of episiotomy is entitled to hold a more prominent place in the obstetric procedure than is accorded it by most writers. Owing in part to the feeble endorsement it has received at the hands of obstetric authors this measure is almost wholly neglected by practitioners. The majority of physicians I undertake to say have never performed it at all. Another reason why it has not received more attention is to be found in the fact that a laceration is generally looked upon as capable of causing no more damage to the pelvic floor than is done by the incision and it is believed that it may be quite as easily repaired. The fact is, however, that a laceration of the perineum is frequently, I may say usually, a by far more complex lesion than a simple separation of the structures in a single plane. It is oftener a sundering of the fascia and the muscular structures in several planes. It follows therefore that the restoration of the perineum to its original integrity after a laceration is a by no means simple operation.

A greater or less degree of relaxation of the pelvic floor with a corresponding gaping of the introitus is a too common result of suture even by expert operators. The incision on the other hand divides the structures in a single place and permits an easy and complete restoration of the parts.

Even should the incision be extended by a tear or should lacerations take place at other points the repair is still materially simplified and the result more satisfactory than would have been possible without episiotomy. The argument that incision adds to the danger of sepsis does not hold in aseptic practice, and in the event of septic exposure a complicated laceration is more favorable to absorption than a clean cut incision. From these considerations I have been led to make more frequent use of episiotomy for the prevention of perineal tears, and the results in my experience have borne out my expectations. I have not always succeeded in wholly preventing lacerations nor have I succeeded in restoring the perineum in all cases to its primitive integrity, yet in no case have I had reason to regret the incision and in none have I failed of a better repair than could have been reasonably expected without the incisions. Increased experience, too, I am sure, adds increased value to the procedure. It is not called for for the prevention of slight tears; but in any case when the laceration is likely to extend beyond the first degree the incision is better than the tear. I have been frequently struck with the depth and solidity of the perineal body after a typical episiotomy which had been sutured and healed. The tonicity of the pelvic floor is in marked contrast with that which usually follows the immediate suture of a deeply lacerated perineum.

My method is briefly as follows: The instrument I have used is a blunt pointed tenotomy knife. Any good blunt pointed bistoury,

however, answers the purpose. The knife is passed flatwise alongside the head, its cutting edge turned outward and the incision carried to the required depth. Much depends on properly timing the operaion. In many cases it will be found possible to wholly anticipate the tear. Yet the incision should by no means be omitted because a laceration has already commenced where the tear is certain to become extensive without interference. The incision is always best made during a pain while the resisting ring is rendered tense by the pressure of the head. The exact situation of the resisting girdle is more easily determined and the cut is more easily made at this time. Placing the index finger of the free hand just within the introitus as the head is forced down by the pain the cord-like girdle is readily felt and it is this only which should be divided. The point of division should be about one-fourth way from the perineal raphe to the clitoris. This in the distended condition of the parts during a pain is sufficiently far back to avoid injury to the duct of the vulvo-vaginal gland. The incision should be practised on both sides. The depth of the cut need not usually exceed a quarter or third of an inch in the stretched condition of the parts. Its direction should be at right angles with the girdle of resistance at the point cut. It may extend down to the skin but need not invade it, and may be about three-fourths of an inch in length. While various other methods of incision have been suggested and practised the foregoing seems the simplest and the most effectual. Cohen's subcutaneous tenotomy of the bulbo-cavernosus is painful, is liable to injure the corpora cavernosa and moreover does not accomplish the purpose. Nor can I see any advantage in the multiple incisions of Schultze and others over the single division of the ring on each side. Tarnier recommends an incision of the perineum beginning in the median line and passing obliquely to one side, but this divides more important structures than the method adopted and affords no more relief to the over-distention. Pallen's method of cutting above the ducts of Bartholin is liable, as Garrigues remarks, to wound the vaginal bulbs. Garrigues prefers blunt scissors to the knife as more efficiently accomplishing just the object aimed at, cutting neither too much nor too little. The objection to the scissors is the difficulty of using them during a pain. Such at least has been my experience. At the close of labor the incisions as well as lacerations that may have occurred in spite of the incisions should be invariably closed with sutures. For this purpose I prefer catgut prepared under the supervision of the surgeon himself.

With an aseptic management of the labor and the suture and the use of a suitable antiseptic vulvar dressing during the post-partum week union is practically assured.

THE HEART IN DIPHTHERITIC PARALYSIS, WITH

REPORT OF A CASE.

BY HENRY CONKLING, M. D.,

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

Read before the Medical Society of the County of Kings, June 17, 1890.

Your attention is asked to certain observations upon diphtheritic paralysis, with especial notes upon the condition of the heart in that disease, from a case that has been lately recorded, the cardiac condition of which may be taken as typical of true diphtheritic paralysis. The manifestations of this particular case have been, in part, in accord with certain others that have been observed and studied in hospital work.

It is an interesting fact in the clinical study of disease that the manifestations of the sequelae of acute affections are sometimes slow in showing themselves by symptoms. This is true even in those cases where the changes are marked by destruction or disorganization of tissue. Functional disturbances distinct from the disease itself, are common in acute affections, where inflammation, limited to one organ, or one set of organs, marks the primary disease. These functional disturbances rarely are of sufficient importance to be called complications. But during the period of convalescence, when the process of natural repair is going on, muscular, nervous, or organic changes may be taking place, in parts remote from the seat of the primary disease. These sequele do not always bear a distinct relation in their gravity to the original disease which may be taken as their exciting cause. This fact, taken with the manner of their manifestations, frequently causes them to be regarded as of slight importance. This view is sometimes expressed in relation to diphtheritic paralysis. It is also frequently stated that strychnia or some of its preparations are specifics in its cure. Both of these statements are open to criticism.

Opportunity was given some time since to study, in hospital work, clinically and pathologically, a number of cases of diphtheritic paraly sis. The conclusion was drawn-almost forced upon one's mindthat the disease was of a most serious nature. Since that time additional opportunities have been given to watch and to treat similar cases. Further deductions have been drawn, with especial attention to certain symptoms and signs, with observations upon particular lines of treatment.

The exact pathological lesion is not perfectly ascertained. It is perhaps in keeping with the nervous changes of degeneration and loss

of substance, where a similarity in lesion produces at times a difference in manifestations. A certain change in the motor cells of the cord, medulla, and cardiac ganglia-a granular condition-may be present. There may be a condition of inflammation, causing swelling; or an irritation, causing an opposite condition of decrease in size. Nutritive change will always produce change in function, and the motive power of nerves, dependent upon nutrition from great centres, is sometimes imperfect without any marked change in the nerve trunks themselves.

A considerable part of an active hospital service has been given lately to the study of cardiac conditions, and the case to be reported is in keeping with these observations.

In the 9th of November, 1889, a young lad aged fourteen was admitted into the wards of my chief at St. Peter's Hospital in this city. The patient had had in September an attack of diphtheria, from which he had recovered. In October he had suffered from a second attack. Convalescence began promptly, but the lad remained in a somewhat weakened condition. His usual strength and activity were not wholly regained. He was easily tired. He grew steadily worse, and his parents at this time were told by a physician that he was suffering from “general debility, with a tendency to consumption." On the 8th day of November he was admitted to the hospital, the journey to which had considerably fatigued him. After a sufficient period for rest, the examination was made.

This found a rather pale lad, somewhat but, not extremely, emaciated; he could stand with difficulty; it was impossible for him to walk; the use of the arms was impaired; there was very little feeling on the left side, but more on the right. He had naturally a high palate; there was paralysis of the soft palate; the line of demarcation between hard and soft palates could not be seen upon deep inspiration; the posterior faucial wall was thickened; the pharyngeal wall was slightly glazed; the voice was of a peculiar high-pitched character; swallowing was painful and difficult.

The tongue was slightly coated, and the membrane of the mouth and lips, with that of the conjunctivæ somewhat pale. There were no abnormal conditions in the eyes.

The urine contained a small amount of phosphates. There was no paralysis of bladder or rectum. The reflexes were present, with the exception of the ankle clonus and the scapular reflex. Some were more marked than others. The lungs were normal and healthy. There was no indication of pulmonary consumption. There was nothing to cause alarm in the working of the diaphragm. But the condition which to the patient was the most important, and which in the examination was the most interesting, was that of the heart,

Inspection showed nothing.

Palpation gave feebleness of apical impulse.

Percussion showed slight diminution in area of cardiac dulness; the sense of resistance seemed to be somewhat lessened.

Auscultation found the first and second sounds faint at the base. There was an undulating sound at the apex; the interval between the first and second sounds was very materially lessened; the clear valvular element of the sounds was wanting; the rebound was imperfect. Now and again there was a tendency to a condition of tremor cordis. But the sphygmograph gave information quite as important as that derived from the associated methods of physical examination. There was certainly a heart, the nervous control of which was not perfect. By the sphygmograph were learned the manifestations of the nervous irritability and the condition of the muscular fibre. Three ounces pressure was used. The tracing showed a short wave of ascent, a rounded summit, a long tidal wave, scarcely any aortic notch, a long diastole, and then, what is always indicative of depression, a dip in the needle before the next line of ascent.

This was the case. It was evident at the time of the examination that the heart was the organ which must be constantly watched, and to the improvement of which all treatment must be directed. It was also evident that this treatment must be given through the nervous system. There were two indications:

1. Cardiac nutrition.

2. Cardiac stimulation.

The condition in the throat excited no alarm. The loss of power in the limbs was of secondary importance. There was danger of the heart stopping in diastole.

The boy was put to bed and kept in the recumbent position. After preparation he was fed with nutritive and stimulating enemata; from time to time the best of all nerve medicines-olive oil-was dropped upon his tongue. General and local faradization was commenced, and continued with an increasing current.

In a few days the throat began to regain its function; sensation began to return throughout the body. The enemata were continued in decreasing number, until the swallowing was perfect.

The patient was fed with the best of food in large amounts, with aids to digestion. A very liberal supply of whiskey was given-always with the food, never alone.

The simple bitters and a preparation of iron were given. Maltine. and cod-liver oil were substituted for the olive oil.

The electricity was continued.

During this period daily examinations were made of the heart.