964 NORTH OF ENGLAND OBSTETRICAL & GYNAECOLOGICAL SOCIETY.

and eventually the struggle had to be given up. Manyof the cases were not recognised on the voyage tobe malarial at all, and inquiry showed that theamount of quinine given was not enough to controlthe fever ; there was not enough of it, nor was thatin stock of the right kind. A similar occurrence tookplace on other boats leaving the East at about thesame date.

Colonel W. W. CLEMESHA related similar experi-ences at an earlier date, and said that inquiry of anofficer who had suffered from inadequate medicalattention on several voyages elicited the reply thatthe medical officers he sailed with were either veryyoung or very old.

Sir MALCOLM WATSON, in replying on the discussion,said it was not an easy thing to educate in thesematters those who provided the money. He oftenremarked that most of his life had been spent not infighting the mosquito, but in fighting men who werepreventing him from fighting the mosquito. Agreat source of malaria in Bombay was the continu-ance of the Hindoo well in private houses, and aslong as the hands of the Indian Medical Service weretied in that way, real progress would be impossible.He instanced one estate on which R7000 were spentin these remedial measures, and thereafter more thanthat amount was saved commercially every year onthat particular land. He did not think the distancethe mosquito could fly was quite the same questionas the control of malaria.. It could fly half a mile,but if its breeding places were half a mile from acantonment, the number of the insects which coveredthe distance and could thereafter infect would proveto be practically negligible. He had carefully investi-gated that question. If there should be a taxationfor the purposes of the campaign, he was sure it wouldmore than justify itself.

NORTH OF ENGLAND OBSTETRICAL ANDGYNÆCOLOGICAL SOCIETY.

A MEETING of this Society was held at Liverpool onOct. 17th, Prof. ARCHIBALD DONALD, the President,being in the chair. 0,11

The PRESIDENT opened a discussion on theTreatmem of Mobile Backward Displacements of

the Uterus.He discussed the significance of backward displace-ment and said that there was a good deal of differenceof opinion amongst writers on the subject. The viewsof various modern writers on the passive congestiontheory were set forth. The objections to the congestiontheory were that retroversion was not the cause ofendometritis or chronic metritis. There were somedifficulties, he said, in explaining the effects sometimesproduced by a pessary. As a result of investigating thesymptoms he had arrived at the following conclusionswith regard to the condition. (1) Complications weregenerally the only things that mattered in cases ofretroversion. (2) These complications were : (a) dis-ordered uterine function; (b) increased weight;(c) prolapse; (d) adhesions. (3) None of these com-plications were produced by retroversion. (4) In asmall proportion of cases an apparently simpleretroversion caused local pelvic discomfort and evena certain unexplained effect on the nervous system.(5) 7 ..e treatment of retroversion was nearly alwaysthe treatment of complications. More than 90 percent. of all the patients sought relief from symptomswhich were common to all cases of endometritis andchronic metritis, and for these curetting was nearlyalways advisable. A series of cases in which curettinghad been the only treatment was recorded. Mechanicaltreatment was carried out (a) by pessaries, and (b) byfixation or suspension operation. Pessaries seemed ofuse as a temporary measure in cases of sterility andearly pregnancy, and very occasionally in uncom-plicated retroversion. In his opinion there were -far

too many operations for fixing and suspending theuterus. The great majority were unnecessary, andmany of them were harmful.

Prof. HENRY BRmGS imagined that a student,ignorant of all gynaecology including its nomenclature,would naturally classify the backwardly-displaceduterus within the pouch of Douglas as a hernia andaim at the strengthening of the deep portion of thepelvic floor and the rectification of the position of theuterus. He said that it was more than singular to haveto acknowledge, for example, that the best use of a3 or 3t-in. ring pessary was advocated 24 years agoby the late Sir William Sinclair (Trans. Obstet. Soc.,1900) in the treatment of the retroflexed graviduterus ; even to-day this advance was not to be foundin the obstetrical text-books. Prof. Briggs. had notthe least doubt that a pessary in situ and frequenturinary catheterism, in gentle and persistent effect,totally out-classed manual reposition.

Dr. G. W. FITZGERALD agreed that not all retro-displaced uteri required treatment. Symptomsaccompanying the displacement were not necessarilydue to it. The important matter was to find whattreatment would give the best results. If the curettecould show results equal to abdominal section, thenthe minor treatment was to be preferred. He curettedall cases that produced symptoms, and only rarelyfound more radical treatment necessary.

