[Ill.u.s.tration: 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, r.e.c.t.u.m, or small intestines; fibroids a.s.sociated 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.

[Ill.u.s.tration: 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 a.s.sociated with this malformation.

When the body of the uterus is bicornate the r.e.c.t.u.m lies in the middle line of the pelvis, and a median vertical fold of peritoneum, the _ligamentum vesico-rectale_ pa.s.ses, 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 r.e.c.t.u.m and the neck of the uterus divides the recto-v.a.g.i.n.al fossa into a right and a left half. This peritoneal ligament requires careful treatment, or the surgeon may accidentally open the r.e.c.t.u.m 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 antic.i.p.ated before the operation, as an imperfect vertical septum was known to exist on the posterior v.a.g.i.n.al 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 v.a.g.i.n.al route. The existence also of a median longitudinal septum, partial or complete, in the v.a.g.i.n.a 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 "

Middles.e.x 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 "

Middles.e.x 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 Middles.e.x 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.

[Ill.u.s.tration: 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 cliotomy, such as sepsis, peritonitis, shock, and the risks of the anaesthetic. There are certain special dangers, such as haemorrhage; injury to the vesical segments of the ureters, and especially the bladder; injury to the intestines, especially the r.e.c.t.u.m; acute intestinal obstruction; thrombosis and pulmonary embolism. These risks and dangers are considered fully in their relation to all forms of abdominal gynaecological 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 haemorrhage, 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

v.a.g.i.n.al 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 interst.i.tial (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 gynaecologists 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 sh.e.l.led 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 sh.e.l.led 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 sh.e.l.ls 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 pa.s.sed 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 Caesarean 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 cliotomy 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 a.s.sure 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 a.s.surance, 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:--