A System of Operative Surgery, Volume IV (of 4)

e same principle to the cervical pedicle when removing the uterus for fibroids. The result was dismal failure. Ma

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 s

per had great consequences; it came at a time when the attention of gyn?cologists was centred on improvements in hysterectomy. The method was promptly tested and adopted in London

ion on the part of a few surgeons to prefer the total operation, mainly on the ground that

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

ump left after subtotal hysterectomy come to be

of the uterus at the time of the pr

ervical stump subsequent

d the hysterectomy was really a

on the cervix is not mal

lates requires sepa

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 leas

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

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 e

e 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

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 leucorrh?a, 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 fibr

are. Of these sixty-three patients had attained the age of fifty years and upwards. Among these sixty-three women there were eight c

he surgeon should have the uterus opened immediately after its removal and assure himself that the en

ropped 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,

horled 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

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

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

uction 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 subtot

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 s

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

gan, but it may become attacked by cancer. Blacker reported a case in which a woman, thirty-nine years of age, underwent bila

nd removed both ovaries and Fallopian tubes; the latter contained pus. Four yea

ittal section in order to display the great thickening of th

removed the uterus by the abdominal route (total hysterectomy). The corporeal endometrium was cancerous throughout.

th 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 an?mic as the result of long-continued menorrhagia. The physical and clinical signs of the disease are those pr

ts posterior wall. The anterior wall is occupied by a mass of tuberculous adenomatous tissue. The p

de of irregular tracts of endometrium containin

h 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 adenomyomat

terectomy gives admirable re

VALUE OF BE

ut 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 healt

esults of preserving at least one healthy ovary in this operation are admirable, especially in women under forty years of age,

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

ine years later (1907) I operated again for intestinal obstruction, and found this ovary healthy and functional, for a rip

nt comfort of the patient, and they depend mainly on the conservation of a healthy ovary. These three points relate to: (a) the p

ion 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

ted ovary is a very precious possession to a woman unde

ies, in the present condition of o

ear of life, a belated ovary re

e parts of the uterus occupied by the decidu

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 o

dification of this operation known as the Abel-Zweifel method, by which a small segment of the menstrual area

tised it, but I cannot express any opinion as to it

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 effort

History of Hystere

Cervix in Operation for Uterine Fibroids. A new method. Trans

lh?hle. Im Anhang: Thelen: Die Totalextirp

e development of Total and Subtotal Hysterectomy for Fibroids, in The

es tumeurs fibreuses de la matrice par la méthode suspubienne. Gaz

w of the serre-n?ud and clamp period of hysterectomy. He states that Tillaux, in

cer of the Cervical Stump

902, gives an admirable critical summary

says on Hysterectom

and Gyn. of Gt. Bri

. Am. Gyn. Soc

. of Obstetrics

de Chir. Abdom., 1905

ynécologie, 19

t. Med. Journ.

Occurrence of Cancer in the Ut

s and Carcinoma of the Cervix. Tra

ture on Adenomyoma of the Uteru

ghteen and a half years subsequent to Double O

a of Uterus. Ibid.

n der Eierst?cke und Nebe

rning the Value

he Uterus, with brief notes of twenty-eight cases. Tra

ted Ovaries. The Medical Pres

and Ovarian Physiology and Pathology in Rab

istory of sixty cases. Transactions of t

e hundred cases of Supravaginal Hystere