Opening
Transcriber’s notes:
Italic text is denoted by underscores and bold text by =equal signs=. An underscore is also used in conjunction with curly brackets to indicate that the characters within the brackets are subscripted in the original text, e.g. a_{1} (seen mainly in illustration captions).
The table of contents contains a mix of italicised and non-italicised entries that generally correspond to different heading levels in the body of the text, but the correspondence is inaccurate and not all headings are listed. No attempt has been made to correct these anomalies.
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Various inconsistencies of spelling and hyphenation occur throughout the text; some are simple typographical errors but most are probably variations attributable to the book's multiple authorship. Words with variable spellings that occur with similar frequency (e.g. trocar / trochar, aneurism / aneurysm) have not been changed, but most other spelling inconsistencies have been ‘corrected’ to the predominant form (e.g. Caesarian --> Caesarean, turbinate --> turbinal). Omitted letters have been corrected by inserting the missing letters in square brackets (e.g. sella turc[ic]a). Simple typos such as uretha (urethra) and polpyus (polypus) have been corrected silently, and likewise with missing punctuation such as commas omitted from the index and the table of contents. An apostrophe is used inconsistently with the proper noun Bruening / Bruenings.
Inconsistencies of spacing and hyphenation have been treated similarly. For example, spaces have been removed from the abbreviations i.e. e.g. and from percentage values. Compound nouns that occur equally often with/without hyphens, have not been changed, e.g. bone forceps / bone-forceps, attic wall / attic-wall, whereas those that are more frequently either hyphenated or not hyphenated, have been standardised accordingly, e.g. punch forceps --> punch-forceps, heart-failure --> heart failure.
OXFORD MEDICAL PUBLICATIONS
A SYSTEM OF OPERATIVE SURGERY
OXFORD: HORACE HART PRINTER TO THE UNIVERSITY
OXFORD MEDICAL PUBLICATIONS
A SYSTEM OF OPERATIVE SURGERY
BY VARIOUS AUTHORS
EDITED BY F. F. BURGHARD, M.S. (Lond.), F.R.C.S. (Eng.) TEACHER OF OPERATIVE SURGERY IN KING’S COLLEGE, LONDON SURGEON TO KING’S COLLEGE HOSPITAL SENIOR SURGEON TO THE CHILDREN’S HOSPITAL, PADDINGTON GREEN
IN FOUR VOLUMES
VOL. IV
OPERATIONS UPON THE FEMALE GENITAL ORGANS OPHTHALMIC OPERATIONS OPERATIONS UPON THE EAR OPERATIONS UPON THE LARYNX AND TRACHEA OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES
LONDON
HENRY FROWDE HODDER & STOUGHTON Oxford University Press Warwick Square, E.C.
1909
EDITOR’S PREFACE
Great as have been the advances made in Surgery during the last fifteen years, there is no direction in which they have been more noticeable than in the elaboration of those comparatively small but important details of operative technique which do so much to ensure a low mortality and a successful result.
These improvements have been developed simultaneously throughout the whole of the vast field covered by modern Surgery, and it has become increasingly difficult for any single writer to deal with such an important subject as Operative Surgery in an authoritative and efficient manner. The scope of the subject is so wide that it is difficult to ensure that the work when published shall be thoroughly up to date, while a second and even greater difficulty is for any one, however great his ability and experience, to deal equally exhaustively and authoritatively with all of the many branches of which he would have to treat.
To avoid both of these difficulties and thus to make sure that the work shall reflect faithfully the present position of British Operative Surgery, the plan has been adopted of securing the co-operation of a number of prominent British Surgeons. Each writer deals with a branch of the subject in which he has had special experience, and upon which, therefore, he is entitled to speak with authority.
Besides the two important points just referred to, a third equally important one has been kept in view throughout. Particular care has been taken to make the work of as much practical utility to the reader as possible. Not only are the various operations described in the fullest detail and with special reference to the difficulties and dangers and the best methods of overcoming and avoiding them, but the indications for the individual operations are described at length, and the after-treatment and results receive adequate notice.
It is therefore hoped that the work will be useful alike to those who are about to operate for the first time, and to those surgeons of experience who desire to keep themselves informed as to the progress that has been made in the various branches of Operative Surgery.
The division of the work into a number of sections each written by a different author, necessarily involves some overlapping of subjects and some diversity of opinion upon points of technique. Efforts have been made to prevent overlapping of subjects as far as possible by care in their distribution and by conference between the authors concerned, but no attempt has been made to harmonize conflicting views. Each author supports his individual opinions by the weight of his authority, and any discrepancies may be taken to represent the absence of unanimity on various minor points that is well known to exist among surgeons of all countries.
The task of editing a work contributed to by so many writers might well appear to be an onerous one, but, owing to the promptitude, courtesy, and forbearance of all concerned, it has been a source of great pleasure, and the Editor’s most cordial thanks are tendered to all those who have devoted so much time and trouble to the work.
PREFACE TO VOLUME IV
Every effort has been made to keep this volume strictly within the definition of a work upon Operative Surgery--a somewhat difficult task in the case of certain of the special subjects with which it deals. In some cases methods of examination or manipulation have been described that are not strictly operative in nature, but their inclusion has been justified upon the ground that many of them are essential in operations upon the regions concerned, and all require special manipulative skill and dexterity.
The Index to this volume has been arranged in five parts, one part for each Section comprised in it. In this way it has been possible to economize space and, it is hoped, to render the task of reference easier.
In the Section on Vaginal Gynæcological Operations, instrument blocks have been kindly supplied by Messrs. Montague, Down Bros., and Griffin. The remaining illustrations are from original sketches by the author.
In the Section on Ophthalmic Operations, Messrs. Weiss have kindly supplied the instrument blocks. The remainder of the illustrations are original. Mr. Mayou desires to thank Mr. W. H. McMullen for valuable help in reading the proof sheets.
In the Section on Operations upon the Ear, all the illustrations, with the exception of the instrument blocks kindly supplied by Messrs. Mayer and Meltzer and a few illustrations from Tod’s Manual of Diseases of the Ear, are original.
In the Section on Operations upon the Nose, the instrument blocks have been supplied by Messrs. Mayer and Meltzer, who have also furnished them in the Section on Operations upon the Throat. Mr. F. A. Rose has kindly read the proof sheets of the latter Section, for which Mr. Harmer desires to thank him.
CONTRIBUTORS TO THIS VOLUME
JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital, and Senior Surgeon to the Chelsea Hospital for Women, London
Abdominal Gynæcological Operations
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
Vaginal Gynæcological Operations
M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic Surgeon to the Children’s Hospital, Paddington Green
Ophthalmic Operations
HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital
Operations upon the Ear
W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)
Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital
Operations upon the Larynx and Trachea
StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)
Professor of Laryngology and Physician for Diseases of the Throat, King’s College Hospital, London
Operations upon the Nose and its Accessory Cavities
I. ABDOMINAL GYNÆCOLOGICAL OPERATIONS
By JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea Hospital for Women, London.
PAGES
I. CŒLIOTOMY
Preparation of Patient, 3. Basins, Dishes, and Instruments, 4. Suture and Ligature Material, 5. Dabs, 5. Gloves, Operating Table, Anæsthesia, 6. The Incision, 7. Misplaced Viscera, 8. Closure of Wound, 8 3-9
II. OVARIOTOMY
The Operation, 10. Cysts of the Broad Ligaments, 14. Spurious Capsules, 15. For Carcinoma of Ovary, 15. Incomplete Ovariotomy, 16. Anomalous Ovariotomy, 16. Ovariotomy followed by Hysterectomy, 17. Repeated Ovariotomy, 17. Pregnancy after Bilateral Ovariotomy, 17. Ovariotomy at Extremes of Life, 18. Ovariotomy in Old Age, 19. Mortality, 19 10-20
III. OÖPHORECTOMY
Operation, 22. Abdominal Hysterectomy after Bilateral Oöphorectomy and Ovariotomy, 25. Mortality, 25. Operation for Primary Cancer of the Fallopian Tube, 26 21-28
IV. OPERATIONS FOR EXTRA-UTERINE GESTATION
Indications, 29. Operation, 29. Concurrent Intra- and Extra-uterine Pregnancy, 33. Results of Operative Treatment, 34 29-35
V. HYSTERECTOMY AND MYOMECTOMY
Indications, 36. Subtotal Hysterectomy, 36. Total Hysterectomy, 40. Mortality, 44. Risks of Abdominal Hysterectomy, 45. Abdominal Myomectomy, 46 36-49
VI. ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY
Cancer of the Body of the Uterus and Fibroids, 52. Sarcoma, 53. Cancer of the Uterus after Bilateral Ovariotomy, 55. Adenomyoma of the Uterus, 56. Fate and Value of Belated Ovaries, 56 50-60
VII. HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS
For Cancer of the Cervix, 61. For Cancer of the Body of the Uterus, 63 61-65
VIII. OPERATIONS FOR DISPLACEMENT OF THE UTERUS
Ventro-suspension for Retroflexion of the Uterus, 66. Ventro-fixation for Prolapse of the Uterus, 67 66-68
Chapter IX
OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY
Cæsarean Section, 69; _Immediately after the Death of the Mother_, 72. Ovariotomy and Hysterectomy during Pregnancy and in Labour, 73. Ovariotomy during the Puerperium, 76. Fibroids and Pregnancy, 77. Pregnancy with Cancer of the Cervix, 82. Concurrent Uterine and Tubal Pregnancy, 82. Pregnancy with Tumours growing from the Pelvic Walls, 83. Operations for Puerperal Sepsis, 83 69-85
X. OPERATIONS FOR INJURIES OF THE UTERUS
Gynæcological, 86. Obstetric, 87; to the Pregnant Uterus, 89; to the Gravid Uterus in the course of an Abdominal Operation, 89. Bullet Wounds of the Pregnant Uterus, 90. Stab-wounds of the Pregnant Uterus, 91 86-92
Chapter XI
THE AFTER-TREATMENT, RISKS, AND SEQUELÆ OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS
After-treatment of Abdominal Operations, 93. Complications of Abdominal Gynæcological Operations--Metrostaxis, 95; Bed-sores, 95; Post-anæsthetic Paralysis, 95; _Giving way of the Wound_, 96; Hæmorrhage, 97; Intrapelvic Hæmorrhage, 98; Pneumonia, 99; Parotitis, 99; Thrombosis, 101; Pulmonary Embolism, 101; _Foreign Bodies left in the Abdomen_, 105; Tetanus, 107; Injury to the Intestines, 109; Intestinal Obstruction, 110; _Perforating Ulcer of the Stomach and Small Intestine_, 111; Injuries to the Bladder, 111; to the Ureter, 112. The fate of Ligatures, 117. Post-operative Kraurosis, 120. The Cicatrix, 120 93-122
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, 125. Operations for Repair of a Complete Laceration of the Perineum, 127. Operation for Laceration of the Pelvic Floor, 132 125-133
XIII. OPERATIONS UPON THE URETHRA AND BLADDER
Extirpation of a Urethral Caruncle, 134. Operations for Incontinence following Labour, 134; for Vesico-vaginal Fistula, 135; for Recto-vaginal Fistula, 139; for Cystocele, 140 134-141
XIV. OPERATIONS UPON THE VULVA AND VAGINA
Operations upon Bartholin’s Glands, 142. Operations for Atresia of the Hymen and the Vagina, 143. Dilatation of the Vulval Orifice, 143. Colpotomy, 144; Anterior, 145; Posterior, 147; Lateral, 148 142-148
XV. OPERATIONS UPON THE UTERUS
Passage of the Uterine Sound, 149. Reposition of a Chronic Uterine Inversion, 151. Curetting the Uterus, 152. Dilatation of the Cervix, 156--Rapid Dilatation, 157; _Gradual Dilatation_, 159. Operations for Hypertrophy of the Cervix, 160. Trachelorrhaphy, 161. Vaginal Fixation, 164 149-164
XVI. OPERATIONS FOR NEW GROWTHS OF THE UTERUS
For Uterine Fibro-myomata, 165--for Pedunculated Tumours, 165; for Sessile Tumours, 166; for Interstitial Tumours, 167. Vaginal Hysterectomy, 167--for Carcinoma, 168; _for Fibroids_, 173 165-173
SECTION II
OPHTHALMIC OPERATIONS By M. S. MAYOU, F.R.C.S. (Eng.)
Assistant Surgeon to the Central London Ophthalmic Hospital; Ophthalmic Surgeon to the Children’s Hospital, Paddington Green.
I. GENERAL CONSIDERATIONS APPLICABLE TO OPERATIONS UPON THE EYE
General Preliminaries to an Operation, 177. Local Preparation of the Patient, 80. Making and Healing of Wounds in the Globe, 182--Purification of Hands, 182; of Instruments, 183; Direction of Incision, 183; Position of Incision, 184; Dressings, 186; Bandaging, 186 177-186
II. OPERATIONS UPON THE LENS
Surgical Anatomy, 187. Discission or Needling, 189--_for Cataract_, 189; for High Myopia, 190. Capsulotomy, 192. Evacuation, 194. Evulsion of the Capsule, 195. Extraction of the Lens, 195. Modifications, 201; _Delivery of the Lens by Irrigation_, 203; Extraction of the Lens in its Capsule, 204; Subconjunctival Extraction, 204. Couching, 209 187-210
III. OPERATIONS UPON THE IRIS
Iridotomy, 211. Alternative Methods--Kuhnt’s Operation, 212; Ziegler’s, 213. Iridectomy--Optical Iridectomy, 214; Glaucoma Iridectomy, 217--for small Growths of the Iris, 225; for Prolapse of the Iris, 225. Transfixion of the Iris, 226. Division of Anterior Synechiæ, 227 211-227
IV. OPERATIONS UPON THE SCLEROTIC
Anterior Sclerotomy, 228. Cyclo-dialysis, 229. Sclerectomy, 231. Posterior Sclerotomy, 232. Paracentesis of the Anterior Chamber, 233. For Penetrating Wounds of the Globe, 234. Electro-magnet Operations--with Small Magnet, 237; _with Giant Magnet_, 238 228-239
V. OPERATIONS UPON THE CORNEA AND CONJUNCTIVA
Removal of a Foreign Body from the Cornea, 240. Cauterization of the Cornea, 240. Operations for Conical Cornea, 241. Removal of Tumours involving the Cornea, 243. Tattooing the Cornea, 243. Scraping Calcareous Films, 243. Operations upon the Conjunctiva--Removal of Foreign Bodies, 244; _for Pterygium_, 244; Expression, 245; Conjunctivoplasty, 245; Removal of Tarsal Cysts, 246 240-246
VI. OPERATIONS UPON THE EXTRA-OCULAR MUSCLES
Squint Operations, 247. Tenotomy, 248. Advancement, 251 247-254
VII. ENUCLEATION OF THE GLOBE AND ALLIED OPERATIONS
Enucleation, 255. Evisceration, 257. Mules’s Operation, 259. Frost’s Operation, 259. Operations upon the Socket after Removal of the Eye--Paraffin Injection, 260. Operations for Restoration of a Contracted Socket--Skin-grafting, 261; Inclusion of Flaps (Maxwell’s Operation), 261 255-262
VIII. OPERATIONS UPON THE EYELIDS
Surgical Anatomy, 263. Suture of Wounds of the Eyelids, 263. Operations for Ankyloblepharon, 264; for Symblepharon, 264. Upon the Palpebral Aperture, 265--Canthoplasty, 265; Canthotomy, 265; Canthorrhaphy, 265; Tarsorrhaphy, 266. Ptosis Operations, 267; _Shortening the Eyelid by Excision of a portion of the Tarsal Plate_, 267. _Attachment of the Lid to the Occipito-frontalis Muscle_, 268. Advancement of the Levator Palpebræ Muscle, 272. Grafting a portion of the Superior Rectus into the Lid, 273 263-274
Chapter IX
OPERATIONS FOR ENTROPION, REPAIR OF THE EYELIDS, TRICHIASIS, AND ECTROPION
Electrolysis, 275. Skin and Muscle Operation, 275. Rectification of a Faulty Curvature of the Tarsus--Burow’s Operation, 276; Streatfield’s Operation, 277. Transplantation of the Lash-bearing Area--Arlt’s Operation, 278. Ectropion Operations, 279--for Passive Ectropion, 280; _Snellen’s Suture Method_, 280; Fergus’s Operation, 281; Kuhnt’s Operation, 281; Argyll Robertson’s Operation, 282. For the Active or Cicatricial Form, 284; VY Operation, 284; _Denonvillier’s Operation_, 285; Fricke’s Operation, 285; _Thiersch’s Skin-grafting_, 287. Repair of large Losses of Substance from the Eyelids, 287; De Vincentiis’ Operation, 287; Dieffenbach’s Operation, 288 275-289
X. OPERATIONS UPON THE LACHRYMAL APPARATUS
For the Relief of Lachrymal Obstruction, 290--_Dilatation of the Canaliculus_, 290; Slitting the Canaliculus, 291; _Syringing the Lachrymal Duct_, 292; Probing the Lachrymal Duct, 292; the Insertion of Styles, 293. For Obliteration of the Canals, 294; Obliteration of the Canaliculi, 294; _Excision of the Lachrymal Sac_, 294. Opening a Lachrymal Abscess, 297. Operations upon the Lachrymal Gland--_Removal of the Palpebral Portion_, 298; Removal of the Orbital Portion, 299. Operations upon the Orbit--Exploration of the Orbit (Krönlein’s Method), 299; Evisceration of the Orbit, 301; Opening an Orbital Abscess, 301 290-301
SECTION III
OPERATIONS UPON THE EAR
By HUNTER F. TOD, M.A., M.D. (Cantab.), F.R.C.S. (Eng.)
Aural Surgeon to the London Hospital.
Chapter I
EXAMINATION OF THE EAR: GENERAL CONSIDERATIONS WITH REGARD TO OPERATIONS
Examination of the Ear, 305--Sources of Illumination, 305; Technique of Examination, 306; _Method of cleansing the Ear_, 307. General Considerations with regard to Operations--Preliminary Surgical Toilet, 309; Anæsthesia, 310. Position of Patient and Surgeon, 313 305-313
II. OPERATIONS UPON THE EXTERNAL AUDITORY CANAL
Operations for Furunculosis, 314. Removal of Exostoses from the External Meatus, 316. Removal of Foreign Bodies--_by Syringing_, 322; by Instruments, 323; _by Post-aural Incision_, 326; by Operation upon the Mastoid, 327. Operations for Stenosis of the External Meatus, 328. Operations for Atresia, 330; for Aural Polypus, 331 314-334
Chapter III
OPERATIONS UPON THE TYMPANIC MEMBRANE AND WITHIN THE TYMPANIC CAVITY
Surgical Anatomy of the Tympanum, 335. Paracentesis, 336. Artificial Perforation of the Tympanic Membrane, 340. Division of the Anterior Ligament, 341. Division of the Posterior Fold, 341. Intratympanic Operations, 342; Division of Adhesions, 342; Tenotomy of the Tensor Tympani, 346; _Tenotomy of the Stapedius_, 347. Removal of Granulations from the Tympanic Cavity, 348. Operations upon the Ossicles--_Direct Mobilization_, 349; Removal of the Ossicles, 351 335-363
IV. OPERATIONS UPON THE EUSTACHIAN TUBE
Catheterization, 364. Passing of the Eustachian Bougie, 369. Washing out the Tympanic Cavity through the Eustachian Tube, 372 364-372
Chapter V
OPERATIONS UPON THE MASTOID PROCESS: WILDE’S INCISION AND SCHWARTZE’S OPERATION
Surgical Anatomy, 373. History of the Mastoid Operation, 375. Wilde’s Incision, 377. Schwartze’s Operation, 378. Treatment of Special Conditions--in an Infant, 389; _Subperiosteal Abscess_, 389; Bezold’s Mastoid Abscess, 389; Necrosis, 390; Osteomyelitis, 390 373-390
VI. THE COMPLETE MASTOID OPERATION
Methods of Operation, 392; Küster-Bergmann (Schwartze-Stacke) Operation, 393; Wolf’s Operation, 396; Stacke’s Operation, 397; Preservation of the Ossicles and Tympanic Membrane, 399. The Formation of Post-meatal Skin Flaps, 401. Closure of the Wound, 404. Skin-grafting after the Mastoid Operation, 405. After-treatment of the Case, 410. Difficulties and Dangers of the Operation, 412. Results, 415 391-416
VII. OPERATIONS UPON THE LABYRINTH
General Considerations, 417. Indications, 417. Surgical Anatomy, 420. Methods of Operating, 421; _Curetting a Localized Lesion of Wall_, 421; Opening the Vestibule, 422; _Removal of the Cochlea_, 424; Extirpation of the Labyrinth, 425 417-428
Chapter VIII
OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS OF OTITIC ORIGIN
On Intracranial Complications in General, 429. Operations for Extra-dural Abscess, 430. Operations for Meningitis of Otitic Origin, 433 429-438
IX. OPERATIONS FOR LATERAL SINUS THROMBOSIS OF OTITIC ORIGIN
General Considerations, 439. Exposure of the Lateral Sinus, 440. Opening of the Lateral Sinus, 442. Ligature of the Jugular Vein, 446. Exposure of the Jugular Bulb, 454 439-458
X. OPERATIONS FOR INTRACRANIAL ABSCESS OF OTITIC ORIGIN
Indications, 459. Operation, 460. After-treatment, 469. Complications, 469. Prognosis and subsequent Progress, 470. Recurrence of Symptoms, 471 459-471
SECTION IV
OPERATIONS UPON THE LARYNX AND TRACHEA
By W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)
Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital.
