806

resembling chronic rheumatism. When this occurs t

confinement to bed again becomes necessary. Drugs tconfer only temporary relief. Frequently one of a }

fatigue party from among the convalescents had to "

be readmitted to hospital for painful, occasionally:for swollen feet. This was not a mere plea to ]escape work, for often as not it was a Gurkha who (

was thus disabled, a man who. was always willing fto help and seldom a shirker. The sooner a patientis put on exercises, at first in the ward and then as 1one of a fatigue party, the better. Too protracteda stay in bed or hospital renders the feet verysensitive. A return to the normal condition is bestbrought about by encouraging a normal circulation ,which will follow on the physiological use of the I

parts concerned. Salford.

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:

Medical Societies.ROYAL ACADEMY OF MEDICINE IN

IRELAND.

SECTION OF OBSTETRICS.Unusual Degeneration of the Cervix.-The "Dublin Arethod

for the Third Stage of Labour.-The Alexander-AdamsOperation. .A MEETING of this section took place on March 12th, Dr.

M. J. GriBSOX, the President, being in the chair.Dr. ALFRED SMITH showed a case of an Unusual De-

generation of the Cervix in a patient, aged 60, the mother of16 children, who consulted him for a profuse slimy discharge.The menopause came on ten years ago. She had enjoyedgood health up to August last, when she noticed a slimydischarge from her vagina, without hoemorrhage, pain, oroffensive odour. On bimanual examination the vaginalportion seemed to have disappeared, the margins beingflush with the vaginal vault, the os being so dilatedas to admit the index and middle fingers. Thereseemed to be no internal os ; the cavity of the uteruswas greatly dilated ; the mucous membrane felt likevelvet pile. This slight palpation caused hoemorrhage.On curettage, quantities of brain-like matter reportednon-malignant came away, as in cancer. Simple pan-hysterectomy was performed. The total length of the uteruswas 12 cm., fundus 35 cm., cervix 8 5 cm., greatest iwidth 6-7 cm. The fundus was normal, but the cervical

portion was greatly thickened, due to the transformation ofthe normal muscle wall into a spongy mass infiltrated withmucoid material, directlv continuous with much mucus in thecavity of the cervix. The whole contour of the cervix wasaffected, more markedly in the anterior and left wall. The truecervical wall was represented by a thin layer of fibro-musculartissue. No evidence of malignancy. The specimen was in thenature of a channelled mucous polypus, but was remarkable inthat it engaged more or les5 uniformly the whole of the cervicalwall.-Dr. E. HASTINGS TWEEDY said it seemed to be anadenomatous condition of the mucous membrane, somethinglike a mucous polypus, spreading over the entire surface.-Dr. R. J. ROWLETTE said he had never seen anything likethis exhibit. It possessed remarkable similarities to the

glandular structure found in mucous polypi. Why a tumourshould sometimes be so confined and at another time so

diffuse as this was a problem.Dr. T. P. C. KIRKPATRICK investigated the claim put

forward that the method of conducting the third stage oflabour, known for so long as the "Dublin method," hadoriginated in Dublin. He showed by extracts from the Midwifery " of Fielding Oald, published in Dublin in 1742,that this method was not then taught by him. After Ould,the next work on midwifery by a Dublin writer was thatpublished by Foster in 1781; yet even in this work the’’ Dublin method " was not clearly described. lnl768,how-ever, John Harvie had published in London a short pamphletin which he gave a clear and exact description of the method.It seemed probable, then, that Harvie was the first to de-scribe the method, and that subsequently it was adopted as

the teaching of the Dublin Lying-in Hospital. Thoughthe Dublin school might not be able to claim thehonour of having first described the method, yet thatschool deserved credit for so early necognising its value.and for so consistently teaching it.-Dr. R. D. PUREFOYsaid he thought the idea of robbing the Rotunda.

Hospital of the credit of producing a practice whichobstetricians all the world over admitted was a markedlysafe one might have been left to someone else. That Dr.

Kirkpatrick had succeeded in the task he for one was veryunwilling to admit. He had not studied Ould’s book withsufficient care to know his views on the management of thethird stage, but to the Dublin school this method ofmanagement of the third stage had long been credited, andin Spiegelberg’s 11 Midwifery it was alluded to as the Dublinmethod. The fact that Dr. Harvie described the methoddid not prove (although he must be given full credit forhaving used it in his own practice) that it originated inEngland. He could not help thinking that this practicehad been known for a very long time, and in thoseearly days they were not so keen to support their-claims as originators because it was considered that

