Dyer Hook Sanborn.

The American journal of obstetrics and diseases of women and children online

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Maternity of Mannheim give these results : Of 6,935 cases deliv-
ered, 26 perforations, 0.37 per cent.; mortality of mother, 7.69
per cent. ; living child obtained in 63 per cent. The mortahty of
Cesarean section for ttye last ten years was 10 per cent. This shows
the mortality of perforation to be less than that of Cesarean section.
That of symphyseotomy has been given also as 10 per cent. Sym-
physeotomy also has the disadvantages of being far from free
from danger, having a long convalescence, and being liable to
cause impaired bladder functions. Another element that has to
be considered is the prejudice among the public and physicians
against Cesarean section. Many women who are brought to a
hospital refuse absolutely to submit to a section. They cannot be
turned away, and something must be done to deliver them. The

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indications that were considered to justify perforation, in the 26
cases that were operated on in this way in the Maternity, were :
Rise of temperature, bad general condition of the mother, eclamp-
sia, threatened rupture of the uterus. Of twenty cases, narrowed
pelvis existed in all. If a pelvis is so contracted that delivery is
impossible, the patient and physician think only of a Cesarean
section; if the deformity is less, they attempt delivery by other
means, and often the patient is reduced to a low condition before
she will submit to a radical interference. Hence, the author con-
cludes that it is the duty of obstetricians to popularize as much as
possible the idea of Cesarean section as the best method of secur-
ing a Uving child, but that there will still remain many cases that
must be delivered by perforation, on account of the impracticabil-
ity of using other means.

Experimental Hydramnion in Nephritis. — Eugene Bibergeil
(Berl. Klin, Woch,, April 10) gives the results of experiments
made on two dogs, by producing nephritis by the use of a drug,
and then examining both mother and fetus as to the presence of
ascites. Hydramnion is known to be the result of fetal mal-de-
velopment, which results in derangements of the life processes of
the mother. Nevertheless, spontaneous interruption of the preg-
nancy is rare. In both cases experimented on nephritis was pro-
duced in the mother, changes in the fetal kidneys, hydropsy (as-
cites and hydrothorax) in the mothers, a small amount of effusion
in the fetuses. The amniotic fluid was increased in amount in
both mothers. The author draws the conclusion that nephritis
may not only produce effusion into the tissues and cavities of the
mother, but may also increase the amount of amniotic fluid, and
hence may be one cause of hydramnion, at the same time pro-
ducing effusions in the fetus.

Etiology and Therapy of Urogenital Fistula in Women. — Oscar
Vertes {Monatsschr. fur Geb. und Gyn,, April) considers the
etiological factors at work to produce a urogenital fistula, and
describes 24 cases seen by him. Of these 24 cases, 20 were the
result of labor, 4 of the use of pessaries. Of these 20 cases, 13
were deformed pelves. One was narrowed relatively to the size
of the child. In long labors, that have been badly conducted, the
pressure on the soft parts of the pelvis produces a necrosis that
ends in fistula. It is generally the pressure of the hard skull
presenting that causes the necrosis. In 15 of the 20 cases the
child's head presented. An operative intervention may also con-
tribute to the formation of the fistula. Of the 20 cases, only two
were spontaneous births. The use of forceps is generally neces-
sitated. A sharp instrument used to perforate the skull may be
the cause. It is difficult to tell whether the pressure of the head
or the instruments was the real cause of the injury. There are
several facts that go to show that the injury was by instruments :
if the escape of urine begins at once after labor, it is probable
that the instrumental interference was the cause. When it results
from a pressure necrosis it does not appear for from 3-6 days

