whether the vagina be long or short, the length of the cervix and the location and size of the uterine arteries. If the preliminary examination has shown the cervix to be displaced, this should be borne in mind in locating it from the abdominal side. It also gives opportunity to calculate the position of the ureters, and to determine adhesions, which latter must be dealt with before finally delivering the tumor. They should be most carefully manipulated, the rule being to enucleate in the line of demarcation if it can be discovered. Hemorrhage from the adhesions is not usually serious, except in individual cases. Supposing the tumor to be delivered, the two points of supreme importance are to determine the

FIG. 14. No. 35.-An interstitial fibroid growing in posterior wall of uterus, the anterior wall having been opened to show A, cavity of uterus. B. B., second part of first ligatures, showing method of tying between ovaries, C. C., and uterus, to prevent passive and regurgitant hemorrhage.

exact locations of the ovarian and uterine arteries on each side and to avoid the ureters in subsequent dissection.

Catgut is used for all sutures and ligatures, which are left within the abdomen. First, a ligature of suitable size is passed through the upper part of the broad ligament in such a manner as to surely include the ovarian artery outside of the ovary and tube. This is usually passed as a double ligature, the first part of which is securely tied and controls the circulation through the ovarian artery; the second part (Fig. 14, B. B.) is brought sufficiently close to the tumor to be tied between the growth and the ovary including the Fallopian tube adjacent to the uterus; this latter controls all passive hemorrhage from the tumor, its place frequently being taken by a large Well's forceps. The parts between the two ligatures are then entirely divided outside of the ovary, and sufficiently far from

the outer ligature to leave a secure stump. The opposite side is treated in the same way, which allows of the still further elevation of the mass. The tumor is now entirely supplied by the uterine arteries, the exact locations of which are to be determined. They enter laterally just above the vaginal attachments to the uterus, and are in relationship to the ureters, the latter coming from below and passing in front of them. Upon either side of the uterus the separation begun by the division already made outside of the ovary is carried downward parallel to the border of the uterine mass a varying distance, according to circumstances, without ligature. This can safely be done and not cause hemorrhage. As the fundus of the bladder is approached, an incision conforming to and slightly above the attachments of the bladder to the uterus, is carried through the peritoneum and transversely from side to side. The bladder is then separated from the tumor by the finger until the anterior vaginal attachment of the cervix is reached, and this separation is carried laterally sufficiently far to expose the uterine artery upon either side. This is definitely located and as definitely ligated, not en masse, but enclosing sufficient tissue to make sure there will be no slipping of the ligature, carefully and intelligently excluding the ureter. This ligature should be applied close to the uterus. If the operation was not begun through the vagina, the latter is immediately opened close to the cervix sufficiently to allow the introduction of one finger, which then becomes a guide for the further complete severance of the tumor. If the operation was commenced through the vagina, this first opening is sought from above and is followed in the subsequent dissection. The separation of the remaining portion of the broad ligament is conducted close to the tumor. Hemorrhage from the latter is entirely passive and receives no attention save to sponge away sufficiently to keep the landmarks in view for the subsequent manipulations. With the finger in the vagina from above as a guide, the whole mass is cut away, keeping as close to the tumor as possible. The open ends of the secured uterine arteries can always be located, and if it is deemed advisable, a separate ligature can be applied to each of them directly, between the cut end of the artery and the ligature already in place. The removal of the tumor gives easy access to the pelvis for further manipulation, which consists in uniting bv a continuous suture the edges of the broad ligament from above downward on either side; in doing this it may be well to enfold the stump of the ovarian artery as well as the stump of the uterine artery, by so doing completely covering them with peritoneum.

The vagina is then closed by also uniting the cut margins in the lateral plane from broad ligament to broad ligament, care being taken to turn these edges towards the vagina so as to coaptate the vaginal margins and the edges of peritoneum above it. One of two methods is usually employed in doing this. First, the suture of the broad ligament is continued on the vagina from one side, gradually coapting the edges of the vagina and tied when the opposite side is reached. The suture from the other side coaptates the peritoneum, but in doing this each stitch also includes some vaginal tissue, thus binding the peritoneum down to the closed vaginal vault, and preventing any oozing between the peritoneum and the tissues below. Or the suture from either side includes peritoneum and vaginal margin at once, meeting its fellow from the opposite side in the middle, where they are tied to each other. Douglas pouch is then cleasned, the patient brought down to the level, and the abdominal wound sutured. Deep stay sutures, usually of silkworm gut or silver wire are passed through all the tissues down to the peritoneum, a continuous suture of catgut closes the peritoneum, and one or more of these continuous sutures are applied so as to coaptate the different layers of the abdominal wall. a final one uniting the skin. The vagina is then cleaned, and a strip of aseptic gauze inserted in such a way that the lower end is accessible. After urination or the use of the catheter, a couple of inches of this gauze are drawn out and cut off, thus making it always easy to obtain a free end and avoiding any contamination from below.

The abdominal wound is inspected first on the eighth or the ninth day, and the rule is to find union by first intention. The urine is measured for the first two or three days to determine the quantity passed, and so to make certain that the ureters are not involved. In no case in our experience have the ureters been injured, but in two cases the bladder has been opened at the time of operation, closed by immediate suture and primary union obtained. with no disagreeable after-effects. So far as the writer knows in only one case has there been ventral hernia, the first case operated upon by amputation through the cervix and ventral fixature of the stump. This method was used in the first four cases, but since then has not been employed. So far as known, all of these cases reported as cured are still living, except one, death having resulted in this case two years after the operation from causes in no wise related to the same, and we have been in frequent communication with the larger portion of them, the results having been entirely satisfactory.

7 Miss A. J. C.

"

Ether. Yes. Extra-peritoneal

treatment of the

Oct. 27.
1894.

Feb. 13.

Percentage of deaths to total number of cases, 5.88.