In addition, I find it necessary often in the beginning of treatment to give a combination of aloin (1-5), strychnine sulp. (1-60), and belladonna ext. (%), from one to two pills a half-hour after each meal, according to the exigencies of the case, reducing gradually as the case case progresses to one twice a day (morning and night), then to one after supper, and finally stopping any and all. A valuable adjuvant of this is active massage before retiring.

In the very severe cases, where dilatation of the large intestine has become so great, particularly around the sigmoid flexure, that no responsiveness of the muscular power is possible, the case passes into the realm of surgery, and resection of so much of the intestine as is irredeemable, is the dernier ressort.

Perineal Lacerations in Country Practice.

By H. H. WILSON, M. D.

Stockbridge, N. Y.

Inasmuch as a woman's health is in large measure due to the integrity of her generative organs, it is our aim to prevent, as far as possible, anything that will cause a deviation from the normal.

We all know how an old perineal laceration will produce, in time, cystocele, rectocele, prolapse of the womb, and disorganization of all the organs in the pelvis by withdrawing the support of the pelvic floor.

These lacerations, whether superficial, moderate, or deep, are due to a variety of causes, generally a large head, a rapid second stage, or the forceps are accountable for the condition.

In most cases this can be avoided by holding back the presenting head, allowing it to come down on the perineum, then holding it back again, repeating this as often as necessary until the parts have sufficiently dilated to allow it to pass. By watching carefully during this operation, we can tell pretty accurately when the tension has become too great, as the perineum will become white and bloodless. Then, by pressing back the head

for a moment, we relieve the dangerous strain.

It is preferable to have the patient in the lateral position when both hands can be used to advantage, as the force with which the head descends sometimes requires the strength of both hands to control.

When the perineum will not dilate sufficiently to allow the head to pass without tearing, a double episiotomy will frequently give the desired room, and the integrity of the parts be preserved. Some will say, "Why more harm in a perineal tear than in two episiotomy incisions?" For two reasons at least. The incisions heal more readily because of their position, and because a perineum once torn is more prone to tear again in following confinements.

The operation of episiotomy does not result in injury to surrounding parts when properly performed. The incisions are made on each side of the vulvar opening through the tense ring felt half an inch above the border of the vulva. These incisions must be made parallel with the axis of the vulvar opening. They may be made with a pair of blunt-pointed scissors or a blunt-pointed bistoury, and should be a quarter of an inch deep and an inch long.

When we have a moderate laceration, or when episiotomy incisions have been made, immediately after delivery one or two sutures should be inserted, and the surfaces of the wounds drawn closely together. If it is done at this time little or no pain is felt owing to the numbness of the parts.

Forcible instrumental deliveries are probably the cause of many of the deep complete lacerations involving the rectal wall. This, too, can generally be avoided by care. Sometimes, when the life of the mother or child or both is at stake and every second is precious, we cannot wait for the perineum to dilate and the surrounding parts to adjust themselves, and it is in these cases that we get our deep lacerations.

The restoration of the parts when in this condition is a more serious matter, and for many reasons cannot well be un

dertaken at this time. The patient is exhausted before we begin; generally there is such a flow of blood that our work cannot be satisfactory; and afterward the irritation caused by the lochia will prevent healing, and healing, and promote sloughing.

It is far better practice, in such a case, to wait three weeks or a month until the lochia have ceased, in the meantime keeping the wounds clean by frequent carbolic douches, and then doing a repair operation and complete perineorraphy.

As routine practice there is nothing superior to creolin solution as a wash for the vulva, and it should be used several times each day.

Vulvar pads of gauze and absorbent cotton should be used and changed very frequently.

Headaches---Their Treatment.

R

M. Sig.-Take a teaspoonful in one-third glass of lithia water every two hours.

For Syphilitic Headache use blue mass or calomel in 8th to 1-6th grain doses every hour for two or three days, and also:

R Powd. iodid potassium,

3iij.

Powd. muriate ammonia. Comp. syr. sarsaparilla. M. Sig.-Take one teaspoonful in one-third of a glass of water three times a day.

Or, in place of the blue-mass-andcalomel treatment, take:

Powd. carb. ammonia,

Powd muriate ammonia. ãā zij Tinct. cimicifuga

Tinct. nux vomica.

Tinct. digitalis.

31

gtt. cxcij

gtt. lxxxviij ää 3j.

M. Sig. Take one teaspoonful in two tablespoonfuls of water two hours after each meal. If there is Hypochondriasis and depression of spirits, use:

M. Sig.-Take one teaspoonful in a tablespoonful of water two hours after meals.

Uremic Headaches require hot bath as the best measure to excite diaphoresis ; or, in lieu of the bath, use large hot-water bags over the region of the kidneys. If bags cannot be obtained, use hot-mush poultices. Give the following internally: Acetate potassium, Citrate potassium Infus. digitalis . .

Ꭱ

M. Sig. Take one teaspoonful in one-third of

a glass of water three times a day.

Use a saline cathartic if the above fails

to relieve the headache.

Sig.-Take one capsule every two hours, followed by a gill of Holland gin well diluted with water, until the kidneys act very freely. Then reduce the capsules to one three times a day, followed by the gin three times a day.

The caffein and gin are the surest treatment I ever used. As a drink, the oldfashioned bitartrate of potassium, 3j to aquæ Oij, drank during the twenty-four hours, is excellent.

Headache of Cerebral Effusion: Give saline cathartics first, then the tincture digitalis and acetate potassium mixture mentioned above.

Comp. spts. lavender.

Bromide soda..

Sig. This quantity to be taken in half a glass of water well stirred up, half an hour after each meal.

Headache of Cerebral Congestion requires :

R Bromide soda.

3j

.

3 ss 3ijss.

M. Sig.-Take a teaspoonful in two tablespoonfuls of water every two hours.

A Disappointing Footling.

By P. T. B. SHAFFER, M.D. Elizabeth, Pa.

It has been my good fortune to deliver a living baby, in most of my cases of foot presentation, by rapid delivery of the head; but this one disappointed me and proved unusually difficult.

On the morning of March 31st I was called to attend Mrs. æt. 30 years, primipara, who had been suffering with diarrhea for about a month. Says she ceased to menstruate August 4th last-239 days. Examination revealed an os not

spoonfuls of water every hour until relieved.

For Dyspeptic Headache the following is admirable:

erate character.

I had all things made ready, and at 5 A. M., finding left foot presenting, I ruptured the membranes and proceeded to bring down the right foot, but to my chagrin the pains did not seem to advance the labor. Traction was used with increasing force and the resistance was not overcome. Examination of the fetus over the abdomen discovered a submaxilla; over the side, the same result. I felt positive that it could not be interlocked heads of twins, for thus it is