Researches into the causes of the latent form of gonorrhea in man have disclosed that in cases apparently cured vital gonococci still reside within the seminal vesicles, epididymis and other deeper structures. This may be at the time unattended by urethral discharge. The seminal fluids of such individuals either contain no spermatozoids, or they are impaired vitally and may even be defunct. Thus man is frequently the cause of sterility. Graefe, of Halle, a. s. (1895), accepts that in 50 per cent. of cases of matrimonial sterility is owing to azoospermia. L. Seeligmann (Muenchen, 1893,) computes that the barren marriages under his observation are owing to the male in 75 per cent. of the cases. B. Vedeler (Christiana, 1895,) reports the results of his study of 310 women married one year or longer without conceiving: The husband was examined in fifty cases. He concludes that in 70 per cent. of the cases the husband is the cause of the sterility, owing directly.to azoospermia, impotence, etc., or indirectly to his infection of the wife with gonorrhea. In woman per se, sterility is present in 30 per cent. of the cases, mainly owing to neoplasms or atrophy of the uterus. In determining the capability of the male it is no longer sufficient to be assured of his conjugal potency. It becomes necessary to examine his discharges for living spermatozoa. The destructiveness and the tendency of gonorrheal inflammation to extend urge that the treatment of gonorrhea, in its early stages, be vigorously undertaken. In very recent times a few European states, in true recognition of the importance of the matter, provided for the public treatment gratis of all individuals afflicted with gonorrhea. This, I believe, is certain to become a fixed policy with all nations and communities in the future. Though treatment is not specially within the scope of this paper, two remedies deserve brief mentioning here. The one remedy is Fuller's method of stripping the seminal vesiculæ by massage movement through the rectum. The seminal vesicules have been shown to be the permanent seat of the gonococci in the cases that presented the heretofore incurable type of this disease. From here the urethra is repeatedly invaded; here the spermatozoa are devitalized; and from this region the infectious material is transported to the sexual mate. The second remedy deserving special mention is ichthyol. It is as much a specific as nitrate of silver, and while the latter remedy is applicable only to surface lesions, the ichthyol by virtue of its penetrating effect applies also to the more deep-seated and chronic forms of the disease. It is the remedy par excellence in chronic pelvic inflammations of this kind. Applied in vaginal tampon and by inunction over the inguinal region, its anodyne, antiseptic, astringent and absorbefacient effects, and withal its penetrating property, make it a most desirable remedy. Of all remedies known to the author it is the most potent and frequently successful. In the hands of the author this remedy used in conjunction with other conservative means has saved many a woman a mutilating operation, which viewed by our former resources, seemed futile to even hope for. 194 East Michigan Street. THROMBUS OF THE LABIA. BY DR. S. A. GOODWIN, MONTPELIER, IND. On the 8th of November last was called at 6 A. M. to wait on Mrs. H. in her first labor. She was delivered in about two hours of a healthy female child; her labor was natural and easy. I remained about an hour after the child was born, and during that time she felt well and drank some tea and ate a light breakfast. About two hours after arriving at home was sent for in great haste to return. When within two squares of the residence could hear her screaming. On entering the room found her suffering intense pain. Upon examination I soon found that the pain was occasioned by a large and very painful swelling of the right labium. It was necessary to give her a couple of hypodermic injections of morphia to temporarily relieve the pain. The mass increased until it had acquired the size of a new-born child's head, exceedingly painful, and extending to the perineum. The labium was everted so that it appeared to be covered externally by the mucous membrane. We applied cloths wrung out of hot water and solution of acetate of lead, and succeeded in keeping it from rupturing. The tumor became dark in color-almost black-and very hard. In three days the tumor was ruptured and contents removed, which was a dark coagulation of blood. The wound healed rapidly, and in five weeks all that remained to indicate any abnormality was the cicatrix. What surprised me in the case was the easy labor, and feeling so well for a time after labor. She had some