- Email: [email protected]
KIDDERMINSTER INFIRMARY AND CHILDREN'S HOSPITAL.
HOSPITAL MEDICINE AND SURGERY. were
removed,
a
gauze drain
was
substituted,
and
a
light
dressing was applied, the wound being disturbed as little as possible. The pulse was 158. No further haemorrhage occurred from the wound but the patient died suddenly at 2
A.M. on
the 13th.
the abdomen the small intestine found spreading from the abscess region over the parietal peritoneum but there was no pus or lymph between the coils of the intestine. The large bowel was contracted and there was a large quantity of blood and pus in Douglas’s pouch. The appendix was found lying behind the cascum and running upwards and slightly inwards (Fig. 1); it was about four inches long and the last inch was completely gangrenous ; there was no concretion. The abscess cavity was behind, and somewhat internal to, the cascum and behind the last part of the ileum. The walls of the cavity were formed by the following structures-ceecum, ileum, duodenum (second part), psoas muscle, iliac vein, vena cava, and the iliac fascia in the right iliac fossa (Fig. 2). In the cavity In the duodenum just where it were pus and blood clot. turns up and in to run across the right crus of the diaphragm was a perforation with sloughing edges of about the size of The ulceration on the mucous surface was smaller a pea. than that on the peritoneal. On opening the duodenum and ileum they were found to contain a large quantity of blood. The iliac veins and the vena cava were normal. The rest of
Neoropsy.-On opening
was
distended and pus
the organs
were
was
normal. FIG. 1.
Diagram showing position of appendix. FIG. 2.
161
fatal case with haemorrhage from the external iliac artery. J. D. Malcolm3 at the Clinical Society of London reported a case with severe haemorrhage which recovered, the source of the bleeding not being ascertained, and in the discussion that followed other cases were mentioned, Charters Symonds reporting a case in which he found the external iliac artery and vein opened. Box and Wallace4 report a fatal case of bleeding but the source of the haemorrhage was not discovered ; two severe hemorrhages occurred per rectum. Ramsayrecords a case of sloughing of the external iliac artery in which the vessel was ligatured and recovery took place. Dyce Duckworth reports a case in which the bsemorrhage occurred on the eighth day, with recovery. Moynihan, quoting Murphy and Mayo, states that the bleeding occurs from small vessels on the inner side of the appendix. Perforation of the stomach and duodenum are also wellknown complications and the following cases have been reported. Dieulafoy’records a fatal case of baematemesis following removal of the appendix in which acute necrosis of the mucous membrane of the stomach was found. Warren Lowreports a case of perforation of an ulcer of the stomach with appendicitis. Lediard and Sedgwickreport a case of perforation of an ulcer on the pancreatic surface of the second part of the duodenum ; there was no acute inflammation of the appendix and the abdomen was not drained. In the same paper they also quote a care of gastric ulcer under the care of F. Victor Milward. Watson Cheyne and H. Wilbereport a case of perforated gastric ulcer with appendicitis. Bolton Carter" gives particulars of a case of an appendix abscess which was opened and drained with an indiarubber tube in which there was bsemorrhage from the wound and death occurred. Post mortem the appendix was gangrenous and lying deeply ovei the pelvic brim. The ulcer which had perforated was on the anterior surface of the second part of the duodenum. The direction in which the abscess had tracked and the direction in which the tube was inserted are not given. The case described differs from all those quoted above in that the perforation in the duodenum was-in the wall of the abscess and that the perforation was certainly into the duodenum. Whether the perforation was caused by the tube used for drainage resting against the duodenum is doubtful, as it was removed and gauze was substituted when the haemorrhage occurred, but from the direction in which the tube ran it most likely did rest against the second part of the duodenum and was the cause of the fatal result. The case described by Bolton Carter may have been of this nature but in his case the appendix was hanging -over the brim of the pelvis and the abscess wall probably did not include the duodenum.
a
I
KIDDERMINSTER INFIRMARY AND CHILDREN’S HOSPITAL. A CASE OF SUCCESSFUL EXCISION OF A PORTION OF RIGHT LUNG FOR PULMONARY TUBERCULOSIS.
