OPERATION FOR LARGE FIBROID OF THE UTERUS

WITH REMARKS.

J. G. Earnest, M.D., Atlanta, Ga.

Minnie Turner, aged 42 years, negro, of medium height and slender build, married, has never been pregnant. Her menses for several years past have been irregular, coming about once every three to five months, lasting three days and accompanied by rather severe pain during the whole time. Pulse 80, temperature 99, when admitted to the Grady Hospital, January 6th. Appetite good, tongue coated, bowels constipated. Complained of pain and pressure in the abdomen and looked like a woman ready to be confined at full term. The abdomen was occupied by a fibroid tumor that extended from the bottom of the pelvis to the margin of the ribs and stood out very prominently in front.

She first noticed a small hard mass just above the pubis nine years previous. This mass steadily increased in size until the present enormous proportions have been reached. After some preliminary treatment, consisting mainly of clearing out the bowels and improving her digestion, she was brought to the operating table at 2:45 p. m., January 14th. A long incision in the median line, reaching from the pubis nearly to the ensiform cartilage was necessary to get out the tumor which was nearly symmetrical in shape and was firmly adher ent to the abdominal and pelvic walls over its entire surface, except the upper portion which was completely plastered over with coils of intestine and omentum. The adhesions were evidently of long standing, as they were unusually tough and vascular and bled so freely from the abdominal walls that the hemorrhage from this source proved to be a very serious matter, threatening the life

of the patient. On account of the large surfaces involved and the great number of bleeding points it was impossible to tie or clamp the vessels or even bring them into view, until the tumor was removed. This required an unusual length of of time on account of the tough adhesions in the lower pelvis and the large number of ligatures that were necessary to secure the vessels in the omentum and coils of intestine dissected off from the tumor. In the meantime, the hemorrhage was partially controlled by packing pads wrung out of hot water in between the abdominal walls and the tumor. Finally the broad ligaments were clamped and cut loose at the upper side, the bladder stripped down and the cervix cut through and the tumor removed.

The toilet of the peritoneum was made in the usual manner, by tying off the uterine and ovarian vessels, uniting the cut surfaces of the cervix and covering the raw surfaces with peritoneum. Plain cat gut being used exclusively in the abdomen. The abdomen was flushed with hot salt solution and closed with three rows of sutures. The peritoneum and muscle sheath with No. 2 plain catgut, the skin and fascia with silk-worm gut interrupted.

She had while on the table by infusion 1,000 C. C. normal salt solutions-and hypodermicaly camphor ether Gtt. XV., strychnine 1-30 grain, Spartin Sulph. Gr. II. When put to bed the foot of the bed was elevated about forty degrees and a pint of warm salt water injected high up into the rectum, while the body was covered with blankets and surrounded with bottles of hot water,11

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The tumor weighed forty-one pounds and eight ounces. The operation lasted two hours and five minutes: When she left the table her pulse was 168 and very small. Half an hour later it had dropped to 144 and at 10:00 p. m, it was 120 and of fair volume. The foot of the bed was not changed for twenty-four hours, when it was dropped down to about twenty degrees, in which position she was kept for two days before bringing it down to a levels She had two grains of Spartein Sulphate and 1-40 grain

of strychnine hypodermically every four hours and a pint of salt solution with a tablespoon full of panopepton by rectum. After two days the rectal injections were discontinued.

On the night of the fourteenth day after the operation she began coughing freely and the temperature ran up to 104 degrees. There was considerable dullness on percussion over upper part of both lungs. On the following day there was a small amount of rust colored sputum. The high temperature continued with more or less variation for a week, when it dropped to normal. The patient left the hospital on the thirty-second day after the operation with normal temperature, good appetite and rapidly improving in strength and flesh.

