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The doctor does not tell us that he corrected the position at all, but simply ruptured the membranes, applied the forceps and delivered. "Unless rotation occurs, delivery of a fullsized head thru an average pelvis is practically impossible," says Playfair. That the child was only "seemingly dead" after being delivered in a mento-posterior face presentation and not quite dead is a miracle to me, and if the mother was not torn all to pieces, of which he says nothing, is another one.

Following the report of this forceps case I read of a case commencing as follows: "Mrs. B., 22 years, primipara, saw her at 3 a.m.; everything seemed natural, pains regular and strong. Membranes ruptured naturally, head of child prest and bulged perineum at each pain, but at the end of the pain it would jump or be jerkt back under the pubic arch. This condition continued nearly all day," etc.

Now, after this man had allowed this condition to continue nearly all day, resting on his oars I suppose, or meditating on the sixteenth verse of the third chapter of Genesis, where it says: "Unto the woman he said, I will greatly multiply thy sorrow and thy conception; in sorrow shalt thou bring forth the children," etc. "After this condition continued all day" the doctor seems to have popped the question to himself: what am I here for, anyhow? Then the picture of his forceps, that he had used four times in twentyfive years, loomed up before him; but he had left them at home! What does the doctor do now? He makes a hook of his finger, introduced into the rectum, and with the aid of the other hand on the occiput he makes a little traction on the child's head and keeps it from "jerking back." By this means he succeeded in delivery, after how long time he does not state. After what he seems to consider a brilliant success, he exclaims, "now if I had had my forceps, I would have played the dThen the doctor cites Davy Crocket's motto: "Be sure you are right, then go ahead." If he had brought his forceps with him as he should have done, and had gone ahead to deliver the child as soon as the child's head ceast to advance, pains being regular and strong, as he states, then he would have been right.

To go

to a confinement case and leave the forceps at home I consider to be criminal neglect. It is no wonder that he used his forceps only four times in over twenty-five years, when he thinks he would have been playing the dif he had used them in such plain, imperativ indications. He might have saved the mother hours of suffering, and would have lessened the danger of asphyxia of the child, and the chances of bruising or lacerating the mother's rectum with his finger.

I have stated before, and herewith reassert, that I lost only two children out of my seventythree delivered with forceps. One of these two happened in a case like the one under consideration. In my case it was a midwife that had been resting on her oars, or fingering around about the woman's rectum, for over twenty-four hours. The woman was delivered in less than fifteen minutes after I made an examination and heard the history of the case. The child was born asphyxiated, but I kept it alive for over two hours, when I was called away. Had they persisted in following my instructions, I believe the child would have been saved.

When delivery is delayed in consequence of shortness or entanglement of the cord, expression alone is frequently all that is necessary to force the child thru the vulva.

St. Louis, Mo. H. L. STAUDINGER, M.D.

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Forceps in Breech Presentation. Editor MEDICAL WORLD:— :-Your comment on Dr. Lloyd Reed's article, July WORLD, page 323, has led me to report a case of confinement which I was called to attend on the night of September 9, 1901. I examined the woman and found the cervix well dilated. I broke the bag of water, examined further, and found that I had a breech presentation to contend with. I "rested on my oars" for a reasonable length of time, and no progress being made, I concluded to apply the forceps, which I did, delivering her without much trouble of a ninepound boy, which I handed to the nurse. then went back to the mother, broke another bag of water and delivered her of a seven-pound girl, also a breech presentation, but without the aid of the forceps. I then exprest, by the Credé method, the largest placenta I ever saw. This was followed by a severe postpartem hemorrhage, which I controlled by ergot and hot injections. Mother and children did well. I couldn't do without THE MEDICAL WORLD. It is the most practical journal I take. Elderton, Pa. C. E. KEELER, M.D. [Did you have a boy and a girl (twins of different sexes) and only one placenta?—ED.]

Forceps to the Breech.

In all cases of breech presentation every means necessary for the restoration of suspended animation in the infant should be provided beforehand.

In cases of unusual delay during early stages accompanied with symptoms of exhaustion, and due to a large breech, small pelvis, or some other abnormity, a finger, blunt hook, or fillet may be passed over the groin and used for traction, the traction being directed toward the child's sacrum rather than toward its thigh, thus lessening danger of fracturing the femur. If possible to reach a foot, it may be pulled down. Forceps and the vectis have been employed; their use is questionable. They may be tried, however, before embryotomy, which may, very rarely, become a last resort in bad cases of impaction.-King's Manual of Obstetrics, last edition, just out, pages 302 and 303.