THE
(Under the care of Mr. J. LIONEL STRETTON.) patient, a female, aged 28 years, was admitted to the infirmary on July 19th, 1900. There were signs of tuberculous disease at the apex of the right lung, for which she was treated with increasing doses of creasote with temporary benefit. After her discharge the symptoms-cough, expectoration, and night sweats-increased in severity and she suggested the possibility of removing the diseased portion of lung. A full explanation of the danger was given to her and to her husband and they both desired the operation to be undertaken. She was readmitted on August 2nd, 1900, when the following note was made. " The patient gives a history of being treated four years ago for a delicate chest. For the past year and a half she has had a continuous cough with expectoration and night sweats ; she has also been losing flesh. There is dulness over the right apex as far down as the Tubular breathing and lower border of the third rib. crepitant rales. The evening temperature is slightly raised and she has night sweats. The urine contains a trace of THE
Diagram showing position
of abscess cavity within dotted circle and perforation of duodenum.
albumin." Remarks by Mr. RUSSELL HOWARD.-The interest of this On August 7th the patient was placed under ether. A case lies in the two complications-hoamorrhage and perforavertical incision was made, about three inches long, with its tion of the duodenum. Haemorrhage is a fairly well-known complication and 3 THE LANCET, March 3rd, 1906, p. 600. 4 THE LANCET, June 6th, 1903, p. 1588. appears to be usually from erosion of the iliac vessels or the 5 THE LANCET, June 6th, 1903, p. 1590. deep circumflex iliac artery. J. C. Lewislrecords a case of 6 and Corner, Diseases of the Appendix, p. 176. Quoted by Battle haemorrhage from the common iliac vein. G. Sourdille2 relates 7 THE LANCET, June 25th, 1904, p. 1789. 8 THE LANCET, Sept 10th, 1904, p. 761. 1 Medical Record, New 9 THE LANCET, June 11th, 1904, p. 1641. York, 1894, p. 463. 2 Bulletin de la Société d’Anatomie de Paris, 1894. 10 THE LANCET, Nov 2nd, 1901, p. 1194.
162
OBSTETRICAL SOCIETY OF LONDON.
centre over the third rib, two inches from, and parallel to, the breast bone. The third rib was separated from its cartilage and about four inches of it removed. On opening the pleura the lung was found closely adherent. The hand was introduced and the adhesions were with great difficulty separated down to the lower level of the third rib. There was profuse boenaorrhage, which was arrested by sponge pressure. The portion of lung separated was then surrounded with a serre-nceud and cut away, leaving a stump of about the size of a five-shilling piece. For the first 24 hours after the operation the patient remained in a very collapsed condition and suffered from pain and cough.. At the end of 48 hours an attempt was made to remove the serre-noeud. but as rather free haemorrhage occurred the wire was twisted and left on. For the next few days there were considerable difficulty in breathing, constant cough, and haemorrhagic expectoration. There was also a good deal of hmmorrhage from the wound. Blood was found to collect in the pleura and had to be removed with a syringe. The breathing and cough gradually improved and the haemorrhage ceased after the seventh day. In spite of great care with the dressings symptoms of sepsis supervened and on the 22nd it was deemed advisable to make a counter opening in the back and thread a large drainage-tube through. From that date improvement was continuous though slow. The wire came away on the 25th. The tube was removed on Nov. 7th and the wound was healed by the 14th. Her cough and expectoration entirely ceased by Nov. 23rd. A specimen of the sputum was sent to the Worcestershire county council laboratory for examination at the end of October and the report stated that no bacilli could be found. The portion of lung removed consisted of about half of the right upper lobe and contained a cavity. Unfortunately it was destroyed before a thorough examination had been made. Remarlcs by Mr. STRETTON.-As I was unable to find any account of a similar operation it was necessary to devise the method of performing it. The chief difficulty I foresaw was the question of adhesions and this proved to be correct. The removal of one rib gave ample room for all the manipulations. It was found impossible to fix the stump in the wound because this caused dragging on the root of the lung accompanied by alarming symptoms of collapse. In future this difficulty could be overcome by removing several ribs and so allowing the chest wall to be brought down to the
etump. I had a letter from the patient in June of this year. She is still travelling about as a hawker but as she has not been in this town since I am unable to state what condition her lung is in. The removal of a portion of lung for the cure of pulmonary -tuberculosis is no doubt heroic and it is probable that it will be some time before patients will submit to the risk involved. With increased experience I have no doubt that the danger The operation is not one of can be considerably lessened. extreme difficulty and if cases were secured at an early stage the percentage of recoveries would probably be greater than are obtained under the methods of treatment now adopted.
