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DEAR DOCTOR :Again, his [Dr. Parker's] management of the case was as crude as possible. A midwife would have done better, for she would have recognized on first examination the cause of delay and would have pulled the cervix forward into the axis of the true pelvis at once, instead of going to bed and allowing the patient to wear herself out by trying for 20 hours to force the fetal head thru the sacculated anterior wall of the lower uterin segment. The midwife might even recognize that the patient had a pendulous abdomen that, allowing the uterus to antevert, placed the cervix in the hollow of the sacrum and allowed the fetal head to present in the unfavorable position known as "Naegele's obliquity"-presentation of the anterior parietal bone-one of the two vertex positions which befuddles the average family physician and sets him whining because he cannot find a suture. Be it as it may about the midwife, Dr. Parker failed to recognize the cause of dystocia and correct it. Had a graduate nurse of the lying-in department of my private hospital shown as much ignorance and incapacity in handling a case of pendulous abdomen, cervix in the hollow of the sacrum, sacculated anterior wall of lower uterin segment and the consequent fetal presentation in Naegele's obliquity, I would have canceled her diploma. My nurse would have washt out the rectum and sigmoid with a 2 percent alum enema, shaved the external genitals, sterilized her hands and sterilized her patient from breasts to knees, paying particular attention to the inside of the thighs, buttocks, and external genitals. She would then resterilize her hands, put on a pair of steril rubber gloves, carefully open the vulva and sterilize with tincture of green soap the mucous membranes of the labia majora and minora, carefully removing the smegma from the hood of the clitoris. would then catheterize the patient with a steril soft rubber catheter, resterilize her gloved hands in a of 1 percent lysol solution, and make a careful vaginal examination to learn the condition and confirm the "diagnosis of presentation" she had already made by abdominal palpation and a Bowles stethoscope before sterilizing the abdomen. Knowing that in primipara, as a rule, the cervix opens in the ninth month, she would slip a finger into it and pull it forward into the axis of the true pelvis where it belonged. If, on the other hand, it was a second or later pregnancy, knowing that in these cases the cervix opens in the fifth month, she would

She

slip two fingers into the cervix, pull it forward, hold it there, have an assistant put on an abdominal binder tightly, the patient lying on her back, to help hold the anteverted uterus and fetus in the axis of the true pelvis. This done, she would keep her patient on her back, introduce the first and second fingers of the other hand into the cervix, and with four fingers-two of each hand -complete the first stage of labor at once by rapidly dilating the cervix bimanually, much in the same way as one does a sphincter ani, save that one uses fingers instead of thumbs. If you askt her why she completed the first stage at once by dilating bimanually, she would tell you that: (1) while still retained within the undilated cervix, tho the head be on the perineum, rotation of the occiput forward will not occur; (2) that labor stops with a head in the deep transverse position, deep in the pelvis and vagina; (3) and that unless rotation is made bimanually, this is the position that calls so often for easy, low forceps. She now resterilizes her gloved hands, introduces two fingers of the left hand into the cervix once more, reaching as deeply and as nearly behind the posterior parietal eminence as possible. With the fingers of the right hand in the proper groin, she locates the fetal chin and, waiting for a pain, uses the chin as a lever to rotate the occiput forward bimanually out of the deep occipito-transverse position. She retains what she gains for several or many pains until the head becomes fixt in an occipito-anterior position. A second nurse has aided in the rotation by rotating forward the shoulders and hips with the fingers of one hand in the loin and the fingers of the other buried deeply in the abdominal wall.

Now that the case has been cleared up, my nurse insists that the patient bear down effectivly and intelligently in the true axis of delivery, accepting nothing less than downright, intelligent expulsiv efforts. She incites pains and keeps them going by traction on the pelvic floor between pains, with two fingers of the left hand in the vagina, and during pain uses the same two fingers to force the long anterior lip of the cervix behind and above the symphysis. Her gloved hands are resterilized and the external genitals washt off with steril deci-normal salt solution every five pains. The right hand, inserted between the separated recti muscles, holds the fundus backwards during pain, thus retaining fundus and fetus in the axis of delivery. With both hands busy doing something effectiv for her patient every moment, my nurse completes delivery in two hours or less without forceps, and prides herself on having done modern obstetrics. She does not fear the expression "meddlesome midwifery," knowing that the phrase is the refuge of inertia and the patient's greatest safeguard against the obstetric ignorance, in

capacity, and dirt of the average medical man. She believes, too, that if the attending physician is as helpless and nearly as inefficient as an old lady, he belongs in the old lady class. That, I fear, would be her opinion of Dr. Parker, who ignorantly allowed his patient to suffer for 20 needless hours, maintaining his inertia and self-respect by nursing the fetich of "meddlesome midwifery." His case was a simple one. He had to interfere finally, and, had he known his business, he would have interfered at once. A case that needs assistance should have it at once—now, not 20 to 40 hours from now; and the man who does not know on examination when assistance is needed is unfit to practise obstetrics.

