Oedema in the tumors, especially the soft variety, is not unusual, and inflammatory attacks often occur. The latter probably originate, not in the tumor, but in its peritoneal covering or mucous capsule.

Interstitial or mural fibroids are situated entirely within the muscular walls of the uterus. These may push out into the abdominal cavity and become sub-serous, or into the uterine and become sub-mucous. The latter usually have a distinct root or pedicle, but may be entirely extruded and covered only by mucous membrane. Cases 3 and 4 illustrate these two varieties. Now, when these sub-mucous fibroids begin to be extruded into the uterine cavity, they act as does any other foreign body in that locality, and set up muscular contractions in its walls. They are thus forced in the direction of the least resistance, into the cervix. Should the pedicle be a strong one, and of high attachment, the uterus may thus be inverted by its own efforts. This procedure has been dubbed "the birth of the polypus."

For

Increased depth of the uterine cavity, and marked displacements of its body are common results of fibroid growths. The canal of the uterus shows these various flexions, as well as the protrusion of the various nodules into its lumen. these examinations I have found the Jennison's sound very useful, but all sounds must be used with the utmost caution in these cases, as injuries of the delicate capsule may lead to a sloughing of the tumor later on from interference with its

nutrition.

The sub-serous variety may reach a considerable size before any symptoms are apparent, as they have much space in which to develop. And in this connection a point worth remembering is the tendency which they have, in their upward growth, of drawing the uterus up with them, greatly lengthening its cavity at times. The cervix may thus be pulled beyond the reach of the examining finger. On the other hand, if the tumor is small and the pedicle a long one, the bunch may be found low in the cul-de-sac, while the

This variety

original attachment is high up on the fundus. often becomes immovably wedged or adherent, and very troublesome. It is very easy to mistake an adherent fibroid, in this location, for a sharply retro-flexed uterus. Here the sound and the rectal examination will clear up the condition. The cervix, too, may be the seat of origin of either submucous, sub-serous, or mural fibroids, and they are apt to be an especially troublesome variety, particularly in case of pregnancy. They do not have to grow very large at any time, before pressure symptoms appear. When sub-mucous, they push readily into the vagina, and if large, even through the vulva, and are liable by their weight to pull the uterus well down. The bunch must not be mistaken for a. prolapsed or inverted uterus, a blunder which has frequently been made. It may be of interest to note here that the opposite error has been made, and an inverted uterus cut off for a polyp. The patient recovered!

So long as the interstitial or sub-mucous tumors remain small, the only change that we may be able to detect in the feeling of the uterus, will be a slight enlargement and more globular form, and some increase in consistency. We thus have a condition at this stage which presents the picture of chronic metritis. When the tumor is located near the os, the vaginal portion of the os is much shortened as a rule. The direction of the cervical canal may help us to locate our tumor in these cases, as the growth occupying one lip, will naturally push the opening towards the opposite side. Evacuation of the bladder with a catheter will prove a help where extensive examination is to be made. It must be remembered, too, that fibroma may be located in the bladder wall itself, and closely simulate an ante-verted uterus. I have recently seen such a case, where the fibroid was three inches in diameter, and apparently had never had any uterine attachment.

I promised a word more about Case 2. She pursued a perfectly normal course for eight days, her temperature and

At this

pulse never reaching over 99 and 85 respectively, after the extirpation. She slept well, ate heartily, and the bowels and kidneys were working well. On the eighth morning following the operation she took a glass of milk at 7 A. M., at which hour she waked from a perfect night's rest. At 7.05 she called for the bed pan and had a natural stool. time she joked and laughed with the nurse, and expressed herself as feeling well. At 7.15 a nurse passing her door heard heavy breathing, entered, and found her unconscious. At 7.20 she was dead. One pupil was widely dilated and one contracted, and the face was drawn to one side.

Evidently a cerebral embolus had done its work suddenly. Friends of this patient informed me after her death, that she had suffered from a "shock" and paralysis of one side seven years ago, and had entirely recovered. She made no mention of this fact, either to me or to the house physician, and there was nothing in her condition to show it. We both made careful physical examinations before suggesting anæsthesia. The possible connection between this cerebral clot and the sudden stopping of her previous hæmorrhages by the operation, may be a profitable field to speculate in, but I firmly believe that she would have died without the operation, and that it in no way influenced the date of death. Nevertheless, a spirit of fairness compels me to report failures as . well as successes.

SCLERODERMA,

BY JOHN H. URICH, M. D., BOSTON, MASS.

The word is partly of Greek and partly of Latin origin -hard, dry, and derma, skin.

Skloros

Scleroderma is usually described by neurologists and dermatologists, but the diffuse form is perhaps more frequently seen by the general physician whom the victim consults for rheumatism or disability. The disease is fortunately rare.

The pathology of the disease is fully discussed in the works. on dermatology, yet we know really nothing of the essential causes, and the data are not yet at hand upon which a satisfactory theory can be based. The disease is variously regarded as a tropho-neurosis dependent upon changes in the nervous system; a perversion of nutrition analogous to myxedema, due to disturbance of the thyroid function; a sclerosis following widespread endarteritis. The first of these theories is the one most generally held.

SYMPTOMS.

Rheumatismal pains and cutaneous sensations of tingling, pricking and formication, muscular cramps and neurotic sensations may precede the outbreak of the disease. There are two stages characteristic of this disease: The period of infiltration, where the oedema is firm, involving the subcutaneous tissue, and at first pitting, upon strong pressure, with finger, but later becoming so indurated and tense as hard leather. The face is expressionless. The lips are opened with difficulty. The chest, shoulders and arms are either immobile or movable with great difficulty. The abdominal surface is seldom attacked. This condition may come on very insidiously, and may require months or years for its full development, or the progress may be rapid. The upper extremities are sometimes so affected that the fingers resemble curved talons. The helplessness of some patients is so extreme that they require to be dressed and fed, even when they can travel with relative comfort.

The second or atrophic stage: The cedematous or infiltrated areas undergo induration and contraction. The skin becomes more tightly drawn over the underlying structure, and becomes dry, scaling, fissured, or ulcerated; muscles waste considerably. The teeth may fall. The fingers may be permanently flexed into the palm, or forearm on arm. Patient who may have enjoyed a fair degree of health, now suddenly experiences rheumatical pains and neuralgias, ma

rasmus takes place, which frequently ends fatally with renal, cardiac, or pulmonary symptoms.

Miss B., age 52.- Father died at 79 of apoplexy. He was in active business during greater portion of his life, but was almost totally disabled from muscular rheumatism.

brother

A

the only other member of family — has rheumatic Two of father's brothers still living disabled from same disease.

gout.

Mother's family very intellectual.

Mother died of a

disease similar to the one to be described.

PERSONAL HISTORY.

I knew this lady personally for about twelve years, and excepting occasional attacks of rheumatism and neuralgia, she apparently enjoyed most excellent health. Her weight was 185 pounds; florid complexion. She said many times. during her final illness that she never knew what sickness. She was inclined to worry a great deal.

meant.

were no

PRESENT ILLNESS.

Although her declining health covered a period of about four years, during two and one-half years of this time, there particularly marked symptoms indicating any alarming condition. The most prominent indication of failing health was the gradual emaciation, yet so insidious was this condition that instead of causing fear on the part of patient, she was somewhat delighted to think that she was becoming reduced in flesh, in many respects feeling more comfortable. The only other noticeable feature during these two and onehalf years, were the more frequent attacks of neuralgia and rheumatism, usually confined to left shoulder and right hip.