Hysterectomy

“ In those cases in which complete removal of the disease is impossible the operation of hysterectomy should not be performed, because, cure being out of the question, the symptoms of hemorrhage, pain, and discharge may be as well relieved by less dangerous forms of palliative treatment. When the disease extends beyond the limits of the uterus, hysterectomy is much more difficult and dangerous than when the uterus is freely movable. ”

“ The greatest obstacle to the success of vaginal hysterectomy in the radical treatment of cancer of the neck of the uterus is the limitations which the anatomical environment imposes on the surgeon, for as soon as the disease overruns the cervix it implicates the vagina, the bladder, the vesical portions of the ureters, and the rectum. ”

“ Preservation of the Ovaries in Hysterectomy.—Many surgeons consider it advisable to leave the ovaries in hysterectomy for fibroid tumor of the uterus in case these organs are not diseased. If the woman has not yet reached the menopause the disagreeable symptoms of the artificially induced menopause are thus avoided, and any metabolic function that the ovaries may possess is preserved. In hysterectomy for fibroid in women under forty years of age with healthy ovaries it is advisable to leave these organs if this can be done without seriously complicating the operation. ”

“ Hysterectomy after bilateral ovariotomy. After the removal of both ovaries for cysts or tumours, the uterus is a useless organ: it is fast becoming the practice under such conditions to remove it. There is much to be said in favour of this procedure, especially if the uterus be large and flabby, because it tends to fall backwards into the pelvis. In such circumstances it is better surgery to remove it than to perform hysteropexy. The risk of intestinal obstruction after bilateral ovariotomy is greater than after hysterectomy. ”

“ 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 assure himself that the endometrium is free from cancer. ”

“ The most satisfactory method of dealing with cancer arising in the corporeal endometrium consists in performing total abdominal hysterectomy (see p. 40) , removing not only the uterus and its neck, but both ovaries, Fallopian tubes, mesometria, and any enlarged lymph glands that are detected. In the course of the operation the surgeon should avoid any undue handling of the uterus, and, in withdrawing it from the pelvis, care should be taken not to infect the operation area with any fluid or semi-fluid stuff which is liable to escape from the cervical canal. ”

“ The remote results of hysterectomy for cancer of the cervix are poor. In the very great majority of all cases submitted to operation recurrence has taken place. It seems very probable that a few of the cases of recurrence are due to transplantation of cancer-cells into healthy tissue during the operation; but the vast majority die because all of the diseased tissues have not been or can not be removed. ”

“ If enucleation is practicable in tumors which have their origin in the central stratum of the wall of the uterus, the operation must be regarded as equally hazardous, if not more so, than laparo-hysterectomy. ”

“ The cases likely 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. ”

“ When pregnancy complicated with fibroids goes to term and the tumour occupies the neck or the lower segment of the uterus so as to offer an impassable barrier to the passage of the fœtus, abdominal hysterectomy is a necessity. ”

“ Mortality. The risk to life in abdominal hysterectomy for cancer of the body of the uterus is somewhat greater than after removal of the uterus for fibroids. This is due to the fact that when the cancer ulcerates and sloughs, the risk of sepsis is therefore increased ”

“ When a woman is submitted to hysterectomy for fibroids we can assure 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 assurance, for she may have in her uterus many ‘seedlings’ or ‘latent fibroids’ and one or several of these may grow into formidable tumours. ”

“ From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. ”

“ There is a wealth of statistics regarding operations for cancer of the cervix uteri. Despite the figures obtained by radical operators like Wertheim, the vast majority of those surgeons who practise either vaginal or abdominal hysterectomy have obtained far inferior results to those of Byrne, with his cautery, which is still in use. Wertheim once reported the astonishing figure of 61 per cent of 5‒year recoveries. ”

“ In discussion Henrotin stated that he had practically given up abdominal hysterectomy. Currier stated that surgery was a failure as a cure for cancer.
At an earlier session of the Society, 1900, 104in a discussion of Pryor’s paper, Van de Warker asserted that surgery had done nothing for cancer; Lapthorne Smith said that many women did better if left alone. J. Byrne stated that hysterectomy for cancer was a crime. Engleman thought that cancers left alone may insure a longer survival than those treated surgically. ”

“ In regard to marital relations in women with a belated ovary, nothing trustworthy is forthcoming, but I believe the retention of an ovary is an additional factor in promoting domestic bliss. The question 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 of opinion that the preservation of the vaginal segment of the neck of the uterus is an important factor, as it leaves the vagina intact, and though such women are sterile, they are certainly nubile. ”

“ 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. ”

“ A medical doctor diagnosed Elsie as having endometriosis, meaning, the lining of her uterus had migrated to the fallopian tubes, where it continued to bleed regularly into the abdominal cavity, following the same hormonal cycle as the endometritial tissue that lines the uterus. The doctor offered to try hormonal manipulation and if this proved unsuccessful, offered a hysterectomy. That would certainly eliminate the symptoms! ”

