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 A SERIES OF NINE ABDOMINAL PAN-HYSTERECTOMIES PERFORMED IN 
 ONE YEAR FOR UTERINE FIBROMYOMA. 
 
 BY 
 
 F. A. L. LOCKEIART, M.B., Edin., 
 
 Lecturer in Gynfecoiogy, McGill University, Gynu'cologist to tiie Montreal General 
 
 llospitiil and I'rotestant Hospital for tlie Insane, Montreal. 
 
 (Reprinted from the Montreal Medical Journal, October, 1898.) 
 
A SERIES OF NINE ABDOMINAL I'AN-HYSTERECTOMIES 
 
 PEHBXJRMED IN ONE YEAR FOR UTERINE 
 
 FIBROMYOMA.' 
 
 liV 
 
 V. A. L. LO( KHAKT, M.H., KlJIN., 
 
 Lucturcr in Gyna-cology, Mc(illl University, Gyniucoiogist lo the Moiitri-al CiMit-ral 
 Hospital and Protestant Hospital for the Insane, Montreal. 
 
 As nine patients have undergone abdoniino-vaginal hysterectomy 
 for utei'ino iibroid disease at my hands from January, 1897, to Jan- 
 uary, 1898, only one of whom died, the following analysis of the cases 
 may prove of interest. 
 
 The average age of the patients was 40 years and 6 months, the 
 youngest patient being 32 and the oldest 57 years of age. In only 
 two had the climacteric been reached and in these two it had oct,urred 
 two and thirteen years respectively befoi-e operation. The age at 
 which these women first menstruated averaged thirteen years and 
 eleven months, the extremes being twelvt^ and .seventeen. 
 
 Sterility.— i-i\x of th(> patients wrre married, and of these, three 
 were absolutely sterile, one had luul one miscarriage but no full-time 
 children; one had had one full-time child and no miscarriages; and 
 one had carried seven children to full-time and had miscarried once. 
 Of those who were absf)lutel}- sterile, one uterus contained an inter- 
 stitial tumour, while tlu; other two patients had multi-uodular tumours 
 .scattered all through the uterus. The patient who had miscarried 
 once had two interstitial tibroiils, while the uterus of the woman who 
 had carried seven children to full tune was the seat of gentsral fibroid 
 enlaro-emont and oni' siuali sub-mucous nodule. These women had 
 l)een married for from twd to twenty-seven years. While the number 
 is too small upon which to form any opinion, it is .seen that in this 
 .series the sterility was most marke(| when the tumours were inter- 
 .stitial, but it is (piite likely that the presence of these growths played 
 a very small part in the production of this sterility. 
 
 SyDiptoMs.—ViGmhu'Ue was a marked symptom in cases 2, -S, and 4, 
 but in case 'A was due to defective vision and was cured by the patient 
 wearing proper glasses. 
 
 Abdominal enlargement was the chief complaint in cases 8, 5, 6, <S 
 and 9, although it was plainly evident upon inspection in all. 
 
 Head before the Medical Society of Northern New York, October llth, »S98. 
 
Pressure symptoms in the form of pain in tlie pelvis and thighs 
 and obstruction to the circulation in the limbs were noticed in all but 
 Nos. 1 and 9. It is strange that none were felt in case 9 as the 
 tumour was a large one, l)Ut their absence may be accounted for by 
 the fact that the growth was entirely abdominal, resting on the Vn-im 
 of the pelvis and was so firm as not to sink down into any of the 
 hollows which contain the nerves and vessels. In No. 6, the tumour 
 and uterus encroached to such an extent upon the right side of the 
 pelvis thet the vessels of that side were pressed upon, resulting in 
 oedema and swelling of that leg. 
 
 In cases 4, 8, and 9, advice was sought chietiy on account of Hood- 
 ing, the tumour being entirely sub-mucous in Nos. 4 and 9, but more 
 deeply situated in the uterine muscular tissue in No. 8. In all of the 
 other cases, the growth was either sub-serous (as in the majority) or 
 interstitial. Menstruation was b(jth too frequent and too profuse in 
 cases 1, 2. 4, 5, 7, an<l 9, while in Nos. 3 and (i, the flow was very 
 scanty, and in both ca,ses the tumour was entirely of tlie sub-serous 
 
 variety. 
 
