Frederic Francis Burghard

VAGINAL GYNÆCOLOGICAL OPERATIONS
BY
JOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.
Professor of Obstetric Medicine, King’s College, London Obstetric Physician and GynÆcologist to King’s College Hospital

CHAPTER XII
PREPARATION OF THE PATIENT FOR PERINEAL AND VAGINAL
OPERATIONS: OPERATIONS FOR INJURIES TO
THE PERINEUM AND PELVIC FLOOR

PREPARATION OF THE PATIENT

In operations upon the perineum and vagina, the same scrupulous precautions against sepsis should be taken as in abdominal section. Before proceeding to practical details, it will be useful to consider a few points regarding the distribution of bacteria in these parts. Not only the ordinary bacteria of the skin, but also those from the rectum, and, under certain conditions, from the urine and the vaginal secretion abound on the perineal and vulval surfaces. The healthy virgin vagina may be considered free from pathogenic organisms, harbouring only the harmless vaginal bacillus of DÖderlein. After sexual congress the vagina contains pathogenic organisms, and in conditions such as carcinoma of the cervix and body of the uterus, and in all forms of vaginitis, many varieties of bacteria are present in great numbers.

The normal uterus is germ-free; in fact the external os uteri may be said to divide the bacteria-free from the bacteria-containing area of the genital canal. But in carcinoma and in the various forms of septic endometritis, the uterus not only contains many pathogenic bacteria, but acts also as a continual source of infection to the vagina and external genital organs. It follows, therefore, that this area may be exceedingly difficult to render sterile, and in certain conditions this is indeed impossible. None the less, every effort should be made to attain this object; for even if the organisms cannot be entirely removed, yet their numbers can be considerably reduced, and it must be remembered that the action of septic organisms is, to a great extent, directly proportionate to their numbers.

The same general principles apply to the preparation of patients for operations on the perineum and vagina as for operations on other parts of the body. Very particular attention, however, must be paid to the bowels; nothing is more prejudicial to the success of an operation, or more annoying to the operator, than to have the area of operation soiled by an escape of fÆcal matter from an imperfectly emptied lower bowel. The aperient should be given at least 24 hours before the time of operation. A copious soap-and-water enema should follow after the usual interval, and, an hour or two beforehand, the lower bowel should be thoroughly washed out with a gentle stream of warm water.

The external genitals should be shaved, and washed with ethereal soap solution and hot water the day before the operation, then douched with a 1–2,000 solution of perchloride of mercury, and a compress, soaked in the same solution, laid over the vulva. After the enema has acted, and after the final wash-out, the washing and douching should be repeated and a fresh compress applied.

If there is any vaginal discharge, the vagina should be douched out three times a day for two or three days previous to the operation, with an antiseptic such as 1–4,000 perchloride of mercury, or 1% formalin. The healing of a perineal wound is considerably impaired if it be continually bathed in an unhealthy vaginal discharge.

When the patient is on the table and under the anÆsthetic, the external parts should again receive a thorough final disinfection, and, in addition, the vagina should be thoroughly swabbed out with ethereal soap solution, by means of swabs on holders. A final douching with 1–2,000 perchloride of mercury completes the process.

In all cases of vaginal hysterectomy for carcinoma, particular attention must be paid to the preliminary disinfection of the vagina by means of douching for two or three days before the operation. The vagina is swarming with various kinds of bacteria, and by careful attention to these principles the risk of sepsis will be materially diminished.

After the above preparations have been carried out, the patient is anÆsthetized and placed on the table in the lithotomy position, the legs being kept well apart and fixed by means of a crutch. The buttocks are brought well to the edge of the table, and a Kelly’s pad may be placed beneath them. The legs should be encased in sterilized towels or linen stockings, and towels placed on the hypogastrium (Fig. 29).

OPERATIONS FOR THE REPAIR OF COMPLETE LACERATION OF THE PERINEUM

Under the term colporrhaphy (suture of the vagina) is included any operation in which denudation and subsequent suturing of one or both walls of the vagina is carried out. Anterior colporrhaphy includes the various operations devised for cystocele; posterior colporrhaphy, the procedures carried out for incomplete rupture of the perineum (colpo-perineorrhaphy), prolapse of the pelvic floor, and to produce narrowing of the vagina.

The appearance of the parts in this condition is quite characteristic (Fig. 30); the laceration of the recto-vaginal septum appears as a triangular space with its apex upwards, its sides equal, and its base formed by the retracted sphincter ani (Fig. 32). The separated ends of the sphincter are seen as two slightly depressed circular spots at the base of each side of the isosceles triangle a, a'. The object of the operation is to adapt these two ends, repair the recto-vaginal rent, and re-form the perineal body. There is often much irregular scar tissue about the opening, which may cause additional difficulty at the operation.

The instruments necessary are six Spencer Wells artery forceps, long dissecting forceps with hooked points, a pair of sharp-pointed angular and a pair of sharp-pointed curved scissors (see Fig. 31), flat curved needles and Schauta’s needle-holder (Fig. 73).

The preparatory treatment consists in regular gentle purgation daily for a week, dieting, rest in bed for three days, and antiseptic vaginal douches of lysol (1 drachm to the quart).

Operation. The patient is placed in the dorsal position on a Kelly’s pad, and after the usual purification, denudation is commenced. The skin over the circular depressions corresponding to the ends of the severed sphincter (Fig. 30, a, a') is seized with the dissecting forceps and slightly raised. This portion of skin on either side is removed by means of the scissors, thus baring the ends of the sphincter and opening up the cellular tissue.

The point of one blade of the scissors is now buried in the cellular tissue at this bared spot on the operator’s right side, and is carried along the free torn edge of the recto-vaginal septum between the deep and superficial tissues until the apex of the laceration is reached. A similar incision is made on the opposite side.

The triangles of the vaginal flap are now raised by means of catch-forceps and the scissors passed carefully into the cellular tissue, and the recto-vaginal septum is split transversely, producing a raw surface somewhat the shape of a butterfly in outline (Fig. 33). A median extension of the denudation is made in an upward direction for another inch in length to form a supporting column. This flap may, if the tissues are sufficiently redundant, be removed along the line running at its base. The raw surface should be swabbed over carefully, and any bleeding points secured by ligatures. Large venous sinuses are very often opened, and, should the bleeding recur after the adaptation of the flaps, the operation will inevitably fail.

Closure of the recto-vaginal rent is first carried out by interrupted sutures, as is seen in the semi-diagrammatic drawing (Fig. 32). The threaded needle in a holder is passed from the rectal side of the flap through the flap on to the raw surface, then over the rent on to the raw surface of the other side; it finally finds its exit again on the rectal side of the flap. Four or more sutures may be passed in this way, a final one bringing the cut ends of the sphincter ani together. Each suture should be tied and the ends cut short before the next one is inserted, and the knots will lie just beneath the mucous membrane of the rectum.

We have now a large butterfly raw surface to deal with. The extension corresponding to the head is first of all dealt with by four or more separate sutures (Fig. 33, a). The large raw surface is now reduced in size by the passage of a deeply buried suture (Fig. 33, b); those used in the preceding manoeuvres are best of silk. The buried suture should be catgut, and is passed in a spiral direction, as is seen in the diagram; the area of the raw surface is very much reduced by it (Fig. 33, b').

The parts to be brought together will now present the appearance shown in Fig. 33, B, and they are approximated by means of silk sutures, which are entered on the skin surface on one side, passed beneath the raw surface, and made to emerge on the skin surface on the opposite side. Four to six of these may be inserted.

Great care must be taken to see that no bleeding points are left unsecured, and a current of hot 1 in 4,000 perchloride solution should be allowed to play over the surface, after which the sutures are tied. Each suture should be left about an inch and a half long in order to facilitate removal later on. A gauze drain should be passed into the vagina and an antiseptic gauze pad placed over the perineum.

After-treatment. The patient’s knees should be tied together, the urine drawn off by a catheter every six hours for the first 48 hours, and the wound kept as dry as possible. Throbbing and pain in the perineum with slight rise of temperature are generally indicative of suppuration taking place either between the flaps or along the sutures. A smart purge should be given on the morning of the third day and daily afterwards. If there are any scybala left in the rectum it is better to inject a little warm olive oil into it through a catheter before the bowels are expected to act.

The patient should be allowed to get up on the twenty-first day. There should be proper control of flatus and motions from the date of operation.

