WHAT MAY WE EXPECT FROM THE SUBTOTAL HYSTERECTOMY ? By L. M. SZAMEK, m.d. (Vienna) Calcutta (Former Director of the Franenkrankeninstitut, Charite in Vienna) The question, whether subtotal hysterectomy should be regarded as a recognized method of treatment in cases of uterine lesions has not been decided yet. Weibel (1939) brought this topic before the Gynaecological Society of Vienna in 1924 and his conclusions were that this operation should be eliminated entirely because of its many disadvantages and replaced by total hysterectomy. This should be the operation of choice every time, when the uterus has to be removed by the abdominal route. Actually, it should be obvious at first sightthat complete removal of an organ may indicate more surgical judgment than a partial one, and that a stump left behind may have troublesome sequels, particularly the later development of a carcinoma. Therefore, we are not at all surprised that many clinicians have completely discarded subtotal hysterectomy as a worthless operation. But reviewing the literature we find on the other hand that this operation is by no means unanimously condemned. Almost all the Vienna gynaecologists took part in the general discussion, which followed had the Weibel's lecture. I myself (1924) opportunity of expressing an opinion derived from experiences of 268 cases at Latzko's Clinic in Vienna. Summarizing these, I felt authorized to intercede for the maintenance of subtotal hysterectomy because I was in a position to explain the reasons for our having obtained good results by this procedure. I also called special attention to the factors which had brought this operation into discredit; these factors persist to this day and are due to loose indications. Subtotal hysterectomy should be reserved for absolutely clean cases, i.e., cases without any sign of inflammation either in the intra-peritoneal parts of the sexual apparatus or of the cervix. The group of cases in which subtotal hysterectomy is definitely indicated would include condifibroid disease of the tions such as following such as can be uterus, indefinite bleedings ' the term under hemormetropathia grouped rhagica ', particularly when this condition occurs in relatively young women. To this we would

606

further indication pregnancy in women, suffering from progressive tuberculosis of the lungs. The latter formed a considerable proportion of the cases, operated on in Latzko's Clinic, as subtotal hysterectomy was considered to combine most advantageously interruption of pregnancy and permanent sterilization. We used this procedure in preference to Scllheim's socalled minor csesarean section with ligature and partial excision of the tubes, since it relieves the patient of menstrual trouble and loss of blood. This we assumed would be a help to the whole system in its struggle against the fundamental disease. Control examinations, even years later, revealed the fact that the health of these women had improved in a large percentage of cases and that no climacteric troubles had followed, quite apart from the excellent results of the operation itself. By selecting such clean cases only, for subtotal hysterectomy and subjecting infected ones to total hysterectomy, we found that we could reduce incidents of morbidity and mortality to a minimum. It follows, that we could not accept at that time, any more than we do now, the rigorous demand, formulated by AVeibel, that an operation should be discarded, which in our opinion has a definite value, provided that its indications are strictly observed. Considering how frequently these indications are disregarded, we must not be surprised at the increasing percentage of morbidity and even mortality reported from certain sources. Just to mention one example, Newell (DeLee and Greenhill, 1938) stated that subtotal hysterectomy for conditions complicated with pelvic inflammations, including chronic cervicitis, had a much higher mortality than complete hysterectomy with the same complications. We also absolutely agree with the editor of this Year Book that it should be regarded as an insult to surgery, f.i., to cauterize or conize a bad cervix before performing a subtotal hysterectomy, etc. Cases like these should a priori never have been treated by subtotal hysterectomy. When pleading for subtotal hysterectomy there should be obviously some reasonable justification for this. The greater facility of this operation should scarcely be considered an argument in its favour, for a surgeon of skill should not find difficulties in going deeper into the parametrium and removing the cervix along with the fundus. We should emphasize the importance of saving the cervix for a very definite reason. It is evident that by leaving the cervix the adjoining parametrium and the paracervical tissue can also be saved and these form the so-called architecture of the fornix vaginse. There is no doubt that by conserving the normal fornix vaginas cohabitation will in no way be interfered with, whereas the destruction of the anatomical of to lead disturbance architecture may function. add

as a

[Oct., 1939

THE INDIAN MEDICAL GAZETTE

Finally, the circumstance that subtotal hysterectomy may give a lower percentage of morbidity and mortality than total hysterectomy lS one that should be also taken into considerationQuoting the publications of Tyrone (1938); subtotal hysterectomy gives a mortality ?J 1.0 per cent as compared with the 2.2 per cent of total hysterectomy. Dannreuther (1938) quotes a mortality percentage of 1.1 per centOur

own

statistics indicate

a

1.1 per cent mor-

tality. Of course all the aforementioned advantage^ have to be disregarded if it is thought that any real danger might arise for the patient by leaving the cervix behind. These dangers lie in "ie possible formation of a post-operative exudatea near the stump and the later development of carcinoma. Discussing these two points we would like }? state that the dangers of a stump exudate disappeared almost completely as a result of ?lU strict indications which stipulate that there should be no local inflammation. Thus, the incidence of exudates in cases which remaine under observation amounted to a very sma _

figure.

observed consequences of any and the existing exudates were improve^ gravity by means of conservative treatment (diathermy' etc.) in a very short time. These good resm may have also been due, we believe, to certain details of our operative technique. For examp* ' after ligature of the uterine vessels and remoV of the body of the uterus, the cut surface of tP cervix should appear almost white and ^lo? less, so that there is no necessity for any ado tional stitches or ligatures. We avoid a suturing the stump for the purpose of appr?x! to mating its cut surfaces, because we believe to be not only unnecessary but even harmfmAs regards the development of a in the retained cervix, there is no conclusl proof that the removal of the body to the development of a malignant disease, carcinoma does not occur more often in cervix after subtotal hysterectomy than in cervix of a normal woman. For a survey of the percentage of such i*1 ^ dents, only statistics should be considered. ^ is recently afforded by a publication of 0^ Hennington, in which are reported 107 casess ^ carcinoma developing in the stump in 1,667 total 0.57 cent. Um We

never

?

carcino^

predisp08^ "

?

.

hysterectomies, i.e., per tunately the world literature on not at my disposal at present,

.g

this topi? but I do .g t

in assuming that 1 per cent. this is a figure which should not be disregard e n But, considering the fact that patients who been operated on are particularly asked to re for gynaecological controls, we should be am detect early departure from the normal m ^ cervix. After all a secondary operation can (Continued at foot of opposite page) believe that I

am wrong

percentage possibly exceeds

?{ the (iContinued from as 1 radically performed as uterus were still present. therefore say 1 and In conclusion, we ..g merits 1T^ the u subtotal hysterectomy of Upration definite value in benign inflaromation sign no on this Provided that there is ^ ^ stan must It ?r infection. sub indication. treatment, saVing Compared with x~ra^Wqntaa;e has the ad

^^/body

,

,

alteram

hysterectomy

^Compared tees,

with total apart from the ^es^f tality, the so-called archi vaginae. Both these factors play a

Pture

an

f? of the

important part

"woman's sexual life. RefereecES joUrnW. T. (1938)XL1, p. 373. T p. (1938). ^eal Jt)eLee, J. B, and GreentoU, Gj olo0y.

?Dannreuther, V?l-

Su-r0->

1938

^.eBook

le?f. Book oj Obstetrics and ^ Publishers, Chicago. v /ralb?. ^yn" Zentr Szatnek, L. M. (1924). n P p g3G. CVU. ^?2507. de, qijr0 Vol. Tyrone, C. H. (1938). Ann. rh d'e'r Fraue \vJien. W. (1939). Lebrbuch _Weibel, ^^, ?cn vol. 4

II.

Verlag Urban and

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