presentations, the introduction of the hand to relieve an arm, may extend a light perineal tear. A few other causes for perineal injury are malpositions and malpresentatjons, scarred or rigid perineum, flat sacrum, a narrow pubic arch causing over-distention, and some reflex impulse causing a sudden violent uterine contraction which forces the entire child and instruments out with one pain. In a case of the last variety, in which the contraction or labor pain occurred just as the blades of the forceps were being locked, a complete perineal tear resulted, extending up two and a half inches on the rectal wall. Perineal injuries may give extensive bleeding with sloughing of tissue, may afford an entrance for infection, and later, if they are not properly repaired, may entail such consequences as prolapsus of all the pelvic organs. The almost fatal hemorrhage which may occur, with injury to the clitoris or vestibule, is, fortunately, very rare. Prophylactic measures should be begun during the latter months of pregnancy. Hemorrhoids should be treated during pregnancy, especially in primiparae over thirty years of age. Atresia vaginae needs gradual dilatation. Bands of mucous membrane ex tending across the lumen of the vagina should be cut. During labor, especially when the accoucheur is pressed for time, the temptation to hurry matters is very strong, and it often leads him into making matters more difficult. The amniotic sac should not be opened until dilatation is complete, although in vertex cases, if the position is not faulty, and there is no apparent disproportion between the head and maternal parts, the accoucheur may venture to cut the first stage short, af ter having satisfied himself as to the dilatability of the os uteri, yet in breech presentation, and still more in footling cases, it is absolutely necessary to prolong the first stage as long as possible, even if the bulging sac comes down to the vulva. The bag of waters must not be broken until the dilatation of the cervix is complete beyond peradventure, as this is the only chance we have of preventing the cervix from contracting around the child's neck, and thus interfering with the delivery of the aftercoming head; I will not call it retraction, for the condition must not be confounded with true physiological uterine retraction. In cases in which the anterior lip of the uterus is wedged in between the pubic bone and head, and acts as an obstacle to the progress of labor, it should be pushed up with the side of the index finger, in the interval between labor pains, and kept there until the contraction is completed. Before a resort to forceps, the acchoucheur must not fail to have the patient's bladder and rectum empty. The employment of high forceps, I consider a capital operation, always a dangerous procedure, and it should never be done by the general practitioner, unless he has had considerable experience, for even in expert hands, the destructive results are sometimes unpleasant, although by the use of Tarnier's latest traction forceps we may reduce the degree of injury which may be occasioned. Version is a wiser procedure, especially if the head is not yet engaged, or even if it is so engaged, but yet movable above the brim of the pelvic inlet.. Before applying medium forceps one should make a thorough examination. for diagnostic purposes-the patient being anaesthetized, and the whole hand being introduced if necessary. Having made a diagnosis, the operator should follow the mechanism of labor in that particular position, so that in the extraction he may closely imitate the natural process, never forgetting that a rapid extraction does not signify skill. The grasp of the blades should be occasionally relaxed, thus allowing for rotation, which generally occurs spontaneously. The alternate descent and recession of the head are the best means of over coming rigidity, especially if the parts are small and the head is above the moderate size. Great caution is necessary in the application of forceps in contracted pelvis; when the head has been wedged in for some time, before attempting to introduce the blades, one should always examine to see if a laceration does not already exist. Version should not be undertaken until the dilatability of the cervix and upper part of the vaginal canal has been determined, and even with a dilated cervix there is probability of a tear, if the amniotic fluid has escaped prematurely. As the head reaches the pelvic floor, the rapidity of its progress should be at the command of the operator, who should use chloroform, certainly in primiparae, to control the strength. and the frequency of the uterine contractions, and thereby the rapidity of the expulsion, as it is just at this time that unforeseen injuries in the rectovaginal septum begin. As a preventative of laceration, one physician recently advised placing adhesive straps, two inches broad, on the perineal skin, extending from the labium majus on each side to the hip on the opposite side and another trans 217 verse strip over the perineum. This cannot be kept in an aseptic condition, nor can it save a perineum, which usually tears as a continuation of the rent started above on the postvaginal wall, Dr. Weston has advised the introduction of a deep suture into the perineum, from side to side, when a complete rupture before the head descended upon the perineum is anticipated, so as to bring the parts into accurate opposition. In two cases of elderly primiparae, in which I was certain that an extensive laceration would result, I introduced two strong catgut sutures in a curved fashion deeply into the pelvic floor, anterior to the rectum. The first traversed the tissues just within