at the wrist on a fruit jar. A pack of absorbent cotton having been dipped in a solution of carbolic was found tightly bound on the cut and the hemorrhage fairly well controlled. This was taken care of and the wound healed by first intention. This is an excellent example of what can be done by the home nurse. When called to see a case where hemorrhage can be stopped by pressure, a good opportunity offers to demonstrate the use of a tourniquet quickly made from a handkerchief and a short stick. A crowd of curious spectators is usually present at such a case. It is not a place to air one's knowledge, but is a good opportunity for inculcating a practical point in the care of the injured which will not soon be forgotten. In all cases of flooding, women should be taught to go to bed, to lie quietly, have the foot of the bed elevated and cold compresses applied. All pregnant women should know what to do when there is threatened abortion. The care of those apparently drowned and those suffocated from gas and other causes brings out the technique of artificial respiration. The administration of emetic in poisons, carefulness in handling scalds and burns, cleansing of the alimentary canal, and cold baths in spasms of children with high fever, comprise, in a general way, some of the most important emergency procedures. The superficial understanding of nursing must not lead to a dangerously superficial study of the action of drugs. The common remedies, such as salts, castor oil, camphor, turpentine and carbolic. acid may be permitted by the doctor, under his direction, with advantage to both patient and doctor. Be alert for the mistakes of the home nurse until you are sure she understands. Trust the serious cases only to the well-trained graduated nurse, and save your patient and your reputation. Knowledge imparted to the laity does not lessen the physician's practice. He will have just as many calls, but not so many unnecessary ones. A little insight into the wonderful science for the alleviation of human suffering leads patrons to hold in higher respect the doctor who helps them in distress and forewarns them of danger. MORE Schools for the children and better salaries for the teachers. Don't practice political economy on the kids. "Brothers and sisters," began the old parson, "I shall not choose any particular text this morning, but shall preach from where I open the book, and no matter where, I shall find the wrath that is to come upon the wicked who will be cut off when they have shuffled off this mortal coil. *** It is now open, and-" Here the parson was interrupted by a lawyer of his flock, Deacon X, who had been asleep and hearing the words, "open, cut, and shuffle," forgot himself and cried out: "It's yours! What did you open on?" The surprise of the good man in the pulpit was great, but the deacon collapsed when the reply from the parson came, "It is opened on Kings." You may have observed that a cheap automobile usually acts that way. E Tumors in Infancy. BY ARTHUR W. Day, M. D., Brooklyn, N. Y. OVERY practicing physician realizes the anxiety of the newly-made mother concerning the physical soundness of the infant to which she has given birth, and the importance of being able to reassure her or tactfully forewarn her by a proper diagnosis and prognosis of whatever defect may be present in the child. This is the motif of Dr. Day's valuable and practical article. He classifies and differentiates the tumors of the head most frequently met with in the new-born, the caput succedaneum, the cephalhematoma in its three varieties, cysts, vascular tumors, meningocele, encephaloma and hydrocephaloma. Most serious, of course, are those of the last three varieties, because they communicate with the brain. Treatment of the simpler forms of tumor is unnecessary or exceedingly general; they usually right themselves. What to do in the case of the more serious tumors is, as Kipling says, "another story," which we trust we can persuade Dr. Day to tell at some future time. The idea of this article is to enable the practitioner at least to properly diagnose their true character and to prognosticate their gravity and course, and thus to satisfy the anxious mother at the earliest possible moment, and to gain the respect and confidence of all concerned. As soon as the turmoil and excitement attendant upon labor are over, the first thought of the intelligent mother, and one of greatest concern to her, is whether the infant is perfectly formed; whether or not there exists any deformity in that little creature for whom she has suffered so much. Repeatedly she asks the physician to see, or the nurse to look, and when she is alone with her treasure she examines and scrutinizes every inch of it on her own account, ever fearful, ever anxious that it is not physically perfect. And usually it is