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until after the foetus has been extracted. Any rota-tion is carefully rectified, and a small incision madein the median line until the membranes (which must notbe ruptured) are reached. Next the incision is enlargedupwards and downwards on a bistoury, the hand intro-duced, and the child extracted. The uterus is now broughtout and thoroughly emptied of placenta and membranes.The edges of the uterine incision are everted by an assistantand deep carbolised silk sutures inserted, with, if necessary,a few superficial catgut ones. He strongly deprecated anyinterference with the uterus after the operation by usingintra-uterine douches or by the introduction of a drainage-tube. The debate was then adjourned to the next meeting.

ROYAL ACADEMY OF MEDICINE IN IRELAND.

A MEETING of the Obstetrical Section was held onFeb. 12th, Dr. Horne, President, in the chair.Exhibits.-Dr. W. SMYLY : (a) Six cases of Pyosalpinx ;

(b) Three Uteri Extirpated for Cancer.Dr. MACAN: (a) Fibrocysbic Tumour of Uterus;

(b) Double Dermoid Cysts of Ovary ; (c) Dermoid Cyst ofOvary with Cancerous Degeneration of Cyst Wall.Notes of a Case of Ruptured Uterus, with Recovery.-

Dr. BARRY said : "The patient, aged thirty-five, a primi-para, was thirty-eight hours in labour when I saw her; liquoramnii had drained away early in labour. On making adigital examination, os uteri about the size of a florin,thick and rigid. On passing my finger through the osuteri I detected a tear passing in an oblique direction forabout four inches. No prolapse of intestine. Promontoryof the sacrum easily felt, with vertex presenting at thebrim of the pelvis. Conjugate diameter measured threeinches. Having passed a catheter and drawn off about apint of bloody urine, I got an assistant to steady the uterus.Keeping pressure in the axis of the brim of the pelvis, Iincised that portion between the os uteri and the tear.

Applying forceps, I failed to deliver. Perforated head,when an easy delivery was effected, but considerable diffi-culty was experienced in extracting the shoulders. Theplacenta, which was morbidly adherent, was attachedto the fundus and slightly posteriorly. The patient madea good recovery. I saw her three months after delivery,when, on examination, the uterus was found normalin size and position, menstruation being normal andpainless. Os externum quite small, admitting withdifficulty the point of a sound, very little evidenceof rupture remaining."- Dr. ATTHILL said the case as idescribed by Dr. Barry was a remarkable one, and, asfar as he (Dr. Atthill) was aware, no similar one hadbeen recorded. Here was a woman thirty-eight hoursin labour, and in whom the waters had long beforedrained away, with so small a conjugate diameter that thehead never came in contact with the os, yet a rent occurredin a position so situated that the finger passed into the oscould detect it; it evidently was a rupture of the cervix.How it could have occurred under the conditions detailedDr. Atthill was unable to explain.

’

Focal Fistula following the Removal of AbdominalTumours.-Mr. M’ARDLE read a paper on this subject. Afterdetailing cases of this trouble he explained that the condi-tion seemed to be due to extension of suppuration from thetumour into the intestine, ulceration from the intestineextending into the tumour, local necrosis of the bowel walldue to pressure of the tumour, tearing of the coats of thebowel during the operation, disturbance of the nutrition ofthe bowel owing to injury of the vessels of the intestine,and constant pressure of-the glass drainage-tube in contactwith the bowel. In reference to the treatment, Mr. M’Ardlesaid : " The situation of the opening in the bowel will morethan any other circumstance determine the extent ofsurgical interference. While referring to this matter, thereis one method of determining the site of perforation whichdoes not seem to be as generally recognised as it deserves.I refer to inflation with hydrogen gas. As a diagnostic aid,gaseous distension is infinitely superior to the injection offluids, since it does not interfere with the steps of anyoperation which may be deemed necessary after its use,while fluids are a source of constant annoyance duringsuture of the bowel. Often the character of the dischargesuffices to show the position of the opening; at othertimes the relation the intestines bear to the tumour

indicates the locality of the fistula. When the open.ing is in the rectum, closure is almost certain, owingto (a) fixity of this portion of the gut, (b) great vascularsupply, and (c) the chance of extra-peritoneal healing,hence early operative interference is contraindicated."-Dr. ATTHILL had met with three cases of fsecal fistula inhis practice. In one of them the case had been diagnosedas one of suppurating ovarian tumour. The operation wasperformed under very unfavourable circumstances, thetemperature before it being 103°. The tumour proved to bea suppurating one, and in addition there also was a deep-seated pelvic abscess, which during the removal of thetumour ruptured, discharging very fetid pus. In this casefseces were discharged through the wound on the fifteenthday after the operation. Dr. Atthill thought in this case itwas due to the softening of the intestines at the seat of thepelvic abscess. This patient recovered perfectly, the fistulaclosing in about six months. In the second case the fistulaformed on the tenth day after the operation, the tumourbeing a small ovarian one, very firmly bound down byadhesions in the left inguinal fossa. An operation to curethe fistula was performed nearly a year after, which endedfatally. The third case was one which occurred seven daysafter vaginal hysterectomy for malignant disease. Thefseees were discharged per vaginam for a few days; the fistulathen closed.

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Reviews and Notices of Books.A Treatise on the Ligation of the Great Arteries in Con-

tinuity, with Observations on the Nature, Progress, andTreatment of Aneurysm. By CHARLES A. BALLANCE,M.S. Lond., F. R. C. S., Assistant Surgeon to St. Thomas’sHospital; and WALTER EDMUNDS, M.A., M.C. Cantab.,&c., F.R.C.S., Resident Medical Officer at St. Thomas’sHome. Illustrated by 10 Plates and 232 Figures.London: Macmillan and Co. 1891.

FOR many reasons the pathological and clinical questionswhich arise in connexion with the ligature of large arteriesare, and will probably always continue to be, of greatinterest and importance. Although the introduction of

antiseptic surgery has profoundly influenced the course ofwounds and the results of operations, it has not as yet beenfollowed by those perfect results in cases of ligature ofgreat arteries that have been obtained with other tissues.The authors of this work are able to show that eventhe most recent results of operations upon great arteriesare by no means satisfactory, and that the danger ofsecondary haemorrhage is still a very real and pressing one.The chief object of Messrs. Ballance and Edmunds is toshow how this failure comes about, and how it may beavoided. To obtain the solution of these problems theyhave carried out an elaborate series of experiments whichhave occupied them for six years, and which they in thistreatise fully detail. The main results they have obtainedare not new, although they are now supported by exact andminute observations, which were not possible in earlier days.Since the publication in 1810 of Jones’s classical work onHaemorrhage, surgeons have generally sought so to tie theirligatures as to rupture the inner and middle tunics of thearteries, and have regarded such a rupture as an additionalsecurity. On looking back it is evident that such a

conclusion was too hastily arrived at. Jones’s experi-ments were not completed, and his dicta were opposed tothe clinical experience of some of the leading surgeons ofthe day. So it has always been. Men arise from timeto time whose writings have an undue influence upontheir fellows, whose opinions are accepted too readilyand too generally, and Jones seems to have been ofthis number. For nearly a century his work and his

teaching have been unquestioned, and have formed the basisfor the surgical treatment of arteries in Europe and America.The experiments of Messrs. Ballance and Edmunds show-we think conclusively-that the division of any portion of as