little hemorrhage, and the tissues apparently fell together nicely. In a few days, however, the temperature rose to 104. Shortly after this there was a free discharge of pus from the bladder, and on examination much induration of the left side of the vagina was found. The abscess had opened into the bladder. After several weeks the abscess cavity closed and the patient is now, six years after operation, in perfect health. A similar case was noted by a colleague of mine; in this instance, however, the bladder was not implicated.

Should we decide on myomectomy, the easiest method of controlling bleeding is by means of a gauze rope applied around the cervix, and clamped with artery forceps, thus avoiding the necessity of tying. If the myoma be small, the incision is made directly over it, and as soon as the nodule is exposed it is grasped with a meso-forceps and twisted or shelled out. Where the nodule is large and partially subperitoneal, a lozenge-shaped piece of muscle is usually excised with the tumor. Care should be taken not to sacrifice too much muscle, as so much contraction may occur that it will be found almost impossible to bring the margins of the cavity together. After carefully palpating the uterine walls to be sure that no other nodules remain, and having turned in the mucosa and sutured with cat-gut, should the uterine cavity have been opened at any point, the various cavities are totally obliterated by cat-gut sutures, three or four rows being used if necessary. It is upon this total obliteration of all dead spaces that the success of the operation depends. Often there is bleeding from the stitchholes on the surface. This is usually controlled by placing one or more cat-gut sutures at right angles to the others.

The operator need not be alarmed if the temperature rise to 100, or even to 102 or 103 a few days after operation. This we have noted very frequently. In such cases dead spaces have undoubtedly been left behind, and there soon occur a disintegration and absorption of the blood.

One should always remember that myomectomy is a much more dangerous operation than hysterectomy, and if the patient be weak or any other contra-indication exist the complete operation should be chosen. The latter operation is the one of choice after the menopause, myomectomy being applicable during the child-bearing period.

The operator should also bear in mind the possibility of leaving some myomata behind. I recently saw in the dispensary a patient on whom myomectomy had been performed nine years previously. She had been perfectly well for several years, but when admitted to the hospital a second time the uterus was fully five times the normal size and everywhere studded with myomata..

Where the resultant incision in the uterus is long, and it is necessary to hold the organ up on account of its large size intra

abdominal shortening of the round ligaments is preferable to suspension. I am familiar with a case in which, following a myomectomy, the uterine incision became intimately blended with the abdominal wall over a wide area. Pregnancy followed, Cæsarian section was performed, and the patient died. Suspen

sion in such a case is an entirely different problem to the simple operation for displacement as in the latter there is no raw surface whatsoever.

I would strongly advise giving the preference to myomectomy in all suitable cases, but in every doubtful instance hysterectomy should be performed.

Hystero-Myomectomy with Preservation of the Ovaries.-In those cases in which it is deemed safer to perform hysterectomy, if the patient has not passed the menopause, we should endeavor to save the ovaries. In the first place we have no right to remove normal structures, and in the second place preservation of the ovaries will relieve the patient, to a great extent, of the troublesome hot flushes and nervous phenomena naturally associated with the menopause. Thus, where the operation is performed on a woman, say, thirty-five years of age, these unpleasant phenomena are generally deferred until the usual time for the cessation of menstrual life, or for several years at least. We make it a point to preserve one or more ovaries wherever feasible. Spinelli and others are still more conservative, and whenever possible preserve, at least, the lower segment of the uterine cavity, in other words some of the mucosa from the body is left in situ and the menstrual In the function, although naturally limited, is still preserved. near future it seems probable that this plan of treatment will often be adopted.

In performing the ordinary hysterectomy with amputation through the cervix it is well always to remember the blood supply of the pelvic organs. From above downward we have the ovarian

artery and veins easily exposed to the outer side of the ovary. Next comes the artery of the round ligament which, although small, often occasions much oozing if not tied. On freeing the folds of the broad ligament the uterine artery with its accompanying veins is seen skirting the side of the cervix near the internal os. On the opposite side a similar system of vessels is encountered. We may then roughly compare the hysterectomy with amputation at the cervix to an ordinary amputation with four main vessels, the ovarian and uterine on each side.

Where the growth is situated in the body of the organ and the The round cervix is long, the operation is as a rule quite simple. ligaments are first tied and the organ can be lifted still higher out of the abdomen. Portions of the ovarian vessels passing to the uterus are controlled at the uterine horn, and the uterus is freed

on each side. After opening up the broad ligaments laterally

and separating the bladder reflection anteriorly, the uterine vessels are readily exposed and tied. Many operators employ only cat-gut for the uterine and ovarian arteries. We still feel much

Only

safer with silk, and always use it for the larger vessels. After tying the uterine arteries, taking of course good care not to include a ureter in the ligature, we cut through the cervix, encountering little or no bleeding, except from the tumor. We usually cup the cervix slightly, and then close with cat-gut sutures. occasionally is the cautery introduced into the cervical canal. The broad ligaments are then closed with continuous cat-gut sutures, care being taken to cover the stumps of the appendages. bladder peritoneum is drawn over to that of the posterior surface of the cervix. The pelvis now presents a perfectly smooth surface, offering little opportunity for the subsequent development of intestinal adhesions.

The

Hysterectomy with Removal of the Appendages.--If it has been deemed advisable to remove the ovaries, the operation is carried out in precisely the same manner, save that the ovarian vessels are tied just before they reach the ovary instead of on the uterine side.

