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allowed to carry the patient to a condition where life is well-nigh intolerable, becoming at such a time unfortunately, often inoperable.
The menopause has received too much credence as a factor in eliminating or restraining the growth, and while some cases do undoubtedly improve at that time, the majority do not, a large number are unaffected, and others seem actually to grow worse. Also, these tumors cause a prolongation of the functions of menstruation, and more often than any other cause, excepting always malignancy they serve to accentuate and indefinitely extend most of the disagreeable features of the menopause. If the time of the menopause be approaching, and there are no urgent symptoms, it is better to await its effects, carefully watching the patient in the meantime; but it urgent symptoms are present, especially severe hemorrhage and repeated attacks of local peritonitis with no marked counter-indications, interference is fully warranted.
The resulting mutilation has been constantly brought up as an argument against extirpation. This is hardly worthy the importance attached to it, since the corresponding mutilation occurs without objection in various intra-abdominal procedures. A scar from the pubes to the region of the umbilicus or even above it, because for cosmetic reasons it may affect the after-life of a young woman, cannot have much weight when all circumstances are considered. The mutilation is only known to the patient herself, and at the most to a very few of her intimate friends, whereas the deformity caused by such a growth is apparent to every one, and engenders great sensitiveness. A between the two, the concealed scar or the very apparent growth, all other circumstances aside, who can doubt that in any given case the former would be selected? We frequently remove diseased adnexæ for much less serious disturbances than are commonly found in connection with fibroids. In recent years many boldly urge extirpation of the normal uterus where the adnexæ are diseased; how much more argument then can be urged for total extirpation when both uterus and ovaries are diseased? The loss of the child-bearing power by reason of the removal of the ovaries or uterus is not a sufficient objection, because in cases of tumor requiring such removal usually the child-bearing power is a!ready lost, or else its continuance is undesirable. If pregnant, the condition in itself becomes a menace, and extirpation may be, and often has been, required to save the life. The removal of diseased ovaries is universally accepted as desirable. The retention of healthy ovaries and a uterus diseased in the manner under consideration may be very undesirable. Probably more cases of danger by reason of
pregnancy with this condition could be cited than of such pregnancy safely conducted.
We are convinced that much of the discomfort in the cases which have gone to middle age, that is, rising fifty years, is due to diseased ovaries in connection with a uterus which has undergone no retrogression at the time of the menopause. Also, that some of these tumors considered by themselves alone might reasonably be expected to decline with the cessation of the menses, but disease of the ovaries causes such a continuous irritation and consequent increased blood supply that declension is impossible. (Figs. 8 and 9, C and D.) In such cases removal of the ovaries would give a m relief, but if it can be shown that mortality from total extirpation can be reduced to approximately what it is from ovariectomy, the entire relief afforded by the hysterectomy makes the latter the more desirable operation. On the other hand, it is desirable to retain one or both ovaries, if healthy, since this unquestionably mitigates the great discomfort resulting from such an abrupt precipitation of the menopause, frequently at a time of life when none of the functions are by nature adapted to such a change.
Too much importance should not be attached to the immediate suffering and somewhat long convalescence, since the former is usually well borne and the latter is not so much due to the immediate effects of removal as to recuperation from the pre-existing conditions arising from the growth itself. Six to eighteen months may safely be counted upon as necessary for complete recovery, and often a much longer time is demanded, but through all this period improvement is constant and progressive, and confident expectation of full recovery makes it cheerfully endured. The objections to removal are many, but so are the objections to retention ; the danger to life stands pre-eminent, and should always be given the first importance. In the hands of the best operators, the death rate has been reduced to the vicinity of five per cent., and, considering the severity of the manipulation required, this is remarkably low.
As favoring interference it can safely be held out to the patient that in case of survival a cure results, that there is no possibility of recurrence, and that complete relief is obtained with a restoration to a life of usefulness and enjoyment. We know of no operation at all comparable to this for severity, which gives such complete immunity from subsequent complications. We have kept in personal touch with a number of these cases ever since the operation, and have not only been gratified, but surprised at the satisfactory results. We can recall a number of such cases, women who are now engaged in all
the duties of their respective stations in life, and enjoying its pleasures, and we have had repeated testimony that health has never been better than since the operation. It is for such reasons that in suitable cases we believe the operation to be an ideal one.
The line of treatment in any given cases will depend upon the gravity of the symptoms present, the size of the tumor, its relationship to the uterus proper, whether sub-mucous, interstitial, or subperitoneal, the age of the patient, the present general health and a favorable prognosis. As it is one purpose of this paper to give special prominence to hysterectomy in cases suitable for it, other methods of treatment will receive only passing attention.
