pubis. In some rare cases the blood-tumor is anterior to or obliquely to one side of the uterus, but these are very rare.

Abdominal palpation reveals the presence of a tumor of varying size, and which sometimes extends up to the navel in peritoneal hæmatocele, but in the subperitoneal variety no tumor whatever may be discoverable by these explorations, unless conjoined manipulation be added to it for the sake of deeper and more thorough search.

DIFFERENTIATION.-Hæmatocele may be confounded with pelvic cellulitis or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and dislocated ovarian cyst.

The tumor of cellulitis develops slowly, with great pain; is hard at first, and then softens; is tender from the first; does not elevate the uterus or press it forward; and is not often accompanied by metrorrhagia. Retroversion will readily be detected by the uterine sound, conjoined manipulation, and the absence of anæmic symptoms.

The development of extra-uterine pregnancy is slow and gives the signs of gestation.

Fibrous tumors grow slowly, are painless, and move with the uterus, and they are hard, irregular, and do not lift the uterus against the symphysis.

Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia, and yield fluctuation readily to palpation.

COMPLICATIONS.-The complications to be feared in this disease are septicemia, suppuration and abscess, and peritonitis.

COURSE, DURATION, AND TERMINATION.-The hemorrhage may be so severe as to destroy life immediately. Five such instances have been recorded by Voisin; I have met with one; and Ollivier d'Angers mentions two in which death occurred in half an hour from a varicose uteroovarian vein. Such a termination is, however, very rare.

As a rule, absorption takes place unaided by art; in some cases suppuration occurs, and the mass is discharged as if it were a large abscess by the vagina, rectum, bladder, or abdominal walls; and at other times septic absorption, accompanied by septic peritonitis, destroys the life of the patient.

PROGNOSIS. The prognosis will depend in great degree upon the severity of the constitutional symptoms. As a rule, it is decidedly favorable unless the surgical tendencies of the attending practitioner alter its natural inclination. The prognosis of the peritoneal form is graver than that of the subperitoneal, and when the tumor is very large the danger is greater than when it is small. A large tumor argues great loss of vital fluid, which may in itself destroy life, and the necessity for the absorption of a large amount of coagulated material which may poison the blood.

The usual causes of death are loss of blood, shock from sudden invasion of the peritoneum, peritonitis, secondary discharge of the encapsulated mass into the peritoneum, or septicæmia.

TREATMENT. Should the physician be called in the inception of the attack, the patient should at once be placed in the recumbent posture, all excitement around her be quelled, the head be kept low, warmth be applied to the soles of the feet, and perfect quiet enjoined. An effort should be made to check the flow by applying bladders of ice or cloths wrung out of hot water over the hypogastrium, pain and tendency to

shock met by the use of morphia hypodermically, and ammonia and brandy freely administered by the mouth. This is all that promises benefit, and further efforts should be avoided as calculated to do absolute harm.

After reaction has occurred let it be borne in mind that the factors which tend to the production of death are-1st, peritonitis; 2d, septicæmia; 3d, suppuration and discharge through some dangerous outlet ; and let all efforts be directed toward the prevention of these events.

All pain should be quieted by opium or one of its salts, hypodermically or by mouth or rectum; the patient should be thoroughly nourished by milk and strong animal broths, given as often as every two hours; febrile action should be controlled by the coil of running ice-water and quinine; and strict quietude observed, all unnecessary examinations being avoided, as belonging to the most pernicious class of perturbing influences.

Should the case progress favorably, no surgical procedure looking toward the artificial evacuation of the accumulated blood either by bistoury or by the aspirator should be thought of, however large the accumulation be; for experience has proved that cases left to nature, as a rule, do better than those interfered with.

On the other hand, the great value of surgical interference in those cases in which suppurative action occurs, or in which septicemia develops itself either in acute or chronic form, must not for a moment be lost sight of. Should the case not progress toward recovery, should the symptoms of septicemia develop as a sharp attack or as the insidious hectic fever, the accumulated blood or pus and blood should at once be evacuated, and the nidus from which it is discharged be thoroughly washed out with a 24 per cent. solution of carbolic acid or a solution of the bichloride of mercury, 1 to 2000 of water. Should the accumulation be attainable, tuto, cito, et jucunde, by the vagina, an exploring-needle should be carried into it, and as soon as the fluid is seen to flow a sharppointed bistoury should be slid along this and a free opening be made, all the contents of the sac evacuated, and antiseptic washing be at once practised by means of Davidson's syringe and a glass tube.

