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of some continental ammunition which was knownto possess a steel casing.Sometimes metallic traces, too small in amount to

be analysed, could be identified by means of thespectograph, but this method was still in its infancy.

A brief discussion followed, in which Mr. J. H.RYFFEL, Dr. MORGAN FINUCANE, Mr. BARRY O’BRIEN,Mr. W. M. WALKER, and the PRESIDENT took part;Prof. SMITH replied.

MEDICAL SOCIETY OF LONDON.

AT a meeting of this Society held on March 25th,the chair was taken by Dr. WALTER CARR, thePresident, and a discussion on the

MEDICAL INDICATIONS FOR THE INDUCTION OFABORTION AND PREMATURE LABOUR

was opened by Mr. EARDLEY HOLLAND. Reviewingthe legal and ethical position, he pointed out that theonly lawful object of abortion was to save the mother’slife or prevent serious injury to her health. Themedical profession was trusted implicity and giventhe widest possible freedom of judgment. It hadnever been practicable to lay down strict rules forthe medical indications, which had changed as

medicine had advanced. The advent of insulin, forexample, had made possible many pregnancies indiabetic women. Great difficulties occurred whensocial, personal, and economical factors added theirweight to a medical indication which in itself mightseem inadequate. The ethical standard had notbeen lowered by modern practitioners, but themodern gynaecologist was less fitted than his prede-cessors to form an opinion on the indications forabortion because he leaned more towards surgeryand less towards medicine.The medical indications might be classed as : (1)

positive indications, (2) debatable indications, and (3)a heterogeneous and unclassifiable collection ofcombined medical, personal, and social considerations.Among the positive Mr. Holland put hyperemesisgravidarum of the toxsemic type ; acute and chronicnephritis ; chronic valvular disease of the heartwith failure of compensation ; pulmonary tuberculosis(about which there was great difference of opinion) ;Graves’s disease ; insanity, and certain cases ofBacillus coli pyelitis, which did not yield to treatment.The debatable indications included multiple arthritisdeformans during pregnancy ; hypothyroidism, suchas early myxoedema ; hyperthyroidism ; albuminuriaof pregnancy ; eclampsia in a former pregnancy (asomewhat slender reason) ; certain cases of cardiacdisease, and slight cases of pulmonary tuberculosiswhich might have a bad effect on pregnancy ; formerpuerperal insanity ; severe nervous or mental dis-turbances in early pregnancy due to fear in a formerconfinement, and as a better alternative to Caesareansection than craniotomy. Very debatable were anew class of eugenical indications which might betermed "feetal." One of these was refractorysyphilis, as for example in a case where, in a formerpregnancy, the Wassermann reaction could not bebrought to negative except by what was practicallyan overdose of arsenobenzene. Another was idio-pathic epilepsy in the husband. It was interestingto contrast the hospital figures with those of privatepractice ; the former showed a great preponderanceof " positive " indications. From 1924 to 1927inclusive, out of 4000 gynaecological operations,only thirty-one had been for the induction ofabortion. Twenty-nine of the operations had beenundertaken for " positive " reasons ; eight of thesehad been for uncompensated cardiac disease, sixfor pulmonary tuberculosis, four each for nephritisand Graves’s disease, and the remaining five foi

hyper- and hypothyroidism, tuberculous disease oj

jhe bladder, congenital syphilis. One had beenfor mental disorder in a previous pregnancy, andonly one, on the grounds of " general bad health,"came into the " doubtful " category. In the speaker’sprivate practice of about 3500 patients he hadinduced abortion on twenty-eight occasions since1919. The number of inductions performed forpositive reasons had been only 19, a much lowerproportion than in hospital. The grounds hadbeen very varied. Of the six operations where theindications were debatable one had been on a womanof 45 suffering from debility, who had undergone asevere operation for an infected gall-bladder twoyears before and who had a family history of tuber-culosis, and one on a patient just recovering from along series of severe ailments which showed a verybad state of general health, and who had complainedof exhaustion and rapid pulse ; another had been forgeneral ill-health, visceroptosis, a very recent bereave-ment and a consequent desire to join her husband inIndia immediately. These cases represented theclass of patients about which the most difficultquestions arose.The induction of premature labour was quite a

different problem. Apart from the toxsemias ofpregnancy, the medical indications were not at allcommon. The principle in cases of later pregnancycomplicated by disease was to treat the disease andneglect the pregnancy. This applied especially topneumonia, in which the extra strain of an inducedlabour was very undesirable. Finally, so long as thephysician were honestly intent on the welfare of hispatient and believed that she would benefit by theoperation, he could not possibly exclude extra medicalconsiderations from turning the scale in doubtfulcases where a medical indication existed.

