1880

attempt has been made by the profession in Englandto inform their foreign colleagues that there existin our island spas and climatic stations of the highestrank. Continental spas should not be regarded as competingwith British spas, nor British with continental, the indica-tions for the two groups differing so widely that they arecomplementary to each other. Speaking generally, the

categories of foreign invalids for which our spas are typicallysuitable include those who thrive in a relatively cool climateand are able to walk well, those who in association withcomplete change derive benefit from baths which are

neither very hot nor taken in close succession, and thosewhose maladies are held to be tributary to the waterswe possess-that is to say, the muriated, sulphuretted,iron indifferent, earthy, and alkaline sulphated. A com-

prehensive view of British spas from an international

standpoint is that, whereas for Britons they are mineralwater stations with climatic advantages, for foreigners theyare climatic stations with the advantage of mineral waters.It has been objected that our spas are intolerably dull, butthere are very many on the continent visited annually bythousands of invalids which are not in any way more

lively. Excessive rainfall has been urged against all ofour resorts, but on the European mainland, too, it isnot uncommon for a whole season to be spoilt by per-sistent downpour of rain; and, as a matter of fact, insummer less rain falls in the eastern division of Eng-land than at some of the stations of Western Europe.Our seaside resorts possess for foreigners advantages which,if not so well defined, are even wider in range. Foreignersare accustomed to and demand higher temperatures insummer than are agreeable to English people. This difficultymay be met by sending continental patients to the warmerof our coast stations. We have, in addition, inlandclimatic stations where the air, though bracing, is not devoidof sedative qualities. Among such stations may be mentionedHindhead, Church Stretton, Crowborough, Okehampton, andBen Rhydding. When the inhabitants of Central Europebecome as well aware of the advantages of British healthresorts as we are of the indications for theirs, there will bea free interchange of invalids instead of as now a movementin only one direction-and that away from our shores. Inorder to accomplish this purpose a book is now under con-sideration with descriptive monographs written and the wholecollated by whatever chapters may appear to be necessary.The PRESIDENT, Mr. E. SOLLY, Dr. F. BAGSHAWE, Dr.

R. FORTESCUE Fox, Dr. A. MANTLE, Dr. F. H. HUMPHRIS,and Dr. J. LIDDELL took part in the discussion whichfollowed, and Dr. WOOD replied.

EDINBURGH OBSTETRICAL SOCIETY.

The Modern Treatment of Contracted Pewas.-LccnternDemonstration.

A MEETING of this society was held on Dec. 14th, Dr.F. W. N. HAULTAIN, the President, being in the chair.

Sir JOHN HALLIDAY OROOM read a paper on Modern Treat-ment of Contracted Pelvis. At the outset he referred tothe diminution of sepsis in hospital practice, which per-mitted many interferences now which were impossible inthe olden days, and he further referred to the fact that

sepsis still continued in private practice. He thought itwas useless to discuss the methods of dealing with thenarrow pelvis until practitioners recognised the fact that acareful and accurate measurement of the pelvis in everyprimiparous woman, and in every multiparous womanwith a bad obstetrical history, must be carried out.He referred to the fact that in midwifery, as well as in

general medicine, preventive treatment was more important,instancing the successful prophylaxis of obstetric com-

plications in the Pre-Maternity Home in Edinburgh. Hedivided narrow pelvis, for all practical purposes, into threecategories. First, those below 3 inches ; second, those above3 ; and third, those between 3 and 3-. With the first

variety there was no difficulty in dealing, because in themthe only treatment, when diagnosed before labour, was

Cassarean section, which, of all abdominal operations, was byfar the most satisfactory. He then dealt with the question ofsuch cases being seen late in labour, and with the field ofcraniotomy, which he pointed out as getting more and morecircumscribed every day. He recommended a more general

use of maternity homes and nursing homes for the treatmentof all obstetric operations. Sir John Halliday Croom pointedout that with the disappearance, in hospitals at least, of

puerperal septicaemia, confidence in the forces of nature hadreturned, and labour in a narrow pelvis was allowednow to complete itself spontaneously in a great pro-portion of cases. This method of treatment was strikinglysuccessful both for the mother and child. He believedthat spontaneous delivery might be looked for in caseswith a conjugate of slightly under 32 inches in flat

pelves and 3 inches in generally contracted pelves. TheWalcher position should never be omitted in these cases asan aid to the fixation of the head. The duration of thesecond stage of labour was to be limited only by the con-dition of the mother and child. The great difficulty centredround the quarter of an inch between 3 and 3 inches. In thatsmall area there was a choice of treatment. If the conditionwere recognised early, there was the option of inducing pre-mature labour ; if not seen until term, there was the choiceof attempting to deliver by forceps or by some operation forenlarging the pelvis. The position of the operation of theinduction of premature labour was that it was perfectly safefor the mother, but unfortunately was accompanied by a veryconsiderable infantile mortality. In regard to high forcepsoperations in narrow pelvis, the mortality and morbidity tothe mother were unquestionable. This was absolutely provedby statistics. The fcetal mortality in these cases ran between20 and 40 per cent. He then referred to the developmentof the operations for the enlargement of the pelvis. These.

operations were not uniformly safe for the children, andwere not unassociated with considerable risk to the mother.The cases in which these operations were useful were thoseof moderate contractions in which, after ample time hadbeen given for the head to enter the brim, it still remained,unengaged. There pubiotomy might be expected to befollowed by spontaneous delivery, but if necessary, and

particularly if the child’s life were endangered, might bejustifiably supplemented by forceps delivery. He thoughtthat no high forceps operation should be seriously undertakenunless the operator was prepared to perform one of thesecutting operations if necessary.

