2
30 outline of the hairball. 2. Round-celled Sarcoma of the Bladder Wall. 3. Carcinoma of the Kidney. Mr. R. C. DUN: (1) Lymphadenoma; and (2) Vermiform Appendix containing Threadworms. Professor E. E. GLYNN: (1) Two Human Hairballs; and (2) Hairballs from Animals. Dr. W. B. WARRINGTON : Tumour in the Right Posterior Fossa of the Cerebellum. It was the size of a small walnut, growing between the fifth and seventh nerves. During life the only focal symptom was right corneal areflexia. The posterior fossa was explored on the right side, but owing to the interior and anterior site of the tumour its presence was not deteoted at the operation. Histologically the tumour was composed of innocent fibrous tissue. Professor J. W. W. STEPHENS and Mr. F. A. G. JEANS: Chinese Lady’s Foot. Surgically it was in a condition of pes cavus, whilst pathologically the deformity was mainly produced by a change in the os calcis, which was L shaped, the patient walking on the insertion of the tendo Achillis. Professor STEPHENS : (1) Bilharzia of Bladder and Intestine ; (2) Guinea-worm ; (3) colour photographs from Lip of Tsetse Fly ; (4) Redshank trapped by Cockle ; (5) Fossil Tsetse Fly ; and (6) Bot Parasite on Tapeworm. Dr. W. BLAIR BELL : Sarcoma of the Ovary. The specimens were discussed by Mr. F. T. PAUL, Mr. C. THURSTAN HOLLAND, Mr. NEWBOLT, and Mr. LITLER JONES. Professor STEPHENS read a paper on the Relation of Black- water Fever to Malaria.-Dr. W. T. PROUT discussed the paper, and said that he supported Professor Stephens in his view as to the relationship between malaria and blackwater fever. The more he had seen of this disease in the tropics, and his experience was very considerable, the more he was impressed from a clinical point of view with its relationship to malaria. He thought some of the figures cited by Professor Stephens very convincing, and he considered that additional confirmatory evidence might be cited in the results of the prophylactic use of quinine. Where this had been systematically done it had been found that blackwater fever had diminished as well as malaria.-Dr. LLOYD ROBERTS Mr J. BRADLEY HUGHES, Dr. C. 0. STALLYBRASS, and Dr. R. E. HARCOURT also spoke, and Professor STEPHENS replied. MIDLAND OBSTETRICAL AND GYN&AElig;CO- LOGICAL SOCIETY. Exhibition of Speoi,?116’nS.-Extra-uteriwe Gestation oocurring Twice in the Same Patient. - Titbal Jlole -Suppurating - Z/<%?’y6’M70M complicating Pregnanoy. A MEETING of this society was held at the Royal Infirmary, Derby, on Dec. 2nd, 1913, Professor WALTER C. SWAYNE, the Presidtnt, being in the chair. ; Mr. H. T. HICKS showed two specimens of Chorion- epithelioma occurring after Pregnancy at Full Term. The lirst specimen was obtained at the necropsy on a patient who had given birth to a full-term living child about three months before death. A small nodular growth was present in the uterine muscle close to the left cornu, and metastases were found in the lungs, kidneys, liver, and othey viscera. An important point in connexion with the case was the absence of uterine hoemorrhage. Apart from a .light loss of blood about 16 days after delivery, uterine symptoms were absent. ’I he patient was admitted as an acute liver condition. The hepatic area was explored and small secondary growths in the liver "’ pt- ’mnd at the time of operation. Microscopical sections rev t-aled the nature of the neoplasm. The second specimen consisted of a uterus enlarged to about the size of a two mOIiLh,,’ .,,ation and containing a diffuse dark-coloured necrotic growth. which had the typical characteristics of chorion-epithelioma. The organ was removed from a patient who had suffered from attacks of bleeding for a month after delivery at full term. A small embolic growth was preselit in the anterior wall of the vagina ; this was also removed. The patient was operated upon six weeks after delivery, and nine months later was apparently in good hfalh -Mr. H. BECEWITH WHITEHOUSE described a case of Chorion,epithelioma which he had seen under the care of Dr. Thomas Wilson, and which only revealed its true nature when operation was required owing to severe intraperitoneal haemorrhage. At the laparotomy the bleeding point was found in the left mesosalpinx, and was due to erosion of one of the veins in a pampiniform plexus by an embolic deposit. He was interested in Mr. Hicks’s first case, particularly since he also had met with one example of chorion-epithelioma which had caused no uterine haemorrhage and which was only discovered at the necropsy.