toneal or intestinal adhesions. This enucleation was successful when the pocket was thick and the adhesions soft; but when it was thin or friable, when adhesions were thick, when the pus was contained in such fragile envelopes, no matter how it was treated, rupture was with difficulty avoided, at least in the dependent parts, and often it would take place sooner than desired.

Even if the small intestine was well protected, even when effusion was slight, septic pus soiled the fingers and the peritoneum, and the operation was finished under bad conditions. If on the contrary total ablation is done, the uterus, attached from below upwards, flexed and drawn up, bringing the adnexa along with it, whose enucleation, commenced at the lower part, is rendered easier, the entire utero-ovarian mass can be removed en masse. If rupture occurs, it takes place below the adnexa, while upper adherent parts serve as a protection to the peritoneum; an immediate irrigation during the operation and limited to the pelvis, removes the septic fluid and cleans both instruments and fingers. Such is the method that I shall now detail and is an imitation of that employed by our American confrères.

the

The patient is placed in the Trendelenberg position with the operator on the left. The incision made, the uterus is brought to view and dissected off from Douglas' pouch; a traction forceps seizes and draws up the fundus; compresses hold and protect the intestines. A large valve, placed at the pubic end of the incision opens the wound and gives light on the utero-ovarian mass. (Fig. 1.)

An anterior peritoneal flap is cut by a transversal incision extending from one broad ligament to the other, made some distance from the bladder, at a point where the peritoneal covering of the corpus uteri turns off from the muscular structures and becomes movable on the anterior surface of the cervix. The finger tears and increases the incision, detaches the flap and pushes it back. The bladder is pushed into the true pelvis and the lower segment is denuded, as well as the parametric tissue, in the midst of which the uterine artery may be seen by transparency. (Fig. 2.)

We must now, as I have already said, attach the uterus from below upwards. The uterine artery must first be secured; nothing is simpler than to push a clamp into the parametric tissue and seize on both sides. Silk ligatures may be used instead, if preferred. Temporary hæmostasis thus accomplished, I take a dis

secting forceps and scissors and I attack the vaginal insertions; I cut obliquely, little by little penetrating the uterine tissues and I open the anterior cul-de-sac. As soon as the opening is sufficiently large, I seize the cervix with traction forceps and draw it from the vagina by bending the lower segment, and this allows

me little by little to complete the circular incision and entirely free the cervix. The posterior vaginal section always bleeds, and one or two hæmostatic clamps may be necessary. (Fig. 3.)

Now come the difficulties. Commencing on the left we should continue to section close to the uterus and arrive at the adnexæ. The method of removing them will depend upon their size and condition. A large tube with thick walls is not very dangerous, but a thin and distended pocket requires much care. The tube is included between the two layers of the ligament or bound down behind it. It is well to tear the anterior layer, cut the round ligament, enter the parametric tissues, break or cut a few fibrous bands very near the purulent pocket, slide between them and the pelvic wall in order to cut the upper border of the broad ligament outside the adnexa.

The tumor is partly freed but it still is attached to the deep adhesions; this is the delicate part. Be particular to separate from below upwards, and in all probability the tube can be enucleated without rupture, and raising up the mass, any adherent intestine can be easily detached. Separate from below upwards in order to leave until the last moment the upper adhesions, and so that rupture will take place towards the true pelvis. (Fig. 4.)

If rupture occurs, I advise absolutely the flushing of the pelvic cavity. Some surgeons have a horror of pouring water into the peritoneal cavity. Now I understand that extensive irrigation and diffusion of septic matter are to be avoided, but I do not see how a circumscribed washing of the contaminated parts can extend over the cavity and I do not see the use of leaving soiled peritoneal surfaces up to the end of the operation and I believe it is far safer to rapidly remove the septic matter before going on.

When the adnexæ are detached from the true pelvis, separated from the uterus or left adherent to the horn, the same manœuvre is repeated on the right side, and according to whether it has been or not difficult, the utero-ovarian mass is removed in whole or in several pieces. It now remains to make a definitive hæmostasis and dress the pelvic cavity.

If the peritoneum has been perfectly protected and drainage unnecessary, the vagina is occluded as in the operation for fibroids; a strong needle and a few separated sutures are sufficient; this is a sure means of arresting the bleeding in the posterior vaginal wall. Next the broad ligaments are sutured with inter

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Fig. 4.

G. DEVY

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rupted catgut sutures, the lower ones, which are perpendicular to the course of the uterine artery, include the vessel at one or two points. To end up, the anterior peritoneal flap is sutured to the vaginal stem and to the region of the uterine artery. We thus have a line of sero-serous sutures in the shape of a crescent or

horseshoe. The abdomen is closed without drainage, if the peritoneal cavity is perfectly clean.

But if infection is to be feared, the vagina is left open, a few sutures being placed on the bleeding points. The uterine artery is tied. Then gauze strips are loosely but exactly packed into the pelvis, in order to wall off the focus, to protect the intestine from being infected and to set up protective adhesions. The strips extend through the vaginal wound in order to obtain drainage so that the abdominal incision may be completely closed and a good cicatrix result. But gauze is not a good drain, and for this reason a large drainage tube must be inserted in the midst of the gauze strips.

And lastly, if septic material has been scattered through the peritoneal cavity, a second drainage tube is to be inserted in the abdominal incision so that the discharges and irrigations of the pelvic cavity may easily flow out after the gauze has been removed. I have certainly saved one patient by this means, and recently I trembled when I heard a celebrated German surgeon say that he had never drained the peritoneal cavity.

Such is the method to which I wish to call attention. I have only employed it up to the present time in a few cases, and consequently I shall wait for a while until I can publish some statistics bearing on this method.

Rue de Penthèvre, Paris, France.

TOTAL HYSTERECTOMY FOR LARGE FIBROIDS.

DR. LE BEC.

Surgeon to the St. Joseph's Hospital, Paris.

THIS method is specially adapted for the removal of largesized fibromata in cases where it is not possible to extract the tumor by the vagina. In the year 1891 I endeavored to perform this operation by a combined method, published in the Bulletin of the French Congress of Surgery for 1893, p. 161. By this operation I tried to remove the greatest part of the tumor by the belly and the most inferior part by the vagina. Something similar was tried by Martin, Chrobak, Freund and Péan. I performed this operation only nine times, for I soon observed that