adopt which ever seems best, but it should always be remembered that surgical cleanliness must be absolute and not the smallest break must occur, for it is evident that washing the hands with the utmost care and attention to detail will be of no avail if these hands become contaminated at any time during the conduct of the case. The rules for surgical cleanliness of the Out-Door Department in the Lying-In Hospital have worked well in over eighty thousand cases and we have no hesitation in quoting them as a safe procedure.

When the physician assumes the care of the woman who expects to be confined, he should feel that he is responsible for her welfare, not only until the child is born but until the woman has completely recovered. He must therefore make a careful antepartum examination of each case and likewise guard against the numerous complications of pregnancy which may arise, such as toxemia, etc.

He must also make certain that the general health of the patient is such that she will be able to bear the added strain of motherhood, and he

must likewise warn her against various complications of pregnancy that may occur. He must likewise instruct the patient when to send for him, and have her prepare the room in which she expects to be confined. An abundance of hot water, clean linen and towels must always be provided by the patient. A good sized fish boiler makes an excellent sterilizer for instruments, etc. During the course of labor much time may be saved by adopting for the patient the postural treatment which is especially valuable during the first and part of the second stage. Forceps and other operations are resorted to daily by many practicing obstetrics with but

little more reason than, that the patient has been in labor longer than appears necessary.

I would strongly urge that the first stage of labor be observed more carefully than it has been in the past and that obstetricians, both in hospital and private practice, exert their efforts to making this stage as short as is compatible with perfect safety to both mother and child; for by so doing much suffering will be spared the mother, and the accoucheur will husband his time, first by instructing the woman how to make the best use of her pains, instructing her to hold her breath and bear down when the pains are weak and ineffectual, or in case of a strong rapidly recurring uterine contraction to open the mouth and use as little as pos

sible the auxiliary muscles of expulsion. In both of these the use of posture will be of great assistance. In the weak pains the sitting posture will allow the weight of the uterine contents to bear steadily on the cervical zone, slowly dilating the parts by the force exerted by the bag of waters, whereas in the case in which the contractions are severe the patient may possibly recline to better advantage than by walking about or sitting in the chair (Figs. 18 and 19). Again, in moderate degrees of pelvic contractions, the chair will be of great advantage, allowing full dilatation to take place before the patient has become worn out by long continued efforts and the consequent thinning out of the lower half of

the uterus with the not infrequent contraction of the ring of Bandl which, when carried too far, will mean an impossible delivery by normal process. Even in the second stage in old primiparas, the chair may be used to great advantage to dilate the rigid pelvic floor. Of course here the greatest care must be used not to carry it too far.

It has never been intended that the patient should be placed in the sitting posture at the beginning of labor and continued in that position, but rather that it be used to rest the expectant mother's efforts and allow the weight of the liquor amnii to do its part to the best advantage. Each case must be judged by itself, the patient going from the bed to the chair or walking about as is most comfortable for her, and yet bringing the first stage of labor to an end in the shortest time possible without risk.

alleviate

Kindly sympathy and encouragement will do a great deal to' the patient's suffering during labor and aid her confidence in the attending physician, so that she may make the best use of all her own efforts, both mental and physical to shorten the actual time of her labor.

Normal labor cases are best delivered in their own beds. The Kelly

Fig. 13. Metal containers for sterilized nail-brush, cotton, douche-tubes, and vulvar pads,
as used in the Out-door Service of the Lying-In Hospital.

pad serves to protect the bed from the patient's discharges and also the patient from the bed.

The lateral position may be used at the time of delivery as it raises the patient's genitals from the bed and thus improves the asepsis of both

patient and attendant. The position of the patient during delivery may, however, be a matter of choice with the physician.

When an operation becomes necessary, the patient is removed to the kitchen table and after anesthesia is properly induced, she is put into the lithotomy position with the assistance of a small canvas leg holder or

twisted bed sheet. The towels are draped as follows: One across the perineum suspended from a strip of adhesive plaster passed around the thighs; one is pinned around each leg and one is laid across the abdomen. This procedure insures quite thorough asepsis of the immediate field of operation and the surroundings, which together with the care bestowed in cleansing the hands, affords a satisfactory method of guarding against the possibility of ordinary puerperal infection. The preservation of the sterility of the hands after such a preparation is largely a matter

of training and the habit of refraining from contamination of the clean hands, is only acquired by continued thoughtful practice and the development of what may be termed an "aseptic conscience."

When instruments become necessary, we may regard the average female pelvis in so far as the use of forceps is concerned, to include such slight variations that these may be safely disregarded. Therefore our forceps' blades must be devised in such a manner that they will be neither too large nor too small to readily pass into and through the pelvis up to the