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dense to X rays. The rules laid down that a uretericstone should give a homogeneous shadow, sharp inoutline and lying along the recognised course of theureter, which passed across the tips of the trans-verse processes of the lumbar vertebra to the regionof the sacro-iliac joint and then turned downwardsto the spine of the ischium and finally inwards tothe junction with the bladder. Miss Stavely showedby radiograms that these criteria were by no meansalways obeyed and that there was great variety inthe nature and position of the shadows thrown. Shedemonstrated examples of laminated stones ; of stoneswhich showed in the radiogram only after gradualabsorption of the iodine from the intravenousinjection ; and of a stone in the intramural part ofthe ureter which gave a mid-line shadow. In oneseries of films the passage of an opaque catheter upthe ureter had displaced a stone along almost thewhole length of the ureter, and she pointed out thatif a radiogram had not been taken with the catheterin place before injection of the opaque fluid, such adisplaced stone might easily have been missed.

Miss E. H. ROCKSTRO gave a summary of a reporton 299 cases of ureteric calculi treated at UniversityCollege Hospital and St. Peter’s Hospital for Stoneduring the years 1928-37. Her figures showed aproportion of three males to one female, but thispreponderance was partly due to the fact thatSt. Peter’s Hospital took male patients only. TheUniversity College Hospital figures gave the usualproportion of two males to one female. There wasa slight preponderance of left-sided calculi, and in2 per cent. bilateral calculi were present. Theyoungest patient was 5 years old and the oldest 78.Half of the patients were between 26 and 45. Multiplestones were rather uncommon. The stone mightbe arrested in the lumbar region, in the iliac fossa,in the pelvis, or at the entrance to the bladder.Impaction was commoner at the lower end than atthe upper ; in the whole series 38 stones had beenheld up in the region of the second or third lumbartransverse processes and 171 in the pelvis. Thosewhich had been arrested at the fourth lumbarvertebra showed a very distinct right-sided pre-ponderance (16 right to 1 left). The speaker thoughtthere must be an anatomical cause for this-possiblythe crossing of the root of the mesentery on the right.Colic was much the most important symptom, andwas present in 82 per cent. of the cases. In 14 therewas no colic, and in 3 others there was no statementabout colic in the notes. In 64 per cent. of thecases with colic there was radiation of the pain, andalthough radiation to the external genitals was notso common as the textbooks would have us believe,there had been such radiation in 19 per cent., infour-fifths of which the stone had been in the pelvicureter. A feature which Miss Rockstro thoughtreflected credit on the general practitioners who hadreferred the patients was that in only one hadappendicectomy been performed under a mistakendiagnosis. Open operation for the removal of thestone had been resorted to in 47-7 per cent. Therewere 13 deaths in the series.

Prof. R. E. KELLY described and showed a curioushollow calculus which was one of two he had removedfrom the kidney of a boy of 19 years.-Mr. H. P.WiNSBURY-WHiTE referred to the case in which a stoneimpacted in the intramural part of the ureter hadgiven rise to appearances suggestive of new growth,and said that it was a feature of stones in this situationto give extraordinary cystoscopic appearances. He

regarded abdominal distension as a very common

accompaniment of renal colic. Provided it was of

suitable size he believed in giving plenty of time fora stone to pass before he resorted to operation. Hehad known one to pass after nine months. As longas the stone was in the lower ureter the kidney functionwas well maintained; the lower the stone, the less thedegree of pelvic dilatation. He used ureteric catheter-isation in preference to open operation when possible,and where stones were impacted intramurally hehad found the high-frequency cutting current muchsafer than the coagulating current : it did not giverise to sloughing and sepsis.-Mr. R. M. HANDFIELD-JONES related the story of a girl who had been treatedat the age of 10 on an extension as a case of tuber-culosis of the right hip. Two years later her appendixhad been removed at one hospital, and the pain stillpersisting another hospital had removed the " remainsof the appendix " and left her with a ventral hernia.When she was 23 he had removed a stone from theupper end of the right ureter.The CHAIRMAN said that he had operated on 86

cases of ureteric calculi and in another 60 cases or sothe stone had passed without operation. The grosserthe stone, he found, the less the symptoms, and tinystones often gave a lot of trouble. It was essentialto give morphia in large doses while the pain wassevere, though it had no effect in helping the stoneto pass. The drugs he had found useful were benzylbenzoate and papaverine, which relaxed the ureter.In cases of calculous anuria nephrostomy was not theright treatment. It was better to go straight for thestone and drain the ureter at the site of removal.He never now sutured a ureter after removal of astone, and he thought that after nephrolithotomythe less suturing done to the pelvis of the kidney thebetter. If a flat rubber dam drain was put down tothe site of operation it was surprising how few casesleaked even a little. He wanted to know what aphlebolith was, and why when it showed so plainlyin a radiogram it could not be found in the post-mortem room.