“ When the tumour is not likely to cause difficulty it may be wise to close the abdomen. If the tumour is pedunculated and incarcerated, he may be able to extract the tumour and ligature the pedicle without disturbing the pregnancy; a big fibroid invading the broad ligament may be enucleated; a large cervix fibroid will render delivery impossible, and will necessitate hysterectomy. ”

“ Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus (lithopædion) , or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a Cæsarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. ”

“ Among the rarer forms of death after hysterectomy may be mentioned acute perforation of the stomach or the small intestine, cerebral hæmorrhage, lobar pneumonia, thrombosis of the right auricle, embolism of the femoral artery ending in gangrene of the leg, suppression of urine, and acute mania. ”

“ This disease has not received adequate recognition at the hands of British surgeons, yet it is a condition which occasionally causes much doubt in the surgeon’s mind in the course of hysterectomy. This adenomyomatous change affects the endometrium and is, in some cases, associated with 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 anæmic as the result of long-continued menorrhagia. ”

“ No large vessels are found on the anterior or posterior surface of the uterus. An arterial twig runs along the round ligament, bringing the ovarian artery into relation with the deep epigastric artery. If the surgeon thoroughly appreciates the distribution of the ovarian and uterine vessels he will at once perceive that if the four forceps are properly applied to the vessels the blood-supply is under absolute control: indeed, in many cases a subtotal hysterectomy can be performed without the loss of more than an ounce of blood. ”

“ When, however, the disease occurs, as it usually does, from septic infection at a miscarriage or a labor, more 201 radical treatment must be used. This treatment comprises frequently-repeated intra-uterine douches, thorough curetting of the uterus, and, finally, hysterectomy in extreme cases.
Every case of acute endometritis should be carefully watched and treated until the disease is cured. Acute endometritis, especially if gonorrhea is the cause, is very prone to become chronic and to extend to the mucous membrane of the Fallopian tubes and the ovaries. ”

“ It is also useful to pass a glass catheter and withdraw any urine that has accumulated during the operation.
If there is evidence of free oozing it is most likely to come from the cut edges of the vaginal wall in a case of total hysterectomy: under such conditions it is easy to apply a pair of fenestrated forceps to the oozing area and leave them on for thirty-six hours. They will cause the patient trifling inconvenience. Care must be taken not to fix the blade too far on the anterior flap, or it will lead to subsequent sloughing of the bladder. ”

“ In a hysterotomy, as in a cesarean section, the doctor removes the fetus by making an incision through the abdomen and uterine wall to gain access to the uterine cavity. A hysterectomy requires the removal of the entire uterus. These two procedures represent about 0.07 percent of second-trimester abortions. National Abortion Federation, 330 F. Supp. 2d, at 467; Planned Parenthood, supra, at 962–963.
B After Dr. Haskell's procedure received public attention, with ensuing and increasing public concern, bans on "'partial birth abortion'" proliferated. ”

“ 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 ”

“ Surgical Treatment.—The surgical processes resorted to for the cure of fibrous tumors of the uterus vary in their nature and gravity with the relations of the growth to the different strata of the uterine fibres. The nearer the mucous membrane, the simpler, safer, and more successful the operation for their removal; the more remote from it, the greater the difficulty and danger. Proximity to the cervix is another element of facility and safety. The removal of the cervical polypus is scarcely ever followed by serious consequences. ”

“ It cannot be urged with too much force that when it is fairly evident that a woman has an extra-uterine gestation, it should be dealt with by operation without delay: and my experience of the operation leads me to believe that it is a wise plan to remove the placenta at the primary operation. Fortunately very few extra-uterine fœtuses survive to term.
In cornual pregnancy, or, as it is often termed, ‘pregnancy in the rudimentary horn of a so-called unicorn uterus,’ the removal of the uterus is often necessary ”

“ In a case of prolapse of the ovary, or a gravid tube or ovary in the earliest stages, the operation presents no difficulty and can be carried out with the ease and safety of the simplest ovariotomy; but there are many cases where the tubes and ovaries contain pus and are distended into cysts as big as a fist, or even as large as the patient’s head, which are adherent to bowel, uterus, bladder, indeed everything with which they come in contact; this renders their removal tedious and exacting for the surgeon and dangerous to the patient. ”

“ For the last six months has suffered severe pain over right ovary, increased by exercise or pressure, and at the menstrual period. Believing that the dysmenorrhœa and fits both arose from the same cause, on January 3, clitoris was cut down to the base. After this operation she never had a fit, and all untoward symptoms left her except the dysmenorrhœa; she was therefore re-admitted May 27, 1861, and there being some narrowing of the cervix, it was incised with the hysterotome. June 21, catamenia came on without pain, and continued to do so regularly. ”