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cavity was washed out with copious irrigations of a 1 in 300solution of ]ysoL The temperature rose to 1035°, butnext day had fallen to normal and the patient made a goodrecovery. Soon afterwards. however, signs of pulmonarytuberculosis appeared and she spent some months in asanatorium. ’

It might be questioned, said Mr. Gough, whetherthis was really a case of placenta accreta. It wasclearly a morbidly adherent placenta, but perhapsnot one of the most adherent. Generally, the diagnosisof placenta accreta had been made after an unsuccess-ful attempt at its manual removal.

’8V-hat was the proper course when the placentacould not be delivered in the usual way ? MostEnglish text-books said that it must be removedmanuallv after a certain time-one or two hours.Any important post-partum haemorrhage was, ofcourse, an indication for the immediate emptying ofthe uterus. In this case, with no loss of blood forthree hours and then only a minimal loss, the safercourse was the one adopted. The forcible scrapingaway of the placenta in fragments entailed a grave risk Iof perforation of the uterus, shock, and haemorrhage,and the later development of septic complications. Arisk of leaving the placenta was, he supposed, thatseparation might take place and post-partumhaemorrhage occur when no help was at hand ; butit seemed unlikely that a closely adherent placentawould suddenly become detached. This fear mighthave some weight in dealing with a patient in aremote country district, but in an institution it mightbe entirely disregarded. Then there was the risk ofsepsis being favoured by the retention ; it had occurredin this case, but was evidently of the sapraemic type.

Mr. J. E. STACEY( Sheffield) described a specimenof bilateral tarry ovarian cysts ; the PRESIDENT andMr. A. A. GEMMELL (Liverpool) reported a case ofuterine sarcoma which ruptured and caused acutesymptoms 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 Sepsiswas read by Dr. JAMES YOUNG. He said that the totalmortality in these islands was about 4000 yearly ;between 1911 and 1926 inclusive there had been66,421 deaths in England and Wales. The mostimportant single cause was sepsis. For 1926 the totalmaternal mortality-rate in England and Wales was5-14, and the sepsis rate 1-60, per 1000 live births.The causes of puerperal sepsis might be clinicallyconsidered as : (1) Contagion-namely, contact infectionwith a virulent microbe introduced from without, inwhich the phenomena were similar to those presentin other infective diseases, for example, tetanus,erysipelas. (2) Trauma. Here the wound was theprimary factor and overshadowed in importance the

, source and nature of the microbes, which belongedto the widespread micro-organisms capable ofcausing wound infection. (3) A uto-infection. Here ’Ithe microbes were present in the genital canal before ilabour or they reached it from some distant source, Ifor example, bowel, teeth, or tonsils. The essentialdistinction between these three clinical types was notundermined by the fact that in some cases two ofthe factors might, be operating together.

Auto-infection, said Dr. Young, had sometimes beenadvanced as an explanation of the persisting highdeath-rate from sepsis in modern times, despitethe application of the aseptic principle. Thatit probably played a minor role was, however,suggested by an analysis of the records of largematernity practices. In the Edinburgh MaternityHospital about a century ago and in other large

hospit,als-e.g., Dublin-puerperal fever was a

negligible cause of death when contagion was obviouslyin abeyance ; then years might pass without a deathfrom sepsis. There was similar evidence in extensive emodern practices. Thus in the extern practice of theEdinburgh Maternity Hospital there had been 5000successive, sp ontaneou8 , normal deliveries with 2 deathsfrom sepsis; there had been 888 cases in the externpractice of the Birmingham General Hospital withno deaths; whilst there had been 47,593 deliveries inthe unselected practice of the East End MaternityHospital in London with 5 deaths from sepsis, or

