In 1901 a patient had bilateral ovariotomy performed; five years later she complained of severe uterine hæmorrhage. I removed the uterus by the abdominal route (total hysterectomy). The corporeal endometrium was cancerous throughout. The patient survived the operation six months. Similar cases have been recorded by Martin, Butler-Smythe, and Playfair.
Adenomyoma of the Uterus. 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. The physical and clinical signs of the disease are those present in patients with a large degenerating submucous fibroid. Indeed the surgeon often removes the uterus under this impression, and, after the operation is completed, when he divides the uterus expecting to see the usual encapsuled tumour, to his surprise finds a uterus with greatly thickened walls (Fig. 16).
Fig. 17. An Adenomyomatous and Tuberculous Uterus. The uterus is opened by a vertical incision in its posterior wall. The anterior wall is occupied by a mass of tuberculous adenomatous tissue. The patient, a spinster aged 46, was in excellent health four years after the operation. Two-thirds size.
Microscopically the adventitious material is made of irregular tracts of endometrium containing glands and strands of unstriped muscle tissue.
It is important for the surgeon to recognize these cases because, contrary to the rule with simple uterine fibroids, these adenomyomatous uteri are often adherent to the adjacent bowel and to the bladder: in connexion with this fact several observers have pointed out that uteri affected with this disease are often associated with inflammatory affections of the Fallopian tubes, and there are good reasons for the belief that the adenomyomatous change has a microbic origin. In this connexion it is worth mention that adenomyomatous uteri are sometimes tuberculous (Fig. 17). Some examples of this disease have been mistaken for cancer of ‘the body of the uterus’.
In this disease subtotal hysterectomy gives admirable results, immediate and remote.
THE FATE AND VALUE OF BELATED OVARIES
The only improvement of any importance made in Baer’s operation of subtotal hysterectomy concerns the ovaries. These Baer removed with the Fallopian tubes, but in 1897 I advocated, at the Obstetrical Society, London, that they were of great value to the patient, and pointed out that their conservation, when healthy, spared the patient the annoyance of that curious vaso-motor phenomenon, known to women as ‘flushings’, which is the only obtrusive sign of the menopause.