Bond. An Inquiry into some Points in Uterine and Ovarian Physiology and Pathology in Rabbits. British Medical Journal, 1906, ii. 121.
Doran, A. Subtotal Hysterectomy: after history of sixty cases. Transactions of the Obstetrical Society, 1905, xlvii. 363.
Thomas, G. C. The after histories of one hundred cases of Supravaginal Hysterectomy for Fibroids. Lancet, 1902, i. 294.
CHAPTER VII
HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS
The modern operation of hysterectomy as a radical measure for the relief of cancer of the uterus has a somewhat curious history. In 1878 Freund extirpated the uterus for carcinoma of the cervix through an abdominal incision; his method was quickly practised by other surgeons, but the great mortality of the operation soon caused it to be abandoned for the vaginal route advocated by Czerny and supported by Schroeder, Olshausen, Martin, and Péan amongst other gynæcologists. This method, however, has been abandoned, for, although the operative mortality of vaginal hysterectomy for cancer of the uterus has fallen to 5 per cent., the operation has disappointed expectation, as it can only be employed on early cases of the disease with anything like a hopeful prospect of curing the patient, and, even when performed on carefully selected cases, the risks of recurrence are so great and often follow so rapidly on the operation that surgeons have lost confidence in the method. This has induced gynæcologists to turn their attention again to the abdominal route. The cancerous uterus is now subjected to what is known as ‘radical abdominal hysterectomy’, a method with which the names of Ries, Mackenrodt, Dührssen, and Wertheim are closely associated.
Hysterectomy for cancer of the cervix. The greatest obstacle to the success of vaginal hysterectomy in the radical treatment of cancer of the neck of the uterus is the limitations which the anatomical environment imposes on the surgeon, for as soon as the disease overruns the cervix it implicates the vagina, the bladder, the vesical portions of the ureters, and the rectum. The ‘radical abdominal operation’ enables the operator not only to remove the uterus and its neck, but the broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and the infected para-uterine connective tissue, and by affording the operator free access to the floor of the pelvis the proceedings may be carried out with a free exposure of the operating field, thus allowing important structures like the ureters to be dissected out of implicated tissue. Indeed it has even been recommended, in cases where the bladder has been extensively involved, to resect this viscus and engraft the ureters into the rectum.
The primary object of these extensive operations is not only to facilitate the wide removal of connective tissue around the cervix in early cases of carcinoma, but also to allow the advantages of operative treatment to be extended to patients to whom it would be otherwise absolutely barred.
One great danger which attends operations for the removal of cancerous organs is what may be called ‘post-operative cancer-infection’, that is, in the course of the operation tracts of connective tissue are opened up and become soiled with cells, which engraft themselves on this tissue and on the peritoneum, and give rise to extensive masses of cancer which are often described as recurrent cancer. This accident often causes the patient to die quicker than if the primary cancer had been left untouched. In the radical operation it is one of the essentials to avoid soiling the wound with cancer cells. This rule, of course, applies to operations for cancer in any part of the body.