the uterus is removed the kidneys experience a relief at once, since this increased tension ceases. When, after the emptying of the uterus, anuria supervenes, it has been advised to perform decapsulation of the kidney, with a view to the relief of the pressure on the kidney, and successful results are claimed by Edebohls in such

a case.

Indications for Pubiotomy.-Otto v. Franqué (Münich. Med. Woch., March 7),details two cases operated on by him by pubiotomy for contracted pelvis, in order to avoid perforation of the skull of the child. The indications are for this operation, instead of symphyseotomy or Cesarean section, in slightly contracted pelves where a moderate enlargement of the pelvic ring will allow of delivery of the child by high forceps or version. When there is fever during labor, the membranes having ruptured too early, and the uterus having become infected by examinations by careless midwives, this operation with dilatation of the cervix by an inflated rubber bag permits of early delivery of a living child. It takes no longer than perforation and extraction. The great advantage is the obtaining of a living child. The pubiotomy wound is much more easily cared for and guarded against infection from the genital tract than the symphyseotomy wound.

Increase in the Size of the Pelvis Obtained by Pubiotomy.-A.. Van Cauvenberge (L'Obstétrique, January), has sought by accurate measurements to find out the exact amount that we may expect to gain in the various diameters of the pelvis by the operation of pubiotomy. Pubiotomy consists of an artificial increase in the size of the pelvis by a section of the pubic arch at one side of the symphysis. The author has measured his cases before and after operation: First, the distance between the two anterior iliac spines; second, between the iliac crests; third, between the trochanters; fourth, from the apophysis of the last lumbar vertebra to the upper edge of the symphysis. Internally: True conjugate, diagonal conjugate, bisacro-iliac, transverse and the oblique diameters. After the operation the bones are separated from one to five centimeters on the cadaver. In the living subject the separation is somewhat greater, so that often a spontaneous labor takes place. This should not be carried out too rapidly, and it is best to make pressure with the hands or with an elastic ligature on the sides of the pelvis, to prevent lacerations of the soft parts. At the time of labor the sacro-iliac articulations are more elastic than

during pregnancy. The anteroposterior diameters are at first increased only slightly; later, as the bones separate more, the increase becomes greater. The true conjugate increases a little more than the diagonal. When the bones separate 4 centimeters, the true conjugate increases 1.6 centimeters. Separation of 6 centimeters gives an increase of 1.7 to 2 centimeters. The transverse increases from 2.5 to 3 centimeters. The obliques increase 2.5 to 3 centimeters. The author believes that the question of easy healing of the wound and perfect consolidation of the pelvic basin remains still undecided. An excellent result of pubiotomy is that the di

ameters remain somewhat enlarged, a great benefit in a following pregnancy. Pubiotomy permits of delivery in a more contracted pelvis than will symphyseotomy; the smallest that can be delivered by the latter is a diameter of 6.75, while by pubiotomy the lowest limit is 6.50 centimeters. The operation is less dangerous than symphyseotomy; the bladder and urethra are undisturbed. The soft parts are thicker at the side than in the middle and hemorrhage is less.

Acute Puerperal Infection and Hysterectomy.-G. Berruti Giornale di Gin. e di Ped., Jan.) states that the mortality from puerperal infection when hysterectomy is done is greater than when the ordinary therapeutic resources are resorted to, since, at the present day, the mortality by these means reaches only 10 per cent. In cases of infection without localization, the enormous mortality when hysterectomy is done, 76.5 per cent., proves that this kind of operation is not appropriate for the condition; curetting, irrigation and injections of the serum of Marmorek give better results. Autopsy in the cases of hysterectomy, which show no localization of peritonitis, show that the operation could not be of benefit in cases of general infection. When there are remains of the placenta or of membranes after abortion, hysterectomy is useful only when executed promptly and by way of the vagina, so as to avoid the diffusion of the infection. Late operation is contraindicated. The mortality under operation is very great. With localization of the inflammation in the periuterine tissue it is better to incise and drain the pus collection. In case of retention of the placenta, emptying and disinfection of the uterus are the appropriate means of cure. In cases of suppurating fibromata, operative perforation of the uterus, or suppurating ovarian cysts, radical intervention is a necessity, but such cases are not true cases of puerperal infection. Hence, the author concludes, that hysterectomy is not generally applicable to puerperal infection.