 Where the patient suffered from dysmenorrhd'a, the pain began 
 with the How and lasted during the period in six cases. In No. 7, the 
 pain began a few days before the How and lusted until four days after 
 the latter had cea.sed. This patient had a multiiocular cyst of the 
 left ovary, which, I think, accounted for the pre and post-menstrual 
 pain, as it is not often that tlie pain conies on .some days before the 
 How unless the appemlages are (lisease<l. 'I'lie situation of the tumour 
 ill this series of ca.ses made no difference in the degree of pain felt by 
 the patient. 
 
 Iteration.— In the ttrst four cases, the operation was performed as 
 follows: After thoroughly curetting the uterine cavity and closing 
 the cervix with a running catgut suture, the abdomen was opened by 
 the usual incision in the middle line, and Ijoth broad ligaments were 
 tied off in sections with stout catgut ligatures, the ligature including 
 the Qvarian and uterine arteries, aii<l were divided. Peritoneal flaps 
 were dissected off the uterus in front and behind, the anterior flap 
 includino- the l)ladder. The vagina was then opened and its attach- 
 ments to the cervix were divided with scis.sors, and the whole mass 
 removed. Anterior and posterior peritoneal fla|)s were united to the 
 anterior and posterior vaginal w^alls respectively so as to cover over 
 the raw surfaces and also to prevent undue shortening of the vagina, 
 after which the top of the vagina was closed in by a running suture 
 of catgut. The abdominal cavity was then wiped dry and the incision 
 in the abdominal wall closed by three rows of sutures. These con- 
 
s 
 
 sisted of a continuous suture of fine catgut for the peritoneum anrl 
 one row of internipt(!il silkworm gut sutures for the fascia of the 
 rectus and another similar row for the skin. 
 
 In the tith, 7th and 8th cases, after curetting the uterine cavity 
 and closing the cervix with catgut, the vagino-cervical attachments 
 were separated, the uterus pushed well to each side and the space 
 thus formed was packed with gauze. The ahdomen was then opened 
 and the ovarian vessels were ligated and divided. An anterior flap 
 of peritoneum was then foi-med and the broad ligaments opened up in 
 such a way as to permit of the ligature of each uterine artery per 
 visu. The posterior flap of peritoneum was then formed and the 
 division of the hroad ligaments completed. As the vaginal attach- 
 ments had heiMi previously dividetl from below, the uterus and tumour 
 were quite fr«M' and could be lifted out of the abdominal cavity. All 
 bleeding points were then secured by fine catgut ligatures and the 
 two vaginal walls united. The peritoneal flaps were then sutured 
 together so as to cov(>r in all of the raw surface including the ligatures 
 which had been applied to the ovarian and uterine arteries. The only 
 point of difference in the operation in the 5th and 9th cases is that 
 the whole operation was performed tlu'ough the abdomen as the 
 cervices were too high up in the vagina to allow of the combined 
 operation. 
 
 Covtplicatlons. — The operation was complicated in four cases. In 
 No. 1 the right ovary formed a cystic tumour, containing ten ounces 
 of a dark grumous fiuid, composed largely of extravasated blood. 
 This was densuly adherent to its corresponding tube, the upper part 
 of the rectum and to theposterior surface of the uterine fibroid. These 
 adhesions wt-re separated and the cyst was removed, after which the 
 tumour and uterus were likewi.se removed by total hysterectomy and 
 the abdominal cavity wiped dry. The incision was closed by three 
 rows of sutures without any drainage being employed. 
 
 In case No. '.i the complication was caused by the patient having 
 undergone a previous abdominal section, as a result of which the 
 omentum was Hrndy adherent to the ol<l cicatrix. This adhesion was 
 separated with some difticulty and the operation of hy.sterectomy pro- 
 ceeded with. 
 
 The seventh patient of the series had a multilocular cyst of one 
 ovary, in addition to the uterine fibroid. This was the size of a large 
 cocoanut, and was densely adherent to the surrounding intestines, but 
 was eventually removed before proceeding with the hysterectomy. 
 
