MEETING VI.-MAY 11, 1898.

Dr R. MILNE MURRAY, Vice-President, in the Chair.

I. Harold Malcolmson, M.B. C.M. Edin., Holywood, County Down, was duly elected an Ordinary Fellow of the Society.

II. Dr J. L. Lackie showed (for the President)-(1.) A MYOMA OF THE OVARY, which at first sight had all the appearances of a sarcoma, but there were no adhesions and no ascites. The tumour was easily removed, and the patient did well. (2.) A LARGE DERMOID OVARIAN removed from a girl of 16. It at first was supposed to be malignant, and the abdomen was frequently tapped for ascites. Ultimately laparotomy was performed with a most satisfactory result. (3.) A FIBROID, removed by myomectomy, which was necessary in order to reach the ovaries, oöphorectomy being the object of the operation. The patient had done well. (4.) A LARGE FIBROID, removed by abdominal hysterectomy. The patient died. She had been much reduced by hæmorrhage.

III. Dr Brewis showed a FOUR MONTHS' PREGNANT UTERUS and LARGE FIBROMYOMATOUS TUMOUR, removed by hysterectomy.

IV. Dr Jardine, Glasgow, showed—(a.) TWO UTERI from cases of Cæsarean section; and (b.) a DRAWING of a CURIOUS CENTRAL TEAR

OF THE PERINEUM.

V. Dr R. C. Buist showed a SPECIMEN OF MALIGNANT ADENOMA OF FUNDUS UTERI. The notes of the case were: Mrs M. (52), widow; eighteen months after menopause, at 50 she had a return of bloody discharge, and after it had come irregularly for six months, she consulted Mr Greig, who curretted. I found ou microscopic examination of the scrapings that they were from a malignant adenoma. In August last I removed the uterus and appendages per vaginam by ligature. The convalescence was complicated by a transient cystitis and by a megrim headache, but the patient was able to be up on the twelfth day, and is well. The specimen shows a circumscribed prominence of irregular papillary appearance, and about a centimetre high, growing from the upper part of the anterior wall of the fundus. The microscopic examination coincided with that of the scrapings.

VI. Dr Haultain showed a specimen of TUBAL GESTATION.

VII. Dr J. Haig Ferguson showed two SPECIMENS OF TUBAL GESTATION, removed from the same patient at one operation, the one a mesometric sac, the other a lithopædion. The patient from whom the specimens were removed is a married woman, aged 29 years. Her first child was born in May 1891. It was a cross-birth, and

only survived one hour. A second child was born at the seventh month in February 1892, and likewise only survived one hour. After that her menstruation was quite regular till January 1894, when she had sudden amenorrhoea, and had missed four periods, when she was seized with violent abdominal pain and shivering. At that time she resided in Ireland. There is no history of discharge of bloodclot or membrane of any kind. For these symptoms she was treated with poultices by her medical attendant, and was confined to bed for several weeks. The periods then returned as usual, and she was quite regular till February 1898, when she again missed two periods. Dr D. J. Graham has kindly furnished these notes of the patient's history.

Dr Ferguson saw the patient first on 11th April 1898; she was then suffering from pelvic pain and retention of urine. On examination a fluctuating tender swelling the size of a goose egg was found on the left side; the uterus was enlarged and pushed to the right side. A small piece of decidual membrane was passed per vaginam, in which typical decidual cells were seen microscopically. Left tubal pregnancy was diagnosed, and Dr Ferguson thought it probable that it had ruptured into the mesometrium, thus setting up the sudden attack of retention of urine. The retention, however, did not last long. On the 19th April Dr Ferguson performed abdominal section for the purpose of removing the gestation sac. It was comparatively easily removed, and just as it was touched by the fingers the mesometrium ruptured, but the hæmorrhage was soon controlled, and the sac was removed along with the corresponding ovary. On the right side an irregular nodulated swelling was discovered, attached by a narrow pedicle (close to the cornu of the uterus) to a very much dilated and tortuous tube, which was adherent to the uterine fundus. The tube closely resembled small intestine in appearance, and was filled with serum. This sac was the lithopædion, and was filled with the bones of a four months' foetus. The lithopædion lay in the peritoneal cavity, attached to the tube by its narrow pedicle, looking as if it had been originally extruded through the peritoneal covering of the tube. The right ovary was cystic, and was removed at the same time. The patient has made an uneventful recovery.

VIII. RECENT MODIFICATIONS OF ANTERIOR COLPORRHAPHY-CASE OPERATED ON FOR CYSTOCELE RE

MAINING AFTER VAGINAL HYSTERECTOMY.

By R. C. BUIST, M.D.

