CHAPTER V

HYSTERECTOMY AND MYOMECTOMY

_Hysterectomy is the name applied to the surgical operation for the removal of the uterus._

=Indications.= Hysterectomy is mainly required in the radical treatment of fibroids and malignant disease (carcinoma, sarcoma, and chorion-epithelioma). It is occasionally required for injury, and certain morbid states due to acute and chronic sepsis; and for a condition but little understood, termed generically fibrosis. Hysterectomy is also carried out for such conditions as diffuse adenomyoma of the uterus, hæmato-metra, tuberculous endometritis, and on rare occasions for chronic inversion of the uterus and inveterate dysmenorrhœa.

The presence of fibroids in the uterus is a common cause for which hysterectomy is required, and the history of this operation is full of interest.

The uterus may be removed by two methods. In one, access is obtained to the uterus through an incision in the belly-wall; this is termed abdominal hysterectomy. In the other, the whole uterus is extirpated through the vagina, and on this account it is termed vaginal hysterectomy or colpo-hysterectomy.

The abdominal method of removing the uterus may be performed in two ways:--

In one the body of the uterus and a portion of its neck is removed; this is called subtotal hysterectomy (or supravaginal hysterectomy). In the other the body of the uterus and the whole of its neck are excised: this is total hysterectomy (or panhysterectomy). The ovaries and Fallopian tubes may, or may not, be removed, according to the disease for which the operation is undertaken. This is a matter which will receive ample consideration later on (see p. 56).

For the satisfactory performance of abdominal hysterectomy the Trendelenburg position is necessary.

SUBTOTAL HYSTERECTOMY

The abdomen is opened by the median subumbilical incision; but when the operation is performed for the removal of large tumours it will frequently require extension above the umbilicus. The operator should never allow himself to be embarrassed by a small incision. As soon as the peritoneal cavity is reached, the surgeon introduces his hand and carefully makes out the nature of the case, the presence or otherwise of adhesions, other tumours, and the relation of the fibroid to the uterus, and determines whether it is impacted in the pelvis. The uterus is then carefully lifted out through the incision, or drawn out with the assistance of a volsella; the intestines and omentum are isolated from the pelvis with a large warm dab.

In a simple case the broad ligaments are seized with hæmostatic forceps; if the ovaries and tubes are healthy and the surgeon wishes to preserve them, the forceps are applied between the ovary and the uterus; but if they are obviously diseased and must be sacrificed, the forceps are applied to the broad ligaments near the brim of the pelvis beyond the outer pole of the ovary. In some instances the round ligament of the uterus can be seized with the same forceps, but in many cases it is necessary to clip it separately. It is an advantage to secure the round ligament at this stage, for the forceps controls its artery and prevents the stump of the ligament unduly retracting the peritoneum. The broad and round ligament on each side are divided, and the uterine artery is exposed on each side of the uterus and caught with forceps: a peritoneal flap is then fashioned on the anterior wall of the uterus at its junction with the neck, taking care not to injure the bladder; and a similar flap is cut on the posterior wall. The uterus is then detached at a point well below the junction of the cervix with the body of the uterus: if the forceps are correctly applied to the vessels the detachment of the uterus is an almost bloodless proceeding: a small vessel here and there will perhaps require the application of a pair of forceps.

The principle involved in this part of the operation may be explained by reference to the diagram (Fig. 9). The blood-supply of the uterus follows four routes; two of these are the ovarian arteries which traverse the broad ligaments to reach the cornua of the uterus, where they anastomose with the terminations of the uterine arteries; the latter come into relation with the uterus near the junction of the body and cervix, and then ascend the sides of the uterus to the cornua. No large vessels are found on the anterior or posterior surface of the uterus. An arterial twig runs along the round ligament, bringing the ovarian artery into relation with the deep epigastric artery. If the surgeon thoroughly appreciates the distribution of the ovarian and uterine vessels he will at once perceive that if the four forceps are properly applied to the vessels the blood-supply is under absolute control: indeed, in many cases a subtotal hysterectomy can be performed without the loss of more than an ounce of blood. When the broad ligament is clamped and detached there is a spurt of blood from the uterine cornu which lasts until the corresponding uterine artery is caught with the forceps, and the cessation of the bleeding at the uterine cornu is a sign that the artery is securely clipped. It must be remembered that with a small tumour in the uterus the vessels follow their normal courses and can be easily found, but when the uterus is deformed by huge tumours, the vessels are not so easily seen, and they are of large size and give rise to furious bleeding when divided. In dealing with large and vascular uterine fibroids another factor has to be reckoned with, namely, the enormous veins in the pampiniform plexus, interspersed with lymphatics which in some cases are as thick as the index-finger; it is not an uncommon thing to meet with lymphatics in this situation a centimetre in diameter and filled with straw-coloured lymph.

