PART III.

MEDICAL MISCELLAN u

Reports, Transactions, aud Scientific ]ntellige~lee

ROYAL ACADEMY OF M E D I C I N E IN I R E L A N D

Presldent--SIR CHARLES BALL, M.D., F.R.C.S.1.

General Secre ta ry- - J . A. SCOTT, M.D., F.R.C.S.I.

SECTION OF OBSTETRICS.

President~--H. JELLETT, M.D., F.:R.C.P.I. Sectional Seeretary--G. FITzGIBBON, M.D., F.R.C.P.I .

Friday, January 6, 1910.

THE PRESIDENT in the Chair.

A Series o] Cases illustrating the Operation of Pubiotomy (with skiagrams).

Da. E. HASTINGS TWEEDY exhibited six of nine patients on whom he had performed pubiotomy. The President exhibited one. The three patients not shown lived in the country and could not be brought up to the meeting. They in no way differed from those shown. The most recent operation had been performed eight weeks previously, and four years had elapsed since the first was performed. All the patients walked withou~ discomfort or limping, and had. made uneventful recoveries.

THE PRESIDENT said that the ease of pubiotomy which he showed was done shortly after his election to the Rotunda. He had not performed the operation before or seen it per- formed, and, therefore, as he found it easy and the result appeared to be excellent, he considered that other people

Section oj Obstetrics. ~75

ought not to find any difficulty. Dr. Hayes ' s skiagram showed the condition of the bones very clearly.

DR. MAURIC~. HAYES said he thought there was a great deal in favour of showing the negative instead of the reproduction of it, as in the latter a lot of the detail is lost. The first patient was Mrs. C. The line of incision through the body of the left pubic bone could be traced in the skiagram. There was bony union. The next negative was of a patient named Mrs. K., who was a patient of Dr. Jellett. The line of incision in this case was very well marked. I t ran obliquely downwards and inwards towards the symphysis. There was no union in this case so far, but she was able to walk about already. The next case was Mrs. N. In this the negative showed a separation of the fragments by about three- quarters of an inch in the left pubic bone, through which the incision was made. This patient has, of course, fibrous union. I t was a question whether there was any absorption of the separated fragments, but certainly there was a great deal of separation between them. The next case, Mrs. G., had a symphysiotomy. The pubic articulation was indistinct, apparently from callous formation. The separation between the adjacent portions of the os pubis was more marked below than at the upper margin. The next ease, Mrs. D., had a pubiotomy and symphysiotomy. The pubic articula- tion was indistinct, apparently from callous formation. The incision through the left pubic bone could be seen to run ver- tically downwards. I t could also be seen that the separated portion was in three fragments. Whether this was a frac- ture it was impossible to say, but it did seem something like a comminuted fracture. The articulation at the sym- physis was indistinct in this case also. The next case was Mrs. O'T. The line of incision ran downwards and in- wards. The upper and inner fragment of the left os pubis has been cut off, resulting in fibrous union. This case was almost a symphysiotomy. The next case was Mrs. L. The line of incision cannot be traced in this negative. There was no doubt of bony union here. The next case was Mrs. S. In this the incision went through the inferior ramus of the left pubic bone, and there was also bony union.

PROFESSOR ALFRED SMITH said that he had never seen so many living specimens and skiagrams. He (Professor Smith) certainly did think, from what he had seen demon-

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strated by Dr. Tweedy and also by the skiagrams of Dr. Hayes, that Dr. Tweedy had made out a strong case, and it would require greater arguments to do away with the result. In reference to the skiagrams shown, in one of these there was a case of bony union which had a subse- quent normal delivery. This was very interesting, as it showed what did really occur. In this case there was no evidence that there was any increase in the size of the pelvis. He thought the Section should feel grateful to :Dr. Tweedy for showing these cases, and he would certainly stand by him at any rate in opposing the English opponents to pubiotomy.

SIR WILLIAM SMYLY said that the operation recommended itself to him very strongly. He certainly thought it a superior operation to symphysiotomy. In some cases one is limited to the operation of pubiotomy or extra-peritoneal C~esarean section. I t was both instructive and interesting to see these women and how well they walk about.

