She entered the Woman's Hospital. Assisted by Drs. Shibley and White, I made abdominal section. On account of extensive adhesions, thick abdominal wall, and the exhausted condition of the patient, it was thought unsafe to attempt to remove the tumor. I therefore decided to ligate the ovarian artery, and then to ligate the uterine artery as far down as it was thought safe without risk of producing gangrene of the uterus. I applied two ligatures to each uterine artery for about two-thirds of the distance from the tube to the internal os. I did not remove the ovaries and tubes. The patient made a good recovery; an abdominal fistula remained for several weeks.

This drawing is intended to show the method of operation. The right tube and ovary have been tied by ligature 2 and removed. Ligatures 1 and 3 are introduced on an aneurism needle and tied. Ligature 4 shows the lowest point at which I have ligated. Ligature 5 might be considered to be within the danger line. The left tube and ovary have not been removed, but ligature 1 includes the tube and artery. I have ligated the uterine artery as low as the point indicated by ligature 3 on the left side. The drawing is somewhat diagrammatic, but the arteries are as natural in their position and relations as I could draw them.

Three months after the operation the uterus was about twothirds its former size, and three months later it was one-half its original size. For the past six months the atrophy has been continuous. She has had occasional slight hemorrhages, but considers herself well.

I have since performed this operation three times, and so far

with good results. The second operation was performed about five months ago, and the patient was doing well when I last saw her, several months after the operation. The last two cases are too recent to judge of the permanent results.

This operation will be useful in certain cases in which it is desired to cause atrophy of the uterus and immediate cessation of menstruation. In such cases ligation of the ovarian arteries and of the uterine arteries along the side of the uterus, together with removal of the Fallopian tubes, will accomplish this result by cutting off the chief blood supply to the fundus and body of the uterus. By this operation the shock attendant upon hysterectomy, which is so often fatal in very anemic patients, will be avoided.

Great care and judgment must be exercised, in the cutting-off of the blood supply of the uterus, not to go beyond the limit of safety as regards gangrene. The minimum amount of blood supply necessary for life of the uterus cannot be stated, but I have demonstrated that the ovarian artery and the uterine artery for two-thirds of the distance from the tube to the internal os can be safely ligated.

Dr. Franklin H. Martin has shown, in his operation of ligation of the uterine arteries through the vagina, that it is safe to ligate both uterine arteries as they cross the ureters. It must, however, be remembered that the uterus is fed by perpendicular branches from the utero-ovarian arteries, and hence that each uterine segment is supplied by its own straight artery. The uterus is very tolerant to variation, or even to sudden cessation, of its blood supply.

In the ligation of the arteries many nerves, including the automatic menstrual ganglia, will necessarily be destroyed, and immediate cessation of menstruation will result. This artificial menopause will lessen the nourishment of the uterus.

This operation will aid in:

1. Atrophy of uterine myoma.

2. Cessation of menstruation.

3. Atrophy of the uterus and checking uterine hemorrhage. The operation heretofore performed to induce artificial menopause has often failed, or the desired result has not been obtained for months or even years.

URETHRAL CARUNCULÆ.1

BY

EDWARD NICHOLAS LIELL, M.D.,

Lecturer in Gynecology, New York Polyclinic,
New York.

My object in bringing this paper before you is to direct attention to the frequent seat of new growths about the female urethra. There is hardly any affection to which women are liable which causes greater discomfort or pain than urethral caruncle. By this term is meant the spongy excrescences or vascular growths arising from the urethral mucous membrane. They are of a soft, spongy texture, generally irregular in outline, and of a granular appearance. Their size varies from a pin's head to an ordinary marble, occasionally larger. As to their structure, they consist of hypertrophied papillæ, extremely vascular, the vessels being enormously developed and tortuous; nerve filaments have also been found to exist in them, though their sensitiveness is not positively due to the presence of these. They are of a deep-red color, of slow growth, and, as already stated, they are generally exquisitely sensitive to the touch.

My observations lead me to state that when small these growths are generally sessile; as they increase in size, however, their base forms more or less of a pedicle. In the majority of cases from one to three in number are present; not infrequently, however, we meet with cases where as many as ten or twelve are found. They are met with either along the borders of the meatus, or just within it along the lateral and posterior walls of the urethra; at times they may extend within the canal for an inch or more.

