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Medical Societies

ROYAL SOCIETY OF MEDICINEAT a meeting of the obstetrical section on Nov. 16,

with Prof. F. J. BROWNE in the chair, a discussion onPlacenta Praevia

was opened by Mr. C. H. G. MACAFEE, who described theresults in 191 cases treated since 1937, with a maternalmortality of 0-5% and a gross foetal mortality of 22%.He spoke of the importance of removing -all cases ofplacenta praevia to hospital, without vaginal examinationunless there is serious haemorrhage. In his own seriesfew cases had been examined before admission, and ifthis rule were generally observed the maternal mortalitywould be immediately lowered. One of the main causesof foetal mortality was prematurity. This could bereduced only by carrying on the pregnancy to as nearterm as possible. In support of this expectant treat-ment he submitted the following arguments :1. In the absence of vaginal manipulations severe initial

haemorrhage is uncommon. A sudden severe hoemor-

rhage is theoretically possible in multiparae, but is rarein primigravidae. The proportion of primigravidse andmultiparse having no haemorrhage before term is striking.

2. Some have a sharp but small haemorrhage at 30-34 weeks,without further loss. In some of these the placenta canlater be palpated inside the os without further hoemor-rhage. This has been found to be due to infarction ofthe separated area.

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3. In his series were many cases where several haemorrhagesoccurred without embarrassing mother or baby. Foetaldeath was commoner in the first two years of his series,when pregnancy was terminated earlier.

The previous obstetric history might be a guide to treat-ment. Previous easy and rapid deliveries suggestedthat the case may be treated by the vaginal route,whereas a history of long and difficult labours indicatedthat such treatment would result in a stillbirth. Ahistory of large babies justified active treatment at anearlier stage.Mr. Macafee appealed for removal of the terms lateral,

marginal, and central from obstetric literature, since thetwo former were not used consistently. He preferredProfessor Browne’s classification into four types : (1)where the edge of the placenta dips on to the lowersegment ; (2) where the edge of the placenta reaches theinternal os ; (3) where the placenta overlaps the internalos but does not cover it at full dilatation ; and (4) wherethe placenta covers the os when fully dilated.The decision as to when vaginal examination should

be carried out must be made by someone with experience.In this series it was performed in all cases, but only afterall preparations had been completed for immediatelyundertaking whatever treatment was deemed appro-priate. Therefore it was postponed until the end ofexpectant treatment. After the first haemorrhage thecervix and vagina should be inspected per speculumto exclude any local cause of bleeding. He consideredvaginal examination essential, because without it nobodycould distinguish a placenta praevia from other causes ofbleeding or decide on the type and the best method oftreatment. Type 1 could be treated by rupture of themembranes. In type 2, if the placenta lay anteriorly,rupture of the membranes was sufficient; but if it wasposterior, caesarean section was preferable. Type 3was associated with the highest fcetal mortality, probablybecause treatment was required earlier in gestation. Intype 4 the results were better : treatment, which wascsesarean section, was undertaken nearer term. Therewas one maternal death due to staphylococcal septicaemia.For anaesthesia, Mr. Macafee used cyclopropane andoxygen. Most of the caesarean sections were done throughthe lower uterine segment.

Mr. L. G. PHILLIPS described the results in 143 con-secutive cases of placenta preevia treated at QueenCharlotte’s Hospital, with a maternal mortality of 1-4%.He attributed the lowered mortality of recent years tofour factors. First, general practitioners now recognisedthat these cases were better treated in hospital, whereasepsis, blood-transfusion, and skilled nursing were

available. Hence the patients now arrived at hospitalin good condition. The second factor, which in his

series was the most important, was blood-transfusion.In one published series for 1925-36, 56 cases died ofhaemorrhage, and of these only 3 had had transfusions.In a modern well-equipped hospital it should be rarefor a patient to die of haemorrhage. The third factorwas the greater use of caesarean section, which was thebest method of treatment in all cases of central placentaprsevia, and all cases in which a sharp haemorrhageoccurred with an undilated cervix. More considerationwas now given to the claims of the child, and the methodsof rearing premature children had so greatly improvedthat where the child was 36 weeks mature, there was astrong case for caesarean section. The fourth factor wasimproved team-work.

