Closure of Vagina. Editor MEDICAL WORLD:-On page 323, July number, Dr. Reed, of Iowa, reports a case of closure of vagina. As I have had a similar case, I will tell how I disposed of it. On November 24, 1902, I was called to see Mrs. F., primipara. Husband said she was suffering very much. When we arrived a ninepound boy had been born just before I got in the house. Baby died in four days of pneumonia. The mother did well, as I heard nothing to the contrary for seven weeks, when the husband came to me to "fix things." When I examined her I found that the vagina had closed up completely, as smooth and solid as the palm of her hand. Not knowing what else to do, I took an ordinary bistoury and made an incision in median line, cut thru about half an inch of solid and firm tissue. I cut down to the proper depth. Did all with due antiseptic precautions, put in iodoform gauze, and had it changed every day for ten days. She made a good recovery, and is four months in another pregnancy.

This was the first case of the kind I ever had seen or heard of. I think if Dr. Reed will treat his case as I did mine he will get good results, and the husband will call him blessed, and the wife will say amen. Success to THE MEDICAL WORLD. I like it better than any journal that comes to my office.

Parker, Texas. J. T. WATSON, M,D.

Memphis, Class 1897.

Obstetric Notes.

Editor MEDICAL WORLD:-I write this for information: On page 310, "Puerperal Eclampsia" footnote, you say: "You should have seen patient and examined her urin, etc.' Where a patient lives from one to six miles from office and the charge is from $10 to $25 for attending, and the physician has to make three visits after delivery, how can he go and see a patient and examin urin, etc., for nothing? I think eight out of ten cases would object to pay for such services. I often examin urin when I am suspicious, but find that the majority expect gratuitous treatment for same. What is the remedy?

I cannot for the life of me see how some physicians have such large obstetric practise and never have to use forceps. They must get the selected cases. I know for a certainty that in some of the cases I have attended in the last eight years it would have been impossible to deliver without them unless cesarean section had been performed. I use "Tarnier's axis traction," and find them a great boon when necessary. Whenever I can I always get along without them. I never use ergot except when uterus is empty. I give cimicifuga to

I had the prescription filled, and have tried it since in a number of cases with perfect success. Last week I delivered a primipara, breech presentation, weight of child ten pounds, without laceration; and, in fact, all of the primipara cases I have used it on have not been lacerated (except a forceps case, slight). Only objection I find is that it smarts for a minute or two.

I have had a chance to become a full fledged member of some of the gilt-edged hospitals and have my name appear in gold letters, etc., to hang on the wall of my office, but I have had my eye teeth cut some time, and thanks to THE WORLD, I am on to such stuff. I think the majority of these swindlers must think the doctors dead easy by the way they stock us up with all kinds of money (parting)

schemes.

Saltpeter for Gangrene.—Triplets, with One Placenta.

Editor MEDICAL WORLD:-I have been a reader of THE WORLD for some years, ard have not as yet contributed much to make it the interesting journal that it is. Thinking it not the better way to shut one's self up like a clam and give nothing to benefit the profession, I wish to speak of a remedy which, so far as I know, is original with me. Case, man, age eighty one, gangrene in foot. When first seen by me little toe and front of foot were black and dead. Disease spread rapidly until the entire front of foot was involved. Amputation not advisable at any time on account of condition of blood vessels and general debilitated condition of

AUGUST, 1903]

patient. Remedy: I dissolved about one ounce of saltpeter in about a half gallon of water, wet the dressing in this solution, and ordered that it be kept constantly moist with solution. Result was as follows: Line of demarcation formed, over which the disease did not appear to pass. The patient died, as I had expected he would. I flattered myself that my treatment was a success, even if I did lose my patient, like many of the successful surgical operations we read about.

Second:-Male, aged about seventy, gangrene in toe, which I amputated, and used dressing as in Case 1, with perfect recovery. In latter case patient was in much better physical condition in every way. I do not report the above to boast of a discovery, but to call attention to this treatment, with the hope of having others try it and report success or failure in WORLD.

