126

hours’ urine is used to estimate the daily discharge ofphosphates.

Mr. A. P. GOULD read a paper on Wound of the CommonFemoral Vein, which will appear in full in a future numberof THE LANCET.—Mr. J. II. MORGAN spoke of a case ofperforating bullet wound of the sternum, that led to throm-bosis of the left innominate vein and pyaemia.—Mr. MARMA-DU]3:E, SHriILD doubted whether the septic processes weredirectly due to the wound of the vein with the cat’s-meatknife. He thought, iodoform should have been freely used.-Mr. GOULD, in reply, said the wound went right across thefront of the vein and admitted the finger easily. Iodoformhad been dusted around the wound, but not on it. Hecould not help thinking that the septic poison was intro-,duced at the time of the infliction of the wound.

CAMBRIDGE MEDICAL SOCIETY.

AT the meeting on Dec. 3rd, James Carter, F.R.C.S., in thechair, the following communications were made :-

Abortion.-Dr. BoxALL read a paper on this subject, andexhibited the foetus and appendages from a complicatedcase of miscarriage. During the tenth week of gestation,and as the result of over-exertion on the part of the patient,haemorrhage set in and miscarriage threatened. The patient:kept about for six weeks, but during the succeeding five weeksshe was laid up, and ergot was given persistently. The haemor-rhage, however, continued, and her general health suffered.Meanwhile neither the patient nor her medical attendanthad suspected the persistence of pregnancy, especially asthe menstrual periods had continued regularly during theearly months of gestation. An early miscarriage was sup-posed to have occurred at the onset of the bleeding, and thepatient was thought to be suffering from subinvolutionconsequent upon it. Careful examination, however, detecteda feebly-acting foetal heart, and the uterus was found toreach as high as the umbilicus, and to be partially dis-tended with blood-clot. Two days after this examination thefoetus appears to have succumbed. The product of conceptionwith a great quantity of clots was expelled within the week—i.&., at the end of the fifth month of gestation. It was thenapparent that the placenta, though normally situated, had be-come partially detached; the lower portion had consequentlyatrophied, while the upper half had undergone a compen-sating hypertrophy. As regards the causation of miscar-riage, the author, referring to the action of ergot on thepregnant uterus, pointed out that, though under certainconditions ergot is a powerful oxytoxic, the drug, beingincapable of initiating uterine contractions, is in itselfunable to produce premature labour or miscarriage; more-over, that, apart from the various affections peculiar to thepelvic organs of the female, the cause of miscarriage is farmore frequently the result of accident than is generally ad-mitted ; but, on the other hand, with respect to the syphilitictaint, miscarriage, and especially early miscarriage, is notso generally the direct effect of the syphilitic virus as issupposed, and certainly not to such an extent as to warranta diagnosis of syphilis from one or more miscarriages whenother evidence is not forthcoming.-Dr. W. DUNCAN thoughtthe case reported was a good illustration of the importanceof making a careful abdominal examination. He agreedwith Dr. Boxall in thinking that early abortions were notnearly so frequently the result of syphilis as is stated inbooks; but at the same time he had seen casesin which the sys-tematic employment of anti-syphilitic remedies, both beforeimpregnation and during the whole period of gestation, hadbeen attended by the happiest results. Dr. Duncan con-sidered that absolute rest in the horizontal posture, withexhibition of opium provided there were pains, was the besttreatment for threatened abortion; but if there were nopains whatever, and haemorrhage only, he had found that theadministration of five or ten drops of the liquid extract ofergot everv three hours was of the greatest service.

Cystic Ovaries removed for Dysmenorrhcea.-Dr. WILLIAMDurrcArr showed the ovaries, studded with cysts, which hehad removed from a young woman, aged twenty-three, onaccount of intense dysmenorrhoee., from which she hadsuffered ever since the onset of the catamenia. She hadbeen subjected to various treatment in different hospitals-viz., blisters to ovarian regions, division of the cervix, intro-duction of stem pessaries, puncturing the cervix, &c.,-andall to no effect. Dr. Duncan kept her in the hospital for a,couple of months, with the daily use of the hot douche; but

at the end of that time he recommended abdominal section,having first carefully explained to the patient and hermother what it was proposed to do. Six months subse-quently she was perfectly well and absolutely free fromany pain. The various conditions which demanded theoperation (removal of ovaries and tubes) were then discussed.Dr. Duncan considered that it was perfectly justiiiable in(a) chronic disease of the ovaries and tubes, especiallywhere there is a history of antecedent pelvic inflammationand a prolonged course of other treatment has proved of noavail, and (b) in excessive metrorrhagia due to uterine myoma,which is threatening the patient’s life, and where the meno-pause is not likely to ensue for some years. Dr. Duncandisapproved of the operation in hysterical epilepsy.

