[Reprint from the St. Louis Courier of Medicine, November, 1885.] 
THE INDUCTION OF PREMATURE LABOR IN 
CERTAIN CASES. 
Walter Coles, M. D 
[Headbeforetlie St. Louis Obstetrical and Gynecological Society, Sept. 17,1885.] 
THE induction of premature labor in certain cases is now 
regarded by all leading obstetricians as a perfectly legiti- 
mate and highly commendable procedure. And yet no opera- 
tion in obstetrics has been more severely criticised or tardily 
adopted in the older civilized countries, unless we except 
England, where it originated, and even there it was discussed 
for a long time before it was put into practice. It is said by 
some, though not generally admitted, that it was first performed 
by Mary Donally, an obscure midwife, in 1738. The first authen- 
tic account of this operation, however, was the result of a for- 
mal consultation, held in London about the year 1756, it beimr 
put into successful practice shortly afterwards by Dr. McCauley. 
It was fifty years after this before the operation was recognized 
in Germany, and even as late as 1827 it was formally protested 
against by the French Academy. In 1831 it was performed for 
the first time in France by Prof. Stoltz, and with the “most 
perfect success.” 2 
Although we hold that there are cases where the condition of 
the mother may be such as to call for the induction of abortion 
as a dernier ressort—both the mother and child being doomed to 
perish when it is neglected—still this is not the class of cases 
that is intended to be considered in this paper, which refers 
rather to the induction of labor at a late period of pregnancy, 
when the operation is performed in the interest of both parent 
and offspring, or, in other words, after the seventh month, when 
the child may be considered viable. 
This question is always one of grave responsibility, and should 
be discussed in a spirit of true conservatism. It presupposes a 
condition of things requiring decisive action, yet the line of 
policy to be pursued must be governed rather by sound discretion 
than cast-iron rules. The cardinal point to be borne in mind is 
that the operation is undertaken as a means of averting special 
dangers to the mother or child, generally both. 
Although the child is considered viable at the end of seven 
months, it is still more liable to survive as the full period of 
pregnancy is approached. There is a strongly rooted popular 
fallacy that a seven-months child is more prone to live than one 
born at eight months, but of course we recognize the absurdity 
of such an idea, and naturally regard the child’s chances of life 
as materially enhanced as it approaches maturity. Hence the 
induction of labor should always be postponed as long as the 
circumstances of the particular case will admit. 
The indications for the induction of premature labor are quite 
numerous and varied. The mere mention of some of them will 
suffice, while others admit of more or less discussion. The first 
and most common is where there exists a disparity between the 
capacity of the pelvis and the size of the child.. In a large ma- 
jority of such cases the difficulty is with the mother, the dimen- 
sions of the pelvis being too small to admit of the passage of an 
ordinary fetal head at term: yet, by the anticipation of this 
event, labor may be accomplished with perfect safety to both 
mother and child, without even the aid of instruments. Again, 
the pelvis may be of ordinary capacity, or even above the aver- 
age, and still the fetus may habitually attain extraordinary di- 
mensions, so as to seriously jeopardize the life of the mother 3 
and involve a sacrifice of the child. Sometimes both of the 
foregoing conditions of pelvic contraction and extraordinary 
fetal development may coexist. 
As it does not often happen that these difficulties are recog- 
nized by the accoucheur in advance of the first labor, it is un 
fortunately true that many valuable lives are thus lost which 
might otherwise be saved. It is chiefly, therefore, after the 
peril of one confinement has been passed that the physician has 
an opportunity of improving the experience which previous 
events have demonstrated. Most obstetrical authorities hold 
that it is useless to undertake this operation with any promise 
of success when the shortest pelvic diameter falls below two and 
one-half inches. English obstetricians place the minimum limit 
at two and three-fourths inches. Some few deliveries have been 
accomplished where the diameter has been but two and one- 
fourth, and that limit has been mentioned by Tarnier and a few 
others, but it is evident this is not sufficient space to admit the 
passage of a viable child except with the rarest of exceptions. 
Whenever, therefore, the shortest diameter falls below two and 
three-fourths, or at least two and one-half inches, it is a case for 
craniotomy. For it must be borne in mind that the average 
fetal head at seven months measures in its bi-parietal diameter 
two and three-fourths inches, which is susceptible of a compres- 
sion varying from one-fourth to half an inch. At seven and a 
half months the transverse diameter of the head measures three 
inches; at eight months three and three-sixteenths inches; at 
eight and a half months, three and three-eighths inches; at nine 
months from three and one-half to three and three-fourths inches. 
