volsella may be held in the left hand, or given to an assistant, to keep the uterus depressed, whilst the more familiar right-hand fingers do the intra-uterine work. The cavity of the uterus is thus brought within full reach of the fingers, and we can — and in all those cases of imperfect delivery in the early months we ought to — control the empty- ing of the cavity from fundus to os (fig. 4). Whilst the method of gaining access to the interior of the uterus by pressing it down from above is that which has hitherto been ordinarily followed, my own experience leads me to expect that this second method, which I have just described, will largely supersede it. For, first, it is applicable 1 12 Morbid Conditions of Pregnancy, in all cases where the other can be employed, and in some where the rival method is not available. Second, it is less painful, and may be carried out occasionally when there is not time for the administration of an anaesthetic. Third, it saves the expenditure of muscular power demanded of the practitioner, who presses and keeps the uterus pressed down from above only by overcoming the resistance of the abdo- minal walls. The one circumstance that will enable the bi- manual method to hold its ground is, that we may find our- FiG. 4. Vertical Section of PELAas, showing relations when TJtenis is hauled down, a, symphysis ; h, bladder ; c, uterus ; d, perineum ; c, rectum ; /, volsella. selves called on to clear out the uterus at a time when we have no volsella at command, whilst our hands we always carry about with us. I close by reading the notes, from my ward journal, of a case which I had under treatment quite recently in the Royal Infirmary, the occurrence of wliich, indeed, suggested to me the desirability of making this brief communication on a most important subject : — Case of A bortion. 1 1 , CASE, — IMPERFECT ABORTION AT AN EARLY MONTH ; CONTINUOUS HEMORRHAGE; DILATATION WITH SPONGE-TENT; REMOVAL OF FRAGMENT OF OVUM ; RECOVERY. A. E., set. 39, married, recommended by Dr. Alexander of Leslie to the Infirmary; was admitted, 15tli February 1876, into ward 12, medical, complaining of a red discharge from the vagina, which has lasted nine weeks. History of 'present attach. — The discharge began as an ordinary catamenia, and at first did not excite any alarm. Patient was nursing her last baby at the time (a child of fifteen months) ; but when she found the discharge still con- tinuing to flow beyond the period of an ordinary catamenia, she stopped nursing. The discharge was then accompanied by considerable pain, of a bearing-down character, situated in the inguinal and hypogastric regions. This continued for about five weeks. Since then the patient has been free from pain. She did not observe any shreds or clots in the dis- charge ; but at the end of December (three weeks after its commencement), while sitting one day at the fire, she was aware of a body suddenly coming away from her, which she describes to be of a firm consistence, dark red, and about the size of an egg. Two other smaller bodies also came away, and the discharge for the moment was very copious. It has latterly been diminishing in quantity and becoming lighter in colour; but last Wednesday (9th February) it was as bad as ever, and two small bodies like blood-clots came away. History of previous health. — Is good, but patient has been falling off since the discharge began. Ohstetric history. — Patient has been married seven years, and has had four children. One is dead, the others are all healthy, the eldest being about six years old. All the chil- dren were carried to the full time. The labours were easy, with the exception of the last but one, which was protracted. On that occasion the lochia was very abundant, and a few weeks after patient suffered from pain in the back. On ap- H 114 Morbid Conditions of Pregnancy. plying for medical aid, she was told tliere was ulceration of the womb. There is no history of miscarriage. Menstruation began at the age of 20. It has not been attended by pain or undue discharge. Present condition. — Patient is a fairly-developed woman of average height. There is no expression of suffering or obvious emaciation. Integument natural. Temperature normal. Abdomen. — On inspection, a dark line between the um- bilicus and pubis is seen, and lineas albicantes. There is no tenderness on palpation. Percussion note is tym- panitic. Vaginal examination. — The ostium vaginoe is patulous, walls relaxed and very moist, at lower part of anterior wall a rough puckered surface is felt. Os uteri is rather high, is transverse, and directed shghtly backwards ; the anterior lip is thick, and some irregularity is felt on both lips. The finger can be passed through the cervical canal and internal os, but is immediately met by a round body of soft consistence, which seems to project from the uterine wall. Diagnosis. — Incomplete abortion. Ihth Fehruary. —Tamix 98°, pulse 76, resp. 20. 16th Fehruary. — Ordered hypodermic injection of ergotin — Vesp. A large sponge-tent was introduced. 11 th February. — An examination with a view to operation was made to-day under chloroform. On removing the sponge- tent, the mass could be felt projecting through the os. The anterior lip of the uterus was seized with a curved volsella, and the uterus was pulled down and kept fixed in the lower part of the pelvis. Professor Simpson then was able to ex- plore the entire cavity of the uterus with the forefinger, and peeled off without difficulty the polypoid body. This was adherent to the back wall of the uterus, somewhat low down and towards the left side ; and whilst the patient was still asleep the surface of its attachment was distinctly felt by the resident physician and some members of the clinical class. Case of Abortion. 1 1 5 The removed body proved, as had been anticipated, to be a fragment of an ovum. It was of the size of a walnut ; and, under the microscope, the structure of placental villi in different stages of growth could be easily seen, Vm-p. — Had shivering in afternoon, skin moist. Ordered ergotin injection. \Wi February. — Slept well all night. No discharge; no pain. 2od February. — A slight discharge the last day or two, but which is lighter in colour than before. Patient has no pain, and is looking well. 24it]h February. — On examination bi-manually and with the sound, the uterus is found to Idc of normal size. 2^th February. — Patient discharged, well. 1 1 6 Mechanism of Labour MECHANISM OF LABOUR. THE HEAD-FLEXION IN LABOURS OOME of the most valuable contributions that have been made in recent years to our understanding of the pheno- mena that come under the obstetrician's observation we owe to Professor Lahs, of Marburg. His writings seem to have attracted little notice as yet from our home litterateurs; but his chief work, published two years ago,^ when it becomes better known, will do good service in two directions. On the one hand, it will help to dispel errors that are harboured in some text-books and teachings ; and, on the other, it will guide to a truer conception of many of the phenomena of pregnancy and parturition. As an illustration of the former service, I may note how satisfactorily he lays the antiquated ghost of gravi- tation that is called up from time to time to explain the pre- dominance of head presentations over all the others. This poor ghost, called up sometimes in pages that make persistent and peculiar claim to be accounted scientific, appears in the page of Lahs to be at once a needless and a useless ghost : needless, for the phenomenon is shown to be due to other causes ; and useless, for it is unequal to the task imposed upon it, and greater weight of the presenting part is the effect and not the cause of its low position. It does not become, to my mind, any more needful or useful that it is commonly brought on the stage under the great auspices of Aristotle.^ ^ Edinburgh Medical Jourtml, xxiv. 865, 1878-79 ; and Transactions of tlic Edinburgh Obstetrical Socictij, v. 75. 1878-79. " Die Theorie dcr Gchurt. Boun, 1877. •* The gravitation theory is also noticed only to be put aside in the latest Movements of Head in Passages. 1 1 7 It is, however, ratlier to an illustration of the value of his work in the other direction that I wish now to invite the attention of the Society. I wish to show, namely, how his explanation of the production of the Flexion of the Head applies to a particular case that I do not know how to ex- plain accordiDg to previously accepted theories. Let me first call to mind in a sentence or two the various movements impressed on the foetal head during labour. They are usually set down as six in number.^ But two of them may be struck out of the enumeration, seeing that they go on more or less progressively throughout the second stage, and simultaneously with some one of the other movements. The first movement of Descent or Engagement (as the French call it) may for a time be distinguished from every other change in the relation of the head, but it does not cease when the central point of the head leaves the straight line of the axis of the brim to move along the curved line of the circle of Cams. So with the second movement of Adjustment — the synclitic movement of Kueneke,^ by virtue of which the engaging plane of the head is kept more or less nearly ad- justed or levelled to the plane of the pelvis through which it is passing. The synclitism is not confined to the planes parallel to the brim, but is continued, at least theoretically, when the canal begins to curve forwards, and its planes meet that of the brim at a gradually increasing angle. The other four movements occur in contrasted pairs. The first * (I. Flexion) and third * (III. Extension) are the converse one of the other. So are the second •(" (II. Internal Ptotation) productions of the French and Belgian schools. See the suggestive treatise Da V Accommodation en Ohstctriquc, by Dr. J. Martel ; and the admirably- systematic Cours cV Accouchcmcnls of the younger Hubert. 1. Descent. The clearest and most compact account of the mechanism of labour that I know of in English \d\\ be found in an article by the late Dr. Ritchie in the Medical Times and Gazette for 1865, 381. 2. Levelling. * I. 3. Flexion. + II. 4. Internal Eotation. * III. 5. Extension. t IV. 6. External Eotation. - Die Vier Factorcn der Gehurt, 35. ii8 Mechanism of Lab ottr. and fourth -f (IV. External Eotation). Of the odd pair,* No. I. occurs in a tyj)ical case at the inlet ; * No. III. at the outlet of the pelvis. Of the even pair, "f No. II. takes place when the head is within the cavity of the pelvis ; -f* No. IV. when it has got free of the canals. For the due appreciation of each of these four movements there are four questions that have to be asked and answered : 1. What ? 2. Where ? 3. How ? 4. Why ? If we try to answer these four questions in regard to the first of the four movements — the Flexion — we get more assistance from Lahs than from any other writer on the subject, more particularly when we try to answer question 3. But let us briefly take up the questions in their order. I. — THE NATURE OF FLEXION. The answer to the question, What is Flexion ? offers no difficulty. It is a bending of the head forward. The head rotates on its transverse diameter, and is bent at the occipito- atlantoidal articulation, so that the chin is approximated to the sternum. It is sometimes called " the Eoederer obliquity," because Eoederer^ described the head as being so placed in the uterus that the chin was bent on the thorax, and the face directed to the fundus uteri, while the occiput alone, conical and pointed, entered the upper aperture of the pelvis. According to him, the head engaged in the brim not with its straight or occipito-frontal plane parallel to the plane of the brim, but with an oblique or sub-occipito-bregmatic plane parallel to that of the brim. But this leads us at once into the second question, which has regard to — II. — THE SPHERE OF THE FLEXION. Where does it take place ? Whilst Eoederer gave the head an exaggerated degree of flexion ere yet it had escaped from the uterus, Kueneke^ goes to the other extreme, and does not ^ Icones Utcrilh(,mani Ohscrvationihus illustratcc. Gott., 1759. Tab. v. 21. 2 Oixre Citato, 50. sphere of the Head-Flexion. \ 19 allow the Hexion to take place until the internal rotation has been completed, and the sinciput is pressing upon the tip of the sacrum. To say that the chin is bent towards the sternum at the close of gestation, and before labour begins, is simply to say that the foetus maintains, through the whole course of its de- velopment, the form imparted to it at its earliest formation. When the outlines of the embryo can first be clearly recognised, we have a boat-shaped body incurved on its anterior aspect, and any degree of extension of the trunk or head that is met with, either before or at the full term, is a deviation from the normal attitude. Hence when the membranes rupture we find a point near the centre of the sagittal suture correspond- ing to the axis of the pelvic brim. The movement of flexion, which brings a point nearer and nearer to the occipital pro- tuberance into correspondence with the axis of the brim, begins whenever the advancing head meets with distinct re- sistance from the parturient canals. In certain cases, with relaxed soft structures and roomy pelvis or small foetal head, there may never occur any marked increase of the normal incurvation. No appreciable flexion occurs, or occurs only at the floor of the pelvis. Most frequently it occurs markedly when the head first comes into relation with the resistant pelvic walls. But not seldom it has already begun witliin the cervical canal, and, in the case which has led to this com- munication, the soft or, as Lahs prefers to call them, the elastic canals alone have had an opportunity of making their impress on the head. It occurs highest up in cases where the normal-sized head meets with early resistance from rigi- dity of the elastic or narrowness of the bony canals, or where a large-sized head has to pass through canals of normal calibre and resiliency. So we are brought to the subject of which, as I have indicated, Lahs helps us to give the most satisfactory explanation, viz. : — III. — THE CAUSE OF THE FLEXION. In answering the question, ^02<; is the head-flexion produced ? obstetricians have usually followed Naegele in pointing out how I20 Mechanism of Labozir. the spine of the child is articulated to the base of the skull at a point nearer the posterior than the anterior extremity of the long diameter of the head, and they have assumed that the par- turient force was transmitted to the base of the head through the medium of the resistant spinal column. The long diameter of the head thus comes to represent a lever with two arms, a shorter posterior and a longer anterior. The parturient power causes the occiput to descend first, say some, because its force acts most directly on the shorter posterior arm. Others would more correctly refer the flexion to the resistance pl'esented equally from below to both extremities of the lever by the pelvic walls. The resistance supposed to be bearing^ equally on both extremities will tell with greatest effect at the extre- mity of the longer anterior arm, so that the forehead is more powerfully resisted, and the occiput is allowed to take the advance of it through the canals. But this mode of explana- tion leaves us quite at fault when we have to do with a foetus such as I show to the Society now. (See fig. 5.) It was the first child of a young married woman who suffered from albuminuria from the sixth month of pregnancy, and in whom premature labour set in about the seventh month. Mr. Gray, house surgeon to the Maternity, was called to see the woman, but the child was expelled before his arrival. It had evidently been dead for a few days. She had had labour pains going on more or less for some fif- teen hours, with occasional drib- bling away of the liquor amnii. The placenta was not preserved. Fig. 5. ^ A\'iH'tl)cr the soft .stnicturcs do not present more resistance in the back than in the front sections of the pelvis — as I believe will be found to be the case — must be determined by direct researches such as those presented to the Society at its last meeting by Dr. Ilart. Cattse of the Head-Flexioji. 121 The premature child measured 17 inches in length. The head measured Al\ inches in the occipito-mental diameter, 3-^- inches in the occipito-f rental, and 2^ inches in the suL- occipito-bregmatic. In its transit through the canals the head of this foetus has received an impress which remains, and which enables us to read off the relations of its various parts. The chin fits into a depression in the thorax that could only have been pro- duced under prolonged or powerful pressure. The elongated appearance of the nucha, which presents a surface continuous with the sub-occipital surface, instead of meeting it at an angle, confirms the impression of extreme flexion that had existed intra partum. But absolute certainty is attained when we notice the circular compression of the head that has taken place in the plane of the sub-occipito-bregmatic dia- meter, with the compensatory elongation of the head in the occipito-mental diameter, and when we observe the situation of the caput succedaneum over the upper portion of the occiput, with its centre at the posterior fontanelle. When we look, further, at the dimensions of this head, it becomes clear that it has never come into any relation of pressure with the bony canal. Hence we are prepared to listen to Lahs, when, in ordinary cases, he asks us to attend more to the influence of the elastic canals instead of paying almost exclusive regard to the rigid bony tube in searching for the cause of the flexion. Here it is, in a most pronounced degree, where only these elastic canals could possibly exert an influence. But when we look again at the fcetus we see that the uterine force could not have been transmitted to the head through the medium of the spinal column. The fcetus had been some time dead. Its tissues, all of them, have lost all resiliency. The trunk is limp and flaccid; the vertebral column can be twisted easily in any direction ; the uterine pressure could be as readily transmitted through the folded- up limbs as through the doubled-up trunk ; the whole body is just as serviceable for the transmission of force as a molluscous animal, and no more. This prepares us to listen 122 Mechanism of Labour again to Lahs when he asks us to regard the parturient power as transmitted to the presenting head, not through the foetal axis alone, or mainly, or at all, but through all the uterine contents that lie above the zone immediately embraced by the expanding passages. This zone, it may be well at this point to remark, has received from Lahs the fitting designation of " the girdle of contact." " The general contents-pressure," by which we are to understand the sum of all the forces that aid in the expulsion of the uterine contents, acts perpendicu- larly to the surface of this girdle of contact. The result is that every point of the presentiug part of the child in this girdle of contact is driven forward with equal force in the direction of least resistance. The force bearing on a point in the anterior part of the head is as great as a point in the posterior part ; and were the head-globe, as we sometimes speak of it, a perfect sphere, the hindhead and forehead would descend at the same level as they engaged in, notwith- standing that the spinal / column is nearer the '' occiput than the chin. But the form of the advancing head is not that of a sphere, and it is in showing how the normal shape of the head necessitates its flexion under ordinary circumstances that the most original part of Lahs's work consists. His explanation will be most easily under- stood if I show you his diagram (see fig. 6) and quote his own words. The diagram represents a liead-presentation, with the still imperfectly expanded os forming the girdle of contact. " The head," he says, " is a wedge, whose surfaces are found through the tangents which we make on those Shape of the Fcetal Head. 123 points of the surface of the head which are immediately embraced by the girdle of contact. These tangents are a d and h e. Wlien a force acts on such a wedge in the direction of the parallel lines a c and h f, that is, perpendicular to the plane of the girdle of contact (and the general contents- pressure as the dominating expulsive power always acts in that direction), it will push forward the surface h e through the girdle of contact by so much the more, as the angle e hf is less than the angle c a d. That is to say, in such a case there will be a depression of the hindhead." This angle he calls the guiding-angle. And the law is, that that end of the cephalic ovoid will be guided foremost, the tangent of whose surface in the girdle of contact meets the perpendicular of that zone at the smallest angle. I desire to point out here how Lahs's diagram applies itself admirably to the head of the child in Plate C. of Braune's well- known illustrations^ (see fig. 7.) Let the divided margins of the external os represent a section of the girdle of contact (a b). Eun a line {b f) through the anterior lip (b) along the back of the symphysis pubis, and another {a c) parallel to it through the back lip (a), and it will be seen that they indicate the canal through which the parturient force will expel its contents in a straight line. Apply now a tangent [e b) to the occiput at the anterior lip, and it will be seen to meet the anterior straight line at an angle (e b f) of 10°. Apply a similar tangent {d a) to the sinciput at the posterior lip, and it will be seen to meet the posterior line at the larger angle (c a d) of 35°. Wlien the parturient forces are in action the occiput will tend to descend more rapidly than the forehead in the ratio of three and a half to one. It is noteworthy that the section of the foetal head in Braune's plate is oblique. Lahs applies his theory simply to the straight occipito-frontal diameter of the head. When we see it capable of application to such a section as Braune's, we may conclude that it is applicable to any similar section ^ Die Lagc clcs Uterus unci Fcetus, etc. 124 Mechanism of Labour. which runs from a point in the hindhead between the parietal and occipital bosses to the opposite point in the frontal region. If the head be looked at in profile the line that runs Fig. 7. over the vertex between the parietal protuberances may be regarded as a ridge from which there are two inclines — the shorter one runnimr downwards and backwards towards the Cause of the Head-Flexion. 1 2 5 occipital protuberance, the longer running downwards and forwards towards the frontal eminences. The posterior gradient is everywhere the steeper of the two, and this, supposing the theory of Lahs to be true, enables us to comprehend more fully the force of the special factor on which it fixes our attention. This result of the peculiar wedge-like shape of the head is produced during the continuance of a pain. But when the pain has reached its acme, and begins to relax, there comes into play another force, which continues to increase the flexion that has been initiated in the manner I have described. The resiliency of the elastic canals, namely, now begins to assert its influence. Here the observations of Lahs are not so original. Other obstetricians have pointed out this effect of the elasticity of the soft walls even during the pain, but I give the explanation of their influence in his terms, and with his diagram, the rather that I first learned it from his paper on the subject in 1870.^ The quotation or paraphrase which I make now, however, is stUl from his last work, Die. Theorie der Geburt (p. 196). "We are to think of the head as in the position represented in this woodcut (see fig. 8). When the head is compressed in its greatest periphery in the line of the girdle of contact a & by the elastic walls, as they resile at the close of a pain, the pressure will be applied to the points a and h. To ascertain the effect on the head, we must break up the forces a and T) into their components of c and d for a, Fig. 8. and e and / for h. Then we see that the quanta of force re- presented by e and d exert no influence on the head. The forces c and /, on the other hand, act in precisely opposite directions, and as their points of pressure do not lie in the same straight line, they impart to the head a rotation in the 1 Der Durchtrittsmechanisnmis dcs FriKhtkopfcs, etc. Archiv fur C^ynceko- logie, i. 430. 126 Mechanism of Labour. direction indicated by the arrows c and /. This rotation pro- duces an approximation of the chin to the sternum, and pro- motes the descent of the hindhead. In other words, the flexion which is begun during a pain is kept up and increased by the elastic reaction of the soft canals that immediately ensues. Now, I have still an impression, which may be only a pre- judice, that Lahs goes too far in minimising the influence of the lever form of the long diameter of the head, and letting us retain the old explanation of the production of the flexion only in as far as the specific gravity of the body of the foetus exceeds that of the surrounding liquor amnii. One cannot help thinking that under the influence of the form-restitution- power, as Schatz calls it, of the uterus, when the uterus gathers itself as a resistant tube around its contents, the pressure of the fundus must sometimes bear upon the breech of the child — more particularly when the liquor amnii is scanty — so as to make its influence perceptible through the spinal column. At the same time, the more I look at such a picture of the condition of the child as is seen in Braune's plate already referred to, the more I am disposed to accept the doctrine that the fcetus is compacted with its surrounding fluid into a homogeneous medium, for the transmission of the general-contents-pressure to the zone of the presenting part that is meeting with resistance in the maternal canals. And, as I have indicated, I am prepared for a wide application of Lahs's explanation of the production of the flexion when I see how satisfactorily it explains the flexion in the case of this flaccid foetus. Here the shape of the head is the perfect wedge-shape of the normal full-sized head ; and if we place it in a canal, and observe the angles formed by the tangents respectively of the sinciput and occiput in the girdle of con- tact with the perpendiculars to that zone, we see how, under the general pressure from above, the occiput must have advanced first, because it was placed at the small or guiding angle.^ ' If the reatler will draw a line on tlic head in fig. 6, in the direction of the occipito-frontal diameter, and run two perpendicular lines from its two Effect of the Head-Flexion. 127 And again, when we remember that the head was driven pre- maturely through a primiparous cervix, we know that just in these conditions of prematurity and primiparity the soft or elastic canals are most resistant and resilient. Hence, as each pain relaxed, there would be a very distinct increase of the flexion as the part of the wall in contact with the occiput pushed it forward below the level, say, of the bi-parietal diameter, whilst the part of the wall in contact with the sinci]3ut pressed it backwards at a higher level, IV. — THE EFFECT OF THE FLEXION. Everybody is agreed as to the answer to question 4, Wliy does it occur ? It is to bring a smaller longitudinal diameter of the head into relation with the diameters of the canals through which it is moving. There are three longitudinal diameters, of which one is straight, the other two oblique. Their respective average measurements may be set down at 5 inches for the oblique occipito-mental, and 4| inches for the straight occipito-frontal. As for the sub-occipito-bregmatic, the length of it varies according as we carry the bregmatic ex- tremity of it forward to the anterior part of the large f ontanelle, when it measures 4 inches ; or toward the posterior angle, when it measures 3| inches ; or still further backwards to a point in the sagittal suture, when it may measure little more than 3 inches in length. Hence, when a head enters the brim with the plane of the occipito-frontal diameter parallel to the plane of the brim, it presents a line which corresponds pretty closely to the usual measurement of the right oblique diameter of the pelvis, or 4i inches. But as the flexion goes on and in- creases, the diameter that runs in the line of the right oblique of the pelvis becomes diminished to 4 inches, 3| inches, or even to 3 inches, in cases of marked resistance in the parturient passages. That the head will thus more easily traverse these canals — " that understands itself," as the Germans say. extremities, he will at once see that the occipital angle is much smaller than the frontal one. 128 Mechanism of Labour HEAD MARKINGS.! At a meeting of the Obstetrical Society on JSTovember 27, 1878, I showed a Fcetus from a case of difficult labour. I wished specially to bring under the notice of the Fellows the head-markings it exhibited (see fig. 9.) Three of these were artificial, and easily understood. Thus, on each side of the head the fenestrated mark, due to the firm forceps-grip, was easily noticeable, as well as the perforation in the occi- pital bone, which was found neces- sary to allow of extraction. The two other markings were, however, of quite a different nature, and occurred very rarely. They were due to a dis- tinct deformity of the pelvis, and the resulting impressions on the fcetal head. The first of these was a deep indentation over the right half of the a Inner bound'ary"f promontory froutal bonc. Coinciding laterally and ^PosrrfotSorder of promontory postcriorly with parts of the froutal c Mtrkofforceps- blade. and coroual suturcs, and evidently due to pressure against the projecting promontory of the sacrum. Behind, there was a transverse bar at the nape of the neck, where it had lain opposite the posterior aspect of the pubis. These markings explained fully the state of affairs when operative interference was begun, the nature of the interference, and the character of the pelvic deformity. The head had evidently lain well down in the pelvic cavity, markedly flexed, and almost perfectly rotated, with the occiput forward and to the right, and the sagittal suture running somewhat obliquely up to the left. The marked flexion pointed to the pelvis being a decidedly con- FiG. 9. — FcETUS, with Head- Transadioiis of the Edinburgh Obstetrical Society, v. 12. 1878-79. Head- Markings in Difficult Labours. 129 tracted one, while the promontory mark proved clearly that it was " flat." It was, therefore, a " flattened universally contracted pelvis;" and it was this combination which had caused the very rare and interesting head deformities they now saw. In striking contrast with the preceding specimen was the one I next exhibited. The case had occurred in the practice of Dr. Wilhamson of Leith, and was a transverse presenta- tion where Dr. W. had turned. As he had some difficulty in extracting the head, I was sent for. When I arrived, how- ever, the difficulty had been overcome. In front of the right ear there was a vertical furrow and depression of bone about an inch in length. On the opposite side of the head was a transverse mark just behind the left ear. The cause of these was evident. The pelvis was ricketty, and the projecting pro- montory had made its mark on the extended head as it passed down after turning. The transverse mark was due to the pressure of the posterior aspect of the pubis. 1 30 Morbid Conditions of Labour MORBID CONDITIONS OF LABOUR. ON DYSTOCIA WITH DORSAL DISPLACEMENT OF THE AEM.i "TN 1850 Sii- James Simpson made his weU-known commu- nication^ to this Society on a "New Form of Obstruction in Head Presentations from Posterior Displacement of the Arm." In 1859 ]\Ir. J. Jardine Murray ,3 of Brighton, met with a similar case which he recorded, accompanied with some re- marks by Dr. Eastlake. In 1862 Mr. Cox of Sudbury, among other cases in midwifery, records* a case of convulsions where the head presented " with the forearm placed across the back of the head." In 1867 Professor Play fair ^ published " Notes of a Case of Difficult Labour due to Displacement of the Cliild's Arm," in which, after the delivery had been effected by craniotomy, it was found that the arm was dis- placed behind the head. In 1868 Dr. Angus MacdonakP contributed to our Transactions the history of two cases of this form of dystocia that had come under his observation. And in 1870 Mr. Lambert^ described the subject more fully in a communication founded on a case of arm displacement, which did not, liowever, strictly belong to the same category, seeing that the forearm had fallen down below the head, 1 Edinburgh Medical Journal, xxiv. 961, 1878-79 ; aud Transactions of the Edinburgh Obstetrical Society, v. 97. 1878-79. '- Edinburgh Monthly Journal, 389, 1850 ; and Selected Obstetrical Works, 381. =' Medical, Times and Gazette, i. 027. 1861. ^ Dublin Quarterly Journal of Medical Science, xx.\iv. 281. •''' British Medical Journal, i. 194. 1867. " Edinburgh Medical Journal, i. 59. 1869. " Transactions of tlie Edinburgh Obstetrical Society, ii. 20.3. Dorsal Displacement of the Ann. 131 iilthough tlie arm occupied an unusual position, and was placed in relation to the posterior instead of the anterior part of the head. Eeference to these, or some of these cases, form the staple of what systematic writers give when treating of this subject; and in Crede's^ exposition of the disturbances of labour from displacement of the arms along with the pre- senting head, he describes the dorsal displacement in this single sentence : — " In very rare cases the upper arm places itself as far as the elbow straight up along the head, whilst the forearm lies in behind, in the nucha of the child." A week ago, on the 19th instant. Dr. M'Watt asked me to see an out-door Maternity patient, as my colleague, Dr. Macdonald, was unwell. The woman, Mrs. M., 31 years of age, had already had six easy labours at the full term, the last eighteen months previously. She was last unwell in June, quickened in October, and was taken in labour before 8 P.M. on the 18th inst. She was ill all night. "When seen in the morning, the os uteri had been found but slightly dilated, and the head presenting, but difficult to reach. She had had strong and constant uterine contractions all the day of the 19th. At 6 P.M. the os having been well dilated, and the head not descending, the membranes had been ruptured by Mr. Wilson, the student in charge of the case, who felt then that there was some displacement of the hand. From this time, though the pains had been continuous, the labour made no progress. On the contrary, the uterine orifice seemed to have become narrower, and when Dr. M'Watt had visited her at 9 p.m., he found the uterus acting irregularly, and, liaving introduced his hand so far as to recognise the dorsal displacement of the arm, came to ask my aid in the delivery. I found matters as they had been described to me by Dr. ]\I'Watt. The external orifice of the uterus was deeply fissured from the previous labours, so that the anterior and posterior lips hung loosely apart. The head of the child was high up, quite above the plane of the brim. Four fingers ^ Klinischc Vortrdgc ilber Geburtshulfc, 563. 132 Morbid Conditions of Labour. were passed at once into the vaginal canal so as to get better access into tlie uterus, the walls of which were in a state of continuous retraction, with occasional painful efforts at more active contraction. The internal os was re- sistant. The head, which was of small dimensions, was high in the right occipito- anterior posi- tion ; and to its left side, between the ear and the symphysis, the elbow could be distinctly felt. The relation of the head to the pelvis, and of the arm to the head, is re- presented in fig. 10. The uterine walls were firmly closed round the child, and the tense fibres in formed a kind of shelf, by the displaced arm was arrested. The child had not come into any relation with the pelvis, and the whole play of the labour was going on within the uterus itself. "We chloroformed the patient so that the exact relation of the head and displaced left arm could be more clearly made out ; and as her energy was ex- hausted, and her pulse beginning to rise, we delivered her easily with a pair of Tarnier's forceps. When the head was drawn into the pelvis, the arm remained within the uterus and came down afterwards with the trunk. Strong compres- sion of the uterus was required for the separation and expul- sion of the placenta. The child was a rather small female. After it was born it was easy to place the left arm, which was slightly congested, in the situation in which it had been felt in relation with the head in vtero. Fio. 10. the lower segment of the uterus on which the projection formed Dystocia from Arm Displacements. 13, FREQUENCY OF ARM DISPLACEMENT. The relative frequency of head first labours complicated with procidence of one or both of the upper extremities, is yariously given by different authors. Madame Lachapelle^ found in 15,652 labours only 8 with a procidence of the u.pper extrem- ities either alone or with prolapsus funis. Hecker'^ gives 8 in 3339, or 1 in 417 cases of descent of arm with head, as the statistics of the Munich Hospital. Pernice^ has out of 2891 labours, 43 in which there was descent of hand or arm alone or with the cord, from the Halle Maternity. In the records of our own Maternity, Dr. M'Watt finds 5 cases of descent of the hand or arm along with the head, among 2512 labours. The diversity of the figures may be due to the circumstance that, in some of the institutions, a note is only taken of cases where the whole arm was procident, or led to some delay in the labour, whilst in others all the possible deviations in the rela- tion of the upper extremities were registered. In the Halle statistics, for example, there were only 8 out of the 43 cases that were full arm displacements. The remainder were dis- placements of one or both hands simply, or of hand and cord. DEGREES OF DISPLACEMENT. 1 have met with illustrations of the three different degxees of displacement. 1. Of the hand. — I have sometimes felt the hand with the fingers placed at the side of the head, or spread over the parietal bone through the yet unruptured membranes, and have seen, as is so commonly the case, that it was withdrawn beyond the head, so that when the waters escaped the head passed on alone. 2. Of the forearm. — I have met the forearm coming through ^ Pratiqtoe des Accouchements, iii. 214. 2 Klivik der Geburtskumde, ii. 144. ^ Ble Geburtcn mit Vorfall dor Extrcmitdtcn nebcndem Kopfc, 11. Leipzig, 1858. 134 Moi^bid Conditions of Labour the brim of the pelvis, along with the head, when the second stage was beginning, and fonnd it then easy to be replaced. 3, Of the arm. — But the really difficult cases are those, of which I have also seen illustrations, where the upper segment of the arm was thrown along the side of the head, whilst the hand and forearm preceded it through the pelvis. The dorsal displace- ment cases belong to the same category. The peculiarity in this special variety of displace- ment consists in this that, whilst the arm proper is applied to the side of the head, it is an unusual relation. Commonly, the arm lies in front of the ear, its bulk being added to the shortest transverse diameter of the head — the bi-temporal, whilst the fore- arm either hangs below the head in the parturient canal or is applied flatly to the side of the head. Occasionally, however, the arm is applied to the side of the head, so that its bulk is added to the broader bi-parietal diameter ; and it is when we have the arm in this position, with the forearm flexed at the elbow, and the hand lying behind the occiput, that we have the special form of dystocia signalized and figured (seelig. 11) by Sir James Simpson, and which was present in Mrs. M. Fifi. 11. MODE OF PRODUCTION. To inquire into the manner in which this displacement comes about would thus lead us into the general question of the causes of procidence of the upper extremities, whether these are to be found in Fault of the First, the Second, or the Third Factor of labour. On this discussion I do not propose to enter. But I cannot help expressing the opinion that in our patient the primary fault most probably lay in irregular contractions of the uterus. She was a multiparous female, as all the others Iiave been in whom this variety of arm displacement has been observed ; and the multipara is more prone to irregular action Delay in Ann Displacements. 135 of the uterus than the primipara. The pains which kept this multipara awake the twelve hours of the night of the 18th, and which went on painfully and continuously for ten hours of the following day, without leading to the usual rupture of the membranes, could not have been the pains of a regularly contracting uterus. The hand of the child was felt at the side of the head at the time the membranes were ruptured. Three hours later it was beyond the reach of the exploring iingers, and though we could fancy it to have been drawn up by the muscular action of the foetus itself, we know that the lower segment of the uterus was by this time in a state of persistent retraction and intermittent action, so that the os then felt smaller than it had done when the membranes were ruptured. At the same time, I cannot doubt that the angu- larities of the compound foetal presentation would tend to keep up the irregular action of the uterus already in process, and so a vicious circle would be established, under which, without artificial aid, the mother or the child, or both, would sooner or later have had a bad quarter of an hour of it. This leads me to offer a remark as to the CAUSE OF THE DELAY in such cases. When the arm descends with the head, it may have a deleterious influence in various directions, apart from the obvious difficulty caused by the addition to the bulk of the presenting part. Thus Cred^ and Hecker both point out the preponderant frequency with which the occiput is turned to the right instead of to the left side of the pelvis in cases of arm procideuce in general. This applies to the special condition under discussion. Of the six cases where the position is noted the occiput was to the right in three. Secondly, the elbow in some cases hitched on the brim of the pelvis and prevented its descent. Thirdly, we must theoretically believe that the head as it travels through the pelvis accompanied by the arm so displaced will be hampered in its usual movements, though of this we have no recorded observation. But, fourthly, in our case the delay 136 Morbid Conditions of Labour. was clearly due to the detention of the irregularly shaped compound presentation of the child within the irregularly con- tracted uterus. There was certainly no hitching on the pelvis. The uterus and its contents might have been pushed simultaneously into the brim. The head woidd have been free to pass under the impulsion from above of a truly acting uterus ; but during an examination, one got the impression that the irregular projection of the elbow beside the head had the effect of an irritant on the uterine nerves, and dis- turbed the normal current of uterine action. TREATMENT, I do not enter the wide field of the management of dystocia from arm displacement, or even from the dorsal displacement of it. In Sir James Simpson's case, he re- placed the arm by a movement, the first stage of which is represented in this woodcut (fig. 12). In our case, how- ever, there seemed to be but two al- ternatives: on the one hand sedatives might have been administered to allay the uterine irritation and arrest the uterine action. But the long escape of the waters and the commencing rise of the patient's pulse, made the alterna- tive indication of immediate delivery by forceps very clear. And, on the other hand, there was every prospect that a Fig. 12. force acting steadily on the head would either bring it alone through the cervix, whilst the elbow was detained above the contracted shelf in the lower segment of the uterus, or that if the arm descended with it, they would travel together safely through the roomy pelvis. The forceps, accordingly, was put on and the head alone came down in their grasp under a traction, which was very gentle, but which Treatment of Dystocia from Arm Displacements. 137 was kept up so continuously and so long, that when the head came to the floor of the pelvis, Dr. M'Watt sln-ewdly remarked that surely I was breaking one of the rules for the working of the forceps. He referred, of course, to the rule which teaches us to work only with pains, and where no pains are present only at intervals. But, whereas powerful and interrupted traction would have been likely to irritate the uterus and might even have endangered its structures, we know that a spasmodically contracted part of it will yield to gentle, long-continued pressure either from below or from above. Hence the traction which called forth Dr. M'Watt's criticism — a traction which may beneficially be adopted in some other forceps cases also ; and a traction, I may add, to which the Tarnier traction-rods lend themselves very kindly. NOTES OF A COMPLICATED CASE OF LABOUE, WITH EEMAEKS ON THE POSTUEAL TEEATMENT OF PEOLAPSUS FUNIS.^ The case which I wish to bring before the notice of the Society presents some features of interest in respect — \st, of the diagnosis of pregnancy ; 2t?, of the duration of pregnancy ; 'M, of the painlessness of parturition ; Mh, of prolapse of the umbilical cord, and its remedy by the postural treatment; ^th, of the employment of the forceps ; and, Wi, of the management of the third stage of labour. I. — DIAGNOSIS OF PEEGNANCY. Mrs. A. B. was in full process of parturition when she arrived at the Infirmary on the 29th of November ; but she had left home by the advice of her iiiedical attendant, who saw her the night before, and told lier she was labouring '^ Edinburgh MedicalJourTial, ix. 915, 1863-6-i ; and Transactions of Ediii- burgh Obstetrical Society. December 1863. JMorbid Conditions oj Labour. under a dropsical ovarian tumour. And yet nothing in obstetrics is more easy, when we are on our guard, than to distinguish between a gravid uterus at the full term and a dropsical tumour of the ovary. There may be a common sensation of fluctuation, a common smoothness of surface, even a common situation in the abdominal cavity, but it needs only the application of the stethoscope to detect the distinct placental and cardiac sounds, or the touch of the finger per vaginam to recognise the hypertrophied uterus \vith the moving body in the interior. In the present in- stance, the mistake was made by a very able and accom- plished practitioner, simply from his omitting duly to examine the case. He found the woman seated on a chair when he was summoned to see her ; and, having already made up his mind that she could not be pregnant, he contented himself with putting his hand over the abdomen, and feeling the tumour through her dress. He then told her that she should go off to Edinburgh, and have something done for it. And when she asked him for a line to secure her admission into the Infirmary, he added that they were all interested in this kind of tumour at present, and that no recommendation was needed, for her case would commend itself. Now, the pre- judice in his mind may have arisen from the circumstance that, when the patient, who is forty-four years of age, and the mother of seven children, had miscarried at the fifth month two years ago, he had been led to form the opinion, which he then expressed to her, that she could never again become pregnant. But he was further led astray by the cir- cumstance that more than ten months had elapsed since the date of her last menstruation ; and it seems not to have occurred to him that the case might be, as indeed it was, a case of II. — PKOTKACTED GESTATION. The patient menstruated in the beginning of January ; but the period lasted only two days, instead of four, as usual, having ceased (ju the 3d or 4th of the month. It was not Protracted Gestation. 1 39 till she felt " stirrage" in May, however, that she imagined herself to lie pregnant, and began to think of making pre- parations for her confinement. She expected herself to have been delivered about the close of September or beginning of October, but it was not, as I have stated, till the end of November that the event took place. Supposing her not to have become impregnated till the period succeeding that at which the catamenia so abruptly ceased, she could not have carried the child less than 300 days; and if, as is in the highest degree probable, both from the shortened menstrua- tion and the date of quickening, she became impregnated at the period in January, we have a term of utero-gestation ex- tending in this case to 329 days. The condition of the child at birth, and especially of its head, indicated a corresponding degree of development. It measured 21 inches in length, and weighed over 10-^ lbs. The head measured 14f inches in circumference ; the anterior fontanelle was small, and the membrane firm; and the posterior fontanelle was so far obli- terated, that the corner of the occipital could not be depressed below the parietal bones. III. — PAINLESS PARTUEITION. Our patient having had all idea of pregnancy banished from her mind, set out from home, and reached the Infirmary without experiencing any uneasiness ; and it was only whilst she was sitting in the nurse's room, explaining the cause of her arrival, that a sudden gush of water from the vagina re- stored her to the conviction that she was after all to give birth to a child. The uterine contractions were going on, although she was unconscious of any pain; and they must have been o'oins on for some time, for when the clinical clerk, Dr. Watson, saw her, almost immediately after this rupture of the membranes, he found the os uteri already fully dilated, and the head exposed. The woman had given birth to all her former children easily enough ; but %vith all of them she had, like other women, been conscious of the pain usuall}" 140 Morbid Conditions of Labottr. attendant on the uterine contractions. On this occasion, however, the first stage of labour was completed, not only without any suffering having been experienced on her part, but also without her ever being conscious that labour was in any degree in progress. And throughout the whole progress of the labour the uterine contractions seemed not to be accom- panied with the slightest pain ; for before the head entered into the j)elvic brim, the patient was unconscious of any sen- sation of suffering when the hand over the abdomen coidd feel the uterus distinctly contracting ; and afterwards, when the head was passing through the pelvic canal, there was no kind of pain, only a feeling of fulness resulting from the pres- sure of the head on the soft parts of the pelvis. The histories of such painless labours have from time to time been related to our Society ; Jourdain,^ Chailly,^ Montgomery,^ and many others, have published similar cases ; and their importance in a medico-legal point of view calls for a due notice of them in works on Medical Jurisprudence.'* I had never before met with a case of absolutely painless parturition ; but Dr. Von Eitgen, the venerable professor of midwifery at Giessen, told me some years ago, that in the course of his practice he had seen seventeen women who passed through the parturient process without any pain ; and from his observation of these cases he had been led to form the conclusion that the act of parturition is normally and physiologically a painless one, which only becomes painful and pathological in consequence of the abnormal and artificial mode of life led by the great mass of civilized womankind. His conclusion I have some- times advanced as an argument in answer to those who object to the use of anaesthetics in midwifery, on the ground of the fancied physiological character of the pain. ■■ Vclpcau, Be V Art dcs Accouchoncnts, i. 451. Paris, 1835. - CJiailhj-Honori, TraiU xiralique dc I'Art dcs Accouchemculs, 244. Paris, 1842. ^ Signs and Symptoms of Preg^iancij, 607. London, 1856. * E.g., Wharton and StilU, Z01 . Philadelphia, 1855. Prolapstis Funis. 141 ^v^ — prxOLAPftus funis, and its replacement by the POSTURAL TREATMENT. I first saw the woman on going to visit, for my uncle, the patients in his ward in the Infirmary, at one o'clock p.m., about a quarter of an hour after she had been seen by Dr. Watson. On making an examination, I found that a compli- cation had occurred, from the falling down of a loop of the umbilical cord, of four or five inches in length, opposite the left sacro-iliac synchondrosis. The umbilical vessels were pulsating vigorously, and the prolapsus must have taken place very shortly before, as there was none to be felt when Dr. Watson made the examination. We can easily understand the occurrence of prolapsus of the funis in cases of preternatural presentations and mal- presentations of the head, or where, from contraction of the pelvic brim, the presenting part of the child is prevented from adapting itself closely to the lower segment of the uterus ; but the conditions of its descent in cases of normal head-pre- sentation have not yet been accurately ascertained. In the present instance, we have a concurrence of three of the conditions that have been more especially insisted on as favouring the occurrence of this accident. First, The patient was a multipara, with a very relaxed and dilatable cervix uteri ; and, perhaps, there was a want of tonicity in this part of the organ, associated in her with the absence of sensation during uterine action. Secondly, The placenta was placed very low down on the uterine wall, for the opening in the mem- branes was bounded in part by the placental margin ; while, thirdly, the umbilical cord was inserted into the placenta within an inch of that part of its border ; — two conditions the importance of which have come to be abundantly acknow- ledged since the younger Naegele specially called attention to them in an essay on the subject.