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ROYAL SOCIETY OF MEDICINE.

SECTIONS OF ANAESTHETICS ANDOBSTETRICS.

AT a combined meeting of these Sections on

March 2nd Dr. CECIL HUGHES, President of theSection of Anaesthetics, in the chair, there was adiscussion on

ANIESTHESIA IN OBSTETRICS.Mr. EARDLEY HOLLAND said that professional

anaesthetists were now beginning to take an interestin the administration of anaesthetics in obstetrics, abranch which they had hitherto much neglected. Themethod used for this work, if it was to be generallyadopted, must be simple and safe, and capable of beingemployed by those who had not had special training.It was necessary in this work that pain should be ’,abolished, or materially diminished, over long periodsof time, and the form of anaesthesia used must notlessen the force and frequency of the uterine contrac-tions, nor endanger the life of the foetus. Anaestheticswere used for two distinct purposes in this specialty :(1) to relieve the pain of labour; and (2) for obstetricoperations, such as version and Caesarean section.For the second purpose the most suitable anaestheticwas that which was best for operations in general ;deep and prolonged ether anaesthesia, however, wasundesirable for the foetus, which was also very sensi-tive to morphia. This drug should not be given withintwo hours of delivery. He thought highly of stovaine,certainly for Caesarean section, which it made almostbloodless.

Reverting to the relief of pain in ordinary or normallabour, Mr. Eardley Holland declared that everywoman ought to be saved the pains of labour. Thestatement of the whole question by Simpson 81 yearsago had not been improved upon since, and the onlysubsequent advance had been the Junker inhaler.If practising midwives could not alleviate the pains oflabour, 75 per cent. of women must go on suffering inlabour in this country, as that proportion were attendedat the present time by midwives. This inabilityto relieve the pain of the mother was the great bar tothe advancement of the midwife. He did not see anyobjection to midwives giving analgesic drugs, such aschloral and morphia. The anaesthetic requirements ofthe first stage of labour were different from those ofthe second stage. In the latter, especially in primi-parae, the pain was very severe. The pain in the firststage could easily be made tolerable by such drugs aschloral, or morphine and hyoscine together ; but in thesecond stage a general anaesthetic was usually needed.Emotional conditions heightened the intensity of thepain, and the apprehensive state engendered byconversation about the perils of childbirth made itdesirable to try to restore their confidence in the lastmonths of pregnancy. The method of common use foi

anaesthetising these women was that of intermittentchloroform anaesthesia. This should not be given untilthe second stage had begun-certainly not until thefirst stage was nearing its end. As soon as it wasevident that the pain of the uterine contractions waEnot being well borne, grs. 30 of chloral should bEgiven or an injection of morphia and hyoscineThis, with a repetition of the hyoscine, carried thEpatient, with very little pain, on to the second stagEof labour. At the onset of the second stage, chloro.form was given by the Junker inhaler. This was nothe contended, sufficiently taught to medical studentsThe anaesthesia must not be deep enough to interrup1the uterine contractions. Under light anaesthesiapowerful bearing-down efforts were associated witlperfect relaxation of the pelvic floor. There shoulcbe a deepening of the anaesthesia for the most painfupart of the process of birth, when the head passecthrough the vulval orifice.

Dr. JOSEPH BLOMFIELD said the obstetriciai

tolerated, in labour, a condition of affairs-i.e., absenc4of anaesthesia—which he would not allow in any othe

surgical connexion. Even when an anaesthetic wa:

used it was often left until too late, and was notskilfully administered. Every woman in labour shouldbe free from pain from first to last. The absence ofthe anaesthetist from such a large proportion of thesecases was simply due to the fact that he had not beenasked to cooperate. In certain cases nitrous oxidea,nd oxygen was the ideal anaesthetic, but it must beadministered by somebody familiar with the apparatus.and generally home conditions were not very suitablefor it. For some it was an inefficient anaesthetic, andthese women would only become excited with it. Heagreed with Mr. Eardley Holland that the anaestheticfor general use was chloroform, as it was almostinvariably successful. He had not had experience ofthe synergistic method, which was advocated and usedin the United States-namely, the use of morphia andmagnesium sulphate, followed by ether and quinine perrectum. He had found that ethyl chloride was a veryuseful drug when the pains began, and its effect couldbe reinforced by very weak chloroform.