The surgeon now secures the vessels. The ovarian pedicles are transfixed and ligatured with silk as in ovariotomy: the round ligament is usually included in the ovarian pedicle. It occasionally happens that a fibroid situated near the uterine cornu will grow in such a manner that it widely separates the ovarian ligament, the Fallopian tube, and the round ligament from each other as shown in Fig. 10. In such a condition it is impossible to save the ovary without risk, and also inadvisable to attempt the inclusion of the round ligament in the pedicle containing the ovarian vessels. In these circumstances the round ligament is easily secured by a mattress suture, which should include both layers of the corresponding broad ligament.

When the surgeon decides to leave an ovary and the corresponding Fallopian tube, these structures are carefully examined to determine if they are healthy and free from any suspicious fluid. _When the endometrium is septic or cancerous both ovaries and tubes should be removed._ When the surgeon decides to leave an ovary and its corresponding Fallopian tube, he should take care in securing the ligatures to include the ligament of the ovary: it is very liable to slip out of the encircling loop of silk. It is often convenient to include the round ligament of the uterus in the pedicle, but it is not a disadvantage when it is tied separately.

The uterine arteries are ligatured with thin silk; these vessels as they run up the sides of the uterus are accompanied by veins, so that there is a vascular tract at the point where the cervix is divided. If after the uterine vessels are secured there is oozing from these veins, it is easily controlled by a mattress suture. This kind of suture is so useful that the mode of inserting it may be given in more detail. In the diagram (Fig. 11) the silk is represented in position before it is tied, and in that particular instance it is represented as being passed through the peritoneal flaps from before backwards, and this is usually the most convenient route; occasionally the reverse direction is easier. It will be noticed in the diagram that this suture not only controls oozing from the tissue in the immediate neighbourhood of the uterine vessels, but it also embraces the main vessels, and thus serves as an additional security against hæmorrhage; it also brings the peritoneal flaps into apposition.

As soon as the oozing of blood has been controlled, the cervical canal is examined to ascertain if it be free from polypi or cancer. Should the condition of the cervix be in the least degree suspicious of cancer it must be extirpated. When it is healthy, then the flaps are brought together by one or two interrupted sutures, and the edges more carefully approximated by a continuous suture of thin silk. In suturing the flaps it is necessary to avoid puncturing the bladder, which is quite close to, and often forms part of, the anterior flap. Care must also be taken in passing the needle (especially when it has sharp edges) in the neighbourhood of the stumps of the uterine arteries, or they will be pricked, and then free bleeding will cause delay in the operation.

When this operation is properly performed, there should be no projecting stump on the floor of the pelvis; the sutured edges of the peritoneum merely appear as a thin line below the base of the bladder.

The pelvis is now cleared of blood and clot; the dabs and instruments are counted, and it is also useful to examine the condition of the vermiform appendix, and if grossly diseased it should be removed.

The abdominal incision is then sutured in the way described on p. 9.

TOTAL HYSTERECTOMY

This operation differs from the preceding in the fact that the neck of the uterus is removed as well as its body. The abdomen is opened in the usual way and the uterus is withdrawn from the abdomen and the arteries controlled by forceps, and the broad ligaments divided exactly as in the case of the subtotal operation. Unless the uterus be very big it is drawn well out of the abdomen and the bladder peeled off its anterior aspect. The surgeon then feels for the extremity of the cervix and opens the vagina with the scalpel and carefully detaches it from the neck of the uterus, taking great care to keep close to the cervix in order to avoid wounding the bladder or the ureters. As soon as the uterus is detached, the cut edge of the vagina is seized with the volsella to prevent it retracting. In some instances the body of the uterus may be removed as in the subtotal operation, and the cervix detached separately; occasionally the surgeon begins his operation with the intention of performing the subtotal operation, but finds the cervix unhealthy or cancerous, and removes it.

