also must we speak of the mitral regurgitation of anemia and some acute febrile disorders.

Mitral stenosis starting in childhood is more serious than when starting later, because the constriction tends more to increase, and also because the constricted orifice does not enlarge with the growth of the heart. The amount of the stenosis has to be measured, so far as we can do it, by the size of the right ventricle, which works hard to cover the pulmonary congestion. Very little trouble need be anticipated, so long as the second sound is heard at or beyond the apex. If this is not heard there, an over-exertion or worry might easily weaken the compensation, whether symptoms have been present or not. When decided dyspnoea and dropsy, etc., have set in, we begin to worry in earnest in proportion to the severity of the symptoms. But even here, as in mitral regurgitation, we must not lose courage too soon and give up the fight, as if all were lost.

JUBILEE NUMBER OF THE ANNALS OF SURGERY.-The December number of the "Annals of Surgery" has been made a special jubilee number as it is the sixth number of the fiftieth volume. It consists of nearly four hundred pages of surgical material in which a number of articles of unusual interest are found. Such men as Macewen, of Glasgow; Jones, of Liverpool; Cushing, of Baltimore; Mayo, of Rochester; Rovsing, of Copenhagen; Bastianelli, of Rome; Lane, of London; Scudder, of Boston; Barling, of Birmingham; Eisendrath, of Chicago, and Deaver, of Philadelphia, together with a number of other somewhat less prominent writers have combined to make a volume that will long be unsurpassed in the limits of a single number of any of our present periodicals. Both the editors and the publishers should be congratulated upon the success that they have attained in this semi-centennial number.

HOMOEOPATHIC LEAFLET SERIES.-The Gazette is in receipt of Vol. I., No. 1, of an homœopathic leaflet series that began to be issued in January of the present year. It is planned to have this appear quarterly, and to make it more particularly for the layman than for the physician. Its purpose is to demonstrate that the practice of homeopathy is not a series of experiments founded on impossible opinions, but is based upon a law that is scientifically demonstrable. The first leaflet consists of four pages in which we find short notes upon "The Origin of Homœopathy," "What is Homœopathy?" "Progress of Homœopathy," "Samuel Hahnemann," and a number of other similar subjects. To those who are instrumental in starting this propagandistic idea we extend our best wishes, and will gladly do anything in our power to further their plans for the advancement of a cause in which we all have the most vital interest.

THE SELECTION OF A REMEDY.-Dr. Wheeler, in the "Homœopathic World," in an article on "Symptoms," has the following to say concerning the selection of a remedy. We would like to recommend the entire article to our readers as most worthy of perusal, and regret that our space prohibits its complete abstraction: "The question of the selection of the remedy led to the old argument as to whether the totality of the symptoms is the safest guide, or whether the pathological condition is not pre-eminently to be considered. Of late years there has been a very obvious change in the precept that is most followed, and whereas ten or fifteen years ago the second of the alternatives mentioned above would have been generally acclaimed, there is now a tendency, and a growing tendency, to revert to a position nearer to Hahnemann's own."

HEART DISEASE IN PREGNANCY.

BY HENRY EDWIN SPALDING, M.D., Boston, Mass.

A serious chronic cardiac lesion in a pregnant woman should always be a source of anxiety to the attending physician. This, in the first place, because the increased strain upon the circulatory apparatus in a normal pregnancy tends to seriously aggravate the pre-existing heart lesion; and, second, because the changes in the heart, blood vessels, and blood current, incident to pregnancy, and the ever present liability to septic infection, not only aggravate the present trouble, but also invite new and acute complications.

It is generally conceded that there is normal hypertrophy of the left heart incident to gestation. To some extent, in cases of valvular or aortic lesion or stenosis, this is a protection because it allows compulsory dilatation within the bounds of safety. But if from repeated pregnancies, or other causes, there is already extreme dilatation, there is then little relief to be gained from this hypertrophy.

The limits of this paper will not admit considering in detail the various forms of heart disease, any one of which may complicate gestation and parturition.

Generally speaking valvular disease, if not extreme, that antedates pregnancy is not a serious matter if properly cared for. When, however, it develops acutely during pregnancy it is more dangerous. This may be because it is usually accompanied by simple, or ulcerative, or exudative endocarditis, suppurative myocarditis, atrophy or fatty degeneration of the myocardium, and by disturbances in other organs, which are the direct result of the cardiac troubles, or come from the same causes, which have produced the heart lesions themselves. Other organs most likely to be affected are the kidneys from congestion and albuminuria, and the lungs from congestion and edema.

Prognosis. In all cases there is danger. In mild cases of chronic heart lesions, with proper care, the prognosis is not grave. Various authorities estimate the mortality at between 25 and 50 per cent. of severe cases, during gestation, parturition, and the puerperium. These estimates are, of course, taken from hospital statistics where the mortality would unquestionably be greater than in private practice. Most of these cases come to the hospital only when they have reached the critical stage, without having had any proper medical care. Personally I do not recall any mortality, but my forty-three years' experience has been mostly in private practice. During my several years' service in the maternity we have had many mild and serious cases. I recall only three extremely hazardous cases, all of which went through parturition, and left the hospital in an improved condition.

Abortion occurs from placental apoplexy or degeneration, or from hemorrhage in about 25 per cent. of serious cases. Usually a cardiac case begins to improve immediately after delivery. The free escape of blood relieving the heart strain, and the emptying of the distended abdomen, removing mechanical pressure against the heart, doubtless account for this. Somebody has very aptly said "there is a maternal and a cardiac delivery."

