HX00039160 Columbia (Bnttergftp intiieCttptrfltegork College of ^{jpgtctang ano Hmrgeons Hibvaxp A TEXT-BOOK OF GYNAECOLOGICAL SURGERY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofgynaecOOberk Plate I. — Principal Structures of the Female Pelvis, seen from below (semi-diagrammatic) . i, Vagina. 2, Anus. 3, External sphincter. 4, Tuber ischii. 5, Levator ani muscle. 6, Coccyx. 7, Urethra. 8, Bladder. 9, Ureter. 10. Anterior fornix. 11, Vaginal cervix. 12, Uterine aitery. 13, Rectum. 14, Trunk of uterine and superior vesical arteries. 15, Pouch of Douglas. 16, Sigmoid. A TEXT-BOOK OF GYNAECOLOGICAL SURGERY BY COMYNS BERKELEY M.A., M.D., B.C.Cantab., F.R.C.P.Lond., M.R.C.S.Eng. Gynaecologist and Obstetrician to the Middlesex Hospital, Senior Physician to the City of London Lying-in Hospital, Surgeon to In-patients at the Chelsea Hospital for Women, Consulting Gynaecologist to the Eltham Hospital, Examiner in Diseases of Women and Midwifery to the University of Oxford and to the Conjoint Board of England ; formerly Examiner in Diseases of Women and Midwifery at Apothecaries' Hall, London AND VICTOR BONNEY M.S., M.D., B.SC.LOND., F.R.C.S.ENG., M.R.C.P.LOND. Assistant Gynaecologist and Assistant Obstetrician to the Middlesex Hospital, Senior Surgeon to Out-patients at the Chelsea Hospital for Women, Gynaecologist to the Hospital for Epilepsy and Nervous Diseases, Maida Vale ; formerly Hunterian Professor, Royal College of Surgeons of England, and Emden Research Scholar, Cancer Investigation Laboratories, Middlesex Hospital WITH 392 FIGURES IN THE TEXT FROM DRAWINGS BY VICTOR BONNEY, AND 16 COLOURED PLATES NEW YORK FUNK AND WAGNALLS COMPANY 1911 AIX RIGHTS RESERVED 3 en ID TO WILLIAM DUNCAN AND JOHN BLAND-SUTTON OUR SPONSORS IN THIS BRANCH OF SURGERY PREFACE This book, which is concerned wholly with the operative side of gynaecology, is a record of our own personal methods, and of experience acquired during our years of service at the Middlesex Hospital and the Chelsea Hospital for Women. It may also be taken as reflecting the practice of the school of gynaecological surgery to which we belong. It sets forth in detail the indications for gynaecological operations, the preoperative preparation, the operative technique, the postoperative treatment, and the dangers to be avoided, with the possible complications and their appropriate treatment. The black-and-white illustrations, depicting the successive stages of all the most important and the most frequently performed operations, will, we believe, be found helpful in elucidating the text. The subjects of the coloured plates have been carefully chosen with the object of illustrating the female pelvic organs in their normal and in various pathological states. We venture to hope that the volume will be of service on the one hand to those who are proposing to follow this department of surgery more particularly, and on the other hand to those who are occasionally called upon to perform gynaecological operations, and have not had opportunity for acquiring the ripe experience which long apprenticeship in the gynaecological wards and operating theatre brings. To our publishers we must express our thanks for the courtesy with which they have carried out our wishes and the care with which the work has been produced. January, 191 1 CONTENTS CHAPTER PAGE i. General Operative Considerations i 2. Surgical Technique ..... 3. Operating Theatre and Appointments 4. Operations in Private Houses 5. Examination and Preparation of the Patient 6. Operations on the Vulva .... 7. Operations on the Vagina .... 8. Operations on the Cervix .... 9. Operations on the Cavity of the Uterus . 10. Hysterectomy : General Considerations 11. Vaginal Hysterectomy .... 12. Radical Hystero-Vaginectomy by Paravaginal Section ....... 13. Opening and Closing the Abdominal Cavity 14. Subtotal Hysterectomy by the Routine Clamp and Ligature Methods .... 15. Abdominal Total Hysterectomy . 16. Hysterectomy for Cervical Myoma 17. The Radical Abdominal Operation for Carcinoma of the Cervix ...... 18. Operations for Broad-Ligament Myomata . 19. Abdominal Myomectomy .... 20. Cesarean Section ..... 21. utriculo plasty ...... 22. Operations to Remedy Malpositions of the Uterl 23. Ovariotomy ....... 24. Operations on the Broad Ligament 7 5i 65 7i $7 127 153 185 212 227 261 276 292 319 338 361 406 413 421 434 438 452 463 x CONTENTS CHAPTER PAGE 25. Operations on the Fallopian Tubes and Ovaries 476 26. Operations for Extra-Uterine Gestation . . 503 27. Ovarian Tumours Complicating Pregnancy, Labour and the puerperium ..... 512 28. Uterine Myomata Complicating Pregnancy, Labour and the puerperium ..... 516 29. Cancer of the Cervix Uteri Complicating Preg- nancy and Labour ...... 521 30. Operations on the Intestinal Canal . . . 524 31. Operation-Wounds of the Bladder, Ureter, and Bowel ........ 539 32. Postoperative Treatment ..... 547 33. Methods of Administering Saline Solution . 573 34. Postoperative Complications .... 582 35. Postoperative Complications (continued) . . 598 36. Postoperative Complications (continued) . . 616 37. Postoperative Complications (continued) . . 629 38. Postoperative Complications (continued) . . 650 39. Postoperative Complications (concluded) . . 665 40. Immediate Results of Operations on the Female Genital Organs ...... 677 41. Remote Results of Operations on the Female Genital Organs 695 Index ......... 711 LIST OF PLATES PLATE i. Principal Structures of the Female Pelvis, seen from below ..... Frontispiece Facing page 2. The Female Pelvic Organs, seen from above . 276 3. Multiple Myomata of the Uterine Body . . 292 4. Central Cervical Myoma 338 5. Myoma of the Anterior Uterine Wall and Cervix 352 6. Myoma of the Right Broad Ligament . . 406 7. multilocular ovarian adeno-cystoma of the Left Side ........ 452 8. Ovarian Dermoid Cyst ..... 456 9. Bilateral Papilliferous Ovarian Cysts . . 460 10. Bilateral Malignant Ovarian Tumour . . 464 11. Broad-Ligament Cyst of the Left Side . . 468 12. Bilateral Hydro-Salpinx . . . . . 478 13. Bilateral Pyo-Salpinx ..... 484 14. Right Tubo-Ovarian Cyst ..... 494 15. Large Ovarian Abscess of the Left Side . . 496 16. Ruptured Tubal Pregnancy .... 504 A TEXT-BOOK OF GYNAECOLOGICAL SURGERY CHAPTER I GENERAL OPERATIVE CONSIDERATIONS Under this head we discuss the proper bearing of the surgeon, the question of speed in operating, and the desirability of reducing to a minimum the number of operative manipulations. THE BEARING OF THE SURGEON The surgeon when operating should always remember that the character of the work of his subordinates will be largely influenced by his own bearing. Whilst it is impossible to lay down definite rules suitable for all temperaments, nevertheless there are certain points a consideration of which will, we trust, prove as useful to those beginning gynaecological practice as they have been to us. Anyone who has taken the trouble to study the work of a number of operators cannot fail to have observed how variously the stress and strain of operation is borne by different minds, and will deduce from a consideration of the strong and weak points of each operator some con- ception of the ideal. The keystone of the surgeon's bearing should be self- control, and whilst it is his duty to keep a general eye 2 GYNECOLOGICAL SURGERY upon all that takes place in the operating theatre, and without hesitation to correct mistakes, he should be con- tinually on his guard against becoming excited or losing his temper. The man who, when confronted with a diffi- culty, gets flurried and unsteady has mistaken his vocation, however dexterous he may be, or however learned in the technical details of his art. The habit of abusing assistants, the instruments, or the anaesthetist, so easily acquired and with difficulty lost, is not one to be commended ; the mental incertitude of which such behaviour is the indirect expression will inevitably spread to the other members of the staff, so that at the very time when the surgeon is most in need of effective help he will find it fail him. The assistants should be encouraged to look forward to each operating day as one of strenuous but pleasurable work, but this object will not be attained if constant fault- finding forms part of the routine. It will also be well for the surgeon to remember that his bearing will be the subject of keen criticism by the spectators, and that there is nothing so much admired as fortitude in adversity. On the other hand, he must avoid any temptation of " play- ing to the gallery," for sooner or later such conduct will be detrimental to the patient. A surgeon should not gossip, for it is impossible for him to do his best work if he is continually engaged in irrelevant chatter ; whilst a silent surgeon is unprofitable to those around him, for he should clearly outline the steps of the operation as it proceeds, and by apposite and instructive remarks compel the attention of those who are there to learn. It is the mark of a good operator to become more and more silent as the difficulty of the operation increases, of a bad one to become more loquacious. It falls to the lot of every surgeon, sooner or later, to stand face to face with threatened disaster when operating, and even among the best there must be moments when the heart sinks. On such occasions the operator should remember that if he does not hesitate, the deliberate and GENERAL OPERATIVE CONSIDERATIONS 3 vigorous application of general surgical principles will always, temporarily at any rate, surmount the difficulty, whilst half-hearted, and nervous measures merely increase it. A sturdy belief in his own powers and a refusal to accept defeat are the best assets of a calling which pre- eminently demands moral courage. Before operating, the surgeon should go over in his mind the various possibilities of the projected procedure, so that he may be the better able to meet them. Like- wise, after the operation he will find it profitable to recall the difficulties he has encountered and the technique he adopted in surmounting them, for it is only by cultivat- ing a habit of self-examination that his workmanship will continue to improve. In hospitals it necessarily happens that a very large amount of work must be got through in a single operating day, but it is a grave mistake, for mere show, to undertake more work of an arduous nature than the physique and mind of all concerned can fairly tolerate. Operations performed when everybody is tired out are ill done ; the surgeon's hand and mind become less steady, his assistants are less apt, the nurses are less careful, and the patient is exhausted by long waiting. The surgeon would do well to recollect that until the day of his retirement he should take - every opportunity to improve his technique, for he may rest assured that he will never be perfect, and that there is some good lesson to be learnt from seeing the work of any operator, even if it be only what to avoid. Lastly, nothing is so contemptible as publicly to decry the work of other men. To hear a surgeon loudly pro- claiming the faults and failures of another indicates that he has not attained to that experience which begets leniency, shows a lack of good-fellowship, and argues an absence of nicer feeling which sooner or later will be injurious to his patients, and which makes a man an unpleasant and unprofitable member of society. 4 GYNAECOLOGICAL SURGERY SPEED IN OPERATING Speed as an indication of perfect operative technique is the characteristic of a fine surgeon, as a striving after effect is the stock-in-trade of the charlatan. An operation rapidly yet correctly performed has many advantages over one as technically correct yet laboriously and tediously accomplished. The period over which haemorrhage may occur is shortened, the tissues are less bruised, the time of exposure of the peritoneum in abdominal section is minimized, the dose of the anaesthetic with its attendant evils is reduced, and shock, which is the expression of all these factors, is lessened. Moreover, less strain is thrown upon the temper and the legs of the operator and his assist- ants, and the interest of the latter and of the onlookers is maintained at its highest level. There is, however, one aspect of rapid operating which must not be lost sight of, namely, the fact that there is a much greater liability for oozing to occur after the operation has terminated ; for where a man has taken two hours to perform an operation, any bleeding, if it is going to occur, will have declared itself in that time ; whereas, had the wound been finally closed at the end of a quarter of an hour, the opportunity of dis- covering the bleeding would have been lost. It is for this reason that the results of the brilliant surgical prodigy and of the old-fashioned laborious plodder are not so different as at first sight might be expected, since the after-results due to mauling and exposure of the tissues by the latter are in the former balanced by the local peritonitis and fever set up by post-operative oozing. Rapid operating, then, should be acquired only as the result of continual practice and constant thought as to how best to reduce the manipulations required without sacrificing the efficiency of the operation or increasing the danger to the patient. Thus obtained, speed is an attribute in the highest degree to be desired and striven for. GENERAL OPERATIVE CONSIDERATIONS 5 It is impossible to lay down any rules as to speed for the various operations dealt with in this work, so much de- pending upon the nature of the case and the circumstances in which they are performed, for an operation which may only take thirty minutes with full hospital assistance, may take double that time when performed with a single assistant in a private house. We find that all major operations, with a very few exceptions, such as the radical extirpation for carcinoma of the cervix, can be performed well under an hour, and most minor operations under half an hour. Patients undergoing even the severest operations will maintain their condition well for an hour, but every five minutes after that period is increasingly detrimental to their welfare. OPERATIVE MANIPULATION The surgeon should continually endeavour to reduce the number of manipulations required in a given procedure to the minimum consistent with its proper performance. Any- one who will take the trouble attentively to observe the performance of an operation cannot fail to be struck by the number of unnecessary movements made. This wastage of time and effort cannot, of course, be entirely abrogated, much of it being the expression of the wavering intentions of the operator in the face of new difficulties continually presenting themselves. Nevertheless some part of it is due solely to bad habits and a lack of determination on the part of the surgeon to subject his movements to examination, and to improve upon them wherever possible. Thus, to per- form the primary incision through the abdominal skin and fascia by a series of niggling cuts is an example of bad technique, as is the practice of passing a needle on a forceps, removing and laying down the forceps, and then extracting the needle with the fingers of the left hand. The needle should, of course, be extracted with the forceps and the two returned to the instrument-tray together. 6 GYNECOLOGICAL SURGERY These examples might be multiplied many times, but they will suffice for the purpose we have in view. Manipulations should be conducted with the finger-tips ; there is nothing so inelegant as to see the surgeon's hands sprawling over the operation area, obstructing not only the spectators' but his own view. It is better, whenever possible, to keep the hands out of the wound entirely by performing the necessary manoeuvres instrumentally. The long dissecting- forceps illustrated on p. 9 will be found very useful in this connexion. CHAPTER II SURGICAL TECHNIQUE INSTRUMENTS The aim of the surgeon should be to use as few instru- ments as is compatible with the efficient performance of the operation he is engaged upon. There are many reasons for this. The fewer instruments a surgeon has, the more uses he learns to put them to, and he is thus able to save time in immaterial details of the operation which can be profit- ably expended on its essential features. Thus, a Spencer Wells pressure-forceps may be efficiently used for hcemo- stasis, as a retractor, as a needle-holder, as a dissecting forceps, as a probe, and as a swab-holder. The surgeon who is accustomed to make one instrument serve many purposes maintains his self-reliance, no matter what the nature of the operation or the circumstances under which he is called upon to perform it, whilst one whose habit it is to use a special instrument for every separate manoeuvre may become flurried, unstable, and unreliable when these are not forthcoming. In choosing his instruments, a surgeon should therefore have these points in mind and avoid if possible those whose uses are limited to some special manoeuvre, and should remember that a fictitious value has often been and will again be given to some instrument solely on account of the halo surrounding its inventor's name. It has been our experience, that those who are for ever advocating the advantages of some new instrument lack the manipulative skill and ready resource which are the characteristics of the surgeon by grace of nature. Com- plicated instruments should be avoided whenever possible, 7 8 GYNECOLOGICAL SURGERY for, however well they may work in the instrument maker's shop, they soon get out of order from the wear and tear of boiling. In the long run it is cheapest to use instru- ments of the best steel and of the finest workmanship, for though their initial cost be greater, they last longer and are not likely to fail at some critical moment. Instru- ments, we would add, should be kept in perfect order, for such defects as sprung forceps, loose-jointed scissors, and blunt knives, though not very noticeable in a straight- forward operation, become painfully apparent when the difficulty and strain of the case test every joint of the surgeon's armour. Simplicity, then, in instruments, as in other things, should be the key-note of the operation, but simplicity with efficiency. In medio tutissimus ibis : an outfit so large as to require for its conveyance a bag resembling a seaman's chest is ridiculous ; one so small that it can be carried in the trousers pocket is dangerous. The following are the instruments we use : Scalpel and scalpel carrier. — The scalpel measures 5f in., its blade being if in. Larger instruments than these are inconvenient for use in the pelvis. Scalpels should not be boiled, at all events for more than a few Scale f Fig. 1. — Berkeley's scalpel case. minutes, or the edge will be blunted ; they are best ste- rilized by absolute alcohol, and the scalpel case shown in Fig. i, which keeps them continuously immersed in this fluid, is a most convenient carrier. Forceps. Dissecting. — Dissecting forceps should be 7 in. long for use in the bottom of the pelvis ; the whole of the last inch of the jaws should approximate and be INSTRUMENTS 9 grooved transversely, for the convenient seizing of needles and masses of tissue, and their points should be rat-toothed Fig. 2. — Bonney's dissecting forceps. to give a better hold in manoeuvres requiring delicate manipulation. The instrument shown in Fig. 2 fulfils these requirements. Spencer Wells. — Two sizes are required, 5 in. and 7 in. The jaws should approximate before the ratchet Fig. 3. — Long Spencer Wells forceps. Fig. 3a. — Short Spencer Wells forceps. locks, so that it is possible to seize small objects without clamping them (Figs. 3 and 3a). Kocher's. — These forceps are of a similar shape to the Spencer Wells, but their jaws are longer (2 in.) and their ends are furnished with rat-teeth. They are par- ticularly convenient for holding masses of tissue firmly, 10 GYNAECOLOGICAL SURGERY as, for instance, when clamping the uterine arteries on the side of the uterus. We use two sizes, 5| in. with straight Fig. 4a. — Angular Kocher's forceps jaws, and 8 in. with angular jaws, the latter being very useful for panhysterectomy and Wertheim's operation (Figs. 4 and 4a). Ring forceps. — These should be 10 in. long (Fig. 5). They are perhaps the most generally useful forceps in the whole outfit, for besides carrying swabs they are admir- Fig. 5. — Ring forceps. able for securing and tying bleeding-points deep down in the pelvis, and for steadying and pulling up diseased appendages, whilst they make very good bowel clamps. INSTRUMENTS ii Round-ligament forceps. — The forceps shown in Fig. $a are required for the operation of intraperitoneal shortening of the round ligaments. Fig. 5a. — Round-ligament forceps Shot forceps. — For closure of the shot-and-coil suture a short pair of forceps similar to those used by a carpenter will suffice (Figs. 6 and 6a). Scissors. — -For gynaecological surgery the scissors should be 6 in. and 7 in. long. Of the iifflniiii— Fig. 6. — Shot-and-coil ligature. Fig. 6a. — Compression forceps for shot-and-coil ligature. former size three types are required, those with straight blunt-pointed blades, those with blunt-pointed blades bent on the flat, and those with sharp-pointed blades set at an angle in the plane of the shanks. The longer scissors are most useful for deep abdominal work, and the best pattern is Mayo's, which has straight, blunt-pointed blades. We have had a pair made to the same pattern with blunt-pointed blades bent on the flat, which we have found of great service, especially in the radical operation for carcinoma of the cervix (Fig. 7). Yolsella. — The best-pattern volsella is Fenton's. It is 7 in. long, and effects a very firm hold (Fig. 8). 12 GYNECOLOGICAL SURGERY Retractors. Abdominal. — We have tried various patterns on the market, and find the two best to be the gloved Fig. 7. — Scissors of various types. a, blunt-pointed blades bent on the flat; b, straight blunt-pointed Mayo's scissors; c, angular-pointed scissors. hand and a self-retaining form designed by one of us (Fig. 9). This instrument consists of two parallel bars Fig. 8. — Fenton's bull-dog volsella. with a solid retracting blade on each, and two removable solid blades which slide on the bars and are automatically fixed at any point directly pressure is applied. One cross- INSTRUMENTS 13 bar with a ratchet which controls the parallel bars is also fitted. A ratchet catch is fixed to the sliding parallel bar, which works in conjunction with the ratchet on the cross-bar, thus enabling the operator to fix the blades at any point, without danger of slipping. By means of the sliding blades this instrument will efficiently retract the largest incisions, so that additional retractors are unnecessary. On the other hand, by removing these blades the instrument can be used for small incisions. Fig. 9. — Berkeley's retractor. The ratchet effectually controls the tendency to slipping noticed with Gosset's retractor when the muscles are rigid or the instrument is somewhat worn, and the four blades also prevent the instrument from slewing round, which is a common fault with Gosset's retractor. Berkeley's retractor is particularly useful in the radical operation for carcinoma of the cervix, a splendid view of the field of operation being obtained by its use, and its four blades keeping the india-rubber sheeting in position. Vaginal. — Auvard's weighted speculum (Fig. 10) is a necessity for the proper performance of vaginal surgery. It should not be made unnecessarily heavy, as it is apt i4 GYNECOLOGICAL SURGERY in that case to tear or bruise the soft parts. The operator must remember that should it slip out of the vagina it will break any china receptacle that may be underneath it. In minor operations on virgins the use of Auvard's speculum is undesirable or impossible without lacerating the vagina. In such cases we prefer the use of a narrow vaginal retractor held by the hand (Fig. ii). For vaginal hysterectomy, hys- tero-vaginectomy, and paravaginal section, longer and broader re- tractors are convenient for holding back the bladder or rectum. The pattern we use has a blade measur- ing 4 in. by 2 in. (Fig. 12). Clamps. The clip retractor. — This instrument was devised for securing india-rubber sheeting over the edge of the wound and abdo- minal skin in cases where infection or bruising of the wound-edge is to be expected from the nature of the operation. It also forms a useful retractor (Fig. 13). Vaginal clamp. — We devised the instrument shown in Fig. 14 to clamp the vagina preparatory to its section in Wer- theim's operation, after having tried every other pattern made for the same purpose we could obtain. The blades, which are set at a T-angle to the shank, measure 2\ in. across ; they are longitudinally serrated, and are slightly bowed so as to close with a spring action. The shanks measure 6 in. to the joint, and are bowed so as to include the uterus without compressing it, being at their widest points 2| in„ apart. The handles measure 7 in. from the joint, and are provided with two pairs of Fig. 10.— Auvard's speculum. INSTRUMENTS 15 Fig. 11. — Narrow vaginal retractor. Fig. 12. — Broad vaginal retractor. Fig. 13. — Bonney's clip retractor. Fig. 14. — The Berkeley-Bonney vaginal clamp. i6 GYNECOLOGICAL SURGERY finger-rings, the lower of which end 3| in. from the joint and are used for adjustment, whilst the upper, which are Fig. 15. — Intestinal clamp. at the extreme ends of the handles, are used when actually clamping the vagina. The blades of these forceps will be found amply large enough to span the breadth of any vagina, their failure to accomplish this in some operators' hands being due to the fact that the previous division of the paravaginal tissue has not been sufficient. This clamp secures a very firm hold, minimizes the risk of injuring the ureter, and allows of direct traction upwards on the vagina. Intestinal clamps. — The ring forceps already described make very efficient bowel clamps where end-to-end anasto- mosis has to be performed. For lateral anastomosis they will not do. We, therefore, always carry a pair of the 13 13 Fig. 16. — Bonney's needles — curved and half-circle. clamps illustrated in Fig. 15, their blades being 4! in. long. These clamps may be also very conveniently used in place of Playfair's probe in minor operations on the uterus. INSTRUMENTS J 7 Needles. Curved. — For many years we have used curved needles of the pattern shown in Fig. 16. They have the great advantage of being able to be firmly held at any angle in any forceps ; they are also easy to thread and difficult to blunt. The front half of the haft of the needle is bayonet-shaped _____^ =========== ==»=> with sharp-cutting edges, s!L '/z whilst the hinder half is Fig# 16«.— Long straight needle. flat with a circular eye. They are made in various shapes and sizes, from No. i, suitable for perineoplasty, down to No. 13, suitable for intestinal anastomosis. Straight. — For suturing the skin wound, 4-in. bayonet-ended needles are the best (Fig. 16a). Needles should be carried in the small perforated metal box in which they have been sterilized (Fig. 17). Worrall's needle. — We never use needles fixed on handles, for they are clumsy and soon get blunt. We must, however, except an aneurysm-needle, which we use to raise Fig. 17. — Needle-box. Fig. 18. — Aneurysm-needle. Fig. 18a. — Worrall's needle. the ureter in Wertheim's operation, and the notched needle designed by Worrall, which is an extremely useful instrument when working in a position difficult of accessibility, such as the depth of the pelvis in Wertheim's operation, or high up in the vagina in vaginal hysterectomy (Figs. 18 and 18a). C i8 GYNECOLOGICAL SURGERY Michel's clips. — We have referred to the advantages of these (p. 288). The best apparatus for applying them is that shown in Fig. 19, in which the adaptation for- ceps is furnished with a bridge on which the clips are carried. Silk box.— The most convenient apparatus for car- rying silk is a metal box contain- ing three reels, so arranged that the threads, Nos. 4, 2, 1, can be with- drawn without ex- posing the whole reel. This metal box may be boiled with the silk remaining in situ (Fig. 20). Gloye box. — If rubber gloves are sterilized with the instru- Fig. 19. — a, Forceps for applying Michel's clips ; b, forceps for re- moving them. Fig. 21.— Glove box. ments they are very likely to Fig^O.-Silk-hgature box. be perforated. To obviate this, and to save the time wasted by two separate boilings, we use a perforated metal box to contain them during sterilization and transport (Fig. 21). INSTRUMENTS 19 Infuser. — The infusion apparatus shown in Fig. 22 holds a container for the solution, india-rubber tubing, a Fig. 22, — Berkeley's saline infusion apparatus. scalpel, dissecting-forceps, aneurysm-needle, a sewing-needle, and cannula in a small compass, measuring 8| in. by if in. It should reside perpetually in the operator's bag, for he may be called upon to perform this operation at any moment. Sounds. — The ordinary uterine sound should be made of steel, except its last 2| in., which should be of copper, so that it can be bent if necessary (Fig. 23). For sounding the bladder the smallest- sized Fenton's dilator does very well in the absence of the ordinary bladder-sound (Fig. 24). Dilators. — Fenton's dilators will be found the most useful, because they are double-ended, so Fig. 22a.~ Cannula of Berkeley's saline infuser. s c !4 Fig. 23. — Uterine sound. 20 GYNAECOLOGICAL SURGERY that the number of instruments required to be carried for this purpose is halved ; they can be boiled, and the r Fig. 24. — Bladder-sound. curve on the instrument facilitates their introduction. Owing to the leverage obtained by their length, they are Fig. 25. — Fenton's uterine dilators. very powerful instruments, and must be used with caution (Fig. 25). Curette. — We always use for gynaecological operations the flushing curette shown in Fig. 26. It is unnecessary Sc • ' Fig. 26. — Flushing curette. for the blade to be a greater breadth than f in., and this can be passed into the uterus easily after a dilatation to No. 9 Fenton. For curetting the cervix, our practice is to use a sharp scoop (Fig. 27). Fig. 27. — Sharp scoop. Clover's crutch. — -In hospital practice the patient is best retained in the lithotomy position by poles and foot INSTRUMENTS 21 rests, but for operations in private houses an ordinary- Clover's crutch is a necessity (Fig. 28). Paquelin's cautery. — Paquelin's cautery is useful to burn the raw- base left after the removal of a urethral caruncle. It is also used to cauterize the cervix in malignant disease after curetting, and to am- putate the vagina in Wertheim's operation. This cautery, as usu- ally supplied by instrument makers, is an expensive instrument, and that sold for doing "poker" work will serve the same purpose, and cost about a tenth of the price. To make these cauteries work satisfactorily, the surgeon should remember that old naphtha must be used. Table. — For hospital work the table described at p. 52 is, we find, entirely satisfactory (Fig. 29). For private Fig. 28.— Glover's crutch. Fig. 29. — Hospital operating table. 22 GYNECOLOGICAL SURGERY work it is the greatest advantage to the surgeon to possess a portable table of his own. Many nursing-homes, it is true, are well provided in this respect, but there are others in which the apparatus that does duty for it is incapable of giving an efficient Trendelenburg tilt. For operations in private houses an efficient table must be either possessed or borrowed, and, in the latter event, emergency and want Fig. 30. — Berkeley's portable table. of time may compel the surgeon to operate on an improvised table, greatly to the patient's disadvantage. The portable table designed by one of us* (Fig. 30), can be rapidly packed and as rapidly put together ; its weight (34 lb.) allows of its being easily carried, and its mechanism, simple withal, gives a correct Trendelenburg tilt to any required angle. It has been tested up to 20 stones and found quite rigid. * It is manufactured by Messrs. Allen and Hanburys. SUTURE MATERIAL 23 SUTURE AND LIGATURE MATERIAL Sutures and ligatures may consist of silk, thread, silk- worm-gut, or catgut. The relative advantages of these materials may be discussed under five headings : ease of sterilization, strength, security, absorbability, cost. Ease of sterilization. — -The only material that runs any risk of being inefficiently sterilized is catgut, for the other three substances are not injured by boiling. There are various processes by which catgut can be sterilized, but all of them have the disadvantage of being more or less elaborate and of weakening it to a considerable degree. Strength. — The strongest material for its size is silk- worm-gut ; after it thread, then silk, and lastly catgut. Security. — The knots of catgut are apt to become loose owing to its slippery surface and pulpy nature. Silk- worm-gut, and to a lesser extent thread, also share in this disadvantage. A silk knot is the most secure. Absorbability. — Silkworm-gut is never absorbed. We have removed it apparently unchanged at the end of many years. Silk and thread are undoubtedly absorbed, though slowly, unless so thick that encystment by fibrous tissue occurs before the process is complete. With regard to silk, it is difficult to say where the line can be drawn between absorption and encystment, but we believe that No. 4, at least, is completely absorbed after about a year's residence in healthy tissue. Catgut is absorbed perfectly. In areas of suppuration neither thread, silk, nor catgut is absorbed, for the phagocytic action of the tissue cells is in abeyance. Cost. — Simple linen thread is the cheapest of all, then silk, after this silkworm-gut, and lastly catgut, which, owing to the long preparation required, is the most expensive. Conclusions. — For general operative work we use plaited China silk. Its strength is great, its knot secure, its sterility can be ensured, its cost is reasonable, it can be used several times, and in small sizes it is absorbable. 24 GYNECOLOGICAL SURGERY We have used thread and found it good, except that owing to its great strength and thinness it is liable to cut through the tissues, and that owing to its smooth surface the turns of the knot fail to bite and it is apt to slip. We limit the use of silkworm-gut to skin sutures in situations, such as the perineum, where absorption of septic material along the suture is to be feared. We have entirely given up the use of catgut, believing it to be a bad and treacherous material. We have not arrived at this decision hastily, but as the result of many years' experience on our own part and study of that of others. Every year, in spite of the elaborate methods adopted to sterilize catgut, a case or two of tetanus due to its use is recorded. This accident has never happened to us, but we have seen suppuration follow its use so often that we believe that, even though it be sterile, it has some peculiar irritant effect on the tissues. The whole merit claimed for catgut rests on its absorba- bility, but there, to our minds, lies one of its chief dangers, for we have seen quite a number of cases in which the too rapid absorption of catgut has led to the giving way of the wound and exposure of raw surfaces. In addition, we have knowledge of instances in which the peritoneal flap covering the stump of the uterus after subtotal hysterec- tomy has separated, allowing the bowel to become adherent and causing death from intestinal obstruction. A similar accident has also happened to the parietal wound. The knot tied by catgut is unsafe, and we have known cases where secondary haemorrhage has resulted from this cause. Moreover, in a suppurating focus catgut is absorbed no more than silk, and we have seen stitch-sinuses of prolonged duration due to its use. Its one advantage over silk is that it saves the patient the risk of late suture- suppurations occurring, say, six months after the operation, by which time catgut would have been absorbed. We think this a very poor gain to purchase at such risks. The SWABS 25 trouble of preparing catgut oneself, and the responsibility undertaken if one uses that sterilized by other people, are, quite apart from its extra cost, further reasons why we have abandoned its use. SWABS Material. — While sponge as a material for swabs has certain definite advantages, such as pliability and absorp- tiveness, and certainly can be sterilized, though with much trouble, we think that the most suitable material out of which to make them is Gamgee tissue or absorbent wool covered with gauze. Either material is much cheaper than sponge, can be boiled or steamed, and so sterilized at a very short notice, can be made into swabs of any size, and is easily obtainable. Method of making. — For vaginal operations the swabs must be small, about the size of a double walnut, and are most conveniently made by tying up a piece of wool of that size in an outer covering of white gauze. For abdominal operations two sizes are required, one large, 12 in. square, for packing the intestines, and one small, 6 in. square, for purposes of swabbing. These are best made of Gamgee tissue cut a little larger than the size required, and the edges turned in and sewn over. In hospital practice, for the sake of cheapness, pieces of wool similarly cut and covered with white gauze sewn over at the edges may be used (Fig. 31). Sterilization of swabs. — Swabs are best sterilized by steam, for, remaining dry, their absorptive power is not diminished. Where steam sterilization is not obtainable they should be boiled for one hour and then transferred to 1 — 1,000 biniodide of mercury solution until they are required, when they must be wrung out in sterilized water. Wet swabs are much less absorptive than dry ones and hence, in order to work with a practicable number, they must be washed over and over again as the operation proceeds. 26 GYNAECOLOGICAL SURGERY Number required. — For minor operations two dozen of the small swabs described will be required. For major vaginal operations at least three dozen are necessary, and in addition two larger flat ones, similar to those described for abdominal operations, and measuring 4 in. square, to which a piece of tape has been sewn, are needed for introduction into the pelvic cavity to prevent prolapse of the bowel and omentum into the vagina. For abdominal opera- tions the number required will depend upon whether the surgeon cares to have the swabs wrung out again and again in the course of the operation, or prefers, once having soaked a swab, to lay it aside. The first method has the advantage that a smaller number is needed, whereby the danger of leaving one in the peri- toneal cavity is minim- ized and expense and labour are lessened ; but, on the other hand, it involves more handling of the swabs and a greater risk of infection, whilst to perform the opera- tion as expeditiously an extra nurse is required to wring them out. The second method requires a greater number of swabs, but the superior absorptive power of dry wool over wet Fig. 31— Swabs. STERILIZATION 27 allows of this being done without necessitating the use of an embarrassing number. We find that for all ordinary abdominal operations fourteen is a sufficient number, two of the large size described and twelve of the small. For extensive procedures such as the radical abdominal operation for carcinoma of the cervix, double the number of the smaller size is needed. For convenience of counting, dry swabs should be made up in packets — of the large, containing two each ; of the small, six each. At the outset of the operation one packet of the large and two of the small should be opened, nor should fresh packets be opened until each swab of those first put out is thoroughly soaked through. If, how- ever, the first method be employed, namely, to wash out the swabs in the course of the operation, only eight are required in all, two of the large size and six of the small. Of the two methods, we much prefer the second. The importance of carefully counting the swabs before and after the operation is insisted on elsewhere. METHODS OF STERILIZATION Sterilization may be accomplished by means of heat or chemicals. STERILIZATION BY HEAT Heat will kill every sort of known bacterium or spore if the temperature is high enough and the length of appli- cation sufficient. There are three methods of sterilization by heat : (1) dry heat, (2) steam, (3) boiling water. 1. Dry heat. — Dry heat is an unsatisfactory method. It can only be carried out efficiently by special apparatus. When applied to dressings, towels, or aprons in bulk it takes a long time before the temperature at the centre of the mass is sufficiently raised, and there is some risk of scorching. Further, it spoils the temper of steel instru- ments. We do not employ it. 28 GYNAECOLOGICAL SURGERY 2. Steam. — This is the best method, especially when applied superheated. Steam sterilizers of various patterns are sold at all instrument makers', and the pattern chosen will depend chiefly upon whether they are intended for hospital or private use. Fig. 32. — Hospital sterilizer. It is, however, important that the apparatus should be of the " high-pressure " variety to ensure the steam being driven into the recesses of the mass of material being sterilized. Where very large quantities of dressings, towels, etc., are required to be sterilized at once, it is also imperative to be able to exhaust the air from the sterilizing chamber STERILIZATION 29 before admitting the steam. In the smaller instruments for use in private work this elaboration is not necessary. Steam sterilization in hospital work. — For hospital work the high-pres- sure sterilizer made by Manlove and Alliott, or some similar pat- tern, will be found excellent. (Fig. 32.) This apparatus can be supplied with steam drawn direct from the boiler supplying the other machinery of the hospital, or it can be worked by a row of gas-jets. The me- chanism is simple, and can be managed by any competent nurse after instruction. Al- though such a steril- izer could be used to sterilize the entire operative outfit at one exposure, it is more convenient in hospital to reserve its use for the overalls, towels, swabs, and dressings, leaving the instru- ments, ligatures, and gloves to be separately sterilized in a boiler placed in or adjacent to the operating theatre. Steam sterilization in private work. — The surgeon will find the possession of a small high-pressure steam sterilizer of the greatest convenience to him. The pattern illustrated in Fig. 33, and made to work Fig. 33. — Home sterilizer. GYNECOLOGICAL SURGERY at a steam pressure of 10 lb., has been found by us to be very efficient. It contains one long drum (Fig. 33a) large enough to take the entire outfit required for the operation. This drum is supplied with a canvas case into which it is put after being removed from the sterilizer, so that it is conveniently transported to the place where the operation is to be performed. The outfit required is made up as follows : — ■ Three overalls and three masks. The rubber gloves, drainage- tube, and catheter. The instruments and ligatures. Six towels. A set of swabs (p. 25). The dressings, a many -tailed binder, and a roll of white gauze. It is an excellent plan to put up the six components of the outfit just enumerated in separate muslin bags with the name of the contents in- scribed thereon in marking-ink. The drum is then packed in the reverse order of this list, and, the apertures in its side being opened, it is placed in the sterilizer. The reels of silk should have been previously soaked in water and the gloves wetted inside. One hour's sterilization at a pressure of 10 lb. to the square inch will be sufficient. If instruments have been thus sterilized, they should not be kept in the drum for more than twelve hours, or they will rust. Though sterilized outfits for operations can be obtained nowadays from instrument makers in all large towns, yet it is a great advantage for the surgeon to be " self-con- tained " in this respect. The possession of the apparatus Fig. 33^. — Drum of home sterilizer. STERILIZATION 31 described and of a portable operating table renders him quite independent of the time and place at which his ser- vices may be required. A smaller " emergency " drum, containing overalls, masks, towels, swabs, and dressings, should always be kept on hand for those cases in which instant action is required. For such a case the instruments and gloves and silk are to be boiled separately when the surgeon has reached his destination, and during the preparation of the patient for the operation. 