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THE TBANSACTIONS

OF THE

EDINBURGH OBSTETRICAL SOCIETY

THE TRANSACTIONS

EDINBURGH OBSTETRICAL SOCIETY.

VOL. XXXII.

SESSION 1906-1907.

EDINBURGH: OLIVER AND BOYD,

PUBLISHERS TO THE SOCIETY

19 0 7. ^>/

PRINTED BY OLIVER AND BOYD, TWEEDDALE COURT EDINBURGH.

PREFACE

This, the thirty-second volume of the Society's Transactions, contains a record of its proceedings during the Session 1906-1907.

In it, as in former volumes, the views brought forward in the Papers are to be considered as those of the writers themselves, and not as those of the Society as a body.

The Editor.

October 1907.

%\

EDINBURGH OBSTETRICAL SOCIETY.

OFFICE-BEAKEKS FOE SESSION 1906-1907.

|)rtsibent. JOHN WILLIAM BALLANTYNE, M.D., F.R.C.P.Ed.

©uc-|^rcsibtnts.

DAVID BERRY HART, M.D., F.R.C.P.Ed. WILLIAM FORDYCE, M.D., F.R.C.P.Ed.

([Treasurer. WILLIAM CRAIG, M.D., F.R.C.S.Ed., 71 Bmntsfield Place.

£ecrd aries. JAMES LAMOND LACKIE, M.D., F.R.C.P.Ed., 1 Randolph Crescent. GEORGE FREELAND BARBOUR SIMPSON, M.D., F.R.C.S.Ed., F.R.C.P.Ed.,

50 Melville Street.

librarian.

FRANCIS WILLIAM NICOL HAULTAIN, M.D., F.R.C.P.Ed.,

12 Charlotte Square.

Cbitor of ^Transactions. ANGUS MACDONALD, M.B., F.R.C.S.Ed., 27 Manor Place.

$Vtcmbcrs of Council. ALEXANDER HUGH FREELAND BARBOUR, M.D., F.R.C.P.Ed. NATHANIEL THOMAS BREWIS, M.D., F.R.C.P.Ed., F.R.C.S.Ed. JAMES HAIG FERGUSON, M.D., F.R.C.P.Ed., F.R.C.S.Ed.,

M.R.C.S.Eng. JOHN MARTIN MUNRO KERR, M.B., CM., Glasgow. Professor Sir JOHN HALLIDAY CROOM, M.D., F.R.C.S.Ed.,

F.R. C.P.Ed. SAMUEL SLOAN, M.D., F.F.P. & S.Glas., Glasgow. WILLIAM MACRAE TAYLOR, M.B., F.R.C.S.Ed. EDWARD WILLIAM SCOTT CARMICHAEL, M.D., F.R.C.S.Ed.

List of Presidents, Vice-Presidents, Treasurers, Secretaries, and Librarians of the Society.

	PRESIDENTS.
	Year.		Year.
Dr William Beilby, .	1840-41	Sir A. R. Simpson,	1882-83
Sir James Y. Simpson, Bart.	1842-57	Dr John Connel	1884-85
Dr John Moir, .	1858-59	Sir J. Halliday Croom,	1886-87
Dr Alex. Keiller,	1860-61	Dr C. E. Underhill, .	1888-89
Dr T. H. Pattison, .	1862-63	Dr D. Berry Hart,	1890-91
Dr T. Graham Weir, .	1864-65	Sir A. R. Simpson,	1892-93
Sir James Y. Simpson, Bart.	1866-67	Dr A. H. Freeland Barbour,	1894-95
Dr John Burn, .	1868-69	Dr Alexander Ballantyne,	1896-97
Dr Charles Bell, .	1870-71	Sir J. Halliday Croom,	1898-99
Dr L. R. Thomson,	1872-73	Dr R. Milne Murray, .	1900-01
Dr Matthews Duncan,	1874-75	Dr James Ritchie,	1902-03
Sir A. R. Simpson,	1876-77	Dr N. T. Brewis,	1904-05
Dr David Wilson,	1878-79	Dr J. W. Ballantyne, .	1906
Dr Angus Macdonald,	1880-81

Sir J. Y. Simpson, Bart.. Dr Alex. Ziegler, Dr J. Cowan, R.K, Dr Fairbairn, Dr Charles Ransford, Dr R. B. Malcolm, Dr Charles Bell, . John Kennedy, Esq., Dr John Moir, . Dr T. H. Pattison, Dr Beilby, . Dr T. Graham Weir, Dr R. B. Malcolm, Dr John Moir, . Dr T. Graham Weir, Dr John Moir, Dr W. dimming, Dr A. Thomson, . Dr T. H. Pattison, Dr David Wilson, Dr T. Graham Weir, Dr George S. Keith, Dr T. Graham Weir, Dr Alex. Keiller, Dr T. H. Pattison, W. S. Carmichael, Esq. Dr John Burn. . Dr Charles Bell, . Dr William Bryce, Dr J. A. Sidey, . Dr William Menzies, Dr L. R. Thomson, Sir A. R. Simpson, Dr J. Matthews Duncan, Dr Angus Macdonald, Dr R. Peel Ritchie, .

VICE-PRESIDENTS.

. Year. 1840-41 1840-41 1842 1842 1843 1843 1844 1844 1845-47 1845-47 1848 1848 1849-53 1849-53 1854-55 1854-55 1856-57 1856-57 1858-59 1858-59 1860-61 1860-61 1862-63 1862-63 1864-65 1864-65 1866-67 1866-67 1868-69 1868-69 1870-71 1870-71 1872-73 1872-73 1874-75 1874-75

	Year.
Dr James Young,	1876-77
Dr Alex. Milne, .	1876-77
Dr R. Peel Ritchie, .	1878-79
Dr Angus Macdonald, .	1878-79
Sir A. R. Simpson,	1880-81
Dr Robert Bruce,	1880-81
Dr James Carmichael, .	1882-83
Sir J. Halliday Croom,	1882-83
Dr Angus Macdonald, .	1884
Dr Charles E. Underhill,	1884-85
Dr William Ziegler,	1885
Sir A. R. Simpson,	1886-87
Dr Leith Napier,	1886
Dr D. Berry Hart,	1887-88
Dr James Foulis,	1888-89
Dr A. J. Sinclair,	1889
Sir A. R. Simpson,	1890
Dr Peter A. Young, .	1890-91
Dr John Playfair,	1891-92
Dr Freeland Barbour, .	1892-93
Dr A. Ballantyne,	1893-94
Dr James Ritchie,	1894-95
Sir J. Halliday Croom,	1895-96
Sir A. R. Simpson,	1896-97
Dr R. Milne Murray, .	1897-98
Dr N. T. Brewis,	1898-99
Dr J. W. Ballantyne, .	1899-1900
Dr Samuel Macvie,	1900-1901
Dr F. W. N. Haultain,	1901-1902
Dr J. Haig Ferguson, .	1902-1903
Sir A. R. Simpson,	1903-1904
Professor J. A. C. Kynoch. .	1904-1905
Sir J. Halliday Croom,	1905-1906
Dr D. Berry Hart,	1906-1907
Dr William Fordyce, .	1907

vili LIST OF OFFICE-BEARERS	AND HONORARY FELLOWS.
	TREASURERS.*
	Year.		Year.
Dr Ransford,	1840 to 1842	Dr J. A. Sidey, .	1859 to 1867
Dr G. Paterson, .	1842 to 1847	Dr James Young,	1867 to 1875
Dr Cumming,	1847 to 1854	Dr William Craig,	1875
Dr Keiller, .	1854 to 1859
	SECRETARIES.
	Year.		Year.
Dr Ransford,	1840 to 1842	Dr Alexander Milne, .	1873 to 1875
Dr G. Paterson, .	1840 to 1847	Dr C. E. Underhill, .	1875 to 1879
Dr Dunsmure,	1842 to 1847	Dr James Carmichael, ,	1875 to 1881
Dr Cumming,	1847 to 1854	Dr D. Berry Hart,	1879 to 1883
Dr Keith, .	1847 to 1849	Dr A. H. Freeland Barbour,	1881 to 1886
Dr J. M. Duncan,	1849 to 1852	Dr R. Milne Murray, .	1883 to 1889
Dr Keiller, .	1852 to 1859	Dr N. T. Brewis, .	1886 to 1893
Dr J. A. Sidey, .	1854 to 1861	Dr J. W. Ballantyne, .	1889 to 1896
Dr A. R. Simpson,	1859 to 1865	Dr F. W. N. Hauitain,	1893 to 1897
Dr Peter Young, .	1861 to 1863	Dr J. Haig Ferguson, .	1896 to 1901
Dr W. Stephenson,	1863 to 1867	Dr William Fordyce, .	1897 to 1904
Dr R. Peel Ritchie,	1865 to 1873	Dr Lamond Lackie,	1901
Dr G. Stevenson Smith,	1867 to 1871	Dr Barbour Simpson, .	1904
Dr James Andrew,	1871 to 1875
	LIBRARIANS.
	Year.		Year.
Dr J. Jamieson, .	1875 to 1879	Dr R. Milne Murray, .	1889 to 1899
Dr C. E. Underhill, .	1879 to 1883	DrF. W. N. Hauitain,	1899
Dr Peter Young, .	1883 to 1889
EDITORS OF TRANSACTIONS.
	Year.		Year.
Dr J. W Ballantyne, .	1896 to 1*99	Dr J. Lamond Lackie, .	1901 to 1905
Dr N. T. Brewis,	1899 to 1901	Dr Angus Macdonald, .	1905
LIST OF	FELLOWS	OF THE SOCIETY.

HONORARY FELLOWS.

1898 Atthill, Lombe, M.D., Monkstown Castle, Co. Dublin.

1897 Bantock, Dr George Granville, 14 Upper Hamilton Terrace, Lon- don, N.W.

1901 Bar, Prof. Paul, M.D., Rue la Boetie, 122, Paris.

1906 Bossi.. Professor L. M., The University, Genoa.

1886 Bozeman, Dr Nathan, 296 Fifth Avenue, New York.

1901 Chrobak, Professor R., University of

Vienna. 1898 Coe, Prof. Henry C, M.D., 27 East

Sixty-fourth St., New York. 1898 Cullingworth, Charles J., M.D.,

D.C.L., 14 Manchester Square,

London, W. 1898 Doyen, E., M.D., LL.D., Rue

Piccini, 6, Paris. 1882 Emmet, Dr, 93 Madison Avenue,

New York.

* Previous to 1861 the office of Treasurer was conjoined with that of Senior Secretary.

LIST OF FELLOWS.

IX

1900 Fehling, Professor Herman, M.D., 1 1901

Kaiser Wilhelm's University, Strassburg. 1882 Freund, Emeritus Professor W., 1 1902 Kleiststrasse, 5, Berlin.

1901 Fritsch, Prof. H., University of 1895

Bonn.

1902 Garrigues, Prof. H. J., Tryon, North 1898

Carolina.

1891 Gusserow, Prof., Charite, Berlin. 1903 1882 Hegar, Professor, Albert Ludwig's

University, Frieburg. 1882

1898 Kelly, Prof. Howard A., M.D.,

Johns Hopkins Hospital, Balti- 1903 more, U.S.A. 1907 Kinoshita, Dr Seichu, Professor of 1906 Obstetrics and Gynaecology, Im- perial University, Tokio, Japan. 1905

1892 Koeberle, Dr Eugene, Strassburg. 1898 Leopold, Prof. G., M.D., Seminar

Strasse, 25, Dresden. 1901

1906 Makieyeff, Professor Alexander

Matvejevic, The University, | 1876

Moscow. 1895 Martin, Prof. Dr A., N. Greifs-

wald. 1905

1903 Morisani, Professor O., San Felice 1897

a Piazza Dante, 10, Naples. 1892 Miiller, Professor Peter, Berne

Switzerland. 1889 Olshausen, Professor, Frauenklinik

Artillerie Strasse, 13, Berlin.

Ott, Professor D. von, M.D., Pro- fessor of Obstetrics, University of St Petersburg.

Pestalozza, Professor, Instituts Obstetrico Policlinico, Roma.

Pinard, Professor A., Rue Cam- baceres, 10, Paris.

Pozzi, ProfessorS., M.D., Hopital Broca, Paris.

Schauta, Professor, Kochgasse, 16, Vienna.

Schultze, Professor B. S., Univer- sity, Jena.

Segond, Dr Paul, Quai d'Orsay, Paris.

Simpson, Emeritus Prof. Sir Alex. R., LL.D., 52 Queen St.

Sinclair, Prof. Sir William Japp, Garvock House, Dudley Road, Manchester.

Sneguireff, Professor W., University of Moscow.

Turner, Principal Sir W., K.C.B., LL.D., D.C.L., 6 Eton Terrace, Edinburgh.

Veit, Professor, University, Halle.

Williams, Sir John, Bart., M.D., LL.D., Plas Llanstephan, Car- marthenshire.

Winckel, Prof. Von, Ludwig-Maxi- milian's University, Munich.

Zweifel, Professor, Frauenklinik University, Leipzig.

CORRESPONDING FELLOWS.

1884 Arnott, Brig. Surg. -Lieut. -Col. Jas., 8 Rothesay Place.

1887 Baumgartner, Dr H. S., Newcastle-

on-Tyne. 1892 Beilby, Dr J. H., Bromsgrove. 1863 Belgrave, Dr, Sydney.

1888 Bentley, Dr Arthur J., Cairo. 1880 Bosch, Dr Van Den, Liege. 1880 Brock, Dr W. J., Edinburgh.

1863 Brown, Dr R. C, Preston.

1887 Chepmell, Dr C. W. J., London. 1894 Curatulo, Prof. G. E., Rome.

1869 Davies, Mr Thos., Manchester. 1873 Donovan, MrW., Birmingham.

1877 Engelmann, Dr G., Kreuznach. 1896 Eyres, Hugh, Richmond.

1864 Finlay, Right Hon. Sir R. B., M.D ,

LL.D., K.C., London.

1883 Fraser, Dr Dyce, London.

1892 Fraser, Dr Hugh E., Dundee.

1879 Glaister, Prof., Glasgow. 1877 Grassett, Dr F., Toronto.

1868 Grenser, Dr Paul W. T., Dresden.

1864 Greve, Dr, Norway.

1875 Groesbeck, Dr Hermann J., New

York. 1897 Gunsberg, Charkow, Russia.

1853 Hall, Dr D., Montreal.

1870 Haynes, Dr Stanley L., Malvern.

1880 Helme, Dr J. M., Carnforth. 1885 Helme, Dr T. A., Manchester.

1865 Henderson, Dr E., China.

1893 Howard-Jones, Dr J., Newport. 1887 Hume, Dr T., Surgeon-Major, India.

1881 Hurst, Dr George, Australia.

1882 Husband, Dr H. Aubrey, Manitoba.

1893 Hutchison, Dr Robert, London.

1894 Jennings, Dr David D., New York.

LIST OF FELLOWS.

1871 Johnston, Dr A. C, R.N., London.

1882 Johnston, Sur.-Maj. Wilson, India.

1845 Keith, Dr George S., Currie. 1867 Kingston, Dr, Montreal. 1874 Kleinwachter, Prof. L., Gratz.

1871 Lambert, Dr, Paris.

1887 Limont, Dr J., Newcastle-on-Tyne.

1867 Lord, Dr Richard, London.

1878 Macdougall, Dr John A., Cannes.

1879 Machattie, Dr Thomas A., Australia. 1862 Mackay, Dr M. A., Canada.

1870 M'Kendrick, Prof., Stonehaven. 1869 M'Millan, Dr T. L., Australia. 1879 Marshall. Dr Thomas, London. 1866 Martin, Dr Karl, Berlin.

1860 Milburn, Dr George, London.

1883 Mills, Dr B. Langley, India. 1897 Minchin, Dr, Charkow, Russia.

1861 Mitchell, Sir Arthur, LL.D., Edin-

burgh. 1877 Moolman, Dr Henry, South Africa. 1869 Mossop, Mr Isaac, Bradford.

1884 Neve, Dr E. F., Kashmir. 1849 Norris, Mr H., Petherton.

1857 Parker, Dr, Nova Scotia.

1869 Paton, Dr J. W., Bath.

1885 Puckle, Dr S. Hale, Bishop's Castle.

1880 Reid, Dr James More, Aldershot.

1878 Serdukoff, Dr A., St Petersburg.

1887 Shiels, Dr G. F., San Francisco.

1870 Smith, Dr D., Montrose. 1890 Smith, Dr William, America. 1861 Stephenson, Prof. W., Aberdeen.

1888 Stevenson, Sir Edmond Sinclair,

Cape of Good Hope. 1854 Storer, Dr H., Boston, U.S.A. 1875 Sutugin, Dr V., St Petersburg.

1867 Thomson, Mr W., Wrenbury. 1880 Turner, Dr William, Gibraltar.

1885 Underhill, Dr F. T., Vancouver. 1861 Veale, Dr H. R. L., London.

1864 Whiteford, Dr James, Greenock.

1886 Whitton, Dr A. B., Aberchirder.

1865 Wollowicz, Dr C, St Peters-

burg.

ORDINARY FELLOWS.

ARRANGED CHRONOLOGICALLY.

Note.— Those marked with an asterisk have been Members of Council. Members of Council continue in office two years.

Date of Admission.

1866 1867 1867 1867 1868 1868 1869 1870

1870 1870 1870 1871 1871 1872 1873 1875

1875

10

15 *

Thomas John Fordyce Messer, M.D., F.F.P. & S. Glasg., Garelochhead, ......

John Charles O^ilvie Will, M.D., CM., Aberdeen, .

William Spalding. M.D., M.R.C.S. Eng., Gorebridge, .

George Dickson, M.D., F.R. C.S. Ed., . ♦James Andrew, M.D., F.R.C.P. Ed., . *William Taylor, M.D., F.R.C.P. Ed., .

James Ormiston Affleck, M.D., F.R. C.S. Ed., F.R.C.P. Ed., .

William Craig, M.D., F.R, C.S. Ed., . '♦Professor Sir John Halliday Croom, M.D., F.R.C.S. Ed.,

F.R.C.P. Ed.,

'♦Alexander Ballantyne, M.D., F.R.C.P. Ed., Dalkeith,

William Borwick Robertson, M.D., L.R.C.S. Ed., London, . '♦James Carmichael, M.D., F.R.C.P. Ed., '*Peter Alexander Young, M.D., F.R.C.P. Ed., . '♦Charles Edward Underhill, M.B., P.R.C.P. Ed., F.R.C.S. Ed., '♦John Play fair, M.D., F.R.C.P. Ed., Hon. F.R. C.S. Ed., '♦Henry Macdonald Church, M.D., F.R.C.P. Ed.,

James Lindsay Howison Herbert Porteous, M.D., F.R.C.S. Ed., M.R. C.P.Ed., New York .

LIST OF FELLOWS.

XI

Archibald Bleloch, M.B., Sc.D.,

Joshua John Cox, M.D., F.R.C.S. Ed., Eccles, Manchester,

20 *Thomas Rutherford Ronaldson, M.B., F.R.C.P. Ed., .

Charles H. Thatcher, F.R.C.S. Ed., .

*John Brown Buist, M.D., F.R.C.P. Ed.,

George Herbert Bentley, L.R.C.P. & S.Ed., Kirkliston,

Andrew Douglas Ramsay Thomson, F.R.C.P. Ed., Musselburgh

25 James Stitt Thomson, M.D., F.R.C.P.Ed., F.R.C.S. Ed.,

Lincoln, ......

John Archibald, M.D., F.R.C.S. Ed., Bournemouth, . *****David Berry Hart, M.D., F.R.C.P. Ed., ♦David Menzies, M.B., F.R.C.S. Ed., . Donald Roderick Morrison Murray, M.B., CM., Leith, 30 Robert Spence, M.B., CM., Burntisland, • .

George Mackay, M.B., F.RCS. Ed., . James Henry Croudace, L.R.C.P. & S. Ed., Stafford, . Alexander Dinsey Leith Napier, M.D., M.R. C.P.L., Australia John M'Watt, M.B., CM., Duns, 35 * William Nicol Elder, M.D., L.R.C.P. & S. Ed.,

Henry Hay, M.B., CM., ....

Abraham Wallace, M.D., F.F.P. & S. Glasg., London, *John Rogerson Hamilton, M.D., CM., Hawick, George Roth well Adam, M.D., CM., Melbourne, 40*****Alexander Hugh Freeland Barbour, M.D., F.R.C.P. Ed., James Murray, M.B., CM., . . .

Andrew James Duncan, M.D., L.R.CS. Ed., Dundee, T. Edgar Underhill, M.D., F.R.C.S. Ed., Barnt Green, ♦* William Loudon Reid M.D., F.F.P. & S. Glasg., Glasgow, 45 ****James Ritchie, M.D., F.R.C.S. Ed., F.R.C.P. Ed., . William Alexander Finlay, M.D., F.R.C.S. Ed., Trinity, James More, M.D., M.R.C.S. Eng., Rothwell, Kettering, Thomas Rennie Scott, M.D., CM.. Musselburgh, ♦George Hunter, M.D., F.R.C.S. Ed., F.R.C.P. Ed., . 50 John E. Ranking, M.D., F.R.C.P.L., M.R.C.S. Eng., Tun

bridge Wells, .....

♦Arthur Douglas Webster, M.D., F.R.C.P. Ed., . William Haig Brodie, M.D., F.R.C.S. Eng., M.R.CP.Lon. London, ......

James Hewetson, M.B., CM., Hohnfield, Reigate, ♦♦Samuel MacYie, M.B.. CM.. Chirnside, 55 John Waugh, M.D., CM., London,

Hugh Logan Calder, M.D., F.F.P. k S. Glasg., Henry Anderson Peddie, M.B., CM., .

Thomas Fisher Gilmour, L.R.C.P. Ed.,L F.P. & S. Glasg. , Lslay Andrew Stark Carrie, M.D., M.R.C.S. Eng., London, . 60 William Black Alexander, L.F.P. & S. Glasg.,

Harry George Deverell, M.D., CM., . ♦George Keppie Paterson, M.B., F.R.C.P.Ed., . Herbert R. Rendell, M.B., CM., St John's, Newfoundland, David Smart, M.B., CM., Liverpool, . 65 ♦♦♦Nathaniel Thomas Brewis, M.B., F.R.C.P. Ed., F.R.C.S. Ed *John William Ballantvne, M.D., F.R.C.P. Ed., Thomas Proudfoot, M.B., F.R.C.P. Ed., W. Fraser Macdonald, M. B., CM., Glasgow, . William Spence, M.B., CM., Dollar, . 70 William Wright Millard, M.B., CM.,

John Mowat, M.D., CM.,

James Lumsden Bell, M.B., CM., Driffield, Yorkshire, *Thomas Brown Darling, M.D., CM., . , ,

Date of Admission. 1876 1876 1876 1876 1877 1877 1877

1877 1877 1877 1877 1878 1878 1878 1878 1878 1879 1879 1879 1879 1879 1879 1879 1879 1879 1879 1880 1880 1880 1880 1880 1881

1881 1881

1881 1881 1881 1881 1882 1882 1882 1882 1882 1882 1882 1882 1882 1883 1883 1884 1884 1884 1884 1884 1884 1884

Xll

LIST OF FELLOWS.

*Harry Melville Dunlop, M.D., F.R.C.P. Ed., . 75 * Robert William Felkin, M.D., London.

James K. King, M.D., Watkins, New York, .

William Marshall, L.R.C.S. Ed., Milnathort, .

Fourness Barrington, M.B., F.R.C.S. Eng., Sydney, Australia •Francis William Nicol Haul tain, M.D., F.R.C.P. Ed., 80 *John Struthers Stewart, L.K.C. P. & S.Ed., .

Frederick Anastasius Saunders, F.R.C.S. Ed., L.R.C.P. Ed. Grahamstown, South Africa,

John Smith, M.D., M.R.C.S. Eng., Kirkcaldy,

William Gayton, M.D., M.R.C.P.L., M.R.C.S. Eng., London

Gustave Michael, M. B., CM., London, . 85 ** James Haig Ferguson, M.D., F.R.C.P. Ed., M.R.C.S. Eng. F.R.C.S. Ed., .....

John Edward Gemmell, M.B., CM., Liverpool,

Robert Stewart, M.B., CM., . . .

Surgeon-Captain Robert Charles Macwatt, M.B., B.Sc, CM. 7th Bengal Cavalry, Bombay *E. H. Lawrence Oliphant, M.D., CM., Glasgow, 90 James Hogarth Pringle, M.B., F.R.C.S. Eng., Glasgow,

John Walton Hamp, L. F. P. & S. Glasg., L.S. A. , Wolverhampton

James Auriol Armitage, M. D. , C M. , Wolverhampton,

William Henry Miller, M.D., F.R.C.P. Ed., .

John M'Call, L.R.C.P. Ed., Portobello, 95 *Thomas Wood, M.D., CM., ....

Hugh M'Callum, L.R.C.P. &S. Ed., Kinloch-Rannoch,

Nutting Stuart Fraser, M.B., M.R.C.S. Eng., St John's, New foundland, ......

Augustus Alexander Matheson, M.D., F.R.C.P. Ed., .

