The primary mortality of simple oöphorec_A System of Operative Surgery, Volume 4 (of 4)

with hysterectomy for primary cancer of the Fallopian tube, is about 5%,

and this is low in comparison with abdominal hysterectomy for cancer of

the cervix; it is due to the fact that tubal cancer does not so readily

become septic (Doran).

REFERENCES

DORAN, A. A table of over fifty complete cases of Primary Cancer of the

Fallopian Tube. _Journal of Obst. and Gyn. of the British Empire_,

1904, vi. 285.

BLAND-SUTTON, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400.

---- On Cancer of the Ovary, _Brit. Med. Journal_, 1908, i. 5.

CHAPTER IV

OPERATIONS FOR EXTRA-UTERINE GESTATION

The systematic surgical treatment of extra-uterine gestation we owe to

the genius of Lawson Tait. His first operation for this condition was

performed in 1883. Tait wrote that he conceived and carried out this

operation in obedience to the canon of surgery relating to the arrest of

hæmorrhage, and which is valid in other regions of the body.

Many surgeons (even a butcher) had removed living, dead, and putrescent

extra-uterine fœtuses from the abdomen of living women, but Tait was the

first to attempt the operation in those early stages of tubal gestation

in which the tube bursts, or expels (tubal abortion) the products of

conception through the cœlomic ostium or a rent in the gestation-sac,

into the abdominal cavity, accompanied by an escape of blood so abundant

that it may destroy life in a few hours.

=Indications.= The operative treatment of extra-uterine gestation

depends mainly on the stage at which it is required.

When a gravid tube is detected before rupture, the operation is

practically that of oöphorectomy: and is simple and safe.

When the operation is required in consequence of the bursting, or

abortion, of an early gravid tube, great promptness is often required on

the part of the surgeon to prevent the patient dying from hæmorrhage,

and although the operation in these circumstances is really an

oöphorectomy, it often has to be performed in the patient’s room as an

emergency operation and without the elaborate surroundings of a modern

operating theatre.

There are few accidents which test the skill, nerve, and resource of a

surgeon more than cœliotomy for a suspected intraperitoneal hæmorrhage

from a gravid tube, and few operations are attended with such brilliant

results. Surgeons are often astonished to find a large amount of blood

in the pelvis due to a small perforation in a gestation-sac no bigger

than a cherry (Fig. 7).

=Operation.= In removing tubes of this kind it is necessary to apply the

ligature on the uterine side of the rent in cases of rupture of the

tube, but when the rent involves the wall of the uterus the opening will

require the application of a mattress suture for its complete closure.

In some rare instances of the interstitial variety of tubal pregnancy,

the uterus has been so involved that in order to effectually control the

bleeding it has been found necessary to remove the uterus.

After the pedicle has been safely ligatured and the blood removed, the

abdominal incision is sutured as described on p. 9. When the shock due

to the bleeding and operation has been great, it is sometimes judicious

to pour one or two pints of saline solution at the temperature of 102°

F. direct into the abdominal cavity.

[Illustration: FIG. 7. A GRAVID FALLOPIAN TUBE. There is a hole in the

gestation-sac, and tufts of villi project through it. The patient was in

the seventh week of her tenth pregnancy when she was seized with

abdominal pain and died in ten hours from hæmorrhage. (_Museum of St.

Bartholomew’s Hospital._) Natural size.]

The majority of cases of internal bleeding from gravid tubes in the

early stages are submitted to operation at periods varying from a few

hours, days, weeks, or even months, after the primary bleeding.

When the tube bursts, the hæmorrhage may not be so profuse as to induce

death; and the woman, recovering from the shock, does not manifest such

grave symptoms as to demand surgical aid. The consequence is that the

patient sometimes remains for several weeks under palliative treatment

(unless a renewal of bleeding kills her), and at last she seeks surgical

advice. Appreciation of the true nature of the case leads to operation.

In such cases, when the abdomen is opened, the free blood in the

abdominal cavity is easily removed by sterilized dabs of absorbent

material. The damaged tube and ovary are removed as in oöphorectomy.

When there is much free blood care must be taken that no clots are left

in the iliac fossæ. When the blood has remained in the belly for several

weeks after rupture, it is judicious to insert a small drain for a few

days. The importance of removing blood and blood-clot from the

peritoneal cavity is demonstrated on p. 98.

Where a tubal pregnancy progresses beyond the third or fourth month and

invades the broad ligament before giving trouble from internal

bleeding, an operation may be necessary at any moment. At this period

the operation consists in exposing the parts by a median subumbilical

incision, and then opening the gestation-sac, turning out the fœtus,

placenta, and clot, and controlling the bleeding by firmly packing the

cavity with dabs. The edges of the sac are then stitched to the lower

end of the wound; the upper part of the incision is closed, and the sac

is drained with a rubber tube of suitable size and allowed to gradually

heal.

In cases where the pregnancy continues beyond the fourth month to full

time an operation may be required at any moment. Up to the fourth month

it may be even possible, in some cases, to remove the embryo, placenta

and gestation-sac on the same plan as an ovarian cyst. This is

occasionally possible even when the gestation runs to term, but in the

majority of cases, when the gestation has passed the fourth month and

the fœtus is alive, the surgeon cannot expect to deal with the sac in

this summary manner, (unless it be a cornual pregnancy) he has to reckon

with the placenta.

[Illustration: FIG. 8. A GRAVID FALLOPIAN TUBE, CONTAINING TWINS.

(McCann’s case. _Museum R. College of Surgeons._) Full size.]

In operating for the removal of a gravid tube in the early weeks, the

surgeon may be exercised in his mind in regard to the opposite tube, for

a careful study of the literature of this subject clearly shows that the

patient is liable to conceive in the opposite tube, and in some

instances this has happened within a few weeks of the removal of its

fellow. The liability of a repeated tubal pregnancy may be fixed at 5

per cent. Moreover, in operating for tubal pregnancy, the opposite tube

should be carefully examined, because both tubes may be gravid, though,

as a rule, the pregnancies are of different dates. To spare a woman a

recurrence of tubal pregnancy it has been urged that the surgeon should

remove the opposite tube, but men of ripe experience and judgment are

averse to such a proceeding, for it is an established fact that uterine

pregnancy is not uncommon after unilateral tubal gestation. My own

experience is in harmony with this. In some cases of unilateral tubal

abortion the operator has cleared out the tubal mole and clot, and left

the tube. This is not good practice: I think a tube which has once been

pregnant should be removed. If the opposite tube is obviously diseased,

and this happens in a small proportion of patients, it should be

removed.

The method of dealing with the sac of an extra-uterine gestation after

the fifth month depends in a great measure upon whether the fœtus is

alive or dead. The gestation-sac after this date consists usually of the

expanded tube closely incorporated with the tissues of the broad

ligament, which may be thick in some parts and very thin in others. To

the walls of the sac, coils of the intestine, and particularly the

rectum, adhere. Experience decides that the safest plan, after exposing

the gestation-sac through an abdominal incision, is to cut into it and

remove the fœtus and placenta. When the fœtus is dead there will be

little trouble from the placenta. The edges of the incision are stitched

to the margin of the abdominal wound and drained.

In those rare cases where the amnion erodes the tube and invades the

belly (ventral pregnancy), the gestation-sac, with its contents, has

been successfully removed by merely transfixing its base with silk

ligatures.

The great danger of operations for extra-uterine gestation after the

fifth month, when the fœtus is alive, or only recently dead, is the

furious bleeding which accompanies the detachment of the placenta. It

may be stated that an operation for tubal pregnancy after the fifth

month of gestation, with a quick placenta, is the most dangerous in the

whole range of surgery. About two-thirds of the patients die. The

greatest danger is hæmorrhage, and the other is sepsis when the placenta

has been left to slough. It cannot be urged with too much force that

when it is fairly evident that a woman has an extra-uterine gestation,

it should be dealt with by operation without delay: and my experience of

the operation leads me to believe that it is a wise plan to remove the

placenta at the primary operation. Fortunately very few extra-uterine

fœtuses survive to term.

In cornual pregnancy, or, as it is often termed, ‘pregnancy in the

rudimentary horn of a so-called unicorn uterus,’ the removal of the

uterus is often necessary; there is, however, a variety of this form of

pregnancy in which the fully developed cornu may be spared, namely, that

in which the rudimentary but gravid cornu is connected with it by a

distinct and usually solid pedicle. Many such have been observed and

very carefully described.

In nearly all varieties of tubal pregnancy the uterine tissues are

sometimes so torn that it is difficult to arrest the hæmorrhage: in

this case it is now and then a wise practice to remove the uterus.

=Concurrent intra- and extra-uterine pregnancy.= The operative treatment

of this condition requires consideration under three headings:--

1. =Tubal and uterine pregnancy coexist, but the complication is

recognized in the early stages.= In this condition the signs are those

of an early tubal rupture or abortion (Fig. 7); in the majority of the

reported cases operation has been undertaken with the impression that

the trouble was simply due to tubal pregnancy, the intra-uterine

gestation being detected, or in some cases merely inferred from the size

of the uterus, in the course of the operation.

In these circumstances the operation is carried out as for a simple

tubal pregnancy, care being taken to disturb the uterus as little as

possible. In many instances such an operation has been followed by

brilliant consequences, for the intra-uterine pregnancy has remained

undisturbed and the patients have become the happy mothers of living

children.

Occasionally the operation has been followed by miscarriage and other

untoward results, but, speaking generally, a gravid uterus is very

tolerant of interference.

2. =Uterine and extra-uterine pregnancy running concurrently to term.=

(Compound pregnancy.) This may be described as the most dangerous

combination to which child-bearing women are liable. In order to show

what a disastrous conjunction it is to women with two ‘quick’

children--one intra- and the other extra-uterine--I have arranged some

recorded cases in the table on p. 35. Fortunately this form of compound

pregnancy is rare, but a rarer combination has been recorded by Menge,

in which the extra-uterine fœtus occupied the ovary and ran nearly to

term. When the woman came into labour, the ovarian pregnancy was

regarded as an obstructing tumour, and preparations were made for

performing cœliotomy. The intra-uterine child was born in the meantime.

When the supposed tumour was extracted, to the surprise of all it

contained a living fœtus. The mother and both children survived.

3. =Uterine pregnancy complicated with a sequestered extra-uterine

fœtus.= This is a very rare condition, but some cases have been very

carefully recorded (Leopold, Stonham, Worrall).

The physical signs are those of a pelvic tumour incarcerated by a gravid

uterus. The nature of the swelling may be sometimes accurately inferred

before operation, as in Worrall’s remarkable case. The sequestered fœtus

should be removed by cœliotomy.

After the death of the fœtus the operative treatment of extra-uterine

gestation is, as a rule, a simple proceeding, the fœtus and placenta can

be easily and safely removed. We have no certain means of deciding when

an extra-uterine fœtus is dead, nor do we know exactly how long after

the death of the fœtus the placental circulation ceases, but we do know

that in course of time, if the fœtus is retained, the placenta

disappears, because in cases where the fœtus is in the condition known

as lithopædion there is usually no placenta. When a retained

extra-uterine fœtus is wholly or partially converted into adipocere, the

tissues have a strong tendency to adhere to the walls of the sac. This

is especially marked in connexion with the hairy scalp.

Although a sequestered extra-uterine fœtus is uncommon, yet a surgeon

may stumble on one when he least expects it: these bodies may remain

undisturbed in the pelvis many years, even fifty, and be only discovered

in the post-mortem room, but they are always liable to be infected from

the adjacent bowel or bladder; then suppuration is inevitable. In some

instances the pus makes its escape at the umbilicus, and as the sinus

persists the surgeon explores it, and, on laying it open, is surprised

when he extracts the fœtus, sometimes entire.

This is sometimes referred to as ‘navel delivery’, and of this several

examples have been recorded. In one such case a fœtus was extracted by a

butcher: the woman recovered, and the account of this remarkable case

ends thus: ‘She had a navel rupture, owing to the ignorance of the man

in not applying a proper bandage’ (_Phil. Trans._, Abridged Edition,

1805, vol. viii, p. 517). This is a good instance of professional bias

in the apportioning of blame.

Usually, when pathogenic micro-organisms gain access to the

gestation-sac the fœtus decomposes, and fistulæ form, by which pus,

accompanied by fragments of fœtal tissue and bones, finds an exit and

affords evidence of the nature of the case. These fistulæ may open into

the rectum, bladder, vagina, uterus, or some spot on the anterior

abdominal wall below or near the umbilicus. The treatment is simple, and

consists in dilating the sinus and extracting all the fragments. If this

be thoroughly carried out the sinus quickly closes. Partial operations

are useless: if but a bit of a bone remain, a troublesome sinus will

persist. It is bad practice to attempt to extirpate the sac in such

condition; such an operation usually terminates fatally.

In a case of old-standing lithopædion it is unusual to find any trace of

the placenta. J. W. Smith operated on a woman in whom a lithopædion had

caused intestinal obstruction. The fœtus had probably been retained

15-1/2 years, and the placenta was represented by a calcified encapsuled

ball, with an average diameter of 6 cm.

