892 JUNE x8, I921g OPERATIVE TREATMENT OF GENITAL PROLAPSE. tKurnc"^TOLJOUUWAI

women free from active malaria until the confinement.Then as the vital powers of resisting disease are muchlowered by the excessive fatigue of child-bearing, it isnecessary to give 10 grains (in very small doses) a day forfive or six days, as very often, if not given, a revere attackof malaria will delay recovery with these doses.

I have never found quinine cause abortion. On theother hand, I have treated cases of abortion in nativewomen (who do not take quinine), in which the frequentabortions were undoubtedly caused by chronic malaria, forwhen given the above prophylactic doses they were able togo to term and give birth to healthy living children.With regard to the effect of quinine on the non-pregnant

uterus, undoubtedly in a small percentage of cases it causesexcessive and too frequent periods. Years ago I found thatwhen 5-grain doses of quinine caused deafness or noises inthe ears it was a sign that a smaller dose (3 grains) wassufficient as a prophylactic, and the majority of womenunder 120 lb. weight will, I think, find this smaller dosewill keep them free from active malarial manifestations.Recently I have treated this menorrhagia also as a sign

that only smaller doses of quinine need be taken, and ifthe 5-grain prophylactic dose is necessary it should betaken in 21-grain doses twice a day; the few cases treated,however, are not sufficient to lead me to any definite con-clusions, and I would value greatly the experience of othersin treating this very trying complaint.

WALTER FISHER, M.R.C.S., L.R.C.P.Kalene Hill, Northern Rhodesia.

*tptrts of iociettes.THE END-RESULTS OF PLASTIC VAGINALOPERATIONS FOR GENITAL PROLAPSE.

THE first British Congress of Obstetrics and Gynaecologywas held at Birmingham on June 3rd and 4th, when thefollowing societies were represented: the Obstetrical andGynaecological Section, Royal Society of Medicine; theEdinburgh Obstetrical Society; the North of EnglandObstetrical and Gynaecological Society; the GlasgowObstetrical Society; and the Midland Obstetrical andGynaecological Society.The opening session in the morning of June 3rd was

presided over by Professor H. BRIGGS, President of theObstetrical and Gynaecological Section of the Royal Societyof Medicine. Mr. CHRISTOPHER MARTIN, chairman -of theMidland Obstetrical and Gynaecological Society, welcomedthe Congress to Birminglham, and expressed the hope,wllich was echoed by various speakers throughout theday, that this Congress would now become an annualaffair, and the chief and authoritative mouthpiece ofBritish gynaecology.The morning session was devoted to a discussion upon

the operative treatment of genital prolapse, opened byDr. W. E. FOTHERGILL and Dr. F. H. LACEY, of Manclhester.The title of their paper was " The End-Results of PlasticVaginal Operations for Genital Prolapse."

Dr. W. E. FOTHERGILL said that the discussion hadoriginated at a meeting of the Nortlh of England Societyheld at Liverpool in December, 1918. Professor H. Briggshad described the treatment of a case of procidentia, ina patient aged 18, by a vaginal operation combined withventrofixation, but advocated a modification of Gilliam'soperation. Dr. W. F. Shaw deprecated abdominal opera-tions for prolapse, preferring the vaginal methods used inManchester. Other members urged that the end-resultsof these measures should be ascertained and publishedand a collective investigation by the society was suggested.At subsequent meetings this project was developed andthe scope of the inquiry came in question. It was pro-posed to exclude all except cases of complete prolapse, butthis was not thought feasible. The term "genital pro-lapse " had a fairly definite connotation all over tlle worldand medical men constantly used the word " prolapse" asincluding both so-called vagino-uterine prolapse and so-called utero-vaginal prolapse. In view of these considera-tions, it was decided at a Council meeting of the North ofEngland Society in December, 1919, that the inquiryshlould include "cases of (1) cystocele, (2) rectocele, (3)prolapsus uteri, and (4) elongated cervix protruding from

the vulva "-namely, in two words, eases of "genitalprolapse." At an ordinary meeting of the society inLiverpool in October, 1920, Dr. F. H. Lacey gave a pre-liminary report on traced cases operated on at St. Mary'sHospital, Manchester, during the years 1914-15-16. Sub-sequently it was arranged to defer the further considera-tion of the subject to this meeting.

Dr. Fothergill briefly indicated the steps by which ho-was led to his present technique, starting with his wvork inEdinburgh under Sir A. R. Simpson and David BerryHart, who used at that time anterior and posterior colpor-rhaphies of moderate size, amputation of the cervix, andrepair of the perineum. These were done as separateoperations, and in some cases all four were used for onepatient. Chromic catgut was the suture material, and theimmediate results were good. On coming to Manchesterin 1895 he found that, owing to the initiative of ProfessorA. Donald, surgical treatment of genital prolapse wasalready highly efficient; anterior colporrhaphy incisionswere larger than those done in Edinburgh, and the wholethickness of the vaginal wall was removed. Donald hadalso combined the operation of posterior colporrhaphywith perineorrhaphy in a single operation done from abovedownwards.

