OBSTETRICS. UNDER THE CHARGE OF EDWARD P. DAVIS, A.M., M.D., PROFESSOR OF OBSTETRICS AND DISEASES OF CHILDREN IN THE PHILADELPHIA POLYCLINIC; VISITING OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL, ETC. A SUCCESSFUL CESAREAN SECTION FOR PHYSOMETRA. It is not usual to find Cæsarean section performed after the death of the fœtus, but ECKERLEIN reports (Centralblatt für Gynäkologie, 1892, No. 8) a case in which a large fœtus was contained in a pelvis so small that its exit was impossible. The patient had been in labor several days before she came to the hospital, and had ceased to feel evidence of foetal life. Upon examination, the uterus was found tympanitic, and a foul discharge was present. The pelvis was so highly contracted that embryotomy would have been more dangerous than an abdominal section, and as the patient and her husband greatly desired the subsequent birth of a living child, it was determined to perform the conservative Cæsarean section. It was impossible to use an elastic ligature, as the head of the child was impacted at the pelvic brim. The foetus was found to be putrid, and was easily removed. The uterus when emptied, contracted very quickly and perfectly, but subsequently bled from the site of the placenta. It was accordingly tamponed with gauze and closed by two rows of sutures. After closure, the uterus was cleansed with sublimate solution 1 to 4000, then with a 4 per cent. solution of boric acid, and restored to the abdominal cavity. The patient made a tedious convalescence, suffering from abscess of the abdominal wall, which rendered union delayed. She recovered, however, and was discharged with the uterus high in the pelvis, the tissues of the pelvis being free from exudate. POST-PARTUM HEMORRHAGE AND HEMATOMA OF THE VULVA. FÜTH describes in the Centralblatt für Gynäkologie, 1892, No. 14, the case of a multipara who had previously suffered many attacks of severe illness, who was delivered by the use of the forceps. Uterine hemorrhage followed delivery, which was checked by hot injections and the use of the iodoformgauze tampon. There was noticed a tumor of the right labium which impeded somewhat the delivery of the head. The day after delivery the tumor had become so large as to occupy the whole space externally at the bottom of the pelvis. It was bluish in color, and its coverings began to necrose. Hæmatoma was diagnosticated, and a few days after the patient showed a small, frequent pulse, and rise of temperature to 102° F. The tumor was incised and a large blood-clot removed. The cavity was thoroughly cleansed, and as free hemorrhage occurred, two stitches were taken, and the remaining portion tamponed with iodoform gauze. A second tumor occurred upon the left side, which was also incised and found to contain decomposed blood, with fragments of connective tissue. This was also disinfected and packed with gauze. The patient's condition afterward was very critical for over a week, but recovery finally ensued. An explanation of the hemorrhage which occurred, although the uterus was well contracted, is to be found in the frail condition of the patient's health and atheromatous disease undoubtedly present in her smaller blood vessels. THE TREATMENT OF ASPHYXIA IN THE Newborn. FOREST (Medical Record, April 9, 1892) describes a method for resuscitating asphyxiated infants as follows: He places the child on its face, its head down, and expels fluids from the mouth by pressure upon the back; the child is then put in a pail or tub of hot water in a sitting posture, supported by one of the operator's hands across its back, its head bent backward. The physician grasps the child's hands with his other hand, carries them upward until the child is suspended by the arms, leans forward himself and blows air into the child's mouth; the infant's arms are then lowered, its body is doubled forward, and its thorax pressed between the hands of the physician. Air is thus expelled. Especial advantage is claimed for this method from the fact that the hot water maintains capillary circulation, and tends to assist in promoting the action of the heart. PURPURA HÆMORRHAGICA COMPLICATING PREGNANCY. The Transactions of the Obstetrical Society of London, vol. xxxiii., contain a number of interesting papers, and among them one by PHILLIPS upon the subject mentioned above. He finds that the prognosis in pregnancy complicated by purpura hæmorrhagica is extremely grave, most cases proving rapidly fatal. Death usually occurs from post-partum hemorrhage or from septic infection. Abortion or premature labor is the rule. These cases have a different rash from those in the non-pregnant. The disease is not hereditary, but often causes intra-uterine death. CHOREA