great dyspnoea on attempting to lie downhence compelled to sit in a chair, a feeling of intense thoracic oppression. Has a mitral murmur. The urine upon boiling became almost solid, showing the large amount of albumin escaping.

My attention was not called to this case until it had assumed a very serious aspect. The death of the child was evidently due to lack of nourishment from blood impoverishment upon the mother's part. The fœtus, which had been dead for some time, was expelled December 25th, the confinement not being expected until the 15th of February.

In this case the wonderful powers of trinitrin were demonstrated most conspicuously; she was also given digitalis, strychnine and iron. Suffice it to say, she recovered and is still living in a fair state of health, the kidney trouble, however, continuing. The latter most likely existed prior to the pregnancy, and she had at the time an acute attack engrafted upon the chronic trouble.

No. 26. This case was a study. Patient subject to hysterical convulsions of the type opisthotonos; was in this condition numerous times prior to dilatation of the cervix. After the cervix was dilated the labor was rapid; a nine pound boy with an unusually large quantity of liquor amnii.

No. 30. Woman small in size and stature; labor rapid; third child, a boy. Had postpartum hemorrhage and torn perineum, the child having been born about twenty minutes before my arrival.

No. 31. The youngest primipara, sixteen; short labor, lasting about two and three-fourths hours.

No. 33. Gave birth to the second child at thirty-six, after an interval of about twelve years.

No. 36. Child emaciated and feeble from disease of the placenta; somewhat prema

ture.

No. 39. Interference with labor by the very short and fleshy cord being drawn tightly over the neck.

No. 40. Complicated presentation-right hand by the side of the face.

No. 47. An unusual and peculiar case. Had very severe false pains, which had no effect upon the os, produced no dilatation, this continuing for about three days and only allayed by repeated doses of morphine, when finally the os began to dilate, the labor then terminating at the end of fourteen hours.

After the birth of the child, it proved to be a case of retained placenta, the only one in this series. I tried various means to secure its expulsion, but all failed, when my father, whose obstetric experience extended over forty years was called to assist. Some ether was given and it was found to be one of those unfortunate cases in which manual detachment was necessary. My father introduced his hand into the uterus, and slowly separating it, finally removed it entire. As anticipated, septic infection followed. The temperature rose, the abdomen became tympanitic, the lochia suppressed partially, at no time completely, but during the entire illness there was sufficient milk secreted to nourish the child. Antiseptic injections, internally, quinine, iron, brandy, and all the milk she could possibly take, were ordered, when at the end of ten days the difficulty was controlled and she finally made an excellent recovery. She was since confined a second time, another physician attending her, with the same history repeated.

No. 48. Repeated and almost incessant vomiting characterized this case as a peculiarity.

No. 51. A short and fat cord impeded delivery.

No. 54. The cord wrapped around the neck three times very tightly, thus impeding delivery.

No. 55. Child and placenta both born, the whole contents expelled from the uterus by nature alone.

No. 59. Very narrow vagina, as also the next, No. 60, large child.

No. 61. Suffers very little during her labors; they are easy. She remarked to a friend that giving birth to a child was no more burden to her than to milk a cow. This was her eleventh confinement at thirty-five. After

No. 62. A unique and interesting case. Patient, æt 24, primipara, had nephritis of pregnancy with immense cedema of the lower limbs, the skin being distended to the utmost; extended upward to the abdomen, involving the external genitalia, the labia being immensely swollen; was unable to walk or sit, not being able to bring her lower limbs in apposition, hence compelled to recline in bed with her limbs widely separated. The chief clinical feature was the dropsical effusion, very little urine being secreted; the other symptoms were comparatively insignificant. I was called to see her about two weeks before labor came on; had it occurred at this time the parts would have sloughed, unless incisions would have been made to let out the effused fluid. By the time labor came on the swelling had disappeared to the knees, under the use of trinitrin, acetate of potash, and tincture of digitalis. This stimulated the renal functions to such an extent that she would pass a chamberful of water during a night. Labor came on, with an occipito-posterior position; after a time ether was given, which I feared might have a bad effect upon the kidneys, but to my pleasure no bad results ensued; forceps were applied the child delivered, and a happy recovery followed.

