In an admirable paper on fibroids, read before the American Gynecological Society, Dr. S. C. Gordon reaches the following conclusions: +1. Uterine fibroids are always more or less troublesome, and in a large majority of cases produce a state of chronic invalidism. 2. "In a large percentage of cases they are complicated with excessive hemorrhages, peritonitis, salpingitis and ovaritis, with purulent collections and adhesions, producing continual suffering. 3. "Many of them do not cease growing at the menopause, but increase. 4. "Many of them undergo degeneration, either calcareous, cystic or malignant. 5. "Hysterectomy is not a very dangerous operation if made in the early history of the case- not more so than ovariotomy. 6. "In addition to the saving of life, it relieves, in nearly all the cases, the woman from a life of invalidism." In Dr. Gordon's experience with fibroids, he had met with malignant degeneration in three cases, while two out of Price's first eight hysterectomies died as a result of malignant degeneration; hence this is not a rare complication. Surgical interference does not in all cases mean hysterectomy; though, being the most radical, it must necessarily be the most certain, procedure. Besides hysterectomy, we may remove the ovaries or perform myomectomy. Myomectomy has not been enthusiastically received by the profession, though it has been successfully practiced, in suitable cases, by Martin. Removal of the ovaries is a valuable procedure, which has not been practiced as often as it should. It is applicable in bleeding fibroids, of moderate size, when both ovaries can be wholly removed. The mortality should not be greater than from ovariotomy from other causes. For other cases in which operation is indicated, hysterectomy is the only radical mode of treatment. I say in which operation is indicated, because I do not take the extreme view that all demand removal. †Trans. Amer. Gynæc. Soc., 1893. Fibroids which develop near the menopause, and grow slowly, should be closely watched, and operated upon only if they show a tendency to behave badly. The mortality should be but little greater than from ovariotomy, unless the operation is done to take advantage of the last chance. Two of the four cases I report, occurring in the practice of Dr. R. B. Maury and myself, illustrate the postponement of the menopause, one being 57 and the other 52 years of age. In one of these malignant degeneration was already under way. In one of the cases a portion of the tumor was so imbedded in the broad ligament that its removal was deemed impossible without sacrificing the life of the patient. The larger part of the tumor, with the whole uterus, was, however, removed. The other cases were done by the Baer method. The Baer operation is done with the Trendelenburg posture. After opening the abdomen, a silk ligature is made to transfix the broad ligament near the cervix, and again near its outer edge, which on being tied ligates the ovarian artery; a clamp is placed under the ovary and to its outer side, and the broad ligament severed close to the uterine tissue. After treating the other side in a similar manner, the knife is drawn around the uterus and tumor, dividing the peritoneum about one or two inches above the bladder, and an anterior and posterior flap of peritoneum stripped down. Next, the uterine arteries on each side are ligated, as they run up along the side of the cervix, and with the assistant making traction upward on the tumor the cervix is cut through at the vaginal junction. As the remaining portion of the cervix drops back, the peritoneal flaps will be found to fold in over it; the flaps may be held in place by a few stitches. The abdomen is then closed, with or without drainage, as the case may indicate. Case 1. Mrs. R., age 57; widow for twenty-five years; one child, thirty-six years ago; one miscarriage, thirty years ago. Eleven years ago commenced having menorrhagia; the bleeding gradually increased in amount, until for the past six months she has been bleeding constantly, except latterly, when she would miss a few days at a time. Five years ago she noticed a growth in the right iliac region. Has suffered pain in the left side for fifteen years. For the last six years has had attacks of pain severe enough to confine her to bed and necessitate the use of morphine. The last attack of this sort lasted twelve weeks. The growth was irregular in shape, stretching from one iliac crest to the other, and going two and a half inches above the navel. The tumor filled the pelvis almost completely, resting on the perineum almost at the vaginal outlet. Operation December 13, 1893, by the Baer method. On the left side, between the layers of the broad ligament, was a tumor as large as a fœtal head, with no apparent connection with the uterus. In the tumor on the right side, which was the larger and sprang from the uterus, were cystic formations, filled with a dark bloody fluid of syrupy consistence. This tumor opened up the broad ligament, and was with difficulty enucleated from its bed. The operation was, however, completed satisfactorily, and the patient's recovery was uneventful. A microscopical examination by Dr. E. C. Ellett showed both tumors to be fibrous in nature, with commencing sarcomatous degeneration in the larger one.