connection with particular interest his earliest operation, reported to the Royal Medical and Chirurgical Society in September, 1889, also his work on the peritoneum and on the cecal pouches, together with his services in securing an established position for the "interval operation," all of which are matters of common report, well within the cognisance of my hearers. Time and space forbid me to enlarge upon this theme, nor do these inflexible tyrants permit me to do more than mention the names and acknowledge the services of Kelynack, of Hawkins, of Walsham, and of Lockwood. It has been my pleasant privilege, gentlemen, to bring before you this evening some facts and circumstances with all of which it is possible all of you have not been familiar, and this evening fulfilled the pleasant expectations with which I have crossed the Atlantic to lay this my tribute to your fellow-countrymen before my colleagues of the Glasgow Gynecological and Obstetrical Society, of which I have been elected an honorary president. Let me conclude by expressing again my hearty congratulations upon the part you have borne in the early development of this great subject, as well as upon the skill and surgical acumen with which you have sustained its further evolution along the best lines of modern surgery. DISTORTION AND DISPLACEMENT OF THE UTERUS DUE TO A MYOMA. BY G. SCOTT MACGREGOR, M.D., FIBROID tumours may be found growing from almost any part of the uterus. Submucous and subserous fibroids tend to become pedunculated as they increase in size, and when this occurs their removal is easily accomplished. But removal of the interstitial variety may be very difficult, more especially if the tumour has become impacted in the pelvis, and has caused much distortion of the uterine body. When, for example, the tumour springs from the cervical segment, raising the uterus out of the pelvis on its vertex, the vascular relations become so altered as to make enucleation a matter of no small difficulty. In the first place, the effort to get at the various No. 2. G Vol. LX. vessels at the pelvic brim fails, because the large tumour chokes the pelvis, and the vessels are spread out over its lateral or posterior surface, and can only be reached individually. It is most important, therefore, that these large vessels should be ligated one by one, in order to diminish the vascular supply to the tumour, and avoid deluging the field of operation with blood, and also endangering the weak and anæmic patient by too great hæmorrhage. All this takes up time, and thus tends not only to complicate the operation, but to render the ultimate recovery of the patient a matter of grave doubt. The importance of these points is, I think, well brought out by the following case, which lately came under my care, and led to the enucleation of a large uterine fibroid tumour. This tumour sprang from the posterior lip of the cervix, and grew downwards, filling the pelvis; and upwards, pushing the uterus before it until it came to occupy the left hypochondrium, where the fundus of the uterus likewise lay. The uterine canal was, therefore, greatly elongated. In one of the photos (p. 100) the sound is seen in situ. The history of the case is as follows: Bella M., spinster, æt. 38, residing in Stornoway, consulted me on 23rd January concerning a large abdominal swelling. She told me that two years ago she noticed that she was getting stouter, and consulted a surgeon in Glasgow, who advised an operation. He performed laparotomy, but did not remove either the uterine fibroid or the ovaries. On her recovery she returned home. The tumour, however, began rapidly to increase in size; she lost flesh, and felt so weak from repeated hæmorrhages that she resolved to return for further advice. When I first saw her on 23rd January she had a pale, anxious expression, and was much emaciated. Vaginal examination showed the following characteristics :-The vagina was short, and no cervix could be made out. A soft semifluctuating mass appeared to fill the whole roof of the vagina, so that the fornices were entirely obliterated. A mere slit in the vaginal roof was all the indication of an os externum, and on pressure with the tip of the examining finger it seemed to glide away indefinitely. A large solid mass filled up the pelvis behind, and was continuous with the tumour, which filled up the abdomen and extended into the right hypochondrium, as felt bimanually. I performed the operation of panhysterectomy on 29th January, 1903. My first incision extended from a point 1 inch above the os pubis up to the umbilicus; I then caught up the peritoneum and cut into it, when I came upon a soft glistening structure which puzzled me a little until I had carefully examined it with my finger. I then enlarged my incision to a point midway between the umbilicus and the xiphisternum. The bladder was then seen to be firmly adherent to the anterior surface of the tumour, its fundus being on a level with the umbilicus. On passing my hand into the abdomen, I made out the following points:-The pelvis was completely choked with the lower part of the tumour; this filled the greater part of the abdomen, and extended up into the left hypochondrium. There was no ascites. The tumour had numerous adhesions to the peritoneum, and especially one strong broad ligamentous band passing from its superior anterior surface to become firmly adherent to the peritoneal surface of the abdominal wall at the site of the old cicatrix. This band I ligated and divided. An attempt was now made to elevate the tumour out of its bed, but unsuccessfully. As the tumour was somewhat rotated on its long axis from right to left, the right broad ligament came to lie more in front, and was likewise situated high up in the abdomen. The ovarian vessels were enormously dilated and tortuous. These were individually ligated and divided, and the tube and round ligament were treated in the same manner. With a strong pair of large toothed volsella the upper end of the tumour was then sufficiently elevated to allow me to reach, although with difficulty, the left broad ligament and ovarian vessels that were lying behind. On their division, I was able to raise the tumour partially out of the abdomen. Meanwhile, the bowels had to be kept in towels wrung out of hot water. An incision was now carried across the tumour, dividing the peritoneum in front and along the white line, and the bladder was deflected off the swelling and pushed down into the pelvis. I then worked down the left side until I had reached, ligatured, and divided the uterine vessels. An assistant now passed a Fergusson's speculum into the vagina, and I cut over it. The tumour was then tilted forwards, the peritoneum incised behind, the right uterine vessels tied and cut, along with some other adhesions, and the tumour was free. I next passed a gauze drain through the cut end of the vagina, and inverted its edges with a fine catgut suture. The pelvis having been carefully examined for any oozing points, the anterior and posterior cut surfaces of the peritoneum were brought together with a continuous fine catgut suture. Two pints of normal saline solution were poured into the abdomen; the wound was then closed in three layers, and a buried silver mattress suture was put in where the old cicatricial tissue remained. The patient made an excellent recovery. The first specimen of urine drawn off after the operation was blood-stained, but the urine was thereafter perfectly normal. Description of the tumour.-In one photo the sound is seen in situ, while in the other the uterine canal is slit open in its entire extent. The tumour gives the appearance of a large swelling, with a neck or sulcus dividing the larger from the smaller fibroid situated superiorly. A microscopical examination showed the tumour to be a myoma; a secondary dematous change had begun in the lower or larger swelling, while the smaller tumour was of a more recent origin, and quite an independent growth situated on the fundus of the uterus and divided by a distinct sulcus from the primary tumour. The entire tumour measured 17 inches in length; its greatest girth was 24 inches; its weight, 14 lb. The sound passed 10 inches along the uterine canal, and the cervical canal from os externum to os internum measured 4 inches in length, as seen in the photo where the canal is laid open. Both ovaries were greatly enlarged and cystic. The right |