HOW TO EFFECT THE EXPULSION OF THE By R. G. WOODWORTH, M.D., Pueblo, Colorado. No more trying time falls to the lot of the physician and none involving greater responsibility in the course of labor than that immediately following the delivery of the child. I have read not a few books upon obstetrics which presume to state all that should be done and what should not be done at this critical period. One says traction should be made upon the cord; another, that pressure externally only should be made, and still another, that while pressure is being made with one hand upon the abdomen, slight traction should be exerted upon the cerd; another, that pressure externally only should be made; every work to explain the dangers of this or that method. It is pretty nearly conceded by all writers now that neither traction alone nor traction and pressure combined are admissible in the extraction of the placenta, but that it should be effected wholly by external manipulation. I believe this to be very good teaching, with one exception, which I shall proceed to mention further on. If you scan the various works on obstetrics extant, you will often be struck with the emphasis which writers place upon what should be done under a given circumstance, but the details how it should be explicitly accomplished are very meager indeed. Now it is this notorious and lamentable deficiency which induces the writing of this article. If a writer on obstetrics teaches that the delivery of the placenta should be effected by external pressure over the womb, does that imply that the directions are sufficiently explicit for the physician, who is not a sage in this line from experience, to go ahead and succeed in delivering the placenta. No, not by any means. Why not? For the reason that the details of the application are wanting. Nothing is said precisely how that pressure is to be exerted, and nothing is said as to the dangers resulting from a wrong application of that pressure. It is true that many cases we all have, where by slight friction over the womb the placenta is expelled, but no one can doubt that if sufficient time were allowed the womb would accomplish this without either the friction or the pressure. Many encomiums are easily won from the laity for which no adequate skill commensurate with the praise has been exhibited, but it is those cases whose successful termination warrant whatever approbation may be bestowed to which I wish to refer. The method which I follow with excellent results, stated as plainly as my language will allow, is this: After the delivery of the child I note for a few minutes the contraction and relaxation of the uterus. After a repetition of this for a few times, I feel quite certain there exists no immediate danger from hemorrhage, and it is then I begin the delivery of the placenta by bimanual pressure. How do I apply the pressure? Take your place beside the mother, press the finger tips down upon the abdomen (the right hand on the right side of womb, the left on the left) beneath the womb, so as almost completely to encircle the same by both hands, and then, not by pressing the womb down and backward against he spine, but sustaining and supporting it, and, if need, gently carrying it toward the vaginal outlet, begin to squeeze it, exerting firmer and firmer force until you are rewarded with the appearance of the placenta and all coagula. If I have made you comprehend my explanation I think you will believe, as I am fully convinced, that this is the ideal way. Pressure with one hand can accomplish nothing in a womb that is not able to take care of itself if sufficient time be allotted. Pressure with one hand has no sustaining power over the womb and only tends to drive it out of place. Pressure with traction on the cord simultaneously is a dangerous procedure, as the pressure is apt to be slight compared with the traction, and, as stated before, tends to displace the uterus. Traction exclusive of pressure is the most dangerous, as this is done with no reference to the contractions, and hence can only result in facilitating the occurrence of hemorrhage. These methods are quite likely to be followed by retention of portions of the secundines, and expose the mother to the additional danger of puerperal fever. Bimanual pressure not only secures safety against retention of any portion of placenta, but also accomplishes the expulsion of all coagula. For aught I know the directions I have attempted to emphasize and elucidate may be just the ones writers on obstetrics. have attempted to render obvious in their works. But as I said before, I searched for some definite scheme by which external pressure might be applied efficiently and skillfully, without detri ment to the mother, and as a means of successfully avoiding those grave dangers of hemorrhage, retention of secundines and puerperal fever. The exception to the successful achievement of bimanual pressure exists, if it exists at all, in strongly adherent placentae of a period less than full term. Such a case I had only this morning, May 21, 1898, in which premature labor came on at seven and a half months. The bag of water ruptured before I was called and before the uterus had dilated to the size of a five-cent piece. The child was delivered nicely, being a pretty dry labor, but when I attempted bimanual pressure for the delivery of the placenta I found it of no avail. The placenta was rigidly adherent and there was a strong temptation to pull on the cord; this I resisted, and so resorted to the only alternative of detaching same