As soon as the uterus is removed and all bleeding under control, then the blood-vessels are secured with ligatures; the ovarian artery and vein are secured on each side in the usual manner. The chief point in this operation is the method of dealing with the vaginal opening. In the subtotal operation the vessels concerned in the stump are the uterine arteries, but in the total operation the territory of the vaginal arteries is invaded, and these vessels are apt to bleed when the patient is returned to bed, unless care is taken to secure them in the course of the operation. The parts which require most attention are the lateral angles in the immediate neighbourhood of the uterine arteries; these angles may be secured by a mattress suture involving the anterior and posterior wall of the vagina; any oozing on the anterior or posterior wall is commanded by a mattress suture involving these walls separately, so as not to completely close the vaginal opening. Bleeding from the cut edges of the vagina may also be readily controlled by means of a continuous suture of thin silk. The peritoneum is sutured over the cut ends of the vagina, so that when the operation is completed a thin seam is seen lying under the base of the bladder.

In cases where the uterus is removed for septic conditions, such, for example, as an infected or gangrenous fibroid, or when cancer of the corporeal endometrium and a submucous fibroid coexist, I modify the last stages of the operation. After the ovarian and uterine arteries are ligatured, the cut edges of the vagina are secured in the following way: the cut edge of the peritoneum covering the bladder is stitched to the cut edge of the anterior wall of the vagina, and in the same way the peritoneum in relation with the posterior vaginal wall is stitched to the corresponding cut edge of the vagina. The flaps at the lateral angles of the vaginal opening are drawn together with a suture and the intervening segment is left with merely the cut edges in apposition: this affords a route for the escape of pus if required.

Whether the peritoneum is sutured over the vaginal opening, or whether the edges are merely left in apposition, the recesses of the pelvis are thoroughly cleared of fluid and clot. The dabs and instruments are counted, and the wound sutured as recommended on p. 9. In septic conditions the abdominal incision should be closed with a single row of through and through sutures. Before the patient leaves the operating table it is useful to examine the vagina and mop out any blood which has found its way there in the course of the operation. It is also useful to pass a glass catheter and withdraw any urine that has accumulated during the operation.

If there is evidence of free oozing it is most likely to come from the cut edges of the vaginal wall in a case of total hysterectomy: under such conditions it is easy to apply a pair of fenestrated forceps to the oozing area and leave them on for thirty-six hours. They will cause the patient trifling inconvenience. Care must be taken not to fix the blade too far on the anterior flap, or it will lead to subsequent sloughing of the bladder.

When there is free oozing of blood from the cervical canal after subtotal hysterectomy, it is easily and safely controlled by applying a pair of fenestrated forceps on each side of the cervix, but not too deeply, or the ureters may be nipped. These should be left on for thirty-six hours.

The details of the operation set forth in this account refer to a simple or uncomplicated hysterectomy, and under these conditions it cannot be described as a difficult operation to any surgeon accustomed to abdominal operations, but the complications not infrequently met with in connexion with uterine fibroids are occasionally very formidable, and tax the skill and resource of the boldest; _e.g._ fibroids which are inflamed and adherent to the colon, rectum, or small intestines; fibroids associated with unilateral or bilateral pyosalpinx, or a suppurating ovarian cyst incarcerated in the pelvis by the enlarged uterus; fibroids complicated by cancer in the neck of the uterus; or a cervix fibroid firmly incarcerated in the pelvis by a big fibroid in the fundus of the uterus, and pushing the bladder upwards in front of the tumour.

=Cervix fibroids.= The operative treatment of this variety needs separate consideration because these tumours do not lend themselves to any routine method.

When the uterus with the tumour in its cervix can be raised out of the pelvis far enough to allow the necessary manipulations, then total hysterectomy can be performed easily and quickly. Occasionally the tumour is wide and so fixed in the pelvis that it will be necessary to split the uterus longitudinally and to enucleate the fibroid from its bed; then an ordinary subtotal or total hysterectomy can be carried out. The enucleation of a large impacted cervix fibroid requires to be conducted carefully, without undue display of force, or so much shock is produced that the patient’s life will be placed in the gravest peril.

=On hysterectomy when the uterus is double.= Fibroids and cancer arise in malformed uteri, as well as in those of normal shape (Fig. 13). When the body of the uterus is double (bicornate) and the surgeon stumbles upon it in the course of a pelvic operation he may be puzzled if he is not familiar with the anatomical conditions associated with this malformation.