Robert Mackenzie, M.D., CM., Nairn, 100 Thomas Jackson Thyne, M.B., F.R.C.P. Ed., .

Ernest T. Roberton, M.D., M.R.C.S. Eng., New Zealand, •Samuel Sloan, M.D., F.F.P. & S. Glasg., Glasgow,

James Wm. Fox, L.R.C.P. &S. Ed., Southampton,

John Frederick Sturrock, M.B., CM., Broughty -Ferry, 105 Alexander Primrose, M.B., M.R.C.S. Eng., Toronto, Canada,

Arthur Per igal, M.D., M.R.C.S. Eng., New Barnet, Herts,

James Aitken Clark, M.B., CM.,

Edward Carmichael, M.D., F.R.C P. Ed.,

Charles Clark Teacher, M.B., CM., North Berwick . 110 Robert Inch, M.B., CM., Gorebridge, .

Ellis Thomas Davies, M.D., M.R.C.S. Eng., Liverpool,

John Orr, M.B., CM., Eccles, Lancashire, •George Owen Carr Mackness, M.D., CM., Broughty -Ferry,

Francis Joseph Baildon, M.B., CM., Sotcthport, 115 Surgeon-Lt. Ralph H. Maddox, M.B., M.R.C.S. Eng., I.M.S Bengal, ......

James Williamson Martin, M.D., F.R.C.P. Ed., Dumfries,

James Andrew Blair, M.D., CM., D.Sc, Newcastle-on-Tyne, •John Thomson, M.D., F.R.C.P. Ed., .

Robert Kirk, M.D., F.R.C.S. Ed., Bathgate, . 120 * William Fraser Wright, M.B., CM., Leith, .

Richard Joseph Tristan, L.R.C.P. & S. Ed., Retford, Notts,

Robert Henry Blaikie, M.D., F.R.C.S. Ed., .

James Hutcheson, M.D., F.R.C.S. Ed., .

A. A. Jervis Pereira, M.D., Delag^a Bay, 125 Christopher Martin, M.B., F.R.C.S. Eng., Birmingham

John George Havelock, M.D., CM., Montrose,

JohnPirie, M.B., CM.

Date of Admission.

1884 1884 1884 1884 1884 1884 1884

1885 1885 1885 1885

1885 1885 1885

1885 1885 1886 1886 1886 1886 1886 1886 1887

1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887 1887

1887 1887 1887 1887 1887 1887 1887 1888 1888 1888 1888 1888 1888

LIST OF FELLOWS.

Xlll

135

140

145

150

155

160

165

170

175

180

James Gibson Graham, M.B., CM., Glasgow, .

Robert Adams Brewis, M.D., CM., Dursley, .

John Allison, M.D., CM., Kettering, Northampton, .

Archibald Cowan Guthrie, M.B., CM.,

Samuel Beatty, M.B., CM., Pitlochry,

Professor James Chalmers Cameron, M.D., Montreal, .

Albert Edward Morison, M.B., F.R.CS. Ed., M.R.CS. Eng.

West Hartlepool, ..... George H. Temple, M.B., CM., Weston-super-Mare, . Norman L. Boxill, M.B., CM., Barbados, John Hunter Helm, M.B., CM., Jiatho, George Scott MacGregor, M.D., CM., Glasgow, William Sneddon, M.B., CM., Cupar-Fife, . Thomas Watts Eden, M.B., CM., London,

* William Fordyce, M.D., F.R.CP. Ed.,

Charles E. Harvey, M.B., M.R.CS. Eng., Sav-la-Mar Jamaica, . ...

Alexander Lang Murray, L.R.CP. & S. Ed., Australia, *GeorgePirrie Boddie, M.B., CM., . .

James F. W. Ross, M. 1)., Toronto, Canada, Hugh Jamieson, M.D., CM., ....

Thomas Wm. Nassau Greene, L.R.CP. Ed., L.R.CS.I Dublin, ......

Prof. John Clarence Webster, M.D., F.R.CP. Ed., Chicago,

* William George Aitchison Robertson, M.D., F.R.CP. Ed., William Basil Orr, M.D., CM.,

* Edward Farr Armour, M.B., CM., . George Wilkinson, M.D., CM., Liverpool,

* James Lamond Lackie, M.D., F.R.CP. Ed., . James Wilson, M.B., C.M., .... Archibald Maclean, M.D., CM., Kilmarnock, Frederick William Lyle, M.D., CM., London, Thomas Dobson Poole, M.D., CM., Liuthwaite, Charles Newberry Cobbett, M.D., CM., Alberta, Alexander William Gordon Price, M.B., CM.,

Hugh Shapter Robinson, M.R.CS. Eng., L.R.CP. Ed., London *George Matheson Cullen, M.D., CM.,

Frederick Albert L. Lockhart, M.B., CM., Montreal, Canada

Edmund Frederick Tanney Price, M.B., CM.,

Ernest Theophilus Roberts, M.D., CM., Keighley,

Owen Foulkes Evans, M.D., CM., Liverpool, .

James Duncan Farquharson, M.B., CM., Newcastle- on- Tyne,

Harvey Littlejohn, M.B., F.R.CS. Ed.,

Robert Wise, M.D., CM., London,

William Russell, M.D., F.R.CP. Ed.,

Alexander Scott Duncan, M.B., CM., Polton,

Prof. William Keiller, F.R.CS. Ed., Galveston, Texas, U.S. A *Michael Dewar, M.D., CM., .

Gains T. Smith, M.D., Moncton, New Brunswick,

John Hugh Alexander Laing, M.B., CM.,

Robert Thin, M.B., F.R.CP. Ed.,

Alexander Henry Vassie, M. B., CM., London,

James Harvey, M.D., CM.,

Alexander Henderson, M.B., CM.,

James Smith, M.D., CM.,

George Balfour Marshall, M.D., CM., Glasgow,

William Booth, F.R.CS. Ed., .

Richard T. Yoe, M.D., Louisville, Kentucky, U.S.A.,

Alexander Bruce Giles, M.D., CM..

Date of Admission. 1888 1888 1888 1888 1888 1888

1888 1888 1888 1888 1888 1888 1888 1888

1889 1889 1889 1889 1889

1889 1889 1889 1889 1889 1889 1889 1889 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1890 1891 1891 1891 1891 1891 1891 1891 1891 1891 1891 1891 1891

XIV

LIST OF FELLOWS.

Hamilton Graham Langwill, M.D., F.K.C.P. Ed., Leith,

185 Herbert Ernest Lee, M.B., CM., Australia,

Charles Martin, M.B., CM., Newton A bbot, . William Murray Cairns, M.B., CM., Liverpool, Robert Dundas Helm, M.D., CM., Carlisle, . James Thomas Moore Giffen, F.R.C.S. Ed., Chester, .

190 Frank Dendle, M.B., D.P.H., Islcworth,

Frederick Thomas Anderson, M.D., F.R.C.S. Ed.,

Simson Carstairs Fowler, M. B., CM., Juniper Green,

Prof. John Alexander Campbell Kynoch, M.B., F.R.C.P. Ed.

Dundee, . Walter John Shaw, M.B., CM., Cockburnspath,

195 Robert Stirling, M.D., CM., Perth, .

William Henry Vickery, F.R.C.S. Eng., L.R.C.P. Lond.

Weston-super-Mare ....

William Ramsay Smith, M.B., CM., Australia, Charles Frederick Ponder, M.D., CM., Tasmania, John Tod, M.B., CM., Leith, .

200 George Henry Walter Smith, M.D., CM., Sydney, Australia Charles Croomhall Easterbrook, M.D., CM., Ayr, Walter Petrie Simpson, M. B., CM., Bathgate, *James Ernest Moorhouse, M.D., CM., Stirling, D. W. Johnston, F.R.C.S. Ed., Johannesburg, South Africa,

205 David George Davidson, M.B., CM., .

Allen Thomson Sloan, M.D., CM., . Robert Balfour Graham, F.R.C.S. Ed., Albert Frederic Rosa, M.D., CM., George Benjamin Mitchell, M.B., CM,

210 Henry Robins, M.D., Jamaica,

Linn J. Schotield, M.D., Warrensburg

George Morton Wilcockson, L.R.C.P. & S. Ed., Reading

John MacRae, M.D., CM., Murray field,

George Wade, M.D., CM., Melrose, .

215 Philip Grierson Borrowman, M.D. , CM., Crieff]

William Herbert Gregory, M.D., CM., Beverley, Forks, James Gibson Cattanach, M.B., F.R.C.P. Ed., Alexander Maitland Easterbrook, M.B., CM., Gorebridge, Robert William Roberts, L.R.C.P. & S. Ed., North Wales,

220 Claude Buchanan Ker, M.D., F.R.C.P. Ed., . Charles Alexander Butchart, M.B., CM., Frederick Maurice Graham, F.R.C.S. Ed., L.R.C.P. Ed., Robert Hoggan, M.B., CM., Liberton, James Livingstone Thompson, M. B., CM., Australia,

225 John Stevens, M.D., F.R.C.P. Ed., .

Hugh Lewis Hughes, L.R.C.P. & S. Ed., Dowlais, Sylvaniis Glanville Morris, M.D., CM., Mardy, Thomas Easton, M.D., CM., Southampton, David Robertson Dobie, M.D., CM., Crieff, .

230 Gopal Govind Vatve, M.D., Bombay, .

Robert William Beesley, M.D., CM., Bolton, . William A. Stephen, M.D., CM., Loftus -in- Cleveland, William Edward Fothergill, M.D., CM., Manchester, George Sandi son Brock, M.D., CM., Rome.

235 *John Martin Munro Kerr. M.B., CM

John Montgomery, M.B., CM., Birmingham, *Robert Cochrane Buist, M.D., CM., Dundee, . Robert Thomson Ferguson, M.B., CM., Anstruther, Angus Vallance MacGregor, M.D., CM., West Hartlepool,

240 Charles William Donald, M.D., F.R.C.S. Ed., Carlisle,

Leven, Fife, .

, Whitby,

! Mo., U.S.A., '.

Date of Admission. 1891 1891 1892 1892 1892 1892 1892 1892 1892

1892 1892 1892

1892 1892 1892 1892 1892 1892 1892 1892 1892 1892 1893 1893 1893 1893 1893 1893 1893 1893 1893 1893 1893 1893 1893 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1894 1895 1895 1895 1895 1895

250

255

260

265

270

275

280

285

290

295

LIST OF FELLOWS. XV

Date of Admission.

John Strutbers, M.B., CM., TransJcei, South Africa, . 1895

B. W. Broad, M.B., CM., Cardiff, .... 1895

Edwin Hindmarsh, M.B., CM., 'Bengal, . . 1895

Patrick Mackin, M.D., F.R.CS. Ed., New Zealand, . . 1895

G. Edgar Helme, M.B., CM., Manchester, . . . 1895

Percy Theodore Hughes, M.B., CM., Broomsgrove, . . 1895

John Hosack Fraser, M.B., F.R.CP. Ed., Bridge of Allan, . 1895

Stewart Grant Ogilvy, M.B., CM., Fauldhouse, . . 1895

Thomas Howard Morgan, M. D., F.R.CS. Ed., Queensland, Aust., 1895

William Macrae Taylor, M.B., F.R.CS. Ed., . . . 1895

David James Graham, M.D., F.R.CP. Ed., . . 1895

Walter William Chipman, M.D., F.R.CS. Ed., Montreal, . 1895

John dimming, M.D., F.R.CS. Ed., F.R.CP. Ed., . . 1896

Sol Jervois Aarons, M.D., CM., London, ... . 1896

Robert Beveridge, M.B., CM., Leith, . . . 1896

John Anderson, M.B., CM., Pitlochry, . . . 1896

Thomas John Burton, M.D., CM., Australia, . . 1896

Robert Gordon M'Kerron, M.B., CM., Aberdeen, . . 1896

Frederick John M'Cann, M.D., M.R.C.P.L., London, . 1896

David Robert Taylor, L.R.C P. & S.Ed., Ayton, . . 1896

George William Simla Paterson, M.B., CM., . . . 1896

Robert Henry Watson, M.D., CM., Hamilton, . . 1896

Thomas Marshall Callender, M.D., CM., Sidcup, . . 1896

Lewis Grant, M.D., CM., Neston, .... 1896

Robert Robertson, M.B., CM., . .... 1897

James Wilkie, L.R.C P. & S. Ed., Portobello, ... 1897

Andrew Graham, M.D., Currie, .... 1897

Roderick Murdoch Matheson, M.D., F.R.CS. Ed., . . 1897

*Robert Jardine, M.D., F.F.P.S. Glasg., M.R.CS. Eng.,

Glasgow, . . . . . . . 1897

Daniel Charles Edington, M.D. , CM., Penrith, . . 1897

John Macmillan, M.D., F.R.CP. Ed., F.R.CS. Ed., . . 1897

Harold Sherman Ballantyne, M.B., CM., Dalkeith, . . 1897

Ernest Edward Porritt, M.D., F.R.CS. Ed., New Zealand, . 1897

William John Garbutt, M.B., CM., Birmingham, . . 1897

Henry John Forbes Simson, M.B., F.R.CS. Ed., London, . 1897

William Alexander Potts, M.D., CM., Birmingham, . . 1897

Angus Macdonald, M.B., F.R.CS. Ed., . . . 1897

Bernard Samuel Story, M.D., F.R.CS. Ed., New Zealand, . 1898

Alexander Macdonald, M.B., F.R.CS. Ed., | . . . 1898

George Robert Livingston, M.D., CM., Dumfries, . . 1898

Charles Carmichael Forrester, M.B., CM., . . . 1898

William Morrison Milne, M.B., CM., . . . . 1898

William Joseph Murphy Barry, M.D., M.R.CP.Ed.,

Penarth, . . . . . . . 1898

John Christie Forbes, L.R.C. P. & S. Ed., Liberton, . . 1898

Alexander Cruikshank Ainslie, M.D.. CM., . . . 1898

Henry Aylmer Dumat, M.D., F.R. C.P.Ed., Durban, South

Africa, . . . . . . . 1898

Gabriel Maurange, M.D., Paris, .... 1898

John Thomas Woodside, L.R.C. P. & S. Ed., Stewartstown, . 1898 George Freeland Barbour Simpson, M.D., F.R.CS. Ed.,

F.R.CP. Ed., 1898

Alfred Charles Sandstein, M.D., Ch.B., New Zealand, . 1898

Alfred Shearer, M.B., Ch.B., Newtown, N. Wales, . . 1898

John Henry Rhodes, M.B., Ch.B., Kendal, . . . 1898

James Duncan Slight, M.D., Ch.B., Leicester, . . . 1898

Francis John Harvey Bateman, M.D., CM., London, . . 1898

Robert John Johnston, M.B., CM., . . . . 1899

XVI

List of fellows.

William Bertie Mackay, M. D. , Berivkk-on- Tweed,

Edward William Scott Carmicliael, M.D., F.R.C.S. Ed..

James Wilson M'Brearty, F.R.C.S. Ed., L.R.CP. Ed., New Zealand, ......

George Crewdson Thomas, M.D., CM., London, 300 John Eason, M.D., F.R. C.P.Ed., Leith,

William John Barclay, M.D., F.R.C.S., Ed., New Zealand,

Frederick Adolphns Fleming Barnardo, M.B., Ch.B., India,

Alexander Dingvvell Fordyce, M.D., F.R.C.P. Ed., .

William Thomas Ritchie, M.D., F.R.C.P. Ed., 305 Owen, St John Moses, M.D., CM., B.Sc, Calcutta, .

Charles Wakeham Holmested, L.R.CP. & S. Ed., L.F.P.S Glasg., Tuxford, .....

Donald MacGregor, M.D., CM., Jedburgh, *Harry Oliphant Nicholson, M.D., F.R.C.P. Ed.,

Thomas Scott Brodie, M. B., CM., Wishaw, . 310 William Hope Fowler, M.B., Ch.B., .

John Stanley Manford, M.B., B.S., Neivcastle-on-Tyne,

Ogden Watson Ogden, M.D., M.R.C.S., Newcastle-on-Tyne,

John Craig, M.B., Ch.B., ....

William Hartley Bunting, M.D., F.R.C.S. Ed., Birmingham, 315 Theodore Charles Mackenzie, M.B., Ch.B., Aberdeen, .

Donald George Hall, M.B., M.R.C.S. Eng., Sussex, .

Hugh Corbett Taylor Young, M.D., CM., Sydney,

John Boyd Jamieson, M.D., F.R.C.S. Ed.,

Malcolm M'Larty, M.B., CM., 320 Peter Joseph Henry Ferguson, M.B., CM.,

Frederick Gardiner, M.D., CM.,

George Mackie, M. B., Ch.B., Malvern,

Kenmure Duncan Melville, M.D., Ch.B.,

John Thomas Dickie, L. R. C P. & S. Ed. , 325 William Ernest Frcst, M.B., Ch.B., .

Frederick David Simpson, M.D., F.R.C.S. Ed.,

Francis Wilfrid Harlin, F.R.C.S. Ed., L.R.CP. Ed., Queens- land, ......

William Darling, M.B., F.R.C.S. Ed.,

Robert Macfarlane Mitchell, M. B., F.R.C.S. Ed., Australia, 330 Malcolm Campbell, M.B., F.R.C.S. Ed.,

James Ramsay Munro, M. D. , Ch.B., Spalding,

George James Rogerson Carruthers, M.B., Ch.B.,

Hilda Maud M'Farlane, L.R.CP. & S. Ed., Burntisland,

George Dickson, M.D., CM., .... 335 Elsie Maud Inglis, M.B., CM.,

George Robertson. L R.C.P. & S. Ed., Dunfermline,

John Jeffrey, M.B., F.R.C.S. Ed., Jedburgh, .

John Wishart Kerr, M.B., Ch.B., Glasgow,

William Harold Graham Aspland, M.D., M.R.C.S. Eng. China, ......

340 William Taylor McArthur, M.D., F.R.C.S. Ed., California,

Alexander Waddel Greenhorn Clark, M.B., CM.,

Henry Overton Hobson, M.D., CM., London,.

Robert Patton Ranken Lyle, M.D., Ch.B., Newcastle-on- Tyne, ......

Frederick William Kerr Tough, L.R.CP. & S. Ed., St Helen' Junction, Lancashire, .... 345 Robert Ashleigh Glegg, M.D., Ch.B., Leith, .

Walter Scott Patton, M.B., Ch.B., India,

David Whiteside Maclagan, M.B., Ch.B., New Zealand,

Kennedy C M'llwraith, M.B., M.CP. & S. Ont., Toronto,

LIST OF FELLOWS.

XV11

350

35 i

360

365

370

375

380

385

390

395

400

Robert Alexander John Harper, M.D., Ch.B., Dalkeith,

William Hogg Prentice, M.D., Ch.B., Pendleton,

Alexander Mowatt Malcolmson, M.D., Ch.B., Corstorphine,

David Albert Callender, M. B. , Ch. B. , Knutsford,

Caleb Williams Saleeby, M.D., Ch.B., London,

John Andrew Douglas Thompson, Halesowen,

John Ligertwood Green, M. D., Ch.B.,

William Sloss, M.B., Ch.B., Australia,

Charles James Hill Aitken, M.D., CM., Cape Colony,

E. R. Secord, M.D., Ontario, .

F. E. Thompson, M.D., Montreal, John M 'Gibbon, M.B., CM., Thomas James Thomson, M.D., CM., Charles Mowbray Pearson, M.B., Ch.B., Ewen John Maclean, M.D., M.R.C.P. Lond., Cardiff, James William Somerville, M.D., CM., Galashiels, Alexander Miller, L.R.C.P. Ed., L.F.P.S. Glasg., Glasgow, Hugh Faulkner, M.B., Ch.B , Banbury, Duncan Macnab Callender, M.B., Ch.B., Lancaster, Robert Cranston Low, M.B., Ch.B., . Benjamin Philip Watson, M.B., Ch.B., John Macdonald, M.B., CM., Cupar-Fife, . Mabel Hardie, M. B. , Ch. B, , Stockport, John Sullivan, M.B., Ch.B., . Charles William Somerville, M.B., Ch.B., China, Frank Mayes Willcox, M.B., CM., . John Tennant, M.B., CM., Scunthorpe, Alexander Simpson Wells, M.B., F.R.CS. Ed., Cape Andrew Binny Flett, M.B., Ch.B., William Henry Eden Brand, F.R.CS. Ed., L.R.C,

Banchory, ....

Francis Cavanagh, M.B., Ch.B., Sheffield, Alfred Lambre White, L.R.C.P. & S. Ed., Manchester, Robert Bathgate Johnston, L.R.C.P. & S. Ed., Penrith William Llewellyn Jones, M.D., F.R.CS. Ed., Merthyr

Tydvil, ......

Robert Wilson Gibson, M.D., F.R.CS. Ed., Orton, .

Philip Henry Mules, M.B., Ch. B., New Zealand,

Andrea Francis Honyman Rabagliati, M.D. , Ch.B., Bradford

Donald Gregor MacArthur, M.D., CM., Aberfcldy, .

Henry Martyn Stumbles, M. B., Ch.B., Amble,

Gilbert John Farie, M.B., Ch.B., Bridge of Allan,

Cameron Robertson Gibson, M.B., Ch.B., Gretna,

James Mathieson Kirkness, M.D., Ch.B.,

Katherine Jane Stark Clark, M.D., Ch.B., D.P.H., .

David Halliday Croom, M.D., Ch.B., .

Eleanor Russell Elder, M.B., Ch.B., Leith, .

Robert William Johnstone, M.D., Ch. B.,

James William Keay, M.D., Ch.B.,

Ivan Cochrane Keir, M.D., Ch.B., Melksham, .

Alexander Grant Macdonald, M.B., CM.,

Charles John Shaw, M.D., Ch.B., Montrose, .

Frederick Porter, M.B., CM., ....

Sherwin Gibbons, M.D., Los Angeles,

Russell Gerald William Adams, M.D. , Ch.B., New Zealand,

Duncan Campbell Lloyd Fitzwilliams, M.D., Ch.B,

London, . Clarence Brian Dobell, M.B., M.R.C.S. Eng., M.R.C.P.L,

Cheltenham, .....

Town

P.Ed

Date of Admission. 1901 1901 1901 1901 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1902 1903 1903

1903 1903 1903 1903

1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1903 1904 1904 1904

1904

1904

X.V111

LIST OF FELLOWS.

405

410

415

420

425

430

435

440

445

450

455

460

Hugh Stevenson Davidson, M.B. , Ch.B.,

Andrew Milroy Fleming, C.M.G., M.B., F.R.C.S. Ed

Rhodesia, ..... Thomas William Edmondston Ross, M.B., Ch.B., Cardiff, John Benjamin Hellier, M.D., M.R.C.S. Eng., Leeds, . John Thomas Williams, M. D. , Treharris, William Brown, M.B., Ch.B., Braemar, John Hepburn Lyell, M.D., CM.. Perth, Henry Hugh Robarts, M.D., Ch.B., Haddington, Thomas Garnet Stirling Leary, M.B., Ch.B., Australia, Robert Balfour Barnetson, M.B. , Ch.B., Portobello, . James Lochhead, M.D., Ch.B., Earlston, Arthur Charles Strain, M.D., Ch.B., West Hartlepool, Lewis Beesly, L.R. C.P.Ed., F.R.C.S. Ed., James Crawford Gibb Macnab, M.B., F.R.C.S. Ed., Dysart, Andrew Alexander Hall, M.B., Ch.B., . Robert William Lessel Wallace, M.B., Ch.B., Bournemouth, Alfred Thom Gavin, M.B., CM., Dunaskin, . Alastair MacGregor, M.D., CM., Market Harborough, Edmond Frost, M.D., CM., Eastbourne, Edith Cochrane- Brown Pitts, M.B., Ch.B., New Zealand, James Brownlee, M.D., Ch.B., Middlesbrough, William Joseph Maloney, M.D., Ch.B., Cairo, Peter M'Ewan, M.B., Ch.B., Bradford, George Douglas Mathewson, M.B., Ch.B., Henry Grey Brown, M.B., Ch.B.,

Richard James Harley, M.D., L.R.C.P. &S.Ed., Murruyjirld Andrew Fleming, M.B., Ch.B., Corstorphine, Robert William Craig, M.D., Ch.B., Ford, Henry John Dunbar, M.D., Ch.B., .

