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patient remained comfortable for ten days, when he beganto complain of general malaise. Three days later (June 3)he became very restless, complaining bitterly of pains every-where and going into floods of tears. His temperature roserapidly to 103° F. There was slight neck rigidity ; no

abnormality was discovered in the chest, abdomen or legs.The edges of the wound in the lumbar region were slightlyinflamed. A radiogram revealed a foreign body situated inthe spinal canal, opposite the upper limit of the first lumbarvertebra (see figure). On lumbar puncture the fluid was notunder pressure but was slightly turbid, containing a moderateamount of pus and a small number of red cells. A gram filmshowed short-chain streptococci, and culture yielded hsemo-lytic streptococci.Laminectomy was performed on June 4 under endotracheal

gas, oxygen and ether anaesthesia. The lamine of the lastdorsal and first four lumbar vertebrae were removed, and thecanal explored extradurally without success. The dura wasthen incised and the piece of shrapnel was felt lying againstthe posterior aspect of the cord in the position indicated bythe radiograms. It was seized with a pair of forceps andremoved without difficulty. It was found impossible to stitchthe dura, so the posterior spinal muscles were carefully suturedin position. After returning to the ward the patient was laidflat on his back without pillows and with the foot of the bed

Anteroposterior and lateral radiograms showing foreign body lyingin spinal canal at level of first lumbar vertebra.

raised. Chemotherapy was begun immediately, two intra-muscular injections of Prontosil Rubrum 5 c.cm. being givenin the first six hours, followed by 1 gramme of sulphanilamidethree-hourly by mouth. Neck rigidity and Kernig’s signwere present the next day. but he was moving his legs well.The temperature did not rise above 99 4° F. ; the pulse-ratevaried between 110 and 140. He was unable to micturateand catheterisation was necessary twice each day.On June 7 the abdomen was very distended and resonant

all over, the bowels not having moved since operation. An

enema, given the previous night, had been retained. Prostig-min 1 c.cm. was given hourly for six doses, followed by aturpentine enema, with a fair result. This was repeated thenext day and all distension disappeared. The bowels werethen kept open with calomel gr. 2 every night. The knee-jerks were absent and the plantar response was flexor on bothsides. The stitches were removed on the 13th. Tue knee-jerks were now present, the left brisker than the right ; theleft plantar response was doubtful and the right absent.He began to pass urine invohmtarily on the 14th and eathe-terisation was not subsequently required. Voluntary controlwas re-established a month after operation, but with increasedfrequency. By three weeks after operation (June 25) theneck rigidity had passed off and Kernig’s sign was no longerpresent. The left knee-jerk was still brisker than the right,and there was a suggestion of a patellar clonus on the leftside. The ankle-jerks could not be obtained and the plantarsremained uiiehajigc,(’t.

Sulphanilaxnide was continued until June 28, the dosagebeing : 1 g. three-hourly for 20 doses ; 1 g. four-hourly for20 doses ; 0 5 g. four-hourly for 20 doses ; 0-5 g. three timesa day for 14 days ; making a total of 75 g. The patientstarted to get up after a month. There was no change in thephysical signs, save that the left plantar was now definitelyextensor. Throughout the whole postoperative period his

temperature never rose above 100° F. ; but the pulse did notreturn to normal for six weeks. At that time the knee-jerkswere brisk and equal and there was no patellar clonus ;ankle-jerks were obtained on reinforcement ; both plantarresponses were now flexor. Sensation was normal and Rom-berg’s sign was negative. Two months after operation hewas walking well with the aid of a stick ; but there was stillsome muscular weakness of the legs, more on the right side.

I wish to thank Mr. Reginald Vick for his suggestionsand permission to publish this case.

Medical Societies

ROYAL ACADEMY OF MEDICINE IN IRELAND

AT a meeting of the Section of Obstetrics on Dec. 20,1940, with Dr. R. M. CORBET the president, in the chair,Prof. O’DoNEL T. D. 13ROWNE read a paper on the

aetiology of the Lower Uterine Segment andUterine Descent

He regarded the ligaments as the main factors in uterinesupport. Owing to the growth of the lower uterinesegment in pregnancy the transverse cervical ligamentsare spread upwards on each side, fanwise, as a lateralbrace between the broad ligaments ; thus they stabilisethe uterus. The uterosacral ligaments decussate and arespread out over the posterior surface of the lower two-thirds of the uterus and, in addition to strengthening thenew lower uterine segment, prevent undue falling forwardof the heavy fundus. Thus these ligaments are tauteven before labour and it would be easy for prolongedand strong uterine pains in difficult labour, or forcibleinstrumental or other delivery through an undilatedcervix, to rupture the taut and widely separated liga-mentous bands. He suggested that forcible downwardtraction tore the lowermost fibres, thus depriving thevaginal vault of its attachment to the under surface of thepelvic ligamentous support. The subsequent pull of theunsupported cervix upon the higher portion of the cervixwhich was still fixed by the intact ligaments resulted insupra,vaginal hypertrophy of the cervix. When coincidentdamage occurred to the upper and lower ligamentoussupports uterine descent resulted. He defined highrectocele as a true hernia, at the bottom of the pouch ofDouglas, between the two adjacent borders of theuterosacral ligaments. The cure of this relatively rarecondition was by approximation of the uterosacral liga-ments, either from above or per vaginam, and heemphasised that an extensive colpoperineorrhaphy-which served in low rectocele-would not suffice.