Mr. WILLIAM GILLIATT agreed that certainly whenthe doctor was working with single-handed assistancechloroform was the favourite anaesthetic. Etherseemed to diminish the strength of the uterinecontractions and so delayed the birth .of the child.Not only had the woman in labour the right to besaved pain, but the obstetrician preferred that thewoman should be lying still, for then it was easierto keep the operation aseptic. Chloroform was morepotent and acted more quickly than ether ; but gas-and-oxygen, with the addition of a little ether, was bestduring the passage of the child’s head. It stimulatedrather than checked the uterine contractions and anyvomiting was but slight. There was some danger ofchloroform poisoning if that anaesthetic were used,and if any toxaemia was already present that drugmight increase it. The danger of trouble was increasedif the patient were given more than one kind ofanaesthetic for the labour and a complication. He gavedetails of five serious cases, two of which endedfatally, one in 36 hours, the other in 15 hours. Whenspinal anaesthesia was used for a patient for whominhalation would be dangerous, no inhalation shouldbe given at the same time. In his maternity wards henow used ether.

Dr. H. A. RICHARDS said the choice of the anaestheticshould depend on the state of the particular patient.He agreed that if a patient had previously been given

, an anaesthetic no subsequent anaesthetic shouldcontain chloroform. For a second anaesthetisation

, gr. 1/100 atropine should be given half an hour

; beforehand, then ether. If the patient was accustomedto being violently sick, nitrous oxide and oxygen should,

be used when she seemed to be unduly apprehensive: of pain. For Caesarean section it was best not to give: any chloroform at all. Twilight sleep -did not comej into the range of the discussion, as it was not an

- anaesthetic. His objection to using ethylene in private: practice was that there was usually a fire in the room, and it was a very explosive substance.) Mr. H. E. G. BOYLE spoke highly of the skilled administration of gas-and-oxygen by Dr. Wesley; Bourne at Montreal; from this he had gained the

impression that it was one of the finest of all anaes-thetics. After obtaining the patient’s confidence one

. could produce by this mixture a condition of analgesias in which the patient would do just what she was asked to. Certainly it did not diminish the propulsive- efforts of the uterus. When the woman bore down,

well it shortened the duration of the labour. Ether.

could be used just when the head was being born,t and then a mixture of CO2 and oxygen could be given

for a few minutes. He would like to see gas-and-i oxygen more used in obstetric practice in this country.I Dr. H. BECKETT-OVERY said he did not know1 whether specialists appreciated how much some

I patients suffered after their confinement-sometimesfor months or years after delivery. Even after an

a uncomplicated confinement some women sufferede severely from shock, and if it could be shown thatr there was a general anaesthetic which was available fors all purposes, it was, he considered, the doctor’s

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bounden duty to use it. In the case of women whoseos was dilating rapidly he at once gave hyoscine andmorphine, a measure which seemed to quieten theemotions, so that by the time the second stage wasreached the patient was able to use the chloroformherself. He hoped that the old attitude that it wasnot necessary to use an anaesthetic for women inlabour had now passed from the profession for good.In quite 70 per cent. of the cases he did not think asmall quantity of an analgesic drug brought about anyappreciable delay in the birth process, and it was aconsiderable gain to the patient, as the head couldbe delivered without any laceration.

