Showing ligament drawn out to full length with first suture inserted and pressure forceps attached to each end. lique muscle and introduce the second suture. The ligature carrier (Fig. 3) is threaded with a stout silk ligature and the assistant retracting the upper margin of the skin incision sufficiently to expose at least an inch of the surface of the external oblique muscle above the line of incision, it is inserted as shown in Fig 9. The liga Fig. 9. Fig 10. Showing loop of round ligament braided under the external oblique muscle. The second suture also of silkworm gut is now inserted. It penetrates the skin a quarter of an inch from the margin of the incision near the lower angle; then the thicker part of the loop of round ligament as it emerges from under the external oblique muscle above, then the muscular margins of the incision through Showing insertion of ligature carrier for burying loop the roof of the inguinal canal at its of round ligament under external oblique muscle. ture securing the loop of round ligament is now engaged in the ligature carrier (See Fig. 9) and as the latter is withdrawn this ligature is pulled through after it. With this ligature the loop of round ligament is drawn through under the belly of the external oblique muscle as shown in Fig. 10. lower angle, then it catches the free loop of the round ligament which has been folded down across the wound and emerges through the skin below at a point opposite its insertion above. (See Fig. 11.) This suture secures the free loop of round ligament folded across the base of the incision and assists in closing the incision in the roof of the inguinal NEW ENGLAND MEDICAL MONTHLY. Fig. 11. Showing position of both sutures before they are tied. The second suture penetrates the free loop of round ligament, at A before it passes through the skin at A. 313 of two weeks and usually the patient is confined to bed for another week afterwards. The pessary is not removed until two weeks later, when the attached ligaments may be considered strong enough to sustain the uterus without its aid. Thus you see the ligament is securely embedded in muscular tissue, to which it becomes permanently attached and being woven into the muscle as it is, and folded upon itself twice, there is no possible chance whatever for it to become detached and retract into the abdominal cavity again. As only two sutures are employed which serve the double canal as well as the external incision purpose of securing the ligament and through the skin. closing the incision the operation can Showing method of securing suture ends upon completion of the operation on both sides. The wound is now flushed with normal salt solution and the sutures are tied, the upper one first. These two sutures usually suffice for closing the incision perfectly, and they serve also to secure the ligament until it becomes firmly attached in its new position. The ends are left long and fastened together across the median line of the abdomen as shown in Fig. 12, after the operation has been repeated upon the ligament of the other side. be quickly executed. It should never consume more than twenty to thirty minutes for both sides, from start to finish and it can frequently be completed in ten minutes. I will admit that it is one of the most difficult operations to learn and I would not advise anyone to attempt it until they had seen it done several times, yet when the details have been mastered and the operator has learned by experience just where the ligament is to be found, it is perfectly simple. The application of this operation is somewhat limited, since it should. be confined to movable (reducible) posterior dislocations, which may be maintained in a corrected position by a pessary, and where prolapsed and sensitive ovaries prevent the wearing of a pessary to correct an associated displacement of the uterus. When the uterus is displaced posteriorly and is fixed by adhesions or exudation, I always prefer to open the abdomen (after some preparatory treatment to remove inflammatory exudation) free it and bring it forward and suspend it from the anterior abdominal wall, after the manner which has been suggested by Howard Kelly. I mean by this, not ventral fixation, where, as shown in Fig. 13, the uterus is attached by its an Fig. 13. Showing position of uterus after ventral fixation. terior face by a broad surface of adhesion to the abdominal wall and remains permanently fixed there in an unnatural position, but that the posterior face of the fundus is attached to the anterior abdominal wall by two sutures only, which are placed close together, permitting only a limited adhesion of the two surfaces, as shown in Fig. 14 and that subse Fig. 14. Showing first position of ventral suspension. quently the two peritoneal surfaces stretch out, forming a suspensory band, which permits the uterus to swing in an easy anterior position, as shown in Fig. 15. Fig. 15. Showing ultimate position of ventral suspension. The suspension ligament is eventually longer than shown. The operation is not always done correctly, as some operators tie the sustaining sutures in the abdominal incision and include the fascia, which prevents the pulling out of the peritoneum from the abdominal surface and holds the uterus too closely against the abdominal wall, fixing it. When done in this improper manner the result desired is not attained and the operation is not a success so far as the mobility and position of the uterus are concerned. When the uterus is fixed against the anterior abdominal wall it must prove a serious impediment to subsequent pregnancy, but when it is suspended in the manner described, the suspensory band develops with the uterus, lengthens out as the uterus increases in size, and causes no more interference than do the round ligaments and other normal supports of the uterus. I will describe briefly the correct technique of the operation. The abdomen is opened in the median line by an incision only sufficient to admit two fingers, which terminates barely an inch above the pubis. The operator inserts the middle and index fingers through the incision and down into the pelvis. Sweeping them around posteriorly to the fundus he quickly separates the adhesions, lifts the fundus up and frees the appendages on each side. He now puts the fundus under his control by grasping the top of the fundus with a pair of angular, tenaculum forceps. forceps. Drawing the fundus up into the wound, he holds it there while he examines the appendages. If the condition is such as to require removal of any portion of them it is done at this point before proceeding with the operation. This done, the peritoneum on each side near the lower angle of the incision is seized with pressure forceps and drawn out, as shown in Fig. 16, and