DR. GIB~O~" FITzGIBBON sa id- - In regard to one of the cases shown in Dr. Tweedy's series, in which he did a symphysiotomy, he remembered the case being done when he was Assistant Master in the :Rotunda. That woman had had three children since, the second and third being born by the natural efforts, and one of these weighed 91bs. ; but in the fourth pregnancy an extraperitoneal C~esarean section had to be done. He asked was there any condition of the pelvis shown in the skiagram to account for this? The interval between the symphysiotomy and the section was four or five years, and he would like to know whether there was callous formation or other change in the pelvis which prevented the natural delivery of the fourth child.

])R. HOLMES said that Dr. Tweedy's splendid series of cases completely proved that pubiotomy was an operation which was going to remain as a definite treatment in mid- wifery. With regard to union there was considerable doubt as to whether bony union was better than fibrous with regard to future delivery.

DR. NmLL said he knew a case of pubiotomy, and he had delivered the same patient on two previous occasions of healthy living children by induction of premature labour.

DR. TWEEDY said that it would greatly strengthen the hands of any of us going over to London if we could say that we

Sectio~ of Obstetrics. 377

here in Dublin were solidly in favour of this operation. He was very thankful to Dr. Hayes and Dr. Freeland for bringing down these cases. I t would be a very different exhibit if not fortified by the photographs. Not only was the opera- r successful, but it was the easiest operation one could perform. He was a great believer in the education of modern general practitioners, and thought tha t any well- informed general practitioner who dared a t tend a midwifery case in a proper manner was quite competent to perform this operation. Over and over again it has been shown tha t Che subsequent trouble was not due to the pubiotomy but to the tearing of the cervix, or tearing of the vagina. The ordinary operations undertaken by the general practitioner were more difficult than the operation of pubiotomy.

THE ~:)RESIDENT said that although it was quite possible tha t the subcutaneous operation was preferable, still he was very doubtful as to the advantages gained in using a sharp needle. In his case he had not performed the subcutaneous operation of B u m m , as he had made an incision large enough to admit a finger. He thought this was safer in view of his want of experience.

A Case o] Ccesarcan Section ]or Eclampsia. DR. KATHERINE M. N. MAGUIaE read a paper on the above

subject.

The Treatment o] Eclampsia. SIR WILLIA~I J. SMYLY read a paper on this subject. PROFESSOR ALFRED SMITH said--You have all listened to

the excellent lines of t rea tment laid down by Sir William Smyly. Do not go away with the idea tha t eclampsia occurs .only before delivery. A great percentage of cases occurs after �9 lelivery. He saw a case occur six days after delivery. This pat ient had a perfectly natural confinement, but a few days la te r she had typical scanty urine loaded with albumen. Now this patient was treated by excellent practitioners, who followed the rules of t rea tment as laid down regarding fluids and diets, and notwithstanding she afterwards developed the ~ypical eclamptic fits. This patient, who had four children, never had any previous trouble. After all that he had heard from Sir William Smyly there was one thing that

378 Royal Academy o/ Medicine in Ireland.

impre s sed i tself upon his mind , and t h a t was t ha t t he r ea l source of the ac t ive cause of e c l amps i a was no t ye t dis- covered . There were p robab ly m a n y causes . W h e n he was Ass i s t an t Mas t e r of the R o t u n d a H o s p i t a l t he re was a " run " of cases of ec lamps ia . All got well fol lowing w h a t was then the s t anda rd i s ed t r e a t m e n t of po t a s s ium bromide and chloral or chloroform, and they t hou gh t t h e y had discovered all t ha t was n e c e s s a r y ; bu t t hen t hey had a run of bad cases, in which this t r e a t m e n t had no effect whatso- ever. H e n c e the pre.~ent d iscuss ion should s t i m u l a t e t h e m to come to a def ini te conclusion, if possible , as to the origin of ec lamps ia , and to s t a n d a r d i s e the i r t r e a t m e n t .

