tremities. The appetite has been fairly therefore often difficult to see under the good, but sleep disturbed. microscope. These casts often contain granular matter, and red and white blood corpuscles and fat cells. Present condition: The urine is still scant and high-colored, and contains albumen. The albumen is constant and there is oedema Casts are always significant of alteration of the lower extremities after exertion. in the tubules of the kidneys. Normal Under the microscope the urine presents urine has no casts. hyaline casts with epithelial cells attached The width of the cast represents the exwith red and white blood corpuscles. There tent of dilation of the tube through which is tenderness in both kidneys, with hyper- it comes. Blood corpuscles point to hemortrophy of the left ventricle of the heart. rhage of the kidneys. The capillaries are Morning temperature normal, pulse 80. ruptured and there is an escape of red blood Evening temperature 991⁄2 to 100, pulse 100. corpuscles into the tubules of the cortex. Rest more or less disturbed. Epithelium casts point to desquamation of the epithelium in the tubules. White blood corpuscles point to migration of the white cells through the vessels. The fatty granular cells point to fatty degeneration of the kidneys. The kidneys are the chief servants of the tissues of the body, and through this service they are liable to be affected by the presence in the blood of chemico-toxic and organic infectious substances. From the history of this case this disease had its origin in an aseptic condition of the blood during the tonsilitis. The reason we think so is because of the changed condition of the urine that is referred to in the history of the case. Usually Bright's disease is a disease of middle life, but it often makes its appearance in the young through the presence in the blood of organized infectious material being eliminated through the kidneys, as is shown in this case. Tubular nephritis often assumes a chronic character from the start. It seems to originate of itself. Sometimes it is attributed to wet and cold or other unfavorable surround What is the significance of the presence of albumen in the urine? The presence of albumen is significant of an abnormal condition of the glomeruli of the kidneys. The function of the glomeruli is to act as filters. ings. Now, if the filters become too porous, or, other words, too open, substances pass through which should not; hence the transudation of the albumen into the urine. in These changes in the character of the urine, in reference to quality and quantity, are what first direct our attention to disease of the kidneys. An albuminous urine is almost always a concentrated urine and this almost always produces more or less irritation of the urinal tract. When we have the chronic tubular disease, we have also hypertrophy of the left ventricle of the heart. The increased size of the heart seems to be brought about by the obstruction in the renal arteries. The kidneys are a very vascular structure. The renal arteries divide and subdivide, and form the vascular tufts of the glomeruli and form arches between the medullery and cortical structure of the kidney, and form a plexus of capillaries around each tubule, of which there are about 500 in number in each kidney. When the structure of the kidney is swollen by the presence of inflammatory products it offers more or less resistance to the free circulation of the blood through the renal arteries. But what is more important than albumen in the urine is casts. The hyaline casts are the ones most frequently found and are the most important form of casts. The structure of the hyaline cast is some coagulated material, probably albumen. They are to a certain extent the ground work for the attachment of the different substances seen If the circulation is maintained, there under the microscope. The hyaline casts must be an increased pressure in the circuare clear as glass and colorless, and are lation in the arteries, and, in order to main tain the increased pressure, the left ventricle normal condition; if not, the degenerative of the heart is called upon to do more work; changes continue, the kidneys become dihence its increase in size and impulse as we minished in size and changes in the interhave in this case. tubular connective tissue take place. In this case the prognosis is probably esse malum. Under the stethoscope we find the impulse of the left ventricle stronger than usual and its area increased. We find it too far over to the left side. While we find the impulse of the left ventricle increased, we do not find a corresponding increase in the pulse, but the action of the pulse is quick and feeble. Treatment.