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slender reasons, and that a certificate often meant alicence to play in the streets. When a panel patientwas really ill the burden of his care fell on the hospital,and the National Insurance scheme ought to recognisethat work in some quite definite way. A seriousillness in a middle-class family meant a financialcrisis ; the voluntary hospital had instituted smallpaying wards, but this accommodation was far tooscanty. Municipal nursing homes, like those ofScandinavia, were an inevitable step. The voluntaryhospital, he said, had ceased to exist as such, andpatients often complained that they could not affordto be treated in it. The only voluntary thing leftwas the consulting staff. If voluntary hospitalswere to continue, said the speaker, let them be runon a sound financial basis, and not have to descendto the level of sending out their students dressed asnigger minstrels with barrel-organs to collect funds.

Dr. HOWARD STRATFORD said that the point ofreal difficulty in the relationship between public andprivate medical men lay in the clinics. It was feltby general practitioners, and also by the BritishMedical Association, that the basis of a nationalmedical scheme should be the provision of the servicesof a general practitioner or family doctor to everyindividual. In emergency the family doctor and noone else was called in. Every clinic should displaya large notice : Have you a family doctor ? ‘? If not

get one ! "

The PRESIDENT agreed that public and privatedoctors should hold periodical conferences. Privatepractitioners, he said, either singly or in combination,should start clinics for periodical examination-

especially of expectant mothers-for the" betterclasses." These centres might reduce the incidenceof rickets in well-to-do children to the low levelachieved among the poor by the present welfareclinic.

NORTH OF ENGLAND OBSTETRICAL

AND GYNECOLOGICAL SOCIETY.

A MEETING of this society was held in Manchesteron Jan. 22nd, with Dr. F. H. LACEY, the President,in the chair.

PROLAPSE WITH STRANGULATION OF THE URETHRA.

Prof. LEITH MURRAY (Liverpool), after a referenceto the infrequency of a clear definition of the conditionin text-books, described four cases of prolapse withstrangulation of the urethra. All the patientswere elderly multiparæ, their ages ranging from 67to 84, and all had similar symptoms and physicalsigns-namely, considerable local pain, marked

urinary frequency, especially by day, difficulty in

walking, and a blood-stained discharge. He thoughtthat strangulation of the protruding mass mustoccur at some stage of the process, owing to themarked livid colour, and that, although infectionwas present, this must be secondary. There wasno tendency to urinary retention, so there appearedto be no urgency in the treatment, which consisted inthe application of adrenalin and chloretone ointmentfor a day or two, replacement of the urethra byfinger pressure (under anaesthesia in two cases),and the use of a self-containing catheter for a fewdays. There was no recurrence in three of the casesover a period of one to four years, but in a fragileold lady of 84 there was a slight recurrence for tendays after removal of the catheter. This was con-trolled by daily observation and reposition, and the

patient was reported to have been free from symptomsduring the last seven months.

ASCHHEIM-ZONDEK TEST IN ECTOPIC PREGNANCY.

Mr. W. W. KING (Sheffield) described a case

illustrating the value of the Aschheim-Zondek testin ectopic pregnancy in the presence of hydatidiformdegeneration of the chorion. After referring tothe rarity of cases in which the test could be ofdefinite clinical value in ectopic pregnancy, he paidtribute to the support it gave in confirming thenecessity for immediate operation in a difficult case.The patient had gone 17 days over her time before the

so-called period commenced, but this delay as well as certainindefinite symptoms such as pains in abdomen and leftshoulder were ascribed to " chills," "over-eating," and" rheumatism " respectively. The only physical sign wasthe doubtful presence of free fluid, and even under anees-thesia no suspicious appendage swelling was palpable ;but on arrival of a positive report on the urine, operation wasinsisted upon. Laparotomy showed free blood, whichwas mostly clotted, in the peritoneal cavity and a tubalmole which revealed naked-eye and microscopical evidenceof early vesicular degeneration. The presence of thisdegeneration would account for the positive reaction inspite of the fact that the foetus was apparently dead.