 Mrs. M., first case (No. 5) is deserving of a somewhat fuller descrip- 
 tion. She was a widow, 57 years of age, complaining of weakness 
 
.111(1 pain ill tli.- back and l(^ft <,'r()in. Tluvsr symptoms had l.t'.-ii 
 prosont for the last tliviM- years and, at tiiiios, wen- so sevcuv as to 
 contine the patient to bed. She has lost Hesli rather rapidly during 
 the past year, and she attributes this to her appetite having' beer, very 
 poor. Even since her symptoms commenced thnie years ago, she has 
 had a profuse thin yellowish watery discharge, Ijut it has been neither 
 hsemorrliagic nor malodorous. Menstruation began at fourteen years 
 of age, recurred regularly every four weeks, lasting for four days, and 
 was always accompanied by severe pain. She was never pregnant. 
 Menstruation ceased entirely thirteen years ogo, at wliich time she; 
 had a submucous Hbroid removed. On making a vaginal examina- 
 tion, a inultiparous cervix was felt high up and to the right in the 
 vagina. The centre and whole [of the left side of the pelvis were 
 tilled with a hard mass. Binianually, the mass was felt to be the size 
 of an adult head and to be firmly fixed in the pelvis. It was rounded 
 and well defined on the right side, but it gradually became more and 
 more indistinct to the external hand on the left side, pressure oyer 
 the upper part of the mass on the side causing intense pain, which 
 lasted for nearly 24 hours. The diagnosis was a uterine fibroid 
 tumour with chronic pelvic peritonitis, the tenderness on the left side 
 being probably caused by th(> inclusion of the ovary of that side in 
 adhesions. 
 
 At the operation, the uterine cavity was curetted, the instrument 
 bringing away a quantity of broken down purulent material. On 
 opening the abdomen, the ctecum, descending colon and rectum were 
 found to be adherent to the tumour, a ma.ss the size of a small orange 
 lying between the descending colon, the left Viroad ligament and 
 rectum. After separating the cjBcum from the tumour, work was 
 begun on the left side, the adhesions being so dense that their division 
 had to be begun with the knife. While separating the colon from the 
 ma.ss below it, a quantity of intensely fu'tid pus welled up from 
 what, on further dissection, proved to be an old pyosalpinx, which had 
 ruptured on the posterior surface where it was closely adherent to the 
 rectum. This abscess sac (the left tube and ovary; was .shelled out 
 of its bed of adhesions, tied off and removed. All of the pus was 
 carefully wiped up as soon as it appeared at the orifice of therupturl^ 
 the general peritoneal cavity being protected by a large pa.l. The 
 tumour and uterus were now comparatively five, so both broad liga- 
 ments were tied off and divided, together with the uterine artery on 
 each side. An interior and posterior Hap of peritoneum were formed, 
 after which the vaginal attachments were divided and the whole mass 
 removed. The raw surface was packed with iodoform gauze, one end 
 
