103° F.; night sweats; progressive loss of flesh; diarrhea more or less constant, and pulse averaging 110 to 112. Menses always irregular.

Physical examination: height, 4 feet 6 inches; general emaciation; heart, seemingly far back in the thorax, anemic murmur at times; lungs, right apex solid and moist râles all over right side, left apex solid and left lower lobe clear; abdomen, the uterus completely filled the abdominal cavity and palpation of the abdominal organs was impossible, pregnancy of probably eight and a half months' duration.

Vaginal examination showed the vaginal canal quite long and running directly forward, the os uteri very high up and difficult to reach. The promontory of the sacrum was easily reached, and the conjugate vera was less than 6 c.m. The pelvis was not only shortened antero-posteriorly, but also crowded in transversely. No part of the child presented. The anal orifice pointed backward and slightly upward.

The patient's mental condition was bad. She suffered constantly from the increasing abdominal pressure: dyspnea was marked.

September 28, the day following her removal to a private hospital, Dr. W. F. Edmunson, of Pittsburgh, saw the case in consultation, and it was decided that Cæsarean section offered the best chance for the mother, and the only chance for the child. It was thought wise to improve the patient's general condition for a week before the operation was attempted, but the afternoon of the day following the consultation, September 29, the patient began to have regular uterine contractions. She was given a sedative, and careful preparation made for the operation.

September 30, the patient was anesthetized by Dr. H. W. Taylor, chloroform and oxygen being used; was placed in a modified Trendelburg position and abdominal section done. A living male child was delivered weighing 41⁄2 pounds. It was puny but cried lustily.

A hasty examination of the pelvic inlet showed a shortening of all diameters of the pelvis, so that it would have been impossible to deliver a child weighing even two pounds through the parturient canal. The repair work was done as usual, catgut being used throughout. The patient made an uneventful recovery, was up on the eighth day, and went home on the sixteenth. The baby lived but a few days. It was tubercular and seemed to have no vitality at all. One year after operation the patient is in fairly good condition. The operation seemed to have checked, temporarily, the activity of the tubercle bacilli.

Case 2. Mrs. Y. Age 34 years.

This patient first became pregnant about June 26, 1908. A careful examination at this time disclosed the following: weight, 96 pounds; height, 5 feet; heart and lungs normal; abdominal palpation revealed nothing abnormal. Pelvimetry: interspinous diameter 16 c.m., intercristic diameter 22 c.m., external conjugate 151⁄2 c.m., conjugate vera 91⁄2 c.m., internal transverse 9 c.m., internal oblique 91⁄2 to 10 c.m.

The fact that the patient's mother was a small woman, and had had small children with no severe labors, and also the fact that the patient's husband was of small stature led to the conclusion that a living child might be had by an induced labor or a natural labor if the presenting head was small. Then the patient and her husband refused the radical Cæsarean section. Pregnancy was uneventful, and after the sixth month frequent examinations were

made to keep track of the relation between the presenting head and the pelvic inlet.

By February 7, 1909, the head of the child was riding above the brim and could only with difficulty be made to engage. The patient was about seven months' pregnant. She was taken to the Pittsburgh Homeopathic Hospital and labor was induced using Dr. Cook's method. The patient was in labor about thirty-six hours, that is, it took the presenting head, the position O. L. A., thirty-five hours to complete the first stage. The os uteri was relaxed and easily dilated. The second stage lasted forty-five minutes. No instruments and no lacerations. The child was a male and weighed 41⁄2 pounds. It lived but five hours. The third stage lasted ten minutes. Recovery uneventful.

The patient became pregnant again about June 6, 1909. Toxemia developed and the uterus was emptied about June 12, by currettement. Recovery normal.

The patient again became pregnant about November 7, 1909. Her health was very good and continued so until June, 1910. Her condition improved somewhat after that, and it was hoped that she could go to term, August 14. However, during the first week in July, the pulse, which had averaged 110 to 120 per minute for a month past, began to go higher. Vaginal examination and palpation showed the presenting head above the brim, and it could not be forced into the inlet or even made to approach any engage

ment.

The kidneys became less active, both as to quantity and quality of secretion. The urea dropped from 20 gm. to 6 gm. daily, the total solids running about 30 gm. per twenty-four hours.

With all this a lack of nerve control developed. It was decided to operate at once. This would give an eight months' child.

On July 15, Cæsarean section was performed, and at 8.30 A. M. the patient was delivered of a male child weighing 6 pounds and 9 ounces. The child cried as soon as delivered. The recovery of the patient was uneventful, and she left the hospital on the nineteenth day, with a bright and healthy youngster. Today, November 15, 1910, both mother and child are well and happy.

The technic used in both operations was that elaborated by Dr. J. H. McClelland in his article on "Technique of Cæsarean Section," to be found in the Transactions of the Homeopathic Medical Society of Pennsylvania, 1907, page 111.

