If the interests of the community are superior to that of the individual, and as the maintenance of the race depends upon reproduction, it is evident that children should be born into the world continually. It also follows that they should be born right, and that their mothers should suffer a minimum in bringing them into the world, all of which is merely preliminary to saying that the practice of obstetrics is one of the most important fields of labor, if not the most important, in which the doctor can be engaged. It behooves him, therefore, to thoroughly understand his business in this line of work more than in any other, for two individuals are always in interest, one full of unknown potentialities, the other with a valued place in the world. The physician's responsibility in these cases is not often realized, because the occurrence of childbirth is so very common. Just as we had occasion to say a few months ago about mother love, one of the grandest emotions, if not the grandest known in the world, to which few people ever pay any attention because it, too, is so very com

mon.

Aside from understanding his business, the obstetrician should be deferential in manner, prompt and fearless in his work,

and use good sense without stint in the exercise of his judgment. He should be master of the anatomy of the parturient canal, the passage-way of the mother through which the new comer finds his way to the outer world. He should be thoroughly familiar with the obstetric anatomy of this little voyager, by which we mean the body in bulk, as it presents a large and tight fitting mass, obliged to pass through a curved canal of changing dimensions, some of them bony and hence resisting, and others softer and yielding. He must bear in mind that this body is composed of two essential parts, the larger and firmer of which is the head, having different diameters, which it is his object to help nature in passing through this canal and extruding from its opening by way of the smallest. This makes its progress easier, quicker, and less painful to the mother. He should take into consideration that this globular head is hinged upon the body, and is usually acted upon indirectly, the uterus compressing the body and limbs. of the child, thus forcing them down, and they, in turn, transmitting this impulse to the head. The essential problem in the mechanism of labor is to see that this globular mass of different diameters takes

its passage through the canal in such a way as to engage in its narrowest dimensions. This simply involves assuring flexion of the head as it passes through the mother's pelvis until the occiput engages under the pubic arch, after which, extension must take place, the head turning upon the trunk as if on a hinge. The forehead, face, and chin sweeping successively over the perineal body, and thus causing the least possible distention of the vulva, because presenting its shortest possible diameters.

With these few cardinal points firmly fixed in his mind, the obstetrician should readily know just when and how to use the forceps to aid nature when she seems unable to help herself. Nor should this assistance be delayed after nature's helplessness becomes manifest. To do so is to delay a painful process at greater cost to the patient than if help is rendered her at once. There are times when nature is unable to cope with herself because she has done defective work in past years. For instance, in extreme deformities of the bony pelvis, or in the presence of tumors that will not permit the passage of the child. Or there may be present obstruction of more recent origin; for instance, a cancer of the cervix. Under these conditions, the child can not be delivered through the natural channel, but must be born otherwise, or it and its mother must pay the usual penalty of delay in such cases, which is death. No one presuming to practice obstetrics has the right to offer any excuse for failing to notice conditions of this kind immediately upon the first examination of the mother. Should he find and recognize any of these, it is his imperative duty to, at once, make the necessary preparations for a speedy delivery of the child and the relief of the mother by abdominal section. If he should require help that would be

some time in arriving, his duty is to still the pains of labor by any means with which this can be done. For it is not only brutal to allow a woman to needlessly suffer torturing pain, but it weakens her, and to that extent jeopardizes her advantages of ultimate recovery.

We might say many more things of similar import and just as important, but deem this sufficient to indicate the only kind of man or woman, as the case may be, that should have the right to engage in this field of work. Some of these qualities, unfortunately, are natural to the individual, and can hardly be grafted upon him if nature has failed to instill it with the original germ of conception. To such we have simply to say, please leave these cases alone if you possibly can, unless you have competent help ready at hand.

How to Handle Children.