:DR. HORNE said a d iscuss ion on ee l amps i a was a lways of pa r t i cu Ia r in te res t . There was one cl inical fact r ega rd ing Dr. M a g u i r e ' s case, and t h a t was t h a t the re was no micro- scopic e x a m i n a t i o n m a d e of the ur ine to a sce r t a in as to wha t was exac t ly the condi t ion of her k idneys . I qui te agree with w h a t Professor Smi th said t ha t we ge t cyc les of cases which ge t well on some pa r t i cu l a r k ind of t r e a t m e n t , and cycles of cases on which this pa r t i cu l a r k ind of t r e a t m e n t had n(> effect, and hence we are in a m y s t e r y as to the exac t cause of ec lamps ia . H e men t ioned the case of a w o m a n five and a half m o n t h s p regnan t who was seized with convuls ions . The re was comple t e amauros i s which l a s ted for th ree mon ths . S h e was kep t in hospi ta l t i l l de l ivery took place. :During t h i s t ime she was kep t on a mi lk diet . W h e n labour set in there was a r e tu rn of the convuls ions . They were all agreed t h a t convuls ions coming on a f te r labour is a c o m p a r a t i v e l y ra re event . Rega rd ing the t r e a t m e n t of ec lamps ia , he had a d o p t e d the m e t h o d laid down by Dr. Tweedy of giving m o r p h i a , rec ta l in jec t ions and m a m m a r y in jec t ions , and he was a g rea t bel iever in large doses of morph i a g iven a t once.

:DR. HASTINGS TWEEDY said t h a t he would like to sugges t ano the r theo ry as to the cause of the toxmmia t h a t i nduc e d ec lamps ia , as well as the fit i tself . H e be l ieved t ha t the food ea ten was the p r ima ry fac tor in the disease. The p r e g n a n t s t a t e was, of course, e sscn t ia l in br inging abou t the a l t e red re la t ions of the food par t ic le to i ts an t i -body , b u t o the r p red i spos ing fac tors were also at work, such a s insuff ic ient fluid in t ake to the sys t em. There was no d e a t h a m o n g s t the las t t h i r ty ec lamps ies t r e a t ed in the R o t u n d a

Section of Obstetrw~, 379

Hospital, and these statistics covered a period of nearly three years. When the disease had once developed, the administration of even milk is sometimes sufficient to excite a fresh attack of convulsions, and he is in possession of evi- dence that suggests that an anaphylactic condition is estab- lished in respect to food. The t reatment consisted of abso- lute starvation. If the fits recur repeatedly the patient was turned on to the right side, so as to allow the outflow of mucus from the mouth. If they saw the patient getting blue they turned her over with her face towards the ground, and immediately there was an outflow of mucus from the mouth, and an immediate gasp for breath. An internal student saved a case last year by this treatment. He was deterred by the theory of laking of the blood from injecting plain water under the breasts. He substituted bicarbonate of sodium instead of sodium chloride. I t was the injection that had been employed for many years in diabetic coma (�89 dr. to 1 pint of water). The bowels were lavaged with gallons of water repeatedly until there was an action and the system was saturated with morphia. None of his cases died during labour, but a considerable time after labour; the shortest was five hours after delivery and the longest was forty- five hours after delivery. They had now reached the point that they could treat eclampsia successfully, and as long as milk was given to a patient she was not treated successfully, because the patient was saturated with some poison and wanted absolute rest. If a woman was about to die he would perform C~esarean section; if before labour abdominal section ; if during labour vaginal section. The preparation for abdominal section is very long, and the patient was exposed to the manipulations of scrubbing and movements during that time which was highly deleterious. Chloroform was the deadliest alrug any woman or man can take suffering from inefficiency of the liver. Ether was better, but it also had its dangers, as it might excite inflammation in the lung. If one delivered through the vagina one could deliver without ether or chloroform or any general anaesthetic.

Da. CRO~'TON said he was extraordinarily interested to hear Dr. Tweedy's remarks about antibodies. When milk was taken into the stomach it seemed to him it had to be dealt with by live cells, and only that protein which was a natural protein could get into the blood and stimulate the tissues,

'380 Royal Academy of Medicine in Ireland.

"~o form an antibody when these were already present in the tissue juices and in the blood ferment to deal with that protein. He did not think it had to be modified by the s tomach cells before it was absorbed, and when it was absorbed it was only the protein from which the patient was living upon before she was born. There was also the ques- tion of blood pressure to be considered. Thus people with nephritis of pregnancy had a high blood pressure, and if one gave them nitrites they lost their albumen and they did not get eelampsia when labour came on. Another point he wished to ask Sir William about was whether he had had much bleeding at the time ec]ampsia came on, because there have been reports in which the fits stopped at once after a large bleeding, and it was essential that the bleeding be con- tinued till the blood pressure was normal.

