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one-half inch above the junction of the hepatic and cystic ducts. It was found impossible to remove it by the milking process, so the duct was incised and a nonfaceted stone, which was one and three-fourths inches long and weighed two hundred fifty grains, was delivered. The wound in the duct was closed and the patient made a good recovery.

In pursuing his anatomic work where hundreds of cadavers were examined only one case of stone in the hepatic duct was found. This was a female subject forty years of age who died of pulmonary tuberculosis. Though there were no signs of inflammatory changes in the liver, gall-bladder or ducts, a single stone was found in the hepatic duct. Some biliary sand was found in the liver substance. The prominent cause is probably an obstructed common duct. They may also stand as a proof that gall-stones may form in the bile passages. While such stones are rare, their possible presence should be remembered and a careful inspection of the parts be made before the gall-bladder is surtured to the abdominal wall. When a stone is found in the hepatic duct, an attempt should be made to force it into the gall-bladder or to crush it. When these measures fail, the common or hepatic duct may be incised and the stone delivered.

C. G. D.

GYNECOLOGY.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

DYSMENORRHEA.

HERMAN and Andrews (Journal of Obstetrics and Gynecology of the British Empire, January, 1903) have taken up the natural history of dysmenorrhea in so far as such pain is amenable to cure through dilatation of the cervix. The paper is based upon cases taken from the records of the London Hospital and from the private practice of one of the authors. Only those cases were selected whose after histories were known. In a large majority of the cases, if not in all, medicinal treatment had been tried and had proved unsuccessful.

The writers have been able to find no author who has analyzed his cases of dysmenorrhea to ascertain its frequency, the duration of the cure, or in what respects such cases differ from those wherein the monthly pain is not curable by dilatation. In 1881 one of the writers published a paper in the "Transactions of the Obstetrical Society of London," showing that in women with anteflexion no greater proportion menstruate with pain than among those whose uteri are straight.

Sir J. Williams, in eight hundred seventy-three cases, found only eleven of acquired menstrual pain. The experience of the writers is different. Of sixty-seven cases cured by dilatation, in about one-third the pain came on after the onset of the menstruation. It was also found that dysmenorrhea may be acquired at almost any time during the first half of intermenstrual life and that the result of treatment is not mate

rially affected by the length of time the dysmenorrhea has lasted, the age of the patient when treated, or the duration of the married life.

The pain felt with menstruation may be of two kinds-one a general aching due to the congestion of the pelvic organs. This kind of pain precedes menstruation and is relieved by bleeding from the uterus. Sharp spasms of uterine colic characterize the second variety of menstrual pain. It is of importance to remember that the first variety is not affected by dilatation of the cervix, while this operation often affects a cure in the second variety. Clinically the two forms of dysmenorrhea can be distinguished by the fact that the pain due to congestion precedes menstruation, often by several days, while the spasmodic variety begins with the flow or a short time after its appearance.

The authors show that in their cases cured by dilatation, the pain was of the paroxysmal kind in four-fifths while amongst those not cured by dilatation it was constant in three-fourths. It was observed also that patients, the subjects of spasmodic dysmenorrhea, roll around in their pain, while the pain of pelvic congestion is relieved by quiet recumbency.

In most cases of dysmenorrhea there is no sign of organic disease of the uterus. The cervical canal of a young multiparous woman has never been seen narrow enough to hinder mechanically the passage of the few ounces of blood that are lost at each menstrual period. But the cervix, if not narrow enough to hinder the outflow of blood, may yet be small and rigid and not dilate as it should during pregnancy and may thus produce painful spasms.

OBSTETRICS.

BY THOMAS STONE BURR, A. B., M. D., ANN ARBOR, MICHIGAN.

DEMONSTRATOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN,

PUERPERAL ECLAMPSIA.

