Midwifery. PREVENTION AND TREATMENT OF BY W. H. TAYLOR, M.D., tory by the sucking of the child, by which the fissures are necessarily torn open, so that whatever progress may have been made toward heal ing is undone each time the child is applied to the breast. With such opinions of the causation of fissured nipple but two means of treatment seem applicable; the first, the use of a nipple-shield, by which the nipple is proThe cause of the lesion is the child's sucking, tected to a considerable degree during sucking, in which act the child compresses the nipple be is sufficient in mild cases, but is of little or tween its tongue and the roof of the mouth no use in severe cases. The only remedy on and draws it into the mouth, thereby subjecting which I rely, and which is adapted to all cases, it to firm compression and tension, whereby the is entire cessation from nursing with the affected epithelium is abraded and minute fisures formed. nipple for from forty-eight to seventy-two As this process is repeated at brief intervals, no hours, during which time the process of repair opportunity for repair is afforded, but at each being uninterfered with by the child, healing successive period of sucking the laceration is will so far have progressed as to allow nursing enlarged. From the intense pain experienced with little or no suffering. Such suggestion by the mother the flow of milk decreases; the usually awakens protest, on two grounds; first, child consequently makes greater suction effort, that discontinuance of the use of the breast for with corresponding injury to the nipple; so that the period mentioned will result in permanent it is not rare to have the child vomit small cessation of the flow. While I cannot deny its quantities of blood which it has drawn from occasional occurrence, yet such result is excepthe abrasions. The act of sucking is so ex- tional. Usually the flow will be re-established ceedingly painful to the mother that it is post- in a short time after re-applying the child to the poned till the distension of the breast with milk breast. But even if the danger of such cessacompels her to submit to its being performed. tion were great, the treatment is still to be The long-deferred nursing, the traction by the advocated, for we shall thereby probably avert child's mouth and the diminished flow of milk suppuration, when nursing must necessarily tend to increase the amount of blood in the cease and other evils increase. gland, causing engorgement, an early stage of inflammation. The maternal heroism which prompts the mother to persist in nursing her child at such sacrifice to her own comfort, commendable though the spirit be, is fraught only with evil; for the conditions detailed are aggravated till the changes are such that suppuration of the gland is unavoidable. say That The second ground of opposition to the advice given is that cessation from nursing will lead to accumulation of milk in the breast, and that such accumulation will result in abscess. cessation from nursing will lead to temporary induration of the breast is a matter of daily observation. That suppuration is likely to result from this accumulation of milk alone I do not admit. I from such accumulation alone, for I believe the means resorted to to overcome it often lead to the apprehended evil. To guard against the anticipated ill consequences of cessation from nursing, it is usual to resort to artificial The treatment of the fissures described is means for removing the milk from the breast. usually unsatisfactory. Medical literature shows I am persuaded that from these efforts the evils a countless array of applications for sore, are greater than from the accumulation of milk. chapped, cracked, fissured, ulcerated nipples; When we remember that irritation of the nipple and all, in my opinion, are of but little value; by the child's mouth is the natural means for for, however great the remedial power of the exciting the secretion. it is obvious that the application may be, it is rendered entirely nuga-effort to remove the accumulation by drawing Although we must recognize other influences -for example, cold, contusions, epidemic influences as potential in the production of abscesses, yet I have sketched the most common history of such production. the nipple is unphilosophic and will be unsuccessful. Again: the use of various mechanical appliances, breast-pumps, etc., is often productive of serious injury by contusing the portion of the breast compressed by the instrument, and may possibly induce abscess. ap With such views of the action of these pliances I discard them entirely and forbid all effort to remove the milk by suction. That it is desirable to relieve the tension of the breast which occurs for a few hours after nursing has ceased, must be recognized by all. For such purpose I have the breast very gently stroked with the hand with camphorated oil, the movement always being from the periphery toward the nipple. The effect of such manipulation continued from ten to fifteen minutes will be to cause the milk to flow. I seek to divert the the blood from the breasts and to deplete by giving a saline purgative. If the pain be