THE SURGICAL TREATMENT OF FIBROIDTUMORS OF THE UTERUS.

BY

JOHN HOMANS, M. D.Surgeon to the MassachtTSetts General Hospital, etc.

Reprintedfrom the Boston Medical and Surgical Journal ofMarch 7, fBgj.

BOSTON:DAMRELL & UPHAM, Publishers,

283 Washington Street.1895-

THE SURGICAL TREATMENT OF FIBROIDTUMORS OF THE UTERUS.1

BY JOHN HOMANS, M.D.,Surgeon to the Massachusetts General Hospital, etc.

In what I have to say in regard to the treatment offibroids, I shall not attempt to mention all the namesof the very eminent operators who have written onthe subject. I doubt if one man could read in a daythe communications published during twenty-four hourson this operation. You can read them for yourselvesin the American Journalof Obstetrics and in the vari-ous other journals and medical magazines published athome and abroad. My remarks will be drawn frommy own experience, and, such as I have to make,would be confused and uninteresting if mixed up withreferences to others’ writings, so I will not try tomention all those I would like to, because I think itwould lessen your interest in the subject and make mypaper too long. Let me say at the beginning that myremarks will have no reference to fibroids presentingthemselves at the uterine or vaginal outlets. Forsuch the proper treatment is removal per vaginam, andthis has always been successfully done by me in allcases where the patient had not become septic; thislast condition being common where a large fibroid ofmany pounds’ weight has begun to protrude afterlabor, the condition not being recognized by the at-tending physician for some days, until sloughingfibroid, uterus, and the patient herself have becomethoroughly septic. So much for fibroids extruding or

1 Read before the Boston Society for Medical Improvement, Jan-uary 7, 1895.

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being expelled from the uterus. What I have to saywill be limited to the surgical treatment of fibroidsafter the abdominal cavity has been opened. Thedealing with fibroids by abdominal ablation is becom-ing more common as we become more certainly suc-cessful in our methods of operating, and feel confidentthat we can remove a non-adherent fibroid tumor in afairly healthy woman without much violence and withalmost sure promise of success.

Fibroids do not always cease to grow at the meno-pause ; many of them do, but in many cases theygrow and give rise to hemorrhage and other serioussymptoms. They also sometimes become cancerous.This condition I have seen twice. Wisdom is shownin choosing the cases requiring operation.

The reasons which lead me to remove a fibroid byabdominal section are : (1) If it actually causes muchdiscomfort. (2) If it threatens death by hemorrhage(and it does sometimes not only threaten, but causesit as suddenly as a pulmonary hemorrhage does).(3) Because it may increase and become too burden-some to allow life to be worth living. (4) Because itmay develop a cancerous character. (5) Because byits pressure on the abdominal organs it may destroylife. (6) Because it may become cystic and thor-oughly adherent. Such a tumor I have never success-fully removed. I do not mean fibroids with dilatedlymph-spaces, but fibroids with cysts as clear and dis-tinct as those in ovarian tumors. (7) Because it maybe an ever-present anxiety. (8) Because it may causeedema of one or of both extremities and phlebitis, tobe followed perhaps by the passage of an embolus intothe circulation, causing death by renal or hepatic dis-ease. (9) Because they sometimes are twisted withthe uterus as a pedicle and must be removed atonce to save life, I have seen this once. (10) Be-

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cause a very sensitive single woman, in good health,and active, demands its removal on account of the dis-figurement it causes. (11) Because the operation,to-day, in experienced hands, is almost uniformly suc-cessful. The mortality from all cases, promising andunpromising, probably varies between three and tenper cent. The reasons for not operating are: (1)When the tumor gives no trouble, uneasiness or dis-turbance and the patient does not desire its removal.(2) When it is not accompanied by hemorrhages. (3)Because no one can positively say that it may notremain stationary or even retrograde. Without beingomniscient, we cannot tell the future course of a fi-broid. I have watched some tumors twenty years andmore, and then removed them because they havegrown and become annoying, and I have watchedothers grow smaller; but I operate more frequentlythan I used to. I have seen about 650 fibroids, and Ihave operated on but 93. 1 should have done well tohave operated upon a greater proportion of them.