PARTRIDGE (American Journal of Obstetrics, Volume XLVII, Number III), after discussing various theories as to the cause of eclampsia, concludes that the condition is due to an accumulation of bye-products of metabolism, the result of failure of the liver, spleen and emunctories to do their work properly. Toxins elaborated in greater amount than normal, by irritation cause inefficiency of the liver and spleen, and throw upon the skin, kidneys, et cetera, more work than they can perform. The toxins comprise carbonic acid, ammonia, urea and acetone.

In discussing treatment, the essayist speaks of the use of chloroform and other sedatives, notably opium, chloral, and bromid of sodium to control the symptoms. Rational treatment must aim at the cause. Pilocarpin is dangerous and may cause edema of the lungs. Active catharsis and diuresis are to be attained. The salines, or croton oil (one or two drops) and digitalis are recommended to this end. Sweating may be induced by hot packs, or the hot-air baths. Great stress is rightly laid upon the use of a hot normal salt solution (one drachm of common

salt to a quart of water). This may be given by a high enema, to be retained, or better by injection into the cellular tissue or into a vein. The writer states that the solution should be heated to 100°. (I have had better success with a solution registering 115° or 120°). The salt should be given as long as it is absorbed. As high as sixty ounces can be injected into the cellular tissue. Active diuresis and sweating follow, and the tissues are thoroughly cleansed. Such transfusion can be given as often as every three hours. Any region of the body which contains a fair amount of cellular tissue may be utilized as the site of injection. Partridge considers the prompt emptying of the uterus the best treatment, and describes at length his method of inducing labor. This procedure should certainly be followed when eclampsia manifests itself, as it usually does, during the last month of gestation.

Partridge reports nineteen cases out of six hundred ninety-four pregnancies. Of these, nine were primiparæ and ten multiparæ. Of the nineteen mothers, five or 26.3 per cent died. Of seventeen living children, two or 11.7 per cent died.

As to the time of onset of the convulsions, thirteen or 68.4 per cent were antepartum, four or 21 per cent were interpartum, and two or 10.5 per cent were postpartum. The mortality was as follows: Antepartum, four deaths or 80 per cent; postpartum, one death or 20 per cent. In eleven cases or 57.8 per cent, convulsions ceased with delivery. In three cases they increased after delivery. In five fatal cases the number of convulsions averaged 9.4; in fourteen patients who recovered, the average number was 7.9. In every case albumin was present in the urine, and every patient also showed edema. The urea was not estimated.

PEDIATRICS.

BY ARTHUR DAVID HOLMES, M. D., C. M., DETROIT, MICHIGAN,

Professor of pediaTRICS IN THE MICHIGAN COLLEGE OF MEDICINE AND SURGERY.

CROUPOUS PNEUMONIA IN INFANTS.

COUTTS (Edinburgh Medical Journal, September, 1902) says that the symptoms and pathology of croupous pneumonia in infants are mainly the same as those in adults, any modifications being those due to the younger age of patients, but it will be noticed that the apices of the lungs are more often attacked in children, and if the physical signs are ill-developed this predilection of croupous pneumonia in infants to attack the apices may afford valuable diagnostic aid in discriminating between the two forms of the disease, as it is rare for the signs of bronchopneumonia to be limited to or even predominate at one apex. There is nothing in the nature of a specific for croupous pneumonia either in shortening or modifying its course. All that is required is rest in bed in a well-ventilated room, along with careful nursing and diet. Great care should be given the latter, and the author says alcoholic

stimulation is seldom required in lobar pneumonia, and if so, it is more frequently after the crisis. The author says the principal points in the active treatment of croupous pneumonia in children are comprised in the efforts to control the temperature, when excessive, to alleviate the pain and procure sleep, and to relieve the strain upon the right heart, and adds that the temperature should be controlled by hydrotherapy properly applied. For the pain a single dose of opium may be considered, but hot fomentations or mustard and linseed poultices may do all that is necessary. Cardiac failure, which is most to be dreaded, must be combated, and strychnin and alcohol are the only drugs upon which firm reliance can be placed.

