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were normal. The pulse was slow and full, from 50 to 60periminute. The temperature was slightly above normal.The respirations were stertorous. It was three weeks beforeshe regained full consciousness. Daring this time she

- objected to the light, and after she began to talk again saidthat things were upside down. Examination of the field ofvision showed left nasal hemianopia. The pupils reactednormally. The patient was now (Jane, 1901) in excellenthealth and seemed to have no recollection of her illness

previously to the complete return of consciousness. Whilethe patient was in such a grave condition a diagnosis oftumour of the occipital lobe was made, but the subsequentrecovery of the patient would seem to negative this. Thesecond case was that of a woman, aged 32 years. She wasemaciated, anasmic, and the subject of mitral incompetenceand bronchitis. On April 28th she returned home from workfeeling dizzy, she vomited frequently, and towards nightbecame unconscious. She resisted attempts at examinationand rolled about the bed. Her temperature was 103° F. andher pulse was 120. The tongue was dry and coated. Theeyes were kept closed and the limbs were rigid. Urine andfseces were passed involuntarily. She vomited during thenext day and remained unconscious for four days. Doubleoptic neuritis was present. There was no albumin or sugarin the urine. There was noticed to be pigmentation of theskin and of the mucous membrane of the mouth. This, com-bined with the great prostration, would justify a diagnosisof Addison’s disease, possibly associated with tuberculousdeposit in the brain. The patient had a secondattack of coma in which she died. There was no

post-mortem examination. The third case was thatof a woman, aged 53 years. She complained on July 10th,1896, of severe pain at the back of the head. She was dis-tressed and her manner was altered. There was no vomit-ing or optic neuritis. After a week she began to have astaggering gait and moved about with her eyes half shut.Her memory failed and she neglected her dress and person.She became somnolent and took to her bed. Towards theend of August slight weakness of the right band wasobserved and optic neuritis was detected. A diagnosis ofcerebral tumour in the left arm centre was made. The skullwas trephined on Sept. 10th over the left Rolandic area.The brain bulged, but no tumour was found. A trocar wasinserted into the lateral ventricle and a quantity of fluid wasevacuated. The patient died 12 hours after the operation.At the post-mortem examination a tumour of the size of awalnut was found in the left frontal lobe. The tumour wasa glioma and was not multiple. An erroneous diagnosis asto the position of the tumour was founded on the paresis ofthe right hand. Similar cases had been described by Brunsand Ferrier.

Mr. J. PHILLIPS read notes on a case of PerforatingDysenteric Ulcer of the Colon with complications. A

woman, aged 32 years, was admitted to the Bradford RoyalInfirmary under the care of Mr. Althorp with sinuses inthe right loin. There was a history of influenza twelvemonths before, followed by " inflammation of bowels " eightmonths before; the latter illness caused her to keep her bedfor two or three months and was followed by right-sidedpleurisy. Two months later a lump formed in the rightloin which was opened and had discharged ever since. ’,The largest of three sinuses in the loin admittedthe finger, which passed up under the diaphragm.The chest was normal. The urine was normal. On

April 24th the sinuses were scraped and a quantityof foul granulations removed. The sinus passed up-wards and to the right beyond the reach of thefinger. Two days later, on removing the packing, eggand milk came from the wound. A duodenal perfora-tion was diagnosed and an anterior gastro-enterostomy wasperformed, but the patient died from pneumonia two dayslater. At the necropsy, on removing the colon pus wasfound burrowing up behind the ascending colon to the sub-phrenic cavity, which was bounded above by the diaphragm,below and in front by the liver, and on the inner side by thekidney and duodenum; in the latter was an apertureadmitting two fingers. The diaphragm was perforated andthe lower lobe of the right lung was in a condition of septicpneumonia. The retro-colic pus was due to perforation oftwo small ulcers just above the cseoum. The case appearedto be one of dysentery with perforation of a colic ulcer.followed by right subphrenic abscess, and eventually by per-foration of the abscess through the diaphragm and duodenum.

Dr. BAXTER-TYRIE read notes on some cases of Empyema.

