which in many cases they did not rally, the latter appearing like those who had experienced a moderately severe labor with rather more than the usual loss of blood. If the tumor were very large the element of shock will necessarily be considerable, whatever method be adopted in removing it, whether it be removed rapidly or slowly. The disastrous effects in such cases are not due merely to the sudden diminution of pressure by the removal of a large mass of material; in fact, in most cases no serious result need be feared from such a cause, especially if the place of the tumor be quickly filled by a sufficient quantity of dilute solution of sodium chloride at a proper temperature. The bad effects are due to the staggering blow which is inflicted upon the heart, brain, and lungs in the removal of the great volume of blood and other fluids which the tumor contains. I very much question the utility of removing enormous myomata and sarcomata from weak, enfeebled, and practically moribund women, their stock of vitality being too small for reaction. Little is said about such cases by those who are in the habit of publishing tables of their statistics. The conditions for drainage by this method are most favorable. With the broad ligaments and their ligatures turned into the vagina, and with a sufficient quantity of sterilized gauze in the vagina and supravaginal space to carry off secretions, there should be no septic complications; it is essentially an open method of treatment. With the peritoneal wound closed intestinal adhesions and obstruction are very unusual. The gauze may be gradually withdrawn, a few inches being pulled down and cut off each day until all has been removed. There is little more to be said concerning the treatment of such cases during the period of convalescence. The bowels must be kept freely open from the beginning, a bitter tonic must be given if the return to health is slow, and I prefer to use antiseptic vaginal douches daily after the gauze has been removed. The ligatures may not come away for weeks, but that is a matter of no consequence. I have never seen a case in which the pelvic roof did not become as firm as could be desired, or the vagina present any unusual conformation which would interfere in any way with its functional purposes. It may very properly be asked in these days, when many hysterectomies are being performed, Is the justification 'Dr. Polk informs me that he has removed the uterus by this method fortytwo times, with but two deaths, at the date of reading this paper. for the removal of so important an organ as the uterus, as an every-day operation, sufficient? I reply, in most cases the justification is ample. The organ is not essential to life, and, in the greater number of cases in which its removal is determined upon, is entirely inadequate to the function of gestation. If it can be removed with comparatively little danger to life, and its presence is a constant menace to health and comfort, what is to be gained by its retention? The question of mutilation has not the serious significance which it had a few years ago. If the uterus is removed the appendages should be removed also, which means the rapid induction of the menopause, relief to constant suffering, and the ability to assume anew a proper share in the duties of life without the sense of weariness and distress which the presence of the tumor made inevitable. Unfavorable mental influence as a sequel to this operation I have never seen, and can conceive of no reason why the mind should be influenced unfavorably by it any more than by the natural occurrence of the menopause. Of course in exceptional cases mental injury is possible. The influence of the operation upon the sexual appetite is likely to be governed by the temperament and previous history of the individual, just as is the case if the ovaries and tubes alone have been removed. Sexual desire does not reside in the genital organs; it is often intense when they are inactive, it may be intense if they are absent. It would seem accordant with physiological law, however, that the removal of organs associated with certain functions should gradually be followed by the abolition of those functions and the phenomena associated with them, and it would be unreasonable to expect that the genital apparatus would prove an exception. To those with whom sexual desire has long been absent, or has been overshadowed by the excess of suffering which has accompanied the development of the tumor, it is improbable that it will be restored by any surgical measures of whatever character. In the near future I believe we shall more frequently resort to radical measures in the treatment of myoma than is now deemed advisable, and, as in the case of ovarian tumors, we will not wait until the patient has been reduced to extremities by pain and hemorrhage or by such extensive growth that an operation will offer unusual difficulties. 159 EAST 37TH STREET. LIGATION OF THE BROAD LIGAMENTS OF THE UTERUS FOR UTERINE FIBROIDS.1 REPORT OF MY SIXTH CASE. BY [FRANKLIN H. MARTIN, M.D., DECEMBER 16TH, 1892, I had the honor of presenting to this Society a description of a new operation for the treatment of fibroids and hemorrhage of the uterus. The operation consists in the ligation from the vagina of more or less of the broad ligaments of the uterus with their vessels and nerves, the extent of the ligation depending upon the result sought, from a simple ligation of the base of the ligament, including the uterine arteries and branches of both sides, without opening the peritoneum, to a complete ligation of the ligament of one side, including both uterine and ovarian arteries, with partial ligation of the opposite ligament, without opening the peritoneal cavity if possible, but by doing so if necessary. When that report was made' I recited two cases, the