BY MARY A SPINK, M D. INDIANAPOLIS, Ind.

RS. M., forty-two years old. Married fifteen years and mother of three children, the youngest being six years of age. The patient had goitre more or less apparent from her girlhood; the thyroid was notably larger before each menstrual period but the eyes were in no way affected and there was no discomfort noticed until three years after the birth of the last child. The two years following this birth were marked by irregular menstruation, which entirely ceased during the third year without any pain whatever.

Mrs. M., informed me that she had been through the routine treatment of external and internal applications of iodine, also long treatment by galvanism. Upon inspection I found the neck over thyroid enlargement measured twentytwo and one-half inches, the eye-balls protruding to such extent that the lids would not cover them; her pulse was irregular; the pulse from one hundred and twenty to one hundred and fifty per minute. Upon examination of the pelvic organs the uterus was found enlarged and very much congested, and, to my surprise, complete atresia of the cervical canal, this I proceeded to dilate gradually, by the galvanic bougee, requiring several applications. As soon as

the canal was complete a discharge of dirty brown liquid escaped. This symptom caused me to suspect something more in the cavity of the uterus since the escape of the fluid did not diminish the size of the organ. I then used forcible dilatation which resulted in the discharge of several large fibrous clots, seemingly partly decomposed. The uterine walls were next thoroughly curetted. This operation being followed by a discharge resembling menstrual flow, lasting several days. In, the course of two weeks all the distressing symptoms of the Exopthalmic Goitre had disappeared, leaving the neck but slightly enlarged-measuring about sixteen inches.

Mrs. M., remained under my observation for a year. The menstrual function was resumed and regular. There was no recurrence of the disease.

The second case I shall report was that of an unmarried lady aged twenty-four. She had never menstruated. The Exopthalmas developed at puberty. She had never experienced pain or tenderness in the pelvic region. I found the uterus rather small with complete stenosis, and, as in the former case, dilated with galvanic current, using an applicator attached to the negative pole, about five minutes once daily. After giving half an hour's repose from the Galvanic treatment the Faradic current was applied over each ovary. This was continued six weeks when menstruation occurred. The treatment was continued thrice weekly for three months. The menses appeared regularly and the Exopthalmus gradually disappeared. Observation for several years shows no tendency to return.

DIARRHOEA OF OLD AGE.

BY DR. BELLE CRAVER, TOLEDO, O

AVING had the care of aged parents for the past ten or twelve years, has given me an opportunity not always obtained elsewhere of observing some of the senile diseases of the digestive apparatus. One of the most frequent disturbances of the alimentary tract is diarrhoea in one of its many forms.

EITIOLOGY.-This condition is more frequent in persons who grow old rapidly, and in many cases seems to arise from

a state of the intestinal tract that is part of the senile marasmus. Epidemics of diarrhoea are frequently met with in old people who are inmates of asylums and hospitals.

Errors in diet are prominent causes of senile diarrhoea. Exposure to cold, sudden chilling of the body and abruptly checking the perspiration are common causes of diarrhoea in the aged. Diarrhoea in aged gouty persons frequently acts as a safety valve, as great relief often follows slight attacks. One writer finds a distinct difference between senile diarrhoea and the diarrhoea which is met with in the senile period of life, but which accompanies hepatic, renal, thoracic and various other chronic affections, and to which very properly has been given the name of symptomatic diarrhoea.