Prof. J. KAY JAMiBSON said that the pelvic fascia wasmerely a sling for maintaining the genito-urinary organsin position. He said that there was no anatomicalevidence whatever of the lower uterine segment, batthere was no doubt that in a certain phase of life it didexist. Anatomists had no opportunity of seeing it atthat time.-Prof. A. H. DAVIDSON mentioned threeoperations which gave the operator insight into theso-called cardinal ligaments of the uterus : vaginalhysterectomy, the Fothergill operation, and Wertheim’soperation. Mackenrodt’s ligaments varied according tothe position of the uterus-whether it was pulled up orpulled down. In the Wertheim operation it was neces-sary to divide these ligaments as near to their insertionas possible. In treating uterine prolapse he preferred todo a Fothergill operation. The lower uterine segmentarose from the isthmus of the uterus, and this was theportion of the non-pregnant uterus to which the cardinalligaments were attached.-Dr. J. S. Qunsr remarked thatthe anatomist and the gynaecologist held different viewsas to how the lower uterine segment was formed. Hethought a high sliding rectoc le was always due to ahernia of congenital rather than traumatic origin.

Dr. BETHEL SOLOMONS said that the supports of theuterus were definite and even though Mackenrbdt’sligaments were obviously the important supports everyligament helped, and a section of the pelvis showed thalthe levator muscles and fascia were indirect supportsthrough the vagina. He did not himself perform thetypical Fothergill operation ; he cut the utero-sacratligaments and sutured them to the front of the cervix.

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After denuding the anterior surface he picked up thebladder pillars and brought them together in front of thebladder. These pillars he believed to be part of thepubo-coccygeus muscle. It was not necessary to sutureMackenrodt’s ligaments in order to cure the prolapse : infact there was danger of including the ureter in doing so.To cure a high rectoc4e he brought together tissue highup in the vagina which might or might not be the utero-sacral ligaments.-Prof. O’DONEL BROWN, replying,said that he had placed markers of bismuth and othermaterials in the lower uterine segment at known intervalsduring gynaecological operations, and had subsequentlyseen the radiograms of those markers throughout thepregnancy. He believed high rectoc Ie to be a herniaoccurring through the posterior vaginal fornix, fromabove, in contradistinction to low rectocele, commonlyseen following skin tears incurred during delivery andtaking place in the lower part of the vagina. He hadencountered only two cases of high rectocele and hadcured them by approximation of the inner borders of theutero-sacral ligaments. In his opinion, high rectoc Iecould occur as a congenital deformity, and had been suchin one of the two cases he had seen. He disagreed withapproximation of the bladder pillars as a step in thetreatment of prolapse. Anatomically, these so-calledbladder pillars could not be demonstrated by dissectionor at operation unless a fold was artificially created eitherby picking up the tissues with a dissecting forceps, byplacing stitches so as to pucker the bladder wall, and thusproduce something that appeared as a pillar of thebladder.

Amputation and Repair of the CervixDr. EDWARD SOLOMONS reported on a series of 302

cases operated on between 1931 and 1939 ; only 104came subsequently to hospital for examination. Theoperations performed were Emmet’s trachelorrhaphy,Schrceder’s partial amputation of the cervix and circularamputation of the cervix ; included in the last were someSturmdorf amputations. The suture material usednearly throughout the whole series was chromic or tannedcatgut. Patients were later questioned concerningbenefit from the operation, symptoms then present, thepresence of discharge, the number of children sinceoperation, the nature of the confinements, marital rela-tionship since operation and whether any change inmenstrual discomfort had occurred. A careful bimanualexamination, followed by inspection of the cervix, wasthen made. If discharge was present it was investigated.He found that of the 104 subsequently examined 94 werebenefited, backache being the commonest remainingsymptom ; 70 had no discharge after operation ; 3 had aworse discharge after operation than before, discharge hadimproved in the remainder. Trachelorrhaphy gave thebest results for fertility, 23 out of a possible 30 subse-quently becoming pregnant. Healing was complete in72, the result was bad in 1, and the remainder showedvarious degrees of slight ectropion or erosion. No casesof carcinoma of the cervix have been encountered afteramputation or repair.

