whether in such a case of inter-arytenoid tumour as the one described, the pulmonary mischief might not be caused by the act of coughing. Dr M'Bride hardly thought this likely. At the same time, it was but quite recently that the first autopsy of a case of primary laryngeal phthisis had been made. During life it was, of course, impossible to be certain as to the absence of deepseated, small, caseated nodules. He did not think that the connexion between inter-arytenoid tumour and phthisis had yet materially advanced beyond the stage of clinical observation. It must also be remembered that in phthisis, and with rare exceptions, if any, in phthisis only did a true tumour appear in this situation. With regard to the nasal tumour, he would like again to call attention to the fact, that had the tumour been attached by a shorter pedicle to the lower part of the posterior nares, the operation would have presented little difficulty. It was the fact that the neoplasm was inserted in the most inaccessible part of the nasal cavity by a long pedicle that made its removal only possible by means of traction with the finger. Moreover, at one period of the operation, the growth had got impacted in the left nostril in such a manner that it could only be felt after it had been pushed back again with a gum elastic catheter; this fact alone gave some idea of its mobility. Dr Johnston had referred to hydrobromic acid in tinnitus, as recommended by Dr Woakes, especially in the pulsating variety. Dr M'Bride thought his experience as to its negative value tallied with that of many other observers.

OBSTETRICAL SOCIETY OF EDINBURGH.

SESSION XLVII.-MEETING II.

Wednesday, 9th December 1885.-Dr HALLIDAY CROOм, President, in the

Chair.

(Continued from page 876.)

Dr Underhill thought Dr Barbour had done well in separating the scientific from the practical side of the question under discussion. Further, he was very glad of the opportunity we had had of listening to the exposition of the scientific aspect of the question by Dr Hare. We were often too apt to overlook the importance of the scientific views of such subjects. It was long since Sir James Simpson showed the relations of the stump-like surface of the uterus post-partum to this disease, and Semmelweiss insisted upon the danger of the dissecting-room poison in the lyingin room. It was not, however, until Pasteur brought the demonstration of the causation of this condition clearly forward, that the treatment based on this demonstration was regularly adopted. The result was that after antiseptics came to be systematically applied we had an enormous fall of the mortality from this cause, a EDINBURGH MED. JOURN., VOL. XXXI.—NO. X.

6 F

its cure.

greater fall of death-rate than had been effected by any other means. The success which followed the adoption of perfect cleanliness gave the key to the pathology of the conditions. It seems to him the prevention of puerperal fever was a point demanding greater attention at the present time than We should go to our patients in a scientifically clean state, and see that all our surroundings are clean. We should bear in mind the polymorphic character of the poison we have to deal with, a poison which may come from scarlet fever, from erysipelas, from a defective drain, and from other sources. The cause of the autogenetic form corresponds to the form of organism found in dead tissue. If we remove the source of the infection by washing out the uterus in these cases the symptoms disappear more rapidly than those arising from any other cause. He believes, accordingly, that this variety of septicæmia is much more amenable to treatment than that arising from general septic poisoning. In this case, if we remove the cause we remove the effects. When, on the other hand, the poison comes from the outside the case is different, and the treatment is vastly more difficult. Thus it comes to be most important to attend to prevention; and when we do meet with a case treatment ought to be prompt. He agrees with the others who have spoken as to the value of corrosive sublimate, and would resort to it in all such cases.

