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Dr. Welch, who pronounced the tumor to be a very peculiar form of uterine fibro-cyst, or cysto

myoma, has very kindly banded me a very elaborate report of it, which I here append.

Dr. Welcli's report of Mrs. B.'s case.

CYSTIC MYOMA.

In connection with the part of the tumor extirpated, there were removed both ovaries, the fundus and upper part of corpos uteri, the left Fallopian tube entire, a part of the right tube, the left parovarium, and portions of the broad ligaments.

The portiou of the cyst wall removed (apparently its upper and anterior portion) measures 24 centimetres in breadth (laterally), and 18 centimetres in height (vertically). Its median surface is in close apposition with the portion of uterus removed, but is separated from it by a little lax connective tissue. The cyst wall is furthermore adherent to fundus uteri by old tibrous adhesions. The portion of uterus removed measures 6 centimetres in breadth at fundus, 4 centimetres in length, and 3 centimetres in antero-posterior diameter. A probe passes 24 centimetres into the uterine cavity. The left Fallopian tube, with its fimbriated extremity, has been removed entire. It measures 11 centimetres in length, is pervious, and appears normal. It is separated from the outer surface of the tumor by the upper portion of the broad ligament (mesentericus tubal), in which can be distinctly seen the normal contours of the parovarian tubules. The right Fallopian tube has been severed close to the uterus; but a detached portion, measuring 10 centimetres in length, and not including the fimbriated extremity, has been removed, and remains attached to the tumor by a short mesenterium tubal. With this exception, none of the right broad ligament was removed, it having been cut close to the uterine wall.

The right ovary was removed, and is present in a separate piece. It is of norinal dimensions and appearance. It contains two corpora lutea, one small and yellow, the other large, with gray convoluted walls and bloody contents. (These were proven to be corpora lutea by microscopic examination.) The left

ovary has also been removed, and lies at the line of junction of left mesenterium tubal, with cyst walls. Although preserving the

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contours of a normal ovary, it is much flattened out by the pressure of the tumor. It measures 5 by 4 centimetres. sented under the microscope the normal ovarian stroma, containing even ova, but no large Graafian follicles, and showed clearly the parenchymatous and vascular zones.

The left ovarian ligament is very much thickened, and for a portion of its extent is incorporated with the cyst wall. The right ovarian ligament was cut off close to the uterus. With the exception of a subserous myoma, about the size of an almond, near the left cornu, the uterus appears essentially normal. The tumor, as far as can be julged from the portion removedl, is a unilocular cyst. Its external surface is smooth and glistening, and presents numerous fibrous adhesions. The peritoneum passes continuously from the uterus and the upper portion of the broad ligament upon the outer surface of the tumor. The tumor seems to have grown between the layers of the lower part of the lett broad ligament, and into the pelvic and surrounding connective tissue, displacing the uterus forwards and upwarıls, and contracting adhesions with the right ovary and Fallopian tube. The wall of the cyst varies considerably in thickness in different parts. Its average is 4-6 millimetres in thickness; but in some places it is very thin, measuring only 1 millimetre; in others very thick, 4-5 centimetres. The thickest part of the wall corresponds to an ill-defined myomatous growth, in its anterior wall. There are several smaller myomatous nodules in the eyst wall, some distinctly circumscribed. In most places, two layers can be distinguished, of about equal thickness, in the wall, firmly united, an outer, laxer and paler, and inner firm and gray.

The microscopical examination shows the chief constituent of the cyst wall to be smooth muscular tissue, in the form of interlacing bundles and fibres. These muscular fibres have no more regularity in their arrangement than in an ordinary uterine myoma, appearing now as longitudinal, and now as transverse or oblique sections. The smooth muscular tissue is mixed with a considerable amount of connective tissue, which in many places, especially in the outer wall, is distinctly mucoid in structure. The inner layers are in many places rich in round and flat cells, and contain considerable yellowish blood pigment. There is no epithelial living to the cyst, although the inner sur. face is comparatively smooth ; in many places quite as smooth as

in ordinary parovarian cysts. Careful search was made both upon the fresh and hardened specimens for an epithelial lining. In most places the smooth muscle-fibres closely compacted, and in parallel arrangement, constitute the inner lining. In some places the inner border is hyaline and structureless. There are numerous lymph-spaces (interstices) in the cyst wall, but they are of microscopic dimensions, and not notably dilated. It is not apparent in what way the cyst-cavity was formed, or what metamorphosis the muscular tissue has undergone in its development.

