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MEDICAL SOCIETIES

EDINBURGH OBSTETRICAL SOCIETY

AT a meeting of this society held on June 8th,Dr. JAMES YOUNG, the President, being in the chair,Prof. R. W. JOHNSTONE, Dr. E. CHALMERS FAHMY,and Dr. R. J. KELLAR presented a communicationon

Primary Ovarian Pregnancywith a report of two cases.

In the first case operation was undertaken onaccount of symptoms indicating an acute rupture ofan ectopic pregnancy. Laparotomy revealed a

ruptured ovarian pregnancy, a foetus of about sixweeks’ gestation being found in the pelvis. Thetube on the side corresponding to the ruptured ovarywas normal; serial sections of the ovary (which wasremoved) showed the presence of chorionic villi inthe ovarian stroma. The corpus luteum was foundin a different part of the ovary, apparently separatefrom the gestation sac. In all probability thecondition was one of implantation on the surface ofthe ovary. Sections of the tube showed no evidenceof pregnancy.

In the second case operation was undertaken onaccount of a simple serous cyst of the left ovary.Laparotomy revealed not only a serous cyst on theleft side, but a very early pregnancy in the rightovary. This had ruptured, and blood was present inthe peritoneal cavity. The haemorrhagic area wasexcised from the ovary, which was left "in situ "with its healthy tube. Serial sections through theexcised portion showed the presence of chorionic villiattached to an active corpus luteum. Accordingto the patient’s history the pregnancy was of aboutfifteen days’ duration. In this instance the pregnancyhad occurred in the mature follicle. !

In both cases microscopic examination revealedthe presence of large epithelioid cells in the ovary.The origin of these were discussed, and the conclusionwas reached that many of them, at least, were

decidua-like cells derived from the cells of the ovarianstroma. Detailed examination proved beyond doubtthat both cases were examples of primary ovarianpregnancy.Dr. D. MILLER read a communication on the

Influence of Age on the Process of Childbirth

based on a series of 154 cases of pregnancy and labourin girls of 17 years of age or less, and of 88 casesin which the patient had passed the age of 40 at thetime of her first confinement. The cases had beentreated for the most part in the Edinburgh RoyalMaternity Hospital. Each of these age-groups wasconsidered separately in regard to the course of

pregnancy, the duration and complications of labour,the type of delivery, and the end-results to motherand child.

PREGNANCY IN VERY YOUNG GIRLS

Of the 174 cases of pregnancy in young girls,2 were 13 years of age at the time of the confine-ment, 8 were 14, 18 were 15, 41 were 16, and105 were 17. In the majority of the patientspregnancy proceeded normally and without incidentto full term. The minor disturbances of pregnancywere not encountered more frequently than usual.On the other hand, there was a high incidence ofvenereal disease and of albuminuric toxaemia.

Dr. Miller thought that the undue frequency oftoxaemia should be attributed to the inevitable lackof supervision associated with illegitimate pregnancy,.rather than to the youth of the patients. Suchcomplications of labour as contracted pelvis, mal-presentation and mal-position, and injury to thesoft tissues were not more common than in olderwomen, and the average duration of labour did notdiffer appreciably from that regarded as normal fora first labour. The proportionment of spontaneousdeliveries was 85 per cent., and in not more thaneight cases in the total series of 174 patients wasinterference required on account of disproportion.It appeared probable that the relatively freer mobilityof the pelvic joints and the greater elasticity andresiliency of the soft tissues in the young patientadequately compensated for such potential dispropor-tion as might cause obstruction in an older woman.There were two maternal deaths in this series. Bothwere cases of eclampsia, and in neither had thepatient been seen by a doctor until after the onsetof convulsions. Four of the infants were stillborn,and a further seven died within a fortnight of birth ;the total stillbirth and neonatal death-rate, 6-5 percent., compared with a mortality-rate of 11-S per cent.for all viable children born in the hospital over thefive-year period 1927-31.

PREGNANCY IN ELDERLY PRIMIPARae

In the series of elderly primiparae analysed the highincidence of albuminuric toxaemia was a noteworthyfeature, 10-7 per cent. of the patients suffering from.this complication in spite of careful antenatal super-vision. There appeared also to be an increased.

tendency to fibroid tumours, mal-presentation, and.possibly to accidental haemorrhage. Contracted pelvis.had not been found to occur more frequently than inyounger women.

In the majority of cases labour was not undulyprolonged, and in many it was rapid and easy ; on.

the other hand, the proportion of patients in whom.labour did exceed the statutory 18 hours was much.greater than in younger women. The most frequent.cause of delay was primary uterine inertia it wasnatural, moreover, that the physical effort of labourshould be borne less well by the patient over 40,and a tendency to undue fatigue in the second stage,was noted in a large proportion of cases. Not more-than 40 per cent. of all the patients delivered them-selves spontaneously; delivery being effected byforceps in 38 per cent., by Csesarean section in 12 percent., and by breech extraction in approximately10 per cent. There was one maternal death in the series :.the patient, who had had no antenatal supervision, was,admitted to hospital late in labour ; the pelvis was.contracted, and the child presented as face. She;died of post-partum shock some hours after cranio-tomy. Twenty-two of the infants were stillborn or diedshortly after birth, giving the high mortality of

2 6 per cent., and one which was all the more regrettablein view of the improbability, in most cases, of furtherpregnancy.The findings in this series supported the view that

pregnancy and labour in the elderly primipara weremore commonly associated with difficulty and dangerthan in younger women. The higher incidence ofalbuminuric toxaemia, and of such complications as.fibroid tumours and mal-presentation, demanded.specially careful antenatal supervision and examina-tion. In the absence of complications the management.

