"Weak, nervous and trembling after slight exertion."

Back came the "diagnosis" letter, which read :

“According to my diagnosis what you need to cure you completely is å thorough special treatment from the Spitting up of Vucus, Pains and Sorene88 Acro88 the Back, Poor Digestion, Constipation, Nervousne88, Defective Elimination and Uric Acid Conditions."

The words that we have italicized are those that had been filled in on a typewriter. The "full-size treatment" sent in this case consisted of the four boxes containing the pills labeled respectivly: Prescription Numbers "16759," "29408," "30651" and “4039"-price, $3.

Another letter sent from a small town in Illinois had a cross placed against the following symptoms :

"Have sick headache."
"Heart trouble."
"Stomach trouble."
“Are depressed in spirits."
"Have twitching of the muscles."

The "diagnosis" letter to this supposititious patient read:

"According to my diagnosis what you need to cure you completely is a thorough special treatment for the Headache, Poor Circulation, Stomach trouble, Depressed Spirits, Tuitching Muscles, Defective élimination, and Uric Acid Conditions."

Here again the words we have italicized had been filled in with the typewriter-and the same boxes of pills were sent. Another symptom blank the Journal had mailed from a town in Ohio with crosses against the following: **Are troubled with catarrh." "Have dizziness." “Are depressed in spirits." "Have too frequent desire to pass water." Quack Jiroch "diagnosed" this case :

"According to my diagnosis what you need to cure you is a thorough special treatment for the Catarrh, Dizziness, Depressed Spirits, Bladder Trouble, Defectiv Elimination and Uric Acid Conditions."

In this case, too, the recipient of the diagnosis got the same stock "full-size treatment" Prescription Nos. 16759, 29404, 30651 and 4039—with the usual request for a remittance of $3.

From a city in Pennsylvania the Journal had a symptom blank sent in describing as well as is possible by mail a case of diabetes mellitus.

The person sending it in stated explicitly that he bad diabetes and also put crosses against the following:

"Are losing flesh."
"Feel weak and all run down."
"Have itching or burning of skin."
"Have boils and pimples on face and on neck."
"Have too frequent desire to pass water.".

Diagnosing by mail is, of course, an anomaly. The scientifie value of a diagnosis of ailments in persons who have never been seen and whose symptoms are described by the persons themselves is nil. Nevertheless if any conclusion at all could be reacht regarding the hypothetical case just described, it must have been that the patient was suffering from diabetes mellitus. What did Jiroch say ?

"According to my diagnosis what your case requires now is a thorough special treatment for the Kidney Trouble, Itching Skin, Impure Blood, Nervousness, Headaches, Defectiv Elimination and Uric Acid Conditions."

And the treatment? The same "full-size treatment" sent to the sufferer from consumption, rheumatism, etc., that is, Boxes Nos. 1, 2, 3 and 4 (Prescriptions Nos. 16759, 29408, 30651 and 4039). Worse yet, the diabetic-in common with all others-was told :

"For your case I would advise a mixt diet."

A "mixt diet" recommended to a supposititious diabetic to whom the starches in such articles as bread, biscuits, potatoes, etc., and sugars, sirups and sweets might, in the amounts ordinarily taken, be deadly! A mixt diet, indeed !

Other diagnoses just as worthless as those detailed above could be given, but these are sufficient to make plain the worthlessness of the diagnosis and the fraudulence of the Jiroch "treatment.' Yet the Jiroch concern said about Jiroch:

"I am a specialist and I do not have one remedy that cures everything . . : My special treatments are made up of my own private preparations perfected after years of successful practise.'

One thing will be noticed regarding the fake diag. nosis. No matter what other ailments the patients were supposed to have, they were all suffering-according to Jiroch-from "Defectiv Elimination and Uric Acid Conditions." Whether it was a case of consumption, kidney disease or "female trouble" every person whose case Jiroch professed to diagnose

By

cious use of morphin, either alone or combined with hyoscin or scopolamin. My own experience would lead me to recommend a more general use of these drugs.

