lixity of detail, forgetting that one case, provided the author can select a type case, is better than twenty, and strangely overlooking the fact that there is nothing in all this array to convince the reader, who generously takes it upon trust.

Sims came to the Gynecological Society like an inheritance, and we claimed but never absorbed him. He stood out alone like a prophet in the wilderness telling strange things. Everything about him was convincing, both in word and manner and, so long as he kept in close touch, his influence never waned. He was like all men of his temperament, over-sensitive. He wore his heart upon his sleeve and his emotions were ever swaying his judgment.

In his book where he tells of the value of cotton in surgery, and says it can no longer be used because of its price, the result of a cruel and unjust war, we catch a delightful glimpse of the man, and also have an instance of how his convictions right or wrong obtruded into whatever he might do. But all this was essential to the development of the rare personality of Sims. Had he been deliberate, calculating, coldhearted and scheming he never would have achieved either his fame or his results. What man among us would leave a little town like Montgomery and without money or friends would rush into the thick of the battle of a great city simply as the apostle of a new idea, and yet, that was the only consistent thing Sims with his temperament could do. He would have died in Montgomery of a broken heart had he remained there after he had demonstrated his idea and opened a new world for surgical exploit.

I have sought to show how the young society was welded together and made harmonious by divergent examples of the personal factor. Differences of opinion, variety in the point of view, and the ever changing logical perspective mean health and progress in scientific thought. A fact is a many-sided thing and is wrought out between the hammer and the anvil in the conflict of ideas, and we do not know it, until it rises above the confusion of battle and takes its place clear and star-like in the firmament of knowledge and becomes radiant forever. It has been decreed that in the battle of ideas that some men are to be hammers and others are to be anvils, whereby the truth is forged out and the complex fabric of knowledge made stronger and human progress and endeavor made lasting and secure. The victory is not always to the one who strikes the blow. The anvil may proclaim, clear and resonant, and the fabric wrought between them is refined and perfected thought.

INTRA-ABDOMINAL

AMPUTATION OF THE UTERUS:

A MODIFICATION OF HYSTERECTOMY.*

BY F. H. DAVENPORT, M.D., BOSTON.

The indications for hysterectomy are now pretty well established, the mortality has been reduced to such limits that it may now rank with other abdominal operations as a practically safe procedure, and interest has now centered upon the technique. I desire to call your attention to a modification of so-called abdominal hysterectomy which I have practiced for about two years.

Fig. 1. Freeing of uterine body by division of broad ligaments.

My position with regard to the relative advantages of abdominal and vaginal hysterectomy is this. Where it is possible in a young married woman to leave the cervix I prefer to do so; hence for suitable cases I choose the abdominal route. I operate by the vagina, of course, for cancer either of the cervix or body. In other cases, I am governed by the conditions present. If a patient single, or near or past the menopause,

* Read before the American Gynecological Society, Washington, D. C., May. I, 1900.

with a small or medium-sized fibroid which is non-adherent, objects to the scar of the abdominal operation, I operate by the vagina, especially as I expect less shock and a quicker and more comfortable convalescence in the latter case. On the other hand, in a younger married woman, even though the tumor is small and can be easily removed by the vagina, I choose the abdominal route. It is of a good deal of importance that the vagina be preserved so that it may be functionally serviceable. A short

ened vagina, with a contracted vault is not a desirable condition of affairs under these circumstances. There is no danger of the abdominal scar being stretched by pregnancy, and hernia, while a possibility, is in these days of careful suturing a remote one.

Again, when the uterus is to be removed for chronic inflammation, or its results, there is usually concomitant disease of the appendages, and the abdominal route gives full opportunity for seeing the exact condition of all the pelvic organs, and for doing what is necessary under control of the eye. Therefore, as I have said at the beginning, the indications for hysterectomy, and in my own case, for abdominal hysterectomy, are very clearly established.

In studying the technique of so-called abdominal hysterectomy, it has seemed to me that the operation might be simplified. I have felt that there were a large number of cases where the body of the uterus only need be removed, leaving the whole cervix, and perhaps the lowest segment of the uterine body. Where the uterus is the seat of chronic inflammation, which keeps up a salpingitis, and perhaps a peritonitis, it

is only necessary to obliterate the uterine canal and remove the inflamed tubes to effect a cure. The lower part of the uterus and cervix will drain freely into the vagina, and will very soon atrophy. A small interstitial fibroid may be situated so that only the upper part of the body will be involved, but where myomectomy alone would be inadvisable. For such cases, the modified operation is clearly applicable. If the abdomen is opened for disease of the appendages, and on inspection the uterus seems to be involved so that the removal of the upper portion

would be wise, it can be done quickly and without adding to the risk. of the patient.

The essential feature in which my method differs from the operation as usually done, is that the uterine arteries are not ligated, or indeed, disturbed. By whatever method these are tied, whether by dissecting between the layers of the broad ligament, and isolating and tying the artery, or ligating it by including the whole thickness of the broad ligament near the uterus, it is a more or less difficult procedure. By the first method, it involves some opening up of the sub-peritoneal space, thereby increasing the chance of septic infection, and it is certainly good surgery to limit this as much as possible.

My own method is as follows. The broad ligament of each side is seized by a long clamp running from the free space between the ovary and tube, and the pelvic wall, and ending close to the uterine wall at a point a little above the level of the internal os. A second clamp is carried down each side parallel to the uterine wall and inside the ovary. The points of these clamps lie nearly in apposition. The broad ligament is then divided parallel to the first clamp. (Fig. 1.) The clamps being firmly applied there is no bleeding. A needle armed with a ligature of fine silk is then passed through the angle of the broad ligament between the ends of the clamps and securely fastened. With a scalpel the uterine tissues are then divided at a level with this suture in such a way that the anterior and posterior incisions slope downwards and meet in the centre. This is done from one side of the uterus to the other, a little at a time, and the bleeding which is usually slight is controlled by the continuous suture which follows the incision. (Fig. 2.) The needle with the silk which has been tied at the angle, is introduced into the anterior surface of the uterus just below the free edge, carried through the tissues and brought out at the angle of the wound, reintroduced into the posterior wall and then emerges on the posterior surface of the uterus at a point corresponding to its entrance. (Fig. 3.) This is drawn tightly, and when enough free space has been gained by the use of the knife, another suture is taken. This is continued until the body of the uterus is completely separated and the other side is reached, when a final stitch is securely tied at the angle of the broad ligament between the clamps. By this method there is practically no bleeding. It is not necessary to strip the peritonæum off the uterus, and the wedge-shaped removal of the uterine body permits the ready and close apposition of the edges of the peritonæum. Any little bleeding points along the line of suture may be secured by separate sutures later. When the clamps which control the outer segment of the broad ligament are removed,