the nympha near the lower end, one-half of an inch in front of the anus, and came out at the same point in the nympha on the opposite side. The second started about a half inch lower down, closer to the posterior commissure, and followed the same course, anterior to or above the first one, but more deeply situated. The loop thus formed was elliptical and included the sphincter vaginae and transversus perinei muscles, perhaps some anterior fibres of the sphincter ani muscles, and possibly also fibres of the levator ani et vaginae muscle as well as some of the pelvic fascia. The result was gratifying in both cases, as it gave full con-trol over the lacerated and retracted muscles, bringing them in close coaptation, and simplified the subsequent steps in the repair of the vaginal injury. I fully recognize the importance of securing union of muscle and fascia separately, to assure a strong pelvic floor. This method does not produce a bundling of these tissues, but only holds the parts together until the oth er sutures are introduced, both perineal and vaginal. The method is of The method is of value in inevitable laceration, but the exercise of ordinary care will save many cases from injury if the obstetrician will control the advance of the head, thereby preventing too rapid extension of the same, and also caution the patient against applying too much. expulsive effort while the occiput is passing through the distended vulva. The forehead should not be allowed to slip over the distended perineum until the occiput is expelled. If this precaution is observed, it will rarely be necessary to "shell out" the head by pressure through the rectum. Hofbauer, in the Centralblatt fur Gynakologie, No. 5, 1901, describes the following technique for the preservation of the perineum: "The right hand. is laid flat on the perineum, the frenulum is left plainly in sight, and exerts a pressure forward upon the head through the perineum." When the pos terior angle of the large fontanelle appears and the greatest circumference is passing, the head is rotated to one side to throw the strain off the perineum. This "anticipated external rotation" is about 40 degrees. The results, he says, are very good. After the use of forceps, the instrument is removed, when the large fontanelle appears and then the method described above is followed. In occiput posterior positions, the head should not be extended, the anterior fontanelle not delivered, until the margin of the perineum rests in the nape of the child's neck. As this is the time when haste to deliver, will do damage, it is better to allow half an hour to pass, after the head has reached the pelvic floor, before it is permitted to be expelled. The instructions given in works on obstetrics are, support of perineum, pressure on advancing head, chloroform, forceps, and episotomy. With the careful and patient obstetrician these mean very much, yet in some cases any and all of them are of no avail. In breech presentations undue haste will give considerable annoyance, and if the breech seems too large for the canal, Malcolm MacLean's method of dilating the latter by withdrawing the closed fist severel times is excellent. We should use every effort to keep the head flexed, by well and properly directed abdominal pressure. When the cervix has closed around the neck of the aftercoming head, the extent of the injury is influenced by the amount. of traction power exerted. The methods of operative repair of postpartum injuries of the genital canal are so variously described by authorities, that I will confine myself to the treatment adopted in my own practice, and I believe my technique differs but slightly from others. Lacerations of the cervix which are not extensive are not to be repaired immediately, but left for secondary operation, for spontaneous repair sometimes occurs in very bad cervical tears. If hemorrhage is excessive the uterovaginal tampon of sterile or 5 per cent iodoform gauze left in for twenty-four hours, usually controls it. In one case in which the laceration was quite severe, the tampon did not control the bleeding, and it was necessary to press down the uterus, grasp the lips with large forceps and run a catgut ligature around the angle of the tear before hemorrhage was stopped. I used vaginal retractors, and had the patient placed on the table, in order to render these postpartum manipulations less difficult, for it is this inconvenience which interferes with the proper obstetrical work in private practice. Immediate repair of the cervical laceration is rarely successful, whereas trachelorrhaphy two months later gives excellent results. Injuries to the fornix and vagina are treated according to their depth. If superficial, they will heal quite readily, leaving more or less scar tissue, if strict aseptic care is employed until the tenth day. In cases in which I can put in a fine catgut stitch, without leaving any small pockets, where the accumulating and putrefying lochia may act as a commencing nidus for producing sapraemia, or what is much worse, puerperal septicaemia, I do so, but if they are deep, I begin on the second. day by irrigation, and with the aid of a speculum place in them iodoform or sterile gauze, which is renewed daily. In this way they heal by granulation. The two-bladed speculum is not applicable in shallow vaginal tears, as distension of the mucous membrane prevents recognition of them. 219 When I encounter cases of relaxation of the pelvic floor, in which the submucous muscles and fascia have been lacerated without any surface injury, I fully explain the situation before I finish my attendance, warn the patient of the probable consequences if it is not attended to at a