Brief reference to a case or two will illustrate my point. Not long ago I was called upon to terminate labor in a young, extremely nervous primipara whose pains had become so severe in the last four or five hours of labor that she and the family friends were frantic, and insisted that the doctor must use instruments and end her suffering. I found dilatation not more than one-third complete, and advised a quarter grain of morphin, to be repeated when necessary, and the packing of steril gauze against the undilated os. The doctor reported later that after six or seven hours of comparativ rest, the packing was removed, dilatation found to be complete, and in a short time an easy delivery took place, with no ill effects on the child, and certainly with greatly conserved strength and nerve energy on the part of the mother. I have seen the same happy results in many similar cases, and emphasize the fact that with these drugs in the first stage of labor, and preferably chloroform in the second, we may successfully meet and control most of the danger arising from excessiv pain.

(Straub, in Münchener Med. Wochenschrift, called attention to the danger of combining morphin with general narcotics and hypnotics. In a case where chloroform was given after a preliminary injection of morphin for a minor operation death resulted from respiratory paralysis, altho the general narcosis was not a deep one. means of experiments in rabbits it was shown that the slowing of the respiration remained for several hours after the injection of morphin, and if a general narcotic or hypnotic had been administered, this rate was further diminisht. In Dr. Arnold's method of using the morphin in the first stage and the chloroform in the second there might be sufficient time elapsing between to permit the morphin effect to wear off. In case it had not, the chloroform would probably not be needed.

We submitted this article to Dr. Arnold for personal correction, and he writes us as follows in regard to the subject of anesthesia:

Editor MEDICAL WORLD:-I have just read the proof sent me. Have no corrections, I believe, except as to the interjected reference to Straub's paper-and no serious objection to this, but I was not favorably imprest with the value of his observations on this line when I read it some time ago, for I have seen, especially in my internship, at Jefferson Hospital, morphin used almost routinely by one of the chiefs there for years, as a preliminary for general anesthesia, and with nothing but good results. This has often been corroborated in my experience and observation at Samaritan Hospital also. However, my practise is not to give morphin and then chloroform-seldom or never have had to do this. The thought I wanted to convey was that where anything had to be given in first stage, morphin and scopolamin or hyosin was the preferable and comparativly, safe thing to use; but where the woman reacht the later, second stage, without anesthetic, then chloroform was preferable. You see, I did not mean to combine the two, altho I have often seen it done without harm.

J. O. ARNOLD 2503 N. 18th Street, Philadelphia.

Straub's observation upon the combined use of morphin and a general anesthetic, quoted above,

has been given a wide reading, and therefore Dr. Arnold's experience with the same in great numbers with uniformly good results is a very important matter and deserves equally wide attention. We do not have to fear them now, as we had since reading of Straub's experience. Our readers will be glad to learn of the actual safety of this method of producing anesthesia.-ED.)

Lacerations. Comparativly few, if any, primiparæ escape lacerations. In multiparæ, of course, the percentage of tears is not so high. It has been estimated that some degree of laceration takes place in fully 90% of all full-time deliveries.

Many physicians give as the cause of tears, “too short a time in labor," while others assign the cause to “too great a disproportion between mother and child." About 50% of physicians, according to my canvass, are using no other method to prevent lacerations than the so-called "protection of the perineum" with the hand, and this should probably be named as a third large factor in the production of tears. My own opinion is that the support or pressure of the hand on the perineum has never prevented many tears, and there are good obstetricians who go further than this, and say that such pressure predisposes to tears.

If too rapid labor is a large factor in producing lacerations, then we must meet this sign of danger by anesthesia and such other methods as will give the soft parts time to dilate. This means that in practically all difficult labors, if the obstetrician is to give his patient the benefit of the kind of service to which the seriousness of her case entitles her, he must have some one to help him.

The number of torn vaginas and perineums could be very greatly lessened by the aid of a good anesthetist, and the family physician is as fully justified in calling an assistant to help him prevent a serious laceration as he is in asking for help in the repair of such an injury. More time, more anesthesia; more careful study of the conditions present, with a view to correcting malpositions, etc.; all of which means the more frequent employment of an assistant, constitute the accepted methods of preventing lacerations after labor has begun.

Dangers may come to the child from overzealous efforts at preventing tears; especially from taking too much time for the outlet to dilate when for any reason the condition of the child demands haste. In such cases, as in many other cases where tears

seen to be inevitable, episiotomy is undoubtedly indicated, as, for instance, in a recent case. A primipara had been in labor about thirtysix hours, with extremely hard pains a greater part of this time, when her physician detected weakness of the fetal heart sounds and called for help. Dilatation was about complete, the head was well engaged, but high, and the condition of the child called for immediate action. Ether was given at once, forceps applied, and the head brought down to the outlet without difficulty; then a good, free unilateral episiotomy was done. The delivery was easily and quickly completed, the child was saved, and the mother's soft parts sustained no other injury than the clean posterolateral incision, which was easily sutured.

