cations of carbolic acid. The flaps are then stitched together with a running catgut suture over the top of the stump, care being taken to make them cover all the ligatures on either side. I use catgut ligatures on the broad ligaments and also for stitching the flaps. The advantage of using a single ligature for each broad ligament is that it puckers up the end of the ligament and carries it down alongside of the cervix, so that the raw surface is very easily covered by the peritoneal flaps.

In a general way the advantages of this operation and the superiority over the method of total extirpation consist in the following points:

1. It involves the least possible loss of blood; indeed, it is rare for any hemorrhage to occur.

2. It is easy of execution, for the reason that the stump of the cervix can be brought up near to the abdominal wound and the details of disposing of the traumatic tissue carried on with ease and comfort to the surgeon.

3. It is applicable in its general plan to all cases of fibroid

tumor.

4. It requires less time than total extirpation.

5. Convalescence, as a rule, is rapid and free from complication. Moreover, the patients require no special after-treatment whatever. It is not necessary to put gauze in the cervix or in the vagina, consequently there are no dressings to be attended to. The after-treatment consists in regulating the functions of nature and removing the stitches from the abdomen. The openbowel treatment is employed, and as a rule the patient urinates without assistance.

Dr. Haywood Smith, of London; Dr. H. N. M. Milton, of Cairo, Egypt, and Dr. Baer, of Philadelphia, have contributed, independently of each other, the suggestion of ligating the uterine artery in continuity.

Zwiefel has adopted the formation of distinct peritoneal flaps and the ligation of the stump inside the flaps. These were the distinctive features of my operation. With this method he has reported a series of 51 cases with 2 deaths-a mortality of only 4 per cent. This may be regarded as the standard of results in the operation for hysterectomy for fibroids, and brings it into sharp rivalry with simple ovariotomy. Not all of the abdominal operators have adopted this method of supravaginal hysterectomy. Some of them continue to employ the method of panhysterectomy. Abdominal hysterectomy was developed by Freund in the treat

ment of cancer of the uterus. The adaptation of this method to the treatment of fibroid tumors was first suggested by Bardenhauer, but before he had an opportunity to put it into execution,

Martin of Berlin, either acting upon this suggestion or upon his

own initiative, applied the method in two cases, both of which were successful. This was in 1889. The operation was accomplished in two distinct steps; first supravaginal amputation, second removal of the cervix. Martin leaves the wound in the

vagina open, packs the pelvis with gauze and secures drainage per vaginam. Chrobak of Vienna, adopted this method for a time, but modified it by making distinct peritoneal flaps from the anterior and posterior faces of the uterus, with which he covered over all raw surfaces, and the ligatured stumps. Chrobak later became a convert to the method of retaining the cervix. In this country the technic of total extirpation as practiced by most operators, differs from the German method. Instead of making two distinct steps in the operation, the dissection is carried down into the vagina and the tumor, uterus and cervix are removed en masse. The traumatic tissue is disposed of as after vaginal hysterectomy. These men are not all devoted to this method exclusively, sometimes the supravaginal method is employed. Formerly silk was used almost exclusively for ligatures. At the present time this has been pretty generally discarded for an absorbable material and chromic gut and kangaroo tendon are indiscriminately employed. The angiotribe still holds its place as a reliable hemostat and is especially serviceable in controlling the uterine artery in continuity in cases in which the cervix is retained. I use it constantly, although not exclusively.

It has gradually become the custom in hysterectomy for fibroid tumors to leave one or both ovaries. The tubes when healthy may be retained also. By the retention of the ovary the patient is supposed to derive benefit from the continued secretion of that organ. As a matter of fact, there is less disturbance of nerve balance, a more satisfactory recovery, and a larger measure of good health and enjoyment secured in those cases in which the ovary is preserved. In opposition to total extirpation I have this to observe, that the technical difficulties involved in the removal of the cervix, and the control of hemorrhage from the vagina where it has been incised, surpass those encountered in all the rest of the operation. Moreover, by leaving the cervix as a stump and covering over the raw tissue by peritoneal flaps, the pelvic organs are adjusted to as nearly a normal position as possible, and the traumatic tissue necessitated by the operation is disposed of as perfectly as in a plastic operation. The percentages of recovery are about the same in the two methods. There are certain conditions, however, in which removal of the cervix is indicated, and then complete extirpation of the entire organ by either the German or American method is in order. These conditions are suppurating complications in which pus has escaped during operation, the exposure of large raw surfaces due to the

stripping off of extensive adhesions from the walls of the pelvis or intestines and the presence of cancer in either the body of the uterus or the cervix. The removal of the cervix as a prophylactic against the later development of cancer is based upon a very remote contingency. The cervix atrophies after supravaginal amputation. It does not degenerate into cancer.

