563

OBSTETRICS IN DUBLIN

THE reputation of Dublin as one of the leadingobstetric schools of the world has been maintainednot only by the enthusiasm of successive generationsof students and practitioners grateful for its practicalteaching, but also by the clarity with which the clinicalresults obtained at the three maternity hospitals areevery year correlated and presented. In the London

hospitals no doubt the amount of supervised obstetricwork is much larger, but most of this work is recordedand laboriously tabulated by the obstetric registrars,to little purpose. The medical reports from the threematernity hospitals of Dublin are presented to thesection of obstetrics of the Irish Royal Academy ofMedicine where the fruits of their discussion may beeven more instructive than the reports on whichit turns. Under its new master, Dr. Andrew Davidson,no drastic change has been made at the Rotundain the methods and principles which have proved ofvalue in the past. The maternal mortality remainsat a commendably low level : in 1934 it was only0-83 per cent. with a morbidity-rate of 4-2 per cent.,despite the large number of complicated cases

admitted. In the past 15 years this institution hasbeen responsible for the supervision of some 57,000confinements with 267 deaths, the percentagemortality being 0-46.This year discussion at the section was concerned

chiefly with some aspects of midwifery which are atthe moment much in the public eye. Breechpresentations, it seems, present no terrors to theRotunda staff. External cephalic version was per-formed successfully in 19 cases, 18 infants beingborn alive. The fcetal mortality was however evenless when the breech presentation was uncorrected,for then there were only 2 dead infants out of a totalof 62. Such a record reflects the greatest credit

upon the conduct of these cases. None of the reportsthrows much light on uterine inertia, which is by farthe most ticklish problem that faces the obstetricianto-day. Dr. Davidson hopes that hormone therapymay provide the solution. Dr. Gibbon FitzGibbonsimply asks that each case of this nature should bereported in detail. The treatment of 23 cases of

placenta praevia was varied ; last year’s excellentresults were not repeated. The vexed question of

disproportion claims most attention in the reports.The master of the Rotunda condemns routine inductionof labour by puncture of the membranes in suchcases, but he believes it has its place. In the pasthowever labour had certainly been induced unneces-sarily ; greater knowledge was needed of the condi-tions under which it should be done. The mastersof the Coombe and of the National Maternity Hospitalboth appeared to concur, but several who took partin the discussion questioned whether induction of

premature labour for supposed disproportion was everjustifiable in the primipara. Dr. Davidson thinksthat external pelvimetry will often draw attentionto cases of contracted pelvis, and that internalpelvimetry, combined with an estimate of the weightof the infant, will help materially to strengthen thejudgment regarding the prognosis for delivery. Thenis much difference in the recourse to Csesarean sectiorat the three hospitals. It was done 26 times at thECoombe, 2-2 per cent. of all deliveries ; 41 times aithe Rotunda, 0-6 per cent. The master of thERotunda would have it resorted to only when th(indications are absolutely clear ; under the very bes-possible circumstances the risk is at least three time Igreater than that of vaginal delivery under the wors-possible circumstances-a very pointed warning

Eclampsia was treated upon the lines that have

long been advocated in Dublin and the mortalityremained at about the level of 10 per cent. At theCoombe the practice continues of allowing deliverywithout any attempt to save the perineum.

A YEAR’S SURVEY OF CRIME

OFFICIAL figures about crime are generally soothing.If the tables register decreases, we can share in thecredit due to a better world. On the other handif crime is going up, we can still believe that thingsare not really worse-it is only that our excellentpolice are more alert in bringing rascals to justice.Part of the soporific effect produced by officialstatistics may be due to other causes. The annualvolume for England and Wales, just published(Cmd. 4977, 3s. 6d.), gives us the figures for 1933-a receding period in which our interest is diminishing ;will the Home Office never manage to catch up thistwelve months of arrears 1 There is somethingunexhilarating too about the way in which the infor-mation is presented. An introduction of 13 pagesis all too short and too jejune. The speculativecomments which were prefaced to these annualvolumes a few years ago have apparently been cutdown in the interests of economy. We could betterhave spared the tedious 40 pages which tabulateall the possible crimes we can commit; the curious cancull this information from the statute-book or frommanuals on the criminal law. The very figures them-selves refuse to be sensational. Take, for instance,the steadiness of inquest statistics. In 1928 (thefirst full year after the amending Act of 1926) therewas a total of 31,553 ; in 1933 it was almost

unchanged at 31,669. Here, however, one fact ofinterest can be extracted. The post-mortem examina-tion without inquest, made possible by the 1926

