If this method can be adopted without hemorrhage or other difficulty, its advantages are apparent. The pedicle can then be returned to the abdominal cavity without any of the objections which have been urged against this procedure. There is no ligature to be discharged by ulcerative process, or to become encysted, or to induce inflammation. There are no purulent or inflammatory products to be in any way removed or provided for; the pedicle is wholly living tissue, and has no irritative qualities which render its return to the abdominal cavity objectionable. My object will have been wholly accomplished if the feasibility of enucleation in ovariotomy has been shown with sufficient clearness to insure a trial of the method by other surgeons.

DISCUSSION ON DR. MINER'S PAPER.

After the reading of the preceding paper, the President, Dr. ROBERT BARNES, of London, said:-I am glad to hear the paper, as I was the first to introduce the method of enucleation into England. I think it a good method, but it cannot wholly supersede other modes of dealing with the pedicle. In some cases, enucleation is the only mode of removal practicable; but these are exceptions to the rule. I must say that I do not share Dr. Miner's dread of leaving silk and silver ligatures in the peritoneal cavity, for I have frequently seen them left there without mischief. I have also seen the perchloride of iron used to sponge bleeding points left after the sundering of strong adhesions, and without any of those formidable results which some writers attribute to its passage through the Fallopian tubes after intra-uterine injections. In ovariotomy, the great thing is security against hemorrhage; and that, I think, is best gained by the use of the clamp or the ligature. The operation of ovariotomy demands still more study than has been given to it, and I congratulate Dr. Miner upon having very materially added to the stock of knowledge regarding it.

Dr. JAMES P. WHITE, of Buffalo, said :—I am cognizant of twenty or thirty cases in which enucleation has been used. It is not a very difficult operation, but in some cases it is impossible for instance, where the growth of the tumor has been rapid and the pedicle is short and large. In these cases, the cyst cannot be safely enucleated. I have no doubt, however, that enucleation is often the best method of treating ovarian tumors, but the subject merits a great deal of study and consideration, and the cautery, the clamp, the ligature, and enucleation, all deserve attention, and should be severally used according to the special indications of individual cases.

Dr. E. R. PEASLEE, of New York, said:-We should not confine ourselves to any one method of treatment in the removal of ovarian cysts. Nor is enucleation always feasible. In some cases, short and large vessels enter into the cyst directly from the pelvis, and do not become capillary. In these, enucleation will not answer, because it cannot arrest the hemorrhage. Such an instance I have met with, and the patient bled to death. Again, owing to the thinness and the friability of the cyst-wall, it will sometimes break down before the adhesions can be broken up. But I feel under great obligations to Dr. Miner for introducing this method, for I have removed tumors by enucle tion, which I am confident could have been removed in no other way. In most cases the ligature can be used, and I then see no particular advantage to be gained by enucleation. But I would adopt it in cases of cysts adherent to the liver. I am myself inclined to the use of the ligature, which I generally cut close. As I have only once seen the pedicle slough, I do not share Dr. Miner's fears on that score.

Dr. G. KIMBALL, of Lowell, Mass., said :—I have tried enucleation but once, but believe that I might have saved some lives had I known of this method

earlier in my practice. I feel very much indebted to Dr. Miner for his suggestions on this subject. Dr. Keith's great success has been obtained with the cautery, and I think that the profession is still at sea as to the proper method of dealing with the pedicle. I myself generally use the clamp, but I adapt the treatment to the particular case.

Dr. WHITE said:-As a rule, I prefer cauterization, because it leaves fewer foreign bodies in the cavity of the abdomen; and I am sure that, in my practice, I have seen as many children born from women who have lost one ovary as I have lost cases of ovariotomy. I think that the treatment of these tumors should be eclectic, and that each case should be separately studied with a view to its treatment.

Dr. ALEXANDER R. SIMPSON, of Edinburgh, said :—In regard to the application of the cautery, Dr. Keith has used it very successfully; personally, I am ready to use any method that the case may demand. The great strength of Dr. Keith lies in the thorough preparation of his cases, and in the care which he takes with them. There is always a difference in operators, and Dr. Keith does not consider minutes wasted that will prevent hemorrhage into the peritoneal cavity.