Ileitis' tln-ust into tin- vaj,qnti for Iniiiiagf and to nllow of its removal- 
 Tho vertical flap was sown to the rt'ctuni and to the peritoneum at 
 th»' upj)er niur^'in <jf tlie raw surfaci; on tlu, posti-rior pelvic wall, after 
 which tin- whole ahdoniinal cavity was well swahbed out and a ;,dass 
 • Irainaye tuhe inserted, the incision heinj; hurriedlv closed with two 
 rows of sutur(!s as the patient was in such a weak condition. A small 
 j,'auze wick was introduced into the tube to assist drainage, l>ut the 
 abdominal cavity was not Hushed out with salines as this would only 
 have tended to spread any pus which had escaped from the abscess 
 and not been removed by the swabs. The tube was removed on the 
 third day, as it remained (|uite dry after the firat 48 hours. The 
 orifice of the track of the tube was kept open by a li<fhtphig of gauze 
 for a few days until it had apparently granulated up. The vagina] 
 packing was removed daily for one week, at the end of which time 
 dressing was discontinued as thert; was no discharge. As far as pulse 
 and temperature went, the patient made a good convalescence, the 
 pulse only once going abovts 100 after tin; first 24 hours, it touching 
 102 beats per minute on the second day. The tempei-ature was still 
 l)etter, not reaching 100°F. once after operation, although it stood at 
 102°F. the day before. Notwithstanding this practically non-febrile 
 chart, the pulse and temperature being taken every two hours, on the 
 eleventh day as the patient was turning hersiOf in bed, a great (pian- 
 tity of pus gushed up from the track of the tube, leaving a cavity 
 wliich only closed up after over thrive weeks careful attention, the 
 cavity being washed out dailj' with hydrogen peroxide, a small rubber 
 drainage tube inserted and the opening covered with gauze. This 
 shows how pus may form and only indicate its presence by slight rises 
 of pulse and temperature and also without occasioning the slightest 
 degree of pain, there being absolutely none in this case. A culture 
 from the contents of the ruptured tulie, taken at the time of operation 
 but before the tube had been removed from the abdomen, showed that 
 the (mly germ present in the pus was the B. coli. Unfortunately, no 
 cultui'e was taken from the pus which escaped from the tract of the 
 drainage tube, so that it is impossible to say just what germ was 
 present. It is well-known that the colon bacillus will cause suppura- 
 tion l>ut is not a very virulent germ, so that it is probable that the 
 bottom of the drainage tube track was infeet<vl by some of these 
 bacilli which had penetrated the wall of the bowel where it was 
 weakened hy the .separation of the adhesions This patient made a 
 good recovery eventually. She has l)efn seen within the last four 
 weeks and is (juite well, there being no evidence of weakness at the 
 site of the drainage tube. 
 
The only other case worthy of detailod mention is No. 8. this being 
 tilt! f)nly on«' followed l»y n fatal termination. This patient was a 
 .strung nmltiparous wunmn, thirty-one years of a},'e, who had a sub- 
 umcous Hbroi<l the sizi- of an adult head. Beyijnd the fact that she 
 suffered from intense dysmenorrlujea and menorrhaf,'(t'a, the only point 
 in the history worthy of note is the extreme rapiility of growth of 
 the tumour. In March, I.S94, th.; patient's pelvic contents were very 
 carefully examined undt-r anjesthesia, at which examination the uterus 
 was felt to 1h' antt'-Ht-xt-d l»nt not enlarovd, Karly in iH!)7, the 
 patient married, and in .lum- of that year con.sultrd me for pelvic 
 pain. On making a local examination, tin- uterus was found to be 
 the .seat of a Hbroid the size of a very large cocoanut. Intra-nterine 
 galvani.sm was given a fair trial, Itut its oidy effect was to cause such 
 great pain that l)()th the pati(!nt and her husbanrl insisU'd upon an 
 operation being performed. On October 28rd, 1897, abdomino-vagi- 
 nal pan-hysterectomy was performed in my private hospital. There 
 was absolutely no complication and the operation was ovei- in sixty- 
 live minutes. The patient's recovery was smooth and uneventful 
 until the night of the :ilst, hei- pulse, respiration and temperature 
 being well represented by the accompanyitig chart of the average for 
 the whole nine cases. She had been feeling vc^ry well all day, laugh- 
 ing and chatting with her husband and parents. At 11.1^0 p.m. she 
 woke up complaining of pain in the left iliac region. Her bowels ha<l 
 moved during tht; day, but the nur.se now emptied them by an enema 
 and gave her 3ss of brandy as she felt weak. This made such an 
 improvement that the patient went to sleep, the pul.se being regular 
 and .strong. At 1..S0 a.m. she again woke up and said she had a " queer 
 sensation.' Her pulse was irregular and weak and her hands cold. 
 She was given more brandy, Imt it did lier no good, and 1 was sent 
 foi-. Before I could arri\e, however, she suddenly sat up in bed, 
 vomited a little thin watery Huid and fell back again, only breathing 
 three or four times after I reached the l)edside at 1.40 a.m. Unfortu- 
 nately no post-mortem examination was allowed, Vjut I have no doubt 
 in the least but that the cause of death was pulmonary embolism. 
 There had been no evidence of a cardiac disease to be discovered 
 although the patient's heart had been carefully examined on .several 
 occasions during the five or six years that she had been under my 
 care. Septicaimia was out of the que.stion, as there was not the 
 slightest symptom of it from the day of the operation. Slipping of 
 a ligature, followed by internal haemorrhage, may also be put to one 
 side as a cause, as it was eight full days after the operation by which 
 time the pelvic vessels have become effectually plugged and there was 
 