3. Sterilization by boiling. — Boiling for half an hour renders any article sterile. The method is very generally used for instruments, ligature material, and gloves, and can be extended to the swabs and towels. For overalls and dressings it is not convenient. It has the great advan- tage that it is always applicable. Ligature material after boiling should be transferred to 1 — 40 carbolic acid and water, rubber gloves to 1 — 1,000 watery solution of bin- iodide of mercury, and swabs and towels to the same, from which they should be carefully wrung out in sterilized water before use. STERILIZATION BY CHEMICALS The use of chemicals for primary sterilization is limited principally to the skin of the operation area and of the hands. of the surgeon and his assistants, but they are also usefully employed as a means of maintaining the sterility obtained by heat. In some quarters it has been the fashion of late years to belittle the use of " antiseptics," and to speak of " aseptic surgery " as though it were something quite apart from the use of chemical means of sterilization. Such a conception is, of course, untenable : no surgery is " aseptic " which does not in part rely on the use of " anti- septic" solutions to that end. For, leaving out of account the impossibility of sterilizing the hands of the surgeon and of his assistants without the use of antiseptic solutions, instruments, gloves, towels, etc., though sterile when re- moved from the steamer or boiler, can only remain so for a 32 GYNECOLOGICAL SURGERY very short while when exposed to the air. It is true that the chances of dangerous contamination from dust or tap- water are small, but that they do exist is undeniable. We, therefore, use antiseptic solutions not only for preparing the hands and the skin of the operation area, but also for the immersion of instruments, ligatures, and other appliances. Perchloride and biniodide of mercury. — As anti- septics, the great advantages of the salts of mercury are the ease with which they can be carried and their very powerful bactericidal action. On the other hand, they are very poisonous and discolour steel instruments, whilst the perchloride forms with albumin an inert compound. They are also decomposed by lead, tin, and copper, so that they cannot be put into vessels made of those sub- stances. Of the two salts, the biniodide is much the better, because it does not form a combination with albumin, is not so poisonous, and does not so readily blacken steel. It is somewhat more expensive than the chlorine salt. For sterilization of the skin the best solution is that advised by Lockwood, containing 3 parts of methylated spirit and 1 part of water in which biniodide of mercury has been dissolved in a proportion of 1 — 500 of the mixture. Watery solutions are of no use for this purpose, because they do not penetrate the greasy surface of the skin.* Carbolic acid. — Carbolic acid is an inconvenient chemical to carry about. It does not combine with albumin, so that its properties are not destroyed by admixture with blood or pus, neither does it injure instruments placed in it. On the other hand, it is very irritating to the skin of the hands, and produces unpleasant partial anaesthesia of the finger- tips. For these reasons it has been largely given up ; but the adoption of rubber gloves obviates these disadvantages, and we have, therefore, reverted to its use for the immer- sion of instruments and ligatures after they have been * C B. Lockwood, "Aseptic Surgery." STERILIZATION 33 sterilized. For this purpose a i — 40 solution is sufficiently strong. Alcohol. — We use absolute alcohol to sterilize scalpels (see p. 68). It is also an efficient sterilizer of the skin, and may be so used when the salts of mercury are not available. Iodine. — -The use of iodine to sterilize the skin has been much lauded lately. It is undoubtedly an efficient bactericide, and has the further advantage of great pene- trativeness. On the other hand, the skin of some persons is very intolerant of iodine, and we have known severe dermatitis set up by its use. We have, therefore, only employed it under conditions of emergency. We must add that we find it the most generally useful chemical to use for vaginal irrigation where a definitely sloughing or suppurating condition exists in that region. Peroxide of hydrogen. — Peroxide of hydrogen (10 volumes) is the best antiseptic to use for sloughing and foul wounds or surfaces. Lysol and crude sanitas. — These two substances are useful for douching when a foul vaginal discharge is present. Lysol should be used in the proportion of a teaspoonful to a quart of warm water, crude sanitas at a strength of a fluid ounce to the pint. The latter is a very powerful deodorant. General remarks on the use of antiseptics. — The uses of antiseptic substances may be thus summed up : — Wounds. — The application of antiseptic solutions to wounds is undesirable as a general rule. Healthy tissues are already aseptic, whilst if the tissues are diseased and infected a solution sufficiently strong to destroy the bacteria will also kill or seriously damage the tissues. It is to be remembered that healthy cells and serum are in them- selves powerfully bactericidal, and the greatest care should be taken to preserve this power intact. An exception to the rule is the case of a wound covered by a layer of necrotic and infected tissue to which powerful germicides may be 34 GYNECOLOGICAL SURGERY applied without affecting the living cells underneath. The dressing of a sloughing abdominal wound with peroxide of hydrogen or the irrigation of a septic uterine cavity with strong mercurial solution may be cited as examples. The skin. — The difficulty of sterilizing the skin is well known. It is probably impossible to destroy all the organisms which are contained in the epidermis and the sebaceous and hair-follicles. For this reason the surgeon is probably best advised who limits his endeavours to sterilizing the skin-surface only. It is possible by too violent scrubbing or long-continued fomentation so to sodden and loosen the surface epidermal cells that they easily detach. Such particles conveyed into the wound may be potent carriers of infection. A smooth, dry condition of the skin is that most favourable for surface sterility. For this reason some think it better to prepare the skin of the operation area within a few hours of the operation, and after the final application of spirit biniodide solution to keep it dry by means of a simple gauze dressing. Similarly in regard to the preparation of the surgeon's and assistants' hands, care should be taken not to use strong antiseptic solutions for such length of time as to roughen the skin. In the effect which chemicals exercise on the hands, personal idiosyncrasy counts for much. Mercurial salts are very irritating to some skins if long applied. We are not in favour, therefore, of prolonged immersion in such solutions. Two minutes' careful swabbing with spirit biniodide solution after thorough washing is probably sufficient to sterilize the skin-surface. The spirit solution should then be washed off in i — 4,000 watery biniodide solution, and the gloves put on filled with the same solution. As we have remarked elsewhere, the habitual use of rubber gloves for all purposes of examination and opera- tion is the best of all safeguards against the presence of virulent bacteria in the skin. The vagina.- — For routine vaginal douching a watery SUTURES 35 solution of biniodide of mercury, i — 4,000, is the best. In some persons it sets up a good deal of irritation after a few days' use. In such an event, a simple boric-acid douche should be substituted. Where the douche is being used to cleanse rapidly a foully infected vagina, as in carcinoma of the cervix and similar conditions, formalin, 2 per cent. ; iodine, a dram of the tincture to a pint ; or crude sanitas, a tablespoonful to the pint, will be found serviceable. Swabbing with peroxide of hydrogen, 10 volumes, is also excellent. SUTURES In all cases where a curved needle is being used, we believe it is better to mount it on a Spencer Wells pressure- forceps rather than hold it directly with the fingers. The hand obstructs the view, handling the needle is liable Interrupted sutures. /»* ■ (' to prick the glove, and, as there are certain situations where the hand cannot be used, by mounting the needle on a forceps on every occasion the operator accustoms himself to the most generally useful method. For similar reasons needles should always be withdrawn either with the dis- secting-forceps in the left hand or the pressure-forceps in the right. Interrupted sutures. Simple. — The advantage of the interrupted suture is that if it becomes septic the remaining sutures in its neighbourhood are not necessarily affected. The single interrupted suture is used for such purposes as closing the fascia in an abdominal wound, for the uterine wall in Cesarean section, or in perineoplasty (Fig. 34, a). 36 GYNAECOLOGICAL SURGERY Lembert's (Fig. 34, b). — This suture is specially useful when it is particularly necessary to get a water-tight or gas-tight suture line in the peritoneum, so that it is the suture chosen for the third layer in intestinal anastomosis, the second layer in closing wounds in the bladder, etc. Mattress (Fig. 34, c). — In cases where a suture is used, not only to approximate the parts but to secure haemos- tasis, a mattress-suture will be found the most useful one to employ. A good example of its application is the closure of the cavity left in the uterine wall after the enucleation of a myoma, or in approximating the wedge-like flaps of the stump in subtotal hysterectomy. Figure-of-8 (Fig. 34, d). — This suture is very useful in closing the mouth of a small aperture, such as the external cervical os as a preliminary to total hysterectomy. Cross suture. — The cross suture is useful for tying a piece of silk to be used as a tractor. The suture is passed like a mattress-suture and the looped end tied to the free ends (Fig. 34, e). Continuous sutures (Fig. 35). — A continuous suture has the great disadvantage that if one portion slips the whole goes, and if one portion becomes septic the whole is affected. Further, it leaves no room for drainage between the suture- holes, so that if there is any oozing below it the blood is pent up. Its advantages are, that it secures a more perfect approximation and hsemostasis, and it is more rapidly performed than a series of interrupted sutures. Simple (Fig. 35, a). — This is the most generally useful continuous suture, and we use it as a routine in closing the peritoneal flap of a hysterectomy and in suturing the peritoneum of the abdominal wound. It is also used in the first layer of bowel suturing. Lembert's (Fig. 35, b). — This is used in the second layer of bowel suturing, and gives also a very neat result in closing the peritoneal flaps in hysterectomy or in any similar condition. Blanket (Fig. 35, c). — This is a pretty suture, gives a SUTURES 37 very good approximation, and has the advantage of securing each stitch of the suture before the next one is passed. It is only used for skin surfaces. Cushing's suture (Fig. 35, d). — This modification of the continuous Lembert suture is useful in certain circum- stances, such as attaching the anterior peritoneal flap to the back of the cervical stump in subtotal hysterectomy. The glover's stitch (Fig. 35, e). — This method pro- Fig. 35. — Continuous sutures. duces marked eversion of the wound-edges and is rarely indicated. It is a good haemostatic suture. Pleating (Fig. 35,/). — This suture is used for puckering the ovarian ligament in ovarian suspension, and for closing the gap of the broad ligament and approximating the stamp of the round ligament to the stump of the uterus in hys- terectomy. Purse-string (Fig. 35, g), — Useful for closing gaps, as, for instance, holes in the broad ligament. Invaginating (Fig. 35, h). — Used in closing over the stump of the appendix and for obliterating small holes in the bladder, etc. 38 GYNECOLOGICAL SURGERY KNOTS The kind that we usually employ is the ordinary granny with three knots. It is the simplest and quickest, and has the great advantage that the first knot can be held taut while the second knot is being applied. For the reef-knot the advantage is claimed that the more it is strained the tighter it becomes. The essence of any knot used for surgical purposes is that its first knot should hold secure, and in this the reef-knot fails to a certain degree because it cannot so well be held tight while the hands are being shifted to secure the second turn. The surgeon's knot is the securest of all, since the first turn is double, and therefore will not slip. We have found it to have the disadvantage of throwing more strain on the silk, with the result that breakage is more likely. It is important to remember that with all knots it is the second knot that usually breaks the silk. METHODS OF TYING PEDICLES There are nine different ways by which pedicles may be tied (Fig. 36). Which special method is followed depends partly upon the idiosyncrasies of the operator, partly on the particular pedicle to be tied, and partly upon the time at the disposal of the operator. Method a consists in surrounding the pedicle with a piece of silk and tying it with a suitable knot. It is the simplest and quickest, but at the same time it is the most dangerous, because with it the pedicle is most likely to slip. If the pedicle, therefore, contains any important vessels, or if it is much on the stretch, this method should not be followed. It serves very well for the cut ends of the round ligaments, for pieces of omentum, and for slight adhesions. In Method b the pedicle is transfixed through its centre, and one of the halves being tied, the ligature is then brought back so as to surround both halves and tied again. TYING PEDICLES 39 Method c is a quicker method than Method b, and safer than Method a. Its advantage over a is that it does not Fig. 36. — Methods of tying pedicles (see text). slip, and its disadvantage when compared with Method b is that the blood-supply to the portion of the pedicle distal to the ligature is not entirely cut off and an anastomotic 40 GYNAECOLOGICAL SURGERY circulation may in certain circumstances be re-established to such an extent as to cause dangerous oozing, whilst occasionally even an artery of some size may be left un- occluded in the small portion of tissue outside the grip of the ligature. This may, however, be obviated by bringing back the ligature ends after tying the knot so as to include the whole mass, and then tying again in a manner similar to Method b. In Method d the tissue to be ligatured is transfixed in alternate directions at either edge and then tied — the so- called mattress-ligature. It is the most generally useful method of ligature in gynaecological surgery, and may be applied in various conditions. It effects a grip of the enclosed tissue which, if the knot be firmly tied, is almost incapable of slipping. It is employed chiefly for bunching up and closing raw and oozing surfaces. As applied to a pedicle, its disadvantages are those of Method c. Method e obviates the disadvantages attaching to Method d. After the mattress-ligature has been tied with a double knot, the free ends of the ligature are made to encircle the whole pedicle and are again tied. Method / is one of the safest, the pedicle being trans- fixed by a double piece of silk, the loop of which is cut, making two separate ligatures, and each half of the pedicle is then tied separately. Method g is an elaboration of Method e, a separate liga- ture being passed round the whole pedicle after the two halves have been tied. It is a more perfect method than the other, because it secures any small vessel which may have escaped the transfixion-ligature at the point of trans- fixion, while the " surround " ligature alone is capable of controlling the pedicle in the event of either of the other two ligatures slipping. Its disadvantage is the amount of ligature material that is of necessity buried in the tissues. Method h is the most perfect of all from the point of view of security, and takes the longest time. It differs from Method / inasmuch as the " surround " ligature is LIGATURES 41 made to transfix a small piece of tissue externally to the pedicle, which prevents this structure from slipping. Where a pedicle is too broad to be secured by any of the preceding methods, the chain-ligature (Method i) must be employed. This is the common method of ligaturing omentum. LIGATURES Ligatures are divisible into two classes : (1) occluding and (2) suboccluding. 1. An occluding ligature is one that entirely cuts off the blood-supply to the part distal to the ligature. The different methods shown in Fig. 36 {a, b, e, j, g, h, i) are examples of this variety. The tissue distal to the ligature is practically in that condition known as white infarction, and undergoes anaemic necrosis. An occluding ligature has certain definite advantages in that the haemostasis is not only immediately perfect, but, supposing the ligature holds, permanent. The likelihood of contracting adhesions is much less, or reduced to a minimum, because the tissues distal to the ligature are incapable of taking any active part in such an adhesion. The condition is comparable to that which obtains when a portion of foreign tissue is experi- mentally implanted in the peritoneum of an animal. In these cases it is only after the lapse of many weeks that thin filamentous adhesions form round the foreign substance derived from the vascularization of the coagulable lymph thrown out by the peritoneum. Moreover, areas of white infarction appear to possess a certain immunity against bacterial infection as compared with red infarcts — a point to which we shall immediately refer. 2. Suboccluding ligatures are those in which the main blood-supply to the portion distal to the ligature is cut off, but a track of capillary anastomosis remains {see Fig. 36, c, d). Of this the mattress-ligature is an example, and the tissues distal to it are in circumstances of red infarction. It occa- sionally happens that after a suboccluding ligature has been 42 GYNECOLOGICAL SURGERY applied the collateral capillary circulation may develop to such an extent that oozing subsequently starts from the cut surface, and a haematoma is formed round it in the peritoneal cavity, which may be the starting-point of a good deal of local peritonitis with some constitutional disturbance. It is owing to this cause that certain patients do not make the rapid convalescence which might be expected. It is further a fact that the tissues in the engorged and partially devitalized state which obtains in a red infarct are peculiarly liable to bacterial infection. As an example of this, the case of the omentum may be cited, partial strangulation of a portion of which is soon followed by very acute symptoms, whereas the common method of ligaturing omentum leaves, distally to these ligatures, equally large or larger areas of it in a condition of anaemic necrosis without producing the slightest ill effects. Again, a reference to general pathology will show that whereas white infarc- tion frequently occurs without any symptoms (e.g. the spleen and kidney in endocarditis), red infarction is always marked by acute pain and inflammatory symptoms. Thus the tissue distal to a suboccluding ligature is much more likely to become the seat of an acute bacterial infection than that distal to an occluding ligature. Moreover, since the cells of the former are not dead but merely damaged, adhesion much more readily occurs. This is rendered the more likely if its surface is surrounded by blood clot due to oozing from the cut surface. Thus the use of sub- occluding ligatures may be followed by plastic peritonitis and the formation of adhesions of such gravity that serious symptoms may follow. From a consideration of these various points it is, we think, obviously better, wherever possible, entirely to occlude the blood from the area distal to a ligature. It is for this reason that the practice of what appears an exces- sively massive and clumsy method of ligation of the tissue leads to results which on first consideration would seem to be unobtainable. LIGATURES 43 Retroperitoneal haematoma. — By a retroperitoneal hema- toma we mean an effusion of blood due to a vein being pricked or perforated by a needle as a transfixion-ligature is being passed round some vessel. The most likely stage for this complication to occur is when the ovarian or uterine arteries are being ligatured, when, if the ovarian or uterine vein is pricked or perforated, blood will escape under the peritoneum into the cellular tissue at the brim of the pelvis or in the broad ligament. The accident, which is at once recognized by the appear- ance of a dark-blue turgid swelling, can on most occasions be avoided if care is taken, when ligaturing the ovarian artery, to pull tight the ovarico-pelvic ligament, and pass the needle through an avascular spot. Also, when liga- turing the uterine artery in, for instance, a subtotal hysterectomy, after passing the needle through the cervical tissue, care must be taken to tie the vessels under the forceps grasping them, and not to transfix the remains of the broad ligament as by a mattress-suture, as it is nearly always when doing this that the vein is injured. If such an accident does occur, the tissue over the effused blood should be at once grasped with forceps and another ligature passed. It is sometimes rather difficult to tell, after the second ligature has been tied, whether one has success- fully arrested the haemorrhage, because, of course, the blood which has already escaped will still be in situ ; great care should, therefore, be taken during the remainder of the operation to examine at intervals the retroperitoneal haematoma, to ascertain whether it is increasing in size. If the vein is badly injured, the escape of blood may be rapid and marked, so that the blue swelling quickly spreads along under the peritoneum, distending the spaces of the cellular tissue. If this occurs, a deliberate search must at once be made for the vessel by separating the layers of peri- toneum and dissecting, if necessary, the cellular tissue till the bleeding-point is discovered, which may at times be a difficult and tedious matter, as the effused blood ploughs 44 GYNAECOLOGICAL SURGERY up the tissues in the neighbourhood, altering both their relation and, by the staining, their appearance. The complication of a retroperitoneal hsematoma may at times be quite serious. We remember a case in which the effused blood from a large ovarian vein infiltrated the tissues up to the perinephric fat before the haemorrhage could be arrested. DRESSINGS Abdominal section. — It is our practice to use very simple dressings after abdominal section. The wound is covered with several layers of sterilized white gauze, over this a large pad of white sterilized wool is placed, and the whole is kept in position by a many-tailed binder. Some surgeons prefer the use of medicated gauze and wool, but we have given them up because they occasion- ally cause irritation of the skin, and moreover we believe that infection of the wound after it has been closed is a very unusual event, especially if Michel's clips are sub- stituted for penetrating skin-sutures. It is in most instances unnecessary to change the dressing until the day on which the stitches or clips are taken out, but where much oozing has occurred, or where drainage is being employed, this rule must be departed from. In the first case, a single change of dressing will be required, the skin when exposed being lightly swabbed over with biniodide spirit solution before applying the new one. In the second case the dressing must be changed as often as is necessary, the skin being cleaned up each time this is done. There is always a difficulty in keeping the lower end of the wound covered, because the dressing and binder tend to ride upwards. To prevent this, perineal bands may be attached to the binder, but they are uncomfortable and soon become soiled. A better method is to fix the gauze covering the wound by painting its lower edge with collodion. DRESSINGS 45 We do not think well of the method of entirely collodionizing the wound, because it prevents the escape of blood and serum, and so creates a possible bacterial nidus. It is probable that could the surface of a carefully closed wound be protected from chafing and injury, it would heal admirably exposed to the air, for all dressings have the disadvantage of preventing drying by evaporation, a moist surface being particularly favourable to the' growth of bacteria. Yaginal operations. — For all operations on the vulva and perineum, a T-bandage is required to retain the dressing. This should consist of sterilized gauze covered with a pad of sterilized white wool. It will have to be changed every time the patient passes water or defalcates, and also after each vaginal douche (if such be given) and each examination. The use of medicated dressings is contra-indicated, because the vulval surface, especially in some persons, is very intolerant of chemicals, and readily becomes irritated and sore. After operations on the vagina, cervix, or uterus, if vaginal packing is indicated it is best done with simple sterilized gauze. It should be removed in twenty-four hours, and not replaced, after which the vagina should be douched three times a day with a weak antiseptic solution, such as biniodide of mercury, i — 4,000 ; lysol, 1 drachm to a quart ; or boric acid, 1 drachm to a pint. The first two solutions, after being used for some days, sometimes cause a degree of irritation. The patient should always be nursed in the sitting posture to promote drainage. Where some foul condition of the genital canal exists before the operation, such as a sloughing uterine polypus, it is better to pack the vagina with iodoform gauze instead of plain sterilized gauze. For intra-uterine packing, simple sterilized gauze is the best, except in cases of acute intra-uterine sepsis, when iodoform gauze should be substituted. Intra-uterine 46 GYNECOLOGICAL SURGERY packing should be withdrawn permanently in twenty-four hours. DRAINAGE When to drain. — The occasions on which drainage is to be employed after abdominal sections for pelvic disease is a matter for nice discrimination. For, on the one hand, failure to take this precaution, when called for, may lead to death, severe illness, or a second operation for retained pus ; on the other hand, unnecessary drainage, while probably never a cause of severe infection under modern conditions, may induce discharge where none would have otherwise existed, prolongs convalescence, and tends to leave a weak spot in the scar. The mere presence of pus in the pelvis is not a sufficient indication for drainage, and this is particularly true of cases of pyo-salpinx, for in a large number of such cases investigated for us at the Middlesex Hospital, in which the pus had been sequestered for a considerable time, no organ- isms could be isolated. Such sterile pus is often extremely evil-smelling, so that fetor is no indication for drainage. On the other hand, pus primarily formed in the peri- toneum, such as occurs round necrotic tumours, the inflamed appendix, or a suppurating hematocele, probably contains active streptococci or colon bacilli, and the same holds good for the contents of inflamed ovarian cysts, suppu- rating solid tumours, or a recent pyo-salpinx. Under such conditions the operation area must certainly be drained. As a general rule, it may be laid down that where the peritoneum covering the pelvic organs and the coils of gut in relation to them shows signs of acute or subacute peri- tonitis with definite reddening and injection, drainage should be employed, whether pus be present or not ; but where, even in the presence of a large collection of pus, the peritoneum is pale, uninjected, and inert in appearance, drainage is not necessary. There are certain cases in which a drain is advan- DRAINAGE 47 tageously inserted for a short time, i.e. cases in which future suppuration or extravasation, though not likely, is at least possible. Thus, after resection of intestine, if there be some doubts as to the soundness of the suture-line a small drain may be inserted down to the involved coil and removed after the end of forty-eight hours ; or, again, in certain cases of hematocele, where, by reason of the preoperative presence of fever, infection of the pelvic peritoneum appears likely to have occurred, it is a wise precaution to insert a small drain for a couple of days. Drains left in for this period form a track along which the products of suppura- tion or of extravasation, taking place later on, may find a way. Abdominal or vaginal drainage. — It would at first sight appear that a vaginal drain should have certain advantages over an abdominal one, partly because it necessitates no weakening of the abdominal wound, and partly because of its dependent position. Of these points the first is true, but in regard to the second there can be no doubt that vaginal drainage is less efficient than abdo- minal, although the current in the latter case is against the force of gravity ; for where both abdominal and vaginal drainage are simultaneously employed, the dis- charge is much freer, and continues much longer from the upper than from the lower opening. The reasons for this are not entirely obvious, but it may be remarked that an opening into the top of the vagina is placed, not at the bottom of the pouch of Douglas, but well up on its anterior wall, so that it does not really directly drain the lowest portion of the pelvic cavity ; and further, that there is a great tendency for this opening to close prematurely, either by rapid adhesion to a prolapsed coil of sigmoid colon or, as frequently happens after total hysterectomy, by the bladder falling back and adhering to the rectum. A vaginal drain is also not easy to keep in position, 48 GYNECOLOGICAL SURGERY is impossible to maintain clean, troublesome to take out, and difficult to reinsert. On these accounts we consider that for drainage of the pelvic peritoneal cavity the abdo- minal route is the best. Drainage material.— After giving a long trial to drainage by gauze wicks, we have abandoned the method in favour of the soft rubber tube. It is questionable to our minds whether a gauze wick really does assist the flow of fluid through an opening, even when lightly packed. Certainly, when tightly packed it actually obstructs it, and its with- drawal is always followed by a gush of pent-up discharge. A gauze wick leaves a track along which, after its removal, fluid may subsequently make its way, and this is its solitary virtue. Tube drainage has the advantage of acting as an immediate indicator of extravasation of blood, urine, or intestinal contents, if that occurs, and the surgeon is at once apprised of the disaster. Gauze drainage, on the other hand, is very misleading, for bright blood filtering up it very often comes from the edges of the abdominal wound, whilst extensive intraperitoneal bleeding may be merely indicated by sero-sanguinolent discharge, owing to the blood corpuscles becoming entangled in the meshes of the material. And, further, extravasated urine filters up so slowly that its small quantity diverts the mind from the possibility of a leak in the urinary apparatus ; and we know of a case that was lost from this cause. Management of the drain. — Where drainage is em- ployed merely as a precautionary measure, and not of necessity, we use a piece of J-in. tube and withdraw it in from twenty-four to forty-eight hours. For regular drainage, f-in. tube should be employed, or, what is perhaps better, a small sheaf of three or four |-in. tubes. The tube or tubes should be left in situ for at least forty-eight hours, and may then be daily pulled up a little way and the excess cut off. If the discharge is only serous, the tube should be entirely withdrawn when the discharge DRAINAGE 49 is reduced to a small quantity. It should not be left beyond this time, as its presence may excite a suppuration which would not otherwise have taken place. If the discharge is purulent, the withdrawal of the tube should be post- poned for at least five days, i.e. till a definite track has formed down which it is easy to repass the tube after cleansing, or to substitute one of a somewhat smaller calibre. If a sheaf of tubes has been used, one may be withdrawn at a time. The tube must on no account be left in situ too long, since its pressure may cause perforation of damaged intes- tinal wall. It is a mistake to irrigate the abscess cavity through the drainage-tube, as a rule. If free drainage has been provided, irrigation will do no further good, and may do harm by inhibiting the activity of the tissue cells. One frequently sees sinuses that have been kept open solely by misapplied zeal in this direction. In conclusion, it is a matter of importance to prevent the tube from slipping into the abdominal cavity. For abdominal drainage, transfixion with a safety-pin is the most generally useful method, but in vaginal drainage the tube must be lightly fixed to the cut edge of the vaginal wall by a piece of No. i silk. This will yield in a week and leave the tube free. FIXATION OF TISSUES AND PRESERVATION OF SPECIMENS Fixation. — It often happens that a surgeon will wish to remove a portion of tissue for microscopical purposes. The piece removed should be placed forthwith in " acetic alcohol " (absolute alcohol 2 parts, pure glacial acetic acid 1 part), in which it may remain from half an hour to twenty-four hours ; after this it should be transferred to absolute alcohol, in which it may be kept until it is con- venient to imbed it. This is a very rapid method of fixing, and, when necessary, small pieces of tissue may be cut in paraffin, stained, and examined within four hours of removal. 50 GYNECOLOGICAL SURGERY If a quicker examination than this is required, the tissue had better be cut direct with a freezing microtome. Method for preserving specimens. — We have found the most satisfactory way to fix and mount specimens is that invented by Jores and modified by Rowntree, as follows (Arch. Middx. Hosp., vol. x.) : — [■ i. Immerse the specimen for 24 — 48 hours in Sodium sulphate . . . . . . 20 grm. Sodium chloride . . . . . . 10 ,, Magnesium sulphate . . . . . . 20 Formalin. . . . . . . . . . 50 c.c. Water . . . . . . . . to 1,000 ,, 2. Immerse the specimen for 12- — 24 hours in 50 per cent, naphtha-free methylated spirit. 3. Immerse the specimen for 4 — 6 hours, until the colour returns, in Pure naphtha-free methylated spirit. 4. Immerse the specimen for 2 — 3 days in Sodium acetate . . . . . . . . 20 grm. Glycerine . . . . . . . . 500 c.c. Water . . . . . . . . . . 500 ,, 5. Immerse the specimen for 2 — 3 days in pure glycerine. 6. Mount the specimen in liquid paraffin. CHAPTER III OPERATING THEATRE AND APPOINTMENTS OPERATING SUITE In most cases the surgeon will have to make the best of the theatre he finds at his disposal when he is first appointed to the staff. Operations are daily performed with the greatest success in the most unfavourable cir- cumstances, and the surgeon must always remember that the results of his work will be due to his own forethought and skill rather than to a perfect theatre and its appoint- ments. It is, however, more encouraging for a surgeon to operate amidst surroundings as perfect as may be, and we will now indicate what in our opinion these should be. The operation suite should consist of seven rooms : the operating theatre, the anaesthetic room, the surgeon's dressing-room, the immediate-preparation room, the dis- robing room, the sterilizing room, and the nurses' store- room. Theatre : light. ■ — The daylight should be admitted through a window having a northern aspect. This window should occupy the greater part of the north side of the theatre, and terminate 3 ft. from the floor. The upper edge should be continued as a sloping skylight for 12 ft. Artificial light is always a difficulty, and the method chosen must depend upon the funds in hand. The ideal method is to have the electric light with linolyte lamps arranged right round the walls of the room in such a way that, whilst avoiding an unpleasant glare in the eyes of the surgeon and his assistants, an even and comparatively shadowless light suffuses the whole theatre. 5i 52 GYNAECOLOGICAL SURGERY In addition, a hand-lamp will be required, attached to a wall-plug which should, of course, lie flat with the wall. Floor. — The floor should be impermeable and capable of being washed, perfectly smooth, and not subject to roughing from traffic . Walls.— The walls should be covered with parian cement, and then painted with as many coats as necessary of enamel. The surface resulting is very hard, perfectly smooth, and capable of being washed or steamed. Ceiling. — A part of the roof of the theatre should be made use of for a skylight, set at an oblique angle to the window and continuous with it. The rest of the roof should slope down from the highest part of the skylight, and the ceiling should be made of a substance sufficiently smooth and dense to bear thorough washing. No cross beams or rods should be permitted, as they collect dust. A flat ceiling should be avoided, for moisture condensed on it drips downwards. All the angles between the walls, ceiling, and floor should be rounded and made smooth, and the frames of the doors and windows should be flush with the walls. Shelves. — Shelves should not be fixed in the theatre, but in an adjoining room, and should be so arranged that the bottles they support, containing the antiseptic solutions, can be seen through a glass panel in the wall through which the india-rubber tubes to deliver the fluid should pass. Operation table — A most excellent and simple table for hospital use is one devised by Herbert Spencer (Fig. 29). It is the type we use both at the Middlesex Hospital and at the Chelsea Hospital for Women. Other tables. — Four other tables are required: 1, anaesthetist's table ; 2, instrument table ; 3, swab table ; 4, additional-material table. All of them should be made of glass and vitreous enamelled iron, and should be mounted on castors. c 0) a o a> O 6 •00 54 GYNECOLOGICAL SURGERY 16 SC Fig. 37a. — Glass bowls. Basins and bowls. — All basins and bowls should be made of porcelain enamel, which does not chip except under the roughest usage, and which can be boiled. For im- mersing the arms as well as the hands, long glass bowls car- ried in an enamelled iron frame are re- quired. Two of these should be placed in the theatre within convenient reach of the operating table (Fig. 37a). Douche-pan. — It is necessary in vag- inal operations to have some recep- tacle into which the douche - fluid may run as it leaves the vagina. Kelly's india-rubber pad is generally used for this purpose, but for hospital work it is far inferior to a metal douche - pan devised by Dr. Stuck, an old resi- dent officer at the Chelsea Hospital for Women. This douche-pan has se- Fig. 37b— Stuck's douche-pan. veral advantages : OPERATING SUITE 55 it can be detached from the table and sterilized between the operations ; whilst allowing the douche - water and blood to escape into the pail below, it retains any pieces of growth or mucous membrane that may have been de- tached ; it will serve as a tray to hold instruments ; and, lastly, it collects the escaping douche much more effi- ciently than the Kelly's pad. (Fig. 376.) Anaesthetic room. — This room need not necessarily open into the theatre ; indeed, it is better that there should be a passage between. It should contain a cup- board in which the anaesthetic drugs and apparatus may be stored, and a table on which the anaesthetic register can be placed. Surgeons' dressing - room. — This should contain wash- basins and a bath, and be in communication with a lavatory. It should open into the immediate-preparation room. Immediate preparation room. — In this room the final preparations of the surgeon and his assistants are made, and the instruments and ligatures sterilized. There should be no wash-basins, but one long porcelain trough into which water is delivered by four rose jets controlled by elbow-taps, and so arranged that cold, hot, or tepid water can be delivered at will. Above the trough a glass shelf should be fixed to hold the soap and nail- brush boxes. The room should contain a metal table to hold the drums containing the sterilized overalls. It should have fixed in it a sterilizer (if possible worked by steam) for the boiling of instruments, ligatures, etc., and all other things which cannot be conveniently sterilized en masse by the main sterilizing plant contained in the main sterilizing room. A shelf for holding the large glass jars containing antiseptic solutions has been already men- tioned, and an apparatus for the delivery of hot and cold sterilized water should also be fixed in this room. This immediate-preparation room should lead directly into the theatre and also into the sterilizing room. Sterilizing room. — This room should contain a Manlove 56 GYNECOLOGICAL SURGERY and Alliott high-pressure sterilizer for dressings, and a dish- boiler large enough to take all bowls, basins, dishes, etc., and they should be worked by high-pressure steam if possible. Here also should be kept the instrument case, made of glass and metal with a sloping roof. This room should lead direct into the immediate-preparation room, and into the nurses' store-room. Nurses' store-room. — In this room the nurse can re- move her aprons and cap and wash her hands preparatory to her final preparation, which should take place in the immediate-preparation room. It should, therefore, contain wash-basins, besides cupboards in which can be kept over- alls, towels, sheets, mackintoshes, dressings, and all other theatre stores. It should be furnished with a large table and some chairs ; and here all cutting out, sewing, and other necessary work should be done. The room should be in communication with the sterilizing room. Disrobing room. — It has always seemed to us that one of the chief defects of modern operating suites is the failure to provide a room wherein the surgeon and his assistants may remove their soiled overalls, gloves, and masks, and into which all contaminated articles, such as soiled towels, basins containing blood, pus, tumours, or the dirty instru- ments, can be removed. As a rule, the immediate-pre- paration room has to serve for this purpose — obviously a grave fault of arrangement. The disrobing room should contain a washing-trough for the hands, a second trough for washing the instruments and basins, a sink for con- taminated fluids, a metal receptacle on wheels for the soiled linen which is to be washed, and one for all articles to be destroyed. This room should lead immediately off the operating theatre, and should communicate with the main passage and the surgeons' dressing-room. Visitors. — The accommodation of onlookers at gynae- cological operations is always a matter of difficulty, because unless the spectator is quite close it is difficult to see much. In hospitals where a large number of students have to be THE STAFF 57 accommodated some sort of a gallery or stand is a necessity. Visitors allowed on the floor must wear overalls, which should be supplied from the nurses' room. STAFF OF THE OPERATING THEATRE In ideal circumstances in hospital practice the surgeon, in our opinion, requires, when operating, a staff of six, if everything is to run perfectly smoothly and the technique is to be as aseptic as it is possible to make it. In private operations this number is rarely possible, and four is the most that one can usually obtain. More than six is unadvisable, for the greater the number of people who are touching the instruments and the operation area, the greater chance will there be of septic infection. The safest plan is to reduce the number of the staff to the most efficient minimum, for below this the risk-curve rises, because at one moment some of the assistants will have to perform duties which cannot be in keeping with surgical cleanliness, and at the next moment they will be called upon to perform duties which ought to be so, and thus the aseptic technique breaks down. In hospital the staff should consist, besides the surgeon, of— i. First assistant. 