Bandl's Ring.-Cæsarean Section. Another sign of danger to be lookt for in protracted labor with severe pains and little or no progress, is that of a high contraction ring and con

are

put posterior. The forceps were then removed, a perfectly easy bimanual rotation done, and under light anesthesia the child was born without further aid and in good condition.

The method of bimanual rotation of the persistent occiput posterior consists of introducing the oversupinated left hand, or half hand as the case may require, into the vagina, with the ulnar border pointing upward toward the mother's left, the thumb pointing downward and toward the mother's right, and the palmar surface of the fingers against the right side of the child's head. With the external hand, pressure is made thru the abdominal wall above the symphysis, against the left frontal region of the child's head, downward and toward the mother's left; thus holding the head in the pelvis, keeping it in a state of flexion, and combined with the action of the internal hand pressing the occiput forward from the right, quickly and easily produces the desired rotation. At the same time the assistant, who is usually the anesthetist, greatly facilitates the maneuver and prevents the tendency of the head to return to its former position by swinging the body of the child from the mother's right side toward the median line, and holding it there by pressure of the hand on the abdomen.

a

To Detect Paternity. When an emulsion in an isotonic sodium chlorid solution of the red blood corpuscles of a man by whom a woman is pregnant is injected in the skin of that woman, a certain reaction, shown by erythema, takes place within six hours. The same emulsion from any other man gives no reaction.-Critic and Guide.

tho not an essential part of my illustration. While perhaps two or three weeks premature, yet the child appeared to be well developt, and breathed and cried as soon as born, but gradually weakened and died about twelve hours after birth. Dr. Applegate and those of us who assisted him have speculated as to the probable cause of death. There certainly was no traumatism. The mother had bled freely, but this was forty-eight hours before, and her condition was good at the time of operation. The long interval of no bleeding had presumably, restored the child's losses, in part at least, and its heart sounds were well heard before the operation. Having had pointed out to me in the Wertheim clinic of Vienna the fact that pituitary extract absorbed from the mother may have a fatal effect on the child, under certain conditions, causing it, even when apparently normal at birth, gradually to weaken and die some hours later, it seems the most probable cause of death was the administration of pituitrin to the mother long enuf before delivery for a previously weakened child to have received a fatally toxic dose. While, of course, this is but a theoretical suggestion, yet I have recently collected enuf reports of otherwise inexplicable deaths of the newborn where pituitrin had been used on the mothers, to make me quite careful to know the condition of the child before I employ this very useful and at the same time very dangerous obstetric aid.

Protracted Labor. Protracted labor, with that peculiar type of suf. fering, both mental and physical, so often seen when the efforts of hard labor are unavailing, is always a sign of danger, and should be met by the most careful study of the conditions present. Here, I am quite sure, is where many grievous obstetric sins are committed. Either there is no attempt to find the cause, or the attempt is a failure for want of an assistant and anesthesia. A hopeless disproportion recognized at the earliest moment after a fair test of labor, and met according to the indications; or a faulty presentation or position corrected, as it so often can be corrected under an anesthetic, means all the difference between success and failure in scores of cases. Thus, in one case, on examination I found a large head still freely movable and a promontory that could be reacht with the greatest ease. Trying the head in the inlet bimanually, which is often the only practical form of pelvimetry, left no doubt of the impossibility of safe delivery by the vaginal route.

In another case the head had descended well at first, but in spite of extremely hard pains, there had been no further progress for four or five hours I had chloroform given at once, for the peculiarly aggravating noneffectiv pains, with the head for several hours almost on the pelvic floor, indicated beyond a reasonable doubt that the condition was one of malposition, and would therefore require anesthesia to correct it, if not to make the diagnosis. I found the occiput in the hollow of the sacrum. Bimanual rotation was quickly and easily done, and upon removal of the anesthetic the patient required no further assistance.

In a third case, a diagnosis of right occipitoposterior position was easily made by palpation and the history of the labor. Vaginal examination under chloroform verified this diagnosis. As it is not so easy or so desirable to rotate the head when it is yet high in the pelvis, I applied forceps and brought the head down to the pelvic floor in the course of least resistance, namely, with the occi

EXAMINATION QUESTIONS.

a