splint, pins are used to secure this belt to the splint. The thigh is brought parallel with the sound one and in the center line of the body; the splint is attached to the upper end of the limb by a strip of the same stuff as the upper girdle, encircling limb and splint and secured by pins to the outside, one piece encircles below the knee, another round the calf, all pinned snugly to the splint. In this way the limb is secured to the splint.

The extension weight is attached to the cord that passes from the "stretcher," the cord passes over a pully set in a standard to enable the weight to act freely on the limb by traction.

The pully is placed at a proper height so that by the traction of the weight and cord the heel shall be raised an inch free of the bed, and thus avoid sores by pressure, which are very painful and distressing to the patient.

The amount of weight varies in different cases. In muscular subjects seven to ten pounds may be needed to prevent more shortening, in more slender ones, five to six pounds.

Sand Bags.-We have used sand bags in lieu of a splint with much comfort to the patient, especially quite aged ones. Two bags, one on each side the limb, the outside one is heavy enough to anchor limb to and extends from the hip to below the foot, the one inside the limb extends from the knee down. The bags are tied together with the leg between them, two or three strips of cloth are used from the knee to the foot; the hip is tied to the upper end of the long bag with a wide strip of the same stuff.

To Counteract Eversion.-The foot of the long splint is sunk in a deep slot cut in a piece of wood eight or ten inches long, four deep and three-fourths thick. This contrivance keeps the splint and limb from turning outwards. When sand bags are used the foot is attached to the inside bag by a few turns of a roller, the foot, instep and ankles being protected from chafing with soft cotton wool or lint.

The spaces between the limb and the splint are filled by interposing batts of various sizes, where needed, so as to equalize the support the splint can give the limb. When the trochanter drops

down and backward it can be well supported by batts placed under it.

When the skin on the sacrum and hips are appearing red and fretting, rub the parts with lanolin, two parts, vaseline, one part. Tincture of lobelia seeds, locally, also prevents sores.

Support the system with quinine and tinct. of nux, or fl. ext. cinchona and nux. Pepsin, lupulin and euonymin to promote digestion, or euonymin, nux and fluid hydrastis, or the hypophosphites combined with nux, fluid hydrastis and fl. ext.cinchona. Combinations of gelsemium scutillaria, cypripedium, belladonna, byoscyamus. Small doses of lobelia seed and capsicum with cypripedium often produce rest. If opium or morphia is used, exercise great caution with them. We have treated very bad cases successfully without them.

The standard that bears the pully should be securely nailed to the floor, and braced to the foot of the bed, so as not to yield to the traction of the weight.

More or less shortening may occur in a few weeks after treatment has begun and is owing to absorption of the neck of the bone, a frequent occurrence in old people.

Consolidation may take place in six weeks, or delayed to eight or ten. Recovery is always attended with shortening. The amount of lameness may depend on the arthritis, or non-union, of the fragments by bone or not at all. Shortening may then be from one to two inches or more even under the most judicious treatment.

If the health fails severely before the fragments are united, the patient must be released from all restraints, and got upon crutches, in the open air. Some old people are best treated with simply a broad and well padded belt around the hips to steady the fragments, and a light weight for extension, the lower part of the leg and the foot are steadied by two short sand bags on either side, tied together with the foot and leg between them, the heel is protected with batts and the elevation of the pully.

In all cases counter-extension is made by raising the foot of the bedstead six to twelve inches. A small pillow is placed under the head for comfort. Scrupulous cleanliness of the bed and person is im

perative to prevent bed-sores, chafing, and promote comfort and health. The food must be very carefully attended to and constipation guarded against by the careful use of cascara sagrada and euonymin. Avoid diarrhea also. See that the clothes are not soiled by urine. In women the urine may be voided on a large sponge, carefully placed, and the bed clothes protected by a rubber cloth under the sponge. After using, clean the sponge well in warm solution of borax and permanganate of potassium. Jos. ADOLPHUS, M.D. Atlanta, Ga.

A Case of Foetal Malformation. On the night of April 2d, 1889, I was called to see Mrs. W., aged about forty, the mother of five children, one stillborn.

I found her to be a woman of sanguine temperament, and in labor at full time. She had been in labor about six hours, but her pains were very irregular and ineffectual. After questioning her pretty closely, I became satisfied that the foetus was "still," and had been for two days

or more.

On making an examination, I found the vagina moist and cool, the os uteri dilated to some extent, and in a relaxed and dilatable condition, but I was puzzled as to the presentation. It was clearly not a shoulder presentation, and as clearly not the breach that presented, but upon further examination I found that it was the head, with the occiput looking to the right sacro-iliac synchondrosis. Nothing could be ascertained by the fontanelles, on account of the malformation of the bones of the cranium.

The position of the head was learned only by passing the hand up to the eyes and nose of the foetus, which was performed with difficulty. In the space of an hour after my arrival the pains increased in force and frequency, the liquor amnii escaped, the head passed the os uteri, and the second stage of labor promised to be of short duration, but on account of the soft and pulpy condition of the head, it soon passed the os externum without dilating the soft parts sufficiently, and the shoulders being large and well-formed, considerable time

elapsed before the termination of the second stage. During the latter part of the second stage the mother suffered excruciating pain, but after the placenta and membranes were withdrawn, which was soon accomplished, she became quite comfortable, and remained so during the time I was with her.

The child was dead. It was of the male sex and had a large and perfect form in every particular except the head. I am sure that the child would have weighed fully nine pounds.

Now, what seemed most strange in this case was the unnatural condition of the cranial bones. The occipital bone seemed to have developed from at least seven centers instead of four. The parietal bones seemed to have four centers of development instead of one, and the frontal bone had a like unnatural number of centers. None of these fragments of bone were larger than a silver quarter dollar, and they were all entirely disconnected, and were floating loosely beneath the pericranium.

I have seen several cases in my practice in which there were slight irregularities in the cranial bones, but I have never before met a case in which the bones of the cranium seemed to be developed from so many centers, and the development arrested so long before reaching perfection.

J. H. CHRISTIE, M. D.

Canaan, Ind.

Diagnosis and Treatment Wanted.

I wish to ask assistance from some of the BRIEF family in regard to a case in which I take considerable interest. Being yet quite young in the profession, my practice in gynecology has been somewhat limited.

My patient is a married lady. She has been married ten years, during which time she has never been pregnant. She is now thirty-five years old, and the origin of her trouble dates back sixteen years, when, during a menstrual epoch, she was caught in a shower, causing suppression, which continued for six months. Since that time, she has had all the medical aid in her reach, and all failed to effect a cure. Five months ago, coming under my care, I found her very anæmic,

complaining of incessant pain in the top of her head, with tearing or drawing pain over left ovary, and considerable tenderness at the seat of pain. Her bladder is very intolerant, which compels her to void her urine often, with slight scalding at times. Generally worse just before and during menstruation. She has leucorrhea constantly, but not very pro

fuse.

Digital examination reveals a slight prolapsus of uterus. No tenderness to the touch, but has a bearing-down pain in lower part of bowels, and minor symptoms of uterine troubles, which is apparent to every reader of the BRIEF.

Now, I would like to know what gives rise to her bladder trouble at menstrual periods; also, if she has ovarian disease. In fact, I want a diagnosis and best treatment, as I am very anxious to relieve my patient. Let me hear from you, brethren, relative to my case.

I like the BRIEF well; may it live long and continue to prosper.

Tolu, Ark. JOHN D. WATERS, M. D.

Ruptured Perineums.

I am a constant reader of the BRIEF, and am well pleased with the tone of its general correspondents.

Let me ask Dr. Cauble, Taylor, Nevada, if he finds twenty to thirty per cent of his cases with torn perineums after parturition? If so, why? Or, how does it happen to be so?

I have practiced obstetrics for twelve years, with over 400 cases, and I give you my word, as an honest physician, that I have only had four cases of torn perineums in them all, and lost but one case. This was a negro girl, unmarried, who had been in labor two days, and attended by a "gray."

I was then practicing in old Virginia, and had to ride twenty miles to see my patient. I now believe that had I not been worn out by the ride, I could have saved her.

Now, gentlemen, I mean to say that with proper support and remedies there is no need to rupture, except in cases of rigid soft parts, or where it is caused by injudicious use of the forceps. I have used the following in these cases, and it has never failed me:

Malarial Hematuria.

I notice, in the October number of the BRIEF, 1889, page 474, that R. C. Smith, M. D., of Ezzell, Tex., wants, through the columns of your valuable journal, some suggestions on the treatment of malarial hematuria.

The doctor says that this disease causes him to shudder, as about 90 per cent of those who contract the disease, in his locality, die. I must say that the literature of hemorrhagic malarial fever is very meagre and dates back only a few years in the past. Our old authors do not mention it, and even our recent standard authors are nearly as silent. Why this is so it is difficult to give a good reason, for the same causes and conditions, which now engender it, have existed in all past time, and must have exercised the same pathogenic efficiency as now.

"Malarial hematuria is an hepatic renal affection, of malarial origin, depending upon malarial toxæmia for its existence and striking morbid manifestations."

"That malarial hematuria is of malarial origin, there can scarcely be a doubt. Its occurrence in the same season of the year, its striking resemblance and strongly marked physiognomy to the malarious bilious fevers, endemic in those districts, and its general amenability to the same therapeutic agents, reveal its kinship, stamp it as allied to and of common origin with these fevers."

Malarial hematuria, like all other fevers of a malarial origin, is marked in its attack and progress by various shades of intensity, some cases being comparatively mild and even intermittent in form, while others are deeply virulent, pernicious and rapidly fatal in character.

In the milder cases the systemic disturbances are less threatening and the local symptoms less aggravated; the blood that is passed in the urine or from the bowels is not decomposed and disintegrated, as in the violent and acute

cases.

When, however, the type of this disease is violent and malignant, the patient will be troubled, from the onset, with distressing nausea, frequent retching and vomiting of a greenish fluid with mucous flocculi, the pulse will be small, frequent and feeble, the skin shriveled and surface cool or cold, with shrunken and pinched features and the frequent emission of dark, bloody urine, presenting the appearance of disintegrated and broken-down red blood-cells loaded with bile pigments in the form of small black granules."

"I deem it of very great clinical and therapeutic importance, that the differential diagnosis, between this malignant type and the milder forms of this disease should be clearly understood by the medical profession, in order to adopt the best and most rational treatment, suited to its varying conditions and manifestations."

In the milder form of malarial hematuria, the treatment is easy and simple, but in the violent and malignant form of this disease, we will have ample scope for the exercise of our deepest thought and grandest skill.

When called to a malignant type of this disease, we should promptly apply dry cups over the epigastrium and right hypochondrium to relieve the congested state of the stomach and liver, and in order to maintain the circulation in the skin, follow the cups by a blistering plaster over the same region, as well as to stimulate the liver to its secretory action.

To relieve the systemic disturbances caused by this type of the disease, such as nervous irritation and the distressing nausea that usually attends this disease, give a hypodermic injection of morphia.

To arouse the secretions and establish the function of the liver, give, to an adult:

If the stomach should still be troubled with nausea, or a tendency that way, give an emulsion (R. H. Day's) each dose consisting of one drop of creasote, one-eighth grain of morphia sulph., three grains of soda bicarb., and one drachm of mint water. Repeat the dose every two or three hours, as required. Frictions of mustard and capsicum should be rubbed over the spinal column and also to the hands and feet, or better still, flour and mustard-two parts of flour to one of mustard, made or mixed with syrup, and applied, in form of a plaster, to spinal column and to hands and feet.

As soon as the calomel has produced three or four well-defined bilious discharges, we should commence the use of quinine, but not in too large doses. It is all a mistake to give large doses of quinine in this type of malarial hematuria, except in the congestive pernicious forms of intermittent fever, when you desire to prevent a recurrence of the paroxysm. In this type of fever, from five to ten grains of quinine every three to five hours, until there is slight manifestation of cinchonism, then at longer intervals, so as to keep up a moderate impression on the system, to antagonize the malarial poison and tone up the nervous centers.

As soon as the function of the liver is established, and enough quinine has been introduced into the system to make its physiological effects manifest, then we should commence to give from twenty to thirty drops of the muriated tincture of iron every four hours, with a view of toning up the debilitated blood vessels, reconstructing and vitalizing the hemoglobin and the red blood corpuscles and thus restoring the nor

mal and vital condition of the blood.

If the kidneys should fail to secrete urine, use frequent frictions over the lumbar region with warm whisky, spts. turpentine and the tincture digitalis. Frequently the administration of a few

drops of turpentine-three to five dropsin an emulsion, will act favorably upon the kidneys, especially if combined with sweet spts. nitre and watermelon tea. The spts. turpentine will assist the warm frictions to hasten the action of the kidneys, as well as to act favorably upon the stomach and bowels.

The foregoing being my views of the etiology, essential nature and treatment of this disease, I hereby give it to the readers of the BRIEF family, hoping that some one may be benefited.

P. S.-In this article, I have drawn from an article written upon this disease by R. H. Day, of Baton Rouge, La., and published in the Medical and Surgical Memoirs of Prof. Jones, New Orleans, La., for which I give due credit. M. K. STURDIVANT, M. D.

Avinger, Tex.

A Case for Diagnosis and Treatment. Mrs. C., aged twenty-one years, brunette, good figure, well-proportioned; weight in health, 115 pounds; weight now, 90 pounds. Have inquired as to her health from childhood, and find it as follows:

Perfectly healthy to the age of nine years, when she began having chills and fever. Was in bad health for two years. Grow none during that time; became very anæmic. At the age of eleven was again in good health. Menstruated at age of fourteen. Was perfectly healthy until the Autumn of 1885, when at school she became irregular. The menstrual flow stopped for three months, then menstruated once, and missed again for four months. Health began to fail; would have an occasional chill, with but very little, if any, fever following. Constipation was also present.

Received treatment during the Summer of 1886. Was relieved of the irregularity, but the flow was always very painful. Constipation persisted. Health good otherwise. Was married in November, 1886. In the Spring of 1888, bore a child. Except the ordinary symptoms of pregnancy, health was good. Had an easy labor. No fever during the puerperal stage. Was up on thirteenth day. Out and about on the twenty-fifth

day. Lost about fifteen pounds during lactation.

On Jan. 6th, 1889, about 8 P. M., was taken with severe pain in top of head, which grew worse until it was unbearable. Fifteen grains antipyrin repeated in two hours gave some relief. Went to sleep at 1 A. M. and rested well. Arose in the morning felt as well as usual, but complained of vertigo several times during the day.

Was attacked on the night of the 7th, (and about same time as night before). Symptoms the same, only more severe. She became perfectly wild and delirious. No fever. Would clasp hands over top of head and almost scream from pain. One-quarter grain of morphia sulph. and one one-hundred-and-twentieth grain of sulph. atropia gave almost immediate relief, but produced great nausea. Suffered with head no more that night, but about 8 P. M., on the 8th, was attacked again, but not so severe. Became unconscious and remained so for twenty or thirty minutes with a grunting respiration, from which it was impossible (by any means tried) to arouse her; as quick as thought she awoke, smiled, and was perfectly rational.

Health remained moderately good; would suffer occasionally with nausea and vertigo, until Feb. 23d, about the same hour at night, she was again taken with severe pain in top of head and epigastric region. Gave mustard emetic. Emptied stomach thoroughly. Head trouble grew more severe. Tried nitrite of amyl, by inhalation; no relief. Again gave hypodermatic injection morphine and atropia, which gave relief in fifteen minutes.

Was all right until the next night, about same time, when she was again taken, same as before, only this time the breathing was the most prominent symptom. There was also a swallowing of the tongue. It would drop back in throat very much resembling a patient that had a little too much chloroform. She would be talking perfectly rational when, as quick as thought, she would go to sleep, begin a grunting respiration (from which it was impossible to arouse her). The grunting respiration would go on for one or two minutes, then cease breathing, or apparently so. It was not