-Milk diet, tincture of ferri chloridi, fifteen drops three times a day after meals, and strychnine one-fortieth grain three times a day after meals. For pyrexia at night four grains phenacetin at bed-time. The iron is for the purpose of overcoming Whenever we have obstruction to the cir- the anæmia; the strychnine gives tone to the culation we also have dropsical accumula- heart and nervous system; the phenacetin tions in the cellular tissues. Where we lowers the temperature and produces perspihave altered nutrition of the vascular cells ration, and a diversion from the kidneys to of the vessels we have the tendency to fatty the skin. Under this treatment the urine degeneration with the liability to exudations has become more copious, with less albumen of serum into the cellular tissues. In the and an increase in strength. chronic form of Bright's disease the whole of the kidney is not uniformly affected. While some of the tubes are being blocked by fresh inflammatory deposits others are undergoing disintegration of the epithelium with an abundant exudation into the urinary Read before the South Kansas Medical Society at Newton, tubules. As the disease continues, the vascularity diminishes and the vitality of the cells is more and more impaired and they undergo retrogressive changes. Pelvic Presentations and Their Kansas, November 15, 1892, By H. L. McILHENNY, M.D., Norwich, Kas. This is a subject of such great importance There is no difference between the acute that every practitioner should be posted as and the chronic form of the disease, only to the proper line of treatment. In the disthat in the chronic form nature makes an cussion of the same I do not expect to preeffort at repair and more time is required sent anything new, but to review the subject for the changes to take place in the recon- and relate some of my experience, extending struction of degenerated connective tissue over a period of seven years. Unlike many cells, which is a lower form of structure than other branches of medicine, the nature of the normal structure. While some tubules such a case, falling into the hands of the are being reconstructed in this way, others are undergoing atrophy and degeneration until the whole kidney is involved, while the patient succumbs to a general breaking up of the walls of the blood vessels. As the disease advances in the chronic form, fatty cells are gradually increased in amount as the degeneration proceeds. Prognosis. If the patient is to get well, the fatty stage may pass off. The degenerated cells may be carried away by the urine. Those which remain are absorbed. The retrograde process gradually ceases and the cortex of the kidneys returns to the obstetrician, is somewhat a matter of chance, and at no time can he feel sure that his very next case will not be one involving the difficulties of an after-coming head in the pelvis. Under the head of pelvic presentations all the cases where the lower extremities of the child present are usually included, which may be breech, footlings or knee presentations. While it is of some importance that the physician should be able to recognize the presenting part, in so far as the mechanism and management are concerned, they are almost identical. Pelvic presentations are not at all infrequent, yet their frequency is variously estimated by different authori- on the umbilical cord in the interval elapsties. Those in which the breech alone pre- ing between the birth of the body and that sents being the most frequent. According of the head. At this time the cord is comto Churchill, one in fifty-two cases; while pressed between the head of the child and others say it occurs more frequently, or once the pelvic walls, thus arresting the circuin thirty-five to thirty-eight cases. Foot-lation of its vessels, so that there is an lings occur once in about ninety cases; knee imperfect æreation of the fœtal blood. Pulpresentations being extremely rare. monary respiration not being established, In my own experience I have found pelvic the child is asphyxiated. Another condipresentations occurring more frequently than tion may exist which will produce a like recorded by any statistics with which I am result, viz.: that the placenta is often sepaacquainted, extending over a period of seven rated by the uterine contractions when the years. Have attended on an average about body of the child is being expelled, thus profifty cases of obstetrics each year, and dur-ducing an arrest of placental respiration. ing this time and of this number seventeen Indeed, this I believe to be a more frequent were cases of pelvic presentations. In all of cause of death to the child than compression them the breech presented, except one, which of the cord; at least in the two fatal cases was a footling. Hence it will be seen that in my own experience this condition existed. the ratio of breech presentation in this set By some authority another cause of danger of cases is much greater than that of most to the child is the compression of the placenta authorities. I have never met a case of knee between the contracted uterus and the hard presentation. fœtal head, thus arresting the function of The causes of pelvic presentations as yet the placenta. With this theory I cannot seems obscure. To my mind, however, it agree. It looks unreasonable to suppose seems plain that some peculiarity exists in that a placenta, which has not been