cases of labor complicated with uterine fibroids over half of the mothers and nearly two-thirds of the children die.

The treatment of fibroid tumors of the uterus is preeminently surgical. Even the administration of ergot and savine may be looked upon as a surgical method of treatment, for the effect striven after in the use of these remedies is the extrusion, or partial extrusion, of the growths, whose removal is completed by surgical means. While the deaths directly due to the use of ergot are probably few, most writers discountenance the treatment for these reasons: the ergot treatment is tedious, painful, often ineffective and even at times dangerous. When the tumor is forced into the uterine cavity, or through the cervix by the contractions induced by the medicine' the practitioner must be ready to interfere surgically, otherwise sloughing and sepsis are imminent.

The ideal operation for a fibromatous tumor is the removal of the tumor, leaving the uterus intact. Unfortunately in many cases this result cannot be attained. Nevertheless this should be striven for wherever possible. The marvelous success of Schroeder and Martin in enucleating fibroids, and thus preserving the uterus, should encourage us to an imitation of their work. The enucleation of fibroids, whether by the genital canal or by laparotomy, is in the true line of conservative surgery.

When a sub-mucous tumor projects into the uterine cavity or the vagina, its attachment is usually by a pedicle of greater or less thickness. When the pedicle is thin the tumor may be twisted off. The torsion seems to arrest all hemorrhage at the same time from the highly vascular mucous-membrane covering the pedicle. When the latter is thick attachment may be severed with scissors, ecraseur or galvano-caustic wire. I prefer the latter method as less dangerous, cleaner, more rapid and thoroughly aseptic.

When the tumor is attached by a sessile base the mucous-membrane and capsule over it may be split with a knife after carefully dilating the cervix under aseptic precautions, and then enucleating the tumor from its base. To arrest hemorrhage, a tampon of iodoform or creolin gauze may be packed against the bleeding surface. Great care is requisite, however, not to allow the tampon to remain too long, as the secretions may be backed up through the tubes and cause salpingitis or other inflammatory disturbances in the pelvic cavity. I am sure I produced a pelvic peritonitis in one case by the

use of a tampon to arrest hemorrhage after amputation of the cervix.*

Sloughing of a sub-mucous fibroid is not necessarily fatal, as careful disinfection of the genital canal before and after operation will often avert sepsis.

Vaginal enucleation of sub-serous tumors of the cervix may sometimes be practised. The operation was first done by Czerney. An incision is made through the vaginal fornix, avoiding the large vessels on the sides of the cervix, and the tumor enucleated from the tissue of the cervix and the pelvic connective tissue.

Tumors of considerable size may be delivered by intra-uterine and vaginal enucleation. If the growth is too large to remove entire it may be diminished in size by subdividing it with scissors, saws specially devised for the purpose, or the galvano-caustic wire. The operation should always be completed at one sitting, for to allow part of the tumor to remain is an invitation to septic absorption. Judgment and experience are required, however, to decide when the growth has reached a size that does not permit its safe removal by way of the vagina.

The enucleation of fibroids through an incision in the abdominal wall-laparo-myomectomy-is indicated in certain cases where the tumor cannot be removed by the vagina. It is at once a graver operation than the latter, and accompanied by a considerable mortality. If the tumor is sub-serous and attached by a thin pedicle, its removal after section of the abdominal walls is not difficult. The pedicle may be transfixed by a double ligature and tied tightly, the tumor cut off above the ligature, the peritoneum stitched over the end of the stump, and the external wound closed. Unfortunately, the tissues of the pedicle often shrink after the tumor is removed, and hemorrhage may take place from the stump. To avert this accident various measures have been adopted by different operators. Some remove a wedge-shaped plug from the face of the stump and sew the opposing raw surfaces firmly together by

*In reference to this point Sir Spencer Wells says: "I have occasionally put on one or two pairs of pressure-forceps to a pedicle, either before cutting away the polypus or when bleeding occurred after cutting away, and have left the forceps hanging out of the vagina for several hours; and I prefer this method to the more common one of applying perchloride of iron and plugging the vagina."

deep and shallow sutures, lastly bringing the peritoneum together over all. This is usually efficient, but consumes valuable time. Other operators clamp the stump in a wire-snare (Koeberle's serrenoeud) or a constrictor of parallel steel bars (Keith's clamp) and bring it outside of the abdominal wound, where the constricted. portion of the stump mummifies or sloughs off. The peritoneal covering of the sides of the stump is stitched to the parietal perito neum, and so closes the peritoneal cavity against any discharges from the end of the stump. This method gives better results than the intra-peritoneal method, but leaves much to be desired in the way of surgical neatness and rapidity of healing. It is also at times attended by other inconveniences and dangers, especially if the pedicle and uterus are much put upon the stretch.

When the growth of the tumor is sessile and directly under the peritoneum, or covered by a very thin layer of uterine tissue, it may be enucleated by making a bold incision over the tumor and shelling it out of its base.

