VOL. XIV. No. 25.

TERMS: $3.50 A YEAR.

ORIGINAL ARTICLES.

As regards the nature of the tumor, no positive diagnosis was made before the opera

FOR FIBROID OF THE UTERUS.-RECOVERY FROM OPERATION.

BY L. E. NEALE, M. D.

Chief of the Department of Obstetrics in University of Maryland. Demonstrator of Obstetrics, Etc.

Read before the Gynecological and Obstetrical Society of Baltimore. Stated Meeting held October 12, 1886.

Martha Bayton, colored, æt. 27 years, Va., an intelligent domestic, never pregnant or married. General health good and early history unimportant.

She first observed an abdominal enlargement during the fall of 1884, i. e., about two years from date, and the increase of this enlargement was accompanied by a gradual diminution of the menstrual flow, which, however, remained perfectly natural in other respects. The abdominal enlargement, it seems, was ascitic, for she had been tapped by another physician in Oct., 1885, when a large quantity of straw-colored fluid was removed, after which a tumor in the right iliac region was quite perceptible.

The fluid reaccumulated, distended the abdomen to forty-one inches in its greatest circumference, and forced the posterior vaginal wall outside of the vulva, whence it protruded

movable in the ascitic fluid, the failure of the uterus to descend with the posterior vaginal wall, in the absence of other recognizable cause to sustain it in its high position, (for the tumor did not fill up or press upon the pelvic brim) might have led to the diagnosis of adhesions, which, as already mentioned, were not suspected in this case.

The patient was in fair health, which was, however, beginning markedly to run down, and, although greatly inconvenienced by the abdominal distention, she was able to continue her household work up to date of admission into the University of Maryland Hospital, Sept. 15, 1886.

The operating room was fumigated with chlorine gas, generated by igniting a mixture of equal parts of ether and chloroform, it was then thoroughly scoured, cleaned and ventilated.

The spray was not used at any time, and the water, previously boiled, was carbolized too little to destroy germs.

The usual preparation of the patient was observed.

Operation Sept. 18, 1886, 11 A. M.

Incision in the median line finally enlarged to three inches and about three gallons of ascitic fluid removed. The tumor was found to be a non-pediculated, subperitoneal uterine fibroid, growing from the right cornu uteri and strongly adherent to the right anterior abdominal wall. Salpingitis and periovaritis existed on both sides, the appendages being closely and firmly adherent to the uterus.

All things considered, removal of the uterine appendages was judged to be the most favorable and practicable operation. This I found

task. In deed, I do not hesitate to say, it might have proved too difficult, save for the presence of my kind friend and teacher, Prof. Wm. T. Howard, who, both by wise council and practical help, assisted materially in the performance of the operation. For this I am happy to make public acknowledgment and to express my sincerest gratitude.

Silk ligatures were used and applied close against the uterine wall; the abdominal cavity was washed out with warm water poured into it from a pitcher; the incision was closed with ten silk sutures, and the usual simple dressings applied.

Duration of the operation nearly two hours. The patient rallied well, convalesced uninterruptedly. A menstrual like flow occurred from the third to the seventh day after the opertion. The sutures were removed on the sixth day. Patient discharged on twenty-first day, viz., Oct. 9, 1886, with no return of the ascites; incision thoroughly united and shrunk to 2 inches in length; tumor sunk below umbilicus making only a slight prominence through the abdominal wall; vagina retracted into normal position, and patient's general condition quite good.

I believe I am right in stating that in this case no positive diagnosis was made before the operation, although I must qualify this by saying that Prof. Howard did incline towards solid tumor, and in as much as fibroids of the uterus are the most frequent abdominal tumor in the African race, he suspected a fibroid.

of its strong adhesions to the anterior abdominal wall, and as it was non-pediculated would have necessitated supra-vaginal hysterectomy. The mortality of this operation under general operators (excepting Keith and a very few others) when compared with the natural death rate from fibroids-particularly nonbleeding sub-serous fibroids-we know to be fearfully discouraging: indeed, I had almost said render the operation unjustifiable. my case periovaritis and salpingitis existed on both sides, in all human probability unfitting the woman for generation; moreover, the fibroid was not very large and for all these reasons, with the full concurrence of all present, Prof. Wm. T. Howard included, the least of the two serious operations was selected, and as it seems with a satisfactory result.

In

Although I propose in this little article merely to give a brief clinical report of my case leaving the general subject of castration to be disposed of by older, more competent, and more experienced men, I cannot refrain from touching upon a few interesting points in connection with the operation, in the hope of eliciting instructing remarks from the members of the society.

I do not hesitate to say the most thorough, interesting article upon the subject I have been able to obtain, is that of Olshausen, published in the Handbuch der Frauenkrankheiten, Vol. II., ed. 1886. As this has not yet been translated into English and hence is practically a closed book to some of us, I shall here take the liberty to quote a few brief passages with especial reference to castration when performed for uterine fibroids.

