just, however, I must remind my hearers that I do not regard the foetal dangers from Cæsarean section as great, in so far as concerns the operation itself, and freely admit that the mortality to children thus deliv ered is due almost entirely to delay in interference.

3d Proposition.--The third and last proposition which I shall make and discuss is this: the operation is exceedingly simple, and may be performed with ra pidity and certainty.

To one who has never attempted it, gastro-elytrotomy may appear a procedure upon which the timid practitioner might fear to venture. It is certainly as simple as the Cæsarean section, which has so often been performed by men who had no surgical acquirements. Let us analyze its steps. Incision through the abdominal muscles is as simple as when performed for Cæsarean section. Lifting of the peritoneum is perfectly easy, and when the vagina is made to protrude into the iliac opening by means of a sound passed into it, there can be no difficulty in cutting down on the point of the sound. After this, delivery by version is not as difficult as when performed per vias naturales.

No parallel should be drawn between the lifting of the peritoneum of the non-pregnant and pregnant subject. In the latter it is ample and movable to a degree which is entirely different from what obtains in the former.

I will trespass only a few minutes longer upon the patience of the Society in detailing the consecutive steps which I should advise, from the experience which I have had in this operation.

1st. The operator should be provided with a pocketcase of instruments, a blunt hook, cautery irons, ether, persulphate of iron, and Barnes' dilators.

2d. The patient, being anæsthetized, should be placed on a firm table, and the os fully dilated by Barnes' dila

tors.

3d. The abdominal wound should be made, the peritonæum lifted, the vagina opened, and the child delivered, by version if the head present, by extraction if the breech do so.

4th. The iliac fossa should be cleansed by a stream of tepid water, introduced through the abdominal wound and escaping through the vagina; and if hemor rhage exist, ligatures should be applied, if possible through the abdominal wound, to the bleeding vessels. Should this be impossible, a metallic vaginal speculum should be introduced through the abdominal wound to the bleeding spot, and the actual cautery carefully applied. Should this fail, the abdominal wound being closed by suture, the uterus should be excited to firm contraction, the speculum introduced through the va gina, and a small sponge slightly saturated with solution of persulphate of iron placed in contact with the wound. Should even this fail, I should not hesitate to tampon the vagina, guarding against concealed hemorrhage by keeping the uterus in condition of persistent contraction.

5th. Should no undue hemorrhage occur, I should have the vagina cautiously sponged out with a very weak solution of carbolic acid once in every twelve hours.

A CASE OF CHOREA COMPLICATING PREGNANCY.

BY WILLIAM GOODELL, M.D.

Read before the Philadelphia Obstetrical Society, April 7th, 1870.

A. B. At the age of three years, during the dropsy following scarlet fever, was attacked by chorea, which lasted for six years, and then yielded to treatment. At ten, after a great fright, this disease returned for about a year. At thirteen it was again reproduced by fright, and continued until the appearance of the catamenia, in her fifteenth year. When sixteen years old, the shock of her father's sudden death caused a relapse of about three months' duration. In all these attacks the movements ceased during sleep. She was now free from any symptoms of chorea, but not from very severe headaches, which were accompanied by distressing vomitings. Her appetite was voracious, her intellect dull; she became very reticent and solitary in her habits, always laughing in an embarrassed manner when spoken to. At this time she worked in the damp cellar of a confectioner, and there contracted a subacute form of rheumatism-which affected her elbow and ankle joints—and also an intimacy with a young lad of her own age, which resulted in pregnancy. When quickening was first observed she was married to him; but shortly afterwards her old disease returned, increasing daily in severity, and interfering much with her rest at night.

She was admitted into the Preston Retreat on March

19th, 1870, when nearly eight months advanced, and within a few days of her nineteenth birthday. Her physique was that of an over-grown girl; her color, appetite, and digestion good. Choreic movements limited to the right extremities; facial grimaces constant ; occasionally the tongue would protrude for a moment, and then rapidly disappear with an audible cluck. She experienced great difficulty in feeding and dressing herself; locomotion that of a drunken person. The pupils were dilated; conjunctivæ clear and nacreous; intelligence dull. Her pulse was over 100; cardiac impulse strong, but, owing to the constant agitation of her thoracic muscles, no accurate examination of this organ could be made. Urine high-colored, free from albumen, but dense with urates; specific gravity 1029. She was immediately purged, and put on a course of iron, quinia, and bromide of potassium.

March 20th. According to her own account she slept well last night, but her fellow-patients complain of her incessant movements and groanings. They took turns in keeping her covered up, and in preventing her from falling out of bed, which happened several times during the night. Under treatment she improved so rapidly that five days later, on the 24th, she exhibited hardly a trace of choreic movements, even when Dr. A. H. Smith, a stranger to her, saw her at my request; but this, unfortunately, was her best day.

March 25th. The old movements have returned in full force; complains of headache, and excessive muscular soreness, which she attributes to the constant motion. March 26th. Rested poorly last night; is no better.

A cathartic was given, and the bromide increased. March 27th. Did not sleep at all last night; had to be held in bed most of the time; movements worse than ever, and now bilateral; articulation jerking. A combination of valerian, morphia, and swt. spts. nitre soothed her for a time. At 1 o'clock P.M. she uttered a wild scream, and immediately began to contort the muscles of the whole body in the wildest manner imaginable. She was incapable of articulating, and seemed unconscious of the presence of even her husband, who soon after came in; yet she always opened her mouth for the medicine, and forced herself to swallow it, although deglutition was very difficult, and attended with such frightful choking spasms as to require three persons to restrain her.

At 4 P.M., observing that the paroxysms increased at regular intervals, I suspected labor, and grasping her tightly about the waist, supported her up three flights of stairs to the delivery-room, she staggering and stumbling all the way like a person excessively drunk. Although she was perfectly conscious, and tried hard to keep quiet, it required the united aid of three persons before I could make a vaginal examination. The cervix uteri was conical and barely admitted the finger, but it was evident labor had commenced with a vertex presentation. At the end of two hours, finding the movements so violent that it was impossible to keep her on the bed, and that the os was dilating very slowly, with great difficulty I put her sufficiently under the influence of ether to introduce the smallest of Barnes' dilators. But, although breathing stertorously,