To guard against excessive bleeding, an elastic ligature-a piece of rubber tubing-may be tied around the cervix, including within the ligature the arteries supplying the uterus and appendages. Even large growths may be removed in this way. If the cavity left in the uterine tissue is too large to get good coaptation between its walls, it may be packed with iodoform gauze as practised by Fritsch, and the edges stitched to the abdominal incision, in order to secure free drainage and make the cavity accessible to external

treatment.

Deep intra-mural, or even sub-mucous tumors may be treated by this method, but the results are less and less favorable the more the uterine cavity is opened.

Sometimes the uterine walls are so occupied by the new growths that their total removal can only be accomplished by the excision of the entire uterus, or at least that portion above the cervix. This operation is one of the gravest in surgery and gives, in the hands of nearly all operators, a high mortality. The total extirpation of the uterus, including the cervix by way of abdominal section, has not been very often done, but with present methods should give more favorable results than supra-vaginal hysterectomy.

In the latter operation the stump very often gives trouble, either from hemorrhage or sepsis.

Complete removal of the uterus at the vaginal junction approaches the conditions of vaginal hysterectomy, and should give very little higher mortality than the latter. However, at best, the complete or partial extirpation of the uterus is an operation of great gravity, and should only be resorted to when all other means promising success have been tried.*

Tait has called especial attention to the soft ædematous myofibroma, which often gives the impression, on examination, of containing cysts. This tumor frequently fluctuates in size, being now larger, now smaller, without any apparent cause. These, as well as fibro-cystic growths of the uterus are particularly suitable for complete extirpation by abdominal section. No other operation or method of treatment seems to control their growth or arrest the hemorrhage which is a frequent accompaniment.

In 1872 Lawson Tait, of Birmingham, and Alfred Hegar, of Freiburg, almost simultaneously devised the operation of removal of the uterine appendages-ovaries and Fallopian tubes-with the view of artificially inducing the menopause, and thus arresting the growth of fibroid tumors by cutting off the principal source of blood-supply to the growth. This operation has now probably been done over one thousand times with very satisfactory results. Tait's own results, as shown in a statement recently furnished by him,† are extremely favorable. In 426 cases 16 died-a mortality of 3.75 per cent. Tait also declares that 95 per cent. of the cases of fibroid operated by removal of the uterine appendages are cured; that is to say, the bleeding is arrested and a large proportion of the tumors diminished in size, some disappearing altogether. These effects have been established by many observers, especially when the cases have been properly selected. As above pointed out, in the soft cedematous growths the arrest of the bleeding does not seem to follow so regularly as in the hard, nodular fibroids.

The cause of the arrest of the hemorrhages after removal of the appendages is probably due, as suggested by Mr. Knowsley

*Several American surgeons have done complete extirpation of the uterus successfully, and A. Martin reports 11 recoveries out of 16 operations-a pretty high mortality. Fritsch's mortality in all cases of hystero-myomectomy, including enucleations, is 25 per cent; Bantock's 22 per cent.

*McNaughton Jones: Diseases of Women, 4th ed., p. 340.

Thornton to cutting off the blood-supply by ligature of the large vessels in the broad ligaments, and not merely to removal of the ovaries and Fallopian tubes. As a matter of fact, the mere extirpation of the ovaries alone often fails in producing the expected

result.

The high mortality of the abdominal hystero-myomectomy, and the opposition on many sides to the removal of the ovaries, which it was claimed by many, unsexed the woman,† led Dr. George Apostoli, of Paris, about 1882, to experiment with the galvanic current in the treatment of uterine fibroids. It is true, Cutter, Kimball, and perhaps others, had used galvanism successfully for this purpose before, but Apostoli developed a method by which the application of electricity is reduced to scientific exactness. improvements in the instruments for generating, measuring and applying electricity now permit the physician to administer this remedy with as much exactness in dosing as any other therapeutic agent at his command. It would take too much time here to describe the apparatus or the methods in us. For a full description I refer to pages 327-350 of "Practical Electricity in Medicine and Surgery," by Liebig and Rohé, and to Dr. G. Betton Massey's excellent little book on "Electricity in Diseases of Women," both published by F. A. Davis, of Philadelphia.

In 1887 Dr. Apostoli reported 278 cases treated by this method with a successful result (arrest of hemorrhage, diminution in size, disappearance of pain and pressure symptoms) in 95 per cent. The average number of applications was fifteen in each case. In August, 1889, Dr. Thomas Keith and his son, Dr. Skene Keith, published a detailed record, without commentary, of 106 cases treated according to the method of Apostoli. The average number of applica tions in the cases treated to a termination was twenty-eight. Three of the cases died during or shortly after the discontinuance of the treatment, but in neither case was the fatal result attributable to the applications. Admitting, however, for the sake of argument, that the electricity was the cause of death, a mortality as low as *Am. Gynecol. Trans., 1882.

†This objection is not tenable, as the "unsexing" consists merely in anticipating the menopause, which is one of the natural characteristics of the human female.

The Treatment of Uterine Tumors by Electricity, Edinburg, 1890.