the uterus from the bladder, vagina, and rectum, and then I clamp the other broad ligament and cut it off (doing one on the side just as Dr. Baldwin does on both sides), and then ligate the arteries and remove the forceps or clamps. The principle of the operation is of course the same. I never use Dr. Wight's clamps for this operation although I use them in vaginal hysterectomy. I use Kelly's. They do not slip and control the hemorrhage just as well, and leave the peritoneum that you close with your continuous suture in better condition than you would with Dr. Wight's. Those are excellent instruments for clamping broad ligaments from below, but from above I prefer Kelly's, because they are smootherfaced and do not injure the peritoneum. They are shorter and not in the way like long forceps. In the use of instruments, however, it depends entirely on who has hold of them as to the way they answer.

Dr. Chas. Jewett: I was interested, Mr. President, in the iodoform-poisoning. That I recognize as an established fact, but I have never seen a case which was at all troublesome, though I have used iodoform freely in the cavity of the uterus and the vagina. I wish the Doctor would explain to us the chemistry of this poisoning. I suppose the iodoform decomposes and liberates iodine, but it cannot be free iodine that does the work. The iodoform, I assume, is absorbed as a whole.

With regard to the method of hysterectomy, I would like to have heard the technique a little more fully explained. I did not understand how it is that the Doctor ties while his clamps are on the ligaments without leaving any ligature in the peritoneum.

Dr. Walter B. Chase: I am very much pleased with the method the Doctor has advanced for operating. I never thought of that course, but I do not see why it would not be feasible.

As to the question of iodoform-poisoning, while I have no theory to offer regarding its development, I have seen two wellmarked cases and one fatal case, but in that case there was a very large amount of iodoform used in the knee-joint cavity and it was not difficult to explain the fact that poisoning had taken place because the amount was so very large. That was years ago, and it was a surprise to the gentleman who used it that the effect should have been fatal. I am inclined to believe that the advantages which come from iodoform can be had by using smaller quantities than possibly some of us have been accustomed to use, and I rarely put more than five grains into the uterine cavity. After curettage or any other condition I use those little pencils

which dissolve rather slowly and contain five grains, and as far as I am able to judge, the peculiar effect of the iodoform locally is just as good with a small quantity as with a larger quantity, and so I have given up the use of the ten-per-cent. gauze in cavities and restricted it where I deemed it best to use iodoform-gauze, either in the abdominal cavity or uterine cavity, to not stronger than five per cent.

As regards the technique of Dr. Baldwin's operation, I would like to hear more in detail as to some of the steps he takes that were not very fully brought out.

Dr. L. G. Baldwin: Mr. President, in regard to the iodoformpoisoning, I do not know how it acts. I did not report this case as a case of iodoform-poisoning positively, but rather to get your opinion of what it really was. I went faithfully over the case and had two or three consultations over it with a view of discovering if there was any other cause, and the opinion was that it was due to sepsis somewhere, and that in a few days it would develop; but two weeks passed and nothing came of it and she went out perfectly well, the pelvis perfectly clear, and in every way in a satisfactory condition.

As to the matter of the further technique of the operation, if the forceps are put on as low down as possible, and then the broad ligament put a little way from the forceps, the arteries themselves stand out very prominently from the other tissues, and I have found no trouble in grasping them with an ordinary artery-forceps and ligating them with the forceps in position. The other steps that Dr. Chase speaks of, I do not know just what he refers to. I simply put the forceps on, cut off right down to the uterus, put the forceps on the other side and cut down to the uterus on that side. Then make a flap of the peritoneum and dissect down the bladder, and posteriorly the same, cut the uterus off, and then tie the arteries if there are any that are not caught in the forceps. If there is a thick, broad ligament from involvement or invasion of it, it is easy to put on another forceps, and then beginning on the side nearest you, simply stitch over the broad ligament and draw the flaps anterior and posterior across the stump.

Dr. Jewett Is there not danger of after-hemorrhage from crushing the vessels with forceps like these?

Dr. Baldwin: No, sir, I think not, because, in the first place, the forceps hold easily and you do not need to squeeze them so hard as an ordinary forceps. You can take three thicknesses of ordinary writing-paper and shut them down to the lowest notch and

they hold perfectly, owing to the slanting shape of the teeth and the opposing fenestrum.

Dr. Jewett presented some recent specimens of pus-tubes.

INSTRUMENTS.

Dr. A. J. C. Skene: You are all aware that the most perfect hemostatic that we have ever had in surgery is the clamp and cautery. That has been proved, I think, beyond a shadow of doubt in the treatment of the pedicle of ovarian tumors as practised by Keith and some of his followers. There are two reasons why it has not been more generally used: One, because the principle of the treatment has not been generally understood; and the other, and perhaps the most important reason, is the fact that it is diffi cult to obtain and use the necessary heat. It is hardly correct to say that hemorrhage is controlled by the cautery. It would be more in keeping with the facts to say that bleeding is controlled by strong compression, and then heating the clamp or forceps so as to desiccate the tissues within the grasp of the clamp, and in that way to effectually seal a considerable portion of the end of the artery. I have always believed in this method as the best for the reason that it is, in the first place, one of the most perfect hemostatics-it is more sure than any ligature. It leaves the stump in the best possible condition to heal, leaves no septic material whatever in the wound; no ligature to loosen or to decompose and set up inflammation, no ligature to wander about and get into the other viscera, as often occurs long after the patient has recovered from the operation.