Dr. S. A. S. MALKIN (Nottingham) spoke of thesynergistic method-i.e., administration of morphiaand magnesium sulphate, followed by the rectalinstillation of ether and quinine in olive oil. TheAmerican view of it was that only a small dose ofmorphia was given and that the magnesium sulphatekept the action more effective and over a longer time.The quantity of ether needed was also small, and itwas said that the administration could be rendered soautomatic that the constant attention of the obstet-rician was not required. He had used the method in20 cases, of which 12 were entirely successful-i.e.,the patient slept between the pains and stirred onlywith the pains. In some cases the woman had notknown when the child was born. In one case therewas excitement, in two the method failed completely,in one he gave the morphia rather late, the secondstage supervened quicker than he expected, and thechild was born blue. Now that he was betteracquainted with the technique he felt certain ofsecuring a large percentage of successful cases withthe method, which, he was convinced, possessedadvantages. ____

SECTION OF ORTHOPEDICS.A MEETING of this Section was held on March 6th,

Mr. W. RowLEY BRISTOw, the President, in thechair, when Mr. HARRY PLATT read a paper on the

TREATMENT OF ACUTE OSTEOMYELITIS.

The literature, he said, offered conflicting advice,usually based on very small series of cases collectedover very long periods. The outstanding contribu-tion to the subject in the last decade had been madeby Clarence Stau, of Toronto, who had recorded207 cases at the Children’s Hospital during 12 years.The greatest mortality occurred in the age-group10-15, and was twice as great in males as females. Mr.Platt’s series at Ancoats Hospital, Manchester,numbered 41 in five years. He then outlined theanatomy of the blood-supply of growing and adultbones on which the infective process depended.The acute osteomyelitic process began in the meta-physeal cancellous tissue just under the epiphysealdisc, because of the " end-artery " system andsluggish blood-supply. The focus rarely spreadinto the joint, but more often to the subperiostealspace and thence along the surface of the shaft.The " gutter operation had been based on theerroneous belief that spread occurred early alongthe medullary canal. The Toronto school had shownthat the cancellous tissue of the metaphysis offeredconsiderable opposition to the spread of infection,and that the juxta-epiphyseal focus remained smalland localised when the periosteum was extensivelystripped. The medullary canal was invaded late,and through the Haversian canals from the sub-periosteal space. This fact had been established bythe most convincing experimental, clinical, operative,and post-mortem observations in Toronto, and Mr.Platt had confirmed it in his own series. In olderchildren there might be atypical localisation, especiallyin the radius and ulna. and occasionally in the fibula,the infection reaching the bone by the nutrient arteryand spreading up and down the medullary canal.

Early and Differential Diagnosis.There were two main clinical groups : those in

whom local and constitutional signs appeared abruptly

after two or three days prodromal period, a phasewhich might indeed almost be non-existert, andthose in whom the prodromal stage lasted three orfour weeks with important localising signs whichall too often passed unnoticed. During the prodromalstage a tiny juxta-epiphyseal focus was smouldering.The signs were fixed pain at the end of a long boneI and metaphyseal tenderness, which might be accom-I panied by intermittent limp and general seediness.In these cases diagnosis should be increasingly possiblein the future, if the significance of the J ocalising signswere more widely appreciated. In the next phase thesigns became more insistent and bony swelling wasadded to them; the juxta-epiphyseal focus was justreaching the periosteal space. Unfortunately, thiswas often taken for some other acute infection,usually rheumatism. Yet there was a marked dis-tinction between the joint pain, tenderness andmuscular spasm of rheumatism, and the painful,thickened, tender metaphysis. It was importantto decide whether indeed there was such a thing asacute. monarticular rheumatism, and, if so, howcommon it was, in order that students might betaught to think first of acute osteomyelitis. Anearly exploratory puncture was a minor operationwhich did no harm if the diagnosis were not confirmed.and might save many lives and limbs. Specialdiagnostic difficulties and high mortality were

presented by osteomyelitis of the flat and hiddenbones. In the pelvis the ilium was usually affected,and there was early extra-osseous spread and largeintermuscular abscess, or the infection might spreadwidely in the diploe. Pain and tenderness mightbe absent or inconspicuous, and the condition shouldbe suspected in any acute toxaemia without localisingsigns. There might be referred pain down the thigh,pelvic tenderness, or a sense of resistance between thetrochanter and the iliac crest. Mr. Platt urgedexploratory puncture without delay in every suspiciouscase.

Treatment.,The principles governing treatment were : (1) early

and efficient drainage and early sterilisation of thewound ; (2) avoidance of further devascularisationof infected and uninfected bone, and infection mustnot be introduced into uninfected areas duringoperation ; (3) systemic infection must be combatedby all forms of general and specific treatment, suchas immune transfusion and intravenous antisepticmedication.

