From recent experiments Professor Botkin asserts that:

1. Bitters diminish the digestive power and retard digestion; they diminish the quantity of peptones.

2. Bitters diminish the secretion of the gastric juice. If they produce a feeling of hunger, it is only by irritating the gastric mucous membrane.

3. Bitters have no influence upon the secretion of the pancreatic juice or the bile.

Bitters not only do not diminish, but 4. actually promote fermentation in the contents of the stomach.

From all this, the author is led to believe, contrary to current medical views, that bitters are of no use in the treatment of disorders of digestion.-L' Union Médicale du Canada.

The

The setting or reduction of dislocations may be made painless, according to Dr. Grigorieff (in Meditzinskaie Obozrenye) by the hypodermic injection of cocaine into three or four points in the neighborhood of the joint. Russian surgeon uses the ordinary syringe and a 5-per cent. solution of cocaine, injecting 15 minims at each point. The anesthization of the part takes place in from three to five minutes, and the effect of the remedy is not only to deaden all sense of pain, but to relax the muscles, etc., around the joint to that extent that reduction is rendered very easy, as well as painless. -National Drug.

Dr. Jackson says the preliminary washing of the parts with scap and water before using cocaine should be avoided, as the alkali of the soap prevents anesthesia.

General Aphorisms.-1. When called to a case of obstetrics go at once, and take with you the following in an obstetric bag: Forceps, Davidson syringe, an elastic catheter, size eight, a good pair of forceps, a couple of sutureneedles, silver wire and silk, thread, scissors, a hypodermic syringe, a forceps and needleholder combined, antiseptic absorbent cotton,

corrosive sublimate tablets, chloroform, chloral, morphine, fluid extract ergot, and atrophine tablets.

2. Be clean in person and in thought at the obstetric bed-side. Have your hands warm, aseptic and antiseptic, and nails closely cut.

3. Corrosive sublimate is the most reliable antiseptic for midwifery, and as there is some danger connected with it, its use should be subject to the following conditions and restrictions: (a) use tablets made by a reliable firm; (b) for the hands use a solution 1 to 1000; (c) for the external genitals 1 to 2000; (d) for the vagina 1 to 4000; (e) for the uterus I to 18000 and not more than two quarts; (f) use another disinfectant for the vagina and uterus with women suffering from anemia, phthisis, nephritis, or disease of the digestive organs.

4. After attending a septic case, or a post mortem, you can attend a case of midwifery as soon as you change your clothes, and go through a thorough washing with an antiseptic solution of a reliable character, preferably corrosive sublimate, 1 to 18,000.

5. If possible, have your patient to take a bath before the denouement, and to have on nothing but a night-gown, a pair of drawers, and a pair of stockings for the labor.

6. The patient's bed should be so placed that it can be approached from both sides. Mattress should be firm, covered by water-proof cloth, and a piece of blanket, over this a sheet, and under the patient's buttocks another piece of blanket.

7. The American rule is to put your patient in a dorsal position, and have her covered.

8. When examining your patient remember, (1) never to use lard or vaseline; nothing is as good as carbolized oil; (2) never to unnecessarily push, pull, or jostle your patient; always to look when you think it is going to help you; (4) always to examine your obstetrical patients with the index finger of your right hand, and your gynecological ones with the left; (5) never to rest the thumb on the mons veneris,

which is indelicate; (6) to make few examinations.

9. At the first examination ascertain (1) whether the woman is in labor, and at what stage; (2) the condition of the perineum; (3) the presence of any tumor of the vulva; (4) the condition of the vagina, its roominess, moisture, etc.; (5) the condition of the cervix; (6) and condition of the pelvis.

10. To reach the cervix when not low down, the fingers should be extended so that the posterior commissure fits into the space between the index and middle fingers, and the perineum pushed strongly backward and upward.

NORMAL LABOR.

The First Stage of Labor.-11. Labor is commenced when the distended cervix is ac

companied by regular contracting pains not relieved by opium.

12. The first stage of labor consists of the dilatation of the cervix to allow the exit of the presenting part.

13. Patient can sit up or walk about till os is two-thirds dilated, then she should be put to bed, night-gown rolled up to the arm-pits, drawers and stockings to be kept on.

