From this we see how all important hyperemia is, both in causing the elimination of the infection, and in promoting the activity of the regenerative forces, and I am sure that to one who partially appreciates the defensive and life giving forces of the blood, a preparation, that, when introduced within the soft tissues surrounding the teeth, is capable of producing a marked and lasting hyperemia of the parts. This preparation, which is known as the ethyl borate gas, is especially prepared, at the time of its administration, in a machine particularly adapted to its making.

Necessary Aids

The gas is an unstable oxygen compound, formed by the uniting of the Dunlop compound oxygen with the Dunlop ethyl borate solution. In the free state it is a transparent, semi-volatile liquid of a slightly acrid taste, but pleasant odor. In the gas machine, and under pressure of about one-half an atmosphere, or seven pounds, the liquid becomes surcharged with oxygen from the specially prepared gas in the tank, and is discharged through the needle as a highly diffusible oxyethl-borate gas with the oxygen in loose combination. Upon its release into the soft tissues of the mouth, the oxygen is separated from the compound and passes into the blood, while the ethyl borate is precipitated into the interstices of the soft tissues. Though still active, the oxygen thus liberated is so modified as to have lost considerable of its oxidizing powers, and is taken up by the blood without producing any untoward symptoms. The oxygen joins with the hemaglobin, producing oxy-hemaglobin and liberating the carbon dioxide locally from its union. This, according to Professor Bier, increases either the resistance or phagocytic powers of the blood. The carbon dioxide thus precipitated when taken up by the red corpuscles, causes an increase in their size, and through this they cause a dehydration of the blood serum that results in a concentration of the opsonins contained therein. By this concentration of the opsonins, and possibly to some extent from the alkalinizing effects of the carbon monoxide, as suggested by Bier, the phagocytic powers of the leuccocytes are greatly increased, and the infection is correspondingly diminished.

In general, this seems to be the effect produced by the oxygen liberated from the gas. The ethyl borate precipitate, which falls deep into the tissues, produces its effects by causing a stimulation of the vasodilator nervous mechanism locally, in such a way as to cause almost immediately a most distinct hyperemia to be established. It is this hyperemia which means so much as our foremost therapeutic agent, but which alone, and unaided by our other efforts would be quite ineffective in its curative prop

OBSTETRIC CLINIC, KANSAS CITY GENERAL HOSPITAL

Under the auspices of the Medical and Surgical Club, held March 12, 1918.

By Geo. C. Mosher, Senior Attending Obstetrician, and Buford G. Hamilton, Junior Attending Obstetrician. Gentlemen:

It gives us a great deal of pleasure to see so many of you interested in the work which everyone of you who is engaged in general practice must himself, encounter in his own experience.

Surgery of a major type is of value to you, mainly from the point of diagnosis, and you send the patient to an expert operator in whom you have confidence. Obstetrics you will yourself manage in a great majority of instances.

I see a number of my old students here and to them the clinic must be of peculiar advantage practiced several years ago. as a contrast to methods which we taught and It is hoped that these ward walks and clinical demonstrations may attract each month those of you who care to follow out the demonstration of modern obstetric practice. You are always welcome.

The greatest interest which is being manifested in the domain of obstetrics and gynecolthose points which pertain to lessening shock ogy today is on the question of diagnosis and have in the series of cases shown today an opand minimizing dangers of sepsis. We shall portunity to see how these are manifested.

The first patient, Mrs. C., is a primip, aet 32. Her blood pressure ranges from 140 mm. to 160 mm. Her urine shows albumin and casts. She has some headache but no other symptoms. She has been in ineffectual labor for 36 hours with an R. O. P., cervix somewhat softened but no engagement. We find by the tape that her McDonald measurement is 37 and by the pelvimeter that the Ahefeld is 26, these being interpreted that the Ahlfeld is 26, these being interpreted should indicate a foetus of 52 c.m. Now you will understand the calculation of the length of the foetus by external measurements is not exactly a mathematical one but it is wierd and sometimes astonishing how near we come to the total length of the foetus by the estimate which is, of course, always verified post partum by measuring and weighing the baby. The reason for delay in this case which has pelvic measurements 29-25 and 191⁄2 c.m., is that the head has not rotated and therefore there is no adjustment possible of the head and the pelvic canal. We do not avail ourselves of the other pelvic measurements if these three are reasonably harmonious, but if

either is abnormally short the interval or true conjugate and the inter trochanteric by Whitridge Williams pelvimeter is also taken.