Dr. Fothergill was gradually convinced by clinical experi.ence that the uterus, vagina, and bladder were mainly keptin position by the lateral combinations of unstriped muscleand connective tissue known as the parametrium and theparacolpos, and this was demonstrated by him to theRoyal Society of Medicine in 1907. The practical applica-tion was that anterior colporrhaphy could be improvedby carrying the incision well up and out on either sideof thle cervix, fully exposing the paracolpos, so thatclosure of the wound must bring together in front of thecervix structures formerly at its sides. This he demon-strated to the Edinburgh Obstetrical Society in 1908.Subsequently he found that by carrying the incisionround behind the cervix instead of in front of it, anteriorcolporrha'phy and amputation of the cervix could be con-veniently combined in one single operation. When thewound was closed the cervical stump passed upwards andbackwards so far that the uterus was left in a position ofanteversion, thus dispensing with the need of excessivenarrowing of the vagina. An improved technique andmodifications were afterwards described in tlle BRITISHMEDICAL JOURNAL (Apiil 12tb, 1913) ; the AmericanJournal of Surgery (May, 1915); and in the Journal ofOb8tetrics and Gynaecology of the British Empire (Marchand May, 1915). Dr. Lacey had traced as far as pos-sible the after-histories of tlle cases treated by Dr.Fothergill at St. Mary's in 1914-15-16, so that sincethese operations were done periods varying from fourand a half to seven and a half years had elapsed; nocases treated by mere perineal repair were included.One hundred and fifty - six patients replied to Dr.Lacey's letter of inquirv; of these, 150 stated withoutqualification that they were cured, while 6 did not. Ofthese 6, No. 1 had had three children since the operation,and the womb has gone down again; No. 2 said the" womb was not as it sliould be," but on examination noprolapse nor other abnormality was found; No. 3 hladchronic bronchitis and asthma, and the operation wastherefore a failure from the start; in No. 4 the uterus wasin good position, but there was some vaginal prolapse;No. 5, a case of rectocele only, lhad an instrumental labourand was torn badly, and there was a slight recurrence ofrectocele ; and in No. 6 nothing was found on examination,but she said she still lhad pain at .times. This gave97?1-per cent. of cures. As to the ages of the patients,about one-third had passed tlle menopause.In 124 cases combined amputation of the cervix with

anterior colporrlhaphy was done, while in the remainder thecervix was retained. Thirty-two were examples of elong-ated cervix witlh inversion of the vaginal walls from abovedownwards. It would be unreasonable to expect that thenew pelvic floor should always stand the test of labour;the original pelvic floor did not always do so. Frolm thispoint of view it was of interest to note tllat 21 of tllewomen under 40 and 3 of those over 40 lhad since bornechlildren, and 2 othlers were now p)regnant; and, of the.se26, 23 head had the cervix removed by thle combined opera:tion. To thle 24 patients 30 chlildrenl had been horn;23 labours were natural and 7 instrumental, but in no

OPERATIVE TREATMENT OF GENITAL PROLAPSE; 89f3aZIALJUS

case was labour obstructed. Four patients hiad hiad twolabours eaclh with no recurrence of prolapse; 17 onelabour eaclh, with no recurrence, and one was badly tornwith a slialgt recurrence of rectocele. Another had onelabour and said that the womb fell slightly when she wastired. Another had three labours, and in this case therewas recurrence, requiring another operation. Thus pro-lapse sufficient to cause inconvenience had only returned inone out of 24 cases. The speaker wvas therefore of opinionlhat the addition to these vaginal operations of anyabdominal intervention was unnecessary and undesirable,increasing the risk and discomfort to which the patient wasexposed. He especially deprecated the use of abdominalmeasures not in addition to but instead of vaginal surgery.

Dr. F. H. LACEY said tllat the patients were mostlyworking women wlho had to return to work in cotton millsand other laborious work very soon after operation. Helhad written to 750 patients and received 521 replies, and455 (87 per cent.) replied to tlle question,"'Did tlle wombkeep up well now?" with the answer "Yes." Of thosewlho said "No" he had examined 29: 17 of these hadsome prolapse or other discoverable abnormality; one onlyhad procidentia, and she was aged 75 andhad chronicbronchitis. Another hiad chronic bronchitis and astlhma,while another hadlhad to return to the cotton mill imme-diately after operation. Two others had had labourswithin one year after; 2 had elongated cervices, and theremaining 10 had other conditions which had nothing todo with the previous operation-for instance, cystitis andgenile vaginitis. The remainina 12 did not feel right, butthey slhowed no anatomical abnormality.T'The following table shows the relation of age to success

and the percentage of successful cases grouped in decades:Under 20 (1 case) ... ... ... 100 per cent.21 to30(75cases) ... ... ... 8731 to 40 (200 cases) .. ... ... 8941 to50(108cases) ... ... 9..9551 to60(47 cases) ... ... ... 8961 to 70 (21 cases) ... ... .. 8775 (1 case) .. ... ... ... 100