The degree of pelvic contraction must be our guide as to the 
time at which labor should be invoked. For, taking into con- 
sideration the measurements just mentioned, and making a fair 
allowance for compression of the cranial bones, we can form a 
tolerably correct estimate of the limits beyond which parturition 
at any given period would be possible. 
Of course it must be understood that these figures are mere 
approximations which are liable to exceptions, for we have no 
means of ascertaining beforehand what the size or firmness of 
any particular head may be. This is especially the case in first 4 
pregnancies, fr»r, although the accoucheur may be aware of a 
slight pelvic contraction, he naturally shrinks from operative 
interference, hoping that by some good fortune labor may be 
effectually accomplished through the diminutive size and pliabil- 
ity of the fetal head. If, as is sometimes the case, this proves 
small and yielding, all may go well, but should the child be large 
and the head correspondingly developed, we at once encounter 
very serious difficulty, necessitating artificial delivery, and in- 
volving probably the life of the child, and possibly also that of 
the mother. 
We believe that where due discretion is exercised the induc- 
tion of premature labor should be resorted to in this class of 
cases with increasing frequency, offering, as it does, less hazard 
and suffering to the woman, and affording a far better chance 
to the child than forcible delivery by the forceps after a tedious 
labor, to say nothing of the risk of being compelled after all to 
resort to craniotomy. We can all recall many cases of this 
character, where women in successive labors have passed 
through great agony and peril with the loss of all or most of 
their children. In all such instances where the pelvic deform- 
ity is slight and the children have been found by experience to 
be large and vigorous at maturity, there can be no sort of ques- 
tion that the anticipation of the natural term of pregnancy by a 
few weeks would avoid much suffering and save many lives. 
The dread of such an operation in the minds either of the pro- 
fession or laity is founded rather on theoretical than practical 
grounds, and when properly done, offers no extra hazard to the 
mother, while it affords every possible advantage to the child. 
Ossification in the fetus is greatly accelerated during the latter 
part of pregnancy, and the resistance of the head is correspond- 
ingly enhanced. As an example of what nature can do in this 
respect, it is only necessary to recall the fact that in birds and 
fowls the egg is covered with a hard shell within twenty-four 
hours, and although this is not altogether analogous to the point 
under discussion, yet it is a fact which has been observed in all 
cases of premature birth—even where nature is only anticipated 
by a few days—that the cranium is found to be decidedly more 
yielding. Hence Playfair remarks that a “week or a fortnight 5 
might make all the difference between a labor of extreme sever- 
ity and one of comparative ease. ” 
In regard to the propriety of resorting to the induction of 
labor in primiparte, Tarnier expresses himself in the following 
forcible manner. He says: “Many accoucheurs hold that in a 
first pregnancy premature labor ought not to be thought of 
when the pelvis has a diameter of more than three and three- 
eighths of an inch. Indeed, the fact that the woman is pregnant 
for the first time has been regarded as a formal contraindication 
of the operation. We shall state our own opinion the more 
freely on this subject, as we cannot understand why there should 
be any doubt about it. Premature artificial delivery is an inno- 
cent operation; how great, therefore, would be the regret if, 
after having waited until term, it became necessary to perform 
embryotomy upon a child which might have been saved by the 
former operation! In the interest, therefore, of the child itself, 
were it not better that it should encounter the inconvenience 
of a premature birth than the danger of a difficult delivery by 
the forceps ? We would, therefore, in a case of first pregnancy, 
recommend premature delivery whenever we felt uncertain as 
to the result of labor at term, at the risk of being accused of 
having accomplished it unnecessarily; with much less hesitation, 
therefore, would we advise it when the pelvis is so contracted 
that labor at term would probably be very difficult or even im- 
possible. ” 
In this connection I am reminded of a remark made by one of 
the gentlemen who participated in the discussion at our last 
meeting, viz., that when opportunity offered he always “en- 
deavored, to examine his primiparous patients two months before 
confinement. ” At first sight this might seem to some as unnec- 
essary, but when we reflect upon the importance to the female 
of the information to be thus derived, and which can be acquired 
in no other way, the proceeding appears in an altogether differ- 
ent light. It is the duty of the obstetrician to take a practical 
view of all things, and to run no unnecessary risks. No false 
modesty or diffidence should stand in the way when there is a 
possibility that a human life is at stake. Although such an ex- 
amination might turn out to be needless in all save rarely excep- 6 
tional cases, yet, if every woman could be made to understand 
that she might prove the exception, such a proposition, so far 
from seeming meddlesome in her sight, would strike her as of 
the most essential importance. It is to be hoped that the day will 
yet come when it will be considered the proper and customary 
thing for every female, pregnant for the first time, to consult her 
physician as to her physical fitness for the trial before her; in 
this way many malpositions might be corrected and pelvic de- 
formities ascertained in time to avoid danger and possible death. 
