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"Weak, nervous and trembling after slight exertion."
Back came the "diagnosis" letter, which read: "According to my diagnosis what you need to cure you completely is a thorough special treatment from the Spitting up of Mucus, Pains and Soreness Across the Back, Poor Digestion, Constipation, Nervousness, Defective Elimination and Uric Acid Conditions."
The words that we have italicized are those that had been filled in on a typewriter. The "full-size treatment" sent in this case consisted of the four boxes containing the pills labeled respectivly: Prescription Numbers "16759," "29408," "30651" and "4039"-price, $3.
Another letter sent from a small town in Illinois had a cross placed against the following symptoms: "Have sick headache."
"Are depressed in spirits."
"Have twitching of the muscles."
The "diagnosis" letter to this supposititious patient read:
"According to my diagnosis what you need to cure you completely is a thorough special treatment for the Headache, Poor Circulation, Stomach trouble, Depressed Spirits, Twitching Muscles, Defective elimination, and Uric Acid Conditions."
Here again the words we have italicized had been filled in with the typewriter-and the same boxes of pills were sent. Another symptom blank the Journal had mailed from a town in Ohio with crosses against the following:
"Are troubled with catarrh."
"Are depressed in spirits."
"Have too frequent desire to pass water." Quack Jiroch "diagnosed" this case:
"According to my diagnosis what you need to cure you is a thorough special treatment for the Catarrh, Dizziness, Depressed Spirits, Bladder Trouble, Defectiv Elimination and Uric Acid Conditions."
In this case, too, the recipient of the diagnosis got the same stock "full-size treatment" Prescription Nos. 16759, 2940, 30651 and 4039-with the usual request for a remittance of $3.
From a city in Pennsylvania the Journal had a symptom blank sent in describing as well as is possible by mail a case of diabetes mellitus. The person sending it in stated explicitly that he had diabetes and also put crosses against the following:
"Are losing flesh."
"Feel weak and all run down."
"Have boils and pimples on face and on neck." "Have too frequent desire to pass water." Diagnosing by mail is, of course, an anomaly. The scientific value of a diagnosis of ailments in persons who have never been seen and whose symptoms are described by the persons themselves is nil. Nevertheless if any conclusion at all could be reacht regarding the hypothetical case just described, it must have been that the patient was suffering from diabetes mellitus. What did Jiroch say?
"According to my diagnosis what your case requires now is a thorough special treatment for the Kidney Trouble, Itching Skin, Impure Blood, Nervousness, Headaches, Defectiv Elimination and Uric Acid Conditions."
And the treatment? The same "full-size treatment" sent to the sufferer from consumption, rheumatism, etc., that is, Boxes Nos. 1, 2, 3 and 4 (Prescriptions Nos. 16759, 29408, 30651 and 4039). Worse yet, the diabetic-in common with all others-was told: "For your case I would advise a mixt diet."
A "mixt diet" recommended to a supposititious diabetic to whom the starches in such articles as bread, biscuits, potatoes, etc., and sugars, sirups and sweets might, in the amounts ordinarily taken, be deadly! A mixt diet, indeed!
Other diagnoses just as worthless as those detailed above could be given, but these are sufficient to make plain the worthlessness of the diagnosis and the fraudulence of the Jiroch "treatment." Yet the Jiroch concern said about Jiroch:
"I am a specialist and I do not have one remedy that cures everything . . . My special treatments are made up of my own private preparations perfected after years of successful practise."
One thing will be noticed regarding the fake diagnosis. No matter what other ailments the patients were supposed to have, they were all suffering-according to Jiroch-from "Defectiv Elimination and Uric Acid Conditions." Whether it was a case of consumption, kidney disease or "female trouble" every person whose case Jiroch professed to diagnose
was a sufferer from "defectiv elimination and uric acid conditions."
The Postoffice Stops the Fraud.
The matter preceding represents the investigations made by the Journal some time ago. That which follows is taken largely from the memorandum of Assistant Attorney-General Lamar to the postmastergeneral recommending the issuance of a fraud order. Judge Lamar's report says that after a thoro review of the evidence submitted with the report of the postoffice inspectors who investigated the Dr. Jiroch Company he finds the facts to be as follows:
"The Dr. Jiroch Company and Dr. Jiroch_are engaged in selling medicins thru the mails. In order to obtain the names and addresses of persons to whom they may direct their solicitations, they advertise in newspapers and magazines having a general circulation thruout the United States."