Richard Alfred Blake, M.D., Ch.B., Pretoria, South Africa, John Herbert Gibbs, F.R.C.S. Ed., Alice Marion Hutchison, M.D., Ch.B., Barbara Martin Cunningham, M.B., Ch.B., India, W. T. Chouhall, M.D., Sydney,

Alexander Angus Martin, F.R.C.S. Ed., North Shields, James Andrew Gunn, M.D., Ch.B., James Lawson Russell, M.B., Ch.B., Todmorden. Archibald M'Kendrick, L.R.C.P. k S.Ed., Kirkcaldy, Alexander Scott, M.B., CM., Broxburn, Archibald Simpson, M.B., Ch.B., Darlington, Hirjee Nowon Anklesaria, L.R.C.P. & S.Ed., Bombay, Archibald Cotterell M 'Master, M.B., Ch.B. . Arthur James Lewis, M.B. , Ch.B., Herbert Park Thompson, M.D., Ch.B., Samuel Davidson, M.D., CM., Kelso, William Fowler Godfrey, M.B., CM., H. St John Randell, M. B., Ch. B., Cape Colony, Kaikhuson Dadabhoy, F.R.C.S. Ed., L.R. C.P.Ed., India, William Joseph Baird, M.B., Ch.B., Earls Barton, . Edward Burnet, M.B., Ch.B., . Arthur Samuel Walker, M.B., Ch.B., Ashley, Archibald Dunlop Stewart, M. B. , L. R. C S. Ed. , Henry Fleet Gordon, M.D., L.R.C.P. & S. Ed., Winnipeg, Edward Alexander Elder, M.B., Ch.B., Ethelbert William Dyer, M. B., Ch.B. , London, William Torrance Smith, M.B., Ch.B., Midcalder, . Arnold Davies, M.B., Ch.B., Menai Bridge, . Thomas Graham Brown, M.B., Ch.B.,

Date of

Admission.

1904

1904 1904 1904 1904 1904 1904 1904 1904 1904 1904 1904 1904 1904 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1905 1906 1906 1906 1906 1906

1906

1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906 1906

ALPHABETICAL LIST OF FELLOWS.

XIX

John Bruce M'Moreland, M.B., Ch.B.,

William Omand Sclater, M.B., Ch.B.,

Archibald George Kirkwood Ledger, M.B., Ch.B., Darwen, 465 Frederick James Greig, L.R.C.P. & S.I., Lt.-Col., R.A.M.C. Stirling, ......

Duncan Lorimer, M.B., Ch.B.,

Charles Robert Paterson Mitchell, Glasgow, .

William David Osier, .....

John Halley Meikle, M.D., .... 470 David Lloyd Roberts, M.D., F.R.C. P., Manchester, .

James Sutherland Edwards, M.B., Ch.B.,

Alexander Murray Drennan, ....

Mary Caroline Hamilton, L.R.C.P. & S. Ed., L.F.P.S. Glasg

Elsie Mary Macmillan Barnetson, M.B., Ch.B., Joppa, 475 John Andrew Macleod, M.B., Ch.B., Inverness

Hugh Smith Reid, M.D., Ch.B., 477 Allan Macdonald Dick, M.B., Ch.B., .

Date of

Admission. 1906 1906 1906

1906 1906 1906 1906 1906 1906 1906 1907 1907 1907 1907 1907 1907

ORDINARY FELLOWS.

ARRANGED ALPHABETICALLY.

(a.) LIFE MEMBERS.

Adam, Dr George Roth well, 84 Collins St., Melbourne, Aus.,

Anderson, Dr John, Newholme, Pitlochry,

Ballantyne. Dr Harold S., Ashton, Eskbank, Dalkeith,

Ballantyne, Dr J. W., 24 Melville Street, 5 Barbour, Dr A. H. Freeland, 4 Charlotte Square,

Barclay, Dr William John, Invercargill, New Zealand,

Brock, Dr G. Sandison, 2 Via Veneto, Rome,

Burnet, Dr Edward, 4 Fingal Place, .

Cavanagh, Dr Francis, 396 Ecclesall Road, Sheffield, . 10 Chipman, Dr W. W., 285 Mountain St., Montreal, Canada,

Chouhall, Dr William T., 233 Macquarie St., Sydney, Australia, ......

Craig, Dr John, 71 Brunts field Place, .

Craig, Dr William, 71 Bruntsfield Place,

Croom, Dr David Halliday, 17 Alva St., 15 Croom, Prof. Sir John Halliday, 25 Charlotte Square,

Cumming, Dr John, 70 Bruntsfield Place,

Dobell, Dr C. B., 1 Royal Well Terrace, Charlton, Cheltenham

Dumat, Dr Henry Aylmer, 7 Devonshire Place, Durban Natal, South Africa, ....

Fleming, Dr Andrew M., C.M.G., Salisbury, Rhodesia, 20 Fowler, Dr Simson, Waverley, Juniper Green,

Frost, Dr Edmund, Chesterfield, Meads, Eastbourne, .

Gibson, Dr R. Wilson, Town Head House, Orton, Tebay,

Grant, Dr Lewis, Neston, Cheshire,

Hart, Dr D. Berry, 5 Randolph Cliff, . 25 Inch, Dr Robert, Gorebridge, ....

Johnston, Dr D. W., P.O. Box 2022, Johannesburg, Trans vaal, ......

Livingston, Dr George R., 47 Castle Street, Dumfries,

1879 1896 1897 1883 1879 1899 1894 1906 1903 1895

1906 1900 1870 1903 1870 1896 1904

1898 1904 1892 1905 1903 1896 1877 1887

1892 1898

XX

ALPHABETICAL LIST OF FELLOWS.

30

55

40

45

M'Arthur, DrW. Taylor, 959 S. Figueroa St., Los Angeles,

California , . M'Brearty, Dr J. Wilson, Greymouth, West Coast, New

Zealand, .......

M'Farlane, Dr Hilda M., Bendameer, Burntisland,- .

Macnab, Dr James, C. G., The Towers, Dysart,

Maddox, Dr Ralph H., I. M.S., c/o Messrs Thomas Cook &

Son, Ludgate Corner, London, E.C., Martin, Dr Christopher, Cleveland House, George Road,

Edgbaston, Birmingham, . . . . .

Melville, Dr Kenmure, 2 Nile Grove, . . .

Morgan, Dr T. H., Gympie, Queensland, Australia, . Mules, Dr P. Henry, Bishopdale, Nelson, New Zealand, Pereira, Dr A. A. Jervis, Consul de Grece en Mozambique,

Lourenco. Marques, Delagoa Bay, South Africa, . Pitts, Dr Edith Cochrane-Brown, Strathmore, Christ Church,

New Zealand, .....

Ponder, Dr Charles F., Glenorchy, Hobart, Tasmania, Ranking Dr J. E., Tunbridge Wells, . Ross, Dr James F. W., 481 Sherbourne Street, Toronto, Canada Russell, Dr J. Lawson, West Lodge, Tormorden, Simpson, Dr G. F. Barbour, 50 Melville Street, Simpson, Dr W. Petrie, Viewbank, Bathgate, Simson, Dr H. J. F., 36 Grosvenor Street, London, W., Struthers, Dr John, Nqamakwe, Transkei, South Africa, Vatve, Dr Gopal Govind, c/o H.H. The Rajah of Miruj

Bombay, India, ..... Wells, Dr A. Simpson, 56 Orange Street, Cape Town, South

Africa, .......

Date of Admission.

1901

1899 1901 1904

1887

1888 1900 1895 1903

]888

1905 1892 1881 1889 1906 1898 1892 1897 1895

1894

1903

(6.) ANNUAL SUBSCRIBERS.

Aarons, Dr S. Jervois, 14 Stratford Place, London, W., . 1896

50 Adams, Dr Russell G. W., Langley Dale, Blenheim, New

Zealand ....... 1904

Affleck, Dr J. O., 38 Heriot Row, . . . . 1869

Ainslie, Dr A. C, 49 Minto Street, .... 1898

Aitken, Dr C. J. Hill, 19 Church Street, corner of Oxford

Street, East London, South Africa. . . . 1902

Alexander, Dr W. B., 8 Blenheim Place, . . . 1882

55 Allison, Dr J., Fuller House, Kettering, Northampton, . 1888

Anderson, Dr Fred. T., 20 In verleith Row, . . . 1892

Andrew, Dr James, 2 Atholl Crescent, .... 1868

Anklesaria, Dr H. N., 12 Colaba Causeway, Bombay, India, . 1906

Archibald, Dr J., Hazelden, Wimborne Road, Bournemouth, 1877

60 Armitage, Dr J. A., 58 Waterloo Road Wolverhampton, . 1886

Armour, Dr E. F., 6 Bruntsfield Terrace, . . . 1889

Aspland, Dr W. H. Graham, Church of England Mission,

Peking, China, . . . . . . 1901

Baildon, Dr F. J., 42 Hoghton Street, Southport, . . 1887

Baird, Dr W. J., Earls Barton, Northants, . . . 1906

65 Ballantyne, Dr A., Ashton, Eskbank, Dalkeith, . . 1870

Barnardo, Dr F. A. F., Capt. I. M.S., Ferozepore, Punjab,

India, . . . ..... . 1899

Barnetson, Dr Elsie M„ 31 Morton Street, Joppa, ' . . 1907

ALPHABETICAL LIST OF FELLOWS.

XXI

70

75

SO

85

90

95

100

105

1.10

115

120

Barnetson, Dr R. Balfour, 31 Morton Street, Portobello, Barrington, Dr Fourness, 213 Macquarrie Street, Sydney,

Australia, ......

Barry, Dr W. J. M., 29 Plymouth Road, Penarth, Glamorgan,

Bateman, Dr F. J.Harvey, Heath End, Blackheath, Lond. ,S.E

Beatty, Dr Samuel, Craigvar, Pitlochry,

Beesley, Dr R. W., 135 Deane Road, Bolton, .

Beesly, Dr Lewis, 13 Torphichen Street,

Bell, Dr J. Lumsden, Driffield, Yorkshire,

Bentley, Dr G. H., Loanhead House, Kirkliston,

Beveridge, Dr Robert, 9 James Place, Leith, .

Blaikie, Dr R. H., 10 Mayfield Gardens,

Blair, Dr J. A., 16 Windsor Terrace, Newcastle-on-Tyne,

Blake, Dr R. A., Padn oiler, Sunnyside, Pretoria, South Africa

Bleloch, Dr A., 26 Gilmore Place,

Boddie, Dr G. P., 73 Brimtsfield Place,

Booth, Dr William, 2 Minto Street, .

Borrowman, Dr Philip G., Galvelmore, Crieff,

Boxill, Dr N. L., Buttalls, St George, Barbados,

Brand, Dr Eden, Bellfield, Banchory, .

Brewis, Dr N. T., 6 Drumsheugh Gardens,

Brewis, Dr R. Adams, The West Gate, Dursley, Gloucestershire

Broad, Dr B. W., The Sanitorium, Cardiff,

Brodie, Dr T. Scott, 21 Belhaven Terrace, Wishaw,

Brodie, Dr W. Haig, 6 St Stephen's Road West, West

Ealing, London. W. Brown, Dr H. Grey, 1 Cluny Avenue, . Brown, Dr J. Graham, 3 Chester Street, Brown, Dr William, Braemar, .... Brownlee, Dr James, 6 Seaton Terrace, Linthrope Road

Middlesbrough, ..... Buist, Dr J. W., 1 Clifton Terrace, . Buist, Dr R. C, 166 Nethergate, Dundee, Bunting, Dr W. Hartley, 20 Hagley Road, Edgbaston

Birmingham, .....

Burton, Dr Thomas J., Port Hedland, West Australia, Butchart, Dr C. A., 52 Leith Walk, Leith, Cairns, Dr W. Murray, 67 Catherine Street, Liverpool, Calder, Dr H. L., 60 Leith Walk, Leith, Callender, Dr D. A., Hazelmere, Toft Road, Knutsford,

Cheshire, ..... Callender, Dr D. M., 6 Rose Bank, Lancaster, Callender, Dr T. M., Inverard, Sidcup, Cameron, Prof. James C, M.D., 941 Dorchester Street

Montreal, ..... Campbell, Dr Malcolm, 17 Walker Street, Carmichael, Dr Edward, 21 Abercromby Place, Carmichael, Dr E. W. Scott, 32 Rutland Square, Carmichael, Pr James, 22 Northumberland Street, Carrnthers, Dr G. J. R., 4 Melville Street, Cattanach, Dr J. G., 3 Alvanley Terrace, Church, Dr H. M., 36 George Square, . Clark, Dr A. W. G., 24 Braid Crescent, Clark, Dr J. A., 4 Cambridge Street, Clark, Dr Katherine S., Craigleith Poorhouse, Cobbett, Dr C. N., Edmonton, Alberta, Canada, Cox, Dr Joshua J., 38 Deansgate, Manchester, Craig, Dr R. W., Pathhead-Ford, Dalkeith, . Oroudace, Dr J. H., Foregate House, Stafford,

Date of

Admission.

1904

1884 1898 1898 1888 1894 1904 1884 1877 1896 1888 1887 1905 1876 1889 1891 1893 1888 1903 1883 1888 1895 1900

1881 1905 1906 1904

1905

1877 1895

1900 1896 1894 1892 1882

1901 1902 1896

1888 1900 1887 1899 1871 1901 1893 1875 1901 1887 1903 1890 1876 1905 1878

XX11

ALPHABETICAL LIST OF FELLOWS.

125

130

135

140

145

150

155

160

165

170

Cullen, DrG. M., 50 Minto Street, .

Cunningham, Dr Barbara M., Dufferin Hospital, Nagpur

Central Provinces, India, . Currie, Dr A. S., 20 Oxford Terrace, Hyde Park, London, W. Dadabhoy, Dr K., Karachi, India, Darling, Dr T. Brown, 1 3 Merchiston Place, . Darling, Dr William, 2 Warrender Park Terrace, Davidson, Dr D. G., 9 Granville Terrace, Davidson, Dr H. S., 4 Dundas Street, . Davidson, Dr Samuel, Kelso, .... Davies, Dr Arnold, Grammar School, Menai Bridge, North

Wales, ......

Davies, Dr E. T. , 1 St Domingo Grove, Liverpool,

Dendle, Dr Frank, Overton House, Spring Grove, Isleworth,

Deverell, Dr H. C, 12 Windsor Street,

Dewar, Dr M., 24 Lauriston Place,

Dick, Dr A. Iff., Edinburgh University Union,

Dickie, Dr J. T., 37 Lauriston Place, .

Dickson, Dr George, 9 India Street,

Dickson, Dr George, 14 Ardmillan Terrace,

Dobie, Dr D. Robertson, Heathfield, Crieff,

Donald, Dr C. W., 28 Portland Square, Carlisle,

Drennan, Dr A. Murray, 36 Woodburn Terrace,

Dunbar, Dr H. J., 1 Kew Terrace,

Duncan, Dr A. J., 158 Nethergate, Dundee, .

Duncan, Dr A. S., .....

Dunlop, Dr H. M., 20 Abercromby Place,

Dyer, Dr E, W., c/o Messrs Webster, Steel & Co., 5 East

India Avenue, Leadenhall Street, London, E.C., . Eason, Dr John, 58 Northumberland Street, . Easterbrook, Dr A. M., Am prior, Gorebridge, Easterbrook, Dr C. C, Glengall, Ayr, . Easton, Dr Thomas, 23 East Park Terrace, Southampton, Eden, Dr T. Watts, 26 Queen Anne Street, Cavendish Squar

London, W. , . .

Edington, Dr D. C, 4 Portland Place, Penrith, Edwards, Dr J. S., University Union, Elder, Dr Edward A., 6 Torphichen Street, Elder, Dr Eleanor, 4 John's Place, Leith, Elder, Dr W. Nicol, 6 Torphichen Street, Evans, Dr O. F., 20 Princes Avenue, Liverpool, Farie, Dr G. J., Strathallan House, Bridge of Allan Farquharson, Dr J. D., 242 Westgate Road, Newcastle-on

Tyne, ......

Faulkner, Dr Hugh, St John's House, Banbury, Oxon Felkin, Dr R. W., 12 Oxford Gardens, North Kensington

London, W., ....

Ferguson, Dr J. Haig, 7 Coates Crescent, Ferguson, Dr P. J. H. , 9 Windsor Street, Ferguson, Dr R. T., Middlemarch, Anstruther, Fife, . Finlay, Dr W. A., 50 Trinity Road, . Fitzwilliams, Dr D. C. L., 64 Brook Street, Grosvenor Square

London, W., .....

Fleming, Dr Andrew, St John's Road, Corstorphine, . Flett, Dr A. B., 60 George Square, Forbes, Dr J. Christie, Ardv* ich, Liberton, Fordyce, Dr A. Dingwall, 19 Coates Crescent, Fordyce, Dr William, 20 Charlotte Square, Fothergill, Dr W. Edward., 13 St John Street, Manchester,

Date of

Admission.

1890

1906 1882 1906 1884 1900 1892 1904 1906

1906 1887 1892 1882 1891 1907 1900 1867 1901 1894 1895 1907 1905 1879 1890 1884

1906 1899 1893 1892 1894

1888 1897 1906 1906 1903 1879 1890 1903

1890 1902

1884 1885 1900 1895 1880

1904 1905 1903 1898 1899 1888 1894

ALPHABETICAL LIST OF FELLOWS.

XX111

Forrester, Dr C. C, 3 Albert Terrace, .

Fowler, Dr W. Hope, 5 St Vincent Street, 175 Fox, Dr J. W., 18 Bernard Street, Southampton,

Fraser, Dr J. Hossack, Fernfield, Bridge of Allan,

Fraser, Dr Nutting S., 205 Gower Street, St John's, New foundland, ......

Frost, Dr W. E., 6 Atholl Place,

Garbutt, Dr W. J., 1 Bournbrook Rd., Selly Pk., Birmingham 180 Gardiner, Dr Frederick, 9 George Square,

Gavin, Dr Alfred T., Doonlea, Dunaskin,

Gayton, Dr William, Ravensworth, Regent's Park Road Finchley, London, N.,

Gemmell, Dr J. E., 28 Rodney Street, Liverpool,

Gibbons, Dr Sherwin, 1013 Braly Building, Los Angeles, California, ......

185 Gibbs, Dr J. H., 7 Coates Place,

Gibson, Dr Cameron R., 101 Forest Road, Nottingham,

Giffen, Dr J. T. M., 138 Boughton, Chester, .

Giles, Dr A. B., 4 Palmerston Place, .

Gilmour, Dr T. F., Port Ellen, Islay, . 190 Glegg, Dr R. Ashleigh, Public Health Office, Leith, .

Godfrey, Dr W. F., 46 Cumberland Street

Gordon, Dr Henry F., 178 Colony Street, Winnipeg, Canada.

Graham, Dr A., Curriebank, Currie,

Graham, Dr D. J., 26 Rutland Street, . 195 Graham, Dr F. M., 16 Mayfield Gardens,

Graham, Dr J. Gibson, 17 Ashton Ter., Dowanhill, Glasgow

Graham, Dr R. Balfour, Leven, Fife, .

Green, Dr John Ligertwood, 23 Minto Street, .

Greene, Dr T. W. N., 45 Dartmouth Square, Leeson Park Dublin, .......

200 Gregory, Dr W. H., North Bar Street, Beverley, Yorks,

Greig, Dr F. J., Lt.-Col. R.A.M.C., 16 Melville Ter., Stirling,

Gunn, Dr . J. A., Materia Medica Department, University of Edinburgh, ....

Guthrie, Dr A. Cowan, 21 Pilrig Street,

Hall, Dr A. A., 8 Vanburgh Place, Leith, 205 Hall, Dr D. G., 30 Brunswick Place, Hove, Brighton

Hamilton, Dr J. R., Elm House, Hawick,

Hamilton, Dr Mary, Pengarth, St Agnes, Cornwall,

Hamp, Dr J. Walton, Penn Road, Wolverhampton,

Hardie, Dr Mabel, High Lane, near Stockport, 210 Harley, Dr R. J., ....

Harlin, Dr Francis W., Peak Downs District Hospital Clermont, Queensland, ....

Harper, Dr R. A. J., Abbey Road, Barrow-in-Furness

Harvey, Dr Charles E., Kingswood, Sav-la-Mar, Jamaica W.I., ....

Harvey, Dr James, 7 Blenheim Place, . 215 Haultain, Dr F. W. N., 12 Charlotte Square,

Havelock, Dr J. G., Sunnyside, Montrose,

Hay, Dr Henry, 11 Great King Street,

Hellier, Dr J. B., Glengariff, North Grange Road, Headingley Leeds, .....

Helm, Dr J. H. , Clarence Cottage, Ratho, 220 Helm, Dr R. Dundas, 13 Portland Square, Carlisle,

Helme, Dr G. Edgar, Gloucester House, Rusholme, Manchester

Henderson, Dr Alexander, 21 Pitt Street

Hewetson, Dr J., Holmfield

Date of Admission. 1898 1900 1887 1895

1887 1900 1897 1900 1905

1885 1885

1904 1905 1903 1892 1891 1882 J901 1906 1906 1897 1895 1894 1888 1893 1902

1889 1893 1906

1906 1888 1905 1900 1879 1907 1886 1902 1905

1900 1901

1889 1891 1884 1888 1879

1904 1888 1892 1895 1891 1881

XXIV

ALPHABETICAL LIST OF FELLOWS.

Hindmarsh, Dr Edwin, Mozufferpore, Tirhoot State Railway Bengal, India, ..... 225 Hobson, Dr H. Overton, Villa Sakkara, Helouan, Egypt

Hoggan, Dr Robert, Liberton Park, Liberton, .

Holmested, Dr C. W., Tuxford, Newark, Notts,

Hughes, Dr H. L., Llwyn-Werm, Dowlais, Glamorganshire,

Hughes, Dr P. T., County Asylum, Broomsgrove, Worcester shire, .... .

230 Hunter, Dr George, 33 Palmerston Place,

Hutcheson, Dr J. , 44 Moray Place,

Hutchison, Dr Alice M., 204 Bruntsfield Place,

Inglis, Dr Elsie M., 8 Walker Street, .

Jamieson, Dr Hugh, 1 Strathearn Road, 235 Jamieson, Dr J. Boyd, 43 George Square,

Jardine, Dr Robert, 20 Royal Crescent, Glasgow, W.,

Jeffrey, Dr John, Glen Bank, Jedburgh,

Johnston, Dr Robert B., Bishopyards, Penrith,

Johnston, Dr R. J., 1 Buccleuch Place, 240 Johnstone, Dr R. W., 13 Torphichen Street, .

Jones, Dr W. Llewellyn, 58 Thomas St., Merthyr-Tydvil,

Keay, Dr J. W., 12 Brougham Place, .

Keiller, Prof. Wm., 210 Levy Building, Galveston, Texas U.S.A

Keir, Dr Ian C, The Limes, Melksham, Wilts, 245 Ker, Dr Claude B., City Hospital, Comiston Road,

Kerr, Dr J. M. Munro, 7 Clairmont Gardens, Glasgow,

Kerr, Dr J. Wishart, 107 Greenhead Street, Glasgow,

King, Dr J. K., The Glen Springs Sanitorium, Watkins New York, U.S.A., .....

Kirk, Dr Robert, Rowan Bank, Bathgate, 250 Kirkness, Dr J. M., 14 Dalkeith Road,

Kynoch, Professor Campbell, 8 Airlie Place, Dundee, .

Lackie, Dr James, 1 Randolph Crescent,

Laing, Dr J. H. A., 11 Melville Street,

Langwell, Dr H. G., 4 Hermitage Place, Leith, 255 Leary, DrT. Garnet S., Grand Hotel, Melbourne, Australia,

Ledger, Dr A. G. K., 97 Blackburn Road, Darwen, .

Lee, Dr Herbert E., Gunnedah, N.S.W., Australia,

Lewis, Dr Arthur J., c/o R Shaw, Esq., 36 Woodburn Terrace

Littlejohn, Professor Harvey, 11 Rutland Street, 260 Lochhead, Dr James, Earlston,

Lockhart, Dr F. A. L., 23 Mackay Street, Montreal, Canada,

Lorimer, Dr Duncan, 74 Bruntsfield Place,

Low, Dr R. Cranston, 6 Castle Terrace, . .

Lvell, Dr John, 15 Marshall Place, Perth, 265 Lyle, Dr F. W., 97 Gordon Road, Ealing, London, W., '

Lyle, Dr R. P. Ranken, 11 Ellison Place, Newcastle-on-Tyne

Mac Arthur, Dr D. G., Aberfeldy,

M'Call, Dr John, 25b Abercromby Terrace, Portobello,

M'Callum, Dr H., Kinloch-Rannoch, . 270 M'Cann, Dr F. J., 5 Curzon Street, Mayfair, London, W..

Macdonald, Dr Alexander, 42 Polwarth Terrace,

Macdonald, Dr A. G., 11 Manor Place,

Macdonald, Dr Angus, 27 Manor Place,

Macdonald, Dr John, Marathon House, Cupar-Fife, . 275 Macdonald, Dr W. Fraser, 16 Buckingham Ter., Glasgow, AY

M'Ewan, Dr Peter, Royal Infirmary, Bradford, Yorks,

M'Gibbon, Dr John, 22 Heriot Row, .

MacGregor, Dr Alastair, Stafford Lodge, Market Harborough

Date of Admission.

1895 1901 1894 1900 1894

1895 1881 1888 1905 1901 1889 1900 1897 1901 1903 1899 1903 1903 1903

1890 1903 1894 1894 1901

1884 1887 1903 1892 1889 1891 1891 1904 1906 1892 1906 1890 1904 1890 1906 1902 1901 1890 1901 1903 1886 1887 1896 1898 1903 1897 1902 1884 19d5 1902 1905

ALPHABETICAL LIST OF FELLOWS.

