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Professor Whitridge Williams writes as follows : —• " Unfortunately, history shows that advances in the practice of medicine and surgery are rarely attained in a thoroughly rational manner, but that a period of undue enthusiasm, or even of almost reckless abuse, usually precedes the establishment of the actual value of a given procedure. From my personal experience and reading, as well as from my intercourse with other medical men, I believe that we are at present going through such a stage in connection with Csesarean section, and I propose to utilize the short time at my disposal in giving my reasons for this conviction. Generally speaking, I consider that the operation is being abused in two ways—first, that it is frequently employed unnecessarily ; and, secondly, that, even when strictly indicated, it is not always performed at the time of election, with the result that its mortality becomes needlessly high. The prime factor concerned in bringing about this abuse is defective medical training, with consequent ignorance of the wonderful adaptability of nature and of the resources of obstetrical art. Subsidiary factors are to be found in the technical ease of the operation, and in the glamour which still surrounds it in the professional and lay mind, as well as in an underestimation of its mortality." Professor Newell writes as follows :— " There is no question but that many Ceesarean sections are performed every year simply because the consultant called to the case has no knowledge of obstetrical* diagnosis and technique. He sees a patient whom the family physician has failed to deliver, and, without the proper knowledge to determine what the patient really needs, he empties the uterus by the abdominal route as the easiest method. His surgical conscience would probably not allow him to perform an ordinary operation with so little appreciation of the needs of the patient, and women in labour should not be exposed to such unscrupulous methods. There is no doubt but that many women are sacrificed every year to the lack of professional conscience which permits a surgeon to determine the fate of a patient as to whose needs he is in absolute ignorance, except that it is probably necessary to deliver her by some means, and even then an immediate delivery may not be indicated under the conditions present in the given case." It must be understood that the foregoing quotations apply to American practice. It is to avoid the development of such a state of affairs here that I urge the necessity for the provision of post-graduate teaching. For myself I will only add that between 1895 and 1898 there were two Csesarean sections done at the Rotunda Hospital, Dublin. The number of confinements under the care of the hospital in the same period was between nine and ten thousand. The gross maternal mortality for the intern patients of the hospital —i.e., 2-16 per 1,000 —was less than it had ever been before or has been since, and the extern mortality was neither noticeably less nor more than in other years. When we remember that Csesarean section, in addition to carrying a certain amount of risk with it, is also an operation that in some cases may result in causing a permanent injury to the patient, it is very difficult to understand how the practice of obstetrics can be benefited by its extended adoption. District Maternity Hospitals.—l am entirely in agreement with your views that district maternity hospitals under the management of Hospital Boards are a great advantage to the community, and that their erection should be encouraged, provided they are used for their proper purpose. Like you, too, I am thoroughly opposed to their being turned from that purpose and used as surgical hospitals. There are various reasons for considering such a course unsatisfactory, but my principal objection, as Consulting Obstetrician, is that the performance of operations for possibly septic conditions in maternity hospitals is calculated to increase the risk of the septic infection of maternity patients. Such an objection —if valid, as I believe it to be —is sufficient in itself to condemn the practice of treating surgical and obstetrical patients in the same building. Miscellaneous. —I have also had an opportunity of criticizing the pamphlets which have been written by Dr. Paget on the aseptic technique of labour and the puerperium, and the prevention of sepsis, and his suggestions to expectant mothers. I regard them as most valuable, and I think that if the directions contained in them are carried out conscientiously by nurses and by patients they will materially aid in reducing maternal mortality not only from septic infection, but also from the other complications of pregnancy and labour. I hope that full effect has been given to his recommendation that sterilized maternity outfits shall be available for the use of all patients. I understand that the aseptic technique which he recommends has been condemned in some quarters as expensive and too complicated. I cannot agree with this view. The aseptic management of a labour case, just as of an operation, must entail more expense than its haphazard management. Similarly, the technique to be followed by a nurse working in a private home or small hospital, if she is to maintain even comparative asepsis during labour, must be complicated. These things are obvious and unavoidable, and the only way to escape from them is to assume that labour does not require aseptic management. If, however, we agree that it does, as I think is right, then Dr. Paget's suggestions are framed in as inexpensive and uncomplicated a fashion as probably is possible. I hope that they are included in the teaching and practice of the maternity hospitals throughout the country, that they will be followed by all registered maternity nurses and midwives, and that medical practitioners generally will do all in their power to assist and to encourage their universal adoption. Lastly, I have followed with much interest the work done by Dr. Elaine Gurr in the establishment of ante-natal clinics in the various large centres. Such clinics must be regarded as one of the most important steps in the reduction of maternal mortality. Pregnancy and labour are physiological conditions, and in the healthy woman must be treated as such. Slight variations from the normal are, however, liable to occur, and if neglected are cumulative in their effect, and may lead to the most serious consequences. It is for this reason that ante-natal clinics are of value even to the healthy woman, while in the case of the woman with definite organic disease they are essential. Here, too, the co-operation of the medical profession is necessary.

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