2. Second assistant. 3. Anaesthetist. 4. Swab nurse. 5. Instrument nurse. 6. General nurse. Some surgeons dispense with the swab and instrument nurses, and do this work themselves with the aid of the first or the first and second assistants. Such an arrange- ment will serve for minor operations, and in private work often has to suffice for any operation, but for major operations it is a drawback to the operator to take on duties other than those of the operation itself. If dry swabs are used, the swab nurse is not a necessity, because 58 GYNECOLOGICAL SURGERY no wringing out is required. Nevertheless, she may be usefully employed to keep count of their number and exercise a general supervision over their use. The general arrangement of the theatre during an operation is indicated in Fig. 38. « DUTIES OF THE STAFF The surgeon, his assistants, and the instrument and swab nurses should not touch any article liable to have been infected after the time they have prepared for the operation. First assistant. — A good first assistant is made, not born. His duties are next to the operator's in importance, and can only be perfectly learnt by a long apprenticeship thoughtfully served. Self-abnegation should be his key- note : he should neither offer advice when it is unasked for, nor take upon himself any of the manipulations proper to the surgeon, unless requested to do so ; he should be silent, watchful, and keep his head and hands out of the wound. He should, of course, direct the attention of his chief to any point which the latter has obviously over- looked. His position in an abdominal operation is on the left side of the patient, opposite to the operator, but in a vaginal operation he is on the right side, so that his right hand is at the service of his chief. One of his main objects should be to give the operator as clear a view as possible by properly retracting the wound, and in this regard it may be mentioned that the assistant is apt to forget that the structures on the right side of the middle line are, by reason of the position of the operator, least visible to the latter. He should concentrate his mind on how best to facilitate the actions of the surgeon, whether he is in agree- ment with him or not. These qualities are quite distinct from those required by the operator himself ; and indeed many good surgeons are hopeless assistants, and conversely, of course, a good assistant may be a poor operator. Second assistant. — This assistant's position in an o a o 13 c "i o 13 £> C eJ •oo "C 3 H3 o Oh •ofi 60 GYNECOLOGICAL SURGERY abdominal operation is at the right hand of the operator. In a vaginal operation he stands on the patient's left side. His duties consist chiefly in anticipating the wishes of the operator in regard to the instruments he requires, to do which he should studiously acquire a knowledge of the technique usually followed in abdominal operations. It is, therefore, a post of the greatest educational value to those who intend to follow a surgical career. The second assistant must also be ready to lend help in retracting the wound-edge on his side, and to carry out such other duties as the surgeon may direct. Anaesthetist. — The anaesthetist is responsible, of course, for the choice of the anaesthetic and its administration, and must inform the surgeon when at any time the patient's condition seems to be getting seriously worse. The anaes- thetist should not allow himself to be influenced in any way by remarks of the surgeon as to changing the anaes- thetic, " pushing it," etc., if the patient's life is likely to be endangered thereby, for should the patient die whilst under the influence of the anaesthetic, the responsibility will rest upon him and not upon the surgeon. If the operating table is moved by a screw or any other apparatus near the patient's head, the anaesthetist will raise the table to the angle required. Instrument nurse. — The instrument nurse or theatre sister will be responsible for the proper sterilizing of all instruments, ligatures, sutures, dressings, surgeons' and nurses' overalls, masks, towels, swabs, and gloves ; also for the preparation of antiseptic solutions for the hands. Her place during the operation is at the instrument table, where she threads the needles and bands them to the second assistant as he may ask for them. Swab nurse. — The swab nurse and the general nurse will get the patient ready on the table, fixing her legs if necessary, tucking the nightdress up, and removing the binder so that the operation area is only covered by the dressing. The swab nurse will then finish the preparation STAFF OF OPERATING THEATRE 61 of her hands, after which she will be ready to hand the swabs from the tin in which they have been sterilized, or wash them if wet ones are being used. In both cases she may be held responsible for the number used, although the surgeon should satisfy himself before he closes the abdominal wound that there are none missing. If dry swabs in large numbers are being used, the nurse may find it difficult to tell the surgeon at once when he asks her how many swabs she requires to make her number correct, and she will find it easier on this account to have the swabs done up in packets of six before they are sterilized, and the total number of swabs in the box written down on a piece of paper before the operation commences. The swab nurse will also hand out the sterilized towels, dressings, gauze, etc., as the surgeon requires them. General nurse. — The general nurse will be required to fetch and carry porringers and boxes with sterilized towels and dressings therein, to prepare antiseptic solutions, get ready saline infusions, sterilize any additional instru- ments that may be required, and generally to make herself useful, but, of course, from the very nature of her duties she cannot keep her hands absolutely aseptic ; she will not need, therefore, to wear gloves, nor will she require a mask, but she must, of course, be dressed in a sterilized overall, will initially prepare her hands as carefully as the rest of the staff, and must wash them subsequently as often as occasion requires and opportunity offers. Health and cleanliness of the operator and staff. — It goes without saying that all concerned in the perform- ance of an operation should be in good health, and should not be suffering from any septic condition such as sore throat, nasal disease, septic wounds on the fingers, etc., and if any one of them has been in contact with a septic case previous to the operation, he or she should have had a hot bath and an entire change of raiment just before coming to the operation. With the advance of education and the better understanding of the principles of hygiene 62 GYNECOLOGICAL SURGERY by the general community, it seems superfluous to remark that everyone should take a daily bath and wear clean clothes. The teeth of surgeons and nurses should be kept in perfect order. The inferior results of some operators may be in part due to the septic condition of their mouths. The hair of the operator and of his assistants should not be unduly long, and the nurses' hair should be kept well brushed and cleaned. The surgeon has little control over the toilet of a nurse, but at any rate he need not employ an untidy woman. Doctors and nurses should, of course, be most particular in keeping their nails clean. One has seen an operator commence the preparation of his hands by a vigorous cleaning of dirty nails with nail- scissors, scrubbing brush, etc., when the nails to commence with should have been reasonably clean. Lastly, one who is constantly operating should avoid touching pus or any other septic material as much as possible. It is better to keep the hands free of septic bac- teria than to rely upon destroying them afterwards by washing and antiseptics. COSTUME OF OPERATOR AND STAFF Overalls. — Overalls should be made of thin linen, should fasten up at the back, and should have sleeves down to the wrist. It is not uncommon to see a surgeon, having taken the greatest care about the preparation of his hands, and covered them before the operation with sterilized rubber gloves, put on an overall the sleeves of which end well above the elbow, so that a large portion of his arm is bare. Instruments and ligatures may quite easily touch the bare arm, and we have seen operators examining the stomach, spleen, kidneys, and other ab- dominal organs with a large portion of the bare unsterilized arm in contact with the abdominal viscera. The operator can, if he likes, wear a mackintosh under the overall. This will not add to his comfort, and in the majority of cases is unnecessary, but in septic cases, or OPERATING COSTUME 63 where a large quantity of fluid may be expected to be evacuated, it should be worn. Masks (Fig. 38a). — Masks should be worn by the surgeon, his assistant, and the swab and instrument nurses. Masks have various uses : (1) they soak up any perspiration, which is a more satisfactory way of dealing with this excretory product than allowing it to fall into the peritoneal cavity ; (2) if made after the pattern devised by us, they will keep loose pieces of hair and dan- druff from falling about the operation area ; (3) most important of all, they prevent saliva from being projected into the wound, for if it carries with it septic debris from decayed teeth, or bacteria from an unhealthy throat, the results may be dis- astrous to the patient. That such a danger is not fanciful we have proved F . M A . _, , f r lg. 3&7. — Operating mask. by going through dummy operations over " culture plates " in the place of patients, and giving such directions and holding such converse as would be necessary in a real operation. These plates, com- pared with controls exposed for an equal length of time, showed a definitely larger number of colonies on incubation. Gloves. — India-rubber gloves which have been boiled and placed in biniodide of mercury, 1 — 1,000, or sterilized water, according to the wish of the operator, until they are required, should be worn by the surgeon and nurses for all operations. We cannot conceive the least objection to their use ; 64 GYNAECOLOGICAL SURGERY they can be absolutely sterilized, the hands cannot ; and this alone, one would have thought, should have been sufficient to ensure their universal use. There are still a few operators, however, who decline to use them, and they point with pride to the fact that their death-rate is no higher than that of their colleagues who use gloves. But if these operators would only wear sterilized gloves their death-rate would be lower, unless their experience differed from that of everyone else who has taken to wearing gloves. Apart from the question of mortality, the use of sterilized gloves lowers the percentage morbidity in a marked fashion, and such complications as stitch-abscesses, etc., are now very rare with surgeons who wear gloves. Gloves are objected to on the score that they make more troublesome certain operations markedly requiring the sense of tissue- appreciation, such as difficult cases of diseased appendages with adhesions to the bowel ; but this is purely a matter of practice, and if a surgeon will always wear gloves, no matter what operation he is doing, he will find this difficulty soon disappear. Again, it has been argued that gloves are dangerous because if they are pricked or torn the bacteria which have been herded up inside will escape. This possibility is avoided by filling the gloves with mercurial solution before putting them on, when a certain amount will remain, and the hand will be kept bathed in it. Finally, it is most important to remember that gloves not only prevent the operator's hands from infecting the patient, but also prevent the patient from infecting the operator's hands with any pus that may be present, so that the hands of a surgeon who habitually uses them are never exposed to the risk of severe infection. We think that everyone in active surgical practice should adopt the use of india-rubber gloves not only for operative purposes but habitually when engaged in seeing out- patients, going round his wards, or examining patients in private practice. CHAPTER IV OPERATIONS IN PRIVATE HOUSES Where an operation is to be performed in a private house, the whole responsibility for the details concerned in it rests on the surgeon, and it will be necessary for him not only to prepare his own outfit but to give minute directions to the nurse in charge as to all arrangements required for its performance. THE SURGEON'S OUTFIT Although the instruments required for any given opera- tion are, of course, the same whether it is to be performed in a hospital or at the patient's home, it is advisable in the latter case to carry sufficient additional ones, so that in the event of the operation turning out to be of a different nature from the one anticipated, the surgeon may not find himself embarrassed at the last moment by want of the proper tools. These additional instruments need not be sterilized, but should be carried in the bag in case they should be required. Thus, when performing a minor operation, sufficient pressure-forceps, ligature material, and a scalpel should always be at hand, lest it be necessary to open the abdomen. Similarly a pair of bowel-clamps should always be carried in case a portion of the intestine should have to be resected. The methods of sterilizing the instruments and the rest of the surgeon's outfit for work in private houses and little-known nursing-homes, and the best means of their transport, will be found fully described elsewhere (pp. 29-31). f 65 66 GYNECOLOGICAL SURGERY THE NURSE'S DUTIES The duties of the nurse will be indicated under the following heads : — Preparation of the room. — A well-lighted and well- ventilated room on the first floor should be chosen, and one not situated near a water-closet. All superfluous furniture, together with the carpet, curtains, and pictures, should be removed. The day before the operation the walls should be well dusted, and all the woodwork, includ- ing the tops of the doors and windows, washed or dusted with damp dusters. The furniture also should be dusted, and the floor thoroughly washed with soap and water, and, when dried, well swabbed with clean water, after which it should be scrubbed with perchloride of mercury, i — 1,000. On the morning of the operation the woodwork and furniture should again be dusted with a damp duster. If, however, there is insufficient time for this preparation, owing to the urgency of the operation, it is better not to disturb the dust, but simply to push the furniture gently on one side, and place a sheet soaked in perchloride of mercury, i — 1,000, over the carpet beneath the operating table. Bed. — If possible, a single iron bedstead with a spring and horsehair mattress should be procured. The bed should be dusted with a damp duster, should not have any valance, the mattress should be well aired, and the bed made as follows, from below upwards : A blanket, lower sheet, mackintosh sheeting, draw-sheet, upper sheet, blanket. Just before the operation, two or three hot-water bottles should be placed in the bed. After the operation is over, and just before the patient is returned to bed, these bottles must be taken out of the bed, and if the operation has been of such a nature as to necessitate their further use, they must be applied outside the blanket. Operation table. — Every operating surgeon should have his own portable table. Most of those on the market are OPERATIONS IN PRIVATE HOUSES 67 designed for general surgical purposes and give an un- satisfactory Trendelenburg tilt. The table that one of us has designed will be found in this respect simple in mechanism and light to carry (Fig. 30). It should have on it one blanket, a piece of mackintosh, and a sheet. In the absence of some such table the best substitute is a narrow kitchen-table, which if the Trendelenburg posture is required may be tilted on blocks, or the patient's buttocks may be elevated by bolsters lashed on in the shape of a wedge. Instrument tables, etc. — Four small tables will be re- quired : one for the anaesthetist's apparatus, one for the instruments, one for a basin of biniodide of mercury, 1 — 1,000, for the hands (if the instrument table is large enough, this can be placed upon it), while the fourth will be needed for the basins to hold the swabs. If suitable tables cannot be procured, an ironing board, or leaves of an extension table resting on chairs, will answer the purpose. The tables should be well dusted and covered with clean towels wrung out of biniodide of mercury solution, 1 — 1,000. Washstand. — On this should stand three basins : one for washing the hands with soap and water, one containing clear water to rinse the soap off, and one containing a solution of biniodide of mercury, 1 — 1,000, for completing the preparation of the hands. In this the india-rubber gloves may be left till they are wanted. Chairs. — Two chairs are required : one for the anaes- thetist, and one (in the case of vaginal operations) for the operator. If the operation necessitates the Trendelenburg position, it would be better to have a stool or a low chair for the anaesthetist to sit on. Pail or foot-bath. — This should be properly cleansed, and is necessary for the reception of any soiled water, whilst in vaginal operations it is necessary to have such a receptacle for the douche to flow into on leaving the vagina. Linen. — Besides the sheets already mentioned, a number 68 GYNECOLOGICAL SURGERY of old towels will be needed : a dozen will be sufficient for any case. They should not be new for the obvious reason that new towels soak up fluid very badly. Temperature of room. — The temperature of the room should be between 70 ° and 75 ° F. Accessaries. — -The nurse must provide the following accessaries : — A nail-brush that has been sterilized by boiling. A cake of soap, germicidal if possible. A bottle of brandy. A long rubber rectal tube. A large-sized soft rubber catheter with a glass fun- nel attached for administering saline or brandy enemata. A bath thermometer to test the heat of solutions. Some table salt, in case the surgeon wishes to give a saline injection. Though not a necessity, a bed-cradle to keep the clothes off the patient is usefully added to this list. If the nurse is unable to obtain a proper bed-cradle, an efficient substitute can be made with two wooden hoops as used by children, cutting them in halves and joining the four curved pieces by three straight pieces of wood 2 in. broad. Water. — Three gallons of cold water which has been boiled must be provided, and three gallons of water must be boiled just before the operation. Pieces of gauze should be tied over the top of the jugs ; and provision should be made for a further supply of water in case it should be needed. It is customary for the surgeon to bring his instru- ments, ligatures, gloves, dressings, aprons, masks, towels, and swabs already sterilized, but if he elects not to do so the nurse will have to sterilize them for him as follows : — Instruments. — A kettle or saucepan, preferably a fish- OPERATIONS IN PRIVATE HOUSES 69 kettle, is three parts filled with water and a piece of washing soda the size of a cob-nut is added ; this will prevent the instruments from rusting. The instruments, excepting the scalpel, are then boiled for half an hour. As the edge of the scalpel is dulled by boiling, some other method of steril- ization is preferable, such as putting it in absolute alcohol or carbolic acid, 1 — 20, for two hours before the operation. The needles should be stuck in a piece of lint before they are boiled. Dishes, etc. — A large dish for instruments, say 14 in. square, and a smaller dish 8 in. square for sutures, ligatures, and needles. In the absence of surgical dishes, meat dishes will suffice. For a major operation, two wash basins will be required for the swabs ; for a minor operation, two large pudding basins, one for the clean and one for the dirty swabs. These dishes should be boiled if possible, or at any rate scalded, before use, and then, having been turned upside down on a sterilized cloth to keep out all dust, should be covered with towels until required. A pint measure will be required for mixing the anti- septic solutions, and also bowls for solutions. Ligatures. — Silk, thread, and silkworm-gut should be boiled for an hour. The sterilization of catgut is beyond the province of the nurse, in private work at least. Gloves. — The gloves are sterilized by boiling for half an hour. The nurse must not forget to wet them inside beforehand. They should be boiled separately from the instruments if possible, so that they may not be holed. When sterilized they should be transferred to a large bowl of antiseptic solution. Overalls. — It is impossible to sterilize overalls in a private house. If the surgeon, therefore, does not bring his own, they had better be dispensed with, and towels used instead to swathe the operator and his assistant. Towels. — The towels for surrounding the operation- area should be sterilized by boiling and afterward trans- ferred to a 1 — 1,000 biniodide of mercury solution. When 70 GYNAECOLOGICAL SURGERY required for use they must be wrung out. As they must of necessity be used wet, between them and the patient pieces of waterproof batiste should be placed. A similar arrangement will be needed if they are used instead of overalls for the surgeon and his assistant. Swabs.- — If the surgeon leaves the nurse to prepare the swabs, these should be sterilized by boiling for one hour, and afterwards transferred to a i — 1,000 solution of biniodide of mercury. They must be wrung out in plain sterilized water before use. CHAPTER V EXAMINATION AND PREPARATION OF THE PATIENT I. BEFORE THE OPERATION All patients before being subjected to any operative procedure should undergo a certain amount of preparation at the hands both of the surgeon and of the nurse, and it is only in operations of a very urgent nature, as, for instance, a ruptured tubal gestation associated with an alarming internal haemorrhage, that this preparation should be dispensed with. The amount of preparation necessary depends upon whether the operation is of a major or minor kind, and on the state of health of the patient. Examination of the Patient Before any patient is subjected to an operation it is the duty of the surgeon to acquaint himself by personal examination with the general condition of her health. For this purpose he should make an examination of her heart, lungs, and kidneys, since their condition may have an important bearing upon the result of the operation. It is quite obvious that if the patient is suffering from some serious or fatal disease an operation on the score of expediency is contra-indicated, and one should only be performed when absolutely necessary to save life or for the relief, perhaps only temporary, of some distressing local condition. In cases where the patient's life is not in immediate danger it may be wiser to postpone operative measures until she is better able to stand them and there is less risk. For instance, women who have been flooding from 7i 72 GYNECOLOGICAL SURGERY fibrosis of the uterus are bad subjects for operation. The heart is flabby and weak, and in danger of failing under the stress of a severe operation, and the profound anaemia predisposes to femoral or other thrombosis with all its attendant risks and discomforts after the operation. These patients should not be operated upon until the next period is nearly due, and in the meantime measures should be taken to improve the general health. In cases of acute pyo-salpinx, unless the patient has general peritonitis we have found it much safer to wait till the acute attack has passed off and the temperature is approaching the normal, by which time the opsonic index of the patient is such that she is able to deal with any pus that is let loose during the operation. It must also be remembered that the anaesthetist's choice of the anaesthetic is influenced by the report given to him of her general health. The shock following a major operation is, of course, much more severe than that after one of a minor character, and is sometimes the direct cause of death. It may there- fore be that whereas the general condition of the patient would not contra-indicate a slight operation, one of a serious nature would be highly dangerous. After a long and severe operation, perhaps accompanied by a serious loss of blood, the heart may fail, and great difficulty is experienced in restoring its balance. Four days prior to any major operation a hypodermic injection of liq. strych- ninae rr\iii is with advantage given twice daily, or the same amount in a mixture three times daily. This lessens the danger of postoperative shock, and is said to keep the intestines well contracted and so render them less liable to become distended after the operation. In hospital practice it falls to the lot of a surgeon to have to operate upon many patients who are debilitated by a life of constant hard work and hardship amidst insanitary surroundings, and who have been in daily want of sufficient and wholesome food. Many of them PREOPERATIVE EXAMINATION 73 have, in addition, still further diminished their resist- ing power by drink. Where a major operation is con- templated on a patient such as this, it is advisable to keep her at rest and feed her up for at least a week beforehand. Cardiac disease. — Heart disease is not necessarily a contra-indication to operative measures, although, of course, these cases assume a more serious aspect, since shock itself is a powerful depressant of the heart. As chloroform may not be a safe drug to administer to a patient suffering from some forms of cardiac disease, it will be the surgeon's duty to inform the anaesthetist of this complication, should it be present, before the anaesthetic is administered. Patients with compensated valvular disease stand all ordinary operative procedures as well as healthy persons, but where compensation is failing, no operation should be undertaken, except of urgent necessity. From the surgeon's point of view, fatty degenera- tion of the cardiac muscle is the gravest of all heart lesions, and the more so because its presence is with difficulty diagnosed before the operation. The most valuable indica- tion of cardiac degeneration is the detection of sclerotic changes in the accessible arteries. On this account the surgeon should never forget to examine the radial artery at the wrist and the brachial artery at the bend of the elbow. A tortuous condition of these vessels, especially when combined with an alcoholic history, is an almost sure sign of a heart enfeebled by fatty degeneration. These patients bear severe operations exceedingly badly, the rapid heart-action thereby induced leading not infrequently to acute dilatation, which often proves fatal in a few days. At the present day post-mortem findings show that this condition accounts for more deaths after major operations than does any other cause. Pulmonary disease. — As will be seen later on, ether has a tendency in some cases to cause bronchitis or broncho- pneumonia. If, therefore, on examination of the lungs, 74 GYNAECOLOGICAL SURGERY the surgeon should detect any signs of bronchitis, he would be wise to postpone the operation until these have cleared up. If the operation is imperative, chloroform must be used, not ether, or spinal anaesthesia must be employed. Patients suffering from pulmonary tuberculosis take anaes- thetics badly, and run a danger of an acute exacerbation of the disease. Renal disease and diabetes. — The urine of the patient should always be carefully examined for albumin, blood, sugar, and pus before an operation is undertaken, and the quantity passed in the twenty-four hours should be measured. No patient with diabetes should be subjected to an operation unless it be one of an urgent nature to save life. If it is very important that an operation be performed, and there is time, the diabetes must be treated by careful dieting and codeia, commencing with half a grain three times daily and increasing the dose to as much as six or eight grains in the twenty-four hours ; when the amount of sugar excreted has been lessened the operation may be undertaken with more chance of success. We have operated successfully upon patients with advanced diabetes. The two great risks that confront the surgeon are coma and gangrene, both of which appear to depend upon the presence in the blood of /3-oxybutyric acid and diacetic acid. The risk of coma and gangrene may be minimized by the exhibition of large doses of carbonate of soda for some days beforehand ; and at the operation, acting under Dr. Pavy's advice, we have injected, intravenously, a car- bonate-of-soda solution containing two drachms of this drug to two pints of sterilized water. In cases of post- operative diabetic gangrene we have seen remarkable im- provement rapidly follow the administration of large doses of bicarbonate of soda by the mouth. Again, if albumin is detected in the urine, the patient should, if possible, be treated until the amount has considerably diminished or disappeared. Patients with renal disease do not stand operative measures very well. Ether is an unsuitable PREOPERATIVE EXAMINATION 75 anaesthetic for those suffering from Bright 's disease, and chloroform when diabetes is present. Thyroid tumours. — Patients with simple goitres, as long as these are not interfering with respiration, bear operations as well as other people ; but where symptoms of Graves' disease are present the case is very different. Such patients take the anaesthetic very badly, and there is a liability to sudden death during the operation, or un- controllable heart hurry and failure in the days immediately succeeding it. Insanity. — We have performed operations, both major and minor, upon insane patients, and have not found that the convalescence or the mental condition was materially affected one way or the other as a result. Of course, no surgeon should undertake an operation upon an insane person, except in great urgency, unless he has been advised by a mental specialist that the result of the operation would be beneficial to her. Besides patients actually insane, there are those whose mental stability is trembling in the balance, and in these more than in any others it is proper, both for the good of the patient and for the protection of the surgeon, to take the advice of a mental specialist before performing an operation. Pregnancy. — If during the routine examination of his patient before operation the surgeon should discover that she is pregnant, he will decide not to operate, except in cases of real necessity, because of the liability, especially in some women, to miscarry even after slight operations. Directions to the Nurse It is, of course, a matter of prime necessity that the nurse or nurses should have been thoroughly trained and have an adequate knowledge of asepsis and antisepsis, and how to prepare themselves and the patient for opera- tion. In hospitals and good nursing-homes the surgeon 76 GYN/ECOLOGICAL SURGERY should lay down a routine to be followed in all cases, and for its execution the ward and theatre sisters are to be held responsible. In a well-organized institution, possessed of the services of highly-trained and intelligent women, much responsibility is thus removed from the shoulders of the operator, but it still behoves him to exercise a general supervision over the ward and theatre work, and, without harshness, to insist that it be properly performed. If the operation is to take place at the patient's house the surgeon cannot delegate his responsibility in this manner, and he should therefore be careful to choose capable nurses and to give them minute directions for preparing the patient, preparing the operating room, and sterilizing the instru- ments and dressings (if he does not do this himself). To one who is frequently operating, it will be found both convenient and a great saving of time if he has his directions printed, so that the nurse can be given a set. Unless this is done, the nurse cannot be held responsible if anything is forgotten. Communications to the Patient and her Friends If the patient is a married woman, her husband should be informed of the exact nature of the operation, together with its probable results and risks, as estimated from the practice of experienced surgeons. If she be single, then her mother or nearest living relative should be informed of these details. Exactly how much should be told the patient is a more difficult matter to decide. Of course, the patient has every right to know the worst as well as the best, and if she requests to be informed of the exact degree of danger as far as experience shows, she should be told. The only way in which this can be conveyed to her is by telling her of the death-rate in similar cases with skilled operators under favourable conditions ; and this should be done. As a rule, the patients themselves are not so inquisitive as this, and the most they will ask is whether the operation PREOPERATIVE EXAMINATION 77 is dangerous or not, the answer to which will depend on the nature of the operation. With major operations the patient must be told, if she asks, that there is an element of danger, but, if the condition warrants such a statement, that this is only slight, and certainly nothing approaching to that which she must run if the disease is left untreated. In a few cases, but only a very few, when an operation is necessary to save life and when the patient is so nervous that the truth as to the danger involved might ensure her refusal to submit to it, the gravity of the operation may be somewhat minimized, with the consent of the husband or nearest relatives, after they have been put in full possession of all the facts. If the operation is of such a nature that the ovaries or uterus will have to be removed, the patient and her husband if she be married, or the patient and her parents if she be single, must be made thoroughly to understand that the results will be sterility and the menopause. Lastly, the surgeon will be wise if, before he performs a major operation on a patient which will probably neces- sitate the removal of the ovaries or uterus, he obtains from her a letter, signed and witnessed, giving him a free hand. This is now a rule in many hospitals for all patients, and it would be better if it were so in private work. The neglect of this simple precaution has caused much trouble and anxiety to surgeons in the past. In rare cases a patient will consent to the removal of one ovary or one tube, but not of both, and in these circumstances it becomes a moot point whether the surgeon should operate or not. We think he would be consulting his own interests best, and also those of the patient, if he refused, because in many cases there is no means of knowing the exact condition of affairs until the abdomen is opened, and then if both appendages are diseased a great difficulty presents itself. If, however, a surgeon elects to operate under such restricted conditions, he must be careful not to do more than he has had leave to do, and therefore he 7« GYNECOLOGICAL SURGERY should not interfere at all with any other diseased structures, since an examination of them might start such serious haemorrhage that they would have to be removed. Of course, if these restrictions are imposed, the patient is entirely responsible for the results of the operation, should, say, a pyo-salpinx or an ovarian tumour be left behind. When from experience a surgeon knows that certain operations are not always successful, such as curetting for bleeding in endometritis, dilatation of the cervix for dysmenorrhcea or sterility, removal of a urethral caruncle, perineoplasty for prolapse, etc., he should be perfectly open with the patient and tell her that he cannot guarantee a successful issue, but that in a large number of cases the operation is successful, whilst on the other hand there is no serious danger in it if properly performed. The patient will fully appreciate this, and will practically in all cases consent to an operation. The disappointment of a patient who, having been told by her surgeon that some operation will cure her, discovers that she is very little or no better, is naturally great, and she will very likely lose faith in that surgeon and turn for relief to someone else. Preparation of the Patient Report on the pulse, temperature, and urine. — In every case the nurse should take the pulse and temperature morning and evening before the operation and chart it ; she should also measure the quantity of urine passed in the twenty-four hours and make a note of that. PREPARATION OF THE PATIENT FOR MINOR OPERATIONS Preoperative rest in bed. — As a rule, if the patient remains in bed for twenty-four hours before the operation this will be sufficient. In certain diseases, when the parts require some days to render them aseptic, the patient need not be kept in bed all the time. Shaving the vulva. — Before any operation on the genital organs, the vulva should be shaved. In major PREOPERATIVE PREPARATION 79 operations all the pubic hair must be removed, but in minor operations it will suffice to shave that on the labia majora only. The instruments required are scissors, razor, shaving brush, and mercurial soap. The hair covering the vulva should at first be cut short with scissors, after which the parts should be well lathered for several minutes before the razor is used. The razor must be sharp, and should be dipped for a second into boiling water before use. The different portions of the labia majora, mons veneris, and perineum are rendered taut by the fingers of the left hand, whilst with the razor in the right hand the hair is removed ; the accumulation of hair and soap being wiped from the razor when necessary by wool swabs. By using a safety razor all creases in the skin can be closely shaved even by one inexperienced in this art. If the patient is very fat, the nurse may experience some difficulty in shaving the necessary area, but this may be overcome by propping up the pelvis with a pillow underneath the patient's buttocks or by first placing the patient in the knee-elbow position. Bath. — After being shaved, the patient should have a hot bath consisting of 10 gallons of water at a temperature of 105 F., to which has been added five pints of a solution of carbolic acid, 1 — 20. She should well wash her body with soap and water, especial attention being devoted to the locality of the operation, and after drying she should return to bed. Local antisepsis. — The patient now lies on her back, with her nightgown drawn up round her waist, on a clean draw-sheet with mackintosh underneath, and a vaginal douche is given of biniodide of mercury (t — 2,000), 2 quarts. The vulva and parts immediately adjacent are rendered as sterile as possible by the nurse scrubbing them with ab- sorbent wool dipped in ethereal soap, which is then removed with warm water, after which the parts are finally swabbed with biniodide of mercury (1 — 2,000), and a compress 8o GYNAECOLOGICAL SURGERY consisting of a pad of Gamgee tissue wrung out of biniodide of mercury (i — -2,000) is adjusted over the vulva and kept in position by a sterilized T-bandage. Douching. — -The following articles are required : A douche-can, a bidet, a bath thermometer, a measure and jug. The douche-can should hold two quarts and have 6 ft. of tubing attached to it. Near the free end of the tube should be a tap, and to the free end should be attached a glass nozzle. All pillows having been removed to tilt the pelvis, the patient is placed on the bidet, the douche-pan is raised to a height of about 6 ft., and the nozzle of the douche intro duced, first separating the labia. Before the nozzle is passed, the vulva should be swabbed with biniodide of mercury, 1 — 1,000. In the preparation of the douche the nurse should be particularly careful to ensure that it is of the strength ordered and of the proper temperature, for by neglecting to take these precautions she may seriously injure the patient by poisoning or scalding her. The chemicals to be used in the douche should always, therefore, be first measured and then mixed with the water in a jug, and the temperature tested with a bath thermometer before the solution is poured into the douche-can. The douche-can, bidet, and tubing should be made aseptic by carefully washing and scrubbing them with soap and water, and afterwards with carbolic acid, 1 — 20, while the glass nozzle should be boiled both before and after its use, and between whiles kept in a solution of biniodide of mercury, 1 — 1,000. When giving a douche for antiseptic purposes, the tem- perature of the solution should be 105 F. It should take five minutes for two quarts of douche to run through. If the surgeon wishes, therefore, for a more prolonged douching, arrangements must be made to empty the bidet, so that a pail will be required in addition, or a bidet can be obtained with an outlet to which rubber tubing is affixed, the free PREOPERATIVE PREPARATION 81 end being dropped in the pail ; the solution will then run out of the bidet into the pail. Whenever a vaginal operation is contemplated the patient should be instructed to douche herself twice daily with some mild antiseptic for a week beforehand. Bowels. — The evening but one before the operation the patient is given some aperient that will cause the bowels to act thoroughly. It does not signify particularly what aperient is given, so long as it is effective, and with this knowledge the patient may choose her aperient. In the absence of any particular fancy, she may take the following, which will be found most efficient : — B? Mag. sulph. 5ii. Sod. sulph. 