The pedicle having been reached by one of the above methods, and rendered tense by traction upon the tumor, it is severed by Casper's long scissors, or by Siebold's instrument, or by one similar to it, and the growth is removed by means of rotary movements. If the removal of the tumor be difficult, owing to its large size, it may be commi nuted or compressed. No other instruments designed for severing the pedicle deserve mention, as they are either unnecessary or inappropriate. The conviction that the removal of a fibroid provided with a pedicle, by section of the latter, is the simplest and best method, is at present pretty generally accepted. The danger of hemorrhage during, or, rather, after such an operation was, at first, much dreaded and considerably over estimated. Experience shows that the pedicles very rarely contain vessels of large size, and that hemorrhage from the severed end is, consequently, insignificant. Should it be at all profuse, it may be readily checked by a good tampon, or by cauterization of the bleeding point.
The possibility of violent secondary hemorrhage from pedicles which do contain larger vessels must, however, not be disregarded. The primary hemorrhage, even in such cases, is trivial, because the muscular contraction resulting from the mechanical irritation of the uterus controls the bleed ing. After a certain time the muscular contraction ceases and hemorrhage occurs. It is consequently advisable, when the patient cannot remain under the immediate supervision of the gynecologist, to insert a tampon. If hemorrhage be particularly apprehended, by reason of anaemia on the part of the patient, the pedicle may be severed by the galvano-cautery,' which is, however, very unsatisfactory, because one is by no means certain of obtaining an apparatus in good working order, and because it does not perfectly protect against secondary hemorrhage.
Separation of the pedicle by means of the wire ecraseur of Braxton Hicks, by that of Meier and Meltzer ' or by the constrictor of Maisonneuve is simpler, but does not secure complete protection against hemorrhage. The ordinary erraseur is very difficult of application, in spite of Marion Sims's chain adjuster, and does not afford immunity from hemorrhage.
Bayard' witnessed such dangerous bleeding, after removal of a pedicri lated tumor by the icraserer, that a resort to acupressure was necessary. The chief danger attending the use of the ecraseur consists in the inclusion by the loop of the tissue adjoining the tumor.
Tillaux' opened the peritoneal cavity, while removing a fibroid with the ecraseur, and death resulted from peritonitis.' The removal, by Boeckel,'
of a myoma attached to the posterior lip of the os uteri, with a wire con strictor, was followed by fatal tetanus.
The separation of pediculated fibromata by ligation of the pedicle, a method often resorted to since the time of Levret, must be absolutely re jected. The danger from septicternia, phlebitis, peritonitis, etc., attend ing this method, are so great that its employment might almost be desig nated as malpractice. Idras ° recently reported another fatal case of this kind. West ° says that R. Lee lost nine out of twenty cases of this variety, thus showing the mortality attending the method to he almost twice as great as in lithotomy, and higher than in Asiatic cholera. If the pedicle can be easily ligated and if hemorrhage seems likely to occur from antemia, let ligation b3 resorted to, but let the pedicle be imme diately cut off, below the ligature, in order that gangrene of the tumor be avoided.
In some cases, the pedicle is so thin and slender that a few powerful, rotatory movements suffice to separate the tumor. This process is, how ever, seldom adapted to the removal of pediculated fibroids, and must be employed only where it succeeds without resort to unusual force.
The pedicle must be divided as near to its uterine attachment as pos sible. In certain cases this rule may be disregarded, since its observance is often difficult and liable to produce lesions of the uterine tissue. The remnant of the pedicle usually produces no inconvenience. It contracts and remains as an insignificant stump, or gradually sloughs. away. If such a remnant be easily accessible, it may be destroyed by cauterization. It is not proven that new fibroids may be developed from the stump of the pedicle, a fact explained by the anatomical character of these tumors. The case is, of course, different if only partial enucleation of a large fibroma has been performed.
Although the removal of pediculated fibromyomata is not always easy or safe, the operation is still so comparatively trivial and so free from danger, that it is the plain duty of the physician to remove thorn. as soon as the pellicles are accessible without much difficulty. The rev2rse is true of interstitial fibromyomata. These interstitial tumors which have grown symmetrically in both directions, and hence project equally into the uter ine cavity and into the peritoneal cavity, must not be enucleated, since the operation would involve too serious a laceration of the peritoneum.