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contracted conjugate; and even for minor de- a certain position, endeavoring to dilate the viations of face cases, and badly-rotated occip- vagina, and when nature could not complete ito-posterior cases, we have the shape of the the delivery, the surgeon was called to destroy face and head markedly fitted for the best the child and to save the mother. means of delivery."
The second concept was the obstetrical, and The explanation of flexion by Labs is an had its origin with the introduction of the advance over the previous theory of articula. forceps, in the early part of the eighteenth tion of the spine to the occipital bone. Deeper century, and has led to a closer study of the than these phenomena of the mechanism of mechanism of labor, occupying its time mostly, labor is the force which the uterus exerts, and however, in the study of the fætus and pelvis. the manner in which it is applied. The ab- The third concept dates from the introduction dominal muscles take no part directly in the of ovariotomy, in the early part of this cenexpulsion of the uterine contents. action is to sustain and conserve the uterine contractions. They cannot be applied in an Cases in Hospital Practice. effective manner in expulsion. Dr. Hart concludes the paper above referred
ACUTE ULCERATIVE ENDO. to with these words: “Future observations
CARDITIS. are still needed as to the shape of the head after
BY A. E. BRADLEY, M.D., labor, as bearing on any peculiarity of mechan
Resident Physician Philadelphia Hospital. ism, and I hope that this communication will Difficult as is the diagnosis of this affection, direct the attention of obstetricians to an in- one would hardly think it could possibly be teresting field."
confounded with phthisis, but such was a fact These mouldings which the head undergoes in the case herein described. So obscure is teach us not only the peculiarity of the mechan- ulcerative endocarditis in its clinical manifestaism, but also enable us to understand the man- tions, that it is rarely that its existence is ner in which the force is applied, and also known until an autopsy demonstrates its something of the nature of its action. The presence; however, it is rather humiliating to common succedaneum found over the parieto- be obliged to announce that the writer went so occipital region, which disappears in twenty- far wrong in his diagnosis as to consider his four or forty-eight hours, is similar in its forma- patient suffering with advanced phthisis. The tion to the extreme elongation of the occiput existing conditions, however, were such as, in in great flexion of posterior rotation, or the a measure, to exonerate him from too severe elongation of the frontal region in frontal criticism. The following is the case in point:presentations, and shows the manner in which CASE 1.-Kate R.; æt. 30; was admitted the fætus makes its way by elongation under to the medical ward on Nov. 3d, 1887; she was moderate and gradually applied force.
a married woman, and had borne two children, This closer study of the mechanism of labor, both of whom died in infancy. Her history, the study of the placenta, and the changes as far as could be obtained, was as follows: which the uterus undergoes during gestation eight months before she had had a slight and immediately preceding birth, belong more hemorrhage from the lungs, being the foreparticularly to the gynæcological concept of runner of a cough which followed, and became labor. The process by which cur present finally chronic. Her present illness began standpoint has been reached has been gradual. four weeks previous to admission, by an exThe first concept was midwifery, which con- acerbation of the cough, followed by rapid cerned itself with the most external phe loss of flesh and loss of appetite. At no time nomena of labor, such as holding the hands, was there any diarrhæa. making pressure, administering drinks, com- On the night before admission she expectoforting the mind of the patient, placing her in rated considerable blood, had a great dyspnæa, and much coughing, which was ac- Thorax.- Pleuræ normal, no adhesions ; companied by pain, especially on the right lungs crepitant throughout, lower lobes much side. On examination, the following condition congested; ædematous in all portions. was noted:
Heart.-Weight 13 ozs. Right chambers Inspection: a feeble, care-worn, much-dilated; all cavities contained clots, that of emaciated woman, presenting a flattened chest, right ventricle extending far outinto pulmonary with ribs and interspaces very prominent, artery. Tricuspid orifice admits to the middle and infra-clavicular regions much depressed. joint, three fingers. Left auricle dilated, walls On inspiration, expansion was seen to be much thickened, endocardium very opaque. Mitral impaired. Patient was very anæmic, eyes orifice is a little narrowed, scarcely admitting bright and glistening. Satisfactory physical two fingers to first joint Edges of valve examination could never be made, owing to segments thickened, and on auricular faces are patient's extreme weakness. Heart-apex to be seen six or eight small fresh vegetabeat seen in sixth interspace, and a palpa- tions. Left ventricle hypertrophied and contion felt to be forcible, with a shock and a siderably dilated; walls nowhere more than one diffuse impulse. Percussion could not be per- half-inch in thickness. Aortic valves incomformed because of pain, which each attempt petent; the left coronary segment is almost elicited. On auscultation, loud râles were entirely destroyed. Three large, ragged heard all over the entire chest, anteriorly and vegetations project from the remnant. The posteriorly, and thought at the time to be right coronary segment presents from its the breaking-down râles of phthisis. Voice under surface a large vegetation, and the valve sounds could not be employed, for the patient is here seen to be perforated. The intercorowas never able to speak above a whisper, nary segment has a slight perforation, and a simulating a tubercular involvement of the large flat vegetation on its under surface. larynx. A distinct double mitral murmur was Liver.- Normal in appearance; weight, detected, but no murmur at aortic cartilage 4 lbs. 8 ozs.; gall ducts pervious. was found on the slight examination which her "Spleen.- Weight, 17 ozs
. ; large
, irregular, condition allowed. Pulse ranged from 120 to ovoidal, and lobulated. About its middle, 140 per minute, was feeble and compressible. extending across its whole area transversely, is
Expectoration was bloody, frothy, and to be seen an enormous infarct, its breadth at abundant, always difficult, and accompanied cortex of the organ measuring two inches. by much pain. Probably, amount of blood On section, it presents the characteristic wedge lost after admission, and before death, did not shape. It is firmer and lighter in color than exceed eight ounces. Tongue was clean; the surrounding parenchyma. Other smaller teeth covered with sordes; temperature, on infarcts are to be noted scattered through the admission, was normal, afterward was not organ. In the artery supplying this area was taken, through oversight.
found lodged an embolus, similar in all The urine contained a marked ring of al- appearances to the aortic vegetation, from bumen, but no casts could be found. Dropsy which, no doubt, it had been torn by the had at no time ever existed. The treatment action of the blood current. was purely symptomatic, stimulants being Kidneys.-Large; combined weight, 14 freely employed. The dyspnea gradually ounces. Capsule slightly adherent; vortex became worse and worse, and death ensued irregular; and parenchyma showing chronic on Nov. 13th, two days after admission. diffuse, parenchymatous nephritis.
Autopsy, performed by Dr. E. O. Shake- Stomach and intestines normal. Brain not speare and the writer, revealed the following examined. condition :
Thus an autopsy made a diagnosis which, Body of a woman of medium height, very had it not been allowed, would have passed as much emaciated.
a death from phthisis.
Here we had a history of chronic cough, the third day; but is relieved, as a rule, by an hemorrhage from the lungs, loss of flesh eight-ounce enema of warm, thin gruel, slowly and appetite, pain in the chest, aphonia, injected, or exceptionally by a five or seven anæmia, and much emaciation-a picture and a half grain dose of calomel, the choice almost, in itself, of the last stages of phthisis, being influenced by the character and promiand yet necropsy showed the lungs to be nence of abdominal symptoms. Under this normal so far as any structural change was plan of treatment diarrhea is not commonly concerned, and the whole seat of the trouble excessive. When necessary, it is treated by to be an ulcerative vegetative endocarditis. one-grain suppositories of the aqueous ex
tract of opium.
From the beginning the patient receives at
intervals of two hours during the day, and Notes of Practice.
three hours during the night, and immediately
after the administration of nourishment, two THE TREATMENT OF TYPHOID
or three drops of a mixture of two parts tincFEVER.*
ture of iodine and one part pure liquid carDr. J. C. Wilson, Physician to the Jefferson bolic acid. This dose is administered in an Medical College Hospital, treats his cases of ounce of iced water. enteric fever by the systematic use of laxative Unless the temperature exceeds 104° F., doses of calomel during the first ten days, and the fever calls for no special treatment, beyond by carbolized iodine, as originally suggested cold sponging, which is practiced in every by Professor Bartholow, throughout the course case at least twice in the twenty-four hours. of the disease. The most careful attention is A higher temperature receives prompt attengiven to the details of nursing, dietetics, and tion. hygiene, and symptoms are treated as they After trial of the list of new antipyretics, the become prominent.