Operations could be regarded in terms of drainage.Subperiosteal and metaphyseal drainage in theearly stages gave excellent results. Subperiostealdrainage alone was usually insufficient, and couldonly be regarded as a minor procedure of urgencyin patients who were too ill for anything else. Thecavity should be lightly sponged out, but no curettageshould be done. Of Mr. Platt’s 41 cases, 22 hadbeen treated in this way and 14 had healed withoutsequestration. There was no justification for the" gutter " extension, which should be condemnedas futile and dangerous. The gutter ’operation, ordiaphyseal drainage, had its indications when themedullary canal and cancellous tissue were widelyaffected, as when the process had started in the centreof the shaft or in neglected cases of primary meta-physeal infection. Of the four cases so treated byMr. Platt one had died and two had had extensivenecrosis and chronic suppuration. On the subject ofsubperiosteal resection of the diaphysis Mr. Platt’smind was " open and to let." The procedure mustcompete satisfactorily with conservative operationsif it was to be accepted. In theory it was better thanthe gutter operation for neglected cases when theshaft was riddled with infection.

Primary Resection.Mr. ALEXANDER MITCHELL spoke of the importance

of blood culture on admission. Simple incision wasuniversally disastrous, except in the mild type ofpneumococcal osteomyelitis. In an early case of

septic osteomyelitis of a long bone he had found that

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removal of a piece of the cortex for drainage gavea good intermediate, and in most cases a good end-result. Resection in subperiosteal infection had notreceived the attention it deserved. Extensiveresection of the humerus, tibia, or femur was not,however, very satisfactory. His practice of resectingthe whole length of an infected shaft must be regardedas an alternative to amputation. In 90 per cent. ofcases, with careful after-treatment by extension andearly muscle exercise, a good result would be ensured.It was very important to get the tibialis anticus, orinterior muscles of the leg, to act early. Plaster ortight splints were almost sure to prevent regeneration,but if the limb were kept in a Thomas splint with acertain amount of extension, but not fixed in sucha way as to prevent voluntary movement, regenerationwas almost sure to follow. Two days after operationthe packing should be removed and a periostealsuture done, except for a gap at each end for drainage-tubes. The bone should then be treated with eusolor flavine. Another argument against resection wasthe high mortality, but in a series of 70 cases treatedduring the last five years primary resection had beenperformed 13 times with only one death, a patientwith active septicaemia. The total number of deathswas ten. The risk of removing a large sequestrum wasmuch greater than that of a primary resection. Sub-periosteal resection was not a routine treatment,but it had a place, and suitable cases could be recog-nised by the experienced surgeon. He had not seenany good follow blood transfusion in acute osteo- Imyelitis. He had never seen a case in private practice,although he would expect the hospital child to beless liable to bone infection. He strongly agreedwith the importance of impressing upon students thegravity of the disease and the need for early diagnosis,particularly of making a routine examination of theends of the long bones in children with an unexplainedrise of temperature.Mr. ERIC LLOYD described a series of 29 cases from

Ormond-street Hospital, all of which had been underhis personal care. The Staphylococcus aureus was thecause in a very high proportion (19 cases) and wasmuch more lethal than the streptococcus. Onlyone was due to the pneumococcus. Eleven had died.The lower limbs were involved far more often thanthe upper. None of the cases gave negative bloodculture, and there was a high incidence of cardiaccomplications : pericarditis, pyopericardium, andulcerative endocarditis. Treatment should be some-thing between the gutter" operation and the

periosteal incision, leaving only a portion of thecircumference to act as a splint. The pendulum had,perhaps, swung a little too far away from amputation.Blood transfusion and intravenous medication hadbeen tried, without striking results. Some of thestreptococcal cases seemed to make a remarkablerecovery however they were treated, while some ofthe staphylococcal ones made no effort in spite ofevery kind of help. Diaphyseal excision had notbeen generally practised recently.