Plural Births and Plural Placentas. Editor MEDICAL WORLD:-On page 353, August WORLD, Dr. J. O. Morrow, of Ohio, mentions a case of triplets in which there was but one placenta, and adds: “Now what I want to know is, is it usual or unusual to have one single placenta when three or more children are born at the same labor?"

In his Manual of Obstetrics, King says each ovum usually has its own amnion and chorion, tho they may have a common amnion with individual chorions. If there is but a single chorion the twins are of the same sex. Neither King nor Parvin makes any reference to the arrangement of fetal appendages in triplets, but, of course, the same rule in regard to the chorion would hold good in the latter as well as in the case of twins.

Dr. Morrow's triplets were all of the same sex; there was but one placenta, and since the placenta is formed chiefly from the chorion, it is natural to conclude that this was a case of a common chorion.

As before mentioned, it is stated by good authorities that where a common chorion exists, the children are of the same sex. Dr. Morrow's case would tend to verify this statement. The following case has, however, raised a question in my mind as to whether the above is invariably the rule. On the 30th of last May I was summoned some four miles distant to attend Mrs. B. in labor. As I entered the room I was struck by the enormous size of the patient's abdomen, and remarkt that there were appearances of twins. The patient replied that her friends had frequently exprest the same opinion. In answer to my questions in regard to her labor pains, she told me they were not so severe now, but that she had had several severe pains about twenty minutes or one-half hour before.

I then proceeded to make an examination, but what was my surprise to find a head completely born, and yet the mother and attending women were unaware of it; this explained the meaning of those hard pains a half-hour before.

The child was immediately delivered; and now feeling certain of twins, I applied two lig tures and cut the cord between them. The baby was a well-developt girl of about five pounds or five and one half pounds weight, but was dead and had apparently been so for several hours.

The second child presented head foremost but refused to engage properly in the superior strait, owing to a slight obliquity to the right and consequent infringement of the head upon the pubic ramus of that side. After several hours of fruitless endeavor to effect a proper position, the forceps were applied and a four (?)

pound boy delivered, considerably shriveled, rather poorly developt, with cyanotic hue and delayed inspiratory effort. In order to promptly carry out resuscitating measures, time was not taken to tie the cord, but it was clampt with hemostatic forceps and immediately severed. The child was soon revived and was placed in the care of one of the attending women, while I turned my attention to the patient.

I still found the womb so distended and firm that my suspicions were excited, so I again washt up in preparation for a vaginal examination, upon making which the examining finger came in contact with another head. All pains and expulsiv efforts seemed to have ceast, and as there was considerable hemorrhage, twenty minims of fluid extract ergot were given, and the same dose repeated in half an hour; this in addition to massage of fundus uteri. As the patient was becoming very nervous and excited, she was given fifteen grains each of chloral hydrate and potassium bromid, with one-eighth grain each extract hyoscyamus and cannabis indica. Chloroform could not be tolerated owing to dyspnea.

Suddenly without giving time to rupture the bag of waters, violent expulsiv efforts came on and the child was shot forth with appendages intact. I quickly attempted to rupture the sac, but it seemed exceedingly tuf; so, after wrenching at it a few times, I siezed a grooved director and plunged it into the sac and liberated another girl about the size of the first one, well developt, but apparently dead. There was no perceptible pulsation of cord; but thinking I possibly detected a faint fluttering of the heart, I clampt forceps on the cord, severed it, and began Schultz's method of resuscitation, while the father got buckets of hot and cold water into which the child was alternately plunged. These measures, together with flagellation and blowing in mouth, were of no avail; however, during the expiratory pause in practising Schultz's method, a considerable quantity of fluid resembling liquor amnii flowed from the nostrils and mouth. This fact leads me to believe that inspiratory efforts were made before the sac was ruptured, and even before birth, since the interval between birth and the opening of sac was so brief that more signs of life would have been manifest if inspiration had occurred subsequent to birth.

Soon after birth of the third child the placenta belonging to the first two babies was born. Both cords were attacht to it, and it was apparently a single placenta from its origin, there being no evidence of its having fused. Now the first two babies having had a single placenta in common, I am led to believe they had a common chorion, and

possibly a common amnion, since there was no evidence of a "bag of waters" for the second child; and yet, contrary to authority, they were not of the same sex. That it was the boy and girl to whom the placenta belonged and not the two girls, there can be no doubt, since the third child (girl) was born with appendages intact.