A typical advertisement is then presented, of which the assistant attorney-general says:
"It will be noted that the representations contained in this advertisement are calculated to lead the reader to believe, among other things, (a) that for the purposes stated Dr. Jiroch will give free to anyone suffering from any of the symptoms described and responding to the advertisement a treatment for the permanent relief of the disease from which such person is suffering; (b) that this treatment will consist of special medicins adapted to the particular disease from which the applicant is suffering; (c) that Dr. Jiroch can and will diagnose and determin the disease from which the person so responding is suffering by means of the check marks placed before the symptoms set forth in the advertisement; and (d) that he can by this method cure kidney and bladder ailments, rheumatism, stomach, liver and bowel disorders, heart trouble, nervous weakness, catarrh and all other diseases arising from impure blood, uric acid conditions, etc."
Then follows the statement that those who answer the advertisements receive a stock letter, one of which was put in evidence, and with the letter the so-called free proof treatment which was "the same in every case.' The advent of the second letter was described and the letter itself put in evidence and the fact noted that the person who had answered the advertisement was sent, unaskt, a "three-weeks' treatment," for which he was expected to send $3. Then the memorandum continues:
"In the investigation of this case letters were written to the Dr. Jiroch Company by the inspectors under assumed names and askt treatment for the turn: following conditions in (1) 'Severe headaches for some time and no medicin will give me any but temporary relief,' (2) 'A bad cough that I have had for quite a while-am all the time hawking and spitting,' (3) Loss of sexual power,' (4) 'Simply will not make flesh-otherwise well,' (5) "Too fat and bust lacks development,' and (6) Female troubles.' In each of these cases, except that numbered 5 above, the applicant was sent the correspondence quoted above, and the affection of the applicant was diagnosed as follows: (1) Headache, defectiv elimination and uric acid conditions; (2) cough, spitting up slime and mucus, defectiv elimination and uric acid conditions; (3) failing manhood, defectiv elimination and uric acid conditions; (4) being too thin, defectiv elimination and uric acid conditions, and (6) female trouble, defectiv elimination and uric acid conditions. In case numbered 5 the applicant was written a letter in which she was advised that the symptoms given by her were rather unusual in combination and askt to give further particulars. In reply the inspectors gave the following information: "Thirtyone years old, 5 feet 5 inches high, weight 154 pounds, not much fat on my breasts, have been fleshy ever since I was a young girl, both parents dead, father small, mother fleshy, breasts always have been flat.' Thereon the respondents sent to the writer the same letters as were sent out in the other cases, diagnosing her affection as obesity."
The Claim of Individual Treatment. The judge notes further:
"If a remittance is not received promptly in response to the letter accompanying the treatment for which a remittance of $3 is askt, other letters are sent the sufferer in which he or she is advised, among other things, that 'the treatment I sent you is exactly what you need,' that it was made up of my own private prescriptions, especially for your individual requirements,' that 'the treatment is a thoro one for every symptom and condition you describe, and designed to cure you permanently,' and
that 'I made a careful diagnosis of your symptoms and made up a treatment for the ailments you told me you wanted to be cured of.'
"The evidence also shows that when a remittance is received and a report blank submitted, it is the practise of the respondents to advise the remitter that his case requires further treatment and to send him another supply of medicin for which they ask a remittance of $5, together with another report blank, on the receipt of which, filled out, they send him more medicin, and so on; and that the purpose of the representation that they have reserved for his use a free 'two-weeks' additional treatment' to be sent him after the receipt of his remittance of $3 and the report blank filled out is to give them an opportunity of sending him additional medicins, for which they ask further remittances.'
The memorandum then states that the post office department had the assistance of some well-known practising physicians of Washington, while, on the other hand:
Dr. Adams Testifies for Jiroch.
