The varieties are: (1) Sub-peritoneal, which are pedunculate or sessile. (2) Interstitial. (3) Sub-mucous, which are pedunculate or sessile. (4) Fibromata of the round ligament. (5) Fibromata of cervix, which may be within the broad ligament or upon the external os.

The complication of pregnancy in the fibromatous uterus is grave, and not as rare as is supposed, as it is well known that sterility or early abortion is regarded as almost constant sequellæ of this condition. Pregnancy rarely complicates the sub-mucous variety, occasionally the interstitial, but does complicate the subperitoneal variety with comparative frequency, as is shown by different observers. Gueterez states that of 295 myomatous women, 51 became pregnant, or about 17 in every 100. Durkee, quoted by Howard Kelley, makes the proportion only 2.03 per cent.

I can not coincide the wide difference in the statistics of these two surgeons; but it is an established fact that many myomatous uteri carry their pregnancies to term and are delivered without difficulty. The myomata in these cases are generally of the pedunculated, sub-peritoneal variety.

The consensus of surgical opinion is, and my own observation bears this out: that small myomata situated upon any portion of the uterine body do not generally interfere with normal pregnancy and delivery, if they be of the pedunculate variety.

It is also the consensus of opinion that sessile myomata will produce abortion, though I have observed two; one, quite the size of an egg, neither of which interfered with pregnancy or parturition.

If the tumor is situated upon the lower third of the uterine body or upon the cervix, and is of any size, prompt intervention is demanded; first, because the progress of pregnancy will most probably be interrupted; second, should pregnancy progress to term, descent of the uterus into the pelvic cavity will be seriously impeded, and there will be a serious mechanical obstruction to delivery.

Before referring to myomectomy it is only proper that the other methods of intervention, which have been resorted to in this condition, should be mentioned. Susserot, out of 147 pregnancies complicated by fibroma, says that forceps were applied

in 20 with the result that 8 mothers and 15 children succumbed. Version was performed in 20, of which 12 mothers and 17 children were lost. In 21 cases it was necessary to artificially extrude the placenta, of these 13 mothers died. Collectively the maternal mortality was 53 per cent., and that of the children 66 per cent.

The other obstetric operations which have been suggested are: (1) Artificial miscarriage. (2) Premature artificial delivery. (3) Craniotomy and cranioclasty. (4) Cæsarian section. These all have for an end the emptying of the uterus, without attacking the tumor, and should, therefore, be termed paliative procedures. The radical operations have a double end in view-emptying the uterus and extirpation of the fibroid.

Vaginal enucleation may be practised in the cervical variety projecting into the vagina. If at term, or the fetus is viable, and delivery is impossible or even improbable, Hysterectomy, Porro-Cæsarian section, or simple Cæsarian section with removal of ovaries, have been suggested. It must be conceded that in the gravest of the fibromatous conditions, hysterectomy is indicated, but the procedure, which appeals to me as both rational and conservative, would be Cæsarian section and myomectomy in a majority of cases.

Formally Porro's operation, or complete hystorectomy, was the method used in dealing with all pregnant myomatous uteri, irrespective of viability, location, or character of tumor. The excuse for these methods has been that violence done the uterus in the performance of myomectomy and the consequent uterine contractions, is nearly always followed by abortion.

Statistics extending over more than twenty years, or from the birth of aseptic surgery to the present day will not give foundation for this belief.

R. H. Turner, of Paris, in a monograph published in 1900, gives the following statistios of myomectomy during pregnancy.

Between the years of 1874 and 1890, thirty-three of these operations were reported with 61 per cent. fœtal mortality, and 36 per cent. maternal mortality. But between the years 1890 and 1900 the reported operations are forty-four, with only 21 per cent. foetal and 9 per cent. maternal mortality.

Of the 79 per cent. of pregnancies in the latter series, or

children who survived the operation, twenty-five went to term, two went to eight and one-half months, three to seven and onehalf months and three are reported as having continued, the results of two of these three is uncertain.

From January 1900 to the present time I can find but six cases of successful myomectomy during pregnancy, including the one I am about to report. Doleris reports a large pedunculated myoma with recovery. Lewis reports removal of sub-peritoneal fibroid followed by normal delivery. Muir Evans reports removal of pendunculated myoma, the case was in the eighth month and doing well when reported. Gemmel reports the removal of three myomata in early pregnancy with delivery at term. Emmett reports the removal of nine sub-peritoneal myomata with delivery at term.

The case which I will report gives the following history: E. H., age 28, admitted to Nashville Hospital May 3, 1901. Family history: Father dead, cause unknown. Mother living, has chronic rheumatism. One brother living.

