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Contemporary titans: Joseph Bolivar DeLee and John Whitridge Williams
volume 120 number 5 November 1, 1974
American Journal of
Obstetrics and Gynecology Transactions of the Ninety-seventh Annual Meeting of the American Gynecological Society
Contemporary titans: Joseph Bolivar DeLee and John Whitridge Williams Presidential address
D. N. DANFORTH, M.D. Evanston, Illinois
S I N C E T H E F 0 U N D I N G of this distinguished Society it has been traditional that the President deliver an address. If their preambles can be taken at face value, many of the Presidents have found difficulty in selecting a subject. In my own case this offered no special problem, for over the years, and indeed over my entire professional career, I have had an abiding admiration for two Fellows of this Society who were contemporaries, and who have had an mdelible influence on our discipline. Each era has its own titans. but rarely in the same generation do we find two men who so completely dominated the obstetric scene as did Joseph Bolivar DeLee and John Whitridge Williams. They were almost of an age: Williams was born in 1866 and DeLee three years later. Presented at the Ninety-seventh Annual Meeting of the American Gynecological Society, Hot Springs, Virginia, May 23-25, 1974. Reprint requests: D. N. Danforth, M.D., 636 Church St., Evanston, Illinois 60201.
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Both enunciated important dicta that were to have permanent effects on our discipline. Roth wrote textbooks that became canon to countless medical students, general practitioners, and obstetricians. Moreover, both textbooks have long survived their original authors and have been carried on by their pupils or their pupils' pupils through 14 editions. Both books were beautifully and strongly illustrated. Both were written in lucid, compelling style, am.l \'
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Fig. 1. Photograph and signature of Joseph Bolivar DeLee. (From Floyd E. Keene, editor: Album of the Fellows of the American Gynecological Society 1896-1930, p. 167, 1930.)
Fig. 2. Photograph and signature of John Whitridge Williams. (From Floyd E. Keene, editor: Album of the Fellows of the American Gynecological Society 1896-1930, p. 625, 1930.)
Calvin Coolidge; of Mary Pickford, Charles Lindbergh, F. Scott Fitzgerald, Will Rogers, and Rudolph Valentino; of Scarface AI Capone, Sacco and V anzetti, and, in l 929, the devastating collapse of the stock market. So it vvas against this background that the Fellows of the Society in the twenties pursued the developments in obstetrics and gynecology that were new and exciting and that form the basis for much that is now common knowledge. As we approach the one hundredth anniversary of the founding of this Society, its is fitting that we pause to reAcct on some of the things that have gone before. I wish to recall something of these two remarkable men, Drs.
1can Gynecological Society during the 1{ years that they both were Fellows, some 50 years ago. These remarks should not be considered as an attempt to compare Drs. DeLee and Williams, or to suggest \Vhose contribution was the greater; both were true giants, but they are not to be compared, for many reasons. Not the least of these is that they were from wholly different backgrounds and their talents, personalities, and objectives were entirely different. Doctor DeLee's mother and father were Jewish immigrants from Poland who met in New York City, where his father had established himself as a small merchant. Dr. DeLee (Fig. 1) was one of ten children. '·!\·'~::: !:~ ·;;;:._:_; ~~ ~~;!d, ' ~!-:..L- DcL~L~ w(;t c j.JOut. They lived on Henry Street in a semi-slum area, and in a house where the Henry Street
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of the remarks they made and the pictures they described from the rostrum of the Amer-
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Fig. 3. "Diagram constructed at right angles to the plane of the serial sections. Showing the ovum partly free in the uterine cavity, and partly embedded in the compact layer of the decidua. D.C. , decidua capsularis. D.V., decidua vera." (From Williams, J. W.: An Early Ovum in situ in the Act of Aborting, Trans. Am. Gynecol. Soc. 44: 100 [Fig. 14], 1919.)
settlement was later established." Through the generosity of his brother Sol, who was a successful business man, the DeLees moved to Chicago, where Dr. DeLee assisted in the family's support by installing doorbells, wires, and lights , and doing occasional work in a drug store. His electrical work financed his first year at the Chicago Medical School, later to become Northwestern University Medical School. He was high-strung, restless, and outspoken. " He seemed to shun social activities ... (and ) found it difficult to mix with other people. No one knew him well socially hecause he was not a soc ial person. Even when he was not working he spent much time alone." He never married. He raised, and later donated, prodigious sums of money to the carr of obstetric patients. His enormous energies were largely devoted to providing proper facilities and standards for obstetric care and spn·ading thf' gospe l of exct>llenct> :! ! ohst<'trio:· practicf'. John \Vhitridgc WillialllS ( Fig. 2 ) is described as an "aristocrat." He was horn in Baltimore, the son of a distinguished Baltimore physician. His maternal great-g randfather began practicing medicine in Rhode Island in 1770, and received honorary degree' from both Han·ard and Yale. His paternal grandfather and great-grandfather were Virginia la wyers, and the family tradition of professional life was yery great indeed. He entered J ohns Hopkins Uni\'ersity at the age
of 18, and "graduated wi th the A.R. degree two years later . . . . His medical course at the University of Maryland was also completed in two years, an d at the early age of 22 his medical career was before him." H e then spent a year in Vienna and Berlin to obtain more thorough grounding in pathology and bacterio logy. On his return he was attached to the gynecologic staff of the newly opened Johns Hopkins Hospital , but spent the greater part of his time in Dr. W elch's laboratories. ln 1892 he was elected to Fellowship in the American Gynecologica l Society . H f' was 26 years of age at the time. thf' youngf'st person (·\·er to bf' admitted to Fellowship in this Society. He was President of the Society in 1914·, four years before DeLee hecame a Fellow. Herbert Little comlllented that '' his relation to his coworkers ... i was ) comparable- to. perhaps sometimes rloser than , father and son. l : ndemonstrative. hut sin( ('rt· a11d a lways fair-minded . lw hrnug·ht out al l that w;ts hest in those who worked with him rather than for him.'' Never anxious for a large private practice, he regarded a case ;t \\.ef·k a~ ample, a nd frt>quent lv referred patients to younger assoc iatt·s. To his younger wen , on one point lw was insistent: ·'\\<'rite at least one paper a ,·ear, a nd do the job thoroughly ." Dr. \.Vi lliarns was happily married , a point curiously omitted by his biographers. He had t>vo daughters: one of them married a physician,
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Fig. 4. "Purely diagrammatic, to show the interior layer of the ani fascia torn and distracted during th e passage of the fetal head. a, Urogenital septum; b, sphincter ani." (From DeLee, J. B.: The Prophylactic Forceps Operation, Trans. Am. Gynecol. Soc . 45: interleaf pp . 72-73 [Fig. 2], 1920.)
