OUR DUTY TO OUR OBSTETRIC PATIENTS.

By E. S. WRIGHT, M.D.,

Salt Lake City, Utah.

This difficult part of our practice has been a subject of great interest to me, not from any particular love I have for it, as I have repeatedly said the first part of my profession to be dropped, if any, will be obstetrics, not that it is less important than others, but that it is decidedly the most tieing and often the most trying practice we have. No matter what the business or pleasure or when participated in, no conscientious physician can rest comfortably after once called to his labor case. No matter what the stage may be, unless he drops everything and proceeds often by no other means than his presence to relieve the anxiety of the patient and friends.

Should he presume to interpret the feelings of unnecessary anxiety and wait his own pleasure, almost certain will the fates step in and rush the business and to his everlasting condemnation and chagrin he will be left to explain something that will not admit of satisfactory explanation, and curses low but long will follow. The importance of this particular practice is emphasized by the numerous operations, to relieve suffering women, performed almost daily after weary suffering and fatigue that might largely be overcome through care and thoroughness on the part of the accoucheur. True, with the best possible care, cases will arise that must be dealt with subsequently. I refer to cases that leave their bad effects upon the uterus and that cannot be reached with a primary operation, owing to condition of the parts at this particular period; especially primary operations for lacerations of cervix which I think is practically abandoned by the best men in the profession.

The great purpose of the physician is to employ such measures as will tend to bring his patients through this severe ordeal in as good bodily condition as possible; unto this end he makes all else subservient, and whatever tends to bring about the desired result must be employed, whether he be detained one hour or seventy-two hours.

Cleanliness, as in all other procedures of a surgical nature, is understood to be his aim, not only at the time of labor but during the antepartum period.

I regard obstetric practice with the deepest concern from start to finish, and as soon as patients come under my observation, and the sooner the better, my rule has been to enter into detailed advice bearing upon each particular case. This advice consists mainly in a careful, earnest talk with the patient about her case, and secure her confidence by a practical assurance you are interested in assisting her as often as necessary with advice or medicine to mitigate one of the conditions of life not easily explained and so much dreaded by all. In this field comes suggestions how best to teach our patients what offers the best means to endure the expected ordeal and overcome the terrors of it.

Not the least is the suggestion that dieting will do no good ordinarily in limiting the trouble, but, on the contrary, patients will often diet themselves at their own expense, as the child will thrive largely though the mother may not, at least the mother will not be in a fit condition to pass through the expected ordeal upon a starvation diet. Hence, I like to see patients hearty and robust before labor sets in. I do not mean a surplus of flesh, as I consider this objectionable, but find no difficulty in overcoming this condition by advice relative to judicious exercise in the open air, and cases that have employed this means have done best in my practice, by strengthening abdominal and uterine muscles and rendering them strong in contractions before and after labor, a very important desideratum, as all will agree. Of course, massage, bathing, sleeping in well ventilated apartments, tend to the same end. The bowels, skin and urinary organs all receive proper attention and such measures advised as will help elimination, so essential to our patient's well being. The breast and nipples properly massaged will assist naturally the defect threatening our generation of a poor milk secretion. To overcome sore nipples and their sequelæ, abscess, cleanliness and gentle but constant manipulation of the nipple between thumb and finger with gentle drawing out imitates nursing and helps better than applications of ointment to ward off the difficulties above referred to.

A qualitative urinalysis is practiced by all up-to-date obstetricians and looked after not once, but a number of times, as time permits; in fact, all avenues of excretion, kidneys, bowels and skin, receive proper attention, and advice not in parables but specific and definite should be given relative to the care of these emunctories. The common belief that swelling of the extremities and face is natural should be discountenanced, and persons taught the natural condition is freedom from swellings.

The above deails carried out earnestly, our patient should be in a condition to go through labor with confidence in the outcome, and under the judicious use of chloroform much of the fear of labor is alleviated, irrespective of the patronizing sympathizers who so considerately offer their suggestions with a shudder as to what has to come.

I do not consider it the first duty upon being called to a case to proceed with an examination, but rather learn to interpret the progress of the case by observing the effect of a few pains and other points of interest which can be determined by an external examination of the abdomen. I consider it a great point gained to be able to attend a labor without a single vaginal examination; at the same time know the progress of the case by other means. This is not an easy matter, however, and often in the interest of all concerned a vaginal examination becomes necessary. The use of synol soap as a lubricant and antiseptic has given me great help in accomplishing the work desired both in cleansing the field of labor and hands of operator. I would like to make a point against the statement sometimes made that instruments can be used with impunity in all cases, as I am informed some persons teach. They have their use, but this paper will not admit of a discussion as to the propriety of using them, but such a general statement as above should only be mentioned to be condemned.

