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REUBEN PETERSON, A. B., M. D.
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN The University OF MICHIGAN.
CHRISTOPHER GREGG PARNALL, A. B., M. D.
FORMERLY FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.
THE CAUSES OF STERILITY.
WARD (American Journal of Obstetrics, Volume LIV, Number II) comments on the low birth rate of the American born population, and in explanation of the apparently increasing sterility of American women considers a number of factors.
First of all the husband may be impotent, and in a large percentage of cases he is the cause of the condition. This percentage has been estimated at from sixteen to seventy.
Sterility due to functional or organic defects in the woman may be absolute or relative according as to whether conception is impossible or not. Sterility is more common as the social requirements of women are increased. Women are much more apt to become pregnant during the middle period of sexual activity, that is from twenty-five to thirty-seven years of age. Sexual incompatibility is shown to be an occasional course of sterility, as after a sterile marriage divorced couples may reproduce with new partners.
In a study of sterility the essential factors necessary to a conception must be considered: They are: (1) the production of healthy spermatozoa; (2) the production of a healthy ovum; (3) union of the spermatozoon with the ovum; (4) implantation of the fertilized ovum in the uterine mucosa.
With regard to the first factor, except under rare conditions, gonorrhea is the cause of unhealthy spermatozoa in almost every case where the male is at fault.
Sterility, resulting from absence of healthy ova, is met with in cases of nondevelopment of the ovaries, acute and chronic inflammation, long continued congestion, fibrosis, neoplastic formations, constitutional disorders, and other diseases affecting remote organs.
The union of the male and female elements may be prevented through various causes. Malformations, obstructions resulting from stricture, and new growths, displacements, leucorrhea, operative failures, et cetera, would all tend to make it difficult for the spermatozoon to meet and unite with the ovum.
Concerning the fourth factor, the implantation of the ovum, a large number of cases of sterility are probably due to a failure of this process. Endometritis whether due to infection or passive congestion
prevents the proper lodgement and nutrition of the fertilized ovum. Sterility accompanying fibroid tumors is probably due to the associated change in the endometrium.
The writer believes that the majority of cases of sterility are due to mechanical obstruction resulting from adnexal inflammation, and a large proportion of the remaining cases he attributes to disease of the endometrium. Gonorrhea, being the most common cause of tubal, ovarian, and endometrial inflammation, is consequently the most important factor in the causation of sterility.
C. G. P.
ARTHUR DAVID HOLMES, C. M., M. D.
ACUTE ENCEPHALITIS AND POLIOMYELITIS IN CHILDREN AND CEREBRAL AND SPINAL INFANTILE
LEONARD GUTHRIE says (Clinical Journal, July 5, 1905) it is now recognized that acute encephalitis and anterior poliomyelitis are one and the same disease. In the former the affection is of the brain; in the latter it is of the spinal cord. So we may speak of cerebral and spinal infantile paralyses. Sufficient postmortem evidence has been obtained to establish the pathologic identity of the two affections.
In infantile spinal paralysis the morbid anatomy shows acute congestion, thrombosis of the small vessels, cell exudation, and small hemorrhages into the gray matter of the anterior horns supplied by the anterior spinal arteries. This leads to softening and necrosis of the areas involved, owing to the cutting off of the blood supply. In time the necrotic products become absorbed, contraction and cicatrization occur, with atrophy or destruction of the ganglionic cells. Doctor F. E. Batten has discovered precisely similar initial changes in the subcortical area of the brain in one case of fatal and acute hemiplegia in a child; and in another, in which paralysis of the seventh nerve with death from respiratory failure occurred, he found in the medulla congestion, and perivascular exudation, with destruction of the facial nucleus.
Thus we may consider that cerebral and spinal infantile paralysis are pathologically identical. There seems little doubt that, as Doctor Batten contends, the primary condition is one of thrombosis of small blood-vessels, but as yet it is undecided whether such changes are due to specific infection producing acute inflammation, or whether the thrombosis is dependent upon altered blood conditions arising from different causes. In favor of an acute specific infection may be urged the existence in epidemics of both forms and their prevalence in certain months, notably in late summer and in early autumn.
This suggests bacterial invasion, but at present no specific bacteria
have been identified. On the other hand, the cerebral form, at all events, of infantile paralysis has so frequently occurred in the course of, or in the wake of, acute specific diseases, such as morbilli, pertussis, diphtheria, scarlatina, and influenza, that it is difficult to regard the fact as a mere coincidence. And yet it is certain that both forms may occur independently of any coincident or preceding illness. On the whole, it seems most probable that some specific organism is present, and that its action is favored by the existence or by the lowering effects of one or other of the specific fevers.
The onset of both forms is usually marked by grave constitutional disturbance. In poliomyelitis, except in very mild cases, there is, usually, a sudden invasion, with headache, pains in the back or limbs, vomiting, pyrexia, and sometimes convulsions. In a few hours or days one or more limbs are found flaccid and motionless. The limbs are often exquisitely tender on handling. In time pain, tenderness, and fever subside, and entire limbs or certain groups of muscles in them are found to be paralyzed and flaccid. The muscles waste, the tendon reflexes disappear, and the electrical responses show the reactions of degeneration, whilst the temperature and circulation of the affected limbs are lowered. The paralysis is always at first more extensive than can be accounted for by the actual extent of the destructive lesion, and it is only after the lapse of time that the amount of damage caused can be ascertained. In acute encephalitis the initial symptoms are more severe and lasting than in the spinal form. The onset is usually sudden; pyrexia, headache, vomiting, delirium, unconsciousness, and convulsions are common. A condition of stupor or semiconsciousness may last for days or weeks, with affections of special senses, such as sight, hearing, speech, loss of sphincter control, and more or less widespread paralysis or paresis and sensory disturbance. As in the spinal form, the initial symptoms are usually more widespread than the lesion would appear capable of producing, so the prognosis must always be guarded. Sooner or later there are local signs which indicate the true or chief extent of the mischief, and these will vary according to its situation. In many cases the condition would seem not to advance. beyond the stage of congestion and perhaps temporary thrombosis of small vessels, for otherwise recovery could not be so complete as in many cases it is.