the mother who calls the attention of the physician to the little lump on the baby's head, which he, in his attention toward the general condition of the child, has not noticed, or if he has, but carelessly. It was the experience of the writer of this paper to have had just such a little patient with a minute lump on its head. The disastrous termination in this case led him to look up the subject. Great is the satisfaction in being able to give a reasonably definite prognosis. favorable, to relieve the anxiety of the mother; and if unfavorable, to add to one's reputation as a skillful diagnostician. Classification of Tumors. If The tumors most frequently met with in the new-born in the region of the head are the caput succedaneum, the cephalhematoma, of which there are three varieties: the cysts (unilocular and dermoid), vascular tumors, and the more serious tumors, protrusion of the contents of the skull, consisting of what is most commonly known as meningocele, encephaloma and hydrocephaloma. Depending upon the intensity of the pressure of the os uteri upon the presenting part, there is produced within its ring either a simple discoloration of the skin, a serous tumor, or a sanguineous effusion. The German authors were the first to use the term caput succedaneum. This swelling is developed during labor after the rupture of the membrane, and is so common that it can almost be called physiological. It is entirely subcutaneous, and usually contains serum, or it is sero-sanguineous; or, on account of greater pressure exerted, or rupture of small vessels due to their fragility, or of both causes combined. The skin is congested and the serum is formed under the scalp, very rarely beneath the pericranium; the scalp preserves its usual density, and the bone and pericranium are in perfect integrity. In the sero-sanguineous variety the scalp is quite vascular. Small ecchymoses. may be seen on its surface. There may be ecchymosis on the pericranium and on the surface of the skull, but the bone remains intact. The caput is formed during the passage, does not increase after birth and usually disappears in twenty-four hours or a few days. It is of little consequence clinically, except as it becomes infected and forms an ab scess. Cephalhematoma. The cephalhematoma was given its name by Naegele in 1811, but Michalis was first to investigate and describe in 1804. It is estimated as occurring once in 250 births. It is usually discovered some hours after labor, and reaches its fullest development in two or three days. There is an effusion of blood caused by the ruptured blood vessels between the aponeurosis and bone and the periosteum or in the diploë, which latter situation we shall not consider because it does not form a visible tumor. The sub-aponeurotic variety is due to the violence of labor in addition to external violence. It is more rapidly formed, the skin is discolored, not circumscribed, and has not the bony circle about it which is so characteristic of the second variety. The The sub-pericranial variety is the most common, and is the one usually meant when cephalhematoma is spoken of. Its favorite location is over the posterior and superior angle of the right parietal bone; occasionally over the left parietal, or it may occur simultaneously on both sides. The next favorite site is over the occiput. The substance of the scalp is uninjured. The periosteum is thickened, and on its under surface are several small points of ossification. surface of the bone is partly smooth and partly sprinkled with irregular osseous rugosities. The blood stimulates ossifica. tion, as shown by the hard bony ring around the base of the effusion, and later on by crepitation. The effusion is absorbed in two weeks to four months. The detached periosteum becomes ossified on its internal surface and after the absorption of the blood adheres to the cranium, leaving this part of the skull thicker. Clinically, it forms a slightly tense, fluctuating tumor, never passing over a suture. On pressure inward at edge one may feel the surface beneath. The skin is not usually discolored, although occasionally it may be red and edematous or pulsating. A bony arch is felt around it in about two days. The tumor reaches its development in a day or two, and becomes more tense, round, defined, elastic and fluctuating. Pressure on the tumor does not cause alteration in volume. There is no impairment of health, no cerebral symptoms, such as stupor, coma or convulsions. It is distinguished from traumatic hemorrhages of the scalp and caput succedaneum in that the latter are soft, pit on pressure, are diffuse, not defined with bony circle, do not fluctuate and are not limited by sutures. It is distinguished from cysts by the osseous circle. In hernia cerebri, perforation in the skull may be felt, and there is