PROGRESS IN MEDICINE.

PREVENTIVE MEDICINE.

BY ELIAS H. BARTLEY, M.D.,

Professor of Chemistry and Toxicology, and Lecturer on Diseases of Children, Long Island College Hospital, Brooklyn.

THE GERM THEORY A CENTURY AGO.

Under this caption the British Med. Journal for February 11, 1888, contains an editorial review of a pamphlet of 87 pages, published in 1788, and entitled: “A Treatise on Fevers, wherein their Causes are exhibited in a new point of view, to prevent Contagion; and Putrid Sore Throat, Inflammatory Fluxes, Influenza, Consumptions, as well as the Low Nervous Fevers that terribly affect the Spirits, may be cured with ease.”

The most remarkable part of the book is the speculative or explanatory part, consisting of an exceedingly ingenious argument, based upon the analogy of admitted facts, to prove that the cause of contagious fevers is some invisible noxious matter in the air. Of the intimate nature of this matter he says: Some consider it to be a sulphurous exhalation from the earth; but this cannot be, for, if so, acrid and sulphurous fumes would increase it, instead of checking or annihilating it. Another theory is that it is due to the products of putrefaction; but how can dead putrid matter ever get such activity as to work such astonishing results? It must therefore be something endowed with a more powerful activity than anything belonging to the mineral kingdom or simply putrefying matter, and must, therefore, be something “actually living.” He further concludes that these living organisms must have an existence independent of the body in which they are found. For this view, surprising and novel enough at first, loses some of its singularity, if we search for resemblances elsewhere. Now, just as it was well known that itch is due to the presence of acari, insects visible by the aid of the microscope, so close attention to these matters in numberless cases during many years, has proved beyond a doubt that the gaol distemper, putrid fever, plague, and infectious epidemics generally, proceed not from matter putrid in itself, but from invisible insects also, that, floating in the air at times, are lodged in the skin in immense quantities; feeding here in clusters, they produce pimples, pustules, etc.; for instance, the eruption of small-pox. He overlooks, or fails to mention, the possibility of their entering by the air passages or digestive system. “Medicines,” he says, “which poison insects without injuring the constitution have always proved specific.” These insects, which constitute contagion, are communicated by air, the raiment, 144as by contact. He admits that vegetables as well as animals suffer from the ravages of these animalcules. He believed that they originated from eggs and not de novo. He advises fumigations with sulphur and frankincense to destroy contagion in rooms, and shows that many diseases in lower animals are cured or prevented by the use of certain agents known to kill insects.

In summing up his theory, he says that, generally speaking, there are two sources of these animalcules. First, from subterranean sources, which operate in all sorts of weather and are accompanied by electrical phenomena. Second, from the surface of the earth, swamps, filthy lakes, stagnant ponds, etc. The eggs left on the soil develop in summer, and “the multitudes effluviate into air.”

The essay is interesting to us because of the very clear foreshowing of a theory that we are apt to regard as the creation of recent years. It is a good example of the power of attentive observation and inductive reasoning, which is so seldom met with even in scientific medical men of the present day.

ALBUMINURIA A FREQUENT RESULT OF SEWAGE POISONING.

Dr. George Johnson, in Br. Med. Jour. for March 3d, gives the histories of four cases of albuminuria which he believes were the result of breathing sewer air. In addition to other diseases, the result of drain poison, the author has met with several cases of albuminuria which he believes can and does under continued exposure to the sewer poison, result in incurable disorganization of the kidneys. He thinks that, in the absence of other probable exciting causes of albuminuria, the possibility of sewer poisoning should be constantly borne in mind. It is needless to dilate upon the importance of discovering the exciting cause of a disease so serious in its consequences as nephritis. In each of the four cases cited, albuminuria and casts were found in the urine, and blood in two of them. In each case defective drainage was proven, and in two of the four an immediate improvement occurred on removing this cause. One proved fatal from suppression of the urine.

The author suggests as an interesting point, that amongst the various diseases resulting from drain poison, diphtheria is in a very large proportion of cases associated with albuminuria.

It would be interesting to know whether a large proportion of cases of diphtheria occurring in houses having defective plumbing suffer with albuminuria, than in houses where no such defect exists. If these observations are confirmed, we may learn from them something of the cause of the great fatality of scarlet fever and diphtheria in houses which contain defective drains.

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SEWER-AIR POISONING.

The question of sewer-air poisoning has received no inconsiderable attention at the hands of sanitarians within the past few years, some claiming that it is a carrier of many of the contagious diseases, including malarial affections, while others have denied its harmful action in these respects.

The last class, in substantiation of their claim, point to the assumed fact that plumbers and those who work in sewers are not, as a rule, especially subject to the diseases generally attributed to sewer air. That plumbers are not exempt from troubles of this kind is attested by numerous examples. According to Science, an inquest was recently held in Liverpool, Eng., on the body of a plumber’s apprentice who had been engaged in repairing pipes which connected with the sewer. Quantities of gas came through these pipes, and at the time the young man complained of pain and sickness, and died forty hours afterward. The jury rendered a verdict of poisoning by sewer air.

According to the Sanitary News, Dr. Vaughn, of the Michigan State Laboratory of Hygiene, claims to have found the specific germ of typhoid fever in the air of a soil pipe from the prison at Jackson, in that State, during an outbreak of typhoid fever.

The Sanitary Inspector for February and March, reproduces from the Medical News an article by Dr. Henry Hun upon this subject. Dr. Hun cites twenty-nine cases in support of his statements. The histories are those of non-contagious diseases, and therefore were probably cases of illness produced by non-infected sewers. He says: “In all of these twenty-nine cases there was an escape of a large amount of sewer gas into the air which the patients breathed; and at the time that the case was observed, it seemed extremely probable that the sewer gas was the cause of the disease.

“From the consideration of these twenty-nine cases, we may conclude that it is probable that the following conditions may result from sewer-air poisoning:

“1. Vomiting and purging, either separately or combined.

“2. A form of nephritis.

“3. General debility, in some cases of which the heart is especially involved.

“4. Fever, which is frequently accompanied by chills.

“5. Sore throat, which is frequently of a diphtheritic character.

“6. Neuralgia.

“These conditions may occur separately, but are frequently combined, and it is especially common for the fever to be associated with other symptoms of sewer-gas poisoning. Finally, in cases of sewer-gas poisoning, there is one group of symptoms which is almost always 146prominent, and these symptoms are: loss of appetite, drowsiness, extreme prostration, and a dull, unpleasant feeling in the head; and whenever this group of symptoms occurs, not as the result of an attack of acute disease, but as a chronic condition, we are justified in suspecting that the patient is exposed to sewer-gas infection.”

EFFECTS OF FOOD PRESERVATIVES ON THE ACTION OF DIASTASE, PANCREATIC EXTRACT AND PEPSINE.

This subject has recently received experimental study at the hands of Dr. Henry Leffman and William Beam, the results being published in the Analyst for June, 1888.

The antiseptics selected were those which have been known to be used to preserve articles of food and drink. They were salicylic acid, boric acid, sodium acid sulphite (sodium bisulphite), saccharine, beta-naphthol and alcohol.

In the following experiments a solution of arrow root starch, 30 grains to the litre, was used.

To 100 c.c. of this solution was added 0.5 c.c. of maltine diluted to 50 c.c. with water.

The figures give the proportion of antiseptic to the whole volume of liquid.

Experiments with Maltine.