Medical Societies. OBSTETRICAL SOCIETY OF LONDON.
were frequently affected, one showing a stage of the disease than the other. In
more
the
advanced
early stage
the capsule was firm but later it became broken down and tumour tissue proliferated through it. Germinal epithelium was absent as a rule. No Graafian follicles or corpora lutea were found. Previous benign change in the ovary was always present. The most common forms of cancer in the ovary were the glandular cystic form and the alveolar with connective tissue increase. The growth was found near the surface and in the folds in early specimens. The origin of the growth was from the follicle cells and from cells which had been derived from the germinal epithelium. The so-called
of the German pathologists were masses of degenerated protoplasm ; they were retrogressive products of the follicle cells. Karyokinesis was not well marked in these cancerova
cell tumours. The cells found in cancer of the ovary resembled those found in benign growths, but differed in their distribution, irregular arrangement, and in the amount of proliferation.-Dr. T. W. EDEN said that two points, at any rate, Dr. Mcllroy appeared on to have made an important contribution to their knowledge. One point was that she had traced the invasion of the ovarian stroma by cells derived from malignant changes in the germinal epithelium. The second was that she believed she had traced the transition stages by which the epithelial cells of a benign cyst became transformed into the malignant cells of an adeno-carcinoma.Dr. H. RUSSELL ANDREWS congratulated Dr. McIlroy on the excellent demonstration that she had given and asked her whether her researches had led her to agree with the teaching of some German writers that many adenomatous or pseudo-mucinous ovarian cysts which appeared to be perfectly innocent to the naked eye proved to be malignant on microscopical examination. If this teaching were accepted it became the surgeon’s duty to remove all adenomatous ovarian tumours whole without diminishing their size by tapping, however large they might be.-Mr. J. S. FAIRBAIRN said that there was one point in the paper which he had not been able to follow and that was the statement that the carcinomatous tumours in all cases followed on a previously benign growth. The proof of this was far from complete and, as he understood, was based on observation of histological changes in different parts of the tumour, in other words, on tracing the transition of a regular goblet-celled epithelium into an irregular epithelium growth of carcinomatous cell.-Dr. H. WILLIAMSON said that from his own observations he could confirm two of the conclusions which Dr. McIlroy had arrived at. The first was with regard to the development of the cells of the membrana granulosa and the second was the recognition of the part played by later downgrowths of the germinal epithelium in the genesis of ovarian tumours.Dr. MARY THORNE did not consider that pain was such a very rare symptom in the earliest stage of carcinoma of the ovary and quoted a case of her own in which acute pain was the first thing which attracted attention.-Dr. MCILROY
replied. A short communication was read by Dr. C. J. NEPEAN LONGRIDGE on 64 Cases of Contracted Pelvis. These cases were treated during 19C5 at Queen Charlotte’s Hospital. The system of admission was arranged so that it was possible to recognise and treat if necessary the cases of contracted pelvis at an early date. The results in these cases were satisfactory as regarded the mothers, no death or serious complication being noted. Eight infants died, three of whom were suffering from some abnormality incompatible with life. A special feature of this series was a group of 14 cases in which labour was unaided and spontaneous, the most remarkable case being a primipara who gave birth to a living child weighing
Canoer of the Ovary.-Contracted Pelvis.-Adenoma of the Labium.-}[xhibition of ,Specimens. A MEETING of this society was held on July 4th, Dr. W. R. DAKIN, the President, being in the chair. 5 pounds and 12;f ounces through a true conjugate of two Dr. A. LOUISE MCILROY read a paper (followed by and seven-eighths inches in ten hours. Nine of these patients a, demonstration) on Primary Cancer of the Ovary. were primiparæ and five were multiparæ. Two of the infants Primary cancer of the ovary occurred in women about were born dead, one being macerated and one hydrocephalic. the time of the menopause or after, but was found in Labour was induced by bougies in 17 multiparæ and in six The date of induction was determined by young patients; in the latter cases menstruation was primiparæ. inuienced. cessation of the periods occurring. Previous estimating the relative size of the head and the pelvis. child-bearing had no influence. Pain was not a marked Delivery was unaided in 17 cases, five patients were desymptom, patients seeking operation on account of the livered by forceps, and one by version. The mothers all swelling of the abdomen. Ascites was present in most made a good recovery and one infant was born dead. A cases. Metastasis depended upon the duration of the second infant died on the third day with an imperforate disease and the integrity of the tumour capsule. anus. The time which elapsed between the passage of the The probability of recurrence was great. Malignancy was bougies and the birth of the child averaged 92’6hours. In rarely suspected previously to the operation. Both ovaries 18 of the 64 cases delivery was brought about by forceps and
Primary
removed,
a
gauze drain
was
substituted,
and
a
light
dressing was applied, the wound being disturbed as little as possible. The pulse was 158. No further haemorrhage occurred from the wound but the patient died suddenly at 2
A.M. on
the 13th.