There is still another class of cases, already adverted to, which 
are occasionally encountered, where the propriety of the induc- 
tion of premature labor should be taken into serious considera- 
tion. I allude to those cases wherein the pelvis is 'appar- 
ently normal, but where the child habitually proves to be of 
extraordinary size. I am quite sure that all of the gentlemen 
present can recall instances in their experience where this state 
of things has caused the death of the fetus in several successive 
labors in the same individual. For example, I know of a lady, 
the wife of a tobacconist residing on Geyer avenue in this city, 
who has been confined three times. She is rather above medium 
height and weight, the picture of physical health and with a capa- 
cious pelvis. She is some twenty-eight or thirty years of age. The 
husband’s age is about fifty; he is five feet seven inches tall,thick 
set and powerfully built. The wife was attended in her first 
confinement by a skilful obstetrician, and after a most difficult 
labor was delivered by forceps of a still-born child weighing, in 
the nude state, fourteen pounds. In her second labor she had a 
similar experience and was delivered instrumentally with diffi- 
culty by a well-known midwife who is said to be quite expert 
with the forceps. This child was also born dead, and is said to 
have weighed eighteen pounds. The father informs me that 
there can be no mistake about this, for he weighed the child 
twice on two separate and reliable scales. 
Being anxious for a living child and disheartened at his past 
experience, the husband resolved to have two physicians present 
at the third accouchment of his wife, so that in case of trouble 
they could assist each other. Dr. Atkinson and myself were 
engaged, and each of us informed of the two preceding labors. 7 
We met together, talked the matter over, and concluded that in- 
asmuch as the pelvis was capable of admitting the passage of 
an eighteen-pound child, we had every prospect of a happy ter- 
mination of the case in hand. Labor came on suddenly with a 
rupture of the amnion, and I happened to be the first to reach 
the house. On making an examination I was horrified to find 
an enormous foot protruding from the vulva. Dr. Atkinson ar- 
rived in a few minutes and I hastily informed him of the situa- 
tion. We lost no time in apprising the husband of the condi- 
tion of affairs and gave it as our opinion that the chances of 
saving the child were very slight, indeed. We made every effort 
to turn by external manipulation, but in vain, and finally, when 
the buttocks descended, I stood ready to apply forceps to the 
head at the earliest possible moment. This proved impossible, 
however, for the head was arrested at the superior strait; the 
shoulders and arms were delivered with difficulty, and when this 
was accomplished, the vagina was filled by an immense neck, 
while the shoulders were jammed close up against the vulva. It 
was absolutely impossible for want of space to so manipulate 
the second blade as to get the forceps to lock. Delivery was 
finally completed at the expiration of an hour by continuous 
traction with the finger in the mouth. The child was dead of 
course, and weighed, naked, fourteen and a half pounds. This 
lady has not been pregnant since, but should she become so, I 
should unhesitatingly recommend the induction of labor at the 
eighth month, as the most certain means of securing her an easy 
labor and a living child. 
Cases are occasionally met with in which tumors within the 
pelvis or within the abdomen and infringing on the entrance 
to the pelvis might call for the induction of premature labor; 
in which event the same general principles would apply as to the 
conditions already discussed. 
The relation of this operation to the management of placenta 
previa is so fully recognized in practice as to preclude the ne- 
cessity of further notice. We pass on therefore to the mention 
of many conditions of the mother’s health in which the induc- 
tion of premature labor might afford her great relief and save a 
child otherwise doomed to perish with her. Among these may 8 
be mentioned persistent vomiting, chorea, anasarca arising from 
albuminuria, heart disease or other causes; ascites, certain dis- 
eases of the heart, lungs or liver; hydramnios; tensity of the 
abdomen—cau ing distressing pressure upon large blood vessels 
and other organs; aneurism, mania, convulsions, and in fact any 
disease or condition of the mother, ‘ ‘provided only”—as Playfair 
remarks—“we are convinced that the termination of pregnancy 
would give the patient relief, and that its continuance would in- 
involve serious clanger. 
