[Reprinted from the American Journal of Obstetrics and Diseases of Women and Children, Vol. XXI., April, 1888.] REMOVAL OF THE UTERINE APPENDAGES AND SMALL OVARIAN TUMORS BY VAGINAL SECTION, WITH A REPORT OF TWELVE SUCCESSFUL CASES. BY HENRY T. BYFORD, M.D., President of Chicago Gynecological Society; "Surgeon to the Woman's Hospital of Chicago; Gynecologist to St. Luke's Hospital. As an advocate of the merits of vaginal section for the re- moval of the uterine appendages and small ovarian tumors, I have to contend with the most difficult of obstacles, viz., its abandonment by its originators, Drs. T. G. Thomas and Rob- ert Battey. These surgeons shared -the fate of all originators or inventors : they met with the drawbacks and reverses that belong to imperfection of method and a want of an extended experience either by themselves or others. Probably the chief reason for their failure to develop the operation was the brilliant rise of abdominal section following the intro- duction of the antiseptic system, dazzling and blinding their judgment and luring them into the main avenue of triumphant advance. Dr. Battey, in a monograph read at the British Medical Association, August 3d, 1880, said: " Of the fifty-four cases (of Battey's operation) he is now enabled to tabulate, in thirty- 2 Byford : Removal of Appendages four the abdominal section was made, with twelve deaths ; whilst in twenty cases of the vaginal section there were but three deaths. In other words, the mortality of the ab- dominal method was 53^ per cent, and of the vaginal method but 15 per cent." Thus we see that the advantages wTere apparent from the first, in the removal of diseased ovaries. I have found records of forty-nine cases of oophorectomy and ovariotomy with a death rate of 12.24 per cent, viz., fifteen by Battey, with three deaths; five by Goodell, with one death; four by J. Marion Sims, with no deaths; twelve by myself, with no deaths ; one successful case by each of the following operators: T. G. Thomas, Trenholme, West, William H. By- ford, W. L. Atlee, R. Davis, J. T. Gilmore, C. E. Wing, Howard A. Kelly, J. G. Smith and Bouilly. And one fatal case each by Drs. A. Prince and W. H. Baker. This is a splen- did record for the first forty-nine cases. With such a begin- ning the operation deserves a more extended trial. I shall describe the operation as I have now come to perform it, briefly relate my cases, and then state the conclusions that may be drawn from a study of them. Mode of Operating.-The usual preparations for a lapa- rotomy, including thorough disinfection of the vagina and evacuation of the intestines, are made. The patient is placed in the dorsal position, the anus stopped up by a strip of lint, the vagina again douched and sponged out with a 1 : 2,000 solution of the bichloride of mercury. A perineal retractor is intro- duced, the cervix seized, and a strong silk thread passed through the posterior lip, to serve in pulling the cervix up- wards and forwards, and exposing the posterior vaginal wall in front of the cul-de-sac of Douglas. The uterus is wiped out and disinfected with a five-per-cent solution of carbolic acid in water. An assistant then holds the cervix forward by the silk thread, while another draws the perineum back with a retractor. The Vaginal Incision.-The operator seizes the posterior vaginal wall a little below the cervical junction, with a tenacu- lum, and cuts through it with sharp-pointed scissors from a point a little below the cervix straight down the median line an inch and a half. In order to avoid the arteries supplying the cervix, the incision should not reach quite to it. Those below in the median line seldom prove troublesome. The by Vaginal Section. 3 rectum may be easily avoided by making this first incision through the vaginal wall only. The cellular tissue behind the cervix is then drawn forward by the tenaculum, and cut with the scissors in the median line. If a hole in the peritoneum is not made, the deeper tissue is hooked forward and cut again. When the peritoneum is opened, its edge is hooked out and cut down the median line as far as its translucency indi- cates that the rectum is not reached. If the peritoneal opening then be too small it will be easily torn larger by the fingers. Excessive bleeding, if such happen to occur, may be readily controlled by long slender hemostatic forceps or by a tem- porary ligature. I seldom pay any attention to it. Grasping and Ligating the Ovaries and Tubes.