The Cardiological Aspect.Dr. B. T. PARSONS-SMITH emphasised the very

serious consequences which pregnancy imposed uponpatients suffering from structural heart disease.Even under the most favourable conditions an addi-tional strain was inevitable. The blood volume wasincreased; diaphragmatic excursion was especiallyrestricted, limiting the functions of the thoracicviscera, and metabolic changes took place as a resultof impaired endocrine balance. It might be con-

cluded that, by causing these additional stresses,pregnancy would further deplenish the circulatoryreserve and favour decompensation. Management ofthe patient was a very serious problem ; the physicianmust satisfy himself as far as possible whether thecardiac reserve was likely to be equal to the additionalstrain, or whether compensation might be failingor already exhausted. Either of these events mightnecessitate the termination of pregnancy. Circu-latory failure was, however, an extremely variablequantity. In its minor forms it need not obviatethe successful conduct of pregnancy, but when welldeveloped it might be an indication to terminate.Statistics covering 15 years’ experience at QueenCharlotte’s Hospital showed that, out of 196 cardiaccases, 49, or 25 per cent., had had their pregnanciesartificially terminated. Abortion had been induced infive cases (2-5 per cent.) ; premature labour had beeninduced in 34 cases (17-5 per cent.) ; Caesarean section thad been performed at term in 10 cases (5 per cent.).Of the remaining 147 patients, 119, or 60 per cent.,had gone on to normal labour at term, although allof these had had gross structural disease with somefailure of compensation. Thirteen had had a spon-taneous premature labour after the twenty-eighth

.

week ; three had aborted spontaneously, and 12 haddied undelivered. Excluding these, the death-roll °

was two (40 per cent.) after induction of abortion,C seven (20 per cent.) after induction of prematureL labour, one after Caesarean section at term, three after

; spontaneous premature labour, and seven after. spontaneous delivery at term. The high mortality-i rate after artificial abortion was significant.r One of the most important clinical factors for, assessment was the myocardial degeneration and the

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degree of its compensation. From the point ofview of congestive heart failure the indications werepersistent tachycardia (120 or over) ; cardiac dilata-tion ; diminished tone of the first heart sound andgallop rhythm. All these were very serious. Thenthere was the pulse of 120 or over at rest, and theirregular action typical of auricular fibrillation ;venous stasis ; venous engorgement; oedema ; pul-monary, renal, and gastro-intestinal engorgement;a respiration of 20 or over ; orthopnoea ; attacks ofcardiac asthma, and pulmonary oedema. Whetherthese were primary or the outcome of valvulardisease or myocarditis, their development duringpregnancy might be a sufficient indication for itstermination unless they responded promptly totreatment. Even if compensation were restored,induction might ultimately be necessary, and in thepresence of gross cardiac failure it entailed graverisks. Other possible indications were various formsof valvular lesion, hastening decompensation ; mitralstenosis, and aortic incompetence. There was littleto choose between the gravity of these two con-

ditions ; myocardial reserve was the deciding factor,but when they were combined the risk was far greater.Hence the importance in all doubtful cases of anelectrocardiogram to determine the presence ofdefective muscle function and to differentiate betweenthe various forms of arrhythmia which might coexist.Auricular fibrillation was of outstanding importancein most women of child-bearing age ; it representedthe mitral late stage of chronic rheumatic carditis.and was a disastrous complication which necessitatedinduction. According to Dr. G. H. Hunt, 40 per cent.qf these cases died during pregnancy, and 50 per cent.suffered from decompensation. In his group ofmitral stenosis cases without enlargement there wereno deaths, and only 3 per cent. developed failureduring pregnancy. In the group with enlargementthere were 12 per cent. of deaths and 27 per cent.developed decompensation phenomena. Signs ofarrhythmia and premature contractions might gener-ally be disregarded entirely ; paroxysmal tachycardiaand auricular flutter were important only in so faras they failed to respond to adequate treatment.Heart-block might be associated with serious defectsin the myocardium but, if uncomplicated, its effectson the circulatory function in pregnancy were likelyto be minimal. Three cases of partial and one ofcomplete heart-block had progressed successfully tonormal labour. The physician should assume thatthe majority of cardiac patients would develop somedegree of failure during pregnancy and that suitableantenatal care would enable most of them tomaintain adequate compensation. In a few cases,however, heart failure might be so grave and refrac-tory as to threaten health and life.