Mr. Dobyns introduced and examined as an expert witness for the respondents Dr. Nathaniel H. Adams, of Chicago. The physicians called by the government testified that the symptoms set forth in the advertisement of the respondents, taken alone or in combination with any or all of the others, were symptoms of a large number of diseases; that each of these diseases required different treatment; that it was utterly impossible to tell the cause of these symptoms from the information obtained in accordance with the system followed by the respondents; that some of the diseases giving rise to those symptoms were incurable or only curable by a surgical operation, and that a postponement of proper treatment in many of those diseases would be dangerous.
"These facts are so well recognized as hardly to require expert testimony to prove. They were admitted by Dr. Adams, who stated it as his belief, however, that the marking of the coupon in the manner directed by the prospectiv patient would afford to the respondents a clue by the use of report blanks, they could in the course of time determin with some certainty the disease from which he was suffering." Then Judge Lamar continues:
Only 2% Admit Benefit.
"I find from the evidence in this case that whether this treatment prescribed by the respondents is of value in any case where given in accordance with this system is entirely a matter of chance; and that this is well known to the respondents. That this is a fact is shown not only by the evidence above referred to, but also by the testimony of Inspector Angier, who conducted the investigation in this case. Inspector Angier wrote to a large number of patrons of the respondents, and only 2% of those who replied stated that they had been benefited by the treatment given to them. There are also a large number of complaints in the case, alleging dissatisfaction.
90% of the "Diagnoses" Made by Clerks. "Inspector Angier also testified, and no evidence to the contrary was submitted by the respondents, that but about 10% of the coupons on which the diagnosis and treatment are predicated are considered by Dr. Jiroch. The rest of the blanks are handled by clerks, who place on them numbers indicating the disease from which the applicant for treatment is suffering; these numbers indicate the medicins to be sent and the names of diseases or symptoms to be filled in in the diagnosing letter by other clerks. ters sent out, however, altho forms, are printed in imitation of typewriting and bear the signature of Dr. Jiroch in facsimile of handwriting.
In summing up. Judge Lamar says:
"From the evidence in this case it is clear, and I find, that the representations in the advertisements and circular matters of these respondents are false and fraudulent in that:
"1. Dr. Jiroch does not give free for advertising purposes a remedy for the permanent relief of disease; but on the contrary requires from persons who answer the advertisement a payment for the treatment which he prescribes.
"2. Dr. Jiroch does not intend to 'go over your other questions and symptoms and prepare my answer in full, and to pay careful attention to every phase of your trouble and write you fully in a day or so and tell you what else ought to be done to cure you completely,' as represented in the letter accompanying the free treatment, but intends to at that time send the addressee in a few days a form-letter
made up by a clerk, together with certain medicins put together by a clerk, in accordance with the system followed in the conduct of this business.
"3. The free treatment does not consist of medicins adapted to the particular disease from which the applicant is suffering, but is in fact merely a tonic and laxativ sent to all alike without regard to the particular symptoms of the individual case.
"4. The respondents cannot and do not determin the disease or affection from which the applicant for treatment is suffering by means of the marking of the symptoms set forth in the advertisement; and therefore cannot and do not prescribe medicins adapted to the cure or relief of the disease from which such applicant is suffering, unless by chance. "5. The respondents do not know whether or not the applicant is curable, for they do not have sufficient information on which to determin this fact.
"6. The respondents cannot by this method cure kidney and bladder trouble, rheumatism, stomach, liver and bowel disorders, heart trouble, nervous weakness, catarrh and all other diseases arising from impure blood, uric acid conditions, etc.; but on the contrary this system is utterly impractical and any benefit resulting therefrom is due to chance.
"The postmaster at Chicago reports that the respondents receive approximately 275 pieces of firstclass mail daily."
As a result, the assistant attorney-general for the postmaster-general recommended the issuance of a fraud order which, as previously noted, was put in force June 24, 1914.-Journal of the American Medical Association.
How to Proceed Against Unlicensed Practicians.
The State Board of Medical Examiners of the University of the State of New York give the following instructions as to the proper method of procedure when it is desired to drive out an unqualified practician in that state, which may serve for other states:
1. Make sure that the practician is not registered in the county clerk's office; the law requires that all practicians shall register their licenses with the county clerk.
2. Obtain evidence, sufficient as a basis for a complaint, that the practician is attempting to diagnose or to treat human disease, injuries, or physical conditions.