NORTH OF ENGLAND OBSTETRICAL ANDGYNÆCOLOGIAL SOCIETY.

Exhibition ot 8pecimens.-The Digestive Porver of the Peri-tone.itm.- Concealed Accidental Haellwrrllage.-liacte’l’io-logical Diagnosis of Puerperal Infection.A MEETING of this society was held at Leeds on May 17th,

Dr. T. B. GRIMSDALE, the President, being in the chair.Dr. LLOYD ROBERTS (Manchester) showed: (1) Multiple

Fibro-myoma, the largest growth being intra-ligamentary ;the latter was enucleated from the broad ligament and theuterus was removed by supra-vaginal hysterectomy; and (2)a large Fibre myoma of the Fundus removed by abdominalmyomectomy, the uterine bed being sutured with silk.

Mr. WALTER THOMPSON (Leeds) showed: (1) Fibro-myoma Enucleated from the Broad Ligament; and (2)Large Spindle-celled Sarcomatous Uterus weighing 12pounds, removed by total abdominal hysterectomy.

Dr. J. BRAITHWAITE (Leeds) showed three Fibroidsremoved by abdominal myomectomy. In Case 1 theuterine cavity was opened ; in Case 2 and Case 3 the cavitydid not require opening. Reference was made to two othersimilar specimens not shown.

Dr. E. 0. CROFT (Leeds) showed a Complete recentTubal Abortion. The abdomen was opened and found tobe full of blood in which a perfect ovum of about sixweeks’ development was discovered. The Fallopian tubewas unruptured, but its outer end was dilated into a cavityand the fimbriated opening was gaping widely.

Dr. J. B. HELLIER (Leeds) showed : (1) Hasmatoma(Ectopic Gestation) removed from the Broad Ligament byColpotomy (chorionic villi were present) ; (2) Tubo-uterineGestation removed by Supra-vaginal Hysterectomy ; and(3) Uterus removed for Carcinoma of the Cervix from apatient who had passed a Hydatidiform Mole three monthspreviously.

Dr. BRAITHWAITE (Leeds) read a paper on the DigestivePower of the Peritoneum. Cases were described in whichthe evidence seemed to point conclusively to the possibilityof the absorption of extra uterine gestation products, not onlyin the early stages, but at full term.

Dr. A. E. L. WEAR (Leeds) read a paper on a case ofConcealed Accidental Haemorrhage in which death ocpurredsuddenly from syncope two hours after the uterus had beenemptied and all bleeding stopped.

Dr. ARNOLD W. W. LEA (Manchester) read a paper on theBacteriological Diagnosis of Puerperal Infection: its Valueand Limitations. A more accurate knowledge of the bacterialinvasion of puerperal infection was essential if further pro-gress was to be made in the treatment. The uterine lochiafrom cases running a normal course were in the early days ofthe puerperium free from bacteria, though after the sixth oreighth day organisms were often present. In cases of sus-

pected puerperal infection some of the uterine lochia mightbe obtained free from contamination with the vaginal dis-charge. The technique was briefly as follows. The patientwas placed on her side and a duck bill speculum was passed ;the vagina and cervix were cleansed with cotton wool. Asterilised glass tube was now introduced into the uterus andsuction was made by a syringe. The tube was removed, theends were sealed, and its contents were taken away forexamination. 18 cases of puerperal infection were

examined bacteriologically by this method. Culturesof the lochia were made on agar and gelatin tubes andin some of the cases anaerobic cultures were also made.The blood was examined in 14 cases. The results of theseobservations were as follows. Streptococcic infection wasfound in 10 cases. In six cases the streptococci were in pureculture, in two cases associated with streptococcus pyogenesaureus and albus, and in two cases with anaerobic bacteria.Of these, three recovered and seven ended fatally. Many ofthese cases were seen in the late stages of the disease and wereof a very severe type. In one case vaginal hysterectomywas performed and the patient died from septic peritonitiswhich was not checked by the free drainage of the pelvisestablished by the operation. In nine cases of streptococcicinfection cultures of the blood were made on agar tubes. Inseven the blood was sterile, even in the later stages. In twocases streptococci were found in the blood. Both thesepatients died. With regard to staphylococcic infection theseorganisms were found in five cases. In two cases they wereassociated with streptocoeci ; in two cases the staphylococcus