choice is antipyrin. It is used in single doses Due regard being had to the peculiarities of ten to fifteen grains, and repeated when of individual cases, the general plan is as fol- the temperature again rises beyond 104° F. lows:
If this remedy fails of its effect, large comUpon the evening of admission the patient | presses of several thicknesses extending across receives seven and a half to ten grains of calo- the chest and abdomen from the neck to the mel in combination with ten grains of sodium pubes, and freely wet with iced water, are bicarbonate, at a single dose. If the case be used. The gradually cooled bath is held in still in the first week, which is not usual with hospital patients, this dose is repeated every Alcohol has no necessary part in the rousecond night until its third administration ; if | tine treatment of enteric fever. Many cases do already in the second week, a single dose not require it; some are unquestionably beneonly is given. After the tenth day it is given fited by it, while to a considerable proportion cautiously or omitted altogether. If there be it is an absolute necessity. Dr. Wilson beconstipation, the first dose of calomel is fol- lieves that the employment of alcohol in the lowed by two or three large stools, mostly of treatment of fevers should be regarded not as the consistency of mush, the later dose by stools a dietetic but invariably as a medicinal measdecidedly liquid. Diarrhæa is not regarded ure.
as a contra-indication. On the contrary, it Space does not permit the discussion of the
almost always becomes less troublesome after treatment of complications, nor of the managethe action of the mercurial. During the sub- ment of convalescence. If perforation occurs sequent course of the disease, constipation is during or after the period of defervescence, not allowed to continue at any time beyond namely, in the fourth week or later, laparot* Medical News, Dec. roth, 1887.
omy should be performed.
THE USE OF WATER AT MEALS. who has made this subject a special study,
Opinions differ as to the effect of the free cold water should be given to persons who ingestion of water at meal times, but the view have sufficient vitality to react, and hot water. most generally received is probably that it di- to the others. In chronic gastric catarrh it lutes the gastric juice and so retards digestion. is extremely beneficial to drink warm or hot (British Med. Journal, Dec. 3d, 1887.) Apart water before meals, and salt is said in most from the fact that a moderate delay in the pro- cases to add to the good effect produced. cess is by no means a disadvantage, as Sir William Roberts has shown in his explanation of
A CASE OF PSEUDO-ANGINA PECthe popularity of tea and coffee, it is more than
TORIS. doubtful whether any such effect is in reality
BY PROF. ROBERTS BARTHOLOW, M. D., produced. When ingested during meals, water may do good by washing out the
Of Jefferson Medical College, Philadelphia. digested food and by exposing the undi- In a clinical lecture on "Some Respiragested part more thoroughly to the action of tory Neuroses” (Med. News, Dec. 10th, 1887), the digestive ferments. Pepsin is a catalyptic a case of pseudo-angina pectoris was described, body, and a given quantity will work almost in which there had not been any antecedent or indefinitely, provided the peptones are coincident rheumatism, syphilis or diphtheria, removed as they are formed. The good and in the intervals of the seizures no evidence effects of water, drank freely before meals, of heart disease. There were symptoms, howhas, however, another beneficial result-it ever, of a neurotic character, which Trousseau washes
away the mucus which is secreted by has described under the name of "masked the mucous membrane during the intervals epilepsy." of repose, and favors peristalsis of the whole The therapeutics of such a case was summed alimentary tract. The membrane thus up by the lecturer in the following words :cleansed is in much better condition to receive It is important in respect to treatment to food and convert it into soluble compounds. recognize the true nature of these attacks.
