A B S rl~ RAe T S .

SECTION OF OBSTETRICS. Friday, November 5, 1909.

The President, DR.

JELL}~TT,

in the Chair.

Exhibits. Multiple Myoma. DR. E. HASTINGS TWEEDY exhibited a specimen of multiple myoma' of the uterus. In such cases one would, if possible, perform a myomectomy. But in the case before them it would have been very difficult, as the uterus was absolutely riddled with tumours. It appeared as a smooth myomatous uterus, but on splitting it they could hardly see any muscular structure, and each of the two or three hundred myomas was absolutely distinct, some degenerating, some not. The patient had a temperature, and macroscopic specimens had the appearance of malignancy,. but Dr. Rowlette told him he could find no malignant disease. Wertheim's Operation. DR. TWEEDY exhibited a specimen of an ordinary Wertheim's operation in a girl about twenty-four years of age. There was very considerable ulcerative cancer spreading into the broad ligament. The operation went well until he began to remove the cervical part of the uterus. The cancer then broke away, and he got the end of the vagina. He was able to shut off the intestines, and the woman did not become infected. What was particularly interesting was that he traced up the ureter, and found that while the cancer spread above and below the ureter, it was not diseased. The ureter was so intimately associated with the cervix that in dealing with it one had to hug the cervix to

A bstracts.

313

avoid the ureter. He pushed down the bladder far into the vagina, and got his finger between the vagina and bladder. He worked the bladder laterally, and was able to dig the. ureter completely out of the cancer, and took away the microscopic evidence of the disease. That was three weeks ago. The patient had gone on very well until a week ago, when her temperature ran up, and a fcetid discharge arose. Though she could now hold a certain amount of urine in the bladder, still a quantity passed away, and he had no doubt he was now dealing with a ureteral fistula. In the majority of cases such fistulre healed spontaneously; but from the accounts which he had read on the subject he found that the ureter practically never became patent again. The urinary discharge would dry up. The ureter cicatrised, and the kidney ceased to secrete. They would get a hydronephrosis only so long as there was some fluid passing through the ureter. If they did not allow a drop to escape through the ureter, the kidney would not secrete urine; and his hope was that the cicatricial matter would absolutely occlude the ureter, and the kidney would become inert. 8TH V'l ILLIAM S~IYLY said ureteral fistula was a risk that anyone was liable to who undertook Wertheim's operation. Recently, when assist.ing in a case where the ureter had been cut accidently and \V here implantation into the bladder was impossible, he had persuaded the operator to ligature it with silk and fix it in the abdominal wound. In that case it was found necessary afterwards to extirpate the kidney. THE PRESIDENT OF THE )\.CADE~IY said he had once transplanted ... the ureter into the bladder, and as far as he knew no leakage occurred, and no obvious kidney tumour developed. He would be interested to see the result in Dr. Tweedy's case, as it was difficult to understand why hydronephrosis should not occur when the ureter was completely blocked whereas it occurred where the obstruction was only partial. DR. FITzGIBBON recalled a case of Sir Arthur Macan in which the urine continued to be secreted as freely as ever from the kidney belonging to the detached ureter, and showed no sign of cicatrisation of the cut end of the ureter, or blocking off of the kidney. DR. JELLETT said one could understand that there was a

314

Section. of Obstetrics.

"land of race between the function of the kidney and the destruc-tion of the substance by back pressure, and he would be inclined '-to think that hydronephrosis would result before the destruction -of the kidney substance.. DR. TWEEDY, in replying, said that he had in his remarks -exactly SUJDUled up the conclusions of the experiments that he had read, the last. being ITODl the Johns Hopkins Hospital within -the last six months. The ureter was simply cicatrised over, there was no patency, and the kidney ceased to secrete. Sir William .Smyly's case was not comparable with the condition of spontaneous healing. It was almost impossible to get the ureter to unite permanently by tying.

Pyosalpinx. DR. PUREFOY exhibited a specimen of pyosalpinx, which had .reached a very considerable size in a short time, and had arisen under circumstances which made its origin difficult to account for. The patient had been married several years, and was childless. She had lived abroad, and had had malarial fever and other illnesses incident to residence in a tropical climate. She carne under his care for a t.rifling catarrh of t.he uterns, and became, as -ne believed, cured. She went to the country, for a tew weeks, where she was attacked with what she thought to be malarial , lever, with severe abdominal pains and tenderness, On her return -to town it was quite easy on palpation to find a tumour taking its origin from some of the pelvic organs. He waited for six weeks before operating. On opening the abdomen a rounded liumour caine into view completely concealing the uterus, to which it was extensively adherent. In separating it, to his great -distress the sac ruptured, and a. quantity of pus escaped. He WaB, however, happy to add that the patient had an uninterrupted zecovery, There was no ground for thinking the condition to be -due to any gonorrhmal affection. There was no evidence of tubercular disease, still he took it that it originated in tubercular .salpingitis, She had no signs of tuberculosia, but her family .historv . was unfavoura ble. DR. TWE}4~DY said it seemed to him worthless to leave a uterus -that could be of no use when the tubes were gone. When a tube burst, and pus -flowed. into the pelvis, it was largely a matter of

Abstracts.

