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LECTUR
ON THE
TREATflENT OF
FIBROID TUMORS OF THE UTERUS
Medical, Electrical and Surgical.
BY
FRANKLIN H. MARTIN, M.D.
prokessor of gynecology post-graduate medical school of chicago;
siir(;eon woman's hospital of Chicago; gynecologist Chicago
CHARITY hospital AND THE POST-GRADUATE HOSPITAL;
CHAIRMAN SECTION OF OBSTETRICS AND DISEASES OF
WOMEN OF THE AMERICAN MEDICAL ASSOCIA-
TION (1895); PRESIDENT CHICA(;<>
GYNECOLOGICAL SOCIETY
(1895); ETC., ETC.
AUTHOR OF ELECTRICITY IN OBSTETRICS AND GYNECOLOGY.
THE F. A. DAVIS COMPANY, PUBLISHERS.
PHILADELPHIA. - NEW YORK. - CHICAGO.
1897.
^-
COPYRIGHT ACCORDING TO ACT OF CONGRESS
BY FRANKLIN H. MARTIN, M.D.
#•
- PREFACE.
It was the lot of the writer of these lectures to have entered
J the practice of gynecology at the dawn of antiseptic surgery.
^ With the possibilities revealed by this great advance, for fifteen
years, the surgeons of civilization have been struggling toward
perfection. In a little more than a decade wonders have been
accomplished and surgery developed to a science. During this
period of unprecedented activity the treatment of fibroids of
the uterus has received a large share of attention and may now
be said to have reached as high state of perfection as any other
branch of surgery. The benign nature of these tumors, their
slow development, their small mortality without treatment
made patients reluctant to accept the radical operations.
Hence minor medical and surgical means were sought and
persistently cultivated to the limits of their possibilities,
Krgot, electricity, the Battey-Tait operation and ligation of
the broad ligaments are minor treatments which have relieved
much suffering, cured not a few patients, and saved many from
the more dangerous procedure of hysterectomy. In the devel-
opment of these minor means, not only, but in the cultivation
and improvement of the major surgical technique the writer
has devoted a greater portion of his professional time for the
last ten years. The object of these lectures is to place in per-
manent shape the outcome of this decade of work and to place
in the hands of his friends and students a mirror, as it appears
to him, of the present status of the treatment of fibroids of
the uterus.
FRANKLIN H, MARTIN, M,D.
September 1, 1896.
LECTURE I.
Anatomy, Histology, Varieties, Etiology, Degen-
eration, Spontaneous Disappearance, Etc.
The designation, •' Fibroid Tumors of the Uterus, "
which is employed throughout this work, is used for
convenience, euphony, and because it has become the
established and accepted term in America, for all
myomatous or fibromatous enlargements of the uterus.
These enlargements are also called: Myoma or
Fibromyoma Uteri; Fibrous Tumors; Tumeur Fi-
breuse ; Myofibroma Uteri; and Hysteroma and Mus-
cular Tumors of the Uterus.
gross anatomy.
Fibroid tumors of the uterus vary in size from a
scarcely perceptible enlargement of the uterus, to a
tumor which may weigh more than one hundred
pounds. No definite limit of maximum dimension
can be assigned; some grow rapidly to an enormous
size, while others, under apparently the same condi-
tions, increase slowly and never attain such propor-
tions as to produce deformity.
The gross appearance of fibroids of the uterus
differs as widely as does their size. There is no
accounting for the great variety of shapes assumed
by these benign growths. Each one is a law unto
itself. For convenience we divide them according to
their method of development, which influences their
contour, into:
1. Interstitial.
2. Intramural.
3. Subperitoneal.
4. Submucous.
An Interstitial Fibroid is one in which the new
growth is uniformly distributed throughout the body
of the uterus, without any large, distinct nuclei of
development. The external appearance of such a
fibroid is that of a symmetrically enlarged uterus,
without external nodular enlargements, or without
irregular projections of a submucous nature into the
cavity of that organ. These symmetrical tumors often
grow to weigh many pounds, and frequently enlarge
the cavity of the uterus until it will measure many
inches in depth, proportionately increasing the area of
the endometrium. I have examined such cases where
the uterine canal measured fourteen inches in depth.
Intramural Fibroids are those in which the new
tissue is confined to the walls proper of the uterus,
but in which several distinct centers of development
are apparent to the naked eye. While each center
may possess several nuclei, the manner of growth is
not uniform throughout the uterine walls. This
variety makes the uterus irregular and the direction
of the canal uncertain. The separate distinct centers
of development, as felt through the uterine tissue,
are much firmer and less elastic than the new tissue,
which makes the typical interstitial variety. Its out
surface frequently exhibits to the naked eye, white
cartilaginous centers surrounded by loose connective
tissue; these centers are often easily enucleated from
the muscular tissue of the walls of the uterus. From
the standpoint of gross anatomy this variety is distinct
and unique. The intramural fibroid is much less
liable to develop into very large tumors, because of
their tendency to become pedunculated.
A subperitoneal Fibroid is one which grows from
one or more centers of development, which may
become pedunculated, and projects from the walls of
the uterus into the peritoneal cavity. The gross
appearance of these projections when cut through is
that of the intramural variety.
A Submucous Fibroid is one which grows from
one or more centers of development and projects
from the walls of the uterus into its cavity. This
variety resembles the intramural in its gross appear-
ance. It may become pedunculated and then becomes
an uterine polypus.
I make the unusual distinction between interstitial
and intramural fibroids, not only on account of
anatomic reasons, but from a therapeutic and surgical
standpoint, since their action under the influence of
ergot, electricity and the knife is strikingly different.
In the examination of an unusual number of
fibroids, I can approximate the relative percentage of
the occurrence of the several varieties as follows:
Interstitial 55 per cent., subperitoneal 20 per cent.,
intramural 15 per cent., submucous 10 per cent.
HISTOLOGIC CHANGES.
Fibromata. — Fibroid tumors of the uterus are rarely
fibromata; they are less rarely a mixture of fibromata
and myomata; while in a large majority of cases they
are pure myomata. According to Bland Sutton, ''typ-
ical fibromata are generally dense tumors consisting
of wavy bundles of fibrous tissue. The bundles are
composed of long slender fusiform cells closely packed
together. The tissue of the tumors, often arranged in
whorls, is permeated by blood vessels." This same
writer says: "The difficulty of distinguishing
between a myoma, a slowly-growing spindle-celled
sarcoma and a pure fibroma is well known to skilled
histologists."
Myomata are tumors composed of unstriped muscle
fibers. Myomata are composed of long fusiform cells
with a rod-like nucleus; the size of the cells vary
greatly in different tumors. The bundles of muscle
fibers are often interwoven in such a manner that the cut
surface presents a characteristic whorled appearance.
(Bland Sutton.) The well-developed tumor consists
of unstriped muscle fibers mixed with more or less
fibrous connective tissue and fusiform cells. (Garri-
8
gLies.) According to Pozzi, on microscopic section
fibromata (fibro-myomata) present smooth muscular
fibers and connective tissue in varying proportions.
Blood Vessels. — The vascularity of fibroid tumors
varies greatly. Hard fibroids composed of an unusual
amount of fibrous material constituted in the main of
long fusiform cells, closely packed together, contain
smaller and fewer vessels than the soft or myomatous
tumors, composed of unstriped muscular tissue- fibers
more loosely packed. The latter are frequently very
vascular, the blood vessels being easily traced into
their interior. The former are often surrounded with
a loose fibrous capsule which frequently contains a
free distribution of blood vessels, from which the
tumor proper draws its nourishment. The moderately
vascular are slow in growth while the soft vascular
tumors develop rapidly. " The vessels that traverse
these soft tumors are often of larger size," says Sutton,
"especially the veins, and furnish a loud systolic bruit
on auscultation."
'• Some of these myomata are so richly furnished
with blood vessels that on transverse section they look
not unlike erectile tumors. Indeed Virchow speaks
of them as 'cavernous or telangiectatic myomata.''
The vessels seen on the cut surface are for the most
part veins. Many excellent examples of the extreme
vascularity of such tumors may be found, and it may
easily be conceived that under varying conditions,
such tumors would alter in size, and in some cases
this has been so marked that the tumor seemed to be
erectile." (Bland Sutton.)
Winkle says: " Ordinarily these tumors are not
very vascular but in exceptional cases, not only the
adjacent tissues, but the tumor itself contains a great
numV^er of large vessels."
Nerves. — According to good authority nerves have
been traced into the substance of fibro-myomata.
According to Winkle, Astruc asserted that he found
them in the parenchyma of a polypus, and Bidder, in
a large fibroid, once found a nerve fiber Hartz
described them and their method of termination in
the nuclei of the smooth muscular fibers. Dupuy-
tren also traced nerve fibers into these growths.
Lymphatics. — Fibroids of the uterus contain lym-
phatics.
Conclusions. — In the proportion that the histology
of a fibroid tumor approaches in microscopic struc-
ture fibromata^ does it increase in density, become less
vascular, has a more definite capsule, is less intimately
connected with the muscular tissue of the uterus, is of
much slower growth and is much more liable to be of
the intramural variety.
In the proportion that the histology of a fibroid
tumor approaches in microscopic structure, myomata.
does it decrease in density, become softer and more
vascular, is its capsule more indefinite because the
new growth is more intimately distributed with the
the muscular structure of the uterus, is of more rapid
growth and is much more liable to be of the interstitial
variety.
DEGENERATIVE CHANGES.
Fihrocysts. — Mucoid Degeneration. — According to
Bland Sutton large uterine myomata are especially
prone to undergo a change, whereby large tracts of
the tumor substance soften and become transformed
into mucin. When this takes place extensively
the tumor is converted into a spurious cyst. He
adds that the degeneration is preceded by edema
of the connective tissue and that the cells assume the
characteristic spider-like form to which the term
myxoma is applied. Virchow says this myxomatous
degeneration is characterized by an effusion of mucous
fluid among the muscular bands, and that it is dis-
tinguished from simple edema by the presence of
mucin and the multiplication of the nuclei and small
cells. When the bands between the small round cells
and the edema disappear, small fluid collections exist
which form the spurious fibrocysts.
The true fibrocysts, according to Pozzi, have a very
10
different origin. " These cysts are formed in pre-
existing cavities, in dilated lymj)li spaces comparable
to the similar dilatations which the blood vessels pre-
sent. The fluid which they contain is limpid and
coagulates on contact with the air. Leopold has
termed these tumors 'lymph angiectatic myoma.' It
must be noted that this lymphatic origin of certain
cystic tumors of the uterus had already been clearly
formulated by Koeberle. This formation seems to
be due to the development of part of the tumor
along the path of the lymph vessels contained in
the broad ligament. On the internal surface of such
tumors we can demonstrate an epithelial investment
which distinguishes them from simple cavities formed
from softening of the neoplasm or apojolexy into
its substance. There are also mixed forms in part
vascular and in part lymphatic."
Induration. — Fibroids contract, reduce and harden
as a rule following the menopause, while occasionally
they disappear entirely. The same change takes place
after confinement, in myomata of the fundus of the
uterus which complicates pregnancy. The change
resembles much that occurs in a fibroid after the
removal of the appendages. The cause of the change,
in each instance, is doubtless due, to a lessening of
the blood supply.
Fatty Degeneration. — Literature does not record
many well authenticated cases of fatty degeneration of
fibroids. That it does occasionally occur, there is lit-
tle doubt, although so rarely that from a clinical
8tandi)oint it is of little value.
Calcareous Degeneration.— 0\di uterine myomata,
both large and small, are liable to become infiltrated
with earthy matter. The change only occurs in slow
growing tumors containing a large proportion of
fibrous tissue. The calcareous material is not deposited
in an irregular manner in the tissues of the tumor, but
corresponds to the disposition of the fibers; on exam-
ining the sawn surface of a completely^ calcified
uterine myoma we find the whorled disposition of the
11
fibers so completely reproduced as to leave no doubt
as to the nature of the mass. When these calcified
tumors are macerated and the decayed tissues washed
away, the earthy matter retains the shape of the tumor,
but its exterior presents an irregular, porous, almost
worm-eaten appearance. The calcification is confined
to the tumor itself, and though we may occasionally
find isolated nodules of earthy matter dotted about
the capsule, this part of the tumor is not converted
into a hard resisting shell.
Suppuration. — Suppurating fibroids may be fibroid
enlargements of any variety which by some accident
have become infected. Fortunately it is a condition
which occurs but rarely. Occasionally a subperitoneal
fibroid, which in process of pedunculation has been
deprived of a portion of its blood su^Dply, by a grad-
ual narrowing of the pedicle, may become infected by
migration of microbes through the walls of an adjacent
intestine upon which pressure has been long main-
tained. An interstitial fibroid may be converted, in
rare instances, into a suppurating mass through infec-
tion, by direct continuity, from a suppurating endo-
metritis. Submucous polypi, of low vitality and small
resistance to pathogenic microbes, quite often are
infected from the endometrium and the vaginal secre-
tions, and suppurate,resulting in an offensive discharge
of pus, and occasionally, hemorrhages — all of which
may give rise to a suspicion of malignant disease of
the uterus.
Carcinomatous Degeneration. — I have had an
opportunity of examining and having under observa-
tion, for long periods, an unusually large number of
fibroid tumors of the uterus, and I have never known
one to undergo carcinomatous degeneration. My
experience coincides with that of the best authorities
on this subject. Fibroid tumors do not predisjDose to
carcinomatous degeneration. Cancerous changes may
occur, however, in a fibroid uterus as a coincidental
disease, but in no way as a direct result of the fibroid.
Spontaneous Disappearance. — Almost every author-
12
ity who has watched the course of many fibroid
tumors of the uterus, has witnessed the spontaneous
disappearance of one or more of these growths, with-
out any apparent cause. Gusserow at one time suc-
ceeded in gathering from literature thirty cases in
which this undoubtedly occurred. Of these thirty,
thirteen were associated with pregnancy, while the
majority of the remainder were connected with the
menopause. It is not difficult to explain the disap-
pearance of a fibroid which has been coincidental with
pregnancy; the process of involution of the uterus
which occurs after confinement, is imparted to the
myoma, which so nearly resembles the uterine tissue,
and the tumor, consequently, is greatly diminished,
or disappears altogether. Then too, the decrease of
the blood suiDi)ly to the uterus, as involution takes
place, deprives the tumor of its accustomed nourish-
ment, and thus causes its diminution.
The reduction in size, or disappearance of a fibroid
at the menopause may be accounted for on the theory
of diminished blood supply, and consequent starva-
tion. When senile atrophy begins in the organs of the
pelvis, and m^enstruation ceases, with consequent
decrease in the requirements of blood supply, the
uterus atrophies, and necessarily a tumor dependent
upon that organ for nourishment, must also suffer
anenda and reduction in growth.
But, occasionally, fibroids of the interstitial variety
will suddenly and mysteriously disappear, without
any apparent cause. 1 know of one which decreased
in size, fully two-thirds, as the result of a simple
exjjloratory operation.
These tumors may also be spontaneously expelled
by:
1, Pedunculation — a gradual narrowing and length-
ening of the pedicle, until by violence or suppuration
the stem separates. This may occur with either a
subj^eritoneal or a submucous i)olypus.
2. Enucleation — This may occur with a submucous
or an intramural of the hard variety (fibromata)
13
which is usually surrounded with a loose capsule, and
which at its nearest approach to the mucous mem
brane becomes infected. The suppuration will grad-
ually encircle the mass, and by means of uterine con-
traction, the tumor will slowly be shelled from its bed
and expelled from the uterus.
3. Suppuration. — Spontaneous disappearance of
fibroids occurs as the result of suppuration following
infection.
ETIOLOGY.
Pathologists have been unable to satisfactorily dem-
onstrate the causes for the development of fibroids of
the uterus.
Pozzi says of Velpeau's theory, attributing the
development of fibroids to the presence of a blood
clot in the uterine tissue: "The spontaneous organi-
zation of coagula after ligation of the arteries sug-
gested the idea that the same process might result in
the formation of these neoplasms. But experimental
study has demonstrated that this organization of coag-
ula is nothing but an ingrowth of the elements of the
vessel's wall and thus this edifice of theor}^ founded
on lack of observation, collapses altogether.
"Klebs asserts (Pozzi) that these tumors have their
origin in a proliferation of the connective tissue and
muscular layers of certain vessels ; the different nod-
ules thus formed become aggregated to make one
tumor. Kleinwachter describes the evolution of fibro-
mata as due to a round cell which is found along the
capillaries and produces a partial obliteration of them;
these cells then become fusiform and produce nod-
ules. In other words, our knowledge of the subject
is still very imperfect."
Winkle, without any clear demonstration or expla-
nation, attributes the dependence of these growths
to the peculiarities of the vessels of the uterus, in
that the arteries are subjected to a very high pressure
before they reach the uterine wall, notwithstanding
their convoluted course
14
Senn believes in Cohnheim's theory of tumor devel-
opment as modified by himself, viz.: That tumors
never develop from mature tissue but from a matrix
of embryonic tissue. According to Senn this matrix
of embryonic tissue may be either of pre- or post-natal
origin. "A fibroid," he says, "in the majority of cases
springs, no doubt, from a matrix of mesoblast in the
uterine tissue, while in exceptional cases the tumor
may start from a similar matrix in the wall of blood
vessels.'*
AGE AND DOMESTIC CONDITION AS PREDISPOSING
CAUSES.
Fibroids seldom occur before puberty. In 575
autopsies upon females by Winkle, 12 per cent, had
these developments. Of 135 examined in the dead
house by him, under 35 years of age, only 5 per cent,
had fibroids.
Dr. Emmet, who has made a most careful study of
this subject, basing his opinion on recorded cases,
says: "It is impossible to determine with accuracy
the age at which these growths are most likely to
appear, since their development is, as a rule, slow at
first, and they may exist for an indefinite period
before their presence is recognized. The age can
only be approximately inferred from the average one
at which professional advice was first sought, and this
would seldom be before the tumor had reached a suffi-
cient size to cause hemorrhage or some other disturb-
ance. We may also gain some information as to the
rapidity of growth from the length of time elapsing
after the birth of the last child, for a fibroid, it is well
known is a cause of sterility. In the table is shown
the age at which 225 women, who had fibroid growths,
were first examined. The earliest age was 18, an
unmarried woman; the next a sterile woman at the
age of 22; 1 at 23; 10 between the ages of 24 and 25."
His table then gives 25 cases between the ages of 25
and 30; 50 cases between the ages of 30 and 35; 48
cases between the ages of 35 and 40; 42 cases between
15
the ages of 40 and 45; 25 cases between the ages of
45 and 50; 8 cases between the ages of 50 and 55;
and 5 cases between the ages 55 and 60. Thus accord-
ing to this table, which corresponds closely with the
experience of other writers, the age of greatest liabil-
ity to fibroids is shown to be between 30 and 35
years.
According to Emmet, based upon statistical tables,
•'between the ages of 30 and 40 years the unmarried
woman is fully twice as subject to fibrous tumors as
the sterile or as the fruitful;" he adds, "It seems as
if it were the purpose of nature that the uterus should
undergo the changes dependent upon pregnancy and
lactation about three years throughout the childbear-
ing period, and that if the uterus is not physiolog-
ically occupied in childbearing, a fibroid will the
more rapidly develop. . . . This will also be the
case with the married woman who has taken means to
prevent conception, as well as with her who has been
sterile from some cause beyond her control, but to a
less degree in the latter case. . . . Finally, the
woman who may have been fruitful in early life, but
remained sterile long afterward from some accidental
cause, may have a tumor developed, but is less liable
thereto from having once borne a child."
Brooks Wells says: "Myomata of the uterus are
more common in old maids than in married women."
This statement is often disputed by gynecologists who
do not frequent the dead house. Very many exam-
ples of myomata appear postmortem whose presence
was not even suspected during life.
Race. — It is an undeniable fact that the negro
women, with the environments of this country, are
more liable to have fibroids of the uterus than
white women. This statement is doubted by Dr.
Middleton Mitchel, of Charleston, S. 0. I can not
but believe, however, that Mitchel is wrong, espec-
ially as far as the negro women living in the
northern and colder latitudes of the country are
concerned.
16
SUMMARY.
The cause of fibroid tumors of the uterus has never
been satisfactorily demonstrated.
Fibroids of the uterus rarely occur before puberty,
and seldom before the age of 25, while the greatest
number develop between the ages of 30 and 40 years.
The unmarried state predisposes women to the
development of uterine fibroids. Married women
who prevent conception, while less liable to develop
fibroids than unmarried women, are still much more
prone to them than childbearing women. Childbear-
ing women are the least predisposed to fibroid of the
uterus.
Xegro women are predisposed to uterine fibroids.
LECTURE II.
Symptoms — Diagnosis.
A knowledge of the existence of a fibroid tumor of
the uterus may be gained by the diagnostician by
first (obtaining the symptoms as appreciated by the
patient — the subjective symptoms; and further by
acquainting himself with the actual physical changes
by direct personal examination of the patient — the
objective symptoms.
SUBJECTIVE SYMPTOMS.
Pelvic Symptoms. — Among the early local symp-
toms of fibroid tumors of the uterus may be enumer-
ated an irritable bladder amounting frequently to
positive dysurea; rectal pressure; sensation of pelvic
fullness; low backache or sacralgia, and frequently
pain on cohabitation. These symptoms are all ijro-
duced by a gradually enlarging uterus, and resemble
many of the pelvic disturbances of early pregnancy,
from which they must be differentiated. As the
tumor enlarges ihe sensation of fullness extends to the
lower abdomen, the j^ressure on the nerves to the
lower extremities causes pain in the line of the nerves
on the anterior or posterior aspect of the thigh, or on
both. Even edema of the extremities may occur
from pressure on the veins extending to them, and
the appendages are frequently pressed upon, resulting
in severe pain on one or both sides, while as the
tumor begins to fill the abdomen symptoms of painful
pressure on many or all the imp(H'tant organs of the
pelvis will be experienced.
18
Symptoms due to Functional Disturbances. — The
most important symptom under this head is that due
to the disturbance of the function of menstruation.
In 75 per cent, of all fibroid tumors of the uterus the
menstrual flow is increased, on account, 1, of increased
area of the endometrium due to interstitial enlarge-
ment of the uterus, 2, of increased vascularity of the
uterus due to the demands of the hypertrophied tis-
sues, and 3, to the venous blood congestion due to
pelvic i^ressure. In a large majority of cases pain is
an accompanying symptom. This dysmenorrhea is
caused, either by the abnormal contractile power of
the changed uterus, by submucous projections into
the uterine cavity, exciting painful contractions of the
organ, or by a frequently accompanying endometritis.
The development of the tumor influences decidedly
the change of the menstrual function. In the early
stages of the fibroid the patient will notice but a slight
lengthening of the menstruation, but as further devel-
opment is made the quantity of the flow will be in-
creased. This changed condition, while at first it may
attract the attention very slightly, as it gradually in-
creases, will at last convince the patient that some-
thing serious is afflicting her. The flow will increase
rapidly, not only in length of period, and in quantity
at a given time, but finally it will frequently become
irregular and occasionally almost continuous. At the
same time pain will often gradually develop, so that
with the exhaustion of depletion will come the agony
of physical suft'ering. These pains if caused by en-
dometritis, will be of a dull aching character, accom-
panied occasionally with slight uterine contractions;
if caused by the effort of the uterus to expel submu-
cous masses or polypi, it will be like those accompa-
nying the uterine expulsive pains of a miscarriage or
confinement; if caused ])y a pressure of the inordin-
ately congested hypertrophied uterus upon the tubes
and ovaries it will be severe and of an almost continu-
ous character in the ovarian regions.
The function of the bladder suffers from direct
19
pressure of the enlarged uterus, or from a subperito-
neal enlargement. Frequent urination will first be
noticeable, while the tumor is yet small, and later pain-
ful micturition, with severe lasting x^ain in the bladder,
as a direct result of traumatism produced by the en-
croachments of the uterus. Comjilete stopi)age of the
urine and painful distention of the bladder may finally
occur from impaction of the increasing tumor.
The function of the rectum is frequently im^^aired
by direct pressure of the tumor uj^on that organ.
Obstinate constipation will be complained of, while
the interference of the tumor with the circulation will
favor the development of hemorrhoids and their pain-
ful symptoms. Temporary imi3action of feces in the
large and small intestines occur as a direct result of
the pressure of a large tumor.
Deformity Produced by Fibroids. — One of the most
embarrassing symjDtoms to many patients, who are
afflicted with fibroid tumors, and frequently the firsi
to attract their attention, is the change in the contour
of the abdomen, which is enlarging. Upon closer ob-
servation and examination of the lower abdomen, they
discover the un wieldly mass, the tumor, which, as it
gradually increases in size, produces a deformity that
no device can conceal, while the patient, in order to
maintain an upright position, must throw her shoul-
ders back in a manner to make the tumor appear most
embarrassingly conspicuous.
General Co)istifufiona1 Disturbances. — Reflex ner-
vous disturbances are early symptoms in many of
these cases. Nausea, palpitation of the heart, indi-
gestion, gaseous distensions of the bowels, flashes of
heat due to vasomotor disturbances, headache, dizzi-
ness, occasionally spasmodic cough and all the symj)-
toms accomj^anying nervous storms, irritable temper,
, from dynamos of the
non -alternating or non-interrupting variety employed
for incandescent street or house lighting and c, stor-
age or secondary batteries,
PRIMARY BATTERY.
There are several distinct fcjrms of primary cells
emijloyed by gynecolcjgists in the treatment of fibroids:
Portahh Battery. — The old reliable pm-table bat-
tery is the one with zinc and carbon elements excited
47
by a fluid of sulphuric acid and bichromate of potas-
slum in water in cells of glass, or better, hard rubber.
The voltage of each of these cells when freshly charged
is about 2 volts. Therefore a battery of this descrip-
tion of about 18 cells properly connected makes a
very suitable portable battery for the treatment of
fibroids.
There are several so-called dry-cell batteries of
secret construction which appeal to one on superficial
observation, because of the claims of their inventors,
of cleanliness, durability, and freedom from objec-
tionable fluids. All such batteries should be looked
upon with suspicion, until they have proved them-
selves capable of furnishing an electro-motive force of
from 30 to 40 volts for periods of five to ten minutes,
several times a day for several months, otherwise the
cost of recharging makes them too exiDensive.
Office Batteries. — For office battery where porta-
bility is not required, the Law cell, the improved Le
Clanche, the Diamond Carbon, or cells of similar con-
struction should be employed. They should be
attached to a selective switchboard of such a construc-
tion that any portion of the battery may be employed
at will. These cells may be placed in an adjoining
closet, or cellar, and connected with the switchboard
by a cable of wire, or they may be placed in a cabinet
beneath the switchboard. As these cells have an
average voltage of one or one and a quarter volts each,
a battery of about 40 cells should be selected.
Streei Wire Current. — One of the most satisfactory
office fixtures for electricity is a connection from an
incandescent lighting system of the uninterrupted or
non-alternating variety reduced by some safe form of
rheostat. One of the simplest rheostats is the Mc-
intosh (Fig. 1). It is comi:)act, easily comi^rehended
and regulates the current in gradations from zero to
the full strength of the street current, and reverse,
without the slightest possibility of a break. A fuse
box is also connected with this rheostat which will
bum out and disconnect the current from the patient
48
in case of an accidental dangerous increase of the elec-
tricity from any nnlooked for source.