Antiseptic used. Amount. Fehling’s Solution reduced by the Maltose formed.

None. None. 245 cc.

Salicylic acid. 1 to 500. No sugar formed.

Salicylic acid. 1 to 1,000. No sugar formed.

Salicylic acid. 1 to 20,000. 245 cc.

Boric acid. 1 to 1,000. 245 cc.

Sodium bisulphite. 1 to 1,000. 245 cc.

Saccharine. 1 to 1,000. 18.5 cc.

Saccharine. 1 to 500. 5.6 cc.

Beta-Naphthol. 1 to 1,000. 204 cc.

Beta-Naphthol. 1 to 500. 174 cc.

Alcohol. 1 to 25. 245 cc.

Experiments with varying amounts of diastase showed that one part of salicylic acid to 1,000 of liquid prevented the diastasic action completely. Saccharine in the proportion of 1 to 1,000 prevented the formation of sugar when the proportion of diastase was 1 to 1,000 of liquid. When the proportion of diastase was reduced to 1 in 2,000, salicylic in the proportion of 1 to 3,000 prevented the formation of sugar. It seems, then, that the weaker the diastasic solution, the more is its action hindered by salicylic acid, saccharine, etc. Sodium bisulphite has little if any power of hindering diastasic power.

147 Experiments with Fairchild’s Pancreatic Extract.

Antiseptic. Amount. Fehling’s Solution required.

None. None. 78 cc.

Salicylic acid. 1 to 1,000. No sugar formed.

Saccharine. 1 to 1,000. No sugar formed.

Beta-Naphthol. 1 to 1,000. 78 cc.

Boric acid. 1 to 1,000. 78 cc.

Sodium bisulphite. 1 to 1,000. 80 cc.

The tests were made with 0.2 grams of the extract.

It seems from these experiments that salicylic acid and saccharine, in the proportions used, entirely prevent the action of pancreatic ferment upon starch.

In similar experiments with saccharated pepsine with hydrochloric acid, except that the temperature was kept at 105° F., sodium bisulphite and boric acid were without effect.

Saccharine and salicylic acid had a slightly retarding action. Beta-naphthol almost entirely prevented the action.

With pancreatic digestion of albumen the results were practically the same, but the retarding action of the salicylic acid and saccharine was not quite so well marked.

From these experiments it will be seen that salicylic acid prevents the conversion of starch into sugar under the influence of either diastase or pancreatic extract, but does not seriously interfere with peptic or pancreatic digestion of albumen. Saccharine holds about the same relation as salicylic acid.

Sodium bisulphite and boric acid are practically without retarding effect.

Beta-naphthol decidedly interferes with the formation of sugar by diastase, but not with the action of pancreatic extract on starch.

It almost entirely prevents both peptic and pancreatic digestion of albumen.

The bearing of these experiments upon the sanitary question of permitting the use of these preservatives in foods, is self-evident. Prof. Leffman says: “Their use is scarcely allowable under any circumstances, and certainly only when the nature of the preservative and the amount is distinctly stated.” The use of saccharine as a sweetening agent must be looked upon as deleterious to health, and ought to be forbidden by sanitary authorities.

MILK AND SCARLATINA.

In a recent number of the Journal, we published an abstract of the reported investigations of Mr. Power, Dr. Cameron and Dr. Klein of a disease among cows, which they believed had caused scarlatina among persons using the milk. The conclusions reached by these 148gentlemen seemed so startling that the Agricultural Department of the Privy Council began an investigation of the disease. The investigation was given into the hands of Dr. Cruikshank, whose reports are published in the British Medical Journal of December 17, 1887, and January 21, 1888.

We have only space here to reproduce the conclusions reached by Dr. Cruikshank, which are as follows:

1. The nature of the contagium of scarlet fever is unknown.

2. The micro-organism regarded by Dr. Klein as this contagium is the streptococcus pyogenes.

3. Streptococcus pyogenes is found sometimes in company with staphylococcus pyogenes aureus, as a secondary result in scarlet fever and many other diseases.

4. A streptococcus was first observed in scarlet fever by Crooke, later by Löffler, Huebner and Bahrdt; but its exact relation to scarlatina, and its undoubted identity with the streptococcus from pus and puerperal fever, was definitely established in 1885 by Frankel and Freudenberg.

5. Both the Wiltshire and Hendon cow diseases were called cow-pox by the people on the farms.

6. Both diseases correspond in their clinical history.

7. The ulcers on the teats correspond in naked eye and microscopical appearances, and the latter vividly recall the appearances of cow-pox.

8. Calves inoculated from the discharges of the ulcers are similarly affected.

9. Post-mortem examination of such calves, or of calves inoculated with streptococci isolated from scarlet fever cases, show similar appearances.

10. The post-mortem appearances in such inoculated calves are the result of septicæmia.

11. There are no specific visceral changes in cow-pox, apart from complications or coincident affections.

To the above criticism of Dr. Klein’s investigation of the Hendon cow disease, this gentleman claims that Dr. Cruikshank studied a different affection, and that the organisms were not the same. It is insisted upon by Dr. Klein, that Dr. Cruikshank’s conclusions were the result of studying cow-pox and not the peculiar disease he described as the Hendon cow disease.

THE CAUSE OF DEATH IN PHTHISIS.

Dr. R. W. Philip has made an experimental study to determine the cause of death in phthisis. The results of his study are published in the Brit. Med. Jour. of Jan. 28th, 1888.

149His experiments were conducted with an extract prepared from fresh sputum from phthisical patients, as follows:

The sputum was treated with alcohol, put in a sterilizer, and heated to 37 to 40° C. for some time, filtered clear, and evaporated at a low temperature until the alcohol was expelled. This extract was used for subcutaneous injections in frogs, mice, and rabbits.

This extract was found to possess very marked toxic properties upon these animals, which manifested themselves by a depression of the higher nerve centres and of the heart. The depressant action upon the heart seemed to be exerted through the cardio-inhibitory mechanism, and is more or less completely antagonized by atropine.

The toxic principle he believes to be the result of the growth of the tubercular bacilli, and allied to the ptomaines. He found the quantity of the substance to be extracted from the sputum to be proportional to the abundance of the bacilli present in it. These observations are in accordance with the observations of various experimenters with other pathogenic organisms, and with the theory that seems to be gaining ground that immunity is the result of such by-products of the growth of these organisms.

SURGERY.

BY GEORGE R. FOWLER, M. D.,

Surgeon to St. Mary’s Hospital and to the Methodist Episcopal Hospital, Brooklyn.

CONTRIBUTIONS TO THE STUDY OF MYXŒDEMA FOLLOWING TOTAL OR PARTIAL EXTIRPATION OF THE THYROID BODY.

