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 a.n.a.lysis 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 gynaecologists, 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 multiparae.

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 Gynakologie_, 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 Koeberle introduced the serre-nud, 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 suprav.a.g.i.n.al 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 gynaecologists 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 a.n.a.lysed, 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 haemorrhages 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 v.a.g.i.n.al 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 a.s.sociated with changes in the mucous membrane of the uterus, which not only causes excessive bleeding, but sets up inflammatory conditions giving rise to leucorrha, 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 a.s.sure himself that the endometrium is free from cancer. If there be any suspicion in this direction he should remove the cervix.