severe enough to demand anodynes I give Dover's powder, because it both relieves pain and relaxes the engorged tissue. With management the fissured nipples heal, and threatened abscess is generally averted. That such happy result is always obtained can be said of no plan of treatment. When suppuration seems inevitable our only course is to hasten it, and while awaiting the progress of the case to mitigate discomfort. As a very important means of relief I urge support of the breast by means of a broad bandage passed under the breast and around the neck. By this means we relieve the upper part of the breast and the skin over it of the continuous dragging sensation consequent on its increased weight, and also facilitate the return of blood from the breast, thereby lessening the engorgement of the breast. If this support does not relieve the pain sufficiently I administer opiates freely. Dr. J. S. Parry, following McClintock, advises late opening of abscess of the breast, and I am inclined to adopt the practice. When discharge is effected, as perfect antiseptic dressing as possible should be applied. As soon after evacuation of the pus as the breast will tolerate pressure I resort to strapping, expecting thereby to prevent re-accumulation of pus, to obliterate the cavity and hasten union of the opposed sur faces, to compress the distended blood-vessels, thereby lessening the engorgement, and, by the continuous pressure, to stimulate absorption of effused material.-American Practitioner and Walsh's Retrospect. A CASE ILLUSTRATING "MISSED LABOR." AT a recent meeting of the Obstetrical Society of London, Dr. Barnes stated that the term, "missed labor," proposed by Oldham, was not justified by the facts of Oldham's case; which proved on autopsy to have been one of extra-uterine gestation. Discussing other cases of presumed missed labor, accepting the arguments of Stoltz and Muller, the author affirmed that no authentic example of missed labor— this term being taken to mean the prolonged retention in utero of a foetus, living, at term -is yet known. He cited examples of the retention of the ovum, which had perished in utero at pre-viable age, for some time, and notably until the arrival of the natural term of gestation. He related a case which came under his own care :- A lady, aged thirty-nine, had borne three still-born children, the last of them five years ago, before consulting Dr. Veitch, at Penang, in December, 1872. Pregnancy dated from early in November preceding. The usual signs of pregnancy were manifest; she verified quickening; and up to the seventh month she felt movements of the child. About the eighth month, after a slight accident, a flow of blood came. Three weeks later another bleeding occurred, but no labor pains. Eleven months after the presumed date of conception she came to England. There was an impression that she might be suffering from fibroid of the uterus. She came under the author's care in December, 1873. Under chloroform, the cervix uteri having been dilated by laminaria tents, he felt what he took to be the interior surface of the uterus; the sound passed six inches. In January, 1874, some colored discharges went on. Pieces of bone, which turned out to be bits of the spinal column, passed by vagina. After dilatation by tents, more bones were removed by fingers and forceps. In February this manœuvre was repeated, and by craniotomy forceps the remaining parts of a fœtus, which Correspondence. appeared to have reached the eighth or ninth month of gestation, were extracted. Her To the Editor of the CANADIAN JOURNAL OF MEDICAL SCIENCE. health then improved, the discharges became less offensive, and the uterus gradually shrank, as in ordinary involution, but more slowly, until it reached the common conditions of the COUNCIL EXAMINATIONS. SIR, Will you kindly permit me to express through your columns the regret that many medical practitioners feel at the ill-advised step non-pregnant state, and the patient perfectly taken by those students who have been unfor recovered. The author submitted that this was a clear instance of the retention of a foetus dying in utero at a viable stage, for some months after the normal term of gestation had been reached; and that in this sense the term "missed labor" might apply. EXCORIATIONS AND FISSURES OF THE NIPPLE. -Prof. Gio. Simula, 1880, Sassari, in a memoir on this subject, establishes the frequency of such troubles; 30 per cent. of nursing women being affected, according to Hinkel, 20 per cent. according to Schraden. The nipples are ordinarily affected in the first days of nursing, but rarely later on. The causes are generally want of cleanliness, aphthæ in the mouth of the children, and the continual suction, which acts, says Joulin, like permanent cupping; the nursing of a child several months old sometimes induces these troubles. The accidents are of gravity, or not, according to the intensity of the inflammation. The pain may be so excessive as to induce convulsions; the inflammation may extend to the mammary gland itself, whence abscess in this organ is accompanied by high fever. The nipple may be completely destroyed, and the resulting cicatrization prevent nursing thereafter from that breast. As preventive treatment, Professor Simula, prefers lotions of pure water to the astringent washes recommended by Trousseau and Cazeaux, which, in the end, he is persuaded cause the exfoliation of the epidermis. Against fissures of the nipple he recommends lotions of glycerine in a solution of bicarbonate of soda, (Startin). He considers the application of compresses wetted in pure water, over the parts, as the best treatment in these affections, allowing the child to nurse as seldom as possible.