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.

CESARIAN SECTION.

Hertsch (Arch. f. Gyn., B. xxxvii., H. 1). Twenty-two Cæsarian sections have been done at Leipsic according to the Saenger method, with but one death,-seven within less than a year. In only three of these cases so far as known did a subsequent pregnancy occur. Two of them were delivered by artificial abortion, one by a second section. The latter patient was first operated in June 1887 and again in DecemThe second operation was complicated by the fact that the uterus and loops of intestines were adherent to the abdominal wall and that a partial ventral hernia had developed at the site of the abdominal incision the fundus uteri lying forward between the thighs. The uterine incision was made through the fundus. A chromic catgut suture was encountered which had become firmly encysted, no absorption having taken place. Silk was used for the deep and juniper catgut for the continuous peritoneal suture. The woman was sterilized in compliance with her own request by ligation of the tubes. The case is the fourth in the literature of Cæsarian section in which the operation with uterine suture was repeated upon the same woman. Chromic acid gut in the Leipsic experience seems to justify what Leopold has claimed for it. The juniper gut appears to satisfy in still greater degree the requirements of a good suture in point of ductility and absorbability. That it may be made perfectly aseptic both their clinical results and bacteriological tests had abundantly proven.

The author thinks adhesion of the uterus to the abdominal wall more likely to occur when silver wire is used for the uterine suture than with absorbable catgut. The former acts as a foreign body and irritates. In experiments upon rabbits the application of iodoform collodion over the line of uterine suture served to prevent adhesion to the abdominal parietes. It had not, however, succeeded clinically. Stitching a fish bladder over the uterine incision was equally unsuccessful. After all, the abdominal adhesion is practically unimportant except on recurrence of pregnancy. The author advises the hypodermic use of ergot just before operating as a prophylactic against. inertia uteri after delivery. He calls attention to the importance of carefully examining by percussion for intestinal loops adherent to the line of the old abdominal wound before making a second section.

THE COMPLICATION OF PREGNANCY BY FIBROMATA.

Phillips (Annals Gyn. and Pæd., March, 1890). The following complications are liable to result from fibromata of the gravid uterus,

viz.: abortion, local peritonitis with intestinal adhesions and their consequences, obstruction of the pelvis necessitating a Porro or Cæsarian operation, abnormal presentation and death of the foetus, adherent placenta, placenta prævia, insufficient uterine contractions, tardy involution, disintegration of the tumor and peritonitis, torsion of the pedicle and consequent gangrene.

GALVANISM FOR THE INDUCTION OF PREMATURE LABOR AND THE TREATMENT OF CERVICAL STRICTURE.

Bayer (Trans. German Gyn. Soc., Am. Jour. Obstet., April, 1890) comments upon the uses of the constant current in obstetrics. For the induction of labor stable applications of the electrodes are preferred. This method is more especially applicable where the cervix is but slightly prepared. It acts by loosening the cervical tissues. applicable also in spontaneous labor with rigid cervix and in physiological strictures of the neck of the uterus. For provoking contractions labile applications or intermitting currents are required. Twenty to twenty-five milliampères usually suffice. The cathode is placed in the cervical canal and a large diffusing electrode externally over the abdomen.

METHODS OF CRANIOTOMY.

Donald (Annals Gyn. and Pæd., April, 1890). Despite the fact that craniotomy on the living child is falling into disfavor, there is still a field for that operation. The following are some of the indications: Unsuccessful forceps or version cases in which the head cannot be extracted; death of the foetus; such a condition of the mother that Cæsarian section would almost certainly be fatal; certain deformities of the foetus. In the lesser degrees of pelvic deformity the author advises perforation and extraction by the forceps. In the higher degrees of deformity he advocates, first, version and extraction of the body, then perforation through the palatal process, cephalotripsy and extraction with the cephalotribe or by manual traction upon the body and the inferior maxilla combined with suprapubic pressure.

PRACTICE OF MEDICINE.

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.

VEGETARIANISM.

Dujardin-Beaumetz (Therapeutic Gazette, March, 1890) gives an exhaustive description of vegetable forms of diet, speaking of their relation to the individual and to the place of habitation. After giving the chemical composition of various kinds of foods, the author gives

certain indications for the vegetable diet. Ptomaines are the result of putrefaction, and immediately upon the killing of animal matter they commence to develop. They are, or may be, non-poisonous at first, but soon become toxic in character. Although not stated in the paper, we can suppose that in a condition of health the body can render such compounds inert. These organic changes, the author believes, are not so prominent in vegetable food, and there are certain conditions in the body where animal food is harmful and where vegetable food is a therapeutic agent. Certain of these are described:

1. Renal insufficiency (chronic renal disease).

2. Gastric dilatation.

3. Putrid diarrhoea.

4. Chronic gastritis.

5. All changed conditions of gastric juice. 6. Uric acid diathesis.

[NOTE. The opportunity will here be taken of speaking of a treatment for pulmonary tuberculosis which is being used in this country: hot water and meat. It is certainly not unscientific to suppose that the term health refers to a bodily condition in which perfect strength, perfect function, and perfect harmony among all organs are present. When the lungs, in limited or extensive areas, are diseased, one of the organs that throw off excrementitious products is prevented from doing its usual work. Moreover, all consumptive patients are in a condition of auto-infection, and are constantly developing in themselves the products of tissue destruction, which the body must throw off. Therefore the other organs of excretion, the skin, liver, and kidneys, must do a twofold work. They must do the work of the lungs and also get rid of the poison developed in them. A considerable experience in post-mortem consumptive work has revealed in the great majority of cases chronic renal change, not always to be detected before death. It is certainly unscientific, because a certain line of treatment has benefitted one series of cases to use the same treatment in all cases of

whatsoever nature. To give consumptives huge quantities of animal. food, with a small portion of bread, prepared so as to be wholly nonnutritious, is opposed to all common-sense rules, and such treatment will invariably hasten death by causing additional circulatory disturbances.-H. C.]

THE WARNINGS OF GENERAL PARALYSIS OF THE INSANE.

Savage (of Guy's and Bethlem Royal Hospital, London), in a paper read before the Harveian Society, describes general paralysis as the disease of civilization. It is common in cities; it is not in isolated districts; the inhabitants of such districts have died of the disease after having lived in cities. It is regarded as a degeneration rather than a

disease of special lesion. It is found mostly in middle-aged married men. Constitutional syphilis is very commonly present. There may be a local origin to the disease, but the author does not believe that local surgical treatment will ever be of service in treatment, "for the degeneration follows on the predisposing condition."

The forms of onset are two: gradual and sudden. In the first it is always the higher faculties that show signs of decline. The artist loses his delicacy of touch; the actor fails in memory or enunciation; the artisan commits blunders in his work. Mental and bodily weaknesses show themselves. Probably for some time organic tissue-change has existed, and the onset runs parallel with the commencing degeneration, or, secondly, may manifest itself in an explosive manner.

The author has found that locomotor ataxy may be the first evidence of the disease, or may develop some time during its course. In certain cases the ataxic condition has not shortened life. Very valuable testimony is given in this connection from a series of cases in which ataxy has been present for several years, at the end of which general paralysis has made its appearance. In such cases syphilis has always

been present.

The major part of the paper has been given to the early symptoms and signs, naming and describing them in detail. From this description we have made the following classification, coming under the head of

MANIFESTATIONS.

Early Fatigue.-Inability to work or walk; associated with mental indecision; hypochondriasis alternating with mental buoyancy.

Temporary Aphasia.-Sudden onset; sudden cessation; irregular recurrence; associated with fatigue; mild in character (trembling of lips); severe in character (complete); before great mental disturbance; before changes in handwriting.

Changes in Handwriting.-Peculiar formation of words; omission of words; separation of syllables; fatigue in writing; alteration in mode of holding pen.

Facial Expression. -The "fat" face; obliteration of lines of face; skin greasy; unilateral sweating.

Loss of Power and Sensation.-Fainting-fits; attacks of vertigo.

Sensory Defects. -Neuralgia; headache; double sciatica; rheumatic pains (these were found to be present a year or two before the general paralysis was recognized); loss of sight (temporary); affections of hearing; changes in taste; changes in smelling (inability to detect the smell of pepper is sometimes present).

Intellectual Changes. Loss of power of social accommodation; memory defects; loss of attention; want of persistence; changed characteristics.

Instability.-Muscular tremors (fine muscles); uncertainty of gait; easily affected by alcohol; easily affected by poisons; pupils rapidly and somewhat persistently affected by atropine.

PREVENTIVE MEDICINE.

BY E. H. BARTLEY, M.D.,

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

PREVENTION OF TYPHOID FEVER.

In a paper upon this subject, published in the Annals of Hygiene, 1889, p. 7, Dr. R. H. Reid concludes:

1. "Typhoid fever is caused by the introduction of a specific germ into the alimentary canal.

2. "That this germ multiplies in the alimentary canal, and in turn is thrown off in the stools of the patient.

3. "That its vitality is much greater than at first supposed, resisting a variation of temperature ranging from even below the freezing point to 133° F. without being destroyed.

4. "That the germ may be communicated from one person to another by water, milk, foods and air.

5. "To prevent its spread, all dejecta should either be burned at once (which is preferable) or thoroughly disinfected, by throwing them into a pot of boiling water and thoroughly cooking them, or using some effective germicide, such as a strong solution of bichloride of mercury, in sufficient quantities to be sure of their destruction before they are buried, which should be at a sufficient distance from any neighboring water supplies as to insure their freedom from contamination.

6. "If the water supply is of a suspicious character, thoroughly boil it before using, and then place it where there is no possibility of its becoming infected. If ice is to be used to cool the drinking water, keep it out of the water, only packing it around the water-vessel."

In an article on the same subject, in the same journal, p. 225, by Dr. Stephen B. Smith, he gives the following suggestions, as means of stamping out this infectious disease:

First of all comes the absolute need of destroying in every instance the excreta, or the germs therein, as they are expelled from the patient. This should be made a legal necessity. Then, when as much attention is given to the plumbing, draining and ventilation of the home, as in