pleasure of examining the lately published System of Medicine, edited by Dr. William Pepper, in which I find so carefully written, and exhaustive an article upon acute articular rheumatism, by R. P. Howard, that I would gladly, if time permitted, quote from it at length, I am forced, however, merely to summarize some of the valuable deductions which was made from a great variety of observations and statistics, many of which were the well established results of the late discussions of the Medical Society of London. Their conclusions are substantially as follows:

While the Salicylates undoubtedly exercise a remarkable control upon the articular pain and the fever of acute rheumatic polyarthritis an effect to be compared to that of quinia upon paroxysms of ague-nevertheless

1. "Relapses are more frequent-probably considerably more frequent under treatment by Salicylates than under treatment by other methods."

"Authorities are generally agreed that the Salicyl compounds do not arrest or control rheumatic inflammation of the endo, or pericardium, or pleura, or subdue the pyrexia, if these complications in well marked degree exist and there is strong evidence to show that they do not at all constantly prevent the disease from involving those organs, even after the articular affection has subsided under their use. Inestimable as is the benefit conferred by these remedies, in promptly relieving the articular pain and fever, they do not secure the great desideratum in the treatment of acute articular rheumatism-protection to the heart."

In this connection Flint is quoted as believing "that rheumatic endo, and peri-carditis are more common since the introduction of the salicyl treatment than when the alkaline method was relied upon almost entirely" and advising "the administration of alkalies with the Salicylates to protect the heart."

3. "Notwithstanding the prompt removal of the pain and reduction of the fever by the Salicylic compounds, the average duration of acute articular rheumatism is not very considerably lessened by these remedies." "Nor do the Salicylates materially alter the time spent in hospital by rheumatic patients; some evidence indicates that they actually prolong that period." Under this head I give place to the following figures on account of their special interest, which relate to the "average residence in hospital under the

salicylates, according to several recent authors, and are remarkably uniform with but two exceptions: Copland, 36 days; Warner 34.9; Hall, 34; Southey, 32.5; Broadbent, 31.2; Powell, 31; Finlay and Lucas, 29.7; Owen, 23; Brown, 21.9; or a general average of 30.4 days for the salicyl remedies.

Under full Alkaline treatment:-Owen, 26 days; Dickinson, 25; Fuller, 22.2; Blake, 24; or a general average of 24.3 days for full Alkaline treatment."

This as will be noticed gives an average duration of 6.1 days less for the full Alkaline than for the treatment by Salicylates. "These statistics favor Greenhow's opinion, that patients treated with Salicylate of Sodium regain their strength slowly, and are long in becoming able to resume their former occupations.

4. "Certain unpleasant, or toxic effects are produced by Salicylic acid and Salicylate of Sodium; such as nausea, vomiting, abdominal pain, frontal headache, tinnitus, incomplete deafness, vertigo, tremor, quickened respiration, very rarely amblyopia, and even temporary amaurosis, and not unfrequently delirium. A feeling of prostration and general misery is not uncommon."

Practically, the greatest advancement in medical science, during the last quarter of a century, has been in the direction of a more accurate study of the pathology of special diseases and their tendencies, combined with a more judicious use of remedies already known. Thorough knowledge of our remedies, is as necessary to us, as familiarity with his tools to the artizan. Is not this the key to the fact the most skilful physicians use comparatively fewer remedies than the inexperienced? I once heard Dr. Frank Hamilton say of a certain Dr. Mason, with whom he was acquainted, that he so perfectly understood the use of opium as to be able to produce with it almost any desired effect.

Along this line of close clinical observation and study must he our most successful work as practitioners. We must not hesitate to add new remedial agencies to our list when they have been thoroughly tested, but not sooner. The command "Prove all things!" is supplemented by the no less binding injunction "Hold fast that which is good!"

ARTICLE VII.

THE PREVENTION OF LACERATION DURING LABOR.

BY DR. G. D. LADD, OF MILWAUKEE.