-St. Louis Medical and Surgical Journal. tunate before the Council, in seeking comfort in the columns of the daily press? There can be but one course to pursue for any one having a real grievance, in order to get redress, and that is to bring the subject before the notice of the Council in proper form. There is no difficulty in doing so, nor from past experience can any one complain of harsh injustice in the rulings of the Council. It is certainly very questionable taste to vilify examiners, and publish insinuations, before the possibility of a proper investigation; while the prejudice thus excited may be fatal to that calm consideration the question merits. If any good whatever can proceed from the acrimonious correspondence the public has been lately treated to, it appears to the writer to lie in the propriety of the Council at its next meeting considering the advisability of doing what there is good example for elsewhere, that is, granting a supplementary examination each year to students who have passed in three or more branches, to take place three months after the first examination. It is also to be hoped that the farce of holding examinations in two places may be done away with. The absurdity of the present state of affairs in this respect is too manifest to require more than passing notice. How would the College of Surgeons of England treat a proposal to have its exminations held in Oxford, or Cambridge, or wherever else there might hap MEDICAL COUNCIL EXAMINATIONS. There was great excitement in Toronto, on the 2nd of May, among a certain class of Medicos, "when news of 'Sullivan's' victory came." On making inquiries, we found that about 57 per cent. of the candidates at the Council Examinations had been rejected, and we were very sorry to discover at the same time, that a few of the best students of the Toronto Schools were so unfortunate as to be included in the "black list." Some of these reached a high aggregate (from 70 to 80 per cent.), but came below 40 (or more correctly, under 38), on one subject, and in consequence, were rejected; not for the whole examination, however, but for that subject on which they received the low marks. It adds a very unpleasant uncertainty to the results of examinations, when a certain number, who receive a high average of the marks should be rejected, while others, well known to have less knowledge, should be passed. There is, however, such an element of uncertainty in all examinations, which we must acknowledge, even though we very much regret it. assumed some discretionary power, and reduced the minimum to 40, or as low as 38. We think ample justice would have been done this year if the minimum had been reduced still lower. The Council might safely adopt the percentage required by our National University, i.e. 50 per cent. of an average on the aggregate, and 33 per cent. as the minimum on any one subject. This is considered a high standard, and certainly would seem so by comparison, when we consider the fact that it is only a few years since the Senate of Toronto University required simply 25 per cent. on all subjects. We believe, as a matter of fact, that such a standard is quite as high as is, required for a simple pass, in any part of the world, and certainly higher than the average. At the present juncture, having confidence in the honesty and ability of the examiners, we think the Council is bound to stand by their decision. Any other action would make the whole examination a sublime farce, and afford direct encouragement in the future to all rejected candidates to abuse, bulldoze, and "petition" againt any examiners, who might have the temerity to pluck them, even though they richly deserved it. At the same time we would feel glad, if a special examination could be given, during the summer or fall, to those who obtained exceptionally high marks on the aggregate, but came a little below the mark on one subject. One of the most unpleasant features of this excitement about the results of the examinations, is the fact, that grave charges have been made against Dr. Sullivan, of Kingston. There is always serious ground for suspicion as to the impartiality of a jury of rejected candidates, who meet in solemn conclave to discuss the This year there appears to be a hardship in merits of their examiners. We were deeply a few cases, and we think that in the future grieved to see in the daily papers a report of a such accidents might be avoided, if the Council meeting, held in Trinity School, on the 2nd of fixed a definite and reasonable rule, with refer- May, at which statements were made to the ence to the standard required from the