It sometimes happens that the fetus dies in utero towards the 
latter end of successive pregnancies. When it is found that this 
is dependent upon degeneration of the placenta, it has been sug- 
gested by good authority that it would be well to anticipate 
these changes, and consequent death of the child, by the induc- 
tion of premature labor, provided the period of viability has 
arrived. Should this proneness to placental degeneration be de- 
pendent upon syphilitic taint, however, which is very often the 
case, this procedure will be found of doubtful utility, for the 
reason that a syphilitic child when born prematurely would in 
all probability die under the best of care. Moreover, modern 
experience would indicate that the fetus can be more efficiently 
treated within the uterus than outside of it. I would, therefore, 
be slow to recommend the induction of premature labor in cases 
where there was a well grounded suspicion of syphilis, but 
rather depend upon vigorous medication directed to the mother’s 
system, commencing early, with the hope of thus influencing 
the nutrition of the placenta. 
In operating for the induction of premature labor the object 
in view is to excite normal physiological action in the uterus, 
with as little departure from natural conditions as possible. It 
has been in accordance with this idea that various methods have 
been advanced by their special advocates. Among these may 
be mentioned stimulation applied to the breasts, recommended 
by Frerichs and Scanzoni; various forms of vaginal tampon as 
practised by Hiiter, Busch, Schoeller and Braun; the douche, 
introduced by Kiwisch and modified by Blot, Tyler Smith and 
others; carbonic acid jets into the cervix, as used by Scanzoni; 
dilatation of the cervix by tents as suggested by Kluge, and sub- 9 
sequently by means of special instruments, such as the dilator 
of Busch, the spheno-siphon of Schnackenberg and the well- 
known rubber bags of Barnes. Then we have the various 
mechanical processes of intra-uterine stimulation; the detach- 
ment of the membranes accredited to Hamilton; the injection of 
small quantites of tar-water between the uterine walls and the 
amniotic sac, known as “Cohen’s Method”; the introduction of 
bulbs, bougies, etc., into the uterus, as suggested by Krause, 
Simpson, Tarnier and others; in addition we have electricity, 
oxytocics and puncture of the membranes. 
Some of the foregoing methods are more theoretical than 
practical, while others are not free from danger. They are all 
more or less uncertain as to the time required to bring on labor, 
though some are far more efficient than others. Among the 
earliest and most reliable is puncture of the membranes. This 
procedure is, however, not the safest for the child, especially in 
'primiparse, as the fetus is thus subjected to a maximum direct 
pressure by the uterine walls, a condition which is hazardous to 
its life, if the labor be at all prolonged. At the same time spe- 
cial circumstances may dictate this method in preference to 
others, as for example, in certain cases of placenta previa, when 
it is desirable to speedily contract the uterus and increase the 
energy of its action. This should not be done, however, prior to 
partial dilatation of the os, if the operation of turning is contem- 
plated, in which case preference should be given to other meas- 
ures tending to excite contractions and at the same time pro- 
moting dilatation without interfering with the integrity of the 
membranes. Perhaps the most objectionable of all the older 
methods of provoking labor is the administration of ergot and 
other oxytocics, for apart from their uncertainty they are now 
clearly recognized as absolutely dangerous. 
Since this operation is called for mostly in cases of deformed 
pelvis, it wdll be found that some of the methods recommended 
are by no means easy of performance. If the brim is narrow, 
the uterus is high up and the os will be found pointing back- 
wards and beyond the reach of the finger, so that it will re- 
quire skilled assistance in order to successfully introduce tents 
or Barnes’ dilators into the cervix. Even when the uterus is 10 
steadied and pushed down from above, these manipulations will 
be found exceedingly difficult, and in some cases quite impos- 
sible without introducing the hand more or less completely into 
the vagina, under chloroform. It frequently happens that a 
Sims’ speculum and a vulsellum prove of great service. Tam- 
poning the vagina is very simple, but not by any means a cer- 
tain method of inducing labor. The same may be said of 
douches; they frequently require to be often repeated, and may 
finally fail in the absence of other supplemental means. The in- 
jection of carbonic gas or of water into the uterus is conceded 
to be dangerous, a number of fatal cases having been reported 
byDepaul, Salmon, Simpson, Barnes and others; and in view 
of the fact that there are other methods of equal efficiency and 
involving less trouble, time and risk, they should be discarded. 
