Fifth, rays of different degrees of penetrating power can be filtered out of the emanation from an excited Crooke's tube, by placing in its path various substances, such as sole leather, plain or impregnated with normal salt solution, when it is desired to eliminate those rays that are absorbable by the skin, aluminum when it is desired to eliminate the so-called "soft" rays in general, silver when the rays of high penetration constitute an undesirable factor, etc. Sixth, volume, as well as penetrative power, constitutes an important element in the physiological influence and therapeutic efficiency of this force. Seventh, volume is directly proportional to the amount of current traversing the tube, and indirectly proportional to the degree of tube vacuum. Eighth, the intensity of the X-ray varies inversely as the square of the distance, hence, the location of the source of the rays (anode), as regards its distance from the lesion, and determination of the time duration of the exposure are factors of the first importance. Fortunately these can be calculated mathematically and are easy to ascertain; unfortunately they are as much neglected by the average exponent of roentgenotherapy as they are easy of attain ment. Ninth, it is necessary that the quality and quantity of the rays therapeutically administered, should be under intelligent control and susceptible of measurement, and here we are confronted with a grave difficulty. The penetrating power can be satisfactorily determined by Benoist's penetrameter, and Pfahler's modification of this instrument (Archives of Physiological Therapy, June, 1906), has rendered it entirely safe as far as injury to the operator is concerned; but no practical instrument has yet been devised which will measure ray volume or quantity with any degree of accuracy, and volume is of as much importance in this equation as penetrating power. The operator is therefore obliged to rely upon his experience with his own individual tubes for his estimate of their physiological and therapeutic efficiency, this knowledge of one tube is of no value as regards determination of the index of any other, and every tube is an unmodified interrogation point to any radiologist who has not used it before. It is apparent, from the foregoing, that although a man may be an excellent surgeon or an erudite physician, these qualifications, of themselves, do not by any means constitute him a competent roentgenotherapeutist or justify him in wholesale condemnation of this remedial measure, because of unfortunate results, or a lack of good results which may have come under his observation from roentgenization as it is commonly applied at the present time. The attainment of satisfactory results necessitates on the part of the operator, a good knowledge of the physical properties of the ray, a broad and comprehensive familiarity with its clinical behavior, and an intimate knowledge of the possibilities and behavior of his individual tubes and generating apparatus. These qualifications are, unfortunately, exhibited by but few of those who are roentgenizing pathological conditions today, a generous estimate placing their number in the United States at about fifty, and it is a matter of wonder that there are so many happy results and so few accidents. It is also not to be wondered at, that the vast majority of surgeon-radiologists are much better surgeons than radiologists, but this unfortunate fact is responsible for a very large proportion of the sweepingly pessimistic reports of cases from high sources, that have been ineffectually roentgenized. Due appreciation of these facts is gradually permeating the general professional mind, however, and inducing Roentgen operators to fit themselves properly by conscientious, special study for their work, and the time is not far distant when the beneficent potentialities of this remedial agent will be accorded the high rank they deserve in the management of this most distressing and destructive ailment. Lacerations of the Parturient Canal, their Pre vention and Immediate Treatment. NORTON R. HOTCHKISS, M.D., New Haven. It is not the purpose of this paper to institute new thoughts or ideas on this subject, but its intention is to emphasize the necessity of the proper observance of all injuries to which the parturient canal is subjected. We have undoubtedly reached the position in modern methods of asepsis and technique where it should be a disgrace to the obstetrician of today to leave many lacerated cervices and perinei to the after care of the gynæcist, to say nothing of the almost permanent invalidism of the patient, not only as to the pelvic organs and generative canal, but also to the one great bane of all physicians, the nervous and neurasthenic conditions of these patients, despite all the success gained in a reparative way by later operations. An inspection of a great many cases repaired by the gynæcist will show perfect union and function of the perineum and uterus, but still a train of nervous symptoms follow. We have only to revert to the fact that before these cases met with injuries in their parturition they were healthy and normal individuals as respecting their nervous history. So it becomes a duty which is more and more necessary that the obstetrician of today should be at least skilled