By the way, I might add that to prevent postpartum hemorrhage, my nurse would not interfere with or hurry the third stage of labor. Above all other things she would not masse the uterus, and she would not give ergot before the delivery of the placenta, unless she wisht to court postpartum hemorrhage or retained placenta just to see how expert she could be in finally controlling the condition. With a funis clamp on the cord close up to the vulva, a hand would be laid on the abdomen over the fundus as a sentinel only. As soon as the fundus raised to the umbilicus and the clamp at the vulva advanced four inches-both signs showing that the placenta was detacht and lying loose in the lower uterin segment-she would express the placenta by the Dublin-Crede method, reinforced by pressure backwards into the pelvis and vagina by the other hand above the pubes. This is the modern method of expressing a placenta. This done, my nurse would give a hypodermic of ergotole and her assistant would knead the uterus for 30 minutes, while the patient was being washt and scrubbed up once more. An abdominal binder would now be put on snugly, and if there had been any tendency to hemorrhage and uterin relaxation, a box-bandage would be used, the uterus being splinted on four sides to prevent uterin relaxation and protect against concealed hemorrhage. The treatment of hemorrhage is wholly mechanical, whether one uses a box-bandage, gauze packing, or ergot. In a hemorrhage of moment, ergot is worthless. It is, however, an elegant trouble maker if given before the uterus is emptied, and it is a safe, if not a satisfying, remedy when given with judgment. nurse would use it if, after being put to bed, the patient's pulse ran up to 90; but instead of trusting it she would unpin the abdominal binder, empty the uterus by expression, and continue the massage for 30 minutes.

My

When I sat down to the typewriter I intended only a business letter to the Editor, but have quite forgotten my original intentions when touching upon a subject in which I am really interested. I must apologize to

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Dr. Parker Speaks for Himself. Editor WORLD:-The worst mistake you have made in relation to matters on which I have written is in supposing that I cannot stand criticism. On several occasions I have found fault with you because you did not criticise sufficiently; and when one Dr. Kelly exceeded the limit of gentility, as it appeared to me, I wrote you that I was glad you inserted his article. About this time you publisht a short article from me in which I insisted that the way to learn was to criticise each other. Oh, no, my friend, I am not a coward, but actuated by the principle: "Lay on Macduff, and dam'd be he who first cries: hold, enuf!"

In relation to my medicin deal, the brethren are jumping at all sorts of conclusions before understanding me. It's all very simple. I am simply trying to arrange my office for convenience and using medicins just as any reputable physician uses them.

In relation to the discussion over the case of obstetrics, I will bunch the argument into one question: If two doctors work and pull at a woman for sixteen hours, and until both doctors are tired out, and in any kind of a case. what is going to become of the woman at the other end of the rope?

In reply to Drs. West and Smith, in December WORLD, I have to say that I always aim to deliver at end of full term, not before nor after. I have waited from "six hours" to eight months; and in several cases, when the woman thought the term was full and when she had regular pains and passing spurts of water, I have delivered her two weeks afterwards and everything was easy.

Now, gentlemen, you must beat me before you are justified in jumping on roughshod. I am sixty-one years old, have practised thirty-eight years, and have delivered about twelve hundred women. I have never lost a woman in confinement. I have had all kinds of presentations, hour-glass contraction, postpartum hemorrhage, and puerperal convulsions; but not placenta previa in my own cases. I have never had a perineum ruptured sufficiently to need repair; never a lacerated os, never a case followed by rectovaginal or cysto-vaginal fistula. I have never had to call in consultation nor had assistance in a single case. I have delivered with instruments in difficult cases when there was no one present but myself and the woman, and when the woman was trying to turn somersaults. One of these was a Swede woman in the city of Hannibal, Mo., in about

1874. During the past five years I have been attending cases in adjoining towns, going right past other doctors, some of them older than myself, and helping other doctors in difficult cases.