COMPLICATING PREGNANCY. In the same volume as the above, MCCANN contributes an elaborate paper upon chorea in pregnancy and after labor. He divides the disease into three forms-true chorea of pregnancy, hysterical, and mixed. In true chorea, quickening causes an exacerbation, as do fœtal movements, and peripheral stimuli, such as suckling. Chorea most often occurs in pregnant patients between the ages of eighteen and thirty. It is most common in the first pregnancy, and during the third or fourth month. It is most usually traced to a previous attack of chorea, rheumatic fever, or hereditary rheumatic history. Epilepsy, nervous disorders and fright, mental emotion, anæmia, are also causative factors. A pregnant patient will not have chorea, however, unless she has a hereditary predisposition to nervous excitability, a disordered condition of the blood, and some exciting cause; foetal movements aggravate the disease. In severe cases, the motor cortex, mental centres, and spinal cord are involved. The majority of mothers recover, some become maniacal, others die in delirium or paralysis. If labor occurs at term, the risk to the child is not increased. Choreic movements rarely cease after delivery, although less severe. If chorea has occurred in childhood, it is almost sure to return during pregnancy. The younger the patient is during the first pregnancy, the more liable the chorea to return. So far as treatment is concerned, the patient should be put as absolutely at rest, mentally and physically, as possible. Change of scene and surroundings is often useful. Iron, arsenic, and nourishing food should be freely given. The bowels should act regularly, and diaphoretics should be used if the skin is dry. To procure sleep, chloral, in doses of from thirty to forty grains, is recommended. Chloroform may be employed in very violent cases. To avoid abrasions, the patient should sleep in a padded bed; the mattress laid upon the floor, the walls of the room being also padded. Strychnine has been used successfully, pushed until symptoms of poisoning began. Antirheumatic treatment is sometimes useful. At labor, the patient should be controlled, and hemorrhage should be avoided. Especial care should be taken in antiseptic precautions. Labor should be induced where the mother shows signs of exhaustion, where mania or serious mental affection exists, and in cases of heart complications. The decision to induce labor rests upon an accurate diagnosis, as hysterical chorea is common, and may easily deceive. BACKWARD DISPLACEMENT OF THE UTERUS AND STERILITY AND ABORTION. The concluding paper of this volume of Transactions is by HERMAN, who endeavors to ascertain the relationship between backward displacement of the uterus and sterility from an analysis of 3641 cases. He concludes that backward displacement of the uterus does not cause absolute sterility nor habitual abortion. In the later years of the childbearing period, backward displacement causes a small amount of relative sterility and also a tendency to abortion not so great as that produced by other causes. THE OBSTETRIC ASPECT OF THE PELVIC PERITONEUM. STEPHENSON, in the British Medical Journal, 1892, No. 1630, p. 645, draws attention to the fact that during pregnancy the ligaments of the uterus are put upon the stretch by the continued growth of the ovum, and that their attachments to the pelvic walls are often loosened. The peritoneum covering the uterus yields gradually, its thinning being supplied by continued and rapid growth. When expansion of the neck of the uterus is rapid during labor, the resistance of the peritoneum over the internal os is considerable; when, however, the expanding force acts gradually, the tissues yield imperceptibly, but to a remarkable degree. Stephenson employs a term used in physics, to describe this yielding of the uterine peritoneum, styling it a "viscous resistance." From this point of view the uterine peritoneum plays a considerable part in the dynamics of labor, and its rupture in cases of rupture of the uterus is easily explained. It has also a considerable part in resistance often found at the internal os when forcible dilatation or operative procedures are necessary, and its involution proceeds with that of the body of the uterus. MYOMECTOMY DURING PREGNANCY. STRAUCH (St. Petersburger medicinische Wochenschrift, 1892, No. 10) reports the case of a patient four months pregnant who complained of pain in the left side of the abdomen. The fundus of the uterus was found midway between the pubes and the umbilicus. A tumor the size of a large goose's egg, easily movable and painful, was felt at the left side of the uterus. The tumor increased while the patient was kept under observation, and