Storage Ixitttn'ies may be used as a source of elec-
tricity for gynecologic practice. However, as they are
not econ(jniical and wherever they can be used to
advantage they must be near some other source of elec-
49
tricity, it is obvious that one would seldom select this
form of battery.
MILLIAMPERE METER.
To employ galvanism in gynecologic practice with-
out a milliampere meter is criminal. There are three
reasons for this: 1, because the resistance through the
abdominal walls is so small and variable, that no one,
no matter how experienced, can even approximately
estimate the amperage of a current by the number of
cells employed. 2, because of the powerful current
often required in this kind of work, a dangerous dose
might easily be given, and 3, because of inaccuracy in
recording cases.
F Kit- RE -2.
A milliampere meter should be selected which has
two readings : One scale reading to 500 milliamperes
and one reading to 50 milliamperes. This presup-
poses in reality a double instrument. By changing a
switch either reading may be selected without the
necessity of changing the connections.
The best milliampere meter I am acquainted with
is the Weston. It is reliable, convenient, double
reading, dead beat, and can be used in any position on
a level without regard to the poles of the earth. The
principal objection to this instrument for general use
is its expense (Fig. 2).
50
An instrument which I have employed more than
any other in my work outside of the office is the Mc-
intosh instrument (Fig.3). It is of the galvanometer
type and much cheaper than the Weston. It is ap-
proximately correct, and bamng the fact that it must
be carefully adjusted to the polarity of the earth, be-
fore each using, and that the indicator is not dead
beat, it is a very satisfactory instrument. It has a
double reading; is made in two sizes, one large for
office use and one small for portable purposes.
ELECTRODES.
In describing electrodes for use in the treatment of
Figukp: s.
fibroid tumors I will limit my description to those
which I actually employ in my own work and leave
the innumerable confusing curiosities which adorn
the ordinary instrument catalogues unmentioned.
Ahdominal electrodes in use by me are of two kinds
according to the dose required. When a current of
less than 50 milliamperes is employed a large si^onge,
a large felt (^r a large spongio-pyoline instrument may
be emjjloyed. These electrodes should be not less
than six })y eight inches of an oval shape. They
shoukl be thoroughly washed in warm water before
using, and all surplus water squeezed out before the
51
application is made. For a current above 50 milliam-
peres a clay electrode or the author's membranous
abdominal electrode should be emx)loyed. These
being the only instruments which I have found in my
experience which will uniformly distribute the cuiTent
and prevent burning of the skin in spots.
The clay electrode is the cheapest form of the two.
If made as recommended by Goelet, wrapped in cheese
cloth with a rubber back it is comparatively clean and
makes a suitable instrument where efficiency and
economy alone is desirable. It is constructed of jjot-
ter's clay of the consistency of putty molded into a
cake, about eight by six inches in diameter by one inch
in thickness.
Fiia-RE 4.
The membranous abdominal electrode devised by the
writer, is a water electrode, the cavity of the disk hold-
ing the water being covered with animal membrane,
the membrane furnishing the surface of contact (Fig,
4). This instrument when filled with warm water
makes an ideal electrode. It is cleanly, its temperature
is easily regulated and it diffuses the current perfectly.
For internal electrodes I employ intrauterine, vagi-
nal and rectal instruments.
The intrauterine electrodes are of two varieties;
flexible concentration and soft copper.
The flexible concentration consists of platinum wire
wound spirally over soft copper for varying distances
tipped with hard rubber, and the portion of the in-
52
strument not active, is covered with some insulating
material as rubber or linen covered with shellac.
These instruments may be made of any diameter. I
have them in sets of two, three and five millimeters in
diameter respectively. The active surface which I
ordinarily employ is four square centimeters (Fig. 5).
In knowing accurately the active surface of an elec-
trode, one can estimate more definitely the particular
effect to be exj^ected from a known current. This
will be explained more comprehensively when we con-
sider treatment technique.
Soft copi:)er electrodes are employed in order that
the uterine mucous membrane and deeper tissues may
become infiltrated by cataphoresis with the salts of
copper produced by a combination of tissue and cop-
o^
Figure 6.
per electrolysis, which occurs at the positive j^ole. I
have these electrodes made in sets of three instru-
ments, each instrument having an electrode of diifer-
ent caliber on either end (Fig. 6). This makes six
diameters — 2, 4, 6, 8, 10 and 12 millimeters. The
length of each electrode surface is six inches. The
portion of the staff not employed in the uterine canal
is insulated with a loose rubber muff.
Vfujinal electrode. — I employ an instrument for
this purpose like the one shown in Fig. 7. It has an
active surface of alxjut sixteen square centimeters, the
staff of it being insulated with hard rubber over a
copper core. The instrument is about six inches
long and about three-quarters (jf an inch in diameter.
ReeUd electrode. — I employ a long bulbous-
pointed instrument about four inches long and one-
53
half inch in diameter for a rectal electrode. The insu-
lated portion has a metal surface of about ten square
centimeters. The staff is insulated with hard rubber.
Effects of Galvanism on Living Tissues. — Fortu-
nately the effects of electricity upon living tissues has
been so thoroughly studied, clinically and experi-
mentally, in the last few years that we are in a posi-
tion to make some i^retty definite statements about its
action. These studies, too, have not been limited to
the living tissues, but have been carried into the
chemic, physiologic and bacteriologic laboratories to
such an extent that we have many experimental proofs
which have proved true several former theories and
exploded many others.
In applying galvanism to the tissues of the body
the employment of two electrodes is necessary. In
applying electricity to fibroids of the uterus the inter-
nal electrode is usually termed the active pole while
the external one is called the passive pole. We speak,
therefore, of three kinds of effects from the applica-
tion of the current in this manner: Polar effects,
inter-polar effects and general effects.
The polar effects differ materially with the pole
employed. In several respects the effects at the two
poles are diametrically opposed.
Effect on Sensihility. -The positive pole or anode acts
as a sedative while the negative or cathode pole acts as
an irritant. This effect on the sensory nerves is called
the electro-tonic effect and the two effects are ex-
pressed as the anelectro-tonic effect ( sedative ) and the
catelectro-tonic effect (irritant). The use of electricity
in gynecology with its employment of large doses has
abundantly demonstrated to me the electro-tonic effect
of galvanism.
Effect on Blood Vessels. — The i^ositive pole con-
tracts blood vessels in its immediate neighborhood
while the negative pole dilates them. These vaso-con-
strictor and vaso-dilator effects are easily demon-
strated.
Chemic Reaction. — The result of tissue electrolysis
54
between the poles produces an accumulation of alkalin
elements at the negative pole and acid elements at the
positive pole. This results in an acid reaction ob-
taining at the positive pole and an alkalin reaction at
the negative pole. If the electrolysis is persisted in
with a powerful dose these polar accumulations become
caustic acids and caustic alkalies resiDectively.
Effect on Tissue. — The acid accumulation at the
positive pole when it becomes sufficiently concen-
trated fi'om the effect of a strong dose coagulates the
soft tissues and renders them for a short distance from
the i3ole hard and dry. On the other hand the alkalin
accumulation at the negative pole when strongly con-
centrated by a strong dose of electricity, dissolves the
tissues and liquifies in the same manner as does caustic
alkalies.
Effect on Pathogenic Microbes. — A zone of uterine
tissue around the positive pole of a depth varying
from a fraction of a millimeter to one or two millime-
ters according to whether the dose of current is small
or great is rendered bacteriologically sterile by the
employment of the galvanic current. This effect
according to experiments made by Gautier, Apostoli,
Enrico Burci, Vittorio Frascani and others, is not due
to the electricity direct but rather to the chemic
changes occurring around the positive pole as the
result of electrolysis. For instance, if a copper elec-
trode is employed oxychlorid of copper is formed as
the result of a combination between the electrolyzed
tissues and copper. This chemic combination is an
active germ destroyer and in solution it is driven by
cataphoresis into the tissues to a considerable distance,
carrying its antiseptic projjerties with it. There is
scarcely any antiseptic effect at the negative pole.
INTERPOLAR EFFECTS.
While it is easy to demonstrate polar action it is not
an easy matter to make an ocular demonstration of the
interpolar effects of the galvanic current on living
tissues.
00
From exj)erience in the emi^loyment of this current
on living healthy and ]3athologic tissue, experience of
many earnest investigators extending over a period
now of several years, we are convinced that evidence
enough has accumulated to justify us in saying that
the following definite effects occur in tissues so acted
upon: 1, interpolar electrolysis, 2, stimulation of
trophic nerves, 8, cataphoric action.
Interpolar Electrolijsis undoubtedty occurs be-
tween the poles as well as at the metal poles them-
selves. When such electrolysis occurs in a fibrcjid
uterus it is easy to account for the reduction in size
of that growth. When the molecules of weaker ten-
acity in such tissues become decomposed into their
constituent elements ozygen, hydrogen, carbon, etc.,
these elements, as gas or solid i^articles, immediately
on their release become foreign substances. While
seeking for new combinations some of them are taken
into some of the many absorbents traversing the tis-
sues and are carried out of the system. Others form
new combinations with free elements in the tissues, or
with the decomposed material of the electrodes, or
fluids surrounding the electrodes on the surface, and
still others are liberated at the poles as solids or gases.
Stimulation of Trophic Nerves. — While the elec-
trolytic effect of the current may account for reduc-
tion or absorption of growths, I believe that this re-
sult is materially hastened by powerful stimulation of
the trophic apparatus of the uterus by electricity. We
are forced to believe this by the fact that the general
nutrition and functional activity of all the organs, any
way coming under the influence of the current, are
markedly improved.
The Cataphoric Action of the Galvanic Current. —
This is the property of a current of electricity which
enables it to push or conduct fluids in bulk through
membranous or porous conductors in the direction of
the current flow, from the positive toward the nega-
tive pole. This is also called electrical cataphoresis.
Fluids near or on the positive pole, either simple or
56
holding in solution drugs or chemicals, will be driven
into the living tissues when living tissues are made a
portion of the conductor. So that the tissues of the
uterus may become impregnated with any drug which
can be dissolved in water by sun-ounding an intra-
uterine iDOsitive electrode with a film of cotton satu-
rated with the particular fluid and causing a current
to traverse the tissues.
TJie general effect of galvanism upon the tissues is
that of a powerful tonic. Irregular practitioners, for
a large number of years, employed electricity in some
form successfully because of its power to stimulate
general nutrition. It mattered but little what form of
electricity was employed, or where it was applied so
long as some portion of the sick man became a part of
an electric circuit; it was sure to stimulate him, im-
prove his nutrition and make him feel a stronger
man. The powerful doses employed in the use of gal-
vanism in the treatment of fibroids exaggerates this
tonic effect of electricity to such a degree that many
physicians have endeavored to attribute to it all the
credit for improvement of fibroids under electricity.
Summary of Effects of Galvanism in the Treat-
ment of Fibroids of the Uterus.
Polar Action: Negative Pole a. Irritant; h. Vaso-
dilator; c. Alkalin; d. Liquifies tissues; e. Anti-
septic (slight). Positive Pole a. Sedative; b.
Vaso-constrictor; c. Acid; d. Coagulates tissues; e.
Antiseptic (powerful).
Interpolar action: Electrolysis and trophic stimu-
lation.
General Action: Powerful tonic.
THE APPLICATION OF GALVANISM TO THE TREATMENT
OF FIBROIDS.
What is the present status of the treatment of these
benign tumors by electricity? With the brilliant
results of i)resent surgery as a competitor, one must
have considerable courage to offer electricity as a
remedy at all in these cases. But as an abdominal
57
surgeon with at least average success, and at the same
time as one who interested himself early and enthusi-
astically in the much-lauded Ajiostoli treatment when
it made its (Uhutin this country, I am constrained by
sense of justice, knowing well both sides, to say that
in the interest of those who have fibroids of the
uterus, that the knife, even in these times of brilliant
successes in surgery, is used too often and electricity
too little. If a brilliant hysterectomy with its aver-
age mortality of 5 per cent, ended the matter, and the
95 per cent, recovering gained health immediately, we
could have but little to say. When, however, we
must reckon on the months of nervous suffering with
which the majority of these patients who have their
tumors removed have to contend, after this operation,
before they receive the well-earned cure, and when we
take into consideration the not large but certain per-
centage of fistulas, hernias and other well-known dis-
tressing sequelae following oiDerations, and last but not
least when we remember the grim specter of that 5 or
10 per cent, who did not recover, are we not justified if
we have a conscience (especially when we realize that
a fibroid of the uterus when left alone seldom proves
fatal) in giving our patients the benefit of a treat-
ment, which seldom fails to relieve these cases, and
while it frequently fails to cure, never kills and never
does harm and never inferferes ivifh the success of
an operation, if it in the end fails to cure?
Experience in the treatment of fibroids of the
uterus by electricity has taught me how to select my
cases, when to encourage a patient to receive elec-
tricity and when to encourage her to select an opera-
tion. Rules which I have formulated and allowed to
influence me but not control me (because I make
frequent exceptions to them in individual cases) are
as follows:
WHEN ELECTRICITY IS SPECIALLY INDICATED.
1. In bleeding fibroids in women approaching the
menox^ause.
58
2. In all inoperable cases.
3. In incipient fibroids in women over 40 years
of age.
4. In all bleeding fibroids of the smooth interstitial
variety which have no symptoms but hemorrhage.
5. In all cases (not accompanied with pelvic pus
accumulation) which refuse to have an operation.
TECHNIQUE OF TREATMENT OF TYPICAL CASES.
A typical case for the successful treatment of
fibroids of the uterus by electricity is that of the inter-
stitial variety, in which the new tissue is uniformly
distributed throughout the uterus, enlarging it to a
symmetrical tumor of varying sizes, and proportion-
ately expanding the uterine canal. These cases are
almost invariably of the hemorrhagic variety because
of the expansion of the uterine mucous membrane.
The hemorrhage occurs as an exaggerated menstrual
flow. These tumors vary in size from a growth the
size of one's fist to a tumor filling the abdomen with
a uterine canal many inches deep. Those not exceed-
ing six to eight inches in length and three to four
inches in lateral diameter are the ones in which elec-
tricity accomplishes the best results.
METHOD OF PROCEDURE.
We seek in these cases, a, to transmit through
these tumors, for its electrolytic effect, as strong a
current of galvanism as the patient will bear, without
severe discomfort, and, at the same time, not to
severely cauterize the tissue at the poles, b, We seek
to get acid accumulation at the positive pole located
in the uterus, of sufficient density to coagulate the
tissues and thus lessen the bleeding c, This same
acid at the positive pole we expect to combine with
the cojji^er of the electrode and form salts, which salts
in solution, by the cataphoric action of the current
will be driven into the uterine tissues, immediately
surrounding the electrode, and as a styptic materially
aid in curing excessive flow, d, We seek further to
59
obtain the powerful antiseptic effect as the result of
chemic changes occurring around the internal elec-
trode, in order to cure the endometritis which almost
invariably exists as a painful accompaniment of
fibroids.
After an antiseptic vaginal douche the patient to be
treated is placed upon a table on her back with her
buttocks drawn well to the edge and feet supxDorted by
stirrups. The size, shape and direction of the uterine
canal is obtained by the use of large, flexible sounds.
A large copper electrode, then, of suitable diameter, is
properly shaped and passed to the bottom of the
uterine canal, and the vaginal portion insulated with
the'rubber muff. This electrode is then attached to the
positive terminal of the battery. A clay, or the writer's
membranous abdominal electrode, is next passed under
the loose clothing and placed on the abdomen and
then attached to the negative pole of the battery.
The current is now gradually turned on while the
milliampere meter is carefully watched and the fea-
tures of the patient are closely scanned for signs of
pain, until the current reaches 100 to 150 or even 200
milliamiDeres, according to the tolerance of the
patient and the size of the active internal electrode.
If the active electrode is of the ordinary diameter of
from 3 to 5 millimeters, a current strength of 100
milliamperes can be used safely in any particular
case for every two inches in length of this electrode
which is active. To he more accurate, the current
should not exceed in strength 25 milliamperes for each
square centimeter of active surface of the internal
electrode.
So that in the general run of cases one can safely
give the patient as strong a current as she will bear
without danger of producing excessive cauterization
at the active pole. This will vary from 100 to 200
milliamperes. The time of each treatment should be
five minutes for the maximum current employed.
The treatment should be given as often as every sec-
ond day. Except in cases of continuous flowing, the
60
treatments are best given between the menstrual
periods.
These cases begin to improve almost immediately.
The lirst improvement is in relief of neuralgic and
so-called pressure pain. In a few days they find that
their general strength is improved. Reflex disturb-
ances such as stomach irritation, palpitation of the
heart, occipital headache and backache will be re-
lieved. The patient will begin to eat and sleep nat-
urally. There is a general feeling of well being
engendered. In a few days the leucorrhea or puru-
ent discharge from the endometrium will diminish.
As the patient arrives near the menstrual period, she
finds that the old premenstrual aches are not present,
the old despondency is absent. If the treatment has
been sufficiently active the menstrual flow will arrive
without iDain frequently. Occasionally, the first
month, the flowing is fully as free as usual, although
frequently it is much less. If the treatment is con-
tinued for two or three months these patients will
begin to maintain that they feel perfectly well.
All the old distressing symptoms will very often dis-
appear entirely, they will gain flesh and the uterine
discharge will become normal. While the tumor will
still be apparent to the physician's examination it
will almost invariably be found to be much dimin-
ished in size. When the time arrives in the treatment
that these patients are symx^tomatically cured, that
is when they feel no symiotoms, I usually discharge
them. I always inform them that the tumor has not
disappeared, and that sometime it may again give
them the old difficulties. As long as they are free
from these they may be satisfied that the tumor
is not growing — on the contrary decreasing in size.
However, if the old symj)toms begin to return I
instruct them to seek relief again in the electricity.
The above treatment applies to the typical bleeding
fibroids of interstitial variety.
Where the uterus is large and the canal is deep, it
is necessary sometimes to attack the mucous mem-
61
brane by piecemeal, in order to get sufficient concen-
tration with the dose tolerated to accomplish sufficient
changes in "the endometrium to check hemorrhage.
The concentration necessary should approximate 25
milliamperes for each square centimeter of the elec-
trode in contact with the mucous membrane. For
examiDle, if a patient will only bear a current of 100
milliamxDeres, one should select an electrode of copper
or zinc or platinum with a diameter of proper dimen-
sions, insulated to all but 4 square centimeters of its
distal end. The depth of the canal is measured. Then
commencing with the distal end of the cavity, the
exposed active surface of the electrode is made to
cover in successive treatments its whole surface. By
doing this the whole mucous membrane is acted uj^on
uniforndy without employing at any time a larger
dose than 100 milliamperes.
INOPERABLE AND COMPLICATED CASES.
The cases which are referred to the writer for elec-
trical treatment, in these days when active surgery
offers such a large percentage of recoveries from hys-
terectomies^ are for the most part complicated cases,
which the ordinary surgeon shuns.
One complication which frequently induces the sur-
geon to shift the responsibility of these cases, is that
of severe purulent metritis and endometritis, accom-
I^anied frequently with discharges of gangrenous
masses from submucous fibroids, all accompanied with
much pain, more or less hemorrhage, and with the
discharges inclined to be very offensive. The patients
are usually poorly nourished, with white and waxy
skin in consequence of septic absorptions. When
they reach this stage they are frequently pronounced
malignant. The outlook for an operation certainly is
not flattering.
Now the writer has been honored frequently by
having such cases sent to him for electrical treatment,
by different friends of his who are conscientious sur-
geons.
62
What have we to deal with? Usually a tumor of
large size extending to the navel. It is soft, with
nodular masses projecting from its peritoneal surfaces.
The cervix is soft and patulous, with a canal large and
irregular. Sometimes a small nodular mass is pre-
senting at the cervix, This is usually soft and easily
broken down. The endometrium and all cavities from
which masses have been projected or from which
masses have sloughed away are infected and ulcerat-
ing, and emitting a discharge which rapidly becomes
offensive. From the large mucous membrane periodic
and irregular uterine discharges are occurring, serving
to swell the already copious outpour.
The writer has treated by electricity and symptom-
atically cured several of these cases in which a diag-
nosis of cancer had been made by men of more than
ordinary talent.
I prefer, when it is practicable, to dilate the canals
carefully in these cases, and remove with a dull curette
the sui3erficial debris before beginning the electricity.
I then select one of the largest copper electrodes
which can be inserted and make it the active positive
pole, inserting it to the bottom of the canal with its
whole surface uninsulated.' With the abdominal elec-
trode in place, a current is gradually turned on until
a strength of 200 milliamperes is reached, or the max-
imum amount under that strength that the patient
will tolerate.
These treatments should be given every other day.
Antiseptic douches should be employed night and
morning.
These cases respond rapidly. The powerful anti-
seijtic action on the mucous membrane makes itself
apparent by the decreased odor of the discharge. The
passing and withdrawing of the electrode opens and
provides free drainage for the secretions. The tissues
become tanned by the salts of copper which are forced
into them by catai)horesis, and the discharge of blood
is lessened. The patient is toned by the general efPect
of electricity on her system. In a word, it is fre-
63
quently marvelous what a transformation will take
place in these apjmrently hopeless cases in a few
weeks of judicious galvanic treatment.
While these cases are apparently hopeless, often-
times when they are "given over' by the surgeon,
they are frequently symi)tomatically cured by this
simple remedy. The writer has a long list of such
cases, and they constitute some of the most satisfac-
tory work he has ever had placed to his credit.
INOPERABLE TUMORS TREATED BY OTHER THAN THE
INTRAUTERINE METHOD.
There is a class of comi^licated cases of difiPerent
kinds in which it is impossible, because of the contor-
tions of the growth, to enter the uterine canal with
an electrode. Occasionally the tumor has displaced
the cervix so that it is drawn high in the vagina above
the bladder, out of reach of finger or sound; while
again it is drawn up posteriorly with the uterine canal
forming an acute angle with the vagina. In all cases
where it is imjoossible to reach the canal, if they are
treated by electricity, it is necessary to employ it
without the advantages of an intrauterine electrode.
Only in the most desperate cases, in which submit-
ting to an operation is clearly suicidal, would one
think of employing electricity as a means of treat-
ment, when an intrauterine electrode was impossible.
But it is in just these cases, with their distressing
neuralgic and pressure symptoms, with dyspeptic com-
plainings and bowel irritations, the result of reflex
nerve disturbances, in which an operation is discour-
aged, that we find patients ready to catch at any straw.
In many of these cases I believe that electricity not
only offers a straw, but a veritable lifeboat to their
despairing bodies.
When an intrauterine electrode is not practicable,
then we should employ some other form of internal
electrode which will have the effect of causing the
current of galvanism to pass directly through the
largest portion of the tumor.
64
If the vagina is not distorted so but that a vaginal
electrode may be employed, that instrument should be
used (Fig. 7), placing its active point posterior to
the tumor. This should be made tiie negative pole.
The abdominal electrode should be placed in such a
position that the largest diameter of the tumor is
interposed between it aiid the vaginal electrode. A
current of 50 to 100 milliamjjeres may be safely em-
ployed, if tolerated, for a period of five minutes. The
treatments may be given as often as every second day,
and in a few cases every day where it is well borne.
When a vaginal electrode can not be employed to
advantage in these cases, a rectal electrode (Fig. 8)
should be employed. This should be placed well up
opposite the tumor. It should be employed as the
Figure 7.
Figure 8.
negative pole. It should have an active surface of
more than eight centimeters and the current should
never exceed 200 milliamperes.
All we can expect to accomplish in this treatment
is that beneficial action derived from passing a strong
direct current through any tissue containing muscles,
nerves, lymphatics and blood vessels, viz., a powerful
trophic stimulation to the part, and incidentally a
powerful general tonic effect on the general system.
These cases get great relief. Neuralgias stop.
Troublesome abdominal reflexes cease. Circulation
is improved. Nutrition is stimulated. Sleei)lessness
disappears. Bowels are stimulated and relieved of
troublesome distension symptoms. The tumors often
seem to decrease in size. The degree to which each
65
of these symptoms are relieved varies, of course, much
in individual cases. The writer has seen a large num-
ber of cases completely and for an indefinite time,
relieved of all these symptoms. In fact, some of the
most gratifying cases of relief he has, are of this
variety„ Their cases are apparently so hopeless that
often any relief is very gratifying.
LECTUKE VI.
SURGICAL environments: operating room; steril-
izers; STERILIZING INSTRUMENTS, LIGATURES AND
hands; CATGUT PREPARATIONS; PREPARATORY
AND AFTER TREATMENT OP PATIENTS.
DRAINAGE.
The environments of a patient who is about to submit
to a surgical oiDeration for a fibroid of the uterus must
be made surgically clean.. These environments include
operating room, bed, sterilizers, instruments, ligatures
and operators' and assistants' hands and clothing.
OPERATING ROOM.
In a imvate house a room should be selected which
has direct light through one or two large windows; a
room which can be stripped of furniture, hangings
and carpets. It should be convenient to the bedroom
of the patient, or better the bed can be placed in the
room in readiness for use when the o^oeration is fin-
ished — the operating room constituting the bedroom.
The woodwork of this room should be thoroughly
scrubbed with soap and water, and the walls and ceil-
ing carefully wiped free of dust. The room should
be thoroughly aired by opening the windows and a
reliable means of heating should be at hand in order
to render it dry and to keep it at a temperature of
80 degrees F. when required. The table, which is
selected for the operating table, and the stands for
instruments and dressings, together with all recep-
tacles or slop tubs and basins should be carefully
scrublx^d and then conscientiously wiped with a 1:500
solution of chlorid of mc^rcury. All tin, iron or i3orce.
lain basins should be boilM for one-half hour in a wash
67
boiler or other large boiler, as a means of sterilization
Tho bed, if possible, should consist of a hair mat-
tress which has recently been purified by steam. In
a hospital a largo steam sterilizer should be jirovided
where hair mattresses can be sterilized frequently.
The bed should be comjjleted with dry sterilized
sheets, blankets and pillow slips. If there is no
sterilizer at hand the bedding can be sterilized by
boiling in water one-half hour, and drying in a pure
room, and ironing with a hot iron by an intelligent
attendant or nurse. Growns, towels and aprons should
be sterilized in the same manner as the bedding, pro-
vided there is no regular steam sterilizer at hand.
In an institution the operating room should have
floor and walls of such material that they can be thor-
oughly washed with antiseptic solutions and jjrovided
with a central drain which will allow the cleaning of
the walls and floors with water direct from a hydrant
through a hose. The drain should be reliably trapped,
or better, drain directly in to the external air. For
convenience, a perfectly fitted oj^erating room should
have several anterooms, including a preparatory room
where the solutions are prepared, the water sterilized,
and where the heating apparatus for the sterilizers
and the sterilizers themselves are located. This room
should have washable walls. There should also be
one or more anesthetizing rooms, and finally there
should be convenient dressing and wash rooms for
the surgeon and his assistants. The private operating
room which I use at the Woman's Hospital is shown
in Fig. 9. It has direct side light and a large skylight.
Its walls and floors are of marble. It is lighted at night
entirely by incandescent electric lights, gas being
impracticable where an anesthetic is necessary; these
lights are in abundance, so that an operation can be
performed equally well at night or day. The prepar-
atory room is adjacent. This is shown in Fig. 10.