Should the accumulation point toward the abdominal walls, the opening may with perfect safety be accomplished there. I have operated thus upon 3 cases, with recovery in all, but the accumulation had at the time of operation assumed the character rather of an abscess than of an hæmatocele. A. Martin of Berlin has operated by abdominal section upon 8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden has done so upon 1 case, with recovery. Zweifel has collected 30 cases operated upon by free vaginal incision, with a result of 3 deaths, giving a mortality of 10 per cent. Mere puncture through the vagina he found followed by a mortality of 15 per cent.

The question of surgical interference in pelvic hæmatocele is still sub judice. In my judgment, the rule of practice may, with the present light which we have to guide us, be safely formulated thus: So long as the symptoms are good and the case progresses toward recovery, avoid surgical interference of all sorts, however great be the sanguineous effusion. So soon as symptoms of decided septicemia or septic peritonitis develop themselves, evacuate the accumulation by a free opening practised by the safest outlet which presents itself, and use antiseptic washings thoroughly.

FIBROUS TUMORS OF THE UTERUS.

BY WILLIAM H. BYFORD, M. D.

RELATIONS AND STRUCTURE.-These tumors grow from the muscular and connective tissues of the uterus, and consequently partake of the character of these tissues. Sometimes the substance of the tumor consists principally of connective, at others of muscular, tissue. The variations in the relative proportion of these two fibrous substances constitute the main differences in the characters and appearances of the tumors, and lead to the different terms applied to them, as myomata, fibromata, myo-fibromata, etc. The firmer the tumor the more connective tissue it contains. When we inspect, either ante- or postmortem, a uterus with a fibrous tumor attached or contained within its wall, it will be found to present a much darker hue than natural. Instead of the normal light rose-color, it is generally dark, sometimes almost of a purplish tint. The time of menstruation makes some difference; just before it is darker than soon after the menstrual flow. The color also varies with the character and size of the tumor. In large solid tumors the color is darker than in the large fibro-cystic variety; indeed, in some of the latter the pearly color strongly reminds one of an ovarian cyst. We cannot therefore depend on the color or shape of surface for a diagnosis. Even after the abdominal cavity is opened the contour of the uterus is usually not regular. If we make an incision into the tumor, we find that it is surrounded by a distinct capsule, which limits and defines its boundaries and separates it from the adjacent substance. This envelope is not a cyst or other form of membrane: it is continuous with, and inseparable from, the muscular structure of the uterine walls. It, in fact, is a condensed layer of the fibrous substance of the uterus. In cases of true encysted tumors the cyst-wall is the generating portion of the growth. In fibrous tumors of the uterus the growth produces the capsule by displacing the surrounding substance in every direction, pressing it strongly against the unaffected fibrous tissue and condensing it into the smooth capsule. It is thus engendered in, and enveloped by, the muscular walls of the uterus. These latter of course grow to dimensions sufficient to keep pace with the increasing tumor. The growth may, as a consequence of such a connection, be hulled out or enucleated, and will not be reproduced. Inflammation or other degenerating processes may occasionally cause adhesion of the capsule and tumor, but this is an accident of uncommon occurrence. To understand this mode of encapsulation we must remember that the uterine muscles are irregularly stratified,

and that the tumors are developed between the strata as between the leaves of a book, separating them sufficiently to gain lodgment and room.

The appearances of the substance of the tumor are not uniform. In many cases the color of the interior of the tumor is dark gray; in some it is dull red; again, sometimes almost livid. The surface of the tumor after the capsule has been removed is often marked by sulci denoting a division into lobules. In other cases the tumor is smooth and symmetrical in shape, and the fibres distinctly visible to the naked eye. The smooth tumor is apt to be very dense and comparatively difficult to destroy, while the lobulated variety is less dense and sometimes easily broken to pieces. But the difference of density does not correspond altogether with the color or shape of surface.

We seldom find large tumors of uniform structure. In some places they are of solid fibrous structure; in others there are cavities of greater or less size, containing a tenacious red serum. These cavities, which seem to be made by localized disintegration of the fibrous tissue, are sometimes of great size, containing several pounds of serum (Atlee). Much more frequently they are small and hold a small amount of fluid. I have met with several where the substance of the tumor seemed to be made up of alveoli filled with a tenacious fluid the color of milk.

