Finding
Thisis most important, as, if it be left till the greater portion has become loosened from its attachments, there is danger of disintegration of the loosened tissue, and of consequent blood-poisoning.
Paper
Clinical Memoranda
Abstract
viz., that of compression and expulsion; the former, compression, diminishing the vascularity of the primary albuginous or sarcomatous state, and converting it into inert fibro-cartilaginous, cretaceous, or osseous matter, thus effecting that change in the disease from a soft erectile, easily congested or inflamed, and growing or active tissue, into that dense and more compact and less organised structure which is not so capable of congestion and inflammation. This condition constitutes its passive form, usually observed after the cessation of menstruation, when (following years of suffering, the consequences of uterine irritation, inducing haemorrhages and sympathetic or reflex pains and distress) a state of cood health often follows, interrupted only, as far as the fibroid is concerned, when by mechanical irritation it incommodes adjacent organs. Of all the means of relieving such secondary annoyances, parietal support is the most eligible, to procure which the "pelvic band" is by far the most effective means. Medicinally, ergot of rye with borax, the application of cold externally, by compress or otherwise, and pcr vaginam by douche, with mineral acids and astringents, the recumbent posture, the pelvis being kept above the level of the heart, and a high and dry situation, will be found amongst the most effective remedies. To aid expulsion there is nothing like ergot of rye and borax, taken in doses of from fifteen grains to thirty of the former to five of the latter. When enucleation of a large mass is attempted, the most dependent portion should bc renmoved as soonas possible after it becomes detached from the uterine wall. Thisis most important, as, if it be left till the greater portion has become loosened from its attachments, there is danger of disintegration of the loosened tissue, and of consequent blood-poisoning. To accomplish the enucleation of a large intramural fibroid, the cervix uteri, when it is required to expose the disease, should be incised laterally throughout its entire length on both sides ; after which it is easily dilated by sponge-tents, and by the fingers or hand, and the swelling may then be gradually peeled off from the walls of the uterus by repeated efforts, as the patient is able to bear it-always removing, by ligature or otherwise, from time to time, such portions of the disease as may come within reach. To do so, I prefer, as a rule,the ligature applied by Gooch's cannula to the ecraseur, because during the process of separation there is always an attempt on the part of the womb to expel the disease, and at the same time to keep dilated and open the os tincze and cervix, thereby rendering future operations more easy than when the piece is at once cut off and the remainder retires withini the embrace of the uterus. When the chief bulk of the disease has been removed, the remaining portion is usually absorbed, and the cure is completed, as shown in the case above quoted. Passing by the considerationi of recurrent and fibrocystic disease, I would call attention to fibroid degeneration of the cervical portion of the uterus. This perhaps is, if not the most frequent, a very common form of the disease-often, I believe, mistaken for tVongc,meent, or uterocervical areolar hyperplasia, simple induration, and even for carcinoma. The microscope, and a more attentive investigation of the subject, will, I think, confirm the conclusions to which observations extending over a period of thirty years now enable me to make the following brief and concluding remarks. There is scarcely any condition of the uterus which is accompanied by more distressing symptoms and disorders than that under consideration. It may be shortly described as presenting usuially an increase both in bulk and length of the cervix uteri, which becomes much firmer and often nodulated, the nodules being generally more indurated than the surrounding tissae; the os is patulous, and one or both labia are everted, and the lining membrane congested, inflamed, and granular. With the speculum, the labia are in its early development seen to be injected, becoming afterwards, however, often pale and exsanguineous. The disease usually commences in the labial portion of the cervix, and subsequentlyimplicates the deeper structures, extending at times throughout the whole length of the cervix, and in some instances is continuous with similar degenerations in the body and fundus; when so, there is usually considerable deformity, resulting from flexion and torsion of the organ. The symptoms may be briefly described as rectal, vaginal, or vesical pains and irritation, bearing down, thick mucous leucorrhcea, weariness and aching in lumbar and sacral regions, and in the hips and thighs, with lameness of one leg, sympathetic pains in the dorsal region and scrobiculus cordis, nausea, and other dyspeptic derangements, with various nervous and hysterical affections. No general treatment that I am aware of gives permanent relief to this distressing malady. The entire removal, however, when practicable, of the diseased structure proves the truth of the foregoing pathological description, by the complete relief to the symptoms which usually follows the means which I here advocate for the cure of the disease. When simply labial, it may be amputated by means of the ecraseur, or destroyed by the actual cautery or bromine; but I prefer and always employ potassa caustica for this purpose, whether the affection be superficial or deep-seated, for the following reasons. It may be used with perfect impunity, and it gives comparatively little pain. It may be employed with such accuracy and precision as nothing but the scalpel otherwise can afford; and, when proper caution is observed, it leaves no injurious consequences behind, as puckering and contractions of the adjacent vagina, etc. It is impossible here to do more than very concisely to mention the moduis o erandli of this remedy and its results. By means of my expanding cylindrical speculum, the patient lying on her left side, I procure not only a more extensive view of the uterus than by other means, but the upper part only of the vagina being thereby expanded, a basini is, as it were, formed edgeways, which is filled with vinegar and water up to the exact line, as far as that on which you intend to operate, with the potassa caustica. In doing so, all risk of injury, by the melting and debr-is of the caustic, is obviated. When the disease is of long standing and very hard, after one or tw0 applications of the potassa caustica, its character is obvious. Contrasted with the surrounding red normal tissue, it is distinctly seen to be of a white colour (like that of white India-rubber or the fat of beef) relief from pain is often immediately felt after separation of the first slough, and this is, I believe, owing to the removal of the tissue investing the disease, which beforehand prevented it from being expelled, by the fruitless contractions which its presence usually provokes. On the contrary, it will be seen, after each application of the potassa, that the white fibrous matter, rubbed down to a hollow by the caustic, becomes in three or four days a projection, and thus, however deeply implicating the cervix, the whole is gradually thrust forward so as to be brought under the solvent action of the potassa till the whole is enucleated. When no remaining disease can be felt, it only remains to pass a large-sized bougie daily to the extent of the wound to prevent cohesion of its sides whilst healing. From amongst a mass of cases, I must content myself by enumerating some of the favourable results I have seen from such treatment: speedy and entire relief from pains, lameness, in a word the symptoms already mentioned as indicating the disease, followed, in several instances, by pregnancy and healthy labours. In illustration of the subject, I would conclude by quoting the following case recently treated by me in the Hospital for Women. I do so the more readily, because it was taken by Dr. Snow Beck, who had, previously to treatment, demonstrated microscopically the fibroid character of the disease, although the extreme foetor of the discharges, and the severity of the pains, and the sallow and distressed aspect of the patient had suggested the possibility of cancer. It will be remarked that, by acting in accordance with this view of the pathology of the case, notwithstanding the difficulty and extreme caution required in using so powerful an escharotic at such a depth, a perfect cure resulted, the patient continuing entirely free from the pains, headaches, and other distresses which had made her life for so long almost insupportable. M. H. T., aged 45, married twenty-four vears, was admitted May I5th, I872. She had had twelve children, the youngest seven years ago. She had children quickly. Nine years ago she saw me on account of leucorrhcea. She had leeches applied occasionally. On admission, the lips of the uterus were very tender on pressure, with an induration in the cervix, giving almost the feeling of carcinoma, together with an offensive discharge. Potassa caustica was applied to the lips and neck of the uterus about twice a week for about eighteen times. Ergot was administered, and as the growth was rubbed down, the uterus pushed the fibroid growth forward. The result was complete removal of all fibroid deposit with entire relief from pain, leaving a small round os uteri with normal tissue around it.
Authors
Journal
British Medical Journal