operation four times during the last week, one patient being only eleven months old, suffering from both laryngeal and pharyngeal diphtheria; the urgent symptoms were at once relieved. In another case aged eighteen months, where death was impending, the tube was introduced without difficulty and the child relieved, and recovery would without doubt have been the result had not the child died of pneumonia on the second day. In another case, one of malignant diphtheria in a child of two years, the patient succumbed on the second day after the operation. In another case he found the patient cold and livid, pulseless, and unconscious. After the tube was introduced cold water was dashed on the child's face, and in about five minutes he looked around and asked for his father; took some milk and passed into a quiet sleep. This child died from pneumonia three hours later. DR. WAXHAM said that in the eight cases that recovered,

in every instance false membrane was observed; when the tube was introduced the membrane was ejected, either in large flakes or broken-down masses. He recommended that in treatment after intubation nothing at all irritating should be given, as when a child takes fluid of any kind a few drops will trickle into the trachea and cause violent coughing, and this irritation will often lead to pneumonia. In a child rugged and strong bichloride of mercury may be given to hasten disintegration of false membrane. The most remarkable case coming under his observation was a child of four years upon the verge of suffocation, when, upon the tube being introduced, a considerable portion of false membrane was thrown out through the tube and the violent symptoms subsided at once. The thread was removed, and the second day after the operation the child was playing about the room and continued about the house during the four days that the tube was worn, and finally made an entire and perfect recovery. DR. WAXHAM thought that in regard to the comparative value of tracheotomy and intubation very much might be said. The text-books give as the percentage of recoveries tracheotomy about one in three, but these statistics are made up from the most favorable reports. If a physician has one recovery out of three or four cases he is justly proud of it and reports the case; on the other hand, if there is one recovery out of 15 or 20 cases, no report is made. He had known one physician to have operated 50 times with but two recoveries. DR. WAXHAM held that the thread should always be removed, as it is a constant cause of irritation, and that no difficulty need be experienced in removing the tube with extractors. He thought intubation had a grand future.

from

DR. E. FLETCHER INGALS did not take an enthusiastic view of intubation excepting for

In

young children, when he thought it would be found more satisfactory than tracheotomy. very young children tracheotomy does not result well, and he thought intubation would be unsatisfactory in older ones until we have larger tubes. He stated the accepted opinion of surgeons to be that a tube of less than onefourth of an inch in diameter cannot furnish sufficient air for a child to live on. DR. INGALS thought that DR. WAXHAM had been remarkably successful with intubation, and had demonstrated its utility, for which he deserved credit. DR. INGALS thought that intubation of the larynx is preferable to tracheotomy in children less than three and a half years of age; children much older than this cannot get a sufficient amount of air through the tube now in use. He said, also, that in performing one operation he had had trouble with the gag, which was not large enough for the child, a boy of five years, who lifted his teeth from the gag and closed them on the doctor's finger. He thought there was no need of the thread remaining, as there could be little difficulty in removing the tube. DR. INGALS thought in cases where it was difficult to get the consent of friends, or where the conditions are such that tracheotomy cannot be performed right away, intubation would be of value; there are cases not membranous in which intubation may be of value. The statistics looked pretty bad for tracheotomy, but he had seen statistics of 15 or 16 cases where half of them were recoveries. His success had not been quite so good, but he attributed this to the fact that he had operated on five children who were almost dead, or at least had stopped breathing before the operation began. He had the good fortune once to save a child who had not breathed for what seemed to him 20 minutes. One of the strong points in favor of intubation is that it may be done early, and it does no harm even if unnecessary.

