operations in surgery. Radical removal of the uterus means to lay bare some inches of the ureter and to dissect to the obturator foramen in getting most of the paravaginal and paracervical fat and to own an equipment that will illuminate adequately this deep cavern. The so-called Wertheim's seen by me in England and the Wertheim's usually seen in America before the American Gynecological Club's German trip of 1912, were almost without exception ordinary total hysterectomies, bringing scant paracervical or para

vaginal structure and not cleaning off the lateral pelvic walls clear down to the pelvic floor. A radical operation takes nearer two hours than one and a half hours. In the best hands the mortality is necessarily very high and a not inconsiderable number of ureters are injured. Wertheim told us that cancer of the cervix in fat women should not be attacked by the upper route but by the lower. Those cancer cases which come early and give the better results with the Wertheim operation, an enlarged Byrne operation will usually suffice to cure. When the glands are involved, we all know how seldom cure is recorded.

The gynecologist who is in the habit of doing a reasonable proportion of his hysterectomies by the vaginal route is able to institute comparisons upon a basis of experience. Exclusive of hospital patients, my private records show seventy-eight vaginal removals of the uterus. Comparing the partial hysterectomy of Byrne with the Schauta vaginal hysterectomy, as seen in four cases at his clinic and in three done since seeing those cases, I can say that the cautery knife can make neither so wide nor so intelligent a dissection as the steel knife and scissors of Schauta and his assistants. The heated platinum blackens and shrivels and obscures structure. This is a handicap. It takes great skill to dissect out the ureter in a genuine Austrian "Erweiterte Operation." The lovely pictures in the book are more dressed and trimmed up by the artist than my series of careful sketches taken over the Viennese shoulders, which show the frequent difficulty in identifying and clearing the ureter.

I have seen Werder do his operation in Pittsburg, but inasmuch as the cervical parametrium presents the danger zone of extension in cervix cancer, it seems to me that, as long as a vaginal attack has been undertaken, the whole work had better be completed through the vagina. The only excuse for any of this clumsy, slow cautery technic is the sealing of the lymphatics. The lymphatic channels which carry dangerous cells are those of the lower portion of the broad ligaments, and these are sealed by Werder in his vaginal cautery work. The cautery clamp on the ovarian and round ligament vessels of the upper third of the broad ligament is, therefore, an unnecessary precaution against cancer located in the cervix, and a considerable difficulty and complication. His clamp follows the method of Downes. Downes' clamp is a modification of the Skene clamp, adding to the power and ecraseur action of the original instrument. Therefore, the operation advocated by Werder is a combination of two Brooklyn hysterectomies that with electrohemostatic clamps namely Skene's, on top of a Byrne cervix amputation.

I have seen Percy (and others) cook the core of the womb with an assistant's hand inside the abdomen grasping the uterus and have not failed to note somewhat brutal tools, shock, a huge, shut-in slough, and a considerable death-rate. We know now how this radiation in the pelvis, heating until all the red cells in the body have time to pass, may disintegrate them, and that autopsy has shown gastric ulcers corresponding with the findings after extensive superficial skin burns.

Technic is purposely presented to you this evening rather than

results. Not that careful reports lack weight in argument, but that each operator of sorts must judge for himself. Every man of wide experience and trained judgment who controls ample material must

reach his own conclusions in any operative procedure. Demonstrate your technic to me; show me the kind of case to which you believe your operation better adapted than any other; let me see you go through the steps, and, if it seems reasonable, I will give it a conscientious test. This is particularly the case in such instances

as cancer of the cervix where few operable tumors come to any one individual, and where many surgeons must try out a claim. It is especially true when, disappointed with a newer radical method, we are asked to turn back to an older plan that presents new features.

By an enlarged Byrne operation I mean: a. Take the core out of the uterus, removing all of the canal of the body of the uterus as well as the cervix, so that the circular scar of the burn, in its inevitable contraction to a stricture, does not yield the characteristically severe dysmenorrhea that results when only the cervix and part of the canal of the uterus is removed. Byrne often employed this technic, saving only the fundus of the uterus. The advantage of leaving the fundus is that one secures a roof for the pelvis (Fig. 2, c). It practically peritonealizes this operation. It prevents bowel adhesions. We who have often done a Byrne cautery operation for the lower part of the broad ligament and then treated the remainder of the uterus like an ordinary vaginal hysterectomy, need of course, to sew the broad ligaments together as a final step. But this additional removal is unnecessary, because in cancer of the cervix the recurrence is not in the upper part of the broad ligament but in the lower part, and it is not good surgery because cutting and sewing should not be done in the neighborhood of cancer tissue.

b. Take all the paravaginal and paracervical tissues that can be safely removed. Our vaginal hysterectomies that have taken in a large part of the broad ligament by the method of Schauta (preceded by the sweeping pelvic incision of Schuchard) taught us how to secure the needed free access. This knowledge and experience of the distance we can safely go have been important enlargements of the Byrne method, which, as far as I know, he never used. Big or water-cooled specula seem to me clumsy and unnecessary. Even Byrne's wet gauze guards placed under the retractors narrow the passage. Two retractors, acting just where one is working, usually suffice.

c. To use the gloved finger in the rectum and the thermometer or little finger in the bladder is to have a guide to deeper and further work than we were able to do in Byrne's time. This development and enlargement of Byrne's method Percy has contributed. It has been shown that the long heating of Percy may cause disintegration of all the red corpuscles. Percy's iron cooks a considerable area steadily. To the red knife edge this grave objection does not apply. Byrne's knife touches only one point at a time.

d. In certain cases one opens the abdomen and has the assistant hold the uterus in the gloved hand so that he can report when the