neithiT the pallor Mor the sijrhinj; rcHpiration which ar»! seen in inter- 
 nal liBBniorrhajrp, 1 have? little douht but that the pain in the left 
 side of the pelvis coniplainod of at i \.'M) was causfMl hy tho tcaiporary 
 arrest of an einholisni in one of the p(;lvic vesscds. This hecanie 
 dislodged and subsequently foun<l its way into »»ne of the pulmonary 
 vessels and so caused death. 
 
 After Treuthient. — In these nine cases, opium was only given to 
 three patients, each of whom received ten minims of Battley's solution 
 hypoderniically ouc^ on the night after the operation. 
 
 Only two of the patiiints re(|uired post-operative use of the catheter, 
 viz., in Nos. 3 and 8, who rcipiired it for 48 and 72 hours respectively 
 
 Stimulation after operation was nworted to in the majority of cases- 
 not as a routine measure, but because each j)atient re(|uired it. 
 
 The following table will show the j^articulars as to kind and (|uan- 
 tity of stinuilant employed : 
 
 Case. 
 
 Kind and Quantity ov Stimulant Kmpuoveo. 
 
 tStr)'(vhniTie gr. .,'y q. ♦! h. tor Ist 8 (luys. 
 
 •• ,',, t. i. d. tor Ist 21 (lays. Brandy ^s-s in nutri- 
 tive, enetnata q. 4 h. tbi- 'Jl days. 
 
 linmdv 3S8 in mitritive enematu q. 4 ii. lor 2 days aiui ehani- 
 (Xkgne o*^H [). v. 11. for vomiting for one <lay. 
 
 Brandy as above, .\Imo l> stvliue enomula during Isl night. 
 
 ■• '• •' Also slryehnine gr. 4',, q. 4 li. lor 10 days. 
 Al8«) 2 saHne onematii during the Ist 8 hours. 
 
 7 , Strychnia gi'. ,,'^ I. i. d. lor 2 days. 
 
 8 ! « .. ^1^ I j J t,j|. o iiyys. One salijie eneinu as .soon 
 j as removed from the table. 
 
 I 
 
 U ! Strychnia gr. A q. 4 b. for 10 day.-*. One wdine enema Just 
 I after operation, and o>'«-^8s brandy or whiskey as required 
 ; for several days after operation on account of a weak heart. 
 
 From the accompanying chart whieli represents the average of the 
 morning and evening pulse, respiration and temperature of nine cases 
 for eight days and eight cases for the remaining six days, it will be 
 seen that the temperature reached the highest point on the second 
 day after operation, when it ran up to 100.2° F., steadily declining 
 from here to normal, which was reached on the eighth day. The pulse 
 
s 
 
 and respiration were the most rajjirl on the night after the operation, 
 reaching 105 and 2G respectively. They then steadily fell until the 
 tifth day when they both again quickened, taking three days to reach 
 S8 and 23 respectively and again fall to the point from which the 
 second rise started, viz., 82 and 20, in the vicinity of which they 
 reniaineil until the patients were discharged. 
 
 A few of these patients returned to hospital after dismissal, com- 
 plaining of the usual symptoms of the menopause, and were given 
 ovarian extract, gr. v., t. i. d., after meals. All showed considerable 
 amelioration of their symptoms for the tirst few weeks but the 
 improvement was only temporary. 
 
 Although the one death brings up the mortality in the above series 
 to 11.11 per cent., it will be acknowledged, I think, that that death 
 was entirely unpreventable, and the combined results show that abdo- 
 minal hysterectomy for moderate sized fibroid tumours of the uterus 
 is not an operation which ought to be followed by a high rate of 
 mortality when proper precautions are taken not only at the time of 
 operation, but in the preparation and after treatment of the patient.