from the mucous membrane, and a thick and heavy layer spread over its
external hemisphere. A greater part of the muscular wall is therefore
applied to the outer side of the tumor. If in this position all the
fibres of the uterus vigorously contract, the fibres near the mucous
membrane must be overcome by the heavy layer outside. But the opposite
wall plays an important part by supporting the weaker layer at the
fundus of the tumor, and adding its own force in overcoming the
capsule, where it usually gives way. The position of the tumor makes
its escape from the concentric action of all the fibres of the uterus
impossible, and every one knows that when the resistance is partially
overcome the uterus is stimulated to more vigorous action, and the
pains will not abate until the mass is expelled. If not too large, it
is driven out without undergoing great laceration, but if its size and
attachments are such as to make this impracticable, it will be broken
into fragments and expelled piecemeal.
In subperitoneal tumors there is, next the uterine cavity, a thick and
strong stratum of fibres, while immediately under the peritoneum the
layer is very thin and comparatively weak. When the uterus is acting
with vigor the former contract forcibly, and the mass becomes
pedunculated; but that is all, for the tumor lies outside the field of
concentric action and escapes the crushing influence to which the
submucous variety is subjected. The amount of force exerted upon it is
that exercised by the weaker layer of fibres in a state of conquered
antagonism, and the rupture of the capsule is impossible.
In the case of a fibroid tumor situated in the central stratum of
fibres the antagonism is equal at all points, and it is evident that
there is no tendency to rupture of the capsule, and much less crushing
influence exerted upon it than if it were situated slightly nearer the
mucous membrane. This variety of the tumor, therefore, yields to ergot
only as it may be starved out by diminution of its blood-supply and as
the effect of pressure, which we all know are the two conditions most
favorable to absorption.
Now I think we have arrived at a point in this investigation where we
can draw inferences as to the forms of tumors likely to be effected by
ergot in different ways, as well as those that will not be effected by
it. We do not expect ergot to cause painful and efficient contractions
in the healthy unimpregnated uterus; its fibres are not capable of such
contraction, and it is not until the fibres have become greatly
developed that they are susceptible to the impressions of ergot. In
cases of early abortion its action is very unreliable, but after the
fourth month of pregnancy it acts quite efficiently.
In tumors of the uterus the development of the fibrous structure is
sometimes so slight that it is incapable of contraction; there may be
so many nuclei of degeneration that there are not enough sound fibres
left for efficient contraction. Then, where there are many small tumors
developed in the uterine walls, the circulation is cut off to such a
degree that they degenerate into a cartilaginoid substance, and
sometimes they are infiltrated with calcareous material. In none of
these cases will ergot cause any appreciable results. When, however,
there are {265} but one, two, or three nuclei of morbid growths, as
they increase in size the fibres undergo the development necessary to
enable them to contract with great efficiency and render them
susceptible to the influence of ergot.
Another condition which influences the hypertrophic growth of the
fibres is the situation of the tumor. Subperitoneal tumors do not cause
as great growth in the fibres of their neighborhood as the intramural
or submucous varieties. A single intramural tumor causes great
development of the whole uterine tissues, but the development of the
wall in which it is situated decidedly predominates. The submucous
neoplasm so soon gains the uterine cavity that the development is
nearly the same in the whole organ. When, therefore, we administer
ergot for the cure of fibrous tumors of the uterus, the beneficial
action of the drug will depend upon the degree of development of the
fibres of the uterus and the position of the tumor with reference to
the serous or mucous surface. The nearer the mucous surface, the better
the effects. If the tumor is very near the lining membrane, we may hope
for its expulsion en masse or by disintegration.
We can often select the cases in which good results may be expected.
There are four conditions which are usually reliable for this purpose:
they are--smoothness of contour, hemorrhage, lengthened uterine cavity,
and elasticity. A smooth, round tumor denotes, for the most part,
uniform textural development, hemorrhage, a certain proximity to the
mucous membrane, a lengthened cavity, great increase in the length and
strength of the fibres; and elasticity assures us of the fact that
cartilaginoid or calcareous degeneration has not begun in the tumor.
An even, nodulated tumor may be composed of many separate solid masses.
These displace and prevent the growth of the fibres to such an extent
as to render contractions inefficient. When hemorrhage is not present
the tumor is probably near the serous surface, and consequently not
surrounded by fibres. A short cavity denotes short, undeveloped fibres,
while hardness is indicative of unimpressible induration.