FOR completeness sake it is needful to mention here a few facts which are well known to all gynecologists. The earlier discussion as to the mechanism of cases of prolapse has resulted in the general recognition of the two large groups of cases: (1) Cases with an initial retroversion or retroflexion; (2) Cases with initial weakness

of the pelvic floor and cystocele. Cystocele implies the existence of weakness, not only of the pelvic floor, but also of the muscular wall of the bladder. The normal bladder can empty itself in virtue of its intrinsic contraction in whatever position the body may be. In cystocele this power no longer remains, and unless the patient adopt special means the bladder is never entirely emptied and the bladder wall is thus never fully contracted. The vicious circle is thus closed, the impairment of the muscle prevents complete evacuation of the bladder, the incomplete evacuation of the bladder prevents the restoration of the muscle. From this point of view, the obliteration of the cystocele is an important factor in the success of any treatment of prolapse.

The fact that scar tissue is weak tissue is one of the most important elements in the failure of operations for prolapse of the female genital organs, and in many ways the process of devising new operations has been one long endeavour to get rid of this weakness or to ensure that the scar or line of greatest weakness should not coincide with the line of greatest strain.

Fehling replaced the excision of a median flap from the anterior wall of the vagina by the excision of two lateral flaps. More recently an endeavour has been made to replace the line of scar by a new median raphe or fillet, as in the operations described by Gersuny, and at the International Medical Congress in Moscow by Marsi. Theilhaber of Munich has shifted the venue somewhat when he says that by excising the whole. anterior and lateral walls of the vagina he supports the cystocele, not from the lax tissue underlying the vagina, but from the unyielding attachment of the lateral tissues of the vagina to the pelvic bones.

The last three years have seen various proposals made, not for the support, but for the obliteration of the cystocele. Theilhaber suggests that, if necessary, excision of the posterior wall of the bladder, or at least of its muscular layer, might be practised, and argues that from the old method of performing anterior colporrhaphy by pulling forward the vaginal mucous membrane with forceps, the success of some of the older operators was probably due to involuntary excisions of this redundant layer. Winter, Lejars, and Pasteau have each proposed to stitch the lax bladder together in folds separately from the treatment of the vaginal wall, from which Winter excises a longitudinal median flap. V. Arx has made a similar proposal, but unites it with what may be considered a modification of vaginal fixation of the uterus.

Thevariations of these operative methods will be most easily seen from the series of diagrams which I have prepared. In the interpretation of these diagrams it is important to note that if the muscle of the bladder wall be incapable of full contraction it will at first, at any rate, simply lie in wrinkles round the circumference of the less deep but still present dip of the cystocele.

In September 1897 I had occasion to operate for cystocele on a

patient whose history is of considerable gynecological interest. Mrs A., aged 52, had had six children and four miscarriages, these latter being all about the third month. Her deliveries were always spontaneous, the first five being attended by a midwife only. Since the first she has had some prolapse.

Menopause occurred at 45, and at 49 some ill-smelling irregular bloody discharge set in. The bladder symptoms misled a surgeon who was consulted to assume that the bladder was involved in malignant disease, and he declined to operate. The patient was then fortunately put under the care of Dr Barbour, who in September 1895 amputated the cervix for epithelioma. During the next year she suffered so much from pelvic pain that she desired further operation for the enlarged cystic ovaries which she was found to have. This was not, of course, a result of the previous operation. Her attendant and the surgeon who had been called in consultation resolved upon, and made all the arrangements for, total extirpation, but the night before the operation the surgeon telephoned to me that owing to an accident he would be unable to operate, and asked me to do so. Though the patient had previously had trouble from the cystocele, and, in particular, was unable to empty her bladder unless she leaned forward, I thought it better to perform a simple extirpation, which I did by ligature. This was in September 1896. The patient recovered well, and I may add that microscopical examination of the cervical stump showed no sign of recurrence of the epithelioma. Some months later the patient had a little bloody discharge, which I found to be due to a mass of granulation tissue round one of the ligatures on the left, and which stopped on the removal of this. At the same time she complained of discomfort, due to the cystocele, which had not been affected by the previous operations. In the beginning of September 1897 I made on the anterior vaginal wall a mesial incision, extending from the urethra to the fundus of the vagina, dissected on each side between the vagina and the bladder with the handle of the knife, stitched the loose bladder wall together in folds with chromic gut, and then shortened the anterior vaginal wall by bringing the two ends of my longitudinal incision together, so that it became transverse, and stitching it up in that position. This leaves a little redundant tissue at the sides of the vagina, which may be trimmed or not, according to the taste of the surgeon. Apart from this there is no excision of tissue in the operation. As the vulvar cleft was rather long I then carried the knife round the posterior part of the aperture, splitting as in Tait's operation. The result is, up to the present, completely satisfactory.

Among the other points of interest in the case we may note that the amputation of the cervix and afterwards the total removal of the uterus and its annexa did not cure the cystocele, though there was no doubt as to the efficient attachment of the vaginal wall to the broad ligament.