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I will, in more or less detail, refer to some cases of reputed malig. nant diseases of the womb, and of its appendages, which have come under my notice, and for which means have been used, with a view to curative agencies.
Cases of Cauliflower Excrescence. Case. I.--Mrs. - Tumor small, insensible, springing from the os uteri. Drain of watery fluid from vagina constant and great ; occasionally hemorrhage ; much exhaustion, and evident sinking from disease. A ligature was applied round the tumor. It came away, bringing a few shreds only of what it had surrounded. Dis. charge ceased. Upon examination no tumor was to be discovered. The os uteri from whence it sprang, was found healthy. Strength returned, and the patient after a time left the city without complaint. I have not heard of her since. Case II.-Mrs. M
The history of this case is very much the same with that above given. There was an insensible tumor springing from the os uteri, irregular in its outline, or rough from small projections. Watery drain constant from vagina-at times hemorrhage. Ligature was applied, and in a few days came away, bringing scarcely anything with it. The noose had sticking to it some very small remnants of the large tumor which it had surrounded. This woman recovered perfectly. Case III.-Mrs.
This woman had a tumor like those above described, and with like symptoms. She died exhausted by discharge of water and hemorrhage. I saw her after death. Scarcely any appearance of tumor was discovered. In this case ligature was not applied.
CASE IV.-Mrs. K- I was desired in December, 1846, to visit Mrs. K. I found her in bed, thin, pale and sallow, and appa. rently suffering from some chronic and exhausting disease. She said she was over 40 years old, had been married ten years, and had never had children. Her complaint, she continued, was a tumor of the womb, which was of more than a year's notice by her. At times much hemorrhage occurred from it, and at all times a watery discharge. Of late this had become so great as to exhaust her exceedingly, and she thought that it would be impossible for her to survive many weeks if it continued. It was sufficient to wet forty large towels a week, sometimes eight in a day. It was water, without colour, without smell, and without inucus. The disease was in no sense, or in itself, a painful one. It pressed against the sacrum and produced pain in that bone, and it obstructed much the rectum, and so troubled its functions. She added, that within a short time emaciation had rapidly increased, and her strength had failed. She wanted to live. She would endure anything that she might live. I have heard the desire to live expressed by many, and when death was near at hand by cause of sudden diseases, or accidental occur. rences, without precursory disease ; but I never heard it utter itself with such emphasis as it spoke from that woman. She had a face which expressed in the strongest manner her whole feelings, and
having passed her hand over it as if to remove from it whatever might diminish the power of what she had to say, bent her eyes upon me as I leaned over the foot-board of her bedstead, and said, " Have you
the heart, Sir, to do an operation which may save life, though it be at the risk of taking it? That is the question which I want answered, and in the most distinct manner." I said that I believed I was equal to my whole professional obligation, and would state to her what might be my duty specially to her, after I had learned by an examination what was her disease, and that I would act as that duty seemed to me to demand. She said that her case had already been examined, but no operation recommended, but she could not yet give up. She begged me al once to make the examination which was to settle the course I was to pursue.
Upon examination I found a tumor filling the vagina, and which was most developed in its sacral aspect. It was hard and perfectly insensible. It was not regular in its outline, but had projections, and superficial, and deep sulci between its rounded and ridge-like inequalities. It was of a greyish colour, and the discharge from it was an inodorous, colourless water. I said I saw nothing in the character of the tumor to forbid an operation. I described to her the operation, the ligature, and stated that it would give her little or no pain. I learned that a professional friend of great surgical knowledge and reputation had been asked to see her, but had not called, and said that I would request him to see her, as I wished to have his opinion of the operation I had in view. He called the next day, and wrote me that he thought the tumor presented no objections to the ligature, that an operation in the case might be done, but that in. flammation might follow, and the tumor might re-appear.
This opinion was stated to Mrs. K. She determined to submit to the operation, and to abide the issue.
