less; fatal cases have occurred and, besides, urinary fistulæ form which do not close. Since the urine was acid, the case_could not have been one of vesical catarrh. In non-tubercular ulcers, simpler measures should be employed; e. g., making an artificial vesico-vaginal fistula. He thought the excision of a piece the size of the palm of the hand is more dangerous than the high lithotomy operation.

DR. VEIT (Berlin) did not think the high lithotomy operation on the female bladder particularly grave; he had seen it performed three times. Nor were there any difficulties in closing the wound subsequently; he thought such ulcers could be cured by permanent drainage or the formation of an artificial fistula. At all events, something had to be done; high lithotomy would be appropriate if neither drainage nor artificial fistula proved effective. DR. HIRSCHBERG could see no difference between the male and female bladder with reference to the high lithotomy operation, and still maintained that it was not free from danger. Besides, tuberculosis of the urinary organs extends from above downwards; for this reason, too, he would abstain from operating. He had twice curetted the bladder without ill effect.

DR. SCHATZ did not think curetting practicable, owing to the large, broad surface. A permanent cure could, of course, not be expected in his case. The corresponding kidney was certainly diseased. As regards the high lithotomy operation, there was indeed a difference between the male and female bladder. In the female, the bladder is a large sac from which a piece the size of the palm of the hand might well be excised.

DR. ZEISS (Erfurt) read a paper on

THE ALEXANDER-ADAMS OPERATION.

The operation has attracted little attention in Germany, although it should not be lightly rejected. The reader first discussed the objections raised against the operation. It has been said that in retroflexion of the uterus the relaxation of the retrouterine ligaments had not been considered. But it is necessary, after the operation, if it is to be effective, to insert a pessary and fasten the cervix behind, thus allowing the ligaments to recuperate. It has also been objected that one anomalous position is simply substituted for another; but it will be possible to avoid this extreme through the dexterity acquired by practice. Fritsch maintained that treatment by pessaries could take the place of the operation. The reader does not believe that pessaries would always have this certain effect. He then spoke of his operations, one of which was a case of subinvolution after abortion in the fourth month; although a small hernia had formed on one side, the uterus was normal in position, with a small amount of descensus. The second patient had discarded the pessary for the last two months; the position of the uterus is normal. The reader thought that his results entitled him to champion the cause of the operation. With reference to the indications, he stated that we possess already some very good methods of operation for prolap

sus.

DR. SLAVIANSKY (St. Petersburg) reported concerning his own operations. In the third case, he did not find the round ligaments; in the fourth, he found them with difficulty; in the fifth, he found them readily. Doléris failed to find them in the dead subject. Altogether, among nine cases, the speaker failed to find the round ligaments in two cases; in four or five cases he had great difficulty in finding them. But where the ligaments are present, the operation is easily performed; the ligament can be drawn out to a length of eleven centimetres without encountering the peritoneal envelope. He had not yet performed the operation for prolapsus. Where he failed to find the ligaments, he inserted a pessary and kept the patients in bed for a month. In these cases the retroflexion persisted. The speaker summarized his opinion in this, that the operation is appropriate for certain cases of retroflexion with free mobility of the uterus, if it can be done; but thus far it is impossible to know the latter beforehand.

DR. KUESTNER had done the operation twice, and in one case had reinserted the pessary after the operation. While the patient was still in bed, the uterus again became retroflexed; he dispenses with the intrauterine stem pessary. He holds that in those cases where the pessary is useless the operation likewise fails. Only in those cases in which the uterus could be easily replaced, and the patient is to be spared the wearing of a pessary, would the operation be appropriate. He had had no difficulty in finding the round ligaments, perhaps because he makes his first incision in a different way. The course was always apyrexial.

DR. SLAVIANSKY added that the operation often runs smoothly in a few cases, then difficulties are encountered. When the ligaments have been drawn out for six centimetres, we are still uncertain whether we really have hold of them, as the uterus fails to move; it does so only when ten centimetres have been pulled out. Time will have to elucidate the subject.

DR. MUNDÉ (New York) had found the ligaments readily in his first case; then he failed in several cases. His assistants likewise did not find them from without, even in the dead subject. In those cases in which the drawing out of the ligaments had succeeded, the result had been good. The operation is indicated when pessaries no longer suffice. He had operated in eight cases.

DR. KUESTNER detaches the fat from the round ligament by stirring with a sound, and he believes that he has succeeded in finding it.

DR. WINCKEL enumerated the following objections to the operation:

1. Persons who have undergone the operation must continue to wear their pessary.

2. One of the patients has suffered a hernia from it.

3. It is impossible to calculate how soon the stretching of the ligaments will recur. The operation is still too young, and in the case of prolapsus, starting from false premises, has been again abandoned. On the strength of the German operations we are not justified to speak of successes; the subject is still too recent. DR. SKUTSCH (Jena) read a paper on

MEASUREMENT OF THE PELVIS-A METHOD OF MEASURING ALL THE PELVIC DIAMETERS.

Despite the many experiments made in this direction, we are generally unable to measure the pelvis with that exactness and fa

cility which are desirable in view of the importance of the subject

This matter has recently gained in prominence by the improvements made in the Cesarean operation which permit its performance where the indications are relative. The effort to improve the reliability of our diagnosis as to the narrowing of the pelvis is therefore particularly justifiable at the present time.