the abdomen the small intestine found spreading from the abscess region over the parietal peritoneum but there was no pus or lymph between the coils of the intestine. The large bowel was contracted and there was a large quantity of blood and pus in Douglas’s pouch. The appendix was found lying behind the cascum and running upwards and slightly inwards (Fig. 1); it was about four inches long and the last inch was completely gangrenous ; there was no concretion. The abscess cavity was behind, and somewhat internal to, the cascum and behind the last part of the ileum. The walls of the cavity were formed by the following structures-ceecum, ileum, duodenum (second part), psoas muscle, iliac vein, vena cava, and the iliac fascia in the right iliac fossa (Fig. 2). In the cavity In the duodenum just where it were pus and blood clot. turns up and in to run across the right crus of the diaphragm was a perforation with sloughing edges of about the size of The ulceration on the mucous surface was smaller a pea. than that on the peritoneal. On opening the duodenum and ileum they were found to contain a large quantity of blood. The iliac veins and the vena cava were normal. The rest of
Neoropsy.-On opening
was
distended and pus
the organs
were
was
normal. FIG. 1.
Diagram showing position of appendix. FIG. 2.
161
fatal case with haemorrhage from the external iliac artery. J. D. Malcolm3 at the Clinical Society of London reported a case with severe haemorrhage which recovered, the source of the bleeding not being ascertained, and in the discussion that followed other cases were mentioned, Charters Symonds reporting a case in which he found the external iliac artery and vein opened. Box and Wallace4 report a fatal case of bleeding but the source of the haemorrhage was not discovered ; two severe hemorrhages occurred per rectum. Ramsayrecords a case of sloughing of the external iliac artery in which the vessel was ligatured and recovery took place. Dyce Duckworth reports a case in which the bsemorrhage occurred on the eighth day, with recovery. Moynihan, quoting Murphy and Mayo, states that the bleeding occurs from small vessels on the inner side of the appendix. Perforation of the stomach and duodenum are also wellknown complications and the following cases have been reported. Dieulafoy’records a fatal case of baematemesis following removal of the appendix in which acute necrosis of the mucous membrane of the stomach was found. Warren Lowreports a case of perforation of an ulcer of the stomach with appendicitis. Lediard and Sedgwickreport a case of perforation of an ulcer on the pancreatic surface of the second part of the duodenum ; there was no acute inflammation of the appendix and the abdomen was not drained. In the same paper they also quote a care of gastric ulcer under the care of F. Victor Milward. Watson Cheyne and H. Wilbereport a case of perforated gastric ulcer with appendicitis. Bolton Carter" gives particulars of a case of an appendix abscess which was opened and drained with an indiarubber tube in which there was bsemorrhage from the wound and death occurred. Post mortem the appendix was gangrenous and lying deeply ovei the pelvic brim. The ulcer which had perforated was on the anterior surface of the second part of the duodenum. The direction in which the abscess had tracked and the direction in which the tube was inserted are not given. The case described differs from all those quoted above in that the perforation in the duodenum was-in the wall of the abscess and that the perforation was certainly into the duodenum. Whether the perforation was caused by the tube used for drainage resting against the duodenum is doubtful, as it was removed and gauze was substituted when the haemorrhage occurred, but from the direction in which the tube ran it most likely did rest against the second part of the duodenum and was the cause of the fatal result. The case described by Bolton Carter may have been of this nature but in his case the appendix was hanging -over the brim of the pelvis and the abscess wall probably did not include the duodenum.
a
I
KIDDERMINSTER INFIRMARY AND CHILDREN’S HOSPITAL. A CASE OF SUCCESSFUL EXCISION OF A PORTION OF RIGHT LUNG FOR PULMONARY TUBERCULOSIS.
