Medical press and circular
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Maaer Maser^nrfag H .iipwisr, rnf«»:T, J-H^ LAC^Jani- H«a:^ >» tW MrTikSLmmmm^ Uihnn A. rriLD.< ^-«w*.-Os: Mnrrl ISai.. sa ft J«kn « Wnnd»»i. nc Issar t»«»nc*e- I—R. C-F-krfmi . rf §*"* , ., H^xT^x.— ^'ts. MKTok Ijfei.^ sc Riisni ■ Oiajiilimi.sssi ^wW^-jw^-iS* f<f lirmw B«y. M-^ rf a as^ R.-^i:k&.— Jn. M4c-r-t 2JC4^ ja T^ Mad mot «f Ars^nrlL ILV-*" %;it^nnti^ N>e^N\. Av . ^w tv,- Kvsyvrt*. tV\m xV^N l^x^V^'^N)x>|^ M «W HOA.Jv-m ^^twv-K Ik l^i^iiial kt$$ md (Siivmlm. "SALUS POPULI SUPREMA LEX." k<= Vol. CXVIIL WEDNESDAY, APRIL 5, 1899. No. 14. i. ©rigtnd Communications. **■ — — — «THE TERM " CONSERVATIVE SURaEUY " ' \S IT HAS BEEN PROPOSED TO APPLY ir TO THE UTERUS AND ITS J^ APPENDAGES. ^ j^ By LAWSON TAIT, F.R.CS.Eng., Ac., A ^^Ate Fresidant of Masons College, and Piofeeaor of Gjnnoology. '•■ I WAS very mnch amused some months ago by B ^eXi article in the Nineteenth Century on AnsBsbhetics, ..«i which it was recommended to the laity that each ^J^e of us should " refuse resolutely to take chloroform tB.r-»r allow any member of our family to take it without ret obtaining a guarantee from the ansBsthetist that ^^e will administer it on an open cloth held at a given V^iBtance from the nose, and that the time taken to 'i-»«at U8 under shall not be less than eieht minutes." ''T^. was amused because the Nineteenth Century is ^^^»abli8hed in London, the yery hot-bed of new anns- X ^^^etics and new methods of administering them. I **''a8 amused beci^use h^re was Simpson, of 1851, ^jH^iAiuing back after nearly fifty years and his method er )ing forced back on the medical profession through Jf-^ lay journal ^an offence of the direst description, ^i^he offence was resented, of course, by a large k ^mber of medical journals in this country, on the ^^. mtinent, and in America, and, of course, the. :J-?^'eate8t amount of fun was to be had out of the '^^iticism. and opiKwition of our trans- Atlantic 1.^'^Mends. One of tne most prominent, and I think w«i»e best of the American medical weeklies had ._ ^ leading article on the subject in which the Vtf'T'ry dimcult task was fully accomplished of -=^1^, .mitting the need and justice of the outcry on ^^ ' 9 part of the patients as voiced by the Nineteenth ^^^^^^niury, " The fault in this country,'* says the article, M,-^ B ^^^ ^^^ most part limited to the administration of 9^^ ler, where the most inexcusable indifference to the < ^. tient's comfort is often demonstrated. The man *o gives the anesthetic in a hospital is regularly the _ ungest man on tlie staff, a fresh graduate with l>^3oretic teachings alone, or the example of another »^ 3m as his guide. The cone soaked with ether is •wded down over the patient*s face, and he makes a , irageous effort to stand it for a time. Yery soon, ^. wever, he struggles to save himself from what these. /**. ^ients afterwardis describe as a feeling of imminent i. ^ f ocation and death, and gains a breaui of fresh air 1^ •^* y in those cases when the orderly or orderlies are ^f. If I had time I could illustrate my purpose as well in the matter of new drugs, but I shall content myself with one short quotation concerning one of the newly passing foibles, " Thyroid " and its use in bleeding fibroids. In the Medical Nevoe (Phil.) p. 17, Moseley reports " That while some natients can take comparatively large doses of thyroia with impunity, others are injuriously affected by small amounts " and having established this extraordinary conclusion con- cerning our cherished sweet-bread, he tells us that they have a marked influence in bleeding fibroids, in checking the excessive loss of blood, and in some cases in diminishing the size of the growth. ^ His observations were extended over five cases, and is an example of the sort of thing which almost renders our desire to see new drugs kept out of the market by Act of Parliament till they had passed through mill of judicious and stipendary investigation. The fault of this logical deficiency is not, of course, confined to affairs medical, for we find the jzeneral affairs of the whole nation ruled, say at a General Election, by the words and votes of the floatingresiduum of voters in the least important, and generally there- fore the most incompetent electoral country, and we seem now to be on the threshold of a vast upheaval within the serene demense of our National Church, the result of a ruthless spirit of innovation and desire for new methods and new manners, not even a revival of the good old things so faithfully followed by our ancestors for over a ^ousand years. But in mattera medical we ousht to do better than that, particularly is it possible in matters of surgery when we have proof of results not tangible in the sister art of medicine, save within very limited lines. For the last forty years, I think, hardly an inaugural address