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A Case of Gun-shot Wound of the

Abdomen with Seven Perforations
of the Intestines; Operation and
Recovery.- Pearse......

553 A New Substitute for Iodoform in

Surgical Cases.-Condon................. 555 Blastomycetic Dermatitis, with Re

marks on Three Cases.-Frick......... 229 County Sanatorium for the Treatment

of Pulmonary Tuberculosis.—Moore 476 Chorea Minor.-Owens.....

200 Constipation.-McGill...

52 Case of Malingering.-Bowen......... 96 Cause and Possible Prevention of

Gastric and Intestinal Hemorrhages
Following Operations for Appendi-
citis, Hernia and all other Opera-
tive Procedures Involving the Blood
Supply of the Omentum and Vis-
cera.-Summers...

469 Club Foot with Special Reference to

the Post-operative Treatment.-
Edmonson......

273 Diffuse Spreading Cellulitis, with Re

port of Three Cases.-Suddarth...... 245 Different Stages of Epilepsy and Its

Distinct Pathology.--Hughes...... 498 Dermatitis Venenata.-Frick....... 90 Emergency Therapeutics.-Marrs....... 457 Ectopic Gestation: with Report of Cases.-Campbell......

539 Etiology of Syphilis ; with a Few

Practical Points on Tertiary Cases

of Several Years Standing.–Bogart. 49 Expectant Mother, The.-Shelley........ 417 Fibroid Tumors of the Ovary.-Lanphear.......

202 Fragmentary Clinical Therapy of the

Static Current from the Generalist's
Scrap Heap. -Burnett........

369 Goitre ; With a Report of 182 Opera

tions upon the Thyroid.—Mayo...... 100 Intestinal Antisepsis in Fevers.Waugh......

203 Is There a Rational Basis for a Scientific Therapy?-Waugh........

45 Intestinal Tuberculosis and Its Surgery .......

156 Indirect Effects of Valvular Lesions.Milroy.......

279 Improper Management of Epileptics.Hughes......

287 Impetigo Contagiosa.-Lau.......... 337 Is Vaginal Cesarean Section Justifiable?-Findley..........

139 Large Aneurism of Femoral Artery in

Scarpa's Triangle-Presentation of
Case --Dandurant........

422 Need of Sexual Education.-Fassett... 62 Neuroses.-Marrs........

297 Office Treatment of Rectal Diseases. -- Mason.....

329

Prophylaxis and Sequela of Venereal

Diseases.-Geiger....... Post-Graduate Study.-Benedict........ 207 Pathology of Lobar Pneumonia.Cramp.......

293 Pyloric Stenosis-Report of Case.Campbell.........

430 Postoperative Hemorrhage in Abdominal Surgery.—Walker

87 Pulmonary Consumption, Bright's Dis

ease and Diabetes Mellitus.-Felch.. 93 Prevention of Deformity.-Lord......... 41 Post Graduate Study.–Benedict......... 135 Poisoning by Rhus Toxicodendron or

Rhus Řadicans.—McKee......... 98 Rupture of the Maie Urethra.--McDermott.........

321 Removal of the Uterus for Chronic In

flammation.-Witherspoon.............. 377 Rachitis.- King.........

383 Report of an Unusual Appendicitis ;

Operated and Recovered.-Clinton. 495 Rational Treatment of EczemaSchalek.......

534 Repairing Lacerations After Confinement.-Reeves....

95 Suprapubic Cystotomy as a Prelimin

ary to and as a Route for the Performance of a Considerable Number

of Prostatectomies.-Elam.............. 289 Second Case of Dual Personality.Burnett........

485 Some Points on the Management of

Labor.-Hardin........
Surgical Treatment of Goitre Based

Upon Two Hundred Operations.-
Mayo.......

183 Surgical Treatment of Total Prolapse

of the Uterus, with a Report of Operated Cases (Illustrated).Theinhaus........

192 Some Pathology of the Morphine

Habit and My Preferred Method of
Treatment.- Burnett......

148 Surgery of the Paralyses.-Lord... 513 Simplified Method of Preparing Catgut.-Everett........

426 Tumors of the Cerebellum, with Report of a Case.-Coulter.......

236 Treatment of Varicose Veins.—Mayo.. 52 Treatment of Nocturnal Enuresis.Butler...........

496 Treatment of Patients after Abdominal Operations.- Morton........

8 The Physical Signs of Disease; Their

Scope and What They Should Teach

the Modern Physician.-Hardin...... 527 The Entoning of the Neurones in the

Practice of Medicine and Surgery.
-Hughes.........

