The expulsion of largo fibroids from the vagina after their enuclea tion is sometimes quite difficult, resulting even in rupture of the perineum. Incisions into the latter are occasionally necessary (Dupuy tren, Marion Sims), or the tumor must be comminuted before its expul sion can be effected. After the removal of the tumor it is usually unnecessary, and may even prove dangerous, to remove shreds of tissue or retained portions of the capsule with sharp instruments. Let the uterus and vagina be washed with a five per cent. solution of carbolic acid (or 1:2000. bichloride of mercury), and tampons dipped in glycerine and iodoform be inserted. The after-treatment, such as drainage, etc., is conducted in accordance with general surgical principles.
Beside the manifold dangers attending the operation, which have been cited above, collapse may follow. It is proportional in severity to the length of the operation and to the loss of blood. The general condition of the patient, also, at the time of operation will, of course, have impor tant bearings on the development of this as well as other complications.
A special modification of the operation of enucleation has been re cently devised for those cases in which the fibroids start from the cervix, and are situated without the peritoneal cavity, growing in a downward di rection. Such growths have been observed to narrow the lumen of the vagina. Caselli ' has reported a case of this kind, in which he success fully removed a myoma by splitting the vaginal wall which formed a cov ering for the tumor. Van Derveer ' proceeded in a similar manner in the case of a sub-peritoneal fibroid growing from the posterior wall of the uterus. By opening Douglas's pouch he succeeded in removing the growth per vaginam.
Czerny 2 has also recorded two successful cases of this kind, in one of which Douglas's pouch had to be opened. He likewise mentions two other cases, one of which had a fatal termination. Lomer (1. c., p. 283) men tions a successful case operated upon by Frankenhiiuser. and a second case by SchrOder. In the latter case the tumor occupied the anterior wall of the uterus, and was successfully " peeled out " of the loose tissue beween the bladder and uterus. A case operated upon by Olshausen,' also belongs in this category. It concerned a tumor that had grown downwards push ing the posterior vaginal wall down before it. Enucleation was made possible without opening the peritoneal cavity and the patient made a good recovery.
In a general way it may be stated that this method is applicable only to the smaller tumors which are situated outside the cavity of the peri toneum. Growths so situated are, however, very apt to cause consider able disturbance.
We have already emphasized the difficulties attending a strict discrim ination between partial enucleation or amputation of a fibroma, and incomplete enucleation. There are numerous cases, however, in which the impossibility of a complete removal of the tumor is recognized from the beginning, and in which, nevertheless, circumstances make it neces sary to at least amputate a portion of the fibroid. Cases of incarcerated fibromata, reaching low into the pelvis, and producing serious symptoms by pressure upon the intra-pelvic organs, are those to which the above remark applies. In these cases it is at least necessary to remove those parts of the tumor situated within the pelvic cavity. The results of the operation, when performed under these circumstances, are very variable. This may be partly due to the difficulty with which broad-based sub-mu cous fibromata are differentiated from interstitial ones. It is easier to understand how the remnant of the tumor should, in the former case, remain unchanged than in the latter class of cases, in which an intersti tial fibroid is partially destroyed and robbed of its nutrient vessels by in complete enucleation.
P. Muller,' Miinnel (The cit.), Chiari,' Chrobak,• Hutchinson, McClin tock, Schroder and others have reported favorable cases in which partial amputation of the tumor resulted in the removal of the symptoms due to pressure. In some instances cicatrization, even attended in certain cases by diminution in the size of the tumor, occurred along the line of incision. In very rare instances the tumor is subsequently entirely ex pelled, without undergoing mortification.' After partial enucleation gan grene, however, usually occurs, and may, in isolated cases, lead to a cure, the tumor being expelled or gradually undergoing complete mortification.
In the majority of the cases death results from pytemia or septicaemia, the danger of which should be always borne in mind when partial enu cleation is undertaken. Very instructive cases, of this kind, are reported by Marion Sims, by Spiegelberg,' Riedinger and Breisky.' In all those cases of uterine fibroids which threaten the patient's life, and in which relief can not be obtained from the operations already de scribed, laparotomy with removal of the tumor, or of the uterus with the tumor, is the last resort. The following remarks will show that this op eration is undoubtedly justifiable in certain cases, although the belief that laparotomy for the removal of large uterine fibroids is neither more diffi cult nor more dangerous than ovariotomy, is decidedly erroneous. These operations are not to be compared, even with reference to their relative utility.