is not confined to the vaso-motor centres, but it acts also upon the cardiac ganglia. It is, therefore, a cardiac vascular poison. Upon the muscular tissue of the uterus hydrastis causes contraction and relaxation. In some cases this action may be observed in the small intestines. From one or two drops of a ten-per-cent. solution of hydrochlorate of hydrastine injected subcutaneously, gave rise to energetic uterine contractions. The author prefers this salt and that of the phosphate of berberine, as in small doses they have the same effects as the fluid extract.

PRACTICE OF MEDICINE.

ON SUGAR FOUND IN THE URINE IN DIABETES MELLITUS AFTER INGESTION OF CARBO-HYDRATES. — Prof. Worm-Müller has made some very exhaustive studies on the chemically important subject of ascertaining the capacity of diabetic individuals to assimilate the various carbo-hydrates. His conclusions are especially valuable and reliable, since parallel observations were made on healthy and diabetic persons. His experiments related to the ingestion of, a, grape sugar; &, fruit and grape sugar; c, starch; d, cane-sugar; e, milk sugar.

From the original publication as appearing in Pflüger's Archiv. für die gesammte Physiologie, vol. xxxvi, Nos. 3 and 4, we abstract such deductions as have a direct bearing on therapeutics (Therapeutic Gazette):

a. In all experiments with grape-sugar the secretion of sugar was found in diabetes to be essentially the same as under normal conditions.

b. Experiments with grape-sugar in light forms of diabetes proved:

TREATMENT OF ANGINA PECTORIS.-Huchard of the Bichat hospital of Paris (Jour. de Medecine, No. 3, 1885), reports that the results of numerous autopsies confirm the views of Jenner and Pavey in regard to the pathology of angina pectoris, which is due to cardiac ischemia from ossification of the coronary arteries. Remedies acting on the nervous system consequently cannot be curative. There are cases simulating in some of their symptoms angina pectoris, but entirely distinct in their pathology, being in effect neuroses; these Huchard designates false angina pectoris. It is cases of this character which are said to be cured by such remedies as the bromides.

The rational treatment of true angina pectoris consists in the persistent exhibition of the iodides, and Huchard claims to have cured in this manner not less than twenty cases. He prefers the iodide of sodium, of which he gives 5 to 10 grain doses three times a day, continuing the treatment for months and even for years. Under the influence of the remedy, the paroxysms are at first diminished in frequency and intensity, and finally altogether cease.

PATHOLOGY.

L.

CYCLIC ALBUMINURIA.—At the last annual meeting of the British Medical Association, Dr. Pavy read a paper having the above title, in which he draws attention to the variation in the amount of albumin present

at different hours of the day in the urine of patients who show no other sign of derangement of the kidneys than the albuminuria. He has observed that in a majority of the cases of physiological albuminuria that have come under his notice, the urine in the morning was free from albumin. In the course of the forenoon, or sometimes not until noon or after, albumin would make its appearance, the quantity gradually increasing until it reached a maximum at about 5 or 6 o'clock, after which it diminished again, and generally disappeared before bed-time. In several cases in which albuminuria had been discovered to exist, he had based a favorable prognosis upon this peculiarity, and whenever a patient was found to have albuminuria without impairment of health, he would certainly examine the urine passed at different hours, and in case he found the cyclic character present he would unhesitatingly pronounce a favorable prognosis.

L.

A DEFINITION OF GOUT.-Dr. Milner Fothergill gives the following succinct account of the pathology of gout (Medical Record, Nov., 1885):

When kidneys first appear in the animal kingdom, the form of urinary secretion is uric acid. Uric acid belongs to animals with a three chambered heart and a solid urine (reptiles and birds). The mammalia possess a four chambered heart and fluid urine, the form of urinary secretion being the soluble urea. When the human liver becomes depraved or degraded, it has a tendency to form primitive urinary products. To the question, "What is gout?" the answer is: "Gout is hepatic reversion, when primitive urine is formed by a mammalian liver."