pulsation; pressure on tumor causes cerebral symptoms and is usually situated over the sutures. Nevi and angiomata have the same character as when situated on other parts of the body, but a cavernous angioma situated over either fontanelle, or at the root of the nose or at the occiput in the midline will offer many difficulties in diagnosis, for they pulsate and may be reduced by pressure. They are, when over a suture, to be chiefly distinguished from a brain protrusion, but the color of the skin, the juicy, berry-like feel and the ability to move and touch bone beneath, generally fixes it. Unilateral cysts of prenatal origin are often found in the scalp, but are easy of diagnosis. The dermoid cyst is harder to detect, and is supposed to be the result of inclusion of a portion of the epiblast. It is usually found over a suture at the outer angle of the orbit or over the root of the nose. They are of chief significance in that they often extend deeply into the orbit or even into the cranial cavity by means of long, pointed processes between the sutures or because of the partial or complete absorption of the bone over which they lie. It is well to remember this fact in making prognosis as to removal. Brain Cysts. And now the most serious of all, those communicating with the brain, should be detected early, even though small. I refer to the meningocele, the encephaloma, the hydrocephaloma. They are all due to an arrest of development in the cranial bones. Adhesions of the cephalic hood of the amni at an early embryonic period to the underlying tissues of the aphalic end of the embryo or the pressure of a contracted amnion upon that region, represents one of the factors. Circulatory disturbances which result in an intracranial inflam mation, terminating in bands of adhesions, or which result in fetal hydrocephalus, represents the other factor. The last condition acts by pressure from within the skull, which prevents the closure of the vault of the cranium in different places or in all parts. The result is a defect in the bony covering of the brain, more or less complete, which permits of the escape of part or all of the brain, with or without more or less meningeal cystocele. The time of the action of the disturbing force determines the kind of tumor. The head is normal or hydrocephalic. The rest of the skull is usually softer and there are other deformities of the body, such as club foot, etc., present. The encephalocele is usually hard, but may be a fluid tumor, varies from size of egg to that of an adult head. It contains brain substance, is usually pedunculated, and situated over the sinciput or the occiput. The hydroencephaloma contains brain and a cavity filled with fluid which communicates with the lateral ventricle. The meningocele is more common, and the tumor which is most likely to be confounded with the simple tumors on account of its frequently giving no brain symptoms. It is a protrusion of the meninges through an opening in the skull. The sac may or may not contain cerebral fluid or it may contain nerve tissue; is usually situated along middle line, is round, elastic, soft and fluctuating, varying from the size of an olive to that of an egg-plant. It pulsates synchronously with the heart-beat. The sincipital variety is situated near the root of the nose and communicates with the orbital or nasal cavity. The occipital or posterior meningocele is the largest and most common. There are two varieties of the occipital: the superior, above the spine; and the inferior, below the spine. The pedicle may be small or broad; some tumors are small or sessile. The integument may be red in spots or quite vascular like an angioma. It is frequently covered with scalp-tissue and hair. It is soft and fluctuates, and pressure decreases the size to a varying degree, producing coma or convulsions, or not. Such pressure increases the intracranial tension, causing the baby to close its eyes or cry, and the fontanelles to bulge. Extra pressure causes pain and vomiting or convulsions. The child is restless when lying on tumor. Straining movements, such as caused by crying, increases the size and vascularity of the tumor. When the infant is quiet, the tumor is smaller and less tense. An increase in the cerebral fluid in the ventricles or in the meninges favors the formation of the tumor. There are two theories in regard to the development: One that it is due to the pressure from dropsy within, springing from the cerebral ventricle on the earliest stages of development as a non-membranous cyst without brain substance, or the fault is primarily in the arrest of development of the bones; their failure to come together in the midline anatomical regions to the cleft palate and the hair lip. The treatment of the simple tumors of the head is unnessary or limited in its extent; that of the serous tumors, undeveloped and unsatisfactory, but the question of diagnosis is important if only to satisfy a worried mother at the earliest possible moment and gain the respect of all concerned for personal ability and keenness of observation. 