315

.chance if the patient would recover. If the pus was septic, he knew of no way to avoid the giving of sepsis. If there was drny doubt as to the n sture of the pus, it would, he thought, be safer to cut awav the uterns, and the tube at the other side: this .' would have provided a large hole for free drainage. That hole and the vagina should be packed with a large quantity of iodoform gauze, and the gauze spread out right over the pelvis whither the pus had flown, a nd to which the intestines wo uld come the moment the patient was moved out of position. SIR W. SMYLY said he had taken out one tube, and the woman had become pregnant afterwards, He did not think it good practice in every case to remove both tubes and uterus, but where there was soiling of the pelvis and where both tubes had to be removed, he considered it good practice to remove the uterus also, DR. IIoRNE said he had recently adopted the practice recommended by Dr. Tweedy in a similar case, the patient did very well up to the fifth day, when she complained of pain in the region of the heart, and rapidly sank in a few hours; he wished to ask Dr. Purefoy what treatment he adopted when the pus escaped into the abdominal cavity? DR. J ELLETT thought it difficult to say positively that the case was tuberculous, and he suggested that. it o-riginated as one of extra-uterine pregnancy, and that a ha-matoma formed in it and suppurated. He was afraid he was in a minority in thinking it good practice to leave the uterus even if both tubes were removed. If any portion of the ovaries was left behind, menstruation would continue, which was an important matter from the point of view of the mental comfort of the patient. DR. PUREFOY; in reply, said it was possible to lift the tumour out of the abdomen to some extent. He had packed the surrounding area with sponges, and the patient escaped contamination from the fact that the adj acent structures had been protected, and the point of exit was outside the incision, and somewhat out of the scene of operations. His recollection was that there was no palpable disease of the other tube, and the case "vas so serious that he wae glad to avoid any unnecessary removal of other parts, and to conclude the operation so far as was compatible with the safety of the patient.

316

Section of Obstetrics.

President's Address. THE PRESIDENT read his Address on "The Teaching of Practical Midwifery in the past and at the present time." See p. 209, ante. Friday, December 3, 1909. The President, DR.

JELLETT,

in the Chair.

Exhibits.

.

M1/0maf OU8

Uterus .

DR. GIBSON exhibited a specimen of myomatous uterus with necrosis of one large tumour and carcinoma of the endometrium. The patient, from whom the uterus had been removed a few weeks previously, was over sixty years of age, and twelve years past the menopause. She knew that she had the tumour for many years and had been given to understand that it would never do her any harm after the change of life. She had never been pregnant, and enjoyed good health up to four weeks before he saw her, when she suffered from a severe attack of uterine hremorrhage. She had not had any discharge from the menopause to that time. She had no pain, and except that she thought she had been getting thinner for the past five or six months, she noticed no change in her general health. Examination showed a large myomatous uterus with the cervix unaltered. There was no hremorrhage, but when the sound was passed the uterine cavity bled freely. He decided to perform panhysterectomy. When the abdomen was opened, as the uterus felt peculiarly soft it was grasped with a museau-forceps in what seerned to be the most solid part. The forceps, however, tore a hole in the surface of the uterus, and a large quantity of yellowish creamy fluid escaped. Fearing that the uterus would tear, it had been carefully packed It off, so that none of this fluid got into the peritoneal sac. proved, however, not to be pus. The removal of the uterus was easy, but scattered everywhere over the pelvis he found nodules which were deposits of carcinoma. These and the condition of the uterus showed the great extent to which the disease had J

Abstracts.