J. L. Reverdin (Congrès Francais de Chirurgie, 2 session, Paris, 1886.) This disease, following frequently in the after-history of cases of extirpation of the thyroid body, and called by Kocher, of Berne, cachexia stumpriva, was first described by Reverdin, and by him called “operative myxœdema.” His description of this disease coincides in general with the views now generally held, although we find some not unimportant deviations from Kocher’s conclusions; for instance, the latter observed the disease twenty-four times following thirty-four operations, it appearing to attack by preference those who had not attained their full development. On the other hand, R., basing his experience upon copious statistics, believes the disease is comparatively rare, following upon operations of the thyroid in only twenty-seven per cent. of cases. In his experience, it likewise preferably attacks children and young persons, but that it occasionally 150fails to occur after complete thyrotomy. Further, R. has observed a milder form of the disease, differing essentially from the graver type of the affection, which latter invariably tends progressively to a fatal termination. In the milder form, the disease is described as oscillating between relapses and improvement, lasting for years, cure sometimes resulting. Several cases are detailed supporting these observations. In two of these, it was supposed that the thyroid had been extirpated in toto, but it was subsequently discovered that a small portion of the gland had remained. Three cases are worthy of especial note. In these, after partial extirpation, in one the right lobe, and in two the left having been removed, an imperfect form of the disease made its appearance after several months. The characteristic signs, such as swelling of the face and limbs and hesitancy of speech and of muscular movements were absent; while the other symptoms, such as general weakness, pains in the limbs, chest, and head, greater or less loss of memory, chilly sensations, reminded one distinctly of the more complete form of the disease. In all these cases slow improvement followed. Another case is worthy of notice from the fact that, two months after the operation, the remaining lobe had so atrophied as to be scarcely distinguishable. Cases of this atrophy following partial extirpation have been observed both in Germany and in England.

UPON LUXATION OF THE HEAD OF THE RADIUS FORWARD.

Raestock (Deutsche Militärärztl. Zeitschrift, 1887, p. 331) has, by means of experiments upon the cadaver, shown that this accident occurs in forced pronation while the radius is resting upon the ulna at the point where the former crosses the latter, the ulna acting as a fulcrum. The head of the radius is pressed against its capsule and tears the latter. More rarely, the accident may occur in forced supination, by pressing the bone against the posterior edge of the ulna, the head of the radius being luxated through a rent made by a rupture of the external lateral ligament between the outer and inner sides; upon pronating the hand, this outward dislocation is converted into a forward one. The annular ligament is either torn or else the coronoid process of the ulna is broken. In either case the interposition of the annular ligament in the fold of the joint becomes an obstacle to reduction. In the experiments as detailed, great force was necessary in the production of the luxation.

Should active and passive movements, manipulation, etc., fail to remove the obstacles to reduction, the author advises a resort to secondary resection of the displaced head of the radius; this, with proper precautions, is certainly a most wise and rational procedure.

151

CHOLECYSTOTOMY, WITH LIGATURE OF THE CYSTIC DUCT.

Zielewicz (Centralblatt f. Chirurgie, No. 13, 1888,) proposes in addition to the so-called “ideal” method of Spencer Wells, that of suturing the gall bladder to the abdominal wound, to ligate the cystic duct, in order to insure the patient against the return of the biliary lithiasis. The only case in which he has tried it was one in which an attempt was being made to perform cholecystectomy, but the adhesions between the gall bladder and liver were so dense and unyielding as to render the removal impossible, on account of severe hæmorrhage. He therefore passed two ligatures around the cystic duct and divided the latter between them. The gall bladder was then fastened to the abdominal wound, incised and emptied of its contained calculus and biliary secretion. The patient made a good recovery, a fistula remaining, of which the writer says, that “after a time it was almost closed.”

The author claims for this operation the following advantages: 1st. Rapid healing without a resulting fistula. The gall bladder is practically removed from the organism. With appropriate after treatment, its secretion soon ceases, and it becomes obliterated. 2d. The operation is simple and less dangerous than cholecystectomy, and gives the same results.

In contrasting this operation with cholecystotomy, it may be said that the latter simply aims at removing the existing calculi, and makes no provision against the recurrence of the same. Where the “natural” method of Bernay is adopted, and the gall bladder dropped back into the abdominal cavity after suturing the incision made in its walls for the removal of its contents, in case of a recurrence of the disease, the entire operation must be repeated. In the “ideal” method of Spencer Wells, only an incision need be made, in such an emergency, at the site of the first operation. Troublesome fistulæ, however, are apt to remain.

In cholecystectomy, on the other hand, hæmorrhage from breaking down of adhesions between the gall bladder and the surface of the liver, it is claimed, is a frequent and troublesome complication. It is claimed by Thiriar, however (“De l’intervention chirurgicale dans certains cas de lithiase biliaire,” Revue de chirurgie, 1886, No. 3), that cholecystectomy is a less dangerous operation than simple cholecystotomy. Again, by Bardenheuer, that hæmorrhage from the liver can be readily arrested. The abstractor witnessed an operation in which the liver was accidentally wounded and the resulting hæmorrhage arrested by the thermo-cautery.

Hertin, a French naval surgeon, in 1767, after experiments made upon dogs, proposed, in wounds of the gall bladder, extirpation of the latter, after ligature of the cystic duct. In these experiments he demonstrated 152the feasibility of the operation of cholecystectomy upon the lower animals, at least.

Campaignac, in 1826, proposed ligature of the cystic duct, with partial resection of the gall bladder (Journ. hebdom. Bd. ii, 1829). K. Zagorski has recently attempted this latter procedure on dogs, with fatal results (Przegl. lekarski, 1887, No. 48). Nevertheless, to Zielewicz belongs the credit of being the first to demonstrate, by its successful performance, the feasibility of combining in man the two operations of ligature of the cystic duct and cholecystotomy with suture of the gall bladder to the abdominal wound. Upon further trial the operation may prove to be not only feasible, but to follow out a rational indication with relative safety.

SUPRA-PUBIC PROSTATECTOMY.

A. F. McGill, F.R.C.S. (The Lancet, February 4, 1888). The operation consists of two parts: (1) The opening and drainage of the bladder; and (2) The removal of the prostatic valve which prevents the egress of the urine. A full sized silver catheter, curved according to the nature of the case, is passed into the bladder, its contained urine withdrawn and its cavity washed out with a warm saturated solution of boracic acid till this is returned clean and unchanged. The usual rubber rectal bag is now introduced and filled with fourteen ounces of water. The bladder is now rendered prominent by injecting it with a sufficient amount of warm boracic acid solution. The catheter is retained in the bladder, and the fluid with which the latter has been distended, prevented from escaping. The usual median supra-pubic incision is now made, the bladder exposed and made to project into the abdominal wound by depressing the catheter. A large curved tenaculum is now passed transversely into the bladder, touching as it goes the point of the catheter. An incision is now made longitudinally through the bladder wall, the fluid being prevented from escaping by plugging the opening with the finger. The bladder is now seized with nibbed forceps, and applied on each side of the incision, the catheter is withdrawn from the urethra and the bag from the rectum, and the first part of the operation is complete. The interior of the bladder and its neck is now examined, in order to ascertain the exact nature of the prostate enlargement. A pedunculated middle lobe can be removed with the curved scissors, but in the case of a sessile middle lobe, this must be assisted with the finger and forceps. The “collar” enlargement is removed with greater difficulty. In order to insure the patency of the urethra, it is advised to pass the forefinger into the canal as far as the first joint. It is claimed that the hæmorrhage is not excessive. The operation completed, 153drainage is effected by passing a rubber tube out of the abdominal wound, the latter being partially closed by a point or two of suture. The tube is removed after forty-eight hours.

The author’s experience is limited to five cases, four of which have proved successful, while the fifth case is still under treatment. He claims that, in cases operated upon early, before diseased bladder or surgical kidney have developed, a radical cure may confidently be expected.