Dr. THEOPHILUS PARVIN, of Indianapolis, said:-Enucleation is of use when the pedicle is too short for the clamp. I have had two cases: one complicated with pregnancy was attended by considerable hemorrhage. This I checked by the application of flannels dipped in hot water. In such cases I can recommend hot water, and I referred to the same agent in the discussion of yesterday on uterine hemorrhage. I think, contrary to Dr. Miner's statement, that it is settled that there is no peritoneal coat to an ovarian tumor, as there is no peritoneal covering to the ovary itself. Enucleation is of value where there are peritoneal adhesions, but I believe that it can be very often dispensed with by the use of hot water. I recognize its advantages, but do not think that it is the only treatment for ovarian tumors.

Dr. MINER, in reply, said :—I agree that possibly in some cases enucleation may not be of service, and that torsion, the ligature, and even the cautery may have to be used. But in ordinary cases of ovarian tumor, I deem it to be a plain piece of surgery; and I have myself never seen a case in which the cyst could not have been removed by enucleation. Where there is bleeding, I resort to torsion; but enucleation does not interdict the subsequent use of the clamp, the ligature, or the hot iron.

THE TREATMENT OF FIBROID TUMORS OF THE UTERUS.

BY

WASHINGTON L. ATLEE, M.D.,

OF PHILADELPHIA.

IN opening the discussion on The Treatment of Fibroid Tumors of the Uterus, a question that has for many years engaged my attention, it will be imposssible to present the subject properly in the short space of time allotted to me; and I must, therefore, ask your indulgence if, in adhering closely to the text and compressing my material, I should fail in satisfactorily elucidating the several points in this paper.

I beg, also, to premise that, in bringing this subject before the Section on Obstetrics, I shall not go into the detail of every method of treatment. This I think would be out of place before an assembly of such enlightened men, who are already familiar with its written history. I shall merely refer to my own experience. Every gentleman, who will engage in this discussion, has an experience of his own, and if each one will bring his personal contributions, able architects of our profession will rear a structure out of these materials which no individual could erect from his own observations, and which will stand as a lasting memorial of this day's work. In this way we will be likely to arrive at the best practical results for the benefit of Science, Art, and Humanity.

My methods of treatment have been surgical and medicinal. In the use of medicine I have principally confined myself to iodine, ergot, and muriate of ammonia. Many years ago I lost faith in iodine, and now seldom use it, and only as a local application. As early as 1845, I introduced the use of ergot in the treatment of uterine fibroids, and have ever since employed it. In proof of this I may refer to my essay on Fibrous Tumors of the Uterus, published in the Transactions of the American Medical Association for the year 1853. Ergot, no doubt, acts in two ways in influencing the nutrition of fibroids of the uterus: (1) on the muscular tissue of that organ, and (2) on the capillary circulation of the tumor itself by contracting its smaller vessels. Notwithstanding this action of the medicine, I have never been so fortunate as to see a fibroid quietly disappear under its sole influence, although in many cases the size has been diminished, while in others no effect has been produced. The reason of its variability in action may be explained in the course of this paper. Recently, Hildebrandt has introduced the hypodermic use of ergot, and with results, in his hands, quite extraordinary. I cannot, however, conceive how this agent can accomplish more by its subcutaneous employment than by its administration by the natural passages. It certainly acts more promptly through the cellular tissue. But it is questionable whether this increased speed of action is a sufficient compensation for certain inconveniences to the patient from this mode of its application, as well as for the greater tax on the time, convenience, and patience of the medical attendant.

In the consideration of the treatment of uterine fibroids, it must also be kept in mind that spontaneous cures may result in consequence of

fatty degeneration; that diminution in the size of the tumors is often observed in advancing age, through senile atrophy of the muscular fibres; that fibrous induration sometimes occurs, the muscular tissue becoming scarcer as the connective tissue hardens, and that this induration is followed by calcification and an arrest of growth.

With these preliminary remarks, I will proceed to discuss the subject of treatment more definitely. In doing so understandingly, it will be necessary to keep in view the relative position of the tumor with the uterus. Hence I will make the somewhat arbitrary division into the following heads:

I. Tumors usually accompanied with hemorrrhage, embracing (1) fibroids occupying the vaginal canal; (2) fibroids within the cavity of the uterus; (3) interstitial, submucous fibroids; (4) interstitial fibroids. proper; (5) recurrent fibroids.

II. Tumors usually not accompanied with hemorrhage, including (1) interstitial, subperitoneal fibroids; (2) sessile, peritoneal fibroids; (3) pedunculated, peritoneal fibroids; (4) interstitial, cervical fibroids; (5) myomatous degeneration of the uterus; (6) fibro-cysts of the uterus.

