mortality is very great, and the wound heals very slowly, and is apt to leave fistulæ.

2. Hegar's Method.-Hegar makes on the posterior surface of the sacrum a V-shaped incision with the base turned upward, cuts muscles and ligaments on the edges of the bone, detaches the rectum, and cuts the sacrum with a chain-saw between the third and fourth sacral foramina in a slanting line, preserving the periosteum on the posterior side. The end of the sacrum is not detached, but only thrown upward, and later replaced.

In regard to the whole procedure of sacral hysterectomy it may be said that a cancerous uterus that cannot be removed by the vagina is not fit for extirpation.

Perineal Hysterectomy (Zuckerkandl's Method) opens the way to the uterus by a transverse perineal incision from one tuberosity of the ischium to the other, and by separating the vagina from the rectum.

Abdominal Hysterectomy (Freund's Method) for carcinoma was at first attended with such extreme mortality that the operation was universally abandoned, and was only used as a necessary addition to vaginal hysterectomy (vagino-abdominal hysterectomy) when difficulties were encountered which could not be overcome in any other way. Still, by the easy access it gives to all the pelvic organs it is preferable to the sacral and the perineal methods. And the great success obtained with abdominal hysterectomy for fibroids of the uterus has brought some operators back to abdominal hysterectomy for cancer also. It offers the advantage that one can remove more of the broad ligaments, and thus come farther away from the seat of the disease. By previous introduction of flexible catheters into the ureters by Kelly's method (p. 163) these organs may be avoided.

Perineo-vaginal Hysterectomy (Schuchardt's Method).'—The same advantages are, however, claimed for the perineo-vaginal method, which is particularly adapted to cases in which one of the broad ligaments is involved in the cancerous degeneration. The patient is placed in the dorsal position with drawn-up feet. On that side on which the ligament is affected an incision is made from a point between the middle and posterior third of the labium majus, encircling the anus at the distance of two finger-breadths, and ending about the level of the tip of the coccyx. This incision is deepened, especially in its anterior part, in the adipose tissue of the ischio-rectal fossa, until the wall of the vagina is exposed. Next, the whole vaginal wall is split from below up to the cervix, and after that the operation is the same as in common vaginal hysterectomy with ligatures-circular incision around the cervix, opening of the pouch of Douglas, severance of the ligaments, separation of the bladder from the uterus, only with this difference, as it is claimed, that everything is done 1 Centralbl. f. Chirurgie, 1894, No. 30, Beilage, p. 61.

with the greatest ease, and that all ligations are made under the guidance of the eye. Both ureters can be extensively laid free, and even diseased parts of the bladder may be cut out. The incisions are only made on one side, and the wound heals by granulation in three weeks.

If the uterus is movable and any part of it is cancerous, the whole organ, in my opinion, should be removed, together with the appendages. If it is immobile, a suitable palliative treatment up to extirpation of the cervix is indicated.

In order to be able to extirpate cancerous glands from the pelvic floor it has been advised to ligate the anterior division of the internal iliac artery, which normally gives off the superior vesical, the vaginal, the uterine, the obturator, the middle hemorrhoidal, the internal pudic, and the sciatic arteries, and by the ligation of which the surgeon would be enabled to work in a bloodless field. But the internal iliac artery and its branches are subject to many variations. Frequently there is no separation into an anterior and a posterior division, or the anterior division may be so short that it cannot be ligated. It would, therefore, be necessary to tie the whole trunk of the internal iliac, which can be done. It lies between the upper end of the sacrum and the upper end of the great sacro-sciatic notch, and is usually an inch to an inch and a half in length, but sometimes it is only half an inch long. It lies at the inside of the psoas muscle, under the peritoneum. The vein lies behind it and somewhat to its inner side, the ureter in front and to the outer side (Fig. 83, p. 82).

The obturator artery is especially erratic, not unfrequently arising from the posterior division of the internal iliac, and sometimes from the external iliac or the epigastric, which is of so much more importance as the obturator gland is more liable to be affected than any other. But when once glands are affected there is no telling how far the infiltration extends, and under such circumstances it is better to desist from operation.

F. Papilloma.

Under the name of papilloma many different tumors have been described which have in common a dendritic, digitate, or villous shape. Most of them are simply a form of carcinoma of the cervical portion-Clarke's cauliflower excrescence (see p. 508). Others are fibroid polypi (p. 470), formed by increase in size of the papillæ of the cervix, and are generally covered with stratified flat epithelium. They have a pedicle composed of connective tissue and muscular fibers. Others, again, contain glands, and belong, therefore, to the mucous polypi (p. 408). Others, again, are sarcomas that have taken the papillomatous form (p. 504).

