HISTORY OF THE REMOVAL OF A LARGE SESSILE SUB-MUCOUS FIBROID BY ENUCLEATION. By HENRY MOELLER, M.D., New-York. a native of Germany, æt. THE patient, Mrs. X46, is the mother of ten children, the youngest of whom is ten years old. She was perfectly well until nine years ago, when she had an abortion at about the third month of pregnancy. After that, she never regained her full health, though she had no marked suffering until two years and a half ago. At that time, menstruation became more painful and prolonged, the flow was more profuse, and appeared every three weeks, the intervals between the periods being less than two weeks. She gradually became anæmic, lost flesh and strength, and was fretful and irritable. This condition continued until about a year ago, when she consulted me. She then had, in addition to those already mentioned, the following symp toms: rheumatic pains in both legs, especially the left, which was quite cold and had varicose veins; swelling of the feet and the lower parts of the legs, which was more marked at the approach of menstruation; a variable appetite and impaired digestion; great tendency to constipation and tympanitic swelling of the abdomen; a very irritable bladder, small quantities of urine, of high specific gravity, being discharged at short intervals; a constant feeling of uneasiness in the pelvis, which at menstrual periods became increased to severe pain, most intense over the right iliac fossa, that confined her to bed for from one to three days. At these periods the flow, after having been established for a day or two, would cease for a day, and then make its reappearance after excessive pain throughout the pelvis and the discharge of clots. From the sixth to the tenth day, the flow consisted of a serous liquid of a turbid, bloody appearance. During the intervals of from ten to fourteen days be tween the periods, there was more or less discharge of a muco-purulent liquid. As the patient objected to a vaginal examination at that time, palliative means were employed for the relief of distressing symptoms. Ferruginous and other tonics were used with some little benefit, as she did not lose strength while taking them. Pepsine was given for the digestion, and sometimes a mild cathartic was of service. She continued in about the same condition until the 8th of last August, which was the eighth day of menstruation, when the pain through the pelvis, back, and limbs became excessive, the suffering being like that of labor, while the anodynes usually employed gave her but little relief. A digital examination being now consented to, a hard, resisting tumor about the size of a man's fist was discovered, protruding partly through the os uteri, which was largely dilated and very thin and tense. The insertion of the finger between the tumor and the os was difficult and gave intense agony. Pressing the tumor upward allowed the escape of a moderate amount of reddish serum. Later in the day, several large clots were discharged, which relieved the patient very much. Serum and clots were discharged alternately up to August 17th, the patient suffering more or less during the whole time. After making the diagnosis, an operation for the removal of the tumor was advised at once as the only means of giving permanent relief. This the patient readily consented to; but owing to the absence of Professor T. G. Thomas from the city, it was delayed. From August 29th to September 5th, clots and blood were again discharged. Professor Thomas being then called in consultation, confirmed the diagnosis. The lower portion of a hard tumor was felt attached by a broad base to the posterior wall of the cervix and uterus when the uterus was pressed firmly down. The following diagram will convey to the mind of the reader the attachments of the growth. September 9th, at 3 P.M., was agreed upon as the time for the operation. At that hour the patient, after a light dinner of beef-soup, egg, and a little wine, was ready for the operation, and confident of its success. A table having been prepared, the patient was placed on her back upon it, and ether administered. Prof. Thomas then proceeded to operate in the presence Having of Drs. Brown, Ward, Walker, and myself. introduced the whole hand into the vagina, he passed along its palmar face a pair of long, curved scissors, and by these cut into the capsule. Putting his index-finger into the opening thus made, he tore the orifice so that he could run between the capsule and tumor a grooved director made for the purpose, as large as a No. 10 steel sound; sliding the scissors in the groove of this, he then cut freely across the capsule over its entire unattached surface. Removing the scissors, he commenced enucleating the mass, and after thirty minutes of very hard labor, removed a fibroid the size of a large Irish potato. Again passing in his hand, he detected at the fundus a round, protuberant body, which he at first regarded as the fundus uteri, but upon further investigation he found this to be a portion of the mass already removed, and after twenty minutes more of effort, he removed this also, with the entire capsule of the tumor. The whole operation occupied fifty minutes. There was not much hemorrhage, and the patient stood it well. The following diagram, taken by photograph, represents the tumor with its capsule attached. It was of about the size and shape of a moderate-sized human heart when bereft of its capsule. It was three inches and half in length, three inches wide, an inch and a half thick, and its weight was a trifle over eight ounces. It was composed of twelve fibroids, varying in size from that of a kidney to that of a large pea. Each fibroid had its own capsule, and all were connected most inti mately by thick and strong fibrous bands looking like the columnæ carneæ. Similar bands also surrounded the entire surface of the tumor, and were equally firm in their attachment to its capsule and the uterine wall. Sections having been taken, were found to be very white and glistening, like tendon; and when examined by the microscope, were seen to be almost entirely composed of slender fibres arranged in closely packed bundles. The patient regained consciousness in about an hour after the operation and complained of pain. She was |