-Mr. CHRISTOPHER MARTIN asked if any hydatidi- form degeneration of the placenta was present in either of Mr. Hicks’s cases. He would like to know in what proportion of cases hydatidiform mole preceded chorion-epithelioma.- The PRESIDENT thanked Mr. Hicks for bringing these two interesting cases forward. He was particularly interested in the same because he had had two very similar cases. In one, before operation, definite haemoptysis was present which had been attributed to pulmonary metastasis. After opera- tion the symptom disappeared, and the patient made a good recovery and remained well after several years. Leith Murray had shown that in some cases there is a definite tendency to retrogression of these growths.-Mr. HICKS, in reply, thought that Mr. Martin had raised a most important point as regarded the incidence of chorion-epithelioma to vesicular mole. The views of Teacher and Marchand were that the malignant growth as a rule follows the latter. In his own experience this had not been the case, since in a series of four examples three had succeeded full-term gestation. Mr. HICKS next exhibited a specimen of a Complete Cast of the Female Bladder which had been passed per urethram. The patient had suffered from retention of urine, the result of pressure from a retroverted and incarcerated gravid uterus. The latter had to be emptied, and about a week later a small portion of the cast appeared at the urethral orifice. The whole cast was delivered by traction from below. The patient ultimately made a complete recovery.-Dr. C. E. PURSLOW related the details of a case where a complete cast of the bladder was passed by a woman who had had for a fortnight retention with incontinence due to a retroverted gravid uterus. The patient died from ascending infection of the kidneys.-The PRESIDENT also recorded details of a fatal case of exfoliation of the vesical mucosa secondary to retroversion of the gravid uterus. Mr. HICKS also showed (1) ’a specimen of a large Tubo- ovarian Cyst of the left uterine appendage, a similar and smaller cyst being present in the opposite adnexa, and (2) a small Dermoid of the Left Ovary containing three teeth. The interest in the latter specimen lay in the fact that the patient was X rayed for diagnostic purposes, and the photograph showed three distinct shadows lying near the left sacro-iliac synchondrosis. The abdomen was explored for supposed ureteric calculi, when the small tumour containing the teeth was discovered, the latter accounting for the shadows. Mr. MARTIN showed a Uterus and Both Appendages removed on account of Bilateral Tubal Gestation and small Multiple Uterine Fibroids. Dr. PuRSLOw exhibited a specimen of Unruptured Inter- stitial Ectopic Gestation removed from a patient aged 32, who had been married five years and had not previously been pregnant. Menstruation had been regular up to 10 weeks before operation. She then had amenorrhcea for six weeks, and subsequently on three occasions noticed a brown discharge. It was thought that there had been an abortion, and she was sent by her medical attendant to Dr. Purslow with a view to having curetting performed. On examina- tion, the uterus was found to be slightly enlarged and a small swelling was noted attached to its right cornu. Tubal gestation was diagnosed. On opening the abdomen the swelling was found to occupy the right uterine cornu, the corresponding round ligament being attached rather to the inner side of the centre of the swelling. The tube was perfectly normal. The tumour was removed by excising a wedge-shaped portion from the wall of the uterus, the patient making a good recovery. No blood was present in the peritoneal cavity. Mr. WHITEHOUSE read a short communication upon a case of Extra-uterine Gestation occurring Twice in the Same Patient, together with a Note on the Treatment of Tubal Mole. The author observed that the case raised- an im- portant point as to whether an operator is justified in removing the uterine appendage in cases of tubal mole or incomplete tubal abortion. Personally, he did not believe that it was good surgery to sacrifice the ovary and tube in these