desding with the generalities of the advances of surgery has omitted reference to the history of ovariotomy as one of its crowning glories. But I do not accept the story in that way at all. I think the whole thing discreditable, and for one reason only, even if no others were available, that whereas Nathan Smith penetrated the secret to the very depth, and published it in 1827, his great dis- covery was pushed aside by " new methods, ' and the great advantage of it was withheld from suffering humanity for more than half a century. Surgical 342 The Mbdical Press. ORIGINAL COMMUNICATIONS. April 5, 1899. historians, writing towards the end of the coming century, will not look on this as a brilliant record. Arrived at the year 1878 we put the remoTals of ovarian tumours down with a mortality of 5 per cent., and then paused to look round. The start of abdo- minal surgery from this point was made when I showed that 100 consecutive exploratory incisions could be done with a hardly appreciable mortality, and then I formulated and established the law that when conditions in the abdomen threatened life or made it unbearable, we were justified in opening the abdomen to discover the site and nature of the disease. Out of this, as a matter of course, arose one by one and rapidly, as my records show, all the modem and fully accepted operations for gall- stone, &c., which now nil large textbooks. Among these records fully numerous operations on the uterus and its ap^ndages, most of which have become classic, and will remain so, unless upset for a time by men merely restless and new methods wholly unnecessary. It is needless to say that in this loner battle, going over now a period, so far as I am concerned, of more than thirty years, I have not, I did not consider it necessary, and it certainly would not have been advis- able to make public every step in the process. Mis- takes were made, methods employed were found to be faultj^ and imsuccessful, and nothing would have been ^ined by dilating upon them or even di-awing attention to them. Just as I started, Dieulaioy had introduced his aspirator — an instrument in the device of which he had been anticipated by Bowditch and Protheroe Smith ; indeed, by many others, until we get back to the Roman surgery of Pomi)eii; and Maisonneuve had fought the battle of the drainage tube. The pelvis did not escape either of those pro- ceedings, and they were fully employed. Between 1871 and 1878 my carriage bag always had an aspirator, but for at least twelve years I have not used it. With it I carried a number of ingenious devices for making openings in the vagina, and get'- ting drainage tul^ into something, never knowing exactly what, sometimes curing, but more often fail- ing to do real permanent good. But as it dawned on me that the peritoneum had no real terrors if respect- fully treated, I found that it was better to ascertain accurately what was needed by careful ante-mortem examination, rather than make nap-hazard shots from below, and after a series of trials came my paper on "Treatment of Pelvic Suppuiution by Abdominal Sutures," which revolutionised thepracticeof pelvic sur- gery all over the world. Not only so, but it cleared up the pathology of the pelvis and put a stop to the eternal and ignorant wrangling about perimetritis and para- metritis which had gone on for nearly thirty years. Of this, of course, the present generation has no need to know anything, and traly it does not as may be seen from the contents of a paper by Dr. Noble in the_ Philadelphia Medical Journal of July last, entitled the "Conservative Treatment of Pelvic Suppuration of Puerperal Origin." He begins, as is not unusual with such people, by references to, and conclusions derived, according to his interpretation from my own writings, and succeeds, as is equally usual, in completely distorting my teaching. He poes so far as to quote my own words almost verbatim, and then commenting on them in this sentence: *' These elementary pathological facts are now gene- rally recognised, sJtnough some years ago they wei-e sharply controverted, more especially by the disciples of Tait." According to his contention the truth was first established by the publication of four cases of " True Pelvic Abscess," by Dr. Chai'les P. Noble, in August, 1891, before English gynaecology was bom. He gives his idea of the differential diagnosis between pelvic cellulitis and pus-tubes or intraperitoneal abscess (re- garding these two as the same) and misses the funda- mental parts of my teaching on this subject first published ten year before his paper of 1891, that there are two varieties of intraligamentous suppura- tion, one in the outer half of the layers, which he has recognised and another in the inner half, quite as easy to recognise, found in the left side, having a sign which there is no mistaking, and tJ^en he goes on to describe such