DR. H. T. BYFORD said that there was another way of drawing the line which would more accurately describe the usefulness of the two operations. Intubation seemed to him the operation for private practice, and statistics so far are comparatively favorable to it as such. But the cooperation of the patient's friends, the preparation of the inspired air by passage through natural channels, the freedom of intubation from grave responsibilitiy, its bloodlessness, the simplicity of treatment afterwards, as well as the greater rapidity with which the mucous membrane around the vocal cords will get well, are conditions which have less bearing in hospital practice, where we have trained nurses and all modern appliances, and there is more hope of success in tracheotomy. While he did not think this latter operation favorable for private practice, such advantages as having the tube under the eye, and within reach of

the fingers, of an attendant, the case of local medication, the possibility of removing shreds of membrane and plugs of mucus, and of inspecting the parts by removing the tube, and which, in hospital practice, must secure for it some consideration. He said that there was one clinical fact that had not been mentioned in this connection, yet which, more than all other things put together, accounts for the success of intubation and the failure of tracheotomy as life-saving measures: in the one the patient can cough; in the other he cannot. After intubation the patient can normally close the glottis, compress the inclosed air in the lungs, and with sudden expulsive force expel everything that is sufficiently loosened. This accounts for the fact that with such a small tube the patient experiences no difficulty. After tracheotomy the patient has no means of compressing the air and expelling it with sudden expulsive force; he can simply inspire and expire forcibly and after exhausting efforts get rid of a little of the mucus. This desperate condition of affairs has led some surgeons to employ the dangerous and barbarous custom of introducing feathers or other irritants into the tube to stimulate the mucous membrane, which excites the patient and scatters the mucus both upwards and downwards. When somebody invents an appliance which will enable the patient to really cough through the tube, then tracheotomy will be placed upon a rational basis, and will stand some chance of becoming a useful operation. The doctor thought that tracheotomy had made a poor showing for its years of trial.

DR. G. C. PAOLI said that malignant diphtheria is a morbid poison, and that in epidemic cases there are very few recoveries. He stated that in such cases exudation takes place in the larynx or pharynx, and that an operation would only result in sending the patient more quickly to another world.

DR. W. E. QUINE said that he had operated 12 times for tracheotomy and had not had one recovery in diphtheritic cases. He knew he was not alone in an experience of unvarying failure in cases of this kind; and he knew some surgeons now regard tracheotomy with very little enthusiasm. Itseemed to DR. QUINE unfair to place intubation of the larynx in contrast with tracheotomy upon the basis of the assumption that tracheotomy is always a dernier ressort, that it is done when the patient is absolutely moribund, and that intubation is done under the most favorable circumstances. This is not the fact. DR. QUINE said he was personally cognizant of two of Dr. WAXHAM'S cases in which the patients were in extremis, and in which death would undoubtedly have occurred in two or three hours had not relief been afforded. Surgeons rarely had occasion

to perform tracheotomy under more discouraging circumstances.

DR. J. J. M. ANGEAR said he wished to call attention to a physiological and anatomical fact that had not been alluded to, viz: that the arytenoid cartilages are not mature and that the chink of the glottis is held open by positive muscular action in small children, whereas in adults and older persons the arytenoid cartilages are mature and the chink is never closed. DR. ANGEAR said that a large number of children who suffocate will suffocate when there is no membrane present to cause suffocation, but simply some diseased condition that has interfered with the action of the delicate little muscles that draw back the arytenoid cartilages.

When inflammatory action has interfered with these muscles drawing back the artyenoid cartilages, some mechanical interference like this tube will assist these muscles to keep the chink of the glottis open and let air in. He thought a large number of children who died of diphtheria did not choke to death, but died of poison in the system, and he did not think either the tube or the tracheotomy, or any other process, could save them. If there was interference with the opening of the chink of the glottis, he had no doubt that the introduction of the tube would save the life of the child.

DR. J. S. KNOX said that the curses of tracheotomy are the subsequent thoracic complications, either heart clots or congestion and inflammation of the lungs, producing fatal results, and the reason probably is that tracheotomy is the final resort in cases of laryngeal obstruction. He thought that if tracheotomy were performed as early as intubation, there would be fifty per cent. of recoveries. great advantage of intubation is that it can be performed early, and the early operation of intubation would no doubt save many a life that tracheotomy would not save if performed late. He thought that tracheotomy performed as early as intubation would show as good results.