first of which was operated upon November 15th, 1892. At that time I could do but little more than describe the operation and give the immediate results. At the Milwaukee meeting of the American Medical Association, held in June, I reported in detail five cases, including the first cases operated upon. In that report the result of Case I. was given in the following words: "Tumor not materially affected; hemorrhages ceased temporarily." Subsequent reports show hemorrhage increasing again. The patient thinks that the tumor has increased somewhat. I have not had an opportunity to examine the patient for several months. On the whole, the hemorrhage is less than formerly and the tumor not materially increased, although the operation cannot be said to be a success." Since the above report I have received more 1 Read before the Chicago Gynecological Society, November 17th, 1893. ? THE AMERICAN JOURNAL OF OBSTETRICS, April, 1893. 3 Journal of the American Medical Association, September 2d, 1893. gratifying news. The patient is markedly improved in every way. The tumor has materially diminished in size, there is no longer excessive hemorrhage, the pressure symptoms have subsided, and the woman pronounces herself in better health than she has enjoyed for years. Subsequently I received a letter from the physician into whose hands she fell after leaving me, and he informs me that immediately after her operation she had a severe attack of la grippe, which was prevailing in the locality at the time, and which, he thinks, accounts for the poor condition immediately following her operation. At any rate, her condition is now much improved, and, judging from the history of my later cases, I believe she will completely recover. This case I reported a failure in my series of five; I now wish to transfer it to my improved list. Case II. of the series concluded as follows: "I have seen this patient every month since the operation was performed (December 3d, 1892). The hemorrhage has ceased completely. There has been very scanty flow at the menstrual period; all pain has ceased. The uterus had materially diminished in size at the end of one month; at the end of three months it was but little larger than a normal uterus. The patient's health has improved, so that from a state of almost complete invalidism she was transformed into a comparatively strong and healthy woman. The improvement was progressive from the day of the operation." I can now say, after the lapse of a year from the date of the operation, that I have never seen a woman, in the deplorable state this woman was, do better following either a hysterectomy or a Battey-Tait operation. The tumor, which was interstitial before operation, was eight by five inches, riding above the brim of the pelvis. Case III., the patient wrote, four months after the operation: The "flow is about one-third the time in duration and onethird the amount it was formerly; otherwise not improved." This was a small bleeding interstitial fibroid, and on account of its smallness I ligated the broad ligament of but one side. The patient has not reported for a month. Case IV.-large, adherent fibromyoma extending to the umbilicus, profusely hemorrhagic, for which laparatomy had been unsuccessfully performed, neither the appendages nor the tumor being removable-was the next case upon which I operated. The patient had not been out of bed, on account of loss of blood and general weakness, for several months. With considerable difficulty I ligated the base of both broad ligaments, including the uterine arteries, January 5th, 1893. In my June report I said of this case: "The flowing ceased immediately and the patient was relieved of her drain for over two weeks. She then had a few days' flowing, which resembled an ordinary menstruation. She has rapidly and steadily improved since that time. She has menstruated regularly but scantily, and without pain. She can at this time (June, 1893), five months after the operation, attend to her duties as a housewife, and considers herself cured. The tumor has become reduced in size until it is no longer noticeable as a deformity, and so that the patient herself is no longer conscious of its presence." Since the foregoing report was written in June I have seen this patient several times, the last time within the month. The patient was then examined by several physicians, one or two of whom, on independent examinations, failed to notice any abnormal enlargement. The uterus is still somewhat larger than normal, but is not more than three by four inches in diameter, while the testimony of at least three experienced diagnosticians will bear me out in the estimate that its former diameters were not less than four and a half by eight inches. The patient is in good health now; menstruation is regular but scanty, and she is free from pain. Case V. was one referred to me by Dr. F. H. Geer: "There had been constant hemorrhage for three months; diagnosis, interstitial fibroid tumor about size of a four months' pregnancy. I operated on patient January 8th, 1893. She had a little subsequent temperature, and one month after operation the ligature sloughed from left broad ligament, from becoming infected from the vagina. Four months after operation Dr. Geer reported that the menstruation only lasted two days; very scanty, no pain. Fibroid diminished in size until the uterus is about normal. Patient claims that she is cured." This is the June re port; I have no subsequent one. CASE VI.-The case which I wish to make a preliminary report upon to-night has been of extreme interest to me, because the patient was the wife of a well-known physician and a specialist of national reputation, who a short time since was obliged to leave this climate on account of lung trouble and seek relief in the milder climate of California. In the latter part of July last, |