317

extended without any symptoms. The patient did very well. He also exhibited a specimen of carcinoma of the cervix removed by Wertheim's operation. The patient was twenty-five years of age; married four years. Four months before he saw her she had a perfectly normal labour, and suffered from nothing either before or after her babe was born. She had no bleeding until six weeks before he saw her, when she described a creamy discharge with streaks of blood. The disease in the cervix was advanced, and the specimen showed the very large amount of tissue which could be removed with the uterus by this operation. The patient made a good recovery, and was the fourth under the age of thirty for whom he performed Wertheim's operation this year. SIR WILLIAM SMYLY said it was very difficult to prophesy in myoma. He recalled a case in which the patient had had a uterine tumour for thirty years. Six months after seeing her it was fixed in the pelvis with malignant disease. PROFESSOR ALFRED SMITH cited a case in which, after some hesitation as to giving advice, he dilated the uterus, and found what he thought to be a tiny ulcer. He scraped away sufficient for a microscopic examination. The pathologist pronounced it to be malignant disease, rapidly growing, in which the prognosis would be very bad. I t was, however, a typically ideal case for good results, and he removed the uterus, but within nine months the patient was dead. The case brought home to him the fact that the useful information given by the pathologist could be extended to state whether the tumour was actively growing or not. THE PRESIDENT (DR. J ELLETT) said the opinion given twenty years ago as to a tumour not doing harm might have been perfectly correct then, in view of the risk of operation; but now it is possible and right to advise the performance of operation on account of the great improvement in their technique. Ovarian Pregnancy. DR. E. HASTINGS TWEEDY exhibited a specimen of ovarian pregnancy, probably the first exhibited in Ireland. A. H.: aged twenty-five; married four years; three children, last five and a half months ago (June, 1909); one abortion. Menstruated September 18, 1909, first and only time since delivery.

31~

Section. of Obstetrics.

November 5th.-Acute pain in right IOV\Ter abdomen, from which she almost fainted. Examined at 4 p.m. November 5th in extern department. ery tender mass the size of a hen's egg to the right of. retroverted uterus. Left appendages normal. Tumour on right could not be definitely localised to ovary or tube. Diagnosis .-Extra- uterine pregnancy. November 13, 1909.-In the interval had several attacks of pain. Morning of November 13 pain more severe, and associated with slight uterine hsemorrhage, On admission, tumour increased to twice its former size, otherwise physical examination the same. Operation.-November 16, 1909.-Ether. Right Oophorectomy. Both tubes and left ovary microscopically perfectly normal. Blood clot about three inches in diameter completely obscured right ovary. This was clamped and removed, ovarian tissue being cut through in removal. The case had fulfilled all the conditions laid down for ovaria n pregnancy. He thought the specimen was worth public acknowledgment by the Section.

,r

8.'1Jlhilitic Elepl,anria.","';.'. DR. TWEEDY also exhibited a specimen of elephantiasis of the vulva, specific in origin. M. B., aged thirty; married fourteen years; last pregnancy ten years ago; three dead-born children; one .child lived two hours. Wassermann's reaction for syphilis positive. (Reported from Sir A. Wright's Laboratory.) Has always had a yellowish purulent vaginal discharge. For ten years has had a tumour of the vulva, which has grown slowly but steadily. Physical Examination.-Hypertrophy of labia minora, measuring about two and a half by three and a half inches. Considerable osdema. Induration and osdema involved labia majora, and extended down to ischia-rectal fossa on either side. Operation.-Excision. Interrupted catgut sutures. DR. ROWLETTE said the specimen of ovarian pregnancy showed to the naked eye the corpus luieum. A section taken through the corpue luteurn and ~ the edges of the blood-clot showed a proliferation of the cells of the corpus luteum and the mass of blood-

Abstracts.

319

clot in which three or four villi were seen. The other specimen consisted of lax connective tissue covered with a thin skin. Thelaxity was probably due to an increase of the lymphatic spaces.. DR. FITZGIBBON quoted a ease reported in the November number of The American Journal of Obstetrics. On the day the woman expected to be delivered she complained of pains. These went off, and twelve days later she went intohospital. A tumour was found strongly resembling an ovarian cyst, On opening into it a foetus was found. This was delivered and resuscitated. The child was up to term, and free from deformities, and the patient made a complete recovery. DR. JELLETT said the case was one in which they must suppose a person capable of making a mistake until he could conclusively prove that he had not made one. It was not a question of distrusting the po wers of diagnosis of Dr. Tweedy and Dr. Rowlette, but rather a question as to whether the wholeprofession would accept the po\ver of the Section to express an. opinion. He, therefore, urged Dr. Tweedy to refer the specimen to a committee. His own opinion was that it was an ovarian pregnancy. DR. TWEEDY, in reply, said he was quite agreeable that thediagnosis should be confirmed. SIR WILLIAM SMYLY proposed that Dr. Tweedy's specimen be· sent to the Reference Committee for report. PROFESSOR ALFRED SMITH seconded, and the motion was, passed unanimously. (For report, see meeting of April 1; 1910).. Painless

Lf1b'J1a~.

DR. SPENCER SHEILL read a paper on above subject. p. 222, ante.

See

Friday, January 14, 1910. The President, Dr. J ELIIETT, in the Chair.