The older methods of measurement confined themselves almost exclusively to the determination of the conjugate diameters, but the knowledge of the other, especially the transverse diameters, is equally important. Our requirements can be satisfied only by a knowledge of the narrowness or width of the entire pelvic canal.

The author then entered more fully into Kuestner's method (Arch. f. Gyn., XVII.) of measuring all the dimensions of the lesser pelvis in the living woman, and Freund's method of determining the transverse diameter of the pelvic inlet, by means of a flexible leaden rod; these contained the fundamental ideas of his own method. He started with the following reflection: Generally it is not feasible to make the two terminal points of the internal pelvic diameters simultaneously accessible to measurement by means of compasses, because the vagina usually cannot bear the necessary tension. But if we succeed in determining the position in the space of each of the terminal points to a fixed third point, one after another, and then in representing outside the pelvis the relation of the terminal points to the same fixed point, we have the means of direct measurement. This can be done by the following apparatus:

To the abdomen of the woman is fastened, by a belt and thigh straps, a concave board resting firmly on the symphysis and the anterior superior spines of the ilei. To this board is then applied the steel slide, the main portion of the apparatus, which has two sleigh-like processes that can be covered by movable slides. Next is inserted into one of the sleighs a rod of pure lead nickel-plated, by means of a steel rail situated at one extremity, and accurately fitting into the sleigh; then the slide moved over it locks it firmly. The other, knob-shaped end of the leaden rod is introduced into the vagina, under the direction of the index and middle fingers (the index finger being in a thimble open in front) and bent to one of the terminal points of the diameter to be measured (e. g., the transverse diameter of the pelvic inlet); then the other, free hand loosens the slide, the rod is liberated, is carefully withdrawn so as not to alter its form, and laid aside. A like leaden rod is then inserted into the other sleigh, bent to the other terminal point of the diameter in the same manner and withdrawn. The main slide is now removed from the pelvic board, and both rods reinserted into the sleighs which they respectively occupied before. The distance of the end points can now be measured directly with a rule. As in every organic measurement, the values obtained are, of

course, not mathematically exact; but the sources of error are as small as possible. The elasticity of the rods is insignificant. Of particular importance is the careful handling of the rods lest they lose their form; the fingers must exert appropriate counter-pressure while the distended soft parts are trying to regain their state of rest. If necessary, the tension of the vulva can be eliminated

by short lateral levers and a grooved speculum. It is advisable, lest the rods interfere with one another when inserted into the main slide, to guide one as far as possible into the right, the other as far as possible into the left half of the pelvis. Measurements made of pregnant and non-pregnant women showed that the re

sults are satisfactory if correctly executed. The apparatus is manufactured by Kirsche, instrument maker, Jena.

DR. KUESTNER exhibited a new pelvimeter, having balls at the ends, with which the measurement of the transverse diameters can be made with ease. If the vagina is distensible enough to allow the pelvic end points to be touched, it must be possible to reach the terminal points of the tranverse diameter also by means of a pair of compasses; in some cases, however, the vagina cannot be stretched to that extent.

DR. FIRNIG (Cologne) exhibited

A SPONDYL-OLISTHETIC PELVIS.

Anna Sophia F., æt. 25, from Apweiler, Co. of Geylenkirchen, District of Aix-la-Chapelle, was received December 25th, 1885. Parents dead; father of an accident, mother of nervous fever. Brothers and sisters, of whom she had several, all died young. She claims to have always been healthy, with the exception of an attack of nervous fever, two years ago. Had learned to walk at the age of one year-a statement subsequently confirmed by her relatives. Menstruation commenced in fourteenth year, always regular, lasting four or five days, not associated with much pain. Early in April, 1885, last period; a few days later, first coitus which led at once to conception. Nausea, vomiting, salivation, heart-burn, headache, toochache in the first month. Quickening first felt about the middle of June, that is, about the end of the fifth or beginning of the sixth month. Movements not specially located. In the last two months dyspnea, but not very great. On Jan. 11th, the patient was presented before the Medical Society of Cologne, with the positive diagnosis of spondyl-olisthetic pelvis. The patient is five feet tall, not very strongly built, but healthy. Features regular, almost handsome. The skeleton shows absolutely no rachitic changes. Chloasma gravidarum on the forehead. Breasts small, rather pendulous, moderately tense. Glandular tissue ample, areola of medium size, plentifully set with sebaceous glands. Nipples good. Milk exudes. Thoracic organs healthy. Abdomen very short and pendulous, covering the vulvar fissure. When the abdomen is lifted, the greater part of the vulvar fissure is visible in the erect position. Distance between the last rib and the crest of the ilium only the width of two fingers. The spinal column runs straight from above downward, having the normal posterior and anterior curvatures in the regions of the neck and thorax. The lumbar portion is very short and strongly curved inwards. On external inspection, the whole pelvis shows no abnormalities except a slight inclination; the sacrum, otherwise normal in form, projects at its upper end backwards at a right angle to the lumbar spine. This step-like protrusion is from two to two and a half centimetres broad, and two fingers can be readily placed upon it. When the patient walks about dressed, every one would think she wears one of those fashionable and