DR. SHRILL, referring to Dr. Maguire's case of eclampsia, said, although we can have no reasonable doubt that it was a case of eclampsia, still there was a possibility that it was not, for it might have been ur~emia or cerebral h~emorrhage. He recalled a case (when he was Assistant Master of the Coombe) which had been diagnosticated as eclampsia, but when a post-mortem was made by Prof. McWeeney it was shown to be a case of cerebral heemorrhage. The reason he made this remark was because the h~emorrhage did not relieve the blood pressure, and diaphoresis was not the rule in eclampsia, but the child having had eclampsia would seem to indicate that it was a genuine case of eclampsia. He also agreed that it was desirable to use more morphia and scopolamine. He did not think Dr. Tweedy's new theory as to the cause of eclampsia was proved. In fact, after what Dr. Tweedy had stated he would almost hesitate to put milk into his tea.

DR. PUREFOY said that for many years in Dublin free vene- section was the regular t reatment for eclampsia, and in a fair number of cases recorded the patients recovered. In the Coombe Hospital the mortality was enormous. He thought venesection valuable in the early stages of a case, and had seen venesection of great use in the latter stages of cases when the convulsions, the condition of the lungs, and the ~ondition of the right heart showed that the patient 's life was in danger. So there was still something to be said in favour of the expectant treatment, and the rapid emptying of the uterus is very rarely called for indeed. The argument

Section o] Obstetrics 351

against the emptying of the uterus was that the convulsions do not always cease after the uterus was emptied. The prin- ciple of the treatment was to eliminate this unknown poison, unless one accepts Dr. Tweedy's theory. He was greatly struck by the plan of treatment adopted by Sir William Smyly of giving more moderate doses of morphia in fixed doses and at regular short intervals. This was a plan of treatment which recommended itself to his mind.

DR. Natal said he had heard of a case in which a patient: got well after forty fits, and the albumen disappeared from her urine. He referred to Dr. Tweedy's method of taking away the milk diet, and said there was a tendency against giving milk at present in enteric, and he had not been giving milk for some time as he thought it too easily underwent. fermentation. He would like to ask Dr. Tweedy whether he. would agree with giving the patient whey.

DR. TWEEDY.--Fits have come on after whey. I)R. NEmL mentioned a case of eclampsia in which post-

mortem examination showed that the stomach was empty and the urine had been filled with blood.

DR. FITzGIBBO~ said with regard to venesection in Sinclair and Johnston 's midwifery there was a series of cases which had been at first treated by venesection together- with copious purgation, but later on in the series purgation seemed to have been left out, and venesection was continued or increased, and on reading over the results they seemed ~o be better in the earlier lot of cases, which goes to point tha t the real benefit was more in the purgation than in the vene- section. I n the case referred to by Dr. Sheill, which was diagnosticated as eclampsia and which was post-mortem found to be cerebral hmmorrhage, he would like to mentio~ a case which he had seen in private with typical eclamptic seizures, and just before he started giving an ansesthetic she had a very violent seizure which lasted for a long time, after which the patient remained in deep coma until she died thirty hours afterwards. She was delivered whilst in coma. He believed the cause of death was cerebral hsemorrhage, because she was completely paralysed on one side of the boely. In this case he had no doubt the violent eclamptic fit brought on the cerebral hsemorrhage, and he thought the same remarks app]iecl to the case referred to by Dr. Sheill.

THE PRESIDENT said there seemed to be many interesting

382 Royal Academy of Medicine in Ireland.

theories of eclampsia, so perhaps he would not be wrong in bringing forward his own, which he had held for some ten :years or more, and which the discussion strengthened. The theory was that it was futile to look for one cause to explain all cases of eclumpsia; that, in other words, there was no one theory which would fit all cases and ever be translated into a positive fact. I t seemed to him that to search for the origin of eelampsia was the same as to search for the origin of the Nile, which came out of a lake, which in turn was fed by a number of rivers. Any of these might be considered to be the source, and all contributed to its waters. If one took a number of cases of eclampsia one would probably find different ~etiological factors in most of them, and any of these might be called the factor, but the others were also contributory. With regard to the question of diagnosis he was inclined to agree with Dr. Sheill that there was a great obscurity. With regard ~o the large number of cases of eclampsia met with by Dr. Tweedy he would probably find that some of his cases could not be classified as eclampsia.

