The operation is certainly not indicated if the hemorrhages have lost their menstrual type, or if the menopause has arrived.
Baker-Brown' first performed a much leas formidable operation for the relief of hemorrhage. It consisted in incising the cervical canal, the os internum, and, if practicable, the capsule of the fibroid. Experience shows this operation to be adapted to the long-continued control of tha bleeding. N6laton, McClintock,' Spiegelberg,' Barnes,' Savage,' and others, includ ing myself, have obtained good results from this method. The raloon ale of the effect produced by this, by no means trifling operation, is ex plained in some cases by the section of many dilated vessels in the uterine mucous membrane, and their subsequent obliteration by the process of cicatrization.
In the majority of cases, however, the result is, according to my experi ence, attained by the release from pressure of the uterine mucous mem brane, which has been distended and partly destroyed by the tumor. In consequence of this relief, the collateral congestion of the remaining mucous membrane is relieved, and hemorrhage from it diminished.
Spiegelberg first advanced this theory, and supported it by demonstrating the fact that this method is only successful when the tumor is adjacent to the os internum, and the mucous membrane covering the growth is, therefore, directly relieved from pressure by the incision. Since the presence or absence of the anatomical conditions necessary to the success of the operation are not easily determined in advance, it has not found general acceptance.
I have always performed the operation with Sims's curved scissors, after dilating the cervical canal by means of sponge tents, and have in addition incised the mucous membrane in and above the 03 internum. I have never seen unpleasant consequences follow the operation, nor are any recorded in literature. Yet it might give rise to parametritis, peri tonitis and septicemia, just as readily as incision of the cervix for other objects. Like most gynecologists, probably, I have not recently per formed this operation.
Several authorities, as for instance Scanzoni, recommend local abstrac tion of blood in order to prevent excessive menstruation by depletion of the uterine vessels. The distinction between the loss of blood produced by artificial means, and that due to natural agencies is so slight that benefit is probably only exceptionally afforded by this treatment. It has not been generally adopted, so far as I am informed.
Cauterization of the uterine mucous membrane has been quite pro perly received with greater favor. This intrauterine method of treat
ment is, in many cases, the only one capable of setting a limit to the bleeding. Since solid escharotics are unsatisfactory, on account of the frequently varying form of the uterus, and because they usually only affect the secretion which covers the mucous membrane, without reach ing the latter, fluid escharotics have long been exclusively used.
The modus operandi of the different escharotics is identical. The cauterizing fluid, when brought in contact with the uterine mucous membrane, saturates it as far as possible, diminishes its tumefaction, tans it, as it were, and antagonizes menstrual congestion. The large, dilated vessels contract and are partially obliterated. Sometimes the escharotics produce superficial follicular ulcers, which interfere with the growth of the tumor or leave, as a result of their cicatrization, a tough cicatricial tissue in the place of the swollen hypertrophic mucous membrane.
The many dangers attending intrauterine injections are now known and sufficiently appreciated. The injections may produce uterine colic, which may, if too often repeated, lead to metritis, perimetritis and peri tonitis. The irritation may directly involve the parametrium or the peri metrium, and so give rise to dangerous inflammation.
The injected fluid may, under exceptional circumstances, in the pres ence of special pathological conditions, pass through one of the Fallopian tubes into the peritoneal cavity. The following cut represents the uterus of a patient, in whose case intra-uterine injections of liquor fern chloride had been repeatedly made and with excellent results. After one injection made, perhaps, when the os uteri was not sufficiently dilated, all the symptoms of peritonitis from perforation appeared, and the patient quickly succumbed The peritoneal cavity contained a large quantity of the fluid, which had escaped through an aperture in the uterine wall. The perforation had resulted from rupture of the wall, which was atro phied, as is so often the case with uterine fibromata. The atrophied portion had yielded to the pressure of the injected fluid, since experiments proved that the syringe used could not have reached the point of perforation, and was hence guiltless of the injury. These dangers may be completely avoided by never resorting to intra-uterine injection, unless the cervical canal and the os internum have been sufficiently dilated to afford the injected fluid free exit iu a stream of the same size as the in-flowing current.