Another point I have been able to accomplish with a certain amount of success is the avoidance of troublesome hemorrhoids, so common as a sequelæ of labor, by supporting with a cloth dipped in hot water at the height of a pain the rectum with its exposed mucous membrane and enlarged veins. In fact, hot water to the perineum generally possesses considerable virtue, as well as being a comfort to the patient, by stimulating the circulation in the blanched and pressed parts.

One of the foremost duties of an obstetrician, when he accepts a case, is to make up his mind to wait and wait the progress of a normal labor, without permitting other matters to thrust themselves upon him and cause him to seek justification in haste, frequent examination, instruments, etc. The condition of the patient is a better guide than a desire on our part to get through and go. This taken into consideration will bring to us often one of the most monotonous routines of life in cases that we have reason to believe should get along better; why a multipara detains us beyond many first labors is not clear, but they do come, and I have sought as an explanation that former lacerations have

healed and left scar tissue to dilate, instead of muscular fibre. Another likely cause is inflammation of the cervix, persisting for a long time, creating a similar condition by following the pathological rule of inflammation-first hyperæmia, congestion, cicatricial tissue and contractions.

The importance of good care during a first labor cannot be overrated, and, to insure it, personally I would favor the rule employed elsewhere that the fee for primiparae be made $35.00, while the present fee governs multiparae.

The immediate repair of perineum has been a rule of my practice, let it require one or many sutures, and I find silk worm gut, fastened with shot, as nice as anything for the accomplishment of this purpose.

I have not deemed it of sufficient consequence to quibble over the minor point as to whether a patient needs a binder or not. I use them, and, certainly, from the way they stay, I cannot see how it is possible for any harm to result. They are comforting and serve as a point for pinning a cloth to support the cotton and gauze worn to absorb disharges.

The uterus, as a rule, is carefully looked after for the first twelve or twenty-four hours, to insure contractions and possibly save some after-pains. Where the uterus is not misplaced and drainage is good, little or no difficulty arises, but in misplacements and poor drainage I have met the greatest difficulty to keep secundines in a healthy condition and prevent sepsis. These are the cases that will cause trouble and necessitate irrigation with or without curetting, preferably, if possible, simple douching without the use of a curette.

Lately I have adopted a plan at the end of a week to use under proper precautions a douche the same as careful women do after an ordinary menstruation. The mental effect is at least good and the physical, at this period, not objectionable.

In regard to feeding there seems to me no good reason why a woman should be limited to a thin and watery diet, but rather be encouraged, especially after the effects of chloroform have passed away, to eat good plain food, but not to excess. My rule is to allow a fair quantity and quality, say, bread and butter, a poached egg, small piece of broiled steak, mush with cream and sugar, and, in season, about the second day, some strawberries, though other fruits generally have not been entirely agreeable. I consider better by far, as a galactagogue, plenty of liquids and nothing better than egg-nog, gruels with cream and sugar, accord

ing to the fancy of the patient. Somatose has reported virtue, but I have not used it to say what good it contains.

My preference is for the above-mentioned foods, believing them to make a quality of milk better by far than that produced by malt extracts or beer.

IN WHAT DOES THE CONTRACT DOCTOR DIFFER FROM THE VETERINARY SURGEON?

By WILL B. DAVIS, M.D.,

Pueblo, Colorado.

In the first place, they are both, usually, men of a variable degree of education. But to equalize in this respect, we will suppose two brothers, twins, of equal physical and mental accomplishments, equal in every way, and of common tastes and inclinations in all particulars, except that one chooses to become a doctor of the ailments of human beings, and the other of beasts.

The doctor of men, then, is what we shall call a physician, and the doctor of beasts a veterinarian.

They each enter upon their respective professions. The doctor of men seeks, and obtains, employment from one or more corporations to administer medically and surgically to their employees. The veterinarian is engaged by several large stock farmers to care for the health of their herds.

The physician and the veterinarian look alike, dress alike, walk alike, talk alike, and are for all the world counterparts, one of the other in everything but the difference in their occupation, if this is to be called a difference.

If there is a difference in their occupations, it has already been defined, in that the calling of one is to administer to the ailments of human beings, and that of the other to the ailments of beasts.

Thus far, each has been engaged to do service according to his desire, and each is to receive about the same amount of pay for such service. Neither the employees whom the physician is to administer to nor the cattle and horses whom the veterinarian is to look after have been consulted, nor, so far, does their relationship to their respective medical attendants differ.