Robert L Jefferson.

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

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BAUER. Warschau. Werner KHnkhardt, Leipzig. 1908. Pp.

748. Illustrated.

This practical work is of unusual value and should be in every
medical library, because from it the physician can get informa-
tion on any doubtful case of hermaphrodism that may present
itself in his practice.

The development of the embryo is accurately described. Nearly
all important literature relating to embryology is made use of
to place before the reader everything that is so far known on the

After completing the embryological study, the author describes
the varieties of hermaphrodism, and for practical reasons ac-
cepts for pseudohermaphrodism the classification of Klebs.

Hermaphrodism has been described by Aristotle, Hippocrates
and Galen. The old imperial laws regarding hermaphrodites
are mentioned. As late as 1602, the Parisian Parliament con-
demned a hermaphrodite to death by burning at the stake, be-
cause he had performed the functions of the sex in which he
declined to be classed.

While ancient and medievel literature contained observations

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on hermaphrodism, the scientific study did not begin until the
nineteenth century.

A genuine hermaphrodite is an individual who, while able to
impregnate another, may itself be impregnated or may impreg-
nate itself. Such condition does not exist in human beings.
Even in a functional sense, true hermaphrodism is exceptionally
rare in the human race. Only five cases of true hermaphrodism
are on record. Numerous cases have been reported in literature
but the microscope failed to verify the correctness of such

An unusually large number of cases is cited, the greatest
number that has ever been published by one author, with obser-
vations, interesting histories and instructive cuts. The publica-
tion does credit to the genial and diligent author.

Transactions of the Southern Surgical and Gynecological
Association. Volume XX. Edited by W. D. Haggard,
M. D. Pp. 570.

This volume contains the forty-eight papers and the discussions
which came before the society at its twentieth session held at
New Orleans on December 17, 18 and 19, 1907, many of which
are of very great practical interest and value and which fully
maintain the high standard this association set for itself at its
first meeting twenty years ago.

State Board Questions and Answers. By Max Goepp, M. D.,

Professor of Clinical Medicine at the Philadelphia Polyclinic;

Assistant Visiting Physician to the Philadelphia General

Hospital. Pp. 684. Octavo. Philadelphia and London:

W. B. Saunders Co., 1908. Price, $4.00, net.

This is a compilation of the questions asked by the various

State examining boards during the last four years, and its purpose

is to provide a convenient compend for the use of those who

wish to prepare themselves for State board examinations.

Answers are given in a condensed form, the definitions being

largely taken from standard text-books.


The Suprarenal Capsules in Puerperal Eclampsia and Neph-
ritis* of Pregnancy. — On account of the universal presence of
hypertension in puerperal eclampsia and the possible effect
of the suprarenal capsules on the production of hypertension,
J. L. Chiri6 (Tribune MSdicaky June 13, 1908) has made a
careful microscopic examination of the suprarenal capsules in
nephritis of pregnancy. Seventeen cases of eclampsia were
examined, of which twelve showed retroplacental hemorrhage,
one nephritis, and four died in coma. Fourteen cases of infec-
tion were also examined. The conclusions at which the author

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has arrived are that in these coiuiitions there is a constant
cortical and medullary hyperplasia of the suprarenal capsules.
Medullary hyperplasia occurs before cardiac hypertrophy.
Suprarenal hyperplasia is secondary to the diseased kidney
condition. This hyperplasia bears a special relation to the
antitoxic function of the gland, and may play an important
r61e in the production of increased arterial tension of eclampsia.
In these cases it is by the intermediary action of the hyper-
function of the gland that a relation of cause and effect is estab-
lished between the difficulties of renal secretion and the modifi-
cations of arterial pressure; clinically, this relation has been

