  BY JOHN BLAND-SUTTON, F.R.C.S. (Eng.) Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea Hospital for Women, London CHAPTER I CŒLIOTOMY When the abdomen is opened for the purpose of removing a diseased viscus, the operation receives a specific name, such as nephrectomy, gastrectomy, splenectomy, and so forth. In many instances the abdomen is occupied by a tumour which defies the skill of the surgeon to localize to any particular organ until it is exposed to view through an incision; it is usual to apply the term coeliotomy to an operation of this kind, and it merely implies that the belly is opened by a cut. Coeliotomy is a useful expression, because many abnormal conditions arise in the abdomen which require treatment through an incision in its walls which do not lend themselves to an expressive term, for example, the removal of omental cysts, the evacuation of pus, blood, or the removal of foreign bodies, &c. It is true that a coeliotomy performed on an uncertain diagnosis may become a colectomy, ovariotomy, hysterectomy, &c., and the preliminary step to the performance of the operations to be described in this section is an abdominal incision, or coeliotomy. For whatever purpose a coeliotomy is required in the treatment of diseases of the female pelvic organs, the preparation of the patient and the initial steps are alike; it will therefore be convenient to describe the manner of carrying them out. The preparation of the patient. It rarely happens that an operation is so urgent as to leave little time for a thorough preparation of the patient. It is desirable that the preliminaries should occupy two days at least. During this time the patient is kept in bed and the bowels are freely evacuated, either by calomel at night, with a saline draught in the morning, or by an ounce of castor oil. On the morning of the operation the large bowel is thoroughly emptied by a soap and water enema, care being taken to use soft soap, to avoid producing a pimply eruption known as the ‘enema rash’. It is well known that injuries to the abdominal organs, whether by accident or in the course of a surgical operation, are liable to be followed by septic parotitis. Recent writers attribute this complication to microbic infection of the ducts of the salivary glands (see p. 99); its occurrence may be avoided by including careful cleaning of the teeth among the preliminaries advisable for an abdominal operation. It is such a simple and comfortable ordinance that there is no reason for not following it. The preparation of the skin needs to be very thoroughly carried out. After a warm bath the hair is shaved from the abdomen, pubes and vulva, and the skin is well washed with warm soapy water and swathed in gauze compresses wrung out of a solution of perchloride of mercury, 1 in 5,000. These compresses remain for twelve hours. The abdomen is again washed, and a second compress is applied which remains on until the operation. Occasionally patients object to have the abdomen and pubes shaved. In such cases the hair can be easily removed by a depilatory. I have found a powder prepared according to the following formula useful:— Sodium monosulphide, 1 part; calcium oxide, 1 part; starch, 2 parts; sufficient water is added to make a stiff paste, which is spread over the parts. After five minutes it is washed off by means of a dab of cotton-wool and the skin freely washed with warm water. This preparation is only efficacious when freshly prepared. The washing and application of compresses require care on the part of the nurse, for some patients have skin so tender that it is easily blistered, and a crop of small pustules is a source of inconvenience, and leads to stitch-abscesses. In certain cases over-preparation may be worse than no preparation. When patients are advanced in years it is extremely necessary to protect them from being chilled by undue exposure. It is well to clothe their lower limbs in warm flannel garments or drawers made out of Gamgee tissue. No open doors or windows should be permitted; though in summer this is comfortable to the surgeon it may be disastrous to the patient. In winter the temperature of an operating-room should not be below 65°F. In this way ether pneumonia is best avoided. In operations, such as oÖphorectomy, ovariotomy and hysterectomy, it is the rule not to operate during menstruation; experience has taught me that operations performed during this period are not followed by evil or untoward consequences, and for many years I have disregarded it. Immediately before the patient is placed on the table the bladder should be emptied naturally, or by means of a sterilized glass catheter. In all pelvic operations it is a great advantage to employ nurses who have had a special training in ‘abdominal nursing’. Basins and dishes. All receptacles such as basins, pots, instrument dishes and the like should be boiled. Mere rinsing or washing in warm water is insufficient. Instruments. These should be constructed of metal throughout, as this enables them to be thoroughly sterilized by boiling. Needles and scalpels may be enclosed in perforated metal boxes. Forceps and the handles of scalpels are nickelled, and this keeps them bright. The follow The surgeon should make a practice of employing a definite number of instruments and dabs for all occasions, as it will save him much anxiety in counting them at the end of the operation. During the operation the instruments and silks are immersed straight from the sterilizer in warm sterilized water. Suture and ligature material. The most useful material at present employed in pelvic surgery is silk. This material has a wide range of usefulness, as it is employed to secure pedicles, for the ligature of blood-vessels, and for sutures; it can be obtained of any thickness, and is easily sterilized by boiling without impairing its strength. In abdominal surgery there are four useful sizes, No. 1, 2, 4, and 6, of the plaited variety of silk. The thread is wound on a glass spool and boiled for one hour immediately before use. If any silk is left over from the operation it may be reboiled once or twice without impairing its strength. (The fate of silk ligatures is discussed on p. 117.) Many surgeons employ catgut and hold it in high esteem. I regard it as an unsatisfactory and dangerous material; moreover it cannot be boiled, which is the simplest and safest method of making ligatures sterile. Dabs. Nothing is so convenient for removing blood from a wound as sponges; their absorbent property and softness are excellent, but they are difficult to sterilize; therefore they are highly dangerous, and on this account should be banished from surgery. An excellent substitute is absorbent cotton-wool enclosed in gauze (Gamgee tissue). This material can be cut to any size or folded into any shape, and is easily sterilized by heat, or by boiling, without damage to its absorbent properties. For a coeliotomy six dabs are prepared of various sizes, according to the nature of the case. These are boiled for one hour and then immersed in sterilized warm water and washed from time to time in the course of the operation. I always employ six dabs, then there is no difficulty at the end of the operation concerning their number. The dabs at the completion of the operation are destroyed. Many serious consequences have arisen from dabs and instruments accidentally left in the peritoneal cavity after pelvic operations. This subject is considered on p. 105. The operator should remember that his responsibility in this matter is determined by a decision in a Court of Law. The employment of dry gauze dabs in abdominal operations is ob Gloves. Increasing experience proves that gloves are most valuable in securing freedom from sepsis. It is a very important matter that the surgeon, the assistant, and the nurses who help at the operation should wear rubber gloves boiled immediately before the operation for ten minutes. The wearing of gloves diminishes the mortality of the operation, and minimizes its unpleasant and often dangerous sequelÆ, such as suppuration around sutures, septic emboli, tympanites, and the like. Care must be taken to impress upon all who take part in an operation that it is as essential to thoroughly wash and disinfect the hands before inserting them in gloves as when no gloves are worn. It is also necessary to warn nurses that the smallest hole in a glove renders it useless. To the operator thorough disinfection of the hands is of the highest importance, for he may puncture or tear the gloves during the operation; or a difficulty may arise in the course of it which will render it advantageous for him to remove one or both gloves to overcome it. It is with me a rule that if in the course of an operation it is necessary to remove the gloves, I resume them for the final stages, and particularly for the insertion of the sutures. The use of rubber gloves marks a most important advance in operative surgery. The operating table. In many cases of coeliotomy a table such as is employed for the ordinary operations of surgery answers very well, but for hysterectomy, oÖphorectomy, and similar procedures it is a great convenience to use a table on which the patient can be placed in the Trendelenburg position, that is, with the pelvis raised, and the head and shoulders lowered: this allows the intestines to fall towards the diaphragm and leave the pelvis unencumbered. There are many varieties of tables employed for this purpose. As these tables are made of metal, it is necessary before the table is tilted to fix the patient’s arms parallel with her trunk, otherwise they fall across the edge of the table, and in some instances a troublesome paralysis of the muscles of the upper limb has been the consequence. It is worth while pointing out that most of the examples have happened in the course of long operations (see Post-anÆsthetic paralysis, p. 95). AnÆsthesia. The majority of surgeons employ a general anÆsthetic, such as ether, chloroform, or a mixture of chloroform and ether, in pelvic operations. The most usual practice in London is to render the patient unconscious with nitrous oxide gas and maintain the anÆsthesia with ether. It is a method which has given me the greatest satisfaction. As In exceptional cases pelvic operations such as ovariotomy and hysteropexy have been successfully performed with the aid of intradural injections of a solution of eucaine, novocaine, or stovaine. The incision. The operation-area is isolated by sterilized towels and the pelvis well tilted and so arranged as to face a good light. When the patient is completely unconscious, the operator (standing usually on the right side with the assistant opposite him) freely incises the wall of the abdomen in the middle line between the umbilicus and the pubes (this incision is conveniently termed the median subumbilical incision; its length varies with the necessities of the case, but is usually 7 to 10 centimetres). The first cut generally exposes the aponeurotic sheath of the rectus; any vessels that bleed freely require seizing with hÆmostatic forceps. The linea alba is then divided, but as it is very narrow in this situation, the sheath of the right or left rectus muscle is usually opened. Keeping in the middle line, the posterior layer of the sheath is divided and the subperitoneal fat (which sometimes resembles omentum) is reached; in thin subjects this is so small in amount that it is scarcely recognizable, and the peritoneum is at once exposed, and, as a rule, the urachus comes into view. In order to incise the peritoneum without damaging the tumour, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall; the surgeon then introduces his finger, and divides the peritoneum to an extent equal to the incision in the skin. It is important to remember that the bladder is sometimes pushed upward by tumours, and lies in the subperitoneal tissue above the pubes; it is then liable to be cut. On entering the peritoneal cavity, the surgeon introduces his hand, and proceeds to ascertain the nature of any morbid condition that he sees or feels, or he evacuates any free fluid, blood, or pus which may be present. Occasionally he finds that attempts to remove a tumour would be futile or end in immediate disaster to the patient; then he desists and closes the wound, and the procedure is classed as an exploratory coeliotomy. Should a removable tumour, such as an ovarian cyst, an echinococcus colony in the omentum, or the like be found, it is removed. Before suturing the incision, the surgeon usually spreads the omentum over the small intestine; occasionally he will be surprised to find this structure, even in well-nourished women, represented by a mere fringe of fatty tissue attached to the lower border of the transverse colon. The recesses of the pelvis are then carefully mopped in order to remove Misplaced viscera. In addition to tumours and normal enlargement of the uterus due to pregnancy, or an overfull bladder, there are certain malformations as well as displacements of normal viscera the surgeon may encounter in the pelvis which will, in some cases, cause him a certain amount of embarrassment, such, for example, as a bifid uterus or a spleen which has elongated its pedicle, or even twisted it, and, falling so low in the abdomen as to occupy the pelvis, may even cause prolapse of the uterus. In some of these cases it drags the tail of the pancreas with it. The cÆcum and the vermiform appendix often occupy the true pelvis; in middle-aged and elderly women the transverse colon sometimes forms a loop (the omega-loop), the extreme convexity of which often reaches to the pelvis. I have seen the right lobe of the liver extend into the pelvis, and come in contact with the unimpregnated uterus. It is important to remember that a kidney sometimes occupies the hollow of the sacrum; such a misplaced kidney has been removed under the impression that it was a tumour. When a kidney occupies the pelvis it lies behind the peritoneum as when it occupies its normal position in the loin. A horseshoe kidney is a fertile source of divergent opinion in diagnosis. A very large hydronephrosis simulates very closely an ovarian cyst until exposed through an abdominal incision; in such a contingency the operator performs nephrectomy; when the kidney is large enough to resemble an ovarian cyst it can easily be removed through the median incision. A very distended stomach will reach the hypogastrium and has many times been mistaken for an ovarian cyst; such a distended stomach has received a thrust from an ovariotomy trocar and the operator has been astonished to see food issue through the opening. Tumours of the pelvic organs are often complicated with abnormal and diseased conditions of the intestines, large and small; it is therefore necessary for any one undertaking gynÆcological abdominal operations to be prepared to perform resections of the colon, enterorrhaphy, gastro-jejunostomy, and the like when necessary. Transposition of the viscera is a rare anomaly to encounter in the course of an abdominal operation. I met with it once in 3,000 coeliotomies; the condition was recognized before operation. Closure of the wound. There are about fifty methods known and advocated for the closure of the median subumbilical incision, and the following is a list of materials used by surgeons for this purpose: silk, silkworm-gut, catgut, linen thread, and horsehair; silver, iron, aluminium, bronze, and platinum wire, and Michel’s metal clips. The object of these various methods and materials is to obtain a firm scar. The first requisite for securing an unyielding scar is perfect asepsis; but even the most perfectly healed abdominal scar may yield. Nature in her great operation of uniting the lateral halves of the belly-wall in a median cicatrix, the linea alba, cannot secure a non-yielding scar, it is therefore presumptuous of the surgeon to think he can always ensure it. The method which has given me the best results is a simple one. The peritoneum, sheath of the rectus, and rectus muscle are carefully approximated by interrupted sutures of No. 4 silk carefully sterilized and inserted with the hands covered with rubber gloves. The sutures are inserted at intervals of rather less than 2 centimetres apart. Care must be taken to include the peritoneum in these sutures. The skin is then brought together by a continuous suture of No. 2 silk. When the operation has been undertaken for a septic condition, such as pelvic peritonitis, suppuration of an ovarian cyst, an acute pyosalpinx, or the like, then it is useless to introduce buried sutures for the muscular and aponeurotic layers, as they will quickly become infected. In such conditions the abdominal walls are brought together by interrupted sutures involving all the layers. Those who are curious in regard to the various methods of closing median coeliotomy wounds should consult a brochure published in 1904 on The Closure of Laparotomy Wounds as practised in Germany and Austria, by Walter H. Swaffield. This little book contains the detailed methods and views communicated to him by more than fifty leading surgeons. In Great Britain there is plenty of variety in the methods and material employed for the closure of the incisions in abdominal operations, but at the present time there is a marked tendency to return to the older and simpler methods. The most dangerous and unreliable suture material for the abdominal incision is catgut (see p. 96). In studying the details of such operations as ovariotomy and hysterectomy from books, it should be remembered that it is merely the principles that can be explained. There are so many details in every operation that can only be learned from watching, or, what is far better, assisting a skilful and experienced surgeon in their performance. This is true of all forms of surgical procedure. No man can become a navigator without going to sea, however thoroughly he masters the principles of seamanship from books, so no surgeon can acquire the art of operating from merely reading descriptions of surgical operations. If a surgeon can bring to bear upon abdominal gynÆcological operations, in addition to mere surgical dexterity, a competent knowledge of the pathology of the organs, he will find it of the greatest assistance. I would warn him particularly to take little heed of the sneers of those eminently practical surgeons who affect to despise pathology. CHAPTER II OVARIOTOMY Ovariotomy signifies the removal through an abdominal incision of cystic and solid tumours of the ovary, and parovarian cysts. The history of this operation is of great interest to surgeons because it was the forerunner, so to speak, of all abdominal gynÆcological operations; they followed as a natural consequence on the establishment of ovariotomy, and operations on the abdominal viscera generally are to be regarded as an extension of pelvic surgery. It is usual to state that ovariotomy was first performed by Ephraim McDowell, of Kentucky, 1809: this is of historical interest only, for it had no effect whatever in drawing attention to the feasibility of removing ovarian cysts: it was in fact a still-born operation. The pioneers of this operation were undoubtedly Baker Brown and Spencer Wells in London, Thomas Keith in Edinburgh, and Clay in Manchester. These surgeons brought the operation out of a ‘slough of despond’ and placed it on firm ground. Spencer Wells and Keith were fortunate later in their work in receiving guidance from Lord Lister’s discovery of antisepsis: this, combined with the introduction of the short ligature, firmly established the operation. The improvement in securing the pedicle has played an important part in the development of ovariotomy. McDowell tied the pedicle, but left the ligature hanging out of the wound. Doran, who has written an excellent review of this matter, ascribes the intraperitoneal method of dealing with the pedicle to the systematic advocacy of Tyler Smith. The method has been followed by brilliant results. Baker Brown used to sear the pedicle with a cautery, and this method was adopted with great success by Thomas Keith. The method of ligature is so simple and safe that the cautery for this purpose has been long abandoned. The operation. The preliminary preparation of the patient and the necessary instruments are described on p. 5. The Trendelenburg position is not so necessary for the removal of large ovarian tumours as the smaller examples which are apt to be firmly adherent to the floor of the pelvis. In cases where the abdomen contains free fluid, ascitic or due to In the early days of ovariotomy it was the custom to tap the cyst, or, in the case of multilocular tumours, to force the hand into the mass and break down the septa of contiguous loculi and allow the viscid material to escape. These devices were recommended because it was regarded as a method making for safety to extract the cyst through a small abdominal incision. Occasionally it is possible to extract the wall of a large single-chambered parovarian cyst, after tapping, through an incision 7 centimetres in length. When the tumour is multilocular, or malignant, or full of grease or pus, it is difficult and extremely dangerous to tap it, as the material may infect the peritoneum either with septic matter or with malignant particles, and end disastrously. Cases have been reported in which, after traumatic rupture, or tapping, of a dermoid, the epithelial contents escaped into the belly. Subsequently the peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovarian cyst contracts typhoid fever, the cyst may become filled with pus which contains the bacillus typhosus. Such a case occurred in my practice in 1907. For many years I have abandoned the use of clumsy trocars of all kinds and remove the tumour entire, although it may require an incision from the ensiform cartilage to the pubes. These large incisions heal quickly, and are no more prone to hernia than the short incisions. This is the only way of ensuring the safety of the peritoneum from being contaminated by the harmful, dirty, and often malignant contents of the cysts. In dealing with burst cysts a free incision enables the surgeon to thoroughly and gently clean the peritoneal cavity. The abdominal cavity is opened by a median subumbilical incision (see p. 7). Occasionally a difficulty may be encountered on reaching the peritoneum, for, if the cyst has been infected, the peritoneum and cyst wall may be so intimately adherent that they cannot be separated. In these circumstances it is a wise plan to extend the incision upwards and enter the abdominal cavity above the tumour. It is also to be borne in mind that when the tumour adheres to the abdominal wall it is extremely probable that a coil of intestine may be adherent also. When a tumour is impacted in the pelvis it may push the bladder high in the abdomen; in such an event this viscus is apt to be opened in making the incision. If the surgeon has any doubt concerning the position In a typical case, when the peritoneum is opened the surgeon at once recognizes the bluish-grey glistening surface of the ovarian cyst, and gently sweeps his hand over it in order to ascertain its relations and to learn whether the cyst wall be free from adhesions. It is of the utmost importance to be satisfied as to the nature of the tumour, especially when the operator follows the unsatisfactory practice of tapping, for if he plunge a trocar into a uterine tumour, or into a pregnant uterus, he will involve himself in anxious difficulty. Decomposing fluid, tenacious mucus, or blood-stained fluid may obscure the parts, and should be sponged away: they indicate a ruptured cyst, a malignant tumour, or a twisted pedicle. Much free blood may be due to the bursting, or abortion, of a gravid tube. When the surgeon has satisfied himself that the cyst or tumour is free to be removed he lifts it out of the abdominal cavity, and if in this process the wall be so thin that it is likely to burst, or actually leaks, the weak spot may be freely incised with a knife over a convenient receptacle. Adhesions. Although the surgeon may have had reasons to suspect the presence of adhesions, frequently he finds none, and on other occasions when he least expects them there are many. The most frequent adhesions are omental, and fortunately they are the least important: they should be detached and tied with thin silk. Adherent epiploic appendages require the same treatment. Intestinal adhesions require care and patience. When the intestines are adherent by strands and bands, these may be cautiously snipped with scissors; when the adhesions are sessile and soft the gut may be gently detached by means of a moist dab; but if very firm it may be necessary to dissect off a piece of cyst wall and leave it on the gut. The vermiform appendix requires especial care, for it may be mistaken for an adhesion and divided. When intestines are accidentally opened in the course of an ovariotomy they require the most careful attention. Wounds in the colon may be safely sutured. Holes in adherent small intestine may sometimes be sutured, but if the gut has been extensively involved it may be necessary, and often judicious, to resect a few centimetres and join the cut ends by a circular enterorrhaphy. Adhesions to the parietal peritoneum are as a rule easily detached with the finger. The most serious adhesions are those which occur in the depths of the pelvis, involving the uterus, bladder, or rectum, and the separation of these may involve such accidents as wounds opening the rectum or bladder, and injury to the ureters and iliac veins. The treatment of such misfortunes will be considered later. The pedicle. When the tumour is withdrawn from the belly the pedicle is easily recognized: the Fallopian tube serves as an excellent guide to it. The pedicle consists of the Fallopian tube and adjacent parts of the mesometrium containing the ovarian artery, pampiniform plexus of veins, lymphatics, nerves, and the ovarian ligament. When the constituents of the pedicle are unobscured by adhesions, the round ligament of the uterus is easily seen and need not be included in the ligature. In transfixing the pedicle the aim should be to pierce the mesometrium at a spot where there are no large veins, and tie the structures in two bundles, so that the inner contains the Fallopian tube, a fold of the mesometrium, and occasionally the round ligament of the uterus; whilst the outer consists of the ovarian ligament, veins, the ovarian artery, and a larger fold of peritoneum than the inner half. Pedicles differ greatly; they may be long and thin, or short and broad. Long thin pedicles are easily managed. The assistant gently supports the tumour, whilst the operator spreads the tissues with his thumb and forefinger, and transfixes them with the pedicle needle armed with a long piece of silk doubled on itself. The loop of silk is seized on the opposite side and the needle withdrawn. During the transfixion care must be taken not to prick the bowel with the needle. The loop of silk is cut so that two pieces of silk thread lie in the pedicle. The proper ends of the thread are now secured, and each is firmly tied in a reef-knot; for greater security the whole pedicle may be encircled by an independent ligature, taking care that it embraces the pedicle below the point of transfixion. (I use No. 4 plaited silk for transfixing the pedicle, and a piece of No. 6 silk for surrounding it.) After the operator has gained some experience in this simple mode of tying the pedicle, he may, if he thinks it desirable, practise other methods. After securely applying the ligature the tumour is removed by snipping through the tissues on the distal side of the ligature with scissors. Care must be taken not to cut too near the silk, or the stump will slip through the ligature; on the other hand, too much tissue should not be left behind. The stump is seized on each side by pressure forceps, and examined to see that the vessels in it are secure; it is then allowed to retreat into the abdomen. Should it begin to bleed it must be caught with forceps, drawn up, retransfixed, and tied below the original ligature. Occasionally a pedicle will be so broad that it is unsafe to trust to this simple form of ligature. Broad pedicles will require three or more ligatures. When several ligatures are required it is important to remember that the ovarian artery lies in the outer fold of the pedicle and the uterine When an ovarian tumour has undergone axial rotation and has tightly twisted its pedicle, the ligature should be applied to the torsioned area: a single ligature is then sufficient. It is impossible to frame absolute rules for ligaturing the pedicle. In this, as in all departments of surgery, common sense must be exercised, and at the present day, when ovariotomy is practised so widely, no one would think of performing this operation without assisting at, or watching its actual performance by an experienced surgeon. Having satisfied himself that the pedicle is secure, the surgeon examines the opposite ovary, and if obviously diseased it should be removed. The operator then sponges up any blood or fluid which may have collected in the recesses of the pelvis. Whilst employed in this way he gives instructions to have the dabs and instruments counted. When the operator limits the number of dabs to six he can easily have them displayed before him. The incision is sutured in the manner described on p. 9. Cysts of the broad ligaments. Occasionally the surgeon on opening the abdomen finds that the cyst or tumour is situated between the layers of the broad ligament. Sessile cysts of this kind are removed by what is known as enucleation. The peritoneum overlying the cyst is cautiously torn through with forceps until the cyst wall is exposed; then by means of the forefinger the surgeon proceeds to shell the cyst out of its bed, taking care not to tear the capsule or any large vein in its wall; it is also necessary to exercise the greatest care to avoid injury to the ureter. It is not uncommon, after enucleating a cyst in this way, to find the ureter lying at the bottom of the recess. (For treatment of an injured ureter see p. 112.) When the enucleation is completed the walls of the capsule are carefully examined for oozing vessels which require ligature. The capsule can often be closed in such a way as to bring its walls into apposition and thus obliterate its cavity; it then requires no further attention. When there is much oozing the capsule is treated on the plan known as marsupialization. The edges of the capsule are brought to the lower angle of the abdominal wound and secured with sutures, and a drain, either of gauze or a rubber tube, is introduced, and the remainder of the wound closed in the usual manner. Enucleation is usually accompanied by more loss of blood than simple ovariotomy; this, and the prolonged manipulation, is often responsible for severe shock. Spurious capsules. It is necessary for the surgeon to remember that an ovarian cyst, and especially an ovarian dermoid, is sometimes invested by a spurious capsule. It is now well known that slow effusions of blood, tuberculous exudations (Fig. 4), hydatid cysts, and ovarian cysts become enclosed by capsules of fibrous tissue formed by the organization of the peritoneal exudation which their presence excites. These capsules are often so firm, and so completely encyst the fluid exuded into the pelvis in cases of tubal tuberculosis, that such encapsuled collections of fluid resemble, and are often mistaken for, ovarian cysts. It is also necessary to mention that true ovarian cysts project from, but never invade the layers of the broad ligament. From time to time cases are reported in which ovarian cysts, especially dermoids, have been found between the layers of the broad ligament: such are in all probability instances in which a false capsule has formed around the cyst, and the surgeon committed an error of observation in regarding it as a layer of the broad ligament. Ovariotomy in carcinoma of the ovary. When an operation is undertaken for the removal of solid or semi-solid tumours of the ovary, and especially when bilateral and accompanied by vomiting, it is incumbent on the surgeon to make a careful examination of the gastro-intestinal tract, for in many of these cases cancer will be found either at the pylorus, or in the cÆcum, or the colon, and particularly in the sigmoid flexure. In such circumstances the ovarian masses are secondary to the cancerous focus in the gastro-intestinal tract. Bilateral malignant tumours of the ovaries are sometimes secondary to primary cancer of the gall-bladder and the breast. Some of these secondary cancerous tumours of the ovaries form masses as big as the patient’s head.