1 in about 9500. During 1927, in the practice of theQueen Victoria’s Jubilee Institute midwives, therehad been 53,502 deliveries with 6 deaths in normal,spontaneous births, or about 1 in 8900. On includingin this record all the deaths which could directly orindirectly be attributed to sepsis, the maximalfigure, including normal and abnormal cases, wasseen to be less than 0-5 per 1000. The conclusionwas that the very small septic death-rate in theselarge bodies of women, who could not be regardedas selected from this standpoint, was an argumentagainst self-infection, operating alone, being an

appreciable component of the death-rate in the restof the community. Dr. Young discussed the resultsof recent bacteriological research, which he saidsupported this view. The records of the old hospitalsshowed that contagion was the dominating cause ofthe deaths from sepsis. Instrumentation was thenrare-the forceps rate in the Edinburgh MaternityHospital a century ago was 1 in 472 cases (Simpson)-and trauma was negligible as a cause of sepsis. Ifthe Queen Victoria’s Jubilee Institute midwives’practice could be taken as typical of midwives’practice nowadays, contagion (as judged from theincidence of normal cases dying from sepsis) was anegligible cause of death in over 50 per cent. of themidwifery of England and Wales which was in thehands of midwives. He quoted these figures merelybecause they were the only large records available,and not because they necessarily demonstrated anysuperiority, qua simple contagion, of the midwives’over the doctors’ practice. He did not think therewas any evidence that this was so. Contact infectionof the normal by the abnormal and infected case

was a risk in modern maternity hospitals, and it wasdifficult to exclude completely. In Dr. Young’sopinion, trauma due to instrumentation was probablythe main cause of the present septic death-rate.On analysing the factors at the back of the greatlyincreased instrumentation of modern times, heconcluded that it was unwarrantable to consider thatthis was entirely or even largely attributable to

malpractice. That with satisfactory antenatal careand an efficient maternity service, the maternalmortality could at once be lowered was, however,supported by the record of the East End MaternityHospital, London, where during four years in 9000cases the total maternal mortality had been reducedto 0’67 per 1000. Here the instrumental rate wasbetween 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 infectionin hospitals call for care in the extension of the hospitalsystem of maternity service.I

(3) There is evidence that trauma is the most importantcause of the death-rate from sepsis. This is not entirely aproblem involving the medical attendant; it hasimplications of a wider nature.

(4) The immediate need is an improved machinery formaternity practice based on a midwife-doctor combination.From the standpoint of immediate policy the importance ofthis overshadows all other considerations-e.g., " research,"and there is reason for the hope that by this means alonea lessening of the death-rate is possible.

(5) Improved education of the public, midwife, andmedical student and the assistance of the central and localauthorities are all necessary for the creation and workingof a satisfactory machine.

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D iScu8sion.Dr. WILLIAM FORDYCE said that the question of

segregation of confinement cases in hospitals wasimportant, and he wondered if it was really a goodthing for normal cases to be confined in hospitalswhere there was only a limited amount of space.He thought that forceps delivery in selected casesprevented the trauma that might otherwise be causedby long-delayed labour. He regarded the statistics ofpuerperal sepsis of 100 years ago as not very reliable.

Prof. JAMES HENDRY quoted three cases of pyrexiaof extraneous origin-i.e., from an infective rhinitis,a commencing whitlow, and a septic wound on theskin of the patient’s husband-to show the importancewhich contagion might have. He advocated separateaccommodation in maternity hospitals for cases sentin after interference outside.

Dr. DOUGLAS MILLER quoted from statistics ofthe Royal Maternity Hospital, showing that theincidence of pyrexia in cases delivered instrumentallywas much larger than in those whose delivery hadbeen spontaneous. He had found a marked variationin the bactericidal power of the blood in pregnantwomen, which might explain the variation in individualsusceptibility to infection.

j Dr. J. M. ]3owip, thought the whole machinery ofmaternity service in this country needed overhauling.This reorganisation might be done in two ways:(1) by the present system of trained midwives workingalone in normal cases and assisted by doctors indifficult cases; or (2) a new race of specialists mightarise which would devote itself exclusively to

midwifery.I Dr. KEPPIE PATEBSON attributed great value toprolonged antiseptic douching after delivery even innormal cases, but believed it to be of greater valueafter manipulative interference.The PRESIDENT thought that haemolytic streptococci

might be rendered temporarily inert by normalvaginal secretion, but under certain circumstancesthey might regain their hasmolytic action. lie alsourged the segregation of complicated cases, but forthis a large hospital was required. Trauma was notdue only to instrumental interference, as normallabours were often associated with very severe trauma.

Dr. C. W. SOMERVILLE described three confinementscomplicated respectively by measles, encephalitislethargica, and diabetes.I Dr. CHARTERIS GRAHAM described ten cases ofi Caesarean section performed by himself.

Reviews and Notices of Books.GYNCOLOGY.

