uterus simply and solely because we know of no function for it, and because it may become the seat of malignant disease. Your nose and mine may become the seat of malignant disease, yet we would hardly consent to its amputation even if its known "functions" had already been destroyed. The argument that a diseased uterus should not be left after the tubes and ovaries are out loses much of its seeming weight when we remember that infectious disease of the uterus is dangerous solely from its possible extension to the tubes and ovaries, and, furthermore, that the ovaries and tubes having been removed, uterine disease is easily curable by means far more simple and safe than hysterectomy. Basing their arguments upon these grounds which we believe to be untenable, vaginal hysterectomy has been performed by some surgeons for disease of the ovaries and tubes. This fad has become so common in some cities that the laity have it, and come to one with the sentiment epitomized as follows: "Dr. So-and-So says I ought to have the whole business out." While it is probably better for these patients to "have the whole business out" than to leave the "whole business" in, it is not the best thing for them. If the disease has resulted in tubal occlusion with the confinement of pus or fluid in an enlarged tube which forms a complete sac, it is safer and better to do a salpingectomy either from above or below, leaving the uterus in situ to be curetted either at the same or another sitting. There is one class of chronic infective cases in which we advocate vaginal hysterectomy, and that is the class in which tubal disease has gone on to rupture of the tube between the broad ligament folds, with extravasation of pus into the pelvic cellular tissue. These cases are diagnosed by the fact that there exists no sulcus between the pelvic mass and the uterus. The abscess practically envelopes one side of the uterus at least, and as no definite sac exists it is impossible to make a clean ablation of the disease, either from above or below, without removing the uterus. -In puerperal sepsis of a violent type vaginal hysterectomy has been successful in saving some cases. The writer never having operated for this trouble cannot express an opinion of value upon the subject. Some cases of pelvic pain in which no pathological lesion is described, are said to have been cured by vaginal hysterectomy, even after removal of tubes and ovaries had failed. Insanity also.is said in rare cases to have been cured by vaginal hysterectomy. Beyond these limits we do not believe it justifiable to do vaginal hysterectomy. Removal of this organ for obscure, remote pains, and nervous phenomena has proven a failure, and the men and women who find it necessary to subject a large proportion of their patients to this operation are, we believe, unacquainted with the limitations of vaginal hysterectomy, and with the usefulness of many medical and surgical measures which the conservative gynæcologist frequently calls to his aid. Having considered in this imperfect way the question, When shall we do this operation? let us turn our attention for a few moments to the various methods of operating. The method by use of the ligature, the clamp, and by enucleation without ligature or clamp, each has its advocates and much time and ink has been spent upon arguments as to which is best. To our mind each method has its advantages and disadvantages. To the man who has used nothing but ligatures that is probably the best method. The man who is especially skillful with clamps doubtless has a better result than he would by trying ligatures in a few cases. The truth is that all the methods are good, but each one is especially adapted to a class of cases. For instance, Dr. Pratt and his followers have made a great deal of capital over the ability to remove the uterus, tubes and ovaries without the use of clamp or ligature. That this can be done in many cases there is no doubt, but it is also a fact that in other cases it is an absolute impossibility. Cases of well advanced cancer are especially unfavorable for the procedure, and many have died from secondary hemorrhage following hysterectomy by this method. In order to accomplish this operation, it is necessary to keep so close to the uterine body that if there is the least involvement of the broad ligament, the disease is not all removed and early recurrence is certain. Dr. W. E. Green has recently proven by careful collection of statistics obtained from operators in our school, that the mortality of vaginal hysterectomy by ligature was 1.7 per cent., by the clamp, 2.3 per cent., and by enucleation 5.2 per cent. On the other hand, the method of enucleation is especially applicable to removal of the uterus when that organ is not enlarged, or is perhaps atrophied. It is easy, quick and clean in cases of simple prolapsus, and is useful in certain cases of beginning cancer. The clamp method is very rapid, and comparatively easy; there is danger of wounding intestines and ureters, and cystocele sometimes follows, but taken all in all it is the best method in cases where the uterus is very large, and the patient in such condition that time is an important factor. Ordinarily time per se is not very important, and it makes very little difference whether one is a half hour or an hour in doing this operation, provided each step is carefully and exactly executed. The ligature is a slower method than either of the others, but it can be used in nearly all cases; it is sometimes followed by some sloughing of the stumps, but I have never known of a fatal result from this cause. Perhaps its greatest disadvantage is the possibility that a ligature may slip and allow hemorrhage. Here, of course, painstaking is of great importance. Personally I never know for certain what method I shall use in a given case till the operation is over. One had best make preparation for and be familiar with all three methods, and then be governed by the circumstances which develop as the operation proceeds. If the uterus is not the seat of malignant disease, or if the process is young, it is useless to use clamps or ligatures if the operator keeps close to the uterine body and no bleeding occurs. If the uterine or ovarian artery is wounded, it can be ligated within sight. If the bleeding is profuse, the regular method of ligating the broad ligament in sections better be followed. If the patient is in bad condition, and it is necessary to terminate the operation as quickly as