Some time since I attended Mrs. W. in labor. Nothing unusual about the case except in number of children: three, all boys; one placenta, all three cords entering this one placental mass. Now, what I want to know is, is this usual or unusual, to have one single placenta when three or more children are born at the same labor? Will those who have had experience in this line turn Methodist for the time being and get right up and give in experience ? J. O. MORROW.

Lisbon, O. Mother, Aged Fifteen Years; Baby, Weight Fifteen Pounds.

Editor MEDICAL WORLD:-On the night of April 17 I was called to see Mrs. G., aged 15 years. Found patient in labor; os dilating; presenting part of child unusually high; physical condition apparently good. Labor continued with some little remissions with very little progress until the morning of the 21st, when to the utter astonishment of myself and all present, she was delivered of a fifteen-pound boy; and to my great satisfaction without laceration! think of it: a fifteen-year old girl delivered of a baby the size of two in one. Patient made a speedy recovery. Mother and grandmothers were very much concerned about the child's head, which lookt more the shape of a smokestack than a child's head; but all soon came right. ONSLOW REAGAN, M.D.

Alexander City, Ala.

Retracted nipples may be made more prominent by surrounding them with a broad band of flexible collodion painted on in several layers so that as it contracts, the skin of the areola is drawn and puckered. They may also be drawn out temporarily for a single nursing by heating a bottle so that the contained air becomes rarified, when the neck of the bottle is applied over the nipple, and as the bottle cools the nipple is drawn into the neck. The elongation continues for a time after removal of the bottle.

353

Morphin and Chloroform to Increase Labor Pains.

Editor MEDICAL WORLD :· -I am using the forceps less every year, believing them to be a mischief maker. The usual plea of the physician to use the forceps is a contracted pelvis. He tells his patient that she is built too small on the inside and baby cannot be born without the use of forceps. He gives chloroform, applies forceps, compresses the skull and very often, if child is not killed, injures the brain and tears the perineum. Sometimes two years after a forceps delivery this same woman who is built too small on the inside" has another baby with two or three labor pains-in fact, quicker than it takes the doctor to get to her, on account of a previously torn perineum ; and in later years, if both children are living, the chances are that the forceps child will be stupid, and the nonforceps child will be bright, while the mother will be suffering with a case of procidentia, a reminder of the man who used his "oars too vigorously. I think such a man ought to be "perplext. I know of a number of such cases in other doctors' practises. Of course, every physician will say he knows how to use the forceps. I say I do. Whenever I use them I use them to overcome the rigidity of the perineum and pelvic muscles. I have never had a case of contracted pelvis. I believe it to be exceptionally rare. If you do not compress the child's head with the forceps, you add to the diameter of the child's head; and if you make vigorous traction something must give, and usually it is the perineum.

At the present time, in ordinary cases, I wait until the membranes rupture and pains get severe; and instead of using forceps I give grain 1⁄2 and sometimes grain j of morphin, with grain of atropin by the mouth, and instruct patient to hold her breath and bear down hard when she has a pain; and about an hour before head is born I give a few drops of chloroform by inhalation after each pain to rest and quiet the patient; and as the head advances and shows on the outside, I hold it back and retard progress so as to give perineum plenty of time to relax, and after head is born I hold the shoulders back, and deliver one at a time, slowly, and very often I do not even have a tear of the fourchette.

The morphin and chloroform diminish the pain and misery, and enable patient to bear down with more vigor and thus increase the strength of the uterin contractions; and child is born as quickly as when forceps are used, and with better results. I have had one case of eclampsia. I applied the forceps and gave sufficient veratrum hypodermically and by the mouth to control the convulsions. In this case

Editor MEDICAL WORLD:-Several contributors rather boast of not using ergot. It is doubtful whether there is any remedy more rationally used than this when given just at birth (not before) to act on the uterus and avert hemorrhage. Dr. Beuneti is right also, in combining it with cinnamon (page 253), but the ergot is the more important. Why a practician should boast of its nonuse or of inability to handle forceps is not easily explained. A pair of forceps cost only slightly more than a pair of oars (to rest on), and are more serviceable.

