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572 THE MEDICAL JOURNAL OF AUSTRALIA. JVIa y 9, 1931. Special Articles on Diagnosis. pling may he produced by quite other agencies in childhood.'' Conversely, the absence of stippling does not exclude !. plumbism. There is no characteristic alteration in the (Contributed by Request:) white cells. This may be a negative sign of slight value. (i) In regard to the Burtonian blue line, two essentials XLIV. are required: Sufficient circulating lead in the blood and a septic dental factor--no blue line is found in the absence CHRONIC LEAD POISONING. of dental sepsis. The line occurs as a row of minute blueblack dots just at the gum margin. It is best shown by inserting a stiff white card between tooth and gum, raising . Cit k o .v ic lead poisoning is the result ot the absorption the gum margin--Gihson's test. The blue line is not of small quantities of lead for a continued period, as opposed to acute lead poisoning, the result of taking a large quantity, for example, of the acetate, in one dose. necessarily confined to tbe incisor teeth, it may occur at the gum edge of any septic tooth. U) Lead in the urine. This can be detected only by an Many of the manifestations of chronic lead poisoning may : expert chemist in a first class chemical laboratory. At be so abrupt in their appearance that they are called acute, least one litre of urine is required and it must he col but the underlying pathological process is a long continued ` lected so as to be free from lead contamination, for . one. ' ' example, lead foil on- cork or bottle. A clear pickle bottle ! There are two forms of lead poisoning seen in Australia: or, better still, a winchester is washed first with tap water, (i) Of adults, an. industrial disease: (ii) of children, a then with distilled water and finally with 20% hydrochloric house disease. acid in distilled water. Decomposition may be prevented The latter is almost entirely, so tar as is known at., present, confined to north-eastern Australia, from the northern rivers of New South Wales up. The former is' seen in certain industrial centres, where such operations' as lead refining, enamelling and battery making are in ' progress. It is also seen to a less degree nowadays among painters, printers and plumbers. . . Certain features are common to both diseases. by adding formalin, 20 cubic centimetres to the litre. Lead present above 0-05 milligramme per litre is regarded as ` pathological. The presence of lead In the urine does no: necessarily prove that any lesion under consideration is due to lead poisoning, any more than a positive Wasser- mann reaction proves that an ulcer on the tongue is syphilitic and non-malignant. It does, however, indicate that lead, a tissue poison, is present in the body and is being -excreted by the kidneys. Some patients with Le a d Po is o n in g in Ch il d r e n . plumbism may show no lead in the urine and lead may . be found in the nrine of patients in whom no other The forms of lead poisoning found among children are manifestation can be found. held to be the simple paralytic, the cerebral and the minor '(k) Albuminuria, usually unaccompanied by casts, is forms. ' ' common in all degrees of lead poisoning, from the mildest Certain features are common to all these forms: abortive forms to the most severe paralysis. The amount (a) The patients are usually over two years and under eight years--the veranda age. ' - varies from a faint cloud with salicyl-sulphonic acid to a heavy deposit of 0-5% Esbach. Actual renal damage to the " .. (6) The sexes are equally affected. . extent of inefficiency is rare during the initial stages. (c) There is an available source of lead, for example, ' The Simple Paralytic Form. powdering paint on walls, fences or railings. In the simple paralytic form the following muscles are id) The means of transferring the lead to the mouth is affected. In the lower extremities the peronei and exten by nail biting, finger sucking or drop catching. sors of the foot may give rise to the common foot drop. (e) Usually there is a stage of preceding moderate ill In the upper extremities the extensors of the wrist, health, lack of appetite, listlessness and pallor. (/) Colic consists of a sudden spasm of pain, "doubling up" and coming on without warning, unaccompanied by especially the extensor digitcyrum communis and extensor indicis may be affected so that the wrist can be extended if the fist is closed (Gower's sign). Involvement of the trunk is rare, but paralysis of the diaphragm. has been diarrhoea, but sometimes by vomiting, and localized mainly' to the upper part of