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Lorsqua la document est trop grand pour 6tra reproduit en un seul clichA. il est film* A partir da i'angia supAriaur gauche, de gauche * droita. at da haut an bas, en prenant le nombre d'imagaa nicassaira. Las diagrammas suivants illustrent la mAthoda. 1 2 3 1 2 3 4 en 6 J<.-.'aMIIT;^>/?«M(Wr'WHE^«lJK«HBr MtCtOCOTY RISOlUTKm TEST CHART lANSI and ISO TEST CHART No 2| 1.0 12.2 132 1 3.6 2.0 1.8 _^ A PPLIED IM^GE Inc S^ '6^3 East Ua.n Street r^S "oCiester. New Yori. 1*609 uSA 'J^S ("^16) *82 - 500 - Phone ^= (7' 6) 288 - 5989 - ro« —7^ NOKMAL LABOUR BT yj, PRESTON ROBINSON, M.D., Attending Physician to the County Carlton General Uospitkl. BufirinUA from Vu Montreal Medical Journal, October, tSOt. ^'m^mim^mmm mmsm NOilMAL LABOUR.' ^K.I'HRMTII.N HuHINsilN, M.I)., Atteniling rhyninaii to tlir C'oii; y Carllnn (ivnrral llcmpiiul. The suliji'ci of iinrihiil liilmiir in i,'i ncnil iiniciici' is ninrc iiiiimriiint than has >;iii(rull\ litcii rcco^'iii/.i'il. My nlijn t it^. ihrnfcprc, (n (niiliin' ttie >ulij('il liriilly, wiili ilir ti(>|>i' of iiriiij.'iiif; out mhih irii|poriaiii cli>- cussion on tlic whole .-iilijci I of oK; Idric al inatlin'. At the outset 1 (Icsirc In say that if llir laily wcit licllrr iiil'T'iird with rc^'ard to the ^Toat iin|ior'ani'(' of tiic pro|»T iiianajiciiiriii ami troatini lit of the patient iluniij; prestation, as well as during.' iier dejuery and after treatment, it is my linn helief that l!ie oft nsullant wreekin,ir of the mother's lieaiih woiihl lie inatiiially mininii/ed, and the mani- fold operations and trealnieni of the aniliitious ;.'ynn'eo|()e-ist woiiM Im- eonsideralily diminished. It is not my desire, however, to depreciate the ;jood ollices of the giiya'eolo^iist, Imt rather to eliide ourselves, the general practitioners, for our many failures in the past to lirinj; our patient successfully throMj.'li her jjestation and pueriierium. Lest I might he considered pessimistic, let me |ay at the outset, from ohservation, that I believe the results ohtained at present in the maii- agenient and treatment, es^'cially of the puerperal stal". an' much t)etter than the results obtained hy ourselves and our predi'cessors ten or fifteen years apo. Tor this improvement. inutandinjr by the ]irofessioii of asepsis and antisepis as applied to labour and the pueri)eral state. 