Again, I have never had to mutilate a child nor resort to Cesarian section; but this is luck, I presume. I have known young doctors to mutilate when it was not necessary.

In fine, gentlemen, I consider myself an expert in obstetrics, and if any of the fraternity need help in difficult cases, and if not too far from me, I stand ready to show them. Clayton, Ill. H. J. PARKER.

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Editor WORLD:-In Dr. Blakeley's case of confinement (page 440, November WORLD), I would not have given any ergot, but: pulsatilla gtts. x, cimicifuga gtts. x, water 3iij; teaspoonful doses, and proceeded to deliver with forceps.

Dr. Parker's case (page 445) I believe could have been delivered without instrumental aid in as short a time as he did with instruments. I would have given her the above mixture, and also gelsemium gtts. x, water 3ij. I would have given the above two mixtures in teaspoonful doses every half hour, in alternation. At every examination I would have used freely carbolized vaselin, one drop of carbolic acid to the ounce. Should the pains not become vigorous, I would have given about two doses of grain of strychnin.

I would not give calomel in constipation of typhoid fever, but bryonia instead. DR. GEO. E. MILLER.

Fayetteville, Ark.

Treatment for Sterility. DEAR EDITOR:-On page 491 of Dec. WORLD, I notice an appeal from a doctor's wife. From the description she gives of herself I can't see why she cannot conceive, unless the trouble is with her husband. I would like to have a history of her husband's life before marriage. I will state a plan, or a mode of procedure, that I have used in three cases like the doctor's wife. In all three of the patients, whose ages ranged from 23 to 32 years, I introduced a speculum into the vagina, then introduced a large uterin sound into the uterus and let it remain there for 20 minutes; then removed it and had the husband to have intercourse as soon as possible thereafter, and instructed my patient to

put a pillow under her hips and remain on her back with the knees drawn as near on the chest as possible for one hour. In all three cases the woman became pregnant. Neither had ever borne children. You can think this over, and if you think it wise you can advise the doctor's wife to use this plan. Another point I forgot to mention: I did this work on the second day after menstruation. This perhaps is not very scientific, but it has workt beautifully with me. I also advised the husband to abstain for one month before the operation, and during that month I had my patients to take the following R: .. Ziij

Aletris cordial Celerina, āā . .

One teaspoonful before meals and at bedtime. Anderson, S. C. W. FRANK ASHMORE.

To "A Wisconsin Doctor's Wife." We are receiving several letters per day to be sent to "A Wisconsin Doctor's Wife" see "A Childless Wife's Appeal," page 491, December WORLD—(and we usually have to pay the postage). Dr. H. F. Ballard, of Culiom, Ill., very thoughtfully inclosed a copy for our perusal of his sealed letter to be mailed to the lady. We have concluded to present it here, to see what you think of it:

MY DEAR MADAM:-Excuse me for writing you, but your letter in THE MEDICAL WORLD struck a sympathetic chord, and your experience is an exemplification of "how not to do it." Don't, please don't, use any uterin dilators, uterin tonics, suppositories, nor anything else, not even injections. Let your womb alone and quit thinking about it. Stop weeping over your childless condition and devote yourself to your husband. Don't talk to him about your condition, but let him see that you love him, children or no childrenand the chances are, nine out of ten, that inside of two years, or even less, you will have a baby of your own to share your love with your husband. You are thinking and worrying so much about the matter that you can't conceive. Quit it, and devote yourself to your husband. The baby will come when you allow yourself to get into a normal condition again. Excuse this plain talk, but it is all the medicin you need. Respectfully,

H. F. BALLard.

Treatment for Sterility.-Electricity.-Horses vs. Automobiles.-Absorbent Treatment

for Bubo.

Editor WORLD:-In regard to "A Wisconsin Doctor's Wife," December WORLD, page 491, I think her condition is due to cervical endometritis. Remove the endometritis and pregnancy will likely take place. I have had some such cases and have treated them successfully with the positiv pole of the galvanic battery. Use a copper intrauterin electrode attacht to the positiv pole. Have a large pad on the abdomen attacht to the negativ pole. Turn on anywhere from 30 to 50 milliamperes for ten minutes. A few such treatments, if administered properly, should bring about results, if my diagnosis is correct.

