THE "WEIR MITCHELL" TREATMENT Dr. W. S. Playfair concludes an interesting and quite exhaustive article on this subject as follows: The principal elements in the systematic treatment of these cases are— 1. The removal of the patient from unhealthy home influences and placing her at absolute rest. 2. The production of muscular waste and the consequent possibility of assimilating food by what have been called "mechanical tonics," viz: prolonged movement and massage of the muscles by a trained shampooer, and muscular contractions pro. duced by electricity. 3. Supplying the waste so produced by regular and excessive feeding, so that the whole system, and the nervous system in particular, shall be nourished in spite of the patient. pressed regarding the utility of blisters, the "blister treatment" of acute rheumatism is deserving of careful consideration Blisters in various ways, and applied in accordance with various notions, have long been used in the treatment; but the "blister treatment," properly speaking, of acute rheumatism has been systematized by Dr. Davies, of the London Hospital, and Dr. Dechilly, of France. The latter, however, applied a large blister to cover the joint, and permitted it to remain on until sufficient inflammation occurred to produce abundant serosity. Dr. Davies, on the other hand, was content to apply the blisters around rather than on the joint itself. It is a remarkable fact that blistering brings about a neutral or alkaline condition of the urine, how acid so ever it may have been before the blisters were applied. More or less strangury occurs in some instances. So remarkable is the relief to pain produced by the blisters that patients petition for their renewal from time to time. Cardiac complications are comparatively infrequent, and the duration of the disease is reduced to the limits of the favorable cases. Indeed, I may sum up the testimony as to the 1. The removal of the patient from her home efficiency of this method in the words of Dr. surroundings, and her complete isolation in lodgGreenhow, who affirms that the treatment of rheu-ings with only a nurse in attendance, is a matter matism by blisters is quite as successful and less objectionable than by salicylates. The good effects of the blister treatment afford a strong justification of the neurotic theory. When first ascertained, the result was ascribed to the withdrawl of a quantity of acid serum from the neighborhood of the affected joints. The change in the character of the urine, induced by successive blisters, rendered further explanation necessary. The increase of our knowledge respecting the influence of peripheral irritation on the state of the nerve-centres, and especially on the trophic system, has paved the way to a better appreciation of the facts; nevertheless the final explanation remains to be made. A combination of the blister treatment with salicylic acid, with alkalies, or with the tincture of iron, may often be made with signal advantage. The importance of a proper diet is not less than is stated by Dr. Fuller in the quotation made from his paper. Solid food should not be allowed in any case. Liquids composed of starchy and saccharine matters are only less hurtful. Milk and animal broths are the articles to be depended on chiefly until the cessation of all joint troubles will permit the gradual restoration of a solid dietary. Lemonade and carbonic acid water are allowable, unless they produce flatulence, when they will excite fresh joint mischief. Anodynes are to be avoided if possible; when necessary, atropine is preferable to morphine, if adequate to relieve the pain, which it usually succeeds in doing. The complications which may arise in the course of rheumatic fever demand more careful treatment than I can give them at the conclusion of this article. On each of these I shall offer one or two brief observations: of paramount importance. This is a point on which I am most anxious to lay stress, since it is the great crux to the patient and her friends; and constantly appeals are made to modify this, which I look upon as an absolute sine qua non. I attribute much of the success which I have been fortunate enough to obtain in my cases to a rigid adherence to this rule. In almost every instance of failure in the hands of others of which I have heard, some modification in this rule has been agreed to, in deference to the wishes of the friends—as, for example, treating the case in one room by herself in her own house, or in admitting the occasional visits of some relatives or friends. While, however, the patient is to be rigidly secluded, it is incumbent to secure the attendance of a judicious nurse, with sufficient intelligence and education to form an agreeable companion. To shut up a refined and intellectual woman for six weeks with a coarse-minded, stupid nurse can only lead to failure. I have had more difficulty in obtaining suitable nurses, sufficiently firm to insure the directions being carried out, and yet not over-harsh and unsympathetic, than in any other part of the treatment. Whenever my case is not doing well, I instantly change the nurse-often with the happiest results. In adding to the isolation the patient is put at once to bed, to secure absolute rest. In many cases she is already bedridden; in others there has been a