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of labour should not be influenced by the patient’sage, though in view of the tendency to uterine inertia,quinine should be exhibited for some days before theonset of labour. Hospitalisation was desirable inall cases, and while disagreeing with those who

advocate routine Csesarean section in all primipara-,over 40, Dr. Miller thought it justifiable to extendthe relative indications for this operation to coversuch conditions as entailed a serious risk to the childwith vaginal delivery.

REVIEWS AND NOTICES OF BOOKS

Recent Advances in Town PlanningBy THOMAS ADAMS. In collaboration with F.LONGSTRETH THOMPSON, E. MAXWELL FRY, andJAMES W. R. ADAMS. London: J. and A.Churchill. 1932. Pp. 400. 25s.

° IT is common knowledge that one of the chiefevils of our urban civilisation is overcrowding. Mr.Thomas Adams, the principal author of this book,is especially well qualified to discuss this matterbecause he has spent many years in America, and,although an Englishman, he received the honourof being appointed town planning adviser to the

municipality of New York. In this city the degreeof congestion has become almost unbearable, itschief cause being the skyscraper type of buildingwhich at certain times of the day disgorges thousandsof people on to thoroughfares far too narrow toaccommodate them. It is generally assumed that ithe skyscrapers were the necessary consequence ofthe restricted site in which the business site of NewYork was situated. Yet the average height of

buildings in Manhattan Island is less than that in theCity of London, and now it is suggested that the- skyscrapers owe their existence more to the desirefor advertisement than to any real economic or- commercial need.

The authors show that in all countries the remediesto be applied to the maladies which afflict our

industrial towns can be sought only by the strict- observance of certain principles of planning. Andthe word " plan " must be construed in its widest.sense. First there has to be a preliminary survey-of the district under consideration. For this purposethere must be undertaken extensive researches whichinvolve a study of topography, the history and

government of the area, existing land uses, com-munications, industries, distributions of population,housing, statistics of public health, sanitary, and othermunicipal services, and the preservation of amenities.The next step after the preliminary survey is an

.advisory regional plan in which practical proposalsare put forward with the object of regulating thefuture development of the district as a whole. When- once the social and industrial characteristics of the

region have been correctly visualised, it becomes

necessary to undertake a number of advisory towndevelopment plans, and these latter may be directedeither towards the improvement of existing townsor may assume the- form of projects for entirely new- urban centres such -as Welwyn Garden City. The

prime need of the day is for decentralisation, for byno other means will it be possible to re-establishhygienic conditions in our existing overcrowdedtowns. Also. this seems the only way to alleviatethe traffic congestion which is the direct and indirect-cause of heavy casualties.The book contains a number of photographs

illustrating schemes for housing and road development,and diagrams showing the zoning of industries, openspaces, residential areas, and other elements whichmust be given their proper mutual relationship in aTegional plan. It also explains the steps which shouldbe taken before any particular proposal can receive i

the assent of the urban district council or the otherpublic authorities concerned. It is clear, as is herestated, that " we must not expect by law what canonly be obtained by the work of sympathetic admini-strators and trained town planners ; by adequateresearch and sound philosophy ; and by education ofthe public and of the bodies they elect to representthem." Housing, the provision of open spaces, theorientation of streets so that buildings receive a

certain share’of sunlight, and the improvement oftraffic facilities have an incalculable bearing uponpublic health.

If town planners are to fulfil their object of estab-lishing favourable conditions in these respects theyneed the active assistance and cooperation of doctors,and the full value of such cooperation can only beachieved if medical men have a proper appreciationof the other issues involved. They will find thisbook most useful in presenting much of the neededinformation. ’

Proctoscopic Examination and the Treatmentof Hemorrhoids and Anal Pruritus

,

By Louis A. BUIE, B.A., M.D., F.A.C.S., AssociateProfessor of Surgery, The Mayo Foundation,Minnesota. London : W. B. Saunders Co., Ltd.Pp. 178. 16s.

THE first -section of this book gives a clear descrip-tion of the indications for and technique of a thoroughexamination of the rectum. From the records of theMayo Clinic Dr.’Buie estimates that probably 20 percent. of cases of carcinoma of the rectum seen at theclinic have been missed previously owing to incompleteexamination. The case-histories show either thatthey have been treated on medical lines for intestinalirregularities, often over long periods, or thatineffective operations for hemorrhoids, or otherminor associated lesions, have been done. The tenillustrative cases set out on pages 33 and 34 willremind most readers of similar tragedies in theirown experience. Dr. Buie speaks well of the valueof the Hanes or inverted position for proctoscopicexamination, and though he describes in detail thetypes of instrument which he is accustomed to use,he claims no peculiar merit for them over other

recognised patterns. He has made a detailed studyof 1000 cases of haemorrhoids, and adds a report onthe pathology of 100 cases of haemorrhoids removedby operations. His conclusion is that haemorrhoidsare due to degeneration of the vein walls and areconstantly accompanied by varying degrees ofthrombosis and infection. This section is wellillustrated. Partial sacral block is the form ofanaesthesia which has been used at the Mayo Clinicsince 1923 for haemorrhoidectomy and is obviouslypreferred by Dr. Buie to any other. Lundy’stechnique of injection of the caudal canal and theposterior sacral foramina is clearly described and evenone not acquainted with the landmarks ought to beable to follow the procedure from this account.But in our view the fear of spinal anaesthesia hereexpressed is exaggerated, for by the " low " techniquesafe and efficient anaesthesia can be produced ; more-