causes of this change are not clearly known. Certain poisons have this property of breaking up the blood corpuscles by direct action upon them. In certain septic conditions, puerperal fever, pyemia, etc., hemoglobinemia occurs. Physiologists now believe, but it is not formally established, that the red blood corpuscles are broken up and converted in the liver into bile pigment. It is supposed that in disease this process is interfered with, the destruction taking place in excess of the power of conversion, or the process stopping short at the stage of destruction. Paroxysmal hemoglobinuria occurs as an independent disease.

It is noteworthy that many of the reported cases of hemoglobinuria have been ascribed in their first onset to a fall or blow on the back, though a chill is always the determining cause of subsequent attacks. The disease has been said to depend upon syphilis, but in what way is not explained. The strongest argument in favor of this doctrine is that one patient lost his liability to attacks on anti-syphilitic treatment. But the force of this is modified by the knowledge that though some cases are very obstinate, others recover of themselves. One case specially is known to me in which no attack has occurred for several years, though no special treatment has been followed, except care to avoid as far as possible exposure to chills.

It is worth bearing in mind that albuminuria is occasionally persistent in these cases, and Dr. Ralfe believes that this is due to a permanent inability to dispose of the albuminous material set free by the destruction of the red blood corpuscles. But if this were true, the albumen excreted should be globulin, not serum albumen, a suggestion already made some years ago by Sir William Gull; and I have endeavored to test the truth of this hypothesis, but my analyses always showed that serum albumen was present as well as globulin. I should be very glad to see this point investigated by so competent a chemist as Dr. Ralfe.

Toxic Hematuria. Hematuria may follow the application of a fly-blister, or the internal administration of cantharides. The latter is seldom practised, but the drug has been recommended on quasi-homeopathic principles by Dr. Sidney Ringer for nephritis, and in that condition I have seen it even in one-minim doses cause distinct hematuria. When given for criminal purposes the dose is usually large, and the hematuria is accompanied by strangury, vomiting, and symptoms of irritant poisoning. Turpentine does not usually cause hematuria, though the readiness with which the violet odor appears in the urine shows that it is absorbed and excreted by the kidney. I

have had one very interesting example of hematuria due to this cause in a varnish maker who was sent to be examined for life insurance. He seemed a perfectly healthy man, but after he had gone I examined his urine, and found it contained a little albumen. I then noticed the odor of violets, and closer examination showed that the albumen was due to the presence of blood. There were no other evidences of renal disease, but there was certainly some special susceptibility to the action of turpentine, as this gentleman informed me that he was not personally engaged in the manufacturing processes, though he was much about the factory. I tried to follow up the case, but could not, as he abandoned the proposal.

Narcotic and vicarious Hematuria. I have no personal experience of these conditions. Laycock (Nervous Diseases of Women, p. 229) mentions hematuria as not uncommon in hysteria, but I have not yet recognized a case, though I have certainly met with one or two cases of hematuria in women which I have not ventured to class in this paper. Sir W. Roberts mentions menstruation, hemorrhoids, and asthma as conditions in which vicarious or supplementary hematuria occurs, but I can only quote him, and leave the matter without further comment, as I have never met with such cases. Dr. G. H. Savage states that hematuria may occur spontaneously in acute mania and general paralysis.

Treatment. A very few words as to the general treatment, which must be specially regulated in each case by the cause. Undoubtedly hematuria usually passes off by rest, after a shorter or longer time, independently of drugs. But, as we have seen, there are persistent cases in which we are bound to do our best, and ample opportunity is afforded for trying all known remedies. My experience has been that they are all very untrustworthy, and I hesitate to give the preference to any

one.

Acetate of lead, ergot, hamamelis, gallic acid, and perchloride of iron should have a fair trial. In hemoglobinuria a ten-grain dose of quinine should be given at the commencement of the attack, and five grains three times a day till convalescence is established. Chloride of ammonium, recommended by the late Dr. Warburton Begbie, has never been followed in the hands of others by the fortunate results he obtained.-British Medical Journal.

GRAVITY AS AN EXPECTORANT.-It is claimed that in cases of pneumonia, where there is great embarrassment of breathing from accumulation of secretion in the bronchial tubes, great benefit may often be derived by inverting the patient, and having him cough violently while

in this position. It is easily accomplished by a strong assistant standing on the patient's bed, seizing the sick man's ankles, turning him with his face downward, and then lifting his feet four or five feet above the level of the mattress. If the patient, with his face over the edge of the bed and his legs thus held aloft, will cough vigorously two or three times, he will get rid of much expectoration that exhaustive efforts at coughing failed to dislodge when not thus aided by gravity. Life has been saved by repeated performances of this maneuver in pneumonia accompanied with great cyanosis, due to inundation of the bronchial tubes with mucous secretion. It, of course, will have no effect on the exudate in the vesicles. Gravity is of value in a similar way in emptying the lungs of mucus during etherization.-Polyclinic.