detached, the shape of the uterine cavity in certain should have its function arrested by reason women, for I have attended a lady in two of a contracted uterus. If this were true we successive confinements, both of which were might expect a very great mortality of whatbreech presentations; and I learned that ever presentation. It should not be forgotten two years after I last attended her she that there is greater danger to the child in again had another breech presentation. footling than in breech cases, for the reason The final result of these cases, as regards that in the former the maternal parts are the mother, are not more unfavorable than less perfectly dilated and the birth of the in vertex presentations. The first stage of head is more likely to be delayed. As to the labor, however, is usually tedious, as the mechanism of these cases but little need be rounded breech does not adapt itself to the said. The simplest division in which the lower segment of the uterus as does the breech is described is that of four positions head; hence dilatation goes on slowly. The similar to those of the vertex, viz.: first, results as to the child are quite different. second, third and fourth. In these positions the presenting parts (or breech) are subjected to about the same forces as in vertex pre Churchill estimates the mortality as one to three and one-half. This is certainly too high a death rate; at least it is not consist- sentations, yet the changes of position in ent with my own experience, and is greater than should occur in the hands of the careful physician, if properly managed. However, the risk to the child is great under the most favorable conditions. the breech in its progress is less uniform than that of the head, on account of its imperfect adaptation to the pelvic cavity. In the first position-left sacro-anteriorthe sacrum of the child points to the left In the seventeen cases above cited, I had foramen ovale. As labor advances, the but two (2) deaths occur before delivery pains acting on the body of the child, the could be completed. The causes of this breech is gradually forced through the pelvic mortality are conceded to be due to pressure cavity, its progress being as a rule more slow than that of the head, until the lower jeopardy every moment, and one or two strait of the pelvis is reached, when about minutes may decide the question of life or the same rotation takes place, as in cases of death, caused by compression of the cord the occiput. By some this rotation is denied, and interrupting foetal circulation, as also but there is no doubt that it does occur in by a premature separation of the placenta. the majority of cases. The left hip now be- Some one has suggested that where delivery comes engaged behind the pubes and the of the head could not be effected at once to right toward the sacrum; at this point a establish pulmonary respiration by passing motion similar to extension seems to take one or two fingers into the vagina and pressplace, the right hip rotating slightly and ing it back to admit air into the child's distending the perineum, and is expelled; mouth. This procedure in my hands has the left hip soon following. When the hips been a failure. It wont work. To assist. are once born, the feet soon follow, unless the legs are extended on the abdomen of the child. The arms of the child are sometimes found on the thorax of the child, yet they are more frequently extended over the child's head, in which case there is an unavoidable delay and an increased risk to the child. nature in completing birth of the head is theone thing necessary now. Supposing the face to have rotated to the cavity of the sacrum, the first thing to do is to carry the body of the child well up over the pubes and abdomen of the mother without making traction or interfering with flexion of the To correct this trouble we should be chin on the chest. In many cases this will cautious, and every move should be made so be sufficient to complete delivery. Unhappily as to favor the natural motion of the joints, all cases are not so easily disposed of. Should. lest we fracture some of the bones of the there be a delay now, traction must be used, arm. The finger of the attendant should but applied in such a way as to insure flexion. be introduced to the posterior, as there will Keeping the child in the same position, the be more room toward the sacrum, and carried index and middle finger of the right hand down to the elbow, where it can be drawn are placed on the back of the child's neck over the face and outward, and the forearm and push the head into a flexed position; liberated. A similar procedure should then then by passing the index and middle finger be used in liberating the other arm. This of left hand on the superior maxilla or in-done, the shoulders soon follow. By some troducing the index finger into the mouth we are told that the arms are seldom ever of the child, delivery will be completed extended over the head unless some traction without further trouble in the majority of has been made in order