XXV

280

285

290

295

300

SOf

310

315

320

126

330

MacGregor, Dr A. V., Durham House, West Hartlepool,

MacGregor, Dr Donald, Seaton House, Jedburgh,

Macgregor, Dr G. S., 2 Burnbank Terrace, Glasgow W.,

M'llwraith, Dr Kennedy C, 54 Avenue Rd., Toronto, Canada

Mackay, Dr George, 74 Bruntsfield Place,

Mackay, Dr W. B., 23 Castlegate, Berwick-on-Tweed,

M'Kendrick, Dr Archd., 120 High St., Kirkcaldy,

Mackenzie, Dr R., Napier, Nairn,

Mackenzie, Dr T. C, Aberdeen Royal Asylum,

M'Kerron, Dr R. Gordon, 1 Albyn Place, Aberdeen, .

Mackie, Dr George, Boyd's Lodge, Malvern, Worcestershire,

Mackin, Dr Patrick, 12 Ingestre St., Wellington, New Zealand,

Mackness, Dr G. O. C., Fort Street House, Broughty-Ferry

Maclagan, Dr D. W., Kaponga, Taranaki, New Zealand,

M'Larty, Dr Malcolm, 7 Bellevue Place,

M'Lean, Dr Archibald, Crosshouse, Kilmarnock,

Maclean, Dr Ewen, J., 12 Park Place, Cardiff,

Macleod, Dr J. A., The Asylum, Inverness,

M 'Master, Dr A. C, Australasian Club, Melbourne Place,

Macmillan, Dr John, 48 George Square,

M'Morland, Dr J. B., 19 Merchiston Gardens,

MacRae, Dr John, Lynwood, Murray field,

Mac Vie, Dr S. , Chirnside, ....

M'Watt, Dr John, Duns, ....

Macwatt, Dr R. C, 7th Bengal Cavalry, c/o Messrs King,

King & Co., Bombay, India, Malcolmson, Dr Alexander M., Dalveen, St John's Road

Corstorphine, .....

Maloney, Dr W. J., Kasr-El. Aing. Hospital, Cairo, . Manford, Dr J. Stanley, 1 Osborne Terrace, Newcastle-on

Tyne, .......

Marshall, Dr G. Balfour, 19 Sandyford Place, Glasgow, Marshall, Dr William, Milnathort,

Martin, Dr Angus, 25 Northumberland Square, North Shields Martin, Dr Charles, Dagenham House, Newton Abbot, South

Devon, ......

Martin, Dr J. W., Charterhall, Newbridge, Dumfries,

Matheson, Dr A. A., 41 George Square,

Matheson, Dr Roderick M., 33 Buccleuch Place,

Mathewson, Dr G. P., 25 Cluny Gardens,

Maurange, Dr Gabriel, 6 Rue de Tournon, Paris,

Meikle, Dr J. Hally, 12 Midmar Gardens,

Menzies, Dr David, 20 Rutland Square,

Messer, Dr Fordyce, Woodlands, Garelochhead,

Michael, DrGustave, 5 Cambridge Place, Chestergate, Regent

Park, London, N.W., Millard, Dr W. W., Middlefield House, Leith Walk, . Miller, Dr Alexander, 1 Royal Terrace, Crossbill, Glasgow, Miller, Dr W. H., 51 Northumberland Street, . Milne, Dr W. M., 10 Newington Road, Mitchell, Dr C. R. P., 1 Bowmont Gardens, Glasgow, Mitchell, Dr G. B., 1 Skinner Street, Whitby, Mitchell, Dr R. M., Government Hospital, Coolgardie

Western Australia, .....

Montgomery, Dr John, The Highlands, Balsall Heath

Birmingham, .....

Moorhouse, Dr J. Ernest, 6 Melville Terrace Stirling, More, Dr James, Rothwell, Kettering, Northampton, . Morison, Dr Albert E., Wellington Road, West Hartlepool,

Date of Admission. 1895 1900 1888 1901 1879 1899 1906 1887 1900 1896 1900 1895 1887 1901 1900 1890 1902 1907 1906 1897 1906 1893 1881 1879

1885

1901 1905

1900 1891 1884 1906

1892 1887 1887 1897 1905 1898 1906 1877 1866

1885 1884 1902 1886 1898 1906 1893

1900

1895 1892 1880

1888

62

XXVI

ALPHABETICAL LIST OF FELLOWS.

Morris, Dr S. Glanville, Brynawel, Mardy, Glamorganshire

Moses, Dr 0. St John, 8 Lansdovvne Road, Calcutta, .

Mowat, Dr John, 5 Hope Park Terrace,

Munro, Dr J. Ramsay, Sutter ton, Boston, 335 Murray, Dr A. Lang, Killara, Sydney, N.S.W., Australia,

Murray, Dr D. R., 41 Albany Street, Leith,

Murray, Dr James, 1 Brandon Street, .

Napier, Dr A. D. Leith, 28 Angas Street, Adelaide, South Australia, ......

Nicholson, Dr H. Oliphant, 20 Manor Place, . 340 Ogdcn, Dr 0 Watson, 38 Jesmond Road, Newcastle-on-Tyne

Ogilvy, Dr Stewart Grant, Fairmont, Fauldhouse,

Oliphant, Dr E. H. Lawrence, 23 Newton Place, Glasgow,

Orr, Dr John, Heather Lea, Clarendon Road, Eccles, Lanes.,

Orr, Dr W. Basil, 13 Braid Road, 345 Osier, Dr W. D., 11 Montgomery Street,

Paterson, Dr G. Keppie, 19 Albany Street,

Paterson, Dr G. W. Simla, 147 Kruntsfield Place,

Patton, Dr W. Scott, Capt., I. M.S., " Scotts Burn," Landour Mussoorie, N.W.P., India,

Pearson, Dr C. M., 14 Manor Place, . 350 Peddie, Dr H. Anderson, 24 Palmerston Place,

Perigal, Dr A., New Barnet, Herts,

Pirie, Dr John, 15 Ardmillan Terrace,

Playfair, Dr John, 5 Melville Crescent,

Poole, Dr T. D., North Side House, Linthwaite, near Huddersfield, .....

355 Porritt, Dr E. E., Wanganui, New Zealand, .

Porteous, Dr J. Lindsay, 83 Warburton Avenue, Yonkei New York, ......

Porter, Dr Frederick, 65 Morningside Road,

Potts, Dr W. A., 118 Hagley Road, Edgbaston, Birmingham,

Prentice, Dr W. H., Brunswick - Terrace, Brood Street, Pendleton, Manchester, . 360 Price, Dr A. W. Gordon, 9 Grange Road,

Price, Dr E. F. T.. 1 Middleby Street,

Primrose, Dr Alex., 100 College Street, Toronto, Canada,

Pringle, Dr J. Hogarth, 172 Bath Street, Glasgow, .

Proudfoot, Dr Thomas, 30 Lauriston Place, 365 Rabagliati, Dr A. H., 1 St Paul's Road, Bradford, Yorkshire,

Randell, Dr H. St John, Aliwal North, Cape Colony,

Reid, Dr H. S., 5 Ravelston Park, . .

Reid, Dr W. L., 7 Royal Crescent W., Glasgow,

Rendell, Dr Herbert R., P.O. Box 606, St John's, New- foundland, . . . . . . • .

370 Rhodes, Dr J. H., Vicarage Terrace, Kendal, .

Ritchie, Dr James, 22 Charlotte Square,

Ritchie, Dr W. T., 9 Atholl Place, . . . .

Robarts, Dr Henry H., Wemyss Place, Haddington, .

Roberton, Dr Ernest, Cotele House, Symond Street, Auck- land, New Zealand, . 375 Roberts, Dr D. Lloyd, 11 St John Street, Manchester,

Roberts, Dr Ernest T., Oaklands House, Keighley,

Roberts, Dr R. W. , Grove Place, Port Talbot, Glamorganshire,

Robertson, Dr George, Braehrad, Viewfield Place, Dunfermline,

Robertson, Dr Robert, 26 Royal Circus, 380 Robertson, Dr W. B., St Anne's, 101 Thurlow Park Road, West Dulwich, London, S.E., . . . .

Robertson, Dr W. G. Aitchison, 26 Minto Street,

Date of Admission. 1894 1900 1884 1901 1889 1878 1879

1878 1900 1900 1895 1885 1887 1889 1906 1882 1896

1901 1902 1882 1887 1888 1873

1890

1897

1875 1904 1897

1901 1890 1890 1887 1886 1884 1903 1906 1907 1880

1882 1898 1880 1899 1904

1887 1906 1890 1894 1901 1897

1870

1889

ALPHABETICAL LIST OF FELLOWS.

XXV11

385

390

395

400

405

410

415

420

425

430

Robins, Dr H., Sav-la-Mar, Jamaica, W.I.,

Robinson, Dr H. Shapter, Talfourd House, 78 Peckham Road

Camberwell, London, S.E., Ronaldson, Dr T. R., 8 Charlotte Square, Rosa, Dr Albert F., 28 Pitt Street, Ross, Dr J. W. E., 1 Clare Street, Cardiff, Russell, Dr W., 3 Walker Street, Saleeby, Dr C. W., 13 Greville Place, London, N.W. Sandstein, Dr Alfred C, 23 Latimer Square, Christchureh

New Zealand, . Saunders, Dr F. A., Grahamstown, Cape Colony, South

Africa, ......

Schofield, Dr Linn J., Warrensburg, Mo., U.S.A., Sclater, Dr W. O., 16 War render Park Crescent, Scott, Dr Alexander, The Firs, Broxburn, Scott, Dr T. R., Musselburgh, ....

Secord, Dr E. R., 112 Market St., Brantford, Ontario, Canada

Shaw, Dr C. J., Royal Lunatic Asylum, Montrose,

Shaw, Dr W. J., Cockburnspath,

Shearer, Dr Alfred, Newtown, N. Wales,

Simpson, Dr Archibald, The Hospital, Darlington,

Simpson, Dr F. D., 7 Kew Terrace,

Slight, Dr J. D., 61 London Road, Leicester,

Sloan, Dr Allen T., 22 Ahercromby Place,

Sloan, Dr S., 5 Somerset PI., Sauchiehall St. West, Glasgow,

Sloss, Dr William, Windsor, Sturt Street, Ballarat, Mel

bourne, Australia, ....

Smart, Dr David, 74 Hartington Rd., Sefton Park, Liverpool, Smith, Dr G. H. Walton, Pendower, Oxford St., Paddington,

Sydney* Australia, ......

Smith, Dr Gains T., 15 Church Street, Moncton, New Brunswick,

.Canada, ......

Smith, Dr James, 4 Brunton Place,

Smith, Dr John, Hrycehall, Kirkcaldy,

Smith, Dr W. Ramsay, Winchester St., East Adelaide, Aus

Smith, Dr W. Torrance, Linwood, Midcalder,

Sneddon, Dr William, 58 Bonnygate, Cupar-Fife,

Somerville, Dr C. W., London Mission, Wuchang, by Hankow

Central China, ..... Somerville, Dr James W., 12 Abbotsford Road, Galashiels, Spalding, Dr William, Gorebridge, Spence, Dr R., St Ninians, Burntisland, Spence, Dr William. Sydney House, Dollar, Stephen, Dr W. A., Loftus-in-Cleveland, Yorkshire, . Stevens, Dr John, 78 Polwarth Terrace, Stewart, Dr A. D., 8 Brougham Place, Stewart, Dr J. S.. 15 Merchiston Place, Stewart, Dr R., 25 George Square, Stirling, Dr R,, 4 Atholl Place, Perth, Story, Dr B. S. , Wellington, New Zealand, . Strain, Dr Arthur C. , Grange House, West Hartlepool, Stumbles, Dr H. M., Amble House, Amble, Northumberland Sturrock, Dr J. F., Arima, Bronghty-Ferry, . Sullivan, Dr John, 34 Gilmore Place, . Taylor, Dr David R., St Helen's, Ayton, Taylor, Dr William, 12 Melville Street, Taylor, Dr W. Macrae, 12 Melville Street, Teacher, Dr C, Ciaieend, North Berwick, Temple, Dr G. H., Ailanthus, Weston-super-Mare,

Date of

Admission.

1893

1890 1877 1893 1904 1890 1902

1898

1885 1893 1906 1906 1880 1902 1903 1892 1898 1906 1900 1898 1893 1887

1902

1882

1892

1891 1891 1885 1892 1906 1888

1902 1902 1867 1878 1884 1894 1894 1906 1884 1885 1892 1898 1904 1903 1887 1902 1896 1868 1895 1887 1888

XXVlll

ALPHABETICAL LIST OF FELLOWS.

435

440

445

450

455

460

465

470

475

477

Tennant, Dr John, Scunthorpe, near Doncaster, Thatcher, Dr C. H., 8 Melville Crescent, Thin, Dr Robert, 25 Abercromby Place, Thomas, Dr G. Crewdson, 34 West Hill, Sydenham, London S.E., ......

Thompson, Dr F. E., 20 Park Avenue, Montreal, Canada, Thompson, Dr Herbert P., c/o Mackay, 52 Morningside Road Thompson, Dr James L., Castlemaine, Victoria, Australia, Thompson, Dr John A. Douglas, Comberton House, Hale- sowen, Worcestershire, ....

Thomson, Dr A. D. R., 19 Bridge Street, Musselburgh, Thomson, Dr John, 14 Coates Crescent, Thomson, Dr J. Stitt, Castle Hill House, Lincoln, Thomson, Lr T. J., 31 Morningside Road, Thyne, Dr T. J., 16 Randolph Crescent, Tod, Dr John, 69 Ferry Road, Leith, .

Tough, Dr F. W. K., 24 Junction Lane, St Helen's Junction Lancashire, .....

Tristan, Dr R. J. , 28 Carolgate Retford, Notts, Underhill, Dr C. E., 8 Coates Crescent,

Underhill, Dr T. Edgar, Dunedin, Barnt Green, Worcestershire

Vassie, Dr Alexander H., 98 Priory Road, West Hampstead.

London, N.W., .

Vickery, Dr W. H., 1 Trewartha Park, Weston-super-Mare,

Wade, Dr George, St John's, Melrose, .

Walker, Dr Arthur S., Ashleigh, Middlesborough,

Wallace, Dr Abraham, 39 Harley Street, London, W. , Wallace, Dr R. W. L. , The Royal Boscombe and West Hants Hospital, Bournemouth, ....

Watson, Dr B. P., 6 Castle Terrace, .

Watson, Dr R. H. , Rousden, Park Road, Hamilton, .

Waugh, Dr John, 36 Finsbury Pavement, London, E. C. ,

Webster, Dr A. D., 18 Minto Street, .

Webster, Prof. J. C, 706 Reliance Building, 100 State Street Chicago, U.S.A.,

White, Dr A. L., Tantallon, Manchester Road, Castleton Manchester, .....

Wilcockson, Dr G. Morton, Whitley Cross, Reading, .

Wilkie, Dr James, Selville House, Portobello, .

Wilkinson, Dr George, 3 Dingle Hill, Liverpool, S., .

Will, Dr J. C. Ogilvie, 17 Bon-Accord Square, Aberdeen,

Williams, Dr J. T., Bronygar, Treharris, Glamorgan shire, ......

Willcox, Dr F. Mayes, 8 Strathearn Road,

Wilson, Dr James, 53 Inverleith Row, .

Wise, Dr Robert, 290 Ivy dale Road, Nunhead, London, S.E.

Wood, Dr Thomas, 182 Ferry Road, .

Woodside, Dr J. T. , Stewartstown, Co. Tyrone,

Wright, DrW.F., . , .

Yoe, Dr Richard T., 2103 Floyd Street, Louisville, Kentucky U.S. A

Young, Dr H. C. Taylor, 209 Macquarrie Street, Sydney, New South Wales, .....

Young, Dr Peter A., 25 Manor Place, .

Date of

Admission.

1902

1877

1891

1899 1902 1906 1894

1902 1877 1887 1877 1902 1887 1892

1901

1887 1872 1879

1891 1892 1893 1906 1879

1905 1902 1896 1881 1881

1889

1903 1893 1897 1889 1867

1904 1902 1889 1890 1886 1898 1887

1891

1900 1871

CONTENTS

I.— COMMUNICATIONS RELATING TO OBSTETRICS.

PAGE

Inaugural Address on the Future of Obstetrics. By J. W.

Ballantyne, M.D., F.R.C.P.E., F.K.S.E. ... 3

The Management of Some Difficult Occipito-Posterior Cases. By

J. Lamond Lackie, M.D., F.R.C.P.(Ed.) ... 28

On the Prognosis of Pregnancy in Patients with one Kidney, with Notes of an Unusually Complicated Case of Labour after Nephrectomy. By James Haig Ferguson, M.D., F.R.C.P.E., F.R.C.S.E., F.R.S.E . 57

Successful Treatment of Puerperal Fever by Antistreptococcic

Serum. By Dr Garnet Leary ..... 67

Exophthalmic Goitre in its Relation to Obstetrics and Gynaecology. By Professor Sir Halliday Croom, M.D., F.R.C.P.E., F.R.C.S.E 143

Epilepsy and the Status Epilepticus in connection with Pregnancy and Labour, with Illustrative Cases. By Professor Robert Jardine, M.D. (Ed.), F.F.P.S. (Glas.) . . . .165

A Series of Five Cases of Cesarean Section for Contracted Pelvis. By Professor John A. C. Kynoch, M.B., F.R.C.P., F.R.C.S. (Ed.) 221

II.— COMMUNICATIONS RELATING TO GYNECOLOGY.

Two Cases of Pregnancy complicated by Fibroid Tumours, treated by Hysterectomy. By N. T. Brewis, M.B., F.R.C.P.E., F.R.C.S.E 49

XXX CONTENTS.

PAGE

Case of Acute Albuminuria, caused by the Pressure of a Tumour on both Ureters — Operation — Recovery. By Frederick Porter, M.B., CM. 75

Intractable Uterine Haemorrhage, and Arterio- Sclerosis of the Uterine Vessels. By Elizabeth H. B. Macdonald, M.A., M.D., Ch.B 83

A Clinical and Anatomical Study of Thirty Cervical Fibroids removed by Abdominal Hysterectomy. By F. W. N. Haultain, M.D., F.R.C.P. (Ed.) 121

Hysterectomy for Fibroid Tumours in Pregnancy. Two Cases.

By A. H. F. Barbour, M.D., F.R.C.P.E. . . .136

Bilateral Ovarian Dermoid Tumours, complicating Pregnancy. By

Malcolm Campbell, M.A., M.B., B.Ch., F.R.C.S.E. . .184

Six Cases of Vaginal Cesarean Section. By N. T. Brewis, M.B.,

F.R.C.P.E., F.R.C.S.E 191

III.— MISCELLANEOUS COMMUNICATIONS.

A Case of Repeated Abortion due to Syphilis ; Treatment by Potassium Iodide. Birth of Child with Congenital Goitre. By B. P. Watson, M.D., F.R.C.S.E 204

The " Byrth of Mankynde." (Its Contents.) By J. W. Ballantyne,

M.D., F.R.C.P.(Edin.), F.R.S. (Edin.) . . . .236

TABLE SHOWING SPECIMENS EXHIBITED AT MEETINGS.

I.—OBSTETRICAL AND TERATOLOGICAL.

PAGE

Foetus (extra-uterine), four months', removed by vaginal section ;

and a portion of the placenta (Dr Brewis) . . . 140

Foetus, frozen sections of, showing hidden cervical spina bifida (Dr

J. W. Ballantyne) . . . . . . .121

Kidneys, pair of cystic (adenomatous), from a still-born foetus

(Dr J. W. Ballantyne) . . . . . .120

Ovum, specimen of an early (Dr James Ritchie) . . . 48

Pelvis (justo-minor, with rickets), from primipara who died in

eclamptic coma (Dr Haig Ferguson) . . . .142

Specimen, analogous to "Foetus Ovideus," obtained from a

multipara (Dr Haultain) ...... 48

II.— GYNECOLOGICAL.

A. AFFECTIONS OF UTERUS. (1) Fibkoid Tumours— (a) Simple —

Fibroid, soft subperitoneal, resembling ovarian cyst, removed by abdominal hysterectomy (Dr Haig Ferguson) ...... 47

Fibroid, multiple, giving rise to retention of urine (Dr

Haultain) ...... 75

Fibroid, cervical, growing from anterior wall of cervix and

removed by pan-hysterectomy (Dr Brewis) . . 141

Pelvic Abdominal Tumour, consisting of — (1) large sub- mucous fibroid j (2) fibroid between the layers of right broad ligament and united with the submucous fibroid (Dr Haig Ferguson) . , . .142

xxxi

XXX11 TABLE OF SPECIMENS.

(1) Fibroid Tumours — continued, (a) Simple — continued.

Fibroid, cervical (Dr Fordyce) . . . . 1 04

VA. Jfr.

Fibroids, multiple, removed for pressure symptoms (Dr

Fordyce) . . . . . . |f>4

Fibroids, multiple, removed for post-climacteric haemor- rhage (Dr Fordyce) . . . . 1 64

Uterus containing a large Submucous Fibroid attached by

broad pedicle to fundus (Dr Brewis) . . . 190

Fibroid, large soft oedematous, removed by hysterectomy

(Dr Brewis) . . . . . .190

Fibroid, cervical, weighing 12 lbs., causing retention of urine; removed by supravaginal hysterectomy (Professor Kynoch) ..... 220

Mucous Polypus and Adenomatous Growth associated

with Fibroid Uterus (3 specimens), (Dr Haultain) . 75

Fibroids complicating Pregnancy —

Uterus with large Cervical Fibroid, removed at the fifth month of pregnancy j Caesarean section and hyster- ectomy (Dr Brewis) . . . . . 44

Uterus with Fibroid Tumour in lower uterine segment, removed at term by supravaginal hysterectomy after Caesarean section (colloid degeneration of the fibroid), (Dr Brewis) ..... 45

Uterine Fibroid, complicated with pregnancy at fourth

month, removed by hysterectomy (Professor Kynoch) 220

(b) Degenerated —

Fibroid, large subperitoneal, showing mucoid degeneration,

with a very small pedicle (Dr Brewis) . . . 141

Fibroid, interstitial, showing necrobiosis (Dr Fordyce) . 164

(c) With malignancy —

Uterus showing combined Fibroid Tumour and Carcinoma

(Dr Fordyce) 164

TABLE OF SPECIMENS. XXxiil

(2) Malignant Disease of Uterus —

PAGE

Uterus with Fundal Carcinoma, removed by vaginal hyster- ectomy from multipara eet. 55 (Dr Haig Ferguson) . 46

Chorion Epithelioma of Uterus, removed by vaginal hyster- ectomy from patient set. 38 (Dr Haig Ferguson) . . 46

Sarcomatous Uterus, round-celled, which filled entire cavity, perforated the wall, and involved the peritoneal cavity j abdominal section (Dr Haultain) .... 74

Uterus with Adeno-carcinoma of body, removed per vaginam

from multipara aet. 42 (Dr Haig Ferguson) . . 163

Carcinoma of Uterus (3 specimens — 2 cervical, 1 corporeal),

removed by vaginal hysterectomy (Dr Fordyce) . . 1 64

Uterus with Adeno-carcinoma of the body, removed by vaginal

hysterectomy from multipara set. 44 (Dr Haig Ferguson) 191

(3) Other Uterine Conditions—

Inverted Uterus of puerperal origin, removed by vaginal

hysterectomy (Dr Haig Ferguson) .... 46

Uterus (transformed into abscess cavity), removed by vaginal hysterectomy one year after double pyosalpinx had been removed by abdominal section (Dr Haig Ferguson) . 47

Specimen of Diffuse Uterine Fibrosis (Dr Haultain) . . 74

Uterus removed by abdominal hysterectomy for perforating abscess of its wall, arising from septicaemia after abortion (Dr Haultain) ...... 74

Specimen showing Tubercular Endometritis (Dr Haultain) . 164

Uterus removed by vaginal hysterectomy for bleeding (and, from same patient, a Haematoma of left broad ligament) (DrBrewis) ....... 190

B. AFFECTIONS OF THE OVARIES.

Fibrous Tumour of Ovary, which had been wedged in pelvis,

simulating uterine tumour ; abdominal section (Dr Barbour) . 121

Iluptured Ovarian Cyst, with pseudo-myxoma peritonei (Dr

Barbour) ........ 121

Ovarian Tumour (cyst), removed by abdominal section from a patient who had been operated on by Thomas Keith nineteen years before (Dr Brewis) . . . . . . 141

TEANS ACTIONS

EDINBURGH OBSTETRICAL SOCIETY,

FOE SESSION LXVIIL, 1906-1907.

Meeting I.— November 14, 1906. Dr J. W. Ballantyne, President, in the Chair.

I. The Treasurer {Dr Wm. Craig) made his Annual State- ment, which is given below : —

INCOME.

Balance from Session 1904-1905,

Arrears, . . . .

Bank Interest on Deposit Receipts, .

Interest on Consols, .

Entrance Fees from 28 new Ordinary- Fellows,

Annual Contributions from 380 Ordinary Fellows,

Composition for Life-Membership from Four Ordinary Fellows, ....

Transactions sold,

£10 9 6	1 5 0	0 3 8
29	8	0
95	0	0

21

4

0 0

2 0

£563 6 2

174 16 11

£738 3 1

EXPENDITURE

Corporation Duty,

Income Tax,

Shorthand Reporters,

Commission to Collector,

Doorkeeper's Salary, .