Act, is proving its value. For every six such cases in1928 there were eight in 1933. There has been no con-

spicuous rise in non-jury inquests in the same period.Crime as a whole fell in 1933 below the figures for

1932 which was in some ways a peak year. If theexperts rightly relate this improvement in part tothe decrease in unemployment, it is yet notable thatattempted suicide is still going up. Last year’sfigure was a record for this offence. In the volumefor 1930 we were officially told that in recent yearsit was not the practice to prosecute for attemptedsuicide unless special reason existed-e.g., to keepthe offender in custody for his own protection. Since1925 a person charged with this offence can be dealtwith summarily instead of being sent for trial. Thischange may have increased the number of cases

brought to the knowledge of the police. We observethat the only other offence where discretionarylatitude exists is that of Sunday trading. Over30,000 persons were found guilty of it in 1933, but afootnote to the table tells us that in most districtsit is not the practice to prosecute for Sunday trading :in the exceptional areas, it seems, a few traderscheerfully run the risk of repeated fines. The murderfigures are, as usual, steady. Of the 58 personsarrested on this charge in 1933 one committed suicideon arrest and another before trial; one was certifiedinsane before trial; five were found insane on arraign-ment, and sixteen were found "guilty but insane."We get a hint here of the price we pay for the defectsin our system of diagnosing and treating mental

i disease. If we turn to the figures of criminal lunatics. detained on Dec. 31st, 1933, we find that 439 were; so detained where the charge was murder ; no fewer. than 104 of these had then been in institutions like

564

Broadmoor for 20 years and over. The correspondingfigures for attempted murder, felonious or maliciouswounding, rape, indecent assault, and other offencesmake equally lamentable reading.The criminal statistics of the year as a whole must

be correlated with the changes of population. If

juvenile delinquency is increasing, it must be remem-bered that there were more boys and girls betweenthe ages of 10 and 14 to commit offences. Evenwhen this allowance is made, it is sad to find thatchildren and young persons are becoming more ill-behaved. If the year 1933 is compared with theyear 1911 and the number of indictable offences is

adjusted to the relative totals of population, we findthat a figure of 288 (per 100,000) for boys and girlsunder 16 charged with indictable offences has leaptup to 370 in 1933, whereas the corresponding figurefor older persons has dropped from 232 in 1911 to189 in 1933. In part this increase may be due tothe development of juvenile courts and to the growingrecognition of the fact that the treatment of thejuvenile offender is dominated by regard for his ownbest interests. The increase in young persons’offences is largely connected with charges of larceny,which may often be trivial enough. There is alsoan increase in sexual offences committed by youngpersons from the age of 16 to 21. One happy featurerepeats itself in 1933-namely, the comparative goodbehaviour of the female sex. Whether it be dueto natural virtue or to the sheltered life, the pro-portion of offenders is nearly eight times higheramong males than among females.

ECLAMPSIA AS AN ENDOCRINE DISORDER

IN spite of a vast and ever-swelling literature, thecause of eclampsia and the pre-eclamptic toxaemiaof pregnancy remains obscure. This is not for lackof speculation. "Theories " of eclampsia and

appropriate regimes of treatment are numerous

enough, though none can yet hold its own on abasis of direct evidence. In particular, attempts todemonstrate that the disease is an expression ofdisturbed endocrine balance have multiplied of lateyears, and attention has been directed naturally tothe pituitary. Evidence for and against the ideaof an over-secretion of the pressor hormone of the

posterior lobe was summarised in these columns justa year ago, when we concluded that the hypothesismust at present be regarded as unproven. More

