4. Pain, at first absent; later, becoming paroxysmal, and subsequently continuous, and relieved only by the regular administration of anodynes; in fact, just the character of the pain of malignant disease. 5. Still further, the steady advance of the disease, the aggravation of the symptoms, loss of flesh and cachectic appearance, which developed in these patients, are all in favour of a malignant neoplasm. 6. A remarkable similarity in the physical signs of the pelvis, the tumour being of the same consistence and in the same position primarily in both cases, though it is true in Case V. it subsequently became abdominal; and furthermore, its vaginal aspect came to have the nodulated feel of a malignant new growth. At first the contents of the tumours are fluid to some extent, for they can be withdrawn by aspiration; but subsequently they become quite solid, and the only effect of aspiration is to create smart hæmorrhage. The fluidity of the tumour at an early date was most probably owing to the fact that a portion of it was cystic-in fact, a cysto-sarcoma-and that hæmorrhage had occurred from the lining of the cyst wall. One might readily understand the occurrence of hæmorrhage in these cases, for during the act of defecation (especially in the existence of obstinate constipation, as in both these patients), the pressure of the bowel contents from behind, and the increased intra-abdominal force from above, would be quite sufficient to account for the rupture of badly supported vessels at their weakest points, which, even if only capillary oozing resulted, would in time suffice to fill a cavity such as I venture to think existed. Or, yet again, the fluid contents may have simply been the result of considerable blood extravasation into the midst of a solid tumour, which had a more loosely constructed centre. Or, it is possible, though quite improbable, that there was a cyst formation primarily, and a secondary sarcomatous growth around it, which, after invading the cyst wall, would allow capillary oozing to take place into the previous cystic contents for the mechanical reasons just mentioned. The subsequent solidity was simply the result of the removal of the fluid contents, collapse of the walls around, and possibly some increased cell proliferation from the irritant action of the aspiratory needle. These are, of course, mere theories-to my mind, plausible-though quite subservient to facts. The fluidity of the tumour does not prevent its being sarcomatous, for in the only case on record, we know there was an abundance of fluid contents. The differential diagnosis requires to be made from two lesions -hæmatoma and carcinoma. Cases of hæmatoma in the rectovaginal septum are very rare, though (1), the displacement of organs produced in Case V., the uterus being raised upwards into the right inguinal region; (2), the hard feeling of the tumour; and (3), the pressure symptoms resulting-dysuria, retention of urine, and constipation-were all in favour of this view. But in Case V. the patient had passed the menopause, and the prolonged subsequent history of both cases makes this view quite untenable, as absorption of the swelling or suppuration in it would have occurred. These cases were not carcinomatous in their nature for two reasons-(1), there was never any evidence of ulceration in these tumours; and (2), there was a total absence of secondary deposits. Both of these changes would have occurred if the lesion had been cancerous. The treatment most advisable would appear undoubtedly to be aspiration of the tumour per vaginam (using every antiseptic precaution), as this accomplishes all that can be done by any operative procedure; for although there is very little danger following the abdominal section, its adoption cannot furnish us with any further reduction of the tumour. The plan followed by Dr Mundé in his case of making an opening into the tumour through the vagina and scraping out its interior did not have a favourable termination, probably because a septic condition arose before the operation, which was quite sufficient to justify its adoption. The relief thus given by any operative procedure is not very encouraging; and later on, when the symptoms become aggravated, they must be treated as in malignant disease generally, by anodynes. The obstinate constipation was best met by the constant use of cascara sagrada in gradually increasing doses. V. ON THE TREATMENT OF LABOUR DELAYED BY OBSTRUCTION AT THE PELVIC BRIM. By SAMUEL SLOAN, M.D., F.F.P.S.G., Obstetric Physician to, and Lecturer on Clinical Obstetrics at the Maternity Hospital, Glasgow; Vice-President of the Glasgow Obstetrical and Gynecological Society. (Read before the Society, 11th November 1885.) As a preliminary to my remarks on the treatment of labour delayed by obstruction at the pelvic brim, it will be necessary to define the nature of this obstruction. It must be remembered that