=Results of operative treatment.= In order to afford some notion of the

risks attending the surgical treatment of extra-uterine gestation, as

well as to give an idea of its relative frequency in hospital practice,

the following figures will serve. From 1896 to 1907, both years

inclusive, 116 operations were performed for extra-uterine gestation in

the Chelsea Hospital for Women. During this period all the varieties of

tubal pregnancy were encountered (ampullary, isthmial, tubo-uterine),

including the rare condition of a full-time living fœtus free among the

intestines, and the more uncommon condition of a full-time cornual

pregnancy. There were four deaths in the series, one in 1897, 1902, and

two in 1905. Death in the fatal cases was attributed to pulmonary

embolism, peritonitis, and in two to heart failure.

A TABLE SHOWING CASES OF CONCURRENT INTRA- AND EXTRA-UTERINE

PREGNANCY (COMPOUND PREGNANCY) RUNNING TO TERM, WITH THE FATE OF THE

MOTHER AND CHILDREN.

+-----------+-------+---------+--------------+--------------+

+-----------+-------+---------+--------------+--------------+

+-----------+-------+---------+--------------+--------------+

[1] This fœtus was killed by means of a stilette passed through the

abdominal wall of the mother into its thorax. The patient had two

subsequent confinements without difficulty. In 1898 the ‘lump’ had

shrunk, but was movable and caused no difficulty. _Pacific Medical

Journal_, September, 1898.

[2] Intra-uterine child born naturally at the seventh month.

Extra-uterine fœtus died, set up septic changes, and was removed by

cœliotomy some weeks later.

REFERENCES

LEOPOLD. Ovarialschwangerschaft mit Lithopädionbildung von 35-jähriger

Dauer. _Arch. f. Gyn., 1882_, Bd. xix. 210.

MENGE. Eine reine Ovarialschwangerschaft mit bebendem Kinde. _Vide_

Fränkische Gesellschaft für Geburtshülfe and Frauenheilkunde.

_Münch. med. Wochensch., 1907_, liv. 2452.

SMITH, J. W. _Jour. of Obstet. and Gyn. of the British Empire, 1908_,

xiii. 180.

STONHAM, C. Lithopædion, _Trans. Path. Soc., 1887_, xxxviii. 445.

WORRALL. Ectopic Gestation complicating Normal Pregnancy. Abdominal

section. Recovery. _Med. Press and Circular, 1891_, i. 296.

CHAPTER V

HYSTERECTOMY AND MYOMECTOMY

_Hysterectomy is the name applied to the surgical operation for the

removal of the uterus._

=Indications.= Hysterectomy is mainly required in the radical treatment

of fibroids and malignant disease (carcinoma, sarcoma, and

chorion-epithelioma). It is occasionally required for injury, and

certain morbid states due to acute and chronic sepsis; and for a

condition but little understood, termed generically fibrosis.

Hysterectomy is also carried out for such conditions as diffuse

adenomyoma of the uterus, hæmato-metra, tuberculous endometritis, and on

rare occasions for chronic inversion of the uterus and inveterate

dysmenorrhœa.

The presence of fibroids in the uterus is a common cause for which

hysterectomy is required, and the history of this operation is full of

interest.

The uterus may be removed by two methods. In one, access is obtained to

the uterus through an incision in the belly-wall; this is termed

abdominal hysterectomy. In the other, the whole uterus is extirpated

through the vagina, and on this account it is termed vaginal

hysterectomy or colpo-hysterectomy.

The abdominal method of removing the uterus may be performed in two

ways:--

In one the body of the uterus and a portion of its neck is removed; this

is called subtotal hysterectomy (or supravaginal hysterectomy). In the

other the body of the uterus and the whole of its neck are excised: this

is total hysterectomy (or panhysterectomy). The ovaries and Fallopian

tubes may, or may not, be removed, according to the disease for which

the operation is undertaken. This is a matter which will receive ample

consideration later on (see p. 56).

For the satisfactory performance of abdominal hysterectomy the

Trendelenburg position is necessary.

SUBTOTAL HYSTERECTOMY

The abdomen is opened by the median subumbilical incision; but when the

operation is performed for the removal of large tumours it will

frequently require extension above the umbilicus. The operator should

never allow himself to be embarrassed by a small incision. As soon as

the peritoneal cavity is reached, the surgeon introduces his hand and

carefully makes out the nature of the case, the presence or otherwise of

adhesions, other tumours, and the relation of the fibroid to the uterus,

and determines whether it is impacted in the pelvis. The uterus is then

carefully lifted out through the incision, or drawn out with the

assistance of a volsella; the intestines and omentum are isolated from

the pelvis with a large warm dab.

[Illustration: FIG. 9. A DIAGRAM TO SHOW THE ARTERIAL SUPPLY OF THE

UTERUS.]

In a simple case the broad ligaments are seized with hæmostatic forceps;

if the ovaries and tubes are healthy and the surgeon wishes to preserve

them, the forceps are applied between the ovary and the uterus; but if

they are obviously diseased and must be sacrificed, the forceps are

applied to the broad ligaments near the brim of the pelvis beyond the

outer pole of the ovary. In some instances the round ligament of the

uterus can be seized with the same forceps, but in many cases it is

necessary to clip it separately. It is an advantage to secure the round

ligament at this stage, for the forceps controls its artery and prevents

the stump of the ligament unduly retracting the peritoneum. The broad

and round ligament on each side are divided, and the uterine artery is

exposed on each side of the uterus and caught with forceps: a peritoneal

flap is then fashioned on the anterior wall of the uterus at its

junction with the neck, taking care not to injure the bladder; and a

similar flap is cut on the posterior wall. The uterus is then detached

at a point well below the junction of the cervix with the body of the

uterus: if the forceps are correctly applied to the vessels the

detachment of the uterus is an almost bloodless proceeding: a small

vessel here and there will perhaps require the application of a pair of

forceps.

The principle involved in this part of the operation may be explained by

reference to the diagram (Fig. 9). The blood-supply of the uterus

follows four routes; two of these are the ovarian arteries which

traverse the broad ligaments to reach the cornua of the uterus, where

they anastomose with the terminations of the uterine arteries; the

latter come into relation with the uterus near the junction of the body

and cervix, and then ascend the sides of the uterus to the cornua. No

large vessels are found on the anterior or posterior surface of the

uterus. An arterial twig runs along the round ligament, bringing the

ovarian artery into relation with the deep epigastric artery. If the

surgeon thoroughly appreciates the distribution of the ovarian and

uterine vessels he will at once perceive that if the four forceps are

properly applied to the vessels the blood-supply is under absolute

control: indeed, in many cases a subtotal hysterectomy can be performed

without the loss of more than an ounce of blood. When the broad ligament

is clamped and detached there is a spurt of blood from the uterine cornu

which lasts until the corresponding uterine artery is caught with the

forceps, and the cessation of the bleeding at the uterine cornu is a

sign that the artery is securely clipped. It must be remembered that

with a small tumour in the uterus the vessels follow their normal

courses and can be easily found, but when the uterus is deformed by huge

tumours, the vessels are not so easily seen, and they are of large size

and give rise to furious bleeding when divided. In dealing with large

and vascular uterine fibroids another factor has to be reckoned with,

namely, the enormous veins in the pampiniform plexus, interspersed with

lymphatics which in some cases are as thick as the index-finger; it is

not an uncommon thing to meet with lymphatics in this situation a

centimetre in diameter and filled with straw-coloured lymph.

[Illustration: FIG. 10. A FIBROID GROWING NEAR THE RIGHT UTERINE CORNU.

It separates the ovarian ligament, Fallopian tube, and round ligament of

the uterus from each other. Full size.]

The surgeon now secures the vessels. The ovarian pedicles are transfixed

and ligatured with silk as in ovariotomy: the round ligament is usually

included in the ovarian pedicle. It occasionally happens that a fibroid

situated near the uterine cornu will grow in such a manner that it

widely separates the ovarian ligament, the Fallopian tube, and the round

ligament from each other as shown in Fig. 10. In such a condition it is

impossible to save the ovary without risk, and also inadvisable to

attempt the inclusion of the round ligament in the pedicle containing

the ovarian vessels. In these circumstances the round ligament is easily

secured by a mattress suture, which should include both layers of the

corresponding broad ligament.

[Illustration: FIG. 11. THE MATTRESS SUTURE. A diagram to show the

method of applying it.]

When the surgeon decides to leave an ovary and the corresponding

Fallopian tube, these structures are carefully examined to determine if

they are healthy and free from any suspicious fluid. _When the

endometrium is septic or cancerous both ovaries and tubes should be

removed._ When the surgeon decides to leave an ovary and its

corresponding Fallopian tube, he should take care in securing the

ligatures to include the ligament of the ovary: it is very liable to

slip out of the encircling loop of silk. It is often convenient to

include the round ligament of the uterus in the pedicle, but it is not a

disadvantage when it is tied separately.

[Illustration: FIG. 12. THE STUMP AFTER SUBTOTAL HYSTERECTOMY. To show

the method of applying the continuous suture.]

The uterine arteries are ligatured with thin silk; these vessels as they

run up the sides of the uterus are accompanied by veins, so that there

is a vascular tract at the point where the cervix is divided. If after

the uterine vessels are secured there is oozing from these veins, it is

easily controlled by a mattress suture. This kind of suture is so useful

that the mode of inserting it may be given in more detail. In the

diagram (Fig. 11) the silk is represented in position before it is tied,

and in that particular instance it is represented as being passed

through the peritoneal flaps from before backwards, and this is usually

the most convenient route; occasionally the reverse direction is

easier. It will be noticed in the diagram that this suture not only

controls oozing from the tissue in the immediate neighbourhood of the

uterine vessels, but it also embraces the main vessels, and thus serves

as an additional security against hæmorrhage; it also brings the

peritoneal flaps into apposition.

As soon as the oozing of blood has been controlled, the cervical canal

is examined to ascertain if it be free from polypi or cancer. Should the

condition of the cervix be in the least degree suspicious of cancer it

must be extirpated. When it is healthy, then the flaps are brought

together by one or two interrupted sutures, and the edges more carefully

approximated by a continuous suture of thin silk. In suturing the flaps

it is necessary to avoid puncturing the bladder, which is quite close

to, and often forms part of, the anterior flap. Care must also be taken

in passing the needle (especially when it has sharp edges) in the

neighbourhood of the stumps of the uterine arteries, or they will be

pricked, and then free bleeding will cause delay in the operation.

When this operation is properly performed, there should be no projecting

stump on the floor of the pelvis; the sutured edges of the peritoneum

merely appear as a thin line below the base of the bladder.

The pelvis is now cleared of blood and clot; the dabs and instruments

are counted, and it is also useful to examine the condition of the

vermiform appendix, and if grossly diseased it should be removed.

The abdominal incision is then sutured in the way described on p. 9.

TOTAL HYSTERECTOMY

This operation differs from the preceding in the fact that the neck of

the uterus is removed as well as its body. The abdomen is opened in the

usual way and the uterus is withdrawn from the abdomen and the arteries

controlled by forceps, and the broad ligaments divided exactly as in the

case of the subtotal operation. Unless the uterus be very big it is

drawn well out of the abdomen and the bladder peeled off its anterior

aspect. The surgeon then feels for the extremity of the cervix and opens

the vagina with the scalpel and carefully detaches it from the neck of

the uterus, taking great care to keep close to the cervix in order to

avoid wounding the bladder or the ureters. As soon as the uterus is

detached, the cut edge of the vagina is seized with the volsella to

prevent it retracting. In some instances the body of the uterus may be

removed as in the subtotal operation, and the cervix detached

separately; occasionally the surgeon begins his operation with the

intention of performing the subtotal operation, but finds the cervix

unhealthy or cancerous, and removes it.

As soon as the uterus is removed and all bleeding under control, then

the blood-vessels are secured with ligatures; the ovarian artery and

vein are secured on each side in the usual manner. The chief point in

this operation is the method of dealing with the vaginal opening. In the

subtotal operation the vessels concerned in the stump are the uterine

arteries, but in the total operation the territory of the vaginal

arteries is invaded, and these vessels are apt to bleed when the patient

is returned to bed, unless care is taken to secure them in the course of

the operation. The parts which require most attention are the lateral

angles in the immediate neighbourhood of the uterine arteries; these

angles may be secured by a mattress suture involving the anterior and

posterior wall of the vagina; any oozing on the anterior or posterior

wall is commanded by a mattress suture involving these walls separately,

so as not to completely close the vaginal opening. Bleeding from the cut

edges of the vagina may also be readily controlled by means of a

continuous suture of thin silk. The peritoneum is sutured over the cut

ends of the vagina, so that when the operation is completed a thin seam

is seen lying under the base of the bladder.

In cases where the uterus is removed for septic conditions, such, for

example, as an infected or gangrenous fibroid, or when cancer of the

corporeal endometrium and a submucous fibroid coexist, I modify the last

stages of the operation. After the ovarian and uterine arteries are

ligatured, the cut edges of the vagina are secured in the following way:

the cut edge of the peritoneum covering the bladder is stitched to the

cut edge of the anterior wall of the vagina, and in the same way the

peritoneum in relation with the posterior vaginal wall is stitched to

the corresponding cut edge of the vagina. The flaps at the lateral

angles of the vaginal opening are drawn together with a suture and the

intervening segment is left with merely the cut edges in apposition:

this affords a route for the escape of pus if required.