weary, protracted effort, and the complete repose is in itself a great gain and relief, 2. Under the second head comes systematic muscular movement, having for its object the production of tissue waste. This is administered by I may a trained rubber, and here again is a great practi- sary to do much more in this direction. cal difficulty. The so-called professional rubbers say, on looking back at my cases, that the only are, in my experience, worse than useless, and I ones with which I have any reason to be disaphave had to teach de novo a sufficient number of pointed are those in which the primary selection strong, muscular young women; and the aptitude has been bad; and in the few in which the results for the work I find to be very far from common, were not thoroughly satisfactory, I had doubts as since a large proportion of those I have tried have to their suitability for the treatment, which I exturned out quite unsuited for it. I cannot attempt pressed beforehand. These include one case of any description of this process. I need only say chronic ovarian disease, and one of bad ante-flexthat it consists in systematic and thorough knead- ion with fibroid enlargement of the uterus, in both ing and movements of the whole muscular system of which the local disease prevented any really for above three hours daily, the result which at beneficial result. In the third I had to stop the first is to produce great fatigue, and subsequently treatment in a week, in consequence of cardiac a pleasant sense of lassitude. Subsidiary to this is mischief; two others were cases of positive mental the use of the faradic current for about ten to disease, and in one case there was true epilepsy. twenty minutes, twice daily, by which all the mus- I have no doubt that any positive coexistent organcles are thrown into strong contraction and the ic disease of this kind should be considered a concutaneous circulation is rendered excessively ac-traindication. In my other cases the results have tive. The two combined produce a large amount of been all that could be wished, and in many of muscular waste, which is supplied by excessive them the patients have been restored to perfect feeding; and in consequence of the increased health after having been helpless, bedridden invaassimilation and improved nutrition, we have the lids for years; in one case twenty-three without enormous gain in weight and size which one sees ever putting a foot to the ground, in others sixteen, in these cases, it being quite a common thing for a nine, six, and so on. In two instances my patients patient to put on from one to two stones in weight were in such a state that it was found absolutely in the course of five to six weeks. The feeding, at impossible to move them except when anesthetized; regular intervals, constitutes a large part of the and they were brought to London by the medical nurse's work. At first from three to five ounces of men long distances under chloroform, in each case milk are given every few hours; and for the first leaving in six weeks perfectly cured. few days the patient is kept on an exclusive milk. diet. By this means dyspeptic symptoms are relieved, and the patient is prepared for the assimilation of other food. This is added by degrees, pari passu with the production of muscular waste by massage, which is commenced on the third or fourth day. By about the tenth day the patient is shampooed for an hour and a half, twice daily, and by this time is always able to take an amount of food that would appear almost preposterous did not one find by experience how perfectly it is assimilated, and how rapidly flesh is put on. It is the usual thing for patients to take, when full diet is reached, in addition to two quarts of milk daily, three full meals, viz: breakfast, consisting of a plate of porridge and cream, fish or bacon, toast and tea, coffee and cocoa; a luncheon, at I p. m., of fish, cutlets or joints, and a sweet, such as stewed fruit and cream, or a milk pudding; dinner at 7 p. m., consisting of soup, fish, joints, and sweets; and, in addition, a cup of raw meat soup at 7 a. m. and II p. m. It is really very rare to find the slightest inconvenience result from this apparently enormous dietary. Should there then be an occasional attack of dyspepsia it is at once relieved by keeping the patient for four and twenty hours. on milk alone. Such is a brief outline of the method to which I am here to direct your attention. As to the results, I have already published several remarkable illustrative cases, so that it is perhaps not neces HIGH FORCEPS OPERATION. BY PROF. BRAUN. Braun performed upon Wednesday, November 8, before the class will serve to convey the teachings The patient, a native of Austria, unmarried, thirty-two years old, in her fifth pregnancy at full vember 7, and entered the lying-in ward of the term, felt labor pains towards the evening of NoFirst Obstetrical Clinic at 2.30 A.M. November 8. Abdominal palpation revealed pregnancy at full Heart tones were loud and regular. By combined term, a large child, head presentation, first position. external and vaginal examination a contracted pel vis was demonstrated. The measurements were: 66 211⁄2 cm. 25% 302 The os became fully dilated at 5 o'clock A.M., and the rupture of the bag of waters occurred some