the fundus is Fig. 16. Showing peritoneal margin drawn out and needle inserted for first suture. brought to the lower angle of the incision as shown in Fig. 17. A curved needle carrying medium sized silk is inserted upon the peritoneal flap on the left, as shown in Fig. 16; the ligature is drawn through and the needle is again inserted upon the posterior face of the fundus, the ligature drawn through again and it is inserted next upon the right peritoneal flap, as shown by the lower of the two sutures in Fig. 17. Thus the suture is made to include only the peritoneum and subperitoneal fascia on each flap and only the peritoneum and a few muscular fibres on the posterior face of the fundus. The second suture is inserted just above the other as shown in Fig. 17-upon the peri Fig. 17. Showing location of both sutures on peritoneal flaps and uterine fundus before they are tied. toneal flaps and just posterior to the first on the uterine fundus. When these two sutures are tied they are within the peritoneal cavity and they approximate closely the peritoneum of the posterior face of the fundus with that of the anterior abdominal wall and when the abdominal incision is closed the peritoneum closes over them and they are buried in the peritoneal cavity, where they become encysted. They are not removed subsequently but give no trouble, whereas when the sutures are tied in the wound and outside of the peritoneal cavity, they frequently provoke suppuration and are discharged or have to be removed. When the deep silkworm gut sutures employed for closing the abdominal incision are introduced, care should be taken to insert the two lower ones so they will afford support to the suspension sutures and prevent a too early sagging of the uterus from the abdominal wall before firm union has taken place. is my custom not to remove the silkworm gut sutures for two weeks in these cases for this reason. This operation is simple of execution, and under proper aseptic conditions the mortality is nil, independent of any associated disease of the adnexæ, which may require their removal. It is necessary before instituting the operation, to give the patient careful preparatory local treatment directed towards removing as completely as possible inflammatory conditions of the appendages and surrounding exudation. Some operators prefer in these cases to free the uterus through an incision in the vagina posterior to the uterus and then shorten the round ligaments. But in my experience there is great risk of wounding adherent intestines and less accurate and less careful work can be done in this manner, in these cases, at least, than through an abdominal incision. I have intentionally not mentioned. other operative procedures, such as. vaginal fixation, because, in my opinion, they have no merit, and only serve to substitute one unnatural position for another, after which the patient is no better off 316 NEW ENGLAND MEDICAL MONTHLY. than before and oftentimes her condition is worse. It has been conclusively shown that the position of the uterus resulting from vaginal fixation is a serious menace to subsequent pregnancy. My results with the operations I have described have been such as to make me prefer them and to advise TWO CASES OF CARCINOMA SUCCESSFULLY TREATED BY THE ELECTRO-MERCURIC METHOD. BY G. BETTON MASSEY, M. D., Read before the Philadelphia County Medical Society, May 11, 1898. them strongly in cases where they MRS. B., aged 66, had the right are appropriate. I am happy to be able to report not a single failure with either ventral suspension or shortening of the round ligaments and not a single case where either of these operations have interfered with pregnancy. After the ligament operation the patient will sometimes complain of a pulling sensation at the seat of the wounds, when the pessary is first removed, but this soon passes off. If pregnancy occurs within a year after the operation, which has occurred in two of my cases, but which I think should be avoided, the strain upon the ligaments from the growth and ascent of the uterus produces much discomfort, but nothing more. There are scores of women who would welcome the knowledge that they could be permanently relieved of the train of symptoms which go with posterior dislocation of the uterus, especially if they knew the cure involved no risk of life. It is nonsense to contend, as some do, that these displacements do not produce serious discomfort and that it may be relieved by a pessary or local treatment with tampons. No woman cares to be continually running to her physician or to carry around in her vagina, for a lifetime, a pessary, which often becomes foul, making her repulsive to herself as well as others. 116 WEST 74TH STREET. GONORRHEA.-The following mixture for injections is credited to M. Duquaire, Le Progrès Médical: B Methylsalicylate, gr. xv. Bismuth subnitrate, 3 v. Liq. vaselin, iij. M. Sig. Three injections to be given daily, after passage of urine, the mixture being retained as long as possible in the urethra.- The Med. Bulletin. breast removed for carcinoma of a malignant type in January, 1897. Ten months later she came under my notice with seven carcinomatous nodules which had developed in the course of a lymphatic vessel, which extended in a line from the scar upwards towards the clavicle. These growths were the size of hazelnuts, were in the subdermic tissues, and were rapidly increasing in size. On the 11th of December, 1897, she was placed under ether and, with the assistance of her physician, Dr. Ida E. Richardson, and of Dr. Willard Thompson, the cataphoric method was applied by means of three small gold electrodes amalgamated with mercury, the electrodes being so inserted as to include all seven of the growths in their field of influence. Before turning the current on an excess of metallic mercury was injected through the electrodes in order that an abundance of this metal would be in proper situation for cataphoric dissemination throughout the growths. The current was now turned on without shock, the active electrodes being positive and a large pad on the back negative. Before the full current employed-500 milliamperes had been turned on there was evidence of change in the growths surrounding the electrodes, and by the expiration of fifteen minutes all of the growths had been softened and an area beyond them infiltrated and changed to a grayish hue. The application was complete at the end of fifteen minutes, when the current was turned off and the patient put to bed. The application in this case was followed by considerable pain, lasting four hours, but it ceased at the end of that time and the patient was thereafter comfortable. The spot was dressed with a dry powder and remained in an aseptic condition until the debris came away, |