that, like the hot-water vaginal douche itself, it was so often misapplied. THE EVOLUTION OF HYSTERECTOMY IN AMERICA. DR. ERNEST W. CUSHING, of Boston, read a paper bearing this title. Dr. Burnham, of Massachusetts, first removed the uterus successfully in this country in 1853, and was soon followed by Kimball, and the operation thus inaugurated by these gentlemen came to be known as an American procedure. On account of the great mortality there were few imitators for many years. About three patients in four died. When, however, one considered the fact that only the severest, the advanced cases were submitted to operation, and the further fact that antisepsis was not yet known, it would be seen that this mortality rate was not high. Death was due to sepsis and late operation. Burnham operated no more after 1876, and attention was turned chiefly to such measures as the cautery, injections of ergot, and removal of the ovaries. Hysterectomy began to gain some in favor after the introduction of improvements in the treatment of the stump. Marcy described his method in 1881, and Dr. Cushing thought it was probably the best way of treating the pedicle until Stimson introduced ligation of the uterine artery in continuity about eight years later. Mention was next made of the operation by Dr. Mary Dixon Jones, 1888, during which the vagina was opened. Bantock's visit to this country in 1887 led to almost universal adoption of his method here. The difficulty of applying it in cases of tumors deep in the pelvis was overcome by careful technique. It seemed so perfect that nothing further appeared to be required, yet since the introduction of Stimson's method of tying the uterine arteries in their continuity, in 1889, it had almost gone out of date. Some of the most eminent men in New York then at once abandoned the extraperitoneal method of treating the stump and also extended hysterectomy to other conditions. Eastman, in 1887, had already published his modification of Schröder's method. In October, 1891, Joseph Price had operated on two cases by opening into the posterior vaginal fornix and tying off the broad ligament by link suture, and had also passed up clamps from below, thus modifying and improving Jones' operation. Yet Price favored Bantock's operation, with which he had had an exceedingly small mortality. Polk and others had made efforts to get rid of clamps, and Kelly varied Martin's procedure by leaving the stump unseared, covered with peritoneum, unconstricted. But neither this nor Byford's method, which was next described, seemed to gain any general acceptance. Mention was next made of the Dudley and Goffe method of intra-abdominal by extraperitoneal treatment of the uterine stump, but the objection applied to it that in all the cases there was rise of temperature the third or fourth day, which required dilatation of the cervix. For this reason some had preferred to remove the cervix altogether, and others refrained from putting ligatures into the cervix. The Trendelenburg posture had had an important influence on the application of hysterectomy, and to Dr. Krug chief credit was given for popularizing it in this country. Ever since the International Medical Congress in 1890 there was a feeling that a change was coming, but it was not until the meeting of the American Gynecological Society in 1892, after the reading of the papers of Polk and Baer, that the profession turned with almost dramatic suddenness from the extra-abdominal to the intra-abdominal treatment of the stump. Dr. Cushing used Dr. Polk's own words in the description of his procedure, which, in connection with the former paper of Dr. Stimson, had worked a revolution in practical hysterectomy. The further points of interest related to the extension of hysterectomy to cases of such extensive disease of the adnexa as to demand their removal, first advocated by Polk and supported by Krug, and lastly to choice of routes, the vaginal now being preferred by many in cases where formerly they had only practised the abdominal. TRANSACTIONS OF THE WASHINGTON Stated Meeting, Friday, November 2d, 1894. The President, HENRY D. FRY, M.D., in the Chair. DR. HENRY D. FRY presented a specimen of and one of SARCOMA OF THE UTERUS TUBAL PREGNANCY, both of which were successfully removed. DR. H. L. E. JOHNSON presented an OVARIAN TUMOR AND VERMIFORM APPENDIX REMOVED FROM DR. JOSEPH TABER JOHNSON, in discussing Dr. H. L. E. Johnson's specimen, said the gynecologist should confine his work to the uterus and ovaries. He thought the doctor should not have removed the appendix; he added an additional risk to his operation, which might have been bad for his statistics. He had been tempted himself to remove the appendix, and in a case in which there was a concretion he contented himself with squeezing out the mass and leaving the appendix. DR. H. L. E. JOHNSON complimented Dr. Fry upon his diagnosis and successful operation in the case of tubal pregnancy. DR. GEORGE N. ACKER said that Dr. H. L. E. Johnson should be commended for the removal of the appendix. He thought that Dr. J. T. Johnson did wrong in forcing the concretion out of the appendix, thereby leaving the opening patulous, and harm might follow. DR. WILLIAM P. CARR read a paper entitled OÖPHORECTOMY FOR FIBROID TUMORS OF THE UTERUS.' DR. JOSEPH TABER JOHNSON said he agreed with Dr. Carr