in its favor before the American Gynecological Society in Chicago in October of the same year.' Unfortunately within nine months the disease returned in the cicatrix, although at the time of the operation it was thought to have been thoroughly removed. I am sorry to say that in all the other successful cases of vaginal hysterectomy which I have performed, both in the hospital and in private practice (twenty-four cases), a speedy return has been the invariable rule, so that I am now pretty well satisfied that it is a rare occurrence for a cancer of the cervix uteri to be seen by me early enough to promise success from a complete extirpation of the organ. This may of course be only my misfortune, but I do not see why patients of this class should not come under my observation as early as under that of some of my colleagues who do this operation very frequently and who report excellent immediate and ultimate results. Of the twenty-seven vaginal hysterectomies which I have performed for cancer in hospital and private practice, only three have died from the operation. These were my second and third cases, where I did not appreciate the danger of the hemorrhage from the numerous small vessels wounded when opening the posterior and anterior peritoneal pouches. In both these cases death seemed to be due to loss of blood from this source. My last case, operated on last summer in Hanover, N. H., died of surgical shock, superinduced by excessive previous anemia, but not from loss of blood during the operation. The immediate mortality cannot be said to be so great, being only eleven per cent. In one case, after removal of the uterus, it was found that the rectum was so badly torn by the traction on the uterus, which was adherent to its anterior wall, that it required a very tedious application of catgut sutures to close the rent. The patient, however, made a very rapid recovery and was well for over a year, when the disease returned and she eventually succumbed to it. I have made up my mind most positively that in no case will I ever again remove the uterus for cancerous disease, whether of the cervix or body, per vaginam or by abdominal section, unless the organ is so movable that any possible extension of the disease to its surroundings can be absolutely excluded. It is not worth while to remove a cancerous uterus unless one can be positively sure that all the diseased tissue has been excised, even though the patient may recover

1 See Gynecological Transactions, 1884.

without trouble from the operation. I confess that, so far as technical facility is concerned and a better survey of the field, I by far prefer abdominal hysterectomy in Trendelenburg's position for cancer of the uterus to the vaginal method. I have always employed ligatures for the vessels, never having been able to make up my mind that the clamps were reliable as permanent hemostatics.

So far I have not happened to meet with a case where I could conscientiously perform the now so popular operation of extirpation of the uterus per vaginam for diseased appendages and pelvic suppuration. I do not deny that I may see such a case at any time; indeed, I had one in my service last spring, where, after a comparatively simple celiotomy for adherent tubes and ovaries, for some unknown reason, weeks after the recovery of the patient, a diffuse pelvic inflammation with large exudates set in, with the eventual breaking down into pus of one portion of the exudate after the other. As I was about going on my summer vacation, I turned the case over to the assistant gyne-cologist, Dr. Brettauer, with the remark that if I were to remain on duty I should certainly do vaginal hysterectomy in this case and open all the pelvic sinuses and abscess pockets. Dr. Brettauer performed this operation in two sittings, and told me that he found it exceedingly difficult, the patient almost succumbing from secondary hemorrhage. However, she eventually recovered her health entirely. I do not, therefore, question the justifiability of vaginal extirpation of the uterus for suppuration of the appendages and pelvic tissues in properly selected cases; but my experience certainly leads me to regard such cases as not very common, as rather the exception than the rule in diseases of the adnexa and pelvic inflammations, and I cannot help questioning the judgment of surgeons who report with pride several hundred such operations performed by them during the last three or four years with but trifling mortality. It seems to me that these gentlemen are riding a hobby as fascinating as it is likely to be ephemeral, for I believe some leading German operators (Leopold, of Dresden, for instance), who surely are not timid with the knife, are calling a halt on this indiscriminate and reckless vaginal slaughter of the uterus. A few more years will doubtless put this operation where it belongs-that is, in the position of a most excellent method for diffuse pelvic suppuration which resists less radical measures,

but not to be recommended for chronic endometritis or diseased appendages which can be safely removed by celiotomy.

Removal of Fibroid Tumors per Vaginam was performed twenty-one times when the tumor had become polypoid and dilated the uterine canal sufficiently to permit its being drawn into the vagina by volsella forceps, or when Nature herself had already delivered the tumor into the vagina. Care was always taken, before cutting through the pedicle, to incise the capsule of the tumor as near the uterine wall as possible and enucleate the growth, so as to avoid injuring the uterine tissue proper.

This accident is the more liable to occur, unless this precaution is taken, because the traction used to deliver the polypus usually inverts more or less that portion of the uterine wall to which the tumor is attached. Some of these operations were exceedingly difficult.

In three cases the fibroid tumor was embedded in the tissues of the cervix only and projected deep into the vagina. Fig. 29 shows such a hard fibroid, in a virgin 40 years of age. It was removed with great difficulty by splitting the capsule and enucleating it with the fingers while traction was made on it with

volsella. It weighed two pounds. The vagina and perineum were badly torn, and repaired by a secondary operation. The second case was similar, but the tumor was not quite so large. In the third case the woman was six months pregnant, the membranes were ruptured, and the umbilical cord was prolapsed. I removed the tumor in the same manner, by splitting its capsule, enucleation, and traction. It weighed three pounds. I then. removed the fetus and placenta. All three women recovered.

FIG. 29.-Interstitial cervical fibroid removed by vaginal enucleation and traction, weight two pounds.

Abdominal Hysterectomy for Fibroid Tumors of the uterus was performed by me twenty-nine times with four deaths.' Until the Trendelenburg position was introduced into this country I always employed the extraperitoneal treatment of the pedicle,

'Since January 1st, 1895, I have done three additional abdominal hysterectomies for fibroids, all successful. I removed all but the cervix and closed theabdominal cavity completely, without drainage, as here described.

transfixing it with long pins, ligating it with an elastic ligature underneath the pins, and attaching it to the lower angle of the

FIG. 30.-Pregnancy at six months. Interstitial cervical fibroid weighing three pounds removed by enucleation and traction.

abdominal wound. The parietal peritoneum was then stitched to the peritoneum of the pedicle below the ligature according to Hegar's methol, and the abdominal wound closed. My