Whether the peritoneum is sutured over the vaginal opening, or whether

the edges are merely left in apposition, the recesses of the pelvis are

thoroughly cleared of fluid and clot. The dabs and instruments are

counted, and the wound sutured as recommended on p. 9. In septic

conditions the abdominal incision should be closed with a single row of

through and through sutures. Before the patient leaves the operating

table it is useful to examine the vagina and mop out any blood which has

found its way there in the course of the operation. It is also useful to

pass a glass catheter and withdraw any urine that has accumulated during

the operation.

If there is evidence of free oozing it is most likely to come from the

cut edges of the vaginal wall in a case of total hysterectomy: under

such conditions it is easy to apply a pair of fenestrated forceps to

the oozing area and leave them on for thirty-six hours. They will cause

the patient trifling inconvenience. Care must be taken not to fix the

blade too far on the anterior flap, or it will lead to subsequent

sloughing of the bladder.

When there is free oozing of blood from the cervical canal after

subtotal hysterectomy, it is easily and safely controlled by applying a

pair of fenestrated forceps on each side of the cervix, but not too

deeply, or the ureters may be nipped. These should be left on for

thirty-six hours.

[Illustration: FIG. 13. A BICORNATE UTERUS. This uterus is shown in

coronal section; each cornu contains a fibroid. Removed from a spinster

aged 32 on account of acute pain probably caused by the axial rotation

of one cornu. Two-fifths size.]

The details of the operation set forth in this account refer to a simple

or uncomplicated hysterectomy, and under these conditions it cannot be

described as a difficult operation to any surgeon accustomed to

abdominal operations, but the complications not infrequently met with in

connexion with uterine fibroids are occasionally very formidable, and

tax the skill and resource of the boldest; _e.g._ fibroids which are

inflamed and adherent to the colon, rectum, or small intestines;

fibroids associated with unilateral or bilateral pyosalpinx, or a

suppurating ovarian cyst incarcerated in the pelvis by the enlarged

uterus; fibroids complicated by cancer in the neck of the uterus; or a

cervix fibroid firmly incarcerated in the pelvis by a big fibroid in the

fundus of the uterus, and pushing the bladder upwards in front of the

tumour.

=Cervix fibroids.= The operative treatment of this variety needs

separate consideration because these tumours do not lend themselves to

any routine method.

When the uterus with the tumour in its cervix can be raised out of the

pelvis far enough to allow the necessary manipulations, then total

hysterectomy can be performed easily and quickly. Occasionally the

tumour is wide and so fixed in the pelvis that it will be necessary to

split the uterus longitudinally and to enucleate the fibroid from its

bed; then an ordinary subtotal or total hysterectomy can be carried out.

The enucleation of a large impacted cervix fibroid requires to be

conducted carefully, without undue display of force, or so much shock is

produced that the patient’s life will be placed in the gravest peril.

[Illustration: FIG. 14. A BICORNATE UTERUS SHORTLY AFTER DELIVERY. The

pregnancy occurred in the left half. The vesico-rectal ligament is well

shown.]

=On hysterectomy when the uterus is double.= Fibroids and cancer arise

in malformed uteri, as well as in those of normal shape (Fig. 13). When

the body of the uterus is double (bicornate) and the surgeon stumbles

upon it in the course of a pelvic operation he may be puzzled if he is

not familiar with the anatomical conditions associated with this

malformation.

When the body of the uterus is bicornate the rectum lies in the middle

line of the pelvis, and a median vertical fold of peritoneum, the

_ligamentum vesico-rectale_ passes, from its anterior aspect through the

gap between the uterine cornua to become continuous with the peritoneum

covering the posterior surface of the bladder (Fig. 14). That portion of

the vesico-rectal ligament which lies between the rectum and the neck of

the uterus divides the recto-vaginal fossa into a right and a left

half. This peritoneal ligament requires careful treatment, or the

surgeon may accidentally open the rectum or the bladder. In closing the

peritoneum over the cervical stump it is sometimes necessary to bring

the edges of the abnormal fold into apposition vertically by a

continuous suture.

In a case of this kind in which I performed total hysterectomy for

cancer of the neck of the uterus the extensive peritoneal connexions

were somewhat troublesome, and when the uterus was removed it seemed as

if the floor of the pelvis had been stripped of its serous covering. The

bifid nature of the uterus had been anticipated before the operation, as

an imperfect vertical septum was known to exist on the posterior vaginal

wall. The patient made an excellent recovery.

Experience teaches that bicornate uteri cause more difficulties in

diagnosis than in technique, but the presence of the vesico-rectal

ligament would probably bar the removal of the uterus by the vaginal

route. The existence also of a median longitudinal septum, partial or

complete, in the vagina would be another difficulty.

=Mortality.= In order to give some idea of the great improvement which

has taken place in the operation of abdominal hysterectomy for fibroids

in London the following figures will be found of great interest.

In the year 1896 the results of abdominal hysterectomy for fibroids in

the hospitals of London may be inferred from the following table:--

St. Bartholomew’s 7 with 3 deaths

St. Thomas’s 5 " 2 "

St. George’s 1 " 0 "

Middlesex 6 " 1 "

University College 3 " 0 "

Samaritan 17 " 4 "

Soho (for women) 1 " 0 "

Chelsea Hospital for Women 9 " 1 "

__ __

49 " 11 "

In these hospitals and the New Hospital for Women the returns in 1906

are as follow:--

St. Bartholomew’s 26 with 4 deaths

St. Thomas’s 40 " 2 "

St. George’s 8 " 0 "

Middlesex 50 " 0 "

University College 21 " 1 "

Samaritan 37 " 2 "

Soho (for women) 60 " 1 "

Chelsea (for women) 80 " 1 "

New (for women) 26 " 0 "

___ __

348 " 11 "

The returns during 1906 and 1907 from my service at the Chelsea

Hospital for Women and the Middlesex Hospital, as verified by the

Registrars, were 101 abdominal hysterectomies for fibroids; all the

patients recovered. Of these 101 operations, 7 were total and the

remainder subtotal hysterectomy.

[Illustration: FIG. 15. VILLOUS DISEASE OF THE UTERUS. The uterus is

shown in sagittal section. The cavity is dilated and occupied by a

villous tumour growing from its posterior wall. Successfully removed

from a multipara aged 83. Full size.]

=The risks of abdominal hysterectomy.= The dangers of hysterectomy are

those common to cœliotomy, such as sepsis, peritonitis, shock, and the

risks of the anæsthetic. There are certain special dangers, such as

hæmorrhage; injury to the vesical segments of the ureters, and

especially the bladder; injury to the intestines, especially the rectum;

acute intestinal obstruction; thrombosis and pulmonary embolism. These

risks and dangers are considered fully in their relation to all forms of

abdominal gynæcological operations in a special chapter (see Chap. XI).

Among the rarer forms of death after hysterectomy may be mentioned acute

perforation of the stomach or the small intestine, cerebral hæmorrhage,

lobar pneumonia, thrombosis of the right auricle, embolism of the

femoral artery ending in gangrene of the leg, suppression of urine, and

acute mania. These are fatal conditions which follow any major operation

in surgery, and have no special connexion with hysterectomy.

The removal of the uterus has been rendered so safe that even in

advanced age it has been employed with success, as the subjoined table

shows:--

TABLE OF CASES IN WHICH HYSTERECTOMY WAS PERFORMED ON WOMEN OF

SEVENTY YEARS AND UPWARDS.

-----------+------+----------------+---------+-----------------------

_Reporter._|_Age._| _Nature of |_Result._| _Reference._

| | Operation._ | |

-----------+------+----------------+---------+-----------------------

Bland- | 73 |Subtotal for | R. |_Trans. Obstet. Soc._,

Sutton | | Fibroid 28 lb.| | 1900, xli. 300.

Stewart | 70 |Subtotal for | R. |_Australian Med. Gaz._,

McKay | | Fibroid 19 lb.| | 1907, 14.

Bland- | 83 |Vaginal Hyst. | R. |_Trans. Obstet. Soc._,

Sutton | | for Villous | | 1906, xlix. 46.

| | disease. | |

| | Fig. 15. | |

Malcolm | 74 |Total for | R. |_Brit. Med. Journal_,

| | Fibroids. | | 1907, ii. 1571.

-----------+------+----------------+---------+-----------------------

ABDOMINAL MYOMECTOMY

_Under this general term it is usual to include operations for the

removal, through an abdominal incision, not only of pedunculated

subserous fibroids, but also sessile and interstitial (intramural)

fibroids of the uterus._

The earliest operations of this kind were performed by Spencer Wells

(1863); but little attention was given to this matter until the

advantages of abdominal myomectomy were strongly advocated by A. Martin

(1880) and Schroeder (1893). The operation has been practised by many

surgeons and gynæcologists imbued with conservative ideals in regard to

the uterus. In its early days the operation was attended with a very

high mortality, but the great improvements in hysterectomy have limited

very materially the scope of abdominal myomectomy.

ABDOMINAL MYOMECTOMY AND ENUCLEATION FOR FIBROIDS

_Abdominal myomectomy._ This signifies the removal of one or more

pedunculated subserous fibroids through an incision in the abdominal

wall, preserving the uterus, Fallopian tubes, and the ovaries.

_Abdominal enucleation._ In this operation a sessile fibroid is shelled

out of its capsule: the uterus, ovaries, and tubes are preserved.

_Hysterotomy._ In this operation a submucous fibroid is removed, through

an incision in the wall of the uterus, which opens the uterine cavity.

The preliminary steps for each of these procedures is the same as for

ovariotomy, and the Trendelenburg position is of great advantage.

After opening the abdomen the intestines are carefully protected by a

warm dab, and the tumour carefully examined.

When the stalk is narrow it may be transfixed and secured with silk

thread, like the pedicle of an ovarian cyst. When the pedicle is short

and broad the tumour should be shelled out of its capsule, and any

obvious blood-vessel is easily secured with forceps and ligatured with

silk. The opposite flaps of the capsule are brought into apposition by

mattress sutures, and the redundant portions of the capsule cut away and

the free edges carefully brought together by a continuous suture of thin

silk.

When a fibroid is embedded in the wall of the uterus, the tumour is

exposed by cutting through its capsule and seizing it with a volsella;

as a rule, it shells out quite easily. This is followed by free

bleeding. The vessels are then seized with forceps and ligatured with

thin silk. In order to completely control the oozing, mattress sutures

are passed through the wall of the capsule on each side, their number

varying with the size of the tumour.

In some instances a uterus contains ten or more fibroids, and each must

be enucleated and the capsule secured with ligatures, as described

above.

Sometimes the oozing is difficult to control, and the surgeon sutures

the edges of the capsule to the lower angle of the incision, and stuffs

the cavity or bed of the tumour with gauze.

In removing a large submucous tumour through an incision in the wall of

the uterus, the surgeon necessarily opens the uterine cavity

(hysterotomy). After controlling the bleeding the walls of the uterine

incision are closed, as in Cæsarean section.

In many instances in which the surgeon attempts to carry out myomectomy

or enucleation, he has such difficulty in controlling the oozing that he

is driven to remove the uterus.

It is admitted by most writers that the ideal method of dealing with

fibroids requiring removal by cœliotomy is to remove them either by

ligature or by enucleation. In actual practice this ideal operation of

removing the tumours and leaving the uterus and ovaries intact can only

be carried out in a small proportion of cases, probably in less than 10

per cent., and it is fair to state that enucleation and hysterotomy are

often more troublesome and serious operations than hysterectomy; also

the preservation of the uterus is not always an advantage to the

patient.

When a woman is submitted to hysterectomy for fibroids we can assure her

that the tumours will not recur, but after a myomectomy or enucleation

in a woman in the reproductive period of life we cannot give her this

assurance, for she may have in her uterus many ‘seedlings’ or ‘latent

fibroids’ and one or several of these may grow into formidable tumours.

There are three conditions in which myomectomy and enucleation are

legitimate procedures:--

1. A young woman contemplating marriage, or a married woman anxious for

offspring, if her tumour be single and admits of myomectomy or

enucleation, may have her uterus spared. Although I have carried out

these measures on many occasions, I only know of five patients who have

subsequently borne children.

2. Occasionally in pregnancy (see p. 82).

3. Myomectomy is a very safe undertaking in patients at, or after, the

menopause, where a stalked fibroid gives trouble by twisting its

pedicle, or by shrinking to such a size that it falls into the true

pelvis and becomes impacted; or, more rarely, the pedicle of such a

tumour entangles a loop of small intestine and obstructs it.

In order to give the matter a statistical basis I have drawn up an

analysis of ninety-five consecutive cases of myomectomy and enucleation

out of my practice, with the subsequent history of some of the patients.

This experience covers a period of twelve years.

Of these ninety-five patients three died as the result of the

operation--two from pneumonia in the fourth week after operation, and

one a few days after operation: in this case there is reason to believe

that the tumour was complicated with cancer of the body of the uterus.

Six of the women were submitted to myomectomy during pregnancy, and in

four cases the operation was undertaken under the impression that the

tumour was an ovarian cyst which had undergone axial rotation. These

cases occurred in the days before I recognized that ‘red degeneration’

of fibroids complicating pregnancy caused them to be painful and tender

(see p. 78). In one patient this complication was clearly recognized. In

the sixth patient the tumour was regarded by some capable gynæcologists,

who examined her, as a tubal pregnancy complicating a gravid uterus.

