nose as far posterior as the pharyngeal wall, one finds the inferior surface of the sphenoid above the naso-pharynx. This can be done. by the sense of touch alone. Withdrawing the instrument until the curette passes just above the junction of the anterior and inferior wall of the sphenoidal cavity, it is forced backward and of necessity upward through the roof directly into the cavernous sinus at its junction with the anterior circular. Withdrawing his spoon after opening the sinus, Langworthy found that it contained some pus. Removing the calvarium and brain, and incising the cavernous sinus from above, the curette was found to have perforated the sinus exactly as outlined. Pus was slowly draining out.

Symptoms Simulating Otitic Brain Abscess; Normal Brain Found on Autopsy.

A. E. Taussig and N. W. Sharpe, St. Louis (Surgery, Gynecology and Obstetrics, Vol. iv, No. 6), report in great detail a case in which a diagnosis of otitic brain abscess was made but in which upon operation and autopsy no abscess could be found. The patient was a male, aged sixty-three. He had had several attacks of gonorrhea, the last one a year previously. Formerly a hard drinker. Left otitis media since early youth. Sudden illness; headache, pain in both knees and both calves, vertigo. Temperature 105° F. Sensorium clouded. Pulse 62. Pupils equal and react. Tongue dry and brown. Slight cough. Both knees and right shoulder tender. Pulse hard and tense. Urine acid, amber, sp. gr. 1020, trace of albumin, much pus but no casts. Provisional diagnosis, acute articular rheumatism. Later joint disturbance less conspicuous, that of the sensorium more so. ' Alternate delirium and somnolence. Babinsky reflex marked on right side. Blood: no agglutination with typhoid bacilli. cytosis, 39,000; polymorphonuclears, 91 per cent., no bacteremia. Right-sided general convulsions, repeated and growing more violent. Operation as stated revealed nothing. Patient died on table. Brain immediately examined and found normal. Post-mortem examination of other organs of the body not. allowed.

Leuco

The authors compare this case with one of a colleague's an infant which had suddenly exhibited acute cerebral symptoms, temperature 104°, rigidity of the extremities, muscular contractions, retraction of head, partial suppression of urine and loose stools. Stupor, coma and death. Autopsy showed a normal brain and that both kidneys were in a condition of acute parenchymatous inflam

mation. Also with a case reported by Hoppe in a man of twenty-eight, who had a discharge of fetid pus from right ear, marked cerebral symptoms, pulse 60-70 and temperature 99° to 101.2° F., in whom a diagnosis of brain abscess or purulent meningitis was made. Autopsy showed no abscess nor purulent meningitis, not even even a congestion, but a marked interstitial nephritis.

Cerebellar Abscess.

W. D. Black, St. Louis (The Laryngoscope, Vol. xvii, No. 7), reports in detail a case of cerebellar abscess occurring in the course of a chronic mastoiditis. Symptoms of intracranial involvement appearing in a boy of fourteen years, a radical mastoid operation was made and the cerebrum explored without the finding of an abscess. As there was no improvement in the head symptoms and the general condition grew worse, an operation for the exploration of the cerebellum was undertaken. undertaken. At first the brain prolapse following the first operation was attended to (time, one hour and five minutes), and then, as Black was preparing to make the opening for the exploration of the cerebellum, the respiration suddenly ceased. The heart continued to beat for six bours, during all of which time artificial respiration was practiced. Autopsy revealed an abscess of the cerebellum about the size of a hickory-nut and situated about the centre of the right lateral lobe. Symptomless (?) Mastoiditis.

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A. B. Bennett, Washington (N. Y. Medical Record, April 13, 1907), reports a case of symptomless" mastoiditis, followed by purulent meningitis and death. Following an attack of influenza in November the patient had severe earache. almost absolute deafness and congestion of the membrana tympani, right and left. Under treatment these symptoms disappeared. Suddenly, seven weeks later, there appeared headache, vertigo, nausea, vomiting, temperature 97.4° F., and pulse 72. Slight congestion of Schrapnell's membrane and along the mallei. No mastoid symptoms. Both mastoids were exenterated, finding carious bone and pus. Death took place in a few hours. Autopsy revealed a diffuse lepto-meningitis, "the brain being literally bathed in pus. There was an absence of the left tegmen tympani, but the infection took place "via a thrombosed right lateral sinus, as the dura over the absent tegmen tympani showed no pachymeningitis.

externa.

He who practices self-drugging has a fool for a patient.

Obstetrics.

WILLIAM GILLESPIE, M. D.

[Our subscribers are requested to make free use of this department by sending in questions touching on obstetrics. All inquiries will receive careful and courteous answers. Special care will be taken to guard against any possible medico legal complications Address DR. WILLIAM GILLESPIE, May and June Streets, Cincinnati.]

Blood-Clot Theory of Eclampsia.

Barrie tells us that the successful editorial writer must be blind in one eye. It would seem that those who theorize on the causation of eclampsia must be similarly qualified, and have a single eye to the needs of their theory.

Our Eastern friends have recently rediscovered that in certain cases of fatal eclampsia the liver is the seat of serious disease, and we have livers discussed so exclusively as to arouse the suspicion that women down East are all liver.

But it is in a northern climate, with long, cold nights, so admirably fitted for shin-toasting and speculative thought, that works of genius are most apt to appear, and it is in the Journal of the Minnesota State Medical Association and Northwestern Lancet that the latest new theory of the causation of eclampsia is presented. A woman who suffered from eclampsia subsequently developed phlebitis of the leg. A girl with menstrual disturbances has an attack of hystero-epilepsy. It is recognized that such attacks frequently come at such a time, particularly if the flow is delayed. Cases dying from eclampsia show post-mortem clots in brain and other organs. In pregnancy the menstrual blood is suppressed and retained. In the latter weeks the membranes begin to separate, and it may be that blood is retained which should go to the child. It is necessary to our theory, therefore there is retention of blood in the mother. As blood-clots are found in eclampsia it is plainly evident that clots from retained mentrual flow and circulating in the mother is the cause of eclampsia.

Could anything be plainer to a man with one eye? Males have been known to have convulsions, and we have no evidence that in them there is retained menstrual flow, however active they may have been in restraining the flow in others. Convulsions of all kinds show extravasated blood in brain and other portions of the body. Deaths from asphyxia show similar lesions. Patients recovering from eclampsia do not always, or even usually, have milk leg; nor do all cases of phlebitis have eclampsia. When emboli break loose from the thrombotic vein and

float in the circulation, various disturbances may arise, but eclampsia is not one of them.

But we must not tire our readers with matters that are not necessary to our theory. Many years ago a brilliant Washington correspondent had for some time kept his paper supplied with direful prophecies. The paper finally telegraphed him to stop theorizing and send the facts, but he wired back, D- the facts; they hamper me." So it is with us; if we examine too critically the facts we may lose a theory of eclampsia, and that is a catastrophe too dire to contemplate. Notes on Current Literature.

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In the Canadian Practitioner and Review for September, and also in the American Journal of Obstetrics, appears a paper in which Kennedy C. McIlwraith gives the results of his observation of twenty-seven labors in twentythree women with contracted pelves. It is one of the papers which might with profit be republished by every journal on the continent. It indicates, with ability and force, the superiority of version over forceps in pelves contracted chiefly in the antero-posterior diameter of the brim, if forceps are used in the usual way. He proves the proposition, as, indeed, did Goodell, many years ago, but does not demonstrate superiority to forceps used to better mechanical advantage. He is correct in ascribing the death of one of the children to the previous attempt with forceps, and if the other gentlemen who use instruments with one blade to the occiput and the other to the forehead had his powers of observation and judicious deduction, modern text-books would soon cease to advocate such an application. But he does not prove that version is superior to forceps if they are applied according to the mechanical indications, probably because such an application, used and described in Cincinnati, has never been heard of that far north. If one blade is placed posterior to the head and the other anterior to it, it may be canted past the promontory just as certainly and just as easily as in version, with the additional advantage that there is no necessity for haste, either in securing engagement of the head or in subsequent delivery. The mechanical relations of head and brim are such as to invite and render easy such an application. The head presents transversely, and tends to approach that side of the pelvis toward which the occiput points. This leaves ample space between forehead and pelvis through which the anterior blade may be worked around the forehead to its place upon the anterior side of the head. Since adopting this method of delivery antero

posterior contraction at the brim has lost most of its terrors for us, unless the deformity is excessive. To one who is possessed of the requisite skill and judgment for procuring such results as detailed in his paper, we confidently commend this newer and better method.

Difficulty in Locking Forceps.

QUERY NO. 27.-In a recent case the head became stationary just above the inferior strait, and upon attempting to apply forceps I could not adjust the blades so that they would lock without considerable difficulty. Having finally locked them they lost their hold upon the first attempt to make traction. What is the mechanical explanation of the difficulty?

In this position of the head several conditions may give rise to trouble. Even the experienced operator may be deceived as to the height of the head with reference to the pelvis. If it is proportionately large it may by moulding appear to descend, and unless special care is exercised we may think the head engaged at the inferior strait when in reality its equatorial diameter is far above this point. If this mistake is made we err not only as to the height to which the blade must pass, but as to the distance the shank must be carried backward to bring the blade into the pelvic axis. If this mistake is made they grasp the head too far back and may not be secure, but even if they grasp the head firmly they tend to extend it and augment the difficulties of extraction. That the head will become actually extended we do not mean to imply, for under such circumstances the occipito-frontal diameter is too great to permit of such a movement, but this tendency is sufficiently present to greatly augment the resistance to be overcome.

Or, the head occupying the right oblique. diameter of the pelvis and being disproportionately large, the left blade in being brought forward finds insufficient space in which to pass and stops short of attaining a position at the side of the pelvis. The right blade is even more apt to meet with difficulty in passing between the side of the forehead and the pelvic wall. As a result of this mechanical arrangement it will require force to secure locking of the instrument, and the blades will grasp the head only with their anterior edges, and the hold is necessarily precarious. This difficulty may be overcome in one of several ways. By patient effort the blades may be worked to the sides of the pelvis, where one will grasp the side of the occiput while the other grasps the opposite side of the forehead. If this application is secured delivery can be safely effected. As the head begins to distend the pelvic floor the rotation of the

occiput from left to right will bring the blades into the right oblique diameter of the outlet. The left blade may be left on the side of the head while the right is worked forward upon the right side of the pelvis, so that when locked the instruments occupy the opposite oblique diameter of the pelvis and the head is seized regularly.

If this manipulation cannot be carried out you may succeed in applying the second right or anterior blade by insinuating it between the anterior side of the head and the right ramus of the pubes. One of these maneuvers is always possible in my experience. If the blades are placed in the opposite oblique diameter to that occupied by the head, they will, when the occiput rotates beneath the pubic arch, be at the sides of the pelvis. In such a position they will not project and offer violence to the soft parts.

Increased Resistance at the Inferior Strait.

QUERY NO. 28.-I have been surprised many times by observing slow but satisfactory progress suddenly arrested when the head arrived at the inferior strait. Why should progress suddenly cease when the head has escaped the restraining influence of the cervix? Of course, exhaustion will account for many of these cases, but in some of them the force of the pains seem to be augmented but no progress ensues.

Has the head escaped the restraining influence of the cervix? Careful observation will convince the attendant that the forehead has not entirely passed the cervix when the capet succedaneum is protruding at the vulva. Most lacerations of the cervix occur after it has so far retracted that it is only to be reached by the examining finger by a special effort. We therefore have a combination of forces of resistance. The cervix still offers resistance, there is necessity for a readjustment of the head because of a narrowing of the transverse diameter at the outlet, and if the head is proportionately large additional moulding may be necessary before it can pass between the tubera ischii. In addition, we have the resistance of the pelvic floor offered to the occiput while the coccyx restrains the top of the head and the sacral excavation receives into its hollow the side of the forehead. It, therefore, frequently happens that we encounter our chief difficulties when the termination of the labor seems near at hand. It is a failure to recognize the true mechanics of the low forceps operation which has induced men to construct light, weak, inefficient instruments for delivery at the inferior strait. In many cases only an instrument capable of sustaining a great force will prove effective.

Genito-Urinary Diseases.

BY E. O. SMITH, M. D.,

Lecturer on Genito-Urinary Diseases, Medical College of Ohio.

Venereal Prophylaxis.

Wilcox, of Providence, R. I., discusses this exceedingly important problem in social hygiene in a very comprehensive article published in the N. Y. Medical Record for August 3, 1907. He deplores the fact that statistics on venereal diseases are so unreliable, but he obtains the following facts from the best sources at hand:

"Venereal diseases have the hideous distinction of being second on the list of endemic contagious diseases responsible for a large individual proportion of deaths of the human race, tuberculosis being first. Morrow estimates that one-eighth of all patients in the New York hospitals suffer from venereal diseases or their consequences, and the number is gradually increasing. The same authority claims that 60 to 80 per cent. of still-births are the result of syphilis, while of all involuntary sterile marriages, 30 to 35 per cent. are due to gonorrhea. Venereal diseases and criminal abortion are ranked close rivals in their causation of race suicide. Fournier claims that one-seventh of the population of Paris is syphilitic. Among the more than 225,000 syphilitics in New York City, 50 to 85 per cent. among the female cases are believed to have been innocently acquired. If anything in the practice of medicine has forcibly impressed me, it has been the ignorance, the apathy, the indifference of young men to the dangers of gonorrhea.

"Neisser estimates that 80 per cent. of all adult males have at some time had gonorrhea, and ranks it next to measles in its widespread prevalence, while Bransford Lewis ranks it far above syphilis as a direct cause of death. Those who are inclined to regard this disease in the light of a trivial ailment should ponder the following facts: (1) Of all miscarriages at or before the third month, threefourths are due to a latent gonorrhea in the male. (2) Our blind asylums report 20 per cent. of their inmates as sufferers from the effects of gonorrheal infection of the newborn. In Germany there are to-day some 30,000 blind as a result of gonorrheal ophthalmia. (3) Of all cases coming into the hands of the gynecologist, one-eighth are due to gonorrhea; and of all deaths from diseases peculiar to women, some 80 per cent. are believed to result from the same cause. Gonorrhea produces its fearful wounds

in the young households of to-day; syphilis silently deteriorates generation after generation."

He further states that a fruitful source of prostitution and the origin of numerous cases of venereal diseases is the almost universal ignorance of the young people of both sexes regarding (1) the sexual instinct and the need of controlling it; (2) the possibilities of conception; (3) the danger and mode of contracting venereal diseases.

After discussing the different methods aiming to suppress or restrict the evil, he concludes that none of them either restrict or suppress, and they have failed utterly in their attempts.

Since ignorance is the most potent cause for the existence of syphilis and gonorrhea, the remedy, then, is to impart a knowledge of the truth and correct the many fallacies now permeating the minds of our youth.

He believes in a progressive sexual education with the parents as the first and most natural instructors. He would have scientific facts pertaining to these diseases distributed to the general public through the several municipal and State boards of health. Physicians should be required by law to report the nature and source of all cases of venereal diseases, solely for statistical purposes, suppressing the names of the individuals; hospitals and dispensaries to do the same.

The public is to be taught: (1) That continence is compatible with health; (2) the stoppage of the visible discharge is positively no proof of the cure of gonorrhea; (3) the comparison of gonorrhea with a severe "cold in the head" is a grave error and far from the truth; (4) syphilis is curable; (5) venereal diseases may be innocently acquired, and that they do not have their exclusive origin in licentious indulgence.

Hysterical Retention of Urine.

Paul La Roque (American Journal of Dermatology and Genito-Urinary Diseases for September) reports a case of this character. He calls attention to the fact that the patient will usually show other symptoms of hysteria, and emphasizes the importance of making sure of the diagnosis by thorough and careful examination, excluding all other possible

causes.

His treatment is the administration of copious rectal enemata, and he has never had this to fail. The rationale of this treatment he explains through the nerve supply to rectum and bladder, being from the same origin, and that the rectum is seldom if ever emptied without the simultaneous emptying of the

bladder if there be urine in it. In fact, it is impossible to retain the bladder full of urine while the bowels are allowed "to move" unless there is present some organic disease. Relieving this distressing condition without the use of the catheter will ofttimes avoid the development of traumatic urethritis and cystitis.

Unilateral Nephritis; Nephrectomy.

Angerer (Archiv f. klin. Chirurgie, lxxxi, 2) reports two cases of unilateral nephritis resulting from traumatism of the loin. No renal symptoms appeared at the time of the injury, but showed themselves several weeks afterward. The trouble began with colicky pains in the kidney, accompanied with hematuria. The urine showed albumin and casts, and the general health was profoundly influenced. In one case the operation of nephrectomy was undertaken on account of the hematuria, and in the other the severity of the pains brought the patient to operation. Recovery was perfect in both cases, and all signs of renal disease disappeared completely. In In both cases the kidney was large, congested, with hemorrhagic areas in the cortex. author believes the operation was indicated and was justifiable, as each case recovered promptly. He believes nephrectomy would have been dangerous on account of the liability to post-operative hemorrhage.

Insinuations are Dangerous.

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The

An English druggist, or chemist, as they are called there, recently sold a proprietary remedy on application of the customer and attached thereto the following sticker: 'Caution.-Sold without our recommendation or responsibility, and supplied only upon this understanding. Suit for damages was brought by the manufacturer of the proprietary article. In the course of the trial the druggist said that he preferred to push his own goods to those of others, but was practically compelled to keep articles which were advertised, as there was 'a demand for them from the gullible public," on many of which, as in the present instance, he made very little profit. He admitted that had the extra 2 per cent. discount for which he had contended been allowed, the sticker would not have been used. The pharmacist was right in fact, but wrong in principle. No selfrespecting pharmacist will sell anything which he knows to be a fraud, but he should not keep the article on hands and should not fight it because of insufficient profit, for a higher reason is usually easily found.

E. S. M.

"3. Up to the present time formaldehyde gas evolved by the Marine method, using one pint of formalin to six and one-half ounces of potassium permanganate, is the best method for use in terminal disinfection of houses."

This is undoubtedly true, but, at the same time, is inaccurate and incomplete. The potassium permanganate-formalin method of generating formaldehyde gas for use as a disinfecting agent was first reported by Dr. Johnson, of Sioux City, early in 1904, and in the same year Evans and Russell, of the State Board of Health of Maine, conducted independent experiments, which proved the practicability of this method beyond question. Although the splendid work of Dr. McClintic had added much of importance to the literature on this subject, the U. S. Public Health and Marine Hospital Service lays no claim to having originated the method, and the credit for having done so should be given to the proper person.

The statement is incomplete in the fact that of the five factors essential for efficient disinfection by this method, namely, cubic capacity of room, temperature, relative humidity, proportion of chemicals and length of exposure, but one is given, and that is scarcely correct. When Evans and Russell used the proportion of six and one-half ounces of potassium permanganate to the pint of formalin they were also using two pints of formalin per 1,000 cubic feet, twice the quantity necessary, under proper conditions, to secure an efficient disinfection, while the amount of potassium permanganate was not sufficient to give a dry residue. In their later work they used the proportion of seven and one-half ounces to the pint, and reduced the amount of formalin, necessary with proper conditions of temperature and relative humidity, to one pint per 1,000 cubic feet. Dr. McClintic found that the proportion of one to two, or eight ounces to the pint gave the best results, and this is now ac