Hysterectomy for uterine fibroid disease in early pregnancy / by Alban H.G. Doran.

  • Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927
Date:
1902
Catalogue details

Licence: In copyright

Credit: Hysterectomy for uterine fibroid disease in early pregnancy / by Alban H.G. Doran. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

    3/8 page 1452
    Cullingworth,1 who recently wrote an interesting article on the subject well worth perusal and by Mr. J. Bland-Sutton whose papers on the same question appeared in The Lancet.3 All obstetricians and surgeons who undertake hysterectomy should study Dr. Leopold Thumim's valuable monograph on operative experience since 1885.3 There was an excellent discussion at a meeting of the Obstetrical Society of London in 1901 after the reading of a communication by Dr. Archibald Donald on fibroid tumours complicating pregnancy and labour, to which I shall have occasion to refer. I will now relate the three cases in my own recent experience. I am indebted to my friend and colleague, Dr. C. Hubert Roberts, for the instructive drawings illustrating the relation of the tumour to the uterine cavity. Case 1. Pregnancy in an elderly primipara; uterus lying between two fibroid, outgrowths, one obstructing the pelvis; hysterectomy at the fifth month; recovery.—A full report of this case was published in The Lancet.4 The patient was 40 years old. She had been married two years and had never been pregnant till on this occasion. I watched the progress of the pregnancy for a month and found that a large fibroid mass behind and below the uterus did not rise, but, on the contrary, was beginning to block the pelvis. In consultation with Dr. Roberts it was agreed that it was not advisable to wait till term and then to undertake a Caesarean section. I therefore performed retro- peritoneal hysterectomy in the fifth month of pregnancy on Nov. 1st, 1900. The patient was in good health in July, 1902. The illustration (Fig. 1) is reduced from a drawing in the Transactions of the Obstetrical Society, vol. xliii., 1901, Fig. 1. Uterus and tumour, Case 1, seen from in front. U.T., Uterus, F H Foetal head, showing one ear ; three fingers are also visible. U. F., Upper fibroid which occupied the right hvpocbondrium and did not interfere with the pregnancy. L F Lower fibroid which blocked the pelvis. (Museum, St Bartholomew’s Hospital, Pathological Series XLIV., 3090, C.). J pi. 12. The upper tumour occupied the right hypochon- drium ; the lower, which sprang from the back of the posterior segment of the uterus, fitted closely into the pelvic cavity and pushed the cervix up against the pubes. Both fibroids were very hard aod had the lower been pushed upwards the uterus might have been ruptured between them like a peach between two stones. The specimen is preserved in the museum of St. Barthoh mew’s Hospital. Case 2. Fibroid uterus; numerous abortions; pregnancy to term, child saved; six years later pregnancy with large fibroid in the posterior part of the inferior segment involving the cervix; violent attacks of pain; hysterectomy at the fifth month; recovery. — A woman, aged 39 years, who had i Fibroid Tumours of the Uterus complicating Pregnancy, a Record of Pemonal Experience, St. Thomas s Hospital Reports, V°2* The Surgerv of Pregnancy and Labour Complicated with Tumours, The Lancet, Feb. 9th (p. 382), 16th (p. 452), and 23rd (p. 529), 1931Chirurgisch± Eingriffe bei Myomen der Gebiirmutter in Schwan- gerschaft und Gfcburt, Archiv fur Gyniikologie, vol. lxiv p. 457. B A Case of hysterectomy for Uterine Fibroid in the Fifth Month of Pregnancy, The Lancet, March 2nd, 1901, p. 621. been married 17 years, was brought to me by Mr C Eastwick-Field of Midhurst on Jan. 3rd, 1902, as he suspected pregnancy complicated by uterine fibroid. She had aborted no less than nine times, the last occasion being six years ago; then she became pregnant again and by careful treatment Mr. Eastwick-Field succeeded in keeping off the usual accident, so that she was safely delivered at term of a healthy boy, now five years old. Ten years ago she was under treatment in a hospital for dysmenorrheea. Menstruation was regular till August 20th, 1901, when it was last seen. About a week earlier the patient noticed a small lump somewhat to the right of the middle line in the hypogastrium. This lump enlarged ' till the end of October and since then it seemed to remain stationary. In the second week of October there was discharge for several days and two large clots were passed. During November a watery, brownish, and odourless discharge e.-caped from the vagina for nearly a fortnight, then watery fluid came away in quantities ; it ceased and for the last five weeks there was no more discharge. Morning sickness began at the end of September and lasted till the end of November, after which date it ceased altogether. On Deo. 28th the patient noticed a second lump in the left iliac fossa ; she thought that she felt movements in it. On the same day violent labour-like pains set in and lasted for nearly three days. The patient had always experienced difficulty in holding urine long since the birth of her child and the trouble increased during the present pregnancy. Contractions were detected in the mass on the left, the vagina showed purplish colouration, and the os was very patulous. The mass on the right felt very hard ; on that account the condition was suspected to be more probably fibroid complicating pregnancy than extra-uterine gestation. The patient was tall, anaemic, thin, and much exhausted from the recent violent attack of pain when she came under my care. I found an oval, hard, solid tumour occupying the hypogastrium and right iliac fossa ; it reached to within three inches of the umbilicus and was fixed. On its left and behind it, separated by a distinct cleft, was an oval soft tumour reaching almost to the left hypochondrium and extending to the middle line. On palpation this soft tumour was felt to contract and a souffle was clearly audible. The cervix, wide and patulous, was completely displaced to the left but was not actually squeezed against the brim. The hard tumour on the right descended into the right fornix and indeed occupied all the pelvis except the corner to the left where the cervix lay, but did not come down low. It was continuous without any groove with the right side of the cervix ; at that point the pulsations of the uterine artery were very clear. The whole was quite fixed. The breasts were small, the nipples were rather large, and a little moisture exuded from them on pressure. The urine was scanty and high-coloured ; it con- tained a trace of albumin. The temperature never exceeded 99 2° F. during the four days before operation when she was under my* observation. The pulse was rapid and exceeded 120 on Jan. 5th after a sleepless night due to attacks of pain round the tumour. There was no history of any general illness. On consultation with Mr Eastwick-Field and Dr. Roberts it was agreed that owing to the position of the tumour it could not be pushed up. Three courses remained : (1) to empty the uterus ; (2) to wait till term and to perform Caesarean section ; and (3) t6 remove the uterus at once. The first course, induction of abortion, might have been practicable, but even if so it would have entailed consider- able danger and if successful would have saved for the patient a uterus which had already proved itself unfit to bear—a more than questionable advantage. Dr. Donald had recently reminded us5 how, now that the results of opera- tions on fibroid tumours have so much improved, induction of abortion is no longer the safest course for the patient. This obstetric operation in cases of pregnancy so seriously com- plicated with fibroid tumours as to render any interference necessary is a procedure not by any means free from danger. The cervix is more or less difficult to reach and the uterine cavity is distorted, hence retention of the placenta or the decidua and impediments to the free escape of blood and lochia are necessary results. The danger of primary septic infection is considerable, whilst the risk of a more chronic infection leading to degeneration s Fibroid Tumours complicating Pregnancy and Labour, Transas tions of the Obstetrical Society of London, vol. xlm., 1901, p. loo.
    digitised image 1
    digitised image 2
    digitised image 3