My operation, as described in my first article (before I had learned of the work of Dorsett or Gottschalk), differed from theirs in three essential features:

1. I included in all cases the whole base of the broad ligament, in order (a) to include not only the main channel of the uterine artery, but all collateral branches; (b) in order to include the nerves as well as the arteries of nutrition; (c) in order to dimin ish nerve reflexes.

2. I included in desperate cases not only the base of the broad ligament with the uterine artery and branches in my ligatures, but, when practicable, ligated high enough on one side to include the ovarian artery.

3. I advised accomplishing this result, if possible, without opening the peritoneal cavity, but by doing so if necessary.

Prof. Gottschalk says: "I see nothing novel in the method described by Dr. Martin, as all operators have thus tied the uterine vessels in every case of total vaginal extirpation." I consider that decidedly juggling the case. We all admit that

all operators have thus tied the uterine vessels in every case of total vaginal extirpation; so do they all tie in the same operation both ovarian arteries, and occasionally the Fallopian tubes; but that does not necessarily imply that Prof. Gottschalk or any other operator would proceed to tie all these structures in simply ligating the uterine artery. His operation, as we can judge of it from the paragraph already quoted, implies ligation of the uterine artery pure and simple.

In the April number of THE AMERICAN JOURNAL OF OBSTETRICS, 1893, I published my first article on ligation of the broad ligaments, giving minute description of technique, theory of action, and execution, illustrated by two cases. Five months later, on September 30th, 1893, in reply to Küstner, Gottschalk first published his technique in the Centralblatt für Gynäkologie, No. 39, which coincides with mine, not only in its minutest details, but also in description, as far as the two operations could be alike.

I cannot agree with Prof. Gottschalk that the incidental including of the nerves of the broad ligament, or ligation by deliberate forethought, needs no special mention. Take almost any organ or portion of the body of an animal, and deprive it of its nerve supply in one instance and of the arterial supply in the second, the fact will be demonstrated that the greatest disturbance and change of nutrition will occur in the organ deprived of its nerve supply. Again, ligate a large artery to a given portion of the body in two animals, and in one include also the nerve supply in the portion of the animal in which the artery alone is ligated collateral circulation will become established in a few hours or days, while in the portion of the animal deprived of both blood and nerves collateral circulation will be restored

very slowly, frequently never, and the nutrition of the part will suffer greatly.

Prof. Gottschalk in his letter completely ignores my second point of difference-viz., the including of the ovarian artery on one side. He likewise ignores my third point of difference, or my suggestion to disregard the peritoneum if it becomes necessary to penetrate it in order to accomplish the desired result.

Starting, then, from our original proposition: 1. Did Prof. Gottschalk first suggest the idea and execution of the operation in question? No; since that was done by Dr. Dorsett in May, 1890, or more than two years before Prof. Gottschalk's paper at the Brussels Congress. 2. Did Prof. Gottschalk first publish and describe his ideas and technique in recognized medical literature? Again no; since Dr. Dorsett published the idea in May, 1890, while I myself described in detail the technique, as far as it applied to ligation of the uterine artery, five months in advance of him, or in April, 1893. 3. Does Prof. Gottschalk show that his theory, execution, and description are identical with mine? A third time no; inasmuch as the operation claimed by Prof. Gottschalk includes but one of three important features of the operation claimed by me.

Finally, as Prof. Gottschalk has brought up the delicate matter of whose name my operation should bear, I submit, as the completed operation was described, executed, published, and named by me independently and without the knowledge of similar but minor work in the same direction, that the operation should be known as Martin's operation of vaginal ligation of the broad ligaments for uterine fibroids.

Yours very truly,

FRANKLIN H. MARTIN.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF CINCINNATI.

Meeting of February 22d, 1894.

The President, WM. H. TAYLOR, M.D., in the Chair.

FIBRO-CYSTIC TUMOR OF THE UTERUS.

DR. ZINKE.-Mrs. X., æt. 47; very much emaciated; mother of one child born twenty years ago; never had a miscarriage. Has not felt well since the birth of the child. A tumor was first noted eighteen years ago, and had grown steadily until it now filled the whole of the abdominal cavity. The tumor was fluctuant two inches above the symphysis and solid below that

point. The solid mass of the tumor filled the pelvic cavity so that the os externum could not be reached except by forcing the finger high up between the growth and the symphysis.

Diagnosis. Fibro-cystic tumor of either the uterus or ovary, or a fibroid tumor of the uterus complicated by a large ovarian cyst. The patient was very weak; temperature every afternoon 101°; pulse 130, wiry and compressible. Her physical condition was such that even operative interference promised very little. On the 16th of this month a free incision was made in the median line, eight inches in length. A cyst, universally adherent, presented itself. The adhesions were very strong, firm, and exceedingly difficult of separation. The tumor was punctured with a trocar, with a view of emptying it, and a large amount of chocolate-colored fluid escaped. After reducing the tumor in size I found it impossible to separate the adhesions, and most of them had to be ligated and severed by the knife. After it was freed anteriorly and from the omentum and intestines above, I attempted to get my hand behind to separate the adhesions there. In this attempt I broke through the cyst and its contents freely flooded all of the abdominal viscera. After a good deal of hard and persistent work I succeeded in eventrating the growth, but it proved impossible to liberate the solid portion from the pelvic cavity, and I was obliged to fix this large and solid mass in the abdominal wound. About twenty hypodermic injections of whiskey, as well as a transfusion of sterilized salt-water solution, had to be made to keep the patient alive long enough to get her off the table. The following morning the temperature was 99°, the pulse 130. She died of exhaustion forty-eight hours after the operation. The fluid removed from the cyst consisted of degenerated fat globules; no streptococci could be discovered. The tumor had its origin in the posterior wall of the uterus.