Exhibits. Fibroi~

Myomata. PROFESSOR ALFRED SMITH exhibited a specimen of fibroid, myoma. The patient had come to him in October last greatly dis-

320

Section. of Obstetrics.

tended, with a note from the doctor stating that he had tapped her a week previously in order to enable her to come to hospital. The patient told him she had been in the hospital fifteen years previously. He looked up the record, and found she had come in with a tumour about the size of a four and a half months' pregnant uterus. She had complained of no symptoms, menstruation was normal, she had no inconvenience whatever, and, according to the teaching then in vogue, he advised her to go home, as there was no reason for her to risk an operation. On the present occasion he did an exploratory operation to ascertain why there was such enormous distention. To his astonishment he found the tumour very little increased in size. It was a fibroid myoma of the entire uterus, and attached to it were great omental adhesions. Cullen, in his book, called it a parasitic fibroid myoma, because it obtained its major blood supply from Sources outside the uterus, and stated that in parasitic myoma the omentum became attenuated. In the specimen before them they would observe that the fragment of omentum was big and fat, although the myoma was parasitic. A pathologist had told him that the specimen had undergone sarcomatous degeneration. The chief point of interest was that the case brought home to them the lesson that the present day teaching as to interfering operatively in cases of fibroid myoma were perfectly justified. PROFESSOR SMITH also exhibited a specimen of calcified fibromyoma, or uterine stone. It lay to the right of the uterus, and he thought it was a small ovarian tumour. DR. PUREFOY said the case illustrated the wise change which had been made in the treatment of fibro-myoma, and gave examples from his own experience in support of the present practice. DR. KInD said it occurred to him that it was quite possible for adhesions to take place between the omentum and the uterus without having to look on the tumour as altogether parasitic. DR. JELLETT said that calcified myomata of the uterus possessed a certain amount of interest to others than gynsecologists. He recently found a patient with prolapse who had a similar myoma in the middle line behind the symphysis. Dr. Watson, on seeing the case, remarked that the tumour could Gause a considerable amount of confusion in the minds of Xvruyiste, as it might be mistaken for stone in the bladder.

321

Abstracts. DR. E.

HASTINGS TWEEDY

showed :-

1. A Case oi Ovarian Oyst and Pregnancy. M. E. N., aged twenty-eight, 2-para, was admitted on December 25, ] 909. Previous labour had forceps. She last menstruated on March 17, 1909. On examination there was found a tumour, cystic in consistence, reaching to the ensiform cartilage, overlying a pregnant uterus. An obliqne groove, running across the abdomen two and a half inches below the umbilicus, separated the tumour from the uterus. There was a marked fluid thrill over the tumour, the greatest circumference of which was forty-five inches. Tympany was present in the flanks. A fcetal heart was audible. Diagnosis of ovarian cyst and pregnancy was made. Ovariotomy was performed three days later, without complication, when twenty-five pints of clear, almost watery, fluid were evacuated. A full term uterus was evident. Thirty hours later the patient fell into labour, and was delivered by forceps when the second stage had started of a 7110. child. 2. A Oase of Hypophrenic Abscess complicating Pregnancy. P. M., aged twenty-five, primipara, was seen in the extern maternity, and being deemed a General Hospital case was advised to go to one, but having tried one of these institutions was there advised to come to the Rotunda. She had been in a general hospital suffering from pneumonia until a week before Christmas. She was in great pain on admission to the Rotunda on January 5, and had been so from shortly after the time of her discharge from the general hospital. There was no history of gastric or renal trouble. On examination it was found that there was a tense resistant mass, dull on percussion, and well defined in its lower margin, which stretched from beneath the left costal arch across the middle line to the right costal arch, oceupying the left hypochondriun.., the epigastrium, and to a slight extent the right hypochondrium. The uterus was th e size of a six months' pregnancy, and there was no communication whatever between the uterus and the growth. Mr. Heuston agreed that the diagnosis was hypophrenic abscess. An exploratory incision was made under local auresthesia, and a general anresthetic was given, when it was found necessary to enlarge the incision to below the umbilicus. The peritoneum was thickened and inflamed. A mass, cystic in VOL. XXVIII.

X

322

Section. 01 Obstetrics.