Rest, during and after a hemorrhage, is, of course, a necessity. If the hemorrhage is due to a sub-mucous fibroid, which is quite apt to be the case, its enucleation by way of the vagina and cervical canal will often give a permanent and satisfactory relief. Curetting is of uncertain permanent value, and we personally place little or no reliance upon it, except for temporary relief. Removal of the tubes and ovaries has given marked relief in certain cases, in others it has failed; and the objection to it is the impossibility of deciding whether or not it will afford help. In cases which, for any reason, are unfitted for the more radical operation, or in cases where consent to extirpation cannot be obtained, I should always unhesitatingly advise and employ it. In doing this operation much has been made of removing the Fallopian tubes very close to the uterus, but to our mind this is not a significant feature. The blood supply controlled by the removal of the appendages comes from the ovarian arteries. Did we merely ligate these arteries in continuity, leaving the ovary and tube in place, the supply would finally be compensated for by collateral anastamosis; by removing the ovary and tube, however, as well as ligating the artery, the definite volume of blood supply is controlled. The short stump of the Fallopian tube does not seem to require such a nourishment as would materially affect the life of the tumor, and any effect it may have upon the subsequent development must come through its nerve supply. The extent of this is problematical, although most extensive claims in this direction have been made, and the writer is skeptical. The ligation of the uterine arteries has also helped some of these cases, but the procedure is indefinite, the blood supply is rather diverted than diminished, and reasoning from analogous conditions elsewhere in the body, one
would theoretically expect that the ovarian artery would take on a compensatory function. Apostoli's method and all other methods of treatment depending upon electricity also lack definiteness. Certain it is that Apostoli's method has not given as favorable results in other hands as he has shown for it himself. In one case, No. 24, electricity had caused an acute inflammatory process in the ovarian tumor complicating a multiple fibroid, and the operation for the removal of the former was most difficult, barely saving the patient's life.
Of all other methods proposed for the relief of these growths hysterectomy, abdominal or vaginal, or combined, as the case may be, offers the surest and most satisfactory relief. As has formerly been stated, if the statistics of the several methods prove this one to equal or excel every, other, it would seem that we had arrived at a solution of the question. Removal by the vagina should be confined to tumors free from adhesions, and which are capable of delivery by splitting the uterus and the method differs in no wise from that employed in vaginal hysterectomy for other purposes. Abdominal hysterectomy is more appropriate in larger tumors than in those complicated by adhesions and peculiarity of position.
The details of the operation by the vagino-abdominal and the abdominal methods may be briefly summarized as follows: Since it is necessary that the operation should be aseptic from beginning to finish, careful attention to this end should be given to the vagina and to the, abdomen. If necessary, the cervix should be curetted and packed with gauze, and, in some cases tightly sewed up. The patient should be catheterized after anæsthesia. By the former method, with the patient in the lithotomy position, and with the vagina distended by whatever means are most familiar to and convenient for the individual operator, the cervix is grasped by volsellum forceps, drawn strongly downward and forward, and a transverse incision made behind the cervix at the utero-vaginal juncture, which, if possible, opens into Douglas' cul-de-sac. This is carried laterally to the bases of the broad ligaments, thus giving opportunity for further examination of the tumor and its relations from the vaginal side. The incision is then made to encircle the cervix, and, so far as possible, the bladder is separated from the tumor. Beyond these definite incisions little practical can be accomplished through the vagina in growths so large that it is necessary to open the abdomen from above; in fact, in the larger growths, Douglas' pouch cannot be opened, and little more than the circular vaginal incision can be accomplished. This, however, is of much assistance in the final severance of the tumor from the abdominal side. Having now accomplished this much from the vagina, we pack the latter with sterilized gauze, and changing the position of the patient, all due care having been observed to maintain asepsis, open the abdomen. The abdominal opening should be in or adjacent to the median line since this better gives ready access to both sides of the abdomen and pelvis. There is no objection to going through either rectus muscle, and many operators now claim that in a long incision this gives a more secure cicatrix and one less liable to subsequently develop a hernia.
The first incision should avoid the bladder and be sufficiently long to admit the whole hand, as by this means we determine the size and shape of the tumor, whether single or multiple, the presence of adhesions, their extent and relationship, whether the attachments are normal, whether the bladder is high or low, or laterally displaced, whether the broad ligaments are lax or tense. or thickened, or cedematous, or occupied by tumors, and whether the tumor itself is movable. Profuse hemorrhage from the abdominal incision may indicate adhesions within the abdomen, and ædema of the abdominal wall may mean adhesion of the tumor to the wall itself, and is not a favorable symptom. We are also able te estimate how long an opening is necessary to deliver the tumor, the size of the tumor determining the size of the opening. should be carried as low as possible, being careful to avoid the bladder. In one case, No. II, the first stroke of the knife opened into the bladder, which was carried very high. This was immediately and carefully closed, and by the use of a self-retaining catheter for the first few days of convalescence it gave not the slightest trouble of any kind. After going as low as possible with the incision, it should be extended as high as necessary and the tumor delivered. first placing the patient in Trendelenberg's position. Care should be taken at this stage not to eviscerate since it is unnecessary, and if the opening extend above the umbilicus, a couple of temporary silk sutures passed through the abdominal wall may materially as. sist in controlling the intestines. The listing out of the tumor affords relief to all pressure symptoms, and often renoves embarrassment to respiration and heart's action and materiały simplifies the conduct of anæsthesia. It gives ready opportunity to ascertain any abnormal position of the bladder, whether it be very adherent,