Dr Foulis hesitated to say anything on a condition about which, as it seemed to him, so little of what is really certain is known. He came to the meeting with his mind filled with doubt as to the nature of the disease which we have been discussing, and he was bound to say that nothing which had been said as yet had served to clear up any of those doubts. And so it seemed to him that, not knowing the nature of the disease, it is premature to ask, How can we apply a remedy? Are we to conclude that this new organism is the only cause of puerperal fever in all parts of the world? Is puerperal fever a name given to that form of bloodpoisoning arising after parturition only, or is it a specific fever ? There are numerous forms of the fever, as Dr Underhill has pointed out. The symptoms are endless-neuralgia, fever, etc., etc. this micro-organism then is the cause, is the puerperal state the only one in which it can develop? Is inflammation the process which produces the nidus in which this micro-organism can develop, or is the inflammation the result of the development of this micro-organism? If we regard the condition of the puerpera we see that the blood is circulating in all directions, and that a poison introduced into the blood gives rise to the fever, etc., which we call blood-poisoning. we are correct, then, in attributing the symptoms of this disease to the circulation of this poison in the blood, how, he would ask, can we explain the disappearance of these symptoms which, it is claimed,

If

so often follows the local application of antiseptic douches to the uterus? He has abandoned the idea that puerperal septicemia is a specific disease at all, but believes that there may be many sources of infection. Further, the poison may even be absorbed by the lungs, as in breathing an infected atmosphere tainted by the emanations from a water-closet or drain. So far as the specific cause is concerned we are, it seems to him, in the dark. But not so much in the dark as we would be did we set aside the germ theory of the disease. That the condition arises from the introduction of germs he thinks admits of no doubt, and this ought to give us the clue to our treatment. Thus we should see that no woman has a child in a bad atmosphere; we should see that no "vaccine" material be introduced by the hand of the doctor or the nurse. He regards the prevention of puerperal blood-poisoning by a preparatory treatment of the patient by means of certain drugs as a suggestion of a line of treatment which may prove of the highest importance. He thinks the treatment by the washing out of the uterus by means of antiseptics after the development of the fever is too late. Why not wash out the uterus as soon as the child is born, so as to prevent the development of the disease at all. To him it seems that to wait until the fever has developed is very much like locking the door after the steed is stolen.

The President, in closing the discussion, thanked Dr Hare, a stranger, for the valuable contribution he had made to the discussion, and at the same time took this opportunity of conveying to Dr Barbour, on behalf of this Society, its thanks to him for originating the discussion, and opening it by a contribution of such scientific and clinical importance. The whole subject was admittedly a difficult one, but he thought that discussion had done much to clear the ground. For example, take the question of washing out the uterus with some antiseptic lotion in cases of puerperal septicæmia. Of the value of this there could be no possible doubt. He had himself, both in hospital and private practice, met with cases post-partum and post-abortum where marked septicemia had set in with a high temperature, and where, after one or two washings of the uterine cavity with 1 in 2000 solution of perchloride of mercury, the temperature had fallen, the symptoms of septic poisoning disappeared, and the patient made an excellent recovery. Of the value of intrauterine antiseptic irrigation in cases of autogenetic septicemia there could, to his mind, be not the faintest doubt. Still, till now, there was the difficulty in explaining this action. Dr Barbour had shown to-night that micro-organisms require rest for their development. They will not multiply in the circulatory fluid. The fact that they do not multiply in the circulating blood explains why the washing out of the uterus acts beneficially. It cuts off the supply of microbes, and as those already formed do not increase in the moving blood, their ultimate elimination is only a matter of strength

and time. As to the value of antiseptics in obstetric practice nothing could be more remarkable than his own experience in the Edinburgh Lying-in Hospital. Entering on duty in an entirely new hospital, in his first quarter he met with an outbreak of puerperal fever, in which he lost three successive cases. He then had introduced careful antiseptics, drawing up strict rules for nurses, pupils, and resident-surgeon, and from then till now, a period of six years, he had not lost a single patient from that cause. Whatever theories might be urged to explain it, the fact remained that the adoption of antiseptics had practically stamped out the scourge of puerperal fever, not only in the Edinburgh Hospital, but at Prague, in London, in the pavilion Tarnier in Paris, in Copenhagen, and indeed, wherever this treatment had been honestly and carefully carried out. He congratulated the Society on the discussion, and believed that whatever might be its intrinsic value as an addition to our scientific knowledge of the subject, and he believed this was great, if it pressed home on the Fellows the importance of the most minute antiseptic details in obstetric practice, the evening had been well spent.

