The Gonorrheal Puerperium.

Cumston (Amer. Jour. Obs. and Dis. of Women and Children, October, 1899) writes: Saenger made the statement before the first Congress of German Gynecologists that one-eighth of gynecological affections were of a gonorrheal nature; and in order to get a correct idea of how often complications during the puerperium are due to gonorrhea, he examined the gynecological records of the Leipzig clinic and found that 26 per cent of the pregnant wo men were affected with the pathologic process. In order to corroborate this statement he referred to Oppenheimer, who a year previously had studied the cases in the gynecological clinic of Heidelberg, and who had found that 27 per cent of the pregnant wo men there admitted were afflicted with gonorrhea and that 40 per cent of the children born in the institution presented a gonorrheal ophthalmia. That this latter affection could never be produced by normal lochia has been demonstrated by Zweifel, who inoculated the conjunctiva with healthy lochial discharges and always with a negative result. Lomer, who at that time was connected with Schroeder's clinic, had also made researches for the gonococcus in 32 pregnant women and found the organism present in 9 of them, or, in other words, 28 per cent.

It must be said that Saenger made his diagnosis from a purely clinical standpoint, as he did not consider bacteriological examinations reliable, and he also pointed out the importance of gonorrheal ophthalmia as a diagnostic point of gonorrhea in women recently confined.

From these figures it at once becomes evident that more than 25 per cent of pregnant women are afflicted with gonorrhea, while at the same time the mortality during the puerperium is comparatively small, and Saenger concluded that gonorrheal infection complicating the puerperium

can occur in the two following manners, namely: (1) To an existing gonorrhea there is added a septic infection, which he terms a puerperal-gonorrheal mixed infection; (2) gonorrheal infection which ascends during the puerperium, in which case the disease is due entirely to the gonococcus.

The Modification of Cow's Milk for Artificially Fed Babies.

The modification of cow's milk for artificially fed babies is of greater importance than is generally conceded. It is comparatively simple when one knows the constituents of mother's milk and cow's milk. The following tables of modification may be of use to the general practitioner: For convenience 24 ounces is the amount prepared in each instance:

No. I. For infants to two months: Milk, 3viii; cream, 3iss; sugar, 3i; gruel, 3xivss.

No. 2. For infants two to five months: Milk. 3viii; cream, 3iii; sugar, 3i; gruel, 3xiii.

No. 3. For infants six months to one year: Milk, 3viii; cream, 3ivss; sugar, 3i1-6; gruel, 3xiss.

These tables are after Holt's modification and are based on the supposition that the milk used contains 3 per cent fat and the cream 16 per cent.

Milk fat can be easily determined if it be remembered that the relation of cream to fat is as 5 to 3.

Early Diagnosis of Measles.

The early contagiousness of measles is undoubtedly imperfectly understood by the profession. Commonly it is supposed that little danger exists until the catarrhal symptoms make their appearance and that the acme of the contagious period is the stage when temperature, rash and catarrhal symptoms are at their height. This, however, is not the fact, for, from the number

of recently discovered symptoms, it has been fully demonstrated that the greatest danger is in the pre-eruptive stage. Koplik was the first to describe the bluish-white, slightly-raised, rounded efflorescences, which occur on the mucous membrane of the cheek and in some cases on the mucous membrane of the lips. The number of spots is usually from six to twenty, but in exceptional cases several hundred have been counted. The spots are usually found opposite the lower molars, and occasionally are confined to one side. The spots cannot be removed by wiping over them, but can be readily removed by forceps without leaving any abrasion of the mucous membrane. Koplik's spots are pathognomic of measles. In every case where they were found the typical eruption made its appearance within a few days. These spots usually make their appearance during the first few days of the prodromal stage. Their average duration is six or seven days and they begin to disappear upon the appearance of the characteristic eruption.--(Wiener Med. Cresse, 1898, xxxix, 806.)

In addition to Koplik's spots there is the erythemato-pultaceous stomatitis of Comby, which is present two or three days before the eruption. This consists of an unnatural reddening of the mucosa of the gums with a white, pultaceous deposit.

The soft palate phenomenon of Sevestre, which consists of an erythema, has also been noted to occur before the cutaneous eruption.

Bolognini's sign, although not pathognomonic of measles, is very commonly associated with it. From the number of diag nostic signs which are present before the eruption makes its appearance the diagnosis should be made without fail.

A Peculiar and Interesting Case.

Recently the writer learned of an interesting, peculiar and obscure case. Child 5 months old, previously happy and healthy, began to be unusually cross and lose flesh. Simple remedies failed to give relief and resort to opiates was had. Emaciation and restlessness continued for two months. The mother noticed something protruding from the rectum and upon investigation it was found to be the end of a string. Within a few hours the child passed a string two and one-half yards long. Immediately the restlessness disappeared and the child began to gain flesh.

Gastric Ulcer in a Child.

W. L. Johnson (Medical Council, October, 1899) reports the case of a girl aged 5, who for more than 10 months had suffered from pain in the stomach soon after eating. Red blood mived with mucus was vomited on two occasions and on palpation there was tenderness in the left hypochondriac region. Suitable dietetic and medicinal treatment was prescribed and for some time there has been o pain or hematemesis. -(Philadelphia Medical Journal, Nov. 4, 1899.)