appearance, which, when opened, was found to contain, firstly, a watery fluid followed by an immense amount of pus was apparent. The intestines were kept back by sponges, but a good amount of foul-smelling, purulent fluid escaped. The sac of the abscess was carefully irrigated with saline, and then the peritoneal cavity. A Keith's tube and CHI3 gauze were placed in the abscess sac and CHI a gauze in front of the stomach. The sac seemed to have no connection whatever with any viscus. The patient suffered from shock after the operation, and needed a good amount of stimulation. Irrigation, with continuous saline, was commenced soon after the operation was finished, a pint being given for the first hour, half a pint for the next three hours. It returned after this, so was discontinued. Antistreptococcic serum 10 cc.s were given. Twenty-eight hours later patient started in labour, and was delivered by forceps of a six months' fce tus three hours afterwards. Forceps were applied when the os was fully dilated, owing to excessive straining. The placenta followed in due course. The convalescence so far has been very stormy. The Keith's tube was removed on the day following the operation, and was replaced by a small Kocher's tube; this was changed daily until the fourth day. The CHIa gauze was removed with difficulty on the third day. A great quantity of discharge came away on the dressings. Great difficulty was experienced in getting the bowels moved and in finding food which would not make her vomit. On the third evening symptoms of iodoform poisoning appeared. Patient became very restless, later becoming delirious. She had severe pain in the abdomen, and iodine was found in the urine. There was no rash. On the fourth night the pulse, which had ranged from 104 to 110, rose suddenly to 140, and later to 160. On the seventh afternoon patient had a rigor, and complained of great pain in her back. The appearance of the patient at present would lead one to suppose that there was nothing wrong with her. The pulse is about 120, the temperature is subnormal, but she has suffered from incontinence of freces. A culture was taken by Dr. Rowlette and showed no growth. The rarity of hypophrenic abscess following pneumonia, the accompaniment of pregnancy making it still more rare, are the reasons for the case being brought before you on this occasion. PROFESSOR SMI1'H said the first case opened up the very large

Abstracts.

323

question as to operative interference during pregnancy. Formerly there was a superstition that they should not operate, but that had been quite altered; and there was not one of them who had not from time to time to do operations in pregnant patients. He had removed ovarian cysts and fibroid tumours from pregnant women, and in only one case in a number of such operations was pregnancy interrupted. The point was of considerable importance to the general practitioner. Personally he advised the removal of cyst as it might be a question of urgency at any moment owing to torsion of the pedicle, and they could not guarantee what might happen after delivery. As regards the time for operation, he would not operate until after the period had passed which corresponded to the usual time of the patient's menstruation. DR. PUREFOY cited several cases in which he had operated without interrupting pregnancy. DR. FITZGIBBON drew attention to a case in Mercer's Hospital the previous week of a young woman who had been operated on twelve weeks previously for gastric ulcer. She had come into Mercer's on account of vomiting, and a tumour low down in the pelvis transpired to be a four months' pregnancy, which had obviously begun some weeks before the operation, and had gone on without interruption. DR. SOLOMONS, in reply, said the case of the cyst was up to full term. There had been two cases lately in the hospital about five months pregnant; one went to full term, and the other aborted after the operation.

Some Hints and Suggestions on the Teaching of J.llidwl:jery and Gynwcology. DR. FRED. W. KIDD read a paper on this subject. See page 235, ante. Friday, Februa1'Y 25, 1910. THE PRESIDENT

in the Chair.

Pyosalpinx. DR. E. HASTINGS TWEEDY exhibited this specimen which had been removed from a lady who had been ill for twelve months as

324

Section of Obstetrics.

a result of puerperal sepsis. She had been delivered in the country, and neither the doctor nor the nurse had been in time for the delivery. She got· very ill, and was very septic. He explored the uterus, and took a culture, and found only a diplococcus like that of pneumonia. During labour the patient had a cough, and expectorated some muco-purulent discharge, but the doctor said there was no pneumonia present. He was again sent for in a fortnight, and found her worse than before. He performed Prior's operation. He packed the posterior fornix with iodoform gauze, and gave her diplococcus vaccine. She improved for a time, but after six weeks he was again sent for, and this time found a tumour about the size of a fist in the region of the right broad ligament. With great difficulty he opened into an abscess about Poupart's ligament. A culture once again grew only a diplococcus. After six months he saw her again, and she was a mere skeleton, and in a wretched state. The sinus was partially closed, and he opened it freely. Her temperature fell, and she got sufficiently well to be sent to the country. . She came back with temperature 1050 and palpitation of the heart. There was a large tube felt on the right side. The uterus was normal. When she menstruated the discharge flowed freely through the sinus. Again he sent her away, and again she got a temperature, and he decided a fortnight ago to do a radical operation. An old tubercular sinus that she had had as a child, and which was healed for many years, re-opened, and a quantity of very tubercular p-u.-s continuously exuded from it. He operated last week. The patient had been obviously losing flesh daily. The pulse was never under 110, and the evident involvement of the heart made him fear the operation. He injected the sinus with iodine, and cut round it and clamped it. Whilst doing so he unfortunately opened into it. He opened the abdomen and removed the tube. He plugged with iodoform gauze all round the raw surface. The patient's pulse was 130 when she went to bed. He waited until the third day to take out the plug. The plug came out with the greatest ease, but he felt convinced that her vitality was so low that no adhesions were made, for within two hours after the plug was taken out the pulse rose to 150 and 160, and she died acutely septic two days afterwards. He greatly feared that the incision he accidentally made in the sinus had been handled by the glove.

Abstracts.

