OBSTETRICS.

BY CHARLES JEWETT, M.D.,

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

Hospital, Brooklyn.

MINUTE ANATOMY OF THE PLACENTA IN EXTRA-UTERINE GESTATION.

D. Berry Hart (Ed. Med. Journ., Oct., 1889).

This brief paper

gives the results of a histological study of the ectopic placenta in the following material:

1. Tube with placenta attached from a ruptured tubal gestation at the second month.

2. Broad ligament gestation at the fourth month.

3. Abdominal gestation entirely extra-peritoneal and at nearly full

term.

4. Abdominal gestation, with foetus probably intra-peritoneal and

placenta certainly extra-peritoneal.

In the tubal gestation the villi lay imbedded in decidual cells, no intervillous system existing. The muscular wall, however, contained large sinuses.

The broad ligament pregnancy illustrated the destructive changes which take place in the placenta when it is developed in the connective tissue. The villi were less perfect in contour, blood-extravasation was present, and the decidual cells were few and less perfect.

In advanced abdominal pregnancy, the placenta being in pelvic connective tissue and but little displaced, the villi were fairly perfect, decidual cells were found and large extravasations of blood, which perhaps indicates an attempt at a placental sinus system.

In abdominal pregnancy with extreme displacement of the placenta, the placenta was found converted into a mass of organizing blood-clot, showing great compression and distortion. There was an entire absence of decidual cells and no recognizable intervillous sinus system. The abdominal veins at the placental site, however, were enlarged. The damage done to the placenta in extra-uterine pregnancy is in proportion to its displacement.

The foetus is frequently killed by the injury sustained by the placenta. When the foetus escapes by secondary rupture into the peritoneal cavity, and the placenta suffers little displacement and little disturbance of its functions, the gestation may go on to a more favorable termination.

MITRAL STENOSIS AND LABOR.

Three more cases

D. Berry Hart (Ed. Med. Journ., Aug., 1889). are reported, in two of which post-mortem examinations were held with

results confirmatory of Dr. Hart's previously published conclusions. He finds that pregnancy accelerates the morbid changes, Fresh endocarditis is lighted up, the obstruction is increased and compensation fails. The prominent danger is from sudden over-distention of the right heart on the completion of the third stage of labor.

The extent of the dilatation of the right heart may be determined during life by the area of percussion-dulness, the existence of venous pulsation and of hæmoptysis.

For treatment, it will be remembered, Dr. Hart advises strophanthus, forbids ergot and other measures that tend to prevent a moderately free blood-loss at the close of labor and recommends venesection if required to relieve the right heart.

THE ORIGIN OF PERITONEAL INFLAMMATION,

Bumm (Archiv. f. Gyn., B. 36, H. 3) distinguishes the following forms of peritonitis:

1. The non-infectious form, which originates from the action of mechanical or chemical irritants, without micro-organisms.

2. The septic forms caused by micro-organisms (a) a streptococcus peritonitis. This form is regularly found in the peritonitis of puerperal women. Its purulent secretions are infectious. (b) A putrid peritonitis after abdominal operations or perforation of the intestines. Its secretions are not infectious.

3. Specific inflammation of the peritonæum caused by the influence of specific germs. To this form belongs especially tuberculous peritonitis but not gonorrhoeal. Gonorrhoeal virus when pure is aseptic. It leads generally only to a fibrinous inflammation. The gonococcus thrives only on mucous membranes; on a serous surface it soon perishes.

THE FORCEPS OPERATION.

Münchmeyer (Am. Jour. Med. Sci., Jan., 1890) makes a critical study of 206 forceps deliveries in 7,322 labors from the case books of the Dresden clinic. The frequency of forceps operations was 2.8 in every hundred labors. The total morbidity was 32 per cent., much greater in high operations. The mortality was 3.4 per cent., but in no case attributable to the forceps alone. Extensive lacerations occurred in 119 women; 141 cases had no post-partum fever. The foetal mortality was 29 per cent.

M. concludes that high applications of the forceps should be restricted to experienced hands, and in all cases the instrument should be used as rarely as possible. Feeble pains or the absence of pains never alone justify resort to the forceps. Positive danger to mother or child is the only valid reason for their use. In formulating these conclusions the author has not been unmindful of the fact that in many

instances the condition which called for the forceps, as well as the instrument itself, contributed to the unfavorable results.

CAFFEIN IN POST-PARTUM HÆMORRHAGES.

Misrachi (Annals Gyn., Dec., 1889) commends in strong terms the use of caffein in the treatment of post-partum hæmorrhage. It acts directly as a cardiac tonic and stimulant, and as a remedy for the acute anæmia of the nervous centres. Indirectly, as a general excitant, it promotes uterine contractions. Ergot should also be given in combination with it as a direct excito-motor of the uterus.

The following is a modification of Tanret's formula for the hypodermic solution:

This quantity may be injected subcutaneously from three to five times, at intervals of fifteen minutes.

ALCOHOL IN THE TREATMENT OF PUERPERAL FEVER.

Martin, of Berlin (Annals of Gyn., Nov., 1889) pleads for the more extensive use of alcohol in the therapy of puerperal fever as proposed by Runge. It acts mainly by fortifying the resisting and recuperative power of the individual, and is particularly adapted to the stage of general septic infection.

