The teeth seem to be more susceptible to decay at this time than otherwise but there is no reason why this should not be attended to during pregnancy. If cavities are present they may be filled temporarily. It is necessary to brush the teeth at least twice a day.

It is advisable for a pregnant woman to know what is likely to occur by way of complications during this period and this knowledge should be regarded in the sensible light of avoiding trouble. Knowing what may occur to a pregnant woman by no means assures her that it will take place and therefore she must not be frightened by the knowledge of such possibilities. As the entire system takes part to a greater or less extent in the development of the unborn child, all the organs must be kept in as good a condition as possible and where they are diseased proper attention should be given to get them well.

Among the first things to be considered under the heading of complications of pregnancy are disturbances of the kidneys. These cannot be treated by the patient herself but they may be largely avoided by a knowledge of their danger. It is advisable for every pregnant woman to take note of the amount of water she passes daily and this can only be done by measuring the same. Between two and three pints of urine should be voided in twenty-four hours and if the amount is less than this more water ought to be taken. The urine, moreover, should be clear and light in color. If it is dark and a sediment is deposited at the bottom of the bottle it means that the urine is too concentrated. A patient ought to bring her urine to the physician for examination at least once a month up to the seventh month and then every two weeks. If the patient is not well, however, the examination of the urine may need to be done much more frequently. The presence of abnormal constituents in the urine can only be detected by the employment of tests which are to be done by the physician. It is a mistake however to bring a specimen that is passed in the morning or the previous day and allowed to stand. A part of a specimen collected during a period of twenty-four hours should always be sent.

In

Nausea and vomiting is one of the most common and distressing ailments with which most women are affected during the early months of their pregnancy. Some women may not be disturbed at all and others vomit so frequently that they lose their strength rapidly and may require to have their baby taken away before they can recover. many cases these extreme vomiting spells may be avoided if the patient presents herself to the physician as soon as she is unable to control the vomiting by the measures about to be noted. A cup of very hot tea or coffee taken as soon as the patient arises, or even in bed if possible, will do much to alleviate the ordinary attack. Moreover, proper attention to the bowels and careful eating, which means that the woman should eat six small rather than three large meals daily, will do a great deal to prevent trouble. As a rule the nausea with or without vomiting

occurs in the early morning hours and later in the day the patient may feel perfectly well. Plenty of fresh air is an important factor and should always be insisted on. If the vomiting does not subside promptly and persists after the eighth or ninth week, a physician should always be consulted to further advise the patient.

Indigestion is frequently present during pregnancy and manifests itself especially by the condition known as "heartburn." This is due to the abnormal development of acid in the stomach and may be avoided in many cases by refraining from all fatty foods until the attack is over. Various alkaline substances such as milk of magnesia and bicarbonate of soda may be satisfactorily employed in this condition.

occur.

While the mother is carrying her child the various waste products from the latter must be taken up by the mother and gotten rid of in addition to those from her own system. Where the mother is unable to get rid of this material a condition of poisoning results which may become very serious for both the patient and her child. A great deal can be done to provide against the bad results if the mother is careful to note certain symptoms and report to her physician as soon as they These include serious or persistent vomiting, constant headache, attacks of dizziness, puffiness about the face and hands, blurring of the sight or spots before the eyes and various painful sensations, particularly in the pit of the stomach. These symptoms are not a necessary accompaniment of the pregnancy and should not be accepted by the patient as such. If they are present they should be taken care of and if treated in time a great deal can be accomplished. Among the things that the patient herself can do to avoid this complication is to scrupulously guard against continued constipation, to avoid eating an excessive quantity of meat, to drink water liberally, to take plenty of outdoor exercise and keep all the living rooms well ventilated day and night, to bathe every day if possible, to wear light but warm and comfortable clothing, to sleep at least eight hours a day, to have the urine examined at regular intervals and to consult a physician as soon as any symptoms of illness appear.

Care during the earlier months of pregnancy, particularly at the time of the menstrual periods is necessary to avoid the womb emptying itself before the baby is full grown. Miscarriages are due to accidents or possibly to some disease of the mother or to some fault in the womb itself, so that after every miscarriage, even if it does not apparently amount to much, a physician should be consulted because the habit is very apt to prove dangerous to the mother's general health and even life. Prevention of this accident lies in guarding against over exertion in the early weeks, to avoid crowds and crowded rooms, etc. If a woman bleeds at any time after her periods have once stopped she should go to bed at once and send for her doctor, remaining perfectly quiet until he comes. If the miscarriage comes on before the second

month it may appear as nothing more than an unusually severe menstrual period. It may happen, however, that the contents of the uterus are not entirely expelled and that a portion of the same may remain behind and keep up the bleeding, and in certain cases cause blood poisoning. It is very important therefore that everything, which passes away should be preserved for the inspection of the doctor when he comes. Proper care and treatment are extremely necessary in this accident and a great deal of ill health may be averted if the proper attention is given to the same. Unfortunately a great many women regard the same entirely too lightly and subsequently suffer from its effects.

