cedure to be adopted depending upon the ravages which the disease has made and the period of time elapsing between the beginning of the disease and the opportunity for interference. F.)

TREATMENT OF OBLIQUE FRACTURE OF THE LEG BY THE MODIFIED

EXTENSION METHOD.

Bilter (Deutsche med. Wochenschrift, 1889, No. 33). The many methods suggested for the management of spiral and oblique fractures of the tibia is evidence of the great difficulties which attend the treatment of this class of cases. The tendency to displacement by muscular contraction, the fragments gliding one upon the other, together with the weight of the foot, are the principal factors in the production of the characteristic deformity. It is desirable to eliminate, in the first placethe action of the muscles. Stromeyer suggested division of the tendo, Achillis as a means of accomplishing this object. A much simpler method, according to B., consists in the employment of a modified extension and counter-extension by means of adhesive plaster, as now commonly employed in the treatment of fractures of the thigh. The reason for its non-employment heretofore probably depends upon the prevailing impression that the purposes of extension were not accomplished unless the traction was brought to bear entirely below the seat of fracture; a somewhat difficult task to accomplish in the great majority of cases, from the slight space available for the purpose of the application of the plaster. Bardenheuer has shown that the strips of adhesive plaster may be carried above the point of fracture, even extending to the knee, with advantage.

For the simplest cases of oblique fracture of the leg, B. recommends the application of extension by means of adhesive plaster applied in the long axis of the limb. For the more difficult cases, on the contrary, in addition to the longitudinal extension, there is added transverse- and rotation extension. The extension plaster may be applied over the ends of the fracture itself, or in the neighborhood thereof.

The advantages of this method consist in the facility with which the point of fracture may be kept under direct observation and its applicability therefore to compound fractures, and the certainty with which the replacement of the ends of the bones may be effected and maintained, Passive motion of the ankle-joint is possible at an early period of the treatment, and the occurrence of pseudo-arthrosis avoided with greater certainty.

Mention is made of Bardenheuer's extension experience in the treatment of fractures of the extremities by the extension-method, and the fact that, in 440 cases of fracture of the leg, in not a single case did there occur failure of union.

BY CHARLES JEWETT, M.D.,

Professor of Obstetrics and Diseases of Children and Visiting Obstetrician, Long Island College Hospital; Physician-in-Chief of the Department of Diseases of Children, St. Mary's Hospital, Brooklyn.

MANAGEMENT OF SHOULDER PRESENTATIONS.

E. P. Wells (Am. Jour. Obstet., Mar., '90) reports several cases of cross-presentation for the purpose of directing attention to the great advantage of the knee chest position in facilitating the performance of version. The practice is an old but neglected one. What is often a difficult may thus become an extremely easy operation. The contractions of the uterus are much less powerful in the inverted position. The fœtus gravitates away from the brim, the hand is readily introduced and all the manipulations are extremely simplified. Cephalic version is generally feasible in cases in which the podalic only would be possible in the dorsal posture.

For cephalic version the manipulation consists in pressing the presenting shoulder away from the brim in a direction toward the child's breech with the internal hand, the other hand assisting by external pressure over the head. The shoulder easily passes out of reach the head taking its place at the brim.

For podalic version the direction of the pressures is reversed, the external hand being applied over the breech. In these procedures the hand is introduced but a very short distance into the uterus. If they fail, which is rarely the case, resort may then be had to the passage of the hand deeply into the uterus for the purpose of bringing down a foot.

INCOERCIBLE VOMITING OF PREGNANCY.

Gueniot (Arch. d'obstet. et de gyn., Jan., '90) recognizes three sources of this malady, viz. : 1. The pelvic organs. 2. The nervous system. 3. The gastro-intestinal apparatus. All should be taken into account in directing the treatment.

The therapeutic measures recommended in the various morbid conditions are as follows:

Pelvic Disorders.

1. Utero-deviation. Elevation of the pelvis; Gariel pessary. 2. Erosion. Topical applications; even cauterization.

3. Vaginismus. Narcotics by vaginal douche or suppository, etc. 4. Periuterine lesions.

ladonna or cocaine, etc.

Horizontal decubitus; topical use of bel

5. Ovarian lesions. Rarely susceptible of diagnosis.

6. Stenosis of os internum.

Undue adhesion of the ovum to the lower uterine segment. Dilatation of the cervix after cocainizing, etc. Neuroses.

The bromides or chloral by enema; Chapman's ice bag; ether spray for five minutes to the epigastric and dorsal regions before meals, electricity, inhalation of oxygen, etc.

Lesions of the Digestive Organs.

Diet, diluted milk and light bouillon alternately, a coffee-spoonful every half hour, vichy, ice pellets, laxatives, nutrient enemas, flying blisters over the epigastrium, etc. (A writer in the Canada Lancet finds an unfailing remedy, regardless of the pathology, in a blister over the fourth or fifth dorsal vertebra. J.)

TRANSMISSION OF MICRO-ORGANISMS FROM MOTHER TO FŒTUS.

Simon (Arch. d'obstet. et de gyn., Jan., '90). Researches made upon rabbits show that the placenta is not a physiological filter, as has been supposed, for the bacilli of anthrax. The penetration of the bacilli corresponded with the duration of the malady. In cases of long duration they were found abundantly in all the fœtal structures.

CARDIAC INSUFFICIENCY IN ITS RELATION TO ABORTION.

Dr. M. Hanfield Jones (Br. Med. Jour., Mar. 15, '90). Much attention has been recently paid to to the relation of heart disease to pregnancy and labor, little has been given to cardiac disease as a cause of abortion. This paper deals chiefly with cardiac insufficiency independent of valvular affections. The writer assumes with most authorities, that the left ventricle is found normally hypertrophied at the close of pregnancy owing to the increased work entailed on the heart by the growth of the uterus and its contents. This physiological hypertrophy he thinks sometimes fails or is imperfectly developed. The systemic circulation is then impaired, the walls of the capillary vessels suffer degeneration and hemorrhage frequently takes place between the uterine wall and the fœtal membranes. The ovum thus becomes a foreign body and is cast off. The treatment advised is rest in the recumbent posture, the use of stimulants, cardiac tonics, liberal diet and general hygienic measures.

INFANTILE OPHTHALMIA.

Grossman (Br. Med. Jour.). It is estimated that about thirty per cent. of all cases of blindness result from ophthalmia neonatorum, and that there are in the United Kingdom no less than seven thousand-blind from this cause. The gonococcus is to be found in the pus in the majority of cases, not in all. The disease may arise therefore not only

from gonorrhoeal but in a certain proportion of cases from other vaginal

secretions.

Ophthalmia of the new born is always preventable, by timely interference always curable. For prophylaxis experience has shown that a thorough cleansing of the eyes with tepid water and subsequent drying, immediately on birth of the head, is almost universally successful. The additional use of sublimate or silver is still more efficacious (a 1-1000 solution of the former or 2-100 of the latter).

For the remedial treatment great stress is laid upon the importance of frequent and thorough removal of the pus. The preferred antiseptic is the nitrate of silver. A 2 per cent. aqueous solution should be applied over the whole conjunctival surface once or twice daily after cleansing and continued till the secretion ceases to be purulent. The author believes, however, that a weaker solution, even 1-2 per cent., is effective for either prophylactic or remedial use.

[These observations go to enforce the necessity of at least carefully cleansing and drying the eyes as soon as the head is born in all cases in private as well as hospital practice.-J.

PRACTICE OF MEDICINE.

BY HENRY CONKLING, M. D.,

Pathologist and Assistant Visiting Physician to St. Peter's Hospital; Physician to the Department of the Chest, Brooklyn City Dispensary.

ANGINA PECTORIS.

Balfour (Edinburgh Med. Jour., April, 1890) regards pain in the region of the heart as of little consequence, as far as being indicative of heart trouble, until after middle life. Acute inflammatory affections are, of course, excepted. There are certain affections which sometimes produce pain-occasionally severe-in the cardiac region. Among these are mentioned neuralgic pains associated with constipation, gastro-duodenal dyspepsia, intercostal neuralgia and myalgia; and cardiac muscular pains, probably either rheumatic or gouty.

The author regards angina as a neuralgic condition. The working force of the nerve affected is diminished. The nerves involved are probably branches from the aortic or cardiac plexuses, or some of the larger nerves from the pneumogastric or sympathetic.

The pain is a dull ache in mild cases. When the attack is severe "it feels as if a mailed hand grasped the chest in the cardiac area,and squirted through its fingers flashes of excruciating agony." The pain

radiates in various directions. It may go to both shoulder joints, down the arm, to the fingers, up into the neck, and sometimes into the groin and lower extremities. The patient feels choked; respiration, however, is unimpeded. Mere nervous excitement prevents the due expansion of the lungs. The countenance may be Hippocratic or may be merely haggard or anxious. It is interesting to note here that the author does not consider the pain in the left upper extremity as diagnostic of angina pectoris, as is so often stated. Angina is very frequently simulated by malingerers, and too much stress laid upon the description of such pain may be misleading.

The causes, of whatever nature, are believed to affect directly or indirectly the nervous force of the heart. A tumor, aneurism, or dilated aorta may produce pressure on the cardiac or aortic plexuses and so become a cause. Sclerosis of the coronary arteries is often present, but does not necessarily belong to angina pectoris, in the author's opinion, inasmuch as changed conditions in the coronary arteries are often found where, during life, angina had never existed. Fatty degeneration is regarded as a similar concomitant. Any changed relation between the coronary arteries which nourish and the cardiac muscle which is to be nourished is liable to cause angina. The author has never seen a case of true anginå in which signs of dilated heart were not present. The force of dilated and hypertrophied muscle are discussed at some length.

[NOTE. In this article the pronuciation angina is used instead of old angina. This corresponds with the best authority on medical terms, Campbell's Language of Medicine, where the long pronunciation is considered as incorrect.]

DIPHTHERIA.

(Lond. Med. Rec., Feb., 1890) The use of iodoform as a local application, applied in powder, through the nares or the mouth, is advocated. It is believed to be beneficial to the diseased tissue, inasmuch as it prevents putrefactive changes and thus arrests development of bacteria. It has the effect of an anodyne, and no case was affected by salivation, diarrhoea, or general poisoning. Nausea was never produced by the use of the drug. Probably very little is absorbed, as it remains on the diseased surface for some time. As it is a fine powder, iodoform is easily applied.

Peroxide of hydrogen (hydroxl) has been used in a series of cases of diphtheria. The indication for its use, as would seem from the paper, is simply as a solvent of the membrane, which comes away in small fragments. No statement is made of better results from this