monium carbonate was given for the same purpose, and not as an expectorant. For elimination, small doses of calomel were occasionally given.

FREDERICK P. MUFFE, M.D. 425 Kearny St., San Francisco, Cal.

Some "Little Things" in Obstetric Practise. Editor MEDICAL WORLD:-Since I am fond of talking with intelligent people, and since, in my opinion, one of the best signs of intelligence in a physician is his being a regular subscriber to THE MEDICAL WORLD, I will join the journal's monthly symposium with a brief talk on a few practical points. To me, THE WORLD takes the same place in our profession that the prayer meeting does in the church. It stimulates to higher thought and study. It cares not for long lectures to fill up space, but simply wants the cream of current thought in the fewest words. Some of the most helpful things I have ever seen appeared in THE WORLD. For instance, I never knew how to successfully treat typhoid fever until I gained the knowledge from THE MEDICAL WORLD.

I want to speak of a few of the "little things" in practise. It is a good old saying, "If we will take care of the pennies the dollars will take care of themselves," and it is about the same way in medicine. The busy practitioner is apt to pay too little attention to small things.

Almost every physician can diagnose lobar pneumonia, but how many, especially if the patient is trying to deceive, could differentiate beginning erysipelas from sunburn? How can abscess of the breast be prevented or cured? This brings us back to the little things we should do.

The accoucheur is generally engaged for some time before the confinement is expected, and he should go to work at least one month before labor to prepare the patient for the ordeal. He should look well to her general health, and especially should give attention to the breasts. The multipara will need less attention than a primipara, so I will speak principally of the latter, altho the suggestions which I make can be applied to any one.

Some four weeks before confinement begin to harden the nipples. Dr. Turner Anderson, a successful practitioner and teacher, says that the best way to do this is as follows: Take a one-ounce bottle of the kind called "salt mouth," and fill it half full of green tea-leaves. Add one teaspoonful of table salt, and then fill the

bottle with whisky. Let this stand for 24 or 48 hours. Instruct the patient to put her nipples into the bottle thus filled three or four times a day, turning the bottle up so as to wet them well. This will harden the nipples admirably by the time they are ready for actual service. This plan has been so satisfactory to me I have never tried to improve on it.

After the patient is delivered, keep her on a light diet for a few days and do not let her drink much tea. A full diet and tea-drinking will sometimes cause so great a flow of milk that the breast will "cake." Avoid putting the child to the breast too often. It is not only a worry to the mother, but might disgust the child so it would not try to nurse when the milk does start. If the nipples are small and deprest, I think the old way of stretching them with a hot bottle very good. Get a large bottle with a smooth mouth; heat it well, but avoid heating the neck. Place the nipple into the mouth of the bottle, pressing it sufficiently tight to keep the air from passing in. As the bottle cools, the condensation of the air in the bottle will cause traction on the nipple, generally stretching it sufficiently for the child to get hold, and once the child gets opportunity to establish suction, no further stretching will be necessary.

When the milk starts well a "caked breast" may result in spite of precautions. Now will come up the question of using the breast pump, or something to get the milk out. Use a pump with a good broad flange so it will press well on a large surface of the breast. I think it is less liable to bruise it. After all the milk is out take equal parts of lard and camphor gum, mix and melt over a gentle fire. Keep the breast well coated with this, rubbing gently from base to nipple.

In excoriated nipples, sometimes the fissures are so small a careful examination will be required to find one, or they may be so large that a portion or all of the nipple is destroyed. But large or small, they cause excruciating pain. The mother dreads the coming of the time for the child to nurse, and sometimes the suffering is too great to permit of nursing at all. In this event prescribe at once lanolin 3iij, adeps 3ij; mix. After the child has nursed, wash all of the saliva off the nipple, dry gently and apply the ointment, washing it off before the child is put to the breast again. This will generally heal sore nipples in a few days. Should it fail

and the pain be too unbearable for the child to nurse, it will become necessary in some cases to apply a weak solution of cocain to the fissure and draw the milk with a breast pump. Should an abscess result, open it so soon as satisfied that pus has formed. Do not expose the patient during delivery, a mistake sometimes, tho I hope rarely, made. When the baby is delivered, pull it from under the edge of the cover sufficiently to wipe its face with a soft white cloth. It is a good practice to have a spool of white linen thread in the obstetric bag. Never use a large or dirty string; the dirty one might cause some septic poisoning, while the large one might occasion secondary hemorrhage. three vessels being surrounded by a gelatinous mass, the large cord would only compress the vessels by pressing this mass against them, and when the gelatinous portion of the cord began to break down it would leave the vessels loose again. A small thread drawn tight will cut down to the vessels proper and will never loosen up. After cutting the cord it is a good practice to apply a second ligature, because of its assistance in preventing the possibility of hemorrhage.