5L Ext. glycyr. gr. xx. Olei pimentae iru. Ess. menth. pip. irtv. Infus. sennce ad §i. On the morning of the operation an enema composed of two pints of soap and water is injected, after the action of which the parts are thoroughly cleansed, as before. If the operation is one for perineoplasty, posterior colpor- rhaphy, recto- vaginal fistula, etc., to guard against any faecal matter soiling the operation area it is found best to administer an enema the night preceding the operation as well as one on the morning of the operation. Where the patient only enters the hospital or nursing-home on the day before the operation an ounce of castor oil should be given about 3 p.m., so that its action is over by the time the patient is ready to go to sleep, and then on the morning of the operation an enema of soap and water is administered about three hours before. After the enema has acted, the parts should be thoroughly cleaned up again, a vaginal douche given, and the compress re-applied. Bladder. — The patient should pass her urine just before the operation. It is not, as a rule, necessary to use the catheter. G 82 GYNECOLOGICAL SURGERY Dress. — The patient should have on a clean night- gown, flannel dressing jacket, and a pair of clean flannel drawers, or, better still, long - woollen stockings reaching to the groins. The hair is dressed in a plait, and any false teeth should be removed before the patient gets on the table. Food. — Up to the day of the operation the patient may have her ordinary diet, supposing it to be a judicious one, and at 6 a.m. on the day of the operation, if this is to take place at 2 p.m., she is given a cup of tea and two thin slices of bread and butter. At 10 a.m. half a pint of beef-tea is allowed, and nothing further until after the operation, for if the stomach is not empty during the anaesthesia the patient may vomit and pieces of food may be inhaled and suffocation result. PREPARATION OF THE PATIENT FOR MAJOR OPERATIONS Preoperative rest in bed. — It would benefit most patients to be kept in bed for a week before the operation, so that the nervous and vascular systems may be quieted and the intestinal canal cleared of any accumulation. This is a counsel of perfection, and many patients will not submit to such a lengthy preparation ; indeed, in certain cases the surgeon will only be able to obtain the patient's consent if he operates within twenty-four or thirty-six hours. Shaving. — The nurse's duties in this respect are the same as are set out for operations on the vagina. It is most important that all the vulva should be shaved and the vagina thoroughly douched before an abdominal section, since it is sometimes necessary during the removal of an abdominal tumour to employ some manipulation per vaginam, or the pelvic cavity may have to be drained by this route. Bath. — As for minor operations. In individual instances, on account of the serious condition of the patient, a bath may not be possible, in which case the surgeon will direct the nurse to wash her in bed. PREOPERATIVE PREPARATION 83 Local antisepsis. — For the operations of vaginal hys- terectomy and colpotomy the local antisepsis is the same as that for minor operations. In cases of abdominal section it is most important that the field of operation should be rendered aseptic, since not only will the risk of stitch-abscess be greatly diminished, but also there will be less chance of the surgeon infecting his patient by introducing septic organisms from the skin into the peritoneal cavity. Having returned from her bath, the patient is put to bed and her nightdress rolled up to her chest, the bedclothes covering her having been previously removed, with the exception of a blanket, which is turned below the pubes. On account of the exposure that will be necessary to carry out the following directions, all windows and doors should be closed and the tempera- ture of the room should not fall below 65 F. Sterilized towels having been placed under the patient, and over her chest and legs, to cover the nightgown and blanket respec- tively, the abdomen, pubes, and sides are thoroughly washed with soap and water, and the skin, if it will stand such treatment, is scrubbed with a sterilized nail-brush. Particular attention should be devoted to the umbilicus, especially in stout patients, in whom this depression may have to be cleansed with wool held in dressing forceps. All soap having been removed by swabs of absorbent wool, the nurse again washes her hands, after which she rubs turpentine well into the operation area. After removal of the turpentine by swabs, ether is applied to the same surface until the swabs used with this fluid are no longer discoloured. Lockwood's spirit biniodide solution is then rubbed over the skin, after which a sterile gauze pad is applied until the operation. An alternative method of disinfecting the skin is by iodine. It can be used in acute cases where there is no time to prepare the skin as already described. A 2 per cent, solution in rectified spirit is painted over the abdomen on the morning of the operation, and again a few minutes «4 GYNAECOLOGICAL SURGERY before it begins. The skin must be perfectly dry or the iodine will not penetrate deeply. In urgent cases, therefore, the skin must not be washed and the pubic hair should be dry-shaved. Bowels. — The patient's bowels are kept well acting by the administration of an aperient every day if necessary, and the final preparation is similar to that for minor operations (p. 81). Bladder. — When any major operation is about to be performed, it is very important that the nurse should draw off the urine with a catheter just prior to the patient's entering the operating room. If this precaution is neglected, perhaps because the patient has recently passed her water, the surgeon may be in danger of wounding the bladder ; for the kidneys act very quickly during the anxious moments just preceding the operation, and if the patient micturates naturally, it may happen that she does not completely empty the bladder, or the urine may accumulate so quickly that this organ is found at the operation to be distended. If the nurse has any difficulty in passing the catheter and drawing off the water, she must be sure to tell the operator, as this may be an indication that the bladder is displaced, and the operator will then use extra care in opening the peritoneal cavity. Dress and food. — -As for minor operations (p. 82). If the patient is very weak she should, if possible, be fed up and stimulants and tonics given before the operation. II. PREPARATION OF THE STAFF AND PATIENT AT THE OPERATION The surgeon and assistants. — Having removed what articles of clothing they consider it necessary to dispense with, the surgeons and assistants prepare their hands and arms. These should be thoroughly scrubbed with a nail-brush, soap, and hot water, using two or three PREPARATION AT THE OPERATION 85 basinfuls of hot water or, better still, holding the hands and arms under running water. All soap is then re- moved with plain water, after which the hands and arms should be well soaked in mercurial solution. The swab nurse then takes the sterilized overalls from the box and puts them on the surgeon and assistants. In like manner she adjusts the masks. The surgeon and his assistants then put on the sterilized india-rubber gloves. The plan followed in America and at some institutions on the Continent of having a suite of dressing and bath rooms for the surgeons near the operating theatre, so that the surgeon has facilities for dressing in a sterilized suit before the operation, and having a bath if he wishes, has everything to recommend it. The nurses. — The swab and instrument nurses should wear sterilized overalls, masks, and india-rubber gloves, and should prepare their hands and arms in a way similar to that described for the surgeon. The patient. — For vaginal operations the patient, having been anaesthetized, is placed in the lithotomy position, and the site of the operation is treated. The compress is removed and the vulva thoroughly douched with biniodide of mercury, 1 — 2,000. Some ethereal soap is poured into the vagina, and the canal is thoroughly swabbed with a wool swab on a pair of ring forceps, after which it is care- fully douched with biniodide of mercury, 1 — 2,000. Steril- ized leggings are now fastened on and a sterilized sheet with an oval aperture in the centre, 6 in. by 4, is draped over the abdomen and buttocks so that the operation- site is alone exposed. Abdominal operations. — The patient, having been anaes- thetized, is placed on the operation table, and her legs being securely fixed to the leg pieces, she is tilted into the Trendelenburg position. Her nightdress is then drawn up round the waist, and the bandage and dressing are removed by the general nurse. The second assistant now takes sterilized towels from the box and places one over the S6 GYNECOLOGICAL SURGERY chest of the patient, one over each arm, and one over the pubes and the blanket covering the legs. By this means the operation area is surrounded by sterilized towels. Over these again a sterilized " operation sheet " is now placed. This consists of a large sheet having an oval aperture in its middle which sufficiently exposes the area of the abdomen to be incised and no more. If the abdomen has been previously prepared., no further treatment of this kind is absolutely necessary, but as an additional pre- caution, especially where the perfect preparation of the patient beforehand cannot be guaranteed, the abdomen may be swabbed with absolute alcohol, the site of the incision may be again scrubbed with a nail-brush, soap, and hot water, and finally swabbed with a i — 1,000 solution of biniodide of mercury in a mixture of spirit and water, 3 to i. In cases of abdominal panhysterectomy for malig- nant disease, the patient, before she is anaesthetized, should have her vagina, after a final douche, lightly packed with sterilized gauze, which will collect any pus or malignant debris that is disturbed during the necessary abdominal manipulations, and this gauze should be withdrawn during the operation by the general nurse just before the vagina is opened, so as to obviate the risk, as far as possible, of any septic material escaping into the pelvic cavity. It is in such cases also that we strongly advise the use of steril- ized india-rubber sheeting for covering the edges of the wound. The anaesthetic — The anaesthetic is better administered in another room, but if the operation must take place in the room the patient is occupying, or if she must be anaes- thetized in the operating-theatre, then all the instruments and appliances should be covered over with sterilized towels, so that they may be hidden. CHAPTER VI OPERATIONS ON THE VULVA URETHRAL CARUNCLE Preparation of the patient. — See pp. 78-82. Instruments. — -Clover's crutch, Auvard's speculum, bladder-sound, Paquelin's or other cautery, a pair of fine rat - toothed forceps, scissors or scalpel, and silk suture No. 1. There are three different ways in which a urethral caruncle can be treated : 1. Cauterization. 2. Excision and cauterization. 3. Excision and suture. Cauterization. — The point of a bladder-sound, or, better still, a small three-bladed urethral dilator, is inserted into the urethral orifice and pressed against the anterior urethral wall. This will prevent the cautery from burn- ing the anterior wall and so favouring a stricture. The operator or assistant then separates the labia majora, and the caruncle is very thoroughly destroyed with the point of the cautery, which should be heated to a dull- red colour only. Finally, vaseline is smeared over the area of operation. (Fig. 39.) Dangers. — If the cauterization is too severe, a stricture at the orifice of the urethra may result, which, however, can be easily dealt with. Excision and cauterization or suture. — The orifice of the urethra is dilated as before, and the caruncle is then 87 88 GYNECOLOGICAL SURGERY seized with fine forceps and either dissected off the posterior urethral wall with the scalpel or snipped off with a fine pair of scissors ; the excision being carried somewhat wide of the growth so as to include a small piece of healthy Fig. 39. — Cauterization of a urethral caruncle. mucous membrane. The rather free bleeding is then stopped either by cauterization or by passing a fine suture from one cut edge of the mucous membrane through the under- lying muscle to the other cut edge and tying it. (Fig. 40.) Dressing and after - treatment. — See Chapter xxxn. URETHRAL CARUNCLE 89 Some patients after this slight operation get retention of urine. This may last for one or two days. It can be relieved by the usual methods, and is of no serious importance. The patient may be allowed to get up the next day. Recurrence. — Urethral caruncles have a marked ten- dency to recur, and in some cases more than one operation Fig. 40. — Excision of a urethral caruncle. is necessary to cure this condition. Therefore, although the operation is a simple one, it behoves the operator to do it very thoroughly, in order to obviate recurrence if possible. In addition, it is desirable that the patient should be informed of this tendency to recurrence, lest on its taking place she should suspect the operator of being unskilful. 90 GYNAECOLOGICAL SURGERY PROLAPSE OF THE URETHRA Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, dissecting forceps, two pairs of Spencer Wells forceps, two curved needles No. 13, scissors, and silk No. 1. Operation. — That portion of the urethra which is . Fig. 41. — Transfixion of prolapsed urethra. prolapsed is caught with pressure-forceps and drawn for- wards so as to put it on the stretch. A suture is then passed across the urethral canal, in its passage transfixing the prolapsed mucous membrane (Fig. 41). The mucous membrane in front of the suture having been removed with scissors (Fig. 42), that portion of the suture which can be seen traversing the urethral canal is pulled down out of the canal and divided so that two sutures are now avail- able (Fig. 43), one to anchor the cut mucous membrane SUBURETHRAL ABSCESS 9i to the orifice on the left side and the other for the same purpose on the right side. These sutures having been tied, the cut edge of mucous membrane is sutured to the urethral orifice with as many interrupted sutures as may be found necessary (Fig. 44). Complications. — This operation may result in a slight amount of stricture at the urethral orifice if the operator has improperly cut away part of the mucous membrane Fig. 42. — Removal of the prolapsed urethra. of the vestibule instead of limiting the excision to that of the urethra. Dressing and after-treatment. — See Chapter xxxn. It is usual to allow the patient to get up at the end of a week. SUBURETHRAL ABSCESS Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, scalpel, dissecting forceps, two pairs of pressure-forceps. 9 2 GYNAECOLOGICAL SURGERY Operation. — The abscess is incised, the pus evacuated, and the cavity thoroughly swabbed with pure carbolic acid. Dressing and after-treatment. — The cavity is packed with iodoform, sal-alembroth, or sterile gauze. The general Fig. 43. — Prolapsed urethra : Fixation of the mucous membrane. lines of after-treatment are described in Chapter xxxn. The gauze is removed the day following the operation, after which the cavity is irrigated with biniodide of mercury, i — 4,000, and then packed lightly every day until healing by granulation has taken place. The patient is able to get up as soon as the purulent discharge ceases. URETHROCELE URETHROCELE 93 Preparation of the patient. — See pp. 78-82. Instruments. — Auvard's speculum, Clover's crutch, blad- der sound, scalpel, dissecting forceps, two pairs of pressure- forceps, scissors, curved needle No. 13, silk sutures No. 1. Operation. — A bladder sound is passed through the urethra into the urethrocele. An incision is then made f&t Fig. 44. — Prolapsed urethra : Suturing the mucous membrane. through the mucous membrane of the vagina on to the point of the sound, so that the sacculated portion of the urethra is opened. The urethrocele is then excised, together with that portion of the vaginal wall which covers it. The hole in the urethra is closed with one or more fine silk sutures. The opening in the vagina is finally closed by interrupted silk sutures passed through the vaginal tissue but not including the mucous membrane of the urethra. Dressing and after - treatment. — See Chapter xxxn. The patient can get up in ten days. 94 GYN/ECOLOGICAL SURGERY HYDROSTATIC DILATATION OF THE BLADDER In certain cases of functional incontinence in young women, after the various methods of treatment by drugs have been tried and failed, a cure or, at any rate, great improvement may be obtained by the hydrostatic dilata- tion of the bladder. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch and a catheter attached to a glass funnel by four feet of rubber tubing. Operation. — The bladder having been emptied of urine, warm boric lotion is gradually run into it from the funnel. The pressure must be regulated so that the bladder is not distended too forcibly, and this is effected by noticing the position of the bladder per abdomen from time to time and holding the funnel containing the lotion about 4 ft. above the level of the patient. About two pints of the boric lotion is run into the bladder and allowed to remain there for twenty minutes, and then withdrawn. After-treatment. — The patient may get up the next day. IMPERFORATE HYMEN Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, a pair of sponge- holding forceps. Operation. — A small incision is made in the bulging hymen from before backwards, and the thick blood and mucus allowed to escape without any assistance such as pressure on the uterus. When the flow of retained fluid decreases, the incision is enlarged, and another made at right angles to it ; but after this, authorities differ very much as to the best treatment. Some operators recom- mend that nothing else should be done beyond the applica- tion of a sterilized diaper, to be changed whenever it is soiled. Others insist that it is better to try to remove all the retained fluid possible by gently irrigating with a boric-acid douche. We think that if the vagina alone is distended the IMPERFORATE HYMEN 95 retained fluid should be evacuated as completely as possible by swabbing and douching, but that where the uterus itself is distended it is better to leave it to drain by itself. Dangers. — The dangers connected with this operation are those of sepsis and haemorrhage. Sepsis. — This is a very real and serious danger, and in the past was the cause of many deaths. Sepsis is due to organisms entering the enormously dilated genital tract and finding therein a retained fluid upon which they can thrive, multiplying rapidly. The distended state of the Fallopian tubes which is so often present forms a direct route to the peritoneum, and double suppurating haemato- salpinx and general peritonitis have often resulted. Haemorrhage. — This is intraperitoneal in character, and is due to the rupture of a dilated Fallopian tube or tubes. The fact that the Fallopian tubes are dilated cannot, however, at first be ascertained, and for this reason the abdominal swelling should not be pressed upon ; since, if the tubes are distended, it is a proof that their ampullary ends must have been sealed, and the peritonitis causing this may also have fixed them, so that when pressure is applied there is a danger of their being ruptured or of the adhesions fixing them being torn. If, after evacuation of the retained fluid from the vagina, the patient shows signs of intraperitoneal bleeding, the abdomen must be opened and the condition dealt with. (See pp. 129, 216.) This also should be done if the Fallopian tubes are ascertained by bimanual examination to be dilated. Dressing and after-treatment. — See Chapter xxxn. The sterilized pads are to be removed when soiled, and if the patient, by a rise of temperature, shows any signs of sepsis, the vagina must be douched twice daily with a warm solution of biniodide of mercury, 1 — 4,000. If definite signs of salpingitis appear, the condition must be treated on the usual principles, remembering that it is always better, if possible, to postpone an operation until the acute stage has subsided. 96 GYNECOLOGICAL SURGERY The patient should be sat up during convalescence in order that better drainage may take place, and she will remain in bed until all discharge has stopped. ABSCESS OF BARTHOLIN'S GLAND Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, and two pairs of pressure-forceps. Operation. — The abscess is opened by an incision parallel with the long axis of the labium majus ; the upper limit of the incision must not reach too high, otherwise the bulb may be injured. The pus having been evacuated, the abscess cavity is well douched with biniodide of mercury, 1 — 2,000, then swabbed with pure carbolic acid and lastly packed with sterile gauze. Dressing and after-treatment. — The general lines of after-treatment will be found discussed in Chapter xxxn. The gauze should be removed next morning, and the cavity repacked twice daily after douching. Where there is much oedema and swelling, hot fomentations may be applied for some days until it subsides. No particular time can be given for the patient to get up, as this must depend on the length of time the cavity takes to granulate. EXCISION OF A BARTHOLINIAN CYST Preparation of the patient. — -Sec pp. 78-82. Instruments. — Clover's crutch, scalpel, six pairs of pressure-forceps, dissecting forceps, two half-circle needles No. 9, two curved needles No. 9, and silk sutures No. 2. Operation. — An incision running parallel with the long axis of the labium majus down to the cyst-wall is made with the scalpel (Fig. 45). This incision should be at the junction of the skin and with the mucous membrane, so that the resulting scar may not cause dyspareunia. The upper limit of the incision must not reach too high, other- wise the bulb will be incised and troublesome bleeding BARTHOLINIAN CYST 97 will result. A pair of pressure-forceps is then applied to the cut edge of the mucous membrane and the cyst-wall is separated from the surrounding connective tissue with the handle of the scalpel (Fig. 46). It will be found to separate quite easily in all directions, unless it has been the seat of inflammation, till its upper and posterior surface Fig. 45. — Excision of Bartholinian cyst : Incising the mucous membrane. is reached. This part will not separate easily, and generally the enucleation has to be finished by cutting with the scalpel through the firm strands of connective tissue in this situation (Fig. 47). It is at this more adherent part that the branches of the internal pudic artery and vein are found, and these will require ligaturing with No. 2 silk. H 9 8 GYNAECOLOGICAL SURGERY Fig. 47. — Completing the enucleation. BARTHOLINIAN CYST 99 When enucleating the cyst, care must be taken not to button-hole the vaginal surface of the labium. Apart from any spurting vessels, it is sometimes very difficult to control oozing from the venous plexus in the bed of the cyst ; and since this bed is sometimes rather large, Obliterating the cavity left. and if not obliterated would form a pocket in which blood could accumulate, it is best to bring its raw edges together by interrupted silk sutures applied inside the cavity, commencing at the bottom and gradually obliterating it (Fig. 48). The edges of mucous membrane are then sutured with a continuous suture (Fig. 49). 100 GYNECOLOGICAL SURGERY Difficulties. — Some difficulty may be experienced in enucleating the cyst if it has been inflamed and the wall is consequently adherent to the surrounding structures, or if during its enucleation the cyst is punctured. Dangers. Bleeding. — Rarely, owing to a ligature hav- ing slipped, secondary haemorrhage may take place to a Fig. 49.— Closure of the wound. serious extent, forming a large hsematoma. If this occurs, and pressure with a firm pad of cotton-wool and T-bandage does not stop it, the patient will have to be anaesthetized, the sutures removed, and the bleeding-point secured. Sepsis. — If the cyst is suppurating and is punctured during its enucleation, the pus will soil the seat of operation, and this part will, therefore, have to be most carefully VARICOSE VEINS OF VULVA 101 cleaned with biniodide of mercury, i — 1,000. The cavity should be drained for a few days with an india-rubber tube in such cases. Dressing and after-treatment. — See Chapter xxxn. The patient requires to be kept in bed for about ten days. HYDROCELE OF THE CANAL OF NUCK Preparation of the patient. — See pp. 78-82. Position of the patient. — Lying flat on the table. Instruments. — Scalpel, scissors, dissecting forceps, four pairs of pressure-forceps, four curved needles No. 7, silk sutures Nos. 2 and 4. Operation. — An incision is made through the skin over and parallel with the long diameter of the swelling, care being taken to avoid wounding the wall of the sac. The sac, having been exposed and opened, and its contents evacuated, is dissected out and its neck of communication with the peritoneum, if it exists, is ligatured with No. 2 silk. If the internal abdominal ring seems unduly large, it should be closed with one or two interrupted sutures passed through the arching border of the transversalis and the internal oblique muscles and Poupart's ligament respectively. The external abdominal ring is closed with a couple of No. 4 silk sutures. Any bleeding having been stopped with ligatures or pressure-forceps, the skin incision is closed with a few interrupted silk sutures. Dressing. — This consists of gauze, wool, and a spica bandage. After-treatment. — See Chapter xxxn. The skin-stitches will be removed at the end of a week, and the patient can get up in ten days. VARICOSE VEINS OF THE VULVA As a result of pregnancy, and even apart from it, the veins of the vulva may become varicose. In some patients, during pregnancy, so bad is the condition that labour has to be induced to avoid rupture of the veins or 102 GYNECOLOGICAL SURGERY obstruction during delivery. Varicose veins of the vulva must not be excised during pregnancy. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, dissecting forceps, scissors, six pairs of pressure-forceps, aneurysm-needle, silk ligatures and sutures No. 2, and four curved needles No. 7. Operation. — The labium of the affected side must be stretched so that the skin-incision over the dilated veins may be accurately made. This can be done by an assistant pulling on the upper end of the labium while the operator pulls on the lower end ; or the operator may stretch the labium between the thumb and index-finger of his left hand. An incision is then made through the skin down to the varicose veins. The skin-edges being held apart, the veins are dissected from their bed with the handle of the scalpel and dissecting forceps. The veins, having been well freed, are ligatured as far apart as possible at the upper and lower angle of the wound with No. 2 silk passed on an aneurysm-needle, after which the portion between the ligatures is excised. Any oozing having been arrested, the skin-incision is closed with a few interrupted sutures of No. 2 silk. Dressing and after-treatment. — See Chapter xxxn. The patient may get up at the end of ten days, the stitches having been removed after a week. HEMATOMA OF THE VULVA If the effused blood is not absorbed with the usual treatment of cold compresses, or if it appears likely to suppurate, then the clot should be turned out. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, dissecting forceps, four pairs of pressure-forceps, four curved needles No. 7, silk sutures No. 2. Operation. — An incision is made over the swelling through the skin down to the effused blood. The blood- clot is turned out, after which the cavity is thoroughly EXCISION OF VULVA 103 douched with a solution of biniodide of mercury, 1 — 2,000. Any bleeding-points having been ligatured with No. 2 silk, the edges of the incision are, lastly, brought together with interrupted sutures passed deep to the cavity so that the latter is obliterated when the sutures are tied. If suppuration has taken place, the operation is per- formed in a similar way, but in this case the cavity is packed with gauze and the wound allowed to granulate up. Dressing and after-treatment. — See Chapter xxxil. If suppuration has not occurred, the patient can get up in ten days, the skin sutures having been removed in a week ; otherwise she must rest till granulation is complete. WARTS OF THE VULVA If the ordinary treatment of cleanliness and oxide of zinc powder does not cure the warts, or if they are too large to be treated in this way, then they should be removed. The bleeding may be very smart, especially if the warts have to be removed in pregnancy. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scissors curved on the flat, dissecting forceps, six pairs of pressure-forceps, four curved needles No. 7, silk No. 4. Operation. — The warts should be removed with the scissors, after which the raw surfaces are closed with mattress-sutures. Dressing and after-treatment. — 'See Chapter xxxn. The sutures are removed in seven days, and the patient gets up three days later. EXCISION OF PART OR WHOLE OF THE VULVA Indications. — -The vulva may be removed in whole or in part for cancer, tubercle, leucoplakic vulvitis, or hyper- trophy of the clitoris or labia due to elephantiasis or syphilis. Preparation of the patient. — See pp. 78-82. Instruments — Clover's crutch, bladder-sound, scalpel, twelve pairs of pressure-forceps, scissors, three curved io4 GYNAECOLOGICAL SURGERY needles No. 7, three curved needles No. 3, silk Nos. 2 and 4, stout silkworm-gut. Operation for complete excision. — An oval incision is made with the scalpel through the skin and subcutaneous tissue down to the deep fascia and well clear of the disease. The incision commences above the clitoris on each side, includes both labia majora, and ends posteriorly to the Fig. 50. — Excision of vulva : Making the outer incision. fourchette (Fig. 50). A second incision is now made round the urinary meatus and the vaginal orifice (Fig. 51). The structures lying between these two incisions down to the deep fascia are then dissected away in a single piece, all spouting vessels being clamped for the time being with pressure-forceps and ligatured with silk after the growth has been removed (Fig. 52). At times there is very troublesome bleeding, especially EXCISION OF VULVA 105 from the dorsal artery of the clitoris and some of the large vestibular vessels, and it is difficult to pick up Fig. 51.— Making the inner incision. the bleeding-point, in which case the haemorrhage can be effectually controlled by passing a mattress-suture under the bleeding area. Fig. 52. — Excising the diseased area. io6 GYNAECOLOGICAL SURGERY The right and left edges of the outer incision above the level of the urethral orifice are now approximated with interrupted silkworm-gut sutures passed deeply to the raw surface. Below this level the cut edges of the skin and vagina respectively are similarly united (Fig. 53). If there is any difficulty in approximating the cut edges of the skin and vagina, the lower end of the vagina should be freed for about an inch so that it can be pulled down and brought into close apposition with the skin edge, thus Fig. 53. — Suturing the wound. covering the raw surface left after the removal of the growth. Removal of inguinal glands. — In all cases of malig- nant disease of the vulva the inguinal glands on both sides should be removed, whether enlarged or not. Some authorities prefer to remove these glands from seven to fourteen days after the primary operation, but we our- selves think it is preferable, when possible, to finish the operation at one sitting. The removal of the glands is best carried out after the vulva has been excised and all the bleeding-points secured. The leg on the side to be first dealt with having EXCISION OF VULVA 107 been extended, an incision should be made running up- wards and outwards parallel with Poupart's ligament and starting from the upper part of the already denuded area. The skin-edges of this incision having been turned back, all the soft tissues down to the aponeurosis, including of course the horizontal inguinal glands, should be dissected out in one piece, starting at the outer angle of the incision (Fig. 54). -Removing the inguinal glands. All bleeding-points having been secured, the inguinal incision should be closed with interrupted silkworm-gut sutures, after which the thigh is flexed, and the other side is similarly dealt with. The patient being restored to the lithotomy position, the vulval wound is united in the manner previously described (Fig. 53). 108 GYNECOLOGICAL SURGERY Danger. — If the growth is large and the clitoris and labia minora are affected, there may be some difficulty in dissecting the mass away without injuring the urethra. It will be found safer in these circumstances to put a bladder-sound into the urethra whilst the structures in its neighbourhood are being removed. There is also a danger in these cases that, if sloughing occurs in the neighbourhood of the urethra, the resulting contraction of the tissues round its orifice may result in serious difficulty with micturition. Dressing. — The vulval wound is covered with dry gauze held in position by a T-bandage. If the inguinal glands have been removed, dry dressings and a spica bandage are applied to each side. After-treatment. — The general lines of after-treat- ment will be found in Chapter xxxn. It will be necessary to use the catheter for the first week after the operation, so as to prevent the wound from being contaminated with urine. After this operation pain is generally a marked feature, being due to the tension on the stitches ; this can be relieved by morphia. Owing to the situation of the wound and the nature of the disease for which the operation is generally under- taken, there is a liability, even with the greatest care, for a certain amount of suppuration to occur, and at times this is very marked, resulting in high fever with considerable constitutional disturbance. If inflammation intervenes, any sutures causing injurious tension, suppuration, or inter- ference with free drainage are to be removed, and hot fomentation should be applied every four hours. In the more severe cases, with sloughing, the parts should be irrigated with a io-volume solution of peroxide of hydrogen before the application of each new fomentation. The sutures in the groin may be removed at the end of a week, the remaining sutures may be left in a day or two longer. PERINEOPLASTY 109 If the wound heals by first intention the patient may get up in a fortnight to three weeks. Partial excision. — The operation of partial excision is carried out on the same lines, but the area of removal is smaller. The ablation of enormously hypertrophied nymphae is associated with extraordinarily free haemor- rhage, and many pressure-forceps should be at hand. CLITORIDECTOMY The clitoris is occasionally removed when hypertrophied. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, four pairs of pressure-forceps, dissecting forceps, three curved needles No. 7 and three No. 3, silk sutures Nos. 2 and 4. Operation. — -The skin is incised round the base of the diseased organ, and the clitoris is then separated and severed at its junction with the pubic arch. As the arteries of the clitoris are cut, their mouths are seized with pressure forceps, after which they are secured with No. 2 silk liga- tures. Any bleeding, which at times may be very free, can be controlled by pressure and by the sutures of No. 4 silk, which are inserted to bring the skin-edges together, being passed deep to the raw surface. Dressing and after-treatment. — -See Chapter xxxii. The patient can get up in ten days. PERINEOPLASTY Indications.— This operation is performed for an old ruptured perineum, a relaxed vaginal outlet, rectocele, cystocele, or prolapse — either to cure these conditions or to render possible the wearing of a pessary. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, sharp angular and flat blunt-pointed scissors, eight pairs of pressure-forceps, rat- toothed dissecting forceps, perforated shot and coil, curved needles Nos. 1 and 7, shot compressor, silkworm-gut and silk sutures No. 1. no GYN/ECOLOGICAL SURGERY i. The operation for incomplete rupture. — This opera- tion aims at extending the perineum forwards so that its anterior edge just covers the vaginal inlet. i. Demarcation of flap. — The operator inserts the points of a pair of angular scissors in the middle line just behind the posterior limit of the vaginal outlet. The buried blade of the scissors is then slipped under the mucous Fig. 55. — Perineoplasty (incomplete) : The skin incision. membrane on the left side in an upward direction and internally to the labium minus till its point is just above the level of the posterior extremity of that structure. The blades of the scissors are then closed so that the mucous membrane is incised at the line of its junction with the skin (Fig. 55). A similar incision is now made on the right side, care being taken that the upper limits of each incision are on the same level. ii. Reflecting the vaginal flap. — A flap of mucous PERINEOPLASTY in membrane is thus marked out, and the next step consists in dissecting up this flap as far as the upper limit of the incisions (Fig. 56). If the right plane of tissue be struck, the dissection can often be accomplished with the point of the index finger alone, or by swab pressure, otherwise separation must be effected with the scissors ; in either Fig. 56.— Reflecting the vaginal flap. case the flap of mucous membrane as it is raised must be supported and kept on the stretch by one or two pairs of forceps fixed to its free edge and held by the assistant. Some operators still introduce the first and second fingers of the left hand into the rectum so as to keep the recto- vaginal septum on the stretch. By this manoeuvre there is less danger of wounding the rectum, but if it is practised a clean glove should be put on after the fingers are 112 GYNECOLOGICAL SURGERY withdrawn. The operation can be better performed after a little experience without inserting the fingers into the rectum, for the chance of infecting the wound is diminished. The flap of mucous membrane having been thoroughly freed, particularly at the sides of the vagina, a V-shaped portion with its apex towards the cervix is excised (Fig. 57). The reason we advocate the removal of this portion of Fig. 57. — Fashioning the vaginal flap. the flap is that if a case of incomplete rupture of the peri- neum be carefully examined after healing has taken place, it is evident that there is more mucous membrane on the posterior vaginal wall than was present before the injury. This increase is due to the fact that the raw surfaces which resulted from the laceration, instead of becoming approxi- mated, are covered over with a new mucous membrane, and a condition more approaching the normal is secured if this piece of tissue is cut off, for on suturing the PERINEOPLASTY "3 gap the correct forward curve of the vaginal canal is restored. iii. Restoring the posterior vaginal wall. — The free ends of the V-incision are now held in two pressure forceps (Fig. 58), while the gap in the reflected flap of mucous membrane is closed with interrupted catgut sutures on a curved needle, commencing at the apex of the incision and ending at the points of the forceps, the sutures being tied so that the knots lie outside the vagina (Fig. 59). iv. Approximating the edges of the levator ani muscles.- — Where great relaxation of the vaginal outlet is present, it is proper to unite the levator ani muscles behind the vagina. The edges of these muscles appear in the depths of the wound as a couple of ridges, one on either side. These, being defined, are united in the middle line by several No. 1 silk sutures passed on a small curved 1 IT4 GYNAECOLOGICAL SURGERY needle. Simple interrupted sutures may be used, but if there is much oozing, mattress-sutures are better, on account of their haemostatic effect. It is not, however, necessary to unite the muscles by buried sutures in all cases, the ordinary deep sutures now to be described being usually sufficient. Fig. 59. — Restoring the posterior vaginal wall. v. Introduction of the deep sutures. — A new posterior vaginal wall having now been fashioned of mucous membrane, the edges of the skin-incision are trimmed up with scissors, and silkworm-gut sutures on a curved needle are intro- duced, the needle entering at a point in the skin just PERINEOPLASTY 115 external to the raw surface on the right side, emerging at the corresponding point on the left side. Whilst the suture is being passed it should be kept as deep as possible, but the rectum should not be penetrated, and therefore, if the operator has not had his finger in the rectum during Fig. 60. — Introduction of deep sutures. the introduction of the sutures, he should make certain before tying them that their position is correct. Three or four such sutures are passed, the most anterior one corresponding to the upper limit of the incision, and their ends are temporarily secured by a pair of pressure- forceps (Fig. 60). vi. Restoring the perineum. — After all blood-clot has been washed away with a hot mercurial douche, the silk- n6 GYNECOLOGICAL SURGERY worm-gut sutures are secured in turn, commencing at the most posterior, the assistant meanwhile holding the others out of the way. The two ends of a suture, having been cut level, are threaded through the coil of silver wire and afterwards through the perforated shot, which is forced home by holding it gently with the shot compressor. Fig. 61. — Securing the deep sutures. When the edges of the raw surface are approximated and the tension appears to be sufficient, the shot is forcibly crushed, after which the free ends of the suture are cut off about half an inch from the shot (Fig. 61). The other sutures in turn are treated in a similar fashion until with the tightening of the last the wound is com- pletely closed. An additional suture is then inserted, if necessary, on PERINEOPLASTY 117 each side externally to the middle line, to anchor the flap of mucous membrane to the skin (Fig. 62). Fig. 62. — Anchoring the vaginal edge to the skin. 2. The operation for complete rupture. — In complete rupture the rectum is implicated, so that the vaginal and Fig. 63. — Perineoplasty (complete) : General view of a complete rupture. rectal canals at their lower ends become conterminous and the patient loses control over flatus and faeces (Fig. 63). n8 GYNECOLOGICAL SURGERY The operation about to be described aims at restoring the vaginal and rectal canals and forming a new perineal body between these two structures. i. Demarcation of the anterior flap. — The points of the angular scissors being inserted at the left external limit of the recto-vaginal septum, the incision is carried across its free edge (Fig. 64). The incision is then continued Fig. 64. — Splitting the recto- vaginal septum. up on the left side, and afterwards on the right, in the manner described on p. no (Fig. 65). ii. Separating the sides of the rectum. — The points of the scissors are now inserted at the external limits of the recto- vaginal septum, and the skin is incised posteriorly for half an inch on each side of the anus externally to the lacerated sphincter, so that all the incisions taken together form more or less the shape of the letter H, and the lower end of the rectum is separated at its sides (Fig. 66). A pressure-forceps is now applied at each angle of the vaginal flap, while others are attached to the outer PERINEOPLASTY 119 Fig. 65. — Demarcating the anterior vaginal flap. Fig. 66. — Separating the sides of the rectum. 