1144

took. He submitted the contribution because thecase clearly showed that one possible path of infectionbetween the nose and the intracranial structures wasvia the lymphatic channel. The patient, a man aged33, had suffered from nasal obstruction due to polypion both sides. These were removed and the ethmoidalcells exenterated. Following this, a temperature of1038° F. quickly developed and pneumococcus wasgrown from the turbid cerebro-spinal fluid. Deathtook place five days after the operation.

Dr. W. JOBSON HORNE gave a short contribution,supported by an epidiascopic demonstration, on the

R61e of the Lymphatics in Laryngeal Disease.Twenty-five years ago, he said, it occurred to him thatthe lymphatic supply of the larynx was an open fieldfor research, and since then, as the material arrived,he had been following the subject up. First he dealtwith cases in which there was established disease inthe larynx, and the lymphatics became involvedsubsequently. It was strange that there were veryfew diseases of the larynx in which the adjacent andcorresponding cervical glands became implicated.One notable exception to this was malignant diseaseof the larynx. In this, sooner or later, the glandsbecame involved, and the period at which thatoccurred depended largely on whether the cancer wasextrinsic or intrinsic. In the case of the latter, thedate of gland involvement depended on whether thepart of the larynx attacked was covered by squamousepithelium or by columnar epithelium, it being earlierin the latter than in the former, and the results ofinterference in these cases was less satisfactory. Asto the r6le of the larynx in lymphatic disease, heshowed sections from cases of Hodgkin’s disease andof mediastinal sarcoma in which the larynx becameinvolved. He said that some sarcomata seemed tobe remarkably benign, and some authorities consideredthat they should be classified with the granulomata.He did not claim that the condition of the larynx wasresponsible for Hodgkin’s disease, but it was one siteof infection, and the particular vulnerable site wasbetween the cartilages of Santorini and Wrisberg.

The second session was devoted to clinical cases.

In the evening the Section entertained Sir StClairThomson, the President of the Society and a prominentmember of the Section, to dinner.

EDINBURGH OBSTETRICAL SOCIETY.

AT a meeting of this Society held on May 12thDr. R. W. JoHNSTONE, the President, being in thechair, Dr. F. J. BROWNE described a case of

Concealed Hcemorrhage with Placenta Prcevia.The patient, he said, was a primigravida who hadcompleted eight months of her pregnancy and wasadmitted to hospital on account of vaginal bleeding.Placenta preevia was diagnosed and the vagina waspacked. Twelve hours later the pack was removed andexternal version attempted, but was not perseveredwith on account of the large amount of old blood-clotthat was passed. The membranes were thereforeruptured and spontaneous delivery took place threehours later. The placenta was normal in appearanceand size, but overlying it was a quantity of fairlyold blood-clot, which covered practically the entireportion which had been prsevia and extended into theupper portion as well. The clot weighed over 12 oz.A catheter specimen of urine contained a moderatequantity of albumin. Three other cases described byHolland, Williamson, and Swayne were discussed,after which Dr. Browne stated that none were casesof purely unavoidable haemorrhage, and his own caseshowed that in some cases of placenta praevia thehaemorrhage might be concealed ; the concealedhaemorrhage, however, might be due to mechanicalseparation of the portion of the placenta situated inthe lower uterine segment and in this event would beunavoidable. Placenta preevia could not be excluded

in a case of concealed haemorrhage, and some cases’of concealed haemorrhage without albuminuria mightbe accounted for in that way. In all cases described,however, albuminuria was present and, therefore, itwas justifiable to presume the bleeding to be oftoxaemic origin ; thus bleeding in placenta praeviamight sometimes be accidental.

Dr. W. F. THEODORE HAULTAIN spoke onSome Practical Aspects of Antoiatal Care,

the great importance of such care to mother, child,doctor, and the State being pointed out. Dr. Haultaindisagreed with the relative frequency of the vertexpositions as stated in the leading text-books on thesubject. From statistics of 1000 cases seen within14 days of labour at the antenatal clinic of the SimpsonMemorial and Royal Maternity Hospital, Edinburgh,and another 1000 uncomplicated full-term cases

delivered in the labour ward of the same hospital,the relative frequency in round figures was found tobe L.O.A. 60 per cent., R.O.A. 30 per cent., R.O.P.8 per cent., L.O.P. 2 per cent. The figures for primi-parae and multiparae were taken separately in eachcase, but little variation was shown in these two maingroups.