Taking those of reproductive age,lhe found that 330successful cases had 67 children after the operation; 19improved cases had 6 children; and 33 failures had 16children. For the 67 clhildren forceps were used in32 per cent. of cases; for the 6 children forceps were usedin 80 per cent. of cases; andfor the 16 clhildren forcepswere used in 62 per cent. of cases; so that botlh failuresand improved cases showed a higher ratio of labours, andthese labours amongst the improved and failures sboweda higher ratio of instrumental deliveries. This was whatwould be expected, and it was obvious that a colporrhaphyor any other operation could scarcelvbe expected to standthe strain of parturition better thanthe normal and naturalpelvic floor. Dr. Lacey had only seen one death aftervaginal operation, and that from pulmonary embolism.He considered abdominal operations unnecessary in thevast majority of cases, but admitted that rarely theabdominal route might be necessary in addition-forinstance, in cases of congenital prolapse, or where certaincomplications existed, such as adlhesion in a retroverteduterus. In St. Mary's Hospital no prolonged preparationDf the patient was used; only one vaginal douclhe wasgiven before coming on the table; the vagina was then.leansed with cresol, followed by perchloride, iodine beingapplied externally. No vaginal douching was used afteroperation, the parts simply being kept as dry and cleanas possible.

-Dr. A. DONALD, as a further introduction to the dis-cu-3,sion, gave a short account of the history and earlytehlnique of colporrhaphy in Manchester. He believedtlhat the operation had been more frequently done in thatcity than in any other city in this country, and as theoldestImember of the present staff of St. Mary's Hospitallhe was able to speak of the earlier days of the operation.Wlhenhe was a resident durinog the years 1884-87 itseemed to him that operative treatment on lines similarto those emuployed in the radical cure of hiernia mighit bestuccessful, although there was little encouragement intlleliterature of the subject. It was said that failure alwaysresulted; andthe standard textbook indicatedtllattllreemethod; of treatment miglht be tried: (1) Pessaries inmild cases;- (2) a plastic operation on the vaginaandperineum to enable the patient to wear a ring pessarv inediuim cases; and (3)an operation which was meant to

cause a union of the anterior to tlle poster-iia -aginal wallin advanced cases. In 1888, as surgeon to the hospitaT,he put his theory into practice, and in that year operatedon six cases, in three of whiclh coimparatively full notes ofthe operation were taken.The technique then employed was, witlh certain modifi-

cations, similar to his present methods. The cervix wasamputated in cases where it was hypl.eitrophied. Thevaginal mucous membrane was divided transversely whlereit was inserted into tlle cervix in front, and stripped upoff the cervix. Tlle cervix was then divided- into two lips,anterior and posterior, and a wedge was excised from eachlip, cai-e being taken to preserve a strip of the mucousmembrane of tlle cervical canal of eacll lip, wlicil w%vasbrouglht into apposition witlh tlle corresponiding vaginalmucous membrane. On the anterior vaginal wall adiamond-slhaped flap was dissected off, the wlhole tlhickc-ness of the vaginal mucous mem-ibrane being removed. Tlheraw surface was then broughlt together with a continuouscatgut suture in the deep tissues, a-nd this was covered iuand buried when the lateral edges of tlleCutinucous mem-braue were stitched in the middle line. On the pos'eriorwall a triangle was mapped out, with the apexclose to thecervix and tlle base at the vagrinal outlet. The sides ofthe triangle diverged, so that at the base they reaclhed themiddle of the labium minus of eacll side. T'lhe posteriorcolporrhapby was done in stages from above downwards,tlle triangular flap being separated from its apex for aboutan inch, and then the sides brought togetlher before tlleiucisions were carried lower down. The deeper tissueswere brought together by a continuous cataut suture, wlhiclwas buried by the stitchles uniting the mlucous memllbrane.The healing was not so good in tllesedays, because thecatgut was not so reliable and came away early, and inmost of the cases there was still a tendency to prolapse:but as a rule they satisfied the condition laid down in tlletextbooks, and enabled a ring to be retained.

In 1891lhe operated on two cases of very bad procidentia.In both the vagina was completely everted and a largeulcerated mass protruded from the vagina whlich could notbe reduced until after the patient had been in bed for twoweeks in one case and for three weeks in the otlher. Inboth tllese cases the operation was completely successfulland the prolapse did not return. These cases finalljestablished hiis belief in colporrliaplhy as a curative opera-tion. The number of colporrlhaplhy operations at St.Mary's Hospital hadnow enormously increased, and the'late Dr. Walls, Dr. Fothergill, Dr. Clifford, and Dr. FletclhieShawhad all given practical proof of their faith in theoperation as a curative measure.

Dr. HERBERT SPENCERwas fairly satisfied with vaginaloperations and agreed that the abdominal method war-,unnecessary. He thought that in someeases of severeprocidentia no operation would be certain to cure, but thatsometimes the best method mightbe the removal of theuterus jIer vaginam and packing of the tissues witlh gauze.He had performed colporrhaphy in 1887. He did not usecatgut as he considered it might cause sepsis and tetanus,but instead used buried silk or silkworm-gut passed witha sewing needle.

