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hind the bulging perinæum. The thumb is at liberty to do service at the head when required. The fingers being so placed, the index-finger may at any time be introduced between the labia in order to determine the progress of the head. The finger-nails should always be closely trimmed.
Guarding the Perinæum.-When, after examination, it is found that the head approaches the floor of the pelvis and begins to press upon the perinæum, the hand, in the position described, enables the operator, at the beginning of every pain, to note the expulsive force exerted and the progress of the head. If the perinæum become tense, and the head be forced downward and outward, the fingers then press the perinæum inward, backward, and slightly upward. This is done in order to lift the head upward and outward, as well as to flex the head upon the sternum. When the bulging perinæum is not prominent enough to be grasped and to enable the operator to hold it with the fingers in the hollow of the hand, the head not sufficiently advanced, and the perinæum not tense but relaxed, and it is noted that the uterine contractions have ceased, the hand should be removed, and the patient should stop all exertions on her part and wait for the next pain. With the next pain or the pain following, when the pain is strong, the expelling force vigorous, and the perinæum tense and bulging, then all the strength possible should be brought to bear upon the anterior margin of the perinæum, pushing it backward, inward, and slightly upward, so as to make it glide over the head, forehead, and face of the fœtus, the nape of the neck being well under the pubic arch. The fingers, getting well behind some part of the face, help to lift the head out of the vulva by an outward and upward movement. Should, however, the expelling pain stop short before the head is born, although the perinæum may relax, it is best to hold on to the head, through the perinæum, with a firm grip until the next expulsive pain comes on, because this is almost sure to be last. When, however, the final effort comes, the uterine contraction, aided by the auxiliary expulsive power, forcing the head outward, then is the proper time for the accoucheur to exercise all his strength, to bring to bear upon the perinæum a counter
force equivalent to the expulsive force exercised, and to press the perinæum back with the fingers and hand, retracting it over the head and face.
The Breathing.-In the last efforts, when all the forces at the command of the parturient should be concentrated, with the one sole object in view, and that is to expel a passing body through a canal over an elastic commissure, the breathing should be suspended during the acme of the pain. It is self-evident that, when a certain force, aided by an auxiliary force or forces, produces a given power, acting as a unit in the propulsion and expulsion of a body, the expulsive power is diminished when these forces are divided. The uterus contracts upon the body of the fœtus, aided by the respiratory muscles, the abdominal walls, diaphragm, etc., all acting as a unit in producing this expulsive force. If the respiratory muscles be diverted, either by rapid and short breathing or by crying lustily, there is just so much force lost.
Regulating the Pain.-The pain, or rather the contracting forces, may largely be controlled by the attending physician. To let the woman press, push, or cry, when it is not necessary, is to permit a useless expenditure of force. Therefore, when the hand at the perinæum perceives that the expelling force has ceased, the patient should desist from further effort. The strength of the patient and the expulsive forces can and should be economized; so that, when the last crowning expulsive struggle comes, she may press with all her might, exercising, for the instant, a greater and a more prolonged force, straining every nerve, and, with the aid of the accoucheur at the perinæum, the final act is accomplished.
Résumé.-With a normal pelvis and normal soft parts, presenting no obstruction during the act of parturition except at the perinæum, when the head can enter the superior strait and pass the inferior, the perinæum will invariably yield or can be made to yield. Forceps should never be used, and the perinæum may be preserved in its integrity by proper care. In my own experience, when I have been called for the express purpose of ap plying instruments in a primipara, I never used them when the
perinæum presented the only difficulty to be overcome. of the important qualities to be exercised by the accoucheur at this time are patience and good judgment, with a thorough knowledge of the anatomical structure and relations of the parts; and the most available, sensitive, and harmless instruments to be used in all such cases, are the hands and fingers. We have seen that the only obstacle in the second stage of labor in the primipara is that elastic structure called the perinæum, sometimes less elastic than at others, when it is called rigid; but, whether more or less elastic, it can, in my belief, always be overcome with proper management. Preserving the perinæum consists, then, in the operation of a counter-force drawing it back over the head and face, while the expulsive forces push the fœtus through the orifice of the vulva; and when the head is once at the perinæum, this seldom requires more than three or four good pains, lasting not much longer than ten or fifteen minutes.
A CASE OF CONSERVATIVE SURGERY; RESEC-
By R. B. BONTECOU, M. D., of Rensselaer County.
THIS gentleman, Mr. D. C. Lewis, now a resident of Nicaragua, happening to be in New York, has kindly consented to have his case presented to the Association; and, being interesting in its results, it having been one of the first resections of the shoulder practiced during the late war, I thought it might be of interest to you.
Mr. Lewis was twenty years old and a private in the Eleventh Massachusetts Volunteers, when wounded at the first battle of Bull Run, July 21, 1861. He was taken prisoner and kept in Richmond for several months, until, when nearly dead from exhausting discharges and depressing prison-influences, he was exchanged and sent to Fortress Monroe, Virginia, and was admitted to the Hygeia General Hospital, January 17, 1862, then under my charge.
When he entered the hospital, he was much emaciated, and the left shoulder was greatly swollen and was perforated with a number of sinuses about the joint and scapula. Early in February, 1862,
his condition having improved under generous diet, I removed the head and three inches of the shaft of the humerus, by a V-shaped incision, selecting that method on account of the sinuses. Great vascularity and a cheesy condition of the parts rendered it diffi
cult to secure the blood-vessels. There was also much difficulty encountered in removing the large, irregular mass of bone in which the dead head, in three pieces, was inclosed. Gangrene subsequently attacked the wound, destroying the tissues, which