559 Use and Abuse of the Obstetrical For. ceps.-Gray......

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SOME POINTS ON THE MANAGEMENT OF LABOR.

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C. B. Hardin, M. D., Kansas City, Mo.

HE ease with which labor is conducted, as regards the medical attend-

ant, depends greatly upon his knowledge of the anatomy of the parts
concerned in the process, and his familiarity with the mechanism of

“delivery.” At the risk, therefore, of going beyond the caption of
my paper, I shall allude briefly to the three stages of normal labor.

We will assume that everything is in readiness, with the child in its
normal position (left oocipito anterior) and the mother impressed that this
painful process has begun. The three stages are by no means an arbitrary
division, or in any sense imaginary, as the division is based upon the ac-

6

tion of diverse force, to the production of diverse ends. So much depends upon a complete knowledge of these stages, as to the behavior of the pby. sician, to constitute it the foundation stone of his necessary obstetric attention. Particularly is this true as regards the first two stages of normal labor. The first stage embraces cervical dilatation. The second the expulsion of the child. The third by no means unimportant, placental delivery. All of these should be studied and understood; the structures, also, which are concerned in these processes, with the direction of the forces peculiar to each. The mention of this mechanism could not be considered of trivial importance when it bas been observed by me, time and again, that the medical attendant would direct bis patient to "bear down” during the first stage of labor.

The first requirement as regards the doctor about to attend a case of confinement, is to be surgically clean, and keep so until he leaves his patient, at least. There is no surgical operation where cleanliness is of more importance than here, and no aid of greater weight toward preventing unfortunate sequelae incident to labor. Inattention to cleanliness can easily convert a physiological process, which normal labor is, into a pathological one, with its regretful and direful consequences. Am I di. recting my remarks only to the young and inexperienced? And am I writing this paper as an attempt to teach these the way of conducting labor? By no means; but rather to physicians as a whole, for while the young may not know from actual experience, older ones often forget, and fail to take all advantage afforded by opportunity. The behavior of the physician is divided into two great divisions, viz., what to do-what not to do. There is equally as much danger in doing too much as too little. Only aim to do that which nature fails to or can not do. I have said, "be clean," directing my remarks to the physician. See

' that your patient is also clean. If

you have time at your disposal, direct that a good bath and an enema be given her. I would lay special stress upon this little, yet important point of completely emptying the lower bowel, for reasons too obvious to dwell upon.

As to cleaning the vagina beyond a mere douching, I think it not only unnecessary, but might be positively harmful, thus opening channels for infective processes.

The vulva and adjacent structures external to the genital canal, should be cleansed with soap and water and some mild antiseptic solution Then in line with the physician's duties should be an examination per vaginam, to determine the stage of labor, or whether this process has really begun. It is at times very embarrassing, when first initiated into the presence of a patient supposed to be in labor, while trying to determine this fact. The character and duration of the pains, the condition of the os and the presence or absence of vaginal secretions all serve, upon the first examination, usually, to place you upon grounds to conclude one way or the other, as to whether labor has really begun. If the os admits a finger-tip, the pains are pericdic; the presence of a bountiful gelatinous secretion in the vagina and other well known signs of labor are present you can fairly assume the onset of the process, and that your services will be immediately and continuously required until labor is ended.

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How often should you examine your patient per vaginam? Much Variance exists. In normal cases perhaps only about a half dozen or less times during the first stage, if the case is a primpara-perhaps oftener than a woman who has borne children before. Always be sure that your examining hand is aseptic as possible upon these introductions. One point of great value-and has been to me, particularly in latter years employed-and that is to simplify attendance upon a parturient woman by doing as little, to do what is necessary, as possible, a point hitherto stated. Try to eliminate complexity and mystification as much as possible from the atmosphere. You will certainly earn your fee, even though but little may be required of you. The first examination, externally and internally, will reveal much to the competent observer. It shows the stage, if labor has begun, the position of the fetus, the dimensions (sufficiently accurate as a rule) of the pelvis, and ofttimes enables him to prognose with some definiteness, the duration of the process. Hence, the signs mirrored, to the physician are both objective and subjective in character, both of which are of equal value to the expert interpreter of obstetric signs and symptoms.

