An Address on the Treatment of Bleeding and Other Uterine Fibroids by Removal of the Appendages
Authors: A. Doran
Journal: BMJ (1894)

11{.'RlEA&TMIENT OF UTI.ARINE FlBRlOID)S."is e.ll11ly tas; thl eighlth day.Tl'lis syiiiptom ap)pea.redoil tile t%ven lty-lhl st (lay inl a patieiit on wliom I op)erated ill 1'ebruary, 18'S+.In C(ts1e thserle i%.s al feeliiig of e'xtremel wel4kne(ss ailid dlis(cmlfort wlivii a sli(rilt sliow appeazsred dlui-ill t}le t}iird WN1 k. '1Th l i iliary e^ruption sooii after opera(tion iiuist not be iraiiked as a ineui-osis of tile smnel class, if it be a neurosis at X111.InL CSase vi tllere were free pe(rspirations aind numb- iess of tlle tipper extremities.III C'aset II tlsere was sexvere lUn1bar Paini three n1ontlis after o}plt-iatoii, bUt t11e sutlPriiig was in great partdeue to a eliill.iNoineb of tlieseileuroses iilvolvez any dlanger.T}le stirgeon must alwrays.endeavour to remove e-very trace of ovarian.tissue.T}sis is easy andl safe wlien, as ill Cas 1X', tle ovariaii ligament is elongated.T}le task, howevc-r, not rarely proves to be impossible.The ovarian ligament, often very long wlien its ovary lias become a large cystic tumour, is, in tlle normal condition, frequeiitly too sliort to allow of a safe pediele if all the ovary be cut away.In casesi of large myma t}liis ligament frequently remains unstretched ang nmotyoliypertrop}liied.Moreover, j ust as small myo- mata sometimes devclop on tlle ligament close against t}le ov1ai', SO, on tlle (it l.er liand, semi-detaclied pieces of ovaiiail tissue may lie oni tlle ligameiit close against tlle uterus.Tlle operator must tie tlle ligature asclose to the uterus as possible * tlien, if any trace of ovarian tissue re- main on tlle stump, it will be oii tlle distal side of the ligature, where it will almost certainly undergo atrophy.When the surgeonl finds that the ligature, as lie pulls it tgliht, cuts into t}le pedicle.tllat means that it is cutting into ovarian tissue.The silk sliould be loosened and tied closer to the uterus.The ovariRn ligament is very tough, and is not readily cut by the ligature silk.In Case I, tliough there was a distinct piece of ovarian tissue left, the catamenia were completely suppressed, nor, as otlier cases (ii, III) liere related will prove, does the leavring of a minute piece of ovarian tissue prevent the involution of a Iiitlierto growingo fibroid.W\e must not overlook tlle fact that the operation is not witliout danger.The appendages may be diseased and stroDgly adherent to the tumour and adjacent structures, as in one case which I will relate; but their separation and re- moval will not involve mucli peril if the operator be fairly experienced.The operation must not be performed when tlle anaemia is SO marked as to involve in itself immediate danger to life.Under sucli circumstances the hemorrliage sliould be cliecked for a time by local applications aind ergot (if that drug is of any avail), and tllen tonies must be given.In the summer of 1890 I lost a case by operating too late.The patient, a single woman aged 40., had bled severely for siX years, and all kinds of treatment liad been tried.She was very anoemic, aind subject to frequeiit syncope, even when lying in bed.A solid fibroid reachled to the umbilicus; the cavrity of thge uterus measured five and a-lialf inclies thie cervix was expanded by a submsucous growth.The urine was distinct-ly albunminous.The fluid blood and clots which came away at evrery period were ver,y pale.On June 2fitb, I1990, I operated.The