Dr. T. G. STEVENS considered that, prior to 1913, Londonwas far behind the Manchester school in the treatmentof prolapse. He was convinced that the metlhod describedby Dr. Fothergill and Professor Donald was the best,thbtanyease of procidentia, however bad, could be cured byit, and that if failure occurred it was due to the patientgetting up too soon or, more rarely, to a subsequent labour.He considered the operation could not be properly doneunless catgut was used. There must in everysucll opera-tion be some risk of sepsis, for the field was not an asepticone. He preferred raw to chromicized cataut, as in thelatter the surface was likely to behardened and organismsremained intact in thenmiddle, giving rise to sepsis andsecondary haemOrrhage. For moderate cases of prolapseas extensive an operation was necessary as intlle severecases, and the more severe the procidentia the easier wasthe operation. He considered that abdominal operationsplayed no part in the treatment of prolapse, but in a smallpercentage of cases-for instance, persistent retrofiexion,leading to sacral pain-hehad had resort to a Gilliamoperation. This, however,had nothing to do witlh thetreatment of prolapse.

Dr. A. E. GILES complimented Dr. Lacey upon theamount of work he had carried out in tracing the after-

JUNE iSt 19211;v',, 89-3

894 JUNE I8, 1921] OPERATIVE TREATMENT OF GENITAL PROLAPSE.

histories of such a large numnber of cases. He consideredthat anatomical cure was tlhe only real criterion of successin the operative treatment of genital prolapse. It was notenough to trust to the patient's report that shle felt -well;exam-iination misialgt reveal a certain dearee of recurrenice.He had found tile vaginal plastic operation satisfactory inabout 96 per cent. of cases. He did not find it necessaryto amputate the cervix; if the uterus were ptut into properposition tlle hyperplasia of the cervix, whiclh was due totile procideutia, tended to disappear. He protested aaainstwholesale amputation of tlhe cervix except in hlyperplasiaof the vaainal portion in nulliparae, and claimed that as

good results could be obtained by ventrofixation by propermethods, combined in certain cases with tlle vaginaloperation.

Dr. J. E. GEMMIELL (Liverpool) favoured the combinedabdominal and vaginal metlhods, and described a metlhodof ventrofixation used by him in which the utero-vesicalpouch was obliterated. He had operated upon 480 casesat the Women's Hospital, and had traced the end-resultsin 192. The answers in all cases were satisfactory. Hehad done colporrhaplhy alone in 40, interposition in 27, anda vaginal plastic operation combined with ventrofixationby his own method in 125. In advanced age lie preferredinterposition when the uterus wvas atroplhied and there wascomplete prolapse of tlje vaginal walls. Especially inyoung women of child-bearing age he favoured tlle com-bined method-thle vaginal operation combined with ventro-fixation-as there was need of less removal of vaginaltissue, there were better results in parturition, and by hismetlhod a new fibro-muscular support was formed for theuterus inside the abdomen.

Dr. WALTER SWAYNE (Bristol) considered that details oftechnique mattered little; the important thing was thatcertain anatomical requirements should be fulfilled.Abdominal operation was incorrect anatomically; thedamaged pelvic floor must be reconstructed on anatomicalprinciples. He used buried catgut and did no abdominaloperation unless there was some such coudition present asretroflexion, or diseased ovaries or tubes. Where extensiveplastic operations were carried out on women of child-bearing age they should be warned tllat subsequent labourmight destroy the effects of a successful operation.

Dr. C. D. LOCHRANE (Derby) said that the ideal opera-tion for prolapse should meet four requirements: (1) Itsllould restore the parts to normal or as near that as

possible; (2) it should be applicable to all ages; (3) itshould not interfere witlh future pregnancy or labour ; and(4) it should be the simplest, least dangerous, and leastexpensive possible. He lhad come to the conclusion thatthe vagino-plastic operation gave the best results, and hehad during the last six years given up all other types ofoperation. He empllasized tlle importance of a carefulpreliminary examination to determine the sites of injury.He liked to get cases into a lhospital three days beforeoperation for vaginal cleansing. A light vaginal pack,soaked in 1 in 1,000 flavine, in saline, was left in over

night, on the nighlt before operation. On the table thevagina, vulva, and perineum were swabbed with flavine(1 in 1,000) and picric acid (2 per cent.) in methylatedspirit. He considered a good anterior colporrhaphy of tlletvpe described by Fotlhergill tlhe most essential point. Incases witlh m-arked cystocele the bladder sliould be sepa-rated and puslhed up before closino the wound. He hadfound a liglt application of bipp to the wound in tilesecases useful in preventinia cellulitis. He used no buriedsutures, but secured a broad approximation of the levatoresani with figure 8 silkworm-gut sutures, then closino thewound from above downwards in the usual wav witlh theshortest. cataut sutures inserted deeply, and including intheir deeper parts the already approximated borders ofElhe levatores ani. The silkworm-gut was removed on thefifteentlh day.

Professor H. BRIGGS thought it was possible to becomeobsessed witlh particular metlhods. It was only inmportantto work' along anatomical lines. He used catgut in alleases and thought that Dr. Stevens's secondary lhaemor-rhage miglit be due to excessive trauma. He protestedagainst elaborate descriptions of special iuetlhods andagcainst a tendency to make exaggerated statements.Dr. WALTER GRIFFITH tIlOugllt tllat abdominal operation

miglht be necessary in certain conditions, as whlere a retro-sexed uterus was -complicated by adlhesions or bv proolapsedInflamed ovaries.

