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the point of interest being that each uterine contractionmade the fibroid harden and protrude, causing the patientextreme pain.Dr. Marshall divided the cases into three classes :

(A) Cases which might safely proceed to term.

(B) Cases requiring operation, but suitable for

myomectomy. (C) Cases requiring hystero-myomec-tomy. As to Class A it was doubtful if there was

any justification for the induction of abortion, as somany apparently hopeless cases proceeded to term.Large fibroids which had almost occluded the pelvisoccasionally rose with the growth of the uterus,aided no doubt later by the development of the loweruterine segment, and normal delivery followed. Inthe Class A cases the main complaints to be fearedwere pain and haemorrhage. Rest, sedatives as

indicated, and general treatment usually met thesecases, which, if not improving, must be considered asincluded in Class B. The indications for myomectomywere torsion of a subserous fibroid with necrosis,prolapse, or impaction of a subserous fibroid in thepelvis, an anterior fibroid causing retroflexion likelyto cause abortion or incarceration and excessive pain.The cases suitable for this line of treatment were ofthe subserous type. It was not advisable to removean interstitial fibroid of any size during pregnancy,because of the attendant haemorrhage, the weakeningof the uterine wall, and the frequency of abortionfollowing. In three cases he had performed thisoperation, two proceeding later to term, the thirdaborting on the third day. In Class C the fibroidswere generally very extensive and patient had extremepain. Rest and the usual methods did not ease her.The majority of cases which went to term terminated

spontaneously, but one had to be prepared to meetmore than usually severe labour-pains, uterine inertia,and malpresentations, and in neglected cases ruptureof uterus would follow. Dr. Marshall recalled one casein which a fibroid in the pouch of Douglas had to bepushed past the brim to permit delivery, and he feltthat had this been impracticable a posterior colpotomymight have been done. The correct line of treatmentwas Csesarean section, in cases of obstruction, providedthe patient was otherwise in a state for this operation.In the case of a fibroid which might be removed later ’by myomectomy, it was best to perform that operation ’iat a later date, but in the presence of extensive ’,fibroids or possible infection Caesarean hysterectomywas the ideal line of treatment. Under propersupervision craniotomy should never be required, andpulling a child past an obstructing fibroid withforceps was certainly to be condemned. Post-partum haemorrhage, both primary and secondary,was apt to occur in a uterus the seat of submucousand subserous fibroids. The possibility of thesecomplications should not be forgotten, and means tocombat them should always be at hand and usedpromptly. A more serious danger was sepsis.Pressure or injury during parturition might lead todegeneration and subsequent sepsis, or the tumourmight be injured during forceps delivery and laterbecome infected. In conclusion, Dr. Marshall expressedhis astonishment at the extraordinary shrinkage notedin uterine fibroids after a pregnancy.

Discussion.

Prof. J. M. MUNRO KERR congratulated Dr.Marshall on his interesting communication. In viewof the great tolerance of uterus and patients to fibroidshe almost felt inclined to look upon pregnancy,labour, and the puerperium as the complications.In the past year he had seen four cases in whichhysterectomy had been contemplated, but two ofthese had been carried safely to full time, when thepatients had living children by means of Caesareansection. Fibroids were apt to degenerate duringpregnancy owing to the altered metabolism, andProf. Kerr advocated the practice of eliminationwith rest in all cases. In cases where only onetumour of several caused trouble, this could often beremoved by myomectomy. This operation was asimple one in pregnancy ; rupture of uterus rarely

followed it, and cases were recorded in whichoperators had gone down as far as the deciduawithout disturbing the pregnancy.

Dr. W. D. McFARLANE had seen many cases whichhad appeared hopeless go to term. He agreed thatstimulation of the excretory organs was of greatadvantage. One case of interest was that of a patientwho had a pregnant fibroid uterus impacted inthe pelvis. Laparotomy was performed, the uteruslifted from the pelvis, and the woman proceeded toterm and delivered herself normally. After deliverythe tumour was so reduced in size as to be almostunappreciable.

Dr. J. LINDSAY spoke from his experience as ageneral practitioner, whose attitude was to givepregnancy the preference to fibroids. He had neverseen abortion follow fibroids, and in cases wherefibroids had been appreciated in early pregnancy hehad not experienced any difficulty in delivery.

Dr. CRAIG had had examples of abortion andsterility resulting from fibroids. In one case he hadfound a small fibroid in the pouch of Douglas ; at thesecond confinement difficulty was experienced, andat the third induction proved necessary. Growthcontinued and hysterectomy was ultimately required.In reply Dr. MARSHALL expressed satisfaction at

the importance laid on the medical treatment offibroids. The pregnancy was the all-important thing,and effort must be directed towards its preservation.He felt disinclined to accept myomectomy with itsattendant risks, and in cases where operation wasunavoidable greatly preferred hysterectomy.

SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on Nov. 24th,Dr. GODFREY CARTER, the President, being in thechair, when Mr. W. W. KING opened a discussion on

The Treatment of Ante-partum Haemorrhage.From an analysis of various hospital reports, coveringnearly 60,000 deliveries, he had estimated that theincidence of this complication of childbirth was

2-5 per cent. as opposed to the usual estimate of 0-2per cent. Mr. King confined his remarks to thatvariety of ante-partum haemorrhage which resultsfrom placenta praevia, and showed that on theoreticalgrounds haemorrhage, shock, and sepsis should be thethree great dangers which would threaten the lifeand health of the mother. Prematurity. haemorrhage.and the direct results of treatment were the corre-sponding causes of foetal death. In the 898 cases ofplacenta praevia analysed 7-6 per cent. of the mothersand 55-3 per cent. of the children lost their lives.The figures were identical with some published20 years ago, and show that there has been no improve-ment in the results of treatment during these years.A study of the maternal mortality showed that15-9 per cent. of the total deaths occurred in womenwho were admitted to hospital in so grave a conditionthat they died undelivered. Out of 58 patientswho were delivered 15-7 per cent. died of haemorrhage,18-9 per cent. of septicaemia, and 51-7 per cent. ofshock. Considering the nature of the disease it wassurprising that haemorrhage had caused so few of thedeaths. This would appear to show that the methodsin common use for the arrest of haemorrhage wereefficient at least in this respect. Most, if not all, ofthe deaths from septicaemia were the result of faultytechnique and should therefore have been avoided.Tissue-trauma in the presence of haemorrhage was

the great cause of shock, and the need for the gentlestmanipulation, and, above all, of avoiding rapiddelivery, did not appear even yet to have been fullyrealised. More than half the total deaths were dueto this cause, and, in the majority of cases, it wasclear from the records that death had resulted fromthe too hasty extraction of the child. The otherdeaths were not of obstetrical importance, with theexception of one from rupture of the uterus. In

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one other case this catastrophe was recorded, butthe patient recovered. As to details of treatment,INir. King advised palliative treatment in the interestsof the premature child when the haemorrhage wasslight and the conditions suitable. With severe lossand the patient not in labour Caesarean section wasgenerally the best treatment. In cases in which thepatient was in labour the Champetier de Ribes bagshould be used in the interests of all living and viable,children. Version should only be used for the deadand non-viable. Rupture of the membranes was onlysafe when the haemorrhage was slight and the os atleast half dilated. By adopting palliative treatmentin suitable cases under proper conditions, by Caesa,rean.section and by the use of the Champetier de Tubes.bag, it should be possible to reduce considerablythe enormous foetal mortality of placenta pranvia.The maternal death-rate would be reduced by earlytreatment, careful asepsis, gentle manipulation, andslow delivery. Morphia and intravenous glucosewere advocated in the prevention and treatment ofshock. Strychnine was useless and pituitary extractdangerous.

-Discussion.discussion.

The PRESIDENT said that his practice had alwaysbeen to effect delivery as soon as possible, irrespectiveof the life of the child.--Mr. P. E. BARB PR stated thatin his experience version was the most satisfactorymethod of treatment. He asked what evidencethere was that patients died of shock. He thoughtthat haemorrhage was the most common cause ofdeath.-Prof. M. H. Pt3rrn,IP::, while agreeing upon thewhole with the main propositions of the paper,thought that Caesarean section should be more com-monly performed for placenta praevia. He emphasisedthe danger of rapid delivery and of even slightpost-partum haemorrhage.—Mr. J. CmsHOLM relatedhis conversion from rapid delivery to the saner methodof slow extraction,

MANCHESTER MEDICAL SOCIETY.

A SPECIAL meeting of this Society was held onNov. 23rd in conjunction with the members of theLiverpool Medical Institution in the Medical Society’sReading Room, University of Manchester. After themeeting the visitors were entertained to dinner by themembers of the Manchester Medical Society. Dr.T. A. GooDFELLOW, President of the ManchesterMedical Society, was in the chair.

Dr. R. J. M. BUCHANAN read a paper on

Points of Clinical Interest in the Diagnosis ofAbdominal Diseases.