Vaginal Hysterectomy for Cancer of the Cervix of the Pregnant Uterus.-R. Condamin and A. Condamin (An. de Gyn. et d'Obst., March) say that it has been considered useless to operate on women pregnant during the course of a cervical cancer, because it was thought to be a necessarily fatal condition. The authors differ with the earlier writers in this, since it is not proved that recurrence of cancer after radical operation is always the case. It has been the practice to take into account only the welfare of the fetus. The fetus, however, is constantly menaced by the uterine cancer, by abortion, hemorrhage, and dystocia. Only 34 per cent. of infants survive when pregnancy is allowed to go on to its end. In the case of the mother we know that the existence of pregnancy aggravates the condition and renders the spread of the disease more rapid. Thirty cases are cited by the authors to show that one may hope for a radical cure after operation, if total extirpation of the uterus is done sufficiently early. Provided the parametrium is not invaded operation may be successful. Up to the sixth or seventh month hysterectomy of the pregnant uterus

does not differ much from the operation in uncomplicated cases. After that time the uterus may be easily emptied during the operation. A vaginal operation has the advantage that the operator can see just what he is doing. The chances of peritoneal infection during the operation are much reduced. The authors' résumé is as follows: 1. In the presence of an operable cancer of the cervix, complicated by pregnancy, it is the duty of the surgeon to operate; by doing a total hysterectomy the mother has a chance of being saved; the chances of the life of the fetus, in case the pregnancy is allowed to go on, are very much reduced. 2. If the parametrium is involved the mother has no chance of life, and the fetus alone need be considered. 3. In the sixth or seventh month, if delay will not endanger the mother, the pregnancy may be allowed to go to term. 4. The operation to be preferred is vaginal hysterectomy, without incision of the lateral culs-de-sac. 5. After the eighth month it is best to perform abdominal hysterectomy, on account of the size of the child.

The Status of Perforation of the Living Child as an Aid to Labor. -Rudolf Katz (Monatsschr. für Geb. u. Gyn., April) defends perforation of the living child in difficult labors as it has been made use of in the Maternity Hospital of Mannheim. Veit has stated that every case that might lead to the necessity for perforation should be taken to a good hospital, and treated by symphyseotomy or Cesarean section, so as to obtain a living child. The author contends that there are cases in which it is impossible to avoid doing a perforation. Such cases are those in which the patient has been under the care of a midwife or a physician for many hours, in which many examinations have been made with unclean hands, fever has set in, or the bladder or uterus has been injured in attempts at delivery. Such cases are very unfavorable for operation of any kind, and perforation is the most rapid and promises the best results. In many cases there is a probability that the child would not live, even if successfully delivered by Cesarean section. The mortality of Cesarean section of symphseotomy would be nil were all cases operated on when the patient was free from fever and in good general condition. But such is far from being the case in the service of a maternity hospital. The statistics of the Maternity of Mannheim give these results: Of 6,935 cases delivered, 26 perforations, 0.37 per cent.; mortality of mother, 7.69 per cent.; living child obtained in 63 per cent. The mortality of Cesarean section for the last ten years was 10 per cent. This shows the mortality of perforation to be less than that of Cesarean section. That of symphyseotomy has been given also as 10 per cent. Symphyseotomy also has the disadvantages of being far from free from danger, having a long convalescence, and being liable to cause impaired bladder functions. Another element that has to be considered is the prejudice among the public and physicians against Cesarean section. Many women who are brought to a hospital refuse absolutely to submit to a section. They cannot be turned away, and something must be done to deliver them. The

indications that were considered to justify perforation, in the 26 cases that were operated on in this way in the Maternity, were: Rise of temperature, bad general condition of the mother, eclampsia, threatened rupture of the uterus. Of twenty cases, narrowed pelvis existed in all. If a pelvis is so contracted that delivery is impossible, the patient and physician think only of a Cesarean section; if the deformity is less, they attempt delivery by other means, and often the patient is reduced to a low condition before she will submit to a radical interference. Hence, the author concludes that it is the duty of obstetricians to popularize as much as possible the idea of Cesarean section as the best method of securing a living child, but that there will still remain many cases that must be delivered by perforation, on account of the impracticability of using other means.