a case which he did not diagnose, but mistook when he need not have done ; for which he opened the abdomen correctly enough but did not Sroceed to complete the operation as he should have one. Subsequently he attacked the abscess from the vagina, as he might have done at first if he had been at all familiar with my teaching, or had been one of those disciples upon whom he pours the vials of his contempt. It is not for such blundering as this that I now draw attention to Dr. Noble, but because he is an example, though a very bad one, of the clouding school of abdominal surgery. Of these most exist in Germany, and the movement seems to be reaching England, and whilst I would be the last, by my utmost endeavour to deride change merely bcK^tuse it was new, I deprecate change when introduced for no other purpose than its novelty when its novelty leads us on the track of the investigation of facts already quite familiar to us, but concerning which we have not arrived at final conclusions. That suppuration in the pelvis should not be made the subject of surgical rule diffei*ent from that affect- ing other regions nad to be my ciy for neai'ly ten years, or as I put it that a surgical writ shall run in the pelvis as it does in the knee joint, and I carried my point against all comers. The chief opposition was, of course, from the uterine tinkerers vmo were overwhelmed by seeing their consulting- rooms emptied of the helpless sufferers, who came day after day for a glycerine plug, or month after month for new pessaries. They raised the cry of "spaying women, "emasculation of women" (astrange mixture of etymological definition), and even went so far as to say that we surgeons operated for the fees at the end of the cases. This cry ceased, however, when it was shown that the operating table of the surgeon was much cheaper in the long run than the consulting-room of the pessary -monger ; and, per- sonally, I am now in a position to say that I should have been a much richer man if I had never seen any of these cases, for as I had to give bed room to the great bulk of them I was out of pocket, and largely, by the whole transaction. The strange thing is that the cry is still kept up by beardless boys who tell us what they can have no personal knowledge of, whether it be trae or not, " that the reckless way in which, in the past, gynfiecologists have removed uterine appendages without adequate justification, is the opprobrium of our art." In the past I was in the habit of checking such nonsense by saying that such iniormers either knew of such proceeding or they did not. If they did not they were liars. If they did it was their business to give such infor- mation as would put the offenders on their trial for felony; and failing to give such in- formation, they were themselves accessories after the fact, and so liable to indictment. I went so far as to serve notice on a well-known L')ndon physi- cian who was guilty of this that I should prosecute him if he did it again, and since that time he has been quiet. Another parrot crv still being repeated was that most operations made the patients absolutely sterile. But then they were so rendered by the disease before our operation. Disease of the knee-joint makes a man lame, amputation of the limb confirms the lame- ness, and the best case of a " conservative " result of an excised knee-joint I have ever seen did not get about free from lameness^ in fact, I think the lame- April 5, 1899. ORIGINAL COMMUNICATIONS. The Medical Press. 343 neas was worse than it would have been with a first- class artificial limb. Double pyosalpinx reuders a woman absolutely sterile. Nay more, as a rule she cannot have intercourse. Removal of the appendages does neither increase nor decrease the sterility, and it often removes completely and permanently a grave interference with marital life. Opening and draining a double pyosalpinx may do as much, but that it will cure sterility— pigs may fly, but I have yet to see a flight of them. Foiled in all such arguments, our critics have found another platform, and I take again Dr. Noble us my example ; he is as good for my pui*pose as any other of the score from wnich I might select, they are all as deficient in logical acumen as he is, they put their cases quite as badly, and they ai*e all as open to the same suspicion of quackery, there is no use mincing terms or using plausible phrases to hide the pill which must be swallowed. It is forgotten, or, at least, seldom acknowledged by gynaecologists, that the adoption of measures does not rest with them, but with the mess of the profes- sion, men in general practice, upon whom rests the responsibility of advising their patients for what seems to be the best. It is perfectly true that the profession will be and must always be governed by the weight of a great name, so that I had a vei-y hard fight after the International