If the practice among women is delicate and difficult, it is hard to find words to adequately express what the practice among children is. If sympathy is required in the treatment of patients generally and of woman in particular, more is required in that of children, and we know of no better word to designate this greater requirement than that of love. A man who wants to practice medicine among children, should love them. So also should anyone who sets out to teach children. For in no other class of practice, with no other kind of patients, is it so necessary to be painstaking. Sympathy alone will not help us to maintain the proper attitude towards these little charges. They must be loved to be indulged as much as is necessary to win their confidence and their friendship, without which it often becomes difficult to do them much good. This work is

needlessly and foolishly made more difficult than it is naturally, by the prevailing practice of threatening children with the doctor as though he were one of their greatest enemies instead of being one of their best friends. It is well to make it a practice to always pay children some pleasant attention, even if it is only a momentary one in passing. They appreciate it, and readily reciprocate it. The

possibilities before it. While every child can not be such a prize, any child may be. But it is not on this account alone, by any means, that we deem it especially entitled to our affectionate consideration, for this, we think, it merits because of its helplessness and innate goodness.

the strongest influences that helps the beginner to get into practice, but one that helps the older one to retain it. Mothers usually have more trouble than they can get along with in handling a sick child, without being obliged to put up with its additional troublesomeness because of the visitations of an objectionable doctor. They will discharge such an one with pleasure for one whom the child is glad to see, for it not only means less trouble to her at the time, but less afterwards because of the doctor's influence upon the child.

It should not be difficult to love these little tots, because it seems really hard to do otherwise, and yet it is a regrettable fact that there is much less of this affection given them by physicians than we like to see. They are the hope of the future. The humblest child may grow up to be the greatest in. dividual of the age in which it lives. Many are the instances in the past in which not only infants, but children of good growth and even youths, who at the ́time seemed nothing but most commonplace, eventually grew up to be the greatest among those of their times. To treat a child with indifference is like passing a closed pocketbook or a package without a second thought. The one may be empty and the other filled with trash, and yet both are capable of holding valuable treasures. A child is a human being, full of potentialities, and with limitless

Practice.

Elsewhere we have something to say upon the responsibility and qualifications of the obstetrician, where we fail, however, to mention the fact that he is the man who, through incompetence or neglect, makes lots of work for the gynecologist. Nature does much of this, because he lets her do it. Much is done by him because he interferes with her in her good work. And some they both do together. Just what the proportions are between these different factors, we do not pretend to say, and it is not necessary to know, but the fact remains that gynecology would be a much less important specialty than it is if obstetricians averaged as high a grade of efficiency as do gynecologists. But so long as woman has her special ills, whether due to bad obstetric practice or other causes, gynecologists will be necessary as they are now. While the work of the obstetrician always verges upon the emergency order, that of the gynecologist almost always admits of abundant deliberation. He, too, must thoroughly understand the anatomy of the female genital organs. Besides this, he should understand the peculiarities of her nature, and be in sympathy with them. He should never forget that she is not of the same sex as he, and that this makes their mutual relations all the more difficult because delicate. He must be

much more tactful than the obstetrician, because, while the latter sees his patient in extreme suffering and excitement, she comes to the former in cold-blooded deliberation, though, withal, extremely nervous. Without a recognizable sympathy for her, which, however, should only be intangibly evident, felt by her rather than capable of being seen by any body, he can never hope to secure her confidence sufficiently to obtain a free and frank statement of her entire condition, and how it affects her. Such men had much better give up this line of work, because, if not endowed by nature with this special sympathetic quality, they will never make the success that they might achieve in other fields. A physician and surgeon should always be genuinely sympathetic with his patients, but this is not so essential elsewhere as it is in gynecologic practice. Women are much more emotional than men. They have infinitely stronger intuitions, and they tell quickly whether they can lay the innermost workings of their emotional natures before him or not. The ideal gynecologist is a man whom the average the average woman is not afraid to trust with her person, with the profoundest secrets of her entire life, as well as with her physical welfare. He who cannot inspire her to do this promptly, has missed his avocation, and should change it. Success in gynecologic practice, and by success we mean the cure of our patients, depends upon a thorough knowledge of the intricacies of each patient's emotional nature and the effects produced upon it, not only by her own physical suffering and condition, but also by the many other extraneous influences that help to make up her symptom complex. Many a feminine back-ache and head-ache is not due so much to trouble within her pelvis as it is to irritation in her home life. A wretch of a husband,

or a nagging mother-in-law, the secret worry of the hidden knowledge of a wrong acting brother, sister, or other relation or cherished friend, causes secret suffering, for the alleviation of which she drifts into the hands of the gynecologist, under the mistaken idea that they are all traceable to a simple leucorrhea, a slightly misplaced womb, a partly painful menstruation, or some other varying functions.