Experimental Hydramnion in Nephritis.-Eugene Bibergeil (Berl. Klin. Woch., April 10) gives the results of experiments made on two dogs, by producing nephritis by the use of a drug, and then examining both mother and fetus as to the presence of ascites. Hydramnion is known to be the result of fetal mal-development, which results in derangements of the life processes of the mother. Nevertheless, spontaneous interruption of the pregnancy is rare. In both cases experimented on nephritis was produced in the mother, changes in the fetal kidneys, hydropsy (ascites and hydrothorax) in the mothers, a small amount of effusion in the fetuses. The amniotic fluid was increased in amount in both mothers. The author draws the conclusion that nephritis may not only produce effusion into the tissues and cavities of the mother, but may also increase the amount of amniotic fluid, and hence may be one cause of hydramnion, at the same time producing effusions in the fetus.

Etiology and Therapy of Urogenital Fistula in Women.-Oscar Vertes (Monatsschr. für Geb. und Gyn., April) considers the etiological factors at work to produce a urogenital fistula, and describes 24 cases seen by him. Of these 24 cases, 20 were the result of labor, 4 of the use of pessaries. Of these 20 cases, 13 were deformed pelves. One was narrowed relatively to the size of the child. In long labors, that have been badly conducted, the pressure on the soft parts of the pelvis produces a necrosis that ends in fistula. It is generally the pressure of the hard skull presenting that causes the necrosis. In 15 of the 20 cases the child's head presented. An operative intervention may also contribute to the formation of the fistula. Of the 20 cases, only two were spontaneous births. The use of forceps is generally necessitated. A sharp instrument used to perforate the skull may be the cause. It is difficult to tell whether the pressure of the head or the instruments was the real cause of the injury. There are several facts that go to show that the injury was by instruments: if the escape of urine begins at once after labor, it is probable that the instrumental interference was the cause. When it results from a pressure necrosis it does not appear for from 3-6 days

after delivery. Of 18 instrumental deliveries, 10 were done with forceps. Atresia of the vagina and formation of large cicatrices go to show that the instruments caused the fistula. In forceps operations the fistula occurs in the lower third of the vaginal wall, while in spontaneous delivery it occurs higher up. Usually there is a combination of pressure and violence of instrumental interference responsible for the injury. Four cases were the result of pessaries pressing too severely and too long on the vaginal walls. As to the operative treatment of these cases, kolpokleisis was the first effective operation proposed; but it was found to occasion serious complications, such as pyelonephritis and nephritis. Laparotomy has been proposed, to bring the fistula better into view. Many cases may be cured by the method of freshening the edges of the fistula and closing them. Total extirpation has been proposed, and is done in cases of women who have passed the menopause, as in two cases produced by the pessary. It seems a serious operation to propose where the menstrual life is not over, but we must remember that some of these cases are cut off from all society and all the usual forms of activity, by the severity of their injuries; and in these cases total extirpation will restore them to usefulness. Of the author's 20 cases, total extirpation was done 7 times. In 7 cases the freshening method was successful. In 5 cases no operation was attempted. Fourteen cases were cured, 4 were not helped, I died.

GYNECOLOGY.

Prolapse of the Uterus.-J. Henrotay (Bull. de la Soc. Belge de Gyn. et d'Obst., T. XV., No. 1) records a most unusual case of total prolapse of the uterus. The patient was only nineteen years of age; her menstrual history was normal. She denied having had sexual intercourse, and had had no previous illness, save an attack apparently of erythema nodosum. She had been for eight years an ironer, standing at her work. The prolapse had been observed by her two years before consultation and had gradually become total.

Menstruation and Immature Red Blood Cells.-Teobaldo Soli (Annali di Ostet. Gin., March) has examined two series of patients, making 194 examinations of the blood, in order to determine whether there is an increase of immature red blood corpuscles in the blood of menstruating females. Several authors have claimed that there is a menstrual anemia, and that to supply the place of the blood lost at the catamenia, the blood-producing organs put forth numerous immature blood cells. The first series of observations was on four women, lasting over a period of 40 days, including two menstrual periods and the time between them. Patients were selected that were normal in every way, and the examinations were made each day under the same conditions. The second series comprised 10 women, whose blood was examined before, during, and after menstruation. Out of the 194 ex