| _Age | _Period |_Result | _Reference
_Recorder._| of | of | to | to
|Patient._| Pregnancy._ |Mother._| Volume._
------------+---------+--------------------+--------+-----------------
Horrocks | ? |5th month | ? |1900, xlii. 242.
Routh | 33 |33 weeks | R. |Ibid., 244.
Doran | 40 |5th month | R. |1901, xliii. 178.
Donald | 43 |9th month | R. |1901, xliii. 180.
Donald | 34 |4th month | R. |Ibid.
Donald | 34 |4th month | R. |Ibid.
Donald | 41 |4th month | R. |Ibid.
Routh | ? |8-1/2 months | R. |1902, xliv. 41.
Doran | 39 | ? | R. |1904, xlv. 119.
Doran | 30 |4th month | R. |Ibid.
Doran | 30 | ? | R. |Ibid.
Boyd | 42 |8th month | D. |Ibid., 106
Boyd | 40 |3rd month | R. |Ibid.
Fairbairn | 22 |5th week post partum| R. |Ibid., 194.
Doran | 38 |4th week post partum| R. |1904, xlvi. 274.
Taylor | 33 |3rd month | R. |1905, xlvii. 333.
Andrews | ? |3rd day post partum | R. |Ibid., 4.
Lea | 39 |7th week post partum| R. |Ibid., 1
Boyd | 42 |4th month, total | R. |1907, xlix. 49.
Bland-Sutton| 39 |4-1/2 months | R. |1907.
Dauber | 31 |3rd month | R. |1908.
McCann | 25 |4-1/2 months | R. |Ibid.
Spanton | 33 |2-1/2 months | D. |Ibid.
------------+---------+--------------------+--------+-----------------
TABLE OF CASES IN WHICH ABDOMINAL MYOMECTOMY WAS PERFORMED DURING
PREGNANCY
From the _Transactions of the Obstetrical Society_, 1900-8, both years
inclusive.
-----------+---------+--------------------+---------+-----------------
|_Age of | _Stage of | |
_Recorder._|Patient._| Pregnancy._ |_Result._| _Reference._
-----------+---------+--------------------+---------+-----------------
Donald | 31 |3rd month | R. |1901, xliii. 194.
Walls | ? | ? | R. |Ibid., 195.
Routh | ? |5th month | R. |1904, xlvi. 279.
Spencer | 41 |9th month | R. |Ibid., 122.
Malcolm | 32 |7th week post partum| R. |Ibid., 15.
Doran | 28 |2nd month | R. |1905, xlvii, 426.
Vaughan | ? |4th month | R. |Ibid., 427.
Vaughan | ? |3-1/2 months | R. |Ibid.
Swayne | 40 |5th month | R. |1908, l.
Swayne | 35 |4-1/2 months | R. |Ibid.
Williamson | 32 |7th month | R. |Ibid., 73.
Scharlieb | 37 |4-1/2 months | R. |Ibid.
Scharlieb | 39 |3-1/2 months | R. |Ibid.
-----------+---------+--------------------+---------+-----------------
=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 fœtus.
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 fœtuses runs
concurrently to term._ This is an exceedingly dangerous, though a rare,
combination. The table on p. 35 shows how deadly a compound pregnancy
is to the mother: it sets forth also the fate of the children.
3. _Uterine pregnancy is complicated by the presence of a quiescent
(sequestered) extra-uterine fœtus._ Many cases have been reported in
which a fœtus of this character has occupied the pelvis, yet the woman
conceived and the child was safely delivered at term; but a sequestered
fœtus 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.
REFERENCES
BLACKER, 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 that it has been tried, but with no encouraging measure of
success; it is a very desperate proceeding, and has been occasionally
successful by the abdominal, as well as by the vaginal route. It is
possible that vaginal hysterectomy may now and then be a wise operation
in acute puerperal infection, but better results have been attained by
ligature of the thrombosed pelvic veins, and by drainage of the pelvic
cavity. Some interesting operations, with brilliant results, have been
published by Trendelenburg, Michels, Cuff, Bumm, and others.
