I do not know. Only a few weeks ago I took a pessary from a woman, which she said she had worn six months; she said that she had forgotten the thing, and had become rather frightened. She stated that it entirely relieved her. I have my doubts as to whether these conditions are ever relieved permanently by any treatment except by operation.

Dr. Goggins: I do not know that I could add anything to elucidate the subject further, still I do not see much use of differing as to the treatment for displacement of the uterus, when really the fact is we should make as perfect a diagnosis as possible. Really, it is not a difference in treatment when you come down to a proper diagnosis of the case. I treat many cases where I do not do any operation; I try to isolate the cases that do not require it, by making thorough examinations. However, I do not believe there is any such thing as a misplaced uterus, if you will watch the case, and go at it properly. I think you will find there are symptoms; those cases usually have a heavy uterus, and the idea is to reduce the size; nearly all of these could be improved by the use of a curette. Sometimes we should use one thing, sometimes another, owing to the sensitiveness of the part, then use glycerine, or boro-glyceride tampons. Remove them frequently, every day, or every other day. Sometimes the use of the pessary is necessary; it requires great skill to fit the pessary in such cases. When I see it is absolutely necessary, I operate on the case.

Mr. McAdory: I have nothing further to say. I am glad to see gentlemen jumping on to this paper, and I am glad to see the experience of all the gentlemen who have discussed this paper are in line with the paper itself, and if I did not make it clear enough on reading it, in rushing through it, I think if they will read it over they will find it in their line.

THE SUTURE IN THE SURGERY OF THE VASCULAR SYSTEM.

REMARKS ON ITS LATEST DEVELOPMENT AND

PRESENT TENDENCIES.

BY RUDOLPH MATAS, M. D., of New ORLEANS, LA.

In the study of the methods of treatment which have been applied by surgeons for the relief and cure of the injuries and diseases of the vascular system, two elementary ideas may be recognized as having presided over the technical evolution of this branch of surgery.

The first is the idea or principle of compression with obliteration and suppression of function in the vessels involved; and the second, the idea of repair with a preservation of vascular function.

The first is best exemplified by the ligature, and the second by the suture as applied to the larger blood vessels.

It is the idea of controlling the circulation in the blood vessels by pressure in its manifold applications (forcipressure, digital and mechanical compression, acupressure, torsion, etc.) but especially typified by the circular ligature, with its consequent structural and functional obliteration of the ligated vessel, that dominated the rise, growth and progress of surgery in general, and of vascular surgery in particular, from the dim and remote past, throughout the early Greco-Roman period, until it was lost in the mist and darkness of the middle ages. Again resurrected by Parè, it flourished with steadily growing vigor during the Renaissance as a consequence of the discovery of the circulation by Harvey, and was launched with sti!! greater impetus by the genius of Hunter and the brilliant galaxy of men whose names still remain in our contemporary literature as monuments to the ceaseless activity of the surgeons of the eighteenth and nineteenth centuries. Finally came the Listerian discovery which gave us the modern aseptic and absorbable ligature in its present practically finished form, and made possible the finer technic of the aseptic suture of the bloodvessels as the latest expression of its highest evolution.

The suppression of vascular function as a necessary consequence of the obliterative action of the ligature, with its dependence upon the collateral circulation for the preservation of

the tributary peripheral parts, and the constant and wellfounded fears of thrombus formation which was believed, until recently, to be the necessary consequence of arterial irritation or injury, stood in the way of further progress and of the accomplishment of the surgeon's ideals, which always aim at repair with preservation or restitution of function. It is only in the last decade that the suture has come to claim its legitimate place in this most important department of surgery.

The suture, aiming, as it does, at the repair of the injured vessel with the preservation of its blood carrying function, recognizes the limitations of the collateral circulation, its inadequacy in many vascular territories of the organism, and the consequent danger from ischemic necrosis of the distal parts.

The technical procedures, which are the outcome of this conservative idea, provide not only for the repair of the injured vessel without obstructing its lumen, but also aim, when practicable, to restore the continuity of the divided vessel either by direct approximation of the cut ends, or by the substitution of other normal tubular channels (veins) which may be made to officiate for the lost part of the artery.

In the pursuit of this ideal, the surgeon simply applies the conservative principles which govern his conduct when operating in other parts of the body, e. g., the alimentary canal which, in a surgical sense, bears many close analogies, (even to the nomenclature of the operations involved,—as we shall see later), to the modern surgery of the vascular system.

