REMARKS UPON THE Enucleation of Uterine Fibroids, WITH ILLUSTRATIVE CASES, BY T. GAILLARD THOMAS, M. D,, V.TT ' Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Surgeons, New York (Rejrinted from tie Arcliyes of Clinical Surpry, July, 1876.) NEWYORK: Rutledge & Co., Publishers, 102 West Forty-Ninth Street, 1876. CONTRIBUTORS ARCHIVES OF CLINICAL SURGERY. Cornelius R. Agnew, New York. D. Hayes Aonew, Philadelphia. Edward L. Keves .....New York. A. F. A. King, Washington. Chas. M. Allin, New York. James L. .Little, New York. Herman Aithof, “ Edmund Andrews, Chicago. Francis A. Ashford, Washington. Morell Mackenzie, London. Erskine Mason, ...New York. J. Ewing Mears Philadelphia. John Ashhur»t, Jr, Philadelphia. Francis Bacon, New Haven. Julius F. Miner, Buffalo. E. M. Moore, Rochester, N. Y Fordyce Barker, New York. J. K. Barton, Dublin. Emil Noeggerati,', New York. F. N. Otis, “ Robert Battey, Georgia. Henry J. Bigelow, Boston. Montrose A. Fallen.... “ “ Williard P>rker, “ “ Clarence J. Blake, “ Thos. S. Bond, Chicago. J. H. Biinton, Philadelphia. Henry G. PffLrd “ “ J. H. Pooley, Columbus, 0. C. B. Porter, Boston. Freeman J. Bumstead,...New York. J. H. Plobart Burge, Brooklyn. Alfred C. Post. New York. C. P. Putnam, Boston. Samuel C. Busey, Washington. Wm. H. Byford; Chicago? Robert Reyhurn, Washington. I). B. St. John R mis i...New York. T. T. Sabine, James R. Chadwick, Boston. David W. Cheever, “ Henry B. Sands, “ “ J. J. Chisolm, Baltimore. J. Solis Cohen Philadelphia. T. B. Curtis lioston. Lewis A. Sayre, “ “ J. Marion Sims. “ “ A. J. C. Skene, Brooklyn. John T. Darby, New York. L. A. Duhring, Philadelphia. Henry H. Smith Philadelphia. J. Smith, New York. T. Dwight, Jr., ..Boston. T.ouis Elsherg, New Yotk. Stephen Sniith. “ “ S. Fleet Speir Brooklyn. T. Addis Emmet, “ “ Paul F. Eve, Nashville. D. M. S’imson, New Y< rk. Robert W. Taylor, “ “ Geo. J, Fisher, Sing Sing, N. Y, A. Fournier, Paris. C. C. F. Gay, Buffalo. Isaac E. Taylor “ “ J. S. Thebaud, “ “ Wm. Thomson Philadelphia. Geo. W. Gay Boston. Wm. Goodell,.. Philadelphia. J. W. S. Gouley, New York. T. Gaillard Thomas...New York. J. H. Thompson, Washington. J. Orne Green,... Boston. A. Voisin, Paris. Clinton Wagner, New York. F. H. Hamilton New York. Wm. A. Hammond “ “ Albert G Walter, Pittsburgh. Samuel B. Ward, Albany, N. Y Chas. Heitzman “ “ Berkeley Hill London. Robert F. Weir, New York. Samuel Whitall, “ James C. While, Boston. R. M. Hodges, Boston. T. Holmes. London. Joseph W. Howe New York. James P. White Buffalo. E. Wigglesworth, Jr.,..Boston. Jarvis S. Wight, Brooklyn. Ralph N. Islnim, Chicago. J. Taber Johnson. Washington. Henry W. Williams,.. Boston. James R. Wood, New York. W. W. Keen Philadelphia. and others REMARKS UPON THE Enucleation of Uterine Fibroids, WITH ILLUSTRATIVE CASES, BY T. GAILLARD THOMAS, M. D., Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Surgeons, New York. (Reprinted from tie Wires of Clinical Snrpry, July, 1876.) NEWYORK: Rutledge & Co., Publishers, 102 West Forty-Ninth Street, 1876. REMARKS UPON THE Enucleation of Uterine Fibroids, WITH ILLUSTRATIVE CASES, T. Gaillard Thomas, M. D., Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Surgeons, New York. One of the most valuable contributions made by America to gyn- aecological surgery, emanated from W. L. Atlee, in reference to the management of sessile sub-mucous and interstitial uterine fibroids. In the year 1853 he presented to the American Medical Association an essay entitled “The Surgical Treatment of Certain Fibrous Tumors of the Uterus heretofore considered beyond the resources of Art.” This essay received the prize of the association, and to-day stands as the pioneer article in the surgical literature of these grave and often irremediable cases. Both in this country and in Europe the lead of this bold surgeon has been followed, and the method which he advocated a quarter of a century ago, and which slowly battled with a pretty decided opposi- tion has come to be recognized as a legitimate surgical resource. If I may be allowed to epitomize the views of Atlee, as published in 1853, I would do so in these three propositions. First—lf a non-pediculated tumor cannot, from the nature of its attachment and envelopes be expelled or drawn by mechanical means through a dilated os uteri, it is advisable to make by the knife a means of escape for it into the uterine cavity, through its capsule or enveloping tissues. Second—If the tumor, thus offered an outlet, cannot be removed, it should be forced into and out of the uterine cavity by persistent use of ergot and cutting the cervix. Third—The tumor, once coming within reach, it should as soon as practicable be enucleated and removed by the surgeon. 