-The assistant relaxes the traction upon the cervix and removes the retractor, and the operator introduces two fingers of the left hand into the cul-de-sac and over the sacro-uterine ligament, grasps an ovary or small cyst and draws it out into the vagina. The tube usually follows and can be grasped for ligating the same as in the abdominal way of operating. A needle is then passed through the broad ligament and the double ligature drawn through. The ovary and tube, after being grasped by an ovary forceps, are held by an assistant as the operator ties the pedicle in two halves. While the ligature is being intro- duced, the vaginal walls are held away from the ovary and tube by a side vaginal retractor on the left side of the patient placed so as to press back the edges of the incision, and another of the same length along the anterior vaginal wall. The liga- ture should be long, to facilitate the tying, for the knot must be drawn tight by the ends of the forefingers or thumbs intro- duced to the point where the thread enters the broad ligament. Cysts may be punctured after having been drawn down to the incision by the finger around the pedicle, or by a sharp hook or forceps, and then tied and cut off. Closing the Peritoneal Cavity.-The cul-de-sac is sponged out, and a small soft sponge, attached to a holder, left in while interrupted sutures of juniper catgut are introduced so as to include both vaginal and peritoneal edges. The cul-de-sac is again sponged out and the sutures all drawn tight as the sponge is withdrawn for the last time, so that the bloody oozing will be immediately checked. Before the lower sutures are tied a drainage tube about three inches long, whose ex- 4 Byford : Removal of Appendages ternal end is wrapped in iodoform gauze and attached to a thread, is guided by the finger well into the cul-de-sac, and the remaining sutures immediately tied. The thread is then re- moved from the cervix, the cervical cavity and vagina wiped out, lightly sprinkled with iodoform, the uterus anteverted bi- manually, and a long strip of iodoform gauze pushed little by little into the vagina until the cervix is tamponed in the back part of the pelvis. The end of the gauze should project so as to come in contact with a dry piece laid on the vulva and afford capillary drainage. When there are no adhesions and the cul-de-sac is deep, so that the incision is a clean cut into the peritoneal cavity, no drainage is necessary ; on the other hand, if the parts be'too ragged, or be infected by pus, the peritoneal edges may be united to the vaginal edges so as to close the raw surfaces on each side without closing the wound except by a loose tampon. In Case VIII., the cul-de-sac should have been left open, while in Case IX. drainage was entirely unnecessary. Adhesions.-Adhesions that do not involve the intestines may be loosened with the same freedom as in abdominal sec- tion. Bands and omental adhesions may often be brought into sight and ligated or compressed by forceps before being cut or torn loose. Bleeding may be controlled by sponge-pressure or finger-pressure, hemostatic forceps, ligature, pieces of ice, or water at 120° F. introduced into the cul-de-sac, persulphate of iron, rectal tampons, rectal and vaginal tampons combined, etc. The uterus is necessarily retroverted while the ovaries and tubes are being tied and cut off, hence its posterior surface and the entire cul-de-sac may be sighted, and bleeding points treated without danger of injuring the intestines. The danger of using ice or very hot water is much less than in abdominal section, since the intestines are much less in the way; a little omentum is often all that is felt of the abdominal viscera dur- ing the entire operation, and even that is seldom seen. After-Treatment.-The drainage tube is pulled out by the string soon after the first twenty-four hours, according to the condition of the parts-usually in about thirty hours. The tampon is left from forty-eight to sixty hours unless it pro- duces a rise of temperature before such time. If the first reaction is excessive and does not rapidly subside, an icebag is placed over the lower abdomen. The remainder of the treat- by Vaginal Section. 5 ment is like abdominal section, except that the patient may talk more and move the limbs more freely. Instruments.