It is entirely in marble. The battery of Boeckmann's
sterilizers is shown in the foreground. In the far-
ther end are two large tanks in which the water is
68
sterilized for the operation, one being filled with cold
sterilized Avater and the other with hot water. They
are connected with the operating room by large fau-
cets which pass through the wall. Directly otf from
this room is an anesthetizing room, and adjacent to
this are two dressing rooms with washing utensils.
In the oj)erating room is a spectators' rail which sep-
arates the ojDerator, assistants, nurses and all operat-
ing paraphernalia from those who may be invited to
vritness operations.
Sterilizers. — In a private house, in emergency cases,
an ordinary copper or tin wash boiler may take the
place of the most elaborate sterilizer. The gowns,
towels, gauze operating sheets and all large articles
used externally can be thoroughly sterilized by boil-
ing for thirty minutes. For sterilizing instruments,
silkworm gut, silk and other smaller articles a smaller
kitchen article such as a sauce pan, or porcelain-
lined flat pan, may be utilized as a sterilizer.
In large institutions large steam sterilizers are em-
ployed. I have used the Arnold sterilizer for dress-
ings and instruments and other small articles until
quite recently, since which time I have adopted for
my hospital work the Boeckmann steam sterilizer (Fig.
11). These sterilizers are simple in construction, dur-
able, inexpensive, efficient for all work, even the steril-
ization of catgut, and they possess the advantage of
sterilizing with steam, while at the same time when the
process is finished the articles are left perfectly dry.
At the Woman's Hospital several of these sterilizers
are employed and everything that is liable to be
required in several operations is sterilized, and the
unopened sterilizers are placed in the operating room
for future use. Surgeon's and nurses' gowns, towels,
gauze, silk and silkworm gut in cotton -stoppered test
tuVjes are removed as they are required at the time
oi the operation, while a separate hot water sterilizer
(Fig. 12) is employed immediately before the opera-
tion for steriliziug iho instruments.
Lif/atures.—l employ braided silk, silkworm gut
71
and catgut for sutures and ligatures. Silk and silk>
worm gut I sterilize by boiling, or by steam in the
Boeckmann sterilizer. They are placed in small skeins
in large test tubes loosely stoppered with cotton and
subjected to a temperature of boiling water for twenty
minutes on two successive days when t have no sterilizer
at hand, and to the temperature of the superheated
steam for a like length of time in my hospital work. I
only open at the operation a sufficient number of tubes
^^
Figure 11.
for the operation in hand, the balance being reserved
for future cases. Tubes of silk and silkworm gut may
be prepared in considerable numbers and sterilized by
steam with an efficient cotton filter and afterward car-
ried to operations anywhere. On opening, the cotton
stopper is first burned down low with the tube, then
removed and the skein of material carefully lifted out
72
with sterilized forceps and placed in sterilized water
when it is ready for use.
Cat gut is the form of absorbable ligature which I,
employ for buried sutures. I have it sterilized in the
Boeckmann sterilizer with dry heat at a temperature
of 284 degrees F. for a period of three hours. Previ-
ous to sterilization, the catgut, cut in suitable lengths,
is wrapped in oiled paper, one thread in each paper
and the paper enclosed in small hermetically sealed
envelopes. While this accomplishes perfect steriliza-
tion, as can be demonstrated by bacteriologic tests it
has been argued that sterilized catgut may act as a
very favorable nidus for the growth of pathogenic
germs in tissues in which it is buried, tissues which
Figure 12.— Boeckmann*s Instrument Sterilizer.
without the presence of this i)erfect sterilized culture
medium would be competent to resist the few germs
left in a wound, after ordinary surgical precautions
had been exerted. For this reason I not only render
my catgut aseptic with heat but I sui)plement that
process by saturating it with non-poisrmous antisep-
tics. According to Arthur Wocxlward Booth's admir-
able article in the TJirrdpculir (Jfrzcffr, December,
1894, he found that pyoctanin blue in a 1 to 1000
alcoholic solution will render catgut thoroughly anti-
septic and at the same time imjjart to it a longer life.
Pyoct?inin is a much more i)owerful antise])tic than
chromic acid and therefore may be employed in more
73
diluted form. Compared with bichlorid of mercury it
is a more perfect germicide, non-poisonous, and it im-
parts a longer life to the gut. Catgut saturated with
pyoktanin becomes an antiseptic suture, the antiseptic
of which can in no way prove a source of danger.
THE writer's method OF CATGUT PREPARATIONS.
A skein of new catgut is cut into about four lengths.
This makes the threads of about forty inches each.
Each section of the skein is twisted into a loose knot
and they are soaked in ether for twenty-four hours in
order to remove the fat. It is then boiled in alcohol,
in a closed jar, for one hour in the steam sterilizer.
Before boiling in alcohol the bunches are divided into
their separate threads and each thread twisted into a
little coil. After the sterilization by alcohol it is care-
fully removed from the jar by an intelligent conscien-
tious nurse, with sterilized forceps in sterilized hands,
to a jar containing a solution of pyoctanin 1 to 1000
in absolute alcohol. Here it is allowed to remain for
twenty-four hours in order to become thoroughly sat-
urated with that powerful antiseptic. I then have it
distributed into small wide-mouthed one-half ounce
bottles, containing oil of juniper. Into each of these
bottles about four of the forty-inch strands are placed.
The bottle is then corked with a rubber stopi^er and
is not opened until it is to be used at an operation,
when the catgut is threaded directly from the bottle.
The bottle, or several bottles, with their rubbsr stop-
pers may be immersed in a 1 to 1000 bichlorid solution
on the instrument table ready to be opened by the sur-
gical nurse in the course of the operation. After it
has once been opened I discard any small amount of
catgut which may remain after the operation, prefer-
ring to use always from a fresh supply.
Instead of boiling the catgut in alcohol it may be
sterilized in closed enveloi^es in the Boeckmann ster-
ilizer as before described, at a temperature of 284
degrees F., and then treated from that point in the
same way as that sterilized by boiling in alcohol.
74
It seems to me that this is an ideal and simple
method of catgut preparation. There can be no doubt
of its absolute sterilization after it has been boiled in
alcohol for two hours, or after it has been submitted
for three hours to a temperature of 284 degrees F. in
the sealed enveloi^es in the Boeckmann sterilizer.
Dr. Booth found that pyoktanin permeated every
fiber of catgut when it had lain in a 1 to 1000 alcoholic
solution of the drug for twenty-four hours.
Dr. Booth quotes Sternberg as quoting Jaenicke on
the antiseptic properties of pyoctanin as follows:
Staphylococcus pyogenes aureus restrained by solu-
tion of 1 to 2,000,000; bacillus anthrax aureus re-
strained by solution of 1 to 1,000,000; streptococcus
pyogenes aureus restrained by solution of 1 to 333,000.
In blood serum stronger solutions are required.
Thus we have not only a sterile catgut, but we have
that sterile catgut thoroughly saturated with an effi-
cient and non-poisonous antiseptic. The juniper oil
preserves the catgut indefinitely, it fixes the pyctanin
so that it will not stain the hands, and it keeps the
catgut soft and pliable.
The life of the catgut in the tissues prepared by this
method is a little less than that prepared by chromic
acid, but considerably longer than that prepared by
bichlorid of mercury. By placing it in small bottles
it can be handled economically without the necessity
of ever being obliged to open twice the same supply.
Spomjes. — Sea sponges are not safe when prepared
under the most careful supervision, whereas gauze
sponges may be perfectly reliable whenever there is
the simplest device at hand in which they may be
boiled.
The best gauze sponges are made from loose-mesh
gauze folded into three or four thicknesses, with the
edges fastened with a running stitch of cotton thread.
They may be made of any size. These sponges are
sterilized in a steam sterilizer, or in emergency cases
they may be sterilized by })oiling with the instruments.
In laparotomy cases I prefer those sterilized by the
76
dry metliod. They are then used but orice and are
discarded. This is not economical because of the
large number of sponges frequently required, nor is it
necessary. The advantage possessed by the dry sponge
is in the increased absorptive power of the gauze.
Gauze. — The writer has devised an apparatus in
which to sterilize gauze for operations, either for hos-
pital operations or o^^erations away from home. Chas.
Truax, Greene & Co. kindly constructed this apparatus
for me, as well as the furniture shown in the operating
room in Fig. 9. It consists of a little stand which fits
into the catgut sterilizer of the Boeckmann ajDparatus,
or which can be set into any steam sterilizer (Fig. 13).
Figure 13.
Figure 14.
The stand contains seven large test tubes, two inches
in dicimeter, and about eight inches in length. In
each of these tubes can be placed all the gauze of any
one kind that will be required at any ordinary oi)era-
tion, which is about two yards of sheet iodoform gauze.
Ordinarily I have two tubes filled with iodoform sheet
gauz(^, one with j^lain sterilized gauze, one with one-
inch strip i(jdoform gauze cut the strong way of the
cloth, one with two-inch strij) iodoform gauze cut in
the same way, and one with a skein of silkworm gut
and a skein i)i braided silk. These tubes are loosely
filled and tlieir mouths closed with cotton. They are
then Bu})jected U) steam sterilization in the Boeck-
78
mann or other steam sterilizer at maximum heat for
one hour. They are then set aside and the following
day they are again subjected to the superheated steam
for one hour, and then dried by removing the cork in
the top of the Boeckmann sterilizer so as to get the
action of the diy heat. The contents of the tube are
now thoroughly and permanently sterilized, and will
remain so for weeks if the cotton stoppers in the
mouth of the tubes are not removed.
When I wish to preserve these tubes for indefinite
use I have the nurse slip a sterilized rubber cap over
the cotton and the end of the tube before removing
them from the sterilizer. They may then be set aside
for an indefinite time.
When I wish to operate away from the hospital, I
place the rack containing the tubes required into a
metal box (Fig. 14), and that in turn is stored away in
my instrument bag.
Preparation of Operator and Assistants. — It
should not only be taken for granted but should be
insisted on, that any and all persons participating in
the high calling of surgery should take a general bath,
including the hair, every day.
Dress. — For important operating, such as we have
to deal with, special dress for the oj)erator and assist-
ants is indispensable. Suits of white ducking or
linen should displace the street apparel. Over this
sterilized gowns should be worn. In this dress the
operator can be comfortable and do hard work in a
temperature of 80 degrees F. When he is through
oi^erating all wet clothing, made so by perspiration
and the fluids of the operating room, can be replaced
by his (ordinary dry out-door dress and the reminders
of the operating room are left behind.
Preparation of Hands. — After the nails are filed
.short and smooth the hands and forearms should be
thorougldy scruV)l)ed for fifteen minutes in hot water
with a stiff nail brush and plenty of pure soap. The
water should be changed at least five times. The time
should be estimated by an actual time piece and not
79
by guess work. A nurse should supervise this part
of the work in imx3ortant operations, and report to the
responsible chief any laxity on the part of any partici-
pant. The spaces beneath the nails should be thor-
oughly brushed and the undersurface of the nail
scraped with a steel nail cleaner. After the soaj) and
water scrubbing, the hands should be washed in alco-
hol and then immersed in 1:1000 biohlorid of mercury
solution, and this solution brought into contact with
all irregularities by means of the hand brush. The
hands should, finally, be rinsed in warm sterilized
water. Before beginning the operation the hands
should be rinsed in hot water which is placed in a
basin close to the operator, so that it may be used from
time to time during the operation. After the hands
are once washed they should not be allowed to come
in contact with anything before or during the opera-
tion which is not surgically sterile.
A7Tangetnent of OperatiiKj Room. — The steam or
dry heat sterilizers containing dressings should be
convenient to the nurse. Reservoirs of sterilized
water, hot and cold, should be i)laced near the sponge
table. Two large glass irrigators should be at hand.
The table with which the Trendelenburg position may
be obtained is necessary, and should be placed in an
advantageous position for light and assistants. For a
laparotomy, the arrangement of the furniture and par-
ticipants of the operating room should be approxi-
mately as follows: The table near the center of the
room with the head of the patient near the chief win-
dow. Anesthetizer at head of patient. Operator on
right of table (from head). Chief assistant and assist-
ants opposite the operator with the chief nearer the
head of the table. The surgical nurse in charge of
instruments at stand to right of operator. Nurse in
charge at foot of table with sponge dish on small
stand in reach of second assistant. Assistant nurse to
her right, the latter to work sponges, and to attend to
irrigators, sterilized water, etc. Superintending nurse
without regular assignment, ready for emergency. To
so
left of operator, small table with sterilized solution for
hands. Back of the assistants a similar table. Visit-
ing physicians, admitted after everything is ready for
the operation to begin, are arranged around the room
out of reach of the operating corps, or any concerned
in the oi3eration.
If the case is one where a vaginal operation is
required, the head of the patient is directed away
from the window, and the patient in the exaggerated
lithotomy position is placed with the buttocks directed
toward the light. The limbs are supported on either
side by two assistants. The operator sits at the foot
of the table with the instruments at his right hand.
To the left is the nurse with sponges and the irrigator.
PREPARATORY TREATMENT OF PATIENT FOR LAPAROTOMY
OR VAGINAL OPERATIONS.
Kidneys. — The failure to recognize obscure kidney
disease in jiatients before submitting them to a severe
operation has been the cause of many avoidable deaths.
We should not only recognize kidney difficulties in
every case but we should also know when a case is
laboring under some form of kidney trouble, whether
that stage has been reached beyond which it is safe to
proceed. It is not enough that the urine in any given
case is approximately of normal quantity, of approxi-
mately normal specific gravity, and that it gives
negative results in tests for albumin and sugar. It is
necessary to learn the history of the case, to estimate
the sijecific gravity in a twenty-four hour specimen, to
ascertain the amount of urea for twenty-four hours,
and supplement this with a thorough and complete
microscopic examination.
In diabetes we should not operate. In interstitial
nepl iritis when the disease is not far advanced an
oi^eration may be risked with proper preparatory treat-
ment. These latter cases arc^ tlie very ones which from
their great difficulty of diagnosis are often neglected,
and consequently disaster results. The importance of
the suVjject must be my excuse for entering into
81
primary details. The following summarizes the signs
of chronic interstitial nephritis: Lowered sj^ecific
gravity of urine; patient arising at night to void
urine (when there is no bladder or urethral disease
to give rise to such a procedure); an enlarged heart
with accentuated second sound; a tense pulse and
diminished urea. Albumin is frequently absent. The
diagnosis is doubly sure when hyaline casts are
found.
Every patient should be scrutinized in all these
points. If the foregoing state of affairs exist to a
marked degree I refuse to operate. If, however, with
the above symptoms I find a normal quantity of urine,
which does not show a reduced specific gravity under
1010 to 1014 and the amount of urea does not sink
lower than six or seven grains to the ounce, if the
patient is w^ell preserved generally without advanced
heart disease, I am confident that I can operate with
safety, if I can secure proper preiDaration.
I i^repare these patients, first by placing them on
an exclusive farinaceous diet w^ith miik and fruit for
an indefinite number of days before the operation. A
week or ten days before the operation a diuretic is
added with instructions to drink large quantities of
water, the object being to increase the daily quan-
tity of urine from 60 to 100 ounces, in order to thor-
oughly flush the kidneys and rid the patient of dan-
gerous accumulations. With 60 to 100 ounces of
urine flowing for several days, with the patient living
on a non-nitrogenous diet, with the urea in improved
proportion considering the diet, I feel safe in risking
an operation.
Dr. Charles W. Purdy, who has had an enormous
experience in watching the behavior of kidney diseases
under oj^erations, says in reference to chronic parcii-
ch}jmafo}iS nephritis: "I see no reason why these
cases, if unaccompanied with dropsy may not be ope-
rated upon if carefully selected."
Boivch. — In prei^aring patients for an ordinary
laparotomy I begin preparations of the bowels two
82
nights before the morning of the operation. The
first point is to seek thorough emptying of the bowels
throughout their entire length. The second point
should be to render their contents thoroughly aseptic
and the third should be to impart to them a maximum
tonicity.
The bowels are emptied by means of mercurials and
salines. The first night of ^preparation, six grains of
blue mass are given. The next morning at 6 A.M., one
drachm doses of citrate of magnesia are given every
hour until the bowels move, or feel as though they
would move with the aid of a small enema. This
ought to insure a thorough movement of the entire
length of the intestinal canal. If the movements are
such, with the above treatment, to insure a thorough
evacuation, and to start a free flow of bile, as indi-
cated by the yellow glistening appearance of the stool,
no further catharsis is necessary. The lower bowel
should be thoroughly evacuated, however, by the
employment of large enemas of soap and water,
repeated four or five times during this second day of
preiiaration. The last enema should be given late in
the afternoon of this second day of preparation, if the
operation is to be done the following morning, and
the next morning if the ox)eration is to bo iDerformed
in the afternoon. The bowels are rendei"ed aseptic by
large doses of bismuth and salol. During the first
and second days of jn-eparation, gr. x of salol and gr.
XX of subnitrate of Insmuth should be given every
six hours.
The bowels are stimulated by means of carminatives,
alcolujlic stimulants and strychnin. The second day of
I^rei^aration 1 drachm doses of tr. of cardomon in one
ounce of brandy are given every six hours. Strychnin
is commenced three days before Iho o])eration iii 1-40
gr. doses every eight hours, andgradually increased in
quantity until 1-20 gr. doses are given. The bowels
should be kejjt in a thoroughly as(^])tic condition by
feeding the patient a milk diet for two days lu'fore
the ojieration.
83
External Preparations of the Patient. — The i&rst
day of the preparation the patient should receive a
thorough general bath and then be placed in clean
clothing and a clean bed. The abdomen should then
be rubbed with a saturated solution of permanganate
of potassium until it is of a uniform mahogany color.
This should be scrubbed off by means of a si^onge
or brush and the application of a saturated solution of
oxalic acid. A green soap compress should be
bound on the abdomen, this latter to remain all night.
Vaginal douches of, first, soap and water; second,
1 :5000 bichlorid solution, and third, plain sterilized
water should be employed this first night. These
should be repeated the night before the operation,
and a last vaginal douche given immediately before
the operation. The second night of preparation should
begin with shaving of the abdomen and pubis, and
should be followed by applying a bichlorid comjoress.
Immediately before the operation, after this compress
is removed, the abdomen should be scrubbed with green
soap and hot water, this to be followed w4th alcohol or
ether, and covered with an antiseptic towel until the
incision is made.
The bladder should be evacuated by means of a
catheter immediately before the operation.
Dress. — The patient is to be put in a long, loose,
woolen night gown immediately after an operation,
and is thoroughly covered, except the abdomen, with
flannel blankets during the oi:)eration.
Operation. — I am suspicious of an operator who
operates on time. The best operators are those who
oj)erate w^ell in the smallest space of time; this
implies that the best operators are slow operators.
An abdominrd incision should be a clean, true, unhag-
gled cut, so that accurate coaptation is possible. Cold
sponges should be employed on the external incision
in order to contract the capillary vessels and check their
bleeding without the necessity of forceps. Forceps
should be employed, however, everywhere in abdomi-
nal surgery that their use will save blood, because
84
most of our old-fashioned shock was caused by unnec-
essary loss of blood. Keep the operative field free
from oozing points if possible, even at the loss of a
little time. The peritoneum is best opened between
two catch forceps elevated so as to present a
thin fold. After a small opening is made, the finger
passed into the cavity should act as a guide upon which
to complete the incision. The peritoneal edges should
be attached to the integumentary edges by means
of catch forceps, to j)revent its peeling off from the
abdominal walls in the subsequent manipulation. In
all j)elvic surgery of smaller tumors the pelvis should
at this point be elevated by means of the Trendelen-
burg table ; the elevation being sufficient to draw the
bowels away from the field of operation, and to elevate
the contents of the pelvis. Sterilized silk or catgut
should be employed for any pedicle which it is safe to
tie and drop. Catgut may be employed to close sim-
ple peritoneal rents.
Drainage should be employed in all cases where
extensive enucleation has occurred, where there is a
slow venous oozing from separated adhesions or where
aseptic matter has in any way contaminated the peri-
toneum. Drainage, in competent hands, never does
any harm, therefore, where there is the slightest
doubt, it should be employed. It has saved many
lives, and made more comfortable those who might
not have died without it, but who have 'been given
the advantage of it.
After my operation is finished, the peritoneal cavity
is thoroughly dried; then if there has been at the
operation a process of enucleation, leaving of neces-
sity slight oozing points, or in cases where ordinary
adhesions have bjeen separated, after drying the cav-
ity as far as i)ossible, I place in the cul-de-sac a glass
drainage tube and puirip out any remaining fluid.
I next protect the abdominal contents from the
abdominal wound with a large flat sponge, and insert
the sutures^ after which I again pump the drainage
tube. If there is more than a drachm of bloody fluid,
85
I leave the tube in until the sutures are nearly all tied
and the sponge removed; then I make a last trial of
the tube. If the fluid amounts to one-half drachm or
more, and is bloody, I allow the tube to remain; if,
on the contrary, it is nearly dry, or the contents
is simply colored water, the result of flushing, if
it has been employed, I remove the tube. What has
been done influences one in regard to drainage. I
almost invariably drain after it has been necessary to
flush. I believe the peritoneum is satisfied, to an
extent by the flushing, and will consequently neglect,
in a degree, to absorb any remaining fluid. Ex-
perience seems to sustain that argument. Mikulicz
drain is almost indispensable in a limited number of
cases. Cavities may be packed with gauze which can
not be reached with glass drainage tubes. Hemor-
rhages in cavities so packed will cease, when a glass
drain would not avail. Operations are now possible
with the Mikulicz drain which were impossible with-
out it. The question about drainage is not, shall we
drain, but how, and how often.
To Prevent Intestinal Ohstruction. — In abdominal
surgery one is constantly watching the behavior of
the intestines. They are our prominent point of
attack in our preparatory treatment, they are our
greatest source of anxiety during the operation, and
upon their management after the oi3eration much
watchfulness is imposed. All of this anxiety is caused
by our desire (with the exception of care against
wounding when operating) to prevent obstruction.
It, therefore, is a point in the technique of this work
to which discussion may profitably be directed.
The pathology of obstructions is well summed up
by a valuable contribution on this subject by Dr.
Ashton, of Philadelphia, from which I quote:
"Adhesions between the intestines and raw sur-
faces: a, to an omental stump; b, to the edges of
the vaginal wound following supra-pubic or vaginal
hysterectomy ; c, to a pedicle ; (/, to raw surfaces on
the intestinal wall.
86
"2. Paralysis of the intestines.
"3. Local spasm of the intestines.
'•■4. Impacted feces.
"5. Bands of inflammatory lymph.
''6, Adhesions between coils of intestines or
between the gut and neighboring parts, due to trau-
matic inflammation.
"7. Kinking or twisting of the intestines, due to
faulty technique.
"8. Including the intestines within the loop of a
suture of the abdominal wall, or between the edges of
the abdominal incision.
"9. Slipping of a coil of intestines through a slit or
an aperture."
Under the first head, "Adhesions between the intes-
tines and raw surfaces," we must seek our remedy
daring and following the ox3eration. Intestines should
be handled and ex^Dosed as little as possible in order
not to produce hyperemia or denudation of their sur-
faces. An omental stumj^ of any considerable size
should be selveged by inverting its raw edges with a
running catgut, or with ligature. When denudations
of the pelvic or intestinal pertioneum can not be rein-
forced by a suj)erabandance in the neighborhood, care
should be taken to carefully arrange the intestines in
as near the normal position as jjossible. A pedicle of
large size should be covered by securing over its end
the peritoneal covering with a running stitch of cat-
gut. Raw surfaces of any considerable size on the
inte.stines should be covered with peritoneum if joossi-
ble, with the edges well secured. Paralysis of the
intestines may be avoided by emptying them thor-
oughly previous to the operation of all irritat-
ing matter (which may ferment and cause dis-
tensi(m ) by rendering the contents aseptic by means
of bismuth and salol, and the employment of full
doses of strychnia to act as a muscular tonic. Car-
minatives, such as wintergreen, cardamon, etc. may
also be employed as antiseptics and inuscular tonics.
During the oj^eration the intestines should not be
87
handled or chilled in order to avoid paralysis. After
the operation, nourishment of non-fermentive and
easily absorbable nature should be employed. The
bowels should be stimulated to early action in order
to keep them empty and avoid the beginning of dis-
tention, which soon leads to f)aralysis. An early move-
ment of the bowels, or free passage of flatus, assures a
normal disposition of the bowels as regards location.
If they adhere after such time, it will be in an advan-
tageous, not cramped position.
A flat sponge beneath the abdominal wound, after
carefully spreading down the omentum and before
the wound sutures are inserted, will avoid including
an intestine within the loop of a suture, or between
the edges of the abdominal wound.
When ventral fixation of the uterus is practiced,
great care should be exercised in disposing of the
intestines in such a manner as to avoid their slipping
through the opening left between the uterus and the
abdominal wound.
AFTER-TREATMENT.
The immediate after-treatment consists in stimulat-
ing the i^atient out of any tendency to nervous shock
which may exist. She should be surrounded in bed
with dry heat, and in hospitals x^laced on a water bed.
If there has been any considerable loss of blood, the
feet may be elevated in order to restore blood pressure
in the brain. In severe cases of shock from loss of
blood, it is well to bandage the blood out of the lower
extremities by means of elastic bandages. A saline
solution under the integument may assist to fill the
blood vessels. Oftentimes the difficulty is not lack of
fluids so much as lack of tone, which allows a patient
to bleed to death, as some one has put it, "into her
own dilated capillaries and venules." Here direct
arterial stimulants and vaso-constrictor remedies are
called for, as well as strong nerve stimulants. la
these cases, I immediately order hypodermics of nitro-
glycerin, strychnin and digatalin. Stimulating ene'
88
mas of whisky and warm water may also be given.
What is done for shock should be done promptly, as
patients who are allowed to go on for a few hours
with a sub-normal temperature and high pulse, are
with great difficulty restored.
Dressing Glass Drainage Tube. — The glass drain-
age tube, when it is allowed to remain, should be
emj^tied with a syringe with a long rubber nozzle the
first time in one hour. If the fluid is more than a
drachm it should be dressed again in an hour, if a
drachm or less, the interval between dressings should
be increased one hour, and the same rule followed
until the fluid is less than a drachm and of a light
amber color, and the interval from four to six hours.
At this time the tube may be removed. If it is left
longer than thirty-six hours, a piece of sterilized
gauze should be put in its place for six hours, when
the latter is removed and the wound is closed with
slight pressure and its closure is obtained by extra
pressure of external straps.
Care of Capillary Gauze Drain. — If capillary gauze
drain has been employed instead of the glass drainage,
the protruding gauze (from vagina or abdominal
wound) should be kept abundantly covered with a
pad of loose flufl'y gauze, and this should be changed
as often as it becomes saturated with fluids. If all
drainage ceases in twelve to twenty-four hours as indi-
cated by dry dressings, the gauze packing may be
removed. However, if drainage is free and the patient
is normal it may remain forty-eight to sixty-two hours.
When it is possible this drainage should have its exit
through the vagina. After it has been removed a
loose gauze packing should be placed over the wound.
Dressings. — The wound is closed with silkworm
gut, including all parts of the wound edges, and
dusted with sterilized iodoform, and the dressing is a
thick one of iodoform gauze, held in place by adhe-
sive straps tight enough to take the strain off the
sutures without jjuckering the integument. Over
this is i)laced a liberal allowance of absorbent cotton.