When the body of the uterus is bicornate the rectum lies in the middle line of the pelvis, and a median vertical fold of peritoneum, the _ligamentum vesico-rectale_ passes, from its anterior aspect through the gap between the uterine cornua to become continuous with the peritoneum covering the posterior surface of the bladder (Fig. 14). That portion of the vesico-rectal ligament which lies between the rectum and the neck of the uterus divides the recto-vaginal fossa into a right and a left half. This peritoneal ligament requires careful treatment, or the surgeon may accidentally open the rectum or the bladder. In closing the peritoneum over the cervical stump it is sometimes necessary to bring the edges of the abnormal fold into apposition vertically by a continuous suture.

In a case of this kind in which I performed total hysterectomy for cancer of the neck of the uterus the extensive peritoneal connexions were somewhat troublesome, and when the uterus was removed it seemed as if the floor of the pelvis had been stripped of its serous covering. The bifid nature of the uterus had been anticipated before the operation, as an imperfect vertical septum was known to exist on the posterior vaginal wall. The patient made an excellent recovery.

Experience teaches that bicornate uteri cause more difficulties in diagnosis than in technique, but the presence of the vesico-rectal ligament would probably bar the removal of the uterus by the vaginal route. The existence also of a median longitudinal septum, partial or complete, in the vagina would be another difficulty.

=Mortality.= In order to give some idea of the great improvement which has taken place in the operation of abdominal hysterectomy for fibroids in London the following figures will be found of great interest.

In the year 1896 the results of abdominal hysterectomy for fibroids in the hospitals of London may be inferred from the following table:--

St. Bartholomew’s 7 with 3 deaths St. Thomas’s 5 " 2 " St. George’s 1 " 0 " Middlesex 6 " 1 " University College 3 " 0 " Samaritan 17 " 4 " Soho (for women) 1 " 0 " Chelsea Hospital for Women 9 " 1 " __ __ 49 " 11 "

In these hospitals and the New Hospital for Women the returns in 1906 are as follow:--

St. Bartholomew’s 26 with 4 deaths St. Thomas’s 40 " 2 " St. George’s 8 " 0 " Middlesex 50 " 0 " University College 21 " 1 " Samaritan 37 " 2 " Soho (for women) 60 " 1 " Chelsea (for women) 80 " 1 " New (for women) 26 " 0 " ___ __ 348 " 11 "

The returns during 1906 and 1907 from my service at the Chelsea Hospital for Women and the Middlesex Hospital, as verified by the Registrars, were 101 abdominal hysterectomies for fibroids; all the patients recovered. Of these 101 operations, 7 were total and the remainder subtotal hysterectomy.

=The risks of abdominal hysterectomy.= The dangers of hysterectomy are those common to cœliotomy, such as sepsis, peritonitis, shock, and the risks of the anæsthetic. There are certain special dangers, such as hæmorrhage; injury to the vesical segments of the ureters, and especially the bladder; injury to the intestines, especially the rectum; acute intestinal obstruction; thrombosis and pulmonary embolism. These risks and dangers are considered fully in their relation to all forms of abdominal gynæcological operations in a special chapter (see Chap. XI).

Among the rarer forms of death after hysterectomy may be mentioned acute perforation of the stomach or the small intestine, cerebral hæmorrhage, lobar pneumonia, thrombosis of the right auricle, embolism of the femoral artery ending in gangrene of the leg, suppression of urine, and acute mania. These are fatal conditions which follow any major operation in surgery, and have no special connexion with hysterectomy.

The removal of the uterus has been rendered so safe that even in advanced age it has been employed with success, as the subjoined table shows:--

TABLE OF CASES IN WHICH HYSTERECTOMY WAS PERFORMED ON WOMEN OF SEVENTY YEARS AND UPWARDS.