120 GYNECOLOGICAL SURGERY ends of the lacerated sphincter muscle of the rectum (Fig. 67). iii. Splitting the recto-vaginal septum. — The anterior flap is now dissected up as described at p. 111 (Fig. 68), and a V-shaped piece is excised (Fig. 69). iv. Restoring the posterior vaginal wall. — The ante- rior flap is then sutured with an interrupted silk suture Fig. 67. — Applying the marking forceps. as described at p. 113, and the new posterior vaginal wall is thus fashioned. v. Restoring the anterior rectal wall. — The forceps which have been fixed to the outer ends of the lacerated sphincter are approximated, and the edges of the gap in the anterior rectal wall, being freshened, are united by interrupted silk sutures which include only the muscular layer of the rectal wall, the knots being tied so that they lie in the depth of the perineal wound (Fig. 70). Fig. 69. — Fashioning the vaginal flap 122 GYNECOLOGICAL SURGERY vi. Restoring the perineum. — The perineum is now restored by drawing together the lateral margin of the wound with deeply inserted sutures of silkworm-gut, fastened with shot and coil. Of these sutures the posterior one is most important because it completes the approxima- Fig. 70. — Restoring the anterior rectal wall. tion of the lacerated sphincter (Figs. 71 and 72). If it is deemed necessary, the edges of the levator ani muscles may be separately united by buried sutures (p. 113). Dangers, i. Sepsis. — Owing to the situation of the wound, and the impossibility of procuring asepsis, suppura- tion after perineoplasty is a possibility in the most favour- PERINEOPLASTY 123 able circumstances. It does not usually give rise to much constitutional disturbance, but occasionally severe symptoms of sepsis may appear. Suppuration is a disaster, since it may increase the deficiency of the perineum. In this event, no further operation should be undertaken for six months. If the wound shows signs of suppuration, all stitches must be immediately removed and fomentations applied. Care must be taken to avoid puncturing the rectum when Fig. 71. — Passing the posterior deep suture. dissecting up the posterior vaginal flap, since such an accident will increase the risk of infection of the operation area, and may lead to the formation of a recto-vaginal fistula. ii. Haemorrhage. — As a rule the rather free oozing stops as soon as the deep sutures have been passed and tied, but if there are any spurting vessels, or if the venous oozing is very marked, the bleeding-points must be secured with mattress-sutures or ligatures of fine silk, for if this be not 124 GYNECOLOGICAL SURGERY done, and the bleeding continues, either a haematoma will form under the flap with the result that the wound will break down in a day or two, and perhaps suppurate, or the patient will have to be again anaesthetized, the wound opened up, and the bleeding-spots secured. It is as well to remember that an alarming amount of bleeding may take place into the wound without much external evidence, and we recall a case where a patient in Fig. 72. — Securing the deep sutures. these circumstances nearly bled to death, a fatal issue being averted only by an injection of saline solution into the me- dian basilic veins after the haemorrhage had been arrested. Dressing and after-treatment. — See Chapter xxxn. If after the operation is finished marked oozing between the stitches occurs, it can be arrested by plugging the vagina with tampons. The patient should not get up before the twenty-first day, the stitches being removed on the seventh to tenth day. DISARTICULATION OF COCCYX 125 REMOVAL OF THE COCCYX . The coccyx of a woman may require to be removed because of severe pain due to its presence. This pain may be neuralgic, gouty, or rheumatic in character, and more or less continuous, or it may trouble the patient only in defalcation or in sitting down, in which case the coccyx may be found to be fractured, dislocated, anky- losed, or the seat of chronic arthritis. In certain cases the presence of pain can only be attributed to a neurosis. Before deciding to remove the coccyx the surgeon must satisfy himself by careful examination that the pain is really connected with this bone, and is not due to fissure in the anus or some rectal trouble. Preparation of the patient. — The perineum, anus, cleft between the two buttocks, and adjoining skin should be treated as for perineoplasty (pp. 78-82). Position. — The patient should be placed in the Sims semi-prone position, the buttocks pointing towards the window. Instruments. — A scalpel, pair of scissors, dissecting forceps, six small pressure - forceps, bone - forceps, two small retractors, two needles No. 7, silk No. 2, and silk- worm-gut. Operation. — The following are the steps of the pro- cedure : — i. Exposure of coccyx. — An incision is made over the posterior surface of the coccyx and the structure exposed. ii. Freeing and removal of coccyx. — The coccyx is next seized with a pair of forceps, freed from its deep con- nections with the scalpel, and removed by disarticulation through the sacro-coccygeal joint. iii. Closure of wound. — All bleeding-points having been arrested with silk ligatures No. 2, the wound is closed with silkworm-gut passed deep to the raw surface. Danger. — At times the bleeding from the middle sacral artery is very smart, and if the end of the vessel, as it i26 GYNECOLOGICAL SURGERY may be, is difficult to secure, a little piece of the sacrum must be* chipped away, when the artery, which is more loosely attached higher up, can be secured. Dressing. — A piece of sterilized gauze, a pad of wool, and a T-bandage must be applied. After-treatment. — See Chapter xxxn. The stitches are taken out on the seventh day, and the patient gets up on the fourteenth. CHAPTER VII OPERATIONS ON THE VAGINA ATRESIA OF THE VAGINA Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, scalpel, scissors, bladder- sound, dissecting forceps, six pairs of long pressure-forceps, four half -circle needles No. 9, silk No. 2. There are various degrees of atresia of the vagina, and three types may be taken : 1. Where there is simply a transverse septum across the vagina in some part of its course. 2. Where the vaginal canal in some part of its course is absent. 3. Where there is no vagina. In these conditions an operation may be indicated for retained menstrual fluid or to render the patient nubile. With these malformations it will also be convenient to consider the operative treatment of hsematometra. 1. Transverse Septum of the Vagina In most cases of so-called " imperforate hymen " in which the menstrual fluid is retained, if a careful examination be made the condition will be found to be due to a trans- verse septum of the vaginal orifice, the perforate hymen being stretched over the swelling that is presenting at the vaginal orifice. In other cases the septum may be higher up the canal. Some of these are perforated by a circular hole like a diaphragm. Operation. — The operation, if the septum is complete, is similar to that for imperforate hymen (p. 94). If the 127 128 GYNECOLOGICAL SURGERY septum is perforate, but is the cause of marital difficulty, it should be dissected away. Complications. — As during the patient's convalescence the cut septum may unite, rendering the operation useless, after the fluid has escaped the vaginal septum should be dissected away. Any oozing from its cut surface can be controlled by a silk suture uniting the edges of the septum. 2. Absence of the Vagina in some Part of its Course Operation. — A sound is passed into the bladder and held by the assistant. The operator, having introduced the index finger of his left hand into the rectum, so that it, together with the sound in the bladder, may act as a guide, makes a trans- verse incision in the position of what should be the vaginal orifice, and then with the index finger of his left hand, and scissors if necessary, gradually enlarges the wound in an upward direction, taking care to avoid the rectum and the bladder, until the vaginal canal is reached, when the retained fluid is allowed to escape with the same precautions as are observed in the operation for imperforate hymen (p. 94). The further steps of the operation depend on the length of the wound, but if possible the skin at the orifice should be dissected free all round, and then sutured to the mucous membrane of the vagina so that the raw surface is covered. Dangers. — The patient is subject to the same dangers as are mentioned at p. 95, and they must be dealt with in the same way. In addition, a careless operator might wound the bladder or rectum ; and lastly, if the raw surface has not been covered with skin, the wound is very likely gradually to contract, so that in a few months the patient is in practically the same state as before. After the menstrual fluid is evacuated, therefore, the wound is plugged with gauze. Dressing and after-treatment. — Tor the general after- ATRESIA OF VAGINA 129 treatment in these two operations, see Chapter xxxn. The day following the operation the gauze is taken out, the newly formed vaginal canal is kept patent with a plug of lint, and a few days later a perforated glass tube, specially made for the purpose, is substituted. In the case where a septum has been divided, the patient gets up when the discharge ceases. For the second condition no definite time can be laid down, but it is important to remember that the patient when convalescent will have to wear a glass dilator for some hours a day for many months, and perhaps even longer. If the use of the dilator is omitted, through carelessness, there is the greatest risk of the canal closing, and cases are on record where the same patient has been operated upon for this condition over a dozen times. In intractable cases the question of hysterectomy has to be carefully considered. 3. Total Absence of the Vagina If by rectal examination it is ascertained that the vagina is absent, a plastic operation, on the score either of nubility or of haematometra, is, in our opinion, useless ; but if at the patient's urgent solicitation such an opera- tion is attempted, the procedure to be followed is similar to that described at p. 128, and differs only in that it is more extensive. Dangers. — The dangers are similar to those described at p. 95, but in this case it must be remembered that the new vagina is almost certain to contract, and in most cases so much so as to render the operation useless.* Operation for Haematometra When the vagina is absent, or nearly so, and the uterus is functionally active and dilated with retained menstrual * J. F. Baldwin {Journ. Amer. Med. Assoc, 1910, iv. 1362) has successfully constructed an artificial vagina on four occasions by resecting a portion of the ileum and implanting it between the bladder and the rectum. J i3o GYNECOLOGICAL SURGERY fluid, the best and proper operation is total hysterectomy. The Fallopian tubes should be removed with the uterus, as they also are distended with retained blood, but the ovaries, unless diseased, must on no account be removed. As has been indicated, the operation of making a vagina when none, or virtually none, exists is most unsatis- factory, practically all the cases reverting to their former state, and having to submit to further operative measures. Some operators have indicated oophorectomy as being the best treatment if the blood can be evacuated from below. There is, however, no sense in sacrificing healthy genital glands for the sake of a deformed and useless uterus ; moreover, there is at least one case on record where this operation was essayed and the girl continued to menstruate because a small piece of ovary had been left behind. In many cases it would be difficult if not impossible to avoid this owing to salpingitis and severe matting of the ovary and Fallopian tube. H^MATOMETRA OF AN UNDEVELOPED HORN This rare condition, occasionally met with, requires operative treatment. The distended horn lies close against the unicorn uterus, of which it forms the outer half, and may be mistaken for a blood-cyst of the broad ligament if the relation of the round ligament to the tumour is not observed. It is usually possible to remove it, leaving the functional half of the uterus intact, by an operation similar to that of salpingectomy (p. 497). LONGITUDINAL VAGINAL SEPTA A septum of the vagina may be longitudinal, and when complete produces a double vagina. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, vaginal retractor, scalpel, six pairs of pressure-forceps, dissecting forceps, four half- circle needles No. o, silk No. 2. VAGINISMUS 131 Operation. — The septum should be dissected away and the raw edges joined with sutures, after which a piece of sterile gauze should be left in the vagina. Dressing and after - treatment. — See Chapter xxxn. The patient gets up on the tenth day. VAGINISMUS Certain cases of vaginismus are much improved by enlarging the vaginal orifice. The operations devised to this end consist of (1) stretch- ing the vulval orifice ; (2) Fenton's plastic operation. 1. Stretching the Orifice Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Sims' glass dilators. Operation. — The orifice can be stretched by placing the thumbs or index fingers just within the vagina and forcibly abducting them until the fibres of the sphincter have been lacerated ; or Sims' glass dilators can be inserted, commencing with a small size and gradually increasing the size until the desired effect is obtained. After the operation is completed, a dilator somewhat smaller than the largest size passed, but sufficiently large to stretch the orifice, is inserted and allowed to remain in position until the patient is well recovered from the anaes- thetic and complains of its presence. Dressing and after-treatment. — See Chapter xxxn. The patient can get up the day after the operation. The glass vaginal dilator should be worn night and morning for one hour until the tendency of the orifice to contract spasmodically disappears. If the patient has any difficulty in introducing the dilator, which should be well lubricated, some 5 per cent, cocaine ointment can be applied at the vaginal orifice for a few minutes before its insertion ; and if the dilator left in after the operation causes much distress on being passed, a smaller size can be used at first. ^ GYNECOLOGICAL SURGERY 2. Plastic Enlargement of the Vaginal Orifice Preparation of the patient. — See pp. 78-82. Instruments. — -Clover's crutch, scissors and scalpel, four pairs of pressure-forceps, dissecting forceps, four curved needles No. 7, silkworm-gut. Operation. — The mucous membrane on the posterior vy Fig. 73. — Plastic enlargement of the vulval orifice : Re- flecting the vaginal flap. wall having been dissected up as a flap (Fig. 73), the peri- neum is incised half-way down to the anus, the cut being in the long axis of the vagina. The wound then gapes, and a raw surface more or less diamond-shaped is formed (Fig. 74)- Sutures of silkworm-gut are now inserted so as to affix the cut edge of the flap of mucous membrane to the cut VAGINISMUS i33 skin-edges (Figs. 75 and 76), the upper and lower angles of the wound are approximated, and the resulting scar is transverse to the long axis of the vagina. Another and simpler method of performing this opera- tion is to make a longitudinal median incision through the skin and mucous membrane, stretch the wound till it Fig. 74. — Incising the perineum. becomes diamond-shaped, and then suture it up so that the upper angle of the diamond is approximated to the lower angle, and the suture line when finished is transverse to the vagina. Dressing and after-treatment. — For the general lines, see Chapter xxxn. The stitches are removed on the seventh day. 134 GYNECOLOGICAL SURGERY ig. 75. — Suturing the vaginal flap to the skin. Fig. 76. — The operation completed. VAGINAL MYOMA i35 MYOMA OF THE VAGINA Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, vagi- nal retractor, bladder-sound, scalpel, scissors, six pairs of Fig. 77. — Vaginal my- oma : Incising the cap- sule of the tumour. long pressure-forceps, dissecting forceps, four half-circle needles No. 7, silk No. 2. Operation. — The method to be chosen depends upon whether the tumour is pedunculated or sessile. Pedunculated myoma. — The mucous membrane cover- ing the pedicle at its junction with the tumour should be incised and reflected and the tumour shelled out. The pedicle is then ligated with mattress-sutures of 136 GYNECOLOGICAL SURGERY silk to check haemorrhage, and the mucous membrane over it is brought together with a few interrupted sutures. Sessile myoma. — The sound is passed into the bladder or the index-finger into the rectum, according to whether the tumour is on the anterior or posterior vaginal wall, in order to ascertain the relation of these organs to the tumour. Fig. 78. — Enucleation of the tumour. The mucous membrane covering the tumour, together with the capsule, is then incised (Fig. 77), and the tumour is easily enucleated with the finger or scissors (Fig. j8). Any bleeding is controlled by the silk sutures which unite the edges of the mucous membrane, and which should be passed deep to the raw surface left after the enucleation of the tumour. If any spurting vessels can be seen, these may be ligated in the usual way before the wound is sutured. VAGINAL CYSTS *37 Dangers. — The bladder, ureters, or rectum may be wounded during the enucleation. Dressing and after-treatment. — See Chapter xxxil. The patient gets up in a fortnight. VAGINAL CYSTS Preparation of the patient. — See pp. 78-82. Instruments. — Auvard's speculum, vaginal retractor, Clover's crutch, scalpel, scissors, dissecting forceps, six pairs of long pressure-forceps, four half-circle needles No. 7, silk No. 2. Operation. — Auvard's speculum is inserted into the vagina if the cyst is on the anterior wall, or a vaginal retractor is held in position against the anterior vaginal wall by an assistant if the cyst is on the posterior wall. The mucous membrane covering the cyst is seized with rat-toothed dissecting forceps and carefully incised till the cyst-wall is exposed. The cyst is enucleated with the index-finger or handle of the scalpel. The excess of mucous membrane covering the cyst is cut away, any oozing is stopped, and the wound united with a silk suture No. 2. Complications. — With the primary incision or during the enucleation the cyst may burst. The cyst-wall may then be very difficult to remove. Dangers. — With large cysts there is a danger of wound- ing the ureter, bladder, or rectum, and the bleeding may be serious. In these cases, therefore, it may be safer either to open the cyst, plug it with gauze, and let it heal by granulation, or remove only that piece of the cyst- wall, together with the mucous membrane covering it, which projects towards the vaginal canal. The edge of the cyst-wall can then be sutured to that of the mucous membrane, the remainder of the cavity being plugged with gauze and allowed to granulate up. Dressing and after-treatment. — See Chapter xxxn. The patient gets up in about a fortnight. i38 GYNECOLOGICAL SURGERY PARTIAL VAGINECTOMY FOR MALIGNANT DISEASE OF THE VAGINA The vagina may be the seat of sarcoma in early life, and of carcinoma at a later period. As a rule, the patients apply for relief too late for any operative measures of a radical nature to be undertaken, and any palliative measures, such as scraping and cauter- izing the growth, may only make matters worse by causing a fistula earlier than would otherwise have occurred. If the patient is seen at an early stage of the disease and the growth is situated close to the outlet, it may be removed by partial vaginectomy. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, vaginal retractor, scalpel, bladder-sound, six pairs of long pressure-forceps, dissecting forceps, four half-circle No. 7 needles, silk No. 2. Operation. — The relation of the bladder and rectum having been ascertained, the speculum is inserted so as to expose the growth, which is then steadied with forceps. The mucous membrane having been incised all round and well clear of the growth, the latter is separated by scissors or scalpel. Any oozing can usually be stopped by sutures passed through the raw surface ; if not, the bleeding-points must be ligatured. When the bleeding has ceased, the mucous membrane is sutured with No. 2 silk sutures. Difficulties. — If the disease occurs in an elderly woman the vaginal canal may have atrophied, and in this case it may be a difficult matter to get at the growth properly. If so, a paravaginal section (p. 295) will be found of great service. Dangers. — If the growth is on the anterior wall the bladder may be injured during its removal, and the rectum may be injured when the growth is being removed from the posterior wall. Alternative method. — H the growth is extensive, and ANTERIOR GOLPORRHAPHY 139 is not limited to the first inch of the vagina, a hystero- vaginectomy is the best treatment (see p. 261). Dressing and after - treatment. — See Chapter xxxn. The patient gets up in a fortnight. ANTERIOR COLPORRHAPHY Indications. — -This operation is performed for the relief of cystocele or prolapse of the anterior vaginal wall, and consists in removing a portion of the mucous membrane of the anterior vaginal wall, and so narrowing the canal. In the hands of many' surgeons this operation does not appear to be very successful in its ultimate object, and on this account it has of late years gone out of fashion. Many failures, however, may be fairly attributed to in- sufficient tissue being removed. In our opinion, the slighter cases of protrusion of the anterior vaginal wall are suffi- ciently relieved by an efficient perineoplasty ; in the more severe cases, with great redundancy of the anterior vaginal wall, this remedy is insufficient, and an anterior colpor- rhaphy should be performed in addition. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, scal- pel, six pairs of pressure-forceps, rat-toothed dissecting forceps, bladder - sound, volsella, curved needles No. 7, silk No. 2. Operation. — The speculum having been inserted in the vaginal canal, the cervix is pulled down with the volsella. The anterior vaginal wall is now put on the stretch by four pairs of pressure-forceps, one applied just behind the urethral orifice, a second at the junction of the vaginal vault with the cervix, while the third and fourth are applied laterally opposite each other. Exactly how far apart the lateral forceps are to be fixed depends on the amount of redundant tissue, and can best be esti- mated by altering their position until, when they are drawn together, the cystocele is obliterated. i. Demarcation of flap and removal. — The mucous 140 GYNAECOLOGICAL SURGERY membrane being stretched by traction on the forceps, an incision is made with a scalpel, between each pair of forceps, through the mucous membrane, so that a diamond-shaped piece of tissue is delineated (Fig. 79). This piece of mucous membrane is then very carefully dissected off from the Fig. 79. — Anterior colporrhaphy : Demarcation of the area to be denuded. base of the bladder (Fig. 80) by means of the scalpel and fingers, the latter in some cases being quite sufficient. Any oozing will usually stop after the application of pressure-forceps or on suturing the wound ; in some cases the bleeding is rather more than can be arrested by these means, and it should then be controlled by the application of ligatures. ANTERIOR GOLPORRHAPHY 141 ii. Obliteration of the denuded area. — Interrupted sutures of silk are passed with a half-circle needle, com- mencing at the right external angle of the wound and continuing transversely across the vaginal wall, to terminate at the left external angle (Fig. 81), so that the scar lies transversely to the vaginal axis. Fig. 80. — Denudation of the demarcated area. Dangers. — Care must be taken when dissecting off the mucous membrane not to injure the bladder. If the scalpel is being used, this can be avoided by keeping the cutting edge towards the flap and away from the bladder ; also by passing the sound into the bladder from time to time, and so estimating the amount of intervening tissue. 142 GYNECOLOGICAL SURGERY Dressing and after-treatment. — For the general lines of after-treatment, see Chapter xxxn. The patient may get up on the twenty-first day. She should be careful for some months following the operation not to follow any occupation which causes straining, as until the parts have Fig. 81. — Suture of the wound. thoroughly contracted up there is danger of the vaginal wall again becoming stretched. POSTERIOR COLPORRHAPHY Indications. — This operation, which removes a portion of the mucous membrane from the posterior vaginal wall, is indicated in cases of rectocele and prolapse of the posterior vaginal wall. It is best performed in combination with perineoplasty, and the operation of posterior colporrhaphy in these circumstances is the same as that of perineoplasty, except that a much larger piece of mucous membrane POSTERIOR GOLPORRHAPHY i43 must be removed, and therefore a larger flap will have to be dissected up. In some cases of rectocele the protrusion of the posterior vaginal wall is limited to its upper part only, in which case the operation now to be described will suffice. Fig. 82. — Posterior colpor- rhaphy : Demarcation of the area to be denuded. Preparation of the patient. — See pp. 78-82. Instruments. — -As for anterior colporrhaphy (p. 139). Operation, i. Demarcation of the flap. — With a pair of forceps the lowermost portion of the bulging vaginal mucous membrane is seized and the rectocele is with- drawn to its full extent. The mucous membrane being now drawn taut, a diamond-shaped incision is made (Fig. 82), and a piece of mucous membrane is dissected off (Fig. 83). ii. Obliteration of the raw surface. — The raw surface is obliterated by running a continuous suture of silk from the right lateral angle of the incision to the left i 4 4 GYNAECOLOGICAL SURGERY (Fig. 84), so that the resulting scar lies transversely to the direction of the vagina. Dressing and after-treatment. — See Chapter xxxn. The patient may get up on the twenty-first day. g. 83. — Denudation of the demarcated area. URETHRO-VAGINAL FISTULA Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, scis- sors, scalpel, dissecting forceps, bladder-sound, four pairs of pressure-forceps, four curved needles No. n, silk No. 1. Operation. — A bladder-sound having been introduced into the urethra, the vaginal mucous membrane in the neighbourhood of the fistula for about half an inch is VESICOVAGINAL FISTULA i45 dissected off. As many interrupted sutures of silk as may be necessary are passed deeply to the raw surface. When the sutures are tied the fistulous opening is entirely obliterated. Dressing and after-treatment. — See Chapter xxxii. The patient gets up on the fourteenth day. Fig. 84.— Suture of the wound in posterior col- porrhaphy. VESICOVAGINAL FISTULA A vesico-vaginal fistula may be closed by paring or flap-splitting, performed through the vagina. Preparation of the patient. — In addition to the prepara- tion mentioned at pp. 78-82, the surgeon must be sure that there is no cystitis and that the bladder, except for the fistula, is in a healthy condition. If cystitis is present, this must first be cured by appropriate treatment, for the chances of the operation-wound uniting if the urine is already septic are remote. K 146 GYN/ECOLOGICAL SURGERY Instruments. — Clover's crutch, Auvard's speculum, vaginal retractors, scalpel, dissecting forceps, six pairs of long pressure-forceps, four half-circle needles No. n, shot, coil, shot compressors, silkworm -gut, silk No. 1. 1. Operation by paring. — Auvard's speculum is inserted into the vagina, which is then thoroughly douched with hot water, and the bladder by means of a catheter in the urethra is also freely washed out through the fistula. i. Excision of vaginal mucous membrane in the region of the fistula. — The vaginal wall in the neighbourhood of the fistula having been steadied with pressure-forceps, an incision is made with a sharp scalpel in the mucous membrane of the anterior vaginal wall surrounding the fistula and about half an inch from its edge, by which means the amount of mucous membrane to be removed is delineated. The strip of mucous membrane thus determined is then care- fully dissected off the bladder, leaving an oozing raw surface. ii. Insertion of sutures. — Thin silkworm-gut sutures are now inserted. The needle is entered through the vaginal mucous membrane just externally to the raw area, and is kept deep to the raw surface and brought out at one edge of the fistula. The needle is then re-inserted in the opposite edge of the fistula, kept deep to the raw surface on that side, and brought out through the mucous membrane of the vagina clear of the raw area. After a sufficient number of sutures have been passed, the bladder is care- fully washed out with warm boric solution, which is passed by means of a catheter through the urethra, and escapes, together with any blood-clots, into the vagina through the fistulous opening, and the fistula is then closed by approxi- mating the sutures with shot and coil so that the raw areas on each side are closely in contact. The sutures may be applied from side to side, or from above downwards, according to whether the edges of the fistula approximate more exactly in one direction or the other. Difficulties. — On account of the cicatricial contraction VESICOVAGINAL FISTULA 147 of the tissue in the neighbourhood of the fistula, it may be impossible to bring the edges of the opening together, or, having done so, it may be found that the tension on the stitches is so great that the sutures will probably cut out. In these circumstances the cicatricial tissue in the neighbourhood of the fistula may be divided first, by incising it in a direction parallel with the long axis of the vagina on either side, thus freeing the edges of the fistula, after which it is closed in the manner already described. The wounds in the vaginal mucous membrane made to relieve tension are then closed with sutures, so that the direction of the incision will eventually be at right angles to the long axis of the vagina. Dangers. — In removing the strip of mucous membrane from the anterior vaginal wall the mucous membrane of the bladder may be injured, in which case the rather free oozing may be difficult to arrest. Irrigation with hot water, and the application of sutures if this is unsuccessful, may be necessary. If any portion of the mucous membrane of the bladder becomes tucked into the wound when the sutures for closing the fistula are tied, healing will not be complete and a small fistulous track may remain. If the fistula is near the neck of the bladder, care will have to be exercised in preparing the raw surface round the opening, and also, when passing the sutures, that the ureters are not injured. Lastly, at times, after the operation is completed there is rather free oozing of blood into the bladder. If this takes place, the bladder must be thoroughly irrigated every hour or two with hot boric solution containing adrenalin (1 — 1,000) through a double - channelled catheter, so as to prevent the clot from distending the bladder and so interfering with the sutures. Dressing. — A gauze drain is inserted into the vagina and a self-retaining catheter left in the bladder. After-treatment. — For the general lines, see Chapter xxxii. On the day following the operation the gauze 148 GYNAECOLOGICAL SURGERY is removed, after which the vagina is douched twice daily with biniodide of mercury, 1 — 4,000. The sutures are removed in fourteen days, and the patient gets up at the end of three weeks. The bladder should be continuously catheterized for a week, after which it should be emptied every two hours for the next two or three days, and then at progressively increasing intervals. Most particular care must be taken Fig. 85. — Vesico-vaginal fistula : Demarcation of the flap. that the bladder is not infected during the necessary manipulations. At the end of three weeks the patient may be permitted to pass urine naturally. Urotropine in 5-grain doses should be given three times daily during the whole of the convalescence from the operation. 2. Operation by flap-splitting. — This is a more elabo- rate but better operation, especially in cases where the defect is large. Its exact technique will require to be varied according to the position and size of the fistula. The steps are commonly as follows : — VESICO-VAGINAL FISTULA 149 i. Resecting the fistulous opening. — The mucous mem- brane of the anterior vaginal wall half an inch from the neighbourhood of the opening into the bladder is seized with pressure-forceps, and a horseshoe-shaped incision with its base uppermost is then made with a scalpel round the opening and half an inch from it (Fig. 85). This piece of mucous membrane, delineated by the Fig. 86. — Dissection of the flap. incision made, is dissected as a flap with a scalpel, and the edges of the opening are well undermined so as to separate the vaginal wall from the bladder base, which is now exposed (Fig. 86). ii. Suturing the hole in the bladder. — A purse-string suture of No. 1 silk is passed through the muscular coat of the bladder base and round the hole in the bladder, about a quarter of an inch from it, so that when the suture is tied the hole is closed and the edge is inverted into the bladder (Fig. 87). If the hole is too large for a purse-string suture, i5o GYNECOLOGICAL SURGERY it must be closed by interrupted sutures, but in either case the silk should not penetrate the mucous membrane. iii. Preparing the flap of vaginal mucous membrane. — The flap of vaginal mucous membrane which has been reflected is now partly removed, the portion cut away including the opening of the fistula (Fig. 88). Fig. 87. — Closing the hole in the bladder. iv. Suturing the vaginal incision. — The remainder of the flap is pulled down and united to the cut edges of the original incision with interrupted silkworm-gut sutures, which may be fastened with shot and coil for ease in sub- sequent removal (Fig. 89). After-treatment. — See Chapter xxxn. The sutures in the vaginal mucosa should not be removed before the tenth day, or later. The treatment of the bladder is the same as that proper to the last-described operation. VESICOVAGINAL FISTULA 151 Fig. 88. — Preparing the vaginal flap. 89. — Suturing the vaginal flap. 152 GYNAECOLOGICAL SURGERY Alternative Operations In cases in which closure by vaginal operation has failed, the surgeon has a choice of two other methods. One consists in opening the abdomen, separating the bladder from the cervix and the vaginal wall, and suturing the apertures separately. The other consists in closing the upper part of the vagina by a plastic operation, thus making it an annexe of the bladder. Subtotal hysterec- tomy must also be performed to arrest menstruation. RECTO-VAGINAL FISTULA Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, vaginal retractor, scalpel, scissors, six pairs of long pressure-forceps, dissecting forceps, four half-circle needles No. 11, shot, coils, shot compressor, silkworm-gut, silk No. 1. Operation. — -The method of treating this condition depends on the position of the fistulous opening. If the fistula is near the anus, it is best to cut through the perineum into the rectum, so that the local condition becomes that of complete rupture of the perineum. The wound can then be closed by the method described at p. 117. If the opening is high up in the recto-vaginal septum, its edges should be freshened and the fistula then closed with silkworm-gut sutures. If the fistula occupies a position between these two extremes, probably the best result will be obtained by dissecting up the posterior vaginal wall beyond the opening and removing that portion which is perforated, then closing the hole in the rectum with separate sutures of silk, and afterwards suturing the cut edges of the vaginal mucous membrane in the manner described in the operation for posterior colporrhaphy (p. 143). Dressing and after-treatment.— See Chapter xxxn. The patient may get up in three weeks. CHAPTER VIII OPERATIONS ON THE CERVIX ATRESIA OF THE CERVIX This condition is usually the result of operations on the cervix, or of the application of strong caustics such as nitric acid. Haemato-trachelos is the result if any part of the cervix remains, the uterus forcing the menstrual blood into the. cervix and distending it. Where the whole cervix has been previously removed or destroyed, the body of the uterus becomes distended together with the Fallopian tubes, and the whole will require removal. For haemato-trachelos the following operation will be sufficient : — ■ Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, vol- sellae, uterine sound, Fenton's dilators, scalpel, four half- circle needles No. 11, silk No. 1. Operation. — -Auvard's speculum having been inserted into the vagina, the cervix is seized with two volsellae and drawn down, and an attempt may then be made to over- come the obstruction by passing a sound or the smallest Fenton's dilator. If this fails, the knife will have to be used to make a passage. After the fluid has been evacuated, the cervical canal should be dilated to No. 12, and its mucous membrane if possible sutured to the vaginal surface of the cervix, after which the canal is packed with gauze. Dangers. — In long-continued obstruction the Fallopian tubes become dilated and adherent to surrounding structures, and may rupture during the evacuation of the retained blood and mucus. In such a case it is better to perform salpingo-hysterectomy. 153 i54 GYNECOLOGICAL SURGERY Dressing and after-treatment. — The general lines of after-treatment are described in Chapter xxxn. A glass stem-pessary should be inserted into the cervical canal, and kept there until the patient gets up, that is in about fourteen days. The vagina should be carefully douched three times a day. DILATATION OF THE CERVIX Indications. — -This operation may be indicated in cases of dysmenorrhoea and sterility, for removing a myomatous, mucous or placental polypus of the uterus, for enucleating a submucous myoma, as a preliminary to curetting the uterus, and as a means of diagnosis in cases of suspected cancer or other intra-uterine disease. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, uterine sound, two volsellae, Fenton's dilators, one long pair of Spencer Wells forceps, one pair of ring forceps, scissors, two curved needles No. 9, silk No. 2. Operation. — Before the operation is begun, the patient is examined bimanually to ascertain the position and mobility of the uterus and the presence or absence of any disease of the Fallopian tubes or ovaries. The speculum is then inserted into the vaginal canal and a vaginal douche given, after which the anterior lip of the cervix is secured with the volsellse, the uterus is thus steadied, and the sound is passed to confirm the position of the uterus noticed on bimanual examination and to ascertain its length (Fig. 90). Instead of both volsellae being fixed to the anterior lip of the cervix, the posterior lip may be seized with the second volsella. It is better to use two volsella? than one, because a firmer hold of the cervix is secured, but in some cases where the cervical tissue is soft, as after a recent mis- carriage or labour, one volsella will probably be suffi- cient. In these cases, indeed, it is better if possible to use instead a ring forceps so as to avoid wounding the DILATATION OF CERVIX i55 cervix and making an additional channel for possible in- fection. The dilators are now taken from the dish in which they have been previously arranged in order, dipped in Fig. 90. — Dilatation of cervix Passing the sound. glycerinum acidi carbolici (B.P.), and pushed up the cer- vical canal ; the operator commencing, of course, with the smallest instrument, unless from the appearance of the os it is obvious that the dilatation can be begun with a size larger than this. i56 GYNECOLOGICAL SURGERY It is here to be remarked that the passage of a gradu- ated dilator up the uterine canal is a manoeuvre least of all requiring mere muscular force. The operator should constantly have before him a mental picture of the shape, length, and direction of the uterine canal as previously- determined by his bimanual examination and the passage of the sound. He is thus enabled to control and regulate the force he is using in accordance with the varying resist- ances the point of the dilator encounters at different parts of the uterine canal, and by correctly directing the instru- ment he minimizes these resistances as far as is possible. The dilator should be held in the right hand, with the second, third, and fourth fingers slightly extended, so that if it slips, because of a too sudden or a too forcible manipulation, the finger-tips will impinge on the left buttock of the patient before the dilator has travelled any distance, and perforation of the uterine wall will be avoided. While the dilator is being passed, the operator or his assistant should not only hold the volsellas firmly with his left hand, thus steadying the uterus, but should actually assist the dilatation by pulling the cervix over the dilator (Fig. 91). The amount of force to use in passing the dilator will depend on the condition of the cervix, and such know- ledge can only be gained by practical experience. But nothing approaching the full force the ODerator is capable of using is ever justifiable. There are various types of screw dilators on the market, but, in our opinion, they are much inferior to the graduated instruments, and of these Fenton's dilators are the most suitable we know of for the purpose under discussion. When the operator judges that the particular dilator he is using has been in position for a sufficient length of time, he directs his assistant to extract it, whilst he himself has the next largest dilator ready, so that it can be introduced at once, before the internal os has time to contract. Amount of dilatation. — The amount of dilatation will DILATATION OF CERVIX i57 vary with the object in view. When used for sterility, dysmenorrhoea, or as a preliminary to curettage of the uterus, a dilatation up to No. 12 Fenton will be found sufficient. For conditions, however, which require the introduction of a finger, such as the removal of retained Fig. 91. — Passing the dilators. products of conception, the digital exploration of the cavity of the uterus, or the removal of small submucous myomata, the dilatation must be carried to No. 18. !#. krl Conclusion of the operation. — If the object of the operation is the cure of dysmenorrhoea, no further steps are usually taken beyond the dilatation already described. Some operators, with a view to make more permanent i5» GYNECOLOGICAL SURGERY the enlargement of the canal, insert a glass stem-pessary into the uterus for a week or ten days. We do not do this, and we choose the day or two before the menstrual flow as the best time for the operation, not only because dilata- tion is easier then, but because the " period " supervenes before the effects of the operation on the cervix can have passed off, and thus the efficacy of the operation is imme- diately put to the test. Only in the event of excessive bleeding from the dilated cervix do we plug the cervical canal with sterilized gauze, which is withdrawn in twenty-four hours. Dressing. — The vagina having been douched, a light plug of sterile gauze is inserted for twenty-four hours. After-treatment. — See Chapter xxxn. The patient may get up in a week. Difficulties. — The difficulties of dilatation may be described under four heads : i. It may be impossible to introduce even the smallest dilator through the external os. 2. With a patent external os the passage of the internal os may be impossible. 3. With patency of the canal it may yet be impossible to increase the amount of dilatation beyond a certain point because of the rigidity of the cervical tissue. 4. As the dilatation is continued the length of the dilator passing into the canal may get less and less. 1. If the obstruction is at the external os, and the sound itself will not pass, the direction of the passage should be ascertained by a fine silver probe, and the vaginal cervix should then be split bilaterally with a pair of fine-pointed scissors, so as to open up the lower portion of the cervical canal. Any haemorrhage from the incision can easily be controlled by suturing the split cervix with silk sutures after the dilatation is accomplished. 2. Difficulty at the internal os is also often surmounted DILATATION OF CERVIX 159 after lateral incision of the cervix, but where the stenosis at this point is very extreme, the use of Fenton's dilators must be led up to by the passage of fine probes. 