described I have no doubt, from the feeling conveyed to my hand whilst in the womb, that there were several interstitial tumours, and it seems probable that so many abnormal growths, by altering the course of the uterine fibres, must have interfered with their contractile efforts and led to the feeble and irregular uterine action observed during the labour. When only one or two fibroids exist I have often seen labours completed in a comparatively easy and natural manner. That in this case some of the tumours should have subsequently disappeared and some remained shows, I think, that they were not all exactly of the same nature. Dr. PLAYFAIR said that Dr. Madge's case was of great interest to him, as affording farther corroborative evidence of the possibility of spontaneous absorption of fibroid tumours of the uterus, a subject on which he had formerly read a paper before the Society, and, farther, of the important influence of pregnancy, or rather of the involution of the uterus after delivery, in favouring the process, a point on which he had particularly insisted in his paper. It was satisfactory to find so carefully recorded a case brought forward, on the diagnosis of which the most sceptical could hardly throw any doubt. Although all the tumours had not disappeared in this case, some of them had, and the rest had materially diminished in size, showing that they had undergone the same process of involution as the rest of the uterine tissue, which, considering their identity of structure, was, after all, not so surprising. The number of carefully recorded instances of the spontaneous absorption of uterine fibroids was now so great that the possibility of the occurrence seemed to him (Dr. Playfair) as conclusively proved as any fact could be, or required to be. JULY 3RD, 1872. JOHN BRAXTON HICKS, M.D., F.R.S., President, in the Chair. Wm. Michell Clarke, M.R.C.S. (Clifton), and James Ryer Thomas, L.R.C.P. Lond., L.R.C.S. Edin. (Tinnevelly, Madras), were elected Fellows of the Society. IRREGULAR UTERINE CONTRACTION. By E. H. TRENHOLME, M.A., M.D., B.C.L.; PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN, THE practical importance of the subject which I have the honour to lay before you this evening must be my excuse for occupying your time. I trust that each member will thoroughly investigate and criticise what may be advanced, as it is well known that correct deductions for guidance in the treatment of disease can only be made from correct premises, the result of accurate observation. Spasmodic contraction of the uterus is naturally divided into irregular contraction during the birth of the child, and irregular contraction during the delivery of the placenta. 1st. Irregular contraction of the uterus during the expulsion of the foetus is recognised by short, partial spasms of the walls of the organ. These contractions accomplish but little in the way of dilating the os or advancing labour. They do not occur regularly, either in respect to the space of time intervening between their return or their duration. By placing the hand upon the abdomen over the uterus we can frequently detect irregular and partial muscular contraction of the organ. The pains are of a short, sharp, and painful character, and also usually cause the patient intense anxiety and distress. Upon making a vaginal examination you will find but slight bulging of the fœtal membranes during the pains, also, not unfrequently, an unequal dilatation of the muscular layers of the os uteri. The internal layer is least dilated, sometimes not more than half the extent of the external layer. With regard to this last statement, I may say that the diagnosis is not always so easy as one would naturally suppose, as the internal layer of muscular fibres is thin, and might be mistaken for a thickened decidua. When the finger has reached the os, and is attempted to be passed between the neck and the membranes, we encounter adhesion more or less firm and extensive between the opposed surfaces. When the adhesions are on one side the os is found, not in the median line of the pelvis, but drawn away from the centre toward that side on which they exist. As a necessary consequence of such a condition of things there are obliquity of the womb and irregular oblique presentation of the presenting part at the brim of the pelvis, together with retarded engagement and its consequent results. The existence of these adhesions is ascertained with but little difficulty, as the finger readily detects their presence, and also shreds of muscular fibres attached to the decidua. In these cases the membranes can be scraped by the fingernail and the portions detached preserved for microscopic examination. I have upon many occasions removed in this way shreds from that part of the decidua which had been adherent to the uterus, both during the dilatation of the os and after the removal of the placenta, and found them to be composed of muscular tissue. The existence of the adhesions is also recognised by the fact that, when they are broken up by the finger, the protruding portion of the membranes increases in size rapidly; the uterus, which was oblique, soon returns to its central position; the presenting part engages; the irregular, ineffective, spasmodic contractions become regular and powerfully expulsive, and a tedious, lingering labour becomes a normal one, and is speedily brought to a satisfactory conclusion. I have but little doubt that more extensive and correct observation will demonstrate that the great majority of oblique presentations are due to this cause. The manner in which these abnormal adhesions are produced, and the way in which they cause irregular spasmodic contractions of the uterus, are worthy of remark. In speaking of this matter we can arrive at probable conclusions only, and I shall therefore submit that these adhesions may be due to 1st. A pathological condition of the inner surface of the uterus existing previous to conception; or, 2nd. To injuries of the parts concerned during gestation; or, 3rd. Result from partial, instead of complete, separation of the decidua having taken place before term, i e. that the ripening of the decidua has not been uniformly accomplished; or, 4th. To a combination of two or more of these causes. We will now consider the value of these different hypotheses. 1st. In favour of the idea that these adhesions may be due to a diseased state of the internal surface of the uterus existing previous to gestation we have the well-established fact that a part or tissue once the seat of diseased action seldom or never regains its original state of perfect health, and is liable to subsequent derangement. Experience teaches us to be careful in effecting the delivery of the placenta in those cases where we have encountered strong adhesions in a previous labour, as we know such patients are obnoxious to them on a subsequent occasion. 2nd. Adhesions may occur during gestation as a result of local extravasation, either from shock, a plethoric state of the system in general and the uterus in particular, or by direct violence applied over the parts affected, as by a blow upon the abdomen; or, possibly, by injury to some part of the neck or lower segment of the uterus upon the brim of the upper strait of the pelvis. Such an injury as this might be caused by a false step, jump, or fall. For my own part I am of opinion that this is not an uncommon cause of such adhesions. This view is confirmed by the fact that in most of the cases of retarded labour due to irregular uterine contraction that I have met with the adhesions were situated within a short distance of the os. 3rd. The adhesions may be due to a partial ripening or want of that cell maturation by means of which the decidua is separated from the internal surface of the womb at term in natural labour, and which, by the way, is, I have no doubt, the determining cause of labour. The strength of the attachment will determine the extent of the irregular contractions, and consequent pain and delay in parturition. The induction of labour at all where these adhesions exist is probably due to the separation already mentioned having taken place to a sufficient extent to cause uterine irritation and subsequent muscular contraction of the walls of the uterus. This view of the case does not require us to look for or suppose a pathological state of the membranes of the uterus or the surface of the uterus itself, but regards it simply as due to a lack of that perfected development of the mucous membrane which is usually completed at the end of the ninth month. 4th. Lastly, these adhesions may be the result of two or more of the above-named causes. There may be a predisposing plethora of the vascular system, accompanied by shock or blows, or, a weakened state of the walls of the uterus the result of former disease or injury, and this by a subsequent |