89
and all retained with a binder. The dressings are not
disturbed for four days unless there is pain or tem-
perature. At the end of the fourth day the dressings
are carefully removed, and the wound is thoroughly
but carefully washed with equal parts of 95 per cent,
alcohol and 1:5000 bichlorid solution. Iodoform is
again applied and the dressings renewed. The seventh
day, t>efore the stitches are removed, I again have the
wound washed in the same manner and, after their
removal, dressed as before.
In vaginal operations the vaginal wound is dusted
with sterilized iodoform and the vagina loosely packed
with strij) gause. It is removed m forty-eight hours
and after twelve hours vaginal douches of bichlorid
of mercury solution followed by plain water are em-
ployed once or twice daily.
Botvels — If flatus has not passed freely, per rectum,
in twelve hours by the simple emj^loyment of a rectal
tube, I employ the "one, one, one" enema, one ounce,
of sulj)hate of magnesia, one ounce glycerin and one
ounce water. If this does not start the gas in two
hours, I order it repeated in double quantity. If this
enema is not retained, and flatus has not passed, I
order an enema of soap and water one ]3int, with one-
half drachm of turpentine. If they are still obdurate,
I begin one-half grain doses of calomel in ten grains
of bicarbonate of soda, given every two hours for four
doses, or until gas passes, alternated with drachm
doses each of gran, citrate magnesia and sulphate
magnesia in an ounce of water. Following these rem-
edies in one hour, another "one, one, one" enema is
given. It must be an obstinate case indeed that will
not yield under the above remedies. If the stomach
is irritable and will not tolerate the bicarbonate of
soda, the calomel may be given dry on the tongue.
Other salines may be substituted for the above if
they are objectionable. The bowels should be moved
from above on the fifth day with small doses of
some effervescing salt, or, if required, a more vigorous
laxative.
90
Diet. — First week, fluids; second week, semi-solids;
third week, semi-solid and solid food in small quanti-
ties: fourth week, good substantial food, with a few
curtailments. As soon as the patient is out of the
anesthetic, I begin to give hot water in teaspoonful
doses as often as every fifteen minutes. If the stom-
ach tolerates this, the quantity is increased to one-half
ounce, and the interv^al may be increased in length.
If the patient is nauseated and the hot water causes
vomiting (and it should be hot water), or increases
the nausea, it should be withheld. When the patient
can take the hot water, and still complains of thirst
and begs for cold water the nurse is instructed to let
her rinse her mouth with cold water. Ginger ale is
a good alternate with water for the first twenty-four
hours. After twelve hours, drachm doses of peptonized
milk may be sandwiched with the water. If pepton-
ized milk is offensive, plain sterilized milk may be
substituted, or sterilized milk and lime water. Milk in
some form, I feel to be the most perfect food. It
should be increased every hour until ^- ounce doses are
given by twenty-four hours, to one ounce by forty-eight
hours, and to two ounces by the end of sixty-eight
hours. Barley water may be alternated with the milk
Later, the monotony may be relieved with the meat
and shell-fish broths, thin gruels, etc. The fourth or
fifth day the patient may be allowed to extract the
juice of broiled beef by chewing it: the fiber, of
course, should be rejected. Tea may be given the
second or third day as a relish. Orange juice, and the
juice of other fruits, may be given in small quantities
the third or fourth day. Rules can not be laid down
in regard to the diet of these patients, general princi-
ples only can be hinted at. They)atientBhoukl beseen
each day and her wants studied. If stimulants are
required, one of the best is good brandy. Chami^agn©
is all right if its sweetness dcjes not make it objection-
able. If i)atients are unable to retain enough by
stomach to properly nourish them, enemas of either
milk or stimulants should be resorted to.
91
Getting Up. — Uncomplicated laparotomy cases are
gradually bolstered up until they can sit in a bed with
a bed rest at about the fifteenth or sixteenth day, sit
up in a large chair at the twenty-first day, and leave
the hospital from the twenty-eighth to the fortieth
day.
92
LECTURE VII.
THE author's operation OF VAGINAL LIGATION OF THE
BROAD LIGAMENT AND OTHER MINOR OPERATIONS.
Vaginal ligation of the contents of the base of the
broad ligaments, for the cure of fibroids of the uterus,
was devised and performed by me as a new and original
operation Nov. 15, 1892, and was described and pub-
lished in the April number of the American Journal
of Obstetrics in 1893. In the January number of the
American Journal of Obstetrics, 1894, I reported six
cases treated by the new operation.
The operation as originally described by me is as
follows: The ligation of more or less of the broad
ligament of the uterus, with its vessels and merves,
the extent of the ligation depending upon the result
sought, from a simple ligation of the base of the liga-
ment, including the uterine arteries and branches of
both sides without opening the peritoneum to a com-
plete ligation of the ligament of one side, including
both uterine and ovarian arteries, with partial ligation
of the opposite ligament without opening the peri-
toneal cavity, if possible, but by doing so if necessary.
The results sought in the operation are, first to
check uterine hemorrhages by cutting off blood chan-
nels, and secondly to produce atrophy of the fibroid by,
1, depriving it of nourishment through the blood ves-
sels and, 2, by changing the nutrition of the uterus
by interfering with its nerve supply.
Immediately after publishing my first article on
this operation there were two claimants for priority;
Dr. Walter B. Dorsett, of St. Louis, and Prof. S.
ys
Gottschalk, of Berlin, Grermany. Dr. Dorsett, in a
letter to the American Jonrndl of Obstetrics, claimed
that he had suggested a similar procedure to my oper-
ation in an article he published in the St. Louis Cour-
ier of Medicine in 1890, the article bearing title of
"A Case of Atrophy of the Female Genitalia fol-
lowing Pregnancy and remarks." In this article he
made the following observation: "I believe that in
the treatment of uterine fibroid . . . to ligate
the uterine artery would not be an unscientific pro-
cedure. On the contrary the more I have thought
of it the more I am inclined to believe that it would
be the most certain mode of treatment." Dr. D.^r-
sett, while advancing the theory, had not at that
time carried it out on a living woman.
Prof, Gottschalk based his claim of priority on an
article read by him at the Brussels Congress, Sept.
16, 1892, with the following title: " Die Histogenese
und Aetiologie der Uterusmyome." In the latter
paragraphs of this article he casually suggested liga-
tion of the uterine arteries and stated that he had
performed the operation twice. This is what he said:
"The bilateral ligation of the uterine arteries ap-
pears to be the therapeutic measure in this regard
for the earliest incii3ient stages of myoma. This
offers no difficulties in its technique; it is easily
performed in a few minutes. . . I have already
performed this ligation in two cases in which I was
able to early diagnose the development of multiple
myoma with best results."
Thus these two men both suggested tying the
uterine arteries for the cure of fibroids and at least
one of them (Gottschalk) jjerformed the operation
twice before I described my operation. This would
definitely decide the question of priority in their
favor if the operation they suggested was identical
with mine. Their operation is not identical in
theory, in execution, or in description with mine,
and therefore their claim of priority for ni}-^ opera-
tion can not be substantiated.
94
The operation suggested by these men simply in-
■cludes the ligating of the uterine artery from the
vagina, while, 1, I ligate in all cases, the whole base
of the broad ligament, in order, a, to occlude not
only the main channel of the uterine artery, but all
collateral branches; 6, in order to destroy the func-
tion of the nerves as well as the arteries of nutri-
tion; c, in order to diminish nerve reflexes. 2. I
include, in desperate cases, not only the base of the
broad ligament with the uterine artery and branches
in my ligatures, but when practicable ligate high
enough on one side to take in the ovarian artery.
3. I advise accomplishing this result, if possible,
without opening the peritoneal cavity, but by doing
so, if necessary.
TECHNIQUE OF OPERATION.
The preparation of a patient for vaginal ligation
of the broad ligaments of the uterus should be sim-
ilar to that demanded for vaginal hysterectomy, as
described in my Lectures VI and IX. Ether is used as
an anesthetic and the patient is placed on the operat-
ing table in the exaggerated lithotomy position with
buttocks brought to the end of the table, with an assist-
ant on either side to support the limbs and hold the
vaginal retractors. A broad, short vaginal retractor
above and below exposes the cervix, which is trans-
fixed with a strong silk ligature to be employed in
handlinLc the uterus. The uterine canal is dilated and
the uterine cavity curetted with a dull curette and
thoroughly irrigated with 1:1000 bichlorid solution
and then loosely packed with iodoform gauze. This
procedure cleans the uterus and makes it impossible
for the vaginal wounds to become infected by a septic
uterine discharge. The uterus is now drawn down in
order to jjut the broad ligaments on the stretch and
then drawn to the right side so as to expose the left
vaginal vault. The mucous membrane of the vagina
at the utero- vaginal fold on the left side is tlieu^
caught with a tenaculum and incised with a i)air of
95
curs^ed scissors. One blade is allowed to enter beneath
the mucous membrane and a curved incision one and
one-half to two inches long is made over the broad
ligament and at right angles to it (Fig. 15). By
means of the index fingers of the two hands the oper-
,^^'*i-/'.., .
''JnW
Figure lo.
ator now separates the vaginal tissue from the broad
ligament and carefully separates the broad ligament
in front from the bladder for a height of two inches
and laterally for nearly the same distance (Fig. K)).
The bladder should be carefully separated in this way
in order to avoid the danger of wounding the organ,
96
and by pushing the separation laterally the ureter is
forced out of danger. One then carefully separates the
broad ligament posteriorly to the same height as in
front, without, if i^ossible, penetrating the peritoneum.
Now, by passing one finger behind the other in front,
the whole base of the broad ligament, representing two-
FlGURE 10,
Figure 17.
thirds of its bulk, can be grasped (Fig. 17) foradistance
of an inch to an inch and a half from the uterus. In
this grasp one can easily feel the throb of the main
trunk of the uterine artery and occasionally several
branches. The curved pedicle needle is then passed,
97
armed with No. 10 silk, strong pyoktaninized catgut or
kangaroo tendon, and guided by the index finger of the
left hand (Fig. 18) is made to jDenetrate through the
broad ligament. The ligature is drawn through, the
needle removed and the base of the broad ligament is
thoroughly ligated at a distance of one inch or more
from the uterus. The ligature is cut short, leaving it
Figure 18.
Figure 19.
buried in the tissues. The other broad ligament is
treated in the same manner; the vagina is well steri-
lized with bichlorid solution and the vaginal incision
accurately approximated with fine antiseptic catgut so
as to completely bury the broad ligament ligatures
(Fig. 19). The handling string is now removed from
the cervix, and the end of the gauze strip packed in
98
the uterus is tied to another strip and the vagina is
filled loosely with a gauze drain.
The after treatment of these cases is very simple.
The vaginal and uterine gauze is removed tho second
or third day, and twice a day thereafter a bichlorid
vaginal douche 1 :2000 followed by plain douche are
given = Figure 20 shows the joosition of ligatures
when only the base of the broad ligament is ligated.
Figure 20.
SELECTION OF CASES.
Interstitial fibroids of the uterus of moderate size
are the cases in which the best results will be o})tained
by this operation. Subi:)eritoneal fibroids sijringing
from the fundus of the uterus especially would
scarcely be benefited to any great extent by depriving
the lower part of the uterus of its nourishment.
Neither would one expect to obtain any lasting ben-
efit from this oj)eration in cases of pedunculated sub-
mucous fiVjroids. On the other hand, in true intersti-
9U
tial growths depending upon the whole uterus for
their nourishment, cases where the tumor is the
uterus, and these represent 75 per cent, of all fibroids
of the uterus, wherever it is possible to tie the base of
the broad ligament from the vagina, this operation
may be expected to accomplish prompt and decided
relief of symptoms and a rapid reduction of the tumor.
The cases in which the most satisfactory results must
be exj)ected are incipient or small fibroids of the in-
terstitial variety which show themselves late in the
menstrual life. Here, we have a uterus which is
small enough so that it has not risen above the brim
of the pelvis, one which can be easily reached from
the vagina so that its broad ligaments are accessible
from below. Such a fibroid, too, from the age of the
patient will reach a state of quiescence as soon as the
menopause is established. In such cases, then, a major
operation is particularly undesirable, because it is not
imperatively demanded and because of a reasonable
chance of relief at the approaching change; on the
other hand the symptoms (with severe hemorrhage
usually as the principal one) are such that immediate
relief is earnestly sought, if one can be reasonably
certain of obtaining it without submitting to a dan-
gerous and radical procedure. These are ideal cases
for this operation.
Another class of cases in which this operation has
been employed with gratifying success and in which
it will j)robably find favor with the most radical oper-
ators, are those of continuous and profuse hemor-
rhage in which the desperateness of the drain is such
that the patients are depleted to such a degree, that no
radical procedure can be thought of, until a minor
operative procedure has checked blood waste and
recuperation is accomplished. My fourth and sixth
cases were like the above. In the fourth case hemor-
rhage was very profuse and the patient was completely
exsanguinated and so weak that she had not been out
of bed for several months. Some time before I deter-
mined to submit her to my operation an attempt had
100
been made to remove the appendages, or, if possible,
when the laparotomy was in progress, the uterus.
From complicated adhesions and the weakness of the
subject neither operation was possible after the abdo-
men had been opened. The tumor was large and the
elevation of the uterus in consequence was great, and
it was with the utmost difficulty with the aid of the
most competent assistants, that I finally succeeded in
ligating thoroughly the base of each broad ligament.
Both ligaments contained several arteries, some of
them as large as the normal radial artery. They were
all tied in mass. Hemorrhage stopped from the
instant of tying the last ligature and it has never
recurred. It has now been over three years since I
operated on this case. The uterus has reduced until
it is but slightly larger than normal. The woman (I
examined her but a few months ago) is perfectly well.
She has a slight menstrual flow each month, and is
free from pain.
Case six was of a severe hemorrhagic nature in a
typical interstitial fibroid of three by five inches in
diameter. The woman was too weak and dei^leted for a
radical operation. I did my operation on her and the
result was marvelous. In three months' time she had
recuperated so that any radical ojjeration might have
been done without danger.
Dr. Humiston, of Cleveland, reported to me a case
in which he used my operation as a procedure of last
resort, in a patient nearly moribund from hemorrhage.
She was so weak that he only attempted ligation on
one side. The woman stopped bleeding instantly and
eventually recovered. Hence, the operation may with
propriety V)e employed as a rational temporary expe-
dient in desperate cases of whatever variety, where
uterine blood loss is conspicuous.
CASES.
In selecting cases for this operation I have been
very careful. In the majority of them I have oper-
ated on. there seemed no alternative. All were des-
101
perate ones, like cases 1, 2, 3, 6 and 8, or they would
not submit to a more radical i^rocedure, and milder
means, as electricity, ergot, etc., would not accomplish
satisfactory results. I have been more conservative
in adopting the operation, I am afraid, than the results
in the few cases I have o^Derated on would justify.
One reason for not adopting the operation in a larger
number of cases is that I wished first to learn of the
remote results. It is now over three years since my
first operation and most of the operations which I
have performed were during the first year. I have,
therefore, a three years' history to analyze in the
majority of my cases. In the following report there
are no instances in which, at least, a year has not
elapsed since the operation.
Case 1. — This was an interstitial fibroid in a maiden lady 36
years old, in size extending above the umbilicus. The hem-
orrhage was exhaustive and the patient greatly reduced in
consequence. Her heart was hypertrophied and her con-
dition was such that no surgeon with a proper care
•for his statistics or his patient's life would have ven-
tured a hysterectomy. She was operated on by my oper-
ation Nov. 15, 1892. The hemorrhage decreased about one-
half for several months after the operation. The tumor in
the first four months materially decreased in size. In May,
1894, the hemorrhage is reported much modified, and no
longer a source of alarm. The patient at that date considered
her condition greatly improved, hemorrhage cured, tumor
materially reduced and pressure symptoms subsided, March
12, 1896, four years and three months after the operation the
patient reports herself well. The original fullness produced
by the tumor she can no longer feel. No pain. The last flow-
ing of any consequence was November, 1894. Since then the
flow has been very slight until last July, when it practically
ceased. "I have color in my lips and cheeks. I walk two
miles or more every day," she writes. This report is certainly
very gratifying.
Case 2. — The second case was a married woman 40 years of
age who had been under electrical treatment for a hemorrhagic
myofibroma of the uterus. The galvanism decreased the size
of the growth but did not materially lessen the exhaustive
hemorrhage. The tumor was of the interstitial variety and
the uterus appeared the size of a three months' pregnant
uterus. When the patient entered the Woman's Hospital for
operation December, 1892, she had been having almost contin-
uous hemorrhage for several months. Upon exposing the
102
uterus with the retractors at the time of the operation, the cer-
vix was large, blue and vascular. As the vagina was large the
operation was very easily executed. The ligature on the left
side included fully two inches in width of the broad ligament
at a distance of at least an inch from the uterus. When I
tightened this first ligature one of the spectators, a well known
gynecologist, called my attention to the fact that the cervix
had perceptibly paled in appearance. The broad ligament was
easily exposed on the right side, and fully as much of it ligated
as on the left. If there had been any doubt of the procedure
affecting the vascularity of the uterus, it vanished when the
second ligature was tied. The cervix immediately paled until
it was nearly as white as a piece of cartilage.
The covering of the broad ligament was so loosely attached
in this case that I could easily feel the main channel of the
ovarian artery, and it would have been an easy matter to have
included it in the ligature.
After over three years I can promise this case a
perfect cure. The uterus has reduced to normal size.
The hemorrhage has ceased completely. All pain has
disappeared. A slight menstruation, normal in quan-
tity, occurs each month. The patient's health has
improved so, that from a state of almost complete
invalidism she is transformed into to a strong healthy
woman. The improvement has been progressive from
the day of the operation. I have seen this case within
the month (March 1896).
Cane 3. — This patient was operated on in January, 1893. She
had an incipient interstitial fibroid of two years' standing
which was profusely hemorrhagic in nature. I tied the base
of both broad ligaments including the uterine arteries and
their branches. The relief was immediate. The menstrua-
tion for the next four months was scanty. The patient gained
in health and strength rapidly. The tumor, which was the
size of a four months' pregnancy at the time of the operation
decreased markedly in size within three months. Four
months after the operation I lost track of this case, as she
lived m a distant State and neglected to keejj me jjosted. Her
last letter gave a rejjort of perfect health.
CVi.sY:! 4. This patient had a large, bleeding fibroid filling the
I^clvis, which extended to the umbilicus. The uterus and
appendages were firmly adherent and immovable. Laparotomy
had been attempted on the case, with the object of removing
the appendages or the tumor. The abdomen was opened, but
the adhesions and unusual complications rendered it impossible
t() remove the tumor or even accomi)lish the oblation of the
appendages. The patient was so unusually reduced from loss
lOi
of blood at the time of my operation that she had not been
able to be out of bed for three months.
I operated on the jjatient in January, 1893, at the Post-
Graduate Medical School of Chicago, The operation was
accomplished with great difficulty because of the large size and
immovability of the uterus. Finally, however, after consum-
ing more than an hour in time I succeeded in ligating thor-
oughly the two broad ligaments well above the uterine arteries
and their branches.
In June following I made the following report on the case :
"The flowing ceased immediately and the patient was relieved
of her drain for over two weeks. She then had a few days'
flowing, which resembled an ordinary menstruation. She has
rapidly and steadily improved since that time. She has men-
struated regularly but scantily, and without pain. She can at
this time (June, 1893), five months after the operation, attend
to her duties as a housewife, and considers herself cured. The
tumor has become reduced in size until it is no longer notice-
able as a deformity, and so that the patient herself is no longer
conscious of its presence."
Since the foregoing report was written in June, I
have seen this patient several times, the last time
within the month. The patient was then examined
by several physicians, one or two of whom on inde-
pendent examinations, failed to notice any abnormal
enlargement. The uterus is still somewhat larger
than normal, but is not more than three or four inches
in diameter, while the testimony of at least three exper-
ienced diagnosticians will bear me out in the estimate
that its former diameters were not less than four and
a half by eight inches. The patient is in good health
now, Jan. 1, 1895; menstruation is regular but scanty,
and she is free from pain. The patient, so far as I
know, has remained well.
Case 5. — This case was a woman with an interstitial fibroid
about three by five inches. She was about 30 years of age, and
the growth had been noticed for three years. Her principle
symptoms were profuse menorrhagia with severe menstrual
pain. The case was referred tomeby Dr. F. H. Greer, of Colum-
bus, Neb. I did my operation on the woman Jan. 8, 1893. She
had a little subsequent temperature, and one month after the
operation the ligature sloughed from the left broad ligament.
Four months after the operation Dr. Greer reports the woman
V(^ell. "Menstruation scanty, no pain. Fibroid diminished in
size until the uterus is about normal. Patient claims that she
104
is cured." This report was made in June, 1893. I iiave been
unable to get any history subsequent to that date.
Case 6*. — This was the wife of a physician of more than ordi-
nary abihty and reputation. The patient was about 36 years of
age, slightly above the average height, with well-proportioned
frame, but poor in flesh, with a skin blanched and a body almost
exsanguinated. The uterus was about the size of a three
months' gravid uterus. The tumor was uniform and evidently
interstitial. The uterus was in normal position. The cervix
was nearly two inches in diameter, the os patulous.
The history of the growth dated back, undoubtedly, several
years. The patient had borne no children. The menstruation
had for nearly two years increased in quantity and duration,
until now, while coming with absolute regularity, it lasted fifteen
days, and that in spite of vaginal and uterine tampons, the re-
cumbent position, ergot, hydrastisand the rest. She flowed each
month until she was completely exhausted, scarcely recovering in
the next thirteen days sufficiently so that she could assume the
upright position without fainting. Accompanying this unusual
discharge was uterine pain, which in its severity brought the
patient to the point of unconsciousness. During the four days
in which the woman could drag herself around in the latter
part of each intermenstrual period she did so with the greatest
discomfort on account of the pressure and neuralgic pains of
the pelvis. Upon examination of the broad ligament from the
vagina the finger could detect on either side the large, pulsat-
ing artery as it fed the tumor. The latter was movable, the
appendages apparently normal, the broad ligaments accessible.
In fine, here was an ideally typical case — a hemorrhagic fibroid
of the uterus, a bed-ridden patient, an authentic diagnosis, an
unusually interested physician to carefully watch and estimate
the result, and one who enthusiastically demanded a trial of the
new operation. Under the circumstances it seemed to me that
much depended upon this case, as though the fate of this oper-
ation must necessarily be more than usually linked with this
particular patient.
I operated on this case Aug. 2, 1894, at the Chicago Hospital,
with Dr. Robert Dodds and Dr. Oksschct as assistants. The
left broad ligament was carefully dissected from the peritoneal
covering behind, and from the bladder in front, until fully
two thirds of it could he grasped by placing one finger behind
it and another finger or instrument in front of it. When
{.'r.ifif;ed in this manner several beating branches of the uterine
art<-ry, together with the main artery itself could be detected.
This entire mass was then ligated in two sections with No. 12
braided silk, the silk cut short, the parts irrigated and the
vaginal wound closed with catgut. After treating the opposite
side in the same manner, the vagina was cleansed and loosely
jjacked with iodoform gauze. When the operation was finished
the throbbing arteries, which could be distinctly felt before,
105
could no longer be found. The cervix, which was large and
prurplc previous to the operation, became pale and cartilagin-
ous in appearance as soon as the ligaments were secured.
The patient remained in the hosiDital three weeks.
The first menstruation was due the day following the
operation. It began the next morning, but was so
slight and painless that the patient would not believe
that it was her menstruation until several days had
elapsed and no other flow apjDeared. It lasted about
three days and was barely perceptible; absolutely no
pain. The after treatment consisted in vaginal
douches after removing the gauze, light diet and the
recumbent position for two weeks.
August 30, the second menstruation reappeared;
there was a little of the old pain, but not sufficient to
require anodyne of any kind; the flow was half the
usual amount and lasted six days. September 28, the
third menstruation appeared; the amount was normal
in quantity, lasting but four days; the pain was
slight. October 26, the fourth menstruation appeared;
the amount normal in quantity, lasting but four
days; the pain was slight. The patient was seen and
examined by me just before the last menstruation.
She had gained several pounds in flesh, her cheeks
and lips were red and she was a i^icture of health and
robustness. Her feelings were in accord with her
appearance, as she enthusiastically assured me that she
felt perfectly well. On examination I found the
uterus was reduced in size. It was little, if any,
larger than normal. Its bulk had decreased one-half.
The cervix was small and normal. No arterial pulsa-
tion could be felt in either broad ligament or around
the vault of the vagina.
The next report I received was in January, 1894:
" I have to report," the husband says, " that Mrs. X.
menstruated from December 19 to 21:. That the
amount was about the same as before, /. c, slightly
above the normal. Pain rather excessive for two days
(possibly due to rheumatism and neuralgia). After
flow had ceased I examined and found liGfature in
105
vagina and also small sinous opening to left side of
cen'ix. Since then ihere has been slight discharge
from same. She had been suffering some pain at
that point, no pain since ligature came away." He
adds enthusiastically: ''Taken all in all, the result
so far is a grand success." Jan. 17, 1894, he writes:
" Mrs. X. is up to-day (the fifth day) after the easiest
menstruation she has had in her life; pain moderate
and only one day. This in face of the right side still
discharging. In the next two months I exjDect to
have a well woman. The uterus is no^7 practically
normal."
I have lost track of this patient entirely, and I
regret that I am unable to complete so interesting a
history. If the- husband of this patient should read
this report I hope that he will communicate with me.
Case 7. — Mrs. S., Denver, Colo., aged 35, uterus about double
the normal proportions, containing two or more centers of de-
velopment and an extremely hemorrhagic tendency, was the
seventh case operated on. The case had been treated unsuc-
cessfully by curettement, electricity and the ordinary remedies
for checking uterine hemorrhages. The uterus was retroverted
but free from adhesions. The patient was prepai;ed carefully,
and at the Woman's Hospital, on Nov. 11, 189.3, 1 ligated the
base of both broad ligaments, and shortened the round liga-
ments. The uterus was drawn well down, and each broad
ligament, after incising the mucous membrane covering them
in the vault of the vagina, was dissected free from the bladder
and rectal attachments and then ligated with two strong liga-
tures. These ligatures were placed high enough to include tho
uterine artery, all its Ijranchcs, and all of tho contents of the
base of each broad ligament. The ligatures were cut short
after they were tied, the mucous membrane of the vagina was
reunited with a running catgut ligature, and the vagina jxicked
with iodoform gauze. The round ligaments wore then short-
ened and the uterus left in a position of anteversion. Three
days later tho gauze was removed from the vagina, an anti-
septic douche was given and a Smith-Hodge pessary was in-
serted. The antiseptic douches were then continued daily.
The first menstruation was duo four days after tho operation.
It did not appear. The second menstruation also failed to
appear, notwithstanding the fact that menstruation had ordi-
narily been exhaustive.
One of the wounds caused in the operation for
shortening the round ligament suppurated, and obliged
107
the i)atient to remain in the hospital until the latter
part of January. Dizziness was complained of about
the time when the menstruation was due. This symp-
tom continued with different degrees of severity for
some time, gradually disappearing. February 13,
three months after the operation, the first flow ap-
peared. The patient writes: "First menstruation
came on the 13th of this month, without pain, but
quite profuse for first two days. Since then has con-
tinued, including to-day (the 18th). Discharge light."