moments later. The head engaged in the superior strait and advanced very slowly until a segment of one-third its volume was within the pelvic cavity. The head now became firmly fixed, with the sagittal suture in the transverse diameter, and a considerable caput succedaneum began to form. The corpus uteri continued to contract powerfully, at regular intervals, without effecting in the slightest degree any change in the position of the head, while the collum uteri became distended, and finally reached to the umbilicus. Later the condition of tetanus uteri was observed, and the corpus uteri could be felt as a firm hard tumor above the umbilicus, very sharply differentiated from the distended, relaxed collum uteri, situated below. At 11.30 o'clock A. M., the woman received a hypodermic injection of morphia, and at 12.30 o'clock p.m., she was taken into the lecture-room for the application of the forceps. Prof. Braun, after careful disinfection of his hands by liberal use of a 3 per cent. solution of carbolic acid, 10 per cent. solution of potassium permanganate, a solution of hydrochloric acid of similar strength, green soap and a brush, examined the woman, and confirmed the diagnosis previously made in the lying-in ward. He said the child would weigh more than 3500 grammes, and would have a greater length than 50 cm. After cathe terization, the vagina and external genitals of the patient were copiously irrigated with a 3 per cent. solution of carbolic acid, immediately before the application of the forceps. While Prof. Braun is in no sense of the word a strict disciple of Lister, he is no disbeliever, and always gives his patient the benefit of a doubt, with the exception of the spray. In passing, it may be mentioned that careful irrigation with disinfectant fluids was employed under his direction long before Esmarch called public attention to the subject. Prof. Braun speaks in unmitigated terms of disapprobation of Tarnier's forceps, Alexander Simpson's instrument, and Felsenreich's modification of the last-named forceps. Felsenreich's forceps, which have been used at the clinic for some months past, present few points of difference from Alexander Simpson's original instrument. For the past six months there has been much discussion in the Vienna Obstetrical Societies as to the value of the last-named three instruments. For this reason, Prof. Braun has allowed his assistants to use them at the clinic. The results, upon the whole, have not been favorable. Mother and child have, in a number of cases, sustained serious injury. Prof. Braun himself never uses these instruments, and pronounces the principle to be radically false, and the instruments themselves a fashionable folly (“ Moderner Schwindel "). The patient having been slightly chloroformed, was placed upon her back, with her lower extremities elevated, and the blades of the forceps were adapted to the long diameterof the foetal head, the maternal tissue being guarded by the introduction of four fingers above the pelvic brim. Seated quietly in his chair, the operator applied traction in the axis of the pelvic brim, and after a few, though sometimes powerful efforts, brought the head down into the middle of the pelvic canal, where rotation was effected by readjustment of the blades, and the birth of the child rapidly followed. Prof. Braun never uses the forceps as a lever or compressor. The child proved to be a male, weighing 3900 grm. with a length of 52 centimetres. The child was profoundly asphyxiated, but when the cerebral congestion was relieved by its elevation above the level of the placenta, the breathing became normal, and the facial yperæmia disappeared. The placenta was at once expelled, the corpus uteri being thrust downwards towards the symphysis in For the operation, Prof Braun selected his own such a manner as to cause complete descent of the instrument. This is the long forceps of Sir James collum uteri into the cervical canal. The collum Simpson, with the fenestræ closed by a thin metal-uteri folded upon itself as if telescoped. lic plate (Hohl's modification), the whole instrument, including handles, being covered by a thin layer of hard rubber. The weight of the instrument is 600 grammes. The advantages claimed for the instrument are: 1. The impermeable, smooth surface. 2. The easy, antiseptic cleansing, because septic material finds no lodgement in any groove. 3. The durability, because hard rubber resists rust, chloroform, chloride of iron, carbolic acid which is not the case with the nickel or gold-plated ⚫ instrument. 4. The instrument requires no heating apparatus. 5. The avoidance of all sharp, metallic angles and points, which injure the skin of the head and face. When the cord ceased to pulsate, 30 minutes after its delivery, it was severed, but not ligated. This departure from custom was made, in order to show that ligature of the cord, after cessation of pulsation, is not a scientific necessity. Prof. Braun is not an iconoclast, however, and in the lying-in-ward all umbilical ends are ligated in two places. After careful irrigation of the vagina with a 3 per cent solution of carbolic acid, an iodoform tent, weighing 5 grammes, was introduc ed into the uterus. At the time of writing, both [motherland child are thriving.