Wiedow ' has collected a larger number of cases. He found records of one hundred and forty-nine operations for fibroids, and fifteen of the number had a fatal result. This is equivalent to a mortality of about 10 per cent.
In seventy-six cases particulars of the final result of these castrations are given. There were observed: At the present time, therefore, the following may be said concerning the value of spaying for uterine fibroids The operation leads with great certainty to an arrest of hemorrhages, provided the uterine tumors are not too large, and not in a condition of cystic degeneration.
It is a much safer operation than extirpation by laparotomy. (The mortality of castration has been reduced to about ten per cent., that of radical extirpation is above thirty per cent.) On the other hand those who recover from the operation of castration still carry with them their uterine tumors, the presence of which entails manifold dangers. Again, a not insignificant proportion of those operated upon continue to have the same pains, and other symptoms due to the presence of the fibroids, as before spaying.
Those who survive extirpation of the fibroids are permanently and completely cured.
Spaying must be classed with those measures which are directed against the chief symptom of fibroids, namely, the bleeding. Certainly among these measures, the operation is one of the most valuable, particularly as it can be used even in those cases where extirpation of the myoma seems contra-indicated or actually impossible.
Spaying is indicated, more particularly, in cases of smaller fibroids that give rise to severe hemorrhages, and in all those cases where removal of the tumors appears too dangerous.
It must, nevertheless, always be conceded that total extirpation of the fibroids is the " ideal " method of dealing with these growths. So, too, in comparing mortality statistics of the two operations under discussion, it must not be forgotten that myomotomy has certain " cures" in its favor, which experience has shown to be unattainable by castration.
It seems sufficiently demonstrated, by the results of the above-mentioned modes of treatment, that radical relief from uterine myomata can be attained only by extirpation. In view of the numerous difficulties and dangers attending these tumors, their extirpation is indicated whenever practicable. The operation is easy in cases of sub-mucous fibroids which
are provided with pedicles. The pedicle may he divided, even if it be rather broad, provided the tumor projects sufficiently beneath the mucous membrane to permit of its being encircled by the fingers or instruments, and to allow its pedicle to be elongated by traction.
Attempts at extirpation are facilitated by projection of the myoma beyond the os uteri, particularly if it be possible to easily trace the pedicle upward. This is usually practicable, because the most violent symptoms only occur after the tumor has been forced through the os uteri When dilatation of the os has not taken place, the tumor must be ren dered accessible by sponge-tents and incisions into the cervix. It is or dinarily impossible to decide whether the tumor be provided with a pedi cle or not until it is drawn downward. If the tumor be small, a sharp hook or a puce a cremaillere will suffice to draw it down. If it be larger it cannot be moved without Museux's or Greenhalgh's hooked forceps.
The larger the tumor, the more necessary it is to draw it downward in order to reach the pedicle, and the more dangerous is it to do so, because of the liability to traction upon, and injuries to, the peri-uterine tissues resulting in para-metritis and peri-metritis. Inversion of the uterus may also happen, in which case severe injuries may be inflicted upon the uterine parenchyma by the measures adapted for the removal of the fibroid. If the tumor be of.large size it is often impossible to reach the pedicle with such ease, and reduction of the dimensions of the tumor by partial excision is inexpedient on account of the profuse hemorrhages certain to attend this operation. Under these circumstances, the pedicle may be best reached by a resort to the method described by Simon.' Transverse incisions are made into the tumor, or only through its cap sule, with Cooper's scissors. The growth can then be elongated by trac tion applied to its most dependent part, and the pedicle is thus rendered accessible. Hegar attains the same end by spiral incisions around the tumor.