'I'here is yet much room for advancein(>nt. however, and we. as physicians, sliould not be satisfied till we are able, even in abnormal and dilVicult casen. to guide our patient throu;,'h her oft-dreaded and all imjiortant event, without any lacerations or complications of any kind. Now, what is the physician's duty with regard to a patient in the early stages of gestation, whr, engages him for her confinement, and who may or may not draw his attention to any of the various ills to which she may l)e subject at this tim(>? Some women there are who are so healthy, or who from instinct or acquired knowledge, so regulate their habits by an obedience to Nature's laws, that tliey n^qiiire little or no advice during this period. Many, however, stand gr(>atly in need of special treatment or advice to guide them aright in this important era. Who can estimate the importance of a woman's environment, as well as that of her general health, in its effect upon hei xpected ofrs|)riiig • Read before the Canadian Medical Association, Sept. 18, 190J. wllllr ll l.« Ml III lllc ('illl> .•Illl.niinU' ^lllJ,'<■: \\\i \r M'U'lllltic llUfSiti- piiioii ill ilii< liiiiiiiiM f.iinily liiiri not Vi' riiiilidl a cliiiiu.v iiloii;; tins line, Ut W" Iriirn t'luill lln- iinillci;:\ of riilii|MIMll\r illliltii|n\ illld pll\>ii>- lii,i.'y iliiii a inalili} iiuiiIh r. >ui iiniinli il diiriii;: ;:l^laIi(ll l>\ n lined iind • 111 . rl'ul loiiiii.uiv, and the \>iM im-i-ildc cnv ininmrnl. laiiiiDl fail to prn- diiic ihr most r||.viral)lc and In uliliy fi-iliirt!' iii lur iliiid jjnili pliysii-:'.!, iiK ma! and ifinial. Willi n-ard to lin' dhi of liir |iaiiini during; p'-latimi. and ollnr i.\;ii(nic ircaliiii nt, 1 -li;;li ^ay liiili. a> llir >.iu\r l'i inral rnli'!- apjily as .11 'llh.T llllh -. 'I'll,- liiiUiU Sllnlllil lir frl.' 11 la li d li\ la\alisc' funds, liiild la.\ali\..-. Miiiii iMJ walrl-. > Ic. and lllr dirl >llnu|d lie liulnlioii>, lull Mill (■\ii--i\r. I'lTiia]!.- llir iiiii>l iiii|in| lain nrMalir <>( ihr \\liii|i> iMi.ly lo uahii al llii> ini|'nil,inl |'( rind an- ihc li\( r and kidiMX-, wjinsc fiiniliun> in lii'' niiisl liiailliy air iifllinas priaic ni lu' rcfraili'fv nn i'M'Ii sli;rtil jirmnca- lion. 'I'lixa iiiia- nf \aiiiiiis kind.-, willi liuir ni'illilndinous ni'farioiis rllrci.- — now Will wmiliy of our sii.-|ii(ion in almusi, cvcrv fiiiictional ili'viation fnan Ik ahh— ^lioiild lie douldy doiilitrd in ilic lasc of tlu' jiri;.'nant woniaii wIki nianil'r.-l.- aii\ .-[iccial di-niriiaiicT of Imt pliysio- ]ri;.'ical fiiniliiilis. rn;.'nanui li li\ ilu "I- r\ant and rrady |iliysician. I.rt ns not wait, tlii'ii, till sea 'Oil- nianifi -taiion, nf allpiiniinnria arc ii|i|)aroiit or Ihr Mood lircniris .-iircliarui d \. I'l liiliriilpin or lali\i rdin. urra or iirir acid; jiiit set aloni witlioni delay liv ilie ordinary eliininaiive pro- cesses, to rid "iir )i:iiiiiit "i ilie \\a^te jirodiu ts reiaini'd in tlie |i!o(.d. 