lymph nodes. After ridding them of the putrefactive bacteria often found in getting the pus, they grew as a grayish, slightly woolly colony which penetrated the medium rather deeply and discolored it brown. The mycelium was clear or slightly brownish, and presented numerous spherical double contoured bodies. The course of the disease is usually chronic, as in y case it took several months for a patch to attain the size of a silver dollar. It may remain dormant for several months or years with irregular periods of activity, but as a rule the progress is continuous. The disease progresses peripherally, showing tendency to healing in the center of the lesion. Healing takes place by exfoliation, dessication and absorption. The lesion flattens down with disappearance of papillary growth and also the discharge. The original patch is usually followed by several more, showing conclusively that the infection is usually carried from place to place, as in this case it was carried from the leg to the face, also to the left leg. The usual sites are the parts more liable to infection, such as the hands, wrists, arms, face and legs. However, no region is exempt. There have been no cases reported where the mucous membranes have been affected. The eyelids are sometimes the seat of inoculation, the lashes being destroyed and an ectropian produced from scarring with a severe conjunctivitis, which is no doubt due to exposure rather than the parasite. The subjective symptoms vary, as a rule. In the case reported there was no pain, the patient seemed in rather good condition, though some cases suffer from some other trouble entirely foreign to Blastomycosis. According to Hyde's report of a few cases under constant observation, one died of tuberculosis, one remained in good health seven years after lesions were healed and then developed grave symptoms of systemic infection; three died before lesions were healed and two developed symptoms before the cutaneous lesions appeared. About 70 per cent of the cases occur in men because they are more prone to infection; the average age is above 40 years. The infectious character is dem onstrated by the infection being carried 'from one location to another and by the inoculation of other animals. There has been no definite relationship shown between this malady and other local or systemic diseases. The pathological features were first shown by Gilchrist in 1894. Busse six months later showed the significance of the organism and that the disease was due to a saccharo-mycetic fungus. Since that time, however, the clinical and pathological features have been worked out. by Americans mainly-namely, Gilchrist, Wells, Hessler, Brayton, Hyde, Montgomer, Hecktoen, Ricketts, Ormsby and Stelwagon. The disease is due to the Blasto-myces forming miliary abscesses in the epidermis and upper part of the corium. They can be found usually in budding pairs, in some cases a dozen or more can be found in one field, while in others they are very difficult to locate. In well strained specimens the parasite is seen to be a round, oval and irregular body, having a well defined double, contoured capsule and a fine or coarsely granular protoplasm which is separated by a varying width. The average size is from 7 to 20 microns in diameter. The budding forms are found in all stages of development. The secondary changes are more or less destructive of horny layers, enormous overgrowth of pickle cells with downward growth. In the corium there is an infiltration of leucocytes, endothelial and plasma cells. The clinical differentiation is sometimes very difficult, especially between this and Tuberculosis Verrucosa Cutis. In Tuberculosis Verrucosa Cutis the border of the lesion has a deeper and more violaceaus color-the period of evolution is much slower, and is limited to a single site as a rule and a smaller one. The microscope, however, is the only sure means of diagnosis. The vegetating syphilides are distinguished from blastomycosis by the facts that they are smaller, are situated around the parts which are closely opposed, the history of the initial lesions with characteristic, secondary manifestations. The treatment of these cases is radical removal of patches with curette, iodide of potash internally and X-ray. These measures have been productive of brilliant results. In reviewing the history of my case, the systemic infection with the great cachexia was too severe to be benefited by any medicinal or surgical treatment. In early cases, especially where the lesions are not so extensive, good results can be expected. Much credit is due Drs. Hall, McVey, Conover and McKillip in the preparation of this article. *SOME PRACTIGAL POINTS IN OBSTETRICAL PRACTICE. C. LESTER HALL, M.D., Kansas City, Mo. I wish to go on record as saying that the practice of obstetrics is the most important work in the practice of medicine. The reasons are obvious-two lives are to be cared for. The future health of child and mother largely depends upon the proper management of the childbearing and lying in state. To take charge of a woman in early pregnancy and conduct her through the entire period of gestation-to properly prepare her for approaching confinement and subsequent getting up involves a weight of responsibility not approached in any other field of professional labor. Having said this much by way of a preliminary, I want to go on record also as saying that the pecuniary reward for the assumption of such responsibilities is altogether inadequate, and not at all commensurate with the services rendered by the successful obstetrician. I am emboldened to make these statements from an experience stretching well night over forty years and having passed through the transition of the young, inexperienced physician (with a liking for the work, so characteristic of the beginnig doctor) to that stage of experience where the infatuation has passed away. *Paper read before the Kansas City Academy of Medicine, September 2, 