procedure as this will give the best results, and if later it can be dispensed with, with care it may be closed. One other little procedure I would strongly advise when doing a colostomy for anal atresia-namely, draw down the colon toward the anal site as far as undue tension will permit before attaching it to the abdominal wall; then when, later, soundings are made for the rectal pouch or terminus, it may be found sufficiently close to the anal site to permit of its early attachment to that location in just exactly the same manner as that above described for colotomy, and in two sittings.

We hope to make such an effort in the case above reported when the pelvic outlet is larger; the tuber ischii in this child being somewhat closer than usual will make the operative procedure in that direction quite difficult. Few children born with these malformations so marked as to require colostomy recover from the operation, and fewer still attain the age of maturity. Indeed, they seldom live beyond the age of childhood. Keating, who has enjoyed a very extensive and varied practice, has but one case of colostomy to his credit, and makes no reference to its period of life. Vogl, closing his article upon anal and rectal malformations, in referring to colostomy, says: "That children may recover from such an operation has often been shown, but whether they thrive or grow up I am not able to say. At least, I have never seen an adult in whom an artificial anus has been established in either lumbar or inguinal regions in the early days of life." In the Medical News, September, 1883, Dr. Fenwick, of Montreal, reports a case of imperforate anus to the surgical section of the Canadian Medical Association, September 5, 1883. The patient, a man, "no age given," had a fecal fistula at the root of the penis, said to have been the result of an operation made when a baby for the cure of atresia. I am surprised that so very many authors, both in this country and in European nations, make no further report of cases in which colostomy has been performed, so that the benefits of the operation, if any, may be observed.

One might very readily imagine that an occlusion of the bowel in the new-born sufficient to require colostomy, instead of being quite common, as is claimed, is indeed, on the contrary, quite a rare occurrence, and this to me would seem especially apparent from a perusal of works upon obstetrics. For to whom are such cases presented if they are not to the obstetrician?—and yet I find

in their writings but little more than a mere mention of such cases having occurred. Hence I judge they either do not report them very faithfully or the cases do not so very frequently occur. In the practice of midwives, however, I believe an occlusion is occasionally overlooked, and in support of my belief permit me to report the following:

I was called in a great hurry to see Mrs. R. on December 10, 1895. I found her almost distracted over her baby, a boy five days old. The infant was in a state of coma preceding death, its abdomen enormously distended and discolored, the discoloration extending over the entire abdominal surface and upon either side, radiating out upon the back well toward the vertebra. Even the mother at this time was satisfied there was no hope for the life of her baby, and I was called merely to certify to the cause of death, which I readily found was peritonitis following anal atresia. The midwife who attended the case is above the average in intelligence. She had simply failed to discover the condition.

Since writing the above I find I am at variance with some noted surgeons in advising an early operation in those cases of anal atresia in which the rectum fuses with the posterior wall of the vagina. Thompson, of London, while reporting (in the London Lancet of February, 1894) a successful operation for closing the vaginal opening and uniting the rectum at the normal site, quotes Mr. Crisp as having performed twelve similar operations, eleven of them being successful, and gave it as Crisp's advice that the operation be deferred until the girl has grown up to about the age of fourteen years, so as to allow the parts to become thickened.

In the same journal, however, in the following month, Dr. Newman, of London, deplores the fact that a young girl who was brought to him at the age of eight years for the same condition had been so long neglected by her parents. He operated at once, and for weeks after apple pips (which he was positive were not eaten since the operation) were occasionally discharged. The intestines had also been enormously distended with fecal matter. He maintained that they should be operated upon younger still than this child was. I am inclined to favor operative procedures, in this particular class of cases, between the ages of six and twelve years, as indicated by circumstances and the developed condition of the child.

A CASE OF THE PORRO OPERATION; RECOVERY

OF MOTHER AND CHILD.

BY DAVID BARROW, M.D.,

LEXINGTON.

MRS. H., forty-four years of age, has been married twentythree years. She has two living children, one twenty and the other fifteen years old; one miscarriage between the birth of the two children. Five years ago I saw her for the first time in consultation with a medical friend, and found at that time a fibroid tumor pretty well filling the pelvic cavity. She was losing a good deal of blood, was quite anemic, and suffering from pressure symptoms. I visited her but twice, as in a short time she sought the advice of another physician. For several years she has been under the care of Dr. Bryan, in the main getting along fairly well. In July I saw her with Dr Bryan. Previous to January, for two years, her menstruation had been regular, but that month the period did not return. Her general health had improved, the abdomen had progressively enlarged, and all symptoms suggested pregnancy. The fetal heart could not be heard, but she thought she felt the movements of the child. On manipulating the abdomen the large tumor could be plainly mapped out, and as many as four nodular masses could be distinctly felt over its surface. The smooth part of the tumor was above the umbilicus. A digital examination revealed an interesting condition. The vagina was large and soft; the cervix was high up and hard to reach with the examining finger, and was jammed tightly above the symphysis pubis. Occupying and filling the pelvic cavity was a large fibroid mass, very hard, and even by the use of firm pressure it was impossible to displace it upward. This mass extended below and had crowded the cervix out of the pelvic cavity.

We gave the opinion that the patient was pregnant, and also stated that it would be impossible to deliver her except by surgical