Speaking of this operation when weighed against myomotomy, which as I understand it, includes supra-vaginal hysterectomy, he (op. cit. vol. II., p. 709-10 etc.) says: "I do not believe the time has yet arrived, when we can give a correct judgment with certainty upon this point. It should, nevertheless be remembered that Hegar and Wiedow, from the most recent observations upon large fibroids, even when subserous in character, hold castration to be very successful, and

hence they together with Kn. Thornton limit the indications for myomotomy to pediculated and cystic myomata."

The termination of this question Olshausen thinks must be governed by the given case and the operator, and that no absolute rule can be made. President Reamy speaking upon this subject, in his address before the American Gynecological Association, recently assembled in this city, said: "The operation of hysterectomy should not, as a rule, be performed in these cases. Spaying has met with more favor and success than any other surgical procedure." Hays' Journal of October, 1886, states: "Though the value of castration may have been disputed by several authors on theoretic grounds, yet all objections to it fade away before the statistics compiled by Wiedow, which justify us in regarding castration as the operation to be preferred in uterine fibromata." (p. 604) With regard to the results of castration for fibroids, Goodell, (Virchow and Hirsch, ib. 1878 II., p. 568), collected 98 cases; in 78 of these amenorrhea occurred, in 8 menstruation became more difficult, and in 12 it persisted.

Wiedow, in later statistics reviews 76 cases, in which the menopause occurred at once or after slight bloody discharges in 61

the decrease of the tumor is rapid and very marked, thus, Lawson Tait observed a five pound fibroid entirely disappear in six months after the operation. In a case where castration was performed intra partum (for fibroids) Williams observed the uterus to diminish to a size less than its virgin condition, the uterine cavity measuring only two inches, in seven months after the operation.

Olshausen says in one case he has also observed a marked and rapid involution of a large fibroid after castration. This patient was 39 years old, was in a profound state of anemia with general edema, and [entered the clinic in such an exhausted condition that it was only after a considerable time he dared to perform an operation. The uterus was of the size of a seven to eight months pregnancy. Three months after the operation, the tumor had shrunk to one half, and one year later to one-third its former size, and so it had remained after four and a half years, when he made his last observation. In this case menstruation never returned; the woman became the very picture of health, and performed the heaviest farm work. Amenorrhea did not occur at once, but there was an almost continuous bloody discharge for six to eleven months after the operation; then the bleeding occurred irregularly, with intervals of half a year, until they finally disappeared entirely, three years after castration. But the general condition so markedly improved during the first half year that a favorable result was then apparent. In another case, 37 years old, the menopause occurred at once and continued 24

be noticed that among those cases in which the menopause occurred at once, there was one case, and the only one O. has observed, in which the ovary was removed only on one side, as it was impossible for him to find the other ovary. Of course the probabilities are that it was functionally destroyed and hidden by disease, or indeed, may have been congenitally absent. Leopold, in one case, failed to extirpate any ovary, but merely ligated several blood vessels, and yet no further uterine hemorrhage occurred.

According to Olshausen, amenorrhea occurs in three-fourths of all cases of castration, and remains permanent. A slight uterine hemorrhage of several days duration, here, as after ovariotomy, may occur several days after the operation without signifying true menstruation. This may continue for hours or days, but is rarely profuse. Schroeder holds that a small bit of ovarian tissue, left after supposed removal of the ovary, may prove sufficient for a continuance of function. And again, Dr. Spencer Wells (American Journal of the Medical Sciences, October, 1886) tells us: "Wiegel counted, out of six hundred women examined, no less than twenty-three with more than the ordinary two ovaries." "Instances of regular menstruation, and even of pregnancy after double ovariotomy, have been met with sufficiently often to show how easy it is for the expectations of a surgeon to be thwarted by a condition which he can neither foretell nor determine exactly at the time of his operation." Such cases, however, are of course the exceptions. The largest and most recent statistics of castration for fibroids, according to Olshausen, is furnished by Wiedow, who gives 149 cases with 15 deaths, or a mortality of 10 per cent. Eleven of these Eleven of these deaths were due to septic-peritonitis. I have never seen the statistics of Mr. Lawson Tait, and other leading operators in this field, for castration when performed for uterine fibroids, but suspect the mortality must fall below 10 per cent.

Although it does not pertain strictly to the case herein reported, I am sure it would be interesting to hear an expression of opinion from those who have performed castration for psychical or other disorders not connected with fibroid tumors of the uterus, and when no anatomical evidences of disease are recognizable in the ovaries or appendages.

