Even if strictest antiseptic precautions will doubtless diminish the dan gers of an operation under such circumstances, surgical interference must never be attempted too soon. The general condition of the patient will have to govern our decision in this direction.
There is an evident diversity of opinion regarding the method of the operation, some recommending that the enucleation be performed at one and others at two sittings.
Matthews Duncan, Marion Sims, many others and myself have recom mended the latter method, but never to the exclusion of the former.
If it be easy to remove an intra-parietal myoma at ono sitting, it would of course be unwise not to do so. It only seems advisable to await the effect of the pains and of beginning necrosis in order, perhaps, to bring the operation to a speedy end, at one or more subsequent sittings. This method is, at all events, better than a systematic attempt at the invariable completion of the operation, during one sitting. If the operation be undertaken with this end in view, it is often necessary to inflict most serious injuries, and even then to abandon the undertaking, after great exhaustion and injury to the patient.
After the patient has been thoroughly brought under the influence of an anaesthetic she should be placed in the lithotomy position. Some operators, as Marion Sims, always prefer the lateral decubitus. The location of the tumor sometimes renders the latter position more appro priate. Even after careful disinfection of the vagina, and, if possible, the cavity of the uterus, it is well to employ a two to three per cent. solution of carbolic acid throughout the entire course of the operation.
if the os uteri is not sufficiently patulous to render the tumor accessible, it should be enlarged with scissors. Dilatation of the os with sponge tents, etc., is slower, less certain and more dangerous, because gangrene and infection are thereby invited. Even after enlargement of the os, by means of incisions, the tumor is often not sufficiently accessible. In this case the operation must be interrupted and ergot given with a view to producing descent of the tumor by means of uterine contractions. When the tumor has been brought within reach, which is effected through fixation of the uterus by external pressure on the fundus and by means of traction with a sharp hook, the capsule should be split, at its mostdependent part, with a bistouri or the scissors. (If the fibroid projects far into the uterine
cavity it may be better treatment to make the incision into the capsule as near the base of the tumor as possible. llegar). It seems superfluous to use Sims's speculum for this procedure, or to excise a part of the cap sule (Meadows).
Perforition ' of the capsule with escharotics (Simpson), with the hot iron (Hutchinson), or by the galvano-cautery (C. Braun), has not been generally adopted. These methods are recommended for the prevention of hemorrhage, when the capsule is perforated, but they fail of accom plishing this object in serious cases. The bleeding may, then, be best controlled by immediate section of the vessels in the capsule, and by a rapid completion of the operation, but it may become so severe as to ne cessitate the use of the tampon.
The use of styptics during the operation is inappropriate. If a por tion of the tumor is exposed by the incision in the capsule, onucleation is at once begun. For this purpose the tumor must be seized and drawn as far downward as possible. Museux's, Greenhalgh's, or similar toothed forceps may be used. Marion Sims, A. Martin and others have invented special sharp hooks or hooked forceps, by which it is claimed that the tumor may be more firmly held, and the soft parts of the patient pro. tected. None of the instruments perfectly accomplishes these ends. For reasons already given, too powerful traction must not be made with such instruments upon the tumor. Traction should never be so firm as to invert the uterus, as Hutchinson recommends.
Enucleation may be best accomplished with the fingers, which usually separate the loose tissues of the capsule with facility. Tumor adhesions should be divided with the knife or scissors. If the hand can not reach high enough, it may be replaced by the enucleators recommended by Sims. C. Braun sometimes successfully used the cranioclast for crushing the tumors. As the enucleation proceeds the tumor must be drawn or twisted in a downward direction. If it is not easily accomplished the capsule may be separated, so far as possible, and the operation suspended for a few days, until beginning gangrene shall have produced t. diminu tion in size, and a loosening of the connections of the fibroma.