OBSTETRICS.

GEORGE KAMPERMAN, M. D.

DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

CAESAREAN SECTION.

ALLEN (American Journal of Obstetrics and Diseases of Women and Children, 1909, Number II) makes a plea for more frequent performance of Caesarean section. He thinks that fear of criticism prevents many an obstetric surgeon from doing the operation because his particular patient does not present the usually accepted indications. In his opinion the field for Caesarean section should be widened. He gives the indications as they are generally accepted to be, and also states them as he thinks they should. be. Contraction of the pelvis stands in the foreground as an indication, and most of the discussion refers to it.

The usually accepted indications are: (1) Contracted pelvis with a true conjugate of seven centimeters or less, a conjugate of from seven to eight and one-half centimeters being considered only a relative indication; (2) carcinoma of the cervix and pelvic tumors. Only a few operators have performed the operation for (3) eclampsia and (4) placenta previa. He considers that figures obtained by pelvimetry are not reliable as indicators. The size of the fetal head is too often disregarded. In a patient not infected, any disproportion threatening the life of the child or threatening to cause severe injury to the mother, should be considered an indication for Caesarean section. The conservative operation in narrow pelvis too often ends with crushing of the fetal head. High forceps is considered to be in many cases a more serious operation than Caesarean section. In multipara the history of the previous labors is the important point in determining the indication. As far as mortality is concerned, for the mother the laparotomy is no more dangerous than a difficult forcep delivery, while for the child it is much more favorable. He considers it a mistake to attempt to do version with breech extraction in any case where it would be unsafe to deliver the head with forceps. He quotes opinions from Davis, Reynolds, Warren, Pool, Brown, Boemaire, Reddy, Kerr, and Fry, all of whom endorse Caesarean section in preference to difficult forcep operations or versions.

Symphyseotomy and pubiotomy have given some excellent results but are not a substitute for Caesarean section. Certain claims for them cannot be denied, but they do not deliver the child, and there must follow delivery through the pelvis with risks of unfavorable mechanism, and danger of laceration to the mother. Results obtained are not as yet so favorable for mother and child as the results of abdominal section and the after

treatment presents more difficulty. Fry is quoted as giving the indication for pubiotomy to be a living child and some contraindication to Caesarean section.

Caesarean section compares favorably with induction of premature labor in cases where contraction is sufficient to demand abdominal section at term. To obtain a normal delivery labor would have to be induced so early that the life of the child would be threatened. Many prematurelyborn infants thrive poorly, and many of them die.

In eclampsia Caesarean section offers a quick method of emptying the uterus. In placenta previa (centralis) Caesarean section is indicated only when temporizing measures have not already been resorted to, and before. the woman is exhausted from hemorrhage.

Analysis of two hundred and twenty-nine cases, of Caesarean section by twenty operators show a mortality of 1.2 per cent for primary cases, 3.8 per cent for secondary cases, and 12 per cent for late cases.

PEDIATRICS.

ARTHUR DAVID HOLMES, M. D., C. M.

A STUDY OF THE BLOOD IN PERTUSSIS.

KOLMER read a paper on this subject before the meeting of the Philadelphia Pediatric Society, November 10, 1908. He had studied the blood in over one hundred children, twenty-seven having pertussis, with the object of determining the working standard for the total number of leukocytes and the proportions of the leukocytic elements in the blood of institutional children of various ages, to ascertain if it were possible to diagnose pertussis with some degree of certainty early in its course and in typical cases by a study of the blood. He conducted a study of the blood in conditions resembling the catarrhal stage of pertussis (bronchitis and laryngitis) for the purpose of ascertaining whether the blood changes peculiar to pertussis occur in them also, including a study of the blood in cases of pertussis modified by complications, and his conclusions are that there is certainly present early in pertussis a leukocytosis, which affects mainly the small lymphocytes and that these changes are characteristic, serving in a great many cases to diagnose pertussis before such diagnosis can be made from the clinical symptoms.

In many instances a provisional diagnosis should be made and reexamination of the blood later will clear up all doubt. While the method may consume too much time for the general practitioner it will be of great value in institutions to prevent the spread of an epidemic of whooping-cough,

LARYNGOLOGY.

WILLIS SIDNEY ANDERSON, M. D.

LARYNGOLOGIST TO HARPER HOSPITAL, DETROIT, MICHIGAN.

THE COMMON COLD: ITS PATHOLOGY AND TREATMENT, WITH ESPECIAL REFERENCE TO

VACCINE THERAPY.

ALLEN (London Lancet, November 28 and December 5, 1908) summarizes his views as follows: (1) It has been shown that there are at least five organisms capable of the production of an attack of acute nasal catarrh, namely: (a) the bacillus influenzæ; (b) the bacillus septus; (c) the bacillus of Friedlander; (d) the micrococcus catarrhalis; and (e) the micrococcus paratetragenus. (2) These may be present in the nasopharyngeal space in a certain percentage of cases which exhibit no pathologic features; increase of virulence and lowered resistance of the tissues may then light them up into activity. In other cases the infection is one from without. (3) Each organism produces its own type of cold and a differential diagnosis of the organism is possible from a consideration of the clinical features; this is more difficult should the infection be a multiple one. (4) This differential diagnosis is of considerable value both in prognosis and in treatment. (5) Chronic nasal catarrh is probably always due to infection by the bacillus of Friedlander, unless the Eustachian tube and middle ear be involved by the micrococcus catarrhalis; chronic tracheal catarrh due to infection by the micrococcus catarrhalis or micrococcus paratetragenus to which secondary infection by staphylococci, streptococci, pneumococci, and other pathogenic organisms may be superadded. (6) For infection local defect of opsonin and for cure increase of opsonin are probably necessary conditions. (7) By means of the injection of the corresponding bacterial vaccines an attack of acute cold due to any given organism or organisms can be considerably shortened and complications be probably prevented. (8) In a similar manner chronic infections may be cured. (9) By injection of the vaccines of the several organisms in appropriate doses and at appropriate intervals considerable if not complete immunity against future. attacks of acute cold may be secured. In those who are very susceptible and fall victims to every epidemic that may occur, the best procedure probably is systematic immunization every four to six months against all the "cold" organisms and special immunization against the particular organism or organisms which may be responsible for the appearance of subsequent epidemics against which protection is desired.

