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C. H. Whitford (Bristol Med.- Chir. Journal) says his experience, covering fourteen years, is limited to twenty-three cases. He lays down the axiom that "In the absence of symptoms of severe internal hemorrhage, and in the absence of a pelvic tumor, which can be differentiated from the uterus, a diagnosis of ruptured tubal pregnancy is unjustifiable." He differentiates a "fulminating" from "remittent" type of rupture. Early tubal pregnancy may be confounded with: (1) simple abortion; (2) retroverted gravid aterus; (3) intra-uterine pregnancy complicated with pelvic tumor.

a

In the fulminating type the only chance for the patient lies in immediate operation. In the remittent type small blood tumors, which seem to be growing smaller from week to week, may be treated on the expectant plan. While conceding the justifiability of this plan, the author is, nevertheless, forced to the conclusion that "the safest and therefore the best surgery is to remove in every case the extravasated blood and the damaged tubes."

Diagnosis of Extra-Uterine Gestation by Roentgen Rays.

Lichtenstein (Munch. med. Wochenschrift) insists upon the value of the Roentgen rays in the diagnosis of extraaterine gestation. A case of extra-abdominal tumor is reported in full, in which the diagnosis of extra-uterine gestation was verified prior to operation. Sjagren, of Stockholm, has also utilized the Roentgen rays in a case in which the diagnosis clinically could be narrowed down to extra-uterine gestation, pregnancy in a double uterus, or pregnancy complicated by a movable myoma. A skiagram readily revealed the extra-uterine gestation.

The writer considers that an X-ray examination should always be made in cases of abdominal tumor in women where the possibility of advanced extra-uterine gestation cannot be excluded with absolute certainty from the clinical examination alone. In advanced extra-uterine gesta

tion the fetal parts and the position of the child are observed on X-ray examination much more plainly than in uterine gestation, on account of the thinness of the fetal sac, the smaller amount of amniotic fluid, and the non-interference of the uterine walls and placenta with the rays.

Separation of the Normaily Inserted Placenta. in the Course of Pregnancy.

Jules Gaston, in the Annales de Gynecologie et d' Obstetrique, November, 1906, gives a detailed résumé of this question. Many years ago Mauriceau reported in a

treatise a certain number of observations of retroplacental hemorrages. Following the appearance of this article were others by Peu, 1694, and Leroux, 1776. But it is J. L. Baudelocque who handles this question with especial frankness in his treatise on the art of delivery. Some years afterward Mme. Boivin and Mme. Lachapelle, however, denied the existence of this affection. Later writers since the observations of Winter, have made contributions to the study of placental separation. Among these observers are Tarnier, Mm. Henry, Pinard, Varnier, RibemontDessaignes, and Champetier de Ribes.

Gaston opens his discussion with a consideration of the etiology and pathogenesis. Under the first heading he considers anatomico-pathological causes and ordinary clinical causes. Under symptoma tology he discusses the general condition, abdominal pains, the condition of the uterus, and accessory signs. An interesting section deals with statistics. That on pathological anatomy, including reports on post-mortem examination, is of great interest. Gaston refers to the theory of Schickele, who thinks that the placental separation may take place in such a manner that small effusions of blood on the interior of the decidua form progressively, so that coagulation follows, and with it arrest of hemorrhage. He believes that the hematomata act like a solid foreign body in bringing about pain, and consequently uterine contractions. Gaston belives that in cases in which the patient is suddenly attacked by intense pain in the

abdomen, with all the signs of severe internal hemorrhage, the uterus has not had time to react. He thinks that the separation precedes all of the phenomena of contraction.

Cæsarean Section Necessitated by Obstruction of Pelvis by Non-Pregnant Half Bicornute Uterus.

Brown (Surgery, Gynecology and Ob. stetrics) reports the case of a multipara, thirty years old. Previous deliveries fairly normal. Bleeding during the present pregnancy and diagnosis of placenta previa made because of a soft, boggy mass felt; later the diagnosis was changed to fibroid. The abdomen was opened and the uterus incised. The placenta was pushed to one side, the membranes ruptured and the living child extracted. The "tumor was brought up, and, from the attachment of the right tube and ovary, recognized as the non-pregnant half of a bicornute uterus. The wound in the pregnant half was sutured, and after a median incision in the non-pregnant half its cavity was emptied of a large amount of sympathetic

decidua and then closed with sutures. The abdominal wound was closed without drainage. Recovery.

Curettage in Puerperal Infection.