Congress at Lond« n in 1881, when Spencer Wells said that he had only once seen such a case as I described in his life. I answered by publishing a long series of my own cases which had been previously under his own care. This cost me his personal friendship, a result I regi'etted as long as he lived, and still regi*et, but I won the battle. I silenced Mathews Duncan by compelling him, almost by threats, to come with me to a neigh- bouring house in London, to see me remove two huge bags of pus in a patient under the care of Dr. Chap- man Grngg, which had quite recently been under that of Dr. Duncan. I met the personal difficulty with another case in London, when six distinguished prac- titioners met me and assui-ed themselves that I had exaggerated my diagnosis, that there was nothing much the matter, by taking Keith to London, making him oi)erate, and then submitting to them his written report of the operation. Now another battle rages, and I shall halt no more in it than I did in the former, though my fighting powers are no longer as shai-p as they were, nor my taste for wai-fare as great. We ai*e told once more, though the contrary has been proved over and over again, that in a considerable majority of cases there is diminution or total abolition of the sexual ins incts This is not true, in fact it is absolutely untrue. It is a subject on which, of course, the publication of facts is extremely difficult, either one way or the other. But my own facts establish the conclusion that the cases of abolition ai*e extremely few, not more than 5 per cent., but they get greatly tattled about by loose-minded women and by men whose sense of honour and proper reticence Jn matters concerning their wives is strangely defective. On the other hand, the instances of restitution of marital relations, which had been entirely destroyed by disease and i-estored by the operation required are at least 60 per cent, of all the cas' s. In a few instances the mysteri- ous fact remains that women who before operation had little or no sexual appetite have it developed after treatment to an extent which becomes inconvenient. I removed the appendages, twelve years ago, of a lady noted in public estimation to the highest degree. She had had one child, and her husband had never shown any sexual response whatever, till after the operation, when it became oppressive to him and he died. She lived as a widow for three years, applying to me from time to time for arrest of this symptom, until it got so bad that I advised removal of the uterus, and this I carried out, not only without benefit, but rather with an increase of the trouble. She gi'eatly objected to the idea of a second man-iage. and bad always resented my advice and the advice of her parents, in that direction ; but at last, and entirely to save her conscience from the reproach of wi'ong, she man-ied again, and a few months ago the fact was announced in eveiy paper in Europe. It ip, therefore, perfectly useless to say that in a few cases the sexual tastes are destroyed What kind of an argument it is, I shall consider afterwards, but mean- time I go on discussing it on what merits it has, to prove the argument, and put in semi -decent form, the word "conservative" is introduced, a piece of rampant deceit and chicanery. Dr. Noble has two papers that I have already quoted, and another on "The Conservative Ti-eat- ment of Fibroid Tumours by Myomectomy.'* The paper is hardly worth i-eferring to, reekinjf as it does of all the work of Simpson, Penn, Marion Sims and others of less note, who brought myomec- tomy as far as it would go, moi*e than a quai'ter of a centuiy ago, and there it was left by all of us. But the paper is a useful warning of a common logical error, the use of the indistributed middle term, or in plain words, the use of a term devoid of definition and employed with various and iri'econcileable mean- ings in the coui*se of the same argument. Thus in the one paper he alludes to the preservation of parts of ovaries diseased and adherent, and bits of occluded tubes as " conservative surgery," whilst in the other the same thing means removal of the whole uterus, the absurdly so-called pan-hysterectomy, revived from the moral of Pean's " Morcellement," and hashed up as something new. The term " conservative surgery " was introduced by Ferguson in the late " fifties," and was the cause of a hot feud between him and the more logi- cally-minded Syme. But, as Ferguson puts it, it was fair enough, and became afterwards limited almost entirely to its best example, that of excision of the knee-joint. Ferguson was a prince of opera- ting surgeons, and none who can remember his magnificent figure and wondrous featui-es, unmoved as he made the knife fly, as things in the old days, with a i*apidity which few eyes could adequately follow, can easily believed that such an operation as excision of the