ing a little more than on previous days. An examination with a Sims' speculum revealed a malodorous discharge from the left lateral fornix of the roof of the vagina. The temperature was elevated one degree. Daily irrigation for a week ended the trouble. In both cases he is confident latent mild infection was responsible for the hemorrhage.

In no other instance has hemorrhage occurred, and he has the utmost faith in the hemostatic properties of the instrument.

The advantages of the electro-thermic angiotribe of Downes in pelvic and abdominal surgery seem to be a more reliable hemostasis than by ligation; freedom from hemorrhage during operation; the ease of its application in locations in which the use of ligatures would be very difficult and uncertain; the greater security against dissemination in radical operations for malignant disease; the ability to sterilize unclean areas before suturing, as in intestinal and appendiceal surgery; lessening the tendency to the formation of post-operative adhesions; the increased speed in operations, such as removal of the uterus, the appendages, or the vermiform appendix, and the greatly lessened amount of pain following operation.

The disadvantages are the danger of accidental injury of the bladder, rectum, and ureter; the necessity of great precision in its employment, and the special care necessary to keep the paraphernalia in good working condition.

DISCUSSION: Dr. Andrew J. Downes, of Philadelphia, in speaking of his instruments, stated that for four years he has not used a ligature except in the case of a woman upon whom he operated for extra-uterine pregnancy, and who was moribund at the time. He has performed intestinal anastomosis and gastroenterostomies with these instruments; other surgeons have removed gall-bladders, kidneys, etc., with them as aids. Personally, he has done four or five hundred hysterectomies with them,, while other surgeons have performed seventy hysterectomies with them.

He does not think hemorrhage in two cases reported by Dr. Bovee can be attributed to the use of this method.

Dr. Charles P. Noble, of Philadelphia, has used the Downes' instruments a number of times in cases of removal of the uterus for cancer, and said they are a great advance in this operation. They possess a number of advantages over the application of the ligature. The chief advantage of the clamps over the ligature is that after the uterine arteries are tied on each side, when one comes down to the vaginal plexus, which is the most troublesome part of the operation when the ligature is used, the veins. are apt to leak and flood the field, requiring a number of ligatures to secure hemostasis around the cut vagina. If these instruments are used, the field will be perfectly dry. There is no trouble from hemorrhage.

From the standpoint of recurrence of cancer, the instruments have not been used long enough to give figures as to results; but one can believe from the work of Byrne that much better results can be obtained with the aid of these instruments than with ligatures, etc.

Dr. Howard A. Kelly, of Baltimore, said he saw Keith, of Edinburgh, in 1887, remove an ovarian tumor with Skene's instruments; that those instruments were not satisfactory, and when Dr. Downes brought out his instruments he procured a set of them and has found them satisfactory, with the exception that he has not been able as yet to install a satisfactory plant in the Johns Hopkins Hospital for their use. While the Downes' instruments are practical and useful in surgical work, he thinks if surgeons exercise more care as to the character of ligatures they use daily, it will limit the use of the Downes' method of instrumentation. He referred to the importance of using fine silk ligatures which control bleeding from large blood-vessels, and are practically innocuous.

OPERATION FOR LARGE RECTOCELE:-Dr. George H. Noble, of Atlanta, Ga., presented the technique of an operation which is intended only for large rectocele. Small rectocele is relieved by the ordinary perineal operations. In large rectocele not infrequently there is more or less tediousness, loss of blood in the denudation, and certain objections to puckering the overstretched and distended tissues together and forcing them into the rectum.

Furthermore, there are unsatisfactory results by infecting the strong and resisting recto-vaginal septum.

This operation is presented for the purpose of overcoming those objections. In the technique it will be observed that the rectocele is actually resected, and that the strong or normal recto-vaginal septum above the weak occluding point is drawn down to the level of the levator ani muscle and securely anchored. The steps are: (1) A thorough dilatation of the anus. and recleansing of the rectum. (2) Denudation of a wide collar, as it were, the ring around the neck of the rectocele, beginning high up in the vagina and extending near to the promontory of the rectocele. It is unnecessary to remove the mucosa over the last point mentioned, as it is cut away in the resection. By proceeding with the denudation from within outward, the veins of the recto-vaginal septum are cut through at a high point and secured with compression forceps, and the necessity of repeatedly cutting the same vessels in the process in repairing the wound is avoided. (3) Two fingers are placed upon the promontory of the rectocele, carried into the vagina, and out through the anus, forcing the retrocele ahead of them, and in this way completely everting it through the anus. It is seized with a pair of forceps at the point where it protrudes and is gradually drawn down step by step until the lax portions are secured and a feeling of tenseness is felt. If in drawing the anterior rectal wall down the normal parts of the rectum do not come as low as the levator ani, the rectum should be liberated by dissecting it from the vagina, which will permit of further descent and allow all of the overstretched tissues to project beyond the anus. (4) A light pair of compression forceps is then placed upon the neck of the rectocele just external to the anus for the purpose of holding it in position. (5) Two sutures, preferably medium sized kangaroo tendon, are passed through the unruptured portion of the perineum close to the sphincter ani muscle after the manner Emmet inserts his tension sutures in perineorrhaphy. These two sutures in passing across from side to side should take up the prolapsed portion of the anterior wall of the rectum. When tied, they closely approximate and anchor sound or healthy