"Quain's Anatomy," 9th ed., 1882, vol. i. p. 451.

Some, finally, are true papillomas. In these the tumor is formed by hypertrophy of the papillæ of the vaginal portion. It contains highly dilated capillaries and larger vessels with very thin walls, but no epithelial elements. It gives rise to a profuse watery discharge and hemorrhage, but the general health does not suffer much, and if the growth is removed by an operation in the healthy tissue, no relapse follows. But when these tumors become old, epithelial elements appear in them, and they take on the structure of epithelioma. This true papilloma is likewise found springing from the mucous membrane of the body of the uterus, but is exceedingly rare in that locality.

Treatment.-True papilloma is to be treated by amputation of the cervix, or, if situated in the cavity, by curetting and cauterization.

G. Enchondroma.

Enchondroma has been found in the cervix, but is very rare. It should be removed by amputating the cervix.

H. Tuberculosis.

Next to the tubes, the uterus is the part of the genital tract which is most commonly the seat of tuberculosis. It may be primary or secondary, and the latter may again spread from neighboring organs or be due to infection through the blood. The disease is usually limited to the mucous membrane. It occurs in three forms-the acute miliary, chronic diffuse, and chronic fibroid form. Of these, the chronic diffuse is by far the most common, and is characterized by the formation of cheesy masses. Tuberculosis is nearly always limited to the body of the uterus; and, on the other hand, in a considerable portion of the few cases of cervical tuberculosis on record the disease did not invade the body.'

Diagnosis.-Besides offering the symptoms of endometritis, the uterus is considerably enlarged, which is partly due to tuberculous infiltration, partly to hyperplasia of the normal elements. Knobs may be felt near the cornua. If the os is closed, pus may accumulate, so as to form a fluctuating tumor (pyometra, p. 326). If it is open, caseous masses may be expelled from it. Shreds removed with the curette and examined microscopically may show bacilli and cells, as described on p. 288. As a rule, a tubercular affection is at the same time found in the tubes and the lungs.

Tuberculous ulceration of the cervical portion may be mistaken for carcinoma. Microscopical examination of a piece cut out from the

J. Withridge Williams, "Tuberculosis of the Female Generative Organs," Johns Hopkins Hospital Report in Pathology, ii. Baltimore, 1892, p. 126.

neighboring tissue shows, however, an entirely different structure in the two diseases.

Treatment.-As to general treatment, the reader is referred to what has been said in speaking of tuberculosis of the vulva (p. 288). The local treatment consists in curetting and the application of iodoform. If the disease relapses and the general condition of the patient is not too bad, the uterus, together with the appendages, should be removed by vaginal hysterectomy.

PART V.

DISEASES OF THE FALLOPIAN TUBES.

CHAPTER I.

MALFORMATIONS.

THE tubes are sometimes unusually large. In most cases this increase in size is due to the presence of some abdominal tumor, with which the tube is connected and grows in length and width. But even apart from any such complication it has been found to measure six inches and a half in length. One tube may be longer than the other.

They may be wound in a spiral or be abnormally contorted, conditions which predispose to retention of fluid, inflammation, and extrauterine pregnancy.

There may be from one to three accessory abdominal ostia. They are surrounded by fimbria and situated near the abdominal end of the tube, on the upper part of the wall.

There may also be accessory tubes, either as cystic diverticula starting from the tube, but without communication between the two cavities, or as independent tubes with fimbriæ starting from the mesosalpinx. In the latter variety ectopic gestation may take place— paratubal pregnancy.1

The tubes may be absent, on one or both sides, which is due to a destruction of the corresponding part of the Müllerian ducts in the embryo.

In other cases there may be a partial or total absence of tunneling of the tubes, the result of an arrest of development (p. 30). In others, again, the tube is normal near the uterus, but is soon lost in the connective tissue of the broad ligament. The corresponding ovary is usually absent or little developed.

Deficient development of the tube may be the cause of pain at the menstrual period, and local peritonitis, when ovula and blood from the Graafian follicles fall into the abdominal cavity.

At the fimbriated end of the tube is often found a little cyst called the hydatid of Morgagni. Its inside has a ciliated epithelium, and it is filled with a clear fluid. As a rule, it has only the size of a pea, but it may acquire that of an English walnut. It is not of surgical

interest.

1 Sänger, Monatsschr. f. Geburtshilfe und Gynäkologie, 1895, vol. i. No. 1, p. 25.