While many hystero-myomectomies offer little difficulty, others are by no means so easy. Sometimes the growths are exceedingly large and so distorted that it is at first hard to get one's bearings. Under such circumstances it is always advisable to seek out the round ligaments and sever them at once. This invariably renders the tumor more mobile. The left tube and ovary are then usually tied off, and the tumor rolled outward and to the right, as recommended by Dr. Kelly. The uterine vessels on the left side are now controlled and severed, and the cervix is cut across with the upright slant so that the cervical stump and consequently the uterine vessels left on the right side will be longer. Clamps are applied to the right ovarian vessels, and the entire tumor is removed en masse. It is astonishing with what ease an otherwise difficult operation is rendered comparatively simple by this "from left to right" operation of Kelly. Great care must be taken with the ureter, and if the operator has the least suspicion that one or both have been injured he should seek each ureter as it crosses the pelvic brim, and follow it through the pelvis and carefully outline it to its vesical insertion.

Several months ago I had a very difficult hystero-myomectomy in which the patient was exceedingly anemic, and the vagina was filled with a very vascular submucous myoma. While liberating a subperitoneal nodule adherent to the right pelvic brim I found it necessary to tie the ovarian vessels. There was only one point at which the vessels could be controlled, and that merely wide. enough for a single ligature. After having emptied the pelvis I felt rather uneasy about the right ureter, although no suture had

been placed anywhere near the usual ureteral site. As a matter of fact the ureter had been included with the right ovarian vessels. It was released with ease, and the patient made a perfect recovery.

Sometimes the ureter is carried up out of the pelvic cavity by large tumors, and there is great danger of it being tied or cut. If, after tying the round ligaments and releasing the tube and ovary, the blunt dissection be carried down close to the uterus the danger is minimized. In some instances it may be necessary to perform a preliminary myomectomy, thus diminishing greatly the size of the uterus and allowing the ureters to drop back into their normal position. The same result may be accomplished by bisection of the uterus.

Bisection of the Uterus.-In not a few instances, on opening the abdomen, the operator is confronted with a very discouraging problem. The pelvis is filled with a nodular tumor glued everywhere to the omentum and intestinal loops or firmly wedged in the pelvis. In some of these cases it is next to impossible to gain a point of cleavage, and were it not for bisection of the uterus the operation would either have to be abandoned or the resultant injury to the intestine from the difficulty in the separation of adhesions would be so great that the chances of the patient's recovery would be minimized. In such difficult cases the uterus is firmly grasped with meso-forceps on each side, and the organ is boldly split in the middle. As the incision is increased fresh meso-forceps grasp the uterine walls on either side, and eventually the entire organ is separated into two halves or divided as far as the cervix. We would naturally expect to see injury to the surrounding parts, but by this operation we reach the adhesions from their under surfaces where they are lightest. You would also naturally expect much hemorrhage, but if the uterine halves are kept taut with the meso-forceps no danger from this source is to be feared.

With the uterus now in halves the respective portions are removed entire or amputated through the cervix, the vessels being controlled in reverse order to the usual method, namely, first the uterine, then the round ligament, and finally the ovarian vessels. The remainder of the operation is completed in the usual way.

Abdominal Hysterectomy with Preliminary Amputation through the Cervix.-In a certain number of cases, in which the adhesions are so great that bisection of the tumor is not feasible, it may be possible after severing the round ligaments to push down the bladder so that the cervix is exposed. The uterine vessels are The then clamped on both sides, and the cervix is cut through. cervix is then drawn strongly forward, and Douglas' sac is opened from below. The cervix is now drawn still further upward, and all the adhesions are gradually separated from the under surface. The ovarian vessels are clamped on each side, and the tumor is

delivered. In these desperate cases all vessels have been clamped and the organ is removed without a ligature having been applied. The vessels are tied with silk and the operation is completed in the usual way.

Where the intestines are densely adherent to the tumor, always sacrifice the part of the myoma or its overlying layer of uterine muscle, as the case may be, leaving it attached to the intestines. This raw flap adherent to the gut is now turned in on itself in such a manner that the bleeding is checked and a smooth surface left.

Complete Abdominal Hysterectomy.-While amputation of the cervix is usually preferable, first, because it is easier, and, secondly, on account of the remaining portion of the cervix forming a good firm support for the vaginal vault, still in not a few instances the complete operation is clearly indicated. For example, where a large cervical myoma exists there is often no normal cervix left and the growth has so encroached on the vagina that a small cuff of this must also be removed. In these cases after tying the uterine arteries low down near the ureter it is not very difficult to free the mass on all sides until the vagina is exposed. In every case, however, where there is great danger of injury to the ureters these should be carefully outlined to see that they are intact.*

In all cases in which we suspect adeno-carcinoma or development of sarcoma in a myoma, splitting of the ureter should never be performed as we run the risk of not only implanting cancer and sarcoma cells upon healthy tissues, but also of setting up a general peritonitis as in these cases virulent pus organisms are very liable to be present. Knowing that we may at any time encounter malignant growths in the uterus, when we are operating for myoma, I have made it a rule where the uterus has been amputated at the cervix to always have the organ opened at once so that if, perchance, a malignant growth exists the cervix may also be removed before the abdomen is closed.

Treatment of Myoma Complicating Pregnancy. If pregnancy occurs when the uterus is studded by large and small myomata which apparently encroach on the uterine cavity to such an extent that they almost preclude the possibility of the pregnancy advancing over a few months, hysterectomy should undoubtedly be performed irrespective of the ovum. In other cases in which the myoma is cervical and so plugs the pelvis that labor through the normal passages is impossible, the question should be laid squarely before the family and the alternative of complete hysterectomy at once or Caesarian section at term followed by hysterectomy at a later period discussed. The uterus might possibly be removed

*Doyen's operation where Douglas' sac is opened, the cervix firmly grasped and drawn backward and upward and then freed from the vagina on all sides and the uterine vessels are clamped and cut is also a method of complete hysterectomy to be strongly recommended,