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Page 1: MIDLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY

30

outline of the hairball. 2. Round-celled Sarcoma of theBladder Wall. 3. Carcinoma of the Kidney.

Mr. R. C. DUN: (1) Lymphadenoma; and (2) VermiformAppendix containing Threadworms.

Professor E. E. GLYNN: (1) Two Human Hairballs; and(2) Hairballs from Animals.

Dr. W. B. WARRINGTON : Tumour in the Right PosteriorFossa of the Cerebellum. It was the size of a small walnut,growing between the fifth and seventh nerves. During lifethe only focal symptom was right corneal areflexia. The

posterior fossa was explored on the right side, but owing tothe interior and anterior site of the tumour its presence wasnot deteoted at the operation. Histologically the tumourwas composed of innocent fibrous tissue.

Professor J. W. W. STEPHENS and Mr. F. A. G. JEANS:Chinese Lady’s Foot. Surgically it was in a condition of pescavus, whilst pathologically the deformity was mainly producedby a change in the os calcis, which was L shaped, the patientwalking on the insertion of the tendo Achillis.

Professor STEPHENS : (1) Bilharzia of Bladder andIntestine ; (2) Guinea-worm ; (3) colour photographs fromLip of Tsetse Fly ; (4) Redshank trapped by Cockle ; (5)Fossil Tsetse Fly ; and (6) Bot Parasite on Tapeworm.

Dr. W. BLAIR BELL : Sarcoma of the Ovary.The specimens were discussed by Mr. F. T. PAUL,

Mr. C. THURSTAN HOLLAND, Mr. NEWBOLT, and Mr. LITLERJONES.

Professor STEPHENS read a paper on the Relation of Black-water Fever to Malaria.-Dr. W. T. PROUT discussed the

paper, and said that he supported Professor Stephens in hisview as to the relationship between malaria and blackwaterfever. The more he had seen of this disease in the tropics,and his experience was very considerable, the more he wasimpressed from a clinical point of view with its relationshipto malaria. He thought some of the figures cited byProfessor Stephens very convincing, and he considered thatadditional confirmatory evidence might be cited in theresults of the prophylactic use of quinine. Where this hadbeen systematically done it had been found that blackwaterfever had diminished as well as malaria.-Dr. LLOYDROBERTS Mr J. BRADLEY HUGHES, Dr. C. 0. STALLYBRASS,and Dr. R. E. HARCOURT also spoke, and Professor STEPHENSreplied.

MIDLAND OBSTETRICAL AND GYN&AElig;CO-LOGICAL SOCIETY.

Exhibition of Speoi,?116’nS.-Extra-uteriwe Gestation oocurringTwice in the Same Patient. - Titbal Jlole -Suppurating- Z/<%?’y6’M70M complicating Pregnanoy.A MEETING of this society was held at the Royal Infirmary,

Derby, on Dec. 2nd, 1913, Professor WALTER C. SWAYNE,the Presidtnt, being in the chair. ;

Mr. H. T. HICKS showed two specimens of Chorion-epithelioma occurring after Pregnancy at Full Term. Thelirst specimen was obtained at the necropsy on a patient whohad given birth to a full-term living child about three monthsbefore death. A small nodular growth was present in theuterine muscle close to the left cornu, and metastases werefound in the lungs, kidneys, liver, and othey viscera. An

important point in connexion with the case was the absenceof uterine hoemorrhage. Apart from a .light loss of bloodabout 16 days after delivery, uterine symptoms were

absent. ’I he patient was admitted as an acute liver condition.The hepatic area was explored and small secondary growthsin the liver "’ pt- ’mnd at the time of operation. Microscopicalsections rev t-aled the nature of the neoplasm. The second

specimen consisted of a uterus enlarged to about the size of atwo mOIiLh,,’ .,,ation and containing a diffuse dark-colourednecrotic growth. which had the typical characteristics of