A ligature was passed round the tumor, in the close of December, and it was purposely applied as high as it could be done. It was not found so easy to do this as was supposed, and as those who never made the attempt may imagine. The tumor filled the vagina. It was exceedingly irregular in its outline. The double canulæ of Gooch was used, and easily carried along the fingers, to the root of the tumor. The attempt now to separate the two, by keeping one fixed, and sweeping the other horizontally round the iumor, was embarrassed by many obstacles. It was at length done, and the silver clasps carried along the tubes to make them again one instrument. The ligature was now drawn tight and secured. Some pain followed this part of the operation, but soon subsided. It resembled the dragging sensation which I have heard complained of in other cases. The next day I found the instrument very far out of the vagina, and upon examination discovered that the ligature did not embrace the whole of the tumor, but had been carried by the canula into one of the deep depressions of the tumor, instead of encircling the base. I state this thus particularly, as a caution in applying the ligature round uterine tumors, especially malignant ones, which are much more apt to be
irregular in their outline than are the non-malignant. Said a physician who very kindly assisted me in this operation, let those who are astonished at a failure in doing such an operation try to do it themselves, and they may learn that there are difficulties in the way they hardly dreamed of. The ligature was now removed, and then applied again, and with entire success. It was tightened every two or three days, and each time showed that there was a gain on the tumor. Some days the ligature could be drawn an inch before it stopped. Generally not so much. There was always pain on drawing the ligature. It, however, was never a permanent pain, or of any long continuance. An opiate was often given to remove it, and doubtless made the time of suffering shorter. The instrument began at length to project farther and farther from the vagina. The ligature showed by its length that very little of the tumor remained encircled by it. I now examined the vagina, and found it empty. I could feel nothing but the canula, and a small loop of ligature encircling a portion of the original tumor which had not disappeared. The os uteri, excepting this spot which looked to the sacrum, was perfectly smooth and even in its outline, not a shred of tumor remaining except at the point referred to, and this was firmly within the grasp of the ligature. There was no discharge from the vagina. There had been scarcely any since the ligature was applied. What discharge did take place was the liquified tumor as it was cast off by the living textures from which it had been separated by living agencies. Nothing like a tumor had been thrown off. The ligature was now daily tightened, and I daily looked for its coming away. On the twenty-second day from the use of the canula, I found Mrs. K. in unusual spirits, and hiding something under the bed-clothes as I entered. I asked what it was. She at once drew out the instrument, which she said had come away that morning, and which she was now rubbing very carefully to restore to it its original brightness. I asked if anything had come away with the ligature. She replied, yes, and showed me a thin small mass, like dense membrane, on a towel. Upon examination I found that portion of the tumor remaining, round which I felt the ligature, of the size say, of one joint of the thumb, projecting from the posterior lip of the os uteri. I asked how it happened that the instrument had come off before separating the tumor. She said that she felt a strong desire to rise from bed to evacuate the bowels, and that, in suddenly moving, the instrument had been caught in the bed-clothes and was torn away from the vagina, giving her exquisite pain. I made no attempt to re-apply the ligature, for such was the stiuation of the remaining portion of the original disease that I did not believe that a ligature would hold on it.
Mrs. K. now rose from bed. Took exercise. Got excellent appetite. Gained flesh, and felt well. Not the smallest drain occurred from the vagina of water, of pus, or of blood. Her feet and ankles swelled, but at length this swelling disappeared. But after some weeks signs showed that the disease had returned. There was again water, and blood, and pain. She began to fail, and in five months after the operation she died. To the last she never regretted the operation. It had lengthened life and enabled her to enjoy it. Cheerfully would she submit again to the same measure, if it promised her the least chance of continued existence. I could offer her no inducements to submit to it. Her power of living was well nigh gone, and she sunk and died.
Cases of Uterine Polypi removed by Ligature. Case V.-Miss. S., aged 18. Came under my charge last summer. She was perfectly anæmic. I have seen many instances of this disease, but in no one do I remember its physiognomy to have been more strongly marked. The lips, gums, tongue, inside of cheeks, carunculæ lachrymales, nostrils, every texture was blanched. She had suffered from uterine hemorrhage for about four years. She had grown tall in that time, the time of growing, and was not emaciated. Other signs were palpitation on exertion or mental emotion, with dyspnea, a sharp, quick, and frequent pulse, pink-colored veins, ringing or rather buzzing in the ears, and a throbbing of the cerebral arteries, compared to the sound of the discharging pipe of a steam engine. Stomach at times irritable. Great feeling of lassitude, and of exhaustion. The catamenial periods were attended by excessive flow, and in the intervals hemorrhage was frequent. She had been recently examined, and a tumor projecting out of the os uteri diagnosed. Upon examination I found the tumor to be very hard, insen. sible and small, of the size of a small pullet egg. Hemorrhage attended, and followed the examination. I could not reach the pedicle, if the tumor had one. I was disposed to consider it as springing from the cervix with a broad base. The ligature was applied. I tried different canulæ in this case, and though the tumor was not large, I found the largest instrument to answer best.