Dr. R. H. PARAMORE (Ruaby) was surprised that tlherewas no reference to myorrlhaphy of the levator ani duringtlle discuLssion. Was that now considered of little value?He considered that if its edges were broualgt together tlheunion did not persist, and if it did that would be an

abnormal condition.Professor GAMMELTOFT (Copenhagen) did not consider

abdominal operation necessarv. He used cataut, andcarried out a myorrhaphy of the levator ani in periileor-rhaphy.

D'. J. S. FAIRBAIRN said it was sometimes difficult tojudge of the amount of narrowina of the vagina tllat wouldfollow plastic operations. He only removed tlle cervix incases wlhere there was extreme elongation, clliefly owingto tlle danaer of secondary lhaemorrlhage. The position ofthe uiterus varied widely within normal limits, and he

considered a symptomatic cure far more importaiit thanan anatomical one.

Mc. FURNEAUX JORDAN had for many years done a com-

bined operation, but gradually had come to rely entirelyupon the method described by Fotlhergill. He found liegot better results and patients were more comfortablewhen -the cervix was amputated. He believed a plasticoperation to be sufficient.

Dr. MILES PHILLIPS thought that no one set prodedurewould cure every case. Plastic operation alone cureda large percentage of his cases, but in about 4 or 5 per

cent., chiefly women over 60 with atrophy of the uterus, heremoved tlhe uterus fromn the vagina, and in addition did an

extensive plastic operation, excisiug a large portion of thepouch of Douglas and stitching the broad ligaments under-neath tle bladder. He considered abdominal operationunnecessary in prolapse, but a few cases returned withretroversion, and if such failure to get the uterus into an

anteverted position could be anticipated, it might be betterto do an abdominal operation and complete the cure at thesame time.

Dr. T. W. EDEN tilought tllat no set procedure suitedevery case. He had found 'the methlod of vaginalhysterectomy described by Dr. Miles Phillips useful in some

cases. Also in congenital prolapse in young women whereligaments and supports were lax and the round ligamentspoorly developed it was useful to duplicate the utero-sacralligaments, obliterating the pouclh of Douglas, antevertingtlle uterus, and at tlle same time shortening the roundligaments which were lax and long. He emphasized theimportance of anteverting tlle uterus and considered thatif left retroverted recurrence was almost bound. to takeplace.

Dr. W. H. C. NEWNIAM hlad almost entirely given up theabdominal method and got uniformly satisfactory resultsby plastic procedures.

Dr. FOTHERGILL, in reply, said that lie had very littletrouble with secondary haemorrhage, and wlhen it occurredit could be easily checked by packing. Cases complicatedby cancer, fibroids, or prolapsed ovaries were not beingtalked of; the discussion was on genital prolapse. Ofcourse, he operated on suchi cases by the abdomen. Hedid not do the interposition operation. Deatlls hadfollowed it, aud one slhould not risk killing patients inorder to cure prolapse. He did not like vaginal hyster-ectomy in prolapse, and in his experience some of tileworst cases of prolapse had occurred after the uterus was

removed. Cougenital prolapse miglht cause difficulty, butin hlis hands thev liad been cured by plastic methods.

Dr. DONALD agreed that secondary haemorrhage was

one of tlle drawbacks. He did not pacl for it, as tlhepacking stretclhed the parts too much and spoiled thieoperation. He considered a symptomatic cure more

important tllan anatomical. The addition of an abdominaloperation to a plastic greatly increased the risk, especiallyin old women, and vaginal hysterectomy often resulted inultilmiately increasing the prolapse. He did not troubleabout getting the uterus into a position of anteversion.

The afternoon session was devoted to the demonstrationof specimens and to slhort commiinunications. Dr. CLIFFORDWHITE exhibited two specimens showing an unusual condi-tion of sutures after Caesarean section. Dr. EWEN MA&CLEANdemonstrated a specimen slhowing a degree of absorptionof silk sutures after Caesarean section; hysterectohiy liadto be done for fibroid five montlhs afterwards, and severalsilk sutures were foand unabsorbed, while luicroscopicallydistinct phagocytosis was seen in the uterine wall around

TTu BLMEDICAL JOUxA1

PATHOO.XA0,GCALNGEUNQI4S,-WJpStr EPEIITEI.IjU,If |M R.- 3, .

$

sL =AqTEI~ ..P OGICA_ IH N E 1N &X EAL T --

the suiture area. The demonstration of these three speci-mens led to a brisk discussion of the relative muerits of silkand catgut in Caesarean section, in whlich Drs. HERBERTSPENCER, EARDLEY HOLLAND, MILES PHILLips, anld Co-iYNsBERKELEYtook part.

Dr. EWEN MACLEAN demnonstrated anothierspecSiieiensliowing combined* fibromvyoma anid carcinomua of' the

uteruLs. He referred tothle rarity of the combination,olly0.4 per cent. in 500 cases in wliichl hehlad removed the

uterus for fibroid. Dr. HERBERT SPENCER and Dr. EDGEbothIconsideredthlat Dr. Maclean's figures showed an unusuallylow cancer incidence in the fibroid-containing uterus, andthe former thought it miglht have something to do withthe district in wllich Dr. Maclean practised. He had found6 out of 200lhad unrecognized cancer of the uterus, andtllere were many mnore cases in wllich it was recognized.

