making an instrumental labor a necessity. The interference with the oxidation of the blood without doubt increases the number of still-births. Nor are these the only dangers. Though few deaths are reported from chloroform in obstetric practice, yet undoubtedly many deaths occurring within forty-eight hours after delivery and reported as heart-clot, etc., may be due to the depression following the administration of chloroform. In cases where the uterine contractions persist, and the woman holds her breath to more efficiently "bear down," she is in a favorable condition for the occurrence of epileptiform syncope if chloroform is being administered. Without exception, whenever chloroform is used, a full dose of ergot should be given as soon as the head is delivered. It is also well to give ten grains of quinine at the beginning of the second stage of labor. Belladonna or nitroglycerine may also be used. A hypodermic injection of atropine (gr. 1-120), or sulphate of strychnia (gr. 1-60), will add to the safety of the patient. In view of the dangers above mentioned, it is urged that chloroform should be placed upon the same platform as other drugs; never to be given as a routine practice; or, in response to the pleadings of the patient, and simply to diminish pain, but only when the indication in the case imperatively demands it. A SERIES OF COMPLICATED LABORS; SHOULDER PRESENTATION; EXPULSION OF CHILD WITH HEAD DOUBLED UPON TRUNK. Benjamin Edson (Med. Council, Phila., Feb., 1897) says that, as a rule, complications in labor result from contracted or distorted pelves, with small birth-canals and a large foetus, but an unusually large pelvis may cause complications as well. The case of Mrs. C., of Brooklyn, illustrates this. She is twenty-four years old, weighs over 200 pounds, and has a uniformly enlarged pelvis. She was confined in 1893 for the first time, a shoulder presentation: the child was still-born. The writer does. not know the particulars of this labor, as the patient was not under his care then. In 1894 Dr. Edson was called in consultation, found the patient in labor, with arm and shoulder presenting at vulva. The child was turned and delivered, breech first; child still living. In September, 1895, Dr. Edson was called; found her in labor, with several hands and feet presenting. "After duly assorting them," she was delivered of twins at about six months of utero-gestation. They lived but a day or two. In June, 1896, she was again in labor. The doctor found the membranes ruptured, and the right arm presenting; pains almost continuous and strong. An attempt to replace the arm in the knee-chest position failed. An assistant was sent for, with the intention of giving chloroform. In the meantime, with the patient on her back, the doctor "balanced the child above the mother's pelvis." The pains became violent, the shoulder progressed rapidly, the head doubled upon the left shoulder and chest, and head and chest were delivered en masse, the breech following. The child weighed ten and one-half pounds. Both mother and child did well. It is hardly necessary to say that the mother's pelvis was spacious. Her abdomen was extremely pendulous, extending, when in a sitting position, beyond and below her knees. Most writers admit the possibility of such a mode of delivery only when the child is small or immature and the birth-canal unusually large. In this case the child was at full term and well developed, was born alive and is still living. UNUSUAL CASE IN MIDWIFERY PRACTICE. Bernard Loughrey, of Melbourne (Intercolonial Med. Jour., of Australasia, Dec., 1896), reports a case cf labor, interesting because of the unususal number of complications. The patient was thirty-two years old, had had five children and two miscarriages, had been curetted after each miscarriage. In September last, when seven months pregnant, she was taken with severe hæmorrhages, coming on without warning; these persisted, at intervals for two days, when labor pains commenced, and Dr. Loughrey was called. On examination, he found the cervix partially dilated, and a complete placenta prævia, which was detached from the os for a short distance; the pains frequent but ineffectual. For over an hour it was impossible to separate the placenta sufficiently to rupture the membranes. But at length one side was detached, and the membranes ruptured. A breech presentation was delivered as rapidly as possible, the child being livid and apparently lifeless. After twenty minutes of artificial respiration the child was breathing well, and an attempt was made to express the remaining portion of the placenta. The uterus was unusually distended, and no impression could be made upon it. On inserting his hand in the uterus to peel off the placenta, he found another child with unruptured membranes in utero. After removing