With all these advantages in mind, I have sought for a long time to adapt the method to other operations, and some of you may remember that quite some time ago, about two or three years ago I presume, I presented an artery-forceps that was to be used on this principle. But I found in the use of that forceps that it was not applicable in controlling small arteries, because of the difficulty of employing the heat from an actual cautery-iron. The difficulty is in obtaining the degree of heat required. If it is too much and you char the tissues, that spoils the operation, because charred tissue does not become revitalized, or organized, or absorbed like an exudate, but acts as an irritant in the wound and is apt to give trouble. It is extremely difficult to use the heat from a cautery-iron sufficient to do the work and not overdo it, so I have labored to adapt electricity to give the required heat, and the forceps I presented I have improved upon, and now have one that I

know answers the purpose. The electrodes are connected to the handles of the instrument, the artery is seized, and the current turned on and so regulated that it will just dry the tissues. The heat should be from 190 to 2co degrees, not more. The walls of the artery will sometimes stick to the blades of the forceps and it may pull them apart and the hemorrhage start, but if it is held for a moment and just the proper desiccation, or heat, or cooking obtained, and then the instrument be separated enough to slip off-then it answers the purpose.

I have also had made compression and cautery forceps like these (indicating forceps used by Dr. Baldwin), which I use in vaginal hysterectomy. I first did vaginal hysterectomy as follows: I separated the uterus from the vagina by opening in front and behind, and then in the ordinary way; seizing the lower portion of the broad ligament with these forceps, I divided the broad ligament with the cautery in place of using the scissors, and applied the thermocautery-knife to desiccate that portion of the broad ligament held in the forceps, and then immediately removed the forceps. The upper portion of the broad ligament including the ovarian artery was treated the same, that is, pulled well down, and protecting the other tissues with retractors while using the cautery, I have been able to remove the uterus in that way, but it is extremely difficult to do it with the thermocautery. Now with the forceps I speak of (which happen to be all in the hands of the electrician at the present time, because he is improving on them), the heat is supplied by a coil of platinum wire inside the head of the forceps, leaving the surface perfectly smooth or but very little roughened. The heat does not extend to the outside of the forceps and all the tissues are protected. I think I shall be able in that way to do vaginal hysterectomy without a ligature or compression-forceps with much less trouble than heretofore.

For the broad ligament-pedicle in ovariotomy I have the clamp that I have always used, that is Dawson's clamp modified. This clamp takes in the broad ligament, and then the sliding-plate pushes it up and reduces the size very much more than the Baker-Brown clamp or this one that Dr. Baldwin uses. When the pedicle is sufficiently compressed the current of 190 degrees is used until the parts are desiccated.

In ovariotomy, and in amputation of the breast, and in vaginal hysterectomy, I believe that I can get along by this means of controlling the bleeding vessels and leave the parts in an infinitely better condition to heal than I can by any other means. I am

hoping that when I have had more experience and have better developed the compression-forceps that I can do vaginal hysterectomy in very much less time than by using the ligature or forceps; for although the forceps answer the purpose and simplify the operation of vaginal hysterectomy very much, they are always a source of annoyance to the patient and some anxiety to the surgeon. Notwithstanding the many statements that they cause no pain, I find in my patients, on the contrary, that they do cause pain, and I am always a little anxious when they are taken off for fear of starting the hemorrhage. When none of the arteries bleed after the clamps are taken off, there is always a little bleeding from the raw surfaces. And more than that, there is sloughing of the compressed, dead tissue of the stump, that is very apt to cause a purulent discharge for a long time and sometimes septicemia.

So far as this method of controlling hemorrhage is concerned, it certainly reduces the chances of sepsis. I never can feel so sure of any ligature as I can of this compression and heat-method, because the very heat employed sterilizes the tissues and the instrument, and everything it comes in contact with; so I believe I can see the time coming when I shall probably never use another ligature, but shall control all bleeding vessels in all operations that I do by the means in question.

The strength of

There is one objection to this for general use, and that is the difficulty of obtaining the electric current. I can get from the electric light the kind of current that will give me any degree of heat for any of the small or large instruments and that answers the purpose admirably, but that is only available in one's office or in a hospital equipped with the Edison current or the electric-light current. I am hoping, however, that I can make it available for all kinds of practise by the use of Dr. Byrne's battery. I think that will be sufficient to answer every purpose. current that is required for the forceps is exceedingly weak, whereas in the compression-forceps and in the clamp for the broad ligamentpedicle a decidedly strong current is necessary to give the required heat and the current must be regulated carefully and accurately. The stump properly treated should look like a piece of horn, almost translucent, and to get the current that will do that, and to know that it will do it and no more, will be very difficult perhaps with the Byrne battery or any battery. But with the electric light one can test the current on a piece of beef and decide just what current is required.

Now the great difficulty that was experienced with the heavy