Two objections to this method occur to us: (1) Whoever has performed or witnessed supra-pubic cystotomy, either for the purposes of removal of a calculus or a neoplasm from the interior of the bladder, must have been struck by the difficulties in the way of a thorough appreciation of the condition of its posterior wall low down, or of the cystic neck. Unless specially devised instruments are available for each particular form of prostatic enlargement, it would seem to be a matter of great uncertainty as to just how much of the growth is removed. (2) Until satisfactory granulation of the wound surfaces has been accomplished, drainage, to be efficient, must be facilitated by placing the patient upon one or the other side, a position difficult to maintain, particularly in old people.

RESEARCHES UPON THE VAGINAL PROCESS OF THE PERITONEUM AS A PREDISPOSING CAUSE OF TENDENCY TO EXTERNAL INGUINAL HERNIA.

H. Sachs (Archiv. f. Klinisch. Chirurgie, Band xxxv., p. 321–372) advocates quite decidedly the view, basing his opinions upon preparations of the spermatic cord examined and upon microscopic examinations of cross sections of the latter, particularly as to the relations of the vas deferens and the vessels to the vaginal process of the peritoneum, that the latter is formed before the beginning of the descent of the testicle rather than as a portion of the abdominal wall formed or dragged into position by the testicle in its descent. In proof, he alleges that he has always found, in cases of incomplete descent of the testicle, that organ upon the posterior wall of the vaginal process, and not on the floor of the same. In females, the formation of the canal of Nuck cannot be said to be due to any dragging.

The entrance to the opening of the vaginal process is found covered by a valve arrangement, and the same is particularly noticeable in the canal of Nuck. The opening of the vaginal process can be caused to gape through a spreading out of the mesentery attached to the ilium or that of the sigmoid flexure. The diameter of the opening is, in general, greater on the right side than on the left in boys, while in girls this difference is not observed. Further, the different forms of the incompletely obliterated opening of the vaginal process agrees with the 154most frequently occurring forms of the hernial sac in inguinal hernia. The relations of the vaginal process to the elementary parts of the spermatic cord are not constant. On the contrary, the relations which the smooth muscular structures of the cord bear to the vaginal process, in so far as their arrangement into bundles, and their positive relation to the posterior and lateral walls of the same are concerned, are quite constant, and almost form an integral part of the same. The obliteration of the vaginal process depends upon a granulating process, which begins in the middle third of the funnicular portion, and from thence proceeds more rapidly in a downward than in an upward direction. This granulation formation takes place essentially during the first ten to twenty days after birth; after this time it takes place more slowly. The canal of Nuck, on the contrary, is found to have almost entirely disappeared at the time of birth. They are both found to be more frequently open upon the right side.

From these observations it would appear that it is not essential to the production of inguinal hernia that a broad and short inguinal canal should be present. The only essential predisposing cause, in children at least, depends upon the condition of the vaginal process of the peritoneum itself.

The question of the legal responsibility of employers is an interesting one, in connection with this question. Hernia cannot be considered as an accident, in the surgical sense, according to Socin (Korrespondenzblatt f. Schweizer Aertze, 1887, No. 18), but is really a slowly occurring disease, to which certain well-defined anatomical peculiarities act as predisposing causes.

ACID SUBLIMATE SOLUTION IN SURGERY.

E. Laplace (Deutsche Med. Wochenschrift, No. 40, 1887), after repeated and careful examinations and experiments, became convinced that dressing materials consisting of wood-wool, made with sublimate in the usual manner, were far from being germless themselves, much less efficient as antiseptic applications. Gauze, however, showed much better results, but were far from realizing an idealistic asepsis. He likewise found that ordinary sublimate, in the presence of albuminous material, is quickly precipitated and becomes at once ineffective. L. experimented at first with hydrochloric acid as a means of preventing changes in the sublimate from occurring in the presence of organic matter, and particularly albuminous material. But, as hydrochloric acid itself was far from possessing the stability needful for the purpose of preparing dressings, he substituted for it, with the most gratifying results, tartaric acid. The proportions are as follows: sublimate, 1 part; tartaric acid, 5 parts; distilled water, 1,000 parts.

155

OPERATIVE TREATMENT OF PYOTHORAX.

E. Rochelt (Wiener med. Presse, No. 32 and 38, 1887). The expansion of the lung is greatly impeded after the usual operation for empyema by incision, by the free entrance of air in the pleural cavity. Mader, Subbolik and Immerman devised means for preventing this. R. operates by first resecting a rib, leaving the periosteum intact, and subsequently opening the pleural cavity by means of a trocar and canula. A drainage tube accurately filling the latter is now introduced, through which a disinfecting fluid is injected and its outer opening closed by means of a spring clamp. The tube is connected to an aspirating bottle, into which the pus is discharged. The tube is again clamped, and the bottle into which the pus has been aspirated removed, being replaced by another containing a sublimate solution, 1 to 500. Removal of the clamp and raising and lowering the bottle thoroughly irrigates the pleural cavity. This being accomplished, the patient holding his breath in expiration, and the clamp again applied, the irrigating bottle is removed, and a short hard rubber tube connected to the outer end of the drainage tube. This hard rubber tube has a soft rubber diaphragm which acts as a check valve, effectually preventing the ingress of air during inspiration, but in no wise interfering with the egress of fluid from the pleural cavity during expiration, fits of coughing, etc. For purposes of further irrigation the short rubber tube containing the valve may be removed after guarding against the entrance of air by clamping the drainage tube beyond, and the washing bottle reapplied. During the intervals of irrigation, absorbent antiseptic dressing are kept applied.

The abstractor would suggest the application of this method, particularly in recent cases and in children, without the previous resection of a rib. The increased support afforded the canula by the greater thickness of the thoracic walls would be a still greater safeguard against the entrance of air into the pleural cavity. A certain proportion of acute cases will recover without resection of a rib.

WOUND-HEALING UNDER THE DRY ASEPTIC SCAB.

Prof. Kuester (Centralblatt f. Chirurgue, March 17, 1888,) in reply to remarks made by Dr. Sonnenberg before the Association of Berlin Surgeons, January 9, who characterized K’s method of treating the wound after the operation for the radical cure of hernia as an “open method,” objects to this designation of his method, and takes occasion to more fully describe his method as follows: After the reduction of the contents of the sac, the latter is sutured and excised, and the ring is also closed by suturing. The wound cavity itself is now closed by several rows of buried sutures, so arranged as to bring together the 156edges of the several layers, tissue to like tissue. In congenital cases he does not loosen the sac, but sutures its opposing surfaces down to the point where the testicle lies free. The wound of the skin is now closed by a continuous silk suture, and an iodoform and collodion mixture brushed over the line of suturing until it is perfectly covered in and blood no longer oozes through. No drain is used, and no further dressing is deemed necessary. If, after two or three days, a split occurs in the scab or crust formed by the drying of the iodoform and collodion, the gap is quickly filled by a slight oozing from the deeper portions of the wound, which, upon drying, becomes a bar against infection.

There can be no doubt, if thorough asepsis is observed and obtained during the operation, the method of completely obliterating every space in which blood clot or serum could accumulate would do away with the necessity for drainage. This granted, it follows, as a natural sequence, that absorbent dressings are superfluous, simple protection of the line of suturing from atmospheric influences, infection, etc., being alone indicated. The iodoform and collodion compound would seem to fulfil this admirably. The method could scarcely find application in large or deep wounds, particularly if the latter invaded planes of dense connective tissue, fasciæ, etc. Here it would be manifestly best to provide drainage, etc.

