PATHOGENESIS OF EPILEPTIC IDIOCY. r z i o8 abdominal wall, and it was opened by a clean vertical incision. After the delivery of the child, the hand was passed into the organ and the cervix carefully examined. Two rows of cat-.gut'sutures were applied to secure the uterine wound, and the haemorrhage was arrested by careful sponge pressure .before closing the external incision. The abdominal wall was united with three layers of continuous catgut sutures, and a superficial row of interrupted silk

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... stitches. The vagina was leleansed from blood clot, and wiped out with antiseptic .,gauze, and a piece saturated with iodoform emulsion was inserted into the canal. The abdomen was dressed just as after an ordinary ovariotomy. No'sickne"ss followed the operation, and the temperature .never rose to 1OI°. The patient sat up at the end of the fourth week, and left the hospital soon afterwards in good .healtb. REMARKS. The surgical treatment of labour, associated with severe pelvic deformity, has been in British practice mainly regulated by the possibility or otherwise of performing a mutilating operation. Craniotomy has been successfully accomplished in cases in which the conjugate diameter has measured less than 2 inches, and the transverse 3 inches, or a little over. Dr. Playfair states I that on the Continent a4sesarean section has been selected when the antero-posterior -diameter measured 2 inches ; and that some foreign authors, in cases where the child has been known to be alive, have iecommended its performance, even when the conjugate -diameter amounted to 3 inches. From these statements it is evident that the practice of different countries has been hitherto marked by considerable variation, and that obstetricians have regarded the diameters of the pelvis as Their chief guide. Whenever examination has clearly revealed that a patient was labouring under considerable deformity a careful estimation of the pelvic dimensions was accepted as the essential basis for settling the question between crani--otomy and Caesarean section; and if it could be demonstrated that sufficient room existed for the delivery of a collapsed cranium by forcible extraction, craniotomy has been gener--ally recognised in this country as the correct procedure. Up to the present time British practitioners have regarded -eraniotomy as the safer alternative for the mother in all cases of severe pelvic distortion. Variable results, however, have 'been recorded by different authorities, and statistics prove that it must be considered a very risky operation. Dieterman, -of Berlin, has given an account of 239 craniotomies, with a mortality of 12 per cent. His own mortality from 1882 to i887 :he states to have been 9.4 per cent. Recent statistics from Leipzig present a mortality of 8 per cent. In the report of ,Guy's Lying-in Charity it is mentioned that the mortality sfter craniotomy from I865 to I875 amounted to 6 out of i8 cases, or 33.3 per cent. In the report of the same charity, 4rom x875 to I885, 24 cases are reported with 4 deaths, or a mnortality of i6.6 per cent. I have been unable to obtain any reliable information respecting the comparative mortality of craniotomy and -Cesarean section in this country, and it is my opinion that any existing statistics would prove at the present time practically valueless, as abdominal section followed by extraction -of the foetus though an artificial opening in the parietes of the uterus has frequently been performed when the patient has been exhausted by delay, and after many unsuccessful efforts to deliver the child piecemeal per vias naturale8. This is, doubtless, the explanation of the high mortality of the -operation up to recent times. Fifty-fve years ago Dr. Edward Rigby wrote2: "There is no doubt but that in England it has been peculiarly unsuccessful......and there is -every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. In France and some other nations upon the European Continent the CLesarean operation has been and continues to be performed where British practitioners do not think it indi--eated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and -frequent repetition of tormenting though unavailing pains, -and before her life is endangered by the accession of inflamma-'tion of the abdominal cavity." The separate results of these operations in the future will help to define clearly when craniotomy or any other form of mutilating operation is justifiable, and'how far it is lik8j to be superseded by Caesarean section. The recent recordsJf abdominal section received from America, are very. f4vodirable. Dr. W. Myers3 gives a statement of twenty operatiops, resulting in the saving of eighteen mothers, a mortality of io per cent.; nineteen of the children were also saved, mortality 5 per cent. Surely the indications for selecting craniotomy are very different now from what they were before themodern developments of abdominal surgery; and we can rightfully anticipate that recent advances will exercise an increasing influence upon this question. In the near future, I believe that Caesarean section will prove as safe a surgical proceeding as craniotomy to the mother, and that it will be practised more generally in this country. Unfortunately I must admit that there may be circumstances in which delivery by craniotomy is the only possible method of treatment. Caesarean section requires all the preparation and all the surgical appliances which are essential for any other abdominal operation, and the surroundings of the patient may render it impracticable. Cases of great emergency may sometimes happen in distant parts of the country where little help is available, and where the requisites for a serious surgical procedure cannot be obtained. Under these conditions, a mutilating operation may be the only proceeding which can be resorted to with the hope of saving the life of the mother.