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behind. Available evidence pointed towards posteriorvaginal section as the treatment of chronic hsematoceledistending the pouch of Douglas. Tubo-ovarian cysts,simple papillomatous growths, and salpingo-oophoriticlesions, if accessible from below, could be removed fromthe pouch of Douglas by posterior vaginal section. It wasevident that where there were matting, thickening and firmfixation, especially towards the lateral walls of the pelvis,there was difficulty in securing the pedicle. More room wasobtained by removing the uterus which in infective inflam-mations was often, as Landau had urged, in an incurablestate. Dr. Briggs removed the uterus in two of the casesquoted because of the conditions alluded to. One patientlost her life from hsemorrbage 30 hours after operation ; thehaemorrhage had been concealed behind the cyanide gauzepack. This case was a posterior vaginal section for adherenthydrosalpinx with thickened broad ligaments and an en-

larged stiffened uterus. The specimen was carefully examinedpost mortem ; the stump was apparently securely held by thesilk ligatures still in situ; the end of the stump wasswollen and its margins were recurved; the uterine arterywas tested by injection and water oozed through the vesselsof the stump, but a thicker pigmented starchy solutionwould barely pass. Shrinkage of the stump and difficulty insecuring the proper constriction of thick rigid tissuesrendered tense by forcible traction during operation ex-

plained the incomplete hasmostasis. The results in the casesof removal of the appendages with vaginal fixation forretroversion effected by anterior vaginal section were toorecent to report upon. In the 16 cases there had been onedeath from haemorrhage as reported.-Mr. BURTON had nothimself opened Douglas’s pouch for hoematoceles, as all hiscases during one year got better very well without, and heagreed with Dr. Briggs that they generally did if leftalone; at the same time he was of opinion that by operationthe patient’s stay in hospital would often be shortened. Hehad opened the peritoneum per vaginam six times during theyear for inflammatory tubal affections, removal of enlargedovaries, and once for removal of a dermoid containing about12 ounces of fat. There was less shock than by theabdominal route. By this operation a scar was avoidedas was the danger of ventral hernia in the cicatrix. -Dr. E. T. DAVIES thought that vaginal section was onlypracticable in a minority of cases of pelvic disease-viz., small tumour formations and inflammatory productswhich encroached upon or were adherent to the pelvicfloor, early ectopic pregnancies with recurrent or drippinghaemorrhages, or suppurations which became encapsuledin Douglas’s pouch. These if they do not recover

spontaneously by absorption, as many do, may be

safely and easily opened and drained through the posteriorfornix. The fulminating ectopic ruptures with copioushsemorrhage into the general peritoneal cavity with intensecollapse should always be attacked from above by laparotomy.Pus tubes and ovarian abscesses with dense adhesions to the

pelvic floor might more safely be opened from below. Therecould be no doubt, however, that the abdominal route bylaparotomy offered far greater facilities for precision in

diagnosis, dealing effectively with adhesions and stanchinghaemorrhage, the whole field being so much betterunder the control of the operator than is possible bythe vaginal route.-Dr. GEMMELL referred to the absenceof shock after vaginal section due probably to theabsence of physical irritation of the peritoneum from thecooling and handling of the intestines which was inevitablein abdominal section. He did not agree with the view that

by the abdominal route a better inspection of the field ofoperation could be obtained, for by means of the anteriorvaginal incision the uterus and appendages could be turnedout for inspection and replaced with little or no irritation tothe patient. Whilst convalescence was rapid there was

greater freedom from pain and the vaginal incision cicatrisedearly, yet, just as in abdominal section, the wound did notalways heal by first intention and hernia might occur.-Dr. GRIMSDALE considered that owing to the want ofaccurate diagnosis in pelvic disease the vaginal operationshould be limited to the most simple cases. Slight errorsin accurate diagnosis were more likely to assume graveproportions during vaginal operation than during abdominaloperation. He did not suppose that anyone would contendthat the actual opening of the peritoneum was safer in oneplace than in another. The ease of the operation wouldtherefore be in the long run the measure of the safety of anymethod.-Dr. BRIGGS replied. :

LEEDS AND WEST RIDING MEDICO-CHIRURGICAL SOCIETY.