Some years ago, in 1887, I think, my friend Dr.Keith, then of Edinburgh, now of London, wrote methat I must lay down my knife from fibroids and thatthey could be treated successfully, that is, made bear-able, by electrolysis, ala Apostoli. To this treatmentI gave a thorough trial for nearly three years, andthen abandoned it as a routine method, as uncertain,unsatisfactory and tiresome in the extreme; but I stilluse it in certain cases of hemorrhage and pain in apatient otherwise strong and whose tumor is quiescent.I published all my electrolysis cases, results, and con-clusions in the Boston Medical and Surgical Journalfor March 12, 1891. The cure of fibroids by removalof the ovaries and tubes is uncertain. Perhaps theligature of the ovarian artery by cutting off a portionof the blood-supply to the uterus has much to do with

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the success which sometimes attends this procedure.I have seen a fibroid the size of a cricket-ball entirelydisappear at the end of four weeks after removal ofthe ovaries and tubes, and I have seen some continueto grow, and one to be extruded from the os uteri twoyears after removal of the ovaries and tubes, thetumor having become a large polypoid growth, andthe woman had lost her ovaries unnecessarily twoyears before. I think we may dismiss this plan oftreating fibroids by removal of the ovaries and tubesas uncertain and unreliable. As I have said before,it does not seem necessary to enumerate all the sur-geons who have contributed to the literature of thetreatment of fibroid tumors. In the United StatesMartin, Dudley, Gordon, Baer, Baldy, Byford, Kelley,Edebohls, Polk, Price, Krug and others have reportedexcellent work and intelligent practical measures. InGermany, besides Schroeder, Hager, Kalteubach andmany others have written on this subject. Themethod which I have gradually, and independently,come to use is nearly like the operation called theSchroeder-HofEmeier method, but it removes moreof the uterus and is more simple in the application ofthe sutures. So far as lam concerned, it is the out-come of my work and experience during the pastthirteen years, and I am satisfied with it, though Ihope to improve upon it.

There are four principal methods of removing thetumor and treating the pedicle. The intra-peritoneal,first described by Schroeder; the extra-peritoneal,Koeberle and Pean; complete removal of all uterinetissue, first, I think, described by Eastman; and themethod of vaginal fixation described by Byford. Themethod of treating these tumors by ligature of theuterine arteries from the vagina, recently proposed byFranklin H. Martin, must not be omitted, and bids

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fair to be useful. I have long ago given up the extra-peritoneal treatmentby means of the wire and dcraseur.It has always seemed to me unsurgical and clumsy.Indeed, in many cases it would be impossible to getthe wire around the tumor until it had been enucleated,and by that time it would have been so nearly re-moved that one had better tie the uterine arteries thancompress them by the wire, and then cut off the tumor,sewing the peritoneum together over the stump.

Such a case I lately operated on in a woman fifty-eight years old. Her physician, Dr. A. D. Sinclair,had known of the presence of the tumor for elevenyears, and she was sure it had increased in size rapidlyduring the past four months. The abdominal wallswere thick with fat, and the tumor felt very elastic,more like an ovarian than like a uterine tumor. Onopening the peritoneum the tumor was seen to beuterine, and could not be lifted out of the abdomen.It had grown from the posterior part of the neck andbody of the uterus and the intestines were incorporatedwith the peritoneum on its under surface and its upperend; that is, they lay in the peritoneum, which formedthe capsule. There was no other way to get thistumor out but to make an incision through its perito-neal covering at its upper side and peal the peritoneum,with the intestines, back. In doing this the left ureterwas laid bare for a large part of its length, and wascarefully dissected from the tumor. If I had pinchedup the tumor in the wire of an ecraseur, I shouldeither have enucleated it unintentionally or I shouldhave included some part of the bowel or of the tor-tuous ureter in the noose. Or suppose that I hadcarefully enucleated the tumor before the applicationof the wire, I should only have had the neck left to beconstricted ; and how much more surgical, neat anddexterous to divide this, after ligature of the uterine

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arteries, and turn it out and cover the back of thestump with peritoneum, making the treatment of thestump extra-peritoneal, than to encircle it with a wirenoose and transfix it with a long pin and straddle theabdominal wound with the pin, leaving the stump andthe neck to slough away in two or three weeks, insteadof having an abdominal wound with no break in itscontinuity. The convalescence is surprisingly rapid inmany of these intra-peritoneal cases. In one case itwas difficult to persuade a patient to remain more thantwo weeks after the operation. I am sure that thetreatment by the wire ecraseur will soon be whollyabandoned.

