It was Baker-Brown who emphatically recommended partial excision of fibromata in order to render them gangrenous. He incised the capsule, and chiseled or scraped out as much as possible of the tumor with a knife. He describes a successful case thus treated in the " Obstetrical Trans actions," London, I., p. 329. Only sub-mucous fibromata, with broad bases, are, according to him, adapted for this treatment.
In the " Obstetrical Transactions," III., p. 67, Baker-Brown reports six other cases treated in this way. In one of these the tumor disappeared by gangrene. In four cases marked diminution occurred, and death, resulting from pymmia, terminated one. Baker-Brown subsequently partly aban doned the operation.' Nevertheless he reported two more successful cases. It produces a painful impression to find the statement frequently repeated by Baker-Brown, in the debates of the London Obstetrical Society, that any one can assure himself of the truth of his statistics by making in quiries at the London Surgical Home.
This method of treatment has not found many adherents. Playfair ° re ported a case of complete cure after long suppuration, by this means. Green halgh's new method, consisting in incision of the capsule and destruction of the tumor by the actual cautery, belongs in this category. In one of his cases the tumor was an incarcerated fibroid of the posterior lip. Its capsule was opened, at its most dependent part, and the tumor itself cauterized with the hot iron. After the occurrence of gangrene, a tumor larger than a child's head was gradually peeled out, the operation occupying a number of days. The cure was complete. In another case the hot iron was applied directly to a tumor occupying the os externum. The gangrene, inaugurated by this process, lasted some months, but the patient made a good recovery.
Far more bold and original methods were resorted to in three other cases of incarcerated fibromata, which were not accessible from the os uteri. In these cases Greenhalgh reached the tumors by perforating the vagina with the hot iron, at the points where the pressure of the fibromata pro duced bulging of the vaginal walls. Gangrene occurred in two cases. In one of these the tumor was entirely extruded, after repeated cauteriza tions, and the patient recovered. The other case terminated in fatal pyasmia, after sloughing had lasted a month. The third case was one of
incarcerated, spontaneously sloughing fibroid, which terminated by peri tonitis.
The operation of spaying must be classed with the symptomatic reme dies, since it aims chiefly to bring about a cessation of bleeding. But it has also been claimed for this operation, that it diminishes or even obvi ates the necessity for the more radical surgical measure of enucleation of the fibroid tumor.
The operation of castration (spaying) was introduced into modern gyne cology by Hegar, and immediately following him by Battey. This was in 1872.' The removal of healthy ovaries in cases of fibroids of the uterus was first practiced by Trenholme ' (January, 1876), and a little later by Hegar (August, 1876). The latter has very clearly explained the principles un derlying the subject under consideration.
Experience has shown that with the advent of the menopause, the bleeding caused by fibroids not infrequently ceases, and that, moreover, retrogressive changes are inaugurated. It is certain that these tumors often cease growing after the climacteric period is reached. Now, an ar tificial " change of life " can be secured by removal of the ovaries, and, as Ilegar has pointed out, ligation of the nutrient vessels probably plays some part in bringing about this result. At times, however, no effect of this kind is obtained, and cystic degeneration of the uterine tumor occurs. For this reason Hegar advises that castration should not be done when the patient is already near the menopause, nor in those cases in which the growth of the uterus is undergoing degeneration or shows cystic forma tions, nor, finally, when the tumors are very large.
Heger also holds that sub-peritoneal fibroids with accessible pellicles, and sub-mucous fibroids projecting far into the cavity of the uterusi should be removed and should not be treated by castration. On the other hand, spaying is indicated in small intra-parietal tumors, and in all those cases where enucleatien or extirpation is beset by difficulties Since 1881 I have collected a number of cases, fifty-seven in all, includ ing twenty-one reported by Heger. Of this number ten died, forty were very much benefited, and in seven cases no improvement resulted. In no instance did the tumor disappear. It appears from this computation that the mortality was 17.5 per cent.