Malignant Disease of the a’sopltag?ts.--Ex7tibition ofSpeeimens and Lantern IJe11Wnstration.

A PATHOLOGICAL meeting of this society was held onFeb. 17th, Mr. C. J. WRIGHT, Vice-President, being in thechair.

Dr. POWELL WHITE read a short communication on

Malignant Disease of the (Esophagus and showed the follow-ing specimens :-1. Sarcoma of the Pharynx. The primarygrowth was a small ulcer in the right sinus pyriformis; it didnot invade surrounding structures. The glands in the neckformed a mass half as large as the man’s head. There weremetastatic deposits in the liver, lungs, and heart. 2. Lympho-sarcoma of the Mediastinum invading the Heart and the(Esophagus. 3. Cystic Kidneys in an Adult. The left kidneyweighed 4 Ib. 14 oz. and the right 2 Ib.; he thought thattheir origin was a congenital malformation. 4. MultipleDiverticula of the Small Intestine from the same patient asthe cystic kidneys. There were about 30 diverticula situatedalong the mesenteric border of the small intestine; theywere formed by protrusion of the mucous membrane througha deficiency in the muscular coat. 5. Spheroidal-celledCarcinoma of the Upper End of the (Esophagus with Meta-static Deposit in the Stomach.

Dr. BEDFORD PIERCE (York) showed :-1. IntracapsularFracture of the Femur in a male, aged 64 years, the line offracture being immediately below the articular surface of thehead of the bone. In this case there was no shortening untilsome weeks after the injury. 2. Repair of Fracture of theRadius under most unfavourable circumstances, the patientbeing 84 years of age and maniacal, and no treatment waspossible. Nevertheless, the bone had united well. 3. ADiverticulum of the Bladder the cause of which was obscure.The diverticulum was about half the size of the bladder andconnected with it by an opening that would just admit agoose quill. 4. Brain of a Microcephalic Idiot of low type.Dr. Pierce pointed out that the posterior lobes were smallrelatively to the rest of the brain and that they failed tocover the cerebellum. He remarked that the brain whenfirst removed weighed 38 oz. and that after being hardenedin formalin for six weeks it had gained 10 oz. in weight.

Mr. GOUGH communicated a short paper in which weredetailed the Microscopical Changes in the LymphaticGlands, Spleen, Liver, and Lungs from a case of Hodgkin’sdisease. The paper was illustrated by microscopical pre-parations.

Dr. WEST SYMES (Halifax) showed a Dermoid Cyst of theOvary containing fully-formed teeth, hair, skin, and bonefrom a patient, aged 39 years. At the operation the cyst wasfound to be very adherent to surrounding structures. Theadherent vermiform appendix was removed with the tumour.The patient was discharged after an uninterrupted recovery.

Dr. CHURTON showed :-(1) A Thoracic Aneurysm whichhad pointed in the axilla ; and (2) the Parts involved in aSubphrenic Abscess.

Dr. R. H. HALL showed a Perforated Gastric Ulcer froma young man, aged 22 years. The symptoms were indefiniteand death rapidly took place.

Dr. EURICH (Bradford) showed :-(1) A Large Ulcer of theStomach, death having been due to haemorrhage ; (2) aPrimary Sarcoma of the Sternum; and (3) a Glioma of theBrain from a boy, aged five years.

Dr. HELLIER showed a specimen of Hsemorrbage into theOvaries and a Skiagram of Congenital Deformity.Dr. EDGERLEY (Menston) showed a specimen of

Forencephaly in which the area involved extended fromconsiderably in front of the position of the anteriorlimb of the Sylvian fissure on the left side to theposterior parietal lobule and from the upper part ofthe second frontal convolution above to the inferior tem-poral sulcus. In this area the brain cortex was entirelyabsent and the white matter was represented only by a thinmembrane separating the cystic space from the lateralventricle on the inner side. The outer wall was formed bythe pia arachnoid membrane. The optic thalamus wasatrophied and the opposite half of the cerebellum was muchreduced in size. The pyramidal tract on the same side wasdiminished in the crus, pons, and medulla. The patient fromwhom the brain was taken had died at the age of 43 yearsand had been a congenital hemiplegic imbecile who had

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suffered from epileptic fits for 15 years before her death.The area involved corresponded to the distribution of themiddle cerebral artery-a fact supporting the theory ofvascular occlusion as a probable cause.Mr. LITTLEWOOD showed among other specimens :-(1)

Tuberculosis of the Flexor Sublimis Tendon secondary toDisease of the Synovial Sheath; (2) a Pedunculated Sub-synovial Lipoma removed from the knee-joint ; and (3) Cystsof the Left Ovary and Half of the Right Ovary also contain-ing Cysts removed from the same patient.