The plan of treatment is not intended to replace but rather to supplement local disinfectant measures and the use of tonics' and forced feeding.

The forms of alcoholic most used by Martin have been cognac, champagne, the heavy wines and punches. The quantity given amounted in many instances to little less than a bottle of cognac or its equivalent daily. Several severe cases of septic disease in childbed are reported in detail, which afford striking proof of the value of alcohol in the treatment.

HYPODERMIC INJECTIONS OF A COMMON SALT SOLUTION IN POST-PARTUM

HÆMORRHAGE.

This plan of treatment in acute anæmia has been successfully employed in the Dresden Lying-in Hospital in a large number of cases. The quantity of fluid used is nearly a quart of a six per cent. solution. The solution should be sterilized by boiling, and cooled to 98° F. The infraclavicular or infrascapular regions are the preferred sites for the injection. The dispersion of the fluid may be promoted by gently manipulating the swollen tissues about the point of puncture.

BY HENRY CONKLING, M.D.,

Pathologist and Assistant Visiting Physician to St. Peter's Hospital; Physician to the Department of the Chest, Brooklyn City Dispensary.

THE RELATION OF TONSILLITIS TO RHEUMATISM.

Haig-Brown (British Med. Asso., Aug. 1889) classifies tonsillitis as specific (exanthematous or diphtheritic), sporadic or epidemic, follicular and interstitial. In all cases of tonsillitis the whole structure is involved, but the great majority of cases have the intensity of the disease manifested in the follicles. Occasionally the inflammation is more marked in the interstitial tissue.

These forms are regarded as having distinct and individual features. They are not considered as merely differing in degree A patient who has had an attack of follicular tonsillitis will probably suffer from subsequent attacks. But when suppuration has taken place and the abscess has formed and healed, a second attack is not common.

The author continues the discussion of the follicular form. It occurs under two opposite climatic conditions, one of winter and one of summer. The first is when the air has been saturated with moisture for several days in succession, developing a fog; with a gentle east wind. The second is when there have been successive hot and dry days, with the humidity about 80. These are the atmospheric conditions that favor rheumatism.

Rheumatism and tonsillitis are both liable to occur under septic influences. Rheumatism, quite as frequently as tonsillitis, may appear in connection with drain poisoning. This has been proved by the analysis of the medical list of a large institution, where, previous to repairing the drainage, the throat and acute rheumatic patients made 25 per cent. of the cases. In the year subsequent to the change the two diseases constituted 6 per cent. of the list.

The author found that, in an analysis of 119 cases of tonsillitis, 38 of the cases had been subject to repeated attacks of rheumatism; 28 suffered from rheumatism during the attack; in 10 cases the parents were rheumatic; the remaining cases gave negative information.

In both tonsillitis and rheumatism there is a tendency for the disease to recur; both are marked by perspiration during the attack; in both there is a liability of endocardium and pericardium becoming inflammed. The author believes that many cases of so-called febricula in children are follicular tonsillitis. There may have been no prominent throat symptoms and the throat examination was not made.

The author believes that the cause of many cases of cardiac valvular disease may be found in follicular tonsillitis.

The tendency of the fever of follicular tonsillitis is to subside on the third day.

The author concludes by advancing three theories. 1. Rheumatism is a general disease, which frequently manifests itself in the throat; 2. The inflammed tonsil is the receptable for the rheumatic poison, and its mode of entrance into the body; 3. The specific germ after entrance into the body causes inflammation of the tonsils, the fibrous, and the fibro-serous membranes.

GLYCOSURIA.

Ord (Lond. Med. Soc., Oct. 1889) presented a paper concerning certain conditions in which sugar is found in the urine and in which the disease diabetes is not present.

An organic condition quite commonly present is an excessive afflux of blood to the liver and other glycogenic organs. A vasomotor paralysis resulting from central or peripheral causes will produce this. Hepatic irritation, direct or indirect, from the condition of neighboring organs, causing dilatation of the hepatic artery, is regarded as a factor.

A new and interesting theory under the name of compensatory hyperamia is advanced. The author believes that, by this means, arterial obstruction elsewhere may be balanced. The constant use of the term arterial is noticed in this part of the paper. It is considered that any great contraction of arteries in parts, near to or remote from the liver, may produce an extra amount of blood pressure in the arteries of the liver and so set up glycosuria.

Heredity is traced as a factor in causation. In the cases recorded the parents were well advanced in years; some were the subjects of diabetes and others of glycosuria. The glycosuric children of these parents were over fifty.

Attention is drawn to the relation between gout and glycosuria. Glycosuria is often found as a symptom of gout, and the diathesis is the probable cause of the sugar in the urine.

Glycosuria is frequently found in people subjected to great nervous If none of the conditions mentioned above is found we must

strain.

look for an ætiological factor in tissue imperfection.

TISSUE IMPERFECTION.

This condition in the body may be marked by

1. Abnormal tissues.

2. Abnormal constitutional states.

Cases illustrative of this may be found in stout people suffering from glycosuria. These people may have an increase of weight by inheritance, or due to habits, as from lack of exercise or alcoholic