Da. TWEEDY here defined what he considered eclampsia, and said no cases had been included in his list which had not had albuminuria or which had ever had other fits.

THE PRESIDENT said he only wished to show there was extreme difficulty in classifying eelampsia. Cases of cclampsia occurred without albuminuria, and cases of albu- minuria may get convulsions which are not eclampsia, and the idea was very prevalent that one should search for a positive cause for them all. Therefore, the time had not yet come when one could talk of the theory which could be translated into a fact.

SIR WILLIAM S3IYLY, in reply, said that Stroganoff had a run of three hundred and sixty cases, and Dr. Smith and Dr. Horne had spoken of runs of cases, but had this proved his good t reatment? He looked to the person who had the best results, and at the present day it was neck and neck between Dr. Tweedy and Professor Stroganoff. Dr. Tweedy was a grea~ optimist, and he said he was not going to have any more deaths. Professor Stroganoff was also optimistic and he said he was only going to have 2 per cent. of deaths. As to milk diet he remem- bered Professor Tarnier said if milk was given for five days

Section of Anatomy and Physiology. 383

there would be no convulsions. He thought that milk was quite a specific, but it might be only so comparatively, and though milk is certainly bet ter than any other kind of food still it might be worse than no food at all, and he quite understood that milk was better than other foods.

DR. MAGUIRE, in reply, said tha t the pat ient ' s urine had been examined microscopically, and granular and hyaline casts found, but not so many as might have been expected with such a quanti ty of albumen as was present. She thought it would be very difficult to carry out Dr. Tweedy 's t rea tment of giving no food in private practice. She would like to know what Dr. Tweedy would substi tute for milk when at last food had to be given, and what he would do if, af ter prolonged abstinence from food, a patient still persisted in having fits.

SECTION OF ANATOMY AND PHYSIOLOGY.

President--PaOFESSOa E. P. McLOUOHL~N, M.D. Sectional Secretary--ADaMS A. McCoNNELL, M.B.

Friday, January 27, 1911.

THE PRESIDENT in the Chair.

~a) Acromegalic Skeleton; (b) Femur with Separate Ossific Centre ]or Third Trochanter; (c) Displacements caused by Pleural Effusion (illustrated by slides).

PaOFESSOR A. C. GEDDES demonstrated the skeleton of an acromegalic subject. He showed a series of lantern slides illustrating the change in facies during the twenty-five years of life for which the disease persisted. The record of the dissection of the body was also illustrated by lantern slides. The points to which attention was specially directed were : - - (1) The great length of the facial skeleton. This was shown to be due to the great increase in height of the maxillm. This increase especially affected the alveolar processes of the bones. (2) The mandible was a remarkable bone, the greates t change being the increased length of the body, which was set at an open angle with the ascending ramus. The vertical height of the symphysis was much increased.

384 Royal Academy o] Medicine in Ireland.

(3) The skull vault was in parts enormously thickened, in parts extremely thin. (4) The pituitary fossa was enor- mous. (5) The vertebral column was completely ankylosed except in the case of the joint between the third and fourth cervical vertebrae. (6) The ribs were very large, more par- ticularly at their anterior ends. (7) The pelvis was enor- mously broad, and the sub-pubic angle very great. (8) In the limbs the bones showed an extraordinary prominence of the muscular crests with an equally extraordinary degree of atrophy of the general thicknesses of the shafts. (9) The bones of the hands and feet were not unduly large, but ther~ was a considerable coalescence of the carpal and metacarpa l and of tile tarsal and meta tarsa l bones. (10) The joints, throughout the body showed the changes associated with the so-called disease, rheumatoid arthritis.

A complete report upon the microscopic and macroscopic structure of the soft tissues of this case was published in the Edinburgh Medical Journal, March, 1909.

(b) t)ROFESSOR GEDDES next showed a human femur show- ing a distinct centre of ossification for the third trochanter. He pointed out that little was to be found in the text-books concerning this centre, and expressed the hope tha t some of those present would be able to give the meeting some definite information as to its frequency.

