fourth patient had a gonorrheal intraperitoneal abscess with double pus tubes, and still has a gonorrheal endometritis.

While I do not accept the argument as valid that the uterus should be removed with its appendages because if left behind it will almost surely render the patient an invalid, I do believe that in many of these cases it is desirable to remove the uterus along with the ovaries and tubes. From my standpoint, what is gained by hysterectomy in these cases is that oozing can be much better controlled if both uterine as well as both ovarian arteries are tied, and that a very considerable part of the raw surface left after the separation of adherent appendages can be covered over by the flap of peritoneum dissected off from the front of the uterus and broad ligaments. In this way drainage can be dispensed with in many cases when otherwise it should be employed, and the number of hernias following such operations can be greatly reduced. Post operative intestinal adhesions also, I feel confident, will be less common than after the older operation; and the reason for this is quite apparent. A gain is made by removing the uterus itself also in cases of longstanding chronic metritis with a large, infiltrated uterus. Such a uterus, when left behind after the removal of the ovaries, can keep up reflex symptoms.

Abdominal versus Vaginal Hysterectomy.—Abdominal hysterectomy has been performed thirty-seven times, and the uterine appendages only have been removed twenty-seven times, whereas vaginal hysterectomy has been performed but twice. The advocates of vaginal hysterectomy as an improvement upon abdominal section for the removal not only of cancerous uteri, but also for small fibroids, certain ovarian tumors, and for the inflammatory and suppurative diseases of the uterine appendages, will naturally claim that the interests of these women would have been better subserved had vaginal hysterectomy rather than abdominal section been done upon the great majority of them. They advocate vaginal hysterectomy rather than celiotomy upon the following grounds: (1) that after vaginal hysterectomy there are no ventral hernias; (2) that the pri mary mortality is less than that after celiotomy; (3) that the ultimate results are better than after celiotomy; (4) that the convalescence is shorter than after celiotomy; (5) they claim also that vaginal hysterectomy is especially indicated in the worst cases of pelvic inflammation and suppuration, because

that by it the barrier of adhesions formed by peritonitis, which shuts off the general peritoneal cavity from the pelvis, is not broken down by the operation done from the vagina.

I wish only to point out that, however much truth there may be in the claims now made for vaginal hysterectomy, its advocates have as yet not established their position, and that they have very decidedly overstated its relative merits. They have insisted very strongly upon the great frequency of ventral hernia after celiotomy. The results of those who employ nonabsorbable buried sutures, as illustrated by my own report tonight, show that, while there is something in this claim, after all it is of small and relative rather than of absolute importance. Moreover, it may be found that the percentage of vaginal hernias which develop after vaginal hysterectomy is not very dissimilar from that of ventral hernia.

The question of primary mortality is largely a personal matter and depends upon the skill of the operator and upon his judgment in the selection of cases for operation. These factors are again influenced by the conditions which he can control in the clinic in which he operates, and also by his selfishness or unselfishness as to whether he considers the good of his patient or merely the piling-up of statistics embracing a low mortality; and even here I believe the advantage lies with celiotomy. This is indicated by contrasting the mortality of vaginal hysterectomy as given by Jacobs,' of Brussels, 4.2 per cent, with that of abdominal hysterectomy given by Baldy, 2.7 per cent, and by the known results obtained by Kelly, between 1 and 2 per cent, and that reported by myself.

The claim that the ultimate results obtained after vaginal hysterectomy are better than after celiotomy, is one which I doubt and which has to be proved by time rather than by argument. I wish merely to point out in this connection, that it is admitted that when vaginal hysterectomy is employed it is necessary in many cases to do partial or incomplete operations, leaving behind ovaries or parts of ovaries, pus tubes or parts of pus tubes, and depending upon drainage to effect a cure. This claim and admission will hardly convince those who have been accustomed to remove completely diseased organs by abdominal section, and who have seen the bad results following incomplete operations.

1

1 American Gynecological and Obstetrical Journal, June, 1895, pp. 744-896.

A great deal is said of the advantages of vaginal hysterectomy because after it women can be made to sit up as early as one or two weeks after operation, whereas abdominal surgeons advise their patients to remain in bed from three to four weeks. This argument when investigated is a very weak one, because patients are not well within one or two weeks after vaginal hysterectomy. Their pelvic wounds are not even healed up, and oftentimes even longer after an operation the sloughing processes have not been completed, but give rise to foul, stinking discharges. No surgeon of experience will accept the claim that such patients are well because they can be forced out of bed at this time. One is inclined to suspect that the hygiene of hospital wards makes it desirable that these patients shall be urged to return home at the earliest possible day. When it is recalled that the nutrition of many of these patients is profoundly depraved and that their nervous tone is in a similar condition, it will be admitted that a rest in bed even longer than three or four weeks, under good hygienic conditions and with good food and nursing, is a most valuable factor in restoring them to health.