chorion-epithelioma. The organ was removed from a

patient who had suffered from attacks of bleeding for amonth after delivery at full term. A small embolic growthwas preselit in the anterior wall of the vagina ; this wasalso removed. The patient was operated upon six weeksafter delivery, and nine months later was apparently ingood hfalh -Mr. H. BECEWITH WHITEHOUSE described acase of Chorion,epithelioma which he had seen under thecare of Dr. Thomas Wilson, and which only revealed itstrue nature when operation was required owing to severe

intraperitoneal haemorrhage. At the laparotomy thebleeding point was found in the left mesosalpinx, and wasdue to erosion of one of the veins in a pampiniform plexusby an embolic deposit. He was interested in Mr. Hicks’sfirst case, particularly since he also had met with oneexample of chorion-epithelioma which had caused no

uterine haemorrhage and which was only discovered at thenecropsy.-Mr. CHRISTOPHER MARTIN asked if any hydatidi-form degeneration of the placenta was present in either ofMr. Hicks’s cases. He would like to know in what proportionof cases hydatidiform mole preceded chorion-epithelioma.-The PRESIDENT thanked Mr. Hicks for bringing these twointeresting cases forward. He was particularly interestedin the same because he had had two very similar cases. Inone, before operation, definite haemoptysis was present whichhad been attributed to pulmonary metastasis. After opera-tion the symptom disappeared, and the patient made a goodrecovery and remained well after several years. Leith

Murray had shown that in some cases there is a definitetendency to retrogression of these growths.-Mr. HICKS, inreply, thought that Mr. Martin had raised a most importantpoint as regarded the incidence of chorion-epithelioma tovesicular mole. The views of Teacher and Marchand werethat the malignant growth as a rule follows the latter. Inhis own experience this had not been the case, since in a seriesof four examples three had succeeded full-term gestation.

Mr. HICKS next exhibited a specimen of a Complete Castof the Female Bladder which had been passed per urethram.The patient had suffered from retention of urine, the resultof pressure from a retroverted and incarcerated gravid uterus.The latter had to be emptied, and about a week later a smallportion of the cast appeared at the urethral orifice. Thewhole cast was delivered by traction from below. The

patient ultimately made a complete recovery.-Dr. C. E.PURSLOW related the details of a case where a completecast of the bladder was passed by a woman who had had fora fortnight retention with incontinence due to a retrovertedgravid uterus. The patient died from ascending infectionof the kidneys.-The PRESIDENT also recorded details of afatal case of exfoliation of the vesical mucosa secondary toretroversion of the gravid uterus.

Mr. HICKS also showed (1) ’a specimen of a large Tubo-ovarian Cyst of the left uterine appendage, a similar andsmaller cyst being present in the opposite adnexa, and(2) a small Dermoid of the Left Ovary containing threeteeth. The interest in the latter specimen lay in the factthat the patient was X rayed for diagnostic purposes, andthe photograph showed three distinct shadows lying nearthe left sacro-iliac synchondrosis. The abdomen was

explored for supposed ureteric calculi, when the smalltumour containing the teeth was discovered, the latter

accounting for the shadows.Mr. MARTIN showed a Uterus and Both Appendages

removed on account of Bilateral Tubal Gestation and small

Multiple Uterine Fibroids.Dr. PuRSLOw exhibited a specimen of Unruptured Inter-

stitial Ectopic Gestation removed from a patient aged 32,who had been married five years and had not previouslybeen pregnant. Menstruation had been regular up to 10weeks before operation. She then had amenorrhcea for sixweeks, and subsequently on three occasions noticed a browndischarge. It was thought that there had been an abortion,and she was sent by her medical attendant to Dr. Purslowwith a view to having curetting performed. On examina-

tion, the uterus was found to be slightly enlarged and asmall swelling was noted attached to its right cornu.

Tubal gestation was diagnosed. On opening the abdomenthe swelling was found to occupy the right uterine cornu,the corresponding round ligament being attached ratherto the inner side of the centre of the swelling. The tubewas perfectly normal. The tumour was removed by excisinga wedge-shaped portion from the wall of the uterus, thepatient making a good recovery. No blood was present inthe peritoneal cavity.