Dr. WARDROP GRIFFITH showed two specimens of Pneu-monic Lung, one of which was associated with infectiveendocarditis ; also specimens of Malformation of the

Tricuspid Valve and of Abnormal Chorda Tendinea in theLeft Ventricle.Mr. MOYNIHAN showed among other specimens:-(1) Three

Examples of Acute Perforating Appendicitis ; (2) Intussus-ception in a dog; (3) Photographs and Watercolour Drawingsfrom cases of Retro-peritoneal Hernia ; and (4) (withDr. GRIFFITH) Right and Left Duodenal Hernias.Mr. MOYNIHAN and Dr. POWELL WHITE showed a Tumour

removed by operation from the Retro-peritoneal Tissuesoccupying the positions of the suprarenal body and kidneywhich were entirely absent ; the mass also extended into thescrotum. Microscopically it consisted of myxomatous tissuecontaining fat and the remairs of glandular epithelium.Mr. WARD and Dr. POWELL WHITE showed a Retro-

peritoneal Tumour removed by operation. Microscopicallyit was a lympho-sarcoma.

Mr. WALTER THOMPSON showed an Epithelioma of theUpper Jaw arising from the nasal surface.

Dr. ALLAN showed among other specimens :-(1) TheIntestines from a case of Typhoid Fever in a woman, aged70 years ; (2) Ulcerative Colitis apparently due to Influenza ;and (3) a Collar-like Stricture in the Lower Part of the

(Esophagus.Dr. BRONNER (Bradford) showed numerous microscopic

specimens demonstrating the Various Growths of the Naxes-sarcoma, cylindroma, papilloma, myoma, adenoma, carci-noma, tuberculous growths, &c. ; also specimens illustratingthe degenerative and hypertrophic changes which take place Iin the mucous membrane of the nares. I

Dr. TREVELYAN showed :-(1) Diphtheria Bacilli from acase of Membranous Stomatitis without involvement of theFauces ; and (2) True Hypertrophy of One Lung from aCase of Long-standing Quiescent Disease of the other Lung.

Dr. TREVELYAN and Mr. SECKER WALKER showedSections through the Cerebrum and Cerebellum from a caseof Suspected Intracranial Abscess. There was no abscessfound, although during life the symptoms were so marked asto necessitate an exploratory operation. The specimenshowed considerable haemorrhage along the tracks of the

exploring trocar. No gross lesion such as would accountfor death was found in the body. More than 40 micro-scopic preparations were shown illustrating the naked-eyespecimens.

Professor BIRCH gave a lantern demonstration on the Com-moner Blood Spectra produced by Drugs and Poisons.New specimens recently added to the Anatomical and

Pathological Museums were shown by Dr. GRIFFITH andDr. TREVELYAN respectively.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF SURGERY.

Dislocations and Fractures of the Astraga11ls.-Excision ofthe 6’<BCMNt.

A MEETING of this section was held on Jan. 20th,Mr. R. L. SWAN, the President, being in the chair.

