NORTH OF ENGLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY.

1245 average residence in the clinic was three weeks, but some patients stayed there much longer. The PRESIDENT expressed the Association’s gratitude to Prof. Winckler for having come so far to show the

Dr. Bride decided to do Caesarean a living child, and at the same time sterilised the woman by removing portions of both Fallopian tubes. The child died of convulsions on the eleventh day. high level on which psychiatry stood in Holland. Nothing was found to account Sir FREDERICK MOTT said it had been his privilege for the placenta prsevia habit.-Dr. J. E. STACEY said to see the fine institution which Prof. Winckler directs, that it was very rare to have recurring central placenta and on his recommendation, other English alienists praevia.—Dr. W. W. KING asked to what extent the visited it, and came back with a fund of instruction. cervix was dilated and criticised the second Caesarean When William of Orange rode into Leiden, after the section, and also the sterilisation of the patient.siege, he asked the burghers whether they would have Dr. FLETCHER SHAW said that one did not expect a Caesarean scar to stand difficult deliveries in future a university or a remission of taxation, and they chose Sir Frederick Mott wondered in how pregnancies.-Dr. BRIDE said that the cervix was a university. many English towns such a choice would be made. only slightly dilated ; he did not consider possible In conclusion, he referred to themany-portal system of rupture of the old scar. At operation the old scar entry to the medical profession in this country, and could hardly be seen. Dr. H. CLIFFORD (Manchester) described a case of commented on the advantages of a single State full-time ectopic gestation. Mrs. F. was admitted to examination. hospital on Nov. 30th, 1922, with a history of amenorrhaea since February, 1922. Foetal movements NORTH OF ENGLAND OBSTETRICAL AND were active till two days before admission. The GYNÆCOLOGICAL SOCIETY. foetus appeared to be full-term, foetal limbs were rather prominent, the head high up and in R.O.P. A MEETING of this Society was held in Sheffield position. No foetal heart sounds were heard nor on Nov. 16th. Prof. M. H. PHILLIPS was in the chair. The cervix was protruding from movement felt. vagina ; presenting part could not be definitely felt. Exhibition of Cases and Specimens. Dr. J. BRIDE (Manchester) showed a tumour Radiographs gave no assistance ; the temperature was slightly raised ; the cervix was cleansed and replaced simulating complete ulcerated prolapsus uteri. He and supported by a ring pessary. Labour did not removed it from a 2-para, pregnant four months. come on and the patient was discharged at her own It was situated in the interval between right labium on Jan. 5th, 1923. She was readmitted on majus and minus, and resembled an ulcerated complete request the 26th when the foetus was in the same position, prolapse. It had been noticed for 12 months and was and the temperature was slightly higher. Bougies steadily getting bigger and was removed without were inserted into the cervix on two occasions, but affecting the pregnancy. Microscopically it was a could only be pushed 3t inches. Temp. 102° F. and fibroma. The PRESIDENT showed specimens of (1) adeno- pulse 120. On Jan. 29th and Feb. 4th the patient had 4-minim doses of Dr. Jenkins’s stock residual myoma of rudimentary uterine cornu; and (2) salpingo- vaccine.! On Feb. 14th Dr. Clifford opened the csecal fistula. The first specimen was removed from abdomen found a full-term macerated and foetus 7-para aged 44, who had had menstrual pain for in a sac with placenta almost entirely attached the last seven years and recently pain not associated lying with menstruation. A swelling the size of a golf ball to outer abdominal wall. This was stripped off without bleeding ; the membranes were not removed and the was attached to the left side of the supravaginal cavity was drained and irrigated by Carrel Dakin’s cervix, diagnosed as adenomyoma of Gaertner’s duct. method for three weeks. The cavity rapidly became At operation it was found to be rudimentary, and six weeks after operation there was a smaller, left cornu of uterus attached to supravaginal cervix, revealed and also to pelvic wall. A section of the cornu showed sinus 12 inches long. Inquiries afterwards fact that in March, 1922, the patient had severe the spaces filled with dark blood, lined by columnar abdominal pain with vomiting followed a little later cubical epithelium, embedded in " cytogenous or haemorrhage lasting five days. Afterwards she by mantle " similar to uterine endometrium. The second had considerable abdominal pain, and in May confrom 32 was removed 3-para aged specimen years. Last child was born three years ago, followed by sulted a surgeon who thought she had had appendicitis. severe abdominal pain for two weeks. Patient was Dr. Clifford considered that the condition was very SHAW and Dr. admitted into hospital in November, 1922, suffering difficult to diagnose.-Dr. FLETCHER D. DOUGAL agreed with him.-The PRESIDENT also from subacute attack of bilateral salpingo-oophoritis. but pointed out that a dead foetus is not Five weeks later she was seen with fixed tender agreed, retained long in utero.-In reply, Dr. CLIFFORD said the of the which to uterus was swelling right thought that it was sometimes very difficult to diagnose fcetal to contain pus. Four weeks afterwards swelling had death. disappeared and the patient felt much better. She Dr. S. B. HERD (Liverpool) described two cases of was readmitted August, 1923, for dysmenorrhoea and lethargica associated with pregnancy : encephalitis backache. A retroverted adherent uterus and slight (1) Primipara aged 24. No history of previous enlargement of the appendages were found. The illness. Pregnancy normal up to thirty-sixth week. right tube was firmly fixed to the caecum, and the The patient then had headaches, albuminuria, and with the thickened area of the caecum was removed oedema of the ankles. She had treatment and slight tube. The end of the tube was found prolapsed showed signs of temporary improvement. A week into the cavity of the caecum, the ostium being patent she had severe headaches and a fit. later Admitted and well away from the opening of the vermiform to hospital: Blood pressure, 130 mm. of Hg ; albuThe was be condition to the thought appendix. result of rupture of the peritubal pyocele into the minuria, 3 g. per litre. No uterine contractions. The caecum.—Dr. BRIDE recalled a similar case in which patient had six fits in six hours following admission -apparently typical eclamptic fits. Next day a an ectopic pregnancy had ruptured into the caecum.The PRESIDENT said that originally this case had been living child was delivered. Later in the day rhythmic clonic contractions of jaw muscles commenced. The diagnosed as an ectopic cyst by the house surgeon. The patient was Dr. BRIDE gave an account of two consecutive temperature was slightly raised. restless and confused, and at the end of five days, as with central and Caesarean placenta praevia pregnancies section. A 2-para, aged 34, was seen on Nov. 20th, she was becoming worse, was transferred to another she died on the twentieth day after 1922, three months pregnant, with history of Caesarean hospital, where She had ptosis of upper eyelid, delivery. section, by Dr. Fothergill, whom the speaker had and weakness of nystagmus, facial muscles. Post-mortem assisted. The living child then delivered was still of was corroborated, lethargica encephalitis diagnosis alive and healthy. On April 21st, 1923, the patient and no evidence of toxaemia was found. The second was admitted into hospital eight and a half months 1 Brit. Med. Jour., April 15th, 1922. pregnant; she had severe bleeding with central ______________