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
best results have been attained in the chronic forms of the disease
where the thrombosis was limited. There is great uncertainty in a given
case as to the extent of the thrombosis and the number of veins
implicated. As has already been mentioned, there are two routes for
gaining access to the thrombosed vessels--the extraperitoneal and the
intraperitoneal. I prefer the intraperitoneal route (cœliotomy), for it
enables the surgeon to deal with the vessels, iliac or ovarian, of both
sides, as well as allowing a thorough examination of the pelvic organs,
and it permits the drainage of any collection of serum or pus found in
the pelvis. From a study of the reported cases it is clear that the best
results are obtained by cœliotomy. The ligature of thrombosed ovarian
veins in chronic puerperal pyæmia promises good results for the future,
but it needs further experience to teach us the kind of case in which it
is likely to be successful.
REFERENCES
BUMM, 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
cœliotomy 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, cœliotomy 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, 2-3/4 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 solutions, especially perchloride of mercury.
Cases are known in which, under these conditions, the woman has died in
the course of a few hours.
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 cœliotomy, 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 fœtus is hindered or obstructed by narrowness of the pelvic outlet,
tumours, or undue size of the child. This form of injury is called
_spontaneous rupture_, to distinguish it from the rupture due to
midwifery implements. The uterus is frequently torn in the obstetric
manœuvre known as ‘turning’.
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 cœliotomy 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 fœtus
and membranes are extruded from the uterus into the belly, cœliotomy 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; 12-1/2 feet of small intestine, detached from
the mesentery, were extruded with the fœtus. Cœliotomy 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. Cœliotomy 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 cœliotomy; 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.
[Illustration: FIG. 24. DIAGRAM REPRESENTING A GUNSHOT INJURY OF THE
UTERUS. The woman was aged 28, and in the seventh month of pregnancy.
The bullet was extracted from under the skin on the left side, four
inches behind the anterior superior spine of the ilium. The line A B
represents the track of the bullet. (_British Medical Journal_, 1896,
vol. i, p. 332.)]
=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 cœliotomy.
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 carefully examined in order to determine if the bullet passed
through this organ. In some instances the fœtus has been injured by the
bullet. When free bleeding follows a bullet-wound of the gravid uterus
the hæmorrhage is usually due to damage of blood-vessels connected with
the intestines.
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 cœliotomy, 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 fœtus. 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 fœtus 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 completely severed
as a result of the stab. Steele attempted to deal with this
extraordinary lesion surgically, but the child died a few hours later.
REFERENCES
ALBARRAN. 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 fœtus, &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 Fœtus _in utero_ from Gunshot-wound: Recovery
of the Mother. _Lancet_, 1897, ii. 1045.
STEELE, D. A. K. Stab-wound of Fœtus _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 OPERATIONS
The 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,
or milk and water are given, and if retained they may be taken in
increasing quantities. On the fourth day an enema is given to clear the
bowel, and then the patient will take fish, chicken, &c., and soon get
on to convalescent diet.
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 suppuration has taken
place in the wound and healing has been retarded, especially in a
patient in whom operations have been performed for septic conditions, it
is a useful precaution to advise her to wear a well-made belt. This is
more necessary for women who have to get their living by hard work.
COMPLICATIONS OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS
=Metrostaxis.= 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.
REFERENCES
BÜDINGER. 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 cœliotomy 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 the custom, the wound is liable to burst asunder. This accident is
prone to occur in patients whose abdominal wall has been greatly
distended by a large tumour, and especially by pregnancy. On the whole
the accident is more prone to complicate Cæsarean section than any other
operation on the pelvic organs, and cases have been reported in which
there has been a repetition of the accident. The largest collection of
case-reports in which the wound has burst open after cœliotomy has been
made by Madelung; a perusal of his paper shows that it is an accident
with a high mortality. It is a fact that cases of this kind are rarely
published, and from inquiries I find that it is of common occurrence. It
has certainly diminished since surgeons have widely adopted the method
of securing the wound with buried suture, but this is not always a
preventative. The complication which makes the accident so unfortunate
for the patient is the protrusion of the intestines.
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.
REFERENCES
MADELUNG, 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
the abdominal wall, that in closing the incision he should employ
through and through sutures, and not attempt to suture it layer by
layer. I have noticed the same tendency to stitch-abscess in cases of
diffuse pelvic inflammation due to infection by the gonococcus.