ROYAL ACADEMY OF MEDICINE INIRELAND

AT a meeting of the section of obstetrics of thissociety held on Jan. 27, with Dr. J. S. QUIN, thepresident, in the chair, a paper on the

Treatment of Placenta Praevia

was read by Dr. A. H. DAVIDSON (master of theRotunda Hospital). This embodied a statisticalreview of the results achieved in this condition by theDublin maternity hospitals during the past five years.There were, he said, 304 cases, with 19 maternal deaths,5 of which were due to haemorrhage and 6 to sepsis.The incidence of anaerobic and Bacillus coli infectionswas high, suggesting that great care should be takenbefore intravaginal manipulations. Embolus, broncho-pneumonia, cardiac disease, and the anaestheticaccounted for the rest of the deaths. There were161 fcetal deaths (mortality 53 per cent.). Thetreatment adopted in 179 cases was compressionwith the half-breech ; there were 105 deaths in thisseries (a fcetal mortality of 74 per cent.). Willett’sforceps was used in 38 cases, with 12 deaths (a fcetalmortality of 31 per cent.) ; caesarean section wasdone in 24 cases, with 1 fcetal death ; the membraneswere punctured in 36 cases, with 6 fcetal deaths;and the vagina was plugged in 11 cases, with 5 foetaldeaths. There were 19 spontaneous births, with2 foetal deaths. Of the infants lost, 100 had reacheda stage of maturity which entitled them to methods

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of treatment that aimed at reducing the fcetal

mortality. The incidence of foetal abnormalitywas above the average, suggesting that radiographyshould be used before resorting to caesarean section.

Vaginal examination should not be made beforeadmission to hospital, and blood-transfusion shouldbe more frequently used before the actual treatmentwas started. Postpartum haemorrhage should be

guarded against in all cases. Version and the bring-ing down of a leg was invaluable in urgent cases

but its use should be greatly restricted when themother was in good condition and the foetus morethan 34 weeks old. In such cases puncture of themembranes was recommended for lateral, Willett’sforceps for marginal, and csesarean section for centralor partial placenta prsevia.The PRESIDENT noted that a third of the deaths arose

from bleeding after the condition had been diagnosed.He felt that these deaths were in most circumstancespreventable. In a patient who was already bledalmost white a very small amount of haemorrhagepost partum might be the deciding factor. Heemphasised the great amount of care necessary afterdelivery. He severely condemned anyone whoattempted to examine a patient suspected of havinga placenta prsevia unless he had at his disposal themeans of dealing with any eventuality that mightarise. He mentioned the installation of a blood-storage bank at the Meath Hospital and said thatit was now always possible to obtain blood for trans-fusions from it without having a donor. It hadalready proved a life-saving measure in many cases.The giving of this blood was no more complicatedthan the giving of ordinary intravenous saline.

Dr. J. F. CUNNINGHAM (master of the NationalMaternity Hospital) said that there had been 19deaths in Dublin in five years from placenta praevia,and most of these had been due to sepsis. Thetreatment of these patients before their admissionto hospital accounted for a great many of the deathsfrom sepsis. The importance of not interferingwith them before admission to hospital could notbe too strongly emphasised. There was great roomfor improvement in the methods of diagnosis. At

present no method was really sufficiently accurateto be followed regularly. Csesarean section shouldbe done more frequently in placenta prsevia, butmany of the patients were in too bad a conditionon admission. If the case was clean when the patientwas first seen, csesarean section should certainly bedone. In any case with very severe bleeding anda fairly certain diagnosis of placenta prsevia, if thepatient was in a condition to stand it, csesarean

section should be done. Vaginal plugging shouldbe abandoned. Recently a patient had been admittedto hospital having been plugged on four occasions :she was operated on next day but died four dayslater from acute sepsis, the result of treating her inher home by plugging four times. Many of thesepatients came into hospital in so bad a condition thatit was impossible to save them by any method. Healways condemned the giving of pituitary extractin placenta pr2evia ; it was definitely dangerous.He did not like using the extract at all in hsemorrhageof any kind and thought that there was such a thingas pituitary shock, which should certainly be avoided.He classified placenta prsevia into central, partial,and marginal, for he thought that students wereconfused by the terms " marginal " and " lateral."