they were generally admitted. He hoped that he mightobtain evidence that this method of treating the third stagewas in general practice in Ireland very shortly after SirFielding Ould’s book was published, although not speciallyalluded to, because it was generally recognised. He con-sidered it a pity that they should be deprived of the credit ofwhat he believed to be the practice of the Dublin school fora very long time.-Sir WILLIAM SMYLY expressed their in-debtedness to Dr. Kirkpatrick for his careful research.There was no doubt that the description published by Dr.Harvie was what was now generally known as the Dublin,method, but credit was more often given to the personwho popularised the method than to the person who-first described it. The method appeared to be only men-tioned by Dr. Harvie, who did not even appear to attachmuch importance to it, as he placed two other methodsbefore it, whereas in Dublin it was exclusively and systemati-cally taught for generations. When Spiegelberg visited thiscountry he reported that the two things which impressedhim most were the Dublin method of the delivery of theplacenta and the use of chloroform in Edinburgh. SirWilliam Smyly did not think Crede’s method was the sameas the Dublin method; it was much more active and,designed to get rid of the placenta as soon as possible. SirWilliam Smyly thought the very best method was the onereferred to as being practised by primitive people-i.e.,sitting in the crouched position and rubbing the hypo-gastrium with the hand, and he suggested that the Dublinmethod was an adaptation of that. After trying different.methods he had come back to the Dublin method as the best..- Dry. TWEEDY said that all Dublin obstetricians had beenaccustomed to look upon Sir Fielding Ould as the founderof the Dublin method of dealing with the third stage oflabour. The method was not described in Ould’s book,which, however, was written when the author was only 21years of age, and before he had acquired any practicalexperience in obstetrics. It was, therefore, quite possiblethat the method described by Harvie originated with Ould.-Professor A. J. SMITH said that he had gone through the-literature to ascertain the claims of Dublin but he could’get nothing but tradition to support it. Sir Arthur Macan,.although very much in favour of German methods and’literature, was convinced that this method originated in.Dublin. Harvie’s book did not come under their notice attthe time. He agreed with Dr. Purefoy that the case was-not proven.-Dr. KIRKPATRICK replied.

Dr. D. G. MADILL reported the After-results in 250 Casesof the Alexander-Adams Operation performed at the Rotunda,Hospital during four years, and described the method of

doing the operation with a single incision.-Professor SMITHsaid that in his own experience the type of case suitable forAlexander’s operation hardly required an operation at all.Patients who came into St. Vincent’s Hospital complainingof backward displacement, menorrhagia, and menstrual painwere first examined under an anaesthetic. If the uterus wasfound to be mobile a simple method of replacement wasadopted by applying the weight of the ordinary Rotundadouche, which usually brought the uterus through the-Bozeman’s catheter into position. The patient was then put.back to bed and examined on the third day ; the uterus, was.

807

’usually found to remain in position. In that type of case’-the Alexander operation was usually performed, and gave goodresults in a limited class of cases, but he thought it wouldnot do so if the uterus was enlarged.-Dr. TWEEDY saidneither Dr. Madill nor anybody else could say that he hadnot been mistaken in bimanual examinations, and it wasthe possibility of these mistakes which robbed Alexander’soperation of its value. Personally he favoured the operationof ventrosuspension, but his results from vaginal suspensionhad also been good. Nine patients on whom this operationhad been performed all expressed themselves as having been’improved, and four had become pregnant and delivered them-selves normally. He thought Dr. Madill had curtailed theoperation greatly when he suggested that it should not bedone for sterility.-Dr. GIBBON FITzGIBBON thought thatany operation for the cure of retroversion of the uteruswould produce as good results as the statistics brought’-forward showed. He agreed with Dr. Tweedy that therewere no complications after ventral suspension. He hadnever found any trouble arising afterwards in pregnancy orparturition. Out of seven cases in which he had done

vaginal suspension during the child-bearing period, one

afterwards had twins and two others had had single preg-nancies, without complications. Many cases of retroverted’mobile uterus caused no symptoms unless there was trouble inthe tubes, in which case ventral suspension enabled an attempt,to be made to correct the cause of the sterility. One cameacross adhesions of the tubes in cases with a mobile retro-verted uterus, but with practically no thickening of the tubeswhich would be palpable by bimanual examination.-Dr.PUREFOY said Dr. Madill had pointed out to them the points

Iof chief importance in the successful performance of the Ioperation. During Dr. Purefoy’s Mastership at the Rotundathis operation had not come into general use there, and he’was against it because a woman came into the hospital and- said that that was the third miscarriage she had since"she had this operation performed by the inventor in

Liverpool. He had on several occasions since seen the

operation performed in the Rotunda Hospital, and he’thought Dr. Madill’s statement a powerful one for the opera-tion rn the cases he had indicated.-Dr. B. SOLOMONS saidthat in cases of prolapse of the uterus, in addition to plasticwork by the vagina, he considered Alexander’s operation veryuseful. In cases in which the retroversion occurred postpartum, and where palliative treatment failed to produce a- cure, an Alexander-Adams operation was most suitable.He suggested if either Alexander’s operation or ventral