LAPAROTOMY FOR ILIUS.-DR. Henry F. Beam, of Johnston, Pa., (N. Y. Med. Record), reports the case of a lady, aged forty-eight years, who had been confined to bed for two months suffering from an obscure trouble. She had jaundice, the pulse was small and rapid, the temperature was 101° F., the patient suffered intense pain, and had fallen away forty pounds in weight. For three days she had had occasional attacks of stercoraceous vomiting. Palpation of the abdomen caused great pain, especially in the right iliac region, where there was a prominence resembling a hernia, beneath which could. be felt a hard, round substance. An attempt to move the bowels by enemata was unsuccessful. It was finally determined to operate, and accordingly, chloroform having been administered, an incision two inches in length was made over the point of swelling. The ilium was opened at its point of junction with the cæcum, and the knife immediately struck a hard body. The incision being prolonged, a calculus the size of an English walnut was removed. This was found, on section, to consist of a small nucleus, the size of a buckshot, surrounded with concentric layers of a material resembling lime, about one-sixteenth of an inch in thickness. The patient made a good recovery.

C.

SURGERY.

ON ROSE-COLORED URINE AFTER TRAUMATISM. Verneuil, who has studied this subject with particular care for the past 15 years, communicated his views to the French Surgical Congress, April 6-12, 1885. abstract from the Wein. Med. Blätter, June 25, 1885, the following points:

1. After operations on wounds the urine often deposits a rose-colored sediment on the margin of the vessel, which may be called rose acid.

2. This phenomenon coincides usually with oliguria and concentration of urine, both of which symptoms are ordinary sequelæ of traumatism.

3. The urine of the above description entertains. certain relations to various lesions of the liver, such as cirrhosis, chronic congestion, hydatid cysts, and cancer.

4. The rose-colored deposit is especially frequent in persons addicted to drink when subjected to traumatism, and depends in these cases upon hepatic alterations produced by alcoholism.

5.

This secures a semeiotic value for the deposit,as

TOXICOLOGY.

POISONING BY MURIATE OF COCAINE.-Dr. Kennicott (Chicago Med. Jour.) reports a case of poisoning by muriate of cocaine. The case was that of a lady who had been taking cocaine for the relief of hay fever. By mistake she got the pure salt and snuffed two-thirds of five grains up her nostrils. In fifteen minutes she became dizzy, her vision failed, sinking sensation was felt and great weakness. When seen by the doctor, in half an hour, she was in a semi-comatose condition. From this she could be easily aroused, but she answered questions with difficulty. Her temperature was raised, her skin hot and dry, radial pulse very rapid and weak, pupils widely. dilated, deglutition and articulation difficult. She complained of dry fauces, bitter mouth, cold shivers. Later she became drowsy; her eyes closed. There was moderate dpspnoea. Her extremities were cool and mind clear. In about three hours she recovered.

NEW SERIES, VOL. X, No. 4. WHOLE NO. 241

Original Communications.

AN ANALYSIS OF 189 INSTRUMENTAL OBSTETRIC

MR

CASES.*

BY E. P. CHRISTIAN, M. D.

R PRESIDENT, and members of the Society. In response to the invitation of your esteemed President to read a paper before this Society, I have prepared an abstract of the records of my instrumental obstetric cases from the beginning of my practice, about a third of a century past. I have chosen this as the subject of my paper because I thought one may more creditably to himself and more profitably to others, offer a paper on a subject in regard to which he has the greatest amount of facts to present, to classify and to make deductions from, and because I am prepared to present a considerable mass of interesting facts by reason of a carefully kept record of my cases, and a record made at the time of occurrence, and because of its being a practical subject.

In looking over these records, I have had strongly impressed upon me the fact of the unreliability of the memory alone. That it is a very wide-meshed net which retains not always the most important facts it has gathered, and another truth-that it is not always possible to know at the time which are the important facts, not necessarily and perhaps not ordinarily the most pronounced on account of novelty or other impressive characteristics, but very likely the common incidents, the minutiæ, "the little things and things which are despised" which confound the wise,

The inference from this has been that an immense amount of valuable experience and observation is lost, not only to the profession in general, but for use to the individual, in passing years, by reason of this frailty of the memory. And as a corollary, that not necessarily the man of largest experience can be of greatest service to the profession and to science, but he whose experience is most available for use, whose observations have been most carefully noted and recorded. The experience of the one may be like the hoarded riches of the miser in

* Read before the Detroit Medical and Library Association.

$2.00 a year. Single copies, 30 cents.

secret vaults, and of the other to the brisk and lively capital of the active business man.

The excuse and justification, then, for this paper upon a much written-of subject, is that it is a compilation of recorded facts, and is commended to you, not by attempts at literary embelishments, but simply by reason of the observations it contains.

As will be seen by the appended tabular statement, there were 189 instrumental deliveries.