'I'he prineipal leasiins why onr jiree-iii'iit jiatieiit is peculiarly exposed n> the diMi,t;i'is nf auin-intn\i(aticin are tliat she is ex]iosed to an increase of waste a> uell a> a diniinniinn of iMniinn. l-"ir>l. lier blood contains an increased anioiini of poisn;, niai.rial due to sliinulation of tlie nielaholic proces-es lo provide for ill" noiirishnieiit and prolection of tile fu'lus and llie I issiii-wasle jiassiiii.' into her eireiilalion from the fietiis. Seioiidly, ihe enlar;:iiij; uterus may produce rellexly a spas- modic contraction of the Mood vessels, and as it enlarp'S there is a con-tantlv im rea.-iiifr ir.lra-alidoininal |ire-siire with a jjrnwiiiir liability to ni'elianical interfi rcmc with the action of the liver, bowels and kidneys. 1 need not here eniinierato the various sym])toms of llioso toxaemias f uniliar to you all. but would only em]>)iasize llie ini])ort-inco of frequeiii urinalyses lo ascertair. the jiresi'uco or absence of albumen or sujrar, and above all. to measure the a]i]iroxiniate elimination of urea from a 2\ hour sample of urine, .\hicli may be deemed a reliable clini- cal index of elimination. A miiToseopic examination showinsr lln^ state '( Ihr k H.lirV ll>^lll^ Mill r(i|ll)ili !!' llil' ll.ll.l l.i|Ul|iil I'.iT .III cMllt l|lilt;l|ilM!i. I llitM'. |il lb. |i^. Illiilllu'i c| III ...lljr Mll.i.-il_\ Ullll I. J. I v. I |.i l'i\:i||i|,l III |Fi( jiiiiiiK \, Imiii.- I nioyiii'-i I II- ii;iin ^i I. !!•-.• I'.h inr in ili,' imii- MllilPII lit' nil llll' ill- ill. II III..- i'.ll'lrt- lllirill.' I.li.nlil' .III I ihi' |M|. I |M|-,|| >tlll< ■.Mil : i'rilU!nll> Mil.llllli;: nf [ ij'l i:ll:l 111 V IIUIV n»M I . i Mrlll ill il 1 1 ■! <■. .'illriMUMli III ill llrl. -t I Mil: iriiliiiiilc iM'iii.!., rill -.. ;r. -If'IlM i\;llililP' I lii-i h ll;!i >{ llllMli'iM .1- U' rf. r 1 .llli.l rcfit iiiiiv !"■ 1. i|inrc.i| l.v .;M ■ m iljliic ainl «i;il,i iinl |i;ilhnl. IrntMiKiii In -|>l,iiiil nil HI- laii lir ili|ii|ii| aii'l cnni riiil liv i^-ill'hs I If a-ipi I ■ ruii|Miii. nia\ In' !!-'■ i-iiini'lirab li iiv iiilli'-ii'ii lii-iiianiial inai.i{'ii:;i! on. to iiilMilila:;!-. Sli..ii|.| ih,. di-jilac ,jii. n: tiiiiiiioni* iiiii il alril \vitli ii-liiliwil ami Ll^nriii'- an''\i-i i'Mi. If ili'i'r i- no palllnliwic al i ullilll i.^li ulliri' than a nlviial di -i lial'.::i' nr rin-iiiii nf the OS iili'ri, till 11 liTal « illi ml r.ilr n( -iKif a|>|ilir:ii imi-^, m- ililali' llir on; if l'ij;iil, ililair iiinli r cliliiinrdi'Mi. «liiili nun. Imwrvri-. [inniiiir 1111 aliorliuii. liiciitiiiii nl' which >hiiii!il alwa\>. I '■ ina.lr if -lull |irnM ■lure he hi il Mitisl'ii.iorilv with litlh' aiil frmii llir iili>li Iriiian. W liili iiinMI.