Sub-serous fibromata are not adapted for enucleation. Only those in terstitial fibroids which project far into the uterine cavity are to be treated by this method. The separation of broad-based fibromata, with very large pedicles, is, under these circumstances, not always easy, and many contradictory statements, in the literature of the subject, may be explained by this fact. Many an operator has been astonished at the fa cility with which the " enucleation " of a large interstitial myoma was per formed because lie had really only been dealing with a broad-based fibrous polypus. The only practical point of distinction between these varieties is the capsule of the tumors. If the removal of the fibroid can only be effected after the perforation of a genuine capsule the tumor is, indeed, an interstitial fibroma, and enucleation has in that case really been accom plished.
If the capsule be absent, the case is one of fibrous polypus, or of a half extruded interstitial myoma, which had already perforated its capsule and could be easily removed, either artificially or spontaneously.
Velpeau seems to have first conceived the idea of enucleation of fibro myomata projecting into the uterine cavity. Amussat first performed the operation and invited criticism upon it.' He was followed by Velpeau, Boyer, Berard and Maisonneuve.' Some what later Atlee gave a new impulse to the performance of enucleation in his work entitled " The surgical treatment of certain fibroid tumors of the uterus, heretofore considered beyond the resources of art," Philadel phia, 1853.
Various authors (as, for instance, Gilette, Annal. des. G'ynecolog. 1875, III. p. 68) have called attention to the worthlessness of all so-called statis tical compilations regarding the result of any operation for determining the value of the latter. In the first place it is well known that more suc cessful than unsuccessful cases are published. There are, moreover, great differences in the temperaments of various patients and in their physical conditions at the time of the operation. The manner in which the operation is performed, or accidental circumstances relating to the after-treatment, also, often influence the result.
So far as the operation in question is concerned, there are special diffi culties in the way of utilization of statistics, because, in the first place, the exact significance of the term enucleation has not been definitely estab lished. It is, moreover, frequently not stated whether, in a given case, the myoma was an encapsulated or only a broad-based one. In some instances
the operation has been performed upon gangrenous tumors, and, in others, the expectant treatment has been adopted, after the first operative inter ference, until gangrene has occurred. In still other cases the tumor has been removed at one sitting.
It is even more important, in estimating the results of a given plan of treatment, to ascertain whether enucleation was performed upon a tumor already protruding into the os uteri, and was oonsequently of easy access, or whether the reverse conditions obtained. The above remarks will suffice to show the hopelessness of attempts at proving the value or otherwise of this operaticni by statistics, and yet one cannot di,' reuse with the latter as a starting-point for inductive reasoning.
The same statement holds for all important operations. Statistics con cerning ovariotomy, for instance, only proved, in the beginning, that the operation was justifiable in certain cases. At present the statistics are disregarded, and scientific significance is alone attributed to the results of individual operators.
Just so long as the enucleation of interstitial fibromata is not per formed, in any considerable number of cases, by individual operators, so long must we be content with statistical evidence obtained from medical literature. We, therefore, insert separately at this place the statistics at present published. These must not be tabulated together, since some series of observations might then be counted several times. An analysis of these statistics, which are of varying value, would necessitate too detailed a consideration of each case, and thus transcend the limits of the present work.
West' carefully collected the cases published between 1840 and 1858, and reports 27 of enucleation with 14 deaths and 13 recoveries. lie, therefore, justly characterized the operation as one of the most dangerous kind. Manna's' well-known work, containing reports of 47 cases with 30 cures and 17 deaths, next appeared. Miinnel, himself, collected 22 new cases (since 1858), in 17 of which complete, and in 5 of which partisl, enucleation was performed. Three cases resulted fatally. Twelve of the 17 were neither pregnant nor puerperal women, and all made good recoveries C. Braun ° collected 60 enucleations, with cures in 41 cases, i.e. in 68 per cent.