Part 4 (1/2)
A woman, fifty-seven years of age, had a large submucous fibroid in the uterus. At the operation the clomic ostium was not only patent, but the carcinoma protruded through it and nodules of growth could be seen on the wall of the r.e.c.t.u.m at the point where the tube rested on the bowel.
The patient recovered from the operation and enjoyed good health for eleven months, then signs of recurrence became manifest and she died a few weeks later.
[Ill.u.s.tration: FIG. 5. PRIMARY CANCER OF THE FALLOPIAN TUBE. An ovarian cyst a.s.sociated with primary cancer of the corresponding tube. The clomic ostium is open and the cancerous material has leaked out on to the cyst wall. Half size.]
[Ill.u.s.tration: FIG. 6. A SECTION OF PRIMARY CANCER OF THE FALLOPIAN TUBE. This is the cyst wall and cancerous tube represented in the preceding drawing: it shows the cancerous infiltration of the cyst wall.
Half size.]
A woman, forty-nine years of age, had a large fibroid in her uterus and a Fallopian tube stuffed with cancer, but the clomic ostium was completely occluded. The uterus, ovaries, and tubes were removed. The patient subsequently remarried and was in good health three years later.
Primary cancer of the Fallopian tube is almost invariably unilateral and its a.s.sociation with fibroids of the uterus is unusual. It is necessary for the surgeon to remember that a cancerous Fallopian tube may lead to complications with an ovarian cyst. Our knowledge of primary cancer of the Fallopian tube has grown up within the last twenty years, and some of the recorded cases puzzled the reporters because the disease was a.s.sociated with a cyst, sometimes of a large size.
In Fig. 5 I have represented an instructive specimen, which is an ovarian cyst complicated with primary cancer of the corresponding Fallopian tube. In this instance the cyst was as big as a cocoa-nut and multilocular: the ampulla of the tube is stuffed with cancer, but the ostium is patent and a 'stream' of cancerous material has flowed over the wall of the cyst. In addition, the cancerous material has infiltrated the wall of the ovarian cyst. The patient recovered from the operation, but a year later she had an extensive recurrence.
The primary mortality of simple ooph.o.r.ectomy, or ooph.o.r.ectomy combined with hysterectomy for primary cancer of the Fallopian tube, is about 5%, and this is low in comparison with abdominal hysterectomy for cancer of the cervix; it is due to the fact that tubal cancer does not so readily become septic (Doran).
REFERENCES
DORAN, A. A table of over fifty complete cases of Primary Cancer of the Fallopian Tube. _Journal of Obst. and Gyn. of the British Empire_, 1904, vi. 285.
BLAND-SUTTON, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400.
---- On Cancer of the Ovary, _Brit. Med. Journal_, 1908, i. 5.
CHAPTER IV
OPERATIONS FOR EXTRA-UTERINE GESTATION
The systematic surgical treatment of extra-uterine gestation we owe to the genius of Lawson Tait. His first operation for this condition was performed in 1883. Tait wrote that he conceived and carried out this operation in obedience to the canon of surgery relating to the arrest of haemorrhage, and which is valid in other regions of the body.
Many surgeons (even a butcher) had removed living, dead, and putrescent extra-uterine ftuses from the abdomen of living women, but Tait was the first to attempt the operation in those early stages of tubal gestation in which the tube bursts, or expels (tubal abortion) the products of conception through the clomic ostium or a rent in the gestation-sac, into the abdominal cavity, accompanied by an escape of blood so abundant that it may destroy life in a few hours.
=Indications.= The operative treatment of extra-uterine gestation depends mainly on the stage at which it is required.
When a gravid tube is detected before rupture, the operation is practically that of ooph.o.r.ectomy: and is simple and safe.
When the operation is required in consequence of the bursting, or abortion, of an early gravid tube, great promptness is often required on the part of the surgeon to prevent the patient dying from haemorrhage, and although the operation in these circ.u.mstances is really an ooph.o.r.ectomy, it often has to be performed in the patient's room as an emergency operation and without the elaborate surroundings of a modern operating theatre.
There are few accidents which test the skill, nerve, and resource of a surgeon more than cliotomy for a suspected intraperitoneal haemorrhage from a gravid tube, and few operations are attended with such brilliant results. Surgeons are often astonished to find a large amount of blood in the pelvis due to a small perforation in a gestation-sac no bigger than a cherry (Fig. 7).
=Operation.= In removing tubes of this kind it is necessary to apply the ligature on the uterine side of the rent in cases of rupture of the tube, but when the rent involves the wall of the uterus the opening will require the application of a mattress suture for its complete closure.
In some rare instances of the interst.i.tial variety of tubal pregnancy, the uterus has been so involved that in order to effectually control the bleeding it has been found necessary to remove the uterus.
After the pedicle has been safely ligatured and the blood removed, the abdominal incision is sutured as described on p. 9. When the shock due to the bleeding and operation has been great, it is sometimes judicious to pour one or two pints of saline solution at the temperature of 102 F. direct into the abdominal cavity.
[Ill.u.s.tration: FIG. 7. A GRAVID FALLOPIAN TUBE. There is a hole in the gestation-sac, and tufts of villi project through it. The patient was in the seventh week of her tenth pregnancy when she was seized with abdominal pain and died in ten hours from haemorrhage. (_Museum of St.
Bartholomew's Hospital._) Natural size.]