’

placenta prsevia.

section, delivered

1246 that of a primipara aged 28. Healthy up to the thirty-fifth week of pregnancy. On admission the patient was restless and excited, and there were incoordinated clonic movements of head and limbs present during sleep. Reflexes normal. Albuminuria, 2 g. per litre. Chorea gravidarum was diagnosed and treated with parathyroid extract, calcium lactate, and sedatives. On fourth day after admission the patient was delivered of a still-born child. The temperature rose to between 100° to 102° F. Diplopia noticed on following day. Delusions, restlessness; became worse, and was transferred. Diagnosis of myoclonic lethargica encephalitis was made. The patient was slowly recovering-four months later-but complete recovery was not expected. Dr. J. CHISHOLM recalled one case in a 2-para with marked clonic movements of abdominal walls with symptoms of internal obstruction. Caesarean section no was performed; obstruction was found and movements continued afterwards. The patient was dull and apathetic, but recovered. The child also had Dr. Chisholm mentioned lethargic encephalitis. another case in a five and a half months’ pregnancy diagnosed as pernicious vomiting at first. Though She had labour was induced, the patient died. case was

nystagmus also.

Dr. FLETCHER SHAW read

a

paper

on

the

and

Disadvantages of Supravaginal Advantages Hysterectomy and Panhysterectomy. He said that some gynaecologists believed panhysterectomy should be done whenever the uterus

had to be removed, while others believed that supravaginal hysterectomy was the better operation for many cases, though they would probably always do panhysterectomy if the cervix was badly lacerated. In a period of 18 months he had had three patients in whom carcinoma of the cervix occurred after supra vaginal hysterectomy, and his object in bringing the subject before the Society was to see if other gynaecologists had had any similar cases. Although these three cases were seen in a period of 18 months, they were the only ones he had ever had, and so far as he knew none of his colleagues at St. Mary’s Hospital had had a single case, so that the occurrence after supravaginal hysterectomy was very rare and it was probably merely a coincidence that he should get these three in so short a period. If that proved to be the case he still thought there was a distinct use for supravaginal hysterectomy, as it was a much quicker operation and caused less shock to the patient and, moreover, did not entail the opening of the vagina, which, no matter how carefully cleaned, was potentially a septic passage. In a consecutive series of supravaginal hysterectomy and panhysterectomy he found the mortality higher after panhysterectomy, and in the investigation of the convalescence of a consecutive series of both types the patients after supravaginal hysterectomy had, on the whole, a smoother time than those in whom the complete operation had been done. He still thought supravaginal hysterectomy was useful in nulliparous women, but panhysterectomy should always be done where the cervix was badly lacerated or in any way

diseased.