Having concluded that the patient is at term and the labor being ineffectual the cervix should by rectal examination to be undilated and the presenting part free above the inlet, we are to decide as to whether we advise an immediate caeserian section agreeing with our friend Rudolph Holmes that obstetrics is a lost art or else we set about to assist nature in her attempt to bring the labor to a close by means more in harmony with the plan of voluntary emptying the uterus by trying to supply the elements to the problem which nature has aparently failed to bring into play. That is dilatation, better flexion and more forceful efforts on the part of the pains which are stimulated by the Vorhees bag according to the plan worked out by Charles B. Reed of Wesley Hospital, Chicago, and reported by him in S. G. and O., a series of 1000 cases.

Please note that stress is to be put on first, accurate diagnosis; second, failure of powers of nature; and third, supplying the artificial help in a manner least likely to cause shock, interference with mechanism, loss of liquor amnii or infection. All these we believe we find in the Vorhees bag properly placed and carefully watched. Barnes fiddle bag we have not found as efficacious although some of our confreres still employ this veteran agent. You will observe we use slight anesthesia in the introduction of the bag. This is our own variation as Dr. Reed introduces the bag without an anesthetic. We have found that the average patient is very apt to be apprehensive of any operative interference in labor and in her shrinking from being hurt she becomes panicky, delaying the process and working herself into an emotional stew which is not conducive to the best efforts to help herself because she has become exhausted. Dr. Geo. F. Pendleton, who has usually given the anesthetic for me, has acquired a facility of keeping the patient at just about the proper degree of analgesia, not a definite anesthesia and she usually rouses as soon as we are through with the placing and filling the bag. Dr. Buford Hamilton, my junior attending, has in the meantime filled the bag into a roll occupying the least possible space and firmly grasped it by a Paen forceps, having first satisfied himself the bag is perfect, that is, that no leaks exist. We use a metal piston syringe for filling, although Reed prefers an ordinary Davidson syringe. Our dilatation is done with a set of the old reliable Hegar's dilators graduated up to 20. The latter admits the large size bag. The dilators are passed rapidly as you see to avoid unnecessary delay and as soon as No. 20 passes readily the bag is introduced. It will be observed that we use long retractors instead of bivalve speculum. This is

perhaps a matter of being more familiar with the retractors. Also the dorsal position is used rather than the lateral for the same reason. The cervix is held down firmly by two vulselli, one in either lip of the cervix. This is also a refinement over some operators' technique and really is an aid in accurate placing of the dilators and the bag with the least delay.

The bag being placed is held by a long uterine dressing forceps within the uterus while the water is slowly forced into the cone of the rubber bulb. We secure the rubber pipe of the bag by folding it on itself and slipping on two of Pettit's funis clamps; a bit of adhesive adhering to the lower abdomen keeps the bag in position while it is doing its work. The patient is re turned to bed and in a variable period from 20 minutes to six hours labor is on. It is usually some what shorter than a similar labor in which no artificial stimulus is employed.

Let us repeat: we have never yet ruptured the membrane nor has any patient developed after labor is inaugurated, an infection.

You will observe that McDonald and Ahlfeld have been several times mentioned, and in order to make it clear it may be well to explain just what is meant by these names used in an obstetric sense.

Several years ago Ahlfeld said it was not a matter of pride to be able to boast of having delivered a patient of a 12 pound baby but a disgrace that the average mother should be unnecessarily mutilated and subjected to shock because of the terrific stress of a long labor and the overgrown baby so often born asphyxiated or suffering from brain lesion due to difficult forceps operation. He devised a method of measuring the child in utero, placing one end of the pelvimeter, thus, at the upper border of the synphysis and the other at the fundal pole of the uterus. He then read the index, subtracted 2 c.m. for thickness of the skin and multiplied by two which he declared gave the length of the foetus from vertex to sole, and was able to prove it post partum. McDonald reached the same end by using a tape measure thus, over the parabola described by the contour of the maternal abdomen and taking 35 c.m. as indicating a foetus. of 50 c.m. total length maintained that such a measurement meant a foetus at full term. Ahlfeld took the diameter between the points of the pelvimeter and if it measured 27, he subtracted 2 for the skin and doubled the 25 which also gave 50 as the length. Now, we are not always willing to induce labor on account of the measurements alone, but in case of indication of interference we agree with Dr. Chas. B. Reed that in the cases where labor has been induced for cause, our post partum results have agreed with the antepartum calculations with at most 2 c.m. variation.

