THERAPEUTICS OF LOBAR PNEUMONIA.

Brem contributes a paper on pneumonia to the Johns Hopkins Hospital Bulletin for October, 1905, and in closing presents the following summary of the therapeutics of the disease:

1. Elimination of the toxic agent. Internal hydrotherapy. 2. Amelioration of harmful influences: (a) Fever, external hydrotherapy; pain, ice bag and analgesics; restlessness, insomnia, delirium — external hydrotherapy, analgesics, and narcotics. (b) Respiratory indications: (1) Heroin or morphine every two hours for a respiratory rate of 36 or greater; (2) oxygen inhalation is probably useless and may be harmful. (c) Circulatory indications: (1) Circulatory sedatives are probably contraindicated, excepting the nitrates, which may be of benefit during early periods of increased cardiac work. (2) Alcohol indicated in alcoholic cases; may be of benefit when there is no circulatory insufficiency. (3) Circulatory stimulants contraindicated, except members of the digitalis series. The indication is low blood pressure associated with one or more of three conditions, namely, respiratory insufficiency, small urinary output, edema of lungs.-— Therapeutic Gazette.

OBSTETRICAL

VARYING TONICITY OF THE UTERINE MUSCLES WITH REFERENCE TO THE DANGER OF PERFORATION DURING CURETTEMENT.

(Catherine von Tussenbroek, Zentralblatt für Gynaekologie, No. 34.) It has been eleven years since Vauder Mey called attention to the fact that very frequently during a curettement a sudden relaxation of the uterine wall takes place; he was able to show his students that the sound would oftentimes enter the uterine canal 2 cm. deeper after the curettement than before. Von Tussenbroek is surprised that this variation in the tonicity of the uterus has attracted so little attention. Since her attention has first been called to it, she claims to have been able to observe it almost regularly. In some cases where the relaxation

is only slight it might escape notice. She performs the curettement in the usual manner, after having scraped the uterus two or three times, the uterine cavity becomes more roomy and the walls become relaxed. If the curettement is now carefully continued, one can observe how the tonicity again returns, and the uterine cavity again becomes smaller, and at last one can hear the characteristic scraping sound, called by the French the "cri uterin." According to the usual teaching this sound does not occur until the mucous membrane has been scraped off. Tussenbroek, however, does not believe this explanation to be correct. She claims that the curette takes off the mucous membrane with the first stroke, and not gradually; so after the first stroke of the curette the instrument is already on muscular tissue, and consequently we should get this characteristic sound immediately, which usually is not the case. She believes therefore that the

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cri uterin" is a sign that the uterus which was at first relaxed has again regained its tonicity, and that instrument is now gliding along a more solid and tense base. The flabbiness of course increases the danger of perforation. A number of illustrations are given that show that this transient relaxation is probably due to the mechanical irritation.— Medical Fortnightly.

OBSTETRICAL BINDERS.

Povey, in the Dominion Medical Monthly, gives the following uses of the obstetrical binder as determined by his own personal experience. He advocates its use in practically all cases. The binder itself consists merely of a piece of unbleached muslin long enough to surround the abdomen and broad enough to extend from the pubes to the sternum; two pieces of the same material, three inches wide and eighteen inches long, are securely sewed to the posterior border (to avoid the use of safety pins, on which the patient would have to lie), so that when the binder is applied they hold it down in position, and, being pinned anteriorly above the pubes, hold the vulvar pads in position. Several of these simple binders should be on hand, so that as one becomes soiled another may be applied. A good sized pad of

