WALCHER'S POSITION, WITH REPORT OF A CASE.

BY ALFRED MOORE, M.D.

MEMPHIS.

Place the woman on the table on her back, with buttocks projecting over the edge and her feet hanging down with thighs extended, and you have the position known as Walcher's, the opposite of that of lithotomy, or flexion of the thighs.

Illustrating Walcher's Position (after Hirst).*

In 1889 Walcher announced that by extending the thighs of a parturient woman the true conjugate was increased very nearly a centimeter. This is of importance, especially in difficult labors, where the gain of a fraction of an inch is of material value.

The modus operandi of this position is not yet settled. Whether the conjugate vera is lengthened on account of the

* We have to thank the well-known publisher, Mr. W. B. Saunders, of Philadelphia, for the use of this cut, which appears in Hirst's excellent Textbook of Obstetrics, published by Mr. Saunders.

VOL. XIX-29

mobility of the sacro-iliac joints allowing the sacrum to rotate back and forth on its transverse axis as the symphysis is elevated or lowered, as held by Jewett; or whether the distance between the promontory and symphysis remains stationary, no matter what position the latter is in; whether it is the lowering of the plane of the inlet from the symphysis to a point below the promontory instead of the promontory, thereby allowing one parietal eminence to glide into the sacral curve before the other has to pass the symphysis, as held by Ayers (Obstetrics, April, 1899), is the correct solution of the mechanism of this posture, is not of such great value to the practitioner as is the fact that it aids the head to enter the pelvis. King (Manual of Obstetrics) and Hirst (Textbook of Obstetrics) also claim that the conjugate vera is increased, and the latter recommends its systematic trial in difficult cases.

While the inlet to the pelvis is enlarged by this posture, the outlet is diminished, and as the head enters the cavity the thighs should be flexed, so as to allow the head more room at the outlet.

I recently attended a primapara 33 years of age, whom I delivered with the aid of the forceps of a fine boy baby. She was in labor twelve hours and had suffered a good deal. The cervix was dilated but the head made no progress and I decided to deliver. The forceps were applied, the head lying in the R. O. A., and traction made in the axis of the superior strait. Several attempts were made to deliver, but without any gain, and I was about to adopt other means to deliver. I thought of trying with the woman in Walcher's position, which succeeded admirably, and as the head entered the cavity of the pelvis the thighs were raised and the delivery completed.

In this case I had to suture the perineum. Mother and baby are now doing well, and the baby owes his existence to

Walcher.

Randolph Building.

A CASE OF DISSEMINATED INSULAR SCLEROSIS (?).

BY WM. KRAUSS, M.D., PH.G.

Pathologist and Visiting Physician to St. Joseph's Hospital, &c., &c.

The object of this clinical note is to reiterate how routinism will cause one to make errors in diagnosis.

The case is that of a white male, aged 28 years, laborer, who came under my charge with nausea, vomiting, great prostration, vertigo, anorexia, and constipation. He admitted having been on a spree, and, as he had some tremor, it was ascribed to that cause. A history of syphilis was denied ; the family history was not inquired into. The diagnosis of alcoholism was entered. The stomach symptoms yielded to active purgation and hypodermatic injections of strychnin, and he was able to take a fair amount of nourishment, but gave some trouble on account of restlessness, with occasional busy delirium. His temperature at this time (fourth day) was subnormal; there had not been any rise since his admission; his pulse, which was so weak and thready that it could not be well counted, was about 130. The tongue was coated with a white fur and his breath was very foul. Accordingly the urine was examined, but showed good elimination and no evidence of renal disease. There was some nystagmus, and the vertigo had not abated. The delirium and tremors were ascribed to cerebral anemia, due to the withdrawal of the alcohol; the strychnin was therefore continued, together with increasing doses of tincture of digitalis, until after three days he was taking thirty drops every three hours, with only moderate improvement in his pulse and general condition, although his brain symptoms had improved very much. Sulfonal and morphin were given on alternate nights for his insomnia (he never got strychnin after supper), and he was put upon a general tonic, including arsenic. At the end of ten days I began to suspect that there was a hole in my diagnosis. As I came upon him unawares I failed to notice any tremor, which, however, developed after I spoke to him. I now felt certain that he was suffering from a progressive trouble, and a more careful examination and inquiry into his previous history was made. The family history was negative; he had had the ordinary diseases of childhood but had had no infectious disease in the last few years. He had trembling for six months, which he ascribed to drinking, but it was getting worse, and he drank whiskey to "steady his nerves." All the reflexes were exaggerated, especially those of the knee and