This subject is one of especial interest both to the obstetrician and to the gynecologist and yet one who has practiced obstetrics only, can hardly appreciate the extent of the calamity which befalls a patient when there is a laceration of the cervix uteri or perinæum, or which may result from abrasions of lesser extent. If septicemia does not result, the patient may make comparatively good progress toward recovery during the time she remains under observation as a puerperal patient. Her labor has probably been brought to a more speedy termination than would otherwise have been the case, there may be only slight soreness after delivery and during the first few weeks, involution may progress as rapidly as though no injury had occurred. Those who have rightly interpreted the symptoms which follow; who have traced the cause through all the distress, suffering and oftentimes utter helplessness which follows; who have seen women, young in years, become stooped, faded and wrinkled from suffering, whose temper and stomachs are irritable, who are often hysterical and sometimes insane from the constant irritation to the nervous system; those who have seen the early and temporary symptoms disappear under the removal of the cause, such can appreciate the importance of this subject. Right here let me urge the importance of examining every woman whom you deliver, a few weeks after her confinement. If the patient has been so unfortunate as to have a rupture of the perinæum, you can, and should detect it immediately after delivery, but this will not be the case where there is laceration of the cervix. You can also determine a few weeks later whether complete involution is taking place or whether there is any displacement of the uterus. If you do not take this precaution some other practitioner will discover what you have overlooked, or

your patient will continue her complaints to you and remain under your observation an invalid to a greater or less degree.

Probably the most frequent cause of laceration of the cervix is the early rupture of the membranes; this may occur spontaneously and in a certain proportion of cases is perhaps unavoidable but a predisposing cause of this accident may be found in too frequent or too long continued examinations which by removing natural resistance or support may allow the cervix to be unequally distended and rupture.

The

Incalculable harm has undoubtedly been done by physicians in carly rupturing the membranes. The cases which require such interference are extremely rare and teachers unite in saying it should not be done until the os is fully dilated; even then the membranes are of farther service in dilating the vagina and external parts only excuse which can be advanced for interference in this stage of labor is to save time. If your patient is importanate during the first stage it is likely in a large measure from consideration for yourself and in any event should have no influence where her welfare is concerned. The physician who undertakes the care of a woman during parturition should let nothing interfere with his giving all the time that may be required to the case; if he cannot do this he is criminal in undertaking the care of it. The writer has heard physicians boast of "hurrying up" an obstetric case that they might meet some engagement; let us consider how this was probably done. You have all observed how much more frequent and severe the uterine contractions become after the liquor amnii has drained off. This is undoubtedly frequently resorted to as a means of hastening labor and the method is pernicious in proportion as it increases the uterine contractions. Time must be allowed for dilation; safety requires it, and in proportion as this time is shortened or the force increased, the danger of the rupture is increased. Another factor which favors injury where the membranes are ruptured is the substitution of a more or less hard and uneven surface in place of the hydraulic wedge, elastic and pressing equally in all directions, which is the natural means for dilating the canal. By this means, before the first is complete the second stage of labor begins. The uterus now becomes pressed between the presenting part and the pelvic bones and where the head presents it is between two bony surfaces; this causes irritation and as a consequence the contractions

become more frequent and forcible; the practitioner perhaps also crowds back the anterior lip of uterus and the head suddenly passes through the os; fortunate it will be if, bruised, rapidly and unevenly dilated, this part is not ruptured. Another proceeding which is undoubtedly frequently resorted to as a means of shortening the first stage of labor and which may be as injurious in its results as that just described is the pressure made by the finger within the os either before or after the membranes have ruptured. This can be made at any time after the parts are dilated sufficiently to admit the finger and just in proportion as this pressure is continued does it increase the liability to rupture. Rapidity of dilation is not compatible with safety. Pressure at this time causes pain; it excites the voluntary effort of your patient; it may and perhaps does hasten the involuntary contraction of the uterus, but by so doing it interrupts or destroys the rhythm of contraction, if we may so term it, and in like proportion does harm. The greatest injury which is done by pressure of the finger is directly upon the tissues of the os itself. Such force cannot be evenly applied; sweeping the finger around the circle or a portion of it does not accomplish this for the pressure is not upon all parts at the same time. Nature has adapted the strength or resistance of the tissue to the strength of the person; the force which your patient can exert is approximately the force which her tissues will withstand and you can not add your own strength without danger of injury. Furthermore there is an interval for rest and as such it is just as necessary for a safe dilation of the parts as is the shorter time of pressure, for this structure cannot withstand continuous pressure. By either excessive, unequal or continuous pressure, the muscular tissue becomes unequally stretched or torn at some point and by weakening this portion allows the mucous surfaces to tear also.

A small percentage of the cases of laceration are perhaps unavoidable but it is undoubtedly true that injury is far more frequently the result of interference on the part of the attendant.

The perinæum and external parts are subject to the same rules which govern dilation in other portions of the canal, but here it is more directly under the control of the accoucheur. A middle aged practitioner was heard to remark not long ago that he had given up the care of these cases as he had been particularly unfortunate in having laceration of the perinæum occur in his practice. He was