He emphasised the importance of definite pain as asign of organic disease. He considered the terms" neuritic, "

neurosis," and so forth in relation toabdominal disease as mostly wrong and certainlyunsafe. So-called functional disease was the last tobe sought for. Dr. Buchanan drew attention toabdominal pain caused by disease in the thorax-e.g.,empyema, pulmonary syphilis, pericarditis, and spinaldiseases-and to pleuritic effusion as an early heraldof malignant disease in the abdomen. He thoughtthat too little attention had been paid to carefulauscultation of the abdomen, especially in localisingperitonitis, and pointed out the value of light ausculta-tion of the abdominal aorta for a bruit which he foundpresent in pathological conditions in which the aortais pressed upon, especially malignant disease. Dr.Buchanan suggested that this physical sign might betested as occasion arose. He considered that delay inrecuperation of the blood after heematemesis favoured.a diagnosis of malignant disease. Profound anaemiaoften accompanied malignant disease of the caecum.Dr. Buchanan emphasised the prevalence of venousthrombosis in malignant disease, and said that in anycase of thrombosis the viscera should be examined.He spoke also of the exacerbation of symptomswith pyrexia noticeable in cases of leaking gastric and

duodenal ulcer. Dr. Buchanan advocated that allcases in which X rays are used a complete "watchthrough " should be* done. He pointed out the easewith which disease of the appendix could be revealedeven to the demonstration of concretions, andillustrated this with lantern-slides. In such cases thecaecum was often distended, a Jackson’s membranepresent, and plication called for. Dr. Buchanan drewattention to the tender spots on the back in the regionof the suprarenals in Addison’s disease. His addresswas illustrated with water-colour drawings, radio-graphs, and lantern-slides.

Mr. G. P. NEwBoLT read a paper upon the

Diagnosis and Treatment of Carcinoma ofthe Large Intestine,

based upon 60 cases upon which he had operated. Ofthese 36 occurred in the sigmoid colon, 11 in thesplenic flexure, 11 in the csecum, 8 in the hepaticflexure, and 4 in the transverse colon. Out of 33resections done up to 1917, 12 patients were alive atpresent. Sigmoid and splenic growths were, hethought, most favourable. He emphasised theimportance of an early diagnosis in these cases if asuccessful result was to be obtained, pointing out thedifficulty in diagnosis where the growth was small.Radiology had done a good deal in helping the exactlocation of some of these growths. He consideredthat a three-stage operation of csecostomy, followed byexcision of the growth with direct union, and later bya closure of the csecostomy, was the ideal operationin the absence of obstruction. Paul’s operation wasthe best, in cases where obstruction was present.Csecostomy should be done in patients who were veryill in consequence of acute obstruction. As 37 out ofthe 60 growths were situated in the sigmoid andsplenic regions Mr. Newbolt advocated incision onthat side in cases in which the situation of the growthhad not been exactly diagnosed. Where obstructionexisted he advocated exploration from the right sidewith the view of localising the growth, and then acsecostomy, with free removal of the growth laterwhen the intestines were empty. He suggested thatthe median incision was rarely necessary.

Dr. MURRAY BLIGH read a note on

Kefosis in Children,in which he referred to the lack of practical assistancein the diagnosis of the condition and in the estimationof its degree. He considered there was urgent needof means to measure precisely the extent of acidosisin children. 11 referred to the practice of limitingthe amount of food or of actually starving childrenimmediately before operation and to the tendency ofthe anaesthetic, whether ether or chloroform, to converta relatively mild ketosis into a severe intoxication.The custom of postponing operations because thetested urine showed the presence of acetone, thesaturation of the child with bicarbonate of soda, andthe infliction of a second period of starvation wasbased on unsound knowledge. The qualitative testfor acetone indicated nothing more than that acetone,diacetic acid, and oxybutyric were present in theblood and were being eliminated in the urine. Thepresence of acetone in the urine of children wasmisleading as evidence of depletion of alkali reservein the blood. It suggested the possibility of dangerswhich did not exist, and it led to uncontrolled treat-ment with alkalies. Dr. Bligh recalled the experi-ments of Prof. Haldane and his co-workers in whichthe eating of large quantities of alkali led to a stateof alkalosis as evidenced by diuresis, increasedalveolar CO2, and diminution in the ammonia in theurine, but the appearance also of acid bodies in theurine. Acidosis occurred without acetonuria and alsooccasionally along with acetonuria when there was norelationship between the two conditions. The causesof acidosis were multiple. Physiologically it was adiminution below certain limits in the alkalinityof blood plasma. Clinically such a condition mightresult from bacterial infection. from fermentation andits resultant lactic acid production ; from internal