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after delivery. Of i8 instrumental deliveries, lo were done with
forceps. Atresia of the vagina and formation of large cicatrices
go to show that the instruments caused the fistula. In forceps
operations the fistula occurs in the lower third of the vaginal wall,
while in spontaneous delivery it occurs higher up. Usually there
is a combination of pressure and violence of instrumental inter-
ference responsible for the injury. Four cases were the result of
pessaries pressing too severely and too long on the vaginal walls.
As to the operative treatment of these cases, kolpokleisis was the
first effective operation proposed; but it was found to occasion
serious complications, such as pyelonephritis and nephritis.
Laparotomy has been proposed, to bring the fistula better into
view. Many cases may be cured by the method of freshening
the edges of the fistula and closing them. Total extirpation has
been proposed, and is done in cases of women who have passed
the menopause, as in two cases produced by the pessary. It seems
a serious operation to propose where the menstrual life is not over,
but we must remember that some of these cases are cut off from
all society and all the usual forms of activity, by the severity of
their injuries; and in these cases total extirpation will restore
them to usefulness. Of the author's 20 cases, total extirpation
was done 7 times. In 7 cases the freshening method was success-
ful. In 5 cases no operation was attempted. Fourteen cases were
cured, 4 were not helped, i died.


Prolapse of the XTtems. — J. Henrotay (Bull, de la Soc, Beige de
Gyn. et d'Obst., T. XV., No. i) records a most unusual case of
total prolapse of the uterus. The patient was only nineteen years
of age; her menstrual history was normal. She denied having
had sexual intercourse, and had had no previous illness, save an
attack apparently of erythema nodosum. She had been for eight
years an ironer, standing at her work. The prolapse had been ob-
served by her two years before consultation and had g^dually
become total.

Menstruation and Immature Bed Blood Cells. — ^Teobaldo Soli
(Annali di Ostet, Gin,, March) has examined two series of pa-
tients, making 194 examinations of the blood, in order to deter-
mine whether there is an increase of immature red blood corpus-
cles in the blood of menstruating females. Several authors have
claimed that there is a menstrual anemia, and that to supply the
place of the blood lost at the catamenia, the blood-producing organs
put forth numerous immature blood cells. The first series of ob-
servations was on four women, lasting over a period of 40 days,
including two menstrual periods and the time between them.
Patients were selected that were normal in every way, and the
examinations were made each day under the same conditions.
The second series comprised 10 women, whose blood was exam-
ined before, during, and after menstruation. Out of the 194 txr

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aminations immature red blood corpuscles were found in only
five examinations, from two patients. The uniformly negative
results obtained are believed by the author to show that there is
no output of immature red cells at the time of menstruation, but
that the blood corpuscles lost are replaced by an activity of the
hematopoietic organs, which form mature cells at this time as at
any other period.

Hernia of the Ureter. — Carli (Gajssetta Medica Italima, Anno
IV., No. 40-41) tells us that the literature of hernia of the ureter
shows it to be quite a rare condition. The term means the pro-
trusion of the ureter through hernial passages. It never pro-
trudes alone, but accompanied by a hernia of the omentum or
intestine, either inguinal or crural. The ureter may accompany
the hernial sac, or may be alone, or with the bladder. The author
reports 3 cases, i a typical, genuine hernia of the ureter, another
with the ureter accessory to the bladder. These cases may be
classified as herniae of the uterer alone, that is, simple hernia, or
with other organs ; as inguinal or crural, and the inguinal as ex-
ternal and internal, or direct. Simple hernia of the ureter is rare
as the inguinal variety, more common as crural. Hernia of the
ureter combined with hernia of the bladder is relatively frequent
as inguinal, but unknown as crural. Hernia of the ureter may
occur at any age, and is not common in women as a crural variety.

Oastrohysteropexy with Fixation by the Bound Ligaments. —

Teodoro Morisani (Archivio di Ostet. e Gin,, March) brings
forward a somewhat new combination of operations for the fixa-
tion of the retroverted uterus. This operation differs from those
practiced by other operators, in that he executes a gastrohystero-
pexy, making use of the round ligaments as a means of fixation.
The uterus is not brought up close to the abdominal wall, nor is
an adhesion produced between the two. On the contrary, there
is a space left between the organ and the abdominal parietes, so
as to permit a degree of mobility of the uterus. The round liga-
ments represent a temporary sustaining power for the uterus, to
act until adhesion with the abdominal parietes shall have formed.
The process has all the advantages of a gastrohysieropexy, with
that of shortening the round ligaments; it is easy of execution,
and avoids the dangers of silk ligatures. It relieves the train of
nervous symptoms referable to retrodeviations of the uterus, and
permits of the breaking up of adhesions, as well as of whatever
operative interference with the adnexa is necessitated by the con-
dition that may be found to exist.

