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before the mouth of the womb is sufficiently dilated to allow the child to pass. It is true that the first stage of labor can be shortened by inserting the fingers into the mouth of the womb and instructing the patient to bear down with the abdominal muscles, but the second stage will be correspondingly lengthened and the danger to both mother and child increased. To be constantly tugging at the anterior lip of the cervix for the purpose of saving time or appearing to do something for your patient is inexcusable; besides, as a result, you will see a bruised and torn cervix-the most prolific cause of sub-involution, displacement and disease of the uterus in women who have borne children.
It is, or should be, at the close of the first or beginning of the second stage that the cervix slips over the head of the child, but this may be delayed until the head is almost ready to pass over the perineum. If in any case it becomes necessary to dilate the cervix, do it as nearly as possible like nature herself would do it, from above downward, by thoroughly cleansing and oiling the hand, introduce it into the uterus, close the hand so that the fist will become almost as large as the head of the child; now make gentle traction during the pains as the fist passes out, making ample room for the head of the child to follow. This will effectually do what you have failed to do by rupturing the membranes and trying to dilate from below with the fingers.
Tears in the cervix are much more detrimental to the health of a woman than partial rupture of the perineum. You may look for such tears in the long axis of the head of the child; that is, if the child is in the first position, you may expect the tears in the left side of the cervix if it be unilateral, and the opposite if the child is in the second position.
The membranes should never be ruptured until ready for the second stage of labor, because, if they remain intact, the head of the child will recede as soon as the pain is off, thus prolonging this stage of the labor, which is nothing to compare with a like condition in the second stage. I have mentioned some injuries that take
place in the second stage of labor, but thought proper to mention them here as this is the only time to take steps to prevent them.
Anesthesia is not to be thought of in the first stage of labor unless it becomes necessary to forcibly dilate the cervix in the manner mentioned above, but it is quite as necessary to get relief from a portion of the suffering during the first as the second stage of labor. Chloral hydrate has been so effectual in my hands I have never found it necessary to seek for a better remedy.
It frequently happens that the patient lives in the country and the physician is pressed for time. The question would naturally come up as to what he should do under such circumstances. I answer, if there are any complications he has no right to leave his patient; if not, it is better to give her proper attention in the first stage as to diagnosis and preparatory treatment, and leave her with some neighbor who has been instructed what to do provided the child is born in his absence, and leave her to nature during the second and third stages rather than hurry her into the second stage before dilatation of the cervix is complete.
DR. H. W. CROUSE, Victoria: I can not understand how the author of the paper just read can arrive at the date of confinement so closely. I have been practicing medicine for years, and have had many cases of obstetrics, but have never been so fortunate as to get my date of labor fixed so accurately. The concensus of opinion of obstetrical men upon this point today is that we can never exactly state when labor will occur. The general rule utilized today, I believe, is the taking of the last menstrual period and counting from that 280 days. We find this to be fallacious, because, as is legally recognized by the English and American governments, some women may only go 240 days and some as far as 320, but that 280 is the mean average. We have to take into consideration the well-known fact that menstruation may continue for the first three or four months of pregnancy. I have come in contact with one case which menstruated the entire nine months, every twenty-eight days. Utilizing the period of quickening as the data, we have found that this varies at least one month. Frequently the statement of the patient is incorrect, from the fact that she may take intestinal gas, and its accompanying gurgling movements, etc., for fœtal move
ments. We have, after summarizing all of the points from which we can build up our conclusions, but one which is absolutely accurate: that pregnancy positively exists; that is, the foetal heart beat. The first period, which we are able to secure the confirmation of pregnancy through this means also varies decidedly. Playfair, Lusk, Granden and Jarmon, Hermann and others tell us that we may be mistaken, and that after all careful investigation that there is but one positive sign of conception, and that is the fœtal heart beat. At the termination of the first stage of labor, the dilatation of the os by means of the fingers is a rather difficult proposition, and, in the average case, I believe should not be attempted. In my opinion, we should simply make a careful pelvic measurement, a careful examination as to the presenting part, and, having made up our diagnosis as to the presentation, leave the case entirely alone if everything is found normal. Why we should hasten labor and cause extra exertion on the part of the woman with a normal pelvic cavity and presentation is beyond my ken. In my opinion, such efforts are simply meddlesome midwifery. When we are called into the country and have to make the first pelvic examination and find a normal presentation, the best thing to do is to let your patient alone —that is, if you wish to avoid the liability of infection.
SECTION ON SURGERY.
CHAIRMAN'S ADDRESS. THE RELATION OF ANATOMY
WM. KEILLER, F. R. C. (Ed.),
In opening the Section on Surgery I have first to thank you very heartily for the honor you have conferred upon me in making me Chairman of the Section. From the time I joined the Association, eleven years ago, I have endeavored to identify myself with the Surgical Section by frequent papers, and I fear by too great a tendency to get on my feet on all occasions, and no official position could have been more welcome than the one which I occupy today.
That anatomy is one of the foundation stones of all sound medicine and surgery is a truth that does not need to be emphasized to this Association, and yet as a teacher of anatomy, and especially of human anatomy as it must appeal to the doctor, I feel that I have something to say for my subject which is worth while. Great progress has been made in the past ten or fifteen years in the practical application of anatomy to surgery. With aseptic methods, reliable ligature, which can be buried in dozens with little fear of their giving trouble, in days when pus in a primary operation has become a reproach and a synonym for dirt surgery, the field for successful operation has become enormously extended and there is no organ in the body which may not have to be approached by knife or suture. Surely, then, it is time that surgical applied anatomy become a prominent feature in the curriculum of every medical school.
Let us think for a moment of some of the things that exact anatomy has done for surgery. Among amputations Syme's amputation at the ankle-joint, Taraboef's on the upper third of the leg, hip
joint, shoulder-joint and interscapula-thoracic amputation are triumphs of careful or faulty amputations that we see are evidences that there is more anatomy in the principles which should govern good amputations than some would make you believe. I do think that text-books on operative surgery dwell too little on the anatomic basis of successful stump-making in each section of the extremities. There is all the difference imaginable between taking off a member and getting the best possible stump; and it is nearly all a question of the careful application of general principles to the anatomy of the part, the varying retractility of the muscles, the distribution of the blood-vessels. But amputation is the last resort of the good surgeon, and conservatism is the watchword of the modern surgery of traumatisms. And it is here that an accurate knowledge of the interrelations of muscles, vessels, nerves and bones will enable one surgeon to save, while another would sacrifice a limb, on which, perhaps, depend a wife and children for life's necessities. In abdominal surgery it is marvelous what anatomy and asepsis have made possible. One noticeable feature of modern abdominal surgery is the passing away of large pedicles. The largest ovarian tumors are only fed by the ovarian and uterine and a few adventitious vessels, and these are looked for intelligently and secured in small ligatures, where several years ago great pedicles were strangulated in silken ropes and complicated Staffordshire and other knots. The uterus, however large, is only supplied by two arteries on each side and these secured, its removal, except for adhesions, is comparatively simple. But the ovarian and uterine arteries are very close to the ureters, and the surgeon who has a vivid picture in his mind of their interrelations will, other things being equal, be the safer operator. It is the careful anatomic work of Kelly and my own. contemporaneous but the less known work on the blood-vessels of the kidneys that has put exploration of the pelvis of that organ on a sound anatomic basis, and to Kelly we owe the rules for its safe performance. A little anatomic rule tells the surgeon at once which is the upper and which the lower end of the first piece of collapsed or distended bowel he may meet in operating for intestinal obstruc