THE
(Under the care of Mr. J. LIONEL STRETTON.) patient, a female, aged 28 years, was admitted to the infirmary on July 19th, 1900. There were signs of tuberculous disease at the apex of the right lung, for which she was treated with increasing doses of creasote with temporary benefit. After her discharge the symptoms-cough, expectoration, and night sweats-increased in severity and she suggested the possibility of removing the diseased portion of lung. A full explanation of the danger was given to her and to her husband and they both desired the operation to be undertaken. She was readmitted on August 2nd, 1900, when the following note was made. " The patient gives a history of being treated four years ago for a delicate chest. For the past year and a half she has had a continuous cough with expectoration and night sweats ; she has also been losing flesh. There is dulness over the right apex as far down as the Tubular breathing and lower border of the third rib. crepitant rales. The evening temperature is slightly raised and she has night sweats. The urine contains a trace of THE
Diagram showing position
of abscess cavity within dotted circle and perforation of duodenum.
albumin." Remarks by Mr. RUSSELL HOWARD.-The interest of this On August 7th the patient was placed under ether. A case lies in the two complications-hoamorrhage and perforavertical incision was made, about three inches long, with its tion of the duodenum. Haemorrhage is a fairly well-known complication and 3 THE LANCET, March 3rd, 1906, p. 600. 4 THE LANCET, June 6th, 1903, p. 1588. appears to be usually from erosion of the iliac vessels or the 5 THE LANCET, June 6th, 1903, p. 1590. deep circumflex iliac artery. J. C. Lewislrecords a case of 6 and Corner, Diseases of the Appendix, p. 176. Quoted by Battle haemorrhage from the common iliac vein. G. Sourdille2 relates 7 THE LANCET, June 25th, 1904, p. 1789. 8 THE LANCET, Sept 10th, 1904, p. 761. 1 Medical Record, New 9 THE LANCET, June 11th, 1904, p. 1641. York, 1894, p. 463. 2 Bulletin de la Société d’Anatomie de Paris, 1894. 10 THE LANCET, Nov 2nd, 1901, p. 1194.
162
OBSTETRICAL SOCIETY OF LONDON.
centre over the third rib, two inches from, and parallel to, the breast bone. The third rib was separated from its cartilage and about four inches of it removed. On opening the pleura the lung was found closely adherent. The hand was introduced and the adhesions were with great difficulty separated down to the lower level of the third rib. There was profuse boenaorrhage, which was arrested by sponge pressure. The portion of lung separated was then surrounded with a serre-nceud and cut away, leaving a stump of about the size of a five-shilling piece. For the first 24 hours after the operation the patient remained in a very collapsed condition and suffered from pain and cough.. At the end of 48 hours an attempt was made to remove the serre-noeud. but as rather free haemorrhage occurred the wire was twisted and left on. For the next few days there were considerable difficulty in breathing, constant cough, and haemorrhagic expectoration. There was also a good deal of hmmorrhage from the wound. Blood was found to collect in the pleura and had to be removed with a syringe. The breathing and cough gradually improved and the haemorrhage ceased after the seventh day. In spite of great care with the dressings symptoms of sepsis supervened and on the 22nd it was deemed advisable to make a counter opening in the back and thread a large drainage-tube through. From that date improvement was continuous though slow. The wire came away on the 25th. The tube was removed on Nov. 7th and the wound was healed by the 14th. Her cough and expectoration entirely ceased by Nov. 23rd. A specimen of the sputum was sent to the Worcestershire county council laboratory for examination at the end of October and the report stated that no bacilli could be found. The portion of lung removed consisted of about half of the right upper lobe and contained a cavity. Unfortunately it was destroyed before a thorough examination had been made. Remarlcs by Mr. STRETTON.-As I was unable to find any account of a similar operation it was necessary to devise the method of performing it. The chief difficulty I foresaw was the question of adhesions and this proved to be correct. The removal of one rib gave ample room for all the manipulations. It was found impossible to fix the stump in the wound because this caused dragging on the root of the lung accompanied by alarming symptoms of collapse. In future this difficulty could be overcome by removing several ribs and so allowing the chest wall to be brought down to the
etump. I had a letter from the patient in June of this year. She is still travelling about as a hawker but as she has not been in this town since I am unable to state what condition her lung is in. The removal of a portion of lung for the cure of pulmonary -tuberculosis is no doubt heroic and it is probable that it will be some time before patients will submit to the risk involved. With increased experience I have no doubt that the danger The operation is not one of can be considerably lessened. extreme difficulty and if cases were secured at an early stage the percentage of recoveries would probably be greater than are obtained under the methods of treatment now adopted.