Mr. King referred to the greater relative frequencyof vesicular .degeneration of the chorion in tubalthan in uterine pregnancies.The PRESIDENT said he had found needling the

pouch of Douglas helpful in the diagnosis of doubtfulcases of tubal gestation.

Dr. M. M. DATNOw (Liverpool) said he had carriedout the test in three cases of tubal pregnancy, with acorrect result in each case, and therefore consideredit of value in arriving at a diagnosis. He believedthat the reaction was never positive more than48 hours after delivery or abortion except in cases ofhydatidiform mole or where chorion-epithelioma haddeveloped.

TWISTED HYDROSALPINX.

Mr. J. E. STACEY (Sheffield) showed a specimen of atwisted hydrosalpinx removed from a nulliparouswoman aged 29, who had been married for four yearsand had complained of abdominal pain (with pre-menstrual exacerbations) for three years. Shesought medical advice on account of sterility alone.

’ Bimanual examination revealed a retroverted uterus with

a mass of enlarged matted appendages palpable in thepouch of Douglas, and as Rubin’s test was negative alaparotomy was performed. It was found that the righttube had been converted into a hydrosalpinx 5 in. long whichhad undergone one complete twist and contained blood-stained serous fluid. In the process of torsion the broadligament had been torn and there was a large hiatus init, thus preventing the ovary being involved, but this organwas cystic and bound down by adhesions. Right salpingec-tomy was performed, and as the left tube was thickenedand the lumen occluded at the fimbrial end, left salpingo-stomy was carried out, and an infected retrocæcal appendixwas also removed.

Mr. Stacey discussed whether salpingostomy waspreferable to a more radical operation in patientscomplaining of pain and sterility, and mentionedone case in which pregnancy had followed bilateralsalpingostomy.

DEGENERATING FIBROID.

Dr. C. P. BRENTNALL showed a specimen of afibroid with red and cystic degeneration, removed froma primigravida aged 27, who had complained ofcontinuous pain and tenderness apparently due to thetumour, and present for four months. The fibroid,which was extensively adherent to omentum andcolon, was almost uniformly degenerate, and showedareas of cystic degeneration containing a fluid which,after fixation, somewhat resembled chocolate inappearance. Dr. Brentnall referred to the opinion

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frequently expressed that red degeneration of a

fibroid in pregnancy affords no indication for opera-tion. He had collected two series of hospital casesand found that the eleven patients who had enuclea-tion performed, all went on to full term, while of31 instances in which no operation was performed,one mother died of peritonitis following hysterectomytwo months after delivery, and there were fourabortions, one premature labour with death of thefoetus, one macerated child, and four neonataldeaths. In view of these results, of the dangerof changes such as those in the specimen described,and also of the possibility of the development ofsarcomatous metaplasia or dense adhesions roundthe tumour, Dr. Brentnall advocated early surgicaltreatment when red degeneration was diagnosed inpregnancy.

Prof. LEITH MURRAY defined the late stage of reddegeneration as chronic necrobiosis, or grey degenera-tion, and considered that all cases should be allowedto settle down under morphia unless, in spite of thistreatment, there was an increase in the degree oftoxaemia.

CARCINOMA OF PERINEUM.

Dr. K. V. BAILEY showed a specimen of carcinomaof the perineum removed from a patient aged 36,who was single, and had complained of soreness in theperineal region for two months. Examination revealeda deep excavating ulcer of the perineum extendingup to, but not actually invading the external sphincterani muscle, with extensive glandular involvement inboth groins. As a result of extensive treatment

comprising three applications of radium, colostomyand excision of the left iliac and both sets of inguinalglands, and finally of excision of the ulcer, the patienthad been rendered comfortable. The perineumreadily healed by granulation and the glandularareas were being treated with X rays.

EDINBURGH OBSTETRICAL SOCIETY.