IIaematocelefrom a RlllJtuJ’ed Grar(fian 11’ollicle.-Dr. WM.DUNCAN showed a specimen consisting of a left ovary witha hsematocele due to a ruptured Graafian follicle and limitedby a piece of omentum. The right ovary contained a cystabout the size of a walnut, which had been ruptured. Thepatient from whom they were removed had been under Dr.Duncan’s care in the out-patient department of the lfiddle-sex Hospital for about a year. She was a married woman,aged twenty-six, with three children, the last two years old.Since last confinement she had suffered from pelvic pains ofthe usual kind, accompanied by menorrhagia and muchdysmenorrhoea. On examination, an elastic, elongatedswelling, about the size of a tangerine orange was feltto the left of the uterus, and it was thought to beprobably a dilated Fallopian tube. The condition locallyremained exactly the same during the whole time thepatient attended the hospital, but her general health wasmuch deteriorated. She was advised to submit to operation,to which she consented. Abdominal section was performedby Mr. Bland Sutton, who had no difficulty in removing bothovaries and tubes, together with the hematocele and sur-rounding omentum. The patient made an uninterruptedrecovery.

ACADEMY OF MEDICINE IN IRELAND.

Placenta Pi-6evia.A MEETING of the Obstetrical Section was held on

Nov. 26th, 1886.Dr. FLEMING read a paper on the Etiology of Placenta

Proevia, and then went on to enumerate the various ideas asto the source of the blood, giving as the most feasible thatof Schroeder-namely : 1. That uterine contractions impelthe blood from the place from whence the placenta has beenseparated. 2. That from the separated portion blood circu-lating through the chorion villi becomes lost. 3. That un-

guarded examination may lacerate the placental tissue and socause foetal haemorrhage. The separation of the placenta ismost satisfactorily explained as follows :-1. Owing to itsformation the placenta cannot adapt itself to the extensionof the organ. 2. It is unable to retract with the cervicalzone during labour, the membranes being still intact. Withregard to the treatment, until within recent years the obste-trician’s choice was limited in the early stage, before the oswas much dilated, to the following methods :-1. Pluggingthe vagina, which is ineffectual, and increases the risk of sepsis.2. Forcible dilatation, version, and immediate extraction-fraught with extreme danger to the mother, as it increasestenfold the risk of post-partum haemorrhage, owing twolaceration of the soft parts. 3. Forcible dilatation andextraction by instruments; this method is, of course, opento the same objection as the last. 4. Separation of theentire placenta; this certainly controlled the haemorrhage,but inevitably destroyed the child. Dr. Fleming then drewattention to the methods adopted in the Rotunda Hospitalfor several years past. 1. The membranes are ruptured ifthe presentation is normal. This acts by allowing theplacenta to retract within the lower segment, and by causingthe presenting part of the foetus to act as a plug. This issufficient in a large number of cases. 2. Intero-externalversion is performed, a leg is brought down to act as a plug,and expulsion by natural efforts is waited for or aided verycautiously when the os is sufficiently dilated. Expulsionmay not take place for a considerable time. The advantagesclaimed for this treatment are-(a) it abolishes the use of thetampon and lessens the risk of sepsis; (b) it allows earlyoperation before much blood has been lost; (c) it arrestsheamorrhage; (d) it enables the patient to rally, gives theos time to dilate, and lessens the risk of post-partuin

127

haemorrhage from lacerating the cervix or vaginal soft parts.3. In some cases-when everything favours extraction, suchas a well-dilated os, and head low down —delivery is some-times practised with forceps; and, in other cases, it, is found

necessary to diminish the calibre of the head by perforationand extract rapidly. With reference to the statistics of thecases occnrring in the Rotunda Hospital for the past threeyears, ending Nov. 3rd, 1886,4514 cases were delivered duringthis period, and in this collection twenty-three cases ofplacenta prsevia were observed in which there wns a

maternal mortality of four deaths, three oi which werecomplicated with other serious affections, such as pleuro-pneumonia, sloughing fibroid tumour, and multiple fibroid,preventing contraction subsequently; and one patient wasin a collapsed state when admitted. Out of the&e twenty-three cases eleven infants were lost.A short discussion, in which Drs. More Madden, Byrne,

Kidd, and Mason joined, followed the reading of the paper.

WOLVERHAMPTON AND DISTRICT MEDICALSOCIETY.

AT the meeting on Thursday, Dec. 2nd, 188C, Dr. S. A.Smith, in the chair,

Dr. Evnvs showed the spleen and kidneys from a case oftyphoid fever characterised during life by Pxtremely hightemperature and treated by cold packing. The organs con-tained numerous infarcts of various ages. The spleencontained an abscess with ill-defined walls.Mr. GouGH read a paper on the Use of Axis-traction

Forceps in Midwifery. He described the object, mechanism,method of application, and special advantages of theseforceps, and showed that their superiority was not merelyconfined to the simpler forceps cases, but was of the greatestvalue in face, brow, and occipito-posterior case", and

occasionally where the after-coming head is arrested at thebrim in breech cases. He felt bure that as the old-fashionedstraight forceps gave way to the double-curved instruments,so would these eventually be superseded by axis-tractionforceps,

____________

Reviews and Notices of Books.Lectures on Medical Pathology. By 11. GAWEN SUTTON,

M.B., F.R.C.P. London: Baillière, Tindall, and Cox.1886.

