1406

paralysis of the left side of the face ; (4) hemi-anaesthesia of left side (back and front) extendingfrom head to foot. On the following day he had leftoculomotor paralysis. Rapid improvement followed,and in 3i- weeks he could walk fairly well and usehis hands. He was thought to have had a smallhaemorrhage in the right crus cerebri. Last February,while doing clerical work, he had severe headache atthe vertex, with vomiting, but there were no physicalsigns, and both pulse and temperature were normal.On the following day, however, the headache wasworse and he had head retraction. Mr. Haymanthought the patient had a leaking congenitalaneurysm at the base of the brain, and that the- first symptoms were due to rupture of it, and thesubsequent ones to leakage. The Wa,ssermann was

- negative.-Dr. A. A. MoNCRlBFF asked whether ligatureof the right carotid artery might be of benefit; thismight conceivably save the patient further heemor-rhages, with a possible fatal termination.-Dr.WILKIE ScoTT spoke of a patient, a boy, who hadthree recurrences of bleeding, the third being fatal.Blood was mixed with the cerebro-spinal fluid, andall his attacks came on after exertion. In anotherpatient on two occasions attacks came on after ridinga bicycle. A month ago Dr. Scott had made a post-mortem examination on a man, aged 25, who appearedquite healthy, was a teetotaller and non-smoker. Hewas suddenly seized with severe pain in the head andbecame unconscious. A month later he had a similarattack and died in it. A cerebral aneurysm half thesize of a hazel-nut was found. Usually these wereregarded as cases of meningitis.

Mr. G. MAXTED showed a girl 10 years of age whohad

_

Unilateral Exophthalmos.On the admission of the girl to hospital in July,1927, because of carditis, proptosis of the right eyewas noted. Since December of that year she hadbeen in hospital with pericarditis and effusion, andgeneral oecl.ema. There was no accompanyingdiplopia; the pupil reacted normally and the discappeared to be healthy. Vision in the right eyewas 6/12, but there was a hypermetropia of 3D. Thefellow eye was emmetropic. Globe movements werenot hampered. There was no nasal abnormality.The heart was enlarged, and there was a loud systolicbruit at the apex, with systolic and diastolic bruitsin the aortic area. Mr. Maxted thought she mighthave a non-malignant tumour of the optic sheath,since the condition was not becoming worse.-Dr.F. J. PoYNTON suggested that she might be a rheu-matic child with a tendency to haemorrhages, whichwhen they occurred were gradually absorbed.

Mr. MAXTED also demonstrated a girl aged 6 years,with

Bilateral Congenital Dislocation of Lens.She was brought to the hospital for advice sixmonths ago because she held objects very close toher eyes. Each lens was seen to be partially dis-located and to be the seat of well-marked lamellarcataract. Five months ago the right eye was needledtwice. Most of that lens was now absorbed, leaving aclear area in the outer half of the pupil. She wasnow wearing a correcting lens for this eye.

Mr. M. W. BuLMAN showed a boy, aged 8, withCongenital Scoliosis.

His back had been deformed ever since birth, and hepresented a marked lateral curvature in the dorso-lumbar region which was not amenable to correctiveefforts. On the right side there was only half atwelfth dorsal vertebra, and there was a twelfth ribon the left side. He asked whether the case called foran appliance to prevent the condition from becomingworse.-The PRESIDENT said these cases were notpromising, and he had usually been content to puton a jacket of some kind, particularly for smallchildren who were growing fast.

Dr. B. MORGAN showed a boy, aged 11, who had

Symptoms Associated with Cervical Rib.He had had weakness in both hands for three years ;the hands, with the lower third of the forearms, wereblue and cold, and both, but especially the left, wereclaw hands. It was impossible to abduct the fingersof the left hand. There were no sensory, tactile, pain,or thermic disturbances. X rays showed a rudi-mentary cervical rib on the right side, and an enlargedtransverse process of the seventh cervical vertebraon the left. There was also subluxation of the leftsternoclavicular joint. Dr. Morgan said that it wasvery rare for symptoms to be attributable to cervicalrib, and that in this case they were much morelikely to be due to a fibrous band which ran to thefirst thoracic rib. He thought that surgery shouldbe tried.-The PRESIDENT also commented on therarity of symptoms due to cervical rib.-Mr. ERICLLOYD referred to a case at Great Ormond-streetChildren’s Hospital in which a child’s symptoms hadbeen attributed to cervical rib, but the diagnosisarrived at in hospital was syringomyelia.