In marked contrast to K’s method is that of McBurney, who, providing against infiltration by suturing the entire thickness of each edge of the wound together in such a manner as to render it practically but one layer, packs the wound cavity, and thus obliterates the inguinal canal, the latter filling up by granulation, a firm cicatricial plug taking its place.

THE TREATMENT OF CAROTID HÆMORRHAGE.

Mr. Frederick Treves (The Lancet, January 21, 1888). In the neck, pressure upon the carotid artery, in hæmorrhages from the branches of that vessel, cannot be applied in the ordinary way with success, nor could it be maintained for a sufficient length of time, if the pressure succeeded in arresting the hæmorrhage, to be of service. Treves proposes, however, to occlude the vessel temporarily by throwing a broad piece of catgut around it, tying it in a loose loop, and then making traction upon the same. The circulation through the vessel is at once arrested, but can be at once restored upon relaxing the tension upon the loop. He relates four cases in which the method proved successful, so far as the arrest of the bleeding was concerned. One of the patients succumbed to the great loss of blood sustained prior to the application of the ligature, although the other carotid had been previously tied. In the first case the loop remained in situ for four days. 157The second case was the fatal one. In the third and fourth cases the loop was removed on the seventh day.

The method is based upon the fact that temporary arrest of the circulation in certain cases of hæmorrhage from the limbs, where ordinary means may be employed to exercise pressure, are quite sufficient, not only for the purposes of a temporary expedient, but also seems as a curative measure. This temporary modification of the blood current may be all that is required in many instances. Just how long the blood current may need to be checked, must be carefully studied in each individual case. The thought occurs to us, however, that some risk may be run of setting up an ulcerative action in the vessel walls by the prolonged application of a loose ligature, upon which must be exercised an intermittent pressure, by the pulsation of the vessel itself.

ARTIFICIAL AID IN THE FORMATION OF CALLUS.

Prof. Helferich (Archiv. f. Klinische Chirurgie, Band 36, 4. Heft, 1888). In cases of delayed union, and even in normal cases, to hasten the natural process of repair, H. advises the application of an elastic rubber bandage in such a manner as to retard the return flow of venous blood, by this means favoring an increased amount of pabulum to the field of repair, thus indirectly augmenting the formation of callus. The patient must be taught to regulate the pressure, attention being directed to the condition of the nails, in order that the bandage may be adjusted to suit the varying condition of congestion present. Œdema may be controlled by the application of a flannel bandage to that portion of the limb below the site of fracture. It is claimed that by this method the cure, in normal cases even, is considerably shortened. The process of repair is hastened by keeping the limb in a dependent position. The presence of small erosions at the site of fracture is not a contra-indication to the use of the elastic band. The time of application is of some importance, a too early application leading to too active hyperæmia; while, on the other hand, if too long delayed, the period of time in which the action will take place has passed. In wired compound fractures and in resections, pressure may be applied in from five to fourteen days after the operation, providing inflammatory symptoms are absent.

Thomas, of Liverpool, has recommended a procedure, which is known as the percussion method, to hasten the repair in delayed bony union, in cases of imperfect union, and in ununited fractures. This consists of percussing, once in a day or two, the site of the injury with a small copper hammer for five minutes or more, and subsequently bandaging the parts firmly.

It is suggested that the formation of varicose veins may be an objection 158to the method of Helferich. Further, it is quite clear that the method is not to be thought of in tuberculous subjects, as well as in cases of large open wounds at the site of fracture, or where a gap is left by resection of bone, removal of tumors, etc. The question of its applicability to atrophic members is an open one.

COMMUNICATION OF TUBERCULOSIS BY RITUAL CIRCUMCISION.

F. S. Eve (The Lancet, January 28th, 1888), relates the case of a Jewish child, in whom, six weeks following the usual rite, a small swelling appeared in each groin. They were found to be filled with caseous material, which, upon being inoculated beneath the skin of guinea pigs, gave rise to tuberculosis in the latter. The “Mohl,” or person performing the rite, had ejected some wine from his mouth over the cut surfaces of the prepuce. It was subsequently learned that this person had died of pulmonary consumption shortly afterwards. Another child in the same house, operated upon by the same person, suffered from the same infection. Both children finally recovered.

Similar experiences have been recorded by Eisenberg (Berlin Med. Woch., No. 35, 1886), and Meyer (Centralblatt f. Chirurgie, No. 46, 1887). Of greater importance, because of a probably greater frequency, is the transmission of syphilis in this manner. A group of cases of this kind were recently collected and made the subject of study at the London Hospital.

TRANSPLANTATION OF THE SKIN.

Baratoux and Dubonsquet (Progres. Med., No. 15, 1887). D. treated two extensive wounds caused by burning, in which no attempt at cicatrization seems to have been made, although granulation was progressing well, by transplantation. Simultaneous auto-transplantation, and pieces of skin from a frog’s back the size of a thumb-nail, was practiced. Most of the latter lost their pigmented aspect after ten days, and adhered well, taking on the natural color of the human skin. The wound where the frog’s-skin transplantation had been performed healed more rapidly than the other where human skin was used, the cicatrix being softer as well. B. treated cases of ulceration of the nose, and also perforations of the membrana tympani, successfully by transplantation of frog’s skin, healing taking place in from one to two weeks.

In three old cases of perforation of the drum membrane, the margins were freshened by touching them with nitrate of silver, and a piece of frog’s skin attached. In three days a cicatrix had formed, with considerable improvement in the hearing. Transplantation must be practiced with a healthy granulating wound, hæmorrhage being avoided. According to the authors, the wound should be irrigated with a strong 159solution of carbolic acid, and dried; the pieces of skin should also be washed in a weak solution of carbolic acid.

It suggests itself to the abstractor that still better results would be obtained by substituting a sterilized solution of chloride of sodium, say of the strength of 6 to 1,000, for the strong carbolic solution recommended, to be used just prior to the operation. The changes produced in the vessels and their contained blood by the use of strong disinfecting solutions are calculated to prevent early adhesion of the new skin. At least such is the general experience of recent observers. Reliable disinfection of the ulcerated surface may be obtained by keeping the parts covered with gauze wrung out of a 1 to 12,000 solution of potassio-mercuric iodide for a day or two previously.

OBSTETRICS.

BY CHARLES JEWETT, A.M., M.D.,

Professor of Obstetrics and Diseases of Children, and Visiting Obstetrician, Long Island College Hospital; Physician-in-Chief to the Department of the Diseases of Children, St. Mary’s Hospital, Brooklyn.

THE IMPROVED CÆSAREAN SECTION.

Garrigues (Am. J. M. S., May, 1888,) describes in detail a successful case of Cæsarean section with observations on the technique of the improved operation. He prefers a long abdominal incision, and eventration of the uterus before opening it, the advantage claimed being the easier application of the rubber constrictor. The constrictor is more manageable if held in the hand of the assistant instead of the clamp, since it can be loosened and tightened as required. To prevent prolapse of intestines he sutures the upper end of the abdominal incision before turning out the uterus, tying the sutures before that organ is opened. Extraction of the fœtus by the head is much easier than by the feet. When a long uterine incision is required, it is better to go an inch into the fundus than to extend the wound into the lower segment, which may cause troublesome hæmorrhage.

Removal of the ovaries for the prevention of subsequent pregnancies he thinks not justified. The omentum he pushes up above the uterus to prevent adhesions to the suture line and the consequent danger of subsequent intestinal obstruction.