Barnes’ rubber bags, or tents of tupelo or sponge, offer a valua- 
ble means of commencing dilatation of the cervix and stimulat- 
ing uterine action. Instances have been recorded, however, in 
which the head of the child has been deflected by the presence 
of Barnes’ dilator, producing a shoulder or breech presentation. 
According to my own experience, the method of Simpson and 
Krause, which consists in the introduction of a gum bougie be- 
tween the uterine wall and the amniotic sac, proves by far the 
safest and surest means of inducing labor. The bougie should 
be of large size, and slowly and carefully pushed up from four 
to eight inches, and allowed to remain in situ’, the free end be- 
ing wrapped in raw cotton and coiled up into the vagina. In 
this way it does not discommode the patient, who may be per- 
mitted to sit up or even walk around the room, if she so desires. 
The passage of a bougie as thus described is quite painful, and 
in sensitive patients it might have to be done under the influence 
of an anesthetic. Should the instrument happen to come in 
contact with the placenta, experience teaches that no serious 
bleeding results. If, as is sometimes the case, the amnion is 
ruptured in passing the bougie, it is not a matter of much re- 
gret, since the puncture usually occurs high up, and hence the 
escape of fluid will be slow, while at the same time it hastens 
labor. The superiority of this method consists in its simplicity, 
its efficiency and its freedom from all risk to either mother or 11 
child; it has also the further advantage that it can, if necessary, 
be easily supplemented by any other means, such as dilatation 
of the cervix, the douche, or puncture of the membranes. On 
account of the uncertainty, trouble and risk attending the 
douche, however, especially when force is used, or the fluid is 
injected into the uterus, I prefer other methods and only 
employ it when the water has free exit, and under no circum- 
stances would I feel safe in introducing the nozzle of the syringe 
further than necessary to have the stream, which should be con- 
tinuous and gentle, come in contact with the membranes. When 
thus employed the douche may prove very efficient, and is highly 
commended as a means of inaugurating uterine contraction. The 
strong testimony against the douche, however, which has been 
recorded by many European authorities, such as Barnes, Play- 
fair, Tarnier and others, should not be ignored, and I can only 
say that I have gotten along very well without it. The pres- 
ence of a bougie will be found in no wise to prevent the passage 
of a tent or Barnes’ dilator by its side into the cervix, and the 
two can thus remain and mutually assist each other. 
In most of the cases in which I have employed the bougie, no 
additional measures have been required; in some, pains have 
commenced promptly and regularly from the moment of introduc- 
tion, while in all instances labor has supervened within twenty- 
four hours. Instances are recorded, however, in which the uterus 
has proven extremely torpid in spite of a combination of three 
or more of the most approved methods. 
Time is always an object in this operation, especially when 
the physician has to visit the patient at a distance. It is of 
equal importance that the woman be not discouraged and worn 
out by long continued efforts to attain the object in view. In 
order, to encompass these ends, we would recommend three 
measures for the induction of premature labor in the order of 
their respective merits. 1st, The bougie; 2nd, Tents or other di- 
lators',; 3d, The douche. 
I have induced premature labor, independent of cases of 
placenta previa, five times; twice with the same patient. In one 
case there was a breech presentation, and the child was still- 
born. Another child died during the first week. The remain- 
ing children survived and did well. 12 
Case I.—Was somewhat remarkable in its history. Mrs. 
H. an extremely emaciated lady, residing in Cincinnati, 
was taken by her husband to a watering place in West Virginia 
near Parkersburg, where I then resided. She had been exam- 
ined by several physicians, and was said to have an ovarian 
tumor. The abdomen was enlarged, and contained a uniformly 
firm and rounded tumor, occupying a central position, and ex- 
tending several inches above the umbilicus. The patient was 
suffering great distress in breathing, owing to the enlargement 
of her abdomen, and this was aggravated by extensive tubercu- 
lar deposits in both lungs; in short she was in the last stage of 
phthisis. 