Five of these patients went to term and were delivered of living

children. The sixth miscarried two months after the myomectomy.

Of the ninety-two successful myomectomies, five subsequently became

pregnant and had living children, but in each instance the fibroids were

subserous. I have not known a patient to become pregnant after abdominal

myomectomy for a submucous fibroid, large or small. In calculating the

probability of pregnancy from these statistics it must be mentioned that

the patients fall into three categories:--

1. Forty women were in the child-bearing period of life and married;

many of them were multiparæ.

2. Twenty were single women and probably capable of bearing children in

a favouring environment.

3. The remainder were spinsters or barren wives.

A significant feature in the after-history of ten of these women is the

fact that some years later other fibroids grew in the uterus, and

hysterectomy became a necessity on account of menorrhagia in seven of

them; of these, two died from the operation, which was difficult and

tedious. One patient was operated upon two years after the myomectomy,

and had borne a child in the interval, and the other seven years.

The last fact to mention is that one patient, from whom a submucous

fibroid had been enucleated from the cavity of the uterus (hysterotomy),

died four years later from cancer arising in the body of the uterus (see

p. 51).

Olshausen has recently considered this question, and indicates that the

chief objection to the abdominal enucleation of uterine fibroids is its

high mortality.

He furnishes a table of 563 cases, collected from twelve operators,

including himself; of these 59 patients died, representing a mortality

of 10.5 per cent. Olshausen, in the years 1900-5, performed enucleation

on 124 patients with 14 deaths. Eight of the patients subsequently came

under notice with recrudescence of fibroids. Christopher Martin has

performed abdominal myomectomy 73 times with 1 death.

The question of myomectomy, when fibroids complicate pregnancy and

labour, or give trouble after labour, is considered in detail on p. 78.

REFERENCES TO REPORTS OF HYSTERECTOMY PERFORMED FOR FIBROIDS IN

MALFORMED UTERI

BLAND-SUTTON, J. Fibroids in a Unicorn Uterus. _Clin. Journ._, Lond.,

1901-2, xix. 1.

BLAND-SUTTON, J. Case of Fibroids in both halves of a Bicornate Uterus.

_Proc. R. Soc. of Medicine_, 1908. Obstet. and Gyn. Sect., ii. 95.

CZERWENKA. Uterus bicornis unicollis, &c. _Centralbl. f. Gyn._, Leipz.,

1900, xxiv. 207.

DORAN, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous

Subject. _Brit. Med. Journ._, 1899, i. 1389.

GOW, W. J. Cystic Intraligamentous Myoma with Double Uterus. _Trans.

Obstet. Soc._, Lond. (1898), 1899, xl. 134.

HEINRICIUS. Ein Fall von Myoma im rudimentaren Uterus bicornis

unicollis. _Monatschr. f. Geburts. u. Gyn._, Berl., 1900, xii. 419.

KAMANN. Uterus bicornis unicollis with a Myoma in the Left Horn;

Subtotal Extirpation of the Left Horn. _Centralbl. f. Gyn._, 1905,

xxix. 795.

MARTIN C. The Ingleby Lectures. On the Dangers and Treatment of Myoma of

the Uterus. _Lancet_, 1908, ii. 1682.

OLSHAUSEN, R. In Veits’ _Handbuch der Gynäkologie_, Wiesbaden, 1907, Bd.

ii, p. 607.

ROUTH, A. Fibroid of One-horned Uterus. _Trans. Obstet. Soc._, 1888,

xxix. 2 and 57, with a good drawing.

CHAPTER VI

ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY

The great success which followed the use of the short ligature in

ovariotomy induced several surgeons to apply the same principle to the

cervical pedicle when removing the uterus for fibroids. The result was

dismal failure. Matters improved somewhat after Koeberlé introduced the

serre-nœud, and this continued the safest method until 1892. In the

meantime antisepsis had begun to take effect in pelvic surgery, and

attempts were made by Bardenheuer (1881), Polk, and other surgeons to

avoid the dangerous difficulties connected with the treatment of the

stump by removing the cervix as well as the uterus (total hysterectomy),

and they attained an encouraging measure of success. Nevertheless, other

surgeons (Goffe, Milton, Heywood Smith, and Stimson) felt that the

enucleation of the cervix was not always necessary, and sought to find a

way of avoiding it. The credit of solving this difficulty fell to Baer

of Philadelphia (1892), for he showed that it is dangerous to constrict

the neck of the uterus with ligatures, it is only necessary to secure

the arteries.

Baer’s method of supravaginal hysterectomy, or, as it is now commonly

termed, the subtotal operation, soon supplanted the total method of

Bardenheuer. The publication of Baer’s paper had great consequences; it

came at a time when the attention of gynæcologists was centred on

improvements in hysterectomy. The method was promptly tested and adopted

in London. The effects of this improvement in technique in a few years

revolutionized the surgical treatment of uterine fibroids, as the

statistical results set forth on p. 44 amply prove.

The great advantage of Baer’s method is its simplicity and safety; but

there is a disposition on the part of a few surgeons to prefer the total

operation, mainly on the ground that the cervical stump left after

subtotal hysterectomy is liable to become attacked by cancer.

As far as I can ascertain, Dr. M. Mann, of Buffalo, was the first to

draw attention to the occurrence of cancer in the neck of the uterus

after the body of the organ had been removed. He stated in 1893 that he

‘removed an ovarian tumour and the body of the uterus, by accident,

along with it; the cervix was left’. The patient recovered. ‘Six months

afterwards cancer developed in the cervix, from which she died.’

When cases of cancer supposed to arise in the stump left after subtotal

hysterectomy come to be critically analysed, they fall into four

groups:--

1. The disease existed in the neck of the uterus at the time

of the primary operation, but was overlooked.

2. Cancer attacked the cervical stump subsequent to subtotal

hysterectomy.

3. The fibroid which necessitated the hysterectomy was really

a sarcomatous tumour of the uterus.

4. The suspected growth on the cervix is not malignant, but a

granuloma.

Each of these postulates requires separate consideration.

Many observations have been published which show beyond dispute that

surgeons have performed subtotal hysterectomy in ignorance that the

cervix was already cancerous, and the hæmorrhages of which the patients

complained before the operation were due as much to the cancer in the

neck of the uterus as to the fibroids. This should serve as a warning

that, in cases where the surgeon contemplates performing a subtotal

hysterectomy, he should carefully examine the cervix beforehand; at the

time of the operation he should also critically examine the cut surface

of the cervix, and if it be in the least suspicious he should remove the

neck of the uterus. It is necessary to remember that cancer attacks any

part of the cervical endometrium, therefore an early cancerous ulcer in

the middle of the cervix will run a great chance of being missed by a

surgeon who is content with a subtotal hysterectomy.

It is certain that cancer does occasionally attack a cervical stump left

after subtotal hysterectomy at such an interval after the operation as

to make it certain that the cancer did not exist at the time of the

operation. Such a case occurred in my practice. I performed subtotal

hysterectomy in 1901 on a woman forty-two years of age, mother of one

child; eighteen months later there was a cancerous ulcer on the cervix;

the whole of the cervical stump was promptly removed and the nature of

the disease established microscopically. In 1908 the patient was in

excellent health.

In another case under my care I performed total hysterectomy for

fibroids in ignorance that the patient had cancer of the cervix. Some

months after the operation cancer recurred in the vaginal vault and scar

of the hysterectomy; the neck of the uterus had been preserved by the

doctor, and on examination the cancer was found. In this instance,

although total hysterectomy was performed, it had no effect in staying

the course of the disease.

It is necessary to utter a caution in regard to the occurrence of cancer

of the cervix after subtotal hysterectomy. I removed a uterus

containing a large globular submucous fibroid from a barren married

woman forty-five years of age. Six years later she came under my

observation with a large granulating and bleeding growth on the cervix

uteri. I had no doubt from the naked-eye characters that this was a

primary carcinoma, although it surprised me to find it there, especially

as the woman had never been pregnant. On my urgent representations she

allowed me to remove the cervix. On microscopic examination the

suspected cancer turned out to be a granuloma. Two years later the

patient was in good health. Polk has recorded a similar experience.

These facts show that caution is necessary in accepting reports of

cancer of the uterine stump after subtotal hysterectomy.

=Cancer of the body of the uterus and fibroids.= In deciding between

total and subtotal hysterectomy for fibroids the probable presence of

cancer requires consideration in another aspect. Although uterine

fibroids do not predispose to cancer of the neck of the uterus, many

writers in recent years have expressed their suspicions that the

presence of a submucous fibroid favours the development of cancer in the

corporeal endometrium. Piquand, in 1905, drew attention to this matter

and emphasized what other observers had pointed out, namely, that a

submucous fibroid is often associated with changes in the mucous

membrane of the uterus, which not only causes excessive bleeding, but

sets up inflammatory conditions giving rise to leucorrhœa, salpingitis,

pyosalpinx, and morbid changes in the endometrium, rendering it

susceptible to cancer. His statistics support his conclusions, for they

represent that in one thousand women with fibroids fifteen will probably

have cancer of the body of the uterus. My own observations support this

opinion. This complication is found most frequently between the fiftieth

and the sixtieth year of life. If we narrow the ages of the patient and

exhibit the liability in its most emphatic form it would run thus: that

in patients submitted to hysterectomy for fibroids over the age of fifty

years, about ten per cent of them will have cancer of the corporeal

endometrium.

In 1906 I looked through the case-notes of five hundred patients who had

been submitted to operation for uterine fibroids under my care. Of these

sixty-three patients had attained the age of fifty years and upwards.

Among these sixty-three women there were eight cases of cancer of the

corporeal endometrium; the nature of the disease in each case was

verified by careful microscopic examination.

Consequently, in performing subtotal hysterectomy for fibroids in women

of fifty years and upwards, the surgeon should have the uterus opened

immediately after its removal and assure himself that the endometrium is

free from cancer. If there be any suspicion in this direction he should

remove the cervix.

=Sarcoma.= The most insidious danger which besets the surgeon in dealing

with fibroids of the uterus is the occurrence of an encapsuled sarcoma

in the guise of an innocent fibroid. I have for some years dropped the

name of myoma for these common uterine tumours, preferring to apply the

term fibroid in a generic sense to all encapsuled tumours of the uterus.

Every histological condition is found in them, from the hard calcified

body looking like a block of coral to a soft diffluent collection of

œdematous connective tissue, and tumours composed of tissue

indistinguishable from spindle-celled sarcomata.

I have elsewhere recorded briefly a case in which I removed the uterus

from a woman forty years of age, which contained a fibroid as big as an

ostrich’s egg. On section it appeared to be a moderately firm fibroid,

with its tissue whorled as is usual in hard fibroids and enclosed in a

complete capsule. Some months later the patient complained of pain, and

on examination a hard mass occupied the floor of the pelvis; a portion

of this was excised and submitted to three competent histologists, who

reported the growth to be an innocent fibroid. The patient died fourteen

months after the primary operation with her pelvis filled with recurrent

growth. The tumour was a spindle-celled sarcoma.

Much has been written regarding the sarcomatous degeneration of

fibroids. In this matter I have maintained an attitude of active

scepticism. My experience amounts to this: the case which I have briefly

described is the only example in a thousand cases of hysterectomy in

which an encapsuled sarcoma in the guise of an innocent fibroid has come

under my observation, therefore I come to the conclusion that it is an

uncommon event, and on turning to the literature of the subject it will

be found that unequivocal examples are few.

From a careful study of the question, I have formed the opinion that if

a woman with fibroids and concomitant cancer of the neck of the uterus

seeks advice on account of hæmorrhage, and the cancer has attacked the

vaginal portion of the cervix, the nature of the case will be

appreciated. The cases likely to be overlooked are those where the

cancer is situated somewhat higher in the cervical canal than usual, so

that it is not easily detected by the examining finger, and so low in

the cervix that the disease is not exposed when the body of the uterus

is amputated in the course of a subtotal hysterectomy. A knowledge of

this, as well as the fact that cancer of the cervix is almost

exclusively a disease of women who had been pregnant, should make the

surgeon particularly careful in performing subtotal hysterectomy for

fibroids in women who have had children, in order to assure himself that

it is not cancerous.

In addition to the liability of the stump left after subtotal

hysterectomy to become cancerous, it is stated by some surgeons that the

patient is more liable to intestinal obstruction than after the total

operation. This objection is easily met, because a perusal of their

writings shows clearly that they do not perform the operation properly.

In subtotal hysterectomy, performed according to Baer’s instructions,

there should be no stump projecting from the pelvic floor, but merely a

thin seam underlying the base of the bladder.

[Illustration: FIG. 16. AN ADENOMYOMATOUS UTERUS. The organ is shown in

sagittal section in order to display the great thickening of the

endometrium. From a spinster aged 43 years. Two-thirds size.]

I have dealt in detail with these two methods of hysterectomy, because

when it can be performed subtotal hysterectomy is, as a rule, a simpler

operation than total hysterectomy. There are conditions in which it is

imperative to remove the whole of the cervix, especially when the canal

is very patulous and perhaps septic; when it is large and hard, or large

and spongy; and especially if there is the least suspicion of malignancy

in the cervix, or in the body of the uterus.