I. ENDOLARYNGEAL OPERATIONS
Indications, 475. Operation by Indirect Laryngoscopy, 477. Operation by Direct Laryngoscopy, 479 475-486
II. EXTRA-LARYNGEAL OPERATIONS
Thyrotomy, 487. Hemi-laryngectomy, 495. Anatomy of the Laryngeal Lymphatics, 496. Total Laryngectomy, 498. Comparative Results of Extra-laryngeal Operations, 502. Infrathyreoid Laryngotomy, 510 487-516
III. OPERATIONS UPON THE TRACHEA
Tracheotomy, 517; in Diphtheria, 526; _in Conditions other than Diphtheria_, 544. Tracheo-fissure and Resection of the Trachea, 546 517-548
IV. INTUBATION OF THE LARYNX
Intubation v. Tracheotomy in Diphtheria, 549. Indications, 552. Operation, 553. Difficulties, 555. After-treatment, 556. Complications, 557 549-558
V. TRACHEOSCOPY AND BRONCHOSCOPY
Indications, 559. Tracheoscopy, 560. Upper Bronchoscopy, 562. Lower Bronchoscopy, 562. Complications, 563. Results, 566 559-566
SECTION V
OPERATIONS UPON THE NOSE AND ITS ACCESSORY CAVITIES
By StCLAIR THOMSON, M.D., F.R.C.P. (Lond.), F.R.C.S. (Eng.)
Professor of Laryngology and Physician for Diseases of the Throat, King’s College Hospital, London.
Chapter I
GENERAL CONSIDERATIONS IN REGARD TO OPERATIONS UPON THE NOSE AND NASO-PHARYNX
Sources of Illumination, 569. Local Anæsthesia, 572. Local Ischæmia, 573. Bleeding and its Control, 574. The Protection of the Lower Air-passages from the Descent of Blood, 576. Shock, 577. Sepsis and other Complications, 577. Asepsis, 578. After-treatment, 578. Cleansing the Nose, 579. After-results, 580 569-580
Chapter II
OPERATIONS FOR INJURIES, DEFORMITIES, FOREIGN BODIES, AND RHINOLITHS: OPERATIONS UPON THE TURBINALS: OPERATIONS IN SYPHILIS AND LUPUS
Operations for Injuries to the Nose--Fractures of the Nasal Bones and Septum, 581. For Congenital Occlusion of the Nostrils, 582. Removal of Foreign Bodies, 584; of Rhinoliths, 586. Operations upon the Turbinals, 586; _upon the Inferior Turbinal_, 587; upon the Middle Turbinal, 592. For the Results of Syphilis--Sequestrotomy, 594; _Post-syphilitic Adhesions of the Velum_, 595. For Tuberculosis, 596 581-596
III. OPERATIONS UPON THE NASAL SEPTUM
For Deformities--Removal of Spurs, 597; _Perforating the Septum_, 598. For Simple Deviation, 598; _Gleason-Watson Operation_, 599; Asch’s Operation, 599; Moure’s Operation, 599. For Combined Bony and Cartilaginous Deformity--Submucous Resection, 601. Complementary Operations, 610. For Perforation of the Nasal Septum, 611. For Abscess, 612. For Hæmatoma, 612 597-612
Chapter IV
OPERATIONS FOR REMOVAL OF NASAL GROWTHS THROUGH THE NOSTRILS: OPERATIONS FOR OBTAINING DIRECT ACCESS TO THE NASAL CAVITIES AND NASO-PHARYNX
Removal by the Snare, 613. Removal by Forceps and Curettes, 615. Lateral Rhinotomy (Moure’s Operation), 618. Rouge’s Operation, 622. Combination of Moure’s and Rouge’s Operations, 625. Extension of Rouge’s Operation to allow of Access to the Maxillary Antrum, 625. Other Methods, 625 613-625
V. OPERATIONS UPON THE ACCESSORY NASAL SINUSES
Operations upon the Maxillary Sinus--_Catheterizing the Maxillary Sinus_, 626; Puncturing from the Nose, 626; _from the Alveolar Margin_, 628. _Operation through the Canine Fossa only_, 631; the Caldwell-Luc Radical Operation, 631; Drainage through the Nasal Wall only, 637. Operations upon the Frontal Sinus--_Catheterizing and Washing out the Frontal Sinus_, 638; Opening the Frontal Sinus in Acute Suppuration, 642; Killian’s Operation, 642; the Ogston-Luc Operation, 651; Kuhnt’s Operation, 653. Operations upon the Sphenoidal Sinus, 653; Sounding and Washing out, 653; _Opening the Sphenoidal Sinus_, 656. Operation in Multiple Sinus Suppuration, 659 626-660
Chapter VI
OPERATIONS INVOLVING THE NASO-PHARYNX: OPERATIONS FOR RETROPHARYNGEAL ABSCESS: OPERATIONS FOR NASO-PHARYNGEAL ADENOIDS
Methods of obtaining Access to the Naso-pharynx through the Nose, 661; through the Mouth, 662. Retropharyngeal Abscess, 664. Removal of Naso-pharyngeal Adenoids, 665 661-672
LIST OF ILLUSTRATIONS
FIG. PAGE
1. Secondary Cancer of the Ovary 15
2. Secondary Cancer of the Ovary in Section 16
3. An Infected Fallopian Tube 22
4. A Tuberculous Fallopian Tube and Ovary: Entire and in Section 23
5. Primary Cancer of the Fallopian Tube 27
6. A Section of Primary Cancer of the Fallopian Tube 27
7. A Gravid Fallopian Tube 30
8. A Gravid Fallopian Tube, containing Twins 31
9. A Diagram to show the Arterial Supply of the Uterus 37
10. A Fibroid growing near the Right Uterine Cornu 38
11. The Mattress Suture 39
12. The Stump after Subtotal Hysterectomy 39
13. A Bicornate Uterus 42
14. A Bicornate Uterus shortly after Delivery 43
15. Villous Disease of the Uterus 45
16. An Adenomyomatous Uterus 54
17. An Adenomyomatous and Tuberculous Uterus 55
18. Uterus with the Decidua in situ 58
19. Cancer of the Uterus 64
20. The Fundus of a Uterus 68
21. Portion of Ovary and Fallopian Tube 71
22. A Uterus distorted by Fibroids 76
23. A Gravid Uterus in Sagittal Section 79
24. Diagram representing a Gunshot Injury of the Uterus 90
25. The Pulmonary Artery and Adjacent Part of the Lung and Trachea 103
26. A Pair of Pressure Forceps 106
27. The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy 114
28. A Uterus in Sagittal Section 119
29. Patient prepared for Operation 126
30. Complete Laceration of the Perineum 128
31. Long-handled Sharp-pointed Scissors curved on the flat 129
32. Complete Laceration of the Perineum 129
33. Complete Laceration of the Perineum 130
34. Laceration of the Pelvic Floor 131
35. Repair of a Lacerated Perineum, with Non-union of the Sphincter Ani, before a Plastic Operation 132
36. Repair of a Laceration of the Perineum after a Plastic Operation 133
37. Auvard’s Self-retaining Speculum 135
38. Knives for freshening the Edges of a Vesico-vaginal Fistula 135
39. Toothed Forceps for use in Vesico-vaginal Fistula 135
40. Emmett’s Hook 136
41. Sims’s Operation for the Repair of a Vesico-vaginal Fistula 136
42. Simon’s Operation for the Repair of a Vesico-vaginal Fistula 137
43. Repair of a Vesico-vaginal Fistula by Dédoublement 138
44. Repair of a Vesico-vaginal Fistula. Sims’s Operation 139
45. Stoltz’s Operation for Cystocele 141
46. Sims’s Vaginal Rest 144
47. Pozzi’s Retractors 145
48. Anterior Colpotomy 146
49. Martin’s Trochar for Pelvic Abscess 147
50. The Passage of the Uterine Sound. _Introduction of the point into the external os uteri_ 149
51. The Passage of the Uterine Sound. _Commencement of the tour de maître_ 149
52. The Passage of the Uterine Sound. Completion of the tour de maître 150
53. The Passage of the Uterine Sound. _Entry of the sound into the uterine cavity_ 150
54. Chronic Uterine Inversion 151
55. Volsella for fixing the Cervix 153
56. Hegar’s Dilators (three sizes) for dilatation of the Cervix Uteri 153
57. Metal Bougies for dilatation of the Cervix 154
58. Bozemann’s Double-channelled Tube 155
59. Budin’s Celluloid Catheter 155
60. Murray’s Flushing Curette; Blunt Curette 155
61. Dilatation of the Cervix 157
62. Marckwald’s Operation for Congenital Hypertrophy of the Cervix 161
63. Hegar’s Operation for Supravaginal Elongation of Cervix 161
64. Emmett’s Scissors (left) for Trachelorrhaphy 162
65. Trachelorrhaphy 163
66. Pedunculated Fibroid Polypi in various Stages of Extrusion 165
67. Wire Écraseur 166
68. Submucous Fibro-myomata, capable of Treatment by Morcellement 167
69. Galabin’s Broad-ligament Needle (right) 169
70. Jessett’s Broad-ligament Needle 169
71. Vaginal Hysterectomy 170
72. Vaginal Hysterectomy. Final stage 171
73. Schauta’s Needle-holder 172
74. Window of the Operating Theatre, King’s College Hospital 178
75. Bull’s-eye Electric Hand-lamp 179
76. Lang’s Eye Speculum 181
77. Undine for washing out the Conjunctival Sac 182
78. Cataract Extraction 183
79. Sympathetic Ophthalmia 184
80. Cystoid Scar after Glaucoma Iridectomy 184
81. An Eye Bandage 185
82. A Pressure Bandage 185
83. A Lens Three Weeks after Needling 187
84. Anatomy of the Anterior Segment of the Eye 188
85. Eye Speculum 190
86. Fixation Forceps 190
87. Secondary Cataract 192
88. Capsulotomy. The method of incising the capsule 193
89. Capsulotomy. The method of dividing a dense band 193
90. Iris Forceps 196
91. Iris Scissors 196
92. A Vectis 196
93. Pagenstecher’s Spoon 196
94. Lens Extraction 197
95. The Knife entering the Anterior Chamber in Cataract Extraction 198
96. Making the Counter-puncture in Cataract Extraction 198
97. Incision and Iridectomy in Cataract Extraction 199
98. Opening the Capsule with Forceps in Cataract Extraction 200
99. Cataract Extraction 201
100. McKeown’s Irrigation Apparatus for washing out the Anterior Chamber 202
101. Subconjunctival Extraction 205
102. Iridotomy 212
103. Iridotomy 212
104. Iridotomy by Ziegler’s Method 213
105. Iridotomy by Ziegler’s Method 214
106. Iridotomy by Ziegler’s Method 214
107. Optical Iridectomy 215
108. Optical Iridectomy 216
109. Optical Iridectomy 217
110. The Normal Angle of the Anterior Chamber 218
111. The Angle of the Anterior Chamber from a Case of Recent Glaucoma 219
112. The Angle of the Chamber in a Case of Chronic Glaucoma 220
113. Iridectomy for Glaucoma 221
114. Iridectomy for Glaucoma 222
115. Iridectomy for Glaucoma 222
116. Iridectomy for Glaucoma 223
117. Glaucoma Iridectomy 224
118. Prolapse of the Iris through a Punctured Wound of the Cornea 226
119. Cyclo-dialysis Operation 229
120. Cyclo-dialysis Operation 230
121. Lagrange Operation for the Production of a Cystoid Scar in Chronic Glaucoma 232
122. Lagrange Operation for Chronic Glaucoma 232
123. Hollow Needle used for Paracentesis of the Anterior Chamber 234
124. Author’s Chair for the Localization of Foreign Bodies in the Eye by the X-rays 236
125. Small Electro-magnet for extracting Pieces of Steel from the Eye 238
126. Large Electro-magnet 239
127. Electro-cautery 241
128. Tattooing Needles 243
129. Graddy’s Forceps 245
130. Tenotomy 249
131. Tenotomy by the Open Method 250
132. Prince’s Forceps for Advancement 252
133. Advancement by the Three-stitch Method 253
134. Enucleation 256
135. Mules’s Operation. First step 258
136. Mules’s Operation. 258
137. Maxwell’s Operation for Contracted Socket. First step 262
138. Maxwell’s Operation. Final step 262
139. Canthorrhaphy 266
140. Harman’s Operation for Ptosis 270
141. Ptosis Operation. Panas’ 271
142. Ptosis Operation. Advancement of the Levator Palpebræ 272
143. Ptosis Operation. Advancement of the Levator Palpebræ 273
144. Treacher Collins’s Entropion Forceps 276
145. Lid Clamp 277
146. Streatfield’s Entropion Operation 277
147. Arlt’s Operation for Trichiasis 278
148. Snellen’s Sutures 280
149. Fergus’s Operation for Slight Ectropion of the Lower Lid 281
150. Modified Kuhnt’s Operation for Severe Ectropion. _Second step_ 282
151. Modified Kuhnt’s Operation. Fourth step 282
152. Argyll Robertson’s Operation for Ectropion. Second step 283
153. Argyll Robertson’s Operation for Ectropion. Final step 283
154. VY Operation for Ectropion of the Lower Lid due to a Scar. First step 284
155. VY Operation for Ectropion. Final step 284
156. Denonvillier’s Operation for Ectropion of the Lower Lid. First step 285
157. Denonvillier’s Operation for Ectropion 285
158. Fricke’s Operation 286
159. De Vincentiis’ Operation to replace the Loss of the Inner Portion of the Lower Lid 288
160. De Vincentiis’ Operation completed 288
161. Modified Dieffenbach’s Operation to replace the Loss of the whole Lower Lid. First step 289
162. Modified Dieffenbach’s Operation. Third step 289
163. Canaliculus Dilator 291
164. Canaliculus Knife 291
165. Lachrymal Syringe 292
166. Muller’s Retractor for Excision of the Lachrymal Sac 295
167. Axenfeld’s Retractor for Excision of the Lachrymal Sac 295
168. Excision of the Lachrymal Sac 296
169. Excision of the Lachrymal Sac 296
170. Excision of the Palpebral Portion of the Lachrymal Gland 298
171. Clar’s Lamp 305
172. Gruber’s Aural Speculum 306
173. Angular Spring Forceps 306
174. Examination of the Ear 307
175. Aural Forceps holding Cotton-wool 307
176. Milligan’s Intratympanic Syringe 308
177. Neumann’s Syringe for Subcutaneous Injection 311
178. Burkhardt-Merian’s Aural Instrument 315
179. Crocodile Forceps 324
180. Imray’s Scoop for extracting a Foreign Body 325
181. Aural Probe 332
182. Wilde’s Aural Snare 332
183. Wilde’s Snare being passed round an Aural Polypus 333
184. Wilde’s Snare gripping the Neck of Polypus 334
185. Polypus arising from the Attic Region 334
186. Anatomical Preparation of the Middle Ear 336
187. Paracentesis Knife held in position in the Hand 338
188. Tympanic Membrane showing Incision in Acute Suppuration of the Middle Ear 339
189. Line of Incision in Acute Suppuration of the Attic 339
190. Lines of Incisions in Intratympanic Operations 341
191. Cutting through Intratympanic Adhesions 343
192. Free Edge of Tympanic Membrane cut through 344
193. Sexton’s Instrument 345
194. Method of using Siegle’s Speculum 345
195. Division of Intratympanic Adhesion with Excision of Handle of Malleus 346
196. Schwartze’s Tenotomy Knife 347
197. Lucae’s Probe 350
198. To show Sites of Perforation in Attic Suppuration and Caries of the Ossicles 351
199. Removal of the Malleus by Wilde’s Snare. First position 354
200. Removal of the Malleus by Wilde’s Snare. Second position 354
201. Delstanche’s Ring-knife 354
202. Removal of Malleus by Delstanche’s Ring-knife 355
203. Ludwig’s Incus Hook 356
204. Zeroni’s Incus Hook 356
205. Removal of Incus by Zeroni’s Hook 356
206. Pfau’s Attic Punch-forceps 357
207. Removal of the Outer Attic-wall with Forceps 358
208. Diagrammatic Section to show Correct and Wrong Positions of Incus Hook 360
209. Eustachian Catheter 365
210. Passing the Eustachian Catheter 366
211. Passing the Eustachian Catheter 366
212. Passing the Eustachian Catheter 367
213. Passing the Eustachian Catheter 367
214. Author’s Graduated Eustachian Bougie 370
215. Left Temporal Bone, showing Anatomy of the Middle Ear and Mastoid Process 374
216. Diagram showing Position of Sink Incisions in Post-aural Operations 380
217. Schwartze’s Operation 381
218. Schwartze’s Operation 383
219. Schwartz’s Seeker 384
220. Schwartze’s Operation completed 385
221. The ‘Radical’ Mastoid Operation 393
222. Stacke’s Protector 394
223. The ‘Radical’ Mastoid Operation 395
224. Pfau’s Curette for the Eustachian Tube 396
225. The ‘Radical’ Mastoid Operation completed 397
226. Wolf’s Operation 398
227. Stacke’s Operation 399
228. Post-meatal Skin Flaps 400
229. Post-meatal Skin Flaps 401
230. Closure of Wound after ‘Radical’ Mastoid Operation 402
231. Körner’s Post-meatal Flap 403
232. Panse’s Post-meatal Flap 403
233. Stacke’s Post-meatal Flap 403
234. Skin-grafting of Mastoid Wound Cavity after Operation 407
235. Ballance’s ‘Stopper’ for pushing in the Graft 407
236. Pipette for sucking Air and Fluid from beneath the Graft 408
237. Skin-grafting of Mastoid Wound Cavity after Operation 408
238. Skin-grafting of Mastoid Wound Cavity after Operation 409
239. Posterior Portion of Skin Graft covering Outer Surface of Wound Cavity 409
240. Diagram to show Exposure of the Semicircular Canals 423
241. Operation upon the Labyrinth 424
242. Extirpation of the Labyrinth 425
243. Method of Removal of Bone by the Forceps 435
244. Diagram to show the usual Points at which the Lateral Sinus is primarily infected 443
245. The Lateral Sinus exposed and opened 445
246. Incision for Exposure of the Internal Jugular Vein 448
247. Exposure of the Internal Jugular Vein high up 449
248. Ligature of the Internal Jugular Vein low down in the Neck 451
249. Free Exposure of the Lateral Sinus, which has been incised, with Ligature of the Internal Jugular Vein 452
250. Method of suturing the Open End of the Internal Jugular Vein in the Neck 453
251. Topography of the Auditory Region of the Skull 462
252. Exploration for a Temporo-sphenoidal Abscess 463
253. Exploration for a Cerebellar Abscess 467
254. Skiagram showing a Tumour of the Larynx 476
255. Horsford’s Instrument for transfixing the Epiglottis 478
256. Multiple Papillomata of the Larynx 480
257. Tube-spatulæ used for Laryngoscopy 481
258. Removal of Multiple Papillomata by Direct Laryngoscopy 483
259. Intrinsic Tumour of the Larynx 488
260. Extrinsic Tumour of the Larynx 488
261. Thyrotomy 491
262. Total Laryngectomy 499
263. Total Laryngectomy. Gluck’s Method 501
264. Infrathyreoid Laryngotomy 510
265. Instruments for Laryngotomy 512
266. Laryngotomy Canula fitted with Inner Tube 513
267. Skiagram showing an Angular Tracheotomy Tube in the Trachea 518
268. Anatomy of the Larynx and Trachea and the Position of Incisions for the Operations in this Region 524
269. Tubes for Tracheotomy 527
270. Trachea showing Ulceration caused by a Badly Fitting Tube 537
271. Stenosis following Tracheotomy 539
272. Tubes used in the Treatment of Stenosis of the Larynx 540
273. Trachea showing Ulceration into the Innominate Artery after Tracheotomy 541
274. Aneurism of the Aorta perforating the Trachea 542
275. Sarcoma of the Trachea 547
276. Instruments for Intubation of the Larynx 553
277. Instruments for Bronchoscopy 561
278. Instruments for Bronchoscopy 562
279. Upper Bronchoscopy with the Patient in the Dorsal Position 564
280. Lower Bronchoscopy with the Patient in the Dorsal Position 565
281. Laryngoscope Lamp 570
282. Clar’s Electric Light 571
283. Frontal Search-light 571
284. Meyer’s hollow Vulcanite Nasal Splint 582
285. Krause’s Trochar and Canula 583
286. Nasal Punch-forceps 583
287. Post-nasal Forceps 584
288. Nasal Dressing Forceps 585
289. First Step in removing the Anterior End of the Inferior Turbinal, which is seen to have undergone Polypoid Degeneration 587
290. Nasal Scissors 588
291. Amputation of the Posterior End of the Inferior Turbinal 590
292. Nasal Spokeshave 591
293. First Step in the Removal of the Anterior End of the Middle Turbinal 593
294. Second Step in the Removal of the Anterior End of the Middle Turbinal 593
295. Cresswell Baber’s Nasal Saw 597
296. The Gleason-Watson Operation for Deformity of the Septum 599
297. Asch’s Cutting Scissors 600
298. Lake’s Rubber Splint 600
299. Bayonet Knife 604
300. Incision for Submucous Resection of the Septum 604
301. Making the Incision from the Convex Side in Submucous Resection of the Septum 605
302. Dull-edged Detacher 605
303. Denudation of the Septum in Submucous Resection 606
304. Complete Denudation of the Deviated Septum 606
305. Ballenger’s Swivel Septum Knife 607
306. The Method of employing Ballenger’s Swivel Septum Knife 607
307. Submucous Resection of the Septum 608
308. Submucous Resection of the Septum 609
309. Submucous Resection of the Septum 609
310. Semi-diagrammatic Transverse Section of the Nose 610
311. Operation for Perforation of the Septum 611
312. Nasal Snare 613
313. Luc’s Nasal Forceps 616
314. Tongue Clip 617
315. Incisions for Lateral Rhinotomy (Moure’s Operation) 619
316. The Area of Bone removed in Lateral Rhinotomy 620
317. Lateral Rhinotomy 621
318. Rouge’s Operation. First stage 623
319. Rouge’s Operation. Second stage 624
320. Catheterizing the Maxillary Sinus 626
321. Lichtwitz’s and Moritz Schmidt’s Antrum Needles 627
322. Puncturing the Maxillary Sinus 627
323. Antrum Drills 628
324. Solid Rubber Obturators 628
325. Antrum Nozzle 628
326. Washing out the Maxillary Sinus from an Alveolar Opening 629
327. The Incision in the Caldwell-Luc Operation upon the Maxillary Sinus 631
328. The Caldwell-Luc Operation upon the Maxillary Sinus 632
329. Opening the Maxillary Sinus from the Nose 633
330. Carwardine’s Punch-forceps 634
331. The Opening into the Maxillary Sinus from the Inferior Meatus of the Nose 635
332. Denker’s Operation 636
333. Catheterizing the Frontal Sinus 639
334. Radiograph to show the Value of the Röntgen Rays 640
335. Radiograph showing Canula in the Frontal Sinus 641
336. Killian’s Operation upon the Frontal Sinus 643
337. Killian’s Operation upon the Frontal Sinus 644
338. Periosteal Elevators 645
339. Killian’s Triangular Curved Chisel 645
340. Citelli’s Bone-forceps 646
341. Hajek’s Bone-forceps 646
342. Killian’s Operation upon the Frontal Sinus 647
343. Radiograph of the Sphenoidal Sinus 654
344. Radiograph of the Sphenoidal Sinus 655
345. Catheterizing the Sphenoidal Sinus 656
346. Killian’s Long Nasal Speculum 657
347. Radiograph showing a Probe in the Sphenoidal Sinus 658
348. Sphenoidal Punch-forceps 659
349. Adenoid Curette 668
350. The Removal of Naso-pharyngeal Adenoids 668
351. Removal of Naso-pharyngeal Adenoids 669
SECTION I
OPERATIONS UPON THE FEMALE GENITAL ORGANS
I. ABDOMINAL GYNÆCOLOGICAL OPERATIONS
BY
JOHN BLAND-SUTTON, F.R.C.S. (Eng.)