-i.iiir miiluifrrv 1^ surclv 10 he ill pn ( all il. vil 1 l.ilii \r iinu h -i Ili-i in;: ran hr av li' ' aiiil iiiiiih iijipniiati il aiil i-aii I cious ohsti'liiciaii. (' I'rmitli '1 li\ till prmliiil. I .iivl'ul a' •! jinh n many 1 asrs thr sl.i;:i' nl ilihiiiiiiii is a minli | li nriiliinL'iil- a- in.irlv iiaiiil'iil ami tiilimis pniri >-, •inr jiiha]- in ihi- imnlilii 1 ilrcadv urak. hm r-sin.-ili\r am vhaiiMiil [lali IT. ul- lll Sllrll 11 I . usual ]irailirr is to ,^'i\r a 11 \v x( nil- 111 ilih rilniiii, ami the siinir h'.i- tatioii is a(ciiin|ilishril hy llir lint:vrs. >»illii>iii -iiirrriiiLT, in lliiv. t live iniiiiilrs. u'iih wmilil have takni hy naturi's patii'ilt ami lon:;- siitrcrinj: inrthml liniirs to arcoiiipli-h. 'I'lmii I sonn'tiii!' - t;i\i' InT anotlur (liar.cc in the skuikI or 1 .\piil?i\r sta.iTf. vvhiih i- ol'i. 11 'on slow ior tin- jiiitiint's paliimo or wiiik lomlilion: ihr laltrr < onililimi lui'':: usually the cllinf milcx of ihr h llLith of lillio 1 wail hnforr 1 imai!; supplcnunt Iht work hy that most \aliiahlo thouirh nniT-t ilaiiL'iTou- instninrnt in inii!<'>t<'rmis hamls. the fon 1 ps. \ii.J li.T.. I .l,,„rr lo Kt.'.. inv lH.|„.f 111.,. „ .I..XI.T..1.. h,iM.|. Ill, for- ..■|... ..,, I.. „^,,| H„.,.>l„lh ,„ ,in,„,, ,„u ,.^.. o' . ..um.ni ^^l„,•,. ""ll-"l.M. rx,,.,„ iMTlMj,, ,sir,,M. ...„(,..„, I |„|,,. .„■ ,.M,v„... !noh- MM.ilv, wmIk.iii injun |<, , iilur iiM.th.r or dnld. Many ,,1^,,. .„r,ir «l..rf ilir \,.ri..x im .Mr, im.U |„rp. mmI ihr \a>;.iia an.l iM.riM.uiM . ..iMjun.turl. -,,,.,11. Tl,. .,• ,.,, i|„. .„.,,, ,|,a, ,„,• Irv- M>f nn II,.. |„ii,..n... in „„ „ii,„,,,t i„ .,,, ,)„. ,„.n„.,„„. „„,| „i,.t.. '""""• "" ''• ''■ ■'"• 'I'li^''' ^" 'ill. will I... M,.v I,. r>,|,imv th,. ,«.rin- fiiiM. |>.t|,m|..- i.iii,|.;..i,1v into till- ,11111^. 'i;ih..' tire .aMs «l„.r.' tli.. .■.xp.ri.nc ,| ol,,>t.iruiaii .an . rown liinis..lf with ^l..n. alih.Hi^'li til.- .•x.vll.n,.. ..f l,i^ wn,k inav n.'V.T !..• nroKiiiz..! •v an>.,i„. I,ut luniM.lf in il„. w.tI.I. On 1!,.. .,tl„T liaii.l. ih.. ol.st.- in.ian «lio lails in pr.A, niativ,. i„a.\ .n.vu, l,„i,>.ir «,ih j,.w..l„ l.v -'.uni,:; ,, ii„„v „r |,>, i„i|..rrr, t uiiioi, „f il„. la.vmf.l |„.,-,n.Mil tissiifJ, "ii.l 111.- [.atunr. kii.,ul..,l>;,. „|- ih.. I.nijiant stitilnnjr ..|M.rati..n n.vs- >aiy ,11 1,.T .\l;-,i.,r.|iiiarv an.l uni.|ii.. .as... A \,,,r or s.. lat.T lii^ |.::ifnl ivturiis «ill. I..u..,rrlu.a ,,,,.1 I,.,,,,,,;.- ,|,„u, aii.l sinking' an.l pains valoiv, ||,. now r.^.aU to li. r tl„. fa. t lliut -I,.' l,a- a in;r ,li.,.i,.c m another an-l . ntirdy .lilT.r. lit (l..|,l. th-- <:yiiim,loj;istV n^alni. who is in liirn nn.l.n.l .v.t irrat.fiil to hi* ...nfr.r,. for such fruitful supi-iv. It IS not iiiv |,urpoM. to >:„ int.. th.^ ,l..tail< ,,f tl,c wrhis ojifniiuli of th.- .liir.Tfiit sta;;..s of lahour whi, 1, ,^vry .il.st.trician works ..iit more or less satisfa.t.Mil.v f.,r liims.ir. | |,..;r |,,iv,. ,0 in.'iiti..n .hhiroforni as u most u.