fever and headache and retention of urine: was necessary to use catheter until tumor was ruptured. This is the first and only case I have ever seen of the kind in nineteen years of quite an extended obstetrical practice. [In the Transactions of the Indiana State Medical Society for 1892, pages 244 to 249, Dr. Goodwin may find, reported by Dr. G. W. H. Kemper, of Muncie, a case of vaginal thrombus, under the title, "A Case of Labor with Unusual Multiple Complications." These complications were eclampsia, placental adhesin and inversion of the uterus, as well as the thrombus. In Dr. Kemper's case the thrombus was the size of a goose egg. It was in the posterior wall of the vagina, and was opened and emptied under chloroform, preceding successful delivery by forceps of a living child, followed by after-pains, with ever sion of the uterus. The adherent placenta was removed and restoration of the uterus effected and the mother's life saved. It is doubtful if a more serious series of complications may be found recorded in the annals of obstetrics. vaginal thrombus, developing within a half The present writer also reported a case of hour following labor, with laceration of the perineum. It was at the labio-vaginal junetion, and was the size of the double fist. It broke through the mucous membrane, and upon evacuating the clot left a large and ragged walled cavity. Quite a large cicatrix was left, but there was no deformation. The writer has delivered the same woman twice since the accident without inconvenience. Dr. T. Parvin (Science and Art of Obstetrics, Lea Bros. & Co., first edition, pages 500 to 502,) says hematoma of the vulva or of the vagina is infrequent. Dubois gave but three cases in 14,400 labors. Winckel gives one to 1,600. In thirty-five out of forty-three cases collected by Perrot, the thrombus occurred after labor. Winckel found six fatal cases in fifty. As to treatment Barker says if the tumor form during labor and is an obstacle to delivery we must at once remove clots, deliver by the forceps and then apply cotton compresses saturated with a solution of persulphate of iron. In cases like that of Dr. Goodwin's, coming on after labor, it is better to delay the incision three or four days unless gangrene is threatened, as there is less danger of consecutive hemorrhage (Schraeder). Lusk covers the subject of thrombus of the vaginal walls thoroughly in his "Science and Art of Midwifery," Appleton & Co. second edition pp. 578-581. Lusk also gives the anatomy of the bulbs of the vaginal vestibule (page 4), from which the hemorrhage usually occurs. They are situated between the vestibulum and pubic arch of each side and are two curved leech shaped masses of reticulated veins. They correspond (Kohelt) to the two separated halves of the male bulbous urethræ; they are of erectile tissue and when distended with blood are over an inch in length. When these masses of veins are pressed upon in labor between the head and pubic arch rupture and thrombus of the labia majora occur. Most of the vulvar cases originate in the labia majora; next in frequency from the minora, and occasionally between the outer and inner fascia of the perinæum. The most frequent point of rupture is at the junc. tion of the larger and smaller labia. In any case of vaginal or vulvular thrombus the indications are to arrest the hemor rhage and to avoid infection. Thorough asepsis and antisepsis, and in cases which have opened spontaneously, packing with gauze and the use of a compress will meet the indications. A. W. B.] ACQUIRED GENERAL CAPILLARY TELEANGIECTASIS IN ADVANCED LIFE. BY W. H. TERRELL, M. D., FILLMORE, IND. I desire to report an interesting case, one which is, according to the authorities that I have consulted, a rare affection of the skin. The patient is a married lady, forty-seven years old, and has always had fairly good health. She is the mother of two children, the youngest of whom is nineteen years old. The menopause has been established about two years. Some three years ago she called my attention to a bright red discoloration of the skin on the back of her wrist. On examination I found the color to be due to a dilation of the capillaries of the skin. The skin was perfectly smooth and slightly elevated. The back of both wrists and both forearms, almost to the elbows, were involved. The top and outer side of the feet and the outer aspect of the legs, to about half way to the knees, were also affected. She said it first began about fifteen. years ago. It first appeared in small patches on the outer edge of the feet, next on the wrists, and gradually extended to the extent given above. She had shown the affection to several doctors, none of whom could tell exactly what it