THE TREATMENT OF MUGUET IN THE NEWLY-BORN. MAYOUD (Revue Medicale, May 14, 1902). During an epidemic of muguet which occurred among the newly-born in the Creche of la Charitie during the month of February, 1902, the mouth was swabbed with nitrate of silver. In twenty or more cases of muguet treated by this method we obtained satisfactory results, and it appears to us that silver nitrate acts more surely and more rapidly than the borates. A solution of one to one hundred was first tried and then three to one hundred, the latter proving more effectual. A cotton swab is improvised, and after dipping this into the solution the child is permitted to suck it, this method sufficing in mild cases. In cases of thick plagues direct application is made with the swab. Neutralization of the silver nitrate with salt solution is not necessary. In order to avoid vomiting as a result of the application, it should be made in the interval of feeding. The application may be repeated every twenty-four hours if necessary, but very often once suffices. The treatment was used in twenty-three cases of muguet in breast-fed infants. In sixteen cases a single application effected a cure; in six cases two cauterizations were required, and in three cases a third application was necessary. The writer thinks that the use of solution of nitrate of silver, one to thirty, is destined to replace the borates which are so frequently without effect.

TUBERCULOUS CERVICAL ADENITIS.

MITCHELL (Johns Hopkins Hospital Bulletin, July, 1902), in a comprehensive paper upon "Tubercular Cervical Adenitis," its etiology, pathology, symptoms, treatment, et cetera, draws the following conclusions:

(1) Tuberculous cervical adenitis is primarily a local disease of very frequent occurrence, more often in young persons; in itself not extremely serious, and rarely, if ever, proving fatal.

(2) It bears a certain definite relation to tuberculosis of the lungs, and serves as a starting point from which tuberculosis may spread. (3) The tuberculin test as an aid to diagnosis is positive and harm

less.

(4) While recovery may often take place under good hygienic conditions, surgical interference is clearly demanded in most cases.

(5) When surgical treatment is resorted to, the operation should be radical in all cases.

(6) Recovery may be predicted in seventy to eighty per cent of cases so treated. Tuberculosis of the lungs after complete removal of the glands is comparatively rare.

(7) Tuberculosis of the lungs, unless far advanced, is not a contraindication to operation, the removal of the glands apparently exerting a beneficial influence on the condition of the lungs.

INFANT MORTALITY.

THE statistics compiled by the Registrar General of Great Britain for 1900, gives 927,062 children born during the year, of which 142,912, or about fifteen per cent, died before reaching one year of age. The three most frequent causes of death were diarrhea, bronchitis and pneumonia. Rhodes, in revising the statistics (British Medical Journal, August 16, 1902), calls attention to the fact that although improved methods of sanitation have reduced the general mortality from twentytwo to eighteen per cent, the mortality of infants is as high today as it was fifty years ago.

OPHTHALMOLOGY.

BY WALTER ROBERT PARKER, B. S., M. D., Detroit, MICHIGAN.

CLINICAL ASSISTANT IN OPHTHALMOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

CONTRIBUTION TO THE STUDY OF THE DIFFERENTIAL DIAGNOSIS BETWEEN GLIOMA AND PSEUDO

GLIOMA RETINÆ.

JULIUS FEJER (Archiv. f. Augenheilk, November, 1902) reports an important case illustrating the difficulty in certain cases in making the diagnosis between glioma and pseudoglioma. In a backward, rhachitic child of four years, examination of the apparently blind left eye showed a yellowish reflex through the pupil, detachment of the retina, with atrophic patches in places surrounded with pigment scattered over its surface. The eye was free from inflammation, and the tension normal. In the right eye the entire fundus was covered with various-sized atrophic areas, involving the choroid and retina. The media on both sides were clear. Three weeks later photophobia and lacrimation began, the pupil was dilated and the tension was found to be increased to 1. Enucleation was advised, as an intraocular growth was suspected. This was refused and the patient taken to Fuchs, in Vienna, who considered "the yellowish white spots in both eyes to be the beginning of a glioma, especially as increased tension has appeared on the left side." The diagnostician not being absolutely sure, he advised waiting, and

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