The

The PRESIDENT said that he did not intend to say anything against the practice of intubation, but he did not believe that it would take the place of tracheotomy. The early experience of the president in tracheotomy had been almost the same as that of DR. WAXHAM in intubation. In the first fifteen cases operated on but half of them recovered, and bis later experience was better than that reported by DR. WAXHAM, as within the last month he had had three cases of tracheotomy, all recoveries, while DR. WAXHAM reports four cases of intubation, all fatal. So far as his own personal experience went, he thought tracheotomy had the advantage. The president thought that if he should put a tube in a child's

throat for the relief of laryngitis and the child died without his having performed tracheotomy, he should consider himself very much to blame. He had no doubt that cases of extreme diphtheritic laryngitis got well after tracheotomy; he had seen diphtheria of the pharynx and of the larynx recover after tracheotomy. Although he did not feel enthusiastic about intubation, he thought it had a very good place and that in many cases might be very useful, but could never supplant tracheotomy.

DR. WAXHAM said he never found the tube occluded when it was removed. In one case when he introduced the tube a portion of the membrane was crowded down ahead of it, obstructing it entirely, and the tube was ejected and was then completely filled with membrane; the child recovered subsequently. On removing the tube on the fourth or fifth day he did not find it occluded.

DR. A. B. STRONG said, in conclusion, that he had had some experience with tracheotomy, having had twelve cases with but one recovery. He had no doubt that in cases of diphtheria the membrane could come up through the opening. The case read was reported as spasmodic croup, and was not supposed to be one of false membrane, but he believed the child would have died without interference, and that belief was shared by DR. DANFORTH, the attending physician. DR. STRONG said that he would hardly feel safe in leaving the tube in the trachea of a child without the thread. He agreed with the president that large pieces of membrane could not readily pass through such a long tube. In the case reported the tube was entirely free from membrane or pus when taken out.

A LARGE LIVER.

BY C. W. HEFFNER, M. D., BELLEFONTAINE,

OHIO.

This case is of interest to me for several reasons, but especially for two, viz: Its rapid growth, and because I do not know what the trouble was.

The unfortunate man was 39 years old; had, for several years, been employed as laborer in a gas works; complexion dark; well muscled and rather firmly built; always had very good health, never had any sickness. As I get the history of the case it runs as follows: About Feb. 1st, 1885, he began to have slight uneasiness, after meals, in the stomach, also a feeling as if "bloated;" no pain of any sort, and working all the time at driving wells, having left the gas house and entered the pump business. This "dyspepsia," as he called it, continued to trouble him more or less at times until about the 5th of August, 1885, when he said he noticed

an enlargement at the "pit of his stomach." Previous to this time, however, his bowels were very much constipated, and he frequently got medicine from his physician for them.

He continued at work again until August 25th or 26th, when not feeling as well as usual he rested, working again Friday and Saturday, August 28th and 29th. Sunday morning, Aug. 30th, he noticed for the first time that his feet were slightly swollen. This alarmed him and he called his physician. He had noticed for three or four days previous to this that his breath was shorter, but thought nothing of it. He was going about and this, with the treatment given him, lessened the oedematous condition of the feet, and to all appearances he was better. On September 7th he was up town to see his physician, having for a day or two been shorter of breath than usual. He now noticed that the "swelling" in his side was slightly increased. Tuesday night (Sept. 7), being so much more distressed than usual, he had his physician called, without, however, gaining any relief. Enlargement in the region of the liver increased very rapidly. Wednesday found him no better, but very much worse; breathing rapid, pain not so bad until evening, when the suffering was considerable. Thursday morning found him very much worse pulse 120, respiration 60, shallow and painful; suffering intense. Thursday at 4 p.m. he changed physicians. Friday morning at 8 a.m., in company with attending physician, I saw the patient. Found pulse 160 to 200, irregular and intermittent; temperature slightly below normal; respirations 80 per minute, actually panting. Hypochondriac region very much distended; pain almost intolerable.

I do not know the treatment before, but now he got hypodermic injections of morphine, gr. ss, and atropine gr. . This did little or no good, and he died at 11 a.m.