a nd the other a lawyer. In his 196+ Presidential Address, Dr. Eastman stated that Williams's outstanding contribution was the men he trained , so many of whom became distinguished leaders in our discipline ; his second most outstanding contribution was the influence he exerted, over three decades, on the development of academic obstetrics in the United States; and the third was Dr. Williams' textbook. In the Transactions for the years 1919 to 1931 arc recorded nine original papers by these two pre-eminent obstetricians and 43 papers that they discussed. Five of the meetings were held here a t the Homestead, where we are now gathered. On only two occasions did they clash, and in eac h of them time has proved that DeLee was correct. The first of these occurred in 1919, the year after DeLee's elrction to Fellowship, and must haw constituted an unpleasant introduction to the Society. The eighteenth paper on the program was by Edward P. Davis of Philadelphia on cesarean section. In discussion, DeLee observed that "The mortality from cesarean section ranges from 2 per cent in some neigh-
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borhoods to 10 to 20 per cent in others. The occurrence o! intestinal and omental adhesions (to the uterine scar) is still very nearly the rule, and not the exception, after the old classic cesarean. The scar in the fundus subjects the woman to the danger of rupture in a subscyuent prrgnancy and labor. These complications must be avoided if we are to enlarge the indications for the operation, and this can be done only by means of new operations." H e then spoke firmly in favor of the low cervical cesarean section which, although not new, had received no enthusiasm in America. "By placing the uterine incision in the cervix and lower uterine segment it is possible to reduce almost to nothing the danger of intestinal adhesions . . . and to eliminate the danger of rupture in subsequent pregnancy and labor." The technique he advocated is much the same as the operation that is standard practice today. Williams was a later discussant: "In regard to what Dr. DeLee has said, the healing of the cesarean section scar . . . depends upon the way the wound is sewed, and whether the woman becomes infected . .. . When the old-fashioned conservative (classic ) operation is properly done, the danger of a weakened scar is very slight and the probability of rupture remote. I have not adopted the ... technique of dissecting back the bladder, and am ... skeptical as to its advantages." One of DeLee's important contributions was his role in popularizing this operation, often in the face of formidable opposition. On the same program Dr. Williams presented a meticulous study of "An early ovum in the act of aborting." Thirteen excellent1 large, low-power photomicrographs were part of the presentation, and the descriptions were made in the greatest detail. The specimen would now be called by the term that Arthur Hertig coined, a "blighted ovum" (Fig. 3). In concluding his paper, Williams stated that "the specimen may be regarded as a striking confirmation of Mall's dictum that primary abnormalities of the ovum are probably the most freauent cause of abortion and th:H the a ttempted abortion in this instance must be regarded as a conservative effort on the
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part of Nature to rid the organism of a structure which had failed to accomplish its allotted task." The second serious difference of opinion occurred a year later, in 1920, when Dr. DeLee presented his now-classic paper on "Prophylactic forceps. " In the paper he proposed episiotomy, outlet forceps, and manual removal of the placenta if it is not delivered vvithin five to ten minutes. He presented a detailed description of the pelvic soft parts and the manner of their damage when the woman is forced to deliver the head spontaneously by her own effort (Fig. 4). Episiotomy prevented much of this damage (Fig. 5). H e insisted that prophylactic forceps saves the mother the debilitating effects of an unnecessa rily prolonged second stage, and saves the babies' brains from injury and from the immediate and remote effects of prolonged compression. Parenthetically, it is disturbing to some of us, and at times even grotesque, to observe the increasing numbers of modern women who demand spontaneous delivery, and whose obstetricians comply, regardless of the length of time the fetal head must pound against the pelvic floor. Williams was the first discussant, and declared that . there are only two things in Dr. DeLee's paper in which I entirely agree. The first is to allow the cervix to undergo spontaneous dilatation, and the second is the correctness of the general anatomical considerations which he has adduced. With the rest of it I do not agree ... . If his practice (of episiotomy and prophylactic forceps ) were . . . widely adopted. the women would be worse off ... th an had th eir labors been conducted In the same ye:u. 1920, Williams presented olle of n1any papers that were to have great
impart on ohstetric practice of the time. In the twcntie~. syphilis was the most importa nt cause of perinatal death , accounting for up to 26 per cent of the deaths. Among 4,000 women delivered over a 3Y2 year period, Williams found 11.2 per cen t to have syphilis, and both diagnosis and treatment were sporadic. Efficient treatment a t that time was regarded as a course of five or six injections
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Fig. 5. " The perineotomy. Cut are the skin, the vagina, the urogenital septum, the outer layer of the levator ani fascia with its reflection over the deep transverse perinei muscle, the fascia over the levator ani both external and internal (the latter is called the fascia endopelvina ). The portion of the fascia endopelvina between the levator ani pillars is called (by the author) the 'intercolumnar fa scia' and is shown at A. a, Urogenital septum; b, levator ani fascia; c, levator ani muscle or pillar ; d, cut edge of deep transverse perinei muscle." (From DeLee , J. B.: The Prophylactic F orceps Operaton, Trans. Am . Gynecol. Soc. 45: interleaf pp. 7'!.-73 [Fig. 3] , 1920.)
of salvarsan followed by mercurial treatmen t. Of the affected patients who had no treatment, only half the babies were free of syphilis; of those incompletely treated, 67 per cent were free from disease, and, with good treatment, 94 per cent were without disease. The three charts a re notable , not only because of their content. but also be('aus~? of thf' handsome red contrasting color of the bar graphs. With due respect to modern editors and publishers, some will conclude that 50 t- years ago either they were more understanding of authors' problems or their technology was superior. At the same meeting DeLee commented a t some length on a group of papers having to do with the delivery of health care. If any of us are concerned by the image of the modern obstetrician he will find that others
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Fig. 6. "Sagittal mesial section showing relations of tumor and disolacement of visrPr" xI,; " , u v n1 tHwaw >, j. W.: A :Study of Frozen Sections Through a Cadaver Showing the Anatomical Relations of a Large Uterine Myoma, Trans. Am. GynecoL Soc. 47: interleaf pp. 134-135 [Fig. 1] , 1922.)