ankle; there were no areas of anesthesia; when he lay quietly in bed he could be quite still, but any effort at coördinated movements would bring on trembling, which was not so marked when executing coarser movements, such as clothing himself; eating was more difficult, and he spilled fluids in the effort to drink. I tried to induce him to write his name, but any effort to bring the pencil to paper brought on such violent,trembling that he refused to make any other effort. The pupils were symmetric and reacted promptly to light and accommodation, but not without bringing on violent nystagmus; there was neither diplopia nor strabismus. His mental and physical powers were undoubtedly below par, as far as one could judge in a stranger, and his speech, though not exactly "scanning," was very deliberate, and the tongue was protruded with a tremor which was too coarse to be called fibrillar; during the delirium, when he was under the influence of hyoscin, the speech was thick, but this had been ascribed to the drug.

The diagnosis of multiple sclerosis was made with some reservation, knowing the difficulty of correctly recognizing this condition. The differentiation lay between it and alcoholic tremor, results of slight encephalitis (red softening) or leptomeningitis. Chorea, paralysis agitans, hysterical and drug tremor were excluded. The tremor was evidently a volitional or intention tremor, and different from alcoholic tremor, which is persistent; mercurial poisoning and saturnism could be positively excluded; as against the results of acute brain trouble, the absence of fever, the history of trembling for some months and absence of leukocytosis were noted.

Against the diagnosis of disseminated sclerosis might be urged the incomplete previous history and the absence of other sclerotic symptoms, such as girdle pains, optic symptoms, marked sensory disturbance, spastic paralysis, muscular atrophies and very great vertigo, but when it is remembered that the disease is very slow in its development, these symptoms may be expected later. The three pathognomonic signs, scanning speech, nystagmus and intention tremor, can be said to be present in this case.

After a residence of five weeks in the hospital without improvement, he was sent to the county poor and insane asylum and was thus lost sight of.

The more acute symptoms at the beginning, and which at first led me astray in the diagnosis, were undoubtedly due to alcoholism, as they yielded to appropriate treatment.

210, 212 and 214 Randolph Building.

A CASE OF CHRONIC GLEET

Of Seven Years' Standing Cured in Two Weeks by Injections of Potassium Permanganate.

BY EDWIN WILLIAMS, M.D.

MEMPHIS.

The patient is a young man æt. 27, who came to my office first on August 16, suffering from a discharge from the urethra which had persisted since 1892. The discharge was slight, yellow in color, and was most noticeable in the morning. He had to wear a small piece of cotton over the glans at all times to prevent his clothes from becoming soiled. There was no chordee or other evidence of an acute urethritis. He noticed after an overindulgence in stimulants or other excesses that the discharge was more profuse than at other times. His health was perfectly normal in other respects. Microscopic examination of the discharge showed the gonococci. He was first put on diluent alkaline drinks, warned against all kinds of excesses, and told to come back the second day following.

When he returned the second day he was given the following prescription: R Saloli, 3 ij; olei santali, f3 ij; oleoresinæ cubebæ, f3ij; extracti pancreati, 3i. M. et ft. capsules no. xxiv. Sig.: One capsule two hours after each meal.

The above prescription was taken faithfully for three days, with no apparent change for the better. It was then decided to pass sounds and irrigate the bladder with potassium permanganate. The sounds were passed up to no. 18 American and a slight stricture in the prostatic portion discovered which had never given the patient any trouble. This was dilated on three successive days. The bladder was then irrigated with potassium permanganate and distilled water in the proportion of three grains to the ounce, the patient passing it back through his urethra.

This procedure was gone through with every other day for about two weeks, when much to the patient's gratification and my delight the discharge ceased, with the exception of a little mucus. This mucus, which was perfectly clear, was