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vigorously, relaxes so little, that after the expulsion of the placenta the uterin cavity is almost obliterated, and the amount of the bloody lochia is reduced to the minimum. On the other hand, in multipara, the uterin muscle being in some degree weakened by stretching and perhaps by some destruction of muscle substance that has occurred in previous pregnancies, the uterus after labor does not contract so firmly and the relaxations between the contractions are greater in degree and point of duration. Moreover, when the uterin muscle has been over stretcht, as it is in plural pregnancies or in hydramnios, or when the labor has been exceedingly long or unusually precipitate, very firm contraction does not appear after labor and there are apt to occur other periods of over relaxation. This condition, in civilized women, is so very common that it is necessary to study it under the head of the physiology of the puerperium, and yet the consequences of a failure of the uterin muscle to contract with maximum intensity after labor are always unpleasant and may be disastrous. A relaxation of the uterin muscle fibers implies a loosening of the countless living ligatures that bind the large vessels of the puerperal uterus. The immediate effect is an escape of blood into the uterin cavity. Oozing out gradually from the imperfectly closed blood vessels and sinuses, and, finding space in the enlarged uterin cavity to collect, it forms clots often of considerable size, which act upon the uterus, like any foreign body in it, as an irritant, exciting it to activ contractions which only cease when the foreign substance is expelled. These activ contractions of the uterus are always painful, with a pain like that of a cramp in any other muscle. These painful contractions, caused primarily by lack of firm contraction, and immediately by the presence of clots in the uterus, are called, appropriately enuf, after-pains. For the reasons already given, they are not experienced by primipara unless the uterus has been unduly distended or the labor has been too prolonged or too precipitate. On the other hand, they are constant phenomena in multipara, and the physician's treatment of them constitutes almost always a part of his routine management of the puerperal state in such patients. Apparently a trifling matter, it is one of utmost importance. In the first place, the pain is sufficiently distressing to demand relief, but, more important still, these after-pains indicate, to the educated physician, the presence within the uterus of blood clots or other putrescible material; and until they are expelled, and the uterus is induced to remain in a state of firm contraction, the woman is not entirely safe from the dangers of septicemia. Moreover, it is necessary to be familiar enuf with the clinical features of after-pains to be able to distinguish them from the pain of peri-uterin inflammation. should not be difficult. The intermittent character of the after-pains, their cramp-like nature, the fact that pressure does not increase the pain, and that the pulse and temperature are unaffected, suffice to distinguish the painful contractions of the uterus after labor from the pain of inflammation.

This

For treatment, see further quotations from authorities in Quiz Department of this issue.

The Actual Source of Danger in Administering Anesthetics by Artificial Light. As students, all practicians have had imprest upon them the danger incident to the use of anesthetics by artificial light, but generally the conception is somewhat hazy regarding wherein the actual danger exists. H. C. Wood calls attention to the fact that the vapor of ether, being heavier than air, sinks to the floor; therefore, in giving ether at night the light should be placed high above patient and operator. Even with this precaution, the vapor has passed eight feet to a flame and exploded

with disastrous consequences. The belief is quite general in the profession that the danger lies in ignition of the vapor, and the consequent burns induced.

It is now known that the danger from chloroform is common to not only patient and operator, but to any other person who may be in the room, and that the chances of ignition and explosion are rare and comparativly slight. When the vapor of chloroform comes in contact with a naked flame there is a resultant decomposition into chlorin and hydrochloric acid. When the chlorin is inhaled there is a sense of weight in the head and tingling in the nostrils, and a dry, spasmodic cough develops, and there is a feeling of distress with each respiration. This condition may develop in patient, attendants, and operator, and it may become so severe in the case of the patient as to usher in stertorous breathing and failure of heart and respiration. Cases are on record where death of both patient and attendants has resulted under such conditions.