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Fig. 7. "Sagittal section through right side of body, 3 em. from midline, adjacent to figure 2, showing relations of blood vessels, ureter and pelvic musculature. x Y~ ." (From Williams , J. W. : A Study of Frozen Sections Through a Cadaver Showing the Anatomical Relations of a Large U t(' rine M yoma, Trans. Am. Gynecol. Soc . 47: interleaf pp. 134-1 35 [Fig. 10), 1922. )
wt're also troubled some years ago. DeLet' observed that the safeguard ing of women to soc iety depends on the obstetrician. ''Why," he asked. "do we not have more obstetricians? Why so many surgeons and so many in other branches of m edicine? The a nsvvC'r is very simple, too simple. T he life of the obstetrician is not a happy one: the work is very hard and the remuneration is very little . . . . It costs money nowadays to have a baby .. .
(and ) many cannot afford to pay fees com m ensurate with the work. Therefore, somebody must put up the money to give the poor women good obstC'tric care.'' He th en spoke of the low esteem in which the obste trician was held both by the publi c and by health officials, insisting that Pvel)' effort be m ade to improve the dignity of this work . ''ThC' p revention (of fetal and maternal d amage) requires a high degree of obstetric skill, much
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Fig. 8. "Diagram showing still more advanced pregnancy. Maternal surface of placenta in contact with decidua basalis. Fetal surface composed of central chorionic membrane and a peripheral cxtrachorionic zone cove red by decidua. Fetal membranes reflected at margin of central portion giving rise to circumvallate ring." (From Williams, J. W .: Placenta Circumvallata, Trans. Am . Gynecol. Soc. 51: 269 [Fig. 6], 1926. )
higher than is generally known, and the only way to get the public to appreciate it is to let them know that we doctors consider a normal obstetric case of th e highest pathologic dignity." In 1921 a group of papers was presented dealing with obstetric trends, and pointed criticism was made of Potter's routine version and extraction and also of DeLee's prophylactic forceps. Potter defended his thesis firmly but gently. DeLee was very testy at times. H e was much more outspoken in responding, and began by chastising Dr. Rudolph Holmes, who had been especially critical: "In the first place, I desire to dispose of some of the arguments which my colleague from Chicago has advanced. The statistics ... he has adduced are ... mostly bad and ..1..
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Holmes had quoted ) should not be applied, even if they were true, to the general prac-
titioner, neither should they be applied to this Society. Dr. Holmes is charging windmills in a great many of his remarks." Dr. Eden of London had been extremely critical of prophylactic forceps . "Dr. Eden . . . complained bitterly of the high mortality (of the newborns) of his clinic, and the large number of stillbirths. Fifty babies, he said, had died in spontaneous normal labor in the hands of his own expert assistants, and he thought something out to be done about it. I too think something ought to have been done about it; (perhaps 40) of these (50) healthy full-term babies might have been saved by the prophylactic forceps operation. I claim that interference by a skilled accoucheur at the proper time can prevent (much of the) danger and destruction. For Dr. Potter's method (of ver-
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results condemn it. His . . . published (infant) mortality . . . is about 7.5 per cent.
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Fig. 9. "Diagram of uterus late in pregnancy, showing circumvallate placenta in situ with well developed 'annulus.' Note relations of chorionic membrane, extrachorionic decidua, and duplicature of membranes. " (From Williams , J. W.: Placenta Circumvallata, Trans . Am. Gynecol. Soc. 51 : 270 [Fig. 7], 1926.)
This is much too great, and these women are paying too high a price for their relief of pain in the second stage." In 1922 Dr. Williams presented a most meticulous study of the anatomical distortions caused by a huge uterine myoma. The woman ·...-as :Tcri,-cd by tlw department of a nil tomy as a specime n for dissection, and since she looked as though pregnant Dr. Williams was immediately notified. Frozen sections were prepared, and the incomparable Max Brode! made the lO magnificent drawings that illustrate the paper (Figs. 6 and 7). Many parallels were drawn with the circumstance of pregnancy, including the presence of hydroureter and the huge vascularity needed to nourish the tumor, which measured 35 by 20 by 15 em.
In 1925 Dr. DeLee presented his very wellillustrated history of low cervical cesarean section. The II excellent drawings are published with a striking red contrasting color. This very handsome paper proYoked little reaction regarding the propriety of the operation , hut there was considerable discussion of some of the historical statements. In I926 Dr. Williams presented by title his well-known and still widely quoted paper on circumvallate placenta, which was profusely and brilliantly illustrated by Mr. Brode! (Figs. 8 and 9). Both his concept of the pathogenesis of this lesion and the illustrations are now classic. In 1927 Dr. DeLee presented a paper on the mechanism of cervical laceration in labor and the manner of its repair ( Fig. 10) . The
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Fig. 10. "Detail of suture (of lateral laceration of cervix)." (From DeLee,] . B.: Two New Ideas on the Mechanism of Cervical Laceration During Labor. A Preliminary Report, Trans. Am. Gynecol. Soc. 52: 65 [Fig. 2), 1927.)
paper is notable in several respects but in one especially, since he advocated routine inspection of the cervix and repair of lacerations, a practice that did not become standard and routine until many years later. Also, he observed that Pituitrin before delivery was one of the greatest causes of cervical laceration. In the same year, Dr. DeLee's discussion of Arthur Bill's paper on the use of prophylactic transfusion in placenta previa was significant, for it appears to be one of the early recommendations for the double-setup examination in cases of antepartum bleeding. "If there is sufficient hemorrhage to justify interference, the patient is prepared for every possible rnethod of treatment, and we decide what we shall use after this examination." Central placenta previa was always treated by cesarean section, perhaps another departure since Braxton Hicks' version was still practiced in many areas. He also took a firm 't~nrl
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ternal version, stating that if the version can be easily and gently accomplished without
anesthesia, this is proper, but if not the attempt should be abandoned. (This was in discussion of Bartholomew's paper which advocated repeated attempts at external version, and anesthesia if they were unsuccessful.) At the same meeting Dr. Williams discussed George Kosmak's paper on "Fundamental training for obstetrical nurses.'' His remarks, uttered almost 50 years ago, will strike a chord in the hearts of some modern readers: "Everyone admits there is something radically wrong with the nursing situation, and much of the responsibility is ours, for we allowed the control of the developing nursing schools to drift entirely into the hands of the nurses and hospital superintendents .... The result is that in most institutions the training schools are run primarily for the benefit of the nurses, and especially for the advancement in the status of women in general, and with relatively little regard to the weifare of the patients or to the medical needs of the hospital. Indeed, I think it is safe to say that in the majority of the best hospitals advice concerning the conduct of training schools is rarely asked of the more experienced members of the staff, and that when it is volunteered it is regarded as impertinent interference. "Moreover, the strictly medical teaching is done in great part by young men who stand rather in awe of the nursing authorities, with the result that the type and scope of the instruction is dictated by the latter and often resembles the compressed curriculum of a medical school instead of the practical instruction which is desirable. In other cases the young teachers, carried away by their enthusiasm, waste hours in teaching about rare diseases which have no practical significance." After World War I, fewer women applied for nurses' training because of the new and more lucrative job opportunities for educated young women. One answer was an effort "to bolster up and dignify the profession of nursing by giving it a university status. To my mind, this would mean a great advance in Prlnr~tinn
problem care."