to hasten delivery. cases. A valuable adjunct to hasten deMy own experience does not justify this livery of the head is pressure through the statement. I have found that unless we abdomen, which should be used at the same have a small child and a large pelvis the ex- time that traction is being used. This tension of the arms one or both of them- combination will seldom fail. Many auwill take place six times out of ten, even thorities advise the application of the forceps. though the expulsion of the child is left en- to the after-coming head where any delay tirely to nature's powers. When delivery of in the birth of the head takes place. If the the hips has taken place, I am well aware delay be due to lack of expulsive force in a that the temptation is strong to make trac- pelvis of normal size, the manipulation just tion and hasten delivery, but the wise phy- described will be all sufficient in almost sician withholds his hand, thus avoiding every case. The indications for the use of unnecessary trouble. The arms and shoulders the forceps might be found in the following being extracted, the delivery of the head is conditions: Where a disproportion exists benow of the greatest importance, as the safety tween the size of the head and the pelvis; of the child depends on a speedy delivery of when the head is in the superior strait and While the danger to the mother the chin to the front; in rigidity of the soft is not great, the life of the child is in parts; in too large heads, as hydrocephalus. the head. In such cases as these, by the judicious use of the forceps, many dangers may be obviated. The indiscriminate use of the for.ceps in all cases is not good practice. 'Laryngitis, with Report of a Case. March 28: Temperature 100 F., pulse 130. Breathing still embarrassed; general condition unchanged. March 29: Respiration comparatively easy. Rested well last night. Other symptoms unchanged. March 30: Improvement continued until this evening, when she became rapidly worse. March 31: Temperature 100%, pulse 120; very restless Read before the Republican Valley Medical Society, April, and dyspnoea increasing. April 1: Pulse 1892, By S. C. PIGMAN, M.D., Concordia, Kansas. 140, temperature 101; symptoms unchanged, sleep much broken and patient weaker. April 2: Pulse 140, intermittent; temperaIt is not my intention to discuss the differture 100 4-5. Respiration very difficult, ent diseases of the larynx, for your experi- voice whispering, cyanoses marked. April ence and text-books have made you familiar 3, 2 A.M.: Pulse weak and intermittent; with them. A history of the case furnishes symptoms of carbonic poisoning increasing; the text of this paper, and while there may can be aroused with difficulty. Tracheotomy be a dearth of originality in the manage- performed at 2:15 A.M. Tube obtained and ment it proves that good results come from introduced at about 12 o'clock same day. old methods, and that the "flower safety Pulse 130, temperature 100 4-5. Patient may be plucked from the nettle danger," and brighter. Liquid nourishment and stimulife saved by surgical interference in most lants ordered. Temperature of room to be unpromising cases. Dr. F. A. McDonald, of Aurora, in whose practice this case occurred, has kindly fur nished me these notes. kept uniform at 75° F., and atmosphere moist. A capsule, containing quiniæ grs. ii and phenacetin grs. iv, to be given every four hours, and a teaspoonful of the following mixture every two hours: R M. Potass. brom.... grs. xv .grs. v m v 3 ss Mrs. Clara Brown, aged twenty years. Patient consulted me February 17, 1891. Is hoarse; no cough. Prescribed ammon, chlor., syr. ipecac with solution. February 26: Voice improved; no pain or tenderness over larynx. Ordered medicine continued. March 20: Patient confined to-day; child born before I arrived. Says she has not entirely April 4: Pulse 120, temperature 991⁄2 F. recovered from her cold. Is still hoarse; Expectoration abundant and patient fairly has neither dyspnoea or dysphagia or cough. comfortable. April 5: Pulse 100, temperaThere is slight tenderness over larynx. ture 100 F. Takes plenty of nourishment; Former prescription was refilled and spray auscultation reveals signs of bronchitis. of ammon. chlor. grs. v to 3i ordered. March Treatment continued with addition of 24: Did not see patient; some respiratory counter-irritation over sternum. difficulty reported. March 26: Temperature Pulse 100, temperature 101 F. Bronchitis 100 F., pulse 120. Inspiration and expiraseems aggravated. Patient rests well and tion embarrassed; some cough, dry and continues to take nourishment. abortive in character. Prescribed quinia Pulse 100, temperature 101 F. Expectorasulph. grs. iv every three hours and the fol- tion abundant and patient stronger. April lowing mixture: R April 6: April 7: 8: Temperature and pulse same. April 9: No change in symptoms. Strength improving and treatment continued. April 10: Pulse 98, temperature 101. Bronchitis subsiding; tongue clearing. April 11: Pulse 92, temperature 100 4-5. Closed tube to note |