364

no further, in which there are likely to be more and moreold people and fewer young people. The health servicewould be sensible to remember the help that pensionersand married women have given in these difficult times.Even in easier times they could offer valuable supportto the recruits whom we all hope the service will get,and for themselves have the healthy satisfaction of doinga worth-while job.

1. J. Obstet. Gynœc., Brit. Emp. 1957, 64, 815.

THE SECOND STAGE

IN these days of strict training for natural childbirth itis widely held that the first stage of labour should nor-mally be a time of rest and relaxation in an atmosphere ofquiet efficiency. The time for hard physical effort comeslater, in the second stage. A first labour is seldom con-cluded naturally without at least a short period of push-ing by the mother to assist the uterine action. But it is

perhaps not always remembered that much of the secondstage needs no help from the mother, the uterus aloneadvancing the presenting part down to the perineum. Apatient who is urged to push too early in the secondstage may achieve little which could not be done as well

by the unaided uterus, her exertions leaving her exhaustedtowards the end of her labour when her efforts are re-

quired. Constance Beynon 1 believes that there are otherdisadvantages both to too early and to too vigorouspushing. She points out that the secondary powersapplied while the presenting part is still gripped by thecervix or the upper vagina-broadly the site of insertionof the transverse cervical ligaments-will produce onthese important supporting structures a downward thrustwhich may well be a significant factor in the causation ofvault prolapse. Similarly, straining efforts made while

part of the anterior vaginal wall is below the head mayresult in this part of the wall being rolled down beneaththe head with potential damage to the underlying struc-tures around the bladder base, perhaps leading to stressincontinence. Mrs. Beynon believes that these ten-

dencies will be slighter in the absence of straining efforts,since the early part of each contraction pulls the vaginataut and prevents it and the structures deep to it beingpushed down in front of the presenting part. She likensthe process to a sleeve with a loose lining : the slower thearm is passed down the sleeve the less the tendency forthe lining to roll out at the wrist, especially if the liningis held firmly at the top.

Theoretical considerations apart, Mrs. Beynon’s methodof allowing the patients to follow their own inclinations inthe second stage of labour, forbidding any mention ofpushing by those in attendance, seems to prove its worthin practice. In a clinical trial a much shorter period ofpushing and a lower forceps and perineal-laceration rateswere found in patients managed in this way than in asecond group more actively encouraged to push the childout. Although, because of variable factors, this was notstrictly a controlled trial, the method seems to have muchto commend it. Thus, the atmosphere of tranquillity whichshe describes in the second stage contrasts sharply withthe scenes of violent muscular effort when the " labouringwoman is persistently urged to take an active part.

For the normal case this policy of non-interventionseems reasonable. There are circumstances, however, inwhich the vigorous cooperation of the patient can con-tribute significantly to the safe delivery of her child.Breech delivery, for instance, achieved by the patient’sefforts with minimal interference by the attendants is

greatly to be preferred to breech extraction under generalanaesthesia. Rarely in the multipara the pains will almostdisappear in the second stage, leaving the head stationaryin the middle or lower part of the pelvis; and here, aswith the breech which the patient cannot quite push overthe perineum, brief adoption of the squatting positionmay have dramatic effects.

1. See Manchester Guardian, Feb. 5 and 6, 1958.2. See Suffern, C. Lancet, 1957, ii, 1174.

ARMY MEDICAL HISTORY ON SHOW

IT seems that in this country few museums, apart fromthe famous national ones, can be said to prosper 1; and ifmany of the rest are ill attended it may be because theyare ill tended. But no such accusation can be laid againstthe R.A.M.C. Historical Museum, at Crookham. Built

up in the past five years by Major-General R. E. Barnsley,who remains the curator, this collection sparkles; and itsexistence should be more widely known.The collection is mainly for the non-specialist: the

muniments section is held elsewhere (at the R.A.M.College, Millbank); and no effort has been made to dupli-cate the purely technical collections that were already inbeing. But, without entering into technicalities, thisgroup of apparatus, models, plaques, letters, drawings,photographs, standards, medals, and so on illustrates bril-liantly the development of the Army medical servicesfrom the time of the Peninsular War, in which the Dukeof Wellington had miserably small medical resources athis command, down to and beyond the war of 1939-45,with Field-Marshal Montgomery writing soon after itstermination of a Corps "whose contribution to victoryhas been beyond all calculation ".The medical relics include "Dr. Wilde’s electric alarum

indicator with insulated explorer and forceps," which putsfar back into the 19th century the date when metallic foreignbodies-in this case bullets-were first localised electrically.2There is a wealth of paramedical objects-including a letterfrom the indefatigable Miss Nightingale, who took time off atScutari to communicate at some length with a young admirerin England. Also on view is a quilt knitted by Queen Victoriafor patients at Netley Hospital. (There is an old story, pro-bably apocryphal, that this was applied only to fortify thedying, but, as this became widely known, its single purposemay not have been wholly achieved.) Inevitably, too, themuseum shows something of our military history proper.(Who knows the origin of

" Thomas Atkins " ?) And for theunwarlike it provides welcome evidence of evolution from thedays, not so long ago, of the cat-o’-nine-tails, of brandingdeserters, and of " crime-and-punishment " books whose everypage is filled with charges of drunkenness.The collection reveals doctors, in war and in peace,

as incorrigible magpies: the trophies range from a Russiandrum won at Sebastopol to a Coptic cross collected by asurgeon in Lord Napier’s Abyssinian Campaign of 1868.Perhaps the keenest medical collector of all is GeneralBarnsley himself, who (ignoring the adage that good wineneeds no bush) is at present bent on discovering a pre-1914 horse-drawn heavy ambulance-wagon to place out-side the museum-perhaps hoping thus to distinguish it,for the benefit of visitors, from the commandant’s officenearby. Any reader lighting on a disused horse-drawnheavy ambulance-wagon in his garage is invited to offerit to the museum.The museum is open to the public on Mondays to Fridays from

10 A.M. till noon and from 5 till 7 P.M., and on Saturdays from10 A.M. till noon. Visitors are welcome at other times, includingSundays, but are asked to write in advance to the Curator, R.A.M.C.Historical Museum, Queen Elizabeth Barracks, Crookham, Hants.