325

The bacteriological examination of the pus failed entirely to indicate the acutely septic nature of the sinus discharge. PROFESSOR ALFRED SMITH said they could sympathise with Dr. Tweedy on the unfortunate result of so clifficult a case. It was interesting to note that while septic troubles following parturition were generally regarded as bilateral, the case was exceptional in being unilateral. He had read that the best protective for surrounding an area where they were likely to open an abscess cavity was a rubber dam, which was used inside the abdomen, and could be adapted to any little crevice. He did not, however, think it would have made any difference in Dr. Tweedy's case. DR. JELLETT said he thought Dr. Tweedy was right in attributing the fatal result to his own action; but he doubted if the infection came from the sinus: he thought it was just as likely to have come from the tissue around the abscess in the peritoneal cavity.

Pregnancy aruZ Labour after Veniro-fucaiun: of the Uterus (HystCTOpe'J;£S Ilypogast.ria). SIR VVILLIAM SINCLAIR delivered an address upon the above subject. See page 252, ante. Friday, April 1, 1910. THE PREsIDEN~r in

the Chair.

from Committee of Reference in regard to specimen of ovarian pregnancy reported by Dr. Tweedy at the meeting of December 3, 1909. DR. ROWLETTE said the specimen consists of an oval blood-clot, three inches long in diameter, to which is adherent a small piece of tissue, partially embedded in clot. The outer surface of the clot is laminated, and the coats peel off readily.. On cutting through the specimen, the tissue is found to be tough, greyishpink in colour. Between it and the clot is a bright yellow band, one inch long by three-eighth inch broad, obviously the wall of a ruptured corpus luteum in which the clot must have formed. .111.icroscopically.- The grey tissue is ovarian tissue, with a partial covering; of peritoneum; the yellow band consists of COMMUNICATION

Section. of Obstetrics.

326

typical lutein cells; in the clot near the yellow band are numerous chorionic villi. No embryo was discovered. The specimen is one of pregnancy, the ovum having developed in a Graafian follicle. "We have examined the specimen described by Dr. Rowlette in the accompanying manuscript, and are of opinion that the case is one of ruptured ovarian gestation. The possibility of its having been tubal or tubo-ovarian is excluded by the fact that the tube was found to be normal and separate from the ovary at the operation. From the close relation of the Iostal structures to the lutein cells, it appears probable that the impregnation took place in a Graafian follicle, from which the corpus luteum subsequently developed.-H. C. EARL, A. C. O'SULLIVAN, H. JELLETT." (a) Sarcoma of Body of Uterus. (b) Carcinoma of Body of IIterus.

DR.

exhibited specimens of the above by way of contrast. The patient in the first case was a girl, aged twenty. Her symptoms were frequent and heavy menstruation, and a considerable amount of leucorrhceu almost entirely of pure pns. Examination showed the uterus to be considerably" enlarged and very nodular. He passed a Bozeman's catheter and washed away a considerable amount of pus situated at the upper part of the uterus. The diagnosis was apparently myoma, but he thought it might possibly be a case of sarcoma. As against the myoma was the age of the girL The operation presented no particular features. He did a supravaginal hysterectomy, leaving a portion of the cervix. There was a tumour in the right broad ligament lying between the hilum of the ovary and the uterus. After removal the condition of the endometrium as shown in the specimen was plain to be seen. There was enormous proliferation apparently of mucous membrane all over the upper surface, and on the posterior wall a nodule almost like a myoma which had lost its blood supply. On examination it was proved to be sarcomatous. The uterine wall was extraordinarily thick. At first sight the specimen gave one the impression of recent parturition. A section through the uterine wall showed nothing but muscular tissue, and he did not know how to explain the thickening. The J·ELLE.TT

"-

327

patient made an excellent recovery. He had not removed the remainder of the cervix as the malignant growth was entirely separated from it by an inch and a half of tissue. The second specimen was from a woman, aged about fifty-five or sixty years. She had gone into. hospital complaining of profuse discharge. He found a large uterus, also. nodular. He washed out the uterus and found great retention of pus. On scraping with a blunt curette he brought away a lot of sloughing growth. The scrapings were carcinomatous. On opening the abdomen he found the uterus comparatively free. There was very little extension of the growth in the neighbourhood of the cervix, and the fundus was entirely free. But on the left side there was a growth extending up into the pelvic glands behind the peritoneum. This he thought he was able to extirpate. On the other side there was a similar extension. The glands all along the aorta were enlarged. He removed them to the level of the second lumbar vertebra. He removed the uterus and a good deal of the vagina. The uterus lay low in the pelvis, and when he cut across the vagina he was within an inch of the vulva. The condition of the patient after the operation was fairly satis.. factory, and he thought he would try to take away another gland higher up. He split the peritoneum further along the ureter, and found the remaining gland firmly adherent to the lower vena cava. The patient gradually got weaker, and died in a couple of days. The case was one of long standing, and he thought her heart muscle was weak. There were no obvious symptoms of sepsis. DR. PUREFOY said the ease of sarcoma was, in his experience, quite without parallel. He would watch for the subsequent hstory of the case, as he himself had had a patient aged sixty-five who died of secondary disease in the left lung a few months after he had removed a large fibrous uterus, which for thirty years had caused inconvenience only by its size. He did not remove the cervix. With regard to the second case, it was admitted that a proportion of the enlarged and hardened glands, the appearance of which suggested malignant disease, did not really contain it. Nevertheless, any of them who had such a case would, no doubt, endeavour to remove the glands as completely as possible. In the case of an aged patient, they had to consider whether they were warranted in carrying out a prolonged