3. If the cervix is rigid, increasing difficulty may be experienced in passing the dilators, and great patience must be exercised, for while, if the dilators pass easily, there is no need to wait more than a few seconds before introducing the next size, in cases of marked rigidity it may be necessary to leave the dilator in situ for several minutes before introducing the next one. If on removing the dilator the internal os is found to grip the instrument very tightly, this is an indication that the dilator has not been left in long enough to relax the muscular spasm, and it should therefore be re-introduced. As a means of softening the cervix, especially when any difficulty in dilating is anticipated, or even as a routine treatment, a hot vaginal douche, followed by the introduction of glycerine tampons into the vagina the night preceding the operation, will often be found to accomplish the object in view. Some authorities still advocate the use of tents the night before the operation. In our opinion, the severe pain they cause and the troublesome manipulation necessary for their introduction entirely outweigh any advantage obtained by their use. The cervix of a virgin or of a sterile married woman is more rigid than that of one who has borne children. The cervix of a senile uterus is often very difficult to dilate. It may also be remembered that the cervix is particularly soft for two or three days preceding the period, and this is a good time to dilate it. 4. This difficulty is very common with beginners in this class of work, and has probably happened to everyone who has essayed the operation of dilatation of the cervix. What happens is this : the first few dilators are passed easily, which leads the operator to introduce the dilators more quickly than he should do. The lower part of the canal dilates more readily than the upper part, and the i6o GYNAECOLOGICAL SURGERY operator, unconscious of the fact, fails to notice that the distance to which each dilator is passed is successively diminishing. After a while this may become patent to him, and he will have to retrace his steps and commence again with a dilator quite low down in the series. If he fails to recognise his error, he will mistake the dilated cervical canal for the whole cavity of the uterus and per- form a very incomplete curettage or exploration. Dangers. — -The frequency with which dilatation of the cervix is performed and the ease with which it is in most cases carried out have caused the very definite risks associated with it to be overlooked, especially by those who have but small experience in this class of work. There are few operations which entail such a respon- sibility on the gynaecologist as a difficult dilatation of the cervix. The operation is usually carried out for a condition not in the least dangerous to life, and yet its careless per- formance may result in disasters of the first magnitude. Complications The following complications have often occurred : — i. Lacerated cervix. — Putting aside those conditions in which the cervix is very soft, as just after a mis- carriage, it is probable that nearly always when the cervix is dilated above Fenton No. 7 there is a certain amount of laceration of cervical tissue in the neighbourhood of the internal os. Those who state that it need not occur if proper care be taken, speak without sufficient evidence. At any rate, whenever the dilatation is sufficient to admit a finger, fibres of the cervix will be found lacerated, in many cases to a much greater extent than the operator would have suspected. Again, it is well known that in most, cases dilatation is more difficult up to No. 7 than afterwards. This is said to be due to the resistance of the internal os, which later on is stated to " give," although what really happens is that its fibres are ruptured. Lacera- tions such as these do not constitute an appreciable danger, DILATATION OF CERVIX 161 Sometimes, however, owing to rigidity of the cervix, or to excessive force being used, the tissue is badly lacerated. The laceration may run up to the vaginal vault from the external os, or it may commence in the neighbourhood of the internal os, so that, the points of succeeding dilators catching in it, it is gradually enlarged until the uterus is perforated into the broad ligament. A bad laceration may be suspected if, when there has been any difficulty in dilatation, the instrument suddenly and without warning slips in very easily. In many cases the cervical tissue can be felt, and sometimes heard, to tear. The risks of laceration are bleeding and sepsis. Bleeding, unless from some considerable artery, can be controlled by plugging the cervix with gauze. If this fails, the measures enumerated under the heading of rupture of the uterine artery must be applied. Sepsis can be prevented or minim- ized by strict asepsis during the operation and antisepsis afterwards. ii. Rupture of the uterine artery. — This rarely occurs. When it does, there is no difficulty in recognizing the fact, the bleeding being very brisk, and arterial in character. It is caused by laceration of the cervix. If the laceration runs up from the external os, it may be possible to see the bleeding spot, in which case it can be seized with forceps and secured by a mattress-suture. If the bleeding spot cannot be identified, owing to the laceration being limited to the upper part of the cervical canal, the vaginal cervix on the bleeding side should be split laterally, the full extent of the laceration exposed, and the bleeding vessel secured as before. Short of this, the bleeding vessel may sometimes be controlled by a pair of ring forceps clamped on the vaginal vault, one blade passed up the cervical canal, and the other applied outside it. If none of these methods is sufficient, the uterine artery of the damaged side will have to be exposed and tied in the base of the broad ligament by the method described under Vaginal Hysterectomy. 162 GYNAECOLOGICAL SURGERY iii. Perforation of the uterus. — Perforation of the uterine wall is generally due either to carelessness or to ignorance ; in rare instances, however, it cannot be avoided. In dilatation of the cervix, not only should no undue force be used, but the position of the uterus should be very carefully determined, since, with the uterus retroflexed or anteflexed, perforation would be likely to occur if the operator was unaware of the malposition. The dilator should be held in the manner indicated in Fig. 91, and not in the closed hand, for if held properly it is more difficult to employ excessive force, and the extended ringers are ready to act as a break. Excessive force should be avoided, because the internal os may suddenly lacerate and allow the dilator to rush on, and so perforate the uterus. As regards liability to perforate through ignorance, the ope- rator should remember that in cases of cancer, of retained gestational products, of senility and of superinvolution, the uterine wall is apt to be so soft that very slight pressure on it with a dilator may cause perforation. Lastly, and rarely, the uterine wall may be very soft apart from any condition which would make one suspicious, and it is in these cases that perforation cannot be entirely guarded against. Perforation into the peritoneal cavity may be suspected if a dilator suddenly slips in much farther than the one that preceded it. There is no doubt that in some cases the uterine body stretches during dilatation, and therefore a dilator may pass farther than the one preceding it ; this stretching, however, is only slight, so that if a dilator passes markedly farther than the sound which indi- cated the length of the uterine canal, perforation may be diagnosed. To confirm this, the dilator should be immediately withdrawn and the cavity carefully examined with the uterine sound, when, if the accident has occurred, the perforation will soon be detected. Results of perforation. — Fortunately, owing to the aseptic surroundings in which dilatation is carried out DILATATION OF CERVIX 163 at the present day, perforation of the uterus, as a rule, causes no bad symptoms. If, however, the cervix is being dilated for some septic condition, such as certain cases of retained gestational products, sloughing myomata, or cancer, the patient may die from peritonitis. Rarely, severe hsemorrhage into the peritoneal cavity may be caused. Perhaps the most serious result possible is the escape of irritant douche solution into the peritoneal cavity through a perforation in the uterus of which the surgeon is unaware. There are cases on record in which the uterus has been perforated during dilatation for the removal of retained secundines, and a piece of bowel has prolapsed through the rent ; in one, the operator pulled down and cut off 6 in. of bowel before he became aware of his mistake. In this case the abdomen was opened and the divided ends of the bowel were successfully sutured. If the uterus is perforated, the operation should be at once abandoned, and the uterus lightly plugged with sterile gauze. No douche should on any account be given. A careful watch must then be kept for signs of internal hsemorrhage or of peritonitis. Hemorrhage after perforation. — In the case of haemorrhage it is noticed, on the patient recovering from the anaesthetic, that the pulse is much faster than is usual after a simple dilatation, and the patient complains of severe abdominal pain, a symptom which is never present in an ordinary case. She is pallid, cold, and restless, and examination of the abdomen, even at this early period, discloses much suprapubic rigidity. Symptoms such as these indicate immediate exploration of the pelvis through an abdominal incision, and the perforation, having been located, must, if possible, be sutured. In cases, however, where the laceration is very extensive and the haemorrhage uncon- trollable by sutures, the uterus should be removed, pre- ferably by the subtotal method. Finally, if the cavity of the perforated organ is known to be septic, the treat- ment offering the best chance to the patient is a total 164 GYNECOLOGICAL SURGERY hysterectomy, the vagina being left wide open into the pelvis to secure free drainage. Peritonitis ajter perforation. — After perforation, peri- tonitis arises in three ways : (i) Direct infection of the pelvis by organisms from the interior of the uterus. (2) The presence of blood in the peritoneal cavity, not sufficient, perhaps, to give rise to the classical signs of internal haemorrhage. (3) Escape of the douching solution through the perforation. (1) In the case of direct conveyance of sepsis from the uterus to the peritoneum, the symptoms do not come on for at least twelve hours after the operation, and then present the ordinary characters of peritonitis, local or general, as the case may be. (2) With peritonitis the result of hsemorrhage, signs of peritoneal irritation are present more or less from the time the patient recovers from the anaesthetic, and steadily increase for the next twenty-four hours. The physical signs are those of a pelvic haematocele. (3) The introduction of irritant douche solutions into the pelvis gives rise to immediate and very violent symp- toms. With the introduction of the more commonly used mercurial solution the patient is in great pain, the pulse is very fast, the lower abdomen soon becomes distended and rigid, and in about four hours a violent diarrhoea begins. The treatment of peritonitis following perforation of the uterus will depend upon the knowledge the operator has of the cause and of the degree of the symptoms ex- hibited. Where the introduction of irritant douche solutions can be excluded and the symptoms are not fulminant, it is best to wait, for in many cases the peritoneal reaction remains local, and after some days the pain and fever subside. If, however, it is known or strongly suspected that a poisonous solution has escaped into the pelvis, or DILATATION OF CERVIX 165 if early and rapidly augmenting symptoms should present themselves, the abdomen should be opened, the rent sutured, the pelvis mopped out and drained both through the vagina and through the abdominal wound. In these cases it is bad practice to remove the uterus, since the in- fection of the peritoneum has already occurred, and the operation, besides increasing the shock, opens up large areas of healthy tissue to infection. Prolapsed intestine. — If the bowel has prolapsed through a uterine rent, the proper treatment is to open the abdo- men, carefully pull out the bowel, clean it if healthy, and resect it if damaged. The rent in the uterus is then to be sewn up, or the organ removed, as seems most advisable at the time. Perforation into the broad ligament. — Perforation into the broad ligament is caused in a somewhat different manner. Laceration of the cervix first takes place in the neighbour- hood of the internal os without the operator being aware of the fact. The points of the succeeding dilators are then thrust into this laceration, and the uterine wall is gradually torn until the dilator slips through into the broad ligament. This occasions more bleeding than is usual, which leads to a digital examination and the discovery of the accident. Its results may be nil if the operation has been carried out under aseptic conditions and no large artery has been torn across. On the other hand, a hematoma of the broad ligament may rapidly form, or at a later date the symptoms of pelvic cellulitis may manifest themselves. Where the hsematoma is small, the only symptom is pain referred to that side, and within a short time a swelling can be felt in the broad ligament. In exceptional cases, however, the effusion of blood is very large, and, lifting the peritoneum off the side wall of the pelvis, mounts into the iliac fossa, or even into the loin. Haematomata of this magnitude give rise to the ordinary signs of internal haemor- rhage, and a very definite swelling, the outer limits of which are dull on percussion, can usually be felt. We have noted, 166 GYNAECOLOGICAL SURGERY however, that in extremely rapid effusions of blood under the posterior parietal peritoneum great intestinal disten- sion occurs, due probably to interference with the splanchnic nerves. Such distension may mask the tumour formed by the haematoma. A similar condition of affairs is seen in acute haemorrhagic pancreatitis. iy. Rupture of a pyosalpinx. — If on bimanual examina- tion it is found that the uterus is fixed, and there is some thickening in the fornices, it behoves the operator, if he considers dilatation a necessity, to use every care. If he has diagnosed a pyo-salpinx, he would not, of course, essay dilatation of the cervix before that condition was cured, for fixation of the uterus is commonly observed with salpingitis, and forcibly moving a fixed uterus in such a manner is liable to set free any collection of pus in its immediate neighbourhood. The rupture of a pyo-salpinx is a most serious disaster, and may set up in a few hours a peritonitis which may prove fatal. Even supposing that the diseased tubes do not contain pus, the disturbance of the parts caused by the dilatation may accentuate any symptoms of sal- pingitis already present, or may light up anew one that is quiescent. The above remarks also appertain to ovarian abscess. y. Salpingitis — As we have already said, salpingitis is sometimes present in a minor degree before the operation, and may be accentuated by the manipulations incident to its performance. More commonly, however, it is a direct result of the operation, and may be brought about in three ways : (i) If the cavity of the uterus be already infected, there is a risk of the uterine secretion being forced into the tube by the piston-like action of the dilator. (2) The cavity of the uterus may be infected by the instruments used, and this infection may subsequently spread to the tube. (3) Subsequently to the operation, owing to some failure DILATATION OF CERVIX 167 of asepsis in the after-treatment, organisms may ascend the genital canal and infect the tube. The symptoms are those of pelvic peritonitis. The time of onset of the disease varies ; most of the cases occur within a fortnight of the operation, many of them within a few days. It is, however, to be remarked that endometritis set up by dilatation may be responsible for an attack of salpingitis many months later. vi. Peritonitis. — Of the several causes of peritonitis after dilatation, perforation of the uterus, extension from salpingitis, and rupture of a tubal or ovarian abscess have already been dealt with. But the condition may also result from a direct extension of infection through the uterine lymphatics from a wound in its lining mem- brane. Peritonitis following dilatation of the cervix is local to the pelvis, as a rule, but occasionally, when the organism is of a very virulent nature or the infection overwhelming in character, e.g. a ruptured pyo-salpinx, it becomes rapidly generalized. The earlier the symptoms appear the graver is the outlook. In the worst cases no pelvic tumour can be felt. In those of lesser severity, a mass lying behind or around the uterus can usually be felt within a few days. This swelling is a conglomerate consisting of an inflamed tube, a mass of blood-clot or collection of pus, singly or in association as the case may be, and surrounded by ad- herent intestines and thickened omentum. Treatment of peritonitis. — The onset of peritonitis after dilatation is a serious disaster, and the proper course for the surgeon to pursue will be a matter of the greatest concern to him. The difficulty that presents itself is to decide whether the peritoneal cavity should be explored or not. Each case must be treated on its merits, and no general rule can be laid down. Where the physical signs are entirely local, it is better to wait in the hope that the inflammation may subside. In this case, hot fomentations with glycerine and belladonna or laudanum 168 GYNECOLOGICAL SURGERY may be applied to the abdomen and morphia given internally for the relief of the pain, whilst vaginal injections of some antiseptic solution at no° F. often afford relief and favour absorption. Fever should be treated with quinine. If the symptoms increase, and there are unequivocal signs of pus-formation, the abdomen should be opened, the condition dealt with, and the pelvis drained. All cases presenting the signs of general peritonitis should be at once treated in the manner described at p. 601. yii. Pelvic cellulitis. — This is due to direct spread of infection through a laceration of the cervix or body of the uterus, usually the former. The symptoms may begin any time within the first three weeks, most commonly occurring, as after labour, from the tenth to the fourteenth day. With a rise of pulse and temperature a tender swelling in the affected broad ligament is discovered. As a rule, the disease remains strictly local, and tends after about a week to get well. More rarely the swelling may extend up into the iliac fossa, or a definite abscess may form. Occasionally these cases are further complicated by femoral thrombosis and severe signs of general sepsis. Treatment of pelvic cellulitis. — Unless there is a definite collection of pus, the patient may be treated in a way similar to that indicated for slight local peritonitis. If pus forms, it should be evacuated without delay by an incision through the vaginal fornix ; a drainage-tube should afterwards be inserted. viii. Injury to the capsule of a myoma. — If the uterus which is being dilated contains a submucous myoma, the point of a dilator may penetrate its capsule. In such an event no evil results may follow, but occasionally the tumour is gradually extruded through the rent with much haemorrhage and, usually, more or less septic symptoms. In other cases, acute septic changes may be set up in the tumour without extrusion. The dilatation of a myomatous uterus is, therefore, a proceeding associated with definite danger. SUTURE OF LACERATED CERVIX 169 TRACHELORRHAPHY Indications. — This operation is performed for those cases of lacerated cervix in which the exposed surfaces of the laceration are covered as the result of chronic cervi- citis with a redundant gland-bearing epithelium giving rise to a profuse leucorrhceal discharge. It has, however, the disadvantage that it leaves a strip of diseased mucosa in the restored cervical canal, and thus sometimes fails in its object of stopping discharge. It is not a good operation when much hypertrophy and elongation of the cervix exists, since it does not remedy this condition. In such cases tracheloplasty or amputation of the vaginal cervix is preferable. In those cases of repeated abortion in which no cause can be found other than that of the lacerated cervix, the operation of trachelorrhaphy has proved successful. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, two volsellae, dissecting forceps, four pairs of long pres- sure-forceps, scalpel, uterine sound, four curved needles No. 7, silk No. 2, silkworm-gut, shot and coil, shot compressors. Operation. — Auvard's speculum is inserted into the vaginal canal, and then, with volsellse on the anterior and posterior lips, the cervix is brought to the vulval orifice. The volsellas are now separated so that the lacera- tion is opened up as much as possible (Fig. 92), the anterior volsella being given to an assistant to hold. An incision is made across the cervix in the receding angle between the two lips, thus deliberately deepening the laceration (Fig. 93). The surgeon proceeds to mark out with a scalpel on both lips of the cervix the limits of the pieces of mucous membrane he proposes to remove (Fig. 94). Four areas of mucous membrane having thus been delineated, this tissue is dissected off (Fig. 95). In dissecting off the mucous membrane, it must be remembered that a narrow piece 170 GYNAECOLOGICAL SURGERY of this structure has to be left on each side of the middle line to form a lining for the cervical canal when it is remade ; otherwise as much mucous membrane must be dissected off as is possible, special care being taken completely to remove all the mucous membrane together with the sub- jacent cicatricial tissue at the receding angle of the lacera- Fig. 92.— Trachelor- rhaphy : Exposure of the laceration. tion. During the dissection of these flaps the bleeding may be rather free, but will, as a rule, stop when the raw surfaces are approximated. Should, however, the haemor- rhage obstruct the field of operation, it can usually be kept in check by an assistant directing a stream of hot water on to the cervix. The lacerated surfaces having been sufficiently denuded, TRACHELORRHAPHY 171 silk sutures — as a rule, three on each side will be sufficient — are passed by means of a curved needle held in a pair of pressure-forceps. The needle is inserted in the anterior lip at the outer edge of the laceration close up to its receding angle. It is then carried through the cervical tissue deeply to the raw surface, and brought out at the edge of the Fig. 93. — Deepening the laceration. mucous membrane which has been left as a lining for the cervical canal. It is now re-introduced into the posterior lip at the edge of mucous membrane, opposite its point of exit in the anterior lip, carried through the cervical tissue deeply to the raw surface, and brought out at the outer edge of the laceration (Fig. 96). The remaining sutures are passed on each side in a similar manner. The raw surfaces can thus be accurately approximated without any suture 172 GYNAECOLOGICAL SURGERY intervening between them which, acting as a foreign body, might prevent their union (Fig. 97). The sutures having been tied, a sound is passed into the uterus to ensure that the cervical canal is patent, and the vagina is well douched with biniodide of mercury, 1 — 4,000. Fig. 94. — Demarcation of the areas of denudation. If the surgeon prefers to remove the sutures, silkworm- gut must be used and fastened with shot and coil. Failures. — The failures of this operation are due, as a rule, to an insufficient amount of mucous membrane being removed, to the receding angle of the laceration not being properly denuded, and to the too early removal of the sutures. TRACHELORRHAPHY m Dressing and after-treatment. — See Chapter xxxn. If silkworm-gut sutures have been used, they are removed on the tenth day, the shot being cut off with scissors, the coil removed, and the suture pulled out. If silk is used, the sutures can be left in. The patient gets up on the twelfth or fourteenth day. Fig. 95. — Denudation of the demarcated areas. TRACHELOPLASTY Indications. — In this operation the entire inner surfaces of the lips of the laceration are removed. It is indicated in the same circumstances as trachelorrhaphy, to which, in our opinion, it is preferable. Preparation of the patient. — See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, i 7 4 GYNECOLOGICAL SURGERY Fenton's dilators I to 12, two volsellse, six pairs of long pressure-forceps, dissecting forceps, curette, sharp scoop, uterine sound, bladder-sound, scalpel, half-circle needles No. 9, silk Nos. 2 and 4. Operation. — -The cervical canal should be dilated to 12 Fenton and thoroughly scraped, and the body, if Fig. 96. — Trachelor- rhaphy : Introduc- tion of the sutures. need be, curetted. This proceeding, besides removing the diseased mucosa higher up, renders the subsequent intro- duction of the sutures much easier, from the dilated state of the canal. This done, the operator steadies the lips and excises the inner surface of each, the two lines of incision meeting on the lateral aspect of the cervix just above the receding angle of the laceration. A wedge- shaped piece of tissue is thus removed (Fig. 98). The TRACHELOPLASTY i75 Fig. 98.— Tracheo- plasty : Removal of the diseased areas. 176 GYNAECOLOGICAL SURGERY anterior and posterior lips, now attenuated into a couple of flaps, are sutured at their middle portions to the anterior and posterior halves of the edge of the lumen of the cervical canal, thus joining the mucous membrane of the vaginal surface of the lips to that of the cervical canal (Fig. 99). Fig. 99. — Suturing the flaps to the ridge of the cervical canal. Right and left of this the two flaps are directly united together (Fig. 100). The sutures being tied and cut short, the vagina is douched with a 1 — 4,000 solution of mercury, and packed with sterile gauze for twenty-four hours. AMPUTATION OF VAGINAL CERVIX 177 Dressing and after-treatment. — See Chapter xxxn. The patient may get up in fourteen days. AMPUTATION OF THE VAGINAL CERVIX Indications — This operation is performed for hyper- trophic elongation of the cervix, congenital elongation of the cervix, and severe cases of laceration of the cervix with marked hypertrophy of the lacerated portion. It is Fig. 100.— Completing the suture of the flaps. also indicated in cases of leucorrhcea when associated with a severe erosion which a thorough scraping with a sharp spoon has failed to cure. It is further indicated in those cases of old-standing cervical erosion which, by reason of their tendency to bleed, their irregular red surface and indurated feel, suggest that they may be in many cases the precursors of cancer. Preparation of the patient. — -See pp. 78-82. Instruments. — Clover's crutch, Auvard's speculum, Fenton's dilators 1 to 12, volsella, vaginal retractors, six M 178 GYNECOLOGICAL SURGERY pairs of long pressure-forceps, dissecting forceps, curette, uterine sound, bladder-sound, scalpel, curved needles No. 7, silk Nos. 1 and 2. Operation. — Before commencing this operation it will be found a useful plan to dilate the cervical canal up to Fig. 101. — Amputation of the vaginal cervix : Incision of the mucous membrane. Fenton 12. This proceeding greatly facilitates the intro- duction of the sutures from the cervical canal and also renders the covering-in of the raw surface easier. If the operation is being performed for inflammatory disease, the uterus should be curetted. i. Identifying the limits of the bladder. — The bladder- sound is passed into the bladder to ascertain its extent. AMPUTATION OF VAGINAL CERVIX 179 ii. Removing the cervix. — Auvard's speculum having been inserted, the cervix is grasped by the volsella, and a circular incision is made through the mucous membrane at whatever level is determined on (Fig. 101). The upper edge of the incised mucous membrane is then separated for Fig. 102.— Reflection of the cuff. some little distance with the handle of the scalpel, forming as it were a cuff all round (Fig. 102), and the cervix is amputated at the junction of the reflected mucous membrane (Fig. 103). Purse-string sutures of silk No. 1 are now inserted, so that the mucous membrane of the vaginal surface is carefully joined to that of the cervical canal. The needle, threaded with silk, is passed from the i8o GYNECOLOGICAL SURGERY cervical canal outwards through the uterine wall, and emerges on the surface of the raw stump about a quarter of an inch from the margin of the canal. It is then carried through the cut edge of the vaginal mucous membrane opposite its point of entrance, and is continued along one- Fig. 103.— The amputation. third of its circumference. It is now re-introduced through the raw surface of the stump into the cervical canal close to the point from which it originally started (Fig. 104). Three of these sutures will usually suffice to approximate neatly the vaginal and cervical mucous membrane (Fig. 105). If the bleeding from the stump is more than can be controlled by the pressure of these AMPUTATION OF CERVIX 181 sutures, it may be arrested by one or more mattress- sutures passed through the tissue of the stump. Dressing and after-treatment. — See Chapter xxxn. The patient gets up on the fourteenth day. Fig. 104. — Insertion of the sutures. SUPRAVAGINAL AMPUTATION OF THE CERVIX Indications. — In very severe cases of laceration, in which the tear has run up into the vaginal vault, if it is thought advisable to remove the cervix, supravaginal amputation must be performed, and this operation is also indicated in cases of hypertrophic elongation of the supravaginal portion of the cervix. It is not, however, a good operation, owing to the tendency for stenosis to occur as a result. Its 182 GYNECOLOGICAL SURGERY performance for carcinoma of the cervix has been almost abandoned. Operation. — The cervix having been seized with a volsella, the mucous membrane is incised all round at the junction of the cervix and vagina. This mucous mem- x Fig 105. — Securing the sutures. brane is then reflected in front, together with the bladder, and at the back and sides, with the handle of the scalpel or the ringer, as far as the level of the uterine arteries, which will be felt pulsating one on each side. These are secured with a No. 4 silk ligature by means of Worrall's needle (Fig. 18a), close to the cervix, so as to avoid dam- aging the ureter, The cervix is then amputated below CERVICOVESICAL FISTULA 183 the level of these ligatures, and the cut edge of the vagina and lining of the cervical canal are approximated by sutures of No. 1 silk as described at p. 179. Dangers. — When the cervix has to be removed high up, the bladder or rectum may be wounded. The recto-vaginal fossa may be opened, in which case it should be closed by a silk suture. The ureters may be included in the ligatures that secure the uterine artery. For results and treatment of this accident, see pp. 251 and 656. The ligatures on the uterine artery may slip, causing secondary haemorrhage. If so, the patient must be again anaesthetized and the bleeding-point secured. Peritonitis or cellulitis may result from septic infection. These conditions must be treated on the ordinary lines. Dressing and after-treatment. — See Chapter xxxn. CERVICO-VESICAL FISTULA Preparation of the patient. — See pp. 78-82. It is absolutely necessary to cure cystitis, if it exists, before attempting the operation. Instruments. — Clover's crutch, Auvard's speculum, dis- secting forceps, six pairs of long pressure-forceps, volsella, vaginal retractors, scalpel, scissors, two curved needles, two No. 7 and two half-circle No. 11, silk Nos. 1 and 2. There are two varieties of this condition : (1) where the fistula lies at the bottom of a deep laceration of the vaginal cervix ; (2) where the communication is through the wall of the cervix some distance above the vaginal vault. Operation. — In the first variety, the closure of the fistula should be combined with a trachelorrhaphy. The edges of the vaginal mucous membrane which abut on the laceration must be undermined and retracted sufficiently to get a clear view of the opening in the bladder-wall. The bladder-wall is separated for half an inch around the opening, and the aperture is closed with a purse-string suture by preference. The edges of the vaginal mucous 184 GYNAECOLOGICAL SURGERY membrane and the cervical laceration are pared, and a series of sutures is inserted, beginning at the end of the laceration where it encroaches on the vaginal vault, and continued downwards as far as the external os, thus closing the vaginal mucous membrane over the aperture in the bladder and restoring the integrity of the vaginal cervix. In the second variety, the bladder must be turned entirely off the supravaginal cervix, following the technique of the first step of the vaginal hysterectomy (p. 227), and the hole in it must be separately closed by a purse-string silk suture. The vaginal cervix is now pulled well down, and the perforation on its anterior wall freshened and closed with silk sutures. Finally, the cut mucous membrane of the anterior vaginal fornix is united by silk sutures. Dressing and after-treatment. — See Chapter xxxn. If No. 1 silk sutures be used, there is no necessity to remove them. The patient may get up in ten days. UTERO-VESICAL FISTULA This complication is of very rare occurrence. It must be dealt with by an abdominal operation. The bladder should be separated from the uterus, and the openings in both organs carefully closed with fine silk sutures. An alternative method would be to remove the uterus and then suture the vesical opening. CHAPTER IX OPERATIONS ON THE CAVITY OF THE UTERUS CURETTING General remarks and indications. — We are of opinion that inflammatory disease of the cervix, and cervix only, is extremely common in parous women, and not uncommon in virgins as well, whilst a corresponding condition of the corporeal endometrium is comparatively rare. The only symptom of chronic cervicitis is leucorrhcea, and on ex- amination of the cervix an erosion, which is its outward visible sign, will always be found. Corporeal endometritis does not cause a leucorrhceal discharge, although nearly always associated with it because of the coexistent cervicitis. The secretion of the corporeal glands is a watery, not a mucous fluid. This is extremely well seen where a great overgrowth of the corporeal endometrium coexists with a healthy cervix. Such a condition occurs in some cases of uterine myomata, a leading feature then being a copious watery discharge from the uterus. Where this watery discharge is not present there is certainly no hypertrophy of the endo- metrium, inflammatory or otherwise. The other symptoms associated with corporeal endo- metritis are excessive menstrual haemorrhage or irregular losses between the periods, but as these often depend on diseased conditions of the deeper parts of the uterine wall, their occurrence is not pathognomonic of changes in the endometrium. The corporeal endometrium is the softest " mucous membrane " in the body ; it is succulent and thick, and strips i85 186 GYNECOLOGICAL SURGERY off readily with the curette. The cervical endometrium, on the other hand, can scarcely be described as a " mem- brane " at all. It consists of a surface layer of short columnar cells standing almost directly on the subjacent muscle in which, most deeply embedded, are the racemose mucus-producing cervical glands. The healthy vagina con- tains many organisms, and their passage up the cervical canal is unimpeded. They do not, however, find their way beyond the internal os. In pathological infections of the vagina (e.g. by the gonococcus) the same holds true, as a rule. Gonococcic endocervicitis is constantly present, while gonococcal endometritis is fortunately comparatively rare. A want of appreciation of these facts of anatomy and pathology is the reason of the frequency with which the curette is used in inappropriate conditions. One con- stantly sees the corporeal endometrium stripped off by the blunt curette where the cervix alone is at fault, while the diseased cervical glands, the sole origin of the leucorrhceal discharge, are left uninterfered with because nothing less than a sharp scoop strongly applied suffices to eradicate them from the dense matrix by which they are surrounded. In many of the cases proper for curetting, it is the cervical endometrium alone which should be erased. To sum up, leucorrhcea per se is an indication for curet- tage of the cervix only. Abnormal haemorrhage, pain, and uterine enlargement, though they may indicate corporeal endometritis, are much more likely to be due to some altered condition of the deeper parts of the uterine wall which a superficial denudation of the mucosa will not cure. Curetting means scraping, and the cavity of the uterus may be scraped for endometritis, mucous polypus, retained products of conception, membranous dysmenorrhea, and to obtain a piece of the lining membrane for microscopical examination. Preparation of the patient. — See pp. 78-82. Instruments. — Those for dilatation (p. 154), and in addition a blunt flushing curette and a sharp scoop. CURETTING 187 Operation. — The cervix is dilated with all the precau- tions mentioned under the description of that operation (p. 154). The extent of dilatation depends on the condition to be dealt with. If digital examination of the uterine cavity is not intended, a dilatation up to No. 12 Fenton will suffice. Before pulling out the last dilator the operator pro- poses to employ, the douche solution that is being used is allowed to flow through the curette into the vagina and round the cervix, so that these parts may be rendered as aseptic as possible before the curette is introduced. The dilator is then withdrawn and the curette is carefully inserted through the cervical canal into the uterine cavity, the flow of the douche solution being temporarily stopped. Opportunity is now taken carefully to sound the cavity in order to ascertain that no perforation exists, for in this event the introduction of an injurious chemical solution into the peritoneal cavity will convert what is usually only an untoward accident into a serious disaster. A solution of biniodide of mercury, 1 — 4,000, at a temperature of 115 F., will be found the best douche to use. The uterus being steadied by the volsella, the curette, held in the operator's right hand, is passed up to the fundus of the uterus (Fig. 106), and drawn firmly, evenly, and systemati- cally from above downwards over the posterior uterine wall, then over the anterior wall, and then laterally, special attention being paid to the two cornua, as diseased tissue in this situation is likely to be missed. Very little force is to be used ; and the curettage is continued until a grating, heard or felt, indicates that the musculature is reached. The flushing curette is now laid aside, and the operator, taking up the sharp scoop, vigorously scrapes the wall of the cervical canal and the erosion that surrounds the external os (Fig. 107). Where no evidence of corporeal disease is present, the mucosa of the body should not be interfered with, and the cervix should alone be treated. i88 GYNECOLOGICAL SURGERY Some surgeons conclude the operation by applying pure carbolic acid, or iodized phenol (carbolic acid 3 parts, iodine 1 part), to the denuded surface by means of a wool Fig. 106. — Curetting: Applying the curette. swab on a Playfair's probe or narrow-bladed forceps. It is good practice in gonorrhceal and frankly septic cases, but is not necessary in all cases. CURETTING 189 Dangers. — The dangers of curetting are (i.) sepsis, (ii.) haemorrhage, and (iii.) perforation of the uterus. i. Sepsis. — What has been said with regard to sepsis (p. 167) applies here also. Fig. 107. — Applying the sharp spoon. ii. Haemorrhage. — Sometimes after curetting the bleed- ing is very severe, and, if not dealt with, becomes dangerous. Always supposing it is not due to grave laceration of the uterus, it can best be arrested by packing the uterus with sterile gauze, or with gauze impregnated with iodoform or igo GYNECOLOGICAL SURGERY mercury, as the operator chooses (Fig. 108). If no gauze is available, the effect of a very hot douche, 120 F., or the application of iodized phenol or carbolic acid, may be tried. It sometimes happens that severe haemorrhage will take place some days after a curetting, and if so it must be Fig. 108. — Packing the uterus with gauze. treated on similar lines. We remember a case in which on two occasions, the eleventh and fourteenth day after a simple curetting, the patient, who had convalesced with a perfectly normal temperature, had such severe and sudden haemorrhage that on both occasions she nearly died. No cause was ever discovered for this complica- CURETTING 191 tion, but it was probably due to the fact that the uterine artery had been wounded, the thrombus at the site of the injury becoming detached later. iii. Perforation of the uterus. — The curette, like the dilator, may be pushed through the uterine wall, and the uterine wall may be scraped through by a too vigorous use of this instrument. The operator must also remember that the point of the curette may catch in a laceration near the internal os, and that such a laceration may be curetted and so made worse. Common prudence, and the knowledge that a laceration may be present, should prevent this from happening, and if a laceration has not been felt by the finger, its presence may be suspected when, instead of passing in smoothly, the point of the curette catches against something at the internal os and there is some difficulty in getting it through that orifice. Great care should be taken when curetting a uterus in which carcinoma of the body is suspected, especially in senile cases, for in such the wall may be very thin and soft. The results and treatment of perforation are dealt with at p. 162. Dressing and after-treatment. — See Chapter xxxn. If the uterus has been plugged the gauze must be removed in twenty-four hours. The patient may get up in ten to fourteen days, but in any event not until all haemorrhagic discharge has ceased. RETAINED PRODUCTS OF CONCEPTION Preparation of the patient. — See pp. 78-82. Instruments. — As for curetting the uterus (p. 154). Operation. — The steps of the operation are the follow- ing :— i. Dilatation of the cervix. — The cervical canal is dilated, in the manner already described (p. 154), until the index finger can be introduced into the uterine cavity — i.e. to No. 18 Fenton. Before the last dilator in use is removed, 192 GYNAECOLOGICAL SURGERY the vagina and cervix are well douched with biniodide of mercury, 1 — 4,000. ii. Digital examination. — Auvard's speculum is removed, and the operator having re-dipped his right hand into Fig. 109. — Removal of retained conceptional products : Digital exploration of the uterus. biniodide of mercury, 1 — 1,000, the dilator and volsella are removed by the assistant, and the operator, making counter- pressure with the left hand over the pubes, passes l\is first finger into the cavity of the uterus (Fig. 109). If the RETAINED GONGEPTIONAL PRODUCTS 193 fundus cannot be reached in this way, either because the uterus is retroverted or the patient very fat, the volsella may be reapplied to the cervix, and the uterus can then be pulled down over the finger and steadied by the assistant during the exploration. Fig. 110. — Evacuation of the uterus with the ring forceps. iii. Removal of retained products with finger or with ring forceps. — Any portions of placenta or membranes that may be felt are now detached with the finger, which is then withdrawn, and, the ring forceps being introduced, the loose pieces are removed (Fig. no). The finger is then N 194 GYNECOLOGICAL SURGERY introduced again, and if undetached portions are still felt, the procedure is repeated. iv. Curetting. — Authorities differ as to whether the curette should be used after the retained products have been removed by the ring forceps or the finger. It may be said to depend upon whether the miscarriage or labour has quite recently taken place and the operation is being done for sepsis, or whether it has occurred some time previously and the operation is being performed for haemorrhage. If for recent cases, nearly all authorities agree that there is a serious danger in curetting, because innumerable lymph-channels are thus opened up as sites for infection. In favour of this contention is the fact that serious local lesions such as peritonitis or cellulitis often appear after curetting in such cases ; and the records of many deaths from general infection could now be collected. On the other hand, in old-standing cases of retained products producing haemorrhage, and associated with little or no sepsis, the operator will obtain better results by using the curette. For the method of curetting, see p. 187. v. Packing the uterus. — The last steps in the opera- tion, whether the curette is used or is not used, are to douche the interior of the uterus with biniodide of mer- cury, 1 — -4,000, and to pack the uterine cavity with gauze (Fig. 108) for twenty-four hours, as free oozing is likely to occur. If sepsis is present, iodoform gauze is preferable. Dangers and difficulties. — The dangers and difficulties are those discussed under the heads of Dilatation and Curetting. Dressing and after-treatment. — The general after- treatment is discussed in Chapter xxxu. If the uterus has been plugged, the gauze is removed in twenty-four hours ; and if the haemorrhagic discharge has ceased and the temperature is normal, the patient gets up in from ten to fourteen days. MUCOUS POLYPI i95 REMOVAL OF POLYPI, MUCOUS, MYOMATOUS, OR PLACENTAL Preparation of the patient. — See pp. 78-82. Instruments. — The instruments required will depend upon which variety of polypus is being treated. In any case a douche apparatus, a Clover's crutch, an Auvard's speculum, scissors, two long pressure-forceps, a volsella, and a sharp spoon will be required. For a polypus of the body, Fenton's dilators, a curette, an additional volsella, a uterine sound, a pair of ring forceps, two curved needles No. 7, and silk No. 2. For a myomatous polypus a scalpel may be necessary. Mucous Polypus of the Cervix Operation. — The vagina is douched with biniodide of mercury, 1 — -4,000, after which Auvard's speculum is inserted. The cervix is then steadied with volsellae, and the polypus seized with ring forceps and slowly twisted off (Fig. 111), after which in all cases the cervical canal should be scraped with a sharp spoon, since the polypus is only a localized expression of a general disease of the mucosa there. As a rule, when the polypus is twisted off there is little or no bleeding, but if there is more oozing from the stump than the operator cares to leave, the stump may be touched with the actual cautery, or the cervical canal may be plugged with gauze. Mucous Polypus of the Body Operation. — If when operating for mucous polypus of the cervix the uterus is found to be enlarged, it is always well to dilate the cervical canal and make a digital examina- tion to ascertain whether there are any polypi in the uterine body. There need not, however, be polypi in the body with polypi in the cervix ; in the latter case it will be the symptoms that have suggested the presence of a polypus, and the cervical canal must be dilated in order that a 196 GYNECOLOGICAL SURGERY digital examination may be made to confirm the diagnosis. For dilatation of the cervix, see p. 154. Fig. 111. — Evulsion of a mucous polypus. Removal of the polypus. — The polypus is removed by seizing it with a ring forceps and twisting it off. Although the polypus may be felt with the finger, the operator REMOVAL OF POLYPI 197 may not be successful in catching it with the forceps, in which case the polypus may be scraped off in the course of the curettage which should always terminate an operation for mucous polypus of the body, since this con- dition is merely a local indication of the general disease of the endometrium. For the method of doing this see p. 187. Fig. 112. — Removal of a myomatous polypus by enucleation : Incising the capsule. If there is haemorrhage and it cannot be arrested by a hot intra-uterine douche, the uterine cavity must be plugged with gauze. Myomatous Polypus of the Cervix Operation The polypus, if small, is seized with a volsella, and if its pedicle is thin it can be twisted off in 198 GYNAECOLOGICAL SURGERY the manner already described for a mucous polypus (p. 195). If too thick for this, the pedicle can be severed by the scissors. No haemorrhage to speak of will result in either case, the muscular portion of the pedicle contracting round the vessels and so occluding them. Fig. 113. — Reflecting the capsule. The polypus may, however, be so large that the pedicle cannot be reached, in which case, the polyp having been seized with a volsella, its capsule should be incised (Fig. 112), and then reflected with the handle of a scalpel (Fig. 113), and the tumour twisted out of its bed (Fig. 114), pieces of it, if necessary, being cut away with scissors, REMOVAL OF POLYPI 199 The collapsed capsule is then twisted round to torsion the vessels, and cut through at its base with scissors (Fig. 115). Occasionally, enormous myomatous polypi are met with entirely filling the vagina. These must be dealt with by the operation of morcellation, to be presently described. Fig. 114. — Enucleation of the tumour. Myomatous Polypus of the Body Methods. — The exact method of procedure differs in these cases according to the condition of affairs found at the operation. (a) When the pedicle can be reached. — -If the pedicle is accessible, the removal is carried out in the same way as that described for myomatous polypus of the cervix. 