It must, however, be borne in mind that cancer has attacked the scar

left in the vagina after a total hysterectomy (Quénu). At the present

time the subtotal method enjoys the greatest favour in London, but it

must be remembered that where the total operation is most indicated, it

is often difficult of execution. Although I have a decided preference

for the subtotal operation, especially in spinsters and barren wives, I

have performed total hysterectomy in more than 200 patients, so that I

am in no way blind to its merits.

=Cancer of the uterus after bilateral ovariotomy.= The uterus, after

complete removal of both ovaries, is not only a useless organ, but it

may become attacked by cancer. Blacker reported a case in which a woman,

thirty-nine years of age, underwent bilateral oöphorectomy for a uterine

fibroid: eight years later cancer attacked the neck of the uterus and

destroyed the patient.

[Illustration: FIG. 17. AN ADENOMYOMATOUS AND TUBERCULOUS UTERUS. The

uterus is opened by a vertical incision in its posterior wall. The

anterior wall is occupied by a mass of tuberculous adenomatous tissue.

The patient, a spinster aged 46, was in excellent health four years

after the operation. Two-thirds size.]

In 1902 I performed abdominal myomectomy on a woman forty-seven years of

age, and removed both ovaries and Fallopian tubes; the latter contained

pus. Four years later this patient came under observation with extensive

cancer of the cervix.

In 1901 a patient had bilateral ovariotomy performed; five years later

she complained of severe uterine hæmorrhage. I removed the uterus by the

abdominal route (total hysterectomy). The corporeal endometrium was

cancerous throughout. The patient survived the operation six months.

Similar cases have been recorded by Martin, Butler-Smythe, and

Playfair.

=Adenomyoma of the Uterus.= This disease has not received adequate

recognition at the hands of British surgeons, yet it is a condition

which occasionally causes much doubt in the surgeon’s mind in the course

of hysterectomy. This adenomyomatous change affects the endometrium and

is, in some cases, associated with interstitial and subserous fibroids:

it causes often great enlargement of the uterus, and under these

conditions the fundus can be felt high in the hypogastrium. The patients

are often profoundly anæmic as the result of long-continued menorrhagia.

The physical and clinical signs of the disease are those present in

patients with a large degenerating submucous fibroid. Indeed the surgeon

often removes the uterus under this impression, and, after the operation

is completed, when he divides the uterus expecting to see the usual

encapsuled tumour, to his surprise finds a uterus with greatly thickened

walls (Fig. 16).

Microscopically the adventitious material is made of irregular tracts of

endometrium containing glands and strands of unstriped muscle tissue.

It is important for the surgeon to recognize these cases because,

contrary to the rule with simple uterine fibroids, these adenomyomatous

uteri are often adherent to the adjacent bowel and to the bladder: in

connexion with this fact several observers have pointed out that uteri

affected with this disease are often associated with inflammatory

affections of the Fallopian tubes, and there are good reasons for the

belief that the adenomyomatous change has a microbic origin. In this

connexion it is worth mention that adenomyomatous uteri are sometimes

tuberculous (Fig. 17). Some examples of this disease have been mistaken

for cancer of ‘the body of the uterus’.

In this disease subtotal hysterectomy gives admirable results, immediate

and remote.

THE FATE AND VALUE OF BELATED OVARIES

The only improvement of any importance made in Baer’s operation of

subtotal hysterectomy concerns the ovaries. These Baer removed with the

Fallopian tubes, but in 1897 I advocated, at the Obstetrical Society,

London, that they were of great value to the patient, and pointed out

that their conservation, when healthy, spared the patient the annoyance

of that curious vaso-motor phenomenon, known to women as ‘flushings’,

which is the only obtrusive sign of the menopause.

It is now admitted by those surgeons in London who have had much

experience of hysterectomy for fibroids, that the immediate results of

preserving at least one healthy ovary in this operation are admirable,

especially in women under forty years of age, for the retention of an

ovary is of striking value ‘in warding off the severity of an artificial

menopause’ (Crewdson Thomas).

Although I have left one or both ovaries in the performance of abdominal

hysterectomy for fibroids in more than 300 patients, in only two

instances have I found anything detrimental in the practice. In these

two patients it was necessary to remove one of the ovaries. Since 1906 I

have modified the method by leaving only one ovary, even when both were

healthy, and find that the immediate good consequences of the operation

are in no way impaired. There is reason to believe that whatever good

effects follow the practice of leaving a belated ovary (that is, an

ovary divorced from the uterus and left in the pelvis), they are

temporary, for in the course of a few years the ovarian tissue

disappears and the patients experience the usual symptoms of the

menopause. It is possible that the rate of atrophy of the secreting

tissue of a belated ovary depends on the age at which a patient is

submitted to hysterectomy.

In 1898 I performed subtotal hysterectomy on a woman, thirty-one years

of age, for fibroids, conserving the right ovary. Nine years later

(1907) I operated again for intestinal obstruction, and found this ovary

healthy and functional, for a ripe corpus luteum was visible on its

surface. Even a portion of an ovary, if it contain follicles, will

maintain menstruation.

In performing abdominal hysterectomy for fibroids, there are three

points which require consideration in relation to the subsequent comfort

of the patient, and they depend mainly on the conservation of a healthy

ovary. These three points relate to: (_a_) the patient’s comfort in

securing freedom from flushings; (_b_) if she be married, her marital

relations; and (_c_) if single, her nubility.

In regard to marital relations in women with a belated ovary, nothing

trustworthy is forthcoming, but I believe the retention of an ovary is

an additional factor in promoting domestic bliss. The question of

nubility is interesting; I am able to state that women who have had

subtotal hysterectomy performed, with conservation of one ovary, have

married and lived happily with their husbands; and I am of opinion that

the preservation of the vaginal segment of the neck of the uterus is an

important factor, as it leaves the vagina intact, and though such women

are sterile, they are certainly nubile.

Without overstating the case it may be said that a belated ovary is a

very precious possession to a woman under forty years of age, whether

she be married or single.

In regard to the fate of such ovaries, in the present condition of our

knowledge it may be stated that:--

In a woman under the fortieth year of life, a belated ovary remains

active and discharges ova.

[Illustration: FIG. 18. UTERUS WITH THE DECIDUA IN SITU. The parts of

the uterus occupied by the decidua represent the menstrual area of the

uterus.]

An ovary belated after the fortieth year of life atrophies, and

menopause symptoms will often ensue in the course of a few months after

the operation. The retention of an ovary minimizes the menopause

disturbances, and they are never so acute and prominent under these

conditions as they are when an acute menopause is induced by the sudden

and complete removal of all ovarian tissue. Some experienced observers

maintain that an ovary is a valuable possession to any woman who

menstruates, even at the age of fifty years, the persistence of

menstruation being obtrusive evidence that this gland is functional.

Experimental evidence, obtained from rabbits, proves that the removal of

the whole uterus has no deterrent effect on ovulation, and it does not

prevent the occurrence of œstrus and ovulation at periodically recurring

intervals. There is no necessity to appeal to experiments on animals in

this matter, as clinical observations on women are most eloquent in

proclaiming the great value of a conserved ovary when the uterus is

removed on account of troublesome and dangerous fibroids.

In reference to the value of ovarian tissue after hysterectomy for

fibroids, attention should be drawn to a modification of this operation

known as the Abel-Zweifel method, by which a small segment of the

menstrual area of the uterus is left as well as one or both ovaries:

this permits menstruation to continue in a subdued form.

Doran has particularly studied this method and practised it, but I

cannot express any opinion as to its value, never having had the courage

to perform it.

My aim in performing hysterectomy for fibroids is to abolish as

completely as possible the menstrual area of the uterus (Fig. 18), and

up to the present my efforts have been successful, and I have no

complaint from any patient that this disagreeable phenomenon has

manifested itself, although I have been at great pains by my own

exertions, as well as by the kind efforts of those who have been

associated with me in my hospital work, to keep in touch with women who

have been so unlucky as to require such a serious operation as the

removal of the uterus.

REFERENCES TO THE HISTORY OF HYSTERECTOMY FOR FIBROIDS

BAER, B. F. Supra-vaginal Hysterectomy without Ligature of the Cervix in

Operation for Uterine Fibroids. A new method. _Transactions of the

American Gynæcological Society_, 1892, xvii. 235.

BARDENHEUER. _Die Drainierung der Peritonealhöhle._ _Im Anhang: Thelen:

Die Totalextirpation wegen Fibroid._ Stuttgart, 1881, 271.

GOFFE, I. RIDDLE. This surgeon furnishes an interesting account of the

development of Total and Subtotal Hysterectomy for Fibroids, in _The

Transactions of the American Gynæcological Society_, 1893, xviii.

372.

KOEBERLÉ, E. Documents pour servir à l’histoire de l’extirpation des

tumeurs fibreuses de la matrice par la méthode suspubienne. _Gaz.

med. de Strasbourg_, 1864, xxiv. 17; 66; 158. 1865, xxv. 78; 118.

POZZI, S. _Traité de Gynécologie_, 1905, i. 424. This contains an

interesting review of the serre-nœud and clamp period of

hysterectomy. He states that Tillaux, in a communication to the

Academy in 1879, proposed the use of the word Hysterectomy.

LITERATURE RELATING TO CANCER OF THE CERVICAL STUMP AFTER SUBTOTAL

HYSTERECTOMY

DORAN in his Harveian Lectures, London, 1902, gives an admirable

critical summary of this important question up to that date.

BLAND-SUTTON, J. _Essays on Hysterectomy_, 1905, 2nd Ed., 60.

---- _Journal of Obs. and Gyn. of Gt. Britain_, 1904, v. 434.

MANN, M. _Trans. Am. Gyn. Soc._, 1893, p. 123.

POLK. _Am. Journ. of Obstetrics_, 1906, liv. 78.

QUÉNU. _Rev. de Gyn. et de Chir. Abdom._, 1905, Sept.-Oct., ix. 720.

RICHELOT. _La Gynécologie_, 1903, viii. 399.

TURNER, G. _Brit. Med. Journ._, 1905, ii. 953.

REFERENCES IN RELATION TO THE OCCURRENCE OF CANCER IN THE UTERUS AFTER

BILATERAL OVARIOTOMY

BLACKER, G. F. Uterus with Fibroids and Carcinoma of the Cervix. _Trans.

Obstet. Soc._, 1896, xxxvii. 213.

BLAND-SUTTON, J. A Clinical Lecture on Adenomyoma of the Uterus. _Brit.

Med. Journal_, 1909, 1.

BUTLER-SMYTHE. Carcinomatous Uterus removed eighteen and a half years

subsequent to Double Ovariotomy. _Trans. Obst. Soc._, 1901, xliii.

214.

PLAYFAIR. Carcinoma of Uterus. Ibid., 1897, xxxix. 288.

MARTIN, A. _Die Krankheiten der Eierstöcke und Nebeneierstöcke_, 1899,

s. 907.

REFERENCES CONCERNING THE VALUE OF BELATED OVARIES

BLAND-SUTTON, J. Abdominal Hysterectomy for Myoma of the Uterus, with

brief notes of twenty-eight cases. _Transactions of the Obstetrical

Society_, 1897, xxxix. 292.

---- The Value and Fate of Belated Ovaries. _The Medical Press and

Circular_, 1907, ii. 108.

BOND. An Inquiry into some Points in Uterine and Ovarian Physiology and

Pathology in Rabbits. _British Medical Journal_, 1906, ii. 121.

DORAN, A. Subtotal Hysterectomy: after history of sixty cases.

_Transactions of the Obstetrical Society_, 1905, xlvii. 363.

THOMAS, G. C. The after histories of one hundred cases of Supravaginal

Hysterectomy for Fibroids. _Lancet_, 1902, i. 294.

CHAPTER VII

HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS

The modern operation of hysterectomy as a radical measure for the relief

of cancer of the uterus has a somewhat curious history. In 1878 Freund

extirpated the uterus for carcinoma of the cervix through an abdominal

incision; his method was quickly practised by other surgeons, but the

great mortality of the operation soon caused it to be abandoned for the

vaginal route advocated by Czerny and supported by Schroeder, Olshausen,

Martin, and Péan amongst other gynæcologists. This method, however, has

been abandoned, for, although the operative mortality of vaginal

hysterectomy for cancer of the uterus has fallen to 5 per cent., the

operation has disappointed expectation, as it can only be employed on

early cases of the disease with anything like a hopeful prospect of

curing the patient, and, even when performed on carefully selected

cases, the risks of recurrence are so great and often follow so rapidly

on the operation that surgeons have lost confidence in the method. This

has induced gynæcologists to turn their attention again to the abdominal

route. The cancerous uterus is now subjected to what is known as

‘radical abdominal hysterectomy’, a method with which the names of Ries,

Mackenrodt, Dührssen, and Wertheim are closely associated.

=Hysterectomy for cancer of the cervix.= The greatest obstacle to the

success of vaginal hysterectomy in the radical treatment of cancer of

the neck of the uterus is the limitations which the anatomical

environment imposes on the surgeon, for as soon as the disease overruns

the cervix it implicates the vagina, the bladder, the vesical portions

of the ureters, and the rectum. The ‘radical abdominal operation’

enables the operator not only to remove the uterus and its neck, but the

broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and

the infected para-uterine connective tissue, and by affording the

operator free access to the floor of the pelvis the proceedings may be

carried out with a free exposure of the operating field, thus allowing

important structures like the ureters to be dissected out of implicated

tissue. Indeed it has even been recommended, in cases where the bladder

has been extensively involved, to resect this viscus and engraft the

ureters into the rectum.