328

Section

0.1

Obstetrics.

operation for the complete removal of all the enlarged glands they could feel. DR. JELLETT, remarked that Sir William Sinclair, on his recent visit, had said to him that he was in the habit of telling his class that cancer of the body of the uterus occurred only in comparatively well-to-do cases, and" cancer of the cervix in very poor patients. Sir William's idea was that the only way to prevent cancer of the cervix was by improving the conditions under which the patients lived. In his (the speaker's) experience the rule did not apply in Ireland. DR. HOLMES said that, looking back on the cases in the Rotunda, the number in the extern dispensary of cervical cancer seemed to him to be more numerous than the house cases. Neglect of discharges might set up disease, but the upper classes, if anything went wrong, generally had the rnatter seen to. DR. PUREFOY said his experience did not correspond with Sir William Sinclair's. He would like to know if, from inspection of the sections, it was possible to determine whether the sarcoma had occurred in the connective tissue or muscular cells. Dr. JELLETT said that there was a doubt in the mind of Prof. O'Sullivan, who reported on the specimen as to its origin in the ovary. Prof. O'Sullivan's report is as follows :" The uterus was large, the body being four inches in length and the wall a little over an inch thick at the thickest part. The upper two-thirds of the cavity were filled by an irregular growth, with numerous polypoid excrescences proj ecting into the lumen. The surface of the growth was acutely inflamed and partially necrosed, and covered in places with a thick layer of pus, which contained a variety of organisms-bacilli and cocci. The growth could be seen to infiltrate the posterior wall of the uterus, and secondary nodules could be felt in the upper and posterior part of the walL The ligament of the ovary was also infiltrated, and the ovary itself was converted into a mass, partly nodular and partly cystic. Under the microscope the tumour showed a very cellular structure, spindle and large round cells with numerous nuclear figures. The solid tumours in the ovary had a similar structure. A large nodule lay in the upper uterine wall, which was of a dull grey colour on section, and proved to be of similar structure."

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329

Supp'urating Ovarian Cyst 'with Tubereulcr Pyosalpinx. exhibited this specimen. A girl, B. N., aged nineteen, had four years ago tubercular disease of a finger, which was amputated. Her menses, which had always been regular from the time they commenced, ceased in November, 1909, and shortly after that she developed a cough, and had several attacks of vomiting, accompanied by pain in the abdomen. She was admitted to Mercer's Hospital on January 3, 1910, and the speaker first saw her about the end of January. She then had an irregular temperature, varying between 99° and 101°, and pulse from 95 to 110. She had ceased to vomit, but complained of acute pain in the abdomen, and was very constipated. A tumour could be felt extending to one and a half inches from the umbilicus. On vaginal examination the pelvis was found to be filled up by a cystic tumour, which was fixed, and which pushed the uterus upwards and forwards. The left appendages could be felt apparently normal, but the tumour prevented any examination of the right side of the pelvis. The patient was kept in bed and the bowels were freely acted upon, and then the temperature improved, but the pain continued to be severe. On March 1st the abdomen was opened, and an ovarian cyst was found springing from the right side and firmly adherent all over the back of the pelvis. The intestines were completely shut off by the omentum. In freeing the cyst from the pelvis it ruptured, and discharged about two pints of purulent contents. The left tube was greatly thickened and adherent, also containing pus. By working down the left side of the uterus, and then dividing through the vagina the right appendages were shelled out. The left tube which was removed was perfectly normal, and the left ovary was retained in situ, as it seemed quite heal thy. The pelvis was drained through the vagina with iodoform gauze passed from above down, and only iodine catgut was used throughout. Cultures were made from the pus in the tube immediately after the operation with a view to making an autogenous vaccine if the case developed into one of acute sepsis, as was anticipated from the amount of pus which unavoidably got about the pelvis; also saline enemata, two pints, were given every two hours for two days. The temperature rose after the operation to 102°-103°, and the pulse to 130 to DR. FITZGIBBON

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Section of Obstetrics.