Two forms of acute encephalitis are described: polioencephalitis superior, which may affect (1) the prefrontal convolution of the brain, in which case profound and lasting mental changes may result; (2) the motor areas, either of the cortex or descending motor tract, giving rise to hemiplegia or diplegia; (3) the cerebellum or its peduncles, in which case disturbance of equilibrium and ataxy are the consequences; (4) the occipital lobes, producing (probably) blindness due to the involvement of the double half-vision centers. Polioencephalitis inferior is so called when the nuclei beneath the corpora quadrigemina are attacked, and the result is strabismus or various kinds of ophthalmo
plegia, or when the bulbar nuclei are involved (acute bulbar palsy), in which case any or all of the bulbar nerves may be paralyzed. Sometimes the cranial nerves rather than their nuclei seem to suffer, just as in the spinal form a condition of polyneuritis is sometimes more apparent than poliomyelitis. In some cases encephalitis seems to be subacute and gradual in effect rather than acute and rapidly productive of paralytic symptoms. Recognition of acute encephalitis as a by no means common disease may prevent the error of mistaking it for tuberculous meningitis. This is a point of practical importance considering the great difference in the mortality which attends the two diseases. The conception of a primary thrombosis of smaller blood-vessels as the starting point in both forms is also of importance. It affords a simple explanation of recovery from symptoms which seem to indicate the most extensive lesion. A mild and temporary condition of thrombosis is not incompatible with complete restoration of function. The degree of recovery attained will depend entirely on the amount of structural damage which the thrombosis occasions.
R. BISHOP CANFIELD, A. B., M D.
PROFESSOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.
MARSHALL LAWRENCE CUSHMAN, M. D.
DEMONSTRATOR OF OTOLARYNGOLOGY IN THE UNIVERSITY OF MICHIGAN.
SYMPTOMS AND TREATMENT OF SINUS AND JUGULAR
KENNON, of Norfolk, Virginia, in the June number of the Archives of Otology, discusses this subject and prefaces his remarks with a question as to the frequency of occurrence of the so-called characteristic signs of this condition, namely, chills and rapid temperature fluctuations. His observations, based on a series of fifteen cases, bring out the following signs and symptoms:
(1) Temperature, which may or may not show a sudden fluctuation in height, and which, if attaining to a height of but 101° to 103°, in an opened mastoid, may indicate operative measures.
(2) Chills, which, though frequently absent, are significant if present.
(3) Respiration, varying with the temperature.
(4) A rapid pulse, rising simultaneously with the temperature, to 140 or 150 and seldom falling to normal even though the temperature does so fall.
(5) Cutaneous signs, as sweating after a chill, or a dry, parched skin when the chills are absent. Late in the disease the skin assumes a yellowish hue.
(6) Fetid breath, cracked lips, and sordes, often leading to a diagnosis of typhoid fever.
(7) Absence of mental symptoms except as induced by extreme temperatures.
(8) Early in the disease the strength of the patient, and later a condition of marked emaciation and asthenia.
(9) Optic neuritis is rarely present.
(10) Local signs are unreliable, the presence of granulations on the sinus wall arguing against its involvement, as they act as a protective barrier to infection. Palpation is misleading and the experiment of Whiting is dangerous.
Under treatment, the author advocates early operation and free opening of the sinus, from the knee to the bulb if necessary, great care being taken to avoid setting loose, in the general circulation, pieces of the infected thrombus. When the bulb or jugular vein is involved a rapid resection of the latter should be done.
In his last cases, instead of resecting the vein from the clavicle to the bulb, Doctor Kennon has removed that portion below the facial and has brought the upper end out into the skin wound, thereby avoiding any infection of the neck.
Five cases are reported.
M. L. C.
WILLIS SIDNEY ANDERSON, M. D.
ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.
NOTES ON THE PATHOLOGY OF FIFTY CASES OF INNOCENT LARYNGEAL GROWTHS.
DOCTOR WYATT WINGRAVES (The Journal of Laryngology, Rhinology and Otology, May, 1906) gives very briefly the abstract of the fifty cases, and a concise summary of his conclusions. He classifies them morphologically under two types: (1) Epithelial (papillomata); (2) Mesoblastic or connective tissue growth. The first is essentially epithelial in structure and origin, while the second consists of growths composed of elements varying only in degree from the original vascularized areolar tissue from which they grow, covered with the normal or modified epithelium of the region, and ought to be described as papillomata. He gives the microscopic structure of these growths and discusses their etiology as follows:
"With regard to the probable origin of these papillated and pendulous innocent growths, it is only reasonable to infer that many of them are associated with primary inflammatory conditions. A consideration of their pathogeny would, however, be incomplete without reference to local developmental processes. This has a special significance in connection with those growths found in the region of the anterior