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OBSTETRICAL MEMORANDA.

783

backwards; right (3d), or left (4th) occipito-posterior, forehead forwards. Order of their comparative frequency: 1st, 3d, 2d, 4th. The 3d rotates into the 2d, the 4th into the 1st.

Facial Positions (4).—Right (1st), or left (2d) mento-posterior, forehead forwards; right (3d), or left (4th) mento-anterior, forehead backwards. The 2d rotates into the 3d, and the 1st into the 4th.

Pelvic, or Breech Positions (4).—Left dorso-anterior (1st), left trochanter forwards; right dorso-anterior (2d), right trochanter forwards; left dorsoposterior (3d), right trochanter forwards; right dorso-posterior (4th), left trochanter forwards. Order of their comparative frequency, Ist, 2d, 4th, 3d. Shoulder Positions.-Varieties (2): dorso-anterior, and dorso-posterior, the former occurring twice as often as the latter. In each variety the head may lie in either iliac fossa; the presenting shoulder being, in dorso-anterior position, the left if the head is in the right fossa; in dorso-posterior position, the left if the head is in the left fossa, and vice versa.

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Circumferential measurement of the brim-about 17 inches.

DEVELOPMENT OF THE FŒTUS.

4.0"

[Entries in the column headed "Month" refer to the end of each month.]

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Occipito-frontal..

Occipital protuberance to point of chin... 5%-5%2
Occiput to centre of forehead....

42-5

Sub-occipito-bregmatic.. Midway between occiput and foramen

magnum to centre of ant. fontanelle....

314

Cervico-bregmatic........ Ant. margin of foram. mag. to centre of

ant. font........

Bi-parietal........

Bi-temporal...........

334

Between the parietal protuberances.
Between the ears.

334-4

3/2

[Compare the articles in Part III entitled-ABORTION, AFTER-PAINS, FALSE-PAINS, HEMORRHAGE POST-PARTUM, LABOR, LACTATION, PREGNANCY, PUERPEral Disorders, Vomiting of PREGNANCY, etc.].

ASPHYXIA AND APNEA.

From Drowning.-Remove the person from the water as rapidly and gently as possible, turn the face downwards for a moment, and depress the tongue, in order that water, mucus, etc., may be removed from immediately over the entrance of the windpipe. Give the patient plenty of fresh air, fully exposing neck and chest to the breeze, unless inclement. Turn gently on the face, one forearm being under the forehead, and raise the body up that the water may have free discharge from the mouth. Place patient upon the side and apply stimulants (ammonia, etc.) near the nostrils; or the cold douche, in order to excite respiration.

The above measures being ineffectual, convey the body to the nearest convenient spot, strip it carefully and dry it, and place it on a warm bed, with head and shoulders slightly raised, and at once employ one of the following methods, known as Silvester's and Marshall Hall's.

Silvester's Method.-Pull the tongue forward, to prevent obstruction to entrance of air into the windpipe; produce expansion of the chest by drawing the arms from the sides of the body and upwards until they almost meet over the head. Then bring the arms down to the sides again, causing the elbows almost to meet over the pit of the stomach, and thus producing contraction of the chest. This imitation of the act of respiration should be continued at the rate of fifteen or sixteen times a minute, as in health.

Marshall Hall's Method.-The person should be placed flat on the face, gentle intermittent pressure being made with the hands on the back, the body turned on the side, or a little beyond, then on the face, and the same pressure, etc., continued as at first. The whole body must be worked simultaneously.

ASPHYXIA AND APNEA.

785

The same number and frequency of these artificial processes of respiration should be employed as in the other method.

The Michigan Method.-Lay the body face down, the head upon the arm, and stand astride it; grasp it then about the shoulders and armpits, and raise the chest as high as you can without lifting the head quite off the arm, and hold it about three seconds; then replace the body upon the ground, and press the lower ribs downwards and inwards, with slowly-increasing force, for ten seconds; then suddenly let go, to perform the lifting process again.