OPERATION FOR LACERATION OF THE PELVIC FLOOR

The objects of this operation are twofold: first, to secure the torn ends of the levator ani to the lateral vaginal sulcus and perineum; and, secondly, to draw up or lift the pelvic floor, which is more or less depressed.

The patient is placed in the lithotomy position and a retractor is inserted in the anterior cul-de-sac in order to elevate the anterior vaginal wall: Fig. 34 shows the appearances then seen. The left forefinger or some gauze packing is placed in the rectum and a double triangular space is denuded by means of sharp-pointed scissors, the base line of the double triangle being formed by the hymen. Two tenacula are inserted as indicated in the drawing (Fig. 34, t, t). The mucous membrane is now removed from the M-shaped space, great care being taken to penetrate deeply into the lateral sulci. After all bleeding has been arrested in the usual manner, the sutures should be passed. On the left-hand side of the figure these are indicated as inserted, not tied, whereas on the right they are tied and cut. Subsequently the somewhat quadrilateral raw surface which is left is brought together by five deep sutures, and the operation is complete. A Y-shaped cicatrix will be the result.

Cases in which the perineum is apparently intact, but in which the sphincter is not united (Figs. 35, 36).

These are the cases in which a complete laceration of the perineum is apparently completely healed after operation, but the patient finds that she has incontinence both of flatus and fÆces.

On inspection of Fig. 35 this will be well explained. The patient is lying on her back in the lithotomy position: a represents the sphincter which has been torn through; the two cut ends, b and c, are represented by two dark circular, somewhat depressed spots. The rectal orifice gapes; there is no sphincteric power present. The perineum anterior to the anus is firmly healed.

Operation. The most certain and effectual method in these cases is to split up the healed perineum antero-posteriorly and treat the case as one of complete laceration of the perineum (see p. 128). This has been carried out in the case represented in the illustration (Fig. 35), and Fig. 36 shows the result: the patient entirely recovered power over the sphincter ani and the sustaining power of the pelvic floor was much improved.

CHAPTER XIII
OPERATIONS UPON THE URETHRA AND BLADDER

EXTIRPATION OF A URETHRAL CARUNCLE

Indications. A urethral caruncle is a bright red, tender tumour, usually on the posterior portion of the urethral orifice.

The symptoms requiring interference are pain on micturition, dyspareunia, bleeding and discomfort on movement, and, occasionally, retention of urine which is probably due to apprehension of pain rather than to any mechanical obstruction.

Operation. To be effectual this must be thorough, and may take the form of deep cauterization with a Paquelin’s cautery, or excision. The latter operation consists in excising a wedge-shaped piece of the posterior wall of the urethra containing the caruncle. Free bleeding will usually take place, which must be controlled by means of hÆmostatic forceps. The edges of the wound are brought together by fine silk or catgut sutures, which must be passed completely through the raw surfaces to prevent recurrent hÆmorrhage.

The after-treatment consists in keeping the wound as clean and dry as possible.

OPERATIONS FOR INCONTINENCE FOLLOWING LABOUR

This is probably due to injury to the pelvic floor and the anterior fibres of the levator ani, producing a backward displacement of the urethra.

Operation. The operation recommended by Dudley consists of first denuding the vaginal mucous membrane over a horseshoe-shaped space between the clitoris and the urethral orifice and then drawing the urethra forward with sutures passed through the anterior portion of the orifice and inserted near the clitoris. It will then be seen that the urethra is carried forward nearly an inch. The raw edges are brought together in the usual manner by catgut or silk sutures.

The author’s experience of this operation has been unsatisfactory on the whole, and he has obtained better results by the wearing of a ring pessary.

OPERATIONS FOR VESICO-VAGINAL FISTULA

For simple vesico-vaginal fistula. This condition is fortunately very rare at the present time. Many operations have been devised for this condition, but the original one recommended by Sims, with subsequent modifications, appears to the author to be most efficient and applicable to the large majority of varieties of this condition.

Preparatory treatment. The chief object is to obtain a healthy condition of the fistulous edges, which are nearly always inflamed, thickened, and covered by urinary deposits, usually of a phosphatic character. These are best removed by means of a soft sponge or cotton-wool, and the raw edges treated with a weak solution of nitrate of silver (gr. ij to the ounce). Hot vaginal douches of lysol solution (?j to a quart) should be given night and morning, and the parts freely smeared with vaseline to protect them from the action of the irritating urine. Any cicatricial tissue which may be present around the fistula should be treated by submucous division.

Operation. The instruments necessary are: a Sims’s or Auvard’s (Fig. 37) speculum; two flat spatulÆ; three long-handled knives (Fig. 38), one with a long haft and a short straight narrow blade, and the others with angular blades (right and left); two long-handled, sharp-pointed, curved scissors (right and left); an Emmett’s hook for making counter-pressure (Fig. 40); toothed forceps (Fig. 39) and tenaculum; six Spencer Wells’s forceps; Schauta’s needle-holder (Fig. 73) with short curved needles.

The patient is placed in the lithotomy position. A strip of mucous membrane is then removed from the whole of the vaginal edge of the fistula by means of an angular knife. In the original operation Sims (Fig. 41) made the surface oblique, but Simon (Fig. 42) considered the raw surface should be at right angles to the mucous membrane. The blade of the knife should not wound the vesical mucous membrane.

After the bleeding has ceased, the sutures, which may be of silk or catgut, are passed by means of the needle through the pared edge of the fistula on one side, passing across the fistula, and piercing the raw surface on the opposite side. The entry of the needle should be made about 1/4 – 1/3 of an inch from the raw edge (Fig. 44). Emmett’s hook, shaped like a button-hook, is useful to produce counter-pressure against the needle point. The sutures are tied, and milk is injected into the bladder to test the accuracy of the union.

As a rule, fistulÆ are bounded by rather scanty and inelastic walls, owing to the presence of cicatricial tissue; it is therefore more advantageous not to remove any tissue in order to produce a raw surface, or as little as possible. To fulfil this condition, the method of dÉdoublement or flap-splitting, as practised by Walcher, may be carried out (Fig. 43, A, B, and C).

The patient is placed, as before, in the lithotomy position, and the cervix is pulled down, while the edges of the fistula are kept steady by a volsella on either side. The margin of the orifice is then split all round to a depth of from a quarter to half an inch. Vesical and vaginal mucous membrane flaps are thus produced, giving a large raw surface without any loss of substance. The sutures are passed as shown in Fig. 43, C.

After-treatment. This is very simple: if the patient is able, she should pass water, either in the dorsal or genu-pectoral position, otherwise a catheter should be passed every six hours.

Modifications of this operation have been devised, more especially for the larger fistulÆ: they will be briefly mentioned.

1. Repair by turning up vaginal flaps to form the base of the bladder is recommended by A. Martin of Berlin. He first frees the adherent edges of the fistula and then raises the flaps from the vaginal wall and brings them over the opening, suturing them carefully together. By this method the mucous membrane of the vagina forms the new lining to the bladder, and the exposed raw surface a new anterior vaginal wall. The edges of this latter denuded surface are united by sutures, as in the operation of colporrhaphy.

2. Closure of the fistula by detaching the bladder from the vagina and suturing it independently is described and practised by Mackenrodt.

The patient is placed in the lithotomy position, and the fistula is exposed: the cervix is drawn downwards and backwards by means of a wire loop or tenaculum, and the urethral prominence held with a pair of hooked forceps. An incision is then made in the median line extending across the fistula and through the vaginal walls down to the bladder, in this way exposing the entire base of the bladder. The edges of the fistula are then split so that the bladder and the vaginal walls are separated. The two vesical flaps are now carefully and separately sutured by catgut and the edges of the vaginal wound are brought together as much as possible: if necessary, the fundus of the uterus may be used to assist in closing the opening.

For vesico-utero-vaginal or juxta-cervical fistula. In this affection the cervix is involved, and it must therefore be carefully differentiated from the vesico-vaginal variety, in which the cervix is intact.

In operating upon such cases the chief difficulty will be found in denuding the surfaces necessary for the introduction of the sutures, owing to the density of the cicatricial tissues, which are always present. This is best overcome by drawing the cervix forcibly downwards and backwards and incising the anterior cul-de-sac; the bladder wall with its fistulous opening is then dissected off the anterior surface of the cervix and carefully sutured independently of the cervical laceration; the latter is treated by suture in the usual way (see p. 128). In the deeper forms of juxta-cervical fistula, the above technique is impossible, and suprapubic incision and suture of the bladder must be substituted.