The primary object of these extensive operations is not only to

facilitate the wide removal of connective tissue around the cervix in

early cases of carcinoma, but also to allow the advantages of operative

treatment to be extended to patients to whom it would be otherwise

absolutely barred.

One great danger which attends operations for the removal of cancerous

organs is what may be called ‘post-operative cancer-infection’, that is,

in the course of the operation tracts of connective tissue are opened up

and become soiled with cells, which engraft themselves on this tissue

and on the peritoneum, and give rise to extensive masses of cancer which

are often described as recurrent cancer. This accident often causes the

patient to die quicker than if the primary cancer had been left

untouched. In the radical operation it is one of the essentials to avoid

soiling the wound with cancer cells. This rule, of course, applies to

operations for cancer in any part of the body.

=Operation.= The steps of the radical abdominal operation advocated by

Wertheim are as follows:--

As a preliminary, the cancerous cervix is treated by scraping,

cauterizing, and disinfectants. It is an advantage to carry out these

measures a few days before the main operation. The Trendelenburg

position is indispensable and the abdomen is opened by a free median

subumbilical incision. After isolating the intestines with dabs, the

_ureters_ are exposed by incising the posterior layer of the broad

ligament; they are then traced to the parametrium. It is necessary to

avoid too free a disturbance of their vascular network or they will

slough.

The _bladder_ is then separated from the uterus. The

_infundibulo-pelvic_, the _broad_, and the _round ligaments_ are

ligatured and divided. The particular order in which they are dealt with

is not a matter of consequence. The uterine vessels are secured in the

following manner:--The index finger is pushed along the ureter through

the parametrium towards the bladder, until the tip of the finger appears

there; the vessels are then raised on the finger, which covers the

ureter so as to protect it whilst the vessels are ligatured and divided.

As soon as the uterine vessels are divided the vesical segments of the

ureters are exposed, cleaned if necessary, and separated from the

cancerous cervix.

The posterior layer of the peritoneum is divided and the rectum

separated from the vagina: at this stage the uterus is sufficiently

isolated from the surrounding structures to allow of removal. This is

effected in the following way:--

The two layers of the parametrium are taken off as close as possible to

the pelvic wall, and the vagina closed with bent clamps and divided

below them: the clamps are used to prevent soiling the operation-area

with cancerous cells.

In order to extirpate the _lymph glands_, the peritoneum is divided

upwards and the iliac vessels laid bare, and every enlarged gland from

the division of the aorta to the obturator foramen is removed and the

oozing vessels carefully secured.

The wound is treated in the following way:--

The cavity created by the removal of the uterus is filled in loosely

with iodoform gauze, which extends to the vulva. An exact closing of the

peritoneal cavity over this gauze is effected by the sewing up of the

anterior and posterior flaps of peritoneum. The final step is the

closure of the abdominal incision.

=After-treatment.= This is relatively simple. The strips of iodoform

gauze are removed through the vagina in from five to ten days

successively. The patient gets up on the fifteenth day. The bladder

requires very careful attention, as it is usually paralysed for some

days.

=Mortality.= The immediate mortality of these extensive abdominal

operations for cancer of the neck of the uterus is very high, more than

20%, but recent statistics (1909) show that this death-rate is being

considerably improved with increased experience on the part of the

operators.[1]

[1] Comyns Berkeley and Bonney have published the best immediate results

of this operation which have been obtained in England. _British Medical

Journal_, 1908, ii. 961, and _Lancet_, 1909, i. 320.

=Dangers.= The chief risks of the operation are sepsis,

cancer-infection, and injury to the ureters.

The ureters have proved a fertile source of trouble because they are

deliberately exposed in the course of the operation, and they are

sometimes accidentally divided. It is not uncommon to find a ureter

completely blocked by cancer, and occasionally the ureter, after being

bared by the operator, undergoes necrosis a few days later.

Wertheim points out that in some instances ureteral fistulæ due to

necrosis may be induced to close by the application of iodine or

sulphate of copper. It is, however, unfortunately true that many

patients with ureteral fistulæ after the radical operation have been

obliged to undergo nephrectomy (see p. 112).

The ‘radical operation’ for cancer of the neck of the uterus is on its

trial in Great Britain. The operative mortality is very high, and no

reliable returns concerning the remote results are at present available.

=Hysterectomy for cancer of the body of the uterus.= The most

satisfactory method of dealing with cancer arising in the corporeal

endometrium consists in performing total abdominal hysterectomy (see p.

40), removing not only the uterus and its neck, but both ovaries,

Fallopian tubes, mesometria, and any enlarged lymph glands that are

detected. In the course of the operation the surgeon should avoid any

undue handling of the uterus, and, in withdrawing it from the pelvis,

care should be taken not to infect the operation area with any fluid or

semi-fluid stuff which is liable to escape from the cervical canal.

[Illustration: FIG. 19. CANCER OF THE UTERUS. Coronal section through a

uterus affected with primary cancer of the corporeal endometrium. The

mass measured 10 centimetres transversely and 12 centimetres vertically.

Removed by abdominal hysterectomy. Two-thirds size.]

There is a rare variety of cancer of the corporeal endometrium, namely,

that which attacks small atrophic uteri. These small uteri may sometimes

be extirpated by the vagina, but often the narrowness of the vagina in

aged spinsters compels the surgeon to resort to the abdominal route.

Cancer of the body of the uterus occasionally causes such enlargement of

this organ as to render its removal by the vaginal route difficult as

well as undesirable. When this form of cancer is complicated with

fibroids, as a rule, vaginal hysterectomy is impracticable.

Cancer of the body of the uterus is more frequent in spinsters and

barren wives than in multiparæ; for this reason the cancer often assumes

the massive form, because the cervical canal being narrow, pathogenic

micro-organisms do not obtain such free ingress as in the case of women

with a patulous canal. In some instances the cancerous mass will expand

the uterine cavity and lead to thinning of the walls as in Fig. 19.

Clinically, cancer of the corporeal endometrium is a more insidious

disease than cancer of the neck of the uterus, but since its frequent

association with fibroids has been recognized (see p. 52) mainly as a

consequence of the vulgarization of hysterectomy, many cases are

detected fairly early and with improved results for the patients.

=Mortality.= The risk to life in abdominal hysterectomy for cancer of

the body of the uterus is somewhat greater than after removal of the

uterus for fibroids. This is due to the fact that when the cancer

ulcerates and sloughs, the risk of sepsis is therefore increased; this

also makes convalescence slower.

The remote results vary greatly; these depend in a large measure on the

extent of the disease at the time of the operation. When the cancerous

mass is compact, as in Fig. 19, good results may be expected. When the

growth has perforated the uterine wall and small bud-like processes

project on the serous surface, the disease may be expected to recur

rapidly in the abdomen. Cancer of the uterus remains an opprobrium to

operative gynæcology.

CHAPTER VIII

OPERATIONS FOR DISPLACEMENT OF THE UTERUS

HYSTEROPEXY (VENTRO-SUSPENSION AND VENTRO-FIXATION OF THE UTERUS)

_Hysteropexy is a term applied to an operation for fixing the uterus, by

means of sutures, to the anterior abdominal wall._

This procedure was advocated as a definite surgical operation for

displacements of the uterus independently by Olshausen and Kelly (1886).

The operation when employed for severe retroflexion of the uterus is now

known as ventro-suspension of the uterus; when carried out for prolapse

it is termed ventro-fixation of the uterus. When care is taken in the

selection of patients, hysteropexy is an operation which is followed by

satisfactory consequences.

VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS

The preliminary preparation and the instruments required as those used

for a simple cœliotomy (see p. 5).

=Operation.= The patient is placed in the Trendelenburg position, and

the abdomen is opened as for ovariotomy, except that the incision is

shorter; the operator then determines with his fingers the position and

condition of the body of the uterus. If it be free, it is then

straightened, and the condition of the ovaries and the tubes

ascertained.

In many patients, where retroflexion of the uterus is accompanied by

pain, the distress is often due to a prolapsed ovary, incarcerated in

the pelvis by the retroflexed fundus of the uterus; in another set of

cases the retroflexion is produced by a tumour in the ovary, such as a

small dermoid, but more often the body of the uterus is drawn backwards

by a small fibroid in the fundus of the organ. In these conditions an

operation embarked upon as a simple hysteropexy may become an

oöphorectomy, an ovariotomy, or a myomectomy, according to the necessity

of the case. When the enlargement of the ovaries is due to œdema from

incarceration, they should be left, as the swelling will quickly subside

when the misplacement of the uterus is corrected.

The uterus is fixed to the abdominal wall in the following way:--

A curved needle armed with a silk thread (No. 4) which has been

carefully boiled is passed through the aponeurosis and adjacent

peritoneum on one edge of the wound, then through the anterior surface

of the uterus near the fundus, and finally through the peritoneum and

aponeurosis on the opposite edge of the incision; when this suture is

tightened, it will be found to draw the uterus to the anterior

abdominal wall, and at the same time approximate the edges of the wound.

Two sutures should be introduced. In patients who have had children care

should be taken not to pass the needle so deeply into the uterus that

the suture traverses the superficial parts of the endometrium and

becomes infected: this will lead to a suture sinus. The rest of the

wound is then closed according to the method described on p. 9.

VENTRO-FIXATION FOR PROLAPSE OF THE UTERUS

=Operation.= When hysteropexy is needed for a large, bulky, and

prolapsed uterus, the steps of the operation are the same as for

retroflexion, but it is necessary to introduce a greater number of

retaining sutures. Further, as the uterus tends to slip downward into

the vagina, it is an advantage, as soon as the fundus of the uterus is

drawn into the wound, to transfix it with a stout suture, in order that

the assistant may use it as a tether to keep the uterus in position

whilst the surgeon introduces the main sutures. In some cases, where the

uterus is very large, it may be requisite to employ four, five, or even

six sutures to secure it to the abdominal wall.

In all cases of hysteropexy the uterus is of necessity sutured to the

lower angle of the wound, and is therefore in close relation to the

bladder. It facilitates the operation to introduce the lowest sutures

first and then gradually work up to the fundus. The wound is then closed

and dressed as described for cœliotomy.

=After-treatment.= This is conducted on the same lines as after

ovariotomy.

=Risks.= Hysteropexy, when performed by surgeons experienced in pelvic

surgery, is such a simple operation that it should have no mortality. At

the Chelsea Hospital for Women, from 1904 to 1906, both years inclusive,

this operation was performed on 190 patients, all of whom recovered from

the operation.

Many of these operations were complicated with oöphorectomy, ovariotomy,

or myomectomy. A wide study of operation returns show that hysteropexy

is not absolutely free from risk, as deaths from sepsis, lung

complication, and intestinal obstruction have been reported.

The remote consequences of hysteropexy are of interest. When the uterus

has been enlarged by previous pregnancy its fundus can be brought

without undue strain into contact with the anterior abdominal wall, so

that when it is secured by sutures there is little or no strain on them.

When hysteropexy is performed on spinsters or barren married women in

whom the uterus is small, there is, in many instances, a strain on the

sutures. The effect of this strain is twofold. When the uterus is

attached to the abdominal wall by an aseptic suture, lymph is exuded

from the surfaces of the peritoneum in contact with the retaining

sutures. This effused lymph organizes into a tenacious tissue, and the

strain of the uterus, when the operation is performed on virgins, or the

weight of the organ when it is done for prolapse, will cause the sutures

to erode their way out of the uterine wall, but the plastic material

effused around the silk threads slowly stretches as the uterus descends

into the pelvis, producing a tendon-like structure which may be called

the ‘artificial fundal ligament’ (Fig. 20).

[Illustration: FIG. 20. THE FUNDUS OF A UTERUS. A long fibrous cord

arises from the fundus as a result of hysteropexy performed nearly five

years previously for inveterate retroflexion. Full size.]

In patients in whom the length of the uterus allows its fundus to come

in contact with the abdominal wall without strain, the union may be so

secure that the woman may pass through one or more pregnancies

successfully without disturbing the union, or even stretching it. This I

have proved in twelve instances where some subsequent trouble such as

appendicitis, gall-stones, ovariotomy, cancer of the colon, or the like

has led to a repeated cœliotomy, and has afforded me an opportunity of

examining the condition of the uterus.

In one remarkable case where a small uterus had been securely fixed by

its fundus to the abdominal wall by means of ten thick sutures (the

operation had been performed in a cottage hospital in Yorkshire), the

patient complained of persistent pain, and was sent to me on this

account. I found the sigmoid flexure of the colon caught in one of the

sutures, which accounted for some of the woman’s trouble, but the uterus

was so firmly fixed to the abdominal wall and had been so dragged upon

that it had become a rounded sausage-like organ. Its removal was

followed by immediate relief. Among rare accidents which have followed

this simple operation is tetanus when catgut and wallaby tendon has been

used for the retaining sutures (see p. 107).

REFERENCES

KELLY, H. A. Hysterorrhaphy. _American Journal of Obstetrics_, 1887, xx.

33.

OLSHAUSEN. Ceber ventrale Operationen bei Prolapsus und Retroversio

Uteri. _Centralblatt für Gynäkologie_, 1886, x. 698.

CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY

Pregnancy is apt to be complicated with tumours growing in the walls of

the uterus, _e.g._ fibroids, cancer of the neck of the uterus, or cysts

and tumours of one or both ovaries; morbid conditions of the Fallopian

tubes, _e.g._ pyosalpinx, tubal pregnancy; tumours and cysts in the

broad ligament; displaced viscera occupying the pelvis, _e.g._ the

spleen or the kidney; tumours arising in the pelvic bones, _e.g._

osteoma, enchondroma, or sarcoma; and echinococcus cysts and colonies

growing in the omentum, but occupying the pelvis, or arising in the

pelvic tissues.

This is a formidable list, and any one of them may so complicate the

pregnancy that it may be necessary to remove the tumour, and in some

instances to perform Cæsarean section, or even hysterectomy.

CÆSAREAN SECTION

This signifies the removal of a fœtus and placenta from the uterus

through an incision involving the abdominal and uterine walls.

This operation is required when the outlet of the pelvis is too narrow

to permit the transit of a viable child, as in rickets and osteomalacia;

when the vagina is malformed; when the pelvic outlet is narrowed by

tumours growing from the pelvic wall. Occasionally the passage of a

fœtus is barred by tumours growing from the uterus, especially a large

cervix fibroid, or a fibroid growing from the lower segment of the

uterine wall. An ovarian cyst, especially a dermoid incarcerated by the

uterus, may render this operation necessary. The rarest causes are

cancer of the neck of the uterus and cancer of the rectum.

This operation is advocated by some obstetricians in certain cases of

eclampsia and placenta prævia.

=Operation.= When it is known some days beforehand that the patient will

be submitted to this operation, she should be prepared as for

ovariotomy. Often it happens that the operation is undertaken after

labour has commenced, and in circumstances which make time very

precious. Even then the abdomen, pubes, and vulva can be shaved and

thoroughly washed with warm soap and water, and lightly rubbed with

ether and cotton wool.

The instruments required are those given on p. 5.

When the patient is under the influence of ether and the bladder emptied

with the catheter, an incision is made in the linea alba from the

umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy

is very thin, and, unless the surgeon be cautious, the knife will come

in contact with the uterus before he is aware of it.

The uterus lies just under the incision, and the operator ascertains

that it lies centrally (often the uterus is somewhat rotated to the

right or left), and then makes a free incision through the uterine wall

and extracts the fœtus and placenta; as the uterus contracts, he slips

his left hand behind the fundus, and grasps the uterus near the cervix,

and effectually controls the bleeding. The assistant passes a large warm

flat dab into the belly to restrain the intestines and omentum. The

uterine cavity is sponged out, and the finger passed through the os

uteri into the vagina in order to ensure a free passage for blood and

serum.

The incision in the uterine wall may be closed either by a double or a

single set of silk sutures. When two layers of sutures are employed, the

first set involve the mucous and adjacent half of the muscular layer[;]

these sutures should be fairly close together, for they not only bring

the parts into apposition, but they restrain the bleeding. A second row

of silk sutures is now inserted, including the serous coat and adjacent

half of the muscular layer. These threads should not be tied too

tightly, as the tissues of a gravid uterus are soft and easily tear. In

closing the uterine incision the surgeon should not spend time vainly in

endeavouring to stanch the bleeding from the edges of the incision; this

is best effected by dexterously inserting and securing the sutures.

The recesses of the pelvis are carefully cleaned by gentle sponging, and

the parietal incision is closed as after ovariotomy.

The dressing varies with the fancy of the operator; a piece of

sterilized gauze and a square of Gamgee tissue held in position by a

many-tail of flannel firmly applied is all that is necessary.

Although Cæsarean section is one of the simplest operations that can be

performed on the pelvic organs, it formerly had a very high mortality;

but since the principles of asepsis have been thoroughly established the

death-rate from this operation has been so reduced that it varies from 4

to 10% according to the skill of the operator; indeed the results are so

good in the hands of careful and skilful men that on recovery from the

operation the patient may reconceive, and there are conditions in which

the patient is desirous to produce more children with the knowledge that

they must be extricated by Cæsarean section. There are many instances on

record of women being submitted to this operation twice, and some

thrice; and at least two patients have undergone this operation four

times (Sinclair). In view of the fact that a woman after being

submitted to Cæsarean section may reconceive, it has been urged

(especially by Sinclair) that the anterior surface of the uterus should

be attached to the abdominal wall in such a manner as to promote the

formation of adhesions, so that when the patient needs to be submitted

to ‘repeated Cæsarean section’, the adhesions resulting from the primary

operation will so shut off the operation area from the general

peritoneal cavity, that the uterus may be opened and the fœtus and

placenta extracted by a practically extraperitoneal operation. This

question has been discussed in an able and comprehensive paper by

Wallace, and also by Sinclair.

There is one great danger which women run by becoming pregnant after

Cæsarean section, namely, rupture of the uterus. Some cases illustrating

this accident have been reported. This accident has been discussed by

Wallace.

[Illustration: FIG. 21. PORTION OF OVARY AND FALLOPIAN TUBE. The parts

were removed a year after a supposed complete oöphorectomy had been

performed to induce an artificial menopause. This fragment of ovary

maintained menstruation regularly. Full size.]

Although a few writers, particularly Wallace, consider that all Cæsarean

sections should be performed with a view to ulterior pregnancy, this is

not the opinion of the majority, for there are many women who, having

passed such an ordeal once, have no desire to do so again, and ask for

something to be done to prevent its possibility in the future. This

involves what is known as ‘sterilization’.

=Sterilization after Cæsarean section.= When Cæsarean section is

performed the uterus is preserved, and after convalescence the woman is

in a position to reconceive. There are conditions in which she is most

anxious to produce more children even with the risk of having them

extracted by this operation. On the other hand, some women, knowing the

risks, ask that steps may be taken to prevent a recurrence of what they

consider a catastrophe. This appears a simple matter, but it is not so

in reality, for in many instances in which the operator had been under

the impression that he had effected this by ligature of both Fallopian

tubes in continuity, he has been surprised when the woman has again come

under his notice well advanced in pregnancy.

This has happened even when each tube has been ligatured in two places

and a segment of the tube exsected between the ligatures. Bilateral

oöphorectomy has been recommended, but on the whole, when the patient

and her husband wish that further risks should be avoided, the wisest

plan is to perform subtotal hysterectomy instead of Cæsarean section;

moreover it is a difficult matter to completely remove healthy ovaries,

and _it needs only a small portion to maintain menstruation_ (Fig. 21).

The whole of this matter is one that is really a question of ethics, and

the extreme views are represented by Wallace and Sinclair in the papers

to which reference has already been made. The difficulty of effectively

sterilizing women by simply relying on bilateral oöphorectomy is shown

by the well-established cases in which patients have successfully

conceived after bilateral ovariotomy and oöphorectomy.

The youngest patient on whom Cæsarean section has been carried out with

success to the mother and child was thirteen years of age. The operation

was performed by Gache in Buenos Ayres on account of smallness of the

pelvis. Women have recovered after a self-inflicted Cæsarean section.

REFERENCES

DORAN, A. Pregnancy after Removal of both Ovaries for Cystic Tumour.

_Journal of Obstetrics and Gynæcology of the British Empire_, 1902,

11, i.

GACHE, S. Opération césarienne sur une fille de 13 ans: Guérison.

_Annales de Gynécologie_, 1904, p. 601.

HARRIS, R. P. Six self-inflicted Cæsarean Operations with recovery in

five cases. _Am. Journ. of the Medical Sciences_, 1888, xcv. 150.

SINCLAIR, SIR WILLIAM. Cæsarean Section successfully performed for the

Fourth Time on the same Woman, with remarks on the production of

Utero-parietal Adhesions. _Journal of Obstetrics and Gynæcology of

the British Empire_, 1907, xii. 335.

WALLACE, ARTHUR J. On Repeated Cæsarean Section. Ibid., 1902, ii. 555.

CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER

It occasionally happens that a woman in whom the course of pregnancy is

nearly complete dies suddenly from disease, such as hæmoptysis,

hæmatemesis, cardiac trouble, or uterine hæmorrhage in the preliminary

stage of labour; or is killed by accident. In some such circumstance

attempts are sometimes made to rescue the unborn child, by performing

Cæsarean section. It is true that such efforts are rarely attended with

success, but in cases where death is very sudden and the surroundings

such as to enable the operation to be performed without delay, the child

may be extracted from the uterus and survive. Successful cases of this

kind are published from time to time.

In order to show how necessary it is to act promptly the following case

may be mentioned:--

A woman in the eighth month of pregnancy was found to be suffering from

cancer of the neck of the uterus. The child was alive. I decided to

perform hysterectomy. The uterus was exposed through a free incision in

the abdominal wall and quickly detached from its cervix. The uterus with

the fœtus inside was handed to an assistant, who quickly extracted the

child. Although the time which elapsed from the complete etherization of

the mother until the extraction of the child from the uterus was 2-1/2

minutes, it required the display of some energy to induce the child to

breathe. This is the first record as far as I know of a child being

delivered alive from a uterus detached from its mother. The woman died

on the fourth day after the operation, and the child on the fourteenth.

Möglich had a successful case. A patient aged forty-one years, with

placenta prævia, died from hæmorrhage, and an asphyxiated fœtus was

promptly extracted by cœliotomy. Prolonged efforts at artificial

respiration were successful, and the child was well five weeks later

(see also Sippel).

REFERENCES

HUGIER, M., and MONOD, M. Cæsarean Operation immediately after the death

of the Mother. _Lancet_, 1829-30, i. 899.

MÖGLICH. Ueber Kaiserschnitt an der Toten. _Münchener med. Wochensch._,

1908, lv. 202.

SIPPEL. Sectio Cæsarea in mortua. _Monats. f. Geb. u. Gyn._, 1907, xxvi.

618.

OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOUR

Although the directions in surgical writings are clearly laid down

concerning the course to be pursued when pregnancy and labour are

complicated by an ovarian tumour, the difficulty which often confronts

the operator when he is face to face with the actual case is uncertainty

regarding the nature of the tumour. Although he may begin the operation

under the impression that he has to deal with an ovarian tumour, it may

turn out to be a fibroid, a tumour of the pelvic wall, a misplaced

spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus

(lithopædion), or a calcified hydatid cyst. Thus an expected ovariotomy

may terminate as a Cæsarean section, or as a hysterectomy. In many cases

the surgeon must rely on his own judgment and experience, but it may be

useful to furnish some directions which may help him. It may be useful

also to mention what unexpected conditions are sometimes found. Thus an

experienced gynæcologist like Prof. Olshausen once removed a gravid

uterus under the impression that it contained a cystic fibroid which

would obstruct delivery. When it was examined after removal, the

suspected fibroid proved to be a large sacral teratoma growing from the

fœtus.

=Ovarian tumours and pregnancy.= Before the fourth month of pregnancy,

single and double ovariotomy is attended with a low rate of mortality,

and the risk of disturbing the pregnancy is small. The removal of a

parovarian cyst during pregnancy is more liable to be followed by

abortion than single or double ovariotomy. After the fourth month the

risk is that of an ordinary ovariotomy, but the chances of abortion

increase with each month. It is also a fact that ovariotomy may be

safely carried out between the eighth and ninth months of gestation

without precipitating labour, even when the tumour is incarcerated in

the pelvis.

In many cases in which ovariotomy is urgently indicated during

pregnancy, the pedicle will be found twisted.

When the tumour is situated above the uterus there is rarely any

difficulty in dealing with it, as the pedicle is usually long, but it

will require extra care in applying the ligature, as the tissues, being

unusually vascular and soft, are easily lacerated. Occasionally the

tumour lies in the pelvis below the uterus: in this case the surgeon

carefully insinuates his hand between the pelvic wall and the uterus,

and then gently withdraws the tumour from its incarcerated position.

CASES IN WHICH OVARIOTOMY HAS BEEN PERFORMED NEAR THE END OF THE

NINTH MONTH OF PREGNANCY

+------------+--------+---------+------------------------------------+

| _Surgeon._ | to | to | _Reference._ |

+------------+--------+---------+------------------------------------+

+------------+--------+---------+------------------------------------+

In operating for ovarian cysts complicating pregnancy, the surgeon

should, after removing the cyst, carefully examine the other ovary, for

twin tumours may be present. Berry Hart performed ovariotomy on a woman

in the fifth month of pregnancy, and removed a dermoid of the left ovary

‘enlarged to about the size of a man’s brain by recent hæmorrhage due to

the twisting of a pedicle’. The patient died on the ninth day. A frozen

section was made of the pelvis, and on inspecting the cut surface the

right ovary, converted into a dermoid, was found incarcerated by the

gravid uterus.

Many cases have been published in which ovariotomy has been undertaken

during the late months of pregnancy, or shortly after delivery, and the

surgeons have been astonished to find both ovaries converted into

tumours; in very many instances they were dermoids. Cases of this kind

have been recorded by Knowsley Thornton, F. Page, Cullingworth, Berry

Hart, Malcolm Campbell, and others, including myself. These

observations demonstrate that a woman may have both her ovaries occupied

by dermoids, yet the glands are capable of yielding fertilizable ova.