March 19, 1894, the patient reports: ''Am feeling
fairly well this month. Had pain in back with last
menstruation, which commenced March 13. First
three days quite profuse; last four days very little
No dizziness this month." Aj^ril 18, she writes:
" Menstruation came on four days in advance of
schedule time; continued one week. Am in fairly
good health."
December 14, 1895, two years after the operation, the
husband writes that his wife suffers considerably with
vertigo, especially severe immediately before menstru-
ation. •' The operation performed by you has in a
measure been successful, as the menstrual discharge
is much less than before the oi^eration and the womb
is in much better position."
March 26, 1895, the husband writes: " Her men-
struation is not i^rof use and she has less pain; her
general health about the same" (as in her last letter).
" I think the riding of the bicycle improves her gen-
eral health and strengthens her in those parts wherein
she is weak."
Cases. — Mrs. Z., Muscatine, Iowa. About 35 years of age.
No children. Multiple fibroid of the uterus approximating in
size a four months' pregnancy. Hemorrhage profuse, followed
foi a week by excruciating pain. Patient became extremely
exsanguinated at each menstrual period. Frequently the flow-
ing would last for two weeks. The uterus had been curetted.
Electricity failed to control the hemorrhage and only |)ar-
tially modified the pain The irregularity of the uterine
canal undoubtedly accounted for the failure of the electricity.
Nov. 28, 1893, the patient submitted to my operation for liga-
tion of the broad ligament. The tumor was developed more to the
108
left side into the left broad ligament. I succeeded in separating
the broad ligament for a height of two inches. On the right side
a large double ligature was employed, while on the left side first
a double and finally a second one higher and farther away from
the uterus was applied. The ligatures were cut short, the vagi-
nal vault closed with catgut and the vagina packed with iodo-
form drain. The first menstruation was due three days follow-
ing the operation. A slight watery discharge occurred instead
of blood. Two days following the operation the patient com-
plained of pain similar to that which ordinarily occurred
after menstruation. Feb. 1, 1894, the patient's husband writes :
" She commenced her menstruation Januaj-y 25, and it was
continued until to-day, February 1, one day less than last time.
Had one day of some pain ; not bad. She is getting stronger
and can get around the house without being very tired, although
she has not yet ventured out." February 26, the report is:
"Mrs. Z. was sick this time six days, the same as last time.
Had considerable pain two days which was very severe, the
same as she complained of before the operation. She is get-
ting along very nicely. She is now able to go out, and takes a
walk every day. ' ' March 28, the -husband writes : "I am
ready to make another report, but not as good a one as I would
like. Mrs. Z. was sick on time and the flow was very little
compared to what it has been, iasting but three days, but she
had a great deal of pain -some before she was sick, and it was
quite bad for two days after the menstruation. . . . Every-
thing seems to be working very well if she could only get rid
of that pain." April, menstruation still decreasing in quan-
tity ; the pain decreasing. " There was one day of pain," the
husband writes, " and the flow amounted to but very little."
May 6, he writes : "Mrs. Z. has been feeling splendidly all
this last month. Last week was her time to be sick again.
The flow did not amount to anything, just enough to show.
. , . In regard to her general health, it is excellent. Eats
well, sleeps well and goes out every day the same as other
women. Has gained her natural amount of flesh and a little
more," I examined the patient May 19. The uterus was re-
duced in size one-half. Patient in perfect health.
March 13, 1896, two years and four months after
this woman's operation, I received the following
report from her: " Since the operation I have gained
twenty pounds or a little more up to date. My men-
struation period is abtjut one-half the time and amount
it was before the operation. The pain is very much
less than I had before the operation, but it has not
left me altogether. ... I have the strength of
the average woman now, while before the operati(jn I
109
was comi^elled to be in bed over half the time. Be-
tween my menstruations I enjoy as good health as
any one could ask. . . ."
Case 9. — Mrs. C, aged 41, a resident of Iowa, consulted me
for a bleeding painful fibroid of the uterus in May, 189i. The
tumor was interstitial, uniform in contour, enlarging the ute-
rus to the size of a four months' pregnancy. The hemorrhage
at menstruation was profuse and lasted six or eight days at a
time. The menstrual periods were accompanied with consid-
erable uterine contraction pains. The patient complained of a
great deal of heaviness in the pelvis and pains caused by the
pressure of the tumor. The patient was weak, rather exsan-
guinated and nervous. I concluded that the case was a suit-
able one for my operation. The operation was done May 19,
1894. The lower portion of the uterus was so large and filled
the pelvis so completely that it was with a great deal of diffi-
culty that I accomplished the satisfactory ligation of both
broad ligaments. However, when the operation was finished
I was well satisfied that both uterine arteries had been thor-
oughly shut off.
The patient improved from the first. There have
been no more hemorrhages. I have examined the
patient two or three times since the operation, once
v/ithin six months. The tumor has decreased in size,
but has not disappeared. The pains and pressure
symptoms are much better. The woman is apparently
a healthy woman and does very much as other healthy
women. In reply to my letter of inquiry she said
March 12, 1896, one year and six months after her
operation: " Since the operation I have had but few
hemorrhages, while previous to that I had them very
frequently. I am now quite regular, though I never
go to my full time — about three weeks. I have less
pain, but the heaviness still remains. I am better in
health and strength than before the operation."
Judging from my other cases I expect this woman
to gradually recover. My fear was, when I adopted
this operation, that collateral circulation would speed-
ily overcome the result of ligating of the blood sup-
ply. Experience, however, shows that the results of
the operation are greater the farther away from the
operation we get.
Case 10. — Mrs. S.. aged 35, a resident of the central portion of
110
the State, came to the Woman s Hospital in August, 1894, to
consult me about an interstitial libroid. She had borne no chil-
dren. The uterus was large, regular in contour, hard and about
four by six inches in diameter. It was freely movable in the
pelvis. The woman gave a history of severe monthly hemor-
rhages which lasted anywhere from six days to two weeks at a
time. Accompanying the flooding were severe contraction
pains. The woman was bloodless, pale, weak and extremely
nervous. In all other respects she was normal
I did my operation on the case in August, 1894, with the
assistance of the house staff of the Woman's Hospital. It was
easily performed on account of the movability of the tumor
and the looseness of the broad ligaments.
September, 1891, the patient wrote: ''It is now six weeks
since I have menstruated. The pains are not any better
My bladder trouble (pressure) is much relieved." October,
1894; " I have menstruated since my last letter. The quan-
tity and length of time was small. Had a good deal of pain
the first two days."
November 13, 1894. ' ' Menstruations three weeks apart. I
flowed more than usual."
December 17, 1894. "Pains some less. My changes came '
at the correct date, but was greater in quantity than it should
have been "
January 29, 1895. "I flow a great deal more than I think
I ought. I have to change my napkins six or seven times a
a day."
March 25, 1895. "I was a little better my sick week this
month. The flowing did not last so long as it did before my
operation, but more than is right. My pains are gradually
improving."
May 27, 1895. "I flowed very freely and had a great deal
of pain this month."
Cane 11.— Mrs. Y., the wife of a very intelligent physician of
Indiana, consulted me in November, 1894. She had an inter-
stitial fibroid aVjout the size of a four months' pregnancy. She
was 43 years of age. I operated on her Nov. 7, 1894. Both
broad ligaments were tied, so as to include two-thirds of their
bulk. This occluded the uterine arteries on lioth sides with all
their anomalous branches. I have seen this patient several
times since her operation and the uterus is gradually lessening
in size and the x^atient's symptoms are subsiding. I expect
this case to jjrove successful with a little more time. In reply
to a request from me for a statement ot xji'ogress, the husband
writes March 12, 1894, a year and four months after the oi)era-
tion, as follows : "My Dear Doctor : - In reply to yours of yes-
terday, I have to say that my wife, on whom you operated Nov.
7. 1894, is doing very well as far as the fibroid is concerned. It
has decreased in size some;, not a great deal. The menstrual
flow on two occasions was quite profuse, but the last two
Ill
periods have been very scanty only lasting three days, and only
using one or two napkins in a day, whereas before the opera-
tion she used eight and ten each day for four or five days. She
suffers very little pain, in fact none for the last month. Before
her operation she suffered constantly. Her general health has
greatly improved, and she has gained ten pounds in flesh, is
much more cheerful, and in fact improved in every way. . .
My wife is now past 45 years of age, and I l^elieve if the tumor
does not increase in size until after the menopause, she will
entirely recover."
Case 12. — Miss V., single, age 40, consulted me in November,
1894, on account of a painful bleeding fibroid. She was de-
pleted to an unusual state, and her nervous system was a
wreck. She had an interstitial fibroid with the canal of the
uterus measuring four inches in depth. The uterus measured
approximatelv three by six inches in diameter. The organ was
movable. Hemorrhage occurred only at regular menstruation
periods. At this time it lasted a week or ten days and was very
profuse. Accompanying the flow was great prostration of the
patient and also most excruciating pelvic i^ressure symptoms.
This condition of affairs had been going on for months until the
patient from blood drain and harassment of pain had been
brought to a deplorable state of health.
December 5, 1894, 1 ligated the base of both broad ligaments.
The operation was accomplished with ease because the uterus
was movable and the broad ligaments loose. The patient
recovered nicely from the operation. The next two or three
menstruations were much more normal, the quantity of How
being very small and the pain scarcely perceptible. The
woman was placed on tonics and urged in every way to increase
her blood supply. Her nervous system reacted slowly. Her
menstruations later became more profuse and was accompanied
on several occasions by quite severe pain. While but a short
time has elapsed since the operation the patient is gradually
improving.
March l2, 1896, one year and three months after the opera-
tion, she writes: "The amount of menstrual flow averages
about one-half the amount it was before the operation. Have
gained a little in fiesh. Have considerable pain. Still have
nerves although under better control than formerly."
This patient has improved in many ways. Dur-
ing lier intra-menstrual periods she is compara-
tively well and is able to go about and to do
more work than she should attempt, whereas pre-
vious to her oijeration she was unable to do much.
While she had been neglected for a long time
and her health had reached a low ebb, I can not
but believe that she will gradually improve as a direct
112
result of the diminished flow. Her tumor decreased
in the first four weeks fully one-third. It has not
increased perceptibly to the patient since she left my
care.
Case 13. — Miss B., age 26, consulted me in January, 1895, for
a bleeding intramural fibroid. The uterus was about five
inches long and had a canal three and three-quarter inches in
depth. The canal was a little irregular. In the fundus of the
uterus could be felt two distinct centers of development, one
on the anterior surface about two and one-half inches in diam-
eter, and projecting from the main body of the uterus one and
one-half inches. It was hard and had the unmistakable firm
consistency of a fibroid mass. On the posterior surface of the
fundus at its junction with the neck was a second center pro-
jecting from the uterus about one and a half inches. This
mass was irregular and was fully two inches in diameter. The
symptoms which brought this patient to me were prolonged and
exhaustive hemorrhages and uterine pains. The lady is a
vocalist of unusual talent and these symptoms interfered seri-
ously with her profession. The case was a typical one for hys-
terectomy, especially as the left ovary was enlarged and cystic,
but as that would involve the removal of the ovaries the patient
objected to this because of the popular but unfounded fear
that removal of the ovaries impairs the voice. I therefore
decided to perform my operation on the case. When the
patient was under the anesthetic I confirmed absolutely by
bimanual manipulation my diagnosis as given above. Febru-
ary 1, 1895, I operated on this patient. She left the hospital in
two weeks. She did not have an unfavorable symptom. Men-
struation practically ceased from the date of the operation.
There was but the slightest show each month. No pain what-
ever. In less than a month she was able to attend to her pro-
fessional duties and was stronger than she had ever been. G^his
fjerfect condition of affairs continued until aVjout Dec. 8, 1895,
ten months after her operation. At this time I was called be-
cause of a sudden attack of severe pain she had experienced in
the left side of the pelvic region. The pain was accompanied
with profound prostration and shock, I diagnosed ruptured
cyst of the left side and advised a laparotomy. In making my
examination I was surprised to find a perfectly normal uterus.
I performed laparotorhy on this patient Dec. 28, 1895, and
removed a ruptured ovarian cystof the left side and x^unctured
a small cyst in the ovary of the right side. This gave mo an
opportunity to examine the uterus which I had treated by my
operation a little over ten months before. On the anterior por-
tion of the organ corresponding to the location of the anterior
fibroid described above 1 found buried in the wall and project-
ing a half inch, a fibroid center one-half inch in diameter. On
the posterior surface, corree ponding to the other center which
113
I palpated at the previous operation, was another center dis-
tinct but even smaller than the anterior one. These were both
exhibited to the house staff and physicians present at the oper-
ation. The behavior of this case was most gratifying until the
complication of the ruptured cyst arose. This fortunately gave
me an opportunity of examining by direct sight the results
accomplished by the first operation.
I have no doubt but that those two fibroid centers
would have been starved out eventually and the case
actually cured without any further interference.
General Summary: Thirteen cases operated on in
which more than a year has elapsed since the
operation :
Case 1. — Age 40. Operation Nov. 15, 1892. Very large
bleeding fibroid. Present condition : Tumor much reduced.
Hemorrhages ceased. Patient well.
Case 2. — Age 40. Operation December, 1892. Fibroid inter-
stitial, size of three months' pregnancy. Profusely hemor-
rhagic. Present condition: Tumor disappeared. Absolute
cure.
Case 3. — Operation January, 1893. Interstitial bleeding
fibroid of two years standing. Four months after operation.
Last report : Tumor reduced, patient much improved.
Case 4. — Age 38. Operation January, 1893. Very large ad-
herent intefstitial fibroid. Excessively hemorrhagic. Patient
bed-ridden. Two years afterward : Uterus reduced almost to
normal size. Hemorrhage ceased. Patient well and strong.
Cased. — Age 30. Operation Jan. 8, 1893. Interstitial fibroid
three by five inches in diameter. Profuse hemorrhage. Report
four months after operation : Uterus normal ; hemorrhage
ceased.
Case 6.— Age 36. Operation Aug. 2, 1894. Interstitial
fibroid. Profusely hemorrhagic and painful. Patient much
reduced. Tumor three by five inches in diameter. Six months
after operation much improved. No later report.
Case 7. — Age 35. Operation Nov. 11, 1893. . Incipient inter-
stitial bleeding fibroid. Two years after operation : Tumor
reduced ; hemorrhage ceased.
Case 8. -^ Age 3o. Operation Nov. 28, 1893. Painful, hem-
orrhagic interstitial fibroid, size of four months' pregnancy.
Two years and four months after operation : Tumor much dim-
ished ; hemorrhage ceased ; pain less but not entirely relieved.
Case 9. — Operation May 19, 1894. Interstitial, xjainful, hem-
orrhagic fibroid. Tumor size of four months' pregnancy. One
year and ten months after oxjeration : Tumor slightly dimin-
ished ; hemorrhage materially reduced.
Case 10. — Age 35. Operation August 1894. Tumor inter-
stitial four by six inches in diameter. Hemorrhage and pain
114
excessive. Not much improved eight months after operation.
Case ii.— Operation November 7, 1891. Tumor interstitial,
hemorrhagic, painful and size of four months pregnancy. One
year and four months after operation : Tumor decreased in
size and hemorrhage ceased.
Co.se 12. — Operation Nov, 1894. Tumor interstitial, pro-
fusely hemorrhagic, painful, and three by six inches in diame-
ter. One year and three months after operation : Tumor
reduced ; hemorrhage less ; pain not improved.
Case 13. —Operation Feb. 1, 1895. Tumor intramural,
two centers of development two inches in diameter each. Pro-
fusely hemorrhagic and excessively painful ; hemorrhage and
pain ceased ; tumor nearly disappeared, as demonstrated by a
laparotomy ten months later.
MINOR SURGERY FOR SUBMUCOUS FIBROIDS.
Pedunculated submucous fibroids may frequently
be completely removed through the dilated cervix
without interfering materially with the uterus. Un-
less the tendency to pedunculate is well established
however, and the center of development comprising
the tumor is the only center of fibroid development to
be discovered in the walls of the uterus as shown by
careful bimanual palpation, it should be treated by
hysterectomy either vaginal or abdominal. An excep-
tion to this general rule would be when a peduncu-
lated fibroid is discoverable either in the cavity of the
uterus or hanging from the cervix with a long thin
pedicle. In such a case the polypus should be care-
fully removed from the uterus, even though there
were other centers of development to be discovered.
The uterus as a whole, here, could be dealt with in a
later operation if the removal of the pedunculated mass
did not sufficiently relieve the symptoms.
The removal of an intrauterine i)edunculated
fibroid is usually a simple procedure. If the pedicle
is small and long and the tumor is in a position where
it can be easily reached with forceps, it may be
grasped in a strong vulsellum and the tumor twisted
until the X)edicle is actually twisted in two. This can
only be done with thin pedicles. If the pedicle is
broad the uterus should be sufficiently dilated (the
patient under an anesthetic) to expose the i)edicle, if
115
it is necessary to accomplish this the cervix may be
divided as high as the vaginal junction. The mucous
membrane of the pedicle should next be cut in its
entire circumference. Then the remaining j)ortion of
the pedicle composed of the blood vessels, connective
and muscular tissue should be twisted in the same
way that one proceeds to twist off a small pedicle. If
the remaining portion of the pedicle is small it will
give way by that treatment. If it is rather large and
fleshy, after it has been twisted into a small bulk it
may be grasped by a strong pair of curved pedicle
forceps and the pedicle severed with scissors or a
knife outside of the forceps. If the pedicle is very
vascular the forceps may be left in place for six or
twelve hours. If this does not seem necessary the
forceps are removed and the uterus packed with iodo-
form gauze. If the forceps are left on the pedicle,
gauze should be packed around them. The forceps
may be removed in six or twelve hours without dis-
turbing the gauze.
I do not favor attempting to enucleate a submucous
fibroid of any considerable size if its principal bulk is
buried in the walls of the uterus. Such a procedure
is attended with considerable mechanical difficulty
because of the position of the tumor in the cavity of
the uterus; it is a difficult matter to secure hemosta-
sis in such a location and finally one seldom reaches
in such a procedure more than one of several centers
of developments of the tumors which are situated in
the uterus. In these cases a hysterectomy is more
satisfactory.
A cervical fibroid developing toward the mucous
membrane, if pedunculated, should be removed in the
same manner as that described for removing a pedun-
culated intrauterine fibroid. A cervical fibroid of
small size may be enucleated by incising its capsule,
grasping the tumor with a vulsellum, and dissecting
it from its bed. The cavity may be closed with
buried antiseptic catgut sutures or it may be packed
with iodoform gauze.
116
CURETTEMENT.
In many cases of hemorrhagic fibroids much of the
hemorrhage and leucorrhea is caused by endometritis.
A safe and oftentimes beneficial treatment for such
cases is thorough dilatation of the uterine canal and
curettement of its mucous membrane. While it will
not ordinarily have a direct curative effect it will fre-
quently relieve disagreeable symptoms for a long
period of time. The dilatation should be gradual
beginning with Goodell's dilators and afterward
exploring the anterior of the uterus with the index
finger to discover whether there are any projecting
masses into the interior of the cavity. After thor-
ough dilatation with the cervix exposed and grasped
with small vulsellum forceps in order to steady the
whole organ, a sharp curette should be made to trav-
erse all portions of the endometrium. This should
be accompanied with some form of antiseptic in'iga-
tion. The whole mucous membrane should be gone
over at least three times with the curette, the canal
then loosely packed with iodoform gauze, the vagina
filled with the same and the patient put to bed for
several days. The gauze should be removed in forty-
eight hours. After that antiseptic vaginal douches
must be given for several days
LECTURE VIII.
REMOVAL OF THE UTERINE APPENDAGES.
Battey, Tait and Hegar independently conceived,
performed and contributed to modem surgery the
operation of removal of the uterine appendages. In
1865 Battey "conceived" but did not publish "the
idea of producing an artificial menoj^ause for the
remedy of disease." His idea was published in 1872.
Hegar operated on the first case with the object of
establishing an artificial menopause, a few days before
Aug. 1, 1872, the memorable date of Tait'g first opera-
tion for the same purpose. Battey did his first opera-
tion just sixteen days later, or Aug. 17, 1872 Thus
the time was ripe and three great men of three great
nations, separated by thousands of miles, discovered
the fact, independently of each other, and shook the
tree of progress which has resulted in such an abun-
dant harvest.
The removal of the appendages for the cure of
fibroids of the uterus is based on the facts: 1, that
removal of the uterine appendages eradicates the part
of the economy in which resides the organ or center
of menstruation and produces an artficial menopause;
2, that removal of the uterine appendages accom-
plishes a reduction of the direct blood supply to the
uterus and thereby produces atrophy by depleting the
organ.
ARTIFICIAL MENOPAUSE.
It is yet an unsettled question where the exact seat
118
of control of menstruation is located. It is not the
province of this article to enter into the heated discus-
sion as to whether this remarkable center lies in the
ovaries or whether it is situated in the nerve structure
of the Fallopian tubes. It is enough for us to know
that the menstrual center, wherever it lies, is eradica-
ted, in the maximum proportion of cases, when every
vestige of both ovaries and Fallopian tubes is
removed. It is well that such is the case, because it
would be an awkward and incomplete operation which
would seek to leave either the ovaries or the tubes.
These two organs have a function which of necessity
is incomplete without both of them. It would be
difficult to remove the ovaries without interfering
with the circulation and position of the tube. It
would be equally impossible to remove the tubes
without interfering with the circulation and function
of the ovaries. Then, too, a much more secure and
desirable pedicle can be obtained when both organs
are included in a ligature than is possible if but one
of the organs is selected. Then, as the function for
which each of these small organs is designed is depend-
ent upon both, and the removal of both is easier
and therefore safer than the removal of one of them,
and when we take into consideration the liability of
either of these organs to become diseased, if not
removed when opportunity permits, there seems to be
no further reason why both organs should not always
be removed when it is desirable to produce an artificial
menopause.
REDUCTION OF BLOOD SUPPLY TO THE UTERUS.
In a previous article we discussed the blood supply
to the uterus. We found that the organ depended
upon two sets of arteries for its nourishment, the uter-
ine arteries and the ovarian arteries (Fig. 21). The
normal ovarian arteries are a trifle more than half the
size of the uterine arteries. They supply the ovaries,
the tubes, the fundus of the uterus and anastomose
with the uterine arteries which course along the sides
119
of the uterus giving off frequent horizontal branches
to the uterus. By referring to Fig. 21 it can readily be
seen that the ovaries and tubes may be removed with-
out including the main channel of the ovarian artery.
Such a method of operating would deprive the
removal of the appendages for the cure of fibroids
of one of its chief features of benefit, viz., the reduc-
tion of blood supply to the uterus. For that reason
special care should be maintained by operators adopt-
ing this procedure to include in all cases the main
channel of the ovarian artery in their ligature. By
Figure 21.
tying this artery on both sides the large abnormally
developed uterus is instantly deprived of one-third of
its blood supply.
Dr. Byron Robinson, after witnessing my operation
of tying the broad ligament from the vagina, recog-
nized the value of this principle of cutting off blood
supply to fibroid uteri, and afterward applied one of
the principles of my operation through an abdominal
incision, after having first removed the appendages, by
tying the uterine artery as it courses up the side of
the uterus to join the ovarian artery.
]20
INDICATIONS FOR REMOVAL OF UTERINE APPENDAGES
FOR FIBROIDS.
But a few years ago this was the operation of selec-
tion for the relief of uterine fibroids when an operation
of the severity of a laparotomy was deemed a necessity.
It is seldom performed at present except as an opera-
tion of dernier ressort, when laparatomy has been
instituted with the object of removing the tumor and
uterus and, because of contraindications, the latter
operation is found inadvisable. The reasons for this
change of position are:
1. The operation of vaginal and abdominal hyste-
rectomy has been so perfected that in patients of ordi-
nary strength, with tumors without severe comi)lica-
tions, the mortality of hysterectomy is not materially
greater than that of double oophorectomy.
2. The operation of removal of the appendages fails
about three times in thirteen recoveries to materially
reduce the size of the tumor, and fails in one case in
thirteen recoveries to produce an artificial menopause ;
while hysterectomy on the other hand is absolutely
sure of curing every case of fibroid of the uterus,
which recovers from the operation both of hemor-
rhage and tumor.
This materially narrows the field of this operation
which has done more to develojj modern surgery than
any other discovery of modem time, except the dis-
coveries of Lister. The very enlightenment which it
has created helps to make it obsolete. The operation
now, in the hands of expert abdominal surgeons, is
limited to cases : 1, where for some reason the operation
is dem}mded because of prejudice against sacrificing
of the uterus; 2, in cases where for some good reason
quickness of time in operating is desirable; 3, in
cases where unusual complications are revealed when
tlie abdomen is opened which make hysterectomy
impracticable; 4, in cases of small bleeding tumors in
weak women who are near the menopause; 5, in cases
of small hemorrhagic fibroids in weak women in
121
whom laparotomy would not ordinarily be indicated but
which, are complicated with disease of the appendages.
THE OPERATION.
An abdominal operation is properly divided into
five parts: Incision, removal of pathologic material,
drainage, closure of incision and dressing.
The Incision. — After the skin has been prepared as
described in Lecture VI, sterilized towels have been
placed around the field of operation, the patient is
thoroughly anesthetized with ether and the operating
corps is in its place; the operator standing on the
left side of the patient, with a sharp scalpel makes an
incision from above downward in the median line,
from about two inches below the navel to two inches
above the upper margin of the pubis, an incision
about three inches in length. This incision should
be unhaggled and should extend in dej)th through
the skin, superficial fasciae, the fat between the super-
ficial fasciae down to the deep fasciae which immediately
covers the muscles. In experienced hands but one
stroke of the knife is necessary for this. If the hem-
orrhage is but venous, sponges only are necessary
to keep the wound dry. If there are any arterial
points of bleeding they are caught in the points of
forceps by the assistant. The operator by another
stroke of the knife incises the white deep fasciae, and
if this incision is through the linea alba, the subperi-
toneal space is entered, as will be indicated by the
bulging fat of this space. If the incision is to the
right or left of the line the muscular coat of the
abdominal wall will be exposed. The muscles are
then separated by the handle of the scalpel in a stroke
from above downward which brings into view the sub-
peritoneal fat. The knife is carefully drawn over this
from above downward, and this followed by a sweep
of the scalpel handle separates the fat and subperito-
neal tissue down to the peritoneum. The peritoneum
is now caught in two catch forceps which are held up
and separated laterally so as to present a sharp eleva-
122
tion of that membrane. This is carefully incised
with the knife. When the peritoneum is opened
it will be indicated by its sudden elevation in
consequence of the entrance of air. An experienced
operator will frequently open an abdomen carefully
in thirty seconds. If it is done well it matters little
if it takes five minutes. It is not necessary to seek
for the linea alba if it does not happen to lie directly
in the center of the superficial incision. It is more
important that the wound should be direct and the
different layers parallel than that the muscles should
not be disturbed. When the peritoneum is opened
between the forceps the index finger should act as a
director above and below the opening and the perito-
neum incised with scissors the full length of the
wound, being careful not to wound the bladder below.
Next attach the peritoneal edges of the wound at the
center of the incision on either side to the deep fasciae
with small catch forceps. This prevents peeling off
the peritoneum from the parietes in any subsequent
manipulations.
