in man is comparatively a limited one. But they do not explain why single instead of multiple pregnancies are the rule. Why is it not possible for twin pregnancy to be the rule? Why would it not be better for woman to bear twins each time, and thus be required to endure pregnancy only half as often? Such a condition would not conflict with Spencer's deductions. However, he does not discuss this question, nor can I find a discussion of it anywhere. Had he gone into detail sufficiently to embrace this consideration there is little doubt he would have taken the position that twin-pregnancy is not so favorable to race preservation as single pregnancy. Because if it were equally or more favorable, the principle of heredity would soon develop a race in which twin pregnancy would be characteristic. This à priori conclusion is in harmony with facts. Twin pregnancy is fraught with more danger to the mother and carries a lessened expectation of life to the offspring. It is more likely to result in abortion or miscarriage, involving the mother in danger, which may lessen or destroy her fertility, and may even menace her life. The construction of an increased amount of highly organized tissue is an additional burden, and involves greater elimination of waste products. Hence the increased danger of eclampsia, with its high mortality. Organic mischief in heart or lungs is put to a severer test, and she is less likely to endure the burden of pregnancy and the ordeal of labor. The complications of labor are increased and its dangers intensified. The risks attendant upon the postparturient state are greater. If she escape the increased risks of abortion, eclampsia, dystocia and post-partum hemorrhage, she has before her the doubled demands of lactation. These facts indicate clearly that twin pregnancy has an increased mortality-rate for the mother. The inference also seems justified that it would uniformly tend to diminish her fertility, though on this point there is room for doubt, as families in which twins are found are often large. The effects on the offspring are still more unfavorable. In case of abortion it is always, of course, destructive, and the result is the same in a large percentage of the cases of eclampsia. In labor a larger proportion of children are stillborn, while of those surviving there is an unusually high mortality in the first years of life. Nor do the evil effects end here. There is strong testimony to show that twins reaching adult life are likely to show an unduly large percentage of defectives, both physically and mentally. Dr. Arthur Mitchell published an article bearing on this point in the Medical Times and Gazette of November 15, 1862. I have not been able to see the original article, but quote his conclusions from Mathews Duncan's work on Fecundity, Fertility and Sterility." Duncan evidently considers the article an able one. The conclusions are as follows: 66 1. Among imbeciles and idiots, a much larger proportion is actually found to be twin-born than among the general community. 2. Among relatives of imbeciles and idiots twinning is found to be very frequent. 3. In families where twinning is frequent bodily deformities occur with frequency. These considerations show conclusively that twin pregnancy is not so well adapted to race-preservation as single pregnancy, but we have not yet found the reason why this is true. In the study of this problem some suggestions can be found by looking over the entire order of mammals, and noting what families are characterized by multiple and what ones by single births. It is noticeable that multiple pregnancies occur generally in animals living on concentrated food, and since the pregnant uterus makes substantial encroachments within the abdominal cavity, it seems a rational theory that among such animals multiple births would occur. With a very few exceptions, the carnivora have multiple births. Of animals subsisting on vegetable foods only a few have multiple births, and these few live on the most concentrated | dominal palpation teaches that the diagforms of vegetable foods; and, moreover, nosis of twin pregnancy is easy. some of them, as the squirrel and rabbit, gives the history of a case coming to his have remarkably short periods of gesta- clinic in which he made the diagnosis tion, and bear their young in a com- of triple pregnancy in the presence of paratively immature state. his class. The labor verified the diagnosis. The condition would probably be usually recognized if physicians made it a routine practice to make careful abdominal palpation in each case of pregnancy. Such an examination is perhaps rather the exception. According to the best authorities, the diagnosis is usually made by an application of the mathematical principle that one from two leaves one. Reasoning from analogy, we conclude that as the human family subsists on a diet composed largely of vegetable food, single births, therefore, should be the rule. It does not follow that we should find an exception in high latitudes, where the natives subsist on an animal diet exclusively, because those people have to consume such enormous quantities of food that the amount ingested over-balances the ease with which it is digested; and, moreover, the struggle for existence is so fierce as to leave a diminished force to be expended in reproduction. In harmony with this view is the fact that the very few families of carnivora which are characterized by single births are found only in the high latitudes. Spencer, in showing that fertility depends partly on the ease with which food is procured, makes a quotation which also bears on our proposition that concentrated food favors multiple pregnancies. The quotation is from the writings of the traveler Barrows, and concerns the Kaffirs, whom Spencer characterizes as being rich in cattle, leading easy lives, and living almost exclusively on animal food. Barrows speaks of them as follows: "They are said to be exceedingly prolific; that twins are almost as frequent as single births, and that it is no uncommon thing for a woman to have three at a time." From the foregoing, the conclusion is perhaps justified that single pregnancies are the rule in the human family because its food is derived largely from the vegetable kingdom, and, conversely, that were man a strictly carnivorous animal multiple births