14. Chloral is the best anesthetic during the first stage of labor.

15. The attendant should talk cheerfully and allay the fears of the patient. This is one of his most important duties.

16. The character of the pains during the first stage is described as "acute" and "grinding," and the cry is "high." The pains are intermittent.

17. A delayed first stage is as a rule not dangerous, and the best remedies are time and patience.

18. When once the os is fully dilated the membranes may be ruptured as they are of no further use.

19. Use a straightened hair pin to rupture the membranes, which press against the bulging bag of waters during a pain.

20. Do not rupture the membranes too early, for remember bi-polar version cannot be performed after the membranes are ruptured. And version after the waters are gone is one of the most difficult operations in obstetrics.

The Second Stage of Labor.-21. The second stage of labor consists of the delivery of the fetus from the uterus and vagina.

22. The fetal contents are passive in delivery.

23. The patient should be in a recumbent position during the second and third stages. 24. Chloroform is the best anesthetic during the second stage of labor.

25. The character of the pains during the

second stage of labor is "tearing" and "stretching," and the cry is a "groan." The pains are intermittent.

26. Examinations can be made more frequently.

27. The anterior lip of the cervix may sometimes be caught between the advancing head and the pelvis; become swollen, and edematous and retard labor. Push up the lip above the head, between the pains, and hold it there by the finger tips until the head has descended.

28. During the pains, press back the head of the child, and, between the pains, try to push the perineum gradually over the head. This is the only common-sense way to "support" the perineum.

29. When the head is born, lift it and shoulders towards the symphisis until the posterior arm is swept across the chest and delivered; the shoulders are then depressed, and the anterior arm delivered.

30. In breech presentation nothing should be done to hasten the delivery until the os is fully dilated, or the body of the child born, and as the cord becomes compressed, deliver at once. Manual compression of the uterus from above should be resorted to instead of the usual traction from below. Pressure on the chin or superior maxilla does no good.

31. Ergot-Never give it to a tired uterus. Never give it in first labor. Never give it in a case of grave disproportion, nor in cases of slight disproportion. Hardly ever give it till the head is born. Always prefer steel to ergot. The Third Stage of Labor.-32. The third stage of labor is the expulsion of the afterbirth consisting of the placenta and membranes.

33. Do not be in a hurry to tie the cord; wait till the child cries vigorously; tie it firmly one inch from umbilicus and beyond this, and divide the cord between the two. Dress with absorbent cotton. Wrap the child up and put it in a warm place. Don't try to wash it too clean the first time.

34. Don't be too much in a hurry to get rid of the placenta. A half-hour to an hour is not too long a time. Leave to nature some say, use Crede's method is the creed of many, employ pressure on the fundus uteri and traction on the cord believe others, I say follow the method of your teacher for all three plans are good.

35. Crede's method of expression of the placenta. Stands on the right side of the bed, insert his eight fingers as far down as they will go on the posterior surface of the uterus, places his two thumbs on the anterior surface, and when he feels the womb contract, he tries, as it were, to squeeze the placenta out of the

uterus, at the same time pushing that organ with a moderate degree of force into the hollow of the sacrum.

36. Immediately after the placenta is delivered give a full dose of ergot. Never give it before even if there be hemorrhage.

37. Some measurable hemorrhage is a normal constituent of the phenomena of labor; the placenta presents in the great majority of cases by a point on the amniotic surface; the presenting point is almost invariably near the lower edge of the placenta; the position of the presenting point varies with the position of the placenta; the inversion of the placenta is not due in the great majority of cases to traction on the cord, but is part of the natural mechanism.

38. Always carefully inspect the placenta and membranes, and if a part remains behind in the uterine cavity go in search of it.

39. If the whole placenta be retained in the uterus be very slow about going after it, as a little more patience may overcome the difficulty. But if from any cause a piece of the placenta be retained, you cannot be too quick about making up your mind that it must be removed. 40. Do not give an anesthetic to deliver a retained placenta.

Puerperal State.-41. After placenta and membranes are delivered, the puerperal state commences. The hand is to be kept gently pressed over the fundus uteri.

42. There is no need of kneading the uterus as if it were a lump of dough unless hemorrhage comes on, or the uterus threatens to give up contracting.

43. Uterus is usually well and permanently contracted in a half hour, but should never be left before an hour has elapsed, after labor.

