instrument, is to pack the vagina firmly with iodoform gauze, which is renewed every two or three days.

During all these treatments the patient is kept in bed, and if necessary the pain relieved by hypodermic injections of morphine.

If the elastic pressure does not succeed, recourse is had to one of the following methods of manual replacement, which are used on the anesthetized patient.

Emmet surrounded the tumor with the fingers of the left hand and pressed at the base, making counter-pressure through the abdominal wall on the ring in the peritoneum.

Noeggerath applied the thumb and middle finger to the horns of the uterus, replaced first one of them, then the other, and finally the fundus; counter-pressure was made as in Emmet's method.

Courty introduced two fingers of the left hand into the rectum, which allows pressure on the cervical ring with greater effect, while the fingers of the right hand press at the base of the tumor in the vagina.

Tate of Cincinnati dilated the urethra, introduced the right index-finger into the bladder, and pressed on the ring from this side, at the same time using the left index- and middle finger in the rectum, as Courty did, and applying both thumbs to the horns as in Noeggerath's method. Instruments for replacing the inverted uterus have been devised by White of Buffalo and Byrne of Brooklyn.

If a partial reinversion is obtained in any way, Emmet's device, of pulling the lips of the cervix together over the still inverted fundus, and uniting them with deep silver-wire sutures, may be followed. Thus an elastic pressure is obtained that may lead to complete replacement.

The efforts to reduce the inversion must be continued as long as possible, say for half an hour, different operators relieving one another. If one method does not succeed, and her condition warrants delay, the patient should be given a few days rest, and another method tried. In the mean time, the tumor may be softened with warm vaginal injections and sitz-baths.

Conservative Cutting Operations. Thomas performed laparatomy and dilated the cervical ring with an instrument like a glove-stretcher. This method would probably be the best in old cases in which adhesions have formed between the walls of the internal ring.

Barnes pulled the tumor well down with a tape, and made three longitudinal incisions in the cervix. After that he could easily replace the tumor by manipulation.

Amputation.-When all conservative measures fail, the tumor must be removed. The chief danger of this method is the possibility of the presence of the intestine in the inverted part. An elastic ligature may be applied round the base, and tightened every day. The stran

gled tumor falls off in twelve to eighteen days. Before applying the ligature a bed is made for it by burning a groove with the thermocautery (p. 182).

Some prefer to remove the mass by means of the galvano-caustic wire, or Paquelin's thermo-cautery, which does away with the dangers. of septic infection from the putrefying tumor; and if reinversion of the stump should take place, the cut surface forms a hollow cone from which discharge can escape into the vagina.

The tumor may also be cut away with knife and scissors, but then silver sutures should be drawn through the base before the ablation, so as to be able to close the peritoneal cavity. On each side one suture should be brought out transversely, so as to encircle the lateral bloodvessels, while three middle sutures bring the cut surfaces together.

Destruction of the Mucous Membrane.-In irreducible cases in women near the climacteric, the dangers of amputation may sometimes be avoided by destroying the mucous membrane and producing cicatrization by means of potassa cum calce or the thermo-cautery.

If inversion is produced by a fibroid, this must be removed before an attempt is made to reduce the inversion. It is sometimes difficult to find the line of demarkation. The safest is to make an incision. over the end of the tumor and enucleate it with Thomas's serrated scoop (Fig. 264), which will be described in treating of fibroids. When once the tumor is removed, perhaps parts of the tissue in which it was imbedded have to be cut away. Next, the uterus is to be reinverted and packed with iodoform gauze.

If the tumor is malignant, the whole uterus should be extirpated by vaginal hysterectomy, as detailed under Cancer of the Uterus. If we have to deal with a hollow polypus, it should be pulled down, which is best done by surrounding it with a noose. If there is any difficulty in applying it, a sling-carrier in the shape of a uterine sound with a small crescent at the end will easily bring it up. A small incision is made in the pedicle, through which the sound is passed, and only enters to a depth corresponding to the size of the uterus. The diagnosis thus having been completed, the protruding tissue is removed by ligature, thermo-cautery, or galvano-caustic wire.

I. Hernia Uteri.

Hernia uteri, or hysterocele, is that displacement of the uterus in which it is found lying outside of the pelvis in a sac formed by the peritoneum. The uterus has been found in an inguinal and in a crural hernia. Such cases are extremely rare. They are nearly always congenital malformations. (See p. 394.)

CHAPTER XIII.

NEOPLASMS.

A. Cysts of the Uterus; Adenoma Uteri; Mucous Polypi; Myxoma.

In regard to cysts of the cervix and ovula of Naboth we refer to what has been said above under Lacerated Cervix (pp. 396 and 399) and Chronic Endometritis (pp. 407 and 413). These cysts, being formed by occluded glands, are a kind of adenoma.

Cysts of the corpus uteri are very rare. Sometimes they are multiple. They are supposed to owe their origin to a detachment of the bottoms of uterine glands, or to be developments of Gartner's canal. (Compare Vaginal Cyst, p. 358.)

In speaking of hyperplastic endometritis (p. 408) we have mentioned another kind of adenomas, small benign tumors formed by a conglomeration of hyperplastic uterine glands. They may be sessile and do hardly ever become larger than a walnut, but have a tendency to become pedunculated and form so-called glandular polypi. Such polypi start very frequently from the mucous membrane of the cervix, and hang out from the os, where sometimes they may acquire so considerable a size as to fill the vagina; but that is rare. Most of them come under treatment when they are not larger than a cherry, a pigeon's egg, or a small oyster. They are soft, covered with a dark red mucous membrane. They are full of cavities, the contents of which are thin or thick, clear or dark.