Clinical history: Menstruated at 15, married ten years, sterile. Had always menstruated regularly and was in good health until January of this year, when she fell from a car and hurt her left side. Missed February, March and April menstrual periods; has suffered great pain in left side since; painful urination and defecation. January 30th she claims to have felt mass in left side.

When admitted she had been confined to bed one week; great tenderness and pain over abdomen; exaggerated in left iliac fossa. Constipated, pulse 108, respiration 72, temperature 99.3°. Examination under anæsthesia.

Inspection.-Irregular mass in left lower quadrant of abdomen, linea niger present, breast plump, secondary areola.

Palpation.-Serum expressed from breast; hard, irregular mass extending to costal margin in left axillary line, freely movable latteraly and downward, irregular mass in right lower quadrant of abdomen extending to level of umbilicus, movable laterally; deep sulcus outlined between right and left masses.

Percussion.-Left lower quadrant dull except over colon, left upper quadrant dull in posterior half, normal anteriorly. Right lower quadrant and right upper quadrant normal.

Auscultation.-Negative.

Digital Examination.-Cervix closed, long, soft, except upon posterior lip where there was an apparent slight fibroid condition. No mass in pelvis, fundus of the uterus not palpable.

Diagnosis. Multiple fibroid with pregnancy or uterus bi-cornis with pregnancy.

Operation.-Abdomen opened May 6, which revealed a preg. nant uterus at about three and a half months, with two sessile fibroids upon the anterior portion of the fundus. The uterus was grasped with hands and delivered through incision. The viscera being protected with flat gauze sponges, and the uterus covered with hot sterile towels.

Enucleation of the smaller tumor (the size of an orange) was now accomplished by making eliptical incisions of peritoneal covering of tumor, separation of peritoneal flaps and separation of tumor from its uterine attachment. Considerable hemorrhage was present, which was controlled by deep mural silk sutures. The peritoneal flaps were closed with intestinal silk by continuous suture. The larger tumor (the size of a baby's head) was enucleated in the same manner. The base was larger than anticipated, and in approximating the flaps it was found that approximation could not be accomplished. An area of uterine muscular fiber, 2 inches by 1 broad, being exposed. This area being on the anterior surface of the fundus, convinced me if left exposed, fixation to the anterior abdomimal parietes would take place, which would interfere with the ascent of the uterus during pregnancy, also with subinvolution after delivery.

A bit of omentum was therefore amputated and grafted over the exposed surface. I might state here that the reason for omental amputation was, the omentum was short and I feared enteroptosis when subinvolution was complete.

The abdomen was closed; operation consuming one hour with closure of incision, which extended some two inches above umbilicus. Patient put to bed in good condition.

Post-Operative Treatment.-The usual post-operative abdominal treatment was carried out, with the following precautionary additions. Morphia, and atropia grain were given hypodermatically one hour after patient came from operating room. Chloral hydrate, grains 10 by rectum, twelve, sixteen and twenty hours after operation. Morphia, grain on the following day.

Chloral hydrate by rectum, 30 grains, on second and third days, and ten grains on the fourth day, and morphia grain on the sixth and seventh days to control some suspicious abdominal pains.

Patient made an uninterrupted recovery and was allowed to sit up at the beginning of the fifth week. At the beginning of the sixth week, some abdominal pains, apparently uterine, were exhibited, and she was put to bed and given morphia. These pains were only transient, however, and she was discharged on the beginning of the seventh week in good condition.

Patient was observed during gestation, her condition remaining good.

She declined to return to the hospital for delivery but went into labor at 5 A.M. on October 15th, and after an uncomplicated and uneventful labor was delivered of a 71⁄2 pound girl at 12 M. of the same day. Uterine contraction was good, I might say unusually good. Mother and child both doing well at present time.

The only features in the above which I regard worthy of especial notice are: 1st. The preference of myomectomy to Porro's operation or total hysterectomy at all stages of pregnancy, especially before viability of the child; the former has a maternal mortality of 9 per cent., the latter of 20 to 30 per cent. The former a foetal mortality of 21 per cent., the latter a complete destruction of fœtus before viability and a large mortality afterwards. The former I regard as the acme of conserv. ative surgery, the latter the extreme of radical surgery. 2nd. The careful handling of the uterus and its constant protection with hot towels. 3rd. The precautionary use of the uterine sedatives in the post-operative treatment.

THE EMPLOYMENT OF SOLUTION ADRENALIN CHLORIDE AS A HEMOSTATIC IN SURGICAL PROCEDURES.

BY CHARLES F. SAUTER, m.d., new ORLEANS, LA.

I have recently used Solution Adrenalin Chloride as a hemostatic during operation in three of my cases. Its effect in con