dominal wound this ligature is removed, and a little time is al lowed to make sure that there is to be no more hemorrhage from the uterine wound. Hemorrhage is usually in a great measure controlled by the uterine contraction which follows the enucleation. The mortality of this method for small tumors, in which the traumatism is slight, is surprisingly small.

In case of a large tumor, and consequently of large traumatism with enormous surfaces to be united by buried sutures, closure of the uterine wound involves too great danger of sepsis, and the technique should be modified as follows: After the tumor has been shelled out from the uterine wall an opening is made directly from the tumor cavity to the uterine cavity. If the uterine canal is patulous, a continuous strip of gauze is carried from the tumor cavity directly through the uterine canal into the vagina, and the tumor cavity packed with the same continuous strip. The temporary elastic ligature around the cervix does not interfere with the introduction of the gauze. The uterine wound is then closed, as above described, by buried sutures and deep Lembert sutures of catgut. The peritoneal margins of this wound, thus turned in and united, rapidly grow together, and the whole uterine traumatism, now isolated from the peritoneum, is adequately drained through the vagina. No abdominal drain is required. If the uterine canal is not sufficiently patulous, it may be dilated or bilaterally incised by means of a herniotomy knife, or it may be both dilated and incised. The vagina is loosely filled with gauze to meet that which protrudes from the uterus; an absorbent vulvar dressing, to be changed as often as it becomes moist, completes the capillary drain. The gauze is removed in two or three days. Care is necessary in the closure of the uterine wound that the gauze be not caught in a suture, because then its removal would have to be postponed until after the absorption of the suture.

As shown in the two cases reported, the same principles will apply also to an intraligamentous tumor. The intraligamentous myoma may be shelled out from its bed between the folds of the broad ligament. The same mode of drainage may be used as in the case of intramural tumors, except the route of drainage. This should be not through the uterine canal, but through an opening which is readily made from the tumor cavity to a point in the vagina just back of or in front of the uterus. In exceptional cases it may be necessary, for purposes of haemostasis, to ligature the ovarian or uterine arteries or both. Experience has shown that sloughing of the uterus from thus cutting off its blood supply is not to be feared.

Intra-abdominal closure of the uterine wound and vaginal drainage of the tumor cavity was early suggested by August Marin of Berlin, but this surgeon appears not to have developed or practiced the method extensively.

My own experience during several years with the above technique shows: First, almost entire freedom from mortality; second, prompt and uneventful recovery; third, the most gratifying permanent results.

The method is undoubtedly applicable to a much larger number of tumors than is generally supposed. Any surgeon who is constantly alert to enucleate the tumor and preserve the reproductive organs will be surprised at the number of cases in which this is entirely feasible. The mutilating operation of hysterectomy for myoma is often necessary, but not so often as the statistics of the present time would indicate. A few weeks ago I enucleated thirteen myomas from the walls of a uterus, repaired the uterine wounds thus made and left the organ entire. The result was perfectly satisfactory.

In the vast majority of cases the uterine appendages will be found normal, and in a large proportion of the majority the tumor may be enucleated from the uterus and the wound successfully closed, precisely as would be required for the removal of such a tumor from any part of the body. Cases of very large tumors and cases in which many small tumors are scattered through the uterine wall may require hysterectomy, but the conservative operation of simple enucleation will often apply when the tumor is even larger than the foetal head, and in cases of multiple myomata even when there are several tumors. In one case, fifteen years ago, I removed a forty-five pound myoma and preserved the uterus. This specimen before you must weigh over twenty pounds and yet the uterus was not destroyed. The 'tumor cavity from which it was enucleated was drained through the vagina.

MEDICAL PROGRESS.

Advances in Our Knowledge of Typhoid Fever.

Since the sad experience of our troops at home and abroad last year with typhoid fever, medical interest in the disease has been, if possible, even more keen with regard to everything pertaining to it than before. The spring time nearly always wit nesses a recrudescence of the disease in various parts of the

country, owing to the fact that the melting snows and the spring freshets carry down with them into the water supplies of towns a certain amount of infective typhoid material that has been accumulating during the winter months. Typhoid is one of those diseases of which the practitioner is apt to think that "there is nothing new under the sun," at least, nothing new that has a practical application or is of value in the prophylaxis or treatment of the disease. A glance, we think, at Dr. Taylor's article on "Typhoid Fever" in Progressive Medicine, the new quarterly review of medical progress, edited by Professor Hare,* is apt to disabuse one of any such unprogressive notion.

With regard to prophylaxis of others during the treatment of a case of typhoid, these noteworthy recommendations from a French source are given: (1) Isolate patients suffering from typhoid fever, or at least do not permit them to be treated in a room or ward containing young people who have not previously had typhoid. The warning contains some wholesome advice too often neglected, and sometimes with sad results, because we are persuaded that typhoid is not an air-borne disease, and forget that contiguity favors infection because precautions will inevi tably sometimes be neglected. (2) Nurses for typhoid cases should, if possible, be only such as have typhoid themselves. In a family the young people should be removed. (3) The floor of the sick room should be oiled, so as to be impermeable. Carpets and rugs should be removed, and the raising of dust should be avoided by frequent use of a cloth dampened with antiseptic solution. (4) The nurses should wear linen clothes, which they should remove when they leave the sick room, and in general they should be warned to be circumspect in their relations with others, and especially careful of the utmost details of antisepsis in the matter of the preparation of food and drink for themselves and others.

The review of the question of typhoid infection from oysters is full and conclusive. The possibility of typhoid infection through salads is made clearly apparent, manure being used in bleaching the plants and gardeners being careless in handling it and washing the plants in any sort of water, or sprinkling them with infected cistern water.

The strikingly practical features of this excellent review of the recent literature of typhoid, are the discussion of the question of typhoid without intestinal lesions, and of its corollary that intestinal lesions, even when existent, often play a very

*"Progressive Medicine," a Quarterly Digest of New Methods, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by H. A. Hare, M.D. No. 1, March, 1899. Lea Brothers & Co., Philadelphia.

minor role in the disease. How important these questions are for the matter of treatment is clear at once. All the so-called abortive methods of treatment, all the much-lauded systems for securing intestinal antisepsis, all the many drug formulae and combinations that have been enthusiastically recommended for the treatment of typhoid, assume that the essence of the disease is the intestinal lesions. This is a notion that must disappear before scientific advance of our knowledge of the true nature of the disease.

CHEERFULNESS AND PRUDENCE.

Jest keep the heart a-beatin' warm,
Be kind to every feller;

Look for the rainbows in the storm,
But-carry yer umbreller!

Be brave to battle with the strife,
Be true when people doubt you:
Don't think that money's all in life,
But--carry some about you.

An' when it's time ter shuffle off,
An' you have done yer mission,
Just put yer trust in Providence,
An'-call a good physician!

--Atlanta Constitution.

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