Extra-uterine gestation presents great difficulty in diagnosis, but we delay its consideration till the chapter on that subject (v. Section IX.). In hæmatocele and inflammatory deposits we have the history of the attack to guide us. It may be impossible to form a diagnosis on first examination; but after watching the case for a few weeks and noting any change in the deposit in addition to ascertaining its precise situation, we can form a diagnosis. Pelvic peritonitis frequently occurs round a subperitoneal fibroid, or any fibroid producing pressure; and in such a case it is impossible to diagnose between the tumour and the effusion round it. Many cases reported of gradual absorption of a fibroid tumour under treatment, were probably cases of mistaken inflammatory exudation. PROGNOSIS. In forming our prognosis we must take into account (1) the site of the tumour in the uterus, most favourable when subserous; (2) its position in the pelvis, whether low down and likely to become wedged within it; (3) the symptoms already present, of which hemorrhage is the most important. Though (as already said) they are rarely dangerous to life, they may cause the patient many years of suffering, from which she only finds relief at the menopause. CHAPTER XXXV. FIBROID TUMOURS OF THE UTERUS-TREATMENT. LITERATURE. Atlee-The Treatment of Fibroid Tumours of the Uterus: Internat. Med. Cong. Trans., Sept., 1876. Duncan, Mathews-Clinical Lectures: London, 1879, p. 158. Greenhalgh-On the Use of the Actual Cautery in the Enucleation of Fibroid Tumours of the Uterus: London Med. Chirurg. Trans., Vol. LIX. Hegar u. Kaltenbach-Die operative Gynäkologie: Stuttgart, 1881, S. 416. Leblond-Traité élémentaire de Chirurgie gynécologique: Paris, 1878. Palmer-Laparotomy and Laparo-Hysterotomy, their Indications for Fibroid Tumours of the Uterus: Americ. Gyn. Trans., 1880, p. 361. Simpson, A. R.—The Treatment of Fibroid Tumours of the Uterus; Contributions to Obstetrics and Gynecology, Edinburgh, 1880. Sims, MarionOn Intra-uterine Fibroids: New York Medical Journal, April, 1874. Wells, Spencer -British Medical Journal, May and December, 1878. See also references in the text. THIS is best considered under the heads of medical and surgical treatment. A. MEDICAL TREATMENT. There is no medicine which acts immediately upon fibroid tumours so as to cause disintegration and absorption. We have, however, a very important remedy in ergot of rye; the beneficial effects of this have been brought forward by Hildebrandt,' and by A. R. Simpson, whose paper on the treatment of fibroids may be consulted for illustrative cases. It acts beneficially in two ways-by checking their nutrition through diminishing the amount of blood circulating to them, and by favouring their pedunculation and expulsion; these are both due to its action on the unstriped muscular fibre of the walls of the uterus and coats of the blood-vessels. Success in its use depends, according to Simpson, on securing that the preparation of ergot used be active, that it be properly administered, and 'Berlin. klin. Wochenschrift, 1872, No. 25. that the case be a suitable one. The formula for the preparation which he recommends is— R. Ergotinæ... M. Aquæ.... 3 ii. 3 vi. 3 ss. Three grains of ergotin are contained in twelve minims of the fluid, which is a good medium dose. Chloral is added to make the solution keep; but even with this it becomes after some weeks unfit for use, and should therefore be made up repeatedly and in small quantities. It is administered with the ordinary hypodermic needle. Care must be taken that the syringe contains no air: this is best secured by holding it with the needle upwards and squirting out some of the liquid. The injection is made in the gluteal region, which is readily done when the patient is lying on her side, and on the right and left sides alternately, so as to diminish the frequency of punctures in the same region. Enter the needle vertically and plunge it rapidly deep into the muscle, the point entering to the depth of from an inch to an inch and a half; now empty the syringe, and quickly withdraw the needle. After use, remember to cleanse the needle with water and to replace the wire in it. The patient soon becomes accustomed to the prick of the needle, and, if it be entered deeply into the muscle, there is little fear of local suppuration; after three years* experience we have seen this in but one case, and this was probably due to a bad preparation of the solution. For the first few weeks the injections may be made twice a