she does not like it if that most frequent episode in the district, the B.B.A., occurs in her case, and if you wish to be a success in private you must take more trouble to avoid this than you do on O. C. So many considerations come into the question of deciding whether it is advisable to stay or not, quite apart from the stage of labour in which the patient is, such as the accessibility of the house and the sort of woman in charge as nurse, and the other work the practitioner has to do, that no rules can be formulated; the whole thing is a matter of judgment. For example, a telephone in the house may make it easy to cut things rather fine when a five-mile drive would mean waiting for hours. Sometimes you will find that men in busy practice will allow a trained nurse in charge of the case to make examinations and only advise them when things are evidently imminent. This is bad; for, however much confidence the man may have in the nurse, it entails frequent vaginal examinations, which, as I have shown, is bad technique; and in any case, if anything goes wrong, the doctor in charge must take full responsibility for the acts of his agent.

Your duty at a case of labour is first to watch for anything going wrong and interfere if necessary; and second, to use all justifiable means at your disposal to alleviate your patient's suffering and shorten her time in labour. As I am not considering cases of complicated labour, I will only run over what comes under the second category. The best way to do this is to consider what can be done during each of the three stages of labour. The first stage offers little opportunity for your help. You will find that patients begin to call out for chloroform quite early in this period, but you must harden your heart and persuade them that it will not do, but that you will begin as soon as you can. If she is having good pains you will not have to keep your patient waiting long, but if she is having weak and irregular uterine contractions you will be in for a good deal of bother. What can you do? I think that that there is one thing quite certain and that is that there is no drug in the pharmacopia which will make weak and irregular contractions into strong and effectual ones. Ergot is a dangerous drug to try and quinine is inefficient, even if you give it in big enough doses to cause a splitting headache. As you all know the best thing to do in cases of uterine inertia in the first stage is to get the patient to rest for a time and hope that the pains will come on stronger afterwards. The question is as to the best way to effect this end. If the os is still quite small, and especially if there is some of the spasmodic rigidity of the cervix which is often present with weak pains, then I think that there is no question that the best means of doing this is to use what is most efficient in all cases with pain and spasm, and that is to give a hypodermic injection of morphia. It acts quicker

and with more certainty than any of the sedative drugs like bromide and chloral, it gives greater relief to the patient, and if there is such a thing as spasm of the os, it seems to me to be the most likely thing to relieve it. In such cases, I use one of the tabloids of morphia, gr., with atropine ; I cannot say whether the atropine is of any special value, but it is said to minimise some of the troublesome effects of morphia and it may also be good for the hypothetical spasm, but this combination forms a very convenient and efficient preparation for the purpose.

In rare cases chloroform may be of use in the first stage, viz., in cases where the patient is having frequent colicy contractions of the uterus, causing great pain with very little result, the os remaining hard and rigid. These patients are usually neurotic and highly strung women and a little chloroform may result in marked relaxation of the os, and if things do not progress then a bag may be put in. The worst of an anesthetic in such people is that they often lose what self-control they had, and as they cannot be kept completely under throughout the labour, they are often more troublesome than before as the effect of the chloroform wears off.

When we come to the second stage we come to the time when artificial aid can do most to assist the patient and as it is the most painful part of labour we can congratulate ourselves that we can do as much as we can. Chloroform is of course the chief means to this end. I do not think that there is anything to be said against it except its action in diminishing the uterine activity, and its use is so general and so well known that you will find that many patients stipulate that they are to have it. When is the time to begin its administration? Sometimes you will find it necessary to give a little before the first stage is quite complete as patients sometimes have very severe pains when the head comes down into the cervix to complete dilatation. When once the head gets down into the cavity of the pelvis and the cervix is fully taken up, there is no reason why your patient should not have the benefit of the insensibility it produces. Hence it is best to wait till the head is well through the cervix if you can, but if your patient is evidently suffering greatly then it may be begun before the os is quite fully taken up. As to the best way of giving it. There is no doubt that the Junker is far and away the most convenient. The depth of the anesthesia depends on many circumstances. begin with it is best only to give enough to put her to sleep, so that with each pain she comes to just to the extent of allowing bearing down efforts though not complete complete consciousness. You will find that this is often quite sufficient until the head is passing over the perineum, when the anasthesia may be pushed to the full surgical degree so as to entirely

To

abolish all bearing down on the part of the patient, which enables you to control the delivery of the head so as to save damage to the perineum. These cases are the most favourable ones, when the patient can be kept unconscious and yet the uterine contractions, though slowed, continue strong, and with each one there occurs a certain amount of bearing down effort, so that within an hour the head begins to distend the perineum. Should there be some delay at this stage, the patient may be allowed to come round a little more to see whether that will increase the uterine activity and if this is not enough then she must be put under to the surgical degree and the head delivered by forceps. You will find that patients vary greatly as to the effect of chloroform; some will need only a whiff to keep them quiet and oblivious of pain and the labour will go on very little slower than if no anesthetic was used; on the other hand you may find that your patient only loses her self control and becomes difficult to manage, so that it has to be pushed to its full surgical degree, with the result that there is a very marked slowing in the advance of the presenting part. In other words no absolute rule can be laid down as to the degree of anesthesia required, when possible it ought only to be to the obstetrical degree, but not infrequently it will have to be pushed to the surgical or very near to it to keep the patient under control. For the same reason the exact time of its commencement cannot be stated for if the woman is willing to wait and you are anxious to avoid the use of forceps, then it may be postponed till the head is beginning to distend the perineum, and I think it is unfair to any woman to ask her to do without this amount of relief from our art. On the other hand if she is of the hyperæsthetic order, and getting out of control, or if she has had a long and tiring 1st stage, you will have to begin very early in the 2nd stage, or even just before this.

