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in hard labor, head presenting at brim. Failing to deliver with forceps, the aid of a second physician was sought. A second application of the forceps was likewise futile. .\t 7 a.m. of the second day both these doctors took their departure, promising to return later. They failing to do this, a third practitioner was called in, who, not deeming the Tegretol Vs Trileptal pains of the now ex- hausted woman strong enough, ordered regular doses of ergot and left the patient to nature and the drug. He returned at eleven o'clock that night to find the woman vomiting and in a state of collapse. He sent for a consultant, upon whose arrival the bladder was catheterized and bloody urine withdrawn. It was then decided to send for an ambulance to remove her to a hospital. The ambulance surgeon arrived at the house at about 5 a..m. the tliird day of the woman's labor. She then presented marked pallor of the face and lips, wrist pulse weak and rapid, with every evi- dence of complete exhaustion with entire absence Trileptal 150 of pains. On examination the surgeon found a pro- lapsed, pulseless cord, with head presenting at brim but not wedged in. Having been informed of the fruitless eft'orts of the four physicians who had pre- ceded him to deliver with the Trileptal 135 Mg forceps, he proceeded to do an internal podalic version, which he states he accomplished with comparative ease. He experienced but little difficulty in delivering the body and extremi- tities, but the head remained fast. After vainly tr}ing to deliver this he severed the body Order Trileptal from the head and brought the woman to St. Mary's Hospital, where I was sent for to complete the attendance. As you can i6o MEDICAL RECORD. [August I, 1896 well imagine, the woman presented all the appearance of approaching dissolution from collapse. 'I'he abdo- men was greatly distended, tense, and painful, show- ing the presence of general peritonitis, and in conse- quence of this condition nothing could be determined by abdominal palpation. Upon the introduction of my hand into the uterine cavity I found it filled with intestines. The decapi- tated head I could feel between them, receding before my fingers into the peritoneal ca\ity. I found it somewhat difficult to gain possession of this, owing to its moist, rounded form, but finally, getting my inde.x finger into the mouth, I gently worked it back through the widely torn rent into the uterine cavity and down to the pelvic brim. I retained my purchase and an assistant was able to grasp with a strong pair of for- ceps the remaining portion of the neck, which he held until I applied a pair of obstetrical forceps Trileptal 450 Mg and deliv- ered the head, the placenta following directly. I was desirous of doing a cctliotomy, cleaning out the ab- dominal cavity, and stitching the torn womb, but on consulting with the medical gentlemen present it was deemed unwise, owing to the patient's condition. I then endeavored to produce an inversion with the in- tention of amputating the womb, but my efforts, to- gether with the stimulants the patient was constantly receiving, brought on contractions, which rendered my efTorts of no avail. The uterus was then crowded down into the pelvis and held there by abdominal compresses and bandages. After douching out the cav- ity with a weak solution of carbolic acid, an iodofomi drain was inserted into the rent, and the patient re- moved to the ward where she died five hours after- ward. I will leave comment upon this case to the members of the association. C".\SE II. — .\ strong, healthy German woman, mother of seven children, upon the appearance of labor pains sent for the doctor she had engaged to attend her. On his arrival he stated he was in a great hurry, made an examination, ruptured the membrane, applied the for- ceps, and delivered. One week afterward she was brought to St. Mary's Hospital. On an e.xamination by Dr. John Byrne, the bladder, vagina, and uterus made but one cavity. Fortunately, in this case the uterine rupture did not extend Trileptal Generic Name into the peritoneal cavity. After waiting for proper involution. Dr. Byrne, at one sitting, made a thorough and successful resto- ration of the parts. A few days ago 1 learned from the doctor Buy Trileptal Online that the woman was again pregnant. The position of the ruptures in these cases is not so much a matter of moment as their extent. Sometimes the cervical portion is torn from their body. The ma- jority of the tears have their origin in the thin obstet- rical neck and extend transversely and longitudinally. This portion of the uterus is passive during a pain, and, it being also the thinnest, you can understand how the force of the contracting fundus, pressing the fatus against the Order Trileptal Online bony brim, can destroy the integrity Cost Of Trileptal of the inter\'ening wall. Rarely there may be an ex- ternal rent in the walls of the uterus without injury to the peritoneum and conversely. I believe it to be a difficult matter to detect any but a rupture of so grave a character that there can be no mistaking the objective symptoms. Some ruptures are progressive and cannot be recognized until completion of the disaster. But there can be no mistaking the following symptoms: During the acme of a pain the woman experiences a sensation of something tearing or giving away, followed by vomiting, faint, pallor, shallow respiration, coldness of the extremities, in fact all the symptoms of shock; cessation of the pains generally, but not always; for if the arch of the fun- dus is not destroyed contractions can continue. If