Dr. Garrigues believes Cæsarean section safer than difficult extraction through the natural passages.

Eleven Cæsarean sections were done in this country between December 16, 1886, and February 24, 1888, (Dr. R. P. Harris) all by 160the improved method but one. Six women and eight children were saved. Six of the operations were performed in hospitals, saving five women; five in private practice, saving only one. All the five hospital cases operated by the improved technique were successful. The bad results in private practice Dr. G. ascribes to imperfect antisepsis. He alludes to the tardy adoption by our own countrymen of the antiseptic methods in general obstetric practice which have met with almost universal acceptance elsewhere—in Germany midwives being even compelled by law to use antiseptic precautions in every case of confinement.

Including the above-mentioned case, one hundred and sixty-three Cæsarean sections had thus far been done in the United States (Harris). One hundred and seventy to date of this writing.—Ed.

The paper concludes with a detailed statement of the modus operandi and after-treatment in the modern Cæsarean operation. (A loop of the constrictor can usually be readily passed over the fundus and slipped down to the cervix while the uterus is still in the abdomen as we have shown.) (A Case of Cæsarean Section, N. Y. M. J., August 29, 1885.) Traction upon the constrictor perfectly occludes the short abdominal wound during the incision of the uterus, eventration taking place as the uterus collapses on removing the fœtus. The advantage, therefore, of extending the abdominal incision some inches above the umbilicus in all cases and turning out the uterus before opening it may be doubted. It is sometimes, however, impossible or difficult to apply the constrictor to the uterus in situ. Extraction of the fœtus by the head is certainly easier than delivery by the feet as advised by most writers.

The comparative results of induced labor, version, perforation and Cæsarean section in the Dresden Clinic have been recently considered in a series of papers by Leopold and his assistants, Korn, Lohman and Praeger.

The maternal mortality was as follows:

Induced premature labor 2.2 per cent.

Version and extraction 4–8 per cent.

Perforation 2–8 per cent.

Cæsarean section 8–6 per cent.

The fœtal mortality was in

Premature labor 33.4 per cent.

Version and extraction 41. per cent.

Cæsarean section 13. per cent.

Leopold concludes that while Cæsarean section cannot yet be substituted in all cases for craniotomy, it is at least justifiable as an alternative when the following conditions are present or possible, viz.:

Complete asepsis.

161The patient strong and not long in labor.

The fœtal heart-beats normal in rate and rhythm.

Strauch (Arch. f. Gyn.), analyzing the results in twenty-eight cases of induced premature labor arrives at like conclusions. While the mortality in cases of the mothers was nil, the fœtal mortality was fifty-five per cent. The rights of the fœtus demand a more frequent choice of Cæsarean section, the mortality of which by the modern method is thus far 11.8 per cent. for the mothers and 8 per cent. for the children.

Dr. Felice La Torre, of Paris, reaches the conclusion from extensive clinical research that craniotomy or premature labor is better than Cæsarean section, since the former saves all the mothers.

Krassowski (Arch. f. Gyn., B. 32 H. 2) reports five Porro and two Saenger operations saving six mothers and five children. K. uses thymol 1:1,000 for instruments, and the biniodide of mercury 1:4,000 for the hands, etc. He seals the abdominal wound with collodion to which biniodide of mercury has been added.

Zweifel reports six additional cases of the Cæsarean operation after Saenger, saving five mothers and all the children.

THE MECHANISM OF LABOR IN HEAD PRESENTATION.

Sutugin (Sammlung Klin. Vorträge, No. 310) makes an important contribution to the knowledge of this subject. The paper deals with an “almost wholly neglected factor in the mechanism of labor,” namely, the position of the fœtal trunk in utero, the mechanism of the trunk movements and their effect upon the positions of the head during labor. He first shows that the views commonly accepted with reference to the position of the fœtal trunk during pregnancy are in part erroneous. Observations by the author in six hundred and sixty cases, published in 1875, established the fact that before labor, in either right or left positions, the dorsum of the child is almost invariably turned to the mother’s back, the vertebral column of fœtus, as a rule, lying but little to one side or the other of the spinal column of the mother; and, furthermore, the changes of position during pregnancy, as from right to left, probably take place by rotation along the posterior wall of the uterus. On the occurrence of energetic uterine contractions, especially at the beginning of labor, the back of the child is sometimes rotated to the mother’s side. Kehrer has confirmed the conclusions of Sutugin in observations upon certain of the lower animals. It may be noted in passing that, according to Kehrer’s observations, gravity is a subordinate factor in determining the attitude of the fœtus in utero.

The author of the paper declares that, in a large number of cases examined during the last twelve years he has not in a single instance 162found the back of the child turned wholly forward during pregnancy, not even in first positions of the head. He has more recently made a study of the varying positions of the trunk during labor. Early in the labor, in first positions of the head, the trunk rotates so that the back of the child looks sideways, the shoulders lying in a plane parallel with the introitus. The breech rotates more slowly than the shoulders, the spinal column of the child thus assuming the form of a spiral during delivery. The fœtus, therefore, in its descent moves in a screw-like direction around its own axis, but the back of the child is not turned forward even during parturition, as authors generally have assumed. These views are born out by the frozen sections of Chiara, Waldeyer, and Shroeder. The rotation of the head is in part due to the rotation of the trunk, “the torsion of the axis of the fœtus,” and is not to be referred solely to the action of the pelvic planes. The author claims that a torsion of the uterus upon its axis similar to that of the child also occurs. With reference to the etiology of the torsion in case of uterus or fœtus, he ventures no explanation.

MANAGEMENT OF THE PLACENTAL STAGE OF LABOR.

Fehling (Sammlung Klin. Vorträge, No. 308) compares the views and practice of authorities in the treatment of the third stage of labor. The various methods of placental delivery that have been advocated by different writers are recounted. The reaction against Credé in favor of expectancy, first started by Dohrn and Ahlfeld, has resulted in proving the inferiority of the latter plan, and in a return to more active methods. In a large number of German clinics, the uterus is allowed to rest immediately after the expulsion of the child, without friction. When the placenta lies detached in the lower uterine segment, which is generally the case after fifteen or twenty minutes, nothing is to be gained by longer waiting. The author is favorably disposed toward the practice of Credé, which as he says, has never been shown by its adversaries to be capable of harm when properly conducted. With reference to the mechanism of placental separation, both theoretical considerations and clinical observations favor the views of Duncan, yet the question is not settled. Retained membranes may be removed with the aseptic hand. Yet Credé and Olshausen consider the retention of even the whole chorion free from danger, and clinical experience has shown better results by the expectant plan in case of retained membranes than by interference. These results, the author thinks, in the light of Döderlein’s researches, are explained by the fact that the hand may transport the peccant germs from the vagina into the uterus. The active plan, with a preliminary vaginal disinfection and a vigorous asepsis throughout, should yield better results than expectation. Interference with these precautions 163is, at least, justified in case of atony and hæmorrhage or fever, including, if need be, the use of the curette and subsequently ergot. Dührssen’s method of tamponing the uterus in post-partum hæmorrhage with iodoform gauze is favorably mentioned.

In the event of cervical tears causing troublesome hæmorrhage, Kaltenbach, Schroeder and Leopold practice immediate suture. The author thinks the vaginal tamponade is generally to be preferred. Yet, in certain cases the suture may also be required, or the application of the perchloride of iron on cotton pledgets to the bleeding surfaces.