The

The less dressing used for the cord the better and the easier it is to change; pass the cord thru the hole in the linen, turning it up toward the chest, fold the lower portion of cloth up over it and the ends across; if this is held in place until the band is applied it is sufficient dressing for any cord.

Most baby bands are very unsatisfactory, 90 per cent. being made of two layers of muslin with about two small darts in the lower edge and wide enough to come up well under the baby's arms. These are generally pinned up the back with about five small safety pins, and when put on by most women the child's chest is so cramped it can scarcely breathe. The chest should be left free from any construction. There is only one band I have ever been able to find that will give the pressure over the cord and leave the chest free. This is made with armholes, closing with buttons and button holes over the shoulders, and having a wide opening at one side of the abdomen. The band is put on from in front and after it is buttoned over the shoulder the tails pass around the body, one passing thru the hole, and are pinned in front, one pin holding the band firmly and giving the pressure over the cord and nowhere else. This band will stay just

as left. There is no possible chance for it to slip in any direction. If any brother practitioner desires a pattern I will send one for the ten cents necessary to cover expenses of mailing, etc.

Lay a new born baby on its right side for one day. This will aid to establish the circulation.

Some of the things I have mentioned may seem too small to bother with, but,try them.

In my article on Hysteria in May issue, page 185, fifth line from bottom, the dose of apomorphin should be gr. instead of as given. W. J. SALING.

Ellsworth, Ill.

Chloroform in Parturition. Editor MEDICAL WORLD:

The obstetrician who advocates the use of anesthetics in labor is often criticised by the so-called conservative brethren who assert that the procedure interferes with the normal progress of a natural physiologic process. During the last 12 years of a practice extending over 22 years there have been but few cases in which I have not used chloroform during the second stage of labor, with results so happy as to make me a warm advocate for its employment. The speedy relief obtained by its tranquillizing effects is beyond dispute. It seems to me that the delay in its general adoption by the profession must be due to failure in mastering the modus operandi of administration or to an utter disregard for the interest of the suffering woman.

He who permits a woman to struggle thru such a trying ordeal, without the aid of this potent agent, should be unceremoniously ejected, and replaced by an active, energetic, progressive obstetrician, who, having a means at hand to relieve suffering, gladly uses it.

Among the reasons which may be urged for the use of chloroform in the second stage of labor, the following are prominent:

(1) Because it shortens the period. (2) It prevents shock and exhaustion. (3) It reduces the liability of the cervix and perineum to rupture.

(4) It does not affect the child if properly used.

(5) It does not produce uterine inertia. (6) It does not induce post partum hemorrhage.

(7) It is more pleasant to inhale, and less irritant to the air passages than ether. (8) It is not inflammable.

(9) It is prompt in its effect.

(10) Statistics and experience have shown that it is perfectly safe during labor when properly administered.

(11) It assists the woman in her expulsive efforts by obtunding her sensibility to pain thus produced.

(12) It does not arrest the contraction of the uterus or abdominal muscles.

(13) It weakens the natural resistance of the perineal muscle.

(14) It renders great service to women who dread the pain.

(15) It diminishes the chances of the nervous crises which are caused during labor by the excess of suffering.

(16) It makes recovery more rapid. (17) It calms the great cerebral excitement which labor produces in nervous

women.

(18) It is indicated in normal cases until the pains are suspended or retarded by the suffering caused by maladies occurring previous to or during labor. It is also indicated where irregular and partial contractions occasion internal and sometimes continuous pain without causing progress of the labor.

Anesthesia is the object aimed at, not narcosis. To obtain comparative insensibility to pain requires only a few deep inhalations when the pain is first approaching. This will tranquillize the patient, by obtunding the sensibility, and will also relax the soft parts, constituting the ideal effect.

Chloroform can be conveniently given upon a folded handkerchief held near to, but not in contact with the mouth and nose. My preference is to use a common glass tumbler and insert a handkerchief into it in a way which will prevent its falling when inverted. I pour on the handkerchief from 30 to 60 drops of chloroform and place the glass so that the rim will rest on the nose and chin respectively. In this position sufficient space is allowed for the admission of a proper proportion of air, an essential feature to the safe administration of chloroform. Begin with second stage, with the approach of each pain, and suspend its administration during the intervals. It should never be pushed to complete insensibility in normal labor, the patient only being held in a state of semianesthesia until the child is born, when it should be discontinued.