the abdomen. John Hunter described . it as "dry bellyache" and the description still holds. The observed. Sometimes combinations of all paralysis occur, for example, upper and lower been occasionally paralysed at the same time. forms o( limbs have pulse rate falls even to 40 to the minute. Firm abdominal.' pressure relieves, not increases, the pain. Colic must be distinguished from (i) acute intestinal obstruction of The features of the paralysis are as follows: Flaccidity . is present. The paralysis is slowly progressive. It is a neuritic paralysis, picking out nerves and not segments. organic origin, for example, volvulus; (ii) entero-spasm The reaction of degeneration is present when paralysis is giving rise to a transitory obstruction; (iii) acute appendi citis, distinguished by a rise in temperature and increase . complete. There is no sensory disturbance, apart from pain in affected muscles and on pressing nerve trunks. in pulse rate;' (iv) simple dietetic upsets; (v) biliary Usually complete recovery occurs, even after much wasting ' and renal colic which are rare in childhood. The fact of muscle, but deformity, for example, talipes equina- that in an attack of colic irregularities of the colon may varus, may persist requiring surgical treatment. Most be palpable often\adds to the difficulties of diagnosis. _.. 'striking of all, the paralysis is symmetrical. (Si) Wasting, Especially of the muscles -of the face, occurs, apart from actual paxhl-ysismnd "o[ the subcutaneous fat._Th.jnfraorbita<UaHdl>uccinator muscles are specially This paralysis must be distinguished from: ( ) Diseases of muscles--the myopathies. affected- \ ( ) Other forms of neuritis, such as alcoholic (very . (h) There are certain blood changes commonly seen in eases of plumbism, though they are not necessarily characteristic of this disease. A fall of erythrocytes to as low as 2,000,000 occurs and a greater proportional fall of htemoglobin, so that the colour index is as low as 0-6.. The red cells are altered. There may be poikilocytosis,. anisocytosis with a general diminution in size of the cells, rare in childhood); arsenical (also rare) in which sensory changes are prominent: syphilitic, rare and not usually symmetrical: and diphtheritic, though the dis tribution is rather different, and a history of sore throat or nasal discharge can always he elicited; acute infective polyneuritis, another rare disease, in which sensory changes are very obvious. loss of central haemoglobin so that the cell appears quoit- (e) Spinal conditions: (i) Acute anterior poliomyelitis like, alteration in staining, either a general tendency to is distinguished by its acute onset in a previously healthy take the blue of the Jenner-Romanowsky stains rather than the eosin, that is, a polychromasia, and the classical stippling. The last is claimed -to be characteristic of lead anaemia and by some the presence of more than 500 stippled cells per million is alleged to be pathognomonic of lead. Others are less dogmatic and hold that characteristic stip child, the more asymmetrical distribution and the seg mental rather than the neuritic manifestation, and finally 1 Dr. W. T. Nelson of the Commonwealth Scrum Laboratories informs me that he is engaged on work which still further tends to cast doubt upon the specificity of stippling as a sign of-plumbism. . N36945 DUP050314318 May 9,1931. THE MEDICAL JOURNAL OF AUSTRALIA. 573 by the fact that recovery does not tend to he complete. fluid, distinguish it in the earlier stages, while in the (ii) Progressive muscular atrophy, disseminated sclerosis later the obvious progress to a fatal issue provides an and column diseases of the cord, are rare at this age, and absolute, if late, distinction. Tuberculous meningitis is the distribution and nature of the paralysis are very ' rare in Queensland and is extremely uncommon in different. . children over two years of age. (d) Rheumatism, which has only a very superficial Epidemic Encephalitis.--Epidemic encephalitis may be resemblance. ' ushered in with slight or no rise in temperature, heaviness In most cases it is dangerously fallacious to use the . and, above all, squint or other cranial nerve signs. results of treatment for purposes of diagnosis. It leads Papillcedema is of the utmost rarity, and its presence is to arguing in a circle. Should, however, a patient with always enough to cast grave doubt on the diagnosis. doubtful paralysis make a complete recovery when given rest in a zero position and treatment by magnesium sul phate and potassium iodide, it is often claimed that thiB supports the diagnosis of plumbism. The Neuro-Retinitis of Diabetes and Arterial Hyper tension.