=Pneumonia.= This is a serious and not infrequent sequel of cœliotomy,
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 conditions, and, although it occasionally occurs after
operations which run an afebrile course, the conditions underlying it
are mainly septic in character.
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 œdema 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 œdema 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 œdema 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 the following statistics, which are interesting as showing an
extraordinary variation in the practice of different operators:--
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 cœliotomies: 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 was found occluded with clot and the ovarian vein contained a
thrombus (Byron Robinson).
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 dyspnœa 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
dyspnœa, 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.
[Illustration: 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 die
suddenly in the street, in the armchair, in a bath, or even during
sleep: it is a fair assumption that some of the instances of sudden
death occurring during convalescence from surgical operations may be due
to failure of the heart absolutely unconnected with the operation. It
is, however, undeniable that thrombosis of the pelvic veins after
ovariotomy, or hysterectomy, is a source of fatal emboli. At present
there is very little evidence available as to the cause of the
thrombosis, but it can scarcely be doubted that sepsis, it may be only
of a mild type, is responsible for some of the cases.
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 dyspnœa and signs
clearly indicating the lodgment of an embolus in the pulmonary artery.
Trendelenburg exposed the heart, opened the pulmonary artery, and by
means of polypus forceps succeeded in withdrawing 34 centimetres of
clot. The incision in the artery was carefully closed with sutures. The
man improved considerably as the result of the operation, but died
thirty-seven hours later. At the post-mortem examination the left and
right branches of the pulmonary artery contained an embolus. From the
surgical point of view there are no reasons why such a bold example
should not be repeated with success.
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
rectum nine months after ovariotomy, and Terrillon tells of a pair of
pressure forceps which remained eight months in the belly and came out
close to the navel. One of the most remarkable instances is recorded by
MacLaren, in which a pair of forceps was left in the abdomen in the
course of a hysterectomy. Two years later, a swelling formed in the
right iliac region; this was explored through an abdominal incision, and
the hæmostatic forceps represented in Fig. 26 was found embedded in the
omentum; the forceps had ulcerated into the cæcum and the blades were
lodged in the vermiform appendix. The patient recovered.
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 diarrhœa, and
pains in the lower limbs. The instrument, which measured 5 inches long
and 2-1/2 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.
[Illustration: 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._)]
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 cœliotomy 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.
REFERENCES
GIFFORD, 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,
and tetanus has been noticed to affect patients who have been
ovariotomized in rooms recently plastered.
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.
REFERENCES
DORSETT, 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
cœliotomy 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
should be treated by drainage, using a wide rubber drain; the
convalescence will be tedious, but the fistula will close.
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 like a median post in the floor of the
pelvis. As far as I can judge from the scanty records relating to this
complication after hysterectomy, it is the sigmoid flexure of the colon
which is most commonly adherent to the cervical stump. The best way of
avoiding this accident is to remove the supravaginal cervix so freely
that, when the peritoneum is closed over the incision in the floor of
the pelvis, there is nothing visible except a narrow thin line of suture
at the base of the bladder.
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.[2]
[2] Bland-Sutton, J. On Perforation of the Stomach and Small Intestine
as a Sequel to Ovariotomy and Hysterectomy. _Journ. of Obstet. and Gyn.
of the British Empire_, 1909, xv.
=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 layers of the broad ligament together in the course of a subtotal
hysterectomy.
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.
[Illustration: 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 applied to the right and left uterine artery
respectively. The ligatures were removed, the swelling quickly subsided,
and urine reached the bladder. The woman recovered.
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 the uninjured ureter. Serious accidents of this
kind are less likely to happen now, because the surgeon can avail
himself of the cystoscope and ureteral catheter; with these instruments
it is possible, not only to decide with certainty which ureter is
injured, but also to determine the position and extent of the damage.
See also Vol. III.
