fully dissected out with no untoward symptoms or unfavorable results.

The surgeon's skill is taxed most in caring for and undertaking operations for the removal of the submucous, subserous, subperitoneal and interstitial varieties of tumors connected with the reproductive organs.

The methods used are as follows:

Injections to promote absorption, excision, écrasement, galvano-cautery, avulsion, enucleation, gastrotomy.

It is unnecessary for me to enumerate the special indications that point to the selection of any one of the above-named methods. The more critical the diagnosis and the more careful the study of the adjacent organs and tissues, the more apparent the advantages of some one of the operations mentioned.

The dangers in operating are the same as in other operations, viz., primary or secondary collapse from shock, hæmorrhage, peritonitis, septicemia.

Guarded as we may be against any or all of these dangers, yet the facts at my hand, and they embrace a collection from extensive research and careful compilation, would indicate that in many of these operations the French excel in obtaining satisfactory results; yet their careful estimate is, that where the operations have embraced a partial or complete ablation of the organ connected with the new growth, especially the uterus, out of one hundred operations only thirty-two will survive.

The statistics from our own operations do not show even this percentage of recovery, and it is to be supposed that the present rate would be decreased if in all cases of operation whatever the results were reported.

I close this paper by referring to two cases coming under my observation.

CASE 1st.-Mrs. M—, aged 38, was suffering from uterine fibroid. October 13th, 1873, I operated for its removal. The longitudinal incision through the median line extended from the ensiform cartilage, going to the left of the umbilicus, to within two and one half inches of the symphysis pubis. The abdominal parietes were very tense, owing to their enormous distension.

When the peritoneal cavity was opened a large subperitoneal fibroid pushed through the opening.

It was oval in shape and contained on the posterior surface two nodules the size of a hen's egg each. With this exception the surface was perfectly smooth, and resembled in color a healthy ovarian cyst. Upon palpation distinct fluctuation was felt, which is one of the peculiarities of this form of tumor when grown to such a magnitude. The tumor was perfectly solid, and weighed fifteen and one-half pounds. On passing through the opening it rolled forward, dragging into full view the uterus and its appendages. The growth was from the fundus of the uterus, and was not unlike, in resemblance, a large cabbage; the uterus the stalk, the tumor the head. Owing to the vascularity of the uterus and its appendages it was considered not safe to extirpate the uterus. A double ligature, tied both ways, was passed through the fundus and tumor, and the tumor amputated, The uterus was placed back into the abdominal cavity, and was covered with the peritoneal folds, with a view of causing union and covering over the raw surfaces; but a convolution of intestine fell into contact with the cut surface and rapid adhesive inflammation followed, causing a portion of the intestine to become adherent by means of the exudation. The lymph becoming organized constricted the intestine, and we had in this case continued vomiting from this strangulation. The patient died on the sixth day from this condition of affairs. If the stump had been fastened to the abdominal parietes we might have avoided this sad termination of life. Where subperitoneal fibroids are pedunculated I recommend amputation at the point of union with the uterus, or the ligation of the lateral appendages and amputation at the cervix.

This operation has been successfully performed, and when it is skilfully done I do not consider it attended with greater danger than the removal of ovarian cysts with adhesions.

CASE 2d. The danger and risk of removing a subperitoneal fibroid is much greater than that of a submucous intrauterine, the danger being in the latter in proportion to the amount of muscular structure involved. When we have a submucous intrauterine starting from an intramural, we may find great dif

ficulty in its enucleation, owing to the firm manner in which it is imbedded in the muscular structure. Add to this the complication of a growth extending through the external surface, forming a subperitoneal, and we have an increased risk as well as a barrier interposed to its perfect removal.

These were the circumstances attending an operation in which I assisted my late lamented friend and colleague, Dr. G. D. Beebe, in the summer of 1874.