Anti-Streptococcus Serum.

The committee appointed by the American Gynecological Society to investigate the value of anti-streptococcus serum in the treatment of puerperal infection concludes as follows (Am. Journal of Obstetrics, September, 1899, pp. 308-9):

I. A study of the literature shows that 352 cases of puerperal infection have been treated by many observers, with a mortality of 20.74 per cent; where streptococci were positively demonstrated, the mortality was 33 per cent.

II. Marmorek's claim that his anti-streptococcic serum will cure streptococcic puerperal infection does not appear to be substantiated by the results thus far reported.

III. Experimental work has cast grave doubts upon the efficiency of anti-streptococcic serum in clinical work, by showing that a serum which is obtained from a given streptococcus may protect an animal from that organism, but may be absolutely inefficient against another streptococcus, and prepared is limited only by the number of that the number of serums which may be varieties of streptococci which may exist.

IV. Thus far the only definite result of Marmorek's work is the development of a method by which we can increase the virulence of certain streptococci to an almost inconceivable extent, so that one hundred billionth of a cubic centimeter of a culture will kill a rabbit.

V. The personal experience of your committee has shown that the mortality of streptococcus endometritis, if not interfered with, is something less than 5 per cent, and that such cases tend to recover if Nature's work is not undone by too energetic local

treatment.

VI. We unhesitatingly condemn curettage and total hysterectomy in streptococcus infections after full-term delivery, and attribute a large part of the excessive mortal

ity in the literature to the former operation. VII. In puerperal infections a portion of the uterine lochia should be removed by Doederlein's tube for bacteriological examination, and a uterine douche of four to five litres of sterile salt solution given just afterward. If the infection be due to streptococci, the uterus should not be touched again, and the patient be given very large doses of strychnia and alcohol if necessary. If the infection be due to other organisms, repeated douchings and even curettage may be advisable.

VIII. If the infection extends toward the

peritoneal cavity, and in gravely septicemic cases, Pryor's method of insolating the uterus by packing the pelvis with iodoform gauze may be of service.

IX. The experience of one of the members of the committee with anti-streptococcus serum has shown that it has no deleterious effect upon the patient, and, therefore, may be tried if desired. But we find nothing in the clinical or experimental literature or in our own experience to indicate that its employment will materially improve the general results in the treatment of streptococcus puerperal infection.

Splenic Pseudoleukaemia (Anaemia Splenica;

Splenomegalie Primitiva).

Bertram W. Sippy. (American Journal of Medical Sciences, 1899, cxviii, p. 428 and 570):

The author reports a very interesting case of this rare and fatal disease, gives a very complete clinical history with post-mortem report, and dicusses the theories as to its origin and nature. The patient was 45 years of age, male, Russian. About four years before death, there was noticed a firm swelling in the left hypochondriac region, and from this time his health failed. There was diarrhea followed by constipation, shortness of breath was present at the time the swelling was noticed, and gradually increased. Epistaxis was frequent. Feet and ankles were swollen during the later months of life. There was local discomfort and a feeling of fulness and pressure in the epigastric and left hypochondriac regions. The enlarged spleen reached to within three finger breaths of the pubic bone and an inch beyond the median line. The blood examination showed the red corpuscles reduced to 1,740,000 per cubic millimeter, and the hemoglobin 30 per cent.

The autopsy found the spleen 31x16x9.5 cm., weighing 2350 grammes, with smooth, bluish-gray surface, on section it was red, firm and uniform. Infarcts were present. The retroperitoneal glands were small, pink

ish, forming a chain about the abdominal aorta, and showing no softening or yellow areas. Slight enlargement of the mesenteric, axillary and inguinal glands, showing same characteristics as the retroperitoneal glands. The bones showed a fetal structure. The histology of the spleen was as follows: Slight alteration in most of the malpigian bodies, some showing sclerosis; fibrous tissue formation about veins; extension of fibrous tissue into spleen pulp; areas of marked sclerosis; no signs of acute inflammation or degeneration of cells.

The enlarged lymph glands show fibrous hyperplasia and also hyperplasia of lymph

oid tissue.

The author thinks the enlargement of the spleen precedes the anemia and that the anemia is due to the action of toxic substances produced by the diseased spleen. Seven cases are collected where the spleen has been removed surgically, in five of which cure was thus effected. The author is inclined to advocate this operation in

such cases.

Fragmentation of the Heart Muscle.

A contribution to the knowledge of the Pathology of Fragmentation and Segmentation and Fibrosis of the Myocardium, by John Bruce MacCallum. (The Journal of Experimental Medicine, 1899, iv, p. 409.