The boy is living and doing well. The mother also progrest favorably, altho thruout her pregnancy she suffered from shortness of breath and much of the time from impeded

venous circulation, and at the time of her confinement there was markt edema and dropsy of her limbs. She was a multipara, having two living and healthy children. Twins were hereditary on the father's side, who was himself a twin and had a number of relativs who had given birth to twins; no history of triplets on either side.

It is generally stated that triplets seldom go to full term. This case lackt but ten or fifteen days, and the babies were completely developt. Full term might have been reacht had the mother not done a large washing on the 29th.

I presume some of your readers will contend that the precipitate birth of the third child was due to the small doses of ergot administered prior to its birth. This, however, I am loth to believe, for after the labor was entirely completed a dram of fluid extract ergot was given, and even then prolonged and vigorous massage of the uterus was required to secure the contraction necessary to insure safety from hemorrhage. Ergot is totally condemned by many, but I believe it to be a most valuable drug, not only for the purpose of securing firm contraction and retraction of muscular fibers as a guard against hemorrhage and to give the organ a good start toward the process of involution, but I am convinced that when properly given it is of great aid in the third stage of labor, when protracted. Large doses given at the close of the second stage undoubtedly retard, in the majority of cases, the completion of the third stage, owing to the contraction of the uterus in its entirety without leaving sufficient opening for the exit of the placenta; but given in small doses, say five minims or ten minims, repeated in twenty minutes, the fundus will generally contract nicely while the lower uterin segment remains relaxt, leaving ample room for the expulsion of the placenta. In hemorrhage from the womb other than postpartum hemorrhage, digitalis will frequently be found to be of more service than ergot, since the latter drug does not have the quality of contracting the capillary vessels in so markt a degree as does digitalis.

Will some of the WORLD readers suggest a means of securing healthy tissue in place of the

sluggish, blue, indolent tissue overlying incised or broken-down tubercular glands? Floris, Iowa. L. M. Lowe, M.D.

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Cord Seven Times about the Baby's Neck. Editor MEDICAL WORLD:-August 1, at 6 a. m., I was called to attend Mrs. P., aged 24, primipara, in confinement. Patient had been restless during most of the previous night until 3 a. m., then the pains began to come about ten minutes apart. I found os dilated, and go." When I arrived the pains were sac intact, head presentation, first position. About 8 a. m. the sac ruptured. I administered chloroform. The case progrest very

nicely and at 10.30 a. m. a violent pain would have brought the head had I not held it back to save the perineum. The next pain was so severe that the head, shoulders and all came into the world. The cord was around the

baby's neck seven times. There was no pulbeat in the child. It was dead. On examisation in the cord, no respiration nor heart nation I found the placenta in the vagina and removed it. The cord measured forty-six inches in length.

I have never before had a case where the cord has been more than twice around the the cord was five times around the neck. neck, and find only one case recorded where

and ceilings of four rooms last May, and it has The patient and her husband papered walls. been suggested that she reacht up too much. Could that have had anything to do with the case? CARL A. FJELSTAD.

Glenwood, Minn. [We think not.-ED.]

U. of Minn., 1892.

Rigid Perineum.-The Placenta in Plural Births.-Granular Lids.

Editor MEDICAL WORLD:-In Aug. WORLD (p. 352) reference is made to Dr. Southworth's formula, in Monthly Cyclopedia, for rigid perineum. In the Medical Council of 1901 (p. 362) I saw a similar reference to this formula of chloroform and ether and spirits cologne to prevent tearing of the perineum in child birth. The day I read this article I used the preparation on a primipara of same age. Result, a natural birth of a large child and a very little tear inside of vaginal opening above where I applied chloroform and ether solution. I have not used it since, altho I believe it should be applied more frequently, as we often have torn perineums when we least expect them.

In reply to Dr. Morrow (p. 353), my experience has been one placenta where babes are of one sex, in twins or triplets, and two placentas if of different sex.

I will be pleased to try the Doctor's remedy for

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Easy Versus Difficult Obstetric Experience.