Campbell relates that Brewis, in performing an ovariotomy during

pregnancy, attempted to conserve some ovarian tissue by resecting the

dermoids; this proved impracticable, and both ovaries were excised. Miss

Ivens records a case in which a woman thirty-five years of age was five

months pregnant and required ovariotomy on account of an incarcerated

ovarian dermoid. In the course of the operation both ovaries were found

to contain dermoids. A tumour was successfully excised from each.

Pregnancy continued undisturbed.

REFERENCES

CAMPBELL, M. Case of Bilateral Ovarian Dermoid Tumour associated with

Pregnancy. _Lancet_, 1907, ii. 1760.

CULLINGWORTH, C. J. Three cases of Suppurating Dermoid Cyst, of or near

the Ovary, treated by Abdominal Section. _St. Thomas’s Hospital

Reports_, 1887-9, xvii. 139.

HART, BERRY. See Clarence Webster’s _Researches in Female Pelvic

Anatomy_, Edin., 1892, p. 124.

IVENS, MISS F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts.

_Brit. Med. Journal_, 1908, i. 625.

PAGE, F. Acute Peritonitis after Confinement; abdominal section; Dermoid

Disease of both Ovaries; removal; recovery. _Lancet_, 1893, ii. 250.

THORNTON, K. A case of removal of both Ovaries during Pregnancy. _Trans.

Obstet. Soc._, London, xxviii. 41.

=Ovariotomy during labour.= When an ovarian tumour is discovered during

labour and it impedes delivery, ovariotomy should be performed.

In this condition it follows that the tumour lies in the pelvis; when

the tumour is tightly impacted by the contracting uterus it has happened

that the surgeon has been unable to reach the tumour until he has

emptied the uterus by Cæsarean section. Several operators have had this

difficulty, myself among them. I have added a list of reported cases

drawn from British sources. For this I hope not to be accused of what is

sometimes perhaps facetiously called ‘insularity’. The enormous

population of these islands should furnish material enough to settle the

principles of treatment which should govern these terrible cases of

obstructed labour.

One of the commonest conditions met with in ovariotomy during pregnancy

and labour is to find that the cyst has undergone axial rotation and

twisted its pedicle. The technique in these circumstances is very

simple.

OVARIOTOMY FOR TUMOURS OBSTRUCTING LABOUR AT TERM

-----------+--------+--------+---------+------------------------------

|_Nature |_Result |_Fate |

_Operator._| of | to | of | _Reference._

|Tumour._|Mother._| Child._ |

-----------+--------+--------+---------+------------------------------

Williams |Cyst | R. |No record|_Trans. Obstet. Soc._, xxvi.

| | | | 203.

Spencer |Dermoid | R. | Lived |Ibid., xl. 14.

Boxall[1] |Dermoid | R. | Lived |Ibid., xl. 25.

Bland- |Dermoid | R. | Lived |_Lancet_, 1901, i. 382.

Sutton[1]| | | |

Sinclair[1]|Cyst | R. | Lived |_Lancet_, 1901, i. 158.

Favell[1] |Dermoid | R. |No record|_Brit. Med. Journal_, 1901, i.

| | | | 894.

-----------+--------+--------+---------+------------------------------

[1] In these cases it was necessary to perform Cæsarean section

in order to extract the tumour from the pelvis.

[Illustration: FIG. 22. A UTERUS DISTORTED BY FIBROIDS. It contains a

fœtus of four months’ development. Removed by the subtotal operation

from a primigravida, aged 42. Half size.]

=Ovariotomy during the puerperium.= It occasionally happens that a woman

may go through her pregnancy and labour with an unrecognized ovarian

tumour in her abdomen; during the puerperal period it may cause symptoms

which lead to its recognition, because in the course of the labour the

cyst may burst, undergo axial rotation, or suppurate. When a puerperal

woman possesses an ovarian tumour which gives rise to unfavourable

signs, ovariotomy should be resorted to without delay. The operation in

these circumstances is comparatively simple, and such adhesions as may

be present are usually recent and easily overcome.

Single and even double ovariotomy can be performed during puerpery

without in any way interfering with involution of the uterus or

lactation.

In 1896 I was able to collect fifteen recorded cases of double

ovariotomy during pregnancy, and sixteen in which ovariotomy was

performed during the puerperium, or shortly after abortion. Since this

date McKerron has collected the statistics relating to the whole

question of pregnancy and ovarian tumours in a very comprehensive

manner.

REFERENCES

BLAND-SUTTON. _Surgical Diseases of the Ovaries, &c._, London, 1896, 2nd

Ed. pp. 180-91.

---- The Surgery of Labour and Pregnancy, complicated with Tumours,

_Lancet_, 1901, i. 382, 452, 529.

MCKERRON, R. G. _Pregnancy, Labour, and Childbed with Ovarian Tumour_,

London, 1903.

=Fibroids and pregnancy.= In a large number of instances in which

operations have been undertaken when fibroids complicate pregnancy, they

have been performed on an erroneous diagnosis. The tumours when small

and placed laterally simulate ovarian cysts; when large and lying high

in the abdomen they have been mistaken for renal tumours, and when low

in the pelvis they have been regarded as incarcerated ovarian cysts. The

variety of fibroid most likely to lead to operation, under the

impression that it is an ovarian cyst, is an interstitial fibroid which

becomes painful in consequence of undergoing red degeneration. The

difficulty which faces the surgeon in this condition is to decide on a

safe course.

When the tumour is not likely to cause difficulty it may be wise to

close the abdomen. If the tumour is pedunculated and incarcerated, he

may be able to extract the tumour and ligature the pedicle without

disturbing the pregnancy; a big fibroid invading the broad ligament may

be enucleated; a large cervix fibroid will render delivery impossible,

and will necessitate hysterectomy.

A study of many recorded cases in which hysterectomy has been performed

on account of fibroids complicating pregnancy shows that the operation

had been undertaken on account of a great increase in the size of the

tumours, the concurrent pregnancy not being discovered until the parts

were examined after removal.

Hysterectomy may be necessary at any time during pregnancy; after labour

has begun; and during puerpery on account of fibroids. During pregnancy

it is a straightforward operation, the subtotal operation being

preferable. When it is needed during puerpery it is for septic

complications, and there is no greater difficulty in performing

hysterectomy then than during pregnancy, but the risk to the patient

from sepsis is much greater: therefore total hysterectomy with drainage

is advisable.

Fibroids have many times been enucleated from the gravid uterus and the

pregnancy has gone successfully to term.

When pregnancy complicated with fibroids goes to term and the tumour

occupies the neck or the lower segment of the uterus so as to offer an

impassable barrier to the passage of the fœtus, abdominal hysterectomy

is a necessity.

=Red Degeneration.= Among the new things which the surgical treatment of

uterine fibroids has brought to light is a knowledge of that change to

which these tumours are liable, known as ‘red degeneration’.

This increase in our knowledge of the pathology of fibroids is extremely

useful in diagnosis, for red degeneration is especially liable to occur

in fibroids lodged in a pregnant uterus, and, as I pointed out in 1904,

it has the effect of rendering them painful.

One of the most striking features of a uterine fibroid is its

insensitiveness, and equally remarkable is its painfulness and

tenderness when in a state of red degeneration, but these signs are only

exhibited by such fibroids when associated with pregnancy.

Red degeneration, even in an extreme degree, in fibroids occupying the

walls of a non-gravid uterus is, as a rule, painless. It is also curious

that a gravid uterus may contain four or five fibroids, the size of

large potatoes, in its walls, yet only one will exhibit this red

degeneration and become acutely painful, whilst its companions remain as

insensitive as apples. In the early stages of this change the fibroid

exhibits the colour in streaks, but as the pregnancy advances it

permeates the whole tumour. Occasionally in the mid-period of pregnancy

this necrotic change may be so extreme that the central part (sometimes

the whole) of the tumour is reduced to a red pulp.

The suddenness with which this pain comes on may be illustrated briefly

by the following case:--A primigravida, aged 30, two months pregnant,

was seized with sudden pain during a railway journey. Her condition

became so alarming that she left the train at an intermediate station

and placed herself under the care of a doctor whom she knew. A large,

tender, and increasing swelling was found in the abdomen. The doctor

regarded the patient’s trouble as being due to rupture of a tubal

pregnancy. He asked me to see the patient, and I found a large swelling

on the right side of the abdomen reaching as high as the liver. I

considered that some change had taken place in this tumour consequent

on the pregnancy: it was also probable that it might be an ovarian cyst

which had twisted its pedicle. The swelling was very tender. On opening

the abdomen the tumour proved to be a large subserous fibroid undergoing

red degeneration. The gravid uterus contained several fibroids of the

interstitial variety: it was removed. These fibroids exhibited the red

change in streaks.

It is a curious and noteworthy fact that many of the operations

tabulated on pp. 81 and 82 were undertaken on an erroneous diagnosis. In

some the acute pain and tenderness of which the patients complained led

the surgeons to believe that the troubles were due to an ovarian cyst

which had twisted its pedicle, or to the bursting (or abortion) of a

gravid Fallopian tube.

Practitioners and obstetricians are now becoming familiar with the fact

that when a pregnant woman, who has also fibroids in the uterus,

complains of sudden acute pain, it may be due to one of the fibroids

undergoing red degeneration.

[Illustration: FIG. 23. A GRAVID UTERUS IN SAGITTAL SECTION.

The woman miscarried at the seventh month: delivery was obstructed by a

cervical fibroid. The parts were removed by total hysterectomy. The

small fibroid is in the condition of red degeneration (_Museum, R.

College of Surgeons_). Half size.

]

The cause of this change is unknown. Lorrain Smith and Fletcher Shaw,

after an examination of four specimens, three of which were associated

with pregnancy, believe that the change is due to thrombosis of the

vessels of the fibroid. In two tumours they isolated micro-organisms,

_e.g._ _staphylococci_ in one and _diplococci_ in another: the patients

with these tumours exhibited toxic symptoms.

In my early investigations of this disease I often took the tumours to

the bacteriological laboratory with the hope of finding some

micro-organism which would account for the degeneration. The results

were so persistently negative that the search was abandoned. Since

learning that Smith and Shaw had found micro-organisms in two cases I

had the next specimen which came to hand examined, and it happened to be

the fibroid obtained from the acute case described on p. 79. From the

softened parts Mr. Somerville Hastings succeeded in obtaining

_staphylococcus pyogenes aureus_ in pure culture.

The views here expressed in regard to the red degeneration of fibroids

are founded on an examination of thirty-four recent examples.

REFERENCES

BLAND-SUTTON, J. The Inimicality of Pregnancy and Uterine Fibroids.

_Essays on Hysterectomy_, 1905, 76.

FAIRBAIRN, J. S. A Contribution to the Study of one of the Varieties of

Necrotic Changes in Fibro-myomata of the Uterus. _Journ. of Obstet.

and Gyn. of the British Empire_, 1903, iv. 119.

SMITH, J. L., and SHAW, W. F. On the Pathology of the Red Degeneration

of Fibroids. _Lancet_, 1909, i. 242.

CASES OF HYSTERECTOMY PERFORMED ON PATIENTS IN LABOUR IN WHICH THE

OBSTRUCTION WAS DUE TO FIBROIDS

-----------+--------+-------+----------------+-----------------------

|_Result |_Fate | _Nature |

_Operator._| to | of | of | _Reference._

|Mother._|Child._| Operation._ |

-----------+--------+-------+----------------+-----------------------

Spencer | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._,

| | | Subtotal Hyst.| xxxviii. 389.

Bland- | R. | D. |Total Hyst. |_Trans. Obstet. Soc._,

Sutton | | | See Fig. 23. | xlvi. 238.

Morison | R. | D. |Cæs. Sect., |_Northumberland and

| | | Total Hyst. | Durham Medical

| | | | Journal_, July, 1904.

Acland | R. | ? |Cæs. Sect. and |_Lancet_, 1904, ii.

| | | Subtotal Hyst.| 948.

Spencer | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._,

| | | Total Hyst. | 1906, xlviii. 240.

Spencer | R. | D. |Cæs. Sect., |_Trans. Obstet. Soc._,

| | | Total Hyst. | 1908.

Pollock | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._,

| | | Subtotal Hyst.| 1908.

-----------+--------+-------+----------------+-----------------------

The aim of the surgeon is to save the life of the child as well as that

of the mother. To this end, when the operation is carried out and the

uterus exposed the child is extracted by Cæsarean section. Then in the

majority of cases total or subtotal hysterectomy is performed. This is

sometimes clumsily termed Cæsarean hysterectomy. In some instances the

operator has been content merely to perform Cæsarean section in the hope

that the patient may wish to reconceive.

In order to afford some notion of the frequency with which fibroids

cause trouble to pregnant and parturient women, I have collected

thirty-six cases which have been reported to the London Obstetrical

Society from 1900 to 1908 (both years inclusive), and arranged them in

the subjoined tables: they show in an unmistakable way that pregnant

women with fibroids do often require aid from surgery, and that such

efforts are rewarded with success. There is no condition which

simplifies hysterectomy so much as pregnancy.

A TABLE OF CASES IN WHICH ABDOMINAL HYSTERECTOMY WAS PERFORMED FOR

PREGNANCY COMPLICATED WITH FIBROIDS

These cases are recorded in the _Transactions of the Obstetrical

Society_, 1900-8, both years inclusive.

The primary mortality of simple oöphorectomy, or oöphorectomy combined