Next in order comes subinvolution, that forerunner of uterine displacements, pelvic congestion, and general pelvic distress. Days or weeks are not the true index governing the lying-in period of the parturient woman, but rather the process of involution. What may be a long period to one woman becomes short to the next, simply because her uterus has not had sufficient time to regain its normal size. No better foundation could possibly be laid for a future operation than to allow a parturient woman to get out of bed, go about her duties, indulge in marital relations and otherwise take her place in the family, when the uterus is still large, flabby and filled with unabsorbed and hyperplastic connective tissue. Rare indeed, would be the instance wherein such a woman did not eventually find herself seeking the assistance of the gynecologist to aid her in overcoming a retrodisplacement, prolapse, procidentia, or chronic endometritis.

Not infrequently does the opportunity come to the obstetrician, to cure at the time of his patient's confinement, a previously existing retrodisplacement. A uterus which has been so displaced, and is large and flabby, becomes after confinement a very tractable uterus, freely amenable to a line of treatment which was not possible before confinement, and which may forever cure the patient of her difficulty, and possibly avert a future operation.

Naturally, all the adhesive bands have been broken up by the gestative process. Naturally, also, has the overabundant connective tissue been absorbed and the overdistended blood vessels become pliable and ready to contract. By the thorough removal of all membranes and shreds from the uterine cavity, by keeping the patient off her feet longer than the usual time after her confinement, by the employment of frequent hot douches, by the judicious use of tampons, the knee-chest position, having the patient lie on her stomach rather than upon her back, and by continuing the nursing of her child at the breast, such a condition as chronic subinvolution or displacement can be cured at the time of confinement.

The discovery of the cause of the various infective diseases of the fallopian tubes, ovaries and uterus, such as pyosalpinx, infective ovaritis, endometritis, salpingitis, and the like, has opened our eyes to the great risk which the parturient woman runs of becoming a chronic invalid, and later a victim of the operating table, through puerperal infection of the uterus and the uterine adnexia. It would seem almost like arrogance on my part to suggest the necessity of strict asepsis in the practice of midwifery, as that is a recognised and undisputed duty of the obstetrician. If medical science has demonstrated anything to our entire satisfaction during the last decade, she has forced us to a recog

nition of the power of bacterial invasion through the medium of the uterine mucosa. Yet the indifference to this truth, displayed by a certain few of the obstetricians, even today, results in no smal! percentage of their patients eventually requiring an abdominal section for the removal of infected tubes or pelvic adhesions, which have rendered said patients semi-invalids for a period of years.

Experience and observance in pelvic work have convinced the writer that no woman can suffer an attack of puerperal fever of average severity, without being left permanently damaged in some of her pelvic organs. The facts that she may recover from the immediate attack, that she may be able to bear more children, that she is apparently able to perform her regular duties, are not sufficient arguments to sustain the contention that she has not been so damaged. As the mills of gods grind slowly, so does the latent infection consequent upon puerperal fever develop slowly but exceeding sure. After the initial attack the patient may appear to be well and years may elapse ere the trouble shows itself, when suddenly, after a severe cold, an overstrain, a miscarriage or the advent of the menopause, there develops alarming symptoms, which only an abdominal section can assuage. Then is laid bare the whole story from the beginning, with its startling moral-inflamed adherent tubes; chronic pelvic peritonitis; a retrodisplaced uterus with unyielding bands of adhesions or a tubo-ovarian abscess, all or any one of which was the result of the latent infection planted years ago at the parturient period, and all of which might have been averted by a recognition of, or a careful attention to the unfailing law of bacterial invasion through the uterine mucosa. at the time of confinement.

There are a few operations, which must occasionally be performed during or at the close of the pregnant stage. First, is that delicate procedure which, while it is but rarely demanded, is nevertheless of sufficient importance to entitle it to careful attention; but strange to say, it has received but scant consideration from the men who are best qualified to speak upon it. It is the induction of abortion and miscarriage.

It is but natural and therefore commendable that the honest doctor should shrink from anything pertaining to the premature emptying of the uterus. The honest policeman shrinks from taking a human life, even though it be to save another, yet he must occasionally do it in the discharge of his duties. So the physician, who is the policeman against disease and death, must at times sacrifice one life to save another apparently more valuable. In rare instances, such as a dead fetus, an intractable, adherent, retroverted uterus, a placenta previa, a fibroid tumor, cervical cancer, persistent and exhausting vomiting, dementia, Bright's

disease, cr any condition which seriously threatens the life of the mother, it becomes absolutely essential to the preservation of the mother's life that the uterus be emptied before full term, It is here that our literature is scant as to the best method of procedure. Nature jealously guards her offspring. To induce a uterus to part with its incompleted product, is a task frequently difficult and frought with grave peril. While nature may herself, as in the case of a dead fetus, recognise the difficulty and seek to expel it, yet her tardiness in the recognition and expulsion may cost the life of the mother; hence the physician must have at hand some reliable method of recognising the danger, and some prompt, efficient and safe method of emptying the uterus in just such unfortunate circumstances.

Given a patient who is afflicted with some of the above conditions, wherein a consultation of two or more physicians results in a verdict of abortion, what is the first move? Obviously, the selection of the time must be determined first. Early writers tell us it is better to empty the uterus at what would be the menstrual period, as the tendency to uterine contraction and placental expulsion is then greater. That argument is valid only in case we intend to induce artificial labor and not empty the uterus by force. If there is the possibility of delivering a viable child, then we may wish to induce artificial labor and the time of the month is a consideration; but with no prospect of a viable child, there is little necessity of paying any attention to the would be menstrual periods. The introduction into the uterus of foreign bodies, such as sounds, tents, gauze, catheters and the like, to induce labor, belongs to the antiquated period of septic carrying days, and is not to be considered as an excusable method, save perhaps in the first few days of pregnancy.

