chectic children a tonic course with iron. may advantageously follow the more direct medication. In capillary bronchitis or in ordinary bronchitis, when there is a low state of vitality with debility arising early, we must withhold entirely the depressant remedies, using instead the stimulants freely. In these cases there often arises extreme danger from obstruction with mucus; the child is too feeble to now raise the phlegm in which it is drowning. To depress the system with arterial sedatives, to relieve the cough, to increase the amount of mucus by loosening expectorants is pernicious, is even murderous. By strenuous efforts the child gets air enough; enfeeble it by narcotics and the efforts are crippled; relieve the cough and the secretions settle still closer to the alveoli; loosen the phlegm and more accumulates. The thing to do is to evacuate the offending matter, and this can only be done by a prompt and efficient emetic of zinc or copper. Ipecac is depressing; deaths have resulted from apomorphia. The improvement after thorough emesis is often next to wonderful. I now almost invariably begin the treatment in a child, especially in an infant, with vom dose of an opiate, or preferably, the extract of hyoscyamus or cherry laurel water, as not retarding secretion, should be added. Hot applications to the chest, such as mustard with linseed meal in the proportion of oz. to 8 oz., or hops, are useful as derivatives, and may be continued in the second stage. When the congestive stage has continued for a day or two, we must change our remedies to such as will promote secretion (sooner than this we will hardly succeed), among these ipecac, squills, antimony, lobelia and especially the chloride of ammonium; also, warm vapors impregnated with glycerine or lime. These remedies are useful as long as they are indicated by dryness of the mucous membrane, and should be stopped or lessened in quantity as soon as the cough has become quite loose. At the end of a week or ten days we may begin with stimulating expectorants to aid in the expulsion of mucus, which is again becoming tenacious. Being now less abundant and more difficult to raise, it is thickened by evaporation into the air which is constantly passing over it as it is plastered against the sides of the air tubes. This class of expectorants has a tonic and stimulating effect on the mucous membrane, restor-iting (preceded by some stimulant), by ing it to its natural condition and increasing the functional activity of the cilia and bronchial walls. The most commonly used are squills, senega, the carbonate of ammonium, camphor and the resinous substances, such as benzoes and benzoic acid, tolu, Peruvian balsam, copaiba, cubebs. A small amount of a narcotic may be added if necessary. It is this combination of stimulants and expectorants with a little opium which renders paregoric so useful. Inhalations by spray or otherwise of tar or turpentine are also beneficial, especially in chronic cases. In ca which the air passages are well cleared. A large poultice applied over the whole chest, by virtue of heat and moisture, aids very materially in the improvement. The breathing after these two measures becomes deeper, less rapid and the infant once more finds leisure to nurse. At the same time we must, by all means, try to support the powers of life with stimulants and concentrated food, to enable the child to continue its laborious respiration for a few days, when the danger will usually be passed. The subsequent treatment is similar to that in ordinary bronchitis. I once more would urge upon you the necessity of recognizing the mechanical nature of the danger; when this is appreciated the proper course will suggest itself, and measures be avoided that would make matters worse. OBSTETRICS. Tait On Faradization. DR. R. P. HARRIS presented the following letter from Mr. Lawson Tait, of Birmingham: I have very strong objections to the proposal to treat cases of extra-uterine pregnancy by faradization. In the first place, the diagnosis of these cases must always be haphazard, that is to say, a correct diagnosis will not be made, probably more than once in three times; the result will be that all such cases will be dealt with mischief only, and I venture to predict that this treatment will be dropped, as all such cases are, without explanation of the case, in a very short time. My greatest objection is, that supposing the fetus has passed through the stage of tubal rupture and remained alive, what right have you to murder that child? If it goes on to full time it may be delivered alive, and the woman will have a chance of recovery from the operation far greater than with the faradization treatment of destroying the child. The cases, according to my experience, which recover from the operation are about six out of seven. Every one who has had much experience with pelvic tumors must have seen a certain number of cases where the fetus has died between the fourth and sixth month, and where, after a prolonged course of suppuration, it comes out through the bladder, rectum, etc., these are of course the cases where the tubal rupture has taken place into the broad ligament on the left side. I have seen one right-sided case going into the bladder. It of course killed the patient. In the whole course of my life I have only known of one case where the woman has carried an extra-uterine pregnancy for a number of years after the death of the fetus. We knew with perfect certainty all about this case, and for about eighteen years she has carried on the left side a condensed ovum of extra-uterine pregnancy. I doubt very much if there could be found in the whole world three other such cases; whereas the number of cases who die or have prolonged illness after the suppuration and discharge of the fetus is, even in my own experience, very great. In closing his letter, Mr. Tait writes: I wish you would make this opinion of mine known on your side. In reply I will state: 1. We do not in this country practice. electrolization in cases of extra-uterine pregnancy. No puncturing needle is used, and the electro-magnetic current will not endanger the life of the patient any more if the growth to be acted upon is a tumor than if it be as presumed, an ectopic fetal cyst. The experience of seventeen years in the United States, in which no fatal result is believed to have taken place, has only tended to establish this feticidal method as a valuable means of saving women when in great danger from rupture of the fetal cyst and internal hemorrhage. 