Symphyseotomy and Hebotomy. — V. Cocq {Bull, de la Soc.
Beige de Gyn, et d'ObsL, vol. xix, No. i, 1908), after giving
the histories of four successful symphyseotomies, compares
this operation with hebotomy, concluding that the latter has not
sufficient advantage to supplant the former. Symphyseotomy
is an excellent operation when practised with a good technic
and within its proper limits; that is, in pelves with a diameter
of over 7 cm. and at term. In diameters less than this, it
should never be performed. Cesarean section is more attrac-
tive, but it is not always possible to have the necessary
conditions for its successful performance, i. e., a woman uncon-
taminated by frequent examinations and the possibility of
complete asepsis in the surroundings. In general practice it is
often necessary to deliver by operative means when these con-
ditions cannot be attained. In the country it is not always
possible to secure two capable assistants, nor has every general
practitioner the necessary instruments. In these cases section
of the pubis permits him to save the fetus while lessening the
dangers of the mother. Cesarean section is to be preferred
when the necessary conditions are obtainable. Comparing
symphyseotomy with hebotomy as to its special advantages,
the author believes that a sufficiently strong consolidation of
tissues is obtained by symphyseotomy. As to hebotomy
exposing the patient to less danger from tearing of the soft
parts, these wounds occur when the pelvis is spread apart too
far. This will not happen, provided the operation is not done
in pelves of less than 7 cm. conjugate. The head has a ten-
dency to push the soft parts before it, hence an aid should
keep them in position as far as possible. Another precaution
is to disengage the head in the transverse position, for
in the occipito-pubic position the occiput will be supported
only by the soft parts, which will be much stretched. The
perineum may be incised if necessary. Less hemorrhage is
supposed to occur in hebotomy; but the author finds that when
not done in a woman with varices, the hemorrhage is not greater.
A necessary precaution is to place the finger behind the symphysis
when making the section and to tampon the space with gauze
afterward. In subcutaneous hebotomy there i? generally a

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hematoma, which the author believes is not a condition to be
lightly passed over. He rejects the subcutaneous operation
entirely. As to there being less risk of infection in hebotomy,
the author believes that aseptic precautions render symphy-
seotomy quite as safe. The slightly vascular cartilage is less
likely to be infected than the highly vascular bone. The author
therefore prefers symphyseotomy.

Cesarean Section and Lumbar Anesthesia. — Oscar Polano
(Munch, med, Woch., June 2, 1908) gives an account of three
Cesarean sections done under lumbar anesthesia, with safety
for both mother and child. There was an entire absence of pain
throughout the operation in all three cases. All three patients
suffered from rachitic contraction of the pelvis, and the lumbar
puncture was easily made. The pelvis was slightly elevated
after the injection. There were no disagreeable symptoms,
such as headache or paresis. All three women made a good
convalescence and left the hospital three and a half weeks after
the operation. All dangerous compression of the child's head
and thorax was avoided by this method of delivery. The
children when delivered had a normal red color, the pulse in
the cord was normal, and there was no carbonic-acid poisoning of
the blood in the infant. All of the children were vigorous and
cried loudly when handled. The breathing began naturally
as soon as the cord was cut. In each of these cases the uterus
contracted normally after deHvery and remained well con-
tracted with very little loss of blood. By this method of
anesthesia the painlessness is perfect, and the dangers of asphyxia
for the child and of atony of the uterus for the mother are

Observations on Nursing Women. — S. Jacobins {Arch, f.
Kinderheil., Bd. Ixxxiv, H. i and 2), after observations on many
nursing women who had given up nursing their children for
some reason, not always good a one, finds that menstruation
begins in many women soon after the puerperium, and in the
majority of women before six months. The production of
milk does not seem to be materially affected by its presence.
In the clinic for infants at Berlin, where prizes are offered for
the longest nursing of the children, the author has never seen a
case in which it was necessary for the mother to stop nursing
the child on account of the beginning of menstruation. It
was also noted that when a mother has ceased nursing for an
interval even as long as thirty days, it is possible for her to revive
the flow of milk and to again nurse the child. Such a procedure
is not injurious to the child, the secretion seeming not to have
so changed as to do it any harm.

Diet of Nursing Women. — L. Bouchacourt (Jour, de M6d.
de Paris, June 20, 1908) states that the diet of the nursing woman
should be most abundant, but its quality is also important.
Vegetables should be the most important part of it, meat being
of less value in producing milk. Of the vegetables that pro-

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duce the milk, lentils, cotton-seed oil cakes, carrots, beets,
chicory, parsley, peas and beans are the most valuable. Cod-
liver oil is also valuable. The author believes that milk and
light beers and ales are galactogogues. He would arrange the
diet thus: bread 400 grams, meats or fish 250 grams, dry vege-
tables 500 grams, fresh vegetables 300 grams, vermicelli and
macaroni 100 grams, sweet fruits and candies 100 grams, butter,
milk and cheese 1500 grams, beer or cider 1000 grams, water
1000 grams.

