1245

average residence in the clinic was three weeks, butsome patients stayed there much longer.The PRESIDENT expressed the Association’s gratitude

to Prof. Winckler for having come so far to show thehigh level on which psychiatry stood in Holland.

Sir FREDERICK MOTT said it had been his privilegeto see the fine institution which Prof. Winckler directs,and on his recommendation, other English alienistsvisited it, and came back with a fund of instruction.When William of Orange rode into Leiden, after thesiege, he asked the burghers whether they would havea university or a remission of taxation, and they chosea university. Sir Frederick Mott wondered in howmany English towns such a choice would be made.In conclusion, he referred to the many-portal system ofentry to the medical profession in this country, andcommented on the advantages of a single Stateexamination.

______________

NORTH OF ENGLAND OBSTETRICAL ANDGYNÆCOLOGICAL SOCIETY.

A MEETING of this Society was held in Sheffieldon Nov. 16th. Prof. M. H. PHILLIPS was in the chair.

Exhibition of Cases and Specimens.Dr. J. BRIDE (Manchester) showed a tumour

simulating complete ulcerated prolapsus uteri. Heremoved it from a 2-para, pregnant four months.It was situated in the interval between right labiummajus and minus, and resembled an ulcerated completeprolapse. It had been noticed for 12 months and wassteadily getting bigger and was removed withoutaffecting the pregnancy. Microscopically it was afibroma.The PRESIDENT showed specimens of (1) adeno-

myoma of rudimentary uterine cornu; and (2) salpingo-csecal fistula. The first specimen was removed from7-para aged 44, who had had menstrual pain forthe last seven years and recently pain not associatedwith menstruation. A swelling the size of a golf ballwas attached to the left side of the supravaginalcervix, diagnosed as adenomyoma of Gaertner’s duct.At operation it was found to be rudimentary,left cornu of uterus attached to supravaginal cervix,and also to pelvic wall. A section of the cornu showedspaces filled with dark blood, lined by columnaror cubical epithelium, embedded in " cytogenousmantle " similar to uterine endometrium. The secondspecimen was removed from 3-para aged 32 years.Last child was born three years ago, followed bysevere abdominal pain for two weeks. Patient wasadmitted into hospital in November, 1922, sufferingfrom subacute attack of bilateral salpingo-oophoritis.Five weeks later she was seen with fixed tenderswelling to the right of the uterus which was thoughtto contain pus. Four weeks afterwards swelling haddisappeared and the patient felt much better. Shewas readmitted August, 1923, for dysmenorrhoea andbackache. A retroverted adherent uterus and slightenlargement of the appendages were found. Theright tube was firmly fixed to the caecum, and thethickened area of the caecum was removed with thetube. The end of the tube was found prolapsedinto the cavity of the caecum, the ostium being patentand well away from the opening of the vermiformappendix. The condition was thought to be theresult of rupture of the peritubal pyocele into thecaecum.—Dr. BRIDE recalled a similar case in whichan ectopic pregnancy had ruptured into the caecum.-The PRESIDENT said that originally this case had beendiagnosed as an ectopic cyst by the house surgeon.

Dr. BRIDE gave an account of two consecutivepregnancies with central placenta praevia and Caesareansection. A 2-para, aged 34, was seen on Nov. 20th,1922, three months pregnant, with history of Caesareansection, by Dr. Fothergill, whom the speaker hadassisted. The living child then delivered was stillalive and healthy. On April 21st, 1923, the patient

’

was admitted into hospital eight and a half monthspregnant; she had severe bleeding with central

placenta prsevia. Dr. Bride decided to do Caesareansection, delivered a living child, and at the sametime sterilised the woman by removing portions ofboth Fallopian tubes. The child died of convulsionson the eleventh day. Nothing was found to accountfor the placenta prsevia habit.-Dr. J. E. STACEY saidthat it was very rare to have recurring central placentapraevia.—Dr. W. W. KING asked to what extent thecervix was dilated and criticised the second Caesareansection, and also the sterilisation of the patient.-Dr. FLETCHER SHAW said that one did not expect aCaesarean scar to stand difficult deliveries in futurepregnancies.-Dr. BRIDE said that the cervix wasonly slightly dilated ; he did not consider possiblerupture of the old scar. At operation the old scarcould hardly be seen.