Editor MEDICAL WORLD:-No one's obstetric experience, however vast, can evolve a law for another. When I read of a series of 500 to 1,000 labors without difficulties requiring forceps, I can only feel amazement. The fact remains that I still strike my own share of difficulties. I am positiv that about 250 cases would cover my experience, yet in this number I have had a number of abnormal and difficult ones. I have had two eclampsias, both emergencies; about seven occiput-post cases, some requiring sufficient force to raise the patient completely from the table. Most of these were taken by upward traction under the arch, perhaps mistakenly, but not one was lost or injured to my knowledge. Of placenta previa, severe hemorrhage and puerperal mania, I have seen one case of each. Three difficult versions, one impacted breech, five twin cases, and one triplet case are included in my record.

Contracted pelves are not so rare as some suppose. Only the other day I delivered a primipara, whose external conjugate measured six and three-quarter inches. I have had five or six more about the same. These cases require more than confidence in the doctor, or verbal stimulation. I have had two cases of prolapst cord, with inertia, requiring reposition and immediate delivery. Have also assisted in two craniotomies, and have had many cases where after days or hours of labor it was necessary to dilate and apply forceps above the brim. Of these last all lived except a macerated, syphilitic fetus.

On my graduation I had never seen a labor case, and was immediately confronted by a case of eclampsia, in the backwoods, without assistance.

A series of adherent placenta were among my minor difficulties.

Some of my forceps cases would have deliv evered spontaneously in time; others would have gotten as far as the Pikes Peak railroad

would have gone on a level grade. They were impossible by natural means.

I have applied forceps about fifty times; I have used them at once on arrival, and I have have also waited hours or days. Drugs, including ergot, strychnin, caulophyllin, and cocain, either as stimulants or relaxants, have been useless in my hands. Quinin I have never used. Labor is bad enut without cin

chonism.

In

The idea that a rigid perineum is the main indication for forceps is incorrect. The important mechanical cause is the flattened or the justo-minor pelvis. The notion that forceps must tear the perineum is absurd. They may, certainly, but, properly used, never. occipito-anterior cases, if the head tears the outlet it is when the suboccipito-bregmatic or mental diameter rotates on the pubis; by this time the instruments are either removed or their blades have cleared the orifice. Delivery should be completely under control.

Regarding instruments, I prefer the solid blades of the Tucker McLane type when the head is well up. They are easier to apply, and if possible I complete delivery with them. I find a tendency to slip as the occiput comes under the arch, I substitute the Elliott forceps, but not otherwise. Fenestrated blades often jam between the occiput and pubis, and cannot be removed without danger. I carry a pair of Lusk-Tarnier axis traction forceps, but never use them without a skilled assistant.

When possible I deliver on a table, using the "Walcher" positions. In torn perineums I always make an immediate repair, removing clots, cutting away the shreds and hair, and cleansing. I have seldom failed to get unions. I prefer chromicized catgut sutures.

As to fatalities, I have never lost a woman. Altho I employ antisepsis and the uterin douche after forceps, I have had one bad case of infection. I have had three cases stillborn. These were in contracted pelves with no facilities for section or symphysiotomy. I have also seen children die from difficult non instrumental deliveries. Have also found sepsis to occur in the same class. In primiparas I take pelvic measurements with a view to premature delivery if required.

"Leaving the case to Nature" is often only the catch word of the ignorant. Then let us be consistent and leave all difficulties to the same authority. I neither excuse my use, nor boast of non-use of forceps. If I regard the matter as urgent and my advice is not taken, I prefer to leave it to another and walk out. H. O. CARRINGTON.

520 West 145th street, New York.

Hoffman's anodyne, in dram doses, relieves all types of colic.

SEPTEMBER, 1903]

Another Case of "Perplext "-Great Field to Explore

Abortion.-Aborting Typhoid.

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Editor MEDICAL WORLD:-I have read with some thought and sympathy Dr. Boynton's article on abortionists. Also the Editor's comment, which is indeed poor consolation to a conscientious (?) physician who is acquainted with "womb trouble," displacements," "tumors," "false growths" (and many other causes for local treatments), which he knows are caused by coition, and are only false pretenses for the homely term for murder of a fetus. A lady ex-nurse, mother of five children, askt me: "Doctor, do you call that murder?" On being assured in the affirmativ replied: "Will there be a married woman in heaven?” It is the greatest menace to America, and those who talk temperance and other reforms do not hesitate to destroy the unborn.