Of these, there were three cases of craniotomy whose histories I will first give.

Case 1, No. 12 of Table.-Mrs. C., fourth labor, gives a history of first and third labors of still-born children after very difficult and tedious labors; in her second gave birth to a living but very small child. In her fourth I was called to the patient, eight miles in the country, and after 24 hours in hard labor and unsuccessful attempts to deliver by forceps; with her previous. parturient history in mind, and satisfied that the child could not be born living, and was, as I believed, already dead, I applied the perforator, broke down the head and delivered, and the woman recovered as after a normal labor. This woman was delivered by me of a still-born child by forceps in her fifth labor 15 months after, and in her sixth, seventh and eighth labors of living children, all by forceps, she coming a distance from the country each time to put herself under my care. That I did the safest thing for the mother in this case, I have no doubt, judging by results. Like all operations in obstetrics or in surgery, if it is a necessity, the sooner it is done, when the conditions are ready, the better for the patient, and all unnecessary delay will be to her detriment, and should be avoided. But I am satisfied that in the hands of a more experienced physician than I was at the time, or with the experience subsequently acquired, it would not. have been necessary. I do not believe I should resort to craniotomy now in a similar case.

Case 2, No. 45 of table.-Mrs. W., third labor; small woman with deformed pelvis. Had delivered her two years before in her first, after a long and difficult labor, by forceps, of a small living child. Was called to her in her second, after she had been more than twenty-four hours under the care of an irregular. Head high and impacted; no progress for hours under most forcible

pains and patient becoming exhausted. Made unsuccessful attempts to deliver with forceps with all the force I could apply. I perforated the head, broke it up and delivered her in that mode. She recovered after some inflammation and fever, due much more to the long continued pressure of the head on the soft tissues, from the labor pains and the attempts with the forceps, than to any violence or injury from the subsequent proceedings. I am positive in my mind that she could not have been delivered as safely in any other mode, which also her subsequent history shows, to wit:

Case 3, No. 57 of Table.-October 29th, 1868, less than fifteen months from her last preceding labor, which occurred Aug. 8th, 1867, was called to the same woman in her third labor. In this case the labor continued forty-eight hours before it was terminated by the operation. Unsuccessful attempts were made by myself with forceps and afterwards by Dr. Morse Stewart, of Detroit, for whom I had sent for counsel, apprehending possibly unfavorable results, from her known previous parturient history. Dr. Stuart coincided with me as to the necessity of craniotomy, which was easily accomplished, and the woman soon delivered. She died several days subsequently of intense metro-peritonitis. My regrets in this case are for not having resorted to the operation earlier, after failure to deliver by forceps. Several hours of delay was also caused by reason of awaiting the arrival of Dr. Stuart, for whom I had sent. I have no doubt but the patient's death in this case is chargeable to the delay and repeated forcible attempts to deliver by forceps. Had I resorted to craniotomy as early as in her previous labor, the result, I think, would have been favorable. If I made a mistake in my first case and operated too soon, and perhaps unnecessarily, in the latter I made a more lamentable mistake by waiting too long. And in a similar case in the future and under similar circumstances, I would not increase the patient's risks and prolong her sufferings, simply to be enabled to divide the responsibility and to arm and protect myself against invidious criticisms of neighbors and others.

SUMMARY.-Three operations on two women. The first had borne two dead and one living child by natural labors before the operation, bore one dead and three living children delivered by forceps by myself afterwards. The second woman had borne one living child previous to her first operation.

The three cases of craniotomy from the 189 tabulated cases leave 186 forceps cases. In regard to these, In regard to these, there were points of interest connected with almost every individual case, but a reference to them specifically would extend the paper to an inordinate and tedious length, I shall therefore give only a general analysis of them with a brief detail of the parturient history of some of the more interesting.

These figures, compared with the whole number of labors of each class, and with the instrumental deliveries of each class, exhibit well the truth of the common observation of the increased risks in primiparæ, as also in the later labors of those who have borne very large numbers of children. The prolonged labors of primiparæ increase the suffering and risks, and offer oftener the indications for artificial aid; and the liability to complications in the labors of those who have borne large families (pluriparæ we will call them in distinction) frequently creates the necessity for the same interference. If all other accidents calling for artificial aid, in addition to those alone demanding forceps were considered, this would be much more noticeable.

Thus, while the proportion of primaparæ to whole. number of labors has been about 20 per cent., the number of forceps cases in primiparæ was near 46 per cent. of all forceps cases, and over 26 per cent. of all primiparous labors.