the first placenta and membranes, the second membranes were ruptured and a second child appeared, with foot and hand presentation. This was delivered alive and well, the placenta quickly following. The children, both males, were wrapped in cotton and placed near a fire, but, owing to a sudden change in temperature, both children died the next day. The uterus contracted promptly, and recovery was uneventful. AN UNUSUAL CASE OF TUBAL ABORTION. J. Bland Sutton (The Lancet, February 13, 1897) reports a curious case of tubal abortion, which demonstrates the fact that, under certain conditions, tubal abortion can be differentiated from tubal rupture by clinical signs. A married woman, aged forty-one years, the mother of four children, was last pregnant in May, 1886. From that date she menstruated regularly until June, 1896. In that month, and in July, August and September following, the usual menstrual flow was on each occasion very scanty, merely a "slight loss." July 28th, the woman had severe pain in the lower part of her abdomen, lasting three hours. August 14th a sim ilar attack occurred. September 15th she again suffered great pain, which lasted five days. The pain diminished in severity, but did not wholly disappear, and she applied at the Chelsea Hospital for Women for relief, where she was examined by Dr. Arthur Giles, who detected a swelling in the left half of her pelvis. From the history and the physical signs, he considered the case as tubal pregnancy, and very probably tubal abortion. The writer found, on examination, the left half of her pelvis occupied by a semi-solid swelling, which extended into the false pelvis, and could be felt above the brim. The cervix was patulous. The uterine cavity was three and a half inches in depth. There was slight bleeding from the uterus. October 19th coeliotomy was performed. A uniformshaped clot, about two and a half inches in length, was found in a fold of omentum; beneath it a second clot of the same shape, but much larger, was found, and beneath this in the recto-vaginal fossa a third clot of exactly the same shape, but twice the size of the preceding, was found, and also removed. A rounded, hard body was felt in the left tube. The tube, ovary, and adjacent parts of the mesosalpinx were removed. The right tube and ovary, being normal, were not disturbed. The patient made a quick and complete recovery. The clots were all uniform in shape; the exterior of each was laminated like the blood in the wall of a sacculated aneurism or in the sac of an old hæmatocele of the tunica vaginalis testis. The central parts of the clots consisted of ordinary coagulated blood. The hard body in the tube was a "mole," which on microscopic examination in cross-sections showed many chorionic villi. The ostium abdominale of the tube was widely patent, and the ampullary wall thick, succulent and entire. The case was, therefore, one of " incomplete tubal abortion," but peculiar in this respect: As the blood collected and distended the tubal ampulla it firmly clotted, and was then expelled, with pain, through the tubal ostium into the recto-vaginal pouch. The "delivery,' so to speak, of each clot coincided with each attack of pain, in July, August and September. The only recorded case in any way parallel is by Noble: that of a case of tubal abortion in which the blood clots in the pelvis " were coiled up as though they had been ground through a sausage machine." This was due to a continuous slow bleeding in the tube, the clots being forced out as they formed in a sausage-shaped mass. The shape of the clot in the diagram of the writer is exactly that assumed by the ampullary section of the fallopian tube when in the condition of hydrosalpinx. POWDER FOR CORYZA: The Therap. Gaz. gives the following: R. Subnitrate of bismuth.... Powdered camphor ... This to be snuffed up the nose. 1 drachm. 6 grains. 3 grains. grain. grain. 15 grains. NERVOUS DISEASES AND ELECTRO-THERAPEUTICS. IN CHARGE OF CAMPBELL MEYERS, M.D., C.M., M.R.C.S., Eng., L.R.C.P., Lond., HYSTERICAL APHONIA. BY SANGER BROWN, M.D., CHICAGO, ILL. My apology for calling attention to a mere symptom is that hysteria presents such an endless variety of symptoms that one can hardly attempt to take them all together within the compass of one short paper. I invite attention to hysterical aphonia because, while it is not one of the most frequent symptoms of hysteria, it is one of the most conspicuous when present, and though in a large majority of the cases no very great difficulty is met with in attempting to diagnose it, yet there are cases which have baffled the general practitioner successfully for a number of years. I hope I may be excused if I briefly discuss this symptom somewhat as I would do if it were regarded as a disease, because I am accustomed to discuss medical topics in