(C) ]?ROFESSOR GEDDE8' third communicat ion dealt with the mechanical effects of right-sided pleural effusion as they appeared in the body of a male subject hardened witt~ formalin. He drew special at tention to the mechanical diffi- culties to the venous flow which the displacements of the viscera occasioned. The lumen of the inferior vena cava was shown to be partially obliterated as a result of the down- ward rotation of the apex of the heart round an antero-pos- terior axis passing through the left margin of the inferior caval opening in the diaphragm. The lumen of the superior vena cava was reduced as a result of the forward rotation of the right lung root, that of the vena azygos major by pres- sure against the right posterior edge of the right bronchus., He pointed out that these changes were probably exagge- rated after death as a result of the loss of the resilience of the tissues, but that there could be no reasonable doubt tha t the forces which tended to produce them were operative during life, and in cases of considerable pleural accumu-

Section o] Anatomy and Physiology. 385

lation might well become operative and occasion sudden death.

PROFESSOR Dixon referred to the diversity of opinions ex- pressed in the literature on the subject of a separate ossific centre for the third trochanter of the femur. He was in- clined to think that such a centre usually existed. In regard to the case of acromegaly he pointed out tha t apparently those bones of the head that were developed in membrane were chiefly affected, the internal pterygoid plate, for in- stance, being greatly lengthened, while the external was of normal dimensions.

PROFESSOR SYMINGTON referred to the utility of studying the displacements caused by pathological conditions.

DR. MOORHEAD thought that the investigation of displace- ments by means of hardening reagents would interfere with the pathological findings. He considered that the ana- tomical derangements found after death and the clinical picture of the case often did not correspond.

MR. M'AaDLE, MR. I-IAYES, and DR. CaOFTON also spoke.

Alcohol aud Oxygen Inhalations in Cardiac Faihlre (illustrated by slides).

PROFESSOR COLLINGWOOD described the physiological ex- periments he had performed on animals which led to the administration of alcohol vapour to man in cardiac failure. He stated that animals with heart failure following the administration of over-doses of chloroform had recovered their blood pressure under positive ventilation with alcohol vapour and oxygen. He gave an account of the clinical application of the t rea tment and of the very successful results that had been recorded by Dr. W. H. Willcox in the British Medical Journal of November 5, 1910. In conclu- sion he exhibited an apparatus designed for the administra- tion of alcohol with oxygen which was manufactured by Burgoyne & Burbidges, Coleman Street, London, E.C. This apparatus, he said, could be attached permanently to the oxygen cylinder, for by means of a tap either pure oxygen or oxygen mixed with alcohol could be administered at will. He recommended this apparatus as being especially suitable for operating theatres and hospital wards.

MR. M'AaDLE, MR. STOKES, and DR. CROFTON spoke.

386 Royal Academy o/ Medicine in Ireland.

The Topographical Anatomy o] the Salivary Glands (with diagrams).

PROFESSOR SYMINGTON described the shape and relations of the salivary glands illustrated by specimens and drawings. His description was based upon the results of the examina- tion of a series of coronal sections of a head made about half an inch apart. The position and relations of any salivary glands exposed by these sections were drawn. The pieces of each gland were then removed from the slabs and placed in their natural relation to one another so as to demonstrate the shape of the whole gland, while the structures bounding the cavities from which these pieces had been removed were defined. A drawing was then constructed showing the posi- tion of the glands, &c., viewed from the lateral aspect. The shape of the parotid gland was considered, and also its deep relations, more especially to the facial nerve and external carotid artery. Attention was drawn to the slight extent to which the submandibular gland reaches forwards on the cervical aspect of the mylo-hyoid and the way in which it extends down the neck over the posterior belly of the digastric into the carotid triangle.

PROFESSSOR GEDDES s p o k e , and PROFESSOR SYMINGTON

replied.

THE XVIITH INTERNATIONAL CONGRESS OF MEDICINE.

T~E XVII th International Congress of Medicine will meet in London in the summer of 1913. The exact date was fixed by the International Permanent Committee, which assembled for the first time in London on the 21st and 22nd of April, 1911, under the Presidency of Dr. F. W. Pavy. At the same meeting the l i s t of Sections of the Congress was drawn up. Any views or suggestions concerning the arrangement of this list may be sent to the I-Ion. General Secretary of the Permanent Committee, Prof. tI. Burger, Vondelstraat 1, Amsterdam, or to the Bureau of the Committee, Hugo de Grootstraat 10, The Hague. The Committee will be glad to receive, at the same addresses, any information or propositions concerning the organisation of the Congress.