Surgeon to the Middlesex Hospital and Senior Surgeon to the Chelsea Hospital for Women, London
I. CŒLIOTOMY
When the abdomen is opened for the purpose of removing a diseased viscus, the operation receives a specific name, such as nephrectomy, gastrectomy, splenectomy, and so forth. In many instances the abdomen is occupied by a tumour which defies the skill of the surgeon to localize to any particular organ until it is exposed to view through an incision; it is usual to apply the term cœliotomy to an operation of this kind, and it merely implies that the belly is opened by a cut. Cœliotomy is a useful expression, because many abnormal conditions arise in the abdomen which require treatment through an incision in its walls which do not lend themselves to an expressive term, for example, the removal of omental cysts, the evacuation of pus, blood, or the removal of foreign bodies, &c. It is true that a cœliotomy performed on an uncertain diagnosis may become a colectomy, ovariotomy, hysterectomy, &c., and the preliminary step to the performance of the operations to be described in this section is an abdominal incision, or cœliotomy. For whatever purpose a cœliotomy is required in the treatment of diseases of the female pelvic organs, the preparation of the patient and the initial steps are alike; it will therefore be convenient to describe the manner of carrying them out.
=The preparation of the patient.= It rarely happens that an operation is so urgent as to leave little time for a thorough preparation of the patient. It is desirable that the preliminaries should occupy two days at least. During this time the patient is kept in bed and the bowels are freely evacuated, either by calomel at night, with a saline draught in the morning, or by an ounce of castor oil.
On the morning of the operation the large bowel is thoroughly emptied by a soap and water enema, care being taken to use soft soap, to avoid producing a pimply eruption known as the ‘enema rash’.
It is well known that injuries to the abdominal organs, whether by accident or in the course of a surgical operation, are liable to be followed by septic parotitis. Recent writers attribute this complication to microbic infection of the ducts of the salivary glands (see p. 99); its occurrence may be avoided by including careful cleaning of the teeth among the preliminaries advisable for an abdominal operation. It is such a simple and comfortable ordinance that there is no reason for not following it.
The preparation of the skin needs to be very thoroughly carried out. After a warm bath the hair is shaved from the abdomen, pubes and vulva, and the skin is well washed with warm soapy water and swathed in gauze compresses wrung out of a solution of perchloride of mercury, 1 in 5,000. These compresses remain for twelve hours. The abdomen is again washed, and a second compress is applied which remains on until the operation.
Occasionally patients object to have the abdomen and pubes shaved. In such cases the hair can be easily removed by a depilatory. I have found a powder prepared according to the following formula useful:--
Sodium monosulphide, 1 part; calcium oxide, 1 part; starch, 2 parts; sufficient water is added to make a stiff paste, which is spread over the parts. After five minutes it is washed off by means of a dab of cotton-wool and the skin freely washed with warm water. This preparation is only efficacious when freshly prepared.
The washing and application of compresses require care on the part of the nurse, for some patients have skin so tender that it is easily blistered, and a crop of small pustules is a source of inconvenience, and leads to stitch-abscesses. In certain cases over-preparation may be worse than no preparation.
When patients are advanced in years it is extremely necessary to protect them from being chilled by undue exposure. It is well to clothe their lower limbs in warm flannel garments or drawers made out of Gamgee tissue. No open doors or windows should be permitted; though in summer this is comfortable to the surgeon it may be disastrous to the patient. In winter the temperature of an operating-room should not be below 65°F. In this way ether pneumonia is best avoided.
In operations, such as oöphorectomy, ovariotomy and hysterectomy, it is the rule not to operate during menstruation; experience has taught me that operations performed during this period are not followed by evil or untoward consequences, and for many years I have disregarded it.
Immediately before the patient is placed on the table the bladder should be emptied naturally, or by means of a sterilized glass catheter.
In all pelvic operations it is a great advantage to employ nurses who have had a special training in ‘abdominal nursing’.
=Basins and dishes.= All receptacles such as basins, pots, instrument dishes and the like should be boiled. Mere rinsing or washing in warm water is insufficient.
=Instruments.= These should be constructed of metal throughout, as this enables them to be thoroughly sterilized by boiling. Needles and scalpels may be enclosed in perforated metal boxes. Forceps and the handles of scalpels are nickelled, and this keeps them bright. The following instruments are necessary: Scalpel, twelve hæmostatic forceps, dissecting forceps, two fenestrated forceps which are also useful as sponge-holders, a volsella, six curved needles of various sizes, two straight needles, silks of various thickness, and six dabs.
The surgeon should make a practice of employing a definite number of instruments and dabs for all occasions, as it will save him much anxiety in counting them at the end of the operation.
During the operation the instruments and silks are immersed straight from the sterilizer in warm sterilized water.
=Suture and ligature material.= The most useful material at present employed in pelvic surgery is silk. This material has a wide range of usefulness, as it is employed to secure pedicles, for the ligature of blood-vessels, and for sutures; it can be obtained of any thickness, and is easily sterilized by boiling without impairing its strength. In abdominal surgery there are four useful sizes, No. 1, 2, 4, and 6, of the plaited variety of silk. The thread is wound on a glass spool and boiled for one hour immediately before use. If any silk is left over from the operation it may be reboiled once or twice without impairing its strength. (The fate of silk ligatures is discussed on p. 117.) Many surgeons employ catgut and hold it in high esteem. I regard it as an unsatisfactory and dangerous material; moreover it cannot be boiled, which is the simplest and safest method of making ligatures sterile.
=Dabs.= Nothing is so convenient for removing blood from a wound as sponges; their absorbent property and softness are excellent, but they are difficult to sterilize; therefore they are highly dangerous, and on this account should be banished from surgery. An excellent substitute is absorbent cotton-wool enclosed in gauze (Gamgee tissue). This material can be cut to any size or folded into any shape, and is easily sterilized by heat, or by boiling, without damage to its absorbent properties.
For a cœliotomy six dabs are prepared of various sizes, according to the nature of the case. These are boiled for one hour and then immersed in sterilized warm water and washed from time to time in the course of the operation.
I always employ six dabs, then there is no difficulty at the end of the operation concerning their number. The dabs at the completion of the operation are destroyed.
Many serious consequences have arisen from dabs and instruments accidentally left in the peritoneal cavity after pelvic operations. This subject is considered on p. 105.
The operator should remember that his responsibility in this matter is determined by a decision in a Court of Law.
The employment of dry gauze dabs in abdominal operations is objectionable because it is harsh and irritating to the peritoneum and leads to the formation of adhesions.
=Gloves.= Increasing experience proves that gloves are most valuable in securing freedom from sepsis. It is a very important matter that the surgeon, the assistant, and the nurses who help at the operation should wear rubber gloves boiled immediately before the operation for ten minutes.
The wearing of gloves diminishes the mortality of the operation, and minimizes its unpleasant and often dangerous sequelæ, such as suppuration around sutures, septic emboli, tympanites, and the like. Care must be taken to impress upon all who take part in an operation that it is as essential to thoroughly wash and disinfect the hands before inserting them in gloves as when no gloves are worn. It is also necessary to warn nurses that the smallest hole in a glove renders it useless.
To the operator thorough disinfection of the hands is of the highest importance, for he may puncture or tear the gloves during the operation; or a difficulty may arise in the course of it which will render it advantageous for him to remove one or both gloves to overcome it. It is with me a rule that if in the course of an operation it is necessary to remove the gloves, I resume them for the final stages, and particularly for the insertion of the sutures. The use of rubber gloves marks a most important advance in operative surgery.
=The operating table.= In many cases of cœliotomy a table such as is employed for the ordinary operations of surgery answers very well, but for hysterectomy, oöphorectomy, and similar procedures it is a great convenience to use a table on which the patient can be placed in the Trendelenburg position, that is, with the pelvis raised, and the head and shoulders lowered: this allows the intestines to fall towards the diaphragm and leave the pelvis unencumbered. There are many varieties of tables employed for this purpose. As these tables are made of metal, it is necessary before the table is tilted to fix the patient’s arms parallel with her trunk, otherwise they fall across the edge of the table, and in some instances a troublesome paralysis of the muscles of the upper limb has been the consequence.
It is worth while pointing out that most of the examples have happened in the course of long operations (see Post-anæsthetic paralysis, p. 95).
=Anæsthesia.= The majority of surgeons employ a general anæsthetic, such as ether, chloroform, or a mixture of chloroform and ether, in pelvic operations. The most usual practice in London is to render the patient unconscious with nitrous oxide gas and maintain the anæsthesia with ether. It is a method which has given me the greatest satisfaction. As a rule, it is wise whenever possible to employ an experienced anæsthetist and trust to his judgment in regard to the selection of the anæsthetic.
In exceptional cases pelvic operations such as ovariotomy and hysteropexy have been successfully performed with the aid of intradural injections of a solution of eucaine, novocaine, or stovaine.
=The incision.= The operation-area is isolated by sterilized towels and the pelvis well tilted and so arranged as to face a good light. When the patient is completely unconscious, the operator (standing usually on the right side with the assistant opposite him) freely incises the wall of the abdomen in the middle line between the umbilicus and the pubes (this incision is conveniently termed the median subumbilical incision; its length varies with the necessities of the case, but is usually 7 to 10 centimetres). The first cut generally exposes the aponeurotic sheath of the rectus; any vessels that bleed freely require seizing with hæmostatic forceps. The linea alba is then divided, but as it is very narrow in this situation, the sheath of the right or left rectus muscle is usually opened. Keeping in the middle line, the posterior layer of the sheath is divided and the subperitoneal fat (which sometimes resembles omentum) is reached; in thin subjects this is so small in amount that it is scarcely recognizable, and the peritoneum is at once exposed, and, as a rule, the urachus comes into view. In order to incise the peritoneum without damaging the tumour, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall; the surgeon then introduces his finger, and divides the peritoneum to an extent equal to the incision in the skin.
It is important to remember that the bladder is sometimes pushed upward by tumours, and lies in the subperitoneal tissue above the pubes; it is then liable to be cut.
On entering the peritoneal cavity, the surgeon introduces his hand, and proceeds to ascertain the nature of any morbid condition that he sees or feels, or he evacuates any free fluid, blood, or pus which may be present. Occasionally he finds that attempts to remove a tumour would be futile or end in immediate disaster to the patient; then he desists and closes the wound, and the procedure is classed as an exploratory cœliotomy. Should a removable tumour, such as an ovarian cyst, an echinococcus colony in the omentum, or the like be found, it is removed.
Before suturing the incision, the surgeon usually spreads the omentum over the small intestine; occasionally he will be surprised to find this structure, even in well-nourished women, represented by a mere fringe of fatty tissue attached to the lower border of the transverse colon.
The recesses of the pelvis are then carefully mopped in order to remove fluid, blood, or pus; the dabs and instruments are counted, and preparations made to suture the incision.
=Misplaced viscera.= In addition to tumours and normal enlargement of the uterus due to pregnancy, or an overfull bladder, there are certain malformations as well as displacements of normal viscera the surgeon may encounter in the pelvis which will, in some cases, cause him a certain amount of embarrassment, such, for example, as a bifid uterus or a spleen which has elongated its pedicle, or even twisted it, and, falling so low in the abdomen as to occupy the pelvis, may even cause prolapse of the uterus. In some of these cases it drags the tail of the pancreas with it. The cæcum and the vermiform appendix often occupy the true pelvis; in middle-aged and elderly women the transverse colon sometimes forms a loop (the omega-loop), the extreme convexity of which often reaches to the pelvis. I have seen the right lobe of the liver extend into the pelvis, and come in contact with the unimpregnated uterus. It is important to remember that a kidney sometimes occupies the hollow of the sacrum; such a misplaced kidney has been removed under the impression that it was a tumour. When a kidney occupies the pelvis it lies behind the peritoneum as when it occupies its normal position in the loin. A horseshoe kidney is a fertile source of divergent opinion in diagnosis. A very large hydronephrosis simulates very closely an ovarian cyst until exposed through an abdominal incision; in such a contingency the operator performs nephrectomy; when the kidney is large enough to resemble an ovarian cyst it can easily be removed through the median incision.
A very distended stomach will reach the hypogastrium and has many times been mistaken for an ovarian cyst; such a distended stomach has received a thrust from an ovariotomy trocar and the operator has been astonished to see food issue through the opening.
Tumours of the pelvic organs are often complicated with abnormal and diseased conditions of the intestines, large and small; it is therefore necessary for any one undertaking gynæcological abdominal operations to be prepared to perform resections of the colon, enterorrhaphy, gastro-jejunostomy, and the like when necessary.
Transposition of the viscera is a rare anomaly to encounter in the course of an abdominal operation. I met with it once in 3,000 cœliotomies; the condition was recognized before operation.
=Closure of the wound.= There are about fifty methods known and advocated for the closure of the median subumbilical incision, and the following is a list of materials used by surgeons for this purpose: silk, silkworm-gut, catgut, linen thread, and horsehair; silver, iron, aluminium, bronze, and platinum wire, and Michel’s metal clips. The object of these various methods and materials is to obtain a firm scar.
The first requisite for securing an unyielding scar is perfect asepsis; but even the most perfectly healed abdominal scar may yield. Nature in her great operation of uniting the lateral halves of the belly-wall in a median cicatrix, the linea alba, cannot secure a non-yielding scar, it is therefore presumptuous of the surgeon to think he can always ensure it.
The method which has given me the best results is a simple one. The peritoneum, sheath of the rectus, and rectus muscle are carefully approximated by interrupted sutures of No. 4 silk carefully sterilized and inserted with the hands covered with rubber gloves. The sutures are inserted at intervals of rather less than 2 centimetres apart. Care must be taken to include the peritoneum in these sutures. The skin is then brought together by a continuous suture of No. 2 silk. When the operation has been undertaken for a septic condition, such as pelvic peritonitis, suppuration of an ovarian cyst, an acute pyosalpinx, or the like, then it is useless to introduce buried sutures for the muscular and aponeurotic layers, as they will quickly become infected. In such conditions the abdominal walls are brought together by interrupted sutures involving all the layers.
Those who are curious in regard to the various methods of closing median cœliotomy wounds should consult a brochure published in 1904 on The Closure of Laparotomy Wounds as practised in Germany and Austria, by Walter H. Swaffield. This little book contains the detailed methods and views communicated to him by more than fifty leading surgeons.
In Great Britain there is plenty of variety in the methods and material employed for the closure of the incisions in abdominal operations, but at the present time there is a marked tendency to return to the older and simpler methods. The most dangerous and unreliable suture material for the abdominal incision is catgut (see p. 96).
In studying the details of such operations as ovariotomy and hysterectomy from books, it should be remembered that it is merely the principles that can be explained. There are so many details in every operation that can only be learned from watching, or, what is far better, assisting a skilful and experienced surgeon in their performance. This is true of all forms of surgical procedure. No man can become a navigator without going to sea, however thoroughly he masters the principles of seamanship from books, so no surgeon can acquire the art of operating from merely reading descriptions of surgical operations. If a surgeon can bring to bear upon abdominal gynæcological operations, in addition to mere surgical dexterity, a competent knowledge of the pathology of the organs, he will find it of the greatest assistance. I would warn him particularly to take little heed of the sneers of those eminently practical surgeons who affect to despise pathology.
II. OVARIOTOMY
Ovariotomy signifies the removal through an abdominal incision of cystic and solid tumours of the ovary, and parovarian cysts.
The history of this operation is of great interest to surgeons because it was the forerunner, so to speak, of all abdominal gynæcological operations; they followed as a natural consequence on the establishment of ovariotomy, and operations on the abdominal viscera generally are to be regarded as an extension of pelvic surgery.
It is usual to state that ovariotomy was first performed by Ephraim McDowell, of Kentucky, 1809: this is of historical interest only, for it had no effect whatever in drawing attention to the feasibility of removing ovarian cysts: it was in fact a still-born operation. The pioneers of this operation were undoubtedly Baker Brown and Spencer Wells in London, Thomas Keith in Edinburgh, and Clay in Manchester. These surgeons brought the operation out of a ‘slough of despond’ and placed it on firm ground. Spencer Wells and Keith were fortunate later in their work in receiving guidance from Lord Lister’s discovery of antisepsis: this, combined with the introduction of the short ligature, firmly established the operation.
The improvement in securing the pedicle has played an important part in the development of ovariotomy. McDowell tied the pedicle, but left the ligature hanging out of the wound. Doran, who has written an excellent review of this matter, ascribes the intraperitoneal method of dealing with the pedicle to the systematic advocacy of Tyler Smith. The method has been followed by brilliant results.
Baker Brown used to sear the pedicle with a cautery, and this method was adopted with great success by Thomas Keith. The method of ligature is so simple and safe that the cautery for this purpose has been long abandoned.
=The operation.= The preliminary preparation of the patient and the necessary instruments are described on p. 5. The Trendelenburg position is not so necessary for the removal of large ovarian tumours as the smaller examples which are apt to be firmly adherent to the floor of the pelvis. In cases where the abdomen contains free fluid, ascitic or due to the bursting of a cyst, or pus, it is a wise precaution to conduct the early stages of the operation with the patient in the horizontal position, otherwise the tilting will cause the fluid to gravitate towards the diaphragm. As soon as the fluid has been removed the pelvis may be raised if it be likely to facilitate the operation.
In the early days of ovariotomy it was the custom to tap the cyst, or, in the case of multilocular tumours, to force the hand into the mass and break down the septa of contiguous loculi and allow the viscid material to escape. These devices were recommended because it was regarded as a method making for safety to extract the cyst through a small abdominal incision. Occasionally it is possible to extract the wall of a large single-chambered parovarian cyst, after tapping, through an incision 7 centimetres in length. When the tumour is multilocular, or malignant, or full of grease or pus, it is difficult and extremely dangerous to tap it, as the material may infect the peritoneum either with septic matter or with malignant particles, and end disastrously.
Cases have been reported in which, after traumatic rupture, or tapping, of a dermoid, the epithelial contents escaped into the belly. Subsequently the peritoneum was found dotted over with minute nodules furnished with tufts of hair growing among the visceral adhesions. When a woman with an ovarian cyst contracts typhoid fever, the cyst may become filled with pus which contains the bacillus typhosus. Such a case occurred in my practice in 1907.