knee-joint would meet with his strong ap- proval. In theory it was all right. Consei've the lower limb ; it must always be better than an arti- ficial one. But, alas ! though his pupils carried the banner of this consei^atism far and wide, it did not keep its promise, and on Syme's face there was to be seen, and then only, that strange little smile of triumph as he lopped off a " consei-ved leg." " Con- sei-ve the parts," was his only comment, and the operation took a back seat, and occupies now a very restricted area. Fancy my astonishment, therefoi-e, when I read in the second paragraph of Dr. Noble's second paper this sentence : — " In the recent past true conservatism — that is, the welfare of the patient— has required," &c. This is another theory, and completely confirms my lifelong belief in politics that the advanced Libera,! is the truest Conservative. Certainly, with this definition, we all are, all hope to be, all must strive to be, truly conservative, fiut why should Dr. Noble pretend to be that and exclude others equally earnest in their efforts, and why should he use for himself a phrase which reminds one of the story of the two men who went up into the temple to pray. If he claims exclusively to be a Conservative, then I say he is also a Pharisee, as are also those who use this phrase as he uses it. Foi what is its real intention, other than to declare that he has, and uses, a method of operating which conserves the sexual instinct, as he plainly does in 0 344 The Medical P«»8. ORIGINAL COMMUNICATIONS. Apbil 5, 1899. his oonclnding sentence, together with a hope that the sterility may not be complete, nor completed. In all such cases the probabilitj of the restoration of fertility is so minnte in these cases that it is wholly unworthy of discussion or acceptance, save in some very nnnsnal set of conditions, as when the succession to a crown is concerned, and then I, for one, would not accept the Tesponsibility. Crowned persons are a rule unto themselves, and I never cared to share in the government. For the general public the terrible facts of over population, and the fact that of all children bom one half die before they are five years was enough to dismiss such a bagatelle ^m my mind. When such patients have been married for years and remained sterile, it may be assumed that the sterility is complete, and when the mischief has resulted after the birth of one or more children the patients them- selves usually dismiss the argument with impatience. The second question, I find, is now being directed towards the apprehension of the husband more than to his partner, and here is where the quackeiy comes in. In a recent case where I was concerned, and where it was strongly wished that the case should be crot out of my hands, it was urged that where on the one hand I would geld his wife and make her like a log of wood, another surgeon who was strongly recommended as of the Conservative school, would leave her active, the husband promptly replied that the case was that of hia wife not tluit of a strumpet, and the efforts failed. I confess that this is how I should look at the question* espedally in the light of the published experience of Laudson and others who are practically the leaders of this new movement, aided oy what is probably of far more importance, my own wish and longer established experience. The wholething is based on a misconception of the function of the ovaries, which have no more to do with the sexual appetite than the kidneys. Nor have the Fallopian tubes, nor the nteros; as it is maintained, and as I have proved, sometimes increased by the complete absence of all five. The two most erotic women I have ever come across were two sisters in whom not the slightest trace of uterus or ovaries could be determined, and in one of them I had positive knowledge of the fact of that complete absence when I operated upon her for tuberculous peritonitis. They were in good social position, were not insane, ^et no xind of inducement, social, parental or restrictive could prevail upon these women to refrain from inspiring every man with whom they could get an opportonitjr to have inter- course with them, and fauie de mieua, they were confirmed Sapphists. Finally is it an argument, even if it could be sus- tained, which we, as sui^^ns, can give weight to? I do not often quote Scripture, but I think that a great clinical lesson on this subject may be got in the 6th Chapter of Matthew, when at the 29th verse we are told that " if thy right eye offend thee, pluck it out, and cast it from thee. And if thy right hand offend thee, cut it off and cast it from thee ; for it is profitable for thee that one of thy members should perish, and not that thy whole body should be " in- fected with bacilli, a lesson which is still more em- phatically loddised as pertinent to the present man by my national poet in words which read— "Geld