Pain was produced by tightening the ligature. As soon as pain occurred, the ligature was fastened where it was. Some soreness of the abdomen was complained of next day, and the instrument was not touched. The next day it was tightened, and pain again produced. Soreness of abdomen again occurred. I was satisfied ihat the tumor was insensible, but the neck being very short, if any existed, the strain of the whipcord was upon the womb, at the spot whence the polypus sprung. This explains the pain and the abdom. inal tenderness. In about a week the tumor and instrument came away. The polypus was perfectly white. I scarce recollect so white an animal texture. From this time hemorrhage ceased. The catamenia became regular, and the patient is now perfectly well. The tumor was accidentally lost.
Case VI.—Mrs. W., aged about forty ; has children. Has suffered greatly of late from uterine hemorrhage, and the exhaustion induced. Of late she has been obliged to keep still, and in bed, as in this way only can she prevent flooding. She suffers many of the symptoms given in Miss S.'s case, but not in so severe a degree. Within a few weeks her case has become alarming, and her physician, upon cxamination per vaginam, discovered a tumor projecting from ihe os
uteri I was desired to see Mrs. W., and upon examination detected a tumor, in, but hardly projecting from, the os uteri. It was hard and insensible. It was closely embraced by the os uteri, so close that I could only pass a probe between them. It seemed very much as the glans penis looks in a severe case of phymosis. The woman was bleeding badly every day, but it was not possible to operate. It was advised to give her ergot in ten-grain doses, as often as five or six times daily, if her stomach would bear it. This was done, and pains in region of womb produced, and after a few days I found the iumor so much out of the womb as to allow the use of the ligature. It was applied. Hemorrhage at once ceased. Pain in the womb and abdomen was produced by tightening the cord, as in Miss S.'s
But no untoward complication ensued, and in four days the tumor came away ; since which, Mrs. W. has done perfectly well. The tumor was very firm and of a deep red color.
Cases of Ovarian Tumor. Case VII.-Mrs. ; married, has children. I saw this patient with Dr. Hanaford, A tumor, filling most of the lower part of the abdomen, presented itself. It was unequal in its outline, as if composed of many tuniors. It was felt in the vagina, and so far filling it as to press the neck of the womb firmly against the symphysis, giving much trouble in passing urine. The uterine periodical function continued. Much suffering attended this disease. At times acute inflammatory attacks. The health had sunk, emaciation had occur. red, the situation of the patient seemed hopeless. In its treatment constant efforts were made to sustain the patient while means were used to keep inflammatory processes in check, and to prevent increase of the tumor. Leeches, vesication, iodine ointment, hydriodate internally, sol. muriate of lime, &c., were among the means employed. At length a new symptom showed itself, which was the precursor of recovery. An involuntary and copious liquid discharge took place from the rectum. Some of it was collected in a vessel and examined. It was a perfectly transparent, dense, gelatinous liquid, very adhesive, and having a distinci albuminous odor. There was not the least trace of fecal smell in it at any time. The discharge went on. The tumor grew less. The pains which Mrs. had so long suffered, ceased. She regained appetite, strength, flesh, and is now well. Is not this case of some interest in this regard, that it shows how a disease of the ovary, consisting of a fluid deposit, and threatening life, may disappear, and recovery happen, where opportunity is offered for a constant discharge of the fluid as it forms. The sac or sacs thus have an opportunity to contract. New processes occur in them from exposure to the air, and at length the sac disappears. What is done by a rude surgery, the pulling away, or cutting away the sac, or removal of the tumor by excision, is done by a geniler and wiser hand, and recovery follows. May not the ovary be punctured through the rectum, or vagina, and the natural surgery be thus in some sort imitated ? Case VIII.-E. L., about 30, unmarried. Has a large tumor oc