candi- effect, that Dr. Sullivan had previously dedates. There has always been a mysterious termined to pluck as many men from Toronto vagueness about this subject. At one time 60 as possible, and conducted his portion of the per cent. was required for a pass without an examination with this object in view. The tone oral," and now there appears to be some doubt of the rejected was so extreme, that the public as to whether 50 or 60 be the required percent-press of this city, both disapproved of it and age; and to add still further to the perplexity, ridiculed it. While duly respecting the feelings the Examiners have (very properly we think), of candidates to whom the rejection was a matter of very serious import, we feel sorry, that when deciding to petition the Council for favours, they should place themselves in a false position, by making unjust accusations against one of the Council's examiners. In olden times we were accustomed to attribute deficiency in knowledge of the subject as a common cause of plucking, but such a contingency seems not to have occurred to the late rejected. They appear rather to have condemned Dr. Sullivan at once, when the results were known, and afterwards proceeded to search for evidence to prove his guilt. It is stated that paper with a different colour was used at Kingston, and in this way he was able to dis tinguish the Kingston from the Toronto men. In addition to this, we are told that the results show that the Kingston and Montreal men received higher marks in Surgical Anatomy than the Toronto students. From these facts, supposing them to be such, they jump at once to the conclusion, that Dr. Sullivan deliberately gave his own students high marks, and the Toronto students low marks, in order that he might pass the former, and reject the latter. If we supposed this to be true, we could only designate it as a criminal act, more malignant in character than any that has come under our notice in the history of examinations. If the members of the Council entertain any suspicion of the possibility of such a procedure on Dr. Sulivan's part, they can very easily investigate the matter by examining the papers of the different candidates, which, we suppose, are now in the Registrar's possession. We published the final questions in our last issue, including those on Surgical Anatomy, and our readers can judge for themselves as to their character. No question is asked on any subject which is not taught in any ordinary course of Anatomy and Surgery. It is true, the students, who attended Dr. Sullivan's lectures on Surgery, may derive some advantage in being examined by their own lecturer; but even if we admit this, it does not necessarily follow, that the students of other schools, who knew their Surgical Anatomy should be rejected on a paper that contains no "catch" questions. We now come to the important question in this discussion: Do our students pay sufficient attention to the study of Anatomy? We know, to our sorrow, that in the past they did not, and we have reason to think that they do not even now spend sufficient time in the dissectingroom, where alone it can be properly learned. It is too much the fashion to rush through their dissections as rapidly as possible, and then depend on Gray, whose only redeeming quality lies in its excellent plates, while its general arrangement is as vicious as anything that could be conceived for the student, who wishes to learn his Anatomy perfectly, and has to undergo a practical examination on the dead subject. The schools are not at fault. Every facility is given to the students to dissect under thoroughly competent teachers, and while many make the most of their opportunities, others do not, because in the past they have found that they could manage to pass, and even get high marks by book-work alone. In the old countries, where the examinations are essentially practical, the students spend more time in the dissectingrooms, in the first place dissecting themselves, and sometimes watching the work of others, receiving direct instructions from their demonstrators, and also listening to the demonstrations given to others. They continue at practical work up to the day of examination, on pickled specimens, dried specimens, wax or plaster preparations, skeletons, &c. As a matter of fact, Anatomy can be taught here as well as in any place at the world, but a large number of our students pursue their studies simply with the dreaded examinations in view, and endeavour to get through these with a minimum amount of work. The Council, in their honest efforts to raise our standard, appear to have appreciated this fact, and decided to make the examinations thoroughly practical. Dr. Sullivan has, in our opinion, endeavoured to carry out the instructions he received faithfully and conscientiously. We regret the rather disastrous results, which, as before pointed out, we consider to be due to the high standard required, and to the fact that the students have not been accustomed to examina. tions so practical as those held this year. It should be remembered that Dr. Sullivan was not the only examiner who rejected candidates, as the following figures will show: |