Dr. H. CLIFFORD (Manchester) described a case offull-time ectopic gestation. Mrs. F. was admitted tohospital on Nov. 30th, 1922, with a history ofamenorrhaea since February, 1922. Foetal movementswere active till two days before admission. Thefoetus appeared to be full-term, foetal limbs wererather prominent, the head high up and in R.O.P.position. No foetal heart sounds were heard normovement felt. The cervix was protruding fromvagina ; presenting part could not be definitely felt.Radiographs gave no assistance ; the temperature wasslightly raised ; the cervix was cleansed and replacedand supported by a ring pessary. Labour did notcome on and the patient was discharged at her ownrequest on Jan. 5th, 1923. She was readmitted onthe 26th when the foetus was in the same position,and the temperature was slightly higher. Bougieswere inserted into the cervix on two occasions, butcould only be pushed 3t inches. Temp. 102° F. andpulse 120. On Jan. 29th and Feb. 4th the patienthad 4-minim doses of Dr. Jenkins’s stock residualvaccine.! On Feb. 14th Dr. Clifford opened theabdomen and found a full-term macerated foetuslying in a sac with placenta almost entirely attachedto outer abdominal wall. This was stripped off withoutbleeding ; the membranes were not removed and thecavity was drained and irrigated by Carrel Dakin’smethod for three weeks. The cavity rapidly becamesmaller, and six weeks after operation there was asinus 12 inches long. Inquiries afterwards revealedthe fact that in March, 1922, the patient had severeabdominal pain with vomiting followed a little laterby haemorrhage lasting five days. Afterwards shehad considerable abdominal pain, and in May con-sulted a surgeon who thought she had had appendicitis.Dr. Clifford considered that the condition was verydifficult to diagnose.-Dr. FLETCHER SHAW and Dr.D. DOUGAL agreed with him.-The PRESIDENT alsoagreed, but pointed out that a dead foetus is notretained long in utero.-In reply, Dr. CLIFFORD saidthat it was sometimes very difficult to diagnose fcetaldeath.

Dr. S. B. HERD (Liverpool) described two cases ofencephalitis lethargica associated with pregnancy :(1) Primipara aged 24. No history of previousillness. Pregnancy normal up to thirty-sixth week.The patient then had headaches, albuminuria, andslight oedema of the ankles. She had treatment andshowed signs of temporary improvement. A weeklater she had severe headaches and a fit. Admittedto hospital: Blood pressure, 130 mm. of Hg ; albu-minuria, 3 g. per litre. No uterine contractions. Thepatient had six fits in six hours following admission-apparently typical eclamptic fits. Next day aliving child was delivered. Later in the day rhythmicclonic contractions of jaw muscles commenced. Thetemperature was slightly raised. The patient wasrestless and confused, and at the end of five days, asshe was becoming worse, was transferred to anotherhospital, where she died on the twentieth day afterdelivery. She had nystagmus, ptosis of upper eyelid,and weakness of facial muscles. Post-mortemdiagnosis of encephalitis lethargica was corroborated,and no evidence of toxaemia was found. The second

1 Brit. Med. Jour., April 15th, 1922.

1246

case was that of a primipara aged 28. Healthy upto the thirty-fifth week of pregnancy. On admissionthe patient was restless and excited, and there wereincoordinated clonic movements of head and limbspresent during sleep. Reflexes normal. Albuminuria,2 g. per litre. Chorea gravidarum was diagnosed andtreated with parathyroid extract, calcium lactate,and sedatives. On fourth day after admission thepatient was delivered of a still-born child. Thetemperature rose to between 100° to 102° F. Diplopianoticed on following day. Delusions, restlessness;became worse, and was transferred. Diagnosis ofmyoclonic lethargica encephalitis was made. Thepatient was slowly recovering-four months later--but complete recovery was not expected.

Dr. J. CHISHOLM recalled one case in a 2-para withmarked clonic movements of abdominal walls withsymptoms of internal obstruction. Caesarean sectionwas performed; no obstruction was found andmovements continued afterwards. The patient wasdull and apathetic, but recovered. The child also hadlethargic encephalitis. Dr. Chisholm mentionedanother case in a five and a half months’ pregnancydiagnosed as pernicious vomiting at first. Thoughlabour was induced, the patient died. She hadnystagmus also.

Dr. FLETCHER SHAW read a paper on the

Advantages and Disadvantages of SupravaginalHysterectomy and Panhysterectomy.

He said that some gynaecologists believed pan-hysterectomy should be done whenever the uterushad to be removed, while others believed that supra-vaginal hysterectomy was the better operation formany cases, though they would probably always dopanhysterectomy if the cervix was badly lacerated.In a period of 18 months he had had three patientsin whom carcinoma of the cervix occurred after

supra vaginal hysterectomy, and his object in bringingthe subject before the Society was to see if othergynaecologists had had any similar cases. Althoughthese three cases were seen in a period of 18 months,they were the only ones he had ever had, and so faras he knew none of his colleagues at St. Mary’sHospital had had a single case, so that the occurrenceafter supravaginal hysterectomy was very rare and itwas probably merely a coincidence that he shouldget these three in so short a period. If that provedto be the case he still thought there was a distinctuse for supravaginal hysterectomy, as it was a muchquicker operation and caused less shock to thepatient and, moreover, did not entail the opening ofthe vagina, which, no matter how carefully cleaned,was potentially a septic passage. In a consecutiveseries of supravaginal hysterectomy and panhysterec-tomy he found the mortality higher after panhysterec-tomy, and in the investigation of the convalescence ofa consecutive series of both types the patients aftersupravaginal hysterectomy had, on the whole, a

