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it was possible to demonstrate the actual rupture ofa vein. This appeared to show, said Mr. King, thatthere was serious mechanical obstruction to thevenous flow. The whole picture of the uteri, bothto the naked eye and histologically, suggested theocclusion of the large vessels rather than a permeationof the blood through them as a result of damage totheir endothelial lining. Young had noted the samefact, and postulated an intravascular clotting fromsome unknown cause. Morse explained the appearanceof the uterus upon a theory of torsion of the wholeuterus, and Pollock and others had noted extremetorsion of the uterus from left to right. Torsion ofmyomatous uteri was well known to occur, so thatthere was nothing impossible in a theory of torsionof the pregnant uterus. The greatest difficulty inaccepting this explanation was the frequency ofalbuminuria at the time of hæmorrhage. There was nosufficient evidence that albuminuria often precededaccidental haemorrhage, so it could not be causal.The condition was generally considered to be a niatii-festation of toxaemia, but if so it was different, as Whitridge Williams had said, from any of the ordinarytypes of pregnancy toxaemia. Young stated that heconsidered that the albuminuria was only the result ofthe autolysis of the separated placenta, but his theorywas as yet unproved. Hofbauer had produced evidencein favour of histamine as the causative factor, and hadreproduced in gui nea-pigs the phenomena of concealedaccidental haemorrhage by causing acute histaminepoisoning. The correct treatment was intimatelybound up with the condition of the uterine muscle.Hysterectomy had been advocated because themuscle was supposed to be diseased, but it had nowbeen histologically proved that it was not, andclinically it was well recognised that it had not lostits contractile powers and that repeated pregnancieswere possible and safe. Save in exceptional casesthere was, therefore, no justification for Caesareansection in these cases. G. FitzGibbon had treatedsome cases of concealed accidental haemorrhage withsuccess by palliative measures, and this appeared tobe rational. It was irrational to operate upon a womanin profound shock without any clearly defined reason,as had been done in the past.

Prof. FLETCHER SHAW (Manchester) said that Mr.King had cited the figures of a number of maternityhospitals, showing that albuminuria only occurred inabout 30 per cent. of the cases of accidental hæmor-rhage, and had quoted Whitridge Williams as givingthe figure as 26 per cent. These figures he disagreedwith, and thought the mistake arose from the difficultyin making a diagnosis of accidental haemorrhage.When a patient, far advanced in pregnancy, wasbrought into a maternity hospital suffering fromhaemorrhage the case was diagnosed as one of placentapraevia if the placenta could be felt, and in other casesthe diagnosis of accidental haemorrhage was made.The cases of accidental haemorrhage thus diagnosedfell into two main clinical groups. In one of them thesymptoms were comparatively slight, especially thesymptom of shock ; this group contained the greatbulk of these patients, and he felt sure the largemajority of them were really cases of marginalplacenta praevia. The treatment of these cases wasvery simple, as practically all the patients recoveredif the membranes were ruptured and ergot or

pituitrin was administered, or if-as was done by theDublin School-the vagina was tightly packed. Theother clinical group contained a comparatively smallnumber of cases, but here the patient suffered severelyfrom shock and signs of haemorrhage. These were thepatients in whom treatment was not always satis-factory. These were definitely cases of accidentalhaemorrhage, and in his experience every one of themhad albuminuria. It was quite possible there mightbe some other factor along with the toxaemia as acausative agent of the condition, but he felt sure thetogaemia was always present. As another proof thatthe condition was due to a general cause such as atoxaemia, he mentioned the fact that in all thesesevere cases there were large haematomata formed

outside the uterus, and the condition must thereforebe looked upon as general, and not as due to a merelylocal cause affecting the uterus alone. These severecases of accidental hæmorrhage formed one of themost serious groups met with in obstetrical practice.and no matter what was done there was :1 largemortality. If the vagina was packed or the membranesruptured and pituitrin or ergot administered a fewof these cases failed to respond, and the patient diedof haemorrhage before the child was born, or, if theuterus was emptied, from post-partum haemorrhage.The cases referred to were very few, but lie felt thatwhen they were met with the best treatment wasCacsarean section followed by hysterectomy. Hehimself had treated six such cases in a period of threeyears during the war, and had saved half of them, butit was evident that they were very uncommon fromthe fact that since that time he had not met a singlecase in which lie felt called upon to do an abdominalsection.

Dr. J. E. STACEY (Sheffield) gave figures on ante.partum haemorrhage, from which he concluded thatin both accidental haemorrhage and placenta praeviathe cause was toxaemia.—The PRESIDENT said thathe thought that the treatment should be palliative iteverv case.Mr. A. GouGH showed a specimen of parasitic

my oma removed from a patient aged 42. A peduncu-lated fibroid the size of a fœtal head had its vascularsupply cut off by torsion of its narrow uterine pedicle.At the opposite pole it had adhered to a loop of smallintestine, and there was a free supply of blood throughthe adhesions. The tumour was easily separated andthe patient did well.

