A Text-Book on Diseases of the Eye. By HENRY NOYES, A. M., M. D., Professor of Ophthalmology and Otology in Bellevue Hospital Medical College; Executive Surgeon to the New York Eye and Ear Infirmary; recently President of the American Ophthalmological Society, etc. Royal octavo, 733 pp.; richly illustrated with chromolithographic plates and two hundred and thirty-six engravings. Price, bound in extra muslin, $6; in sheep, $7. New York: Wm. Wood & Co.

This most excellent text-book comes rather late for a review, yet it is so valuable a work that we desire to recommend it to physicians

and students who wish a reliable treatise on eye diseases. It is an elaboration of the book by Dr. Noyes in Wood's Library, and is the most systematic and exhaustive work on the subject by any American author. It would be useless for me to give it an extended review. To quote the opinion of a distinguished specialist, "it is a brilliant testimonial of the ex

tensive knowledge, past experience, untiring industry and literary ability of its celebrated author."

J. M. R.

Transactions of the New York State Medical Association for the Year 1888. Volume v. Edited for the Association by ALFRED LUDLOW CARROLL, M. D. 610 pp. New York: J. H. Vail & Co. 1889.

The State Medical Association of New York is fortunate in having in its lists many of the ablest medical men in America, and more for tunate still in having inaugurated a plan of laying out its work in such a way the topics that most need elucidation are brought under discussion and at the hands of men best able to do them justice. Hence the great value of its transactions, proving as they do a mine of useful knowledge. The Transactions of 1888 add another superb volume to the records of the Association.

D. T. S.

AT a meeting of the Berlin Municipal Council, on June 12th, it was decided that a convalescent home for lying-in women should be established at the expense of the city. A sum of 140,000 marks ($35,000) (£7,000) was voted for the purpose.

Correspondence.

LONDON LETTER.

To one desirous of obtaining clinical and hospital advantages, London offers to him a field tempting beyond expression in its almost unlimited opportunities. London is particularly adapted for the specialist. Her position as metropolis of the world gives assurance of almost unlimited clinical advantages; the vast accumulations of wealth have enabled her philanthropic population to erect special hospitals, where the most approved appliances and the best of medical attention can be given her indigent poor. The surgeon, the ophthalmist, the neurologist, or the specialist in almost any other branch of medicine has only the pleasurable uncertainty of selecting which particular hos pital or hospitals he will attend.

There is in Queen's Square a massive pile of building known as the National Hospital for

Nervous Diseases. It is here that London's renowned neurologists devote many hours weekly to clinical and hospital work. This hospital can probably boast of more distinguished neurologists than any other institution of its kind. Among those who at present compose its staff are Ferrier, Hughlings Jackson, W. R. Gowers Buzzard, Victor Horsley, and Buvor.

In

Furnished with letters of introduction to these most distinguished gentlemen, I, through their influence, secured every advantage which London could afford in a neurological way. the large clientèle of this hospital the suspension treatment in locomotor ataxy has been tried with sufficiently good results to recommend its further use. The combination of cerebral and spinal localization with the surgeon's knife has brought about many results never dreamed of before. Some of the cures effected would sound like a tale taken from the Arabian Nights but for the sober fact of seeing the unmistakable results before you. One case I recall especially. A woman, a bedridden paralytic for years, who upon the removal of the spinous processes of three vertebræ (dorsal, I believe), under the strictest of antiseptic precautions, resulted in recovery and the use of her lower limbs. Electricity apparently has lost none of its prestige

in London, for the best of authorities recommend it highly both in private and hospital work. The use of mechanical appliances to overcome deformities resulting from nervous diseases were numerous and interesting. Among others was one used for extending the spine after operations. It consists of a plaster-of-paris or stay jacket extending from the axillary space to the crests of the ileum, into which are fixed hooks; from these cords are run over pulleys at the lower end of the bed, and so arranged that weights can be placed upon them proportionate to the amount of extension desired. Extension

of the upper half of the spine is made by pads under the arms to which weights are attached. For those suffering from dyspnea, or from any cause unable to recline, a simple device is in use in the hospital here, which an ordinary carpenter can make. It consists of two rods let into blocks, placed far enough apart to allow the bed between. Upon this a board is nailed for the arms to rest; a second elevation, by means of short uprights, on which a short board is nailed. This is covered with a pillow or padded.

