Should this operation be insufficient, we proceed next to incision of the mucous membrane covering the tumour. The purpose is twofold. (1.) It checks hæmorrhage. We have referred to the existence of venous sinuses in the capsule of the tumour, from which profuse hæmorrhage sometimes occurs (v. fig. 246); when these are cut through, they retract and are closed by thrombi. After this operation the hæmorrhages are, for a long period at least, checked. (2.) It favours spontaneous enucleation of the tumour, which comes to protrude through the incised mucous membrane.

The mucous membrane is incised either with the bistoury or with the thermo-cautery as follows. Carry a probe-pointed bistoury, which has the lower half of the blade sheathed, into the uterus through the previously dilated cervix; make one or more incisions, about an inch long and from a quarter to half-an-inch deep, upon the surface of the tumour. The great danger of the operation is the introduction of septic matter; to diminish this risk, Greenhalgh employs the actual cautery with an olive-shaped bulb to incise the mucous membrane and at the same time to destroy the heart of the tumour; he also uses it to burn away, from time to time, portions of the tumour as they protrude through the capsule.

It is evident that the cautery can be used only when we have an interstitial fibroid which has forced itself into one lip of the cervix and projects markedly into the roof of the vagina (v. fig. 244); or when a submucous fibroid has dilated the os sufficiently to become accessible to the cautery. The cautery, of which the Paquelin is the most convenient form, reduces the dangers of hæmorrhage and septic infection to a mini

mum.

The separation of the tumour should be left to the natural efforts, and may extend over a period of months; during this time, to promote uterine contractions, the patient is kept fully under the influence of ergot. Greenhalgh remarks that " spontaneous expulsive efforts shortly followed the use of the cautery."

Should sloughing of the tumour occur during the process of natural enucleation, we interfere to remove the tumour rapidly. Even although there is no sloughing it is sometimes necessary to shell the tumour out of its bed.

The detachment of the tumour from its capsule may be effected by A. R. Simpson's nail curette (fig. 249). It is intended, as its name implies, as a substitute for the finger nail which would be the best instrument were it only strong enough to scrape through the tissues.

Thomas has devised a similar instrument which has the form of an

elongated spoon with a serrated edge (fig. 250); it is worked with a pendulum-like movement of the hand. The advantages claimed for it

Fig. 249.

A. R. Simpson's nail curette, 14 (A. R. Simpson).

are that it limits hæmorrhage and, from its concave form, 'hugs the tumour' so as not to cut deeply into the uterine wall. Before operating,

Fig. 250.

Thomas' spoon-saw (Thomas).

he measures with a whalebone probe the extent of attachment of the tumour to the wall of the uterus.

He has operated more than twenty times with this spoon-saw, and its efficiency becomes more and more apparent with increasing experience.'

Marion Sims employs the enucleator represented at fig. 251, and operates as follows. The tumour is drawn down to the os uteri ; the cap

Fig. 251.

Side-view (to show curve) and face-view (to show cutting edge) of Marion Sims enucleator (Marion Sims).

sule is incised with scissors, and detached as far as possible with the fingers; the enucleator is passed in between the tumour and its capsule, and worked round the former so as to free it on all sides; a tumourhook is now hooked deeply into its substance, with which it is dragged down while the enucleator is used to sever any remaining connections; when necessary, the os is incised to allow it to pass.

C

Fig. 252.

Sir James Simpson's volsella for seizure of utra-uterine fibroids-two-thirds size. The blades are separable, and lock like a pair of midwifery forceps; after being locked, the blades are fixed with a screw-pin which serves as a joint (A. R. Simpson).

When the tumour has been so far enucleated, spontaneously or by the artifical means described, the extraction of it is often difficult on account of its size. When it projects into the vagina, we lay hold of it with large volsella (fig. 252) and make traction while the hand is passed up to the base of the tumour to sever any connection between it and its bed. The fundus uteri is at the same time pressed down and steadied by an assistant. In the case of large tumours, midwifery forceps are used for extraction. To allow a tumour of large size to be extracted, it may be necessary to divide it with scissors or the ecraseur and remove it in portions; we may even require to incise the perineum, if the vaginal orifice be small.

Thus with regard to enucleation and removal per vaginam, it is evident that, from the risks of the operation, we should interfere only when the severity of the symptoms justifies a dangerous operation or when nature is unable to complete the process of expulsion. The circumstances most favourable for removal by this means are when the tumour is small and loosely connected with the uterus, or when it has been already 'born' into the lax and roomy vagina of a multipara.

b. REMOVAL THROUGH THE ABDOMINAL WALLS BY LAPAROTOMY. This operation is of recent date, and medical opinion with regard to it is in the same state as it was in regard to ovariotomy twenty years ago. Although operators have had the experience of ovariotomy to fall back upon, the mortality is as yet 50 per cent. On the other hand we must remember that, as fibroid tumours do not endanger life in the same way that ovarian tumours do, the operation for their removal, being apparently associated with so much more danger, is only had recourse to in extreme that is in unfavourable cases. Whether the removal of fibroid tumours by laparotomy will in the future take the place that ovariotomy has at last gained for itself, we are not in a position to say. The fact that these tumours threaten the life of the patient only in exceptional cases makes this improbable. In reporting some cases of successful operation to the London Obstetrical Society in April 1880, Knowsley Thornton says that he believes that the removal of uterine fibroids by laparotomy is not only justifiable, but is an operation with a position in the immediate future in no way second to that now held by ovariotomy.'

The merits of the operation cannot be judged from statistics, because each operator has tried a different method. Statistics enable us rather to compare the success of different methods of operating than to decide on the merits of the operation itself.

up to Nov.
Dec. 1878,

The following table gives the results of the leading operators.

Pean,1

Spencer Wells,2

1879, had operated 46 times with 30 recoveries.

From the above table two things are evident: (1) the mortality from the methods taken together has been great (45 per cent.); (2) the results from Hegar's method, to be presently described, are remarkably successful (mortality 8.3 per cent.). The number of cases (twelve) is not great; it remains to be seen whether this method will be equally successful in other hands.

Under laparotomy we include (1) the removal of pediculated subserous fibroids in which the uterus is left untouched, and (2) the amputation of a portion of the uterus along with the tumours. The ovaries may or may not be removed at the same time. When a portion of the uterus is cut away, it is necessary, should the operation be during the period of sexual activity, to remove the ovaries; fatal hæmorrhage has occurred when they were left, and even abdominal conception and pregnancy.

The operation may be divided into three stages;-(1) the opening into the abdominal cavity, (2) the diminution of the size of the tumour and its extraction, (3) the treatment of the stump.

1. The opening into the abdominal cavity is made just as in ovariotomy (v. Chap. XXII).

2. The diminution of the size of the tumour is necessary when it is so large that it cannot be projected through the abdominal incision.

When the tumour is cystic, it is diminished by puncturing the cysts before extraction. Large solid tumours are diminished by gouging out portions, which is often accompanied with considerable hæmorrhage. Pean diminishes the size of such tumours by 'morcellement': the

1 Académie de Méd.-Séance, 18 Nov. 1879.

2 Brit. Med. Journ., May and Dec. 1878.

3 Cited by Hegar and Kaltenbach-Operative Gynäkologie, S. 419.

4 Gusserow-Neubildungen, etc., S. 90.

5 Krankheiten der weiblichen Geschlectsorgane, S. 244.

6 Die operative Gynäkologie, S. 420.

7 London Obs. Trans., April 1880.

8 Diseases of Women, 1880, p. 551.