an unruptured tubal pregnancy—a perfectly logical diagnosis. On September 24th, I operated and found that she had a beautiful ovarian cyst on the right side, and the pregnancy going on as usual in the uterus. The cyst was removed and the patient is very comfortable.

This case is related to prove that it is not always possible to correctly diagnose these conditions.

NARRATION OF CASES.

Dr. Jewett I will put on record three recent cases of symphyseotomy, the last being my fifth. Now that symphyseotomies have become so common, a detailed report would be of no interest. Two points, however, I will speak of; the method of operating and an accident which I encountered in the fourth case. The most surgical method I think is the open method as practised by the French. It is substantially as follows: The incision is made from a point above the symphysis and is carried down as far as the clitoris the abdominal wall is opened in the median line close to the joint and to the extent necessary to admit the finger. A V-shaped incision is made at the bottom of the wound just above and parallel with the crura of the clitoris, cutting down to the bone. A sharp hook, caught in the point of the Y, draws the clitoris down out of the way, together with the vessels around it. The lower end of the joint and the rami of the pubes for a little distance can then be readily exposed with the point of the scalpel. Some of the French operators (Farabeuf) use a director to protect the retro-pubic vessels while dividing the joints. The director (gouttière) is broad and strongly curved. It is passed behind the joint from below up or from above downward. The moderately sharp point can be made to hug the joint so closely that the vessels are pushed back, and it is possible to prevent the hemorrhage which otherwise is usually troublesome. After the director is passed you incise the interpubic disk about as you would divide a fistula in ano, upon the director, using a strongly curved bistoury. There is difficulty sometimes in locating the joint, and possibly this difficulty has led to the assumption that ossification is more frequent than it really is. Rocking one half of the pelvis by forcibly flexing and extending one thigh, while the other is held in a fixed position, helps to find the joint. The closure of the wound is simple, a single tier of sutures being all that is necessary. The sutures should be carried down through the fibrous tissues in front of the bones and may even include a part of the disk. This will

help to steady the bones against riding up and down on each other. For delivery the prevailing choice has been version, but there is, I believe, more danger of injury to the soft parts in version and breech-extraction than by forceps. The head can be pressed down into the pelvis so that the forceps-operation is an easy and perfectly practical one. It is the one I have used in four cases. With regard to the after-treatment, the patient will get a good joint, I think, in all cases, provided there is no suppuration, if she is kept in bed with the pelvis immobilized for about four weeks. Some of the Italian cases are said to have been up in eight days, and a good many in two weeks; it was a common practice in the earlier experience in this country to let the patient out of bed at the end of the third week. The full month I think is essential. The joint needs to be firm enough to take care of itself before the patient gets up and puts any strain upon it by walking. For retention the usual adhesive straps and muslin binder may suffice. But I have used in addition to these a firm cushion under each lateral half of the pelvis just without the sacrum. On these the patient rests during the entire period of convalescence. The apposition of the pubic bones is maintained by the weight of the body. To be comfortable the cushions must extend nearly or quite to the shoulders, thinning out toward the upper ends. This method is used by Pinard and other French operators. Bed-sores have not occurred in my experience.

The operation in one case was complicated with a laceration of the anterior soft parts. All writers have alluded to the possibility of this accident. It has probably happened oftener than has been reported. After opening the joint, the pelvic halves are all afloat, as it were, and the intermediate soft structures will tear under very little strain. In the case referred to the child was a pounds, and it presented by the breech. The woman's pelvis was ample except at the outlet. The bisischial diameter measured 31 to 3 inches.

large one, weighing 9

She had been delivered but once before and then by craniotomy. The lateral halves of the pelvis were held by inexperienced assistants. The necessity for rapidly completing the delivery was, of course, urgent. The separation of the bones at the beginning of the delivery was about two inches. At the moment the head was extracted the anterior soft parts were torn through. The trouble was not that the vaginal orifice was small, as the previous labor had left it larger than it ought to have been. The laceration ran up just outside

of the urethra, to the right of it, and entered the base of the blad

der. I could look into the bladder a good deal better than with a Kelly speculum, but it was not so pleasant. The bladder was sutured with a running fine catgut, and the vagina with a similar suture. The wound of incision was closed with silkworm-gut in the usual manner. It was late in the evening and getting dark, and the latter part of the suturing was not done as it would have been with more time and a good light, yet the union of the operation wound was immediate and complete. A soft catheter was left in the bladder for three days. urine came away by the urethra. nearly four weeks. It had closed of urination at the time the woman left the bed. Union of the bones was firm and in a few days the woman walked about the room without difficulty.

From this time a part of the

A urinary fistula persisted for and there was perfect control

In the three cases the mothers and, so far as I know, the children are all living.

Dr. Dickinson: The hour is late, Mr. President, and I have only one word more to add to Dr. Jewett's full exposition of his interesting cases, and that is that the trough-bed furnishes one further facility in treating symphyseotomy. It is exceedingly difficult to lift a patient, even on the narrow hospital bed, without two skilled and strong assistants, to put the bed-pan under her, or catheterize or change the bed linen underneath, so that putting the patient on hard pillows running parallel with the long axis of her body, causes a gap underneath the sacrum into which the beak of the bed-pan can be slipped without raising or otherwise disturbing the patient. Thereby one saves a good deal of uncleanliness, and, by transferring the weight to the ilia and trochanters, the symphysis is pressed into closer apposition.

Meeting of November 6, 1896.

MONSTROSITY.

Dr. Charles Jewett: This is a monstrosity, Mr. President, which is of interest in connection with a subject which was written up by Dr. Jaggard two or three years ago. The specimen was presented to me by Dr. E. Buchaca. It came to him from a midwife who attended the labor and the history is therefore incomplete. There is a ventral fissure and hernia of the abdominal contents. The rectum and urethra are absent. The right lower extremity, together with the corresponding half of the pelvis, is wanting.

There is club-foot of the left lower extremity-talipes equino varus. A partial dissection of the specimen was kindly made by Professor Van Cott. Examining the genito-urinary tract, and that is the point on which the interest in the case mainly hinges, but one kidney was found, and that large and soft with its tissues broken down. The ureter was dilated as far down as the pubic bone, and from that point where it ran over the bone to reach the exstrophied bladder it was stenosed. The dilatation of the ureter above the stenotic por

tion justified the belief that the stenosis had been sufficient to prevent much evacuation of urine from the kidney, although a liquid injected at the pelvis of the kidney could be forced down through the ureter into the bladder. The kidney, too, must for a time have been nearly functionless.

The specimen bears out, in part, at least, the theory set forth by Jaggard. In connection with the study of a monstrosity which he presented at the Chicago Gynecological Society, he had searched

the literature of the subject and he cited several similar cases; in each there had been oligo-hydramnion associated with malformations of the fetus.

It is nothing new that in oligo-hydramnion the fetus is liable to be deformed by reason of the fact that the pressure of the uterine walls upon it is not equally distributed. Jaggard contended that not only may club-foot and other deformities of fetal members be referred in many instances to deficiency of liquor amnii in

the later months of gestation, but that numerous faults of development dating from the early months may be attributed to a contracted amnion. Even atresia ani and atresia urethræ, he thought could be explained, in part, at least, as pressure effects. He called attention to the fact that feto-amniotic bands, commonly attributed to amniotitis may be accounted for by scantiness of liquor amnii, permissive of foldings of the sac wall. These bands, it is well known, are held responsible for a variety