1228

(Continued from previous page.)REFERENCES : A CASE OF PSORIASIS.

Fleisher, Moyer S., and Wachowiak, M.: Archives of Dermatologyand Syphilology, June, 1925. (Monilia as a Possible ÆtiologicFactor in Psoriasis, Preliminary Report.)

Schamberg, J. F.: Archives of Pediatrics, August, 1915,xxxii., 617. (Case of Extensive Fatal Thrush, in Infant,with Involvement of the Skin and Secondary Infection ofMother’s Breasts ; Saccharomyccs Albicans.)

Wilkins, Lawson, and Jones, S. Bayne : American Journal ofDiseases of Children, 1923, xxvi., 77. (Indurated Ulcer ofthe Tongue due to Oidium lactis.)

Christison, J. T. : American Journal of Diseases of Children,1923, xxvi., 250. (Fatal Case of Thrush Involving Skin,Lungs, and Nails. Isolation of Oidium Albicans.)

Castellani and Chalmers : Manual of Tropical Medicine, Baillière,Tindall and Cox, third edition, p. 1079 et seq.

Sasamoto : Jap. Ztschr. f. Derm. und Urol., 20.

ROYAL SOCIETY OF MEDICINE : OBSTETRICS, ETC.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF OBSTETRICS AND GYNAECOLOGY.A MEETING of this Section was held on Dec. 3rd,

Mr. T. G. STEVENS, the President, occupying the chair.Exhibition of Specimens.

Dr. EVERARD WILLIAMS sent descriptions and slidesof two specimens. The first was that of a Fallopiantube containing a loose fragment of menstruatingendometrium associated with endometrioma of theovaries. The patient had had for some time dysmenor-rhoea, and this had been getting worse. The specimenconsisted of both ovaries and tubes, and the uteruswas covered with numerous dense adhesions, whilethere were cysts containing tarry material, these cystshaving ruptured during the removal. Adhesions hadbound the ovaries to the back of the broad ligaments,so that removal of the Fallopian tubes became neces-sary. These tubes, however, were seen to be free,and were normal in appearance. Both ovaries con-tained abundant endometrium in a non-menstruatingphase. The right ovary was exhibited on the screen,showing on one side endometrioma, on the other sideovarian tissue containing an early developing Graafianfollicle. A similar condition was present in the leftovary. In the right tube, in the region of the fimbriatedextremity, were two fragments of tissue lying freeand separate from the tubal mucosa. Those frag-ments proved to consist of endometrial tissue not ina menstrual phase of the cycle. The specimen, itwas contended, confirmed the view of J. A. Sampson,of New York, as to the causation of this condition.The PRESIDENT said he regarded this specimen as

the missing link in the pathology of endometrioma.Many observers had been trying for some time to findendometrium in the Fallopian tube, and now it wasforthcoming. He had always believed that Sampson’sview would prove the correct one.

Dr. CuTHBERT LOCKYER said this was the mostconvincing proof which had been seen up to thepresent. Several observers had found fragments ofendometrium in the menstrual blood in the pouchof Douglas, but this to-night was the most con-vincing evidence of the transference along the tubeof necrobiotic endometrium. But in accepting theimplantation theory as one explanation of endo-metrioma, one must be careful not to push it too far.What the profession was awaiting was informationas to a common genesis for all these and similarconditions.

Dr. W. W. KING said he thought such a fragmentwould have difficulty in getting through the uterineend of the tube. He did not see why it should nothave grown there. He found acceptance of Sampson’sview difficult, as for damaged tissue to implant itselfon undamaged tissue was unique in pathology.The second specimen shown by Dr. WILLIAMS was

a uterus showing multiple polypi of the cervix. Theuterus was removed by vaginal hysterectomy. Exami-nation showed nothing abnormal except that the

cervix felt rough and irregular, and there was nobleeding on examination. A more complete examina-tion under an anaesthetic showed that the cervicalcondition extended far up the canal, and that theroughness previously felt was due to large numbers ofpolypi. The specimen showed an unusual conditionof the cervix ; the endometrium was replaced by adiffuse growth of polypi, and the condition ceasedabruptly at the level of the internal ostium. Therewas no evidence of chronic inflammation, thereforeit was thought the condition was new growth.