somewhat of a stereotyped way. Hysterical aphonia has been pretty clearly recognized and described for a century at least; its etiological conditions are practically the same, of course, as are those of the disease of which it is a symptom, namely, hysteria. In quite an extensive search of the literature of the subject, the youngest case that I have encountered was one occurring in a girl of nine, while the age of the oldest was that of a woman of seventy-four years. In regard to the symptomatology and etiology, at least two fairly distinct types are found; first may be considered that type in which aphonia is merely an accompaniment of many other pronounced stigmata of hysteria, such as hysterical pains, hemianæsthesia, vomiting, etc., occurring either with or without any apparent exciting cause. In such cases it frequently happens that the aphonia is not entirely pure; that is, for hours together, when the other symptoms are most complained of, the patient may be unable to raise the voice above a whisper, but in the intervals may be able faintly to phonate now and then a word or syllable. The second or pure form of aphonia, however, is that in which this symptom occurs suddenly with or without an exciting cause, continues for a longer or shorter time, and constitutes the sole evidence of hysteria. In the impure type the aphonia may be among the first symptoms to appear, or it may show itself only after symptoms have been present for weeks or even months. It may commence as a transient hoarseness, worse when the other symptoms are worse, or as hoarseness associated with an ordinary cold; finally, complete or almost complete aphonia supervenes which may last from several days to several weeks, or even months. In the pure type,, as already stated, the aphonia usually develops suddenly, with or without exciting cause. For instance, the patient comes down to breakfast in his usual health and spirits, and finds, much to his surprise, that he cannot raise his voice above a whisper, or very rarely he may be entirely mute; or the symptom may develop suddenly as the result of a severe emotional shock. The influence of an emotional shock will vary directly with the susceptibility of the individual's nervous system at the time of receiving the shock. This point is of the utmost importance in estimating the influence of emotion in producing disturbance of any function of the nervous system. Many of these cases recover spontaneously and even suddenly after a few weeks or months, with or without treatment; others remain uninfluenced by treatment, the symptom persisting steadily for years. To be sure, there are many mixed cases. A great many methods have been enthusiastically put forward as successful in the treatment, more especially of the pure types above referred to, but in the last few years it has been pretty clearly demonstrated that they owed their success entirely to the influence of the suggestion with which they were accompanied; and in my opinion any method depends for its success upon the facility which it affords the patient for concentrating his efforts upon an attempt to phonate. Hypnotism has been successful in a number of instances, but not more so than the various forms of electricity, more particularly faradism, applied to the larynx, sometimes by a peculiarly shaped electrode applied internally, and at other times simply applied externally. A method advocated by Oliver a few years ago attracted considerable attention and became known as his method, and has given excellent results. His plan was to pinch the posterior part of the arytenoid cartilages between the thumb and index finger, and thus produce an approximation of the vocal cords, at the same time vigorously shaking the larynx and calling upon the patient to make an attempt to phonate, assuring him positively of his ability to do so. At first only vowel sounds were attempted, and gradually the pressure and shaking were diminished, until the patient was able to phonate without assistance. In case any particular sound was not satisfactorily produced. the pressure and shaking were reapplied. A third very ingenious and successful method consists in first getting the patient to cough which in nearly every case can be accomplished; having done this, then have him cough and at the same time pronounce the different vowel sounds, and thus convince him of his ability to phonate. It is probable that in all pure cases any of these methods, if applied with suitable suggestion on the part of the operator, would be successful; but in the case in which the aphonia is associated with other marked symptoms of hysteria, it is doubtful if complete and lasting success will be attained until the other symptoms have in a great measure subsided, and to this end it is often necessary to improve the patient's general health. |