subsequent time, and advise the appropriate operative treatment before the uterine displacement and prolapsus have begun to develop. When the pelvic floor and perineum are torn, my treatment varies with the degree of rupture. If but slight, hardly necessitating a single stitch, I advise aseptic cleanliness, bathing the vulva with an antiseptic solution at regular periods and also after each micturition. The toilet, after an evacuation, should always be made in a downward direction away from the vulva, and finished with a local bath of antiseptic solution. To be Concluded Next Month. Medical Miscellany A Diagnostic Chart of Tumors and Pseudo- Battle & Co. have just issued a complete and unique chart on the above subject, compiled by Dr. Edward C. Hill, from standard works on surgery and pathology. The subject matter is divided into solid neoplasma (subdivided into benign and malignant growths), and true and false cysts. The general characteristics of each division are given, and their 24 classes, embracing over 100 varieties, are compared critically in columns under the following headings: Tissue, Topography, Number, Size, Conformation, Color, Consistence, Nobility, Sensibility, Surrounding Tissues, Occurrence, History of Growth, and Miscellaneous Points. Features of special differential value are emphasized by the use of italics. This chart shows almost at a glance for ready comparison all that could be learned in a diagnostic way from the perusal of hundreds of pages of ordinary text. It stands indeed to such books as an atlas does to a gazetteer. This very convenient and valuable compendium is at the command gratis of every practitioner of medicine, who will take the trouble of writing a postal card to Battle & Co., 2001 Locust St., St. Louis. The Treatment of Symptoms. In a highly interesting article on this subject, Walter M. Fleming, A. M., M. D., of New York City, uses the following language: "Long experience in the treatment of diseases in their incipiency, evidences beyond all debate, that almost invariably, the attack in a large proportion of cases is inaugurated by febrile symptoms of greater or lesser severity. Also, it may be noticed that constipation or torpid inactivity of the bowels prevails. Therefore, the first indication in the incubation or incipiency of the attack, of almost any form or nature, is primarily to allay the fever, pain, nervousness and solicitude of the patient, and secondarily to empty the alimentary canal. These two ends being accomplished, a long advance towards a possible abortive issue of the attack has been made, or in any event, the first indication and requirements are fulfilled, in proper progress toward a cure. "Thus, in the primary treatment of the numerous ills, which are characterized by the above quoted symptoms, the physician will find Laxative Antikamnia & Quinine Tablets at once handy, convenient and reliable, safe and sure, and to which the turbulent symptoms of fever, constipation. pain, sleeplessness, nausea and generally wretched depression yield so promptly and gracefully, that it is certainly refreshing to the physician himself, to note the change in his patient, from suffering and solicitude to comfort and quiet. I certainly know of no other remedy which will so readily and decisively allay and control the symptoms above enumerated." Celerina is a powerful stimulant without the depressing after-effects of alcohol, caffeine, nitro-glycerine, etc. It is also a reliable Nerve Tonic. A pleasant exhilaration is experienced after a dose of one or more teaspoonfuls, and under its continued use a renewed capacity for mental and physical exertion results. It is indicated in all forms of exhaustion, mental inertia and senile weakness. It Is a Bad Habit To whip up the waning physiologic functions of elderly people with strychnine or alcohol; after a short time the deleterious reaction is more certain than the primary stimulation. These patients need help of a character not furnished by a powerful stimulent-their functions need gentle reinforcement and, experience proves, the best agent for this purpose is Gray's Glycerine Tonic. The atonic digestive disturbances almost It constantly present in old age are promptly overcome by the use of Gray's Tonic. stimulates the enfeebled digestive glands to secrete abundant supply of gastric juice. This in turn, assists the assimilation of food and improves the general nutrition. Then, too, these patients feel better because the remedy acts as a prop to the entire system; they are less languid, are not so tally more alert. Many physicians report that the routine employment of Gray's Tonic in those patients in whom are present the signs and symptoms of old age. easily fatigued upon exertion and are menimparts a degree of comfort and well-being. free from after-effects, not obtainable from any other medication; one physician states, "It picks them up and holds them together." Another strong reason for the use of Gray's Tonic in elderly people is that it wards off the tendency to inflammations of the respiratory organs; this fact has been noted and commented upon for many years past and is doubtless due to the fortifying action of the remedy upon the general constitution and its specific influence upon the respiratory tract. Experience shows that it is good practice to administer Gray's Tonic to all patients in whom are noticeable the symptoms due to advancing years. The absolute freedom of the remedy from depressing or other detrimental reaction makes it the safest and most preferable means of combating the exhaustion and enfeeblement of age. NEURILLA NERVE CALMATIVE NERVE HEALTH DOSE: Teaspoonful every half hour until then four times a day. |