dowed adhesions. They also cause traction on and distortion of the various viscera to which they are attached, the intestines of course being the worst sufferers in this connection. By reason of the pain, often severe and persistent enough in itself to cause a decline in general health, as well as a perversion of normal functions of one or more organs because of adhesions, the various results of local inflammation may in time offer sufficient and even urgent indications for operation. From the operative standpoint no graver complication exists than extensive adhesions, and as they surely accompany and succeed acute inflammatory attacks, early upon their development they should receive the recognition due them. The writer is of the opinion that they are positive indications for interference, especially if accompanying symptoms point to a probable decline

in general health. They fearfully complicate the actual removal because of long handling of the viscera, great loss of blood and extended time required to dispose of them, but our own experience has been that such cases bear well the necessary manipulation and recuperate satisfactorily afterwards. The previous intra-abdominal discomforts seem to render the abdominal contents tolerant of extensive handling. No. 65 is a case in point. A succession of acute attacks of so-called peritonitis, accompanied by high temperature, nausea and vomiting, exquisite pain, frequent, and at times almost. constant micturition, with several weeks' confinement in bed, had been treated medicinally by various practitioners, but with no relief save during intervals. The abdomen was so sensitive that examination could be made only under an anæsthetic. A fibroid, filling

the pelvis and slightly movable, was found. On opening the abdomen, the tumor was completely buried in inflammatory deposits which led to the expectation of pus tubes. Enucleation of the tumor was begun, and on either side the tubes and ovaries were found imbedded in densest of adhesions, but no pus. Freeing

FIG. 6, Case 30, Lateral View from Left.-Figs. 4. 5 and 6. No. 30. A, uterus. B, principal bulk of tumor from posterior wall of body of uterus, with a large number of sub-serous growths variously disposed. C, C. ovaries. D, D, tubes made patent by insertion of probes. E, E, small pedunculated cysts attached to tubes. F and G, pedunculated growths which could be displaced at will to any portion of abdominal cavity. Recovery.

them was difficult, the hemorrhage from new and old adhesions. being most profuse. The adnexæ were about ten times the usual bulk, entirely abnormal, and much time was spent in isolating them. The fibroid itself was adherent in every part and its enucleation resulted in still further loss of blood from adhesions. After enucleation to normal lines, hysterectomy was completed with no further difficulty. The case made a most satisfactory recovery.

Hemorrhage is possibly as important a symptom as occurs, and may of itself become the deciding feature. It may show itself only as a rather severe menorrhagia, with a sufficient interval between each month to allow recuperation, or it may appear very irregularly, with long periods of quiescence, necessitating rest and care. only at the time of its appearance; or again it may go on to a serious and long-continued hemorrhage causing great exhaustion at the time, with sufficient intervals for recuperation, and resulting in

marked anemia and deterioration in the general health, and if allowed to continue will result in fatty degeneration of the heart. It may become so profuse as to endanger life itself, so that this symptom has perhaps attained more prominence as a determining factor in deciding upon operation than any other single one which appears in the whole course of the disease. Such a case was No. 52. Anemia was extreme, the intervals between the hemorrhages being too brief to permit any material gain. There was a marked anemic heart murmur, and at the time of operation the blood was perceptibly thin, watery, and pink in color. The patient was kept under careful and painstaking treatment for eighteen days before operating without any perceptible improvement. The results justified the conclusion that the tumor was the cause of disability, since not only the recovery was surgically satisfactory, but improvement in all direction was prompt and beyond expectation. The anemic condition passed practically out of further consideration.