The routine gynecologist may fit her with pessaries, may stuff her with tampons, may fill her with drugs, and distress her with repeated enemata, but all without any other effect than the aggravation of her trouble. A man of genuine heartfelt sympathy, instinctively knows, with almost womanlike intuition, that there are other causes for his patient's symptom complex. A few questions, a hint or two, make the necessary opening; truth begins to trickle out drop by drop after he has punctured her shell of reserve; and this soon becomes a steady flow, which his respectful and deferential bearing and occasional word of reassurance soon encourage into a gushing flow, until she has finally poured out to him all her troubles. After this, his course is easy. If he cannot do much good for her, he can, at least, inform her as to the real cause of her troubles, and let her govern herself accordingly. But his influence goes for a great deal, and the chances are that he can be the means of modifying the cause of her trouble in the various ways open to the doctor and confidential adviser, thereby effecting a cure that the unsympathetic man would find hopelessly beyond his reach.

This constitutes, to a large degree, the ideal gynecologist as it also does the ideal physician. But the ordinary doctor does not have to be this way at all times, though the ideal gynecologist should never be otherwise.

Purpura Rheumatica.

On page 7 of this number will be found an article upon the above subject

by Dr. Frank W. Garber. We call attention to it thus prominently because of its importance.

While cases of this kind are not very common, they are very often overlooked. Some of them are very troublesome and last a long time, and quite often end fatally.

We recall a case of this kind treated by us some years ago. A woman in the early forties, of fleshy build, married, and the mother of one child almost grown, gradually sickened upon the eve of moving her household goods, with an ordinary attack of mild rheumatism, having about a forty-eight hour onset. There was no heart or other complications at the time, and she responded promptly to the usual treatment that had been success

fully given to her, including the use of the salicylates.

After several days' use of this drug, she developed the characteristic hemorrhagic spots of purpura. She became progressively worse, with occasional intervals of improvement, and with successive crops of these spots, new ones appearing as the old ones dried up and began to fade. The prognosis was grave from the first appearance of these lesions, but her life was not in imminent danger until toward the end of the fourth week of their initial appearance, when she developed decided symp toms of heart failure, and proceeded steadily to a fatal termination within onehalf a week, despite every effort made to prevent it. For a time there were some heart murmurs, but they were probably functional, as she had been subject to previous attacks of rheumatism that always promptly responded to the treatment that was instituted at the beginning

of her last illness.

We mention this case simply to show that purpura hemorrhagica does not always end as fortunately as the cases re

ported in this issue. It is one of the worst adynamic signs that we can encounter in either acute or chronic disease. It indicates a loss of stamina, of recu

perative power, of nerve and vascular tone, that it is difficult to overcome, and that is often the percursor of death. Immediately upon its appearance in all serious diseases, it is the duty of the physician to notify the proper individual of the decided gravity of the condition, and the possible, if not probable fatal, outcome of the illness.

Concave or Saddle Nose.

In our November 1901 issue, we published an abstract by Dr. J. F. Lynch on the cure of saddle nose by subcutaneous injections of paraffin. In an article upon this subject in American Medicine, Dr. ative treatment for the same condition E. J. Senn, of Chicago, describes an operthat is better insofar as it will do in cases not suitable for paraffin injection, and in that it gives a good firm bridge. The method consists in splitting the skin over the top of the nose in the median line, stripping it back so as to expose the nasal bones on each side where they join the nasal process of the upper jaw; at which point they are fractured with a narrow chisel, care being taken not to injure the mucus membrane lining the nose; after which, each fragment is elevated from within, one side at a time, and the elevated mass subsequently supported by the transfixion needle. This has run over it at each end a few layers of gauze, or other soft material, and over this a disc of cork, lead or other suitable sutstance to compress the nose laterally to proper proportions, and maintain it in