Severe Bleeding at the Time of Labor. — Schickele (Munch,
med. IVoch.f May 26, 1908) says that severe bleeding at the
time of labor is generally due to implantation of the placenta
over the os, premature separation of the normally located
placenta or to a placenta marginata. The author believes
that bleeding under the placenta is rather frequent, old clots
being found under it after delivery. He believes that such
clots are common causes of abortion and of maldevelopment
of the ovum. Loosening of the placenta seldom leads to danger-
ous bleeding. In case of severe bleeding it is always a question
how much blood the patient has lost and how much she can
lose and live. Facts that have an important bearing on this
are the general nutrition and build of the patient and the con-
dition of the heart and kidneys. Women who have borne
many children within a short period, especially if they have
had habitually severe bleeding, are less able to stand hemor-
rhages. Cases which have lost much blood before admission
to the hospital have a bad prognosis. The pulse is the great
criterion of the patient's condition, as well as her general con-
dition. Sometimes women who are apparently doing well
have a sudden failure of the pulse. One of the best remedies
is injection of saline solution by the rectum and intravenously.
Cases of bleeding after rupture of the uterus bear hemorrhage
much better than those who have placenta previa.

Early Rising After Labor. — Wilhelm Rosenfeld (Gyn, Rund,,
H. II, 1908) calls attention to the possibihty of the position
of the newly delivered woman on her back for nine days being
a cause of retrodeviation. Coe permits his patients to rise
to empty the bladder within three hours after labor. Other
obstetricians allow of special gymnastic movements beginning
three days after labor, consisting of movements of the abdominal
muscles and of the sphincter ani and vulvae morning and evening.
No bad results have been seen from these movements, and
others have begun to allow the puerperal woman to get up
on the third day for an hour or two, in cases in which there is
no rise of temperature. This aids in the involution of the
organs, makes the movements of bladder and bowels easier.
The strength of the muscles is better preserved and the appetite
is better. The questions that must be decided in reference to
this procedure are whether embolism will be caused and whether
prolapsus and retrodeviation will be favored. Prolapsus will

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occur only when there has been a previous lesion of the pelvic
floor, either tearing or stretching the fibers. Long lying in bed
will not cause a union of these ruptured muscle-fibres, as they
immediately retract and the ends do not reach one another.
An etiological factor in prolapsus is atrophy of the pelvic floor.
Long rest in bed will increase the weakness of muscles, while
the natural movements will tend to strengthen them. Women
who have been up for some hours each day feel better and
stronger than those that have lain in bed for nine days and are
then obliged to go home and do their own work and care for the
child. In January, 1908, the author began to allow the puerperal
women to sit up for a few hours each day after the third day
and to increase the time each day to the ninth, when they
finally got up permanently. These patients had undergone a
perfectly normal labor and had no rise of pulse or temperature.
After the first three days a vaginal examination was made and
it was ascertained that there was no abnormal condition of
the genital organs before the woman was allowed to get up.
These women wore a well-fitting binder all the time. From
January 15 to March 30, 160 women were confined at the Vienna
Lying-in Hospital. Of these 102 were able to get up on the
third day. In only one case was there any rise of temperature,
and this was from a beginning mastitis which was relieved by
Bier treatment. No hemorrhages were observed. At the
end of seven days the uteri were at the level of the symphysis,
and at the ninth day could not be felt. The author considers
these results sufficiently good to justify further trials of this
method. All the women stated that they felt better and stronger
than when they lay in bed for nine days.

