cludes her fitness for marriage and maternity, her evolution, her degeneracy as regards indigency in its close relations to prostitution, crime and pauperism; her education, her economic relations. Another important point for consideration is correlation of the sexes in higher education. For inscrutable reasons, if any, other than commercial, exist, women have been forced into relations with men that furnish results of doubtful advantage to her as man's co-worker, or as an economic factor in the tension of modern life. In the evolution of society, women are taking a part constantly increasing in activity.

Van de Warker says: "We are living to-day in the midst of conditions which, prolonged to their logical conclusion, mean reversal of woman's traditional place in the social complex. Social and industrial feminism, which is a revolt in favor of free choice and the exemption from the restraints of marriage on the one side, and a demand for a wider and a more liberal field of labor on the other, have made such progress as to claim serious study by Sociologists. The movement has an aggressive literature of a high class, from that of active propaganda to the dreams. of Ibsen and the novels of the school of Mrs. Ward. In every civilized country women are separating themselves from men in societies, clubs, leagues and conventions to a degree never known before. Changes such as this movement must profoundly affect woman's spiritual and physical life and fall within the sphere of our action."

We cannot avoid careful and thorough investigation of such subjects. Will the worker in the extensive fields solve such problems, or will it be the gynecologist that will be ablest to assign due weight to certain features of such study and pass over others lightly as they merit. Is it more than reasonable to assert such special work must be done by the specially fitted? Can the one whose whole life work has been mechanical in nature be declared abundantly competent to take up such work? Certainly not. Nor can the general practitioner of medicine be considered superior for such study. Dynamics of the pelvis, the physiology of the female pelvic organs and neighboring structures call for fuller investigation. Surely are the special students, the gynecologists, the ones that must solve such problems.

These points I have called to your notice to demonstrate that gynecology has a side other than surgical-that it cannot be handed bodily over to surgery without taking a retrograde course in the development of the science. I would have you believe,

then, that gynecology must continue to exist as a special study, and that the surgical side alone cannot be called gynecology in the proper sense. The gynecologist of the future must devote great attention to these non-surgical subjects, and at the same time advance the field of surgical gynecology. This latter wil! be best promoted by teaching and studying prophylaxis courageously. Surely, the knife alone cannot be the symbol of achievement of gynecology. In practice the gynecologist of necessity will be familiar with the anatomy, physiology and abnormal conditions of the rectum. Being in such close proximity, the urinary systein in women will naturally fall to the gynecologist and furnishes a field for brilliant investigations, a continuation of the work of some of our most prominent gynecologists. The gynecologist must be competent to deal with any abnormality found in the peritoneal cavity, as complications of ovarian or tubal disease are manifold. The female breast, the organ of life to the offspring, is certainly an organ of reproduction, and the student of obstetrics and its offspring, gynecology, is best fitted to study it in its departures from the normal. In practice this branch of the subject is divided between the gynecologist and the general surgeon, the latter exhibiting a spirit of determination to acquire or preëmpt the entire field. To end this prolix consideration of this important subject, I would offer a hope and firm belief that the science of medicine cannot afford to dispense with this field as a specialty, nor will the public interest permit such attempt. As to the future of this specialty I am optimistic, believing as I do that its wonderful achievements are but the skirmish line of the battle to be waged in gynecological study.

THE ROCHAMBEAU.

FURTHER RESULTS IN THE USE OF A MODIFIED
CHAMPETIER DE RIBES BALLOON.

BY

JAMES D. VOORHEES, M.D.,

Assistant Visiting Physician to the Sloane Maternity Hospital and Lecturer on Obstetrics at the College of Physicians and Surgeons, Medical Department of Columbia University, New York City.

THERE is no specialty in medicine where judgment and patience mingled with sympathy on the part of the doctor are so greatly needed, and where censure and hard feeling on account of existing complications and poor results from the standpoint of the patient so easily arise as in the science and art of obstetrics. It is no wonder therefore that so many of the profession shirk or drop this branch of medicine as early in their career as they are able. It is a very difficult matter to determine just when the size of the fetal head is of correct proportion to the capacity of the mother's pelvis to start a labor and so obviate a dangerous operative delivery. It is also very trying to stand by and see a woman suffer excruciating agony without instituting some measures for her relief, expediting her labor without risk to herself or to her child. We know only too well that some are prone to interfere too early and that others are equally prone to simply say "everything is all right" and wait too long. Often whichever way we have decided to act, in retrospect, having lost or injured the infant or having caused deep cervical or perineal lacerations, we have wished that we had acted otherwise in the management of the case.