Although a consultation in this case, held only two wTeeks pre- 
viously, had decided that the abdominal tumor was ovarian or 
fibroid, it seemed strange when I saw the patient that there 
should be any doubt as to the diagnosis. The fetal heart was 
plainly heard; motion was distinct on palpation and also on in- 
spection; even the outlines of the child could be readily made 
out through the attenuated abdominal walls. The patient, how- 
ever, seems never to have suspected her true condition, she hav- 
ing attributed the cessation of her menses to ill health. 
The dyspnea increased rapidly, and the patient and her friends 
began to intercede with me to bring on labor with a view of af- 
fording some relief. She was apparently past the seventh 
month of pregnancy, and it was plain to be seen that she could 
not survive to full term. At first I was disinclined to accede to 
the patient’s earnest solicitations, but in a short time her condi- 
tion became so desperate' that something had to be done, and I 
consulted with Dr. R. P. Davis, and afterwards with Dr. A. G. 
Clark, of Parkersburg. These gentlemen both took the ground 
that as the mother wTas doomed in any event, we should give the 
child a chance for its life. After explaining all the risks our 
decision was eagerly accepted by the wretched patient and her 
friends. 
A large gum bougie was passed six inches into the uterus 
by the side of the membranes at 10:30 a. m. Slight 
pains were immediately excited, and in six hours uterine con- 
tractions were vigorous and regular. At 8:30 r. m a living 13 
child weighing four pounds was born after a remarkably 
easy and natural labor. The mother stood the ordeal better 
than any of us expected, and experienced the most perfect sense 
of relief; in fact her general improvement was very remarkable. 
For the first two weeks she gained in all respects; she slept 
well, her digestion, appetite and strength evinced greal improve, 
ment. Unfortunately, at the end of three weeks however, she 
was seized with a diarrhea which quickly carried her ofl’. 
Owing to the fact that the weather was cool and damp, and 
there being no means of heating the room, which was in a sum- 
mer hotel, the child did not do well; it died in about a week. 
Case II.—Mrs. J. had been in labor seventy-two 
hours with her first child, Dr. John Shickle, of Parkersburg, 
being in attendance, when I was called in. On making an ex- 
amination, I found the head resting against the pubic arch 
which was very narrow, owing chiefly to the encroachment of 
the left ramus towards the median line. On making inquiry I 
learned that the right leg of the patient was several inches 
shorter than the left, it having been dislocated in childhood. 
The consequence was that the pelvis was pushed in on the left 
side—especially the left side of the pubic arch. Delivery was 
effected with difficulty, after perforation of the head, the child 
being very large. Although extremely exhausted, the patient 
made a good recovery, and within six months was again preg- 
nant. I made a note of her reckoning and advised the induction 
of premature labor. In the meantime a consultation was held 
and the pelvis examined, which resulted in a decision to perform 
the operation at seven and a half months. When the proper 
time arrived, a bougie was passed into the uterus; in doing so, 
however, the membranes were accidentally ruptured. Labor 
came on in three hours, and, at the end of nine hours, a girl baby 
was born, which survived and grew up to be a bright and inter- 
esting child. 
Case III.—The same patient, Mrs. J., again became preg- 
nant, and at the end of seven and a half months I brought on 
labor by the same method, only that the amnion was not rupt- 
ured in this case. The result, however, was not equally satis- 
factory; a vigorous male child presented by the breech and was 
suffocated before the head could be extracted. 14 
Case IY.—Mrs. W., aged 19, pregnant with her first child, 
was attacked during the sixth month with violent chorea. The 
contortions of the patient were pitiable to behold. Such was 
the violence of the spasmodic action of all the voluntary mus- 
cles that it was difficult to feed the patient, and short interims 
of sleep were only procured by large doses of chloral. All ef- 
forts at motion so aggravated her suffering that she would pass 
her urine and feces in bed rather than exert herself in the least. 
Thus matters progressed until near the end of the eighth month, 
when it became evident that the patient would die unless re- 
lieved. She was much emaciated and covered with bed-sores 
and bruises. At the request of the family, the late Dr. John 
S. Moore was called in, and we decided to lose no time in bring- 
ing on labor. The patient was chloroformed and a large sized 
bougie passed seven inches into the uterus and left there. I 
should have been satisfied with this, but Dr. Moore suggested 
that while she was under the influence of the anesthetic it wTould 
be better to puncture the amnion in order to hasten labor. This 
was done by means of a stylet. Uterine contractions followed 
promptly and at the end of fifteen hours the patient was de- 
livered, she being kept under the joint influence of chloral and 
chloroform during the latter part of labor. The child was reared 
without difficulty. The mother was kept quiet with chloral for 
thirty-six hours after delivery; for the first day there was some 
twitching of the limbs whenever she was aroused from sleep, but 
this subsided by the second day, and she made a good recovery. 