When an operation is imperativ after night, and cannot be arranged to take place where incandescent light can be secured, it is best to choose ether as the anesthetic, and if any contra-indication to that be present, to select a large room where perfect ventilation is possible, and complete the operation as rapidly as possible. The inhaling masks now on the market, which confine the vapor closely to the face of the patient, are preferable to the more convenient and less expensiv towel method. Other and newer anesthetics are making strong claims for recognition, but it is not likely that they will supplant.chloroform for many years to come. All the major operations have been performed under cocain anesthesia, but only those of extended experience care to use it in the more serious cases. Chlo roform will continue to be used, and will continue to be used recklessly, but no practician has any right to add to its dangers those of poisoning by extraneous products of decomposition, by its ill-advised use by artificial light.

Query.

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Are you paying any advance fees to collection agencies now? Are you signing any contract-notes collection agencies, to be caught up on, a few months later? Didn't THE WORLD stop all that funny business? Is there in all this country a doctor who is fool enuf to get caught on that game now? If there is, he has only himself to blame. What say you? How many thousands of dollars do you suppose is thus saved to the medical profession per year? Did any other medical journal ever render such service to the profession?

Twenty grains of alum to the ounce of water makes an efficient application to apply in tonsillitis and ordinary sore throat by means of a swab or throat brush. It exerts a destructiv action on the teeth, and its application should therefore be followed by rinsing the mouth well with clear water.

ORIGINAL COMMUNICATIONS

Short articles of practical help to the profession are solicited for this department.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors. Copy must be received on or before the twelfth of the month, for publication in the issue for the next month. We decline responsibility for the safety of unused manuscript. It can usually be returned if request and postage for return are received with manuscript; but we cannot agree to always do so. Certainly it is excellent discipline for an author to feel that he must

say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than anything else.-RUSKIN. RECORD

READ

REFLECT

COMPARE

The Process of Freezing to Death.-Frost

bite.-Chilblains.

Editor MEDICAL WORLD:-The early effect of intense cold on the system is noted as soon as the individual passes from the warm room into the cold atmosphere. First there is a sensation of obstructed breathing, as if the passages of the nose were narrowed; simultaneous also is a slight rawness and fulness of the chest. Reaction in the nose soon follows, and a watery discharge is very common as a result of the hyperemia of the mucous membrane. Slight cough and expectoration are noted in some. The breathing then becomes free, and remains so during the exposure to the cold. Parts exposed to the cold at first tingle and show a lack of blood; the setting of the blood inward congests the brain, and frontal headache follows; with the reaction and return of blood to the parts the headache subsides, and a sense of faintness and nausea is often felt, which again rapidly subsides as the circulation becomes full and strong under the stimulating influence of the cold. For a time all of the natural powers combine to combat the inroads of cold, and the individual is alert to every pain and pang from without and within ; there may even be anxiety. Finally the headache is again felt, there are chilly spells, one part after another tingles from cold, then the tingling lessens, and numbness and weight of the limbs follow. The mind is prone to reverie and a sense of security; the cold is noted, but the desire to ward it off is gone, and there is a strong desire to sit or recline, and allow the mind to continue its thoughts. Drowsiness and an almost irresistible desire comes to sleep, and at the same time the sensation in the limbs is lost. The individual may know that he is freezing, but the will is too weak to rouse the body to action. Unless aid soon comes to such a one, death is imminent. Nature has exhausted her vital power, the heart slows, and so does the respiration.

On entering a warm place care must be observed lest the congestion of the internal

organs be relieved too quickly; fainting or even death may follow the setting of the blood to the surface caused by anemia of the internal organs. To stimulate the lungs and heart, and retain part of the circulation in the internal organs, nothing surpasses a cup of hot tea.