2. We do not propose to act upon the fetus after it has escaped into the abdominal cavity, unless the fetus should be very small and be easily accessible to the pole of the battery placed in the vagina. We cannot see that it will be any more a murder to destroy a two or three months' fetus after it has escaped from a Fallopian tube by rupture than while it is still in it. The chief objection lies in the fact that an ectopic fetus will be much more likely to give trouble after its destruction than one that is securely enclosed in a sac from which the amniotic fluid shall have been absorbed. It is true that an abdominal fetus may be delivered alive at term if permitted to live, but it is not correct to estimate the risk of such operations as lower than faradization properly performed, for it is far higher. Primary laparotomy, as far as we know of the operation, has been fatal in 15 out of 19 cases. It is not proposed in this country to operate by faradization upon fetuses of from four to six months. Dr. T. G. Thomas has, it is true, proposed to make the limit 4 months, but the general impression is that it is much safer immediately and remotely, if done in the second and third months, when fetal ossification is very incomplete. The entrance of fetal debris into the bladder is not necessarily fatal as in the case reported by Mr. Tait, for Parry refers to nine cases, four of which recovered. -Obstetric Gazette. Management of Breech Presentations. At a recent meeting of the New York Academy of Medicine, DR. ROBERT A. MURRAY read a paper with the above title (New York Medical Journal), which dealt principally with the measures necessary to be taken to deliver in breech cases and to diminish the percentage of mortality. The importance of an effort in this direction was apparent from the fact that the statistics quoted from authorities, gave a mortality in breech presentations of about one in eight and a half cases. Among the causes of this class of presentations were a contracted pelvis, an excessive amount of liquor amnii, violent movements, and a peculiar formation of the lower segment of the uterus. It was also remarkable what a large proportion of the cases occurred in premature labor and multiple pregnancy. The statistics of Simpson went to show how frequently, the child being dead, the loss of tonicity of the spine and the presence of flaccidity in the tissues, caused malpresentations; those tables demonstrated that there was a constant tendency after the sixth month of pregnancy for the head to present. In a case of breech presentation in which the mother's pelvis was of full size and regular form, and the child of moderate proportions, labor would probably be accomplished without particular difficulty, and the obstetrician had only to wait. If, however, the indications were that the labor would be difficult, if the pelvic cavity was not roomy, or the child of large proportions, version, if it was to be performed, should be done early before the rupture of the bag of waters. If the case was allowed to progress, no obstruction being met with, the critical moment for the child would be just after the birth of the trunk and lower extremities, for now the cord was in danger of becoming compressed between the unyielding head and the pelvic wall. The cord should be pulled. down and placed next the sacro-iliac synchondrosis by the side of the child's head, where it would be least likely to become compressed. The contractions of the uterus might be followed up by the hand, and flexion of the head might be aided by raising the trunk of the child. But in cases in which the limbs were extended upward over the front of the child, so that the toes were near the face, the breech was not nearly so large as the child's head, and, being readily moulded, entered the pelvic cavity; the entire fœtus then presented, as Barnes had well described, the form of a wedge with the base upward. Now, if traction was made by means of hooks, fillet, or forceps, and unsuccessfully, as it was likely to be, the apex would be dragged into the pelvis, and, the cavity becoming more tightly filled, compression of the cord would be increased, and the uterus rendered more irritable, and here the only measure for the safety of the mother and child was to bring down a foot. The use of the blunt hook to do this was difficult, as it was apt to slip and injure the soft parts, or cause fracture of the thigh; consequently, if the child was living, it should not be resorted to. The fillet, if it could be guided over the limb, might cut the tissues or prove too weak to overcome the difficulty. The obstetric forceps had been recommended in these cases, but it was condemned by most authorities. It was only adapted for use on the head. The performance of cephalic version, as recommened by Spiegelberg, would be possible only before rupture of the bag of waters and before the breech became