Treatment. Should a woman with serious heart lesion be allowed to go to full term gestation? If gestation is to be interfered with, at what stage? These are momentous questions. It is a recognized rule that when the mother and fetus are in equal danger, the mother's safety should have first consideration. At best the chances for the life of the fetus, in these cases, is only as three to four. The danger to the mother increases with the advance of pregnancy, not from the disease only, but also from the immediate effects of forced delivery, if that is deemed necessary. I believe, then, that if the woman's condition is such as to quite surely demand an abortion, it should be done in the earlier months of pregnancy. I will briefly report an illustrative case.

Mrs. J—, age 45. Has had eleven children. Her family physician gave this history: "Mrs. J— was confined about eight months ago. Delivery was followed by eclampsia. She came through this by an eyelash. There was albuminuria and cystitis, which had probably been present some months previous to labor. She picked up slowly. Albumen continued in the urine for months, headache, memory impaired, etc. There has been a slight trace of albumen of late. The bladder trouble shows itself from time to time. There has been more or less edema of the face, and lately she has complained of more or less shortness of breath on exertion.' I found a bad mitral lesion with dilatation. It was two and a half months since her last menstruation. I declined to advise interference at that time, and asked her physician to keep her under close observation for one month. He then sent her to me again. The heart symptoms had grown markedly worse. severe from moderate exertion. Swelling of feet. in right leg quite large. With this change for the hesitate to advise an immediate abortion, which I induced a few days later. In cases like this I believe that an early forced abortion is not only justifiable but advisable. On the other hand, if the case has gone on until near the end of gestation, the changes that take place in the pelvic walls, the uterine tissues, and the parturient canal as normal delivery approaches, promote an easy delivery to such a degree that it seems safer to watch the patient. closely, using such medicinal and hygienic measures as may be called for from day to day, and allow the case to go until full term, unless uterine contractions supervene naturally. Care should be taken that gestation be not prolonged beyond the normal period, for an early delivery is greatly to be desired, and an unnatural growth of the fetus should not be allowed. Fortunately in cases of

Dyspnea quite Varicose veins worse I did not

this kind the fetus is ordinarily under the average size. If, however, labor threatens any time after the seventh month it may properly be encouraged.

The three maternity cases already referred to were as serious as any I have ever seen. There was general anasarca; dyspnea from cdema of the lungs so severe patients could not lie down; albuminuria; vertigo, and all of the other bad symptoms usually found in extreme cases. They were in the hospital for observation and treatment from one to three weeks before labor commenced. As labor pains came on they were put in the new chest position, and cautioned not to strain or bear down in the least. Thus the uterine contractions were allowed to do all of the work. Their labors were easy and entirely without complications. The loss of blood incident to delivery so relieved the circulation and heart-pressure, that they were at once able to lie down for the first time in several weeks. As regards general treatment not much can be said, for each case will present special individual symptoms that are distressingly prominent. These distressing conditions must first be relieved, when, perhaps, others may come to the front to demand special attention. In all cases the urine should be frequently examined, and free diuresis maintained. A vegetable diet should be urged, first, to spare the kidneys and, second, for its effect on the fetus in promoting an easy delivery. The digestion should be watched, for flatulent indigestion is a common accompaniment of cardiac weakness. All violent exercise and sudden movements must be avoided. A sudden chilling of the skin should be guarded against, lest increased work thrown upon the kidneys be greater than they can endure, and a crisis of eclampsia be precipitated. Of course the patient should be spared all undue anxiety or violent excitement.

I cannot close this paper without a brief reference to the part the thyroid gland performs in gestation. There seems to be no question but the thyroid gland assumes greater activity and becomes hypertrophied during gestation, thus aiding in the increased nitrogenous metabolism incident to that condition. We all know the depressing effect on the heart's action and the lessened uresis which results from atrophy of the thyroid, or from Graves' disease, which materially lessen the quantity of thyroid secretion. If then the thyroid fails to hypertrophy or take on greater activity than in the non-pregnant state-and certainly if we have atrophy-we shall have deficient metabolism, which is so important as a guard against toxemia, a weakened heart's action, and scanty uresis.

While it is so recently that I have been considering the function of the thyroid in pregnancy, that I am unable to speak with the assurance that comes from large experience, I am convinced that in the administration of thyroid glands, in cardiac diseases and toxemia of pregnancy, we are to find one of our most potent aids. would commend it for earnest consideration and careful trial by the profession.

I

COMPLIMENTARY DINNER TO DRS. WARREN AND BARTON.

One of the most attractive social occasions of the year took place at the State Mutual Restaurant in Worcester on Tuesday evening, March 1. This consisted of a complimentary reception and dinner tendered to Drs. J. K. Warren and J: M. Barton upon the fortieth anniversary of their graduation in medicine. Friends and associates in the medical profession gathered to the number of more than fifty to do honor to these two respected gentlemen. Representatives came from the various parts of Massachusetts and Rhode Island. At six o'clock an informal reception was held in the parlors, followed by the more formal dinner. The postprandial exercises were particularly pleasing. Dr. J. P. Rand of Worcester proved to be a most congenial toastmaster, and

showed his witty vein most aptly. The first toast was to the memory of Dr. Hans Burch Gram, and was given in silence, all standing. Dr. George N. Lapham, of the Rutland Sanatorium, president of the Worcester County Homœopathic Society, voiced the greetings of that society in a succinct speech. One particularly pleasing part of Dr. Lapham's talk was the statement that, while somewhat skeptical upon the question of homeopathy at the time of his graduation, he has become a firm adherent to the law of similars, and is, if possible, becoming more so from day to day as he takes advantage of his unusual opportunity to compare the results of the two methods of treatment in vogue in his institution.

From the Homoeopathic Medical Society of Western Massachusetts Dr. Oscar W. Roberts brought greetings. From this