Whichever process be employed, the effort to restore the temperature of the body must be maintained, the body being well rubbed in an upward direction with the hands, with warm flannels, etc.; bottles of hot water, hot bricks, etc., being applied to the stomach, the axillæ, the soles of the feet, etc., stimulants and beef-tea being judiciously administered when restoration is about taking place. The attempts at resuscitation must be persevered in for several hours, if necessary.

Laryngotomy or tracheotomy, with or without catheterization, or forced insufflations of air or oxygen, have proved successful, as also electro-puncture (Garratt).

In artificial inflation, always press the larynx and trachea against the ver tebral column, so as to close the œsophagus and thus prevent the air entering the stomach.

After Long Submersion is Recovery Possible?-According to Harley (p. 881), dogs kept under water 11⁄2 minutes always died, if water had entered the lungs. If it had not, the trachea being plugged, they survived a submersion of 4 minutes. When persons rise after sinking they usually get some air, and less speedily come into a state from which recovery is impossible. The greatest period between the last inspiration and the stoppage of the heart is 4 minutes. Some think that no recovery has been made after complete cessation of the heart's action. We infer that after complete submersion for 5 minutes recovery is improbable, unless the person had been previously choked, or in a fainting state, so that no water entered the lungs. But in Anderson's case, the patient had been under water at least 15 minutes, and in Garratt's the time was variously estimated at from 15 to 60 minutes.

When is a Case Hopeless?-Harley says (p. 892): "If the eyes are open, the pupils dilated, the conjunctiva insensible, the countenance placid, the skin cold, frothy mucus round the nostrils and mouth, no attempt at respiration, and the heart's action inaudible (when the ear is applied to the chest), the case is hopeless."

Signs of Death.-The following have been suggested as methods of deciding whether death has occurred:

(a.) Tie a string firmly about the finger. If the end of the finger becomes swollen and red, life is not extinct.

(b.) Insert a bright steel needle into the flesh. If it tarnishes by oxidation in the course of half an hour, life may be considered not extinct.

(c.) Inject a few drops of Liquor Ammoniæ under the skin. During life a deep red or purple spot is formed.

(d.) Moisten the eye with Atropine. During life the pupil will dilate. (e.) Look at a bright light, or at the sun, through the fingers held closely side by side. During life the color is pink; after death a dead white.

(f.) After death a dark spot is said to form gradually on the outer side of the white of the eye, from drying of the sclerotic, so that the dark choroid shows through,

(g) Putrefaction is an absolute sign of death. Better delay for it than run any risk of burying alive.

From Foreign Bodies in Air Passages.-If round and smooth, invert the patient and strike on the back: laryngotomy: tracheotomy.

Of the New-Born.-Clean the mucus out of nostrils and throat; catheterize the trachea, and suck up the mucus. "Marshall Hall's method:" by placing child on abdomen, then bringing into lateral posture, repeating slowly and deliberately. "Schultze's method:" by placing the thumbs upon the anterior surface of thorax, the indices in the axillæ, and the other fingers along the back, the face of the child being from you; rotate the child, by swinging upwards, so that the inferior extremities turn over towards you. In a moment re-rotate to the original position. Do not support head or legs in the forward rotation; their bending upon or towards the abdomen gives a forced expiration.

CLINICAL EXAMINATION OF THE URINE.

NOTE. Use morning urine, or a sample of all passed during the 24 hours.

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Quantity (in 24 hours). Normal about 50 fl. oz., from which there may be considerable variation either way, according to the quantity of sweat, the fluidity of food used, etc.

Specific Gravity. If possible, take the mixed urine. Normal is about 1.018, i. e. 18 grains of solids in each fl, oz. If sp. gr. is high, suspect sugar; if low, suspect albumen.

Reaction, in health is always acid in 24-hours' urine. It may be alkaline from medicine, or disease, or shortly after a meal. If excessively acid, examine for crystals of uric acid. If alkaline, let the test-paper dry, so as to ascertain whether the alkali be fixed or volatile.