-^'f.il a.ljun.t. th.- b.n.tit .,f whi.h 1 h.'li.N,. to I,.' jrivat in almost fV.T.v .a>.. wh.n us.mI jii,|i,io,isly. At th.- a.-inc ,)f ..\pulsi(jn. as th.' head is passiii- ih.. intn.iiii.. th,. a„a-sil.,.^ia >lioiil,l -.niTaliv I,.. jmsh.',! to full unions. ioiiMioss. 'I'his not only spaivs th.. patient th.- s.'v.to Jiangs <.f hiliour, but, hy rctaplinj; .■.xpulsi,.ii aii.l l,v r,hixin^' th.. nius- ,.ilar still, tuns of th,. p,.lvi,- Hoop, it !,.>s,iis th,- rlsl: ..f la,rn,li..ns at Ih.. Na;.'iiial ..Hti,.t. I woul.l also re. oi,iM,..n.l th.. jii.li.ious us,, of '■!il- •••■'"nil o.vasi..iMlly ill til,. s,,„M,l all,! Ilvst sta;:..s of lahoiir. It n 1 ,...s n....ll..ss suir.riii- an.l ^pal•,■s iiiiii, <•, >sary ,-.\li.iustion. I.ut anirs- tli,>ia sli.ml.l !.■ av.,i.l.-.l till tli.. latter ]mr! of the e\piilsiv,. sta>r,.. Th.> iiMvhaiiisni of ,\piilsi..ii must he so r.-^riilatiil that th,' smalL'st eircunif.'n.nc.. ..f the li.a.l is eonstantly k..pi within th.. .rrasp of th.. .xistinj.' -ir.ll... Th,. .lii-e.-tioii of ,..\i,ulsion must also he eontroll,.,l lest th.. soft i.arts he sul.j..,t..,l t.i to,, ;:r,at strain hy iiii.'>,lir,etion of the .Iriviiijr ior.e. The h.^ail shouhl !„■ iiermitti'd to .le.seen.l only .so far at eneh pain as can he done without e.xpnsinjr th,- tense structurr.s to risk of tearin?. To reli. ve the p,.lvie floor from un.liie strain hv misdirec- tion of the e.xiiellinf: fore.., j.ress th.. hea.l firmly up int.. th.'. suh-jiuhi.. ar-h and at the sam.. time th.' perim.niii may h.. siipp,,rt,.,1 hv- tli,- jialm of th>> huml ; thu« lllf ltlii\(llli nl^ >>l' iIh' hril:i IIIU) l»' riilllriilliMl till till' Ixrihi mil tf !'ul)i( ii'iiilv ^lrl'U'llt'll to < iiruri' Bufi'ty. liuviiiK thui* Mifrlv ,11 rririi|ili > >l 'if till' ('rrilu iii('tlii>il, milking' mils ^lll1i^il iil iir rx^il to lit' ilu' riit>l .mil \W'il|i lilt' rliilii. Wltllolir ll.lllil liriiily ;:la^'plM;.' tlir lll't'll' illxl ,'rr-.' ''.',1 • i'.\|K-ll)'(l, uliiili IS iiMiiill\ till' laM', I I'liliiiw into till' uti'i'u^ ami ',ia^|> M'rii|M' if III ' il III', with iialiiii''^ In .-^t m>iriiiiii tils, thi' I'mpr^. ami U'twi'fii ,iiy t«(i liaiiils I tarry away, nut only tin' ]il.i(i'iit;i, luit I'Viii tlir ■ li'ciiluai iiii'iiiliraiirF. If tlii^ final art i>f 1 \|>iiImi>ii uf llir pLiuiiia anil contraction of the iitcriih— thus (uiiipl.ti'li iin|'l>m;.' it uf rliil.j. jila- I'l'iitn nii'iiiliraiii'rt anil iin iilmtal 1 i< |iru|irrl\ an uiii|iii-hi'il. am! till' iitiTUs iii-fonliii).'ly fully toiu .. tlnri' is iiiili' or nutliin>: tu fear in tin- putTiHTuI statr. Nuwi' , with our imiMrsul ktiuwlril).'!' of a(H'|)!