smoother time than those in whom the completeoperation had been done. He still thought supra-vaginal hysterectomy was useful in nulliparouswomen, but panhysterectomy should always be donewhere the cervix was badly lacerated or in any waydiseased.The PRESIDENT said that he did not remember

seeing carcinoma of the cervix after subtotal hysterec-tomy, but he had removed cervices for discharge.He believed that panhysterectomy was the betteroperation in all cases.

Dr. W. W. KING showed a specimen of carcinomaof the cervix which he had removed. The patienthad subtotal hysterectomy in 1919 for fibroids. In1923 she had bleeding for three months, and thecervix was found carcinomatous. He recalled anothercase in a nullipara who in 1911 had gonorrhoea. In1918 the patient had a pelvic abscess drained ; in1920 had subtotal hysterectomy for bleeding, andsix to eight months later had ineradicable carcinomaof the cervix. He believed in total hysterectomy inmultiparae, and subtotal in nulliparae.—Dr. BRIDE

said that in a case of a nullipara, he had done apanhysterectomy and found an early carcinoma ofthe cervix.-Dr. CmsHOLM mentioned a case who hadhad a subtotal hysterectomy 25 years ago and whohad bleeding for two months, and was found to haveineradicable carcinoma. She had had one child andone miscarriage.-Dr. CLIFFORD did not remembera case of carcinoma of the cervix occurring aftersubtotal hysterectomy in his practice. He said thatit was so rare that it hardly affected the difference inthe mortality rate between the operations of subtotalhysterectomy and panhysterectomy.

ULSTER MEDICAL SOCIETY.

A MEETING of this Society was held on Nov. 22nd,Prof. W. ST. C. SYMMBRS, the President, being in thechair.

Mr. ANDREW FULLERTON read a paper entitled

Observations on Unilateral Diuresis.He described a continuation of some observations onunilateral diuresis which he presented last year beforethe Congress of the American College of Surgeons,held at Boston. A small irritating calculus in the

pelvis of the kidney, he said, may give rise toa unilateral diuresis so definite and striking as toconfirm the most casual observer. The flow from thesound side may be correspondingly diminished, andthe specimen so concentrated that a copious deposit ofurates is rapidly precipitated. In tubercle of thekidney an exactly similar state of affairs is present inthe early stages. A further example was furnished byunilateral pyelitis. In cases with little involvement ofthe parenchyma of the kidney the picture closelyresembles that seen in stone in early tubercle. In stoneand pyelitis a rapid return to the normal occurs whenthe cause has been removed. In calculus and in theearly stages of tubercle the diuresis is what may betermed acute. When structural changes have occurredin the kidney the specific gravity is still diminished,but by degrees the flow of urine becomes less and less,until finally all the work falls on the sound kidney.The term chronic might be applied to the diuresis inthese cases, but when the flow becomes diminished it isnot strictly applicable. The specific gravity of theurine in the affected side was likely to be low in thefollowing conditions : renal calculus, tuberculosis ofthe kidney, unilateral pyelitis, tumours of the kidney,congenital cystic kidney (when the process is moreadvanced on one side), hydatid cyst of the kidney,hydronephrosis, movable kidney, certain cases of renalpain, and in wounds of the kidney. Statistics were givenof the results of examination in over 500 cases. Mr.Fullerton brought forward this subject to emphasisethe value of a sign that might help in diagnosis whenthe surgeon was deprived of more accurate methods.

Dr. F. C. S. BRADBURY demonstrated a method of

Estimating Urea in Urine,based upon the principle that if a gas is liberatedwithin an apparatus of constant volume, the resultingincrease of pressure is proportional to the amount ofgas liberated. In this method the ordinary hypo-bromite reaction is utilised to liberate nitrogen froma fixed volume of urine, and is carried out in the usualmanner by placing the urine in a small test-tube withina bottle containing the reagent, so that by tilting thebottle the urine and reagent can be mixed at will.The bottle is provided with a perforated rubber stopperinto which is pressed the stem of a manometer such asforms part of a sphygmomanometer outfit of theaneroid pattern. The air space within the apparatushas a complex value, being the capacity of the emptybottle minus the amounts of caustic soda, bromine, andurine added ; minus the volume of the glass composingthe bromine tube and the urine tube ; minus thevolume of air displaced by the stopper of the bottle ;plus the air space inside the manometer ; plus thepotential air space in the reagent due to its power of