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"(The professions of medicine and nursing are) mutually dependent .. .. W f' rr1nnot takP proper care of the sick without the nurse, nor can she without us, but from my point of view nothing can be gained by teaching the nurse to be a poor doctor, and to feel that she is demeaning herself by giving kindly and intelligent care to the sick." In 1928 Dr. Williams discussed a group of papers dealing with pelvic infection and stated that in the Hopkins experience frank obstetric infection occurred twice as commonly in blacks as in whites. Specific inquiry showed this to have no relation whatever to the personal cleanliness of the infected patients. "The more I see of obstetrics in the two races, the more it is borne in upon me that colored women resist infections of all kinds less well than white women .... Everyone is familiar with the relatively high death rate from childbirth in this country, which is higher than in any other civilized country in the world, and it has occurred to me that it may possibly be due to some constitutional inability to resist infection which has developed as a consequence of the admixture of races in this country. Whether this is true or not I cannot say: but at least it would be a more comforting conclusion than that we do dirtier obstetrics (here) than elsewhere." ln the following year, 1929, Williams presented his classic paper on the Naegele pelvis. The patient was a 27-year-old black woman (F ig. 11) who had previously been delivered of six rather smallish babies spontaneously. She fell into labor at term, at home, and had a 17 hour first stage and a 2 hour second stage. Forceps f?iled , and delivery of a living baby we ighing 3,+00 grarus was a ccOH Jplisht•d by what was tem1ed an easy version. Some hours late r she became seriously ill a nd distended. She was admitted to the hospital, where she was seen by Dr. Williams. A diagnosis of ruptured uterus was made and a supravaginal hysterectomy performed . She died two days later. At the autopsy, the entire pelvis was removed along with the last two lumbar vertebrae and the upper ends of the femurs. The dried pelvis ( Fig. 12 ) is meticulously described in the most minute detail,
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Fig. 11. "Front and rear views of patient. Note tilt to left of torso." (From Williams, J. W.: A Clinical and Anatomic Desc ription of a Naegele Pelvis, Trans. Am. Gynecol. Soc. 54: 259 [Fig. 1], 1929.)
Fig. 12. ''Naegele pelvis, front vie'w
xY3." (From
Williams, J. W.: A Cinical and Anatomic Descripti on of a Naegele Pelvis, Trans. Am. Gynecol. Soc. 54: 263 [Fig. 4], 1929.)
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:md rcrna ms as the classic description and --~~ .. 1 . .,.: _ _ [" ..._1_:_. _____ _, ___ , ___ l __ :_ dlld!) ~1~ Ul Lll1~ llHU:"!Udl }Jt"J \' 1~.
In 1930 Dr. DeLee presented to the SocietY the first of 16 motion pictures that he \vas to make. Thf' stated objectives of the films were ( 1) to teach students and nurses. ( 2 I to spread the gospel of good obstetrics throughout the country, and ( 3) to educate the doctors all over the country in proper methods. In all of these objectives the films were spectacularly success[ ul; I doubt there was a medical student or an obstetric nurse who did not see at least several of them. The finai discussion by Dr. DeLee during this era of which we speak was of a paper presented in 1930 by J)r. ~.1cG!innon on music in the operating room. DeLee agreed that music was extremely helpful for cesarean section under local anesthesia. "We found that patients preferred the string quartets as the most soothing and generally applicable." The final paper presented by Dr. Williams before the i\merican Gynecological Society was his monumental work on the "Regeneration of the uterine mucosa after delivery, with special reference to the placental site," a treatise of 32 pages which included no less than 38 illustrations. The original slides must have been striking, but the quality of the published reproductions is for the most part very poor. The number of postpartum uteri that he studied is not recorded in the paper; probably there were more than fifty. Many of the specimens are preserved, and several years ago I had the privilege of seeing some of them at the Johns Hopkins Hospital. From study of the specimens it seemed clear to Williams that six or seven weeks are required for the disappearance of the placental site, and that this disappearance is not caused by absorption but rather by a process of exfoliation which is in great part brought about by the growth of endometrial tissue, with consequent undermining of tlw placental site. In addition to this masterful presentation, he discussed two papers at the 1931 meeting, the last discussions that he was to give before
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the Society, some six months before his sudden and untimely death at the age of 65. The last of these was in response to Arthur Curtis's observation of the salutary effect of small blood transfusions "to women who had very bad vomiting of pregnancy." Said Williams, "I am a skeptic and I am indeed very skeptical about curing pernicious vomiting by the injection of any substance whatever, bccausc I can get the same result by simply talking to the patient and looking at her without injecting anything." These few extracts from the papers and discussions of Drs. DeLee and Williams are of course only the smallest fraction of their contributions to this Society during these years. Perhaps, however, they will provide an overview of these two men who were so vastly different, and whose contributions to the art and science of obstetrics were so massivc. The debt we owe to them and to the other distinguished Fellows of this Society \,vho have gone before is very great indeed. "May we so conduct ourselves that not only we may follow well the example they have set, but that we may maintain our Society in that high place in which our predecessors have left it." The remarks of Drs. DeLee and Williams that are quoted in the text are to be found in the Transactions of the American Gynecological Society for the years indicated. The final quotation of the paper is from the 1942 Presidential Address by W. C. Danforth (Trans. ,\rn. Gynecol. Soc. 67: 1, 1942). The brief biographical data were taken from the following sources: Eastman, Nicholson J.: Trans. Am. Gynecol. Soc. 37: I, 1964. Everett, Houston: Personal communication. Fishbein, Morris, with DeLee, Sol Theon: Joseph Bolivar DeLee: Crusading Obstetrician, New York, 1949, E. P. Dutton & Con1pany. Little, Herbert M.: Trans. Am. Gynecol. Soc. 57: 233, 1932. Slemons, J. !t.1orris: John \AJhitridgc '\AlilliamsAcademic Aspects and Bibliography, Baltimore, 1935, The Johns Hopkins Press.