possible, or if the uterus cannot be pulled down satisfactorily, the clamps are advisable. A ATRESIA OF THE VAGINA. By STEPHEN H. KNIGHT, A.M., M.D., TRESIA of the vagina is a name given in a general way to many different conditions, varying from simple obstruction at the hymenal orifice to complete absence of the vagina. The former condition we may designate atresia hymenalis, the latter as congenital absence of the vagina. The external appearance of the genitals will give no clue to the condition within. There may be congenital absence of the vagina and uterus with full external genitals. and mammary glands normal. There may be again uterus and appendages complete, and no external evidence. As to the degree of occlusion there may be nothing but a pouch having the appearance of a vagina, but further examination discloses a narrow cord where the vagina should be, with the rectum and bladder separated by a thin wall only. When the vagina is present there may be one or more transverse divisions, varying in thickness from a line or two, to an inch and a half. The causes of atresia are two in number-want of development and inflammatory action. Under the head of inflammation we note vaginitis, simple or specific; injuries from violent or frequent intercourse; wounds caused by difficult labors, and external or accidental traumatism. The vagina, as is well known, is formed by the coalescing of the lower portions of the two Mullerian ducts. According as this particular part of the development of the foetus fails to properly take place, or as the vagina fails to open into the urogenital sinus, does there result the various forms of congenital atresia known to exist. Ex As a rule the defect is not made manifest until puberty. Then, if a young girl has the usual disturbances accompanying the catamenia, and there is no discharge, this state of affairs continuing for a number of months, we should be led to suspect some obstruction, especially if the symptoms are gradually more and more severe, and suffering is experienced during the inter-menstrual periods. amination will show the nature of the difficulty. Combined external and internal manual palpation will determine the seat of the obstruction, and whether there is a tumor beyond, formed by the retained menstrual fluid. With a finger in the rectum and sound in the bladder the thickness of the intervening wall is easily apparent. Sometimes also the presence or absence of the uterus and appendages can be determined or whether the tubes are dilated with the retained blood, often a serious complication. be There is but one method of treatment, and that is, of course, surgical. With a sound introduced into the urethra as a guide, one must carefully make a way through the tissues between the rectum and bladder into the tumor above. Sometimes a trocar can plunged into the accumulation of fluid and the opening dilated, or again one must cautiously and tediously, by blunt dissection, proceed slowly ahead until the retention tumor is reached. Means must be taken afterward to dilate the canal thus formed and keep it permanently open. The apparently simple surgical procedure, just outlined, is not without its dangers, for beside the danger of injuring neighboring organs, the rectum, bladder and perineum, a number of instances have occurred where the dilated tubes have burst with fatal result. In the older operations the great bugbear was septic inflammation, and even in these days of clean surgery, in no less a work than Dr. Howard Kelly's new "Operative Gynæ cology," we find the following: "Before, throughout, and after the operation the most painstaking antiseptic precautions must taken, as the accumulated fluid is peculiarly liable to undergo rapid decomposition, and the walls of vagina, uterus, and tubes are in a be state of extraordinary susceptibility to infective processes. Death from infection has so often followed the simple evacuation of the fluid that many surgeons dread the operation." Miss B. was sent to me by Dr. Orrin Fowle, of Moscow, Mich. Although sixteen years of age there never had been any discharge of menstrual fluid. The girl was totally blind, due to opacities of the corneæ of both eyes, the results of an attack of ophthalmia neonatorum. She had been an inmate of one of the state schools for the blind, and had been sent to her home because of persistent headaches, which the medical attendants had not been able to relieve, and because of her inability to retain and properly digest her food. So serious had this latter trouble become that her general health and nutrition had become affected also. Her own physician readily discovered the obstruction and brought the girl to Detroit for treatment. Upon inspection the external genitals were normal, the finger could be introduced three-quarters of an inch or an inch only, the hymen having been torn and stretched by previous examinations. Beyond there was a large, fluctuating tumor. By introducing a finger into the rectum and a sound into the bladder, I could determine that there was probably but one dividing septum, and that it was apparently one-half inch thick. The tumor was too large to reach beyond, and for that reason it was impossible to tell the condition of the uterus and its appendages. The patient was sent to Grace Hospital for operation. She was prepared as carefully as if for a vaginal hysterectomy. Placing the patient in the lithotomy position the vaginal outlet was stretched open by retractors, and an incision made transversely through the mucous membrane. Then by tearing the tissues and by cautious dissection, retaining all the time a sound in the bladder and frequently inserting the finger into the rectum as a guide, an opening was made into the tumor, and the pent-up fluid allowed to escape slowly. Sometimes, in those cases where the Fallopian tubes have been greatly distended, during this escape of the fluid the tubes have burst with fatal result. Efforts then should always be made to allow the escape to take place slowly. In some of the older operations it was done in two or three sittings, this, however, is a bad plan, as it offers an opportunity for septic infection. About thirty-two ounces in all, of black tarry liquid came away from the patient, leaving behind a balloon-shaped cavity, whose walls were crusted and stained by the solid elements of the blood. At the bottom of the cavity the uterus was found normal, but retroverted. (Fig. 1.) The ovaries and tubes were normal also. The crusts were |