rence, we find in the majority of case-records that the procidentia was not manifest until one or more children were born; that there had pre-existed a descensus of the uterus to a greater or lesser degree, and that the descensus had increased in the subsequent pregnancy. In other words prolapsus uteri in pregnancy is but an exaggeration of a pre-existing condition of prolapsus of the uterus and vaginal walls and to the tissue changes resident in the uterus and its appendages. Where the cervix protrudes from the vulvar outlet, pregnancy will rarely supervene. In prolapsus of long standing the usual anatomic findings are eversion and erosion of the lips of the cervix, hypertrophy of the endometrium and uterine musculature and cystic degeneration of the ovaries. Where the uterus is completely prolapsed, pregnancy is usually terminated spontaneously in the early weeks of gestation. Wimmer's case, which went to the sixth month, and Plasse's case, which was interrupted at the seventh month of gestation are notable exceptions to the rule that in extreme prolapsus abortion occurs in the first month of gestation as a result of circulatory and mechanical disturbances. In the event of labor or abortion certain serious complications may ensue. Postabortive and puerperal infections occur in a relatively large proportion of cases because of the ineffectual emptying of the uterus and the occasional presence of ulcers of the cervix. The elongated, rigid cervix offers a serious impediment to the progress of labor. We find labor prolonged by the resisting cervix and the enfeebled uterine musculature. It is no exception for labor to be prolonged two or three days and in some instances five to seven days. So great may be the resisting power of a rigid, elongated cervix that the lower uterine segment and body of the uterus may rupture spontaneously in labor and gangrene of the cervix is known to ensue. Not only does the resistance offered by the cervix prolong labor, but, if not relieved by incision, the lower uterine segment may stretch to the point of rupture. Pregnancy with a moderate degree of prolapse, and in the absence of any considerable elongation and rigidity of the cervix, will usually proceed to term and delivery will be effected without serious embarrassment. If, in the early months of pregnancy, the patient complains of a bearing-down sensation and of bladder and rectal disturbances chargeable to the de scended uterus, a suitable pessary may be worn with safety, and removed at the end of the fourth month. Where the labor is retarded by an elongated, rigid cervix the acknowledged method of procedure is to make a bilateral incision of the cervix (Duhrrsen) and to apply forceps or perform version. When the prolapse of the gravid uterus exists to a degree that renders the patient uncomfortable or incapable of enduring the existing conditions, relief may be found in various ways. In prolapse of a moderate degree, the pessary, worn for the first four months of gestation, will usually afford the desired relief. Most authors advise against the performance of plastic operations on the pelvic floor during pregnancy because such operations are excessively bloody, the trauma of the operation. is liable to induce abortion and the restored pelvic floor is almost certain to give way in a subsequent delivery. However, there are a number of successful cases on record in which the cervix has been amputated and the pelvic floor restored without interrupting the course of pregnancy. The Blood Pressure Index of Eclampsia. (By Harold C. Bailey, M. D., New York City, from Journal Surgery, Gynecology and Obsteterics.) "The greatest danger confronting pregnant women is eclampsia. Concerning its origin and treatment little progress has been made and the death rate is still in the neighborhood of twenty-five per cent." "Suddenness of onset in an apparently healthy woman is one of the characteristics of the disease and from time to time various clinical signs or symptoms have been heralded as indices to the pre-eclampsia condition. In about one-fourth of the cases there are present certain premonitory subjective signs which are indisputable, but the convulsions may follow in a few hours so that there is hardly time to adopt any preventive regime." "For many years changes in the urine have been considered the earliest premonitory signs but the value of these changes have been greatly overestimated. Albumen and casts are almost always present in the pre-eclamptic stage and in the actual condition they are usually present in considerable amount and numbers, but numerous attacks occur while the albumen exists only as a trace, in fact scarcely more than might be considered the normal or physiological albuminuria of preg nancy. Indeed it is probable that the disease is an autotoxic condition produced or accompanied by degeneration of the liver cells and that the kidney lesion is only a secondary one. Seventy-five per cent of the cases show no abnormal urinary signs a short period after delivery." "Percentage of urea as determined by the common clinical tests is of no value. When the amount of urine passed during twenty-four hours can be measured and the total nitrogen can be determined by chemical laboratory methods, distinct value can be assured. Further, if any definite value is to be given this index it must be determined every two or three days in the last month of pregnancy instead of weekly or fortnightly as the general custom is at present. The time necessary for such an elaborate series of tests would place the cost of this form of insurance so high that it would not be acceptable even to the very wealthy." "Examinations of blood pressure in early toxaemia in our own cases and the cases