Mr. WHITEHOUSE read a short communication upon a caseof Extra-uterine Gestation occurring Twice in the SamePatient, together with a Note on the Treatment of TubalMole. The author observed that the case raised- an im-portant point as to whether an operator is justified in

removing the uterine appendage in cases of tubal mole orincomplete tubal abortion. Personally, he did not believe thatit was good surgery to sacrifice the ovary and tube in these

Page 2: MIDLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY

31

instances; since dissection of a number of specimens undernormal saline had shown that the mole is only attached ’by anarrow base, and that no great difficulty need be anticipated,in controlling the bleeding point. He suggested that accessto the mole be attained by a longitudinal incision throughthe wall of the tube. After enucleation and control of thebleeding point the wall might be closed by a continuoussuture of firie silk. With regard to the objection of total orpartial occlusion of the tube, he did not think that the riskof such occlusion was as great in cases of tubal mole as ininflammatory conditions which are from time to time sub-jected to operation by salpingostomy and partial salpingeo-tomy.-The PRESIDENT observed that with regard to Mr.Whitehouse’s suggestion of conservative surgery for tubalmole the same idea had occurred to him, but he had deferredthe experiment because he did not feel certain of restoringthe tubal lumen.-Mr. MARTIN thought that a considerablenumber of cases of tubal mole did not require operation andit could safely be delayed. As to operative treatment, hepreferred the more radical method of salpingo-oophoreotomy,since he thought it was difficult to know what was the causeof ectopic pregnancy. Personally, he considered that thefault lay in the muscle rather than the mucosa of the tube.This being so, salpingotomy would favour the recurrence ofthe condition.-Mr. WHITEHOUSE in reply stated that he didnot consider the risk of obliterating the lumen of the tube avery real one. The operation was certainly easier in the caqeof tubal pregnancy than in the presence of inflammatorydisease ; furthermore, as regarded the repetition of eotopicpregnancy, time alone could answer this question. A studyof the anatomy of tubal mole had convinced him of the possi-bility of conservative measures, and he intended to bring thesame into practice when the next opportunity offered.

Mr. HicKs read a short communication upon a case ofSuppurating Hydropyonephrosis complicating Pregnancy,with remarks upon the symptoms and treatment of pyelitisof pregnancy.-Mr. WHITEHOUSE, in thanking Mr. Hicks forhis paper, said that he was glad to note that the author’sviews regarding the influence of vaccines in this conditioncoincided with his own. Personally, he had never seen acase which, in his opinion, would not have recovered just aswell without vaccines as with them. The majority ofpatients got well on the usual ’l’&eacute;{jimB of absolute rest, light,diet, and urinary antiseptics. Mr. Whitehouse did not

agree with Mr. Hicks’s suggestion that pressure of the

pregnant uterus upon the ureter was the predisposing causeof right side pyelitis, and asked why the right kidney wasthe organ usually attacked in children ? also, why diddilatation of the ureter occur in children and apart from anypressure ?-Mr. MARTIN referred to the rapidity with whichsymptoms of pyelitis were relieved by evacuation of theuterus. If the symptoms did not disappear under ordinary ,,

medicinal measures, he always advised evacuation of theuterus in preference to surgical procedures upon the kidney.-The PRESIDENT was also of opinion that evacuation of theuterus was a therapeutical measure of considerable value insome of these cases, although at times it was difficult tocome to a conclusion, especially if the foetus had reached a,viable age. In such a case he had sometimes been temptedto advise nephrotomy rather than emptying the uterus. -Dr.PURSLOW thought that many cases of pyelitis were due toascending infection from the vulva and were to be attributedto lack of cleanliness on the part of the patient.

EDINBURGH OBSTETRICAL SOCIETY.

The Place of Gynaeoology in the Medical Curriculum and inGeneral Praotioe.

A MEETING of this society was held on Dec. 10th, 1913,Sir J. HALLIDAY CROOM, the President, being in the chair.