American Journal of
Obstetrics and Gynecology Transactions of the Ninety-seventh Annual Meeting of the American Gynecological Society
Contemporary titans: Joseph Bolivar DeLee and John Whitridge Williams Presidential address
D. N. DANFORTH, M.D. Evanston, Illinois
S I N C E T H E F 0 U N D I N G of this distinguished Society it has been traditional that the President deliver an address. If their preambles can be taken at face value, many of the Presidents have found difficulty in selecting a subject. In my own case this offered no special problem, for over the years, and indeed over my entire professional career, I have had an abiding admiration for two Fellows of this Society who were contemporaries, and who have had an mdelible influence on our discipline. Each era has its own titans. but rarely in the same generation do we find two men who so completely dominated the obstetric scene as did Joseph Bolivar DeLee and John Whitridge Williams. They were almost of an age: Williams was born in 1866 and DeLee three years later. Presented at the Ninety-seventh Annual Meeting of the American Gynecological Society, Hot Springs, Virginia, May 23-25, 1974. Reprint requests: D. N. Danforth, M.D., 636 Church St., Evanston, Illinois 60201.
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Both enunciated important dicta that were to have permanent effects on our discipline. Roth wrote textbooks that became canon to countless medical students, general practitioners, and obstetricians. Moreover, both textbooks have long survived their original authors and have been carried on by their pupils or their pupils' pupils through 14 editions. Both books were beautifully and strongly illustrated. Both were written in lucid, compelling style, am.l \'
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Fig. 1. Photograph and signature of Joseph Bolivar DeLee. (From Floyd E. Keene, editor: Album of the Fellows of the American Gynecological Society 1896-1930, p. 167, 1930.)
Fig. 2. Photograph and signature of John Whitridge Williams. (From Floyd E. Keene, editor: Album of the Fellows of the American Gynecological Society 1896-1930, p. 625, 1930.)
Calvin Coolidge; of Mary Pickford, Charles Lindbergh, F. Scott Fitzgerald, Will Rogers, and Rudolph Valentino; of Scarface AI Capone, Sacco and V anzetti, and, in l 929, the devastating collapse of the stock market. So it vvas against this background that the Fellows of the Society in the twenties pursued the developments in obstetrics and gynecology that were new and exciting and that form the basis for much that is now common knowledge. As we approach the one hundredth anniversary of the founding of this Society, its is fitting that we pause to reAcct on some of the things that have gone before. I wish to recall something of these two remarkable men, Drs.
1can Gynecological Society during the 1{ years that they both were Fellows, some 50 years ago. These remarks should not be considered as an attempt to compare Drs. DeLee and Williams, or to suggest \Vhose contribution was the greater; both were true giants, but they are not to be compared, for many reasons. Not the least of these is that they were from wholly different backgrounds and their talents, personalities, and objectives were entirely different. Doctor DeLee's mother and father were Jewish immigrants from Poland who met in New York City, where his father had established himself as a small merchant. Dr. DeLee (Fig. 1) was one of ten children. '·!\·'~::: !:~ ·;;;:._:_; ~~ ~~;!d, ' ~!-:..L- DcL~L~ w(;t c j.JOut. They lived on Henry Street in a semi-slum area, and in a house where the Henry Street
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4
Volume 120 Number 5
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Fig. 3. "Diagram constructed at right angles to the plane of the serial sections. Showing the ovum partly free in the uterine cavity, and partly embedded in the compact layer of the decidua. D.C. , decidua capsularis. D.V., decidua vera." (From Williams, J. W.: An Early Ovum in situ in the Act of Aborting, Trans. Am. Gynecol. Soc. 44: 100 [Fig. 14], 1919.)
settlement was later established." Through the generosity of his brother Sol, who was a successful business man, the DeLees moved to Chicago, where Dr. DeLee assisted in the family's support by installing doorbells, wires, and lights , and doing occasional work in a drug store. His electrical work financed his first year at the Chicago Medical School, later to become Northwestern University Medical School. He was high-strung, restless, and outspoken. " He seemed to shun social activities ... (and ) found it difficult to mix with other people. No one knew him well socially hecause he was not a soc ial person. Even when he was not working he spent much time alone." He never married. He raised, and later donated, prodigious sums of money to the carr of obstetric patients. His enormous energies were largely devoted to providing proper facilities and standards for obstetric care and spn·ading thf' gospe l of exct>llenct> :! ! ohst<'trio:· practicf'. John \Vhitridgc WillialllS ( Fig. 2 ) is described as an "aristocrat." He was horn in Baltimore, the son of a distinguished Baltimore physician. His maternal great-g randfather began practicing medicine in Rhode Island in 1770, and received honorary degree' from both Han·ard and Yale. His paternal grandfather and great-grandfather were Virginia la wyers, and the family tradition of professional life was yery great indeed. He entered J ohns Hopkins Uni\'ersity at the age
of 18, and "graduated wi th the A.R. degree two years later . . . . His medical course at the University of Maryland was also completed in two years, an d at the early age of 22 his medical career was before him." H e then spent a year in Vienna and Berlin to obtain more thorough grounding in pathology and bacterio logy. On his return he was attached to the gynecologic staff of the newly opened Johns Hopkins Hospital , but spent the greater part of his time in Dr. W elch's laboratories. ln 1892 he was elected to Fellowship in the American Gynecologica l Society . H f' was 26 years of age at the time. thf' youngf'st person (·\·er to bf' admitted to Fellowship in this Society. He was President of the Society in 1914·, four years before DeLee hecame a Fellow. Herbert Little comlllented that '' his relation to his coworkers ... i was ) comparable- to. perhaps sometimes rloser than , father and son. l : ndemonstrative. hut sin( ('rt· a11d a lways fair-minded . lw hrnug·ht out al l that w;ts hest in those who worked with him rather than for him.'' Never anxious for a large private practice, he regarded a case ;t \\.ef·k a~ ample, a nd frt>quent lv referred patients to younger assoc iatt·s. To his younger wen , on one point lw was insistent: ·'\\<'rite at least one paper a ,·ear, a nd do the job thoroughly ." Dr. \.Vi lliarns was happily married , a point curiously omitted by his biographers. He had t>vo daughters: one of them married a physician,
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Fig. 4. "Purely diagrammatic, to show the interior layer of the ani fascia torn and distracted during th e passage of the fetal head. a, Urogenital septum; b, sphincter ani." (From DeLee, J. B.: The Prophylactic Forceps Operation, Trans. Am. Gynecol. Soc . 45: interleaf pp . 72-73 [Fig. 2], 1920.)