I prefer the intra-peritoneal treatment, so called,though it is really extra-peritoneal. The method whichI follow in removing a fibroid tumor is the following :

The patient is placed on a liquid and farinaceous dietfor thirty-six hours before operation; the pubes areshaved; the abdominal walls are rendered aseptic bymeans of a hot bath, soap and water, ether and bi-chloride solution, and are covered with a bichloride-of-mercury dressing at least twelve hours before theexpected time of operation, and this is changed imme-diately before the operation ; the vagina is thoroughlydouched with sublimate solution, after being moppedover with soap and water to get rid of the grease.The bowels are opened and the rectum thoroughlyemptied. Everything to be used in contact with thepatient or the operator and his assistants is thoroughlysterilized, and the patient is wrapped in a sterilizedflannel suit made out of a large, thick blanket, eitherin one piece or in two pieces like pajamas. This wassuggested to me by my first assistant, Dr. Edward A.Pease, and is one of the causes of success. It pre-vents any lowering of the patient’s temperature, andkeeps her warm during the operation and afterwards.

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I regard this as one of the important procedures inthese cases. The legs and arms of the wrap aresewed up at the ends, and the abdominal portions canbe tied together with tapes, and loosened and separatedfor the purpose of making the incision in the anteriorabdominal parieties. There is no place for the exter-nal air to get in, except while the abdomen is open.As I have said before, this flannel garment has beensterilized, and so have the sheets, towels, ligatures,instruments, etc., used in the operation. The patientis placed in the Trendelenberg position. Indeed, with-out this position the intra-peritoneal removal of fibroidsin a satisfactory manner would be almost impossible.The incision is now made of the required length andthe tumor is delivered at once, if free from adhesions,by means of the corkscrew, or by any method oftraction which seems most easy. A piece of gauzespread over the tumor is found very convenient inpreventing it from slipping away from the hands ofthe operator. A large piece of gauze is now put inthe abdomen over the intestines, and the sides of theincision above the tumor are often fastened togetherby catch-forceps or by a temporary stitch to preventthe intestines from protruding and to keep them cleanand warm. The tendency of the bowels to protrudevaries in different patients. In most cases the intes-tines lie still and quiet. In others they seem toleap out of the abdominal cavity whenever they geta chance. If in the process of lifting the tumor outof the abdomen adhesions are discovered, it is best tosecure them in some way or to pass an elastic ligaturearound the neck of the tumor or of the uterus to pre-vent hemorrhage. This last procedure is rarely nec-essary, and I have never done it for this purpose.

When the broad ligaments are seen, I usually tiethe left one first, passing the ligature low down and

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close to the uterus by means of Cleveland’s needle,being most careful not to perforate the bladder; thenI tie another ligature about an inch further away fromthe first towards the ovary and beyond the tube, orbeyond the ovary and the tube, and divide betweenthem. The tube, if left intact on the uterine side,prevents infection from a source to which the patientwould be exposed if the tubes were opened. Ileave the broad ligaments as long as possible, sothat my seam over the stump when the operationis finished will be a short one. I do not carewhether the ovary is tied off or not, nor do I neces-sarily remove it, for it is well supplied with bloodfrom the ovarian artery, and will not slough when itsuterine connections are cut off, and in fact, may bewell enough nourished by adhesions ; besides, if it re-mains, perhaps the physiological symptoms, which areoften annoying after removal of the ovaries and uterus,the so-called “ heat flashes,” etc., may not occur ifthe ovaries are left. For the ovaries are the reigningpowers in the generative organs. The expressionshould be, “ The ovaries and their appendages,” not“ the uterus and its appendages.” The uterus andvagina are simply channels for the nourishment andpassage of the ovum and fetus, the product of theovary, and serve to expel the infant into the world.The vagina may be wanting or the uterus may bewanting, but their absence does not imply that of theovaries. If the latter, however, are wanting, the otherorgans, I believe, always are.

I now go through the same process on the rightside, and then make a circular incision through theperitoneal covering of the uterus in front about twoinches above the outline of the bladder wall, which canusually be plainly made out by sight without passing asound into the bladder, and the same distance above

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the rectum behind, the two incisions meeting on eitherside where the broad ligaments are tied, exactly asone would make a circular incision for an amputationof the thigh. These peritoneal flaps I then turnback, by the aid of this little spade-shaped instrument,which is a copy of a periosteum retractor in our caseof instruments for cerebral surgery at the Massachu-setts General Hospital, or else I use a duckbill-shapedblunt dissector, or my fingers. By not getting be-neath the peritoneum into the muscular tissues of theuterus the separation is easy and bloodless, but if atall deep it is difficult and hemorrhagic. The uterusabove the internal os in now denuded of its peritoneumand is ready to be divided. I then feel for the pulsa-tion of the uterine arteries; and if I find them easily(and they are quite superficial), I tie them by passinga ligature of silk around them with an aneurism needle,each one separately ; but if I do not feel them easily,or if there is a hemorrhage going on, from my flapshaving been made too thick, I encircle the uterus atthe denuded point with a strong, small, solid cord ofrubber, and having tied it securely, I cut the tumorand uterus away, and later secure the uterine arteriesat my leisure.