Gliosarcoma in a Still-born Faetus.-RupturedAcute Pyosalpinx.

Mr. D. J. MALAN gave a short communication on acase of gliosarcoma in a full-time still-born foetus.There was nothing abnormal in the placenta nor inthe amount of liquor amnii. No abnormality in thefcetal head was suspected, but when the fcetal headwas opened it showed bilateral internal hydrocephalus.There was some tearing of the tentorium cerebri, butno signs of hsemorrhage. In the cerebral hemispherewas found a round lump, and enclosing it was avery much flattened cerebral cortex, cm. thick,covered by smooth lepto-meninges. Another, smaller,gliosarcoma was found in the other side of the cerebrum.The doctor in this case had been blamed for causingthe state of affairs by putting on forceps prematurelyand damaging the baby. The real cause of the baby’sdeath was the tumour. He advocated more routineexamination of foetuses, when it would probably befound that such occurrences were not so rare as theywere supposed to be. He also gave a description ofa ruptured acute pyosalpinx which occurred in thethird month of pregnancy, the patient being 37 yearsof age. There was abdominal pain, great nausea,and some vomiting, with a blood-stained, offensivevaginal discharge. The temperature was 101° F., thepulse 96, tongue moist and furred, and the abdomenvery tender. The uterus was enlarged to the sizeof a two-months’ pregnancy. On doing a laparotomyfree pus was found in the peritoneal cavity. The leftFallopian tube had a perforation 4 cm. wide, andpus was oozing from this rent.--Several membersdiscussed the communications.

Puerperal Sepsis.Papers on puerperal infection were read by Dr.

H. J. PHILLIPS (Monsall Hospital, Manchester). andDr. L. CoLBBROOK (London).

Dr. H. J. PHILLIPS spoke on Rational Treatmentof Puerperal Infection, and said his intention was todeal mainly with the results obtained from the treat-ment of a series of cases along certain constant lines.The work was done at the Monsall Hospital, which wasManchester’s infectious hospital. Here 22 beds wereset apart for puerperal cases, and the admissionsduring a year varied between 90 and 120. Everyencouragement was given to send cases as soon aspossible, and none was refused, yet still many weretoo advanced and serious when received. In hisexperience of puerperal infection he had been muchimpressed by the great amount of extra-uterineinjuries suffered by these patients, and the gravelyseptic nature of the region when patients were brought.He was not now speaking of tearing of the perineum.On exposing the vagina, remains of a lacerated cervixcovered with foul sloughs, teeming with micro-organisms, were frequently found. The uterus ofsuch a patient could easily become infected, and ifthe local defences failed, the infective process couldbecome widespread. Though the acid secretions ofthe vagina might keep micro-organisms inert, in thealkaline lochia and the body tissues they mightrapidly show pathogenic properties. Merely to drainthe cavity or attack the endometrium was not likelyto produce good results ; therefore he had hoped forsome means of helping the uterine wall to drain itselfby promoting a flow of lymph through it into thecavity. Some time ago he had the opportunity ofseeing glycerine used in the uterus for this purpose,and it seemed to him it might solve the problem, as

1229ROYAL SOCIETY OF MEDICINE : OBSTETRICS, ETC.

it was a powerful tissue dehydrant, and its viscidityenabled it to remain for a long time in contact withthe tissues, while at the same time there was no dangerto the patient. The mixture he used was a 10 per cent.solution of tincture of iodine in glycerine, the iodinepromoting the flow of lymph into the cavity of theuterus. Most of the patients were drained in thisway once daily, the more severe cases twice a day.In the first 100 cases the average number of applicationswas seven, the treatment being continued until allactive inflammation had subsided. In this methodthe local condition was well exposed and could bethorough ly cleaned, and there had been a rapid healingof the lesions. The chief source of trouble was the para-vaginal abscess associated with a badly torn vagina.Pus was found in the uterus in half the severe cases,usually only in small quantity, though in one caseit amounted to 6 drachms. Often the doctor hadassumed from the presence of a profuse purulentvaginal discharge that the uterus was draining well,the fact being that none was coming from it. thesuppuration being high up in the vagina. The intro-duction of the iodine and glycerine tended to produceuterine contractions. In 130 cases in which he hademployed lymph drainage (glycerine drainage) hehad never explored the uterus, except for primaryhaemorrhage ; fragments of membrane, placenta, ordecidua had come away in the manner spoken of.