-'Next to the want of a suitable method, one rea- son for the delay and difficulty in this operation has been the want of suitable instruments. I have had some hemostatic for- ceps made for me by Truax & Co., of Chicago,which are long and light so as to reach from the incision out beyond the vulva, and bent on the flat so as to bring the handles entirely out of the way. The vaginal blade of the perineal retractor is short, as in Jackson's pattern, while those of the lateral retractors are three inches long and quite narrow, taking up but little room and at the same time extending far enough to hold the edges of the incision out of the way. The thread through the cervix fulfils the office of tenaculum forceps. I have devised a slender ovary forceps which enables me to hold the ovary and use slight traction in any desirable direction, and tie the ligatures without risk of mutilating the tissues. Unless ad- hesions exist, neither the ovaries, broad ligaments, nor tubes should be torn nor mutilated. I use a curved needle on a handle for passing the ligatures through the broad ligament, as its adjustment requires but one hand and leaves me the left hand to hold the parts, while guiding the needle point. 6 Byford : Removal of Appendages In addition to these instruments, we should have a pair of perineum scissors, a sharp hook, needle holder, needles about an inch long, stout silk thread (10 Chinese, braided), juniper catgut No. 2, rubber or bone drainage tube three inches long, iodoform, iodoform gauze, T-bandage, antiseptics, etc., etc. Case I.-Mrs. Esther D , of Spirit Lake, Iowa, sent by Dr. L. C. Winsor. Age 39; seven children. Husband left her, because he considered her insane. Attacks of hysterical mania and spasm with intense cephalalgia every few days, requiring from a half to a grain of morphia for their alleviation. Has been bedridden twice, for a year each time. Failure of all treatment. Retroversion. Right ovary enlarged. Operation at the Woman's Hospital of Chicago, July 30th, 1887. Present, Drs. Nelson, Merriman, Piercy, house-surgeons A. J. Tyler, and J. Brown, and two students. The operation was performed as has been described, except that silkworm-gut was used for the vaginal sutures, and the uterus was left in a position of retroversion, under the erroneus impression that the peritoneal cavity would thus be more safely protected. Drainage twenty-four hours; tampon forty-eight hours. The most notice- able thing about the case was that the patient, upon awaking, thought that nothing had been done to-her; and although she could not be kept quiet, had scarcely any reaction. Was made comfortable by hypodermics of water, and never has had one of those headaches, spasms, nor maniacal attacks since. Dr. Winsor wrote me September 9th, six weeks after the operation: "Out of nineteen cases of ovariotomy I never saw so good a recovery." January 2d, 1888, he wrote me that she was doing well. Case II.-Mrs. N n, age 31. Married. One child born several years ago, at eight months. An invalid since her con- finement. Under treatment for seven or eight years, the last three by myself. Retroversion. Right ovary firmly adherent to the sacro-uterine ligament, and left ovary to the posterior sur- face of broad ligament. Husband thought that she was some- times "not in her right mind." Operation July 31st, 1887, at St. Luke's Hospital, assisted by Drs. L. L. McArthur, Frank Cary, and C. A.Foulks. Right tube found enlarged and dilated, but empty and open at peritoneal end. Right ovary loosened from a bed of lymph and removed with its tube. Left ovary loosened and left. Scarcely any reaction. Drainage tube removed at the end of twenty-four hours. Temperature normal on the third day. An unimportant attack of phlebitis attacked the left side about ten days after the operation. The first of December she felt better than before the operation. I undoubtedly erred in leaving the left ovary and tube. She complains much less than formerly, and weighs much more. by Vaginal Section. 7 Case III.-Mrs. J. L. S , of Fort Byron, Ill., age 42. Multipara. Confirmed invalid; unable to sit up longer than a few moments at a time. Constant pelvic pains. Hysterical. Has been an inmate of an insane asylum. Retroflexion. Right ovary in the cul-de-sac of Douglas, and enlarged and tender. Left ovary small. Operation at the Woman's Hospital, August 11th, 1887. Assisted by Drs. Merriman, C. N. White, J. R. Richardson, Tyler, and Brown. But little reaction. Temperature 99.4° F. thirty hours after. Felt better from the time of the operation. Nov. 15th.-In better health than for years. Dec. 24th.-Able to do light housework. Case IV.