Credé (Arch. f. Gyn., B. 32, H. 1) again discusses and defends his method of managing the placental delivery which he prefers to call the external method.

The duration of the third stage need not in the majority of normal labors exceed fifteen to thirty minutes. In many instances a more expectant plan of treatment is better. In occasional cases more rapid delivery is demanded in the interest of the mother. Since the method is free from danger when properly conducted, the expulsion of the placenta may be hastened within reasonable limits if for no other purpose than to save the time of the attendants and to spare the sufferings of the patient. He claims that the amount of blood-loss is diminished under his treatment of the placental stage, and that the membranes are not more frequently retained. Furthermore, he believes the retention of portions of the membranes or placenta to be harmless in an aseptic condition of the passages.

The method of Credé, briefly restated, is as follows: First apply gentle, painless friction in a circular direction over the anterior wall of the uterus, laying the hand flat upon the abdomen. Bring the axis of the uterus in conformity with the axis of the pelvic inlet. If the placenta is not expelled after three or four pains assist the next contraction, at its acme only, by compressing the upper segment, grasping the fundus with the thumb in front and the fingers behind, at the same time using gentle downward pressure. Use slight friction only but no compression during the intervals between the pains nor even during the contraction except at its height. Success usually attends the eighth or tenth pain.

SCARLET FEVER: ITS RELATION TO PUERPERAL FEVER

Boxall (Br. Gyn. J.) in sixteen cases of scarlet fever in childbed found septic manifestations in but one. In forty lying-in patients exposed to the scarlatinal poison the puerperium was entirely normal. Three hundred patients or more were admitted to the hospital during the epidemic of scarlatina therein, yet a comparison of the morbidity during this time with that which immediately preceded the outbreak showed that the prevalence of scarlet fever in the hospital exerted 164no appreciable effect upon the course of the puerperium in patients who escaped scarlatina.

Galabin (Br. M. J.) thinks there is strong evidence of the bacterial relation of puerperal sepsis to scarlet fever. Septicæmia does not represent a distinct entity like scarlatina. Cheyne found the common microbes of suppuration in the blood of scarlet fever patients not infrequently.

MITRAL STENOSIS AND THE THIRD STAGE OF LABOR.

Dr. D. B. Hart (E. M. J., Feb. 1888,) reports eight cases of this complication with seven deaths. With reference to the etiology Dr. Hart thinks the progress of the cardiac lesion is greatly accelerated by the increased amount of work imposed upon the crippled heart during pregnancy. At the beginning of labor, therefore, we may get failure of compensation, dilated heart and engorgement of the lungs. At the close of the labor, if free hæmorrhage does not occur, the extra blood before accommodated in the utero-placental sinuses is returned to the right heart. Death is therefore liable to occur in the third stage from over distention of the right heart.

Dr. Ballantyne (E. M. J., March, 1888,) adds two more cases to the above record, both terminating fatally. Sphygmograms obtained in these cases show that the period immediately following the expulsion of the placenta is the one of greatest danger, and they are entirely consistent with Hart’s theory of the cause of death.

TREATMENT OF ABORTION.

Fry (Am. Obs. J., June, 1888,) advocates the use of the galvanic current as a substitute for the curette for the removal of retained fragments of the secundines. He uses a current of sixty to ninety milliamperes with the anode in the uterus. The application is continued from six to ten minutes and repeated on alternate days. The placental tissue, owing to its relatively low vitality, is destroyed without injury to the uterus itself. Separation and expulsion follow. Hæmorrhage is relieved by the well known hæmostatic action of the positive electrode. Dr. Fry also claims antiseptic properties for the positive pole since here are liberated oxygen and chlorine in a nascent state and also acids.

Goodell thinks the curette an inefficient instrument for the evacuation of the uterine cavity and liable to injure the uterus. He advocates polypus forceps. Parrish finds the curette deceptive. He uses the finger. Longaker prefers the finger. [A Sims’ speculum, a dull curette and a strong, straight uterine dressing forceps, with its joint two and a half inches from its distal end need never fail. The finger is awkward, difficult, painful, and sometimes requires preliminary 165dilation of the cervix. It cannot, moreover, be so easily sterilized, and even though clean primarily is liable to carry septic organisms from the vagina. Injuries to the uterus are for the most part the fault of imperfect asepsis.]

PLACENTA PRÆVIA.

Obermann (Arch. f. Gyn., B. 32 H. 1.) discusses the treatment of placenta prævia by version with the results obtained in sixty-four cases at the Leipsic clinic. The method, which has become known as Hofmeier’s method, he states as follows:

Perform bimanual version with deliberate extraction in case of much hæmorrhage. The podalic extremity of the child makes an effectual tampon. Massage of the uterus during extraction is advised to aid expulsion. Iodoform gauze tampon may be used in case of hæmorrhage in the early months. The colpeurynter is recommended in case of hæmorrhage with a closed cervix. Alcoholic stimulants are given early and often.

The results in the sixty-four cases were eighty-nine per cent. of the mothers and forty-seven per cent. of the children saved.

Nordmann, of Dresden, condemns early resort to operative procedures as a routine measure, a more expectant plan of treatment being competent in a certain proportion of cases.

Robt. Barnes (Br. Med. Jour., March 3d, 1887) sums up his views substantially as follows: The hæmorrhage in placenta prævia proceeds from so much of the lower zone of the uterus as is laid bare by separation of the placenta during canalization. This comprises all that portion of the uterus that lies below the equator of the fœtal head. When canalization is complete the hæmorrhage is almost invariably arrested spontaneously by retraction of the lower zone thus freed. Until canalization is completed flooding is liable to persist, but after that process is accomplished the case becomes practically a natural labor. The too prevalent idea that the hæmorrhage is unavoidable and must go on till delivery is erroneous and mischievous. Enough placental attachment usually remains after complete dilatation to preserve the life of the child. The fœtal life is not necessarily compromised except in certain extreme cases of complete central placenta prævia. His views of treatment follow as a corollary. Expedite the first stage, avoiding violence or precipitation. His caoutchouc bags accomplish this indication and control hæmorrhage. Detach the placenta with the finger from the zone below the equator of the head, thus permitting retraction and arrest of flooding. Rupture of the membranes and the use of the binder meet the indications in certain cases. The vaginal plug may be used in occasional instances if carefully watched. The os uteri moderately expanded and the placenta separated from the lower 166zone, hæmorrhage having ceased, wait. With sufficient dilatation, deliver, if necessary, by forceps, version, or craniotomy. Dr. Murphy’s success by this plan has been unexampled. [Dr. Barnes does injustice to version in placenta prævia, since he appears to assume that immediate extraction and violence to both mother and child are a necessary part of the procedure. The success of that plan he attributes in great part to the fact that, in carrying out the operation of turning, the placenta had probably been detached from the lower zone. These criticisms certainly cannot apply in case of external or bipolar version. With reference to Barnes’ bags, it is safe to say, “the German teachers” are not the only practitioners who have found them, in many cases, more or less impracticable.]

OBSTETRIC SEPSIS AND ANTISEPSIS.

Auvard, writing to the Annals of Gynec., April, 1888, says, while before the days of antiseptics it was better for a woman to be delivered in the street than in a hospital, the hospital ward is now less dangerous than the isolated lying-in chamber of the out-patient obstetric service. He points out the importance of improving the resisting power by use of tonics before the labor, in debilitated patients. In Auvard’s practice every woman takes a thorough bath at the beginning of labor. The whole vulvar and vaginal surfaces and cervical canal are sterilized before expulsion begins, before obstetric wounds are developed. Asepsis before and during the birth is more effectual than the use of antiseptics at the close of labor and renders the latter unnecessary.

