From a careful study of the question, I have formed the opinion that if a woman with fibroids and concomitant cancer of the neck of the uterus seeks advice on account of hæmorrhage, and the cancer has attacked the vaginal portion of the cervix, the nature of the case will be appreciated. The cases likely to be overlooked are those where the cancer is situated somewhat higher in the cervical canal than usual, so that it is not easily detected by the examining finger, and so low in the cervix that the disease is not exposed when the body of the uterus is amputated in the course of a subtotal hysterectomy. A knowledge of this, as well as the fact that cancer of the cervix is almost exclusively a disease of women who had been pregnant, should make the surgeon particularly careful in performing subtotal hysterectomy for fibroids in women who have had children, in order to assure himself that it is not cancerous.
In addition to the liability of the stump left after subtotal hysterectomy to become cancerous, it is stated by some surgeons that the patient is more liable to intestinal obstruction than after the total operation. This objection is easily met, because a perusal of their writings shows clearly that they do not perform the operation properly. In subtotal hysterectomy, performed according to Baer’s instructions, there should be no stump projecting from the pelvic floor, but merely a thin seam underlying the base of the bladder.
[Illustration: FIG. 16. AN ADENOMYOMATOUS UTERUS. The organ is shown in sagittal section in order to display the great thickening of the endometrium. From a spinster aged 43 years. Two-thirds size.]
I have dealt in detail with these two methods of hysterectomy, because when it can be performed subtotal hysterectomy is, as a rule, a simpler operation than total hysterectomy. There are conditions in which it is imperative to remove the whole of the cervix, especially when the canal is very patulous and perhaps septic; when it is large and hard, or large and spongy; and especially if there is the least suspicion of malignancy in the cervix, or in the body of the uterus.
It must, however, be borne in mind that cancer has attacked the scar left in the vagina after a total hysterectomy (Quénu). At the present time the subtotal method enjoys the greatest favour in London, but it must be remembered that where the total operation is most indicated, it is often difficult of execution. Although I have a decided preference for the subtotal operation, especially in spinsters and barren wives, I have performed total hysterectomy in more than 200 patients, so that I am in no way blind to its merits.