WE must be grateful for any contribution that tends topresent our conceptions of disease in a new light, for thereis no denying that our pathological ideas are much restrictedby the habit of dwelling upon the proved facts of morbidlesions rather than on the functional derangements whichunderlie them. Therefore a book like the present is of

great value both for what it contains and for what it

suggests, awakening thoughts upon trite subjects and pre-senting familiar facts in a new guise. These lectures,moreover, which have been published from stenographicreports, possess a freshness and a spontaneity which distin-guish them very agreeably from the cold formalism of theset treatise. Dr. Sutton is not only a physician, but aphilosopher, and, if such a combination be allowed, a poetalso. At any rate he exercises freely the imagination ofthe one mingled with the reasoning of the other. And thewhole is welded by the practical mind of the physician, whodeduces from the facts of pathology the lines of soundtreatment in disease. The lectures traverse a wide tield, butthey form a connected whole; the same thought runs throughthem of the nature of disease, and the student is constantlyreminded of the influences which act on the organismfrom without as potent factors in the derangement of health.There is not a page that is not readable, and often one meetswith a phrase or sentence that deserves to be recorded as anaphorism, embodying in a few words the sum and substanceof a pathological idea. It seems to us that such a work isnot one to be dealt with by the captious pen of the critic.

It is rather to be accepted with gratitude for the thoughtsit contains and the facts on which they are based ; and hewould be bold who would venture to dispute the latter,however he might differ from the former. The simplest andbest course, then, for us to take will be to select, almost atrandom, a few passages, so that our readers may judge forthemselves of the style and matter here presented:--

" By pathology is meant a knowledge of suffering anddisease.’ Then comes the question : ’What is disease?’ Thegreat power of nature, unhindered by human ignorance, isalwnys acting easy’; this is seen beyond dispute as westudy the human body in the construction of the joints,serous surfaces, the heart and vessels ; but we in our igno-rance hinder the working, and bring about uneasiness, dis-ease, incapacity--and that is the origin of pain." (Page 1.)

" There are many causes of disease; we can never say thereis one cause of disease; therefore it is exact to say Thisdisease has arisen in these conditions.’ As much as possiblein thinking about pathology, endeavour to get rid of theword cause.’ (Page 3.)A striking statement in these days of etiological research !

" Blood-circulation is carried on by light and heat, andboth are rhythmical." (Page C.)

" Experience has shown beyond all question that acuteinflammation does not supervene in the healthy body. Whatare the facts which have led to this conclusion ? It hasbeen noticed for many years that when death results fromacute inflammation there has been antecedent disease, andthe exceptions are so few that we cannot but consider that inthese we have overlooked the antecedent disease." (Page 10.)

Again, in a few words—but the whole passage is too longto quote the author sketches the nature of phthisis, andbrings into prominence the contending views of its pneu-monic or tubercular basis. " The best way," he says, " ofregarding phthisis is to recognise that there are external andinternal morbid actions taking away the health and sub-stance of the body.’’ (Page 38.)

Here i3 a remark on bronchitis which illustrates thedoctrine held by Dr. Sutton upon inflammation, as quotedabove:

" I know nothing about bronchitis produced by cold inhealthy people. Some would say, Don’t you find primarybronchitis in children?’ When I have found bronchitis inchildren, I have usually been able to trace rickets, struma,or tubercle. Idiopathic bronchitis I know nothing about.Further. ’Does not bronchitis usually prevail in the wet andcold weather of spring and autumn, and is it not producedby those conditions ?’ Yes, no doubt that is so; but it is inpersons who have clear evidence of other disease." (Page 71.)And many will confirm the truth of this statement-viz :

"Usually persons recover from acute pneumonia, if there beno antecedent tissue degeneration of the lung, extremeblood-poisoning, or violence." (Page 82.)The lecture on Heart Disease opens with some good

advice as to the dealing with persons who have valvularmischief, but in whom the heart is acting with perfect easeand regularity. " So long as the heart is able to carry onthe circulation and breathing, whatever sign of damage wemay find in the heart, we must avoid discouraging thepatient." (Page 84.) Elsewhere, too, we are constantlymeeting with shrewd practical remarks which are well worthbearing in mind. Take, for instance, the following, withreference to dietetics and dyspepsia :-

" I used to be in the habit of saying people ought to eatproperly’; that they should only eat every three or fourhours; they should not eat between meals; they should eatand live by rule. Hut year by year many poor creatures com-plained dreadfully of their stomachs, of its sinlcing, and theybt:came so miserable that their days were almost unbearable.The big bell of Westminster tolled hourly on -that is, pro-perly, and their times for eating were regulated accordingly.But as 1 grew older I looked at the animals, and they wereeating and eating, and evidently whenever they could. Ilearnt at last to thank Heaven that I and others had beenmade as animals, and with use of reason. Let people eatwhen it is necessary, let them take food when they want it,c3

’I