If pus and albumin exist in the same urine it will be necessary to filter the pus corpuscles out and test the filtrate for albumin.

On the other hand, serious kidney lesion may exist without giving evidence by chemical tests of albumin being present, for the albumin is too small in quantity to be readily detected by chemical reagents.

Such conditions of the kidneys are hard to detect, but if repeated chemical analyses be made traces of albumin may be found.

Here the use of the microscope and the centrifuge become imperative, but if careful examinations be made with these instruments casts of a hyaline and granular nature will be found, indicating a chronic interstitial nephritis

In these cases the accompanying symptoms of nephritis, as a rule, are present, making the diagnosis positive:

In ascertaining the amount of albumin present by use of "Estach's albuminometer and reagents," it is of prime importance that the urine is acid in reaction, the composition of Estach's reagent being such as will interfere with the test of the urine is not acid in reaction. That is, some of the citric and picric acids in the reagent will be neutralized by the alkalinity of the urine if not previously acidified.

To accomplish this, acetic acid should be used as the stronger mineral acids may form soluble acid albumins, which will not be precipitated, and hence render the method more unreliable.

This acidifying of the alkaline urine when using Estach's albuminometer is an important fact, and one which is not mentioned in most works on the subject.

The estimation of urea is another important factor in ascertaining the quality of a urine. Upon a recent examination of 600 specimens of urine I have found that the amount of urea can be approximately determined, whether increased, normal, or diminished in quantity before testing for it, by first eliminating all abnormal constituents, such as albumin and glucose.

Then determine whether the usual solids, such as chlorides, phosphates, sulphates are normal in quantity. In other words, if the chlorides, phosphates and sulphates are normal in quantity, albumin and sugar being absent, specific gravity normal, the rule that follows is that urea is also normal in quantity.

If you have a urine of high specific gravity, say 10.30, albumin and sugar absent, chlorides, phosphates and sulphates normal, you can invariably depend on an increase of urea amounting from 8-10 grains per ounce. On the other hand, low specific gravity, 10.14. you can depend on a reduction 6-8 grains per ounce.

Original Articles in Surgery.

CONDUCTED BY

WILLIAM TOD HELMUTH, M.D., LL.D.

GEORGE W. ROBERTS, Ph. B., M.D.

SIDNEY F. WILCOX, M.D.

VAGINAL HYSTERECTOMY.

By GEORGE W. ROBERTS, M.D.,

New York.

HEN any particular operation has been demonstrated to be a justifiable procedure, the altogether too frequent order of events is that many proceed to practice it upon their clientele with little regard to the necessities of their cases. The technique of the operation receives first attention. Anxiety to present a low mortalify rate, the endeavor to compete with rivals, the great impetus given to surgical technique by development of the principles of asepsis, and the comparative simplicity of the problems involved, all conspire to turn the attention of the modern surgeon toward the methods of performing operations rather than toward those questions which tend to limit any given procedure to that particular class of cases to which it is applicable. The result of this tendency is that we often find ourselves more skillful in the performance of an operation than in determining in what class of cases it is actually indicated. In our medical societies we hear numerous operators refer to scores of cases of this or that operation with a very low mortality, showing a high grade of operative skill, yet these same men will not agree on some of the most vital points as to the indications for the operation. This state of affairs results in speedy perfection of technique and rapid advance of surgery, and is perhaps ultimately justifiable, nevertheless it at the same time results in the sacrifice of many lives and organs, and entails much suffering from the fact that patients are subjected to the operation who would have been better off had it been left undone. It costs many human lives to make a good surgeon, and even in the hands of a good surgeon it costs many human lives to perfect the technique of any particular operation and to limit its applicability.

Vaginal hysterectomy has been no exception to the rule, and while we have nothing new to offer upon the subject, we may per

haps hope to compile and rearrange the facts already in hand in such a way as to contribute something to the easy understanding of the subject and correct reply to the questions, "When shall we perform vaginal hysterectomy, and by what method?" Perhaps these two questions are already settled in your minds, but in order to justify one's assumption that it is worth our while to discuss them, it is only necessary to refer to the fact that one of our oldest surgeons and gynæcologists, a man who had a national reputation and unrivaled surgical practice twenty years ago, and still has them, has to his credit less than one hundred vaginal hysterectomies-yet a young man in the same city whose operative experience covers a period of less than five years and of small proportions at that, boasts of having done more than one hundred operations of this character, and so far as can be learned he is not exaggerating. Now, either one of these men is operating on cases which ought to be spared, or else the other is not removing the uterus when that operation is indicated; they do not both understand the limitations of vaginal hysterectomy, and it would certainly be profitable for them to enter into an investigation of the subject.