ON THE IMMEDIATE APPLICATION OF THE PLASTER-OF-PARIS SPLINT IN THE TREATMENT OF CLUB-FOOT.-Prof. George E. Post, M.D., of Beirut, Syria, writes in the Medical Record as follows:

While many surgeons use plaster of paris during the treatment of club-foot, I believe that it is usual, after the tenotomy, to postpone the application of the plaster of paris for at least a week, often much longer. On asking surgeons the reason for this delay, the writer has been told that it was to avoid risk of swelling, and to allow ready access to the wound in case of necessity. An experience of fifteen years in its use, and a large number of cases, have satisfied him that with proper care the plaster may be used from the first, with considerable shortening of the time of treatment and no risk to the patient.

The wound caused by tenotomy of the tendo Achillis or of the plantar fascia, with thorough antiseptic precautions, will heal by the first intention, if measures be taken to keep in coaptation the whole track of the incisions, plus the gap made by stretching the parts in the effort to restore the foot and ankle to their normal positions. This is best accomplished by a pad of aseptic or medicated cotton and wool, which makes soft and even, but most effective pressure, and prevents a vacuum into which air can be sucked or in which blood can be pocketed. The wounds so treated unite readily and as quickly as any other wounds in the deeper parts. As there is no swelling of a wound wnich heals by the first intention, there is no reason from this cause why a plaster bandage may not be at once applied.

Swelling is most apt to occur from pressure

over the metacarpo-phalangal joints of the great and little toes and the dorsum of the foot just anterior to the ankle, and the inner aspect of the tibia just above the internal malleolus. Care in padding with cottonwool the-e places, where the strain from the bandage is felt, will prevent undue pressure and the edema which is sure to result from it.

Of course, swelling will result from too forcible torsion of the foot and undue straining of the ligaments of the complicated tarsal and tarso-metatarsal joints. Experience and the tactus eruditus alone can inform the surgeon correctly of the amount of strain to put upon these tissues at the first dressing. But it is safe to say that the existence of the tenotomy wounds, if properly treated, does not increase the risk of the first torsion of the foot. It is furthermore true that a considerable amount of stretching, or even laceration, of these ligamentous tissues will be borne with inconsiderable swelling, or with swelling at points little pressed by the bandage and plaster.and that a plaster splint, which has been properly padded at the points where bony prominences are thinly covered by skin, will seldom have to be removed

because of edema of the foot.

The practice of the author is as follows: The foot and leg, as far as the knee, are thoroughly cleansed with soap and water, and rendered antiseptic by sponging with a three per-cent solution of carbolic acid. The hands of the surgeons and assistants and all the instruments and accessories are carbolized. The necessary tenotomies are done in the usual manner, but while the instrument is doing its work a wad of aseptic cotton-wool is pressed over the surroundings of the wound in such manner as to press the skin and subjacent tissues into the hollow formed by the separation of the cut subcutaneous tissues, at once arresting hemorrhage, and bringing about immediate coaptation of the whole of the divided tissues. If more than one tenotomy is necessary, an assistant carefully holds the cotton pad over one wound while the other is being made.

Supposing the deformity to be in the right foot, the patient is laid on his back, with the affected leg projecting from the knee beyond the edge of the table. An assistant grasps the calf just below the knee, and holds it firmly to the edge of the table, managing the thumb and forefinger of his hand so as to form a ring at right angles to the axis of the limb, and allow of the application of the bandage as high up as possible. The surgeon, sitting at the side of the table,

with the left hand everts and flexes the foot so as to overcome as far as possible the deformity, and applies an absorbent aseptic bandage, beginning at the inner border of the foot, crossing the sole outward, and surrounding the metatarsus twice. Between

the first and second turns of the bandage a pad of cotton-wool is placed along the outer border of the metatarsus and first phalanx of the little toe, overlapping a little the sole and dorsum, and a similar one along the metatarsus and first phalanx of the great toe. A pad of cotton-wool is then laid over the instep, and then a turn of the bandage carried from the outer edge of the foot, across the pad and instep, to the inner aspect of the tibia above the malleolus, which is also protected by a pad of cotton-wool. The bandage is then carried once or twice around the leg, so as to cover the wound and make equable pressure on the pad over it, and then carried from the outer aspect of the leg obliquely over the dorsum to the inner aspect of the foot, and by repeated figure-of-eight turns around the foot and lower part of the leg, with suitable reverses, the whole, including the heel, is covered. The roller is then carried up to the upper part of the leg and pinned or sewed. During all this process the surgeon's left hand has maintained the foot in the desired position, a point of no little importance, to prevent the movement of the wounds, which will cause oozing of blood and introduction of air. As the left hand can render but inefficient aid in the passing of the roller, it is very desirable to have a clever assistant, who will pass and repass it to the right hand of the surgeon The right hand of the assistant who holds the leg will be the best for this purpose. I lay considerable stress on the surgeon's retaining the manipulation of the foot, that he may judge of the exact position that it is to assume. The co-operation of the two hands of one man is always more perfect than that of two persons.