Relative Frequeney of Vertex Position8.

The efficacy of pads as described by Buist in posteriorcases was then discussed, and statistics were given of70 consecutive occipito-posterior cases which had beentreated at the antenatal clinic during the last twoyears ; 38 of these were primigravidae, and in thesethe pads proved successful in 33 by substituting an.anterior position for the posterior ; in multiparae25 were successful, thus in the whole 70 cases successwas obtained in 82-8 per cent. In every case success,or failure was judged by the position at labour aswell as that found in the clinic after removal of thepads. To achieve success it was stated that (1) thetreatment should not be done till the last month ofpregnancy, (2) the head must be movable, and (3) castoroil should be taken at night when the pads were inposition. No danger could be caused by the treat--ment to either mother or child, and the difficulty ofthe future labour could not be aggravated by thetreatment, which was very simple and would in manycases avoid a tedious and often dangerous labour.The statistics of a consecutive series of cases of

external version in breech presentations was then given.In all 28 cases had been so treated in the last one anda half years, 12 in primiparse and 16 in multiparae.Among the primiparee version was successful on nine-occasions and among the multiparse 14 successes werereported ; thus 82 per cent. of the total number weresuccessful. Ansesthesia was recommended to aidsuccess in primigravidae and the manipulation was not.advised till the last month of pregnancy. Failure inthe primigravidee was attributed to the cases being ofthe " frank breech " variety, the failure in each casebeing noted at the time of manipulation, whereasin the multiparae the two failures were caused by areturn of the breech presentation after it had beenturned. The technique for the measurement of the-diagonal conjugate was described ; this measurementshould not be taken more than six weeks before fullterm, for by that time the perineum and soft partswere soft and the promontory of the sacrum could bereached in most cases with comparative ease, whereasearlier in pregnancy it was usually a very difficultprocedure. By the estimation at this period there

1145

would be still plenty of time to decide on inductionof premature labour if required, and if the pelviswas too small to warrant induction at that timethen the case was one for Caesarean section and notinduction. With regard to the position of the patientto allow this measurement to be taken with the

greatest ease, Dr. Haultain advised the exaggeratedleft lateral position, the woman flexing herself as muchas possible. Extreme gentleness in making theestimation was necessary to obtain satisfactoryresults.

In conclusion, Dr. Haultain thought that antenatalcare did not begin early enough, and suggested thatpatients should be seen after having missed oneperiod ; by that means a large number of abortionsmight be averted, especially those due to a retro-displacement of the uterus ; the bowels could belooked after, and all cases of slight sickness could betreated; thus might hyperemesis gravidarum bepractically obliterated. Rarer conditions such as

tubal gestation could also be recognised before ruptureoccurred and the woman’s life put in danger.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF MEDICINE. IA MEETING of this Section was held on May 14th, IDr. F. C. PURSER, the President, being in the chair.

Dr. R. STUMPF read a paper on

Rontgen-Therapy in Connexion with CertainBlood Diseases.

Having reviewed the treatment of polycythsemia rubravera, pernicious anaemia, and lymphatic leukaemia,he considered the subject of myelogenous leukaemia ingreater detail. In his opinion, the best treatment wasby X rays combined with the administration of arsenic.There was never complete cure, but cases were knownin which improvement sustained over many yearshad resulted from X ray treatment of this condition.Relapses occurred in weeks or months, each responding,but ever more slowly, to treatment. After each treat-ment there was a diminution in the size of the spleen,a drop in the leucocyte count, and an improvementin the patient’s general condition. The focus forradiation was the spleen. The essential point toremember was that each case must be treated on itsindividual merits and no dogmatic scheme could befollowed. The aim was to improve the patient’sgeneral health rather than to attain a rapid diminutionin the size of the spleen and an immediate drop inthe number of leucocytes. As regards technique,it was best to start with small doses and increase themvery carefully. Dr. Stumpf gave an acount of a caseof myelogenous leukaemia. Mrs. B., aged 23, showedfor several months atypical symptoms and suddenlydeveloped a severe pain in her abdomen about a yearago. The spleen was found to be much enlarged andthe leucocyte count was 250,000 per c.mm. She hadhad three courses of X ray treatment, and duringpart of the time was getting injections of arsenic.In the course of treatment the leucocytes graduallyfell from 250,000 to 25,000 per c.mm. This favourablefigure had not been maintained, since it was not con-sidered necessary to give sufficient exposures to theX rays to bring about this result, the patient’s generalhealth being excellent. Frequent blood counts werebeing carried out and sufficient treatment was givento maintain the leucocytes somewhere between60,000 and 90,000 per c.mm. At the beginning oftreatment the spleen reached to below the level ofthe umbilicus and extended across the middle line.It was now three fingers-breadth below the costalmargin and was well to the left of the middle line.The patient’s weight had increased very considerablyand her general condition was excellent.