In such conditions the ovaries and sometimes the uterus should be removed even for the purpose of making the patient comfortable. When Incomplete ovariotomy. The surgeon may start on an operation and, after opening the abdomen, may find many adhesions, yet he feels that the removal of the tumour is possible. He sets to work and overcomes many of the difficulties, but finds at last such extensive pelvic adhesions that it is imprudent to proceed further. In such cases he evacuates the contents of the cyst and stitches the edges of the opening in the cyst to the margins of the abdominal wound, and drains the cavity. This mode of dealing with a cyst is usually termed ‘incomplete ovariotomy’. An incomplete ovariotomy is a very different condition to an enucleation. The cavity left after enucleation closes completely, but when the wall of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhausted. There are few things sadder in surgery than the slow, miserable ending of an individual who has been subjected to an incomplete ovariotomy. Anomalous ovariotomy. In a few instances, generally under an erroneous diagnosis, surgeons have removed ovarian tumours through an opening other than the classical one known as the median subumbilical incision. Under the impression that the tumour was splenic, an ovarian tumour of the right side has been successfully removed through an incision in the left linea semilunaris (R. W. Parker). An ovarian tumour, supposed to be a renal cyst, has been successfully extracted through an incision in the ilio-costal space (Le Bec). Strangest of all, a small ovarian dermoid has been removed through the rectum under the impression that it was a polypus of the bowel (Stock, Peters). Hysterectomy after bilateral ovariotomy. After the removal of both ovaries for cysts or tumours, the uterus is a useless organ: it is fast becoming the practice under such conditions to remove it. There is much to be said in favour of this procedure, especially if the uterus be large and flabby, because it tends to fall backwards into the pelvis. In such circumstances it is better surgery to remove it than to perform hysteropexy. The risk of intestinal obstruction after bilateral ovariotomy is greater than after hysterectomy. Cases are known in which cancer has attacked the uterus years after bilateral ovariotomy and oÖphorectomy (see p. 55). Repeated ovariotomy. Very many cases are known in which women have been twice submitted to ovariotomy. Thus it is the duty of the surgeon when removing an ovarian tumour to examine carefully the opposite ovary. So many examples are known of women who have borne children after unilateral ovariotomy (twins and even triplets) that this alone is sufficient to prohibit the routine ablation of both glands. A second ovariotomy is not attended with more risk than a first ovariotomy. The abdominal incision must be made with extra caution, because intestine may be adherent to it and runs a risk of being wounded. In some instances the cicatrix is very thin, and the surgeon cutting through it is liable to cut the intestine before being aware that the knife has entered the abdomen. Some surgeons recommend that in a second ovariotomy the opening may with advantage be made a little to one side of the original incision. Cases have been reported in which patients have been thrice submitted to ovariotomy: in such instances it is probable that one of the tumours was a sessile broad ligament cyst. Pregnancy after bilateral ovariotomy. It is an interesting fact that several cases have been carefully reported in which women who have had bilateral ovariotomy have subsequently become pregnant. This event has been explained by assuming that in some of the patients a portion of at least one ovary has been left. This meets with more favour than the idea of the existence of a supernumerary ovary. The cases have been collected by Doran. In order to afford some notion of the relative frequency of the various cysts and tumours classed as ovarian, a list of one hundred consecutive examples which I removed at the Chelsea Hospital for Women is appended:—
The case classed as a carcinoma was secondary to cancer of the pylorus; both ovaries were affected. The three classed as tubo-ovarian were probably exceedingly large examples of hydrosalpinx; one was so big that it came in contact with the liver. I have compared this table with the experience of other surgeons, and although there is much variation in them it represents a fair average of the proportions of the different ovarian operations usually classified under the head of ovariotomy. Ovariotomy at the extremes of life. Cysts and tumours arise in the ovary during intra-uterine, and at all periods during extra-uterine life, even in extreme old age: they also attain such dimensions in infants and old women as to demand the aid of the surgeon, and with excellent results. Many years ago I collected the recorded cases and tabulated one hundred instances in which ovariotomy had been performed in infants and girls under fifteen years of age. These tumours fall into three groups:
In the case of simple cysts, adenomata, and dermoids, the results are encouraging. It is possible that some of the cases described as sarcomata belonged to the deadly group now known as malignant teratomata. Ovarian tumours sometimes attain large dimensions in children, and Keen reported a case in which he removed an ovarian tumour from a girl which weighed 44 kilogrammes: the girl weighed 27 kilogrammes after the operation. An ovarian cyst with a twisted pedicle has been found in a foetus at birth (Otto von Franque). The subjoined table shows cases in which ovarian tumours have been removed from infants under three years of age. It is often stated that Professor Chiene performed ovariotomy on an infant of three months. This is an error; it was an ovary occupying the sac of an inguinal hernia. Ovariotomy in Infants Ovariotomy in old age. In 1891 I was able to find twenty-two records of successful ovariotomy in women over seventy years of age. Since that date Howard A. Kelly and Mary Sherwood made a collective investigation, and succeeded in obtaining notes of one hundred cases of ovariotomy performed on women over seventy years of age: the death-rate amounted to 12%. The subjoined table concerns itself with ovariotomy performed on women after the age of eighty years, and the results are remarkable, notwithstanding the circumstance that these women of eighty years and upwards must have been blessed with a stronger constitution than their contemporaries. Ovariotomy in Women of Eighty Years of Age
Mortality. The death-rate after ovariotomy is hard to estimate, especially as surgeons differ widely in the classification of the cases. In the simple and uncomplicated forms of ovarian cysts and tumours the operation should be almost free from risk. Many surgeons, excluding malignant conditions, have had lists of a hundred operations with no deaths. If all kinds of tumours are included as represented in the table on p. 17, a 5% mortality in experienced hands would be regarded as a good result. In general hospital work it is probably as high as 10%. With less experienced surgeons who do not perform many operations the death-rate will vary from 10 to 15%. The risks and after-consequences of ovarian operations are set forth in Chapter XI. ReferencesDoran, A. On complete Intraperitoneal Ligature of the Pedicle in Ovariotomy. St. Bartholomew’s Hospital Reports, 1877, xiii. 195. —— Pregnancy after the Removal of Both Ovaries for Cystic Tumour. Trans. Obstetrical Society, 1902, xliv. 231. Bland-Sutton, J. On Secondary (metastatic) Carcinoma of the Ovaries. Brit. Med. Journal, 1906, i. 1216. —— On Cancer of the Ovary. Ibid., 1908, i. 5. Le Bec. Ovariotomie double; un des kystes enlevÉ par la rÉgion lombaire, l’autre par le devant de l’abdomen; adhÉrences totales; guÉrison. Gaz. des HÔpitaux, 1887, 290. Stocks. Prolapse of an Ovarian Cyst. Brit. Med. Journal, 1857, ii. 487. Peters, H. Ovariotomie per anum. Wiener Klin. Wochensch., 1900, xiii. 110. CHAPTER III OÖPHORECTOMY OÖphorectomy signifies the removal through an abdominal incision of an ovary and Fallopian tube for affections mainly inflammatory. The evolution of this operation is of great interest to surgeons. The removal of ovaries as a surgical operation was introduced independently by HÉgar in Germany and Battey in Georgia, for the relief of pelvic pain and dysmenorrhoea, in 1872. In the same year Lawson Tait performed his pioneer operation and removed an ovary and tube for the relief of pain due to disease of the ovary. Subsequently he advocated bilateral oÖphorectomy for the purpose of inducing an artificial menopause in women with uterine fibroids. From these beginnings the operation began to be performed for the relief of a variety of conditions connected with the generative organs, such as— Pyosalpinx and tubo-ovarian abscess, hydrosalpinx, tuberculous ovaries and tubes, sarcoma and carcinoma of the Fallopian tubes, gravid Fallopian tubes, ovarian abscess, ovarian pregnancy, prolapse of the ovary; finally bilateral removal of the ovaries has been practised for the relief of inoperable cancer of the breast. Bilateral oÖphorectomy is occasionally performed for osteomalacia (a rare disease in Great Britain), as it arrests pain and the excessive output of phosphates in the urine, which is a marked feature of this affection. This extension of the operation we owe to Fehling of BÂle (1887). Time and experience have considerably modified surgical opinion in regard to oÖphorectomy. Removal of the ovaries is no longer practised for the relief of hÆmorrhage due to fibroids: it is easier, safer, and affords greater relief to the patient to remove the uterus (see p. 36). When dysmenorrhoea is so severe as to need radical operation, hysterectomy is the only certain method, with conservation of at least one ovary. The removal of both ovaries in certain forms of insanity is now abandoned, and this is true of bilateral oÖphorectomy for the relief of mammary cancer. In other directions the operation has undergone extension, for in some chronic diseases of the Fallopian tubes it is difficult to completely extirpate the affected tissues without removing the uterus. These will be considered in describing the actual operation. Apart from the many modifications in the details of the operations some operators prefer to remove the ovaries and tubes through an incision in the vaginal fornix. This is known as Colpotomy, or Vaginal Coeliotomy. Some writers attempt to subdivide the various modifications of oÖphorectomy and apply to them special terms: for example, the removal of the ovary and tube would be termed salpingo-oÖphorectomy. Removal of the tube would be called salpingectomy, and the excision of the ovary, oÖphorectomy. This terminology may be precise, but it is certainly clumsy. A few writers designate these operations as ‘removal of the uterine appendages’; this phrase, though comprehensive, is neither precise nor elegant. Operation. The patient is prepared in the same manner, and the same instruments are required, as for ovariotomy. In many of these operations the Trendelenburg position is of the greatest advantage. In a case of prolapse of the ovary, or a gravid tube or ovary in the earliest stages, the operation presents no difficulty and can be carried out with the ease and safety of the simplest ovariotomy; but there are many cases where the tubes and ovaries contain pus and are distended into cysts as big as a fist, or even as large as the patient’s head, which are adherent to bowel, uterus, bladder, indeed everything with which they come in contact; this renders their removal tedious and exacting for the surgeon and dangerous to the patient. Although a suppurating ovarian cyst adheres to surrounding organs, its removal is simpler than in the case of a large pyosalpinx, because the Fallopian tube is intimately enclosed within the folds of the broad ligament, and these connexions serve to bind it firmly in the pelvis. In undertaking the removal of such enlarged tubes the surgeon’s first duty is to expose the parts by a free incision, and then carefully isolate the intestines and upper parts of the abdomen with dabs in order to prevent them from being contaminated with pus. He will quickly recognize in the majority of cases that he has to deal with tubal disease, because As soon as the diseased parts are extracted, a dab is pressed into the hollow to check the oozing: the pedicle is clamped with forceps and the tube and ovary detached. It is the common practice in dealing with inflamed and septic ovaries and tubes to transfix and ligature the pedicles as in a simple clean ovariotomy. The consequences of this practice are not satisfactory, for the pedicles being infected often give rise to trouble, because the silk acts as a seton, an abscess forms which may open up through the abdominal wound, the rectum, or perforate into the bladder, and leads to the establishment of a sinus which persists for many months until the ligature is extruded. There are several methods of avoiding this: for example, the arteries in these broad pedicles may be ligatured separately with thin silk, and the edges of the peritoneum drawn together by two or three mattress sutures (Fig. 11, p. 40). An Infected Fallopian Tube. Fig. 3. An Infected Fallopian Tube. The coelomic ostium of the tube is unoccluded and is in the process of slowly engulfing the fimbriÆ. Removed from a woman in the acute stage of salpingitis. Three-quarter size. In cases where the Fallopian tube is thickened quite up to the uterine angle, it may be exsected from the uterus: in such cases the uterine artery In acute cases of salpingitis the coelomic ostium is open and the infective material can be seen leaking from it (Fig. 3). In chronic cases this ostium is firmly occluded (Fig. 4). Acute cases are dangerous as they are apt to cause post-operative peritonitis. Chronic cases are difficult on account of visceral adhesions. Tuberculous Fallopian Tube and Ovary The most serious complication likely to arise in the enucleation of a pyosalpinx, especially on the left side, is a firm adhesion to the rectum; this may be occasionally anticipated when the patient gives a clear history of one or more sudden discharges of pus from the anus. An accidental tear of the rectum through comparatively healthy tissues may be repaired by interrupted sutures, but when the injury is in tissues altered by chronic suppuration, the only course open to the surgeon is to drain with a wide rubber tube, and it is surprising as well as gratifying to know that a fistula of this kind low in the rectum will often close in a week or ten days. It is important to bear in mind that an undetected tear into the rectum, if the abdomen be closed without drainage, will, in all probability, lead to fatal peritonitis. It has happened that a surgeon in removing a pyosalpinx tore a hole in the rectum; he was unaware of the accident, and a few hours after the operation ordered 10 ounces of saline solution to be injected into the bowel. This fluid passed through the rent in the gut direct into the pelvis with fatal consequences. After removing the diseased parts and securing the large vessels directly concerned in the pedicles, attention is directed to the oozing from the torn tissues in the floor of the pelvis. Any vessel which is bleeding should be ligatured with thin silk, and then the recesses of the pelvis may be firmly plugged with a dab wrung out of hot water: this is a valuable measure of hÆmostasis. This dab is removed in two or three minutes, and any vessel which is bleeding is quickly seen and ligatured. In cases where the enucleation of adherent and inflamed tubes leaves large raw and slightly oozing surfaces in the pelvis, drainage is a wise precaution. After a trial of a variety of measures for this purpose I find the simplest to be a narrow rubber drainage tube reaching to the bottom of the pelvis and emerging at the lower extremity of the abdominal incision. It is rarely required for more than forty-eight hours. Some surgeons are opposed to drainage, and one writer compares it to ‘defending oneself against the sparks of Vulcan with an umbrella’; his mortality is high. In simple cases the incision is closed according to the method described Abdominal hysterectomy after bilateral oÖphorectomy and ovariotomy. After the complete removal of the ovaries and tubes the uterus is a useless organ, and when the ‘appendages’ have been removed for inflammatory lesions, acute or chronic, it may become a troublesome organ. In some instances a uterus devoid of its appendages has been attacked by cancer. In a few instances in which patients have undergone bilateral oÖphorectomy, or bilateral ovariotomy, successful conception has followed the operation (see p. 17). The most annoying consequences which follow bilateral oÖphorectomy for salpingitis, acute or chronic, are hÆmorrhage, pain, or a purulent discharge. Every surgeon with an ordinary experience of this class of surgery has probably had to remove the uterus on several occasions as a sequel to bilateral oÖphorectomy. It is advised by many surgeons, when they find the appendages so hopelessly diseased that they must be removed, to perform subtotal hysterectomy at the same time. My own practice in this matter is to perform subtotal hysterectomy when it is necessary to remove the uterus as well as the appendages in chronic disease; and total hysterectomy when it is deemed advisable to remove the uterus with the appendages in acute infective conditions. The reasons for this modification are obvious, because in chronic conditions there is little liability for the stump to become infected, for experience teaches that though the distended tubes contain pus in chronic cases, yet on bacteriological examination this pus is sterile. In the acute cases the pus swarms with micro-organisms—bacillus colli, staphylococcus, and occasionally streptococcus; these infect the stump, set up suppuration, infect the ligatures, and establish a chronic sinus. To cure this condition it is necessary to remove the stump by the vaginal route. In cases of tuberculous infection of the Fallopian tubes it is not necessary to remove the uterus unless it is obviously implicated by the disease. In several patients I have left an ovary without any subsequent ill consequences. Mortality. In order to estimate the risks of oÖphorectomy it is necessary to classify the heterogenous conditions for which this operation is required. In the majority of cases the chief cause is inflammatory (septic) affections of the Fallopian tubes: other causes are tubal and ovarian pregnancy, and prolapse of the ovary. Tubal pregnancy is considered in a separate chapter, and as prolapse of the ovary is so In order to give some notion of the relative frequency of the infective conditions of the tubes and ovaries usually classed in Hospital Reports as ‘diseased uterine appendages’, I chose one hundred consecutive operations from my case-reports at the Chelsea Hospital for Women. They are classed thus:—
In order to give some idea of the risks of unilateral and bilateral oÖphorectomy, I gathered the following facts from the Hospital Reports, prepared by the Registrar. During the years 1903–7 (both years inclusive) the staff performed the operation of oÖphorectomy for diseased uterine appendages on 287 women. Of these four died. During the thirteen years I have filled the post of surgeon to this hospital I have performed on an average twenty oÖphorectomies yearly for the diseased conditions set forth in the above table. I lost one patient during the whole of this period, and that was in 1902. The chief risks of oÖphorectomy for inflammatory conditions are undetected injury to bowel, especially the rectum, and septic peritonitis when the streptococcus is present in the tubes in acute cases. Operation for primary cancer of the Fallopian tube. This disease is rarely diagnosed before operation. The treatment adopted in the cases first reported was oÖphorectomy, but in the majority of patients the disease quickly returned and destroyed them in a few months. It subsequently became the practice to remove the uterus as well as the tubes and ovaries, but a quick recurrence in these circumstances is the rule. The really favouring factor in the case is the condition of the coelomic ostium of the tube. When this remains open, the cancerous cells escape freely and implant themselves on the pelvic peritoneum and adjacent organs. In very rare instances the coelomic ostium is occluded: in this happy circumstance a fairly long freedom from recurrence may be hoped for. The relation between the condition of the coelomic ostium of the Fallopian tube and the recurrence of cancer is illustrated by the following cases:— A woman, fifty-seven years of age, had a large submucous fibroid