SYMPTOMS.-The common form of diarrhoea in the aged, is caused by over eating. This form of diarrhoea is most marked in corpulent and sedentary people whose appetites are undiminished by age while their stomach and bowels are incapable of their former vigorous action. When diarrhoea in the aged is neglected or improperly treated, it may terminate in what is called serous diarrhoea. This form is usually accompanied with chills and fever. Will mention a case that has just recently come under my notice, and who is suffering from this form of diarrhoea. Was called to see Mr. M., an aged man who had contracted camp diarrhoea in the civil war, but had by care in diet and warm clothing escaped any severe acute attacks until of recent date when I was called. Found the patient with a subnormal temperature and so exhausted from the frequent watery movements as to be unable to speak above a whisper. 1 ordered warm poultices applied to the bowels and felt safe in giving at once the mineral astringents, as the bowels had been completely emptied of their normal feces by the early watery discharges. Gave dovers powder to quiet pain, to be followed in 24 hours by a tablespoonful of Ol-ricini. At last accounts the patient was doing well. In old age an acute diarrhoea may steadily persist while the patient utters no complaint, shows no sign of distress and still the disease may be rapidly tending to a fatal issue. Griping and tenesmus are symptoms which are much oftener absent than present in senile diarrhoea.

TREATMENT.-As a rule aged people are hearty eaters and an attack of diarrhoea is often due to over indulgence at the table, hence my custom of ridding the intestine of the offensive material by giving a dose of Castor oil. Saline purgatives are too harsh. If there is flatulence I give a few drops of laudinum with the laxative.

When urgent symptoms are passed the dilute mineral acids act beneficially by toning up the laxed mucus membranes.

OBSTETRICAL DEPARTMENT.

INDICATIONS FOR THE APPLICATION OF THE OBSTETRICAL FORCEPS AT THE PELVIC OUT-LET.

ELIZA H. ROOT, M. D., Editor.

Prof. Obstetrics Northwestern University Woman's Medical School.
Senior Obstetrician to Wesley Hospital,
Chicago, Ill.

HE time when to apply the obstetrical forceps at
the pelvic out-let cannot be governed by fixed
rules. This must rest with the operator and re-
quires a nicety of judgment gained only by care-

ful study of each case.

In skilled hands the application of the forceps is better made too early-or earlier than is absolutely necessary than too late, for too late means diaster to mother and child. It is not possible to draw distinct lines, marking the indications but for convenience of study we may divide them into five groups.

I. The fault lies wholly with the vis a tergo; head more or less movable; there exists no obstruction in front of the head. (a.) Pains or uterine contractions are inefficient (b.) Umbilical cord is short.

II. Cases where the antero-posterior diameter of the head, though presenting, fails to engage in the corresponding diameter of the outlet; head more or less movable. (a.) Large head occiput anterior; (b.) Occiput posterior.

III. To produce complete flexion in a partially extended head, that cannot be flexed by the expulsive forces without

undue duration of labor or by the hands of the accoucher. Head more or less fixed.

IV. To shorten the second stage of labor for the relief of material suffering.

V. For the immediate relief of the child.

I. (a.) When uterine contractions are inefficient there is want of expulsive force exerted upon the foetus. The cause may rest with the uterus itself; it may arise from the delicate muscular and nervous organization of the patient; from impaired health, as in cases with albuminuria or wasting disease and from weariness produced by a long first stage. (b.) By a short cord or a cord shortened by coils about the neck. In this group of cases the head moves forward and recedes without material advancement. The to and fro movement of the head is especially marked in cases of short cord. The recession of the head is especially marked in cases of short cord. The recession of the head in short cord differs in character from recession following relaxation of the uterine contraction or of expulsive efforts. It has more the appearance of being pulled back and the shorter the cord the more marked is this characteristic-and may be considered diagnostic. The cord shortened by coils about the neck will produce a similar effect.

When conditions under (a) and (b) exist, the natural rythm of the pains is soon disturbed or destroyed. The pains become short in duration and "choppy" in character. The expulsive efforts are unsteady and ineffectual. It is worse than folly to allow these conditions to exist longer than to determine their existence.

The application of forceps is easy and extraction should be attended with little or no danger or added suffering to the mother except in cases of short cord. Here the danger is to the child chiefly. The cord may be torn from the umbilical ring or the placenta may be prematurely separated. This danger is not small and may be obviated to a certain extent if a skilled assistant will use abdominal pressure over the uterus to facilitate its descent with its contents into the pelvis.

II. In this group the difficulty lies in front of the head and not behind it as in group one.