such an apparatus which it is stated could be used by "unskilled persons" I am quite certain I would have lost many of my patients. In the cases referred to, if too great pressure was produced, the oesophagus would expand and cause stomach inflation, but by careful inspirations for a time, followed by pressure on the abdomen, it would pass away without inconvenience.

What appears to me may be urged as facts of value in this connection are the following: The passage to the lungs under ordinary conditions of unconsciousness, except, and even sometimes in swallowing, is always open. The air forced into the lungs does not, as is generally believed, cause a closure of the glottis any more than the deep auto-inspiration of ordinary respiration. Exceptions may be taken to all rules of course.

If forced respiration by my method, use of face-mask, etc., be carefully conducted, the lungs may be as fully inflated as under deep auto-inspiration, and the respirations kept up for a period of time ranging from one to ten hours, according to size of individual and degree of obesity. Thin, spare patients appear to be better subjects than those of opposite build. In the few cases in which from continued work with complete paralysis, the tongue has fallen back and occluded the larynx, a ligature has been placed through it and the organ held forward. Usually extension of the neck will raise the glottis, but cannot always be relied upon; in such cases intubation would be of value. After the face-mask has failed in one or two instances I have saved life by performing tracheotomy, which was called for through the cases being narcotized by opium, (vide previous remarks).

As to intubation, it may have its place in some cases of forced respiration, but to urge its value over the use of the face-mask when the latter has accomplished so much, is unwarranted.

In my earlier cases I was called to attend an infant eighteen days old, which had been given one grain of morphia through the mistake of an old and experienced homoeopathic practitioner. I had not learned the use of the facemask, and was compelled to make tracheotomy, by which forced respiration was kept up for some four hours. The face-mask would have worked admirably in a case of this kind, but only with a suitable apparatus on account of the short respirations in so young a babe. Through various steps in my investigations, I have been enabled to prove its great value; it will save many a life when intelligently applied where the methods of Marshall Hall, Sylvester, or other methods of artificial respiration will fail.-G. E. Fell, in Archives of Pediatrics.

CLINICAL NOTES ON PARALYSIS OF THE DIAPHRAGM.

PARALYSIS of the diaphragm is a rare affection, but in my opinion it is frequently overlooked, though it may be easily detected if searched for. During the past year I have met with six cases. The first case, which I saw with Mr. Stanley, of Small Heath, was that of a young gentleman who had strained his neck over a horizontal bar in an athletic display. Within an hour he complained of numbness and weakness of his legs, and when I saw him these symptoms had increased. He had difficulty in swallowing, and scarcely any power of phonation. I found paralysis of the right half of the diaphragm, the left half acting but feebly. By keeping the patient absolutely at rest, and by careful

feeding, with frequent application of a faradic current to the right phrenic nerve, the patient was kept alive. The diaphragm gradually recovered power, and in six or seven weeks he was quite well. The lesion in this case was probably hæmorrhage around the cord above the origin of the phrenic nerve, the pressure being greater on the right side.

The second case, which I saw with Mr. Hall-Edwards, was that of a young lady who was suffering from influenza, and I was called in on account of severe neuralgic pain in the right lower extremity. The pain was paroxysmal, and of such severity that morphine injections had to be given constantly. On my second visit I found the right half of the diaphragm paralysed. There was no dyspnoea and no alteration of the voice. We decided to apply a faradic current to the phrenic nerves, one pole being placed at the lower end of the anterior triangle in the neck, the other over the hypochondrium. The patient improved with this treatment for a day or two, and then died quite suddenly. This was in my opinion a case of acute multiple neuritis, and the paralysis of the right half of the diaphragm was due to neuritis of the right phrenic nerve, the implication of the left nerve being the probable cause of sudden death.

The next three cases were all due to diphtheria, and were all fatal. I believe that paralysis of the diaphragm is the cause of the great majority of sudden deaths after diphtheria, and that only a few can be attributed to syncope. I believe also that in many cases the diaphragmatic paralysis is not recognized. Of the three cases one was a man and the other two children. In all the cases paralysis of the legs was present, and there was no difficulty in recognizing the diphtheritic origin of the mischief, though in one case the sore throat had been very slight. While at rest in bed there was no dyspnoea, but phonation was very feeble and defecation and micturition impeded. On examination of the abdomen the diagnosis was readily made. The hypochondrium on the affected side became depressed on inspiration instead of being propelled forward, and by placing the hand under the ribs the non-descent of the diaphragm could be easily ascertained. There was compensatory overaction of the lower intercostal muscles and great enfeeblement of the breath sounds at the base of the lung on the affected side. In each case the right half of the diaphragm was chiefly affected, but I believe this is due to the presence of the liver on this side and to the inability of the weakened muscle to push the organ down, while on the left side the muscle can descend until quite paralysed.