Dr. HAROLD CHAPPLE slhowed a specimen illustrating"full time ovarian pregnancy." Tlle foetus had beenretained tllree and a half montlhs after full time; noovarian tissuelhad yet been demonstrated in the wall ofthe sac, buttlle tube was stretched over it and the ovary9f that side was not found. Several speakers discussedthe probability of its being a tubo ovarian pregnancy, audeventually it was decidedto have the matter brought, up

,again at the Royal Society of Medicine after compiletion ofthe pat4ological examination.

Dr.4. I. STRACHAN (Cardiff) showed a specimen of anearlyovum which hethought to be of not more than twolveto fourteen days' development. In an oblique section througlthe cephalic extremity the neural matter could be seen

Just beginning to be differentiated into grey and white.Dr. F. J. BROWNE (Edinburgh) read a communication

entitled "Some points in the pathology of sypllilis of thenewborn, based upon a study of 35 cases." The autlhorpointed out thenecessitv, before airriving at apo8t-mortenbdiagnosis or syplhilis, of taking into account all the avail.able evidence-that derived from theclinicalhistory ofthe parents, the Wassermann test, the placenta, and a

complete nakedl-eye and microscopic examination of thefoetus and its Internal organs, especially the lungs, liver,spleen, tllvroid, tlhymus, and pancreas. Lantern slideswere sliowni illustrating the histological changes inthese organs. Tlle unreliability of naked-eye appear-

ances was discussed, and it was pointed out that theonly evidence obtainable of the presence of syphilis mightbe thehistological clhanges in the organs. The paper wasdiscussed by Dr. EARDLEY HOLLAND, Dr. SWAYNE, andDr. SThACHAN.

Mr. GORDON LUKER read a paper entitled " Notes on

250 cases of ectopic gestation," Dr. LAPTHORN SMITH,Dr. PURSLOW, Dr. EARDLEY HOLLAND, Dr. GILES, Dr.WVILLIAMISON, and Mr. CARLTON OLDFIELD taking part in

the subsequenit discussion.Dr. WSALTER SWAYNE (Bristol) then read a paper on a

case of chorion-epitlhelioma in a nullipara; there had beenthree montlhs' axnenorrhoea, followed by irregularhaemor-rhages; the patient was aged 50, unmarried, and a virgin.Tile primary growth was in the uterus, with secondarygrowths in the mesentery and lymph glands.

Dr. STEVENS led tlle discussion that followed, and doubtwas expressed by several speakers as to whether the case

was. really one of clhorion-epithelioma, the microscopicsection on- view showinag no evidence of the presence ofHyncytiw3m.Intlhe evening an enjoyable dinner was held, the chair

being occupied by Mr. CHRISTOPHER MARTIN. Tlhe toastlist included, in addition to "The King," "The VisitingSocieties," proposed by the CHAIRMAN and responded to byDr. MILES PHILLIPS, and " The Midland ObstetricalSociety," proposed by Professor H. BRIGGs and respondedto by Sir EDWARD MALINS. The morning of Saturdav,June 4th, was spent in witnessing operations at thedifferent hospitals of the city, and arrangements weremade for golf and excursions in the afternoon.

Tlhus lhas come and gone the first Britislh Congress ofObstetrics and Gynaecology-one that was voted by allwho were present to have been a great success from bothtbAe scientific and tlhe social points of view. This' was

largely due to the excellence of tlle arraugements madeand thle lhospitality shown by the Midland Obstetrical andGynaecological Society, the secretary of which, Mr. Beck-witlh Whiitellouse, upon whose shoulders most of thework naturally fell, is to be heartily congratulated.

PATHOLOGICAL CHANGES IN BREAST

EPITHELlUMUl.AT a meeting of the West London Medic-Chlirurgic'alSocietyleld at tle West London Hospital on June 3rd,withl the President, Dr. F. J.MCCACNN, in thlechiair, apaperwas read by SirG. LENTHAL CHEATLEonS r11e path0ologicalclanges inthle epithelium of the breast. Hos aidthlat lie would confine hiis remarkis to two main poits:(1) to indicatetllesurgicalinmportance of theaampullae 6fthe breast ducts; and (2) to draw attention to threeseparate conditions in tlle breast, all of wlhich had beendescribed to hiim a's" parenchymatous inastitis"' bydifferent observers, but of wlhich, in hiis opinion, only onecould betllus justlv described.

1. Whlole sections of two breasts wereslhown; in one theampullae of two ducts contained papillomatous tum'ours,while in theothler one ductampulla- 'contained an even

larger papillomatoustumour. Alltlhe ampullae containingthe tumours were distended bytlhe growiths. Whole setiionsof a third breast w'ere next slhown in whiclh the'amptufllaeof two ducts were distended by cancer. Thje cancer wasundergoing colloid degeneration at the time of excisionofthe breist. Itwas pointed, out tlhat tlhese seceio'ns defmon-stratedsimple growths in one case andmalignant in theremaining two, all occurring inthe ampullae of tlle ducts.Sections were then shown of mammar'y ducts ending inthe nipple surface. There was nothing to .gliard againstthe entrance of irritating agents except the contractionoftlie dense musculature surrounding the 'ducts. Irritatingagents miglht collect in the amlpullae and there.act un-