-Mrs. C n, age 24. Married ten years. Had a child one year after marriage, and another nineteen months later. Dysmenorrhea. Present illness has existed, she says, three years, during which time, up to the time of operation, she had been practically bedridden, and had sat up for an hour or two a day only. Had a temperature varying from 98.4° to 100° F., usually 99.4° to 99.6° F., for the month preceding the operation. Retro- version, endocervicitis, ulceration about the os. Right, enlarged adherent ovary easily felt through the vagina. Operation at St. Luke's Hospital, Aug. 17th, 1887, assisted by Drs. Foulks, C. N. White, and two nurses. Used chrome catgut for the vaginal stitches. Found the right ovary firmly adherent over the sacro-uterine ligament, somewhat elongated, and four times as thick as normal. In pulling the ovary down, an organ- ized blood-clot, the size of the end phalanx of a man's thumb, was squeezed out of it. The tube was three times its natural diameter, and adherent around the ovary. The posterior surface of uterus near the right horn was adherent in the cul-de-sac and, when separated, bled rapidly from two points, one of which was transfixed with catgut, and the other treated by a temporary compress of persulphate of iron along the superficial course of the vessel. This was easily done under the' eye, as the fundus was drawn well down in sight at the vaginal incision. Left ovary slightly enlarged and firmly adherent to the posterior surface of broad ligament. The tube was adherent so tightly at its fimbri- ated extremity that I deemed it safer to ligate it at both ends and cut off the tube between them. I was able to get at the bleeding places and adherent tissues without interference with any other viscera, and with greater ease than would have been possible through a ventral incision. But the most gratifying part of it was that, although the temperature reached 101u F. on the evening of the operation, it did not reach 100° F. after that, and after the second evening was about the same as .before the opera- tion. Drainage for thirty-six hours. Tampon sixty hours. Case V.-Mrs. M m, age 45. Multipara. Miscarriage four years ago. Menorrhagia. Ulceration of the os. Ovarian and pelvic pains. Incapacitated for work. Uterus sometimes 8 Byford : Removal of Appendages normal in position, sometimes retroverted. Small -movable tumor sometimes felt in the cul-de-sac. Operation, Aug. 27th, 1887, at St. Luke's Hospital, assisted by Dr. Foulks, interne Gregory, and nurses. A right ovarian cyst, the size of a small egg, was easily pulled into the vaginal in- cision, punctured, ligated, and cut off. Left ovary, unnatural in shape and color, was also removed. Drainage for twenty-four hours. Iodoform gauze forty-eight hours. Recovery uninter- rupted, except by gastric disturbances. Case VI.-Mrs. C n, age 43. Married when twenty-two years old. Had one child, who is a dwarf, the year after, and dates her present illness from that tinje. Mental condition bor- dering upon insanity. • Anemia, pelvic pains, failing in. health, in spite of treatment. Slight anteflexion. Prolapse' of right ovary in cul-de-sac. Left ovary and tube enlarged. Operation at St. Luke's Hospital, Sept. 8th, 1887. 'Ifo adhe- sions nor difficulty. Drainage for twenty-four hours. Tampon for forty-eight hours. Almost constant nervous vomiting for four days, excited by every noise or rnoiion about her,, Progress favorable, except that after getting up she complained ^that walking still made her feel badly. * Case VIL-Mrs. J n, sent by Dr. J. H. 'Stowell. Age 34. Married. Seamstress. One child. ^Unable to work on account of pelvic trouble. Failure of treatment. Retroversion. Pro- lapsed right ovary. Operation at St. Luke's Hospital, Sept. 26th, 1887, assisted by Drs. Foulks, Stowell, Marble, and interne Gregory. Both ova- ries found enlarged and degenerated, and were removed. The uterus was tamponed in a position of anteversion for three days for the cure of the retroversion. Drainage for forty-eight hours. The temperature went up to 100.4° F. ninety-six hours after the operation, but promptly went down after removal of the tampon, and was normal after the fifth day. She now enjoys better health, and is able now to work steadily at her trade. Uterus remains in normal position. Says she has felt better this winter than in the past twelve years. Case VIII.