TOTAL VAGINAL EXTIRPATION OF A FIVE MONTHS' PREGNANT

UTERUS FOR CARCINOMA OF THE CERVIX.

Mrs. X., æt. 39, mother of a large family, the youngest 4 years of age, was referred to me by Dr. Koehler, of this city, who had made a diagnosis of carcinoma of the cervix. My examination confirmed his view, and vaginal hysterectomy was advised and accepted. There was a strong suspicion that the patient was pregnant, but it was impossible, even on very careful examination, to determine this with absolute certainty. She was a very large and fat woman, with a pendulous abdomen, and this greatly interfered with a satisfactory examination. The operation was performed February 10th at the German Hospital. After the separation of the cervix from its attachments I became aware that pregnancy existed. There was nothing to be gained by hesitating. To proceed and remove the whole of the pregnant uterus was the only solution. After removal of the uterus the

organ was incised and a four and a half months' fetus escaped. The patient is now, one week after the operation, doing well (was discharged cured five weeks later). It is probable that, had I known positively of the existence of pregnancy, I would not have operated upon this woman; and yet, had the operation not been done, I would certainly have placed her life in great jeopardy, because a fatal result would have been almost inevitable at term. Notwithstanding I did this operation without being in possession of all the facts of the case, I have done the very best thing for her.

DR. REED.-We ought to appreciate a member of the Society who will bring a cheerless case, such as the first, and give us an experience which was certainly very trying. Of course we cannot find any fault with Dr. Zinke for leaving the operation in a state of incompletion. The only criticism--and I do not offer this as an adverse one-is that in a case like this we ought to undertake the operation for exploratory purposes and to determine the feasibility of removal. It is an exceedingly fine point in judgment to determine just when to drop exploratory measures and to undertake the radical measure of the completed operation. I am perfectly well aware that our best intentions and our best judgments in this connection sometimes miscarry, that we sometimes find ourselves confronted by a set of circumstances that render retreat impossible; in other words, having gotten in, there is no place left for the completion of the operation, until perhaps we find ourselves in the very midst of the most serious of complications. This woman could not have lived long; she would have died shortly of symptoms resulting from pressure. The temporary hemostasis is certainly effective; yet, considering the intimate relations of the superimposed viscera, it is a question whether it were not better to retire earlier in the game; and yet perhaps it is just as well as it is, for the woman would have been miserable all the time and have died soon.

In reference to the second case, the management of pregnancy, in the case of cancer of the cervix, is a subject which has engaged the attention of men the world over, and about which a great deal has been written the last few years. Where diagnosis becomes practicable before operation, and where there is a reasonable prospect of the patient going through the period of gestation successfully so far as the child is concerned, non-interference is the line to be followed. In that line Cesarean section should be the method of delivery. But we must all recognize the fact that diagnosis is extremely difficult. The usual changes in the cervix, the usual changes in coloration and consistence of the cervical tissues, are gone; the chance of making a successful bimanual examination is gone, for the immobility of the uterus, and the condition of the tissues which have undergone degeneration, preclude the necessary manipulations. This leaves but few methods for the detection of pregnancy. Something over

a year ago I made a cervical amputation for the very reason that there was that complete fixation of the uterus and engorgement of the lateral tissues which would make the complete extirpation impracticable and essentially worthless. The results were as satisfactory as could be expected. The patient regained her strength and went about her duties. But two months ago I received a startling letter from her physician, who said she had then passed four and a half months of pregnancy and there could be no doubt as to the diagnosis. In that case we have an illustration of what may happen. Either in cases in which we have done the amputation or in cases in which the disease may go on in an indolent way for considerable time, one of the dangers of delay in operation is incurring pregnancy. I remember a case reported before our State Society, from the practice of our friend Dr. Reamy, in which amputation was practised during pregnancy, whether as a matter of election or for the relief of an otherwise incurable case I do not now pretend to say. In that case the woman lost her life simply from inability to expel the fetus per vias naturales, perhaps for the want of Cesarean section. These cases are constantly coming before us, and it does seem to me we should hold this before the patient as one of the possible dangers of delay. Of course the line of practice, when possible, is to save the child's life. That is considered one of the criterions upon which to shape our practice. I observe that rule, yet I do not think any tears ought to be shed over the loss of fetal life under such circumstances as these.

DR. BONIFIELD.-How thick was the cyst wall?

DR. ZINKE. It was quite thick where you see it, but anteriorly and above, as well as posteriorly, parts occurred a quarter or even an eighth of an inch in thickness, so that at the time we exposed it we believed we werein the presence of an ovarian cyst, and therefore I made an attempt to deliver, and when I had my hand posteriorly it ruptured and I had to act as I did. Had I recognized the true character of it before, I should have sewed the sac to the abdominal wound and turned out the contents, filled it with iodoform gauze, and let it take care of itself. It was an exploratory incision. I promised the people at the time that if I saw I could not remove it conveniently I should not attempt it. I have seen cases with thick walls in which I had no difficulty.

SALPINGO-OÖPHORECTOMY.

DR. REED.-I have a specimen which has long ago lost its novelty to this Society, and which I present only because it has some value in connection with the associated circumstances of the case. It is an ovary with the tube attached, which I removed this morning. The patient was a woman who four years ago had an attack of what the medical man in attendance called