you, quo he, and what for no ? If that your right hand, leg or toe. Should ever prove your spiritual foe Ton should remember To cut it off—and what for no Your dearest member ? " We are not called upon to play the part of moralists, but this we are called upon to do, to adopt as our guiding principle to do the best we can for our patients and for our art, and then for ourselves. I ( have always held in detestation any surreal pro- ceeding which brings with it a risk that the patient shall have to submit to a second operation. I have, therefore, always steadily opposed all operatioiis for malignant disease undoubtedly pronounoed. Xothing brings so much discredit on our art, nothing so much discredits the individual practitioner. Not only so, but second operations in ttie pelvis are always more difficult than the first, and according to all pnblished facts far more fatal than operations completed at first. So much is this the case that I lu&ve becoi driven by the stem logic of facts to advise a more complete operation than ever in certain kinds of disease of the appendages. I refer to thoee in very young women, wnen the mischief has arisen appa- rently at, or even before, the molimenal period. 1 am certain that of all the cases of suffering from the results of chronic inflammation of the uterine appen- dages they suffer the most, their sufferings oegin sooonest, and they are the most difficult to relieve. Among them I have had my worst and most bitter disappointments of relief expected, and have had discredit in this class of cases. About eight years ago I removed the ntems in one young lady, from whom I had removed the appendages thirteen years before, not only with a failure as a result, but I had made her worse ; she had taken to drinking, been placed in an a^lum, and had altogether gone to the bad. I removed her uterus and cured ner promptly and, alter neuij eight years' success, I think I may say permanentlj. I followed this case up, and hunted up a number of my Imown failures, removed the uterus in eleven mofe cases, and have succeeded in all, and I am now hunting up some more. This is conservative surgery. As a cross to it, I was called to London a few weekaago to a consultation with one of the eminent Yf&Srva^ doctors in a case of this kind. I advised a complete removal, but the jHitient was conservative in the other way. She was sure that it was all in the right ovary, and the rip^ht ovary alone was to be removed. After much argumg and a full understanding in black and white, I consented to divide the operation, and removed the right ovary and tube. We shall see. I do not usually accept a fettered condition such as this, but my colleague is a man for whom I have a great reverence, and he took the responsibility; tiierefore, I acquiesced. M^ belief is consummate in such radical surgery as will preserve my patients from further risk, and I do not regard the *' sexual appetite argument " as worthy of any but the brothel-ieeper, with whom it would, of course, have great weight. Concerning the surgical difficulties and dangers of the so-called " conservative " operation, my old experience of the early " seventies " are confirmed in a paper by Mr. Stanmore Bishop, in the Medicaid Pbbss ahi) CiRCULAB for November 23rd, 1898, and I need do no more than refer to that common-sense contribution to the subject. ADENOMA UNIVERSALE OP THE ENDOMETEIUM INFILTRATING THE MYOMETRIUM IN A VIRGIN, FORMING AN ABDOMINAL TUMOUR —PAN-HYSTERECTOMY— RECOVERY. By JAMES OLIVER, M.D., F.R.S.Ed., F.L.S.. Physician to the Hospital for Women. IiODdon. The patient who is the subject of this annotation IB a virgin. She came under my care in the first instance in November, 1895, and was then only 34 J ears of age. Menstruation was not established until she was 18, and during the four sucoeeding April 5, 1899. ORIGINAL COMMUNICATIONS. The Medical Pbess. 345 yeai-s, i.e., until the patient was 22, the menstrual dis- charge appears to have been modei*ate in amount. It thereafter became more profuse, and during the kst ten yeai*s it has on several occasions (about twelve in aJl) been extremely abundant. The menstrual period preceding her visit to me had been a profuse one and bad lasted six weeks and she was very anaemic in consequence. She had never experienced pain in association with menstiniation. The followmg are the physical signs which were noted in November, 1895. The hypogastrium is occupied hj a small globular and regulai* swelling which arises from tlie pelvis and extends to two and a half inches a.bove the pubes. It is uniformly firm in consistence. The hymen is intact. Hanging from the cervix uteri are two mucous polypi of about the size of small hazel nuts. The hypogastric tumour is the uterus enlarged. On this occasion I merely removed the polypi. The patient thereafter enjoyed fairly good health, losing occasionally rather freely