wedged. The clear indication in such a case was to break up or decompose the obstructing wedge, which was to be done by bringing down one foot. The position of the breech in relation to the pelvis having been determined by ordinary diagnostic points, the hand was to be passed in front of the breech where the foot lay, and one foot seized by the instep and brought down; then the breech would probably soon descend. The cord would be better protected than if both feet were brought down. The foot nearest the pubes was most easily drawn down. If the case was not otherwise complicated, the labor would now go on naturally. If the breech filled the brim, or was forced into the pelvic cavity, little space would be left for the operator's hand, and under these circumstances the hand would have to be passed up to the fundus uteri in order to grasp the foot. That hand should be introduced whose palm would touch the abdomen of the child when introduced. When the foot was reached, preferably the anterior one, it was to be seized by the instep and drawn down out of the vulva. It was essential to get hold of the foot; taking hold of the knee, or hooking the thigh in the groin, would be of no use. During the operation the uterus should be supported by the other hand or by an assistant. If inertia uteri should now exist, we should still have attained by our hold on the foot security for further progress of the case. The operation of extraction by the breech might be divided into: 1. Drawing the trunk through the pelvis. 2. Liberation of the arms. 3. Extraction of the head. the head. Traction on the leg should be carefully made, in drawing the trunk down, coincidentally with the pains. The trunk should be drawn downward and backward in the axis of the brim, external pressure being made by an assistant, the traction being kept up until the breech was fairly in the pelvic cavity. After the extraction of the breech, the cord should be carefully looked after. Liberation of the arms might become necessary if the pelvis was at all contracted, or if traction upon the trunk had been too rapid, or had not been accompanied by external pressure on the uterus. The head being at the brim, Smellie's method might be employed in the manner recommended by Schröder, or the method of Scanzoni. In all cases of breech presentation the forceps should be at hand ready for application to the head if it should be necessary. Particular care should be taken during its introduction not to lacerate the cervix. Passing a catheter up into the mouth of the child at this stage would frequently save life. The subject of the management of breech presentations had been brought to the author's mind forcibly during the past year from the number of cases which he had seen in consultation, in nearly all of which he had found difficulty arising from flexion of the legs on the abdomen, diminishing the size of the breech to a certain extent, and at the same time forming a wedge that became more tightly impacted as the child descended. In all of these cases unsuc cessful efforts had been made to extract before he was called, and he was impressed with the advantage of introducing the hand and bringing down the foot over other methods, such as the use of the forceps, the blunt hook, the fillet, etc. Mammary Functions of the Skin in Lying-in The breast may be regarded as a highly specialised sebaceous gland, or, at least, as a highly specialised cutaneous gland. It may have developed proteid and carbohydrate. Dr. Champneys' most careful and detailed description of the axillary lumps forms the result of an equally sedulous research, which, so far as is known, is unprecedented, and therefore original in the true sense of the word. The lumps that he described as situated in the axilla may, for all practical purposes, be regarded as mammæ. Their evolution follows step by step that of the mammary glands in parturient women, and there are some grounds for believing that they may be the seat of similar pathological affections. Further, Dr. John Williams bore testimony to the effect that, like the breast, the axillary lumps may show changes during menstruation. Lancet. Inflamed Nipples. For sore nipples, DR. WILSON, of Glasgow, recommends: R. Plumb. nitrat., grs. x-xx; glycerini, 3 j. M. Apply before the child is again put to the after suckling, the nipples being washed breast. DR. PLAYFAIR recommends: R. Sul 3 ss.: water, 3 i. M. Apply after suckling. out of the indefinite blastema of the epiblast, either directly or through the intermediary stage of a sebaceous phurous acid, 3 ss.; glycerite of tannin, gland. The distinction made by Dr. Creighton at the discussion of Dr. Champney's paper at the Royal Medical and Chirurgical Society, will, in view of deeper embryological considing erations, appear to be of not great importance. For it is plain that the glandular structures to which "he referred must have originated from epiblastic germs, as the sebaceous sweat, and mammary glands have also done. That a sebaceous gland is also a miniature breast must be regarded as theoretically proven from a chemical standpoint. Milk is a chemical compound in certain proportions of albumen, fat, and sugar, and analysis of sebaceous matter also yields fat and a small proportion of DR. BARNES recommends: After wash away remains of milk after nursing, smear with salve made of: R. Liquor plumbi, 3i.; prepared calamine powder, 3i.; glycerini, 3 i.: M. Vasaline, 3 vij.-Quart. Comp. of Med. Science. Hydrocephalus in Utero; A Case. DR. F. H. LITTLE (Iowa State Medical Reporter): I was called to see Mrs. S., a stout young German woman, the mother of a healthy boy of about two years of age, and at this time in labor with her second child. |