า nal; whether the foetus has reached advanced development, as in abdominal; whether the conditions following foetal death require the treatment.

If the diagnosis has been made early, laparotomy and removal of the foetal sac. Electricity is an uncertain and unreliable remedy, and the cures ascribed to its use are most likely the result of nature's effort to effect a cure. Laparotomy is more trustworthy, and in these cases is almost always a difficult operation, not to be undertaken by an unskilled operator. In favorable cases, in which a trained nurse may be kept in constant attendance, and in which the physician can reach the patient quickly, it is justifiable to wait, after diagnosticating extrauterine pregnancy, to see if the embryo does not die and the sac atrophy-quite a frequent occurrence.

After rupture the indication is for immediate laparotomy, evacuation of the blood from peritoneal cavity, ligature of the sac, and its entire removal. Rupture followed by hemorrhage is, however, not invariably fatal.

In interstitial little can be done until rupture and hemorrhage have occurred, when laparotomy may be performed, ligating the bleeding point, and, if possible, clearing the sac of its contents, along with the placenta. Where this is impossible, ligation of the uterine and ovarian arteries is indicated, or possibly supravaginal amputation of the uterus. It might be well, the diagnosis being established, to try to effect evacuation of the foetal sac into the uterine cavity after thorough dilatation of the cervical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intrauterine pregnancy.

Tubal and ovarian are to be treated as outlined above, when discussing the treatment of early extrauterine gestation and after rupture.

In advanced extrauterine pregnancy always delay until just before the natural duration of normal pregnancy, when the foetus and foetal sac should be extracted by abdominal section. Five such operations have been done, with five maternal recoveries. When death of the foetus has occurred, it is best not to subject the woman to the danger of the several possible terminations, but to perform laparotomy and remove the foetus and

V

its entire surrounding sac. If the exsection of the sac is found to be too difficult or dangerous, it is permissible, some weeks after foetal death, to cut off the cord short, leave behind the atrophied remains of the placenta, stitch the sac wall to the abdominal wall, and thus drain the sac externally. In case the gestation sac is low down in Douglas's pouch, bulging the posterior vaginal wall, vaginal section and the delivery of the foetus by the natural passage may be considered, but it is, as a rule, too dangerous, the mortality being about 50 per cent. It is applicable in case of an old gestation sac undergoing suppuration and containing a much macerated or disintegrated foetus.

XV Pregnancy in One Horn of a Uterus Bicornis
or Unicornis.

Pregnancy in an ill-developed horn of the uterus may exactly resemble a tubal or interstitial pregnancy, and may end in rupture. This is particularly true if the impregnated ovule develops in a rudimentary horn, in which the conditions are almost the same as in a tube, except that rupture takes place later. On the other hand, a pregnancy of this sort may terminate prematurely, or even at term, by expulsion of the product of conception through the natural passage.

The diagnosis of pregnancy in a uterine horn is difficult or impossible. It is mistaken, usually, for tubal gestation.

Labor.
Physiology.

Labor occurs usually 280 days after the appearance of the last menstrual period.

CAUSES OF OCCURRENCE AT THIS TIME.

(a) Periodicity.--The muscular action at the periods is especially marked at the tenth.

(b) Over-distention of Uterus, followed by Retraction.

(c) Maturity of Ovum (fatty change of attachment).

(d) Heredity, or Body Habit, which is, perhaps, the most powerful. At this time slight causes, as exercise, purges, excitement, may begin the process.