M. Demelin (Bull. de la Soc. d'Obst., Paris) says that curettage in puerperal infection is by no means always either necessary or advisable. There are many conditions that are positive contraindications to the use of the curette. These are phlegmasia alba dolens, uterine or periuterine phlebitis, pulmonary embolism, visceral complications, and prolonged infections. In all these such interference is too late. In other cases more energetic treatment is needed, as in generalized peritonitis and uterine perforations. Other forms make curettage useless or dangerous, as in primitive septicemia, in which curettage is followed by a rapidly fatal ending. A sub. acute intoxication follows the surgical opening of the vessels, acting as absorbing mouths. Perforation of the uterus during curettage is no imaginary danger in the softened condition of the infected uterus. It may be followed by severe hemorrhage. The natural barriers constructed against absorption by cellular infiltration or leukocytic reaction are de

stroyed, and a raw surface is left to absorb the poison. The curette should never be used blindly, but directed by the finger in the uterus. It creates furrows in the lining of the uterus and does not evenly remove the surface, so that decidual fragments may remain behind. In many cases intrauterine antiseptic injections are quite sufficient. Forceps for seizing placental remains are dangerous. The author prefers to make a digital curettage, under anesthesia, with rubber gloves. A complete exploration may thus be made without any danger of perforation or of traumatism to the organ.

Blood Examinations in Puerperal Fever. Knowatzki (Beitrage z. Geburtsh. u. Gynak.) offers the following résumé:

1. Prognosis favorable: Slight or no change in the neutrophile blood picture; presence of eosinophiles.

2. Prognosis unfavorable: Leucocytosis of 50,000, severe change of the neutrophile blood picture; absence of eosinophiles; marked decrease of red blood

corpuscles.

3. Improvement: Improvement of the neutrophile blood picture; reappearance or increase of eosinophiles.

4. Change for the worse is indicated by marked alteration of the neutrophile blood picture and diminution or disappearance of eosinophiles.

5. Prognosis absolutely bad: Occurrence of poikilocytosis associated with polychromasia and nucleated red blood

cells.

In conclusion, author suggests whether those leucocytes in which phagocytosis is observed belong in the multinucleated groups, five, four, three or not. If it is true that these cell groups disappear from the circulation because they were used in the combat against infection, we would expect again to meet them as phagocytes.

Clavin in Obstetrics.

A. Labhardt (Muench. med. Woch.), of the Woman's Hospital, at Basel, has investigated the action of clavin in a number of obstetrical cases. Clavin is an active principle of ergot, is soluble in water, and clinical reports are to the effect that it does not cause gangrene or convulsions, but stimulates the uterus to active contraction. It can be given by

mouth or subcutaneously. In eleven cases of ineffectual labor pains, strong contraction of the uterus resulted in all but one patient. It was generally necessary, however, to repeat the usual dose of 0.02 (onethird grain) two or three times. Clavin was also used after childbirth in a series of cases, and the desired action was, as a rule, very prompt; in some cases it was necessary to repeat the dose or to resort to other uterine tonics.

Clavin, the author states, acts well also as a prophylactic against hemorrhage, where an instrumental delivery is contemplated. If compared with ergotin, it will be found that clavin is equally as effective, and possesses the advantage that it may be used even be fore expulsion of the fetus, and that it is entirely free from toxic properties.

Pragnancy Complicated by Ovarian Cysts.

Charles T. Patton (Surgery, Gynecol. ogy and Obstetrics) draws the following conclusions from the study of over three hundred cases. Ovarian cyst is not an uncommon complication of pregnancy. It is a dangerous complication; the danger varies with the kind of treatment instituted for its relief. Removal of the cyst by laparotomy before labor yields the best results for mother and child. The mortality of this operation during pregnancy is not greater than in the non-pregnant state. The case should be operated as soon as the diagnosis is made. Danger ous complications are more frequent in ovarian cysts with pregnancy than when pregnancy is absent. Ovarian cysts are especially dangerous in the early puerperium. Tapping a cyst gives only temporary relief, is not curative, and is a dangerous procedure. It should only be employed in those cases of erroneous distension where operation is absolutely refused. If not removed before labor remove as early in the puerperium as possible.

Retention of the Membranes.