Mr. H. GRAY CROLY read a paper on Dislocations andFractures of the Astragalus, giving a history of several cases.In one case fracture of the body of the astragalus was causedby a horse falling on a man’s foot which was caught in thestirrup. Mr. Croly excised the bone and the man wasenabled to resume his work as a groom. In a case of com-pound luxation of the astragalus forwards and outwards thebone was completely displaced from all its attachments ; thehead and neck of the bone protruded. Mr. Croly excised theastragalus. The accident was caused by the man jumping froma vehicle and alighting on his heel; the foot was forcibly

inverted ; the internal malleolus was completely buried ; thepatient made an excellent recovery and can walk as well asever. The third case was one of complete simple luxationof the astragalus forwards and outwards. The patient, aman in his sixty-ninth year, slipped off the kerbstone intothe channel, violently twisting his foot inwards. On exami-nation by Mr. Croly 11 days afterwards the right foot wasfound to be forcibly inverted, the head and body of the

astragalus resting on the dorsum of the foot externally ; theskin over the head of the astragalus was red and shining ;the internal malleolus was completely buried, a deep groovetaking its place ; there were two sloughs on the outer sideof the foot (ashy grey) and a large deep slough on theinner side of the foot; there was no movement at theankle ; the patient’s health was much impaired. About twomonths after the injury Mr. Croly excised the astragalus.Immediately on the enucleation of the bone the musclesdrew the foot into its normal position and a suitable splint,with footboard, was applied. The patient made an excellentbut somewhat slow recovery and he now can walk without theaid of a stick ; an extra sole on his boot makes up for the slightshortening ; he has an ankle moveable but perfectly firm.-Mr. LENTAIGNE exhibited a cast of Fracture of the Astragalus.This particular injury was exceedingly rare. It was a fractureof the anterior portion of the astragalus, with displacementforwards and outwards of the fractured head of the bone,and was caused by jumping off a car. After an intervaloperation was allowed. The loose head of the astragalus wasfound to be completely detached from all structures exceptby a few threads of fibrous tissue. The head of the astragaluswas reduced and the wound was closed.-Mr. W. I.WHEELER mentioned a case of Dislocation of the Astragalusbackwards the result of a blow by a cricket ball on the frontof the foot when in the flexed position. He said that Mr.Henry Hancock’s statistics of 109 cases of complete removalof the astragalus for compound dislocation, simple disloca-tion, and disease showed 14’6 per cent. death-rate.-ThePRESIDENT said that he had often had occasion to removethe astragalus for aggravated equino-varus in the adult.Mr. JOHN LENTAIGNE exhibited a patient from whom he

had removed the Caecum and a Small Portion of the Ileumfor Chronic Intestinal Obstruction resulting from Stricture atthe Junction of the Ileum and Cascum. The patient, a girl,aged 12 years, had come under his care on April 16th,1898. She was then in a very miserable condition, vomitingfrequently and rejecting almost all food ; the abdomen wasgreatly distended. The bowels were very constipated, nomotion ever coming except after the administration ofpurgatives followed by enemata. The illness had com-menced two years before. On April 22nd Mr. Lentaigneopened the abdomen in the median line and gave tem-

porary relief by forming an intestinal fistula in two stagesafter first emptying the distended ileum by enterotomy.On incising the gut two large basinfuls of pea-soup-likefoeces flowed out and the intestinal cavity was irrigatedand washed out with a stream of warm water ; the openingwas then closed by silk sutures and the gut was returnedto the abdominal cavity. When emptied and flattenedout the intestine seemed to be about four inches across

from the lower margin to the mesentery. The left hand ofthe operator was introduced into the cavity and directedwell over to the left side ; it was then cut down upon andthe bowel was securely fastened to the opening by a fewsutures passing through the parietal peritoneum, muscle andskin. The incision in the median line was closed with threelayers of sutures, the two deeper of silk for peritoneum andmuscle and the superficial of catgut for the skin, covered bya layer of celloidin. The small opening on the left side ofthe abdomen was kept open by a plug of iodoform gauze andon the third day after operation the fistula was made completeby an incision into the bowel. There was an immediateimprovement in the patient’s condition. The bowels emptiedthemselves continuously through the fistula and the vomitingand attacks of pain ceased almost at once. On June 27th,as the patient had got into a good condition and was anxiousto be relieved of the annoyance of the fistulous opening,excision of the cascum was performed with end-to-end sutureof intestine by Kocher’s method. The bowels acted naturallyfour times on June 29th and almost every day after. Theintestinal fistula closed of itself as soon as the bowels acted

normally and on July 12th it had practically closed, neitherfseces nor flatus coming through it. It was now representedby a firm, clean scar, no trace of the opening existing. The

patient was in excellent health and condition, the bowels