A woman, forty-nine years of age, had a large fibroid in her uterus and a Fallopian tube stuffed with cancer, but the coelomic ostium was completely occluded. The uterus, ovaries, and tubes were removed. The patient subsequently remarried and was in good health three years later. Primary cancer of the Fallopian tube is almost invariably unilateral and its association with fibroids of the uterus is unusual. It is necessary for the surgeon to remember that a cancerous Fallopian tube may lead to complications with an ovarian cyst. Our knowledge of primary cancer of the Fallopian tube has grown up within the last twenty years, and In Fig. 5 I have represented an instructive specimen, which is an ovarian cyst complicated with primary cancer of the corresponding Fallopian tube. In this instance the cyst was as big as a cocoa-nut and multilocular: the ampulla of the tube is stuffed with cancer, but the ostium is patent and a ‘stream’ of cancerous material has flowed over the wall of the cyst. In addition, the cancerous material has infiltrated the wall of the ovarian cyst. The patient recovered from the operation, but a year later she had an extensive recurrence. The primary mortality of simple oÖphorectomy, or oÖphorectomy combined with hysterectomy for primary cancer of the Fallopian tube, is about 5%, and this is low in comparison with abdominal hysterectomy for cancer of the cervix; it is due to the fact that tubal cancer does not so readily become septic (Doran). ReferencesDoran, A. A table of over fifty complete cases of Primary Cancer of the Fallopian Tube. Journal of Obst. and Gyn. of the British Empire, 1904, vi. 285. Bland-Sutton, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400. —— On Cancer of the Ovary, Brit. Med. Journal, 1908, i. 5. CHAPTER IV OPERATIONS FOR EXTRA-UTERINE GESTATION The systematic surgical treatment of extra-uterine gestation we owe to the genius of Lawson Tait. His first operation for this condition was performed in 1883. Tait wrote that he conceived and carried out this operation in obedience to the canon of surgery relating to the arrest of hÆmorrhage, and which is valid in other regions of the body. Many surgeons (even a butcher) had removed living, dead, and putrescent extra-uterine foetuses from the abdomen of living women, but Tait was the first to attempt the operation in those early stages of tubal gestation in which the tube bursts, or expels (tubal abortion) the products of conception through the coelomic ostium or a rent in the gestation-sac, into the abdominal cavity, accompanied by an escape of blood so abundant that it may destroy life in a few hours. Indications. The operative treatment of extra-uterine gestation depends mainly on the stage at which it is required. When a gravid tube is detected before rupture, the operation is practically that of oÖphorectomy: and is simple and safe. When the operation is required in consequence of the bursting, or abortion, of an early gravid tube, great promptness is often required on the part of the surgeon to prevent the patient dying from hÆmorrhage, and although the operation in these circumstances is really an oÖphorectomy, it often has to be performed in the patient’s room as an emergency operation and without the elaborate surroundings of a modern operating theatre. A Gravid Fallopian Tube. There are few accidents which test the skill, nerve, and resource of a surgeon more than coeliotomy for a suspected intraperitoneal hÆmorrhage from a gravid tube, and few operations are attended with such brilliant results. Surgeons are often astonished to find a large amount of blood in the pelvis due to a small perforation in a gestation-sac no bigger than a cherry (Fig. 7). Operation. In removing tubes of this kind it is necessary to apply the ligature on the uterine side of the rent in cases of rupture of the tube, but when the rent involves the wall of the uterus the opening will require the application of a mattress suture for its complete closure. After the pedicle has been safely ligatured and the blood removed, the abdominal incision is sutured as described on p. 9. When the shock due to the bleeding and operation has been great, it is sometimes judicious to pour one or two pints of saline solution at the temperature of 102° F. direct into the abdominal cavity. The majority of cases of internal bleeding from gravid tubes in the early stages are submitted to operation at periods varying from a few hours, days, weeks, or even months, after the primary bleeding. When the tube bursts, the hÆmorrhage may not be so profuse as to induce death; and the woman, recovering from the shock, does not manifest such grave symptoms as to demand surgical aid. The consequence is that the patient sometimes remains for several weeks under palliative treatment (unless a renewal of bleeding kills her), and at last she seeks surgical advice. Appreciation of the true nature of the case leads to operation. In such cases, when the abdomen is opened, the free blood in the abdominal cavity is easily removed by sterilized dabs of absorbent material. The damaged tube and ovary are removed as in oÖphorectomy. When there is much free blood care must be taken that no clots are left in the iliac fossÆ. When the blood has remained in the belly for several weeks after rupture, it is judicious to insert a small drain for a few days. The importance of removing blood and blood-clot from the peritoneal cavity is demonstrated on p. 98. Where a tubal pregnancy progresses beyond the third or fourth month and invades the broad ligament before giving trouble from internal In cases where the pregnancy continues beyond the fourth month to full time an operation may be required at any moment. Up to the fourth month it may be even possible, in some cases, to remove the embryo, placenta and gestation-sac on the same plan as an ovarian cyst. This is occasionally possible even when the gestation runs to term, but in the majority of cases, when the gestation has passed the fourth month and the foetus is alive, the surgeon cannot expect to deal with the sac in this summary manner, (unless it be a cornual pregnancy) he has to reckon with the placenta. A Gravid Fallopian Tube Fig. 8. A Gravid Fallopian Tube, containing Twins. (McCann’s case. Museum R. College of Surgeons.) Full size. In operating for the removal of a gravid tube in the early weeks, the surgeon may be exercised in his mind in regard to the opposite tube, for a careful study of the literature of this subject clearly shows that the patient is liable to conceive in the opposite tube, and in some instances this has happened within a few weeks of the removal of its fellow. The liability of a repeated tubal pregnancy may be fixed at 5 per cent. Moreover, in operating for tubal pregnancy, the opposite tube should be carefully examined, because both tubes may be gravid, though, as a rule, the pregnancies are of different dates. To spare a woman a recurrence of tubal pregnancy it has been urged that the surgeon should remove the opposite tube, but men of ripe experience and judgment are averse to such a proceeding, for it is an established fact that uterine pregnancy The method of dealing with the sac of an extra-uterine gestation after the fifth month depends in a great measure upon whether the foetus is alive or dead. The gestation-sac after this date consists usually of the expanded tube closely incorporated with the tissues of the broad ligament, which may be thick in some parts and very thin in others. To the walls of the sac, coils of the intestine, and particularly the rectum, adhere. Experience decides that the safest plan, after exposing the gestation-sac through an abdominal incision, is to cut into it and remove the foetus and placenta. When the foetus is dead there will be little trouble from the placenta. The edges of the incision are stitched to the margin of the abdominal wound and drained. In those rare cases where the amnion erodes the tube and invades the belly (ventral pregnancy), the gestation-sac, with its contents, has been successfully removed by merely transfixing its base with silk ligatures. The great danger of operations for extra-uterine gestation after the fifth month, when the foetus is alive, or only recently dead, is the furious bleeding which accompanies the detachment of the placenta. It may be stated that an operation for tubal pregnancy after the fifth month of gestation, with a quick placenta, is the most dangerous in the whole range of surgery. About two-thirds of the patients die. The greatest danger is hÆmorrhage, and the other is sepsis when the placenta has been left to slough. It cannot be urged with too much force that when it is fairly evident that a woman has an extra-uterine gestation, it should be dealt with by operation without delay: and my experience of the operation leads me to believe that it is a wise plan to remove the placenta at the primary operation. Fortunately very few extra-uterine foetuses survive to term. In cornual pregnancy, or, as it is often termed, ‘pregnancy in the rudimentary horn of a so-called unicorn uterus,’ the removal of the uterus is often necessary; there is, however, a variety of this form of pregnancy in which the fully developed cornu may be spared, namely, that in which the rudimentary but gravid cornu is connected with it by a distinct and usually solid pedicle. Many such have been observed and very carefully described. In nearly all varieties of tubal pregnancy the uterine tissues are some Concurrent intra- and extra-uterine pregnancy. The operative treatment of this condition requires consideration under three headings:— 1. Tubal and uterine pregnancy coexist, but the complication is recognized in the early stages. In this condition the signs are those of an early tubal rupture or abortion (Fig. 7); in the majority of the reported cases operation has been undertaken with the impression that the trouble was simply due to tubal pregnancy, the intra-uterine gestation being detected, or in some cases merely inferred from the size of the uterus, in the course of the operation. In these circumstances the operation is carried out as for a simple tubal pregnancy, care being taken to disturb the uterus as little as possible. In many instances such an operation has been followed by brilliant consequences, for the intra-uterine pregnancy has remained undisturbed and the patients have become the happy mothers of living children. Occasionally the operation has been followed by miscarriage and other untoward results, but, speaking generally, a gravid uterus is very tolerant of interference. 2. Uterine and extra-uterine pregnancy running concurrently to term. (Compound pregnancy.) This may be described as the most dangerous combination to which child-bearing women are liable. In order to show what a disastrous conjunction it is to women with two ‘quick’ children—one intra- and the other extra-uterine—I have arranged some recorded cases in the table on p. 35. Fortunately this form of compound pregnancy is rare, but a rarer combination has been recorded by Menge, in which the extra-uterine foetus occupied the ovary and ran nearly to term. When the woman came into labour, the ovarian pregnancy was regarded as an obstructing tumour, and preparations were made for performing coeliotomy. The intra-uterine child was born in the meantime. When the supposed tumour was extracted, to the surprise of all it contained a living foetus. The mother and both children survived. 3. Uterine pregnancy complicated with a sequestered extra-uterine foetus. This is a very rare condition, but some cases have been very carefully recorded (Leopold, Stonham, Worrall). The physical signs are those of a pelvic tumour incarcerated by a gravid uterus. The nature of the swelling may be sometimes accurately inferred before operation, as in Worrall’s remarkable case. The sequestered foetus should be removed by coeliotomy. After the death of the foetus the operative treatment of extra-uterine Although a sequestered extra-uterine foetus is uncommon, yet a surgeon may stumble on one when he least expects it: these bodies may remain undisturbed in the pelvis many years, even fifty, and be only discovered in the post-mortem room, but they are always liable to be infected from the adjacent bowel or bladder; then suppuration is inevitable. In some instances the pus makes its escape at the umbilicus, and as the sinus persists the surgeon explores it, and, on laying it open, is surprised when he extracts the foetus, sometimes entire. This is sometimes referred to as ‘navel delivery’, and of this several examples have been recorded. In one such case a foetus was extracted by a butcher: the woman recovered, and the account of this remarkable case ends thus: ‘She had a navel rupture, owing to the ignorance of the man in not applying a proper bandage’ (Phil. Trans., Abridged Edition, 1805, vol. viii, p. 517). This is a good instance of professional bias in the apportioning of blame. Usually, when pathogenic micro-organisms gain access to the gestation-sac the foetus decomposes, and fistulÆ form, by which pus, accompanied by fragments of foetal tissue and bones, finds an exit and affords evidence of the nature of the case. These fistulÆ may open into the rectum, bladder, vagina, uterus, or some spot on the anterior abdominal wall below or near the umbilicus. The treatment is simple, and consists in dilating the sinus and extracting all the fragments. If this be thoroughly carried out the sinus quickly closes. Partial operations are useless: if but a bit of a bone remain, a troublesome sinus will persist. It is bad practice to attempt to extirpate the sac in such condition; such an operation usually terminates fatally. In a case of old-standing lithopÆdion it is unusual to find any trace of the placenta. J. W. Smith operated on a woman in whom a lithopÆdion had caused intestinal obstruction. The foetus had probably been retained 15½ years, and the placenta was represented by a calcified encapsuled ball, with an average diameter of 6 cm. Results of operative treatment. In order to afford some A Table showing Cases of Concurrent Intra- and Extra-uterine Pregnancy (Compound Pregnancy) running to Term, with the Fate of the Mother and Children.
1 This foetus was killed by means of a stilette passed through the abdominal wall of the mother into its thorax. The patient had two subsequent confinements without difficulty. In 1898 the ‘lump’ had shrunk, but was movable and caused no difficulty. Pacific Medical Journal, September, 1898. 2 Intra-uterine child born naturally at the seventh month. Extra-uterine foetus died, set up septic changes, and was removed by coeliotomy some weeks later. ReferencesLeopold. Ovarialschwangerschaft mit LithopÄdionbildung von 35-jÄhriger Dauer. Arch. f. Gyn., 1882, Bd. xix. 210. Menge. Eine reine Ovarialschwangerschaft mit bebendem Kinde. Vide FrÄnkische Gesellschaft fÜr GeburtshÜlfe and Frauenheilkunde. MÜnch. med. Wochensch., 1907, liv. 2452. Smith, J. W. Jour. of Obstet. and Gyn. of the British Empire, 1908, xiii. 180. Stonham, C. LithopÆdion, Trans. Path. Soc., 1887, xxxviii. 445. Worrall. Ectopic Gestation complicating Normal Pregnancy. Abdominal section. Recovery. Med. Press and Circular, 1891, i. 296. 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 dysmenorrhoea. 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 HYSTERECTOMYThe 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 Arterial Supply of the Uterus Fig. 9. A Diagram to show the Arterial Supply of the Uterus. 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 A Fibroid growing near the Right Uterine Cornu Fig. 10. A Fibroid growing near the Right Uterine Cornu. It separates the ovarian ligament, Fallopian tube, and round ligament of the uterus from each other. Full size. 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 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 Mattress Suture The Stump after Subtotal Hysterectomy Fig. 12. The Stump after Subtotal Hysterectomy. To show the method of applying the continuous suture. 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 HYSTERECTOMYThis 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 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 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. Fig. 14. A Bicornate Uterus shortly after Delivery. The pregnancy occurred in the left half. The vesico-rectal ligament is well shown. 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. 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:—
In these hospitals and the New Hospital for Women the returns in 1906 are as follow:—
Villous Disease of the Uterus Fig. 15. Villous Disease of the Uterus. The uterus is shown in sagittal section. The cavity is dilated and occupied by a villous tumour growing from its posterior wall. Successfully removed from a multipara aged 83. Full size. The returns during 1906 and 1907 from my service at the Chelsea The risks of abdominal hysterectomy. The dangers of hysterectomy are those common to coeliotomy, 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.
ABDOMINAL MYOMECTOMYUnder 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 FIBROIDSAbdominal 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 coeliotomy 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 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 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 UteriBland-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. CHAPTER VI ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY The great success which followed the use of the short ligature in ovariotomy induced several surgeons to apply the same principle to the cervical pedicle when removing the uterus for fibroids. The result was dismal failure. Matters improved somewhat after KoeberlÉ introduced the serre-noeud, and this continued the safest method until 1892. In the meantime antisepsis had begun to take effect in pelvic surgery, and attempts were made by Bardenheuer (1881), Polk, and other surgeons to avoid the dangerous difficulties connected with the treatment of the stump by removing the cervix as well as the uterus (total hysterectomy), and they attained an encouraging measure of success. Nevertheless, other surgeons (Goffe, Milton, Heywood Smith, and Stimson) felt that the enucleation of the cervix was not always necessary, and sought to find a way of avoiding it. The credit of solving this difficulty fell to Baer of Philadelphia (1892), for he showed that it is dangerous to constrict the neck of the uterus with ligatures, it is only necessary to secure the arteries. Baer’s method of supravaginal hysterectomy, or, as it is now commonly termed, the subtotal operation, soon supplanted the total method of Bardenheuer. The publication of Baer’s paper had great consequences; it came at a time when the attention of gynÆcologists was centred on improvements in hysterectomy. The method was promptly tested and adopted in London. The effects of this improvement in technique in a few years revolutionized the surgical treatment of uterine fibroids, as the statistical results set forth on p. 44 amply prove. The great advantage of Baer’s method is its simplicity and safety; but there is a disposition on the part of a few surgeons to prefer the total operation, mainly on the ground that the cervical stump left after subtotal hysterectomy is liable to become attacked by cancer. As far as I can ascertain, Dr. M. Mann, of Buffalo, was the first to draw attention to the occurrence of cancer in the neck of the uterus after the body of the organ had been removed. He stated in 1893 that he ‘removed an ovarian tumour and the body of the uterus, by accident, along with it; the cervix was left’. The patient recovered. When cases of cancer supposed to arise in the stump left after subtotal hysterectomy come to be critically analysed, they fall into four groups:— 1. The disease existed in the neck of the uterus at the time of the primary operation, but was overlooked. 2. Cancer attacked the cervical stump subsequent to subtotal hysterectomy. 3. The fibroid which necessitated the hysterectomy was really a sarcomatous tumour of the uterus. 4. The suspected growth on the cervix is not malignant, but a granuloma. Each of these postulates requires separate consideration. Many observations have been published which show beyond dispute that surgeons have performed subtotal hysterectomy in ignorance that the cervix was already cancerous, and the hÆmorrhages of which the patients complained before the operation were due as much to the cancer in the neck of the uterus as to the fibroids. This should serve as a warning that, in cases where the surgeon contemplates performing a subtotal hysterectomy, he should carefully examine the cervix beforehand; at the time of the operation he should also critically examine the cut surface of the cervix, and if it be in the least suspicious he should remove the neck of the uterus. It is necessary to remember that cancer attacks any part of the cervical endometrium, therefore an early cancerous ulcer in the middle of the cervix will run a great chance of being missed by a surgeon who is content with a subtotal hysterectomy. It is certain that cancer does occasionally attack a cervical stump left after subtotal hysterectomy at such an interval after the operation as to make it certain that the cancer did not exist at the time of the operation. Such a case occurred in my practice. I performed subtotal hysterectomy in 1901 on a woman forty-two years of age, mother of one child; eighteen months later there was a cancerous ulcer on the cervix; the whole of the cervical stump was promptly removed and the nature of the disease established microscopically. In 1908 the patient was in excellent health. In another case under my care I performed total hysterectomy for fibroids in ignorance that the patient had cancer of the cervix. Some months after the operation cancer recurred in the vaginal vault and scar of the hysterectomy; the neck of the uterus had been preserved by the doctor, and on examination the cancer was found. In this instance, although total hysterectomy was performed, it had no effect in staying the course of the disease. It is necessary to utter a caution in regard to the occurrence of cancer of the cervix after subtotal hysterectomy. I removed a uterus containing Cancer of the body of the uterus and fibroids. In deciding between total and subtotal hysterectomy for fibroids the probable presence of cancer requires consideration in another aspect. Although uterine fibroids do not predispose to cancer of the neck of the uterus, many writers in recent years have expressed their suspicions that the presence of a submucous fibroid favours the development of cancer in the corporeal endometrium. Piquand, in 1905, drew attention to this matter and emphasized what other observers had pointed out, namely, that a submucous fibroid is often associated with changes in the mucous membrane of the uterus, which not only causes excessive bleeding, but sets up inflammatory conditions giving rise to leucorrhoea, salpingitis, pyosalpinx, and morbid changes in the endometrium, rendering it susceptible to cancer. His statistics support his conclusions, for they represent that in one thousand women with fibroids fifteen will probably have cancer of the body of the uterus. My own observations support this opinion. This complication is found most frequently between the fiftieth and the sixtieth year of life. If we narrow the ages of the patient and exhibit the liability in its most emphatic form it would run thus: that in patients submitted to hysterectomy for fibroids over the age of fifty years, about ten per cent of them will have cancer of the corporeal endometrium. In 1906 I looked through the case-notes of five hundred patients who had been submitted to operation for uterine fibroids under my care. Of these sixty-three patients had attained the age of fifty years and upwards. Among these sixty-three women there were eight cases of cancer of the corporeal endometrium; the nature of the disease in each case was verified by careful microscopic examination. Consequently, in performing subtotal hysterectomy for fibroids in women of fifty years and upwards, the surgeon should have the uterus opened immediately after its removal and assure himself that the endometrium is free from cancer. If there be any suspicion in this direction he should remove the cervix. Sarcoma. The most insidious danger which besets the surgeon in dealing with fibroids of the uterus is the occurrence of an encapsuled sarcoma in the guise of an innocent fibroid. I have for some years dropped the name of myoma for these common uterine tumours, preferring to apply the term fibroid in a generic sense to all encapsuled tumours of the uterus. Every histological condition is found in them, from the hard calcified body looking like a block of coral to a soft diffluent collection of oedematous connective tissue, and tumours composed of tissue indistinguishable from spindle-celled sarcomata. I have elsewhere recorded briefly a case in which I removed the uterus from a woman forty years of age, which contained a fibroid as big as an ostrich’s egg. On section it appeared to be a moderately firm fibroid, with its tissue whorled as is usual in hard fibroids and enclosed in a complete capsule. Some months later the patient complained of pain, and on examination a hard mass occupied the floor of the pelvis; a portion of this was excised and submitted to three competent histologists, who reported the growth to be an innocent fibroid. The patient died fourteen months after the primary operation with her pelvis filled with recurrent growth. The tumour was a spindle-celled sarcoma. Much has been written regarding the sarcomatous degeneration of fibroids. In this matter I have maintained an attitude of active scepticism. My experience amounts to this: the case which I have briefly described is the only example in a thousand cases of hysterectomy in which an encapsuled sarcoma in the guise of an innocent fibroid has come under my observation, therefore I come to the conclusion that it is an uncommon event, and on turning to the literature of the subject it will be found that unequivocal examples are few. 