4 T. GAILLARD THOMAS, That this method of treating such cases is attended by the great dangers of septicaemia, peritonitis, hemorrhage, and exhaustion, is not to be denied. But it must be borne in mind that while heroic interference is environed by risks, a Fabian course of non-interference and inactivity is by no means a safe one. The growing tumor creates exhausting hemorrhage, dangerous mental depression and anxiety, and interference with the functions of nutrition and excretion,which slowly drag the patient down to death. Interference should not be practiced unless impending danger urges a resort to it. Cases selected by this rule commonly end in recovery, while non-interference commonly results in death. Although many surgeons here and abroad have, as I have already said, followed the lead of Atlee in this matter, it is still of importance that a fair report of cases thus treated should be made in order that those believing may be strengthened, and that those doubting should be convinced. In this spirit I report the following cases. Case i.—Large Fibroid expelled through opening made in its capsule. Mrs. C., residing at Red Hook, N. Y., aet. forty years, been married thirteen years, the mother of one child eight years of age, called upon me by advice of Dr. Bates, of Rhinebeck, and gave me the follow- ing history of her case. Four years ago her menstrual periods had ceased for six months, and she began to think that the menopause or pregnancy had occurred, when suddenly they reappeared. At the same time she was disturbed by noticing that her abdomen was enlarging. From this time the menstrual discharges became profuse, the health depreciated and the strength greatly diminished. The abdominal enlargement steadily increased meanwhile, and at the time that she applied to me, my note book records it as being “ as large as in utero- gestation between the seventh and eighth months.” Upon her visit to me, on the 9th of June, 1875, I found Mrs. C. very pale, thin, weak and bloodless. The appetite was poor, digestion feeble, pulse rather weak and rapid, and the patient’s mind much depressed about her condition. Physical examination revealed the upper portion of the cervical canal expanded as at the commencement of labor, the walls of the cervix thin, and a tumor filling the cavity above and firmly attached to the walls of the cervix, except on one side, the posterior. The uterine sound on this side passed up about five inches, but everywhere ENUCLEATION OF UTERINE FIBROIDS. 5 else the growth was attached all the way down to the lowest portion of the cervical canal. The tumor which presented was rather soft, and I suspected that it might be fibrocystic instead of purely fibrous. The uterus had, from the history of the case, evidently made deter- mined efforts to expel it; but, on account of the resisting envelope, had entirely failed in doing more than dilating the os externum. This rough diagram, sketched with pen and ink upon the patient’s first visit, will convey an idea of the attachments of the tumor. The patient being unwilling to remain in town, I decided, First—To pass a large aspirator needle into the mass, to ascertain if it contained spaces filled with fluid. Second—If it did not do so, to make an opening into the capsule which would constitute an artificial os for the mass. Third—To give ergot steadily to excite expulsive efforts on the part of the uterus to force out the growth. Accordingly, on the 10th of June, with the assistance of Drs. H. F. Walker, and S. B. Jones, Jr., this course was inaugurated at the patient’s hotel, and on the next day she returned to Red Hook without inconvenience. I did not again hear from her until a fortnight afterwards, when she wrote that ever since she had returned home, she had suffered from 6 T. GAILLARD THOMAS, uterine pains of intermittent character, and a slightly bloody flow of a disagreeable odor. From her attending physician, I subsequently ascertained the pro- gress of the case. The pains referred to steadily forced down the tumor through the opening made in the capsule. It presented exactly as a child’s head would have done, and after between two and three weeks of a process closely resembling labor, it distended the perinseum and by very firm traction on his part, was delivered. During this time, a most offensive odor was given forth by the mass, and the patient suffered from a certain degree of septicaemia. Unfortunately the tumor which was large, decomposed, and almost diffluent, was not weighed. Subsequent to this, Mrs. C. entirely recovered, and now, one year afterwards, is, I believe, in good health. I neglected to say that the attempt at aspiration yielded no fluid whatever. It is probable, however, that the acupuncture resulted in the partial death of the badly organized mass and aided materially in exciting expulsion. The second case which I shall record was seen in consultation, and as a report of it, made by the attending physician, has not been pub- lished, I avail myself of his kind permission to employ his manuscript here. Case 2.