Oliver & Boyd's Account for Vol. XXXI

of Society's Transactions (550 copies)^ Oliver & Boyd's Account for Printing

Billets, Postages, etc., Bent of Rooms and Carriage of Books, Waterston & Sons' Account, The Secretaries and Editor, for Postages, Blocks for Illustrations,

Balance to New Account,1

£0 10	11
0 6	6
11 11	0
1 13	0
1 16	0
102 12	6
30 3	0
5 2	0
11 9	9
0 8	0
8 2	6

£173 15 2 564 7 11

£738 3 1

i Of this Balance, the sum of £250, 10s. 6d. is invested in 2£ per cent. Consols.

A

2 ELECTION OF OFFICE-BEARERS, ETC.

The accounts were audited by Dr Nicholson and Dr Dewar, and found correct.

Dr Freeland Barbour, seconded by Dr Lamond Lackie, moved a hearty vote of thanks to the Treasurer, which was unanimously accorded.

II. The Society then proceeded to the election of Office- bearers for the present Session, and the President announced the result as follows : — President, Dr J. W. Ballantyne ; Vice- Presidents {Senior), Dr Berry Hart ; {Junior), Dr Wm. Fordyce ; Treasurer, Dr Wm. Craig ; Secretaries, Dr Lamond Lackie and Dr Barbour Simpson ; Librarian, Dr Haultain ; Editor of Trans- actions, Dr Angus Macdonald; Members of Council, Dr»K T. Brewis, Dr Munro Kerr, Dr Freeland Barbour, Dr Haig Ferguson, Sir Halliday Croom, Dr Samuel Sloan (Glasgow), Dr Macrae Taylor, Dr Scott Carmichael.

III. The following gentlemen were elected Ordinary Fellows of the Society :— E. Burnet, B.A., M.B., Ch.B., 4 Fingal Place, Edinburgh; A. S. Walker, M.B., Ch.B., Ashleigh, Middles- borough; Archibald Dunlop Stewart, M.B., L.E.C.S.E., 8 Brougham Place, Edinburgh ; Henry F. Gordon, M.D., L.K.C.P. & S.E., 178 Colony Street, Winnipeg, Canada; E. A. Elder, M.A., B.Sc, M.B., Ch.B., 6 Torphichen Street, Edinburgh; E. W. Dyer, M.B., Ch.B., c/o Messrs Webster, Steel & Co., 5 East India Avenue, London, E.C. ; W. T. Smith, M.B., Ch.B., Linwood, Midcalder; Arnold Davies, B.A., M.B., Ch.B., Menai Bridge, North Wales ; T. Graham Brown, B.Sc, M.B., Ch.B., 3 Chester Street, Edinburgh; John B. M'Morland, M.B., Ch.B, 19 Merchiston Gardens, Edinburgh; W. 0. Sclater, B.Sc, MB., Ch.B., 16 Warrender Park Cresent, Edinburgh; A. G. K. Ledger, M.B., Ch.B., Tupsley, Hereford; F. T. Greig, LE.C.P. & S.E., (Lt.-Col. E.A.M.C., retired), 16 Melville Terrace, Stirling; Duncan Lorimer, B.Sc, M.B., Ch.B., 7 Gillsland Eoad, Edinburgh ;

ADDRESS ON THE FUTURE OF OBSTETRICS. 3

Chas. Kobert Mitchell, M.B., Ch.B., Koyal Maternity Hospital, Edinburgh; W. D. Osier, M.B., CM., 11 Montgomery Street, Edinburgh ; Dr J. Halley Meikle, 44 Morningside Drive, Edinr.

IV. INAUGURAL ADDRESS ON THE FUTURE OF OBSTETRICS.

By J. W. Ballantyne, M.D., F.R.C.P., F.R.S. Edin., Lecturer on Mid- wifery and Gynaecology, Surgeons' Hall and Medical College for Women, Edinburgh; Physician to the Royal Maternity and Simpson Memorial Hospital, Edinburgh, etc.

Ladies and Gentlemen, Fellows of the Edinburgh Obstetrical Society, — "To inaugurate," said Dr Johnson, in that famous Dictionary of his, means " to begin with good omens," or simply "to begin." His worthy follower in the art and science of lexicography, Dr James A. H. Murray, in that marvel of patient research and brilliant scholarship, the New English Dictionary on Historical Principles, after quoting Johnson's early definition, proceeds to amplify and lead out the meaning of the rich and suggestive word inaugurate in this manner : " to begin (a course of action, period of time, etc., especially of an important character) with some formal ceremony or notable act; to com- mence, enter upon, to introduce, usher in, to initiate." And then our fellow-countryman, with that dry humour which breaks out now and then even in his Dictionary, places within brackets the following additional definition: "inaugurate, sometimes merely grandiose for begin." Now I feel grateful to Dr Murray for so slyly slipping that bracketed addendum into his already full page; for I see, with relief, that I can shelter myself behind it, and can plead that if this address fall short of being a worthy, a notable, and an auspicious ceremonial act at the commencement of this, the sixty-eighth session of our Society's history, it can at least claim to be, beyond any cavilling, a beginning.

4 ADDRESS ON THE FUTURE OF OBSTETRICS,

A valedictory address naturally enough concerns itself with what is past, and has a ring of finality and farewell in it, vale ! vale! sounding out from it with pathetic cadence; but an inaugural address looks forward to the future and dwells upon it, not without hope and expectation of the good and great things that are to come out of it, for at the very heart of the word inaugural lies the root augur, and the augur had, of all men, to be always looking forward. The Eoman augur was, as we remember, or, as Dr Murray will tell us, if we have forgotten, " a religious official whose duty it was to predict future events and advise upon the course of public business, in accordance with omens derived from the flight, singing, and feeding of birds, the appearance of the entrails of sacrificial victims, and other portents." Now, although the primary visual image thus con- jured up can hardly be said to reside any longer in the derivative words inaugural, augury, and august ; although, also, the augur himself, with his staff and auspicial rites, has long since passed into the thick mists which cover even the brightest phenomena (and he was not very luminous ever) of a bygone age, uttering his vale ! yet the augural spirit is not dead in these days, but is as living and insistent now as it ever was during all the centuries which have elapsed since man first began to ask questions about himself and his future. In vulgar form it is seen in the irresponsible and sensational sisterhood of the lady palmists, the crystal-gazers, and the Sibylline vendors of wonder- working remedies and charms. It assumes scientific shape in the daily forecasts of the weather to be expected in these islands, although it must be owned that the meteorologist, being limited to observations made upon the surface of the earth, and having no stations high up among the clouds, sometimes fails as com- pletely in his foretelling as does the itinerant gipsy. In our own profession we seek, in a legitimate and proper fashion of course, to pierce the veil which hides the future from us, and we have recourse to the bacteriologist with his opsonic index

BY DR J. W. BALLANTYNE. 5

and Widal test, to the histologist with his methods of cyto- diagnosis and differential blood-counts, and to the cryoscopist with his osmotic and ionic actions.

There is, in a sense, the would-be augur in us all; and, having now in hand the giving of an inaugural address, I bethought me that I also might try to play the augur's part and endeavour to forecast the future of obstetric theory and practice. If I fall far short of what you may expect ; if I fail to please even myself (as is indeed very likely) ; if the manner and form of the forecasting be contrary to the traditions of Inaugural Addresses in learned societies ; if, in striving not to be dull, I become extravagant ; and if, in seeking to restrain fancy I run the risk of being prosaic; then let the blame rest upon the etymologies which have led me into such difficult territories, and please let it be remembered that after all "inaugurate" may be only "grandiose for begin."

In Touch with the Future.

I suppose that it was one evening in the autumn that the events I am going to relate apparently took place. I had, I fancy, been reading about some of the marvels of modern psychology, had been learning how a personality can be dissociated (on paper at least), had been grasping, with some difficulty, that the ego is not one but two or three, and had been trying, without entire success, to understand the mysteries of the subliminal and the supraliminal. Then I had begun to wonder what subject I should choose for an inaugural address to the Society which had so highly honoured me by placing me in its Presidential Chair. I was not finding the question one which admitted of easy solution. My mind, in freakish fashion, began to hunt ideas, starting a new one every few minutes, and chasing it until another idea suddenly emerged from the sub- conscious somewhere of brainland and engaged its attention.

6 ADDRESS ON THE FUTURE OF OBSTETRICS,

The house was very quiet, and my thoughts wandered on, undisturbed by any extraneous interruptions, save the occasional fall of a cinder into the fireplace, or the coming of a sort of breathless bark from my dog, enjoying doubtless the exciting pleasure of a subconscious chase after some old enemy. Suddenly the telephone gave one of those undecided, apocopated, monosyl- labic tinkles that we usually leave unanswered, and regard as due to a fault in the apparatus or an error of the operator. On this occasion, however, I put my ear to the instrument and whispered " Hullo ! " To my surprise an answering " Hullo ! " very faint and distant, but quite distinct, came back. "Who are you ? " I asked.

" One nine four nought," was the reply.

" Thank you," I said, " but I don't want to know your number ; I wish to know who you are, and where you are ringing up from."

" I am not ringing up from anywhere," said the voice ; " you are on the Time Exchange, and until you grasp that notion firmly you cannot understand who I am."

" I beg your pardon," I exclaimed in great surprise ; " I have heard of many Exchanges, but never of the Time Exchange."

" That I can quite well believe," replied my unknown cor- respondent. "It was only on rare occasions that you in the beginning of the Twentieth Century got switched on to the Time System instead of the Place System ; you happen to have been attached to-night, and I thought I might venture to ring you up and have a talk. So, now do you know who lam?"

" I am really very sorry," I replied, " but I haven't an idea."

"I thought you might have guessed," he said. I am an officialof the Edinburgh Obstetrical Society, and the time from which I am ringing you up is one nine four nought, or, if you prefer it, nineteen hundred and forty, the Centenary year of the Society's existence. You are not forgetting," he added, "that our Society was born in 1840, having been conceived, so to say, in the last month of 1839."

BY DR J. W. BALLANTYNE.

For the moment I was too surprised to answer this startling communication from the future; but I soon recovered myself and made a suitable reply to the Centenary Official's remark.

The Future of Obstetrics.

The next question that came to me over the wires stimulated my curiosity and determined the course of our conversation: it was, " Now, is there nothing you would like to ask me about obstetrics in 1940 ? "

" If you will let me get my thoughts gathered together," I replied, " there are hundreds of questions I should like to ask you."

"I do not promise to answer them all," replied Nineteen Forty as I may call him, " for there are some matters which I could not make plain to you without a great deal of preliminary explanation, and we have not time for that ; but I will do what I can to satisfy your curiosity."

" What sort of preliminary explanation do you mean ? "

"Well, this simply : Obstetrics has not been the only subject of study in which there have been advances and discoveries ; there have been great changes in surgery, still greater ones in medicine, and a revolution in physics and physiological and pathological chemistry ; it would require a series of lectures to bring your general knowledge of these matters up to the level required for the perfect understanding of all that has been accomplished in obstetrics."

" I fully grasp the situation," was my reply. " I am now in a position similar to that in which an old friend of mine found himself in 1906 : he had been in Central Africa for fifteen or twenty years, and he came back to his native land to find the pathologists speaking the (to him unknown) language of bac- teriology. He had the greatest difficulty in making up leeway, and indeed never quite succeeded in doing so."

8 ADDRESS ON THE FUTURE OF OBSTETRICS,

"You are really in a worse state than he was," said Nine- teen Forty, " but I shall try to make things as simple as I can."

Teaching of Obstetrics.

" Being a teacher," I now said, " I should like to hear about your methods of conveying obstetric information in the year 1940."

"Ah," said my correspondent, "you were, as perhaps you suspected, on the eve of great changes in your teaching methods in the year 1906. You were under the intolerable burden of having to give fifty or one hundred hours of purely theoretical teaching in order to fulfil the requirements of the examining boards. You delivered, each day, a lecture of an hour's length, containing usually a bald statement of a number of facts dis- coverable in almost any reputable text-book upon the subject ; you occasionally tried to relieve the weariness and monotony of your exposition by a passing reference to a specimen or a diagram, or by the introduction of an anecdote or a personal experience ; you adopted a didactic or a grandiloquent style, or, worse still, you read slowly and closely from a bulky bundle of manuscript notes. You occasionally put forceps on to the doll in the phantom, but you lectured all the time, and you expected your students to be taking down your words in their note-books, when you were directing their attention to the movements of your hands in the act of inserting the blades of the instrument. All this was altered at once when in the University and College Eegulations the words 'hour's instruction' took the place of ' lecture ' ; instead of having to give fifty or a hundred lectures, you were asked to supply fifty or a hundred hours of obstetric instruction, a very different thing, as you can imagine. Of course some lecturers preferred to go on in the old way, and they were at liberty to do so; but many chose to vary the methods which had been in vogue. Here, for instance, is a plan

BY DR J. W. BALLANTYNE. 9

which was adopted not so long after the time at which you now are. Each student was supplied with a neatly printed and fairly full statement of the subject of demonstration to be taken up on the following day ; to this were attached two or three blank sheets for the noting down of additional facts, for the drawing of a few diagrams, or for the indication of the page or pages in a large text-book where full details might be found. Having perused this syllabus or epitome the night before, the student came prepared to follow and appreciate the teaching his teacher was ready to give him. It might take the form of a demonstration of pelvimetry in normal and malformed pelvises. On a number of tables were several models of the well-formed and the deformed pelvis, with callipers of various kinds lying beside them. The teacher at first gave a very concise and clear statement of the measurements of the diameters in the normal and in the abnormal pelvis, and of the bearing which these measurements had upon labour, and indicated the various ways in which the diameters could be estimated. The class then broke up into sections for the application of principles which had been enunciated; and, supposing there were a hundred students, ten men went to each of ten tables, and tested the methods and familiarised themselves with the apparatus. On another day the demonstration would consist of the examination of a large number of slides under microscopes, illustrating the appearances of placentas from two months up to the full term, or of the uterine musculature at various stages of development. On another day the electric phantom would be brought into action. "

" I beg your pardon," I here interjected ; " what was the electric phantom ? "

" It was a skilfully made model of the abdomen and pelvis with the full-time uterus inside. By a somewhat complex apparatus, a doll representing the foetus could be expelled from the interior through the canals, exhibiting in its progress the

10 ADDRESS ON THE FUTURE OF OBSTETRICS,

whole mechanism of labour. The rate could be regulated to a nicety, so that a twelve hours' or a twelve minutes' labour could be imitated; further, the process could be interrupted at any stage (when the head was on the perineum, for instance), and the details explained. A student could be placed in charge of the phantom labour at any time, the most favourite being of course the period of vulvar dilatation and of the passage of the head ; if he made any mistake in the method he adopted for the delivery of the head and for the safety of the perineum, he could be checked and shown the right plan. By the touching of a button the pelvis could be narrowed at the inlet or outlet, or be deformed in other ways, and by the use of dolls of various sizes, representing mature, premature, and post-mature foetuses, different kinds of delay or varieties of mechanism could be exhibited. The dolls' heads were so constructed as to permit the occurrence of moulding."

"I can quite understand the value of teaching such as you describe," I said to Nineteen Forty; and I suppose it was supplemented by clinical instruction in the Maternity Hospital?"

" That, of course," was the reply, * and also at the various small maternity sub-centres, scattered over all our large cities. They were sets of two or three rooms, with accommodation for ten or twelve patients, under the charge of an assistant obstetric officer and one or two nurses ; in them normal or nearly normal cases were confined, leaving the central institution for the com- plicated and operative labours. But these were comparatively early changes in our teaching methods," went on my informant ; " others soon followed. One, for instance, was the introduction of the kinematograph and the gramophone. By a perfecting of the methods of obtaining differential radiograms, it became possible to represent internal processes, such as the passage of a stone down the ureter, or of the infant through the passages, by the kinematograph. The pictures thus obtained were thrown

BY DR J. W. BALLANTYNE. 11

upon the screen and utilised in the teaching of obstetrics ; in this way, for instance, the mechanism of labour could be shown and the somewhat cumbrous and uncertain electric phantom replaced. By the gramophone we were able to reproduce and illustrate the cry of the parturient woman in the different stages of labour, and the various sounds made by healthy, by premature, and by semi-asphyxiated infants, as well as by those whose birth had been accomplished by the use of forceps. The different kinds of movement made by the foetus in utero (rotatory, calcitrant, vibratory, or singultant) could be shown by the kine- matograph, while the neophone reproduced accurately the fcetal heart sounds and the uterine bruit."

" Stop ! stop ! " I said, " I cannot follow you any further in your novelties of obstetric teaching."

" I was afraid you would begin to find there were difficulties in understanding all the details," was my friend's reply, " and yet I have only begun to name some of the new methods invented by science for the imparting and for the testing of obstetric knowledge. I was going on to tell you of the micro- kinematograph, by which all embryological processes and organogenetic readjustments could be first represented and then reproduced upon the screen for teaching purposes. I intended then to give you an idea of the automatic and registering gramophone for use at oral examinations, which excluded all conscious and unconscious bias in the testing of candidates for degrees, for it rolled out questions in an ex- pressionless tone of voice, and recorded without feeling the answers given in reply ; and I was hoping to have interested you in the great development of clinical teaching which took place soon after 1906, and more especially after an examination in Clinical Obstetrics was insisted upon by nearly all universities. Perhaps, however, it would be well if I passed on to some other subjects, for, after all, the advances in the clinical teaching of Midwifery were already indicated and could be recognised and

12 ADDRESS ON THE FUTURE OF OBSTETRICS,

foretold by any thinking and observant man, even at the time at which you are."

Obstetrical Societies.

" What, then, may I ask, have you to tell me about our own and kindred societies in the Twentieth Century?" was the next question which I put to Nineteen Forty.

"There was a great and beneficial change in the life and activities of the various learned societies in Edinburgh soon after 1906. By means of a munificent gift from a wealthy man with strong scientific leanings, a large central hall to serve as a meeting-place for all the Edinburgh societies was built. Our own Society was, of course, one of these. But this was found to be a suitable occasion for a rearrangement of the energies and spheres of the different learned bodies, and so gyntecology was united with surgery to form a large surgical society, the Obstetrical Society devoted itself entirely to midwifery, the Medico-Chirurgical Society became the Koyal Medical Society by fusion with the old undergraduate organisa- tion bearing that name (the surgical members of both allying themselves with the newly formed surgical society), and the Pathological Club increased its membership and instituted Anatomical, Physiological, and Psychological Sections. Similarly, the other scientific societies rearranged themselves. Each society had its own afternoon or evening in the month ; but, in addition, there were conjoint meetings on special occasions, when, for instance, the Medical, Surgical, and Obstetrical Societies would unite together for the discussion of subjects in which each had an interest. The Eoyal Society was, as it were, the mother of us all. Through the benefactions of the generous donor already mentioned, the fee for membership was made quite a nominal one, and the member's ticket admitted to all the meetings, but it only conferred powers of contributing to or speaking at one of the societies and at the conjoint meet-

BY DR J. W. BALLANTYNE. 13

ings in which that society took part. The most wonderful part of the hall of the societies was the phonograph room ; at least it will seem so to you," said my friend, Nineteen Forty. u This room," he continued, " was in telephonic communication with all the learned societies in the world, and if you wished to hear the papers read at different places you had only to switch yourself on to any one you might choose. In this way, you missed none of the asides and interruptions which are so often the very soul and life of a discussion. Furthermore, the speaker, knowing that his words were audible all over the world, was very careful as regards his statements, and rarely claimed priority for any suggestion, therapeutic or otherwise."

" But what about understanding the language in which the discussion was taking place ? " was the question which I could not prevent myself from here asking.

"You surely do not think for a moment that the world, and especially the scientific world, was content to go on till 1940 without adopting a universal language," was the answer I received to my question ; and I was so taken aback by the tone of reproach in my friend's voice that I had no remark ready, and so lost my opportunity of finding out what the universal language was. Before I had time to recover myself I found that Nineteen Forty was beginning to describe to me some of the changes which had taken place in the practice of midwifery, and as I did not wish to miss anything of what he was saying, I had to give him my attention,

Obstetric Practice.

" You must know," he was saying, " that the discovery which revolutionised obstetric practice in the twentieth century was that of a tocophoric serum."

" What was that ? " I asked.

"A serum obtained from the blood of pregnant animals which had been treated with cultures from the blood of a

14 ADDRESS ON THE FUTURE OF OBSTETRICS,

human placenta, obtained preferably from a case of placenta praevia," was the reply. " Its introduction into use gave us the means of safely, speedily, and certainly inducing healthy action of the .uterus. In this way a labour could be brought on and a child born with almost the same degree of certainty with which it used to be possible to perform a surgical opera- tion. The day, and in some cases even the hour, could be arranged, and a midwifery case became a certain part of the day's work instead of an uncertain contingency in the middle of any night. In the nineteenth century the introduction of anaesthesia abolished the pains of labour and brought in a new era of obstetric advance; in the twentieth century the discovery of this tocophoric serum did away with the uncertainty of the supervention of labour, and had an almost equally great influence upon our subject. The profession earned the gratitude of countless patients, who said something like this : ' In the past you relieved our pains and sent us to sleep in the midst of our agony; but now you have released us also from the intolerable bondage of our uncertainty, and we thank you for this new boon.' Post-mature confinements, with their risks and delays, were in this manner done away with ; a time suitable alike for patient, nurse, and obstetrician, and calculated as accurately as possible to coincide with the full term of pregnancy, was fixed upon; and the labour was conducted with the same care and aseptic precautions as a gynaecological or other operation."

" But what about premature labours ? " was the question with which I here checked my friend's flow of description.

"I expected that remark," was his reply. 'You must know that the special investigation given to the pathology of pregnancy in the early part of the twentieth century bore good fruit in the discovery of means of successfully preventing the premature termination of pregnancy, and such abnormal labours became very rare. At the same time the tocophoric

BY DR J. W. BALLANTYNE. 15

serum gave us a means of interrupting pregnancy, when for medical or obstetric reasons (such as pelvic contractions, heart disease, etc.) it was regarded as desirable so to do."

The Falling Birth-Kate.

"But the great principle of obstetric practice in the twentieth century," continued my informant, " was the securing of the safety of the infant."

"You mean," I said, "that the falling birth-rate forced obstetricians everywhere to reconsider all their methods, operative and otherwise, from the standpoint of the life of the infant ? "

"Yes, indeed," was the reply; "and I shall now try to make this plain to you. I must introduce some statistics to bring out my meaning, but you, of course, can take your ear from the instrument if you are bored."

" Truly, I shall do no such thing," I protested.

"In 1906 the falling birth-rate in our own and in all civilised lands was at length beginning to attract the attention it deserved. The birth-rate for England and Wales was 35*2 for the decade 1865-1874; it was 347 for the next decade; for the next period of ten years (1885-1894) it had fallen to 31'2; and during the last ten years (1895-1904) it has sunk to 29*0. So much for England and Wales. Sir Henry Littlejohn had a still more depressing account to give of the capital of Scotland. In 1871 the natality in Edinburgh was 34*8 (almost the same as that of England and Wales at the same time) ; in 1881 it was 32'2 ; in 1891, 28'2 ; in 1901, 24-99; and in 1905 it was 22-99.1 Even with these figures

1 The figures for 1906 are now available : the number of births was 7042, and the birth-rate was 22'41 per 1000. The descent, therefore, is steadily going on, and the number of babies born in 1906 is actually less than the number in 1881, although the population has so greatly increased.

16 ADDRESS ON THE FUTURE OF OBSTETRICS,

before you the full gravity and meaning of the position was not recognised in 1906. In order to grasp the significance of the movement, look at the matter thus. In 1881, when the population of Edinburgh was (in round figures) 228,000, the number of babies born was 7360 ; in 1905, when the population had increased to 336,000, the number of babies born was 7741, whereas, if the rate had been maintained, it ought to have been 10,846. There was therefore a shortage of over 3000 babies. It is only fair to the country in general to state that Edinburgh occupied almost the worst position in this matter of a falling birth-rate. Of the sixteen large towns of England and Scotland, there was only one (Bradford) that had a lower birth-rate than Edinburgh; and while London registered 27, Dundee had 28, Manchester, Birmingham, Aberdeen, and Leith had 29, Glasgow and Greenock had 30, and Liverpool had 33."

" But," I here interruped, as my friend paused to note the effect of these undeniably startling figures, "the death-rate had fallen as well as the birth-rate, and so we were no worse than we were before."

" Let us take the Edinburgh statistics again," was the reply. "In 1881 the death-rate was 1886; in 1905 it was 1425, the lowest ever reached till then. While, however, the death-rate was slowly falling from 18 to 14, the birth-rate had come rapidly down from 32*23 to 22*99. If this rate of descent had in each case been maintained for another quarter of a century the two rates would have reached almost the same figure, and any increase in the population of Edinburgh would have had to be put down to immigration, for the birth-rate had been falling much more quickly than the death-rate. Further, while it was conceivable that the natality of Edinburgh would continue to fall till it reached a vanishing point, it was not thinkable that its mortality would do likewise. There might come a year when there were no births, but it could

BY DR J. W. BALLANTYNE. 17

hardly be expected that in that year there would occur no deaths. All these things, however, were to the inhabitants of Edinburgh in 1906 as idle tales; they heeded them not. And yet, to Edinburgh obstetricians at least, the subject of the falling birth-rate was a grave problem, and it became no less grave as the twentieth century proceeded on its way. To put the matter very practically," said Nineteen Forty, "there were many more doctors settled in Edinburgh in 1906 than in 1881, but the number of babies being born. was practically the same. I expect some of you had shrinking lists of midwifery engagements to deplore, but I forbear to press the point."