week, afterwards only once a week. The treatment is continued for several months until its effect is seen in diminution of the size of the tumour or, at least, of the hemorrhage from it. The suitable cases are those in which the tumour is intramural or submucous; "it must be surrounded by layers of muscular fibre, sufficiently developed to be capable of being excited to contraction." When the patient cannot be seen frequently by a physician, a friend or a nurse should be instructed how to apply the needle. Ergot can also be administered in the form of pill, suppository (4 gr. in each), or liquid extract (30 drops thrice daily). When given by the mouth, however, it does not act so quickly or surely as when given hypodermically. Bromide of potassium was recommended by Sir J. Y. Simpson, who believed that it had a marked influence in checking the growth and even in reducing the size of fibroid tumours. It is impossible to say whether, in cases where the tumour diminished in size during its administration, this result was due to the bromide. As a prolonged use of the bromide is generally necessary, small doses (ten grains, three times a day) should be administered. Being a nervine sedative, it is useful to give it in cases where the only symptoms are discomfort from the presence of the tumour or neuralgic pain. Should the tumour be increasing in size, or should there be much hemorrhage, we must have recourse to ergot. When the patient can afford it, benefit is undoubtedly derived from a course of treatment of mineral waters (such as those of Kreuznach) as recommended for chronic metritis. The symptoms due to the weight of the tumour may be relieved by artificial support. Thus patients with a small fibroid often derive great. benefit from wearing a Hodge pessary; the discomfort of a large abdominal tumour is materially lessened by wearing a broad flannel bandage. When the tumour nearly fills the pelvis and is beginning to press injuriously upon the bladder and rectum, we should, when possible, push it up out of the pelvis into the abdomen; this is done before the occurrence of pelvic peritonitis, which may hopelessly bind it within the pelvis. The most favourable case for this manipulation is a subserous fibroid with a distinct pedicle. B. SURGICAL TREATMENT. This consists in the removal of the whole tumour or portions of it through the vagina, or through the abdominal walls. a. REMOVAL THROUGH THE VAGINA. We have seen that this process takes place spontaneously, either by pedunculation and extrusion as a polypus or by enucleation. In operating, we simply favour these natural processes. The former will be described under "Treatment of Polypi" (see next chapter). We favor enucleation of the tumour (1) by dilating or dividing the cervix uteri; (2) by incision of the mucous membrane covering the surface of the fibroid; (3) by stimulating the uterus to contract and expel it spontaneously from its bed, or by laying hold of and forcibly detaching it. These might be considered either as different consecutive operations, or as successive steps in the same operation.' 1 Mathews Duncan Edin. Med. Jour., Feb., 1867. The dilatation of the cervix is effected by sponge tents or a bilateral incision with the scissors; incision with the thermo-cautery, as practised by Thomas, reduces the risk of hemorrhage and septic infection. Sometimes this is all that is required. After the division of the cervix, the hemorrhage (which is usually the indication of the operation) ceases; if the tumour is in the process of expulsion, this takes place more readily through the dilated cervix. Even diminution of the size has been observed after the operation, though there is no explanation of how this occurs. Should this operation be insufficient, we proceed next to incision of the mucous membrane covering the tumour. The purpose is twofold. (1.) It checks hemorrhage. We have referred to the existence of venous sinuses in the capsule of the tumour, from which profuse hemorrhage sometimes occurs (v. Fig. 246); when these are cut through, they retract and are closed by thrombi. After this operation the hemorrhages 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 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. great danger of the operation is the introduction of septic matter; to diminish this risk, Greenhalgh employs the actual cautery with an oliveshaped 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 hemorrhage and septic infection to a minimum. 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." |