For many years I have abandoned the use of clumsy trocars of all kinds and remove the tumour entire, although it may require an incision from the ensiform cartilage to the pubes. These large incisions heal quickly, and are no more prone to hernia than the short incisions. This is the only way of ensuring the safety of the peritoneum from being contaminated by the harmful, dirty, and often malignant contents of the cysts. In dealing with burst cysts a free incision enables the surgeon to thoroughly and gently clean the peritoneal cavity.
The abdominal cavity is opened by a median subumbilical incision (see p. 7). Occasionally a difficulty may be encountered on reaching the peritoneum, for, if the cyst has been infected, the peritoneum and cyst wall may be so intimately adherent that they cannot be separated. In these circumstances it is a wise plan to extend the incision upwards and enter the abdominal cavity above the tumour. It is also to be borne in mind that when the tumour adheres to the abdominal wall it is extremely probable that a coil of intestine may be adherent also. When a tumour is impacted in the pelvis it may push the bladder high in the abdomen; in such an event this viscus is apt to be opened in making the incision. If the surgeon has any doubt concerning the position of the bladder, he should instruct an assistant to introduce a sound into it through the urethra.
In a typical case, when the peritoneum is opened the surgeon at once recognizes the bluish-grey glistening surface of the ovarian cyst, and gently sweeps his hand over it in order to ascertain its relations and to learn whether the cyst wall be free from adhesions. It is of the utmost importance to be satisfied as to the nature of the tumour, especially when the operator follows the unsatisfactory practice of tapping, for if he plunge a trocar into a uterine tumour, or into a pregnant uterus, he will involve himself in anxious difficulty. Decomposing fluid, tenacious mucus, or blood-stained fluid may obscure the parts, and should be sponged away: they indicate a ruptured cyst, a malignant tumour, or a twisted pedicle. Much free blood may be due to the bursting, or abortion, of a gravid tube. When the surgeon has satisfied himself that the cyst or tumour is free to be removed he lifts it out of the abdominal cavity, and if in this process the wall be so thin that it is likely to burst, or actually leaks, the weak spot may be freely incised with a knife over a convenient receptacle.
Adhesions. Although the surgeon may have had reasons to suspect the presence of adhesions, frequently he finds none, and on other occasions when he least expects them there are many. The most frequent adhesions are omental, and fortunately they are the least important: they should be detached and tied with thin silk. Adherent epiploic appendages require the same treatment. Intestinal adhesions require care and patience. When the intestines are adherent by strands and bands, these may be cautiously snipped with scissors; when the adhesions are sessile and soft the gut may be gently detached by means of a moist dab; but if very firm it may be necessary to dissect off a piece of cyst wall and leave it on the gut. The vermiform appendix requires especial care, for it may be mistaken for an adhesion and divided. When intestines are accidentally opened in the course of an ovariotomy they require the most careful attention. Wounds in the colon may be safely sutured. Holes in adherent small intestine may sometimes be sutured, but if the gut has been extensively involved it may be necessary, and often judicious, to resect a few centimetres and join the cut ends by a circular enterorrhaphy.
Adhesions to the parietal peritoneum are as a rule easily detached with the finger. The most serious adhesions are those which occur in the depths of the pelvis, involving the uterus, bladder, or rectum, and the separation of these may involve such accidents as wounds opening the rectum or bladder, and injury to the ureters and iliac veins. The treatment of such misfortunes will be considered later.
The pedicle. When the tumour is withdrawn from the belly the pedicle is easily recognized: the Fallopian tube serves as an excellent guide to it. The pedicle consists of the Fallopian tube and adjacent parts of the mesometrium containing the ovarian artery, pampiniform plexus of veins, lymphatics, nerves, and the ovarian ligament. When the constituents of the pedicle are unobscured by adhesions, the round ligament of the uterus is easily seen and need not be included in the ligature.
In transfixing the pedicle the aim should be to pierce the mesometrium at a spot where there are no large veins, and tie the structures in two bundles, so that the inner contains the Fallopian tube, a fold of the mesometrium, and occasionally the round ligament of the uterus; whilst the outer consists of the ovarian ligament, veins, the ovarian artery, and a larger fold of peritoneum than the inner half.
Pedicles differ greatly; they may be long and thin, or short and broad. Long thin pedicles are easily managed. The assistant gently supports the tumour, whilst the operator spreads the tissues with his thumb and forefinger, and transfixes them with the pedicle needle armed with a long piece of silk doubled on itself. The loop of silk is seized on the opposite side and the needle withdrawn. During the transfixion care must be taken not to prick the bowel with the needle. The loop of silk is cut so that two pieces of silk thread lie in the pedicle. The proper ends of the thread are now secured, and each is firmly tied in a reef-knot; for greater security the whole pedicle may be encircled by an independent ligature, taking care that it embraces the pedicle below the point of transfixion. (I use No. 4 plaited silk for transfixing the pedicle, and a piece of No. 6 silk for surrounding it.)
After the operator has gained some experience in this simple mode of tying the pedicle, he may, if he thinks it desirable, practise other methods.
After securely applying the ligature the tumour is removed by snipping through the tissues on the distal side of the ligature with scissors. Care must be taken not to cut too near the silk, or the stump will slip through the ligature; on the other hand, too much tissue should not be left behind. The stump is seized on each side by pressure forceps, and examined to see that the vessels in it are secure; it is then allowed to retreat into the abdomen. Should it begin to bleed it must be caught with forceps, drawn up, retransfixed, and tied below the original ligature.
Occasionally a pedicle will be so broad that it is unsafe to trust to this simple form of ligature. Broad pedicles will require three or more ligatures. When several ligatures are required it is important to remember that the ovarian artery lies in the outer fold of the pedicle and the uterine artery at the inner end, and it is often possible to secure these vessels separately with a thin piece of silk. The pedicle can then be secured with a series of interlocking ligatures.
When an ovarian tumour has undergone axial rotation and has tightly twisted its pedicle, the ligature should be applied to the torsioned area: a single ligature is then sufficient.
It is impossible to frame absolute rules for ligaturing the pedicle. In this, as in all departments of surgery, common sense must be exercised, and at the present day, when ovariotomy is practised so widely, no one would think of performing this operation without assisting at, or watching its actual performance by an experienced surgeon.
Having satisfied himself that the pedicle is secure, the surgeon examines the opposite ovary, and if obviously diseased it should be removed.
The operator then sponges up any blood or fluid which may have collected in the recesses of the pelvis. Whilst employed in this way he gives instructions to have the dabs and instruments counted.
When the operator limits the number of dabs to six he can easily have them displayed before him. The incision is sutured in the manner described on p. 9.
=Cysts of the broad ligaments.= Occasionally the surgeon on opening the abdomen finds that the cyst or tumour is situated between the layers of the broad ligament. Sessile cysts of this kind are removed by what is known as enucleation. The peritoneum overlying the cyst is cautiously torn through with forceps until the cyst wall is exposed; then by means of the forefinger the surgeon proceeds to shell the cyst out of its bed, taking care not to tear the capsule or any large vein in its wall; it is also necessary to exercise the greatest care to avoid injury to the ureter. It is not uncommon, after enucleating a cyst in this way, to find the ureter lying at the bottom of the recess. (For treatment of an injured ureter see p. 112.)
When the enucleation is completed the walls of the capsule are carefully examined for oozing vessels which require ligature. The capsule can often be closed in such a way as to bring its walls into apposition and thus obliterate its cavity; it then requires no further attention. When there is much oozing the capsule is treated on the plan known as marsupialization. The edges of the capsule are brought to the lower angle of the abdominal wound and secured with sutures, and a drain, either of gauze or a rubber tube, is introduced, and the remainder of the wound closed in the usual manner.
Enucleation is usually accompanied by more loss of blood than simple ovariotomy; this, and the prolonged manipulation, is often responsible for severe shock.
=Spurious capsules.= It is necessary for the surgeon to remember that an ovarian cyst, and especially an ovarian dermoid, is sometimes invested by a spurious capsule. It is now well known that slow effusions of blood, tuberculous exudations (Fig. 4), hydatid cysts, and ovarian cysts become enclosed by capsules of fibrous tissue formed by the organization of the peritoneal exudation which their presence excites. These capsules are often so firm, and so completely encyst the fluid exuded into the pelvis in cases of tubal tuberculosis, that such encapsuled collections of fluid resemble, and are often mistaken for, ovarian cysts. It is also necessary to mention that true ovarian cysts project from, but never invade the layers of the broad ligament. From time to time cases are reported in which ovarian cysts, especially dermoids, have been found between the layers of the broad ligament: such are in all probability instances in which a false capsule has formed around the cyst, and the surgeon committed an error of observation in regarding it as a layer of the broad ligament.
=Ovariotomy in carcinoma of the ovary.= When an operation is undertaken for the removal of solid or semi-solid tumours of the ovary, and especially when bilateral and accompanied by vomiting, it is incumbent on the surgeon to make a careful examination of the gastro-intestinal tract, for in many of these cases cancer will be found either at the pylorus, or in the cæcum, or the colon, and particularly in the sigmoid flexure. In such circumstances the ovarian masses are secondary to the cancerous focus in the gastro-intestinal tract.
Bilateral malignant tumours of the ovaries are sometimes secondary to primary cancer of the gall-bladder and the breast. Some of these secondary cancerous tumours of the ovaries form masses as big as the patient’s head.
In such conditions the ovaries and sometimes the uterus should be removed even for the purpose of making the patient comfortable. When the primary disease is in the cæcum, colon, or sigmoid flexure, and is operable, the growth should be resected and the cut ends of the bowel united by circular enterorrhaphy. In one instance, where the cancer occupied the ileo-cæcal valve, I succeeded in making a lateral anastomosis between the ileum and ascending colon, after performing bilateral ovariotomy. The woman survived the operation two years.
=Incomplete ovariotomy.= The surgeon may start on an operation and, after opening the abdomen, may find many adhesions, yet he feels that the removal of the tumour is possible. He sets to work and overcomes many of the difficulties, but finds at last such extensive pelvic adhesions that it is imprudent to proceed further. In such cases he evacuates the contents of the cyst and stitches the edges of the opening in the cyst to the margins of the abdominal wound, and drains the cavity. This mode of dealing with a cyst is usually termed ‘incomplete ovariotomy’.
An incomplete ovariotomy is a very different condition to an enucleation. The cavity left after enucleation closes completely, but when the wall of an ovarian cyst or adenoma is left the tumour gradually grows again, or it may suppurate so profusely that the patient slowly dies exhausted. There are few things sadder in surgery than the slow, miserable ending of an individual who has been subjected to an incomplete ovariotomy.
=Anomalous ovariotomy.= In a few instances, generally under an erroneous diagnosis, surgeons have removed ovarian tumours through an opening other than the classical one known as the median subumbilical incision. Under the impression that the tumour was splenic, an ovarian tumour of the right side has been successfully removed through an incision in the left linea semilunaris (R. W. Parker). An ovarian tumour, supposed to be a renal cyst, has been successfully extracted through an incision in the ilio-costal space (Le Bec). Strangest of all, a small ovarian dermoid has been removed through the rectum under the impression that it was a polypus of the bowel (Stock, Peters).
=Hysterectomy after bilateral ovariotomy.= After the removal of both ovaries for cysts or tumours, the uterus is a useless organ: it is fast becoming the practice under such conditions to remove it. There is much to be said in favour of this procedure, especially if the uterus be large and flabby, because it tends to fall backwards into the pelvis. In such circumstances it is better surgery to remove it than to perform hysteropexy. The risk of intestinal obstruction after bilateral ovariotomy is greater than after hysterectomy. Cases are known in which cancer has attacked the uterus years after bilateral ovariotomy and oöphorectomy (see p. 55).
=Repeated ovariotomy.= Very many cases are known in which women have been twice submitted to ovariotomy. Thus it is the duty of the surgeon when removing an ovarian tumour to examine carefully the opposite ovary. So many examples are known of women who have borne children after unilateral ovariotomy (twins and even triplets) that this alone is sufficient to prohibit the routine ablation of both glands.
A second ovariotomy is not attended with more risk than a first ovariotomy. The abdominal incision must be made with extra caution, because intestine may be adherent to it and runs a risk of being wounded. In some instances the cicatrix is very thin, and the surgeon cutting through it is liable to cut the intestine before being aware that the knife has entered the abdomen.
Some surgeons recommend that in a second ovariotomy the opening may with advantage be made a little to one side of the original incision.
Cases have been reported in which patients have been thrice submitted to ovariotomy: in such instances it is probable that one of the tumours was a sessile broad ligament cyst.
=Pregnancy after bilateral ovariotomy.= It is an interesting fact that several cases have been carefully reported in which women who have had bilateral ovariotomy have subsequently become pregnant. This event has been explained by assuming that in some of the patients a portion of at least one ovary has been left. This meets with more favour than the idea of the existence of a supernumerary ovary. The cases have been collected by Doran.
In order to afford some notion of the relative frequency of the various cysts and tumours classed as ovarian, a list of one hundred consecutive examples which I removed at the Chelsea Hospital for Women is appended:--
Fibromata 2 Sarcomata 2 Carcinomata 1 Simple cysts 45 Adenomata 25 Dermoids 15 Papillomata 2 Parovarian 5 Tubo-ovarian 3
The case classed as a carcinoma was secondary to cancer of the pylorus; both ovaries were affected. The three classed as tubo-ovarian were probably exceedingly large examples of hydrosalpinx; one was so big that it came in contact with the liver.
I have compared this table with the experience of other surgeons, and although there is much variation in them it represents a fair average of the proportions of the different ovarian operations usually classified under the head of ovariotomy.
=Ovariotomy at the extremes of life.= Cysts and tumours arise in the ovary during intra-uterine, and at all periods during extra-uterine life, even in extreme old age: they also attain such dimensions in infants and old women as to demand the aid of the surgeon, and with excellent results. Many years ago I collected the recorded cases and tabulated one hundred instances in which ovariotomy had been performed in infants and girls under fifteen years of age. These tumours fall into three groups:
Simple cysts and adenomata 41 with 3 deaths. Dermoids 38 " 5 " Sarcomata 21 " 7 "
In the case of simple cysts, adenomata, and dermoids, the results are encouraging. It is possible that some of the cases described as sarcomata belonged to the deadly group now known as malignant teratomata.
Ovarian tumours sometimes attain large dimensions in children, and Keen reported a case in which he removed an ovarian tumour from a girl which weighed 44 kilogrammes: the girl weighed 27 kilogrammes after the operation. An ovarian cyst with a twisted pedicle has been found in a fœtus at birth (Otto von Franque).
The subjoined table shows cases in which ovarian tumours have been removed from infants under three years of age. It is often stated that Professor Chiene performed ovariotomy on an infant of three months. This is an error; it was an ovary occupying the sac of an inguinal hernia.
OVARIOTOMY IN INFANTS
-+------------+-----------+--------+----------+---------------------- | Reporter | Age |Result|_Nature of| Reference | | | | Tumour_ | -+------------+-----------+--------+----------+---------------------- 1|D’Arcy Power|4 months | R. |Dermoid |Trans. Path. | | | | |Soc., xlix. 186. -+------------+-----------+--------+----------+---------------------- 2|MacGillivray|11 months | R. |Cyst |Lancet, 1907, | | | | |i. 1487. -+------------+-----------+--------+----------+---------------------- 3|Roemer |1-3/4 years| R. |Dermoid |Deutsche Med. Woch., | | | | |1883, ix. 762. -+------------+-----------+--------+----------+---------------------- 4|Péan |2 years | R. |Dermoid |Clin. Chir., | | | | |1887-8, 8th series. -+------------+-----------+--------+----------+---------------------- 5|Hooks |2-1/2 years| D. |Dermoid |Am. J. of Obst., | | | | |1886, xix. 1022. -+------------+-----------+--------+----------+----------------------
=Ovariotomy in old age.= In 1891 I was able to find twenty-two records of successful ovariotomy in women over seventy years of age. Since that date Howard A. Kelly and Mary Sherwood made a collective investigation, and succeeded in obtaining notes of one hundred cases of ovariotomy performed on women over seventy years of age: the death-rate amounted to 12%.
The subjoined table concerns itself with ovariotomy performed on women after the age of eighty years, and the results are remarkable, notwithstanding the circumstance that these women of eighty years and upwards must have been blessed with a stronger constitution than their contemporaries.
OVARIOTOMY IN WOMEN OF EIGHTY YEARS OF AGE
--+-------------+-----+--------+------------------------------------ | Reporter |Age|Result| Reference --+-------------+-----+--------+------------------------------------ 1|Owens | 80 | R. |Brit. Gyn. Soc. Journal, iv. 88. --+-------------+-----+--------+------------------------------------ 2|Richardson | 80 | R. |Brit. Med. Journ., 1894, i. 523. --+-------------+-----+--------+------------------------------------ 3|Heywood Smith| 81 | R. |Lancet, 1894, i. 1618. --+-------------+-----+--------+------------------------------------ 4|Spencer | 82 | R. |Brit. Med. Journ., 1893, ii. 1271. --+-------------+-----+--------+------------------------------------ 5|Homans | 82 | R. |Bost. Med. and Surg. Journ., 1888, | | | | 454. --+-------------+-----+--------+------------------------------------ 6|Edis | 81 | R. |Brit. Med. Journ., 1892, i. 860. --+-------------+-----+--------+------------------------------------ 7|Bush | 84 | R. |Ibid., 1894, ii. 67. --+-------------+-----+--------+------------------------------------ 8|Remfrey | 83 | R. |Trans. Obstet. Soc., xxxvii. 152. --+-------------+-----+--------+------------------------------------ 9|Kraft | 84 | R. |Hospitalstidende, Copenhagen. --+-------------+-----+--------+------------------------------------ 10|Owens[1] | 87 | R. |Lancet, 1895, i. 542. --+-------------+-----+--------+------------------------------------ 11|Thornton | 94 | R. |Trans. Obstet. Soc., xxxvii, 158. --+-------------+-----+--------+------------------------------------ 12|Bland-Sutton | 85 | R. |Middlesex Hospital. --+-------------+-----+--------+------------------------------------ [1] A second operation on patient No. 1 in the list.
=Mortality.= The death-rate after ovariotomy is hard to estimate, especially as surgeons differ widely in the classification of the cases. In the simple and uncomplicated forms of ovarian cysts and tumours the operation should be almost free from risk. Many surgeons, excluding malignant conditions, have had lists of a hundred operations with no deaths.
If all kinds of tumours are included as represented in the table on p. 17, a 5% mortality in experienced hands would be regarded as a good result. In general hospital work it is probably as high as 10%. With less experienced surgeons who do not perform many operations the death-rate will vary from 10 to 15%.
The risks and after-consequences of ovarian operations are set forth in Chapter XI.
REFERENCES
DORAN, A. On complete Intraperitoneal Ligature of the Pedicle in Ovariotomy. St. Bartholomew’s Hospital Reports, 1877, xiii. 195.
---- Pregnancy after the Removal of Both Ovaries for Cystic Tumour. Trans. Obstetrical Society, 1902, xliv. 231.
BLAND-SUTTON, J. On Secondary (metastatic) Carcinoma of the Ovaries. Brit. Med. Journal, 1906, i. 1216.
---- On Cancer of the Ovary. Ibid., 1908, i. 5.
LE BEC. Ovariotomie double; un des kystes enlevé par la région lombaire, l’autre par le devant de l’abdomen; adhérences totales; guérison. Gaz. des Hôpitaux, 1887, 290.
STOCKS. Prolapse of an Ovarian Cyst. Brit. Med. Journal, 1857, ii. 487.
PETERS, H. Ovariotomie per anum. Wiener Klin. Wochensch., 1900, xiii. 110.
III. OÖPHORECTOMY
Oöphorectomy signifies the removal through an abdominal incision of an ovary and Fallopian tube for affections mainly inflammatory.
The evolution of this operation is of great interest to surgeons. The removal of ovaries as a surgical operation was introduced independently by Hégar in Germany and Battey in Georgia, for the relief of pelvic pain and dysmenorrhœa, in 1872. In the same year Lawson Tait performed his pioneer operation and removed an ovary and tube for the relief of pain due to disease of the ovary. Subsequently he advocated bilateral oöphorectomy for the purpose of inducing an artificial menopause in women with uterine fibroids. From these beginnings the operation began to be performed for the relief of a variety of conditions connected with the generative organs, such as--
Pyosalpinx and tubo-ovarian abscess, hydrosalpinx, tuberculous ovaries and tubes, sarcoma and carcinoma of the Fallopian tubes, gravid Fallopian tubes, ovarian abscess, ovarian pregnancy, prolapse of the ovary; finally bilateral removal of the ovaries has been practised for the relief of inoperable cancer of the breast.
Bilateral oöphorectomy is occasionally performed for osteomalacia (a rare disease in Great Britain), as it arrests pain and the excessive output of phosphates in the urine, which is a marked feature of this affection. This extension of the operation we owe to Fehling of Bâle (1887).
Time and experience have considerably modified surgical opinion in regard to oöphorectomy. Removal of the ovaries is no longer practised for the relief of hæmorrhage due to fibroids: it is easier, safer, and affords greater relief to the patient to remove the uterus (see p. 36). When dysmenorrhœa is so severe as to need radical operation, hysterectomy is the only certain method, with conservation of at least one ovary. The removal of both ovaries in certain forms of insanity is now abandoned, and this is true of bilateral oöphorectomy for the relief of mammary cancer.