E.Tjdorfdion. — With the index finger of the left
hand I now make my exploration of the abdominal
viscera including the appendages. First the uterus is
sought as a central landmark. From the uterus the
finger is first swept to the left side along the Fallo-
pian tube from the horn of the uterus. Just below
the tube and above the broad ligament is the ovary.
The opposite side is rapidly explored in the same
manner. The exploration takes into consideration
the size and position of the fibroid uterus, adhesions,
the condition of the appendages, the possibility or
feasiVjility of removing them and any abnormal devel-
opments.
Ramovdl of the Appendages. — Our object, it must
be remembered, in the removal of these organs must
be to remove completely every vestige of ovary and
tube and the thorcjugh ligation of the main channel of
the ovarian vessel. When the uterine tumor is not
large, or if it has not developed into the broad liga-
123
ment so as to spread out its folds and make it tense,
it is an easy matter to ligate off the tube and ovary
with one ligature. This is accomplished by lifting
the tube and ovary with the loose broad ligament and
making a pedicle of the infundibulo-pelvic ligament
(Fig. 22 a), the ovarian ligament (6) and the Fallo-
pian tube (c). The ligature No. 10 braided silk or
No, 8 antiseptic catgut threaded in a round non-cut-
ting needle is placed around the pedicle, never
through it except as it ]3enetrates and surrounds a
portion of the infundibulo-pelvic (Fig. 22 a) and the
ovarian (6) ligaments in order to prevent its slipping
Figure 22.
over the edge of the stumi^. If the ligature is allowed to
transfix the pedicle at any other place than through
the firm ligamentous tissues of the two ligaments
mentioned, it is liable to produce venous oozing into
the loose subperitoneal tissue beneath the constric-
tion of the pedicle, resulting in small hematomas
which frequently prove troublesome. After the liga-
ture is placed the ovary and tube are drawn well up
and the strand of silk or catgut is tied firmly, first
with a double twist knot and then two single twists
and the ends cut short (Fig. 23). A pair of snap for-
ceps is then placed on the pedicle outside of the liga-
124
ture and the pedicle is severed about one-fourth
inch from the ligature, the stump cauterized or ren-
dered sterile with some strong antiseptic, this anti-
seiDtic removed by a moist sponge and the pedicle
dropped.
If the uterus is considerably enlarged or if it espe-
cially develops into the broad ligaments, it is impos-
sible to tie off the appendages of each side with a
single ligature. This is because the loose folds of the
broad ligaments of which the pedicle is ordinarily
constructed, have been occupied by the enlarged
Figure 23.
fibroid uterus, and the ovary and tube are each flat-
tened out on the surface of the tumor and are held
fast by the peritoneum, which ordinarily acts as a
mesentery to each, Fig. 24. Under such a disposition
of affairs or any modification of it, the ovaries and
tubes should be tied off' by first ligating the neck of
the tube as near the uterus as possible after anchoring
the ligature by a twist around the utero-ovarian liga-
ment (Fig. 24 a); second by ligating the broad liga-
ment outside the fimbriated extremity of the tube
125
Figure 25.
126
deep enough to include the ovarian artery, anchoring
the ligature by a twist around the infundibulo-pelvio
ligament (Fig. 24); third, after removing the tube
and ovary the two peritoneal edges representing the
broad ligament to which the tube and ovary are
attached between the two ligaments already placed,
should be united from one pedicle to the other with a
running stitch of fine antiseptic catgut. This makes
a perfect exsection of the apiDendages, and leaves the
peritoneum perfectly closed with no tension on either
of the pedicles (Fi^. 25).
DISEASED APPENDAGES.
All cases, unfortunately, are not typical like the
ones we have described. We often meet with dis-
eased appendages when opening the abdomen for the
removal of these organs in cases of fibroids of the
uterus. A pyosalpinx, or an ovarian cyst, or abscess
of the ovaries are often encountered. Almost invari-
ably when these things do exist, localized peritonitis
has rendered them ad.herent to surrounding tissues,
the uterus, omentum, intestines or the peritoneum of
the broad ligament.
When these complications exist, and we have
decided upon the removal of the appendages for the
treatment of the fibroid, we have before us the prob-
lem of enucleation and excision of the diseasecl and
adherent organs. The enucleation of an enlarged pyo-
salpinx, or an ovarian abscess, or a tubal ovarian abscess,
or adherent appendages the result of an old peritonitis
where pus is no longer present, is accomplished in prac-
tically the same way. When the abdomen is explored
the abnormal condition of affairs immediately becomes
api^arent. Frequently there is an inextricable mass;
occasionally the outlines of the tube and ovary can
be traced and they simply appear as enlarged adher-
ent semi-fluctuating cysts; while rarely, the appen-
dages, not materially changed from their normal size,
will be firmly imbedded and adherent.
I begin my enucleation in these cases, by passing
127
the index finger of my left hand, with the palmar
surface directed forward, down behind the isthmus of
the tube just as it is given off from the horn of the
uterus, hugging closely the body of the uterus until
I have reached Douglas's cul-de-sac. As a rule, at
this place I will find a line of cleavage as indicated
by the adhesions between the tube and the uterus and
the ovary, and the intestines and omentum posterior
to the ovary and tubes. This line of cleavage, which
as it gives way feels like two pieces of strong paper
which have been stuck together with fresh mucilage
giving way before pressure of the fingers between
them, can be followed rapidly, first with one finger,
then with two or more, until the whole adherent tube
and ovary are freed and lie ready to be ligated ofP in
the palm of the hand. This is the happy result in
the majority of cases.
In a few cases, especially after long standing disease,
the adhesions are strong and well organized. Here
great care and patience must be exercised, in order
not to go into an adherent bowel, or to the other
extreme and leave a portion of the stroma of the
ovary or a portion of the tube which may be just
enough to prevent the menoi^ause and thus make our
oj)eration a failure. Here, when the line of cleavage
fails to yield readily, it is well to place the patient in
the Trendelenburg position and separate the adhesions
after exposing them to sight. With this precaution
and the exercise of considerable care in manipulation
it is seldom that one need fail to accomplish an
enucleation.
When these adherent masses are once dug from
their beds the stumps, after ligation, should be ren-
dered perfectly sterile by the application of the actual
cautery or strong chemic antiseptics. The parts
should then be dried, and where it is practicable the
raw surfaces should be covered with peritoneum.
Drainmje. — If there is oozing from the raw sur-
faces caused by the enucleation, a glass drainage tube
should be placed in the cul-de-sac of Douglas, the
128
lowest point of the pelvis, while the toilet of the peri-
toneum is being completed and the abdominal sutures
are being inserted. Before the abdomen is closed
the tube should be pumped out in order to ascertain
if there is more blood oozing from the peritoneal sur-
faces than would naturally be taken care of by the
IDeritoneum. If more than a couidIc of drams of pure
blood accumulates in the few minutes that are required
to make the toilet and insert the sutures, the tube
Fkjure 26.
should be allowed to remain, and the sutures tied so
as to enclose it snugly. The tube should not be
larger than an ordinary lead pencil, or about one-
quarter of an inch in diameter. It should be long
enough to project about one inch above the wound
(Fig. 20) The abd(jininal dressings are then placed
upon the wound around the tube and secured by
129
sterilized muslin bands which are pinned to broad
adhesive straps fastened to the sides of the abdomen
at some little distance from the wound. Over the top of
the tube is slipped a piece of rubber dam (Fig, 26 a)
about 12 inches square, the tube penetrating the cen-
ter of the sheet rubber. The tube is then pumped
out with a small glass syringe with a long rubber
nozzle which will reach to its bottom (Fig. 27). After
finally emptying the tube a long narrow strip of ster-
ilized gauze is carried to the bottom of it with a
straight metal sound, a small amount of the same
gauze is left as a loose dressing over the end of the
tube, over this is folded the rubber dam and fastened
with a sterilized safety pin, and over all this is placed
a liberal dressing of sterilized cotton and finally over
this a snugly applied bandage of sterilized cotton.
Figure 27.
Now when it becomes necessary to exhaust the drain-
age tube in an hour or two hours, it will not be neces-
sary to disturb the wound dressing at all. The
bandage is unfastened, the layers of cotton j^arted in
the center and the rubber dam opened and sjDread out
on the cotton, the capillary drain of gauze removed
and the tube exhausted by means of the syringe, an-
other strip of gauze inserted, the rubber dam refolded
and pinned and the external dressings readjusted.
I go into the detail of my method of caring for a
drainage tube in order to justify myself for using it.
As understood by the majority of good surgeons, it is
really a dangerous means of draining. But a few
weeks ago, in a discussion in a prominent society on.
the subject of abdominal and pelvic surgery, I heeird
130
a surgeon of no mean repute condemn the glass drain
and the suction pump, in unmeasured terms, when by
his very language, he demonstrated his ignorance of
the whole matter by saying that it was necessary to
uncover the abdominal wound every time that the
tube is exhausted. It is not necessary to uncover the
wound at all to dress a glass drainage tube. It is not
necessary to infect a glass drainage tube when uncov-
ering it to exhaust it with the suction syringe, if the
one doing the work is trained and competent. The
nurse should be well trained. She should wash her
hands to surgical cleanliness before loosening the
bandage or removing the cotton over the end of the
tube. She should rinse her hands in 1 to 1,000 bichlo-
rid solution before unpinning the rubber dam; she
should again rinse them in bichlorid before removing
the capillary drain; she should take the glass syringe
with its rubber nozzle out of a pitcher of 1 to 1,000
bichlorid solution, rinse it quickly in sterilized water,
rapidly exhaust the tube, and eject the fluid into a
small glass graduate which has just been removed from
an antiseptic solution ; when the tube is dry she should
take the steel sound out of a dish of bichlorid solu-
tion, a strip of gauze out of a fresh supply from a
sterilized package and insert it to the bottom of the
drainage tube. She should again rinse her hands and
then rajndly close the tube and replace the dressings.
Such a procedure requires two minutes if done by an
expert and intelligent nurse. I will agree with every-
body that this kind of drainage can not be carried
out by an ordinary nurse. But when well attended to
it is the most satisfactory method of keeping dry the
free abdominal cavity that we are as yet acquainted
with.
CAPILLARY DRAIN.
Occasionally after extensive enucleation of diseased
appendages we may be so situated that we have no
experienced nurse to leave in charge of a glass drain-
age tube; at the same time we must drain, and must
drain in a manner that the after-care of the drain can
131
be attended to by one of little experience. In these
cases combined capillary gauze and tubular drain,
through the Douglas cul-de-sac, may be resorted to.
A rubber tube one- quarter inch in diameter and about
twelve inches long, and a quantity of sterilized iodo-
form gauze in eight inch strips cut the strong way of
the gauze without knots, are selected. After insuring
thorough cleansing of the vagina the operator, guided
by an assistant's j&nger in the vagina, penetrates the
posterior cul-de-sac into the vault of the vagina with
a pair of sharp pointed scissors. The scissor blades
are then opened and between them from above down-
ward, on a pair of forceps, is carried an end of the
strip of gauze and the rubber tube. The assistant
grasps these in the vagina and makes gentle traction
on them. The operator then loosens his grasp and
catches the abdominal end of the tube with a pair of
catch forceps. The tube is then drawn through until
from two to four inches of its upper end, according
to the extent of drain required, is left in the abdom-
inal cavity Enough of the gauze is drawn through
to make a loose packing for the vagina. A small bunch
of the gauze is left in the abdomen in the cul-de-sac,
around the end of the rubber tube. It is closely
packed so that it will remain in the position in which
it is first placed. The abdomen is then closed in the
usual manner. The vaginal end of the drain is ar-
ranged by cutting the tube off at the vaginal outlet;
and over the vulva and the end of the gauze is placed
a liberal pad of loose sterilized dry strip gauze. Orders
are given to change this outer gauze as often as it
becomes moist. When at the end of twelve to twenty-
four hours there is little drain, a portion of the gauze
may be withdrawn from the vagina, and if the drain
has been slight the tube may be removed at this time.
In twenty-four hours longer, if the drain is still small
or none at all, the drain may be completely removed.
After the gauze has been removed, a liberal vaginal
drain of gauze may be carried on the end of a forceps
to the vault of the vagina. This may be removed in
132
twenty-four hours. After this nothing further is re-
quired but an occasional vaginal antiseptic douche.
If drainage is profuse after twenty-four to forty-eight
hours the gauze drain should be withdrawn more
slowly.
Closing ahdominal Wound. — I favor any method
which will coapt all the tissues of the abdominal
wound in the exact relation and to the same extent
that they were originally. This can be accomplished
by including all the tissues, skin, fat, superficial and
deep fascia, muscle, subperitoneal fascia, and peri-
toneum in a row of silkworm gut sutures placed one-
third of an inch apart. If I have some of my own
specially prepared antiseptic catgut at hand, I fre-
quently sew the peritoneal layer separately with a
running thread of the gut and then include the
remaining layers in the row of silkworm gut. This
is especially desirable if one has a long wound in a
hemorrhagic patient. It completely closes the abdom-
inal cavity from any oozing from the abdominal
incision. It also obviates the necessity of the silk-
worm gut sutures entering the peritoneal cavity,
thus removing the remote danger of adhesions of the
abdominal viscera to the points of peritoneum pene-
trated by the stitch, and danger of septic material
gaining entrance to the peritoneal cavity along the route
of the stitch, in case of external skin or mural sup-
puration. I am careful to include all the tissues of
my wound in order that the abdominal walls after
incision will be as thick at the wound line as at any
other position. If it is not, there will be a concavity
at this point on the peritoneal surface which will act
as a point of resistance, and which will favor abdom-
inal x>ressure on the wound and from which ventral
hernia is more liable to result.
Before tying the silkworm gut sutures, I render the
wound aseptic by washing thoroughly with 1 to 1,000
bichlorid solution (employing care that none of the
jjoison enters the peritoneal cavity ) and finally rinsing
the wound with sterilized water. After tying the
133
main sutures of the wound I always put in superficial
stitches of fine silkworm gut wherever they are
necessary in order to insure coaptation of the skin
edges.
Dressings. — Sterilized iodoform powder mixed with
boric acid is dusted over the wound. Loose steri-
lized strip gauze is placed over the wound, and sev-
eral inches around it, and over this is placed a dozen
thicknesses of sterilized sheet gauze. This is held in
place by sterilized muslin straps which are pinned to
broad bands of adhesive straps attached to the skin
on the outer borders of the abdomen. This prevents
the dressing from becoming displaced by any move-
ments the patient may make, and it also supports the
wound and takes the strain off the sutures. Over this
is placed an abundance of sterilized cotton and over
the cotton in turn is placed a snug abdominal bandage
with a perineal T to keep it in place.
AFTER-TREATMENT.
For detail after-treatment I must refer the reader
to Lecture VI.
Dressing the Wound. — The wound is not disturbed
until the fourth day unless there are symptoms
indicating that it is not doing well, viz., pain, fever,
etc. At the end of the fourth day the nurse uncovers
the wound carefully, washes it thoroughly with
alcohol, and 1 to 2,000 bichlorid solution equal parts,
with sterilized cotton on the end of a dressing
forceps. It is then dried carefully and redusted with
sterilized iodoform and boracic acid. It is then re-
covered with fresh sterile gauze. On the seventh day
the same process is repeated and the stitches removed.
After that it is washed off in the same manner every
day until it is perfectly well.
ANALYSIS OF CASES.
I have removed the appendages for bleeding fibroids
of the uterus in ^o cases. These cases have all recov-
ered from the operation. The history, subsequent to
lU
the operation of a large per cent, of these cases, I have
been unable to trace.
Cases 26, 28, 47, 48, 55, 61, 64, or 14 per cent, con-
tinued to menstruate indefinitely after the operation.
Their symptoms were so severe in 26, 47, 48, 55, or 6
per cent, of the whole number that hysterectomy was
afterward eiiiployed. In none of these cases was
hysterectomy found necessary because of increase of
the growth of the tumor. In the remaining cases, so
far as I have been able to trace them, the tumors have
reduced in size, hemorrhage has ceased and the
patients have been materially benefited while in a
small per cent, actual symptomatic cures were
obtained.
LECTURE IX,
VAGINAL HYSTERECTOMY.
HISTORICAL.
Vaginal hysterectomy is closely associated in it
early history with cancer of the uterus. Greig Smith
says, that it is probable that incision of the uterus was
practiced by the ancient Greeks, but it is certain that
it was subsequently forgotten. Soranus, in his book
of " Diseases of Women," who lived in Rome a century
before Christ, describes the operation as a surgical
procedure for prolapsus. The first authenticated
description of vaginal hysterectomy subsequent to
this was given by Berengarius, of Bologna, in 1507.
In 1560 Andreas A Cruce performed vaginal hyste-
rectomy. J. Schenck a Grafenberg 1617 (Senn)
relates a number of cases in which the uterus was
removed through the vagina in whole or in part by
ignorant persons who had not the faintest idea as to the
diff culty or of the extent and gravity of the operation.
In 1792 Saumonier removed an inverted uterus below
a ligature. Hildanus 1646, Wrisberg 1785, Bernhard
1821 reported cases of accidental or unintentional re-
moval of uteri by the vagina by careless midwives and
others. Intentional removal of the uterus by surgeons
have been reported by Zwinger, Vieusse'n, Baxter,
Faivre, Alexander, Hunter, Joseph Clark and Jack-
son. (Senn.)
The real history of vaginal hysterectomy begins
when it was deliberately planned and executed for the
relief of definite pathologic conditions. To J. M.
136
Langenbeck in 1813 belongs the credit of opening
this page of history. He removed the uterus by
enucleation, using neither clamps nor ligatures and
his case recovered and lived many years. The post-
mortem demonstrated to his incredulous critics the
truth of his claim. Sauter, Jan. 28, 1822; Elias von
Siebold, April 19, 1823; Holscher, Feb. 5, 1824;
Elias voii Siebold, again July 25, 1825; Langenbeck,
again Aug. 5, 1825; Recamier, July 26, 1829; Lan-
genbeck, again Aug. 18, 1829; Roux, Sept. 20 and
Sept. 25, 1830; Recamier, again Jan. 13, 1830; Blun-
dell, Oct. 16, 1830; Siebold 1831, Delbach 1839 are
the bold pioneers who followed the lead of Lan-
genbeck in Europe. From 1839 to the revival of
Czemy in 1878 there are no records of European
cases. In America, however, a few cases were put on
record during this long interval. Palmer Dudley
reports that Dr. John M. Esselman, of Nashville,
Tenn., in September, 1834, removed an inverted
uterus by means of the ligature, his patient recover-
ing. This same surgeon repeated the operation suc-
cessfully in August, 1843, for an inverted uterus
containing a fibroid. This is the first vaginal hysto-
rectomy for fibroids of the uterus I find recorded.
The first vaginal hysterectomy for cancer deliberately
undertaken and successfully executed in this country
was i^erformed by Dr. Paul F. Eve, of Augusta, Ga.,
April 16, 1850. (Am. Journal of Medical Science,
1858.) Dr. L. C. Lane, of San Francisco, operated
for cancer Nov. 11, 1878, and at a later date in the
same year on a second case for cancers. Both cases
recovered. Lane executed this operation inde])endently
of Czemy, who revived the operatic^n in Europe by
I^erforming his first ojjeration April 12, 1878, or seven
months earlier than Lane.
From the revival of Czerny and Lane, with the
dawn of clean surgery, the oi)eration of vaginal hyste-
rectomy became a legitimate ojieration. In less than
twenty yc^ars it has inade wonderful strides. It lias
been performed thousands of times Vjy hundreds of
137
operators, and has, undoubtedly, been the means of
adding many years to the sum total of human life.
VAGINAL HYSTERECTOMY FOR FIBROIDS.
It is argued that a patient suffers less real shock, on
an average, when submitted to a vaginal hysterectomy
than when operated upon by the abdominal route.
The only rational explanation that can be forwarded
to account for this fact is that the intestines and the
peritoneum are not subjected to exjoosure to the air in
the vaginal route, nor are they subjected to the hand-
ling which they are liable to receive in the abdominal
operations. While in our improved methods, the
abdominal contents are exposed and handled to a
small degree compared to former times, at the same
time we can not help but recognize that there is less
shock after a perfect vaginal hysterectomy than after
an abdominal hysterectomy in cases of like severity.
A vaginal hysterectomy avoids the abdominal scar,
which so many patients dread as a brand of mutila-
tion which must be carried through life after all
abdominal operations. Many patients I find have
this wholesome dread to such a degree that there
seems to be no comparison in their minds between
the two operations. An abdominal operation con-
tains all the horrors of a most dreaded affair, while a
vaginal operation with no sign of mutilation left, is
contemplated like a normal labor with dread but
resignation. An abdominal scar, it is true, will fre-
quently become the seat of considerable irritation and
rarely the seat of severe neuralgic jpains. There is
always, too, the remote possibility of ventral hernias
developing in an abdominal scar. It is also claiiiied.
by not a few operators, that safer and more satisfac-
tory drainage can be obtained, when it is required,
through the vaginal route than by the abdominal.
However, as soon as we undertake to do a vaginal
hysterectomy on anything but the smallest kind of a
fibroid, we are hampered by the narrow limits in
which we have to do our work, and, therefore, if the
138
tumor is of considerable size, the extra time its proper
removal from the vagina requires, off- sets what is
gained by non-exposure of the abdominal viscera.
So that the rational surgeon must discriminate here,
as everywhere else in surgery, and select the opera-
tion which best suits the individual case. If he has
a small fibroid, or a large fibroid with relaxed liga-
ments and a large, roomy vagina, he should select the
lower route ; whereas, if he has a large fibroid high in
the pelvis, or a small one with a narrow, contracted
vagina and rigid tissues he should do a laparotomy
and remove the tumor from above.
Methods. — Vaginal hysterectomy for fibroids may
be divided into two grand divisions: 1, removal of
the uterus and its fibroid masses as a whole without
division, or vaginal hysterectomy proper; 2, removal
of the uterus and its accompanying fibroid develop-
ment in piecemeal or morcellement.
1. VAGINAL HYSTERECTOMY PROPER.
Indications. — Vaginal hysterectomy proper for
fibroids must of necessity include only the smallest
tumors, or at best fibroid uteri with long, slender sub-
peritoneal projections. The operation is often the
ideal method of treating small multii)le fibroids, which
are so frequently the seat of severe uterine i)ain and
excessive hemorrhage. Fibroids of considerable size
may frequently be treated by vaginal hysterectomy,
when the uterus is low in the pelvis and the vagina is
large and the tissues loose. It is an easy matter to
turn a complete vaginal hysterectomy for fibroids into
a morcellement should any unlooked for enlargement
manifest itself.
TECHNIQUE OF VAGINAL HYSTERECTOMY PROPER.
The patient should be prepared with the same care
and manner that I have described in Lecture VI on
prepanitory treatment for laparotomy. Special care
should be maintained to rencler the vaginal tract and
external genitalia aseptic. The patient should be
139
anesthetized with ether. She should be placed in the
exaggerated lithotomy position with the limbs sup-
ported by some mechanical device which will hold
them firm and for any required length of time. Oth-
erwise, they should be supported by strong skilled
assistants on either side, who will also hold the vaginal
retractors. Immediately before the operation begins
a nurse or a third assistant should thoroughly scrub
the external genitalia and the vagina with green soap.
This should be thoroughly rinsed off, and the parts
should be thoroughly washed with 95 per cent, alco-
hol and finally rubbed with 1 to 1,000 bichlorid of
mercury and then douched off with sterilized water.
Moist sterilized towels are placed around the field of
operation. The operator takes a seat at the foot of
the table on a small stool. At his right are his instru-
ments with the surgical nurse to do his bidding, At
his left is the nurse who superintends the irrigator of
sterilized water and handles the sponges.
Operation. — Two small vaginal retractors, with short
broad blades, are introduced and held by the assis-
tants so as to retract the anterior and the posterior
vaginal walls and expose the cervix uteri. The cervix
is grasped by a light pair of vulsellum forceps with
four teeth, the uterus rapidly dilated by first intro-
ducing a small dilator and then a large strong one,
until its interior can be reached and thoroughly
explored with a sharp curette. The uterine cavity is
thoroughly curetted and then rendered aseptic by wash-
ing out with a solution of 1 to 100 bichlorid of mercury.
It is then loosely filled with sterilized gauze. Through
the cervix, by means of a curved needle, is passed a
strong double handling string of braided silk, and
this is tied over the os uteri in such a w^ay as to close
the canal. The vulsellum forceps are now removed
and the strong silk ligature is henceforth employed as
a means of handling the uterus. The uterus is now
drawn well down by making strong tractions and the
cervix drawn back so as to expose the anterior utero-
vaginal fold. With a curved scissors the mucous
140
membrane of the vagina at its attachment to the
uterus anteriorly is penetrated and the incisions car-
ried to the right and to the left following the utero-
vaginal junction, until the incisions meet posteriorly
and the uterus is completely severed from the vault
of the vagina (Fig. 27). The assistant now grasps the
Figure 27.
handling string and makes downward and backward
traction, while the operator with the index fingers of
both hands carefully seimrates the bladder from the
anterior surface of the uterus. If there are any firm
bands connecting the two organs, they should be sev-
ered with scissors near their uterine attachment, always
141
keeping the point of the scissors against the firm
uterine tissue. As soon as the utero-vesical fold of
the peritoneum is reached with the fingers the two
fingers should be separated laterally, so as to detach
the bladder from the anterior surface of the broad
ligament, and also for the purpose of pushing the
ureters, which pass under the broad ligaments near
the cervix, well to the sides of the pelvis.
The assistants now draw the cervix forward and the
operator separates the uterus from its posterior
attachments and the two fingers penetrate through
the peritoneum into Douglas' cul-de-sac. The fingers
are then separated laterally tearing the peritoneum in
that direction. A large dry gauze sponge, with a
string attached, is pushed through this opening and
si^read out above the uterus. The broad ligaments
and the appendages are then rapidly examined. The
peritoneum in front of the uterus between it and the
bladder is now torn through and the broad ligaments
are the only attachments left between the uterus and
the patient. If the uterus is not too large and the
broad ligaments are loose and the vagina large, one
pair of strong forceps will secure each broad ligament.
The uterus is drawn well down and the operator slips
his index finger of the left hand behind the left broad
ligament and crowds the appendages toward the
uterus until he can hook the finger over the ligament
outside of the appendages. With the uterus held
well down and steadied by one of the assistants, the
other assistant holding the bladder well out of reach
by a long narrow bladed retractor, the operator with
his right hand slides a strong pair of Byford's clamp
forceps (Fig. 28) over the broad ligament, the poste-
rior blade following the lead of the index finger,
which is still holding the ligament, until they include
its whole width, and project half an inch beyond its
upper edge when they are closed and locked. The
jaws of the forceps should be examined carefully to
see that they include all the tissues necessary, and
that it compresses all portions sufficiently. The locks
142
of the forceps should be securely tied. With the
index finger guiding the scissors, the clamped liga-
ment is now severed close to the uterus. If the
uterus is not too large and the right broad ligament
is long the organ can be delivered as the next step
and when delivered the right broad ligament may be
clamped with ease outside of the vulva. If this is
possible the clamp should be applied outside of the
appendages and the uterus cut away. Frequently,
however, the uterus can not be delivered until the
other clamp is ai)plied and the ligaments severed.