would probably be common. It is possible also that the upright position may be a factor in the problem. To turn, now, to a few practical considerations, we find ourselves confronted first with the question of diagnosis. Pinard, in his treatise on ab Statistics regarding positions and complications are too extensive to quote, and they are really of little practical value, because any physician is likely to encounter but a very limited number of cases. I have twice encountered a complication which is possibly entitled to a moment's consideration. In each case the breech of the first child presented. Progress was satisfactory until the breech was well engaged, after which there was no advance until assistance was rendered. Examination disclosed the fact that with each pain the breech was driven diagonally against the lateral wall of the pelvis, the head and shoulders lying well to the opposite side of the abdominal cavity. The probable explanation is that up to the time of engagement both children were driven downward as one mass by the force of the contractions. After engagement, however, the further descent of the first child being temporarily arrested, an end of the second child was driven down between the uterine wall and the first child. This would displace the head and shoulders of the first child laterally, causing it to assume a diagonal position. The difficulty was easily remedied by hooking a finger into the groin, and, in conjunction with the pains, making traction downwards and sufficiently towards the opposite side that the resultant of forces corresponded to the axis of the mother's pelvis. Were nature unaided, one of two things would happen: either the head and shoulders of the first child would be displaced so far laterally that it would practically assume the transverse posi- | vagina and cut away. An antiseptic vaginal douche was used and instructions given that notification of the return of labor should be promptly sent. Several visits were made to the woman that evening and the next morning, but it was twenty hours until labor began again, and a robust girl was soon delivered. The contraction which delivered the child also expelled the placenta belonging to this child. The placenta of the child delivered the previous day was still retained, but was readily delivered by Crede's method. tion, causing impaction, or the second child would continue its wedge-like action so far as to finally expend its driving force sufficiently near the pelvis of the first child to effect its dislodgement and subsequently the delivery of this child, the second resting, meanwhile on the flare of the false pelvis. In case the first child presents by the head, this complication is not likely, because, the neck being flexible, the head would readily adjust itself in the direction of least resistance. But the trunk is not sufficiently flexible to make this adjustment in case of a breech pre sentation. In these two cases there was also another coincidence, which is perhaps more than a coincidence. In each case respiration was promptly established in the first child, though it had been a breech presentation, but this did not occur with the second child, though it was a vertex presentation. In the first case the second child was saved by prolonged resort to artificial respiration, and is now a robust boy. In the second case artificial respiration failed to save the second child, though its heart was kept beating for forty minutes. In thinking over these cases the idea is suggested that after the first child and all the amniotic fluid have been expelled, there might be sufficient retraction of the uterus to interfere seriously with the placental circulation, or even to cause a partial separation of the placenta. Two cases are not enough to establish such a theory, and I am unable to find any statistics indicating whether the second child is more likely than the first to be still-born. In this connection it is well to remember that the second child is usually expelled promptly after the first. Parvin estimates that in a majority of cases the interval is less than twenty minutes. I once had a remarkable exception to this rule. The first child was a male, and was still-born. After waiting a reasonable time for uterine contractions I attempted to secure them by friction and massage over the abdomen. Failing in this, the cord was tied high in the As to the proper management of such a case, authorities differ widely, from those who would deliver the second child at once to those who advise unmodified expectancy, some even going so far as to say that since the labor is frequently premature it is possible for the mother to carry the second child to term, if the placenta of the first has been delivered. There is naturally a feeling of impatience in the mind of the physician if there is much delay in the delivery of the second child, and it is usually so easily delivered that the temptation is strong to resort to artificial means if nature is slow. In such a procedure there is unquestionably considerable danger of post-partum hemorrhage. The unusual distension of the uterus during pregnancy and the necessarily thin walls of the organ are not favorable to the thorough contraction and retraction necessary to guard against hemorrhage. This danger is slight if the second child is expelled by uterine contractions, while it increases in a direct ratio to the amount of artificial assistance rendered. The Prophylaxis of Scarlatinal Nephritis. In more than a hundred cases of scarlatina seen in the course of six years, in which the patients were for three weeks kept upon milk diet, Ziegler (La Semaine Méd.) has not once encountered nephritis as a complication.