A plaster bandage about two inches broad, and four to six yards long according to the size of the limb, previously well soaked in water, is now to be neatly applied, but never stretched on, and whatever pres sure is made in redressing the position of the foot should be by the left hand of the surgeon, never by pulling the plaster bandage. Both the original roller and the plaster bandage should simply retain what is gained. If necessary a second bandage may be applied, and then the surface covered with a thick cream of plaster. If the bandages have been skillfully applied, the foot

will give very little when the left hand of the surgeon is taken off.

The second phalanx of the great toe, and the third of the other toes, should be left out. It is very important that no crowding of the metatarso-phalangal joints should result. The natural line of the toes should be preserved.

The child should be kept on the table, and prevented from moving the leg until the plaster has hardened. The mother or nurse should carry the child, with the leg held up, and not allowed to dangle, for three days, or until time has been given for the healing of the wounds, and to be sure that there is no swelling.

If the child is old enough to walk, and the deformity has been sufficiently overcome to bring the sole of the foot nearly into position, he may be allowed to begin to use his foot after three days. If, however, the deformity is only partially overcome, or there is a little swelling of the toes, it is well to wait until another splint has been applied, which may be after a week or ten days, according to the judgment of the sur

geon.

Two to four applications of a plaster splint are usually enough to bring about a cure in children under five, who have not very bad club-feet calling for resection of the tarsus, or who have not large callosities from long walking on the dorsum of the foot or on its outer edge.-Medical Record.

THE VALUE OF COCAINE IN OBSTETRICS. Mr. John Phillips, Physician to the British Lying-in Hospital, after a review of the literature of this subject and a statement of his own experience in the Lancet, November 26, 1887, draws the following conclusions:

First, cocaine, in whatever way administered, is a valuable adjunct to the treatment of the vomiting of pregnancy, and in some cases superior to other drugs in use.

Second, during the painful earlier stages of labor, especially in primiparæ, it materially assuages the pains, but neither quickens them nor retards their onset, and hence has no effect on the actual dilatation.

Third, it is useless in mitigating the pains of expulsion and those caused by pressure on the perineum.

Fourth, in the case of sore nipples it relieves the pain attendant on suckling, though the duration of its effects is not sufficiently long to be of material service. It is, however, apparently without any detrimental effect on the suckling.

THE TREATMENT OF POISONED WOUNDS.Dr. A. de Noè Walker has addressed a letter to the British Medical Journal, in which he expresses the opinion that if Burnett's fluid, diluted with one third of water, is at once poured on the abraded surface of penetrating wounds, whether inflicted by a venomous spider, hornet, scorpion, cobra, rattle snake, or rabid dog, the patient may consider himself safe. The poisons of various venomous animals, however, differ widely in composition. Those of the spider, hornet, and scorpion are as yet not thoroughly investigated, but that of the cobra, along with other ophidians, is of proteid nature. That of the rabid dog is (at least recent researches would prove it so) of mierobic origin, and bears no comparison with the others. It is not to be supposed that the same treatment is applicable to all. Alkaline lotions are usually the best for the venomous insects. We know of no antidote for snakepoison when it has once entered the system, and Burnett's fluid or chloride of zinc will not act any better than simple washing the wound with water. The antidote to rabies is probably not to be found in any chemical application. "Reducing" or "decomposing" agents can be found for all the poisons of chemical nature, but if the venom is at all intense, for example, snake poison, the unfortunate part of it is that the amount of antidote requisite to neutralize or destroy the poison would be sufficient to destroy every tissue in the body it came in contact with, and thus, though a poison may be quite easily neutralized in the laboratory (for example, snake poison by permanganate of potash), it can not be effected when it has entered the system. Immediate washing of a poisoned wound under a tap of water will effect more than any application of Burnett's or other fluid. As to cobra poison, when once a lethal dose has entered the circulation, no antidotes or treatment will save the patient.