Under such circumstances the forceps should be care-
fully aj)plied exactly like the first one and the liga-
ments divided with the scissors from below upward
Figure 28.
while the assistant makes slight traction on the uterus
until the organ is free, when it is delivered. The
broad ligament forceps are carefully examined now,
to be sure that each is doing all the work required of
it, viz., including the whole ligament in its .grasp and
firmly comjjressing every portion sufficiently tight to
maintain hemostasis. Should any portion need rein-
forcing, a small pair of straight hemostatic forcejjs
may be ajjplied to the projecting free end of the sev-
ered tissue. Occasionally it is not practicable nor
safe to include the whole broad ligament in one pair
of forceps because of its width and bulk, while again
it may be difficult to j)lace the forceps on the whole
143
ligament at once, because of a too narrow vagina
or a highly situated uterus with short ligaments.
Here the bulky base of each broad ligament
should be clamped first, with short stout catch
forceps and the ligaments severed up to within
a short distance of the forceps' bite. The uterus then
can be drawn down and the remaining portion of the
broad ligaments can be secured in one pair of forceps
on each side. The last forceps are placed on the
uterine side of the first pair. All the forceps are now
held by the assistants to their respective sides of the
vagina with their handles separated in such a manner
as to act as lateral retractors. The sponge is removed
from the pelvis and the toilet of the peritoneal cavity
is made by drying it with sponges on holders. The
posterior retractor is now inserted and the operator
seeks the edge of the peritoneum which covers the
bladder, grasps it with a catch forceps and draws it
down and with a running stitch of antiseptic catgut
attaches it to the upper end of the anterior vaginal
wall. An anterior retractor is now inserted and the
edge of the peritoneum covering the rectum is attached
to the upjper end of tliQ XDOsterior vaginal wall in the
same manner. This insures hemostasis of the anterior
and posterior vaginal edges, and covers an otherwise
uncovered gap of connective tissue space.
Drainage. — The forceps are widely sej^arated, two
narrow retractors hold open the vagina anteriorly and
posteriorly, a square piece of sterilized iodoform gauze
two feet wide is placed with its center over the vulva,
and with a large pair of dressing forceps its folded
center is carried well into the vagina beyond the ends
of the forceps, so as to form a bag. It is then loosely
packed with strips of sterilized iodoform gauze and
the edges of the filled bag are left projecting several
inches from the vulva. It is folded over the vulva.
The handles of the clamp forceps are wrapped in
gauze. A liberal supply of absorbent cotton is placed
over and around the forceps and over the perineum
and vulva, and all held in place by three small perin-
144
eal bandages, one passing between the handles of the
forceps and the other two outside of the forceps
handles.
VAGINAL HYSTERECTOMY BY MORCELLEMENT.
Indicdfions. — Vaginal hysterectomy by morcelle-
ment may be done for fibroids of considerable size, the
limit of maximum size on which the operation may
be safely undertaken depending on the skill and expe-
rience of the particular operator. The writer does not
favor the ojDeration where the uterus is too large to
deliver easily after bisecting, preferring to undertake
such cases by the abdominal route. The operation is
now performed every day, however, by an increasing
number of skillful men on fibroids of every size, even
on tumors reaching well above the umbilicus.
Polk, a firm believer in morcellement for fibroids,
lays down the following indications: 1. Whenever
the mass is largely within the pelvis, especially if it
is fixed therein by adhesions. 2. Whenever the mass
is soft and, therefore, compressable as in myoma and
fibrocystoma. 3. In all other cases where we have a
patient in good condition ^ose pelvis is shallow,
where the vaginal canal is roomy, and in whom the
evidence of a pyosalpinx above the j^elvis brim are
absent. Pean, Segmond, Richelot, Jacobs, Henrotin
and others do not make suppurating appendages a
contraindication to this method of operating.
TECHNIQUE.
Crises with Uterus only Double its Natural Size. —
In these cases the technique is very similar to that for
simple vaginal hysterectomy, with the exception that
the uterus is bisected with an antero- j)osterior incision.
Step 1: The vagina is severed close to the cervix,
as in ordinary vaginal hysterectomy, and the uterus
denuded until the posterior and anterior cul-de-sacs
are opened.
Step 2 : Grasp the anterior lip of the cervix on either
side with strong bullet forceps or two well embedded
145
handling strings, and making strong traction split the
anterior wall of the uterus with strong scissors with
the posterior blade guided by the uterine canal
(Fig. 29). When the scissors have reached the limit
of exposure of the uterus the edge of the split uterus
at the highest point of the incision should be grasped
by the bullet forcei^s, and with this new grasp the
uterus should be drawTi down still farther and the
Figure 29.
splitting process continued. When the uterus is
usually movable or the broad ligaments unusually
long, sometimes at this point the partially split uterus
is completely anteverted and the fundus is delivered.
As a rule, however, whenever it is necessary to split
the uterus at all in order to remove it, the bisecting
must be carried to completion.
146
Step 3: When the bisected uterus is well drawn
down, the increased movability of the organ in conse-
quence of being in two pieces enables one to clamp
the broad ligaments with one, or at most two forceps,
and the respective halves are removed. After one
side has been cut away it is an easy matter to clamp
and remove the opposite half.
Step 4: Finish operation and apply drainage as in
simple vaginal hysterectomy.
Variations of Procedure. — If it is convenient it
is often better to attempt to clamp the broad liga-
ments immediately after opening the two cul-de-sacs,
in order to save the patient as much blood as possible.
When it is not possible to clamp the whole broad lig-
ament, the base of the ligaments with the uterine arte-
ries may be secured. As a preliminary every precau-
tion should be observed to render the cavity of the
uterus aseptic.
Cases icith Uterus More than Double Its Normal
Size. — In these cases the uterus must be removed by
piecemeal. In order to accomplish this so as not to
make a horrible failure, a thoroughly systematic
course must be observed by one skilled in the details
of pelvic surgery and surgical emergencies. No two
cases are alike. Consequently no two operations are
ever identical.
Step 1: Circular incisions around the cervix,
after first grasping the anterior and the posterior lip
of the cervix with strong forceps. The uterus is
denuded anteriorly and posteriorly and the posterior
cul-de-sac is opened. An attemj^t is then made to
enter the anterior cul-de-sac.
Step 2: Clamp forceps are now placed on the base
of each broad ligament high enough to include the
uterine artery and its branches, and the ligaments are
cut nearly as high as the point of the clamp.
Step 3: The cervix is split into halves by a lateral
incision on the line of the uterine canal with strong
scissors or a knife (Fig. 30).
Step 4: With the anterior lip well drawn down and
147
firmly held, the posterior lip is drawn well down and
amputated. The remaining stump of the posterior
half of the uterus is firmly grasped in forceps, keep-
ing the uterus well down in the field of operation.
Step 5 : If the uterus is not too large at this point a
single clamp forceps may be placed on the remaining
portion of the broad ligament.
Figure 30.
Step 6: With hemostasis well secured, from this
point on the splitting of the uterus is continued and
morcellation is proceeded with by amputation of first
one-half or a portion of a half and then the other, sever-
ing the broad ligaments by degrees until by piecemeal
148
the whole uterus is removed. Care should be main-
tained to have a secure hold of the uterus with forceps
at some point besides the point of amputation at all
times, in order that it may not slip out of the field of
operation. As soon as the uterine mass has been
reduced suflBciently so that it may be delivered it
should be removed. Care must be exerted to secure
all large subperitoneal masses which from their situa-
tion might by carelessness be accidently separated
from the tumor and escape beyond the reach of the
finger or forcej^s. As the morcellement progresses a
finger in the x^osterior cul-de-sac from time to time
learns facts of value to the operator.
Bemarks. — The care of the forceps and the care of
the vaginal and jDeritoneal edges, after this modified
operation, is identical to that after the simple opera-
tion. The toilet of the operation field and the drain-
age is the same. If adhesions exist they must be care-
fully separated. If the anterior cul-de-sac is elevated
so that it can not be entered before amputation is
commenced, amputation should be proceeded with and
the uterus gradually drawn down until the cul-de-sao
can be opened.
Accidents to he avoided. — Wounding of the bladder
or intestines and clamping one or both carelessly are
accidents which must be carefully guarded against
in vaginal hysterectomy of any kind. Severing of
important blood vessels before they are securely
clamped is another annoying accident, because of the
tendency of the unsecured blood vessels to retract
into the loose connective tissue of the broad ligament,
where they will continue to bleed out of reach of
hemostatic forceps. To avoid this accident great car©
should be observed to securely clamp all tissues before
severing, and if there is the slightest doubt about the
security of any portion of the divided ligament after it
has been cut, a second clamp should reinforce the first.
To avoid clamping the ureters the forceps should not be
applied to the base of the broad ligament until the
bladder is thoroughly separated from its anterior
149
surface, until the finger can sweep between it and
the broad ligament to the sides of the pelvis.
This insures the pushing of the ureters out of the
reach of the forceps. This same maneuver insures
the integrity of the bladder also. If the bladder
is found so adherent at any portion that it is not
readily separated with the finger, scissors should be
employed to dissect it from the face of the uterus or
tumor, great care being observed to avoid wounding
the bladder with the scissors by keeping the point of
that instrument against the uterus. By following the
imperative rule of separating the bladder early and
keeping it out of the field of oj)eration by the use of
an anterior retractor, it will never be wounded. To
avoid wounding the rectum the same care should be
observed in entering the posterior cul-de-sac as is
exerted in opening the anterior one. If one carelessly
opens this pouch, it is an easy matter to strip the
peritoneal covering of the bowel posterior to the cul-
de-sac and miss entering the peritoneal cavity entirely ;
while by ignorantly pursuing this false track the rec-
tum may be penetrated. To avoid this embarrassing
predicament stick to the uterus. If one does strip off
a portion of the uterine peritoneum it will do no harm
and the rectum is safe.
USE OF LIGATURES FOR VAGINAL HYSTERECTOMY.
By some operators ligatures are emjDloyed for secur-
ing hemostasis instead of clamps. In simple, uncom-
plicated cases ligatures may be employed with ease.
In morcellement, where high and excessive manipula-
tion is required the ligatures are impracticable be-
cause of the. difficulty of applying them, and because
of the difficulty of preventing them from becoming
loosened by the subsequent manipulation of the parts.
When ligatures are employed they prolong the con-
valescence if they are left long and allowed to ulcerate
away. The time required for the accomplishment of
that act is from twelve to forty days. During all this
time it requires great diligence on the part of the
150
attendant to prevent infecting of the ligatures; in fact,
it is seldom prevented. An offensive vaginal dis-
charge bears evidence of the fact, until the ligatures
are finally discharged. If ligatures are employed
and cut short, with the idea of burying them, it fre-
quently happens that they become infected, even
when the greatest care is observed to preserv^e cleanli-
ness. The reason for this is the necessity for drain-
age in almost all of these cases. The method of
drainage makes the wound practically an open one.
Hence the danger of some portion of the otherwise
buried ligatures becoming infected. Once infected
long months of pus discharge from vaginal fistula is
the sequel. This is all avoided when hemostasis is
secured by strong forceps, because the means of hemos-
tasis (the forceps) are removed in forty-eight hours,
and nothing is left of a foreign nature which may be-
come infected.
AFTER-TREATMENT OF VAGINAL HYSTERECTOMY WITH
CLAMPS.
Shock is treated on the lines laid down in Lecture
VI. I must, also, refer the reader to that Lecture
for the detail treatment of the bowels and care of
the patient as regards drink, diet, etc. The bladder
is emptied every eight hours with a catheter until
the forceps and the first drainage is removed. The
catheter should be employed oftener if it is neces-
sary. The nurse employs an aseptic glass catheter
with a small nozzle which will run the urine off into
a bottle. The urethra is carefully exposed before the
catheter is introduced and thoroughly wiped off with
a saturated solution of boracic acid.
Forceps. — The locks of the forceps are carefully
tied at the time they are put on to avoid accidental
unclasping of their blades. The handles are kept
covered with sterilized gauze. If it gets soiled at any
time it is changed. At the end of twenty-four hours
all but the principal forceps are removed. The string
securing the lock is cut, the lock unfastened carefully,
151
the blades opened enough to loosen their grasp on the
tissues and then they are carefully removed. At the
end of forty-eight hours the main forceps are removed
in the same manner. If the tissues in any particular
case showed unusual tendencies to bleed at the time
of the operation I allow the forceps to remain twenty-
four hours longer. When the large forceps are re-
moved they should be opened widely before an attempt
is made to withdraw them, and then they should be
brought out with a backward motion in order to avoid
catching the tissues with the projection on the pos-
terior blade.
Di^essing. — If the external portion of the drain be-
comes soiled with accidental discharges of urine or
excessive drain fluid it should be removed and replaced
with a new^ external pad of loose sterilized gauze as
often as is necessary. Twelve hours after the last
forceps are removed about one-third of the external
gauze drain should be removed and a fresh pad of
gauze placed over the vulva. In twenty- four hours
another third should be extracted, and in twenty-four
hours more, or sixty hours after the last forceps are re-
moved, all of the balance should be taken out. When
the last gauze is removed an external irrigation should
be employed of 1 to 5,000 bichlorid solution followed
by a plain water irrigation. A small sterilized iodo-
form drain should now be carried carefully about three
inches into the vagina on a strong pair of dressing
forceps, and the end of the drain allowed to protrude
from the vagina. Over this is placed an antiseptic
absorbent pad. In twenty-four hours this drain is
removed and then eighty-four hours after the last for-
ceps are removed, and the peritoneum has had ample
time to close, the first vaginal douche is given.
Douches. — This douche must be given with extreme
care by a nurse who understands all the responsibility
she is entrusted with. The douche point must be
made of glass, bulbous, with openings directed only
at right angles to it. The patient should be placed
on her back at the edge of a bed with feet supported
152
on two chairs. A Kelly pad should be under her
buttocks. The reservoir containing sterilized water
of a temperature of 105 should be placed but eighteen
inches above the patient's hips, in order to have but
slight iDressure. The nurse after thoroughly preparing
her hands, inserts two fingers into the vagina about
two and one-half inches, and between the lingers ex-
tending to within one-half inch of their extremities
is inserted the douche point. The water is turned on
with every x^recaution employed to secure immediate
and free return current. The douche is repeated in
this way, the nurse introducing the fingers and douche
point a little further each time until the vault of the
vagina is reached, every twelve hours until the sixth day
from the removal of the forceps, when 1 to 5,000 bi-
chlorid of mercury solution may be substituted for the
I)lain douche, always following the bichlorid douche by
a plain one. It must be obvious why I insist on the
great care in employing this douche. The peritoneal
cavity is expected to close in a few hours after the
gauze is removed. Frequently, there is no doubt, it
is closed off a few hours after the operation is finished.
Notwithstanding this tendency to early closure of the
peritoneal cavity, carelessness in employing the first
few douches, if free return stream is not provided and
great pressure employed by placing the reservoir too
high, might result in breaking up the union of the
tissues and fill the abdominal cavity with the fluids
and debris of the vaginal tract. After each douche
the vulva should be covered with an antiseptic pad.
After each urination or movement of the bowels the
external parts should be douched otf with sterilized
w.iter and the antiseptic dressing renewed.
(jfettuifj Up. — Patients manifest a desire to get up
earlier aft(^r vaginal hysterectcjmy than after abdominal
operations. There is less prolonged reaction in the way
of nervous exhaustion as there is less immediate shock
with the vaginal o])eratiedicle allowed to contract into abdominal
incision.
2. Iiitra-peritoneal Method. — This, as practiced by
Schroeder, consisted primarily in constricting the
jjedicle with the Kleeberg rubber band, removing the
tumor, paring down the stumi), taking from its center
a wedge-shaped piece of the bulky tissue, cauterizing
the canal, closing the stump by strongly sewing
157
together the edges of the wedge-shaped incision and
finally sewing over all the jjeritoneal edges. The
stitching of the stump was intended to bo secure
enough so that all subsequent oozing was made impos-
sible after the final removal of the rubber ligature.
The iDedicle was then dropped, as is the pedicle after
ordinary ovariotomy, and the abdomen closed.
This method was modified by Olshausen, Charles
T. Parkes, Zweife], Hofmeier and others.
(a) Olshausen modified by securing the pedicle
with a rubber ligature, and sinking the whole by
sewing over it the f)eritoneum.
(b) Charles T. Parkes modified it by ligating firmly
with strong silk and cauterizing the tissues of the
pedicle to firm bone-like condition w4th the actual
cautery over a temporary clamp.
(c) Zweifel tied the pedicle firmly with a strong
multiple ligature of silk, securing it in this manner in
several parts.
(d) Marcy of Boston, 1881, secured an intra-
abdominal stump by sewing from the outer edge of
one broad ligament to the other with thirteen cobbler's
stitches; including in the process ovarian arteries,
broad ligaments, uterine arteries and the stump of the
uterus formed by the cervix uteri.
(e) Hofmeier carefully ligated the pedicle in its cir-
cumference without closing the cervical canal, and
closed its abdominal end by covering with peritoneum.
Drainage could take place into the vagina through the
patulous canal.
(/) Goffe and Albert independently employed treat-
ment similar to Hofmeier's, with the addition of
applying a capillary drain through the open cervix
into the vagina.
3. Complete Removal, Eastmaifs methods.
(a) In 1888 Dr. Mary A. D. Jones removed the
entire uterus, including the cervix, by employing long
hemostatic forceps for the lower portion of the broad
ligament, and severing the cervix from the vagina.
(6) Joseph Eastman's method, 1889: The broad
158
ligaments are tied off, including the appendages, the
vagina opened posteriorly by elevating it by means of
a special staff constructed for the purpose, which is
held by an assistant, the vaginal edges are ligated with
long ligatures which afterward serve to invert the
edges into the vagina, and the cervix and stump are
progressively cut away. The iDeritoneum is sewed over
the inverted vaginal edges^ the abdominal wound is
closed, and the vagina packed with gauze. The mass
of the tumor, if cumbersome, may be cut away, pre-
vious to opening the vagina, by putting on a tempo-
rary rubber ligature.
(c) Eastman in 1884 enucleated the stump without
first tying the uterine arteries by peeling the pedicle
portion of the uterus with a serrated gouge, keeping
inside of the uterine arteries in their course up the
side of the uterus.
4. Vcujinal Fixation, Byford's Method, — The broad
ligaments are tied with silk and severed. The cervix
is secured with provisional rubber ligature, the tumor
€ut away, the pedicle firmly tied with multiple silk
ligatures, left long, the stump trimmed and closed with
long silk ligatures, an opening made into the vagina
in front of the cervix, the ligatures securing the
pedicle carried through it by traction on them, the
stump inverted into the vagina, the peritoneum over
the inverted cervix closed by stitching the bladder
peritoneum to that covering the pedicle, closure of
the abdominal wound, and finally j)lacing a special
hemostatic clamp on the inverted pedicle in the
vagina.
Meinert, independently of Byford, suggested pulling
the pedicle into the vagina through Douglas's cul-de-
sac, but is not known to have accomplished it.
Polk, of New York, has removed the entire cervix,
stitching the vaginal stump to the abdominal wall.
Thus briefly do we get an outline history of the
develoi)ment of the technique of this important oper-
ation. Erom the beginning the struggle was in the
direction of accomplishing complete hemostasis of
159
the pedicle without the necessity of invariably fixing
it in the abdominal wall. It was soon demonstrated
that no XDedicle comprised of cervical or uterine tissue
could be made bloodless by any amount of ligating
with non-elastic ligatures which could not from time
io time be tightened as the tissues shrunk. Hence
with silk, steel or clamj) hemostasis it was necessary
to fix the pedicle externally in order that they might
be tightened in case of necessity. Elastic ligatures,
while they accomplished perfect hemostasis, experi-
ence soon demonstrated were not safe ligatures to bury,
because they frequently gave rise to suppuration when
the strangulated pedicle was dropped. At last it
.seemed inevitable that external fixation of the pedicle
was to be the only safe method of accomplishing
abdominal hysterectomy. The displacement of the
tissues necessary for abdominal fixation and its dis-
tressing sequelae — bladder pressure, painful cicatrix,
dragging pain, hernise, depressed cicatrix, etc., made
surgeons slow to accept that means as final, while at
the same time there seemed no other alternative. The
Taginal fixation of Byford's which came in late in the
race, solved many of the difficulties, and if something
better had not speedily followed, it would have become
the ideal method of pedicle fixation. But when the
struggle was at its height the w^hole problem was sud-
denly solved by the ap]3lication of a simple little prin-
ciple described by Stimson in 1889 and i^racticed by
■others and redescribed and emphasized by Baer, of
Philadelphia, in 1892. The principle consists in
obtaining hemostasis of the uterine stum^D by ligating
its blood supply outside of the uterine tissue before
it reaches its substance; or, in other words, by ligating
the uterine arteries at either side of the cervix. East-
man had practically accomplished the same thing in
his old operation of complete removal of the uterus
the same year Stimson announced it, but none of us
recognized the princij^le involved, nor did he announce
with sufficient emphasis why he succeeded. So Stim-
son and Baer get the credit of promulgating and
160
establishing a great but simple principle, and the
uterus is removed every day now, j^artially or wholly,
and the pedicle di'opx^ed with perfect impunity.
5. Ligation of Arteries at Side of the Uterine
Tissue with Intra-abdominal Stuwp: Stiwson-Baer
Mctliod. — This method is accomplished by ligating
the ovarian arteries with or without the broad liga-
ment, severing the broad ligaments after placing hem-
ostatic clamps on the uterine side down to the uterine
arteries, ligation of the uterine arteries, severing the
uterus at the cervix, cauterizing the cervical canal,
trimming the cervix, closing the stump with catgut or
silk, burying the pedicle with peritoneum, closing the
broad ligaments with a running stitch of catgut, and
closing the abdominal wall.
Senn modifies this operation by stri]3ping the tumor
of its peritoneum in front and behind for three inches,
severing the tumor at its bottom so as to leave the
peritoneum like a cufp and then fixing this cuff open
to the lower angle of the abdominal wall, draining it
with iodoform gauze until all danger of hemorrhage
has ceased, when the gauze is removed and the cuff
closed by closing the abdominal wound by tying
sutures inserted at the time of the operation. Stim-
son-Baer principle when thoroughly carried out
makes Professor Senn's precautions superfluous.
INDICATIONS FOR ABDOMINAL HYSTERECTOMY FOR
UTERINE FIBROIDS.
Successful abdominal hysterectomy is the only
absolutely sure cure for large fibroids of the uterus.
Ergot, electricity, ligation of the blood supply will
cure a certain percentage, but hysterectomy removes
at once every vestige of the tumor and with it the
uterus on which it j^ropagates.
The operation of abdominal hysterectomy, in its
I)resent condition of perfection, in the hands of expe-
rienced operators should be the operation of selection
in all fibroids which can not be removed by vaginal
hysterectomy when the patient is in a physical condi-
161
tion which will not jeopardize her immediate recovery
from the operation.
Multiple intramural fibroids of every kind which
are producing distressing symptoms should be sub-
mitted to hysterectomy because there is no absolute
cure for them by any other means.
SuhjyeritoneaJ fibroids when from multiple develop-
ments can only be removed by abdominal hysterec-
tomy; no other treatment will reach them.
Interstitial fibroids of large size, of hemorrhagic
nature, if the patients are in a fair physical condition,
should always be treated by abdominal hysterectomy.
Cystic fibroids can only be cured by hysterectomy.
Any form of treatment less radical only aggravates
these cases.
Suj)purating fibroids imperatively demand hys-
terectomy.
Fibroids complicated with pelvic suppurations,
pyosalx^inx, supi^urating ovaries or appendicitis,
should be removed at the same time that the pelvis is
cleaned out.
Large fibroids complicated with pregnancy where
there is the slightest doubt of a successful normal
ending of the condition of pregnancy, demand abdom-
inal hysterectomy.
ABDOMINAL HYSTERECTOMY — TECHNIQUE.
Uncomplicated Case. — The writer adopts the Stim-
son-Baer operation for uncomplicated hysterectomies
for any cause. The abdomen is opened with a liberal
incision which will allow of easy delivery of the
tumor. The lower end of the incision is carried well
down to within an inch of the symphysis pubis. If
the bladder is unusually high the incision at the
lower end need not include the peritoneum. The
tumor should next be delivered by lifting it out with
the hand or a strong joair of vulsellum forceps fixed
in the fundus of the uterus or top of the tumor. It
is very necessary that the tumor be delivered at this
point in order to continue the work of removal intel-
162
ligently. As soon as the tumor is outside of the
abdomen the general peritoneal cavity should be shut
off with liberal packs of diy sterilized gauze. If the
intestines are inclined to protrude the abdominal
incision may be closed above the pelvis with a tem-
porary silk suture. The broad ligaments are next
clamped with a strong j)air of long jawed hemostatic
forceps far enough away from the uterus so that
another forceps of the same character may be placed
between it and the uterus, and low enough to include
all the upper portion of the broad ligament with the
ovarian arteries. The broad ligaments on either side
are next severed between the forceps to the lower
limit of their bite. This frees the uterus well down
to the cervix and the region of the uterine arteries.
The peritoneum on the anterior surface of the uterus
is severed at the utero-vesical fold transversely, the
ends of the incision ending at the two provisional
forceps placed on the uterine end of the severed
broad ligament. The cervix is then stripped of its
peritoneum anteriorly, care being exercised to sepa-
rate the bladder from it, thoroughly. After the
uterus is well denuded of its peritoneum belov/ the
point marked off by the knife, and the bladder is well
separated a gauze sponge of small size may be placed
temporarily on the denuded surface. It is well at
this point, too, to peel off' a small flap of peritoneum
from the posterior surface of the lower jjortion of the
body and cervix, beginning an inch above the i)oint
at which the stump will be made, and denuding to a
point just below it. The uterus is now drawn well to
one side, retractors placed on the opposite side and the
uterine artery is secured by placing around it a strong
silk or antiseptic catgut ligature. The artery is
securely tied and the ligature left long. A pair of
artery forceps is placed on the tissue secured by the
ligature between it and the cervix, and the tissue sev-
ered between the forceps and the uterus. The oppo-
site side is treated in the same manner. The uterus
ifl now removed by severing it at its neck. The inci-
163
sion is begun about an inch above the vaginal attach-
ment anteriorly and posteriorly and carried toward the
uterine canal in such a way as to leave the uterine
stump, a hollow wedge with the apex at the cervical
canal, and the sides of the wedge the anterior and
posterior surfaces of the stump, which when approx-
imated, form flaps which completely shut off the
cervical canal and the cavity of the pedicle from the
abdominal cavity. The uterus can be severed from
the cervix best with a knife. As soon as the flaps
Figure 28.
are begun posteriorly and anteriorly the stump should
be steadied and controlled by securing these flaps in
strong lock forceps. (Fig. 28.) As the uterus is sev-
ered great care should be exerted not to infect the
abdominal cavity with any septic matter which may
be in the uterine canal, and the cervical canal must
be immediately cauterized or otherwise rendered
sterile.
The stump is now closed by uniting the two flaps with
inversion sutures of antiseptic catgut. The simplest
164
and most satisfactory method of suturing for this pur-
pose in my opinion is the one employed by Prof. A.
H. Ferguson, Fig. 29. The stitch is an interrupted
one as shown in the drawing, and completely closes
the flaps without i^enetratmg their cut surfaces. Prof.
Ferguson uses the stitch in bowel surgery to take the
place of the Lembert suture. When the pedicle is
closed it is dropped.
At this point the upper portion of the broad liga-
Fjoure 29.
