the size of a foetal head, as shown in the photographs. (Figures 4 and 5.) On June 10, 1903, I operated with the assistance of my staff and nurses at St. Winifred's Hospital, removing the pendulous abdominal wall, dissected off the adherent bowel and omentum and closed the wound with layer to layer sutures.

Observations.-Unless there is accurate layer to layer approximation of the abdominal walls incisional hernia may

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occur in the hands of the best surgeon. Among the causes of this condition may be mentioned: 1. A lateral incision is more frequently followed by hernia than a median incision. 2. Hernia follows the through and through" suture more frequently than the "layer to layer" method. 3. Bulging of the abdominal walls is more frequent in suppurating wounds, such as suppurating appendicitis, than in aseptic wounds, on account of the necessary opening for drainage. 4. "Destructive innervation" of the muscle and fascia is a factor in post-operative hernia. 5. Allowing a

patient to sit up and go about in eight or ten days after a cœliotomy is responsible for many a ventral hernia. 6. Inaccurate approximation of the belly walls will weaken the resulting cicatrix. 7. Too early removal of abdominal sutures will leave the union weak. 8. The use of ordinary catgut which absorbs in a few days is a predisposing cause of hernia. 9. Diabetes and constitutional dyscrasias will

militate against firm union. Precautions.-10. It is necessary to support an abdominal cicatrix for three months by a suitable abdominal belt to prevent stretching of the scar. 11. Long incisions are more prone to separate than short 12. Suppurating wounds that heal by granulation should have the fascia firmly united by means of a "double breasted" (Figure 6) suture as soon as there is the slightest indication of bulging of the walls. 13. In a lateral incision the layers of the abdominal fascia should be divided in the

ones.

direction of their fibers and not cut "across," that is, the external oblique should have its fibers divided from above downward and inwards, the internal oblique from below upwards and inwards and the transversalis transversely.

Fig. 6

Such wounds are practically self-closing. The layers should then be sutured together separately with chromocized, cumulized catgut which does not absorb for 21 to 28 days, by which time union is firm. 14. Median incisions, especially in pendulous abdomens, or after abdominal hernia, are best treated by means of the overlapping or 'double breasted method." (Figure 6.) 15. There is no

strength in the muscle fibers. It is the firm fascia covering the muscles which must be firmly united after an incision and kept supported by an abdominal bandage for at least three months to insure a firm unyielding cicatrix.

RODENT ULCER.

H. D'ARCY POWER, L. S. A., Lond.; L. R. C. P. I. Professor of Principles and Practice of Medicine, College of Physicians and Surgeons of San Francisco.

There are some diseases whose names are as familiar as old friends; but concerning which, if we search our own experience, or that of the average medical practitioner, we

find no corresponding acquaintanceship. Such, I think, is the case with rodent ulcer. No more terrible disease afflicts humanity, few are more curable in their early, or more hopeless in their later stage, yet the descriptions in the text-books are scanty, or present an imperfect picture. For these reasons I deem it justifiable to occupy your time with a few remarks, and the report of a case that recently came under my observation.

Rodent ulcer is classified by Dr. Hugh Montgomery, in the American Text-Book of Pathology, as a superficial carcinoma; therefore, a malignant tumor; but it is not clinically a tumor, and as to malignancy, of the three features pathognomonic of that condition, but one is present, namely, eccentric growth, for rodent ulcer does not tend to

recur after excision, is not metastatic, and does not infect the neighboring glands. The best description of the condition with which I am acquainted is that given by Henry T. Butlin, in his work, "On the Operative Treatment of Malignant Disease." The case I now report is an almost perfect exemplification of his description, so that an account thereof will serve to bring before you a picture of the disease in its classical type.

MRS. W., aged 87 years at the time of death; came under