—Sub-mucous Uterine Fibroid. Uterine contractions ex- cited by ergot. Tumor enucleated by Prof. Thomas. Reported to the District Medical Society of Bergen County, New Jersey, by Chas. Hasbrouck, M. D. Mrs. A., aged forty, first menstruated at fifteen, married when twenty years old; has had four children, the eldest nineteen, the youngest between ten and eleven years old; never had an abortion or miscarriage, and until recently never had any serious illness. Pre- vious to the birth of her last child, Mrs. A. always enjoyed robust health. In the winter of 1863-4, a few weeks after the birth of her last child, and before she had recovered fully from the puerperal con- dition, her husband had an attack of typhoid fever and was very ill for several weeks, and Mrs. A. became very much worn down from protracted watching, fatigue and anxiety. Soon after this, she began to suffer from sleeplessness and general nervous irritation. Her appetite remained good, and her nutrition seemed perfect, with rather a ten- dency to the accumulation of fat; her menstrual functions were regular and without pain or any other abnormal symptom; she never had leu- ENUCLEATION OF UTERINE FIBROIDS. 7 corrhoea, backache, nor any other symptom of uterine disease. But at the same time she continued to suffer from general nervousness, sleeplessness, and neuralgic pains in the back of her head, shoulders and chest, down to the waist. Her spine was more or less tender, and she sometimes had a nervous, dry cough, and sometimes vomiting, and almost constantly suffered more or less from the protean forms of hysterical disorders. During all this time her menstrual functions were naturally performed, and on careful examination, by touch and by the speculum, no uterine disease could be discovered. In 1868-9, Mrs. A. began to menstruate rather scantily, although regularly as to time, and became more and more nervous, requiring almost the daily use of chloral-hydrate and bromide of potassium to relieve her nervous disorders and wakefulness. In 1870-1, she began to menstruate more freely. The catamenia continued to recur at the regular time, and continued to be free from any kind of suffering, but they gradually became more and more pro- fuse, until finally it amounted to actual menorrhagia and began to tell upon her strength. This condition continued for several months before my attention was called to the fact; and increased debility, and aggravation of her sleeplessness and general hysterical distresses were the results. Finally, during the past summer, 1873, mY patient called my atten- tion to the fact, that notwithstanding her increasing debility, and very appreciable emaciation, there was a noticeable increase in the size of her abdomen ; and on examination, I discovered a distinct circum- scribed tumor in the hypogastiium, symmetrical, or nearly so, in form, nd about the size of the uterus in the fifth month of pregnancy. The tumor was evidently uterine. By the persistent use of astringents and perfect rest in the horizontal position during the menorrhagic flow, and of tonics, quinia and iron, during the intervals, the amount of the hemorrhage was very materially lessened, and the general health of the patient improved. But the hypogastric tumor remained, and perhaps increased very slightly in size, disturbing the patient’s mind and interfering with her general comfort. November, 1873, I got Prof. T. G. Thomas, of New York, to see Mrs. A., and after a careful examination he expressed the opinion that the tumor was undoubtedly uterine, and most probably a uterine fibroid. But in view of the fact that it might possibly, but not probably, be one of the rare cases in which pregnancy existed with 8 T. GAILLARD THOMAS, regular menstruation, he declined to risk the danger of resorting to the use of the probe or uterine sound, which was necessary to perfect the diagnosis, until about six weeks or two months had elapsed, by which time the existence or non-existence of pregnancy would be developed with entire certainty. February 20, 1874, Prof. Thomas again saw the patient, the uterine tumor had increased slightly in size, but the non existence of preg- nancy being sufficiently evident, he did not