A CASE OF RAYNAUD'S DISEASE. —At the meeting of the Midland Medical Society, held October 19, 1887 (Lancet, November 12, 1887), Dr. Suckling showed a strumous-looking girl, twelve years old, who was suffering from symmetrical gangrene of the fingers and toes. When two years old she was bitten on the right forefinger by a rabbit, and three months after this the fingers began to be blistered. Since that time she has never been free for a month from a sore finger or toe. She suffers from paroxysmal attacks of inflammation in the fingers, accompanied with severe pain. The terminal phalanges, with the distal half of the middle phalanges, are lost in the fore, ring, and little fingers of both hands; the

fingers themselves are swollen, red, and ulcerated at their extremities. The thumb is inflamed and the terminal phalanx is necrosed. There is no anesthesia and no pain. The skin of the legs is bluish and thin, and ulcerated in several places, the slightest injury causing an intractable ulcer. The terminal phalanx of each little toe has been necrosed. The knee

jerk is present, the plantar reflex is lost. The condition of the extremities is always worse in cold weather. There is no history of struma in the family, but the girl herself is weakly and ill-nourished.

PATHOGENESIS OF PTERYGIUM. Theobald writes that if the generally accepted theory of the pathogenesis of pterygium that it has its origin in a marginal corneal ulcer were true, pterygium would be found approaching the cornea from every possible direction. It is known, however, such is not the case, but that it is almost always situated directly over the recti muscles, and that in a very large proportion of such cases it is over the rectus internus. He draws attention to the close connection between the vessels of the recti muscles and those of the anterior portion of the conjunctiva, and points out that the determination of blood to these muscles might influence the blood supply of the overlying conjunctiva, and that this would be the case especially with the recti interni, since they were the largest of the straight muscles, and in close relationship with the conjunctiva, because attached to the sclerotic nearer to the corneal border than any of the others. The muscles he regarded as the usual cause of pterygium, through the localized hyperemia of the conjunctiva to which they give rise.

EXPECTANCY IN THE TREATMENT OF TRAUMATIC PERFORATIONS OF THE INTESTINES.— Reclus, of the Hotel Dieu, Paris, protests against primary laparotomy in these cases. Of twenty-three recent cases thus treated but three have recovered. His treatment is as follows: The patient is not allowed to move hand or foot. The clothes are cut away, the wounds disinfected and closed with iodoformized collodion. The patient is immobilized in a thick coating of cotton wadding, which must be then compressed with a flannel belt, tightly pinned on, as after ovariotomy. Morphia hypodermically and dry extract of opium by the mouth. During the first five or six days food must be withheld; at most a few teaspoonfuls of iced milk are given and some small lumps of ice. If, notwithstanding the foregoing treatment, peritonitis sets in, he operates as a forlorn hope.

than the persistence of muscular contractility

In the general re-examination of old views. and opinions that has been going on of recent years, the question of post-mortem parturition deserves to be reconsidered with the increased care that is now given to scientific investigation.

A not inconsiderable number of authentic cases of parturition after the death of the mother are on record, and some of these have occurred under circumstances well calculated to mislead, if the interpretation given them was not the correct one.

In the great majority of instances these occurrences have been easily and clearly attributable to the formation of gases in the abdomen and about the womb in such quantities as to force out the fetus. In other cases, however, fetuses have been born so soon after the death of the mother that this cause hardly seemed available as an explanation.

In cases, for instance, where the child was born within a few hours after the death of the mother, and especially in that one instance where a living child is said to have been born. alive after the mother's death, it seemed not easy to attribute the birth to any other cause

But in this view there are at least two possible sources of error. The dying woman may have presented an instance of that class of cases in which there is much tympanitis before death, and in which the gases, already abundant, rapidly increased after death. In the second place the birth may have taken place before the death of the mother, and simply been overlooked.

A case in point came to our knowledge some years since, in which the question of inducing labor in a severe case of eclampsia was discussed in a consultation of physicians, and the conclusion reached that the patient was too low to admit of the procedure. She was com atose and moribund. The consultation was adjourned, but, before some of the participants had reached their homes, a casual examination by some of the attendants revealed a child between the patient's thighs, which in every probability was there while the consultation was in progress. An eight months' fetus had been expelled all unperceived by the attend

ants.

If death had taken place in this case a few hours sooner than it did, and had the bed not been examined until after death, the conclusion might very naturally have been reached that the delivery had occurred after death from persistent contractility of the uterine muscles.

Other cases of unconscious delivery shortly before the death of the mother have come within our personal experience, and it is easy to see how, among the many cases of this kind that have occurred, some might have been overlooked until after death, with the result of giving rise to the belief that birth had taken place after the death of the mother.

We do not claim to be in a position to deny that it is impossible for the uterus to retain sufficient contractility after somatic death to expel a fetus contained in it, or that such a thing has occurred.

But when we reflect that a single tonic contraction of the uterus can never suffice to expel a fetus, that, on the contrary, alternate contractions and relaxations are indispensable.