In other directions the operation has undergone extension, for in some chronic diseases of the Fallopian tubes it is difficult to completely extirpate the affected tissues without removing the uterus. These will be considered in describing the actual operation.
Apart from the many modifications in the details of the operations some operators prefer to remove the ovaries and tubes through an incision in the vaginal fornix. This is known as Colpotomy, or Vaginal Cœliotomy.
Some writers attempt to subdivide the various modifications of oöphorectomy and apply to them special terms: for example, the removal of the ovary and tube would be termed salpingo-oöphorectomy. Removal of the tube would be called salpingectomy, and the excision of the ovary, oöphorectomy. This terminology may be precise, but it is certainly clumsy. A few writers designate these operations as ‘removal of the uterine appendages’; this phrase, though comprehensive, is neither precise nor elegant.
=Operation.= The patient is prepared in the same manner, and the same instruments are required, as for ovariotomy. In many of these operations the Trendelenburg position is of the greatest advantage.
In a case of prolapse of the ovary, or a gravid tube or ovary in the earliest stages, the operation presents no difficulty and can be carried out with the ease and safety of the simplest ovariotomy; but there are many cases where the tubes and ovaries contain pus and are distended into cysts as big as a fist, or even as large as the patient’s head, which are adherent to bowel, uterus, bladder, indeed everything with which they come in contact; this renders their removal tedious and exacting for the surgeon and dangerous to the patient. Although a suppurating ovarian cyst adheres to surrounding organs, its removal is simpler than in the case of a large pyosalpinx, because the Fallopian tube is intimately enclosed within the folds of the broad ligament, and these connexions serve to bind it firmly in the pelvis.
In undertaking the removal of such enlarged tubes the surgeon’s first duty is to expose the parts by a free incision, and then carefully isolate the intestines and upper parts of the abdomen with dabs in order to prevent them from being contaminated with pus. He will quickly recognize in the majority of cases that he has to deal with tubal disease, because the distended uterine section of the tube will lie on the more globular outer portion of the tube and assume the familiar shape of a chemical retort. With the fingers the adherent omentum and bowels are carefully detached, and the adhesions between the distended tube or ovary and the rectum are carefully broken through with the finger, and the parts withdrawn from the pelvis. With great care it is usually possible to carry this out without bursting the tube. This is important as it prevents the universal spread of pus in the pelvis. When the tube bursts in the process of removal it is useful to swab it up with some strips of gauze and thus keep the ‘Gamgee dabs’ clean for the final stages.
As soon as the diseased parts are extracted, a dab is pressed into the hollow to check the oozing: the pedicle is clamped with forceps and the tube and ovary detached.
It is the common practice in dealing with inflamed and septic ovaries and tubes to transfix and ligature the pedicles as in a simple clean ovariotomy. The consequences of this practice are not satisfactory, for the pedicles being infected often give rise to trouble, because the silk acts as a seton, an abscess forms which may open up through the abdominal wound, the rectum, or perforate into the bladder, and leads to the establishment of a sinus which persists for many months until the ligature is extruded. There are several methods of avoiding this: for example, the arteries in these broad pedicles may be ligatured separately with thin silk, and the edges of the peritoneum drawn together by two or three mattress sutures (Fig. 11, p. 40).
In cases where the Fallopian tube is thickened quite up to the uterine angle, it may be exsected from the uterus: in such cases the uterine artery will be tied and the flaps at the uterine angle can be brought into apposition by a mattress suture.
In acute cases of salpingitis the cœlomic ostium is open and the infective material can be seen leaking from it (Fig. 3). In chronic cases this ostium is firmly occluded (Fig. 4). Acute cases are dangerous as they are apt to cause post-operative peritonitis. Chronic cases are difficult on account of visceral adhesions.
The most serious complication likely to arise in the enucleation of a pyosalpinx, especially on the left side, is a firm adhesion to the rectum; this may be occasionally anticipated when the patient gives a clear history of one or more sudden discharges of pus from the anus. An accidental tear of the rectum through comparatively healthy tissues may be repaired by interrupted sutures, but when the injury is in tissues altered by chronic suppuration, the only course open to the surgeon is to drain with a wide rubber tube, and it is surprising as well as gratifying to know that a fistula of this kind low in the rectum will often close in a week or ten days. It is important to bear in mind that an undetected tear into the rectum, if the abdomen be closed without drainage, will, in all probability, lead to fatal peritonitis.
It has happened that a surgeon in removing a pyosalpinx tore a hole in the rectum; he was unaware of the accident, and a few hours after the operation ordered 10 ounces of saline solution to be injected into the bowel. This fluid passed through the rent in the gut direct into the pelvis with fatal consequences.
After removing the diseased parts and securing the large vessels directly concerned in the pedicles, attention is directed to the oozing from the torn tissues in the floor of the pelvis. Any vessel which is bleeding should be ligatured with thin silk, and then the recesses of the pelvis may be firmly plugged with a dab wrung out of hot water: this is a valuable measure of hæmostasis. This dab is removed in two or three minutes, and any vessel which is bleeding is quickly seen and ligatured.
In cases where the enucleation of adherent and inflamed tubes leaves large raw and slightly oozing surfaces in the pelvis, drainage is a wise precaution. After a trial of a variety of measures for this purpose I find the simplest to be a narrow rubber drainage tube reaching to the bottom of the pelvis and emerging at the lower extremity of the abdominal incision. It is rarely required for more than forty-eight hours. Some surgeons are opposed to drainage, and one writer compares it to ‘defending oneself against the sparks of Vulcan with an umbrella’; his mortality is high.
In simple cases the incision is closed according to the method described on p. 9; but after the removal of suppurating ovaries and tubes it is better to unite the wound by a single layer of sutures through all the tissues of the abdominal wall: buried sutures in such conditions nearly always give trouble.
=Abdominal hysterectomy after bilateral oöphorectomy and ovariotomy.= After the complete removal of the ovaries and tubes the uterus is a useless organ, and when the ‘appendages’ have been removed for inflammatory lesions, acute or chronic, it may become a troublesome organ. In some instances a uterus devoid of its appendages has been attacked by cancer. In a few instances in which patients have undergone bilateral oöphorectomy, or bilateral ovariotomy, successful conception has followed the operation (see p. 17).
The most annoying consequences which follow bilateral oöphorectomy for salpingitis, acute or chronic, are hæmorrhage, pain, or a purulent discharge. Every surgeon with an ordinary experience of this class of surgery has probably had to remove the uterus on several occasions as a sequel to bilateral oöphorectomy.
It is advised by many surgeons, when they find the appendages so hopelessly diseased that they must be removed, to perform subtotal hysterectomy at the same time. My own practice in this matter is to perform subtotal hysterectomy when it is necessary to remove the uterus as well as the appendages in chronic disease; and total hysterectomy when it is deemed advisable to remove the uterus with the appendages in acute infective conditions. The reasons for this modification are obvious, because in chronic conditions there is little liability for the stump to become infected, for experience teaches that though the distended tubes contain pus in chronic cases, yet on bacteriological examination this pus is sterile. In the acute cases the pus swarms with micro-organisms--bacillus colli, staphylococcus, and occasionally streptococcus; these infect the stump, set up suppuration, infect the ligatures, and establish a chronic sinus. To cure this condition it is necessary to remove the stump by the vaginal route.
In cases of tuberculous infection of the Fallopian tubes it is not necessary to remove the uterus unless it is obviously implicated by the disease. In several patients I have left an ovary without any subsequent ill consequences.
=Mortality.= In order to estimate the risks of oöphorectomy it is necessary to classify the heterogenous conditions for which this operation is required. In the majority of cases the chief cause is inflammatory (septic) affections of the Fallopian tubes: other causes are tubal and ovarian pregnancy, and prolapse of the ovary. Tubal pregnancy is considered in a separate chapter, and as prolapse of the ovary is so often associated with retroflexion of the uterus it is dealt with in the chapter on Hysteropexy.
In order to give some notion of the relative frequency of the infective conditions of the tubes and ovaries usually classed in Hospital Reports as ‘diseased uterine appendages’, I chose one hundred consecutive operations from my case-reports at the Chelsea Hospital for Women. They are classed thus:--
Salpingitis 49 Pyosalpinx 31 Hydrosalpinx 10 Tuberculous 8 Ovarian abscess 2
In order to give some idea of the risks of unilateral and bilateral oöphorectomy, I gathered the following facts from the Hospital Reports, prepared by the Registrar. During the years 1903-7 (both years inclusive) the staff performed the operation of oöphorectomy for diseased uterine appendages on 287 women. Of these four died. During the thirteen years I have filled the post of surgeon to this hospital I have performed on an average twenty oöphorectomies yearly for the diseased conditions set forth in the above table. I lost one patient during the whole of this period, and that was in 1902. The chief risks of oöphorectomy for inflammatory conditions are undetected injury to bowel, especially the rectum, and septic peritonitis when the streptococcus is present in the tubes in acute cases.
=Operation for primary cancer of the Fallopian tube.= This disease is rarely diagnosed before operation. The treatment adopted in the cases first reported was oöphorectomy, but in the majority of patients the disease quickly returned and destroyed them in a few months.
It subsequently became the practice to remove the uterus as well as the tubes and ovaries, but a quick recurrence in these circumstances is the rule.
The really favouring factor in the case is the condition of the cœlomic ostium of the tube. When this remains open, the cancerous cells escape freely and implant themselves on the pelvic peritoneum and adjacent organs. In very rare instances the cœlomic ostium is occluded: in this happy circumstance a fairly long freedom from recurrence may be hoped for.
The relation between the condition of the cœlomic ostium of the Fallopian tube and the recurrence of cancer is illustrated by the following cases:--
A woman, fifty-seven years of age, had a large submucous fibroid in the uterus. At the operation the cœlomic ostium was not only patent, but the carcinoma protruded through it and nodules of growth could be seen on the wall of the rectum at the point where the tube rested on the bowel. The patient recovered from the operation and enjoyed good health for eleven months, then signs of recurrence became manifest and she died a few weeks later.
A woman, forty-nine years of age, had a large fibroid in her uterus and a Fallopian tube stuffed with cancer, but the cœlomic ostium was completely occluded. The uterus, ovaries, and tubes were removed. The patient subsequently remarried and was in good health three years later.
Primary cancer of the Fallopian tube is almost invariably unilateral and its association with fibroids of the uterus is unusual. It is necessary for the surgeon to remember that a cancerous Fallopian tube may lead to complications with an ovarian cyst. Our knowledge of primary cancer of the Fallopian tube has grown up within the last twenty years, and some of the recorded cases puzzled the reporters because the disease was associated with a cyst, sometimes of a large size.
In Fig. 5 I have represented an instructive specimen, which is an ovarian cyst complicated with primary cancer of the corresponding Fallopian tube. In this instance the cyst was as big as a cocoa-nut and multilocular: the ampulla of the tube is stuffed with cancer, but the ostium is patent and a ‘stream’ of cancerous material has flowed over the wall of the cyst. In addition, the cancerous material has infiltrated the wall of the ovarian cyst. The patient recovered from the operation, but a year later she had an extensive recurrence.
The primary mortality of simple oöphorectomy, or oöphorectomy combined with hysterectomy for primary cancer of the Fallopian tube, is about 5%, and this is low in comparison with abdominal hysterectomy for cancer of the cervix; it is due to the fact that tubal cancer does not so readily become septic (Doran).
REFERENCES
DORAN, A. A table of over fifty complete cases of Primary Cancer of the Fallopian Tube. Journal of Obst. and Gyn. of the British Empire, 1904, vi. 285.
BLAND-SUTTON, J. Tumours Innocent and Malignant, 4th Ed., 1906, 400.
---- On Cancer of the Ovary, Brit. Med. Journal, 1908, i. 5.
IV. OPERATIONS FOR EXTRA-UTERINE GESTATION
The systematic surgical treatment of extra-uterine gestation we owe to the genius of Lawson Tait. His first operation for this condition was performed in 1883. Tait wrote that he conceived and carried out this operation in obedience to the canon of surgery relating to the arrest of hæmorrhage, and which is valid in other regions of the body.
Many surgeons (even a butcher) had removed living, dead, and putrescent extra-uterine fœtuses from the abdomen of living women, but Tait was the first to attempt the operation in those early stages of tubal gestation in which the tube bursts, or expels (tubal abortion) the products of conception through the cœlomic ostium or a rent in the gestation-sac, into the abdominal cavity, accompanied by an escape of blood so abundant that it may destroy life in a few hours.
=Indications.= The operative treatment of extra-uterine gestation depends mainly on the stage at which it is required.
When a gravid tube is detected before rupture, the operation is practically that of oöphorectomy: and is simple and safe.
When the operation is required in consequence of the bursting, or abortion, of an early gravid tube, great promptness is often required on the part of the surgeon to prevent the patient dying from hæmorrhage, and although the operation in these circumstances is really an oöphorectomy, it often has to be performed in the patient’s room as an emergency operation and without the elaborate surroundings of a modern operating theatre.
There are few accidents which test the skill, nerve, and resource of a surgeon more than cœliotomy for a suspected intraperitoneal hæmorrhage from a gravid tube, and few operations are attended with such brilliant results. Surgeons are often astonished to find a large amount of blood in the pelvis due to a small perforation in a gestation-sac no bigger than a cherry (Fig. 7).
=Operation.= In removing tubes of this kind it is necessary to apply the ligature on the uterine side of the rent in cases of rupture of the tube, but when the rent involves the wall of the uterus the opening will require the application of a mattress suture for its complete closure. In some rare instances of the interstitial variety of tubal pregnancy, the uterus has been so involved that in order to effectually control the bleeding it has been found necessary to remove the uterus.
After the pedicle has been safely ligatured and the blood removed, the abdominal incision is sutured as described on p. 9. When the shock due to the bleeding and operation has been great, it is sometimes judicious to pour one or two pints of saline solution at the temperature of 102° F. direct into the abdominal cavity.
The majority of cases of internal bleeding from gravid tubes in the early stages are submitted to operation at periods varying from a few hours, days, weeks, or even months, after the primary bleeding.
When the tube bursts, the hæmorrhage may not be so profuse as to induce death; and the woman, recovering from the shock, does not manifest such grave symptoms as to demand surgical aid. The consequence is that the patient sometimes remains for several weeks under palliative treatment (unless a renewal of bleeding kills her), and at last she seeks surgical advice. Appreciation of the true nature of the case leads to operation.
In such cases, when the abdomen is opened, the free blood in the abdominal cavity is easily removed by sterilized dabs of absorbent material. The damaged tube and ovary are removed as in oöphorectomy. When there is much free blood care must be taken that no clots are left in the iliac fossæ. When the blood has remained in the belly for several weeks after rupture, it is judicious to insert a small drain for a few days. The importance of removing blood and blood-clot from the peritoneal cavity is demonstrated on p. 98.
Where a tubal pregnancy progresses beyond the third or fourth month and invades the broad ligament before giving trouble from internal bleeding, an operation may be necessary at any moment. At this period the operation consists in exposing the parts by a median subumbilical incision, and then opening the gestation-sac, turning out the fœtus, placenta, and clot, and controlling the bleeding by firmly packing the cavity with dabs. The edges of the sac are then stitched to the lower end of the wound; the upper part of the incision is closed, and the sac is drained with a rubber tube of suitable size and allowed to gradually heal.
In cases where the pregnancy continues beyond the fourth month to full time an operation may be required at any moment. Up to the fourth month it may be even possible, in some cases, to remove the embryo, placenta and gestation-sac on the same plan as an ovarian cyst. This is occasionally possible even when the gestation runs to term, but in the majority of cases, when the gestation has passed the fourth month and the fœtus is alive, the surgeon cannot expect to deal with the sac in this summary manner, (unless it be a cornual pregnancy) he has to reckon with the placenta.
In operating for the removal of a gravid tube in the early weeks, the surgeon may be exercised in his mind in regard to the opposite tube, for a careful study of the literature of this subject clearly shows that the patient is liable to conceive in the opposite tube, and in some instances this has happened within a few weeks of the removal of its fellow. The liability of a repeated tubal pregnancy may be fixed at 5 per cent. Moreover, in operating for tubal pregnancy, the opposite tube should be carefully examined, because both tubes may be gravid, though, as a rule, the pregnancies are of different dates. To spare a woman a recurrence of tubal pregnancy it has been urged that the surgeon should remove the opposite tube, but men of ripe experience and judgment are averse to such a proceeding, for it is an established fact that uterine pregnancy is not uncommon after unilateral tubal gestation. My own experience is in harmony with this. In some cases of unilateral tubal abortion the operator has cleared out the tubal mole and clot, and left the tube. This is not good practice: I think a tube which has once been pregnant should be removed. If the opposite tube is obviously diseased, and this happens in a small proportion of patients, it should be removed.
The method of dealing with the sac of an extra-uterine gestation after the fifth month depends in a great measure upon whether the fœtus is alive or dead. The gestation-sac after this date consists usually of the expanded tube closely incorporated with the tissues of the broad ligament, which may be thick in some parts and very thin in others. To the walls of the sac, coils of the intestine, and particularly the rectum, adhere. Experience decides that the safest plan, after exposing the gestation-sac through an abdominal incision, is to cut into it and remove the fœtus and placenta. When the fœtus is dead there will be little trouble from the placenta. The edges of the incision are stitched to the margin of the abdominal wound and drained.
In those rare cases where the amnion erodes the tube and invades the belly (ventral pregnancy), the gestation-sac, with its contents, has been successfully removed by merely transfixing its base with silk ligatures.
The great danger of operations for extra-uterine gestation after the fifth month, when the fœtus is alive, or only recently dead, is the furious bleeding which accompanies the detachment of the placenta. It may be stated that an operation for tubal pregnancy after the fifth month of gestation, with a quick placenta, is the most dangerous in the whole range of surgery. About two-thirds of the patients die. The greatest danger is hæmorrhage, and the other is sepsis when the placenta has been left to slough. It cannot be urged with too much force that when it is fairly evident that a woman has an extra-uterine gestation, it should be dealt with by operation without delay: and my experience of the operation leads me to believe that it is a wise plan to remove the placenta at the primary operation. Fortunately very few extra-uterine fœtuses survive to term.
In cornual pregnancy, or, as it is often termed, ‘pregnancy in the rudimentary horn of a so-called unicorn uterus,’ the removal of the uterus is often necessary; there is, however, a variety of this form of pregnancy in which the fully developed cornu may be spared, namely, that in which the rudimentary but gravid cornu is connected with it by a distinct and usually solid pedicle. Many such have been observed and very carefully described.
In nearly all varieties of tubal pregnancy the uterine tissues are sometimes so torn that it is difficult to arrest the hæmorrhage: in this case it is now and then a wise practice to remove the uterus.
=Concurrent intra- and extra-uterine pregnancy.= The operative treatment of this condition requires consideration under three headings:--
1. =Tubal and uterine pregnancy coexist, but the complication is recognized in the early stages.= In this condition the signs are those of an early tubal rupture or abortion (Fig. 7); in the majority of the reported cases operation has been undertaken with the impression that the trouble was simply due to tubal pregnancy, the intra-uterine gestation being detected, or in some cases merely inferred from the size of the uterus, in the course of the operation.
In these circumstances the operation is carried out as for a simple tubal pregnancy, care being taken to disturb the uterus as little as possible. In many instances such an operation has been followed by brilliant consequences, for the intra-uterine pregnancy has remained undisturbed and the patients have become the happy mothers of living children.
Occasionally the operation has been followed by miscarriage and other untoward results, but, speaking generally, a gravid uterus is very tolerant of interference.
2. =Uterine and extra-uterine pregnancy running concurrently to term.= (Compound pregnancy.) This may be described as the most dangerous combination to which child-bearing women are liable. In order to show what a disastrous conjunction it is to women with two ‘quick’ children--one intra- and the other extra-uterine--I have arranged some recorded cases in the table on p. 35. Fortunately this form of compound pregnancy is rare, but a rarer combination has been recorded by Menge, in which the extra-uterine fœtus occupied the ovary and ran nearly to term. When the woman came into labour, the ovarian pregnancy was regarded as an obstructing tumour, and preparations were made for performing cœliotomy. The intra-uterine child was born in the meantime. When the supposed tumour was extracted, to the surprise of all it contained a living fœtus. The mother and both children survived.
3. =Uterine pregnancy complicated with a sequestered extra-uterine fœtus.= This is a very rare condition, but some cases have been very carefully recorded (Leopold, Stonham, Worrall).
The physical signs are those of a pelvic tumour incarcerated by a gravid uterus. The nature of the swelling may be sometimes accurately inferred before operation, as in Worrall’s remarkable case. The sequestered fœtus should be removed by cœliotomy.
After the death of the fœtus the operative treatment of extra-uterine gestation is, as a rule, a simple proceeding, the fœtus and placenta can be easily and safely removed. We have no certain means of deciding when an extra-uterine fœtus is dead, nor do we know exactly how long after the death of the fœtus the placental circulation ceases, but we do know that in course of time, if the fœtus is retained, the placenta disappears, because in cases where the fœtus is in the condition known as lithopædion there is usually no placenta. When a retained extra-uterine fœtus is wholly or partially converted into adipocere, the tissues have a strong tendency to adhere to the walls of the sac. This is especially marked in connexion with the hairy scalp.
