A System of Operative Surgery Part 12

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 Caesarean section in order to extract the tumour from the pelvis.

[Ill.u.s.tration: FIG. 22. A UTERUS DISTORTED BY FIBROIDS. It contains a ftus 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 circ.u.mstances 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 interst.i.tial 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 impa.s.sable barrier to the pa.s.sage of the ftus, 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 a.s.sociated 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 ill.u.s.trated 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 interst.i.tial 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.

Pract.i.tioners 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.

[Ill.u.s.tration: 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 a.s.sociated 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. Caes. Sect., _Trans. Obstet. Soc._, Subtotal Hyst. x.x.xviii. 389.

Bland- R. D. Total Hyst. _Trans. Obstet. Soc._, Sutton See Fig. 23. xlvi. 238.

Morison R. D. Caes. Sect., _Northumberland and Total Hyst. Durham Medical Journal_, July, 1904.

Acland R. ? Caes. Sect. and _Lancet_, 1904, ii.

Subtotal Hyst. 948.

Spencer R. L. Caes. Sect., _Trans. Obstet. Soc._, Total Hyst. 1906, xlviii. 240.

Spencer R. D. Caes. Sect., _Trans. Obstet. Soc._, Total Hyst. 1908.

Pollock R. L. Caes. 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 Caesarean section. Then in the majority of cases total or subtotal hysterectomy is performed. This is sometimes clumsily termed Caesarean hysterectomy. In some instances the operator has been content merely to perform Caesarean 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.

------------+---------+--------------------+--------+----------------- _Age _Period _Result _Reference _Recorder._ of of to to Patient._ Pregnancy._ Mother._ Volume._ ------------+---------+--------------------+--------+----------------- Horrocks ? 5th month ? 1900, xlii. 242.

Routh 33 33 weeks R. Ibid., 244.

Doran 40 5th month R. 1901, xliii. 178.

Donald 43 9th month R. 1901, xliii. 180.

Donald 34 4th month R. Ibid.

Donald 34 4th month R. Ibid.

Donald 41 4th month R. Ibid.

Routh ? 8-1/2 months R. 1902, xliv. 41.