hesitate to use the sound, and found the uterine cavity to measure about five inches. He diag- nosticated the presence of fibroid tumor of the uterus of the sub-mucous variety ; and advised the persistent use of ergot, in the hope of starv- ing out the tumor, or at least, retarding its farther development by diminishing its blood supply; and in the farther hope that the uterus might be induced to take on expulsive action and expel the morbid growth. In accordance with this advice, I gave Squibb’s solid extract of ergot in four grain doses three times a day, beginning February 21, 1874. March 2, Mrs. A. began to suffer from severe pains in the iliac and hypogastric regions. These pains were constant but aggravated in paroxysms. They were evidently uterine, and no doubt the result of the ergot. These pains continued with scarcely an interval of ease, and finally became so severe and exhausting that I was obliged not only to discontinue the ergot, but to resort to hypodermic injections of morphia to relieve the terrible suffering. Even after the discon- tinuance of the ergot, the pains continued to recur daily between twelve o’clock m. and one o’clock p. m., generally requiring a dose or two of the morphia to procure a night of rest. In the meantime the cervix uteri gradually softened down and the os uteri became patulous, so as to admit the first phalanx of my finger, when I could reach the lower portion of the tumor. The pains still continued to recur daily. The os uteri became more and more soft and dilated, until it reached the size of a dollar, the lower portion of the tumor apparently becoming somewhat detached and gangrenous, filling up the os, and emitting a terribly offensive odor. I attempted with a strong polypus forceps to remove the offensive presenting mass, but could only tear away a part of the putrid portion, while as far as I could reach with my finger, I could feel the tumor firmly imbedded, apparently in the posterior and lateral walls of the uterus. The constant suffering of my patient from the recurring pains, loss of sleep, etc., greatly exhausted her. Besides, her pulse became frequent ENUCLEATION OF UTERINE FIBROIDS. 9 and irritable, and her skin was almost constantly bathed in profuse per- spiration, while toward morning she sweated so profusely as to drench her clothing and the bed clothes. The discharge from the gangre- nous mass became more and more offensive and profuse, and it became evident that my patient would die from septicaemia and exhaustion if the efforts of the uterus to rid itself of the offending tumor were not aided by the judicious application of art. Under these circum- stances, I telegraphed to Prof. Thomas, to visit the patient and adopt such farther measures as he might deem necessary and expedient. March 18, 4 o’clock, P. M., Prof. Thomas visited the patient with me; and in view of her weakened condition, the size of the tumor, its extensive attachments and the great danger to the patient from any farther delay, he advised the immediate removal of the tumor, if pos- sible, by enucleation. Accordingly Mrs. A. was placed fully under the influence of ether, and removed to a table in a strong light. Sims’ speculum was intro- duced, when the tumor could be seen filling up the partially dilated os. Dr. Thomas seized it with strong forceps, but it was so putrid as to tear on making traction. After removing as much as possible in this way, the doctor succeeded in passing the loop of an ecraseur around a part of the remaining undecayed portion of the tumor and removed another large piece, the wire of the ecraseur breaking during the process. Having thus cleared the os and cervix of a con- siderable portion of the tumor, he next, partly by the use of an enucleator, and partly by a process of clawing, succeeded in entirely removing the mass, the whole process occupying upwards of an hour. Mrs. A. was then carried to bed after the uterus had been freely washed out with carbolized water, and the effects of the ether allowed to pass off. She vomited several times, pulse frequent and feeble. Brandy and water were given ad libitum and a hypodermic injection of morphia gr. ss. was administered. March 19, A. M.—Has passed a sleepless night notwithstanding the free use of brandy and morphia. Pulse, ninety-six; temperature, ninty-nine. Loathes food; perspires profusely; feels terribly sore. P. M.—Pulse ninety-six; temperature ninety-nine and a-half. Treat- ment—Quinine gr. iij ter in die; beef-tea and milk; morphia hypodermically and by the mouth in sufficient doses to procure rest. Three grains have been taken during the day.. March 20, A. M.