Etiology of Puerperal Retroflexion. — R. Ziegenspeck {Zeni.
/. Gyn.y June 6, 1908) finds it stated that retroflexion in the puer-
peral state arises only when there is parametritis or perimetritis.
Chronic atrophic parametritis never occurs in the puerperal
condition, yet it is the most frequent cause of retroflexion, ac-
cording to some authors. The author has examined every puer-
peral woman having parametritis who has come under his ob-
servation, to ascertain whether the condition came on after labor,
and has found that the most pronounced cases occurred after
labor. In large maternity hospitals the occurrence of infection
is prevented by asepsis, but in the homes of the patients this is
not possible. The author makes it a habit to examine every
labor patient from eight to twelve weeks after delivery, even when
no symptoms are complained of, and has rectified many displace-
ments and kept them in position until cured. Retroflexions
have been found in the first as well as in later confinements.
The first confinement predisposes the patient to retroflexion, and
flexions which have existed previously recur after labor. Over-
filUng of the bladder is a frequent cause of retroflexion, the full
bladder causing the uterus to be pushed backward. If the patient
lies on her side, it is found that anteflexion is increased. Re-

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tention of urine in the puerperium should be guarded against.
It may result from spasm of the pelvic muscles due to trauma
during labor, from injury of the urethra by the pressure of the
head and from edema of the bladder. These factors are more
frequently present in the first than in later labors. Massage and
pressure do not help these cases, but better results are obtained
by the use of a well-fitting pessary and care in emptying the blad-
der and bowels. The author concludes that retroflexion be-
fore labor is more frequent than had been thought, retroflexion
from parametritis and perimetritis are more frequent than has
been supposed, and the continuous position of the patient on the
back after labor, combined with an overfilled bladder, is a cause
of retroflexion. In the last months of pregnancy, the fetal
head presses down into the pelvis and causes a thinning of the
cervical canal which remains after labor and tends to produce
anteflexion or retroflexion. Manual replacement and massage
are here of value.


Uretero-vaginal Fistulas Following Abdominal Hysterectomy.

— Carlos Lepoutre C/owr. des Set. Mid. de Lille, June 6, 1908)
says that vaginal hysterectomy for cancer or fibroma is the prin-
cipal cause of uretero-vaginal fistulas. Abdominal hysterectomy
for removal of a large cancer or a laborious operation done for
adherent salpingitis or for complicated fibromata is also a cause
of this unfortunate condition. Here the ureters are often in-
volved in the growth in such a way that it is almost impossible
to tell their location. The flow of urine from the vagina, although
the symptom that gives the patient the most trouble, is not the
gravest one. The entrance of the ureter into the vagina is far
from an ideal one. There is generally a tortuous, granulating
tract between these organs that may become contracted and
cause retention of urine in the pelvis of the kidney. The ureter
itself becomes dilated and the walls indurated with a marked
periureteritis. CHnically, there is a diminution in the amount
of urine after some time and an impermeability of the kidney
to methylene blue. Lumbar pain and nephritic colic are fre-
quent. The diagnosis is based on the symptoms and on ex-
clusion. At first the amount of fluid escaping from the drains
is marked and its odor is urinous. The patient finds herself con-
tinually soiled with urine night and day, sitting or lying down.
At the same time there is normal micturition of the urine
of the other kidney. Examination of the bladder shows that the
urethra is intact. In the vagina there may be seen a small nodule
in the wall from which the urine flows. A tampon placed in the
vagina soon becomes saturated with urine. Using methylene
blue is of value, since this shows the orifice more easily. The
fistulous orifice can rarely be catheterized. Injection of a colored
liquid into the bladder shows that this fluid does not ap|>ear in
the vagina, and vesico- vaginal fistula is excluded. Examination

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of the kidneys shows a large hydronephritic kidney and pain
in the lumbar region. Cystoscopic examination determines the
side from which the normal urine flows and ureteral catheteriza-
tion shows the distance of the cut portion from the bladder
which varies from two to five inches. The ureteral orifice on
the cut side is elongated transversely, and no urine flows from
it. It is open and very easily catheterized.