Besides this effect upon the density of the tumor resulting from what might be called its usual course, there are numerous modifications in it and in the other properties of the tumors arising from spontaneous degeneration.

It may be said, I think, that without adventitious or supplementary vascular supply the life of a fibrous tumor is self-limited, and it ceases to grow after it has attained to a certain size, and that then it either remains stationary or undergoes degeneration. As I shall have occasion to say farther on, the original supply of blood-vessels cannot be increased to an indefinite degree, and the tumor that grows indefinitely derives a supplementary supply of blood by contracting adhesions to the viscera or abdominal walls. Such adhesions are common and mischievous.

After a tumor has attained its growth, degeneration into the more ele mentary forms of tissue sets in, as the cartilaginous degeneration, and there is often a deposition of earthy material found in it which reduces it to a hard, dense, stationary, and indestructible body. In such cases there is almost a complete loss of vitality in the tumor, and it becomes a calcified mass.

We may easily demonstrate that the structure of these tumors is essentially fibrous. By maceration and careful dissection the fibres are traceable to a greater or less degree in all of them, the proportion and characters of which, as before said, differ greatly. In the smooth, symmetrically-developed tumor the fibres are usually long and distinctly traceable, while in the lobulated light-gray tumor the fibres are more rudimentary and not so easily followed up by dissection.

MODE OF DEVELOPMENT. It has already been stated that the fibrous tumor of the uterus grows in or on its wall and originates in the fibrous structure of the organ. The point of beginning is in one or more fasciculi of the muscular system or the connective tissue of the uterus. If in one fasciculus, the point of origin is very minute, as indeed it is generally at first. The development consists in an hypertrophy of the bundle of fibres

affected and a deposit of material similar in structure to that first involved. Sometimes there are numerous nuclei, and nearly all the fibrous structure of the uterus is involved in fibrous degeneration. In the case where the deposit is defined and occupies a small space, it should be borne in mind that the future tumor, however large it becomes, must occupy the same nidus in which it first originated. The nidus becomes enlarged sufficiently to accommodate the growing tumor.

The nucleus of development is enlarged by the accretion of substance similar, if not identical, in character to its own proper material. The nature of the tumor is determined by this fact, and its fibres are rudimentary in organization, instead of being hypertrophied and highly developed, as those of the uterine wall by which it is surrounded. As the tumor grows the fibrous structure surrounding it is pressed aside in every direction in such a way as to completely embrace the growth and encapsulate it. The tumor does not incorporate the adjacent fibres and grow by inducing degeneration in them, but, as before said, it presses them aside. As it thus moulds and shapes a bed in the solid substance of the interior wall, it impresses upon the embracing muscular fibres an increased vitality, and they grow by hypertrophy of a character similar to that of pregnancy. The fibres become longer, and apparently, if not really, more numerous. This hypertrophy of the uterine fibres surrounding the tumor is equal to the capacity demanded by the increasing size of the growing tumor. In this description of the method of development and the embracing capacity of the hypertrophied fibres surrounding it the reader will trace the formation of the capsule in which the tumor is contained. The inner surface of the capsule is smooth, and there are many feeble fibres of connective tissue seen to connect it with the surface of the tumor. There is no adhesion proper between the surface of the tumor and its capsule.

I must call attention to another point that governs the extent and limits of the growth of the tumor-viz. the number and distribution of its vessels. The vessels entering the tumor represent the minute twigs that supplied the fasciculus in which it originated. They arrive at the point of morbid deposit from the parts constituting the capsule, and there are always several of them. The number of these vessels always remains the same, and their calibre is increased with the hypertrophy of the surrounding tissues. They cannot grow at the demand of the trophic energies of the tumor to an unlimited degree, but their size is limited by the growth of the surrounding parts. As the tumor grows and its capsule expands, the vessels are separated farther from each other, until after a while the area becomes so large that the supply of blood will not admit of further growth and the tumor comes to a standstill. Thus their growth, from the nature of their supply, is limited; hence the usual history of the tumor is one of self-limitation. It is all-important in forming an opinion in reference to the greater or less vitality of the fibrous tumor, therefore, to remember that it is not supplied by one large arterial trunk entering at one place and spreading over its capsule, but that the supply is by a number of small vessels penetrating the tumor at different points; that their number cannot be increased and their growth is limited; that as the tumor grows their capacity to supply it grows gradually less until entirely exhausted: then the growth stops.