In the absence of Dr. V. H. BLAKES his case of

Hirschsprung’s Disease Treated with a Rectal Tubewas shown by Dr. MORGAN. The patient was a girl,aged 6, who when eight days old had had extremeconstipation and had brought up a motion in thevomit. Castor oil relieved her, but she was alwaysconstipated, and the motion passed after a four orfive days’ interval was very offensive. The abdomenwas much ballooned and the child was greatlyemaciated. The rectal sphincter was very tight.The treatment adopted was to tie a small flangedempyema tube into the anus at night by tapesattached to a belt. After two nights of this theabdomen became flaccid, and its circumference was6 inches less. Eserine and pituitrin were given forfive months, followed by an enema and lavage in themorning. The patient was now strong and well andthe bowels were functioning normally.

EDINBURGH OBSTETRICAL SOCIETY.

A MEETING of this Society was held on May 14th,with the President, Dr. H. S. DAVIDSON, in the chair.A paper on

The Value of the Dick Test in Pregnancywas communicated by Dr. D. BAIRD and Dr. R.CRUICKSHANK (Glasgow). Last year, they stated, aninvestigation was conducted at the Glasgow RoyalMaternity and Women’s Hospital into the value ofthe Dick test-i.e., the cutaneous reaction to theintradermal injection of scarlatinal streptococcaltoxin-as an index of susceptibility to puerperalsepsis. Because of the generally accepted view thatthe toxins produced by the scarlatinal and puerperalhaemolytic streptococci are identical, it was thoughtpossible that sensitiveness to the one might indicatea similar degree of susceptibility to the other, and, ifthis were so, that the test might be of value in theprophylaxis of puerperal sepsis.The Dick test was performed in a series of 600 pregnant

women, either during labour or in the last few weeks ofpregnancy. Careful histories were taken on cards speciallydesigned for the purpose, particular note being made ofprevious streptococcal infection—e.g., scarlet fever, tonsillitis,puerperal sepsis-of the obstetric history, and of the healthduring the current pregnancy. Full particulars were

subsequently obtained regarding the mode of delivery,the presence of lacerations, and the puerperium in 500 ofthese cases ; where the puerperium was morbid, even

although not notifiable according to the British MedicalA.ssociation standard, it was classed as puerperal sepsis,care being taken to eliminate those cases of pyrexia due toother causes, such as urinary infection. A number of caseswith a positive Dick test who developed pyrexia in thepuerperium were retested immediately after the pyrexial

1407

period to see if any change in the reaction had occurred.’Some of these were again tested six months later.

It was found that 22 per cent. of pregnant womengave a positive reaction to the Dick test, primiparaegiving a slightly higher rate than multiparae, 25 percent. as compared with 21-5 per cent. The reactionseemed to be more intense in primiparae, irrespectiveof age, than in multiparse. In the latter there wasa decrease in the intensity of the reaction in the olderage-groups which might indicate that with eachpregnancy the patient had a chance, by repeatedslight infection, of becoming more immune. Theincidence of puerperal morbidity also became lesswith advancing years in multiparse, but remainedconstant for all ages in primiparae.

The incidence of puerperal sepsis was so dependenton the general health of the patient and upon the typeof delivery that any reliance on the Dick test as anindication of liability to sepsis would not be justifiable.It appeared, however, that in the present state ofobstetric practice an attempt to produce a temporaryimmunity with a concentrated anti-scarlet serum inall suspect cases at the time of delivery might reducethe incidence of puerperal sepsis.

Drs. BAiBD and CRUcCsHANK also communicateda paper entitled

A Study of the Vaginal Flora in Pregnancy.The physiological changes in the flora of the vaginawere first reviewed, special attention being drawnto the apparently dramatic change at puberty from,a sparse coccal flora and an alkaline reaction to aflora consisting entirely of Doderlein’s vaginal bacillusassociated with a highly acid reaction of the vaginalsecretion. This change had been attributed byMiura, a Japanese worker, to the deposition ofglycogen in the superficial vaginal epithelium whenovulation began, and the bacterial fermentation of theglycogen as glucose for the production of lactic acidin such concentration as to destroy all organisms saveDoderlein’s bacillus. Miura had also stated that inpregnant women there was an increased acidity of thevaginal secretion as pregnancy advanced.The present investigation dealt with the vaginal

flora of 200 pregnant women, a large proportion ofwhom attended at monthly intervals from the thirdmonth of pregnancy until term. Swabs were takenfrom the vaginal vault and smears and cultures made.The pH of the vaginal secretion which was collectedat the same time with a long-handled spoon wasestimated by the " capillator " method.A classification into three grades of vaginal flora was

made : Grade A, composed entirely of Doderlein’s bacillus,the pH of the secretion varying only from 4-0-4-4 ; Grade B,containing a mixture of Doderlein’s bacillus and diphtheroids,pH, z6-2 ; and Grade C, consisting of an abundantheterogeneous flora of diphtheroids, enterococci, staphylo-- cocci, and occasionally vibrios and coliform bacilli, pH,4-8-6-8 with a more common range of 5-2-56. Largeepithelial cells were particularly numerous in Grade A flora.