3. Send a written complaint to the district attorney along with a request that he prosecute the illegal practician under Section 174 of Article 8 of the Public Health Law.
4. If the district attorney refuses to investigate the complaint, notify the Governor, who has the authority to remove from office district attorneys ⚫ who refuse to do their duty.-New York Medical Journal.
CURRENT MEDICAL THOUGHT.
Some Signs of Danger in Labor and How to Meet Them.
Dr. J. O. Arnold, Associate Professor of Obstetrics, Temple University, Philadelphia, in the New York Med. Jour., declares that the prolonged severe pain of labor, in highly nervous women, is capable of producing most serious injuries, among which are puerperal insanity and profound neurasthenia; while postpartum bleeding, puerperal infection, failure of lactation, delayed involution, and prolonged convalescence are all made more probable by labor which leaves the nervous system rackt and prostrated, and the energies of the patient almost completely exhausted. These are some of the direct effects of unnecessarily severe suffering, while it may lead to attempts to terminate labor artificially because of this suffering, which may result in injured babies and lacerations. It is often very difficult to say when the danger point has been reacht. Each case is a study in itself, and must be handled according to its own peculiar conditions and surroundings. Much relief can be given, and the process of dilatation greatly facilitated in many cases, by the judi
cious use of morphin, either alone or combined with hyoscin or scopolamin. My own experience would lead me to recommend a more general use of these drugs.
Brief reference to a case or two will illustrate my point. Not long ago I was called upon to terminate labor in a young, extremely nervous primipara whose pains had become so severe in the last four or five hours of labor that she and the family friends were frantic, and insisted that the doctor must use instruments and end her suffering. found dilatation not more than one-third complete, and advised a quarter grain of morphin, to be repeated when necessary, and the packing of steril gauze against the undilated os. The doctor
reported later that after six or seven hours of comparativ rest, the packing was removed, dilatation found to be complete, and in a short time an easy delivery took place, with no ill effects on the child, and certainly with greatly conserved strength and nerve energy on the part of the mother. I have seen the same happy results in many similar cases, and emphasize the fact that with these drugs in the first stage of labor, and preferably chloroform in the second, we may successfully meet and control most of the danger arising from excessiv pain.
[Straub, in Münchener Med. Wochenschrift, called attention to the danger of combining morphin with general narcotics and hypnotics. In a case where chloroform was given after a preliminary injection of morphin for a minor operation death resulted from respiratory paralysis, altho the general narcosis was not a deep one. means of experiments in rabbits it was shown that the slowing of the respiration remained for several hours after the injection of morphin, and if a general narcotic or hypnotic had been administered, this rate was further diminisht. In Dr. Arnold's method of using the morphin in the first stage and the chloroform in the second there might be sufficient time elapsing between to permit the morphin effect to wear off. In case it had not, the chloroform would probably not be needed.
We submitted this article to Dr. Arnold for personal correction, and he writes us as follows in regard to the subject of anesthesia:
EDITOR MEDICAL WORLD:-I have just read the proof sent me. Have no corrections, I believe, except as to the interjected reference to Straub's paper-and no serious objection to this, but I was not favorably imprest with the value of his observations on this line when I read it some time ago, for I have seen, especially in my internship at Jefferson Hospital, morphin used almost routinely by one of the chiefs there for years, as a preliminary for general anesthesia, and with nothing but good results. This has often been corroborated in my experience and observation at Samaritan Hospital also. However, my practise is not to give morphin and then chloroform-seldom or never have had to do this. The thought I wanted to convey was that where anything had to be given in first stage, morphin and scopolamin or hyosin was the preferable and comparativly safe thing to use; but where the woman reacht the later, second stage, without anesthetic, then chloroform was preferable. You see, I did not mean to combine the two, altho I have often seen it done without harm.
has been given a wide reading, and therefore Dr. Arnold's experience with the same in great numbers with uniformly good results is a very important matter and deserves equally wide attention. We do not have to fear them now, as we had since reading of Straub's experience. Our readers will be glad to learn of the actual safety of this method of producing anesthesia.-ED.]
Comparativly few, if any, primiparæ escape lacerations. In multiparæ, of course, the percentage of tears is not so high. It has been estimated that some degree of laceration takes place in fully 90% of all full-time deliveries.
