The uterus must be merely washed out. The fluid must never be al lowed to remain in the uterus, in order that the latter not be over-dilated or unduly irritated.
It is more difficult to guard against one other source of danger, viz., the results of follicular ulceration. Such ulcers may exert a very favor able influence upon the course of the disease by healing and cicatrizing. They may lead to adhesion of the opposing uterine walls, to obliteration of the cavity of the uterus, and to cessation of hemorrhage, as G. Braun' has observed.
A frequent result of these ulcers is, however, gangrene of the tumors, which may terminate in expulsion of the fibroid and a complete cure.' Fatal septicaemia may, however, follow the gangrene, as I have observed in one case.
When, therefore, one feels confident that ulceration has occurred, after repeated injections, he will under all circumstances be acting wisely to suspend treatment for a time, resuming it cautiously when recurrent hemorrhages show it to be indicated.
I desire to particularly disparage long-continued intrauterine injec tions, in cases of probably soft myoma. Such tumors are specially inclined to become gangrenous, and their intimate connection with the uterine parenchyma facilitates the absorption of septic matters.
Even this slight interference is not to be attempted without the rigid en forcement of antiseptic details.
The form of syringe to be employed is of no more special importance than the kind of fluid used. Personal preference and experience must settle this question, and the fluids recommended are so numerous that we must forego an enumeration of them. There are really only two favorite fluid escharotics, viz., liquor ferH chloridi and the tincture of iodine. Both should be used undiluted. The former is, on account of its free hydrochloric acid, more caustic, but is still weaker since it coagulates the blood covering the mucous membrane, and hence operates less effectively on the membrane itself.
Tincture of iodine is said not to be open to this objection.
Formerly I occasionally saw symptoms of iodine poisoning, in sensitive persons, after repeated applications of the tincture.
But since employing irrigation of the uterine canal after every such application, I have never met with this accident, and I now prefer iodine to other remedies.
Other escharotics, as nitrate of silver, nitric acid, acetate of lead, iodide of lead (Freund), etc., have been employed and commended. The application of these remedies in the form of ointments (Routh, Scanzoni and others) has not met with general favor.
Curetting of the uterine cavity is now also generally employed, since the opinion has gained ground that pathological conditions of the mucous membrane of the uterus are so largely responsible for the hemorrhages observed in cases of myoma. This operation is done as follows: The
patient being anaesthetized, the uterus is pulled downwards and its cavity washed with an antiseptic solution. The curette or blunt scoop is then in troduced, and the cavity thoroughly scraped. I commonly inject iodine after the curetting, and then again wash out the uterine cavity with an antiseptic. In a rather large number of cases treated in this way I have never had occasion to observe serious consequences. Slight cellulitis has, however, sometimes occurred.
The second almost constant symptom, treatment of which is essential, is pain. The prevailing pain with sub-serous tumors, is due to inflamma tion produced by traction upon and irritation of the peritoneum. Acute circumscribed peritonitis may be often developed, chiefly at the time of the menstrual congestion.
If the pain be referable to inflammation, antiphlogistic measures afford the most ready relief. Local abstraction of blood may be indicated in the ease of strong persons, with sub-serous fibroids, particularly if the menses be scanty, as often happens. In still other cases good results will follow the local use of cold, by means of ice bags, cold applications, wet packs, etc. An abdominal supporter often renders good services if the pains be produced or augmented by unusual mobility of the tumor.' Greene's case,' in which he performed laparotomy, on account of the intolerable pain, is unique. After the abdomen had been opened, it was found impossible to remove the fibroma and the wound was closed. The patient recovered and remained permanently free from pain, no change having occurred in the uterus.
Pains resembling those of labor, and due to uterine contraction, are produced by fibroids, particularly by those which are sub-mucous or inter stitial. Although these contractions are often of benefit in producing the expulsion of the tumors, they are sometimes so severe as to require allevia tion. Morphia or other anodynes are, aside from operative measures, the only resource in these cases.
The anodyne may be administered in a vaginal or rectal suppository, hypodermically or in a small enema.
Pain is also produced by pressure of the tumors upon neighboring tissues. Pain due to this cause may often be relieved by pushing the tumor upward, out of the pelvis, and retaining it in its new position by a pessary. (Kidd.) Ringland ' once displaced a tumor upward by means of a Barnes dilator introduced into the rectum. In the majority of these cases, however, provided they are not adapted to other modes of treat ment, narcotics are our only resource.