No. 66. Precipitate labors occupying perhaps ten minutes; large children; I attended her in her ninth and tenth confinements.

No. 78. Face presentation; unusually severe labor; large child.

No. 84. Twins, two girls; each in a separate sac; but one placenta; both presenting by the head, the one somewhat in advance of the other; they were both feeble, living but a few days.

No. 85. Precipitate labor, occupying about fifteen minutes.

No. 91. A severe labor, lasting twentyone hours, and ending with the birth of a tenpound boy; gave ether and applied the forceps; being applied somewhat obliquely, the pressure of the blade upon the left cheek

disappeared without leaving any trace of it.

Many of the cases not quoted, especially toward the end of the series, possessed interesting features; but finding that the paper was already becoming too lengthy, I felt compelled to abridge matters speedily, and so merely passed over them with regret. There was no less than half a dozen cases of precipitate labor, the time occupied varying from ten to sixty minutes; in these labors, especially, the suffering was, as a rule, intense.

It often happens that the doctor is called just in time to support the perineum as the head is about ready to emerge; under such circumstances aseptic measures are idle, and the administration of an anesthetic out of the question. But in the majority of cases the doctor is called in time to be present and conduct the labor. The intense suffering just referred to and which Meigs spoke of by saying, "There is no name for it but agony," impresses me most forcibly of the value of an expedient which is but lightly regarded by many, not appreciated at all by others, violently opposed by some and regarded rightly and justly by but few.

In conclusion then, I will merely touch upon the subject of anesthesia in parturition, to me a very interesting and important topic and one which I fervently advocate. As a rule, I offer it to every parturient woman, and accord her the privilege of accepting it or not as she chooses. The paper having already acquired unusual length, I must refrain from referring to it in anything more than a cursory way. In a former paper read before this society,* I expressed some sentiments in regard to its application and utility, which in the light of additional knowledge and further experience have become more firmly impressed than ever, and I merely wish to add that I reaffirm in the most positive. manner, all that was said on that former occasion. With some physicians, who regard their own comfort and convenience as superior to that of the patient, the administration. of an anesthetic might be regarded as en

Medical and Surgical Reporter, October 27, 1891.

tirely too much trouble, far too burdensome. To such I would suggest that laziness is a quality which should find no foothold in the medical character; especially is it to be condemned in an accoucheur. Above all things, he should be active, vigilant, sympathetic, attending to all details promptly and with an eye solely for the comfort of the patient and the success of the case in hand.

Any and every measure calculated to assist the parturient woman, to relieve suffering and to diminish pain to a minimum, while in the exercise of this function of bringing forth, will find in the writer of this article, an earnest advocate and a staunch supporter.

CARBOLIC ACID USED IN FULL
STRENGTH IN SURGERY.

BY OSCAR H. ALLIS, M. D., (J. M. C., 1866),
Surgeon to the Presbyterian Hospital.

Read before the Philadelphia Academy of Surgery.

Surgeons in early days of antiseptic surgery attributed their success to carbolic acid. As introduced, it was employed in a dilute aqueous or oleaginous solution. For a time it was the sole antiseptic. To-day it is mainly used in general surgery as a bath for surgical instruments. Few surgeons will demand a reason for its abandonment. Few have not personally experienced its benumbing effects, and have thus been able to assign the collapse following its employment to something different than loss of blood, shock of operation or anæsthetic.

With such an experience of carbolic acid in its dilute form I confess that I was quite astonished to learn from my friend, Dr. B. F. | Gardner, of Bloomsburg, that he was in the habit of using the article in its full strength upon extensive cut surfaces, and that, too, with the happiest results. As this article owes its entire value to Dr. Gardner, I will give in detail his method.

