In these cases cures were effected five times and death resulted three times. The operation was also performed three times with the icraseur. In two of the cases death followed. The operation was performed once, but unsuccessfully, with Maisonneuve's constrictor. One successful operation was done with the galvano-cautery. (The bibliography of the subject can be found in Pozzi's work.) The most frequent cause of death is septic infection, running its course under the form of septic peritonitis. Then follow loss of blood, shock, intestinal obstruction, uraemia in consequence of ligation of the ureters, thrombosis of the crural or pelvic veins, and cardiac failure. The last named cause of death is brought about by changes in the muscular sub stance of the heart, such as traumatic atrophy and fatty degeneration following loss of blood. (Ilofmeier, Rose, 1. c.) It has been shown that the particular method of operation to be chosen for the removal of myomas will depend chiefly upon the seat of the growth and its relation to the uterus. But a more difficult problem presents itself when we attempt to clearly formulate the indications for operative interference.
Now for uterine growths of the kind in question removal is by no means a simple necessity, such as is generally the case in ovarian tumors.
Even if we should succeed in reducing the mortality of extirpations of fibroids to the level of ovariotomy, we would nevertheless still have to take into account that fibroids per se are not dangerous to life. Hence the mere diagnosis of fibroid of the uterus is not equivalent to an indica tion for operation. Such indication is found, however, in the following: Rapid growth of the tumor, a size leading to disturbances of circulation and respiration; ascites, origin of the growths in the true pelvis, leading to symptoms of incarceration; violent pains (especially when they suffice to incapacitate the the patient for work), and finally hemorrhages that are not to be controlled by other measures.
Among the rarer indications for surgical interference we will find pregnancy and changes occurring in the tumor, such as gangrene, etc. In all cases the condition of the patient, her age and her station in life, are also to be considered. In persons who depend for existence upon their ability to work, an operation is sooner called for than in those who can command every care and comfort.
In these considerations there will also .be found a reason why these operations will not easily give as good results as ovariotomy. The latter is called for in every case where the tumor is large, whereas extirpation of fibroids is indicated generally in those cases that, owing to their course and symptoms, justify a poor prognosis.
The above considerations sufficiently establish the fact that, in many of these cases, symptomatic and palliative treatment can alone be aimed at. In the first place we must consider those measures which try to arrest the growth of the tumor, or to even reduce its size. We must next discuss
all those methods of treatment the object of which is to produce by con stitutional treatment a favorable effect upon the development of the tumors and upon the symptoms. Finally we shall consider the treatment appropriate for individual symptoms.
We have already stated that there is no therapeutical agent by which a fibromyoma may be made to entirely disappear. No measures adopted for this end can boast of brilliant results. Even when the tumors have disappeared, under a given treatment, it has not been proven that their removal was the result of the therapeutic measures resorted to. The use of ergotin (according to Hildebrandt's method) and the internal administration of ergot' are perhaps exceptions to this rule, although too little clinical evidence regarding this point has been accumulated. It is, however, not to be denied that some of the methods of treatment originally suggested for the complete removal of the fibroids have proven empiri cally useful in many instances. After their employment many of the symptoms have disappeared, or the growth of the tumor has seemed to be more gradual.
The supposed advantages of all the modes of treatment are seldom ap preciable, while unfavorable results often follow them. Neither have we any criterion by which to judge whether any given treatment will furnish better results in one individual case than in any other. One often sees no result, or an unfavorable one after an apparently appropriate course of treatment, while benefit may accrue to the patient from measures ap parently not at all indicated.
We must assign the first rank to those methods of treatment designed to operate more or less directly upon the tumor. Among these methods, the subcutaneous or internal administration of ergot and its preparations is most trustworthy. Although abscesses, at the point of puncture, and even symptoms of ergotism may attend the use of this drug, it, nevertheless, very often retards the growth of the tumors. Particularly the soft tumors which are rich in muscular tissue, become harder, smaller and appear to undergo an arrest of development. After the use of ergot diminution in the hemorrhage, either brief or lasting, very often occurs. Almost as frequently, however, all these favorable results are lacking, and the un pleasant ones necessitate an interruption of the treatment. The sub cutaneous injection of ergotin is tolerated, with special difficulty, by very fleshy persons, such as are so liable to suffer from fibroids at the meno pause. We should entirely discountenance the internal administration of iodine and bt.oinine preparations, no matter of what form, as well as of chlorate of potassium, arsenic,' mercury, turpentine and other similar drugs. There are no convincing proofs of their utility; on the contrary, most of them are calculated to act harmfully by disordering digestion.