Comparison of Results.Dr. Phillips, for purposes of comparison, gave two

series of cases and the results achieved. The firstconsisted of 87 cases which were treated by lymphdrainage, and the second of 110 cases which imme-diately preceded the first named. In both the caseswere of the same type and drawn from the samedistrict. Before lymph drainage was done at theinstitution the treatment of these cases had beencarried out on three main lines. The milder caseswere dealt with expectantly-i.e., with vaginaldouching, Fowler’s solution, quinine, &c. ; the moresevere with anti-streptococcal serum or curetting.Of the 110 cases, 29 per cent. developed com-

plications, 11 developing pus and needing opera-tion ; while of the 87 cases treated by lymphdrainage, only 14 per cent. developed complicationsand only one developed pus. Dealing next with themortality in the two series, that in the first 100 caseswas 13 per cent., the lowest in the institution for manyyears ; and all died of some condition which wasalready established when the patients entered thehospital. Also, since this method was inaugurated theaverage stay in the hospital had been greatly reduced,from 41-5 days to 26-2 days.Acute Blood Infections Laboratory Investigations.Acting on Dr. Colebrook’s suggestion, he had

adopted two lines of treatment in cases with acuteblood infections-namely, the intravenous injectionof arsenical drugs, and the transfusion of immunisedblood to help the patient’s own defensive mechanism.The drug chosen was novarsenobillon. Disappointingresults followed the use of small doses of arsenicalpreparation, large ones were followed by clinicalimprovement. He exhibited lists of cases givingmany details.

Dr. L. CoiJSBBOOK spoke of laboratory investi-gations which he had been carrying out on the samesubject. He said that in considering what was thechief microbic agent of puerperal sepsis it was notnecessary to go further than the haemolytic strepto-coccus, which was probably the cause of 90 per cent.of the troubles of septicaemic cases and localisedinfections. There was no reason for supposing thatpuerperal sepsis was due to a special streptococcus.As to how the streptococcus usually gained entranceinto the genital tract, it was generally taught that itwas not normally present in the vagina, nor in therectum, and he thought infection from both thosesources must be rare. The problem here did not differfrom that of surgical wounds generally. Ordinarynon-hsemolytic streptococci were more easily killed

by leucocytes than were the haemolytic form. Wasthere any evidence that a woman’s resistance to thestreptococcus was lowered during the process ofpregnancy and labour ? P There were now availablemeans of knowing how efficient a person’s blood wasin killing streptococci, and it was found that therewas no general tendency for the killing power of awoman’s blood to be lowered during pregnancy andlabour. He believed that blood invasions from thegenital tract were more common than they weregenerally supposed to be. Blood in the capillarieshad great power of killing off streptococci, and ifa few of these organisms got through in the first fewdays of labour, if the woman’s blood was normal, therewas but little chance of those microbes survivingin the capillaries. But the woman’s blood might notbe normal, and in septicaemia the killing power ofthe blood was greatly reduced; it might be only40 per cent. of the normal. The real reason was thatin septicaemia the leucocytes were not normal ones ;probably the microbes produced a toxin which wasdisabling to them. Then the microbes getting throughwould be able to survive. When a blood culture wasdone on a doubtful case of septicaemia, the bacterio-logist should be asked to state how many microbeshe found to the cubic centimetre ; that gave impor-tant prognostic information. He had only seen onewoman recover who had more than 100 streptococciper c.cm. in her blood.With regard to local treatment, this, it would be

agreed, was not at the moment all that could bedesired. Two lessons learned in the war experienceswere : that wounds infected with haemolytic strepto-cocci and containing damaged tissue and blood clotcould not safely be left to themselves. Haemolyticstreptococci, as Sir Almroth Wright showed, couldgrow comfortably in damaged bloodless tissues andin blood clot. As the streptococci grew, the containingfluid lost all its bactericidal power, and at the sametime the leucocytes were held back. Something ofthat kind must occur in the case of an infected woundof the genital tract. The worst cases of puerperalfever were those in which the lochia were suppressedand those in which instruments had been used andcaused bruising of the tissues. And the war’s secondgreat lesson in this regard was the efficacy of tiuiddrainage, which Dr. Phillips had demonstrated in hisseries of cases.