^ I might add, that the cord ^ H. Fr. Naegele, Gomincntatio dc caicsd quddatn pi-ola2)sus funiculi imibili- calis inpartu, non rard Hid quidcm, sad minus notd. Heidelb. 1839. 142 Morbid Conditions of Labour. was of more than average length, and measured 21 inches, for this too has been noted in connection with prolapsus of the cord; but Avhat exact share is to be attributed to each of these elements in the production of the complica- tion, it would be difficult to decide, for it is a kind of case in which the mind of the accoucheur is for the time less taken up with the cause than with the cure ; lie is more anxious to avert the consequences of the accident, than to determine how it was produced. And here, let me observe, that the gTeat variety of expedi- ents that have been adopted for the remedy of this complica- tion, and the vast variety of instruments that have been contrived for the reposition of the descended cord, are a sufficient indication of the imperfection and unsatisfactoriness of each and all of them. And when we look to the recorded results of these various forms of treatment, and find that, even in the best hands,^ little more than two-thirds of the children are saved, while the average mortality in the general mass involves more than the half, we are prepared to welcome a suggestion so simple and safe, and to adopt a measure so satisfactory as that described in 1858 by Dr. T. G. Thomas of New York, under the designation of " Tlie Postural Treat- ment." The history of the operation, and the mode of carry- ing it out, will be at once understood if I quote the words and copy the illustrations of the ingenious author.^ He says, " In a course of lectures on obstetrics, delivered by me in the University Medical College of this city, about two years ago, 1 Trofcssor HcL-ker, of Jliuiicli, in the recently juiblished second volume of Ills very instructive work on Clinical Obstetrics, gives the statistics of twenty- nine cases of head presentation complicated with prolajjsus funis ; and, after stating that nineteen out of the twenty-nine children had been rescued, he uses these words : — "I do not believe that we can in general achieve much more, for we have too many difficulties to contend with, and there are too many eventualities that may render the results nugatory." — Klinik del- llilurtJikundc, ii. 184. 1864. - See Figs. 13 and 14, in re-modelling which the drawings have been copied fiom Plate C of Braune's Lcf(jc dcs Fcctns. Postural Treatment of Prolapsus Funis. 14; DIAGRAMS ILLUSTRATIVE OF THE POSTURAL TREATMENT OF PROLAPSUS FUNIS. Fig. 13. Inclination of the LTterus in the Dorsal Posture, favouring descent of the Umbilical Cord into the Pelvis. Fig. 14. Inclination of the Uterus in the Knee-elbow Posture, favouring descent of the Umbilical Cord towards the Fundus Uteri. The dotted lines indicate the up^ier and lower limits of the distended cervix uteri. 144 Morbid Conditions of Labour. 1 closely investigated this subject, and came to the following- conclusions : — First, That the causes of the persistence of this accident (whatever may at first have produced it) reduced themselves to two, the slippery nature of the displaced part, and the inclined plane offered it by the uterus, by which to roll out of its cavity ; and, Second, That the only rational mode of treatment would be inverting this plane, and thus turning to our advantage not only it, but the lubricity of the cord, which ordinarily constitutes the main barrier to our success. This, I found, could be readily accomplished by placing the woman on her knees, with the head down wpon the hcd, in the posture assumed by eastern nations in worship, and now often resorted to in surgical operations uj^on the uterus and vagina. Let it be rememb(^red that the axis of the uterus is a line running from the umbilicus, or a little above it, to the coccyx, and it will be seen that by placing the woman in this position, it will be entirely inverted."^ Although six years have already elapsed since Dr. Thomas read his Essay before the New York Academy of Medicine, the proposal is not yet widely enough known, or, at least, the results of the practice have not yet been recorded in sufficient abundance to allow us to make a statistical comparison of it with the multiform methods of treatment which it promises to replace. But, I am well assured, that when it shall come to be adopted as the common method of treating cases of pro- lapse of the cord, when interference is required, the high mor- tality of this complication will be found to be very materiall}- diminished.^ 1 An Essay on Prolapse of the Funis, with a New Method of Treatment. In. Transactions of tlie New York Academy of Medicine, ii. 26. 1858. " Dr. Thomas, with an easily intelligible confidence in the self-commenda- tory character of his suggestion, gave it to the profession supported by the results of only two cases. Dr. Brandeis, of Louisville, has published three cases in proof of the advantage of the postural treatment, but avers that the operation will not succeed where the liquor amnii has entirely escaped, and the uterus is firmly contracted around the child. I have, however, been told of cases where the operation has succeeded admirably, although the waters had all escaped. See Medical Times and Gazette, ii. 220. 1860. Postural Treatme7it of Prolapsus Funis. 145 In the special case before us the result was in every respect most gratifying. Having placed the patient on her elLows and knees, I passed the fingers of the right liand into the vagina, and carrying down the displaced loop of cord into the OS uteri, I could feel it slip away past the presenting head into the dependent uterine cavity. Friction was then applied to the uterus to increase the contractions ; and these having been still further stimulated by the administration of a full dose of ergot, and the head having fairly entered into the pelvic brim, the patient was made to resume the ordinary obstetric position in about a quarter of an hour from the commencement of the operation.^ ^ Dr. Cliiircliill {^Midwifery, 459, 1860) wonders that no one had ever hcfore thought of this plan, "so simple, and so in accordance with common sense." But I have been informed by Dr. Priestley, that Mr. Bloxam, of St. George's, London, had used this kind of treatment for years in cases of pro- lapsus funis, although he had never published any account of it. And in CansUttVs JahreshericUt for 1856, iv. 514, reference is made to a case success- fully treated by the postural method by a Dutch obstetrician, Dr. Kiestra, who recommends that, in cases where the patient cannot be kept long enough d la vache, she should simply be laid on her side, with the pelvis very much elevated. — Niedcrl. Wcchhl. von GencesTc., April 28, 1855. The idea seems to have occurred afterwards independently, both to Dr. Thomas and Dr. Theopold. In the Beidsche Klinik, No. 27, 1860, Dr. Theopold suggests that in cases of prolapsus funis we should place the patient on her knees and elbows ; or if there be any obstacle to the assumption of this position, that we should make her lie on the side down which the cord has escaped, and then, by placing some pillows under the pelvis, the plane of the uterus would be again inverted, not to the same degree, but still sufficiently to allow the cavity of the organ to have a level so much below that of the os as to favour the reposition of the cord and its retention in utero. — Monatsschrift fiir Gehurtslcundc, xvi. 394. Are not the differences which have been observed in the relative frequency with which prolapse of the cord occurs in France, England, and Germany, to be in some degree explained by the different posi- tions in which parturient women are placed in these respective regions ? In France, where, though the patient is laid on her back, the pelvis is kept elevated, the complication occurs, according to Churchill, only in 1 in 373 cases ; in Britain, where the patient is kept on her side, on a nearly level surface, it occurs in 1 in 210^ cases ; in Germany, where the patient is placed on the back, -with the shoulders higher than the pelvis, it occurs as often as 1 in 162 -J cases. K 146 Morbid Conditions of Labour. Y. — APPLICATION OF THE FORCEPS. The uterus continued to contract regularly and steadily, though painlessly, Init the advance of the head was so very slow, in consequence of its large size and extreme ossification, that after the lapse of an hour and a half, or two hours, I deemed it right to act on the principle, which has ever received the hearty sanction and support of this Society, that we ought to interfere to avert the evils of delay, rather than to wait till nature has done her utmost, and left the patient prostrate, and, perhaps, after all, undelivered. The woman was accordingly brought under the influence of chloroform, when Dr. Watson applied the forceps, and speedily effected her delivery. With the birth of the child in this manner, all peculiarity in the history of the case ter- minates. But I may still be permitted to add a few sentences as to the way in which we conducted VI, — THE MANAGEMENT OF THE THIRD STAGE OF LABOUR. With the left hand over the abdomen, I followed down the contracting uterus, as the body of the child was being ex- pelled from its cavity ; and then grasping the uterus, at first gently, then with more force, I compressed it until, within five or six minutes, the placenta, with the membranes, w^as driven into the vaginal orifice and removed. At first sight it will be averred that there is nothing new in this kind of pro- cedure ; and it is not as a novelty in practice that I mention it now. Yet I apprehend that, though a few practitioners amongst us^ are in the habit of foUowmg out this plan in most of their cases, the ordinary practice of the profession in Britain materially differs from it, and consists, as we find it laid down in all our text-books, of waiting ten or fifteen minutes till the return of uterine contractions may have detached and expelled the placenta, then examining to dis- ' Dr. Ncwiiiaii on Ulc Manacjcnicnt oftlic Placenta. — British McdicalJournal, •■VoQ. 1860. Management of Third Stage. i^y cover the position of tlie after-birth, and reniovinL;' it ; and when it does not come away at once, making gentle traction on the cord, wliile the uterns is stimulated to more enerf^etic action by occasional friction, but not with such a forcible degree of compression as would suffice to separate and squeeze out the contents. Or if, in the practice of some obstetricians, the external manipulation of the uterus is insisted on as the cliief element for successful completion of the third stage, yet even with them the internal interference with the cord and placenta is not entirely laid aside. It was only by degrees that the present practice developed itself out of the expectant kind of treatment that followed the rough measures so much in vogue in the early part of the last century ; and we find Dr. Wallace Johnson,^ who seems to have been the first to publish instructions for the treatment of the third stage w4th the aid of external pressure, recom- mending that the compression be made at first by the two hands of the parturient woman, and only subsequently by the practitioner. Then Charles White, of Manchester,' states more precisely, that when, after the birth of the child, a pain comes on, " the secundines will be easily extracted by gently pulling the navel-string, and here an easy pressure upon the abdomen, by assisting the uterus to contract, wdll be of ser- vice." Subsequently, Dr. Clarke, of Dublin,^ rendered the practice still more perfect, by insisting on our "pursuing, with a hand on the abdomen, the fundus uteri in its contrac- tion until the fcetus be entirely expelled, and afterwards con- tinuing for some time this pressure, to keep it, if possible, in a contracted state." But in Germany, up till within the last few years, inter- ference in the last stagie of labour has been directed rather ^ A New System of Midwifery, 200. 1769. In a note lie speaks of the propriety of his practice being "confirmed by Dr. Hunter and Dr. Harvie, the latter of whom appears to have been tlie first who recommended it in his lectures. " - On the Management of Pregnant and L[/ing-in Women, 110. 1772. ^ Collins' Midwifery, 121. 148 Morbid Conditions of Labour. to extraction of the secimdines by traction upon the cord from l)elo\v than by pressure upon the uterus from above, as may be seen by a reference to the standard works of Scan- zoni/ of Wiirzburg, Braun,^ of Vienna, etc. Even Professor Spiegelberg, of Freiburg, who has taken an active and im- ])ortant part in the advance that is now being made in this direction in German practice, gives in his text-book,^ pub- lished in 1858, more prominence to the traction by the cord than to the compression of the uterus. At the meeting of the Association of Physicians and Naturalists, held in Konigs- berg, in September 1860,^ Dr. Crede, the distinguished Pro- fessor of Midwifery in Leipzig, brought prominently before his professional brethren the results of his experience, and proposed as the general rule, in the treatment of the last stage of labour, that the practitioner should seek to effect the expulsion of the after-birth and membranes from the genital cavities by external manipulation alone, without interfering with the cord, or introducing the fingers into the vagina. He liad already recommended this kind of practice in his Clinical Lectures^ on Midwifery, some years before ; but his observa- tions seemed to have exerted no widespread influence till he came forward at the meeting referred to, and, after showing the well-known dangers attendant on the common practice of pulling at the cord, and the great success of his own, made the bold allegation, that when the new plan of treatment should have come into general use, " the spectre of the adher- ent placenta would be scared away" from the domain of mid- wifery.'^' Tlien the profession took the matter up, and Abegg, ^ Lchrbuch der Gehurtshulfc, third edition, 253. - Ibid. 194. "Wion, 1857. 3 Ibid. 120. ■* Monatsschrift fur Gcburtskunde, xvi. 337. ■' Klinische Vortrdgc iibcr Gcburtshiclfc, 599. 1853. '' It ought, however, to be noted that Dr. Crcde has somewhat modified this statement in a more recent article, ' ' Ueber die zweckmkssigste Methode der Entfernung der Nachgcburt," in the next volume of the same journal, p. 274 ; and also in a note to his aljstract of Bossi's paper in the twentj^-second vol., p. 310. Forcible Expression of the Placenta. 149 in Danzig/ Strassman,^ in Berlin, and otliers,^ published suc- cessful results from the adoption of the new practice. We may judge of the improvement effected by the introduction of Credo's plan of treatment by the statistics of Bossi,^ who states that, in the clinical wards at Vienna, w^here the new method was in all cases adopted, the cases of post-partum h?emorrhage only amounted to 1'4:7 per cent., while in the other wards, where the old line of practice was followed, these amounted to 3'52 per cent. In the former the hand had to be passed into the uterus to separate the placenta only once in 315 cases ; in the latter, once in 78. Then we find Goschler^ averring that incarceration of the placenta is most frequently due to an inflexion of the uterus, resulting from its relaxation after labour, and that this can be most effec- tively treated by Crede's method; and the results of the jiractice in the wards of the Berlin Maternity, as given by ])r. Winckel,*^ are all in favour. In the new edition of Naegele's Text-book, the editor, Dr. Grenser of Dresden,'' states that he " has introduced this practice into the Lying-in Hospital at Dresden during the last two years, and has like- wise employed it extensively in private practice, so that he can commend it on the ground of the fullest experience." The name of Professor Spiegelberg^ has been associated with ^ Monatsschrift fur GcburtsJcunde, 264. October 1861. " Verhaiulhmgen dcr Gesdlsclmft fur Gehurtshulfc in Berlin. Sitzung von 26 November 1861. Monatsschrift, xix. 132. ^ E.g., Some of tlie members of the Berlin Obstetrical Society, at the meet- ing referred to. An article by Van Eooyen, in Bonder's and Berlin^ s Arcliiv., iii. 211, in favour of the new method, is noted in Canstatt's JaliresbcricM for 1862. * Wiener MediciniscJie Wochensclirift, Nos. 30-32. 1863. 5 Allgemcine Weiner Med. Zeitung, 1863, No. 37 ; Monatsschrift, xxii. 313. ^ Zur Entfernung dcr Nachgchtirt ; Moiuitsschrift fiir Gchirfskunde, xxi. 365. '' Naegcle's Lehrhuch der GchurtshilJfc, von Dr. Grenser, 246. 1863. ^ Erfahrungcn und Bcmcrkungen iiher die St'&i-ungen dcs Nachgchurtsgc- schnftes. — Wiener Med. Zeitschr if t, ii. 39. 1861. See Ca^isfatt's Jahresbericht for 1862. 150 Morbid Conditions of Labour. that of Professor Crede in connection witli this improvement in German olistetric practice, although his practice differs from that of his Leipzig colleague, in that he does not seek to effect the complete expulsion of the secundines from the genital canals by external pressure, but rather follows the ]>ritish practice of following down the uterus with the hand, and then aiding the contraction of the uterus in the expulsion of its contents by external pressure.^ Doubtless the result of all these discussions will be to bring the German practice more into correspondence w^ith ours ; but perhaps we also may have something to learn in the way of trusting more than we have been in the habit of doing to uterine compres- sion, and less to tractions on the cord. Let me add, that in trying to follow out the process of Crede, we may require to exert very firm, steady pressure on the uterus with one or both hands. In the first cases in which I attempted it, I failed to effect the extrusion of the placental mass from the ^'aginal canal — which is an essential point in the procedure — simply from not making the com- pression with sufficient vigour. SPONTANEOUS EUPTURE OF THE UTEPtUS DURING LABOUR.2 It is not my intention in this connnunication to present a digested treatise on the subject so ably and elaborately handled by Dr. Trask,^ of New York ; but rather to relate the history of a case that came lately under my observation, ^ See an excellent article on the subject in the Monatsschrift filr Gcburts- l-unde, xxii. 15. Bcincrkunijni znr BchandhnKj dcr Nachgdmrtsperiodc, von Heinrich Schiile. - GJns(jow Medical Journal, New Scries, i. 64. 1866. •■* In the Amrrican Journal of the Medical Sciences for January and April 1848, and .Tuly 1856. Rupture of the Uterus. 151 and to offer some remarks on the Etiology, Diagnosis, and treatment of Rupture of the Uterus. Mrs. N., aged 39, had been delivered of six healthy children, after easy labours. She tlien had a miscarriage; but sub- sequently became pregnant, and carried the child to the full term. The birth of the seventh child was notably more tedious than that of its predecessors, and ergot had to be administered freely to augment the uterine pains ; it terminated, however, in all respects satisfactorily. Two mis- carriages followed : the lady fell into bad health, and began to have attacks of menorrhagia, for which she placed herself under the care of my friend Dr. Drummond. " The speculum," he tells me, "showed extensive ulceration of the os uteri, running into the cervical cavity, the os very patent, with a copious unboiled white of egg looking discharge. She was a fine, handsome, healthy-looking woman, and the case was just one of those one desires to meet, as the result of treatment is usually so certain and so successful. Solid nitrate of silver was applied every fourth or fifth day for about two months ; she was placed on an alterative course of mercury, and used various forms of medicated vagmal pessaries. The result was a perfect cure, and shortly afterwards she became pregnant. I am very certain that she had no other uterine disease." When I was introduced to the lady, in April, she seemed to be in perfect health. When she came, some months after- wards, to ask me to attend her in her confinement, she told me that she had ceased to menstruate on the 15th of March 1865 ; and that to judge from the duration of lier previous pregnancies she should be confined about the IGtli of Decem- ber. She engaged a nurse for the middle of December, and had her in the house by the 15th, Labour did not set in, however, at that time, nor in a week after, as might have been expected : and it was only on the night of Saturday tlie SOtli, or rather early on the moriiing of the 31st, that her husband came to call me to her delivery. He had the tediousness of her previous confinement very much on his mind, and asked me to take forceps in my pocket. I laughed, and took them. 152 Alorbid Co7iditions of Laboui^. Arrived at the house, we were met at the bedroom door by the nurse, saying, " Come away, doctor, you are just in time." Without any delay, therefore, although I was so slightly acquainted with my patient, I proceeded to examine ; all the more that she spoke in an uneasy tone, as if a pain were coming on. I was disappointed not to find the head distend- ing the outlet, nor yet filling the vagina, while the os was situated so high up in the pelvis, as to be barely accessible to the exploring finger. Introducing a second finger, I felt that there was something like a clot hanging from the posterior lip, and that the very soft and fiabby os, precisely of a width sufficient to admit the two finger tips, was occupied by what I took to be a finger of a glove-like protrusion of the membranes. I had just observed so much, and that very imperfectly, when the patient, to whom the examination seemed very irksome, made such complaint of distress that I desisted from further investigation. The condition of the anterior wall of the vagina, immediately in front of the os uteri, struck me also as being peculiar ; for it felt tense, as if being drawn towards the two sides of the pelvis : but it did not seem sufficiently distinct to be worthy of special attention. Observing that my fingers were covered with blood, I found, on inquiring of the nurse, that some degree of haemorrhage had been going on for several hours. The patient had been complaining during the afternoon of the preceding day of occasional slight pains, but they had never been sufficiently severe to seem to make medical attendance needful. She had not gone to bed till after ten o'clock. At that time it was noticed that the dress was stained as if with a profuse menstrual discharge, and the discharge had continued to trickle away from time to time, after the labour pains had set in more steadily, which they had begun to do about eleven o'clock. On making palpation over the abdomen I noted merely that the fretus mo\'ed very distinctly on tlie application of my cold liand. The pulse was quiet and natural, the skin moist and warm, and the patient in a condition of the utmost Rupture of the Uterus. 153 placidity. We entered into conversation on some indifferent topics ; and in a little, tlie patient remarked it as strange that the pain should have left the back and gone to the side. Thinking that a pain was coming on, I again examined, and found that what felt like a clot on the back lip was in reality the soft, flabby side of a slight laceration in the cervix, at the upper extremity of which I thought I touched the margin of the placenta. To ascertain this much, I had pressed so firmly on the perineum as to elicit expressions of suffering from the patient; and I had not yet been able to feel the presenting part of the child. I at once went to ask the husband to go for any medical friend to bear the respon- sibihty of the case with me ; and he went and brought Dr. Smith, of Ibroxholm, who lent me the kindliest and most skilful aid and advice that I could have desired. Meantime I brought her under the influence of chloroform, because she was getting restless and anxious to be out of bed, and because, from feeling the abdominal tumour unequally firm, I believed the uterus had been thrown into irregular contractions as a result of the commencing laceration of the cervix. She was only awaking from the influence of the anaesthetic when Dr. Smith arrived, and as she had not been made aware of the necessity of his presence, he was good enough to wait until its effect had been ascertained. It was soon too evident that she had obtained no relief ; and as the pulse was now becom- ing very rapid and feeble, and the skin cold, and the face was taking on a shade of anxiety in expression, she was again anaesthetized, and Dr. Smith soon confirmed my diag- nosis to the extent, at least, of ascertaining the existence of the tear in the os uteri, without, however, being able to assure himself of the presence of the placental margin above it. We agreed as to the necessity of attempting the immediate delivery of the patient by means of turning, after having warned the husband as to the danger attendant on the operation from the probability of an extension of the cervical lesion. Two fingers having been passed through the os, it was easily dilated sufficiently to admit a third, and then the 154 Morbid Conditions of Labour. true state of matters became at once fully apparent. The uterus had ruj)tured : there was a large rent in the left side, through which the child had escaped into the peritoneal cavity, and through which its head could be distinctly felt, while the organ had collapsed, so that the placenta adherent to the back wall had come into close proximity to the os internum. Dr. Smith having satisfied himself as to the nature of the accident, we determined, with the husband's consent, to effect delivery by means of gastrotomy. Some faint, undefined idea as to the possible necessity of such a procedure had crossed my mind before, so that when I sent the husband for assistance, I bade him tell the doctor to 1)ring his pocket surgical case along with him. He had seen me bring midwifery instruments, so that I was rather disappointed to find that he had only made Dr. Smith bring another pair of forceps. Already, ere bringing Dr. Smith into the bedroom, I had listened for the sound of the fcetal heart; but though I failed to hear it, I had drawn no definite conclusion as to its vitality, as the patient com- plained of the pressure of the stethoscope, and w^as too rest- less to allow of a satisfactory auscultation. Dr. Smith was not long in bringing his j)ocket case, and through an incision, of between five and six inclies in length, beginning a little l)elow the umbilicus, the foetus was speedily extracted. The uterus, as I have stated, was collapsed; but it was quite relaxed, and through the gaping rent along all the left side the placenta was easily removed. Persevering efforts were made for upwards of an hour to restore animation to the infant, but without any avail. The abdominal cavity having been cleared out, the sides of the wound in its walls were brought together. The patient was made comfortable, and an opiate was administered. She remained in a very depressed condition during the greater part of the following day. The pulse at times was scarcely perceptible. But the singularly imperturbable placidity of temperament, whicli liad been broken through for a brief space just before the operation, had all returned, and she Rupture of the Uterus. 1 5 5 .spoke to lier husLaiid and children in tlie Lrief sentences that were allowed her, as calmly and with as little manifested emotion as a wife or mother could do who was going int(j another room to pass the night. Tlie pulse became stronger towards evening, and the patient rallied considerably, and remained in comparative ease till the following day, at mid- day, when the abdomen began to be tympanitic. She had also an occasional cough, and as a quantity of bloody serum was driven out through the abdominal wound on these occasions, we passed a catheter through the os uteri and the uterine rent, with the view of removing any of that fluid that might be accumulating in the cavity. The quantity that came away was very small, little more than an ounce. The catheter was therefore passed through the lower angle of the wound, and suction applied by means of an elastic bottle ; but even in this way little more than two ounces of a reddisli fluid, containing a few inflammatory flakes, were withdraw] 1. The tympanitis, and other inflammatory symptoms went on increasing, in spite of the use of opiates, and at night vomit- ing began for the first time to set in. She passed that night and the following day in great distress — which was relieved from time to time by the administration of chloroform — and died in the evening at eight o'clock, having survived the operation upwards of sixty hours. AUTOPSY. Permission having been given us to examine the abdomen, we opened up the wound the day after her death, and found that, though the edges were in perfect apposition, there was no attempt at union of the opposed surfaces in any part of their extent. The intestines were enormously distended with gas, their peritoneal covering being highly injected in some parts of their course, and in the cavity of the abdomen there were a few ounces of the same fluid, of which a small quantity had been withdrawn by the catheter. The uterus was lying- in the pelvis, apparently in the very same condition in which 156 Morbid Conditions of Labour. it had been felt at the time of the operation; the ragged, irregular, bruised-looking sides of the rent lying gaping apart, so as to expose to view at one point the inner surface of the organ. On removing it from the body, the rent was found to run up precisely along the left side of the uterus, immediately in front of the broad ligament, from the level of the os inter- num till within half an inch of the Fallopian tube, where it turned somewhat abruptly forward and upward along the anterior wall, and terminated almost at the mesial line, about an inch below the fundus. The laceration in the posterior lip of the OS was about an inch and a half in length, involving little more than the mucous layer, and could be distinguished from some old cicatrices by its ecchymosed margin. The whole substance of the uterus in nearly all its extent was uncommonly pale, soft, and friable — the knife going through it, as was remarked by the gentleman who made the dissec- tion, as if it were a piece of soft pork or lard. It was not permitted us to Ijring away the entire organ for more minute investigation. A small portion only of the l)ody was removed, and, on submitting some sections of it to the microscope, I found the tissues had undergone fatty degeneration to a very remarkable degree. Not only in the inner layers, but through- out all its thickness, the fibres were seen, full of granular fatty particles, and the connective tissue between the muscular bundles was unusually opaque. REMARKS — PROGNOSIS. As regards the likelihood of the occurrence of the compli- cation in this instance, there was nothing to lead one to anticipate it. There had been delay in last labour ; but there was not even good reason to suppose that this should be pro- longed. Tliere had l)een ulceration of os and cervix ; but hundreds of women recover from that, and have cliildren with the utmost ease. It turned out that the patient liad occasion- ally complained of uneasiness in the lower part of the abdomen ; and, especially during the prolonged stay of the Rupture of the Utertcs. 157 nurse in the house, she had stated sometimes to her that she had an unusual pain in the bladder. It was also afterwards remembered that for two or three weeks she had been very careful to ward off the children when they came dancing round her, and that any shaking of the room seemed to cause her annoyance : but in all this there was nothing specially indicative of the imminent danuer. DIAGNOSIS. The case illustrates at once the great importance of making an early diagnosis of the accident, and the occasional un- certainty of the more prominent symptoms from which such diagnosis should be formed. Had the nature of the case been at the first so obvious as to have led to the immediate extraction of the child through the abdominal walls, one life at least would probably have been saved. As it was, some of the leading symptoms were strikingly masked, or altogether absent. The symptoms that are usually looked on as dis- tinctive of the occurrence are : — Is^. Sudden Cessation of the Pains. — In this case I have no doubt that there was at once a very marked change in the character of the pains from the time of the rupture. But they had not ceased altogether, and only did so gradually ; and I had not the opportunity of observing for myself the sudden change. It may serve as a guide to the recognition of the complication to observe more carefully the change in the seat of the pain. The patient had been feeling the pain before chiefly, if not altogether, in the back, but now referred it constantly to the side ; and this transference of the seat of her suffering from the loins to the left groin, was the only symptom that seemed to cause any uneasiness or apprehen- sion to the patient herself. The existence of the incomplete I'upture of the cervix, however, suggested the idea that the uterus, partially paralysed, was thrown at that side into irregular contractions — an idea which was strengthened by 158 Morbid Conditions of Labou r. the greater firmness of the abdominal tumour on the left than on the right side. Id. Recession of the Fcetal Presentation. — Had there been an opportunity in this case of making an examination before the occurrence of the accident, the recession of the head would, doubtless, have excited a suspicion of its nature. But when we find, on our first examination of a patient, that the presenting part is still beyond reach, we do not at once conclude that the foetus has escaped from the uterus. 2>d. Condition of the Ahdominal Tumour. — In the case of accidental rupture of the uterus, which was related by Dr. Moir^ to the Edinburgh Obstetrical Society, and which I had an opportunity of seeing along with him, the outline of the foetus could be traced through the abdominal wall, not so distinctly as it has sometimes been described to be in such cases, but yet suificiently so to enable us to recognise that it was unmistakably lying high up in the abdominal cavity, in a transverse position. In the case of Mrs. N., although I was able to ascertain by external palpation that the head was placed lowest in the pelvic cavity, as we can do in the great majority of common cases, yet the limbs and other portions of the child's body were not so easily perceptible through the abdominal wall as to lead to the idea that it had escaped from the uterus, and its position confirmed the notion that it was in its proper cavity. Further indications are usually to be obtained from — ■ith. The great general Prostration of the Patient. — In the majority of cases the rapid, failing pulse, the pale, anxious countenance, and the cold clannny skin of the patient, give speedy token that some serious calamity has overtaken her. But here, as in some other recorded cases,^ there was at first very little constitutional disturbance ; and there was tlirough- out, as I have already remarked, a striking absence of that ^ Edinburgh Medical Journal, 313. October 1865. 2 See Traislcs Monograph, Cases ccvi., cc.xxviii., cclxxviii., cclxxiv., excLx., rlvii., ccclxxxiv., &c. Treatment of Rupture of the Uterus. 159 vomiting which is described as such a constant concomitant of rupture of the uterus. ^th. Other less constant indications, such as a sudden, sharp cry of the patient ; a tearing sound, or sensation as if something ha,d given way ; emphysema of the subcutaneous celkilar tissue of the abdominal parietes, as noted by Kiwisch^ and M'Clintock^ — of these there was in this instance no trace. TREATMENT. As to the proper course of procedure, I confess I do see much room for question. 1st. Expectant Treatment. — Should we have left the patient undelivered ? There was some faint possibility that, after the patient had survived an infallible peritonitis, the foetus would have got encysted, and, after many months, might have been discharged through the bowels or abdominal walls. There are such cases ^ on record; but probably we can get at the histories of all such as have happened during the two past centuries, whilst numbers have been left to perish unrecorded. Yet of all the cases on record so treated — or rather untreated — 78 per cent, were lost. 2d. Delivery through the Passages. — Should we have turned or attempted some other form of delivery 2^0" vias naturales ? Sixty-eight per cent, of all the cases recorded to have been thus treated perished, and all the conditions in our case weighed in the scale against the few chances of success. 2>d. Gastrotomy — On the other hand, of the recorded cases where gastrotomy was had recourse to, only 24 per cent, were lost. I take these figures from the essay of Dr. Trask, to which I have already referred. With such statistics before him, we need not wonder to hear him say, " We believe that a neglect of this mode of delivery has contributed much to 1 Klinisclic Vortrdgc. I. Ahthcilmig, v. 254. Prag. 1851. - Dublin Quarterly Journal, xxiv. 450. Nov. 1857. ^ See Contribution on this subject, by Leliniann in tlie Monatssclirift filr Gcburtskundc, xii. 443. 1858. i6o Morbid Conditions of Labottr the exaggerated estimates of the mortality of this accident which are so generally entertained. It is an operation re- quiring no little resolution and true courage under the trying circumstances in which the physician is placed, and conse- quently arises the need of settled principles of practice to guide one in this extremity." . ..." In short, as a general rule, from whatever cause we migltt he led to anticipate a 'protracted, and dijicidt delivery hy the natural 'passages, gastrotomy will afford tJic test chance of recovery." If such a sentence could be written in 1856, with how much more force ought gastro- tomy to be urged as the operation in all such cases in 1866, after our ten years' experience of the triumphant progress of ovariotomy ? ETIOLOGY. More than thirty years ago Dr. Murphy, of London, called attention to morbid transformations occurring in the uterine walls as a cause of rupture during delivery, and detailed^ a number of interesting cases. This paper is one of the highest importance ; but his description of the morbid changes are rather vague and belong to the day of a ruder pathology. In 1856, Trask, in recording the case^ where Dr. Cox suggests that the small extent of the rupture, and the fatty appearance of the liver and heart, are worthy of regard in connection with the occurrence of death so soon after so slight a lesion, adds, " We would still further suggest that the condition of the uterus predisposing to rupture, might possibly be due, in such a case, to a fatty degeneration of the muscular fibre similar to that found in the heart." Earlier in the same year Sir J. Y. Simpson^ published the following sentence: — " Fatty degeneration of the uterine walls, or rather of a limited part or layer of them, from previous inflammatory or irritative disease, or from its mistimed occurrence before 1 Duhlin Journal of Medical Science, vii. 198. 1835. - American Jourtial, 103. July 1856. •' Obstetric Memoirs, ii. 455. Cause of Riipttire of the Uterus. i6i delivery, seems a condition leading in some cases to rupture or laceration during labour." The consentaneous induction of the two writers has not as yet, so far as I know, been verified. But the case before us supplies the proofs. The gentleman who kindly made the dissection for us was, as I have stated, struck with the peculiar lardaceous aspect and feel of the uterine walls. I am well aware that within sixty hours after delivery in any case, we find this preliminary stage in the retrogressive processes already begun in the uteru.s, and I have seen the change begin in the innermost layers of the uterine fibres in the case of women who have died within a shorter period after the delivery. So marked has this been in some instances that I have questioned whether, in severe and prolonged labours, the process may not have been initiated ere the child was fully expelled. But in this particular instance there had been no excessive uterine action. The patient had had a few painful pains before the rupture took place, but with the exception of these the contractions had been comparatively slight; and, even with them, the distress was probably due more to the laceration that was being effected in the uterine substance than to the intensity of the muscular action. In a case where there have been no exhaustive contractions of the uterine walls, we are forced to the conclusion that such a degree of fatty degeneration, occurring to such an extent as was here witnessed, must have taken place anterior to the onset of labour, and induced in the uterus that friability that led to its rupture under its own contractile efforts. Through the kindness of my friend. Dr. Sanders, I have had an opportunity of examining a preparation of a ruptured uterus, from the obstetrical museum of the late Dr. Macintosh. The patient must have died during delivery, or immediately afterwards, for the organ has all the dimensions of the uncontracted uterus at the full term. There is a rent involving the whole left side of the cervix, and running up the body of the uterus obliquely backwards till it terminates within an inch of the mesial line, at a point on a level with L 1 62 Morbid Conditions of Labour. the side of the ovary. In this case also, the muscular fibres in the whole thickness of the organ, at the seat of rupture, present a very marked degree of fatty degeneration. [The most original and important contribution to the study of Eupture of the Uterus that has appeared in recent times is the monograph of Dr. Ludwig Bandl.^ He teaches, that in the ordinary run of cases of rupture of the uterus, the lacera- tion takes place in the cervical portion. He maintains that, in cases where the uterus finds difficulty in expelling its con- tents, as in cases of hydrocephalus, cross-birth, or narrow pelvis, the active muscular walls above the level of the os internum go on contracting and thickening, and its cavity goes on diminishing in capacity, while the passive walls of the cervix become correspondingly thinned, and its canal elongated and expanded. This condition he diagrammatic- ally represents as in the accompanying woodcut (fig. 15). It is an immense help to a clear understanding of the mechanism of rupture of the uterus to have the attention directed to the remarkable thinning that occurs in the lower sphere while the upper active segment acquires more than its original thickness. In his eagerness, however, to establish his doctrine, which requires that the os internum uteri should be normally at the level of tlie pelvic brim, Bandl would have us regard the appearances represented in Braune's Plate C,^ as those not of a normal, but of a difficult labour. This is quite inadmissible. Though he quotes Braune as saying that the pelvis was " nicht besonders weit," we find Braune, in the next page, describing the pelvis as " durchaus normal," with a conjugate 11 cm. in length. Though the head was large, it shows no marked degree of flexion, and lias descended well into the pelvic cavity within the unbroken membranes, while the soft parts give no evidence of undue or prolonged compression. In any case the situation of the os internum at the posterior wall of ^ Ubcr lluptur der Gebdrmutler und ihre Mcchanik. Wien, 1875. ^ Die Luge des Fijliis am Eiulc der i>chic(mgc?\ifh(i/t. Cause of Rupture of the Uterus. 163 the pelvis in Braune's plate (see fig. 14, p. 143) in no way corresponds to the fanciful elevation of it depicted in Bandl's diagram (fig. 15). In Braune's accurate drawing from nature, the posterior part of the os internum is little above the pro- montory of the sacrum ; in Bandl's drawing, from his imagi- nation, it is somewhere about the level of the third lumbar Pig. 15. Over-distension of Cervix, according to Bandl. vertebra. His contention, that the position of the os internum above the symphysis pubis belongs to an abnormal labour, arises from his failing to have recognised the elevation of it which normally takes place during labour when, as Dr. Hart and I have pointed out,^ the anterior half of the pelvic floor gets lifted up c% masse into the abdominal cavity. Again, in his very natural and pardonable eagerness to ^ See Dr. Hart's Papers on " ^ Shidy of Tivo Mesial Vertical Sections of the Female Pelvis." Transactions of the Edinburgh Obstetrical Society, v. 62 ; and " On a Source of Error in the Clinical Estimation of Elongation of the Cervix during Labour." Ibid., 42. 164 Morbid Conditions of Laboztr. establish and extend bis doctrine, Bandl coolly tries to ex- plain away tbe most striking features of the case I have recorded above as due to erroneous observations. His refer- ences to the case, however, show that he has misread it ; and whilst I still gladly accept his doctrine, with some modifica- tion, as the best explanation yet given of the ordinary run of uterine ruptures, my case remains as an illustration of a group which it fails fully to account for.] TURNING v&rms FORCEPS. [In reproducing some cases pubhshed under this title,^ I take the opportunity of pointing out more precisely the forms of pelvic contraction and relations of the foetal head, which re- spectively indicate one or the other variety of operative interference. Apart from the cases one meets with in prac- tice, the best guides are found in the writings of Michaelis,^ Sir J. Y. Simpson,^ Lahs,* and Goodell.^ There are two varieties of contracted pelvis which are to be clearly distinguished from each other in their influence on the mechanism of the advance of the head, and on the kind of interference which in diffi- cult cases they demand from ■pj^ jg the obstetrician. These are Normal Brim. tlic Uniformly or Universally ^ Medical Times and Gazette, xxxix. 465. 1859. 2 Das Engc Bcckcn. Leipzig, 1865. 3 Selected Obstetrical Works, 393. * Die Tlmrie dcr Oehurt, 208-210. Bonn, 1877. ^ The Meclianism of Natural and of Artificial Labour in Narrow Pelves.— Transactions of the Philadelphia International Congress, 111. 1877. Mechanism of Labour in the Small Pelvis. 165 Contracted Pelvis and the Flat Pelvis. (Figs. 16, 17, 18.) Fig. 17. Fig. 18. Jtjsto Minor Brim. Eickety Brim. I. — MECHANISM AND MANAGEMENT OF LABOUR IN THE UNIVERSALLY CONTRACTED PELVIS. In the Universally Contracted Pelvis — Felvis cequabaliter jiLsto minor (fig. 17), there is a diminution in the absolute length of all the diameters, without any marked change in their proportionate measurement. The anterior diameter is less than the average 4 ; the oblique less than 4|- ; the trans- verse less than 5 inches. 1. Mechanism. — The Position of the foetal head at the brim is the same as in a normal pelvis — the 4J in. occipito-frontal diameter of the head corresponding, as usual, to the right oblique diameter (Solayres' obliquity). When the head of normal size and shape adapts itself to such a brim, Flexion necessarily takes place.^ The line of the right obhque diameter of the pelvis, instead of being occupied by the straight occipito-frontal diameter of the head, becomes occupied by the oblique sub-occipito-bregmatic diameter (Eoederer's obliquity). The posterior triangular fontaneUe is felt on a lower level than the anterior quadran- gular fontanelle, which may have ascended so far above the brim as to be almost beyond the reach of touch. The occiput ^ According to the meclianisin described at p. 116. 1 66 Morbid Conditions of Labour. Fig. 19. Extreme Head-Flexion in Pelvis jtjsto minor. descends so low that it occupies the largest space in the area of exploration ; and the designation is sometimes given to this condition of Occi^ntal or Hmcl- head Frcse7itations (fig. 19). When a head so disposed lingers long in its transit tlirougli the pelvis, as it is liable to do in cases that are termi- nated by the natural efforts, it becomes compressed in the plane of the sub- occipito-bregmatic diameter, and elon- gated in the occipito-mental direction. If the caput succedaneum, which in such a case is seated over the upper portion of the occiput, be well-marked, there results the typical sugar-loaf configuration, represented in fig. 20. 2. Management. — When in such a labour the natural powers are unable to supply the requisite force for safely completing the birth, the clear indi- cation is for delivery by means of forceps. If the movement of rotation has taken place, the blades will lay hold of the sides of the fcetal head. But often enough the head requires to be grasped at the brim, when the head is still in the Solayres obliquity, and then the blades are applied obliquely, — the left over the left lambdoidal suture, the right over the right frontal bone, as represented in this woodcut of Sir J. Y. Simpson^ (fig. 21). Even in the unusual cases, where the head is placed more nearly in the transverse diameter, the grasp of the forceps, owing to the marked Eoederer obliquity of the head, is still oblique, and the compression of the head, which is exerted within the blades, is in the safer line of the Fig. 20. Head Moulding in Extreme Flexion. 1 Selected Obstetrical Works, Fig. 9, p. 391. Management of Labour in the Small Pelvis. 167 oblique sub-occipito-bregmatic, and not in the more dangerous line of the straight occi- pito-frontal diameter.^ The action of the forceps in such a case harmonises with the natural pro- cesses ; the compression exerted by the blades favours, and even fur- thers, the moulding that takes place under the natural efforts. To turn the child in such a case would do no good. On the con- trary, it would interfere with the most favour- able mechanism, and de- stroy the practitioner's best chance of offer- ing effective aid. W7iere the anterior fontanelle is inaccessible, or difficult of access, Ttirning is contra-indicated Forceps should he applied. Fig. 21. Long Forceps grasp of Head in Normal Pelvis. II. — MECHANISM AND MANAGEMENT OF LABOUR IN THE FLAT PELVIS. The characteristic feature of the Flat Pelvis is shortening of the conjugate diameter (fig. 18). The obhque diameter may be little modified. The transverse diameter may be in- creased, or it may be of normal length : when the pelvis not only is flat, but also small, the transverse diameter may share in the general diminution, yet even then its excess in length ^ As pointed out by Budin, De la tete du faetus au 'point de mte de VolsUt- rique. Reclicrches diniques et expcrimeiitales. These de doctoral, 1876. 1 68 Morbid Conditions of Labour. over that of tlie conjugate is greater than in a normal pelvis. For when the whole flat pelvis is diminished in size, the shortening is most marked in the antero -posterior diameter of the brim. 1. Mechanism. — The Position of the head at the commence- ment of labour in this form of pelvis is transverse. The Solayres obliquity is absent. The Naegele obliquity, however, may be seen (fig. 22.) That is to say, whilst the hne of the bi-parietal diameter of the head may be parallel to the Hne of the conjugate diameter of the pelvis, so that the sagittal suture runs nearly in the line of the transverse diameter, in a large proportion of cases the head lies at the entrance of the Flat Pelvis, with its bi-parietal diameter placed obhquely to the conjugate of the brim, and its sagittal suture behind, or in front of the line of the transverse diameter. Most frequently the Naegele obli- quity takes place in such a direction that the sagittal suture runs beliind J, 22 t-he line of the transverse diameter, Head at brim of Rickety Pelvis, parallel tO it, but cloSC tO the promOU- a, Symphysis pubis ; 6, promon- ^ ^£ ^^xQ sacrum, with the right or tory of sacrum ; c, sagittal '' _ " suture. anterior parietal bone looking into the centre of the pelvic canal, and occupying the greater portion of the area of exploration. The converse, however, may occur : the sagittal suture may run in front of the transverse line close to the symphysis pubis, and tlie left or posterior parietal bone lies lowest in the canal. The Presentation of the head in a Flat Pelvis is thus quite different from the presentation of the head in a Universally Contracted Pelvis, even before the parturient powers have begun to drive it into the bony canal. But no sooner does the head fairly attempt to make its way through the entrance than the difference becomes still more distinct. Now, if not before, the Naegele obhquity becomes pronounced, and one of the parietal ridges precedes the rest of tlie head in its on- ward progress. But further, instead of the production of the Mechanism of Labotir in the Flat Pelvis. 