200 GYNECOLOGICAL SURGERY (b) When the polypus has not dilated the cervical canal. — If the cervical canal is not dilated, then the presence of the polypus is only an assumption, from the symptoms complained of, and the signs discovered, such as enlarge- ment of the uterus, marked relaxation of the external os, or the sensation of a foreign body on the uterine sound Fig. 115. — Treatment of the pedicle. being introduced. The cervix must, therefore, be dilated for diagnostic purposes (p. 154), and the polypus dealt with afterwards. (c) When the polypus is dilating the cervical canal. — In this case it is of the greatest importance for the operator to satisfy himself that the substance presenting is a fibroid REMOVAL OF POLYPI 201 polypus and not an inverted uterus. On occasion this mistake has been made, and an inverted uterus has been amputated. The operator should in such cases make a bimanual examination to ascertain whether the body of the uterus is in its normal position, or is absent. If the uterine body cannot be felt, this would suggest an inversion, and a further examination may reveal a " cupping " at the fundus, or this can even be felt more easily by a rectal examination. The uterine sound should then be passed, and, if it enters more than the normal distance, there is sufficient evidence that the case is one of polypus. If the sound enters less than the normal distance, this suggests an inversion. The operator must bear in mind, however, that the point of the sound may have caught against the pedicle of the polypus at the point of its attachment, which, if low down, would prevent the instrument from passing to the top of the uterus. In this event a movement of the sound would free it, and it would then continue its advance. Rarely the polypus may be inflamed and adherent to the cervical canal in the region of the internal os, in which case the sound would enter only a very little way. Additional signs are that an inverted uterus bleeds easily on being touched, whereas a myomatous polypus does not ; and that if an inversion has come through the external os, the internal openings of the Fallopian tubes can be seen. There is another condition which may simulate a myo- matous polypus, and that is a submucous myoma which has caused a certain amount of uterine inversion and is presenting. A careful examination on the above lines will reveal the identity of the condition, and the tumour must be enucleated in the manner presently to be described (P- 203). Operation. — If the finger can be introduced by the side of the polypus and its pedicle felt, it may be removed by seizing it with a volsella, drawing it down, and then cutting through the pedicle with scissors, or, if this is not 202 GYNECOLOGICAL SURGERY possible, by first enucleating it from its capsule (p. 198), and dealing with the pedicle afterwards. Excessive size of the polypus. — In some cases the tumour is so large that the existence of a pedicle is prob- lematical. Many of these cases turn out to be a sessile submucous myoma. In this event it should be removed piecemeal, i.e. by morcellation, different parts of the tumour being cut away with scissors until the pedicle, if it exists, can be reached. Partial inversion. — It may be that the polypus, when it is pulled upon, inverts that portion of the uterus to which the stump is attached, so that the operator must be sure he is cutting through the pedicle and not in reality through the inverted piece of uterine wall. This danger is avoided if the tumour is enucleated before dealing with the pedicle. Haemorrhage. — If the bleeding does not stop with the administration of a hot intra-uterine douche the uterine cavity must be plugged with sterilized gauze. Placental Polypus In this case a piece of placenta or membrane has remained attached to the uterus and has become partially organized. The treatment of the condition is the same as that of a mucous polyp. Dressing and after-treatment of operations for polypi. — -When the polypus has been removed the vagina is douched with biniodide of mercury, 1 — 4,000, and tampons of absorbent wool are inserted for a few hours. For the after-treatment, see Chapter xxxn. After the removal of cervical polpyi the patient may get up in two or three days, in fact, when the haemorrhagic discharge has ceased. Where the growth is corporeal and the uterus has been dilated, the patient must stop in bed for ten days to a fortnight. In these cases it is well to hasten the retraction of the uterus by the administration of ergot. REMOVAL OF MYOMATA 203 ENUCLEATION OF SUBMUCOUS MYOMATA The necessity for this operation will be discovered on digital examination of the uterine cavity, made for purposes of diagnosis. Limitation. — Enucleation of a submucous myoma should only be attempted when the meridian of the tumour is free in the uterine cavity, when the tumour is not larger than a Tangerine orange, and when it is apparently the only myoma of any size in the uterus. By this last state- ment it is not meant to exclude cases where there are two small submucous tumours, but when interstitial or sub- peritoneal tumours can be felt it is a much more satisfactory and safe procedure to perform hysterectomy. Preparation of the patient. — See pp. 78-82. Instruments. — -Douche apparatus, Clover's crutch, Auvard's speculum, two volsellae, Fenton's dilators, scal- pel, scissors, four pairs of long pressure-forceps, ring forceps, curved needle No. 7, silk Nos. 2 and 4. Operation. — i. Dilatation of the cervix (p. 154) is the first step in the operation. ii. Incision of mucous membrane. — The index finger of the left hand is passed into the uterine cavity and the relations of the tumour are examined. With the scalpel or scissors passed along the index finger an incision in the mucous membrane covering the tumour is made sufficiently deeply to penetrate the capsule and large enough to allow the point of the finger to pass in. iii. Enucleation from the capsule. — -The index finger of the left or the right hand, whichever is the more convenient, is then pushed through the hole in the capsule and the tumour is enucleated from its capsule, the remaining hand pressing down the uterus from the abdomen to steady it and bring the growth more into reach. As a rule, the tumour will be easily enucleated. When free, it must be seized with a volsella, or, if small, with a ring forceps, and gradually delivered through the cervix. 2o 4 GYNAECOLOGICAL SURGERY Difficulties, i. Adherent capsule. — Sometimes it is not so easy to enucleate the tumour from its bed with the finger, and in these cases the myoma should be seized with a volsella, by means of which the tumour can be twisted in various directions, while the finger tries to free it, helped perhaps now and again by a few careful snips with the scissors. ii. Excessive size. — Roughly speaking, a myoma the size of a Tangerine orange can be delivered through a fully dilated cervix. If the tumour is larger than this, the operator may be able to deliver it by incising the cervix on each side up to the vaginal vault, or more room may even be obtained by pushing the bladder off the uterus and then incising the cervix and the anterior surface of the uterus as high as the peritoneal reflection. If, in spite of this incision, or preferably before its employment, the tumour is found to be too large to deliver whole, it must be cut up and removed in small pieces (morcellation). Myomata up to the size of an orange may be removed in this way ; but if larger, hysterectomy should be performed in the first instance. iii. Adeno-myomata. — These tumours are usually sub- mucous, and cannot from the symptoms or feel be dis- tinguished from pure myomata. They are never truly encapsuled, however, and hence attempts to enucleate them in mistake for a submucous myoma always fail. Dangers, i. Incomplete removal. — It occasionally hap- pens that the operator misjudges the size of the tumour he sets out to remove, and, after tearing away several pieces of it, finds that he cannot finish the enucleation, whilst some myomata and all adeno-myomata have no capsule and cannot be enucleated. The dangers that may accrue from this unsuccessful effort are haemorrhage and sepsis. We have seen a case where bleeding came on so profusely half an hour after a partial enucleation that the patient was only saved by an immediate hysterectomy. Sepsis is brought about by the remaining portion of the ENUCLEATION OF MYOMATA 205 fibroid sloughing out, during the process of which the patient may die, or be dangerously ill for many weeks. The only course, if enucleation prove a failure, is imme- diate hysterectomy. ii. Haemorrhage. — As a rule, there is no haemorrhage to speak of. If it is a cervical myoma that has been enucleated, the bleeding may be serious from damage to the uterine arteries. The treatment for bleeding that a hot uterine douche will not stop is to pack the uterus with gauze, and, this failing, to perform hysterectomy. iii. Sepsis. — Apart from a portion of the tumour being left behind, the patient may be infected by dirty instru- ments or hands, or the myoma may be already septic before the operation. The first source of danger is to be obviated by strict asepsis and antisepsis prior to, during, and after the operation, and, in the case of tumours already infected, by performing the operation with as little laceration of the healthy tissues as may be possible, and subsequently irrigating the uterus thoroughly and packing its cavity with iodoform gauze. iv. Perforation of the uterus. — The uterus may be perforated by a too vigorous use of the finger or of the scissors during separation of the capsule, the operator failing to appreciate the fact that the tumour reaches almost up to the peritoneal covering of the uterus. Again, when the tumour is being removed by morcellation, the operator may incise the muscle-wall with the scissors in mistake for the tumour. If the cavity of the uterus is clean when the accident occurs, no ill results may follow, and, unless the rent is large or the haemorrhage free, the uterus after the removal of the tumour should be packed with gauze and the case watched. If, however, a sloughing myoma is being dealt with, or the rent is large, or a piece of bowel comes through the rent, it is better to perform vaginal hysterectomy after removing the tumour. Dressing and after - treatment. — See Chapter xxxn. 206 GYNECOLOGICAL SURGERY The patient can get up on the fourteenth day if all haemor- rhagic discharge has stopped. Removal of a Large Submucous Myoma by morcellation Occasionally a submucous myoma is so large that it dilates the cervical canal and gradually fills the vagina. Fig. 116. — Morcellation of a submucous myoma : Gutting away the lower pole of the tumour. These cases differ from large myomatous polypi inasmuch as they are attached to the uterus by a very broad base and not, as in the case of polypi, by a pedicle. Preparation of the patient. — See pp. 78-82. ENUCLEATION OF MYOMATA 207 Instruments. — Clover's crutch, Auvard's speculum, scal- pel, scissors, douche apparatus, four pairs of long pressure- forceps, ring forceps, two volsellae, two curved needles No. 7, silk Nos. 2 and 4. Operation. — The steps of the operation are the following : i. Incising the capsule. — The tumour is seized with Fig. 117. — Reflecting the capsule. the volsellae, drawn down, and its lower pole cut away, by which means the edge of the capsule is exposed (Fig. 116). ii. Enucleating the tumour. — The tumour is now gra- dually enucleated, being pulled down with a volsella held in the left hand, while the forefinger of the right hand reflects the capsule (Fig. 117). 208 GYNAECOLOGICAL SURGERY iii. Removing the tumour. — After a sufficient amount of the tumour has been stripped of its capsule, as much Fig. 118. — Continued removal of the tumour. of the denuded portion as possible is removed with a pair of scissors (Fig. 118). The volsella is then passed up into the uterine cavity, but inside the capsule, and the re- mains of the tumour are seized and pulled upon, while with ENUCLEATION OF MYOMATA 209 the other hand the surgeon continues the enucleation, assisting it by a certain amount of lateral and rotatory Fig. 119. — Seizing the upper part of the tumour. traction of the volsella (Fig. 119), so that at last the upper pole of the tumour is shelled out and delivered (Fig. 120). iv. Treatment of the capsule. — The capsule is now O 210 GYNAECOLOGICAL SURGERY seized, pulled down with a pair of ring forceps, and cut off as near the uterine wall as possible (Fig. 121). Fig. 120. — Enucleation of the upper pole of the tumour. An alternative method of treating the capsule would be to pass a ligature round it before its division, but as ENUCLEATION OF MYOMATA 211 a rule there is no bleeding, and if there is, this can be arrested by packing the uterus. Dangers. — The uterine wall may be perforated during the enucleation, or the operator may have misjudged the Fig. 121. — Treatment of the capsule. condition and be unable to remove all the tumour ; in either case the treatment to be followed is that described at p. 204. Dressing and after-treatment. — See Chapter xxxn. The patient gets up on the fourteenth day, if all discharge has ceased. CHAPTER X HYSTERECTOMY; GENERAL CONSIDERATIONS I. INDICATIONS FOR HYSTERECTOMY The uterus is usually removed for conditions affecting the organ itself, but occasionally its removal becomes a matter of necessity in the course of an operation for tubal or ovarian disease or for large tumours of the broad ligament, in order that the object of the operation may be attained. The conditions affecting the uterus for which its removal may be indicated are — Injuries Inflammation New growths' 4. Congenital defects 5. Acquired defects Rupture. Acute sepsis, chronic sepsis, fibro- sis, senile endometritis, tuber- cular endometritis. Myoma, adeno - myoma, carci- noma, sarcoma, chorion-epi- thelioma, hydatid disease, villous papilloma. Haematometra, pregnancy in an undeveloped horn of the uterus. Dysmenorrhea, inversion, haema- tometra, haemorrhage apart from inflammation or new growth. 1. Injuries, i. Obstetrical. — Rupture of the uterus during labour may be an indication for hysterectomy. The advantage of the operation is that it removes the damaged organ and prevents any further haemorrhage and subsequent risk of intra-uterine sepsis. Its disadvantages are — 212 HYSTERECTOMY: INDICATIONS 213 (a) The sacrifice of the organ. (b) That many patients in whom the disaster has occurred are already so collapsed that a radical operation of this nature is unable to be borne. (c) The surroundings under which the operation might have to be carried out may be unfavourable to its success. Extraperitoneal tears and small intraperitoneal tears through the fundus, without persistent prolapse of bowel or omentum, can usually be treated successfully by plug- ging the rent with gauze ; whilst large transverse tears, with deficient retraction of the uterine muscle and profuse external haemorrhage, or cases in which bowel or omentum persistently prolapses or in which it is certain that severe intraperitoneal bleeding is taking place, should be imme- diately operated upon, and if the tear cannot be satis- factorily sutured the uterus should be removed. ii. Operative injuries. — This subject will be found fully discussed in connexion with the dangers of dilatation and curettage of the uterus (pp. 160-68). iii. Accidental injuries. — Most of these injuries occur to the pregnant woman. If the uterus is septic before the surgeon sees the patient, as when the perforation has occurred in the course of an attempted criminal abortion, it is sometimes necessary to remove the damaged organ. If the patient is seen soon after the uterus has been injured, as, for example, in gunshot wounds or goring by cattle, the same treatment may be necessary, or the rent may be sutured after the removal of products of gestation. 2. Inflammation. — -The uterus has been removed for acute puerperal sepsis. The results are, however, disas- trous, and we are of opinion that, if any operative treatment is to be undertaken in such conditions, drainage of the pelvis through multiple incisions gives the best chance of success. If, however, on the abdomen being opened, the uterine wall is found to be the seat of abscess formation, the organ must be removed. The removal of the uterus is sometimes indicated in 2i4 GYNAECOLOGICAL SURGERY chronic septic infection of its interior, usually gonococcal, the symptoms of which, a persistent excoriating discharge and profuse haemorrhage, have defied all other methods of treatment. Most of these cases have already had both appendages removed for pyo-salpinx. There is a group of cases exhibiting most profuse menor- rhagia in which the symptoms are due to a diffuse fibrotic degeneration affecting the whole thickness of the uterine wall. Should repeated curettage fail to relieve these cases, the uterus should be removed, or utriculoplasty performed. Hysterectomy is occasionally done for senile endometritis in which life is menaced by the presence of a pyometra that cannot be cured by dilatation and curettage. Tubercular endometritis is a rare disease, and its symptoms are frequently mistaken for those of carcinoma of the uterus. When the nature of the condition is made clear by proper examination, the uterus should be removed, in the absence of symptoms of generalized tuberculosis. 3. New growths, i. Myoma, adeno-myoma. — Hyster- ectomy as a treatment for these cases may be a matter either of necessity or of expediency. Where the tumour is endangering the patient's life from haemorrhage, pressure, or infection, its removal is abso- lutely necessary. If, again, the symptoms, while not directly endangering life, prevent the patient from earning her living, hysterectomy is practically a necessity. If the symptoms are in any way affecting the patient's health, or seriously interfering with her comfort or social occupation, in our opinion the removal of the tumour is expedient. For the operation, when carried out by skilled hands on patients whose general health has not been seriously deteriorated by prolonged bleeding, auto-intoxication, pres- sure, or pain, is attended with a mortality not greater than that following the removal of a chronically inflamed appendix, that is to say, less than 1 per cent. Indeed, the only unavoidable causes of death, as far as the surgeon is concerned, are pulmonary embolism and the anaesthetic. HYSTERECTOMY: INDICATIONS 215 If, however, the health of the patient has been under- mined by any of the above-mentioned causes, the operation becomes one of much greater gravity. When watching a formidable hysterectomy upon a pa- tient exsanguinated from prolonged bleeding and emaciated from prolonged endurance of pain and toxic absorption, it is melancholy to reflect that there was a time when the tumour could have been removed with perfect ease and almost certain success. A grave responsibility rests upon those who aid and abet the natural inclination of patients to postpone operative procedure until their lives become a misery. It is a curious psychological fact that many medical men of undoubted eminence in their profession will without the least hesitation sanction or urge the removal of so essential an organ as the ovary, while they look askance at the extirpation of one which, having become unfitted for its function of child-bearing, is merely a menacing encum- brance. To tell a woman suffering from uterine myoma that the removal of her uterus will subject her to the risk of madness, of alteration in her nature and sexual feelings, or of unfaithfulness on the part of her husband, is, in our opinion, reprehensible. A woman whose myomatous uterus has been removed by hysterectomy is, except in regard to child-bearing, at no disadvantage compared with her former condition. And, seeing that the majority of women suffering from myomata have passed the common age for child-bearing and that the presence of the tumour renders the occurrence of pregnancy unlikely, this dis- advantage is a very small one. ii. Malignant disease. — Hysterectomy for malignant disease, if the operation be possible, is an obvious course. Further discussion of this point will be found in the chapter for radical operation for carcinoma of the cervix (p. 361). iii. Other new growths. — All other new growths of the uterus are extremely uncommon. Rarely, villous papil- lomata are met with springing from the endometrium. The nature of these tumours and their relation to carcinoma 216 GYNECOLOGICAL SURGERY are so little known that the safest course is to treat them as though they were malignant and extirpate the uterus. Hysterectomy has also had to be carried out for echino- coccus cysts of the uterus. 4. Congenital defects. — There are certain congenital defects of the genital tract which may result in conditions that necessitate the removal of the uterus ; the most common example of these being a hsematometra dependent on absence of the vagina in whole or in part. In some cases the making of an artificial vagina has remedied the condition (p. 129). More commonly, however, such plastic surgery is impossible or unsatisfactory and the uterus has to be removed. Occasionally one meets with cases of hsemato- metra in one half of a double uterus, whilst rarely pregnancy may occur there. In either case removal of the malformed half of the uterus will be necessary. 5. Acquired defects. — Hysterectomy is sometimes indi- cated to stop the periods in cases of intractable dysmenor- rhcea disabling the patient, and also in cases of uterine haemorrhage which is threatening life and for which no definite cause can be found. Chronic inversion of the uterus has been treated successfully by hysterectomy, other methods having failed. Finally, removal of the uterus may be indicated as the remedy for some artificially acquired stenosis of the genital canal producing haematometra. The most common cause of this is scar-contraction after high amputation of the cervix. The conditions affecting the Fallopian tube for which hysterectomy may be indicated are — 1. Tubal gestation. — There are three sets of circum- stances under which the uterus may have to be removed for this disease. (1) The gestation sac may be so adherent to the back of the uterus that the bleeding due to its removal cannot be controlled by any other method. (2) In cases of interstitial pregnancy the uterine wall may be so destroyed that it is impossible to conserve the organ. (3) In advanced cases of secondary intraperitoneal or intra- HYSTERECTOMY: INDICATIONS 217 ligamentous gestation the placenta is almost certain to be more or less attached to the surface of the uterus, which organ may have to be removed to control the haemorrhage due to its separation. 2. Salpingitis. — It is maintained by many Continental authorities that in bilateral salpingo-oophorectomy or salpingectomy the uterus should be removed, for they argue that it is of no further use, and that it may become a source of trouble from haemorrhage and discharge or of danger from cancer. Our practice has not been of this radical nature ; we limit the removal of the uterus to- gether with the appendages to certain cases of salpingitis where it is necessary to remove it in order to control haemorrhage, where, from the size and softness of the uterus, acute metritis is obvious, and where, by reason of adhesions, a more satisfactory, operation is thus effected. There can be no doubt that the removal of the uterus for acute suppurative pelvic inflammation adds an appre- ciable risk to what is already a very dangerous operation. The advantage of vaginal drainage has been urged as a reason for its performance, but we would refer the reader to the remarks upon this subject at p. 47. 3. Carcinoma of the tube. — This rare condition is only adequately treated by removing the uterus in addition to the diseased structures. The conditions affecting the ovary for which removal of the uterus may be indicated are — ■ 1. Ovarian cysts and tumours. — Hysterectomy should be performed in addition to bilateral salpingo-oophorectomy in all cases where the ovary is the seat of operable malig- nant disease. An ovarian cyst may be so adherent to the uterus that its separation is impossible, and in this case the uterus will have to be removed with the tumour. 2. Ovarian abscess. — The remarks above, bearing upon salpingitis, are equally applicable to this condition. The conditions affecting the broad ligament for which removal of the uterus may be indicated are — 218 GYNECOLOGICAL SURGERY Cysts and myomata. — It not infrequently happens that, in order to effect the removal of a cyst of the broad liga- ment, it is a necessity to remove the uterus, from which it cannot be separated ; whilst with a myoma of the broad ligament the removal of the uterus is usually an essential part of the operation. II. COMPARATIVE ADVANTAGES OF SUBTOTAL AND TOTAL HYSTERECTOMY The circumstances in which it may be proper to remove the entire uterus are malignant disease, tubercular endo- metritis, sepsis in all its forms, hydatid disease, villous papilloma of the endometrium, inversion, acquired haema- tometra, certain forms of congenital haematometra, and myomata with co-existent cervicitis. For all other conditions requiring hysterectomy the removal of the body alone will be found sufficient, and, in our opinion, is the best. This, however, is not in accordance with the views of all surgeons. It will therefore be profit- able at this point to discuss the relative merits of the total and subtotal operations respectively. Those who practise the total operation in every case requiring hysterectomy argue that this method is the best because — i. Better drainage of the operation-site is secured. 2. The cervical stump may become septic as a result of the operation. 3. The uterus may be the seat of malignant disease at the time of the operation, though not so diag- nosed. 4. The conserved cervix is useless, and may subse- quently become the seat of malignant or inflam- matory disease. 5. This advantage is gained and these dangers are avoided without any increase in operative diffi- culty and mortality or subsequent liability to interference with the marital function. HYSTERECTOMY: SUBTOTAL AND TOTAL 219 The counter-arguments by which the advocates of sub- total hysterectomy maintain the correctness of their position may conveniently be dealt with in the same order, as follows : — 1. Better drainage. — The objects of drainage in a sur- gical operation are twofold — (1) to allow of the escape of discharges already septic, (2) to permit of the free escape of an anticipated collection of blood or serum which if retained might become infected. We have already stated that if the uterus is infected, it should be removed entire. If the operation of subtotal hysterectomy has been efficiently performed, no collection of blood or serum should occur, and therefore, in what we may term clean cases, the increased freedom of drainage conferred by total hysterectomy is not only unnecessary but is actually harmful, in that it brings the operation area into direct continuity with a surface (the vagina) which is never sterile. 2. Septic stump. — That the stump may become septic in subtotal hysterectomy is true, but this is due to lack of asepsis in the technique and not to the kind of operation performed, for the amputation occurs across a portion of the genital canal which is normally sterile. In total hysterectomy, on the other hand, more or less infection of the operation area always occurs, some of the ligatures almost invariably being separated per vaginam. That the operators themselves recognize this is evidenced by the fact that they always leave the vagina open. 3. Presence of undiagnosed carcinoma. — Occasionally it has happened that the body of the uterus, having been amputated, is found when opened to be the seat of un- diagnosed malignant disease. More rarely the conserved cervix has at the time of operation been the seat of un- recognised carcinoma. The first disaster may be minimized by the habit of carefully examining the body of the uterus directly it is removed, and, in the event of malignant disease being found, forthwith extirpating the remainder of the 220 GYNECOLOGICAL SURGERY organ. The second disaster is very uncommon indeed. In the hands of careful surgeons, both occur very rarely ; but nevertheless these possible complications are undeni- able drawbacks to subtotal hysterectomy. 4. The cervix is useless and liable to disease. — The cervix is not useless. The secretion of its glands is an important lubricant to the vagina. After the removal of the cervix a scar is left across the roof of the vagina, which for some time at all events, and in many cases for at least a year, is the seat of tender granulation-tissue and gives rise to a troublesome discharge until a ligature or ligatures become separated. When healing eventually occurs, there is a tendency for the vaginal vault to become puckered and constricted. Further- more, the ovaries, if they have been conserved, or the intestine or bladder, may become adherent to the line of peritoneal suture overlying the vagina. Any of these sequeke may be the cause of dyspareunia. On the other hand, the conservation of the cervix maintains the integrity of the vaginal vault, and, though the structures mentioned may become adherent to the suture-line across the cervix, yet in this case the cervical stump intervenes between them and the vaginal roof. Subtotal hysterectomy is most often performed for uterine myomata, and it is in the discussion of the operative treatment of this disease that such great divergence of opinion has chiefly occurred. Statistics show that carcinoma of the cervix is very unlikely to affect a woman whose uterus has been removed for myomata, apparently because the invariable antecedent of the former disease is a chronic cervicitis initiated at the time of child-birth, whilst myo- mata are a cause of sterility. The fact remains, how- ever, that carcinoma does sometimes subsequently affect a cervix left after subtotal hysterectomy ; and if this were the only thing to be considered, we should unhesitatingly support the removal of the cervix in all cases. 5. Operative mortality and morbidity. — Whilst admit- HYSTERECTOMY : SUBTOTAL AND TOTAL 221 ting certain of the points claimed for total hysterectomy as a routine method, the question remains whether these advantages are not too dearly bought by the increased risk of the operation as regards mortality and morbidity when compared with the results of the subtotal method in suitable cases. There is no doubt that the subtotal method is always the easier, and sometimes very much the easier, and con- sequently the operation is performed in less time and with a diminished chance of injury to the important structures adjacent to the uterus. In our own hands an average straightforward total hysterectomy takes, under fa- vourable conditions, from thirty-five to forty-five minutes to perform, whereas by the subtotal method we complete the operation well within thirty minutes ; and we believe this to be the experience of others versed in this class of work. The increased risk of injury to the bladder, bowel, or ureters in total hysterectomy is obvious from anatomical considerations, \nd is considerably enhanced in certain circumstances, such as great depth of the pelvis, marked obesity, and abnormal fixity of the uterus. In the hands of experts such accidents are of rare occurrence, but it is none the less true that injuries to the bladder, bowel, and ureter are much commoner in total hysterectomy. We have already referred to the additional danger of infection of the ligatures in total hysterectomy. This, with the risk of the aforementioned injuries, results in an increased mortality and morbidity rate in total hysterectomy as compared with that of the subtotal method. These remarks on the relative difficulties of the two operations, founded upon experience of the work of expert operators, obviously apply with much greater force to the practice of those inexperienced in gynaecological surgery. Setting, then, the advantages claimed for the habitual practice of total hysterectomy against its disadvantages, we are of opinion that it is not the operation of election in all 222 GYNECOLOGICAL SURGERY cases, and that the cervix should be conserved wherever it may reasonably be held to be healthy. III. COMPARATIVE ADVANTAGES OF ABDOMINAL AND VAGINAL HYSTERECTOMY The frequency with which vaginal hysterectomy is per- formed varies very considerably in different countries and in the practice of different surgeons. There are some who consider this method to be the one of election when the extirpation of the uterus is indicated and it is possible to remove it by this route.. There are others who only resort to the method occasionally, and then because there is some very strong contra-indication to the abdominal operation. There are many cases in which -the performance of vaginal hysterectomy is obviously out of the question on account of the size, fixity, or uncertain nature of the tumour. But, limiting the discussion to those cases in which the uterus is removable by either route, the advantages and disadvantages of vaginal and abdominal hysterectomy can be discussed under the following heads : — i. Shock. — There can be no doubt that when vaginal hysterectomy is performed in suitable cases, post-operative shock is much less than if the uterus had been removed per abdomen. This is possibly due to the lesser disturbance and exposure of the intestines and to the position of the peritoneal wound, for it is certain that the pelvic peri- toneum differs markedly from that lining the remainder of the abdominal cavity in its resistance to shock and the spread of infection. From this point of view, therefore, the operation, other things being equal, is peculiarly suit- able for those patients who are unable to withstand any prolonged shock. 2. Drainage. — In cases where drainage is indicated after hysterectomy, it is claimed that it will be more efficiently carried out per vaginam than through an abdo- minal incision. The relative merits of abdominal and HYSTERECTOMY 223 vaginal drainage have been already discussed (p. 47). Quite apart from the question of the facility with which discharges may escape from a vaginal or an abdominal wound, the danger of infecting a non-septic area of the peritoneum when abdominal drainage is employed has to be considered, and therefore, when it is deemed necessary to remove the uterus for acute septic infection, it is, from this point of view, safer to adopt the vaginal route. 3. Operative accessibility. — In certain cases, as, for instance, when the patient is very fat, the uterus is more accessible by the vagina than by the abdomen, and more especially if the uterus is at the same time not enlarged, or even smaller than normal. Occasions may arise also when an abdominal wound is contra-indicated by reason of some unhealthy condition of the abdomen, such as eczema, septic blisters from too hot fomentations, suppurative omphalitis or the presence of a colotomy wound, and also where, in great emergency, the abdominal wall is in a filthy condition. In these cir- cumstances, if the case is otherwise suitable, vaginal hysterectomy is indicated. In the majority of cases, however, it cannot be doubted that the operation is much easier through an abdominal wound. This advantage of greater operative ease would not in itself weigh down the considerations that tell in favour of vaginal hysterectomy, but the increased facility accorded to the operator is associated with greater safety to the patient, since the relation of the diseased organ to the adjacent structures can be more clearly defined, and any complication, such as adherent intestine, omentum, or appendix, can be more easily dealt with and runs no risk of being overlooked. Again, the separation of adhesions is more easily and safely accomplished by abdominal manipulation ; any bleeding-points can be more certainly secured ; and the bladder, rectum, and ureters run less risk of being wounded. 224 GYNAECOLOGICAL SURGERY In abdominal hysterectomy the cut surfaces of the broad ligaments and vagina are separated from the abdo- minal cavity by the accurately sutured peritoneal flaps, whereas in vaginal hysterectomy these raw surfaces are imperfectly covered, and therefore form possible sites for intestinal adhesions. By the abdominal route the operator is at liberty to conserve the cervix if he wishes to do so, or even the whole uterus if he finds the tumour enucleable, whereas by the vagina he has no such choice. Finally, in cases where the uterus is enlarged or adherent, its removal by the abdomen can be carried out so much more quickly that this more than counterbalances the lessened tendency to shock and the quicker convalescence associated with the vaginal operation. 