a nd the other a lawyer. In his 196+ Presidential Address, Dr. Eastman stated that Williams's outstanding contribution was the men he trained , so many of whom became distinguished leaders in our discipline ; his second most outstanding contribution was the influence he exerted, over three decades, on the development of academic obstetrics in the United States; and the third was Dr. Williams' textbook. In the Transactions for the years 1919 to 1931 arc recorded nine original papers by these two pre-eminent obstetricians and 43 papers that they discussed. Five of the meetings were held here a t the Homestead, where we are now gathered. On only two occasions did they clash, and in eac h of them time has proved that DeLee was correct. The first of these occurred in 1919, the year after DeLee's elrction to Fellowship, and must haw constituted an unpleasant introduction to the Society. The eighteenth paper on the program was by Edward P. Davis of Philadelphia on cesarean section. In discussion, DeLee observed that "The mortality from cesarean section ranges from 2 per cent in some neigh-
November I, 19i4 Am. J. Obstrt. Gynccol.
borhoods to 10 to 20 per cent in others. The occurrence o! intestinal and omental adhesions (to the uterine scar) is still very nearly the rule, and not the exception, after the old classic cesarean. The scar in the fundus subjects the woman to the danger of rupture in a subscyuent prrgnancy and labor. These complications must be avoided if we are to enlarge the indications for the operation, and this can be done only by means of new operations." H e then spoke firmly in favor of the low cervical cesarean section which, although not new, had received no enthusiasm in America. "By placing the uterine incision in the cervix and lower uterine segment it is possible to reduce almost to nothing the danger of intestinal adhesions . . . and to eliminate the danger of rupture in subsequent pregnancy and labor." The technique he advocated is much the same as the operation that is standard practice today. Williams was a later discussant: "In regard to what Dr. DeLee has said, the healing of the cesarean section scar . . . depends upon the way the wound is sewed, and whether the woman becomes infected . .. . When the old-fashioned conservative (classic ) operation is properly done, the danger of a weakened scar is very slight and the probability of rupture remote. I have not adopted the ... technique of dissecting back the bladder, and am ... skeptical as to its advantages." One of DeLee's important contributions was his role in popularizing this operation, often in the face of formidable opposition. On the same program Dr. Williams presented a meticulous study of "An early ovum in the act of aborting." Thirteen excellent1 large, low-power photomicrographs were part of the presentation, and the descriptions were made in the greatest detail. The specimen would now be called by the term that Arthur Hertig coined, a "blighted ovum" (Fig. 3). In concluding his paper, Williams stated that "the specimen may be regarded as a striking confirmation of Mall's dictum that primary abnormalities of the ovum are probably the most freauent cause of abortion and th:H the a ttempted abortion in this instance must be regarded as a conservative effort on the
Volum e 120 Number 5
part of Nature to rid the organism of a structure which had failed to accomplish its allotted task." The second serious difference of opinion occurred a year later, in 1920, when Dr. DeLee presented his now-classic paper on "Prophylactic forceps. " In the paper he proposed episiotomy, outlet forceps, and manual removal of the placenta if it is not delivered vvithin five to ten minutes. He presented a detailed description of the pelvic soft parts and the manner of their damage when the woman is forced to deliver the head spontaneously by her own effort (Fig. 4). Episiotomy prevented much of this damage (Fig. 5). H e insisted that prophylactic forceps saves the mother the debilitating effects of an unnecessa rily prolonged second stage, and saves the babies' brains from injury and from the immediate and remote effects of prolonged compression. Parenthetically, it is disturbing to some of us, and at times even grotesque, to observe the increasing numbers of modern women who demand spontaneous delivery, and whose obstetricians comply, regardless of the length of time the fetal head must pound against the pelvic floor. Williams was the first discussant, and declared that . there are only two things in Dr. DeLee's paper in which I entirely agree. The first is to allow the cervix to undergo spontaneous dilatation, and the second is the correctness of the general anatomical considerations which he has adduced. With the rest of it I do not agree ... . If his practice (of episiotomy and prophylactic forceps ) were . . . widely adopted. the women would be worse off ... th an had th eir labors been conducted In the same ye:u. 1920, Williams presented olle of n1any papers that were to have great
impart on ohstetric practice of the time. In the twcntie~. syphilis was the most importa nt cause of perinatal death , accounting for up to 26 per cent of the deaths. Among 4,000 women delivered over a 3Y2 year period, Williams found 11.2 per cen t to have syphilis, and both diagnosis and treatment were sporadic. Efficient treatment a t that time was regarded as a course of five or six injections
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Fig. 5. " The perineotomy. Cut are the skin, the vagina, the urogenital septum, the outer layer of the levator ani fascia with its reflection over the deep transverse perinei muscle, the fascia over the levator ani both external and internal (the latter is called the fascia endopelvina ). The portion of the fascia endopelvina between the levator ani pillars is called (by the author) the 'intercolumnar fa scia' and is shown at A. a, Urogenital septum; b, levator ani fascia; c, levator ani muscle or pillar ; d, cut edge of deep transverse perinei muscle." (From DeLee , J. B.: The Prophylactic F orceps Operaton, Trans. Am . Gynecol. Soc. 45: interleaf pp. 7'!.-73 [Fig. 3] , 1920.)
of salvarsan followed by mercurial treatmen t. Of the affected patients who had no treatment, only half the babies were free of syphilis; of those incompletely treated, 67 per cent were free from disease, and, with good treatment, 94 per cent were without disease. The three charts a re notable , not only because of their content. but also be('aus~? of thf' handsome red contrasting color of the bar graphs. With due respect to modern editors and publishers, some will conclude that 50 t- years ago either they were more understanding of authors' problems or their technology was superior. At the same meeting DeLee commented a t some length on a group of papers having to do with the delivery of health care. If any of us are concerned by the image of the modern obstetrician he will find that others
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Fig. 6. "Sagittal mesial section showing relations of tumor and disolacement of visrPr" xI,; " , u v n1 tHwaw >, j. W.: A :Study of Frozen Sections Through a Cadaver Showing the Anatomical Relations of a Large Uterine Myoma, Trans. Am. GynecoL Soc. 47: interleaf pp. 134-135 [Fig. 1] , 1922.)