The progress or retrogression of a case of epilepsy is interesting, but keeping a record of the number of attacks, the time, and the day of the month on which they occur, where there are a large number attending the clinic, is, to say the least, irksome. To overcome this an arrangement, very simple and easily kept, is used in the hospitals here. It is a table with dates and spaces so arranged that the patient can keep a record of his seizures. The treatLent of epilepsy by borax has received considerable attention lately. It is prescribed in fifteen to thirty grain doses three or four times daily till vesication of the lips or gastric disturbance forbids its further use. It is mostly used in those chronic cases which have failed to succumb to the treatment with the bromides.

Space forbids my dwelling longer on a field so large and interesting. I shall always recall with pleasure the warm reception I received at the hands of the English neurologists, and especially do I wish to thank Dr. Ferrier for his many kind attentions socially and for the extension of hospital privileges so rarely granted a stranger.

LONDON, March 15, 1890.

CURRAN POPE, M. D.

Abstracts and Selections.

HEART DISEASE IN PREGNANCY AND LABOR. The subject of heart disease complicating pregnancy has lately on more than one occasion tober, 1887, Dr. Berry Hart read a paper on occupied the attention of our Society. In Ocmitral stenosis as a complication, giving at the same time the reports of two cases which had been under my own care; while on the same date Dr. Ballantyne fully recorded another similar case. Three other cases were recorded by Dr. Berry Hart in May, 1889, and one by Dr. Fraser Wright in last July. The subject is of such importance that I need hardly apologize for relating at some length the following case, which was treated in the Edinburgh Maternity Hospital during the time that I was Resident Physician. The case, which was under the care of Dr. Halliday Croom, to whose kindness I am indebted for permission to lay these notes before you, was one of pregnancy complicated by aortic stenosis and incompetence, together with mitral stenosis and incompetence.

Jane C., aged twenty-four, primipara.

History. Her mother is still alive and well; no history as to father. When about ten or eleven years old she had scarlet fever and measles, followed immediately by smallpox ; from these she recovered well. She does not know that she has ever had rheumatic fever, but has suffered at times from pains in her wrists. She has always been fairly strong, but as a general servant she has done a great deal of hard work. About two or three years ago she noticed that her feet were swollen at night; this condition, however, passed off without treatment. At the end of 1886 she began to be troubled with shortness of breath and palpitation on making any exertion. In the beginning of January, 1887, she caught a cold which kept her in bed for a day; there were no special pains in the joints. She last menstruated on 9th January, 1887. About this time she had severe pain in her left side, which soon improved; but in the beginning of April it returned, and she was admitted into Dr. Affleck's ward, Royal Infirmary, Edinburgh, on 8th April, complaining of shortness of breath and pain in her left side, the pain being shooting in character and often passing up into both shoulders. At the time of her admission into the infirmary she suffered a great deal from giddiness, with pains in her head. She never had any morning sickness.

I am indebted to Dr. Affleck's kindness for the following notes of her condition while in his ward:

Circulatory System. Pain severe in left

mamma; slighter pain on inside of right mamma; slight palpitation; dyspnea, especially at night; visible pulsation in episternal notch and beating of carotids; apex beat in fifth interspace, about two inches from sternum, feeble and with no thrill; slight thrill between second and third interspaces; slight thrill in episternal notch. Heart not enlarged. Over mitral area the first sound is replaced by a soft blowing murmur, which is propagated round to the axilla. Over aortic area systolic and diastolic murmur heard, harsher and more prolonged than mitral; murmurs conducted up vessels and down sternum. Pulse 80, and regular. Respiratory system normal. At the end of April there was some edema of the feet on standing. She was treated with digitalis, iron, and arsenic. On 1st May sickness after every meal commenced; on 10th May stirrage was first felt; on 13th May she had epistaxis; on 22d July she had irregular pains over the abdomen, together with difficulty in micturition; on 24th July she was in bed with a painful swelling and ecchymosis in the upper part of the left thigh, and with severe vomiting. On 25th May there was some hematemesis. She was now put upon milk diet, the digitalis mixture stopped, and she was ordered bismuth and opium powders, with 3ss. of brandy every four hours; warm opium fomentations were applied to the thigh. On 28th July the pain and ecchymosis were disappearing. From this time until 15th September, when she was sent to the Maternity Hospital, she had occasional hematemesis, extreme prostration, and also sleeplessness at night; she vomited three or four times a day for two or three days at a time, with intervals of a week or two, during which she was better. She at times had some slight hemoptysis, and often required to sit up in bed. in order to breathe at all. Her condition all

this time was most critical.

The

After admission to the Maternity Hospital on 15th September her condition improved considerably; she was kept upon milk diet, and treated with bismuth and opium; 3ss. of brandy was given three times a day. She had no further sickness except once after taking castor oil. She was rarely troubled with breathlessness except at nights now and again. opium was gradually diminished in quantity, and the brandy was stopped for a time, while she was also allowed a little solid food. Byrom Bramwell examined the condition of her heart, which he found to be only slightly enlarged; the apex beat was displaced outward (probably by the uterine tumor); over the mitral area was a distinct presystolic murmur, together with a slight systolic murmur which was conducted toward the axilla; over

Dr.

the aortic area were heard systolic and diastolic aortic murmurs, the systolic being very well marked. These were conducted up the vessels and down the sternum.

On 5th October she got up for an hour, and continued to do so on most days after this. On 14th October she complained of pain in her back and left side, also a little sickness. On 15th October pains still continued; considerable dyspnea during the night. These pains passed off, but recommenced at 11:30 P. M. on 18th October, when the breathing also became exceedingly troublesome. On 19th October she was much better; the bismuth and opium were stopped, and she was ordered M5 of tr. of strophanthus (1 to 20) every four hours. On 23d October it was determined to try and bring on the labor, as she was already a week past her time, and was becoming extremely nervous lest the new quarter, bringing with it fresh doctors and nurses, should arrive before she was well on the road to recovery. Consequently, at 11:30 A. M. on that day, under chloroform, I separated the membranes for about one inch round the cervix with my finger and gave a hot douche. A large Barnes' bag was then placed in the vagina, and only removed to give a hot douche every four hours. No pains resulted from this. On 25th October, at 1 P. M., Dr. Croom, with some difficulty, without chloroform, passed a large-sized bougie for about one inch and a half between the posterior wall of uterus and the membranes; a hot douche was then given every four hours. Early on 26th October the pains began, but were feeble and useless at first. During the evening and night of 26th October she had frequent pains, and became extremely hysterical. Chloroform was given during most of the pains. She complained of severe stabbing pain, especially during the labor pains, in the precordial region and passing up into the left arm.

During the pains the pulse became more rapid and much weaker and less regular; between the pains it was about 90, full and regular. She continued in this state all night and during the whole of the next day, the os dilating very slowly. She was given M5 of tr. of strophanthus every four hours, and 3ss. of brandy every three hours, with beef-tea at frequent intervals.

At 5 P. M. on 27th October 25 minims of tr. of opium were given, but she vomited it at once. She was becoming extremely weak and exhausted, while the difficulty in breathing was so great at times that she had to sit up in bed in order to breathe at all. At 7:40 P. M., when the os was the size of a crown piece, the membranes spontaneously ruptured high up and a certain amount of liquor amnii escaped. At

