Cæsarean operations in Glasgow was due to the greater frequency of the graver degrees of pelvic deformity; for happily dwellers in Edinburgh were not so subject especially to rickets. The restriction of embryulcia was due not only to improvements on the side of the Cæsarean procedures, which limited the application of embryulcia in the greater degrees of contraction, but also to improvements in the use of forceps, turning, and the indication of premature labour which competed with it in the slighter degrees of contraction. Still, as Dr Jardine had stated, there was a field for the embryulcia procedures, and it was important to have students taught how to carry them out. He (Prof. Simpson) was not sure that he would not have been disposed in Dr Jardine's fourth case to have repeated the embryulcia; but, of course, it was only the obstetrician who had the actual condition of the patient before him who could fairly judge which was best.

Dr Kynoch said with reference to the vulvar hæmorrhagic discharge noticed by Dr Jardine in one of the four children, it was a curious coincidence that in four Cæsarean sections which he had observed, three of them during his term of residency in the Glasgow Maternity Hospital, two of the children had this hæmorrhagic discharge, lasting a few days. He believed the temporary application of the elastic ligature tended to produce subsequent uterine relaxation, and that hæmorrhage was best prevented by thorough sponge pressure on the uterine wall after the removal of

the child.

Dr Jardine, in reply, thanked the Fellows for the kindly way in which they had received his contribution. He said that of the 54 Cæsarean sections performed in the Glasgow Maternity Hospital 53 of them had been done in cases of contracted pelves, with conjugates of 2 in. and under. One had been done by his assistant in a case where anterior vaginal fixation of the uterus, done for retroversion, had prevented the os dilating. Turning and craniotomy had both failed, and the section was done as a last resort. The patient had died on the second day. Last year they had dealt with 40 cases of contracted pelves, all requiring operations. In his fourth case he might have performed craniotomy easily enough, but considering that the woman had already had four craniotomies done, and one of them on an eighth month fœtus, he did not think it would have been right to have continued this destructive work. He thought the result, as regards the mother, would have been the same if craniotomy had been done.

XI. Dr Jardine read a SHORT NOTE OF A CURIOUS CENTRAL TEAR OF THE PERINEUM.-Fourteen years ago this patient was attended in her first confinement by two students from the Maternity Hospital. The patient says that the tear occurred then, but the students, if they observed it, failed to report it, as the labour is entered as a normal one. The present confinement was her eighth.

When the head was at the vulva a band of tissue was seen to be stretched over it, and the nurse slipped this towards the left side, when the head was at once expelled. The eight children have all been born through the abnormal opening, as the normal vulvar cleft has evidently never been distended.

At her first labour the head evidently came through the centre of the perineum, and the tear, instead of passing into the vulva, had extended forward, completely separating the right labium minus along its junction with labium majus. The tear extends as far forwards as the clitoris. The condition does not cause the patient any inconvenience. Until the parts are separated you would hardly notice anything was wrong.

I am indebted to my friend Dr John Lindsay for the excellent drawing. As a curiosity, I think the case is worth publishing as a sort of companion picture to Sir J. Y. Simpson's one of 'central rupture of the perineum.' Besides doing the drawing, Dr Lindsay has furnished me with the following extract from an article on Generation, in Harvey's works, which is very interesting, although we cannot subscribe to his conclusion as to the cause:—

'A white mare of great beauty had been presented to her Serene Highness the Queen, and in order that its symmetry and usefulness might not be impaired by foal-bearing, the grooms, as is the custom, had infibulated the animal with iron rings. This mare (by what chance I know not, nor could the grooms inform me) was got with foal; and at length, when no one suspected anything of the kind, she foaled in the night, and a living foal was found the next morning by the mother's side. When I heard of the circumstance, I went immediately to the place, and found the sides of the vulva still fastened together by the rings, but the whole pudendum on the left side so thrust and torn away from the pelvis by the almost incredible efforts of the foetus, that a gap sufficiently wide was made to admit of its escape, such is the force and vigour of a full grown and healthy fœtus.'

XII. TOTAL HYSTERECTOMY DURING PREGNANCY FOR RAPIDLY GROWING FIBROMYOMATA.

By N. T. BREWIS, M.B., F.R.C.P.E., Lecturer on Gynæcology, Royal Colleges School of Medicine, Edinburgh.

MRS B., aged 29, came under my care on the 24th March 1898, on the recommendation of Dr Mackay, complaining of an abdominal swelling and of constant pain in the right side. The patient stated that she had been married sixteen months, and had altered regularly till the last week of November, when the flow appeared for the last time. On New Year's day she felt perfectly well, but thought that for a month previous she had been getting stouter, and as she had now missed a period, and had morning

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sickness, she considered herself pregnant. In the middle of January she was seized with a sharp pain in the right side of her abdomen, and at this time she first recognised the swelling. The patient stated that day by day she was able to note increase in the size of the swelling, and when I first saw her it had extended to the upper limits of the abdomen. The pain continued severe, and was more or less constantly present. Her face, limbs, and chest had become thinner.

Physical Examination.-The abdomen is occupied by a swelling the upper part of which extends below the margin of the ribs. On the right side it passes deeply down into the flank. About 2 inches below the umbilicus there is a depression running transversely from side to side, dividing the swelling into an upper and lower portion. The former can be moved about and made to slide on the latter, to which it is apparently attached by a pedicle. Both portions are of solid consistence, but the upper is the harder, and its surface is more irregular. The foetal heart sounds were not heard. Abdomino-vaginal examination showed that the lower portion was the body of the uterus enlarged and rendered irregular in shape by two outgrowths in the left broad ligament closely attached to the uterus. The larger was about the size of a cricket ball.

It was evident that the patient was four months pregnant, and that she was the subject of at least three subperitoneal fibroids, two growing low down from the left side of the uterus, and one larger, the larger one attached to the fundus by a pedicle. From the rapid increase in size of the latter growth, the pain it gave rise to, and the emaciation which accompanied it, one feared malignant degeneration. Under these circumstances it was clear that the proper treatment was removal of the large tumour, and of the uterus also if it was found that the outgrowths at its lower part were likely to cause trouble in the future. Accordingly the patient was prepared for the operation in the usual way, and special care was taken in cleansing the vagina, in view of the possibility of vaginal section being required.

Operation, 4th April 1898.-The umbilicus was cut out, the peritoneum divided, and the incision extended downwards to the pubes and upwards to within three inches of the ensiform cartilage. The interior was now exposed and the parts were found as described under physical examination. The upper and larger portion consisted of a hard tumour united to the right corner of the uterus by a pedicle about 2 inches in length and 1 inch in thickness, twisted half a circle from left to right. The lower portion was composed of the uterus enlarged to the size of a four months' pregnancy. Projecting under the peritoneum were a number of small fibroids. The round ligaments, Fallopian tubes, and ovaries were greatly hypertrophied. On the left side of the corpus uteri was a rounded sessile tumour with uneven surface, as