*i(i ami aiili»i'])si>', tlnri' is no I'Miisr for si'iitica'tuia. I trust ( may !»■ imnli'tii'd. liowi'Vrr. in thi- rdiiiiri llun. fur itiipiia-izinir tmiri' fsjH'i'ially the universally ailtniltiil mi|M)rtancr of the ili'tails uf asepsis tliroutflioiit the confinenient. 'I'lie nails (■hoiild lie tliuroii>.'hly cleaned anil the hands seruhlied with sojiji unil lioiled water, if nut in suine aiitisi'|itii suliitiun. (ireai' r procaufion still shmilil he exen is<'i| if the phy^iciui ha- recently Ihim exposed to the exalitheinatuus diseases, ili|)htheria or u pust-niorteni cxaininution. The practice of kivpinj; a peurpcrul patient in hid, iisinj,' hed-pan, etc., and almost motionless for ten days, i think has iiuw hecunie almost olisulete. I am 11 thoruii^'h iieliever in altcmliii).' lu nature's calls m the erect posture soon as they uiciir. and 1 eneuiiraj,'!' the patient to sit erect in lied tun as pos.-ih' •, lieiaiise uf the ailvaiitaL'e uf j.'ravity in aiding the ni ..ul etl'ort of the uterus tu rid itself uf the natural dis- eharjre. .\n uecasional douche with warm water or any uf the wi.'ak anti- septic solutions 1 U'lievi to lie useful ii, many i ases. luit 1 tlu not consider it noct'gsury as a ruiiMne practice. Anuthcr point on "liich I wuiihl like to hear some discussion is with regard to the use of irgot after delivery of the ]ilaei'nta. In my early experience I used a as a ruiitine practice. I discarded it gradually, till at jirescnt I tielieve there is little or no need for it. The uiily case in which J would rocommeiid it now, is that uf pussihle pust-|>arten ha-niorrhage from inertia and rilaxatiun uf the uterus. — a cumiilicatioii which I helieve to he entirely a previ'ntahle accident. The apidication of a good pad over the uterus and a snug and well-applied hamlage will G nisurc s.'ifcty in the ciisc of miy utcnis that liui once hovn fully con- triic-lc(l. KrL'dl iiiiiy iilso lie coiisidi red >ii!nctliiiij,' of an aiklitional saft-,'nar(l wIktv, lor any na.~on, itrolon^'iil ana'stlicsia has bocn nt'ccssary. Chloral has iis well uiidcrstood use in the first stajrc of lal.our, wlicrc the OS is ri.irid, lull I am not a liclicvcr in very larj,'c doses. IJettcr sup- picn.ciit its action witli a frw whill's of cliloroforni. even at the risk of diminishing tfinporarily the pains. fe^y ^ THE MONTREAL MEDICAL JOURNAL A MONTHLY RECORD OF THE PROGRESS OF . . . Medical and Surgical Science EDITED BY JAMES STEWART, A. D. BLACKADER, G. GORDON CAMPBELL, FRANK BULLER, H. A. LAFLEUR, ' GEO. E. ARMSTRONG, J. GEORGE ADAMI, < WILLIAM GARDNER, F. G. FINLEY, F. J. SHEPHERD, Subscription price, $3.CX) per annum. ADDRESS ClK moitrtil mtdial Joiinal Co., p. O. BOX 273. PUBLIBHCRS, MONTREAL, Can. >^k^fe^