--In diabetes the condition is a neuro-retinitis, not a papillcedema, and other signs of the disease, for example, high blood pressure, albuminuria or glycosuria The Encephalopathic Form. will be present. The mechanism of the encephalopathic form is at present in dispute. The essential feature is an increase in cerebral pressure owing to either an excessive production or a diminished elimination of cerebro-spinal fluid, which is normal in character in our experience, though Aub and Holt describe an increase of cells and globulin. Post mortem studies of the condition are lacking. The excessive secretion may he due to increased activity Cerebral Syphilis.--Choked disc may be the only sign in . basal cerebral syphilis. It may be combined headache and squint, and secondary optic atrophy may occur, as well as primary optic atrophy with no other frank manifestations of syphilis. The alteration in the cerebro-spinal fluid as regards Wassermann ' reaction, cell count and globulin content must be always investigated. Cerebral Tumour or Cerebral Abscess.--Differential diag of the chorioid plexus, the result either of direct stimulus by the circulating lead or indirectly through the products of nervous tissue degeneration. Little has been said as to deficient elimination in this matter, but the lead may well have a direct action on the nosis from cerebral tumour or cerebral abscess may be difficult in the absence of localizing signs. There may be a simple papillcedema, temporarily diminished by lumbar puncture, a puncture which produces only normal cerebro spinal fluid under varying degrees of pressure. absorbing areas of the meninges. In any case the Sometimes only the course of the disease may be suf increased pressure is manifested by: Severe headache: ficient to establish the diagnosis, but occasioualiy cerebral squint, due to paralysis of the external rectus muscle of._ . tumours-' temporarily cease to progress, or even retrogress, one side; papillcedema; secondary optic atrophy and blind giving all the appearance of a cure. ness; convulsions of all_degrees-of--severity. These may be indistinguishable "ffomTsImple convulsions due to dietetic or other causes, for example, onset of any acute illness. They may be distinguished only by looking for possible sources of lead absorption; history of pallor, loss of appetite and headaches; blue line and blood changes; squint, papilkedema and greatly increased cerebro-spinal In all cases of doubt the presence of some or all of the common features of lead poisoning may determine the diagnosis. These may, however, be absent, as it is held ' that the encephalic form of lead poisoning is a manifesta tion of rapid intake of relatively large quantities. Radi ography of the skull and even ventriculography may be necessary to distinguish these conditions. pressure on lumbar puncture. Of these the possible sources of lead absorption and a history of pallor et cetera Minor Forms. alone may call the parents' attention to the condition. Breinl and Young, in Animals of Tropical Medicine and Rarely is there sufficient disturbance of vision to attract Pathology, described minor forms of lead poisoning as attention, unless the condition has been a long time in follows: . existence, by which time the damage may he great and The'cases may be classed according to the severity irreparable. of the symptoms. The very early cases have no definite The headache is usually severe and frontal and continu ous. It may be sufficient to change a bright child into a very dull one, who will sit holding his head and dreading to be disturbed. The relief of the headache by lumbar puncture is very striking. Squint may be transitory, but is usually constant. Chil dren seldom complain of diplopia--the image of the squint ing, eye is neglected and nothing is said. The paralysis is practically always of the external rectus; it may be bilateral, but is more commonly unilateral and disappears ' symptom. Parents complain of a change in the .' character of the children within the last few years; whilst previously they have been normal and well : behaved, lately they have become peevish and fretful, " were very restless at night, and had lost their appetite , completely. As a rule, only careful cross-questioning elicited the information that the child had been com- ' ' plaining of slight painB in the epigastrium and pains in the legs. The breath was often foul and now and again ulcera rapidly after lumbar puncture. tion was noticed in the mouth. According to the Papillcedema is a simple papillcedema, quite distinct from the hypertensive retinitis