head cannot be brought through the pelvis without the certain destruction of the child.

Forceps Recommended.-Simpson, for the low operation, Poullet v. Hecker or Tarnier, for the high operation. Sawyer's, to protect perineum as the head emerges.

Rules for Application.-In using the Simpson forceps, the left blade is always applied first. The left blade should be held in the left hand and introduced into the left side of the pelvis. Right blade right hand, right side of pelvis.

With the diagnosis of the presentation assumed, and the vagina douched if there is a suspicion of gonorrhoea or septic discharge, the steps in the application of the blades may be summarized as follows:

1. Having introduced two fingers of the right hand into the vagina, the left blade, grasped at the lock by the left hand as a pen, is held almost perpendicularly, with the tip of the blade opposite the vulva.

2. The tip of the blade should enter the vagina and traverse the perineum toward the sacrum.

3. Rotate the blade outward in its long axis, to bring it in apposition with the posterior inclined plane of the pelvis, and thus escape the promontory of the sacrum when the handle is depressed.

4. Depress the handle, carrying it to the left side, the fingers of the right hand in the vagina guiding the blade and protecting the soft parts.

5. Introduce the right blade in a similar manner, substituting right for left in the above description.

6. To grasp the head properly and facilitate locking, rotate forward the right blade when the head occupies the right oblique diameter (L. O. A. and R. O. P.), the left when the head is situated in the left oblique (R. O. A. and L. O. P.). Depression of the handles towards the perineum often aids locking.

Too great compression of the head may be avoided by placing a folded towel between the handles. Tractions should be made in a line parallel to the axis of the parturient canal-with the pains when present, at corresponding intervals when absent.

5. Uterine Hemorrhage from placenta prævia (partial and central) may be so profuse as to demand interference early in pregnancy.

6. Certain Nervous Diseases.-As acute mania, melancholia, or associated inflammatory changes in the brain. Rarely chorea.

7. Certain Blood Diseases.-Pathological hydræmia (pernicious anæmia), leucocythemia.

8. Displacements of Gravid Uterus.-Retroflexion, prolapse, hernia, resisting other treatment.

Always secure consultation and share responsibility.

Methods.-Many have been resorted to, but have been found either too dangerous, slow, or ineffectual. Such are the use of ergot, cotton-root, injections upon cervix or between membranes, inflated rubber bags in vagina or uterus, rapid or gradual dilatation of the cervix, perforation of the membranes, electricity.

The method recommended is a combination of the good features of some of those mentioned, and is as follows :

1st. Disinfect canal by antiseptic douche and pledget of mercurialized cotton in cervix.

2d. Fix anterior lip of cervix with tenaculum and dilate cervix to size of thumb with Hegar's dilators.

3d. Iodoform gauze tampon in cervix and lower uterine segment, and a tampon of antiseptic wool in vagina. Remove at the end of 24 hours. If the ovum is not discharged from the uterus, dilate the cervix further and reapply a larger tampon. The discharge of the ovum is often facilitated by introducing' placental forceps and nipping off a small piece of decidua. When the second tampon is removed, if the ovum has not come away, remove it, using, with strict antiseptic precautions, the finger, or, with greatest care, curette. If there is urgency in the case and the patient can stand an anesthetic, ether is given, the os dilated with bougies and fingers, the ovum cleared out with finger, curette, and placental forceps, leaving the uterus clean. An iodoform gauze tampon is then inserted and allowed to remain 24 hours to insure drainage.

While the interruption of pregnancy before the 180th day is called the induction of abortion, the method given is only appli

cable up to the fourth month. After that time the plan is the same as for the induction of premature labor.

PREMATURE LABOR.

When performed after viability of child.
Indications.-1. For diseases as above.

1

2. Special Indications.—As (a) Contracted Pelvis (8-93 cm.), (b) Placenta Prævia, (c) Advanced Phthisis, Grave Heart Disease, etc. threatening mother's life, (d) Habitual Death of Foetus just before term.

Methods. Antiseptic vaginal douche, Sims's position or dorsal decubitus, aseptic hard-rubber bougie passed in for 7 or 8 inches between deciduæ vera and reflexa, and kept in place by vaginal tampon of iodoform gauze. Labor begins after a variable period, 3 hours to a week, the average being 36 hours. The introduction of a second and larger bougie may be necessary after 12 hours. After 36 hours, if softening of the cervix has been accomplished, it may be further dilated by means of Barnes's bags. * A very satisfactory plan recently introduced (Pelzer) is the injection of about 2-4 oz. of sterilized glycerin between the membranes by means of a rubber tube attached to a syringe. If the mother's condition demand immediate delivery, the method is as follows: (a) Perforate the membranes; (b) forced dilatation of cervix with fingers or Hegar's dilators, followed, if it is still impossible to insert the whole hand, by Barnes's bags (each remaining 15 minutes); (c) forceps, or, preferably, version and extraction (accouchement forcé).

* To apply Barnes' bags successfully the following points should be borne in mind: Before using them the capacity of each bag should be tested with syringe; to secure entrance into cervix roll the bag in its long diameter and catch with dressing forceps; apply the rubber tube to the rectal nozzle of syringe, and after inflation compress with catch forceps. Allow the bag to remain in place for one hour, leaving the patient in lithotomy position in bed, to prevent rupture of the bag.