RECTO-VAGINAL FISTULA

This condition may be defined as an opening between the rectum and vagina through which flatus, or fÆces, or both, may pass from the former into the latter; it is chiefly the result of an imperfect union subsequent to an operation for complete perineum laceration. It may also be caused by the rupture of a pelvic abscess or by the spread of primary malignant disease of the rectal wall.

Operation. If the sphincter ani is incompletely united, it will be found much the most satisfactory proceeding to divide the healed portions of the perineum and make a complete perineal laceration; this may then be treated as described above (see p. 128).

If, however, the sphincter is intact and serviceable the fistula should be pared and the edges brought together by silk sutures. It is not infrequently necessary to perform a temporary colostomy (see Vol. II) in order to divert the fÆcal contents of the bowel during the process of healing.

OPERATIONS FOR CYSTOCELE

In cystocele there is prolapse of the anterior vaginal wall and the corresponding area of the posterior bladder wall. Cystocele often complicates rectocele and prolapsus uteri, and operation upon it is often carried out in combination with colpo-perineorrhaphy.

Operation. The operation for the cure of this affection is very simple, and may be performed:—

(1) By denuding an oval space over the swelling and bringing the raw edges together.

(2) By Stoltz’s operation, which is really purse-string suture.

The instruments necessary are a bladder sound, two tenacula, sharp-pointed angular scissors, a needle-holder and fine silk.

(1) The parts are exposed with a Sims’s or Auvard’s speculum and a volsella, or silver wire is passed through the cervix, by means of which traction downwards and backwards may be exerted. The cystocele itself is fixed by tenacula, and, with the sound in the bladder, an oval incision is carried completely round the base of the cystocele. The whole area contained in this incision is denuded by knife or scissors, care being taken to avoid wounding the bladder mucous membrane.

Any bleeding having been controlled, a spiral buried suture, as in the operation for perineorrhaphy (see p. 128), is passed antero-posteriorly, thus reducing the size of the raw area and making a solid support in the median line. The raw edges are then brought together by sutures. The catheter should be passed every eight hours for three days, and then the patient should be allowed to micturate on her hands and knees.

(2) Stoltz’s operation. The instruments necessary are: a No. 8 male bladder sound; two tenacula; hooked forceps; sharp-pointed angular scissors, and a needle-holder (Schauta’s for preference).

The patient is placed in the lithotomy position and the parts are exposed by means of an Auvard’s speculum. A silver wire or tenaculum is passed through the posterior lip of the cervix, by means of which downward and backward traction may be exerted. Four points must be selected: two lateral (Fig. 45, 1, 1'), fixing the external boundaries of the surface to be denuded; one immediately behind the orifice of the urethra (2); and a fourth in front of the cervix (3). These four points should be capable of close approximation. They are carefully joined by curved incisions so that the area to be denuded is almost oval in shape. The bladder sound is now passed, and the mucous membrane of the vagina kept on the stretch by pressure on its point. The process of denudation should be carried out with a scalpel or pointed curved scissors. It will be found that bleeding rarely gives any trouble. The point of the needle threaded with silk is inserted on the operator’s right side of the urethral orifice and a little below it; it pierces the mucous membrane on the left side of the median line, and again appears upon the surface. By an in-and-out stitch all the way round the circle which has been pared, the point finally issues on the operator’s left side of the urethra and below it: by traction on these two ends the edges of the denuded surface are drawn together and the prolapsed bladder is sutured in its normal situation. A puckered cicatrix results. This method is valuable for prolapsus uteri when combined with the operation of posterior colporrhaphy.

CHAPTER XIV
OPERATIONS UPON THE VULVA AND VAGINA

OPERATIONS UPON BARTHOLIN’S GLANDS

The glands of Bartholin, or the vulvo-vaginal glands, are two racemose structures about the size of a pea, lodged between the layers of the triangular ligament, one on each side of the orifice of the vagina. Their ducts open a little in front of the fossa navicularis, on each side of the vaginal orifice, in the groove between the attached border of the hymen and the labium minus.

Removal of a cyst of Bartholin’s gland. These cysts really arise in the ducts rather than in the gland itself. The orifice of the main duct is very liable to become blocked from inflammation of the vulva, and leads to the formation of a single cyst varying in size from a cherry to an orange. Less common is the blocking of the secondary ducts, wherefrom a collection of small cysts results. The cyst forms a characteristic tense ovoid or pyriform swelling in the posterior third of the labium majus. The chief symptoms the patient complains of are discomfort in walking and pain on coitus.

Operation. The best procedure is complete excision of the cyst. A longitudinal incision is made over its cutaneous surface, and the cyst carefully dissected out, together with the gland itself: care must be taken not to perforate the vaginal mucous membrane stretched over the inner surface of the cyst. Brisk bleeding from vessels at the base of the cyst, usually follows from the cavity which contained the cyst and this must be carefully arrested, otherwise a large hÆmatoma may result. The cavity is closed by five or six interrupted catgut sutures, passing deeply through its sides and floor, so as to ensure complete closure. A gauze drain may be inserted and retained for twenty-four hours.

The method of incising the cyst, swabbing its interior with undiluted carbolic acid, and packing it with gauze is not to be recommended, for cure is neither so rapid nor so certain as in excision.

Incision of an abscess of Bartholin’s gland. Abscesses arise by infection passing into the gland along the ducts, and are a very frequent accompaniment of gonorrhoea. The orifice of the duct can usually be seen red and prominent, and may exude pus if pressure be made over the abscess-sac. Sometimes the abscess bursts and spontaneous recovery may follow, but it is very liable to recur, for infection lurks among the smaller ducts and is carried to a fresh part of the gland, and the process may continue until the whole gland has been thus destroyed.

Operation. The abscess must be freely incised and all pockets and septa broken down. It is stuffed with iodoform gauze, which is changed daily, and the cavity is allowed to granulate up from the bottom. If the abscess recurs, or if it consists only of a small collection of pus surrounded by brawny oedema, the whole gland should be excised.

OPERATIONS FOR ATRESIA OF THE HYMEN AND THE VAGINA

Occlusion of the hymen is the commonest form observed. The vagina becomes slowly distended with blood, forming an elastic pelvic swelling (hÆmato-colpos) upon which the uterus is, so to speak, perched. Later in the course of the disease, this organ itself (hÆmato-metra) and the Fallopian tubes (hÆmato-salpinx) may become affected similarly.

Indications. In atresia of the hymen symptoms only commence after puberty; there is then congenital amenorrhoea with periodic pelvic pain and gradual formation of a pelvic swelling. On inspection the hymen is distended and the blood-tumour above it gives a bluish tint to its surface.

Operation. After administration of an anÆsthetic, careful palpation of the tubes should be made per rectum: if they are distended it is better to open the abdomen, ligature and remove them; if not, the hymen should be incised by means of a crucial opening and the characteristic tarry fluid allowed to escape: no hypogastric pressure should be used.

Irrigation and packing with gauze may be resorted to as after-treatment, but are considered unnecessary by a large number of operators.

Atresia of the vagina may be congenital or acquired. In the latter case the condition results from contraction of adhesions developed from damage done during labour; or it may follow acute septic vaginitis, the introduction of acids or irritating materials to produce abortion, or as a sequel to typhoid fever.

Treatment is by slow dilatation with Hegar’s bougies over an extended period of time; relapse is common.

DILATATION OF THE VULVAL ORIFICE

Indications. This is done for vaginismus due to a pathological spasm of the levator ani and resulting in more or less complete obstruction to coitus.

Operation. Under an anÆsthetic the vulval orifice should be thoroughly dilated by means of the thumbs, and for some days subse quently graduated Sims’s ‘vaginal rests’ (Fig. 46) should be inserted twice daily and worn for twenty minutes at a time. This treatment may be necessary for a fortnight or longer. In many cases of dyspareunia the cause will be found to be due to a thick, fleshy, and unruptured hymen or to tenderness about the remnants of that organ. Under these circumstances, exsection is the better plan to pursue. The hymen is seized with a pair of toothed forceps and removed with curved scissors along its entire base of attachment. Free bleeding often occurs from the raw surface, which must be controlled by ligatures. The two almost parallel cut edges must then be carefully brought together either by continuous or interrupted suture.