Paul Rissmann (Monatsschr. f. Geb. u. Gyn.) tells us that on account of the danger of sepsis, the prolongation of the puerperal period, the late involution of the uterus and the danger of hemorrhage which may be caused by retention, it is always necessary to see that the secundines are removed after labor. They may be

removed frequently by firm pressure on the uterus. When twenty-four hours have elapsed after the birth, if the membranes have not been entirely removed, this should be done instrumentally. When a portion of the membranes is left behind the lochia becomes fetid, fever may ensue, and true sepsis set in. The involution is then much slower and less perfect than in normally delivered cases. Retention of the membranes has in some cases produced severe hemorrages. That physician who does the best for his patient is the one who removes such fragments at once, without waiting for nature to take care of them. The uterus may be massaged until contraction is good, and then pressure kept up by a sand-bag or ice-bag for from six to twenty four hours. When energetic rubbing will not detach the fragments they must be removed with instruments. Retention is less frequent when the third stage of labor is allowed to be prolonged. When Credé's method is used it is apt to occur.

Relaxation of the Sacro-Iliac Synchondrosis, with Report of Cases.

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John Dunlap (New York Med. Fournal) says this condition was first recognized by Goldthwait in 1905. Among the most common causes may be mentioned pregnancy, traumata, sudden wrench or so-called stitch in the back," long recumbency, typhoid fever, or the commoner joint diseases. Blows and falls are the most frequent causes. Symptomatically, these cases are characterized by backache more or less constant, pain in walking, and sciatic pains. The pain is usually referred to one or the other sacro-iliac joint. The signs of this disorder are prominence of the sacrum, muscle spasm, lateral curyature of the spine, obliteration of the spinal curve, and swelling due to distension by fluid. On palpation, the joint is tender and there is free mobility, which may be determined in a number of ways. Differentially, this disorder must be diagnosticated from hypertrophic or osteoarthritic spine, sciatica, neurasthenia, lumbago, muscular rheumatism and typhoid spine. The author goes into the differentiation rather fully. Treatment consists in some variety of support, either in the form of strapping, a corset or an elastic belt. The author reports six cases.

Two Cases of Intraocular Tumor in Which the Transilluminator was Misleading.

Suker, of Chicago (Ophthalmic Record, November, 1906), mentions two cases, in one of which the ocular transilluminator failed to reveal the disease present. He

states:

"The transilluminator, no doubt, is of great value in making a diagnosis as to the presence or absence of an intraocular tumor under certain conditions. Not as much fault can be found with the ocular transilluminator as with the sinus transilluminator. This is an obvious fact from an anatomic standpoint, the eye being easily and readily approached and not surrounded by a dense, bony structure, as are the sinuses. For this reason the transilluminator is much more accurate and reliable for the ophthalmic surgeon than for the rhino-laryngologist.

"The ocular transilluminator will not fail in demonstrating the presence or absence of a tumor when the pupil can be well dilated and the vitreous is not filled with a hemorrhage of any extent, or when the pupil is sufficiently large to admit or emit large pencil of light. It matters not where the intraocular tumor is situated; a shadow can be seen and readily detected providing the two conditions above mentioned obtain, and not a trace or but a scant trace of hemorrhage visible in the vitreous. Should, however, the tumor be accompanied by more or less extensive intraocular hemorrhages, then the transilluminator will fail in reflecting a shadow of the tumor. Particularly is this true in cases of fresh hemorrhages and also true of hemorrhages which have been slightly or not at all absorbed. Because of the hemorrhage, either fresh or partly absorbed, an accentuated red fundus reflex is nearly always obtained, and thus obscures the shadow caused by the tumor."

The negative results obtained in such conditions are not dependent upon the size of the tumor or its density. He presented two specimens, one a large choroidal sarcoma, the other a case of detached retina with extensive exudates which have taken on organization of a malignant

character. In the latter case there were numerous dense hemorrhages, while in the former there were but a few hemor

rhagic areas. In either case a good pupillary dilation was obtainable, therefore no difficulty experienced with the admission and emission of transmitted light. In the latter case the transilluminator failed absolutely to reflect the slightest shadow because of the numerous hemorrhages, hence it almost led to a faulty diagnosis. He concludes that no great dependence can be placed on the transilluminator when the vitreous is permeated with blood.

Eye-Strain and Crime.

Case, of Elmira (Ophthalmic Record, November, 1906), has a long artice on this subject. The following paragraphs express some of his views :

"A study of criminology leads us to a study of the individual, especially the early life. He comes into the world with a neurotic, if not an unstable cerebral mechanism; his surroundings, as a rule, only encourage these hereditary tendencies, and it is not unreasonable to assume that even slight stresses or strains of life may switch him off the tracks into lines of inebriety, licentiousness and other habits which are so often the precursors of crime.'