Many physicians give as the cause of tears, "too short a time in labor," while others assign the cause to "too great a disproportion between mother and child." About 50% of physicians, according to my canvass, are using no other method to prevent lacerations than the so-called "protection of the perineum" with the hand, and this should probably be named as a third large factor in the production of tears. My own opinion is that the support or pressure of the hand on the perineum has never prevented many tears, and there are good obstetricians who go further than this, and say that such pressure predisposes to tears.
If too rapid labor is a large factor in producing lacerations, then we must meet this sign of danger by anesthesia and such other methods as will give the soft parts time to dilate. This means that in practically all difficult labors, if the obstetrician is to give his patient the benefit of the kind of service to which the seriousness of her case entitles her, he must have some one to help him.
The number of torn vaginas and perineums could be very greatly lessened by the aid of a good anesthetist, and the family physician is as fully justified in calling an assistant to help him prevent a serious laceration as he is in asking for help in the repair of such an injury. More time, more anesthesia; more careful study of the conditions present, with a view to correcting malpositions, etc.; all of which means the more frequent employment of an assistant, constitute the accepted methods of preventing lacerations after labor has begun.
Dangers may come to the child from overzealous efforts at preventing tears; especially from taking too much time for the outlet to dilate when for any reason the condition of the child demands haste. In such cases, as in many other cases where tears are seen to be inevitable, episiotomy is undoubtedly indicated, as, for instance, in a recent A primipara had been in labor about thirtysix hours, with extremely hard pains a greater part of this time, when her physician detected weakness of the fetal heart sounds and called for help. Dilatation was about complete, the head was well engaged, but high, and the condition of the child called for immediate action. Ether was given at once, forceps applied, and the head brought down to the outlet without difficulty; then a good, free unilateral episiotomy was done. The delivery was easily and quickly completed, the child was saved, and the mother's soft parts sustained no other injury than the clean posterolateral incision, which was easily sutured.
Bandl's Ring.-Cæsarean Section. Another sign of danger to be lookt for in protracted labor with severe pains and little or no progress, is that of a high contraction ring and con
sequently a dangerous thinning of the lower uterin segment. Not only is the child's life in jeopardy in such a case, but as we well know, there is imminent danger of rupture of the uterus, with all that that means, especially if any manipulativ or instrumental assistance is undertaken.
Some years ago I was called to do a forceps delivery on a very large, strong woman who had failed to deliver herself after many hours of hard labor. The head was in normal position, but was scarcely more than engaged, and dilatation was complete. On examination, Bandl's ring_was found to be high and tightly contracted. Fully aware of the danger, I introduced my hand as carefully as I could to determin more about the condition, and in doing so ruptured the extremely thin uterus below the contraction ring. Without further manipulation, the patient was at once removed to a nearby hospital, where I opened the abdomen, removed the dead child from the abdominal cavity into which it had escaped, and sutured the ragged rent in the uterus. Fortunately, the patient made a perfectly normal recovery.
What might have been practically a repetition of such a case came under my care in the service of Dr. Applegate, at the Samaritan Hospital. A small, frail woman, aged 26 years, who had had one difficult forceps delivery, was brought to the hospital after she had been in labor for more than forty-eight hours, and after two attempts at forceps delivery. Examination revealed a comparativly large, firm, head only partially engaged. It was also easy to discover thru the thin abdominal wall that Bandl's ring was unusually high, and therefore the lower uterus unusually thin, and while there was little hope of saving the child, I had no hesitation in deciding that the only safe delivery for the mother was by the abdominal route. More than a half hour of valuable time was lost, however, before permission to operate was obtained, and by this time the fetal heart could not be heard; but the threatened rupture of the uterus was still a positiv indication for Cæsarean operation, which I proceeded to do. We were unable to resuscitate the child, but the mother made a remarkably rapid recovery.
Spinal Anesthesia in Obstetrics.