until October, 1897, when ehe consulted me because she had been losing con- tinuously for eieht weeks. The physical signs then noted were the following. The hypogastric tumour is slightly larger than it was in November, 1895, and its consistence is hard. Hanging from the cervix uteri is a mucous polyi^us of about the size of a large Ihazel nut. I now advised not only that the polypus should be removed, but that the uterus should be dilated and explored. Bj means of a somewhat sharp ^poon I removed on this occasion from the cavity of the uterus nearly a teacupf ul of material which when -examined under the microscope presented the appear- ance of a simple adenoma. The size of the uterus was thus so gi'eatly reduced that it could not be detected abdominally. About two months after this operation patient began to complain of a watery dis- charge from the vagina, and in consequence of this troublesome symptom which necessitated in May, 1898, the use of three and four diapers a day, she again came under my care. I then found that the hypogastric tumour had reappeared, and that the uterus was of about the same size as it was prior to the last operation. Before submit- ting the patient to hysterectomy I decided to curette freely the endometrium once more, and this I did, removing again about a teacupful of adenoid mate- rial. The watery discharge reappeared soon after this operation, and as it became more and more dis- tressing the patient sought my advice again in October after an interval of only five months. The hypogastric tumour had now ro-appeared, and was as big as it had ever been. I now advised, and per- formed, the operation of pan-hysterectomy, i-emov- ing the whole uterus by the abdominal way. The broad ligament on each side was secured by three ligatures of silk. The lower ligature only on each side, namely, that including the uterine ai-tery was pulled down into the vaginal canal and was left long; the other ligatures were cut short. The uterus weighed twenty-eight ounces, and was equal in size to that containing a tnree months' foetus. On opening the organ anteriorly by a triangular flap, reflected from the cervix towards the fundus, the endometrium (corporeal and ceiTical) showed myi-iads of smooth prominences varying in size from that of a split pea to a walnut. Most of these new growths wei'e practically sessile but a few were polypoid. The muscular tissue of the organ generally was much thickened, and to the naked eye even it was apparent that the new growth had infiltrated exten- sively this stnicture. Sections of the smooth pro- minences and of the underlying muscular tissue dis- play under the microscope the appearances charac- teristic of adenomata, namely, tubes lined with cylindrical epithelium. On account of the manner in which the neoplasm invades the muscular tissue of the organ, pathologists will affirm that the disease is malignant. In attempt- ing, however, to settle this important question we cannot accept the tenete of the pathologist alone and discard altogether the clinical facte. In November, 1895, when the patient in the first instance came under my care, the enlarged uterus formed a hypogastric tumour which was then almost, if not quite as larse as it ever was on any subsequent occasion. At this period the muscular tissue was ah-eady extensively infiltrated by the new growth, as the consistence of the uterine tumour was on this occa- sion as firm as it was at the time the operation of pan-hysterectomy was performed. It is impossible for us to surmise how long the hypogastric tumour may have existed before the patient came under my care; as, however, it increased but little in size between November, 1895, and October, 1897— a period of nearly two years — it is more than probable that it had been in existence, and had maintained a more or less stetionarr stete, for several years. It is quite evident that the disease must have progressed slowly, as the prolonged and excessive hssmorrhage, which occurred when the patient was as yet only 24 years of age, was undoubtedly due to the neoplasm having already attacked the endometrium. With a clinic^ history, such as we have here presented, one would hesitete to characterise the dise^we as malignant. In the case which I have just recorded the specimen is an unique one, and the patient is^ prooablj the youngest that has ever been reported with adenoma- tous disease of the endometrium of so extensive a character. It is an interesting fact thatthe lining of the comua uteri in homed ruminante shows smooth prominences devoid, however, of utricular pores. They are called "caruncles" or '* cotyledonal processes, and they increase in number with the size of the species. In the giraffe as many as eighty of these processes may be detected. In the bison they are softer, thicker, and more obtuse than in the giraffe, and they are lees regularly disposed than in the