Dr. R. M. CORBET agreed that the results in placentaprsevia were unsatisfactory. In the Coombe Hospitalduring his mastership 4 patients with placenta praeviahad died : 1 from sepsis ; 1 from pulmonary embolus

after version had been done and the patient wasquietly progressing in labour ; 1 apparently from theanaesthetic (ether) ; and 1 from severe broncho-pneumonia, which she already had when admitted.The patient who died from sepsis had been trans-fused. There was no particular blood-loss in theother 3 patients, and they were not transfused.Transfusion was very important and could be a life-saving measure.With regard to caesarean section, he had only per-

formed 8 sections for placenta preavia-6 classical and2 lower-segment operations. When the placenta wassituated on the posterior uterine wall, the lower-segment operation had merits. He had donecaesarean section on a patient who had been twiceplugged before admission to hospital. He performedcaesarean section chiefly for the sake of the mother ;therefore he would be prepared to perform it, incertain circumstances, if the baby were dead-anaspect of this treatment which was sometimes over-looked. He called attention to an analysis of 22,000cases of placenta prsevia contributed by L. L.McKenzie to the American Journal of Obstetrics andGynecology in 1937, of which 11,000 were deliveredby caesarean section, with a mortality of 6-6 per cent.,and 11,000 were delivered through the vagina,with a mortality of 8 per cent. ; but in the vaginaldeliveries many methods were used upon whichwe looked with disfavour. The reason why Willett’sforceps, applied to the scalp, produced a lower infantmortality than did the half-breech and version mustbe that the blood-supply was less compressed—i.e.,the head was not so efficient a compressor as the half-breech. Therefore we must lay down very carefullythe limits of the use of Willett’s forceps, lest thematernal mortality be increased.

Dr. D. V. MoRRis mentioned the great difficultyin connexion with these cases in hospital practice.The patients had been repeatedly examined bynurses and doctors before they were admitted andwere often in a very bad state. He doubted theadvisability of plugging the vagina. What wouldin his opinion have the most remarkable results inthe improvement of the treatment of placenta praeviawas the education of the public. It was so veryimportant to get patients to go to hospital earlyand not to have treatment anywhere but in hospital.

Dr. BETHEL SOLOMONS said that the figures broughtbefore them were a great advance on previous figures.He disliked the suggested classification of placentaprsevia. He had always taught that the divisioninto central, partial, and lateral was best. He sawno reason for the inclusion of marginal, for he couldlay down definite lines of treatment according to theclassification stated above. He mentioned a case

of twins and central placenta prsevia at seven months.He had performed csesarean section, and the childrenwere now about eight years old. He did not advocatecsesarean section as the usual treatment at this periodof pregnancy, but this was an exceptional case, forthe mother had lost the previous child. The classicaloperation was the one of choice, for the placentaobstructed the view in the lower-segment operation.He pleaded for the extended use of submammaryinjection of saline solution before manipulations.It was always available, and blood was not. Hehad found it a life-saving procedure, and in hisseries of 138 cases in hospital during his mastership,with 2 deaths, none of the patients had blood-trans-fusions, but nearly all had submammary injectionof saline solution. If blood was available it shouldbe given, and blood-transfusion was an essentialtreatment for puerperal sepsis following placenta

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praevia. Many lives had been saved during hismastership by this method, which must not be for-gotten in these days of chemotherapy. When Willett’sforceps was used, he advocated the long instrumentwhich he had invented. He was entirely against theuse of pituitary extract after version ; he had seenone death from ruptured uterus following its use.

He believed that with great care there should beno death from placenta prsevia.