44. After a half hour, cleanse your patient's genitals, lay her clean, put on the binder from the trochanters to the tenth rib, pinning from below up with safety pins. Put a wad of absorbent cotton over vulva, held in place by a broad bandage, held in place by being tied behind and in front to the binder. Remove this to admit defecation and urination. Renew the wad every six hours.

45. The bladder should be frequently emptied for twelve hours after labor.

46. The bowels should be moved on the third day.

47. After-pains are relieved by stupes of chloroform liniment and morphine, in camphor

water.

48. After-pains are best prevented by keeping the uterus well contracted with ergot. 49. For twenty-four hours after labor, the food should be milk, broths, etc. After this time food may be increased.

The Mechanism of Labor.-50. Without a correct knowledge of the diameters of the pelvis and of the fetus and of the mechanism of labor you cannot properly practice midwifery. You are referred to the text-books for these. I append a few suggestions:

51. Presentation is the part of the child presenting.

52. Position is the way the presentation is situated in the superior straight.

53. After labor has commenced, a position may change, a presentation never.

54. Two presentations are normal, the vertex and breech, all others are abnormal.

THE DIFFICULTIES OF LABOR.

The First Stage.-55. Rigidity of the cervix is produced by premature escape of the liquor amnii or may be due to constitutional peculiarities. Treatment, chloral, warm hip-bath, dilatation.

56. Cases due to cicatrical hardening, or hypertrophic elongation, or agglutination or carcinomatous degeneration of the cervix are generally serious. Treatment, incision, forceps, chloroform.

Eclampsia.-57. Terminate labor as soon as possible without violence by Barnes' dilators, podalic version, and forceps.

58. Chloroform does no good, except to quiet the patient whilst under its influence.

59. Morphine hypodermically and chloral per rectum, and veratrum viride internally in large doses are the remedies indicated in eclampsia.

Placenta Previa.-6o. No expectant plan is justifiable in cases of placenta previa. The uterus must be emptied as soon as possible after the discovery of the trouble, and no matter what the stage of the pregnancy may be. A halting, hesitating practice means danger, both to mother and child.

61. That the life of the child must not be considered in the treatment of the case.

62. That the manner of emptying the uterus must be left to the individual judgment of the medical man in attendance.

63. That in case of central adherence of placenta, the safest and best practice is to separate the placenta entirely.

64. That in cases where placenta is adherent in latero, cervical zone of the uterus, partial detachment may be sufficient; but if the hemorrhage is not arrested, the whole mass should be removed, and means of delivery at once instituted.

65. That the colpeurynter is the only tampon that can be safely used in these cases. That sponges, silk handkerchiefs, and other forms of tampon are nasty, filthy, and septic, and should never be employed.

Prolapse of Cord.-67. Due to mal-presentation, pelvic deformities, hydramnios, sudden loss of liquor amnii, abnormal length of cord; prognosis bad to child. Treatment, reposition, version, and forceps.

Accidental Hemorrhage.-68. Rarely occurs to an alarming extent until the latter months of pregnancy, often not until labor is commenced. Treatment, the same as in placenta previa.

The Second Stage.-69. Precipitate Labor. Treatment, chloral, morphine, chloroform. 70. Prolonged Labor.-Treatment, chloral, morphine, chloroform, forceps, patience, never ergot.

71. Painful Labor. Treatment, chloral, morphine, chloroform, remove the cause.

72. Obstructed Labor.-Cause: (1) abnormal presentations; (2) abnormal maternal soft parts; (3) abnormal fetus; (4) abnormality of the pelvic bones.

73. Abnormal presentations are face, shoulder, body, hand, feet, placenta. Modes of relief are forceps, version, Cesarean section and craniotomy.

74. Rules for forceps. Put the patient in the obstetric forceps position, which in this country is the lithotomy position. The closer you get your patient to the edge of the bed the better.

75. Draw off the urine. Empty the rectum. 76. For all positions of vertex, the long diameter of the child's head being in the left oblique diameter of the pelvis, apply the left or female blade; the long diameter of the child's head being in the right oblique diameter of the pelvis, use the right or male blade.