In all three cases the paralysis was recognized a day or two before death, and special precautions taken, but in each case death occurred quite suddenly. One little boy was brought to my consulting room; observing the feeble cough. and phonation, I had him stripped and examined the diaphragm; I found it paralysed. This enabled me to caution the parents of his grave danger, and I heard afterwards that he died suddenly the day after seeing me. If both halves of the diaphragm become paralysed, death ensues from asphyxia, and the fatality of diaphragmatic paralysis after diphtheria can easily be understood when we remember the severity of the neuritis which frequently follows diphtheria, some patients being paralysed for a year or more.

As to treatment I would recommend that every case of diphtheritic paralysis be kept in bed from the first, and that plenty of nutritious food be given. Iron and strychnine should be administered in large doses. If weakness of the

diaphragm is observed the patient should be raised in bed with pillows, so that the diaphragm may act more easily. A gentle faradic current should be used three or four times a day, and blistering fluid painted over the course of the phrenic nerve in the neck. Stimulants should be given freely.

The prognosis of paralysis of the diaphragm after diphtheria is very grave, and its onset may possibly be prevented by keeping patients in bed and at rest whenever any signs of paralysis are present. The early recognition of paralysis of the diaphragm is very important from a prognostic point of view.

The sixth case was that of a woman, aged thirty-seven, admitted for a second attack of alcoholic paralysis. The hands and feet were dropped, and the usual symptoms were present in a typical manner. The diaphragm was observed to be paralysed, and the patient died suddenly a day or two after this observation. I am not aware that paralysis of the diaphragm has been previously observed in alcoholic paralysis, or that it has been noted as a cause of sudden death, most of such deaths being attributed to cardiac paralysis. This case emphasizes the great similarity that exists between alcoholic and diphtherial paralysis, and as alcoholic paralysis is recognized as being due to multiple neuritis, the paralysis of the diaphragm being also due to neuritis of the phrenic nerves, we may reasonably infer that paralysis of the diaphragm after diphtheria is also due to neuritis of the phrenic nerves. In none of the above cases could a post-mortem examination be obtained.-Dr. C. W. Suckling in British Medical Journal.

BROMISM.

PROFESSOR LÉPINE contributes an interesting article upon this subject. The dose of the bromide of potash has changed very much during the last few years. Gubler found a dose of six grams enormous; most of the French works give ten grams as a maximum dose. Two of the more recent ones, Soulier and Manquat, give this as a limit. Specialists, meanwhile, have a tendency to overstep this, and the tendency seems to be to increase it more and more. Féré, whom every one will concede to be a competent authority, is less reserved than formerly, and does not fear to administer from twelve to fifteen grams. In England, Gowers goes still further, and gives even thirty-one grams at a dose, which he does not advise one to overstep, on account of the vomiting which it is liable to cause. The English do not administer daily doses, but prescribe rather a dose every second, third or fourth day, so that there is given a long time for elimination. As to the German authorities, as for example, Nothnagel and Rossbach, Tappener and Penzoldt, they mostly give fifteen grams as the maximum dose; Bernatzick states twenty grams, and Baehm the same. The writer is not desirous of disadvising the use of these doses as they are sanctioned by undoubted authorities. Experience has also shown that these doses are not dangerous; but the question is, are they necessary.

He does not regard it as sensible to begin with enormous doses when possibly a smaller one will do. Above all, one should not injure the patient, and it is a question whether such doses, as have been mentioned, can be given without harming, even though naphthol simultaneously be given, as Féré recommended. The writer has found antisepsis of the intestinal tract to prevent cutaneous eruptions yet not to influence the nervous depression. He has observed nervous