The Pacific Coast Journal of Homœopathy for November contains the report of the committee on local arrangements for the American Institute of Homœopathy in connection with the recent meeting in Los Angeles. The figures as given should be most satisfactory to all. From it we learn that a total of $3,812 was collected. After all the expenses for the lavish hospitality were paid, a balance of almost $1000 was left in the treasury. We understand that it has been voted to add this balance to the sum of several thousand dollars already in hand for the purpose of starting a homeopathic hospital in that city.

HYSTEROMYOMECTOMY VERSUS PANHYSTEROMYOMEC

TOMY.

BY H. D. BOYD, M.D., Boston, Mass.

In presenting this paper I am well aware that the subject may be thought hackneyed. Nevertheless, we know that the pendulum of surgery is swinging back to more conservatism in dealing with the pelvic organs of women. There has been much practical research work along this line in the last few years. A large number of cases have been carefully examined before operation and followed up afterward, the results noted and deductions drawn. That there may be no misunderstanding of terms, let me state that by hysteromyomectomy I mean the removal of the supravaginal portion of the uterus for fibromyomata; by panhysteromyomectomy, the removal of the body and cervix of the uterus for the same cause.

In consideration of this much mooted subject, it will be necessary to review briefly the anatomy of the uterus, so that we may have a clear understanding of the reasons for and against these operations.

The non-pregnant uterus is contained in the pelvic cavity. Its lower segment is imbedded within the pelvic floor, between the bladder and the rectum. The uterus is connected with the ovaries, the abdominal wall, the lateral and posterior walls of the pelvis, the vagina, the bladder and the rectum, by fibro-elastic tissue, muscular bands and peritoneal folds. Most of these attachments, or so-called ligaments, however, have little influence in supporting the uterus; but owing to the intimate connection of the cervix with the vagina, and this with the pelvic floor and with the sacrum by fibro-muscular bands, the lower segment has the advantage of a relatively fixed position. The body, on the contrary, is freely movable.

The uterine artery, from the internal iliac, accompanies the uneter along the pelvic wall to the attached border of the broad ligament. About two cm. from the cervix, and on a level with the internal os, the artery crosses the ureter obliquely in front to the cervix and passes up the lateral border of the uterus, as far as the angle. It gives off the vaginal artery which supplies the cervix and vagina.

The nerves are derived from the utero-vaginal sub-division of the pelvic plexus and also from the second, third and fourth lumbar nerves. The utero-vaginal plexus divides into two parts, the smaller of which is distributed to the fundus, the larger forms a chain of minute ganglia along the cervix and vaginal vault. The cervical ganglion is especially large and lies behind the upper part of the vagina.

Myoma of the uterus, or fibromyoma, is a typical nodular growth, springing from some portion of the uterine body, usually

above the cervix. Authorities differ as to the origin of myomata, ascribing them to many and varied causes. Kelly and Cullen after an exhaustive study of 1674 of these cases, state: "We still know practically nothing as to the origin of uterine myomata."

Although myomata are present early in life, they seldom have clinical significance until between the ages of thirty and fifty.

The characteristic symptoms of fibromyomata are hemorrhage. excessive flow at periods, anemia, pressure, pains which are variable, depending on the position and size of the tumor. The complications are adhesions, hydrosalpinx, pyosalpinx, ovarian tumors and carcinomatous conditions. C. P. Noble found, in a study of 218 cases, there were complications in 71.

If the patient has been losing much blood, it is essential that she be built up. If the surgeon can choose the time for operation, it is much better to have it before a menstrual period rather than just after one. To prepare the patient for operation, the bowels should be thoroughly cleared out and the twenty-four hours' amount of urine examined. The usual vaginal and abdominal cleansing should be done. After the patient is anaesthetized, a careful bi-manual examination of the growth should be made. The condition of the uterine mucosa should be ascertained by curette. The condition found will have some bearing on the choice of operation; for, if by curettage, malignant changes are discovered, or strongly suspected, a very radical operation is demanded. If nothing suspicious is found in the uterus, the cavity and cervix are thoroughly cleansed

The patient is then placed in position for abdominal operation The skin is thoroughly scrubbed and made as nearly aseptic as possible. The hips are elevated and an incision made in the median line below the umbilicus and carried well down to the symphysis. The tumor is examined for adhesions or other complications. The adnexa are inspected for pathological conditions. The tumor is delivered through the wound. One or both ovaries should be left in the pelvis, if possible. If the ovary is to remain, the ovarian artery is tied near the horn of the uterus. If the ovary is diseased, then the outer end of the broad ligament is grasped and a catgut ligature carried beneath the ovarian vessels and tied. A clamp is placed toward the uterine side of the ligament and the tissues severed between. The round ligament is next tied and clamped in the same way. The peritoneum on the anterior surface of the broad ligament and uterus is now incised from one round ligament to the other. The vesical peritoneum is pushed away with gauze; traction is made on the tumor and the uterine vessels exposed by pushing away the broad ligament from the tumor or The vessels are tied and a clamp applied to the uterine end. The tissue is cut between. The opposite side is treated in the same manner.

If a hysteromyomectomy is to be performed, the cervix is cut through with curved scissors or knife. The cervix is cupped or