" Can you give me now any hints as to the way in which obstetricians in the twentieth century met the dangers of the falling birth-rate ? " was my next question.

"That I will gladly do," was my friend's answer; "but, first, I must point out what perhaps was little recognised or altogether overlooked in 1906. I refer to the aggravations of the falling birth-rate."

The Aggravations of the Falling Birth-Kate.

" What were these aggravations ? " I asked.

"In the first place, there was the infantile death-rate. You were proud, in 1906, of the fall that had taken place in the general death-rate of the country during the preceding half century, and your pride was justified; for there had been a reduction by more than fifty per cent, of the number of deaths between the ages of five and twenty-five years, and between twenty-five and thirty-five there had also been a notable decrease. But there was one circumstance about which little was said, and about which no pride could be felt : the infantile death-rate was practically unchanged at the end of these fifty years of hygienic progress and material advance- ment. To quote from the Report of the National Conference

B

18 ADDRESS ON THE FUTURE OF OBSTETRICS,

on Infantile Mortality (p. 99), held in London in June 1906 : 'In the twenty years ended 1874, we find that out of every 1000 children born alive in England and Wales, 153 never completed their first year, while in the twenty years ended 1904, the ratio was 148 per 1000.' There was, it is true, a slight improvement — 148 instead of 153 — but was it an adequate, a satisfactory, even a noteworthy degree of improve- ment, when contrasted with the fifty per cent, improvement between the ages of five and twenty-five? This, then, I call the first aggravation of the falling birth-rate : fewer babies were being born, and yet they were dying off practically as rapidly during the first year of life as they had ever done.

"A second aggravation was your ignorance, in 1906, of the stillbirth-rate and the abortion-rate of your country. You did not know how many pregnancies ended in the birth of infants who never lived outside the mother's uterus, who, in the words of one of the nineteenth century poets, exchanged cthe amnios-skin of this world for the shroud, the amnios- skin of the next.' You hoped, perhaps, that fewer stillbirths were happening, but you dreaded lest your hopes should turn out ill-founded ; at any rate you did not know, for there was no registration of stillbirths to reveal the frequency of such ante-natal catastrophes. In reality, a steady increase was going on, as Dr Kaye's Yorkshire statistics, local though they were, proved. He found that in 1901 there were 47*6 stillbirths per 1000 livebirths, and the number steadily increased until in 1905 it was 56*3. 'Apply these figures/ said Dr Kaye {Report of the National Conference on Infantile Mortality, 1906, p. 104), 'to the whole country (England and Wales), and it means that the number of stillbirths has grown from 44,270 in 1901 to 52,350 in 1905, an increase of over 18 per cent., while the total livebirths have decreased in actual numbers/ Then as to the abortion-rate, you must surely," said the Official of 1940, '' have had some feelings of dismay

BY DR J. W. BALLAD TYKE.

19

when, in 1906 and in preceding years, you reflected upon the wastage of ante-natal life by reason of abortions. You could hardly shut your eyes to and stop your ears against the testimony of text-books and journal articles which, with striking unanimity, attested the frequency, the growing frequency, of abortion. Some placed the frequency of mis- carriage at one to every three or four pregnancies; others stated that one in every five gestations ended in abortion."

Here I interrupted my informant with the remark that I did not think the abortion-rate was so high as that.

" What reasons have you for doubting it ? "

"Well," was my reply, "in the last series of 100 indoor labours under my care in the Edinburgh Eoyal Maternity Hospital there were not many women who gave a history of having aborted."

"But," said my friend, "did you exclude the primiparas and the women under thirty years of age ? "

" No," I replied.

" Suppose you do that ; how do your statistics stand now ? "

"In the 100 cases there were 21 women of thirty years of age and over, and of them 8 gave a history of previous abortions."

" There you are," said Nineteen Forty in triumph ; " thirty- eight per cent, of your patients who had reached the middle of reproductive life had aborted ! Besides," he continued, "you had only the patients' word for the number of their abortions; it is much more likely that they under-estimated than over-estimated the frequency of such occurrences, especially early miscarriages of six weeks. You must, after all, admit that not fewer but more abortions were occurring in Great Britain in the early years of the twentieth century. There was yet another aggravation to the falling birth-rate, to which I must, for a moment, refer. That was the curiously significant increase in the number of deaths ascribed to premature birth

20 ADDRESS ON THE FUTURE OF OBSTETRICS,

which began to be noticeable in the mortality returns. The infantile mortality from premature birth, which in 1865-1874 was 11-9 per 1000 (for England and Wales), had in 1875-1884 grown to 13-7, in 1885-1894 to 168, and in 1895-1904 to 198. The most striking thing about this increase was that it began as soon as and no sooner than the birth-rate commenced to decline. One can hardly refuse to ascribe some significance to that fact.

"Now, let me gather together these various statements," said Nineteen Forty, "and you will see better how you really stood in the year in which you are living. The infantile death-rate, notwithstanding all recent advances in hygiene and the laborious study of the diseases of infancy, was no better than it was fifty years previously. There was reason to believe that the number of stillbirths and abortions was increasing; and these, although they constituted deaths in a real sense if not in a forensic one, were not included in the mortality tables. The number of infantile deaths ascribed to premature birth was increasing, pointing to a probable increase in the total number of premature births occurring. Finally, there was the progressive and serious fall in the birth-rate. What could the obstetricians of the twentieth century do but strive to counteract these evils ? "

Checking the Falling Birth-Eate.

" How did they check the falling birth-rate ? " was my question, for my informant at this stage in our conversation seemed to expect me to say something.

" They did not check it, they could not check it," was the startling reply; "but they checked the aggravations of it, and so secured some salvage from the wreckage of life which was occurring before, at, and immediately after birth. This salvage more than compensated for the decline

BY DR J. W. BALLANTYNE.

21

in the birth-rate, and thus the civilised nations of the earth were able to maintain their position to some extent, at any rate, if not entirely. So now you see why I so strongly emphasised the aggravations of the falling birth-rate. But matters got much worse before they began to improve."

" In what way ? " I asked.

" I will tell you," was the reply.

" The checking of the falling birth-rate was, as I have said, not an obstetrical problem at all ; at least it was not one which obstetricians could hope to solve. The falling of the birth-rate was not due to less knowledge or less skill in the obstetricians of the day, or to want of training of the midwives and monthly nurses, or to the neglect of chloroform or the forceps, or to the excessive use of these means of relieving pain and hastening the second stage of labour, or, indeed, to any other thing which lay in the power of the medical man to do or leave undone. The causes lay deep among the roots of the somewhat artificial conditions of the sexual relationships in modern society. A nineteenth century writer (Kenan) said : ' The spread of an enlightened selfishness is, in the moral world, a fact of the same nature as the exhaustion of coal-fields in the physical world; in each case the existing generation is living upon and not replacing the economies of the past.' His words apply very exactly to the enlightened selfishness which was the root-cause of the falling birth-rate. The era of personal comfort first, and at any cost ; the age of late marriage, because the entrants upon the matrimonial state wished to begin, not where their parents began, but where they were prepared to leave off; the period of frequent holidays and expensive amusements could hardly be described as other than ' selfish/ although it might be doubted whether it deserved the honour of being entitled ' enlightened.' In any case, such an age was not one in which frequent child-bearing was likely to be thought of with favour, or carried through with enthusiasm.

22 ADDRESS ON THE FUTURE OF OBSTETRICS,

If there was ergophobia in the one sex, there was maieusophobia in the other. Nor was a popularisation of the knowledge of the nature and mode of use of ' checks ' to conception likely to raise the average size of families.

"Matters did not improve after 1906. In fact, it was not long till rumours began to circulate regarding the existence of a new institution, the ' City without a Child,' a sort of municipal agennesia, wherein mental productivity and financial success were held in high esteem, while the reproduction of the race was nothing accounted of. The inhabitants renounced the pleasure and the honour of having families, but gladly accepted all other pleasures and honours that came in their way. The citizens occupied their days in making money, and their nights were not spent round the fireside in the home. They were described as curious places, these experimental childrenless cities : no schools, no toy-shops, no Christmas-trees, no happy young boys and girls on the roadways; nothing but hard- visaged men and steel-eyed women, and bustle and racket, and vain hopes and restless desires; and by-and-by an alarming increase in the frequency of suicide, and in the number of the inmates of the palatial asylum which stood upon a hill overlooking the town. So, in the end, the attempt to reduce the birth-rate to nil was the cause of its gradual ascent again ; and the experiment of race-suicide was in that sense a failure.

"In the meantime the medical profession, and especially the obstetricians, had been busily endeavouring to save some- thing from the wastage of ante-natal life, and to keep alive many of the new-born infants who formerly used to succumb to death in various forms during the first few months of post- natal existence."

Estimation of the Wastage of Ante-natal Life. "In the first place," continued the Official of 1940, "the

BY DB J. W. BALLANTYNE. 23

obstetricians of the early part of the twentieth century set themselves the task of estimating the annual loss of life at and before birth. With the help of a Stillbirth Eegistration Act, and with the assistance of the army of skilled monthly nurses which the Mid wives Bill had called into being, statistics of stillbirths and abortions were obtained. The results were startling, appalling in fact; but after the first excitement incident thereupon had died down, it was seen that in the very magnitude of the loss of ante-natal life that had been going on lay the hope of the future. By diminishing the ante-natal death-rate, by checking the frequency of abortion, it was recognised that there was a means ready to hand to counter- balance the falling birth-rate. If a fifth of the stillbirths and abortions could be prevented, it was seen that the loss accruing from the smaller number of births would be compensated. Further, it was discovered that many of the cases which went to produce the high infantile mortality of 148 per 1000, during the first year of life, were deaths of prematurely born infants. So it became apparent that to check the frequency of premature births would give a means of reducing the high infantile death- rate; in this direction also there lay compensation for the failing birth-rate. You can almost forecast for yourself now the lines along which obstetric practice began to advance," said my friend of 1940; "but I will indicate them very briefly."

Study of Pregnancy, Normal and Pathological.

" The hygiene of pregnancy began to be studied in detail and with an enthusiasm and thoroughness never before arrived at. Patients were encouraged to consult their medical attendants regarding the rules of health in pregnancy, and the latter were prepared to give the advice sought. It was recognised that pregnancy was a severe and a long-continued testing of the structural and functional integrity of all the organs of a

24 ADDRESS ON THE FUTURE OF OBSTETRICS,

woman's body. It was soon seen that while an unmarried or a non-pregnant woman might with impunity, or apparent impunity, break many of the laws of hygiene, a pregnant patient did so at her peril ; and every medical man made it his duty to revise with the pregnant patients all the rules relating to the care of the bodily functions, putting right what was wrong, and warning against possible errors in diet, clothing, habits, and the like.

"Further, in cases of doubt, consultations were freely asked for and given, it being recognised that it was better to check the beginnings of evils in pregnancy than to wait till an abnormal gestation had developed into a labour dangerous for infant and mother alike. Whereas in your time," said my informant, " consultations in pregnancy were seldom asked for, save to determine whether the induction of abortion should be carried out in order to try to save the mother's life at the expense of that of her foetus, in the new era the specialist was called in early enough for his remedial measures to avail both the maternal and the infantile lives. In this way, not only were pathological pregnancies often prevented altogether, but in many instances they were so energetically treated in the early phases that they yielded to therapeutic means that would have been of no use at later stages. Eclampsia was one of the first of the gestational maladies which began to benefit by such a revolution in the management of pregnancy. Whereas it had been common for the urine of a pregnant patient never to be tested — indeed, in many cases it was not customary for the medical attendant to be told about the pregnancy or summoned to the patient till labour was in the first stage — now, the doctor was engaged to look after his patient in the early weeks of her pregnancy as well as in the hours of her labour and in the days of her puerperium. His duties included regular analysis of the urine, as well as the supervision of all the details of the gesta- tion, and the correction of any of the symptoms which might

BY DR J. W. BALLANTYNE.

25

arise. The obstetrician of 1940 finds it difficult to understand why his brethren of the early part of the century paid so much attention to the one month of the puerperal period and so little to the nine months of pregnancy. To him the time of pre- paration for labour was not less but more important than the time of recovery from the effects of labour, for he found that if the former was normal the latter was little likely to be pathological.

" Along with this development of the study of the manage- ment of pregnancy and of the treatment of the disorders of the pregnant state came a marked advance in the knowledge of ante-natal maladies. The mystery of trans-placental trans- mission was elucidated, and stillbirth by reason of foetal diseases and defects became rare. So-called 'habitual' abortion and intra-uterine death were soon shown to be due in every instance to some definite and ascertainable cause ; and the hopelessness which had previously characterised all attempts at treatment gave way to the enthusiasm inspired by frequent success. New and more effective means of keeping prematurely born infants alive were adopted with the best results, and the favourite British operation of the induction of premature labour for contracted pelvis took an enhanced position of esteem among other methods of obstetric intervention. As I have already said, the appreciation of the value of foetal life was the fact which dominated obstetric theory and practice in the twentieth century. Embryulcia, craniotomy, and all such destructive procedures yielded to methods which gave a chance of survival to the child, and thus Cesarean Section, Vaginal Section, and the Induction of Premature Labour took their rightful place in the list of obstetric operative measures. By means of the knowledge which obstetricians gained regarding the state of their pregnant patients {eg, by pelvimetry, physical examinations, etc.) it was possible to detect pelvic contractions, tumours, and the like before the supervention of

26 ADDRESS ON THE FUTURE OF OBSTETRICS,

labour, and so to avoid interference at the time when the occurrence of the phenomena of childbirth was the cause of additional risk and danger. For instance, it became rare for a medical man to be summoned to a full-time labour in which there was an undetected pelvic contraction, and thus, emergency Cesarean Sections or (worse still) craniotomies were hardly ever heard of."

The Problem of Cancer.

" I have greatly benefited by what you have told me," I said to Nineteen Forty; "but can you satisfy my curiosity about one other matter ? It is scarcely an obstetric problem, perhaps, but it is a very pressing one : I refer to the discovery of the cause and cure of cancer."

" I cannot reveal much," was the reply, " but I am permitted to throw out some hints. For instance, it was not long after 1906 that it came to be recognised that there was a curious parallelism between great philanthropic movements and note- worthy life-saving and pain-relieving discoveries."

" What do you mean ? " I queried. " Well, take the case of the abolition of slavery in the British possessions at a cost of £20,000,000 ; that was a great and a beneficent and an unselfish act on the part of one section of mankind for the amelioration of the condition of another and a suffering section ; it was soon followed by the discovery of anaesthesia — that priceless boon. Of course, the anaesthetics themselves had been in existence for years, but their effects were till then unknown."

"I think I see what you mean," I said; "and was there any great philanthropic advance pending in 1906, or soon there- after, which made it possible for the discovery of the cause and cure of cancer to take place as a corollary thereto ? "

My friend hesitated a little before he replied, and then said slowly: "The greatest boon that mankind could voluntarily

BY DR J. W. BALLANTYNE.

27

bestow upon itself would be the abolition of war, would it not ? "

" You think," said I, " that it was that great international blunder — the appeal to arms to settle disputes — that was delaying the discovery of the cure of cancer ? " My informant did not answer this question; at least, if he did, I, in my excitement, failed to catch his reply. So I went on and said to him : " I myself have of late years been inclined to look to the chorion-epithelioma and its embryological relations for the elucidation of the problem of the origin of malignancy ; but I have a friend who believes that the secret lies in the hands of the botanists. He is sure that in the differences of the life- conditions of fungi and bacteria are to be found the explanation of the origin and the theory of the cure of cancer."

" Tell him to make experiment," was the reply which came to me somewhat indistinctly, for it appeared as if my telephone were not recording very clearly. I spoke again, but it seemed as if the connection had been cut ; so, as I did not wish to be rude, I asked for the Time Exchange, No. 1940, and got switched on again. " I wished to thank you very warmly for so kindly giving me so much information about the future," I said. uCan you answer one other question, a personal one ? " I asked. " You described yourself at the beginning of our conversation as an Official of the Obstetrical Society of 1940 ; can you give me no other clue to your identity? "

" I am the President," was the reply.

" Indeed, then," I said, " I am highly honoured, sir, to have made your acquaintance."

I heard what sounded like a laugh, and then this rejoinder came back to me over the wires : " You call me sir, but is it impossible that the President of 1940 should be a woman ? "

I awoke with a start, to find my telephone ringing furiously ; and a call to a serious case at the Maternity Hospital was soon engaging my thoughts. But I have sometimes wondered

28 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

whether it was all a dream; whether it was not in part an " uprush of the subliminal consciousness/' as the psychologists call it ; whether it was not, in certain details, a vision of that future so rapidly advancing upon us, when —

Much that is wrong shall be righted, And man shall see, never affrighted,

Clearly his duty, and do it,

E'en if his life-blood go to it.

On the motion of Br Ritchie, seconded by Br Craig, a hearty vote of thanks was unanimously accorded the President for his address.

V. THE MANAGEMENT OF SOME DIFFICULT OCCIPITO-POSTERIOR CASES.

By J. Lamond Lackie, M.D., F.R.C.P. Ed., Assistant Physician, Royal Maternity Hospital ; Lecturer on Obstetrics and Gynaecology, School of Medicine of the Royal Colleges.

Until quite recently, I had been in the habit of thinking, and indeed sometimes of teaching, that when the obstetric forceps slipped off the head during the operation of extraction, the instrument had been unskilfully applied. "Within the last month I have changed my views on this point entirely. Up till October of this year I had no personal experience of the accident, but during that month I had two consecutive cases in which the forceps slipped, and these form the basis of the present communication.

Case I. — Mrs D., set. 29, primipara, went into labour on Thursday, 4th October, at 2 A.M. The pains at first were slight and very occasional, but the membranes ruptured at 10 A.M. ; and at 11 A.M., when I first saw her, the os was only the size

BY DR J. LAMOND LACKIE.

29

of a shilling. It dilated very slowly, and little progress was made all Friday. During the night the pains were stronger, and at 10 a.m. on Saturday the os was 3 inches in diameter, and a right occipito-posterior position was diagnosed. Pains were strong till 3 p.m., but on examination one found that since 10 a.m. absolutely no progress had been made, and the anterior segment of the cervix had become oedematous. At 4 p.m. the patient was exhausted, and inertia uteri had set in. Chloroform was administered, and the dilatation of the os completed by the fingers. Forceps were then applied to the head, which was well engaged in the pelvic inlet. Strong traction seemed to make no impression, and suddenly, during an extra effort on my part, the forceps came away in my hands. The sensation, to say the least of it, was unpleasant ; one felt that one had fractured or dislocated something, but I take it that the click one feels and hears is simply due to the sudden excessive overriding of the cranial bones which the closed forceps causes as the instrument comes over the head. For- tunately, the damage to the mother's soft parts was slight, but the vulva was somewhat torn by the escaping forceps. I then tried to flex the head and rotate it, but, as I almost expected, my efforts were fruitless, as the head was too high up and too fixed. Forceps were again applied, and appreciating the fact that the occiput was to the back, I endeavoured to apply the blades in that region. Again the forceps slipped when I pulled, and this not once but several times. The instrument was not each time forcibly pulled out of the vagina, as I was always on the outlook for slipping. Here, I may say, that by grasping the application handles, as well as the traction handle, I was better able to appreciate whether the blades were to slip or not; one seemed to be more in sympathy with the position of the blades by sensation conveyed through the handles than through the traction rods. Ultimately, one seemed to find a grip that held, well back over the occiput,

30 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

and the head was born face to pubis, but only with great difficulty, and after the expenditure of much force in traction. There was some laceration of the perinseum. The child, a female, which weighed 9 lbs., was apnceic, but recovered, though it showed signs of compression for two or three days. It is now very well, but has a marked internal strabismus of the right eye, which, however, is now improving. The mother had a normal puerperium. I ought to mention that she was a woman of average stature, and there were no obvious signs of any deformity of the pelvis. This, then, was simply a per- sistent occipito-posterior case, delivered in the usual way by forceps — the only peculiarity being the slipping of the forceps, which shows how excessive was the traction necessary for delivery. I have quoted the case as a contrast to the two which follow.

Case II. — Mrs W., set. 30, ii.-para, expected her confinement on 10th October, but this did not take place till 28th October. Pains commenced at 2 a.m. ; at 4 A.M., when I saw her, the os was nearly but not quite fully dilated. Eight occipito-posterior was the position. At 5 A.M. the membranes ruptured and the liquor amnii began to trickle away. The cervix was still not fully taken up. At 8.30 a.m. there was no change, except that the anterior segment of the cervix had become oedematous. Pains were now slight, and made no impression on the advance of the head, which remained at the brim. Under chloroform, forceps were applied, and, to my surprise, I repeated my experience of 6th October. The forceps came away in my hands with, fortunately, no damage to the mother. I reapplied them, still remembering the position of P.O. P., but the result was the same, and no matter how carefully I applied the instrument well back towards the promontory of the sacrum, the forceps, whenever traction of any degree was employed, came over the head with that click which is so suggestive of

BY DR J. LAMOND LACK IE.

31

serious injury to the child. I applied the forceps no less than six times, but I could not get the head to enter the pelvis. I then tried to turn the child's head round so that the occiput should be to the front, and at the same time I endeavoured to turn the shoulders by external manipulation; but though I could move the head I could not turn the shoulders, and before I could get the forceps applied the head was back to its original position. Finally, I introduced my hand past the head, and with two fingers on the right shoulder and my left hand acting through the abdominal wall, with great ease I turned the child round till it occupied the L.O.A. position. Once more I applied the forceps, and with comparatively little traction the child was born within three minutes. It weighed 10 J lbs., but seemed to have suffered no injury except facial paralysis, which passed off in three days. The mother had a normal puerperium. She was a woman of medium height, and had no pelvic deformity. I delivered her of her first child exactly four years previously, when the labour was almost normal, forceps being applied only to bring the head over the perinaeum.

Case III. — I hoped I had done with difficult E.O.P. cases for the month, but I was mistaken. On Tuesday, 30th October, at 10 a.m., I was called to Mrs B., iii.-para, who had been in labour since 4 a.m. The os was the size of half a crown. At 3 p.m. the liquor amnii began to trickle away. At 5 p.m. the os was nearly, but not fully, dilated ; the position was E.O.P. , and the head was high up and movable at the brim. At 9 p.m. there was no change, and inertia uteri had set in. The patient was chloroformed, and first of all I applied forceps, but the locking was so unsatisfactory that I was not surprised that traction proved useless, and I therefore soon desisted. Eemem- bering my experience of two days before (Case II.), I determined to try internal rotation of the head. I removed the forceps, then pushed the head upwards, and by internal and external

32 MANAGEMENT OF DIFFICULT OCCIPITO-POSTEFJOR CASES,

manipulation turned the head round till the vertex lay in the RO.A. position. A pain came on and fixed it there, and as rapidly as possible I applied the forceps. Extraction was quite easy, and a living child was born, 9 lbs. in weight, with no signs of damage at all. The interesting point about this case was that the patient had been confined twice before, nine years ago and seven years ago, and on both occasions she was very ill, instruments were used, and both children were born dead, having died, the mother tells me, during birth. I cannot help thinking that but for artificial internal rotation the result would have been just the same on this occasion.

The first and the second and the third cases which I have narrated form a striking contrast. The first was a primipara who presented all the usual features of a malposition of the head — a slow first stage, premature rupture of the membranes, and oedema of the anterior segment of the cervix, which one notes seems in these cases always to hang free in the pelvis between the head and the outlet. The second stage was delayed, the descent of the head was only partial, spontaneous rotation did not occur, the forceps slipped several times, but ultimately the patient was delivered simply by excessive forceps traction. Had forceps failed, one had to think of craniotomy, symphysiotomy, or pubiotomy. The second and third cases presented the same preliminary feature as Case I., but the head was still movable at the brim. There were several possibilities of treatment had forceps ultimately failed — Cesarean section, embryulcia, etc. — but the whole object of this paper is to emphasise the fact that to rectify a malposition, if diagnosed early, is possible and sometimes easy. I have rarely been so struck with the effects of treatment as in the second case, where what proved almost an intractable case became quite suddenly, by simply rotating the child, one of the easiest high forceps cases I have ever experienced. The

BY DR J. LAMOND LACKIE. 33

child was large, it was post-mature, but once it was placed in a normal position it was delivered in a very few minutes. Before resorting to a more serious obstetric operation, such as craniotomy, I should certainly have performed internal version, which is generally recommended in these cases, but the chances for the child would then have been much diminished. Every- thing was no doubt favourable for artificial rotation : the head was still not properly engaged, the liquor amnii had not all escaped, and the patients were multiparas. Since in nine cases out of ten an E.O.P. rotates so that the occiput comes forward, one would not attempt this operation if the head were descend- ing with the pains ; one would simply further rotation chiefly by increasing flexion. In all text-books reference is made to artificial rotation of the head when it has reached the pelvic floor, and this is common practice ; but only in a few, and these are foreign, is rotation when the head is high up recommended as a possible method of treatment. I am not sure that in this country the value of artificial rotation of the whole child when the head refuses to enter the pelvis has been duly appreciated. Under the circumstances which prevailed in Cases II. and III., I should be inclined, if an E.O.P. were diagnosed early, to again try artificial rotation, rather than risk a very difficult forceps case — a possible sacrifice of the child by version, or a certain one by embryotomy.