Although a sequestered extra-uterine fœtus is uncommon, yet a surgeon may stumble on one when he least expects it: these bodies may remain undisturbed in the pelvis many years, even fifty, and be only discovered in the post-mortem room, but they are always liable to be infected from the adjacent bowel or bladder; then suppuration is inevitable. In some instances the pus makes its escape at the umbilicus, and as the sinus persists the surgeon explores it, and, on laying it open, is surprised when he extracts the fœtus, sometimes entire.
This is sometimes referred to as ‘navel delivery’, and of this several examples have been recorded. In one such case a fœtus was extracted by a butcher: the woman recovered, and the account of this remarkable case ends thus: ‘She had a navel rupture, owing to the ignorance of the man in not applying a proper bandage’ (Phil. Trans., Abridged Edition, 1805, vol. viii, p. 517). This is a good instance of professional bias in the apportioning of blame.
Usually, when pathogenic micro-organisms gain access to the gestation-sac the fœtus decomposes, and fistulæ form, by which pus, accompanied by fragments of fœtal tissue and bones, finds an exit and affords evidence of the nature of the case. These fistulæ may open into the rectum, bladder, vagina, uterus, or some spot on the anterior abdominal wall below or near the umbilicus. The treatment is simple, and consists in dilating the sinus and extracting all the fragments. If this be thoroughly carried out the sinus quickly closes. Partial operations are useless: if but a bit of a bone remain, a troublesome sinus will persist. It is bad practice to attempt to extirpate the sac in such condition; such an operation usually terminates fatally.
In a case of old-standing lithopædion it is unusual to find any trace of the placenta. J. W. Smith operated on a woman in whom a lithopædion had caused intestinal obstruction. The fœtus had probably been retained 15-1/2 years, and the placenta was represented by a calcified encapsuled ball, with an average diameter of 6 cm.
=Results of operative treatment.= In order to afford some notion of the risks attending the surgical treatment of extra-uterine gestation, as well as to give an idea of its relative frequency in hospital practice, the following figures will serve. From 1896 to 1907, both years inclusive, 116 operations were performed for extra-uterine gestation in the Chelsea Hospital for Women. During this period all the varieties of tubal pregnancy were encountered (ampullary, isthmial, tubo-uterine), including the rare condition of a full-time living fœtus free among the intestines, and the more uncommon condition of a full-time cornual pregnancy. There were four deaths in the series, one in 1897, 1902, and two in 1905. Death in the fatal cases was attributed to pulmonary embolism, peritonitis, and in two to heart failure.
A TABLE SHOWING CASES OF CONCURRENT INTRA- AND EXTRA-UTERINE PREGNANCY (COMPOUND PREGNANCY) RUNNING TO TERM, WITH THE FATE OF THE MOTHER AND CHILDREN.
+-----------+-------+---------+--------------+--------------+ |Recorder.|Year.|_Fate of |_Intra-uterine|Extra-uterine| | | | Mother.| Child. | Child. | +-----------+-------+---------+--------------+--------------+ |Cooke | 1863 | Died | Died | Died | |Sale | 1871 | Died | Lived | Lived | |Wilson | 1880 | Died | Died | Lived | |Galabin | 1881 | Died | Died | Died | |Franklin | 1893 | Died | Lived | Died | |Matthewson | 1894 | Lived | Lived | Killed[1] | |Ludwig | 1896 | Lived | Lived | Lived | |Allardice | 1905 | Lived | ? | Dead[2] | |Menge | 1907 | Lived | Lived | Lived | +-----------+-------+---------+--------------+--------------+
[1] This fœtus was killed by means of a stilette passed through the abdominal wall of the mother into its thorax. The patient had two subsequent confinements without difficulty. In 1898 the ‘lump’ had shrunk, but was movable and caused no difficulty. Pacific Medical Journal, September, 1898.
[2] Intra-uterine child born naturally at the seventh month. Extra-uterine fœtus died, set up septic changes, and was removed by cœliotomy some weeks later.
REFERENCES
LEOPOLD. Ovarialschwangerschaft mit Lithopädionbildung von 35-jähriger Dauer. Arch. f. Gyn., 1882, Bd. xix. 210.
MENGE. Eine reine Ovarialschwangerschaft mit bebendem Kinde. Vide Fränkische Gesellschaft für Geburtshülfe and Frauenheilkunde. Münch. med. Wochensch., 1907, liv. 2452.
SMITH, J. W. Jour. of Obstet. and Gyn. of the British Empire, 1908, xiii. 180.
STONHAM, C. Lithopædion, Trans. Path. Soc., 1887, xxxviii. 445.
WORRALL. Ectopic Gestation complicating Normal Pregnancy. Abdominal section. Recovery. Med. Press and Circular, 1891, i. 296.
V. HYSTERECTOMY AND MYOMECTOMY
Hysterectomy is the name applied to the surgical operation for the removal of the uterus.
=Indications.= Hysterectomy is mainly required in the radical treatment of fibroids and malignant disease (carcinoma, sarcoma, and chorion-epithelioma). It is occasionally required for injury, and certain morbid states due to acute and chronic sepsis; and for a condition but little understood, termed generically fibrosis. Hysterectomy is also carried out for such conditions as diffuse adenomyoma of the uterus, hæmato-metra, tuberculous endometritis, and on rare occasions for chronic inversion of the uterus and inveterate dysmenorrhœa.
The presence of fibroids in the uterus is a common cause for which hysterectomy is required, and the history of this operation is full of interest.
The uterus may be removed by two methods. In one, access is obtained to the uterus through an incision in the belly-wall; this is termed abdominal hysterectomy. In the other, the whole uterus is extirpated through the vagina, and on this account it is termed vaginal hysterectomy or colpo-hysterectomy.
The abdominal method of removing the uterus may be performed in two ways:--
In one the body of the uterus and a portion of its neck is removed; this is called subtotal hysterectomy (or supravaginal hysterectomy). In the other the body of the uterus and the whole of its neck are excised: this is total hysterectomy (or panhysterectomy). The ovaries and Fallopian tubes may, or may not, be removed, according to the disease for which the operation is undertaken. This is a matter which will receive ample consideration later on (see p. 56).
For the satisfactory performance of abdominal hysterectomy the Trendelenburg position is necessary.
SUBTOTAL HYSTERECTOMY
The abdomen is opened by the median subumbilical incision; but when the operation is performed for the removal of large tumours it will frequently require extension above the umbilicus. The operator should never allow himself to be embarrassed by a small incision. As soon as the peritoneal cavity is reached, the surgeon introduces his hand and carefully makes out the nature of the case, the presence or otherwise of adhesions, other tumours, and the relation of the fibroid to the uterus, and determines whether it is impacted in the pelvis. The uterus is then carefully lifted out through the incision, or drawn out with the assistance of a volsella; the intestines and omentum are isolated from the pelvis with a large warm dab.
In a simple case the broad ligaments are seized with hæmostatic forceps; if the ovaries and tubes are healthy and the surgeon wishes to preserve them, the forceps are applied between the ovary and the uterus; but if they are obviously diseased and must be sacrificed, the forceps are applied to the broad ligaments near the brim of the pelvis beyond the outer pole of the ovary. In some instances the round ligament of the uterus can be seized with the same forceps, but in many cases it is necessary to clip it separately. It is an advantage to secure the round ligament at this stage, for the forceps controls its artery and prevents the stump of the ligament unduly retracting the peritoneum. The broad and round ligament on each side are divided, and the uterine artery is exposed on each side of the uterus and caught with forceps: a peritoneal flap is then fashioned on the anterior wall of the uterus at its junction with the neck, taking care not to injure the bladder; and a similar flap is cut on the posterior wall. The uterus is then detached at a point well below the junction of the cervix with the body of the uterus: if the forceps are correctly applied to the vessels the detachment of the uterus is an almost bloodless proceeding: a small vessel here and there will perhaps require the application of a pair of forceps.
The principle involved in this part of the operation may be explained by reference to the diagram (Fig. 9). The blood-supply of the uterus follows four routes; two of these are the ovarian arteries which traverse the broad ligaments to reach the cornua of the uterus, where they anastomose with the terminations of the uterine arteries; the latter come into relation with the uterus near the junction of the body and cervix, and then ascend the sides of the uterus to the cornua. No large vessels are found on the anterior or posterior surface of the uterus. An arterial twig runs along the round ligament, bringing the ovarian artery into relation with the deep epigastric artery. If the surgeon thoroughly appreciates the distribution of the ovarian and uterine vessels he will at once perceive that if the four forceps are properly applied to the vessels the blood-supply is under absolute control: indeed, in many cases a subtotal hysterectomy can be performed without the loss of more than an ounce of blood. When the broad ligament is clamped and detached there is a spurt of blood from the uterine cornu which lasts until the corresponding uterine artery is caught with the forceps, and the cessation of the bleeding at the uterine cornu is a sign that the artery is securely clipped. It must be remembered that with a small tumour in the uterus the vessels follow their normal courses and can be easily found, but when the uterus is deformed by huge tumours, the vessels are not so easily seen, and they are of large size and give rise to furious bleeding when divided. In dealing with large and vascular uterine fibroids another factor has to be reckoned with, namely, the enormous veins in the pampiniform plexus, interspersed with lymphatics which in some cases are as thick as the index-finger; it is not an uncommon thing to meet with lymphatics in this situation a centimetre in diameter and filled with straw-coloured lymph.
The surgeon now secures the vessels. The ovarian pedicles are transfixed and ligatured with silk as in ovariotomy: the round ligament is usually included in the ovarian pedicle. It occasionally happens that a fibroid situated near the uterine cornu will grow in such a manner that it widely separates the ovarian ligament, the Fallopian tube, and the round ligament from each other as shown in Fig. 10. In such a condition it is impossible to save the ovary without risk, and also inadvisable to attempt the inclusion of the round ligament in the pedicle containing the ovarian vessels. In these circumstances the round ligament is easily secured by a mattress suture, which should include both layers of the corresponding broad ligament.
When the surgeon decides to leave an ovary and the corresponding Fallopian tube, these structures are carefully examined to determine if they are healthy and free from any suspicious fluid. When the endometrium is septic or cancerous both ovaries and tubes should be removed. When the surgeon decides to leave an ovary and its corresponding Fallopian tube, he should take care in securing the ligatures to include the ligament of the ovary: it is very liable to slip out of the encircling loop of silk. It is often convenient to include the round ligament of the uterus in the pedicle, but it is not a disadvantage when it is tied separately.
The uterine arteries are ligatured with thin silk; these vessels as they run up the sides of the uterus are accompanied by veins, so that there is a vascular tract at the point where the cervix is divided. If after the uterine vessels are secured there is oozing from these veins, it is easily controlled by a mattress suture. This kind of suture is so useful that the mode of inserting it may be given in more detail. In the diagram (Fig. 11) the silk is represented in position before it is tied, and in that particular instance it is represented as being passed through the peritoneal flaps from before backwards, and this is usually the most convenient route; occasionally the reverse direction is easier. It will be noticed in the diagram that this suture not only controls oozing from the tissue in the immediate neighbourhood of the uterine vessels, but it also embraces the main vessels, and thus serves as an additional security against hæmorrhage; it also brings the peritoneal flaps into apposition.
As soon as the oozing of blood has been controlled, the cervical canal is examined to ascertain if it be free from polypi or cancer. Should the condition of the cervix be in the least degree suspicious of cancer it must be extirpated. When it is healthy, then the flaps are brought together by one or two interrupted sutures, and the edges more carefully approximated by a continuous suture of thin silk. In suturing the flaps it is necessary to avoid puncturing the bladder, which is quite close to, and often forms part of, the anterior flap. Care must also be taken in passing the needle (especially when it has sharp edges) in the neighbourhood of the stumps of the uterine arteries, or they will be pricked, and then free bleeding will cause delay in the operation.
When this operation is properly performed, there should be no projecting stump on the floor of the pelvis; the sutured edges of the peritoneum merely appear as a thin line below the base of the bladder.
The pelvis is now cleared of blood and clot; the dabs and instruments are counted, and it is also useful to examine the condition of the vermiform appendix, and if grossly diseased it should be removed.
The abdominal incision is then sutured in the way described on p. 9.
TOTAL HYSTERECTOMY
This operation differs from the preceding in the fact that the neck of the uterus is removed as well as its body. The abdomen is opened in the usual way and the uterus is withdrawn from the abdomen and the arteries controlled by forceps, and the broad ligaments divided exactly as in the case of the subtotal operation. Unless the uterus be very big it is drawn well out of the abdomen and the bladder peeled off its anterior aspect. The surgeon then feels for the extremity of the cervix and opens the vagina with the scalpel and carefully detaches it from the neck of the uterus, taking great care to keep close to the cervix in order to avoid wounding the bladder or the ureters. As soon as the uterus is detached, the cut edge of the vagina is seized with the volsella to prevent it retracting. In some instances the body of the uterus may be removed as in the subtotal operation, and the cervix detached separately; occasionally the surgeon begins his operation with the intention of performing the subtotal operation, but finds the cervix unhealthy or cancerous, and removes it.
As soon as the uterus is removed and all bleeding under control, then the blood-vessels are secured with ligatures; the ovarian artery and vein are secured on each side in the usual manner. The chief point in this operation is the method of dealing with the vaginal opening. In the subtotal operation the vessels concerned in the stump are the uterine arteries, but in the total operation the territory of the vaginal arteries is invaded, and these vessels are apt to bleed when the patient is returned to bed, unless care is taken to secure them in the course of the operation. The parts which require most attention are the lateral angles in the immediate neighbourhood of the uterine arteries; these angles may be secured by a mattress suture involving the anterior and posterior wall of the vagina; any oozing on the anterior or posterior wall is commanded by a mattress suture involving these walls separately, so as not to completely close the vaginal opening. Bleeding from the cut edges of the vagina may also be readily controlled by means of a continuous suture of thin silk. The peritoneum is sutured over the cut ends of the vagina, so that when the operation is completed a thin seam is seen lying under the base of the bladder.
In cases where the uterus is removed for septic conditions, such, for example, as an infected or gangrenous fibroid, or when cancer of the corporeal endometrium and a submucous fibroid coexist, I modify the last stages of the operation. After the ovarian and uterine arteries are ligatured, the cut edges of the vagina are secured in the following way: the cut edge of the peritoneum covering the bladder is stitched to the cut edge of the anterior wall of the vagina, and in the same way the peritoneum in relation with the posterior vaginal wall is stitched to the corresponding cut edge of the vagina. The flaps at the lateral angles of the vaginal opening are drawn together with a suture and the intervening segment is left with merely the cut edges in apposition: this affords a route for the escape of pus if required.
Whether the peritoneum is sutured over the vaginal opening, or whether the edges are merely left in apposition, the recesses of the pelvis are thoroughly cleared of fluid and clot. The dabs and instruments are counted, and the wound sutured as recommended on p. 9. In septic conditions the abdominal incision should be closed with a single row of through and through sutures. Before the patient leaves the operating table it is useful to examine the vagina and mop out any blood which has found its way there in the course of the operation. It is also useful to pass a glass catheter and withdraw any urine that has accumulated during the operation.
If there is evidence of free oozing it is most likely to come from the cut edges of the vaginal wall in a case of total hysterectomy: under such conditions it is easy to apply a pair of fenestrated forceps to the oozing area and leave them on for thirty-six hours. They will cause the patient trifling inconvenience. Care must be taken not to fix the blade too far on the anterior flap, or it will lead to subsequent sloughing of the bladder.
When there is free oozing of blood from the cervical canal after subtotal hysterectomy, it is easily and safely controlled by applying a pair of fenestrated forceps on each side of the cervix, but not too deeply, or the ureters may be nipped. These should be left on for thirty-six hours.
The details of the operation set forth in this account refer to a simple or uncomplicated hysterectomy, and under these conditions it cannot be described as a difficult operation to any surgeon accustomed to abdominal operations, but the complications not infrequently met with in connexion with uterine fibroids are occasionally very formidable, and tax the skill and resource of the boldest; e.g. fibroids which are inflamed and adherent to the colon, rectum, or small intestines; fibroids associated with unilateral or bilateral pyosalpinx, or a suppurating ovarian cyst incarcerated in the pelvis by the enlarged uterus; fibroids complicated by cancer in the neck of the uterus; or a cervix fibroid firmly incarcerated in the pelvis by a big fibroid in the fundus of the uterus, and pushing the bladder upwards in front of the tumour.
=Cervix fibroids.= The operative treatment of this variety needs separate consideration because these tumours do not lend themselves to any routine method.
When the uterus with the tumour in its cervix can be raised out of the pelvis far enough to allow the necessary manipulations, then total hysterectomy can be performed easily and quickly. Occasionally the tumour is wide and so fixed in the pelvis that it will be necessary to split the uterus longitudinally and to enucleate the fibroid from its bed; then an ordinary subtotal or total hysterectomy can be carried out. The enucleation of a large impacted cervix fibroid requires to be conducted carefully, without undue display of force, or so much shock is produced that the patient’s life will be placed in the gravest peril.
=On hysterectomy when the uterus is double.= Fibroids and cancer arise in malformed uteri, as well as in those of normal shape (Fig. 13). When the body of the uterus is double (bicornate) and the surgeon stumbles upon it in the course of a pelvic operation he may be puzzled if he is not familiar with the anatomical conditions associated with this malformation.
When the body of the uterus is bicornate the rectum lies in the middle line of the pelvis, and a median vertical fold of peritoneum, the ligamentum vesico-rectale passes, from its anterior aspect through the gap between the uterine cornua to become continuous with the peritoneum covering the posterior surface of the bladder (Fig. 14). That portion of the vesico-rectal ligament which lies between the rectum and the neck of the uterus divides the recto-vaginal fossa into a right and a left half. This peritoneal ligament requires careful treatment, or the surgeon may accidentally open the rectum or the bladder. In closing the peritoneum over the cervical stump it is sometimes necessary to bring the edges of the abnormal fold into apposition vertically by a continuous suture.
In a case of this kind in which I performed total hysterectomy for cancer of the neck of the uterus the extensive peritoneal connexions were somewhat troublesome, and when the uterus was removed it seemed as if the floor of the pelvis had been stripped of its serous covering. The bifid nature of the uterus had been anticipated before the operation, as an imperfect vertical septum was known to exist on the posterior vaginal wall. The patient made an excellent recovery.
Experience teaches that bicornate uteri cause more difficulties in diagnosis than in technique, but the presence of the vesico-rectal ligament would probably bar the removal of the uterus by the vaginal route. The existence also of a median longitudinal septum, partial or complete, in the vagina would be another difficulty.
=Mortality.= In order to give some idea of the great improvement which has taken place in the operation of abdominal hysterectomy for fibroids in London the following figures will be found of great interest.
In the year 1896 the results of abdominal hysterectomy for fibroids in the hospitals of London may be inferred from the following table:--
St. Bartholomew’s 7 with 3 deaths St. Thomas’s 5 " 2 " St. George’s 1 " 0 " Middlesex 6 " 1 " University College 3 " 0 " Samaritan 17 " 4 " Soho (for women) 1 " 0 " Chelsea Hospital for Women 9 " 1 " __ __ 49 " 11 "
In these hospitals and the New Hospital for Women the returns in 1906 are as follow:--
St. Bartholomew’s 26 with 4 deaths St. Thomas’s 40 " 2 " St. George’s 8 " 0 " Middlesex 50 " 0 " University College 21 " 1 " Samaritan 37 " 2 " Soho (for women) 60 " 1 " Chelsea (for women) 80 " 1 " New (for women) 26 " 0 " ___ __ 348 " 11 "
The returns during 1906 and 1907 from my service at the Chelsea Hospital for Women and the Middlesex Hospital, as verified by the Registrars, were 101 abdominal hysterectomies for fibroids; all the patients recovered. Of these 101 operations, 7 were total and the remainder subtotal hysterectomy.
=The risks of abdominal hysterectomy.= The dangers of hysterectomy are those common to cœliotomy, such as sepsis, peritonitis, shock, and the risks of the anæsthetic. There are certain special dangers, such as hæmorrhage; injury to the vesical segments of the ureters, and especially the bladder; injury to the intestines, especially the rectum; acute intestinal obstruction; thrombosis and pulmonary embolism. These risks and dangers are considered fully in their relation to all forms of abdominal gynæcological operations in a special chapter (see Chap. XI).
Among the rarer forms of death after hysterectomy may be mentioned acute perforation of the stomach or the small intestine, cerebral hæmorrhage, lobar pneumonia, thrombosis of the right auricle, embolism of the femoral artery ending in gangrene of the leg, suppression of urine, and acute mania. These are fatal conditions which follow any major operation in surgery, and have no special connexion with hysterectomy.
The removal of the uterus has been rendered so safe that even in advanced age it has been employed with success, as the subjoined table shows:--
TABLE OF CASES IN WHICH HYSTERECTOMY WAS PERFORMED ON WOMEN OF SEVENTY YEARS AND UPWARDS.