A word as to the anesthetic used in the latter case may be of interest. Here was a frail, weak woman, who had vomited almost daily thruout the course of pregnancy; who had been nearly three days in labor, with two or three attempts at forceps delivery. It was evident that her failing strength should be conserved to the utmost in the operation about to be performed. In such cases spinal anesthesia by the Babcock method is a veritable godsend. Whatever else may be said of it, I believe this form of anesthesia has a special field of usefulness in obstetrics. It can be easily given by turning the patient on one side, is promptly effectiv, greatly lessens the operativ shock, does not interfere with uterin contractions, lessens hemorrhage, and favors early convalescence by the almost entire absence of postoperativ gastrointestinal disturbances. In all these respects, it workt beautifully in this case, as it has in many similar cases. In the past four or five years I have used it or have seen it used, in all kinds of emergency or other obstetric cases, and have come to look upon it as the anesthesia of choice in most operativ work in hospital obstetrics, at least. In the operativ measures in eclampsia, especially, I have found it to be well nigh ideal.
Hemorrhage from Premature Detachment of Placenta.
Hemorrhage of any considerable amount occurring in the course of labor is another sign of danger that usually must be met promptly and wisely if the life of the child, to say nothing of the welfare of the mother, is to be safeguarded. Such hemorrhage practically always comes from a premature separation of the placenta. The important question is to decide if possible whether the placenta that is being prematurely detacht is high or low in the uterus. The treatment may depend in large measure upon this knowledge. Here again the report of a case or two may be more practical than the recital of abstract methods. Some two months ago I had an elderly primipara, who, when she had almost completed the second stage of labor, began to have rather alarming hemorrhage. It was quite evident that the placenta was being prematurely separated, and that it would be necessary greatly to hasten the birth of the child if the bleeding continued. The hemorrhage was more profuse when the uterus was relaxt between pains. Stimulation of contractions, therefore, was the first and easiest thing to do. This failing, quick forceps delivery was the alternativ. Fortunately the hemorrhage was controlled by massaging the uterus into more rapid contractions, which at the same time hastened the delivery-so much so that it was impossible to prevent a perineal tear, which might not otherwise have occurred. Illustrating another type of bleeding in labor was the case of a woman with the history of having bled rather freely with the onset of labor. This was a multipara with considerable dilatation, thru which I could with difficulty barely reach the abnormally situated placenta. Under the circumstances, rupture of the membranes was the treatment indicated, thus permitting the placenta to retract with the uterin wall, which effectually controlled the bleeding, and spontaneous delivery occurred some four or five hours later. In another case, the margin of the placenta could be easily felt projecting into the half-dilated os. Here careful packing of the vaginal vault tightly against the lower uterin segment, with counterpressure over the fundus, controlled the hemorrhage, and in three or four hours so softened and dilated the os that I easily was able to do podalic version and deliver a living child without excessiv bleeding.
Cæsarean Section for Placenta Previa.
Still another patient with a much more alarming sign of danger from this source was operated upon at the Samaritan Hospital only a few weeks ago, by Dr. J. C. Applegate, with whose permission I use the case for illustration. This was a large, stout multipara, who, shortly after the beginning of labor, bled so profusely that her physician, acting wisely and well, securely packt the vagina and sent her to the hospital with a diagnosis of pla centa previa centralis. Under spinal anesthesia Dr. Applegate did a Cæsarean operation, and found the placenta completely covering the internal os a condition that under any other method of treatment means the death of the child in at least 75% of cases, and an extremely great risk to the mother. With the aid of pituitrin given some fifteen or twenty minutes before the operation, the mother lost very little blood, suffered practically no additional shock from the operation, and made an entirely satisfactory recovery.
Pituitrin Dangerous for Child.
A few words as to the child may be of interest,
tho not an essential part of my illustration. While perhaps two or three weeks premature, yet the child appeared to be well developt, and breathed and cried as soon as born, but gradually weakened and died about twelve hours after birth. Dr. Applegate and those of us who assisted him have speculated as to the probable cause of death. There certainly was no traumatism. The mother had bled freely, but this was forty-eight hours before, and her condition was good at the time of operation. The long interval of no bleeding had presumably restored the child's losses, in part at least, and its heart sounds were well heard before the operation. Having had pointed out to me in the Wertheim clinic of Vienna the fact that pituitary extract absorbed from the mother may have a fatal effect on the child, under certain conditions, causing it, even when apparently normal at birth, gradually to weaken and die some hours later, it seems the most probable cause of death was the administration of pituitrin to the mother long enuf before delivery for a previously weakened child to have received a fatally toxic dose. While, of course, this is but a theoretical suggestion, yet I have recently collected enuf reports of otherwise inexplicable deaths of the newborn where pituitrin had been used on the mothers, to make me quite careful to know the condition of the child before I employ this very useful and at the same time very dangerous obstetric aid.