Pyosalpinz Opening into the Bladder. — Muller and Petitjean
(Gaz, des Hdp., June i8, 1908) say that salpingitis may rarely
open into the bladder, a condition which does not bring about
the healing of the tube, but exposes the patient to severe incon-
veniences and dangers. When a collection of pus arises rapidly
in the pelvis, it is generally the result of a phlegmon of puerperal
origin, and these abscesses are cured definitely in a few months.
Pyosalpinx and dermoid cysts of the ovary which have suppu-
rated are comparatively rare. Opening into the bladder is excep-
tional. At the time of opening there will be a crisis of fever, vio-
lent pain radiating in various directions, vomiting and vesical
tenesmus. Then pus appears in the urine and the pain ceases.
In purely vesical or pyelorenal pus there is an absence of this
violent crisis and a preservation of the normal volume of the
urine. Absence of polyuria indicates a renal lesion. Usually
periods of relief alternate with violent crises of pain when the pus
again empties itself into the bladder. A cure is seldom accom-
plished except by operative procedure. In some cases the general
condition fails and symptoms of sepsis supervene or renal abscess
may occur as a result of ascending infection. Diagnosis is
generally difficult. Laparotomy with the extirpation of the
adnexa is the only treatment that promises permanent relief.
The author describes a case observed by himself.

Bleeding in So-called Chronic Metritis. — G. Ahreiner {Arch.
/. Gyn.y Bd. Ixxxv, H. 2) describes chronic metritis as an afi'ection
in which bleeding sometimes, but not always occurs, in which
there is no appearance of a growth or of real inflammation, but
simply an enlargement of the uterus. After reviewing the litera-
ture on this subject, the author concludes that almost all
writers agree that in chronic metritis the walls of the uterus are
thickened, the connective tissue is increased and the walls of
the blood-vessels are sclerosed and thickened. The thickening
of the vessel walls consists of an increase of the elastic fibers.
Aside from this, the changes are seen only in women who have
been pregnant at some time. Some mention the changes in the
blood-vessels as the cause of the bleeding, others the increased
connective tissue and still others a lessening of the muscular
power. Opinion is not by any means agreed on the subject of
the cause of the bleeding. The author has examined the speci-
mens from five cases observed by himself. In none of them was
there any lesion of the mucous membrane. All the uteri were
thickened and enlarged. Small streaks of connective tissue were
to be seen through the muscular tissue. Macroscopically, groups

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of enlarged blood-vessels were seen on the serous surface. The
increase in connective tissue was not very marked. All the
elements were increased in amount about equally, but the elas-
tic tissue more than any other. The greatest increase in elastic
fibers was about the vessels, and under the mucosa where the
vessels are few this increase was slight. The greatest increase
was in the middle layer of the wall. Arteries as well as veins were
markedly thickened. The author finds no relation between this
process of thickening and inflammation. The changes in the
vessels form a process of physiological sclerosis. He finds no
cause here for the occurrence of bleeding. The effect of the
vasomotor nerve action on the vessels is lost by the increase of
the elastic elements. The veins are less contractile than she
arteries. Of the uteri examined, three had caused hemorrhage
and two had not. The changes were the same in all five. The
muscular tissue loses its power of compression, and venous hyper-
emia and hemorrhage may result from any sufficient cause.
The cause of the hemorrhage lies outside of the uterus itself. On
this hemorrhage ergot has no effect. The author finds the cause
of the bleeding in constitutional conditions; among which are
anemia and chlorosis, any long-continued illness, such as those
of the lung and their complications, typhoid and gonorrhea. In
some there may be a kind of local hemophilia. Any condi-
tion that increases blood-pressure may be responsible for hemor-
rhage, such as heart and kidney diseases, abdominal plethora and
obesity. Any of these conditions may cause bleeding in a uterus
in which the sclerotic changes have gone sufficiently far. The
causes are then general, not local.

Use of Scopolamin-morphme Narcosis in Gynecology. — H.
Sieber {Zent.f, Gyn,, June 13, 1908) gives the results of the use of
scopolamin-morphine narcosis in eighty-eight cases treated at
the Marburg Hospital. It was used only in patients with sound
hearts and kidneys, and women with unstable nervous systems, in
whom cyanosis and restlessness developed, were not considered
suitable for this form of narcosis. The dose was from three to
nine decigrams of scopolamin hydrobromide and one to two
centigrams of morphine muriate injected subcutaneously. The

Online LibraryRobert L JeffersonThe American journal of obstetrics and diseases of women and children → online text (page 75 of 121)