Pseudo-ascites in Ovarian Tumors and its Clinical Significance —

Karl Hormann (Miinch Med, Woch., March 21 (tells us that the
free fluid which is found in the abdomen in ovarian tumors is not
a true ascites, but a secretion from the epithelial covering of the
tumor. This secretion may lie free in the abdominal cavity, and
after a time give rise to epithelial implantations on other parts
of the abdomen, or it may come from a perforation due to rupture

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of a cyst into the abdomen, this cyst continuing to secrete fluid
which increases that in the abdomen. If this fluid is thin it may be
absorbed ; if it is thick and contains much mucin it cannot be. If
this fluid is obtained by puncture, and is found to contain much
mucin, it is from a ruptured cyst. The author describes two
cases which illustrate the subject. In the first there was a large
amount of fluid in the abdomen, which appeared to be the secre-
tion from a cyst the size of a hen's tgg ; there was undoubtedly a
pseudo-ascites. There had been a spontaneous rupture of the cyst,
and a high grade of inflammation of the parietal and visceral peri-
toneum in Douglas' cul-de-sac. The case was at first believed to
be malignant, on account of the bad condition of the patient, who
was very thin, and had palpitation, and because of the rapid in-
crease in the size of the tumor. An exploratory operation re-
sulted in the withdrawal of the thick fluid, and the ttmior was
easily removed, with the happiest results to the patient. The sec-
ond case had a similar appearance of malignancy, but was also
proven to be non-malignant.

Prostitution in Paris as B^pilated from 1872-1904.— L. Butte
(Jour, de Med. de Paris, April 2) gives the results, as to the less-
ening of the amount of syphilis, that has resulted from 32 years of
regulation of prostitution in Paris. In 1873, in the houses devoted
to prostitutes, syphilis attacked 30 per cent, of the inmates. In 1904
it had diminished to 0.6 per cent. This is due to better hygiene,
the use of efiicacious prophylactic measures, the smaller number
of houses of ill fame, and the law against receiving prostitutes that
are minors. These young girls are much more easily inoculated
with syphilis than the older and more seasoned inmates. The lat-
ter have acquired a certain amount of immunity, and rarely be-
come infected. Among the inmates of licensed houses of prosti-
tution the liability to syphilis is extremely slight. Among women
who are registered, but live and ply their business as they like,
there is much more liability to syphilis, since they avoid the pre-
scribed examinations as far as possible, especially when they have
become infected. They may be controlled to some degree by being
arrested for non-compliance with the law, and be confined in a
hospital when found diseased. There were 6,031 registered
women in 1904. Of those who were regularly examined, 51 had
syphilis, and 148 among those arrested, that is, 199 in all. An-
other class is the clandestine prostitutes, especially the minors.
Among 3,530 of these, in 1904, there were 349 cases of syphilis,
a much larger percentage than that among those who were regis-
tered and treated. Hence it may be seen that regulation of pros-
titution has reduced syphilis materially.


Action of Alkalies in Infant Feeding. — T. S. Southworth
(Arch, of Ped., Feb.) shows that in practice the theory of adding
lime-water or bicarbonate of soda to the milk for the sole purpose
of neutralizing its acidity is completely abandoned ; for, by adding

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the usual proportion, i ounce of lime-water in 20 of food, there
is added to the milk from 2]^, to 20 times as much of the alkali
as is required to make it alkaline. This disproportion is greatest
in very weak mixtures. It has also been demonstrated that breast
milk is faintly acid. In spite of these facts, the use of the large
proportions of alkalies is often advisable. Lime-water checks
the immediate action of rennet upon the whole mass of milk and
makes the clotting more gradual, allowing the passage of some
unaltered milk into the intestine, but leaves no large amount of
alkali behind to inhibit gastric digestion. With bicarbonate of
soda added to milk, the action of the rennet, hydrochloric acid and
pepsin, is prevented by the antacid until this is neutralized, fluid
milk meanwhile entering the intestine. The effect of alkalis thus
seems to be to influence the type and place of digestion, reducing
the burden upon the stomach and laying it upon the intestine.