—Pulse ninety; temperature one hundred; discharge slight and not so offensive as before operation; continued treatment. 10 T. GAILLARD THOMAS, The uterus is washed out twice a day with carbolized watei, by means of elastic catheter introduced quite up to fundus. P. M.—Pulse, eighty-five; temperature, ninety-nine and a-half; the discharge becoming more free and offensive, but not as much so as before operation. Rests tolerably; still sweats profusely in the morning. Without giving a detailed statement of the farther progress of the case, I will simply state that from this time Mrs. A. progressed favorably. Her profuse sweats gradually ceased; she soon began to crave food; the uterus soon subsided so as scarcely to be felt above the pubes. A few shreds of putrid matter were washed away by the injections, but the discharge soon ceased entirely, and in a short time the patient was sitting up, still feeble but apparently well, in much better health, at all events, than for several years past. The tumor, as nearly as could be estimated from the pieces, was about as large as a small cocoanut. Case 3.—Sub-mucus Fibroid. Sloughing occurring during effort to gain access to the mass. Death from septicaemia. Mrs. D., age unknown, but certainly not over thirty-five years; married nine years, the mother of two children, called upon me on the fifth of June, 1873, and gave the following history: For two years past, she has suffered from severe menorrhagia, the periods having lasted from eight to ten days, and been so excessive as to cause syncope and exhaustion. Upon her visit to me, she was very pale, suffered from severe palpitation and dyspnoea, and was much depreciated in health. Physical examination revealed the os externum firmly contracted and unyielding, and the uterus half way between the symphisis pubis and umbilicus, and somewhat anteverted. The sound passed five inches into the cavity with ease, and caused no hemorrhage. I at once put her upon the full and steady use of ergot by mouth or rectum; and to aid in dilatation of the cervix, ordered the use of copious vaginal injections of hot water, night and morning. In five or six months, under this course, with good diet, rest at menstrual epochs, and the use of hemostatics internally when hemor- rhage existed, Mrs. D. greatly improved in her general condition, but the cervix still remained closed, and the intra-uterine growth, which I felt confident existed, could not be touched, nor its attachments accu- rately ascertained. During this time I saw her very rarely, as she lived in Brooklyn, ENUCLEATION OF UTERINE FIBROIDS. 11 but I knew that she very conscientiously persisted in carrying out the plan of treatment which I had advised. On October 14, 1873, entered my service in the Woman’s Hos- pital, where the ergot was used hypodermically, and on two occasions the cervix was severed so as to allow the escape of the fibroid in the cavity of the body. On the 29th of December she was discharged, the cervix having so far yielded that the tumor could be readily touched by pressing the finger through the cervical canal. After this I heard nothing of Mrs. D. until , when I was sent for to see her by Drs. Skene and Otterson, who had been called to her on account of the development of grave septicsemic symptoms. I found the tumor sloughing, giving forth a most foetid odor, and the patient seriously affected by septic poisoning. She was quite delirious, the pulse was one hundred, and the temperature one hundred and six degrees. I at once proposed the entire removal of the putrid mass, which, being agreed to, I readily accomplished by enucleation. But systemic poisoning had become too profound to be thus relieved. Mrs. D. did not improve, and soon died. Had this patient remained under observation, or had she known the significance of the initiatory symptoms of septic poisoning, and sent for her physician in Brooklyn early enough, I think that she would have been saved. The next case will demonstrate how perfectly removal of a slough- ing tumor will sometimes put a stop to commencing blood poisoning. Case 4.—Sub-mucous Fibroid enucleated during the progress of septic fever. Recovery. Reported by Joseph D. Anway, M. D., House Surgeon, Woman’s Hospital, New York. Mrs. Mary R.,aet. forty-five, married twenty years, seven children, two abortions, youngest child ten years old, duration of illness five months; menstruation began when she was fifteen years’ old, always regular, no pain, amount always great, time always three or four days. The quantity lost has increased very much during the last two or three years. Physical examination,—Uterus is considerably enlarged. The sound passes to the left and backward five and three-fourth inches, seeming to mount up over something situated in the posterior wall. Diagnosis.