Protracted labor, with that peculiar type of suf fering, both mental and physical, so often seen when the efforts of hard labor are unavailing, is always a sign of danger, and should be met by the most careful study of the conditions present. Here, I am quite sure, is where many grievous obstetric sins are committed. Either there is no attempt to find the cause, or the attempt is a failure for want of an assistant and anesthesia. A hopeless disproportion recognized at the earliest moment after a fair test of labor, and met according to the indications; or a faulty presentation or position corrected, as it so often can be corrected under an anesthetic, means all the difference between success and failure in scores of cases. Thus, in one case, on examination I found a large head still freely movable and a promontory that could be reacht with the greatest ease. Trying the head in the inlet bimanually, which is often the only practical form of pelvimetry, left no doubt of the impossibility of safe delivery by the vaginal route. În another case the head had descended well at first, but in spite of extremely hard pains, there had been no further progress for four or five hours I had chloroform given at once, for the peculiarly aggravating noneffectiv pains, with the head for several hours almost on the pelvic floor, indicated beyond a reasonable doubt that the condition was one of malposition, and would therefore require anesthesia to correct it, if not to make the diagnosis. I found the occiput in the hollow of the sacrum. Bimanual rotation was quickly and easily done, and upon removal of the anesthetic the patient required no further assistance.
In a third case, a diagnosis of right occipitoposterior position was easily made by palpation and the history of the labor. Vaginal examination under chloroform verified this diagnosis. As it is not so easy or so desirable to rotate the head when it is yet high in the pelvis, I applied forceps and brought the head down to the pelvic floor in the course of least resistance, namely, with the occi
put posterior. The forceps were then removed, a perfectly easy bimanual rotation done, and under light anesthesia the child was born without further aid and in good condition.
The method of bimanual rotation of the persistent occiput posterior consists of introducing the oversupinated left hand, or half hand as the case may require, into the vagina, with the ulnar border pointing upward toward the mother's left, the thumb pointing downward and toward the mother's right, and the palmar surface of the fingers against the right side of the child's head. With the external hand, pressure is made thru the abdominal wall above the symphysis, against the left frontal region of the child's head, downward and toward the mother's left; thus holding the head in the pelvis, keeping it in a state of flexion, and combined with the action of the internal hand pressing the occiput forward from the right, quickly and easily produces the desired rotation. At the same time the assistant, who is usually the anesthetist, greatly facilitates the maneuver and prevents the tendency of the head to return to its former position by swinging the body of the child from the mother's right side toward the median line, and holding it there by pressure of the hand on the abdomen.
1. The important pathogenic diplococci are: The diplococcus gonorrhoea, diplococcus meningitidis, and diplococcus pneumoniæ.
2. Germicide is an agent which kills microorganisms. Antisepsis is the inhibition of the growth of microorganisms. Asepsis is the absence of microorganisms.
Steril is the condition of a substance when all microorganisms have been killed or removed.
Disinfectant is an agent which removes or kills infectious microorganisms.
3. Essentials to the life of bacteria: Most bacteria require proper temperature, generally at or near that of the body; oxygen is generally needed, those that cannot live without it being called aerobic, and those that can grow without it anaerobic; nutriment of a proper kind, containing, both organic and inorganic materials; a slight degree of moisture; a medium of slightly alkalin reaction, and rest. Individual bacteria may require modifications of the above essentials. 4. Cover glass preparations may be stained by Ziehl's carbolfuchsin method, Gabbett's method, Gram's method, or Loeffler's method with methylene blue. (See QUESTIONS 5 AND 7.)
5 The fluid must be centrifuged for a long time. of the sediment is placed on a slide with a small quantity of egg albumin; it is covered with some carbolfuchsin, and allowed to steam over a small flame for about two minutes,