rectum to the levator ani muscle and rectal vessels in the deep pelvic fascia. (6) The vaginal side of the wound is completed by doing perineorrhaphy. The protruding rectocele is amputated about three quarters to an inch external to the clamp, and its edges closely sutured with a continuous suture of catgut. The case is then treated as an ordinary perineorrhaphy, except that a wet soft dressing is placed over the protruding stump. The stump retracts within the anus in a week's time and takes care of itself.

The author reports five cases in which he has done this operation, with very satisfactory results.

STARVATION AND LOCKED BOWELS FOR FROM TEN DAYS TO Two WEEKS:- Dr. Howard A. Kelly, of Baltimore, offers for a more extended trial in other fields as well, a method of aftertreatment which he has used in some 15 cases, for the most part in complete tears of the recto-vaginal septum. The treatment consists in two parts- - first, a very limited diet for from ten to fifteen days; second, the locking-up of the bowels during this period. The food is limited to albumin and water, giving nothing the day following operation, and but one dram every three hours on the second day, and increasing this a dram each day until the patient is taking four drams every three hours. In this way the patient is fed in all in a period of ten days, not quite three pints of albumin and absolutely no other food. One patient was continued for fifteen days on this diet without an evacuation. At least two very frail patients were treated in this way. When the evacuation takes place, two drams of licorice powder are given and in some cases an oil enema, and the passage is secured with the patient lying on her side so as to avoid any straining. In no case was there any scybala, or any difficulty with the evacuations.

Dr. Kelly thinks this starvation plan of treatment should have a wider range of utility in treating dyspeptics and cases of hysteria, as well as in all kinds of plastic operations on the intestinal tract.

SURGICAL TREATMENT OF CANCER OF THE HEAD AND NECK, WITH A SUMMARY OF 128 OPERATIONS PERFORMED UPON H10

CASES: Dr. George W. Crile, of Cleveland, O., presented general conclusions, that since the head and neck present an exposed field, cancer here, unlike that of the stomach, the intestines, or even the breast, may be recognized at its very beginning. Every case is at some time curable by complete excision. The field of regional metastasis is exceptionally accessible; that cancer rarely penetrates beyond the extraordinary lymphatic collar of the neck; that the growth tends to remain here localized, and that by freely utilizing all the modern resources of surgery, and by applying the same comprehensive block dissection, as in the radical operation for breast cancer, the final outcome in the surgical treatment of cancer of the head and neck should be not only as good, but even better than that of almost any other portion of the body.

WANDERING OR ABERRANT RETROPERITONEAL FIBROID TUMORS OF UTERINE ORIGIN:-Dr. I. S. Stone, of Washington, D. C., stated that these tumors must reach the space behind the peritoneum by way of the broad ligament. This route is the only one open and is necessarily followed by every fibroid which escapes into any part of the retro-peritoneal space, however remote. After a fibroid becomes well separated from the uterus, it usually remains in the broad ligament indefinitely and will always do so unless other tumors develop in the uterus and are forced to follow directly in the same channel as the one preceding. It will be observed that single tumors are generally found in the broad ligament and the development of others must occur before we can have the variety we are studying. Many sub-peritoneal tumors are seen and few indeed have been noticed where the tumor has lost all connection with the uterus. Such growths cannot become parasitic and receive their nutrition from some other source, as does the intra-peritoneal wandering or parasitic variety. He has no experience with a single wandering tumor behind the peritoneum which has entirely lost its uterine connections, and believes such development an impossibility for the reason mentioned above, that a vis a tergo must exist. The movement of these tumors is therefore directly opposite to that of the intra-peritoneal variety, for the latter must have either