—Sub-mucous fibroid situated in posterior wall. Retro- flexion. Treatment—Hot vaginal baths; Squibb’s fluid extract of ergot, half drachm twice daily. The uterus was put in the position of antever- 12 T. GAILLARD THOMAS, sion, and a Cutter’s retroversion pessary, with large bulb, was intro- duced. December 21st, uterus contracting; patient says she has bear- ing down pains after each dose of the ergot, which last four or five hours. January 6.—Has just finished menstruating. This time the Aoav lasted eight days, and the quantity lost was much larger than at any time previous. The ergot was increased to one drachm three times a-day. February 10.—Patient has again menstruated. The time was three days, and the amount the same. February 24.—She has gained in strength; appears much better in every way; uterus very hard. She is to remain in the hospital two weeks longer, and if there is then no change in the position of the tumor, she is to go home and continue the use of the ergot as she has done here. March 8.—Patient states that she has had several quite severe chills during the last four or five days, followed by fever and sweating. On examination, the os was found dilated so as to admit two fingers, and the growth presenting, which had already begun to slough, and the patient was showing some signs of blood poisoning; temperature one hundred three and a-half degrees. March 9.—The patient under ether; the cervix was divided on either side by Dr. Thomas, the growth seized by strong forceps and traction made. At the same time the tumor was enucleated by the finger and scissors, and removed. The patient was then put to bed, and ordered thorough washing out of the uterus every five hours. March 11, A. M.—Patient doing well; has not had a bad symptom since the operation. The discharge is quite copious, and has a very bad odor. None of it is allowed to remain for any length of time within the uterine cavity. Her appetite is much improved, and she is gaining generally. March 22.—Very little discharge; uterus now measures three inches in depth. April B.—Patient says she feels perfectly well. Uterus now measures two and three-quarter inches. Was to-day discharged. For the report of the fifth case I am indebted to Dr. Stephen W. Roof, of New York, with whom I attended it in consultation. Case 5.—Sub-mucous Fibroid removed by enucleation. Recovery. Mrs. S , aged forty years, married, has borne three children, the youngest fourteen years old. Has been in ill health for the past ENUCLEATION OF UTERINE FIBROIDS. 13 two years, complaining of neuralgic pain in head and face; aching, dragging pain in the back, pelvis, and lower limbs; loss of appetite, vomiting, dysmenorhoea, menorrhagia, and metrorrhagia. Vaginal touch and bi-manual palpation showed the uterus to be greatly anteverted, considerably enlarged, and quite tender on pressure. Suspecting an intra-uterine growth, I introduced sponge tents, and after dilating the cervix so as to admit the finger, could feel the lower portion of a hard, firm, rounded mass which was firmly attached to the posterior and right side of the uterine wall, above the os internum. The diagnosis of sub-mucous fibroid was made, and as the patient was not suffering very severely at the time; and as there had not been any dangerous hemorrhage, I did not deem an immediate operation justi- fiable. I accordingly advised the warm water douche to be used several times a-day to soften the cervix and render it more yielding, together with the internal administration of ergot, hoping to force the tumor through the external os, and then remove it by ecrasement. With this view I gave one drachm of fluid extract of ergot, which acted promptly, but so energetically that I was obliged to control the excessive pain by hypodermic injection of morphia. Shortly after this, my patient had a very severe attack of facial neu- ralgia, with vomiting, which lasted two days, and prostrated her very much indeed. At this time, Dr. T. G. Thomas saw her at my request, and after careful examination, fully concurred in the diagnosis, and advised a continuance of the treatment abovementioned, but the ergot to be given in smaller doses, and as soon as possible the tumor to be drawn down and removed. The ergot was given in twenty minim doses every two hours for four days, but as she was evidently becoming more and more pros- trated, Dr. Thomas again saw her, and an immediate operation was decided upon. On the morning of May 26th, the lady being thoroughly anaesthe- tized, was laid upon her left side, and the