Case V.—During the winter of the present year I received a 
letter from Dr. Robert J. Hornsby, of Bunker Hill, Illinois, in 
forming me that a relative of his expected to be confined in 
June, and in view of the great difficulty encountered in two pre- 
ceding labors, he desired me to be present if possible. At the 
same time I received the following history. Mrs. E. was con- 
fined with her first child some four years since; the labor proved 
very severe and protracted, and was finally terminated with 
great difficulty by forceps. The child was very large and born 
dead. After two years she again passed through the same or- 
deal with a like result. Both Dr. Hornsby and his associate, Dr. 
Gross, of Gillespie, attributed the difficulty to the unusually 15 
large size of the children, and to a contracted pelvis, which is 
deep and narrow, with a short antero-posterior diameter at the 
brim. The patient having narrowly escaped with her life on the 
two former occasions, both she and her friends were extremely 
apprehensive in view of a repetition of the same peril. Besides, 
she was particularly anxious that the coming child might be 
born alive. Later in the spring Dr. Hornsby wrote me that the 
abdomen was of unusual size, indicating that the fetus was 
large. 
After considering all the circumstances, I expressed the opin- 
ion that at full term I could not probably accomplish any more 
than had already been done by her skilful attendants, and as the 
patient resided fifty miles out of the city, I might not be able to 
reach her promptly. I therefore recommended the induction 
of labor at the end of the eighth month, which was agreed upon. 
The calculation was that labor would occur between the 5th and 
10th of June. I accordingly arranged to operate on the 9th 
of May. I reached the patient’s residence about 10:30 
a. m. on that day, and a half hour afterwards passed a large 
sized gum bougie five inches into the uterus and allowed it to 
remain. Pains came on immediately and continued with regu- 
larity and increasing severity, so that by 4 p. m. the os was 
fully dilated, when I removed the bougie and ruptured the mem- 
branes; the pains were extremely efficient, and in less than three 
hours the child was born, and soon gladdened the mother’s heart 
by its cries. The placenta and cord were of unusual size, giv- 
ing every indication that had the full nine months elapsed, the 
fetus would have attained large dimensions. The mother in this 
case made a speedy recovery. A letter from her, dated August 
9th, gives the subsequent history of the child, as the following 
extract will show: 
“Dear Friend:—Your dear little girl is three months old to- 
day and I want to write to you and tell you how well, fat and 
sweet she is. We weighed her this morning, and she weighed 
fourteen pounds, just twice as much as when she was born.” * * 
In conclusion a word should be said in regard to the care of 
the child. A vigorous child, premature by only a few weeks, 
will get along nearly as well as one born at term. But if the in- 16 
fant is feeble, or if born more than a month before its time, 
great care should be exercised to keep it warm, for its vitality is 
easily extinguished by cold. If possible a wet nurse should be 
provided until the mother’s milk flows freely. No time should 
be consumed in bathing it; its body should be quickly sponged 
dry with a soft, warm towel or flannel, a diaper put on, and its 
body carefully wrapped in carded wool or cotton. It can then 
be placed in a basket or cradle and the temperature maintained 
by bottles or bags of hot water. 
If desired, a very effectual contrivance for maintaining a uni- 
form temperature may be manufactured by a tin-smith, consist- 
ing of two rectangular tin or sheet-iron pans. The smaller pan 
being two feet long, by from fifteen to twenty inches in width 
and six inches deep, is supported on four legs two inches long 
and placed in the outer receptacle, which should be four inches 
larger in all its dimensions. The intervening space can be filled 
with water which is kept in the neighborhood of 98°. The outer 
pan may be provided with a faucet by means of which the wa- 
ter may be drawn off' and renewed whenever the temperature 
falls much below the required standard. While it is important 
to keep the temperature of the child up to the normal, it is 
equally dangerous to subject it to excessive heat. Young 
children are exceedingly sensitive to an inordinate temperature, 
and I have known it to prove fatal.