seen in advanced arterio-sclerosis. The swelling may he great, with comparatively little inter-.. . fsrence with vision, up to 10. diopters. Similarly, if the pressure is relieved by ' lumbar puncture, the swelling parents' statements the children were flushed in their faces and appeared feverish. All the symptoms referred to are very definite and may be considered as the commencement of any infectious disease. Even in these early cases lead can be found iu the rapidly subsides until the pressure, has been brought down urine, often in appreciable quantities, and without the to normal and remains there. A papillcedema of 10 diopters has been known to recover completely with such treatment chemical analysis the correct diagnosis would he very difficult. alone. Should there follow failure to treat the papillcedema (a neglected swelling of much less will cause atrophy and In cases of slightly longer duration the pains in the abdomen, intermittent at first, have become more con tinuous. Constipation is the rule, but in rare cases a blindness) the discs assume the typical chalk white colour, history of intermittent diarrhcea is given. Vomiting is the vessels shrink and the retina grows pale. The outlook only very rarely observed. The pains in the calf of is now hopeless. Such cases of blindness have occurred the leg become more marked, the calf muscles are in a child treated three times for papillcedema; the fourth often so painful that the little patients cannot endure .attack was left too long. even the weight of the bedclothes, and at this stage Differential Diagnosis. , the gait of the'child becomes affected. The Burtonian line was observed only in a small percentage of the Tuberculous Meningitis.--In tuberculous meningitis the children. ' child is usually feverish and too ill to get about. The A continuous line is not often found in children, but child with lead papillcedema, on the other hand, is often the characteristic minute black spots occur round alert and lively and afebrile. Kernig's sign, head retrac teeth which are coated with a deposit of tartar, tion and, above all, the reactions of the cerebro-spinal requiring the use of a hand lens for their diagnosis. DUP050314319 574 THE MEDICAL JOURNAL OF AUSTRALIA. Ma y 9, 1931. The symptoms in these children are mainly' those of 3. The presence of stippled .cells with other blood general ill health; there is nothing definite, hut the mother, changes, such as changes in the shape or size of the red complains that the child is listless, has no appetite, "will cells, polychromasia, reduction of haemoglobin to S0% or not play, cries without provocation and is losing weight.. less, and reduction of red cells below four and a half He may sleep hadly, enuresis is not uncommon and slight, million, with or without symptoms of lead poisoning. . abdominal pain, not amounting to actual colic, . is often The symptoms of mild lead poisoning are taken as present. Headache is a very variable symptom. abdominal pain, constipation, headache, debility and tremor. On examination there is at first little to be found. The child is peaky, pale and often flabby. He usually cries Severe Lead Poisoning in the Adult. at any manipulation, but no source of pain or frank tenderness may be found in the limbs or abdomen. Some-' Colic- is very constant and has to he distinguished from: (i) Colic due to acute abdominal catastrophes, tor times there is evidence of mouth breathing, there may he . example, perforated viscus, acute intestinal obstruction, a faint blue line on the gums of septic teeth and there may be a slight suspicion of wrist drop or foot drop. The patients with headache rarely have papilltedema. The acute pancreatitis, (ii) Biliary or renal colic, (iii) Root pains of spinal disease, (iv) Tabetic crises. The "Jerks and gums" are as important in abdominal symptoms are very similar to those described by Mathew diagnosis today as in the past. The pulse is slow in lead in mild cases of industrial plumbism. Evidences of possible lead absorption are always present and should be sought for diligently, even if the child's" own home affords no supply; there may be a neighbour's, a fence on the way to school or, in one case, a bridge rail. Nail biting, finger sucking and drop catching (in wet weather) are the commonest methods of collection. The conditions which may be mistaken for minor plumbism are: Minor degrees of chronic sepsis--of teeth, colic and the other signs of lead poisoning are present. The general characteristics of paralysis are as in chil dren. The most common form is wrist-drop, owing to the frequency with which the extensor in&icis and