MIDLAND OBSTETRICAL AND GYNÆCO-LOGICAL SOCIETY.

A MEETING of this Society was held at Derby onDec. 14th, Mr. FURNEAUX JORDAN (Birmingham’.the President, in the chair.

Dr. C. D. LOCHRANE reported two cases ofDystocia.

CASE 1.—The patient was an 8-para; all her childrenhad been full time and healthy, and she had had no mis-carriages. The case was seen in consultation on June 1st.1925, when Dr. Lochrane found that the head of the fœtuswas born, but the trunk could not be delivered on accountof a firm irregular mass obstructing the upper half of thepelvis. Previously there had been a slight antepartumhaemorrhage, and although- the pains had been strong, thehead had only descended to its present position after themass had been pushed aside.As moderate traction failed to bring about progress in

delivery, the patient was deeply anaesthetised with chloro-form and morphia, and after considerable difficulty themass was pushed up and manipulated above the brim of thepelvis. This allowed the shoulders and the remainder ofa well-developed 10 lb. foetus to be delivered without greatdifficulty. The fœtus showed no oedema or other externalabnormality. Half an hour later a huge, thick, solid placentawas delivered ; it was not markedly cedematous, butweighed 3 lb. :3 oz. Microscopically the placental tissuewas found to be unduly dense in consistence : no spiro-chaetes were found.

Dr. Lochrane said that he had never heard ofanother case of dystocia from this cause. Theclinical and pathological picture did not support theview that oedema from albuminuria was a pre-dominating factor in the production of this hugeorgan, neither was there any suggestion of syphilis.although, unfortunately, blood had not been examinedby the Wassermann reaction.CASE 2.-The patient, a primipara aged 23, was admitted

to hospital on March 7th, 1926, with a history of havingbeen in labour 40 hours. Her temperature was 98.6° F..her pulse-rate 86, and her general condition good. Theuterus was found to be unduly prominent and in stateapproximating to a tonic contraction ; the presentationwas by the breech, and the foetal heart-rate was 114. Theos was two fingers-breadth dilated and was displacedupwards. A cystic mass, the size of a Jaffa orange and con’tinuous with the uterus, occupied the pouch of Douglas. Theobstruction of labour was regarded as due either to a soft

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fibroid of the lower pole of the uterus or to a non-pregnanthorn of a bicornuate uterus.At the Ca?sarean section which was immediately per-

formed the lower uterine segment was found stretched overthe lower pole of the foetus, removal of which allowedelevation of the uterus including the intrapelvic portion.which was non-adherent and easily released, being helddown by a prominent sacral promontory. The appearanceof the uterus at this stage was bicornuate, the left cornu,which contained the placenta, was found to be that portionof the uterus which was incarcerated in the pelvis. Afterthe organ had been manipulated to secure good contraction,the dividing ridge gradually disappeared and all trace ofthe bicornuate appearance was lost before the abdomenwas closed.

In this case, said Dr. Lochrane, it was the ratherless distensible part of the uterine wall, comprisingthe site of placental attachment, which had beenincarcerated or sacculat.ed. W’ithout being able togive any figures lie was under the impression that asimilar observation had been made by others, andthis suggested one possible explanation of this formof partial incarceration of the uterus.

Dr. H. A. LAVELLE reported a case ofRupture of the Bladder followed by Vesico-vaginal

Fistula.The patient, aged 34, was a 2-para 32 weeks pregnant,

and was admitted to hospital on Dec. 31st, 1925, followingan unsuccessful delivery with forceps. Examinationrevealed laceration of the vaginal walls with evidence ofiniury to the bladder, 2 oz. of blood being drawn off bycatheter. A large hydrocephalic head partially fixed inthe brim was palpated, craniotomy was done, and the foetuswas easily delivered. After operation the patient sufferedfrom incontinence of urine, diarrhoea, and signs of lowerabdominal peritonitis accompanied by a pelvic swelling.The temperature remained normal until the seventeenth dayafter admission. On the twenty-first day the swelling,which then reached to the level of the umbilicus, dis-

appeared, following the discharge of 4-5 pints of foul-smellingpus per vaginam. Except for incontinence of urine thepatient made an uninterrupted recovery, hut she was

readmitted a month ago for the closure of a vesico-vaginalfistula in. from the cervix.

