stetric art, nor impressing a fortunate few who may be at all times able to accomplish this obstetric feat, with an incompetency upon my part to practice modern obstetrics. You know, it was a long time before anybody but Edebohls could palpate the normal appendix; and so may we, after a while become affected with imaginitis thusly, and claim to always tell the exact position of an unborn baby.

There is much discussion as to which part of the child ruptures the perineal body when such occurs-whether it be the head or shoulders. I think perhaps quite as much as the head do, the shoulders stand in causative relation to this accident. In a measure these accidents to the perineum can be avoided by resorting to the various expedients at the command of the obstetrician, as lubricating the parts, pressure, dislodging the wedge the shoulders make by advancing one or the other. Now, when the vertex threatens rupture of the tissues in advance of it, the liability of it can be much reduced by introducing two fingers into the rectum and exerting a pressure upward and backward in the presence of a pain, assuming that the woman is in the dorsal position. To avoid rupture many practitioners claim in vertex positions that the head should be delivered between the pains of labor. This, in the vast majority of cases, is another species of "intellectual imaginitis" as the condition, unassisted by the propulsive force of the uterine body, of which the pain is a symptom, could scarcely cause the head to be born. In short, it is the contraction of the uterus which extrudes the child from the mother, and scarcely ever, I fancy, could the head be born, even with your assistance, in the absence of uterine contraction.

As to tears in cervix and perineum, and when to attempt their repair, my idea is to do so at once, even though you but partially succeed, advising if such be extensive, that subsequently a secondary operation might have to be done. Physicians are divided, however, on this point, those opposing this method, claiming that by waiting better drainage from the wounded surfaces can be had, and hence septic states are less liable to occur for this and other reasons. Another class advise immediate attempt, admitting that often complete union will not occur, but that you close many sources in blood vessels and lymphatics of possible infection. There are many reasons why your efforts in the primary operation could be defeated, and yet none why the effort at primary union should not be made; that is, none of any considerable moment.

As regards the perineum, if the operation is properly performed and the separated structures brought into exact apposition, it will be the rarest exception that it will fail. The principal lesion in the recently torn perineum is the separation of the levator ani muscle and the triangular lig ament, and the bursting of the perineal center. The method devised by Dr. Howard Hill, of Kansas City, fulfills this condition very well indeed. By it the levator ani muscle is identified on both sides of the wound, and sutured with chromic gut. The triangular ligament is next sutured, and finally the superficial muscles.

It is not at all difficult to find these structures in a recently torn perineum, if one first takes the precaution to place sufficient gauze in the vagina to prevent obscuring the field by blood coming from the uterus. Good light and few instruments are necessary. By sponging out the

wound with hot sponges, one readily identifies the torn structures, and the introduction of the sutures is an exceedingly simple matter. After suturing the separated structures together, the torn mucous membrane is united by a continuous suture of cat gut, which is continued down on to the skin surface, closing the tear, and thus shutting off the buried sutures from infection, either from the skin surface or the vagina.

We now come, in my opinion, to the most important element in the practice of the obstetric art-"placental delivery." It is here where is put to the test the keenest knowledge of the obstetrician. Why do I say this, when it is generally so easy of accomplishment? For the reason that a bit only of it left attached to the uterine body may be sufficient cause for all grades of that dangerous and often fatal condition to the mother-puerperal sepsis. I wait only for its extraction a few minutes, after the child is born, to afford a little needed rest to the mother, when it is slowly, carefully and completely removed, if possible. The procedure is thus carried out: With a finger or two buried in its structure close to the cord attachment the entire hand often in the vaginawith the disengaged band very slight traction is made upon the cord. After its delivery several turns are made of it on its short axis and it will be seen that a rope of membranes will follow, varying from a foot to two feet in length. A close examination will determine whether it is torn, and thus perhaps a bit yet left in utero. If so, explore with the finger the uterine cavity to remove it. I think the delivery of these membranes an important item, and not to leave them in the uterus amid open mouthed blood vessels and lymphatics, to absorb their poisonous contents, and by their presence inhibit uterine contraction. I used to wait, sometimes for several hours, to see if nature, would not, unaided, ccmplete the third stage of labor; but I find this unnecessary and even dangerous.