latter animal. They are also very pronounced in the uterine comua of the goat and sheep. When gestation occurs in animals possessing these cotyledonal processes their surfaces which previously were smooth become some- what papillose, and into the depressions thus formed the chorionic villi are thrust, and are there retained until parturition takes place. At birth the foetal villi are withdrawn from the maternal processes, and soon afterwards the surfaces of the latter become again smooth. Occasionally the entire caruncle is shed after parturition, and when this happens it is never reproduced. Prof. Mettam, of the Royal Veterinary College, Edinburgh, informs me that the cotyledons in homed ruminante are upheavals of the mucous, membrane, contein a good deal of corium and are very vascular. They are covered by the ordinary epithelelium. Now, the disease which I have just described as occunnng in the human female is an overgrowth of the lining membrane of the uterus, and we may perhaps be justified in believing that it is the revela- tion of a " reversion to type " tendency. The magistrates at St. Albans have decided that bread is meat. A man had been prosecuted under the Poisonous Meat Act for having thrown some poisoned bi*ead to his neighbom**s hens. He was accordingly convicted. 346 Tek Hidical f rkss. ORIGINAL COMMUNICATIONS. Afbii. 5, 1899 ON THE PEEVALENCE OF TUBERCU- LOSIS IN IRELAND AND THE MEASUEES NEOESSARY FOR ITS PREVENTION, (a) By THOMAS W. GBIMSHAW. President of the Medical Section of the Eojal Academy of Medicine of Ireland, Vice-President of the Statistical Soc. of Ire. &c. After some introductory remarks the author pro- ceeded to analyse the principal statistics of tuber- culosis, and especially ot phthisis mortility in Ireland, the analysis being mainly founded on a table of the deaths from tuberculosis in children under 5 yeare of age, and of phthisis at the various ages of active life from 15 to 45, in town and country districts. The result of this analysis showed the following remark- able results : — During the three years dealt with in the table, 1895, 1896 and 1897, the average annual death-rate from all causes for Ireland was 17 3 per 1,000 ; the rate for the town districts (that is towns with a population of 10,000, and upwards) was 25 4, and for the rest of Ii-eland 15*2. For Ireland the death-rate from all tuberculous diseases, exclusive of phthisis, was 07 per 1,000 for country districts 0 4, for town districts 1*5 or nearly four times the lattei rate. For consumption alone the rates were for Ireland 2'0, for counti-y districts 1*7, for town districts 3'3, or nearly double the usual rate. Taking all forms of tuberculous disease, the rate for Ireland was 2*7— for country districts the rate was 21, for town districts 48, or more than doul)le. In the dis ricts with six large towns the rates were — from all causes 262, as compared with 15'2 in country districts ; from tuberculosis other than phthisis 1'6, against 04, or exactly four times the rate ; for phthisis 3*5, against 1*7, or slightly more than double the rate ; and for all forms of tubercu- losis combined 51 against 21, or considerably more than double as comipared with counti'y districts. It will be observed that by far the most important cause of death dealt with in the foregoing remarks is phthisis. This disease alone caused 11*7 per cent, of all the deaths in Ireland during the period under consideration, the percentage for the districts with towns of over 20, 000 population being 13*3, for those with towns of 10,000 inhabitants andupwards 132, or slightly less, as compared with 111 per cent, for the rest of Ireland. These figures point to a conclusion which to many will be somewhat unexpected, namely, that the propoi-tion of deathsf rem consumption to total deaths is very high even in the countiy districts of Ireland. by the report of the British Medical Associatio. that the tendency to the disease of tubercule® among young children in England and 'Wales is m. so marked as it is in the case of phthisis. Ti" forms of tuberculosis which kill young children &r tabes mesenterica, tuberculous meningitis, and fonL* of tubercle other than pulmonary consumption, Wr find that in Ireland the death i-ate of children raidf: 5 years of age from these forms cf tuberculosis wa? 3'5 per 1,000 living at th's age period. In the dis- tricts with towns of 10,000 and upwards the rate ira> 8*7 as compared with 20 in countiy districts, or mar- than four times the rate. In the six large toivns taks collectively it rises to 9*4. in Dublin it reaches II * and in Belfast 100. In the other it is considerate^ below the 10,000 town's rate, the rate for LimenVl being only 33, or less than the average rate fcr Ireland. The very high proportion of deaths in Dubfe and Belfast is veiy remarkable and very serious. If we now pass to the more active periods of life, ar. 