As to their origin, to attribute the development of these neoplasms to any positive element is, at the present day, impossible; their etiology is still obscure. Marriage, with its attendants, is undoubtedly in the vast majority of cases the predisposing cause. So far as my own observations go, all have occurred in married women; yet they are also seen in single

Read at the eighty-eighth annual meeting of the Medical Society of the State of New York, Albany, February 6th, 7th, and 8th, 1894.

women, though more rarely. They are most frequently observed in middle-aged and elderly women, and less often under 30 years of age. Records show that other affections of the genital organs are almost inevitably present, and my experience bears this out in every one of the cases observed personally. One case in particular, in which I removed as many as a dozen small growths, the largest the size of a French pea, and of interest to me because of its novelty, was attended with a dilated vein, the diameter of a goose quill, along the course of the urethra, and a varicose condition of the anterior wall of the vagina, accompanied by considerable hyperesthesia in the immediate vicinity.

The symptoms to which these neoplasms give rise are very evident. The most important is the characteristic pain. This may be described as agonizing or excruciating, occurring toward the closing act of micturition, and very often continuing for a time after. This pain is of such a character frequently that the patient dreads the process of evacuating her bladder; it may radiate to the hips, lumbo-sacral region, or along the thighs. There is a frequent desire to urinate, accompanied by more or less tenesmus, which in some cases is almost unbearable. Unless the growths are of considerable size, they are rarely attended with hemorrhage. The patient complains also of an aching or pressure, for hours at a time, about the lower pelvis and vulva, increased upon motion or contact from any source. A mild pruritus and burning sensation is occasionally present when the growths are very small and situated about the meatus. The patient becomes nervous, irritable, and generally depressed, added to which is the attendant general weakness consequent upon the presence of insomnia.

As to diagnosis, the above history, more or less modified, or the history of painful micturition, gradually increasing and extending over a considerable length of time, should, especially in middle-aged women, lead us to suspect the presence of these growths, and an examination of the urethra should always be made. My observations, in as many as thirty cases within the past ten years, lead me to say that the size of these growths has little bearing upon the attendant pain and suffering; in almost every instance I have noticed that the small and numerous sessile growths were more sensitive and gave rise to greater pain and distress than those of large size and having a pedicle.

In many instances, particularly where these growths are of small size and entirely within the canal, separation of the labia does not render them visible, and the symptoms may be readily attributed to a cystitis or urethritis; dilatation of the urethra, however, which should always be employed, will render the condition obvious.

The treatment of these cases is at times very troublesome and not attended with any degree of immediate satisfaction; patience and perseverance, however, on the part of both physician and patient, will ultimately accomplish the desired end. Cocaine anesthesia is to be resorted to preliminary to treatment; occasionally we will be obliged to resort to general anesthesia. The methods employed by me in the removal of these neoplasms are torsion (twisting them off) and excision (dissecting them out completely). When small they should be drawn down and held in view by means of a tenaculum, and then either twisted off, if possible, by means of a small, curved serrafine forceps, or they should be dissected out, cutting them off completely at their base by sharp-pointed scissors. Torsion gives rise to but slight if any hemorrhage; even in excision hemorrhage is usually inconsiderable. If the latter be rather free or persistent, the application of Monsel's solution of iron, or the actual cautery, or, if need be, tamponing the urethral canal temporarily with a conical plug of iron-cotton, will arrest it. Twice I have had occasion to resort to the sharp curette where the growths were well within the canal, numerous and aggregated, being difficult of complete excision by use of scissors. More rarely, where the growths are single, of large size, presenting outside of the meatus, and affording an easy pedicle, the ligature or actual cautery may come into play in their removal.

These radical measures of treatment have always been fol lowed by the immediate application of a solution of nitrate of silver, repeated each alternate day for a considerable length of time-beginning at first with a drachm to the ounce, and gradually reduced to ten grains to the ounce-as much to do away with an irritable condition of the mucous membrane generally present as to prevent their return. Should these growths show a disposition to return, as they occasionally will, more especially those of small size, the above measures of treatment should again be carefully gone over with. The use of the catheter is rarely required subsequent to operative procedures.