COLPOTOMY OR VAGINAL CŒLIOTOMY

By colpotomy is meant making an opening into the peritoneal cavity through the vagina; the operation is known as anterior or posterior colpotomy, according to whether the opening is made through the anterior or posterior fornix.

Colpotomy has certain advantages over abdominal section. There is less interference with the peritoneum and intestines, and therefore less shock; if pus is present, there is less risk of infecting the general peritoneal cavity, and better drainage; there is no abdominal scar, and therefore no risk of hernia; lastly, there are certain pathological products which can be more easily reached by this route. The operation is difficult in a nullipara, where the vagina is narrow, and easier in a multipara, where the vagina is more capacious, and it is still easier if the cervix can be drawn down as far as the vaginal orifice.

A serious disadvantage is that, during the course of the operation, it may be found impossible to deal adequately with the conditions for which the operation is being performed; in the case of a tumour, for instance, its size, position, or the presence of adhesions may render it necessary to complete the operation by the abdominal route. Further, in more than one instance, the abdomen has had to be opened after the completion of the operation on account of bleeding, the source of which could not be dealt with by the vagina.

Therefore, before deciding upon the removal of a tumour by colpotomy, all the above points must be taken into consideration.

Indications. When the above conditions are fulfilled, colpotomy is suitable for:—

(i) The evacuation of collections of pus or blood in Douglas’s pouch.

(ii) The removal of fibro-myomata, ovarian tumours of small size, and early tubal pregnancies.

(iii) The drainage of collections of pus or the removal of the appendages in cases of acute inflammation where immediate operation is necessary.

(iv) Conservative operations upon the Fallopian tubes or ovaries.

(v) A preliminary to the performance of vaginal hysteropexy.

(vi) Those cases in which the patient’s general condition is unfavourable to the performance of exploration by the abdominal route.

Anterior colpotomy is more suitable for removing small tumours growing from the anterior wall of the uterus, or for conservative operations on the ovaries. Posterior colpotomy is more suitable for removing inflamed appendages, and for evacuating collections of pus or blood from Douglas’s pouch.

Posterior colpotomy has been used for many years for the opening of abscesses and hÆmatoceles in Douglas’s pouch. The anterior operation is of more recent date, and its relative advantages and disadvantages and the indications for its use have not yet been definitely agreed upon by the majority of gynÆcologists. Taking all things into consideration, the disadvantages of colpotomy seem to outweigh its advantages, and, except for the evacuation or drainage of collections of blood or pus behind the uterus, the operation may be said to have few indications.

Anterior colpotomy. A posterior Pozzi’s (Fig. 47) or PÉan’s retractor is passed into the vagina, and the cervix is seized with a volsella and drawn downwards and backwards. A sound passed into the bladder defines its lower limit. A T-shaped incision is now made through the vaginal mucous membrane, the transverse portion just below the point to which the bladder has been found to extend (Fig. 48, b). This incision should pass completely through the vaginal mucous membrane, but no further, and should extend across the whole width of the anterior surface of the cervix. Some operators use a simple longitudinal or a transverse incision. The vaginal mucous membrane is now carefully pushed upwards with the pulp of the finger until the lower limit of the bladder is defined. Great help is gained at this stage by the use of the bladder sound. On pushing up the vaginal mucous membrane still further the peritoneum is reached, and is recognized by its white glistening appearance, and by the fact that its two opposed surfaces glide freely over one another under the finger. The next step is to open the peritoneum: it is picked up with catch-forceps, and a small transverse incision is made into it with a pair of scissors; the finger is passed through, and the incision is extended on either side, care being taken not to pass too far outwards for fear of injuring the ureters or uterine vessels.

After the peritoneum has been opened, the pelvic organs can be carefully examined with the fingers, and the purposes for which the operation has been undertaken can be proceeded with. The next step usually consists in drawing out the fundus of the uterus, by which much more room and much better access to the pelvic organs is gained. To accomplish this, the uterus is caught with a volsella in the middle line, as high up as possible, and drawn downwards and forwards. If necessary, a second volsella is applied above the first, and so on, until the uterus is delivered. A very complete examination of the appendages can now be made, for the tubes and ovaries can be drawn out of the wound and examined directly.

When the object of the operation has been attained, and all the blood has been carefully removed by swabs, the next and final step consists in closing the peritoneal and vaginal wounds. The uterus is replaced, and the peritoneal incision is closed by a single layer of catgut sutures; the vaginal incision is similarly dealt with. The vagina is cleared from blood-clot and gently irrigated with an antiseptic solution. A gauze plug is inserted lightly, and the patient is put back to bed. The catheter should be used every six or eight hours for the first twenty-four hours.

Posterior colpotomy. A posterior speculum is passed and the cervix drawn downwards and slightly forwards with a volsella. A transverse incision is then made through the vaginal mucous membrane at the junction of the posterior fornix with the cervix. This exposes the peritoneum more or less easily, and this structure is picked up with catch-forceps, and a transverse incision made into it with scissors; a finger is passed through this, and the incision is extended on either side. The pelvic organs can now be explored and the tubes and ovaries drawn down and examined. The peritoneal and vaginal incisions are then closed by separate layers of catgut sutures.

To open a collection of pus in Douglas’s pouch, the best method is to pass a pair of sinus-forceps, with the blades closed, into the most prominent part of the swelling. The blades are then opened and the forceps withdrawn. The finger passed into the abscess cavity gently breaks down any adhesions. The cavity is then irrigated with hot salt solution and a drainage tube inserted, which projects just outside the vulva: the lower end of the tube should be carefully packed around with cyanide gauze. The tube should be changed every day and the vagina douched with an antiseptic. Another method is to plunge a Martin’s trochar (Fig. 49) into any softened spot in the swelling and then withdraw the needle, leaving a blunt dilating forceps to extend the opening.

In opening an abscess, the most stringent precautions against sepsis should be observed. The vagina must be most carefully prepared beforehand, by rubbing over with swabs and ethereal soap, and by a subsequent copious douche of 1 in 1,000 perchloride of mercury: otherwise continual reinfection of the abscess cavity occurs, and healing is much delayed.

Lateral colpotomy—Paravaginal section.

Indications. The object of the operation is to increase the amount of room in the vagina in certain cases of vaginal hysterectomy in elderly virgins, or in women who have a small vagina.

Operation. The same preliminaries are carried out as before. The incision is carried completely round the cervix at its junction with the vagina. The lateral margin of the vulva is then held tense, and an incision is made, beginning at the circumcervical incision running down the lateral vaginal wall, through the margin of the vulva and on to the skin externally, ending at a point midway between the perineum and the ischial tuberosity, i.e. about 1½ inches to the side, and in front of the perineum; the incision may be lateral only or bilateral. In sewing up, it is important to reunite the cut edges of the levator ani, or pelvic weakness will result.

CHAPTER XV
OPERATIONS UPON THE UTERUS

PASSAGE OF THE UTERINE SOUND

This is an operation which is much less frequently resorted to than formerly, owing partly to the risks of sepsis attending its performance and partly to the greater perfection of the bimanual examination. Passing the uterine sound should always be looked upon as a surgical operation. The facts learnt by the use of the sound are: (1) the length and direction of the uterine cavity; (2) the condition of the endometrium: bleeding as a rule follows withdrawal in fibro-myomata and endometrial disease; (3) whether a fibroid growth is projecting into the uterine cavity, and if so, how much.

The sound may be passed in the dorsal position (Fig. 61), the cervix being held by a volsella and exposed by means of a posterior speculum, or in the left lateral position, the method usually adopted in the consulting room. In the latter the right index-finger is passed up to the anterior lip of the cervix, the sterilized sound is taken in the left hand with its concavity backwards and its bulbous end is slid gently along the palmar surface of the finger in the vagina until the os uteri externum is reached; through this it should be passed for about a quarter of an inch (Fig. 50). The instrument should now be steadied by the thumb and the two distal joints of the second finger of the right hand, and its subsequent movements controlled by the left (Fig. 51).

If the uterus is in a state of retroversion, the bulbous end will gradually enter the uterine cavity by pressing the handle of the sound forward and at the same time giving an upward and slightly backward impulse to its tip; the rough surface of the handle will be found to be looking towards the sacrum. Should the uterus be anteverted, the handle is held in the left hand as before and passed through an arc of a circle by raising the handle and turning it forward until it lies beneath the symphysis pubis, in the median line (tour de maÎtre) (Fig. 52). The rough surface of the handle now looks anteriorly and the bulbous end is pressing against the internal os uteri; now bring back the handle directly to the perineum and it will glide into the uterine cavity (Fig. 53).