The fact that chloroform lengthens labour makes it likely that if it has to be begun early, or if it has to be pushed beyond the obstetrical degree, forceps will be required to end the labour. That is why you will find that in private practice the use of forceps is so much more frequent than in the district. The Colonel's wife expects chloroform and hence she so often has forceps too; Mrs. O'Grady does not get chloroform and she delivers herself.

This brings me to the consideration of the use of forceps in ordinary cases, and by that I do not mean in cases of absolute necessity, but in ordinary every day cases where it is done as part of the assistance that we can give to mitigate the sufferings of labour. Hence I am not going to talk of the text-book indications but of those which will make you use this means of shortening

labour when you have been in practice long enough to be able to formulate rules for yourselves for this class of case.

The first thing is that forceps must be reserved for the second stage. That you all know. When the os is fully dilated it is always advisable to wait an hour or so to watch the progress of things. If during that time the head has made good progress and appears likely to be born soon, then wait for the natural termination as there is no indication but your own impatience. The next thing is that sufficient care should be taken so as to avoid any chance of injury to the mother or child. That means that you must take plenty of time and especially so in taking the head over the perineum. In these cases of weak pains very little strength is required and, in a patient with a normal pelvis and an ordinary sized child, the fact that you have to use much power probably means that you have been in too great a hurry. There is no need to trouble about pulling with the pains. As soon as the instruments are locked, begin and, by means of a series of pulls, gradually bring the head on to the perineum. Then slowly extend the head as in the normal mechanism, watching the perineum very carefully and only allowing the head to come as far as you find the perineum will stand; by going slowly and keeping the occiput well forward you will manage in most cases to avoid any laceration. If the child is very blue and you think it necessary to expedite matters after the head is born, then draw down the posterior shoulder and deliver the rest of the body by pressure from above so that retraction takes place as the child is born. I have been very much struck in questioning students by the way men fear to suggest forceps for inertia because of the bogie of delivering during a period when the uterus is not actively contracting; as a matter of fact, when chloroform is administered the active contractions are not easily recognisable, although the uterus is quite able to retract down on the child as it is being born.

If patience is a great virtue in the first two stages, it is still a greater virtue in the third stage. It is especially needed in these chloroform cases with weak pains because the uterus has a way of taking rather a long rest after it has got rid of the child, and it is very important not to worry it till you have recognised in the way you are taught that the placenta has left the uterus and is in the vagina If owing to its not leaving the uterus you decide on manual removal, then remember that owing to the risk of sepsis gloves ought always to be worn, and that an intra-uterine douche ought to follow.

The few points I have had time to touch on will be sufficient to indicate where private work differs from district work. The difference largely depends on the more general use of anesthesia. That results in a weakening of the uterine activity, and that in its turn

leads to a more frequent use of forceps to complete delivery. The procedure in these cases is, however, a very different matter from the difficult operations you may see on the district and generally mean little more than lifting the head over the perineum. What I have tried to emphasize is tha: even this slight interference is only justified if you are prepared to take all the precautions that are considered necessary in hospital, and that without these precautions you cannot give your patients the advantages which their sisters obtain in Hospital.

ON

Presentation of the Treasurer's Portrait.

N January 16th one of the pleasantest functions in connection with the work of this Hospital that we have had to record for some years past took place in the Governors' Hall, when the Hospital was presented with a portrait of the Treasurer to be hung in the Grand Committee Room as a lasting memorial of the grand work which he has done for this Institution, and at the same time what might have been a replica but was really a second portrait was presented to Mrs. Wainwright, to be kept by the Treasurer's family as a lasting record of his devotion to the interests of St. Thomas's.

Not only were there many Governors and practically all the Staff present, but the meeting was graced by the presence of many ladies. Mr. Boysen, as the Senior Almoner, introduced to the meeting the Right Hon. The Lord Mayor, Alderman Walter Vaughan Morgan, who is himself not only a Governor, but an active member of the Grand Committee taking an active and keen interest in all that St. Thomas's does.

The Lord Mayor said :

"I have had the pleasure of Mr. Wainwright's friendship for a great many years and nobody has a warmer appreciation of the good work of Mr. Wainwright than I. I did not know him when he first became a Governor of the Institution 40 years ago because I was then in the wilds of the City of London and more or less a country gentleman living in the suburbs. In 1892 I became by force a Governor of St. Thomas's Hospital, I say by force because I was then induced to accept the position of Alderman, when I became, whether I wanted it or not, a Governor of St. Thomas's. This did not satisfy me, I preferred to be a donation Governor rather than a statutory Governor, and I sent my good friend a cheque which I thought covered my dues and he acknowledged it

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