AT a meeting of this society on Jan. 13th, withDr. JAMES YOUNG, the President, in the chair,three papers were read bearing on the

Toxaemias of Pregnancy.Prof. J. M. MUNRO KERR (Glasgow) began by

pointing out that little material benefit had beenderived from the enormous amount of research onthe toxaemias of pregnancy during the past thirtyyears. As Whitridge Williams had said, "it isevident that the cause of eclampsia has not beendiscovered, and that the peace of mind of all con-cerned would have been increased had many of theso-called contributors never written, or at least hadwithheld their contribution long enough to submitthem to ordinarv self-criticism."

The aetiology of the toxaemias must be looked fornot when grave symptoms were present, but farback in the early days of pregnancy when, followingthe embedding of the zygote, great and insidiousforces disturbed the normal physiological processesof the maternal organism. Ir the first place, therewas great activity of all the endocrine glands duringpregnancy, especially the anterior lobe of the pituitarybody and the thyroid. Secondly, there was con-

siderable destruction in the uterine mucosa at the sitewhere the zygote embedded, and later as the placentagrew and developed, the area affected assumed largedimensions. This destruction in the early weekswas very aggressive and the deposition of tissue by

the chorionic villi must result in the discharge of

products of protein autolysis in the maternal bloodstream. In all probability, cases of emesis gravi-darum and hyperemesis were due to disturbedmetabolism resulting therefrom. Thirdly, it hadbeen pointed out by Snorf and Veit that portions of villiwere transported by the circulation. The organism maytherefore have an additional strain upon it in dealingwith such foreign products. Fourthly, metabolismhad distinctly altered during the first three monthsof pregnancy-especially protein metabolism-and

although in the human subject there was seldom adefinite negative phase such as was seen in the loweranimals, something approaching that condition didoccur. It was noteworthy that the sickness of

pregnancy, the disturbances of the negative phase,and the full development of the placenta occurredabout the same time.

These disturbances of the earlv months were

succeeded by a period of relative stability lastingeight to ten weeks during which the grosser manifesta-tions of toxaemia seldom developed, and this wasfollowed by the last phase when outbreaks of toxaemiain one form or another were commonest. The reasonfor this was probably that the placenta from thesixth month onwards was a degenerating organ andthe ectoderm covering the villi had almost disappearedand was more or less degenerating. It seemedinconceivable that an organ in this condition couldhave any activity as an endocrine organ ; thus the

placenta was unlikely to produce special hormone atthis time, but it certainly acted as a store-housefor such a substance. Prof. ialunro Kerr thoughtit probable that an outbreak of toxemia was due toproducts of protein autolysis ; the organism alreadyoverburdened by toxins was unable to stand furtherstrain. The pregnant woman had always a struggleto combat attacking forces-endocrine activity,digestion of the endometrium, and the resultingdisturbing metabolism. If she did not succeed in the

fight the toxins produced further infection, more

especially in the liver, with the result that metabolicprocesses were still further affected. Renal disturb-ances were secondary except where any previousdisturbance existed. Faulty elimination followed, anda vicious circle was created which culminated in grosstoxaemia in one or other of its recognised forms.

Prof. R. W. JOHNSTONE read a paper on a FatalCase of presumably Acute Pregnancy Toxaemiawhich occurred at the seventeenth week of pregnancyand which proved fatal despite drastic operativeinterference.-Dr. JAMES DAVIDSON described a

Fatal Case of Eclampsia associated with extensivecerebral haemorrhage at the thirty-sixth week of

pregnancy.

A CORRECTION.—Dr. A. H. Douthwaite writesin reference to his remarks made at the MedicalSociety of London last week (p. 350). " I remarkedthat it was the hypersthenic individual who so oftensuffered from gall-stones and angina pectoris, andthat possibly their coincidence was as much due tothe tendency of each condition to arise in the robusttype, as to any aetiological connexion between gall-bladder disease and the development of coronaryatheroma."

POLITICAL SPEECHES AT MENTAL HOSPITALS.-A request by a candidate in the Irish Free State GeneralElection for permission to address the attendants atPortrane has been refused by the Grangegorman Ment,aiHospital Committee on the grounds that " the holding of ameeting within the grounds of the hospital would havean unfavourable effect on the patients." Similar requestsin the past have always been refused.