Mr. W. H. OGILVIE showed the records of 51cases from Guy’s Hospital from 1922-26. Acuteosteomyelitis was one of the decreasing diseases.The preponderance of male cases was great, but variedin different localities. Sixty-eight per cent. of caseswere between the ages of 8 and 15. The upper endof the tibia showed the greatest incidence, followedby the lower end of femur, lower end of tibia, andupper end of humerus. The mortality was 21 percent., and 51 per cent. were discharged unhealed.Amputations accounted for 8 per cent., and 16 percent. were sent out healed. There had been threecases of disease of the ilium, of whom one had died ;the mortality from infection of the femur was low,because signs were earlier in that region. The seriesshowed favourable results from radical (" gutter ")operation. The mortality was not so much a questionof treatment as of the virulence of the disease, whichvaried enormously. The average time between theonset of symptoms and admission was 7-4 days.The difference between the adult and childish type

was shown strongly ; in the adult the infection wasapt to be latent, the symptoms less severe, and thecourse much more favourable and quieter. Theaverage time in hospital was three months. Ninety-two per cent. of the organisms were Staphylococcusaureus, admittedly the specific organism of osteo-myelitis in London ; the Edinburgh figures differedfrom those of other centres. Joints were very frequentlyaffected, but this was more a feature of pyaemia thanof osteomyelitis as such. In severe cases the heartand pericardium were often attacked. It was

impossible by clinical means to tell the amount ofpresent or future necrosis, what bone was healthy,and what would survive, and where resection shouldstop. Bone death was always liable to appear atthe edge of the operative interference. Operationshould take into consideration the future problemof repair as well as the immediate problem of infection.All bone which did not die was a potential source ofbone cells, and wide resection might be harmful.He condemned diaphysectomy. Infection in theearly stage was mild, and only dangerous becauseit was in an enclosed space and the blood-vesselswere sinusoids through which pus easily passedinto the circulation. Therefore the drainage opera-tion should lay open only the area infected. Theusual operation produced an extensive wound withpainful dressings and protracted healing, leavinga wide scar adherent to bone and always liable tobreak down. To avoid this Mr. Ogilvie operatedthrough a flap so that the skin scar did not overliethe bone scar ; he removed compact bone for thewhole extent of pus formation and at least one-thirdof the circumference. He left the medullary cavityalone, save for removing loose portions, and inserteda series of Carrel tubes without packing. The skinwas then closed with interrupted silkworm suturesabout an inch apart. This method had all theadvantages of the open and the closed operation.He did not believe in radical secondary operations,which only produced temporary relief. Operationwas only justified for abscess or sequestrum. Hepreferred to insert a silver wire down to the bone,keeping it in place with strapping. The patient couldremove this daily. There was very little discharge,and it stopped the tension in the deeper parts andabolished the intermittent bouts of fever. Transfusionwas no use in acute sepsis.

Mr. N. DUNN described a case of osteomyelitis ofthe spine, and Mr. ALAN PERRY described his experi-ence at the London Hospital, where 75 per cent. ofcases gave a positive blood culture. He regarded thecases as pysemic from the beginning rather than aslocalised foci. Diaphyseal excision had been a

failure in his hands, yielding no regeneration in most

I cases.ROYAL MEDICO-PSYCHOLOGICAL

ASSOCIATION.

A QUARTERLY meeting of this Association washeld at the City Mental Hospital, Fishponds, Bristol,on Feb. 16th, Dr. HAMILTON MARR, the President,being in the chair. A paper dealing with somepoints in the

Histology of the Globus Pallidus.was read by Dr. E. BARTON WHITE. He said that amongthe changes in the globus pallidus in various diseasesseveral authors referred to striking changes in thewalls of the blood-vessels of that body, manifestedas a deposit of an amorphous material in their outerwalls, often sufficient in amount to obliterate themuscular and elastic fibres. It looked like calcifica-tion. Half the hundred cases examined by WestonHurst at the National Hospital, Queen-square, showedthis change in the vessels, sharply limited to theanterior half of the globus pallidus. The ages of thepatients ranged from 20 to 81. Hurst found that thematerial was not calcium, but a large portion of it