If these little points attending the third stage of labor are observed, and carefully carried out, in full recognition of their importance, then many cases would be spared the dangers of puerperal sepsis. The eyes and mouth of the baby should be cleansed several times, shortly after birth, with a boric acid solution, using this solution on no other part of the child's body. Ophthalmia neonatorum and other eye affections can thus often be avoided. Some instill nitrate of silver and other astringents and antiseptics into the eyes of the newly born, but I think that thorough, frequent and immediate cleanliness is all that is generally required. As regards post partum vaginal douching in the majority of cases, where the canal is not too much abraded in and by delivery, it is my custom to desist from its use, particularly for the first three or four days. Then if the secretions become foul smelling and very copious, I resort to weak carbolized or bichlorid injections, once or twice daily. Too many douches, particularly in the absence of pronounced indications, are dangerous as they serve to wash away nature's protective, which is a vaginal secretion ladened with saprophytic and other germs, which are themselves germicides, to many of the pyogenic forms of bac

teria.

In this I have only touched a few of the points met by the physician in ordinary obstetric practice. However, most of those left out, as the

care of the child and mother subsequent to delivery, disposition of the cord, etc., are well known to every practitioner of obstetrics, and to detail them would be a task to your patience and indulgence, without commensurate profit. The process is too long to encompass in one short essay. For a quarter of a century doing perhaps an average work in this line, I have pursued the course indicated, in essence, with added modifications which experience always affords, and my record as regards the unfortunate possibilities of the puerperal state has been of such a nature as to cause not the lightest regret for having used the methods detailed above.

I think no man in medicine so thoroughly inspires confidence in his patient as the one who successfully conducts through to the end a confinement. There is no form of practice which so thoroughly establishes authority, or will do more, or even as much to enable the practitioner to continue as a family medical adviser as to safely, and without accident, carry the woman through this trying and painful period. I have purposely omitted to mention the items in the armamentarium of the well equipped obstetric attendant. It will readily occur to any save the very inexperienced, the many little conveniences and necessities which should be readily at hand, bearing constantly in mind that in handling of such and of the patient, a strict asepsis should be observed. Antisepsis will have less and less application to the "lying-in chamber" as we learn and practice more perfectly the rules governing asepsis. It may be said, also, even at the risk of being needlessly minute, that all superfluous furniture should · be removed from the room of the patient, which should be cleansed with ventilation and sunlight constantly and bountifully afforded.

The birth of a home is that of the child. Every one born may mean in prophecy the establishment of a home in the land. The advent of a child into the world, therefore, means much when taking into consideration the possibilities of human life and human destiny. Being properly born goes far toward the implantation of the seeds of propserity and happiness, while this process improperly conducted, and attended and followed by distortion, and inequality due to mismanagement, may mean of itself a life of regret that birth ever occurred to the child as well as to the mother.

So we can see somewhat from arguments adduced, and a thousand not herein expressed, the importance of competency and consciousness, upon the part of a doctor attending the mysterious process of labor, always remembering his highest claims in the line of duty only embrace the attempt to do that which nature seems inadequate to do unaided.

I shall conclude this fragmentary effort by a reference to the use of the rubber glove worn by many modern obstetricians and surgeons. Outside of strictly aseptic environments it is well for the physician to use every preventive means to avoid accidents and their consequences in labor. It is practically impossible, we contend, to have these aseptic conditions present, even in the best regulated hospitals of our country. Certainly not in the ordinary family house where most of our patients are of necessity confined. I can not be statistical in the use or non-use of this rubber protective to the obstetric hand, for it is hard to obtain data on a point like this, where even in the realm of surgery the use of the glove is of such recent origin, and where such diversity of opinion seems to prevail.

In the obstetric realm this diversity is even more marked, and the limits of its use very much more restricted, and almost wholly confined to a few city practitioners. Apriori, it would seem that rubber tissue can so easily be made sterile, taken with the absolute impossibility of sterilizing the hands of the accoucheur, as of any other integumentary tissue, with more or less unsanitary environments and the harmlessness of using the glove, with its probable aseptic advantages, are arguments in favor of its employment. I can, therefore, see no reason why the glove should not be used, and every one why it should be, in the practice of the obstetric art. It would seem a promising protective to the necessarily more or less. abraded surfaces of the parturient canal, against infection from the streptococcus, staphylococcus and other forms of destructive bacterial action.

In recogntion of these and other arguments, I think their use from year to year is becoming more general in the practice of surgeons and even obstetricians, in this and other civilized countries. It is my firm conviction, that aside from physical perversion, or malformation, that a physician by a close observance-of modern obstetrical rules-should seldom meet with in obstetric practice the severer accidents and sequels to labor.