Frost-bite: The sensation of cold is followed by tingling and aching of the part affected. Numbness and a sense of weight is noted, and then all sensation is lost. On examination the part is white, stiff, and frozen. So insidious is the inroad of cold that a part may be frozen for hours and the individual have not the slightest knowledge of cold, pain or discomfort. The action of frost is first by direct injury to the tissues, and second and more noteworthy, the injury to the nerves that control the local circulation of the frosted area. Rapid restoration to the normal temperature is followed by inflammation, sluf and gangrene. An individual with a frozen finger, toe, or extremity, should first be taken into a room that is scarcely above the freezing point; after bundling with clothing sufficient to keep the body warm, the frozen part should be rubbed with snow, or immerst in ice water, and gently rubbed while the frost is coming out. Gentle friction is necessary as the circulation returns, lest engorgement follow. For a short time after the frost is out the rubbing should continue. After this first step the patient may be put to bed in a cool room. The frosted member should be elevated so that the arterial circulation is retarded, and the venous circulation assisted from the part by gravity. The limb should be left in an elevated position for several days, open to the air with neither cover, nor dressings. The room must be kept cool (40 or 50 degrees F.) Allow the patient plenty of bedding that the room need not be kept warm. If the frost-bite has been superficial, cold compresses of lead-water and laudanum will be soothing, and assist in preventing inflammation. If the deeper structures have suffered from the cold, the lead-water and laudanum should not be used; but at intervals of two or three hours alcohol should be applied to the part, using gentle friction to stimulate the circulation. For two or three days the appearance may be quite normal, and then without apparent cause suddenly the part inflames, becomes swoolen, blackens, and gangrene sets in. If sluf or gangrene should develop, the injured locality. should be covered with a light dressing for a few days until the line of demarkation is establisht between the part that is going to recover, and the part that is hopelessly injured. The nerves are slow to recover after being frosted, and for this reason do not control the capillary blood vessels, allowing of local congestion and distention. Above the injury the normal veins

are not sufficient to carry away the excess of blood; thus thru the weakened walls exudation easily follows, with distention and inflammation, and restoration is retarded, finally ceases, and gangrene ensues. The line of demarkation in superficial injuries is back of that in the deeper structures, making the stump of healthy tissue convex; but where the injury has been deep and of some hours' duration the reverse of this condition is to be found, and the stump is concave. The bone least of all the tissues regains its vitality.

Operations to remove frozen fingers, toes, or extremities must be performed well back of the line of demarkation (especially is this true of the bone) lest a second operation be necessary before the desired result is obtained. Frosted tissues are low in vitality, and healing may be retarded. Primary union cannot be expected as often as in operations on more healthy more healthy

structures.

Chilblains: Parts that have been frosted or exposed to cold for some time and then rapidly warmed behave in a peculiar manner, and thus claim separate consideration. Hyperesthesia of the affected area is the prominent feature of the trouble. The injury is more of the nerves than of the tissues. Rapid rise of temperature in the part, with or without previous exposure to cold, gives rise to very annoying symptoms: burning and itching with reddening and more or less swelling. Moist heat (the bath), heavy clothing, and sudden changes in the atmosphere are all exciting causes. The treatment

of such cases should be first directed to the prevention of rapid changes of temperature of the part affected. When local irritation is present, the itching and pain may be arrested hv the application of cold compresses wet with ad-water and laudanum, or by painting the part with fl. ext. of belladonna, directing the treatment to the injured nerves. Massage and the use of astringent liniments are of value between the times of irritation.

All parts that have been frozen are sensitiv to cold for some time, and should be given massage to restore the functional activity of the vessels and tissues of the part.

Points of interest:

1. To combat cold the system uses up her energy very rapidly.

2. A sense of security and drowsiness are the danger signals of cold.

3. The restoration of a frozen part must be gradual.

4. Heat is the enemy to recovery.

5. Spirituous liquors are never of use in a cold climate during exposure, for with their reaction there is the greatest danger of freezing.

6. Hot tea is the best drink to supply the

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Shall the Country Doctor Move to a City?

Editor MEDICAL WORLD:-In answer to W. Va., who wants advice in regard to country physicians or village doctors moving to town or city, I will give my advice. While at the Pan-American Exposition at Buffalo, I made the acquaintance of a doctor from near the capital of N. Y. He had repeatedly thought of moving to Albany to practise his profession, but he finally decided, as I have, that he "would rather be big dog in a little place than little dog in a big place." Charge for what you do and stay with your practise, and you will be just as well off. After 22 years of experience, I find that it pays to become one of the fixitys of a place. C. A. RIFE, M.D. Kyger, O.

