A System of Operative Surgery Part 8

=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 dematous 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 ma.s.s 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 att.i.tude 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 haemorrhage, and the cancer has attacked the v.a.g.i.n.al 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 ca.n.a.l 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 a.s.sure 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.

[Ill.u.s.tration: 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 ca.n.a.l 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 v.a.g.i.n.a after a total hysterectomy (Quenu). 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 ooph.o.r.ectomy for a uterine fibroid: eight years later cancer attacked the neck of the uterus and destroyed the patient.

[Ill.u.s.tration: 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 ma.s.s 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 haemorrhage. 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, a.s.sociated with interst.i.tial 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 anaemic 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 advent.i.tious 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 a.s.sociated 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 'flus.h.i.+ngs', 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 flus.h.i.+ngs; (_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 v.a.g.i.n.al segment of the neck of the uterus is an important factor, as it leaves the v.a.g.i.n.a 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.

[Ill.u.s.tration: 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 strus 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 a.s.sociated 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-v.a.g.i.n.al Hysterectomy without Ligature of the Cervix in Operation for Uterine Fibroids. A new method. _Transactions of the American Gynaecological Society_, 1892, xvii. 235.

BARDENHEUER. _Die Drainierung der Peritonealhohle._ _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 Gynaecological Society_, 1893, xviii.

372.

KOEBERLe, E. Doc.u.ments pour servir a l'histoire de l'extirpation des tumeurs fibreuses de la matrice par la methode suspubienne. _Gaz.

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

POZZI, S. _Traite de Gynecologie_, 1905, i. 424. This contains an interesting review of the serre-nud 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.

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