was, but all advised her to have nothing done for it so long as it gave rise to no trouble. I had never seen anything exactly like it, and also advised non-interference. I heard no more of the trouble until the past winter, when she again called my attention to the skin affection. She said that it had spread very rapidly in the last year. I found upon examination that it had very much. extended since last examination. It had involved the upper extremities almost to the shoulders and the lower limbs to the hips. Her general health had run down, and she was not feeling stout. She had been told by some of the laity, who very often advise freely, that the skin trouble was due to heart disease, and that she was going to have dropsy. This, with the rapid extension of the skin affection, had considerably alarmed her. Under a course of tonics her general health was rapidly restored, and I advised her to consult Dr. Brayton, of Indianapolis, in regard to the condition of the skin. Dr. Brayton saw her the first of last April. He said the affection is an acquired capillary teleangiectasis of the arterial system. This is the same condition as pertains in capillary nevus or strawberry mark. The congenital form is not uncommon and occurs more frequently on the head, face, neck and shoulders than elsewhere. The acquired form is extremely rare except on the nose of drunkards or on parts that have been frostbitten. Both of these conditions are excluded in this case. At present the affection is limited to the parts named above. The skin over the affected area is a bright red color, showing that it is due to arterial blood. Some places, however, are brighter red than others, which gives the area a spotted appearance. By firm pressure and stroking, the skin can be made to resume its natural color. The skin is slightly elevated but smooth and elastic. There is no oedema or dropsy anywhere. There is no varicosity or enlargement of any of the veins. The heart is normal in sounds and action. In the brightest patches the separate capillaries can hardly be seen, but in most places they are plainly seen. They pursue a wavy course and in places make a beautiful appearance. The largest vessels are about one-half millimeter in diameter. The hairs, hair follicles and glands of the skin are healthy and the skin performs its functions well. In the midst of the brightest patches there are white spots from one-half to one centimeter in diameter. These either have been involved and spontaneously cured or have never been involved. I shall mark some of them with India ink to see if they become involved or grow in extent. As to treatment, where so much surface is involved, there can be nothing done other than keep the general health in good condition and let the local condition alone, so long as the skin shows no tendency to break down. The interesting features of the case are, the rarity of this form of the affection, absence of any apparent cause, absence of the affection upon the face and body, rapid extension within the last year, and involvement, principally, of the extensor surface of the extremities. PRIMARY SYNCHRONOUS AMPUTATION OF THE LOWER LIMBS.* JOHN E. HARRIS, M. D., BLOOMINGTON, IND. Dr. Harris reviewed the literature of the subject and then reported the following interesting case from his practice: The following case is presented for your consideration. (The patient was before the society for examination.) William Staggs, age eighteen years, while working in a stone quarry on July 27, 1895, had both legs crushed by being caught under a stone weighing over five tons. The bones of the left foot, and distal ends of the tibia and fibula, were comminuted, and the skin stripped off from above the ankle to the toes. The right leg incurred a compound comminuted fracture of both bones, midway the ankle and knee, a fracture extending several inches upward through the tibia. The loss of blood had been great, and seeing him half an hour after the accident found that he had rallied from the shock, with a pulse of 78, but weak. As Read before the Mitchell District Medical Society at Bloomington, Ind., December 26, 1895. he was suffering much pain and appealing for relief hypodermic injections of morphia were given him, and at 10 A. M. he was placed on the table, and ether administered. Evident indications of heart failure being observed, hypodermics of digitalis and strychnia were given. In a short time the pulse improved, and the parts made ready, antiseptically for the operations. Assisted by Dr. Jos. M. Rogers, I amputated the left leg five inches above the ankle, the arteries were ligated, and the wound sponged with hot sublimated water, and left open. At this point the amputation of the right