Editor MEDICAL WORLD:-I would be pleased to give at greater length than your columns would admit, my experience regarding the advisability of changing from a country to a city practise. I believe that the statement of facts as they exist to-day in the great teaching centers-with the present system of mis-government and the multiplication of eleemosynary institutions, and their effect upon the practise of medicin, if truthfully placed before a man, and more especially if he has children who would be compelled to make the streets their playground, on account of the stealing of money which should have been used for the purchase of parks-would prevent his coming to the city. It is only the man who has gone thru it that is in a position to give an opinion. Experience teaches fools. In addition to all the risks to the family, a man must be prepared to make an outlay of three to five thousand dollars a year, for at least five years, and possibly longer, before he establishes himself, I care not how well up he is. There are hundreds of men here fully qualified, waiting for something to "turn up. In conclusion I would say that if you will refer to me all inquirers who are thinking of coming to this city, and if I cannot give them information regarding the uncertainties of medical life here to prevent them adding one more to the already too long list of sufferers, then I

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am woefully mistaken. My first attempt at replying to the query would, I am sure, make interesting reading for the inquirer, but I know where, on account of its length, it would go. I would be pleased to write the doctor fully, if he wishes more information regarding this city. F. MARSH SOPER, M.D. Pinkney Court, W. 140th st., N. Y. City.

The Starch Bandage. Editor MEDICAL WORLD:-The article in the Sept. WORLD (page 394) by Dr. Bardwell on the use of the silicate of soda bandage as a permanent dressing for fractures, prompts me to give you my experience with the starch bandage, to further show the folly of spending money for a big stock of patent splints for such work, and nine times out of ten you do not get as good results out of them as you do out of the silicate, starch or plaster-of-paris bandage when properly applied. I have been I have been in the business for forty years and never owned a set of splints. I don't claim I have had a thousand cases, but have had a goodly number. I have treated all my fractures of the leg and thigh with the starch bandage, and all my arm fractures with common board splints properly shaped and padded, and I have never had a bad result; in fact the very best results. I graduated at Bellevue in 1865, and in one of Frank H. Hamilton's clinics, where he had applied a plaster bandage, he remarkt that any butcher could cut a leg off, but it took a surgeon to save one; also that there were three requisits to make a surgeon: a perfect knowledge of anatomy, a natural mechanical skill, and a good degree of common sense. I thought I had a little of all three. I was sure I had the mechanical skill, and as for the anatomy, I could brush up on that before an operation, but the common sense I have often thought since, at times, that I was short on, especially when a fellow would come whining around and I would give him a discount off his bill.

Now there is one thing in the use of the starch bandage I do different from modern teaching, and that is, I apply the bandage at first-do not wait for swelling. If the bandage is properly applied, the evaporation of the starch in drying acts as a poultice and prevents much swelling. I cover the leg evenly with cotton from the toes to the hip, then run a dry roller bandage the full length, then smear it over with thick starch, and apply the starch rollers, five to six layers, smoothing each layer down with a little additional starch, then a dry roller over all. When complete, I put on a straight splint about four inches wide at the top and about three inches at the bottom, ex

tending from a little above the trochanter to four inches below the foot, and bind that on with a dry roller. You can apply extension if you wish. I never have. Before the star gets dry there is not much tendency to contraction, and what there is is counteracted by the straight splint. After it is dry, I remove the straight splint, cut out a strip an inch wide from the toes to the top, then apply straps, two to the foot and one every six inches the whole length of the leg. You can tighten or loosen these or any one of them, as occasion requires. There is no danger of shortening after the bandage is dry, for you have a perfect mould of the leg, and there is no chance for the muscles to contract. In all the cases I have treated I never have had any shortening. The results were perfect. The patient can usually get up in a week and go around on crutches.

There is always a little stiffness of the ankle and knee after you remove the bandage, but that soon limbers up and need cause no anxiety. I know in modern surgery passiv motion of the joints is advocated, but in these cases of starch bandage I think it is uncalled for, and might be injurious to the union that is taking place, and give the muscles a chance.

to contract.

In compound comminuted fractures I cut a trap just large enuf to treat the wound. The toes being left out, you can tell when the bandage is too tight and interfering with the circulation. As long as there is no blueness of nails, it is all right.