- suspension were properly performed there would be very’little difference’ in the results. He found that theAlexander-Adams operation was effective in producinga. cure without inserting a pessary afterwards.-ThePRESIDENT said that in dealing with mobile retro-displacement three classes of cases generally came under- consideration. Firstly, the unmarried woman with uncom-

plicated retrodisplacement. These patients had no

symptoms which could be attributed to displacement, andcorrection of the displacement was not necessary. Secondly,the married woman bearing children and suffering, as many- did, from retrodisplacement complicated with descent,associated with definite discomfort. Examination underanaesthesia and the absence of history of infection enableda:dnegal trouble to be excluded, and in these cases vaginalrepair with correction of the displacement by the Alexander-Adams operation gave excellent results. Thirdly, the sterilemarried woman. If a transverse incision were made the’tubes might be examined’and treated, and the Alexander-Adams operation performed without difficulty. He pre-ferred the Alexander-Adams operation to ventral suspensionbecause relapse was not so liable after parturition, and theposition obtained is more normal.-Dr. MADILL, in reply,-said that he had seen Sir William Smyly perform amodified Gilliam’s operation that morning, and it appearedto have most of the advantages of the Alexander,and, in addition, there was the extra advantage of seeing the’inside of the abdomen. He admitted that a weak point wasthat one could not be absolutely certain, but he was glad tohave the support of the President that one could be fairlycertain after examination under an anaesthetic. He hadnothing to urge against ventral suspension, except to doubtthat the uterus remained in position after confinement. Ifthere was no recurrence he was certain it was a betteroperation than the Alexander-Adams.

Reviews and Notices of Books.Archbold’s Lunacy and Mental Deficiency.By JAMES WILLIAM GREIG, of Lincoln’s Inn, K.C.,and WILLIAM H, GATTIE, of Gray’s Inn, Barrister-at-Law. Fifth edition. London: Butterworth and Co.and Shaw and Sons. 1915. Pp. 1058. Price 36s. net.

THE medical practitioner who comes in contactwith the treatment of insanity and the formalitiesaccompanying the custody of the insane only asincidents of his general practice will hardly needto provide himself with so exhaustive and weightya volume as this. It is, however, otherwise withofficers of county and borough asylums or theircommittees, who, doubtless, will be willing to

defray the cost, and with those who, being theproprietors of licensed houses, have to be con-

stantly and unremittingly certain of their groundin dealing with patients with regard to whom thelaw exercises proper and necessary vigilance. Forsuch as these " Archbold’s Lunacy " is a leadingand authoritative text-book of the law, and if ithas been somewhat augmented in its physicalweight and bulk by the inclusion of the Mental

Deficiency Act, and contains many pages which willnot closely concern him whose professional work isthe purely medical care of the insane, it is never-theless a compendious treatise to which referencemay have to be made at any time, when unexpectedpoints arise, as well as on occasions of more usualoccurrence.

How far the single-volume form may be preservedwithout inconvenience when there is ample materialfor two more readily handled volumes will be amatter for editorial consideration, as the subjectsto be dealt with increase periodically and becomemore or less naturally divisible. The editors inthe present case point out that the law of lunacy,so far as it is governed by the principal Act, thatof 1890, divides itself into two chief groups of

provisions. The first consists of those which areto be administered by the Commissioners and theBoard of Control (constituted by the MentalDeficiency Act), by justices of the peace, county andborough councils, guardians of the poor and theirofficers, officers of county and borough asylums,managing committees and officers of hospitals,visitors, proprietors, and officers of licensed houses,and persons having the charge or being the medicalattendants of single patients. The second group isthose administered by the Lord Chancellor and thejudges for the time being entrusted with the care ofthe persons and estates of lunatics, and by themasters in lunacy, Chancery visitors, committees,and medical attendants of lunatics so found, and bypersons exercising, under the authority of theabove higher officials, powers over the property oflunatics not so found, resembling those exercisedby the committee of the estate of a lunatic who hasbeen so found. How far this classification mightlend itself to a two-volume form in the work inquestion is a matter worth considering, even thoughthe use of a decidedly large book where a smallerone could be made available is only a matter oftemporary inconvenience to the individual. There

are, however, branches of the law of lunacy,included in such Acts as the Criminal Lunatics Acts,the Lunatics’ Removal (India)’Act, 1851, the ColonialPrisoners’ Removal Act, 1884, and the CriminalLunatic Asylums Act, 1860, which fill a good manypages to which recourse would be had only by lawyers