In his own series all cases of placenta praevia weretreated as emergencies. They were examined at onceunder an anaesthetic, the vagina was ironed out, thefinger was passed through the cervix, and the positionof the placenta was ascertained. If the foetus was avertex presentation and there was not much bleeding,the membranes were ruptured. If it was a flexedbreech and the os two fingers dilated, the membraneswere ruptured and a foot drawn down. This was mostlydone when the foetus was either small or dead. A vertexwas never turned to a breech. If severe haemorrhagefollowed rupture of the membranes, the vagina wasplugged with 3-5 rolls of gauze, soaked in 5% ’ Dettol.’The plug was never retained for more than 24 hours.If a central placenta praevia was found, caesarean sectionwas done either immediately or after blood-transfusion.

In Mr. Phillips’s series of 143 cases treated at QueenCharlotte’s Hospital from 1933, the maternal mortalitywas 1-4%, the foetal mortality 53%, and the morbidity16-4%. The foetal mortality was 38% after artificialrupture of the membranes, 93% after bringing down aleg, 6-6% after caesarean section, and 66% after pluggingthe vagina. Though he was not an ardent supporterof vaginal plugging, there were occasions when it wasdifficult to avoid. It should be used only in hospitaland never in domiciliary practice. Any sepsis thatdeveloped in this series was slight and required notreatment.Looking back at his series, he thought he made four

mistakes. (1) Many cases could have been left afteradmission until a severe haemorrhage occurred. (2)The original examination should always have been onthe operating-table, so that an immediate caesareansection could be done. (3) There is no advantage inusing dilators when trying to establish the edge of theplacenta when the os is closed. If a sharp haemorrhageoccurs, a csesarean section should be done. (4) In futurehe would plug less often and do more caesarean sections.

Miss JOSEPHINE BARNES first dealt with 538 cases ofantepartum haemorrhage, treated at University CollegeHospital. They were classified into four groups : (1)placenta praevia ; (2) accidental antepartum haemor-rhage ; (3) antepartum haemorrhage of uncertain origin ;and (4) antepartum haemorrhage from extraplacentallesions. Over half the cases fell into the third groupand the proportion of cases in this group had increasedin recent years, a more expectant attitude being adoptedand the number of vaginal examinations reduced.It was the routine practice to pass a speculum onadmission so that the cervix and vagina could beinspected to exclude extraplacental lesions. Amongthe 538 cases there were 140 cases of placenta praevia, and285 cases of haemorrhage of uncertain origin. The mater-nal mortality of placenta praevia was 2-9% and foetalmortality 52%. Of the 71 dead infants, 38 were lostafter bringing down a leg, and this method had nowbeen abandoned. The infant mortality from caesareansection was 18%, from bringing down a leg 97%, fromWillett’s forceps 47%, and from rupture of membranes36%. The two main causes of fcetal death were prema-turity and placental separation. The maternal morbidity-rate was 15%.

Vaginal examination should not be done outsidehospital and there should be no vaginal plugging.Patients with antepartum haemorrhage, however slight,should be admitted to an institution. On admissiona speculum was passed and preparations made fortransfusion, but the patient should be treated expect-antly unless there was severe haemorrhage. All patientswere advised to stay in hospital till their confinement.

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Artificial rupture of the membranes and applicationof a firm binder was suitable for types 1 and 2, par-ticularly if there had not been much haemorrhage andlabour had begun ; but csesarean section was takingan increasingly important place in the treatment. Itoffered the best chance for the infant and only by itswider employment could the mortality be improved.The tendency at University College Hospital of recentyears had been towards more expectancy and manymore csesarean sections. Vaginal examinations were

usually carried out, but not in cases with severe beemor-rhage, which were best delivered by csesarean section.Since 1936 the results had shown improvement : in66 cases there was a maternal mortality of 1-5% and afoetal mortality of 36%. The deaths were attributablerather to interference than expectancy.

In subsequent discussion every speaker agreed on thevalue of expectant treatment and csesarean section inreducing the foetal mortality.

Reviews of Books

A History of MedicineDOUGLAS GUTHRIE, MD EDIN., FRCSE, FRSE. (Nelson.Pp. 448. 30s.)

Dr. Douglas Guthrie has written a well-balancedand readable survey of the progress of medicine fromImnotef to Osler. The earlier chapters depict the grad-ual differentiation of medicine from magic and theologyin Asia, Egypt, and Gree’ce, and its systematisation in theHippocratic and Alexandrian periods. Its absorption intoChristian theology reinforced by Galenic dogma, and itshalting progress during the dark ages are well described ;the men are remembered, who in such centres as Salernoand Montpellier preserved and transmitted the traditionof more fruitful eras in times when learning was not highlyprized. The chapters on the Renaissance show the in-fluence on Continental medicine of such men asVesalius andPare, and seek to penetrate the obscurity surrounding theenigmatic personality of Paracelsus. Dr. Guthrie remindsus how long it took for the influence of the Renaissanceto permeate English medicine. Despite some earlierreformers and revolutionaries it made no general appealuntil Harvey and Sydenham. The progress of medicinein the eighteenth and nineteenth centuries is presentedto the reader in short biographies of surgeons and

physicians, with an account of the contributions whichthey made to it. The book is profusely illustrated, witha good bibliography and index.