If an abortion is to be induced, and in using that word the writer means the emptying of the uterus at or before the fourth month there is just one safe, rapid and effectual method of doing it, and that is this: first. a thorough bowel evacuation; second, cleansing the vagina and vulva, with shaving and douching third, a general anesthetic, or possibly the injection of cocaine into the cervix. Then place the patient in the lithotomy position, with a good light. Sterile hands and instruments are of course essential. Retracting the perineum, by means of retractors, brings the cervix into view. This is seized with tenaculum forceps and held steady while graduated sounds are introduced one after another into the uterine cavity. A point. of prime importance in the first introduction of a sound or dilator into the uterine cavity, is to know the position of the fundus. Failure to know this fact has resulted not infrequently in perforation of the uterine wall.

The introduction of a sound may or may not be an easy process, depending upon the rigidity of the os and the extent to which it must be dilated. The shorter the pregnancy, the more rigid the os, as a rule. I have seen cases, where it required one hour of the hardest kind of work to dilate the os sufficiently to deliver a four months fetus. After the sounds have done their work, the Goodell dilator comes next. If the thumbs can be employed after the dilators are of no further use, they no doubt afford the safest means of accomplishing the end, but frequently the os is so rigid that but little can be accomplished by that method. The free use of sterile oil or vaseline will facilitate materially the process of dilatation. The method of introducing one finger after another, by making a wedge of them, is very satisfactory. In the absence of any other instrument, I have found a Pratt rectal speculum as satisfactory as anything with which to complete dilatation. Recently my attention was called to the Newell dilator, which I have found extremely satisfactory. It is less likely to tear the surface of the os and dilates very uniformly.

When dilatation is sufficiently complete to deliver the contents, the size of the fetus determines the next step. If it is three months old or over, some form of instrument must be used to seize the head of the fetus and deliver it in toto; otherwise it is torn to pieces and the danger of infection, lacerations and incomplete delivery is present. To meet this requirement the writer has had made a pair of miniature obstetrical forceps, just large enough to seize a three or four months fetus and deliver it without tearing. The lack of such an instrument has caused him, upon a few occasions, more annoyance and vexation than the complications of many a major operation.

After the delivery of the fetus but little difficulty will be encountered with the placenta if it is seized with placental forceps and carefully delivered. A brisk hemorrhage is likely to follow the placental delivery, but it is quickly controlled by the next step, which is a thorough curettage of the entire endometrium, to insure the removal of all shreds and a firm uterine contraction. The douche curet is ideal for this part of the work. No pains should be spared to free the uterus of all membranes. It is not a question of forcibly scraping the uterus, for that is unnecessary and harmful; but rather of reaching the entire surface, especially the two corners of the uterus. The use of strong chemicals in the douche water is unnecessary; salt or plain sterile water is quite sufficient. I make a practice of packing and draining every uterus thus delivered. The iodoform tape, one-half inch wide, with edges folded in and long enough to fill the uterine cavity, is sure to absorb and antidote all possible infection that may be gathered

there. This can be removed in twenty-four or forty-eight hours, according to requirements. A rest in bed, commensurate with uterine involution, is the only guide for convalescence.

The mortality attending such procedure is practically nil. If infection has taken place and becomes well established before the operation, then perforce it may continue to a fatal end in spite of the interference. In placenta previa, the management is much the same, only the work must be done with dexterity and despatch, to avoid the bleeding so generally present in such cases. The writer is of the opinion that it is better in such cases to empty the uterus forcibly and quickly, as above described, rather than to induce labor and wait for nature to expel the contents. The only modification to be made in the procedure, in the case of placenta previa, is not to introduce the sound or dilator further than within the internal os. After dilatation is sufficiently complete, the finger can be slipped alongside the placenta and detach it from the uterine mucosa. Its delivery then is a very simple

matter.

In pregnancy complicated by fibroid tumors, much has been written. I have seen comparatively few cases in which the tumors were so situated as to interfere with normal labor; but I have seen many cases, where the patients had one or more fibroids, which did not in the least interfere with the parturient process. It is not always necessary to abort a woman who has a fibroid so situated as apparently to act as a bar to delivery. It is possible frequently to remove the tumor by abdominal section during the gestative stage, and thus best serve the interest of mother and child. It is surprising and gratifying to observe the surgical ordeals, through which a pregnant woman will pass. without miscarrying.

A paper on the subject of "Obstetric Surgery" would not be complete without at least a few words on that peculiar anomaly of pregnancy, ectopic gestation. It is a well known physiological fact that the uterus undergoes a certain preparation for the reception of the ovum each month. A few days prior to the arrival of the expected guest, that organ cleans house, as it were, and adds new interior furnishings; old shreds of membrane are cast off and a new heavy lining, of a velvety character, richly supplied with blood connections, is formed in the upper part of the uterine cavity: this is the decidua. If the ovum arrives as guest in ordinary (that is, unimpregnated) then the new furnishings are torn down and cast off, and form part of the menstrual flow. If, however, the ovum comes as a royal guest. (impregnated and developed up to six or eight days) then is the reception made fitting to the ovum. The doors and windows of