Dr. BERNARD HART then read the paper which Iappears on p. 658 of our present issue.

Pulmonary Tuberculosis.Dr. GEOFFREY MARSHALL described his experience

with a group of pregnant women suffering from activepulmonary tuberculosis. It had been very difficultto decide in any given case whether the indicationwas positive or doubtful. In the first place, it wasimpossible to group the cases according to the amountor extent of lung tissue involved. Roughly, wherethe patient had been known to suffer from definitesymptoms of pulmonary tuberculosis for a greatmany years, in spite of the fact that the lesion mightbe fairly extensive, she might be expected to completeher pregnancy and labour without coming to greatharm. Where, however, the disease was recent, onemight expect the most tragic degeneration of con-dition ; patients with short histories should thereforehave pregnancy terminated. Patients with pul-monary tuberculosis reacted badly to any kind ofsurgical intervention, having prolonged pyrexiaand in most cases showing signs of extension of thedisease. On the whole they suffered less harm if theywere allowed to go on to the fourth month and thenhad the uterus emptied by abdominal section.

Discussion.Dr. ANTHONY FEIUNG remarked that patients with

Graves’s disease did not often conceive, but of thosewho did, Dr. Gardiner-Hill had found that very manystood their pregnancy extremely well. The indicationfor abortion in nephritis depended on the severityof the condition ; not every case of acute and chronicnephritis need have abortion induced. Patients withtrue myxcedema practically never conceived, andthere was no need to terminate pregnancy for themilder degrees of thyroid insufficiency. There mustbe very few cases indeed where it would be justifiableto cause abortion on account of epilepsy in theparents ; only 30 per cent. of epileptics had anepileptic heredity. He asked how Dr. Hart distin-guished between women who threatened suicidewithout intending to carry it out, and those who werereally likely to fulfil their threat.

Dr. H. B. DODWELL mentioned three young marriedwomen who never passed a winter without severeparoxysmal asthma, producing considerable strainon the heart and a condition quite grave enoughwithout the additional strain of pregnancy. He alsoknew one epileptic woman whose attacks would almostcertainly constitute grave risk to her child if shebore one. She had had one baby whose life hadbeen endangered many times in the first two months.

Mr. T. C. CLARE advocated sterilisation of womenwhose pregnancies were interrupted for medicalreasons. A pregnant unmarried woman who hadconsulted him had not asked him to terminate

pregnancy, but had been worried because she hadonly one kidney. She had also had a slight degree ofpyelitis. Was abortion justified ?The CHAIRMAN mentioned severe chorea as a

possible indication for abortion. He did not agreethat induction was necessary for myxoedema ; themyxoedema of women who became pregnant was saideither to be very slight or to be curable with thyroid.The amount of thyroid required to keep the patientin fair condition was immaterial. Phthisis was saidto flare up acutely after natural delivery ; did it doso after induction ?

Replies.Mr. EARDLEY HOLLAND agreed that there was no

strict necessity to induce abortion for myxoedema,but nowadays it was usual to give the patient thebenefit of the doubt. Epilepsy in the father did notconstitute an indication from the purely medicalpoint of view. He had had to do Caesarean sectionunder spinal anaesthesia because of acute dyspnoea.at the end of pregnancy in a case of Graves’s diseaseand in one of simple goitre. It was wonderful howcardiac cases bore pregnancy if kept in bed ; he allowedthem to go to term and on the tenth day sterilisedthem by excising a loop of the Fallopian tube underlocal anaesthesia. The operation was trivial and tookabout 12 minutes. It was said that the placentaswarmed with tubercle bacilli, both after labour andinduction, and thus constituted a focus of infection,and that therefore labour should be terminatedby hysterectomy. Pyelitis in a single kidney wascertainly an indication for abortion.

’, Dr. PARSONS-SMITH said that the artificial termina-tion of pregnancy was less often justified in primi-parae than in multiparae.

Dr. BERNARD HART agreed that it was extremelydifficult to decide which threats of suicide were tobe taken seriously ; he had no hesitation in givingthe benefit of the doubt. It depended partly onthe history and partly on the precise clinical picture,particularly such things as interference with sleepand impairment of the bodily condition, which madethe risk very serious.

EXTENSION OF ]BURTON-oN-TRENT INFIRMARY.-Property adjoining this hospital has been purchased for theerection of extensions. The new buildings will includenew X ray, artificial sunlight, and ear, nose and throat

departments, a lecture room, and a recreation room fornurses.