In November WORLD some doctor asks about static electricity. My advice is, don't

use electricity unless you know how to use it. I took a private course in electro-therapeutics three years ago. Two years ago I took the correspondence course given by the Lima, Ohio, school. During the past summer I spent a month at Chicago, at Dr. Neiswanger's school, and learned more there in three weeks than I did in the previous two years. A doctor who uses electricity intelligently has a great advantage over his brother practician who does not use this agent.

My letter in November WORLD about horses and automobiles has brought me replies from all over the United States. Most doctors seem to be of the opinion that if a doctor intends to use horses it is better to drive horses that weigh about 900 pounds, and use a team. If a doctor is in a part of the country where he can use an automobile he can do his work much quicker and easier with an auto than with horses. He should use a good machine with plenty of horse power.

Dr. Buehring's query regarding "Blue Ball," page 499: During the past three months I have treated ten cases as follows: Wet a little absorbent cotton with iodin solution and place same on a sponge electrode over the bubo. Place a large pad connected with the positiv pole on the abdomen and turn on the current. Iodin travels cataphoricly from the negativ to the positiv pole, and is carried directly into the bubo. Two or three treatments will cause the bubo to disappear. This is an easy way to make money. I don't know whether this method is original or not. I have never heard of any one else using it. Lancaster, N. Y. C. L. SUESS, M.D.

The Diazo Test.-" Gold Hairpin.”—“ Immune to Their Own Bugs."-The Keeping of Accounts.-Relaxants in Labor.

The

Editor MEDICAL WORLD:-Looking over Dec. WORLD, I find so many good things to comment on that the only possible way seems to be to commence at the first and go straight thru as far as you will permit me. Diazo reaction has been considered diagnostic of typhoid so long and by so many, and the technic so easy, that it seems as tho we had not done our whole duty to any doubtful case unless we use the test. Simply because it is present in mumps, measles, and other diseases, late, doesn't invalidate its usefulness in typhoid.

The "Gold Hairpin " deal is rather an old one to the denizens of the "under world,” if I catch the idea perfectly. Anything that will hold the canal patulous the entire length, as this contrivance surely does, will do the "biz." The usual pessary, however, does not leave an opening "for drainage," but rather thru the irritation which it produces and the partial plugging of the canal will bring on conception frequently. Many prostitutes use a small plug-shaped piece of rubber, which fits the os and canal tightly, which

they, thru frequent use, are able to place in position quickly, and as well as the average M.D. could by the use of a speculum. Many of them have no need of gold hairpins, plugs, etc., as after a miscarriage or two the uterus has learned its lesson too well to allow conception to go far. The gold hairpin idea is more of a money-maker than anything else.

"Immune to Their Own Bugs," from the pen of my old preceptor, is my ticket to a dot. If nature wanted the vagina, mons, labia, etc., scrubbed, doucht, etc., as many would have us believe, she would take care of the job herself; which, in fact, she does, by throwing out the viscid secretion during early stages of labor, and later the bag of waters. These are certainly enuf in any ordinary case, besides acting as a lubricant to the parts. If gonorrhea complicates, a few drops of protargol sol. in each eye, nostrils, and mouth of the babe immediately after birth, and twice a day afterward for a week, puts us on Easy Street. Don't you think, brother, we have troubles enuf in this vale of tears without going out to kick up a fuss somewhere?

If the doctor from Penna. (page 487) wants a winner and a dandy way to keep his accounts, let him write to the Medical Council of Phila. for the pocket account book. One entry for each call or prescription does the trick; no fuss and feathers, and always legal. Small enuf to carry in any coat pocket; will hold 200 names, and it only takes a minute to tell John Smith what his bill is when he wants to know.

Dr. C., of Ill. (pages 489 and 490), is certainly getting up close to the place where he can see light in the matter of handling his parturient women. If he will cut out of his prescription the myrcia comp. (five ingredients), cypripedium, and trillium, giving the caulophyllum alone in doses of gr. & in hot water every 10 minutes, that resistant os will get busy and melt away so fast as to make him wear "the smile which won't come off." Castor oil (which, by the way, can be easily and almost completely disguised), 1 or 2 drams every other night for the last 3 or 4 weeks, will help wonderfully. When I find one of those "slow, dragging pains" cases that makes slow progress and lots of fuss, the old prescription of viburnum comp. changes the tune in short order. One 5-gr. tablet every 10 to 20 minutes for a few doses (with hot drinks, please,) either stops the pains entirely (temporary) or makes them strong and regular. I have been beat out of my fee several times thru the tablets by the woman getting easy and going off to sleep, to wake up later with the pains regular and strong, and the parts being relaxt so much during sleep that but a few pains were needed to complete the labor, and I couldn't get to the bedside. Turner, Ore.