Although I have no experience in the use of ergot in such cases, I
should expect large fibro-cystic tumors to resist the action of ergot.
From this view of the subject it will be seen that I freely admit that
there is a large number of cases in which ergot cannot produce any good
results, in consequence of the nature of the cases; but there is
another reason of equal moment why ergot may fail to act upon such
cases as would seem to be favorable--by the worthlessness of the drug
and its preparations. Squibb of New York, a high authority, says in
reference to this subject: "The molecular constitution of the active
portion of the drug seems, however, in its natural condition to be
loose, and, like a slow fermentation, to be undergoing slow molecular
changes, so that by age its peculiar activity is slowly diminished
until finally lost." And again: "The ergot in the grain, however well
kept, is known to become inactive without any known change in
appearance, though the sensible properties, such as odor and taste, may
and probably do not change. Ergot in powder is known to diminish in
activity much more rapidly than when in grain, and probably soon
becomes inert. The tincture and wine of ergot are believed to change,
though more slowly than the ergot in substance, whilst the extracts and
so-called ergotins are all supposed to change more rapidly."
When all these causes of failure are considered, the variety of {266}
experience met with in the reports upon its trial in the treatment of
these tumors is not surprising. It should not, however, be
discouraging, but should prompt us to more care in selecting the cases
and securing reliable preparations of ergot. I have implicit faith in
the action of ergot when all the conditions I have pointed out are
present. I do not believe it to be uncertain in its action.
In addition to the above conditions, I believe perseverance an
indispensable condition to success, as it often requires several months
to get the best results.
The mode of administration should be governed by the objects to be
attained. If we desire to cause the painless absorption of the tumor,
the doses ought to be moderate in size and not too frequently
administered. Hildebrandt administered by hypodermic injection a
preparation containing from fifteen to twenty grains of the crude drug
to the dose once daily or once every other day; and once a week will
often be sufficient, as proven by cases cited in my address, quoted
above. If we desire to have the tumor expelled, we should administer
full and increasing doses often repeated, and continued until the
object is attained. It will sometimes be necessary to vary the quantity
and times of giving it to suit the susceptibility of the patient--less
or more according to the amount of pain caused by it.
It is not essential to give it hypodermically, although when it does
not produce much inconvenience this is a very efficacious method; it
may be given by the mouth, in suppositories, per rectum, etc.
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.
{267} 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
{268} 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.
I will commence what I have to say on extirpation of deeper tumors by
assuring the inexperienced that the formidable operations required for
their removal are very seldom necessary, and should not be resorted to
until all other and less hazardous efforts have been made.
The operation of enucleation is applicable only to cases of sessile
submucous tumors, such growths as are nearer the mucous than the serous
membrane. If enucleation is practicable in tumors which have their
origin in the central stratum of the wall of the uterus, the operation
must be regarded as equally hazardous, if not more so, than
laparo-hysterectomy. I am aware that such operations have been
recorded, but it is so easy to be at fault with reference to the exact
point of origin that I must be permitted to doubt--not the honesty of
the operators, but the accuracy of their observations. In many cases of
submucous tumors the cervix is dilated so much that immediate
dilatation with the fingers or hard-rubber olive-shaped dilators will
be practicable. When that is not the case, the cervix must be
thoroughly opened by sponge, sea-tangle, or tupelo tents or bilateral
incision: the more patent the mouth of the uterus can be made the
better. The operation is so serious in its nature that the competent
surgeon will study his preparations so carefully as to avail himself of
every means that will enable him to perform it in the most expeditious
and complete manner. Expedition, rendered possible by thorough
preparation, is a most important item; for it must be understood that
every superfluous moment spent in enucleation increases the peril of
the patient. I would not counsel haste, but the earnest and careful
despatch acquired by reflection and experience. When the patency of the
mouth of the uterus is secured, the uterus should be drawn to or near
the vulva by a strong vulsellum and firmly held by an assistant. The
operator may then make an incision with scissors entirely across the
most dependent part of the tumor, completely through the capsule. After
this is done, another incision is to be made from the centre of this
cross-cut upward upon the most prominent part of the tumor, as high as
the instrument can be guarded by the fingers. The fingers should then
be inserted between the tumor and the capsule, and the latter separated
as extensively as possible from the former. In some cases a large part
of the tumor may be thus detached from its envelope. When the whole of
it cannot be detached by the fingers, Sims's enucleator may be made to
finish that task. It can be passed up and around the upper and less
{269} accessible portion. The detachment should, when possible, be
complete before traction is begun. The traction is affected by a strong
vulsellum. By that instrument the tumor, after being firmly seized, can
often be rotated upon its longitudinal axis to assure the operator that
it is loosened at every point. Simple, firm, but slow traction, aided
by pressure of the hand on the upper part, will assist the uterus in
expelling the growth. Should the tumor be too large to pass the mouth
of the uterus and vagina, it may be divided by well-directed efforts
with the scissors or knife and removed in pieces. When the tumor is
semi-pedunculated the capsule may be separated by Thomas's serrated
spoon in a much more expeditious manner. As the tumor is drawn out of
its cavity the uterus usually contracts, and thus prevents the
hemorrhage that might otherwise occur. The surgeon, however, must
always be prepared with plenty of cotton saturated with the subsulphate
of iron with which to plug the uterine cavity. It will very seldom be
necessary to use the ironized cotton, and it should not be employed
until its necessity is apparent. The after-treatment consists locally
in detergent and disinfectant injections, and in such general measures
as will aid in reaction where there are symptoms of shock and
counteract the tendency to inflammation. For both these purposes a
liberal amount of opium will be very useful.