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 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 Cancer of the uterus after bilateral ovariotomy. The uterus, after complete removal of both ovaries, is not only a useless organ, but it may become attacked by cancer. Blacker reported a case in which a woman, thirty-nine years of age, underwent bilateral oÖphorectomy for a uterine fibroid: eight years later cancer attacked the neck of the uterus and destroyed the patient. In 1902 I performed abdominal myomectomy on a woman forty-seven years of age, and removed both ovaries and Fallopian tubes; the latter contained pus. Four years later this patient came under observation with extensive cancer of the cervix. In 1901 a patient had bilateral ovariotomy performed; five years later she complained of severe uterine hÆmorrhage. I removed the uterus by the abdominal route (total hysterectomy). The corporeal endometrium was cancerous throughout. The patient survived the operation six months. Similar cases have been recorded by Martin, Butler-Smythe, and Playfair. Adenomyoma of the Uterus. This disease has not received adequate recognition at the hands of British surgeons, yet it is a condition which occasionally causes much doubt in the surgeon’s mind in the course of hysterectomy. This adenomyomatous change affects the endometrium and is, in some cases, associated with interstitial and subserous fibroids: it causes often great enlargement of the uterus, and under these conditions the fundus can be felt high in the hypogastrium. The patients are often profoundly anÆmic as the result of long-continued menorrhagia. The physical and clinical signs of the disease are those present in patients with a large degenerating submucous fibroid. Indeed the surgeon often removes the uterus under this impression, and, after the operation is completed, when he divides the uterus expecting to see the usual encapsuled tumour, to his surprise finds a uterus with greatly thickened walls (Fig. 16). An Adenomyomatous and Tuberculous Uterus Fig. 17. An Adenomyomatous and Tuberculous Uterus. The uterus is opened by a vertical incision in its posterior wall. The anterior wall is occupied by a mass of tuberculous adenomatous tissue. The patient, a spinster aged 46, was in excellent health four years after the operation. Two-thirds size. Microscopically the adventitious material is made of irregular tracts of endometrium containing glands and strands of unstriped muscle tissue. It is important for the surgeon to recognize these cases because, contrary to the rule with simple uterine fibroids, these adenomyomatous uteri are often adherent to the adjacent bowel and to the bladder: in connexion with this fact several observers have pointed out that uteri affected with this disease are often associated with inflammatory affections of the Fallopian tubes, and there are good reasons for the belief that the adenomyomatous change has a microbic origin. In this connexion it is worth mention that adenomyomatous uteri are sometimes tuberculous (Fig. 17). Some examples of this disease have been mistaken for cancer of ‘the body of the uterus’. In this disease subtotal hysterectomy gives admirable results, immediate and remote. THE FATE AND VALUE OF BELATED OVARIESThe only improvement of any importance made in Baer’s operation of subtotal hysterectomy concerns the ovaries. These Baer removed with the Fallopian tubes, but in 1897 I advocated, at the Obstetrical Society, London, that they were of great value to the patient, and pointed out that their conservation, when healthy, spared the patient the annoyance of that curious vaso-motor phenomenon, known to women as ‘flushings’, which is the only obtrusive sign of the menopause. It is now admitted by those surgeons in London who have had much experience of hysterectomy for fibroids, that the immediate results of preserving at least one healthy ovary in this operation are admirable, Although I have left one or both ovaries in the performance of abdominal hysterectomy for fibroids in more than 300 patients, in only two instances have I found anything detrimental in the practice. In these two patients it was necessary to remove one of the ovaries. Since 1906 I have modified the method by leaving only one ovary, even when both were healthy, and find that the immediate good consequences of the operation are in no way impaired. There is reason to believe that whatever good effects follow the practice of leaving a belated ovary (that is, an ovary divorced from the uterus and left in the pelvis), they are temporary, for in the course of a few years the ovarian tissue disappears and the patients experience the usual symptoms of the menopause. It is possible that the rate of atrophy of the secreting tissue of a belated ovary depends on the age at which a patient is submitted to hysterectomy. In 1898 I performed subtotal hysterectomy on a woman, thirty-one years of age, for fibroids, conserving the right ovary. Nine years later (1907) I operated again for intestinal obstruction, and found this ovary healthy and functional, for a ripe corpus luteum was visible on its surface. Even a portion of an ovary, if it contain follicles, will maintain menstruation. In performing abdominal hysterectomy for fibroids, there are three points which require consideration in relation to the subsequent comfort of the patient, and they depend mainly on the conservation of a healthy ovary. These three points relate to: (a) the patient’s comfort in securing freedom from flushings; (b) if she be married, her marital relations; and (c) if single, her nubility. In regard to marital relations in women with a belated ovary, nothing trustworthy is forthcoming, but I believe the retention of an ovary is an additional factor in promoting domestic bliss. The question of nubility is interesting; I am able to state that women who have had subtotal hysterectomy performed, with conservation of one ovary, have married and lived happily with their husbands; and I am of opinion that the preservation of the vaginal segment of the neck of the uterus is an important factor, as it leaves the vagina intact, and though such women are sterile, they are certainly nubile. Without overstating the case it may be said that a belated ovary is a very precious possession to a woman under forty years of age, whether she be married or single. In regard to the fate of such ovaries, in the present condition of our knowledge it may be stated that: In a woman under the fortieth year of life, a belated ovary remains active and discharges ova. Uterus with the Decidua in Situ Fig. 18. Uterus with the Decidua in Situ. The parts of the uterus occupied by the decidua represent the menstrual area of the uterus. An ovary belated after the fortieth year of life atrophies, and menopause symptoms will often ensue in the course of a few months after the operation. The retention of an ovary minimizes the menopause disturbances, and they are never so acute and prominent under these conditions as they are when an acute menopause is induced by the sudden and complete removal of all ovarian tissue. Some experienced observers maintain that an ovary is a valuable possession to any woman who menstruates, even at the age of fifty years, the persistence of menstruation being obtrusive evidence that this gland is functional. Experimental evidence, obtained from rabbits, proves that the removal of the whole uterus has no deterrent effect on ovulation, and it does not prevent the occurrence of oestrus and ovulation at periodically recurring intervals. There is no necessity to appeal to experiments on animals in this matter, as clinical observations on women are most eloquent in proclaiming the great value of a conserved ovary when the uterus is removed on account of troublesome and dangerous fibroids. In reference to the value of ovarian tissue after hysterectomy for fibroids, attention should be drawn to a modification of this operation known as the Abel-Zweifel method, by which a small segment of the menstrual area of the uterus is left as well as one or both ovaries: this permits menstruation to continue in a subdued form. Doran has particularly studied this method and practised it, but I cannot express any opinion as to its value, never having had the courage to perform it. My aim in performing hysterectomy for fibroids is to abolish as completely as possible the menstrual area of the uterus (Fig. 18), and up to the present my efforts have been successful, and I have no complaint from any patient that this disagreeable phenomenon has manifested itself, although I have been at great pains by my own exertions, as well as by the kind efforts of those who have been associated with me in my hospital work, to keep in touch with women who have been so unlucky as to require such a serious operation as the removal of the uterus. References to the History of Hysterectomy for FibroidsBaer, B. F. Supra-vaginal Hysterectomy without Ligature of the Cervix in Operation for Uterine Fibroids. A new method. Transactions of the American GynÆcological Society, 1892, xvii. 235. Bardenheuer. Die Drainierung der PeritonealhÖhle. Im Anhang: Thelen: Die Totalextirpation wegen Fibroid. Stuttgart, 1881, 271. Goffe, I. Riddle. This surgeon furnishes an interesting account of the development of Total and Subtotal Hysterectomy for Fibroids, in The Transactions of the American GynÆcological Society, 1893, xviii. 372. KoeberlÉ, E. Documents pour servir À l’histoire de l’extirpation des tumeurs fibreuses de la matrice par la mÉthode suspubienne. Gaz. med. de Strasbourg, 1864, xxiv. 17; 66; 158. 1865, xxv. 78; 118. Pozzi, S. TraitÉ de GynÉcologie, 1905, i. 424. This contains an interesting review of the serre-noeud and clamp period of hysterectomy. He states that Tillaux, in a communication to the Academy in 1879, proposed the use of the word Hysterectomy. Literature Relating to Cancer of the Cervical Stump after Subtotal HysterectomyDoran in his Harveian Lectures, London, 1902, gives an admirable critical summary of this important question up to that date. Bland-sutton, J. Essays on Hysterectomy, 1905, 2nd Ed., 60. —— Journal of Obs. and Gyn. of Gt. Britain, 1904, v. 434. Mann, M. Trans. Am. Gyn. Soc., 1893, p. 123. Polk. Am. Journ. of Obstetrics, 1906, liv. 78. QuÉnu. Rev. de Gyn. et de Chir. Abdom., 1905, Sept.–Oct., ix. 720. Richelot. La GynÉcologie, 1903, viii. 399. Turner, G. Brit. Med. Journ., 1905, ii. 953. References in Relation to the Occurrence of Cancer in the Uterus after Bilateral OvariotomyBlacker, G. F. Uterus with Fibroids and Carcinoma of the Cervix. Trans. Obstet. Soc., 1896, xxxvii. 213. Bland-sutton, J. A Clinical Lecture on Adenomyoma of the Uterus. Brit. Med. Journal, 1909, 1. Butler-Smythe. Carcinomatous Uterus removed eighteen and a half years subsequent to Double Ovariotomy. Trans. Obst. Soc., 1901, xliii. 214. Playfair. Carcinoma of Uterus. Ibid., 1897, xxxix. 288. Martin, A. Die Krankheiten der EierstÖcke und NebeneierstÖcke, 1899, s. 907. References concerning the Value of Belated OvariesBland-Sutton, J. Abdominal Hysterectomy for Myoma of the Uterus, with brief notes of twenty-eight cases. Transactions of the Obstetrical Society, 1897, xxxix. 292. —— The Value and Fate of Belated Ovaries. The Medical Press and Circular, 1907, ii. 108. 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. Operation. The steps of the radical abdominal operation advocated by Wertheim are as follows:— As a preliminary, the cancerous cervix is treated by scraping, cauterizing, and disinfectants. It is an advantage to carry out these measures a few days before the main operation. The Trendelenburg position is indispensable and the abdomen is opened by a free median subumbilical incision. After isolating the intestines with dabs, the ureters are exposed by incising the posterior layer of the broad ligament; they are then traced to the parametrium. It is necessary to avoid too free a disturbance of their vascular network or they will slough. The bladder is then separated from the uterus. The infundibulo-pelvic, the broad, and the round ligaments are ligatured and divided. The particular order in which they are dealt with is not a matter of consequence. The uterine vessels are secured in the following manner:—The index finger is pushed along the ureter through the parametrium towards the bladder, until the tip of the finger appears there; the vessels are then raised on the finger, which covers the ureter so as to protect it whilst the vessels are ligatured and divided. As soon as the uterine vessels are divided the vesical segments of the ureters are exposed, cleaned if necessary, and separated from the cancerous cervix. The posterior layer of the peritoneum is divided and the rectum separated from the vagina: at this stage the uterus is sufficiently isolated from the surrounding structures to allow of removal. This is effected in the following way:— The two layers of the parametrium are taken off as close as possible to the pelvic wall, and the vagina closed with bent clamps and divided In order to extirpate the lymph glands, the peritoneum is divided upwards and the iliac vessels laid bare, and every enlarged gland from the division of the aorta to the obturator foramen is removed and the oozing vessels carefully secured. The wound is treated in the following way:— The cavity created by the removal of the uterus is filled in loosely with iodoform gauze, which extends to the vulva. An exact closing of the peritoneal cavity over this gauze is effected by the sewing up of the anterior and posterior flaps of peritoneum. The final step is the closure of the abdominal incision. After-treatment. This is relatively simple. The strips of iodoform gauze are removed through the vagina in from five to ten days successively. The patient gets up on the fifteenth day. The bladder requires very careful attention, as it is usually paralysed for some days. Mortality. The immediate mortality of these extensive abdominal operations for cancer of the neck of the uterus is very high, more than 20%, but recent statistics (1909) show that this death-rate is being considerably improved with increased experience on the part of the operators. Dangers. The chief risks of the operation are sepsis, cancer-infection, and injury to the ureters. The ureters have proved a fertile source of trouble because they are deliberately exposed in the course of the operation, and they are sometimes accidentally divided. It is not uncommon to find a ureter completely blocked by cancer, and occasionally the ureter, after being bared by the operator, undergoes necrosis a few days later. Wertheim points out that in some instances ureteral fistulÆ due to necrosis may be induced to close by the application of iodine or sulphate of copper. It is, however, unfortunately true that many patients with ureteral fistulÆ after the radical operation have been obliged to undergo nephrectomy (see p. 112). The ‘radical operation’ for cancer of the neck of the uterus is on its trial in Great Britain. The operative mortality is very high, and no reliable returns concerning the remote results are at present available. Hysterectomy for cancer of the body of the uterus. The most satisfactory method of dealing with cancer arising in the corporeal endometrium consists in performing total abdominal hysterectomy Cancer of the Uterus Fig. 19. Cancer of the Uterus. Coronal section through a uterus affected with primary cancer of the corporeal endometrium. The mass measured 10 centimetres transversely and 12 centimetres vertically. Removed by abdominal hysterectomy. Two-thirds size. There is a rare variety of cancer of the corporeal endometrium, namely, that which attacks small atrophic uteri. These small uteri may sometimes be extirpated by the vagina, but often the narrowness of the vagina in aged spinsters compels the surgeon to resort to the abdominal route. Cancer of the body of the uterus occasionally causes such enlargement of this organ as to render its removal by the vaginal route difficult as well as undesirable. When this form of cancer is complicated with fibroids, as a rule, vaginal hysterectomy is impracticable. Cancer of the body of the uterus is more frequent in spinsters and barren wives than in multiparÆ; for this reason the cancer often assumes the massive form, because the cervical canal being narrow, pathogenic micro-organisms do not obtain such free ingress as in the case of women with a patulous canal. In some instances the cancerous mass will expand the uterine cavity and lead to thinning of the walls as in Fig. 19. Clinically, cancer of the corporeal endometrium is a more insidious disease than cancer of the neck of the uterus, but since its frequent association with fibroids has been recognized (see p. 52) mainly as a consequence of the vulgarization of hysterectomy, many cases are detected fairly early and with improved results for the patients. Mortality. The risk to life in abdominal hysterectomy for cancer of the body of the uterus is somewhat greater than after removal of the uterus for fibroids. This is due to the fact that when the cancer ulcerates and sloughs, the risk of sepsis is therefore increased; this also makes convalescence slower. The remote results vary greatly; these depend in a large measure on the extent of the disease at the time of the operation. When the cancerous mass is compact, as in Fig. 19, good results may be expected. When the growth has perforated the uterine wall and small bud-like processes project on the serous surface, the disease may be expected to recur rapidly in the abdomen. Cancer of the uterus remains an opprobrium to operative gynÆcology. CHAPTER VIII OPERATIONS FOR DISPLACEMENT OF THE UTERUS HYSTEROPEXY (VENTRO-SUSPENSION AND VENTRO-FIXATION OF THE UTERUS)Hysteropexy is a term applied to an operation for fixing the uterus, by means of sutures, to the anterior abdominal wall. This procedure was advocated as a definite surgical operation for displacements of the uterus independently by Olshausen and Kelly (1886). The operation when employed for severe retroflexion of the uterus is now known as ventro-suspension of the uterus; when carried out for prolapse it is termed ventro-fixation of the uterus. When care is taken in the selection of patients, hysteropexy is an operation which is followed by satisfactory consequences. VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUSThe preliminary preparation and the instruments required as those used for a simple coeliotomy (see p. 5). Operation. The patient is placed in the Trendelenburg position, and the abdomen is opened as for ovariotomy, except that the incision is shorter; the operator then determines with his fingers the position and condition of the body of the uterus. If it be free, it is then straightened, and the condition of the ovaries and the tubes ascertained. In many patients, where retroflexion of the uterus is accompanied by pain, the distress is often due to a prolapsed ovary, incarcerated in the pelvis by the retroflexed fundus of the uterus; in another set of cases the retroflexion is produced by a tumour in the ovary, such as a small dermoid, but more often the body of the uterus is drawn backwards by a small fibroid in the fundus of the organ. In these conditions an operation embarked upon as a simple hysteropexy may become an oÖphorectomy, an ovariotomy, or a myomectomy, according to the necessity of the case. When the enlargement of the ovaries is due to oedema from incarceration, they should be left, as the swelling will quickly subside when the misplacement of the uterus is corrected. The uterus is fixed to the abdominal wall in the following way:— A curved needle armed with a silk thread (No. 4) which has been carefully boiled is passed through the aponeurosis and adjacent peritoneum on one edge of the wound, then through the anterior surface of the uterus near the fundus, and finally through the peritoneum and aponeurosis on the opposite edge of the incision; when this suture is tightened, it will VENTRO-FIXATION FOR PROLAPSE OF THE UTERUSOperation. When hysteropexy is needed for a large, bulky, and prolapsed uterus, the steps of the operation are the same as for retroflexion, but it is necessary to introduce a greater number of retaining sutures. Further, as the uterus tends to slip downward into the vagina, it is an advantage, as soon as the fundus of the uterus is drawn into the wound, to transfix it with a stout suture, in order that the assistant may use it as a tether to keep the uterus in position whilst the surgeon introduces the main sutures. In some cases, where the uterus is very large, it may be requisite to employ four, five, or even six sutures to secure it to the abdominal wall. In all cases of hysteropexy the uterus is of necessity sutured to the lower angle of the wound, and is therefore in close relation to the bladder. It facilitates the operation to introduce the lowest sutures first and then gradually work up to the fundus. The wound is then closed and dressed as described for coeliotomy. After-treatment. This is conducted on the same lines as after ovariotomy. Risks. Hysteropexy, when performed by surgeons experienced in pelvic surgery, is such a simple operation that it should have no mortality. At the Chelsea Hospital for Women, from 1904 to 1906, both years inclusive, this operation was performed on 190 patients, all of whom recovered from the operation. Many of these operations were complicated with oÖphorectomy, ovariotomy, or myomectomy. A wide study of operation returns show that hysteropexy is not absolutely free from risk, as deaths from sepsis, lung complication, and intestinal obstruction have been reported. The Fundus of a Uterus Fig. 20. The Fundus of a Uterus. A long fibrous cord arises from the fundus as a result of hysteropexy performed nearly five years previously for inveterate retroflexion. Full size. The remote consequences of hysteropexy are of interest. When the uterus has been enlarged by previous pregnancy its fundus can be brought without undue strain into contact with the anterior abdominal wall, so that when it is secured by sutures there is little or no strain on them. When hysteropexy is performed on spinsters or barren married women in whom the uterus is small, there is, in many instances, a strain on the sutures. The effect of this strain is twofold. When the uterus is attached to the In patients in whom the length of the uterus allows its fundus to come in contact with the abdominal wall without strain, the union may be so secure that the woman may pass through one or more pregnancies successfully without disturbing the union, or even stretching it. This I have proved in twelve instances where some subsequent trouble such as appendicitis, gall-stones, ovariotomy, cancer of the colon, or the like has led to a repeated coeliotomy, and has afforded me an opportunity of examining the condition of the uterus. In one remarkable case where a small uterus had been securely fixed by its fundus to the abdominal wall by means of ten thick sutures (the operation had been performed in a cottage hospital in Yorkshire), the patient complained of persistent pain, and was sent to me on this account. I found the sigmoid flexure of the colon caught in one of the sutures, which accounted for some of the woman’s trouble, but the uterus was so firmly fixed to the abdominal wall and had been so dragged upon that it had become a rounded sausage-like organ. Its removal was followed by immediate relief. Among rare accidents which have followed this simple operation is tetanus when catgut and wallaby tendon has been used for the retaining sutures (see p. 107). ReferencesKelly, H. A. Hysterorrhaphy. American Journal of Obstetrics, 1887, xx. 33. Olshausen. Ceber ventrale Operationen bei Prolapsus und Retroversio Uteri. Centralblatt fÜr GynÄkologie, 1886, x. 698. CHAPTER IX OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY Pregnancy is apt to be complicated with tumours growing in the walls of the uterus, e.g. fibroids, cancer of the neck of the uterus, or cysts and tumours of one or both ovaries; morbid conditions of the Fallopian tubes, e.g. pyosalpinx, tubal pregnancy; tumours and cysts in the