When Lister introduced his paste, Dr. Gardner used it quite extensively. After an application to quite an extensive wound surface he was surprised to find it turn white,

and that he had used pure carbolic acid. He therefore immediately washed the surface and dressed the wound, keeping it open until oozing had ceased. The case did so well that it inaugurated with him a line of treatment that he has extensively employed. As a typical application let me take an amputation of the female breast. After its removal and the ligation of the bleeding vessels, carbolic acid crystals, dissolved in sufficient water for solution, are applied with a sponge to all parts of the cut surface. Immediately upon the application of the acid the tissues turn white. which is a guarantee of its thorough action.

The wound surface is then washed with water previously sterilized by boiling, and then approximated with provisions for drainage. This is especially necessary, as for twentyfour hours the oozing must find ready exit. During the first few days there is a light local hyperæmia along the borders of approximation, but this declines without crisis.

Dr. Gardner claims for carbolic acid applied in officinal strength :

1. That no systemic absorption attends its use, and hence no danger, no shock.

Hence

2. That it is a local anesthetic. there is not as much pain after the operation. 3. That it is in a measure a hæmostatic, acting especially upon the capillary vessels.

I have taken the removal of the mamma only as an illustrative case. In all operations outside of the pleuritic and abdominal cavities, such as amputations and resections, Dr. Gardner resorts to it.

In hydrocele he lays open the sac freely, then applies carbolic acid to the tunica vaginalis, and concludes with packing or drainage. The operation is not followed by excess of any kind, and recovery is prompt. He has used it in gunshot wounds of the knee and ankle. If he gets such a case after suppuration has set in he freely opens the joint, applies the carbolic acid to every part, washes out all excess freely, secures ample drainage with fixation, and confidently awaits the result. Anchylosis may follow, but this will depend on the extent of the injury, the delay in treatment, the conduct of the patient. Dr.

Gardner has used bichloride of mercury, hydrogen peroxide, iodoform, etc.; none of hem has answered the claims made for them: all have disappointed him, but pure carbolic acid never.

I have said that Dr. Gardner does not use this upon serous membranes, i. e., within the abdomen. I must modify this statement. In a case of strangulated hernia, in which he found patches of sphacelus-not deep, but threatening-he cautiously applied the pure acid and returned the gut. Fortunately, the strangulation had been arrested by operation in time to save the gut. Nothing eventful in the subsequent history, which was speedy.

I do not know Dr. Gardner's theory of the actions of this powerful drug, and shall attempt no explanation. The turning of the wound surface white is due probably to the coagulation of the albumin of the tissues and fluids of the wound surface, and not that the acid has a necrotic effect. That it does not produce a true destruction of tissue may be inferred that after a large breast or thigh amputation he will have primary union and no suppuration. In its use in hydrocele a half drachm or more is injected into the tunica vaginalis, and resolution without suppuration ensues. It is possible that by its action upon the wound surface an action similar to that obtained by heat may be produced, and thus facilitate repair. I will conclude this article by briefly stating my own experience with it.

On entering the wards of the Presbyterian Hospital I found that one of my amputations of the thigh had not done well, and looking at the stump found it swollen and of an angry threatening character. The seam of approximation was perfect. I therefore removed all the sutures, and separating the flaps found them almost in a state of gangrene. Taking carbolic acid pure, I applied it freely, pressing it into the tissues with the sponge applicator, removed the excess, and packing the space between the flaps renewed the dressing. This was done without anæsthetic and without apparent pain. The exposed surfaces soon began to granulate, when they were approximated and recovery soon followed. I

have also frequently applied it upon a carrier with cotton to sinuses and after curetting glands.

PEDICULOSIS.

BY J. ABBOTT CANTRELL, M.D., (J. M. C., 1885), Instructor in Dermatology in Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia and St. Agnes Hospitals, Philadelphia.

Pediculosis seems to share with scabies the increase in number of cases since the arrival of certain elements to our shores; and its being a very disagreeable affection to those of the better walks, a few words upon its characteristics and treatment will not be misspent this morning. As it affects different portions of the body, we may look for an animal peculiar to each region. Upon the scalp the parasite is the pediculus capitis, and ranges in size from 1.410 mm. to 3.174 mm. in length, and about 1 mm. in breadth ; and as it is witnessed upon different nationalities, it has a color unique to each race, being gray with blackish margins upon the European, white on the Esquimaux, black on the colored race, and yellowish-brown upon the Chinese.