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Fig. 7. "Sagittal section through right side of body, 3 em. from midline, adjacent to figure 2, showing relations of blood vessels, ureter and pelvic musculature. x Y~ ." (From Williams , J. W. : A Study of Frozen Sections Through a Cadaver Showing the Anatomical Relations of a Large U t(' rine M yoma, Trans. Am. Gynecol. Soc . 47: interleaf pp. 134-1 35 [Fig. 10), 1922. )
wt're also troubled some years ago. DeLet' observed that the safeguard ing of women to soc iety depends on the obstetrician. ''Why," he asked. "do we not have more obstetricians? Why so many surgeons and so many in other branches of m edicine? The a nsvvC'r is very simple, too simple. T he life of the obstetrician is not a happy one: the work is very hard and the remuneration is very little . . . . It costs money nowadays to have a baby .. .
(and ) many cannot afford to pay fees com m ensurate with the work. Therefore, somebody must put up the money to give the poor women good obstC'tric care.'' He th en spoke of the low esteem in which the obste trician was held both by the publi c and by health officials, insisting that Pvel)' effort be m ade to improve the dignity of this work . ''ThC' p revention (of fetal and maternal d amage) requires a high degree of obstetric skill, much
584
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Fig. 8. "Diagram showing still more advanced pregnancy. Maternal surface of placenta in contact with decidua basalis. Fetal surface composed of central chorionic membrane and a peripheral cxtrachorionic zone cove red by decidua. Fetal membranes reflected at margin of central portion giving rise to circumvallate ring." (From Williams, J. W .: Placenta Circumvallata, Trans. Am . Gynecol. Soc. 51: 269 [Fig. 6], 1926. )
higher than is generally known, and the only way to get the public to appreciate it is to let them know that we doctors consider a normal obstetric case of th e highest pathologic dignity." In 1921 a group of papers was presented dealing with obstetric trends, and pointed criticism was made of Potter's routine version and extraction and also of DeLee's prophylactic forceps. Potter defended his thesis firmly but gently. DeLee was very testy at times. H e was much more outspoken in responding, and began by chastising Dr. Rudolph Holmes, who had been especially critical: "In the first place, I desire to dispose of some of the arguments which my colleague from Chicago has advanced. The statistics ... he has adduced are ... mostly bad and ..1..
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Holmes had quoted ) should not be applied, even if they were true, to the general prac-
titioner, neither should they be applied to this Society. Dr. Holmes is charging windmills in a great many of his remarks." Dr. Eden of London had been extremely critical of prophylactic forceps . "Dr. Eden . . . complained bitterly of the high mortality (of the newborns) of his clinic, and the large number of stillbirths. Fifty babies, he said, had died in spontaneous normal labor in the hands of his own expert assistants, and he thought something out to be done about it. I too think something ought to have been done about it; (perhaps 40) of these (50) healthy full-term babies might have been saved by the prophylactic forceps operation. I claim that interference by a skilled accoucheur at the proper time can prevent (much of the) danger and destruction. For Dr. Potter's method (of ver-
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Fig. 9. "Diagram of uterus late in pregnancy, showing circumvallate placenta in situ with well developed 'annulus.' Note relations of chorionic membrane, extrachorionic decidua, and duplicature of membranes. " (From Williams , J. W.: Placenta Circumvallata, Trans . Am. Gynecol. Soc. 51 : 270 [Fig. 7], 1926.)
This is much too great, and these women are paying too high a price for their relief of pain in the second stage." In 1922 Dr. Williams presented a most meticulous study of the anatomical distortions caused by a huge uterine myoma. The woman ·...-as :Tcri,-cd by tlw department of a nil tomy as a specime n for dissection, and since she looked as though pregnant Dr. Williams was immediately notified. Frozen sections were prepared, and the incomparable Max Brode! made the lO magnificent drawings that illustrate the paper (Figs. 6 and 7). Many parallels were drawn with the circumstance of pregnancy, including the presence of hydroureter and the huge vascularity needed to nourish the tumor, which measured 35 by 20 by 15 em.
In 1925 Dr. DeLee presented his very wellillustrated history of low cervical cesarean section. The II excellent drawings are published with a striking red contrasting color. This very handsome paper proYoked little reaction regarding the propriety of the operation , hut there was considerable discussion of some of the historical statements. In I926 Dr. Williams presented by title his well-known and still widely quoted paper on circumvallate placenta, which was profusely and brilliantly illustrated by Mr. Brode! (Figs. 8 and 9). Both his concept of the pathogenesis of this lesion and the illustrations are now classic. In 1927 Dr. DeLee presented a paper on the mechanism of cervical laceration in labor and the manner of its repair ( Fig. 10) . The
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Fig. 10. "Detail of suture (of lateral laceration of cervix)." (From DeLee,] . B.: Two New Ideas on the Mechanism of Cervical Laceration During Labor. A Preliminary Report, Trans. Am. Gynecol. Soc. 52: 65 [Fig. 2), 1927.)
paper is notable in several respects but in one especially, since he advocated routine inspection of the cervix and repair of lacerations, a practice that did not become standard and routine until many years later. Also, he observed that Pituitrin before delivery was one of the greatest causes of cervical laceration. In the same year, Dr. DeLee's discussion of Arthur Bill's paper on the use of prophylactic transfusion in placenta previa was significant, for it appears to be one of the early recommendations for the double-setup examination in cases of antepartum bleeding. "If there is sufficient hemorrhage to justify interference, the patient is prepared for every possible rnethod of treatment, and we decide what we shall use after this examination." Central placenta previa was always treated by cesarean section, perhaps another departure since Braxton Hicks' version was still practiced in many areas. He also took a firm 't~nrl
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ternal version, stating that if the version can be easily and gently accomplished without
anesthesia, this is proper, but if not the attempt should be abandoned. (This was in discussion of Bartholomew's paper which advocated repeated attempts at external version, and anesthesia if they were unsuccessful.) At the same meeting Dr. Williams discussed George Kosmak's paper on "Fundamental training for obstetrical nurses.'' His remarks, uttered almost 50 years ago, will strike a chord in the hearts of some modern readers: "Everyone admits there is something radically wrong with the nursing situation, and much of the responsibility is ours, for we allowed the control of the developing nursing schools to drift entirely into the hands of the nurses and hospital superintendents .... The result is that in most institutions the training schools are run primarily for the benefit of the nurses, and especially for the advancement in the status of women in general, and with relatively little regard to the weifare of the patients or to the medical needs of the hospital. Indeed, I think it is safe to say that in the majority of the best hospitals advice concerning the conduct of training schools is rarely asked of the more experienced members of the staff, and that when it is volunteered it is regarded as impertinent interference. "Moreover, the strictly medical teaching is done in great part by young men who stand rather in awe of the nursing authorities, with the result that the type and scope of the instruction is dictated by the latter and often resembles the compressed curriculum of a medical school instead of the practical instruction which is desirable. In other cases the young teachers, carried away by their enthusiasm, waste hours in teaching about rare diseases which have no practical significance." After World War I, fewer women applied for nurses' training because of the new and more lucrative job opportunities for educated young women. One answer was an effort "to bolster up and dignify the profession of nursing by giving it a university status. To my mind, this would mean a great advance in Prlnr~tinn
problem care."