Another important matter, too frequently overlooked, is the emptying of the urinary bladder during the process, and to prevent its distention till completion of labor. If your patient is an untried one as to this extremely painful experience, tell her that her course usually embraces fifteen to seventeen hours of intermittent pain ; but while this is true, she learns to stand and becomes more tolerant of pain as she advances.

Scarcely less important than the active duties of the accoucheur are the psychical impressions which he wakes upon his patient. He can ter. rorize, or he can calm her by bis general demeanor while in her presence. Regardless of what may occur incident to labor, he should never seem surprised. His acts and expressions are watched by his patient, in labor as in no other state of pain or suffering, all of which act for or against her welfare. He should be cheerful, encouraging, inspiring and brimful of optimism, and by no accident or complication, however grave and dangerous, should these phenomena change, in appearance to his patient.

If upon examination you find the os dilatable, and say the size of a silver dollar, you should by no

leare the house until com. pletion of delivery, particularly if other signs of labor be present also. Usually the circular fibers of the os uteri slcwly and painfully distend, and an unaided patient generally becomes the victim of almost unendurable suffering. I have made it almost a universal rule, except when

a counterindicated by some physical defect, whether primipara or multipara, at this stage (called the first stage) to administer hypodermically a tablet of morphine and atropine. I have seen notbing follow this practice but good. It seems not to interfere or in any way inbibit the prucess of dilatation, and brings a calm and repose to my suffering patient, beautiful to behold. Ordinarily this makes the administration of chloroform unnecessary till toward the close of the second stage of labor, which latter I also always give except in the presence of an almost painless labor or grave organic disease of my patient. I sometimes, if the occasion demands, repeat the morphine in three or four hours. I am convinced

means

that many of the objections hitherto urged against chloroform, such as tending to profuse hemorrhages, retardation to the process of labor, producing subinvolution of the uterus, etc., can be removed by combining the action of morphine with chloroform, thus lessening the quantity of chloroform otherwise required.

Some otherwise very good obstetricians use neither; but if I were a woman in labor I would never account a physician a good one, barring accidental and unusual conditions, who would withhold these agents from me.

While the os is dilating, and your patient is in comparative repose, under a harmless potion of morphine, you can lie down and sleep if needs be-quite often for some hours, and waken to find that during the interval delightful progress has been made. I sometimes combine strychnine with the morphine and atropine injection if required where the os is dilating too slowly, transgressing physiological laws in this particular, sometimes I place two fingers within it and by their wide separation materially expedite the process. I think this little maneuvre is quite an aid, and perfectly harmless. I am glad to say that the picnic feature of labor has been done away with in latter years. Calling in every neighbor woman, even into the bed chamber, on the occasion of the advent of a newly born baby, is not tolerated by the modern physician. Yourself and nurse, with at most another (often a mother to the patient) are quite enough, in the absence of complications, to bave in the sick chamber.

I wish to speak of the obstetric forceps at this juncture, and its abuse. A physician in obstetric work who makes time only as one of the acci. dents of labor, will often find opportunity to abuse this useful instrument. Only after completion of the first stage, and when progress, not apparent but real, is delayed for a number of hours, say from two to four, together with evidences of a want of adjustment of the fetus and maternal structures, is the use of the forceps justifiable, except when some unusual con. dition of mother or child demands immediate instrumental interference. My admonition would be, study well the indications for the use of forceps. I am inclined to believe that but few physicians would use it merely for an hypertrophied obstetric fee, or merely to save time or to increase the chances of having to do perineal work.

With our modern aids to the process of labor, enabling us to conduct it painlessly, almost, the importunities of our patient nor anything else, aside from necessity, should induce the physician to use the obstetric forceps. One of the most conspicuous opprobriae in the practice of the obstetrio art, in modern times, in my opinion, is the abuse of this most valuable surgical instrument. There is a point in pretended diagnosisthat is, the vast majority of those wbo do obstetric work claim to be able to do, but which is often very difficult, if not impossible, viz., to tell the exact position of the fetal bead in relation to the bony pelvis of the mother. In ordinary practice and under ordinary circumstances it is quite unnecessary to make or claim to make (for I think in such claim we are often mistaken) these niceties of diagnosis.

If perchance you discern a faulty vertex presentation ere the amniotic sao is ruptured, it would be good practice to try and correct it.

I hope by the above admission I am not betraying any of the secrets of the ob.

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