extensor communis Higitorum are affected. The interossei are also often paralysed at this stage. Next in order of frequency come the shoulder muscles, especially the deltoid, then those of the leg, especially the peronei. Least of all arc the muscles of the trunk, larynx and diaphragm. . sinus or tonsils; congenital syphilis; Intestinal worms; Acute anterior poliomyelitis is uncommon in adults chronic intestinal indigestion (John Thomson); thyreoid and does not present the same difficulty in differentiation deficiency in mild degrees; coeliac disease; pink disease; as it does in children. The chief resemblance is to the acute leuchaemia. I have seen all these conditions ascribed _otlier--tox-is--neuritides, -alcoholic neuritis being the most to lead, some by myself, some by others.--------------------------- common. Though much the same groups of muscles are Diagnosis is. not made easier by the fact that congenital involved, the sensory changes are very prominent and the syphilis, thyreoid deficiency and possibly some throat . other almost constant signs of plumbism are lacking. affections are greatly benefited by potassium iodide, .while many patients with chronic indigestion are relieved of much sluggish bowel content by a short course of mag-, nesium sulphate. The only possible method of avoiding " mistakes is to keep all these possibilities,- as-weltaS' absorption,'In mind when exaining-the:shild with chronic ill health and to_use--every method of diagnosis before deciding on a'line of treatment. . Similarly, these signs will serve to differentiate it from such diseases of the nervous system as progressive mus cular atrophy, tabes, disseminated sclerosis and the --myopathies. Lead encephalopathy rarely takes the form seen in childhood; its usual manifestations are headache, delirium, mania, psychic depression, coma or convulsions. These, especially if associated with lesions of the cranial nerves, may simulate cerebral tumour, cerebro-spinal Le a d Po is o n in g in Ad u l t s . . Lead poisoning in adults is in many respects very similar to that, of children. There are certain differences: (i) Age, in that young workers are more affected than the more elderly, (ii) Sex. Abortion is very common among pregnant women, while amenorrhoea, dysmenorrhcea and syphilis, cerebral htemorrhage, epilepsy, chronic alcoholism, uraemia, eclampsia and hysterical or neurasthenic conditions. ' The correct diagnosis is made only by finding on the one hand other signs and/or symptoms of plumbism or, on the other, features opposed to it, for example, changes- in the spinal fluid. But it must also be constantly menorrhagia also oceur. (iii) Source of lead varies with the industry--in lead refineries from the dust, in battery' making from the fumes. . It is notable that whereas in the older trades lead poisoning has diminished through altered methods, for remembered that some of these conditions, for example, syphilis or alcoholism, may coexist with lead poisoning and a cerebral haemorrhage is a perfectly possible end result of lead arterio-sclerosis. : , Even without any of the foregoing frank manifestations, example, the linotype in printing and the cellulose spray in carriage painting, new industries have arisen in which the risks are as great, if not greater, for example, rubber there is in. almost every sufferer from plumbism, child or adult, a degree of dulness, sluggishness and inability to concentrate, often combined with restlessness and manufacture and accumulator making. In adults the irritability. greatest part, by far, of the poisoning takes place from inhaled lead as opposed to the apparently ingested lead of the child.- Late Manifestations of Plumbism. The relationship of nephritis and arterio-sclerosis to Mild Forms of Adult Plumbism. lead poisoning is still a matter of dispute, both in children and adults. . ' ' . The initial period of ill health, pallor, lassitude, wasting As regards adults, lead poisoning is one of .the few and lack of appetite are common to both adult and child. etiological factors admitted by Eishberg in his discussion ' The blood changes are the same in each. The blue line on the -causes of essential hypertension, while Badham in the adult is often as seen ip the child, a narrow blue suma up the matter as follows: line, but where severe pyorrhoea is present there may be: ' a broad blue band, five or six millimetres wide, extending -. back from the gum margin. Urinary changes occur similar - ' to those in children. . ; On the foregoing is based Badham's standard of diagnosis " -of mild forms, namely: ' Our limited knowledge of the sequelae of lead poison ing is no greater than when Legge and Goadhy wrote: "Unless it were 'established that granular kidney nephritis were present in a worker before conimence- - ment of lead employment, we think it would he useless to endeavour to prove that the condition was iudepen- .' A definite sign of a lead intake determined by the presence of a blue line or- lead in the urine in an amount exceeding 0-05 milligramme per litre, together with one or other of the following signs of intoxication: . 