Part 7 (1/2)

1. 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; or, more rarely, the pedicle of such a tumour entangles a loop of small intestine and obstructs it.

In order to give the matter a statistical basis I have drawn up an a.n.a.lysis of ninety-five consecutive cases of myomectomy and enucleation out of my practice, with the subsequent history of some of the patients.

This experience covers a period of twelve years.

Of these ninety-five patients three died as the result of the operation--two from pneumonia in the fourth week after operation, and one a few days after operation: in this case there is reason to believe that the tumour was complicated with cancer of the body of the uterus.

Six of the women were submitted to myomectomy during pregnancy, and in four cases the operation was undertaken under the impression that the tumour was an ovarian cyst which had undergone axial rotation. These cases occurred in the days before I recognized that 'red degeneration'

of fibroids complicating pregnancy caused them to be painful and tender (see p. 78). In one patient this complication was clearly recognized. In the sixth patient the tumour was regarded by some capable gynaecologists, who examined her, as a tubal pregnancy complicating a gravid uterus.

Five of these patients went to term and were delivered of living children. The sixth miscarried two months after the myomectomy.

Of the ninety-two successful myomectomies, five subsequently became pregnant and had living children, but in each instance the fibroids were subserous. I have not known a patient to become pregnant after abdominal myomectomy for a submucous fibroid, large or small. In calculating the probability of pregnancy from these statistics it must be mentioned that the patients fall into three categories:--

1. Forty women were in the child-bearing period of life and married; many of them were multiparae.

2. Twenty were single women and probably capable of bearing children in a favouring environment.

3. The remainder were spinsters or barren wives.

A significant feature in the after-history of ten of these women is the fact that some years later other fibroids grew in the uterus, and hysterectomy became a necessity on account of menorrhagia in seven of them; of these, two died from the operation, which was difficult and tedious. One patient was operated upon two years after the myomectomy, and had borne a child in the interval, and the other seven years.

The last fact to mention is that one patient, from whom a submucous fibroid had been enucleated from the cavity of the uterus (hysterotomy), died four years later from cancer arising in the body of the uterus (see p. 51).

Olshausen has recently considered this question, and indicates that the chief objection to the abdominal enucleation of uterine fibroids is its high mortality.

He furnishes a table of 563 cases, collected from twelve operators, including himself; of these 59 patients died, representing a mortality of 10.5 per cent. Olshausen, in the years 1900-5, performed enucleation on 124 patients with 14 deaths. Eight of the patients subsequently came under notice with recrudescence of fibroids. Christopher Martin has performed abdominal myomectomy 73 times with 1 death.

The question of myomectomy, when fibroids complicate pregnancy and labour, or give trouble after labour, is considered in detail on p. 78.

REFERENCES TO REPORTS OF HYSTERECTOMY PERFORMED FOR FIBROIDS IN MALFORMED UTERI

BLAND-SUTTON, J. Fibroids in a Unicorn Uterus. _Clin. Journ._, Lond., 1901-2, xix. 1.

BLAND-SUTTON, J. Case of Fibroids in both halves of a Bicornate Uterus.

_Proc. R. Soc. of Medicine_, 1908. Obstet. and Gyn. Sect., ii. 95.

CZERWENKA. Uterus bicornis unicollis, &c. _Centralbl. f. Gyn._, Leipz., 1900, xxiv. 207.

DORAN, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous Subject. _Brit. Med. Journ._, 1899, i. 1389.

GOW, W. J. Cystic Intraligamentous Myoma with Double Uterus. _Trans.

Obstet. Soc._, Lond. (1898), 1899, xl. 134.

HEINRICIUS. Ein Fall von Myoma im rudimentaren Uterus bicornis unicollis. _Monatschr. f. Geburts. u. Gyn._, Berl., 1900, xii. 419.