* Case 2. Mrs. D., age 52; married twenty-five years. Four pregnancies; the last eighteen years ago. Had spent twothirds of the previous eighteen years in bed. Last year menses stopped-four months at one time and three months at another. During the past six months menstruation has occurred every three or four weeks, and lasting from three to five days. During the last three months has been constantly under the influence of opium, because of pain in the tumor. The tumor extends two inches above the umbilicus. Operation November 15, 1893, by the Baer method. No difficulty was experienced in the removal of the tumor, and she was discharged at the end of four weeks. Case 3. An unmarried woman; a teacher by occupation; nervous temperament; 35 years of age. For several years had suffered from menorrhagia and pelvic pain. She was much emaciated, and her mental condition bordered on insanity. The tumor, which weighed three pounds, was removed, * Later information from this patient, by letter, establishes the correctness of Dr. Ellett's examination. She is again confined to her bed, suffers pain constantly, and shows evidence of a return of the malignant growth. with both appendages, by the Baer method, and the wound closed without drainage. Convalescence entirely satisfactory. Case 4. Was one of those intraligamentous tumors which until recently would have been considered inoperable. The patient was 33 years of age, a dressmaker, and of good physique. For two years she had suffered pelvic pain and menorrhagia. The uterus, which was in front and to the left, presented numerous small fibroids, and could be felt above the pelvic brim. A globular tumor almost filled the pelvis, but was not to be felt above the superior strait. On opening the abdomen the uterus, and fibroid growths springing from it, were so crowded on all sides that it was difficult to see where to begin work. After two hours' steady work, the uterine tumor and the left appendages were completely removed. The globular tumor on the right side was not disturbed, because of the time already consumed, and we did not think the patient could stand further operating. Every structure had to be tied before cutting, and a large number of ligatures were used. The lower part of the pelvis was packed with gauze, and the ends carried out through the vagina. The patient rallied rapidly from shock, and made a good recovery. A number of ligatures came away through the vagina. Four months have elapsed since the operation. No signs of ovulation have appeared. She has no complaints, and no sensations to suggest that there is still a tumor in the pelvis. OPHTHALMIA NEONATORUM. There is probably no disease that flesh is heir to, not even the "sine qua non" of the abdominal surgeon-appendicitis -that has been made the text for as many contributions to medical literature in the last ten or fifteen years, as the disease of which I wish to speak — ophthalmia neonatorum. We are daily reminded by many sad sights that the last word has not yet been said about it, and while I have nothing new to offer as to its management, I wish to improve the opportunity presented to me to impress upon those of you engaged in obstetrical practice to whom these cases first apply, that it is an easily prevented, easily recognized, and, if properly treated, an easily-cured disease. On the other hand, if no prophylaxis is used it will often appear, and, if not properly treated, will, in many cases, result in serious and irremediable impairment of vision. Following the precedent of other writers on this disease, a few statistics will not be out of place. As to its frequency, the very complete table compiled by Dr. J. L. Minor of this city for the "Reference Handbook of the Medical Sciences" gives 4 in 1000 cases of eye disease. More to the point is the proportion of blind who owe their affliction to this cause; and when I speak of the blind I mean those blind in both eyes. Statistics compiled in various communities differ. Haussman gives the percentage in the asylums of Copenhagen 8, Berlin 20, Vienna 30, Paris 45. In Germany and Austria it is 35, and in Philadelphia 20. Magnus very conservatively gives 10.87 per cent. as the average. What an opprobrium to the medical profession that one in every ten blind persons could have had his eyesight saved and he made a useful member of society instead of a burden, by proper medical attention when the eyes were first attacked. The economic point of view demands consideration. Dr. Lucien Howe of Buffalo has devoted much attention to this subject, and estimates the cost of supporting one blind person for one year at $132 ($2 per week for board, $28 for clothing.) A yearly expenditure of over $6,500,000 is therefore required to care for our 50,000 blind. With men's wages at $1.20 per day, and women's at 40 cents, the yearly loss in wages is $404 for each man and $256 for each woman, a total of over $16,000,000 annually. In 1890 there were in the United States 50,411 persons blind in both eyes, or 805 for each 1,000,000 of population. This is a slight decrease, proportionately, from the returns of the tenth census, but almost double the eighth and ninth. In Tennessee, with a population of nearly 2,000,000, there were, in 1890, 1028 blind. In Mississippi, with a population of 1,300,000, 1025 blind. In Arkansas 786 blind in 1,100,000. Therefore, according to the most conservative estimate, there are in the States represented by the members of this society |