GENITOURINARY.

DEAN LOREE, M. D.

CLINICAL PROFESSOR OF GENITOURINARY SURGERY IN THE UNIVERSITY OF MICHIGAN.

PROSTATIC ABSCESS.

ALEXANDER reports (Annals of Surgery, April, 1909) that during the four years of 1905, 1906, 1907, and 1908 he treated sixty-eight cases of prostatic abscess of gonorrheal origin other than those of senile hypertrophy or of a tuberculous nature. Twenty-six were subjected to perineal median section and drainage into the urethra, while forty-two were prostatectomies. The youngest patient was eighteen years and the oldest was forty-four years. Twenty-eight or more than one-third were between the ages of eighteen years and twenty-five years. In thirty-one patients the abscess occurred at the time of first infection, while in ten it was manifest after two or more attacks supposed to have been cured, and in twenty-seven it became evident after relapsing urethritis. The prostatic suppuration was associated with perineal abscess sixteen times and with ischiorectal abscess five times. He states that the number of ischiorectal abscesses was below the normal as the prostate is the primary cause of the majority of abscesses in this locality coming under the observation of the genitourinary surgeon. Pus was confined to the prostatic capsule in forty-five instances, it had gone beyond its confines in twenty-two, and evacuated via the rectum in one. There was retention of urine in thirty-five cases.

When the abscess is single, especially when large and implicating both lobes, the perineal incision and urethral drainage should be the selected. operation. Prostatectomy should be performed when multiple abscesses exist either in one or both lobes.

The pathology of the removed glands he divides into three classes as follows: (1) A purulent catarrhal inflammation with exudate chiefly within the gland tubules. (2) An interstitial purulent process starting from the tubules, invading the surrounding stroma, destroying the tubules and stroma and forming miliary or larger abscesses. (3) Chronic exudation and productive processes.

DERMATOLOGY.

WILLIAM FLEMING BREAKEY, M. D.

CLINICAL PROFESSOR OF DERMATOLOGY AND SYPHILOLOGY IN THE UNIVERSITY OF MICHIGAN.

JAMES FLEMING BREAKEY, M. D.

ASSISTANT IN DERMATOLOGY IN THE UNIVERSITY OF MICHIGAN.

THE ETIOLOGY AND TREATMENT OF NEVI. SCHALEK has an article in the Journal of Cutaneous Diseases, Volume XXVI, Number CCCXV, entitled: "Nevus Unius Lateris: Report of a Case." While Doctor Schalek describes nevi as being usually congenital he quotes Unna as saying that they are "Embryonic anomalies appearing

and slowly developing after birth." Duhring is also quoted to the effect. that "they are almost invariably acquired during later life."

In reviewing the literature of unilateral nevi Schalek reports them as most rare, the percentage being .033 per cent of all skin diseases. Their distribution usually follows certain defined skin lines. Baereusprung found that they followed the lines of certain nerve branches, in some cases closely resembling the distribution of herpes zoster. It is not now believed that there is any relation between them and these underlying nerves. In some cases coincidental nervous manifestations have been observed.

Montgomery has reviewed the theories of etiology. He concludes that they are due to the trend of the growth of tissues and the adaptation of embryonic sutures. Blaschko thinks these nevi are the sequelæ of fetal disturbances of development, to account for which a disease of the nervous system is not necessary.

Histologically soft nevi exhibit a hyperplasia of the connective tissue cells in the papillary layer in circumscribed aggregations. In the linear nevi an additional hypertrophy of the horny layer and a consequent thinning of the rete is found accounting for their characteristic warty form. A careful study of the cases should render the differential diagnosis of little difficulty.

The prognosis is good. Malignant degeneration has not so far been reported. Extension stops at an early age and is rarely observed after puberty.

The most satisfactory treatment is by the removal of the papillary projections either with scissors or razor and touching the bleeding surfaces. with trichloracetic acid. In extensive patches on the face skin-grafting may be resorted to. The use of liquid air and carbon dioxid is also mentioned.

The case reported was that of an anemic girl, age nine, and of a nervous temperament. Family history apparently negative, unless it be a history of alcoholism on the part of the father. At birth patient presented a nevus on the left heel and another on the left knee. At six months another appeared on the neck. During the next six months similar lesions appeared in different parts of the whole left side of the body. After this time its spread seemed to be checked with the exception of a few isolated lesions. At the present time there are numerous irregular and band-like patches of different sizes, some distinctly warty, others slightly elevated, but all more or less pigmented. But few lesions are found across the median line on the right side of the body. The flexor surfaces are more involved than the extensors. The course of the nerves seems to be closely followed. There have been no accompanying subjective symptoms. J. F. B.