-----------+------+----------------+---------+----------------------- _Reporter._|_Age._| _Nature of |_Result._| _Reference._ | | Operation._ | | -----------+------+----------------+---------+----------------------- Bland- | 73 |Subtotal for | R. |_Trans. Obstet. Soc._, Sutton | | Fibroid 28 lb.| | 1900, xli. 300. Stewart | 70 |Subtotal for | R. |_Australian Med. Gaz._, McKay | | Fibroid 19 lb.| | 1907, 14. Bland- | 83 |Vaginal Hyst. | R. |_Trans. Obstet. Soc._, Sutton | | for Villous | | 1906, xlix. 46. | | disease. | | | | Fig. 15. | | Malcolm | 74 |Total for | R. |_Brit. Med. Journal_, | | Fibroids. | | 1907, ii. 1571. -----------+------+----------------+---------+-----------------------

ABDOMINAL MYOMECTOMY

_Under this general term it is usual to include operations for the removal, through an abdominal incision, not only of pedunculated subserous fibroids, but also sessile and interstitial (intramural) fibroids of the uterus._

The earliest operations of this kind were performed by Spencer Wells (1863); but little attention was given to this matter until the advantages of abdominal myomectomy were strongly advocated by A. Martin (1880) and Schroeder (1893). The operation has been practised by many surgeons and gynæcologists imbued with conservative ideals in regard to the uterus. In its early days the operation was attended with a very high mortality, but the great improvements in hysterectomy have limited very materially the scope of abdominal myomectomy.

ABDOMINAL MYOMECTOMY AND ENUCLEATION FOR FIBROIDS

_Abdominal myomectomy._ This signifies the removal of one or more pedunculated subserous fibroids through an incision in the abdominal wall, preserving the uterus, Fallopian tubes, and the ovaries.

_Abdominal enucleation._ In this operation a sessile fibroid is shelled out of its capsule: the uterus, ovaries, and tubes are preserved.

_Hysterotomy._ In this operation a submucous fibroid is removed, through an incision in the wall of the uterus, which opens the uterine cavity.

The preliminary steps for each of these procedures is the same as for ovariotomy, and the Trendelenburg position is of great advantage.

After opening the abdomen the intestines are carefully protected by a warm dab, and the tumour carefully examined.

When the stalk is narrow it may be transfixed and secured with silk thread, like the pedicle of an ovarian cyst. When the pedicle is short and broad the tumour should be shelled out of its capsule, and any obvious blood-vessel is easily secured with forceps and ligatured with silk. The opposite flaps of the capsule are brought into apposition by mattress sutures, and the redundant portions of the capsule cut away and the free edges carefully brought together by a continuous suture of thin silk.

When a fibroid is embedded in the wall of the uterus, the tumour is exposed by cutting through its capsule and seizing it with a volsella; as a rule, it shells out quite easily. This is followed by free bleeding. The vessels are then seized with forceps and ligatured with thin silk. In order to completely control the oozing, mattress sutures are passed through the wall of the capsule on each side, their number varying with the size of the tumour.

In some instances a uterus contains ten or more fibroids, and each must be enucleated and the capsule secured with ligatures, as described above.

Sometimes the oozing is difficult to control, and the surgeon sutures the edges of the capsule to the lower angle of the incision, and stuffs the cavity or bed of the tumour with gauze.

In removing a large submucous tumour through an incision in the wall of the uterus, the surgeon necessarily opens the uterine cavity (hysterotomy). After controlling the bleeding the walls of the uterine incision are closed, as in Cæsarean section.

In many instances in which the surgeon attempts to carry out myomectomy or enucleation, he has such difficulty in controlling the oozing that he is driven to remove the uterus.

It is admitted by most writers that the ideal method of dealing with fibroids requiring removal by cœliotomy is to remove them either by ligature or by enucleation. In actual practice this ideal operation of removing the tumours and leaving the uterus and ovaries intact can only be carried out in a small proportion of cases, probably in less than 10 per cent., and it is fair to state that enucleation and hysterotomy are often more troublesome and serious operations than hysterectomy; also the preservation of the uterus is not always an advantage to the patient.

When a woman is submitted to hysterectomy for fibroids we can assure her that the tumours will not recur, but after a myomectomy or enucleation in a woman in the reproductive period of life we cannot give her this assurance, for she may have in her uterus many ‘seedlings’ or ‘latent fibroids’ and one or several of these may grow into formidable tumours.

There are three conditions in which myomectomy and enucleation are legitimate procedures:--

1. A young woman contemplating marriage, or a married woman anxious for offspring, if her tumour be single and admits of myomectomy or enucleation, may have her uterus spared. Although I have carried out these measures on many occasions, I only know of five patients who have subsequently borne children.

2. Occasionally in pregnancy (see p. 82).

3. Myomectomy is a very safe undertaking in patients at, or after, the menopause, where a stalked fibroid gives trouble by twisting its pedicle, or by shrinking to such a size that it falls into the true pelvis and becomes impacted; or, more rarely, the pedicle of such a tumour entangles a loop of small intestine and obstructs it.