140, and remained fairly steady for the first four days, when they began to improve, and have since remained from 99° to 1010 and 100 to 120. The lower inch of the abdominal wound opened and discharged a foul-smelling pus for about ten days, and is now granulating, while the pus from the vagina went through the same stages. The patient looks better, is free from pain, but continues the high temperature and pulse. The report received on the specimen was that the cultures contained no pyogenic organism, and except a bacillus which resembled B. coli the pus did not show any other pyogenic organisms. Sections made from the wall of the ovarian cyst proved to be tubercular, while the left tube was normal. The ovarian tumour showed a large single cavity, strongly suggestive of an abscess, and in no w.ay resembling an ovarian cystoma. DR. PUREFOY said he understood there was no evidence of gross uterine disease, and the removal of the uterus did not commend itself to him as the best proceeding under the circumsta nee, It increased the area in which infection might take place, and it was a serious loss to a patient at the age of the case. He thought an adequate opening might have been found in Douglas's space. DR. ROWLETTE said the association of tuberculosis and cystic growth in the same ovary was, he thought, very rare, though one sa w frequently tuberculosis of the tube associated with a certain kind of cystic growth of the ovary. It was indeed rare for any tumour to become infected by tuberculosis. He thought the cyst was really an abscess cavity. With regard to the President's specimen, it seemed to him to be an advanced case of sarcoma starting in the endometrium. He should say the nodule was sarcoma from the beginning. The fact that the uterus was so large showed, he thought, a good deal of resistance on the part of the patient, and that the growth was not very rapid. The fibrosis must have been a reaction to the growth of the tumour, which would be encapsuled to a certain extent. DR. JELLETT, speaking on Dr. FitzGibbon's specimen said he had never before heard of a specimen of tuberculosis of an ovarian cyst, and the first thing to know was the nature of the cyst. If it was purely an abscess starting in the ovary, then the tubercular infection would not be quite so unusual. But, if it

Abstracts.

331

was a proliferating cyst of the ovary, he did not know that he had ever heard of such a conditjon being recorded before, and he thought Dr. FitzGibbon should be asked to give them some further information at a later date. DR. FITzGIBBON, in reply, said the section showed typical tubercular infection, but he did not think anyone could say .. . definitely that it was from a proliferating ovarian cyst, in fact the inner surface of the section did not show anything to suggest ovarian cystoma, but strongly resembled the lining of an abscess cavity. He thought the case, now that he had obtained and seen a section of the tumour, was one of tubercular ovarian abscess. In reply to Dr. Purefoy, he said the condition of the patient appeared so bad, and such a quantity of pus had escaped about the pelvis, that he thought the only chance was to obtain absolutely free drainage, and that this would be best by removal of the uterus, even then he hardly expected the patient to survive.

Our Responsibilities in the Prevention of Inherited Syphil1"s.

DR.

SHEILL

read a. paper on above.

See page 264, ante.

Depressed fracture of the Skull treated by Bullet-forceps.

DR. SOLOMONS showed a specimen of a fractured skull which had been raised by means of one blade of an American bullet forceps. He said that the case occurred in a quartipara, who gave a history of her previous babies having had c ; dents" in their heads. Her pelvic measurements were :-interspinous, 27 em. ; intercostal, 28~ cm.; external conjugate, 17 CID.; conjugata vera, 6} em., transverse of inlet, 13 laO CID. Prolapse of the cord occurred when the membranes ruptured, and version was performed and the child delivered. When born it was found that there was a depressed fracture of the right parietal bone. This was raised as follows :-The point of a sharp bullet forceps was placed in the centre of the depression, the forceps was turned through a right angle, and then raised; it was easily to be seen in the specimen that the cure of the fracture was complete. This method, which was first performed by Dr. Tweedy, had been carried on in the Rotunda Hospital with uniform success. In this case the infant became jaundiced soon after birth, and died on the third day.

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Section of Obstetrics.

There was no paralysis. A post-mortem examination revealed nothing except the mark of the bullet forceps in the brain to the extent of possibly one-eighth of an inch, and evidently this had nothing whatever to do with the death of the child. DR. NEILL said he had seen a deep dent in a child which was born alive, and spontaneously recovered without interference. DR. J ELLETT asked if it was the practice to lift all dents with bullet forceps. DR. PEARSON said the skull of a new-born child was a very pliable structure, and might not require any treatment to elevate a fracture. From a surgical point of view the obj ection which he sa w was the possibility of injuring a meningeal vessel. DR. HOLMES thought any noticeable depression ought to be raised. He had used the method several times, and the children did very well. DR. FITZGIBBON said there was a hoomatoma between the dura mater and the parietal bone, not very extensive, and he asked if the bullet forceps had punctured the dura rnater. DR. SOLOMONS, in reply, said all depressions of any import were raised. There was a puncture in the dura mater when the specimen was fresh.