The abdominal swelling, said Dr. Lavelle, wasundoubtedly due to extraperitoneal extravasationof urine, and it was interesting that this should occurin the presence of a vesico-vaginal opening. Hethought it probable that the fistula dated from thesudden discharge of pus and that the incontinenceprevious to this was due to failure of the sphincter.Dr. LAVELLE also described a case of inversion of

uterus.Dr. ELIZABETH ASHBY reported a case of rupture

of the lower uterine segment during Caesarean sectionand a case of fits during pregnancy.A discussion followed in which the PRESIDENT, Mr.

C. E. PuRSLOW, Mr. MASLEN JONES, Mr. A. M.WEBBER, and Mr. A. B. DANBY took part.

JAMES MACKENZIE INSTITUTE FOR CLINICALRESEARCH.

Blood Pressure.ON Dec. 14th Prof. MURRAY LYON reviewed first the

factors influencing the blood pressure and showed howthe pressure may be altered by the viscosity of theblood, by posture and by mental excitement, musculareffort, and digestion. The effects of these also vary,he pointed out, according to the acceleration or

slowing of the heart-beat. Discussing unduly lowblood pressure, Prof. Lyon instanced cases of hista-mine poisoning with peripheral dilatation and loss ofblood fluid, which give, he said, a clue to treatment, which should be by transfusion with sugar, saline, orgum solution, the aim being to increase the volume ofthe blood. It is noteworthy that a high blood pressuremay be coexistent with a failing heart. The questionwhether it is advisable to attempt to reduce a highpressure he answered by saying that probably an

attempt to do so should be made in most cases;results will show whether it is wise to go on with thetreatment. Prof. Lyon emphasised the importanceof physical and mental rest, which should be as

complete as possible ; in the over-stout and flabby,tiowever, the value of graduated exercise is not to beoverlooked. As regards diet, the danger seems to lienot so much in an excess of protein as in overeatinggenerally. A salt-poor or salt-free diet appears usefulin some cases. He drew attention to the benefit to bederived from venesection, the removal of 3-20 oz.

of blood being followed by a fall of pressure whichpersists. Discussing the influence of drugs, he-

suggested that the almost mysterious effects ofpotassium iodide may be due to a power to reduce theviscosity of the blood. Experimentally, he said, theaction of tissue extracts is undoubted, but it has stillto be confirmed clinically.

LIVERPOOL MEDICAL INSTITUTION.

A MEETING of this Institution was held on Dec. 16th,when Prof. R. E. KELLY read a paper on the

Surgery of the Common Bile-duet,based on records of 50 cases in which the common ductwas explored. Amongst conclusions drawn from these,he said, were : (1) that the common duct may bepacked w.th stones without jaundice, and even withoutpain ; (2) that stones may be found in the commonduct when the gall-bladder is enlarged ; (3) thatmalignant disease may be associated with attacks ofpain and a variation in the depth of the jaundice ;(4) that stones may be associated with deepeningjaundice and no pain ; and (5) that malignant diseaseand stones may be associated. Mere palpation of thecommon duct was insufficient to give accurateinformation of the condition of the duct or its contents.Every dilated common duct should be explored withthe finger, probe, or catheter, and failure to reachthe duodenum by these means should be followed bya transduodenal choledochotomy. Prof. Kelly dis-cussed the difficulty of distinguishing malignantdisease from impacted stones in the ampulla of Vater,and said that he thought that malignant disease inthis situation was very malignant, and that cureswere sometimes due to mistaken diagnosis. As regardsthe details of operation he had used all the incisionsrecommended, and for particular reasons liked themall. He thought, however, that in very obese patientswho had a wide costal angle the complete transverseincision gave wonderful access and a strong scar. Onmany occasions he had used the double catheter ; onewas placed upwards into the hepatic duct and theother down into the duodenum, and the latter servedfor liquid nourishment.

Dr. WALLACE JONES read a paper on

Vital Capacity in Heart Disease.In his experiments, he said, he had used a simple waterspirometer, the readings being expressed as percentagesof the standard normal vital capacity calculated byWest’s formula. Fifty normal men and 50 normalwomen were examined to see how closely the actualvital capacity corresponded with the calculated vitalcapacity. The result showed that though markedindividual variation occurred, the average figure wasvery close to the calculated normal. In organiccardiac disease there was a marked fall in the reading,the average being between 50 per cent. and 60 percent. of the normal figure. The vital capacity waslowest in the mitral stenosis group, especially whenmitral stenosis was associated with auricular fibrilla,tion. In functional cardiac disease the averagereading was 85 per cent., a very high figure in view ofthe marked dyspnoea generally associated with thiscondition. A group of cases was also kept underobservation for a considerable time, and though thevital capacity improved with increase in the cardiacreserve power, the readings only followed slowly thechanges in the condition of the heart.