I. TUMORS USUALLY ACCOMPANIED WITH HEMORRHAGE.

(1) Fibroids expelled from the Cavity of the Uterus, or occupying the Vaginal Canal. The treatment of these tumors will vary according to their size. When small, with a slender pedicle, the tumor may be grasped as high as possible on its neck by means of Luer's polypus forceps, or a similar instrument, and twisted off, or, in other words, removed by torsion.

When larger, with a pedicle not thicker than a finger, it may be seized and brought down with some force so as to stretch the pedicle, which may then be severed at as high a point as possible with Cooper's hernia bistoury, or a probe-pointed bistoury properly wrapped and protected.

When quite large, distending the vagina or filling up the pelvis like the head of a child, a small obstetric forceps may be applied to it, and then placing the patient under the influence of an anesthetic, with the assistance of supra-pubic pressure, the tumor may be gradually brought through the os externum. Having accomplished this, one of several plans may be adopted for the purpose of detaching it: (a) By means of the bistoury the proper coat of the tumor may be severed all around, about an inch or so beyond the insertion of the pedicle, and then the upper end of the tumor enucleated from its peduncular attachment; (b) the substance of the pedicle may be directly severed by the knife; (c) the pedicle may be divided by the écraseur. I have used all these methods, and it is best to be prepared for either operation, as the surgeon must be governed by the circumstances of each case. When it can be accomplished, I prefer the first method, or that by enucleation of the pedunculated end of the tumor.

Immediately after the removal of these large tumors we should use a tampon, charged with persulphate of iron or other efficient hæmostatic and antiseptic, adapting it well against the amputated stump, and allowing it to remain from twenty-four to forty-eight hours. The raw and, usually, inflamed surfaces should afterwards be treated through the

speculum by suitable applications until they are brought into a normal condition.

It may be noticed that I have not referred to the ligature as one of the methods. I have long since abandoned this plan, preferring immediate ablation of the tumor.

(2) Fibroids entirely within the Cavity of the Uterus.-The treatment of fibroids inclosed within the cavity of the uterus must depend somewhat on their size and locality. When large and of long duration, having distended the body of the uterus and dilated the cervix as does the head of a child in the last months of gestation, an examination by the finger will discover a mere uterine ring, through which by firm pressure, particularly when counteracted by supra-pubic support, a tumor within may be detected. This no doubt is the condition precedent to the first form of fibroid which we have considered, and the lapse of time in all probability, if the patient should hold out, would accomplish the same state of things. It is, however, not always safe to wait, but safer to facilitate measures by imitating the processes of nature. To make the tumor more accessible, the os uteri should be dilated by the usual means, and at the same time ergot administered to excite and maintain the contraction of the expulsive fibres of the organ, and in this way also aid in opening the uterus. Or, instead of using dilators to open the os uteri, the action of ergot may first be established, and afterwards the tense edges of the os may be nicked with a bistoury, thus successively dividing the circular fibres, and accomplishing the object in much less time. As soon as the mouth of the womb is sufficiently expanded, a small obstetric forceps may be introduced and applied to the tumor in the same way as it is to the head of a child. Traction should now be made on the tumor under the influence of an anesthetic, and if the circular fibres, as will probably be the case, should resist its escape, the bistoury must be employed until all resistance is overcome, and the tumor is brought into the cavity of the vagina. It is now in the position described under the first head of our subject, and may be managed accordingly.

There is, however, a very important difference between a tumor passing from the uterus into the vagina spontaneously and one brought there by violence, and that difference involves a very grave practical point. This will be at once apparent when it is stated that in the former case the tumor alone occupies the vagina, and that in the latter it is very apt to be accompanied by an inverted uterus. This is particularly liable to occur when the pedicle is attached to the fundus. Usually too, in vaginal fibroids, we find a moulded and elongated pedicle which is readily and safely managed, but in the tumors under consideration the pedicle is usually sessile, and affords but small space for any surgical appliance. Hence, the inverted fundus uteri is in great danger of injury and mutilation, and unusual care is required in amputating the tumor. I believe the safest mode is to enucleate the upper portion of the tumor from its proper coat, and thus free it from its uterine connections. Of course, after this is done, the inverted uterus should be at once replaced after proper styptics have been applied to the raw surface, and the case treated upon general principles.

These fibroids, however, are not always as simple and as easily managed as has been just described. From some cause or other the tumor may have formed adhesions to the surface of the uterus, independent of its original, peduncular attachment. These adhesions may be so situated as to interfere materially with the dilatation of the os uteri, or with the