from lesions of the heart and lungs, and is little more probable in lesions of the kidney.

Grave eclampsia is said to be the one great indication for vaginal Cesarean section. Fry (Surgery, Gyn. and Obst., July, 1905, p. 509) writes: "We recognize eminently its wide scope of usefulness in the treatment of grave eclampsia. It is not intended to replace the slower methods of dilatation in less urgent cases, but is advantageous when a woman is on the verge of convulsions in spite of the active treatment to prevent them, or, when convulsions have occurred and the uterus must be emptied rapidly." My contention is that if the eclamptic attack is so grave as to demand the emptying of the uterus in the least possible time, the choice, so far as time saving is concerned, would be the abdominal route, and in addition it offers greater safety to the fetus. If the child is dead in utero, as is so often the case in grave eclampsia, the cervix, if not dilated, may be incised, but not to the extent recommended by Dührrsen, because perforation and evisceration of the fetus would be indicated, and should not require an extensive incision into the lower uterine segment.

As for placenta previa, vaginal Cesarean section cannot be considered for obvious reasons. Indeed, I am in accord with Rudolph Holmes, who all but unqualifiedly condemns abdominal Cesarean section for placenta previa, and for the following reasons:

1. While fetal mortality is lowered 30%, maternal mortality is raised three-fold.

2. Pelvic contractions, when associated with preveal hemorrhages, may indicate Cesarean section, but it is the pelvic deformity, not the placenta previa, that produces the indication-the same may be said of the rigid os.

3. The acute anemia caused by the preveal hemorrhages renders the operation particularily dangerous as does the hemorrhage attending the removal of the placenta, which is so often found adherent, and whose site is not infrequently in a state of paresis.

I

A rigid cervix presents the one indication for vaginal Cesarean section which is least open to criticism. Contrary to the general impression, obstetricians of large experience see very little of the so-called rigid os. quote from Holmes the following: "Reed's collection contains 453 cases in which the condition of the cervix is mentioned; of these 93 were 'rigid.' Müller gives 48 patients with the cervix described as rigid in a total of 531 cases of placenta previa. In sharp contrast with these figures are the findings of Strassman with 231 cases, Schauta with 254, Webster with about 50, C. G. Cumston with 17, Richardson, at the Boston City Hospital, with 75 cases, a total of 606 placenta previas without a single rigid os."

We are therefore forced to the conclusion that the so-called “rigid os" usually exists in the fancy of the operator, a fact to be accounted for by his desire to terminate pregnancy in the shortest possible time without resort to the more natural and less hazardous methods, such as the use of the bag, tampons and hands. A little time and experience would accomplish the dilatation in nearly all cases without resort to incision. The splitting of the cervix, where these methods have failed, not only permits of the delivery of the fetus, but may permanently correct the obstruction.

FIG. III.-Bisection of the anterior lip of the cervix to the reflected bladder, exposing the amniotic bag; this incision extends through the cervix and well into the lower uterine seg

ment.

It is, however, open to many of the general criticisms which I have to offer for the operation of vaginal Cesarean section as opposed to abdominal Cesarean section.

Without prolonging the discussion, I will briefly enumerate what appear to me valid objections to the Dührrsen operation:

1. Less time is consumed in delivering the fetus by the abdominal route.

2. Greater accuracy is assured in surgical cleanliness by the abdominal route.

3. The abdominal incision is wholly under control of the operator, whereas in the extraction of the fetus per vaginum, the incision may extend beyond the control of the operator, as indeed it has in more than one case, and with fatal results from hemorrhage.

4. In an abdominal Cesarean section, opportunity is afforded of rendering the patient sterile by resecting the tubes when thought advisable, and various lesions, such as adhesions, tumors of the uterus demanding hysterectomy, bands as the result of ventrofixation and diseased appendages, can be dealt with.

5. The abdominal route assures the fetus of the greatest consideration, inasmuch as the application of forceps and the turning of the child in utero are necessarily attended by dangers to the fetus.

6. Rupture of the uterus in subsequent pregnancies through the scar of a Cesarean section is a not uncommon accident, and it is apparent that since the large majority of ruptures of the uterus is in the lower uterine segment, a scar at this point will more likely be disposed to rupture than one located in the fundus.

7. There are as yet no records of injury to the bladder and ureter, and the limited time since the introduction of the operation leaves us in doubt as to the dangers from rupture of the lower uterine segment in future pregnancies, but may we not with fairness anticipate such accidents and therefore proceed with caution?

Returning to the original question propounded in the subject of this discussion-Is vaginal Cesarean section justifiable, I would answer: In the light of the reported cases and judging by the results obtained in the use of other well established methods of delivery in cases similarly indicated, vaginal Cesarean section is not destined to find general favor with trained obstetricians; that the legitimate scope of the operation will be so limited that it will be little practiced. And yet we may expect that it will remain in general favor with a few obstetricians.

3602 Lincoln Boulevard.

SOME PATHOLOGY OF THE MORPHINE HABIT AND MY PREFERRED METHOD OF TREATMENT.

S. Grover Burnett, A. M., M. D., Kansas City, Mo.

Professor Clinical Neurology and the Histological and Applied Anatomy of the Central Nervous System in the University Medical College; Superintendent Dr. Burnett's Home for Nervous Diseases and Inebriates; Consulting Alienist and Neurologist to St. Margaret's Hospital: Ex-president Medical Society of the Missouri Valley: formerly Assistant Superintendent Long Island Home (N. Y.) for Mental and Nervous Diseases and Inebriates.

T

HE interest by the profession in a former paper by me on "Burnett's and Other Methods of Treating the Morphine Habit" prompts me to reiterate much of the method which I have worked out in detail with the idea of meeting the pathologic status of these cases, as well as placing them ultimately in as high degree of restoration as nature is able to make.

After considerable thought on this point it is my humble opinion that nature is not only deprived of the chance to assist in repairing the damage done to the ganglionic cell elements of the brain in the immediate withdrawal and hyoscine methods of treatment, but, instead, further damage is done to the delicate structures by added shock and starvation changes which are sudden in onset and seriously of a deteriorating character before any possible time has been given nature to transfer the habitually drug palsied cell back to a physiological working basis. Palsy any member of the body by putting it into perverted or complete disuse and attempt to restore it to normal by a sudden transformation and see what tenderness, soreness, pain, stiffness and disuse results. Imagine, if you can, these resulting symptoms taking place in the psychic producing structures of the brain, and then imagine the mental output to be anything but that of a lunatic, for the time being and frequently longer.

Any

No skill is required to take the morphine from the patient; any quack, ass, or fool can do that, but, the question is, how can it be done with the least possible shock to the ganglionic brain structure? method used should be directed first and last to the preservation of the brain power of the present, and the full restoration of the physiologic status gradually and ultimately without, at any time during the treatment, interrupting or perverting nature's attempts to repair. In other words, meet nature's demand-whether it means days, weeks, or months. Physiologic restoration must be made and without it the patient is thrown on his own resources, weak, frail, mental equipoise gone, with relapse inevitable. Any method which can not be varied to meet the demands in individual cases is not practical in its application and reason will condemn it.

The different methods have been given in my former paper, and I only refer to them now to condemn them later. First, the acute hyoscine poisoning method, attended by coma, delirium and reactionary prostration of both mental and physical forces.

Second. The abrupt disuse of the drug as is enforced in jails, penal institutions and asylums, where the patient lapses into bades and expectorates lucifer fumes, while the phosphorescent glow of his burning brain illuminates the strand where the fire boats put to sea.

Third. The rapid withdrawal during four or eight days.