77. In delivering with the forceps, make traction during a pain, and carry over the abdomen to complete the delivery of the head. In rigid perineum, or where there is danger of rupture, make traction between the pains, and resist the advance of the head during the pains.

78. Version by external manipulation is dangerous, and not often practicable.

79. With a transverse presentation, one should peform podalic version only after the os is fully dilated, exceptional cases being excluded. "The hand improperly used is more dangerous than any instrument.

80. The fetus should be extracted only when a particular indication for operation exists. In the absence of the latter it will be for the interest of both mother and child to leave the case to nature.

81. Cesarean section is replacing craniotomy. 82. Signs of death of fetus after labor has commenced, are (a) loss of pulsation in the funis; (b) desquamation of the cuticle; (c looseness of bones of cranium; (d) emphysema of scalp.

83. Difficult labors from abnormal fetus are caused by twins, locked twins, double monsters, hydrocephalus, dropsical effusions, congenital deformities, excessive development of the head or the body.

84. Difficult labors from abnormal soft parts, are caused by bands and cicatrices in the vagina, tumors, vesical calculus, vaginal cystoclle, hernial protrusion, scybalous masses in the rectum, edema of the vulva, bloodswellings and polypus.

85. Difficult labors due to pelvic deformities are best prevented by premature delivery. After labor has commenced, forceps, craniotomy, and Cesarean section are the methods of treatment.

Third Stage of Labor.-86. Post-partum hemorrhage is caused by uterine inertia, retained placenta and irregular contraction of the

uterus.

87. Post-partum hemorrhage from retained placenta or a part of the placenta, should be treated by Crede's method of expressing the placenta, or by removing it by introduction of the hand into the uterus.

88. Post-partum hemorrhage from uterine exhaustion is best controlled by means of ergot and external manipulation of tre uterus. This failing introduction of hand, ice, perchloride of iron, etc., may be tried.

89. If post-partum hemorrhage is due to irregular contractions of the uterus give ergot, introduce hand into the uterus, dilate the constricted part, remove clots. Assist by external manipulation. In this kind of post-partum hemorrhage black haw is the specific.

90. Inversion of the uterus and rupture of the uterus are both very serious, especially the latter. The first should be treated hy reposition, the latter by laparotomy.

91. Perineal lacerations if extending half way and including the whole thickness of the perineum should be stitched. Make the diagnosis by ocular inspection and by including the recto-vaginal septum between the finger and thumb. Anesthesia is not necessary and one stitch will be enough. If the rectal wall is ruptured it should be stitched before the one stitch is put into the ruptured perineum.

Puerperal State.-92. Asphyxia. Asphyxia livida Surface is dusky red; and asphyxia pallida, surface is anemic. Diagnosis in first is favorable, in second doubtful.

93. Asphyxia Livida. When signs or beginning asphyxia become manifest, deliver immediately. After delivery, wipe out the mouth (pharynx), and nostrils with a soft cloth on the little finger, to clean them from fluid and mucus; flick the child with end of towel wet in

ice water; do not tie the cord as long as it pulsates; if the child does not respire, dip it in a hot bath for a few seconds, and then in ice water; repeat several times. Try Schultz's method, or Sylvester's.

94. Asphyxia Pallida. Keep the child warm and quiet. Mouth to mouth insufflation does no good, the air only passing into the stomach; but artificial respiration should be tried, by means of catheter passed into the larynx.

95. Never give up so long as the heart beats, no matter how feebly.

96. When the uterus from any reason does not contract well, put the child to the breast as soon as possible after delivery of the placenta. 97. Ophthalmia Neonatorum. Wash the eyelids with water. Let fall one drop of a two per cent. solution of nitrate of silver (gr. x to 3j) on the cornea.

98. Breasts. Apply a bandage if much tenderness; paint with tincture of iodine if any hardness; apply atropine (gr. 1 to 3) locally if much swelling; apply ice if much inflammation; apply dry tannin if fissured nipple ; apply solid nitrate of silver if deep fissure; open well and early in abscess, and treat antiseptically.

99. Fever. Any rise of temperature above 9910 F. during the first puerperal week should put us on our guard examine nipples and breast, give quinine. Remove constipation,

100. If temperature is between 102° and 103° F. wash out the vagina; if above 103° F. wash out the uterus. Bichloride of mercury for former, carbolic acid for latter.