1 69 Eoederer obliquity due to flexion of the head, we get a con- trasted movement of the head. Wliether this movement be a real extension associated with a separation of the chin from the sternum, or whether it be due to a silting of the body and head of the foetus en masse downwards, and to the right (as is probably the case), I do not stop to inquire. Wliat is important to notice is, that the large anterior fontanelle keeps at as low a level in the pelvis as the smaller posterior cone, and, in- deed, shows a constant tendency to descend be- fore it. In many cases this becomes so pro- i''^'^- 23. - Position and Presentation of Head in nounced that the pos- rickety bkim. terior fontanelle may escape beyond the reach of the finger, whilst the anterior fontanelle keeps lower and lower, and comes to lie nearly in the middle of the field of explora- tion. This obhquity having been first clearly indicated by Michffilis as Hkely to be produced under such conditions may be designated the Michsehs obhquity. Instead of a presentation of the liindhead, there is thus a tendency to production of a forehead presentation. In some cases we get the regular brow presentation ; and in tliis form of pelvis we find the main factor in the production of full face presenta- tions. The cause of this descent, or dipping of the sinciput, is due to the excess in size of the bi-parietal 3|- inch over that of the bi-temporal 2| inch diameter. The two parietal bosses at the extremities of the bi-parietal diameter get caught at the extremities of the conjugate diameter of the flattened brim, wliilst the narrower bi-temporal finds space to sink through between them, the occiput sliding at the same time to its own side of the pelvis. Simultaneously with this de- scent of the sinciput, the right parietal bone, which hes in apxDosition with the back of the s}Tnphysis pubis sinks down into the cavity of the pelvis, with its edge overlapping that of its fellow. The left parietal bone then rounds the promontory 170 Aforbid Conditions of Labour Fig. 24. Head Moulding after transit through a Flat Pelvis. of the sacrum, with its protuberance to the left of the most projecting part of the promontory, and, as it is squeezed past this point, it may receive an indentation towards its anterior extremity. The head having thus reached the cavity of the pelvis, in most cases will find space for its easy dehvery with the ordinary movements of Flexion, Eota- tion, etc. The configuration of the head that has travelled through such a pelvis is represented in fig. 24. It may, how- ever, become modified if the head be de- tained for a lengthened period in the lower plane of the pelvis, though even then the side of the head that has passed over the sacrum, is indicated by a red mark along the line which has been crushed past the promontory. 2. Management. — To have recourse to the application of the Forceps in a case of Flat Pelvis, with a head at the brim requiring operative interference, would be to contradict the natural mechanism, and endanger the structures of both the mother and child. The blades applied to the sides of the pelvis would grasp the foetal head in the direction of the occi- pito-frontal diameter. Such a grasp of the head would pro- duce, on the one hand, a compression dangerous to the child ; and, on the other, would at once lessen the size of the fcetal head in the roomy transverse diameter of the pehas, and tend to make it bulge in the direction of the contracted con- jugate. Further, if it did not absolutely hinder, it certainly would not favour the descent of the sinciput. It is in some of these cases that there is theoretically ad- vantage to be gained from the application of the lever. But in the great run of cases, where the condition is time- ously recognised, delivery ought to be brought about by Turning. Wlien the body and limbs of the foetus are born, the base, hh, or narrowest portion of the wedge-shaped head, engages at the brim (fig. 25). It is free, at the same time, to Management of Labour in the Flat Pelvis, lyi adapt its longest (occipito-frontal) diameter to tlie longest (transverse) diameter of the pelvis. In the antero-posterior diameter, the temporal b h, which is the shorter of the two transverse diameters of the fcetal head Fig. 25. Wedge Shape of Fcetal Head in Vertical Section. Fig. 26. Wedge Shape of Fcetal Head as seen from above. (fig. 26), can adapt itself between the promontory of the'sacrum and the back of symphysis pubis. The head is compressed only in this transverse direction (fig. 27), and the overlapping of the one parietal over the other is facilitated (fig. 28). 2.. Fig. 27. Compression in Narrowest Transverse Diameter OF Head. Fig. 28. Moulding of Head from BELOW upwards IN HeAD- last Labours. Low position of the anterior fontanelle thus forms the indica- tion for Turning, which as closely follows the natural mechan- ism as Forceps clearly frustrates it.] Although often spoken of as the most stationary depart- ment of the Art of Medicine, and although often looked upon 172 Moi'bid Conditions of Labonr. as but little susceptible of further improvement, Midwifery is in our day undergoing a series of progressive changes, and is now passing through an era of reform, the end of which it is difficult to foresee and to foretell. Fatal and formidable operations, which were formerly considered to be of para- mount importance, and which were only too frequently called into requisition, are now being greatly restricted in their application, and are gradually becoming supplanted by other operative procedures, at once more simple in their nature and more calculated to effect the great aims of the educated obstetrical practitioner. Not only so, but the class of cases in which any operative interference is required, is becoming always more distinctly defined ; and operative measures of every kind are being daily improved and simplified. We now annul the pains of labour ; and many men are beginning to ask themselves whether the parturient process as we see it in nature might not be safely interfered with, and whether they might not use means to expedite dehvery with advantage to their patients and with comfort to themselves. Some have answered this question in the affirmative, and in the privacy of their own practice they have acted up to their conviction with safety and success ; or, scornful of the ancient dogma as to the evils attendant on meddlesome midwifery, they have even dared to come forward and boldly maintain that artifi- cial interference in every case of labour should form the universal rule of practice. Wliile the main principles of Midwifery, and the great rules that guide us in obstetric practice, are thus undergoing a revision, and sometimes com- plete reversal, the comparative merits of the several opera- tive procedures are being subjected to a closer scrutiny, and the cases are being more clearly defined in which one or the other variety requires to be had recourse to. The relative value of two of the most important of these operations, viz., the operation of podalic version and extraction, and the opera- tion of delivery with the long forceps, has never yet been finally determined ; and the following cases appear to me to be of sufficient interest to demand their publication, because Case of Flat Pelvis. 173 of the very distinct data which they afford us in our efforts to form a jDroper estimate of the relative value of these two operative measures. CASE I. On December 5, 1858, I saw for the first time Mrs B., aged 27, who has been married for nine years, and has given birth to five children, most of them still-born. Her obstetrical history is shortly as follows : — In April 1851, she passed through her first labour, which lasted two days, and ended in the birth of a dead male child. Her next labour, in January 1853, was likewise of two days' duration, and resulted in like manner in the birth of a still- born boy. In her third confinement she was more fortunate ; for the able assistance of Dr Graham Weir having been ob- tained, he performed the operation of podaKc version, and by this means delivered her in a short time of a female child, who still Kves, and is a healthy, thriving little girl. That fortunate event took place on March 8, 1855; and it was exactly two years later, namely, March 10, 1857, that her fourth child, a girl, was born. On this occasion, fate was again adverse, for the case was a foothng one, and the feet were born, or, at least, presented at the birth, according to the account of the patient, for four hours before the arrival of the surgeon, who had been sent for from the Maternity. That gentleman extracted the infant, which showed some signs of life ; but it was found impossible to resuscitate it altogether. It was to aid her in her fifth labour, which occmTed on December 5, 1858, that I was called in. Her pains had com- menced about 10 A.M., and gone on steadily during the day. The surgeon who was in attendance ruptured the membranes about 7 P.M., and afterwards, as he himself told me, made several ineffectual attempts to bring down the head with the long forceps. When I arrived, about half-past nine o'clock, I found the uterine contractions vigorous, but without causing any appreciable advance of the head. This was of large size, presented in the first position, and was tightly jammed into 1 74 Morbid Conditions of Labour. the pelvic inlet, which was slightly contracted. The medical attendant had just listened to the fcetal heart, and found it beating distinctly, but slowly. Deeming further delay unad- visable, I had the patient put under the influence of chloro- form, applied the long forceps to the fostal head — one blade over the left eyebrow, the other behind the right ear — and by using considerable extractive force, I delivered the child speedily, and without any unusual degree of difficulty. The child, however, was dead, its heart had ceased to beat ; and although I perseveringly tried all the usual methods for resus- citation, I failed completely in reviving it, or even in once eliciting any sign of vitality. Should that patient again fall in labour, I need hardly add, that, in the event of my being called in to deliver her, I should adopt the treatment so skilfully and successfully carried out on the occasion of her third confinement by Dr Weir ; that is, I should turn the child and extract it by the feet so soon as the passages were sufficiently dilated, in preference to em- ploying the long forceps to effect delivery. CASE II. Mrs. T., aged 25, the second patient whose history I here take leave to record, has likewise given birth to five children ; but in her case the majority of them were born alive ; and yet her pelvis was more contracted than that of the patient of whom I have already spoken. For while in the latter the conjugate diameter of the pelvic brim was contracted to nearly 3^ inches, and the rest of the bony canal was of nor- mal dimensions, the conjugate diameter of the brim in the case of Mrs. T. measured barely 3^ inches in length, and the cavity and outlet of the pelvis were also of unusually small dimensions. Was there any difference in the modes in which these women were delivered of their children to account for the difference in the mortality of these children at birth ? The history of the two j)atients seems to me to furnish a sufficient answer. Mrs. T. was delivered of her first child on August 11, 1853. Case of Flat Pelvis. 1 75 The labour was a tedious one, and was terminated by the long forceps, which were applied by one of the most skilful accou- cheurs in this city. The child was a female, still-born. In her next labour, which took place on July 4, 1854, my uncle, Sir James Simpson, was called in, and delivered the patient by podalic version of a healthy boy, who lived for three years. Her third confinement occurred on July 4, 1856, when she was on a visit in Ireland. She had only been about eight months pregnant when labour was prematurely induced by the fright or injury which she received in consequence of being thrown out of an Irish car. On this occasion the child was born before any medical man arrived. It was very small when born, but is now a strong and healthy girl. Accident performed for her the operation to which she ought to have submitted at the hands of a skilled practitioner. The history of her fourth labour is involved in an obscurity which can only be cleared up by the gentleman who delivered her, and he is now acting as assistant-surgeon to a regiment in a foreign station. On this occasion my uncle again saw her, and gave her a piece of advice, which I have no doubt he offered her on that occasion also when he himself operated so successfully upon her, and which he is in the habit of giving to all patients in whom the pelvis is so contracted as to render some opera- tive interference necessary for the delivery of a full-grown foetus. I mean, of course, that he recommended her, in the event of her again becoming pregnant, to have labour brought on prematurely, and that he gave her instructions to show herself so soon as she should again have become certain of the presence of a child in her womb. It was in consequence of this injunction that she presented herself in the early part of January last, announcing that she had again fallen in the family way, and soon thereafter I called on her to try to ascer- tain the exact term of utero-gestation. Her data were not very precise ; but having reckoned that she was then in the seventh month of her pregnancy, I told her that I would come and bring on labour in the beginning of February, when, according to my calculation, she would have approached 176 Moi'bid Conditions of Labotir. the termination of the eighth month. With this view I visited her, sound in hand, on the 5th of February; but although the nature of the operation had been fully explained to her already, and its objects and advantages were shown forth to her anew, she positively refused to submit to any operation that would interfere with the natural course of pregnancy. Although it was not the first time that I had had an opportunity of in- ducing premature labour, I was, as I believe most young practitioners would have been, extremely annoyed at losing such a good opportunity for the repetition of the operation, and I used every argument at my command, and tried every possible means of persuasion to induce the patient to submit to it, all the niore that I was firmly convinced in my own mind that it offered the greatest guarantee of safety to her child, and the best chance of recovery to herself. But no kind of argument or entreaty proved of any avail ; she was sure she was near the time when she would " get better" of herself, and it was of no use to interfere. And I may take this opportunity of remarking, that the obstinacy displayed by my patient in this instance, and the determination with which she set herself against the induction of premature labour, are by no means rare phenomena among the child- bearing women of the lower classes, at least in Edinburgh. How it comes to pass I do not know, but it is a matter of not unfrequent observation here, that patients will not subject themselves to this operation, even although they may already have suffered more than once from all the dangers and the pains of long and tedious labours and of instrumental deli- veries; and although they have been clearly told that by having labour brought on a little earlier, these may be all avoided and averted. The moral inertia of the class to which they belong may be in part to blame. In some cases the cause is to be found in the common habit of procrastination ; some patients object from mere obstinacy of disposition, and some from the fear with which they ever associate any procedure that can possibly be spoken of as an " opera- tion." Safety of Ttirning. 177 Having declined, as I have stated, the chances held out to her by the induction of premature labour at an appropriate period, my patient was allowed to carry her child to the full time, and labour did not supervene till the 16th of March. I was summoned to her about six o'clock in the morning of that day, and on going I found that the pains, which had begun about three hours previously, were neither very strong nor very regular, and had only had the effect of dilating the OS uteri to about the size of a shilling. This dilatation had been effected by the pressure of the bag of membranes, an elongated portion of which was protruded into the pelvic cavity, while the head was resting high up on the promontory of the sacrum, almost beyond the reach of the exploring finger, and exerted no influence whatever towards the dilata- tion of the orifice. I left, intending to return in three or four hours ; but at nine o'clock I was again sent for, and on arriv- ing at the patient's bedside, I found the pains strong and steady, a long hernial pouch of the membranes filling the vagina, and protruding externally, the os uteri well dilated and easily dilatable, and the head beginning to press down in the first position between the promontory of the sacrum and the symphysis pubis. I had already made up my mind as to the course to be pursued, so I proceeded at once to put the patient under the influence of chloroform, and then hav- ing introduced the right hand into the uterus, and ruptured the membranes, I turned the child, and extracted it at once. It was a female, of large size, and its respirations were for some time so few and feeble that I found it necessary to make use of alternate baths of hot and cold water for nearly half-an-hour before it gave any very vigorous symptoms of vitality ; but at the end of that time it began to breathe more freely, and to cry, and was then consigned to the care of an attendant. This infant is now thriving to admiration ; and the mother herself made a good recovery. The lessons which these two cases teach us are sufficiently obvious, and the facts brought out in the history of these two women's confinements are of themselves too striking to call M 178 Morbid Conditions of Labour. for any further comment here. The last labour of the second of them shows with what safety and success the operation of turning may be performed in a patient with a greatly con- tracted pelvis, if only the operation be had recourse to at a suf36.ciently early stage of labour. I add now the history of a third patient in whom the pelvis was of normal dimensions, but in whom it was judged expedient to perform the same operation at a period of labour when the head had already advanced to some extent through the pelvic brim, CASE III. This third patient is a strong healthy -looking woman who has given birth to six children. Her first child was born (in 1853) prematurely, and lived only for a fortnight. In her second pregnancy, death of the foetus seemed to have super- vened soon after stirrage was first felt, but it was not expelled till towards the close of the eighth, or beginning of the ninth month. From her rather obscure narrative, I gather that it was on the occasion of this miscarriage that some lesion of the cervix uteri occurred which led to the peculiar condition of the OS to be afterwards described. Her third pregnancy resulted likewise in the expulsion of a dead foetus, when she had arrived nearly at the full term of utero-gestation. On the occasion of her fourth confinement (in 1856) a girl was born four weeks before the full time, which was alive at birth, but lived only a very few hours. Her fifth labour was a tedious one, and the child was still-born. Her sixth labour was terminated on Tuesday, March 29, on which day I saw her for the first time. Dr. J. Alexander Smith was in attendance on the patient, and the labour hav- ing become tedious, he sent to my uncle requesting his aid and advice for the completion of the delivery. In his absence I went instead, and found that the patient had been already two days in labour, the membranes had been ruptured many hours, and the head had passed about half through the pelvic brim, at which point it had long remained without makmg Case of Tttrning. 1 79 any advance. The head was tolerably large, and rather firmly ossified, but by no means to such an extent as to account for the long delay. The only circumstance by which this delay could be accounted for, was the unusual condition of the OS and cervix uteri. The os was very unequally dilated, and the lips were divided into three irregular lobes, which were now soft and much swollen, by three deep fissures, which were evidently of old standing, and the margins of which felt thin and membranous. The largest lobe was placed in front, behind the symphysis pubis, and felt somewhat like one of those folds on the anterior lip of the cervix, which are not infrequently found to be a cause of delayed labour ; but in this case the tumid portion of the cervix was too mobile to be long mistaken for such a fold, and besides it could be felt to be distinctly limited by the deep indentations on either side. As the pains were pretty strong, I endeavoured to push this up behind the head, with the hope that it might slip past during a pain, but the attempt succeeded no better with myself than it had done in the hands of Dr. Smith, who had already made many efforts to attain the same object. The uterus then was contracting regularly, sometimes even power- fully ; the passages were free and well dilated ; the head was not abnormally enlarged, and yet it made no progress. I see no way of accounting for this delay, except by supposing that the irregular condition of the cervix prevented the uterus from exerting its powers with the full purchase necessary for the expulsion of its contents. However that may be, labour liad now been going on for many weary hours, the position of the head had long remained unaltered, the patient's powers and patience were getting exhausted, and it was agreed that delivery with the forceps should be had recourse to. Dr. Smith kindly volunteered to fetch his instruments, as his house was nearest at hand. He brought a pair of long straight forceps, such as I had never before had an opportu- nity of using, and I at once expressed my doubts as to the possibility of applying them in such a case. I made an effort, however, to introduce one blade, but finding its proper ad- i8o Morbid Conditions of Labour. justment impracticable, I did not push the attempt further. When the fingers of the left hand, which I had used to guide the point of the instrument, had been introduced within the OS uteri, I found that the head was still mobile, although it had descended, as I have already said, half-way through the pelvic inlet. This suggested to me the possibility of turning the child, and delivering it by the feet ; and Dr. Smith, hav- ing given his assent to the proposal, I performed the opera- tion at once, and delivered the child. The mother, I need hardly say, was in a state of anesthesia. The labour was terminated about 10 a.m. The child breathed only at in- tervals, and means had to be used for its resuscitation for more than two hours before it was given to the nurse to be dressed. In the evening Dr. Smith saw it, and it then seemed to be quite well, and had several times swallowed some sack- whey, which he had ordered to be administered to it. On calling next morning, however, with Dr. Smith to see our patients, we found that the infant had died about 4 A.i\r., without any appreciable cause. It was lying on its nurse's knee, and, as they told us, " it had gone out like a candle." I do not know how far the death of the child is to be attri- buted to the mode of its delivery. I believe that had it been delivered earlier, either by turning or with the long forceps, its chances of life would have been greater. But lest any one should feel inclined to attribute the death entirely to the operation, let me remind him that the infant was in a state of full vitality for a very considerable period after its birth, and that the previous history of the mother showed a great ten- dency among her progeny to early and unaccountable deatli. fart g^conb. gy:^ecolog-ical. GYNECOLOGY. THE USE OF THE VOLSELLA IN GYNECOLOGY.^ A YOUISrGr graduate just about to enter upon practice, guided by liis text-books on midwifery and the dis- eases of women, would not think of supplying himself with a volsella as a needful part of his equipment for that depart- ment of his work. He would be duly impressed with the need and usefulness of specula, of sounds, of tents, of tena- cula, forceps, &c., but if he thought of the volsella at all, he would only think of it as a superfluity. Thomas,^ Barnes,^ Emmet,* Courty,^ Gallard,^ Leblond,'' Schroeder,^ Sinety,^ give no place to it among the instruments required for gynecologi- cal exploration.^^ Yet the volsella has long been a familiar instrument in the hands of experienced gynecologists. The great French surgeons of the last generation, who occupied themselves with the diseases of women, made frequent use of it. Sir James Simpson ^^ quotes Lisfranc to the following 1 Edinburgh Medical Journal, xxv. 289. 1878-79. - Diseases of Women. 1875. ^ Ihid. 1878. * Principles and Fjuctice of Gynecology. 1879. ® Traite Pratique des Maladies de r Uterus. 1866. ® Le<^ons Cliniques sur les Maladies des Femmes. 1873. '' Traite EUincntaire de Chirurgie Gynecologique. 1878. ^ Handhuch der Krankheitcn der Weihlichcn Gcschlechtsorgane. Leipzig, 1874. ^ Manuel Pratique de Gynecologie. Paris, 1879. 1° Since this was written, the section in Pitha and Billroth's Handhuch der Allgemeinen imd speciallen Chirurgie on " Die Untersuchung der Weiblichen Genitalien," by Chrobak, has appeared. It gives a fair account of the explo- ratory uses of the volsella, p. 5. ^^ Selected Obstetrical and Gynecological Works, i. 621 (footnote). A. & C. Black. 1871. 184 Use of the Volsella in Gynecology. effect : — " Let a speculum be introduced so as to embrace the cervix uteri, and thus prevent the uterus falling by its own weight, then bid the patient bear down as if at stool, and you will perceive that, as the instrument descends, the uterus follows it to the extent of an inch or so from the orifice of the vagina — an immense advantage when the surgeon wishes to bring down the uterus to near the vulva. In cases requiring operation about the cervix, all that the surgeon has to do is to lay hold of the os uteri with a hook, and draw it gently down until it comes fairly within sight ; this may be effected with- out difficulty, and without much inconvenience to the patient." Dupuytren,^ in describing the removal of a fibroid, speaks no less distinctly as to the descent of the uterus when trac- tion is made on the tumour — " The substance of the tumour is caught in the bite of a volsella. Moderate traction is em- ployed, and the patient also requested to strain down as if in labour. She does this readily, so that the tumour soon ap- pears close to the external orifice. It is now grasped with a second pair of forceps, and gentle traction, aided by the patient's efforts, brings it to the vulvar orifice, which it soon passes, and the cervix uteri itself is exposed." 1 reproduce here a woodcut (see fig. 29) from the well-known work^ of Jobert de Lamballe on vesico-vaginal fistulse, in which it will be seen that the cervix is pulled down by means of two pairs of Museux's forceps until the os has been made to pass over the perineum, for the purpose of exposing a fistula in the vaginal roof. In an address^ on " Obstetrics and Gynecology One Hundred Years Ago," I described the use of the volsella in a case of this kind, where I had the privilege of witnessing an operation for the cure of fistula by Professor Stoltz. In liis " Memoir on the Uterine Sound," Sir James Simpson* ^ ififo/is orales de Clinique Chirurgicale. Tome troisieme, 227. 2 Traite des Fislulcs Vesica Uterincs, etc., 4. Paris, 1852. =* Obstetrical Journal of Great Britain aoid Ireland, iv. 587. 1876. * Selected Obstetrical Works, 621. See also Clinical Lectures on Diseases of Women, 170. History of Employment, 185 points out that the uterus " may be drawn down by instru- ments till the cervix reaches the external parts themselves, or even j)i"otrudes beyond them — a circumstance which facili- I'lG. 29. The Uterits hauled down to bring a vesico-vaginal fistula within reach (Jobert de Lamballe). c, anterior vaginal wall ; /, fistula ; c, cervix-uteri ; ;p;p, Museux's forceps. 1 86 Use of the Volsella in Gynecology. tates immensely the operation of the excision of this part of the organ." GoodelP has given a brief but very suggestive account of the use of the volsella, which I quote in full. He says, " One word here on the subject of the volsella. Since it maintains its hold better than the tenaculum, it is to me one of the most precious instruments in my bag, amounting in value almost to a third hand. Apart from usmg it as above described in re-dressing or straightening out any kind of version or flexion of the womb, it subserves other useful purposes. By hooking down the cervix and holding it steady, it materially aids in the introduction of sponge-tents. For the same reason, upon the removal of the tent it renders the exploration of the uterine cavity with the finger very much easier than by the usual plan of forcing the womb down on the examining finger by suprapubic pressure, a procedure always painful, and in a fat woman very difficult of execution. By thus lowering and fixing the womb, it faci- litates very materially the removal of intra-uterine polypi, or the scraping away of benign or malignant growths from the cervix or the fundus. In such cases I usually apply it with- out the aid of the speculum, and generally seize hold of the anterior lip. In re-dressing versions, a mechanical advantage is gained by seizing hold of that lip of the cervix whose name does not correspond with that of the version. But in flexions, as one object of the traction is to stretch out the flexed side the most, that lip should be seized whose name corresponds with that of the flexion. This advice is theoreti- cally correct ; but it may not always be practicable." Battey, in an article on the " Extirpation of the Function- ally Active Ovaries," 2 says, " The cervix is seized with a stout volsella, the uterus drawn down under the pubic arch. 1 Some Practical Hints for the Treatment and the Prevention of the Diseases of Women. Reprinted from the Medical and Surgical Reporter for January and February 1874. ^American Gynecological Transactions, i. 115. History of Employment. and the vaginal membrane and cellular tissue incised with scissors, say one and a half inch in the median line of the pos- terior cul-de-sac, beginning immediately behind the uterus." Nceggerath, in his very original article^ on " The Vesico- vaginal and Vesico-rectal Touch," says, " If we attempt to explore the upper section of the uterus, it must be pulled down by means of a double hook, the points of wliich are turned outwards, introduced into the cervical canal, and it is perfectly safe to dislocate the uterus downwards about an inch and a half. When this is done, with one finger in the bladder and one in the rectum, we are enabled to thoroughly explore the whole of the uterus, from the fundus down to external orifice." The most satisfactory account of the use of the volsella we find in the writings of Hegar — first, in his Operative Gyncco- loyy^ and again still more fully in his chnical lecture on Gynecological Diagnosis.^ In that lecture he begins his re- ference to the use of the volsella by saying, " For some years we have made use of a very sure, and at the same time innocent, method, which consists in applying a volsella to the vaginal portion to fix the uterus, to draw it somewhat downwards, and, where necessary, to make lateral movements with it." In a communication which I read to this Society on " The Complete Evacuation of the Uterus,"^ I showed how the use of the volsella facilitated the access of the finger to the inte- rior of the uterus. In all these quotations, however, with the exception of those of Goodell and Hegar, it will be observed that the men- tion of the volsella comes in almost incidentally, or with ^ American Journal of Obstetrics, viii. 135. ^ Die Operative Gynaekologic von Hegar und Kaltcnhach, 49. Erlangen, 1874. ^ Zur gyndkologischcn Biagnostik. Die Comhinirtc Untersuchung. Volk- mann's Sammlung, No. 105. ^ Transactions of Edinburgh Obstetrical Society, iv. 221. Edinburgh Medi- cal Joitrnal, xxi. 951. 1876-77. 1 88 Use of the Volsella in Gynecology. reference to some special exploration or operation ; and as I become more impressed with the importance of the aid it furnishes us in various directions, I am anxious to press its value upon the Fellows of this Society, and to claim for it a permanent place in every text-book on gynecology, and in every gynecologist's armamentarium. THE INSTRUMENT. Let me say at once that there need be nothing peculiar in the construction of the instrument. Volsellse of different sizes are very useful, and sometimes it is absolutely necessary to have them large and long for the seizure and down-dragging of big intra-uterine fibroids. In such cases I find a pair of toothed forceps (fig. 30) very helpful, which Sir James Simpson had constructed, with separable blades, locking like a pair of SmeUie's midwifery forceps, and capable of being fixed to- gether after they were locked with a screw-pin, serving as a joint. But the instrument for daily use in the common run of cases is a simple small curved volsella of the size here re- presented (fig. 31), each stem ending in three short teeth. Sometimes single-pronged or two-pronged volsellse with longer teeth may be employed ; but I get the greatest amount of service from the small three-teethed variety, which it is better to have made with a catch on the handles like those on Pean's artery forceps, or such as is shown in the woodcut. MODE OF EMPLOYMENT. We know the cervix uteri is richly enough supplied with sensory nervous filaments. For the most part, however, they run to the sympathetic ganglia, and very few liave any direct communication with the cerebro-spinal system. A prick or a crush of the lips is, therefore, even when perceived by the individual, not a cause of acute or lengthened suffer- ing. The cervix uteri is not only very much less sensitive than the labia pudenda, it is even far less sensitive than the Varieties of VolsellcE. 189 Fia. 30.— VoLSELLA for seiziu-e of intra-utcriiK' Fig. 31.— Okdinart Volsella. (Full size.) fibroids. (Two-thirds size.) 190 Use of the Volsella in Gynecology. walls of the vagina in the immediate vicinity. I find that when it is touched with ice the patient does not experience the sense of cold ; and the touch of a cautery on the surface does not cause her pain. Hence, we feel free to use the vol- sella without fear of adding in any marked degree to a patient's distress. When either the anterior or the posterior or both of the lips have been laid hold of, first the cervix, and with it the whole uterus, can be pulled forwards or backwards, to the right or to the left, but, above all, it can be dragged down- wards. The amount of force required to do this on the living subject is exceedingly slight, as I find, on observation of a series of cases, that a force of from 3 to 7 lbs. is sufficient to bring the os uteri to the ostium vaginae, without any discomfort to the woman. I had a favourable opportunity recently of studying the mode of de- scent of the uterus in the grasp of a volsella in a case where the ure- thra had been dilated for vesical explorations, where the finger intro- duced into the bladder could follow down accu- FiG. 32. „ , . rately the movements of Vertical Section of Pelvis, showing re- -^ lations when Utcnis is hauled down, a, syin- the uteruS and anterior physis ; h, bladder ; c, uterus ; d, perineum ; ^yall of the vagina. As c, rectum ; /, volsella. -^ descends, the CCrvix brings with it the posterior angle of what Dr. Hart^ describes as the pubic triangle or anterior segment of the pelvic floor ; that is to say, the anterior wall of the vagina, the bladder, and Edinburgh Medical Journal, xxiv. 896. 1878-79. Mode of Employment. 191 uterus are brought down en masse. The posterior wall of the vagina becomes inverted from above downwards more gradu- ally, being separated from its loose contact with the anterior wall of the rectum, the canal of which remains unaffected (fig. 32). In general, the organ must descend so far as to bring the os clear through the vulva before the utero-sacral ligaments are put upon the stretch. It is when these become quite tense that the patient has any sensation of special dis- comfort. We need not stop to point out that the uterus in this temporary position does not present the usual relations of the prolapsed one. In employing the volsella, it is obvious that it will usually be a comfort, and sometimes a necessity, to have a nurse or assistant at hand to keep it, or some of the other instruments, or parts of the patient, in proper position. But this aid can often enough be dispensed with by the operator tying a tape or string round the handles of the instrument, and giving it to the patient herself to hold, or fixing it on a part of his own dress. SPECIAL USES. 1. ExPLOKATORY. — Let me ask attention, to begin with, to the services it will render us in the Exploration of various conditions of the pelvic organs. (1.) To bring Farts within Range of Vision. — In the great run of cases, two fingers introduced into the vaginal canal can be used to pull back the perineum, and then a finger, or sound, or pair of dressing forceps, or special depressor, press- ing forward the anterior wall of the vagina, brings the cervix into view. Instead of the finger, sound, or other instrument, let the practitioner use such a volsella as I have indicated, and he will find it easy to lay hold of the anterior lip of the uterus, so as to bring os, cervix, and, when necessary, vaginal roof, within full range of vision. (2.) To bring Parts witJiin Beaeli of Toucli. — Wlien the uterus is thus drawn upon, it is obvious that the finger will have more easy access to the higher parts of the uterus. 192 Use of the Volsella in Gynecology, whether it be passed first tlirougli the cervix into tlie interior of the uterus, or whether it seeks to determine the condition of it and its adnexa externally, and its relations through the vaginal canal, through the rectum, or in rarer cases through the bladder, or through two or more of these simultaneously. We thus get a better impression, a, of the size of the uterus, whether that be normal, lessened, or increased ; h, of its posi- tion, when it is the subject of version or flexion in one or another direction ; c, of its relation to pelvic tumours, whether it be attached to them, or independent in its mobility ; d, of the size, situation, and circumstances of the ovaries, and other parts around the uterus. I do not need to state that the use of the volsella which I am describing does not exclude the employment of other instruments for exploration ; and in some cases, after laying hold of the uterus with it, or before doing so, it will be convenient to make use of the speculum, or more rarely of the sound. 2. Operative. — Without entering into details of the various Operations, I may point out some in which it is either abso- lutely necessary or extremely useful to bring down the uterus, or simply to fix it with a volsella. (1.) Operations on Interior of Uterus. — It will be found very helpful, Is^, in Introducing stem-pessaries, tents, medi- cated arrows, or the sound, armed with cotton wadding, and charged with various medicaments ; 2d, in the Removal of foreign bodies, or of neoplasms and fragments of ova, from the cavity of the uterus, whether with the finger or by means of a curette or other instrument. (2.) For Application of Elastic or Esmarch Ring. — To carry out the various operations on the vaginal portion of the cervix bloodlessly, an indiarubber umbrella ring may be car- ried up to the level of the isthmus uteri by passing it over a volsella that has grasped the whole thickness of the cervix in its embrace, or over two volselhB, one applied to the anterior, the other to the posterior lip. (3.) Operations on the Vaginal Portion of the Cervix. — In the many cases where recourse must be had to operative in- operative Uses and Contra- Indications. 193 terference with the os and cervix uteri, the use of the volsella is simply indispensable. Such are, \st, Division of the cervix ; 2d, Amputation of its infra-vaginal portion; Zd, Emmet's operation for the repair of lacerations of the cervix ; Aili, Ee- moval of polypi, etc. (4.) Operations for Bedifying Displaced Uteri. — In restoring the uterus to its proper position in cases of flexion, version, and inversion, the volsella facilitates immensely the reposi- tion. (5.) Operations on the Vagina. — In attempting the closure of fistula high up in the vaginal cavity, or the removal of neoplasms in that situation, the manipulations can in many cases only be satisfactorily carried out when the uterus has been pulled downwards and backwards with the volsella. (6.) Intra- Peritoneal Operations. — In cases where we seek access to the peritoneal cavity through the vaginal roof, as for the removal of the ovaries, extra-uterine ova, &c., the volsella, grasping the cervix, pulls it forwards and down- wards, and makes tense the structures that require to be divided. CONTEA-INDICATIONS TO USE. I have said that, in advocating the more frequent use of the volsella, I do not wish it to be understood that it should supplant the use of the speculum, sound, and other instru- ments with which the profession has long been more familiar. I would now add that, as in the employment of these instru- ments, so in the employment of this, it must always be borne in mind that, notwithstanding the great assistance which we obtain from it, there are conditions, physiological and patho- logical, which forbid its application. 1. Physiologieal. — As a general rule, which has but rare exceptions, the use of the volsella must be abstained from in the two physiological conditions — (1.) of Menstruation; (2.) of Pregnancy. Even in cases where morbid conditions of menstruation or pregnancy call for active interference, the wise practitioner will use the volsella as he would practise N 194 ^^^ of the Volsella in Gynecology. the simplest touch in a menstruating or pregnant female, with more than the usual care and delicacy. 2. Pathological. — (1.) Neoplasms rendering the tissues of the cervix particularly friable or hsemorrhagic, prevent the laying hold of it with the volsella. But the great pathologi- cal contra-indication to its use is found in — (2.) the Inflam- matory changes, not only acute, as of any of the pelvic organs, but even chronic, as especially in the cellular tissues. Hap- pily the cases where the volsella would be most likely to cause pain and trouble are also most likely to be diagnosed and treated without its aid, so that we have in them no great inducement to have recourse to its employment. Atresia Vagincs. 195 VAGINA. NOTES OF SOME CASES OF ATEESIA VAGINiE.i CASE I. — CONGENITAL ATEESIA VAGINA — EETENTION OF MEN- STEUAL DISCHAEGE — EVACUATION PEE EECTUM — PEESISTENT DYSMENOEEHCEA — DEATH FEOM PHTHISIS. "C. P., from Eoss-sliire, set. 20. When 13 years old, she first suffered from a pain of a bearing-down character, accom- panied by uneasiness throughout the whole body. More pains recurred regularly at intervals of a month for fifteen successive months, but no menstrual discharge ever appeared. At this time she was seen by two doctors in her native place, who made a puncture per rectum, through which a bloody discharge escaped. From this operation she had partial relief, but still continued to have more or less pain at the monthly periods, and only a small quantity of discharge passed per rectum. For some months past there has been a constant greenish discharge per rectum, but the menstrual flow has only continued for one or two hours each month. On examination, the external genital parts are found to be perfectly developed, but the orifice of the vagina is completely occluded. " On introducing the small end of a Sims speculum into the rectum, and retracting the posterior wall, a small opening is found in the anterior wall about two inches from the anus. This communicates with the upper part of the vagina, and through it a sound can be passed for a short distance. On passing a sound into the bladder with the finger in the ^ Transactions of Edinburgh Obstetrical Society, iii. 152, 1872-73 ; aud Edinburgh Medical Journal, xviii. 1045, 1872-73. 196 Vagina. rectum, the sei3tum is found to be very tliin. The cervix and OS uteri can be felt distinctly per rectum, " In the treatment, a sound or bougie was ordered to be passed from time to time so as to dilate, or at all events keep open, the recto-vaginal fistula, which ultimately the patient might be taught to use for herself. At the same time the patient, who exhibits a marked tubercular tendency, was placed on nourishing diet, iron, cod oil, &c. For three weeks a sound was passed twice weekly through the rectal fistula, and at the end of that time the patient menstruated more profusely, and with less pain than previously. The same treatment was adopted for three weeks longer, and the result was increase in the discharge and much diminution of the pain." The hospital record goes on to relate how the tubercular diathesis of the patient began to manifest itself in the development of pulmonary phthisis, which ran a rapid course, and ended in her death. A post-mortem examination of the body was refused by the relatives. Had this patient been of a more robust constitution, I would have attempted to form a fresh outlet for the menstrual discharge, by dissecting the rectal from the vesical wall in the normal situation of the occluded vagina; for although the recto-vesical septum felt very thin it was comparatively short, measuring only about an inch and a half in length. But in the reduced state of health in which the patient presented herself, such interference would have been attended with too much immediate risk. The next case which I have to record gave promise of a more successful result. CASE II. — CONGENITAL ATRESIA VAGIN/E — RETENTION OF MEN- STRUAL FLUID — PERFORATION OF OBSTRUCTION — RELIEF. " W. H., a bottler from Leith, oet. 17. The patient, who is a tall anaemic-looking girl, gives the following history of herself. About a year ago she had an attack of pain in back Congen ital A tresia. 197 and loins, accompanied by much sickness, languor, and headache. This lasted with greater or less severity for four days. These symptoms passed off completely, and the patient got quite well. At the end of a month they returned with increased severity, and continued to do so regularly every month until November last. Then the pain returned every night, continuing for several hours, and leaving her weak and exhausted. She began to have difficulty in voiding urine, and suffered much from constipation. "History. — Has had good health till her present illness. Has never had any menstrual discharge. •'' On Examination, a slight bulging is observed in the right iliac fossa. On palpation a distinct swelling is felt in the region, extending upwards for two inches above the anterior superior spine of iUum. It is regular and rounded above, but cannot be defined below, as it extends deeply into the pelvis. The tumour has a boggy feeling, but is not tender to the touch. Percussion dull. " Fe,r Vaginam. — The labia minora are above the usual size, otherwise the vulva is normal. On introducing a finger into the vagina it is arrested about an inch from the vulva by a firm resistant structure which completely occludes the vagina, and in which there is no orifice whatever. " Per Bedurfi. — A tumour is felt anteriorly, extending up- wards, apparently continuous with the pelvic tumour felt externally. By passing a sound into the bladder while a finder is in rectum, a distinct interval can be felt in what would naturally be the vagina. The girl is otherwise healthy. The patient, after being ansesthetised, was placed in the litho- tomy position, and the vagina exposed at the point of obstruc- tion, by means of a Sims speculum. With a small cautery about the thickness of a crow-quill, an opening was gradually forced for a depth of fully half an inch through the centre of the obstructing tissues. Through the opening thus made a thick reddish-brown fluid immediately escaped with some force. Pressure from above was carefully avoided, and the fluid was allowed gently to flow away. About three ounces 198 Vagina. of this jEliiid escaped during the forenoon. On examination with the microscope blood corpuscles, some complete, some broken up and disintegrated, were present in abundance. Fatty granular matter was also present. "The patient had no return of the pain in the evening. The discharge continued to ooze away, about ten ounces in all escaping. A little carbolic oil was applied round the edge of the wound, and the part syringed with a lotion of (one in thirty) carbolic acid. " The discharge continued for four or five days. The patient had no bad symptoms, and was dismissed to the Convalescent Hospital at the end of a fortnight, to return at her next menstrual period," This case, like the other, presented us with an instance of congenital atresia of the vagina ; and though the closure was of less extent, I still had recourse to the perforation of the obstructing tissues with considerable apprehension. Cases not a few were on record, where the puncturing of the simplest kind of obstruction — that formed by a persistent and complete hymen — had been followed by the death of the patient ; and as Puech, in his monograph (De I'Atresie des Voies Genitales de la Femme) has shown, the danger became greater when the obstruction depended on occlusion affecting to a greater or less extent the vaginal tube. Two of the sources of danger before the patient were — 1st, That resulting from the rapid evacuation of the cavity ; and 2d, That wliich arose from the possibility of the absorption of septic matter from a wound-surface. These were avoided in my patient by per- forating the structures by a cauterising metallic rod ; for the opening made was so minute that the fluid only escaped in a narrow stream, and in small quantities ; and even if decom- position had begun in it, the cauterised surface would have prevented the absorption of noxious substances. The use of the cautery for this purpose, I know, has been objected to, and but rarely had recourse to ; but in this instance its result was altogether gratifying, and the opening was easily kept patent. Congenital At7'esia. 199 CASE III. — CONGENITAL ATEESIA VAGINyE — AMENORRHCEA — MENSTRUAL EPISTAXIS. " E. W., aet. 29. — Patient says that, when fifteen years old, she began to suffer from pain in the back, coming on regularly every month, and lasting from three to four days, accompanied occasionally by epistaxis, but no discharge from the vagina. These periodic pains have recurred regularly every month until the present time without any menstrual discharge. Two years and a half ago she was married, and it was not until then that her attention was directed by her husband to some malformation of her genitals. With the exception of entire absence of the menstrual discharge, patient has enjoyed good health uniformly. " Family History. — A sister died of phthisis, set. 22 ; she never menstruated. A second sister, at present ill of phthisis, get. 22, has never menstruated. Eest of her sisters (six) are well. Father and mother alive ; well. "On Examination. — Pudenda normal. Finger, passed through vulva, enters a cul-de-sac about an inch in depth. "Per Rectum. — The finger, passed three inches per rectum, reaches the uterus, which, on combined external and internal examination, feels irregular in shape. On passing a catheter into bladder, the recto-vesical septum is felt to be very thin. The mammse are well developed. Patient has never ex- perienced any sexual desires." These are all cases of congenital atresia, with the occlusion complete. Perhaps I might be allowed to append the history of a case where the contraction resulted from a tedious labour, and was complicated with a vesico, or rather urethro-vaginal fistula ; and though the occlusion was not complete, yet the canal was so narrowed as to render the operation for the closure of the fistula extremely difficult. CASE IV. — TEDIOUS LABOUR RESULTING IN VESICO-VAGINAL FISTULA, AND INCOMPLETE ATRESIA VAGIN.'E. " L. M'Pi., ffit. 29, from Caithness. Patient, who is a 200 Vagina. strong healthy woman, has enjoyed perfect health until her present illness. A year ago, after a labour extending over four days and five nights, she was delivered of a child at full term. During her labour she was unable to pass water, and it was not until a few hours before the birth of the child that she was relieved by the catheter.