Does "causticum" (page 276) always cure whining? It seems to have been given for this, but brought "a full-time boy." I don't consider that aconite should be given often in typhoid (page 264), except in some incipient cases with symptoms unusually sthenic. June number was exceedingly good. Leavenworth, Wash.

J. E. SHORE.

Management of Feeble Labors. Editor MEDICAL WORLD:-One of these cases occurred only day before yesterday. It was a dry labor, primipara, and patient had had pains for eighteen hours before I was called. When I saw her the head was engaged in the upper strait, pains coming on every five minutes, but not strong. I gave her ten grains of quinin, and after half an hour another ten grains. After waiting an hour, pains not being satisfactory, I gave her grain strychnin arsenate. After an hour or so pains came on stronger and every two or three minutes, and the head had come down a little. Now I gave her a little chloroform with each pain, encouraging her to bear down, at the same time my two fingers were in the vagina, stretching the tissues, so that when the head came down it would find them relaxt (and I will say right here that I have had only about half a dozen torn perineums in five years). As progress was still slow, I gave her another ten grains of quinin. After an hour the head was in the cavity of the pelvis, but the pains were feeble and short. After waiting for two hours more and finding that no progress was being made, altho the tissues were well relaxt, I applied the forceps, and with the next pain the head was born with but slight traction on the forceps. The body soon followed, and the tedious time was over, after I had been with her for seven hours.

I do not report this case because there is anything remarkable about it, but because it shows that there are cases where the forceps are indicated; but I also believe that these cases are rare, as they surely have been in my practise.

One more word in regard to quinin to stimulate labor pains: I find it very efficient as a rule, but I have also noticed that there is more bleeding after delivery when I use it than when I do not use it. I do not believe this is due to the quinin, but believe the excessiv bleeding can be explained in this way: When the contractions are good and strong we do not need quinin; after the child is born the uterus continues to contract firmly, and consequently we have no bleeding. When the contractions are poor and weak we use quinin; after the child is born the contractions are still weak, the uterus is flabby and relaxt, and we have bleeding. For this reason I always use ergot or hydrastis after I have used quinin in a case of labor, and I have never had a postpartum hemorrhage follow any of my cases, nor even very much bleeding after a few days. I keep up the hydrastis for several weeks. Adell, Wis.

WM. L. GOETTE, M.D.

Probably Not Maternal Impressions. Editor MEDICAL WORLD:-I noticed in June number, page 274, a report of a case of patella in popliteal space, thought to be due to a maternal impression, by J. R. M., Nona, Tex.

This is a subject of which we know but little or nothing. or nothing. We only form our ideas and opinions from a few cases which we may be fortunate or unfortunate in observing during a life time of practise. There are many cases which seem to prove the maternal impression theory beyond a doubt; but looking at the subject from another standpoint it hardly seems that it could be true. Most all women are taught the idea, and most women during gestation are of a more nervous character than they are before conception. This being true, any thing that might happen out of the ordinary is more fully imprest upon their minds. Where is the pregnant woman who in 280 days will not see a cat or dog fight, or some kind of an anomaly? There are but few. The woman being in an impressionable condition, and having been taught the idea of maternal impressions by her mother or some physician, these occurrences are more fully imprest on her mind. Then, when the child is deformed in any way, the mother looks back over the nine months' gestation to see what has happened that would cause the condition, as in two cases which I will endeavor to report.

Case A. A few years ago a dog bit one of a pregnant woman's children. When the child was born it had a club foot, which the

I do not agree as to the shape.

Case B. A mole was dropt into a pregnant woman's lap unexpectedly, which frightened her. When the child was born it had six toes on each foot and a spot of hair on left forearm. They claimed the hair to represent a mole, and the toes to represent a mole's foot, as a mole's foot has six toes. Otherwise the child was perfectly formed. Since that time the same woman gave birth to another child which had six toes on each foot, six fingers on each hand, had no lips, no nose and no ears, and eyes in top of head without eyelids. What did this one resemble?

