Fibroids causing Sionptoms.—The palliative treatment of symptoms caused by fibroids is not very satisfactory. In most cases it can only be temporary, as the symptoms are likely to increase in severity, and it is in the highest degree ill-judged to allow a patient to become anemic, wasted, and an invalid from haemorrhage or pain before setting about the removal of the cause of her sufferings, since the risk of operation is increased without gaining any advantage by its postponement. Haemorrhage may be relieved by rest in bed at the menstrual epoch. Ergot and ergotin are sometimes given, hut have very little effect, as the loss is not one which can he checked by improving the tone of the uterine muscle. Calcium lactate in 2o-gr. doses may he given with a view to increasing the coagula bility of the blood, and with the same object sterilised gelatin has been injected. Styptol, thyroid extract and hydrastis canadensis have also been employed. An alarming haemorrhage can usually be checked for the time by a firmly applied vaginal or intra-uterine tamponade. Curetting with subsequent tamponade of the uterus gives relief which may last for some months, hut there is a certain amount of risk of setting up necrosis of the tumour. Both pain and haemorrhage are often relieved by the use of copious hot (i to° to F.) vaginal douches. Cases of lriemorrhage may he put under radio-therapy, but it should be remembered that the first effect of the rays is often to increase the hemorrhage for a short time.
f a patient is very anemic and weak it is advisable to put her to bed, and to institute a course of iron and forced feeding (see under Anemia) before subjecting her to operation. The choice of operation depends on the conditions present and on the age and circumstances of the patient. Speaking generally, the most satisfactory operation is a supravaginal hysterectomy, which confers almost complete freedom from the possi bility of uterine trouble in the future, and has less immediate risk than a complete hysterectomy, the operation recommended by' some surgeons on account of the possibility, remote though it is, of cancer developing in the cervical stump. Nlyomectomy or the removal of the tumour, leaving the uterus intact, can be carried out most successfully if the tumour is small and single. The risk is rather greater than that of a supravaginal hysterectomy, and there is always the probability of a second fibroid developing in the uterus. It should be reserved for cases in which pregnancy is still possible, and the whole facts should be put before the patient, as she has certainly a right to decide whether she will run the risk of a recurrence of her tumour for the sake of a rather problematical chance of becoming a mother.
A cervical or pedunculated submucous fibroid can he easily and efficiently dealt with by the vaginal route. Small submucous tumours
may he enucleated by the same route after incising the anterior wall of the uterus. Subperitoneal tumours are best dealt with through the abdomen. In the removal of a sloughing fibroid care must be taken to insureadequate disinfection of the uterine cavity and to provide free drainage afterwards. If the tumour is in the cervix it can be twisted out with Schultze's spoon forceps, and the cavity lightly packed with iodoform gauze. If it is in the interior of the uterus, a thorough douching should be given with antiseptic, and the uterine cavity firmly packed with gauze wrung out of 4o per cent. formalin before the organ is removed. The vagina should then be packed with dry sterilised gauze, which should be removed by an attendant as the vagina is severed, for it is advisable in these cases to do a complete hysterectomy, and vaginal drainage should be provided.
In regard to the after-treatment the practitioner is referred to the article on Operations. He should he especially on the watch for symptoms of intestinal obstruction which sometimes arises after hysterectomy through adhesion of bowel to the wound in the pelvic peritoneum, and also for symptoms of phlebitis, which is a fairly common sequela in these cases.
Fibroids in Pregnancy. —A pregnant woman with a fibroid is exposed to several dangers. She is likely to abort or to he confined prematurely. The fibroid, if situated in the cervix or lower uterine segment, may block the pelvis or may lead to a malpresentation. Its presence may cause ante- or post-partum hemorrhage. During the puerperium, necrosis of the tumour may occur. In spite of all these possibilities it is wonderful how many women with a fibroid go to term, are delivered and recover without a had symptom; and in many cases the fibroid is even reported as having disappeared with the normal involution of the uterus. One must make allowance in these results for mistakes in diagnosis, since not every firm area in a pregnant uterus is necessarily fibroid. Still, sufficient well-attested cases remain to lead one to adopt a waiting policy unless urgent symptoms develop. Even when a tumour seems to block the pelvis it is wiser to wait for labour to begin, as it may be drawn up by the con traction of the uterus. If it is not, Cwsarean section can be done followed by a hysterectomy. If signs of necrosis in the tumour make their appear ance during the puerperium, it is well to remove the uterus at once for fear of puerperal sepsis. The onset of hemorrhage or severe pain during the pregnancy is an indication for hysterectomy. A pedunculated subperitoneal fibroid may be removed without interrupting pregnancy, but attempted enucleation is apt to end in hysterectomy on account of the difficulty of stopping hocmorrhage from the bed of the tumour. R. J. J.