as to the danger of fibroids and the fact that it was overlooked by physicians. It was stated in text books now in the hands of students that few deaths had occurred from fibroid tumors. Dr. Carr had explained how this occurred by stating that fibroids caused other conditions, which were assigned as the cause of death. Operators had started out to remove what were supposed to be healthy ovaries and tubes, in order to check the growth of the tumor; on opening the abdomen the ovaries and tubes were found to be diseased. As to the growth of fibroids after the menopause, he had read a paper upon that subject, and papers had been read by others, showing that where the menopause was not beneficial they usually grow more rapidly or degenerate. Dr. Carr was more radical than he would be. There were many who would not submit to an operation; in such cases palliative treatment, as ergot, potassium iodide, etc., might be tried. Electricity was the greatest humbug of the age, though in the hands of intelligent, expert men familiar with its administration it might do some good. In dealing with fibroid tumors any breaking of the capsule would necessitate its removal, on account of the consequent hemorrhage. A large tumor with adhesions would not be shrivelled by removal of ovaries and tubes. Small fibroids might be benefited, and sometimes soft ones were entirely cured, but the fast-growing and multi-fibroids would not be. The menopause does not always cure, hence the operation could not be relied upon. It was true the operation was less dangerous than hysterectomy, though the latter was no doubt the best. There was a class of cases in which it was advisable, as in the soft myomata without adhesions. To in any way meddle with a fibroid tumor by cutting into it was to be condemned; it would be much better to remove it entirely. He considered Baer's operation an admir 1 See original article, p. 81. able one. There was sometimes great difficulty in finding the ovary, by reason of its being displaced by the tumor. DR. H. L. E. JOHNSON said he was impressed with one point claimed by Dr. Carr-viz., that when both ovaries and tubes are removed the leaving of a small portion of ovary will be followed by regular menstruation. He had recently treated a patient who had been deprived of both tubes and ovaries, and, notwithstanding, she menstruated or flowed regularly. This flow became almost constant, and examination revealed a small uterus filled with villosities; these are to be removed at the hospital. Martin claims ligation of the tubes and ovaries to be superior to removal in some cases, and, further, that after ligation menstruation ceases and atrophy follows. Dr. Johnson gave the history of a case thus treated by himself. DR. GEORGE N. ACKER asked, if adhesions be broken up, would they reform ? DR. W. P. CARR said that they would not; that the iodoform gauze would effectually prevent it. He said the object of his paper was to advise the operation for small tumors. Certainly in large tumors the difficulties would be great. He would not attempt to tear loose any extensive adhesions, and in such cases oöphorectomy would not do. The menstruation following the leaving a small portion of ovary might be a coincidence. DR. H. D. FRY asked Dr. Carr, if he found a small fibroid which gave rise to no symptoms and was not suspected, would he advise removal of the ovaries? DR. CARR said yes; that was the thing to be recommended. Stated Meeting, Friday, November 16th, 1894. The President, HENRY D. FRY, M.D., in the Chair. DR. HENRY D. FRY presented a woman upon whom he had recently performed the modern eclectic CESAREAN SECTION (Sänger's method) because of necrotic disease of iliac bones. The child was living and the mother had entirely recovered from the operation. Also a woman upon whom he had performed. SYMPHYSEOTOMY, the conjugate being contracted to three and one-fifth inches. The bones had reunited. DR. W. M. SPRIGG reported a case of DOUBLE UTERUS AND DOUBLE VAGINA.' DR. W. P. CARR said the cause of double uterus is quite well See original article, p. 78. understood, and, considering the fact that the uterus is developed from two tubes, it is strange that we do not oftener meet with this condition. It probably does occur, as Dr. Sprigg suggested, much oftener than we suppose, as it is a condition very likely to pass unnoticed even when women are under treatment for uterine disease. He had seen a case while resident in Columbia Hospital that he discovered accidentally after having treated the woman some time for endometritis. The practical bearing of double uterus was well illustrated in a case he had recently seen in consultation with Dr. Fozier Mid dleton, of this city. The woman was in bed three weeks before sending for a physician. She then called Dr. Middleton, who found her with a temperature of 102° and an offensive discharge from the uterus, the uterus considerably enlarged. He saw her with Dr. Middleton and was convinced that there was a dead and decomposing fetus in the uterus. The next day she was chloroformed, and after dilating the cervix he passed his finger into the uterus and could feel what seemed to be placental tissue quite plainly, but through a thick membrane. Thinking it was a case of tough membranes adherent to the side of the uterine cavity, he made vigorous efforts to separate |