1905. Whilst my actual experience, notwithstanding the lapse of years, may not have been so great as the younger man, who wholly employs his time and talents in this interesting and important work, yet some things have impressed themselves upon me, the narration of which may not be unimportant to the younger fellows of this academy. I, at least, trust that what I may say may not lead you into error. Some years ago I read a paper before this body, entitled "The Surgery of Obsteterics," in which I said: "When obstetrical practice has reached this idea (as portrayed in my paper) then will the lying in chamber be a quarantine against the work of the gynecologist." Whilst more modern investigation and practice have taught us that all gynic conditions are not dependent upon the neglect of the accoucheur, yet the statement can be repeated today as substantally true. One's services having been engaged to attend the pregnant woman, especially if she be a primipara, he should insist on an early examination to ascertain if the pelvic capacity is sufficient to permit the passage of a full sized baby. This being settled affirmatively, as will usually be the case with the women of this country, where perfect physical development is characteristic, the SO obstetrician should be placed in full charge of the patient, directing her diet, seeing that she is neither over nor under fed; her. exercise, that it is sufficient but not violent; that her secretions are normal, for constipation leads to toxaemia and albuminuria, often to death. However. these facts are axiomatic and so well understood that they need not be dwelt on. We are brought to the bedside of the woman in labor and here the actual work begins. Here, I fear, that if I speak from personal experience and practice, I will encounter the severe criticism of the technical obstetrician, for I am confident I violate at least one prohibitive injunction so clearly insisted upon by text book and teacher, viz: The frequent use of the examining hand. It should not be neces sary to insist that the hand should be clean and every precaution taken to avoid introduction of infection from without, but I insist that much can be accomplished for the relief of the patient and the termination of labor by the judicious use of the examining finger or fingers. First, as every one puts into practice, to determine the position of the child. Second, the use of two fingers to dilate the Os. These, the best of all dilators, can be carefully introduced within the dilating Os, and by careful pressure from within out, cause, without injury the dilation of the Os, and thereby shorten the first stage of labor. This being carefully accomplished, the attendant can withdraw to an adjoining room and wait for the expulsive pains, avoiding meddlesome interference, but with the increase of the expulsive effect, his place is at the bedside of the patient. I insist that at this stage of labor, his presence has at least a beneficent psychical effect, and more, it is within his power to render substantial assistance by the use of the examining hand in further aiding dilation of the Os and stretching the perineum, and with the other hand on the fundus, steadying and correcting the obliquity of the uterus, and by making pressure synchronous with uterine contractions. By these manipulations the expulsive efforts are guided in the right direction and the obstetrician is constantly apprised of the progress of the labor. Granting the efficacy of chloroform at this stage of labor and earlier, in some cases of rigid Os, I want to deprecate the indiscriminate and reckness use of this "Godsend" to the parturient woman. The early use of it not only in many cases modifies nature's efforts, but the patient becomes an early slave to its influence and relies upon its seductive effect to the abrogation of all voluntary effort. I confess to a timidity of the prolonged administration of chloroform in the interest of the viability of the child. I fear the death of the foetus can often be traced to chloroform narcosis. It is certainly wrong to thus abuse so valuable an aid in the obstetrical art, Chloroform should rarely be given to the extent of complete anaesthesia, even in instrumental delivery, for by so doing, we fail to get the important expulsive assistant of the patient. Labor having been completed. we should turn our attention to the possible, and in the primipara, the highly probable, lacerations of the soft parts of the parturient canal. There can be no excuse for failure to recognize injuries to the genital tract, and these in the vast majority of cases, should be repaired without delay. As the result of pressure and stretching the tissues are so benumbed that anaesthesia is rarely neces sary in doing the repair work. Too much attention cannot be given to closing rents in the mucous membrane, which often occur in the lateral walls and upper part of the vaginal outlet. The most gratifying results follow simple approximation of edges of the mucous membrane, whereas, a failure to do so would leave a wide raw surface to granulate and an open avenue for the entrance of infection. The administration of a drachm of fluid extract of ergot soon after the delivery of the placenta answers a double purpose of securing not only organic. but tissue contractibility and rendering less liable postpartum hemorrhage. No safer practice can be employed than to have the nurse or husband make gentle but steady pressure over the fundus of the uterus, for at least on half hour following delivery. During the the days of malaria it was deemed a good practice to administer to the lying in woman quinine to slight cinchonism for two or three weeks. This practice still appeals to us, not simply to combat malarial infection to which the woman is so susceptible, but for its oxytoxic and tonic effect upon the uterus. I can suggest nothing of more importance in the management of the case followwing delivery than strict attention to the