First, let us consider the question of the indications for removing the uterus by the vaginal route. In cancer of the uterus, we have a positive indication for vaginal hysterectomy in all uncomplicated cases in which the uterus is freely movable, showing that the disease has not involved the broad ligaments. Involvement of the vaginal wall to a very great extent by any of the malignant processes except epithelioma, is a contra-indication in most cases. Some cases, however, are so completely relieved of pain by operation even when it is known that complete eradication of the disease cannot be accomplished, that the operation is justifiable. In cases of epithelioma of the cervix extending to the vagina, vaginal hysterectomy with removal of the diseased vaginal mucous membrane is indicated, for epithelioma, being the least malignant form of cancer, offers more hope of recovery than any of the other malignant processes.

There can be no question to-day but that the larger portion of cases of uterine cancer which are operated early recover permanently, and these cases which are followed by recurrence are benefited in that their pain is lessened and their lives prolonged. Early diagnosis of uterine cancer has recently assumed great importance from the very fact that the hope of recovery and of immunity from recurrence is so good in the cases which are operated early. Thus there is placed upon the shoulders of the general practitioner a re

sponsibility which is fully as heavy and as exacting as that which rests upon the conscientious surgeon. Uterine cancer should be diagnosed long before the classical symptoms of pain, profuse hemorrhage and foetid discharge have been noticed. Uterine enlargement, spotting between menstrual periods, gradually increasing profuse menstruation, especially in women nearing the climacteric, should lead to a curettage and microscopical examination of the scrapings. No practitioner will find it beyond his power to scrape out from the uterine wall enough of the diseased tissue to preserve in a drachm of alcohol and send to his friend the microscopist, even if the latter resides in a distant city. If the microscopist confirms the diagnosis, there can be no doubt about the advisability of hysterectomy, and even if he does not, it is better in presence of a clear clinical picture to operate at once, especially if the patient is over forty years of age. Vaginal hysterectomy is indicated in a few cases of metritis and endometritis which are accompanied by marked enlargement of the uterus, severe and exhausting hemorrhages, and which are not cured by repeated curettage and the usual means employed for the treatment of these cases. Often these cases fail to come under the microscopist's classification of cancer, yet their clinical characteristics are such that they threaten life from profuse hemorrhage, and are liable to take on sarcomatous degeneration at any time. My own experience has led me to look for this condition in fat women who are nearing the menopause. Removal of the uterus in these cases relieves them of the disease and removes one menace to life, and unless it is performed they drag along for years, going from one doctor to another, and usually from

bad to worse.

Another indication for vaginal hysterectomy is the presence of one or more senile or intramural fibroid tumors which are so located that they do damage or inflict pain by pressure upon one particular spot in the pelvis, and which at the same time are so small that they will come through the vagina whole or can be easily divided and delivered. Not infrequently do we meet small fibroids so located that they produce damaging pressure upon bladder, ureter, or rectum. These tumors are often so small that a slight change in their location would render them practically harmless, yet they may cause death if not removed. The mortality following vaginal hysterectomy is so much lower than that of abdominal hysterectomy that the lower route is the one to be chosen in these cases. In case the tumor is pedunculated either upon the mucous or peritoneal surface of the uterus, it is not justifiable to remove the whole organ.

This is especially the case in patients who are in the child-bearing period of life. In these cases the tumor alone should be removed either by the abdominal or vaginal route, according to whether the growth is subperitoneal or submucous in location.

Vaginal hysterectomy has within the past few years been applied to the most pronounced forms of prolapsus of the uterus and pelvic organs. There are many of these cases which resist all other means surgical or medical. Perineorrhaphy to the extent of almost complete occlusion of the vagina has been tried and has failed; pessaries are of little or no use, and abdominal fixation has also failed, and furthermore its dangers are practically as great as those of vaginal hysterectomy. If these patients are past the menopause, there can be no argument as to the advisability of a radical operation, and even if they are not, the arguments against this measure are weak and appeal more to sentiment than sense. When the uterus is removed and the vaginal vault fastened to the broad ligament stumps, not only is the prolapsus uteri cured, but also prolapse of bladder, vagina and even the rectum are overcome as the broad ligaments retract and pull up the lax vaginal tissues.

Notwithstanding these results one is not justified in doing hysterectomy for the cure of mild cases of prolapsus which are amenable to other and milder methods of treatment. One can well afford to advise his patient to try the simpler expedients before submitting to a capital operation, even though the mortality is not over three per cent.

Since tubal disease comes as a rule from the direct extension of infective uterine disease by way of the continuous mucous membrane lining uterus and tubes, it is argued by some that when we remove tubes and ovaries for infective inflammations, and even for non-infective conditions, we should at the same time remove the uterus. This advice is based upon the assumption that when the tubes and ovaries are removed the uterus has no function, that it is a diseased uterus at best (in infective cases), and that it is likely to take on malignancy. The word assumption is used above quite intentionally. We have in the past few years become familiar with the functions of some of the "functionless organs," and have found that healthful existence could not go on without them. We are constantly learning of unrecorded functions of various organs, and one cannot as yet assert that menstruation and child-bearing are the sole functions of the uterus. What about the nervous system? Has the uterus no bearing upon its office? This question we cannot answer in the negative, and until we can it is not justifiable to remove a