Dr. A. H. FREELAND BARBOUR read a paper on the Placeof Gynaecology in the Medical Curriculum and in GeneralPractice. The Edinburgh Royal Infirmary had, he said, madea noteworthy change in recent rearrangements of the clinicalteaching in recognising clinical gynaecology as a depart-ment by itself. The University Court in March, 1906,appointed a lecturer on systematic and clinical gynae-cology, distinct from the lectures on midwifery. In

May, 1907, an examination on clinical gynaecology wasintroduced in the final examination, thus coming tosta.’1d alongside of clinical medicine and clinical surgery.

This did, not imply that it was of the same importance asthese other two subjects, but it emphasised the fact that nograduate of the University should be allowed to enter thepractice of medicine without some evidence of possessing atleast an elementary knowledge of this subject. The last

step had now been taken by the recognition of gynaecology as aspecial department in clinical teaching with a board of its ownto direct that teaching. He (Dr. Barbour) had made an analysisof 2000 cases in the University gynaecological ward andfound that 50 per cent. were referred directly or indirectly toconception or childbirth ; 9 per cent. to the want of themenstrual function at puberty ; 7 per cent. to the patientsentering married life ; while 20 per cent. began to sufferlate in life towards the menopause. Experience showed thatpatients of the working and middle classes, who formed thelarger proportion of the elientele of the general practitioner,expected to be treated in the first instance by the physicianwho attended them at their confinements. The examinationand diagnosis depended on him, and the routine treatment ofchronic cases, what was called minor gynmcology, should berelegated to him. It rested with him to say when thecase should pass out of his hands into those of the specialist.In the infirmary, every sixth lecture in the course of clinicallectures was devoted to gynaecology. It might be said thatthe affections of the reproductive system furnished about thatproportion of the work of the general practitioner as far ashis female patients were concerned. The intimate relation-ship of gynaecology with medicine must not be lost sight of.In former days the specialist did not at once enter on hisspecialty, but took up general medicine as well, and graduallyseparated himself from that. A wide knowledge of therelation of their own specialty to other departments ofmedicine and of the features of the individual case

for a time under their care gave them a sound

judgment which made their opinion weighty. Thedifficulties which beset the clinical investigation of gynoe-cological cases had in the past sent the graduate intopractice inadequately prepared to deal as efficiently withdiseases of the reproductive system as with those of othersystems in the female. Unless a graduate had learned as astudent in the hospital or dispensary under skilled guidancehow to make a bimanual examination, and also what might belearned from it, the little gynaecology he had picked up asa student became less, and finally became a skill or know-ledge not possessed. Gynaecology should not be relegatedto a post-graduate course; hence there had been givento every student during recent years in Edinburghan opportunity of learning the elements of gynaecologicalinvestigation, and the clinical examination had been intro-duced into the final examination to ensure that he hadavailed himself of this advantage. While minor gynaecologywould continue to belong to the general practitioner, operativegynaecology had become more and more the work of a

specialist. It was on its surgical side that gynaecology had ofrecent years been specialised. The operating gynaecologist.must be prepared to deal with any abdominal condition thatmight crop up unexpectedly in, or form a necessary part of, anoperation on the female pelvic organs. In other aspects ofgynaecology there had been a tendency in the oppositedirection. In its pathology the idea was current atone time that there was a special pathology of thefemale pelvic organs which found expression in gynmoo-logical literature such as Bennet’s ’’ inflammation of theuterus," and Graily Hewitt’s 11 mechanical system ofuterine pathology." Now the general principles of patho-logy were applied to pelvic disease. It was recognised that,apart from the peculiarities of the anatomical structuresinvolved and the physiological changes implied in men-struation, there was no difference between salpingitis andappendicitis, and that epithelioma of the cervix did notdiffer from epithelioma of the lip. The same idea,hadcrept into clinical work and came out in the term" diseases peculiar to women." " While the gynae-cologist retained his position as a consulting specialist,yet a considerable part of gynaecological practice was

being relegated to the general practitioner. It was significantthat Kelly, of Baltimore, some years after writing his greatwork on operative gynaecology, brought out one on what hecalled medical gynaecology, and in his preface he stated that’’ this period of surgical evolution is now at last clearly atan end." We seem to be at the beginning of a period ofmedical evolution. The discovery of the internal secretion