In preparing cases of very large fibroid tumors of the uterus for operation it is well to keep the bowels open with saline aperients for several days previous to operation and at the same time keeping the kidneys flushed with alkaline waters, so as to relieve as far as possible the congestion of the kidneys which is almost always present in these cases as attested by the presence in the urine of albumen, granular casts, and frequently pus and blood corpuscles. In my early operations I was much exercised over this condition and hesitated to operate on acount of the supposed danger from the anesthetic under such circumstances. As, however, operation was in many of the cases an immediate necessity on account of the pressure of the tumor, the risk had to be assumed. As I do not recall an instance in which any serious complication followed from this cause I have come to think less of it as a draw-back to operation. Ordinarily the kid neys rapidly return to a normal condition after removal of the tumor and the institution of proper post operation: treatment.This treatment consists mainly of saline infusions, high enema for normal salt solutions, the hypo-` dérmic injection of Spartein Sulphate and free use of al kaline waters as soon as the patient can retain them.

Every operating room should be furnished with an electric battery suitable for stimulating the heart's aetion in case of collapse. I am absolutely certain that I have saved two cases on the operating table by the use of electricity that could not have been saved without it. Neither of those cases were being operated for uterine fibroids, but the same condition is liable to come up in the course of any serious operation and for that reason the battery should be a part of the furnishing of every well equipped operating room. Fortunately, it will be needed very rarely, but, if you ever should need it, it will be too late to get one after you find it out. The Trendelenburg Position with artificial respiration and infusion of salt solution may be all that some cases of shock require, but, if the heart stops, nothing but electricity can start it.

Next in importance after securing the action of the kidneys, is the question of when to move the bowels. Thirty years ago operators generally gave their patients all the morphine required to relieve pain during the first week and frequently there was no attempt to move the bowels for that length of time. I followed that plan for several years without any serious trouble from it. Then came the change of opinion that swung the pendulum to the other end of the arc-the argument being that troublesome intestinal adhesions were less apt to form and that the patient's temperature ran lower and there was less danger of septic trouble from the presence of effete matter and poisonous gases in the intestines. Under circumstances that require it (for instance if a rent has been closed in an intestine or a resection of the gut has been necessary in the course of the operation) there is no reason for haste in moving the bowels as a certain amount of gas in the intestines rather stimulates the peristalists and tends to prevent adhesions by preventing the flacid folds of intestines from resting flat against raw or inflamed surfaces. Usually a pint of normal salt solution thrown high up into the rectum every four hours

will not only assist materially in flushing the kidneys, but will generally prevent the lower bowel from clogging and producing over distention by gas above. If there be no contraindication it is best to move the bowels on the second or third day by small doses of some mild saline cathartic given every two or three hours until it acts. As to the use of opiates it seems advisable to use moderate doses of morphine or codeine if required to relieve pain,-it stimulates the patient and tends to prevent post operative shock. However, we should never lose sight of the danger of over dosing with opiates on account of the interference with the excretory apparatus.-especially the kidneys.

DISCUSSION

Dr. F. W. Schnauss, Cecil: I should like to ask Dr. Earnest what current he used. Would it not have been advisable to have removed this tumor in halves as done by Dr. Noble? With a curved knife he divides the tumor and delivers it in halves.

Dr. J. G. Earnest, Atlanta (closing the discussion): In answer to Dr. Schnauss I would state that the kind of electricity feasible was a fairly strong current, no matter whether from a Faradie or secondary. One should

use a course wire and a current of moderate strength.

With regard to splitting the tumor prior to its removal, that procedure is somethimes feasible, although I have never used it in many of my cases. Some operators are very fond of using it in large fibroids of the uterus but I cannot see how this method could be applied in the case I spoke of. This tumor filled the entire abdomen; it weighed forty-one and a half pounds and it would have been a very difficult matter to split it. In fact it was a very difficult matter to even peal it loose from the abdominal wall. I think it was better to operate in this case as I did. I have never been partial to the method referred to, although I have used it a few times. I like the old fashioned way the better.