When the symptoms in connection with a tumor situated in or slightly
outside the centre of the wall of the uterus are so urgent as to demand
surgical interference, the choice of operations lies between
laparo-hysterectomy and öophorectomy. In the light of recent
observation I have no hesitancy in recommending the former for large
tumors and the latter for small ones. As before stated, I regard
enucleation in such cases as hardly practicable, and when successful I
believe it is attended with as much danger as the entire extirpation of
the uterus.
Without entering into details of this operation, I will state that it
is so like ovariotomy as to be governed by the same principles and
require to a great extent the same methods. The incision should be
sufficiently free to permit the removal of uterus and tumor without the
necessity of cutting away the tumor in pieces, as thus mutilating it
gives rise to great and dangerous hemorrhages and of necessity soils
the abdominal cavity. I have always used silk ligatures with which to
secure the pedicle. In most instances we will be obliged to ligate the
uterus near its junction with the vagina. Extra-peritoneal treatment is
probably safer.
Where a small intramural tumor is attended with exhausting hemorrhage,
menacing the patient with a probable fatal loss, and other remedies
have been found inadequate, öophorectomy may with great propriety be
resorted to.
I would refer the reader to the description of this operation as given
elsewhere. There is no other surgical operation by which a large
fibro-cystic tumor can be gotten rid of than laparotomy or
laparo-hysterectomy. Recently I have removed a large fibro-cystic tumor
that grew from the anterior surface of the fundus and body of that
organ without removing the uterus. The tumor was detached by a sort of
enucleation, and the detachment left a large bleeding surface.
Hemorrhage from that surface was profuse, and seemed to issue from
numerous cavernous openings instead of veins and arteries. The
hemorrhage was checked by {270} passing silk ligatures one-eighth of an
inch beneath the surface from one side to the other of the bleeding
surface in several places. When these ligatures were tightened the
tissues were so condensed as to entirely control the bleeding.
This was my fourth laparotomy for fibro-cystic tumor of the uterus, and
the only one that recovered. In all the other three I ligated the
uterus and removed it at the internal os.
Large subserous, fibrous, or fibro-cystic tumors are almost always
covered with a network of great vessels, generally furnished by
adhesions to the omentum. These vessels should be ligated in bundles by
two ligatures around each bundle at least two inches distant from the
uterus. If the two ligatures are not thus widely separated from each
other, when the division between them is made the collapse and
retraction of the vessels will be so great that they will not hold. If
in detaching adhesions a bleeding surface is left on the tumor or
abdominal wall, the bleeding should be arrested by ligatures applied
before the tumor is lifted from its bed. When it is necessary to remove
the uterus, a double ligature around its substance should be applied;
also, when practicable, before the tumor is lifted out. In this method
of securing the vessels we will avoid the terrible hemorrhage that
would otherwise follow the removal of the tumor. The pedicle should
then be brought out and secured by pins in the wound. The cleansing of
the peritoneal cavity and closure of the wound should be done as in
ovariotomy. The after-treatment is also the same as in bad cases of
ovariotomy.
I have not thus far mentioned the treatment of fibrous tumors by
electrolysis; and as the profession has not generally consented to the
adoption of this measure as safe and efficacious, I will refer the
reader to an account given of that process and its results in my work
and other standard works on gynecology.
{271}
SARCOMA OF THE UTERUS.
BY W. H. BYFORD, M.D.