with hand; this accomplished, I again resorted to bimanual pressure, whereupon the uterus was emptied of placenta and clots with the facility of driving a cherry seed from its bed by pressure between thumb and finger. I believe every placenta of full time may be driven out by bimanual pressure in toto, together with all coagula, with dispatch and with a self gratification highly pleasing to the accoucher. I shall here narrate a little experience which came to me several years ago at a time when I had no effective and settled plan in my own mind as to the delivery of the placenta. I was taught it was to be accomplished by external pressure (?) and friction. The child was born, and I spent probably half an hour employing pressure and friction, but all to no avail. The nurse in this case-a professional midwife-growing tired, I suppose, at my ineffectual attempts, said: "Let me get the afterbirth for you." She took the cord, wound it several times about one hand, and, seizing this hand with the other, pulled forcibly upon the cord, giving a grunt--may be of delight-as she saw the stubborn thing come away. In this instance no harm was done, I was wiser, and resolved to find a more acceptable and efficient means of accomplishing the delivery without hazarding in any way the life of the mother. Safe to say, this woman and any other who does as she did remain very dangerous personages to jeopardize the lives of mothers by so notoriously wicked a procedure in so delicately exclusive a calling as accouchements. Gross Commencement.-The Gross Medical College held its twelfth annual commencement exercises at the Tabor Grand Opera House, April 25th, 1899, graduating a class of fourteen. The Western Clinical Recorder.-This is a new bimonthly medical publication, designed especially for the general practitioner. It is published at Ashland, Wis., and is conducted by Drs. Fred Jenner Hodges and Wm. T. Rinehart. It appears to be a useful and practical periodical, and we are therefore pleased to make its acquaintance. OTITIS.* By HUGH BLAKE WILLIAMS, M.D., Chicago, Illinois. The more I see of chronic suppurative inflammation of the ear, the more convinced do I become that the element of chronicity is due to lack of thoroughness in treatment. The method of procedure mapped out below will not succeed in cases where necrosis has occurred, but in all others it will reduce the duration of treatment from months and weeks to days. The patient is placed upon the side, with the affected ear up. The concha is filled with Marchand's Hydrozone, which is allowed to remain until it becomes heated by contact with the skin, when, by tilting the auricle, the fluid is poured gently into the external canal. The froth resulting from the effervescence is removed with absorbent cotton from time to time and more hydrozone added. This is kept up until all bubbling ceases. The patient will hear the noise even after the effervescence ceases to be visible to the eye. Closing the external canal by gentle pressure upon the tragus forces the fluid well into the middle ear, and in some instances will carry it through the Eustachian tube into the throat. When effervescence has ceased the canal should be dried with absorbent cotton twisted on a probe, and a small amount of pulverized boracic acid. insufflated. The time necessary for the thorough cleansing of a suppurating ear will vary from a few minutes to above an hour, but if done with the proper care it does not have to be repeated in many cases. However, the patient should be seen daily and the hydrozone used until the desired result is obtained. Care is necessary in opening the bottle for the first time, as bits of glass may fly. Wrap a cloth about the cork and twist it out. by pulling on each side successively. In children and some adults the hydrozone causes pain, which can be obviated by previously instilling a few drops of a warm solution of cocaine hydrochloride. In this note it has been the intention to treat suppuration of the ear rather as a symptom and from the standpoint of the general practitioner. * Abstract from The Alkaloidal Clinic of Chicago for January, 1899. MARCHAND'S EYE BALSAM (C. P. Vegetable Glycerine combined with Ozone) THE MOST POWERFUL AND AT THE SAME TIME HARMLESS HEALING AGENT KNOWN. HYDROZONE (30 volumes preserved aqueous solution of H2O2) THE MOST POWERFUL ANTISEPTIC AND PUS DESTROYER. HARMLESS STIMULANT TO HEALTHY GRANULATIONS. Sure quickly Suppurative and Inflammatory Diseases of the Inflamed and Granular Eye Lids, Etc. FIRST. Wash the Eye Lids (morning and evening) with lukewarm water containing 2 per cent. of Hydrozone. SECOND Apply Marchand's Eye Balsam to the outer Edge of the Eye. Send for free 240-page book "Treatment of Diseases caused by Germs," containing reprints of 120 scientific articles by leading contributors to medical literature. Physicians remitting 50 cents will receive one complimentary sample of each, "Hydrozone" and "Eye Balsam" by express, charges prepaid. Marchand's Eye Balsam is put up only in one size bottle. Package sealed with my signature. Hydrozone is put up only in extra small, small, medium, and large size bottles, bearing a red label, white letters, gold and blue border with my signature. Glycozone is put up only in 4-oz., 8-oz. and 16-oz. bottles, bearing a yellow label, white and black letters, red and blue border with my signature. Charles Marchand, PREPARED ONLY BY Charles Marchand Chemist and Graduate of the "Ecole 28 Prince St., New York. Sold by leading Druggists. Avoid Imitations. Mention this Publication |