793

HARVEIAN SOCIETY OF LONDON.

The Treatment of Labour in Contracted Pelves.A MEETING of this society was held on March 3rd, Dr. M.

HANDFIELD-JONES, the President, being in the chair.Dr. G. F. BLACKER opened a discussion on "The Treat-

ment of Labour in Contracted Pelves, with Special Referenceto the Justifiability of Pubiotomy, which we print in full onp. 778.

Dr. F. H. CHAMPNEYS emphasised the higher value of themother’s life compared with that of the foetus. He con-sidered Caesarean section a fine operation ; its risks were

slight to the mother, very slight to the child, and its after-effects nil. In all these respects he considered pubiotomycompared unfavourably with it. If for any reason Caesareansection was inadmissible he would prefer craniotomy topubiotomy, as it had no risks for the mother, the so-calledmaternal mortality of craniotomy being due not to the opera-tion but to the conditions requiring it. He advised theinduction of premature labour in slight degrees of contrac-tion diagnosed during pregnancy. As a teacher he

thought that to recommend pubiotomy to the body ofthe profession would be to court disaster. He wouldlike to know how many pubiotomies had been per-formed in private on intelligent patients who could ’,appreciate what was going to be done to them. All change ’,was not progress and England was not a country whichdepended for initiative on foreign work. He pointed outthat abdominal surgery had been rendered possible throughLister and Spencer Wells, and that amongst obstetriciansthere were no greater names than Smellie, Denman, Rigby,and later Matthews Duncan. ’

Dr. G. E. HERMAN looked for improvement in the mortality ’’,and morbidity of childbirth mainly to the improvement ofCaesarean section. The mortality attending this operation in I1904 was 8 per cent. ; but he saw no reason why it shouldnot be reduced far below this. Caesarean section stoodalone among abdominal operations in this respect, that allthe structures dealt with were healthy and normal. The

operator who had to remove a tumour might find difficultiesfrom its- vascular supply, adhesions, &c. But in Caesarean

section nothing of this kind existed, and there ought to be nomortality where the routine procuring of asepsis was regardedas a religious ritual. He did not agree with Dr. Blacker in Ithinking that symphysiotomy was about equal to pubiotomyin difficulty. Subcutaneous symphysiotomy was one of thesimplest and easiest operations. Pubiotomy seemed to hima difficult and tedious operation. He had never done it orseen it done, and at present did not intend to do it. Thereal objection to both operations was the injuries to the softparts involved in the separation of the bones after division.He thought Dr. Blacker gave away the case for pubiotomywhen he suggested that it ought only to be performed inhospitals. What was the use of a treatment that could notbe employed in ordinary private practice ? Lastly, he shouldhave liked to hear more stress laid upon methods of ascer-

taining the size of the child, as he thought that was asimportant as pelvimetry.

Dr. W. S. A. GRIFFITH pointed out the difficulty of

obtaining precise measurements of pelves, and gave anaccount of some experiments he had made. The conclusionhe arrived at was that no exact measurements could be takenunless the whole hand was introduced into the pelvis or thepelvis was contracted to 3 inches or less. He considered that

practice based on precise pelvic measurements, even if theycould be obtained, was a mistake ; many other factors wereequally important. He recommended Caesarean section wherethe head would not enter the brim of the pelvis.

Dr. HERBERT R. SPENCER supported the induction of

premature labour, and declared that statistics of foetalmortality were unreliable unless similar conditions obtainedor cognisance were taken of individual features, such as themethod or time of induction. Whether the child grew updepended largely on the care it received from its mother.He had induced labour six times in one woman, and she hadas a result five healthy living children, and he mentionedmany other cases of multiple premature inductions in hispractice. He regarded individual cases like these as ofmore importance than statistics. He thought Dr. Blackerplaced the elective Caesarean section a little too high(3 inches), thereby excluding some cases suitable for

induction of premature labour. He had induced labour atthe thirty-fifth week in a woman with a conjugate of3 inches and the child, who weighed at birth 5 pounds, was-now a healthy girl of 18. He thought there were risks fromscars and adhesions following Cæsarean section from whichthe mother was quite free after the induction of prematurelabour. The percentage of morbidity following pubiotomywas too high for him, and unlike other operations it couldnot safely be repeated on the same patient. He had neverseen any convincing evidence that pubiotomy was superiorto symphysiotomy, and most of its advocates agreed thatit was only suitable for hospital practice and in non-infected cases. The crucial question raised by Dr.Blacker was what was to be done in the case of patientsin labour when the pelvis was too small to allow thehead to pass. His answer would depend upon circum-stances. He would not exclude craniotomy ; lie would preferCæsarean section if the patient had been skilfully attended;and would remove the uterus or do a retro-peritonealCsesarean section rather than do pubiotomy where there was-infection or laceration of tissues.

Dr. W. J. Gow did not think it possible to measure thepelvis accurately even with the hand inside it, and regardedsuch measurements, even if obtained, as of secondary import-ance. Induction at the thirty-sixth week or Caesareansection if labour had started, were better than pubiotomyfor the size of pelvis indicated. He could only conceive ofone condition in which pubiotomy might be indicated-namely, in a case that had been many hours or days inlabour, with the head jammed in the pelvis, rendering deliveryby Cæsarean section a matter of great difficulty. He wouldnever do pubiotomy as an operation of choice, and wouldeven prefer to do craniotomy.

