that we should be just as cautious not to use the forceps too soon as not to delay too long.

Dr. W. J. Little, Macon: With me the time to apply forceps depends entirely upon the time I reach my patient, and when I feel that they are necessary. I have no scruples at all about putting on the forceps; in fact, I consider them the most humane instrument we possess. In primiparas, where there is no contraindication to the birth of the child from any anatomical defects, or from the size of the head, but simply because the patient is a primipara, where labor is long and protracted, I do not hesitate to relieve the patient with the forceps, knowing by experience that I can probably protect the perineum better with forceps on than with them off. I have always in my satchel a pair of short forceps and when the head is presenting, the perineum bulging, I frequently apply them as a means of controlling the perineum.

Dr. W. S. Elkin, Atlanta: I have been very much interested in this paper. It is very valuable and instructive to the members of this Association for it is a subject with which they have to deal almost daily.

When to apply the forceps is often a difficult matter for the physician to determine, and it is impossible to lay down any hard and fast rule as to when it should be done. It is criminal to delay their application unduly. I always make it a rule to determine the exact position of the fetus by making a thorough examination at my first visit. Then, if the pains are severe and expulsive in character, and two or three hours have elapsed and no progress of the head, it is best to apply the forceps. I believe you run a great deal less risk so far as the mother and child are concerned by the early application of the forceps than by waiting too long. When uterine inertia occurs or the patient is fast becoming exhausted, I al

ways think the forceps should be applied. For a high application I use exclusively Tarnier's axis traction forceps, which enable you to make traction in the line of the pelvis. If the head is on the floor of the pelvis or at the perineum I use Elliott's forceps. Frequently the error with the physician is too much haste after the forceps are applied. Traction should be made at the time of the uterine contractions with great care and in the line of the pelvic and uterine axis. There is very little risk to the child or injury to the mother if these points are observed.

Dr. H. McHatton, Macon: I want to congratulate Dr. McDuffie on his paper. In the twenty-five years I have been a member I think it is the first time this subject has been brought before this Association. It is one of the most important subjects that we have to deal with.

In the vast majority of cases I think the application of forceps is put off too long. I do not remember ever seeing them put on too early. By applying them at the proper time we save the mother, aside from any other consideration, a period of intense suffering, which puts her in a worse condition in regard to taking on a septic condition after the labor. As we increase in civilization and our women get farther and farther away from nature we will find that we will have to use the forceps more and more. I use them now very much more than I did some years ago, and believe the necessity for their use is increasing. As to the kind of forceps, each one should familiarize himself with a certain type and should not be changing about.

I would emphasize the importance of not being in too much of a hurry. Almost without exception, in every forceps delivery I have seen, the operator has been in too big a hurry to deliver. There is no hurry. I put on

my forceps and make traction during the pain and deliver gradually. By following this idea you do less damage and have fewer puerperal complications than when you leave the delivery entirely to nature.

As to the use of chloroform, very often I see these cases put under complete surgical anesthesia for delivery. That, in my estimation, is an absolute mistake. I have seen several children lost in this way by failing to get any cooperation from the mother after delivery of the head. I do not think I abuse the use of the forceps. In the last five cases I have had two multipara and three primipara. I have used the forceps three times, and certainly without any unpleasant results.

Dr. C. L. Williams, Columbus: I am glad the doctor read this paper because I think the subject is of the greatest importance to the general practitioner. There are many physicians in the country not blessed with all the facilities of the city doctor to fall back on. I believe that we should be very conservative in our use of the forceps and I condemn unhesitatingly their unnecessary use. In a practice of twenty years, up to 1886, I used the forceps only once. When my patients had protracted labor I gave them chloroform slightly, and I never had trouble except on one occasion, and that a case of eclampsia. In the last twenty years I have used the forceps perhaps four or five times. In one of my last cases, a protracted one, the patient was begging for relief and though I believed she would be delivered safely without forceps, yet labor was somewhat slow and tedious, and in order to satisfy the family I sent for a physician to administer chloroform that I might deliver the patient with forceps. In the meantime, I gave her a dose of ergot, and by the time the physician came more effectual pains had come on and the woman was delivered. I have had two such cases and I must say that I have not abandoned the use of

ergot. I have had good results with it and I believe that when there is uterine inertia-the pains not effectual-that sometimes ergot is the remedy.

Dr. J. L. Frazer, Fitzgerald: As this is the first time. this subject has been before the Association, and it brings back school days to some of us, I would mention one thing, but, first, as to ergot: I have for seven or eight years now used quinine in 20-grain doses, given 10 grains repeated in one hour if necessary, and believe it gives more uniform contraction than ergot does. One remark that Dr. Anderson made to his class always impressed me: "When the head is brought down, stop and take the forceps off." If the head is delivered with the instrument on, the perineum must, of necessity, dilate that much more. I would rather risk my three fingers against the head as it is delivered than to risk having the instrument there. I have never yet delivered the head with the forceps on, but just when the head is crowding I take the instrument off and hold the head back with the hand.

Dr. J. H. McDuffie, Columbus (closing): I have but little to say except I am grateful to the members who have so kindly and freely discussed this imperfect paper. I want to show this leverage attachment because it is applicable to all ordinary forceps, and those who do not possess a Tarnier will find it of great assistance to them. By its use, traction is made in the proper direction and with infinitely less muscular outlay than when traction is made with the handles alone. When using it the handles show just the direction the head is taking and the progress it is making in descent and rotation, and it is only necessary to steady the handles with the unengaged hand. (Exhibiting the attachment applied to Elliott's forceps.)

THE ETIOLOGY, DIAGNOSIS AND TREAT

MENT OF GALL-STONES.

BY WILLIS JONES, M.D., ATLANTA.

Some idea of the frequency of this condition may be had from the following statistics: In 9,000 autopsies Naunyn found stones in I in every 30 individuals before thirty years of age, and in 1 in every 6 after sixty years of age. Bollinger found stones in 2.7 per cent. between the years of fifteen and thirty, in 5.9 per cent. between the years of thirty and sixty, and in 15.2 per cent. after sixty years of age. Working along these same lines Schroeder found stones present in 12.5 per cent. of all his autopsies. Still has reported 20 cases in children, 10 of which were in infants. Kerh in 360 operations on the gall-bladder and its passages found stones present in 307 of the 360 cases. Striking an aver age of the above figures, we find that the condition is. present in from 10 to 12 per cent. of all individuals, and occurring about four times as often in the female as the male. So we learn that probably no other surgical condition in the abdominal cavity occurs quite so frequently.

No one etiological factor, as we will see further on, can be held accountable for such a prevalent condition, and if we go searching for the cause we will have to consider the union of several factors as essential to their formation. From the prevalence of the condition among those who have passed the middle line of life, and since statistics show us that gall-stones occur about four times.