distutrbed upon the epithelium linina the duLet dilatations.2. Sir Lenthal Clleatle first dealt witlh only onc of the

three conditions he had mentioned wllicll in hiis opiniionjustly deserved theterm"parenchymnatous mastitis." .Alongitudinal section of an affected duct was shown whliclhexhibited in its 'surface a localized patclh of swollenepitheliurn. Among the epitlielial cells were lymphocytes,a few polynuclear leucoytes, .nd also newly dividedconnective tissue cells. There was no ulceration in thisduct. Anotlher duct from anotlher breast.was also' slhownin longitudinal section. It contained a patchl in wvhiclh thesame process seen in tlle previous section was occurring,but ithlad been more intense in character and tlle surfaceof the ductlhad been ulcerated. This condition must beparenchymatous mastitis. It occurred in breasts in whichsome clhronic disturbances were in progress, such as inadvanced 'cancer. In many cases tllh ducts only were

affected, but in some the ducts and a fewv of the aciniwitlh wlich tlley communiicated were also affected. Itcould not be very uncommon to find all tlhe. acinj involvedand some of their ducts sha,ring in the inflammatqrychanaes. Hisnext point 'Was the conditiol lie was anxiousto remove from th-e noluenclature of parelnelhyniatousmastitis, and lie showed many sections of breasts whichdemonstrated his point. He preferred to call it a "diffusebenign neoplastic state." In man.y cases the ducts onlymight be affected; in other parts botlh the ducts and aciniwere undergoinga similar change. The clianges were these:there was a proliferation of epithelium lining the ductsand perhaps some of the acini in connexion with tlem.Thie cells whiclh resulted from tllis proliferation appearedas desquamated cells and collected in great numbers .anddistended tlle ducts. Tllis neoplastic clhange the lecturerconsidered a common cause of cysts in tlle breast. Therewas practically no inflamml;n-atory clhange seen in this con-dition. Wlhere in some cases collections of lymphocytescould be demonstrated these collections were so far apartand small that it appeared impossible to conceive tllattlley could be causing the neoplastic cghange. Thesechanges he regarded as secoadary. Papillomata were notpresent in this condition. The tllird condition describedto hiim as being a form of parencliymatous mastitis heregarded as a state of cancer. Sections were shown in

wllich the ducts, distended with epithelial cells, were beingulcerated by infiltration into surrounding parts by thesecells. The subjects from whom were prepared some ofthe specimens slhown of thiis type of breast ha4 died ofcancer.

The PRESIDENT congratulated the lecturer on the excel-lent series of whole breast sections he had slhown. He

emphasized the close connexion that existed betweenpapillomatous changes and cancer, referring particularlyto these conditions in the uterus.

Jux i8, 1g921JA-a

896 JuNEx4 ,X9211 XDVEW.*LTJOBrrLALMr. MCADAM ECCLES recalled that the late Mr. Keetley,

the founder of the society, had many years ago expressedthe belief that cancer of the breast was always due toinfection through the ducts. Mr. Eccles was certain therewas a close connexion between papillomata and infection.This was well seen in the case of the bladder. He regardedalso many of the cysts of the epididymis as of infectiveorigin. In doubtful breast conditions in women over 50 hethought it safer to advise complete removal of the organ,but not necessarily of the muscles and lymphatic tracts.

Dr. RICKARD LLOYD referred to cases in his practice inwhich cancer had been proved in patients presentingscanty evidence of the true condition on clinical grounds.He also mentioned cases in wllich life had been prolongedvany years after operation at an early stage for cancer.Dr. KNYVETT GORDON spoke as a pathologist of the

difficulty in manv cases in deciding what the true condi-tion was from an examination of only a small portion ofthe breast. The whole breast section was undoubtedly thebest method, but was often impossible. He thought thatwhen intra.acinar proliferation was marked the wholebreast should be removed, and where the basement mem-brane was ruptured the muscles and lymphatic tractsshould be removed as well. He did not agree that ductpapillomata were necessarily benign.

SURGERY OF NASAL DEFORMITIES.AT a meeting of the Medico-Chirurgical Society of Edin.burgh on June 1st, Sir JAMES B. HODSDON presiding, Dr.DOUGLAS GUTEHRIB read a paper on the surgery of nasaldeformities. He emphasized the importance of immediatereplacement of the injured and deformed parts, and ofnot forgetting the possibility of septal deflection. Of thecommon types of deformity, he took first that of lateraldeformity or twisted nose; witlh this there usually wasalso some deflection of the septum, witlh partial or com-plete blockage of the nostrils. The treatment was a sub-mnucous resection of the septum; division of bone wasrarely inecessary. The second group was that of sunkenbridge or saddle nose, produced by violence, by an ex-cessive resection of the septum, or by syphilitic disease.Cases of successful treatment of this type of deformity bycartilage graft were described. The graft was obtainedfrom the seventh costal cartilage, and the advantages ofsuch a graft were that it was a natural tissue, that it couldbe readily shaped to fill the gap, and that it persistedunchanged. The results were least satisfactory insyphilitic disease. The third type was that of nostrildeformity, of which three examples were given-one adeflection of the lower end of the septum, one a stenosednostril produced by redundant tissue of the graft of aprevious plastic operation, and the other a case of alarcollapse.