Dr. AMAND RouTH thought there was no doubt that if thewoman was seen before full time with a conjugate of over3 inches induction was the correct treatment. If a mistakeof too late a date should be made, and dystocia were still

present, the obstetrician could fall back upon Cæsareansection, pelviotomy, or embryotomy. If the conjugate wasunder 3 inches he would prefer to do Cæsarean section at fullterm. Cases seen for the first time at full term should bedivided definitely into two classes : those where previousattempts had, and had not, been made to deliver per viasnaturales. In cases where no attempt to deliver had beenmade with a conjugate up to 3 inches, and a living child,Cæsarean section should be done’; but if the child were dead,craniotomy, provided the conjugate was over 22 inches. Thedifficult cases to decide in this class were those where thechild was alive and the conjugate between 3 inches and32 inches; these were, in his opinion, the only cases wherepelviotomy was justifiable, and he preferred the subcutaneoussymphysiotomy to pubiotomy, as the former operation couldbe more safely repeated, if necessary, at a future labour ;personally even in these cases he would prefer to do Cæsareansection. In the second class where attempts had been previouslymade to deliver with resulting bruising and infection neitherconservative Cæsarean section nor pelviotomy was justifiable,and he considered that embryotomy should be performed ifthe conjugate were over 22 inches, and Cæsarean sectionfollowed by hysterectomy if under 2 inches. He instancedhis last case of Cæsarean section in this class where sub-

sequently sloughs formed both on the child’s head and overthe mother’s abdominal wound. This case had decided himto avoid Cæsarean section in future in all possibly septiccases. , ’

The PRESIDENT congratulated Dr. Blacker on his paperand considered, having regard to the results of continentaloperators, that English’ obstetricians had exercised a wisediscretiofi in their attitude to the operation of pubiotomy, and!Dr. BLACKER replied to the discussion.

MEDICO-PSYCHOLOGICAL ASSOCIATIONOF GREAT BRITAIN AND IRELAND.

Electric-bath Treatment and Excretion of Creatinine.-TyphoidCarrier Infection.

THE quarterly meeting of this association was held onFeb. 24th, at the newly erected Leicestershire and RutlandCounties Asylum, Narborough, near Leicester, ProfessorW. BEVAN-LEWIS, the President; being in the chair.

Mr. MACKENZIE-WALLIS (University College, Cardiff) and

794

Dr. EDWIN GOODALL (Cardiff) communicated a paper on i

Electric-bath Treatment in 120 cases of Mental Disorder. The 1treatment extended over a period of nine years, and as a result of their experience they expressed their preference for theuse of the alternating sinusoidal current in the bath withrhythmic variation, as against the usual faradic and galvanicmethods. They went into considerable detail, describing thecourse of the baths, the kinds of mental disorder treated, the weights of the patients at different stages, the diet, and the results. As a rule those who were mentally improvedgained in body weight at the same time ; the cases which did not improve remained stationary or lost in weight.For purposes of comparison, particulars of the results in aseries of cases, controls, treated by ordinary warm baths.without current, were given. The major part of the paperdealt with an inquiry into the influence of electric and warmbaths upon the metabolism of the body, as shown by excre-tion of creatinine in a series of patients who were keptduring the investigation on a fixed diet. The conclusionswere that previously to the treatment the excretion ofcreatinine in all cases showed a minimum value for the total

daily volume. The electric baths were given daily for singleand recurrent periods of seven days, and during this timethe creatinine figure was markedly increased. Long-continued treatment with the baths tended to cause a markedfall even below the former value. Warm baths, on the otherhand, had little or no influence on the excretion of creatinine.This evidence was believed to be in accordance with theclinical facts as regards the improvements in the patients’mental and physical condition. The excretion of creatininein the urine showed the normal variations with age, weight,and sex. The variations in the volume of the urine seemedto be very characteristic of the insane, as also was the greatproneness of the urine to bacterial contamination.-ThePRESIDENT thanked Mr. Mackenzie-Wallis and Dr. Goodallfor their able paper. He asked whether the amido acids wereregarded as the necessary precursors of urea formation duringprotein metabolism in the tissues, especially in the muscles,and if the creatinine in the urine was simply the surplus ofthose precursors, which were eventually converted intoammonia and carbon dioxide, and so passed the liver and thekidney as urea. He was anxious to know whether there wasa more simple mode of splitting off, as had been suggested byDrexell’s experiments.-Dr. R. PERCY SMITH said that pro-longed tepid baths were used in St. Bartholomew’s Hospitalmany years ago for excited patients, and as a result theynearly always got calmer. Those patients also gainedweight and slept better, and they eventually recovered. Hewas glad to hear that short baths were preferable to longones. In those days there were no sinusoidal currentbaths. He would like to have heard of a larger series ofcases not so treated, for purposes of comparison-i.e.,treated by simple warm baths. Could creatinine be theelusive toxin at the basis of insanity for which so many peopleseemed to be searching ?-Mr. SCOTT WILLIAMSON said thatsome time ago he made some observations in cases of phthisis,who were all undergoing sanatorium treatment, as a result ofwhich some were increasing in body-weight, but the creati-nine did not vary at all with that increase in body-weight.-Dr. BEDFORD PIERCE said the treatment had been tried atthe" Retreat," York, on a considerable number of patients,and the general result seemed to be satisfactory. But thecreatinine excretion was not scientifically tested, so that onlythe general appearance of the patient gave that impression.-Dr. W. H. B. STODDART said that at Bethlem Hospital theywere rather behindhand in that treatment. But he askedwhether it was a good thing to get rid of creatinine. Wasthat substance a poison to the body ? Also did the sinusoidalcurrent increase the creatinine excretion of normal people ?His experience of warm baths was practically the same asthat of Dr. Percy Smith.