Post mortem revealed everything normal, save the liver, which was very much enlarged, weighing 19 pounds. The surface was smooth, and perfectly intact. There was no part of it broken down, no hard nodules, but very heavily pigmented. I was so anxious to know the cause of all these peculiar phenomena that I sent a specimen to a microscopist for examination, but never got any return. One diagnosis before death was Hodgkin's disease; another was cancer of the stomach.

I report the case because of the size of the liver, because of the little attention it attracted until so near the end of life, and because of the uncertainty of its cause.

The COUNT DE LAUBESPIN has contributed 40,000 francs to M. PASTEUR in order to enable the scientist to extend his operations for the prevention of hydrophobia.

OPIUM TREATMENT OF PUERPERAL PERI

TONITIS.

BY GEORGE A. TROTT, M. D., BUCKHOLTS,

TEXAS.

On January 9, 1886, I was called on to attend MRS. B, in her fourth confinement. Examination revealed a cicatrix encircling threefourths of the os uteri, and which I attributed, after questioning the patient, to cauterization for ulceration, several years previous. After ten hours of only ordinarily severe labor, and without instrumental interference, she was delivered of a healthy girl child, weighing eight and one-half pounds. The cicatrix having been necessarily torn asunder in several places during dilatation of the os, and finding the mucous surface of the vagina somewhat abraded, I thought best to order an antiseptic wash to anticipate, and if possible, prevent any evil results. I accordingly ordered 3 j of boracic acid in a pint of hot water twice a day.

Notwithstanding this precaution, I was informed on the 12th, that MRS. B. had had a severe rigor during the night, and I found her suffering with all the usual symptoms of puerperal fever; temperature 103°, pulse 130, and respiration 20; tenderness confined to the uterus. I ordered the boracic acid enema increased in frequency to every four hours, and gave iodine and salicylic acid alternately.

The morning of the 13th, found my patient in the same condition. Treatment continued, with the addition of occasional doses of digitalis to strengthen the heart's action. On the 14th, at 9:00 a. m., the soreness had increased and extended to the peritoneum, and the patient complained of exhausting sweats whenever she fell asleep. She was troubled with vomiting and was perceptibly weaker, with no abatement of the febrile symptoms. I immediately ordered Dover's powder, 12 grains every hour, till she had taken three doses, then continued every two hours for ten hours, making 96 grs. in 15 hours. By this time my patient was thoroughly narcotized; respiration 12, pulse 70, and temperature 99°, with gentle perspiration, and pain and soreness all gone. There was no return of the fever, and the patient progressed rapidly on tonic treatment and is now up.

The will of the late PROFESSOR ROBIN contained the following clause: "If I die in Paris, let my autopsy be made at the earliest possible moment after my death, by one of the prosectors or attendants of the Ecole de Medicine, to be designated by the Dean. My brain and eyes should be removed and studied comparatively. The left eye was destroyed by a blow in 1835, and the optic nerves and convolutions should be studied with this fact injview."

Correspondence.

HEAT AS AN OXYTOCIC.

During the past year there have been three communications in the AGE concerning heat as a new means of hastening labor. There were also a number of articles on the same subject in other journals.

Those old practitioners who are so generally denominated "mossbacks," and "fossils," who know full well that their grand-mothers made use of heat for the purpose noted, are probably keeping still because they dislike to spoil the enjoyment of the new discoverers. I know of many old ladies who learned it from their mothers and grand-mothers, and if it were possible to trace it back we would probably find that these Israelitish women who were too smart for the Egyptian midwives knew of it and practised it. From a somewhat extensive acquaintance among country practitioners in Southern Michigan, I know that for the last fifteen years it has been commonly used, both by neighborhood midwives and medical practitioners. It is no uncommon thing when reaching a confinement case to have the women in attendance remark that they had not dared to soak the patient's feet in hot water, nor put hot cloths to the abdomen, nor give any hot drinks for fear the doctor would not get there in time. A common practice is to take two good-sized flannels, and keep one heating in a common steamer while the other is applied as hot as can be borne to the abdomen and vulva. This, with many practitioners, is considered a good reliable preventative of the rupture of the perineum. CHURCHILL recommends it for the latter purpose.