broad ligament; displaced viscera occupying the pelvis, e.g. the spleen or the kidney; tumours arising in the pelvic bones, e.g. osteoma, enchondroma, or sarcoma; and echinococcus cysts and colonies growing in the omentum, but occupying the pelvis, or arising in the pelvic tissues. This is a formidable list, and any one of them may so complicate the pregnancy that it may be necessary to remove the tumour, and in some instances to perform CÆsarean section, or even hysterectomy. CÆSAREAN SECTIONThis signifies the removal of a foetus and placenta from the uterus through an incision involving the abdominal and uterine walls. This operation is required when the outlet of the pelvis is too narrow to permit the transit of a viable child, as in rickets and osteomalacia; when the vagina is malformed; when the pelvic outlet is narrowed by tumours growing from the pelvic wall. Occasionally the passage of a foetus is barred by tumours growing from the uterus, especially a large cervix fibroid, or a fibroid growing from the lower segment of the uterine wall. An ovarian cyst, especially a dermoid incarcerated by the uterus, may render this operation necessary. The rarest causes are cancer of the neck of the uterus and cancer of the rectum. This operation is advocated by some obstetricians in certain cases of eclampsia and placenta prÆvia. Operation. When it is known some days beforehand that the patient will be submitted to this operation, she should be prepared as for ovariotomy. Often it happens that the operation is undertaken after labour has commenced, and in circumstances which make time very precious. Even then the abdomen, pubes, and vulva can be shaved and thoroughly washed with warm soap and water, and lightly rubbed with ether and cotton wool. The instruments required are those given on p. 5. When the patient is under the influence of ether and the bladder emptied with the catheter, an incision is made in the linea alba from the umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy is very thin, and, unless the surgeon be cautious, the knife will come in contact with the uterus before he is aware of it. The uterus lies just under the incision, and the operator ascertains that it lies centrally (often the uterus is somewhat rotated to the right or left), and then makes a free incision through the uterine wall and extracts the foetus and placenta; as the uterus contracts, he slips his left hand behind the fundus, and grasps the uterus near the cervix, and effectually controls the bleeding. The assistant passes a large warm flat dab into the belly to restrain the intestines and omentum. The uterine cavity is sponged out, and the finger passed through the os uteri into the vagina in order to ensure a free passage for blood and serum. The incision in the uterine wall may be closed either by a double or a single set of silk sutures. When two layers of sutures are employed, the first set involve the mucous and adjacent half of the muscular layer[;] these sutures should be fairly close together, for they not only bring the parts into apposition, but they restrain the bleeding. A second row of silk sutures is now inserted, including the serous coat and adjacent half of the muscular layer. These threads should not be tied too tightly, as the tissues of a gravid uterus are soft and easily tear. In closing the uterine incision the surgeon should not spend time vainly in endeavouring to stanch the bleeding from the edges of the incision; this is best effected by dexterously inserting and securing the sutures. The recesses of the pelvis are carefully cleaned by gentle sponging, and the parietal incision is closed as after ovariotomy. The dressing varies with the fancy of the operator; a piece of sterilized gauze and a square of Gamgee tissue held in position by a many-tail of flannel firmly applied is all that is necessary. Although CÆsarean section is one of the simplest operations that can be performed on the pelvic organs, it formerly had a very high mortality; but since the principles of asepsis have been thoroughly established the death-rate from this operation has been so reduced that it varies from 4 to 10% according to the skill of the operator; indeed the results are so good in the hands of careful and skilful men that on recovery from the operation the patient may reconceive, and there are conditions in which the patient is desirous to produce more children with the knowledge that they must be extricated by CÆsarean section. There are many instances on record of women being submitted to this operation twice, and some thrice; and at least two patients have undergone this operation four times There is one great danger which women run by becoming pregnant after CÆsarean section, namely, rupture of the uterus. Some cases illustrating this accident have been reported. This accident has been discussed by Wallace. Although a few writers, particularly Wallace, consider that all CÆsarean sections should be performed with a view to ulterior pregnancy, this is not the opinion of the majority, for there are many women who, having passed such an ordeal once, have no desire to do so again, and ask for something to be done to prevent its possibility in the future. This involves what is known as ‘sterilization’. Portion of Ovary and Fallopian Tube. Fig. 21. Portion of Ovary and Fallopian Tube. The parts were removed a year after a supposed complete oÖphorectomy had been performed to induce an artificial menopause. This fragment of ovary maintained menstruation regularly. Full size. Sterilization after CÆsarean section. When CÆsarean section is performed the uterus is preserved, and after convalescence the woman is in a position to reconceive. There are conditions in which she is most anxious to produce more children even with the risk of having them extracted by this operation. On the other hand, some women, knowing the risks, ask that steps may be taken to prevent a recurrence of what they consider a catastrophe. This appears a simple matter, but it is not so in reality, for in many instances in which the operator had been under the impression that he had effected this by ligature of both Fallopian tubes in continuity, he has been surprised when the woman has again come under his notice well advanced in pregnancy. This has happened even when each tube has been ligatured in two places and a segment of the tube exsected between the ligatures. Bilateral oÖphorectomy has been recommended, but on the whole, when the patient The whole of this matter is one that is really a question of ethics, and the extreme views are represented by Wallace and Sinclair in the papers to which reference has already been made. The difficulty of effectively sterilizing women by simply relying on bilateral oÖphorectomy is shown by the well-established cases in which patients have successfully conceived after bilateral ovariotomy and oÖphorectomy. The youngest patient on whom CÆsarean section has been carried out with success to the mother and child was thirteen years of age. The operation was performed by Gache in Buenos Ayres on account of smallness of the pelvis. Women have recovered after a self-inflicted CÆsarean section. ReferencesDoran, A. Pregnancy after Removal of both Ovaries for Cystic Tumour. Journal of Obstetrics and GynÆcology of the British Empire, 1902, 11, i. Gache, S. OpÉration cÉsarienne sur une fille de 13 ans: GuÉrison. Annales de GynÉcologie, 1904, p. 601. Harris, R. P. Six self-inflicted CÆsarean Operations with recovery in five cases. Am. Journ. of the Medical Sciences, 1888, xcv. 150. Sinclair, Sir William. CÆsarean Section successfully performed for the Fourth Time on the same Woman, with remarks on the production of Utero-parietal Adhesions. Journal of Obstetrics and GynÆcology of the British Empire, 1907, xii. 335. Wallace, Arthur J. On Repeated CÆsarean Section. Ibid., 1902, ii. 555. CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHERIt occasionally happens that a woman in whom the course of pregnancy is nearly complete dies suddenly from disease, such as hÆmoptysis, hÆmatemesis, cardiac trouble, or uterine hÆmorrhage in the preliminary stage of labour; or is killed by accident. In some such circumstance attempts are sometimes made to rescue the unborn child, by performing CÆsarean section. It is true that such efforts are rarely attended with success, but in cases where death is very sudden and the surroundings such as to enable the operation to be performed without delay, the child may be extracted from the uterus and survive. Successful cases of this kind are published from time to time. In order to show how necessary it is to act promptly the following case may be mentioned:— A woman in the eighth month of pregnancy was found to be suffering MÖglich had a successful case. A patient aged forty-one years, with placenta prÆvia, died from hÆmorrhage, and an asphyxiated foetus was promptly extracted by coeliotomy. Prolonged efforts at artificial respiration were successful, and the child was well five weeks later (see also Sippel). ReferencesHugier, M., and Monod, M. CÆsarean Operation immediately after the death of the Mother. Lancet, 1829–30, i. 899. MÖglich. Ueber Kaiserschnitt an der Toten. MÜnchener med. Wochensch., 1908, lv. 202. Sippel. Sectio CÆsarea in mortua. Monats. f. Geb. u. Gyn., 1907, xxvi. 618. OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOURAlthough the directions in surgical writings are clearly laid down concerning the course to be pursued when pregnancy and labour are complicated by an ovarian tumour, the difficulty which often confronts the operator when he is face to face with the actual case is uncertainty regarding the nature of the tumour. Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine foetus (lithopÆdion), or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a CÆsarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. It may be useful also to mention what unexpected conditions are sometimes found. Thus an experienced gynÆcologist like Prof. Olshausen once removed a gravid uterus under the impression that it contained a cystic fibroid which would obstruct delivery. When it was examined after removal, the suspected fibroid proved to be a large sacral teratoma growing from the foetus. Ovarian tumours and pregnancy. Before the fourth month of pregnancy, single and double ovariotomy is attended with a low rate of mortality, and the risk of disturbing the pregnancy is small. The removal of a parovarian cyst during pregnancy is more liable to be followed by abortion than single or double ovariotomy. After the fourth month the risk is that of an ordinary ovariotomy, but the chances of abortion increase with each month. It is also a fact that ovariotomy may be safely carried out between the eighth and ninth months of gestation without precipitating labour, even when the tumour is incarcerated in the pelvis. In many cases in which ovariotomy is urgently indicated during pregnancy, the pedicle will be found twisted. When the tumour is situated above the uterus there is rarely any difficulty in dealing with it, as the pedicle is usually long, but it will require extra care in applying the ligature, as the tissues, being unusually vascular and soft, are easily lacerated. Occasionally the tumour lies in the pelvis below the uterus: in this case the surgeon carefully insinuates his hand between the pelvic wall and the uterus, and then gently withdraws the tumour from its incarcerated position. Cases in which Ovariotomy has been performed near the End of the Ninth Month of Pregnancy In operating for ovarian cysts complicating pregnancy, the surgeon should, after removing the cyst, carefully examine the other ovary, for twin tumours may be present. Berry Hart performed ovariotomy on a woman in the fifth month of pregnancy, and removed a dermoid of the left ovary ‘enlarged to about the size of a man’s brain by recent hÆmorrhage due to the twisting of a pedicle’. The patient died on the ninth day. A frozen section was made of the pelvis, and on inspecting the cut surface the right ovary, converted into a dermoid, was found incarcerated by the gravid uterus. Many cases have been published in which ovariotomy has been undertaken during the late months of pregnancy, or shortly after delivery, and the surgeons have been astonished to find both ovaries converted into tumours; in very many instances they were dermoids. Cases of this kind have been recorded by Knowsley Thornton, F. Page, Cullingworth, Berry Hart, Malcolm Campbell, and others, including myself. These Campbell relates that Brewis, in performing an ovariotomy during pregnancy, attempted to conserve some ovarian tissue by resecting the dermoids; this proved impracticable, and both ovaries were excised. Miss Ivens records a case in which a woman thirty-five years of age was five months pregnant and required ovariotomy on account of an incarcerated ovarian dermoid. In the course of the operation both ovaries were found to contain dermoids. A tumour was successfully excised from each. Pregnancy continued undisturbed. ReferencesCampbell, M. Case of Bilateral Ovarian Dermoid Tumour associated with Pregnancy. Lancet, 1907, ii. 1760. Cullingworth, C. J. Three cases of Suppurating Dermoid Cyst, of or near the Ovary, treated by Abdominal Section. St. Thomas’s Hospital Reports, 1887–9, xvii. 139. Hart, Berry. See Clarence Webster’s Researches in Female Pelvic Anatomy, Edin., 1892, p. 124. Ivens, Miss F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts. Brit. Med. Journal, 1908, i. 625. Page, F. Acute Peritonitis after Confinement; abdominal section; Dermoid Disease of both Ovaries; removal; recovery. Lancet, 1893, ii. 250. Thornton, K. A case of removal of both Ovaries during Pregnancy. Trans. Obstet. Soc., London, xxviii. 41. Ovariotomy during labour. When an ovarian tumour is discovered during labour and it impedes delivery, ovariotomy should be performed. In this condition it follows that the tumour lies in the pelvis; when the tumour is tightly impacted by the contracting uterus it has happened that the surgeon has been unable to reach the tumour until he has emptied the uterus by CÆsarean section. Several operators have had this difficulty, myself among them. I have added a list of reported cases drawn from British sources. For this I hope not to be accused of what is sometimes perhaps facetiously called ‘insularity’. The enormous population of these islands should furnish material enough to settle the principles of treatment which should govern these terrible cases of obstructed labour. One of the commonest conditions met with in ovariotomy during pregnancy and labour is to find that the cyst has undergone axial rotation and twisted its pedicle. The technique in these circumstances is very simple. Ovariotomy for Tumours obstructing Labour at Term
1 In these cases it was necessary to perform CÆsarean section in order to extract the tumour from the pelvis. A Uterus distorted by Fibroids Fig. 22. A Uterus distorted by Fibroids. It contains a foetus of four months’ development. Removed by the subtotal operation from a primigravida, aged 42. Half size. Ovariotomy during the puerperium. It occasionally happens that a woman may go through her pregnancy and labour with an unrecognized ovarian tumour in her abdomen; during the puerperal period it may cause symptoms which lead to its recognition, because in the course of the labour the cyst may burst, undergo axial rotation, or suppurate. When a puerperal woman possesses an ovarian tumour Single and even double ovariotomy can be performed during puerpery without in any way interfering with involution of the uterus or lactation. In 1896 I was able to collect fifteen recorded cases of double ovariotomy during pregnancy, and sixteen in which ovariotomy was performed during the puerperium, or shortly after abortion. Since this date McKerron has collected the statistics relating to the whole question of pregnancy and ovarian tumours in a very comprehensive manner. ReferencesBland-Sutton. Surgical Diseases of the Ovaries, &c., London, 1896, 2nd Ed. pp. 180–91. —— The Surgery of Labour and Pregnancy, complicated with Tumours, Lancet, 1901, i. 382, 452, 529. McKerron, R. G. Pregnancy, Labour, and Childbed with Ovarian Tumour, London, 1903. Fibroids and pregnancy. In a large number of instances in which operations have been undertaken when fibroids complicate pregnancy, they have been performed on an erroneous diagnosis. The tumours when small and placed laterally simulate ovarian cysts; when large and lying high in the abdomen they have been mistaken for renal tumours, and when low in the pelvis they have been regarded as incarcerated ovarian cysts. The variety of fibroid most likely to lead to operation, under the impression that it is an ovarian cyst, is an interstitial fibroid which becomes painful in consequence of undergoing red degeneration. The difficulty which faces the surgeon in this condition is to decide on a safe course. When the tumour is not likely to cause difficulty it may be wise to close the abdomen. If the tumour is pedunculated and incarcerated, he may be able to extract the tumour and ligature the pedicle without disturbing the pregnancy; a big fibroid invading the broad ligament may be enucleated; a large cervix fibroid will render delivery impossible, and will necessitate hysterectomy. A study of many recorded cases in which hysterectomy has been performed on account of fibroids complicating pregnancy shows that the operation had been undertaken on account of a great increase in the size of the tumours, the concurrent pregnancy not being discovered until the parts were examined after removal. Hysterectomy may be necessary at any time during pregnancy; after labour has begun; and during puerpery on account of fibroids. During pregnancy it is a straightforward operation, the subtotal operation being Fibroids have many times been enucleated from the gravid uterus and the pregnancy has gone successfully to term. When pregnancy complicated with fibroids goes to term and the tumour occupies the neck or the lower segment of the uterus so as to offer an impassable barrier to the passage of the foetus, abdominal hysterectomy is a necessity. Red Degeneration. Among the new things which the surgical treatment of uterine fibroids has brought to light is a knowledge of that change to which these tumours are liable, known as ‘red degeneration’. This increase in our knowledge of the pathology of fibroids is extremely useful in diagnosis, for red degeneration is especially liable to occur in fibroids lodged in a pregnant uterus, and, as I pointed out in 1904, it has the effect of rendering them painful. One of the most striking features of a uterine fibroid is its insensitiveness, and equally remarkable is its painfulness and tenderness when in a state of red degeneration, but these signs are only exhibited by such fibroids when associated with pregnancy. Red degeneration, even in an extreme degree, in fibroids occupying the walls of a non-gravid uterus is, as a rule, painless. It is also curious that a gravid uterus may contain four or five fibroids, the size of large potatoes, in its walls, yet only one will exhibit this red degeneration and become acutely painful, whilst its companions remain as insensitive as apples. In the early stages of this change the fibroid exhibits the colour in streaks, but as the pregnancy advances it permeates the whole tumour. Occasionally in the mid-period of pregnancy this necrotic change may be so extreme that the central part (sometimes the whole) of the tumour is reduced to a red pulp. A Gravid Uterus In Sagittal Section The woman miscarried at the seventh month: delivery was obstructed by a cervical fibroid. The parts were removed by total hysterectomy. The small fibroid is in the condition of red degeneration (Museum, R. College of Surgeons). Half size. The suddenness with which this pain comes on may be illustrated briefly by the following case:—A primigravida, aged 30, two months pregnant, was seized with sudden pain during a railway journey. Her condition became so alarming that she left the train at an intermediate station and placed herself under the care of a doctor whom she knew. A large, tender, and increasing swelling was found in the abdomen. The doctor regarded the patient’s trouble as being due to rupture of a tubal pregnancy. He asked me to see the patient, and I found a large swelling on the right side of the abdomen reaching as high as the liver. I considered that some change had taken place in this tumour consequent on It is a curious and noteworthy fact that many of the operations tabulated on pp. 81 and 82 were undertaken on an erroneous diagnosis. In some the acute pain and tenderness of which the patients complained led the surgeons to believe that the troubles were due to an ovarian cyst which had twisted its pedicle, or to the bursting (or abortion) of a gravid Fallopian tube. Practitioners and obstetricians are now becoming familiar with the fact that when a pregnant woman, who has also fibroids in the uterus, complains of sudden acute pain, it may be due to one of the fibroids undergoing red degeneration. The cause of this change is unknown. Lorrain Smith and Fletcher In my early investigations of this disease I often took the tumours to the bacteriological laboratory with the hope of finding some micro-organism which would account for the degeneration. The results were so persistently negative that the search was abandoned. Since learning that Smith and Shaw had found micro-organisms in two cases I had the next specimen which came to hand examined, and it happened to be the fibroid obtained from the acute case described on p. 79. From the softened parts Mr. Somerville Hastings succeeded in obtaining staphylococcus pyogenes aureus in pure culture. The views here expressed in regard to the red degeneration of fibroids are founded on an examination of thirty-four recent examples. ReferencesBland-Sutton, J. The Inimicality of Pregnancy and Uterine Fibroids. Essays on Hysterectomy, 1905, 76. Fairbairn, J. S. A Contribution to the Study of one of the Varieties of Necrotic Changes in Fibro-myomata of the Uterus. Journ. of Obstet. and Gyn. of the British Empire, 1903, iv. 119. Smith, J. L., and Shaw, W. F. On the Pathology of the Red Degeneration of Fibroids. Lancet, 1909, i. 242. Cases of Hysterectomy performed on Patients in Labour in which the Obstruction was due to Fibroids
The aim of the surgeon is to save the life of the child as well as that of the mother. To this end, when the operation is carried out and the uterus exposed the child is extracted by CÆsarean section. Then in the majority of cases total or subtotal hysterectomy is performed. This is sometimes clumsily termed CÆsarean hysterectomy. In some instances the operator has been content merely to perform CÆsarean section in the hope that the patient may wish to reconceive. In order to afford some notion of the frequency with which fibroids cause trouble to pregnant and parturient women, I have collected thirty-six cases which have been reported to the London Obstetrical Society from 1900 to 1908 (both years inclusive), and arranged them in the subjoined tables: they show in an unmistakable way that pregnant women with fibroids do often require aid from surgery, and that such efforts are rewarded with success. There is no condition which simplifies hysterectomy so much as pregnancy. A Table of Cases in which Abdominal Hysterectomy was performed for Pregnancy complicated with Fibroids These cases are recorded in the Transactions of the Obstetrical Society, 1900–8, both years inclusive.
Table of Cases in which Abdominal Myomectomy was performed during Pregnancy From the Transactions of the Obstetrical Society, 1900–8, both years inclusive.
