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OVER 1000 favorable reports have been received from physicians in hospital and general practice by Messrs. Reed & Carnrick of New York on the merits of Protonuclein. This preparation is regarded by some as possessing greater therapeutic value than any other product introduced to the profession during this century. In diphtheria, typhoid fever and tuberculosis it has power of exceptional value. The manufacturers are now sending out their clinical record of a hundred and fifty cases which they recently announced to the profession. This, with Professor Chittenden's analysis, will merit the attention of every progressive physician who receives a copy.

MELACHOL may be taken, without fear, in any dose from ten drops to ten drachms, only observing that enough water be taken with it to make it palatable. No single remedy has been as successful in relieving the headache and general distress that follows a night of dissipation. Gold, celery, damiana, phosphorous, and a number of other remedies, have been recommended as efficient in restoring lost vigor; among these, phosphorous in assimilable forms undoubtedly stands at the head. Melachol contains phosphorous in a combination which makes it readily acceptable, and to this it probably owes its remarkable power.-National Board of Health Journal, New York.

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THE same satisfactory results following the use of Listerine in all sub-acute and chronic inflammations of the mucous membranes (whether urethral, vaginal, nasal or pharyngeal), is attended by its judicious employment upon the more sensitive surfaces of the eye and ear, and dilutions or combinations are best governed by the varied conditions, too many to be covered in this little work. The presence of pus and the succulent appearance of an abraded surface, with tendency to capillary hemorrhage, are certain indications for Listerine, which has been pronounced by an authority in the treatment of these affections, "A balsamic astringent without a rival." G. S. Hill, M. D., Wilmington, Ohio, says: As a prophylactic in epidemics of scarlatina, diphtheria and relapsing fevers, I have accomplished the highest results with Listerine, using it internally, externally and by hypodermic injection.

AMERICAN ACADEMY OF RAILWAY SURGEONS.

THE following titles for papers have already been received for the Second Annual Session of American Academy of Railway Surgeons, to be held in Chicago, Ill., September 25, 26 and 27, 1895: A Practical Way of Testing Railway Employes for Color Blindness, Dr. D. C. Bryant, Omaha, Neb. Railway Sanitation, Dr. W. M. Bullard, Wickes, Montana. Transportation of Injured Employes, Dr. F. H. Caldwell, Sanford, Fla. Traumatic Neurosis, Dr. Henry W. Coe, Portland, Ore. Concussion of the Brain, Dr. W. H. Elliott, Savannah, Ga. The Use of Gold Foil in Fractures of the Cranium and Resulting Hernia Cerebri, Dr. W. L. Estes, S. Bethlehem, Pa. Wounds that Open the KneeJoint, Treatment, Dr. C. D. Evans, Columbus, Neb. Treatment of Wounds of the Face and Scalp, Dr. Chas. B. Fry, Mattoon, Ill. Sanitary Regulations Governing Railways, Dr. L. E. Lemen, Denver, Col. Injuries of the Hands and Fingers, Dr. John McLean, Pullman, Ill. How to Differentiate Between the Use of Heat and Cold in Railway Injuries, Dr. Wm. Mackie, Milwaukee, Wis. IntraVenous Injection of Neutral Salt Solution in the Treatment of Desperate Injuries; Exhibition of Apparatus, Dr. C. B. Parker, Cleveland, Ohio.

The Baltimore & Ohio Railroad maintains a complete service of vestibuled express trains between New York, Cincinnati, St. Louis and Chicago. Equipped with Pullman Palace Sleeping Cars, running through without change. All B. & O. trains between the East and West run via Washington. R. B. Campbell, General Manager; Chas. O. Scull, General Passenger Agent, Baltimore, Md. Principal Offices : 211 Washington Street, Boston, Mass. 415 Broadway, New York. N. E. Cor. 9th and Chestnut Sts., Philadelphia, Pa. Cor. Baltimore and Calvert Sts., Baltimore, Md. 1351 Pennsylvania Avenue, Washington, D. C. Cor. Wood St. and Fifth Ave., Pittsburg, Pa. Cor. Fourth and Vine Streets, Cincinnati, O. 193 Clark Street, Chicago, Ill. 105 North Broadway, St. Louis, Mo.

Delegates and visitors to the Chicago meeting will find the equipment of the Baltimore and Ohio trains complete in every detail, affording speed, safety and comfort.

MEDICAL JOURNAL

A Weekly Journal of Medicine and Surgery.

VOL. XXXIII.-No. 24. BALTIMORE, SEPTEMBER 28, 1895. WHOLE NO.757

ORIGINAL ARTICLES.

A CASE OF PUERPERAL ECLAMPSIA AND PLACENTA PREVIA PARTIALIS.

READ BEFORE THE CLINICO-PATHOLOGICAL SOCIETY OF WASHINGTON, D. C., APRIL 16, 1895. By W. Sinclair Bowen, M. D.,

Washington, D. C.