-Medical News. Governor Cleveland, of New York, last Monday signed the bill prohibiting the manufacture of 6. The obliteration of the fenestræ prevents the cigars in tenement houses in New York city. feathering of the blade. PRIMARY OPERATION IN LACERATED amount of tissue embraced by each suture. PERINEUM.-NEW METHOD. [Dr. W. L. Barret, Prof. of Diseases of Women in the St. Louis Medical College, describes, in the Courier of Medicine, Feb'y, '83, a new method of performing the primary operation for laceration of the perineum. We extract the following which gives in detail his plan of operating.]-ED. The plan I have pursued is to place the patient in the usual position on the back, with the legs flexed on the abdomen. A satisfactory light is indispensable, and if an artificial light is employed a reflector will be of signal service. The parts are sponged off, and a sponge inserted into the vagina to prevent the uterine hemorrhage from obstructing the view. The vaginal sponge having been introduced, a 'Sims' speculum is inserted into the anterior commissure of the vulva. This exposes the posterior surface of the vagina to the view of the operator, and he can plainly see the whole extent of the rent. Then, with a very fine, short, straight needle, with a trocar point, armed with very fine silk, and held with a needle forceps, the operator begins at the superior or vaginal extremity of the rent, and stitches the mucous membrane together, from above downwards. The sutures are simple interrupted sutures, cut off short on the vaginal surface and left to ulcerate out. Five or six sutures are used to the inch. The needle is entered and brought out only a line or two from the torn edges, so that the suture embraces very little tissue. The cut shows the patient, and speculum in position, and indicates the method of introducing the sutures. The highest suture, viz., that at the superior extremity of the rent, is inserted first, and the lowest last. It also conveys an idea of the No matter how serpentine and ragged the rent may be, it is accurately followed with the needle from its commencement on the vaginal surface to the edge of the fourchette. No trimming of serrated or irregular edges should be resorted to; but, on the contrary, every tongue of tissue should be fitted into and stitched down to its proper place so accurately that the mucous surface cannot gap and discharges cannot enter. The point on which the success of the operation turns, and the only point worthy of consideration in the proceeding, is the exact approximation of the edges of the mucous surface. It is not necessary either to effect apposition or to maintain apposition of the lacerated parts that the sutures should be strong or that they should embrace much tissue in their grasp. The perineum, normally only 14 to 11⁄2 inches in length, is during labor stretched to four or five inches in length. Immediately after labor the parts are flaccid and elongated; and if the torn surfaces are placed in apposition, in the same relationship that they occupied before the injury, they. fit together as naturally and as accurately as an oyster fits into its shell. There will be no tension on the sutures, and no disposition to a separation of the lacerated surfaces; but, on the contrary, the contraction that takes place in the perineal tissues, as involution progresses and the parts resume their ante-partum condition, tends to draw the severed surfaces into closer apposition, and thus contributes to the success of the operation. If the parts have been drawn by deep perineal sutures into artificial relationship, the normal change referred to disturbs the apposition that is forced and unnatural, and opens sinuses, into which irritating discharges percolate and prevent union. When the mucous membrane has been closed in the manner described, the tear in the perineum will also be closed, and I believe that the passage of sutures through the cutaneous surface might be entirely dispensed with; but it has been my habit to introduce one or two superficial stitches, because it approximates the parts more perfectly and insures a neater appearance. I do not believe the external sutures are absolutely essential. I do not bind the limbs together, draw off the urine, nor constipate the bowels, but treat the patient in all respects as if no operation had been performed. On the fourth or fifth day the external sutures are removed. Those in the vagina are left to ulcerate and come away spontaneously. The operation, performed in this way, is simpler, less painful, more rational, and, I believe, more certain in its results than when the usual method is adopted. BORACIC ACID IN THE TREATMENT OF OTORRHOEA.