Sometimes the polypi are formed of myxomatous tissue consisting of a delicate fibrous network, with slight thickening at the points of intersection, and a hyaline or finely granular mucoid basis substance in the meshes, in which we find imbedded single or multiple granular corpuscles. Glandular formations are rare or absent.1

The name "adenoma" is also taken in a narrower sense, and used to designate a tumor formed by an exuberant growth of utricular glands, while the connective tissue between the epithelial tracts is extremely scanty and fibrous, only a small number of medullary corpuscles being present.

In contradistinction from this benign adenoma, some authors speak of a malignant adenoma, which is only the first stage of carcinoma. The microscopical appearance which characterizes it is described as follows: The gland-spaces are very much enlarged, very irregular, and are frequently seen to break through into other gland-spaces. The columnar epithelial cells are attached to the stroma, as a rule, and they are often converted into cuboidal or even squamous cells. These Louis Heitzmann, "The Differential Diagnosis between Fungous Endometritis and Tumors of the Mucosa of the Uterus," Amer. Jour. Obst., Sept., 1887, vol. xx. p. 897.

cells are frequently seen filling up a gland-space. They, however, never infiltrate the interstitial or stroma tissue. The neoplasm extends to, and appears to progressively destroy, the muscular wall by atrophy or, perhaps, fatty degeneration. It persistently progresses as an atypical, glandular, epithelial type of disease.1

Symptoms. Mucous polypi cause hemorrhage, leucorrhea, and sometimes pelvic pain, backache, or dyspareunia. When situated above the internal os, they may work like a ball-valve and cause great dysmenorrhea.

The treatment of mucous polypi and benign adenoma must begin with the removal of the growths. In the interior of the uterus this is done with the curette (p. 176). From the cervix they may be torn off by seizing them with forceps and turning the instrument until the pedicle is severed (torsion). Or they may be cut off with scissors, but then it is well to have a thermo-cautery in readiness, as there may be some hemorrhage. They may also be removed with the galvanocaustic wire or a simple cold wire écraseur.2

After removal of the growth the accompanying chronic endometritis should be treated as described above (pp. 412-415).

Malignant adenoma is an indication for speedy vaginal hysterectomy.

B. Cavernous Angioma of the Uterus.

This neoplasm is very rare. It consists of a tumor formed of

ectatic veins filled with blood.

Pathological Anatomy.-The tumor varies in size from a hickory nut to an English walnut. It is situated in the muscular coat and covered with the endometrium and the peritoneum. The inner surface is nodular. The tumor is either spongy or harder than the surrounding uterine tissue. On incision the cut surface is covered with dark, fluid blood, and after this has been removed a delicate framework with thicker nodules appears. The cavities of the framework, which differ in size and intercommunicate, are filled with fluid blood. The framework consists of smooth muscle-fibers covered with fibrilla of connective tissue with an endothelium. In some places are seen outgrowths of connective tissue forming papillæ. The cavities of the tumor communicate with the veins of the neighborhood.

Etiology. The cause of the formation of uterine angioma is unknown. Perhaps it sometimes originates in a subinvolution of the placental site.

1 H. D. Beyea, Amer. Jour. Obst., Feb., 1896, vol. xxxiii. p. 200.

2 Fibrinous polypi are pedunculated growths formed by layers of fibrin deposited over a remnant of the after-birth left in the interior of the womb after childbirth or abortion. The symptoms and treatment are like those of intra-uterine glandular polypi.

Symptoms.-This kind of tumor gives rise to recurrent and profuse hemorrhage.

The diagnosis can only be made by microscopical examination of the scrapings obtained by curetting.

Treatment. Since this neoplasm may occupy the whole thickness of the uterine wall, curetting may lead to perforation.

In the only case observed clinically, the uterus was removed by vaginal hysterectomy.1

C. Uterine Fibroids; Fibroid Polypi; Fibro-cysts of the Uterus.

Fibroid tumors, or fibroids of the uterus, fibromata, are more exactly called myomata-i. e. muscular tumors or myofibromata, or fibromyomata-names denoting a mixture of muscular and fibrous connective tissue in their composition.

Pathological Anatomy.-Fibroids are so common that they are found in the body of one out of every five women over thirty-five years of age. They are globular tumors composed of several nodules, and may attain enormous dimensions, weighing up to 140 pounds. They are mostly harder than normal uterine tissue, but may be so soft that they impart a sensation which cannot be distinguished from fluctuation. On the cut surface they appear white or pinkish, show an irregular concentric arrangement of the fibers around different centres, and bulge out beyond the surrounding parts. In most cases the tumor is separated from the uterine tissue by a layer of loose connective tissue, the so-called capsule, so that it is easily shelled out, but often this capsule is incomplete, and the tumor is a direct continuation of the surrounding muscular wall. As a rule, the substance is compact and contains less fluid than the surrounding tissue, but sometimes it is full of dilated arteries, veins, or lymph-spaces (cavernous myoma, myoma teleangiectodes and lymphangiectodes). Nerves can be followed into the interior. The uterus grows with the tumor, so that its cavity becomes larger; as a rule, the muscular tissue becomes hyperplastic, and numerous blood-vessels are developed in it. But in exceptional cases, on the contrary, the normal muscular tissue nearly disappears, and the uterus forms only a bag filled with calcified tumors.

Fibroids may be developed in the body or in the neck of the womb, but the cervical are much rarer than the corporeal. In non-pregnant women only 5 per cent. are situated in the cervix; in pregnant women 20 per cent. have this situation, the relative frequency in the state of gravidity being due to the fact that cervical fibroids are likely to cause serious complications of pregnancy and childbirth, which bring the patients under medical observation.

H. J. Boldt, Amer. Jour. Obst., Dec., 1893, vol. xxviii. pp. 834-846. Klob, Pathologische Anatomie der weiblichen Sexualorgane, Wien, 1864, p. 173.