Chrobak " has added 11 cases of his own (all successful), and 12 operated upon by C. v. Braun,' with 5 deaths, to this number, which brings the total up to 153 with 23 deaths, a percentage of 15. If we add 2 cases by Bidder,' and Engstrom,' and two unpublished cases of my own, which were all successful, we get a grand total of 157 cases and 23 deaths, which is equivalent to a mortality of 14.6 per cent.
From the statistics given above, it is at least possible to deduce the conclusion that the enucleation of interstitial fibromata is an exceedingly dangerous operation, and yet not so dangerous as to be unjustifiable, under certain conditions. The statement made above, that every sub mucous, pediculated fibroma, which is accessible, should be removed, does not by any means apply with equal force to all interstitial myomata. In the first place it must be established what tumors of this variety ap pear accessible for the purpose of the operation, and then the indications for the operation in these cases must be defined.
We have already stated that only those interstitial myomata are adapted to the operation which have been chiefly developed in the direc tion of the uterine cavity, and are, therefore, covered by as thick a mus cular layer as possible. It is by no means easy to establish the existence of these relations. It has been held that tumors of this description can not be sufficiently displaced from their original seat, by uterine contrac tions, as to become accessible. But this has not been established. The relations of the tumor to the peritoneum may be better determined by palpation, and if possible by rectal touch. During enucleation it is also wise to locate the tumor, from time to time, by external palpation or by rectal touch, especially when considerable downward traction is being em ployed.
Although large tumors are often successfully removed, very bulky ones projecting far into the abdominal cavity are not adapted to the operation for several reasons. It is, in the first place, rarely possible to completely encircle them. Moreover, marked attenuation of the uterine walls attends the development of such fibromata, and they often can not pass through the pelvis, even when comminuted. Finally gradual and partial enucleation is attended by especial dangers.
Enucleation is, also, always contra-indicated when the tumor has no capsule, or when the tumor's attachments to the uterus are so intimate and so extensive that a separation seems impossible. The so-called adhesions between the tumor and adjoining tissues, which are usually only strong muscular fasciculi extending into the tumor from the uterine walls, very frequently render enucleation impracticable, or so hinder it that it must be interrupted in order to be resumed after the occurrence of necrosis. There
are, unfortunately, no means of discovering this connection between the uterine parenchyma and the tumor before the operation. The relation of the fibroma to the lowest selment of the uterus has the moat impor tant bearing upon the success of the operation. A long and conical por tio vaginalis, with occluded os uteri, renders every effort at enucleation futile. In these cases, the tumor is either located so high in the uterus, or in such close proximity to the peritoneal cavity that the opera tion is either impracticable or too dangerous. The prospects of a success ful operation are in direct ratio to the shortening of the lower uterine segment, to the permeability of the os uteri and to the facility with which the tumor may be felt within the latter.
Courty evidently does not make a sufficiently sharp distinction between interstitial and broad-based sub-mucous fibromata when he requires, as one of the favorable prognostic signs, that the tumor shall, on traction, show evidences of possessing a pediclo. This is, however, often difficult whether from a clinical or from an anatomical standpoint.
At all events, all severe traction on such a tumor, before the perfora tion of the capsule, should be discountenanced, since it may lead to in version, rupture of the peritoneum, hemorrhages, and, through injury of the capsule, to gangrene.
If all the above-mentioned conditions are favorable, the indication for an operation is seldom doubtful. A fibroid of the kind in question almost always produces violent hemorrhages, which, of themselves, threaten the life of the patient. The pains are also, rarely absent, and the beginning symptoms of incarceration are often present. Rapid growth or sterility Marion Sims) may likewise justify the operation of °nucleation, more particularly in cases of cervical tumors. Another indication for enuelea tion is beginning gangrene of the tumor, for the danger of systemic infection is only obviated, in such cases, by the removal of the offending mass. In this spontaneous gangrene the removal of the tumors is, ordi narily, easy, since the capsule has already burst, and the connections between the fibroma and the uterus have been weakened by a dissecting necrosis. One must, nevertheless, not operate too early, even in these cases, for the more difficult the operation the more numerous and unavoid able are the wounds necessitated by its performance and the more easy the absorption of septic matters.