SESSION XLVII.-MEETING III.

Wednesday, 13th January 1886.-Dr HALLIDAY CROOM, President, in the Chair.

I. Professor Simpson showed for Dr Robertson Crease A HYDROCEPHALOUS FETUS. A. B., æt. 36, married. Family history, good. Father died of apoplexy, aged 70 years, and mother about the same age, of bronchitis. On the father's side, history good; no history of any nervous or brain disease. Menstruated at age of 14. Type, 28 days; duration, 3 days; amount abundant and florid. In intra-menstrual period slight leucorrhoea. Has had nine children at full term, all healthy at birth. Her second child, a boy, at age of 2 years, had at attack of acute polio myelitis anterior, and is living. Her first child, female, was still-born, no motion having been felt by the mother for some days previous to birth. The mother is of medium height, well developed. Pelvic measurements-Interspinal, 10 inches; intercristal, 11 inches. Her last menstrual period ended on 2nd March 1885, and she was delivered on 4th January 1886. She states that she has been more or less in pain since 25th December, and that labour began by the escape of the waters on 1st January. I was sent for on 4th January in the afternoon, and found, on examination, the pelvic cavity was filled by a tense fluctuating mass, which, on careful examination, was found to consist of head of child, fontanelle of which were enormously expanded, and the bone thin. Pains were vigorous, and by this time, and when the head had fully distended the perineum, fearing that it would not pass without the size being diminished, preparation was made for

perforation. A drachm of extr. ergot. liq. was administered. The next pain was sufficient to expel the mass en bloc. The placenta was expressed, and the patient has recovered without a single bad symptom. Out of 3476 tabulated cases which have occurred in my practice, I have only met with three dropsical cases, viz., the above-mentioned hydrocephalic, one case ascites, and one hydrothorax. The two latter had to be delivered by forceps after much difficulty. Length of child, 22 in.; circumference at chest, 13 in. Head diameters-occipito-frontal, 6 in.; occipito-mental, 6 in.; sub-occipito-bregmatic, 4 in.; biparietal, 5 in.; bitemporal, 4 in.; trachelo-bregmatic, 4 in. Circumferences-occipito-frontal, 17 in.; occipito-mental, 17 in.; sub-occipito-bregmatic, 15 in. The chief points that call for special notice are-the duration of pregnancy, the length of the first stage of labour, the size of the head, and the peculiar way in which it was projected in an elongated form over the perineum, and no rupture of uterus or perineal tear taking place.

II. Mr Skene Keith showed an OVARIAN TUMOUR, which had been characterized by marked slowness of growth, taking 4 years to attain its size at the operation. The cause of this tardy growth seemed to be a twist on the pedicle. The tumour was firmly adherent, and on this account the direction of the twist could not be certainly determined. Though the operation had been attended with considerable difficulty on account of the adhesions, the patient had done well.

III. The President showed (1) for Mr Lawson Tait TWO PAIRS OF OVARIES AND TUBES, which he had removed from patients of his (the President's) during a recent visit. The one patient was suffering from a very large bleeding fibroid, which had already (three weeks since the operation) become considerably reduced in size. The patient has otherwise done remarkably well, and was then sitting up for some hours each day. The other ovaries were removed from a woman who, seven years ago, had been delivered of a child after a prolonged and instrumental labour. Since then she has led a life of almost continuous and intense suffering, so that she has been entirely unfit for her domestic duties. There was intense dysmenorrhoea and dyspareunia. The ovaries were matted down in the pouch of Douglas, and exquisitely sensitive. The patient was now completely free of pain, and was discharged that morning, twenty-five days after the operation. (2) A PHOTOGRAPH of enormous enlargement of the mammæ in a woman, aged 19, in the fourth month of pregnancy.

IV. The President read a NOTE OF A CASE OF RETENTION OF URINE FROM AN UNUSUAL CAUSE, which appeared at page 734 of this Journal.

Professor Simpson regarded this as an important clinical observa