DR. J. A. CORN.

Horses in Practise. Editor MEDICAL WORLD:-In reply to Dr. C. L. Suess, Nov. WORLD, page 447, on "Horses in Practise," I would give him this advice, which I think most doctors who have had an extensiv country practise and are not extremists will agree with. I have broken and driven bronchos, and never saw one that I had any respect for. There is always something wrong with them. Get good, honest, wellbred horses, at present price of $150 to $200, weighing 1,000 pounds; very little more and no less, unless you have no mud roads, in which case I would just as soon have a 900pound horse. Double teams are not the thing for busy country doctors, unless you have lots of money and can afford to have your driver and your stable man. It takes two blankets in cold weather, and that is work and time. Put them on and take them off fifteen times daily and some at night, and you will soon think one horse can do the work. For mountain work, two horses are best. In fifteen years' practise I use this outfit: Two good, 1,000-pound, safe horses, to alternate, and a warm, closed buggy and a sleigh with top on, all furnisht with a tubular driving (Dietz) lamp on side of top on extension iron. Í have studied the automobile, but can't, for my life, see how it will do for me. For everything it costs me about $500 yearly stable expenses, which includes man and new buggies.

How any sensible, sober man can ruin two and three horses every year and as many buggies I could never understand. Yes, I do some driving. Office practise is not a great thing here, and my practise runs about $3,000, and measly fees at that, which I am trying to raise. And, doctor, when you get a horse that suits you, don't sell for any price. If you have good roads use the automobile. It is far the cheaper and can do so much more work. THOMAS D. WHITE.

Orrstown, Pa.

Editor MEDICAL WORLD:-In reply to Dr. Suess, I will say that a good saddle broncho, one that doesn't buck too much, is what he needs. I keep a buggy, but seldom use it. Do most of my riding horseback and have made rides of fifty and seventy-five miles a day without hurting horse or rider; but how many doctors will do this? Even here in this new country I don't know of one save myself but must ride in his bright new buggy or hire a livery team and driver, and at end of year very little or nothing is saved. I believe the principal reason why so many doctors are poor is this habit of living beyond their means. Collections are good out here, but it's very doubtful whether more than one-fourth of the physicians are laying up anything for sickness and old age. We all know how common it is to hear some brother doctor tell of the big fees and the hard

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Horses vs. Automobile.

Editor MEDICAL WORLD:-Inclosed find draft for $3 in payment for four years' subscription. I note the discussion of the automobile vs. the horse, and thinking that perhaps my experience might prove of some benefit to some contemplating the purchase of an automobile, I will give my experience briefly as follows:

I find that no machine such as manufactured today will replace the horse for country roads. The first cost of a good machine is as much as that of ten horses, and the maximum life of a machine if used over country roads is not over five years. Not being able to use a machine during bad weather, it requires the same number of horses which must be fed thruout the year. The expense of gasoline, oil, repairs, tires, etc., has been more than that of keeping eight horses. The time gained on one trip may be lost on the next in making repairs. I always prefer a horse to make an urgent call, for I am sure to reach my destination.

Will some doctor who has been successful in the treatment of broncho-pneumonia in infants, kindly outline his treatment?

Clayton, Mo. J. ANDREW YOUNGMAN.

An Optimistic View.-A Case of Diabetes. DOCTOR TAYLOR:-" Commercialism in Medicin," in the current issue of THE WORLD (page 484), sounds a little rocky to me. If it stuck to the text I wouldn't butt in; but it strains a few points to make a nasty fling at the church and two fraternal societies. I do not belong to any church, but many of my friends and patrons do, who are honest men and women, the noblest works of God. Doubtless some rascals belong to the church; some may cover their cussedness with a cloak of cant. There are a few nominal Masons and Odd Fellows who do not have the spirit of those grand institutions. There appear to be a few medical men who are in the profession for purely selfish purposes; some even who seem to have bad livers; but a safe percentage are honest. The church is teaching faith, hope, optimism; and the fraternal orders are relieving distress, drying the tears of the widow and fatherless, hastening the time when all will recognize the universal "fatherhood of God and brotherhood of man." Most men are honest and most women virtuous. Cheer up, Brother Butt. Get out into the sunshine and away from the

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