Interest in the history of medicine comes eventuallyto a large—probably to an increasingly large-numberof medical men, but as a rule it does not come early.This attractive presentation of the subject may help topopularise it among students and younger practitioners ;it will certainly give pleasure to those in whom historicalinterest is already developed.Kettle’s Pathology of Tumours

(3rd ed.) W. G. BARNARD, FROp ; A. H. T. ROBB-SMITH, MA, MD. (H. K. Lewis. Pp. 318. 21s.)

THOUGH the second edition of Kettle’s book waspublished 20 years ago, it remains the memento of agreat teacher, carrying the mark of his personality.If some of his many old pupils and friends should viewwith disquiet the advent of a new edition by otherauthors, they may be reassured, for the work has beendone with sympathy and understanding. The originaldrawings have been retained and only such alterationshave been made in the text as were necessary to bring itup to date. The most important of these are in thesections on the experimental study of cancer and on thenervous system, the lymphatic glands, the lungs, and theovaries. The descriptions of the more recently recognisedtypes of tumour are clear and concise, while the new photo-micrographs are in keeping with the other illustrations.The new edition is elegantly produced; but the final

revision was perhaps too hasty, for a few errors haveslipped in. Some of the illustrations for example havebeen reversed, so that they do not correspond withtheir descriptions ; again, two sentences in the formeredition referring to colloid carcinoma have been deleted,with the result that the two illustrations of this tumourwhich have been retained are left without sufficient

explanation. These are small points which can becorrected in subsequent impressions and do not actuallylessen the educational value of the work. Medicalstudents will find it useful because it provides a brief,but (for their purpose) quite adequate and very readable,survey of tumours. Kettle’s drawings are free from theunessential detail which often makes photomicrographsdifficult for beginners to interpret. With diagrammatic’simplicity, they emphasise the more characteristichistological features so as to create a lasting impression.By producing this new edition of his book, the authorsand publishers have met a real need.

Contribuição para o estudo do diagn6stico clinico dalepra nervosa

Contribution to the Study of the Clirzical Diagnosis ofNeural Leprosy. OSWALDO FREITAS JULIÃO. (SaoPaula; Biblioteca SPL. Pp. 203.)

THIS is a careful thesis. The disturbances of motornerves, cranial nerves, and reflexes are described;changes in the peripheral nerves and the sensory,trophic, and vascular involvement are fully studied.Dr. Juliao records 91 cases, many of them being of otherdiseases of the nervous system from which leprosy hasto be differentiated. He divides these into (1) affectionsof the central nervous system, such as syringomyelia,intramedullary tumours, progressive muscular atrophy,and tabes ; (2) affections of the roots and plexuses;and (3) affections of the peripheral nerves, such asvarious forms of polyneuritis, von Recklinghausen’sdisease, and pareesthetic syndromes. The thesis is wellillustrated with clinical pictures and photomicrographs,and a useful list of 174 page-foot references is given.It will be of considerable value to those studying leprosy.

New Inventions

A NEW TYPE OF ENTEROTOME

A NEW spur-crushing enterotome has been designed inan attempt to obviate the weaknesses of existing models.Special attention has been paid to reducing unnecessaryweight and size, and to eliminating screw mechanismswhich require repeated adjustments. The special featuresof this enterotome are that it is carried and manipulatedby a detachable unit, the carrier ; that its jaws are

opposed by spring tension; and that it is so

1,compact that when applied to a spur of :;bowel it may lie entirely below the skin level. tThe jaws present a three-inch crushing "

’surface and are made of nickel-plated, high-carbon,spring-tempered steel. The carrier is designed to engageand spread the jaws. It is equipped with a ratchet-andpawl type of lock and is made of stainless steel. Thisenterotome is not equipped with a mechanism which inother types provides the means of determining and adjust-ing the crushing force of the instrument; the majority ofsurgeons approve of this omission.The advantages of this enterotome are shared by both

operator and patient. The former finds that it is simpleto apply and that it obviates the need for postapplicationadjustments. The latter is assured of reasonable comfortbecause of its lightness, and because little or none of itprojects above the skin level.The instrument was developed and is now being produced

oy Jjown uros. -Ljto.. DOUGLAS TELFORD, FRCSECaptain RCAMC.