By HOWARD A. KELLY, A.B., M.D., L.L.D.and Collaborators. London and New YorkD. Appleton and Company. 1928. Pp. 10432 10s.

MOST British gynaecologists probably cherish th(hope of one day visiting the clinics of the UnitedStates and Canada, but for those who find the idealdifficult or impossible to realise we can conceive ncbetter substitute than a careful study of this volumeby Howard Kelly and 22 collaborators, each speciallyexpert in the subject with which he deals. This isnot a text-book in the ordinary sense of the word ;the author would probably say that it is not meantto be. The junior student will not usually find heresufficient pathology to enable him to understandthe clinical features of gynaecological diseases ; thebook is essentially one for the more advanced manwho has already acquired a good acquaintance withgynaecological pathology. Out of 49 chapters18 are from the pen of Kelly himself, and theseare amongst the most valuable, recording, as

they do, the results of a lifetime of uniqueexperience in gynaecological work. A numberof contributions deal, with special symptoms ingynaecology and with borderline conditions. Forexample, there is a good chapter on backache byRobert W. Johnson, one on pneumoperitonealrontgenography by Rueben Peterson, and a mostuseful one on psychiatry and mental hygiene byEsther Loring Richards. Ureteral stricture as a

possible cause of almost every symptom met within gynaecological practice is fully discussed by GuyL. Hunner ; this condition, it appears, is found inabout 12 per cent. of autopsies. Amongst thesymptoms it may induce are backache, pelvic pain,pain in the hips and down the thighs, bladder irrita-bility, urinary incontinence, headaches, ovarianneuralgia, dysmenorrhoea, dyspareunia, and menor-rhagia ; the occurrence of the last symptom isexplained by damage to renal function and consequent Itoxaemia. After this terrifying list it is good tolearn that stricture can easily be dealt with by iureteral dilatation.In their attitude to " endometritis " American I

gynaecologists seem to be even more advanced than Iourselves, for as a pathological entity it has almostcompletely disappeared. Gonorrhoea is describedas the typical infection of the female genitalia, but I

the gonococcus, though it gains entrance to thetubes through the uterine cavity, rarely leaves anysignificant changes there ; even in bilateral pyosalpinx

i and cervicitis the corpus uteri usually remains normal.The explanation " probably lies in the periodicregeneration of the endometrium." A gonorrhoealendometritis, however, may occur with a loweredresistance as after injudicious instrumentation, a

miscarriage, intra-uterine polyps, or an overwhelminginfection of the tubes or ovaries. The mucous

membrane as well as the musculature of the uterus.may be infected from abscesses burrowing into theuterine wall ; though the writer (Lawrence R.Wharton) does not say so, we presume that in thesecases the mucosal infection never becomes chronic.

Few readers in this country will be inclined to disap-prove of this iconoclastic attitude towards endome-tritis as a pathological conception ; inflammationof the endometrium was always difficult to demon-strate, and certainly neither teacher, student, norpathologist will regret the disappearance of themost confusing chapter in gynaecology. Apparently"senile endometritis " has also been discarded ;-yet in the endometrium after the menopause-there is no periodic regeneration. Nor is there anyreference to the condition recognised in this countryas chronic metritis or subinvolution, with its associatedchanges in the elastic tissue. Perhaps this is included,under the term" myopathic haemorrhages," thoughno explanation is given as to what these haemorrhagesare. A clear account of the distinction between theold and the newer teaching would be appreciatedby the student-reader, who may be puzzled by aclassification quite unfamiliar to him. The chapteron peri-uterine tubal insufflation by 1. C. Rubinis especially good, though it is doubtful whether tubalinsufflation will ever be practised in this country, as itis in America, as an office procedure occupying five toten minutes. Endometriomata (Chap. 39) are dealtwith by R. M. Lewis, who gives an excellent accountof the work of J. A. Sampson, but the reader maywell wonder why the subject is discussed also inChapter 32 under the title of

" adenomyoma." Thesection on menstruation bv Emil Novak is adequateyet succinct; it is disappointing to find no reference-o the hygiene of menstruation. Why is Fallopianpelt " fallopian " throughout the book, whilst the;apitals are retained in Morgagni, Gartner, Sims,Emmett, Kelly, and Novak ?This book does credit to the editor and hisichool, and may be warmly recommended to theadvanced student and to those who wish to keepn touch with the trend of American gynaecologicalopinion.