"It is a matter of daily observation that eye-strain will disturb the mental processes, producing mental inaptitude and backwardness in children. Their comprehension seems obtuse and slow, and confusion of thought exists. Irritability, even to the verge of irascibility, may be the result of a constant nagging eye-strain kept up hour after hour, for days and months, producing serious inroads upon the nerve supply. How far this may be carried towards producing mental unbalances, insanities and criminal tendencies, alcoholic and drug habits, remains to be proven. I think, however, there is no room for doubting the fact that truancy in school children, in a large percentage of cases, can be traced to this cause, and which, when frequently repeated, 'precipitate the individual into the life of a

vagabond and criminal.' Instances are common. This picture I do not think is overdrawn. It is of daily occurrence, not only in the classes that go to make up our criminals, but in every grade of society. The number probably never will be known of those who have led lives of miserable existence, if not made physical wrecks, and many times moral wrecks also, from the expenditure or leakage of nerve force, in an attempt to correct a refractive error."

Diaphanoscopy of the Eye. Würdemann, of Milwaukee (Ophthalmic Record, November, 1906), describes his instrument for transilluminating the eyeball, and states the following regarding its possibilities and usefulness:

It must be remembered that the eyeball is so contained in the socket that a beam of light can only be sent through about the axis of one hemisphere at a time, and while we gain a little by rotation of the eye, yet fully a third of the back of the ball, necessarily including the nerve and fovea, remains impermeable to such examination. Therefore, this method only brings into light the anterior two-thirds of the globe; but it is evident that nearly all of the important structures of the eyeball are in the anterior third, upon which the new method throws more light.

The conjunctiva and the cornea are best observed by direct and oblique illumination, for which transillumination cannot be excelled. Foreign bodies are readily brought into view, and when the tip of the instrument is placed on the sclera, minute foreign bodies and stains from iron rust, emery, etc., are sometimes rendered visible when direct and ordinary oblique examination fails. If the cornea be leukomatous or staphylomatous, the structure will be rendered decidedly translucent by this method, and atrophy of its coats, foreign bodies, exudates and tumors of the anterior chamber be readily brought into view.

The iris is rendered quite translucent, its folds and pigmentation are readily observed. The diseased iris in iritis and glaucoma is seen to be thickened and less translucent. In almost all cases where there has been pre-existing iritis, spots of atrophy, through which the light plainly shows, are observed. Synechiæ may be more readily distinguished; even without

dilation of the pupil, the iridic pigment left on the anterior capsule of the lens is plainly seen.

Capsular cataract shows up well, and even where the lens is entirely opaque a reddish glow will be observed through the pupil if there is no obstruction back of the lens in the vitreous. In some cases the nucleus of the cataractous lens is easily seen. This method has been of especial value in determining the condition of the iris and of the lens in several cases of cataracta accreta, in capsular cataract and secondary cataract, in uveal disease, and especially in two cases of sympathetic ophthalmitis. If a foreign body of any size be in the iris, lens, anterior part of the vitreous or ciliary body, it may be directly seen through the pupil or its shadow may be observed.

The ciliary body of the normal eye shows plainly as a dark ring just outside of the limbus; in high myopia this is fainter, in moderate hyperopia darker, i.e., considering the color of the person, blondes, of course, having less pigment in the ciliary region, as well as in the skin, than brunettes or the dark races.

As a large percentage of intraocular tumors occur in or about the ciliary region, the method is here invaluable for differential diagnosis between retinal detachment, glaucoma and intraocular tumors, not only to prove the presence or absence of such growths, but to show the position, size and area of the tumor. The ball remains translucent in glaucoma and retinal detachment; in intraocular growths a shadow will be cast, clearly defining the nature of the disease, its size, site and area. the lens be clear, under diaphanoscopy the tumor may be directly seen as by the ophthalmoscope. Indeed, I have often observed the optic nerve and blood-vessels without the ophthalmoscope, in using this method. If the lens be opaque, of course the ophthalmoscope is of no service. Diaphanoscopy, however, gives an assured diagnosis, and in such cases I have recently secured several victorious diagnoses.

If

My instrument is also perfect for transillumination of the frontal sinus or the mastoid, and by removal of the cone-shaped tip and placing the lamp in the mouth (the handle being protected by a piece of gauze), it is as good as the larger lamp for the detection of pus within the maxillary sinuses.