1831

pyogenes albus and aureus were in pure culture ; and in onecase they were associated with gas-producing anaerobicbacteria. Three of these cases died and two recovered.Bacterium coli commune was found in one case associatedwith anaerobic bacteria. As to anaerobic bacteria, these werenot investigated in every case, but in five cases they werefound to be present. The gas-producing bacillus was foundin one case associated with putrefactive changes in theuterus. This case ended fatally. In three cases, althoughthe symptoms pointed to severe puerperal infection, theuterine lochia were found to be sterile. In one the perineallaceration was infected with streptococci but the uterine

cavity was sterile. All recovered rapidly. A detailedanalysis of these cases was given in the paper. Streptococcicinfection was by far the most common form of puerperalinfection and presented enormous differences in virulence.In some cases the organisms caused few or no symptoms,remaining limited to the surface of the decidua or

placental site. In other cases they rapidly invadedthe uterine wall either by the lymphatic vessels-theso-called lymphatic form of septicaemia—or through theveins-the thrombo-phlebitic type ; of these, the formerappeared to be the most usual course. The extraordinarydifferences in the results of streptococcic invasion must beattributed to variations (1) in the virulence and type ofthe organism, and (2) in the resisting power of the indi-vidual. Of these factors they did not possess certainknowledge, and as yet bacteriology afforded little help.The gravity of cases must be judged mainly from the clinicalsymptoms. Diagnosis.-l. If the uterine lochia were sterile,microscopically and to culture, infection was eliminated.The gonococcus, however, might be present ; it could berecognised by the microscope and staining. 2. If anaerobicbacteria only could be obtained decomposition was going onin utero. It was a case of saprasmic intoxication. It waspossible, however, that at times these anaerobic bacteriamight cause severe or even fatal infection. 3. If strepto-coccus pyogenes was found the case was one of streptococcicinfection, but severity of the invasion must be estimated bythe clinical signs. 4. If the streptococcus was present withstaphylococcus pyogenes aureus or albus the case might beone of " mixed infection," but it was probable that thestreptococcus was the infecting organism. 5. If a growth ofaerobic bacilli was found there might be bacterium coli com-mune or certain putrefactive bacteria which caused putridendometritis. In pure streptococcic infection there was nooffensive odour of the lochia, which might be very scanty orin some cases abundant and sanious. The treatment of

puerperal infection must be mainly directed by the clinicalsymptoms, but bacteriological examination was of value. Ifthe uterine lochia were sterile no intra-uterine treatment wasrequired. If the streptococcus was present an attemptshould be made to disinfect the uterus by curettage andother local measures. In some cases of streptococcicinfection which resisted milder measures hysterectomy mightsave life, but bacteriology as yet afforded little help in layingdown indications for this operation. If bacteria of putrefac- ’tion were present exploration of the uterus and removal ofdecomposing products were essential. The anti-streptococcicserum should be given in cases of streptococcic infection,but a large series of cases bacteriologically examined wasessential before a true estimate of the value of this treatmentcould be made. Serum was given in three cases of provedstreptococcic infection. In two cases, though repeatedinjections were given, no effect was produced and thepatients died. In one case the serum had apparently afavourable influence.

EDINBURGH OBSTETRICAL SOCIETY.

Exhibition of Specimens.-Eclampsia and the Thyroid Oland.A MEETING of this society was held on June 12th, Dr.

R. MILNE MURRAY, the President, being in the chair.The following specimens were shown :-Dr. D. BERRY HART: 1. A Fibroid Tumour removed by

Pan-hysterectomy for symptoms due to pressure and metror-rhagia. 2. An Incomplete Tubal Abortion in which thegestation sac, measuring two inches by one and a half inches,was partly adherent to the fimbriated portion of the tube andhalf projected beyond the tubal end. The amniotic sac waswell seen and the sac wall, averaging from one-half to seven-eighths of an inch in thickness, showed a good deal of blood

extravasation. 3. A Parovarian Tumour with markedlytwisted pedicle. 4. A Ruptured Ovarian Cyst from a girl,aged 14 years. 5. A large Papillomatous Cyst. 6. AnOvarian Tumour with Myxomatous and Cystic Parts, thelatter lined with columnar epithelium.