In his present aims, the surgeon would aspire to give to the surgery of the vessels the same status of efficiency that obtains in the mechanic arts. He would imitate the humble artisan or plumber who, if called to stop a leaking hydrant pipe does not crush it so as to interrupt the flow of water, or cut off the pipe permanently, thus stopping the water supply, but proceeds to seal the leak by soldering without encroaching upon its caliber. If the pipe is so badly damaged that it cannot be repaired by this simple procedure, the damaged section is cut off and another piece of piping is substituted and joined to the main pipe, thus allowing the water to flow uninterruptedly as before the accident.

While the analogy of the plumber's pipe and of a blood vessel is not fair in its anatomic and physiologic applications, it nevertheless represents a mechanical condition which clamors. for just recognition in the emergencies and contingencies of surgical practice. In the surgery of the gastro-intestinal tract

the same analogy, which not many years ago would have been deemed unjustifiable, has been made good by the accomplishments of modern abdominal surgery. The objections which at one time appeared to be insuperable in intestinal surgery are still urged in connection with the conservative surgery of the larger blood vessels. But the constant and tireless efforts of physiologists and experimental surgeons are gradually overcoming the admitted difficulties of a far more delicate technic; and what would have appeared impossible or impracticable ten years ago is beginning to appear quite possible and reasonable today.

The need of preserving the function of the greater vascular trunks, especially the arteries at the root of limbs, of the neck, and of the accessible viscera, and the obvious dangers which attend their surgical obliteration, has always been apparent to surgeons; but the fear of obliterative thrombosis and secondary hemorrhage, and the difficulties of the technic, have been in the way of the accomplishment of an ideal so far above the crude resources of the art that no one gave serious thought to the matter until comparatively recent times.

The great tolerance of the veins to trauma, which has been recognized for centuries, when the barber phlebotomist subjected these vessels to all manner of insult, without apparent resentment, in th routine practice of venesection; and the demonstration of the successful suture of almost all the large venous trunks, including the innominate vein (Marin) and the vena cava (Schede) and others without complicating thrombosis, have paved the way for the present late recognition of the possibilities of arterial suture.

The last decade has witnessed a wonderful revulsion of surgical opinion in respect to the possibilities of arterial surgery, and what at one time appeared to be illusory and chimerical has, since the later improvements in the aseptic technic and with a perfected instrumentarium, passed to the realm of experimental and clinical fact. Working on this basis, the suture has come to take rank, not as a rival of the ligature, which will always retain its legitimate sphere of usefulness, especially in dealing with lesser secondary divisions of the vascular tree, but simply as a supplementary technical resource by which the higher conservative objects of the surgeon may be accomplished.

As a direct result of the new ideas suggested by the successful suture of arteries, a host of new procedures has sprung up

which may collectively be designated as the "plastics" of the vascular system.

This new chapter in surgery is still in process of formation. Much has been done which has far surpassed even the wildest dreams of our predecessors, but much more still remains to be accomplished before what is now glimmering in the horizon as a possibility can be counted on as a reality. It is on these lines that I now propose to speak of the latest developments and tendencies of the surgery of the vascular system.

SURGERY OF THE HEART.

In a general survey of the more recent developments of the surgery of the vascular system, which are attributable to the adoption of the suture as the hemostatic and reparative agent, the rescue of the heart-the central organ of the circulation— out of the apparent hopelessness of its lesions, appeals to us as one of the most conspicuous and dramatic triumphs of this new department of conservative surgery.

From time immemorial the heart was the holy of holies that no sacreligious hand dare touch without causing its dissolution. It was Fallopius (De Vulneribus, 1600) who wrote: "I'ulnerato corde, non potest homo vivere, nisi miraculoso," and Ambroise Parè, who was the first to observe that injuries of this noble organ were not necessarily fatal, was wont to say when called to attend these cases: "I have dressed thee, my son, may the Lord, our Master, heal thee," and the same feeling of the utter hopelessness of relief by human mediation. possessed all surgeons from the days of Parè, at the close of the sixteenth century, to the time of Billroth, almost at the dawn of the twentieth.

It was not until the experiments of Rosenthal, Bloch, Delvecchio, Salomoni, Elsberg, Bode, and others had demonstrated (from 1895-1897) the remarkable tolerance of the heart. to trauma, that the possibility of cardiorrhaphy began to be seriously considered. After the first case of Farina (1896) had been reported, followed by Cappelan, Rhen, Rotter, and others who paved the way, the surgical treatment of wounds of the heart became established on a legitimate and assured basis.

Two years have barely elapsed since the surgery of the heart was ably discussed and brilliantly illustrated before this society by Dr. L. L. Hill, the able and progressive surgeon of Montgomery, who, presented a little boy after his recovery from