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I cannot agree with Dr. Bosworth in "Don't Try to Abort Typhoid by Purgation." It is generally admitted that the germ of typhoid enters the system by the stomach or bowel. have observed the following: by thoro purgation with or without bowel antiseptics, a large percent of typhoid cases can be aborted. However, I always use antiseptics. Of the diagnosis, when you see several cases in the same community, find two cases in the second week of the disease and two more in the first, the later aborted, the former run their course, could we deny the diagnosis?

The germ first finds its food in the contents of the bowel, and its ptomains produce the first symptoms. If by sweeping out these you can place nature in position to care, for the remainder, why not? Can there be danger from hemorrhage in the first ten days? I think not. As to the forceps, count me with those who think a judicious use is not only justifiable, but humane and an arrestor of disease. Wenatchee, Wash.

H. A. SAUNDERS.

Another Case of "Perplext." - Doctors Should Study Government.-A Great Field to Explore.

Editor MEDICAL WORLD:-I had a case like "Perplext" some 30 years ago. They were a young couple, and the baby came in 4 months after marriage. They wanted me to take it away, but as I was a young man, I did not wish to embarrass myself. It was a good, bouncing girl. They were supposed to be extremely religious people. I left things all right, but when I returned they told me the baby had choked to death. I was astonisht, and made a row, and being a coroner, I summoned a jury, and askt them to produce the body. You never saw a more intensely mad couple in your life. They finally produced the baby. And it was not dead, and I was in, as

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you may imagin, an embarrassing predicament. It taught me a lesson that I shall never forget. The duplicity of the young couple was entirely overlookt, and my lapse from discretion was magnified and condemned. took me years to live down the ridicule; and since that time I have taken every statement made as true regarding such matters. If I have a suspicion at times, I fall back upon my precedent and keep mum.

We are pleased to note that the Editor of THE WORLD does not confine himself strictly to promulgating one idea, but is anxious to help his brothers to an understanding of those problems that should seriously interest all the citizens of this great Republic. I think it timely and exceedingly beneficial to the medical man of our day, that he should become well informed on everything that pertains to good government, that he may promulgate progressiv ideas in his community. To be well posted is a good way to become known. We are too apt to fall into ruts. Hear all things and hold fast to that which is good and practicable.

The law of similia similibus curantur was one of the problems I had to solve while quite young. I am fully persuaded, from experience and otherwise, that it, like Christian Science, is a direct appeal to that subconscious self, which scientists are now convinced is a fact; and when by suggestion it is once aroused, it fully controls morbid states, and some diseases yield readily in some patients; while in others it fails to make an impression, and requires to be bombarded with material substances. There is a grand field here to explore, and many truths to discover. HORATIO S. BREWER. 939 Winthrop avenue, Chicage.

In this connection, the following from the Pittsburg Post for July 28, will be of interest.

PHYSICIAN IS ORDERED TO KILL BABE. Dr. Lilley Receives Midnight Call, but Refuses to Perform Service requested Next Day the Child Cannot be Found. Notifies Authorities and Body is Located-Coroner Decides Murder Has Been Committed. Accused Parents are Held. Brownsville, Pa., July 27.-William C. Arnold, 25 years old, a well-to-do farmer of Jefferson township, Fayette county, was taken to jail in Uniontown tonight by County Detectiv Alexander McBeth, charged with the murder of his son. His wife Mary Effie Arnold, 22 years old, is also charged with murder, and the legal course will be taken with her also as soon as she has recovered from the childbirth that forms a part of the unusual tragedy.

The

Arnold, the son of a leading farmer, last January married Mary Effie Clark, daughter of James Clark, a farmer who became rich from the sale of his coal land of 228 acres at $1,500 an acre. young couple lived on the Price farm near here and were esteemed by the community.

Friday night, late, a me-senger summoned Dr. Lilley, of this place, to see a woman who, the man said, was ill. Dr. Lilley, it is stated, went to the farm and was mysteriously ushered into the house, being cautioned to make no sound, as another family lived in the house. He was taken to a bedroom, where he found a woman and newborn baby lying.

"Now, dearie," said one of the couple to the other, "tell the doctor what you want him to do?"

"Well, we want you to kill the child."

Dr. Lilley lookt in wonderment from one to the other. "You have got hold of the wrong fellow," said he, "if you expect me to commit murder." Then the physician examined the child and drew from its mouth a mass of cloth that nearly chokt it. Again the request was urgently made by both mother and

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