Dr. R. C. BUIST (Dundee): A Uterus removed forDeciduoma Malignum after Hydatid Mole, with Micro-

scopical Section.Dr. J. HAIG FERGUSON : A Myomatous Uterus removed by

Abdominal Hysterectomy.Professor A. R. SiMPSON: 1. Labia Minora and Clitoris

removed for Epithelioma from a patient, aged 32 years.2. A bronze copy of the Porro Medal.

Dr. S. MACVIE: Sketches of Varicose Veins in a womanfive months pregnant.

Dr. H. OLIPHANT NICHOLSON read a paper on Eclampsiaand the Thyroid Gland. The blood during pregnancyincreased in volume with a deficiency of the solid consti-tuents of the serum leading to a lower specific gravity. Thered blood corpuscles and albumin were relatively diminishedwhile the number of white corpuscles was increased. Thiswas one of the first blood changes which followed thyroid-ectomy. Other changes occurred in the blood duringpregnancy : there was always a toxsemia as a result of fcetalmetabolism, and as the foetus grew the maternal blood wouldsuffer to a greater extent as the amount of foetal excretionwould be larger. Towards the end of pregnancy the marginof safety to the mother was greatly contracted. Unsuitablediet, chiefly of the proteid class, or a sudden chill, or avariety of other circumstances might be sufficient to

derange the mechanism and precipitate the symptomsof eclampsia. In pregnancy also there was a hypertrophyof the cardiac muscle and of the muscular coat of the blood-vessels, giving rise to increased vascular tension. It hadbeen suggested that these conditions were dependent uponthe toxic condition of the blood. The toxic theory of

eclampsia was now the one generally held by most obstetri-cians and in this connexion the following points might bementioned. 1. That in every case of pregnancy more or lesstoxasmia existed and that the blood intoxication becamemore profound towards the end of gestation. 2. That

although the eclamptic state was due to a toxsemia, thetoxic agent which excited the convulsions was probably notalways the same-there seemed to be different types of thedisease. 3. That the toxins might be produced in greaterabundance in some cases (twin pregnancies) and that

they were generally more virulent in primiparas thanin multiparoe. In the primipara mechanical pressureon the renal vessels might possibly come more

into play, while in the multipara a certain degreeof immunity against the toxin might have been acquiredfrom previous pregnancies (Allbutt). 4. That in spite ofvery grave toxsemia no alarming symptoms would occur solong as elimination by the kidneys was sufficiently active.Of the nature of the toxins they knew nothing and there wasno clear evidence to show where they were formed. Therewas some reason to believe that the fcetus played animportant part in their production, because after its deaththe various symptoms usually abated. If the fcetus con-tributed a part of the poison, then it was unlikely that theycould exert any control over its formation, so their efforts inthe avoidance of eclampsia might be more usefully directedtowards the maintenance of efficient renal function. A

checking of elimination by the kidney, more or less suddenlyproduced, would result in the development of all the

symptoms of eclampsia. Therefore the whole questionof treatment, prophylactic and otherwise, turned uponelucidating the cause of this renal arrest. What was

it that, during the course of the normal eliminationof the toxins, suddenly threw the kidney out of gear? 1Lange noted that out of 25 pregnancies in which the usualhypertrophy of the thyroid did not occur albuminnriaoccurred in 20. Large doses of thyroidin were administeredto pregnant women in whom the physiological enlargementof the gland had occurred and a marked diminution in thesize of the gland resulted. One might therefore concludethat the normal hypertrophy of the thyroid gland in preg-nancy was the result of a demand for extra secretion to meetthe wants of increased metabolism. With a continuoussupply of artificial secretion the gland was relieved of theadditional strain and resumed its former size. Hallionobserved similar effects, and Murray had on this hypothesisused thyroid extract in certain cases of goitre with

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