Prof. Beebe had introduced the galvanic needle through the posterior wall of the uterus into the fibrous mass, hoping to promote absorption. The first operation was attended with but little result. The second time the current was so strong as to produce a destruction of the tissue; inflammation and suppuration followed, then absorption. I was called to see the patient when suffering from septicemia. An operation was decided upon, and a tumor weighing six and one-half pounds was removed.

The difficulties encountered were, 1st. Intramural fibrous bands running through the uterus and appearing on the posterior surface in the manner of subperitoneal tumors. This tumor could not be fractured by the hand, but was severed by a pair of long curved scissors passed upon the palmar surface of the hand while in the cavity of the uterus, and cut as near the uterine wall as the presence of the fingers would admit. After its complete separation we found great difficulty in removing it from within the pelvis, owing to a narrowing of the transverse diameter to less than three inches. A blunt hook was introduced within the uterus, and there an incision was made by means of a long-handled bistoury, cutting the tumor into halves. Delivery was effected in this way.

XXVI.

PAPILLOMATA, ADENOMATA, MYXOMATA.

BY L. H. WILLARD, M.D., ALLEGHENY, PA.

THREE varieties of morbid growth have been assigned to me as my share of the papers of this bureau, viz.: Papillomata, Adenomata, and Myxomata.

In accordance with the wishes of our chairman and with my own desire, I have endeavored to arrange and describe them anatomically, believing that while we have no good, reliable, or fixed classification, that proposed by Abernethy is, perhaps, the best. As such I have been induced to adopt it, thinking we are benefited in many ways; for should any writer be describing a tumor, if he gives the anatomical characters so far as known, we readily understand the description; while, on the other hand, if a tumor is merely said to be fibrous, or a polypus, we are in doubt in regard to the nature of such tumor or polypus; and when we consider the numerous varieties of what may seem to be fibrous growths, and the still more numerous varieties of polypi, whether they be papillary, adenomatous, myxomatous, fibrous, etc., we are led to consider the old classification unscientific and perplexing. This, in itself, is but trifling when compared to the disadvantages which arise from the incomplete manner of treatment.

It is very evident, or it may appear so, that a polypus of a myxomatous growth may require for its cure a different remedy from a polypus of papillary growth, and so on.

Among the tumors of different tissues, we may have different

symptoms, which, if carefully investigated, may, by their significance, elevate the prescribing of remedies to a higher plane, and give more certain results than we have yet attained.

The remarkable success which many have recorded concerning the cure of tumors, and the skeptical views of others in regard to these cures, may in a manner be thus determined. Not being a skilled pathologist myself, nor laying claim to any research in this direction, I can only view the recent investigations which have followed year by year, as so many advances toward the fulfilment of the most ardent hopes and aspirations that will lead the inquiring mind to a full appreciation of these pathological discoveries, and, by so doing, guide us to a more explicit and certain method of describing and curing these different growths. The paper which I present to-day has in view the arrangement of the varieties mentioned according to their anatomical basis, the first being the

PAPILLOMATA.

Among tumors of this class are included all those which under the microscope reveal a structure similar to ordinary papillæ; and hence we find them generally growing from the cutaneous, mucous, or serous surfaces, forming tumors by hypertrophy of the normal covering, or, where there is but small amount of epithelium, by growth of the connective tissue and vessels. This epithelial covering varies in character in different growths. If the tumor is on the skin, the epithelial layer is very abundant, with few vessels, and hence the tumor will be hard. To this form has been given the name of warts, horny growth, etc. (Such growths as condylomata and venereal warts, being but symptoms of a disease, are not included in this paper.)

The papillomata, when springing from the mucous membranes, are generally soft, succulent, have large vessels, and are called, from their appearance, soft papillomata, varying in their degree of consistence according to the amount of connective tissue. This variety is found in the alimentary canal and genito-urinary organs. They are liable to dangerous hæmorrhages. When examined under the microscope, we find processes of connective tissue, like the papillæ of the skin, with few or many vessels,