The fluid contained in the cyst is thin, dark-brown in color, neutral in reaction, and of a specific gravity of 1012. It contains mucin in small amount, and also gives the reactions of alkalialbumen, with acetic acid and its alcoholic precipitate (so-called paralbuminous reactions). It contains a large amount of serumalbumen. It has no tendency to coagulate spontaneously. A considerable sediment settles at the bottom, consisting in greatest part of red blood-corpuscles (to which the fluid owes its color), some white blood-corpuscles, and granular corpuscles, most of which contain a nucleus. There are in addition some free fat molecules, brownish pigment, and a few corpora amylacea.'

It will be seen that this paper embodies the results of seven cases, in one of which the whole fundus, in one the whole body, and in five the entire uterus were removed. Four of the tumors demanding the operation were large solid fibroids, with no cystic elements; one was a fibro-cyst, partly solid, and partly fluid; and two were peculiar ovarian tumors, which, developing between the layers of the broad ligaments, lifted the uterus entirely out of the pelvis, and made it a mere addendum to their walls.

Out of the seven cases four recovered, and three died. The three fatal cases were all operated on for large solid tumors. Of the four successful ones, one was a case of solid uterine fibroid, one a case of large fibro-cyst, and two were cases of ovarian cysts, with large amounts of solid material in their walls. In recog. nizing this fact, it must be borne in mind that a tumor susceptible of diminution of size by tapping does not render the operation of laparotomy as dangerous as one which, being entirely solid, involves the necessity for a long abdominal incision. As far as my knowledge extends, no one in our country has

VOL. XXXI.-39

had so large an experience in this formidable operation as our distinguished Fellow, Dr. Gilman Kimball, of Massachusetts. He informs me that he has removed the uterus fourteen times, nine times for solid, and five times for fibro-cystic tumors, with the excellent result of six recoveries and eight deaths. In some of his cases the whole, in others a part only, of the uterus was removed.

Let us hope that the next decade will give us even better results than these, and that an operation ad hoc sub judice may by the end of that time have achieved for itself a firm and enduring position.

ON THE MANAGEMENT OF THE THIRD STAGE OF

ABORTION, WITH RETENTION OF MEMBRANES.

BY JOSEPH TABER JOHNSON, M.D.,

DISTRICT OF COLUMBIA.

The main indications for the treatment of abortion are clearly enough set forth in our systematic treatises on midwifery in present use in our schools, and several points have recently been prominently discussed in obstetrical and gynæcological societies and medical journals relating to a better control of hemorrhage, and the necessity of greater care in the after treatment of women who have recently miscarried, as a means of prophylaxis against the ocenrrence of diseases requiring later on the services of the gynecologist.

Piayfair lays some stress upon this point, and declares that sufficient attention is not devoted to this very important item of treatment, and thinks it a frequent source of trouble on the part of patients who have miscarried.

To one acquainted with the more recent obstetric literature, the treatment of abortion is not especially a vexed question until he arrives at the stage which I have selected as the subject for discussion in this short paper.

In cases of too early rupture of the amnion, as the result of strong uterine contractions or too persistent digital manipulation, and a fætus, say under the fourth month, is expelled; and the secundines are retained by the premature contraction of the internal os uteri, where little or no hemorrhage occurs; the patient is feeling comfortable, and no immediate danger seems impending-the questio vexata which needs authoritative solution is, what are we to do? What is the measure of our responsibility ?

The patient and her family, reposing implicit confidence in the physician of their choice, rely confidently upon his advice and counsel at such a time as this. He is supposed to know the dangers, and is looked to for such treatment and suggestions as

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