Sublimate soap and the sublimate solution, with which this soap makes a lather, are well rubbed into the surfaces to be cleansed by aid of the fingers. The dangers of sublimate poisoning do not obtain while the surfaces are intact.

In the event of septic developments during the puerperal period he thinks sublimate irrigation insufficient for genital antisepsis. The vulva and vagina should be scrubbed by aid of the fingers with the sublimate soap and solution. The uterus should be scraped with the curette. Auvard has devised for this purpose a curette with a hollow stem through which a stream of the antiseptic solution is kept flowing during its use. [The mercurial salts may be replaced with a 1:1000 hydronaphthol solution for use within the passages after labor, though the danger from the former antiseptic may be greatly diminished by washing away the mercurial with a final injection of plain boiled water.]

AUTO-INFECTION IN CHILDBED.

Ahlfeld (Cent. f. Gyn., No. 52,) shows that it is not always safe to presume upon the impossibility of self-infection, and reports two 167cases in point. In rare cases infection may arise from organisms primarily present in the genitalia. [This goes to fortify Auvard’s position.]

OCCURRENCE OF GERMS IN THE DISCHARGES FROM THE UTERUS AND VAGINA DURING THE PUERPERAL PERIOD.

Döderlein (Arch. f. Gyn., B. xxxi., H. 3,) finds in a series of carefully conducted observations, that in normal cases the uterine discharges contain no germs, while in the same patients numerous varieties of germ life abound in the vagina. Pathogenic organisms may occur in the vagina apart from any internal examination. These germs may gain access to the uterus of themselves when not carried by intra-uterine instrumentation or manipulation. These conclusions are confirmed by Kaltenbach.

The uterine lochia of women suffering from puerperal sepsis in any form invariably contain germs, the streptococcus pyogenes being constantly present.

SUBLIMATE SOLUTION.

Laplace has shown the importance of acidulating sublimate solutions for general antiseptic use. Neutral solutions on mingling with blood or other albuminous fluids become more or less inert by the precipitation of the albuminate of mercury. That precipitate is not formed in the presence of hydrochloric or tartaric acids. The proportion for sterilizing wounds should be five parts of the acid to one of the sublimate in one thousand of water. [Biniodide solutions require no acid. This is one of the many advantages of the mercuric iodide over the bichloride for antiseptic use. In a series of experiments made for the purpose of determining the reaction of biniodide solutions on albuminous fluids we found that neutral solutions of the biniodide of mercury yield no precipitate with albuminous fluids. No reaction was obtained with a biniodide solution acidulated with hydrochloric acid in the proportion of five parts to the thousand. The addition of organic acids, such as acetic, citric or tartaric, as is well known, causes a precipitate of albuminate of mercury. There is no chemical incompatibility between sublimate soap and biniodide solutions.]

TRICHLORIDE OF IODINE.

One of the new antiseptic agents is iodine trichloride. In contact with organic bodies it gives off iodine and chlorine in the nascent state. The final products, moreover, hydrochloric and iodic acids, are well known oxidizing agents. The strength of solution used is one part in 1,000 or one in 500 parts of water. Such a solution is equivalent in sterilizing power to a 1:1,000 or 2,000 sublimate 168solution. [One disadvantage of this antiseptic is the powerful corrosive action of nascent chlorine and iodine upon metal instruments.]

DANGERS OF ANTISEPTICS.

Senger (Br. M. J., May 19, 1888,) has proved by experiments on dogs and rabbits that the antiseptic agents commonly employed are liable to cause degeneration of the kidneys. He injected into perfectly healthy animals corrosive sublimate, carbolic acid, etc., in one-twelfth the quantity necessary to kill them. Then on extirpation of one kidney he found in all cases, on microscopical examination, glomerulo-nephritis. He also found fatty degeneration of the liver, spleen, the heart-muscle, etc. The various antiseptic agents were found to be injurious in different degrees, corrosive sublimate being the most dangerous, then the others in the following order: iodoform, carbolic acid, salicylic acid, boric acid. These observations especially enforce the importance of avoiding the use of antiseptics in the abdominal cavity, or in other large cavities under conditions favorable to absorption. Sterilized water or a five per cent. chloride of sodium solution should be substituted for use in the peritoneum. Senger has shown that the salt solution in no way injures the organs, and that it possesses moderate antiseptic power, killing the streptococcus pyogenes aureus in twenty-eight minutes.

EFFECT OF ERGOT ON THE INVOLUTION OF THE UTERUS.

Drs. G. G. Herman and C. O. Fowler (Br. M. J., Feb. 11, 1888,) discuss this question, basing their conclusions on the results noted in fifty-eight cases treated with ergot for a fortnight after delivery, and sixty-eight in which a single dose only of ergot was given at the close of labor. In the cases continuously ergotized the diminution of the uterus in size was more rapid than in those who received but a single dose. On the duration of the lochial discharge no appreciable effect was observed from the use of ergot.

Dr. Boxall has made similar observations on two parallel series of cases of one hundred each. Every alternate patient was given a mixture containing ext. ergot. ammon., ♏︎ xv., t.i.d., during the first three days after labor. Dr. B. concludes from the experience of these cases that the practice of giving ergot as described tends to prevent the formation of clots, to hasten their expulsion, and to diminish the frequency, intensity and duration of after-pains. That if omitted at first and given afterwards ergot tends to promote the expulsion of clots and to relieve after-pains.

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ANÆSTHESIA WITH CHLOROFORM AND OXYGEN.

Dr. Kreutzmann (Cent. f. Gyn.) recommends a mixture of oxygen and chloroform vapors as an anæsthetic in obstetric and surgical practice. The mixture may be made by passing freshly prepared and pure oxygen through chloroform on its way to the inhaler. Neudörfer injects a small quantity of chloroform into a balloon filled with oxygen, administering through a face piece. It is claimed for this method, that anæsthesia is at once established after a few deep inspirations without the least excitement, and that there are no disagreeable after-effects, the patient awaking promptly on ceasing the anæsthetic as from a refreshing sleep.

Veit, of Berlin, has operated in seven cases of tubal pregnancy before rupture, in all successfully.

Breisky, of Vienna, has recently performed the first successful laparotomy for the removal of an ectopic viable fœtus in which all the fœtal appendages were at the same time removed. The operation was done at the end of the eighth month. Breisky advocates primary laparotomy with extirpation of the entire sac in preference to the secondary operation.

Brunniche (Cent. f. Gyn.) treated a case of vomiting of pregnancy successfully by feeding the patient through a tube introduced into the upper part of the œsophagus.

Duncan (London Lancet) reports three cases of hyperemesis in which complete relief followed the application of cocaine in five per cent. solution to the vaginal vault and cervix.

Saenger says the process of uterine involution is not a fatty degeneration but normal metabolism.

Dr. Temple, of Toronto, Canada, in a case of post-partum hæmorrhage, hot water and other measures having failed, injected the uterus with a tumblerful of undiluted brandy. Prompt contractions and arrest of hæmorrhage followed.

QUININE AS AN OXYTOCIC.

Dr. Cordes finds in quinine an efficient oxytocic in incomplete abortion. He administers two and a half grains hourly till the desired result is accomplished.

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