quent. The elastic tissue of the uterine structure, the portion external to the ligature would shrink, permitting hæmorrhage to recur, and where the pedicle had been dropped it might be very severe before it was rcognized. Where the elastic ligature was employed, not infrequently the stump external to the ligature would become devitalized and slough, forming a source of infection perilous to the life of the patient. The danger of hæmorrhage was thought to be avoided by the use of the shoemaker stitch, as practiced by Marcy. When ligated the peritonæum was covered over the stump, and the latter dropped back. In firm ligation of the stump this sometimes sloughed, increasing the danger. In 1880, when I performed my first hysterectomy, the use of the clamp was the recognized method of procedure. Even those, who, like Tait, advocated the ligature for the ovarian pedicle, were equally positive in their assertion that the clamp should be used on the uterine pedicle. The pedicle was brought out at the lower angle of the wound. It required to be supported by strong pins passed in such a way as to rest upon the abdomen. These frequently made great pressure upon the skin, particularly when the pedicle was short. It required careful union between the peritoneal surfaces of the stump and the parietal peritonæum in order to prevent the entrance of infection into the abdominal cavity. The external portion of the stump necessarily must slough off, thus decreasing very greatly the ability to keep the wound an aseptic one. The convalescence of the patient was necessarily slow. It was followed by a weakened ventrum, greatly increasing the danger of subsequent hernia. These objections to the procedure naturally led to various attempts to obviate the necessity of treating the pedicle externally. About the same time Eastman and Mary A. Dixon-Jones advocated hysterectomy, and Baer, Goffe and others resorted to the amputation of the uterus below the internal os, while the uterine artery was ligated upon each side and the stump covered with peritoneal flaps. These methods of procedure marked a wonderful improvement upon those previously pursued. In these operations the broad ligaments were ligated and the ligatures placed in non-elastic tissue so that hæmorrhage was less likely to occur. In either method, however, the use of at least four ligatures was required. These ligatures, when of silk or material which is likely to remain in the body without destruction for a length of time, were frequently found to be capable of causing serious disorder and the development of inflammatory masses resulted which frequently broke down in suppuration. I have seen such abscesses occur three or four years subsequent to the operation. Such occurrences were particularly frequent where the thick, heavy-braided silk was employed. Where silk ligatures

are used they should be as fine as is compatible with secure ligation of the pedicle. But silk ligatures are with difficulty maintained in an aseptic condition, particularly where the operation is done through a septic field. When infected they continue a source of irritation, causing the development of an abscess or sinus which remains until the infected ligature is removed or has been thrown off. The occurrence of such a condition is naturally considered a reflection upon surgery and has led to various attempts to avoid its possibility. As a consequence the animal ligature became employed. Catgut is the most easily secured, but requires very careful preparation to prevent its becoming a source of danger. In addition, the sizes sufficiently large to make it a secure ligature are likely to slip when the pedicle is thick, and permit the recurrence of bleeding. It is a foreign body which Nature must take care of, and it may occasion trouble. In recent years it has been recognized that small vessels when secured by hemostatic forceps for a short time would, upon their removal, fail to bleed. In other words, the crushed tissues arrest hæmorrhage and obviate the necessity for application of the ligature. The recognition of this condition caused instruments. to be devised to crush the pedicles containing the larger vessels in order to obviate the necessity of ligation. Among the early advocates of this procedure was the ingenious surgeon, Doyen, of Paris, and nearly a contemporary of his was Tuffier. These gentlemen employed an instrument known as the angiotribe, capable of crushing the tissues. This instrument was permitted to remain on the parts for from thirty seconds to a minute. After its removal, the pedicle was cut and the surfaces left without ligature.

While successful in the majority of the cases, occasionally one would occur in which hæmorrhage would recur, and these have been sufficiently frequent to lead the majority of men to prefer a ligature rather than to trust to the angiotribe alone.

On my recent visit to Paris I had the opportunity to witness operations by Doyen, and found that while he used the angiotribe in all his abdominal operations, he only employed it to crush the tissues and form a groove in which a catgut ligature should remain without danger of its slipping. In this way the angiotribe has an important place and can be employed with advantage when the pedicle of an ovarian tumor is thick, or in the removal of the uterus, when the instrument serves well to prepare a groove for the ligature. This instrument which I exhibit has a simple mechanism, and can be easily and quickly applied, without the manipulation of a cumbersome screw, as in some of the instruments that are offered for our use.

In conclusion, I appreciate the angiotribe as a useful instrument, but would not trust it without being supplemented by the ligature. In catgut properly prepared, we have a ligature which is capable of absorption and yet may remain sufficiently long to insure the patient against hæmorrhage. I have been using this catgut now for several years and have seen no cases in which it has given rise to trouble. It requires, however, careful preparation and preservation. While I have no doubt the catgut for sale in the shops has been conscientiously prepared, yet the opportunities for infection in its preparation and preservation are so great that I prefer to use that which has been prepared under my own direction.