Concerning general treatment Dr. Colebrook saidthat in septicaemia there were often millions ofstreptococci in the circulation, and the defensivemechanism of the patient was largely out of action.It was necessary either to have an agent which wouldkill off many streptococci and so give the leucocytesa chance to recover, or there must be an agent whichwould neutralise the toxins which were damagingand inhibiting the leucocytes. Antistreptococcic serumappeared to have no strong place ; to do any effectivekilling of the bacilli, a pint of it would have to begiven. With regard to drugs, the most hopeful ofthose he had worked with was neosalvarsan, and thekilling power of that was pronounced in a strength of1 in 100,000, reducing 526 streptococci per c.cm. to 3in five hours. Concerning transfusion, one could nothope to save a patient by this alone. Reasons for thisprobably were that by defibrinating blood one deprivedit of about 30 per cent. of its corpuscles and mixed itwhen transfusing with nine times the quantity of thepatient’s own blood. Still, he thought it was rightto go on working at drugs and transfusions.

Prof. LouisE McILROY said the results she had hadfrom carrying out Dr. R. Hobbs’s treatment (injectionof glycerine) had been extraordinarily good, drainagehaving been done for seven days. Most of the casesof puerperal sepsis were due to laceration. Recentlyshe had been raising the patient’s immunity by givingantistreptococcus serum and quinine before clearingout the uterus, and the results had been such thatshe intended to continue the practice. Results fromblood transfusion seemed to last only four or fivedays.

1230 SOCIETY FOR THE STUDY OF VENEREAL DISEASES.

MEDICAL SOCIETY FOR THE STUDY OF

VENEREAL DISEASES.

A MEETING of this Society was held at 11, Chandos-street, W., on Nov. 27th, Dr. WILFRID S. Fox, thePresident, occupying the chair.

Medico-legal Problems in Relation to Venereal Disease.Dr. F. G. CROOKSHANK read a paper on medico-legal

problems in relation to venereal disease, which, he said,touched on the provinces of ethics, politics, sociology,religion, and jurisprudence, and could hardly beappreciated without some acquaintance with historyand with human nature. The crux of the questionwas that, however loudly some might say that venerealdiseases were not different from other diseases, humannature would never permit these diseases to be dealtwith by the ordinary routine of notification and sanitaryadministration. Venereal disease was fundamentallyone of the consequences of breaking the social-sexualcode, and the occurrence of venereal disease in apopulation always seemed to be associated with thebreaking of a social code, no matter what that codehad been. He thought it might be taken as axiomaticthat however the social or moral code might change,and whatever degree of promiscuity or liberality insexual matters might be allowed-and, of course, thesexual and moral code had changed in an extraordinaryway during the last ten years-yet the imputationagainst a person that he had venereal disease wouldalways be actionable. To say of anyone that he orshe was unchaste might at one time have inducedsocial avoidance, though it by no means necessarilyfollowed that it would always do so, but the presenceof venereal disease would continue to make a personshunned by even the most degraded. He did not seehow the lawyers could draft any Bill which, merely bymaking the communication of that disease to anotherperson an offence, would be effective in the preventionof venereal disease unless doctors could definitely say,in more than a few cases, that the suspected personmust have known himself or herself to be in aninfective condition. If it was desired to constitutea new kind of offence it would have to be proved thatthere was guilty intention, and that the person knewwhat he was about. This meant that it would benecessary to prove warning. Could warning beproved unless communication had been made to somethird person ?

Mr. EWART WORT, Barrister-at-Law, pointed outthat while in respect to some sexual offences the lawusually required corroboration, a conviction in sucha case as Dr. Crookshank had instanced would dependupon whether the doctor was to be believed when hesaid he had given warning, or the accused person wasto be believed when he denied it, and from his ownexperience at the Bar the doctor’s evidence would beaccepted.