-----------+------+----------------+---------+----------------------- Reporter.|Age.| _Nature of |Result.| Reference. | | Operation._ | | -----------+------+----------------+---------+----------------------- Bland- | 73 |Subtotal for | R. |Trans. Obstet. Soc., Sutton | | Fibroid 28 lb.| | 1900, xli. 300. Stewart | 70 |Subtotal for | R. |Australian Med. Gaz., McKay | | Fibroid 19 lb.| | 1907, 14. Bland- | 83 |Vaginal Hyst. | R. |Trans. Obstet. Soc., Sutton | | for Villous | | 1906, xlix. 46. | | disease. | | | | Fig. 15. | | Malcolm | 74 |Total for | R. |Brit. Med. Journal, | | Fibroids. | | 1907, ii. 1571. -----------+------+----------------+---------+-----------------------
ABDOMINAL MYOMECTOMY
Under this general term it is usual to include operations for the removal, through an abdominal incision, not only of pedunculated subserous fibroids, but also sessile and interstitial (intramural) fibroids of the uterus.
The earliest operations of this kind were performed by Spencer Wells (1863); but little attention was given to this matter until the advantages of abdominal myomectomy were strongly advocated by A. Martin (1880) and Schroeder (1893). The operation has been practised by many surgeons and gynæcologists imbued with conservative ideals in regard to the uterus. In its early days the operation was attended with a very high mortality, but the great improvements in hysterectomy have limited very materially the scope of abdominal myomectomy.
ABDOMINAL MYOMECTOMY AND ENUCLEATION FOR FIBROIDS
Abdominal myomectomy. This signifies the removal of one or more pedunculated subserous fibroids through an incision in the abdominal wall, preserving the uterus, Fallopian tubes, and the ovaries.
Abdominal enucleation. In this operation a sessile fibroid is shelled out of its capsule: the uterus, ovaries, and tubes are preserved.
Hysterotomy. In this operation a submucous fibroid is removed, through an incision in the wall of the uterus, which opens the uterine cavity.
The preliminary steps for each of these procedures is the same as for ovariotomy, and the Trendelenburg position is of great advantage.
After opening the abdomen the intestines are carefully protected by a warm dab, and the tumour carefully examined.
When the stalk is narrow it may be transfixed and secured with silk thread, like the pedicle of an ovarian cyst. When the pedicle is short and broad the tumour should be shelled out of its capsule, and any obvious blood-vessel is easily secured with forceps and ligatured with silk. The opposite flaps of the capsule are brought into apposition by mattress sutures, and the redundant portions of the capsule cut away and the free edges carefully brought together by a continuous suture of thin silk.
When a fibroid is embedded in the wall of the uterus, the tumour is exposed by cutting through its capsule and seizing it with a volsella; as a rule, it shells out quite easily. This is followed by free bleeding. The vessels are then seized with forceps and ligatured with thin silk. In order to completely control the oozing, mattress sutures are passed through the wall of the capsule on each side, their number varying with the size of the tumour.
In some instances a uterus contains ten or more fibroids, and each must be enucleated and the capsule secured with ligatures, as described above.
Sometimes the oozing is difficult to control, and the surgeon sutures the edges of the capsule to the lower angle of the incision, and stuffs the cavity or bed of the tumour with gauze.
In removing a large submucous tumour through an incision in the wall of the uterus, the surgeon necessarily opens the uterine cavity (hysterotomy). After controlling the bleeding the walls of the uterine incision are closed, as in Cæsarean section.
In many instances in which the surgeon attempts to carry out myomectomy or enucleation, he has such difficulty in controlling the oozing that he is driven to remove the uterus.
It is admitted by most writers that the ideal method of dealing with fibroids requiring removal by cœliotomy is to remove them either by ligature or by enucleation. In actual practice this ideal operation of removing the tumours and leaving the uterus and ovaries intact can only be carried out in a small proportion of cases, probably in less than 10 per cent., and it is fair to state that enucleation and hysterotomy are often more troublesome and serious operations than hysterectomy; also the preservation of the uterus is not always an advantage to the patient.
When a woman is submitted to hysterectomy for fibroids we can assure her that the tumours will not recur, but after a myomectomy or enucleation in a woman in the reproductive period of life we cannot give her this assurance, for she may have in her uterus many ‘seedlings’ or ‘latent fibroids’ and one or several of these may grow into formidable tumours.
There are three conditions in which myomectomy and enucleation are legitimate procedures:--
1. A young woman contemplating marriage, or a married woman anxious for offspring, if her tumour be single and admits of myomectomy or enucleation, may have her uterus spared. Although I have carried out these measures on many occasions, I only know of five patients who have subsequently borne children.
2. Occasionally in pregnancy (see p. 82).
3. Myomectomy is a very safe undertaking in patients at, or after, the menopause, where a stalked fibroid gives trouble by twisting its pedicle, or by shrinking to such a size that it falls into the true pelvis and becomes impacted; or, more rarely, the pedicle of such a tumour entangles a loop of small intestine and obstructs it.
In order to give the matter a statistical basis I have drawn up an analysis of ninety-five consecutive cases of myomectomy and enucleation out of my practice, with the subsequent history of some of the patients. This experience covers a period of twelve years.
Of these ninety-five patients three died as the result of the operation--two from pneumonia in the fourth week after operation, and one a few days after operation: in this case there is reason to believe that the tumour was complicated with cancer of the body of the uterus.
Six of the women were submitted to myomectomy during pregnancy, and in four cases the operation was undertaken under the impression that the tumour was an ovarian cyst which had undergone axial rotation. These cases occurred in the days before I recognized that ‘red degeneration’ of fibroids complicating pregnancy caused them to be painful and tender (see p. 78). In one patient this complication was clearly recognized. In the sixth patient the tumour was regarded by some capable gynæcologists, who examined her, as a tubal pregnancy complicating a gravid uterus. Five of these patients went to term and were delivered of living children. The sixth miscarried two months after the myomectomy.
Of the ninety-two successful myomectomies, five subsequently became pregnant and had living children, but in each instance the fibroids were subserous. I have not known a patient to become pregnant after abdominal myomectomy for a submucous fibroid, large or small. In calculating the probability of pregnancy from these statistics it must be mentioned that the patients fall into three categories:--
1. Forty women were in the child-bearing period of life and married; many of them were multiparæ.
2. Twenty were single women and probably capable of bearing children in a favouring environment.
3. The remainder were spinsters or barren wives.
A significant feature in the after-history of ten of these women is the fact that some years later other fibroids grew in the uterus, and hysterectomy became a necessity on account of menorrhagia in seven of them; of these, two died from the operation, which was difficult and tedious. One patient was operated upon two years after the myomectomy, and had borne a child in the interval, and the other seven years.
The last fact to mention is that one patient, from whom a submucous fibroid had been enucleated from the cavity of the uterus (hysterotomy), died four years later from cancer arising in the body of the uterus (see p. 51).
Olshausen has recently considered this question, and indicates that the chief objection to the abdominal enucleation of uterine fibroids is its high mortality.
He furnishes a table of 563 cases, collected from twelve operators, including himself; of these 59 patients died, representing a mortality of 10.5 per cent. Olshausen, in the years 1900-5, performed enucleation on 124 patients with 14 deaths. Eight of the patients subsequently came under notice with recrudescence of fibroids. Christopher Martin has performed abdominal myomectomy 73 times with 1 death.
The question of myomectomy, when fibroids complicate pregnancy and labour, or give trouble after labour, is considered in detail on p. 78.
REFERENCES TO REPORTS OF HYSTERECTOMY PERFORMED FOR FIBROIDS IN MALFORMED UTERI
BLAND-SUTTON, J. Fibroids in a Unicorn Uterus. Clin. Journ., Lond., 1901-2, xix. 1.
BLAND-SUTTON, J. Case of Fibroids in both halves of a Bicornate Uterus. Proc. R. Soc. of Medicine, 1908. Obstet. and Gyn. Sect., ii. 95.
CZERWENKA. Uterus bicornis unicollis, &c. Centralbl. f. Gyn., Leipz., 1900, xxiv. 207.
DORAN, A. The Removal of a Fibroid from a Uterus Unicornis in a Parous Subject. Brit. Med. Journ., 1899, i. 1389.
GOW, W. J. Cystic Intraligamentous Myoma with Double Uterus. Trans. Obstet. Soc., Lond. (1898), 1899, xl. 134.
HEINRICIUS. Ein Fall von Myoma im rudimentaren Uterus bicornis unicollis. Monatschr. f. Geburts. u. Gyn., Berl., 1900, xii. 419.
KAMANN. Uterus bicornis unicollis with a Myoma in the Left Horn; Subtotal Extirpation of the Left Horn. Centralbl. f. Gyn., 1905, xxix. 795.
MARTIN C. The Ingleby Lectures. On the Dangers and Treatment of Myoma of the Uterus. Lancet, 1908, ii. 1682.
OLSHAUSEN, R. In Veits’ Handbuch der Gynäkologie, Wiesbaden, 1907, Bd. ii, p. 607.
ROUTH, A. Fibroid of One-horned Uterus. Trans. Obstet. Soc., 1888, xxix. 2 and 57, with a good drawing.
VI. ON THE RELATIVE VALUE OF TOTAL AND SUBTOTAL HYSTERECTOMY
The great success which followed the use of the short ligature in ovariotomy induced several surgeons to apply the same principle to the cervical pedicle when removing the uterus for fibroids. The result was dismal failure. Matters improved somewhat after Koeberlé introduced the serre-nœud, and this continued the safest method until 1892. In the meantime antisepsis had begun to take effect in pelvic surgery, and attempts were made by Bardenheuer (1881), Polk, and other surgeons to avoid the dangerous difficulties connected with the treatment of the stump by removing the cervix as well as the uterus (total hysterectomy), and they attained an encouraging measure of success. Nevertheless, other surgeons (Goffe, Milton, Heywood Smith, and Stimson) felt that the enucleation of the cervix was not always necessary, and sought to find a way of avoiding it. The credit of solving this difficulty fell to Baer of Philadelphia (1892), for he showed that it is dangerous to constrict the neck of the uterus with ligatures, it is only necessary to secure the arteries.
Baer’s method of supravaginal hysterectomy, or, as it is now commonly termed, the subtotal operation, soon supplanted the total method of Bardenheuer. The publication of Baer’s paper had great consequences; it came at a time when the attention of gynæcologists was centred on improvements in hysterectomy. The method was promptly tested and adopted in London. The effects of this improvement in technique in a few years revolutionized the surgical treatment of uterine fibroids, as the statistical results set forth on p. 44 amply prove.
The great advantage of Baer’s method is its simplicity and safety; but there is a disposition on the part of a few surgeons to prefer the total operation, mainly on the ground that the cervical stump left after subtotal hysterectomy is liable to become attacked by cancer.
As far as I can ascertain, Dr. M. Mann, of Buffalo, was the first to draw attention to the occurrence of cancer in the neck of the uterus after the body of the organ had been removed. He stated in 1893 that he ‘removed an ovarian tumour and the body of the uterus, by accident, along with it; the cervix was left’. The patient recovered. ‘Six months afterwards cancer developed in the cervix, from which she died.’
When cases of cancer supposed to arise in the stump left after subtotal hysterectomy come to be critically analysed, they fall into four groups:--
1. The disease existed in the neck of the uterus at the time of the primary operation, but was overlooked. 2. Cancer attacked the cervical stump subsequent to subtotal hysterectomy. 3. The fibroid which necessitated the hysterectomy was really a sarcomatous tumour of the uterus. 4. The suspected growth on the cervix is not malignant, but a granuloma.
Each of these postulates requires separate consideration.
Many observations have been published which show beyond dispute that surgeons have performed subtotal hysterectomy in ignorance that the cervix was already cancerous, and the hæmorrhages of which the patients complained before the operation were due as much to the cancer in the neck of the uterus as to the fibroids. This should serve as a warning that, in cases where the surgeon contemplates performing a subtotal hysterectomy, he should carefully examine the cervix beforehand; at the time of the operation he should also critically examine the cut surface of the cervix, and if it be in the least suspicious he should remove the neck of the uterus. It is necessary to remember that cancer attacks any part of the cervical endometrium, therefore an early cancerous ulcer in the middle of the cervix will run a great chance of being missed by a surgeon who is content with a subtotal hysterectomy.
It is certain that cancer does occasionally attack a cervical stump left after subtotal hysterectomy at such an interval after the operation as to make it certain that the cancer did not exist at the time of the operation. Such a case occurred in my practice. I performed subtotal hysterectomy in 1901 on a woman forty-two years of age, mother of one child; eighteen months later there was a cancerous ulcer on the cervix; the whole of the cervical stump was promptly removed and the nature of the disease established microscopically. In 1908 the patient was in excellent health.
In another case under my care I performed total hysterectomy for fibroids in ignorance that the patient had cancer of the cervix. Some months after the operation cancer recurred in the vaginal vault and scar of the hysterectomy; the neck of the uterus had been preserved by the doctor, and on examination the cancer was found. In this instance, although total hysterectomy was performed, it had no effect in staying the course of the disease.
It is necessary to utter a caution in regard to the occurrence of cancer of the cervix after subtotal hysterectomy. I removed a uterus containing a large globular submucous fibroid from a barren married woman forty-five years of age. Six years later she came under my observation with a large granulating and bleeding growth on the cervix uteri. I had no doubt from the naked-eye characters that this was a primary carcinoma, although it surprised me to find it there, especially as the woman had never been pregnant. On my urgent representations she allowed me to remove the cervix. On microscopic examination the suspected cancer turned out to be a granuloma. Two years later the patient was in good health. Polk has recorded a similar experience. These facts show that caution is necessary in accepting reports of cancer of the uterine stump after subtotal hysterectomy.
=Cancer of the body of the uterus and fibroids.= In deciding between total and subtotal hysterectomy for fibroids the probable presence of cancer requires consideration in another aspect. Although uterine fibroids do not predispose to cancer of the neck of the uterus, many writers in recent years have expressed their suspicions that the presence of a submucous fibroid favours the development of cancer in the corporeal endometrium. Piquand, in 1905, drew attention to this matter and emphasized what other observers had pointed out, namely, that a submucous fibroid is often associated with changes in the mucous membrane of the uterus, which not only causes excessive bleeding, but sets up inflammatory conditions giving rise to leucorrhœa, salpingitis, pyosalpinx, and morbid changes in the endometrium, rendering it susceptible to cancer. His statistics support his conclusions, for they represent that in one thousand women with fibroids fifteen will probably have cancer of the body of the uterus. My own observations support this opinion. This complication is found most frequently between the fiftieth and the sixtieth year of life. If we narrow the ages of the patient and exhibit the liability in its most emphatic form it would run thus: that in patients submitted to hysterectomy for fibroids over the age of fifty years, about ten per cent of them will have cancer of the corporeal endometrium.
In 1906 I looked through the case-notes of five hundred patients who had been submitted to operation for uterine fibroids under my care. Of these sixty-three patients had attained the age of fifty years and upwards. Among these sixty-three women there were eight cases of cancer of the corporeal endometrium; the nature of the disease in each case was verified by careful microscopic examination.
Consequently, in performing subtotal hysterectomy for fibroids in women of fifty years and upwards, the surgeon should have the uterus opened immediately after its removal and assure himself that the endometrium is free from cancer. If there be any suspicion in this direction he should remove the cervix.
=Sarcoma.= The most insidious danger which besets the surgeon in dealing with fibroids of the uterus is the occurrence of an encapsuled sarcoma in the guise of an innocent fibroid. I have for some years dropped the name of myoma for these common uterine tumours, preferring to apply the term fibroid in a generic sense to all encapsuled tumours of the uterus. Every histological condition is found in them, from the hard calcified body looking like a block of coral to a soft diffluent collection of œdematous connective tissue, and tumours composed of tissue indistinguishable from spindle-celled sarcomata.
I have elsewhere recorded briefly a case in which I removed the uterus from a woman forty years of age, which contained a fibroid as big as an ostrich’s egg. On section it appeared to be a moderately firm fibroid, with its tissue whorled as is usual in hard fibroids and enclosed in a complete capsule. Some months later the patient complained of pain, and on examination a hard mass occupied the floor of the pelvis; a portion of this was excised and submitted to three competent histologists, who reported the growth to be an innocent fibroid. The patient died fourteen months after the primary operation with her pelvis filled with recurrent growth. The tumour was a spindle-celled sarcoma.
Much has been written regarding the sarcomatous degeneration of fibroids. In this matter I have maintained an attitude of active scepticism. My experience amounts to this: the case which I have briefly described is the only example in a thousand cases of hysterectomy in which an encapsuled sarcoma in the guise of an innocent fibroid has come under my observation, therefore I come to the conclusion that it is an uncommon event, and on turning to the literature of the subject it will be found that unequivocal examples are few.
From a careful study of the question, I have formed the opinion that if a woman with fibroids and concomitant cancer of the neck of the uterus seeks advice on account of hæmorrhage, and the cancer has attacked the vaginal portion of the cervix, the nature of the case will be appreciated. The cases likely to be overlooked are those where the cancer is situated somewhat higher in the cervical canal than usual, so that it is not easily detected by the examining finger, and so low in the cervix that the disease is not exposed when the body of the uterus is amputated in the course of a subtotal hysterectomy. A knowledge of this, as well as the fact that cancer of the cervix is almost exclusively a disease of women who had been pregnant, should make the surgeon particularly careful in performing subtotal hysterectomy for fibroids in women who have had children, in order to assure himself that it is not cancerous.
In addition to the liability of the stump left after subtotal hysterectomy to become cancerous, it is stated by some surgeons that the patient is more liable to intestinal obstruction than after the total operation. This objection is easily met, because a perusal of their writings shows clearly that they do not perform the operation properly. In subtotal hysterectomy, performed according to Baer’s instructions, there should be no stump projecting from the pelvic floor, but merely a thin seam underlying the base of the bladder.
I have dealt in detail with these two methods of hysterectomy, because when it can be performed subtotal hysterectomy is, as a rule, a simpler operation than total hysterectomy. There are conditions in which it is imperative to remove the whole of the cervix, especially when the canal is very patulous and perhaps septic; when it is large and hard, or large and spongy; and especially if there is the least suspicion of malignancy in the cervix, or in the body of the uterus.
It must, however, be borne in mind that cancer has attacked the scar left in the vagina after a total hysterectomy (Quénu). At the present time the subtotal method enjoys the greatest favour in London, but it must be remembered that where the total operation is most indicated, it is often difficult of execution. Although I have a decided preference for the subtotal operation, especially in spinsters and barren wives, I have performed total hysterectomy in more than 200 patients, so that I am in no way blind to its merits.
=Cancer of the uterus after bilateral ovariotomy.= The uterus, after complete removal of both ovaries, is not only a useless organ, but it may become attacked by cancer. Blacker reported a case in which a woman, thirty-nine years of age, underwent bilateral oöphorectomy for a uterine fibroid: eight years later cancer attacked the neck of the uterus and destroyed the patient.
In 1902 I performed abdominal myomectomy on a woman forty-seven years of age, and removed both ovaries and Fallopian tubes; the latter contained pus. Four years later this patient came under observation with extensive cancer of the cervix.
In 1901 a patient had bilateral ovariotomy performed; five years later she complained of severe uterine hæmorrhage. I removed the uterus by the abdominal route (total hysterectomy). The corporeal endometrium was cancerous throughout. The patient survived the operation six months. Similar cases have been recorded by Martin, Butler-Smythe, and Playfair.
=Adenomyoma of the Uterus.= This disease has not received adequate recognition at the hands of British surgeons, yet it is a condition which occasionally causes much doubt in the surgeon’s mind in the course of hysterectomy. This adenomyomatous change affects the endometrium and is, in some cases, associated with interstitial and subserous fibroids: it causes often great enlargement of the uterus, and under these conditions the fundus can be felt high in the hypogastrium. The patients are often profoundly anæmic as the result of long-continued menorrhagia. The physical and clinical signs of the disease are those present in patients with a large degenerating submucous fibroid. Indeed the surgeon often removes the uterus under this impression, and, after the operation is completed, when he divides the uterus expecting to see the usual encapsuled tumour, to his surprise finds a uterus with greatly thickened walls (Fig. 16).
Microscopically the adventitious material is made of irregular tracts of endometrium containing glands and strands of unstriped muscle tissue.
It is important for the surgeon to recognize these cases because, contrary to the rule with simple uterine fibroids, these adenomyomatous uteri are often adherent to the adjacent bowel and to the bladder: in connexion with this fact several observers have pointed out that uteri affected with this disease are often associated with inflammatory affections of the Fallopian tubes, and there are good reasons for the belief that the adenomyomatous change has a microbic origin. In this connexion it is worth mention that adenomyomatous uteri are sometimes tuberculous (Fig. 17). Some examples of this disease have been mistaken for cancer of ‘the body of the uterus’.
In this disease subtotal hysterectomy gives admirable results, immediate and remote.
THE FATE AND VALUE OF BELATED OVARIES
The only improvement of any importance made in Baer’s operation of subtotal hysterectomy concerns the ovaries. These Baer removed with the Fallopian tubes, but in 1897 I advocated, at the Obstetrical Society, London, that they were of great value to the patient, and pointed out that their conservation, when healthy, spared the patient the annoyance of that curious vaso-motor phenomenon, known to women as ‘flushings’, which is the only obtrusive sign of the menopause.
It is now admitted by those surgeons in London who have had much experience of hysterectomy for fibroids, that the immediate results of preserving at least one healthy ovary in this operation are admirable, especially in women under forty years of age, for the retention of an ovary is of striking value ‘in warding off the severity of an artificial menopause’ (Crewdson Thomas).