position of the uterus in the process of involution. I am convinced from my gynecologic experience that this is very much neglected by those who attend women in labor. It is surprising and altogether illogical that the lying in woman should be compelled or even allowed to remain on her back during the process of uterine involution. Take a woman who before impregnation had a retrodisplaced uterus and permit her to maintain the positon of dorsal decubitus following delivery, it naturally results that the heavy organ will gravitate and will assume its old position to the annoyance and discomfort of the patient. Nor is it necessary that the patient should have had a backward displacement of the uterus for a like result to follow a like cause. The ponderous uterus, with its ligamentous supports in a condition of subinvolution, needs little encouragement to fall back into the hollow of the sacrum, which if not early detected and corrected, leads to monthsyes, even years of discomfort. This should not be and will not be in the hands of the painstaking obstetrician. Within the first two weeks following confinement, if at any time the uterine fundus cannot be felt behind the symphysis pubis, suspicion should be aroused as to the position of the organ, and with sterile hands vaginal examination should be made and almost invariably a retroversion or a general sagging of the uterus will be detected. My own method in trying to avoid this condition is to instruct the nurse to keep the patient off of her back, especially after the first few days following delivery. I also explain to the patient the importance of lying upon her sides, the upper knee in advance of the lower, thus tilting the pelvis toward the front and abdominal contents down. In addition to this precaution, the patient assumes the knee chest position daily, beginning about ten days after the birth of the child. In treatment of women within the child-bearing period, who are suffering with displaced uteri and associated endomotritis, I advise, after overcoming the latter, that they become mothers and thus avail themselves of this best of all methods for correcting the malposition. Results have justified the means employed. About a quarter of a century ago, the French obstetricians formulated the practice of allowing the parturient woman to leave her bed within a few days and assume in part, her household duties. A trial was sufficient for its condemnation. Nothing like it has been tried in this country, save by a sect of religious healers of the present day. The American Indian was probably equal to the task, but with the civilize women of this country, such a practice must be fraught with disastrous results. Criticism of such a practice must not be construed into an objection to the woman assuming the semi-erect posture upon the commode, for the relief of bladder and bowels. The position favors the passing of clots and drainage to the well being of the woman and often a threatened sapraemia is aborted by this simple process. Finally, having safely conducted the woman through her confinement and getting up, she should be directed to call at the office at the end of the second month for examination of the cervix. It is a safe practice to defer repair of lacerations of the cervix (except for arterial hemorrhage at the time of labor) until involution is complete. First, because it is difficult at the time of labor to differentiate torn from normal tissue in the patulous cervix. Second, for the additional reason that we frequently have primary union in tears of the cervix, which is favored by anatomical arrangement and vaginal involution. *LECTURES ON NERVOUS AND MENTAL DISEASES. JOHN PUNTON, M.D., Kansas City, Mo. Professor Nervous and Mental Diseases. University LECTURE I. Gentlemen-The department of medicine to which I shall have the honor of be *Introductory lecture delivered at University Medical College, Kansas City, Mo., September 7th, 1905. seeching your attention from week to week during this session will be that of Neurology and Psychiatry, or that branch of medical science which especially relates to the mind and nervous system. My lectures will, therefore, embrace the various morbid conditions of the brain, spinal cord, and peripheral nerves, as well as insanity. In presenting these subjects I am aware that we are challenging the highest department of medicine, inasmuch as it is confessedly the most difficult, but in order to render them plain and practical I shall endeavor to present them in as simple and commonplace phraseology as possible, consistent with their correct scientific aspects. Our study of the nervous system and its diseases naturally divides itself into a consideration of its normal anatomy and physiology, as well as its symptomatology, etiology, pathology, diagnosis, prognosis, therapeutics and prophylaxsis. It will, however, be unnecessary to review each of these in detail, as your previous studies in the various departments. have already prepared you for the more advanced work of the senior year. Only a discussion of the more salient features of each will therefore be attempted or those which are deemed expedient to subserve the usefulness of the text: Inasmuch as a thorough mastery of the anatomy and physiology of the nervous system lies at the foundation of neurological science, I shall at the outset purposely review the more essential features of each, for with these well in mind they not only serve as aids to future study, but greatly assist in reducing clinical neurology and psychiatry to a matter of logical deduction. Definition-A good working definition of the nervous system and one which has the advantage of being both brief and practical is as follows: The nervous system is an apparatus composed of myriads of independent Neurons by which all parts of the human organism are brought into harmonious relationship. (See footnote.) Considered as a unit, it is that organ of the body by which the conditions. |