And, while the proportion of pluriparous labors (11th to 15th inclusive) to all labors was less than 3 per cent., the proportion of forceps cases in pluriparæ (11th to 15th) to all forceps cases was nearly 5 per cent., and to all pluriparous labors was about 19 per cent.

No. 148, 1st labor.--Eclampsia in second stage; labor | followed by peritonitis.

No. 151, 2d labor.-Combined hip and head presentation. Peritonitis.

No. 158, 1st labor.-Eclampsia at beginning of labor.

No. 187, 8th labor.-Chronic Bright's disease. Pulmonary emphysema. Total suppression of urine for four days before death.

No. 188, 1st labor.-Metro-peritonitis. Metritis before labor.

This patient was a small delicate woman, with a husband weighing 280 pounds, young and hearty. The patient was constantly threatened with abortion while carrying the child, often bleeding, with uterine pains, and there was great difficulty in carrying her through. Intense sensitiveness of os uteri, with agonizing pains during labor, and peritonitis had developed within twenty-four hours after its termination.

Of the 13, two were in a dying condition when I was called in to take away the child, living but a short time after, and 8 others had complications of labor which called for the expediting and terminating by the forceps, and of which complications they died. One died of postpartum hæmorrhage in my absence, having given birth in this, her first labor, to a 12-pound baby; and there were but three who had no serious complications of labor, and who died of septic fever.

It will be noticed that among these were four cases of eclampsia. In three of these the convulsions set in at commencement of labor, and in one at second stage. Two of the former died soon after completion of labor, and one after a few days, of secondary pneumonia. The other case died after a couple of weeks, of secondary peritonitis, with complete recovery so far as eclampsic symptoms were concerned. Whether the two complications-eclampsia and albuminuria-and peritonitis had any relation to each other in the way of cause and effect, and which may have operated as such, I am not able to say. In the first three cases, digital and manual dilation of os uteri were employed to complete the labor. The experience which I have had in that way is not encouraging. But in one case of eclampsia, not in this table, in which case the woman lived for a number of days after delivery, and in whom the urine, when tested with nitric acid, became almost solid, the convulsions were immediately and invariably stopped on applying digital dilation, the patient relapsing into quiet stupor, and they were, in that way, held in check until the completion of labor. Of the 186 women delivered by forceps, there were of still-births, 22. The complications of labor and causes of death were as follows:

No. 4, 1st labor.-Difficult and tedious labor. Delay in being called. Patient under another's care. No. 9, 7th labor.-Total placenta prævia.

25.

No. 28, 1st labor.-Eclampsia.

No. 29, 4th labor.-Specific? Same patient as No.

Under care of woman

No. 63, 1st labor.-Delay. 72 hours before sending. Patient aged 43. No. 83, 1st labor.-Patient dying of consumption. No. 96, 3d labor.-Face presenting. Large child. Small woman.

No. 98, 2d labor.-Patient dying of hæmorrhage. Delay in sending. Under care of a woman.

No 104, 2d labor-Prolapse of funis. Cord cold and pulseless when I arrived, distance of six miles.

No. 115, 9th labor.-Face presenting and delay. No. 118, 11th labor.-Breach presentation and forceps to after-coming head, gives history of previous labors all difficult and terminated by forceps.

No. 120, 4th labor.-Prolapse of funis and delay.
No. 125, 2d labor.-Eclampsia.

No. 127 4th labor.-No complication, but weight of child, 12 pounds.

No. 148, 6th labor.-Difficult and prolonged labor under care of a woman; delay.

No. 151, 2d labor.-Combined presentation of hips and head, version and forceps to after-coming head. No. 158, 1st labor.-Eclampsia. Funis broke off at child's abdomen.

No. 181, 10th labor.-Delay; prolonged labor under care of a woman.

No 187, 8th labor.-Chronic Bright's disease of mother, child putrid when born.

Recapitulation.-Of the above table of 22 still-births of forceps deliveries, there are 12 cases which were under the care of others, principally women; many of them at a distance, and my arrival was at a late stage, past all chance of saving the infant. Of the mothers, there were lost (included in preceding table) two, who were dying when I was called to take the child, three cases of eclampsia, one case of combined hip and head presentation with a very prolonged labor, and a case of uræmic poisoning, chronic Bright's disease with suppression of urine.

The following is a tabulated statement of the complications: