common use to medicate and give support to the inflamed nasal membrane. The use of tents of various kinds as a means of conveying remedies to the cavities of the nose is of very ancient origin, and it is therefore amusing to read the altercations in which some surgeons of the present day have indulged as to the priority of their introduction in the treatment of nasal inflammation. Where the discharge is profuse, or when caries or necrosis of the bones is present, I can strongly recommend oakum as a substitute for the cotton tents commonly employed.

In addition to local applications, attention should be given to the general health, which is often seriously impaired. The existence of diathetic diseases should be carefully sought for and the different organs and their functions systematically interrogated. It is perhaps a trite remark that he is a poor specialist who does not look beyond the anatomical limits of his specialty, but successful treatment of his patient will often depend more upon the intelligent appreciation of associated, though remote, pathological processes, than upon the routine treatment with which he assails the organs whose diseases it is his peculiar mission to alleviate.

As a tonic, stimulant, disinfectant and alterative I know of nothing better than the sulphate of quinia. Either alone or combined with mercury it seems to exert a beneficial effect in quite a number of cases of chronic nasal catarrh, and is sometimes an important auxiliary in the treatment.

In the subsequent treatment of the catarrhal otitis media our chief reliance must be placed on the systematic inflation of the middle ear with atmospheric air, and the use of vapors through the Eustachian catheter, or by means of the various appliances in general use. The injection of fluids through the Eustachian tube is a practice of questionable utility, and it is only in exceptional cases that permanent results may be obtained by the use of electricity. Spraying amounts practically to the injection of the remedy in a fluid form, the finely divided particles reaching the upper portion of the tube or middle ear, if they reach them at all, not as spray, but as a liquid injection. Dilatation of the tube with bougies is occasionally of decided benefit; but their use requires caution, as it is not unattended by danger. I believe that the employment of bougies of large calibre would diminish materially the danger and be productive of more good in the dilatation of the tube, or, at least, its lower portion. Among the numerous vapors used may be mentioned the benzoate of

iodine, the iodide, muriate and benzoate of ammonium, and the vapor pini sylvestris (London Throat Hospital Pharmacopoeia). If a diathetic condition be present, or if the general health be impaired, they, of course, call for appropriate treatment; but, as a rule, very little can be expected from constitutional medicinal treatment in chronic catarrhal inflammation of the middle ear. Cubebs, mercury, the salts of ammonium and guaiac will occasionally afford temporary relief, and the use of alkaline and sulphur waters, especially when combined with local treatment, are sometimes of decided benefit; but it is often very difficult to measure the exact amount of influence which the former exert in the production of a cure. The treatment of the tinnitus-the most annoying symptom-will obviously depend upon the condition which produces it. I have rarely seen any marked improvement from the use of hydrobromic acid, and the same can be said of that much vaunted and grossly overestimated drug, ergot. Residence at the seaside will often do more toward dissipating this troublesome phenomenon than all the medicines of the pharmacopoeia.

One word in regard to the treatment of hypertrophic inflammation of the middle ear. Let us take an illustrative case. The drum head is gone, a chronic otorrhoea has been established; the ossicles have long since been swept away in the discharge. Over the promontory the hypertrophic membrane appears as a swollen thickened mass, smooth or granular in appearance, or projecting outward as a welldefined tumor which every one at the outset of his aural studies has mistaken for polypus. This hypertrophic mass encroaches on the cavity of the drum and is the most prolific source of the discharge. The principles which govern us in the management of hypertrophic nasal catarrh are equally applicable here. If ordinary methods fail, or if it be excessive, projecting outward like a polypus, it should be snared or excised with the ring knife, or destroyed by caustic applications, the galvano-cautery, etc.

Adenoid growths are best removed with forceps. The instrument which I show you is one that I have had made by Willms of this city. The blades are fenestrated and slightly flattened posteriorly and superiorly to admit of perfect contact with the walls of the pharynx. Their cutting edges are made on the principle of the Lüer bone-nippers except that they are prolonged downward to the shank. Whe closed the edges should be in perfect apposition. Thus constructed they will cut with ease through the densest growth. No pulling of

dragging is necessary, as is often the case when the dentated or ordinary beveled bladed forceps are used; the operation can be performed without the slightest discomfort to the patient. The blades bury themselves in the mass and bring it readily away. These forceps possess, furthermore, the additional advantage that each blade may be used as a curette. The growths being brought away, the instrument is reintroduced and one blade is fixed, whilst the other is used to scrape off the remains of the vegetations. Should the blade slip, no harm can be done, for it will close with its fellow of the opposite side. We thus have two instruments combined in one. The f-shaped curve of the ordinary Loewenberg forceps has been retained as the most convenient.

Besides remov

This instrument may be put to a number of uses. ing growths from the throat, it may be used for scraping or nipping the granules from the walls of the pharynx, and can be employed to remove portions of the tonsils, the stubs left after old follicular diseases, and other conditions which give rise to irritation and require excision.

In conclusion, gentlemen, let me say that the nose is too often regarded simply in its capacity as the organ of smell, and its important physiological relations to the functions of respiration, audition and vocalization receive but imperfect attention or are altogether overlooked. Within its cavities changes in the air take place which are absolutely essential to normal healthy respiration, and the removal, therefore, of nasal obstruction is as necessary to the maintenance of perfect physiological life as when the obstruction is situated lower down in the air passages. The consequences of impeded nasal respiration detailed above are not exaggerated; they are facts of every-day experience. To insist upon their proper appreciation and upon the radical removal of the causes upon which they depend has been the object of these remarks; for it is only by a more careful study of the pathological conditions of the nose, and their relation to diseases of adjacent and communicating organs, that we may ever hope to emancipate these affections from the dominion of quackery and empiricism and place them under the control of rational therapeutics.

11

MALARIAL FEVER IN PUERPERAL WOMEN.

BY PHILIP C. WILLIAMS, M. D.

It is not my intention to enter into a discussion of malaria, nor to examine the literature of the subject, but simply to report three cases that occurred during the past winter, in order to show the grave embarrassment they presented in diagnosis, and also to call attention to some interesting clinical facts.

Case No. 1.-January 8, 1883, I was called to see Mrs. M., aged 20, of fine physique, in excellent health, and about to be confined with her first child. The first stage of labor was extremely tedious. The pains were frequent and strong, but they accomplished very little in dilating the mouth of the womb. After twenty-four hours the head still remained above the brim, with the occiput in a posterior position. I then administered chloroform to assist dilatation and to allay the severity of the pains. Under the chloroform the os uteri became distensible, but there was no progress in the descent of the head. I then applied the forceps, and failed to bring down the head, notwithstanding the use of much force. Finding that I had to deal with a large, firm head, and also finding that the posterior position was one of the chief causes of delay, I determined to try and change the position. After much patient endeavor I succeeded in bringing the occiput behind the pubis. Being much exhausted, I removed the forceps and waited to regain my strength. Having rested awhile, I reapplied the forceps, and after great effort delivered the cranium without accident to the mother. Supposing the labor practically ended, I laid aside the forceps and waited for the expulsion of the child. The next pain was very strong and expelled the head suddenly and forcibly, and as the chin passed out, to my great surprise and mortification it cut the perineum about two-thirds of the distance to the rectum. The child was soon born, with life extinct, and the head deeply scarred by the blades of the forceps. The placenta was removed without difficulty, and the labor was completed. The child was finely developed-weighed 12 pounds. The head was large, the sutures were fully united, and the cranium as firm as that of a child six or

eight months old. This explained the difficulty experienced in the delivery.

The mother was so exhausted that I determined not to undertake to restore the perineum. Under absolute quiet the mother was gradually restored to a reasonable degree of comfort. I ordered vaginal injections of carbolic acid, and the application of camphor and belladonna to the breasts to prevent the secretion of milk. Thursday night, the third day, the camphor and belladonna was discontinued.

Everything progressed favorably until Saturday night (5th day), or early Sunday morning-forty hours after the discontinuance of the belladonna-when the patient began to complain of most distressing tingling all over the body. The skin soon became hot, dry and bright scarlet, and the patient became slightly delirious.

At this juncture the family became alarmed and requested a consultation. Prof. Chew was called in. We determined that the symptoms were produced by the belladonna, notwithstanding so long a time had elapsed since its discontinuance. Acting upon this supposition, we prescribed morphia and bromide of potash, which, by the next day, relieved the distressing condition.

Everything progressed favorably until the following Friday, January 19th, when during the night (of the 11th day) the patient had a slight rigor, followed by fever and subsequent sweat. The next morning (12th day) the temperature was about 101, and the condition of the patient very comfortable. The following night, about 3 A. M., the rigor was more decided, but not severe. I was sent for early in the morning and found the temperature 103. At my request, Prof. Chew was again called in. That evening the temperature fell to 101.

To prevent rise of temperature the next morning, we ordered 10 grain doses of quinine to be given three times during the night. The following morning (14th day) the temperature rose to 104, notwithstanding the 30 grains of quinine.

During this day Dr. Buckler was called in and we decided to continue the quinine in the same doses. The next day the temperature again stood at 104. The quinine was increased to 50 grains, which still failed to reduce the temperature, which rose to 104 the following morning. We still determined to continue the quinine, and I ordered six grains to be given every 2 hours. I continued this dose for the next 24 hours until 72 grains were administered. This fortunately broke down the temperature and it never again rose above 100. After this the quinine was gradually diminished until it reached about 12