Mr. D. M. GREIG advocated the use of paraffin in pre.ference to a graft operation in cases of sunken bridge wherethe condition was congenital and without scarring; theoperation was easy to perform, could be carried out in thaout-patient room, and had given him excellent results.

Dr. GUTHRIE, in reply, said that his only experience ofthe paraffin had been in removing it where it had failed;it wandered into distant tissues, even into the eyelids,where it gave much trouble.

Treatment of Fractures of the Upper Extremity.Mr. J. W. DOWDEN discussed the principles of the treat-

ment of fractures of the upper limbs. The classical useof splints and prolonged fixation of the parts might give agood result, but much time was wasted. Lucas-Cham-pionniere had revolutionized the older treatment by hisadvocacy of early massage and passive movement. Thespeaker carried the new doctrine a step further, and ad.vocated early active movement. The principles of histreatment in fractures of the upper extremity were asfollows: A sling supported the forearm, tlhe angle at theelbow was altered several times a day, and the range wassteadily and painlessly increased. Active movements ofall joints and muscles were frequently carried out duringthe day, increasing the range steadily, and following onthe hieels of pain. Pain was absolutely the indicatorof how far 'active movement might be carried, and themnethod was so simple that it could be carried out byyou'ng children as well as by adults. Cases of fracture of

the clavicle, of the scapula, humerus, elbow, -forearm, andwrist were described, and the injuries, with the functionaland anatomical results, were illustrated by x-ray photo-graphs. Certain regions offered special difficulties, notablythe elbow and wrist, but even there the results weresuperior to those of the conventional methods. He hadused the method also in severe conlpound fractures due towar injuries, where its superiority was equally marked;he had not had a case of non-union in compound fractureof the humerus treated in this way.Mr. C. W. CATHCART said that tthe results given by this

method were well founded, and were an advance in thetreatment of fractures; they broke througlh the dictumthat a good ffunctional result could not be obtained withouta good anatomical result. But he was doubtful if themethod could be applied to fractures of the lower extremity.Mr. D. M. GREIG expressed general agreement, but saidthat in fracture of the olecranon and in fracture of thehumerus in babies it was not suitable. Mr. PIRIE WATSONsaid he had adopted the method in surgical out-patientwork, modifying it by tlle use of splints for the first fewdays. Dr. C. SOMERVILLB reported a case of fracture ofthe ulna in a chauffeur treated by this method, where theman was using the arm again at his work fourteen daysafter the injury.

Keratodermnia Blennorrhagica.Dr. DAVID LEES reported two cases of this rare condition,

showing casts and photographs of the skin lesions. Thelesions, horny heaped-up growtbs on the skin, withparchment-like areas between, were commonest on thesoles of the feet, but occurred also on the leas, scrotum,back and abdomen. Forty-seven cases in all had beenrecorded. The condition was a manifestation of gonococcaltoxaemia of severe degree, and polyartliritis was ustuallypresent, and also uretlhritis; only once had gonococci beenobtained from the skin lesions. His first case was a managed 22, wlho had unusually extensive skin lesions, witlh anegative Wassermann and positive gonococcal tests. Histreatment was as follows: Local application of a solutionof arsenic and ipecacuanha in rectified spirit; large dosesof gonococcal vaccine (twenty tlhousand million) after pre-liminary desensitization; and injeetions of novarsenobillon.The condition was cured in six weeks and had not recurred.In the second case, a woman aged 63, with the charac-teristic lesions on the soles and legs, bacteriological andserological proof of gonococcal infection was lacking, andthe Wassermtann test was also negative. A similar courseof treatment was given, and again tlle horny growths hadentirely disappeared. In three months they relapsed, butagain cleared up after a second course of novarsenobillon.

DEFICIENCY DISEASE.MCCARRISON'S Studies in Deficiency Disease1 is a notablebook.' It is one whiclh demands careful study andl fullconsideration by all me'dical men. It comes at the righttime when our knowledge of the vita-mins is crystallizing,and when the new idea that disease is not necessarilydue to the activity of a positive agent, but to the absenceof indispensable ingredients of diet, i8 sinking in. Aswas to be expected, most attention is directed to theconditions caused by absence of the antineuritic vitamin,for it was in relation to that material that tlle autlhormade his name by hlis published researches. But quite anadequate account is given of the effects due to the with-holding of other vitamins, including tlle disease pellagra,which in all probability is not quite on all-fours with tlleother ailments, now labelled as Deficiency Diseases."Vitamins are as the spark which ignites the fuel mixture of

a petrol-driven engine liberating its energy. The spark is ofno use without the fuel, nor the fuel without the spark-naymore, the efficacy of the spark is dependent in great measureon the composition of the fuel mixture."

These illuminating sentences (p. 210) really pi@ thewhole problem in a nutshell. Absence of food l14ds to

1Studies z't& Deficiency Disease. By Robert McCarrison, M.D.- D.Sc..Hon. LL.D., Belfast. London: Henry Frowde. and Hodder andStoughton. 1921. (Sup. roy. 8vo, pp. 286; 82 figures. 30s,, net.)