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 the long
uterine cornu of rabbits, that an encircling ligature will ulcerate
through, leaving the lumen of the cornu intact. Clinical observations
regarding ligatures applied to Fallopian tubes in the performance of
Cæsarean section for the purpose of preventing pregnancy prove that this
is a useless measure (see p. 71), for these tubes in many instances have
recovered their patency, and pregnancy has recurred. It is a fair
inference that the ligature ulcerates into the lumen of the tube, which
then heals behind it, without stricture of the canal. A similar
condition of things sometimes arises after Cæsarean section, especially
when the uterine incision is closed by two layers of sutures. Those
sutures which involve the endometrium will ulcerate into the uterine
cavity and cause irregular slight losses of blood until they escape.
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.
[Illustration: 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.]
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 stump on the right side; it was removed, and a silk ligature
tied in a complicated knot was found in it, making its way towards the
cæcum.
On one occasion a woman, who had been submitted to subtotal hysterectomy
in the Antipodes, suffered from frequent micturition and fœtid 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 often
perseverance, even when the patient is under an anæsthetic. The simplest
implement for removing a buried suture is a crochet-hook.
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 cœliotomy has been performed for diffuse
cancerous disease of the peritoneum the cicatrix is liable to become
permeated by malignant disease also.
REFERENCES
BALDY, 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.
SECTION I
OPERATIONS UPON THE FEMALE
GENITAL ORGANS
PART II
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.
[Illustration: FIG. 29. PATIENT PREPARED FOR OPERATION. In lithotomy
position with crutch applied, Auvard’s speculum inserted, and volsella
attached to the anterior lip of the cervix uteri. Kelly’s pad is omitted
for sake of clearness. (_From a photograph._)]
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_{1}_. 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).
[Illustration: FIG. 30. COMPLETE LACERATION OF THE PERINEUM. (_From a
photograph._)
_a_, _a_{1}._ Ends of torn sphincter ani.
_cli._ Clitoris.
_l.i._ Labium internum.
_m.v._ Mons Veneris.
_p.c._ Preputium clitoridis.
_sph._ Sphincter ani.
_ur._ Urethral orifice.
]
=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_{1}_) 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.
[Illustration: FIG. 31. LONG-HANDLED SHARP-POINTED SCISSORS CURVED ON
THE FLAT.]
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.
[Illustration: FIG. 32. COMPLETE LACERATION OF THE PERINEUM.
Semi-diagrammatic drawing of a ruptured recto-vaginal septum, indicating
the method of passing the sutures for its repair.
_r.m.m._ Rectal mucous surface.
_sph._ Torn end of sphincter ani.
_v.m.m._ Vaginal mucous surface.
The arrows indicate the direction of the sutures.
]
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 manœuvres 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.
[Illustration: FIG. 33. COMPLETE LACERATION OF THE PERINEUM. In A the
‘butterfly’ surface has been denuded and the recto-vaginal rent repaired
(_c_).
_a._ Sutures passed through the sustaining column, but not tied.
_b._ The ‘buried’ spiral suture passed but not tied.
In B is shown the oval raw surface left to be brought together by
sutures (_d_) after the buried suture (_b'_) has been tied.
(_Diagrammatic._)
]
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.
[Illustration: FIG. 34. LACERATION OF THE PELVIC FLOOR. The double
triangular surface has been denuded. (_Semi-diagrammatic, from a
photograph._)
The sutures, 1-5, on the operator’s right side are passed and tied;
those on the left are passed but not tied.
_a._ Anus _c._ Cervix _h._ Site of hymen.
_p_{1}-p_{3}._ Sutures passed through the quadrilateral denuded surface.
_r._ recto-vaginal wall.
_s._ Speculum (Pozzi’s anterior retractor).
_t_, _t._ Tenacula.
The arrow denotes the direction in which the sutures are passed.
]
=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.
[Illustration: FIG. 35. REPAIR OF A LACERATED PERINEUM, WITH NON-UNION
OF THE SPHINCTER ANI, BEFORE A PLASTIC OPERATION. (_From a photograph._)
_a._ Ununited sphincter ani.
_b_, _c._ Buried ends of torn sphincter.
]
=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.
[Illustration: FIG. 36. REPAIR OF A LACERATION OF THE PERINEUM AFTER A
PLASTIC OPERATION. (_From a photograph._)
_a._ Repaired sphincter ani.
_b._ Anus.
_s._ Resutured perineum.
]
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.