VARICOSE VEINS
VEINS OF THE VULVA

THE VULVA COMPLICATING

PREGNANCY; DERMOID CYSTS.*

BY WILMER KRUSEN, M.D., PHILADELPHIA, PA.

A varicose condition of the veins of the lower extremities, vulva, vagina, and inferior part of the rectum is quite common during the latter part of gestation; and it is only when such a dilatation of the vessels becomes excessive, or when some accident occurs producing rupture that marked symptoms or serious consequences result. The gravid uterus, by its pressure upon the veins, causes a retardation of blood in the vessels, which gradually become elongated, dilated, tortuous and thickened. The labia majora are usually most affected, and the size may vary from a merely perceptible increase in the normal venous calibre to a mass as large as a foetal head, as in the case reported by Holden. No annoyance results ordinarily, although many women complain of an uncomfortable feeling of weight while in the erect position, and sometimes of an itching or slight desire to urinate.

The recognition of the condition is comparatively easy, the swollen labia with the compressible, dilated blue veins, which can be distinctly. seen and felt beneath the skin, resembling a convoluted mass of angleworms. The chief danger is rupture during pregnancy or labor, giving rise to either a subcutaneous or frank hæmorrhage of alarming character. However, this is rare, as "the same relaxed condition of the tissues which permits such varicosities seems to safeguard the perinæum, which is usually relaxed, from lacerations. These patients, therefore, *Read before the Philadelphia Obstetrical Society, October 4, 1900.

will as a rule escape serious accidents unless the oncoming head be very large." (Darnall.)

Occasionally a fatal result has ensued, as in a case reported by Cazeaux and Tarnier ("Text-Book of Obstetrics"), in which the patient, a pregnant woman in other respects in good health, attempted to leap from her bed and fell upon the edge of a chair, striking the vulva; a hæmorrhage so severe as to prove fatal in a short time was the result. At the autopsy, the only lesion which could be discovered was a contused wound about half an inch in length upon the external surface of the left internal labium; and water injected into the primitive iliac vein

escaped rapidly from this little wound. Had the cause of hæmorrhage been discovered as soon as the accident occurred, the effusion could have been certainly stopped by direct pressure.

The treatment to be employed during gestation is the use of astringent lotions and vulvar pads kept in position by the ordinary T bandage or an elastic bandage. The patient should be cautioned to wear her clothing loose, having no constricting bands at the waist. Rest in the recumbent position for a few hours daily is advisable. Lifting, straining and constipation should be carefully avoided, and the general health and muscular tone of the patient be promoted by tonic treatment.

If rupture should occur, the hæmorrhage may be temporarily controlled by pressure; but as bleeding is apt to recur when the pressure is removed, the direct ligation of the vessel or ligature en masse is advisable. Unusual anxiety is felt and extraordinary care is exercised. during labor, and every effort is made to prevent any laceration of the soft parts with consequent hæmorrhage.

This illustrative case is reported, not because of the rarity of the condition, but because of the unusual size of the varicosities. The patient was a multipara of about thirty years, who consulted her physician for the remarkable vulvar enlargement during the seventh month of gestation. The customary warnings and directions were given and the case watched until the pregnancy terminated. Labor was easy and absolutely normal, no dystocia was caused by the pathological condition, and in a few weeks the vulva had returned to a normal size and appear

ance.

A CASE OF SUPPOSED URETERAL TRAUMATISM.

BY HENRY B. STEHMAN, M.D., CHICAGO, ILL., AND LOS ANGELES, Cal.

In the absence of positive occular demonstration with symptoms pointing to injury of either the bladder or ureter, followed by the escape of urine through a fistulous tract of the abdomen, it is sometimes extremely difficult to accurately locate the defect.

The case about to be reported was one with which I was associated and present points of unusual interest and it seems to me should be reported by permission I am enabled to do so.

Miss, Aet. 50, of medium size, large and deep pelvis, well nourished, with an extraordinary deposit of abdominal fat, had been suffering for a number of years from gradually progressing fibro-myoma, a growth which had developed to a degree that distressing pressure symptoms were caused by its lateral and upward encroachment upon. the abdominal viscera and pelvic organs.

The portion of the growth which filled the left half of the pelvis was developed from the uterine fundus, whereas upon the right side the myoma spread out between the folds of the right broad ligament, the walls of which had naturally been thinned by the process and pressure adhesions universally formed. This intraligamentous portion develop* Read by title before the Chicago Gynæcole gi al Society, June 15, 1900.