Hysterectomy for uterine fibroid disease in early pregnancy / by Alban H.G. Doran.

  • Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927.
Date:
1902
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Licence: In copyright

Credit: Hysterectomy for uterine fibroid disease in early pregnancy / by Alban H.G. Doran. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    found the combination at times to act well in practice. Digitalis given alone is frequently found to aggravate matters in sclerotic cases manifesting angina. To secure, so far as possible, an equable blood pressure we must avoid as well as employ certain drugs. In this sense tobacco is a drug calculated to raise blood pressure and should theoretically be altogether avoided. The physician will, however, have to judge of the advisability of recom- mending this step by the character and circumstances of individual cases. To deprive a man long used to the solace of tobacco of his “smoke,” if he be not a stoic, may be to precipitate rather than to obviate angina. But in any case permission to smoke must be inexorably limited to that minimum which will secure mental as well as vascular equability. We must also endeavour to remove indirect causes of vascular tension. We have been taught by physiologists the value of the play of neurp-vascular action in the splanchnic area as a safety-valve to threatened excess of vascular pressure elsewhere, (and ithe use of certain agents which combat fermentation andf promote the flow into the primic vise of the natural secretions which secure a normal blandness of intestinal content is of the first importance. Among such agents I should place in the first rank the milder mercurials—calomel and blue pill. I have cardio- vascular patients who haVe taken from half a grain to one grain of calomel once or twice a week regularly for a twelvemonth at a time with unquestionable benefit in maintaining an equable blood pressure. This practice on my part is no recent proesdure but I did not derive it from my alma mater, the University of Edinburgh, for when I was in my professional infan 3y my clinical teacher, one of the ablest who ever felt a aulse—the late Professor Hughes Bennett—had, perhaps, among some dislikes one prime aversion—namely, mercury in every form. So that I began practice fully convinced that, did I prescribe that drug to my patients, I shot Id shortly have around me a tremor-struck and gibbering public execrating me as the mercurialised prisoners in a quicksilver mine might their gaoler. From this delusion I was freed many years ago by the distinguished physician who is the President of this College and whose views on the beneficial effects of wisely administered mercurials in securing an equable blood pressure are now so well known. How mer- curials act in these circumstances, whether as eliminants, as Sir William Broadbent suggests,20 or as antiseptics, or as more direct vaso-dilatork, it is not necessary for practical purposes to inquire. Their action is, without doubt, fre- quently beneficial in maintaining a certain softness and pliancy of pulse for long periods. General gastro-intestinal melication by alkalies od acids as required, or by the use of salir.e or other aperients, is indicated for the same reason— namely, to remote or tb correct possible causes of inter- mittent blood pressure of an injurious character. It is po-sible that some of the good repute enjoyed by iodide of potassium in cardio-vascular sclerosis may be due to its efficacy in cases of specific origin, but such a supposi- tion does not account for its general use by observant physicians. Although the drug had some vogue in such conditions before the advocacy by Dr. Balfour of its usefulness, there cm be, no doubt that his emphatic and authoritative utterances in its favour have done much to secure its general adopt: on as a cardio-vascular remedy or agent in treatment. He tompares its action in one place to that of the nitrites-” an I in another refers its therapeutic effects in aortic aneurys n to the reduction by it of intra- arterial blood pressure.2 * The dose he recommends for continuous use as a v^so-dilator is two grains every 12 hours. The one objection to its employment has perhaps more weight in cases of angina pectoris than in cases not associated with these piroxysms—namely, its tendency at times to cause gastro-intfestinal irritation and thus to pro- voke those reflexes whioh induce irregularities in vascular- pressure. But the same objection applies to mercurials, and if the administration of both these useful agents be coupled with a scrupulous care ks to the blandness and sufficiency of diet and the avoidan ;e of condiments such as vinegar ketchups, and effervesce it wines an t beverages, this objec- tion is in no way comj arable to the advantage which is constantly derived from] their u-e in the intervals between attacks of angina. Concerning the modvs operandi of the iodides in inducing a n]ore equable vascular tone there is benefit, that is necessa: attention to gen What has bee pectoris applies sine dolore or 20 Tlio Puls', 1890 p. 182. 27 Op. eit... p. 379. 20 Op. clt,., p. 467. room for legitimate differences of opinion, for much obscurity attends our present knowledge of the subject. We must be content, meanwhile, to act empirically so long as our action is beneficial to the patient and wait for that enlightenment which science sooner or later affords those who industriously look for it and patiently expect its advent. Drugs other than powerful analgesics and vaso-motor agents may be pf service in some cases of angina. If the malady be associated with anaemia due to some specific cause such as malaria, or be attributable, as appears to be the case in’ some instances, to lead poisoning, or be aggravated by defective blood states of the kind more commonly met vyith, the treatment of the accidental state, secundum artem, foy such agents as arsenic or iron or iodide of potassium, a^ the case may be, is calculated to be of In functional or inorganic cases they may be all r to effect a cure when coupled with al hygiene. said as regards the treatment of angina the main to the treatment of angina jyncope trepidosa As Dr. Leech has remarked, although the ultimate influence of the nitrites on the cardiac mqsclc is depressant, it is probable that by inducing a larger number of smaller contractions the nitrites help to unburden pn overladen heart, even if the individual contractions be 1( ss powerful than normal.20 But in the syncopal variety of the complaint, if we still classify it with Heberden’s disease^ hypodermic injections of strychnine find appropriate and, it times, life-saving employment. M. Huchard has well remarked30 that in some severe cases of painful angina the pain itself is the best safeguard against an overdose of a d rect analgesic like morphia. So, also, it may be equally c>gently maintained that in painless or syncopal angina t&e syncopal state is the best antidote against the injurious influence of a somewhat bold use of strychnine. With'. this powerful agent we may usefully combine, as in the lease I have related, the tincture of stro- phanthus, which acts as powerfully on the heart as the pre- parations of digitalis and is less likely than the latter to raise a peripheral obstacle to the circulation as it acts less on the di-tant arteiioles. Such a combination may be to syncopal angina wk|at opium, chloroform, and atropine are to painful angina of k severe type. We have now discussed with such fulness as the limits of our time will permit the nature, causes, and treatment of cardiac pain. Great as still is the obscurity of many important questions which are raised by a study of Heberden’s disease, Ithe retrospect of our progress in the knowledge of anginalpectoris since he wrote in so masterly a manner is not discouraging. The ever-compelling future which justifies and renders interesting the present may be confidently predicted! to show no lessening of the rate of progress which the last century has exhibited ; and it does not require the vision lof the seer to predict that much that is still a sealed book] to us in the matters we have been considering will a centtiry hence or sooner be common know- ledge But that this] devoutly to be desired end may be reached thought mustlever be the handmaid of observation and we must be carefVil to rear the superstructure of our conclusions on the rock of patiently verified fact. By ALBAN H G. DORAN, F R.C.S. Eng., SUKOEON TO THE SAMARITAN FREE HOSPITAL, LONDON. HYSTERECTOMY FOR UTERINE FIBROID DISEASE IN EARLY PREGNANCY. Three somewhat interesting cases of hysterectomy during early pregnancy have recently occurred in my own practice. In all there was a fibroid in the lower segment of the uterus posteriorly, preventing normal labour or delivery through the vagina by any means and in ail immediate removal of the uterus seemed to be the best course to pursue in the interests of the patient. I need not discuss the important question of the treatment of the gravid fibroid uterus at length, as that has been already done by well-known writers, for instance by Dr. C. J. 2:1 Croonian Lectures, The Lancet. July 24th, 1893, p. 1505. 30 Op. clt., p. 676.