perineum elevated with a Sims’ speculum. The os was about three-fourths of an inch in diam- eter, in which the tumor was presented. The tenaculum was firmly hooked into the anterior lip and the uterus drawn down. The cervix was then divided on each side up to the vaginal insertion; the tumor was seized with the vulsellum forceps and an attempt made to draw it out of the uterus and encircle it with the wire rope of Braxton Hicks. Failing in this, a pair of fenestrated forceps were introduced, and a miniature instrumental delivery of the mass attempted, but so extensive 14 T. GAILLARD THOMAS, was the attachment, that no progress could be made. It soon became evident that enucleation was the only means by which the tumor could be removed, and this difficult procedure was done by Dr Thomas, in the following manner: The mass being firmly held by the vulsellum forceps, a pair of scissors curved on the flat were introduced, and the capsule divided, then portions of the mass were peeled from their bed in the uterine wall by the fingers, and cut away with curved scissors. The operation lasted one hour, and the mass, when removed, weighed four ounces. The hemorrhage was trifling, but the shock severe, and continued three hours before reaction was fully established. Intra-uterine injections of carbolic acid, one drachm to a quart of water, were ordered every twelve hours, and were carried up to the fundus in the following manner. A hard rubber nozzle of a posterior nasal syringe, about the size of a lead-pencil, was warmed in the flame of an alcohol lamp, and its shape altered so as to correspond to the axes of the uterus and vagina, this was attached by a piece of rubber tubing to the nozzle of a Davidson’s syringe, through which the injec- tions were safely and thoroughly made. The external genitals were covered with a mass of cotton batting, which had been soaked in a strong solution of carbolic acid and afterwards dried; and quinine given in doses of six grains morning and evening. On the morning following the operation, the patient’s pulse was one hundred and twenty, temperature ninety-nine, respiration twenty- four; had passed no urine since the operation. The catheter was in- troduced and the urine drawn, after which the intra-uterine injection w-as given. This was followed, in half an hour, by a violent chill which lasted an hour and a-half, followed by slight febrile reaction and pro- fuse perspiration lasting through the night. At half-past six this evening, my notes show temperature one hundred and one and one- quarter, pulse one hundred and forty-six. The chill was successfully combated with hot bottles to feet and back, and a glass of hot spiced rum punch, with eight grains of quinine. From this time the quinine has been continued in eight grain doses every twelve hours, the intra- uterine injections made morning and evening, and she has steadily improved without a single untoward symptom. ARCHIVES CLINICAL SURGERY, EDITED BY EDWARD J. BERMINGHAM, M. D. Subscription, $4.00 per annum. invariably in advance. This is a monthly periodical devoted to surgery, which includes all its special departments, as Gynaecology, Dermatology, Laryngology, etc.; and consists of original clinical papers by representative men. There is also a special department for a synop- sis of the interesting surgical cases and operations in the larger hospitals throughout the country, of which we hear so little. A public record of these is thereby kept, which is of inestimable value to those interested in the progress of surgery; as it provides them with a key to the books of the several hospitals, where the complete history of any particular case may be obtained. It will thus be seen that the Archives covers a field hitherto untouched; at the same time it seeks to furnish to the profession entirely original matter of the best quality, and at a moderate price. It has received the unqualified endorsement of most of fie hospital surgeons and teachers, and they have, with hardly a single exception, given it their earnest support. It is but necessary to refer to our list of contributors on the second page of cover to attest the character of the publication. The Journal is issued on the fifteenth of every month. Each number contains not less than forty pages, printed from new type, on heavy calendered paper of the finest quality. Manuscripts, exchanges, etc., should be addressed to the Editor, 102 West Forty- Ninth street, New York City; business communications to the Publishers. Remit- tances should be made by draft, postal money order, or registered letter to RUTLEDGE & CO., Publishers, 102 West Forty-Ninth Street, NEWYORK CITY.