Dr. J. M. MuNRO KERR (Glasgow) alluded to the tendencyin recent years to leave difficult cases to nature. Yet heremembered how Dr. Milne Murray extolled highly the useof axis-traction in high forceps cases and how he couldaccomplish delivery in pelves with a conjugate of 281 inches.But in high forceps difficult cases the foetal mortality wasabout 50 per cent. If these cases were given plenty of time,from 50 to 60 per cent. were delivered spontaneously. Insuch cases one should estimate the size of the head and

pelvis, and give plenty of time for nature to mould the head;-if that failed forceps should be applied. If fair traction wasnot sufficient one should never resort to brute force to pullthe head through, but then perform pubiotomy. In obstetricscare should be taken not to be led by fashions. Even now

pubiotomy was being decried by previous supporters.Dr. J. W. BALLANTYNE advocated the education of public

opinion as to the necessity for careful examination of thepregnant woman to ascertain the presence of such conditionsas albuminuria and pelvic deformity. Obstetrical homeswere much needed, and also an obstetrical bed readilyadaptable to the Walcher position and for the performanceof operations.

Dr. J. HAIG FERGUSON alluded to the complete change intheir views as regards the application of the high forceps,considering it unjustifiable to apply them if the head wasfree above the brim. It was better to give plenty of time formoulding of the head to take place, at least in slighter degree,before applying the forceps. In private practice the fcetalmortality was not nearly so great as in hospital practice.

Dr. W. FORDYCE thought they were losing sight of thevalue of the old operation of turning; it gave the advantageof engaging the narrow wedge of the head in the conjugate,and this could be assisted greatly by the pressure of the handdirectly on the head through the abdominal walls. SirHalliday Croom had given exact measurements of the con-j ugate in his paper, but he (the speaker) had found it ex-

ceedingly difficult exactly to estimate the true conjugate.The diagonal conjugate was a help, and consideration mustalso be given to the position of the head.The PRESIDENT said he thought the maternal mortality

given by Sir Halliday Croom was impossible in experienced

1881

hands ; he had never once seen a woman die as a resultof the application of high forceps. Much was to be

gained by patient waiting on nature’s attempts to mould thehead. It was extremely difficult to measure the pelvis,estimate the size of the head, and the probable amount ofmoulding it would undergo. To discard forceps was a swingof the pendulum in the opposite direction.

Dr. JAMES RITCHIE and Dr. MICHAEL DEWAR also took

part in the discussion.Sir JOHN HALLIDAY GROOM, in his reply, mentioned that

he considered forceps one of the best instruments, mostexcellent in their place, when the head was engaged in thebrim or in the pelvic cavity.

Dr. JAMES YOUNG gave a lantern demonstration on theMode of Action of the Fcetal Structures on the MaternalTissues and the Function of the Decidua. He referred to the

importance of a clear appreciation of the structure of theuterine mucosa in order to understand the changes duringpregnancy. He had already pointed out that the stromathroughout its entire extent was a soft, mobile, protoplasmicmass imperfectly differentiated into cellular elements. Ashe had also pointed out, the fluid and blood escape from thevessels during menstruation was due to tissue change whichled to an active dragging out of the blood elements from thevessels-the structural peculiarity of the stroma allowed of anopening-out of the vessel walls and a displacement of thestroma to the greatest advantage. Menstruation was not a

congestive process. Dr. Young pointed out that the changesinduced by the chorionic epithelium in the pregnant tube,chorion-epithelioma, &c., proved that there was liberatedfrom the chorionic cells a bio-chemical material that spreadinto the surrounding tissues, extending its sphere of actionmore and more with the duration of growth. This substancealtered the maternal tissues in such a way as to leadto an active imbibition of the blood fluid by the tissues,hence the widespread and uncontrolled oedema. Later itled to a dragging of the red corpuscles from the vessels-i.e., after the vessel walls were teased out. This was thecause of the opening up of the maternal vessels whichoccurred in these conditions; it was not due to a

mechanical liberation of the contents from vessels, the wallsof which had been eroded by the advancing chorionic

epithelium. The tissue changes were due to an alteration inthe protoplasmic colloids, with an increase in their affinity forfluid. In the case of the endothelial and connective-tissueelements this was manifested by a distinct intracellularcollection of fluid. The same changes were present in themuscle elements, but here there occurred in the abnormalsites a speedy disintegration and solution. The result ofthese changes in the proximity of the foetal elements was seenin a wholesale passage of the blood through the tissues towardsthe chorionic epithelium. The new vessel formation and thesinuses which developed were due to the same tissue changes.Dr. Young showed vessels from the decidua of two early humanova, which revealed the existence of the same cause of theblood escape. One of these ova was approximately 14-15days old. In the pregnant tube the only regions where theirregular and uncontrolled oedema and hæmorrhage wereprevented were where a decidual change had occurred, andit was clear that, without it, the uterine mucosa would betorn up from fundus to internal os as successive levels cameunder the influence of the chorionic substances. The decidualmembrane localised the changes to the proximity of the ovum.- Dr. B. P. WATSON, Dr. FORDYCE, Dr. HAfG FERGUSON,and Dr. J. LOCHHEAD discussed the subject, and Dr. YOUNGreplied.