Mrs. B., the lady which Dr. M. reported who gave birth to a deformed child, was an unfortunate woman, and the crooked-legged mule was the most appropriate thing she could think of as a cause. As to deformities, malformations or anomalies, my opinion is that there is simply a disarrangement of the cells set apart for a certain portion of the fetus, or an excess or diminution in the number of cells for a part, caused by an imperfect arrangement of the mechanical structures of the nutritional elements. It may be probable that this could be due to the disturbance of the nervous system by these unusual occurrences which may take place in the sight of the pregnant woman, but I do not think this is true. Bonicord, Tenn. I. N. FROST, M.D.

Practical Points in Use of Forceps. Editor MEDICAL WORLD:-Quite a discussion has run thru the columns of THE World in regard to the use and abuse of the obstetrical forceps. Without going into detail, I will only say that ultra views are dangerous. The safe and skilful obstetrician has in his make-up the blending of two qualities: Conservatism and aggressivness; conservatism which prevents meddling in normal labors, and aggressivness which leads him to promptly lend a helping hand when nature proves inadequate to the task.

One point to which I wish to direct special attention is that some in the discussion have advocated the removal of the forceps as soon as the head distends the perineum. In my judgment this should never be done, for when we have full and absolute control of the progress of labor why relinquish a certainty for an uncertainty? The utility of the forceps is never more apparent than as a perineum saver. The occipito-mental diameter of the fetal head is thereby increast, while the bi-parietal is diminisht; and should the perineum be rigid and the labor somewhat precipitous, we cannot in any other way so well retard the rapidly-ad

the pubic arch as with the applied forceps.

Another point I wish to emphasize is that while most obstetrical operations can be performed under cover, yet when we have a forceps case, especially in a primipara, and the perineum is much distended, we can much better and safer gauge the amount of force and tension to be allowed to be put upon it by watching it. In this way I have repeatedly kept the perineum intact when it was stretcht as thin as paper and rupture seemed inevitable. L. B. ALLEN, M.D.

Mt. Pleasant, Iowa.

Graphic Description of First Labor Case.About 700 Forceps Deliveries in Total of About 1,600 Cases.-Treatment of Abortions.-Foot Presentations.

Editor MEDICAL WORLD:-Nature will deliver eighty-six cases out of every hundred if let alone. Then, is it a good thing in obstetrical practise to let the woman twist, howl, rave, and scream like a hyena? Let us use just a little common sense along this line and see if we can find any good sense in sitting by the bedside of a normal case of labor and let the patient suffer for six or ten hours, when she could be delivered in fifteen minutes without any harm to herself or the child. There is no possible danger that can take place up to the end of the first twenty-four hours of labor; if labor is not complete then, there is something wrong and it should be righted. Now, if we are determined to give Nature a chance, the doctor is not needed until after the first twentyfour hours of labor. See the point?

True, Nature goes a long ways with many people. Once it did with me. When I began the practise of medicin in 1882, I was called on the second night, about two o'clock a.m., to attend a primipara. She was rather tall and well developt, age about twenty, and rather on the buxom order. On arriving at a little clapboard shanty, I attempted at drying myself, having traveled some six or eight miles in the rain and terrific squalls of wind, accompanied by lightning that kept the firmament almost in a constant blaze. With great trepidation and misgivings I finally made my start to where the woman was concealed under an old patch-work quilt of many colors. When she saw my movements and evident intentions, she absolutely refused an examination per vagina.

I resumed my position before a little pinepole fire and wondered what was the best thing to do. After sitting there and watching three old women smoke for an hour or so, all of a sudden an extra hard pain got in its work, and she said if I was going to do anything to help her it was time I was at it. Before I could get

hold of any lard or vaselin to anoint my fingers, she concluded to sit up awhile and rest in an old woman's lap; but she had no sooner found an easy place to sit till another hard pain began to play over her abdomen, and she cried out for help. I made a dash for the sure-enuf thing that time, but being somwhat excited, I passed my hand along the first leg I found, which proved to be the other woman's!