the child has entered the jjeritoneal cavit)" it Cheap Trileptal can be felt through the abdominal walls, and an examination per vaginam will show a recession of the presenting parts. Palpation of the abdominal walls will not only show the presence of the child, but the uterus can be felt as a separate body as well. Hemorrhage from the vagina also often takes place. Emphysema at the level of the hypogastric region caused by air in the connective tissue is a symptom not always present. When found it indicates a fatal termination. In my reading on this subject I have not met with the men- tion of a single case in which a woman with a previously ruptured uterus was afterward delivered without a re- currence of the same, an item of considerable impor- tance in the elective treatment of these patients. Preventive treatment resolves itself into a matter of individual judgment. Treatment after rupture de- pends entirely upon the position of the child. If the head presents apply forceps and deliver, having an assistant steady the uterus by pressure. Failing to deliver, craniotomy is advised, but morally and scien- tifically cctliotomy would be the better procedure, pro- viding the child is still alive; in other than vertex presentations with a dead child embrjotomv; incase of a living child podalic version may expedite delivery, but the greatest care is necessary in order not to en- large the tear. In a third class of cases, in which the child is partly within the peritoneal cavity, try and deliver through the vagina. But when the child is wholly within the cavity, cctliotomy is Trileptal Coupon the only justifiable Trileptal Acne operation. The old treatment of passing the hand through the uterine tear and withdrawing the child will only jeopardize the woman's chance for recovery. The old-fashioned expectant plan is not to be thought of in this enlightened era. After the removal of the child and placenta through the abdominal opening, the rent in the uterus is to be sutured, the peritoneal cav- ity cleansed in accordance with the rules of aseptic surgery, and the wound closed. The uterus is then to be douched out with a weak solution of carbolic acid. In cases in which the child has been delivered through the natural passage and the mother after- ward develops symptoms of septicemia, it would be proper to perform cceliotomy for the purpose of re- moving the septic material. In other than cceliotomy cases daily irrigations and drainage are requisite. It is a disputed Trileptal 150 Mg question whether it would not be better in all cases of rupture in which the amniotic fiuid and blood have entered the peritoneal cavity to remove it through abdominal section, as it is well-nigh impos- sible to secure proper aseptic conditions without; but statistics of reported cases up to the present time show a less mortality when drainage and irrigation have been given the preference over cceliotomy. In cases of cceliotomy, where the edges Trileptal Vs Tegretol of a uterine rent are so irregular and injured that they cannot be prop- erly brought together, amputation of the uterus is re- sorted to. The mortality resulting from this proceed- ing has been so great that drainage is preferable. The Purchase Trileptal Online placenta should be removed manually and not ex- pressed. Phimosis — Dr. Martin (Medual News) says this is a frequent agent in causing or aggravating Trileptal 60 Mg diseases in children. The indirect disturbances by reflex are often puzzling and by no means infrequent; it affects digestion very seriously at times. Prolapsus ani ac- companies preputial inflannnation, which will also give rise to symptoms resembling those of stone in the bladder. Phimosis will aggravate the symptoms ot any coexisting disease and be the cause of slow recover)' in many cases. The reflex disturbances from it are of sufliciently frequent occurrence to justify a physi- cian in making an examination of every male child for this condition. August I, 1896] MEDICAL RECORD. 161 Medical Record: A VVefk/y Journal of Medicine and Surgery. GEORGE F. SHRADY, A.M., M.D., Editor. Publishers WM. WOOD & CO., 43, 45, & 47 East Tenth Street. New York, August i, 1896. THE SIN OF SUBSTITLITION. On several occasions previously we have condemned the practice of substituting one preparation for anotlier in the compounding of prescriptions. The evil is a well-recognized Trileptal Cost one and, we have good reasons for be- lieving, is more prevalent than would at first sight ap- jjear. To such as take the requisite pains to examine the question the damaging testimony against the un- principled pharmacist is overwhelmingly evident. The difficulty of finding some efficient remedy for this gross abuse has always been great, and it is with a Buy Cheap Trileptal feeling of congratulation that we notice the action of a leading manufacturing firm of this city in placing the responsibility where it rightly belongs. The firm in question, whose products have gained for Trileptal Tablets themselves a well-deserved reputation for uniformity of strength and surety of action, has directly attacked the evil in the very practical manner as set forth in the follow- ing circular to physicians throughout the country : "Dear Sir: We beg to call your attention to the following statement of facts, which we believe will be of great interest to you as a practising physician re- lying upon the pharmacist for dispensing the medi- cines which you prescribe: "On a recent date a prescription of a physi- cian ordering was sent to — drug store. The bottle dispensed upon this prescription was immedi-

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