Dr. C. HUBERT BOND read a communication on the subjectfrom Dr. ROBERT JONES (Claybury), who stated that hehad tried the electric bath mostly for adolescents chieflyexhibiting melancholia, and the main difficulty lay in gettingthem fed. It was not a very curable form. After con-sultation with Dr. H. Lewis Jones he tried it upon 18 maleand 5 female patients. The latter all improved greatly inhealth, even though two of them were phthisical. Also thetreatment was used in several cases of puerperal insanity andgreatly aided their recovery. Of the 18 men, 9 had left the

asylum ; all had gained weight under the treatment, some

many pounds. As a conclusion, Dr. Jones recommended thetreatment in the melancholia of adolescents and in apatheticcases.-The authors replied-on the various points raised.

Mr. G. SCOTT WILLIAMSON read a paper on TyphoidCarrier Infection. He narrated the results of his investi-gation into cases which had had typhoid fever some timeago, and who were found still to have the bacillus in amotile and active form in the body, these bacilli beingcapable on inoculation into animals of setting up the disease.-The PRESIDENT alluded to the case of the man mentionedby Deane, who 29 years before, had had typhoid fever andthe bacilli were found in his excreta in a motile form. Atone of the asylums an outbreak of typhoid fever was

eventually traced to an old woman, aged 75 years, a dement,very dirty in her habits, who was found to have the bacillusin a virulent form.

EDINBURGH MEDICO-CHIRURGICALSOCIETY.

Athletics and Physical Development.A MEETING of this society was held on March 2nd, Dr.

BYROM BRAMWELL, the President, being in the chair.A discussion on the Use and Possible Abuse of Athletics

during the Period of Growth and Development was intro-duced by Dr. T. M. BURN-MURDOCH. He said that

during the past year public attention had been drawnto this question to a large extent. One could notfail to be struck with the marked change for thebetter on frames normally, deficiently, and defectivelydeveloped under active exercise. Pigeon-breast, hollow

breast, drooping shoulders, stooping, and lateral curvature ofthe spine disappeared, and marked increase in height notinfrequently started when systematic exercises were taken.Marked improvement in asthmatics was common, and surpris-ing results had been noted even in organic heart mischiefwith the attainment of finer chest development. The import-ance of regulated gymnastics along with more strenuousathletic exercises could not be over-estimated, and shouldalways be attended to at school. Dr. Burn-Murdochquoted from the essay of McLaren of Oxford on "Growthand Development " to show the marked improvement whichtook place in army recruits after short training : " But therewas one change-the greatest of all-and that was the

change in bodily activity, dexterity, presence of mind, andendurance of fatigue-a change a hundred-fold more im.pressive than anything the tape measure or the weighingchair could ever reveal." Immense changes for the betterhad taken place in all schools since McLaren wrote, the

pioneer in Great Britain being Dr.*.Almond of Loretto School.Dr. Heard of Fettes College endorsed the immense valueof athletic exercises by saying that the general outcome ofthe present arrangement of athletics in Scotland was

quite excellent." Many other headmasters agreed thatit would be impossible to run a school with anyhope of success without the full development of itsathletic side. Three head-mistresses spoke strongly of thedeficiency of early muscular training in girls, and for thisreason laid great stress upon the necessity for gymnastictraining being given before severe games were indulged in.They stated that no exemptions whatever were given fromgymnastic lessons ; by this means hard games were madesafe, whereas otherwise there would be constant danger ofoverstrain and other mischief. Another lady principal of alarge college said that she could not conceive a girls’ schoolwithout organised gymnastics and games." Many girls onentering public schools had malformed chests and lateral curva-ture of the spine ; for these special exercises were given withexcellent results. Since the introduction of physicalexercise the improvement in the appearance of the girls hadbeen most marked, and ansemia, which formerly requiredtreatment frequently, was now almost unknown. Dr. Burn-Murdoch referred to the intellectual advantages of athleticsand quoted McLaren as saying that " the very élite of the

! university were more often found among the college eight thanamong any other section of the community." Several head-

masters and medical officers of schools had told the speakerthat their best boys intellectually were frequently those whoexcelled in manly exercises and who were well developedboth in mind and body. As regarded the moral value of