but also for the anxious and exhausted state of the patient herself. The labor pains in these cases are most severe, and this, in my opinion, is due to the muscles acting contrary to each other and tearing themselves asunder, as has been already mentioned, when speaking of the unequal dilatation of the os. It is this form of pains that most authors recommend to be treated by bleeding, when the patient is plethoric, and when weak and nervous by tepid bathis, warm injections, sedatives, opium, belladonna, etc. The irregularity of the contractions continues till the adhesions are separated; or, the dilatation of the neck has been slowly and painfully accomplished by the inoperative contractions of the organ; or, until the membranes have been ruptured, so as to permit the child to glide over the membranes, seeing the membranes will not glide over the surface of the uterus, as they should do, to allow the child to be born. To break up the adhesions is an easy matter in those cases where they are situated near the os. The finger gently introduced around the neck, between the membranes and the uterus, readily accomplishes the desired result. Where the adhesions are beyond the reach of the finger, I do not think it advisable to attempt the separation by instrumental means, but rather to rupture the membranes at once, as by this means we effect the chief thing to be desired, viz., the supervention of normal labor. In some cases, after you have broken up the adhesions as far as the finger will reach, you will often find that the os will rapidly dilate, and in a few minutes the finger can be still further introduced and the detachment completed. I give the following case-one out of many-by way of illustrating what has been said: Mrs. L., aged 20, first pregnancy; has been in labor last four and a half hours; pains irregular and spasmodic, and accompanied with intense suffering. On examination, found os dilated to the size of a twenty-cent piece; membranes adherent on the right side, and neck of uterus turned that way. A somewhat thick layer of muscular fibres covered the membranes, spread over the dilated part of the os. As I could not reach all the adhesions, the membranes were ruptured, after which the pains became regular and powerfully expulsive, the os dilated rapidly, and the child was born in less than two hours. By way of illustrating another class of adhesions, I may state that during the past week I attended a Mrs. R., aged 21, in her first confinement. On examination, found womb almost upon the floor of the pelvis, and os dilated to the size of a twenty-cent piece; has bad, grinding pains; little expulsive power for last eight hours. On introducing the finger, could feel no adhesions between the mucous membrane and uterus. Being somewhat in doubt as to the cause of the irregular contractions, I examined more carefully, and then found that there were tolerably strong adhesions between the posterior part of the neck of the uterus and vagina. The adhesions did not exist over the anterior third of the neck. The separation of the parts was easily accomplished, when the expulsive power of the pains was greatly increased, the os dilated more rapidly, but the membranes did not protrude. With the dilatation of the os the womb descended more upon the perinæum, and I then found adhesions between the mucous membrane and the uterine surface, which, when broken up, the labor progressed more rapidly, but I finally was obliged to deliver by the forceps, as the head presented in the third position, and the woman was too weak to complete the labor alone. This case is mentioned not only on account of its unusual character, but also because it shows that external adhesions may interfere with labor as well as adhesions between the mucous membrane and the inner surface of the womb. Before leaving the subject, it might not be amiss to say that the cause of gestation being of shorter duration in first pregnancies is probably due to a inore rapid maturation of the decidua, combined with a very sensitive state of the muscular. surface of the uterine cavity, which favors the induction of muscular contraction before the decidua is thoroughly detached. It also explains why we have trouble in delivering the placenta in many instrumental cases. The adhesions render the contractions abnormal and inefficient, and this condition renders the forceps necessary to complete the delivery, while the adhesions remain, as before stated, to give us further trouble. The effects of adhesions upon the delivery of the placenta deserve some consideration; but as I have not had any cases illustrating my views upon the subject, I shall not longer occupy your attention. We could have no difficulty in attributing hour-glass and spasmodic contractions of parts of the uterus upon the placenta to the same cause that induced such contractions during the first and second stages of labor. In addition to the cause of such contractions, which have been spoken of already, there is the possible irritating effect of the placenta when adherent to the uterus. The mass of the placenta being somewhat firm, and the uterus contracting upon it, might easily cause laceration of some muscular fibres, and thus originate the hour-glass contractions. Also, the contractions might be due to the effect of lacerations of the tissue of the surface during labor, which had left the parts irritable and ready to contract as soon as opportunity offered. As to treatment of retained placenta, I have nothing special to say. We should follow the recognized mode of dealing with such cases, and, when possible, effect the detachment and removal of the entire mass, with its membranes. BOOKS RECEIVED. A TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. By J. LEWIS SMITH, M.D., Philadelphia: Henry C. Lea. 1872. CLINICAL LECTURES ON THE DISEASES OF WOMEN. By Sir JAMES Y. SIMPSON, BART., M.D., D.C.L., D. Appleton & Co, New York. 1872. A TREATISE ON DISEASES OF THE BONES. BY THOMAS M. EARTH AS A TOPICAL APPLICATION IN SURGERY. BY ADDI- 1872. THE URINE AND ITS DERANGEMENTS. BY GEORGE HARLEY, M.D., F.R.S., Philadelphia: Lindsay & Blakiston. 1872. THE DUBLIN PRACTICE OF MIDWIFERY. By HENRY MAUNSELL, M.D. London: Longmans, Green & Co. 1871. Dr. RIGBY'S OBSTETRIC MEMORANDA. By ALFRED MEADOWS, M.D. Philadelphia: Lindsay & Blakiston. 1872. BY S. L. JEPSON, M.D., Wheeling, W. Va. No class of diseases that the physician is called upon to treat is invested with the same amount of interest as those incident to the puerperal state. Indeed, from the very day that a woman becomes pregnant, she is clothed with a new interest, not only for the physician, but for all who take pleasure in watching "those miraculous powers and actions of the living body, that result in forming and perfecting a human being, the crowning work of Deity." Woman, giving promise, by the fact of conception, to suffer the terrible pangs of child-birth that a living soul may be born into the world, is indeed a beautiful being! Her natural charms are now doubly enhanced; and in time of * From the forthcoming Transactions of the Medical Society of the State of West Virginia. Published by permission of the Society. sickness the physician looks upon her with intense interest and solicitude, since on her life and health depends the life of another being, and likewise the happiness of the family. And the sudden, the unexpected death of the puerperal patient is an accident that, more than any other that occurs in the physician's experience, appalls him, and produces a realization of his own weakness in a strife with the "dread adversary." Nor is this true because, by the occurrence of this accident, his reputation is severely tried or even damaged, though this is undoubtedly often the case, but because of the peculiar interest, already referred to, that attaches always to woman in labor, or just released from the pains of parturition. It is not necessary for us, then, to impress the importance of every physician so informing himself as to the cause, prevention, and cure of puerperal accidents, that he shall be able to give his patient such counsel and such treatment as will best conduce to her welfare by enabling her to pass through the process of child-birth, and the critical period following, with the least possible danger. It is certainly our duty as well as our interest to search out, by every possible means, the causes, however deeply hidden they may be, of these fearful accidents, and to devise means whereby they may be avoided, or, if this may not always be, whereby dangerous symptoms may be met promptly, and a fatal result prevented, if this lies within the power of human agency. In furtherance of this end, we propose to present, in |