Albumen by Heat and Nitric Acid. With Acetic Acid, or dilute Ammonia, make the urine slightly acid. If a precipitate appear on boiling, it

CLINICAL EXAMINATION OF THE URINE.

787

may be Albumen or Phosphates. Add a drop or two of Nitric Acid. If the precipitate dissolve, it is Phosphates; if not, it is Albumen. If a deposit or turbidity disappears on heating, it consists of Urates: if not, add a drop of Nitric Acid. If now dissolved, we have Phosphates; if not, Cystine. Other Tests are the Potassio-Mercuric Iodide, the Sodium Tungstate, Potassium Ferrocyanide, and Picric Acid Tests; but the above described one, if care. fully done, will give as good results as any.

Bile Pigment and Acids, if necessary. Vogel's color-table. Marechal's Test, as follows: Put 3 of urine in a test-tube, and pour one or two drops of Tinct. Iodi. to trickle down along the side of the tube, held horizontally nearly, so that the two fluids may touch, but not mix. If bile pigment be present, a fine green color will at once be developed below the red Iodine layer. Noel's Test, Pettenkofer's Test, Nitric Acid Test, Oxide of Silver Test. Sugar, if necessary. Urine containing sugar is usually light-colored, froths readily when poured from one vessel to another, and has a high specific gravity. Fehling's Test, as follows: Add to the boiling urine a few drops of freshly-prepared solution of Potassio-Cupric Tartrate (Fehling's Solution). If sugar be present, a yellow, orange, or red precipitate of Cuprous Oxide will form, 10 cubic centimeters of the solution being reduced by 0.05 gram of diabetic sugar. To prepare Fehling's Solution, dissolve 34,639 grams of pure, crystallized Copper Sulphate in about 200 grams of Distilled Water; also 173 grams of chemically pure, crystallized, neutral Tartrate of Sodium in 500 or 600 grams of a solution of Caustic Soda, of specific gravity 1.12, pouring the first solution into the latter, slowly and a little at a time. The clear, mixed fluid is then diluted with distilled water up to a litre. This solution soon spoils, and must be kept in a dark, cool place. Much more convenient are Dr. Piffard's Cupro-Potassic Paste, and Dr. Pavy's Cupric Test Pellets (see Tyson on Urine, page 57); and still more handy are Wyeth's Compressed Tablets for preparing Fehling's Solution of Potassio-Cupric Tartrate, Û. S. P. 1880, a box of which costs 50 cents, and may be obtained from any good drug-store. The writer has used these Tablets for some two or three years, with extreme satisfaction.

Pavy's Solution is a modification of Fehling's, is equally good for qualitative and volumetric testing, and is intended for those who prefer the apothecaries' weights and measures to the metric system. It is made in the same manner as Fehling's, 100 minims corresponding to 1⁄2 grain of diabetic sugar, and consists of-Copper Sulphate, gr. 320; Potassium Tartrate (neutral), gr. 640; Caustic Potash, gr. 1280; and Distilled Water, f320.

Other Tests for Sugar are Bottcher's Bismuth Test, the Fermentation Test, Moore's, Trommer's, the Picric Acid and the Indigo-Carmine. They are all useful, but will not be detailed here, as one good method is all that the average practitioner wants.

Chlorides. Add a drop of Nitric Acid, and then Silver Nitrate until a precipitate ceases to form. Thus estimate the amount of Chlorides.

Urea.-Place a drop of urine on platinum-foil, and to it add a drop of Nitric Acid, and leave undisturbed in a cool place for a minute or two. If the urea is in excess, crystals of Uric Nitrate form immediately.

Mucus and Pus resemble each other so nearly under the microscope, that it is almost impossible for any one, except an expert, to distinguish between them thereby. Mucus is more cloudy and flocculent to the naked eye than Pus, which latter is generally of a stringy consistence and thickish yellow appearance at the bottom of the vessel. The supernatant liquid being poured off, and an equal bulk of Liquor Potassæ added, the deposit, if containing

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