I have gone into details for the benefit of the young physicians, for the modern works of surgery don't tell you how it is done. I have known physicians to make mistakes both with starch and plaster in fractures of the femur, applying from the hip to the knee only. Of course they could not have a good result, and consequently they condemn the apparatus, when in truth the fault was in their ignorance. I am not writing this to condemn other appliances or to claim extraordinary advantages over them. I am only telling you what I have done and how, and the results I have got out of it. The great advantage with this is, the material is always at hand and costs you nothing. The ladies will make starch and starch the bandages for you when you show them how. Assistants will hold the leg while you are putting them on. After you have all your starch rollers on and the dry roller over all, pull the leg straight and have it in line just as it was before fracture; then have the assistants hold it exactly there while you apply the straight splint. See that the leg lies smooth and nice in the bed with a little packing of some kind on each side to hold it

8

A Case Like that of "Perplext" Arrested and Acquitted THE MEDICAL WORLD

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A Case Like that of " Perplext" Arrested and Acquitted.

Editor MEDICAL WORLD:-I have been reading your valuable journal for several years, and I conclude that it is the only journal that reaches the country practician in the way of rendering real help. I have profited by its many words of advice. With great interest I read the articles on 66 Perplext." Very few practicians have not had one or more cases along the same line. And I have come to the conclusion that we who must earn our bread and the necessaries of life, would better keep quiet, for if we report these cases, the law is so lax that justice often miscarries, and we become the butt of ridicule, and we get a host of enemies by doing what we think is right in the sight of God and man. Silence is often the best policy. I do not uphold any wrongs in this direction, and I believe in standing upon the principles of right and justice; but we must know on which side our bread is buttered. I wish to relate one case in particular. About five years ago the writer was called to attend Miss in confinement. The

family were about half smart taken all together, and the young lady was no exception to rest of the family.

The father of the young lady said his daughter had cramp colic and was very sick. I had heard it reported that the young lady was in the family way, but did not know only from reports. When I arrived at the house her general condition indicated that she was in labor. I called for some warm water and proceeded to make an examination. This she positivly forbad, and her mother also went against me, and said I should not examin the daughter, but give her something for the colic. This I refused to do. While we were arguing about the examination, the child was born. Then she allowed me to attend to her. I found the child to be a strong, healthy youngster to all appearances. I gave her all the attention needed. When I was about to leave she said she did not want any baby, and had a notion to wring its head off. I told her to be careful what she said and did, or I would see if anything happened the baby. That night the child died; said she went to sleep, and

when she woke up the baby was dead. In two days, when I called, it was buried, and they were preparing to move to another state, so I let it go, but I have reasons to suspect that the child was killed by its mother.

About one year after the birth of this child, she gave birth to another one under similar circumstances, followed similarly by death of the child. No physician was present at the time of the birth of this child. The people had the child exhumed and a post mortem made. The verdict was that it died from strangulation, and the young woman was arrested, tried and acquitted, there being no direct evidence to convict her; yet it was the opinion of the people in general that she was guilty.

Now did I do right in this case or not?

We hear so much these days about small families, race suicide, etc., that I want to touch on this question. President Roosevelt is a wise and great man; he wants to see large families; so do I, and many other people. Some writers lay the blame directly on the parents for small families, or no children at all. I do not take this view of the question. It is true I find more miscarriages than at any time previous in a 20 year practise, but who is to blame? I find many in my practise who are anxious for children, and I do not think they try to evade conception in the least. Many women who conceive will miscarry in spite of our best efforts; and for those who never conceive, it is a question as to why they do not. Are they steril and beyond help? or is the male steril? There is but little said about the male being steril in our books, yet I am of the opinion that there are in this land about as many steril males as females. I want to hear from the brothers who read THE WORLD what they think of this question. Again, it is admitted that our foreign population is much more fruitful than the American. Why this is I cannot understand. Why does not some specialist get to work among the nativ Americans and see what is wrong? Here is certainly a good field for some of us.

RACE PERPETUATION.

Consumption and the Opium Habit.

Editor MEDICAL WORLD:-It is rather surprising that any one could for a moment believe that the habitual use of opium could inhibit the progress of consumption or prevent its contraction. All the nutritiv functions are lowered in the opium user. The appetite is lessened, the power of digestion is lessened, and secretions and excretions are lessened. There can be no question that the resisting force of the individual is lessened under such conditions. Every successful phthisiotherapist makes the increase of physiologic

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