to the prevention and the pathology of disease, and grossly neglect the study of its cure.

Too much theory in practice is as bad as too much medicine. One good remedy to cure a disease is worth more in practice than many splendid theories concerning its cause or pathology. Never mix medicine and religion together in the same prescription; when spiritual advice is desired, let it come from a specialist in that line.

The two do not mix well, as their effects are directly opposite. The one tends to encourage them in making a speedy trip to the next world, while the other, by a few well selected doses, and a good assurance that they are going to stay long on earth, has deprived them of making the trip to see their Saviour for years.

We always do more good for ourselves, our patients and the profession, by trying to see how good work we can do, than by finding fault with the bad work others have done.

Cheap prices for services have never gained one-tenth as much practice as making good cures.

POST-PARTUM HEMORRHAGE AS A

NEUROSIS.

BY A. F. KINNE, A. M., M. D.

The time of the society being limited, and as there are still remaining a large number of valuable papers, to the reading of which we want to listen, I propose to omit the first part of my paper, which consists of a brief résumé of the numerous remedies, procedures, and appliances for the arrest or prevention of a post-partum hemorrhage, with which our literature has abounded since the peculiar virtues of ergot were discovered, near the beginning of the present century, and commence in medias res:

But the physiology of the whole parturient process is fundamental. Such an exuberance of literature upon a single topic, from such eminent sources, and so really valuable, is bewildering. The young practitioner cannot easily thread his way through such a wilderness as this, and be prepared to meet these terrible emergencies, knowing at once what to do first and how to be just right all the time, or, what is of far greater importance, be able in all cases to foresee the impending danger and prevent its occurrence, without thoroughly understanding the curious laws that govern the three stages of labor, and especially the third and last.

The first law is, that every contraction of the uterus, during the first and second stages of a labor, must be followed by a period of complete relaxation and repose. To preserve the life of the child, the action of the uterine muscle must be intermittent. Without these periods of entire release from the pressure to which it is necessarily subjected, no child could ever be born alive.

But in the third stage of the labor we are confronted with a new danger to the mother. Another problem of organic life is

to be solved. The placenta is to be detached from the intrauterine walls, and a dangerous and possibly fatal hemorrhage from the large and wide open mouths of the utero-placental vessels at the same time prevented. And to accomplish this result the character of the uterine contractions must be entirely changed. They must cease to be intermittent and become rigidly tonic and permanent.

And it is important to remember here, that such a change as this in the action of an involuntary muscle, cannot occur suddenly, as in the action of a piece of mechanism; the intervention of a certain amount of time is indispensable. A locomotive engineer touches a lever and instantly the action of his machine is reversed and the train moves in the opposite direction. Pluck a heart from the thorax of a living animal and the organ does not appear to recognize its altered circumstances at once; it goes on beating for a while after it is laid upon the plate.

In every case of obstetrics, therefore, attention must be carefully paid, without a failure, to the two following points, both of which have reference to the prevention of a possible hemorrhage.

First, Make a study of the patient's nervous system, and especially of the nerves of organic life. Are these nerves in a normal condition, and, at the critical moment, will the change in the character of the pains of which we are speaking come about with promptness and vigor? And

Second, As soon as the child is born, the hand of the accoucheur should go at once, or at least without unnecessary delay, to the abdominal region over the uterine fundus. The purpose of this proceeding is not to make immediate and indiscriminate pressure there, but to keep the practitioner promptly informed of the manner in which the uterus is behaving itself; to enable him to make some pressure there should a complete or a nearly complete relaxation occur after the placenta has begun to be detached; to enable him, in Playfair's expressive words, to "follow the contracting uterus down;" and finally, to make forcible compression of the uterus after what is now called Crudé's method, in case the unassisted contractions are alone insufficient to complete the delivery by the time when dangerous relaxations of the uterus shall have ceased to recur.

But the navigation at this point is somewhat difficult. There is a Scylla on the one hand and Charybdis on the other, and we

must sail safely between them. In the one case the placenta is delivered too soon, before a state of permanent contraction has rendered the uterus solid. This may happen where the unaided uterine contractions are too vigorous, or where manual assistance has been had in requisition too soon. In either case, when a full uterine relaxation recurs there will be a post-partum hemorrhage, and this, we believe, is the most common form of the disaster. The late distinguished Reuben Dimond Mussey lost his first wife in this way, and because, as he used with weeping to confess to his pupils, he did not at that time know the remedy-the prompt introduction of the hand, to take the place of the placenta, which should, if possible, have been retained a little longer, and also to stimulate the dormant energies of a lagging system of

nerves.

The other case is where help is not afforded in season and the uterus closes down and becomes permanently contracted around the placenta still retained within the uterine cavity. This is the hour-glass contraction of the old writers, but the name is unimportant. It might just as well be called the rolling-pin contraction, or the multilocular contraction, or the dead baby contraction. The uterus takes the form of whatever is contained within it. And the last mentioned case, which is the same in principle, is where nature, exhausted, abandons the job unfinished, and the uterus becomes permanently contracted around its entire contents.

All these cases are liable to end up with a dangerous hemorrhage, and to the old obstetricians they were simply a terror. The difficulty was to overcome the wooden rigidity of the uterine muscles in order to get room in which to operate, and to procure a new permanent contraction afterwards for the arrest of the floodings-the whole business an interference with nature's own plans, a contradictory and well nigh an impossible proceeding. But at the present time, with ergot to change the character of the uterine contractions; chloroform to control temporarily these new contractions; supra-pubic pressure; position, in case the feet are to be brought down; and finally, but not of least importance, the practice of hot water irrigations to mitigate the effects of too long continued intra-pelvic pressure, these cases, though still very grave, have become comparatively much safer and more manageable.

There are cases of post-partum hemorrhage, of course, with which a defective innervation has had nothing to do. Such are the cases which are caused by retained pieces of placenta, by lacerations of the cervix, and so forth. But I am not writing an exhaustive paper upon this accident, and will only remark in passing that those hemorrhages that continue after some degree of contraction has been secured are best treated by hot water irrigation. This measure is not only among the best and safest of our hemostatics, but it fulfills, moreover, better than anything else, the conditions of our new antiseptic midwifery.

Indeed, it would seem that the use of hot water in surgery is rapidly gaining ground. Dr. Engelman, of St. Louis, now holds that a douche of water at a temperature of from 115° to 125° F., delicately small, but delivered with some force, is more destructive of atmospheric germs than the spray; and for checking capillary oozing and keeping clear the field of the operator, better than the sponge. And the place which hot water irrigation has established for itself in the lying-in room is a very important one, indeed it is indispensable. For the alkaloids of decomposition, which are intensely poisonous, and which are formed out of that portion, or those elements of the animal substance which these parasites reject,cannot be generated except by those microbes that get out of the uterine passages and find a lodgement within the living tissues. And in this situation they are protected; they are beyond the reach of an ordinary antiseptic injection; and experience has shown that they can be destroyed in no way so readily and so effectually, as by raising the temperature of the entire pelvic cavity and maintaining it for a short time at from 110° to 120° F. When, therefore, in treating a case of post-partum hemorrhage, the question of a resort to the use of hot water comes up, we need not hesitate. It never does harm; it is effectual, except where the placenta or a portion of it is retained and cannot very well be out of place.

And the same is true of the administration of ergot as a preventive. It is always in order, because it coöperates with nature in changing the pains from intermittent to permanent. And the practitioner who follows Tyler Smith, and gives it in all cases just before the head passes the vulva, will never find that he has made a mistake in so doing.