There is no doubt that within the last few years the number of operative deliveries has been on the increase, and especially is this true in the large cities. Why is this? In the first place, women are marrying late in life nowadays. In 106 primiparæ confined by the writer in private practice, the youngest was twenty-one years old, and the oldest had reached the age of forty. The average age was a small fraction under twenty-nine years. We all know that the cervix and perineum grow more rigid with age. We know that the joints are firmer and become less succulent during pregnancy. We know that the uterine contractions are weaker. We know that the older the woman is, the larger the child, the harder the bones of its skull, the smaller the fontanelles. and the less separated the sutures. No wonder, then, that elderly

primiparæ have more trouble during confinement. In the second. place, the city-bred woman-the "hot-house" patient-unaccustomed to discomfort or pain-we know that such a woman makes the worst of patients. She cannot, and will not, endure pain. Her relatives, her husband, and especially her mother, suffer with her. Only too often after a few hours of labor, she simply gives up and begs for relief. We administer sedatives, or the pains die out, the cervix does not dilate, and finally we are compelled to do something. Often we have to do the whole thing-dilate the cervix, rupture the membranes, mould and drag out the head with the aid of forceps, remove the placenta manually, and repair the damage done. We are at our wits' end in such cases. Again these patients desire the baby to come at a certain date. If one estimates too early a day, woe betide him. Every day she goes over she gets more and more nervous, sleepless and depressed until one has to step in and anticipate nature's process.

There are a great many measures for starting labor and for shortening its duration, so relieving much suffering during confinement, but none to my mind is of more value for these ends in certain cases than the use of a conical cervical dilator-a Champetier de Ribes balloon.

In an article published September 8, 1900, in the Medical Record, the writer reported the first cases in which a modification of this balloon had been used in the service at the Sloane Maternity Hospital. The bags there employed differ very little from those of Champetier. They are identically the same in shape and are made with his principles-to be impermeable, to be inexpansible beyond a certain volume, to be long enough to fill the cervix-in short, to simulate nature's bag as nearly as practicable. These balloons used at the Sloane Hospital, however, were somewhat different in size from Champetier's and made stronger in order to withstand the uterine and abdominal contractions, to resist the tension when filled with a fluid, and to permit a certain amount of traction on the tube without rupture. This required a foundation of thin canvas instead of silk, covered by a thicker rubber outside, but more than all that the seams be firmly sewed and cemented, especially where the tube joins the ampulla.

The operation for the insertion of the balloon is very simple, except in a few instances, and can be done with one assistantthe nurse. An anesthetic is employed only in those cases where a preliminary divulsion or a manual dilatation of the cervix is necessary to get enough room for the insertion of the bag, where the cervix is placed so high that it is very difficult to reach, when

the patient is very nervous and excitable, or where the vulvar orifice is very narrow and sensitive. Here light chloroform narcosis is all that is required, for the time consumed by the operation amounts to only a few minutes in the vast majority of cases. No special introducing forceps or syringe are necessary, although some have been described. I use, however, nearly always a forceps with a pelvic curve and fenestrated blades for the greater ease in the introduction, yet a sponge holder will do. The syringe employed is an ordinary Davidson's. The glass varieties are very apt to break. The metal ones get out of order and cannot be boiled. Of course, the asepsis must be perfect in every detail. It is well to insert the largest size bag possible at the outset and to remember in filling the balloon with the fluid to inflate slowly with slight traction on the tube so that the head, if presenting, will be displaced as little as possible. The patient is left to nature's efforts after the introduction of the balloon unless there is need of hurry when traction can be made at regular intervals on the tube, increasing thereby the strength of the pains and accelerating the dilatation of the cervix. It is only necessary to insert successive bags in cases where great haste is demanded and where the pains are few and far between or stop altogether after the first bag is expelled.

Results. As before stated, in a previous article, the writer reported the first series of cases in which the balloons were used in the service at the Sloane Maternity Hospital. These were 72 in number out of 2,113 deliveries for the two years up to September 1, 1899. The cases selected had sure indications for interfering, and were those in which other methods had been tried and had failed. In all advantages were obtained and the field of usefulness of the balloons was more definitely determined. This second series I want to report so as to further emphasize the utility of the bags and the great amount of dependence we place upon them, especially in private practice.

These cases also are not selected but I publish all in which balloons were employed, the first set occurring in the first 200 cases of my private practice; the second set occurring in the four years ending September 1, 1903, in 4,272 deliveries, subsequent to those before reported, from the service of the Sloane Maternity Hospital.

In my private practice I used the balloons in 39 out of the 200 cases, or about once in every five.

Dry Labors.-There were 47 dry labors, but in only 4 was a