recently attention has been transferred to theanterior lobe of the gland and some observations ofG. Van S. Smith and 0. W. Smith 2 deserve carefulattention. These workers have investigated thedistribution of prolan and cestrin in various tissuesand fluids during normal and abnormal pregnancy.In normal pregnancy, they say, the prolan contentof blood and urine rises during the early months, fallssharply at the fourth month, and thereafter remainsfairly constant ; whereas in toxaemia the levelremains high even when symptoms do not developuntil the sixth or seventh month. The eestrin contentof the blood and urine, on the other hand, displaysa steady rise throughout normal pregnancy, reachinga peak at term, and in cases of toxaemia the rise isoften delayed. The next step in the Smiths’ investi-gation was to analyse the placenta for the samehormones. Here also they find that there is an

excess of prolan and a paucity of oestrin in cases oftoxsemia. And they conclude that it is the placenta

1 THE LANCET, 1934, ii., 490.2 Surg., Gyn., and Obst., July, 1935, p. 27; August,

1935, p. 175.

rather than the pituitary which produces the extraprolan.The immediate value of these experiments lies in

the fact that they suggest a means of detectingtoxaemia before clinical symptoms appear, though itremains to be seen whether such a test will prove a

practical proposition. The underlying significanceof the observations is another matter, and it is notlikely to become apparent until more is known aboutthe nature and functions of the various hormonesconcerned. So far at least six factors-namely,prolan A, prolan B, oestrin, progestin (corpus luteumprinciple), oxytocin, and vasopressin-are known toplay some part in the sexual cycle and pregnancy.Even if no further principles are discovered an

equation involving six factors, none of which isconstant, is not easily solved. The present observa-tions will no doubt be tested and extended in duecourse, but meanwhile they strengthen the suspicionthat eclampsia may one day be recognised as an

endocrine disorder.

THE CALCUTTA TROPICAL SCHOOL

Lieut.-Colonel R. N. Chopra’s report for 1934 ofthe Calcutta School of Tropical Medicine records theretirement of several European officers who haveserved the school well. Lieut.-Colonel H. W. Actonhas since died after a long illness, and his deathexcites the keener regret for the reason that his fertilebrain was still young and vigorous. He had beendirector since 1928, rendering services of equal distinc-tion as teacher, administrator, and research worker.He has left as a legacy to the school the one andonly department of medical mycology in India.The imperial serologist, Lieut.-Colonel R. B. Lloyd,has also retired and Dr. Ernest Muir has severedan association of fifteen years long during whichhis unselfish and painstaking work on leprosy hasachieved a large measure of success. His latestwork on the leprolin tests has shown it to be of

importance in prognosis and treatment. The reportcontains a running record of special investigationin many directions. The epidemic dropsy whichhas been so fatal in Bengal and Bihar during thiscentury seems to be yielding up its secret, for a gram-positive spore-forming bacillus, isolated from thestools in many cases, has been found to agglutinatein high dilution with the sera of convalescent patients.Similar organisms have been recovered from diseasedrice, and it is more than probable that the toxicproducts are elaborated mainly in the rice or in thepresence of rice. In Colonel Chopra’s department afurther study has been made of carbarsone,l an

organic arsenical preparation which is non-toxic andrenders the stools free from amoebae in three to fourdays. A similar drug prepared in India and calledamibiarson has given almost as good results in40 cases,2 the ratio of probable cures to failures being5 to 1. The action of atebrin on monkeys infectedwith malaria has been further studied and some lighton the transmission of kala-azar has been thrown bythe observation that hamsters infected through thebite of the sandfly may not show evidence of infectionfor eighteen months or more. There is a widedemand from hospitals in Calcutta for variousbacteriophages prepared in the school; the per-plexing thing about choleraphage is that one yearit may agglutinate most of the strains of vibrioisolated and another year may not. It seems that

1See THE LANCET, 1933, ii., 663.2Chopra, R. N., Sen, B., and Sen, G.: Indian Med. Gaz.,

June, 1935, p. 324.