Fragmentation of the Myocardium, by

Strickeisen, (Ziegler's Beiträge, xxvi, p. 105):

MacCullum gives first a brief description of the histology and histogenesis of the cardiac muscle cell. In his studies, the tissues were treated by Kolossow's osmic acid method, or by a modification of it, and by ordinary methods. He found that fragmentation of the heart muscle was a more complex process than mere breaking of the fiber. In every case where the breaking is at all prominent, there is a peculiar condition of the muscle, consisting of alternating contraction and extension of the fibers. This contraction and extension is not distributed over large areas, as in normal heart, but adjacent fibers are contracted and extended, and parts of a cell may be in different conditions. The breaking may occur in the cement line, in the contracted or extended muscle, or in a degenerated muscle, the initial stage in the last case being an extreme extension of the muscle. The simple breaks are due to a degenerative process.

Strickeisen has studied 150 cases of violent death in regard to fragmentation of the muscle fibers of the heart. The lesion was most often found in the papillary muscles and the wall of the left ventricle. The auricles were never involved. The break in the cell was often near the nucleus. The intercellular tissue was normal and no hemorrhages were seen. Separation of cells which occurred by ruptures of cells was

most common.

Fatty degeneration was rarely found associated with this condition, but pigment atrophy was recognized as a predisposing

cause.

In 56.6 per cent of the cases studied, fragmentation was present. These cases included instances of phthisis, acute peritonitis, pneumonia, typhoid fever, sepsis, etc. In two cases of tetanus it was marked. The cause is violent contraction of the heartmuscle, as it is very common where death is from asphyxia. It is not present in fatty degeneration because the force of contraction is not sufficient to cause rupture of the fibers. On the contrary, in pigment atrophy the fibers are rendered more friable.

From the frequency of its occurrence, a primary weakening of the heart-muscle can be excluded. It does not occur long before death, as changes do not follow in the fibers or the interstitial tissue as would then be the case. The ruptured ends of the fibers match.

The bearing of fragmentation as a cause of sudden death is decided in the negative. Such cases usually follow great efforts or acute infectious diseases. The heart is weakened, vascular pressure is lowered and the asphyxia which follows is accompanied by fragmentation. This may furnish an explanation of death which occurs suddenly at the beginning of chloroform anesthesia. As a cause of sudden death in itself it is strongly opposed.

UTERUS

AND

Vol. XII-No. 12.

Notes on the Technique of the Operative Treatment of Urethral Stricture.

BY F. KREISSL, M. D.,

Professor of Genito-Urinary Surgery, Chicago Clinical School.

A satisfactory result of a stricture operation is dependent on the following conditions: An exact determination of the localization, extent, quality and caliber of the constriction; accurate cutting-excision of the tissues constituting the stricture, and proper after treatment. These principles, however, can be applied only by selecting proper instruments. To make a diagnosis of stricture some physicians are still using the ordinary metallic stone searcher or elastic bougie, regardless of the possibility of overlooking a number of elastic. strictures, as they will not offer noticeable resistance to the passage of a rod of uniform caliber. These instruments will give little information about the consistence and extent of the stricture in constrictions of smaller caliber, and particularly elastic strictures. Callous strictures are productive of the most distressing immediate and reflex symptoms, and always call for operative interference. The proper instrument for determining a stricture is the bougie à boule, which is provided with a scale on its shaft. On using it, it is to be remembered always to begin the exploration of the urethra with a caliber of a higher number and then lessen it according to requirements. This mode of procedure is important, especially if multiple strictures of different caliber are present. For exploring the membranous and prostatic portion of the urethra, the proper instruments are bougies, the metal shaft of which is curved similar to the ordinary Benique sound. The scale on the shaft is divided into centimeters. The straight shaft is mounted with a scale ranging to 14 centimeters; the curved shaft on one ranging to 20 centimeters. The bladder portion of this

December, 1899.

shaft terminates in a screw-thread, to which olives of various sizes are screwed. By means of the bougie à boule an approximate determination of the stricture along the longitudinal axis of the urethra may be obtained, which can be accompanied by feeling with the hand the engagement of the olive as it enters the constriction and its disengagement as it leaves the same. In this respect the urethroscope, however, will give more accurate information, as it directly presents to view and permits a study of the extent of the changes in the "central figure" caused by the infiltration, as the absence of the longitudinal rugae and the peculiar discoloration of the mucous membrane covering the pathological tissue. By means of the bougie à boule you cannot always determine whether the constriction is of the bandlike, semilunar or valvular variety, whether situated at the upper or lower side of the urethra or surrounding the latter in an annular form.

The "localizer" constructed by the author will meet these conditions. It consists of a rod 18 centimeters long, of a caliber of 14 Char., and provided with a centimeter scale. The "feeler," which is 12 centimeters long, has a globular distal end, which is attached by means of a hinge-joint. This feeler in locked condition is concealed in a groove on the rod. By means of a screw gear in the "pavillon" of the shaft the "feeler" may be tilted up from its recess and the extent of its elevation may be gauged by an indicator beside the screw. The instrument is introduced up to a point immediately posterior to the stricture, which previously has been located by means of the bougie à boule, and can be done with accuracy because the scales of the two instruments are exactly alike; now the "feeler" is turned toward the upper wall of the urethra and elevated from its recess until the hand on the dial indicates a caliber five numbers higher than the caliber of the olive employed to locate the stricture.