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Original Articles in Surgery.
SIDNEY F. WILCOX, M.D.
WILLIAM TOD HELMUTH, M.D., LL.D.
GEORGE W. ROBERTS, Ph.B., M.D.
By NatuANIEL W. EMERSON, M.D.,
NLESS we have some convincing reason to the contrary, rea
son of theory or reason of experience demonstrable after some fashion, we should reflect the judgment of the times and something of the opinions of those who are experts and leaders in the matter which we discuss. This paper claims no originality, but is meant as a brief resumé of a discussion, some phases of which have been obscured by much debate, and is a deliberate assertion of surgical measures as giving the most satisfactory results in a large and important class of cases, always presupposing a suitable discrimination is exercised in selection. This article is based upon sixty-seven cases falling under the above title and embracing probably no unusual variety for such a number. They have all been treated surgically by means chosen after due deliberation as best adapted to individual conditions. In most of them radical measures were used, while in several, either because of reluctance on the part of the patient to submit to the major operation or because of refusal on the part of the consultants to advise the same, recourse was had to methods less radical. These cases will be reported more or less in detail later, with some conclusions drawn from consideration of them. This is a report of definite results so far as can possibly be obtained, and as opposed to those who constantly and under all circumstances, decry surgical interference. We have yet to see a case of fibroid or the report of such a case, so definitely controlled by the exhibition of internal remedies that the result was a cure, or even if apparently beneficial that similar results could be expected in similar cases. The experience here is cumulative, however. Beginning with the operation which amputated the cervix and the extra-peritoneal treatment of the stump, various modifications have been made until the complete hysterectomy as here described is
now the operation of advice and choice. The extra-peritoneal method was early abandoned as one of brute force, most repugnant to a refined surgical art. We cannot now conceive of conditions where it could have a place.
As this paper is a reflection of my own individual experience I pass over all text-book matter, such as pertains to the descriptions, differentiations, and etiological speculations of the varying forms of tumors coming under the heading of this paper, and pass at once to a discussion of some of the symptoms and their meaning, which have rightly come to be considered of first importance to demand
interference. It is astonishing to what a size this form of tumor may attain without developing uncomfortable symptoms; on the other hand, the symptoms may be marked and serious while the tumor may be insignificant in size. First of all may be pain of a somewhat varied character and sometimes almost unbearable. It is a fact, however, that many such cases develop no sensitiveness. Pain in the ovaries is perhaps the most persistent of this class of symptoms, and when one has opened the abdomen and observed the relations of the tumor and ovaries, it is easy to understand why such pain should be severe. The ovaries are frequently diseased, apparently because of disturbance due originally to the changes in the uterus, are therefore enlarged, cystic, with a general hyperplasia of their tissue, and although this in itself would not cause pain, they are in addition dislocated upward by the growing tumor and consequently dragged upon and subjected to much pressure between the tumor and abdominal walls. As a result they become very sensitive, and pain will more often be related to them than to
l'ig. 2, Anterior View.—Figs. I and 2. No. 63. Complicated growth. A,
cervix. B, B, ovaries. C. C, fallopian tubes. D, small cyst with long pedicle attached to right tube. E, tumor completely filling the hollow of the sacrum. F, tumor resting above the promontory of the sacrum. G. sulcus in tumor which rested upon promontory. H, pedunculated tumor-mass freely movable in abdominal cavity. I, intra-ligamentous growth. Recovery.
the tumor itself. The upward drawing and stretching out of the broad ligaments also adds to the local discomfort.
Other painful and disagreeable symptoms are due to pressure on the various contiguous organs. When taking the form of headache it is not often serious, although it is apt to be particularly intractable. Backache is more constant, yet very large tumors may grow without this accompaniment. Indeed it is difficult to understand sometimes why there is no more backache in certain instances, those of tumors completely filling the pelvis and fitting closely into the hollows of the sacrum (Figs. I and 2, E). In some actual pain is produced ; in others such a disturbance of function is set up as often becomes more unbearable than pain itself. The bladder is a frequent sufferer in this way, and while it readily accommodates itself, becoming distorted and displaced, (especially with large and highgrowing tumors), the constant and often difficult urination becomes
Fig. 3, Anterior View.—No. 64. A, cervix. B, body of uterus occupied by
multiple growth. C, C, ovaries. D, small par-ovarian cyst. E, small fibroid pressing sharply on the bladder and causing urinary disturbance out of all proportion to its size. The larger, dense, tumor-mass lying behind it prevented any accommodation on the part of E. F. intraligamentous tumor of left side. G, H, and I, cut margin of peritoneum from which bladder was separted. In the illustration it is drawn higher on the tumor than it actually was, especially from G to H, by reason of the suspension necessary for photographing. This growth caused greatest discomfort because of its lateral extension and pressure, and because of the location of E. Recovery.
most annoying. A large growth is not at all necessary to cause severe pressure-disturbance in the bladder; on the contrary, the writer believes that small growths attached to the anterior wall of the uterus and pressing sharply upon the bladder give greater discomfort than larger ones which press more extensively and evenly upon the whole organ. These latter flatten and broaden and carry high the bladder walls by such a gradual and uniform distension that no marked disturbance results. But a smaller, rounded growth may so press into the bladder, encroaching upon its capacity without assisting in generally displacing its walls (Fig. 3, E), that the sphincter is pressed upon direct by the tumor, or a small accumulation of urine gives urgent desire to micturate. Some such cases can retain urine only a short time, an hour or two, while every little exertion, such as a slight cough, a laugh, a misstep, results in an immediate escape of urine with all the consequent discomfort. Also, the general health is undermined by lack of continuous sleep. the patient being obliged to arise from two to six times in the course of the night in order to urinate.
On the intestines pressure does not cause so marked a disturbance and often in enormous growths it is remarkable how little derangement of intestinal function results. The bowels evidently accommodate themselves by displacement to whatever free space is available, and continue to conduct their function. It is only when pressure in the pelvis becomes direct upon the rectum and sigmoid flexure that hemorrhoids and constipation are marked and defecation difficult. This occurs especially with a class of tumors which fill the pelvis and accurately fit into the hollow of the sacrum. (Fig. I, E.) Palpitation of the heart by reason of its dislocation, indigestion, shortness of breath and dyspnoea, edema of the lower extremities, all caused by pressure, with the necessity for frequent feeding because such small quantities of food can be taken at one time, often give rise to exceedingly annoying conditions and contribute to the general distress.
Aside from the general pain and discomfort, the most important symptoms in this class arise from local peritonitis. The pain is often severe and incapacitating, lasting for a few days and then subsiding only to become prominent in a new location. Only one interpretation can be put upon this development, and it merits most careful consideration in connection with the future of the patient. We must recognize that adhesions are forming, permanent in character and sure to cause future discomfort if nothing more. Also, we must keep in mind that such adhesions are of importance in determining the future life and growth of the tumor. New blood channels are developed, old ones enlarged and perverted, and, at times, much of the nourishment comes through these richly en