Pregnancy complicated with cancer of the cervix. When a pregnant woman comes under observation with cancer of the neck of the uterus in an operative stage in the early months, hysterectomy should be performed: in some instances the cervix has been amputated without disturbing the pregnancy. In the later stages good consequences follow the induction of labour and the immediate performance of hysterectomy. Surprising as it may seem, a uterus immediately after labour can be safely extirpated through the vagina. When the cancer is so advanced as to be inoperable, the pregnancy should be allowed to go to term, and if the cancerous mass offer an impassable barrier to delivery, CÆsarean section should be performed. This operation has been found necessary to extract a dead foetus. Most surgeons in dealing with operable cases of this complication of pregnancy remove the parts through the vagina, because in the abdominal operation the septic cervix is withdrawn through the abdomen; this makes it extremely difficult to avoid soiling the pelvic peritoneum. Concurrent uterine and tubal pregnancy. This condition may require operation in three different circumstances:— 1. Tubal and uterine pregnancy occur simultaneously and the complication is recognized in the early months. Here the operation would be that of oÖphorectomy, and the uterine pregnancy may continue undisturbed to term. 2. Intra- and extra-uterine gestation with living foetuses runs concurrently to term. This is an exceedingly dangerous, though a rare, combina 3. Uterine pregnancy is complicated by the presence of a quiescent (sequestered) extra-uterine foetus. Many cases have been reported in which a foetus of this character has occupied the pelvis, yet the woman conceived and the child was safely delivered at term; but a sequestered foetus may constitute an impassable barrier and require removal (Operations for Compound Pregnancy, see p. 33). Pregnancy complicated by tumours growing from the pelvic walls. When the pelvis is occupied by a chondroma, osteoma, or a sarcoma growing from the innominate bones or the sacrum, or from the fascia of the pelvis and displacing the gravid uterus, the proper course is to perform subtotal hysterectomy. If the obstruction is not detected until the child is viable, and there is no especial call for urgency, interference should be postponed until near term; the child can then be saved by CÆsarean section, and the uterus removed. The operation in such circumstances calls for the exercise of judgment, but it is rarely difficult. Among interesting tumours complicating labour and obstructing delivery, special mention may be made of dermoids and teratomata lying in the hollow of the sacrum. Skutsch has collected the chief German records. Echinococcus cysts (hydatids) have grown in the pelvic connective tissue and obstructed labour. Cases have been reported by Knowsley Thornton, KÜstner, Blacker, and others. ReferencesBlacker, G. F. Clinical Lecture on Uterine Fibroids complicating Pregnancy. The Clinical Journal, 1908, xxxi. 309. KÜstner. Kaiserschnitt wegen eines Echinokokkus im Becken. Zentralbl. f. GynÄk., 1907, xxxi. 1390. Skutsch, F. Ueber die Dermoidcysten des Beckenbindegewebes. Zeitsch. f. Geburts. and GynÄk., 1899, xl. 353. Thornton, J. K. Removal of Hydatids of the Omentum and from the Pelvis. Medical Times and Gazette, 1878, ii. 565. OPERATIONS FOR PUERPERAL SEPSIS (METASTATIC BACTERIÆMIA)Acute septic infection (puerperal) of the uterus, too frequent even in this antiseptic epoch, is a desperate condition, but attempts have been made to deal with it by two methods—either hysterectomy, or the ligature and excision of the thrombosed ovarian veins. So far as hysterectomy for this condition is concerned, it may be stated In some cases of puerperal pyÆmia a careful examination of the patient’s abdomen has enabled the surgeon to feel the thrombosed ovarian vein, and in others the vein has been exposed by an incision running from the tip of the eleventh rib to the spine of the pubes, parallel with Poupart’s ligament. The muscles are divided and the peritoneum reached; this is reflected until the thrombosed ovarian vein is exposed and separated from the ureter. About half an inch below its junction with the renal vein or the vena cava, as the case may be, it is securely ligatured and divided; the vein is then slit up and the clot turned out. The operation, when carried out in this way, is extraperitoneal. In some instances successful ligature of the thrombosed ovarian vein has been effected by the usual median incision into the peritoneal cavity. The object of ligaturing the thrombosed ovarian vein is to prevent the pathogenic micro-organisms in the clot from entering the circulation. Bumm reported five cases in which he ligatured these veins. Three of the patients recovered. It is more than probable that if operative interference be carried out on thrombosed ovarian veins before the condition of the patients become desperate, more of them might be rescued. Success has been attained even in desperate conditions; for example, Friedemann ligatured these veins in a woman whose general condition was not only bad, but who also had extensive bed-sores. She recovered. T. G. Stevens reported the details concerning a woman who died, of acute septicÆmia, eleven days after a subtotal hysterectomy (by Galabin) for fibroids. The right ovarian vein was thrombosed from the ligature in the pelvis to its entrance into the vena cava, and he isolated from the clot and produced in cultures the bacillus pyocyaneus. He also stated that ‘the vein could have been easily dissected out, and possibly the fatal result might have been averted’. This operation rests on sound principles, for the ligature of the ovarian veins prevents the septic blood entering the circulation, thereby setting up, among other things, endocarditis and pulmonary embolism. The great difficulty in dealing with this condition is the selection of suitable cases. Experience teaches that acute cases are unsuitable. The ReferencesBumm, E. Zur operativen Behandlung der puerperalen PyÄmie. Berliner Klin. Wochensch., 1905, xlii. 829. Cuff, A. A Contribution to the Operative Treatment of Puerperal PyÆmia. Journ. of Obstet. and Gyn. of the British Empire, 1906, ix. 517. Ferguson, J. Haig. Abdominal Hysterectomy for Acute Puerperal Metritis and Acute Salpingitis. Obstet. Transactions, Edin., 1906, xxxi. 123. Friedemann, G. Die Unterbindung der Beckenvenen bei der pyÄmischen Form des Kindbettfiebers. MÜnchener Med. Wochensch., 1906, liii. 1813. Lendon, A. A. Puerperal Infection, Thrombosis: Ligature of the Right Ovarian Vein. Australian Medical Journal, 1907, xxvi. 120. Michels, E. The Surgical Treatment of Puerperal PyÆmia. Lancet, 1903, i. 1025. Stevens, T. G. The Bacteriological Examination of a Thrombosed Ovarian Vein (following Hysterectomy). Trans. Path. Soc., li. 50. Trendelenburg, F. Ueber die chirurgische Behandlung der puerperalen PyÄmie. MÜnchener Med. Wochensch., 1902, xlix. 513. CHAPTER X OPERATIONS FOR INJURIES OF THE UTERUS Injuries of the uterus fall into six groups:— 1. GynÆcological injuries. 2. Obstetric injuries. 3. Injuries to the pregnant uterus. 4. Injuries to the pregnant uterus in the course of abdominal operations. 5. Bullet-wounds of the pregnant uterus. 6. Stab-wounds of the pregnant uterus. GynÆcological injuries. The simplest and certainly the commonest accident is perforation of the uterus with a sound, dilator, or forceps in the operation of curetting. Many cases are known in which the uterus has been perforated by clean instruments of this class and the patients have suffered no inconvenience. On the other hand, when the sound or the uterus is septic, perforation of the uterus has been followed by a rapidly fatal peritonitis; indeed, some of these injuries may prove as lethal as a snake-bite. Occasionally very serious consequences follow simple perforations by dilators and curettes; this has induced some gynÆcologists to urge that if, in the course of dilatation and curettage of the uterus, a rupture or perforation of the uterine wall occurs, it is better to perform a coeliotomy and assure oneself of the safety of the patient than to hope that no untoward result will ensue. This advice is too sweeping. When the perforating instrument is clean, and there is little or no bleeding, the case may be left to itself; if untoward signs arise, coeliotomy should be performed. Sometimes a pelvic abscess occurs as a sequence to the accident, and will require evacuation through the vaginal fornix, or, perhaps, by means of an incision in the flank. Verco found a piece of a curette, 2¾ inches long, in an abscess cavity behind the uterus. The patient had been curetted two weeks previously. A perforation, or a rent in the uterine wall, in the course of curetting, is a serious accident when the operator is unaware that such has happened, and proceeds to flush out the uterine cavity with poisonous antiseptic Injuries, in the course of instrumentation of the uterus, are not always mere perforations; some are wide rents—and this is an especial danger in removing sessile submucous fibroids (vaginal myomectomy). A serious complication of tears or rents of the uterine wall, whether the uterus is gravid or non-gravid, is extrusion or prolapse of the intestine. It is also remarkable that in several reported cases the practitioner has mistaken the intestines for ‘secundines’, even in unimpregnated uteri, and has withdrawn them, and even cut lengths of intestine away, before recognizing his error. In one case of this kind, where a practitioner had withdrawn and removed several feet of intestine through a rent in the course of a curettage, I performed coeliotomy, closed the hole in the uterus, joined the cut ends of the bowel with sutures, resected the mesentery belonging to the removed bowel, and thus saved the patient’s life. In another case, where a practitioner had torn the uterus during curettage and intestine appeared in the vagina, there was such free bleeding that I found it prudent to perform subtotal hysterectomy. This patient also recovered. Successful operations of this kind have also been performed by Werelius and Nixon Jones. Palmer Dudley relates that on one occasion, in curetting a recently gravid uterus, he tore the posterior wall without being aware of it, and withdrew eight inches of intestine, thinking it to be secundines; he recognized the error, and pushed the intestine back through the opening in the uterine wall. The patient recovered, and subsequently had two successful pregnancies. These cases show how impossible it is to recommend any hard and fast lines of treatment. Much depends on the circumstances of the case, the character of the injury, and above all on the experience and resourcefulness of the practitioner. Ruptures or tears of the uterus in the process of instrumental dilatation or curettage are by no means rare, and they have a high mortality. Jakob of Munich collected 141 instances of such injuries, and of these twenty-three died chiefly from septic peritonitis. Among these injuries seventy-three were inflicted with the curette, nineteen with the sound, fourteen with forceps (AusrÄumungszangen), and six were due to flushing catheters. Obstetric injuries. The uterus is liable, during labour, to be torn, as a result of its own expulsive efforts, especially when the transit of the foetus is hindered or obstructed by narrowness of the pelvic outlet, tumours, or undue size of the child. This form of injury is called The literature relating to this accident is abundant, and the reports issued from lying-in institutions deal with extensive figures, but unfortunately the reporters are not in harmony on the principles of treatment. There are three methods of dealing with rupture of the uterus:— 1. Treating the patient conservatively, which means at most lightly packing the part with antiseptic gauze. 2. Performing coeliotomy and stitching up the rent in the uterus. 3. Hysterectomy, preferably by the abdominal route, as this enables the peritoneal cavity to be cleared of clot. The only point in which there is any semblance of agreement among obstetricians is this: in cases of complete rupture, in which the foetus and membranes are extruded from the uterus into the belly, coeliotomy is clearly indicated. Admirable reports have been published by Walla, Klien, Ivanoff, and Munro Kerr. Klien’s is a critical and very valuable study, based upon 347 cases of rupture of the uterus published in the preceding twenty years. Of these cases 149 were operated upon, with a mortality of 44 per cent.; 198 were not operated upon, 96 recovered and 102 died—a mortality of 52 per cent. Among the unoperated cases some were not treated in any way, and in these the mortality was 73 per cent., whilst in those treated by drainage, plugging and irrigation, the mortality was only 37.5 per cent. When there is dangerous bleeding Klien advises immediate operation. Lacerations of the vagina make the prognosis unfavourable, and especially injury of the bladder. During the last ten years hysterectomy has been so much improved and the technique so simplified, that the operative treatment of complete rupture of the gravid uterus will be more frequently undertaken in the future than it has in the past, and with every prospect of reducing the heavy bill of mortality at present associated with this grave accident. Donaldson (1908) reports a remarkable case in which the uterus ruptured during forceps delivery; 12½ feet of small intestine, detached from the mesentery, were extruded with the foetus. Coeliotomy was performed, the detached intestine cut away, and the proximal end of the bowel anastomosed into the cÆcum. A long rent in the posterior wall of the uterus was closed with sutures. The patient survived the accident ten days, and died from sepsis; ‘the entire uterus seemed to be a sloughing mass.’ Donaldson states that, had he removed the uterus at the time he operated on the intestine, the patient would probably have survived. Injuries to the pregnant uterus. Some of the most remarkable injuries inflicted on the gravid uterus are the consequences of attempts to induce what is technically called criminal abortion, especially when the abortion is self-induced. Kehr has recorded an example of a desperate effort of this kind:—A widow, twenty-nine years of age, when in the fifth month of an illicit pregnancy, fired a revolver bullet into the uterus through the anterior abdominal wall. Coeliotomy was performed, and the wound in the uterus closed by suture. The woman aborted on the fourteenth day, but recovered. A gravid uterus in the later months of pregnancy is a big organ, and, like the abdominal viscera generally, may be severely damaged by blows, kicks from horses or brutal men, butts from animals, such as a calf or a goat, falls upon the belly, or a fall downstairs, or the woman may be run over. The treatment to be adopted in these conditions varies widely with the circumstances. As a general rule it may be stated that the most satisfactory mode of treatment is coeliotomy; this permits a thorough examination of the organ, and facilitates removal of effused blood. In the late stages of pregnancy accidents of this kind entail CÆsarean section. Among the most curious injuries of this group are those known as horn-rips: these are cases in which the pregnant uterus is torn open by the horn of a bull. An interesting collection of cases illustrating this accident has been made by Robert P. Harris. Even after very severe injuries, in some of which the intestines protruded, women have recovered, and several children survived this terrible mode of delivery. Injury to a gravid uterus in the course of an abdominal operation. In spite of every care it has happened on many occasions that a pregnant uterus has been mistaken for an ovarian cyst, the abdomen has been opened and a trocar plunged into the uterus. In some instances a uterus in which the pregnancy has advanced as far as the sixth month has been removed under the impression that it was a large ovarian cyst, and this accident has happened with a pregnant uterus greatly enlarged in the somewhat rare condition known as hydramnios. A pregnant uterus is also liable to be stabbed by an ovariotomy trocar when the condition is complicated with unilateral or bilateral ovarian cysts. The gravid uterus has very thin walls and, occasionally, resembles so very closely an ovarian cyst as to deceive an inexperienced operator. When the surgeon finds that he has injured a pregnant uterus in the course of an abdominal operation three courses are open to him, each of which has been practised with success by surgeons of renown:— 1. Sew up the incision in the uterus. 2. Perform CÆsarean section. 3. Remove the uterus (subtotal hysterectomy). Several cases have been reported in which injury to a gravid uterus during ovariotomy has terminated fatally, especially when the surgeon followed the plan of sewing up the wound in the uterus. A careful consideration of the reported cases indicates that the best results follow for the patient when the surgeon performs CÆsarean section, as the following record shows:— Sir Spencer Wells had removed a large, multilocular ovarian cyst from the left side of the patient, when he felt what was supposed to be a cyst of the right ovary. When tapped it was found to be a gravid uterus, in which pregnancy had advanced to near the fifth month. CÆsarean section was at once performed and the patient recovered. Injuries of this kind are rarely likely to happen now, for the clumsy ovariotomy trocar is passing out of use. Bullet-wounds of the pregnant uterus. These are very rare, and, like rupture of the uterus, liable to be complicated with injury of the intestines; it is for this reason that the canon of surgery applicable to penetrating wounds of the abdomen should be practised in these circumstances, and the patient submitted to coeliotomy. When the gravid uterus is penetrated by a bullet there may be little bleeding on account of the contracting property of the uterine tissue. In some instances amniotic fluid stained with blood escapes. In operating, the anterior as well as the posterior surface of the uterus should be The best method of dealing with the uterus in such conditions is undetermined, but a study of the few reported cases indicates that the best results follow coeliotomy, with suture of the perforated intestine and the hole or holes in the uterus. The patients usually abort. In Prichard’s case (Fig. 24) hysterectomy was performed, but the patient died. Even in some apparently desperate cases good consequences follow the conservative operation, as the following reports demonstrate:— In a case under the care of Albarran, the patient was aged nineteen years and in the fifth month of pregnancy when shot. There were four perforations of the small intestines, and the mesenteric artery was wounded. He resected 20 centimetres of small intestine. A loop of umbilical cord protruded through the bullet-hole in the uterus; this was resected and the ends of the cord tied. The patient miscarried a few hours after the operation, but recovered. Baudet reported a case in which there were four perforations of the small intestine: he sutured the wounds in the uterus and the holes in the bowel; the woman aborted some hours after the operation, but recovered. In a case under Robinson’s care the bullet entered the uterus and penetrated the right shoulder of the foetus. The patient, who was in the eighth month of pregnancy, quickly miscarried. The bullet was found in the dÉbris. The patient not only recovered, but reconceived, and gave birth to another child in the following year. Stab-wound of the pregnant uterus. Examples of this kind of injury are rare, but some of the recorded cases are remarkable. Guelliot has recorded the details of a case in which a pregnant woman was stabbed in the buttock. The knife passed through the great sciatic notch, and penetrated the uterus and the child’s skull. The woman miscarried of a dead foetus next day. The great sciatic nerve was injured, but the woman recovered, though she remained lame. Steele recorded an example where a woman, six and a half months pregnant, stabbed herself in the lower abdomen with a knife; she was taken to a hospital and kept at rest until the wound healed. Six weeks after the injury the woman was delivered of a live male child, normally developed, but much of the child’s large and small intestines protruded through an opening in the abdomen. The jejunum was ReferencesAlbarran. Plaies multiples de l’intestin et de l’utÉrus gravide par balle de revolver. Bull. et MÉm. de la Soc. de Chirurgie de Paris, 1895, xxi. 243. Baudet, R. Plaies de l’intestin et de l’utÉrus gravide par balle de revolver. Bull. et MÉm. de la Soc. de Chir. de Paris, 1907, xxxiii. 779. Bland-Sutton, J. A Clinical Lecture on the Treatment of Injuries of the Uterus. The Clinical Journal, 1908, xxxi. 289. On two cases of Abdominal Section for Trauma of the Uterus. The Am. Journal of Obstetrics, 1907, lvi. Braun-Fernwald, R. von. Über Uterusperforation. Zentralbl. f. Gyn., 1907, xxxi. 1161. Congdon, C. Abdominal Section for Trauma of the Uterus. The Am. Journal of Obstetrics, 1906, liv. 618. Donaldson, H. J. An unusual Obstetric Complication, causing the removal of 126 inches of Small Intestine. Surgery, GynÆcology, and Obstetrics, 1908, vi. 417. Dudley, P. Discussion on Accidental Rupture of the Non-parturient Uterus. Trans. Am. Gyn. Soc., 1905, xxx. 21. Guelliot. Coup de couteau ayant pÉnÉtrÉ À travers l’Échancrure sciatique jusqu’À l’utÉrus gravide et jusqu’au foetus, &c. SociÉtÉ de Chirurgie, 1886, xii, 337. Harris, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of Pregnant Women. The Am. Journal of Obstetrics, 1887, xx. 673. Ivanoff, N. De l’Étiologie, de la prophylaxie et du traitement des ruptures de l’utÉrus pendant l’accouchement. Annales de GynÉcologie, 1904, 449. Jakob, J. Gefahren der intra-uterinen instrumentalen Behandlungen. Zentralbl. fÜr Gyn., 1906, xxx, No. 19, 561. Jarman, G. W. Accidental Rupture of the Non-parturient Uterus, with report of cases. Trans. of the Am. Gyn. Society, 1905, xxx. 15. Kehr, H. Über einen Fall von Schussverletzung des graviden Uterus. Centralbl. fÜr Chir., 1893, xx. 636. Kerr, Munro. On Rupture of the Uterus. Brit. Med. Journal, 1907, ii. 445. Klien. Die operative and nichtoperative Behandlung der Uterusruptur. Arch. f. Gyn., 1901, lxii. 193. Prichard, A. W. A case of Bullet-wound of the Pregnant Uterus. Brit. Med. Journal, 1896, i. 332. Robinson, W. S. Death of Foetus in utero from Gunshot-wound: Recovery of the Mother. Lancet, 1897, ii. 1045. Steele, D. A. K. Stab-wound of Foetus in utero. Surgery, GynÆcology, and Obstetrics, 1908, vi. 293. Verco, W. A. The Australian Med. Gazette, 1908, 681. Walla, A. von. Ruptura uteri completa, abdominale Totalextirpation. Heilung. Centralb. fÜr GynÄk., 1900, xxiv. 497. CHAPTER XI THE AFTER-TREATMENT. RISKS AND SEQUELÆ OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS The performance of ovariotomy, hysterectomy, and allied procedures is attended by several risks, immediate and remote, which may spoil the best-planned and most carefully executed operation. Some of these may be avoided by careful attention to the details embraced by the phrase ‘after-treatment’. THE AFTER-TREATMENT OF ABDOMINAL OPERATIONSThe patient is returned to the bed with gentleness and usually lies on her back, but many anÆsthetists prefer to turn the patient on one or other side for an hour, until there is a fair return to consciousness. The patient then lies on her back and a pillow is placed under the knees. Hot-water bottles should not be placed in the bed with the patient until she is completely conscious, and they are rarely needed. The healing of blisters caused by hot-water bottles is a slow process. During the first twelve hours the patient complains of pain, thirst, and vomiting. The thirst is in a measure relieved by administering six or eight ounces of normal saline solution by the rectum an hour after the patient returns to bed, and repeating it in three or four hours. The patient may wash her mouth out frequently with water, hot or cold, according to her fancy, and if there is no vomiting she may swallow a little hot water from time to time. As a rule, it is better for her to abstain from swallowing anything for the first eighteen hours; the best way to avoid vomiting after an anÆsthetic is to keep the stomach empty. There is always some pain after an abdominal operation, partly due to tension on the sutures, and colic. The injection of normal saline solution (a teaspoonful of salt to a pint of water) by the rectum often controls this, but occasionally the pain is so severe that it is necessary to give a quarter of a grain of morphine hypodermically, or in a suppository, about twelve hours after the operation, in order to procure sleep. The routine use of morphine after these operations is injudicious and rarely necessary. At the end of twenty-four hours small quantities of barley-water, tea, When vomiting is very troublesome, it is sometimes necessary to keep a patient on rectal feeding two or three days. When there is abdominal distension, this may be relieved by the passage of a rectal tube at intervals of three hours, and if this fails a turpentine enema should be given. Patients should always be encouraged to empty their bladder naturally: many are unable to pass water whilst lying on their backs. In these cases the urine is drawn from the bladder by a carefully sterilized glass catheter. Before passing the catheter, the nurse carefully wipes away the mucus from the urethral orifice. Cleanliness and care with the catheter must be enforced: cystitis causes much misery. During the first few days the quantity of urine passed by the patient is measured, and recorded in the notebook. The temperature should be observed every four hours during the first week and recorded. The first record after the operation is usually subnormal, and in twelve hours it rises to normal or beyond. During the first twenty hours it may rise to 100° without causing alarm; beyond this, if accompanied by a rapid pulse, an anxious face, and distended belly, it will cause anxiety to the surgeon. A temperature of 101° or 102° unaccompanied by other unfavourable symptoms is not a cause for alarm, unless maintained. The state of the pulse is a valuable guide and more trustworthy than the temperature. When the pulse remains steady and full there is no cause for alarm. When it increases in frequency to 120 or 130 beats per minute, and is thin and thready, then there is danger, even if the temperature is only slightly raised. On the seventh or eighth day the sutures will require removal. Occasionally a hÆmatoma forms in the wound; and in patients in whom the operation has been performed for septic conditions, stitch abscesses will occur. In septic cases the sutures require to remain a few days longer, to allow the wound to unite more securely. When oÖphorectomy, ovariotomy, or hysterectomy is followed by a non-febrile convalescence the patient may be allowed to leave her bed on the fourteenth day, and at the end of another week she may return to her home or go to the seaside according to circumstances. When the wound has healed by primary union, and this is usual where aseptic methods have been followed and buried sutures employed for the fascial and muscular layer, an abdominal belt is unnecessary. When COMPLICATIONS OF ABDOMINAL GYNÆCOLOGICAL OPERATIONSMetrostaxis. After ovariotomy and oÖphorectomy, unilateral or bilateral, blood sometimes escapes from the uterus in the course of the first week, and simulates menstruation: it sometimes occurs within forty-eight hours of the operation, and is usually ushered in with a rise of temperature (100°-101°). Bed-sores. These sometimes give trouble when operations are performed on elderly or enfeebled patients, especially when they are thin and have incontinence of urine. With due watchfulness and care on the part of the nurse a bed-sore ought rarely to occur. Post-anÆsthetic paralysis. Paralysis following operations on the pelvic organs occurs in connexion with the upper and lower limbs; it is an awkward and avoidable complication. Some of the simplest cases are those which arise from the pressure upon an individual nerve, such as the ulnar, circumflex, or musculo-spiral, due to the arm coming in contact with the sharp edge of a metal operating table. When the patient’s legs are flexed across the sharp edge of the table and fixed, as in the Trendelenburg position, during a long operation, the external popliteal nerve is liable to be pressed upon by the condyles of the femur. This will lead to paralysis of the muscles supplied by it. In some instances the paralysis is bilateral. Paralyses of this kind are identical with what are known as ‘sleeping palsies’. The more serious paralyses are directly due to the Trendelenburg position, in which there is a great tendency for the arms to be displaced over the head and hang downwards or abducted, as this position causes the clavicle to compress the nerves of the brachial plexus upon the first rib, or the scalenus anticus muscle, and perhaps, as some observers believe, between the clavicle and the transverse processes of the fifth and sixth cervical vertebrÆ. Most of the writers on this subject attribute the paralysis more particularly to drawing the head to one side when the patient lies in the Trendelenburg position with abducted upper limbs, as it tends to stretch the lower cervical nerves of the opposite side, especially the fifth. This stretching is probably a greater factor in producing paralysis than pressure. The form of paralysis produced in this way is that known as Erb’s palsy, and the muscles particularly concerned are the deltoid, brachialis anticus, biceps, and the supinator longus. Sometimes the spinati are involved. Occasionally the paralysis is bilateral. A case has been reported in which there was a total lesion of the brachial plexus, including the muscles of the shoulder girdle. The following facts serve to show that stretching rather than pressure is responsible for this class of paralyses. A patient had undergone a vaginal operation in the crutch position, when the assistant drew her along the table by means of his fingers hooked in the axillÆ over the folds of the pectoral muscles: next morning both upper limbs were found to be paralysed, and they remained in this condition many weeks. In some of the lighter forms the paralysis passes off in a few days, but cases are known in which it has persisted for many months, and as it renders the limb useless for a time it is a serious matter. Halstead refers to a case of bilateral peroneal paralysis following salpingectomy in the Trendelenburg posture which disabled a patient for six months. On the whole prognosis is favourable, and recovery the rule. BÜdinger has described a case in which the upper limb was paralysed after an abdominal operation. The patient died some weeks later, and a clot of blood was found pressing on the surface of the brain at a spot corresponding to the arm centre. ReferencesBÜdinger. Über LÄhmungen nach Chloroformnarkosen. Archiv f. klin. Chir., 1894, Bd. xlvii. 