ADRIAN, MICH.

M. R. MORDEN, M. D.

P. S. Since writing the above I am reminded of a story that seems to "fit in" so well on this subject of oxytocics that I am constrained to ask you to give it space as a post-script to the above.

While spending a cold winter's night in a farm house, in attendance on a case of confinement, a good old Baptist sister relieved the tedium of the slowly dragging hours with some very droll and amusing stories. Among others she told the following:

Two young men, brothers, went west to speculate. They reached a frontier hamlet that, as yet, had but one doctor. At the hotel one was heard to call his brother "Doc." It soon got noised around that а young doctor had arrived, and was looking for a good opening in which to locate. One night a man came to the hotel after bed time, and said that the village doctor was away off on the plains several miles, and

that his wife was about to be confined and he wanted the young doctor that he had learned was stopping at the hotel, to come over and attend the case. "Doc." was accordingly aroused, and his brother taking in the situation, told him, in a whisper, to get up and go, and to make believe that he knew all about it anyhow and have some fun. Accordingly he dressed and went as requested. He made careful inquiry concerning what the women present had already done. They told him how they had used hot drinks, hot footbaths, and hot cloths to the abdomen. He informed them that their treatment was just what he should have used had he been there, and then he asked them if they had "quilled" her. This produced a sensation. Some of the women looked surprised, but could not refrain from giggling. Finally one of their number said they did not know what that meant. He then very coolly asked for a quill and some Scotch snuff, both of which were promptly produced. Having filled the quill with the snuff, he put one end up the patient's nose and blew at the other end. The patient went into a violent fit of sneezing, the waters broke, and in ten minutes the child was born.

The telling of this story made our patient laugh heartily, and as a result a violent pain came on, which was rapidly succeeded by others, and soon delivery was accomplished.

I know full well of another case, where a young physician was sent to a case of confinement because of sickness in the family of his senior partner, who was the patient's choice. The husband kindly warned the young doctor that his wife would be angry and out of patience with his coming, and that he must make the best of it and not mind what she said.

Sure enough, the young doctor found he had got himself into a hornet's nest. He put up with hard "hetchelling," and made himself as useful as he could, assisting about the application of hot cloths, and other means, to at least keep up a show of doing. Whining and faultfinding, however, he found to be his portion, with no show of a let-up. Finally he jocularly told her that he thought he should sit her up in a rocking chair, get in bed himself, have hot cloths applied, let somebody pull on his hands, and he would see what he could do." This made the attendants laugh, but so enraged the patient that a violent pain came on, which lasted a few minutes, and ended in a safe delivery. I am not sure that mental impressions and sneezing have ever been properly noticed and classed as oxytocics.

M. R. M.

INJECTIONS OF HÆMORRHOIDS.

In the AGE of Jan. 25, N. P. BLAKESLEE, of Elmira, Mich., in his query regarding the injection of hæmorrhoids for radical cure, asks:

After

Hav

Was called to the country to attend a lady who was said to be ready to be confined. On arriving at the house I made examination, and found the labor had progressed so far that the os was dilated to the size of a half dollar. Pains slow and sluggish. The woman, however, was strong and healthy, but seemed to be nervous and excited, as she said it was two months too soon for her confinement. The child, however, was born alive, and the head presented. waiting half an hour I gave her a drachm of ergot, followed by three others, in space of an hour. The pains became very severe and more frequent, but the labor did not progress. ing given all the ergot I had with me, I tried pressure, had the woman sit up, and various other ways to cause the labor to proceed, as I had no forceps with me. After two or three hours' waiting I had the pleasure to see the child born with three terrific pains, but I was surprised to find a very small child, it only weighing three or four pounds, and the woman having a very large pelvis. After giving the child over to the nurse, and turning my attention to the woman, I found a partially delivered fœtus of about six months, with head crushed to a jelly. After a half hour I delivered this with a great deal of trouble, and following it, two distinct placentas corresponding to the ages of the fœtuses.

Query: Were there two distinct conceptions at two different times?

ALBANY, MO.

G. W. WHITELEY, M. D.