413 Rialto Building.

THE TREAtment of PATIENTS AFTER ABDOMINAL OPERATIONS.

Daniel Morton, M. D., St. Joseph, Mo.

Acting Chief Surgeon National Guard Mo; Consulting Surgeon, Home for Little Wanderers; Consulting Surgeon, Memorial Home for Aged; Lecturer on Abdominal Surgery, St Joseph's Hospital Training School for Nurses; Professor Dermatology and Genito-Urinary Surgery, Ensworth Medical College 1889-90; Professor Rectal Surgery, Ensworth Medical College 1899-1900; Assistant Surgeon St. Joseph & Grand Island Railway 1893-98: Surgeon St. Joseph Terminal Railway Company 1900-1904; Chief Surgeon St. Joseph & Grand Island Railway and of the Kansas City & Omaha Railway 1898-1904; President St. Joseph Medical Society 1903.

Y experience teaches me that often more knowledge and skill are required in the after-treatment of abdominal section than is required in the primary operation. Many things may arise requiring intelligent handling without which they assume the importance of serious complications, endangering the life of the patient. The operation may be ever so brilliant and yet fail of saving the patient's life if the subsequent attention is rendered in a bungling manner. In no other emergencies more than those following abdominal operations is the resourcefulness of the surgeon taxed to the utmost. The patient's friends usually heave a sigh of relief as the patient passes out of the operating-room, and think now the danger is all over. The loved one has survived the operation, what more is there to fear. The experienced surgeon knows, however, that now the battle has just begun.

We will consider first the various factors always to be considered in every abdominal section, and second, other factors which arise occasionally only.

1. Shock. The best way to treat shock is to prevent it. At the time cf operation remove as far as it is possible every exciting cause. I am very partial to the early morning for all operative work. The patient has usually secured some sleep and the nervous system is thereby refreshed and the depressing effect of the dread of operation done away with while this sleep is being secured. The bodily temperature dissipates very rapidly unless prevented. The temperature of the operating-room should not be below 80 F. This temperature will seem much greater because all operating-rooms must contain moist air as an antiseptic measure. Hot abdominal packs should be laid over all exposed bowels, and no bowels should be removed from the abdominal cavity unless necessary. The simple handling of the bowel is a cause of shock. Prolonged anesthesia is a great factor in the production of shock. Hare says anesthesia prolonged beyond an hour is always a cause of shock. Under prolonged anesthesia nothing stands between the patient and death, except his heart beat and his breathing, all other functions of organic life are suspended and the generation of heat which accompanies them is suspended likewise. The shock of the anesthesia is due in part to this fact, I believe. Hence the necessity for supplying the heat thus lost. Normal salt solution by rectum or under skin is a most valuable remedy. The peritoneal cavity is invaded and the peritoneal fluid lost. The salt supplies the fluids lost and seems to feed the nerve centers which are so vitally depressed. Feeds them if you please, does not stimulate them and leave them with less contained power. It increases or maintains the nerve force. Could some one discover some means which would annihilate shock as pain has been annihilated, what a life saver it would be. 1 believe that the means exists. What a glorious thing it would be to find it. For the flagging heart strychnia of course, but do not rely on strychnia alone as formerly, because I consider it a remedy which forces and squeezes out of the nerve centers the energy which they already have, but does not add one particle of new energy to an already exhausted source. When the operation is over raise the foot of the patient's bed a foot or more, and determine the blood to the brain. Feed the great nerve center without taxing the flagging heart. Here we are dealing with that elusive principle life, which so far materialism has been unable to isolate. We have, so far as we can determine, in these cases of shock the same conditions of the sympathetic nervous system before and after death, no pathological changes discoverable, and yet in one instance there is life, and in the other there is death. What is it that is lost? What is it that has gone? What influence has occupied the cells of the nervous ganglia, producing the phenomena of life, and yet has departed without leaving any tangible evidence of its occupancy? Could we answer these questions we might be able to combat shock and even, perhaps, to bring back life itself. We can hope for no definite or satisfying knowledge except through experimental research. Clinical observation and metaphysical reasoning have failed, but some day some tireless worker will catch the clue and follow it to a successful ending, and fame will place the olive crown upon his brow.

2. Vomiting. Nearly always occurs, and is in my opinion partly due to the effect of the anesthetic on the center in the brain, and partly due to the partial cessation of peristalsis which so often follows handling the