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Volume 120 N umber 5
"(The professions of medicine and nursing are) mutually dependent .. .. W f' rr1nnot takP proper care of the sick without the nurse, nor can she without us, but from my point of view nothing can be gained by teaching the nurse to be a poor doctor, and to feel that she is demeaning herself by giving kindly and intelligent care to the sick." In 1928 Dr. Williams discussed a group of papers dealing with pelvic infection and stated that in the Hopkins experience frank obstetric infection occurred twice as commonly in blacks as in whites. Specific inquiry showed this to have no relation whatever to the personal cleanliness of the infected patients. "The more I see of obstetrics in the two races, the more it is borne in upon me that colored women resist infections of all kinds less well than white women .... Everyone is familiar with the relatively high death rate from childbirth in this country, which is higher than in any other civilized country in the world, and it has occurred to me that it may possibly be due to some constitutional inability to resist infection which has developed as a consequence of the admixture of races in this country. Whether this is true or not I cannot say: but at least it would be a more comforting conclusion than that we do dirtier obstetrics (here) than elsewhere." ln the following year, 1929, Williams presented his classic paper on the Naegele pelvis. The patient was a 27-year-old black woman (F ig. 11) who had previously been delivered of six rather smallish babies spontaneously. She fell into labor at term, at home, and had a 17 hour first stage and a 2 hour second stage. Forceps f?iled , and delivery of a living baby we ighing 3,+00 grarus was a ccOH Jplisht•d by what was tem1ed an easy version. Some hours late r she became seriously ill a nd distended. She was admitted to the hospital, where she was seen by Dr. Williams. A diagnosis of ruptured uterus was made and a supravaginal hysterectomy performed . She died two days later. At the autopsy, the entire pelvis was removed along with the last two lumbar vertebrae and the upper ends of the femurs. The dried pelvis ( Fig. 12 ) is meticulously described in the most minute detail,
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Fig. 11. "Front and rear views of patient. Note tilt to left of torso." (From Williams, J. W.: A Clinical and Anatomic Desc ription of a Naegele Pelvis, Trans. Am. Gynecol. Soc. 54: 259 [Fig. 1], 1929.)
Fig. 12. ''Naegele pelvis, front vie'w
xY3." (From
Williams, J. W.: A Cinical and Anatomic Descripti on of a Naegele Pelvis, Trans. Am. Gynecol. Soc. 54: 263 [Fig. 4], 1929.)
588
Danforth
:md rcrna ms as the classic description and --~~ .. 1 . .,.: _ _ [" ..._1_:_. _____ _, ___ , ___ l __ :_ dlld!) ~1~ Ul Lll1~ llHU:"!Udl }Jt"J \' 1~.
In 1930 Dr. DeLee presented to the SocietY the first of 16 motion pictures that he \vas to make. Thf' stated objectives of the films were ( 1) to teach students and nurses. ( 2 I to spread the gospel of good obstetrics throughout the country, and ( 3) to educate the doctors all over the country in proper methods. In all of these objectives the films were spectacularly success[ ul; I doubt there was a medical student or an obstetric nurse who did not see at least several of them. The finai discussion by Dr. DeLee during this era of which we speak was of a paper presented in 1930 by J)r. ~.1cG!innon on music in the operating room. DeLee agreed that music was extremely helpful for cesarean section under local anesthesia. "We found that patients preferred the string quartets as the most soothing and generally applicable." The final paper presented by Dr. Williams before the i\merican Gynecological Society was his monumental work on the "Regeneration of the uterine mucosa after delivery, with special reference to the placental site," a treatise of 32 pages which included no less than 38 illustrations. The original slides must have been striking, but the quality of the published reproductions is for the most part very poor. The number of postpartum uteri that he studied is not recorded in the paper; probably there were more than fifty. Many of the specimens are preserved, and several years ago I had the privilege of seeing some of them at the Johns Hopkins Hospital. From study of the specimens it seemed clear to Williams that six or seven weeks are required for the disappearance of the placental site, and that this disappearance is not caused by absorption but rather by a process of exfoliation which is in great part brought about by the growth of endometrial tissue, with consequent undermining of tlw placental site. In addition to this masterful presentation, he discussed two papers at the 1931 meeting, the last discussions that he was to give before
November 1, 1974 Am. J. Obstet. Gynecol.
the Society, some six months before his sudden and untimely death at the age of 65. The last of these was in response to Arthur Curtis's observation of the salutary effect of small blood transfusions "to women who had very bad vomiting of pregnancy." Said Williams, "I am a skeptic and I am indeed very skeptical about curing pernicious vomiting by the injection of any substance whatever, bccausc I can get the same result by simply talking to the patient and looking at her without injecting anything." These few extracts from the papers and discussions of Drs. DeLee and Williams are of course only the smallest fraction of their contributions to this Society during these years. Perhaps, however, they will provide an overview of these two men who were so vastly different, and whose contributions to the art and science of obstetrics were so massivc. The debt we owe to them and to the other distinguished Fellows of this Society \,vho have gone before is very great indeed. "May we so conduct ourselves that not only we may follow well the example they have set, but that we may maintain our Society in that high place in which our predecessors have left it." The remarks of Drs. DeLee and Williams that are quoted in the text are to be found in the Transactions of the American Gynecological Society for the years indicated. The final quotation of the paper is from the 1942 Presidential Address by W. C. Danforth (Trans. ,\rn. Gynecol. Soc. 67: 1, 1942). The brief biographical data were taken from the following sources: Eastman, Nicholson J.: Trans. Am. Gynecol. Soc. 37: I, 1964. Everett, Houston: Personal communication. Fishbein, Morris, with DeLee, Sol Theon: Joseph Bolivar DeLee: Crusading Obstetrician, New York, 1949, E. P. Dutton & Con1pany. Little, Herbert M.: Trans. Am. Gynecol. Soc. 57: 233, 1932. Slemons, J. !t.1orris: John \AJhitridgc '\AlilliamsAcademic Aspects and Bibliography, Baltimore, 1935, The Johns Hopkins Press.