A system of practical medicine. By American authors. Vol. 4

by Unknown

In conclusion, I desire to disclaim any expectation that ergot will supplant other modes of treatment. The expert surgeon will, as he always has done, use his instruments to the neglect of remedies less summary in their effects, and in his hands the maximum of safety will obtain; but there are very few general practitioners who ought or would be willing to undertake enucleation of fibrous tumors of the uterus.

Surgical Treatment.—The surgical processes resorted to for the cure of fibrous tumors of the uterus vary in their nature and gravity with the relations of the growth to the different strata of the uterine fibres. The nearer the mucous membrane, the simpler, safer, and more successful the operation for their removal; the more remote from it, the greater the difficulty and danger. Proximity to the cervix is another element of facility and safety. The removal of the cervical polypus is scarcely ever followed by serious consequences. While a polypus situated at the fundus requires greater complexity in the operation for its removal, and must be regarded as a serious one, the difficulty of removing the submucous tumor more remote from the mucous membrane is increased the higher up in the organ it is situated.

Polypi may be removed by torsion, excision, and écrassement; any one of these operations may be successfully and safely employed. No preparation of the patient is usually necessary for the removal of the cervical polypus, because it is accessible under ordinary circumstances. In very rare instances in the virgin or senile condition the vagina may require dilatation. The polypus attached at the body or fundus is not accessible to any of these operations until the mouth of the uterus is sufficiently dilated to permit the introduction of the instruments in the uterine cavity, or until the tumor is in part or wholly expelled.

It will therefore generally be necessary to completely dilate the cervix with sponge, tupelo, or laminaria tents or the fingers. The fingers, when the object can be accomplished by them, are much the better instruments for dilatation. I have several times accomplished the dilatation of the cervical cavity and removed an intra-uterine polypus in the course of half an hour by the fingers.

I prefer torsion, and believe that when properly performed it is the most simple, expeditious, and safe plan of removing a polypus. The tissues entering into the formation of the neck of a polypus are an extremely thin layer of fibres and mucous membrane. We cannot always be sure of placing the écrasseur or applying the knife or scissors exactly at the point of junction between the substance of the polypus and uterine wall; but, as that is the weakest point, it invariably yields to the force applied in the operation of torsion. The tumor is thus completely removed, and without protracted manipulation. No hemorrhage results, for two reasons: (1) there are no large vessels entering the tumor, and the small ones are torn instead of being cut, as in amputations; (2) septicæmia does not occur, for no portion of the tumor is left to slough. In performing this operation the operator must guide a vulsellum with his fingers high enough on the tumor to enable him to fasten the instrument upon or near the central part of the polypus. In two instances, when the tumor was too large to be firmly held by any forceps at my command, I introduced the hand inside the uterus and detached the tumors by rotating them, afterward making traction with the forceps. I brought them into the vagina and delivered them with the obstetrical forceps. One of these weighed forty-six ounces.

To perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position, should be careful to twist it enough to be sure of its detachment before commencing traction. Not less than from four to six complete revolutions should be effected. This procedure will prevent the danger of lacerating the tissues of the uterus.

The greatest objection urged against the operation of torsion is the likelihood of lacerating the wall of the uterus at the point of attachment. If we call to mind what was said about the relative thickness of the muscular strata upon each side of the different kinds of fibrous tumors, we will at once perceive the groundlessness of this objection. In the pendulous variety the whole wall of the uterus is outside the point of attachment, and is strong enough to resist the very few fibres that are carried down with it. Indeed, the polypus has almost no substantial attachment except that formed by the investing mucous membrane. If, therefore, the torsion is performed with sufficient thoroughness before traction is begun, laceration of more than the superficial tissues surrounding the neck of the tumor is next to impossible; consequently the operation is perfectly safe.

Hemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife or scissors, or even by the écrasseur. The danger of hemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. I have never seen hemorrhage succeed torsion. The contractions of the uterus which take place after removing the polypoid growth from the cavity of the uterus in the great majority of cases is as effective in the prevention of hemorrhage as it is when its contents are expelled at the time of labor. I trust that it is not necessary to dilate further upon this part of the subject. However, hemorrhage, although improbable, is yet possible, and we should therefore be prepared for it. After what has been said under palliative treatment about the management of this complication, it will not be necessary to enlarge upon that point. I would therefore refer the reader to the remarks there made.

After an operation of this kind the only treatment necessary is perfect quietude for a few days, cleanliness by injections if needful, and the administration of anodynes to quiet pain. When a tumor has been removed from high up in the uterus, the patient of course should be carefully watched, and if symptoms of inflammation or septicæmia arise they should be treated by suitable remedies.