Dr. QuiN wanted to know what Dr. Solomons re-

garded as indications for operation in these cases.

He believed that some cases of erosion would respond tobeing left alone or to treatment with mild caustics.Dr. A. W. SPAIN agreed that most erosions could be curedby cauterising the cervix two or three days after the men-strual period. He did not think that cancer of the cervixresulted from these conditions of the cervix. Prof.DAVIDSON said that unless the cervix was very muchhypertrophied he preferred the electric cautery tooperation. A fine anatomical cure followed the use ofthe cautery ; and he thought that subsequent pregnancyand labour should be easier when cauterisation wasadopted than when an operation was performed. In caseswith small simple erosions the pH of the vagina was ratherhigh. If the patients were treated by acid media for twoor three- months, or in some cases two or three weeks, itwould be found that the erosion would completelydisappear. Dr. BETHEL SOLOMONS said that in hisexperience cauterising methods were only suitable for thevery early types of erosion. A carefully performedtrachelorrhaphy or amputation cured nearly every case.Dr. E. SOLOMONS in reply said that of the 302 cases, 18had been nulliparous, and of these 18, 4 were single

women suffering from erosion of the cervix. In 60% to70% of all the patients some other operation had beenperformed. The choice of treatment depended on thelesion present.

Reviews of Books

Essentials of General Anaesthesia

By R. R. MACINTOSH, D.M. Oxfd, F.R.C.S.E., D.A.,Nuffield professor of anaesthetics in the University of

Oxford; and FREDA B. PRATT, M.D. Lpool, D.A., firstassistant in the department of anaesthetics in the university.Oxford : Blackwell Scientific Publications. Pp. 334. 25s.

’1’His book is written tor senior students, and tormedical and dental practitioners who want to refreshtheir knowledge of general anaesthesia, but there is muchin it which will also interest specialist anaesthetists. Allforms and methods of general ansesthesia are described,but the main bias of the book is towards anaesthesia fordental surgery. The problems of dental anaesthesia arediscussed fully and practically. Difficulties and dangersare dealt with frankly, and continual stress is laid on thenecessity for cooperation between dentist and an.Ts-

thetist. The book is obviously the outcome of wide experi-ence, and indicates a sympathetic knowledge of humanfrailties, both of patients and of anaesthetists. Drugsand methods used in dental anaesthesia are carefullydescribed, and the chapter on Pentothal is particularlywelcome. The authors emphasise that the effects ofthis drug vary with the speed of its injection.The description (accompanied by excellent illustra-

tions) of the difficulties of tracheal intubation comes as awelcome relief after the bland assumption, by some, thatsuch difficulties do not exist. The chapters on physio-logy and the theories of anaesthesia, no doubt purposelyover-simplified, are full of practical points. Methods ofanaesthesia for major surgery might, perhaps, have beendiscussed more fully. As it is, such interesting and usefuldrugs as cyclopropane and Vinesthene, which have littleplace in dental surgery, have had to be passed overrather lightly, and only one apparatus has been describedfor the administration of nitrous oxide and oxygenin dental surgery ; but, as the authors point out, theapparatus is less important than the man behind it.

Manson’s Tropical Diseases

(llth ed.) By PniLip H. MANSON-BAHR, M.D. Camb.,F.R.C.P. London: Cassell and Co. Pp. 1080. 35s.

IN this edition, the fifth by Dr. Manson-Bahr, muchhistorical and technical matter has been replaced by fiftypages of information on life in the tropics, on bodily andmental conditions that make for success in that life, andon measures that help towards this even before transferto the tropics is made. The author’s signal range ofknowledge on tropical medicine is set out with discrimi-nation, and he acknowledges his debt to constructivecriticism. So might not the time-honoured figure ofnecator by Placencia be replaced by one showing theattitude which it takes up when killed as usual by hotspirit, and which permits immediate naked-eye identifica-tion ? 2 Again in the specific name Wiichereria there isdivergence from the Code of Zoological Nomenclaturewhich demands that names should be Latin or latinised,for Latin had no umlaut. As C. W. Stiles urged 40 yearsago, medical men who have to enter the zoological fieldshould keep the zoological rules. It is not strictlyaccurate to say that Clayton Lane devised floatation forthe diagnosis of nematode eggs in faeces. An indirect-gravity floatation method was devised by Bass in 1909and therefrom developed the direct-gravity floatationmethod of Willis and the direct centrifugal floatation ofLane. Further, the abolition of the stickiness of hook-worm eggs, which the floating solution produces, allowsof their being herded into an area of a few squaremillimeters with consequent rapid diagnosis, the weightof the floating fluid used varying with the specific gravityof the egg species which it is desired to lift.The few small historical and technical blemishes on a

body of great clinical experience and clear expositionare worth mentioning only with the wish to betterthe good.