Dr. A. R. PARsoONs said that his results had beenmuch the same as Dr. Stumpf’s as regards earlyimprovement and subsequent failure to repeat the

first success. He asked whether deep X ray therapyhad any advantage over ordinary X rays.

Dr. MAURICE HAYES said that with deep X raysthe number of treatments were less, the intervalsbetween treatments were longer, and the risk ofdamaging the skin less ; also by deep X rays it waspossible to get a more uniform radiation at the firstdose.

Dr. J. SPEARES wondered if X ray treatment didin reality prolong the life of these cases. As tolymphatic leukaemia, it was his experience that thepatient might live a very long time. He was atpresent treating a patient who had had the disease.for 21 years.!, Sir JoHN MooRE read a Historical Note on

Alkaptonuria, recalling the first example of thisabnormality described in Dublin, at a meeting overwhich the speaker presided 45 years ago.

Exhibition of Radiograms.Dr. J. SPEARES and Dr. G. BEWLEY showed radio-

grams of three cases of diaphragmatic hernia. One ofDr. Speares’s cases had marked gastric symptoms forrelief of which operation was urged. Dr. Bewley’scase was one of eventration.

Dr. C. L. McDoNOGH showed radiograms of(a) rickets with multiple fractures ; (b) sarcoma ofthe sternum. In the former case eight fractures oflong bones were to be seen, the changes typical forrickets being marked in the long bones, ribs, and skull.In the latter case the X ray appearance of the tumour,the failure to find any primary growth, and thenegative W.R. pointed to the very rare condition ofprimary osteo-sarcoma of the sternum.

Dr. T. GARRETT HARDMAN and Dr. LEONARDABRAHAMSON showed radiograms of a chest afterinjection of lipiodol, and gave an account of thetechnique employed. ____

SECTION OF ANATOMY AND PHYSIOLOGY.

A MEETING of this Section was held on April 16th,Dr. C. M. WEST, the President, being in the chair.

Prof. J. M. O’CoNNOR demonstrated Indian inkinjections of the living kidney blood-vessels, and reada paper on

The Blood Flow through the Kiclriey and its Relationto the Theory of Urine Formation.

He said that by diverting the blood of the left kidneydown the vena cava into a reservoir while the bloodpressure is maintained by a reserve of blood in acompensation tube connected with the aorta, theblood flow through the kidney at constant arterialpressure could be examined. On closing off thecompensation tube the flow with falling pressurecould be determined. If the blood flow were graphedagainst the prevailing pressures there was, withfalling pressures, a kink (or kinks) in the graph in thesense of increases or decreases in the blood flow.These kinks occurred at various levels of blood pressureand of blood flow, and were relatively the same at alllevels in any one animal. A similar kink could beproduced by diminishing the pressure in the renalartery by a clamp on the abdominal aorta, while thepressure was maintained constant in the-rest of thebody by having a carotid artery connected with thecompensation tube. Similar alterations in flow eitherpositive or negative resulted from the injection ofdiuretics. These results were in keeping with thesuggestion that the flow of blood through the kidneyis regulated by a compression of the glomeruli by thesecretion pressure of the urine. Experiments in whichthe kidney vessels were injected with Indian inkshowed agreement with the theory that the relative;number of glomeruli uninjected or but partly injected’corresponded with the kink on the graph of blood!pressure and blood flow.The PRESIDENT said that until he had heard Prof.

O’Connor’s paper he had not been aware of anyopening of the glomeruli, and he did not see whyeven when destruction of the capsule occurred, it.