A paper which is now under preparation

gives the remarkable results we have had during the past year in treatment 21 cases of eclampsia and pre eclamptic toxemia by a systematic plan of procedure in which the mortality has been less than in any other reports we have seen. Twenty-one cases have been under observation and all on a generalized plan. Elimination-removal of foci of infection-combating acidosis and in every instance where these prophylactic measures failed to reduce blood pressure or to clear up classical barometic readings foretelling the storm which was approaching the uterus has been emptied and usually by the Vorhees bag

method.

In those cases in which convulsions have succeeded each other in rapid sequence with long hard undilated cervix which menaced the patient if she were allowed to go on in labor caeserean section was done. Each of these patients recovered. Of the entire number all recovered but one which had been delivered before entering the hopsital and who died from a general septic infection three weeks after all convulsions had ceased.

I mention these facts to show you the promise held out in regard to a system of treatment which is standardized. I hope this afternoon to be able to show you the results of this induction if you are in the hospital.

This second patient, Mrs. L., a primip aet. 22, had her last menstrual period May 5, 1917. Her pregnancy has been uneventful and laboratory findings negative. Her measurements show crests 28 c.m., spines 24 c.m., and Baudelocque 20, blood pressure 124 systolic and 70 diastolic. McDonald 36 and Ahlfeld 27.5, which indicates that she is probably at term and the baby 50.5 cm. length. She will have C. O. and Q. and then e allowed to wait developments for 48 hours if nothing transpires.

The third case is a breech. Mrs. S., wife of a soldier, she entered the hospital expecting to be confined within the week. Her McDonald is 34 so as the presenting part is not engaged we estimate she will probably go over for two weeks.

The next case, Mrs. O., a primip, has been in labor 4 hours, she is a normal case aet. 26 L. O. A., and is having twilight sleep given under direction of our interne, Dr. Olsen. The remarkable thing about scopolamine in labor is the relief from shock which the woman experiences when under this semi-narcosis. While scopolamin analgesia has been greatly criticized in this country and was originally condemned in England, a glance at recent British obstetric literature will convince one that the profession is becoming more and more appreciative of its beneits. Articles have recently appeared in the Britsh Medical Journal, the Medical Press and Circular, and other journals giving results of cases

in series, commendatory in tone concerning results.

We use scopolamin when indicated especially in high strung nervous patients and in these in which a long tedious labor is anticipated. This patient has had her second dose, the first having been narcophin gr. .5 and scopolamin gr. 1-200, the second following in 34 hours scopolamin 1200 alone. We have had no blue babies, no hemorrhage nor other maternal grief. The only precaution being in these cases they must be watched throughout as often the baby is born. suddenly and unobserved otherwise, the mother being only semi-rational under her analgesia.

At 4 p. m. We have the satisfaction of showing delivery of the patient on whose case induction with the bag was done at 11 a. m. The voluntary delivery is without incident. Your attention is called to the method of keeping the head flexed to avoid laceration, and the suggestion of the Rotunda Hospital, Dublin, a hemostat placed on the cord at the vulva to indicate by its dropping 2 inches outside, when the placenta is in the vagina. No effort is made to dislodge the placenta. A policy of watchful waiting is always best to follow in this stage.

The final branch of our service is the tragic one, "Northwest Three" in which you see our series of abortions. In these beds are the women who in fancied desperation plot the destruction of their unborn children. Some of them are inevitable, of course, but the great majority deliberately induced. We have now five cases of inin this ward ten and fifteen admissions a week. complete infected abortion; at times there are

The results of treatment here constitute our especial pride as we have, against much opposition, demonstrated the value of a conservative or "hands off" policy in treating abortions as against active interference.