absorbent cotton or other suitable material should be placed on the abdomen just back of the uterus after that organ has been lifted forward. This pad is held firmly in this position while the previously arranged binder is pinned snugly by the nurse, beginning at the sternal end and pinning downward. The hand is gradually removed as the binder is pinned, so that the pad is held in place. The binder is pinned tighter above than below. The vulvar pad is placed in position and the two posterior straps are drawn up and pinned anteriorly, thus holding the binder down and the vulvar pad in position. Sometimes two additional straps can easily be adjusted. The binder may be tightened as the uterus contracts, and by the tenth day, when the uterus is within the pelvis, the pad may be entirely removed and the binder applied firmly throughout its entire length. The advantages of the binder thus applied are: 1. The patient is thus made comfortable. After the uterus has been delivered of its burden the patient necessarily feels a tremendous relief from weight, pressure, and distension. 2. It permits the patient to be moved and turned in bed without the fear that something terrible is going to happen. For a patient to be turned from one side to the other, her position being changed when she becomes wearied, is of very great advantage in guarding against retroversion, descent, and prolapse of the uterus. 3. It has a decidedly beneficial effect on the mental state, for the patient believes that her maidenly contour will be restored. Thus her mind is placed at ease, and this is no small factor in the establishment of an uneventful convalescence. He states that he has seen just as many cases of "after pains" when the binder was not applied as when it was, and in some cases in which he has removed the binder the pains continued. He is of the opinion that when not properly applied it causes retroversion, descent or prolapsus of the uterus, but when applied as he directs, thus allowing the patient to be turned and not requiring her to remain on her back, it possesses advantages far above the objection raised, and even is a great factor in preventing the mentioned sequela. The patient is of the opinion that it actually helps to restore the maidenly contour.

All in all, it seems to Povey that the obstetrical binder is a rational, feasible, and simple device, and when in the hands of a judicious obstetrician a decided help, comfort, and blessing to womankind.-Jour. A. M. A.

IMMEDIATE REPAIR OF PERINEUM.

A half hour after delivery is the best time to properly restore the perineum. At that time the tear can be plainly seen and accurately sutured without anesthesia. The tear is usually crescentic, starting in one of the posterior vaginal sulci (commonly about two inches up the posterior vaginal wall) and sweeping in a curve outward to the middle of the perineum. Sometimes there will be two such tears, which together make the crescent of Emmet. Such tears can be easily closed with one or two continuous catgut sutures, starting at the apex of the tear and bringing the tissues together with an over-and-over stitch, which commences on the mucous membrane and passes to the bot'tom of the tear, then up to the mucous membrane on the other side of the tear; this, if continued, unites first the tear in the vagina and brings the torn skin-edges close to each other. One or two supporting stitches of silkworm gut may be passed through the middle of the perineum from the skin; or a No. 4 catgut may be used and if the wound has not been infected there will be primary union. When the rupture extends through the sphincter ani chloroform should be given as soon as the placenta is delivered and an effort made to clean out the rectum without contamination of the raw surfaces. When the bowel is fairly clean from gauze swabbing and careful irrigation, the rectal mucous membrane must be closed with No. 2 catgut by interrupted stitches one-quarter inch apart, tied in the rectum. When the sutures have been introduced well beyond the anal margin the remainder of the operation is as described above, except that more care must be exercised to bring the separated levatores ani muscles together and hold them in place by passing the silkworm gut stitches through them as well as the skin and subcutaneous tissue.-American Journal of Clinical Medicine.

ASEPTIC MANAGEMENT OF THE CORD.

Dr. J. Thompson Schell read a paper before the Philadelphia Obstetrical Society (Annals of Gynecology, November, 1905), in which he said:

"In this aseptic era in the history of obstetrics it seems passing strange that so little attention has been paid to the aseptic management of the umbilical stump. Dr. Dickinson, of Brooklyn, and Dr. C. S. Bacon, of Chicago, both advocate a method practically the same as the one advised in this paper, and both report good results. The method is as follows: When the child is delivered a hæmostat is placed on the cord three inches from the abdominal wall and a second hæmostat about one inch from the first and the cord severed between. The child is laid to one side, wrapped in its receiving blanket, while the placenta is delivered and the mother attended to. The attention is now directed to the child and the cord is amputated as follows: Grasp the hæmostat forceps in one hand and with a sharp pointed scissors the cord is severed at its skin-amniotic junction and the amniotic covering and Wharton's jelly is then separated from the vessel of the cord by stripping them back with a piece of gauze in a direction away from the abdominal wall. The vessels are now ligated with a piece of No. o sterile catgut and the cord is dusted with an antiseptic powder. The baby is not placed in the tub for about ten days."--Medical Review of Reviews.

MALFORMATIONS OF THE UTERUS, WITH REPORT OF A CASE OF BICORNATE UTERUS.

A. A. Kerr refers to various cases of uterine abnormalities already on record, explaining their mode of formation from the standpoint of embryology. He then reports the case of a young woman of twenty-three, who complained of a right pelvic pain and profuse leucorrhea. Examination showed local tenderness. rudimentary uterine cervix, and an abnormal mass in the region of the right tube. Laparotomy revealed a distinct bicornate uterus, the right cornu being slightly larger than the left. The