121. Cotton, F. J., and Allen, F. W. Brachial Paralysis—Post-narcotic. Boston Med. and Surg. Journal, 1903, cxlviii. 499. Halstead, A. E. AnÆsthesia Paralysis. Surgery, GynÆcology, and Obstetrics, 1908, vi. 201. Turney. Post-anÆsthetic Paralysis. Clinical Journal, 1899, xiv. 185. Giving way of the wound. After coeliotomy the patient runs a risk of the wound being burst open, and this accident seems particularly liable to happen in cases where catgut has been selected for the suture material. Accidents of this kind belong to two categories:— 1. Many cases occur in patients from violent coughing or vomiting, as the straining causes the knots of the sutures to slip. 2. In feeble patients, and those debilitated by anÆmia, diabetes, &c., and especially in septic wounds, the union of the edges of the incision unite very slowly; if the sutures are taken out on the eighth day, as is In dealing with this condition the surgeon carefully and gently cleans the extruded intestines and omentum with sterilized water, returns them into the abdomen, and resutures the wound. ReferencesMadelung, O. Ueber den postoperativen Vorfall von Baucheingeweiden. Verhandlung. d. Deutschen Gesellsch. f. Chir., Berlin, 1905, xxxiv, 2. Theil, p. 168. HÆmorrhage. However carefully an operation may be conducted or whatever material may be employed for ligatures, there is a liability of bleeding after the patient has been returned to bed. Severe internal bleeding is usually due to the slipping of a ligature from an ovarian pedicle, or a uterine artery: it may come from a vaginal artery, especially in total hysterectomy, and occasionally from a vessel in an adhesion which has been missed in the course of the operation, for oozing which is scarcely appreciable when a patient is collapsed may become very free when reaction occurs. Severe internal bleeding is manifested by very obvious signs: pallor, cold skin, rapid but feeble pulse, restlessness, and sighing respiration. When these symptoms are manifested the wound must be reopened, the blood and clot removed, and the bleeding point secured. It often happens, where the bleeding is due to the slipping of a ligature from the uterine or ovarian artery, that by the time the surgeon reopens the wound the patient is so bloodless that there is difficulty in determining the source of the bleeding. In very bad cases it is a wise plan to arrange for an assistant to perform the intravenous infusion whilst the surgeon deals with the bleeding vessel. (See Vol. I, p. 405.) Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored. In some instances the subcutaneous injection of normal saline solution may be employed. A suitable region is the loose tissue under and around the breasts. When this method is adopted the skin should be rendered antiseptic, otherwise troublesome abscesses and cellulitis will arise in the subcutaneous tissue at the situation where the saline solution has been injected. Intrapelvic hÆmorrhage. For many years I have maintained that two factors which have enabled hysterectomy to vanquish oÖphorectomy in the treatment of uterine fibroids are rigid asepsis and perfect hÆmostasis. In the early days of intrapelvic surgery there used to be much discussion on the subject of free blood in the pelvic cavity: some practical surgeons urged that it was harmful and would induce peritonitis, and others took the opposite view. From my own observations I came to the conclusion that effusions of blood in the abdomen were often quickly absorbed, but that this was not invariable; and that post-operative collections of blood were very liable to become septic, especially when drainage was employed. I also pointed out that the large effusions of blood in the abdomen due to tubal abortion, or to the rupture of a gravid tube, are often attended with fever, and in some instances the temperature rises to 103°. In such cases, when operative interference is undertaken, the deliquescent clot present in the pelvis often gives off a musty odour. Much light has been thrown on this condition by Dudgeon and Sargent, who have specially investigated the bacteriology of intraperitoneal effusions. These observers have isolated from intraperitoneal effusions of blood a white staphylococcus, which makes its appearance in the blood within a few hours of being effused, and they are of opinion that the febrile disturbances so frequently found after effusions of blood into the peritoneal cavity are due to the presence of this organism. Apart from the pathological importance of these observations there is a point of practical value connected with them. The white staphylococcus will infect sutures and give rise to stitch-abscesses in the wound; in view of this fact it behoves the surgeon who has to deal with a stale effusion of blood in the pelvis and evacuates it by an incision through Pneumonia. This is a serious and not infrequent sequel of coeliotomy, especially when it concerns diseased conditions in the upper half of the abdomen: pneumonia occurs frequently as a sequel to ovariotomy, hysterectomy, and allied operations, and occasionally has a fatal ending. It may arise from inhalation, or may be due to the dorsal position (hypostatic pneumonia), or it may arise from infection. Inhalation pneumonia is not uncommon, and although it is often attributed to the anÆsthetic, especially ether, it is doubtless due to a combination of causes, such as a cold room, undue exposure of the body, septic teeth, the chilling effects of ether on the tissues of the lung, and occasionally to a dirty face-piece belonging to the ether or chloroform apparatus. Hypostatic congestion of the lungs is liable to occur in the aged and in debilitated patients; it is a complication in such cases always to be guarded against. Embolic pneumonia is the most serious form, and occurs as a sequel to operations for septic conditions, such as pyosalpinx, suppurating ovarian cysts, septic fibroids, and post-operative sepsis; it is also associated with thrombosis, especially when the pelvic veins contain septic clot. In the preceding section attention was drawn to the appearance in intra-abdominal blood-effusions of a white staphylococcus: such collections of blood are prone to decompose and cause the temperature to rise. On several occasions in which blood has been effused freely into the pelvic cavity, either as a consequence of tubal pregnancy, or as a sequel to an operation, such as an abdominal myomectomy, and the blood has been allowed to remain, or it has been inefficiently drained, the patients have died from septic pneumonia. In cases of septic thrombosis the patients run a definite risk from pulmonary embolism. When the embolus is large the patient sometimes dies in a few minutes (see p. 101); but even in cases where the embolus is too small to promptly destroy the patient’s life, its lodgment in the lungs entails in some instances a very serious illness, and occasionally a fatal termination. Parotitis. Septic parotitis, or, as it is sometimes called, symptomatic or secondary parotitis, to distinguish it from mumps, is an occasional sequel to abdominal operations of all kinds. Careful observations have shown that parotitis is more common after operations for septic con Septic parotitis is distinguished from mumps in the following points:— It occurs as a complication of some other affection, is in itself non-contagious, and occasionally suppurates. There are two views held in regard to its etiology: some hold that it is due to direct infection of the duct (Stenson’s) of the parotid gland by micro-organisms from the mouth, whilst others maintain that the path of infection is mainly by the blood-stream. Two able investigations have recently been published in regard to this condition, in which one writer (Bucknall) supports the view that it is an ascending affection from the mouth, and the other (Tebbs) brings forward evidence that the elements of infection reach it by the blood-stream. Lequeu has seen many cases of post-operative parotitis, and at his suggestion Verliac and Morel investigated the condition in the laboratory. They came to the conclusion that this variety of parotitis originates in the ducts of the gland. When parotitis complicates post-operative convalescence, it is almost entirely confined to septic cases: it may occur within two days of the operation or as late as the thirtieth day. It is more common between the sixth and tenth days, and its advent is accompanied by much disturbance. The parotid swells and becomes painful and tender; the skin over it is red and often brawny. These signs are accompanied by fever, malaise, and depression of spirits. In mild cases they subside in a few days, but in severe cases rigors occur, with high fever and suppuration. The mild cases are best treated with warm fomentations, frequently changed. If suppuration occurs, the pus will need to be evacuated by a scalpel, but incisions in a suppurating parotid gland should be carried out with careful regard to the branches of the facial nerve (pes anserinus), and the large vessels intimately associated with it. The surgeon need not be in a great hurry to use the scalpel in these cases, for it seems occasionally as if the skin would slough, and yet when it is incised no pus escapes. This septic parotitis is deceptive in the red and brawny appearance of the skin covering the swollen gland, and the misleading sense of fluctuation. In many instances the inflammatory products escape by way of the parotid duct. Septic parotitis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases. Thrombosis. After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and oedema of the limb. It is noticed most frequently about the twelfth day after operation. In some patients the thrombosis is confined to the superficial veins of the calf and thigh, but when the femoral and internal iliac veins and the associated lymphatics are involved, the oedema is of a solid kind. Apart from the danger which ensues from the detachment of a fragment of clot and its arrest in the pulmonary artery, this complication is often very serious for the patient, for it entails a long confinement to bed, a tedious convalescence, and the oedema of the limb will sometimes persist for many weeks or months, in spite of topical applications, careful bandaging, or judicious massage. Post-operative thrombosis was formerly fairly common after hysterectomy for fibroids and in the later stages of malignant disease of the uterus. Its frequency after operations for fibroids was attributed to the profound anÆmia in patients who had severe and exhausting metrorrhagia. I am convinced that it is due to sepsis. In several instances I have caused the clot found in thrombosed veins to be examined bacteriologically, and pathogenic microscopic organisms have been isolated. I am also satisfied that in some cases of thrombosis of the veins of the thigh, especially those limited to the saphenous veins, the clotting spreads from the superficial veins of the hypogastrium which are infected from the abdominal incision. Pulmonary embolism. In perusing the clinical histories of a series of cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost any surgical operation, here and there a record may be read to this effect: ‘The patient appeared to be doing well after the operation, when she sat up, laughed and chatted with the nurse, then suddenly fell back and died in a few minutes.’ Anything more tragic than this it is difficult to conceive, and, as a rule, after such a sad occurrence, the relatives are so distressed that they rarely permit an examination of the body. Death in such circumstances is usually attributed to embolism of the pulmonary artery. In some instances this is an assumption, but there are many in which an embolus has been demonstrated, and a few in which the source has been detected. Post-operative embolism of the pulmonary artery is an important matter for surgeons interested in the operative treatment of uterine fibroids, for it follows such operations more frequently than any other. In order to afford some notion of the relative liability of patients to this accident after subtotal and total hysterectomy for fibroids, I have gathered Baldy ascertained that among 366 operations for fibroids in the Gynecean Hospital, Philadelphia, there were thirteen sudden deaths attributed to pulmonary embolism. In the Middlesex Hospital between the years 1896 and 1906 (both years inclusive) there were 212 abdominal hysterectomies performed for fibroids. Three of the patients died from pulmonary embolism. Spencer, in eighty-five total hysterectomies, had two deaths from pulmonary embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one sudden death. Mallet collected the records of 1,800 coeliotomies: there were six deaths attributed to embolism, and of these, three followed operations for uterine fibroids. Chas. P. Noble, in forty-two vaginal myomectomies, lost two patients, one from septic endocarditis, the other from embolism; in the latter case the fibroid was gangrenous. Olshausen, from the year 1896 to the end of 1905, performed 366 hysterectomies for fibroids; twenty-seven of these patients died. Five of the fatal cases were due to embolism. Since 1894 I have performed more than a thousand operations of various kinds for fibroids, and have lost one patient from pulmonary embolism. This happened in 1900. The woman was forty-five years of age and profoundly anÆmic from profuse and long-continued menorrhagia. Twelve days after subtotal hysterectomy she asked to be pillowed up in bed; this was done, when she suddenly slipped down the bed in agony and died in fifteen minutes. At the post-mortem examination the right pulmonary artery was found plugged with a thick clot. No thrombosed vessels were found in the pelvis. The symptoms of pulmonary embolism may occur at any period from the hour of the operation up to the thirtieth day. In the majority of patients embolism happens about the twelfth day. The symptoms supervene with great suddenness and seem to be preceded by movement, such as sitting up, getting out of bed, and especially straining during defÆcation. Withrow tells of a patient who was attacked whilst ‘putting on her clothes to leave the hospital’. She died in twelve hours. Reclus, at a meeting of the SociÉtÉ de Paris, 1897, mentioned that a patient quitting the hospital, apparently convalescent from hysterectomy, fell dead in the courtyard from pulmonary embolism. In one remarkable instance a patient complained of sciatic pain fifteen days after hysterectomy. In order to afford relief the surgeon flexed the patient’s thigh on her abdomen and then suddenly extended it. This dislodged a clot, and the woman was seized with the symptoms of pulmonary embolism and died in forty-seven minutes. At the post-mortem examination the pulmonary artery It is important to note that these fatal cases of pulmonary embolism occur when they are least expected, and it is an unusual sequence in patients with obvious thrombosis of the femoral and saphenous veins. The most constant symptoms are urgent dyspnoea accompanied by great distress; in some instances the patient becomes pallid and in others cyanotic. Death may follow in a few minutes; in less severe cases it is delayed several hours, the patient remains conscious, but suffers severe mental agony. A pulmonary embolism is not necessarily fatal, for a woman after a pelvic operation may complain of sudden pain in the chest, urgent dyspnoea, exhibit great mental distress, and in a short time spit up sputum mixed with blood. In a few hours the urgent symptoms subside and in two or three days pass away, and the patient recovers. I have seen five examples of this mild form of pulmonary embolism after hysterectomy. One of the patients appeared to suffer from a succession of small pulmonary emboli. The Pulmonary Artery and Adjacent Part of the Lung and Trachea Fig. 25. The Pulmonary Artery and Adjacent Part of the Lung and Trachea. The artery is completely occluded by a clot derived from a thrombus in the right auricle. (Museum of the Middlesex Hospital.) Three-quarter size. Somerville Hastings refers to a woman thirty-six years of age, anÆmic from profuse, long-continued menorrhagia due to a uterine fibroid, who, whilst waiting in the hospital for hysterectomy, was seized with pulmonary embolism and died three hours later. An embolus occupied the pulmonary artery, resembling a blood-clot found in the left common and internal iliac veins. Hastings also states that in a patient who died from pulmonary embolism, after an operation, a thrombus occupied the right cardiac ventricle, and he thought it possible that this intraventricular clot furnished the embolus (Fig. 25). We must bear in mind that individuals apparently in good health A careful consideration of the matter reveals beyond any doubt that pulmonary embolism occurs much more frequently after hysterectomy or fibroids than after any other operation, and it is especially liable to happen in women who are profoundly anÆmic from profuse and prolonged menorrhagia. This indicates that long-continued and irregular losses of blood induce some change in the composition of this important fluid, which favours its coagulation. It has been suggested that the practice of keeping patients strictly confined to bed for two or three weeks after hysterectomy and allied operations is responsible for the thrombosis which is the source of these fatal emboli. Some American surgeons act on this suggestion and insist on their patients getting out of bed a few days after such operations. This method does not commend itself to British surgeons. In my own practice I make it a rule, even in the most favourable conditions, to keep the patients confined to bed for two weeks. No patient is allowed up until her temperature has been normal for at least three days. The consequences of this practice appear to be justified, for in more than a thousand hysterectomies, only one of my patients lost her life in consequence of pulmonary embolism. In cases of embolism of the pulmonary artery, death does not always occur immediately, but may be postponed for an hour or more after the lodgment of the embolus. Trendelenburg is of opinion that it might be possible to remove this clot by direct surgical intervention. After careful consideration of the matter he carried out this operation on a woman aged sixty-three years; he raised an osteoplastic flap on the left side of the thorax, exposed the conus arteriosus, and intended to withdraw the clot, by means of a specially constructed pump, through a slit in its walls. The patient died from excessive bleeding before the clot could be extracted; the operation was hindered by an adherent pericardium. Trendelenburg has carried out this operation on a man forty-five years of age. This patient was tabetic and sustained a spontaneous fracture of the femur. One month later he was seized with urgent When patients who are profoundly anÆmic from menorrhagia due to fibroids undergo hysterectomy, it is a useful measure to give them twenty grains of citrate of sodium twice daily in order to diminish the abnormal tendency of the blood to coagulate in the vessels. Certainly this drug should be administered if there is the least evidence of thrombosis. Foreign bodies left in the abdomen. Every writer on ovariotomy and kindred operations insists on the importance of exercising the utmost personal vigilance in counting instruments and dabs before, and immediately after, an abdominal operation in order to avert the dangers which ensue when instruments, dabs, gauze, or drainage tubes are accidentally left in the abdominal cavity. Before the era of antiseptic surgery nearly all the patients in whom foreign bodies were left in the abdominal cavity died. In several instances the surgeon has discovered, on counting the sponges and instruments after the operation, one or more to be missing, and, failing to find them in the room, has reopened the wound and recovered the missing article. In many lucky cases, a sponge or compress has given rise to an abscess, and, the wound reopened, the sponge presented at the opening. Often a compress of cotton-wool or gauze has slowly ulcerated into the rectum and been discharged through the anus. When things of this kind are left in the abdomen the risks are not so great now as in pre-antiseptic days, but they cause much discomfort and anxiety as well as suffering: moreover, such an accident entails reopening the wound and occasionally a serious operation for the removal of the missing article, and as a recent decision in a Court of Law fixes the responsibility on the operator, there is always the possibility of an action at law with all its vexations and the liability of being mulcted in damages. The behaviour of foreign bodies left in the abdomen is curious and also interesting from the great length of time which metal instruments will sometimes remain without causing very urgent symptoms, and the tendency they exhibit to penetrate adjacent viscera. Among the early cases Sir Spencer Wells reported one in which a pair of forceps was found in a patient’s bladder who died a month after ovariotomy. Olshausen mentions that a pair of forceps was passed by the A Pair of Pressure Forceps Fig. 26. A Pair of Pressure Forceps: this instrument had remained in the abdomen two years after hysterectomy. The forceps had ulcerated into the cÆcum and the blades had lodged in the vermiform appendix. (After MacLaren.) In order to illustrate the diminished risks run by patients when the instruments and dabs used in operations are thoroughly sterilized, reference may be made to a case recently reported by J. E. F. Stewart (Australia), in which he removed a pair of pressure forceps which had remained in the abdomen for ten years and a half. The patient, who had been more or less an invalid since the primary operation, had suffered from attacks of acute pain, constipation alternating with diarrhoea, and pains in the lower limbs. The instrument, which measured 5 inches long and 2½ across the handles, was lying point downwards in the pelvis, and the ring handles could be felt through the belly-wall before the operation: it had made its way into the small intestine. The tendency for a foreign body, whether hard like forceps, or soft like gauze pads, to erode its way into the intestine is very remarkable. Thus Gifford operated on a patient with intestinal obstruction; an impacted mass was felt in the ileum, it was extracted through an incision in the gut and proved to be a pad of cotton-wool enveloped in gauze. She recovered. Three months previously this woman had undergone abdominal myomectomy. Another source of risk to patients is the practice or habit of packing the pelvic recesses with strips of gauze temporarily, either with the hope of controlling oozing, or to serve as a drain. I have long abandoned this habit. The disadvantage of gauze stuffing which needs consideration in this section is the risk that some portion, or the whole of it, is sometimes left in the wound. Examples are known where long strips of ‘gauze stuffing’, sometimes amounting to a yard or more, have been passed through the anus a year after the operation. Many intractable sinuses have had a forgotten piece of gauze as the cause of their persistence. A woman had coeliotomy performed for peritonitis, the consequence of criminal abortion; she had a long convalescence due to an intractable sinus. Eventually the patient was thought to have tuberculous disease of the appendages, and a mass, formed mainly by the Fallopian tube, was removed. The walls of the tube were intact, but when slit open the tube was found to contain a small gauze tampon (Kouwer). The isolated records relating to foreign bodies left in the abdomen are very numerous. Thus Wilson in 1884 was able to collect twenty-eight cases from periodical literature and personal reports from friends. An interesting discussion took place on the reading of a paper on this subject before an American gynÆcological society, by R. W. Waldo, and the number of cases related by the members is astonishing and refer to such things as sponges, dabs, forceps, a strip of iodoform gauze ‘a yard wide and two yards long’, a pair of spectacles, and ‘an operating-room towel’, which were left in the abdominal cavity. The most comprehensive collection of records relating to foreign bodies left in wounds of all kinds has been made by F. von Neugebauer; they amount to 195. ReferencesGifford, G. T. British Medical Journal, 1907, ii. 1042. Kouwer, Prof. Zentralbl. fÜr GynÄk., 1907, xxxi. 1447. MacLaren, A. Annals of Surgery, 1896, xxiv. 365. Neugebauer, F. v. Monatsschriften fÜr Geburtsh. u. Gyn., 1900, Bd. xi, 821, 933. Zentralbl. fÜr GynÄk., 1904, xxviii. 65. Stewart, J. E. F. Australian Medical Gazette, 1906, xxv. 446. Waldo, R. W. American Journal of Obstetrics, 1906, liv. 553. Wilson, H. P. C. Trans. American Gynecological Society, 1884, ix. 94. Tetanus. This dread complication of wounds occasionally occurs after ovariotomy, and during the ‘reign of the clamp’ it was especially frequent in Germany (Olshausen). Cases have been reported in England, Since Kitasato demonstrated the bacillary origin of tetanus poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the tetanus bacillus. Tetanus, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the tetanus bacillus was detected in some wallaby tendon employed to suspend the uterus. Tetanus has also been traced to infected catgut employed in cholecystotomy (1905). Ed. Martin reported the occurrence of tetanus after vaginal fixation of the uterus and colporrhaphia anterior. Cumol-catgut was employed. Menzer has recorded a similar case which occurred in DÜhrssen’s Klinik (1901). The ligatures were of catgut. Mallet refers to two post-operative deaths from tetanus. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material. In practice it is important to remember that tetanus arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling. Tetanus occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind. ReferencesDorsett, W. B. Two fatal cases of Tetanus following Abdominal Section due to Infected Ligatures, &c. Am. Journ. of Obstet., 1902, xlvi. 620. Mallet, G. H. Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515. Martin, Ed. Postoperativer Tetanus (with references). Zent. f. Gyn., 1906, xxx. 395. Meinert. Drei gynÄkologische FÄlle von Wundstarrkrampf. Arch. fÜr Gyn., 1893, xliv. 381. Menzer. Tetanus Infection after Vaginal Fixation of the Uterus. Zeitsch. f. Geb. u. Gyn., 1901, xliv. 517. Olshausen, R. Tetanus nach Ovariotomie Billroth-LÜcke’s. Handb. der Frauenkrankheiten, 1877–9, ii. 367. Taylor, H. Tetanus after Hysterectomy. Am. Journ. of Obstet., 1908, lvii. 574. Injury to intestines. Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where coeliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut. Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the rectum runs a great risk of being damaged. In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis. It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed. In sewing the abdominal incision the intestines have been pricked with a needle, and in some instances the bowel has been accidentally included in the sutures and sewn to the abdominal wall. On one occasion while securing a very long incision with through and through sutures, while passing the needle through the abdominal wall, it broke, and the broken end came with great force against the anterior wall of the stomach and tore a hole in it. This I secured at once with suture and the accident had no bad consequences. An unrecognized wound of the bowel in the course of a pelvic operation is almost certainly fatal. Accidental injuries, such as punctures and cuts, require immediate suture, and I have never known any harm follow. On the other hand, ragged tears in thickened and inflamed bowel require careful consideration in order to spare patients the inconvenience and distress of fÆcal fistulÆ. In regard to small intestine a very small opening may occasionally be safely secured with fine silk, but in most cases it is wiser, if the bowel is thickened and inflamed around the hole, to resect well wide of the damaged portion and join the cut ends (circular enterorrhaphy). Holes low down in the rectum are difficult to suture securely. These It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a fÆcal fistula which had followed an oÖphorectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube passed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble. If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or cÆcum he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.) Intestinal obstruction. It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:— 1. Adhesions to the abdominal wound. 2. Adhesions to the pedicle, stump, or a raw surface in the pelvis. 3. Strangulation around an adventitious band. 4. Obstruction due to an overlooked cancer in the colon. 5. Strangulation in a sac formed by a yielding cicatrix. The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy. The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies. From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or oÖphorectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment. Perforating ulcer of the stomach and small intestine. A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident. Injuries to the bladder. This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk. The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap. Injuries to the ureter. Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in vaginal hysterectomy, because the vesical segments of these ducts come into close relationship with it. British surgical and gynÆcological periodical literature contains very little that concerns ureteral injuries, but it is only necessary to look into the pages of the Zentralblatt fÜr GynÄkologie to find ample evidence that the integrity of the ureters is frequently sacrificed to modern pelvic surgery. Blau published statistics from Chrobak’s Klinik in Vienna showing that in the interval January, 1900, to January, 1902, the ureters were injured fifteen times. In total hysterectomy seven times; in the course of ovariotomy on three occasions. Sampson stated that from August, 1889, to January, 1904, the uterus was removed 156 times for cancer of its neck at the Johns Hopkins Hospital, Baltimore, and the ureters were injured nineteen times. The injuries were of various kinds, such as ‘ligating, clamping, cauterizing, cutting.’ In abdominal hysterectomy for fibroids the risk of injuring a ureter is not great. Thus Deaver writes that in the course of 250 abdominal hysterectomies he injured the ureter once, but the accident entailed the death of the patient. I have performed hysterectomy on 1,000 occasions and injured the ureter once; my patient had a narrow escape for life and lost a kidney. I have been present on five occasions when a ureter was injured. Four of the operations were for the removal of the uterus on account of fibroids, and one was an ovariotomy. Four of the patients died. The injuries to which the ureters are liable in the course of hysterectomy are as follows:— 1. One or both ureters have been included in the ligatures applied to the uterine arteries. 2. One or both ureters have been cut or completely divided with scissors, or knife, in removal of the uterus. 3. A segment of a ureter 7 centimetres in length has been accidentally exsected. 4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of vaginal hysterectomy, and subsequently sloughed. 5. Ureters exposed in the course of ‘radical’ operations for cancer of the neck of the uterus often slough. 6. A ureter is sometimes transfixed by a needle and thread when sewing The most dangerous injury to the ureters occurs in the course of a subtotal hysterectomy, especially if it is not recognized at the time of the operation. In such circumstances the urine will slowly leak into the connective tissue of the broad ligament and form an extravasation extending into the loin. In some cases the fluid will leak directly into the pelvis, and a sinus will form in the abdominal wound and allow the urine to escape; this may be the first intimation that a ureter has been injured, whereas when a ureter has sustained damage in the course of a total abdominal or a vaginal hysterectomy, the leakage of urine along the vagina will quickly apprise the surgeon of the accident. There is another form of injury to the ureter which should be mentioned. Occasionally a fibroid, but more often a cyst or tumour arising from the base of the broad ligament, will involve the corresponding ureter and carry it upwards in such a way that, when the layers of the broad ligament are reflected, the ureter will be found crossing the crown of the tumour like a strap. In such a case the pressure has usually exerted a banal influence on the kidney, and it is often in the condition known as sacculation. In a case under my own care in which I attempted to remove a malignant tumour of the broad ligament, and in which the ureter ran over its upper pole in this way, thinking it was an adhesion, traction was made upon it, and the ureter came away with a portion of the renal pelvis. At the post-mortem examination the kidney was merely a thin-walled sac with purulent contents. In all cases in the course of an abdominal hysterectomy it is useful for the surgeon to inform himself of the condition of the kidneys. Whilst performing a subtotal hysterectomy, one of the fibroids burrowed deeply between the layers of the left broad ligament; when all the bleeding was checked, I looked carefully to determine that the ureter was safe, and found it kinked by the ligature applied to the corresponding uterine artery; it was at once removed. On palpating the kidneys I found the right kidney small, and shrunken, and useless. Fortunately the woman recovered. The method of treating an injured ureter varies greatly and will depend not only on the extent of the damage, but also on the time at which it is recognized. For example, if the surgeon recognizes the injury in the course of the operation, he will be able to deal with it at once. This we may term immediate treatment. The more difficult cases are those in which the injury is unrecognized at the time of the operation and only becomes obvious in the course of convalescence; the treatment in such circumstances may be called secondary. The primary treatment of an injury to a ureter in the course of a pelvic operation will depend in a large measure on the ability, judgment, and experience of the surgeon, as well as on the extent of the injury. For example, if the ureter be partially divided, the opening may be closed with sutures of thin silk; when the duct is completely divided, the cut ends may be invaginated, the upper into the lower, and retained in position by suture. When five or more centimetres of the ureter have been accidentally exsected, none of these methods is applicable; in such circumstances several plans have been tried. Of these the simplest is ligature of the proximal end with the hope of inducing atrophy of the kidney; in several recorded instances this has proved successful. The surgeon who adopts this method should satisfy himself that the patient has another kidney, and that it is, as far as he can ascertain at the time, healthy. Some surgeons who have divided a ureter have promptly removed the corresponding kidney; others have secured the proximal end in the upper angle of the abdominal incision and removed the kidney subsequently. The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy Fig. 27. The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy (after Lutaud). A, the proximal end of the ureter with the mucous membrane reflected. B, the walls of the bladder, showing the mode of fixing the ureter to its walls. 1 and 2, sutures. It has been suggested that when a portion of a ureter has been resected and the proximal end cannot be engrafted into the wall of the bladder, it should be turned into the cÆcum or the sigmoid flexure, according to its position, and thus preserve to the patient the kidney and save her the distress of a urinary fistula. This method has not found favour with practical surgeons. The most promising procedure consists in engrafting the proximal end of the cut ureter into the bladder. This is known as uretero-cysto-neostomy, an operation which has been made the subject of a valuable thesis by Dr. Lutaud. This thesis appears to have been inspired as a result of two successful operations performed by Ricard. The principle of this method is as follows: The abdomen is opened by the usual median subumbilical incision, and the peritoneum covering the damaged duct is incised and its proximal end exposed: the mucous membrane of the ureter is reflected like a cuff. An opening is made in the bladder wall in a situation convenient for making the junction, and two centimetres of the ureter are allowed to project freely into the vesical cavity, ‘À la faÇon d’un battant de cloche.’ The ureter is secured by sutures to the vesical mucous membrane, and to the muscular coat of the bladder. The sutures should be of thin catgut and must not perforate the bladder or the ureteral walls. The bladder itself near the junction should be attached by sutures to the adjacent peritoneum to prevent dragging (Fig. 27). Lutaud significantly points out that we know little of the subsequent fate of ureters which have been engrafted into the bladder. The immediate results have been successful, but there is good reason to believe that when a ureter has been engrafted into the bladder, its walls become sclerosed by a chronic ureteritis, and its lumen is gradually stenosed. These changes take place slowly and cause little or no discomfort in connexion with the kidney or the bladder, so that they pass unnoticed. If the opinion expressed by Lutaud, that the ureter becomes stenosed after uretero-cysto-neostomy, is found to be a constant, or even a frequent, sequel to the transplantation of a ureter into the bladder, it will cause surgeons to be careful, and not follow too literally the advice given by some writers to the effect that in performing the ‘radical operation’ for cancer of the cervix, if the ureters are implicated these ducts may be divided and their proximal ends engrafted into the bladder. Lockyer, in removing a burrowing fibroid, wounded the bladder and divided the right ureter; he sutured the vesical incision and removed the right kidney. During the twenty-four hours following the operation there was anuria. The abdomen was reopened and then it was found that the left ureter had also been divided. The proximal end of this ureter was engrafted into the bladder through the wound which had been already sutured. Convalescence was disturbed by a urinary fistula. The woman recovered and reported herself in good health three years later. It has happened that after nephrectomy for the cure of a ureteral fistula, the sequel of a ‘radical operation’, the remaining ureter became thoroughly blocked by recurrent growth and the patient died from anuria. In the cases where the injury to a ureter has been overlooked in the course of the operation many difficulties arise before the true conditions are appreciated. In some instances they soon become obvious; for example, Purcell in 1898 performed an abdominal hysterectomy, next day the patient had complete anuria. The abdomen was reopened fifty-eight hours later; a distended ureter was easily recognized behind the ligatures When a ureter is injured in the performance of total hysterectomy, urine escapes by the vagina, and at first there may be some doubt whether the leak is due to an injury to the bladder or to the ureter. In such conditions the quantity of urine voided from the bladder is compared with that which escapes from the vagina; if the quantities are equal, or nearly equal, the leak is in a ureter. A more reliable method is to inject a solution of methylene blue into the bladder through the urethra. If the coloured fluid escapes from the vagina, the leak is in the bladder; if not, it is in the ureter. When a vaginal leakage occurs a few days after a vaginal hysterectomy, it is probably due to necrosis and sloughing of a ureter, or the duct may have been included in a ligature which has separated by sloughing. Noble, in 1902, published an interesting series of injuries to the ureter. One of these is of great value, because it proves that a ureter may be accidentally ligatured and give rise to no symptoms. A woman of thirty-three years of age was submitted to vaginal hysterectomy for cancer of the neck of the uterus, complicated with pregnancy. She died four days after the operation, and at the post-mortem examination the left ureter was found occluded with a ligature. The ureter and pelvis of the kidney were distended with urine. The urine voided during the four days amounted on the first day to 480 c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48 oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull suspicion in regard to any patient, but the facts of the case are sufficient to raise suspicions of another kind, namely, that it is possible and probable that a ureter has been ligatured in the course of an operation, and the patient has recovered without any one having any suspicion that such an accident has happened. As soon as the surgeon clearly establishes the existence of a ureteral fistula he is beset with the necessity of deciding which duct is the seat of damage. Some years ago, when it was the practice to remove the kidney for a persistent ureteral fistula, the decision involved the surgeon in a grave responsibility, for the removal of the wrong kidney could only be regarded as a catastrophe for the patient. Morris has recorded a case in which this actually happened. A woman had total hysterectomy performed for a cervix fibroid by a gynÆcologist; in the course of the convalescence a ureteral fistula was recognized, and as this failed to close spontaneously, a surgical colleague performed nephrectomy, and next day found to his chagrin that he had removed the kidney belonging to It is important to remember that every ureteral fistula does not require an operation. It is always advisable, when it has been clearly established that a woman has a leaking ureter, to wait a little, certainly six weeks, for many fistulÆ of this kind will gradually close. In describing such a case, Jonas draws attention to a cystoscopic sign of some value. He performed a total hysterectomy for fibroids, and on the tenth day the nurse reported the escape of urine by the vagina. The daily output of urine from the bladder, which had averaged 50 ounces, fell to 25 ounces. On cystoscopic examination, urine could be seen issuing from the right ureteral orifice; at first the left orifice could not be seen, but on careful watching a movement was detected similar to the contraction of a ureter discharging urine, but no fluid came from the opening. This is known as leergehen (empty contraction), and it indicates that there is a lateral opening, but not complete interruption in the continuity of the ureter. Such a case should have an opportunity of healing spontaneously. This happened in Jonas’s patient. Weibel states that a ureteral fistula due to necrosis after a radical operation for cancer of the uterus usually occurs in the second week. The earliest day is the seventh, and the latest the eighteenth day after operation. The majority of these fistulÆ heal in from three to twelve weeks. If a fistula persist for more than three months spontaneous healing is not to be expected. A ureteral fistula is a serious matter for the patient. Blacker has had three cases after total hysterectomy. In one the kidney was removed on account of septic changes. The second had an attack of suppression of urine lasting twenty-four hours; it passed off, the patient recovered and the fistula healed. The third died eight weeks after the hysterectomy with symptoms of pyÆmia; a small abscess had formed near the site of the fistula. The fate of ligatures. When a ligature is satisfactorily applied to a pedicle the tissue on the distal side of the ligature is isolated from the circulation. The fate of this tissue and of the ligature has been the subject of much speculation. It is a matter of common observation that when animal tissues are cut off from the circulation, they atrophy; but if pathogenic micro-organisms gain access to such parts, suppuration ensues. In due course, through the activity of the living cells, the dead tissues are detached from the living, a process termed sloughing. When a piece of healthy tissue is removed from the body and immersed in a sterile solution, and absolutely isolated from the atmosphere, decomposition is indefinitely postponed, but as soon as unsterilized air is allowed access to it, putrefactive changes ensue. The pedicle after ovariotomy is in an air-tight chamber, and if the tissues included by the ligature are healthy, and the silk employed for the purpose is absolutely aseptic, this pedicle, when returned into the abdomen, resembles the piece of tissue isolated from contact with the atmosphere. No septic changes occur, but aggressive leucocytes attack the silk and may, in course of time, effect its removal, even the knots. For this desirable result three conditions require to be fulfilled: (1) the ligatured tissue must be aseptic; (2) the ligature should be absolutely sterile; and (3) air or intestinal contents must be excluded. These conditions may be prevented in many ways. The tissues included in the ligature are not always free from infective organisms, especially the Fallopian tube, which is usually included in the ligature, and this structure, especially in cases where oÖphorectomy is performed for inflammatory diseases, often contains septic microbes; this endangers the ligature and leads to the formation of pus, with its complications, sloughing of the pedicle and abscess. The tissues may be healthy and aseptic, but the ligature may have been imperfectly sterilized, or become contaminated by assistants, or even by the hands of the surgeon during its application. The operation may have been conducted aseptically and the tissues be healthy, but the ligature becomes infected by the admission of air as a result of drainage, or implication of the bowel or bladder. I made a careful study of the fate of silk sutures employed in pelvic surgery extending over many years, and came to the conclusion that, even under favourable conditions, silk ligatures disappear very slowly. The silk used to secure an ovarian pedicle may, in very favourable circumstances, disappear in twelve months, but the knots require nearly double that time. The piece of silk which encircles the Fallopian tube is apt to behave in a curious way; in 1898 I removed an ovarian cyst the size of a fist, and tied its slender pedicle with thin silk. Although the recovery was uneventful, the patient complained during many weeks of cramp-like pains on the side from which the cyst was removed. These pains gradually subsided, and ten months later, during menstruation, the patient noticed on the napkin a tiny loop of silk, which she saved. This was the loop of silk which secured the Fallopian tube; it had ulcerated into the tube and been conducted into the uterus and escaped. I have since had a like condition, the loop making its appearance three weeks after an ovariotomy. It has been established by experiments on A Uterus in Sagittal Section Fig. 28. A Uterus in Sagittal Section. Showing silk ligatures which had been introduced in the operation of CÆsarean section four years previously. (Museum, Royal College of Surgeons.) Full size. It is important to emphasize the fact that silk sutures in uterine tissue will, in some instances, remain unabsorbed for many years. A patient who had been submitted to CÆsarean section in 1903 came under my care four years afterwards for the removal of the tumour which caused obstruction; the sutures used to close the uterine incision were visible, and a microscopic examination showed that each silk suture was enclosed in a fibrous tissue sheath (Fig. 28). The fact that silk sutures will resist absorption for such a long period has an important practical bearing, because so long as pathogenic micro-organisms are denied access they remain inert, but if any septic condition arises in their neighbourhood, and these sutures become involved, they will give rise to abscesses and sinuses as surely as if they had been buried but a few days. Patients often suffer great distress and annoyance on account of abscesses and sinuses due to septic ligatures, and a sinus will persist as long as the ligature remains. Abscesses and sinuses resulting from troublesome ligatures may escape in many directions; the most common spot is at the lower angle of the abdominal incision; the rectum is another channel of escape, and also the bladder. When a ligature makes its way into the bladder it will set up cystitis and serve as a nucleus for a vesical calculus. In an unusual case recorded by Edebohls, double oÖphorectomy was performed for uterine fibroids; a year later the ligature on the left side escaped through the vagina; six months later he performed abdominal hysterectomy. The vermiform appendix was adherent to the On one occasion a woman, who had been submitted to subtotal hysterectomy in the Antipodes, suffered from frequent micturition and foetid urine; she came under my care. On dilating the urethra, it was found that the cervical stump had ulcerated through the posterior wall of the bladder and projected freely into the vesical cavity, bristling with thick silk ligatures encrusted with phosphatic deposit. The ligatures were removed, the urine soon became acid, and the vesical discomfort quickly subsided, in spite of the anomalous position of the cervical stump. Until surgeons fully realized the importance of thoroughly sterilizing the silk employed for the pedicles in ovariotomy, it was quite common for the silk loops to ulcerate through the bladder wall and set up cystitis. Many cases have been reported in which a loop of silk, effecting an entrance into the bladder in this fashion, has formed the nucleus of a phosphatic calculus. Post-operative kraurosis. In a small proportion of patients (perhaps not more than one per cent.) who have undergone bilateral ovariotomy, oÖphorectomy, or hysterectomy, the vulva undergoes the peculiar atrophic changes which are characteristic of the condition known as kraurosis vulvÆ. This change, so far as my observations go, is chiefly seen in patients who have been submitted to these operations after the fortieth year of life. The cause of these changes is unknown. The condition is troublesome and inconvenient in married women, but spinsters rarely complain of it. Post-operative kraurosis is as rebellious to treatment, and its causation as inexplicable, as kraurosis occurring independently of operation. The cicatrix. Although the employment of buried sutures has made abdominal incisions more secure in the process of healing, and renders them firmer after union, and thus reduces the chances of a yielding scar, and saves the patient the inconvenience of an abdominal hernia or the annoyance of wearing an abdominal belt, it renders the patient liable to another discomfort, namely, stitch-abscess. This complication arises from a variety of causes—for example, imperfect sterilization of the suture material, or of the patient’s skin preceding the operation. The sutures may be soiled by the hands of nurses and assistants, or the fingers of the surgeon. All these things may be safeguarded, but the operation may have been required for the removal of infected cysts, or pelvic peritonitis: in these cases it is wise not to bury sutures. Troublesome buried sutures should be removed. In many instances this is easy of accomplishment, and in others it requires patience and The disadvantage of stitch-abscesses, apart from the inconvenience they cause patients during their convalescence, is that they often cause the scar to yield at that spot, and necessitate the wearing of an abdominal belt. If the hernia is of small extent, and especially when it is situated near the lower angle of the scar, it is difficult to fit a belt which will restrain it without the use of perineal bands or straps. In such cases a truss, on the principle of those employed for inguinal hernia, is more satisfactory than a belt. Occasionally a scar forms a raised hard red keloid band, and causes some anxiety to the patient. These keloid scars shrink and whiten in the course of a year or eighteen months. Cancer of the cicatrix. Several cases have been recorded in which, after the removal of an ovarian adenoma, a new growth, described as ‘cancer of the cicatrix’, has formed in the scar. These growths are probably due to the soiling of the wound at the time of operation with epithelial fragments from the tumours. After abdominal hysterectomy for cancer of the body of the uterus, or its cervix, the abdominal wound may become infected with this disease, and in cases where exploratory coeliotomy has been performed for diffuse cancerous disease of the peritoneum the cicatrix is liable to become permeated by malignant disease also. ReferencesBaldy, J. M. The Mortality in Operations for Fibroid Tumour of the Uterus. Trans. Am. GynÆcological Association, 1905, xxx. 450. Bartlett, W., and Thompson, R. L. Occluding Pulmonary Embolism. Annals of Surgery, 1908, xlvii. 717. Blacker, G. F. Lancet, 1909, i. 395. Bland-Sutton, J. Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs. Lancet, 1909, i. 147. Blau, A. Ueber die in der Klinik Chrobak bei gynÄkologischen Operationen beobachteten Nebenverletzungen. BeitrÄge f. Geb. u. Gyn., 1903, Bd. vii. 53. Bucknall, R. The Pathology and Prevention of Secondary Parotitis (with Literature). Med.-Chir. Trans., 1905, lxxxviii. 1. Deaver, J. B. Hysterectomy for Fibroids of the Uterus. Am. Journ. of Obstetrics, 1905, lii. 858–74. Hastings, S. A Preliminary Note on Embolism in Surgical Cases. Archives of the Middlesex Hospital, 1907, xi. 78. Jonas, E. Temporary Uretero-vaginal Fistula after Panhysterectomy for Fibroid of the Uterus. Am. Journ. of Obstetrics, 1907, lvi. 731. Lequeu. Sur les parotidites post-opÉratoires. Bull. et MÉm. de la Soc. de Chir. de Paris, 1907, T. xxxiii. 1044. Lutaud, P. Sur un procÉdÉ d’urÉtÉro-cysto-nÉostomie dans le traiment des fistules urÉtÉro-vaginales et urÉtÉro-cervicales. Paris, 1907. Lyle, Ranken. A Series of Fifty Consecutive Abdominal Sections. Journal of the British GynÆcological Society, 1906–7, xxii. 120. Mallet, G. H. Am. Journ. of Obstetrics, 1905, li. 516. Morris, H. Lectures on the Surgery of the Kidney. British Medical Journal, 1898, i. 1039. Noble, C. P. Clinical Report upon Ureteral Surgery. American Medicine, 1902, iv. 501. —— Myomectomy. New York Medical Journal, 1906, lxxxviii. 1008. Olshausen, R. Veit’s Handbuch der GynÄkologie, 1907, 2nd Ed., Bd. i. 715. Purcell, F. A. The Risks to the Ureters when performing Hysterectomy, &c. Journ. Brit. Gyn. Soc., 1898–9, xiv. 174. Robinson, B. Sudden Death, especially from Embolism, following Surgical Intervention. Medical Record, 1905, lvii. 47. Spencer, H. R. Discussion at Exeter on Uterine Fibroids, &c. British Medical Journal, 1907, ii. 452. Tebbs, B. N. Symptomatic Parotitis. Med.-Chir. Trans., 1905, lxxxviii. 35. Trendelenburg, F. Zur Herzchirurgie. Zentralbl. fÜr Chir., 1907, No. 44, 1302. —— Ueber die chirurgische Behandlung der puerperalen PyÄmie. MÜnchener Med. Wochenschr., 1907, xxxiv. 1302. Weibel, W. Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms. Zeitsch. f. Geb. u. Gyn., 1908, lxii. 184. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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