Br Barbour was much interested in Dr Lackie's communica- tion, which drew attention to a method of dealing with occipito- posterior cases which was not sufficiently recognised in this country. It was noteworthy that the head was delivered with much greater ease, lying in the same diameter, with the occiput to the front instead of to the back, because the difficulty was evidently in this case not in the longer rotation the head had to undergo, but in some cause interfering with its engagement,

C

34 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

or with proper flexion. The cause of deficient flexion in occipito-posterior positions was not evident. It had been ascribed to the promontory, but this explanation was not adequate. He congratulated Dr Lackie on his successful management of these cases.

Dr Haig Ferguson cordially thanked Dr Lackie for his interesting and suggestive paper. All present, no doubt, had had experiences such as Dr Lackie's in the slipping of forceps in occipito-posterior cases. In his opinion, this slipping was due to the head being extended and the forceps grip being too near the sinciput and not sufficiently far back on the head. This could be rectified by promoting flexion of the head by manual manipulation, after which the forceps can generally be applied satisfactorily without fear of slipping. When the forceps is applied when the head is extended, traction simply tends to keep up, if not to increase, the extension, and so the delivery of the head is not by any means facilitated even when the blades do not slip off the head. He was much interested to hear that by an apparently comparatively simple manoeuvre, as Dr Lackie described it, a right occipito-posterior position, as in Case II , was converted even into an L.O.A. He would certainly try this method of artificial rotation the next suitable opportunity he had, as it seemed not only rational, but eminently calculated to conserve fcetal life, a point so strongly and rightly insisted on by the President in his address just delivered.

Dr James Ritchie felt indebted to Dr Lackie for having reported cases showing the ease with which in posterior positions, under suitable conditions, the body of the child could be rotated. Kotation of the head alone was not satisfactory. He thought that the chief reason why delivery was more difficult in posterior than in anterior positions lay in the fact that, in consequence of the projection of the promontory there is less room at the posterior end of the oblique diameter than in front,

BY DR J. LAMOND LACKIE.

35

and that the sinciput, being smaller, passes more easily than the occiput.

Br Dewar thanked Dr Lackie for his eminently practical paper. Papers such as the one read were a great help to the practitioner in his everyday life, inasmuch as they refreshed the memory by recalling some of the principles in the treat- ment of difficult cases, which are apt from infrequent application to become dim in the mind. In thinking over those occipito- posterior positions, one or two thoughts had occurred to him. A medical man was sometimes called to a labour case at a very early stage. It was very customary for him, after making the usual vaginal examination and finding the os undilated or only very slightly dilated and the passage dry, to heave a sigh, perhaps, if it should be three o'clock in the morning, and tell the patient and her friends that, as labour was hardly commenced, he would go home, and come back in the morning. He confessed that he used to follow such a practice, but experience had taught him to adopt a different method, which he had now practised for many years. By being content with a simple vaginal examination the medical man missed his best opportunity of rectifying an abnormal position if it should be present. His routine practice was, if the os was undilated, to make an abdominal palpation, as he was anxious to find out, if possible, what presenta- tion and what position he had to deal with. It was easy to read in the text-books what to do in difficult cases, but it was not so easy in practice ; yet, with patience and a little care, if such an opportunity occurred, it was fairly easy, by palpation, to make out whether the presentation was a transverse, a breech, or an occipital one. If occipital, he should try to satisfy himself whether the position was occipito-anterior or occipito-posterior ; if the latter, he should then endeavour to rectify at once, as it is very much easier to rotate the child at that stage, when the membranes were still intact, than at a later stage, when the head was engaged in the brim or in the pelvic cavity. If, however,

36 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

the case was not seen till at a later stage, he favoured internal rotation by the hand rather than by the forceps, as being less dangerous to both mother and child. He narrated the difficulties of an occipito-posterior case, in which the persistence of the position was probably due to the tip of the coccyx projecting forwards at a right angle to the sacrum, and thus diminishing the antero-posterior diameter of the pelvic outlet to something like 3| inches, which was certainly too little to allow the passage of the occipito-frontal diameter of the head, which would be at least not less than 4J inches. The position remained a persistent posterior one, in spite of all his endeavours to rectify it, and while attempting to deliver with forceps, a snap was heard, after which the head was extracted in the ordinary way of K.O.P.'s. The coccyx was fractured. In the patient's second labour the same difficulty occurred, the coccyx having united at a similar angle. On this occasion, profiting by the experience of the previous labour, he forcibly fractured the coccyx with his fingers, so as to avoid damage to the occiput, which was present in the first labour, and delivery was com- paratively easy. On the third occasion, with the tip of the coccyx in the natural position, the position was an R.O.P. again, which very soon rotated into an anterior position, and the child was born without assistance, showing that the peculiar position of the coccyx in the first two labours was the cause of the failure of rotation. With regard to the question raised by Dr Barbour, as to why the head, when rotated from the posterior to the anterior position, should engage in the brim more easily, Dr Dewar thought that an answer would be found in the fact that after rotation above the brim, the belly of the child would adapt itself to the concavity of the uterus and pelvis behind, the spinal column would curve correspondingly, and the occipito- spinal joint coming behind the line of the uterine force, flexion would take place, allowing the head to pass easily through the pelvic inlet in the wide oblique diameter.

BY DR J. LAMOND LACKIE. 37

Br Church joined in the expression of indebtedness to Dr Lackie for his practical and suggestive paper. He referred to the danger of injury to the maternal parts over and about the region of the ischial spine from pressure of the child's head in occipito-posterior positions. Sloughing and septic troubles might supervene from such injury. He had read Professor Sir Halliday Croom's paper on this subject, and had been impressed with the importance of this point. He had met with an illustrative case in his own practice. He expressed the opinion that in all great lying-in institutions a detailed account of every presentation should be recorded in the case books. This would add to their scientific value. For example, "Vertex" was not enough. The particular vertex presentation should be defined, and so on. In connection with occipito-posterior positions, it would appear (from the Talmud) that the ancient Jews were of opinion that most female children were born in this position. Hence a medical reason for the longer puerperium of the mother and the longer Levitical period of ceremonial uncleanness. By kind permission, he had looked at the books of our own Maternity Hospital and found that there were considerably more female than male occipito-posterior positions. Obstetricians of to-day could generalise like the Eabbis of old, but, like them, they still found in occipito-posterior positions possible conditions of danger and difficulty. Dr Lackie had shown us how to lessen the difficulty.

Br Oliphant Nicholson thanked Dr Lackie for his interesting paper, and wished to make a few remarks regarding the management of difficult occipito-posterior labour. He had had quite an abnormal number of such cases recently in his dis- pensary practice, and these positions of the head seemed to be commoner than was generally supposed. Occipito-posterior labour might be easy or difficult ; if it was really difficult, it constituted one of the most undesirable and dangerous complica- tions due to malposition of the foetus — a presenting shoulder

38 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

was infinitely more easy to deal with successfully. There were several methods of management, in these cases, and he had tried them all. He thought everyone who had had a large experience in this kind of case, would agree that the manual rotation of the child's head and body into the correct position was the best. It was the most scientific treatment, and it was also the best for the safety of mother and child. He would like to mention some of the methods commonly adopted, and briefly discuss their application to certain cases. 1. First, there was delivery by the forceps without any attempt to correct the position of the head. This was probably the commonest method of all, because the general practitioner did not always trouble to diagnose the position of the head. If a labour was lingering, and the head did not descend, forceps were applied, and the doctor pulled — often with his utmost strength — till the child's head appeared at the vulva. Most of these cases were persistent occipito-posterior ones. Sometimes rotation of the child's head occurred during traction, especially when axis- traction forceps were used, but generally the occiput emerged behind. Now, even when one knew that the position of the head was occipito-posterior, this method was sometimes good practice. Eobert Barnes had advised it, and when the head was relatively small, and one had not to exert dangerous traction, the delivery was generally safely completed without extensive perineal laceration. 2. A slight modification of this method was gradual rotation of the head carried out by the forceps during traction. The blades were removed and re-applied several times till rotation was completed. This method was applicable to those cases where the head showed indications of rotating during traction; the application of the blades two or three times was the important thing to complete rotation. 3. The next method was the manual rotation of the head alone to carry the occiput behind the pubic arch. It was then held in its new position and forceps applied. In applying this treat-

BY DR J. LAMOND LACKIE. 39

ment it was necessary to know that the case was an occipito- posterior one, and he had to confess — after fifteen years' experience — that he could never be certain of this point by means of fontanelles and sutures. In every case where the head remained high up and would not descend, he made a very thorough vaginal examination. With the patient well over on her left side and under chloroform, the whole of the left hand was passed into the vagina and the fingers pushed over the head until an ear was felt. In occipito-posterior cases an ear was always easily reached; that point by itself was rather suggestive of the position. But this method he had found excellent, inasmuch as it not only verified the position, but indicated the direction in which one should rotate. One always rotated away from the ear. This method of correcting the position of the head by means of the hand was, as a rule, very easily carried out. He always used the left hand, and the head, being firmly grasped, was lifted up right out of the pelvis between the pains. The manoeuvre was often carried out with extraordinary ease; sometimes, however, it was very difficult, and then one must adopt some other means of effecting delivery. The main objection to this method was that, unless the body of the child was rotated at the same time, the head had a great tendency to spring back to its old position. Thus it was always necessary, after rotating the head in this way, to keep one's hand on it, and apply the forceps with the other hand. He wished to mention the advantage, in such cases, of introduc- ing the upper blade first ; after the application of this blade, the head could be kept in position while the lower blade was introduced. He might mention also the advantage of the axis-traction forceps with straight blades — such as Milne- Murray's — for these cases, because with them a better grip of the head over the parietal bones was obtained; the ordinary curved blades were certainly more apt to slip off the head during traction. When the forceps were got on to the head in

40 MANAGEMENT OF DIFFICULT OCCIPITO-POSTERIOR CASES,

its new position and traction was made, the body of the child swung round ; the neck of the child did not break. 4. The best method of all was manual rotation of both the head and the body of the child. The body was rotated through the abdominal wall by placing the right hand behind the shoulder and pressing it forwards, this being done at the same time as the left hand in the vagina rotated the head. In some cases this was easily done, but in others very great difficulty was experienced in getting the body of the child round. Most practitioners had met with these troublesome cases, and the natural thing was to pass the hand still further into the uterus, in order, if possible, to get the body to rotate. Last year, in an exceptionally difficult case of this kind, Dr Nicholson, in passing the hand higher up, came upon the child's shoulder, and grasped it within the uterus. Then rotation was accomplished with surprising ease. He was much impressed at the time with this method, and he had no doubt that others who had dis- covered the manoeuvre had been similarly impressed. On looking up the literature of the subject, he found that it had been described, and advocated to the exclusion of all other methods, by Professor Mcllwraith of Toronto, in a paper published in the Canadian Practitioner and Review of February 1905. He did not know whether others had described the manoeuvre ; but it was certainly one that deserved to be more widely known, and Dr Lackie had brought the matter pro- minently before them in his excellent paper.

Dr Lackie, in reply, said that it was to him quite remarkable how easy the children were delivered after artificial internal rotation at the brim. In the first case he had converted an E.O.P. into an L.O.A. ; in the second he managed to rotate the head only to the E.O.A. position, which, however, was quite sufficient. When it was possible, rotation of the whole child was preferable to mere rotation of the head. He thanked the Society for the kind way in which they had received his paper.

«

?i^» j> . .

[Tnset at page 41.

EXHIBITION OF SPECIMENS. 41

Meeting II.— December 12, 1906. Dr N. T. Brewis, Vice-President, in the Chair.

I. The following gentlemen were elected Ordinary Fellows of the Society :— D. Lloyd Koberts, M.D., F.K.C.P., 11 St John Street, Manchester; J. S. Edwards, M.B., Ch.B., University Union, Edinburgh.

II. Dr Brewis showed— (a) Two examples of endothel- ioma of the ovary, removed from a patient aged 20. Miss McK., admitted September 1906; complaining of swelling in the lower abdomen and pain in that region when she turned herself; duration two months. She had always had pain at her periods, but since January 1906 that pain had been more severe. She had strained herself at that time by lifting a very heavy weight. Two months ago, when an attack of pain had come on after turning herself in bed, she felt a hard lump the size of a marble on the right side of her lower abdomen. This grew gradually larger. A short time after she had noticed the first swelling, she felt another on the left side of the lower abdomen. This also gradually increased in size, but she thought it was softer to the feel than that on the right side. On admission, an irregular mass was filling the hypogastric and lower part of the umbilical region. Menstrua- tion regular, twenty-eight-day type; duration, seven days; quantity fairly copious ; pain present. Operation. — Abdominal section, double ovariotomy; small quantity of free fluid in abdomen. Pathological Report. — Extracts from Mr Muirs letter : — " The condition is that of lymphatic endothelioma, but is undergoing extensive colloid degeneration. The sections from different parts of both the right and left ovaries show that the structure is much the same in all. The essential tissue element is seen to be made up of endothelial cells arranged in a very indefinite manner, but in parts one can make out

42 EXHIBITION OF SPECIMENS.

these cells to be lining lymphatic spaces, and some spaces are filled with cells forming an alveolar-like structure. The stroma in parts is well denned and at others scanty. The areas showing an open network of delicate stroma forming spaces, are really the tumour cells undergoing colloid degenera- tion ; in parts their condition is more advanced, showing complete transformation of the endothelial cells into colloid material; only the stroma persists." Patient went home feeling quite well, on the thirty-second day after operation, having made a splendid recovery, only interrupted by a fainting turn on the eighteenth day after operation.

(b) Bare variety of dermoid tumour, tuberculous tubes,

AND INTRALIGAMENTARY TUMOUR OF THE OTHER OVARY. Miss

B., set. 24, admitted 8th October 1906, complaining of pain in the right side, distension of the abdomen, and occasional pain in the left side. Duration of illness, four years ; symptoms more marked during the last year. Menstruation regular, twenty -eight-day type ; duration, two to three days ; flow less in quantity since onset of pain in the right side a year ago. On opening the abdomen a large grey- walled cyst was exposed, and through parts of the wall of the cyst small yellow bodies like coriander seeds could be seen floating about in the interior of the cyst. The cyst was tapped, clear, straw-coloured fluid and little yellow bodies escaping; the cyst was then removed without any special difficulty. In the situation of the right ovary was a body, yellowish in colour, and in shape and size like a medium-sized horse-chestnut. This was adherent to the omentum, and had to be dissected from dense adhesions to the lower end of the caecum. The fimbriated extremity of the right tube was attached to this body, and was swollen. The left tube was distended in its outer third to the size of a pigeon's egg. A round yellow body the size of a pea was attached to the fimbriated extremity. The left ovary was hard and cirrhotic looking. Under the left ovary and parietal

EXHIBITION OF SPECIMENS. 43

peritoneum, covering the left wall of the pelvis, was a cyst firmly adherent to the wall of the pelvis. The patient, although very sick and much pained for some days after the operation, was making an uninterrupted recovery.

(c) Dermoid tumour of the ovary, which ruptured during administration of the anaesthetic : — Miss R, age 28, admitted 2nd November 1906. Complaint. — Distension of the abdomen ; duration, a fortnight. Some little pain in September 1906 ; frequency of micturition at the end of October, with a little fulness of the lower part of the abdomen. During the next ten days the abdomen gradually became distended, till on the day of operation it had reached the size of a six months' pregnancy. While the anaesthetic was being administered, the swelling disappeared, the abdomen becoming quite flat. On opening the abdomen, greasy fluid, fat, and hair welled up into the wound. A dermoid cyst about the size of a foetal head was found, with a rupture in the cyst wall about 2 inches long. This cyst, a dermoid of the left ovary, was removed. The right ovary was slightly enlarged, and cystic. The abdomen was thoroughly washed out, but great difficulty was experienced in getting rid of all the fatty material. After the operation the pulse kept very fast — over 100 — and twenty- four hours after the operation the patient became very restless. On the morning of the second day she was slightly delirious. The same day a condition of stupor developed. This gradually deepened; her pulse remained between 100 and 130 ; her respirations were at times deep, with long pauses between, but never stertorous, and she died on the third day after the operation. The wound was opened on the day of her death, and there was no sign of peritonitis. The tempera- ture the day after the operation was 99° F. ; the day before her death it was subnormal, and remained so till just before her death, when it rose to 102° F.

(d) Euptured ovarian tumour, presenting microscopic

44 EXHIBITION OF SPECIMENS.

characters of adenocarcinoma and tubercle : — Mrs A., age 53 ; admitted 22nd October 1906; married twenty-eight years; widow twelve years; six children. Complaint — Swelling on the right side of the abdomen, with a continuous sore feeling in that region. Patient had reached the menopause two years before. Between that time and six months ago, she noticed that a swelling was present on the right side of the abdomen. This part then became tender, and had remained so since. Six months ago a red discharge like that at her periods set in, and lasted six weeks. Since then this discharge had returned at irregular intervals, being usually very copious, and sometimes had an unpleasant odour. It was sometimes clotted. She had had pain in the right side, and an uncomfortable bursting sensation for the past six months. Her husband and one child died of consumption. A large firm mass filled the left iliac, left lumbar, lower part of umbilical, and left side of hypogastric regions. A dull note in the flanks changed from side to side with the altered position of the patient. Operation. — On opening the abdomen a large quantity of free fluid escaped. The omentum was found adherent to the tumour. The intestines were roughened, red, and extensively studded with tubercles Ovariotomy was performed. There was considerable bleeding and oozing. Everything in the pelvis was very friable, and bled easily. The left ovary was a normal senile one, and was not removed. Pathological Report. — The tumour had the appearance of a columnar -celled carcinoma. The specimen also consisted in parts of granulation tissue infiltrated with leucocytes, and presenting advanced necrosis, so that its features suggested the probability of tuberculosis. Patient got up on the twenty- first day after operation, having made an uninterrupted recovery, and went home a week later, feeling and looking quite well.

(e) Uteeus with large cervical fibroid, removed at the fifth month of pregnancy. The abdomen was opened, and the

EXHIBITION OF SPECIMENS.

45

foetus, which was not viable, was delivered by Csesarean section ; then the uterus and large cervical fibroid which filled the pelvis were removed by hysterectomy. (Described in paper, page 49). (f) Uterus with fibroid tumour in lower uterine segment, removed at term by supravaginal hysterectomy after Ccesarean section. Mrs B., age 33. Married ten months; no children ; no miscarriages. History. — Patient was confined to bed from Easter Monday 1906 until May 1906 with severe sickness. When she got up she was seized by a violent pain in her left side, chiefly in the left iliac region. Pregnancy, complicated by a fibroid tumour, was diagnosed. She was kept in bed for seventeen weeks on account of the pain. A belt was then given her to wear. She got up, and had no recurrence of the pain. The pregnancy was allowed to go on till full time. When labour set in, the foetal head was found occupying the right side of the pelvis and a hard rounded swelling the left side of the pelvis, both situated just above the brim. The abdomen was opened, and the rounded swelling was seen to be a rounded mass the size of a cricket ball, in the wall of the uterus, at the left side of the lower uterine segment and under the bladder. The child was delivered alive by Caesarean section. The placenta was removed, and the uterus, which had another projection from the wall at the fundus, was removed by supravaginal hysterectomy. On section, the rounded mass was seen to be a fibroid tumour, and the cylindrical projection near the fundus a fibroid growth which had undergone colloid degeneration. Both mother and child did very well, the mother making a rapid recovery. (Described in paper, page 49).

III. Br Haig Ferguson showed — (a) 1. Tubal pregnancy (two months), showing dilated ostium tubse, and ovum partially protruding. Eupture had at the same time occurred slightly into the broad ligament. Free blood in abdominal cavity; operation on account of pain, haemorrhage, and continued

46 EXHIBITION OF SPECIMENS.

orowth of tumour. 2. Complete tubal abortion (about second month). Tube apparently empty, but still bleeding through open ostium. Pelvis full of clot, containing shreds of membrane of gestation sac. Operation for pain, steadily increasing hematocele, and symptoms of internal bleeding. In this case it was necessary to drain through the posterior fornix into the vagina, on account of the large raw surface behind the uterus, which was packed with gauze. Both patients made good recoveries.

(b) Large double pyosalpinx, apparently tubercular. The uterus was removed at the same time, to render operation possible. Free ends of both tubes adherent to each other behind the uterus.

(c) Uterus with fundal cancer, removed by vaginal hysterectomy from a nulliparous patient, aged about 55. She complained of haemorrhage as her only symptom, and there was no pain. Uterus measured 2 \ inches with the sound. Curettage ; scrapings reported as malignant adenoma. Disease limited to fundus. Satisfactory recovery. Patient had weak heart, so the vaginal route was chosen, which, though more difficult in a nullipara, caused less disturbance and shock to the patient.

(d) Chorion epithelioma of uterus, removed by vaginal hysterectomy. This was the second specimen of decidnoma malignum shown here to the Society by Dr Ferguson this year. The patient, Mrs 0., age 38, had an imperfect abortion, and was sent to hospital for curettage. Severe haemorrhage oc- curred after curetting ; scrapings were examined by pathologist, who reported chorion-epithelioma. Uterus was removed by vaginal hysterectomy. Good recovery. Patient remaining well four and a half months after operation. The former specimen, which he now brought for comparison, was removed in April last, and the patient was still in excellent health. Her age was 47.

(e) Inverted uterus, of puerperal origin, after a carefully conducted labour. Insidious commencement, with practically

EXHIBITION OF SPECIMENS.

47

no symptoms. Eecognised six weeks after labour; reduction impossible; vaginal hysterectomy; good recovery. (Case reported in full in Journal of Obstetrics and Gynaecology of British Empire, October 1906.)

(/ ) Soft subperitoneal fibroid, resembling an ovarian cyst. This tumour was removed by abdominal hysterectomy, from a patient aged 60. The uterus was completely upside down in the pelvis, and was normal in size as measured by the sound. She had been treated by pessaries for a considerable time with no benefit. The symptoms were constant bladder irritation, and pelvic pressure symptoms. When Dr Ferguson saw the patient he thought the tumour alongside the uterus was an intraligamentous cyst in close contact with the right side of the uterus. Even after removal the examination of the specimen gave that impression, so soft and fluctuating was the mass. The patient made a good recovery from the operation, and her distressful symptoms had quite disappeared.

(g) Chart showing ante-partum temperature of 105-8° F. (malarial), when child was born alive. The patient, a primi- para, made a good recovery, and the child did well. Labour was to have been induced prematurely on account of a narrow pelvis. The high temperature, however, combined with the quinine, set the labour going just at the time the induction was to have been done, so no further interference was necessary.

(h) Uterus, removed by vaginal hysterectomy, one year after a double pyosalpinx (probably gonorrheal) had been removed by abdominal section. The uterus was removed for persistent, purulent, and offensive uterine leucorrhoea combined with pain, which resisted curetting and all other minor treat- ment. The patient and her doctor both urged hysterectomy, which, owing to the shortness of the broad ligaments (the result of the previous oophorectomy), was a somewhat difficult pro- cedure. The uterus, when opened after removal, was found to be transformed into an abscess cavity, with rough and sloughing

48 EXHIBITION OF SPECIMENS.

mucous surface, and containing offensive pus, penetrating down to and involving the muscular walls. The patient's health was completely re-established after the vaginal hysterectomy, and she described herself as an absolutely transformed woman, as regards her sense of well-being and comfort.

IV. Dr Barbour Simpson showed a replica of the medal presented to Professor Pozzi last July by his colleagues, friends, and former pupils, in recognition of his position as President of the Seventeenth Surgical Congress, Paris, 1904, and of his promotion to the grade of Commander of the Legion of Honour. Dr Simpson mentioned that a Livre oVOr was also presented to Dr Pozzi at the same time, containing twenty-four original contributions by his colleagues, former pupils, and friends.

V. Dr Haultain showed a specimen obtained from a multipara a fortnight ago. The history was that, when the students arrived at the case, they were told that the placenta had already been born. The child was born shortly after their arrival, and the placenta came away thereafter normally. On examination microscopically, the purplish mass of the specimen turned out to be a blood tumour formed of capillaries and large blood-vessels, with practically no connective tissue between the vessels. The whitish mass was composed of necrotic tissue. There was no trace of foetal structure or decidual cells. The mass was about the size of a cocoa-nut, and apparently was some abnormal product of conception analogous to * Foetus Ovideus."

VI. Dr James Ritchie showed a specimen OF an early ovum. The last period had taken place on 4th July; the abortion was on 31st August ; but from the size of the ovum, conception must have occurred only shortly before the date of the period which was missed.

CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS. 49

VII. TWO CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS, TREATED BY HYSTERECTOMY.

By N. T. Bkewis, M.B., F.R.C.P.E., F.R.C.S.E., Gynaecologist, Royal Infirmary, Edinburgh.

Cases of pregnancy complicated by fibroid tumours for which the operation of hysterectomy is indicated are of rare occurrence. I have previously reported to the Society two such cases : one for fibroids obstructing the pelvis and causing severe pain, the other for a tumour of such extremely rapid growth that it filled the entire abdomen in three months. I now wish to add to this record two further cases. In one the tumour filled the pelvis, and caused such severe pressure symptoms that the operation was a matter of urgency, and had to be performed during the sixth month. The other was operated on at full term, chiefly on account of the obstruction which the tumour offered to the passage, per vias naturales, of the child. In over 1000 major operations, I have had to interfere seven times in this manner with fibroids during pregnancy ; ovarian tumours I have removed seven times during pregnancy ; and in cases of malignant disease in the pregnant uterus, I have performed Cesarean section and hysterectomy on three occasions.

In each of the cases I now wish to record, Cesarean section preceded hysterectomy.

The first case is that of Mrs C., aged 37, who was admitted into Ward XXXVI. in October of this year, complaining of great pain in the lower part of the abdomen and in the back. The patient last menstruated in the first week of June. The early symptoms of pregnancy soon asserted themselves. In July, trouble with micturition began — at first the act was painful and difficult, afterwards there was increased frequency. At this time also severe pain in the back set in, followed at a short interval by pain in the abdomen, which confined her to

D

50 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,

bed, and which continued until relief was obtained by the operation. Her menstruation began at 16, was of the twenty- eight-day type, and lasted three days. The amount was copious during the first day, and slight during the remaining two days. There was always pain on the first day.

On physical examination the breasts were found to be large, and colostrum was easily expressed from the nipple. The abdomen was enlarged by a swelling which reached to the umbilicus. On the right side it projected markedly, and pre- sented the signs of a pregnant uterus. On the left there was felt a separate swelling of much harder consistence. Per vaginam, the finger felt this swelling passing down into the pelvis and almost entirely filling the cavity.

The cervix was situated far forward, immediately behind and against the symphysis pubis.

Pregnancy plus a solid tumour was diagnosed ; the patient was anaesthetised, and an attempt made to dislodge the tumour from the pelvis. This attempt failed however. "We were anxious to withhold any further interference until the child became viable, but the pain continued so severe and persistent that it was feared some degenerative change might be taking place in the tumour; moreover, her general condition was becoming each day less favourable, and to add to her misery, and to our anxiety, symptoms of intestinal obstruction and also of ureteral pressure were beginning to manifest themselves. It was therefore clear that we had to consider what could best be done in the mother's interest. With this object in view we determined to open the abdomen, deliver the child by Cesarean section, and then proceed to remove the tumour.

A mesial incision was made from the pubis to above the umbilicus. On opening into the abdominal cavity the gravid uterus at once presented, and was, after some manipulation delivered through the wound. A large fibroid tumour could now be felt filling the pelvis. To get access to this tumour

BY DR N. T. BEE WIS.

51

it was necessary to empty the uterus. To do so, a longitudinal incision, about 3 inches in length, was made in the anterior uterine wall. Through this the five-and-a-half months' foetus was delivered, the placenta was expressed, and the uterine incision sutured. It was now possible to draw the tumour out of the pelvic cavity, where it was found to be growing from the posterior aspect of the supravaginal portion of the cervix. Supravaginal hysterectomy was performed in the usual manner. The cervical mucosa was removed; the vaginal vault was perforated, and a gauze drain passed down into the vagina. The abdominal incision was stitched in layers. The patient made a most satisfactory recovery.

On section, the central portion of the tumour presented the characteristic appearance of a fibroid, but surrounding this and towards the surface there was extensive degeneration. The tissues were much broken down, the spaces thus formed being filled with glairy-like substance.

The operation just described took place on the 2nd of November, and on the following day Case No. II. went into labour, and a similar operation was performed on her, thus forming a notable example of the interesting phenomenon, which most medical men have experienced, of rare cases coming in sequence.

The following are the chief points of interest in the history : —

The patient, 33 years of age, has been ten months married. There is no history of any previous pregnancy or abortions.

Menstruation began at 13, was regular, lasted five days, and, until two years ago, presented no abnormalities. For the past two years there has been a dull dragging pain, chiefly in the iliac regions and upper parts of the thighs, during the menstrual period. There has never been any intermenstrual discharge. For some time there has been increased frequency

52 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,

of micturition, but neither pain nor difficulty. Albumen was present in the urine.

Patient last menstruated from the 7th to 12th February 1906. In the latter part of April 1906 patient had severe sickness, and was confined to bed for two or three weeks. On getting up she experienced severe pain in the left side. This was at times agonising in its severity, and was most marked in the left iliac region. The pain persisted for three or four weeks, and then gradually became less severe. When the pain had subsided, the patient was examined by her doctor, who told her she was pregnant, and also that she had a tumour ; he kept her confined to bed for seventeen weeks. I saw her in consulta- tion at the end of August 1906, when I found her six months pregnant. Growing from the left side of the uterus there was a hard tumour, which filled the greater part of the pelvic brim.

The patient was most anxious to have a living child, and, as the symptoms were now not so severe as they had been, we decided not to interfere until the full term. I ordered the patient an abdominal belt, and advised her not to remain in bed. The support obtained from the belt had the desired effect : there was no recurrence of the abdominal pain.

The patient came into my Home on 27th October, and subsequent to that date was under my personal observation. On 3rd November she complained of pain all day at intervals ; this was felt chiefly in the back, and did not tend to radiate to the front. At 4 p.m. the membranes ruptured. At 6 p.m. the cervix, on vaginal examination, was found to be soft, but only sufficiently dilated to admit the tip of the index finger. The foetal head was found on the right side of the abdomen, above the pelvic brim. On the left side, also just above the brim, there was a firm rounded mass, about the size of a foetal head. Attached to the uterine wall, about 2 inches above and to the left of the umbilicus, there was a projection which, through the abdominal walls, felt like a foetal foot and leg.

BY DR N. T. BREWIS. 53

At 7 p.m. the patient was anaesthetised and a thorough examination made. The head was found -still above the brim, which it was prevented from entering by the tumour. The cervix was still undilated. As the liquor amnii had drained away some hours before, and the child had consequently been exposed to severe pressure between the fibroid and the strongly acting uterus, it was decided that labour should, alike in the interests of mother and child, be terminated as quickly as possible. The safest method for both was undoubtedly Csesarean section.

The abdominal cavity was opened by an incision extending 2 inches above the umbilicus. The uterus was brought into the wound. The obstructing tumour was found to be a fibroid situated on the left side of the lower uterine segment ; it was rounded in shape and about the size of a cricket ball. The projection from the body of the uterus, described above, was found to be an irregularly shaped subperitoneal fibroid situated about lh, inches internal to the insertion of the left round ligament. The bladder had markedly hypertrophied walls and was found to reach to an abnormally high level.

The uterus was opened by an incision about 4 inches long in the anterior wall. Through this the child was delivered and the placenta removed. The uterine incision was then sutured with thick catgut. The tumour was next shelled out of the uterine wall. In spite of all efforts to promote uterine action, the organ remained in a relaxed, flabby condition. Owing to its atonic state and the consequent oozing, it was found necessary to perform supravaginal hysterectomy.

The child, though small, was in no way malformed.

Mother and child returned home well twenty-eight days after operation.

Remarks. — The presence of fibroid tumours in the uterus may complicate pregnancy, parturition, and the puerperium in

54 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS,

a variety of ways. The site which the growth occupies is the chief factor in determining the significance of the complication. For example, subperitoneal growths in the body of the uterus, unless of considerable size, may not give rise to any symptoms during pregnancy, and may not interfere with the progress of parturition ; while a tumour growing in the lower pole of the uterus may give rise to severe pressure symptoms during pregnancy, and may constitute a complete barrier to the passage of the f oetus through the pelvis during labour. An intra-uterine growth may interfere with the development of the product of conception and lead to abortion, with risks of haemorrhage and sepsis, or may hinder delivery, or cause post-partum haemorrhage. Therefore pregnancy may occur in a uterus the seat of a fibroid ; but such a tumour may cause no symptoms during pregnancy, and need cause no anxiety. Here we may leave nature to safely terminate the labour. On the other hand, a fibroid tumour may so complicate a pregnancy that not only are the symptoms during pregnancy urgent and severe, but its presence may place the patient's life in jeopardy when labour sets in. The cases which I have just related belong to this class. The first was an example of a tumour causing distress and danger during pregnancy, the second was an example of a tumour caus- ing danger during labour. When it is clear that a pregnancy, complicated by fibroid tumour, requires surgical treatment, it is possible that the case may be treated, and scientifically treated, by more methods than one, though, doubtless, there must in each case be one method better than any other. In my opinion, this applies to Case No. II., but not to Case No. I.

The propriety of the treatment adopted in Case No. I. could not be questioned. The tumour filled the pelvis, and could not be dislodged ; it presented an impassable barrier to the transit of the child; its presence was a menace to life, and caused symptoms which could no longer be endured by the patient. The indications were so urgent, there was no alternative but to

BY DR N. T. BREWIS. 55

operate without delay in the interests of the mother. The only method other than the one adopted would have been to remove the tumour, leave the uterus, and thus give the mother a chance of carrying the foetus to term. This did not occur to me at the time, but an examination of the specimen shows that such a method, however ideal, was in this case impracticable.

In Case No. II., the tumour gave rise to no urgent symptoms during pregnancy, and in this case our treatment was to be planned and carried out with the view of saving both mother and child, or, better still, mother, child, and uterus. The possible procedures that occur to me other than the one carried out are two in number : —

1. Labour might have been induced at the seventh month and the tumour removed subsequently. Against this plan we have to consider the risk of the induction to the mother, the risk of losing the child, and the subsequent major operation for removal of the tumour.

2. The tumour might have been removed without interfering with the pregnancy. This might have been attempted, but there were not sufficient grounds to ensure the successful carrying out of this procedure.

As events turned out, this result would not have been attained without difficulty and danger. The tumour was placed under the bladder, was sessile, and had a broad attachment to a very vascular part of the uterus, and haemostasis would have been difficult and uncertain. The question of whether the fibroid uterus should be sacrificed after removal of the child and the tumour was considered, and decided in the affirmative : first, on account of the uncertainty of being able to deal satis- factorily with the bed from which the tumour had been removed ; and secondly, from the fact that the remainder of the body of the uterus was not healthy. I think, as events proved, the course which we followed was right and proper. The mother and a healthy child were saved, and the former returned

56 CASES OF PREGNANCY COMPLICATED BY FIBROID TUMOURS.

home well and strong ; and, though deprived of the power of bearing offspring in the future, I think that, after her experience, she will be glad that such an event is not possible.

Dr James Ritchie said they were very much indebted to Dr Brewis for having submitted these two very interesting cases. The class of case referred to was one of extreme gravity in practice. When one discovered a cervical tumour in a married woman, it was often a matter of great difficulty to know how to treat the case. Although the tumour might not be very large at the beginning of pregnancy, it would probably grow very much during pregnancy. Should immediate operation be recommended, or waiting? He thought Dr Brewis had put before them very clearly the rules for guidance in such cases. It would, he thought, be well to explain to the patient the greater danger of waiting for operation till full term rather than having it dealt with at a comparatively early stage of preg- nancy; and, having given the explanation, to allow the patient to choose between early operation and waiting events. In the first case there was no doubt about the procedure which should be adopted.

Dr Lamond Lachie thanked Dr Brewis for the report of two such interesting cases. He said it was quite clear that Dr Brewis had adopted the best possible means of saving those patients, but remarked that it was curious how in some cases nature so frequently seemed to overcome difficulties that at first sight seemed insuperable. The most interesting case he had seen of pregnancy complicated by fibroid tumour was of a lady who had come to Edinburgh on account of a fibroid tumour com- plicating pregnancy, diagnosed by her doctor. Dr Lackie in examining per vaginam had found it absolutely impossible to feel any os. The pouch of Douglas was entirely occupied by

PKOGNOSIS OF PKEGNANCY IN PATIENTS WITH ONE KIDNEY. 57

the fibroid. It was determined to leave the patient for a time, and perform Cesarean section at a later date. At eight months labour set in, and at once preparation was made for Cesarean section. Labour went on very rapidly, and on examination it was found that the cervix had descended, and the os was lying practically in the centre of the pelvis, so that the fibroid tumour which had occupied the pouch of Douglas had risen up, and the head of the child presented in the normal way. After the birth of the child the os had ascended again, and the pouch of Douglas was again occupied by the tumour, and it was found necessary to give chloroform and hook the cervix down, pass in the hand, and remove the placenta. The patient made a good recovery, and went home with the tumour very much less in size than it had been during pregnancy.

Dr Keppie Pater son asked if Dr Lackie had followed up the case, but Dr Lackie replied that he had not done so.

Dr Brewis, in reply, said the case cited by Dr Lackie might have been a pedunculated fibroid.

VIII. ON THE PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY, WITH NOTES OF AN UNUSUALLY COMPLICATED CASE OF LABOUR AFTER NEPHRECTOMY.

By James Haig Ferguson., M.D., F.R.C.P.E., F.R.C.S.E., F.R.S.E. ;

Assistant Gynaecologist, Royal Infirmary, Edinburgh; Assistant Physician, Royal Maternity Hospital, Edinburgh j and Gynaecologist, Leith Hospital.

In recent years, owing to the brilliant and rapid advances of surgery, the operation of nephrectomy has become no uncommon procedure for various diseased conditions of the kidney. It follows that we as obstetricians will occasionally be confronted with the question : Should a woman with one kidney be advised

58 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,

to marry and run the risk of becoming a mother? I am assuming, of course, that the remaining kidney is healthy and equal to its duties in ordinary circumstances.

We know that during pregnancy in healthy women the kidneys undergo hypertrophic changes of a strictly physiological character, so as to enable them to cope with the increased work they have to do. In the same way, as is well known, the one healthy kidney in the patient whose diseased kidney has been removed undergoes hypertrophy, which probably began long before the nephrectomy was performed, the diseased kidney having in all likelihood been more or less functionless for a considerable time prior to operation.1 If in such a case pregnancy should then supervene, further hypertrophy will be required to meet the necessary demands; and as, so to speak, all the patient's eggs are now in one basket, any undue strain on this kidney will at once mean very serious renal insufficiency.

The case I am about to record shows that in a patient whose remaining kidney is healthy, and has had time to become sufficiently hypertrophied to perform the work of two, the strain of pregnancy can be fairly well borne ; for although the patient developed albuminuria, and had a diminished excretion of urea, yet when she was put on proper treatment (though it was somewhat late in the day) the condition yielded fairly satisfactorily to appropriate remedies, and the kidney irritation tended to subside. In fact, this patient with only one kidney had, on the whole, less severe albuminuria and less toxic dis- turbance than many albuminuric primigravidse both of whose kidneys are known to be organically sound, though it is possible, and indeed probable, that in my patient's case the amount and

1 In one case recorded in the discussion on Mr Twynam's paper on nephrectomy in pregnancy {Lancet, vol. i., 1898, p. 165), it is stated that after removal of one kidney in a man, for laceration, where all the work was thrown suddenly on the opposite organ, the amount of urine and urea became normal in four days' time.

BY DK JAMES HAIG FERGUSON.

59

virulence of the toxin or toxins she was manufacturing were comparatively insignificant. It is manifestly impossible to institute comparisons between different patients on this point.

The only other instance of which I have personally known where pregnancy occurred in a patient with one kidney, was in the case of a lady who was married about two years ago, after having had nephrectomy performed. Pregnancy shortly super- vened, and she died, I understand, of eclampsia shortly after a premature labour.

One would, on the whole, I think, prefer, so far as one's limited knowledge goes, that patients who only possess one kidney, even though it is apparently a healthy one, should, if they marry at all, delay marriage till after the menopause. One could not, however, give such uncompromising advice ; it would be impracticable, and indeed in many cases hardly justifiable, besides being highly unwelcome to many of the recipients. Each case would require to be judged on its own merits, and after a careful consideration of all the attendant circumstances. Some patients might be determined to take a certain extra risk for reasons all-important to themselves, and such are apt to listen to no arguments which in any way run counter to their own views and inclinations. I should be strongly inclined to urge, in the interests of prudence, that marriage be delayed till at least three years from the operation of nephrectomy, so as to give the remaining healthy kidney ample time for compensatory changes to occur under the influences of the varying vicissitudes of ordinary life — in fact to establish and consolidate a condition of matters which will enable the one kidney safely and easily to do the work usually undertaken by two.

Of course if the remaining kidney were diseased, marriage, where there is any possibility of child-bearing, should, in my opinion, be out of the question.

Whenever a first pregnancy occurs in a patient with only

60 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,

one kidney, she should be most carefully watched, and placed in circumstances where this watching can be thoroughly and systematically carried out, her urine being examined and tested regularly during the whole duration of pregnancy, with the view of immediately bringing the pregnancy to an end should she show any evidences of renal inadequacy which fail to respond to general treatment.

Special care should be taken to ensure that the excretion of urea is not diminished, and in this connection it is well to remember that the excretion of urea in healthy pregnant women seems to be considerably less than is usually supposed, varying, according to Whitridge Williams, from 20 to 24 grammes in the twenty-four hours. I have certainly in some cases verified this observation, but was inclined to put it down to commencing failure of excretion, and diminishing power in the kidney function, in fact to commencing toxaemia. Be this as it may, there can be no doubt, as Marx has shown, that urea is always diminished in the toxaemia of pregnancy, and that this diminution is a much more valuable, and certainly an earlier indication, than either the presence of albumen or casts, both of which latter may be absent even in bad cases. If this were more generally recognised and acted on, there would, I feel sure, be fewer cases of eclampsia than we now have to deplore.

The same general principles would hold, as regards sub- sequent pregnancies, in the case of a parous woman who had been the subject of nephrectomy, always bearing in mind the fact that primigravidae are more specially liable to the toxaemic disturbances which may be associated with pregnancy.

The same remarks might be applied in the case of a woman with one kidney f unctionless, as, for example, in hydronephrosis, or where only one kidney is diseased and the other healthy, as proved by Luy's separator or by catheterising the ureters. In such cases of kidney disease it would be of great importance to

BY DR JAMES HAIG FERGUSON. 61

discover the exact condition of each kidney, for in my opinion the prognosis as regards the supervention of pregnancy would be worse with two kidneys even slightly diseased, than where only one kidney is diseased (even considerably so) and the other healthy. The advantage one has in the case of the woman with only one kidney is that one knows exactly where one is as regards the condition of the remaining kidney, and can speak therefore with a more certain voice as regards probabilities and possibilities.

I have been unable to find much information in literature on this subject. There is a considerable number of cases recorded where, on account of urgent kidney complications, nephrectomy had to be performed during the actual existence of pregnancy, in many cases with satisfactory results both as regards the mother, the continuance of the pregnancy, and the health of the child.

Fritsch says that pregnancy can be carried through with nephrectomy of one side, and quotes a case of Bovee's in support of this. He says, however, that the remaining kidney, if it becomes in a higher degree a "pregnancy kidney," may easily become insufficient, and that this may lead at once to the most serious eclampsia. Schramm, quoted by Cumston, records a case where the right kidney had been removed and pregnancy and labour were practically normal. He sums up by saying that a patient having but one kidney may go through pregnancy and labour without any injury to her health, but it is probable that such a patient would have diminished resisting power should she be afflicted with chronic nephritis, and that an attack of eclampsia would be fatal to her. In other words, with good fortune, she may pass through her pregnancy and labour safely, but any breakdown will necessarily tend to be greater, and therefore apt to be more disastrous.

The variety of the complications which had to be dealt with in the following case was greater than I have ever before met

62 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,

with in any one patient, and the cases must be few in which so many obstetrical difficulties have been concentrated in one individual. For in addition to the fact that she had, some years previously, undergone the operation of nephrectomy, the patient was the subject of albuminuria, and had besides a contracted pelvis, placenta prsevia, and a cervical polypus, whilst, in the way of obstetric operations, induction of labour and craniotomy were required, and manual removal of an adherent placenta was necessary, in order to complete the third stage.

The notes of the case are as follows : —

F. K, aet. 36, a primigravida, was admitted to the Edinburgh Maternity Hospital at 9.30 p.m., on the 29th December of 1905.

The patient had last menstruated on the 20th of March 1905, and on admission it was noted that in spite of the fact of her being a primigravida, and in the last month of gestation, the foetal head was not engaged in the pelvis, but was freely movable above the pelvic brim. The foetus lay in the left occipito-anterior position.

The patient stated that she was quite well during her pregnancy till the end of October 1905, when her legs became so much swollen that she had to go to bed, where she remained for a week. She had been liable to occasional severe head- aches.

On 28th December, the day before her admission to hospital, she was suddenly seized with severe headache, and flashes of light before her eyes, but she noticed no swelling of hands or face. On admission, her urine, which was scanty, contained 2 grains of albumen and 4 grains of urea per fluid ounce. She was thin and very pale, and there was considerable dropsy of the lower limbs, of the abdominal wall, and of the vulva.

When five years of age she had had scarlet fever, followed by nephritis. In February 1896, her left kidney was removed for tuberculous disease. The symptoms which led up to the

BY DR JAMES HAIG FERGUSON. 63

nephrectomy and which had lasted for twelve months before the operation, were progressive emaciation, blood in the urine, frequency of micturition, night-sweats, and attacks of severe pain in the left lumbar region. She states that she recovered well from the operation, but that the wound did not heal for twelve months afterwards. Since then she has remained well. She has now no pain or discomfort on micturition, but passes water rather frequently — every two hours or so.

Menstruation began when she was 16. years of age, and recurs at intervals of twenty-four days. It is fairly profuse. She has no dysmenorrhoea or intermenstrual discharge.

Examination of the pelvis showed an intercristal diameter of 10 \ inches, and an interspinous diameter of 8f inches. The diagonal conjugate was fairly normal, just slightly under 4J inches. The pelvis was, however, much contracted transversely, and was of a kyphotic type.

The patient's general condition improved under milk diet and complete rest in bed. Her urine increased in quantity up to 50 to 60 fluid ounces per diem. The urea varied from 2 J to 4 grains per fluid ounce, and the albumen decreased to 0*4 grains per fluid, ounce.

In view mainly of the head not having entered the pelvis, it was decided to induce labour, as there seemed some hope of getting the head through if it were not too firmly ossified. Accordingly a bougie was introduced into the uterus on the evening of 3rd January 1906. There was some bleeding per vaginam after this, and this was at the time attributed to a small polypus which projected inwards from the left side of the cervical canal. There were occasional transient pains during the next twelve hours, and at the same time some further bleeding, not severe, but more than seemed to be accounted for by the cervical polypus. On careful examina- tion after the os became patent, there was found to be a lateral placenta praevia, with apparently a somewhat shrivelled

64 PROGNOSIS OF PREGNANCY IN PATIENTS WITH ONE KIDNEY,

placental lobe. The pains almost disappeared during the next twenty-four hours (even though the membranes had ruptured prematurely), and there was not much haemorrhage. On the morning of 5th January 1906, a Champetier de Eibes's bag was inserted through the os, which was about the size of a florin and very rigid. Strong pains came on during the day, and at 3 P.M. the patient was looking and feeling very much worn out, her pulse being 118 to the minute. At 3.30 p.m. she was anaesthetised, the Champetier's bag was pulled slowly down, so as to fully dilate the cervix, as well as to stretch the vagina and perinaeum, the forceps was applied to the foetal head, and every effort was made to effect delivery in this way. All such attempts, however, proved futile, as the head was too large and too firmly ossified to pass through the pelvic brim. I therefore performed craniotomy, and the child was even then with difficulty extracted, as both the cavity and outlet of the pelvis were likewise transversely contracted. The child was delivered at 4.25 p.m., it was a male, weighing 5 lbs. 13 oz., and was 22 inches in length.

The placenta was retained, and after half an hour I inserted my hand into the uterus, found it completely adherent, and verified the diagnosis of partial placenta praevia. After manually detaching and removing the placenta, an intra- uterine douche was given, and it was found necessary to insert three stitches into the perineum The placenta showed a shrivelled lobe.

The puerperium was uneventful. The albumen steadily diminished and ultimately entirely disappeared, and the patient was discharged well on the twelfth day.

This case is mainly of interest from the fact of the patient having only one kidney with which to face the strain of her first pregnancy and labour. Clearly, labour should have been induced at a much earlier date in order to have been of any service in giving the child a chance of life, but unfortu-

BY DR JAMES IIAIG FERGUSON. 65

nately the patient did not come under observation until too late for this operation to have been of any real advantage in the child's interests, and it was done therefore more for the mother's sake than from any great hope of saving the child.

It is to be noted that the patient had a history of nephritis after scarlet fever in childhood, from which she seems com- pletely to have recovered, at least in so far as the right kidney was concerned. Her left kidney was removed for tuberculous disease in 1896, nearly ten years before her confinement, so that during all these years she had manifestly been entirely dependent on the right kidney for all