I have never yet seen a single unfavorable symptom from chloroform given in this manner during labor. The doctor who

once uses it properly will continue to use it in future confinements, and the woman who has once taken it, will in future call for it. If you ask a woman who has taken it, if she could not be induced to exert herself more with it than without it, she will promptly answer in the affirmative. During gestation the heart undergoes a normal hypertrophy, and consequently acquires an increase of capacity that serves to give her quite a resisting power against the depressing influences which have been charged against the use of chloroform in labor.

There is no other one thing that causes more suffering than childbearing, and there is less done for its relief by the profession. I should always advocate the use of chloroform unless strictly contraindicated by some grave pathologic lesion.

I cannot agree with the dicta of narrow minded writers who assert that Divine decree has established the law, that maternity must have its accompanying travail until the second coming of Christ. If this be true how supremely useless all mortal efforts must and will be without remodeling the anatomic structure of the pelvis and perineum, as well as that of the uterus, and changing even the conformation of the fetus. Can anyone assert that the only efforts should be directed to the use of hygienic principles?

Oak Ridge,

H. BASCOM FUTRELL, M. D.

Mo.

Use of Anti-Streptococcic Serum. Editor MEDICAL WORLD:-Mrs. X., a 1 para, delivered at end of a rather long labor, and sustained a laceration. Laceration was sewed, but union did not take place at once, but granulation resulted. Antiseptic pad was placed over vulva, and douches of mild solution, 1-4000, bichloride of mercury used with iodoform on wound surface. Everything went on well, and at the end of first week the bichloride douches, which had been alternated with carbolic acid douches, were entirely replaced by douches of 3j carbolic acid in four pints of water. Iodoform was still used.

Thirteen days after labor, patient had a chill and then pain in abdomen (at noon), and at 4 p. m. writer saw patient, finding every indication of sepsis. Gave ol. ricinum 3 iv for bowels and called next day to find symptoms worse, altho bowels had moved with great pain.

About thirty-six hours after chill I gave 10 c. c. anti-streptococcic serum in ab

dominal fat in front, having made a diagnosis of parametritis and peritonitis.

In six hours symptoms grew better and in sixteen hours the patient was comfortable.

Antiseptic douches, morphin and phenacetin were given in conjunction with serum as follows: Douch of three quarts of water with bichloride every three hours, morph. sulph. gr. (one dose), phenacetin gr. 6 (two doses) three hours apart. All this during first night after serum injection. Afterwards douches only continued.

A slight soreness of abdomen after first day and then recovery, with exception of needle abscess at site of last puncture (injection given with 30 m. hypodermic syringe).

The facts briefly are these: No foreign matter in uterus because symptoms would have shown themselves before the thirteenth day; placenta was closely examined, and Crede's method used after second stage of labor, which expelled clots. The infection took place thru lymphatics.

Since uterus was clean, the curet was not to be used; hence serum alone was indicated. Curetment was reserved till next day if symptoms continued, and another dose of serum would have been added with same adjunct treatment. The quick effect of serum and failure of return of symptoms make above supposition regarding condition of uterus reasonable.

If curetment was not indicated by reasonable certainty, its employment would have injured patient because of effect of narcosis and operation (lowering of vitality, pain, fear, etc.), also risk of presence of large freshly wounded surface aiding new infection; but the curette should certainly be used if cause of trouble is retained -membrane shreds, parts of placenta or clots.

The appearance of needle abscess shows asepsis and antisepsis at site should be very carefully attended to by physician personally, since even tho the body is rendered immune to streptococcus, the staphylococcus germ may cause great injury in a patient of greatly lowered vitality, altho fortunately in this case no great damage resulted.

The site of injection should be such that, in case of abcess formation, the patient will not suffer greatly; viz: on front of abdomen, which makes it possible to lie on back with comfort.

Serum used was that of Marmorek (Paris) sold by Pasteur Vaccine Co., 56 Fifth Ave., Chicago, Ill.

The serum should be kept on hand for emergencies, since it is very important indeed that injection be made from 24 to 36 hours after symptoms appear.

Elk Mound, Wis. DR. WASSWEILER.

Wanted-A Cause for Death.

Editor MEDICAL WORLD:-To the question, self put, "Why do I take THE MEDICAL WORLD?" I have just returned the answer: "Not to read of the successes of Drs. X., Y. and Z.; not to show my own skill, but for the purpose of learning, learning, learning-ever seeking the best means to reduce to a minimum the chances of failure."

I think that, so far as possible, contributors should divide their articles equally between those which bear on their successes and those which bear on their failures; for one and all fail at times, and, despite the great advances made in all branches of the profession during the last fifty years, there is still a deal of groping in the dark. Let me cite a case and ask "What was the cause of death?''