-Indian Lancet. SALICYLIC acid in large doses may give the urine a greenish tinge. Society Reports. ACADEMY OF MEDICINE OF CINCINNATI. OFFICIAL REPORT. Meeting of April 26, 1897. The President, W. E. KIELY, M.D., in the Chair. W. EDWARDS SCHENCK, M.D., Secretary. [The attention of members is called to the Nurses' Central Directory, Telephone 2121, No. 210 W. Twelfth St., which is under the supervision of the Academy of Medicine, and is deserving of the members' patronage.] DR. W. H. DEWITT read a paper entitled Tuberculosis_Verrucosa, with Report of a Case (see p. 575). DISCUSSION. DR. J. L. CLEVELAND: In listening to Dr. DeWitt's interesting report, the question occurred to me, might not the extensive skin tuberculosis, that is said to have existed in this case, produced an immunization by which the pulmonary infection was relieved, which, I understand, happened in this case? Might not nature furnish on this extensive skin surface a tuberculin which is absorbable and curative under certain conditions? We know that certain cases of tuberculosis get well, and who is prepared to say that it is not by a process of immunization? DR. A. RAVOGLI: I feel greatly indebted to Dr. DeWitt for the opportunity given me to see this case, which was without doubt of great interest. We have many varieties of tuberculosis of the skin, some which are the result of toxines produced by the tubercle bacilli concealed in the general system, and some which are caused by the tubercle bacillus in the tissues of the derma, as in lupus vulgaris. There are, however, many forms of cutaneous tuberculosis of ulcerative or vegetating character the result of inoculation by the tubercle bacillus in the skin, either from the outside or from the same indi vidual suffering with tuberculosis. To this last belongs the tuberculosis verrucosa cutis, described at first by Rhiel and Paltauf, to which we refer the case in question. I have no doubt that the lady infected herself with the sputa in cleaning the same from her lips, and in the same way inoculated her face. The skin in this case was not deeply affected. I think that only the papillary layer was involved, or the most superficial layer of the derma, and I believe that this was the reason why the affection so easily disappeared. When the tubercular infection has invaded the derma and its lymphatic system deeply, we have a great deal of difficulty in bringing about a recovery. I remember a case of tuberculosis verrucosa cutis which lasted for years, in vegetating tissues. spite of curetting and cauterizing the The tubercle bacillus does not find very propitious ground in the human body, as it does in the inferior animals, but remains latent and dormant in the tissues where it has found its abode, without infectious results. It remains as an infectious potentiality, and we often see from the scars of a lupus vulgaris healed several years before new tubercles developed, reproducing the disease. Tuberculosis of the skin manifests itself in different forms on account of the anatomical conditions of the different organs affected. When the sebaceous glands are involved we see it in the form of a folliculitis, or in the form of lichen scrofulosorum; when the lymphatics or the subcutaneous tissue is the seat of the affection we see it in the form of erythema induratum, of tubercular gumma, and in rare cases we see the tubercular eczema. The bacillary infection sometimes comes from without. In the British Medical Journal Moynihan referred to a case of a girl who was affected with a patch of tuberculosis verrucosa on the back of one hand by washing handkerchiefs belonging to her brother-in-law, who was affected with pulmonary tuberculosis, and through a scratch in her hand she was inoculated. In regard to the treatment, Dr. De- | and intelligent and physically well deWitt is to be congratulated upon the veloped. The cornea were very small, splendid result. However, we must but the globes seemed to be of normal remember that some tubercular ulcera- size. She had good perception of light, tions, when superficial, heal up very and could see dimly large objects easily. In my hospital service I had around her. The lenses presented a several tubercular ulcerations of the peculiar appearance. The central porskin of lupoid nature, which healed up tion of each lens was chalky and white, easily, simply by using vaseline dress- and the periphery was semi-transparent. ings associated with injections of tuberculin of from one to two milligrammes. The action of tuberculin in these forms is very remarkable, and any antiseptic dressing is enough to facilitate the healing of the ulcer. In these cases we have always a mixed infection; the tubercle bacillus is the cause, but the pus cocci are the factors of the inflammatory symptoms and the breaking down of the tubercular tissues. From these considerations I would not give absolute credit to the remedy and proclaim it as an anti-tubercular agent. As I said, although the result is so gratifying, the assertion of a perfect recovery from tuberculosis must be accepted cum grano salis, when we know the biological nature of the tubercle bacillus. DR. DEWITT: In her right lung there was a cavity the size of a walnut, which has since healed. The diagnosis was confirmed by microscopic examination of sputa and the secretion from the ulcerations upon the face. You can observe from the photographs that considerable tissue of the face was destroyed-in fact, so much that she cannot get her teeth into her mouth from the contraction of cicatricial tissue around that organ. Dr. Ravogli spoke of the superficial character of the disease. I want to call attention to the fact that the tubercular ulcer on the wrist was of considerable depth, involving the structures beneath the skin, and requiring a large amount of granulation tissue to compensate for the loss sustained. Congenital Cataract. DR. S. C. AYRES: I recently saw two cases of congenital cataract in a family of three children, where all were similarly affected. They were aged respectively two, five and seven years. The eldest was a girl, who was bright In the boy the eyes were somewhat different. The cornea were abnormally small, as in his sister's case. In the right eye the lens was entirely opaque. The upper half of the lens was milky, as is usually seen in children, while the lower half was chalky. It looked as if the chalk had been precipitated to the bottom of the lens capsule. His left eye was very similar to his sister's. In the girl I made an iridectomy and then discised the capsule. The chalky lens broke into pieces, but I was able to remove most of them; one small fragment could not be removed. In the boy's case I made an incision through the cornea with a lance-shaped knife and then discised the capsule. The fluid portion of the lens ran out, and with a spoon I removed the chalky portion. The operation on the girl's eye was followed by some slight irritation, but the boy's eye soon cleared up, leaving a black pupil. |