The final claim that vaginal hysterectomy is especially valuable in the more severe cases of pelvic suppuration, because it does not break down the barrier which shuts off the pelvic disease from the general peritoneal cavity, is unquestionably fallacions. Every abdominal surgeon knows by practical experience that it is extremely rare to meet with a case in which both uterus and appendages are absolutely buried beneath a wall of adhesions. At some point the uterus or the uterine appendages are in relation with the general peritoneal cavity; therefore, whether vaginal or abdominal hysterectomy be done, in these cases the barrier between the pelvic disease and the general peritoneal cavity is broken through. Whatever advantage the method has, it must not be claimed that it permits the removal of the pelvic disease without opening the general peritoneal cavity.

Heretofore in this class of cases I have, with one exception, always operated from above and have removed completely the diseased structures. I have become convinced, however, that it is better surgery to drain these cases by the vagina, by making an incision into Douglas' pouch and breaking up the pus sacs with the finger, either making an abdominal section to assist in the manipulations or not, as may be indicated in the particular In this way the barrier can be preserved between the pel

case.

vic disease and the general peritoneal cavity. Drainage will permit these patients to recover from their septic state, and later they can be operated upon for the removal of diseased structures, if necessary.

I by no means believe that the questions at issue concerning abdominal versus vaginal operations have been settled. Like all problems in medicine, they will be settled by the combined experience of the profession, after sufficient time has elapsed to determine definitely the advantages and disadvantages of both methods. I am not inclined, however, to believe that vaginal hysterectomy has a large field-certainly not unless improvements are made whereby operations attempted by this method can be performed with certainty and the present necessity of doing incomplete operations is overcome. When the vagina is roomy and the adhesions not too dense, undoubtedly the operation is entirely feasible from below. But in this class of cases very many patients require plastic work in the vagina; in such cases the abdominal route offers the advantage that both the plastic and the abdominal operations can be done at the same sitting. When the vagina is narrow and the adhesions dense and perplexing, vaginal hysterectomy is rather a demonstration of how by great perseverance and hard work extreme difficulties can be overcome, than an exhibition of the skill of the surgeon in dealing with the complications encountered, and does not compare at all favorably with operation by the abdominal route. The abdominal route offers great advantages in dealing with cancer of the uterus, inasmuch as in this way very much more of the broad ligaments and other tissues surrounding the uterus can be removed. This is especially true if bougies are placed in the ureters, as this permits the removal of very much more tissue than is otherwise possible without injuring these struc

tures.

In conclusion, I wish to point out that a resort to the vaginal method of operating could not have improved the results in the cases reported in this paper. The second and fourth deaths were in cases in which the vaginal method of operation was not applicable. One was a case of abscess behind the cecum, from appendicitis; the other was a case of fibroid tumor extending far above the level of the umbilicus, in which the pelvic portion had undergone calcification, the upper part being cystic. The first and third deaths occurred in patients having general septicemia at the time when they were operated upon. I can see

no ground for the belief that a fatal result would have been averted had the vaginal method been employed. The fifth death occurred from heat-stroke. On the other hand, we do not know how many deaths would have resulted had the vaginal method rather than the abdominal been used. In addition to this aspect of the question, I have no doubt that the remote results will be very much better than they would have been had the vaginal method been employed. Complete operations have been done in every case, which would not have been the case with the use of the lower method. In addition, I can report that not in a single case were fistula of the bladder or bowel caused by operation. In two cases bowel fistula were present at the time of operation. In one of these a cure has resulted, and in the other the fistula is gradually closing. This is a decidedly better showing than that obtained by the vaginal method. Finally, there is the certainty that these patients will not suffer from recurrent attacks of peritonitis due to diseased tubes left in at the time of operation, or from tumors or abscesses of ovaries left behind as a result of incomplete work.

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ANNOUNCEMENT.

Ar the conclusion of what has proved to be an exceedingly prosperous year for this JOURNAL, we are happy to announce the completion of arrangements which we feel certain will greatly enhance its value to the general reader as well as to the specialist, and which, while maintaining in every respect the high standard held for nearly a quarter of a century in the departments of gynecology and obstetrics, will enable it to give equal prominence to diseases of children, a feature which has for a number of years been overshadowed by our other interests. As an important part of this plan we shall publish during the coming year papers on pediatrical subjects by a number of distinguished teachers. These papers will contain much valuable material, will embrace widely differing specialties, and will run through all the numbers of the year. Many of them will be illustrated by plates and figures in the text. The writers will include FRANCKE HUNTINGTON BOSWORTH, M.D., Professor of Diseases of the Throat, Bellevue Hospital Medical College, New York; EDWARD BENNET BRONSON, M.D., Professor of