Dr. J. E. GEMMELL said that he was in agreementwith Prof. Donald that simple retroversion in singlewomen was symptomless in the majority of cases. Inparous women, however, he was of the opinion that thisdisplacement was, in itself, capable of producing adefinite train of symptoms. He could not helpthinking that there was a world of difference betweenan organ that was developed in a particular positionof version, and one that acquired such a position.The vessels of the former had been congenitally adaptedto meet the requirements of the retroverted uterusand could do so smoothly and without embarrassmentto the circulation, whilst in cases of acquired retro-version the vessels shared in the displacement andwere thereby exposed to abnormal pressures that fellchiefly on the veins and consequently led to back-pressure and congestion. The resulting symptomssimulated endometritis and metritis, but he believedthey were essentially due to congestion, and hetherefore supported the mechanical theory. In hisopinion there were three clinical types that demandcorrection and fixation : (1) In a limited number ofcongenital cases when the patient complained ofsterility, repeated abortions, dysmenorrhoea, or

dyspareunia ; the type with neurosis and backachewas expressly excluded. (2) In obstetric types withthe following cardinal signs : a bulky, tenderoedematous and often incarcerated (but not fixed)uterus, associated with pain, menorrhagia, leucorrhoea,or dyspareunia. (3) In cases of simple retroversionaccompanied with early prolapse in young women ofchild-bearing age.Although pessaries and general therapeutic measures

were useful adjuncts, and might even be curative inmild cases, he said he wished to limit himself to thesurgical treatment by ventrofixation of this condition,and proposed to base his remarks upon 125 cases ofsimple retroversion that were published in THE LANCETof June 18th, 1921, in collaboration with Mr. LeylandRobinson.A summary of the results was as follows : 85-6 per

cent. cured, 10 per cent. relieved, 44 per cent. failures.The principles of ventrofixation, Dr. Gemmell said,were not generally understood, and he believed thatthis procedure had acquired an unpopular reputationbecause most gynaecologists had studied the wrongtype of operation. The type he and his colleagues hadpractised was planned to fulfil the three essentialsupon which the success of all gynaecological operationsdepended—namely : (1) Freedoaa. from immediaterisks, such as intestinal obstruction ; (2) freedomfrom the risk of interfering adversely with subsequent

965INFANT HYGIENE, ANCIENT AND MODERN.

conception and parturition ; (3) ability to relievesymptoms.The proof that ventrofixation met these require-

ments was furnished by the following facts : (1) Ofupwards of 700 ventrofixation operations performedby him, one patient died from sepsis under circum-stances that had nothing to do with the operativeprocedure. There were no examples whatever of

post-operative strangulation of gut. (2) Of 220 casesin which a complete after-history was obtained,63 women subsequently became pregnant and weresafely delivered of 104 children without a single caseof dystocia or stillbirth. (3) The effect of ventro-fixation on symptoms had already been dealt with(85-6 per cent. cures).

Successful operative technique depended upon threechief factors : the choice of a suitable fixation-point ;the prevention of adventitious intraperitoneal bandsand holes through which the gut might strangulate ;and the achievement of a fibromuscular fixation andnot of a peritoneal suspension.

Mr. W. GouGii agreed that many patients withretro-displacements were symptomless. If a patientwere told of the retro-displacement, a vicious circlemight be set up. Briefly his practice was : If nosymptoms, leave alone; if symptoms were present,he curetted the uterus and replaced it. If the displace-ment recurred the uterus was replaced and a Hodgepessary inserted for two to three months. If thepatient was thereby relieved, nothing further was done,but if her symptoms, &c., returned, then he operated.He had done all types. of operation except the absolutefixation and found them all equally successful.

Mr. ROBERT A. HENDRY read the conclusionsabstracted from the opening report on the indicationsfor