-Miss R e. Virgin. Sent by Dr. G. S. Ruggles. Age 24. Acute attacks of pelvic inflammation for eight years; confined to the bed most of the time for four years on account of ovarian and pelvic pains and tenderness. Has been treated for pelvic inflammation for two years without benefit. Retroversion with adhesions of uterus and ovaries. Came to the hospital the evening before the operation with a slight diarrhea, and would not listen to a postponement. Operation, Oct. 2d, 1887, at the Woman's Hospital. Assisted by Drs. Wm. H. Byford, Ruggles, Mergler, and internes Tyler and Brown. Vagina narrow, introitus rigid. The cul-de-sac was found to be obliterated and represented by cellular tissue, so by Vaginal Section. 9 that I had to work my way up behind the cervix. Upon peeling the right ovary from its bed of lymph over the sacro-uterine liga- ment, it was found to be a dermoid cyst, the size of a walnut. The right tube was so firmly adherent that I could not separate it by any force that I deemed safe, and was not taken out. The left tube, firmly adherent throughout its entire length over the sacro-uterine ligament, was hard and knotty, over three times its normal size, and contained at its open fimbriated end a muco- purulent fluid. The meso-salpinx was so intimately adherent with its surroundings, that the tube tore entirely away from it. One strip of it was tied and cut. The ovary and infundibulo- pelvic ligament were adherent on the broad ligaments, so that the ovary could, with great difficulty, be brought down far enough to ligate. Hemostatic forceps were applied to two bleed- ing points. The ovary and tube had to be ligated separately. Drainage forty hours. Tampon sixty hours. In this case, it would have been impossible to have removed the tissues by ab- dominal section without eventration, and probably a fatal perito- nitis following. As it was, it presented all the difficulties that a vaginal section could, viz., small virgin vagina, obliterated cul- de-sac, extensive adhesions, hemorrhage, subacute pelvic perito- nitis; and yet, without disturbing the abdominal viscera, it was possible to ligate the tissues and adhesions in full sight, check the hemorrhage by hemostatic forceps, and get the patient to bed with but little shock or subsequent reaction. The temperature remained about 99.5° F. for a number of days afterwards. There were no bad symptoms, and the patient was up in three weeks. About this time, however, the old ovarian pain commenced to come back, and an abscess gradually developed and discharged through the vagina and rectum, probably from septic infection of a ligature. Case IX.-Mrs. C. E. F h, of Maquoketa, Iowa. Aged 28. Married eight years. Two children, four and seven years of age. Illness originated at birth of first child. Unable to be on her feet any length of time, or attend to domestic duties properly. Never benefited by treatment. Retroversion. Prolapse of right ovary and tube in the cul-de-sac of Douglas. Replacement of uterus does not replace the ovary and tube. Operation: Removed the right ovary and tube at the Woman's Hospital, Oct. 18th, 1887. Assisted by Drs. Hoag, Barlow, Weston, Tyler, and Brown. Sewed up the vaginal wound with carbolized catgut, put in a drainage tube, and tamponed the uterus in a position of anteversion. Drainage tube removed in twenty-four hours. In two and one-half days the temperature went up 100.4° F., the highest reached, when the tampon was removed and the temperature went down. The tampon was not wet through. She went home in five weeks, with the uterus in position, and has recently reported herself much gratified with the result of the operation. Her weight has increased from ninety-five to one hundred and eight pounds. 10 Byford : Removal of Appendages Case X.-Mrs. J n, of Chicago. Sent by Dr. Barlow. Age 42. Widow. One child, 16 years old. Sick with pelvic trou- bles ever since. Two and a half years ago had Sims-Emmet operation for cystocele, and Emmet's operation upon the peri- neum, with success. Chronic invalidism. Insomnia. Fre- quent attacks of parametritis. Constant local treatment for several years, but with little benefit. Irreducible retroversion. Enlargement of right ovary. Operation at Woman's Hospital, January 14th, 1888. As- sisted by Drs. Barlow, Merriman, Brown, and Galoway. As the vaginal entrance was too small for the use of the perineal re- tractor, a small side retractor was substituted. The shallowness of the cul-de-sac made the incision consist of a longitudinal vaginal and transverse peritoneal portion, with much cellular tissue between. No farther difficulty. No adhesions. Right ovary contained a cyst with about two drachms of fluid. The hindrance to the reposition of the uterus lay in a parametritis, extending to the posterior surface of the right broad ligament and upper edge of the sacro-uterine. Drainage for thirty hours. Tampon for two and one-half days. Ice-bag used until after the tampon was removed. The cervix was tamponed back in the pel- vis, bringing the fundus somewhat near the axis of the superior strait, and so remains up to the present time. Smooth recovery so far, temperature ranging from 99° F. to 99.8° F. for first few days. The prediction of her physician, that a fresh attack of parametritis would follow the operation, was not verified. Case XI.