This variety is more common in childhood than in the adult on account of the playful manners of the children while at school or on the playground. It is contracted by coming into contact with one so affected, or with some article that has been worn by the affected, as a hat or cap.

The parasite attacks the head, but excites no special lesion, but produces such intolerable itching by its movements that those affected feel an itching all over the scalp at the same time, and it is for the relief of this that the condition of the scalp is produced. The parasite which lives upon the hair selects those portions which are abundantly supplied with hair, as the occiput, and it is here that you must look for it.

A child having presented itself for treatment and complaining of an itching sensation upon the scalp, you necessarily think of pediculosis, and on examining the scalp look first at the occiput, and if it is the pediculus that has caused the mischief, you will find it in

this region; but often you will be unable to find the parasite, but upon the hairs you may witness some small, grayish bodies, which are the eggs of the parasite. Generally this will be sufficient to make a diagnosis. This child, age eight years, will exemplify my remarks. She goes to school, and has contracted it from some other child. You notice with what extreme care the mother has washed the head before coming here. This generally is the case. They think possibly by this means to mask the original trouble, and that you will be led astray as to the real cause of the disease. If the child's head had been washed as often as necessary, this condition would not be witnessed now-that is, not in so marked a degree. Carefully looking through the hair, parting it here and there, I fail to find a single parasite; but upon the hairs, in great numbers, I see small, grayish bodies with the attachment to the proximal end of the hair. These are the nits, or ova, of the pediculus, and as they are present the parasite must have been here, or we would not find the eggs, and as the ova hatch out in about six days you can naturally see how easy it is to produce a condition as bad as this in a short time. Being convinced that the parasite was here, we will find also an inflamed and possibly a pustular condition of the occipital region; and as the parasite lives upon the hair and only comes upon the surface of the skin to get nourishment, it is the insertion of the proboscis that causes the itching, and the scratching, instead of relieving it, causes an irritation of the parts, which may in a short while become decidedly ulcerated.

I take great pleasure in bringing the next case before you because it is a man and it is rare that we find adults so affected; but he is a representative of a class of beings-the tramp-where the use of soap and water is a luxury. You can see, without parting the hair, that the head is filled with possibly hundreds of the parasites; they are small and do not take up much room, and consequently great numbers can get into the hairs of the head of an adult; and now, as I part the hairs

with this stick, that the scalp is one mass of crusted patches, caused by the tearing inflicted by the nails, to get the relief that does

not come.

The diagnosis cannot be mistaken in this variety if you look carefully for the parasite; and if it should not be present the appearance of the ova on the hairs cannot be misjudged.

Upon the body we meet the pediculus vestimenti, the body, or, speaking more properly, the clothes louse, because it lives on the clothing.

The parasite'ranges from 2 mm. to 3 mm. in length and about half that in breadth, and is consequently larger than one of which I previously spoke. In color it is a dirty-white, with black margins. It lives on the clothing

making a habitat of the seams and only leaving its place of abode to receive nourishment which it gets from sucking after it has inserted its proboscis,

Whatever condition that may be produced upon the skin is, of course, secondary, and due to the exertion of the afflicted to relieve the itching, we find a small punctate hemorrhagic spot, about the size of a pin point, left after the withdrawal of the proboscis; but rarely is this perceptible to the naked eye of the observer; but in a short while from the scratching indulged in, the spot becomes perceptible because we have the formation of blood crusts, at the point where the parasite received its nourishment.

In conjunction, or in a short while after the appearance of the puncta is witnessed, we have the parts showing evidence of the decided itching that is present from the character and number of the scratch marks.

As I said before, the animal selects the seams of the clothing for a habitat, and where the clothing clings closest to the body, and preferably around the wristband, the girth of the body, the outer sides of the thighs, and upper portion of chest and back; occasionally a parasite may be found upon the body, but that is due to having disturbed him during his meal hour; the parasite seems to have a distinct affection for certain individuals, such as those who are in poor health, or are