1. The presence of stippled red cells to the number of over 600 per million red cells, with no other blood ehaagsa and with or without aymptoms af lead poisoning. dent of - lead, despite its comparative frequency as a cause of death apart from employment." . With the present limited knowledge of the manner ot onset of arterio-sclerosis and nephritis .among-lead workers, it is impossible to determine the cause and origin, ot such degenerative oliungos in a lead worker. It is comforting to the physician to know that there 2, The presence of stippled cells in number less than 500 per million red ceils, with symptoms of lead poisoning. is a history of past colic or palsy iu any individual adjudged to he affected by arterio-sclerosis and/'r ----------------- -------------- --------- DUP050314320 May 9,19a!. THE MEDICAL JOURNAL OP AUSTRALIA 575 nephritis caused "by his work, hut it is probably fal ' Professor Whitridge Williams, perhaps the most .famous lacious to thins that such an easy means of selection of the American obstetricians, said that in a small propor . picks out those ' by_.their trade from jthose,,v(Jlose_ tion- of eases manual rotation could not he effected and it inherited vascular make-up leads to early,-degenerative ' "then became necessary to apply forceps with the occiput . change. . --.---- still posterior. Downward traction was then made till BlBLIOGKArHY. the head impinged on the pelvic floor; the occiput was then slowly rotated to a transverse and then to an oblique The following authorities have been consulted: ; anterior diameter. The forceps were now taken off, Legge and Goadby: "Lead Poisoning and Lead Absorp reapplied and delivery effected. tion," 1912. , Dr. Nyulasy remarked that Professor Windeyer had Aub, Fairhall, Minot and ReznikofE: "Lead Poisoning," ignored the question of forceps rotation and he quoted Medicine Monographs, Volume VII, 1926. with significant approval a recent paper by Dr. Douglas . Breinl and Young: "The Occurrence of Lead Poisoning Miller, Physician to the Edinburgh Royal Maternity amongst North Queensland Children," Annals of Tropical Hospital. Medicine and Parasitology, Volume VIII. In the, course of his very able paper Dr. Miller said that C. Badham: "Studies in Industrial Hygiene," Number 7, "forceps rotation for occipito posterior cases demanded a "Lead Poisoning," being part of the "Report of the Director high degree of manipulative skill and should be attempted of Public Health, New South Wales," 1925. , only by the expert." On the other hand, Robert Watson, "The Excretion of Lead and Blood Changes in Workers of Belfast, after about thirty years' experience, in a letter Exposed to Lead," "Report of the Division of Industrial to The British Medical Journal in June, 1930, wrote: "The Hygiene, Commonwealth Department of Health," Th e mazueuvre is simplicity itself. There is no feat in obstetrics Me d ic al Jo o t n a l o f Au s t r a l ia , February 16, 1827. so essential in general practice, easier to perform or more M. Fishberg: "Nephritis and Hypertension," 1930. effective. Deep chloroform anesthesia is desirable through J. Lockhart Gibson, A. Jefferis Turn.er and other members out. You diagnose the position of the head, lay your of the staff of the Hospital for Sick Children, Brisbane: blades on as squarely to its sides as possible, lock the `Proceedings of the Australasian Medical Congress," 1892. instrument and keep it locked, then (in a pause between J, Lockhart Gibson: "Ocular Plumbism," 1922. , pains, and gently) push the foetus back towards the uterus L. Emmet Holt: "Diseases of Infancy and Childhood." till its head feels free. Now, still gentle, you .give the . , S. F, Mc Do n a l d , M.D., M.R.C.P., Honorary Physician, Hospital for Sick Children, Brisbane. forceps a half turn (like a key in a lock) and proceed to deliver.. The original'instrnction--to bring the head down until it is fixed and then withdraw the reversed forceps and apply them again--is unnecessary. More, it may do harm. '.Heads can revert too easily. Thus in all but exceptional cases it is safer and easier not to unlock the IBiitlsf) spealcai association liSetos. forceps. The