Standardized Oruek. — In view of the food value of gruels, as
well as their utility as diluents in modification of milk, H. D.
Chapin (Med. Record, Feb. 18) has endeavored to apply the prin-
ciples of percentage feeding to their preparation. He employed
pearl barley boiled in a saucepan for 3 hours and strained, and
rolled oats and barley and wheat flours cooked in a double boiler
for I hour and strained. By analysis of such gruels, made with
I and 6 ounces to the quart, at the New York Agricultural Ex-
periment Station, the figures for the construction of the following
table were obtained :

Approximate Pbrcbntaob Composition op Grubls.

Pearl Barley.

Barley Flour.

Wheat Flour.

Rolled Oats.









I oz. to quart

a " " **

3 " - -


















a. 096









4 - - -

s " " - .

6 - - - :::::::

J " " "

8 " - - :::::::



Plain gruels cannot be made much stronger than 2 ounces to
the quart ; dextrinized, may be made up to as high as 8 ounces to
the quart. The author has employed high proteid gruels in per-
sistent vomiting in patients of all ages, in enfeebled digestive
states of typhoid and other fevers, and in general exhausted con-

Veniiz Caseosa, Hereditary Seborrhea and Acne of the Fetus.
— L. Jacquet and Rondeau (La Presse Med., March 18) consider
the three above mentioned conditions as related to one another and
to the genital development of the infant. Excessive sebaceous
function may be observed during intrauterine life, and vamix
caseosa, which varies much in its presence, amount, systematic
arrangement, texture and consistence, is one manifestation of this .

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overaction of the sebaceous glands. It is composed of cells, free
fat and lanugo hairs. It occurs in the regions in which the hairs
are most developed. Often in the fetus, after the seventh month,
and in infants at term there is a true sebaceous miliary acne, oc-
curring all over the body. The evolution of this condition begins
at the fourth month of intrauterine life, and goes on up to birth.
The authors conclude that the vemix finds its explanation in an
abundant pilosebaceous activity connected with a crisis of genital
evolution, since this increase of function takes place during the
active development of the genital organs. They also believe that
there is an element of heredity about it, inasmuch as many mothers
have seborrhea, and their infants show the same lesions. The
increase of sebaceous activity during the development of the geni-
tals of the unborn infant is analogous to the same condition ob-
servable at puberty.

Facial and Hypoglossal Paralysis After Natural Labor. — ^Arthur
Stein (Zent, fur Gyn., March 18) describes a very rare case ob-
served by him, and examines its cause. The infant was bom at
full term, after natural labor, the mother having no pelvic de-
formity, and the child's skull showing no disproportion to the
pelvic measurements. At birth the child showed a marked swell-
ing over the left mastoid process, which he considers to have been
a true hematoma. There was a left facial paralysis and a paresis
of the left hypoglossal nerve, shown by inability to move the
tongue evenly. The facial paralysis was cured in 8 days after
birth, while the hypoglossal paralysis existed up to the thirteenth
day. The author believes the condition to have been due to long
pressure of the skull at the exit of the facial nerve against the
pelvic bones. He finds only two similar cases reported in litera-
ture, by Schultze. The facial paralysis was due to pressure ex-
ternal to the skull, but there was, at the same time, pressure with-
in the skull, and an internal hematoma, near the exit of the hypo-
glossal nerve, which resulted in the lingual symptoms. The hypo-
glossal paresis could not be accounted for by external pressure
alone, but the internal hematoma must have been of very slight
extent not to have involved other nerves.

Physical Signs in Infants and Children. — S. McC. Hamill and
Theodore Le Boutillier (Jour. Amer. Med, Assn., Jan. 7) have
made a systematic study of certain physical signs found in the
chest in infancy and childhood, i. They find as a normal mani-
festation, constantly present up to 9 or 10 years, and not infre-
quently until the 13th, an area of impaired resonance under the
inner third of the left clavicle. This varies in degree in differ-
ent individuals, and is difficult to elicit in early infancy. It oc-
casionally extends outward to the midclavicular line, gradually
decreasing, and downward to the first interspace, sometimes
blending with the area of cardiac dullness. 2. Concerning the
area of transmission of the bronchial type of breathing, they state
that this is ordinarily heard over the root of the lungs and varies
greatly in diflferent children. Posteriorly it is usually limited to