Difficulties to be met with will be: (1) An acutely anteflexed uterus; if traction is made on the cervix with a volsella the canal is straightened and the difficulty overcome. (2) Spasmodic contraction of the internal os uteri; this soon passes off with a little steady pressure. (3) A fibroid may project into the lumen of the canal. (4) Congenital or acquired stenosis of the external os uteri.

When there is a septic discharge from the vagina, the sound should be passed in the dorsal position and through a speculum.

REPOSITION OF A CHRONIC UTERINE INVERSION

Indications. Chronic inversion of the uterus, with severe hÆmorrhage and bearing-down pain. The uterine fundus presents in the vagina and simulates a fibroid polypus in process of extrusion.

Operation. This is most likely to be successful if continuous pressure be brought to bear against the inverted fundus while an attempt is made simultaneously to dilate the contracted cervix.

The patient is placed under an anÆsthetic in the dorsal position and the whole hand is passed gradually into the vagina. The tips of the fingers and thumb should be pressed into the circular space at which the flexion of the walls of the body on the cervix has occurred. With the palm of the hand upward pressure is made, counter-pressure being exerted by the other hand over the lower hypogastrium. Reduction usually begins by a slight dimpling of the inverted fundus.

A more scientific method of exerting continuous pressure is by the application of Aveling’s sigmoid repositor and elastic cords (Fig. 54). This instrument consists of a vulcanite cup into which is secured a steel S-shaped rod terminating below in a loop. The cup is made of various sizes and should always be smaller than the inverted fundus over which it fits.

After it has been applied, the instrument is carefully packed round with gauze to keep it in place. Two elastic bands in front and two behind are fastened by one end to the steel loop and by the other end to an abdominal belt. By this means constant and direct pressure is obtained on the fundus uteri in the direction of the pelvic axis.

Pain is usual and must be relieved by morphine. The cup usually elevates the fundus and corrects the inversion in about twenty-four hours, but as much as three days has been occupied in the process.

CURETTING THE UTERUS—CURETTAGE

The term ‘curetting’ is applied to the operation of scraping away the lining membrane of the uterus, either for the relief of some pathological condition or for diagnostic purposes.

The endometrium is not removed in its entirety by curetting, for the uterine glands dip down to a slight extent between the muscle fibres of the uterine wall. The endometrium is removed as far down as the muscular coat, and, consequently, those parts of the glands lying amongst the muscular fibres are left intact.

Indications. These may be divided into the cases in which the operation is (1) Remedial and (2) Diagnostic in nature.

The diseased states of the endometrium are many and their exact pathology is still under discussion. It is, therefore, more practical to consider the remedial indications for curetting from the point of view of symptoms.

(i) Uterine hÆmorrhage is the chief symptom which calls for curetting. The causes of the hÆmorrhage may be certain forms of endometritis. Thus hÆmorrhage is a prominent symptom of the so-called ‘hypertrophic glandular endometritis’, a diffuse overgrowth or adenomatous condition of the endometrium, probably the after-result of a previous inflammation. There is one form which gives rise to specially profuse hÆmorrhage—the ‘polypoid’ or ‘villous’ form, which arises usually in women over forty years of age.

The hÆmorrhage from fibro-myoma of the uterus may require removal of the endometrium in order to relieve the bleeding temporarily at any rate. When milder measures fail, curetting is of great service in arresting the profuse menorrhagia which so often accompanies subinvolution of the uterus.

Certain cases in which the actual cause of the hÆmorrhage is not evident are relieved by curetting; amongst these are such conditions as arterio-sclerosis of the uterine vessels.

(ii) A leucorrhoeal discharge is another symptom for which curetting is sometimes indicated.

It may be called for when the endometrium is congested and oedematous from such conditions as displacements of the uterus and chronic subinvolution.

It is better not to curette for a purulent uterine discharge; extension of the infection may be caused and give rise to pyosalpinx.

(iii) Sterility. Curetting should follow dilatation, in the hope that the new endometrium formed may afford a better nidus for the ovum.

(iv) Frequent abortion in the early months. Curetting often cures this by removing the diseased endometrium.

(v) Inoperable carcinoma of the cervix. Removal of the redundant portions of the growth by the curette, followed by cauterization or other measures, relieves the hÆmorrhage and foul discharge. Great caution must be exercised, lest the peritoneum or bladder be opened into by the curette and the sufferings of the patient thereby increased. Cells of the disease may also be pushed into the pelvic lymphatics; considerable febrile disturbance may also follow the operation. In this condition a blunt curette (Fig. 60, B) may be gently used; the same instrument is safest in abortion up to the eighth week of pregnancy; after this date it is better to use the fingers only.

Fragments removed by the curette are subjected to microscopical examination for diagnostic purposes. The various conditions which may have to be diagnosed are:—

1. Carcinoma of the body of the uterus.

2. Retained products of conception.

3. Tuberculosis of the endometrium.

4. Chorio-epithelioma malignum.

Operation. The following instruments are required: a volsella (Fig. 55); a self-retaining weighted speculum (Fig. 37); uterine dilators (Figs. 56, 57); a uterine sound; a Bozemann’s tube (Fig. 58); Budin’s celluloid catheter (Fig. 59); and one or other flushing curettes.

There are many varieties of curettes, and each has its own adherents. The most generally useful is Murray’s sharp flushing curette, which has a groove for the recurrent flow (Fig. 60, A). There are many varieties of blunt curettes. The model depicted in Fig. 60, B, enables the operator to clear out the uterine cornua and is of the best shape.

The patient is placed in the lithotomy position and the various antiseptic precautions already described are carried out. A speculum is passed and the cervix is steadied by a volsella applied to the anterior lip.

The cervix is first dilated up to a suitable degree for the passage of the curette; up to No. 12 Hegar is usually sufficient. The curette is now taken and passed into the uterus. In performing the operation a definite plan should always be followed so as to ensure that no part of the uterine cavity is missed. The curette is passed up to the top of the fundus uteri with its cutting edge directed to the posterior wall. It is then drawn downwards with steady pressure to just below the internal os. It is then again passed upwards and the manoeuvre repeated with just sufficient change of direction to ensure the curette passing over fresh tissue. This is repeated until the whole of the posterior wall has been thoroughly dealt with from side to side. The anterior wall and sides of the uterus are then treated in turn in the same way. Finally the fundus is curetted by a lateral movement of the instrument, especial attention being paid to the Fallopian tube angles, which are very apt to escape the curette.

A rasping or grating sound indicates that the endometrium over a given part has been removed and that the muscular walls have been reached. In spite of the most careful attention it is very difficult to remove the endometrium completely. If a uterus be scraped, as it is thought, thoroughly, and be examined post mortem, strips of mucous membrane will often be found untouched, showing the difficulties of complete removal.

After the operation an intra-uterine douche of 1 in 2,000 perchloride of mercury or some other suitable antiseptic is given with a Bozemann’s tube or Budin’s catheter. If a flushing curette has been used, this of course has already been done. After the douche, some application may be made to the interior of the uterus: the best is iodized phenol (liquid carbolic acid, 2 parts; tincture of iodine, 1 part). To do this the interior of the uterus is first dried with a Playfair’s probe armed with cotton-wool; another similar probe is then taken, dipped into the solution, and passed into the uterus. The vagina is protected by inserting a plug of cotton-wool into the posterior fornix. The uterus is then lightly packed with ribbon gauze. If there is hÆmorrhage, the packing should be firmer, and a vaginal tampon should be placed in below the cervix. The packing should be removed in twenty-four hours. The patient may get up at the end of a week and resume her ordinary duties in a fortnight.

DILATATION OF THE CERVIX

Indications. Dilatation may be performed:—

Contra-indications to the rapid method of dilatation of the cervix are very few: a recent attack of peri- or parametritis would certainly be one, but when the effects of a salpingitis have quieted down there seems very little reason against its use. Where carcinoma of the body of the uterus is known to exist, and in old age, it should only be resorted to with the greatest caution, if at all.

Methods:—

(a) Rapid dilatation by means of graduated metal bougies.

(b) Gradual dilatation by means of tents.