gave a sense of indistinct fluctuation, while her pain grew more acute. It was then thought to be a rapidly growing ovarian cyst. Upon laparotomy a subserous pedunculated fibroid presented at the abdominal incision; its pedicle was ligated, the tumor removed, and the peritoneum stitched over the stump. The operation took but little time, and was followed by uninterrupted recovery. The rapid growth of the tumor had been occasioned by the stimulus of pregnancy; the patient went on and completed a normal pregnancy. THE BLOOD IN PUERPERAL SEPSIS. OTT reports from the clinic of Von Jaksch in Prague (Prager medicinische Wochenschrift, 1892, No. 14) a case of puerperal sepsis in which the examination of the blood afforded information of interest. The patient was probably infected by a midwife who attended her; two days after labor she had a severe chill, followed by fever. The midwife who cared for her had a felon upon the middle finger of her right hand where the skin had been broken. During the patient's illness her urine was examined and found to contain albumin and an abundance of aceton and urobilin. An examination of the blood showed 3,470,000 red to 15,320 white corpuscles, a ratio of 1 to 220. The percentage of hæmoglobin was 8. An examination of the blood stained by Gram's method showed the presence of numerous cocci in groups. Septic panophthalmitis developed on both sides. An examination of the colostrum from the breasts showed the presence of cocci. The patient died about two weeks after labor, and a post-mortem revealed the lesions common in puerperal pyæmia. The cocci present in the blood, and also the condition of leucocytosis which was present, render the report of the case of unusual interest. CHANGES IN THE BONES OF THE MOTHER DURING PREGNANCY, AND THE SIGNIFICANCE OF PUERPERAL OSTEOPHYTES. HANAU reports in the Fortschritt der Medicin, 1892, No. 7, his observations upon twenty cases of pregnancy in which an opportunity was obtained to examine the bones. In those of the pelvis he found especially that in healthy persons an unusual growth of connective tissue was observed without the deposition of calcareous matter. This tissue seemed formed like Haversian systems containing a thick layer of osteophytes. Where osteophytes were absent, these borders or bands of connective tissue also failed. In VOL. 103, No. 6.-JUNE, 1892. 47 other instances, a portion of calcareous matter was present, and in others scarcely any. There seemed to be, then, a relationship between these osteoid zones and the formation of osteophytes. Osteophytes and Haversian systems seem to be analogous. The bones examined could be readily cut, but were not as soft as in osteomalacia. GYNECOLOGY. UNDER THE CHARGE OF HENRY C. COE, M.D., M.R.C.S., OF NEW YORK. THE DANGERS ATTENDING CURETTING. CROCQ (Bull. de l'Académie Royale de Médecine de Belgique, tome vi., No. 4) indulges in a tirade against the use of the curette, which is of interest purely from the unusual stand taken by the author. After discussing the dangers of removing the entire endometrium, he states that the results of the operation "are often either nil or uncertain"-that there is great risk of setting up an acute inflammatory process. He concludes that curettement is to be limited to a small number of obstinate cases which resist milder methods of treatment. [We have quoted these opinions for the purpose of calling attention to an example of ultra-conservatism which should be strongly discouraged. There is no subject that has received more attention from French gynecologists than that of curetting, yet their voluminous contributions to the literature have been frequently an expression of individual opinions based on insufficient clinical evidence. It seems hardly necessary at the present time to defend this indispensable operation, or to dwell upon the matter of technique, which is surely not fully appreciated by the writer. When the operation either fails to relieve the patient, or is followed by pelvic inflammation, the only inference is that the surgeon has not exercised ordinary care and judgment with regard to the selection of cases and the details of the operation. Pathological theories are good in their way, but they do not take the place of practical clinical experience and common sense. The favorable results reported by American gynecologists, notably by Dr. Polk, in the treatment of endometritis by curettement and gauze-drainage are sufficiently convincing even to the conservative mind.-H. C. C.]. THE RELIEF OF SALPINGITIS BY DILATATION AND DRAINAGE of the UTERUS. STRONG (Boston Med, and Surg. Journal, 1892, No. 11), in a short but suggestive paper with this title, advocates repeated dilatation, curetting and |