symptoms of bromism, and he has been struck by their insidious development. The diagnosis is not always easy, and he is convinced that, in case that they are misunderstood they may produce death. Most writers on therapeutics give the symptoms of chonic bromism. Sollier has presented an especially good description. There first appears a dyspeptic condition, which is followed by bronchitis; then eruptions, and finally cachexia, which is characterized by emaciation, an earthy complexion, incipient paralysis of the extremities, trembling of the limbs and coldness, a dirty coating to the tongue, anorexia, diarrhoea, apathy and weakness of memory, sometimes delirium, hallucinations, and intense headache, as well as mydriasis of one eye. Nothnagel and Rossbach also give thirst, and a cough resembling whooping-cough. At the same time there is absence of the pharyngeal reflex and difficult speech, which, in combination with the clouded intellect and tremor of the hands, might lead one into making a mistaken diagnosis of progressive paresis. This is the classic picture of bromism, in its chronic form. The writer does deny the correctness of this, but will question whether all these symptoms will present themselves in the given order. Some may be lacking and the cachexia may appear before the bronchitis; in short, it is of importance for the practitioner to know that the symptoms follow no regular order in their appearance. The writer has recently seen a young tabetic lady, who took the bromide of potash in doses of four grams daily, for the treatment of convulsive attacks. After a few weeks the patient, who was weak and run-down, began to become still weaker and delirious. No eruptions or bronchitis, so that if one had waited for the development of those symptoms, death would surely have intervened. The writer recognizes bromism by the mental and bodily weakness, delirium and difficult speech. If the bromide be discontinued the symptoms soon disappear. Voisin has described a peculiar form of bromism, where, together with the symptoms presented by the writer's cases, there are, besides, distinct and violent delirium, which is described as a general delirium accompanied by hallucinations, ideas of persecution and of fear of being attacked, etc. The writer observed nothing of the kind in his cases. The chief danger of bromism is the depression, which danger is by no means exaggerated. As a rule, leaving off the remedy is followed by a restitution to the normal, yet recovery sometimes may be very slow. Kloepfel has communicated the case of a patient who fell into cachectic state from a three-years' misuse of the bromide of potash, and who required six months to recover. Culler reported the case of a morphine-taker, who was treated with increasing doses of the bromide of sodium, consuming one hundred and twenty-five grams in a week; he fell into a lethargic state, lasting eighteen days, during which time the most violent cutaneous faradization was followed by no reflex. Life was sustained by rectal feeding. Cases which have ended fatally have been recorded. Dr. Hameau has reported a case, where a twenty-two-year-old woman, who was epileptic since her seventeenth year and who was treated with increasing doses of the bromide of potash, two to sixteen grams. In the course of a year she had taken two kilograms of the drug. She was emaciated, cachectic; her forehead was covered with copper-colored papules; she suffered from gastralgic pains and colicky attacks; and, finally, a dry cough bothered her. Delirium set in and she died the following night. A case, described by Dr. Eigner, and of more recent date, a young female epileptic, nineteen years of age, took, in the course

of a year, at least six grams of the potash salt, and in the last two weeks, ten to twelve grams per day. Besides a universal acne and a badly smelling breath, she presented nasal and pharyngeal catarrh, salivation, the saliva being able to be drawn out in shreds, anorexia, meteorism, pains in the forehead and lumbosacral region, and weakness of memory. Toward the end there appeared: somnolence, unequal pupils, trembling of tongue and hands, diminution of the sensibility of the lower extremities, and decrease of the tendon-reflexes, as well as hesitating and difficult speech, without any actual disturbance in articulation. Finally there appeared psychic excitment, which increased to delirium, with hallucinations of the different senses. Death took place from broncho-pneumonia. The changes which take place in the nervous system under such circumstances are not well known; the accumulation of bromides in the tissues ie still a disputed question. Journal of Mental and Nervous Diseases.

SURGERY.

LANDERER ON THE TREATMENT OF FRACTURES.

THAT in the treatment of recent, simple fractures constant efforts should be made toward devising means for reducing the length of time of treatment and returning the patient to his labor, functionally capable, on the earliest possible day, all must fully admit. When, then, a surgeon of Landerer's repute sets forth procedures which he avers capable of accomplishing such advance he demands for such the most careful attention.

In the pamphlet under consideration Landerer lays down the broad proposition that early, permanent removal of confining dressings, together with passive or active motion, and systematic, intelligently applied massage, tend to such results.

Before considering in detail the various steps and proofs of this important allegation one may with pleasure note the author's disapproval of the employment of embrocations or ice in the early stage. "They belong," says he " to a by-gone age-they can have no beneficial effect; away with them! The surgeon's first duty is to make an immediate and absolute reduction and to at once apply a suitable, well-fitting apparatus which will maintain correct position." All surgeons will agree that only exceptional cases will be found in which this rule will not apply.

Turning for example, to a simple Potts' fracture, we find that at the earliest possible moment after the receipt of the injury the limb is placed in a suitable position with adduction of the foot, and a moderately padded plaster splint is applied. Under this, pain, muscular contractions and other discomforts abate at the end of twenty-four to thirty-six hours.

On the fourth or fifth day the splint is removed, good position of fragments and foot assured, and another plaster dressing applied, this time rather more snugly. The patient is now allowed to go about on crutches. On the tenth or twelfth day the splint is "sprung off," and systematic massage, with cautiously made passive movements instituted. These are carried out twice daily. On the thirteenth day the patient is allowed to place foot to ground, first with the