By some means the old woman managed to get the patient back to her bed, and insisted on me making another examination while the patient was lying down. Thinking the change of position might have some bearing as to its whereabouts I readily consented, and found this time a large hard substance pushing in behind the bladder, as I thought, and perhaps due to my neglecting to draw the water off at the proper time. However, I felt excused, as she seemed so wild and flincht like a young mule when about to take it by the bit. I made now several ineffectual attempts to replace it between her pains, but come it would. I then concluded to change my procedure and lunged my whole weight against it during a hard pain, when to my great surprise the whole thing burst! which scared the woman half to death, and scared me even more. Thinking it best to understand the exact status of affairs now, I passed my fingers against the head; but, to my great consternation, it felt just like a piece of well oiled sole leather. Here, again, I was at sea without a rudder, and it appeared that I would certainly lose my reputation before 1 had time to make it. I thought now the head had not only ruptured the bladder, but it had also hookt itself completely under the cecum and was bringing that along, too. I tried several times to skin it back, but it was all in vain; it seemed to be in front, and every time I pusht, it would crack like a pasteboard box. Before I had time to think, labor began in earnest in that shanty, altho I was doing my level best to protect the cecum, and did I guess, because after the head was born I searcht carefully for it. I never could find it.

The patient now snatcht me in her arms and squeezed me several times for saving her life! With a supreme effort I managed to extricate myself and sever the cord, feeling all this time like a monarch of all I surveyed, having stept with one prodigious stride from what you might call a civilian into the front ranks of the scientific medical profession. After stowing the baby away and giving proper (?) instructions as to the mother, during a great wave of happiness and relief that welled up in my soul that seemed to fully repay me for my work, I was about ready to take my leave when an old woman askt me if I had "cleared her." I had never heard the expression before, but hap

pened to think that I had forgotten to remove the placenta. I told her not yet; that I was waiting, as all scientific doctors do, for the womb to contract and avoid hemorrhage.

I now composed myself as best I could, but I began to get very jerky indeed. I took hold of the cord and began to pull, and I could feel the fat around the cord giving way. I tried to pull it in every direction. but it seemed to remain stationary, despite all I could do. By this time my hair began to stand on end, and I could imagin I could hear the clapboards rattling above my head, when an old woman told the patient to "fist up her hands and blow in them." She did so time and time again while I pulled at the cord. By some means the cord broke. I managed to get about eighteen inches of it. Now, I thought sure it would bleed her to death, as it had broken behind where I had so carefully tied it, and believing it meant death anyway, I shot my hand and arm in after it, believing the womb would take my hand as easy as giving birth to a baby, and the old women could not tell what I was doing under that patcht quilt anyway. I found enuf of a fleshy substance to hook my finger in, and I held to it and brought it out, altho I thought several times of letting it go, fearing it might be the womb or other parts of the general make-up which I was not able to tell. patient said she knew the afterbirth had grown to her side by the way she felt during the time of carrying the child; and I told her it was the worst case of attachment I ever saw, and only by the greatest skill used in its management her life was saved; and that was the reason I had postponed it to give her time to recover from the shock.

The

The patient and trio of old women passed the highest compliments on me. Being now much wiser so far as obstetrics are concerned, I mounted my gray steed and was soon wending my way homeward, feeling equal to any emergency.

Now, while I believe in giving Nature a chance, I never allow my patient to suffer unnecessarily. True, there are many people who believe in Nature taking its course.” To all such I just let Nature take its course. It is entirely left with them; I would just as lief stay a day or so with a case of confinement as not if they feed well. I charge according to time employed in such a case, and never make extra charges for the use of the forceps in ordinary cases.

I never let a woman suffer over one hour after the second stage of labor sets in if I can get her consent to have the forceps used, and I always manage to gain her confidence sooner or later. In my practise where I have used them, they always insist on me using them and get