It is recognized at the present time that either complete or supravaginal hysterectomy is contraindicated in women of childbearing age, except in tumors of large size involving the entire substance of the organ, or when complicated by destructive disease of the appendages. Conservation of tissue and of function is the dominant note in the surgery of to-day, and in all cases in which the conditions give promise of future function and justify the attempt at conservation, without the involvement of too great risk, myomectomy as contrasted with hysterectomy is the method of choice. The life history of tumors of the uterus. their degenerations, their malign influence in aggravating, if not producing, complicating disease of the appendages, their interference with impregnation, gestation and parturition, and their probable influence in producing carcinoma of the uterus-their life history, I say, as elucidated by careful and continued study, is gradually overthrowing the old classic teaching, and establishing the rule for the advanced operators in this field, that every neoplasm of the uterus that produces symptoms or that may be discovered incidentally in the process of any pelvic operation, should be removed. Indeed, personally, I go farther than this, and for my own individual guidance have formulated the rule that every neoplasm of the uterus when discovered in a woman during the child-bearing period, wherever situated and whatever its size, large or small, should be removed forthwith. Prophylaxis applies here as in every other field of medicine. Its corollary is equally applicable. The earlier the remedy is applied the simpler its application and the more effectual its results.

This is the position I took in discussing a paper on "The Complication and Degenerations of Fibroid Tumors of the Uterus," read by Dr. Noble of Philadelphia, before the Obstetric Section of the Academy of Medicine, in April, 1901. In a more recent paper read before the Amer. Gynec. Society at Boston, May, 1904, Dr. Noble analyzes, on the basis of complications and degenerations, 1,188 cases of fibroid tumor of the uterus by seven different operators, and comes to the conclusion that, based upon careful clinical and pathological findings at least 795 of these patients

must have been sick women; that at least one-third of them would have died from the degenerations and complications had they not been subjected to operation; that women having fibroid tumors therefore run a far greater risk of losing their lives by not being operated upon than by submitting themselves to operation, and that as a general rule, when tumors are present in the body, symptoms or no symptoms, they should be removed.

Accepting, then, the general principle that these tumors of the uterus should be removed when discovered, the technic of the operation must be varied to meet the various conditions. When the tumors are small, they may be removed per vaginam. This is accomplished either through the posterior fornix, the anterior fornix, or, when necessary, both incisions may be made. Through these incisions one or more fibroids can be shelled out, a buried suture placed in the musculature to control hemorrhage and restore the uterine wall, and the wound covered with peritoneum by the Lembert suture. In this way I have removed from one patient as many as seven tumors, situated in various parts of the uterus, and varying in size from that of a marble to that of a hen's egg. Tumors three inches in diameter can be successfully attacked and removed in this way. The advantages to the patient, of operation by this route, are all those that pertain to the vaginal method in preference to the abdominal. The primary danger is less, the convalescence is more comfortable, the fear of subsequent hernia is obviated and the woman is free from any reminder of mutilation, secured by the absence of a scar. This method is especially adapted to young unmarried women.

Tumors of larger size than 32 or 4 inches in diameter, are better attacked through the abdominal incision. The technic in dealing with the tumor and its immediate field is quite the same as in vaginal myomectomy, but the field of application is far wider. It is astonishing how many and what large tumors can be removed, leaving a functionating uterus. The uterus can be hemisected with impunity quite down to the cervix, the tumors shelled out on either side and the organ restored by stitching together the two halves of the uterus. Even after extensive work of this character women have become pregnant, gone to term and been delivered successfully of living children.

There is an element of danger, however, in myomectomy, especially in these extreme cases, that does not obtain in hysterectomy. It lies in the possibility of an oozing that may occur in the re