(c) Combined gradual and rapid dilatation.

In a large majority of cases rapid dilatation is the operation selected. Its one disadvantage is that when a great degree of dilatation is necessary, or when the operation is performed too rapidly, the cervix is liable to be torn, an event which is especially liable to occur when the tissues of the cervix are rigid. These lacerations are longitudinal in direction and in the neighbourhood of the internal os uteri. They sometimes result in hÆmorrhage, which can easily be controlled by plugging the cervical canal. Unless strict asepsis be maintained, these lacerations of course form a channel for infection of the pelvic cellular tissue.

It is obvious that dilatation will be easier to perform, and laceration less liable to occur, if the cervix is in a softened condition—a physiological state which is always present during pregnancy and labour. Efforts should therefore be directed, when possible, to ensure a soft state of the cervix before performing rapid dilatation.

Immediately after the cessation of a period, the cervix is soft and somewhat patent, and advantage may be taken of this fact. The introduction of a glycerine tampon two hours beforehand produces a certain amount of softening. But nothing ensures so much softening as the introduction of a tent into the cervix about twelve hours previous to the rapid dilatation.

It is therefore recommended in all cases, where possible, to perform dilatation by this latter means, viz. a combination of the gradual and rapid methods.

Rapid dilatation by means of graduated metal bougies. Hegar’s original dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26, the numbers corresponding to the diameter of the bougie in millimetres. Each was 5¼ inches in length, the handle measuring 1½ inches and the bougie the remainder. The bougie formed a slight curve and tapered off to a blunt point.

These bougies were rather short and too sharply pointed, and they could not be sterilized by boiling. To overcome these disadvantages, uterine dilators are now made about the same length as a male catheter, with a sharper curve than Hegar’s original one, and a blunter point; the larger sizes are of hollow metal for the sake of lightness. There are many varieties of dilator, each with minor differences as to length, curve, handle, and shape of the point.

The author uses metal bougies. These have somewhat the shape of the ordinary uterine sound, are thirty-five in number, and graduated in size. Like the sound, the upper portion is bent at an angle of about 160° with the solid handle, a circular shallow depression indicating the 2½ inch mark in the smaller numbers; in the larger this is not considered necessary.

Operation. Instruments: an Auvard’s self-retaining weighted flushing speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine sound; and a set of dilators.

The patient is anÆsthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the labia must be shorn of long hairs; this is followed by cleansing of the vagina and a vaginal douche, and finally the vulva is washed with antiseptic lotion. The speculum is passed and held by an assistant, but if self-retaining, as in Fig. 61, the assistant is not necessary: a sound is then inserted to ascertain the length and direction of the uterine cavity. If anteflexion be present, the anterior lip of the cervix should be seized with the volsella and fixed by slight traction. If retroversion or retroflexion be present, then the posterior lip should be fixed. Traction by the volsella tends to straighten out the uterine canal, and thus makes the passage of the bougies easier. The bougies are now passed in order, commencing with the size which will pass easily. The bougie is passed by means of the right hand into the cervical canal until the internal os uteri is reached; resistance will now be felt. Firm and continuous pressure in the proper direction must be made, and in a short time the resistance gives way, and the bougie will pass into the uterine cavity. An interstitial fibroid produces a tortuous channel and much difficulty will often be experienced in passing a bougie in such a case. It will be found on attempting to withdraw the instrument that it is grasped by the internal os uteri; in the course of one to five minutes this spasm will relax, and only then should the bougie be withdrawn. The next in size should be ready and introduced in the same manner, and the succeeding ones are inserted until the required dilatation is produced. Sterilized vaseline or glycerine of perchloride of mercury may be smeared over the point of the dilator to facilitate its passage. Each succeeding bougie should increase in size by not more than 1 mm.: occasionally a case is met with where this seems too large a difference, and it is really better to have them made with a ½ mm. difference. As a preliminary to the use of the curette, dilatation up to No. 12 Hegar is necessary. The index-finger can be introduced into the uterine cavity after the passage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the Écraseur on intra-uterine growths.

It is evident that the degree of dilatation for exploratory purposes will be governed by the diameter of the operator’s finger, or rather of its second joint, and this varies very much in different people. By means of the finger a uterus can be explored in which the cavity is much longer than the operator’s finger, if the viscus be forced down on to the finger by the pressure of the other hand above the symphysis pubis. The operator must not be satisfied until he has felt the whole extent of the uterine wall, especially the two cornua, which are favourite seats of disease. After completion of the operation it is well to give an antiseptic intra-uterine douche by means of a Bozemann’s tube. The uterus and cervix should be lightly packed with sterile ribbon gauze, 1 inch wide; the free end is left projecting through the os uteri. The packing should be removed in twenty-four hours, and an antiseptic douche given.

Difficulties and dangers. The difficulty due to non-dilatability is overcome by means of the preliminary use of a tent. The complication produced by a fibroid, altering the direction of the uterine canal, has been mentioned. Extreme anteflexion or retroflexion gives trouble during the passage of the earlier numbers, but as dilatation is effected this disappears.

The dangers are:—

1. Laceration of the cervix.

2. Rupture of the uterus.

3. Sepsis and its sequelÆ.

4. HÆmatoma between the layers of the broad ligament.

Laceration of the cervix has been referred to: it begins as a rule at the internal and extends towards the external os uteri; it may be deep or superficial, and is recognized as a sulcus into which the finger can be passed from above downwards: rarely, laceration into the peritoneum may take place.

Rupture of the uterus is liable to occur when the uterine wall has been weakened by the changes which accompany the completion of the menopause, or has been infiltrated by carcinoma, or, more rarely, by vesicular mole.

Sepsis may occur from absorption through a laceration if asepsis has not been maintained: it may lead to an attack of pelvic cellulitis or even septicÆmia.

If the uterus is fixed or not freely mobile, and the condition is complicated by any tubal or ovarian disease, great care must be exercised in manipulation.

Gradual dilatation by tents. There are three varieties of tents—sponge, laminaria, and tupelo.

Sponge tents should never be used, for they are extremely difficult to render sterile.

The commonest and the safest to use, because they can be most easily sterilized, are laminaria tents, made from sea-tangle (Laminaria digitata). These are cylindrical rods, which expand evenly, from imbibition of moisture. Tupelo tents are larger than laminaria and expand more rapidly.

To use tents that are not absolutely sterile is to court disaster, and in former times they were responsible for many fatalities from sepsis. The best way to keep laminaria and tupelo tents is in a solution of 1 in 1,000 corrosive sublimate in absolute alcohol. They may be kept in this for an indefinite period, and so are always ready for use.

Contra-indications. All septic states of the uterus and cervix, for the retention of pent-up discharges is very likely to lead to local or general infection. Tents should never be used then in such conditions as carcinoma of the body of the uterus, sloughing polypus, acute endometritis and cervicitis.

Method of introduction of a tent. The patient is placed in the lateral or lithotomy position and a vaginal douche given. A Sims’s speculum is passed and the cervix seized and drawn down with a volsella so as to straighten the cervical canal. The direction and length of the uterine cavity is ascertained by passing the sound. The most suitable size of tent is now selected, and, being held in a special form of tent introducer or suitable pair of forceps, is passed into the cervical canal, well past the internal os uteri. The end should project slightly into the vagina. The vagina should then be douched again and lightly packed with sterilized gauze. The patient must remain in bed.

The tent should be left in position for twelve to fifteen hours, when it will have exerted its full action. The action of tents is twofold: it causes (1) dilatation, and (2) softening of the cervix, the softening being accompanied by an abundant secretion of mucus from the cervical glands.

Method of removal. Tents are removed by traction on the silk thread attached to the vaginal end. The part of the cervical canal which exerts the greatest resistance to the dilating action is the internal os uteri, and after the tent has been removed a well-marked constriction is always to be seen at this point. If there is much resistance to removal by reason of the tent being gripped at the internal os, it should be taken in a pair of forceps and gently pulled and levered out.

OPERATIONS FOR HYPERTROPHY OF THE CERVIX

This is a congenital condition and there is no thickening of the mucous membrane and underlying tissues; hence the diameter of the cervix is not increased. The operation best adapted for the treatment of this condition is the wedge-shaped incision, recommended by Marckwald (Fig. 62).