Several years ago, to be accurate, in 1914, we began to see that the universal curettement which was fashionable at that time resulted in a vast morbidity and considerable mortality and coming across the writings of Winter, who in 1911, showed a death rate ranging from 11 per cent to 23 per cent in various clinic centers in Europe, we became convinced that a conservative method might give better results. Since that time no abortion has been curetted in our service and we will just glance at the record and call attention to the old regime in contrast:

In the curettement series 1909 to 1914 a hundred consecutive cases showed 221⁄2 days in the hospital, 72 per cent of complications cellulitis, abscesses, etc., mortality 8 per cent. From 1914 until the present, these cases are treated by being placed in the modified Fowler position, given an ice bag over the abdomen; a brisk dose of mag. sulph., and when pain is excessive a hypo of morph. . We have now treated 358 cases

by this expectant plan and our results are days. in hospital 8 1-3; complications 5 per cent; mortality none. There have been two deaths which were of women who had been curetted outside before admission.

When we view this merely from the standpoint of the tax payer, leaving out the welfare of the patient, it is a startling picture, reducing the expense of each patient two-thirds and of course the patient incidentally profits by the conservation. Friends and relations of patients have stormed and outside physicians have often criticized the negative plan of treatment, internes look askance when the temperature moves to 105 and a foul smelling discharge persists, but they are reassured and after observing a few cases won over to our technique.

If we may summarize the service of a day's development in the department, we should like to call your attention to the following essential points:

First, all examinations of prospective maternity patients are by external palpation ausculation and pelvimetry. No vaginal examination is permitted in the division.

Second, the McDonald and Ahlfeld measurements determine when the case is at term. Of

course, these are taken in connection with the calendar history of the patient. On this depends the question of the maturity of the foetus. Third. All toxemics are endangered by the burden they carry, and when prophylaxis fails to relieve them, the ideal mode of induction of labor is by the Voorhees bag rather than by digital or accouchment force dilatation.

Fourth. Patients are tranquilized by scopolamin and suffer less from shock in twilight sleep. We have seen no blue babies, nor ill effects from the use of scopolamin, but the benefits of its exhibition are apparent to any intelligent unprejudiced observer.

Fifth. Infection and its attendant grief to the patient is practically ruled out of the General Hospitals in "West Three" wards by techniqueisolation of cases coming in with temperature, avoidance of vaginal examination.

Sixth. The waiting policy of the third stage, no attempt to deliver the placenta until the hemostat indicates it is in the vagina is the safe and sane method of procedure.

Seventh. Daily examination and recording the height of fundus determines when the lyingin woman is convalescent. She goes home when the fundus is not apparent to touch above the symphysis and the lochia has been for fortyeight hours free from red or brown color.

For prickly heat, apply with sponge, two or three times a day, a two per cent solution of sulphate of copper; cure in three days.

NOTICE

The Illinois Vigilance Association has issued four pamphlets on the problem of venereal diseases for inexpensive or free distribution, as circumstances may require.

Copies will be sent free of charge to anyone sending a self-addressed and stamped envelope. The Association is a welfare organization incorporated "Not for Profit."

The pamphlets are as follows: "Lord Kitchener's Instructions to Soldiers," "Three Great Army Records," "For Our Sons," a translation from the French, by Prof. Alfred Fournier; "For Our Daughters," a translation from the French by Dr. Charles Burlureaux, member of the Society of Sanitary and Moral Prophylaxis of

France.

Three Great Army Records and Prof. Fournier's pamphlet each contain unusual and extremely valuable information. Lord Kitchener's Instructions greatly improved condition in India, while the pamphlet For Our Daughters is an excellent pamphlet on a difficult problem.

Removal-The Physicians Supply Company, whose establishment at 1021 Grand Avenue was

recently destroyed by fire, will occupy new and commodious quarters about the 15th of May in the Lathrop Building, southeast corner of Grand Avenue and 10th Street. This company has been doing business since 1887, and has established an enviable reputation among the members of the medical profession. The general manager of the company, Mr. Allan J. Hughes, wishes to extend his thanks to his patrons for their indulgence during the time his company has been handicapped as a result of the fire. He wil be pleased to have his friends call at the new quarters and inspect his stock, which will include everything new and up to date in the line of surgical and hospital supplies, with a special department for fitting trusses, supporters, and elastic hosiery.

The Neurological Bulletin is the name of a new monthly journal published under the auspices of Columbia University by Paul B. Hoeber in New York City. The editor is Dr. Frederick Tilney, Professor of Nervous Diseases in the Medical Department of Columbia University, and the associate editor is Dr. Louis Casamajor. The first two numbers, for January and Febru ary, have appeared and contain much valuable material gathered from the weekly clinical conferences of the Neurological Department of the College of Physicians and Surgeons. There is a great wealth of material in this department which is worthy of permanent record and neurologists generally will welcome this journal which, while the most recently established, promises soon to be among the leaders in neurological literature.