In order to give the matter a statistical basis I have drawn up an analysis of ninety-five consecutive cases of myomectomy and enucleation out of my practice, with the subsequent history of some of the patients. This experience covers a period of twelve years.

Of these ninety-five patients three died as the result of the operation--two from pneumonia in the fourth week after operation, and one a few days after operation: in this case there is reason to believe that the tumour was complicated with cancer of the body of the uterus.

Six of the women were submitted to myomectomy during pregnancy, and in four cases the operation was undertaken under the impression that the tumour was an ovarian cyst which had undergone axial rotation. These cases occurred in the days before I recognized that ‘red degeneration’ of fibroids complicating pregnancy caused them to be painful and tender (see p. 78). In one patient this complication was clearly recognized. In the sixth patient the tumour was regarded by some capable gynæcologists, who examined her, as a tubal pregnancy complicating a gravid uterus. Five of these patients went to term and were delivered of living children. The sixth miscarried two months after the myomectomy.

Of the ninety-two successful myomectomies, five subsequently became pregnant and had living children, but in each instance the fibroids were subserous. I have not known a patient to become pregnant after abdominal myomectomy for a submucous fibroid, large or small. In calculating the probability of pregnancy from these statistics it must be mentioned that the patients fall into three categories:--

1. Forty women were in the child-bearing period of life and married; many of them were multiparæ.

2. Twenty were single women and probably capable of bearing children in a favouring environment.

3. The remainder were spinsters or barren wives.

A significant feature in the after-history of ten of these women is the fact that some years later other fibroids grew in the uterus, and hysterectomy became a necessity on account of menorrhagia in seven of them; of these, two died from the operation, which was difficult and tedious. One patient was operated upon two years after the myomectomy, and had borne a child in the interval, and the other seven years.

The last fact to mention is that one patient, from whom a submucous fibroid had been enucleated from the cavity of the uterus (hysterotomy), died four years later from cancer arising in the body of the uterus (see p. 51).

Olshausen has recently considered this question, and indicates that the chief objection to the abdominal enucleation of uterine fibroids is its high mortality.

He furnishes a table of 563 cases, collected from twelve operators, including himself; of these 59 patients died, representing a mortality of 10.5 per cent. Olshausen, in the years 1900-5, performed enucleation on 124 patients with 14 deaths. Eight of the patients subsequently came under notice with recrudescence of fibroids. Christopher Martin has performed abdominal myomectomy 73 times with 1 death.

The question of myomectomy, when fibroids complicate pregnancy and labour, or give trouble after labour, is considered in detail on p. 78.

REFERENCES TO REPORTS OF HYSTERECTOMY PERFORMED FOR FIBROIDS IN MALFORMED UTERI

BLAND-SUTTON, J. Fibroids in a Unicorn Uterus. _Clin. Journ._, Lond., 1901-2, xix. 1.

BLAND-SUTTON, J. Case of Fibroids in both halves of a Bicornate Uterus. _Proc. R. Soc. of Medicine_, 1908. Obstet. and Gyn. Sect., ii. 95.

CZERWENKA. Uterus bicornis unicollis, &c. _Centralbl. f. Gyn._, Leipz., 1900, xxiv. 207.

DORAN, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous Subject. _Brit. Med. Journ._, 1899, i. 1389.

GOW, W. J. Cystic Intraligamentous Myoma with Double Uterus. _Trans. Obstet. Soc._, Lond. (1898), 1899, xl. 134.

HEINRICIUS. Ein Fall von Myoma im rudimentaren Uterus bicornis unicollis. _Monatschr. f. Geburts. u. Gyn._, Berl., 1900, xii. 419.

KAMANN. Uterus bicornis unicollis with a Myoma in the Left Horn; Subtotal Extirpation of the Left Horn. _Centralbl. f. Gyn._, 1905, xxix. 795.

MARTIN C. The Ingleby Lectures. On the Dangers and Treatment of Myoma of the Uterus. _Lancet_, 1908, ii. 1682.

OLSHAUSEN, R. In Veits’ _Handbuch der Gynäkologie_, Wiesbaden, 1907, Bd. ii, p. 607.

ROUTH, A. Fibroid of One-horned Uterus. _Trans. Obstet. Soc._, 1888, xxix. 2 and 57, with a good drawing.