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1178 cavity was washed out with copious irrigations of a 1 in 300 solution of ]ysoL The temperature rose to 1035°, but next day had fallen to normal and the patient made a good recovery. Soon afterwards. however, signs of pulmonary tuberculosis appeared and she spent some months in a sanatorium. ’ It might be questioned, said Mr. Gough, whether this was really a case of placenta accreta. It was clearly a morbidly adherent placenta, but perhaps not one of the most adherent. Generally, the diagnosis of placenta accreta had been made after an unsuccess- ful attempt at its manual removal. ’8V-hat was the proper course when the placenta could not be delivered in the usual way ? Most English text-books said that it must be removed manuallv after a certain time-one or two hours. Any important post-partum haemorrhage was, of course, an indication for the immediate emptying of the uterus. In this case, with no loss of blood for three hours and then only a minimal loss, the safer course was the one adopted. The forcible scraping away of the placenta in fragments entailed a grave risk I of perforation of the uterus, shock, and haemorrhage, and the later development of septic complications. A risk of leaving the placenta was, he supposed, that separation might take place and post-partum haemorrhage occur when no help was at hand ; but it seemed unlikely that a closely adherent placenta would suddenly become detached. This fear might have some weight in dealing with a patient in a remote country district, but in an institution it might be entirely disregarded. Then there was the risk of sepsis being favoured by the retention ; it had occurred in this case, but was evidently of the sapraemic type. Mr. J. E. STACEY( Sheffield) described a specimen of bilateral tarry ovarian cysts ; the PRESIDENT and Mr. A. A. GEMMELL (Liverpool) reported a case of uterine sarcoma which ruptured and caused acute symptoms in the abdomen; and Mr. W. GOUGH (Leeds) read notes on parovarian and ovarian cysts _removed during pregnancy. EDINBURGH OBSTETRICAL SOCIETY. AT a meeeting of this Society held on May 9th, Dr. HAiG FERGUSON, the President, took the chair, and a paper on JJ1aternal Mortality from Puerperal Sepsis was read by Dr. JAMES YOUNG. He said that the total mortality in these islands was about 4000 yearly ; between 1911 and 1926 inclusive there had been 66,421 deaths in England and Wales. The most important single cause was sepsis. For 1926 the total maternal mortality-rate in England and Wales was 5-14, and the sepsis rate 1-60, per 1000 live births. The causes of puerperal sepsis might be clinically considered as : (1) Contagion-namely, contact infection with a virulent microbe introduced from without, in which the phenomena were similar to those present in other infective diseases, for example, tetanus, erysipelas. (2) Trauma. Here the wound was the primary factor and overshadowed in importance the , source and nature of the microbes, which belonged to the widespread micro-organisms capable of causing wound infection. (3) A uto-infection. Here ’I the microbes were present in the genital canal before i labour or they reached it from some distant source, I for example, bowel, teeth, or tonsils. The essential distinction between these three clinical types was not undermined by the fact that in some cases two of the factors might, be operating together. Auto-infection, said Dr. Young, had sometimes been advanced as an explanation of the persisting high death-rate from sepsis in modern times, despite the application of the aseptic principle. That it probably played a minor role was, however, suggested by an analysis of the records of large maternity practices. In the Edinburgh Maternity Hospital about a century ago and in other large hospit,als-e.g., Dublin-puerperal fever was a negligible cause of death when contagion was obviously in abeyance ; then years might pass without a death from sepsis. There was similar evidence in extensive e modern practices. Thus in the extern practice of the Edinburgh Maternity Hospital there had been 5000 successive, sp ontaneou8 , normal deliveries with 2 deaths from sepsis; there had been 888 cases in the extern practice of the Birmingham General Hospital with no deaths; whilst there had been 47,593 deliveries in the unselected practice of the East End Maternity Hospital in London with 5 deaths from sepsis, or 1 in about 9500. During 1927, in the practice of the Queen Victoria’s Jubilee Institute midwives, there had been 53,502 deliveries with 6 deaths in normal, spontaneous births, or about 1 in 8900. On including in this record all the deaths which could directly or indirectly be attributed to sepsis, the maximal figure, including normal and abnormal cases, was seen to be less than 0-5 per 1000. The conclusion was that the very small septic death-rate in these large bodies of women, who could not be regarded as selected from this standpoint, was an argument against self-infection, operating alone, being an appreciable component of the death-rate in the rest of the community. Dr. Young discussed the results of recent bacteriological research, which he said supported this view. The records of the old hospitals showed that contagion was the dominating cause of the deaths from sepsis. Instrumentation was then rare-the forceps rate in the Edinburgh Maternity Hospital a century ago was 1 in 472 cases (Simpson)- and trauma was negligible as a cause of sepsis. If the Queen Victoria’s Jubilee Institute midwives’ practice could be taken as typical of midwives’ practice nowadays, contagion (as judged from the incidence of normal cases dying from sepsis) was a negligible cause of death in over 50 per cent. of the midwifery of England and Wales which was in the hands of midwives. He quoted these figures merely because they were the only large records available, and not because they necessarily demonstrated any superiority, qua simple contagion, of the midwives’ over the doctors’ practice. He did not think there was any evidence that this was so. Contact infection of the normal by the abnormal and infected case was a risk in modern maternity hospitals, and it was difficult to exclude completely. In Dr. Young’s opinion, trauma due to instrumentation was probably the main cause of the present septic death-rate. On analysing the factors at the back of the greatly increased instrumentation of modern times, he concluded that it was unwarrantable to consider that this was entirely or even largely attributable to malpractice. That with satisfactory antenatal care and an efficient maternity service, the maternal mortality could at once be lowered was, however, supported by the record of the East End Maternity Hospital, London, where during four years in 9000 cases the total maternal mortality had been reduced to 0’67 per 1000. Here the instrumental rate was between 2 and 3 per cent. Dr. Young’s conclusions were as follows (1) Autogenous infection is a minor primary cause of fatal puerperal sepsis. (2) Contagion is probably of comparatively secondary importance. The well-established risks of contact infection in hospitals call for care in the extension of the hospital system of maternity service. I (3) There is evidence that trauma is the most important cause of the death-rate from sepsis. This is not entirely a problem involving the medical attendant; it has implications of a wider nature. (4) The immediate need is an improved machinery for maternity practice based on a midwife-doctor combination. From the standpoint of immediate policy the importance of this overshadows all other considerations-e.g., " research," and there is reason for the hope that by this means alone a lessening of the death-rate is possible. (5) Improved education of the public, midwife, and medical student and the assistance of the central and local authorities are all necessary for the creation and working of a satisfactory machine.