-Mrs. H d. Sent by Dr. C. A. Foulks. Age 22 years. Married three years eight months. One child, 2£years old. Sick since birth of child. Unimproved by a long course of local treatment. Right ovary size of a small hen's egg, prolapsed and cystic. Removed at St. Luke's Hospital, February 6th, 1888, assisted by Drs. Foulks, Barlow, and Hayman. Left ovary nor- mal and was not disturbed. Uterus sometimes retro verted, sometimes normal in position. Drainage twenty-four hours, tam- pon forty-eight hours. Recovery without appreciable reaction. Uterus remains in normal position. Case XII.-Mrs. J. E. D , of Central Park. Referred by Dr. J. T. Milnamow. Age, 26. No children, one miscarriage. Unable to attend to household duties. Retroversion. Right ovary and tube enlarged and prolapsed. Left tube contained four ounces of watery fluid, left ovary half an ounce. Adherent together and slightly to their surroundings. Vaginal entrance small and very rigid. The left tube and ovary drawn to the in- cision by my slender hemostatic forceps and emptied by a small trocar. The collapsed mass was drawn into the vagina, the thick pedicle ligated in three parts and cut. Drainage thirty hours, tam- pon forty-eight. Is making a good recovery. Uterus in normal position. Operation at patient's house, February 16th, 1888, as- sisted by Drs. J. T. Milnamow, H. P. Newman, Otto Miller, and two nurses. by Vaginal Section. 11 Indications.-A study of my cases will reveal the fact that they were all of the kind in which the uterus was either retro- verted, or changeable in position from the normal to retrover- sion, or was retrovertable without violence to the tissues When the cervix is held back by rigid tissues about it, or the fundus held forward in a similar way, abdominal section is the preferable method. When the ovaries are bound by large masses of lymph high up laterally or anteriorly in the pelvis, this method is also contra-indicated. When an ovarian tumor is larger than an orange and adherent, and larger than a child's head although not adherent, the abdominal method should have preference. By way of comparison, I may say that, although I favor vaginal section for the removal of the appendages when practicable, I chose abdominal section in the other fifteen cases, in which I removed the apendages during the months in which these vaginal sections were performed (from July 30th, 1887, to the present time, February 28th, 1888), excluding ova- rian tumors large enough to become abdominal. In two of the abdominal cases, I had to abandon the operation as impractica- ble after loosening a few adhesions. In one of these incom- plete operations, I could not get through the retroverted broad ligaments on account of the firm adhesions of the Fallopian tubes low down posteriorly, but feel confident that I could have removed the ovaries through the cul-de-sac. It will thus be seen that I advocate vaginal section only for those cases in which the uterus can be retroverted without vio- lence to the pelvic tissues, and in which the ovaries can be reached by two fingers introduced into the vagina and cul-de- sac. To try vaginal section for all cases, or even the majority, would be to again court the disasters that occasionally over- took the earlier operators. That this kind of selection does not exclude difficult and unpromising cases may be inferred from a perusal of the records of Cases IL, III., IV., V., VIIL, X., and XII. Advantages.-Unless there be some advantages in the vaginal method,in the class of cases referred to, its advocacy is, of course, a waste of time. I submit the following: 1st. The ovaries and tubes, when they lie low in the pelvis, are reached with much less interference with the intestines; the shock and reaction are less, and, in case of difficulty in sepa- 12 Byford : Removal of Appendages rating adhesions, the resulting inflammation is much less apt to spread to the abdominal cavity. 