Medical Societies. OBSTETRICAL SOCIETY OF LONDON.
were frequently affected, one showing a stage of the disease than the other. In
more
the
advanced
early stage
the capsule was firm but later it became broken down and tumour tissue proliferated through it. Germinal epithelium was absent as a rule. No Graafian follicles or corpora lutea were found. Previous benign change in the ovary was always present. The most common forms of cancer in the ovary were the glandular cystic form and the alveolar with connective tissue increase. The growth was found near the surface and in the folds in early specimens. The origin of the growth was from the follicle cells and from cells which had been derived from the germinal epithelium. The so-called
of the German pathologists were masses of degenerated protoplasm ; they were retrogressive products of the follicle cells. Karyokinesis was not well marked in these cancerova
cell tumours. The cells found in cancer of the ovary resembled those found in benign growths, but differed in their distribution, irregular arrangement, and in the amount of proliferation.-Dr. T. W. EDEN said that two points, at any rate, Dr. Mcllroy appeared on to have made an important contribution to their knowledge. One point was that she had traced the invasion of the ovarian stroma by cells derived from malignant changes in the germinal epithelium. The second was that she believed she had traced the transition stages by which the epithelial cells of a benign cyst became transformed into the malignant cells of an adeno-carcinoma.Dr. H. RUSSELL ANDREWS congratulated Dr. McIlroy on the excellent demonstration that she had given and asked her whether her researches had led her to agree with the teaching of some German writers that many adenomatous or pseudo-mucinous ovarian cysts which appeared to be perfectly innocent to the naked eye proved to be malignant on microscopical examination. If this teaching were accepted it became the surgeon’s duty to remove all adenomatous ovarian tumours whole without diminishing their size by tapping, however large they might be.-Mr. J. S. FAIRBAIRN said that there was one point in the paper which he had not been able to follow and that was the statement that the carcinomatous tumours in all cases followed on a previously benign growth. The proof of this was far from complete and, as he understood, was based on observation of histological changes in different parts of the tumour, in other words, on tracing the transition of a regular goblet-celled epithelium into an irregular epithelium growth of carcinomatous cell.-Dr. H. WILLIAMSON said that from his own observations he could confirm two of the conclusions which Dr. McIlroy had arrived at. The first was with regard to the development of the cells of the membrana granulosa and the second was the recognition of the part played by later downgrowths of the germinal epithelium in the genesis of ovarian tumours.Dr. MARY THORNE did not consider that pain was such a very rare symptom in the earliest stage of carcinoma of the ovary and quoted a case of her own in which acute pain was the first thing which attracted attention.-Dr. MCILROY
replied. A short communication was read by Dr. C. J. NEPEAN LONGRIDGE on 64 Cases of Contracted Pelvis. These cases were treated during 19C5 at Queen Charlotte’s Hospital. The system of admission was arranged so that it was possible to recognise and treat if necessary the cases of contracted pelvis at an early date. The results in these cases were satisfactory as regarded the mothers, no death or serious complication being noted. Eight infants died, three of whom were suffering from some abnormality incompatible with life. A special feature of this series was a group of 14 cases in which labour was unaided and spontaneous, the most remarkable case being a primipara who gave birth to a living child weighing
Canoer of the Ovary.-Contracted Pelvis.-Adenoma of the Labium.-}[xhibition of ,Specimens. A MEETING of this society was held on July 4th, Dr. W. R. DAKIN, the President, being in the chair. 5 pounds and 12;f ounces through a true conjugate of two Dr. A. LOUISE MCILROY read a paper (followed by and seven-eighths inches in ten hours. Nine of these patients a, demonstration) on Primary Cancer of the Ovary. were primiparæ and five were multiparæ. Two of the infants Primary cancer of the ovary occurred in women about were born dead, one being macerated and one hydrocephalic. the time of the menopause or after, but was found in Labour was induced by bougies in 17 multiparæ and in six The date of induction was determined by young patients; in the latter cases menstruation was primiparæ. inuienced. cessation of the periods occurring. Previous estimating the relative size of the head and the pelvis. child-bearing had no influence. Pain was not a marked Delivery was unaided in 17 cases, five patients were desymptom, patients seeking operation on account of the livered by forceps, and one by version. The mothers all swelling of the abdomen. Ascites was present in most made a good recovery and one infant was born dead. A cases. Metastasis depended upon the duration of the second infant died on the third day with an imperforate disease and the integrity of the tumour capsule. anus. The time which elapsed between the passage of the The probability of recurrence was great. Malignancy was bougies and the birth of the child averaged 92’6hours. In rarely suspected previously to the operation. Both ovaries 18 of the 64 cases delivery was brought about by forceps and
Primary