an abnormally large head may be obstructed at a normal brim; but the treatment of such a case will not be materially different from that for a case of labour where an average head is detained at a contracted brim. Not to complicate the question unnecessarily, I shall also omit all mention of cases where the brim is contracted, only or mainly, in the transverse diameter. Of such cases I have met with several examples. They are not numerous, however, and I shall not consider them in this paper. Obstruction in the conjugate diameter, on the other hand, is a most common cause of delay in labour; and, to the treatment of delayed labour from this cause, so much attention has been directed by the ablest obstetricians of the day, that I feel almost as if I might justly be blamed for "rushing in" where I ought to "fear to tread." But as I have, in the course of my hospital and other practice, seen many cases of this nature, and as the subject seems to me to require further elucidation, I feel that by bringing this question before you early in our first session, I shall be giving our young Society an early opportunity of showing that we can contribute something to the advance of Obstetric Science. Almost every Fellow of this Society must have some experience of cases of delay of the head at the pelvic brim, and I lay my views before you, not dogmatically for your acceptance, but tentatively for your criticism, though naturally with the hope that my propositions may meet with your approval. I have mentioned that I wish to confine myself to the discussion of cases where the obstruction is in the conjugate diameter. Now in pelves with this deformity we may have the transverse diameter proportionally diminished, thus giving what is called a generally contracted pelvis. We may also have what is called the flat pelvis, this being either a normal pelvis flattened, or a generally contracted pelvis flattened. Arranging these, say, in the order of their interest, we have-first, the simple flat pelvis; second, the generally contracted pelvis; and third, the generally contracted flat pelvis. I have specimens of these three deformities here, and also a normal pelvis to compare them with. Clinically, these agree in the fact that the sacrum, projecting forwards at the brim, is generally more or less within reach of the examining finger; whereas in the normal pelvis the finger cannot possibly reach this projection. The consequent diminution of the conjugate diameter varies from a slight and clinically unimportant decrease to a contraction which may be called absolute. In the very slight degrees of contraction there will be no delay which cannot be overcome by the ordinary powers; whereas in the absolute contraction there will be such an obstruction as to prevent absolutely, under any circumstances, the passage per vias naturales of a viable child. Having thus narrowed our discussion to these limits, we necessarily eliminate on the one side, " patience," and on the other, Cæsarean section and allied operations, from the present inquiry. I have just stated that this kind of contraction can be diagnosed by finding that the promontory of the sacrum is within reach of the examining finger, where the deformity is so decided as to come within the above limits. But how are we to ascertain to which of the three kinds of contraction a given case belongs? This is easily done, though not with the most desirable accuracy, by taking certain external measurements of the false pelvis, the only instrument required being an ordinary pair of callipers. We find that, in the normal pelvis, the distance between the anterior superior spines of the ilia is 10 inches; that between the crests at their broadest part being 11 inches. In a generally contracted pelvis these figures will be both diminished, and nearly equally so, giving us, say, 9 and 10 inches respectively. When, however, a pelvis becomes flattened from before backwards, narrowing the conjugate diameter only, as in the rickety pelvis, the relative distances of these points become altered, the crests being approximated whilst the distance between the spines is increased. This will obviously hold in flattening of both the normal and the generally contracted pelvis. I find, it may be worth mentioning, that in the living subject these measurements generally appear under rather than over the true ones. A correct estimate of the internal conjugate is more desirable than attainable, for internal pelvimeters are not of much service. But a fairly accurate estimate of this diameter may be formed by measuring with the index finger of either hand the distance between the sacral promontory and the lower end of the symphysis pubis, and deducting from this lower, or diagonal conjugate, as it is called, about three quarters of an inch. The exact nature of pelvis we are dealing with is important when we consider the mechanism of labour in such