I PRESENT the history of a case of unusual interest to me, combining two of the most dread conditions with which one meets in obstetric practice. Mrs. B. W., aged 24, primipara, engaged me to attend her in her approaching confinement, due May 14, 1894, according to her statement of her last menstrual period. During the last trimester I paid her a weekly visit, procuring a specimen of urine each time for analysis, which was found to be normal. April 14, I was called to see Mrs. B., and found her seated in her bedroom apparently comfortable. She had summoned me at the request of her husband because of an accident which she related as follows: On the previous morning she lifted a large pitcher of water from the floor to the washstand and felt something give way; following this, a sudden flow of blood from vagina accompanied with some pelvic pain. She at once got into bed and remained there, but as both hemorrhage and pain ceased at once she felt no alarm and did not send for me until the evening of the following day. After hearing this history and as twentysix hours had elapsed with no return of hemorrhage or pain, I attributed the hemorrhage to the strain. I directed that she should remain in her room one week and to send for me at once if hem

orrhage or pain should recur. Four days later I was called and found Mrs. B. in bed, quite comfortable as before, but she had again passed some blood from vagina while lying quietly. I then suspected placenta previa and proceeded to make an examination. By abdominal palpation and auscultation, I found pelvis empty. Fetus presenting L. O. A., head movable above superior strait. By vaginal touch found pelvis roomy, cervix normal; os soft but not admitting index finger. The point that most attracted my attention was the difference in sensation imparted to examining finger by the uterus on right and left side of cervix. That on the right side was normal while the left was much more doughy, thicker, and more resistant. Although it was not possible to introduce my finger through the cervical canal and feel the interior of uterus for fear of bringing on premature labor, yet these three points: First, the repeated hemorrhage, second, a pelvis of normal size, yet empty in an eighth month primipara; third, the peculiar feel of one side of the lower segment of the uterus, made a very suggestive picture of placenta previa, but not a certain diagnosis. I instructed my patient to remain in bed and sent for the nurse, making preparations to determine labor if it became necessary.

For a week, I paid a daily visit; no return of pain or hemorrhage. During this time I consulted a number of medical friends about the advisability of inducing labor, but all agreed that an expectant plan of treatment was best.

A week later, upon examination, I found the same state of things as narrated before, but as there was no return of hemorrhage I consented to the patient's request to sit up. She gradually moved about on one floor during the remainder of her pregnancy and all went well. She did not suffer with headache or other symptoms referable to her nervous system.

Early on the morning of May 31, two weeks later than her expected confinement, I was sent for with the message that Mrs. B. was having convulsions. I reached the house in half an hour and found her then in a strong convulsive seizure. Chloroform was administered by inhalation, and on digital examination os was found dilated and placenta extending across from left to right, being attached to the left side. The occiput was presenting at the brim but not engaged. The patient was brought across the bed in the usual position for forceps application, and chloroform continued. I introduced the left blade easily, but finding it so difficult to apply the right I withdrew the left, inserting the right first and then the left without difficulty. When occiput had been brought down into the pelvic canal I detected a prolapsed and pulseless funis.

As soon as the fetus was delivered I passed my right hand in, separating placenta, following down with my left, making some pressure upon fundis uteri.

Thus the labor was ended with not more blood lost than is usual in a perfectly normal case. The perineum was stitched with two silk-worm gut sutures, there being a small laceration; uterus and vagina thoroughly douched with 1-4000 bichloride and then with sterilized water. Perineal pad and abdominal binder applied, and patient made comfortable in bed. She remained in natural sleep for two hours and on awakening drank a glass of milk, complaining only of some headache.

The patient made a rather slow but uneventful recovery and at this time is perfectly well, with the exception of an occasional headache, about once in four weeks. For several months after labor these headaches were of nearly daily occurrence and sometimes very severe, but they have become less frequent and of diminished severity. Repeated urinary analysis, both chemical and microscopical, failed to detect any abnormal condition of the urine, which has always been of sufficient quantity.

This is the only case of puerperal eclampsia occurring in my private practice, although I have seen a number of pregnant cases with marked albuminuria with diminished urea excretion and with hyaline and granular casts. In some of these cases, at least, I believe convulsions were prevented by careful attention to hygiene, diet and medicinal treatment. I have seen several cases of puerperal eclampsia with medical friends, but quite a number in hospital where the cases would be brought in during convulsions, these patients having received no attention during pregnancy. In every case of puerperal eclampsia that I have seen (except the one herein reported) there has been albumen present, with or without other urinary complications.

After narrating somewhat in detail the history of this case, I would ask discussion on certain points.

First, can placenta previa be certainly diagnosed before os uteri will admit examining finger?

Second, were there sufficient indications in this case of placenta previa?

Third, was an expectant plan of treatment as pursued the best?

Fourth, the occurrence of placenta previa and puerperal convulsions at the same time.

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the diagnosis of placenta previa has been made in the last month of pregnancy. The termination of labor by artificial means gives a far less mortality, maternal and fetal, than by risking both until labor comes on spontaneously. My hesitancy in following out in this case the treatment I recommend was due to the uncertainty of diagnosis prior to actual labor.