March 7 I was called fifteen miles from here to see M. K., a boy, aged eleven years, the message being that he had had slight fever for three weeks, but there was no hurry; the next day would do if I could not manage to get there that evening." However, I got there that evening at 7 o'clock. The child was in bed and seemed very bright. He raised up and talked sensibly and quietly, answered all my questions with an intelligence which showed his comprehension of everything asked him, and in fact acted as though there was very little the matter with him, The results of the examination were for the most part negative. The only symptoms were the presence of considerable flatus in the bowels, tongue very slightly coated, and diarrhea for two days, but not copious. There was no pain, no headache and no spots or rash to be seen. temperature was 1041° and the patient was breathing with great regularity with about thirty respirations to the minute.

The

The parents said that he had had slight fever (they used a thermometer) off and on for three months. Two days before he had visited at a house two miles away and played around with other children, and had only taken to his bed the day before.

I reserved my diagnosis of "walking typhoid," and determined to stay the night, simply because of the temperature.

My examination lasted about a half

hour. I then stepped into an adjoining room, weighed out a five-grain phenacetine powder, and told the mother to give it to him, not taking more than five minutes at the most to do this. She went into the little one's room and called me directly. I ran in just in time to catch the child from falling off the bed. He gave one slight gasp and expired. Not a sign of life could I detect during an hour's work with him, which included the injection hypodermically of strychnia, and nitroglycerin, the use of hot water bottles, venesection.

Now, what was the cause (immediate) of death? I have my opinion, but should like others. I have seen several deaths occur, but this one was the most sudden of any.

In my next I will send you an account of a case of cecal abscess which I evacuated per viam naturalem. The operation was done alone in a hovel twelve miles in the country.

Johnson City, Tex. GEO. HARWOOD, M.D.

Milk Sickness or Malignant Epidemic Gastritis Editor MEDICAL WORLD:-I practiced medicine at Constantia, Ohio, from 1873 to 1883. In my large practice there, among cases most difficult to treat were those of so-called "milk sickness."' In the early history of Delaware County Berlin Township was noted for the prevalence of that fatal malady. All who had been afflicted with the disease promptly succumbed after a short, but severe illness.

My first experience with the disease was in the summer and fall of 1879. It remained in that neighborhood for a period of four years. In the summer and fall of 1882 I treated 27 cases of the severest

form, and am happy to state that 25 of the cases fully recovered. In fact during the four years I only lost the two cases above mentioned.

Besides the acute or malignant type there were many cases of a sub-acute form. In nearly every case of whatever type after describing their symptoms, each sufferer almost invariably ended by saying "My stomach hurts me." I became tired of hearing that statement, and yet I always looked for it when they began to describe their symptoms. I must confess I was very much in the dark when I first encountered it. It worried me so that I sought far and near for information, but could not find it. I consulted authors and inquired of medical friends but could get

no help. No one could give me any advice, all stating that they had never seen anything of the kind.

The strange part of it was that altho they suffered for long weeks, not one of them would hear to me calling counsel, saying "if you can't cure me, no one else can." This was confidence with a vengeance. Under the circumstances it contributed to my success, for I was master of the surroundings and my word was law.

Many were taken down suddenly with chill and high fever, complaining of intense thirst with burning pain in the stomach. Others came down gradually, several having malarial symptoms. If any quinin was given, its irritating effects upon the mucus membrane of the stomach stirred up the trouble. The bowels were so constipated that it was almost impossible to get them to move. The urine was often suppressed from 24 to 48 hours. There was tenderness over the epigastric region. The pulse was never above 50 and many times down to 40 and 30. The tongue had a heavy brown fur for the first few days, with red edges and tip. Then it would peel off, leaving a dry, red, glazed surface, that would remain for four or five weeks. Often when patients protruded the tongue, it would crack and bleed.

There was seldom any delirium unless the attack was complicated with malaria. The patients were very restless and nervous, with an insatiable thirst that tormented them day and night. They talked of water in the daytime and dreamed of it at night, imagining being at some cool crystal spring, drinking and drinking, and finally waking in all their misery to find it all a delusion. They suffered the tortures of the damned! Water, pure and cool, everywhere, but they could not drink one drop. Every time they drank any water, which I very seldom allowed, it produced nausea, burning and cramping pains in the stomach. The result would be increased thirst and it would take two or three days to get over the bad effects of it. They never asked for the second drink. Ice acted in the same way.

About the third or fourth week, ulceration of the esophagus would occur. This would cause great pain while taking nourishment. Slight hemorrhages would also take place occasionally.

These patients were sick for about six weeks, and then convalescence was very protracted, extending over a period of three or four months.