Thomas Savage

On Removal of the Uterine Appendages.

ternal. It began in the glands near the surface, or in their deeper parts; but the lecturer bad not met with the disease beginning in the epithelium of the cervical canal. It appeared to begin in the lower more frequently than in the upper part of the cervix ; but it began in the latter situation more often than was generally supposed. The following case (Fig. 3) was given as an instance of the disease beginning in the upper part of the cervix. A patient, aged 40, of very fair complexion, who had had two children and some miscarriages, was seen first in July, 1878. She said that she had not been poorly for six weeks, and that she felt sick, and had very frequent micturition. On examination, the os was found large aDd patulous, and high near the inner orifice, in the posterior wall of the cervix was a hard mass, the size of a pea. It was thought to be a small fibroid. She was seen again in 1879. She said she had had a miscarriage at Christmas-time. Her husband had been away for six months, and returned a fortnight ago, and she had observed a slight loss of blood after coitus since, but at no other time. She had no pain, and no discharge.

Uterine Myoma: Gastrotomy: Recovery.

MARY W., aged 37, single, servant, came to the Womens Hospital as out-patient on May 23rd, 1877, sent to me by my friend Dr. Drury. Her previous history was that she had commenced to menstruate at fourteen, the periods being always profuse and painful. She had been losing almost constantly for four years, and had, during that time, noticed her abdomen increasing in size. She suffered also great pain, especially at what she thought to be menstrual periods. She was very feeble. On examination, there was a lump on the right side of the abdomen. The uterus was high up and flattened behind the pubes, and a large lard mass was felt in Douglass space, which filled up the vagina. The uterine sound passed three inches and a half. The uterus was fairly mobile, and movement of it did not affect the mass in the pelvis. A later note says that the sound passed four inches, the point inclining to the right and a little backwards, as if the fundus were bent over towards the tumour. The tumour in the pelvis was quite fixed. The patient thought she was becoming larger. There was no interference with the bladder or rectum, but she was losing more. On October i6th, 1877, she was admitted into hospital, and the vaginal portion of the cervix was incised with curved scissors, which seemed to give relief to her pain and loss. On January i8th, I878, she was again admitted, and, on the 2ISt, a long laminaria tent was inserted; and the next day, the cervix was again incised under an anaesthetic, and the capsule of the tumour also cut into. She was ordered to have ergotine injections. After this, the loss ceased, and the pain was much relieved ; but they both returned some weeks after leaving the hospital, until she was again admitted for the major operation. To this I would only consent at her most urgent solicitation; for she had now become a most miserable object, and was clamorous to run any risk rather than continue in her present condition. At a consultation of the hospital staff, when the case was laid out for our joint consideration, and the propriety of an exploratory incision suggested to see if the mass were capable of extraction, an opinion was expressed that it might turn out to be a osteosarcoma of the pelvic wall, so firmly fixed did the pelvic mass feel. The operation was performed in the usual way for ovariotomy, under carbolic spray, on November 7th, 1878. The tumour was found to consist of two masses, right and left in the abdomen, and the pelvic mass. This latter could only be removed by separating numerous adhesions to the pelvic brim and cavity, and by my colleague (Mr. Tait) pressing upwards with the greatest amount of force per recitum, I, at the same time, pulling upwards and forwards by traction on the upper mass. A clamp was applied just above the cervix, and the patient, without a bad symptom, rapidly progressed to recovery. She left the hospital on December i ith. When removed, the mass weighed two pounds fourteen ounces, and consisted of three portions ; the pelvic portion, about the size of a foetal head, which seemed to have sprung out of the upper part of the posterior uterine wall; and the two upper portions, right and left, which appeared to have taken rise from the fundus, near the junction of the Fallopian tubes, as I was enabled to pass a sound from below, right and left, for a little distance into each mass; they were about the size of an orange. REMARKS.-The treatment of uterine myoma, of the variety called subperitoneal, forming masses more or less large in the pelvis and abdomen, is one of the most perplexing questionswhich engage the attention of the gynacologist. A very large number, the majority in fact, do not need to be treated; it would be unjustifiable to interfere. We all know cases where they diminish in size at the menopause, or, if not, the patients are enabled to pass through life with little or no inconvenience other than what their weight involves; but, ina certain number, the course of these tumours is as certainly progressive, and towards death, as is the case with ovarian tumours. The removal of myomata by gastrotomy has been of late years proposed and carried out ; and, though the success of this proceeding has been but small hitherto, I am very strongly of opinion that a bright future is in store for this operation. It may now be considered to stand in the same kind of relation to prospective success, though perhaps different in degree, as did ovariotomy thirty years ago. The difficulties and dangers of the operation itself will always be much greater than in the removal of ovarian tumours. The diagnosis also will be less certain. The treatment of the pedicle or stump, when there is one, will not be so easily settled. When there is a fair pedicle, which is rare in these cases, it may be clamped or tied, either whole or in segments; and this is to be met with chiefly in the hard myoma, where a true pedicle, or even the uterus itself, forms the stump. But what is to be done with the large soft myoma, which forms a large, apparently fluctuating, globular mass, in which is embedded the uterus ? The clamp is out of the question; and, from the friable nature ofthe tumour, when it is a thick mass, as is usually the case, the ligature will tear through or will not hold. The cases in which the peritoneal surface of the stump has been sewn to the peritoneal surfaces of the abdominal wound have not been successful, in my experience, as there is the additional difficult task of arresting the hemorrhage from the raw surface of the stump. Possibly, these might be met by tying with a large number of ligatures, all radiating from the uterine cavity as a centre.