I now trim away the uterine tissue by a slantingcut in front and behind, the apex being at about thelevel at which the uterine arteries have been tied. Icauterize very thoroughly the uterine cervical canalat once, as soon as it is opened, with Paquelin’s cautery.I always pass the point through the mouth of theuterus well into the vagina and allow it to remain thereseveral seconds. A cauterization must be so thoroughthat the opening remaining will be large enough to actas a drain for the sloughing which always follows ahot iron, otherwise the external os may get occludedby the swelling (which naturally follows any injury to

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living tissues); and infection from the sloughing mu-cous membrane, might work its way back and contam-inate the stitches by which the abdominal end of thestump is closed, and perhaps also the space lying be-tween the stump and the peritoneum. One of the ad-vantages of the closing of the peritoneum is that evenif this blind space does get infected and an abscess isformed, the peritoneal cavity is not infected, and onlya localized collection of pus is formed which may openspontaneously or be opened from Douglas’s cul-de-sac.This I have never been obliged to do, though natureopened such an abscess for me once. There was gooddrainage, however, and with hot vaginal douches thetrouble soon ceased.

Next I sew the muscular walls of the neck togetherby a continuous suture of silk over the cervical canal,so as to shut out the neck from the abdominal cavity.In sewing the sides of the stump together, it is impor-tant that the silk be put through healthy tissue andnot allowed to pass through the tissue which has beencauterized, as this must slough away, and in this waythe silk may get infected and cause an abscess or adischarge from the ligatures.

I then sew the peritoneal flaps together by a lightcontinuous suture over the stump. I always use fineEnglish braided silk, No. 4, for this suture I do notdare trust to the aseptic qualities of catgut. You willsee that although this method is called intra-peritonealit is really extra-peritoneal, even more so than theplan by which the neck is constricted by the wire andheld outside the skin of the abdomen by a pin acrossthe abdominal wound. I next turn my attention tothe ovarian and round ligament stumps and tie theovarian artery again separately. If the ovaries havebeen removed in whole or in part, I decide whether toremove them more completely or to leave them. There

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is now a sutured line running across the lower partof the pelvis, and, if there is no oozing, the abdomenis emptied of the sponges and pieces of gauze whichhave been put into it, the patient is lowered into ahorizontal position, and the intestines descend to theirnormal place; the omentum is, if possible, spread overthem and the abdominal wound is closed with silk-worm-gut without drainage.

The flannel suit is left upon the patient for twenty-four hours or more, according as seems best and mostfavorable. The convalescence is like thatafter simpleovariotomy. The patient is generally up and abouton the fourteenth day, and goes home by the end ofthe third week. This rapidity of convalescence is agreat contrast to that following the treatment of thepedicle by the clamp. In the latter case convalescenceis slow. The wire comes away sometimes as late asthe third or fourth week, and the slough beyond thewire a week or two later; the abdominal wound isleft with a depression at its lower part, which gradu-ally, in the course of a month, fills up with granula-tions and rises more or less to the level of the surround-ing skin. Something of the depression remains per-manently, and this spot where the stump has comeaway, frequently becomes the seat of hernia.

I do not believe that there is much difference in themortality between the extra- and intra-peritoneal(so-called) methods, success depending more on asepsisthan on method; but if there is any difference, itwould seem to be in favor of the so-called intra-peri-toneal treatment. The whole success of these opera-tions depends upon perfect asepsis combined with ex-perience in abdominal surgery, a kind of surgery whichcannot be taught, but must be learned.

During the last eighteen months I have removed 26fibroid tumors by this method in my private practice.

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There has not been a single case of septicemia. Onepatient died twelve hours after operation, of shock, lossof blood from separated adhesions and diffuse nephritis(Whitney), the method of the operation having nothingto do with the result. All of the others (25 in num-ber) recovered.