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the interscapular space and suprasspinous fossa. It is often con-
veyed to the entire scapular area and can sometimes be heard just
above and in front of the angle of the scapula, about in the pos-
terior axillary line, as a high-pitched, distant, bronchial murmur
simulating the breathing over consolidated Itmg. When heard
here it is usually bilateral if the child is in a position which renders
breathing equal on the two sides. It is much more common in
children under 6 than later. 3. Regarding position of the infant
during percussion, it is emphasized that when the child is so ex-
amined, while lying on one side in intimate contact with the bed-
ding, the elasticity of lower side of the chest is destroyed, the
lung compressed, and the height of pitch of the percussion note
on that side is greatly increased. 4. In examining 275 cases the
writers found that up to the sixth year the apex beat of the heart
is more commonly in the fourth intercostal space and the mid-
clavicular line; after this period it is usually in the fifth space in
or just within the midclavicular line. Occasionally it was found
in the fourth space even until the twelfth year. 5. In determin-
ing the area of cardiac dullness in 191 cases they concluded that
the average outline for children under 3 years of age is : Upper
border, second rib; right border, midsternum; left border, just
without the midclavicular line. From the third to the sixth year :
Upper border, the upper border of the third rib; right border,
midsternum; left border, in or just without the midclavicular
line. From the sixth to the twelfth year : Upper border, third rib ;
right border, from the midsternum to the right edge of the ster-
num ; left border, most commonly in the midclavicular line. 6.
The venous hum was studied in 226 cases ; in 36 of these it was
loudest over the left jugular vein, in all others over the right. In
38 instances it was heard over both jugulars, under the right
clavicle, in the suprasternal notch and over the manubrium. In
some cases it was heard along the right border of the sternum
down to the second costal cartilage. In only 10 was it audible
when recumbent. The frequency of its occurrence over the manu-
brium in cases with entire absence of other signs of enlargement
of the bronchial lymph nodes would show its unreliability as an
indication of the latter condition. The extensive distribution of
the hum necessitates careful differentiation from cardiac mur-
murs. 7. Functional cardiac murmurs were studied in 267 cases
and in another series of 34 under 3 years of age. They emphasize
the point that in the breast-fed children there were no murmurs,
although in two instances the hemoglobin was as low as in the
others which showed murmurs. This they regard as pointing to
the dependence of the murmurs not upon anemia, but upon nutri-
tion. Contrary to the usual belief that functional murmurs are
rare under 3 years of age, thev were heard in 20 of the 34 cases.
Strain of the Heart in Growing Boys. — During his work at Har-
row, Arthur Lambert (Med, Chroru, Feb.) has studied this sub-
ject in regfard to the relation of physiological distention to patho-
logical dilatation and the prognosis in cases of the latter due to

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physical exertion. The primary effects of heart strain are : chronic
hyperthropby ^ind dilatation, gradual dilatation, or acute dilatation.
Symptoms identical with those of strain may be produced by direct
violence or nervous shock, as is shown by cases reported. The
view that the progression is from physiological to pathological di-
latation does not seem borne out. The onset seems to be sud-
den. Two points observed by the writer in the community of 600
boys at Harrow are that cases of heart strain are of infrequent
occurrence, and that their appearance bears no relation to the
severity of the strain to which the boys have been exposed. The
schoolboy heart breaks down as the result of exertion, not be-
cause the strain is too severe for the hearts of boys of that age
and physical development^ but because the individual possesses
some cardiac insufficiency, either primary or inherent, or depend-
ent upon some condition such as anemia or influenza. There is
a tendency to recurrence of the dilatation in the subjects, and the
prognosis should be guarded and each step of renewed active ex-
ercise be watched carefully. The writer believes that pathological
dilatation of the heart of the growing boy from strain, however
short its duration, and however complete its apparent cure, leaves
its indelible mark upon the mechanism of the heart, and that its
effects have to be regarded as an existing factor of greater or
less degree, sufficient perhaps to determine the failure of the

Online LibraryDyer Hook SanbornThe American journal of obstetrics and diseases of women and children → online text (page 90 of 94)