facility with which delivery can be effected with them in this maimer is a shock to one's notions about the parts and the art, but a salutary shock, for modern SCIENTIFIC. obstetrics tends to become paralysed with exuberant theory." A me e t in g o p t h e Vic t o r ia n Br a n c h o p t h e Br it is h Me d ic a l As s o c ia t io n was held at the Medical Society Hall, East Melbourne, on November 12, 1930, Dr . R. G. Mc Ph e e , the President, in the chair. In supporting Dr. Watson's method. Dr. D.' C. Williams, in the same journal, wrote: "I always use Kielland's. forceps, and with this instrument rotation of the occipitoposterior position is so easy that the presentation offers no more difficulty than the ordinary anterior presentation. Obstetric Abnormalities. It is hard to understand why Kielland's forceps has not taken the place of the axis traction forceps in this Pr o f es s o r J. C. Win d ey e r read a paper entitled: "The country ..." Diagnosis and Treatment of Some Common Obstetric In his own practice, Dr. Nyulasy continued, he generally Abnormalities" (see page 551). preferred manual rotation when interference was necessary, Dr . Fr a n k Ny u l a s y expressed high appreciation of Professor Windeyer's extremely Interesting and instructive but in exceptional cases he had used forceps rotation with distinct advantage. address, with its fine illustrations, and then said he would Dr . B. Mil n e Su t h er l a n d expressed his appreciation of .confine his remarks to but one of the many topics dealt Professor Windeyer's address. The professor had presented with, . namely, the occipito-posterior presentation. To his subject in broad outline, omitting minute details, and begin with, he would remind members of the extraordinary it was evident that he had cultivated a sense of touch differences of opinion and practice to be met with among which was beyond the capacity of most practitioners. leading authorities on this familiar subject. Referring to occipito-posterior positions, the presence of For instance. Professor Hastings Tweedie, a past master excessive liq_uor am-nii or abdominal fat mig_ ht make the of the RotundaTTirthe--third edition of his. text_boOk_slated------diagnosis of position exceedingly difficult. Failure to rotate that with the os fully dilated and the membranes"ruptured was usually due to rotation through less than half a semi he made no attempt in delayed cases to turn the occiput circle, the head tending to rotate back into the hollow forward either by the hand or the forceps, but "attended of the sacrum. It was necessary to rotate through three-. to the. common cause of failure of flexion, namely, uterine quarters of a semicircle at least. Walcher's position was inertia." This was treated with a mixture of chloral and of great assistance only in getting the head through the opium, or morphine given hypodermically. When the brim into the pelvic canal; it tended to contract the patient awoke, vigorous pains came on and the head outlet, and the position should he changed to the lateral frequently rotated to the front and was delivered spon or the lithotomy as soon as the head was in the. canal. Not taneously. Tweedie said: "If the head does not rotate, infrequently the head was found in the transverse position, it does not matter much; put on forceps and pull it out and he considered that there was a definite danger in slowly and carefully." rotation by forceps. The process must be a careful Dr. FitzGlhbon,- another ex-master of the Rotunda, operation with no degree of force. expressed similar views. Thus he said: "If at the beginning Dr . Fe l ix Me y er expressed appreciation ,o the paper, of labour the head is still above the pelvic brim, efforts both in its material and manner expressing the author's may be made to change it into the nearest occipito-anterior wide experience and authority. Books were occasionally position. This is most difficult and not necessary." During written by men who had the courage of . the opinions of the second stage, if the occiput had rotated into the hollow others, and so contained shibboleths which had been handed of the sacrum, pressing on the fundus and encouraging down from writer to writer. It could be learnt from the patient to bear down would push the head forward and complete delivery in quite a number of cases. If it Professor Windeyer's teaching of the' management of occipito-posterior positions that trauma should be reduced failed after a reasonable trial, delivery was completed to a minimum. He considered that Professor Windeyer's treatment of this problem was most lucid and convincing. DUP050314321