She

9:40 P. M. Dr. Croom saw her, and advised that the labor should be ended at once. was then put deeply under chloroform, and after dilating the os with the fingers I applied forceps and delivered the child shortly after 10 P. M. The placenta was expressed ten minutes after, and she was then allowed to come out of the chloroform, during the administration of which she had been extremely sick. No ergot was given, as a certain amount of hemorrhage was thought desirable. There was a good deal of bleeding, which had to be checked later by hot douches. After delivery the pulse was 118, and fairly full; half an hour later it was 96, full and regular. She was very sick for some time, and complained of sore throat; the precordial pain was entirely gone, and never reappeared. The child was a healthy male, 23 inches long, and weighing 9 lbs. 10 oz., being the largest child born in the Maternity during the quarter. The puerperium was perfectly normal. She was not allowed to nurse her child. There was no trouble with the breasts, as she had very little milk. She was kept on the strophanthus until 29th October, when the dose was reduced to M4 every four hours; on 31st October it was further reduced to m2. Her breathing was perfectly easy now, and recovery was rapid and uninterrupted. On 7th November she was sent back to Dr. Affleck's ward, where the report of her cardiac condition was given as follows: A distinct precordial thrill exists; over the mitral area the first sound is preceded and replaced by a murmur which is conducted into the axilla; the second sound is impure; over the aortic area both sounds are replaced by murmurs which are conducted up the vessels and down the sternum. After a short stay in this ward she was dismissed in fairly good health, but after undertaking the duties of a domestic servant she again broke down; a short rest, however, soon restored her to comparative health, and when I last saw her, about fifteen months ago, she was able to undertake light domestic duties.

(A series of pulse tracings were taken before, during, and after labor, and a few of the more typical of these were shown, in order to give some indication of the condition of her circulation.)

In all the cases which were recently brought before the Society the cardiac lesion has been only at the mitral orifice; in this one, however, the main lesion was probably at the aortic orifice, although the mitral valves were at the same time stenosed and incompetent, so that the case forms a fitting and interesting addition to the series. The case is a remarkable one, in that there were numerous and extensive cardiac lesions before the commencement of

pregnancy; and it was interesting to mark the increase of existing symptoms and the development of new ones as pregnancy advanced and an extra strain was thrown upon the already overtaxed heart, which, however, rapidly regained its former condition as soon as the labor was completed. When in Dr. Affleck's ward she was for a time in a most critical condition, and it seemed almost as if she were bound to die from exhaustion consequent upon the persistent vomiting; yet she recovered from this, and the interesting point is, that not only did premature labor not supervene, but she even went beyond the ordinary period of pregnancy.

It is generally said that mitral stenosis is the most dangerous heart lesion which can occur as a complication of pregnancy, and that the other lesions are dangerous to a much less degree. The explanations of this are far from satisfactory, and have been fully discussed by Dr. Angus Macdonald in his work on Heart Diseases in Pregnancy, etc., so that it is unnecessary to refer to them further here. The purpose of this paper is to try and show that the great cause of danger is venous congestion, systemic and pulmonary, and that, since this is produced in the early stages of mitral disease, especially mitral stenosis, therefore this is the most dangerous lesion; but that, since it also appears in the later stages of aortic disease, therefore these become equally dangerous in the later stages, although they are less so when the disease is not so far advanced; in other words, the danger of heart disease as a complication of pregnancy and labor depends more upon the extent of the lesion than upon its nature.

In order to establish the truth of this proposition it will be necessary shortly to consider (1) the effects of pregnancy and labor on the normal circulation; (2) the effect of the various heart lesions on the normal circulation; and (3) how these effects interact on one another.

1. During pregnancy there is increased peripheral resistance, due to the circulation of the blood in the placenta, but this is met normally by a slight hypertrophy of the left ventricle of the heart. During the first stage of labor the pains probably cause an increased strain upon the heart, while its action will be weakened to some extent by the exhaustion which follows from the acute physical suffering. During the second stage of labor, however, the bearingdown pains come into play, and the patient, shutting her mouth, presses with all her abdominal muscles, so that there is considerably increased strain upon the heart and some embarrassment of the pulmonary circulation, while the venous portion of the systemic circulation becomes more or less engorged, so that the right

side of the heart tends also to become engorged with blood. This must be obvious to any one who gives the question any consideration, and needs no further explanation. During the third stage of labor, as soon as the placenta is separated and expelled, the uterus contracts firmly and drives the blood suddenly from the uterine sinuses into the abdominal veins, which expand to recieve it until the heart can adapt itself to the altered condition of the circulation.