ASSOCIATE EDITORS

P. I. LEONARD, St. Joseph.
J. M. BELL, St. Joseph.
JNO. E. SUMMERS, Omaha.

CONTRIBUTING EDITORS
H. ELLIOTT BATES, New York.
JOE BECTON, Greenville, Texas.
HERMAN J. BOLDT, New York.
A. L. BLESH, Oklahoma City.
G. HENRI BOGART, Paris, Ill.

ST. CLOUD COOPER, Fort Smith, Ark.
W. T. ELAM, St. Joseph.

JACOB GEIGER, St. Joseph.

S. S. GLASSCOCK, Kansas City, Kan.
H. R. HARROWER, Los Angeles, Cal.
JAS. W. HEDDENS, St. Joseph.
VIRGINIA B. LE ROY, Streator, Ill.
DONALD MACRAE, Council Bluffs.
L. HARRISON METTLER, Chicago.
DANIEL MORTON, St. Joseph.
D. A. MYERS, Lawton, Okla.
JOHN PUNTON, Kansas City.

W. T. WOOTTON, Hot Springs, Ark.
HUGH H. YOUNG, Baltimore.

The Editors' Forum

Doctors May Contribute
to Magazines

Washington, April 3, 1918.
Chas. Wood Fassett, M. D.
Editor Medical Herald,
Kansas City, Missouri.
Dear Doctor:

In reply to your recent letter to Dr. Franklin Martin of the Council of National Defense, the Surgeon General directs me to say that there is no objection to officers of the Medical Reserve Corps contributing articles for the medical press. If, however, these articles in any way bear upon the writer's connection with the military service the manuscript should be referred to the Surgeon General's Office for permission to publish it, before it is sent to the printer. Yours truly,

R. B. MILIER, Colonel, Medical Corps, N. A.

(Authority to Publish)

Medical Official Rank

Why not give medical officers official authority to enforce medical and sanitary recommendations? To do this official rank is necessary. The medical man is the man of the hour today in assembling our army recruits and surround

ing them with health facilities to make them vigorous for action. Only healthy men can win this war and the medical men must select them, keep them well and save with great skill the maimed.

Without ranking authority, high efficiency can not be obtained and maintained. History will repeat itself as in past wars; for instance, as in the Spanish-American war, when thousands of preventable deaths resulted from preventable diseases. And why? Because the little shoulder straps of the medical man were too little to dictate orders to the big shoulder straps of the line officer. Thus recommendations got little further than the recommendation stage, disease producing conditions incubatingly flourished and a long list of deaths was the sum total of a psychological twist that keenly appreciated the sullied indignity of taking orders from an inferior in rank. The average schoolboy of reasoning age would view this action as silly and still it is true. It's wonderful how difficult it may be to communicate with a notch higher shoulder strap in some instances. Not that the decoration is at fault, but the evolutized human nature under it seemed to fail to humanize in its ascent.

There is no reason why a non-medical line officer should pass on the merits of a medical proposition made for life saving efficiency. He is incompetent though his shoulder straps be as big as the moon. Neither is he competent to pass on the brilliancy or non-brilliancy of the medical diagnosis or the procedure of the operating room. That the talent of the most learned and scientific medical and surgical procedure shall await condescending approval of the nonmedical line officer while preventable disease pollutes and destroys, is all wrong. Medical and surgical efficiency in the army means medical rank with authority to enforce the carrying out of necessary medical orders without delay. The Owen-Dwyer bill, lingering in the files of the senate military affairs committee, if passed favorably, will largely authorize medical men to do their duty without hindrance in keeping our soldiers well. Letting mothers' sons die of preventable diseases in our armies is a crime against the hearts and homes that gave them.

And another feature of unrecognized service. Does any one realize that local examining boards and medical advisory boards are supplying and paying their own expenses, giving all of their time if necessary, and working their heads off all over this country, assembling the rudiments of our armies, cheerfully and untiringly doing their bit, without even a button on the lapel to indicate they are serving our country? Why? Is it because they are just physicians? Is it like the negro, when chastized for beating his mule, who said, "It's no bizness to bin a mule."