of others were invariably low. Apparently toxic substances are circulating in the blood which have marked influence on the vomiting center, but with little action on the vasomoter apparatus either central or peripheral.” "In the developed toxaemia of the latter months there is usually present a blood pressure raising principle or else by hormone action or similar means the pressure raised to increase the natural resistance of the body. The fact that in the fulminant type of fatal toxaemia in the latter months the blood pressure is very low points more to the latter idea and also tends to more closely associate the early and late manifestations of poisoning that occur in these women." "The treatment should be entirely concerned with eliminating and limiting the production of the poisons." "With the elimination of the toxins the blood pressure falls and this may possibly be an indication of the extent to which the treatment should be pushed. Even if convulsions ensue there is no reason to direct efforts to the lowering of the blood pressure, for the chronic nephritic and the arteriosclerotic individual goes about with a relative amount of safety with a blood pressure of 200 mm. There is every reason to suppose that the resilient arteries of those comparatively young women are equally able to withstand such a blood pressure." "The history of the disease shows that eclampsia rarely occurs as late as five days after delivery and that postpartum eclampsia is never as fatal as the antipartum or intrapartum conditions. The logical deduction is that the uterus should be emptied in all cases RESISTANT TO ELIMINATIVE TREATMENT where the blood pressure is high and increasing." "CONCLUSIONS." "1. Average blood pressure in the last weeks of pregnancy is 118 mm. of Hg. Fluctuations amounting to 30 mm. of Hg. above this need cause no alarm. 2. Blood pressure over 150 should be thoroughly investigated at once. 3. Blood pressure in eclampsia with convulsions, though usually in the neighborhood of 200 mm. of Hg., may be as low as 155 mm. 4. Convulsions do not occur when the blood pressure is lowered by poor resistance as in the so called fulminant cases or when lowered by veratrum viride or other drugs producing collapse. 5. Treatment should be directed not toward reducing the blood pressure but to the treatment of the toxaemia for the rise of blood pressure may denote only the resistance of the system toward the toxins. 6. Tri-weekly blood pressure examinations combined with the regular urine examinations for albumen and casts offer the best safeguard against the unexpected presence of this disSomers (Omaha). ease. Retention of Fetus in the Abdomen for Forty Years. Weatherhead, in the British Medical Journal, reports a remarkable instance of a ruptured ectopic gestation with subsequent development of the fetus in the abdominal cavity. After false labor pains the patient resumed her general state of good health, and aside from one or two attacks of what was diagnosticated at the time as peritonitis she remained in good health until her seventy-ninth year, when she died of asthenia as a result of an obstinate diarrhea. At the autopsy there was found in the abdomen, attached to the posterior face of the uterus, a well developed set of membranes in which lay a very well preserved fetus of what seemed to be about eight months' development. It had undergone some calcification externally, while the general substance was of a peculiar waxy consistence, being possibly that rare substance, adipocere. uary. Dr. B. S. Peterson of Albion, Neb., has located in Omaha. Dr. J. M. Davey and Dr. O'Connell of Ponca, Neb., have formed a partnership. Dr. D. W. Hershey, a pioneer physician of Nebraska City, Neb., died January 17. Dr. Howard Cooper of Minden, Neb., died at Lowell, Neb., January 11 at the age of 84 years. Dr. G. W. Pringle of Alma, Mich., is a new physician, recently located in College View, Neb. Dr. H. Schemel of Hoskins, Neb., committed suicide by taking carbolic acid, early in February. Dr. H. B. Landis, formerly of King City, Mo., has recenly ope.ed an office in Broken Bow, Neb. Dr. J. S. Wilson of Crab Orchard, Neb., has moved back to Johnson, where he formerly practiced. Dr. J. B. Anderson of Craig, Neb., has entered into partnership with Dr. W. H. Pruner of Kennard, Neb. Dr. N. P. Hanson of Elk Creek, Neb., has removed to Brownville, Neb., where he will practice medicine. Dr. Andrew J. Gillespie of St. Paul, Neb., died December 15th, from apoplexy, at the age of 72 years. During 1911 there were 2145 physicians' deaths reported in the United States, a rate of 15.32 per 1,000. Drs. F. C. Zoll and H. G. Hess of Wayne have formed a partnership and will practice medicine at Wayne. Dr. Moranville of Red Cloud, Neb., is slowly recovering from a serious illness and will seek a warmer climate. Dr. O. E. Longacre of Loup City, Neb., underwent an operation for appendicitis in Grand Island, Neb., recently. Dr. H. L. Burrell of Omaha, has sold his home and departed for California, where he will reside in the future. The Health Commissioner of Omaha reports less contagious diseases in the city this winter than for many years. Dr. J. B. Cain, a pioneer Nebraska physician, died at his home in Omaha, January 25, at the age of 72 years. Dr. A. W. Murphy of Holbrook, Neb., fell upon the stairs and injured his knee seriously the latter part of January. Dr. S. J. Jones of Hastings, Neb., and Miss Georgiana Wright of Portland, Ore., were married in Omaha January 11. Dr. Johnson of Neligh, Neb., has left for Michigan, hoping that a change of climate will benefit his wife's health. Dr. A. B. Anderson of Pawnee City, Neb., has disposed of his practice to Dr. J. C. Waddell, and retired from practice. |