- After her labour, and until her admission into hospital, her urine has constantly dribbled away involuntarily. For six months after her con- finement she was confined to bed, with the ordinary symptoms of pelvic inflammation. " On Examination. — The labia and inner surface of thighs are scalded, and in some parts superficially ulcerated. The vagina is completely occluded by firm, hard, fibrous bands, intersecting one another across it. Between these bands it is difficult to pass even an ordinary catheter. The cervix uteri can be felt posteriorly very much hardened and diminished in size. The os uteri cannot be detected. On passing a small catheter into urethra, a rent is discovered just behind the symphysis pubis. " Professor Simpson endeavoured to expose the fistula by means of a Sims speculum ; but, owing to the amount and firmness of the fibrous bands, it was found impossible to introduce even the smaller end. Two of the bands in front of the cervix were divided by means of an ordinary bistoury, and the walls of vagina kept apart by means of spatulse. In this way space was obtained to introduce the point of the smaller end of the Sims speculum. It was found exceedingly difficult to keep the fistula in view, and secui^e the edges for pairing. By means of the hook and small curved knives, the edges were sufficiently secured to admit of their being brought together by means of four silver sutures. "Patient had no untoward symptoms, and for ten days after the operation was able to pass her urine at will, although very frequently. In the horizontal position she was able to retain it for two hours. " On the eleventh day, however, the urine began again to dribble away involuntarily. On examination, it was found Fibroma Vagince, 201 that a fistula, large enough to admit a No. 8 catheter, still existed. " Patient was sent to the Convalescent Hospital for three weeks, and on her return to the Infirmary, the fistula was closed in the usual way. Patient again made a good recovery from the operation, and now (four weeks after the operation) there is no involuntary discharge of urine ; and, with the ex- ception of having to pass her urine more frequently than usual, she is perfectly well. "The vagina still remains occluded, although not to the same extent. The os uteri remains fixed low down in the hollow of sacrum, and continuous adhesions pass from it both laterally and anteriorly, reducing the vagina at its longest part to not quite an inch in length." FIBEOMA VAGIN^.i The Vagina, having but a passive role to play in the economy, and being subject to changes rather of a mechanical than of an actively vital character, is remarkably free from the ten- dency to the development of the various neoplasms dis- played so remarkably in the uterus. This remark holds good with regard to the fibrous as much as to other forms of new growth. Hence Kiwisch^ is perfectly justified in asserting, notwithstanding the demurrer of Scanzoni,^ followed by M'Clintock,* that "the various fibrous tumours are of rare occurrence in the vagina, and most of them have originated in the uterus, and only spread subsequently in the vaginal wall." And so Davis ^ says — "For one example of tumours ^ Transactioiis of the Edinburgh Obstetrical Society, v. 121, 1877-78 ; and Edinbtorgh Medical Journal, xxiii. 1078, 1877-78. 2 Klinische Vortrdge, ii. Abth. 547. ^ Diseases of Females (Gardner's translation), 543. ■* Diseases of Women, 197. ^ Davis's Obstetric Medicine, 125. 202 Vagina. of this class having its origin from any part of the vaginal surface, there are at least ten which are indebted for their source either to the neck or to the interior of the body of the uterus." I have often seen an intra-uterine fibroid falling through the os and filling up the vaginal cavity, as described by Davis ; and as often, intra-mural and sub-peritoneal fibroids pressing through the vaginal walls from behind and above, blocking up and destroying the canal, as described by Kiwisch. But I have only met with one of notable size which had its origin in the vaginal parietes. The patient, a young servant of 25, was sent to my ward by Dr. Stewart, of Newport, Fife. She suffered from trouble with the water, and had difficulty in going about her duties in consequence of a swelling at the privates, which led her to suppose herself to be the subject of a falling down of the womb. On examination a mass the size of two fists was seen protruding from the vulva, and having much the appearance of an extensive cystocele. It caused the urethra to project far forwards and upwards, while the perineum was kept on the stretch behind, and the vaginal orifice so completely blocked up that the uterine discharges had escaped with difficulty. It had a soft elastic feel, which could be best likened to the consistence of a good-sized lipoma, and was rooted on the entire breadth of the anterior vaginal wall along the upper two-thirds of the urethra and part of the trigone of the bladder, to an extent in all of about five inches. A sound passed into the bladder showed that though the urethra was twisted and compressed, there was no pouching of the bladder into the base of the tumour. The patient was most anxious to be relieved of the mass, which had existed for about two years, and had lately begun to increase in size and become more troublesome. The mucous membrane was divided by an elliptical incision, and dissected off the tumour, which was, as it were, encapsuled on the surface and at the sides with a layer of condensed cellular tissue. At its base, however, where it grew from the urethro and vesico-vaginal septum, it was in intimate union Fibroma Vagince. 203 with the tissues of the part, which were dissected out as close to the neighbouring cavities as was consistent with their integrity, a sound held in the bladder being used as a guide. Some arteries that spouted were secured by torsion. The edges of the wound were brought together by eight silver- wire stitches. Union by the first intention took place at the upper and lower extremities of the wound; but in the middle, towards the neck of the bladder, suppuration occurred, and healing by granulation. The patient soon made a good recovery. Dr. Stewart writes me that, since she left the Infirmary two years ago, she has been in fair general health, and attending to her usual avocations. She had recently been apprehensive that the tumour was growing again, but on examination Dr. Stewart did not find it much altered from the time of her recovery from the operation. The tumom' had much of the look as well as the feel of a fatty tumour ; but on microscopic examination it is found to consist of desmoid or fibrous tissue, and the softness of the texture was caused by an oedematous infiltration of all the structure. In its histological character this tumour closely corresponds with those described by Honing^ and Jacobs,^ and, indeed, with the greater number of these fleshy tumours of the vaginal walls of which the intimate structure has been described. Klebs^ alleges that these solid tumours of the vagina are fibromyomatous, apparently misled by theorizing from the structures whence they spring. Virchow* more correctly describes them as being most frequently of fibrous texture, with a remarkable degree of oedema. Eokitansky^ describes the vaginal fibromata as being de- veloped especially on the posterior surface of the canal 1 Berliner Klinisclie Woclicnschrift, vi. 55. ■■^ Ibidem, 258. 3 Handbuch der Pathologisehen Anatomie, 960. ■* Die Krankhaften GeschivUlsfe, iii. 220. ^ PatJwlogical Anatomy (Sydenham Society's translation ), ii. 270. 204 Vagina. This, however, is a mistake. Of 27 cases,^ where the situation of the tumour is given, 17 were on the anterior wall, 8 only on the posterior wall, and 2 towards the right side. In the case I have described the tumour was attached with a broad basis, as was the case with 19 others of the 27. The remaining 8 were polypoid, with a larger or narrower peduncle. SAECOMA VAGIN^.2 At a meeting of the Edinburgh Obstetrical Society on 12th June 1878, I exhibited two small, round-celled sarcomatous tumours from the vagina. Although not imposing in appear- ance, they were, so far as I knew, unique. Cases were not unknown of Sarcoma Vaginae occurring as a secondary affection, where the disease had first appeared in the uterus. I myself had a case where the vaginal wall had probably been injured during the operation for the removal of a uterine sarcoma, and when the tumour was reproduced in the uterus it was ^ Collected from authorities already referred to, and from — 1. Pelletan. — Clinique Chirurgicale, i. 225. 1810. 2. Baudier. — Bulletin de la Faeulte de Medicine de Paris. 1820. 3. Curling. — London Pathological Transactions, i. 301. 1848. 4. Sir James Paget. — Mediad Times and Gazette, ii. 161. 1861. 5. Lebert. — Anatomie Pathologique, li. 515. 6. Cadge. — Lancet, ii. 631. 7. W. T. Green.— British Mediad, 1870, i. 489. 8. Barnes. — London Obstetrical Transactions, x. 141. 9. Byrne.— DiibKw Quarterly Journal, li. 504. 10. Meadows. — London Ohstetriccd Transactions, xiv. 309. 11. West. — Diseases of Women, 643. 12. Beiqel. — Krankheiten dcs Weihlechen Geschlechtes, ii. 589. 13. Hildebrandt. — Die Neue Gynakologische Universitdts-Klinik und Hchammen Lehr-anstalt, 99. 1876. 14. WiooLESwoRTH.— ^rc/ui;M of Dermatology (quoted in Schmidt's Jahrlmch, 172, 247). 15. Demarqcay. — Pannentierlulletin d<: la soc. anat., 245. 1860. 16. Gremleb. — Preussische Vereinszetung, 33. 1843. 2 TransactioTts of the Edinburgh Obstetrical Society, v. 139, 1877-78 ; and Edinburgh Medical Journal, xxiv. 266, 1878-79. Carcinoma VagincB. 205 found grafted also into the vaginal wall. But in the patient from whom the present preparations were removed the uterus was quite healthy. CARCINOMA VAGINA IN A PEEGNANT FEMALE.i At a meeting of the Edinburgh Obstetrical Society on November 13, 1878, I stated that I had recently a rather rare and interesting case of malignant disease of the genital organs in my Ward, and thought it well to take the oppor- tunity of mentioning it to the Society. The patient was ad- mitted on 7th October complaining of pain in the back and down the outside of the thighs, but more especially of inabi- lity to pass her water. When she stated that she was about three months pregnant, the idea naturally occurred to Dr. Hart, who first saw her, that it was probably a case of retro- flexion of the gravid uterus. Examination, however, showed that, whilst the organ was of the size of the ordinary three months' gravid uterus, it was in its normal position, but kept pressed forwards by a large firm mass occupying the whole of the posterior vaginal wall. On closer scrutiny this was found to be an epithelial cancer, commencing half an inch within the vaginal orifice, extending up the whole extent of the back wall, and laying hold of the upper portion of the posterior aspect of the portio vaginalis. The surface was eroded, but there was little or no discharge. The patient, 37 years of age, married 13 years ago, and mother of seven children, had enjoyed good health till about two months before admission ; but when she came under observation she was already pale and weak, with an anxious, worn expression, and a feeble, frequent pulse. The action of the bowels had ^ Edinburgh Medical Journal, xxiv. 654, 1878-79 ; and Transactions of the Edinburgh Obstetrical Society, v. 2. 1878-79. 2o6 Vagina. latterly become painful. Quinine was administered and opi- ates applied for the relief of the fever and pain ; but her condition went on deteriorating. The cancerous mass began to ulcerate towards the rectum, and the patient sank into a typhoid condition, and died on 7th November. The question of artificial abortion was discussed, but set aside, as it would probably only have hastened her end. Unfortunately, I am unable to show any preparation of the parts, as a post-mortem examination had not been permitted. Fibroid Turnours of the Uterus. 207 UTERUS. THE TEEATMENT OF FIBROID TUMOURS OF THE UTERUS.i A T the meeting of Council, ten days ago, at which it was arranged that, as your retiring President, I should open this session with a special address, I stated that I thought I could venture to address you on the management of Fibroid Tumours of the Uterus, and I do not know that I could well address you on a more important subject. It is not only that they are very common, so that as many as one in every five women have been supposed to be the subject of them. In my own ward journal I find, out of 68 cases admitted during the last three years with disease of the sexual system of which a special record has been kept, 7 cases of fibroid tumour, or 10.3 per cent. It is not even that they are detrimental to health and dangerous to life ; but it is because they exert such a baneful influence upon the repro- ductive powers of those who are affected by them. Out of sixteen married women, e.g., who were the subjects of fibroid tumours, and in regard to whose reproductive functions I have made a note, I find that only three had borne children. Thirteen out of the sixteen were barren. THEIK PERNICIOUS INFLUENCE ON REPRODUCTION. Other diseases of the generative organs may influence the ^ Transactions of the Edinhin-gh Obstetrical Society, v. 4, 1877-78 ; and EclinhurghlAIedical Journal, xxiii. 577, 1877-78. 2o8 Uterus. reproductive process at one or more of its stages ; but a fibroid tumour may mar the process at any or every step. It may compress the ovaries and hinder ovulation. I have known them such a cause of dyspareunia that the patient could not suffer marital intercourse ; or, insemination having taken place, they may hinder the onward progress of the spermatozoa, so that the ovula are never fertilized. Or, again, the spermatozoa may have travelled through the irregular expanded cavity of the uterus, and fertilized an ovum in the Fallopian tube ; but the fertilized ovum does not effect a lodgment in the uterine nest, or becomes attached only to be cast off as an early abortion or miscarriage. The fibroid tumour may lead thus to interruption of pregnancy at any stage, and where the development of the foetus goes on to term, the child is apt to be found at the close in some irregular presentation or position in consequence of the irregularity in the walls of the cavity where it is lodged. Let us even suppose the pregnancy arrived at full time, and the foetus fairly placed. Then labour may be complicated in any of its stages. The first stage may be lingering ; the second seriously obstructed; the third complicated with grave hpemorrhage. They even carry danger on into the puerperium, for a fibroid in the walls of the uterus may be a source of post-partum haemorrhage, or may become the seat of an inflammatory process, dangerous in itself, and extending dangerously to surrounding structures. THEIR PATHOLOGICAL NATURE AND ANATOMICAL SEAT. I do not require to detain you with any lengthened ex- position of their pathological nature and their anatomical relations. Enough if I remind you that whatever their ulti- mate relations, they spring from the middle muscular wall of the uterus, with the elements of which the neoplastic elements are homologous, so that they present, as their most constant and characteristic constituent, quantities of un- striped muscular fibres, largely rudimentary, though sometimes Fatty Degeneration of Fibroids. 209 more developed, collected in twisted bundles among a densely fibrous and granular connective tissue ; and that, as regards their position in the walls, they may be found growing towards the serous surface (sub-peritoneal), or imbedded in the middle of the wall (intra-mural), or projecting towards the uterine cavity (sub-mucous) ; and this relation of them to the thickness of the uterine parietes is a matter not merely of anatomical interest, but of great clinical importance, both as regards the symptoms that arise and the line of treatment that may most hopefully be instituted. NATURAL TEEMINATIONS. Let us glance for a little at the methods by which, in cer- tain cases, the disappearance of these tumours is brought about under the efforts of nature. \st. Fatty Degeneration. — There are few things more certain in pathology than that these myomata occasionally wither in consequence of a process of fatty degeneration being set up in their constituent fibres. In cases where a gravid uterus has such a tumour in its walls, after the expulsion of the ovum, whether prematurely or at full term, when the usual process of retrograde metamorphosis is set up in its proper muscular layers (fig. 33), the same process is set up in the homo- s' « Fig. 33. Unstriped Muscular Fibres from Uterus undeegoino Fatty Degeneration. aa Rod-Shaped Nucleus. gg Fatty Particles. logous neoplasm imbedded among them ; and as the uterine walls return to their normal pre-gravid measurements, the tumour diminishes and may altogether disappear. Our vice- president. Dr. James Young, will recall such a case which I saw with him a few years ago. The patient had an easy 2IO Uterus. enough labour, but a troublesome third stage and some degree of post-partum haemorrhage. AVhen I saw her next day the uterus was felt with its fundus an inch or two below the level of the umbilicus, and a large firm equable mass could be easily manipulated through the relaxed abdominal wall, growing from the upper part of the anterior wall of the uterus, and reaching the size of a child's head into the right liypochondrium. This large fibroid mass became greatly reduced in size during the puerperal week, and when the patient passed from under Dr. Young's observation, it had diminished to the size of a hen's egg, and was lodged within the pelvic cavity. Two years ago I had under my own care and observation a primiparous lady, 36 years of age, in whom, from the fifth month and onwards, I had occasion from time to time to observe the presence of a fibroid tumour on the anterior aspect of the uterus. Through the abdominal walls it felt as if of the size of a walnut, and it projected very distinctly from the surface of the organ. Immediately after labour I could still feel it without any difficulty. Dur- ing the puerperium it grew less with the lessening size of the uterus ; and when the patient went to her home in the country, at the end of two months, I could not any longer trace its presence. I saw her some eight months later, in the fifth or sixth month of her second pregnancy, and still the outline of the uterus was smooth ; the tumour had melted completely away, and had never been reproduced. A third instance I may adduce from the history of a patient of whom I shall have more to say by and by, but who states that after a labour, when she was about thirty years of age, an irregular mass was detected by her medical attendant in connection with the uterus, which she declares to have had the same consistence as a fibroid mass now growing from the same organ. That tumour diminished and disappeared dur- ing lier convalescence, so that she ceased to be able to detect its presence. That these tumours, which disappear in the walls of a puerperal uterus, melt down Ijy a process of fatty degenera- Calcareous Degeneration of Fibi^oids. 211 tion and disintegration, does not, to my mind, admit of a doubt. There is more room for discussion as to whether such a process occurs in them under other circumstances. The fibroid-infested uterus is an organ in which nutritional dis- turbance has ah^eady taken place, and is prone to be repeated. It is an organ, tlierefore, in whicli inflammation is apt to be set up, and in which the effects of chronic inflammatory pro- cesses in general, and this of fatty degeneration of structural elements in particular, are frequently to be observed. The new grow^th, of somewhat low vitality, as evidenced by its feeble vascularity, will be specially liable to such change. Hence, in the case of a patient who died under efforts made to relieve her of the symptoms resulting from a group of fibroids in the walls of the uterus, and in whom inflammatory action liad been set up in the organ, I could see some of the xmstriped muscular fibres taken from the fibroids containing fatty particles, and evidently in an early stage of fatty de- generation. More frequently I have seen such degeneration, and in a more marked degree, in sections of such tumours that had sloughed out or been expelled under strong uterine contractions. I see no reason, therefore, to doubt that a similar process of disintegration may go on in them more slowly but as effectually in cases where the inflammatory action does not run so high, or spread so widely, as to lead to the patient's death ; or in which the tumour continues to be crushed up within the uterine parietes without being expelled through the genital canal. It could only be by a fortunate accident, as it were, that such a change could be seen under the microscope, for it is precisely in such a case that the patient passes from the care of the clinician to better hands than those of the pathological anatomist. 2d. Calcareous Degeneration. — Another degenerative pro- cess to which they are occasionally liable is that which results in the diminution of their size and condensation of their structure along with a deposition of calcareous matter in their substance. This calcareous or osseous degeneration is most likely to occur in the fibroids of aged women. 2 I 2 Ute7'tCS. According to my experience, it is more frequent in the sul)- peritoneal than the other varieties, though last session, through the kindness of Dr. Watson of Mid-Calder, I had the oppor- tunity of exhibiting here an ilkistration of such a process affecting a sub-mucous fibroid, and to this preparation I shall refer more particularly anon. ?}d. Pedunculation and Extrusion. — A third process by which nature sometimes gets rid of these neoplasms results from the physiological properties of the matrix in which they are developed. For the walls of the uterus have inherent in them a tendency to undergo a remarkable degree of develop- ment whenever any body gets lodged within them ; and when the muscular fibres have attained a certain degree of develop- ment, they manifest their physiological character by contrac- tions sometimes tonic and continuous, at other times more energetic but intermittent. The effect of such contractions on a fibroid that is not purely intramural, is to force it towards the surface in the direction of least resistance. If they grow from the external plane of the muscular coat they are driven towards the serous surface so as to become more definitely sub-peritoneal. They may there finally become pediculated, and where the neck is narrow the mass may even liecome detached and be left free to move about in the peri- toneal cavity. Some years ago I had in my ward a woman upwards of forty years of age, with such a roving body, of the size of a hen's egg, that could be pushed about anywhere in the abdominal cavity; and the nature of it seemed to be certified l)y an absolutely similar body of the same firm con- sistence and slightly larger size, which still retained its attachment to the fundus uteri by a narrow pedicle. We are more familiar with those which are driven in the opposite direction. I d(j not know that there is anything to show or to lead us to suppose tliat the inner plane of the muscular fil)res is a more frequent seat of their development. Probably it is rather owing to the circumstance that the tumours so situated are subject to more forcible compression from being more completely embraced by the uterine parietes. V>\\t Spontaneotis Extrusion of Fibroids. 2 1 , however this may be, it is fav from uncommon to find them in the form of an intra- uterine fibrous polypus (fig. 34), sessile or at- tached to the interior of the organ by a longer or shorter neck, under- going thus a process of slow extrusion; and in certain cases we meet them driven down un- der more energetic ac- tion of the uterus, and thrown off by this pro- cess of spontaneous ex- pulsion. In such in- stances the tumour is driven on, covered with an investment from the uterine mucosa. But sometimes the mucous membrane on the surface sloughs off or ulcerates through, and then the naked tumour is driven out of its bed and born by the process which has been termed spontaneous enucleation. Fig. 34, — Uterus laid open, showing Intra-tjterine Poltpus, THEIR TEEATMEXT. Let us turn now, if you please, to the consideration of the means we may adopt to imitate these natural processes or to expedite them where they are in progress. If I do not dwell on the influence of food in this class of cases, and more particularly on the influence of a strict animal diet as suggested by Cutter, it is simply because I have not gathered any experience for myself in this line of treatment. For the same reason — that I wish rather to deal now with methods of treatment of the value of which I have been able to satisfy myself — I pass over the treatment of uterine myomes by means of electricity, and proceed at once to the consideration of their 214 Uterus. MEDICINAL TREATMENT. Here I may at once frankly say, that I know of no drug which on being introduced into the system finds its way to a uterine fibroid, and acts in the way of a solvent on its structures. \st. Mineral Waters. — At the same time, I cannot doubt the powerful influence for good exerted by some of the mineral waters, e.g., those of Kreuznach, the virtues of which were advocated here by Dr. Engelmann last session. For I have seen patients who were suffering from such tumours in whom the symptoms were relieved, and in whom the growth of a previously increasing tumour was arrested, if the bulk was not immediately diminished. These mineral waters seem to me to exert some portion of their influence by acting as sedatives to the sexual organs, lessening the activity of the circulation in them, and so reducing the nutritional activity. One can understand how in this way the effects of the chronic inflammation going on in the organs may be removed and a check be given to the further increase of the neoplasm ; how even, when the muscular walls of the uterus are disburdened of their inflammatory products they may quietly but continuously begin to take on their function, and contract so firmly around the growth as to favour its dis- integration. Id. Bromide of Potassium and Chloride of Calcium. — A similar influence, it is at least highly probable, may Ije exerted by the bromide of potassium. This drug, which enters largely into the composition of some of these waters, has certainly a powerful sedative influence upon the genera- tive organs ; and though, as I have said, neither it nor any other can be regarded as a simple solvent of uterine myomata, I have a strong impression of its value in modifying the conditions tliat favour their development. But T have long ceased to trust to it alone in their medicinal treatment. In some instances I ]ia\'e administered the chloride of cal- cium as recommended by Washington Atlee and Spencer BT^01nide of Potasshmi for Fibroids. 215 Wells, but I have failed to meet a case where the progress- of the tumour was sensibly affected by its use ; and it is to Ije remembered that its prolonged administration is not a matter of indifference, as Wells has noticed the premature develop- ment of an arcus senilis in patients who were employing it. One of its expected advantages, indeed, is the deposition of calcareous salts among the tissues of the tumour or in the walls of its nutrient artery ; but there is no means of con- trolling their deposition in the desired site, whereas in the case of the bromide of potassium, we have to do with a salt which, however it may act, does not lodge in the system, but is being constantly eliminated, so that I have had patients taking it for many months and even for a year or two with- out its producing any constitutional effect, if only they were careful to attend to the recommendation to suspend its use during the menstrual week. 2>d. Ergot of Rye. — But the drug that most powerfully and unmistakably affects the growth of fibroid tumours of the uterus is the ergot of rye. Its influence on the developed muscular fibres of the uterus naturally led to its employment in cases of fibroid tumours with hypertrophy of the sur- rounding walls ; and the concurrent testimony of many gyne- cologists puts the action of ergot in the treatment of these growths among the best established phenomena of thera- peutics. The preparation, for example, to which I have already referred as having been sent here for exhibition by Dr. Watson, was taken from the body of an unmarried female, set. 52, whose case was brought under the notice of the London Obstetrical Society in 1871, by Dr. John Brunton. She had been the subject of a fibroid tumour which reached up as high as the umbilicus, but which disappeared in the course of six or seven months under the administration of full doses of ergot at each menstrual period. When the patient died last summer of disease altogether imconnected with the sexual system, and after she had ceased to suffer from any further haemorrhages, there was found in the upper part of the uterus and growing from the fundus and anterior 2 1 6 Uter2LS. wall — as some of you saw — a condensed and partially cal- cified fibroid of the size of a small mandarin orange. For many years I have been in the habit of treating certain cases of uterine fibroids with ergot of rye during the menstrual period, and bromide of potassium in the intervals, and in many instances with good results. Eather more than a year ago, there came to my ward in the Infirmary here, a woman whom I had had under my care ten years ago in Glasgow, suffering from a fibroid which caused the uterus to rise like a fourth-month organ above the pubis. Under the treatment I have indicated, the tumour began distinctly to diminish in size, and as the patient became freed from her distress, I lost sight of her till she came back bringing with her her old prescriptions. She stated that she had kept well for three or four years, when she began again to suffer from her old symptoms and the re-appearance of a tumour in the lower part of the abdomen. She had gone to live in a distant part of the Highlands, and allowed it to progress till now it filled the abdomen and reached a handbreadth above the umbilicus. On this occasion I kept her under treatment for nearly three months, administering every second day a hypodermic injection of 2 J grains of ergotin, with the result that a slight but a very appreciable diminution occurred in the mass. She was obliged to go home sooner than I desired, but she left under promise to return if the tumour began to grow larger, or if she began to suffer from any aggravation of lier symptoms. The narration of this case has led me into the statement of the method that I have found to be the most effectual for obtaining the full benefit, of the drug. For it seems to me that the doubts as to its efficacy are traceable to one or other of three difierent causes — \st, Tlie use of an inert preparation of ergot ; 2rf, An imjDerfect administration of it ; Sr?, An inap- propriate condition of the patient. As to the first, it is one of the commonplaces of obstetrical therapeutics that quantities of inert preparations of ergot are in all the markets, and tliat much of the uncertaintv as to the value of the druir is due to Treatment of Fibi^oids with Ergotin. 2 1 7 the employment of powders, extracts, and tinctures wliicli are devoid of all active properties. Secondly, with regard to the mode of administration. Wliilu almost any preparation of a good ergot will give the desired effect, it was a step of immense importance in the satisfactory treatment of uterine fibroids when Professor Hildebrandt, of Konigsberg, demonstrated the safety and certainty with which an active dose of ergotin could be administered hypo- dermically. He showed what my own experience, as well as that of Byford, of Chicago, and others has amply confirmed, that the repeated subcutaneous injection of from 2 to 5 grams of ergotin can be counted on with great certainty to excite appreciable contractions in the walls of uteri in which the muscular fibres have become hypertrophied. The preparation of ergotin which I have found most satisfactory is the same which I brought under the notice of tliis Society in treating of the complete evacuation of the uterus after abortions. IJc Ergotinaj, . . . 3ij. Aquse, . . . 3vj. Chloral-hydratis, . . 5ss. M. Twelve drops of the solution, or rather mixture — because the ergotin is partly dissolved and partly suspended — gives a dose of three grains, and this may be regarded as a medium dose, to be administered daily, or every second day, or twice a week after the intiuence of the drug begins to be mani- fested. In making this hypodermic injection, it is necessary to take care, 1st, that the fluid carry with it no small globules of air; and, 2d, that the point of the syringe be carried deeply down through the skin and areolar tissue, right into the muscular strata. Sometimes the injection may be made in the abdominal walls ; in most cases they are borne best in the gluteal regions. I cannot understand how the practice has crept into our hospitals, but I observe that when students are called to make such an injection they pinch up the skin and push the point of the needle obliquely through. 2 1 8 Uterus. and occasionally to some distance among the cellular tissue lieneath the skin. Now the pinching up of the skin may do good and serve to make the surface somewhat tense ; but the needle should certainly always be carried in as perpendicu- larly to the surface as possible, and straight down with one quick stroke into the muscular tissues. Such a preparation, so introduced, is not liable to be attended with the suppura- tions which have deterred some practitioners from the con- tinuance of this mode of administration. It is but rarely even that the patients complain of the pain. I can only recall two out of the many patients in whom I have used it, who objected to the frequent repetition of the injection on the score of local suffering. They may be made daily, or every second day, for several weeks ; or, after some frequent injections for a month, they may be continued once or twice a week for many months without producing any constitu- tional disturbance. Cardiac disease does not constitute a contra-indication to its employment. At least one patient, to whose case I have already referred as ha^dng got rid of some fibroid mass during a puerperium, was commended to my care chiefly because of the distress she suffered from a cardiac affection. I found, indeed, that she had well-marked valvular disease of the lieart ; but it seemed to me that her distress was largely due to the presence of a group of fibroid tumours, some of which were subperitoneal, but one at least was intramural or sub- mucous, and associated with pretty free menstrual discharge. The subcutaneous injections were freely carried out in this case without the faintest drawback, and with the result of a lessening of the menorrhagia and a diminution in the bulk of the lower portion of the general mass, along with great im- provement in the patient's general health. Again, I have used the ergotin hypodermically in the case of a patient who is the subject of chronic asthma and bronchitis, ^\dth nothing but satisfactory results. But there remains the third point, as to the appropriate cases. I believe Hildebrandt has correctly indicated the con- Treatment of Fibroids with Ergot in. 219 (lition most favourable for the use of ergotin in stating that the tumour must be intramural or submucous ; in other words, it must be surrounded by layers of muscular fibre, sufficiently developed to be capable of being excited to contraction, and sufficiently powerful to exert some degree of pressure upon the body in their embrace. For the beneficial action of the drug in such cases depends upon its property of stirring and keeping up continuous contraction in the unstriped muscular fibres of the uterus, the effect of wliich is in some cases to push the compressed tumour more rapidly towards the uterine orifice, and so to favour its extrusion from the cavity ; in others, so to interfere with its nutrition that it ceases to grow or even begins to wither, probably in consequence of fatty degeneration being set up in its fibres. The ergotin perhaps exerts a secondary influence in the direction of cutting off the nutritive supply of these bodies by tending to cause contrac- tion in the walls of the uterine arteries, and so lessening their calibre. Such an influence is not to be denied, and although it is altogether subsidiary towards the elimination of these fibroid tumours, it makes the employment of the drug very serviceable for the alleviation of one of their com- monest symptoms, ^dz., the excessive losses of blood. Sometimes, I have said, the hypodermic injection leads to the rapid extrusion of the tumour. This occurred in the case of a poor woman whom I saw with Dr. Balfour of Portobello, and who came into my ward to be treated. She had long- suffered from pelvic pains and uterine hasmorrhages, and had got into the habit of taking opium freely and frequently. The fundus uteri reached more than half way between pubes and umbilicus, and the sound passed four inches into the uterine cavity. There was a degree of tympanitis and abdo- minal tenderness that necessitated the administration of chloroform to enable us to make a satisfactory examination. Under the use of the hypodermic injections of ergotin the discharge at first diminished, then a fetid discharge began to escape. Frequent examinations even with the finger pained the patient, who was a virgin a?t. 48 ; but after two months' 2 20 Uterus. almost daily use of the injections a sloughy mass was found to have been expelled into the vaginal canal, which was de- tached from the uterus by means of the ecraseur. It was so soft and pulpy that I thought at first the diagnosis as to the nature of the tumour must have been incorrect ; but on more careful examination it was found to be a fibro-myome in a gangrenous condition, many of its fibres breaking down, and some of them crowded with fatty particles. The patient re- covered health to a great degree, notwithstanding that she liad an attack of pleurisy before she left the Infirmary, and the tympanitic state of the abdomen never disappeared. In other cases where the tumour has not been expelled, it lias become reduced in size. Two years ago I saw, with Dr. CuUen of Airdrie, an unmarried lady, 35 years of age, who had become very an?emic from excessive losses of blood. She had an intramural fibroid of the size of a cliild's head. The hypodermic injections were carried out at somewhat lengthened intervals, but kept up for many months by a sister, as they lived at some distance from their doctor; and when the ])atient came to see me last spring her discharges were less profuse, her tumour much reduced in size, and her general health greatly improved. I might make almost the same remarks regarding a very similar case which I saw some nine months ago with Dr. Peter Stewart of Glasgow; only the tumour in this case was originally larger and more irregular, and wedged more firmly into the pelvis, and the diminution in size is not yet so pronounced. In a note which I had the otlier day from Dr. Stewart, he tells me he is using the ergotin in another case of fibroids with promising results. In certain cases, the beneficial action begins to make itself sensible to the patient by relief of lier symptoms before there is any distinctly appreciable reduction in size of the mass. Moderation of the often exliausting heemorrhages is a frequent <-)1)servation. But sometimes other symptoms thus soon get relief. A lady, for example, who was sent to me by Dr. Leith of Comrie, in addition to the weakness caused by menorrhagia, ^v•as suffering from symptoms of pressure on the bladder. Treatment of Fibroids with Ergotin. 2 2 1 The uterus, occupied by a fibroid tumour, was about the size of a large fist, movable, and with a patulous cervix. I ad- ministered an ergotin injection, and advised its repetition two or three times a-week. In six weeks the patient returned, having experienced great rehef from her pressure symptoms, and gathering strength as she had had less loss of blood. Still I could not satisfy myself that the uterus felt much lessened in bulk. After the continued use of the injections, made chiefly by the patient's husband for two months longer, the diminution in the size of the uterus was very perceptible, and the patient's general condition was still improving. In two instances of unmarried ladies where the tumours were subperitoneal, but where there was considerable enlarge- ment of the uterus, and a degree of menorrhagia that would itself have constituted an indication for the use of ergot, I have observed that under the ergotin injections the tumours, without sensibly decreasing in size, became, in the course, in one, of three, in the other, of five months, more super- ficial. Lastly, I have noticed that in several instances, where the tumour was of large size, and where the ergotin-injection treatment has been instituted, a growth, which up till that time had been steadily increasing in size, has had such an arrest laid upon it that it ceased to enlarge. Two ladies, both mmiarried, whose history is illustrative of this occurrence, are at tliis moment in my mind. In one, I had the opportunity of witnessing and watcliing the slow but steady growth of a fibroid during several years, despite the use of the Kreuznach waters, bromide of potassium, chloride of calcium, and internal administration of ergot. Since about eighteen or twenty months ago, however, she had a series of ergotin injections carried out for some two months, there has been no increase in her girth, though her general health is better, and her limbs are stouter. In that case, the period of life may have favourably influenced the condition, as she ceased to menstru- ate a few months after she had begun this treatment. But, in the other case, the patient is still only 35, and though 2 2 2 Utei'us. menstruation goes on regularly, the flow is less, and there has been no increase in her abdominal measurements since more than a year ago she first began to use ergo tin injections. Gentlemen, I might multiply the histories of patients suffering from fibroid tumours of the uterus, whom I have seen benefited by the adoption of Hildebrandt's treatment ; but I fear I have already taxed your patience. In view of the doubts that are still expressed in some quarters, however, I feel that it is quite worth while to have adduced these illustrative cases, which I hope will help to convince you, as they have convinced me, that the hypodermic injection of ergotin is a therapeutic agency of the first importance in the treatment of fibroid tumours of the uterus ; and that where we find such a tumour causing much haemorrhage, seated in a uterus with a patulous cervical canal, and surrounded by some layers of well-developed muscular fibres, we may have recourse to its employment with a well-grounded expectation of seeing the symptoms relieved and the tumour greatly re- duced in size, or it may be expelled altogether, or at least brought more speedily within the sphere of SURGICAL TREATMENT. If I may now ask your attention to the operative measures to be employed for the removal of fibroids, I shall again leave out of consideration some important proceedings, such as the producing of a slough, and so procuring tlie disintegration of the growths, as proposed and practised by Dr. Greenhalgh, with the actual cautery, and the extirpation of the uterus or portions of it through an opening made in the abdominal walls — an operation which has now been pretty frequently performed, which I have myself witnessed at the hands of two different operators, and which doubtless has a triumphant future before it. I wish to speak rather, and that very briefly, of the operations that will always be appKcable to an im- mensely larger number of cases, where we have to do with tumours not so imposing in their size, but important from the operative Treatment of Fibroids. 223 frequency of their occurrence, and tlie urgent call they often make on operative skill. Id. Torsion. — The first method that I always think of em- ploying for the removal of an intra-uterine fibroid to whicli I have got access, is the simple twisting of it so as to loosen it from its attachments. Whether it be pediculated or sessile, large or small, as soon as it can be firmly grasped with the fingers or with a volsella or pair of abortion forceps, it should be twisted steadily and firmly round and round in the same direction until its attachments are felt to yield. It is astonishing sometimes with how friable a neck even a large fibroid still hangs to the uterus, and with how loose a base a broadly sessile one may be imbedded in the wall. The bleed- ing that takes place in such cases is but little, and soon comes to an end. I have seen a fibromyomatous tumour passing from the uterus into the vaginal canal of such large size as to baflle all attempts to reach its base or pedicle even when the four fingers of the hand were pressed into the cavity, and yet the jDcdicle gave way when the great mass had been rotated several times in one direction. A consider- able gush of blood took place at the moment that it was felt to be set free, but no further escape took place during the two hours and more that I spent in breaking down and extract- ing the growth through the narrow outlet. 2d. Cutting, Crushing, or Scratching. — When the pedicle or base will not yield under torsion, they must be divided by some cutting, crushing, or scratching instrument. The cases are now pretty numerous in which I have removed such bodies with the polyptome. For its satisfactory employment, however, the tumour must have a distinct and rather narrow neck, and in any case it is apt to cut obliquely, and may leave a fragment behind. This, of course, usually atrophies ; still one would rather have a smooth surface left. In one or two cases, where the pedicle w\as more easily accessible from below, I have divided it with scissors. In several, where I apprehended hiEmorrhage, I have usetl the (icraseur, and always take the instrument to any case of Uterus. removal of a fibroid. It is not always easy of application, how- ever, and occasionally when it is at work dividing a fibroid of firm texture, it disappoints you by gi^"ing way. I fancy most gynecologists who have had much to do with such cases have sometimes felt the want of an instrument for working their way through the pedicle or base of these bodies. So one reads in the histories of the use of the point of a bistoury, the blade of which is wrapped in lint ; or the handle of a scalpel or such like. I see from the number of the American Journal of Obstetrics that has just come to hand, that Professor Gaillard Thomas showed to the New York Obstetrical Society an instrument which he uses for cutting- through the base of sessile fibroids. It re- sembles a spoon on a long handle not unlike one of Simon's curettes, only the edges, instead of being simply sharp, are toothed or serrated, so as to more easily cut through the tissues, and it seems well adapted for its object. In removing these bodies, I have sometimes been able to make my way deeply through the base with the nail of the forefinger alone. But there always meet one some strands of fibre that are too tough to be thus torn through, and besides the nail bathed in the blood begins to soften, till one wishes that it were made for a little of steel. After trying curettes of various kinds, I have come for the last eighteen months or so to make use of the instrument which I now show you (fig. 35), and which I find immensely serviceable in the digging out of fibroids and other new growths in tlie uterus. The flat sharj » point serves as a substitute for the nail, the edge of which it resembles in size ; the slightly curved stem is long enough to be easily carried up to the fundus uteri, and so slender as Fifi. 35. Nail-Curette, lialf-she. Extirpation of Fibroids. 225 not to occupy much space in the canal ; the handle is broad and square, to give a good hold and purchase in the work- ing of it, and roughened on all sides, except on the surface, towards which the sharp edge of the instrument is directed. When it is being used, the tumour is sometimes dragged down with a volsella by an assistant, particularly when it is very mobile. At other times I have used it where the uterus was simply steadied by pressure from above the pubes. The point is guided to the root of the tumour by the index finger of the right hand, which closely follows it in its track through the severed tissues, the handle being worked all the while by the left hand. It is thus an instrument of extreme simplicity, and as safe in its working as the nail of the finger, for which it is a substitute. One of the patients, in whom I first employed it, had a history wliich presents several points of unusual interest. She was a widow lady 60 years of age, who brought me a letter from Dr. Mackenzie of Kelso, stating that she was the subject of a pelvic tumour, that she had been operated on by Sir James Simpson ten years previously for some uterine affection, probably a polypus, that she had at that period been for some time in a lunatic asylum, and that again she was becoming the subject of mental derangement. The mental malady was clear enough. The old lady was under the con- stant apprehension that something was to happen to her, and she would pass an hour at a time in screaming out. But she attributed all the distress herself to the swelKng, which was very perceptible in the lower part of the abdomen, reaching up to within two inches of the umbilicus. This was found to be the uterus enlarged with what I took to be, from its firm consistence, the vascular bruit, and other characteristics, an intra-uterine fibroid. She was extremely anxious to have the tumour cut out. This I did not feel warranted in under- taking to do ; but as the case seemed a fair one for the hypo- dermic injections of ergotin, I commenced their use every second day. During six weeks that I had her under treat- ment here, I could perceive that the drug was exerting an p 2 26 Uterus. influence ; the tumour began to sink in the abdomen, and the OS uteri began to expand. Her mental condition improved slightly, and she went home. For some weeks, by some mis- take, atropin injections were administered instead of ergotin. By and by, the mental symptoms getting more urgent, she was put under the care of Dr. Tuke in the Saughton Asylum, where again I had the opportunity of watching the progress of the case. Dr. Tuke's assistant. Dr. Bower, carried out the injections very carefully for a few weeks till the expansion of the OS and the descent of the tumour had so far progressed as to render the interior of the uterus easily accessible to the exploring fingers. Partly from the deterioration of the sys- tem from imperfect nourishment — for she made a difficulty about her feeding — and still more from the drain that for some months had been taking place from the uterus, the patient had become very feeble, so much so that Dr. Mac- kenzie had great doubts as to the propriety of attempting the removal of the growth. It was attached to the fundus and posterior wall of the uterus over a widely extended surface ; and I was disappointed to find that it was not simply im- bedded and encapsuled, but closely incorporated at some parts with the muscular coat. It was out of the question to apply an ^craseur, the mass could not be twisted out, and I do not know how I could have got it detached from its place, but for the help of the nail-like curette. By having it dragged upon with a strong volsella by my friend Dr. Horatio E. Storer of Boston, who was present, and by patient determined scratching through of all resistant textures, it was severed from the uterus and removed. Seeing that there was such an intimate union of it with the uterine walls, I was not surprised to find that the mass, though mainly myo- matous in structure, presented at some points sarcomatous elements. The patient rallied from the operation and re- covered her strength to a very remarkable degree. As I had anticipated, however, from the anatomical structure of the tissues, the tumour was reproduced. From time to time sloughy masses were expelled, which presented a purely Cases of Intj'a-tUerine Polypi. 227 sarcomatous character, and some twelve months after the date of the operation the patient died under an excessive loss of blood. I had intended to cite some other cases of a more ordinary character where this instrument has stood me in good stead, but I forbear. Nor do I dare to prolong this address by bringing before you, as it was in my mind to do, some obser- vations on the enucleation of fibroids, or the incision of their mucous covering, or the division of the cervix uteri. The first of these operations I regard as not only justifiable, but sometimes as clearly called for. The second and the third are sometimes required as preliminary steps to the first ; but apart from this, sometimes they have approved themselves as valuable procedures in checking the haemorrhage and favour- ing the spontaneous expulsion of the tumour. On some other occasion I may have an opportunity of treating of these opera- tions. Illustrative Cases. CASE I.^ At a meeting of the Edinburgh Obstetrical Society, held on July 14, 1875, I showed two Polypi, The one, a simple polypus, was removed by the ecraseur. The second one was from a patient who had been sent to me as suffering from cancer of the uterus. On examination, the vagina was found filled with a sloughing mass, and there was a quantity of stinking discharge. The patient was very ansemic, and her look was very like that of a subject of cancer. The tumour was removed by twisting, and was with difficulty extracted from the vagina after separation. No haemorrhage at the time. The patient did well at first, but died suddenly the following afternoon. There was no blood found in the vagina or peritoneum ; the heart was soft and flabby ; the fatal issue, ^ Traiisactions of tlic Edinhurgh Obstetrical Society, iv. 135, 1874-75 ; and Udinburgh Medical Journal, xxi. 549, 1875-76. 228 Uterus. whicli was quite unexpected, may be put down to shock after the operation, CASE i\} On July 11, 1877, I showed, at a meeting of the Edinburgh Obstetrical Society, a large Fibro-myomatous Polypus. The large fleshy mass was divided into four unequal segments, which together formed a rounded body of the size of a large male infant's head. The following notes of the case, by Mr. Walter Strang, have been extracted from the Ward Journal : — C. A., aged 46, residing at Prestonhall, near Markinch, was admitted on Tuesday, 3d July 1877, to bed 4, Ward 12, on the recommendation of Dr. Macdonald of Markinch. She complained of flooding and whites. The usual dura- tion of her menstrual flow had been three days ; but about two years ago it began gradually to increase from month to month, till about November 1875 she began to suffer from distinct menorrhagia. The flow at that time lasted eight days, was excessive in amount, and accompanied with clots. The duration and amount of flow kept on increasing, so that for the last eight months she had menstruated for a fortnight at a time. She has not had much pain at any time, but feelings of intense exhaustion. In the inter-menstrual period there was profuse leucorrhcea. About a month ago, at the commencement of menstruation, she took a pain in the back so severe, that the doctor had to be sent for immediately. Some medicine which he gave her relieved her pain. She commenced to menstruate at the age of 14. Till her present illness, the duration of the flow was always three days, and menstruation recurred with perfect regularity every twenty- eight days. She married at the age of 27, and has had four children, the eldest born twenty-one months after her mar- riage, the youngest eleven years ago. The ages of the children are, 17, 15, 13, 11. She has had two miscarriages, the first (third month) occurred nine months after her marriage ; the ^ Traiisactions of tlic Edinhurgh Obstetrical Society, iv. 408, 1876-77 ; and Edinburgh Medical Journal, xxiii. 265, 1877-78. Case of FibTO-inyoniatous Polypus. 229 second (also third month) took place about nine years ago. Flooding continued for about eight days after the last mis- carriage. All her labours have been easy and normal. Her general health has been excellent till within the last two years, and now she presents a pale, weary, almost cachectic appearance. The lower part of the abdomen was occupied by a firm body, reaching nearly a handbreadth above the pubes, and of the form and feel of the enlarged uterus. A distinct vascular bruit could be heard with the stethoscope, loudest on the right side of the organ. On making a vaginal examination, the exploring finger meets a body immediately within the vulva, firm and fleshy, distending the vaginal walls, and filling up the whole pelvic excavation. On combined external and internal examination, the vaginal mass is felt to move in concert with the uterus ; but it is utterly impossible to reach the vaginal roof, or to pass a sound into the uterine cavity. On 7th July, the patient having been put under the influence of chloroform, in the presence of Dr. Macdonald, Dr. Caldwell from Illinois, and others. Professor Simpson passed his left hand into the vagina, and ascertained that the growth came from within the uterus, though the root of it was not accessible. As neither the chain of an ecraseur, nor the platinum wire of a galvano-caustic battery, could be passed high up on the body, the most prominent portion of it was crushed off with the ecraseur. A second and a third section were thus removed before the body was so far reduced in bulk to allow of its pedicle being reached. This was now found attached to the back wall of the uterus, above the os internum. It was encircled with the Ecraseur, and crushed slowly through, and the wound surface measured 1| inches in diameter. There was no great loss of blood. The perineum was lacerated from the passing in of the hand, and the extraction afterwards of the mass. The cavity was syringed with some warm water and carbolic acid ; and, after the patient was put in bed, an opiate was administered. 230 Uterus. There has been no Lad symptom since the operation. The vagina is syringed twice a day with warm water, and there is every prospect of a good recovery. CASE 111} At a meeting of the Edinburgh Obstetrical Society, on May 11, 1864, I showed a preparation of a Uterus with a large Fibroid Tumour embedded in its interior wall, and a couple of fibrous polypi growing into its cavity. It had been removed from the body of a married woman about 40 years of age, who had never borne any children, and who had first come under my care about five years ago. At that time she suf- fered from frequent attacks of menorrhagia, with almost con- stant leucorrhcea in the intervals. On examination with the sound the cavity was found to be enlarged, and occupied by a polypoid growth. I introduced a series of sponge-tents so as to dilate the cervix, and removed the growth by means of the polyptome. The uterine cavity seemed then to be smooth and regular, and though the walls were thick no marked inequalities were discoverable in their contour. The patient had remained well for a length of time ; but about two years ago she had again come under observation in consequence of a return of some of her old symptoms. Enlargement of the uterine cavity, and the presence of a morbid growth in it, were again perceptible on the introduction of the sound ; and when a simultaneous examination was made with the right forefinger in the vagina, and the left hand over the pubes, the contour of the uterus was felt to be altered by the presence of a firm fibroid mass high up in the anterior wall, whilst the part of the posterior surface accessible to the exploring finger felt irregular, and seemed very tender to the touch. She w\as put upon bromide of potassium ; l)ut the morbid growths were found to be steadily developing when she was seen every three or four months ; and when on one occasion the Edinhurylt Medical Juurnal, x. 276. 1834-65. Removal of Polypi. 231 cervix was dilated with sponge-tents, just sufficiently to admit the finger, the polypus was felt to be beconiiiig pedicu- lated. Some months ago she came to town with the view of having the new polypus removed, and a series of sponge- tents were introduced ; but on the withdrawal of a large tent on the second day, there was found to be a very tight band in the posterior wall, at the level of the os internum, still undilated ; and as this rendered the neck of the polypus, which was attached above it, very inaccessible, it was deemed advisable to allow the uterus to close for the time, with the hope of effecting a more rapid and complete dilatation at some after period. About six weeks ago she was again seen ; but had come only to request that the operation might be de- ferred till her husband — an old man — should have recovered from some attack of renal disease. On her return the cervix was dilated with tangle-tents, and the superiority of these to the sponge-tents was very markedly seen in the completeness with which the dilatation of the whole circle of the os inter- num was effected. But whilst the dilatation was progressing the patient had very uncomfortable threatenings of rigor ; and on the morning of the day on which the removal of the polypus should have been effected, she had a rigor so severe and prolonged that I feared some local inflammation was being set up, and simply withdrew the tent without subject- ing her to what would have been the additional danger of a surgical operation. No local tenderness, however, was mani- fested ; but the discharge from the uterus became excessively offensive, so that it was supposed the tumour had become sloughy, and might perhaps break down and be discharged. The pulse had already risen considerably, and continued to rise to 120 and upwards ; the skin became hot and dry, and assumed a dingy yellow hue ; delirium set in ; and the patient died on the seventh day with all the symptoms of a septic fever. At the post-mortem examination no traces of any peritonitis or other local inflammatory action presented themselves ; but on removing and cutting open the uterus the large polypus 232 Uterus. in its interior, which was about the size of a duck's egg, was seen to be blackened, soft, and sloughy — a result which had, in all probability, been brought about by the pressure of the expanding and inelastic tangle-tent upon its neck. The pedicle had the thickness of about two fingers, and could easily enough have been cut through with the polyptome ; and perhaps the extirpation of the polypus might have led to a more favourable issue, although in view of the repeated and severe rigors which the patient exhibited, the operation would have seemed almost unjustifiable. Close to the pedicle of the sloughy polypus, which sprang from the back wall of the uterus, immediately above the os internum, there was another small tumour of the size of a hazel-nut just beginning to become pediculated ; whilst an intra-mural fibroid of the size of a small cocoa-nut, and of somewhat soft texture, was grow- ing in the anterior wall, and formed the chief part of the mass that had been felt through the abdominal wall on pal- pation over the pubes. I may add, although it seems to have no bearing on the clinical history of the case, that the extremity of the left ureter was found to be folded on itself as it passed through the wall of the bladder, and was dis- tended immediately above into a little pouch, large enough to contain a pigeon's egg. The cavity was occupied with an innumerahle quantity of small calculi — one of which was of about the size of a pea, the otliers of the size of wild mus- tard seeds. CASE iv.i At a meeting of the Edinburgh Obstetrical Society, on 25th January 1865, and during a discussion on the use of bromide of potassium for the removal of Fibroid Tumours and Polypus of the Uterus, I showed a specimen which illustrated all the varieties of fibroid tumours. There was a polypoid tumour within the uterus, an intramural, and several subperitoneal tumours, some of which had become pediculated. The follow- ^ EdinJiurrih Medical Journal, x. 857. 1864-C5. Case of Multiple Fibroids. 233 ing are the notes of the case supplied by Dr. Tiike of the Eoyal Asylum, Morningside, to whose kindness the Society was indebted for the preparation : — " C. E., the patient from whom this preparation was ob- tained, was admitted twenty years ago into the Eoyal Edin- burgh Asylum. She was then in a state of the most violent and dangerous mania ; so much so as to be an object of dread to the attendants. The mania under which she laboured was of a peculiarly animal tyjDe ; she uttered sounds more like the howls of a wild beast than the voice of a human being. When put to bed she rapidly destroyed all the clothes, and arranged them in a sort of nest, in which she sat naked and gibbered, presenting one of the most humiliating spectacles possible to conceive. These attacks recurred about every two years, and lasted for from six to twelve months. During the in- terval she was profoundly demented. In one of these attacks, and from its effects, she died, worn out and exhausted. When excited she was in the habit of gnawing the woodwork of her room, on one occasion eating through two shutters, both of which were two inches thick. The room in which she died is now in the state in which she left it, and the amount of de- struction she contrived to effect is extraordinary, considering the weak state of her system. " In June 1852, an entry appears in her case (she was then 52 years of age), in which it is remarked that the catamenia were very profuse, and that she had attacks of vomiting. In October of the same year appears the following entry : — ' The profuse menstruation continued, and the attacks of vomiting. The abdomen attained a large size, and felt hard and knotty to the hand. She was treated with enemata and purgatives, which were followed by evacuations of hardened feculent matter. The swelling subsided in a great measure, and left only a hard tumour of the size of the fist in the situation of the uterus, apparently of a fibroid nature.' " The tumour increased slowly but gradually, until two or more distinct portions could be detected — the menstruation ceased at the age of 54. Since she came under my observa- 234 Uie7^tcs. tion (two years ago), she never experienced any uneasiness from the tumour ; in fact, I was not aware of its existence until I examined her, amongst other patients, wdien making a careful investigation into the bodily health of all the old inmates, with the view of discovering diseases which are liable to lie latent in the insane to an extent hardly to be credited by any but those accustomed to their treatment." I remarked that the case was interesting, as showing the different forms and relations which fibroid tumours were wont to assume in connexion with the uterus. There were a great number of subperitoneal tumours, which here, as in so many other cases, were the largest in the group, and presented patches of commencing calcareous degeneration. The intra- mural nodules were here mostly small, and not in any in- stance surrounded with very large vessels. But the most important of the group was the large sub-mucous tumour, of the size of a lemon, which had come to project in a polypoid form into the uterine cavity. It was probably when this polypus first began to protrude towards the interior of the uterus that the patient had begun to suffer from menorrhagia thirteen years ago. For there were two stages at wliich patients were specially liable to haemorrhage in connection with fibroid polypi of the uterus — viz., 1st, when the uterine mucous membrane was first pushed out by it, when it was usually thickened and vascular ; and, 2d, after the body had become fairly polypoid, and when, from the effort of the uterus to expel it through the os, or from any other cause, the mucous membrane on its surface got abraded and ulcerated. But the l)eautiful preparation which Dr. Tuke had sent them illus- trated further the extent such tumours may attain without causing any inconvenience. It was explained in this case by the circumstance, that none of the tumours which had attained a large size had been retained in the pelvis. It was where tumours got wedged within that cavity that they caused any inconvenience from pressure on the neighbouring parts, and it was often sufficient to push up the tumour above the brim to afford relief. Medical Ti'eatvient of Fibroids. 235 I further remarked that Dr. Baker Brown, in such a case, incised the os, and found that it generally stopped the haemorrhage. With regard to the use of bromide of potas- sium, I said that I could entertain no doubt as to the reme- dial powers of that drug in many cases of uterine fibroids. I had just a few days previously, for example, seen a case where only a small body like a pea was to be felt per vaginam on the back wall of the uterus, which would pro- bably have escaped my observation, had it not been that the patient had been under treatment for some time for a tumour, which, when she first came to consult me, had been consider- ably larger than a walnut, and gave rise to some distress from its pressure on the rectum. It was a distinct case of a fibroid tumour melting away under the use of bromide of potassium ; and I had seen several such, I had remarked before, that the inconvenience caused by tumours depended greatly on their position. But tumours, as had been re- marked, which generally gave no trouble, are sometimes apt to create much disturbance at each catamenial period, I had had one patient for some time under my care, who very fre- quently, during her menstrual periods, required the use of the catheter, from the swelling that on these occasions was apt to arise in connexion with a large fibroid tumour which was immovably fixed in the pelvis. CASE v.i At a meeting of the Edinburgh Obstetrical Society, held on June 25, 1879, I read Notes of a case of Fibroid Tumour ex- pelled under the use of subcutaneous injections of ergotin, and reminded the Society that in my address at the opening of last session I had expressed myself favourably as to the value of Hildebrandt's method of treating certain cases of fibroid tumours of the uterus by means of hypodermic injec- 1 Transactions of tlic Edinburgh Obstetrical Society, v. 122, 1878-79 ; and Edinburgh Medical Journal, xxv. 260, 1878-79. o 6 Uterus. tions of ergotin. Further experience had since confirmed the favourable impression of the value of this mode of treatment in appropriate conditions. I then showed the fragments of a tumour which had been expelled from one of my Infirmary patients who had been thus treated. Under the microscope the masses were seen to be myom- atous in structure, and it was interesting to observe to what an extent the individual muscular fibres were in process of fatty degeneration. The following is the history of the patient, as drawn up by the clinical clerk, Mr. Alex- ander Bruce, M.B. — Mary M., 54, a widow, residing at West Calder, admitted 23d February, examined 25th February 1879. Complaints. — Swelling in lower part of abdomen ; bloody dis- charge ; pain in the back ; painful and frequent micturition. History of Present Illness. — Patient had always good health till about seven months ago, when she noticed the swelling in the lower part of the abdomen, which caused her consider- able discomfort, especially on making water, which she had to do at short intervals. General Appectrance. — Patient is of average height and de- velopment ; is an albino ; not markedly anoemic. Menstrual History. — Menstruation began when patient was at the age of 14 ; was always irregular ; recurring at intervals varying from three to six weeks ; lasting about two or three days at each time. Has been in abeyance only during preg- nancy and nursing. Seven months ago the discharge at each period became excessive, and it was at this time that she first observed the tumour. For the last three weeks there has been a constant and considerable loss of blood, which has greatly weakened the patient. Obstetric History. — She was married at 17 ; has had nine children, all born alive, at full term, with normal labours. Last child born three years ago. Abdomen. — On inspection, walls flaccid, stria3 of previous pregnancies ; a prominence can be seen above pubes in the middle line, extending about half way to umbilicus. Exp2ilsion of Fibroid undei^ Ergotin. 237 On Palpation. — A hard resistant tumour of rounded form and smooth surface is felt in the middle line above the pubes, measuring 5|- inches transversely, and 4 inches vertically ; the hand cannot be passed between the tumour and the pelvis in front. Percussion. — Dull note corresponding to area mapped out on palpation. Auscultation. — Negative results. On Vaginal Examination. — Ostium vaginae patulous ; vagi- nal walls smooth and moist. Vagina roomy. Cervix easily reached ; looks downwards and backwards. In anterior and right lateral fornices a hard mass is felt. Os dilated admits tip of forefinger ; fissured transversely ; escaping from it some soft gelatinous discharge. The finger can be forced through the os externum, and touches a body on the left and anterior wall. Bi-manually. — The uterus moves with the tumour. Dis- tinct thrilhng pulsation is felt in the anterior part of tumour, which projects into vagina. The sound passes ?>\ inches to the left side. Diagnosis. — Sub-mucous fibroid tumour of the uterus. Treatment. — Eest in bed. ^ Ergotin, .... 3ij. Chlor. hydr., . . . 3j. Aquae, .... §ij. M. Sig. — Sixteen minims to be injected subcutaneously every second or third day. Furtlur Progress. — On ^tli March all discharge of blood ceased. From the lO^A of March to 1st A^oril she had great pain in the uterus ; her temperature during that time ranging from 98°.4, 100°.0, 102°.0, being generally higher in the evenings. She got morphia by the mouth frequently to procure sleep. 238 Uterus. 2cl Ap7'il. — Part of the tumour, about the size, when pressed together, of a hen's egg, came away to-day. Sd April— M. T. 99 ; E. T. 100. Vaginal injections of tepid sohition of carbolic acid, and hip-baths, to arrest the fetid discharge. 5th April. — Another part of the tumour came away to-day. Part in a sloughy condition. Great fetid discharge. E. T. 103. 7th April. — Pain ceased. 15th April. — Pain in uterus. Small piece came away to- day, after which pain quite ceased. Since the last part of the tumour came away there has been a great deal of white discharge, but it entirely ceased on 24th April. There is now no pain, and the temperature is quite normal. Qth May. — On examination, tumour much diminished in size, but still larger than normal uterus. There are one or two irregular nodules on the left side under the peritoneum. A small almond-shaped swelling (the left ovary) is felt in the left side of the posterior fornix. CASE vi.^ At a meeting of the Edinburgh Obstetrical Society, held on May 8, 1878, I showed the Pelvis and Pelvic Contents of a patient, aged 36, who had been sent to my ward under the im- pression that it was a case of inverted uterus. When admitted she was very yellow and anaemic and greatly reduced, pulse quick, temperature high. Local examination showed a rounded pediculated mass in the vagina, which did not allow exact diag- nosis. Tlie tumour looked pale and bled freely. Patient was too ill for further examination ; the jDcritonitis rendering pal- pation impossible. She gradually got worse and died. On post-mortem examination the uterus was in its natural posi- ^ Edinburgh MediailJournal, xxiv. 179. 1878-79. Case of Pediculated Fibroid. 239 tion, and of somewhat large size ; the pyriform body in the vagina was a polypus attached to the cervix by a narrow pedicle. The cause of death was purulent peritonitis. Fig. 36. Uterine Myoma becoming pediculated and in process of extrusion. a, Uterus, with a portion of the anterior wall cut out. h, Polypus, attached to back wall immediately above the os internum. The front of the bony pelvis has been removed : the two halves, cc of the Bladder, which has been divided along with the anterior vaginal wall, are seen in front of the acetabula. 240 Uterus. SAECOMA UTERI.i It is one of the many services whicli Vircliow has rendered to pathology, to have rescued the term Sarcoma from the somewhat vague senses in which it used to be employed, and to have applied it to a group of tumours whose source he has carefully traced, whose structure he has elaborately described, and whose relation to neighbouring groups of tumours he has clearly defined. They spring from a connective-tissue basis, and may therefore be found in all parts of the body where areolar tissue, bone, cartilage, skin, mucous membrane, and the cognate textures exist. In structure they have an affinity with the tissues from which they take origin, consisting of cells, and an intercellular substance freely traversed by blood-vessels. But they differ from the simpler homologous growths — such, for example, as a fibrous tumour — in that the development and increase of the cells predominate over the development of the intercellular substance, whilst the cells tend to assume distinct forms; and from the heterologous growths, the carcinomata, they differ in that there is a distinct formation of intercellular tissue, though of rudi- mentary type, and not a mere infiltration of cells among the pre-existing tissues. The cells present either, \st, a fusiform or oat-shaped outline, when we have the spindle-celled sar- coma ; or, Id, they are more distinctly circular when we have the round-celled variety. Sarcomata with stellate cells and with large myeloid cells are found more rarely, and only in special situations. Such tumours have long been occasionally noticed as occurring in the uterus. In his chapter on fibro-plastic or sarcomatous tumours, Lebert^ gave the history of a case, with microscopic drawings, where the disease sprang from the cervix uteri. Hutchinson recorded a case of intra-uterine ^ Eillnhuryh Medical Journal, xxi. 577, 1875-76 ; and Transactions of the Edinburgh Obstetrical Society, iv. 155, 1874-75. ^ Physiologic Pathol orjiquc, ii. 145. 1845. Bibliography of Sarcoma. 241 sarcoma very fully in the Transactions of the Pathological Society of London in 1857,^ under the designation of Eecur- rent Fibroid Tumour of the Uterus. In the following year^ another case was brought before the same Society, under the like designation, by Callender; and the same cases, with a more complete clinical history, are related by West,^ who had the care during life of the second patient, and to whom belongs the merit of giving the affection a place, though not clearly defined, among the diseases of the uterus. In his lecture on Sarcoma,* Virchow described its occurrence in the uterus from instances that had come under his own observa- tion, and gave reference to previously recorded cases. But it was not till after the appearance of Gusserow's essay ^ on Sarcomes of the Uterus that the subject received due atten- tion, and gynecological literature began to be enriched by the observations of Hegar,^ Winckel,'' Spiegelberg,^ Chroback,^ Leopold,^° Paul Grenser,^^ Ahlfeld,^^ ^j^d especially by a more elaborate thesis by Kunert, an abstract of which is given in the " Archiv fiir Gynaekologie" ^^ f^ i874. So late as 1873 the subject is meagrely treated by Barnes ;^'^ and it is only in the works of Schroeder^^ published last year, and in the last 1 Vol. viii. 287. 2 Vol. ix. 327. ^ Lectures on the Diseases of Wowen, 328. 1864. •* Die KranMiaften Geschwulste, ii. 350. 1864-65. ^ Archiv fur Gynaekologie, i. 240. 1870. 6 Ihicl. ii. 29. 1871. 7 lUcl. iii. 297. 1872. 8 Ihicl. iv. 344. 1872. 9 Ihicl. iv. 549. 1872. " Ihid. vi. 493. 1874. " Ihid. vi. 501. 1874. 12 Ihid. vii. 301. 1875. " Ihid. vi. 111. 1874. 1* Clinical History of the Diseases of Wovicn, 825. At p. 752 he quotes Hutchinson and Callander's cases of "recurrent fibroid." 15 Kranlcheitcn clcr Weihlichen Geschlcchtsorgane. 284. He gives the history with drawings of two cases observed by himself. Q 242 Uterus. edition of Thomas,^ which came into my hands two days ago, that a distinct chapter is accorded to Sarcoma of the uterus. Let me add, that I have looked through the index of the Transactions of our own Society, and that of the Transactions of our younger but more prolific sister in London, without finding a reference to the subject, unless an interesting case, recorded by Hall Davis ^ as one of intra-uterine fibro-plastic tumour, belong to this category. Let this be an apology for bringing four cases under your notice, and offering a few remarks regarding them. The first case is one where we have probably to do with a uterine myoma or fibro-myoma undergoing sarcomatous transformation. CASE I, — PROBABLE FIBRO-MYOMA — REPEATED REMOVAL AND RECOVERY — DEVELOPMENT OF MYO-SARCOMA — REMOVAL AND RECOVERY — DEVELOPMENT OF SARCOMA — REMOVAL OF PORTION, AND DEATH OF PATIENT, I first saw Mrs. B., a widow, of 46 years of age, mother of several children, in consultation with Dr. David Gordon of George Square, on 15th July 1870. She was pale from great anaemia, with a weak, quick pulse, and complained of great pelvic distress. The evacuation of the bladder especially was accomplished with great distress and difficulty. A tumour the size of a child's head, was found rising above the pelvic brim, firm and fixed, and having all the characters of a uterine fibroid. On vaginal examination the pelvic cavity was felt to be completely occupied by a soft, fleshy, elastic mass, which the combined examination showed to be of a piece witli the supra-pubic tumour, and which occupied the whole anterior wall of the uterus. The os uteri could, with difficulty, be detected high up towards the promontory of the 1 Practical Treatise 07i the Diseases of IFovieii, 539, 1875. Has luet with four cases, but their liistories are not recorded. - Transactions 0/ the Obstetrical Society of London, ii. 17. 1860. Case of Myo-Sarconia. 243 sacrum ; and tlie pelvic excavation was so completely blocked up that catheterization of the bladder was almost impossible. The loop of a straight chain-ecraseur was applied as high up on the growth as possible, and a nearly circular portion was removed, measuring 4| inches in diameter, and 2| inches in thickness. On section it presented a uniformly smooth sur- face of pale pinkish colour, with some islands in it presenting the familiar cotton-ball structure and clear white glistening aspect seen on section of an ordinary fibroid tumour of the uterus, and separated from the softer surrounding tissue by a con- nective-tissue capsule (fig. 37). The larger part of the tumour was com- posed of fusiform nucleated cells, v^ith an intercellular matrix having a fibril- lated appearance, and running for the most part in small sections in parallel directions. It presented a marked contrast with the irregular wavy ar- rangement of the fibres and connec- FiG. 37. Sarcoma Uteri seen on Sec- tion, AND SHOWING FiBROID Nodules. tivetissue corpuscles seen in the fibro- matous nodules. In some places among the bundles of spindle-cells there were to be seen rounded nucleated ceUs rather larger than white blood-corpuscles. The patient's earlier history, as Dr. Gordon informed me, presented nothing remarkable ; her elder children having been born without any difficulty. But on 30th November 1865, the birth at the full time of her sixth child was impeded by a soft elastic swelling, which was then, for the first time, discovered in the right side of the vagina, and which necessi- tated the use of the long forceps, which was applied by Sir James Simpson, Dr. Keiller also being present. Witliin a year, on 22d October 1866, having again carried a child to the full time, the delivery had to be terminated artificially by Dr. Keiller, who turned and extracted the infant by the feet. Except in connection with her labours the patient had 244 Uterus. not complained of special distress arising from the tumour ; but, in the following year, it began to be attended with a copious serous discharge, and to produce pain and consider- able difficulty in micturition. In June 1867, accordmgly, a portion of it was removed with the ^craseur by Sir James Simpson, with the effect of relieving the patient for a time from her discomfort. By November 1868, however, her dis- tressing symptoms had returned to such a degree, that re- moval of another slice of the growth was attempted. The tumour at that time must have been very dense and tough, for though the portion removed was of smaller dimensions than that which came away in my hands subsequently. Dr. Gordon tells me that the chains of two different ^craseurs, with which the tumour was seized, snapped asunder, and Sir James had to cut through the constricted part with strong scissors. Again the patient was for a time relieved; and again the mass, which had been felt in the abdomen, seemed to lessen considerably. But on 3d February 1870, the vagina having again become blocked up, a third lobe of the tumour was removed ; and on 24th February a fourth portion. The relief experienced by the patient lasted till the following year, when she was fain to submit to an operation for the fifth time — the amputation, in July 1870, of the mass I have described. After the operation the patient rallied speedily and satis- factorily, and the relief afforded by the operation tided her over three more years. In the spring of 1874, however, her old symptoms began to trouble her; the watery discharge became more profuse than ever ; the dysuria returned ; and, in addition, in April she had a severe attack of menorrhagia, and her health began to deteriorate under repeated uterine hsemorrhages. I saw her again in October 1874, and found her greatly reduced in strength, with a waxy colour, and anxious expression of countenance, more pronounced than one sees in cases of mere anemia or marasmus. There was no marked elevation of the fundus uteri above the pubes ; but the vagina was occupied by a tumour the size of the fist Case of Myo-Sarcoma. 245 with a smooth surface, and having a soft, sodden feeling, bathed with a copious faintly putrescent discharge, and bleed- ing easily when somewhat roughly handled. We deemed it desirable to give her the chance once more of a temporary relief and rally, and on 31st October, with the (icraseur, I removed the projecting mass, Dr. Ogilvie Will of Aberdeen being also present. The chain of the instrument cut through with great ease, and with something like the sensation one experiences in cutting through a cauliflower excrescence. The structure of this last amputated mass much resembles that removed in 1871, except that there are now no traces of fibroid tissue ; the round cells are more numerous, and are found running in parallel rows in a fibrillated but gelatinous- looking matrix, and the spindle-cells are plumper and shorter. There was a slight tendency to haemorrhage from the raw surface, which was controlled by perchloride of iron. The patient seemed to do well for two days, but was attacked with acute and extensive phlebitis in both the lower extremities, and on 13th November she died. A post-mortem examina- tion was not obtained; but when I saw her shortly before her death, I found in the vagina, and springing from the wound surface, a fresh sarcomatous sprout about the size of half the fist, having the feel, and when exposed by separating the labia the exact appearance, of a mass of proud flesh. This, as I have said, appears to me to be a case where, after removal of a large portion of a myome or a fibro-myome, there has sprung up a neoplasm, which became more and more decidedly sarcomatous in its texture.^ But the greater proportion of cases which have been recorded are sarcomata oh origine, and they present themselves under one or other of two forms. Either, 1st, they are circumscribed, and more or less solid bodies projecting polypoidally from some spot on the inner surface of the uterus ; or, 2d, they are more diffused and soft, and spread along the uterine mucous membrane. The next two cases are illustrations of the former, ^ Not unlike what occurred in a case recorded by P. j\I tiller. Archiv fur GynaeJcologie, vi. 126. 1874. 246 Uterus. CASE II. — INTEA-UTERINE SARCOMA — REMOVAL AND RECOVERY ON TWO OCCASIONS — DEATH AFTER FIVE YEARS AND FOUR MONTHS — AUTOPSY. Mrs. M., aged 72, married 46 years, and mother of five children, with some intercurrent miscarriages, was placed under my care in the year 1869 by Dr. Eitchie of Glasgow, who had instructed her to wear a vaginal hall-pessary, kept in position by a wire fixed to an abdominal band, to give relief from downbearing symptoms, from which she had suffered for many months previously. When I first saw her she was a well-nourished healthy-looking old lady, and I found, on inquiry into her symptoms, that besides having had for a long time a feeling of pressure and discomfort in the pelvis, she had more recently been surprised to notice occasional escapes of blood, menstruation being for many years at an end. On making a vaginal examination, I found the genital canals moist and relaxed, the os round and patulous, the cervix and body enlarged and softened ; and when the fundus was pressed down with the left hand above the pubes, the finger of the right passed easily and painlessly into the cavity of the uterus. Within the os internum, I could thus feel very distinctly a soft polypus, which I judged to be the size of a walnut. Not being prepared to attempt its removal, I prescribed ergot, with the view at once of checking the attack of haemorrhage, which had been the immediate occasion of my present visit, and of inducing uterine action to favour the further descent of the intra- uterine body. Two days afterwards the hsemorrhage had ceased, but, on examination, I found the os firmly closed, and the cervical canal quite impervious to the finger. An exam- ination with the sound shortly afterwards, however, showing me that the uterine cavity was enlarged to three inches in length, and occupied still by the foreign body, I dilated the canal with sponge-tents, and partly with forceps, and partly with the finger-nail, broke down and removed the morbid growth which I found springing from high up in the cavity. Case of Intra-uterme Sarcoma. 247 It was too soft and friable to be removed in any other way, and I applied solid nitrate of silver to the ragged basis. She had no bad symptom after the operation, and for some months was in the enjoyment of good health. About eight months subsequently, however, there was a recurrence of the escape of blood ; and she began now to complain more of leucorrhoeal discharge, and as the os relaxed occasionally when the bleedings came on, so as to permit the passage of the finger into the uterine cavity, a new mass could be detected pressing into the os internum. In August 1870, exactly a year after the first operation, I again dilated the canal, and removed, with the assistance of Dr. Munro, into whose care the patient was about to pass, a portion of the diseased mass the size of an egg; but it was felt to have acquired a more extensive attachment along the back wall of the uterus, and its complete extirpation, because of the bleed- ing set up in the very friable substance, could not be effected. Again, for nearly a year, she enjoyed comparatively good health, although the thin, pale, watery discharge soon re- appeared, and by and by became more profuse ; and for the relief of her pressure symptoms, which were sometimes ac- companied with frequent micturition, and even retention, she had to wear a Hodge's vaginal pessary. After this time the haemorrhage recurred, and the profuse watery discharge be- came offensive. Early in 1872, I saw her along with Dr. Munro, when the uterus was found considerably enlarged, the orifice freely open, and occupied with a portion of the neo- plasm hanging through in a sloughy condition, and giving rise to a profuse dirty discharge, having such a fsecal odour as to give rise to the suspicion that a fistulous communication had formed between the rectum and vagina. Her general health was now greatly impaired, her pulse weak, and her skin waxy, and it seemed that any attempt to remove more of the tumour might be likely to lead to a fatal collapse. Means were therefore used simply to keep up the patient's strength, and a portion of the tumour having been expelled, she rallied to a remarkable degree. From time to time, how- 248 Uterus. ever, as Dr, ]\Iunro has informed me, she suffered from in- crease of the watery discharge, and under a good deal of sickness and constitutional distress, the os uteri became more expanded, and pieces of the tumour were thrown off, sometimes as large as a pear, and invariably with some degree of haemorr- hage. These attacks came on every six or eight weeks ; and, on several occasions, Dr. Munro removed the protrviding mass when it was hanging into the vagina. The strength was gradually undermined, and the blood disintegrated; and in the end of 1873, and again in 1874, she had attacks of phle- bitis in both legs but most severe in the left. She sank at last, and died on 29th November 1874, five years and four months from the date of the first detection of the sarcoma. Dr. Munro was allowed to remove the uterus, which he kindly gave me. It is enlarged in size, and presents the general appearance of a uterus at the fourth month of preg- nancy, except that the os is expanded to the size of a two- shilling piece, and occupied by the projecting growth. It measures from fundus to os externally 5" 9'", from side to side at the level of the Fallopian tubes 5" 5'", and from before backwards 3". The Fallopian tubes are seen to be enlarged to a corresponding degree, each having a thickness of from half an inch to 1" V" , and from their free fimbriated extre- mities there project rounded masses, having the appearance of the thrombus projecting from a small vein into a larger trunk. That on the right side pouts out to the extent of half an inch from the tube. They are evidently of the same nature as the growth protruding through the os uteri, though somewhat paler in colour. On cutting open the anterior wall of the uterus the morbid mass was found adhering to the whole surface, but not so firmly as to hinder its being easily detached with the handle of tlie scalpel. In the two lower thirds of the posterior wall, however, the union is much more intimate. Tlic walls of the uterus were everywhere thinned to a remarkable degree. In the middle of the anterior aspect they measure only from \"' to 2'" in thickness. An incision running at right angles to this at the level of the Fallopian Intra-uterine Sarcoma. 249 tubes cuts through a portion where the wall is thicker, but only because of the development of a few sarcomatous nodules within the layers of the muscular fibres. The mucous mem- brane is smoothed out, and presents a cribriform appearance from the processes thrown into it from the surface of the tumour, and a scraping of it placed under the microscope shows it to be deprived of its epithelial covering. In the posterior wall the sarcomatous tissue has firmer hold of, and passes deeply into the whole thickness of the walls — so much so, that at three spots, nearly at a level of the os internum, it has grown right through the muscular wall, and formed slight projections on the peritoneal surface the size of a half-cherr)% \ Fig. 38. Intra-uterine Sarcoma invading the Fallopian Tubes. covered with a thin investment of serous membrane. The walls of the Fallopian tubes are similarly atrophied till there seems to be little more than the serous covering left (fig. 38). On microscopic examination the tumour presents many nucleated cells, both round and spindle shaped ; the latter in by far the greater proportion. But they are for the most 250 Uterus, part filled with fatty granules and molecules, and the fibril- lated tissue around them is also dimly granular. This case is remarkable clinically, because of the frequency and extent of the sloughy masses which were expelled ; and pathologically, because of the manner in which the growth, while rooting itself specially in one part of the uterine wall, yet laid hold eventually of its entire mucous membrane, not only in the body but also in the cervix. In its invasion of the Fallopian tubes, and finding in them a new seat of development, the case is, I believe, unique. CASE III. — INTRA-UTERINE SARCOMA — INVERSION OF THE UTERUS — AMPUTATION WITH ECRASEUR — DEATH — DESCRIPTION OF TUMOUR. J. P., aged 41, unmarried, came from the country into my ward, in the Eoyal Infirmary, on 2d September 1875. She was a stout, well-built, antemic looking woman, and with a somewhat worn expression of countenance. She complained of being very weak, and becoming increasingly weak, from the occurrence of frequent bloody discharges. The first had appeared at a menstrual period, ten months previously, when the amount of flooding alarmed her ; and to the recurrence of her courses at shorter intervals than usual and in increased amount she attributed her weakness. During the inter- menstrual periods there was a copious leucorrhceal discharge, which had only latterly begun to be offensive. She had no pain till two weeks before her admission, when she began to have distress in the pelvis, more particularly felt in the bladder, micturition becoming difficult, and then impossible, so that for three or four days her only relief was obtained by the use of the catheter. Since then slie passed urine of herself, but with some difficulty and in rather small amount. She stated that some months before she had swelling of the left leg from the knee downwards, and both legs were occasionally swollen at night. The urine had a deposit con- taining pus and a few blood-corpuscles, but was free from Sarcoma producing Inversion. 2 5 i albumen. Palpation over the hypogastrium elicited some degree of tenderness ; otherwise nothing unusual was to be felt through the abdominal parietes. On examination per vaginam, a large tumour was felt distending the vaginal walls, and filHng up the pelvis. It was rough and ulcerated at its lower aspect ; the sides felt smooth and fleshy, and in the roof of the vagina it narrowed towards a pedicle, which seemed to come through the os uteri. Because of the pain and bleeding excited when exploratory attempts were made with the sound, and by combined internal and external examination, the exact relation of the morbid growth to the uterine cavity could not at first be ascertained. The patient was ordered to be kept at rest, to use ergot and a tonic internally, and to be syringed with an astringent and disin- fectant injection. Her general condition not improving, and occasional attacks of vomiting coming on, on 18th September I had her brought under the influence of chloroform in presence of Professor Edmonstone Charles of Calcutta, Dr. Halliday Croom, and the resident physician and clerks, with the view"of more fully examining, and, if possible, removing the growth. It was now discovered that the fundus uteri could not be touched through the abdominal walls, that the larger globular portion of the body occupying the vagina was of softer texture than the pedicle, which came through the circle of the OS uteri indeed, but felt as if it were attached to the cervix within a few lines of the orifice. It was impossible to get through the os with the finger except at one point, but the absence of the fundus at its usual level leading me to suppose the uterus might be inverted, by means of the sound I ascertained that such was the case. The tumour, rather firm to the feel as it was packed in the vagina, proved to be too friable to be easily seized with forceps or volsella. With the four fingers of the right hand, I broke off about a half of it, and then the remainder, with the completely inverted uterus, was easily brought down to the vulva. The loop of a chain- ^craseur was applied around the base, but, as it involved the whole of the fundus, the amputation had to be carried through 252 Uterus. a plane nearly at the level of the orifices of the Fallopian tubes. Notwithstanding that it was slowly cut through, there was some jetting of blood from the wound surfaces, and as the patient was already much reduced by loss of blood, I brought the raw margins together with four metallic stitches which completely checked all further hsemorrhage. The patient did not seem to be much affected as to her general condition immediately after the operation, and on the follow- ing day seemed to give fair promise of recovery. On the third day, however, there was a rise in the temperature, and in the evening she died very suddenly, and with some symptoms, such as breathlessness, that led Dr. Groom (I was myself out of town and did not see her) to suspect that she might have had a pulmonary embolism. A post-mortem examination was not permitted. On examination of the amputated fundus uteri, with the adherent growth, it is easy to see how intimate is the union of the latter with the uterine wall. The union, indeed, is so intimate that one cannot tell where the transition takes place from the tissues of the neoplasm to those of the uterus. The growth is found on microscopic examination to be composed of large spindle-cells, each with a clear nucleus, lying close together in parallel bundles, and close up to the serous coat of the uterus some of the well-marked bundles of spindle- cells can be traced among the strata of muscular fibres and connective tissue of the middle coat. The most interesting feature in connection with this case is the Inversion of the uterus. It is now the fourth case of sarcoma uteri with this complication. The first case on record^ will be found in the Lectures on Pathological Anatomy by Dr. Wilks (p. 404), published in 1859,2 but the clinical history is wanting. The next case was brought under the ^ Apparently overlooked by Kunert, etc. , though it is referred to in a note in Virchovfs Onkology. 2 Under the heading " Recurrent Fibroid Disease." In the recent edition — Lectures on Pathological Anatomy, by "Wilks and Moxon, 1875— it is given, p. 561, under the heading " Sarcoma." Frequency of Inversion from Sarcoma. 253 notice of the Berlin Obstetrical Society, in January 1860, by Langenbeck ;^ the patient died without being operated on, and being already very much reduced, the death seemed to be hastened by the bleeding caused by the examination made to clear up the nature of her malady. In the third case, by Spiegelberg,^ the entire inverted uterus was amputated with the ecraseur, and the patient died in thirty hours with acute peritonitis. The frequency of inversion of the uterus as a complication of sarcoma uteri is surely somewhat remarkable. If we add^ to the 39 cases collected by Kunerf^ the case above referred to by Wilks, the 2 given by Schroeder in his text-book, 1 by P. Midler,^ 1 by Ahlfeld,^ and the 4 which form the groundwork of this communication, we have a total of 48 cases of uterine sarcoma ; and in 4 there was complete inversion of the uterus. Besides that Spiegelberg notes a tendency to inversion in 1 of his other cases, the fact, that in 1 out of every 12 cases of intra-uterine sarcoma the organ had become completely inverted, is sufficiently striking, for we find no such frequency of inversion in the cases of the common intra-uterine myomata. But this complication be- comes more remarkable when we consider that aU the 3 patients with inversion, whose history we know, were nulliparous females, or, if 1 of them (Langenbeck's case) had given birth to a child, it was 23 years before the occurrence of the sarcoma- tous inversion. There are two points, however, in connection with the development of intra-uterine sarcomes in which they differ from the common myomes, and which prepare us to expect the production of inversion. In the first place, the sarcoma springing, say, from the fundus uteri, is in intimate union with ^ Monatssclirift ftir Gcburtskuncle, xv. 173. " Loc. cit., 351. ^ I leave out of account cases, such as are recorded by Leopold and P. Grenser, of sarcoma springing from tlie cervix uteri, for in sucli inversion of the organ was not likely to take jjlace. Perhaps some of Kunert's thii-ty-nine cases are instances of cervical sarcoma. '^ Loc. cit., 116. ^ ArcMvfUr Gynackologic, vi. 125. 6 Ibid. vii. 301. 2 54 Uterus. the walls from which it grows, whereas the myoma is surrounded by a capsule, and so more easily separable from the bed in which it lies. The result of this difference in the relation of the two kinds of tumour to the tissues where they originate is, that when the uterus begins to contract for the expulsion of the neoplasm, the sarcoma drags down with it its seat, in the wall of which it forms an integral part; whereas the myome gets gradually detached from its loose connections and becomes pediculated, and perhaps is at last expelled from the cavity of the uterus. Doubtless, also, the condition of the layers of the muscular fibres between the neoplasm and the serous surface differs ; in my case certainly there must have been some degree of paralysis at the site of the tumour, whilst a myome in the same situation would probably have been covered with a layer of healthy muscular fibres, which would concur equally with the rest of the uterine muscles in pressing the tumour towards the cavity. But, in the second place, there is in these sarcomatous cases an unusual relaxa- tion of the walls of the genital canals, more than is to be accounted for by the moistening with the frequently profuse discharge. I was particularly struck with this in the second of the cases which I have related. There were times when though at the first touch of the finger the os was too small to admit it, yet on continued pressure it yielded and opened up ; and, as I have stated, there were times when it opened freely and widely to permit of the escape of sloughy portions of the tumour. It was as if a relaxation and dilatation took place at those times when the uterus was making efforts for the birth of the neoplasm, parallel to the relaxation and dilatation that accompany the contractions of the uterus in ordinary labour. And it is to be remembered that that kind of vital dilatation is not confined to the cervical canal. Though the patient whose case is under discussion was unmarried, and the vulva in a virginal condition, so that the full examination could only be conducted after she was anaesthetized, it was remarkable to what an extent the genital orifice became dilated during the operation, so that first three fingers, and Mechanism of Inversion. 255 then the whole hand, could be passed into the vagina without lacerating the mucous membrane. This point was the more impressed upon my mind from the circumstance that less than three weeks previously I had seen, with Dr. Brotherston of Alloa, a case of a large fibro-myomatous polypus coming down from the interior of the uterus of the size of two fists, and hanging by a somewhat narrow neck into the vagina. The patient in that case also was an unmarried female of about 40 years of age, and after I had succeeded in detaching the tumour from its uterine connection by torsion, I was almost baffled in my attempts to extract it through the firm and unyielding vulva, and only succeeded at last by cutting the tumour into pieces within the cavity, the patient being kept under the influence of chloroform for upwards of two hours. The singular dilatability of the canals, and the intimate connexion between the sarcoma and the part of the wall to which it is attached — at once crivincr it a strong purchase upon its seat and impairing the action of the muscular fibres in that portion of the wall — seem to me to afford a fair explanation of the marked proclivity of the sarcomatously affected uterus to become inverted. In the next case we have an example of the diffuse sarcoma. CASE IV. — INTEA-UTEEINE SAECOMA — PATIENT STILL UNDEE OBSEEVATION. Mrs. C, aged 45, admitted to Ward 14, 4th October 1875, has been married twenty-five years, and is mother of ten children, the eldest born twenty -three, the youngest nine years ago. She had always menstruated regularly and enjoyed good health till eighteen months ago, when she began to suffer from floodings. Within the last four months the pains, which remind her of labour pains, have begun from time to time to distress her. Four weeks ago one of her floodings set in, and continued for seven weeks, large clots sometimes escaping. For a fortnight the bleeding ceased, but 256 Uterus. she had then a profuse watery foetid discharge, and a week before her admission the bleeding returned. She was greatly reduced in her general health, with a weak, quick pulse, and a cachectic expression of countenance. There was nothing to be felt on abdominal palpation. On vaginal examination the uterus felt heavy ; the os ! was soft and patulous, and easily admitted the tip of the finger as far as the os internum, at which a substance with the feel of a soft clot could be touched. The cervical canal having been further dilated with a tent, the cavity of the uterus was felt greatly ex- panded; the front and back walls were covered with soft, ragged, irregular patches of tissue, a larger and more pro- minent portion of which grew downwards from the fundus. But when I attempted to make a combined external and in- ternal examination, the walls of the uterus gave me so much the impression that they were ready to tear, and there began to flow from the already enfeebled patient such a stream of blood, that I was fain to desist, and to arrest the hsemorrhage by a free application of perchloride of iron into the uterine cavity and the introduction of a vaginal plug. She soon recovered from the effects of that bleeding and went home, as further operative interference gave no hope of any good result. She has had less pain since the uterus was dilated, and but little haemorrhage ; but the watery discharge is more pro- fuse and very offensive. A small fragment of the excrescence removed with the finger-nail shows the characteristic appear- ance of the spindle-celled sarcoma. Some large epithelial cells with double nucleus which appear in the field of the microscope may have been derived from the vaginal canal during the abstraction of the minute fragments of tissue. At least there were no similar groups of cells collected in inter- stices of connective tissue, such as we see in cases of car- cinoma. The narration of the cases, with the epicritical remarks, has extended to a greater length than I had anticipated. Etiology of Sarcoma. 257 What further general observations I have to add must there- fore be brief. ETIOLOGY. My cases do not confirm tlie impression made by statistics already pubhshed, that nulliparity favours the development of sarcoma uteri. In one of them, as I have said, the patient was unmarried; but the other three patients were married women, who had each been mothers. As for age they were all approaching, or had passed the menopause. The youngest was 41, the oldest 72 years of age at death. Their social cir- cumstances were comfortable, even the hospital cases not being drawn from the poorest class of society ; and so far as could be ascertained, their family history was good. On looking the ward statistics for the last four years, with the view of comparing the proportion of sarcomata to the more common neoplasms, I find 20 cases of myoma or fibro-myoma, and 32 cases of carcinoma, 2 of which were intra-uterine, whilst there were only the 2 cases above recorded that could be regarded as sarcomatous. SYMPTOMS AND DIAGNOSIS. In most cases these growths give rise to a marked degree of haemorrhage. The usual monthly discharge becomes exag- gerated, or bleedings come on in the inter-menstrual interval, or they are set up in women who had passed the menopause. These hsemorrhages are easily intelhgible when we bear in mind that the tumours are always vascular, sometimes chan- nelled with large and thin-walled bloodvessels; and that, from the softness of their texture, they are easily broken down. But, in certain cases, the tendency to haemorrhage is not pronounced. There is usually, however, a marked degree of leucorrhmal discharge. The succulent and some- times suppurating surface of the tumour itself, and the thickened and expanded mucous membrane lining the cavity in which it lies, furnish a free secretion of a pale, R 258 Uterus. rice-watery, or more yellow fluid, which, in any case, may for a time disappear, though it is almost never absent (only in Leopold's case, where the tumour developed in the cervix) throughout the entire history of any case. This discharge will, for a long time, be odourless, but it acquires something approaching to the disagreeable odour of the cancerous dis- charges in the more advanced stages of the disease, when fragments of the tumour are squeezed into the vagina, and lie within the canals till they decompose. We have seen that the mischief may develop in women who have borne children ; but, after it has appeared, the reproductive function of the orcjan is at an end. For I know of no case of the concurrence of pregnancy and sarcoma uteri, such as we sometimes meet with in myoma or carcinoma: probably from the circumstance that the sarcomatous growths almost always affect the interior of the uterine ca^dty. There has been some diversity of opinion as to whether this affection is attended with pain or not. My own impression is, that pain is not a usual symptom of it, any more than we can speak of pain being a usual symptom of a fibrous pol}^us. In both cases we may have suffering from the enlargement, or from intercurrent inflammation in the uterus or around it ; or, what is still more common, we may have pain from the muscular contractions set up from time to time in the walls of the uterus for the expulsion of the neoplasm. But all this is different from the uncertain, unprovoked, sharp, stinging pain to which a cancerous patient is subject. More particu- larly, I have been struck with the difference between the pain complained of by these patients who are the subjects of intra- uterine sarcoma, and the intense, paroxysmal attacks of suffering, coming on sometimes^ with a marked degree of periodicity, which Sir James Simpson used to point out as characteristic of intra-uterine cancer. It was the absence of this symptom which I had seen in several instances, that ' See an illustrative case in a clinical lecture by Thomas, in the American Journal of Obstdrics, v. 703. 1873. Diagnosis of Sarcoma. 259 first led me to think that, in the case No. IV., we should find, as we did, not the hard, rough surface of an epithelial, but the soft, velvety, friable surface of a sarcomatous growth. In addition, there is disturbance, in the functions of nnglibour- ing organs differing in degree in different cases according to the size and situation of the neoplasm and its bed. Sooner or later the repeated losses of blood, or the continued drain of watery discharge, begin to tell on the patient's general health ; and when the disease has advanced towards its final stages, it usually develops in the sufferer a condition of general cachexia. TJie physical examination of a patient with such a train of symptoms would discover some degree of uterme enlargement, varying according to the size of the morbid mass occupying its interior. It is rarely so large as to form an abdominal tumour, except where we have to do with a myo-sarcoma, or a fibroid tumour undergoing sarcomatous degeneration, when we may find a supra-pubic mass of considerable dimensions, with the vascular bruit and other characteristics of such growths. Where the growth springs from the cervix, or the uterus has become inverted, a polypoidal body will be felt occupying the vagina. The uterus, though enlarged, remains freely movable, unless the tumour be so great as to cause some impaction in the pelvis, or inflammatory adhesions have formed among the pelvic organs — conditions which are both com- paratively rare in the true sarcoma. The sound will pass without difficulty into the interior of the uterus, and detect the extent of increase of the cavity and the presence of a foreign body in which bleeding is easily excited. But it is only when the canal is dilated with a tent — and, as I have shown, the textures are so soft and expansible that a single good-sized sponge-tent may suffice for the dilatation — that the size, consistence, and attachments of the new growth can be discovered, and that a fragment of it can be obtained for microscopical investigation. It is in this way alone that an exact diagnosis can be made out. 26o Uiertis. PROGNOSIS. . The comparative degree of malignancy to be attributed to this neoplasm may be gathered from the significant circum- stance, that West treats of it in the same lecture with fibrous polypi, whilst Barnes gives it a place among the cancers. Although the disease shows a distinct tendency to remain localized in the uterus — these cases being but few where secondary sarcomata were found in other organs — there seems to be only one recorded case (Winckel's first) where removal of the growth was followed by a radical cure ; and it is to be noted in regard to it, that it was a polypoidal myo- sarcoma, and not a pure sarcoma, and that the patient's history does not extend beyond two years from the date of operation. According to Kunert, "in 14 out of 30 cases death ensued within a year after the first appearance, in 1 after 2 years, in 3 after 4-6 years; in 3 cases the patient was still suffering after 2 years ; in regard to the remaining cases, partly observation is awanting, and partly the patients enjoyed tolerable health under continuous medical treat- ment." One case is recorded^ where an intra-uterine sarcoma was the seat of carcinomatous degeneration, and proved rapidly fatal. My own cases confirm the general verdict that we have here to do mth a form of disease which, though it is not the cause of such intense suffering, nor of such rapid constitutional deterioration, nor of such speedy death as cancer, yet has a vicious tendency to recur after apparent complete removal, and to lead sooner or later to a fatal issue. TKEATMENT. Clearly, however, patients who are the subjects of it are not to be abandoned to a hopeless do-nothingism. Wliere the mischief is in an early stage, and in any case where we have it in a polypoidal form, it should always be removed, to ^ Rabl-Riickhard in Bcitrdge zur Gchurtshillfr, i. 76. 1872. Treatment of Sarcoma. 261 give immediate relief from suffering, and with tke justifiable expectation that, for a time — it may be for years — the pro- gress of the malady will be arrested, and the patient restored to comparative health. It may even be of service to her to repeat the operation more than once. In the pediculated forms the growth may be removed with the ecraseur or galvano-caustic wire; but sometimes, as we have seen, it is too brittle, and requires to be broken down, and removed piecemeaL In such cases, and in cases of the diffose sarcoma where the extirpation can be attempted, it may be carried, ont with the curette, fenestrated like Eecamier's, or cup-shaped like Simon's. In any case, it is desirable to lessen the imme- diate hgemorrhage by free application of perchloride of iron and hypodermic injection of ergotin. The profuse and sometimes fcetid discharge can be controlled by astringent and disinfectant injections ; and the patient's general health will be kept up by a generous diet, and the administration of tonic remedies. CAECIXOMA TJTEEL I.— OX THE ee:motal of portions of the diseased TISSUES IX cases OF CAECIX03IA UTEELi '•' The grounds," says Mr. Moore, " on which an operation in cancer may be performed, should be distinctly understood. They are — first, the hope of entirely and finally eradicating the disease ; second, that of obtaining some interval of health and useful life in its course ; third, that of, on the whole, lengthening life ; fourth, that of diminishing the total amount of suffering." — (Holmes's System of Surgery, voL i, p. 557.) 1 British Medical Journal, iL 436, for 1572. Eead before the ilidwiferv Section at the Annual ileeting of the British Medical Association in Birming- ham, August 1872. 262 Uterus. Gynecologists are now-a-days nearly unanimous in re- commending and having recourse to amputation of the cer\dx uteri in cases of malignant disease limited to the vaginal portion. Where the disease is of recent origin, and still restricted to a part which can be so easily removed, every one would see that the first of the grounds stated by Mr. Moore was present in its simplest form, and he would operate as speedily as possible, with " the hope of entirely and finally eradicating the disease." There are successful cases on record enough to warrant any man in repeating it. The instances are rare, however, where we find matters so favourably situated ; for the disease has usually invaded the structures too deeply before the patient applies for relief to allow us to interfere with any hope so sanguine. Now, in this most common run of cases, I fear that, in spite of the encouraging results obtained, and recorded by Dr. Braxton Hicks {Guy's Hospital Bcports) and others, the opinion generally entertained regarding them by the profession is, that they must be allowed to run their gloomy course unmodified, and with only a half- hearted attempt to mitigate the symptoms. But it is well worth while considering whether we may not, by removal of portions of the affected organ, succeed in fulfilling one or other of the minor indications of procuring an interval of com- parative health, or lengthening somewhat the patient's life, or diminishing her distress, in some of those cases where the great extent of the disease has cut from beneath our feet the first ground of interference. DANGERS OF OPERATIVE INTERFERENCE. It is not, certainly, an inviting field for operation. There is no room for brilliant display ; and one cannot help being influenced by the hopelessness that overhangs the final issue of the malady. But, further, many are deterred from inter- fering in consequence of various apprehended risks. 1. Hccniorrhage. — The ordinary digital examination of a case of carcinoma uteri is apt to be attended with a certain Treatvtent of Cervical Carcinoma. 26 J amount of haemorrhage, so that the practitioner dislikes touching it further than will be sufficient to make him sure of his diagnosis. But the bleeding is all from the vascular surface. If he had bruised the surface more deeply with his nail, instead of brushing it with the pulp of the finger, the discharge would probably not have been any greater. And, if such an encephaloid mass be broken into and dug out, and resolutely removed, the only haemorrhage of any extent that takes place — and that is usually not great — occurs when the surface is being broken through, and it becomes less when healthier tissues are reached. Case 1. — A. A., aged 40, single, from Berwick, had an ex- cellent previous history, both personal and family. The present affection dated from May 1871, when the patient was suddenly attacked with a copious sanguineous discharge from the vagina — inter-menstrual — unaccompanied by pain. These haemorrhages returned at varying intervals of two and three weeks. For this condition she sought advice on October 28th, 1871 (six months after the first bleeding). She never had any pain. There was a copious offensive muco-purulent dis- charge. On examination -per vaginam, a large, irregular, nodulated, soft, pulpy mass was felt, involving the os and cervix, and at some points, more especially posteriorly, ex- tending to the body of the uterus. The tumour bled freely on the slightest touch. A small portion, which was removed with the finger-nail without causing further loss during an examination, was found, under the microscope, to contain characteristic cancer-cells. On November 1st, with the uterine scraper applied to the more prominent parts, six or seven pieces, each about the size of an ordinary hazel-nut, were removed. The bleeding was very slight ; and a satu- rated solution of perchloride of iron in glycerine, applied to the surface, arrested it completely. On November 22d, the patient had continued well since the operation. She had had no pain nor haemorrhage. The cancerous mass had not re- curred to any appreciable extent. The outline of the os and cervix uteri was more defined and recfular. The surface was 264 Uterus. less spongy and harder than on the first examination. The leucorrhoeal discharge was diminished. She was discharged relieved, 2. Pain. — Some may shrink from interfering from the fear of causing pain to the patient ; but, apart from the possibility of keeping the suffering in abeyance by the use of anaesthetics, it will be found that, though these patients suffer commonly enough to a degree peculiar to their disease, yet operations for the removal of the diseased mass are not attended with much suffering ; so that they may be had recourse to, although the patient has not been anaesthetised. 3. Aggravation of Disease. — Nor need we fear that the progress of the disease will be hastened by this kind of inter- ference ; for the result of experiment shows that the more thoroughly the disease is removed, the longer it is of return- ing ; and, when it does return, its progress is not more rapid than where it was left to itself. Case 2. — Mrs. W., aged 25, married, the mother of four children, with three miscarriages, having good family and personal history, dated her present illness from a fall from a swing twenty months previous to July 1871. This fall was followed by a smart haemorrhage from the vagina. Since then she had constant pain, with frequent floodings, offensive dis- charge, and increasing weakness. In July 1871, on examina- tion per vaginam, the os and canal of the cervix uteri were found sufficiently patent to admit an ordinary full-sized catheter. The cervix was transformed into a soft friable mass of about the size of a crown, readily bleeding when touched. The body of the uterus and vagina felt healthy. On August 2d, the entire cervix was removed with the chain-(5craseur, close to the roof of the vagina, and saturated solution of per- chloride of iron in glycerine was applied. The patient did well. — July 1872. The patient had had, on three occasions since the operation, a slight inter-menstrual discharge. She had enjoyed good health, and been free from pain and offensive discharge. Per vaginam, the stump of the cervix was felt, still thickened and enlarged, but hard and smooth, Removal of Cervical Carcinoma. 265 not bleeding on pressure. The disease had not advanced since the operation. 4. Risk to Life,. — Again, the operation is not dangerous to life. I have amputated the vaginal portion of the cervix, or otherwise removed parts of the uterus affected with cancer, in twelve cases, and have assisted Sir James Simpson at a great many more, without witnessing any bad result. The only fatal case of which I saw anything was that related by Sir James in his clinical lectures {On the Diseases of Women, p. 174), where the patient sank and died suddenly a few hours after the operation, and where I assisted as a student at the ^ost mortem examination, when no morbid change was dis- coverable in any organ that could be looked upon as the cause of death; and it was concluded that the patient died of collapse. ADVANTAGES TO BE DERIVED. But, even if the risk of operative interference be small, one may ask, What good results are to be expected from it? 1. Arrest of Hcemorrhage. — First of all, you remove the soft expanded vascular surface, which readily becomes the seat of extensive haemorrhages. In many cases of car- cinoma uteri, the profuse bleeding doubtless comes in part from the mucous membrane, which becomes hypertrophied as a result of the excitement in the whole organ attendant on the presence of morbid growth in it ; but, whatever the source of the bleeding, menorrhagic or metrorrhagic, they are always lessened, and sometimes altogether arrested, by the removal of the accessible portions of cancerous tissue. This is more notably the case where we have to do with the so- called cauliflower excrescence, or with the expanded epithelo- matous OS uteri ; and it is so even with encephaloid disease in the form of large irregular protuberances, and invading more deeply the substance of the cervix. 2. Arrest of the Leucorrhcea. — Hardly less detrimental to the health of the patient than these frequent ha?morrhages, is 2 66 Uterus. the incessant discharge of a fluid sometimes ahnost watery in its appearance and very profuse, sometimes less abundant, but of an acrid character, and in the greater proportion of instances possessed of a fcetor which of itself may suffice to declare to an experienced practitioner the nature of the malady. The persistent loss of so much fluid would of itself impair the health, and its deleterious influence is increased by its offensive character ; and this drain is, for a time at least, arrested when the morbid parts are removed, and a sore with a healthy non-malignant surface is left instead. 3, Belief of Pain. — In the case of cancer affecting the cervix uteri, pain is not necessarily a prominent symptom until the disease has made great progress, and is often so trifling as not to attract attention ; nor is it greatly modified by efforts at the removal of portions of the diseased mass. But where the disease is seated in the interior of the uterus, pain is an early, most distressing, and almost constant symp- tom ; and the relief afforded to the patient's suffering by ablation of even a portion only of the diseased tissue is immediate and striking. Let me cite two cases in illustra- tion. Case 3. — Mrs, M., aged 59, a widow and childless, after having ceased for some years to menstruate, began to be troubled with occasional slight discharges of blood and fits of pain in the pelvis. The haemorrhage was not great in quantity, but, becoming pretty constant, the health began to give way. The attacks of acute pain, beginning in the back and passing round to the pubes, became frequent, and assumed a periodic character, coming on usually at bedtime, and pre- venting sleep. There was but shght and inoffensive leucorr- ha;a. The uterus was found retroflected, enlarged by half an inch, with the cervix healthy. The position of the uterus was rectified, and various sedatives employed, without any marked benefit resulting. Suspecting from the peculiarity of the symptoms and the result of examination with the sound, that there was malignant disease in the interior of the uterus, I introduced a series of tents ; and, when the cervical Cases of Intva-ztterine Carcinoma. 267 canal was dilated, could feel a series of indurated nodules just within the os internum. They were partially scraped away ; and fragments, which were examined with the micro- scope, showed many double-nucleated cells in a fibrous stroma. The patient was greatly relieved for a time from her periodic pain, and the htemorrhage abated. But I had found the uterus opened, and oj)erated at a time when I had not satisfactory assistance ; and, as I found her symptoms return, two months subsequently (November 1871), I again dilated the cervix, scraped away the cancerous nodules more completely, and applied powdered persulphate of iron to the raw surface. The patient had a threatening of pelvic peri- tonitis afterwards; but she rallied, and has since greatly recovered her strength, being relieved of the wearing-out pains, and free from the persistent hsemorrhage. Case, 4. — J. F., farm servant, aged 58, single, was admitted into the Eoyal Infirmary on December 14th, 1871. The patient, who was a stout plethoric woman, with a ruddy com- plexion, weighing about nineteen stones, and enjoyed g(jod health until six months ago, when she was attacked by pains in the back and in the right and left iliac regions, accom- panied by a red discharge. The pain, which she described as of an acute stinging character, recurred periodically between 12 noon and 4 p.m. every second or third day. Latterly it had recurred at the same time with increased severity. There was a thin leucorrhceal discharge, without any odour. She had always enjoyed good health until her present illness. The catamenia occurred at fifteen, and ceased five years ago. Her relations were long-lived and healthy. On examination, the vagina was found to be narrow and short. The hymen was persistent, and with difficulty admitted the forefinger. The OS uteri was in its normal position, not shorter nor harder than usual. On combined internal and external examination, the uterus was felt enlarged ; and this was confirmed by the introduction of a sound to the extent of half an inch further than normal. I ordered the patient to have a sponge-tent introduced. Owing to the narrowness of the os uteri, but a 268 Uterus. very small tent could be passed. This caused a great deal of fever and general irritation, and it was found impossible on that account to introduce a larger one for some days. On December 14th, a large-sized tent was inserted ; and on the following day the os was found so dilated as to admit the passage of the forefinger into the cavity of the uterus. The mucous membrane of the uterus was found thickened, especially posteriorly and to the left at the fundus, where there were distinct fungating excrescences, varying in size from a pea to a French bean. These masses were scraped away by means of the intra-uterine scraper. There was a smart haemorrhage. A solution of equal parts of the satu- rated solution of perchloride of iron in glycerine, and water, was injected into the uterus, which stayed the bleeding. The masses removed were examined by the microscope, and found to contain characteristic cancerous tissue. On December 26th, the patient complained of pain over the abdomen. Pulse full, 90. The pain over the abdomen was constant, but not acute. There was no bleeding. Half a grain of opium was given at bedtime. From December 26th to January 15 th, the patient had on two occasions slight attacks of local pain, which lasted each time for about forty-eight hours ; but these were attributable to indiscretions in getting up too soon, and to over-exertion. They were of an inflammatory character. The pain in the uterus had ceased to return periodically, and there was no sanguineous discharge. On January 20th the patient was sent home, feeling greatly relieved. 4. Prolongation of Life. — It would require a more ex- tended series of cases than I am able to present to enable us to determine positively how far the longevity of patients is influenced by surgical interference. But I have seen no case where the operation seemed to have any damaging effect, and cannot doubt tliat the relief from suffering and the arrest of the exhausting haemorrhages and leucorrhoeal discharges must have a directly beneficial influence on the patient's life. Let me cite one case which presents some features of interest; and this, amongst others, that for seven years subsequently to Symptoms of Intra-uterme Carcinoma. 269 the removal of a cancerous excrescence, the patient has re- mained free from any symptom of her disease. Case 5. — Mrs. C, a widow, about 40 years of age, in humble circumstances, mother of one child, was left under my care in May 1865, by my friend Dr. Drummond, on his removal from Glasgow. She had suffered for many months from pro- fuse watery discharges, not always offensive in character, interrupted by occasional haemorrhages, and attended with frequent fits of pain. The uterine neck had been partially dilated by the unaided efforts of nature, so that Dr. Drum- mond could feel a foreign growth within the cavity ; and, on dilating it further by means of tents, he succeeded in remov- ing a soft friable mass, which he regarded as cancerous ; and his opinion was confirmed by Professor Gairdner, who ex- amined a portion of the tissue microscopically.^ The patient had rallied for a time, but when she came under my care her symptoms had all returned, and she was reduced to a state of extreme debility. She was so weak that at first ^ The symptoms of intra-uterine cancer have been thus summed up by Sir James Simpson {Selected Obstetrical and Gynecological MeTnoirs, edited by Dr. Watt Black, p. 769) : "1. The presence of an extensive and disagreeable dis- charge ; 2. Frequent, profuse, and intractable menorrhagia ; 3. The presence of a foreign body in the cavity of the uterus, detected by the uterine sound, and felt by the finger after the dilatation of the cervix, hard, rough, and irregular, or more soft, fungoid, and friable ; 4. Pieces of the morbid texture peeled off or scraped off for microscopic examination ; 5. The periodic recur- rence of pains, slight and intermittent, perhaps, at first, but soon reaching a high pitch of intensity, at which it continues for an hour or two, and then gradually subsides." This tableau of the symptoms of malignant disease in the mucous membrane of the body of the uterus is the most perfect with which I am acquainted, and has been adopted by others, as by Dr. Fordyce Barker, in his admirable Clinical Observations on the Malignant Diseases of the Uterus (reproduced in Braithwaite's Retrospect of Medicine, vol. Ixiii., p. 301, from the American Journal of Obstetrics, Nov. 1870, p. 519). But, according to my experience, it would be improved by placing the intense periodic pain in the first line, and noting that the discharge is not always profuse, and not often offensive. I believe that until the os uteri has been opened up, either under the natural efforts of the uterus at the expulsion of the new growth, or by the surgeon for the purposes of diagnosis and treatment, any discharge that does occur is inoffensive and nearly inodorous. 270 Uterus. I felt disinclined to interfere, lest she should sink under an operation. In July, however, finding that the growth was becoming more accessible, in consequence of a fresh dilation of the OS, and under a fresh and painful effort of the uterus to free itself of its contents, I dilated the canal with a large sponge- tent, and, partly with a wire (5craseur, partly by means of a pair of polypus forceps, I broke down and removed, with the assistance of Dr. P. W. Mackay, now of Hull, all the diseased struc- ture. This woodcut (fig. 39) gives an impression of the situation and / size of the morbid mass which we ' thus removed. The amount of hae- morrhage was not great, although the operation lasted a considerable time ; and there was no bleeding subsequently, in consequence of a free application of perchloride of iron and glycerine, which I made to the whole interior of the organ. She was greatly exhausted, and re- mained long in delicate health ; but her pains never recurred, and her health became so far restored that, when I last saw her some two years ago, she was able to support herself by her own labour. I should add that my own examination of the morbid growth entirely corroborated the opinion that had already been formed regarding it. It very closely resembled, in appear- ance and structure, the ordinary cauliflower excrescence of the cervix. Fig. 39. Intra-uteeine Cancer. CASES SUITABLE FOR OPERATIVE INTERFERENCE. Such being the risks and such the happier results of re- moval of portions of the uterus affected with cancer, you will see that the field for operative interference is very wide. Ajfiputation of Cai^cinomatous Cervix. 2 7 1 Not only in cases wliere we have to do with a cauliflower excrescence, as in fig. 40, or with a mushroom-like epitheloma of the OS uteri where the cervix is healthy, but also in encephaloid cases where there is a projecting fungating mass with a hypersemic surface ; and even in the scirrhous and other varieties, which present an excavated surface, and where the ulceration has not yet perfor- ated the uterine and vaginal walls — in all these we put the patient in a better condition by removing all removable portions of affected tissue. METHODS OF OPEKATING. Fig. 40. Cauliflower Excrescence of the Cervix Uteri. When we have to do with an epithelial cancer of the lips which does not extend to the vaginal wall, and there is a healthy portion of the cervix like a neck to the tumour, or in any case where we have to amputate a projecting mass, by far the most satisfactory instrument is the galvano-cauter. Nothing can exceed the facility and precision of the application of the wire, and the certainty with which portions can be cut off, or more deep-seated parts subsequently cauterised. But it is troublesome to have the battery kept in order and carried about in ordinary practice ; so that, whilst I have experienced the advantages of it, and have wished at every new case that I could have the apparatus at hand, I have had to content myself in most instances with the wire ecraseur in cases of removal of softer tissues, and the original chain Ecraseur of Chassaignac for the amputations through the neck. I prefer the chain ecraseur to the wire, because when a single strong \vLre was used and a rope of several strands, I have found 272 Uterus. it give way before tlie dense tissues of the cervix were cut through. Wliere the disease is more sessile, having a broad base, and extending deeply into the substance of the cervix, it must be dug or scraped out by means of the finger-nail, or with a Eecamier's curette. Simon of Heidelberg has advo- cated this plan of treatment in an admirable paper {Beitrdge zur Gehirtshulfe und Gynmkologie, i. 17), where he has related some very encouraging cases, and has figured the scoops which he uses of different sizes. I have had the instruments made after his model, of the largest and one of the smaller sizes, and found them very serviceable. AFTER-TREATMENT. As has been shown in the cases which I have cited, I have usually followed the removal of the morbid masses by the application of a powerful astringent — most fre- quently the saturated solution of perchloride of iron in glycerine, or the powdered persulphate of iron. These salts of iron serve not only as an effective styptic, preventing any immediate haemorrhage from the injured surface, but they have a slight escharotic action, and help to destroy any of the affected tissue that may have been left. Latterly, I have made frequent use of a saturated solution of chlorate of potash, applied on pledgets of cotton-wool, to cancerous sur- faces. I was induced to do so in consequence of the good results which have followed its use in this way in the hands of the younger Fabbri of Bologna, who has published the history of a case of cancroid disease of the cervix, in which, under the subsequent application of chlorate of potash, the disease has been kept in abeyance for nearly three years. ( Uno Caso di Cancro Epitcliale del Collo utcrino trattato colV AmputazioM della "porzionc intravaginale c quindi col clorato di Potassa. Storia del Dott. Ercole-Federico Fabbri). Carcinoma of the Body. 273 II.— ENCEPHALOMA UTERI IN A CHILD.i At the meeting of the Edinburgh Obstetrical Society, on May 14, 1862, I showed a preparation of the uterus and appendages, which I had removed at the post-mortem dissection of a child eleven years of age. I first saw the girl in consequence of the presence of a large tumour about the size of a child's head, rising from the pelvic cavity and ex- tending liigh up in the abdomen. It was as firm to the feel as a fibroid tumour, but smooth over all its surface ; and, on examination per anum, it could be discovered to be growing from the uterus. It grew rapidly in size, and soon rendered the child unable to go out or take any exercise. The functions of the intestinal canal became interfered with ; pain to a very great degree came on, chiefly in the left side of the abdomen ; the right leg became cedematous ; and in less than six months from the time when I first saw her, the little patient sank and died. On dissection, about thirty-six hours after death, great decomposition had taken place. The thoracic organs, the liver, and the spleen were all healthy. The large intestines were greatly distended with feculent fluid and gas. The large tumour was found to be growing from the back wall of the uterus ; quite soft behind and above. At its upper aspect it was adherent to the bowels ; and there its peritoneal covering was perforated at the point where it was glued to the ileum and sigmoid flexure of the colon. The walls of the uterus, the cavity of which was 2| inches in length, were of normal thickness in front and at the fundus ; the back wall seemed to be all degenerated into the morbid mass, which, on section, presented a number of coagula in various parts. The kidneys were both slightly hydronephrotic. 1 EdinhurgJi Medical Journal, viii. 564. 186'j S 2 74 Uterus. III.— CAECINOMA CERVICIS UTERI ET ORIFICII URETHRA, TERMINATING FATALLY BY RUPTURE OF THE UTERUS.i At the meeting of the Edinburgh Obstetrical Society, on November 13, 1878, I showed a preparation of the genital organs of a woman who had suffered from cancer of the cervix uteri, complicated with deposits at the urethral orifice, and in whom the immediate cause of death was the rare occurrence of a rupture of the body of the uterus. The history of the case, as taken from the Ward Journal, was as follows : — Isabella F., aged 60, a domestic servant, was admitted on 29th October 1878 to Ward 12, Medical, suffering from retention of urine. History of Present Attack. — About a week previous to admission patient began to have difficulty in micturition, which gradually got worse till two days before she came into the Infirmary, when she was quite unable to relieve herself. Her previous health was always good. Present Condition. — External — She is a well-developed woman, of average height and weight, but her muscles are now much wasted ; the expression of her face is somewhat anxious ; the skin is soft and moist. Temperature 98° F. Menstrual and Obstetric History. — Her menstruation was always regular. She had two pregnancies, the labour in both cases being natural and easy. Cannot remember when she stopped being unwell. Physical Examination of the Ahdomen. — The abdominal parietes are lax, and scars of previous pregnancies are seen. There is distinct fulness on the left side, partly in the hypo- gastric and left lumbar regions, but chiefly in the left iliac. On palpation this has a somewhat fluctuating feel. Per- cussion confirms palpation, and auscultation is negative. ^ Edinburgh Medical Journal, xxiv. 653, 1878-79 ; and Transactions of the Edinburgh Obstetrical Society, v. 1, 1878-79. Carcinoma causing Rupture. 275 Fer Vaginam. — The ostium vaginae is patulous. Eound the urethral orifice a thickening is felt, which is ulcerated on its vaginal aspect. The cervix is small, but hardened and eroded, and immovably fixed in the indurated roof of the vagina. Bi-manually the mass described under abdominal examination is found to be the enlarged uterus. No sound was passed. Progress of the Case. — The patient was first admitted to the Surgical Wards, where more than six quarts of urine were drawn off. As she continued unable to make water, she was admitted to Ward 12, where it was drawn off twice daily till she died. About noon on 4th November she began to com- plain of violent pain in the abdomen, especially in the hypogastric region ; this continued till she died, shortly after midnight of the 4th. Treatment. — The urine was drawn off twice a day. Morphia was administered to relieve the pain, and the night before she died ether was injected subcutaneously by Dr. Hart, and brandy was given by the mouth. The post-mortem examination confirmed the diagnosis which had been formed that the case was one of carcinoma of the cervix uteri and around the urethra, and that escape of some noxious fluid had occurred into the peritoneum. Two indurated epithelial masses could be seen at the extremity of the urethra projecting towards the vagina and narrowing the urethral tube. The form of the cervix uteri was still main- tained, though epithelial deposits had taken place in its walls, and extended into the pericervical areolar tissue, and there was commencing necrosis of the surface at the os externum. The lumen was contracted, and the cavity of the uterus greatly expanded above. The walls of the uterus were thinned out so as to give it the form and appearance of the urinary bladder. There was a quantity of sanious fluid still in the interior, and the mucous membrane was the seat of a diphtheritic-looking deposit, consisting of decomposing blood- clot and broken down epithelial cells. At the fundus towards the left side and posteriorly there was a small perforation, the 276 Uter2is. size of a pea, with thin edges, through which the rest of the fluid had escaped, and set up the rapidly fatal peritonitis (fig. 41). Fig. 41. Carcinoma Cervicis Uteri et Orificii Urethr>e, leading to Occlusion of Os Uteri, Dilatation of Uterus, and Perforation. IV.— AMPUTATION OF THE CERVIX UTERI FOR CANCROID DEGENERATION.! At a meeting of the Edinburgh Obstetrical Society, on 23d November 1859, in the absence of Sir James Simpson, I laid before the Society preparations of the Cervix Uteri of ^ Edinburgh Medical Jourual, vi. 571. 1860-61. Amputation of Cervix ivith Bcrasettr. 277 two patients, who were the subjects of cancroid disease of that organ. The two preparations showed remarkably well the different forms which the same disease may assume in different instances ; for while in one of them, the smaller, the morbid change consisted simply in the development of masses of heterologous cells, having the character of scaly epithelial cells, in the interstices of the ordinary tissues of the part, — in the other and larger preparation, there was a further morbid change superadded, consisting in the development of an enormous number of villous papillary projections, growing on the surface of the part, and dividing and subdividing till the whole assumed a marked dendritic appearance. The one cervix, in short, presented an example of the ordinary cancroid growth so frequently met with in other parts of the body ; while the other was an equally characteristic example of the form which the disease is particularly liable to take on this organ, and which was familiar to all as the true cauliflower excrescence of the uterus. In both cases the amputation of the cervix had been effected by means of the ecraseur of M. Chassaignac. In the case of the patient from whom the smaller variety of tumour had been removed, and who was operated on about two months ago, the straight- shaped instrument had been employed. The use of this form of instrument rendered it necessary to pull down the whole uterus, by means of strong hooked forceps or volsella, so as to bring the vaginal portion outside the vulva ; and such a forcible and extensive displacement of the organ must, doubt- less, prove a source of danger to patients thus operated upon (fig. 42). To avoid all risk from this source, on the occasion of the performance of the second operation, a fortnight ago, Sir James Simpson had made use of the Ecraseur which was curved near the point, and which admitted of the application of the chain, without any dragging down or exposure of the uterus at all. The aid of a number of assistants could be dispensed with when the operation was performed by means of such a curved instrument ; for the whole process then consisted — 1st, of inserting into the cer\dx uteri a strong 278 Uterus. volsella, by means of which the only assistant whose presence was necessary might keep the organ steadily fixed while the chain was being carefully applied and adjusted at a safe distance above the line of diseased and altered tissue ; Fig. 42. Cervix Uteri (a) drawn clown by Volsellfc, and (e c) Ecraseur aiiplied. and 2dly, of then slowly working the instrument until the parts it embraced were all sawn through. The patient lay in a perfectly unconstrained position, on her back, during the performance of the operation, and it was possible to complete the whole operation without exposing her person in any degree. In fact, in operating with a curved instrument, everything was done by touch alone ; while, in Amputation of Cervix with Galvano-Catiter. 279 using the straight one, we had to call in the aid of sight as well. No accident of a grave character had occurred in immediate connection with the operation in either of these two cases. In the woman from whom the cauliflower excrescence had been removed, the amputation had been too rapidly performed, and an oozing of blood had taken place for two days subsequently — not to such a degree as to amount to flooding, or to give rise to the slightest alarm — but pretty nearly as much as we sometimes see in women for a day or two after their confinement. Afterwards she had a slight attack of phlegmasia dolens in the right leg, but from that she was now recovering. The other patient was threatened with an attack of pelvic cellulitis, and remained for some time in an anxious condition, but ultimately she got perfectly well. Amputation of the cervix uteri by means of the ^craseur was not always, however, so successful as it has proved to be in these two cases. When in Berlin, two years ago, I heard mention made in the Obstetrical Society there, of a case where the operation had proved fatal in that city in the hands of Professor Langenbeck, one of the most skilful surgeons in Europe. The loop of the chain had been applied high up, and during the working of the instrument a portion of the vault of the vagina had been dragged in, and the consequence was, that the peritoneum was opened into, and the patient speedily died. v.— CAULIFLOWER EXCRESCENCE OF THE CERVIX UTERI REMOVED BY MEANS OF THE GALVANO- CAUSTIC WIRE.i At a meeting of the Edinburgh Obstetrical Society, on December 10, 1862, I showed a preparation of a Cauli- flower Excrescence, which I removed some months ago by means of the galvano-caustic wire. The patient was an elderly woman from the country, who had become very much ■^ Edinburgh Medical Journal, viii. 871. 1863. 28o Utertis. reduced in consequence of tlie constant drain of blood from the affected part ; for the fungous mass was very soft and vascular, and poured out blood at every examination. The constant foetid discharge, moreover, was extremely disagree- able; and, though there could perhaps be little hope of a complete eradication of the disease, the ablation of the mor- bid mass seemed clearly indicated. To have attempted to remove the cervix by means of the knife or scissors, where the tissues were too friable to be seized hold of with the volsella, would have been worse than useless ; and in a case precisely similar I have seen an attempt to remove the cauliflower excrescence by means of the ecraseur fail in con- sequence of the excessive haemorrhage that attended the effort to introduce the chain into the vagina. I decided, therefore, on using in this instance the galvano-caustic appar- atus ; and having succeeded in passing a loop of platinum wire roimd the tumour, the ^current was set on, and in a few seconds the morbid mass was separated from the body. Blood necessarily escaped during the application of the wire, but not a drop was lost after the neck began to be con- stricted ; and when a duck-bill speculum was introduced into the vagina as the patient lay on her back still asleep with chloroform, the white surface of the stump could be seen pre- senting a most satisfactory appearance. Only, within the canal of the cervix two suspiciously granular fungoid spots could be detected, and these I destroyed as effectually as possible by means of the heated loop of platinum wire. The patient presented no unfavourable symptom, was soon able to be out of bed, and had been sent back to her home in the country restored for the time to some degree of health and comfort ; but regarding her ultimate history I have no infor- mation. Cases of Cervical Carcinoma. 281 VI.— EPITHELOMA OF THE CERVIX UTERI.i At a meeting of the Edinburgh Obstetrical Society, on June 12, 1878,1 showed an Epitheloma of the Cervix Uteri, removed by the galvano-caustic wire. At the time of operation there was free bleeding. I at first thought of pulling open the parts and exposing the bleeding surface ; but as I knew the septum separating the anterior fornix vaginse from the peri- toneum was very thin, and might have been torn through, I refrained from doing so, and therefore applied a plug soaked in perchloride of iron. This was a mistake, as the patient died on the fourth day, and on post-mostem examination the cause of death was found to be general peritonitis, mainly in the pelvis. The cause of this was very easily seen to be due to the perchloride of iron corroding through the thin septum into the peritoneum. VIL— SECONDARY CANCER IN A PATIENT WHO HAD BEEN SUBJECTED TO AMPUTATION OF THE CERVIX UTERI.2 At a meeting of the Edinburgh Obstetrical Society, on June 27, 1860, I stated that I had that day made a post-mortem examination of a woman whose case had already been brought under the notice of the Society. The patient was a married woman, mother of six children, and had been subjected to amputation of the cervix uteri in the middle of August last (ten months ago), on account of a cauliflower excrescence of the organ which had been a source of menorrhagia for some years past. The amputated portion of the cervix had been shown to the Society. For two months after the operation ^ TraTisactions of the Edinburgh Obstetrical Society, v. 139, 1877-78 ; and Edinburgh Medical Journal, xxiv. 266, 1878-79. - Edinburgh Medical Journal, vii. 497. 1861-62. 282 Uterus. she remained perfectly well ; but about three months after- wards she began to experience pains like those of sciatica in the right leg and hip. A slight fulness and firmness was felt in the right side of the pelvis on a vaginal examination, which I attributed to the occurrence of a cancerous deposit in the cellular tissue. But as there was a faint chance that it might merely be an inflammatory deposit, local and general deobstruents were for a time employed, but with little effect. The pain continued; the leg began to swell and become cedematous ; and after some months a distinct tumour could be felt in the right iliac fossa. For nearly three months past the patient had been confined to bed, and had gradually sunk, and at last died on June 26, completely exhausted. On making a post-mortem examination, the uterus was found to be perfectly healthy, and although in immediate contact with the diseased mass, yet entirely unconnected with it. At the circle of cicatrix left after the healing of the wound caused by the ^craseur, a ring of darkened, but perfectly healthy tissue, was found. The darkening was evidently due to the transformations occurring in the blood, which must necessarily have been extravasated in the bruised wound made by the instrument. An enormous mass of cancerous tissue was found filling up the pelvis, seated chiefly in the glands and cellular tissue of the right side, but stretching upwards as far as the fourth lumbar vertebra. The right ureter was distended to the size of the thumb, and very thin- walled ; the corresponding kidney felt slightly hydronephrotic. The left ovary had undergone carcinomatous degeneration, and presented a number of distinct cavities filled with soft semi-fluid, or sometimes fluid matter. The left Fallopian tube was slightly distended, and contained some purulent matter. The position and condition of the right Fallopian tube and ovary could not be well ascertained, as they seemed to run into and become amalgamated with the general morbid mass. The tumour was itself made up in part of firm, fibrous portions, but chiefly of soft, encephaloid masses, interspersed with extra vasion clots and occasional fluid or pulpy collections Elongation of Cervix. 283 of broken-down cancer cells. It was firmly bound down to the pelvic bones of the right side, which were eroded and brittle. The omentum contained a good deal of fat, and a multitude of small, hard, carcinomatous granules. The other abdominal and the thoracic organs were healthy. ON AMPUTATION OF THE CERVIX UTERI IN CASES OF ELONGATION.i At a meeting of the Edinburgh Obstetrical Society, on 10th February 1864, in the absence of Sir James Simpson, I showed a drawing of a portion of the anterior lip of the cervix, which had been removed by the ecraseur. There had lately been a patient in the hospital on whom the same operation had been performed, and whose history was as follows : — Joan Campbell, aged 29, admitted to the Royal Infirmary, November 26, 1863. About six and a half years ago patient began to suffer from bearing-down pains. Six months previously she had given birth to a female child. The labour was difficult and tedious — the shoulder presented, and turning was resorted to. Ten months after the birth of the child, her doctor discovered that the cervix of the uterus protruded beyond the vulva. Some kind of instrument was introduced into the vagina, for the purpose of keeping the uterus in its position, — it having fallen down somewhat, — but was withdrawn two days subse- quently in consequence of inflammation attacking the uterus. During the three following years patient suffered from repeated attacks of a similar nature. For five weeks after the birth of her child patient had a constant discharge of blood from the womb. Four weeks after the bleeding ceased she menstruated, and continued to alter regularly every ^ Edinburgh Medical Journal, x. 72. 1864-65. 284 Uterus. month for about the space of one year. Although she had nursed her child for the ten months previous to the first inflammatory attack, it is worthy of notice that she men- struated regularly every month during that period. For the last five years patient has menstruated every two or three weeks. During this period, and especially when " poorly," she suffered from considerable pain in the right groin — so much so at times, that the weight of her clothes was unbearable. On admission, the general health was good. The uterus was somewhat prolapsed, and the cervix elongated. On December 22, Sir James Simpson pulled the cervix outside the labii, applied the ^craseur to the cervix, and amputated a portion about one inch in length. There was almost no bleeding. Patient slept well after the operation, and never had a bad symptom, with the exception that on the day after the operation she required to have the catheter passed, to draw off her water. She made a good recovery, and was dismissed cured on the 12 th of January. The operation in these cases was performed by transfixing the portion to be removed by one or two long needles, and passing the chain of the dcraseur over above them. There was no haemorrhage after the operation. FOEMS OF STEEILITY.i CASE. — STEKILITY FROM DYSPAREUNIA AND RETROFLEXION OF THE UTERUS — CURE — CONCEPTION. Anamnesis. — Mrs. A. consulted me for the first time in April 1877. She stated that she was 35 years of age ; had been married for four years ; had never conceived ; always , suffered pain in the pudenda when coition was attempted ; ^ Transactions of the Edinburgh Obstetrical Society, v. 37, 1878-79 ; and Edinburgh Medical Journal, xxiv. 769, 1878-79. For the history of the labour in this case, see case of Priniiparal Placenta Prajvia, anlca, p. 72. Case of Sterility. 285 and for some time past had begun to lose more than the usual amount of blood at the menstrual periods, which were now also coming on at shorter intervals, and that she was falling off in her general health. Physical Diagnosis. — When I attempted to introduce a finger through the vaginal orifice, I felt that the aperture was still obstructed by an unruptured hymen, and the expression of suffering elicited from the patient made it necessary first to inspect the pudenda. They were everywhere normal and healthy, except that the hymen itself was unusually vascular, and the surface of the navicular fossa at its base was irri- tated and partly abraded. Exercising a little more gentle- ness, I was now allowed by the patient to pass the finger through the hymeneal aperture until I could reach the roof of the vagina. The os and cervix uteri were normal ; but in the posterior fornix I felt a rounded body which, on combined palpation from above, I judged to be the fundus of the en- larged and retroflected uterus. I did not then use the sound, nor did I think it necessary to form a definite diagnosis as to the uterine condition, because the indication for present treatment was clearly to remedy the mischief lower down, and because the examination with fingers or sound could not be conducted without causing unnecessary suffering. Noting, therefore, the displacement, but writing "myome?" as well in my note-book, because the age of the patient and the ab- sence of any traceable cause for the dislocation left me some- what in doubt, I proceeded at once with the Treatment. — Lubricating the finger afresh with soap and warm water, I passed first the index through the orifice, and then gradually insinuated the middle finger alongside of it till the aperture was fairly permeable. The patient was in- structed to use large-sized pessaries of iodide of lead vagi- nally, and to take ergot of rye internally. The dyspareunia completely disappeared. The menorrhagia was checked by the ergot, which the patient at first took for four weeks, and for some months afterwards for a week at a time during the menstruation. In the inter-menstrual intervals she was put 286 Uterus. on small doses of arsenic. Her general health improved ; the menstrual cycles were prolonged to nearly their normal four weeks ; [marital intercourse was carried on healthily ; but the sterility remained. Four months had elapsed, and the uterus still being large and retroflected, I replaced it on 13th August with the sound. The following day the uterus was found to have fallen back into its abnormal position. I therefore again replaced it, and introduced a vulcanite vaginal Hodge pessary, with the view of retaining it in its proper position. The day after the uterus and pessary were in good position, and the patient was instructed to go on wearing it. With the view of pro- moting uterine contraction and disgorgement, and improving further the patient's strength, she used for some weeks pills containing ergotin, extract of nux vomica, and chlorate of potash. From the 23d to the 27th of March in 1878, she menstruated for the last time. She had conceived. I saw her from time to time during her pregnancy, which pro- gressed without any unusual symptoms till towards the close, which was expected in the last week of December. COMMENTAKY. The causes of sterility in a woman, who has been married for some years without conceiving, may lie in any of the planes of the sexual apparatus. Not unfrequently more than one source of difficulty can be found in the same individual. Of this our patient affords a simple illustration. 1. Persistence of the Hymen. — This lady had been married for four years when I first saw her, and up till that time complete connection had never taken place. We all know that conception may follow a coitus where the hymen is un- ruptured, and the accoucheur may find the aperture still narrow when labour supervenes. Such cases are recorded and referred to in the last fasciculus of our Transactions, in a paper by Dr. James Young and the discussion which followed. These, however, are usually cases of illicit intercourse, where Sterility from Dyspareunia. 287 improper familiarities were permitted to an extent which the female, at least, believed to be safe. Even in such cases, where the process is repeated from time to time, the hymeneal orifice may become well dilated, although the borders of the membrane have never been infringed. Not long ago I was consulted by a young lady whose friends were getting anxious about her health, because she had passed six months without altering. She had permitted her lover, to whom she had been engaged for three years, to indulge in such liberties as I allude to, with the result that the orifice had gradually be- come dilated, and though she was sure that there was nothing amiss with her, because she had never lost blood, she was already six months pregnant. Instances of conception with undilated hymen are almost unknown in the case of married women, and in a considerable proportion of cases of sterihty we must set down the sterility as due simply to the perma- nence of the hymen. This permanence may have various causes apart from rigidity, natural or morbid, of the hymeneal tissue. (1.) Ignorance. — The married pair may be simply ignorant of their mutual marital duties. Many years ago I attended a lady in Glasgow in her first confinement, who had been some length of time married before she ever conceived. She had come to my friend, Dr. Drummond, thinking that she must be the subject of some abnormality. He found the organs all normal, but absolutely virginal, and the patient expressed some astonishment when her physician asked if her husband had never attempted to effect an entrance into the vagina. She conceived soon afterwards, and I attended her in that and in her two subsequent labours. (2.) Partial Masculine Impotence. — A hymen of ordinary structure may resist the efforts at penetration of a husband with diminished virile powers. Three years ago I saw a lady of 32, who had been married for thirteen months to a hus- band upwards of 50, who had never previously been married. She wished to know why she had not conceived. There seemed to be no other cause than the persistent hymen. I 288 Uterus. dilated the orifice witli a set of rectum bougies, and she con- ceived within a month, suffered from an early abortion, but again conceived and came to town, and was delivered at the full term of a male child that presented by the breech. (3.) Aivkward Connection. — There is a third and far more frequent class of cases where the persistence of the hymen is due to what I can only designate awkward connection. The husband makes his approach without taking any pains to call up so much as desire on the part of the wife, in whom the parts are still flaccid and dry, and he attempts to effect an entrance without producing any friction of the sensitive ex- ternal organs. The result in such cases is the production of so much suffering to the female, that an unselfish husband suspends his efforts, leaving the navicular fossa tender and irritable, and under a repetition of the process the structures may become so sensitive to pain that the wife dreads his em- brace. Such I take to have been the explanation of the con- dition I found in the case before us. It is sufficient to indicate the conditions under which the persistence of the hymen prevents conception. The Treat- 'ment in all such cases is clear. The orifice must be more or less effectively dilated by mechanical means, or guidance given for its effectual physiological dilatation, and the diffi- culty is at an end. Only in the third group the use of some soothing pessaries or emollient injections may be required to heal the injured surface. In the case of Mrs. A, the passing of two fingers through the vaginal orifice, and the use of some iodide of lead pessaries, sufficed to effect a cure of the hymeneal disorder, and the process, which was a pain or an aversion to the patient, became not only tolerable but pleasurable. The uterine difficulty, however, remained. Four or five months were allowed to elapse, and though coitus was now correctly carried out, the sterility remamed because of — 2. The Betrojlexion of the Uterus. — One might write a book on the conditions of this central organ of the sexual system which are hostile to reproduction. I only invite attention at present to the condition which kept up the steri- Sterility from Retroflexion. 289 lity in our patient — the backward displacement of the uterus. I do this all the more urgently, that the subject of uterine dislocations is one which a certain group of respectable gyne- cologists pride themselves in slighting, or even trying to teach the profession to ignore. Eeviewers may load the pages of our journals till they are ready to sink under the length if not the weight of their strictures on physicians who recognise the existence of these mechanical disorders, and remedy them by mechanical means ; but the man who has seen one such case as this which we are now considering, will be apt to suspect that these review- writers are more skilful in handling the critic's pen than the practitioner's probe. I have seen many such cases. Most frequently, as Dr. Marion Sims^ has shown in his interesting statistics, the backward displacements are prominent in cases of acquired sterility — in cases, i.e., of women who have given birth to one or more children, and have ceased to conceive before their usual period of reproduction was run out. In the present instance, and in other patients whom I have seen, however, the displacement had come about antecedently to marriage, and proved a bar to conception. This it may do either by marring the function of the uterus and Fallopian tubes as the canals for the upward transit of the spermatozoa, or by impairing the function of the uterus as the organ for the re- ception and lodgment of the fertilized ovum. At whatever time the displacement has been produced, and in whatever way it interferes with reproduction, it is of the greatest moment to the barren woman that it should be re- cognised and rectified. Recognition. — It may be recognised by the finger intro- duced into the vagina, and still more definitely when two fingers can be used simultaneously for exploration. The de- tection of it may be aided by dragging down the cervix with a volsella. Greater certainty still can be attained by the combined external and internal examination, by which means ^ Uterine, Surgery, 237. T 290 Uterus. the great proportion of cases can be clearly diagnosed. There remains but the employment of the sound, wliich may be used with due precautions to give absolute certainty of diag- nosis in any case, and which must in some be used as the only sure means of detecting the displacement. Be^osition. — The sound need not by any means be used for the recognition of every case. Many are clearly recognis- able without it. But there are few cases where the reposition is not best effected by means of it. For when the condition has been recognised, it becomes our plain duty to attempt to rectify it. We are sometimes bidden look upon the endome- tritis or general congestion that almost invariably accompany retroflexion as the essential mischief in the patient requiring special treatment. We do weU in many instances to attend to this injunction, but certainly not in every case of retro- flexion. According to my experience the converse more frequently holds good, that if you straighten the uterus, and keep it straight, the congestion disappears, and of this our patient furnishes an illustration. Happily we do not need to follow theorists on either side. But, as a rule, whatever may be done, the uterus must be replaced. The reposition may be effected in various ways. We may do it by internal mani- pulation alone in some rare cases — more particularly if, at the same time, the patient be placed prone, or the cervix be dragged down with a volsella. Better still, in a greater variety of cases it may be brought about by combined inter- nal and external manipulation. Or the patient may be placed in the knee-elbow position, and the posterior wall of the vagina held up with the fingers or a Sims speculum ; or, by letting air rush through a tube to distend the canal, according to Campbell's procedure, the uterus will be straight- ened. I have tried all the various methods in many cases, and in some patients have only succeeded at last in rectify- ing the uterus by simply passing in the sound and turning it round in the method originally described by its British inventor. I have yet to see the patient suffering from a simple retroflexion of the uterus, in whom I can cause any Treatment of Flexions. 291 notable degree of suffering, or induce any dangerous symptom by lifting up the organ with the ordinary sound. Its reten- tion can, in most cases as in the present instance, be best effected by means of a Hodge pessary. NOTICE OF AN ANTEVEESION PESSAEY.i At a meeting of the Edinburgh Obstetrical Society, on No- vember 9, 1870, I brought under the notice of the Society an instrument which I have found useful in relieving the distress attendant on anteversion of the uterus, and in doing so, took the opportunity of making one or two preliminary remarks. A large proportion of the cases of this form of uterine dis- placement call for no kind of mechanical treatment. A cer- tain degree of anteversion or anteflexion is to be regarded as the normal condition of the infantile uterus ; and after the menstrual function is established, it still persists in a con- siderable number of women. M. Panas {Arcliw. Gen. de Medicine, 1869, p. 274) examined 114 women with the view of ascertaining the position of the uterus, and found it straight only in about a third of the cases. His statistics are these : — Uterus straight in 44 ; anteflexed, 40 ; anteverted, 12 ; retro- flexed, 3 ; retroverted, 3 ; lateriverted, 12. He noted, fur- ther, that the uterus was found more habitually erect in pro- portion with the advance of the patient's age, and that early menstruations occurred most frequently where the uterus was still displaced, the mean age at which the menses appeared in women with straight uterus being 16*3 ; whilst the mean age at which they appeared in cases of flexion was 13"2. Beside these congenital cases, we find the uterus becoming displaced 1 Transactians of Edinburgh Obstetrical Society, ii. 217, 1870-71 ; and Edinburgh Medical Journal, xvi. 655. 292 Uterus. forwards as a result of the contraction of peritoneal adhesions, or the growth of a fibroid nodule in its anterior wall, or some morbid influence brought to bear on it during the relaxation of the puerperal period ; and even in these the anteverison or anteflexion does not always give rise to such distress as to necessitate our interference. Again, as is well known, the suffering associated with the displacement is often neuralgic in character, and requires for its relief the use of various nervine tonics and sedatives ; or it may be inflammatory, and require the employment of anti- phlogistics, &c. But there are yet other cases, and these not a few, where we cannot afford rehef to our patients, except by the applica- tion of some mechanical support. I have seen the plan first proposed, I believe, by Dr. Moir, for the treatment of retro- flexion, useful in cases of anteflexion. Especially where it is associated with a marked degree of hypertrophy, I have seen the introduction of a sponge tent straighten the anteflected organ, and set up an absorptive action in the thickened walls. For other cases I have found the intra-uterine stem pessary, with which we are all familiar, yield the most satisfactory re- sults ; and, in the case which has led to my present communi- cation, no other means that were employed afforded any per- manent relief. Various modifications of Hodge's and all other vaginal pessaries were tried for a long series of months and years ; the only instrument that seemed to the patient to give any hope of ease being Dr. Graily Hewitt's. But even with it the pain in the left groin, which was her most distressing symptom, always remained acute as ever when she turned upon her side, so that she could never sleep except when lying on her back. To sit up or stand was for her an im- possibility. The intra-uterine stem pessary was the only in- strument that kept the uterus in such a position as to enable her to obtain the much-desired rest on the side ; but, unfor- tunately for her, the instrument only produced its effect when it was itself kept in position by the wire frame adjusted over the pubes. So great was the relief it gave, however, that, Anteversion Pessary, 293 although it produced a degree of menorrhagia, she had worn it continuously for about a year and a half, till, from its pres- sure on the anterior lip of the cervix, it had begun partially to divide it. Wlien she came under my care I found that by pressing up the fundus with the tips of two fingers the pain was relieved ; and in order to keep the fundus permanently supported in this position I got an instrument made such as I now show to the Society. It is a bivalve pessary made of vulcanite, the fenestrated valves having the relation to each other of anterior and posterior, united by a hinge at their lower end, and kept apart by a slight spring. The anterior valve has a notch in its upper free border to receive and sup- port the body of the uterus ; the posterior is somewhat longer, and, by pressing upwards the posterior vault of the vagina, supplements the function of the recto-vaginal and the utero- vesical ligaments. In some cases where I have employed it, the instrument, as I have described it, has proved serviceable ; but in the particular case to which I have referred, I found it necessary to adapt a tube to the lower end of it, so as to allow of a wire frame passing from it to be fixed over the pubes. The lady has been wearing it for several months, with the happy result of being able to sleep comfortably on either side. She has moreover, been enabled to move about the house ; and, when at the sea-coast during the summer, she enjoyed open-air exercise in the way of driving and boating to a degree to which for sixteen years she had been a perfect stranger. 294 Ovary. OVAEY. CYSTIC TUMOUES OF THE OVARY CONTAINING HAIRS.i A T a meeting of the Edinburgh Obstetrical Society, on April 10, 1861, I showed a preparation of the uterus and ovaries of a woman who had succumbed to Cystic Ovary. The patient, an unmarried woman of upwards of forty years of age, had been aware for several years of the existence of a growth developed chiefly in the left side, but stretching far beyond the middle Kne to the right. As she had become weak and unfit for her work, and was extremely anxious to be relieved of the weight of fluid, Sir James Y. Simpson had tapped her in the ordinary situation, in the belief that the cyst was of the most simple kind, and in the expectation of finding a simple serous fluid, as there had been no history of any inflammatory symptoms whatever. Instead of such a clear liquid, however, there had escaped a greenish-yellow, puriform fluid, which looked, as it escaped from the canula, exactly like the contents of a large abscess. A large basinful of the fluid had been drawn off, when with the last drops of it there had escaped through the tube a single red hair, and it had at the same time been noticed that the portion of fluid that had first come away, and that had now been cooled, had begun to cake and consolidate ; and gradually the whole of the cystic contents became of the consistence of firm butter, having been of a stearoid or fatty, and in nowise of a purulent character. The cavity had again become filled up, and two * Edinhurgh Medical Journal, vii. 886. 1861-62. Dermoid Cystoma. 295 months subsequently to the first operation the patient had a' second time been tapped. The fluid then drawn off still contained a large proportion of stearoid matter, although now mixed up with much serous fluid. On the occasion of this second tapping, Sir James Y. Simpson had introduced a sound through the canula, and had felt it impinge on a hard, bony, or calcareous point on the posterior part of the cyst-wall. The existence of this hard spot I had also been able to verify. Some tincture of iodine had then been injected into the cyst, but without any marked result. The patient had felt herself a little relieved, as after the first operation ; but in about six weeks afterwards she sank and died. At the post-mortem examination the preparation exliibited to the Society had been removed. The uterus was seen to be the seat of a large fibroid tumour, of the intramural kind, which was seated in the left side of the organs, and compressed, distorted, and almost obliterated the cavity. The ovarian cyst was in- timately adherent to the enlarged uterus, so as to form, as it were, a single mass, and it had also acquired adhesions of a slighter kind to the mesentery and small intestines. On opening the sac a considerable ball of loosely tangled hair was found lying in its interior, and two or three long hairs of a similar kind were seen growing from follicles in a skin-like patch on the posterior wall, towards its lower end. A little higher up there was a ridge, in the middle of which was a small calcareous deposit, the same which had been felt by means of the sound during life. I was not aware whether any observations had ever been made in such cases in regard to the colour of the hair, but in the case which I brought under the notice of the Society the hair contained in the ovarian cyst was strikingly like that growing on the head and pubes of the patient, and it would be interesting to know whether this obtained as a general law. 296 Ovary. CASE OF DOUBLE OOPHOEECTOMY, OR BATTEY'S OPERATION: WITH REMARKS.^ On June 12th, 1878, I showed to the Fellows of the Obstetrical Society the ovaries of a patient on whom I had performed Battey's operation two days previously, with the hope of cutting short her life-long menstrual suffering. Nine months having elapsed, I proceed to fulfil the promise I then made to bring before the profession the full record of the patient's case, and to offer some remarks on the operation which was undertaken for her relief. CASE. — DTSMENORRHCEA — INEFFECTUAL DIVISION OF CERVIX UTERI — PELVIC INFLAMMATION — INTERNAL HAEMORRHOIDS CURED BY LIGATURE — DOUBLE OOPHORECTOMY — PREMATURE UTERINE SENESCENCE. M. K., born October 3, 1842, began to menstruate at the age of twelve. From the very first the monthly flow was attended with pain. The suffering generally began a week before the period was due, and continued through the week of the catamenial flow. During the height of the pain she used to be confined regularly to bed for four or five days. Stimulants and sedatives were always administered, such as whisky, gin, laudanum, chloric ether, sal volatile, etc., with the view of lulling the pain. The late Mr. Carmichael, who was her medical attendant, was obliged for many years to keep her under the influence of chloroform when she was at her worst every month. In 1868, Mr. Carmichael took her to see Sir James Simpson, who divided the cervix uteri. An attack of pelvic inflammation ensued, and the dysmenorrhcea continued. In 1872, 1 saw her along with Mr. Carmichael. The uterus ^ Read before the Edinburgh Medico-Chirurgical Society, March 4, 1879. British Medical Journal, May 24, 1879 ; and Transactions of the Edinburgh Obstetrical Society, v. 138. Case of Dysmenorrkcea, etc. 297 was anteflexed, and so sensitive that the introduction of a sound caused unusual suffering. Both ovaries were swollen, and tender to the touch ; the left especially was felt to be fixed with inflammatory adhesions. The general system was greatly reduced, and there was a very marked degree of anaemia, which was traced to constant losses of blood from internal haemorrhoids. There was great congestion and sensitiveness in the rectum, as well as in the genital organs ; and as the most urgent indication seemed to be to check the haemorrhoidal bleedings, and as I had seen in other cases of chronic inflammation of the genital organs a marked improve- ment in the uterine condition after the cure of such a rectal complication, I proposed to Mr. Carmichael that we should try to remove the haemorrhoids. To this he agreed; and, with the assistance of Dr. Halliday Groom, we operated on them in the usual way with ligatures. When the operation was nearly completed, and the last of the haemorrhoidal masses was being transfixed with the needle, the breathing of the patient, who was being chloroformed by Mr. Carmichael, became stertorous, and, for a time that seemed to us to be very long, it ceased altogether. Under artificial respiration, kept up by alternate compression and relaxation of the chest, the patient recovered ; but none of us had ever before such a fright with a narcotised patient. The operation was com- pleted, and was so far successful that the haemorrhage ceased and the patient's general health was greatly improved. She never again looked such a wreck of a woman as she appeared before this operation. But her menstrual pain remained unrelieved ; and her own long-trusted and esteemed doctor having died some time subsequently, she began to come to me from time to time to seek for more relief. Many means were employed. External counter-irritation was long employed without marked effect. Glycerine and wadding-plugs were applied through the vagina ; and after- wards hot water vaginal douches, and from time to time various kinds of medicated pessaries, were employed. What- ever relief she at any time obtained proved only temporary. 298 Ovary. I coiild only console her by telling her that when men- struation ceased she would get rid of pain, and might become a strong active woman. Once when I tried thus to comfort her, and she rejoined that there was little consolation in looking forward to so many years of suffering, I hinted at the possibihty of anticipating the date of freedom by removal of the ovaries. Again, two years ago, after my return from the International Medical Congress in Philadelphia, I told her definitely that they were curing some of her fellow-suf- ferers by this means, but without urging on her the opera- tion. In the end of 1877 she came from Dundee, whither she had now gone to reside, to see me. After I had again con- fessed my inability to do more for her relief, and began to tell her, as usual, that she must be content to mitigate the suffering till the menopause should come, she said: "But didn't you tell me that the American doctors were curing their patients by making them old before the time ?" I put her off by prescribing for her some sedative she had not before employed, and asking her to return in the spring. In March she returned no better ; and asking again, " Can't you do here what the doctors in America can do ? " I confessed that of all the patients I had known, she was just the one most likely to benefit by the operation ; but I added that it was by no means free from danger, and said that I would rather not undertake it till the better summer days. In June she reappeared. She declared she had come to give me a last chance of curing her. I began to speak of delaying the operation. She looked me in the face, saying — " If I funked it before, I think you're funking it now!" " You see, the operation is often fatal." "One in three of the patients die, don't they?" " Yes ; and you might be the one. But how do you know ?" " Oh, I've been reading aU about it. Do you tliiuk, if I do get over the operation, that I shall be free from my pain ? That's what I want to know." " I see no other way of reheving you ; and I see no reason Case of Oophorectomy. 299 to doubt that, if you recover, you will afterwards be quite well. But what if you do not survive the operation?" "Ah! then there will be one poor sufferer less in the world." The indications for the operation having become so clear, it was carried out on June 10th, 1878, when I had the assist- ance of Dr. Berryman, of St. John, New Brunswick, Dr. Halliday Croom, Dr. Hart, and Mr. A. H. Barbour. Eemembering the alarming collapse that occurred when she was under the influence of chloroform during the opera- tion for piles, I had asked Dr. Hart, who took charge of the anaesthetising of the patient, to provide himself with both ether and chloroform. He began with the ether ; but it was long in inducing narcosis ; so that it seemed as if the quantity provided would be all evaporated before the patient was fully asleep ; and the amount of the vapour in the room was becoming so disagreeable that the further narcosis was induced and kept up by means of chloroform, with the usual comfort and success. The abdomen was exposed, the surface washed with a solution of carbolic acid, and the opening made under a cloud of carbolic acid spray. An incision, two-and-a-half inches in length, was made in the linea alba, the lower angle of it being half an inch above the upper margin of the pubic bone. There was considerable difficulty experienced in recognising the surface of the peritoneum, because the omentum stretched down behind it into the pelvis, and was partially adherent at the point of perforation. Two small bleeding points were secured with Plan's forceps. After separating the omentum, and extending the incision, through the peritoneum to the length of the skin-aperture by means of a probe-pointed bis- toury, I passed two fingers of the right hand down into the pelvis to the back of the uterus, ran them along the right Fallopian tube, and, as I had expected, readily found the right ovary and pulled it up to the opening in the abdominal wall. I passed an aneurism-needle, threaded with strong silk soaked in carbolic acid, through the pedicle, so as to be able to tie 300 Ovary. it with a double ligature. After tying it at both sides, I had the ends of one of the ligatures cut short; and then, for security, I tied the ends of the remaining ligature round the entire pedicle. I ought then to have cut the ends short. As it was, however, the first time I had trusted an ovarian pedicle to a ligature, and there was no great length of pedicle to deal with in this particular case, I left the ends long, with the view of being able to pull up the structure before closing the wound, to make sure that no oozing of blood was taking place. I then tried to reach the left ovary. I had left it last, because I knew it was most adherent, and that it was placed lowest in the pelvis, and thus was not likely to be so easily accessible. By introducing the first two fingers of the left hand. I could barely touch it, and the relation of the omentum caused additional difficulty. I therefore enlarged the opening to the extent of three and a half inches, so that it was just of sufficient length to admit the four fingers and palm of the left hand. One felt that the experience the fingers had gained through frequent introduction into the uterus for the detachment of adherent portions of placenta in cases of miscarriage was now immensely helpful in enabling one to distinguish the softer texture of the omen- tum, and in detaching it from the firmer surfaces of the uterus. Fallopian tube, and ovary, to which it had acquired pretty extensive adhesions on this side. After it had been separated, the ovary was caught between the fore and middle fingers, and pulled up toward the wound along with the extremity of the Fallopian tube, which was inseparably glued to it by old adhesions. The ovary was irregular on its surface, from the varying size of some of the ovisacs, which were dropsical; and when it appeared within the wound, surrounded by a crowd of small cysts springing up in the tissues at its base, it gave an impression as if one were looking at an incarnate effervescence. The aneurism- needle, threaded as before, was passed through the broad ligament from behind forward ; and, the thread having been divided, one half was tied outside the fringed extremity of Case of Oophorectomy. 301 the Fallopian tube, where it was adherent to the ovary, and the other half over the Fallopian tube, about an inch from its uterine end. The ends of the inner thread were cut short; and the uttermost thread was made to encircle the whole pedicle, and tied tightly around it. The ovary, with the outer third of the Fallopian tube, were cut off with a bistoury, the remaining ends of the thread were cut short, and the pedicle was allowed to fall back into the pelvis. The long ends of the thread attached to the right ovary, which had been left hanging out of the wound, were now used to pull the pedicle again into view. Whether it was at this moment that it slipped off the pedicle, I cannot tell, but the loop that had been tied round the whole pedicle was found to have got loose; and, as there was a sKght oozing of blood from the surface, a new thread was thrown round the pedicle, and firmly tied. The ends of both the threads having been cut off, this pedicle was also let fall into the pelvis. Very little blood had escaped during the operation. The peritoneal cavity was, however, carefully sponged, and, no further escape of blood being visible from the pedicles as they were looked at in situ, the abdominal wound was closed. It was secured by means of three deep silk sutures, each threaded on two needles, which were passed from within outwards, close to the peritoneal edge of the wound, and half an inch from the skin-margin. The edges of skin were further adapted by means of four superficial horsehair sutures. A piece of cotton-wadding soaked in carbolised oil was laid upon the wound and covered with a thick sheet of the same wadding, and kept on with a flannel roller wound round the abdomen. The clinical history I give from the notes kept by Mr. Barbour. "June IQth. Operation performed to-day antiseptically, lasting from 12.20 to 1.40 p.m.; 3 p.m., pulse 106, weak; 10 P.M., pulse 100 ; temperature 100.4 ; urine was drawn off by catheter. 302 Ovary. "June 11th. Seven a.m., pulse 100; temperature 100.4; 10 P.M., pulse 98 ; temperature 100.4. She felt great pain in the abdomen last night till injection of morphia at 2 a.m. No sleep. She passed urine herself, a few drops of blood after it. Catheter not used again. She was complaining of pain in the abdomen and back. She began to-night to take bromide of potassium; twenty grains taken by bed- time. " June, 12th. Seven a.m., pulse 97 ; temperature 99.8 ; 10.30 P.M., pulse 97 ; temperature 99.8. After a morphia injection at 10.30 p.m., last night, she slept off and on for half -hours till 3 A.M., and after that till 6 a.m. At 10 a.m., the abdominal wound was dressed ; it looked well ; no tension or redness ; no tenderness on pressure. The pain in the abdomen and back was less to-day than yesterday. Menstrual flow began. "June 13th. 10.30 p.m., pulse 104; temperature 100.3. She complained of heat and great thirst since 6 p.m. yesterday, continuing all night. Two-thirds of a grain of morphia was given. The menstrual flow continued. "June 14:th. Eight A.M., pulse 104; temperature 100.3; 10 P.M., pulse 96; temperature 99.6. She still complained in the morning of heat and flatus ; cooler to-night. Two- thirds of a grain of morphia was given. Menstruation continued. "June 15th. Ten a.m., pulse 96; temperature 98.6; 10 P.M., pulse 96 ; temperature 99.8. No one watched by her last night. She slept for two hours ; awoke between three and four feeling very sick ; dosed till seven, when she awoke sick again, and vomited. The bromide was stopped this morning. The wound was dressed at 11.30 a.m. All the horsehair and one silk sutures were taken out : the other silk sutures were removed at 4 p.m. The wound looked well, healing by first intention. Three long strij)s of plaister were applied. There was no inflammation or suppuration around the stitches, which were quite sweet when removed. There was slicfht friction to touch on the riirht side of the abdomen Case of Oophorectomy. 303 this morning, but diminished by night. A tube was passed -per rectum, but only a few bubbles of gas escaped. The men- strual flow was diminished. No hypodermic injection was given. "June, 16^/i. Ten a.m., pulse 96; temperature 99.6; 10 P.M., pulse 96 ; temperature 99.6. The menstrual flow ceased. "June 17tJi. Ten A.M., pulse 84; temperature 99.2; 10 P.M., pulse 96 ; temperature 99.2. No injection was given last night. She did not sleep till the morning. She drank some milk now. " June IStJi. Ten A.M., temperature 99.2 ; pulse 96 ; 10 p.m., temperature 99 ; pulse 84. The oiled cotton was removed. " June 21st. Pain in the lumbar region came on last night and slight discharge. "June 23rd. The discharge ceased. She got up for a little last night, and sat on a chair." From this time, the convalescence of the patient progressed very steadily. At the usual period in July, a menstrual discharge came on. It was, however, of shorter duration and attended with far less suffering than she had ever experienced. In the month of August, the first time for twenty-six years, she passed the dreaded week without having any catamenial flow and without being obliged to keep her bed. There was a slight appearance in the month of September attended with some suffering ; but it lasted only for a day, and did not necessitate confinement to bed. In October and November, she was well. In December, a shght and almost painless discharge at the regular time. In January and February 1879, she remained well, only having some degree of head- ache and general uneasiness at the periods. Yesterday (March 3rd), a few days after the proper day, some uterine htemorrhage began, and with something of the old suffering. It is already lessening, however, to-day.^ ■* It continued in less than the usual quantity off and on for a fortnight. The periods for April and May, however, have come and gone -without any threatening of discharge (May 12). 304 Ovary. On examination, I find that the uterus is becoming distinctly reduced in size when grasped between the fingers. There is no tenderness or fulness to be felt in the situation of the pedicles. The uterus is freely movable. There is no indication of any inflammatory process in the pelvis. The vaginal roof, even, begins to contract and its surface to become roughened from the same kind of colpitis which is frequent in elderly women, and which I have been in the habit of describing to my students as colpitis senilis.^ COMMENTARY — I. HISTORY. The operation which I had thus the privilege of performing for the first time in Scotland has but a brief history. Dr. Aveling has shown^ that the late Dr. Blundell, in 1823, suggested the extirpation of the healthy ovaries in "the worst cases of dysmenorrhoea and in bleeding from monthly determination on the inverted womb, where the extirpation of that organ was rejected." The proposal, however, was still-born — perhaps I should rather say it was prematurely born — and no one carried it into effect for nearly half a century.^ The first in point of time to extirpate the undegenerated ovaries was Professor Hegar* of Freiburg, on July 27th, 1872. It was a case of intolerable ovarian neuralgia. The patient died four days later ; and Hegar did not repeat the operation till 1876. On August 17th, 1872, three weeks after Hegar had operated on his patient. Dr. Eobert Battey of Eome, Georgia, U.S.A., without knowing that it had previously been suggested or attempted, performed the operation on a patient who had been for long a sufferer ^ "Colpitis vetularum " of Dr. Carl Ruge (See Zeitschrift fiir Geburtschul/6 und Oyndkologic, iv. 144). - Obstetrical Journal for January 1879, 617. * The ingenious operations which Koeberle performed in 1863 and in 1869 (see his article "Ovaries" in the Nouvcau Dictionnaire de Medicine ct de Chirurgie jn-atiqiies, xxv. 600-603), are not cases of double oophorectomy. ■* " Die Castration der Frauen," Volkmann's Sammlung Minischcr Vortrdgc, Nos. 136-138, 82. Bibliography of Oophorectoiny. 305 from menstrual distress which nothing had ever effectually relieved. The operation was a success. It was recorded in the Atlanta Medical and Surgical Journal for September 1872. Battey repeated the operation in other patients, and continued to publish the results of them.^ To him, therefore, belongs the credit, not only of having independently con- ceived and carried out the operation with success, but of having impressed the profession with a due sense of its value in a certain group of otherwise intractable cases. It has been repeated by various operators, such as Marion Sims,^ Trenholme,^ Goodell,* Peaslee,^ Thomas,*^ Gilmore,'^ Fallen,^ and Engelmann^ on the other side of the Atlantic ; and in Germany by Freund, Kaltenbach,^'^ A. Martin,^^ and Tauffer.^^ In Britain, the only case that I know of is that to which Mr. Spencer Wells ^^ refers as having been carried out by himself, but of which he has never, so far as I am aware, published the details. Hegar^* and Engelmann^^ have respectively given tables of the operations hitherto performed. In these tables, however, they both register a series of cases which ought not to be included in the same category. They include, namely, cases where only one ovary was removed. ^ Transactions of the American Gynecological Society, i. and ii. ^ Remarks on Battey's Operation in British Medical Jov/rnal. 1877. 3 American Journal of Obstetrics, October 1876. * Ibid., July 1878 ; and Transactions of American Gynecological Society, ii. ^ Transactions of American Gynecological Society, i. « Ibid. 7 Atlanta Medical and Surgical Journal, September 1874. ^ Referred to by Engelmann. ^ American Journal of Obstetrics, July 1878. ■'*' See Hegar, Die Kastration der Frauen, 126. ^^ Berliner Klinische Woclienschrift, 1878, No. 15. ^2 Die Kastration der Frauen, Buda-Pest, 1878. For a copy of the reprint from the Pester Mediz.-Chirurg. Presse, I am indebted to the kindness of Mr. Joseph Bell. ^^ In his interesting lectures on " The Diagnosis and Surgical Treatment of Abdominal Tumours," British Medical Jourrial, 85. 1878. " Op. cit., 126. ^^ Ainerican Jour Tial of Obstetrics, 472. July 1878. U 3o6 ~ Ovary. Now although various operators, and amongst them Battey himself and Dr. Marion Sims, stopped short with the removal of a single ovary, their operation could not have the value and effect of the extirpation of both the ovaries. Whatever idea may have guided the operator in removing one ovary alone, and whatever results may have followed from the operation, all such cases ought decidedly to be eliminated from any table that will serve to guide us to a due appreciation of the value of the operation which Battey first successfully carried out — the double oophorectomy. I exclude even from the Table such cases as the historical one of Pott or the more recent ones of Esmarch and others, where the dislocated ovaries of both sides were excised from hernial sacs. This Table is thus purely a register of the genuine cases of double oophorectomy, thirty-five in number, to which I have had access, or to which I find a reference. After considering II. The Object of the Operation, we shall be able, from a study of the table, to see III. The Indications for the Operation ; IV. The Eesults ; and V. The Methods of conducting the Operation. II. — OBJECT OF THE OPERATION. The object of the operation is to arrest the cyclical changes to which women are subject, by removal of the organs in which the supreme phenomenon of the monthly period occurs. Whatever may yet be discovered as regards the nervous centres that dominate the menstrual flows and ebbs, it seems to me that we are clearly entitled to regard all the other phenomena as dependent on the ovarian changes. Despite the adverse or doubtful opinions of St. Hilaire, Klebs, Beigel,^ and others, and the seemingly adverse ' Pathologisclie Anatomic der weiblichen Unfruchtbarkeit, 70. Braunsch- weig, 1878, Object of Oophorectomy. 307 observations of Slavjansky/ I believe I express not only the opinion of the best emmenologists, but the true position of the best emmenology, in stating ^ that the central spring of menstruation is to be found in the ovaries, and more especially in the successive development of individual ovisacs. Battey^ and Hegar,* in their respective essays, have both collected cases enough from the records of the ovariotomists to show that removal of the ovaries is usually followed by cessation, more or less speedy and complete, of the menstrual discharge. Where patients have continued to be the subject of haemorrhages from the genital fissure, after having been operated on for removal of both ovaries, the discharges may be truly catamenial. In that case, either (1) the operator has removed not an ovarian but some other tumour, and one or both ovaries may have been left ; or (2) one of the ovaries has been only partially removed; or (3) the patient may have been the subject of three ovaries, such as are figured in Winckel's Patliology of the Female Sexual Organs,^ and such as I saw in a preparation brought before the meeting of the German Naturalists and Physicians in 1878, by Kocks. Again, such haemorrhages may not be catamenial at all, but dependent on the presence of polypi or other morbid changes in the uterus. And, again, when a woman who has thus been operated on alleges that she is menstruating regularly, Hegar^ warns us that she may really have no discharge at all, but fears that the admission of the truth will bring a slur upon her womanhood. ^ Archives da Physiologic. 1875. 2 " Emmenologia," ,t7'oiM'n«Z of Obstetrics for Ch'cat Britain and Ireland for 1875-6, 682 ; and Transactions of Edinhw-gh Obstetrical Society, iv. 186, 187. ^Normal Ovariotomy, Atlanta, Georgia, 11-14. * Op. eit., 64-74. '^ Die Pathologic dcr weiblicJicn Sexual- Orgaiie. Leipzig, Erste Lieferung, Tafel xxxiv. « Op. cit., 92. 3o8 Ovary. Table of Tlurtij-jive Cases of Douhle Oojjilioredomrj. No. and Opera- tor's Name. Indications for Operation. Incision Immediate conse- quences. Remote conse- quences. 1. Battey Amenorrhcea ; severe menstrual Abd. Prolonged convales- Great improve- molimina ; epileptic convul- cence ment sions ; vicarious bleeding ; fre- quent pelvic cellulitis 2. „ Continuous ovaralgia ; insanity threatened Vaginal Rapid 'recovery Do. do. 3. , Ovaralgia ; dysmenorrhoea ; in- sanity threatened " Death — 4 Dysmenorrhaja and ovaralgia " Great improve- ment 5. Since first child, metritis, cellu- ,, Bleeding severe, No improve- litis, irritable uterus stopped by ice ; cel- lulitis ; all ovarian tissue not removed ment G. „ DysmenoiThoea ; ovaralgia ; be- ginning menstrual disturbance " Death — 7 Atresia (vaginal) following a for- ceps operation ; severe men- strual molimina " Great improve- 1 ment 8. „ Dysmenorrhoea ; ovarian and ,, Ovarian tissue No improve- pelvic pain (right) not all removed ment 9. Hegar .... Fibroma uteri, with severe bleed- Abd. — Good result 10. „ ing Ditto ditto Ditto 11. „ Fibroid growing rapidly (lateral) Abscess and tedious convalescence Fair result 12 Fibroid and dysmenorrhoea Abd. (lateral) — Very good 13. „ Fibroid ; severe menorrhagia . . . — Death from septic peritonitis — 14. ,, Severe neuralgia ; daily hypo- dermic injections of morphia — Death — 15. „ Retroversio uteri fixed by adhe- sions ; perimetritis — — Good 10. , Dysmenorrhoea ; cystitis ; nerv- ous disturbance Abd. (lateral) — Good 17 Dysmenorrhoea ; irregular men- struation Abd. — Good 18. Engelman... Gastric and bronchial hystero- neuroses " Died — 19. Ovaralgia increased by slightest exertion ; epileptiform attacks " Died — 20 Ovaralgia, dysmenorrhoea, ova- rian pain, and constant pelvic pain " Died 21. Goodell.... Fibroid Vaginal — Cure complete 22. „ .... " Pernicious" menstruation.... — — Somewhat im- proved 23. „ .... Ditto ditto ,, Died — 2-1. Thomas . . Ovaralgia; dysmenon-hoca ; pctil Tiial '• — Somewhat im- proved 25. Trenholme Uterine fibroids — — Cure complete 26. Peaslee Absence of uterus ; amenorr- hrea ; pain in coitu ; hystero- epilepsy Died 27. Gilmore . . Atrophy of uterus ; Amenorr- hoea ; cerebral congestion Abd. — Cured (?) 28. Pallen .... Dysmenorrhoea ; ovaralgia Died — 29. Kaltenbach 80. Freund Uterine tumour ^ Died Died — Fibromyoma .31. Sims Ovarian pain and retroversion. . — Died — 32. A. Martin . . Filiroid — — Good 33. „ 34. TanfTer .... Fibroid Abd. — Good Cure DysmenoiThoea 35. A. R. Sinip- .son Dysmenorrhoea, etc " Good Indications for Oophorectomy. 309 III. — INDICATIONS FOR THE OPERATION. The indications cannot be grouped together according to the pathological condition of the ovaries, which, in most instances, have been the seat of inflammatory changes, and of which the one may be found fixed with inflammatory adhesions, while the other is healthy and free. Various forms of suffering have usually been conjoined in the same patient ; but when we analyse the conditions which have been the warrant for undertaking the operation, we may group them under three divisions. 1. Dysmenorrho&a. — In the first and most frequent group of cases, the patient has been the subject of intense suffering, intolerable, intractable, and lasting for years, at each monthly period. Usually, there has come to be associated with this dysmenorrhoea, whether the seat of the suffering be more distinctively uterine or ovarian, the dyspepsia, the hysteria, the general ill-health that are due partly to the suffering, partly to the remedies used for its relief. In eighteen out of the thirty-five cases, this was the leading indication. 2. Menorrhagia. — Professor Trenholme of Montreal and Pro- fessor Hegar came independently to the conclusion that, in cases of uterine fibroids, with profuse menstrual hsemorrhage, where the strength of the patient was becoming reduced and her life endangered, it would give her the best chance of cure to remove the ovaries. They both put their idea in practice, the former^ in January 1876, the other^ in July of the same year. They have been followed in their practice by Preund, GoodeU, etc., and the results so far have been encouraging. Of the thirty-five patients, eleven were oophorectomised with the view of arresting excessive uterine haemorrhages. 3. Amenorrhcea. — The remaining cases do not lend them- selves so easily to a categorical group. They had only this in ^ Canada Lancet, July 1876 ; abstract in American Journal of Obstetrics, October 1876. 2 Op. cit., 92. 3IO Ovary. common, that the catamenial flow had never appeared, or had become lessened or altogether suppressed. This might be from congenital malformation of the uterus, as in Peaslee's or Gilmore's cases, or from acquired atresia vaginse, as in one of Battey's. But it was not the mere absence of the uterine flow in women, in whom yet the menstrual nisus and the ovular activity were sufficiently manifest, that formed the warrant for operative interference. To justify such a grave operation, there required to be added to this menstrual disturbance some grave constitutional disturbance, such as — a. Threatened Insanity, as in cases recorded by Hegar, Battey, and Thomas. h. Hystero-Einlepsy, and afterwards true Epilepsy, as in the interesting case of the late Dr. Peaslee ; or c. Convulsions, as in Gilmore's and one of Battey's patients. In all the cases as yet recorded, the resources of medicine and surgery have been taxed to the uttermost in behalf of the sufferers, before it has been suggested to them to submit to the double oophorectomy as a dernier ressort. All that is claimed for it is, that it forms an addition to our resources in cases of otherwise intractable suffering, where the patient has as the only alternative the prospect of a life of pain ; and in cases where her life is more immediately endangered by exhausting discharges, or her mind affected from nervous disorders dependent on the ovarian function. IV. — RESULTS OF THE OPERATION. These have to be considered both in regard to the death- rate and to the eff'ects upon the survivors. 1. Mortality. — The mortality attendant on the operation has as yet been high — startlingly high as compared with the recent successes of the ovariotomists. Of the thirty-five patients operated on, thirteen died, giving a mortality of one in 2.7. or 37.1 per cent, 2. Health of the Survivors. — Of the twenty-four patients who recovered, two are reported as having received no Results of Oophorectomy. 3 1 1 benefit; eleven, or 30 per cent., are stated to have been greatly improved; nine only, or 27 per cent., were fairly cured. The results thus far may not seem very encouraging, but I have no doubt they will improve, as has been the case with ovariotomy, as operators acquire more experience in the performance. V. — THE OPERATION. In carrying out the operation, different methods have been adopted as regards the modes of access and the modes of removal. 