Of 200 pregnant women when first seen, 56 per cent. hadGrade Aflora, 10 per cent. Grade B-, and 34 per cent. Grade C.Of the women who were followed throughout pregnancythere was found a remarkable constancy in the vaginalflora and in the pH of the vaginal secretion in those caseswith Grade A flora. The women with Grade B or C florawere divided into those with pus cells in the vaginal smear-an indication of infection of the cervix of vagina-and agroup with " idiopathic " Grade 0 flora, that is, an abundantmixed bacterial flora without pus cells. The flora in theformer group remained Grade B or C throughout, but in thelatter group the flora changed from Grade C to A in two-thirds of 21 cases followed to term, the improvementoccurring usually about the sixth or seventh month ofpregnancy.

The thesis was formed that there was some relationbetween the vaginal flora and ovarian activity, aGrade A flora being a reflex of actively functionalovaries whereas hypo-ovarianism was reflected in aGrade C flora. It was held that the association of anidiopathic Grade C flora with greater age and witha tendency to repeated abortion and the change-

over from a Grade C to A flora during pregnancy werefindings which supported this view. No evidencehas been found to indicate that a Grade C floraincreased the susceptibility to puerperal sepsis, butthe number of women examined was too small toallow of definite conclusions.

ASSOCIATION OF CLINICAL PATHOLOGISTS.

THE fourth summer meeting was held at theCheltenham General and Eye Hospital on June 14th.Dr. J. B. Davey, pathologist to the hospital, occupiedthe chair.-Dr. T. C. Hunt described a combinationof a water excretion and urea-concentration test forrenal function.-Dr. S. C. Dyke gave a brief preliminaryreport upon the phosphate concentration test ofBrain and Kay for estimation of renal function ; hehad found the test somewhat unwieldy for ordinaryclinical use.-Dr. A. F. S. Sladden discussed theimportance of the urinary acid-ammonia ratio as anindex of renal health ; he pointed out that this ratiois extremely constant, and that any departure fromthe normal in the absence of alkali therapy is anindication of disturbed renal function.-Dr. Dykeopened a discussion on the urea-concentration test inthe course of which he asked at what stage of thetest a specimen of blood for estimation of urea shouldbe taken; opinion differed widely on this point.The speaker stated that inasmuch as he regarded thetest as one of the concentrating power of the kidneys,it has been his custom always to take the blood atthe third hour.-Dr. Davey reviewed the results ofthe urea-concentration test as an indication forcomplete prostatectomy. In the course of theafternoon session, demonstrations were given as

follows : Dr. A. Renshaw, a self-filling burette forroutine analytical work; a new type of chamber forcounting the cells of the blood and other technicaldevices ; Dr. Dyke, mice showing results of Zondek-Aschheim test for pregnancy; Dr. A. L. Taylor,recent additions to the pathological museum of theBristol General Hospital; Dr. E. N. Davey, patho-logical specimens from the Gloucester GeneralHospital, and an unusual type of typhoid bacillusisolated from a suppurating mesenteric cyst. Dr.J. R. Collins, senior physician to the CheltenhamHospital, addressed the members on the " Sins of thePathologist " ; in the course of the evening a partyof members was shown -round the baths by Mr.T. Holmes, senior surgeon to the hospital.

ORTHOPEDIC HosPiTALs.-The fifth annual reportof the Royal Cripples’ Hospital, Birmingham, states thatthe work of coordination has gone steadily forward sincethe institution was formed by the amalgamation of theBirmingham Cripples’ Union and the Royal Orthopaedicand Spinal Hospital in 1925. The Newhall-street Hospitalhas been closed and the patients transferred to Woodlands,where three new wards have been provided, together withan operating block and a nurses’ home. Woodlands willnow accommodate 50 adults -and 130 children, and the costof the improvements has been z47,000. The arrangementswith the Birmingham health and education committees areworking so smoothly that it is now practically impossiblefor any Birmingham child under 14 requiring orthopaedictreatment to be overlooked. It is hoped in the near futureto open further extern clinics. During the past year atraining centre and hostel for masseuses, which has roomfor 20 resident students, was opened.-Last year the Shrop-shire Orthopaedic Hospital and Agnes Hunt Surgical Home,at Oswestry, treated 610 adults and 563 children in-patients ;over 40,000 massage and gymnastic treatments were given,and 523 operations performed. The after-care schemegrows more important every year, and a closer liaison hasbeen created between the hospital and various local authori-ties and voluntary orthopsedic associations. In return fora payment of 21 per quarter per patient attending at anyof the treatment centres the hospital undertakes to provideorthopaedic, surgical, and nursing attendance, to supply splintsand appliances, and to alter boots surgically. With an incomeof jE48,541, there was a credit balance on the year of 230.