413 56th Street. Tamponing for Placenta Previa. Ordinary Vaginal Method Useless. Hannes, in Muenchener Med. Woch., declares that tamponing the vagina is of not the least use in arresting hemorrhage from a placenta previa. Compression to be effectual must be applied directly on the placenta, pushing it back into its place, and this is accomplished in an ideal manner by the inflatable bag introduced into the membranes. It acts as a tampon, as a labor contraction-promoting element, and also as a gentle dilating force. The bag is boiled and kept in sterile glycerin. It was thus applied in 246 cases of placenta previa at the Breslau Maternity between 1894 and 1908. Fully 70 per cent of the children were born alive, surviving the first few days, and 83 per cent in the cases in which only the inflatable bag had been used. The bag imitates physiologic conditions, but it requires the constant presence of the physician. Hannes is convinced that the more prevalent the use of a hystereurynter with placenta previa and the earlier it is applied in the individual case, the more children will be born alive and the more mothers will survive. IT Laity and the Medical Profession.* BY MRS. HODGKINSON, Editor of the British Health Review. T is a capital thing to hold the mirror up to one's own life and habits once in a while. Not that we believe in constant and morbid introspection-that is weakening. But, just occasionally, it does a man good to look at himself. The trouble is, however, that when we hold the glass ourselves we are apt to be not quite frank with ourselves-to turn the mirror at an angle which will hide, or at least soften down, some of the unpleasant features which we know are there, but can not quite bring ourselves to view squarely. Sometimes, too, we miss and overlook things. So it is even better to view ourselves occasionally, without shrinking or blinking, in a mirror that someone else holds for us, to "see oursel's as ithers see It makes us wince a little, but it is salutary. This is our idea in publishing here this article of Mrs. Hodgkinson's from the British Medical Journal. We do not pretend that it is all true, or even fair. But it is at least honest, and represents what the "other fellow " is thinking about us and our work, and so it is worthy of our earnest attention and ought to teach us some valuable lessons. It is both right and wise of the physician to get the patient's viewpoint as much as he can; it makes up the complementary half of a rounded and successful practice, of which his skill and personality form the other half. We purpose to begin, next month, a series of short, meaty discussions of this very subject-the laity's attitude toward the medical man. We have, in fact, introduced the subject in this issue. And Mrs. Hodgkinson's paper contributes some interesting data. The author here makes three general criticisms of the doctor: (1) that he is neglectful of public duties, (2) that he is superficial in his attention to the real needs and concerns of his patient, and (3) that he carries specialism to unwarranted lengths. Never mind whether we think these criticisms justified or not. Do not let us get angry or offended about them. Let us remember that they represent the layman's point of view and give them careful and earnest heed. Then, where we feel they are unjustified, let us patiently and convincingly disprove them by word and deed; where they are in any degree justified, thankfully accept and profit by them. In stating the lay view of the relation of the medical profession to the public, there is no need to apologize for erroneous opinions, for mistakes are often highly instructive, and candor offers an opportunity for criticism and enlightenment likely to be extremely useful to all concerned. Therefore, without further preamble, I will put a few of the considerations affecting the lay mind before an audience which seldom hears them frankly stated. Those of us who give any thought to the *Reprint from the British Medical Journal. matter are far from satisfied with things as they are, and, if it be retorted that such persons are in a small minority, I reply that it is a growing one. It has already considerably leavened public opinion, and will leaven it still more thoroughly in the near future. That ideas are accepted entirely subversive of the old attitude towards disease and its treatment is a symptom that the more far-sighted of the profession will not ignore, especially as those by whom they are accepted are the thinkers and readers. The unreasoning part of the public-equally dissatisfied-betakes it |