Discussed by Drs. D. PRINCE, of Illinois, D. T. NELSON, of Illinois, G. A. MOSES, of Missouri, E. S. DUNSTER, of Michigan, and M. SHEPHERD, of Michigan.

Dr. G. A. MOSES, of Missouri, said:

I am obliged to Dr. CAMPBELL for directing attention to this effective and gentle mode of replacing retroverted gravid or otherwise enlarged and impacted uteri. I have lately used much the same method for the purpose of relieving a retroverted impacted fibroid. I had last year a case very similar to the third of Dr. CAMPBELL'S series. The patient was past four months of pregnaney, near five; the uterus was firmly wedged in the pelvis, the base under the sacral promontory, the cervix flexed against the symphysis; strenuous attempts at miscarriage were evinced by frequent recurrent and violent pain, added to which were the pains of nerve pressure and impeded circulation. The patient was unable to eat or sleep. Attempts per raginam, by hand or distending bags, utterly failed to dislodge the fundus.

Adopting the genupectoral position so well urged by Dr. CAMPBELL, the bowels having been evacuated by enemata, the bladder emptied, I introduced into the rectum a curved lever made by bending an ordinary copper vaginal depressor to such a curve as would fit the uterine globe and follow the concavity of the sacrum. This was passed entirely above the fundus, and then, by elevating the handle and keeping the vagina open by the fingers, following and assisting the movements of the uterus, I successfully attempted to reposit the organ. The proceeding was done with comparative ease, with little pain, without anesthesia.

This method I commonly adopt in non-gravid, severely retroverted uteri, rarely, if ever, using intra-uterine repositors, unless to exaggerate the anteverted position in certain cases.

Rectal reposition, either by the air-bag or by the method I refer to, is far more efficacious than the vaginal, which often fails by reason, as Dr. CAMPBELL says, of the impossibility of exerting pressure above the uterine equator. The reposition may be effected in the semi-prone, but the genupectoral presents great advantages.

Paper by Dr. H. L. GETZ, of Iowa, A Few Practical Remarks upon Ruptured Perineum.

Discussed by Dr. H. F. CAMPBELL, of Georgia.

The Section adjourned sine die.

ADDRESS IN OBSTETRICS AND DISEASES

OF WOMEN.

FIBROID TUMORS OF THE UTERUS.

BY HENRY O. MARCY, A.M., M.D.,

BOSTON.

WE have precedent in the history of this Association for the chairmen of the different Sections to depart from the rule requiring an annual review of its progress. Owing to the everwidening of the field of supervision and its increasing army of workers therein, this is the more difficult, while the journalistic efforts made in this direction are more full and complete than the time at our disposal would allow, and renders superfluous the attempt.

For these reasons, I take pleasure in inviting your attention to as careful an analysis of the subject of Fibroid Tumors of the Uterus and their treatment as the occasion will permit. This has an importance to every practitioner of medicine, wherever located, because of the frequency with which he meets with abnormal developments of the uterus; and is practically invested with a new and intense interest, owing to the remarkable progress made in surgery within the last few years, especially in the treatment of uterine and abdominal tumors.

While there remains, to stimulate all to renewed and better endeavor, a long series of obstacles to be overcome, it is very probable that our profession in the present generation has won more enduring triumphs in this direction than in any other.

The peritoneal cavity is no longer the terra incognita of the surgeon, nor is its invasion attended with the fears or dangers of even a very recent period. The removal of ovarian tumors excites no interest from its novelty, or comparatively slight anxiety because of accompanying danger, and except in minor

details it would seem surgery has little to win in this direction.

This Association has reason for congratulation for the original investigations which its members have made in these fields of labor; results recognized wherever surgery has students, and which have given to American gynecology a standing at least equal to the most noted centres of the older civilization. In this connection it would be pleasant to mention a long series of most distinguished names. Our subject demands that Washington L. Atlee, late of Philadelphia, shall be associated therewith almost in the same relation as McDowell with ovariotomy. A generation has passed since this Association awarded to him a prize for his essay* upon "The Surgical Treatment of Certain Fibrous Tumors of the Uterus, hitherto Considered beyond the Resources of Art." So heroic and bold was he as an operator that few dared to imitate him; and even now his teaching is not valued at its full worth. Sims, Emmet and Thomas have done much to establish the value of his observations and enlarge the limits of surgical resource. When we remember the complexity of the anatomical construction of the uterus and its remarkable variety of function, menstrual congestion, the cycle of especial changes incident upon pregnancy, labor, and return to its normal condition, it is easy to understand that such an organ is more especially subjected to abnormal histological changes than any other of the human body.

It is a well-recognized fact that this tendency to tumor formation in the reproductive organs is limited in very large degree to the period of active function. No case has come under our observation where a uterine tumor existed in infancy, and this is of the rarest occurrence prior to puberty.

(There is a specimen in the Warren Museum at Boston, showing both ovaries of an infant enlarged to the size of large beans by encephaloid disease, uterus healthy. Farnsworth, in the Philadelphia Medical and Surgical Reporter, of August, 1871, describes a case of removal of a uterine polyp from a child thirteen months old. Child died of peritonitis.)

Much confusion exists in the nomenclature of uterine tumors given by different authors, as to location, character, etc.

They are distinguished as myoma the more closely they resemble the uterine tissue. Under the term of fibro-myoma, * Transactions American Medical Association, 1853.

Virchow classified all the various forms of uterine growths which are composed of the elementary tissue of the organ; the unstriped muscular and connective tissue. There are none of these growths in which both elements are not found. When the fibrous induration is excessive, then they are from their firmness, rather than their histological character, styled fibrous tumors.

The different relation of these interblending elements is important from a clinical as well as anatomical standpoint, and the composition of these tumors demands a careful histological examination. The soft tumors are composed, in very large share, of smooth muscular fibres, united by a very thin loose connective tissue. It is sometimes difficult to distinguish these microscopically from the uterine substance, with which they may have the closest connection, and give the appearance of only a local hyperplasia.

This class of growths increases much the more rapidly, and, during their active stage of development, the capsule is less distinct. Few vessels enter the tumor direct, and its growth would appear to depend upon the nourishment which goes on, in large measure, by absorption from the surrounding vessels. These tumors are often of a very considerable size, without being able to trace into their substance a single vessel. Turner* described the injection by Goodsire of a pediculated subperitoneal myoma. Vessels of considerable size branched off from the pedicle, and were distributed to the peritoneal surface of the tumor. In the loose connective tissue, between the lobulated portions, vessels were also to be seen, although the lobules themselves were colorless. The tumor, as a whole, was strikingly less rich in vessels than the uterus.

Microscopic examination of uterine fibroids shows the muscular fibres arranged in bundles, which vary in size not only in their constituent elements, but in their numbers, and unite variously at acute angles to constitute larger groups, and thus form open spaces; "these, according to Klebs,† enclose a wide capillary blood-vessel, the walls of which consist of a simple layer of endothelium cells with large nuclei, and are supported by thin layer of fibrous connective tissue."

It is with the greatest difficulty that the capillary vessels can

* Edinburgh Med. Journal, 1861, p. 706, from Gusserow.

+ Handbuch der Pathologischen Anatomie, quoted by Emmet in his Principles of Gynaecology, page 514.

VOL. XXXIII.-12.