Dr. CROOKSHANK said that, at any rate, it wouldbe impossible to induce lawyers to recognise as anoffence an act of this nature unless it could be shownthat the person who committed the act really under-stood his state and had been warned in respect of hisinfectivity. Germany and Sweden appeared to haveadopted legislation in respect to the communicationof venereal disease, and their experience must bevaluable. While, no doubt, a medical examinationbefore marriage would be an ideal arrangement, hecould not help feeling that one could not go safelybeyond the requirement of a statement on oath bythe parties made at the very last moment. Herecalled a case within his own experience of a manwho only on his very wedding day discovered that hewas suffering from venereal disease, the last illicitconnexion having dated from three months previously.The very fact that some such declaration was requiredat the last moment might go some way to induce afeeling of responsibility. It seemed necessary, however,to fall back upon the continuation of the present state

of affairs, even if there was occasional occurrence ofthe position so often alleged to be frequent, whereinDr. A was aware that Mr. B had venereal disease andintended, in spite of all expostulation, to marry Miss C.In England a breach of professional confidence wasnot an offence in itself and so punishable, as was thecase in some countries abroad. If a medical manbroke professional confidence by saying that a certainperson was syphilitic and so injured him, it waspossible for that person to bring an action againsthim for slander or libel, but not for breach of profes-sional confidence. The doctor (granted, of course,that he was sure of his ground) should, however, beprepared to take the consequences, which the speakerdid not believe would be serious to himself under suchcircumstances, and to warn Miss C or her parents. Insuch difficult cases members of the profession shouldhave the courage of their convictions. If theytechnically broke the law and uttered slander in orderto prevent the marriage of a syphilitic to an innocentperson he did not think that in the long run the lawwould punish them very severely, while there wasnothing in the oath of Hippocrates to prevent anyman conscientiously breaking professional confidencein such circumstances.

Mr. WORT dealt principally with the compulsionupon witnesses to give evidence in courts of law.There were certain exceptions to such compulsion.On the grounds of public policy, no husband or wifewas compelled to make a statement which was theresult of communication by the other. No person wascompelled to give evidence in a court of law when theevidence would incriminate himself. And there wasthe third exception, the privilege which a member ofthe legal profession enjoyed in regard to communica-tions made to him in the course of his professionalactivities. This last was an anomaly, but it wasabsolutely necessary by reason of the fact thatwithout that privilege the administration of justicecould not be carried on. It might be asked, why thedistinction between the medical and the legal profes-sions in this respect ? But the point was that of allthe information obtained by the medical man in thecourse of his profession, not one-thousandth partwould ever be the subject-matter of litigation, whilein regard to the communications made to a lawyer,every such communication carried the potentiality oflitigation. This privilege of lawyers was not theprivilege of a profession as such ; it was the privilegeattaching to a particular kind of communication. Dr.Crookshank had referred to the law in other countries.It was part of the penal code in France that anycommunication made by a doctor in breach of hisprofessional oath was a criminal offence, but therewas an exception-namely, when he was compelledto give evidence in a court of law. If further legisla-tion was necessary in order to get to closer grips withthe social problem put forward by Dr. Crookshank,it was for the medical profession above everybody elseto educate the public up to the point of such legislation.Any legislation making it a penal offence to com-municate this disease to an innocent person must takeinto account the state of knowledge of the personindicted. An analogous class of case in this respectwas the receiving of stolen property, which was extra-ordinarily difficult to prove. The law had surmountedthe difficulty by putting certain tests which the jurywere instructed to apply to the particular case. Onesuch test was whether the person had purchased theproperty at a very low price ; if he had done so it mightbe justifiable to suppose that he knew it to have beenstolen. Whether some similar tests could be appliedto persons suffering from this disease was for themedical profession to state. In the case cited by Dr.Crookshank of Dr. A, Mr. B, and Miss C, the onlypossible action would be an action for slander, and tosuch an action justification was a complete defence.But there would be a further defence in the shape ofwhat lawyers called qualified privilege. The difficultywith medical evidence, however, was that occasionallyDr. A went into the box and said one thing, and Dr. Zanother.