CLINICAL SOCIETY OF MANCHESTER.-A meetingof this society was held on Dec. 20th at the Children’sHospital, Gartside-street, Mr. J. Howson Ray, the Pre-sident, being in the chair.-Dr. H. A. G. Brooke and Mr.L. Savatard showed cases illustrating the dermatologicalaffections of Tertiary Syphilis, a case of Molluscum Con-tagiosum, and a case of Primary Lupus Vulgaris in a youth.-Dr. J. G. Clegg showed an interesting case of TraumaticVertical Hemiopia of the Right Eye. A short timebefore being seen the patient had received a blow on theright side of the nose, and the ophthalmoscope readilyshowed a haemorrhage into the sheath of the right opticnerve.-Dr. N. C. Haring demonstrated the uses ofthe Pharyngoscope.-Dr. C. C. Heywood showed a caseof Muscular Rigidity in an infant aged 18 months, and

a case of Intention Tremor in a boy aged 13 years.-ThePresident showed several children with Affections of the Hip-joint, with X ray photographs of each, and demonstratedthe diagnostic points of difference between coxa valga, coxavara, tuberculous hip disease, and tuberculous disease of thegreat trochanter. He also showed a case, on which he had

operated recently, of extensive Cleft Palate and Hare-lip.-Mr. H. H. Rayner showed two cases, undergoing fixationtreatment, of Congenital Dislocation of the Hip-joint, withX ray photographs of these.-Dr. J. A. K. Renshaw showedcases of Tuberculous Laryngitis among others.-Mr. P..R.Wrigley showed a case of Cerebellar Abscess and oneofSarcoma of the Left Frontal Bone, both in young girls.

Reviews and Notices of Books.Internattional Clinics. Edited by HENRY W. CATTELL, A. M.. 9

M.D., Philadelphia, U.S.A. Vol. III., Twentieth series,,1910. London and Philadelphia : J. B. LippincottCompany. Pp. 311.

THIS volume opens with an interesting contribution to thestudy of the ideographic cerebral centre, illustrated by a caseof ideographic aphasia by Dr. H. V. Wurdemann. This is

followed by an article by Dr. Nathan P. Levin on Ehrlich’sDiazo Reaction in Chronic Tuberculosis. This reaction, as iswell known now, is not so absolutely diagnostic of entericfever as its discoverer first thought. Although it is of almostconstant occurrence in this disease, it has occasionallybeen present in a number of other affections, both acute andchronic, and of these it more especially occurs in some of theacute and chronic forms of tuberculosis. Dr. Levin, as aresult of his inquiry into the latter aspect of the value of thereaction, states that it is very rare in the early stages ofphthisis ; that it does occur in a good proportion of theadvanced cases, but not in all of them ; and, lastly, that itis a bad prognostic omen, as, of course, follows from its

occurring in these advanced cases. In his remarks on thetreatment of pneumonia Dr. Joseph H. Lopez emphasises thevalue of the "hot jacket" over the messy, old-fashionedlinseed poultice, which has to be so frequently changed,necessitating the patient to unnecessary exposure and dis-comfort. He gives us various useful formulae, including, weare glad to notice, one containing strychnine, which should begiven without waiting for the profound systemic depressionto be developed. He does not mention the good effect ofanother very valuable drug, albeit also an old-fashioned

one-namely, antimony. Dr. C. K. Austen writes on auto-

serotherapy, instancing cases where it gave good results inpleurisy, tuberculous and otherwise, and finding it efficaciousin the majority of cases. It has also been tried with goodeffect in cases of ascites from cirrhosis of the liver.An excellent contribution is by Dr. L. Howard Russell on

Uncinariasis. He summarises the various signs of the

disease, showing how vast districts of South America are in-fected by it. As regards the blood examination, that for thehaemoglobin is the most important, as nearly all the casescited by Dr. Ashford and Dr. King show diminution of this

constituent, whilst the most important and characteristicsign in the differential count is the eosinophilia. Nearly allthe cases showed this : it is greater in the acute than in thechronic cases, and its decrease under treatment is a goodprognostic sign. The red cells are usually reduced ; in onecase they were as low as 904,000. The changes in the

stools, skin (which is dry and harsh), nervous, circulatoryand digestive systems, are all portrayed, and finally thepatient is shown to have been always undeveloped and toexhibit a peculiar apathy. With regard to the examinationof the stools, the author lays great stress on the quickexamination of the fæces under the microscope with a low