2. We must now shortly consider the main effects of the various heart lesions on the circulation. Mitral stenosis, by preventing the ready passage of the blood from the left auricle into the ventricle, causes engorgement and dilatation of the former; this raises the pressure in the pulmonary veins, and so causes edema and congestion of the lungs; the backward pressure reacts further on the right side of the heart, and causes dilatation of the auricle and ventricle, so that the systemic veins which open into the right auricle become overdistended and engorged. At the same time the left ventricle receives less than its proper quantity of blood, and in consequence atrophies to some extent. Here, then, the most important results are engorgement and overdistension of the systemic. and pulmonary veins, and this condition of affairs, coming on very early in the disease, becomes more marked as it progresses.

Mitral regurgitation produces the same sequence of events, due in this case to the blood being forced back on the lungs by the incompetence of the mitral valves; the results, however, do not appear so early in the disease as in the former case, but eventually become equally marked. The left ventricle, however, tends rather to hypertrophy than to atrophy.

Aortic lesions, on the other hand, produce diminished forward rather than increased backward pressure, but sooner or later they come to produce this latter effect also; here too the left ventricle hypertrophies.

We see, therefore, that all heart lesions come eventually to cause venous engorgement, but that, while mitral stenosis produces it at once, mitral incompetence does not produce it until the disease has been in existence for a rather longer period, and aortic lesions do not produce it until they have been in existence for a considerable time, and have come to produce increased backward rather than diminished forward pressure, which is their primary effect.

3. We have now to show how it is that pulmonary and systemic venous engorgement produce such dire results in pregnancy and labor. We have seen that pregnancy throws an extra strain upon the heart. If, however, this organ is already weakened by disease, it is unable to

withstand this strain, and its action becomes more embarrassed; hence all forms of heart disease are dangerous; but if the disease is not far advanced, the heart may by suitable treatment be brought to perform the work required of it. In mitral stenosis, however, we have seen that the left ventricle tends to atrophy, while its muscular fibers also degenerate, and hence this disease is especially dangerous, more especially as it is now a well-recognized fact that in this lesion, owing probably to the above mentioned degeneration, the heart does not react at all readily to cardiac tonics, such as strophanthus, digitalis, etc. In mitral incompetence and aortic diseases there is already more or less hypertrophy of the left ventricle, according to the extent to which the disease has advanced, and hence the question as to whether the heart can undertake the extra strain thrown upon it by the increased peripheral resistance depends entirely upon the extent to which the disease has advanced.

Abortion is very likely to occur as a result probably of venous engorgement and consequent defective placental circulation, and hence it may occur in any of the heart lesions where this condition of affairs exists.

If labor comes on, during the first stage the heart is very apt to fail owing to the exhaustion of the patient, and its occurrence depends entirely upon the amount of reserve energy left in the organ; that is, on the extent to which the disease has advanced. The defective action of the heart, moreover, tends to increase the venous engorgement which already exists, and hence pulmonary embarrassment is very much increased.

During the second stage of labor the bearing-down pains tend naturally to cause the venous engorgement and to embarrass the heart's action. These effects are normally of trifling importance, but when they already exist as a result of heart disease they become a great element of danger, and the heart often fails from engorgement of its right side and inability to drive the blood through the pulmonary circulation. Here, then, the great source of danger is the venous engorgement which is superadded to that normally produced by the bearing-down pains.

When the placenta is born, we have seen that the blood from the uteriue sinuses is suddenly thrown into the abdominal veins, which expand, and so prevent the right side of the heart from becoming overdistended. If, however, the abdominal veins are already overdistended, they can no longer expand further, and hence the extra blood is thrown into the right auricle, which becomes still further distended and paralyzed.