Operation. The cervix is split bilaterally into an anterior and posterior portion by means of scissors, and out of each portion is excised a wedge-shaped piece of tissue, leaving a deep groove. The sutures are passed as in Fig. 62, and the raw surfaces are brought together.

Circular amputation, as carried out by Hegar, is more suitable for supravaginal elongation of the cervix, the result of prolapsus uteri.

The patient is anÆsthetized and placed in the lithotomy position and the cervix is pulled down by a volsella and amputated transversely by a knife or scissors. A certain amount of retraction of the stump takes place, producing an inversion of the vaginal wall. The raw surface remaining must be covered by uniting the vaginal and cervical mucous membranes. Sutures are passed in the following manner: a short stout, straight needle, threaded with a loop of silk, is passed from the vaginal mucous membrane, across and beneath the raw surface of the stump, and emerges on the mucous membrane of the cervix (Fig. 63). From eight to ten of these sutures are passed at regular intervals and tied. The sutures are removed on the tenth day and the patient should be kept in bed for fourteen days.

TRACHELORRHAPHY.

Indications. This operation is performed for the repair of certain forms of laceration of the cervix. It was formerly practised in every case in which a laceration occurred: it is now only permissible in cases in which there is extroversion of the mucous membrane with certain symptoms, such as hÆmorrhage or free leucorrhoeal discharge accompanied by backache on exertion and general ill health. It was formerly considered that there was a direct relation between cervical laceration and cancer, but further inquiry has failed to corroborate this view.

The instruments required are: a Sims’s or Auvard’s speculum; long-handled, angular-bladed knives (right and left); Emmett’s scissors (right and left) (Fig. 64); toothed dissecting forceps; short stout needles with sharp triangular points, straight or very slightly curved.

Operation. As it is usually found that subinvolution is present and kept up by the laceration, it is best to perform a preliminary curettage (see p. 154) before proceeding to the operation proper.

The patient is placed in the lithotomy position and an Auvard’s speculum is inserted. A piece of stout silver wire or a tenaculum is passed deeply through the anterior and posterior lips of the cervix; steady traction can be made through these and the uterus kept fixed while denudation and suturing are carried out. Should marked extroversion be present, with hypertrophy of the cervical glands, the curette should be freely applied to the diseased surface.

The uterine sound is passed to mark the situation of the internal os uteri, and an antero-posterior linear piece of lining membrane, about a quarter of an inch in breadth, must be allowed to remain untouched. This is necessary to prevent total occlusion of the cervical canal when the denuded flaps are sutured (Fig. 65).

Denudation. The right half of the anterior and posterior lips of the cervix (upper and lower from the operator’s point of view) are first pared by means of the angular knives and scissors, great care being taken to see that the deep angle of the reflexion is not overlooked. The other side is then treated in a similar manner. The tissues will be found extremely hard and resistant, especially if there be much cicatrization about the angle of the laceration.

The passage of the sutures (Fig. 65). The short stout, triangular-pointed needle is first doubly threaded with silk or stout chromicized catgut so that a loop of three to four inches in length is produced. The needle and the silk suture are passed as in Fig. 65, two on either side.

The triangular-pointed needle must be held in Schauta’s specially strong holder (Fig. 73), and should be made to pierce the cervix near the raw surface on one lip, and pushed through the tissues immediately below this to emerge on the strip of unpared cervix already mentioned. It is then carried across the sulcus and is made to emerge through the opposite lip of the cervix. A stout wire is now hooked into the loop and pulled through the needle track. When the two wire sutures are inserted on either side, the flaps are brought together and the wires twisted together.

Results. Primary union is the rule, and the wire sutures may be removed at the end of the tenth or twelfth day. The cervix has the appearance observed in the nullipara, and may lead to complications in any ensuing labour from difficulty of dilatation.

DÜhrssen modifies Emmett’s operation by a flap-splitting procedure which, however, does not appear to possess sufficient advantages to warrant its general introduction.

VAGINAL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri in an anteverted position, by suturing it to the anterior vaginal cul-de-sac.

Indications. These are somewhat uncertain, and the field of utility of the operation is rapidly becoming more limited. Advocates of this procedure recommend it for backward displacement of the uterus with or without adhesions. It is considered specially applicable to cases in which slight retroversion is complicated by moderate prolapsus. The results which have so far obtained do not appear to be so good as those resulting from the use of a well-fitting pessary.

Operation. The technique recommended by DÜhrssen appears to be the most satisfactory, and is as follows: The patient is anÆsthetized and placed in the dorsal position with the knees supported by a Clover’s crutch. After purification of the parts (see p. 126) the cervix is pulled down as far as possible by means of a volsella: a curettage is then carried out as a preliminary measure (see p. 154). If cervical hypertrophy is present, amputation by Marckwald’s method (see p. 160) should be performed, as an elongated cervix acts as a preventive to satisfactory anteversion of the uterus. A transverse or T-shaped incision is now made as in vaginal hysterectomy (see p. 169), and the cellular tissue pushed up by the index-finger until the peritoneum is reached. The peritoneum is now seized with a volsella and cut through, and the edges sutured to the lips of the vaginal wound. The uterine fundus is then anteverted by means of a sound: by pressing the handle of the instrument towards the perineum the fundus is brought into the wound. By means of a rectangular curved needle a stout silk suture is passed through the anterior wall of the fundus as high up as possible: the vaginal flaps are not included, as the suture is to be used for traction only. The uterus is now forcibly pulled down and two other sutures are introduced in the same manner higher up. Three sutures of catgut are passed through the uterine wall, including the vaginal and peritoneal flaps. The silk traction sutures are now withdrawn and the permanent ones tied. The vaginal wound is carefully sutured by means of fine silk.

Difficulties and dangers. The risks of the operation are peritonitis and wounding of one or both ureters or the bladder wall. Absolute rest for fourteen days is necessary and no local after-treatment is called for.

CHAPTER XVI
OPERATIONS FOR NEW GROWTHS OF THE UTERUS

Uterine growths include primary malignant disease and fibro-myomata; the former should be treated by exploration and subsequent vaginal hysterectomy (see p. 168), while the latter should be dealt with according to their relations and attachments to the uterine wall.

OPERATIONS FOR UTERINE FIBRO-MYOMATA

Fibro-myomata may present themselves to the operator in one of the following forms:—

1. As a fibroid polypus still intra-uterine or presenting through a naturally dilated and thinned-out cervix (submucous pedunculated).

2. As sessile growths presenting by their lower segments at the os uteri, which may be closed, or may be in varying degrees of dilatation (submucous sessile).

3. As tumours incorporated in the uterine wall (interstitial).

Operations for pedunculated tumours. If a fibroid polypus be still intra-uterine (Fig. 66) the proper treatment is to dilate the cervix (see p. 156), and, if the pedicle be sufficiently thin, to seize the growth with a pair of stout polypus forceps and twist it off by a slow rotary movement of the handles. Should the pedicle be thicker than the finger, the use of the wire Écraseur is advisable. This is a scientific snare, with a loop of pianoforte wire and a handle or wheel by which it can gradually be tightened, causing the wire to slowly cut through the stalk of the growth (Fig. 67).

The cervix is steadied with a volsella and the loop of the Écraseur is shaped and bent to the size and position of the fibroid. The instrument is then passed into the uterine cavity and the noose pushed over the tumour up along the pedicle. The wire loop is then tightened up by means of the handle or wheel, and the wire cuts its way through and separates the growth from the uterine wall. It is somewhat dangerous to put any traction on the tumour before its separation, as is recommended by some writers, as the uterine wall itself may become somewhat inverted and the wire loop may cut through into the peritoneal cavity.

If the fibroid polypus has passed through the external os uteri, treatment is more simple. Slight traction may be made upon it by means of forceps, and the pedicle severed with scissors; no hÆmorrhage takes place, owing to the retraction of the stump.

Operations for sessile tumours. In submucous sessile fibroids (Fig. 68) in which the lower segment of the uterus is somewhat thinned out and dilated, operative interference may be as follows: Preliminary dilatation of the cervix by bougies may be necessary. The capsule of the tumour is then incised with a sickle-shaped knife and the growth is enucleated by means of the finger or a blunt spoon. In some cases mere incision of the capsule is sufficient, and the uterus expels the growth later on.

Another method of treating these cases is by the operation of morcellement, which consists in removing the tumour piecemeal by means of specially made forceps.