enough in his profession to intelligently care for these cases. Indeed, it becomes a matter of serious import as to whether the ordinary midwife, as licensed by our State Boards, is perfectly qualified to attend to this particular phase of obstetrical delivery. One might say that it is all right for the midwife to attend a case so long as she is able to intelligently detect the presence of these injuries so as to call upon a surgeon to repair them. As a matter of fact, how many of these midwives do detect injuries? How many cases are surgeons called upon to repair immediately? It is my impression that very few of these cases are attended immediately by surgeons. It is only after the train of symptoms begins to develop that they reach the hands of the surgeon. While the licensed midwife comes in for a share of the responsibility in these cases, it is still worse to find that a great many reach the surgeon that were attended by reputable doctors, and apparently without any knowledge on the part of the patient or even the doctor that an injury occurred at delivery. will often elicit from these patients the information that the attending physician did not even examine them after the delivery; how, then, can he state that his patient went through a successful parturition? Inquiry A consideration of lacerations of the cervix uteri often, and in fact with very few exceptions, can be laid to injudicious care on the part of the attending physician. Fortunately one of the acts of Nature permits of a sufficient amount of elasticity of the cervix so that rarely an abrasion occurs, if let alone. It is to the credit of the midwives that few injuries to the cervix result, for the plain reason that they let it alone. On the other hand, the doctor, to hurry up the process of delivery, either by the use of drugs, or by mechanical interference in too early rupturing of membranes, or by manual and irregular dilatation of the cervix, or by the use of forceps before dilatation is complete, becomes the injudicious factor in the production of a great many cervical tears. If this first stage of labor is protracted and tiresome to the patient, it would be far better to give an anodyne for rest to the patient, than to use the hurrying process, because the same slow influence at work in the first stage will only be exaggerated in the second stage. On the other hand, a great many deliveries can be shortened and their cervices can be aided in the process of dilatation by a gentle stretching rotatory manipulation with the index finger, or possibly with two fingers. If a condition of a soft dilatable cervix does not exist, it is far better to leave the process to nature. Later, as dilatation is almost but not quite complete, as the occiput engages in the superior strait, it is often recommended by authors to push up the rim of the cervix over the occiput. This in the writer's opinion is one, if not the prime factor in small cervical tears; it is so frequently forced up over the engaging occiput that a tear is bound to result. Here again a gentle rotatory dilatation with the finger will assist without forcing the stretching at one point to ride over the occiput. Emphasis cannot be put too strongly on the fact that forceps should never be put on until dilatation is complete, for the reason that each blade of the forceps in a high forceps application stretches the cervix unevenly. A little stream of blood will often establish the fact that a cervical tear has occurred even before the first strong traction has been made; still the obstetrician is not content to wait, but pulls and pulls on his forceps until not dilatation but tear enough has been produced to permit the head to escape the cervix. Afterwards the doctor contents himself with the thought that "it was a hard instrumental delivery, and something must tear in these cases," when in reality it was his injudicious and untimely use of the forceps. Granting that a tear of the cervix has occurred, opinions differ as to the advisability of repair. Some even go so far as to state that successful primary union rarely occurs. The fault usually lies with the technique; first, improper apposition of the torn edges, and second, on account of the relaxed and usually oedematous condition of the cervix the stitches are placed so loosely that union does not take place. Every torn cervix that can be detected easily with the fingers should receive surgical treatment at once. There is only one contra-indication, and that is hemorrhage with its resulting shock; but even this condition may have righted itself within twentyfour or thirty-six hours, when even then it is proper to repair the cervix. If, however, the hemorrhage should be from the cervical artery, then it becomes absolutely necessary to at once ligate or stitch, or both, as necessary. Repair of cervix is best done in the dorsal position, with the hips over the edge of the bed, the legs flexed and held by assistants, not necessarily trained. A perineal retractor is usually necessary. Tenacula placed in both. lips of the cervix, and drawing down will usually stop all uterine bleeding. Two or three stitches in each tear is usually all that is necessary. An anesthetic is usually not necessary-in fact the patient hardly ever feels the pain of a cervical stitch. Chromi |