It is a common belief that certain shocks and impressions received by the mother are transmitted to the child and produce abnormalities in the latter. This generally prevalent belief may be dismissed, by the statement that such an impression on the child is impossible. There is no connection between the mother and the child by which nervous impressions may be conveyed, and although the child is attached to the mother's womb through the medium of the afterbirth, there is no actual exchange of blood, so that even if the blood was able to convey nervous impressions, the fact that the circulation of the mother is free from that of the child makes it impossible for the child to be affected by any impression which the mother may have received. Moreover, almost every woman is subjected to some experience which disturbs her mind and may severely frighten her and yet we find very few cases in which babies are born either marked or abnormal. Again, the baby is perfectly formed before the third month and therefore any impressions which a mother may receive subsequently can have no effect in changing the form of the child. Whatever defects in the development are present or have begun in the very early weeks of the pregnancy.

REPORT ON A CASE OF PRIMARY CARCINOMA OF THE APPENDIX.

BY

J. W. MARKOE, M.D.
Attending Surgeon.

The frequency of carcinoma of the appendix has been studied by MacCarty and McGrath and it was found that "one in every 225 of all appendices in the series and one in every 53 partially or completely obliterated appendices was carcinomatous." In a later series of 3039 specimens "there were 18 (0.6 per cent) carcinomatous specimens in all of which the lesion occurred at or near the tip in a portion the lumen of which had been obliterated."

The following case was referred to the author for surgical investigation by Dr. Ramsay Hunt and is published because of the unusual complication of the appendix.

She had been treated for some time in the belief that her symptoms were purely psychical and not due to a condition which might possibly be relieved by operative procedure, but nothing caused any improvement and as a last resort, surgical measures were invoked in the hope of relieving her from a condition of mental distress that had become unbearable not only to the patient herself but also to her family; thus, after a consultation with her physician and family, it was deemed wise to place her for a time in a private sanitarium in order that she might be observed. This was done and the treatment consisted of absolute rest in bed, hot baths, vaginal douches and tonics with absolute freedom from home cares.

During this entire period, she was almost constantly depressed, easily bursting into tears and worried over the slightest thing, which to the ordinary person, would be considered trivial. For five weeks this was continued with absolutely no benefit either physically or mentally so that she requested that something further be done. Accordingly, she entered the Private Pavilion of the Lying-in Hospital.

The examination taken from the hospital records at the time of her admission was as follows:

Mrs. X.; age 34; married 12 years; native of United States; weight 137 lbs. Nothing in her family history pointing to tuberculosis or malignant disease. Has never been very strong and her menstrual history shows that it began at the 13th year, being fairly regular every forty days but with considerable flow, lasting four days. Since her marriage, twelve years ago, she has had one miscarriage and three living children, the birth of the children being always difficult and with the aid of instruments, necessitating repair of the perineum. Four years ago, she began to have severe pains in the region of the left ovary with no definite cause of the onset being found. She was treated abroad for this condition, also in this country, without any appreciable relief.

When she entered my office, she gave one the impression of being constantly in pain, with pale complexion and anxious look which denoted something more than neurasthenia for which she had been under treatment for some time. Careful examination made at that time showed that her lungs and heart were normal; that although the vagina had been repaired, there still remained a moderate rectocele; cervix had a healed bilateral laceration with some ectropion of the mucus membrane; the uterus considerably enlarged rotated to the left side and was fixed in an anteflexed position. On the right side there was a soft mass which was not movable. There is distinct tenderness over the region of the appendix, and after due preparation, she was taken to the operating room and under ether anesthesia given by the drop method, the following operations were performed.

Date of operation March 22nd, 1915. Iodine preparation of skin. Cervix grasped with volsella, and dilated with Hegar's dilators to No. 16. Uterus then lightly curetted and swabbed with iodine, nothing abnormal being found. Skin and mucous membrane incised at posterior vulvar margin. Levator ani muscle exposed and drawn together with chromic gut No. 2 interrupted buried sutures. A superficial layer of chromic No. 2, interrupted sutures was placed anteriorly and posteriorly,

drawing the superficial muscle fibres of the levator ani together. A submucous and subcuticular crown stitch drew down the flap of mucous membrane, closing the wound. The patient was then placed in the Trendelenburg position. The skin of the abdomen was prepared with iodine, then a right rectus incision made. The abdominal wall was very vascular and the pelvis full of adhesions covering a large cyst, the size of an orange, which was found in the right broad ligament. The ad