-A paper was read at a meeting of the State Medical Society of Pennsylvania, by Dr. Charles S. Turnbull, of Philadelphia, from which we quote the following: "A most gratifying experience in the use of carefully done; in fact, the successful treatment of powdered boracic acid in the treatment of chronic any case greatly depends upon the method of clansing purulent inflammation of the tympanal mucous the meatus. If it be carelessly done more dismembrane, the constant symptom of which is charge will be provoked, and an artificial eczema, otorrhoea, has induced me to consider the anti-aggravated by the powder used, defeats the objects septic, or what might be more accurately termed sought by a thorough cleansing. The powder is the 'dry method' of treatment. The marked suc- to be poured into the speculum, ad libitum. A cess that I have met with, induces me to advocate little will drop through, but the bulk of the powder its use in this most frequent form (in this country) will remain in the speculum and this will require of aural disease. Chronic purulent inflammation displacing and packing. To hold the speculum of the middle ear continues its work of destruction still and pack down the powder without causing year in and year out, gradually corroding the con- pain from the edges of the speculum is no easy tents of the middle ear and seriously compromis- procedure. Force cannot be employed because ing the functions of its appendages. Upon these by the pressure the edges of the speculum will cut; delicate parts, covered by an inflamed or ulcerated then too, and suddenly, the mass moves, and whatmucous membrane (which, it must be remembered, ever is used to thrust it down is apt to impinge, acts the part of the periosteum), all sorts of foreign with more or less force, upon the delicate parts bematerial collect, and these with the added irrita- neath. I use a thin steel probe with the point tion from fermenting discharges (caused by the (about 1 line) bent at a right angle, and whilst high temperature of the parts, collections of the the auricle and speculum are held immovable, the bacteria, etc.,) increase the fire of inflammation parts being illuminated with the head mirror, (the which hurns fiercely, and the mucous membrane, head of patient unmoved from first position) I hug in defence of itself, pours out a copious secretion. the inside wall of the speculum, and so can always To remedy these affections, general surgery has done but little, so that in many instances medical men are glad to get rid of 'patients with running ears,' and this added to the prejndices in the minds of the community at large, and in some of the profession too, as to the injurious effect of healing or 'drying up' as it is termed, discharges from the ear, has caused this affection, through ignorance or apathy, to be much neglected. pow No re tell when I am down to its lower orifice. As the powder is filled into the meatus, through the speculum, it is packed, layer upon layer, not tightly, but firmly, meanwhile I gradually withdraw the speculum until it reaches the mouth of the meatus. Here I insert a light pledget of cotton, only to be worn for six or eight hours (until bed time), and then to be withdrawn and not again introduced. My directions to my patients are to permit, in fact, "Bezold conceived the idea that boracic acid endeavor to have all the powder possible 'remain had failed on account of the powder used. He within the meatus. If any moisture be felt, sop therefore procured boracic acid in an impalpable (that is, wipe by pressing) the mass, and soak out powder, and when he began packing the meatus the discharge with absorbent cotton or dry thin tightly with it, obtained excellent results. Since linen, but do not disturb the powder. From the Bezold's paper, Buckner speaks highly of the moment this agent is used all odor, from the most dered acid in the otorrhoeas, and Dr. J. O. Green fetid discharges, ceases, and unless the discharge also recommended Bezold's treatment, which he be extraordinarily profuse, never returns. had used extensively in the meantime. From that action ensues if filled into meatus as I have ditime to the present, with few exceptions, the treat-rected. Of course, the mechanical deafness caused ment recommended by Bezold and Green was by the foreign mass in the meatus was sometimes given a trial, but although Politzer, of Vienna, re- complained of, but this was gladly endured when commended it highly, and Cassells, of Glasgow, explained as only of a temporary nature. did the same thing, no one was satisfied that the "Oftentimes one packing was enough. In other plan of treatment was particularly efficacious, or cases, the packed powder was washed out, by the to be preferred to many others. The great mis-discharge, in a few days, but I persevered, and take, as I have discovered, was in the fact of many have always been rewarded for any trouble in filexperimenters not having observed Bezold's in- ling and repacking. If the discharge ceases and structions, namely, that boracic acid must be nicely leaves a hardened mass of powder, etc., filling the powdered. The ear is not to be syringed at all; meatus, it must be removed, but not by force nor it should be cleansed with absorbent cotton. Ac- by syringing. It must be softened by the instillacording to the charaeter of the intra-tympanal secretion am I guided in the introduction of the antiseptic powder, hence especial note must be made of the exact variety of the discharge as regards color, odor, consistency, etc., etc. "As the cleansing procedure is more or less apt to provoke reflex coughing, it must be gently and tion of warm fluid cosmoline (petroleol), which has the charming recommendation of not becoming rancid by heat, etc. I have been compelled to require my patients, for whom the powdered acid has been prescribed, to bring with them the substance procured, for inspection, since druggists, as a rule, unless according to special agreement, dis |