1. The Modes of Access. — There are obviously two direc- tions along fwhich the surgeon may proceed in trying to reach the ovaries. He may operate from below or from above. a. Elytrotomy. — In America, the operators have, in a con- siderable proportion of cases, reached the ovaries per vaginam. The vaginal operation seemed preferable, because the ovaries were close to the roof of the vagina, and easily accessible through an incision there, whilst the position of the opening was favourable for the free drain of any fluids, haematic or inflammatory, that might escape into the peritoneal cavity. There are, however, some drawbacks to the vaginal operation. These are as follows : — 1. The incision has to be made at the bottom of a canal which is sometimes too narrow to allow comfortable access to it. This difl&culty is all the greater in the case of the vagina of those dysmenorrheic females who have never borne children, and have not lived a married life. 2. The posterior fornix may not offer a surface extended enough to permit the length of incision that is necessary to let fingers and instruments pass up to the ovaries. This drawback becomes more impressive in cases where the ovaries are fixed up at the pelvic brim, and cannot be dragged easily down through the opening. 3. When haemorrhage occurs during the operation, the bleeding point is not easily caught, and the bleeding itself controlled. 4 The patient cannot 312 Ovary. •well have the advantage of antiseptic measures, which can only be imperfectly applied to a vaginal operation. h. Laparotomy. — In the greater proportion of cases, the ovaries have been got at from above, by cutting through the abdominal walls. ao.. By Single Incision. — Usually, a single incision has been made in the middle line, as in the common ovariotomy. hh. By Double Incision. — But in cases of large uterine tumours, where the ovaries are to be removed with a \T.ew of arresting their growth and checking their attendant haemorr- hage, it is sometimes better to make two smaller incisions, one over each ovary. Hegar was thus able to reach and remove both ovaries, in a case where they could not have been removed through a single larger aperture. I have my- self lately seen a patient with such a tumour; and if she ever be subjected to this operation, I am satisfied that it will be easiest and safest to attack the ovaries through two separate small openings at different parts of the abdomen. 2. The Modes of PLcmoval. — The experience gained in ordinary ovariotomy in securing and separating the pedicle is not necessarily applicable to this operation ; for here, on the one hand, we have not to do mth blood-vessels of such large calibre, and on the other, the body to be removed cannot be brought so far through the abdominal wound. The clamp is thus at once unnecessary and inapplicable. a. Tlie Actual Cautery, the use of which has been attended with such good results in many ovariotomies, could here only be apjjlied by means of the galvano-caustic wire ; and the galvano-caustic apparatus, the value of which I brought before the notice of this Society sixteen years ago,^ has the great drawback of being very difficult to keep in working order. h. The Ecraseur. — In some of his cases, Battey separated the ovary with an ecraseur, with satisfactory results ; but it might sometimes be difficult with it so to adjust the grasp of the * Edinburgh Medical Journal, xiv. 872. 1863. Oophorectomy. 313 chain that neither, on the one hand, should any of the vessels in the broad ligament be injured, nor, on the other, should any fragment of the ovary be left behind. c. It is only worthy, in passing, of historical note that, in one case where Battey failed to get an adherent ovary other- wise removed, he tore and clawed it away piecemeal with his finger-nail. d. The Ligature and Knife. — The best of all the means for securing the pedicle, before cutting it through with knife or scissors, seems to me to be the application of a carbolised silk ligature. I had been strongly impressed with its value from reading the results of the experience of my former pupil, Mr. Knowsley Thornton ;i and I employed it in the case of Miss K. with the most gratifying result. A question here suggests itself to me which I think worthy of a satisfactory solution. Is it necessary to cut off the ovaries after strangulating their pedicles ? It would be a great comfort to be able to close the abdominal wound with the absolute certainty that no internal haemorrhage could occur ; and this certainty we should have if we could arrest the ovarian activity by simply cutting off the blood-supply with a ligature. Experiment alone can determine what the result of such a simple application of the ligature would be ; whether, for instance, it might give rise to a gangrenous or inflammatory condition, such as we see occasionally in ovarian cystomata, where the pedicle has become twisted, and such as might introduce an element of danger ; or whether, on the other hand, the capillary circula- tion might not so far keep up the vitality of the organ, that some of the ovisacs would continue to grow and pass through their cyclical changes. We know that structures of simple connective tissue can live on beyond the noose of a firm ligature ; but it has yet to be determined whether a glandular structure like the ovary can live on in such circumstances, and retain any functional activity. Perhaps we could not ^ British Medical Journal, 125, January 26, 1878 ; 594, October 19, 1878. 3 1 4 Ovary. thus safely bring to an end the life-history of the ovisacs, while the connective tissues of the stroma retained their innocent vitality. The question would not be difficult of solution. Indeed, it might by this time have been solved, if our legislatures had not laid an arrest on scientific investi- gation by passing an Act worthy of the dark ages. OVAEIOTOMY CASES.i During a discussion of a case of Ovariotomy, at a meeting of the Edinburgh Obstetrical Society, on June 14, 1876, I remarked that I had seen most of the well-known ovarioto- mists of Britain at work, and had seen the pedicle treated in various ways, and had come to the conclusion that, apart from the favourable condition of the individual case, the success of the operation depended less upon the choice of any particular method of dealing with the pedicle, than upon the care with which each step of the operation was carried out, and the subsequent treatment of the patient conducted. I have operated thrice. In the first case I operated only at the urgent desire of the patient, who was beginning to sink after a second tapping. There were, as I had anticipated, very extensive adhesions, which made the removal of the tumour very difficult and tedious. The pedicle was clamped. The patient died of peritonitis in three days. In the second case all the conditions were entirely favourable. The tumour was easily drawn out through a short incision. The pedicle was seared, and the patient recovered without a drawback. In the third case the adhesions to the abdominal parietes were pretty extensive, though no vessels of any size were divided during their separation. I had hoped to secure the pedicle ^ Transactions of the Edinburgh Obstetrical Society, iv. 273, 1876-77 ; and Edinburgh Medical Journal, xxii. 647. Cases of Ovariotomy. 315 with the cautery, but after careful searing, when the clamp in which the pedicle had been caught was relaxed, oozing of blood occurred, and I was obliged again to clamp it. That patient had also recovered without ever showing any local distress or any febrile reaction. When the hcemorrhage could be arrested by means of the cautery it certainly gave very satisfactory results, and the use of it was free from some of the distress and anxiety attendant on the employment of the clamp. At a meeting of the Edinburgh Obstetrical Society, on May 28, 1879, I showed a preparation of an Ovarian Cyst, and stated that I had, since the previous statement, operated in two other cases successfully. In one there were very extensive, and, at some parts, inseparable adhesions. In both the pedicle and the other structure that had been cut through were ligatured with carbolized silk and dropped back into the peritoneal cavity. I expressed my belief that the ligature would probably be found the best means of treating the pedicle, and the one most generally appHcable in all cases. PELVIC HEMATOCELE.! At a meeting of the Edinburgh Obstetrical Society, on June 12, 1878, I showed the preparation from a case of Pelvic Hematocele which I had had under observation in my ward in the Infirmary, The patient, a quadroon, set. 21, puella publica, had had a child nine months pre\dous to her ad- mission, which only lived three hours. She had been syphil- itic for several years. Menstruation was irregular ; but she had missed her period so distinctly four months before admis- sion that she thought she might be again pregnant. She had, ^ Transactions of the Edinburgh Obstetrical Society, v. 140, 1877-78 ; and Edinburgh Medical Journal, xxiv. 267. 3 1 6 Ovary. however, irregular discharges of blood, and began suddenly, in the end of February, to have intense pain in the abdomen, nausea, and vomiting, with alternate heats and chills. She was admitted on 9th March with great abdominal tenderness and tympanitis, and a dull swelling, rising to within an inch of the umbilicus ; vagina hot and tender ; cervix uteri low, and OS patulous ; all the vaginal roof filled in with a hard mass, which was continuous with the supra-pubic swelling, and in which the outlines of the uterus could not be felt. The whole was very sensitive. Pulse 126 ; temperature 103°. A sedative and expectant treatment had been adopted. The swelling had become very much reduced and the general con- dition improved, till on 1st April the patient had an attack of pneumonia, after which she grew rapidly worse, and after passing some bloody stools on two successive days, she died on 15th April. At the autopsy there had been found very extensive peri- tonitis, the inflammatory deposit on every abdominal organ ; the peritoneal surface stained of a dark colour as high as the umbilicus in front and up to the kidneys behind ; the intes- tinal coils matted together ; a perforation near the lower end of the small intestine ; a quantity of grumous blood in a cyst in the right lumbar region, and a still larger quantity in the pelvic cavity, which was a mass of putrilage, with the outlines of the various organs destroyed and decomposing. No trace of an ovum could be found, but the right ovary was enlarged, and presented a ca^dty that might hold a filbert ; and at the right side of the fundus uteri there was a perforation through the walls, wide as a shilling, on the peritoneal surface, but narrowing towards the cavity of the uterus till it was just sufficient to pass a sound. It was the first fatal case I had seen in the ward, all the others having recovered, usually under an expectant treatment. Method of Case-taking in Gynecology. 317 METHOD OF CASE-TAKING IN GYNECOLOGY.^ OEYEEAL years ago Professor Grainger Stewart prepared a printed scheme for the guidance of his clinical clerks in " taking " their cases, and his example has been generally followed among the physicians and surgeons in the Eoyal Infirmary of Edinburgh. Dr. Emmet of New York has given in his recent work^ an interesting form for recording cases of disease in the pelvic organs of the female ; and I have met with other schedules for guiding the record of such cases. Not being satisfied, however, with any of them, I have lately drawn up a method of case-taking for the immediate purpose of guiding the clinical clerks in keeping records- of gynecological cases in the Buchanan "Ward. It occurred to me that it might interest the Fellows of this Society to have the opportunity of dis- cussing it ; and in submitting it now to their notice, I shall be glad of any suggestions for its improvement. It is printed in the form of a double card with two columns. On the left-hand page or column are noted the points regarding wliich information is to be gained from the anamnesis or recollection of the patient. An experienced practitioner in this as in other departments of medicine has learned how to draw from the patient a few facts of her ^ Edinburgh Medical Journal, xxv. 673, 1880 ; and Transactions of the Edinhiirgh Obstetrical Society, vol. v. - Principles and Practice of Gynecology, 58. Loudon, 1879. 3 1 8 Method of Case-taking in Gynecology. history that giiide him to the seat of mischief, and may even give him a fair impression as to its probable nature ; but the student who is learning to investigate, requires to have some such chart as this to guide him in his inquiries ; and it may even prove helpful sometimes to the skilled practitioner who wishes fully to investigate and keep a record of liis cases. DISEASE— ANAMNESIS. 1. Name ; Age ; Occupation ; Residence ; Makried, Single, or Widow ; Date OF Admission. 2. Complaint and Duration of Illness. a. Genera l History of (o) Present Attack ; (f/) Previous Health ; (c) Diathesis ; (d) Social Condition and Habits ; (e) Family- Health. 4. Sexual History. (1) Menstnmtion — A. Normal — (a) Date of Com- mencement ; (b) Type ; (c) Duration ; (rf) Quantity ; (e) Date of Disappearance. B. Morbid — (a) Amenorrhea ; (6) Menorrhagia; (c) Dys- menorrhoea. (2) Intermenstrual Discharge — («) Character ; (6) Quantity. (3) Pareunia. (4) Pregnancies — (a) Number ; (6) Dates of First and Last; (c) Abortions ; (d) Character of Labours ; (e) Puerperia ; (/) Lactations. 5. Local Functional Disturbances of — (a) Bladder ; (b) Rectum ; (c) Pelvic Nerves and Muscles. 6. General Functional Derangements OF — (ci) Nervous System ; (h) Respiratory System ; (c) Circulatory System ; (d) Digestive System ; (c) Emunctories. PHYSICAL EXAMINATION. 1. General Appearance and Configura- tion. 2. Mammae. 3. Abdomen — (a) Inspection ; (b) Palpation ; (c) Percussion ; (d) Auscultation ; (e) Menstruation. 4. External Pudenda. 5. Per Vaginam — (a) Orifice ; (6) Walls and Cavity; (c) Roof; (d) Os and Cervix Uteri. 6. Combined Examination — (Abdomino- vaginal, Recto-Vaginal, Abdomino- Rectal, Abdomino-Recto-Vaginal, Abdo- mino-Vesico-Vaginal) — (1) Vterus (a) Size; (6) Shape; (c) Consistence ; (d) Sensitiveness ; (c) Position ; (/) MobUity ; {g) Relations. (2) Fallopian Tubes. (3) Ovaries— (a) Size ; (6) Situation ; (c) Sensitiveness. (4) Peritoneum and Cellular Tissue. (5) Bladder. (6) Rectum. (7) Pelvic Bones. 7. Use of — (a) Speculum ; (b) Volsella ; (c) Sound ; (d) Ciirette ; (e) Aspiratory Needle ; (/) Tent or Dilator. 8. Physical Changes in — (a) Nervous, (b) Respiratory, (c) Circulatory, (d) Diges- tive, (e) Emunctory Organs. DIAGNOSIS. PROGNOSIS. TREATMENT. PROGRESS AND TERMINATION. Every case will not, of course, demand inquiry regarding every point registered in the several paragraphs. But on the other hand, any case that comes before us may demand inquiry as to any of these points. And it is well in the history of each case to get information as to some of the sections of Sexual History in paragraph 4. It is important, Method of Case-taking in Gynecology. 3 1 9 for example, to get all the information possible concerning menstruation. It is only by getting the reliable history of the date of its commencement in a large series of cases that we arrive at a determination as to the normal date of puberty. Hence, under the heading of Normal Menstruation, sug- gestions are made for inquiry into this and the other important characters of the natural function. Under the heading of Morbid Menstruation attention is turned to the three directions in which it is liable to be modified : amenorr- hoea suggesting all the varieties of diminution up to complete absence of the flow ; monorrhagia, the varieties of increased discharge ; and dysmenorrhcea, the cases where the period is attended with pain before, during, or after the flow. The second section of the Sexual History has regard to the discharges of various kinds that may occur during the inter- menstrual periods. These have sometimes been ranged under the general category of leucorrhoea, but they vary from the clear albuminous discharge of a uterine catarrh, through the mucous, purulent, creamy, and flocculent discharges of chronic vaginal and cervical inflammations, to the watery, sanious, foetid, fsecal, and urinary discharges attendant on more grave disorders. These are such frequent accompani- ments of uterine disease that inquiry as to their character and quantity in most cases becomes imperative. The third paragraph, on the other hand, will more rarely require to be referred to. It is only in some cases of disease among married women that we meet with "the condition of difficult or painful performance of the sexual function," for which Barnes has supplied us with the very convenient designation Dyspareunia. I have given a place to inquiry regarding Pareunia, because, though the range of cases to which it applies is limited, I agree with the opinion of Dr. Barnes,^ that " dyspareunia in the female is perhaps the most absolute of all the indications of local malformation ^ Clinical History of tJie Medical and Surgical Diseases of Womtn, 65. London, 1878. 320 Method of Case-taking in Gynecology. or disease. It calls the most imperatively for local examination as to its cause. In its milder forms it may make the sufferer's life a course of physical and mental wretchedness; in its severe forms it virtually unsexes her ; and in any form it may lead to the most disastrous social calamities." Kehrer, in his recent very interesting contribution zur Sterilitdtslehre} gives a proportion of 4"1 per cent, of cases of sterility in the female due to vaginism^^s, which, as he points out, is but one of the forms of dyspareunia. The necessity for enquiry into the history of the patient's Pregnancies impresses us when we consider how frequently the results of them, whether terminated prematurely or at the full time, give the first impulse to both acute and chronic maladies. And the investigation can never be complete without enquiry into the functional disturbances of the other pelvic organs, and usually into the more general derange- ments of distant organs and systems of the body. The right-hand page or column gives suggestions for con- ducting the Physical Examination of the patient. It in- dicates both the subjects that chiefly require investigation, and the means to be employed in bringing the senses of sight, hearing, and, above all, touch, to bear upon the organs to be explored. Here also there may seem to be some points suggested for examination that are of minor importance, and methods of exploration indicated that it will rarely be necessary to have recourse to. Still every experienced gynecologist will recognise that points which in general are of trivial import, may in certain cases demand very special attention : and even the methods of exploration which are rarely had recourse to, must be registered to remind us of their importance in certain morbid conditions of the pelvic organs. It may be necessary to note the general appearance and configuration of the patient, the condition of the mammae. ^ Beitrdge zur KUnischcn und experivwntcllcn Gehurtskuvdc tind Gynoc- kologie, ii. 127. Giessen, 1879. Method of Case-taking in Gynecology. 32 1 and changes in the external pudenda. More important in general is the investigation of the abdomen and the vagina ; and the modes of their examination, or the points about them requiring attention, are more fully indicated. The largest space, however, is devoted to the combined examinations by palpation through the abdominal walls, and exploration through the pelvic outlets. This combined examination, especially the abdominal-vaginal, gives by far the most complete and satisfactory results of all the methods of ex- ploring the conditions of the pelvic organs; and, after one has acquired experience in the employment of it, he begins to feel that he can often dispense with all others. To educate himself, however, every practitioner must learn the use of the various aids to sight and touch which are indicated in the seventh paragraph; and to the last the wise practi- tioner will often do well to correct or confirm the impression he has gained from the combined examination by making use of one or other of the instruments which are so helpful in gynecological investigations, and the introduction and im- provement of which have constituted the most important advances in this department of medicine. An eighth paragraph reminds us that we must not as speciaKsts limit our view to the condition of the sexual apparatus, but be prepared to recognise and record physical changes in other systems and organs of the body. Schultze, Spencer Wells, Beigel, and others, have given outline sketches of the abdomen and pelvic cavity and organs, with the purpose of presenting more graphically any changes that occur in the relations of these organs to each other, or to tumours or effusions that may be found among them. The progressive growth of tumours, or the progressive diminution of effusions, or changes in position of the pelvic viscera, can thus be more distinctly registered. I am furnishing the clinical clerks with the three accompanying diagrams. 32 2 Method of Case-taking in Gynecology. Fig. 43. Frokt View of Abdominal Surface, showing Regions: — Right Hypochondriac. Epigastric. Left Hypochondriac. Right Lumbar. Umbilical. Left Lumbar. Right Iliac. Hyiiogastric. Left Iliac. Fig. 44. Outline Vertical Section of Female Pelvis. u, indicating the orifice of the Urethra ; \\ Vagina ; a, Anus. Fig. 45. Outline View of Pelvic Brim, seen from above, showing position of m, Uterus, and 0, Ovaries, when the bladder is well filled. Easily sis. 323 BASILYSIS: A SUGGESTION FOR COMMINUTING THE FCETAL HEAD IN CASES OF OBSTRUCTED LABOUR.^ T ITTLE more than twenty years have passed since British obstetricians began to waken up to the consciousness that they were behind their Continental brethren in their manner of reducing the size of the foetal head in cases of labour obstructed from contraction of the pelvis. Since the days of Smellie little change had taken place in the method of carrying out the gruesome operation. Some mechanical improvements had been effected in the make of the instruments. Early in the forties^ Sir James Simpson furnished the profession with a modification of Naegele's in- strument, which left nothing to be desired for easily and effectively perforating the cranial vault. Davis, Lyon, Murphy, Ziegler, and others had contrived various forms of instruments for fracturing or cutting and removing the bones of the cal- varium, so as to reduce the head to the utmost limit. But that was all. The general teaching and practice in regard to the whole procedure might have been summarised in a single sentence — that after a sufficient opening had been made in the arch of the skull, and the flat bones had as far as possible been fractured and removed, what remained of the head must be dragged out by hook or by crook. The base of the skull — its hardest, most unyielding part — was left unaltered. On the Continent, in 1829, the younger Baudelocque had proposed the use of his cephalotribe for crushing the head in ^Edinburgh Medical Journal, April 1880 ; and Tra'tisactioiis of Edinlmrgh Obstetrical Society, vol. v. - On consulting the Minute-Book of the Edinburgh Obstetrical Society, I lind that he showed it at a meeting held on April 26, 1842. 324 Easily sis. all its parts. His proposal met with a ready response, and speedily cephalotripsy superseded the older forms of cranio- tomy throughout both France and Germany. In Britain, however — alike in London, Edinburgh, and Dublin — the cephalotribe was regarded with disfavour, and the idea of its use was treated with something like disdain. Pupils of Sir James Simpson before the year 1858 may recollect how he would exhibit the bulky instrument of Baudelocque (see fig. 46) and the still more cumbersome Fig. 46. Baudelocque's Cephalotribe. apparatus of Kilian (see fig. 47) ; would tell how, in the only case in which he had tried to use it, the great machine had lost its hold; and would leave the impression on the class that the whole was a stupendous joke. Churchill,^ in his most popular of text-books on midwifery, even in his edition of 1866, concludes his remarks on the cephalotribe by saying, " It would require unusual hardihood to venture upon the latter instrument in private practice in this country." Murphy ,2 coupling the cephalotribe with Davis's osteoto- On the Theory and Practice of Midwifery. London, 1866. Lectures on the Princiiylcs and Practice of Midwifery. London, 1862. The Cephalotribe. 325 mist, concludes that " the prima facie evidence seems against them ;" and referrino; to a cause celehre which he has detailed at length, he says, " Look at the cephalotribe, and ask your- FiG. 47. Kilian's Cephalotribe applied to the Fcetal Head in a Pelvis CONTRACTED AT THE Brim. — {KiUan's Obstetrical Atlas.) selves, How could that instrument be used in Elizabeth Sher- wood's case ? To me it seems impossible." Eamsbotham^ dedicates the last edition of his great work Obstetric Medicine and Surgery. London, 1867. 326 Easily sis. to Sir James Simpson, on a leaf which has on the back of it a motto from one of the Baudelocques, but he gives no hint that he knew of the existence of such an instrument as the cephalotribe. A survival of this strange indifference to the drawbacks of the old proceedings will be found in Professor Leishman's^ text-book, which gravely devotes a large part of its space, even in the third edition, to the discussion of methods that might well have been buried a decade ago in the pages of obsolete text-books, and, after echoing Murphy's remark about Elizabeth Sherwood's case, discusses the constixiction of cephalotribes from a point of view purely theoretical. When studying at various Continental schools in 1857-58, I was greatly impressed with the almost universal use of the cephalotribe. Busch at Berlin, Braun at Vienna, Scanzoni at "Wiirzburg, like their colleagues at other universities, might differ in their views as to the best form of cephalotribe, but none of them thought of reverting to the older craniotomy procedures. Having come to the conclusion that the Scanzoni instru- ment was the best, I went to his instrument-maker in Wiirz- burg to procure one. He did not happen to have any in stock ; but Professor Scanzoni was good enough to allow me to take away the one (see fig. 48) which he had in his own Fig. 48. ScANZONi's Cephalotribe. possession for several years, and had employed in ten or a dozen cases. I brought it home to my uncle in July 1858, ^ A System of Midwifery. Glasgow, 1880. The British Cephalotribe. 327 and he at once recognised that it was free from some of the drawbacks of the cephalotribes he had previously seen. In the following October he was called out during the night to a difficult case. He carried with him his usual armamentarium, in which the cephalotribe had not as yet found a place. The result is recorded in his Clinical Lectures} After perforating the head in the usual way, and further comminuting it with a pair of Murphy's forceps, he left the case for some hours to the efforts of nature. When we went back to the patient in the morning, expecting to apply the cephalotribe, the head was found to have already passed through the brim, and the labour was terminated without any further crushing of the foetal head. This case having led, as he has explained in his lectures, to the invention of cranioclasm and the cranioclast, his attention was for a few years diverted from the use of the cephalotribe, and his mind was disposed rather to dwell upon its drawbacks. In 1861 he showed to this Society a head which had been left in the cavity of the uterus after the trunk had been cut from it, and which he succeeded in extracting with great Fig. 49. Simpson's Cephalotribe. comfort with Scanzoni's cephalotribe. ^ This made him feel that he had not yet fully appreciated the value of the instru- ment. Soon afterwards he satisfactorily delivered with it a woman with a contracted brim ; and as I had further proved ^ On Diseases of Women. Edinburgh, 1872, p. 531. 2 Edinburgh Medical Journal, viii. 282. 328 Easily sis. the value of the instrument in two similar cases — one in the practice of Dr. Milne, the other in that of the late Dr. Andrew Inglis — he set himself to the construction of a cephalotribe which might prove itself as serviceable as Scanzoni's, and which might at the same time, by its smaller bulk and more easy management, commend itself to British practitioners. Hence the instrument (see fig. 49) which he exhibited to the Society in 1864, and with which the Fellows of this Society are sufficiently familiar. In that or the following year I took it with me on a visit to Dublin, and showed the new instrument, among others, to Dr. Kidd. In 1866 that distinguished obstetrician read a communication on the subject to the Dublin Obstetrical Society,^ and made suggestions for modifying the form of the instrument. In October of the same year Dr. Braxton Hicks called the attention of London obstetricians^ to the value of the cephalotribe, and proposed the use of a very serviceable modification of the instrument to which Simpson had given a British cast. From this point the Simpson cephalotribe, either in its original form or as modified by Kidd or Braxton Hicks, has come into more and more general use among British practitioners. Curiously enough, in the meantime, Simpson's cranioclast (see fig. 50) had been finding its way into obstetrical practice in Germany. Professor Braun of Vienna, who is probably Fig. 50. Simpson's Cranioclast. the most experienced, as he is certainly one of the ablest and most accomplished, of German obstetricians, recognising the importance of the new procedure, modified the instrument ^ The DuUin Quarterly Journal of Medical Science, February 1867. 2 Transactions of the Obstetrical Society of London, viii. 275. 1866. The Cranioclast. 329 with which Simpson had proposed to effect it. He enlarged the cranioclast, increased the curve of the blades, and added a screw apparatus to the handles to secure the grasp (see fig. 51). The results of his experience with the cranioclast were pub- lished by his assistant. Dr. Carl Eokitansky.^ These 'con- trasted so favourably with the record of cases terminated with the cephalotribe that very soon in other German schools cephalotripsy began to be supplanted by cranioclasm. The controversy there is not yet at an end as regards their relative value. In the discussion at the Gynecological CongTCss at Munich in 1877, Cr^d^, Olshausen, Schwartz, etc., spoke in favour of the cephalotribe, whilst Spiegelberg, Muller,"Winckel, Fig. 51. Beaijn's Ckanioclast. (Figure relatively too large.) etc., stood up for the cranioclast. The rapidity with which the cranioclast was received into general favour in Germany may be gathered from the circumstance that in Canstatfs Jahresbericht for 1874,^ the reporter, in recording the title of a paper on a new form of cephalotribe, quietly says, " 1st erledigt, wie alle cephalotriben, durch C. Braun's cranio- clasten." In one of the most discriminating papers on the subject, Professor Fritsch^ concludes that the cranioclast is the most universally applicable of all the instruments for crushing and extracting the f cetal head. ^ Wiener Mcdicinische Presse, No. 8-19. See CmistaU's JahresbericM, 592. 1871. 2 11., 812. 3 Dcr Kcphalothryptor mid Braun's Kranioklast j Volkmann's Sammlung, Xo. 127. 1878. 330 Easily sis. My object, however, in the present communication is not to weigh the respective merits and demerits of cranioclasm and cephalotripsy, but to inquire whether there may not be another operative procedure wliich will supersede them both. If we consider more closely the operation for lessening the foetal head, it is best to divide it into three stages of — I. Perforation ; II. Comminution ; III. Extraction. I. — PERFOEATION. The opening in the presenting part of the calvarium may be effected by means of a trephine, straight or curved, such as is so commonly employed in Germany ; or the perforator with a scissors or lance-head point may be employed, as with us. My experience with the trephine lets me understand why Schroeder says,^ " To us the use of the scissors-shaped perforator seems in general to deserve the preference." In every case where I have used Sir James Simpson's perforator (see fig, 52) I have easily succeeded in effecting as thorough a fracturing of the cranial vault as could be desired. In one case of not too contracted pelvis, where the foetus was already some hours dead, after one or two fragments of bone had been lifted out of the margin of the large aperture, the head was Fig. 52. Simpson's Perfokator. found to be so collapsed as to allow of its being drawn through the pelvis by means of two fingers passed within the skull, while the action of the uterus was supplemented by the liands of an assistant pressing the foetus from above. In the great run of cases, however, the diminution of the head is not ^ Lehrhuch dcr Gehurtshulfe, 342. Comminution of Fcetal Head. 331 sufficient to allow of its extraction through, the canals, and it becomes necessary to have recourse to some kind of further II. — COMMINUTION. Ever since I was called to the Chair of Midwifery in our University, I have been in the habit of explaining to my students that there are five different methods by wliich the necessary diminution of the foetal head may be attempted, which are represented by the five expressions — 1. Craniotomy ; 2. Cranioclasm ; 3. Cephalotripsy ; 4. Cephalotomy ; 5. Trans- foration. 1. Craniotomy. — The older craniotomy procedures and apparatus could be very summarily dealt with. It was enough to demonstrate some of the hooks, crotchets, and forceps, and to indicate the rules for their employment drawn up by Sir James Simpson thirty or forty years ago. In a large class of students it is always possible that there might be one or two who would begin their professional career as assistants to practitioners who had not seen the need of furnishing them- selves with more efficient implements. But the time is near when the whole category of them, with rare exceptions, wiU be laid to rest, perhaps to rust, in our obstetrical museums. For, if I may borrow a comparison from the rather too popular game of war, the crotchet, when compared with the cephalotribe or cranioclast, has about the same relative value for the purpose of saving the lives of poor women in labour as the old Brown Bess has, when compared with the Snider or Martini-Henry rifle, for killing their hus- bands in battle. 2 and 3. Cranioclasm and Cephalotripsy. — I confess I have not been able to come to a definite decision as to the relative value of the cephalotribe and the cranioclast. The inevitable elongation of the head in a direction opposed to that in which it is compressed by the blades always seems to me a serious drawback to the value of the cephalotribe. The extraction of the head in accordance with a scientific idea of the mechanism 332 Easily sis. seems in such a condition next to impossible. Hence I have been inclined always first to try the cranioclast, but have found that when the head was still very movable above the brim the cephalotribe took hold and crushed it in a case where it was more difficult to get a satisfactory grasp with the cranioclast. At the same time, I believe the obstetricians are right who hold that the cranioclast is applicable, and may be successfully employed, in extracting the head through a pelvis too con- tracted to admit of the use of the cephalotribe. And I am sure that wherever the head has in the least become fixed at the brim, the cranioclast, which first fractures some of the basal bones, afterwards, during extraction, favours the natural mechanism and moulding of the head. As Wiener^ hints, some of the failures that have been experienced in the use of the cranioclast have risen from the operator not having clearly apprehended the principle of its action and closely followed Sir James Simpson's instructions for its employment. The adaptation of a screw apparatus, such as has been applied to it by Braun and Barnes, will doubtlessly make it more efficient both as a compressor and tractor ; but in the employ- ment of it I have always felt as if I had got a sufficient compression and traction power with a wet towel twisted firmly round the handles. It is important, in applying the soft towel or napkin, to fix a damp corner of it by a single turn round one of the handles, when the next turn, which passes round the other handle, gives as full a purchase for compression as could be desired. But whatever might be the relative advantages or disadvantages of the cephalotribe and the cranioclast, experience and science alike rendered it necessary to explain fully their construction and the principles of their application and working as the instruments by which, in the great proportion of impracticable labours, obstetricians could best accomplish the delivery. 4. CepTmlotomy. — Of the different methods of cutting the ^Archivfiir GynceJcologte, xi. 413, 1877 ; reproduced in the American Journal of Obstetrics, xi. 184, 1878. Transforation. 333 head in pieces I could only indicate, \st, that Belgian ac- coucheurs, following the lead of Van Huevel, had made frequent use of the Forcci^s-scie by which the head is sawn through from below upwards, and had reported results more favourable than those derived from the cephalotribe. But the instrument is very expensive, and has hardly met with any favourable regard out of Belgium. Then, 2cl, Dr. Barnes has proposed to reduce the head by passing round it the loop of a wire Ucraseur, and so cutting it through from above. But my impression regarding this suggestion has been, that in cases where it would be possible to apply a wire round the head of the child it would be easier to reduce it with cephalotribe or cranioclast. The same remarks apply to the analogous Diviseur cephalique of Joulin.^ ?)d, The Lahitom of Von Eitgen, which has a sort of a knife fitted on the cavity of each blade of a pair of forceps, for the purpose of cutting the foetal head from either side, is an utterly unpractical instrument; and although I brought a specimen home with me along with Scanzoni's cephalotribe, it was rather as an obstetrical curiosity than with any idea that it could ever be used in practice, and also because it has a joint of quite peculiar character. 5. Transforation. — There remained the fifth method of operating, which seeks to effect the diminution of the head by drilling holes in the basis cranii, or, as Gueniot^ expresses it, " sapping the sphenoid." It has always seemed to me that it is in this direction we must proceed to arrive at the ideal method of head-comminution. Scientific midwifery demands a dissolution of the bones at the cranial base : can obstetric art accomplish it ? Soon after Sir James Simpson proposed to attack the base by means of the cranioclast, one blade of which was to be passed within, the other outside, the perforated cranium, Professor Hubert of Louvain suggested to the Belgian Academy of Medicine, that the base should be broken up ^ TraiiA d' AccotccJiements, p. 1080. 2 Article Craniotomic in the Dictionnaire Ency eloped iquc dcs Sciences Medicalcs, xxii, 608. 334 Easily sis, from within. The essential character of his operation may be gathered from the designation which he proposed to apply- to it, of Sphenotresia. I was acquainted with the history and nature of the instruments which he invented for the purpose, and the rules for their employment, from his work on mid- wifery, which appeared in 1869.^ I was impressed with his startlingly favourable statistical results, but was detained from inquiring farther into the merits of the operation by the rather complicated nature of the procedure and of the instruments by which it was to be carried out. Perhaps, in regard to the latter point, I formed too hasty a judgment, and I think that I was all the more led to this conclusion from seeing the costly and cumbrous character of the apparatus of M. Guyon. For in 1865 M. Guyon had conceived independently the idea of effecting the dissolution of the basis cranii by a pro- cess which he described as Intra-cranial Cephalotripsy ; and had successfully put it in practice at the Hotel-Dieu in the end of the following year. A case containing his apparatus I found in the collection of the late Sir James Simpson, now in my possession. They consist (see fig. 53) of a long rod or stilette, A D, with cork-screw point, A, a, which is first fixed in the centre of the most accessible presenting part of the skull of the child. Its movable handle, d, has then to be removed, and the larger of two trephines, c, having been sKpped over it, the handle is readjusted to steady the disc which is removed by the crown of the trephine. Through the large opening thus produced in the vertex the finger is passed to explore the base of the skull and to guide the stilette to the sphenoid bone, which in its turn is transfixed. The smaller trephine, c, is now slipped over the stilette, and worked so as to saw a disc out of the solid base. In this way the base may be drilled at two or more points. The head is now seized in the grasp of a pair of forceps, B, with blades as narrow and flat as those of the cephalotribe, but of slighter construction. The handles are very long, so as to give a leverage for compres- ^ Cours cV Accoxvchcmcnts par le Dr. L. J. Hubert. Louvain, 1869. Intra-cranial Cephalotripsy. 335 sion, and are kept closed after application and compression by a spring ratchet. Clearly it was not an apparatus which one could advise a young graduate to add to his obstetric equipment ; and I regret that it did not even occur to myself to make a trial of it until lately. The patient in whom I used it is a small, slenderly -built woman, with a universally and unequally contracted pelvis, having an external conjugate or Baudelocque diameter of 5-| inches, and an internal conjugate i Fig. 53. GtnroN's Apparatus for Intra-cranial Cephalotripsy. diameter at the brim of 2\ or 2| inches ; the latter being esti- mated not only from measurements of the diagonal conjugate through the vagina, but of the true conjugate through the abdominal walls. In a previous labour, when Dr. Hart had tried to deliver her by turning, he had found it necessary to perforate the after coming head, and only effected the ex- 2>2,^ Basilysis. traction with great difficulty. On this occasion, when two holes had been drilled in the base with Guy on 's perforator, and the head was compressed between the blades, I could hardly believe my senses when I felt the head coming through the brim with the exercise of a force of only some five or six lbs. Dr. Hart, Dr. Caird, and Dr. Barbour, who were kindly assisting me, were equally astonished ; and while Dr. Caird was administering chloroform, the others had an Fig. 54. Side View of Head crushed by Guyon's Apparatus. opportunity of satisfying themselves that the head advanced under the uterine efforts; the instrument, wliich they each held in turn, merely serving to guide it through the parturient canals. It was in reahty only used as a tractor when the shoulders had to be dragged through the narrow brim. The head of the child, a male, has been left in the grasp of the forceps, that the fellows of the Society may see how completely it has collapsed under a smgle squeeze (see figs. 54 and 55). Fig. 55. Front View of Head crushed by Guyon's Apparatus. In showing the preparation to the Society I have ventured The Easily st. 337 to prefix this brief historical sketch, because it has led me up to the enquiry, Can we not produce an effective dissolution of the bones at the base of the skull by some contrivance less costly and cumbrous ? I believe the question will be answered in the affirmative. I am convinced that it should always be attempted, and I anticipate that soon in all such cases it will be accomplished. Until some better instrument be proposed, I have to suggest the use of a terebrator (see fig. 56) which bears more resemblance to Blot's perforator than to any other implement. A long steel rod, furnished with a wooden handle, terminates in a point which has a screwing surface of half an inch in length. At this distance from the point, a broad shoulder will prevent the point from passing Fio. 56. Proposed Basilyst. (Half opened.) further through the structures it is piercing. Along one of its sides the rod is excavated to receive a branch, which is jointed to the main stem about four and a half inches from the shoulder. When the instrument is being screwed into the bones, this will be buried in the rod, and enter with it. Pressure on its handle will then push it out, as the blade of a hysterotome is pushed from its sheath, and dilaceration of the cranial floor at the point of perforation must ensue. When the point is first being made to press into the base of the skull, the head may be steadied and fixed partly by pres- sure from above, but still more by traction from below, made either with the finger or a pair of forceps grasping the edge of the perforation, which must, of course, first have been made in the vertex (see fig. 57). That by such an instrument a very complete dissolution of the cranial base can be brought about, I have proved experimentally on the dead subject. Howsoever the loosening and fracturing of this most resist- ant part of the fcetal head be effected, the statistical figures Y . 338 Basilysis. of M. Hubert ^ should encourage obstetricians to the effort to contrive a procedure and an instrument as simple and inexpen- FiG. 57. Section of Defokmed Pelvis and Head of Foetus, with Point of Basilyst entekino (a) Basis Cranii. sive as possible. Here is one of his Tables, comparing the results of the cephalotribe, the forceps-scie, and the transforator : — Cephalotripsy, 170. Forceps-seie, 130. Transforation, 53. Deaths Per Cent. 41-17 Per Cent. 22-30 Per Cent. 11-32 Puerperal Accidents \ followed by Cure \ 20-58 1 26-15 15-09 Natural Lying-in 38-23 57-53 73-58 ^ See the Cowrs d' Accoiuihements of his son, M. Eugene Hubert, 243. Louvain, 1878. Extraction of Head. 339 When we begin to put it in practice, it will be desirable to have a distinctive designation for the operation. I have headed the fifth paragraph with the designation " Transfora- tion," the name adopted by Hubert when he found that the word Sphenotresia led to misconceptions as to the limits of the operation. But it will be convenient, at least, to have a designation that will be applicable to all kinds of disintegra- tion of the base, whether the disintegrator reach it through an opening in the vault, or be directly apphed to the base, as in the after-coming head. The Greek words, /3ao-tc and Au(r ; as indication for oophorectomy, 309. Dyspareunia, importance of, 319 ; case of, 284. Dystocia, from dorsal displacement of arm, 132. Ecraseur in fibroid tumours, 225 ; illustrative case, 229 ; in sarcoma uteri, 243 ; in amputa- tion of inverted fundus uteri for sarcoma uteri, 252, 261 ; in amputation of cervix for carcinoma, 264 ; in intra-uterine carcinoma, 270,271; method of application to cervix uteri, 278 ; in amputation of cervix for elongation, 284 ; in oophorectomy, 312 ; in cephalotomy, 333. Elongation of cervix uteri, treated by amputa- tion, 283. Elji;rotomy in oophorectomy, 311. Emmenologia, address on, 3. Emmet on case-taking in gynecology, 317. Emphysema, of abdomen in rupture of uterus, 159. Encephaloma uteri in a child, 273. Enoelmann, mineral waters in fibroid tumours of uterus, 214 ; oophorectomy, 305. Epitheloma of cervix uteri, 281. Ergotin, administration in abortion, 107 ; in fibroid tumours of uterus, 215 ; causes of fail- ure in action, 216 ; mode of administration, 217 ; in cardiac disease, 218 ; cases suitable for it, 219; mode of action, 219; producing expul- sion of tumours, 219 ; diminishing their size, 220; arresting their growth, 221; illustrative cases, 227. Esmarch, removal of dislocated ovary, 306. EuLENBERO ou goitre, 39. Extraction of comminuted fcetal head, 339. Extra-uterine gestation, usual issue, 16 ; cases of, 98. Fabbri on chlorate of potash in carcinoma uteri, 272. Fatty degeneration of fibroid tumours, 209. Fibroid tumours of the uterus, 207 ; frequency of, 207 ; influence on reproduction, 207 ; pathology and anatomical seats of, 208 ; natural tenninations of, 209 ; fatty degenera- tion of, 209 ; disappearance during puerperium, 210 ; calcareous degeneration of, 211 ; pedun- culation and extrusion, 211 ; free in abdominal ra\ity, 212 ; spontaneous enucleation of, 213 ; their treatment, 213 ; medicinal, by mineral waters, 213 ; by bromide of potassium and chloride of calcium, 213 ; by ergot of rye, 214 ; hypodermic injection of ergotin, 216 ; surgical treatment of, 222 ; by torsion, 223 ; cutting, crushing, or scratching, 223 ; use of nail-cu- rette in, 224 ; illustrative cases of, 227 ; sareo- matous degeneration of, 242. Flexion of head in labour, 116. FoDER^ on congenital goitre, 42. Fwtus, acardiac, 23 ; iutra-uterine .^nallpox in, 30 ; three-limbed acardiac, 30 ; intra-uterine peritonitis in, 34 ; congenital melanoma in, 36 ; congenital goitre in, 36 ; congenital ma- kronephria in, 52 ; cystoma renum in, 53 ; Index. 343 liydruneplirosis in, 54 ; muvements causing funic knots, (iO ; injuries during labour, 76, 81 ; mori;aIity in placenta previa, 81 ; anence- phalous causing liydramnios, 84 ; hydroce- phalic with spina biflda, 97 ; llexion of head, 116; intra-uterine attitude, 119; comminution of the head, 323. Forceps, use of Tamier's, 136 ; proper period of application, 146 ; mark on head, 128 ; turning rersJis, 164 ; application in universally con- tracted pelvis, 166 ; dangers of, in flat pelvis, 170. FoRSTER on congenital hydronephrosis, 54 ; on hydrorrachis interna cystica, 98. Freqnd, M. B., on congenital hydronephrosis, 56 ; on oophorectomy, 305. Fritsch on cranioclasm, 329. Funis umbilicalis, disease of vein, 66 ; exces- sive torsion, 66 ; knot formed during preg- nancy, 68 ; convolutions round limbs, 70 ; prolapsus, 141 ; relative frequency of pro- lapsus ill diflferent countries, 145 (note). Galvano-caustic wire in sarcoma uteri, 261 ; in carcinoma uteri, 271 ; in removal of cauli- flower excrescence, 280 ; for removal of epithel- oma of cervix uteri, 281 ; in oophorectomy, 312. Gastrotomy in rupture of uterus, 159. Gestation, usual length, 17 ; extra-uterine, 98 ; inteiTupted, 105 ; protracted, 138. GiLMORE on oophorectomy, 305. Glass on congenital hydronephrosis, 54. Goitre, congenital, 36. GooDELL on contracted pehis, 164 ; on use of volsella, 180 ; on oophorectomy, 305. Gravitation, influence on presentation of foetus, 116. Green on fibroma vaginse, 204. Greenhalgh on cauterisation of fibroid tum- ours, 222. Gremler on fibroma vaginae, 204. Grenser on the management of the third stage, 149 ; on sarcoma uteri, 241. GuENiOT on sapping the sphenoid, 333. GnssEROW on sarcoma uteri, 241. GuYON on intra-cranial cephalotripsy, 334 ; his apparatus described and figui'ed, 335 ; case in which tried, 335. Gj'necology, use of volsella in, 185 ; method of case-taking in, 317. Hffimatocele, pelvic, case of, 314. Hcemon'hage, remote results of, S3 ; source of, in placenta prtevia, 84 ; post-partum, 88 ; in abortion, 107 ; in fibroid tumours, 234 ; in sarcoma uteri, 257 ; in carcinoma uteri, 262 ; arrested by operative procedui-e, 265. Hai?morrhoids in a case of dysmenorrhoea, 296. Hair in an ovarian tumour, case of, 204. llAKLEY on congenital hydronephrosis, 56. Hart on primiparal placenta prajvia, 77 ; on the position of the os internum during labour, 163. Harvey on the normal period of gestation, 17. Hatin on hydramnios in twin cases, 93. Head, cause of presentation of, 116 ; movements of, 'in passages, 117 ; fle.xion of, 118 ; form ot, 123 ; measurements of, 127 ; markings on, 128 ; position and presentation in universally contracted pelvis, 165 ; in grasp of forceps, 167 ; position and presentation in flat pelvis, 168, 171 ; comminution of, 323 ; grasped by Kilian's cephalotribe, 325 ; by Guyon's appa- ratus, 336 ; perforated by basilyst, 338. Heart, fatty degeneration of, causing post- partum syncope, 89. Hecker on congenital makronephria, 53 ; con- genital hydronephrosis, 56 ; ann displace- ments, 133 ; prolapsus funis, 142. Hegar on frequency of abortion, 106 ; use of volsella, 187 ; sarcoma uteri, 241 ; oophorec- tomy, 304 ; on relation of ovaries to men- struation, 307 ; on fibroids with menorrhagia as an indication for oophorectomy, 309. Hennig on congenital goitre, 41. Hicks, Braxton, on carcinoma uteri, 262 ; on the cephalotribe, 328. HiLDEBRANDT on fibroma vaginae, 204 ; ergotin given hypodermically, 216 ; cases suitable for this, 216. HiLLiER on hydronephrosis, 55. HoNERKOPF on occlusion of the urethra, 60. Honing, histology of fibroma vaginae, 203. HoRNE on congenital hydronephrosis, 54. HowsHip on congenital hydronephrosis, 56. Hubert on sphenotresia, 333 ; statistics of re- sults of cephalotripsy, forceps-scie, and trans- foration, 338. Huevel, Van, on forceps-scie, 833. HuTCHiNsoK on sarcoma uteri, 240. Hydramnios in twins, 92 ; with anencephalous foetus, 94 ; with hydrocephalic fcetus, 97. Hydrocephalus, intra-uterine, causing hydram- nios, 97. Hydi'onephrosis, congenital, 54; causation of, 61 ; illustrative cases, 63. Hydrorrachis, complicated with hydrocephalus, etc., 97. Hjnnen, persistence of, producing sterility, 286 ; treatment of, 288. Hypodermic injection of ergotin, 217 ; case of fibroid tumour treated by it, 236. Hystero-epilepsy, as indication for oophorec- tomy, 310. Insanity threatened, as an indication for oophor- ectomy, 310. Inversion of uterus \vith sarcoma, 250; cause of, 255. 344 Index. Jackson, Hughlinos, on chorea, 100. Jacobs, histology of flhroma vaginaf, 203. JoBEET DE Lamballe on vesico-vagiual fistula, 183. Johnson, G., on hydronephrosis, 54. Johnson, Wallace, on delivery of placenta, 147. JouLiN on diviseur cephalique, 333. JouRDAiN on painless labour, 140. Kaltenbach on oophorectomy, 300. Kehrer on sterility due to vaginismus, 320. Keilleb on congenital goitre, 43. KiDD on the cephalotrilie, 328. Kidneys, iutra-uterine disease of, 02 ; hydrone- phrosis in adults, 61. KiLiAN on hydramnios in twin cases, 93 ; on the cephalotribe, 324 ; instrument flgui-ed, 325. Kiwiscn on abdominal emphysema in rupture of uterus, 159 ; on (ibroma vaginw, 201. liLEBS