Surgical Intervention in Retrodeviations of theUterus Apart from Pregnancy,

presented to the Congress of the Association ofFrench-speaking Gynaecologists and Obstetricians,Geneva, 1923. These were that surgical interventionin uterine deviations, apart from pregnancy, wasindicated as follows : (1) In retrodeviations accom-panying uterine, ovarian, or parovarian tumours inso far as these tumours did not necessitate the sacrificeof the uterus, the pexy was a complementary operation.(2) In fixed, painful retrodeviations. (3) In fixedretrodeviations accompanied by appendage lesions,unilateral or bilateral, which had resisted medicaltreatment. If the appendage lesions were such thatthey required ablation it might be necessary topractise total or subtotal hysterectomy ; if suchwere not the case, the uterine pexy was only a com-plementary operation. (4) In painful, mobile retro-deviations surgical intervention was only indicated if,when the uterus be replaced, the painful phenomenadisappeared. In other cases the pains arose : (a) Fromhysterical and similar states; (b) from multiple visceral Iptoses. (5) In certain rare cases of obstinate sterility Iwhere no other apparent cause could be discovered.(6) In retrodeviations accompanied by repeatedabortion where searching examination eliminated thepossibility of syphilis. (7) In all cases where, inaddition to the retrodeviations, one found a tendency,even -if slight, to prolapse with or without perineallesions. If the perineum were damaged the pexy oughtto be preceded by careful vagina-perineal repair.(8) Painless mobile retrodeviations did not require anytreatment.

The discussion was then adjourned until the nextmeeting to be held at Sheffield, on Friday, Nov. 21st.

At the commencement of the meeting Prof. BLAinBELL, described two cases, one of manual perforationof the puerperal uterus, followed by recovery, and theother of throm.bo-phlebitis of the right ovarian veinassociated with abscesses in the uterine wall.-Mrs.DossBiN CRAWFORD described a case of primarycarcinoma of the vagina.

INFANT HYGIENE, ANCIENT ANDMODERN.

Abstract of a Lecture at the Instruction Course for Teachersof Midwives, Midwives’ Institute.

Dr. H. K. WALLER, lecturing on the above subjectin the rooms of the Royal Society of Arts on Oct. 30th,said that one way of approaching it was for enthu-siastic welfare workers to enumerate everythingmodern and call it good, everything ancient as

unenlightened and worthless. That clearly wouldnot do. It was difficult for us to picture conditionssurrounding infancy in ancient days. Natural selectionmust have worked surely and ruthlessly in many wayswhere it was now tempered by more tender socialconcern. It was certain that throughout all agesthere had been no failure in the demand for passionatematernal devotion. The studies of anthropologistsshowed us that in primitive tribes, where we found thenearest likeness to prehistoric conditions, the task ofmotherhood was an intricate and exacting profession.So it must always have been, and so it was to-day.For workers in infant welfare there was a stimulusin the fact that of recent years the infant had comein for a wealth of close and scientific study. Thespeaker traced briefly the history of hospitals, pointingout that hospitals for the wage-earner’s wife duringthe time of childbirth and lying-in antedated by along while any hospital provision for sick children.One of the oldest children’s hospitals in Londonowed its origin to the revolt of its founder from therules of the general hospital where he was trained,and where he repeatedly fell foul of the authoritiesfor smuggling children into its wards. Dr. Wallerhoped that some surgeon would call attention tothe claims of the infant whose mother needed admission to hospital for the treatment of a mammaryabscess during the early months of lactation. Inmany instances breast-nursing could be saved, or

re-established after a short interval. But it was stillexceedingly difficult to obtain the simultaneousadmission of the infant with its mother. The childhad to find a hasty shelter, sometimes in most unsuit-able quarters, and fell ill, often seriously ill, as theresult of a sudden change to unskilled and unsuitableartificial feeding.

It was suggested that we must recognise a certaininherent reluctance on the part of scientists to interestthemselves in the habits and needs of the very youngchild. The human father, like many fathers in theanimal world, was somewhat ill-equipped withsympathetic feelings towards his offspring, at leastuntil the awkward inarticulate stage of infancy hadbeen passed. The potential father in the scientistand doctor was, he suggested, not a little responsiblefor this lack of interest. Dr. Waller went on to saythat we could not over-estimate the importance ofthe craft necessary to be a successful mother or nurseof young children. Good mothers, of which there washappily always a large preponderance, were not oftenable to impart by means of simple doctrine theessence of their skill. Its acquirement needed beyondall things a patient apprenticeship, and he emphasisedthe advantage held by women who had themselvesto mind children over those who employed othersto do it for them. Among the well-to-do the first-born quite often found its mother completely un-prepared, devoid of knowledge or practice. In the

poor classes the girls were often responsible nursesat the age of 7, and still minding babies when granniesof 70. Neither case was ideal ; in the latter the burdenwas often too heavy. But no one could doubt itfrequently produced a degree of skill seldom seenin the former. The lecturer implied no disparagementin mentioning this contrast, but he referred to itbecause of a somewhat frequent tendency to blamethe poor collectively for a lack of skill in upbringing,even a lack of concern for their infants. No infantwelfare worker of any experience and powers ot- £observation would subscribe to that view.