Method of suturing the pedicle in hysterectomy; a, pedicle unclosed;
b, pedicle and method of introducinf? inversion stitch; c, the comx)leted
pedicle.
ment upon which the provisional hemostatic forceps
were jjlaced must be cared ior. It contains the ova-
rian artery as it passes along the broad ligament par-
allel to the infundiV)ulo-pelvic ligament which should
be securely tied. Next if the pedicle of the broad liga-
ment is long enough so that it can be easily included in
the ligature left long after ligating the uterine artery
165
without undue tension, it should be so included, secur-
ing the ligature from slipping by taking a turn around
thfe infundibulo-pelvic ligament. When the ligament
is in place ready to be tied the forceps should be re-
moved from it and the ligature firmly tied, with a
treble knot, and forceps attached to the pedicle out-
side of the ligature. The opposite side is treated in
the same manner.
Everything is now finished about the pedicle except
closing the peritoneum over the stump. This is
accomiplished by stitching together with a running
suture of antiseptic catgut the two edges of the peri-
toneum which was stripped off the anterior and pos-
terior surfaces of the uterus before amputating the
uterus. When this is done the pelvic peritoneum is
perfectly closed, and as soon as the toilet of the cavity
is completed, the abominal wound should be sutured,
the dressings applied and the patient put to bed.
Remarks. — The Trendelenburg position may usu-
ally be used with advantage immediately after the
uterus is amputated in order to ex^Dose the bottom of
the pelvis. Some operators place their patients in this
position from the beginning of the operation. Drain-
age is not necessary after a normal case.
COMPLICATED CASES,
Unfortunately in the surgery of fibroid tumors
uncomplicated cases are not the rule. The most com-
mon anomalies are the following: 1, pedunculated
tumors; 2, tumors developed into the broad ligament;
3, interstitial tumors involving the cervix; 4, tumors
complicated with diseased appendages; 5, sui^purating
fibroids; 6, tumors complicated with pregnancy; 7,
extra-peritoneal fibroids.
1. Pedunculated Tu)nors. — Tumors of varying
sizes with small pedicles are occasionally found grow-
ing from some portion of the uterus. If they repre-
sent a distinct tumor and the uterus is not involved
with separate or other centers of fibroid development,
and the appendages are not involved, the operator
166
sliould seek to remove the tumor without interfering
with the uterus proper. In order to accomplish the
removal of these pedunculated masses, and secure a
pedicle which may be safely dropped a definite line of
procedure should be followed. If the tumor is only
partially pedunculated so that a portion of its bulk is
buried in the uterus necessitating enucleation, I pre-
fer to remove the uterus, as I consider that the only
absolutely safe procedure under the circumstances. If
the tumor, however, is pedunculated, so that a pedicle
of peritoneum, connective tissue, and the blood vessels
feeding the tumor, without tumor tissue or uterine tis-
sue, can be secured after its removal, I do not hesitate
to ligate and drop the pedicle any more than I would
hesitate to drop the pedicle of an ovarian cyst.
Method: The tumor is delivered. A pair of strong
hemostatic forceps is clamj)ed on the pedicle between
the tumor and uterus, unless the tumor encroaches
upon the pedicle too much to make a clamp effective
after the growth has been enucleated, when instead of
a clamp a provisional rubber ligature should be used.
The tumor should now be cut away. If the pedicle
is long and not involved by the tumor it should be
severed close to the tumor, thus leaving abund-
ance of tissue external to the clamp. If the pedicle
is short and encroached ui)on by the tumor, the inci-
sion should extend around the base of the tumor at a
distance of at least two inches from the provisional
rubber ligature, involving the peritoneal coat and con-
nective tissue capsule of the tumor (the pedicle edges
of the incision being caught on three sides by hemo-
static forceps to control the stump and prevent sliiJ-
ping of the ligature), and the tumor is enucleated,
leaving a pedicle of connective tissue, blood vessels
and peritoneum.
The pedicle is treated in both cases alike. If blood
vessels of considerable size are found in the free end
they should be ligated separately close down to the
provisional clamj) or ligfiture. Then a strong anti-
septic catgut or silk ligature should transfix the pedi-
167
cle near its edges, and, after tying the first knot the
provisional clamp or ligature should be removed and
the ligature securely tied, so as to secure every portion
of the pedicle. If care has been observed to eliminate
all uterine or tumor tissue from the pedicle it will be as
secure now as an ordinary pedicle of an ovarian cyst.
The pedicle should be trimmed down to within an inch
of the final ligature.
The writer has removed two pedunculated fibroids of
large size in this manner, one of ten pounds and another
of eight pounds, in which pregnancy existed, the women
both going on to term afterward and giving birth to
their children without complications. One of these
conceived afterward. Another case of this kind in which
a tumor of large size was removed, afterward conceived
and gave birth without complications to a living child.
2. Tumor developed into the broad Ligaments. — It
is not a rare complication to find these tumors of the
uterus develoxDed in the folds of the broad ligament
to such an extent that the ligament is si^read out
over the growth and its folds tense. Frequently it
will be impossible to deliver the uterus until the por-
tion has been enucleated from the broad ligament.
The line of procedure here is: First, enucleate the
tumor from the broad ligament, and second, deliver
the uterus as in uncomplicated cases and complete the
toilet in the same manner.
First step: Tie if possible the ovarian artery near
the outer edge of the tumor near the pelvic walls. If
more convenient a provisional forcep may be used to
secure the vessel.
Second step: Split the tense peritoneum which
represents the broad ligament, the folds of which
have been eradicated by the burying tumor, by draw-
ing a scalpel over it at its most prominent i3oint in a
direction from the uterus to the side of the pelvis.
Then with the fingers or some blunt instrument the
tumor is gradually peeled from its subperitoneal bed,
constant traction being exerted on it until the uterus
and tumor are delivered.
168
Third step; Completion of the operation as in a
normal case.
3. Interstitial Tumors involving the Cervix. — When
the fibroid has developed low in the substance of the
uteiiis so as to occuj)y the cervix, some management
is required in order to secure a proper pedicle. Two
methods may be pursued; first, complete enucleation
of the fibroid tissue from the cervix, and second, com-
plete removal of the cervix.
When it is possible, I prefer to enucleate the
tumor from the cervix in order to preserve that por-
tion of the uterus for a pedicle and a key to the
abdominal floor.
The first part of the operation is conducted as in a
normal case or if any portion of the tumor is subperi-
toneal as in the last method described. When the
region of the large cervix is reached, a blunt instru-
ment should be employed to comj^letely enucleate it
from all surrounding tissue, the bladder in front and
all lateral tissue in order to insure perfect security of
the ureters. This can only be done by keeping the
point of the enucleating instrument well against the
uterine tissue. If there is difficulty in securing the
uterine arteries definitely, because of the necessary
distortion of the tissues, two strong Tait pedicle-pins
should transfix the cervix, at right angles to each
other, their ends being supported by the abdominal
walls, and beneath these a provisional rubber ligature
should be placed. The tumor is then cut away, down
to the i^edicle-pins, and the uterine arteries are sought
and tied. After insuring hemostasis, the elastic lig-
ature is removed and the fibroid tissue of the cervix
carefully j^eeled out of its ca})sule. From this point
the case is treated as a normal hysterectomy.
Removal of the cervix: Occasionally it may seem
l)est to remove the entire cervix when it is the seat of
the fibroid invasion. The same course should be
pursued here as when the cervix is to be retained.
The uterus may or may not be severed above a provi-
sional elastic ligature, before ligating the uterine
169
arteries. When the cervix has been thoroughly
stripped and the vagina rendered aseptic, the vagina
should be opened at the anterior or i^osterior cul-de-
sac close to the cervix, and one blade of a curved pair
of scissors slipped through into the vagina, and the
cervix completely severed from its vaginal attachment
by following the circumference of the cervix with the
scissors. A guide in the vagina in the form of a staff
may be employed in making the first vaginal incision.
If there are any small bleeding points on the vaginal
edges they should be tied with catgut or twisted with
hemostatic forceps. The vagina should be loosely
packed with sterilized iodoform gauze from above so
as to just reach to the upper end of the severed vagina.
The tissues in the bottom of the pelvis naturally fall
together. ^With abundant drain in the vagina I
simply allow the upper end of the vagina and the
other severed tissues to fall together naturally, con-
tenting myself to close the peritoneum alone with a
running antiseptic catgut suture, exactly as when the
cervix is allowed to remain.
4. Tumors compliccdedwiih diseased Aiypendacjcs. —
Diseased aiDpendages are a frequent accomj)animent of
fibroids of the uterus. When fibroids demanding a
hysterectomy are complicated with diseased append-
ages the disease of the adnexia should be treated in
the ordinary way, and then the hysterectomy should
be carried out on the lines best suited to the case.
Cysts of the ovary, without adhesions, scarcely com-
plicates a hysterectomy for fibroids. The pedicle of
the tumor is at once ligated with strong silk or clamj^ed
with strong forceps and the tumor removed. If it is
of considerable size it may first be emptied with a
trochar.
Pyosalpinx should be attacked as though no fibroid
existed. If there has been bilateral disease of the
appendages with extensive peritonitis and numerous
adhesions, the adhesions should be carefully separated
and the diseased pus tubes and ovaries oarefully enu-
cleated and removed. Then the uterus is removed in
170
the ordinary way. The matter of drainage should be
dealt with here exactly as when no hysterectomy fol-
lows, except that it may oftener be more convenient
to drain through the vagina. If enucleation of the
appendages has been such that large peritoneal adhe-
sions have been separated and there is considerable
unavoidable oozing from raw surfaces, some form of
drain is imperative. As the most dejpendent portion
of the ijelvis is Douglas's cul-de-sac, one should select
that point from which to make vaginal drain. Fig. 30
crudely represents an instrument I have devised for
opening the cul-de-sac and guiding my drainage gauze
into the vagina. The lower instrument represents
a staff which is placed in the vagina as a guide, with a
Figure 30.
tubular end which will act as a counter pressure for the
pointed dressing guide which penetrates the cul-de-
sac from the pelvic cavity. The upper instrument is
a hollow forcei^s with pointed blades, which when
they have penetrated into the vagina guided by the
staff are opened and a strip of gauze of any size may be
pushed ]')etween them and drawn through from below.
The tubular forceps may also act as a guide for a
rubber drainage tube. Those who have attempted to
place drainage tubes or gauze without a i^roper guide
will ajjpreciate the advantage of this instrument.
So, after the uterus is removed a roll of sterilized
strip gauze about the size of the index finger should
171
be drawn through the cul-de-sac into the vagina, the
vagina loosely packed with gauze below and a packing
left in the lower part of the pelvis sufficient to take
care of any oozing from the peritoneal surfaces, Fig. 31.
The toilet of the peritoneum is completed as in ordi-
nary cases and the abdominal wound closed. The
dressing used as a drain is removed as soon as it no
longer soils the dry dressings which are placed in con-
tact with it at the vaginal outlet, usually from twenty-
four to forty-eight hours.
Figure 31.
5. Suppurating Fibroids — Infected fibroids in
which there is extensive interstitial suppuration are
extremely rare. I have not seen more than two such
cases in my experience. One of these I removed.
The tumor had been infected more than a year before
I operated on it. Several abscesses formed at inter-
vals in4he interior of the walls of the large uterus
and then discharged through the cervix. The case
172
failed to successfully drain after several operative pro-
cedures which I attempted through the cervix.
Finally I decided to do a complete abdominal hyste-
rectomy, one which would also include the infected
cer^'ix. The operation is performed practically as
described above for the complete removal of the ute-
rus including the cervix. Extreme care must be main-
tained to proteCc the abdominal contents and perito-
neum from the infected contents of the uterus. If the
vaginal track is employed for drainage,it should be thor-
oughly cleansed first by a competent assistant who is
not allowed to further participate in the operation. All
drain gauze should be drawn from above downward,
never the reverse.
6. Tumors coinpliccded icith Pregnancy. — Fibroid
tumors of large size complicated with pregnancy de-
mands the sacrificing of the product of conception
and the removal of the uterus.
Symptoms: The symptoms of pregnancy are
usually all present in an exaggerated form. Men-
struation which has heretofore been excessive and
frequent on account of the fibroid will cease abruptly.
The tumor will begin to grow rapidly. Pressure
symptoms are much exaggerated. The bowels and
bladder will become crowded and sacralgia and dys-
uria will result. In a word, all the ordinary symp-
toms of growing fibroids of the uterus minus hem-
orrhage, and all the classical symptoms of pregnancy,
will become magnified to a painful degree.
Pedunculated fibroids of the subperitoneal variety,
with small thin pedicles complicating pregnancy may
be removed in the manner described in this lecture
under the head of pedunculated fibroids, without dis-
tur})ing the contents of the uterus. If the tumor
involves the uterine walls to any marked degree and
the tumor is so large that it will prevent full develop-
ment of the fetus or its development to the point of
viability, or the tumor's jjosition is such that it will
interfere with the jjregnancy taking its proper course,
the entire uterus should be removed with the tumor.
173
if it is considered necessary to remove the tumor at
once. If pregnancy is known to exist before an o^^era-
tion is determined on for the removal of the tumor, as
a rule it would be safer to empty the uterus as an
early preliminary measure, if it is feasible, reserving
the operation on the tumor for a time after convales-
cence from the abortion is accomplished.
Operation: However, if it actually becomes neces-
sary to remove a fibroid uterus complicated with preg-
nancy, either as a matter of choice, or accident from
mistaken diagnoses, the operation is proceeded wdth
exactly along the lines of an ordinary abdominal hys-
terectomy. As a rule under these circumstances, the
broad ligaments are loose, and the uterus freely mov-
able making a hysterectomy comiDaratively easy. Any
complication should be dealt with as in ordinary
cases.
7. Extra-peritoneal Fibroids. — It is not infre-
quent that one w^ill find in multiple fibroids that one
or several of the centers of growth have developed
low in the pelvis and in their increase in size they
have gradually elevated the peritoneum and grown
beneath it until they have become actual extra-perito-
neal growths. The degree of such complication vary
much in different cases, from a small nodule growing
beneath the peritoneum from the cervix to a tumor
weighing several pounds elevating the peritoneum in
an irregular manner and distorting all the organs of
the pelvis.
Method of Procedure: These cases are all subject
to removal if they are handled in the projper manner.
They must be enucleated. The peritoneum covering
the abdominal surface of the tumor must be carefully
severed at its point of deflection from the tumor on
to the parietes. The tumor should then be grasped
with strong blunt toothed vulsellum forceps and while
traction is being made to deliver the tumor the fin-
gers should carefully enucleate the growth from its
bed. Great care should be observed in order to enu-
cleate it perfectly and free it absolutely from the ure-
174
ters or the rectum walls. By following the enuclea-
tion the tumor will finally lead to its pedicle which
will be the uterus. The cavity from which it is enu-
cleated should be packed temporarily wdth sterilized
gauze sponges in order to check serious oozing.
When the tumor is finally enucleated and removed,
together with the uterus, in the ordinary manner, the
work of making a pelvic floor must be accomplished.
If there is not peritoneum enough left to cover the
floor of the iDelvis and a large raw surface is inevit-
able, this should be drained into the vagina by a roll
of gauze an inch in diameter with a packing in the
pelvis sufficiently large to cover the denuded surface.
Occasionally the cavity from which the tumor is enu-
cleated may be packed with gauze and drained into
the vagina as a subperitoneal pocket and the perito-
neum closed over it. As a rule these cases require
drainage.
IN DEX.
A
Abdovien:
Contour, with fibroids 19
Abdominal auscultation .... 22
Abdominal electrodes 50
Abdominal Hysterectomy 153
Complete removal 157
Complicated cases 165
Drainage 170
Extra-peritoneal method. . .156
History 155
Indications 160
Intra-peritoneal method. . . .156
Stimpson-Baer method. . . . IGO
Technique 161
Vaginal fixation 158
Abdominal incision S3
Abdominal palpation 22
Abdominal Avound-closing. . . 132
Adhesions 126
Adhesions following laparoto-
my 85
After-treatment:
"Bowels 89
Care of glass drain 8»
Care of gauze drain 88
Diet 90
Dressings 88
Forceps 150
Laparotomy .87
Vaginal Hysterectomy. . . . 150
After-treatment of laparotomy. 87
Albert, Dr 157
Abdominal Hysterectomy . . 157
Aloin 28
Alteratives 29
Ammonium muriate 29
Analysis of cases. .* 138
Anteversion 23
Antifebrin 31
Antipyriu 81
Ajjpeiidaties:
Diseased 126
Removal of 117
Arrangement of operating room. 79
Arsenic 29
Artificial menopause 117
Asafedita 33
Ashton, Dr b5
Astringents 33
Astruc:
Nerves in myomata 8
B
Ballottement 25
Baths for fibroids 28
Battery:
Office 47
Portable 46
Primary 46
Battey operation 117
Belladonna 32
Bidder:
Nerves in myomata 8
Bimanual examination 21
Bladder:
Effects of fibroids 18
In vaginal hysterectomy. . . 149
Blood supply of uterus 118
Blood vessels:
In fibroids 8
Effect of galvinism 53
Blue mass 30
Blundell:
Vaginal hysterectomy .... 136
Boeckmann sterilizer 71
Booth, Dr 74
Bowels:
After-treatment 89
Preparation gi
Bromids 31
Burnham, Dr 15.5
Byford, W. H.
Administration of blue mass. 30
Byford, H.T 158
Clamp forceps 142
Ergot for fibroids 40
Vaginal fixation of stump . . 158
C
Calumbo 28
Cancer of uterus . 24
Cannabis indiea 32
Capillary drain iso
Cascara sagrada :.8
Cataphoric action of galvanic
current 55
Catgut 70
Cells: ■ ■ . . -
Diamond carbon 47
Law 47
Le Clanche 47
(■ern'x:
In pregnancy 25
Position Avith fibroids 20
Chloral 31
Chlorid of iron 34
Chlorid of zinc 34
Cinchona 28
Clamp forceps 142
Clay electrodes .51
Closing abdominal wound. . . 132
Complications in livstorectomy.165
Cohnheim's etiology of fibroids. 14
Constipation 19
Constitutional disturbances . . 19
I
INDEX.
Copper electrodes 52
Curettement 116
Current, street wire 47
Czernv '.
Vaginal hysterectomy 136
D
Deformity produced by fibroids. 19
Delbaeh:
Vaginal hysterectomy .... 13b
Diagnosis of fibroids 17
Diet 90
Differential diagnosis of fibroids 23
Diseased appendages 126
Diseased appendages in abdom-
inal hysterectomy 169
Dorsett, Dr 93
Douches:
After vaginal hysterectomy . 151
Preparatory 83
Drainage ^°*
In fibroids 1<0
In oophorectomy 127
Dress 1°
Dressings. • • • .°°
Dressing the wound irfo
Dudley: ^ _.
Vaginal hysterectomy .... lab
Dupuytren :
Nerves in myomata v
Dysmenorrhea, with fibroids. . 18
E
Eastman :
Abdominal hysterectomy. . .
Elect r if ity:
Apparatus
Current
Indications for use
Electrodfft
Abdominal
Clay
Copper
Flexible
Intrauterine
Rectal
Vaginal
Emmet:
Etiology of fibroids
Ergot:
Duration of treatment . ...
I'lTect on interstitial fibroids
Effect on intramural fibroids
Effect on submucous fibroids
Eff(-ct on peritoneal fibroids
Indications .• • • •
M<'thod of administration . .
Physiologic action
Results
Es.selman :
Vaginal hysterectomy ....
'vaginal hysterectomy ....
Extra-peritoneal fibroid ....
F
Ferguson stitch
Fibrocysts
157
46
46
57
50
50
51
52
51
51
52
52
14
43
. 38
. 38
. 38
. 88
39
41
37
4^1
136
i:^(;
n:;
9
Fibroids:
Anatomy 5
Carcinomatous degeneration, 11
Classification 5
Degenerative changes 9
Diagnosis 17
Electricity in 46
Etiology 13
Histologic changes 7
Medical treatment 27
Minor surge rj- 114
Spontaneous disappearance . 11
Spontaneous expulsion. ... 12
Suppurating 171
Symptoms 17
Treatment 26
Floating kidney 20
Fetal movements 25
Fetal heart tones 25
Forceps 150
Functional disturbances .... 18
G
Galvanisin:
Applied to treatment of
fibroids 56
Chemic reaction 53
Effect on blood vessels. ... 53
Etfect on living tissues. ... 53
Effect on microbes M
Effect on sensibility 53
General effect 56
Interpolar effect 54
Polar effect 53
Garrigues :
Histology of myomata 7
Gauze 76
General astringents 35
General tonics 27
Getting up 152
Glass drain 128
Glass syringe 129
Goffe:
Abdominal hysterectomy . . 157
Goodell's dilators 116
Gottschalk, Prof 93
Gusserow :
Disappearance of fibroids . . 12
H
Hartz:
Nerves in myomata 8
Hegar :
Abdominal liysterectomy. . . 155
Hegar's operation, . . .... 117
Hildebrandt :
Ergot in treatment of fibroids, 40
Hofmcier :
Alxlominal hysterectomy. . . 157
Hydrastis Canadensis 85
Hyoscyamus 28
Hy])OSulpliites 28
JIi/HtcrrctD'iin/:
Abdominal. ..." 155
Vaginal 135
Inoperable cases 61
INDEX.
Instrument:
Used in vaginal drainage. . . 170
Instrumental examination. . . 21
Internal electrodes 51
Interpolar electrolysis 56
Interstitial tumors of cervix . . 168
Intestinal obstruction 85
Intrauterine electrode 51
lodin 29
Iron 34
J
Jones, Dr. Mary A.
Abdominal hysterectomy. . . 157
K
Kelly:
Abdominal hysterectomy. . .156
Kidneys SO
Kimball, Gillman:
Abdominal hvsterectomv. . . 155
Klebs :
Etiology of fibroids 13
Kleeberg :
Abdominal hysterectomy. . . 155
Kleinwachter :
Etiology of fibroids 13
Koeberle :
Abdominal hysterectomy. . . 155
Fibrocysts 10
L
Lane:
Vaginal hysterectomy .... 136
Langenbeck :
Vaginal hysterectomy .... 130
Laparotomii:
After-treatment 87
For removal of ovaries . . . .120
For removal of uterus .... 155
Preparation of bowels .... 81
Preparation of patient .... S3
Latta:
Abdominal hysterectomy. . . 155
Vaginal hysterectomy .... 136
Leopold :
Theory of fibrocysts 10
Ligation of uterine arterie><:
After-treatment 98
Report of cases 100
Selection of cases 98
Technique 94
Ligatures 68
Ligatures in vaginal hysterec-
tomy 149
Lithotomy pcntion :
For ligation of arteries . ... 94
For vaginal hysterectomy . . 139
Lymphatics in fibroids 9
M
Marcy :
Abdominal hysterectomj'. . . 157
Martin, Dr .155
Medical treatment of fibroids . 27
Meinhert :
Abdominal hysterectomy . . . 158
Membranous electrodes. . . . . 51
Menstruation -with fibroids. . . 18
Mercury 29
Mllliampere meter 49
Minor surgery:
Submucous fibroids 114
Mitchel :
Etiology of fibroids 15
Morcellement:
Accidents 148
Indications 144
Remarks 148
Technique 144
Uterus more than doul>le. . . 146
Variations 146
Myomata :
Histology 7
N
Nelson :
Report of treatment with
ergot 45
Nephritis 81
Nerves in fibroids 8
Nitrate of silver 35
Nux vomica 28
O
Objective symptoms 20
Olshausen :
Abdominal hj'Sterectomj-. . , 157
Ooptiorcctomij :
Adhesion.s 126
After-treatment 133
Drainage 127
Dressings 133
Exploration 122
Indications 120
Operation 121
Vaginal drainage 130
Operating room 66
Opium SS
Orarian cyxt:
Diagnosis 25
P
Parkes :
Abdominal hysterectomy. . . 157
P(^an:
Abdominal hysterectomy. . . 155
Pedicle:
Of submucous fibroid 115
Pedunculated tumors 165
Pelvic examination 20
Phenacetin 61
Polk :
Abdominal hysterectomy. . . 158
Pozzi :
Etiology of fibroids 13
Fibrocysts 9
Histology of myomata .... 8
I'regiiaiicy:
Complicating fibroids 172
Normal 24
Tubal 25
Prepared foods 28
Prcixirittion i>j:
Catgut. . ." 72
Hands 78
IV
INDEX.
Patient 80
Vagina 83
Price, Joseph l"i^>
Pyoktanin 73
Pyosalpinx 120
Q
Quassia 28
Quinin 28
R
Recamier:
Vaginal hysterectomj- .... 136
Rectal electrodes -32
Rectum with fihroids 1«
Removal of appendages 117
Removal of cervix 168
Results of vaginal hysterec- _
tomy 1-53
Retroversion 23
Rheostat— xMcIntosh 48
Robinson, Dr. Byron 119
Roux:
Vaginal hysterectomy .... 136
S
Sauter i
Vaginal hysterectomy .... 136
Schroeder's abdominal hyster-
ectomy 1-56
Sedatives 31
Seibold :
Vaginal hysterectomy .... 136
Senn:
Abdominal hysterectomy. . . 160
Etiology of fibroids 14
Sensibility:
Effect of galvanism 53
Silk Jl
Silkworm gut /I
Sims' position 34
Speculum 22
Sponges 74
Stenli/ers o»
Stimson-Raer:
Abdominal hysterectomy. . . 156
Storage batteries 48
Stramonium 32
Strychnia 28
Subinvolution 23
Submucous fibroids 114
Stump in abdominal hysterec-
tomy 103
Superficial stitches 133
Suppurating fibroids 171
Sutttm, Bland:
Blood vessels in fibroids ... 8
Fibrocysts 9
Histology of fibroids 7
Sutures 68
Syringe 129
T
Tait operation 117
Terfmiiiiif;:
Abdominal hysterectomy . . 161
Application of electricity. . . 58
Ligation of uterine arteries. . 94
Oophorectomy 121
Vaginal hysterectomy .... 138
Treatment of fibroids:
Abdominal hysterectomy. . . 155
Electrical 58
Ligation of uterine arteries . 92
Medical 26
Minor surgical 114
Morcellcment 144
Vaginal hysterectomy .... 135
Trendelenburg position .... 165
Tubal pregnancy 25
Tumors:
In l)road ligament 167
Complicating pregnancy. . . 172
U
Urination 19
Uterine artery— ligation .... 92
Uterine contractions 18
Uterine disinfection 139
Uterine sound 22
Uterus:
Position with fibroids 20
V
Vagina in pregnancy 25
Vaginal douche 83
Vaginal electrodes 52
Vaginal fixation 158
VcujindL hi/stcrectomi/ :
Accidents 148
After-treatment 150
Bj' morceilement 142
Douches 151
Drainage 143
Dressings 151
Forceps 142
Getting up 152
History 135
Indications 138
Ligatures 149
Operation 139
Results 153
Technique 138
Vaginal ligation 92
Van de Walker:
Abdominal hysterectomy. . 156
Velpeau :
Etiology of fibroids 13
Virchow :
Classification of inyomata. . H
Fil)rocysts 9
W
Wells:
Etiology of fibroids 15
Winkle:
Bhiod vessels in myomata . . 8
Etiology of fibi'oids 13
Nerves in inyoinata 8
Z
Zweifel :
Abdominal hysterectomy. . . L)7
J. J.
COLUMBIA UiNivr^ivoi
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