The accumulation of mucus is specially | The best results are had from a combination well marked in the morning, when the gas- of remedies addressed to both the true seat of tric walls are covered with a thick, tenacious the malady and to the organs suffering the layer. Food entering the stomach at this most severe functional disturbances. time will become covered with this tenacious As the bromide of sodium is far less hurt. coating, which for a time protects it from the ful than the corresponding potash salt, I will action of the gastric ferments, and so retards direct thirty grains three times a day. As digestion. The tubular contracted stomach, during the paroxysms it is evident that the tenwith its puckered mucous lining and viscid con- sion of the vascular system is abnormally high, tents-a normal condition in the morning I will give the one per cent. solution of nitrobefore breakfast-is not suitable to receive glycerine, increasing the dose from one minim food. Exercise before partaking of a meal until its characteristic action is manifest, at stimulates the circulation of the blood and which point it should be kept for the present. facilitates the flow of blood through the ves- As it is very obvious that errors of diet often sels. A glass of water washes out the precipitate the seizures, and always add to mucus, partly distends the stomach, wakes their violence, a careful regulation of the food up peristalsis, and prepares the alimentary | becomes essential. Indeed, of all the measures canal for the morning meal. Observation we have to propose, this is the most impor. has shown that non-irritating liquids pass tant. The allowance of meat should be redirectly through the “tubular" stomach, and stricted to one meal ; it should be fresh meat, even if food be present they only mix with and small in quantity ; one egg may be given it to a slight extent. According to Dr. Leuf, at breakfast; one vegetable at dinner, such as
spinach, celery, lettuce, or similar non-fer-
gr. xxviij Water,
3 ij. warm skimmed milk.
It is difficult to regulate the diet of these Other anodynes can be incorporated in the subjects; they have fierce appetites, and a
solutions, and, as the vapor is very fine, absorpfiercer way of indulging them ; but every con
tion of the drugs through the pulmonary sideration should be brought to bear that may
mucous surface undoubtedly occurs, hence it be effective in support of their own resolution. is not advisable to administer anodynes inter
Very often we have here, as this morning, nally if the solutions contain anodynes. examples of difficult respiration arising from
Solutions one, two and three were used retiex influences at a distance from the apparent when the cough and expectoration were not seat of morbid action; thus, asthmatic trouble troublesome. In case expectoration was diffifrom renal disease-renal asthma. Difficult cult or the mucus tenacious, number three or breathing, of which the first intimation comes
four was used. If the spasmodic cough was by hoarseness, may be the initial symptom of severe, number five served a good purpose, Bright's disease.
and it was never necessary to give anodynes
internally to relieve the cough or produce THE TREATMENT OF WHOOPING
sleep. The treatment of complications and COUGH.
during convalescence was according to the Prof. J. A. Robison, of Chicago, in Archives indications. of Pediatrics, Dec., 1887, writes as follows :For the past seven years I have employed
LOCAL MASSAGE FOR LOCAL a five per centum solution of carbolic acid,
NEURASTHENIA. moistening a sponge with this solution and
Dr. Douglas Graham, of Boston, Massatying it over the mouth of the patient, in a respirator. But I experienced a great deal of chusetts, arrives at the following conclusions
upon this form of treatment, in a paper in difficulty in carrying out this treatment in the
the Boston Medical and Surgical Journal, case of refractory children, and this led me to
December 15th, 18875 adopt a hint given me by Dr. H. M. Thomas.
1. Massage induces sleep. He suggested that drugs in solution could be
2. Even when massage is applied in the carried by inhalation into the finer bronchial
forenoon its soporific effects may not disaptubes by the use of Semple's atomizing in
pear before bedtime; though, in general, the haler, since this instrument produces a fine,
later in the day massage is used for promotsmoky vapor that is unirritating to the larynx. In the case of children I adopted the method
ing sleep the better.
3. Disagreeable feelings of drowsiness and of attaching a tube to the inhaler and placing it in the child's mouth, so that the vapor would languor do not necessarily intervene between be freely inhaled. I was successful in reliev
massage in the forenoon and sound sleep at
bedtime. Aptitude for rest or work gening the cough and expectoration and cutting short the disease beyond my expectation.
erally follows massage.
4. When people are wakeful after massage, The solutions used were: No. I, five per centum solution of carbolic acid. No. 2, five
they may not be restless or feel the loss of per centum solution of oil of eucalyptus in sleep on the following day. liquid vaseline. No.3, Dobell's solution. No
5. Spinal irritation is relieved or disappears
under massage. 4, Keating's solution
6. For local neurasthenia there is no need R. Thymol,
gr. xy Alcohol,
of general massage, unless the whole system Glycerin,
be secondarily influenced. Water,
7. When affections have come to a stand