cases; for the head, as we shall see, disposes itself, as a rule, differently at the brim in the flat from what it does in the generally contracted pelvis. We know that in normal labours the head at the brim is found, as soon as labour pains have begun to tell on it, more or less flexed, the sagittal suture being in one of the oblique diameters and in the axis of the brim. This may still obtain in the generally contracted pelvis. In the flat pelvis, however, the head lies in an extended position; and, if we reflect that, when in the transverse diameter, before flexion can take place, the parietal protuberances must have cleared the brim, we shall see that no other position is possible. But besides this, you will find on placing a foetal head over the brim of such a pelvis that the broadest part of the head (the biparietal diameter) is placed to one side of the promontory-where alone, in fact, it can find room which seems almost made for it. In moderate degrees of this deformity, again, the vertex of the head will be considerably below the plane of the brim; but in very severe contraction the vertex will be more nearly in the plane of the brim. The head in the flat pelvis, again, whilst having its antero-posterior diameter in the transverse diameter of the pelvis, will have its sagittal suture lying nearer to the sacrum, however, than to the pubes. A few words here as to certain diameters of the head, and the relations of these diameters to the antero-posterior diameter of the flat pelvis, will not be inappropriate, since I find, in the writings of otherwise precise men, so much laxity in this matter, that I can only conclude either that they are not very clear on the point themselves, or that having a vague way of putting what is clear to them, it is often impossible for their readers to understand what they mean to teach. We have two transverse diameters of the head quite distinct from each other. One of these is the coronal-the greatest dis EDINBURGH MED. JOURN., VOL. XXXI.-NO. VII. 4 L tance between the two sides of the coronal suture. I prefer to call it the coronal, and not the bitemporal, the name this diameter usually receives, for when thus named it is apt, I find, to be confused with the bimastoid, with which it has really nothing whatever to do. The other of these transverse diameters is the biparietal-the distance between the two parietal protuberances. Now these diameters indicate the greatest breadths of the cranium at different portions of it, and they are about 1 inch apart. The measurements of these diameters at the base, viz., the bizygomatic and the bimastoid, are less than the corresponding diameters in the cranial vault; and the anterior pair of diameters are individually less than the corresponding diameters posteriorly. Through the kindness of Professor Cleland of this University, who made the coronal section specially for me, I am happily able to show two tracings of sections of a nine months' foetal skull, as nearly as possible through these diameters, showing the two anterior and the two posterior diameters. The measurements will be found to be as follows: Bizygomatic, 2. Coronal, 21. Increase, Only one other diameter-but this time a pelvic one-must be borne in mind. As this diameter has not been recognised as such, so far as I know, though its posterior pole has often been referred to, it may simplify matters if I give it the name of lateral conjugate diameter of the brim. It is an antero-posterior diameter, but lies, as its name implies, to either side of the true conjugate, and not always strictly parallel to it. I find that in contracted pelves this diameter measures from a quarter to half an inch more than the true conjugate. Each lateral conjugate will obviously be of the same length, unless the brim is irregularly contracted. The posterior pole of this diameter will be at the inner portion of the ala of the sacrum, and the anterior pole will be at some part of the pubic bone immediately behind its crest. Viewing the head now in its relation to the brim of a flat pelvis, on which the vertex is resting, we are able to put the matter briefly thus: the head is extended with its long diameter in the transverse of the pelvis, its coronal diameter in the true conjugate of the pelvis, and its biparietal in the lateral conjugate of the pelvic brim. When the base of the cranium rests above the brim, the head is still extended, and has still its long diameter in the transverse of the pelvis; but now its bizygomatic diameter is in the true conjugate, and its bimastoid in the lateral conjugate. In the generally contracted pelvis, when the disproportion is decided, the head will have, whether vertex first or base first, substantially the same position as the above, but it will occupy equally the two sides of the pelvis. It will also have the Naegele, but not necessarily the Michaelis obliquity. If, however, the disproportion |