2d. The wound is less in extent, is at the lower end of the abdominal cavity, is better situated for drainage, is concealed, and is less liable to be followed by hernia. 3d. The bands of adhesion can in this class of cases be more often drawn into the field of vision and tied. 4th. Hot water, ice, and other hemostatic agents can be used with less danger. 5th. Advantage can be taken of the temporary exudate in the cul-de-sac to fix the retro verted uterus in a normal position. 6th. When much time is required, there is much less of that danger which comes from leaving the abdominal cavity open a long time in abdominal section. 7th. The statistics, other things being equal, are in favor of it, although it has been by some operators employed indis- criminately for all kinds of cases. In a series of twelve cases, selected according to the principles I have here advocated, it has given twelve recoveries-a series not long enough to estab- lish any definite conclusions, but long enough to justify a far- ther trial of a hastily abandoned operation. Objections.-1. It is objected to the operation that the ab- dominal method is simpler, quicker, and easier. This is not so in the cases for which vaginal section is indicated. It is, however, true of cases in which the cervix is held back and the ovaries high up or far forward in the pelvis. 2. Objection is made on account of the dilatation of the va- gina, often necessary. No dilatation is necessary, except such as can be accomplished by the retractors, as is shown by Cases VIII., X., and XII. 3. Objection is made that one cannot see as well. I answer that one can, as a rule, see better in this kind of cases than by abdominal incision, except when there is a large incision and eventration. 4. That the stump cannot be so easily tied. This, again, is not true of those cases in which the organs are low in the pel- vis. When there are extensive adhesions, less mutilation is required to bring them into view and reach. 5. Difficulty attending antisepsis. This is only apparent. The method I have adopted of sewing up the wound around a drainage tube leaves only the external end of the tube to be by Vaginal Section. 13 protected. After thorough disinfection of the vagina and uterus, the iodoform and iodoform gauze are sufficient for the time that the tube need be left. If pus or other septic matter in the pelvic cavity require that the vaginal wound be left open, the disinfected vagina will be comparatively harmless, particularly so until the peritoneal cavity becomes closed off above the purulent region. Dangers.-The chief danger would seem to be from sepsis, due to imperfect disinfection of the vagina; to escape of the contents either of a dermoid cyst or suppurating ovary or tube ; or to an adhesion, after the operation, of the posterior wall of the uterus to the sacro-uterine ligaments, so as to shut bloody or other exudates in the peritoneal cavity. Such disasters, as well as that of wounding the rectum, may of course be avoided by care and antisepsis. LITERATURE. T. G. Thomas, American Journal of Medical Science, April 1870; Diseases of Women, 1880, pp. 731 and 759; Private corre- spondence. E. R. Peaslee, Ovarian Tumors, etc., 1872, p. 319. Robert Battey, Normal Ovariotomy, Atlanta Medical and Sur- gical Journal, 1872, 1873, 1874; Summary of the Results of Fifteen Oases of Battey's Operation, British Medical Journal, April 3d, 1880; Extirpation of the Functionally Active Ovaries, for the Remedy of Otherwise Incurable Disease, Trans, of Am. Gyn. Society, Vol. I., 1876; Private correspondence. R. Davis, Trans, of Medical Society of Pennsylvania, 1874, Vol. X., Part I., p. 221. J. P. Gilmore, New Orleans Med. and Surg. Journal, Nov., 1873, p. 341. Clifton Wing, Boston Med. and Surg. Journal, Nov. 2d, 1876, p. 516. Goodell, Trans. Am. Gyn. Society, Vol. IL, p. 257; Lessons in Gynecology, 1887, p. 495. W. H. Baker, Vaginal Ovariotomy, N. Y. Med. Journal, March, 1882. Hegar and Kaltenbach, Operative Gynecology, 1886, p. 320. Olshausen, Die Krankheiten der Ovarien, p. 194. H. 0. Marcy, Private correspondence. Emmet, Principles and Practice of Gynecology, 1884, p. 695. Bouilly, Archives de Tocologie, 1886, p. 1080 (Gazette des Hdpitaux). Hart and Barbour, Manual of Gynecology, 1882, p. 211. J. Greig Smith, Abdominal Surgery, 1887, p. 172. Byford, Diseases of Women, 1888, p. 746. Howard A. Kelly, Private correspondence..