The age of the patient and the rapidity of the growth influence materially a decision for or against operation. In young women, under thirty-five years of age, all the usually accepted favorable conditions cannot be relied upon to affect the subsequent development. The menopause is too distant to be awaited, and if the growth

FIG. 7. No. 54.-A large, symmetrical single tumor, removed from a woman thirty years old. It filled the abdomen, simulating pregnancy at full term, and was increasing. Recovery.

is rapid, as it is likely to be, extirpation more surely becomes the best remedy. A multiple growth in a woman of thirty-one, such as No. 30 (Figures 4, 5 and 6), or a tumor in a woman of thirty such as was removed from No. 54, in the writer's opinion could be

successfully dealt with only by operation. No. 30 was removed, not because of any urgency of symptoms, but solely on account of the patient's age, the unusual complexity of the tumor, and its continuous increase in size. That of No. 54 (Figure 7), was so rapidly enlarging that a perceptible difference in size could be noted. from week to week, and at the operation was found to be enormously engorged and hemorrhagic. Aside from specific symptoms, others occur acquiring considerable importance when accompanying any or all of the above described, such as exhaustion not due to hemorrhage, but because of a profuse leucorrhea following a loss of blood or persisting between the menstrual periods. Or the exhaustion may not be attributable to any special cause, but be only an accompaniment of the general condition. It may lead to indifference to the ordinary interests of life with inability to make the least exertion, and an entire lack of concern in all that makes life worth living.

In the absence of marked causes to account for such a state, careful investigation should be made, looking to a possible malignant degeneration of the tumor. One such case, No. 29, is recalled where the tumor was a large symmetrical mass without adhesions, and without having developed any characteristic phenomena, apart from its size, shape and location. It was kept under close observation for some time before operation was advised, which advice was finally determined upon because of the persistent and progressive general malaise, extending over a period of more than five years. The operation revealed a large fibroid (Figures 8 and 9), symmetrical in form, a growth of the whole uterus, which gave an indistinct sensation of fluctuation when immediately in hand. Further examination after removal, revealed an irregular cavity, frequently crossed by trabecular-like bands, with a rough lining membrane and filled with a thin, serous fluid; microscopic investigation proved it to be undergoing a sarcomatous degeneration. To the writer's mind this case if allowed to go on would have proven hopeless, of course after some interval of time; its removal caused a complete recovery from all previous well-defined and ill-defined symptoms, in fact a restoration to health, with almost no probability of further danger from sarcoma.

The deformity accompanying these growths is worth some consideration; when it assumes the size and appearance of advanced pregnancy (Figure 7), especially in unmarried women, the condition often becomes humiliating, and the writer has frequently been consulted because of this feature alone; after removal assurance has also been given that freedom from both the weight and clumsiness.

as well as the mental freedom (although this was far from being the full benefit received),,was worth all the suffering and risk.

After the consideration of the life history in any given case, examination is necessary to the formation of a correct opinion as to what advice should be offered. The results of a proper examination are usually satisfactory because definite and conclusive. By inspection and external palpation we should note if the growth be solid or fluctuating, and if the latter, then whether the fluctuation. be readily developed as in an ovarian cyst, or difficult to make out as in pregnancy, or if a solid tumor be complicated by an ovarian cyst, as in No. 21 (Figures 10 and 11), which was diagnosed as a fibro-cystic tumor until the operation showed its true nature, or, if ascites be present, and if so, to a marked degree. It should always be questioned whether or not this latter indicates a beginning

Figs. 8 and 9. No. 29.-A, tumor in posterior wall of uterus, originally lying in sacrum, but finally so large that it lay in the abdomen reaching above umbilicus. B, uterus, laid open through the anterior wall, and showing the same lying on the anterior surface of the tumor. C and D, right and left ovary hopelessly diseased in themselves and consequently exercising an unfavorable influence upon the subsequent growth of the tumor. The tumor is undergoing sarcomatous degeneration. A report received August 24, 1898, three and one-half years after the operation, states that recovery is complete and satisfactory.

malignant degeneration. Usually when uterine growths are fibrocystic, fluctuation is not easily brought out. One can also generally determine if the tumor be single, in which case it is apt to be symmetrical, smooth, regular in outline and central in location (No. 54). If it be a multiple growth, the outline is irregular, the line of demarcation between the several separate growths distinct. tumors may be combined in one irregular mass, or one or more