leg was delayed, as his condition was becoming more serious, the pulse being faintly perceptible and rapid. Hypodermics of digitalis, strychnia and whisky were followed by a return force in the heart's action, when I amputated the right leg five inches below the knee-joint, the arteries ligated and the wound sponged with hot sublimated solution. The flaps of both legs, which were autero-posterior, were closed by silk sutures, a drainage-tube having been introduced in the right stump. The wounds were cleansed, dusted with iodoform; with iodoform gauze and cotton dressings and bandaged. At 11 A. M. the patient was placed in bed, with a pulse of 120, irregular and weak; hot water bottles were applied about thighs and body, and the stumps somewhat elevated on pillows. The next morning the patient had rallied and was in a more favorable condition. The stumps were dressed daily, with camphophenique mixed with simple cerate, after cleansing with warm sublimated water. The sutures and drainage tube were removed on the seventh day, the ligatures coming away on the 12th and 14th days. An uneventful recovery followed. AN UNUSUAL OBSTETRIC CASE. BY HOMER J. HALL, M. D., FRANKLIN, IND. Attended on Mrs. S. in confinement April 1, 1896. Primipara, aged 22. Primipara, aged 22. German parentage, healthy. When the child's head was pressing well on the perineum, suddenly its hand appeared through the rectum. The strong pains that followed forced the arm through the rectum to the elbow. As the pain subsided, I forced the arm and hand gently, well up into the rectum, and held it there, supporting the perineum. In two or three more pains a child of average size was born, with the perineum intact. While the nurse was dressing the child I delivered the placenta, and examined carefully for the recto-vaginal wall, which seemed to be entirely absent. Up to this time, nothing had been said to the parents of the accident; but when the infant was dressed and as the mother assured us how well she felt, I said, "Yes, my good woman, you have a nice healthy babe and you feel all right, but you lack considerable of being all right." Then I explained to her and husband her condition as much as necessary, and told them I would need assistance to restore the parts. Dr. Whitesides of our city assisted me in the operation. We first washed out the rectum and vagina with a 1-2000 bichloride solution. A more extended examination revealed a laceration of the rectovaginal wall, extending across the septum and up three inches on either side, making a U-shaped laceration, with the closed part of the U immediately behind the perineum. By taking hold of the flap that was torn loose, and drawing it down to the perineum, I found it filled the rectovaginal opening completely. Then with a medium sized catgut ligature I closed the opening with nine stitches; and washed out the rectum and vagina with the bichloride solution. No anesthetic was used, and she complained of scarcely any pain during the operaThe vagina was washed out tion. twice a day for a week with the same antiseptic solution, then once a day for another week. She had one to two degrees of fever for the first three days; pulse 76 to 88. Diet mostly cream for the first week; bowels moved on the fifth day, by a small injection, and every two days thereafter. One interesting point in this case is, that the laceration healed by first intention, and in twenty days the woman was up attending to her domestic duties. Chloroform to Preserve Urine. The writer has for ten years used and taught a simple method for preserving urines for examination, which will keep them indefinitely. This is simply the addition of three to six drops of chloroform to the ounce of urine, which is shaken with the specimen. Attention is called to this method of preservation by Dr. H. Leffman, of Philadelphia, upon the 1126th page of Saunders' American Year Book of Medicine and Surgery, in the article upon tests for sugar. He states samples thus prepared will keep for months in the hottest weather. Chloroform simulates the sugar reaction with copper sulphate, but not with bismuth subnitrate (Boettger's test), nor with phenylhydrazin. Leffman says the latter much vaunted test is not more delicate or more positive than the bismuth test. A. W. B. DISCRIMINATING AGANIST MEDICAL COLLEGES. The last Iowa Assembly provides that no one of the seven members of the State Board of Medical Examiners shall be an officer or member of the faculty of any medical college in the State. This is an unjust piece of class legislation against an honorable, competent and intelligent class of citizens and taxpayers. No other State has such a law, and it is scarcely likely the Supreme Court will uphold it. |