The instrument used by the author consists of a strong pair of forceps somewhat like those used in lithotomy, with the two distal ends notched with sharp teeth like a volsella. A portion of the tumour is seized between these two blades, and partly cut and partly twisted off. With patience and care the whole tumour may be thus removed. In one case the author was enabled to remove two large growths, each filling a pint measure. This operation is specially suitable in women in whom an abdominal operation is to be avoided.

Operations for interstitial tumours. Interstitial fibroid tumours, if not above the size of a small foetal head, should be treated by vaginal hysterectomy (vide infra); if large, by hysterectomy by the abdominal route (see p. 36).

Vaginal hysterectomy. By vaginal hysterectomy is meant removal of the whole uterus by the vagina, with or without the appendages. The advantages that the vaginal operation possesses over abdominal hysterectomy are, there is less disturbance of peritoneum and intestines, less shock, and no abdominal scar or risk of subsequent hernia. The operation is limited to uteri not exceeding in size the head of a full-time foetus.

Indications. (i) Malignant disease of the uterus (fundus or cervix) in an early stage: chorio-epithelioma malignum.

(ii) Certain cases of fibro-myoma of the uterus.

(iii) Certain cases of inflammatory disease of the uterine appendages complicated by recurrent attacks of local perimetritis.

(iv) Other conditions, such as intractable uterine hÆmorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrhoea.

It has also been advised for irreducible chronic inversion of the uterus, and for severe procidentia uteri. No case of the former has occurred in the author’s experience in which the operation was found necessary. In the latter condition the operation is not to be recommended, the almost certain result of the procedure being prolapse of the vaginal walls and the intestines (enterocele).

Vaginal hysterectomy for carcinoma. The only cases suitable for operation are early ones, in which the disease is still confined to the uterus itself, which should be freely mobile in all directions. No signs of infection of the surrounding cellular tissue and vaginal walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anÆsthesia to settle this point before operation is decided upon. Rectal examination is most important to estimate the condition of the sacro-uterine ligaments, the cervix being pulled down so as to place them on the stretch.

Occasionally, cases of carcinoma of the cervix are seen, in which the cellular tissue immediately surrounding the cervix is apparently free from disease, but if search be made further outwards, a hard, fixed mass is found plastered, as it were, on to the side of the pelvis, indicating advanced disease of the lymphatic glands, or cellular tissue at the outer part of the broad ligaments. Such cases are hopeless for operation.

If the disease is in the sloughing stage, and there is foul discharge, Paquelin’s cautery should be applied to the diseased surface, followed by vaginal douches of formalin (?j to the pint), or some other efficient antiseptic, given three times a day for three days prior to operation. The operation consists of three main stages:—

First of all, the growth, if of the cervix, should receive careful preliminary attention, for it constitutes a continuous source of infection, not only by means of septic organisms, but also of cancer cells, which may become implanted in the wound and cause early recurrence. The cervix is drawn down with a volsella and all visible growth is burnt away with the Paquelin cautery, until apparently healthy tissue only is left. The cervix is then completely closed by the application of a volsella or three or four stout silk sutures, passing through both anterior and posterior lips. The ends of the sutures may be left long if preferred and serve as tractors.

After these preliminary measures against infection have been completed, the removal of the uterus is proceeded with. A posterior speculum, Auvard’s or Pozzi’s, is passed, and the cervix is drawn downwards and somewhat backwards by traction on the volsellum or the long ends of the silk sutures. A sound is passed into the bladder to define its lower limit. A transverse or T-shaped incision (Fig. 48) is now made through the vagina at the level of the cervico-vaginal junction in front. This constitutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, passing through the whole thickness of the vagina, but no further.

The knife is now laid aside, and the operator proceeds to push up the vagina and bladder from the anterior aspect of the cervix with the index-finger or a winged director, until the anterior peritoneal pouch is reached. This is at once recognized by its glistening white appearance and by the manner in which its opposing surfaces glide over one another.

This part of the operation must be conducted very cautiously for fear of injury to the bladder: the pulp of the finger only must be used in the separation. The frequent use of the bladder sound is very useful at this stage, as it is quite easy to wound this viscus laterally. Bleeding from the divided twigs of the vaginal vessels often obscures the field of operation and renders the separation of the bladder troublesome: it well repays the operator to stop all bleeding after making the vaginal incision.

The peritoneum is next picked up and opened with scissors. The anterior fold of peritoneum may sometimes be more easily reached after the bases of the broad ligaments have been ligatured and divided, thus allowing the uterus to be drawn down more readily, and making the peritoneum more accessible. An anterior retractor is then passed to keep the bladder out of the way.

A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-vaginal junction, more or less cellular tissue is traversed, and the posterior peritoneal pouch is opened. By joining the ends of these two incisions the cervix is completely separated from the vagina.

The uterus is now suspended in the pelvis by the attachments of the broad ligaments only; the next step consists in ligaturing and dividing these. The cervix is drawn over towards the patient’s right side by an assistant, so as to expose the base of the left broad ligament. Additional space is gained by drawing aside the left wall of the vagina by means of a retractor. By passing the left index-finger behind the broad ligament the tube and ovary can be easily felt, and if necessary the bent finger can pull them down for inspection; the finger is then placed beside the cervix below and behind the base of the broad ligament. A Galabin’s or Jessett’s (Fig. 70) needle, carrying a stout silk suture, is passed through the ligament from before backwards, on to the tip of the finger (Fig. 71).

The ligature should be passed about one-third of an inch up the broad ligament. It is then tied tightly and the ends left long and drawn aside. The segment of broad ligament included in the ligature is divided as near the uterus as is justifiable; in carcinoma of the cervix at least half an inch from the disease should be allowed. Care must be taken at this stage to avoid injury to the ureters; these lie about one inch distant from the cervix; consequently all ligatures must be passed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now passed through the broad ligament above the first and then a third, and more if necessary. The second generally includes the uterine artery, which can always be recognized by its strong pulsation under the finger; the third ligature will control the Fallopian and ovarian arteries. After the arteries on the left side have been secured and divided, attention is directed to the right broad ligament. The cervix is drawn over to the left side, the fundus delivered, and the upper portion of the right broad ligament is dealt with in a similar manner, but from above downwards. If the ovaries and tubes are diseased, they can now be removed by piercing the pedicle and tying the stump in the usual way.

The uterus having been extirpated, the next step consists in dealing with the wound. First, all bleeding is stopped, and the wound is swabbed clean and dry. The ligatures on either side are tied in two bunches and the ends cut off just within the vagina (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures passed by means of Schauta’s needle-holder (Fig. 73); the walls of the vaginal vault are treated in a similar fashion, leaving a circular orifice in the median line into which gauze can be inserted for the purpose of drainage.

Some operators prefer to control the vessels in the broad ligaments by means of hÆmostatic forceps instead of ligatures. Each broad ligament is clamped in three or more portions and the tissue between them and the uterus cut through. They must be allowed to remain in position for at least forty-eight hours, as recurrent hÆmorrhage is possible if they are removed earlier. The only advantages of the forceps appear to be the rapidity with which the operation can be carried out, and the good drainage. The disadvantages are, that it is a somewhat unsurgical proceeding; there is often much pain from the nipping of the broad ligaments, and inconvenience from the presence of the handles between the labia; the intestines may be damaged; sloughing and risk of sepsis must be reckoned with.

After-treatment. The catheter should be used at first four times daily; the author recommends that the gauze should be removed at the end of twenty-four hours, but some operators retain it longer. The ligatures should be pulled upon a little daily after the seventh day, and they gradually cut their way through the tissues in their grasp. No vaginal douching should be administered until after the expiration of a week.

Vaginal hysterectomy for fibroids. This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a foetal head. Uterine fibroids of such a size can usually be treated in other ways, either temporarily by curetting, or, if submucous, permanently by enucleation through the vagina. The operation is most suitable for uteri containing many small fibroids causing severe hÆmorrhage which cannot be controlled by more palliative measures.

The vagina must be large enough to admit of delivery of the uterus through its lumen. Therefore, in virgins and nulliparÆ, the abdominal operation is always to be preferred. In any case, if the vagina be too narrow, additional room may be gained by lateral vaginal section (see p. 148) or episiotomy.

The operation does not differ in technique from the removal of the uterus for carcinoma, already described. In some cases it may be preferable to bisect the uterus in the sagittal plane before removing it, after the cervico-vaginal attachments have been separated and the peritoneal pouches opened.