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