The case cited by Meigs I will give in his own language. Dr. Eberle of Philadelphia had under his care a lady in Market Street, whose residence was

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INDUCTION OF PREMATURE Labor in RETINITIS ALBUMINURIA. - Mr. Simeon Snell writes in the British Medical Journal: The seriousness of the renal complication is increased by the sight failure, which is present in a certain number of cases. The association of retinitis with Bright's disease is indicative of a very limited period of life, frequently only months. With the albuminuria of pregnancy the retinitis is of less grave import in this respect, but, as far as vision is concerned, it is attended with very serious results. Dr. Culbertson has collected the cases of albuminuric retinitis which have been recorded, and finds that 23.33 per cent. have terminated in blindness, 58.25 have resulted in only partial recovery of sight, and but 18.54 have recovered sight. Silex, who has followed twenty-six patients for a long period, gave the following results: Eleven recovered vision above one-sixth, ten below this, and five were nearly blind, this being due to optic atrophy, choroido-retinitis and detached retina, which showed itself late in two cases.

The retinal affection may show itself at almost any period of pregnancy, and infrequently during the first three months. The appearances in the fundus are generally well pronounced. The margins of the optic disks may be hazy and ill-defined; numerous white patches in the macular region, with some hem orrhages, may all be observed. In other cases blindness or great impairment of sight may be present, with an absence of ophthalmoscopic signs. In a case re

about two and a half squares from his own house. Dr. Ruan lived about a square and Dr. Dewers was distant three squares. After Dr. Eberle had made the diagnosis of placenta previa, the flooding. having been suspended, he engaged the husband of the lady to send off three messages as soon as the attacks should come on again, hoping in this way to secure the prompt attention of at least one of the three physicians. Not long after this hemorrhage came on again and was so violent as to prove fatal before any medical aid could reach her.

cently, which Mr. Richard Favel kindly allowed me to examine, and in which labor was induced for eclampsia at term or nearly so, the young woman was apparently quite blind, but yet there was an absence of ophthalmoscopic signs. On the other hand, the gravity of the retinal affection, as shown by the changes in the fundus, is not always commensurate with the defective vision complained of by the patient, and for this reason it is desirable that pregnant women, with albumen in their urine, should at intervals undergo ophthalmoscopic examination. The gravity of the complication has been sufficiently dealt with.

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HOW CAN A HIGHER STANDARD OF EXPERT MEDICAL TESTIMONY BE OBTAINED?

READ BEFORE THE ALLEGANY COUNTY MEDICAL SOCIETY, PITTSBUrg.

By Samuel Ayres, M. D.

TAYLOR, in his Medical Jurisprudence, page 52, gives the following definition of an expert: "An expert is one who has made the subject upon which he gives his opinion a matter of particular study, practice or observation, and who must have particular and special knowledge upon the subject concerning which he testifies."

Of expert testimony he adds: "It is that testimony given by one expert and specially skilled in the subject to which it relates, or is applicable; concerning information beyond the range of ordinary observation." Now if the word medical be inserted in the above, we shall have a correct definition of what is understood by expert medical testimony.

Upon no one subject do I know of greater need of improvement or reform. than upon this same one which it is my pleasant duty to present for discussion this evening.

We are all, as physicians, aware of the discredit, nay, the ridicule, which too often attaches to expert medical testimony in the courts. But we will not admit that this state of affairs is altogether our own fault. For example, in the domain of mental disorders there is such divergence in opinion between legal and medical responsibility, that it is no wonder the views and opinions of medical men are often set aside or denounced because they do not harmonize with antiquated legal interpretations.

But, nevertheless, there is good ground for the doubt and discredit that surround expert medical testimony. Since doctors proverbially disagree, so it has proved possible, apparently, in any case to obtain those so-called experts who will testify squarely against each other; and this is what has led the law and the laity to undervalue such testimony.

Taylor, above quoted, states on page 5 that The trend of judicial thought in America and England is that the most opinions of medical experts are of little or no value in enlightening courts or juries as to the facts of the cases which are to be determined." Further on he adds, quoting a judicial deliverance : "Whether an individual is insane or not, is not always best solved by abstruse metaphysical speculation expressed in the technical language of medical science. The common sense, and, we may add, the natural instincts, of mankind reject the supposition that only experts can approximate certainty upon such a subject." How is this for a gentle fling at the medical profession? Moreover such exclusive and super-human power has never, I am sure, been claimed by medical experts.

But how shall the question here asked be answered?

It seems to me there are at least three methods, by any one of which a better standard of expert medical testimony might be obtained than at present prevails. Two of these will depend on the legal fraternity; the third on the medical.

Naturally, the first and highest object in obtaining expert testimony is that it shall be not only able and competent, but that it shall be absolutely unbiased and impartial.

In the first place, the selection by the court, or by some judicial authority, in every case requiring expert medical testimony of a commission of three competent physicians who shall be allowed every opportunity to examine the case or the evidence and who shall, after full consultation, render their opinion to the court, would, in my judgment, be a means of elevating the standard of such testimony.

Secondly, only such physicians as are

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