The PRESIDENT said that he did not remember

seeing carcinoma of the cervix after subtotal hysterectomy, but he had removed cervices for discharge.

He believed that panhysterectomy was the better all cases. Dr. W. W. KING showed a specimen of carcinoma of the cervix which he had removed. The patient had subtotal hysterectomy in 1919 for fibroids. In 1923 she had bleeding for three months, and the cervix was found carcinomatous. He recalled another case in a nullipara who in 1911 had gonorrhoea. In 1918 the patient had a pelvic abscess drained ; in 1920 had subtotal hysterectomy for bleeding, and six to eight months later had ineradicable carcinoma of the cervix. He believed in total hysterectomy in multiparae, and subtotal in nulliparae.—Dr. BRIDE

operation in

said that in

of a nullipara, he had done a and found an early carcinoma of the cervix.-Dr. CmsHOLM mentioned a case who had had a subtotal hysterectomy 25 years ago and who had bleeding for two months, and was found to have ineradicable carcinoma. She had had one child and one miscarriage.-Dr. CLIFFORD did not remember a case of carcinoma of the cervix occurring after subtotal hysterectomy in his practice. He said that it was so rare that it hardly affected the difference in the mortality rate between the operations of subtotal hysterectomy and panhysterectomy. a

case

panhysterectomy

ULSTER MEDICAL SOCIETY. A MEETING of this Society was held on Nov. 22nd, Prof. W. ST. C. SYMMBRS, the President, being in the chair. Mr. ANDREW FULLERTON read a paper entitled Observations on Unilateral Diuresis. He described a continuation of some observations on unilateral diuresis which he presented last year before the Congress of the American College of Surgeons, held at Boston. A small irritating calculus in the pelvis of the kidney, he said, may give rise to a unilateral diuresis so definite and striking as to confirm the most casual observer. The flow from the sound side may be correspondingly diminished, and the specimen so concentrated that a copious deposit of urates is rapidly precipitated. In tubercle of the kidney an exactly similar state of affairs is present in the early stages. A further example was furnished by unilateral pyelitis. In cases with little involvement of the parenchyma of the kidney the picture closely resembles that seen in stone in early tubercle. In stone and pyelitis a rapid return to the normal occurs when the cause has been removed. In calculus and in the early stages of tubercle the diuresis is what may be termed acute. When structural changes have occurred in the kidney the specific gravity is still diminished, but by degrees the flow of urine becomes less and less, until finally all the work falls on the sound kidney. The term chronic might be applied to the diuresis in these cases, but when the flow becomes diminished it is not strictly applicable. The specific gravity of the urine in the affected side was likely to be low in the following conditions : renal calculus, tuberculosis of the kidney, unilateral pyelitis, tumours of the kidney, congenital cystic kidney (when the process is more advanced on one side), hydatid cyst of the kidney, hydronephrosis, movable kidney, certain cases of renal pain, and in wounds of the kidney. Statistics were given of the results of examination in over 500 cases. Mr. Fullerton brought forward this subject to emphasise the value of a sign that might help in diagnosis when the surgeon was deprived of more accurate methods. Dr. F. C. S. BRADBURY demonstrated a method of Estimating Urea in Urine, based upon the principle that if a gas is liberated within an apparatus of constant volume, the resulting increase of pressure is proportional to the amount of gas liberated. In this method the ordinary hypobromite reaction is utilised to liberate nitrogen from a fixed volume of urine, and is carried out in the usual manner by placing the urine in a small test-tube within a bottle containing the reagent, so that by tilting the bottle the urine and reagent can be mixed at will. The bottle is provided with a perforated rubber stopper into which is pressed the stem of a manometer such as forms part of a sphygmomanometer outfit of the aneroid pattern. The air space within the apparatus has a complex value, being the capacity of the empty bottle minus the amounts of caustic soda, bromine, and urine added ; minus the volume of the glass composing the bromine tube and the urine tube ; minus the volume of air displaced by the stopper of the bottle ; plus the air space inside the manometer ; plus the potential air space in the reagent due to its power of