perineum, and it will at times slip from under it without further assistance, but if this does not occur, the forefinger may be inserted into the vulva, the arm and shoulder carried forward, and then grasped with the thumb and finger and lifted over the perineum. Hooking the finger into the axilla is not generally advisable, as there is danger of injuring the structures in the axilla, and besides it tends to push the point of the shoulder further out against the perineum. If this is done it should be from behind and the force should be chiefly against the thorax. Care must also be taken in grasping the shoulder not to cause too much pressure and fracture the clavicle. This method has the disadvantage of adding the thumb and finger to the bodies which must pass through the vulva, but this, I believe, is more than counterbalanced by the fact that the shoulder is lifted up and the perineum pushed away from it.

If the anterior shoulder does not catch on the symphysis and is coming down first, the posterior one should be carefully retarded by holding it back with one hand and exerting a careful downward traction on the neck so as to deliver the anterior shoulder first, then after pressing the arm and shoulder a little forward, so that they shall not come directly under the symphysis, the body of the child is brought well up against the symphysis and the posterior shoulder handled much the same as in delivering it first, or supported by the hand placed over the perineum.

When the anterior arm is flexed and the posterior extended it will usually be best to deliver the anterior shoulder and arm first, when the progress of the posterior shoulder can be arrested without undue force. This can usually be done by a moderate backward and downward pressure on the posterior shoulder and neck, which at the same time should disengage the anterior shoulder from

under the symphysis and permit of its delivery. The posterior shoulder should still be held back and the anterior arm and forearm delivered by forward pressure on the former and traction on the latter. If the posterior shoulder is now released it will generally be born spontaneously, but if not can be delivered by raising the head and neck so as to bring the thorax well against the symphysis, and, if necessary, grasping the shoulder as directed above. These manipulations must be done between the pains, for sudden delivery with a sharp pain would almost certainly cause laceration, especially as the elbow was being born. The perineum may be supported here by forward pressure applied over its surface with the outstretched hand, as directed sometimes for the head. The objections against this do not hold good here, for the hand is a real support, inclining the shoulder upward and forward as it should go, and preventing the tendency it has to plow through the perineum; besides, this pressure for the length of time the shoulder requires to be born does not seriously interfere with the circulation of the perineum or reduce its vitality.

If the anterior shoulder can not be delivered first, due to engagement under the symphysis and rapid progress of the posterior shoulder, the same method of procedure may be followed as outlined for delivery of the posterior shoulder first with both arms extended.

Where the anterior arm is extended and the posterior flexed it will usually be wise to deliver the posterior shoulder first, much as may be done when both arms are extended, and then deliver the corresponding arm. This allows the hand and arm to be born along with what might be called the cervico-acromial diameter, extending from the base of the neck on one side to the shoulder on the other. This will obviously cause less strain if care

fully done than for the hand and arm to be born at the same time as the bisacromial diameter, which would be the case if the anterior shoulder were delivered first. If any difficulty is experienced in delivering the posterior arm before the anterior shoulder it should be left alone, for the abrupt point of the shoulder has now passed the perineum and the pressure exerted on it is by the soft tissues of the arm and thorax.

If there is a strong tendency for the anterior shoulder to proceed ahead of the posterior, it may be well to adopt the method of procedure suggested for the same condition when both arms are extended.

When both arms are flexed across the chest we have the condition most likely to cause laceration if left alone, for the perineum is likely to be distended by both shoulders and arms at the same time. About the most favorable thing that can happen at this time is for the anterior shoulder to be disengaged from the symphysis and delivered ahead of the posterior, after which the anterior arm may be delivered, thus allowing the anterior side of the thorax to come in contact with the symphysis and subpubic ligament, and relieving the perineum of considerable strain and allowing the posterior shoulder to be delivered in a manner already described.

When the anterior shoulder is impacted on the symphysis and the posterior shows a strong tendency to advance, the same method of procedure may be adopted as when the posterior arm only is flexed and the anterior shoulder is caught under the symphysis.

29 m

TYPHOID FEVER.

BY F. M BRANTLY, M.D., SENOIA..

After over sixty years wrestling with this insidious disease, I trust that this Association will allow me the privilege to venture some of my convictions so dearly obtained.

Because of want of a more thorough knowledge of the pathology of this disease, the fight against it has been like one beating the air.

Conforming treatment with theory has been about all there was in it; the expectant was the general plan, but the expector was a late comer; like the man who locked his stable door after his horse was stolen.

It is amusing to observe the extremes in treatment of typhoid, and it is remarkable how sincerely and tenaciously some practitioners hold to their special fads. I was amused to hear the utterances of one in high authority say that all he wanted in cases of typhoid was plenty of buttermilk and brandy.

Like the weaver's shuttle, the treatment runs from extreme to extreme. And thus it goes from bad to no better, and we can only hope for improvement when this disease is better understood.

We have some pioneers in the profession who are shedding some light on the causes of this disease. Such men as Manson, McCallum, Ross and Laveran have brought to light facts that are revolutionizing the therapy that will

change the practice, so far as this disease is concerned, and perhaps others.

These pioneers in the profession have settled the fact that typhoid fever is caused by microbes and that they are found abundantly in the blood corpuscles in this disease. Taking a hint from these facts, some of the profession propose and do practice what they call elimination and abortive treatment, which they promulgate as a success. So all new departures must wait their day and time for vindication.

2. BACILLUS TYPHOSUS.

3. BACILLUS TYPHOSUS.

a. Agar Culture. b. Potato Culture. Bouillon Culture showing Flagella.

Miasmatic or malarial fevers are also microbic and are destroyed by the antidote, quinine, by which means it is cut short.

But quinine don't seem to affect the typhoid bacilli, so it behooves us to hunt out other remedies. First, let us look for cause and effect, then fashion our remedies.

Typhoid fever is an infectious disease, caused by microbes generated from animal débris or effluvia, and is found to exist any and everywhere that these deposits are found, regardless of season or clime. Close search always reveals the nidus from whence the microbe comes. They