Although I have left one or both ovaries in the performance of abdominal hysterectomy for fibroids in more than 300 patients, in only two instances have I found anything detrimental in the practice. In these two patients it was necessary to remove one of the ovaries. Since 1906 I have modified the method by leaving only one ovary, even when both were healthy, and find that the immediate good consequences of the operation are in no way impaired. There is reason to believe that whatever good effects follow the practice of leaving a belated ovary (that is, an ovary divorced from the uterus and left in the pelvis), they are temporary, for in the course of a few years the ovarian tissue disappears and the patients experience the usual symptoms of the menopause. It is possible that the rate of atrophy of the secreting tissue of a belated ovary depends on the age at which a patient is submitted to hysterectomy.
In 1898 I performed subtotal hysterectomy on a woman, thirty-one years of age, for fibroids, conserving the right ovary. Nine years later (1907) I operated again for intestinal obstruction, and found this ovary healthy and functional, for a ripe corpus luteum was visible on its surface. Even a portion of an ovary, if it contain follicles, will maintain menstruation.
In performing abdominal hysterectomy for fibroids, there are three points which require consideration in relation to the subsequent comfort of the patient, and they depend mainly on the conservation of a healthy ovary. These three points relate to: (a) the patient’s comfort in securing freedom from flushings; (b) if she be married, her marital relations; and (c) if single, her nubility.
In regard to marital relations in women with a belated ovary, nothing trustworthy is forthcoming, but I believe the retention of an ovary is an additional factor in promoting domestic bliss. The question of nubility is interesting; I am able to state that women who have had subtotal hysterectomy performed, with conservation of one ovary, have married and lived happily with their husbands; and I am of opinion that the preservation of the vaginal segment of the neck of the uterus is an important factor, as it leaves the vagina intact, and though such women are sterile, they are certainly nubile.
Without overstating the case it may be said that a belated ovary is a very precious possession to a woman under forty years of age, whether she be married or single.
In regard to the fate of such ovaries, in the present condition of our knowledge it may be stated that:--
In a woman under the fortieth year of life, a belated ovary remains active and discharges ova.
An ovary belated after the fortieth year of life atrophies, and menopause symptoms will often ensue in the course of a few months after the operation. The retention of an ovary minimizes the menopause disturbances, and they are never so acute and prominent under these conditions as they are when an acute menopause is induced by the sudden and complete removal of all ovarian tissue. Some experienced observers maintain that an ovary is a valuable possession to any woman who menstruates, even at the age of fifty years, the persistence of menstruation being obtrusive evidence that this gland is functional. Experimental evidence, obtained from rabbits, proves that the removal of the whole uterus has no deterrent effect on ovulation, and it does not prevent the occurrence of œstrus and ovulation at periodically recurring intervals. There is no necessity to appeal to experiments on animals in this matter, as clinical observations on women are most eloquent in proclaiming the great value of a conserved ovary when the uterus is removed on account of troublesome and dangerous fibroids.
In reference to the value of ovarian tissue after hysterectomy for fibroids, attention should be drawn to a modification of this operation known as the Abel-Zweifel method, by which a small segment of the menstrual area of the uterus is left as well as one or both ovaries: this permits menstruation to continue in a subdued form.
Doran has particularly studied this method and practised it, but I cannot express any opinion as to its value, never having had the courage to perform it.
My aim in performing hysterectomy for fibroids is to abolish as completely as possible the menstrual area of the uterus (Fig. 18), and up to the present my efforts have been successful, and I have no complaint from any patient that this disagreeable phenomenon has manifested itself, although I have been at great pains by my own exertions, as well as by the kind efforts of those who have been associated with me in my hospital work, to keep in touch with women who have been so unlucky as to require such a serious operation as the removal of the uterus.
REFERENCES TO THE HISTORY OF HYSTERECTOMY FOR FIBROIDS
BAER, B. F. Supra-vaginal Hysterectomy without Ligature of the Cervix in Operation for Uterine Fibroids. A new method. Transactions of the American Gynæcological Society, 1892, xvii. 235.
BARDENHEUER. Die Drainierung der Peritonealhöhle. Im Anhang: Thelen: Die Totalextirpation wegen Fibroid. Stuttgart, 1881, 271.
GOFFE, I. RIDDLE. This surgeon furnishes an interesting account of the development of Total and Subtotal Hysterectomy for Fibroids, in The Transactions of the American Gynæcological Society, 1893, xviii. 372.
KOEBERLÉ, E. Documents pour servir à l’histoire de l’extirpation des tumeurs fibreuses de la matrice par la méthode suspubienne. Gaz. med. de Strasbourg, 1864, xxiv. 17; 66; 158. 1865, xxv. 78; 118.
POZZI, S. Traité de Gynécologie, 1905, i. 424. This contains an interesting review of the serre-nœud and clamp period of hysterectomy. He states that Tillaux, in a communication to the Academy in 1879, proposed the use of the word Hysterectomy.
LITERATURE RELATING TO CANCER OF THE CERVICAL STUMP AFTER SUBTOTAL HYSTERECTOMY
DORAN in his Harveian Lectures, London, 1902, gives an admirable critical summary of this important question up to that date.
BLAND-SUTTON, J. Essays on Hysterectomy, 1905, 2nd Ed., 60.
---- Journal of Obs. and Gyn. of Gt. Britain, 1904, v. 434.
MANN, M. Trans. Am. Gyn. Soc., 1893, p. 123.
POLK. Am. Journ. of Obstetrics, 1906, liv. 78.
QUÉNU. Rev. de Gyn. et de Chir. Abdom., 1905, Sept.-Oct., ix. 720.
RICHELOT. La Gynécologie, 1903, viii. 399.
TURNER, G. Brit. Med. Journ., 1905, ii. 953.
REFERENCES IN RELATION TO THE OCCURRENCE OF CANCER IN THE UTERUS AFTER BILATERAL OVARIOTOMY
BLACKER, G. F. Uterus with Fibroids and Carcinoma of the Cervix. Trans. Obstet. Soc., 1896, xxxvii. 213.
BLAND-SUTTON, J. A Clinical Lecture on Adenomyoma of the Uterus. Brit. Med. Journal, 1909, 1.
BUTLER-SMYTHE. Carcinomatous Uterus removed eighteen and a half years subsequent to Double Ovariotomy. Trans. Obst. Soc., 1901, xliii. 214.
PLAYFAIR. Carcinoma of Uterus. Ibid., 1897, xxxix. 288.
MARTIN, A. Die Krankheiten der Eierstöcke und Nebeneierstöcke, 1899, s. 907.
REFERENCES CONCERNING THE VALUE OF BELATED OVARIES
BLAND-SUTTON, J. Abdominal Hysterectomy for Myoma of the Uterus, with brief notes of twenty-eight cases. Transactions of the Obstetrical Society, 1897, xxxix. 292.
---- The Value and Fate of Belated Ovaries. The Medical Press and Circular, 1907, ii. 108.
BOND. An Inquiry into some Points in Uterine and Ovarian Physiology and Pathology in Rabbits. British Medical Journal, 1906, ii. 121.
DORAN, A. Subtotal Hysterectomy: after history of sixty cases. Transactions of the Obstetrical Society, 1905, xlvii. 363.
THOMAS, G. C. The after histories of one hundred cases of Supravaginal Hysterectomy for Fibroids. Lancet, 1902, i. 294.
VII. HYSTERECTOMY FOR PRIMARY CARCINOMA OF THE UTERUS
The modern operation of hysterectomy as a radical measure for the relief of cancer of the uterus has a somewhat curious history. In 1878 Freund extirpated the uterus for carcinoma of the cervix through an abdominal incision; his method was quickly practised by other surgeons, but the great mortality of the operation soon caused it to be abandoned for the vaginal route advocated by Czerny and supported by Schroeder, Olshausen, Martin, and Péan amongst other gynæcologists. This method, however, has been abandoned, for, although the operative mortality of vaginal hysterectomy for cancer of the uterus has fallen to 5 per cent., the operation has disappointed expectation, as it can only be employed on early cases of the disease with anything like a hopeful prospect of curing the patient, and, even when performed on carefully selected cases, the risks of recurrence are so great and often follow so rapidly on the operation that surgeons have lost confidence in the method. This has induced gynæcologists to turn their attention again to the abdominal route. The cancerous uterus is now subjected to what is known as ‘radical abdominal hysterectomy’, a method with which the names of Ries, Mackenrodt, Dührssen, and Wertheim are closely associated.
=Hysterectomy for cancer of the cervix.= The greatest obstacle to the success of vaginal hysterectomy in the radical treatment of cancer of the neck of the uterus is the limitations which the anatomical environment imposes on the surgeon, for as soon as the disease overruns the cervix it implicates the vagina, the bladder, the vesical portions of the ureters, and the rectum. The ‘radical abdominal operation’ enables the operator not only to remove the uterus and its neck, but the broad ligament, the ovaries, Fallopian tubes, infected lymph glands, and the infected para-uterine connective tissue, and by affording the operator free access to the floor of the pelvis the proceedings may be carried out with a free exposure of the operating field, thus allowing important structures like the ureters to be dissected out of implicated tissue. Indeed it has even been recommended, in cases where the bladder has been extensively involved, to resect this viscus and engraft the ureters into the rectum.
The primary object of these extensive operations is not only to facilitate the wide removal of connective tissue around the cervix in early cases of carcinoma, but also to allow the advantages of operative treatment to be extended to patients to whom it would be otherwise absolutely barred.
One great danger which attends operations for the removal of cancerous organs is what may be called ‘post-operative cancer-infection’, that is, in the course of the operation tracts of connective tissue are opened up and become soiled with cells, which engraft themselves on this tissue and on the peritoneum, and give rise to extensive masses of cancer which are often described as recurrent cancer. This accident often causes the patient to die quicker than if the primary cancer had been left untouched. In the radical operation it is one of the essentials to avoid soiling the wound with cancer cells. This rule, of course, applies to operations for cancer in any part of the body.
=Operation.= The steps of the radical abdominal operation advocated by Wertheim are as follows:--
As a preliminary, the cancerous cervix is treated by scraping, cauterizing, and disinfectants. It is an advantage to carry out these measures a few days before the main operation. The Trendelenburg position is indispensable and the abdomen is opened by a free median subumbilical incision. After isolating the intestines with dabs, the ureters are exposed by incising the posterior layer of the broad ligament; they are then traced to the parametrium. It is necessary to avoid too free a disturbance of their vascular network or they will slough.
The bladder is then separated from the uterus. The infundibulo-pelvic, the broad, and the round ligaments are ligatured and divided. The particular order in which they are dealt with is not a matter of consequence. The uterine vessels are secured in the following manner:--The index finger is pushed along the ureter through the parametrium towards the bladder, until the tip of the finger appears there; the vessels are then raised on the finger, which covers the ureter so as to protect it whilst the vessels are ligatured and divided. As soon as the uterine vessels are divided the vesical segments of the ureters are exposed, cleaned if necessary, and separated from the cancerous cervix.
The posterior layer of the peritoneum is divided and the rectum separated from the vagina: at this stage the uterus is sufficiently isolated from the surrounding structures to allow of removal. This is effected in the following way:--
The two layers of the parametrium are taken off as close as possible to the pelvic wall, and the vagina closed with bent clamps and divided below them: the clamps are used to prevent soiling the operation-area with cancerous cells.
In order to extirpate the lymph glands, the peritoneum is divided upwards and the iliac vessels laid bare, and every enlarged gland from the division of the aorta to the obturator foramen is removed and the oozing vessels carefully secured.
The wound is treated in the following way:--
The cavity created by the removal of the uterus is filled in loosely with iodoform gauze, which extends to the vulva. An exact closing of the peritoneal cavity over this gauze is effected by the sewing up of the anterior and posterior flaps of peritoneum. The final step is the closure of the abdominal incision.
=After-treatment.= This is relatively simple. The strips of iodoform gauze are removed through the vagina in from five to ten days successively. The patient gets up on the fifteenth day. The bladder requires very careful attention, as it is usually paralysed for some days.
=Mortality.= The immediate mortality of these extensive abdominal operations for cancer of the neck of the uterus is very high, more than 20%, but recent statistics (1909) show that this death-rate is being considerably improved with increased experience on the part of the operators.[1]
[1] Comyns Berkeley and Bonney have published the best immediate results of this operation which have been obtained in England. British Medical Journal, 1908, ii. 961, and Lancet, 1909, i. 320.
=Dangers.= The chief risks of the operation are sepsis, cancer-infection, and injury to the ureters.
The ureters have proved a fertile source of trouble because they are deliberately exposed in the course of the operation, and they are sometimes accidentally divided. It is not uncommon to find a ureter completely blocked by cancer, and occasionally the ureter, after being bared by the operator, undergoes necrosis a few days later.
Wertheim points out that in some instances ureteral fistulæ due to necrosis may be induced to close by the application of iodine or sulphate of copper. It is, however, unfortunately true that many patients with ureteral fistulæ after the radical operation have been obliged to undergo nephrectomy (see p. 112).
The ‘radical operation’ for cancer of the neck of the uterus is on its trial in Great Britain. The operative mortality is very high, and no reliable returns concerning the remote results are at present available.
=Hysterectomy for cancer of the body of the uterus.= The most satisfactory method of dealing with cancer arising in the corporeal endometrium consists in performing total abdominal hysterectomy (see p. 40), removing not only the uterus and its neck, but both ovaries, Fallopian tubes, mesometria, and any enlarged lymph glands that are detected. In the course of the operation the surgeon should avoid any undue handling of the uterus, and, in withdrawing it from the pelvis, care should be taken not to infect the operation area with any fluid or semi-fluid stuff which is liable to escape from the cervical canal.
There is a rare variety of cancer of the corporeal endometrium, namely, that which attacks small atrophic uteri. These small uteri may sometimes be extirpated by the vagina, but often the narrowness of the vagina in aged spinsters compels the surgeon to resort to the abdominal route.
Cancer of the body of the uterus occasionally causes such enlargement of this organ as to render its removal by the vaginal route difficult as well as undesirable. When this form of cancer is complicated with fibroids, as a rule, vaginal hysterectomy is impracticable.
Cancer of the body of the uterus is more frequent in spinsters and barren wives than in multiparæ; for this reason the cancer often assumes the massive form, because the cervical canal being narrow, pathogenic micro-organisms do not obtain such free ingress as in the case of women with a patulous canal. In some instances the cancerous mass will expand the uterine cavity and lead to thinning of the walls as in Fig. 19.
Clinically, cancer of the corporeal endometrium is a more insidious disease than cancer of the neck of the uterus, but since its frequent association with fibroids has been recognized (see p. 52) mainly as a consequence of the vulgarization of hysterectomy, many cases are detected fairly early and with improved results for the patients.
=Mortality.= The risk to life in abdominal hysterectomy for cancer of the body of the uterus is somewhat greater than after removal of the uterus for fibroids. This is due to the fact that when the cancer ulcerates and sloughs, the risk of sepsis is therefore increased; this also makes convalescence slower.
The remote results vary greatly; these depend in a large measure on the extent of the disease at the time of the operation. When the cancerous mass is compact, as in Fig. 19, good results may be expected. When the growth has perforated the uterine wall and small bud-like processes project on the serous surface, the disease may be expected to recur rapidly in the abdomen. Cancer of the uterus remains an opprobrium to operative gynæcology.
VIII. OPERATIONS FOR DISPLACEMENT OF THE UTERUS
HYSTEROPEXY (VENTRO-SUSPENSION AND VENTRO-FIXATION OF THE UTERUS)
Hysteropexy is a term applied to an operation for fixing the uterus, by means of sutures, to the anterior abdominal wall.
This procedure was advocated as a definite surgical operation for displacements of the uterus independently by Olshausen and Kelly (1886).
The operation when employed for severe retroflexion of the uterus is now known as ventro-suspension of the uterus; when carried out for prolapse it is termed ventro-fixation of the uterus. When care is taken in the selection of patients, hysteropexy is an operation which is followed by satisfactory consequences.
VENTRO-SUSPENSION FOR RETROFLEXION OF THE UTERUS
The preliminary preparation and the instruments required as those used for a simple cœliotomy (see p. 5).
=Operation.= The patient is placed in the Trendelenburg position, and the abdomen is opened as for ovariotomy, except that the incision is shorter; the operator then determines with his fingers the position and condition of the body of the uterus. If it be free, it is then straightened, and the condition of the ovaries and the tubes ascertained.
In many patients, where retroflexion of the uterus is accompanied by pain, the distress is often due to a prolapsed ovary, incarcerated in the pelvis by the retroflexed fundus of the uterus; in another set of cases the retroflexion is produced by a tumour in the ovary, such as a small dermoid, but more often the body of the uterus is drawn backwards by a small fibroid in the fundus of the organ. In these conditions an operation embarked upon as a simple hysteropexy may become an oöphorectomy, an ovariotomy, or a myomectomy, according to the necessity of the case. When the enlargement of the ovaries is due to œdema from incarceration, they should be left, as the swelling will quickly subside when the misplacement of the uterus is corrected.
The uterus is fixed to the abdominal wall in the following way:--
A curved needle armed with a silk thread (No. 4) which has been carefully boiled is passed through the aponeurosis and adjacent peritoneum on one edge of the wound, then through the anterior surface of the uterus near the fundus, and finally through the peritoneum and aponeurosis on the opposite edge of the incision; when this suture is tightened, it will be found to draw the uterus to the anterior abdominal wall, and at the same time approximate the edges of the wound. Two sutures should be introduced. In patients who have had children care should be taken not to pass the needle so deeply into the uterus that the suture traverses the superficial parts of the endometrium and becomes infected: this will lead to a suture sinus. The rest of the wound is then closed according to the method described on p. 9.
VENTRO-FIXATION FOR PROLAPSE OF THE UTERUS
=Operation.= When hysteropexy is needed for a large, bulky, and prolapsed uterus, the steps of the operation are the same as for retroflexion, but it is necessary to introduce a greater number of retaining sutures. Further, as the uterus tends to slip downward into the vagina, it is an advantage, as soon as the fundus of the uterus is drawn into the wound, to transfix it with a stout suture, in order that the assistant may use it as a tether to keep the uterus in position whilst the surgeon introduces the main sutures. In some cases, where the uterus is very large, it may be requisite to employ four, five, or even six sutures to secure it to the abdominal wall.
In all cases of hysteropexy the uterus is of necessity sutured to the lower angle of the wound, and is therefore in close relation to the bladder. It facilitates the operation to introduce the lowest sutures first and then gradually work up to the fundus. The wound is then closed and dressed as described for cœliotomy.
=After-treatment.= This is conducted on the same lines as after ovariotomy.
=Risks.= Hysteropexy, when performed by surgeons experienced in pelvic surgery, is such a simple operation that it should have no mortality. At the Chelsea Hospital for Women, from 1904 to 1906, both years inclusive, this operation was performed on 190 patients, all of whom recovered from the operation.
Many of these operations were complicated with oöphorectomy, ovariotomy, or myomectomy. A wide study of operation returns show that hysteropexy is not absolutely free from risk, as deaths from sepsis, lung complication, and intestinal obstruction have been reported.
The remote consequences of hysteropexy are of interest. When the uterus has been enlarged by previous pregnancy its fundus can be brought without undue strain into contact with the anterior abdominal wall, so that when it is secured by sutures there is little or no strain on them. When hysteropexy is performed on spinsters or barren married women in whom the uterus is small, there is, in many instances, a strain on the sutures. The effect of this strain is twofold. When the uterus is attached to the abdominal wall by an aseptic suture, lymph is exuded from the surfaces of the peritoneum in contact with the retaining sutures. This effused lymph organizes into a tenacious tissue, and the strain of the uterus, when the operation is performed on virgins, or the weight of the organ when it is done for prolapse, will cause the sutures to erode their way out of the uterine wall, but the plastic material effused around the silk threads slowly stretches as the uterus descends into the pelvis, producing a tendon-like structure which may be called the ‘artificial fundal ligament’ (Fig. 20).
In patients in whom the length of the uterus allows its fundus to come in contact with the abdominal wall without strain, the union may be so secure that the woman may pass through one or more pregnancies successfully without disturbing the union, or even stretching it. This I have proved in twelve instances where some subsequent trouble such as appendicitis, gall-stones, ovariotomy, cancer of the colon, or the like has led to a repeated cœliotomy, and has afforded me an opportunity of examining the condition of the uterus.
In one remarkable case where a small uterus had been securely fixed by its fundus to the abdominal wall by means of ten thick sutures (the operation had been performed in a cottage hospital in Yorkshire), the patient complained of persistent pain, and was sent to me on this account. I found the sigmoid flexure of the colon caught in one of the sutures, which accounted for some of the woman’s trouble, but the uterus was so firmly fixed to the abdominal wall and had been so dragged upon that it had become a rounded sausage-like organ. Its removal was followed by immediate relief. Among rare accidents which have followed this simple operation is tetanus when catgut and wallaby tendon has been used for the retaining sutures (see p. 107).
REFERENCES
KELLY, H. A. Hysterorrhaphy. American Journal of Obstetrics, 1887, xx. 33.
OLSHAUSEN. Ceber ventrale Operationen bei Prolapsus und Retroversio Uteri. Centralblatt für Gynäkologie, 1886, x. 698.