Dr. DAVIDSON, in reply, said that it would beadvisable to establish blood storage in all the hospitals,as had now been done in the Meath Hospital. Hewould like to classify placenta praevia into central,partial, marginal, and lateral. There was a verydefinite difference, so far as treatment was concerned,between marginal and lateral and between centraland partial. One should discriminate betweenmarginal and partial, and marginal placenta preaviashould never be called lateral. Salines shouldundoubtedly be used, but blood-transfusions shouldalso be used. There was too much complacencyabout the treatment of placenta praevia. Peoplewere too inclined to say that these patients cameinto hospital in so bad a condition that nothing butgood luck would save them. They were also tooinclined to say that most of the babies were prematureand therefore it did not matter at all about them, butthe chief thing was to save the life of the mother. Hewould like to deny both these facts very strenuously.In the reports of the three hospitals the remark was

put after placenta-praevia patients " patient in poor.condition " or " patient in good condition." In

only 40 cases out of 300 (14 per cent.) was the remark" patient in poor condition." This meant that70 per cent. at least of these patients were in goodcondition when they were admitted. These patientsdid not require the use of Braxton Hicks version toanything like the extent to which it had been usedin the past. His opinion was that, if it was at all

possible to do so, Braxton Hicks version should beavoided. Of the 161 babies lost, 100 were not pre-mature. A bigger effort should be made to save thelives of the infants in placenta prsevia. Blood-transfusion was of the very greatest importance incases of sepsis ; every septic case of placenta prseviashould be transfused. Plugging should be condemned.He had recently read a paper from Queen Charlotte’sHospital in which the author had advocated pluggingin every case as the one and only treatment forplacenta praevia. This he could not understand atall, for in his opinion it was a form of treatment whichshould be condemned. Pituitary shock was notlikely after the giving of 1 c.cm. of pituitary extract,but it was likely if the dose was repeated. Hethought that the indications for the use of Willett’sforceps were definite and narrow. They should beused only when there was a marginal or a low lateralplacenta prsevia. The maternal mortality fromcsesarean section and from Braxton Hicks versionwas almost the same.

NEW INVENTIONS

ALUMINIUM-WIRE STIRRUPS FOR

AMBULATORY PLASTER CASES

THE type of walking-iron introduced by Prof.Bohler for fitting to ambulatory plasters in thetreatment of fractures below the knee has several dis-advantages. It is heavy, particularly for women orchildren, it is impermeable to X rays, and since itonly extends half way up the leg it requires a consider-able thickness of plaster at its upper end to hold itrigid. In order to overcome these difficulties and achievethe ideal combination of lightness and strengthwhich will satisfy both patient and surgeon I havefound the following method entirely satisfactory.

In place of Bohler’s iron a stirrup (fig. 1) is madeby the surgeon from 3 mm. gauge aluminiumwire known as Bohler’s finger wire. The wire isreadily bent by hand, but when doubled on itself and

FIG. I-Detail of stirrup.

encased in plasterbecomes abso-

lutely rigid andwill stand walkingon as long as re-quired. The appli-ance is made fromone piece of wire6 ft. long, the twoends being twistedtogether in thebridge upon whichthe patient is towalk. The side-pieces are bound

together by a fewturns of fine wirein several places.The loops at theupper ends are

adjusted to restagainst the

ring of feltwhich sur-

rounds the legjust below theknee so thatthe plaster isreinforced bythe wire in itsentire length.This greatlystrengthens itand conse-

quently lessthickness of

plaster is re-

quired. Whenthe plaster hasset the bridgeof wire belowthe heel iscovered with apiece of felt

in. thicksecured in posi-

FIG. 2-Ambulatory plaster withaluminium stirrup in Pott’s fracture.To illustrate the translucency ofthe stirrup.

tion by a few turns of elastic adhesive bandage orplaster-of-paris. This avoids any tendency to slip onpolished surfaces and adds to the patient’s comfort.The actual difference in weight between iron and

aluminium stirrups is considerable : an iron one weighs4 1 lb. ; an aluminium one 1-1 oz. The radiogramin fig. 2 shows the small degree of interference towhich the stirrup gives rise. The advantages of thisform of stirrup are, therefore, its lightness ; its pliability,permitting of adjustment in length or width ; itsgreater length ; and its translucency to X rays.

C. RATTRAY MCCASH, Ch.M. St. And., F.R.C.S.E.