In this connection, Olshausen reports an exceedingly interesting case of a woman 26 years old, who for ten years had suffered severely from a number of disorders, and among others, from paralysis of the inferior extremities. Every evening at a certain regular hour, convulsive attacks of a most violent in

tensity, occurred, lasting with short intervals for one-half hour, during which time she was unconscious. Each attack was announced by pain in the region of the left ovary, and these pains continued during the entire night of the attack. Whenever the ovary was touched during an examination, with or without narcosis, pain was experienced which continued for several hours. Besides this, there were slight attacks of epilepsia brevis or petit-mal, occurring often during the course of the day, at which times the eyes were closed, the head fell upon one side, and after one-quarter to one-half of a minute, the patient awoke to consciousness.

All treatment proved nil and often these violent convulsive attacks had continued daily for ten entire months. On September 26, 1881, castration was performed without difficulty. At the operation not only were the ovaries found to be perfectly normal, but not even had any inflammatory process existed in the surrounding tissue. However, on the very evening of the operation, the convul sions failed to occur, and as yet in four years have never returned, as also has not menstruation. The attacks of petit-mal continued durthe first months after the operation, somewhat more frequent and severe than before, but after half a year they appeared less frequently, and finally disappeared altogether. The general condition of the patient improved from the very day of the operation. Similar cases are reported by Mäurer, Heilbrun, etc., and many others have appeared in our own English literature. In Olshausen's Own words, this case illustrates very plainly, that there are cases of severe cerebral and spinal symptoms, where, notwithstanding the absence of all recognizable abnormalities, (in the ovaries) castration may be performed with great advantage.

Sir Spencer Wells, in the October '86 number of the American Journal of the Medical Sciences, repeats a warning made in 1882, that although he accepts the principle, he sees that the operation has a very limited application, and is so open to abuse that its introduction in mental and neurotic cases is only to be

thought of after long trials of other tentative measures and the deliberate sanction of experienced practitioners." I presume no one will hesitate to accept this palpable truth, but when he adds: "Except in cases where bleeding fibroids may call for the extirpation of healthy ovaries, we might at least, require some evidences of the ovaries being diseased before consenting to their extirpation, etc., in the light afforded by the clinical demonstration of the above typical case of Olshausen, and a host of others that might be readily cited, I think this latter statement could be very justly questioned."

* *

At the recent meeting of the American Gynecological Association in our city, you will all remember with what keen and penetrating acumen Dr. Battey, of Georgia, in reply to a question from Dr. Barker, of New York, asking him to state the grounds on which he would advise the removal of the tubes and ovaries, said: "I do not require in my cases an absolute diagnosis of disease of the tubes or ovaries prior to operation. It is sufficient for me to know that the general health is broken down by reason of the perverted function of the ovaries, that she is utterly miserable, that there is no reasonable hope of restoration to health by other means, and that there is a reasonable prospect of restoration by removal of the ovaries."

Although to some this may seem a little like equivocation, in my opinion (if so young and inexperienced a man may be permitted to hold an opinion upon such an important question), this is as near to definiteness as we can arrive at present, or from present indications are liable to arrive for a considerable time to come. Hence, in some cases at least, I am inclined to rank myself as among those opposing Winckel and a very few others who require anatomical evidences of disease in the ovaries before their extirpation is considered justifiable. I think that in certain cases, ample clinical demonstration has sufficiently proved the following of this doctrine. As regards the age at which such operations are usually performed, Spencer Wells (op. cit.) says: "It would thus seem that in all the that in all the

older patients who submit to abdominal seetion, it is ovariotomy for cystic or other enlargements of the ovary that is done. Out of 171 cases undergoing the operation for hemorrhagic uterine fibroids, 53 were between 30 and 40 years of age, 62 between 40 and 50, and only 9 below 30. The number of cases of oophorectomy for other causes is comparatively small and few of them outside the middle age. The limits of our investigations of the diseases requiring oophorectomy are thus drawn within the narrow compass of 20 years of woman's life, between the ages of 30 and 50. The find here cannot in the common run of things, be very rich except for fibroids." Farther on he says: "The results of myomotomy are deplorable even now, and castration as compared with myomotomy presents us with a striking contrast of a mortality of only 14.6 per cent, a dimi nution of the tumors, a stoppage of the hemorrhages and a disappearance of many of the accompanying symptoms. Moreover, as half this mortality has been due to septicemia, there is here a wide field for surgical enterprise!"

TRACHEOTOMY WITHOUT TUBES.

BY ALEXANDER F. LEE, m. d.

Demonstrator of Anatomy Quincy College of Medicine.

In the issue of the REVIEW of October 23, 1886, in an abstract from the Canadian Practitioner, Dr. Bell, of Montreal, is advocating the use of "clips" in tracheotomy in preference to the tube, and his reason for such preference given. In closing, the REVIEW says: "The favor which this substitute met with in the section is another indication that thoughtful men are looking for something better than old methods in this direction." This would lead one to infer that the non-use of the tube

in tracheotomy was an idea but recently advanced, whereas it has actually been in prac tice a number of years. The late Dr. John T. Hodgen to keep the tracheal wound open, used what might be termed "clips" devised from