4. Site of wound. — One of the chief drawbacks to ab- dominal hysterectomy is the parietal wound, which, apart from its unsightly appearance, is liable to stitch-abscess or to a hernia. A vaginal wound, on the other hand, leaves no visible scar, and, though it suppurates more frequently, does not cause so much distress as an ab- dominal sinus, whilst a hernia in this situation is unknown. On the other hand, a vaginal scar may be the cause of dyspareunia. After a careful consideration of the arguments advanced on both sides, and whilst admitting that the results of those who operate by the vaginal route as a routine method are in many cases very good, we are still of opinion that abdominal hysterectomy in the majority of cases is the safer procedure for the patient. The scope of vaginal hysterectomy has of late years been extended by the adoption of Schauta's paravaginal incision, presently to be described, which very considerably enlarges the operator's field of action. While, however, the difficulty of access to the pelvis is by these means diminished and larger tumours can be dealt with, many of the disadvantages already discussed are not materially obviated. CONSERVATION OF OVARIES 225 IV. THE CONSERVATION OF OVARIES To remove a healthy functional ovary in order to facilitate an operation is ; as a rule, bad practice. The effect of removal of both ovaries in a woman varies considerably according to her age and temperament. The observations of Crewdson Thomas show that by the time a woman has reached the age of 40 the value of the ovaries has depreciated, whilst when she is under 40 their absence may either produce no changes worth speak- ing about or may be responsible for violent menopausal symptoms. The effect of ablation of the ovaries on sexual desire varies. As a rule, this is lessened, accompanied as it some- times is by dyspareunia from atrophy of the vagina and postoperative kraurosis. The result is at times the reverse of this, and in some cases the orgasm is enhanced by the fact that painful ovaries which before interfered with its consummation are no longer present. The result of oophorectomy on the mind varies con- siderably, according to the individual. That the removal of ovaries per se is a cause of insanity or mental instability we do not believe. This used to be a terror held out to women on whom some operation on the genital organs was contemplated, but experience has shown that such teaching has no foundation on fact. On the other hand, it is quite certain that where mental stability is trembling in the balance, the removal of the ovaries, by adding the nervous symptoms of the menopause, may precipitate the catastrophe. In such patients any operation is to be avoided if possible, and, for the reason given above, removal of the ovaries especially. It must also be remembered that whilst it is best to conserve both ovaries if feasible, even part of one may be of service to its owner. Under certain conditions, apparently healthy ovaries may have to be removed, as, for example, when their raw p 226 GYNAECOLOGICAL SURGERY surface due to the separation from surrounding structures is bleeding too freely to be satisfactorily controlled by ligatures, or when, during the removal of a broad-ligament cyst, the ovary is found so flattened out that its separa- tion and conservation would add a considerable risk to the operation. If, again, the surgeon suspects malignant disease in the uterus, he should remove the ovaries, because by so doing he widens the area of excision. In an operation on a patient over 50 years of age, the ovaries may be removed without hesitation if the proceeding is facilitated thereby. A number of experiments by different observers have shown that in animals the removal of the uterus does not hinder ovulation, and apparently this is also true of women. In our experience, a hysterectomy with con- servation of the ovaries in a woman below 40 years of age does not greatly accelerate the appearance of meno- pausal symptoms. This subject is further discussed in Chapter xli. CHAPTER XI VAGINAL HYSTERECTOMY I. THE LIGATURE METHOD Preparation of the patient. — See pp. 82-84. Instruments. — The instruments given in the general list on p. 276 will be needed, but all the pressure-forceps must be of the long variety, and in addition a douche apparatus, a Clover's crutch, an Auvard's speculum, two vaginal retractors, an additional volsella, and a Worrall's blunt-pointed needle will be required. Cleansing the vaginal canal. — The vagina is thoroughly scrubbed with soap and water by means of swabs attached to long forceps, after which it is well douched with biniodide of mercury, 1 — 2,000. If the operation is being performed for carcinoma of the cervix, the growth should first be thoroughly curetted and cauterized, or if it is small it may be entirely excised. In all cases it is well to close the cervical canal with a No. 6 silk ligature, the long ends of which can be used as a tractor. Operation. — The following are the steps of the opera- tion : — i. Identifying the limits of the bladder. — Auvard's speculum having been inserted into the vagina, a sound is passed into the bladder and the relations of this organ are carefully noted. Especially is it important to determine how far down the bladder reaches on the anterior wall of the cervix, since, on stripping it off the cervix prior to opening the utero-vesical pouch, the bladder may be injured. ii. Separating the bladder. — By traction on the cervix the uterus is pulled down towards the vaginal outlet. With a scalpel the mucous membrane on the front half of the 227 228 GYNECOLOGICAL SURGERY cervix is incised transversely as high up as the previously ascertained position of the bladder allows (Fig. 122). The bladder is then separated from the cervix, at first with the handle of the scalpel or with scissors (Fig. 123), and later on, as the layer of cellular tissue between the bladder Fig. 122. — Vaginal hysterectomy by the ligature method : An- terior incision of the cervix. and the cervix becomes looser, with the forefinger, until the utero-vesical reflection of peritoneum is reached (Fig. 124). iii. Opening the utero-vesical pouch. — This is effected by pushing the left index-finger up to the peritoneal reflec- tion and then passing along it with the right hand a pair of blunt-pointed scissors till their ends touch the peritoneum, when one or two very gentle snips are generally sufficient to cut through the peritoneum. The left forefinger of VAGINAL HYSTERECTOMY 231 each hand can then be pushed through into the utero- vesical pouch and the opening enlarged laterally by a stretching movement (Figs. 125 and 126). Fig. 127. — Incising the cervix posteriorly. iv. Opening the utero-rectal pouch. — The cervix is next drawn forwards and the mucous membrane on its posterior surface is incised at the level of the posterior vaginal fornix (Fig. 127). The mucous membrane is now reflected with the handle of the scalpel (Fig. 128), until 232 GYNAECOLOGICAL SURGERY the peritoneum is reached, which membrane is cut through with the points of the scissors pressed against the uterus (Fig. 129). The opening is then enlarged with the fingers Fig. 128. — Pushing back the mucous membrane. (Fig. 130). A quicker and just as efficient a method of opening the utero-rectal pouch is to cut right into it with the points of the scissors directed towards the uterus, just where the posterior vaginal wall is reflected on to the cervix. In either case the primary cut is then lengthened trans- VAGINAL HYSTERECTOMY 233 versely and the incision is carried round on each side of the cervix till the anterior and posterior incisions are continuous. Fig. 129. — Opening the utero-rectal pouch. v. Insertion of swab. — After Douglas's pouch has been opened, a swab to which has been attached a piece of tape is passed into it through the opening made behind the cervix. This prevents the small intestine from prolapsing. vi. Ligaturing and cutting the broad ligaments. — 234 GYNECOLOGICAL SURGERY An assistant having pulled the uterus downwards and to one or the other side, so as to give as much room as possible in the lateral fornix, the operator inserts the index-finger Fig. 130. — Enlarging the opening in the utero-rectal pouch. of his left Jiand into the utero-rectal pouch, palmar surface forwards, and by its pressure steadies that portion of the broad ligament which is in relation with the side of the VAGINAL HYSTERECTOMY 235 cervix, and at the same time with the aid of the thumb he identifies the uterine artery (Fig. 131). He now, with a Worrall's needle held in the right hand, transfixes the broad ligament from before backwards and well above the uterine artery and as near to the cervix as possible (Fig. 132). The needle is tilted somewhat so that its end Fig. 131. — Identifying the uterine artery. impinges on the left finger, and a ligature of No. 4 silk having been attached to the needle, the latter is withdrawn and disengaged from the silk. The ligature is then firmly tied (Fig. 133), and the ends are left hanging out of the vagina and secured by pressure-forceps. By this ligature the uterine artery should be secured, and the tissue between the ligature and the uterus is then divided with scissors 236 GYNECOLOGICAL SURGERY (Fig. 134). The artery on the opposite side having been secured by a similar method, the uterus can be drawn much lower into the vagina. By similar procedures the rest of the broad ligament on each side is transfixed, ligatured, and divided close to the uterus. The highest ligature to be passed (Fig. 135) should be used double, Fig. 132. — Transfixing the lower part of the broad ligament. and, having been divided, one half is used for ligatur- ing the Fallopian tube and the ovarian vessels, and the other for the round ligament of the uterus (Fig. 136), which structures, unless they are firmly secured, may re- tract, causing the ligature to slip, and giving rise to trouble- some bleeding which may be somewhat difficult to control. VAGINAL HYSTERECTOMY 237 When the upper part of the broad ligament on each side has been divided, the uterus is freed (Fig. 137) and can be removed, and if the vessels have been properly secured, there is no oozing from the stumps. If any oozing is present, the bleeding-point is secured with pressure-forceps and liga- tured with No. 4 silk. If the open mouth of the cut end of Fig. 133. — Ligaturing the lower part of the broad ligament. the uterine artery can be seen, it should be picked up with pressure-forceps and ligatured separately with No. 4 silk. Exactly how many ligatures will have to be applied on each side will vary with the skill of the operator and the size of the uterus ; usually two single and one double on each side suffice, but the cut edge of the broad ligament 238 GYNECOLOGICAL SURGERY must be rendered quite bloodless, and if there is any oozing the part where it occurs must be re-tied. The vagina is now thoroughly swabbed, not douched, with a warm solution of biniodide of mercury, I — 2,000, Fig. 134. — Division of the lower part of the broad ligament. and the swab in the utero-rectal pouch is then removed. The ends of the ligatures may be treated in one of two ways : some operators cut the ends off short, while others leave them long. There is a certain advantage in leaving the ends long, inasmuch as, if any bleeding takes place VAGINAL HYSTERECTOMY 239 after the operation, by pulling on them the cut surfaces of the broad ligament can be brought down, and the oozing- point quickly seen and dealt with (Fig. 138). Further, after the end of a week the separation of the ligatures may be hastened by daily making gentle traction on the long Fig. 135. — Transfixing the upper part of the broad ligament. ends. The method has, however, the disadvantage of increasing the liability to suppuration, so that we prefer to cut them short and leave the case in the same con- dition as obtains after an abdominal total hysterectomy. They should not, however, be cut until the operation is 240 GYNECOLOGICAL SURGERY concluded and it is certain that all the vessels are properly secured. vii. Treatment of the vaginal vault. — The treatment Fig. 136. — Ligaturing the upper part of the broad ligament. of the vaginal vault varies with different operators. The most satisfactory proceeding is, probably, to let the cut edges of the vagina fall together naturally, promoting drainage by passing into the utero-rectal pouch a piece of VAGINAL HYSTERECTOMY 241 the gauze with which the vagina is lightly packed, and keeping it there for twenty-four hours. Others prefer carefully to suture the cut edges of the peritoneum over the vagina with a continuous suture of Fig. 137. — Dividing the upper part of the broad ligament. No. 2 silk, whilst others again pass a single suture at the external angles of the vaginal incision so as to narrow but not occlude its open upper end (Fig. 139). Difficulties, i. Separating the bladder. — Sometimes a good deal of trouble is experienced in separating the Q 242 GYNECOLOGICAL SURGERY bladder. This may be due either to the fact that the operator when using the scissors cuts into the muscle of the cervix instead of through the loose connective tissue, or to the connective tissue being denser than normal. In the first event, if the operator fails to recognize what Fig. 138. — Inspecting the pedicles. he is doing, he may open the cervical canal, especially if the cervix has been rendered soft by growth. If dense connective tissue is preventing the proper separation of the bladder, it must be divided by series of small cuts, made with the scissors held on the flat, till looser connective tissue is reached. In such cases it is useful to push the forefinger of the right hand well out on each side of the cervix towards the broad ligament, VAGINAL HYSTERECTOMY 243 as in this region the vesical walls are more loosely attached. From the sides it will then be possible to work inwards towards the anterior surface of the cervix and strike the proper plane of cleavage. ii. Opening the utero-vesical pouch.— Another difficulty Fig. 139.— Treatment of the vaginal vault. may present itself on an attempt being made to open the utero-vesical pouch. The reason is twofold. Either the operator, if inex- perienced, is uncertain when his finger has reached the peritoneum, and is somewhat timid in using the scissors ; or, what is more probable, the forefinger of the left hand pushes the peritoneum in front of it so that it is continually " running away from him." A useful method of identifying the peritoneal reflection 244 GYNECOLOGICAL SURGERY is to rub what you take to be it against the anterior surface of the uterus, when if the tissue is the peritoneum it will slip about on the uterus with an oily sort of feeling. If, on the other hand, the operator experiences difficulty in steadying the peritoneum during its incision, a pair of long forceps can be passed up guided by the forefinger till the peritoneum is reached, when this membrane can be clamped and then pulled down and dealt with. An additional help may be gained by means of a long anterior speculum pushed up between the bladder and the cervix (Fig. 125). Lastly, the opening of the utero-vesical pouch can be postponed until Douglas's pouch has been opened, when the index and middle fingers of the left hand can be passed into it up along the posterior surface of the uterus over the edge of the broad ligament, and so to the utero- vesical reflection, when the peritoneum can be incised as it rests against the fingers. iii. Opening the utero-rectal pouch. — If the posterior incision is made with a scalpel, and the mucous membrane then separated with its handle or the forefinger, the cellular tissue between the vagina and rectum may be opened up and the vagina separated from the rectum for some distance before the mistake is discovered. iv. Bleeding from the posterior flap. — The posterior cut edge of the vagina and peritoneum is much more fleshy than the anterior, and the oozing of blood that takes place from its surface may be very troublesome both during the removal of the uterus and afterwards. The same difficulty may present itself with the anterior flap, though in a much lesser degree. This oozing, especially if it comes only from one or two points, can be temporarily stopped by pressure-forceps. A better way to check the oozing, if it is at all trouble- some, is to obliterate the raw surface of the flap by suturing the peritoneum to the mucous membrane with a continuous suture of No. 2 silk. v. Narrow vagina. — If the vagina is narrow, as in VAGINAL HYSTERECTOMY 245 virgins or women who have not borne children, the opera- tion becomes much more difficult, and the operator, unless he be very expert, may rind great difficulty in passing and tying the ligatures for want of sufficient room. In these cases it is a great help to perform a paravaginal section. Fig. 140. — -Incision in paravaginal section. This is effected by incising the vagina along the junction of the posterior and left lateral wall from the vault downwards, and then carrying the incision backwards through the skin around the rectum towards the coccyx, the anterior fibres of the left levator ani being divided 246 GYNECOLOGICAL SURGERY (Figs. 140 and 141). A good deal of bleeding ensues, which must be checked by ligatures and the pressure of the pos- terior speculum. At the conclusion of the operation the wound is sutured vi. Application of ligatures. — If any difficulty is found in passing the ligatures by the method described at p. 235, this can sometimes be overcome by inserting the needle into the utero-rectal pouch and transfixing the broad ligament from behind forwards. Fig. 141. — Retraction of the wound of the paravaginal section. vii. Passing the higher ligatures. — After division of the base of the broad ligaments, it may be found that the uterus cannot be pulled down properly, and in that case much difficulty may be experienced in passing the higher liga- tures. This difficulty will be due either to infiltration of the surrounding connective tissue by cancer or inflammatory products, in which case it may be impossible to finish the operation from the vagina ; or to the presence of adhesions, or to the large size of the uterus. VAGINAL HYSTERECTOMY 247 Infiltration of the broad ligaments should have been discovered before the operation was started, by pulling the cervix with the volsella down to the vulva and examin- ing the broad ligaments and the utero-sacral ligaments per rectum. If the cervix cannot be drawn down to the Fig. 142.— Anteflexing the uterus — first step. vulva, this in itself is an indication that the operation on the ordinary lines will be a failure, and the more extensive procedures as practised by Schauta will have to be followed, or the uterus removed by the abdominal route. Supposing the fixation is due to adhesions, they should 248 GYNAECOLOGICAL SURGERY be gently broken down, and if the Fallopian tubes or ovaries are diseased these should be removed by placing the upper ligature outside them, i.e. round the ovarico- pelvic ligaments. If the difficulty is due to the size of the uterus, this can be surmounted in one of two ways : Fig. 143. — Anteflexing the uterus — second step. either the fundus of the uterus can be seized with a volsella and, the uterus being ante verted, delivered through the utero-vesical incision (Figs. 142 and 143), when the top portions of the broad ligaments come into view ; or the uterus can be bisected with a stout pair of scissors and each half removed separately (Figs. 144 and 145). Dangers, i. Wounding the bladder. — This is, perhaps, VAGINAL HYSTERECTOMY 249 the commonest accident associated with vaginal hysterec- tomy. Although at times its avoidance would appear to be well-nigh impossible, since it now and again happens to the most expert operators, nevertheless the liability to this accident can be almost reduced to a vanishing point Fig. 144. — Bisecting the uterus — first step. if during the separation of the bladder the operator keeps careful note of its position with the bladder-sound. As there is much greater danger of this organ being wounded sup- posing it contains urine, the operator should pass a catheter himself before making the first incision, for, although the nurse may have emptied the bladder before the operation, 250 GYNAECOLOGICAL SURGERY it is a well-known fact to most medical men from the days of their earliest professional examinations how rapidly Fig. 145. — Bisecting the uterus — second step. the kidney secretes under the influence of fright or anxiety. If the bladder is opened, it must be sutured by the method described at p. 539. ii. Wounding the bowel.— If, when making the first VAGINAL HYSTERECTOMY 251 cut with the scissors, the points are directed against the vaginal wall instead of the uterus, the rectum may be wounded, and it may also be wounded if the cellular tissue between the vagina and the rectum is opened up. The small intestines or omentum, if they lie low in the utero-rectal pouch, may be wounded if care is not taken when cutting into it. If the bowel is wounded, it must be at once sutured according to the method described on page 545. A faecal fistula may result, which, however, as a rule, eventually closes. iii. Oozing. — At times, although there is no serious bleeding, some oozing may take place from one or other of the cut surfaces, in which case it may be found that this will be better controlled by clamping the oozing surface with a pair of long pressure or ring forceps, instead of ligaturing it. The forceps should be removed in thirty-six hours. iv. Injury to ureters. — As the ureter is less than an inch from the cervix at the point where the uterine artery is ligatured, there is a risk of its inclusion, or it may be cut during the division of the lower part of the broad ligament ; hence the importance of keeping as close to the uterus as possible when passing the lower ligatures and cutting the supravaginal cervix free (p. 236). This accident unfortunately is not so very uncommon. If both ureters are occluded the patient will die of anuria unless the obstruction is removed. If they are injured a ureteral fistula is the result. Nothing may be noticed for some days if the ureter has been tied as well, but when the ligature separates, urine commences to dribble from the vagina. This complication may be mistaken for a vesical fistula, but with the latter all the urine dribbles away, whereas if the escape of urine is due to a ureteral fistula the urine on the sound side will collect in the bladder. If there is any doubt, a solution of boric acid, coloured with methylene blue, can be injected into the bladder, and its presence 252 GYNAECOLOGICAL SURGERY ascertained by placing a wool swab in the vagina. As one of the methods of treatment for a ureteral fistula is to remove the kidney of the corresponding side, it will be seen how important it is to determine for certain which ureter has been injured. We know of a case where the failure to take this precaution resulted in the wrong kidney being removed. v. Bleeding. — There is always a certain amount of oozing after the operation, but if the bleeding is at all free either a ligature has slipped or some vessel which did not bleed during the operation has started doing so. In either case the bleeding spot must be religatured. vi. Implantation of cancer-cells. — Care must be taken when removing the uterus for carcinoma to avoid implan- tation of the malignant cells. In the case of a cervical growth this should be thoroughly destroyed beforehand with the cautery. If carcinoma of the body is present, great care should be taken entirely to suture up the external os before commencing the operation. In any case of malignant disease it is most important not to cut into the uterine wall whilst removing it. Some of these cases present a condition of pyometra, and it is important to pass a sound into the cavity to evacuate any pus that may be there before starting to remove the organ. Removal of the appendages. — In all cases in which the operation is performed for carcinoma of the uterus, the Fallopian tubes and ovaries should be removed, as also in septic cases and in all other conditions where they are obviously diseased; otherwise they should be spared, since their removal increases the difficulty of the operation owing to the inaccessibility in some cases of the ovarico- pelvic ligament. It is occasionally good practice to post- pone their removal until the uterus has been cut away. After-treatment. — See p. 45 and Chapter xxxn. The gauze packing is removed from the vagina in forty-eight hours. After this, for the first week the vagina should be VAGINAL HYSTERECTOMY 253 wiped out twice daily with swabs held in ring forceps and soaked in 1 — 5,000 biniodide of mercury. At the end of that time, vaginal douches of the same solution should be given at low pressure until all discharge has ceased. The patient gets up, if she has progressed normally, in three weeks. Fig. 146. — Vaginal hysterectomy by the clamp ligature method : Clamping the uterine artery. II. BY CLAMP AND LIGATURE Instead of ligaturing the vessels before removing the uterus, an alternative method is temporarily to clamp the broad ligaments, postponing the ligation till the uterus has been removed. This procedure has the advantages that it is quicker, and that the ligatures on the broad ligaments can be more securely tied. Indeed, when the 254 GYNAECOLOGICAL SURGERY vagina is narrow and the uterus is high up, it may be most difficult or even impossible to apply the ligatures before the uterus is removed. On the other hand, it cannot be gainsaid that ligation of the broad ligaments after the uterus is removed is more difficult, and that in the event Fig. 147. — Dividing the base of the broad ligament. of the forceps or ligature slipping off, the bleeding-point is more difficult to secure. Operation. — Up to the point when the broad ligaments are about to be ligatured, the operation proceeds on the same lines as those described in the first section of this chapter (Figs. 122-130). 256 GYNECOLOGICAL SURGERY i. Clamping the uterine arteries. — The uterus is pulled well down, and the situation of the uterine arteries felt with the thumb and index-finger of the right hand (Fig. 131), after which the portion of the broad ligament containing them is clamped with pressure-forceps (Fig. 146) and then Fig. 150. — Separating the uterus. divided with scissors (Fig. 147). This proceeding is repeated on the opposite side. ii. Clamping the ovarian artery. — The remaining portion of the broad ligament on either side containing the ovarian artery and Fallopian tube, together with the round and ovarian ligaments, is then secured with a second pair of long-bladed pressure-forceps (Fig. 148), after which the VAGINAL HYSTERECTOMY 257 uterus is cut free on that side (Fig. 149). Fig. 150 shows the same details being carried out on the opposite side, and the uterus removed. iii. Ligaturing the ovarian artery. — The pair of forceps which is clamping the ovarian artery and upper part of the broad ligament is now pulled upon, and with a ligature Fig. 151. — Transfixing the top of the broad ligament. of No. 4 silk this part of the broad ligament is transfixed and tied in halves, the upper passing over the free edge of the broad ligament and securing the ovarian artery, whilst the lower retransfixes the cut edges of the broad ligament below, so as to include, when it is tied, the round ligament (Figs. 151-153). The opposite side is treated in the same way. R VAGINAL HYSTERECTOMY 259 iv. Ligaturing the uterine artery. — The forceps clamp- ing the uterine artery are pulled upon, and this portion of the broad ligament is ligatured by a double transfixion or a mattress-ligature (Fig. 154) ; and the opposite side is treated in a similar manner (Fig. 155) Fig. 154. — Transfixing the base of the broad ligament. III. BY THE CLAMP METHOD Instead of ligaturing the edges of the broad ligament after the uterus has been removed, some operators send the patient off the table with the clamps on. This, in our opinion, is a very bad operation. We have seen one case which nearly had a fatal result from the slipping of the 26o GYNECOLOGICAL SURGERY forceps. Moreover, it is an extremely painful method and is always followed by considerable sloughing of the clamped tissues. If by reason of urgency (for the method has the advan- Fig. 155. — Securing the base of the broad ligament. tage of speed) this practice is followed, the clamps should not be removed until at least forty-eight hours have expired. CHAPTER XII RADICAL HYSTERO- VAGINECTOMY BY PARAVAGINAL SECTION Indications. — This operation has been extensively per- formed by Schauta and other Continental surgeons as a routine treatment for carcinoma of the cervix. We have discussed fully its merits in the chapter dealing with the radical abdominal operation for this disease (Chapter xvn). We ourselves, while preferring the abdominal route for most cases of carcinoma of the cervix, are of opinion that the vaginal route should be chosen where the patient is very fat. Further, we have employed this operation for cases of carcinoma of the body of the uterus with meta- static growth in the vagina where the uterus is freely mov- able and there are no signs of any other extension of the disease. It is also. indicated in certain cases of primary carcinoma of the vagina. Preparation of the patient. — See pp. 82-84. Instruments. — The same as for vaginal hysterectomy (p. 227). Operation. — The following are the steps of the pro- cedure : — i. Separation of the lower two inches of the vagina. — An incision is made round the mucous membrane of the vagina, at its junction with the vulva, with a pair of sharp angular scissors (Fig. 156), after which this canal is freed for its lower two inches with forceps and scissors (Fig. 157). ii. Closing the vagina. — The cut edges of the vagina are now closely approximated with interrupted sutures of No. 4 silk, by which means the canal is closed (Fig. 158). iii. Separation of the lateral and posterior vaginal 261 262 GYNECOLOGICAL SURGERY walls. — The remaining portion of the vagina is next separated from the rectal wall with the scissors and the Fig. 156. — Hystero-vaginectomy : Incising the vagino- cutaneous junction. pressure of a swab held on the index-finger of the right hand, the vagina being pulled forwards or backwards Fig. 157. — Separating the lower part of the vagina. RADICAL HYSTERO VAGINECTOMY 263 as may be convenient, by means of the ligatures held in the left hand (Fig. 159). Fig. 158. — Closing the vagina. iv. Paravaginal section. — The separated vagina being now held right forwards by means of a broad retractor, a deep incision is made with a scalpel along the length of Fig. 159. — Separating the vagina from the rectum. 264 GYNECOLOGICAL SURGERY the vaginal bed on its left side and through the skin to the left side of the rectum and around it towards the coccyx, the anterior fibres of the levator ani being divided, with the result that the wound gapes to a marked degree, and sufficient room is obtained for further manipulations (Fig. 160). Fig. 160. — Making the paravaginal incision. This incision may give rise to very brisk haemorrhage, which must be arrested by ligaturing any individual vessels that are seen spouting, or applying mattress-sutures to any surfaces where there is marked oozing. v. Opening the recto-uterine pouch. — Auvard's specu- lum is now inserted into the wound, and, the vagina being held forwards by the assistant, the peritoneal reflection RADICAL HYSTERO VAGINECTOMY 265 at the bottom of Douglas's pouch is seized with pressure- forceps and snicked through with scissors (Fig. 161), after which a large swab with a tape affixed is placed in Douglas's pouch to prevent the bowels from prolapsing. vi. Separating the bladder and opening the utero- vesical pouch. — The vagina being held well back by an Fig. 161. — Opening the recto-uterine pouch. assistant, the bladder is separated by a few judicious snips with the scissors (Fig. 162), aided by the handle of the scalpel and swab pressure (Fig. 163), until the ureters come into view. These should now be separated as far as possible with the index-finger from the paravaginal and para-uterine tissue. The identification and separation of the ureters is rendered more easy if the bladder be well 266 GYNECOLOGICAL SURGERY separated laterally. A broad retractor is now hooked under the bladder, which is dragged against the pubes, and the utero-vesical reflection of peritoneum having been seized with pressure-forceps, the pouch is opened with scissors (Fig. 164). vii. Ligature of the uterine vessels. — An assistant Fig. 162. — Separating the bladder. pulls the vagina well over to the right side of the patient, and while another holds the bladder well back the operator passes the index-finger of his left hand behind the broad ligament, identifies the uterine artery, and passes round it a Worrall's needle (Fig. 165) to which a piece of No. 4 silk is attached. The needle is now withdrawn, and the lower portion of the broad ligament containing the uterine vessels is ligatured, the uterus being then severed by scissors from that portion of the broad ligament already secured. The right side is treated in the same way. RADICAL HYSTERO VAGINECTOMY 267 viii. Delivering the fundus of the uterus. — The ante- rior retractor having been removed, the operator passes his finger into Douglas's pouch and anteflexes the fundus of the uterus so that it appears below the bladder. The fundus is then caught with a volsella and drawn forwards Fig. 163. — Exposing the ends of the ureters. so that the upper edges of the broad ligaments come into view (Fig. 166). ix. Ligature of the ovarian vessels and round liga- ments. — The anterior retractor is again pushed up below the pubes, this time above the fundus, and is given to an assistant to hold, whilst a second assistant with a pair of strong forceps pulls the fundus, together with the ovary and tube of the left side, well towards the right. The operator now slips his left index-finger behind the uncut portion of the broad ligament and with his right ;68 GYNECOLOGICAL SURGERY hand passes a Worrall's needle over the upper edge of the broad ligament and then through it (Fig. 167). The needle, having been threaded with No. 4 silk, is withdrawn, the silk divided, and the ovarian vessels and round ligaments separately secured on the left side. Fig. 164. — Opening the utero-vesical pouch. The uterus is then cut free on the left side, after which the right side is treated in a similar way. x. Suture of the paravaginal wound. — The para- vaginal wound is now closed by a series of interrupted sutures, fine silk being used for the vaginal portion and silkworm-gut for the skin. Dressing. — The swab is removed from Douglas's pouch and some gauze is lightly packed into the wound along its whole length. RADICAL HYSTEROVAGINECTOMY 269 After-treatment. — See Chapter xxxn. The gauze pack- ing is removed in -twenty-four hours, and the cavity is lightly packed every day with iodoform gauze. In these cases, much sloughing of the long, narrow wound may take place, with marked fetor and a certain amount of Fig. 165. — Transfixing the base of the broad ligament. constitutional disturbance. Should this occur, the cavity must be lightly irrigated with a solution of peroxide of hydrogen, 10 volumes, and the packing changed several times a day. If there is much oedema or sloughing of the external skin, hot fomentations should be applied. The bladder must be catheterized for a week or two, and washed out twice daily with boric-acid solution. Urotropin or salol may be given by the mouth. The stitches closing the paravaginal incision externally should be removed in 270 GYNECOLOGICAL SURGERY a week. The period of convalescence will be a long one, owing to the time taken for the cavity to close. The epithelium from the surface tends to grow inwards, so that eventually a short, very narrow pseudo-vagina may be formed. Dangers and difficulties. — The operation is a very serious one, and should not be attempted except by those Fig. 166. — Anteflexing the body of the uterus. accustomed to vaginal hysterectomy, than which it is much more difficult. The oozing from the vaginal bed and paravaginal incision is extremely free, and, apart from the ligating of any special vessels, the operator will have to rely upon the pressure of the retractors to keep it in check. Great care must be exercised, when separating the bladder and rectum, to avoid injuring these structures. The ureter is also in special danger of being wounded FIXATION OF UTERUS 271 unless great care be taken to define it. The bowel has a special tendency to prolapse. INTERVESICO-VAGINAL FIXATION OF THE UTERUS Indications. — This operation should, of course, never be performed on a woman capable of child-bearing. It Fig. 167. — Securing the ovarico-pelvic ligament. was devised by Freund for prolapse of the uterus. It has been highly praised by some authorities, but we have not performed it sufficiently often to arrive at any con- clusive judgment as to its merits when compared with ventro-suspension and perineoplasty for this condition. Preparation of the patient. — See pp. 82-84. 272 GYNAECOLOGICAL SURGERY Instruments. — Those for vaginal hysterectomy (p. 227) ; but eight pressure-forceps will suffice, and in addition silkworm-gut, shot and coil, and a shot compressor will be required. Operation. — The steps of the procedure are as follows : — i. Incising the anterior vaginal wall. — The procident uterus and vagina are pulled down with a volsella fixed Fig. 168. — Intervesico-vaginal fixation : Denuding the anterior vaginal wall. to the cervix, and the anterior vaginal wall is put upon the stretch. An oval area is delineated by two curved incisions beginning just under the urethra and terminating at the junction of the vagina and cervix. The mucous membrane of the vagina corresponding to this area is now excised and the base of the bladder exposed (Fig. 168). ii. Separating the bladder and opening the utero- vesical pouch. — The bladder is separated from the vaginal FIXATION OF UTERUS 273 Fig. 170. — Delivering the uterus. 274 GYNAECOLOGICAL SURGERY wall, especially laterally, by means of the blunt-pointed scissors and swab pressure (Fig. i6q), and the peritoneum of the utero-vesical pouch, having come into view, is incised transversely. iii. Pulling down the body of the uterus. — The vol- sella having been removed from the cervix, the body of the uterus is progressively anteverted by successive Fig. 171. — The sutures applied. grips of its anterior wall with a couple of volsellse until the fundus in its most dependent portion and the whole length of the body has been dislocated into a position between the bladder above and the vagina below (Fig. 170). iv. Fixing the uterus and closing the vaginal wound. — The wound in the anterior vaginal wall is now closed by interrupted silkworm-gut sutures which are passed so that each of them in the middle of the deep part of its FIXATION OF UTERUS 275 course picks up a portion of the anterior uterine wall (Fig. 171). The uterus is thus fixed upside down with its anterior surface parallel to and in contact with the whole length of the anterior vaginal wall. The operation should be concluded by a perineoplasty on the lines indicated on pp. 109-24. Dressing and after-treatment. — See Chapter xxxn. The patient should, if possible, remain in bed four weeks, the sutures being removed on the tenth day. All work involving straining should be avoided for at least three months. CHAPTER XIII OPENING AND CLOSING THE ABDOMINAL CAVITY Instruments required. — The instruments generally required for abdominal operations are the same in all cases. It will be convenient, therefore, to set them forth in a list to which the reader will be subsequently referred. Where any special instrument is required it will be mentioned at the beginning of the section. A scalpel. Four short and two long Spencer Wells pressure-forceps. Four short Kocher's pressure-forceps. Two ring forceps. One dissecting forceps. One volsella. Two blunted-pointed scissors. One bladder-sound. Berkeley's self-retaining retractor. Six curved needles (Bonney's — two No. 5, two No. 9, two No. 13). One straight 4-in. needle, or Michel's clip apparatus. Three reels of silk, Nos. 1, 2, and 4. Rubber drainage-tube, two sizes, J inch and f inch. A rubber catheter. Opening the abdominal cavity. — The following are the steps of this procedure : — i. Skin-incision. — The length of the skin-incision must necessarily depend both on the size of the tumour and on the amount of fat in the abdominal wall. In an average case it measures about 5 inches, and is situated between the umbilicus and the pubis in the mid-line. Preparatory 276 •*to *£> (N 00 CJ\ O 2.S 03 03 -a a H-3 c o T3 CD S *"' 03 £ ax a O Sh 03 ~ .2 co > ctS "qj -^ ££ ,03 afi 03 03 3 '- OPENING ABDOMINAL CAVITY 277 to this incision the operator steadies the abdominal wall with his left hand, the thumb resting on the right of the median line and the fingers on the left (Fig. 172), while with his right hand he delineates the upper border of the symphysis pubis to ensure that the lower end of the incision shall not be carried too far. It may be necessary to clamp a few bleeding-points, and notably two may require ligature owing to the division of a small transverse artery three- quarters of an inch above the symphysis pubis. Fig. 172.— Opening and closing the abdomen : Incising the skin. This oozing from the cut edges will be more marked if the patient is exsanguinated from any cause, if the tumour is or has been inflamed, if it is of a malignant nature, or if the patient is taking ether and is much cyanosed. ii. Fascial incision. — The linea alba is next incised (Fig. 173), and a streak of fat should mark the interrectal space. If this line of demarcation should not be ap- parent, search must be made for it to one or other side of the incision, and when found the recti should be 278 GYNECOLOGICAL SURGERY separated for the entire length of the incision by placing the forefinger of each hand in the wound and abducting them (Fig. 174). An alternative method is to incise the sheath of the rectus and cut directly through the muscle, or separate the fibres by inserting the points of the scissors between them, which is perhaps the better method, as it does not cause so much oozing. Those surgeons who divide the muscle- layer by these means do so either because they think there is less chance of a resulting hernia, or because on failing to find the line of separation when first incising the fascia they will not trouble to seek for it further. With regard to the fear of a subsequent hernia, we do not think this need be considered, since we have known hernia oc- cur after both methods. And we are further of opinion that there is a distinct disadvantage in cutting through the muscle, since not only is there apt to be a good deal of trouble- some oozing from the torn vessels, but also the incision cannot be so satisfactorily retracted, and the complaint of pain in the abdominal wound during the first few days after the operation is more marked. In some cases, on incising the linea alba and separating the recti, one or two veins running transversely from under the posterior layer of the sheath will be divided, and the cut ends will need ligature. Fig. 173. — Incising the fascia. OPENING ABDOMINAL CAVITY 279 iii. Peritoneal incision. — After the recti and sub- peritoneal fat have been separated by the index fingers, the shiny peritoneum appears, and in most cases no difficulty is experienced in its recognition, since the urachus can be seen as a white cord running through this membrane. The peritoneum is now clamped on the left of the median line with pressure-forceps which are handed to the assistant, or the assistant may clamp it himself, whilst on the right of the median line the sur- geon holds the perito- neum with a pair of dissecting forceps. The peritoneum is then stretched between the forceps, slightly raised, and carefully nicked so that air can enter and displace any intestines or omentum that may be adhering to it, and which other- wise, if a deliberate in- cision were made, might be wounded (Fig. 175). An additional method of obviating this risk is to give that piece of peritoneum which is held by the dissecting forceps a little shake before nicking it, when any adhering intestine or omen- tum will fall away. The abdominal cavity having been opened, the peri- toneum is divided along the entire length of the wound towards the lower angle by inserting under the peritoneum the first and second fingers of the left hand, palmar surface uppermost (Fig. 176), and cutting between the two ; and towards the upper angle by raising it with the index finger Fig. 174. — Separating the recti. 280 GYNECOLOGICAL SURGERY of the left hand, palmar surface uppermost, directing the assistant to do likewise on his side, and then cutting it Fig. 175. — Incising the peritoneum. Fig. 176. — Enlarging the wound towards the pubes. (Fig. 177), in each case avoid- ing the veins which at times are found running vertically towards the pubis. If there appears to be any danger of wounding the bowels or omentum during this divi- sion, a swab may be placed over them first. Difficulties and dangers. — Sometimes, after the recti have been separated, difficulty will be experienced in recognizing the peritoneum, or in making an opening into its cavity, whilst in some cases there is a danger of wounding the subjacent organs. There may OPENING ABDOMINAL CAVITY 281 be several reasons for this, which will be discussed under the following headings : — i. Subperitoneal fascia. — In certain cases, when the peritoneum is adherent to an underlying tumour, the deeper layers of the subperitoneal fascia may be mistaken for the peritoneum, while the peritoneum is mistaken for the surface of the tumour, and under these conditions the surgeon, thinking that the tumour is adherent to the peri- toneum, may endeavour to separate it, and will in reality Fig. 177. — Enlarging the wound towards the umbilicus. be stripping the peritoneum itself from the subperitoneal tissue. It is then of use to remember that at the umbilicus the peritoneum and subperitoneal tissue cannot be separated. ii. Bladder. — This organ may be so distended or dragged upon by the tumour that it reaches half-way up the wound, or even higher, and, if it is not at first recognized, difficulty will be experienced in attempting to open the peritoneal cavity. Suspicion may be aroused on discovering that the tissue presenting after separation of the recti has a fleshy appearance differing from that of the shiny membranous peritoneum, and also that when a small cut is made into it marked venous oozing occurs, an almost sure sign that 282 GYNECOLOGICAL SURGERY the bladder is being wounded. This difficulty and danger may often be avoided by inquiring of the nurse, before any abdominal operation, whether she has found any difficulty in catheterizing the patient, an answer in the affirmative being a forewarning. If there is reason to suspect that the presenting tissue is bladder, the attempt to open the peritoneal cavity at that point should be abandoned, and a point nearer to the umbilicus should be selected. In the more difficult cases a sound should be passed into the bladder to settle the matter. The bladder has often been mistaken for subperitoneal fascia or peritoneum by the unobservant operator, and consequently opened. This mistake may be avoided by bearing in mind the advice given above. The bladder may also be wounded when the peritoneal opening is being enlarged towards its lower end (Fig. 176), which accident may be prevented by holding up the peritoneum and looking at it through its inner surface, when the limitation of its transparency will indicate the position of the bladder. If the bladder is opened, it should be at once closed according to the methods described elsewhere (p. 539). iii. Intestine or omentum. — If the intestines are much distended with gas, if they or the omentum are adherent to the parietal peritoneum, or if both are floated up by free fluid in the peritoneal cavity, there is danger, unless care be exercised, that one or other will be injured when the peritoneum is incised. When it appears that any of these conditions may be present, only the smallest nick should be made at first in the peritoneum, and that very carefully. If the air does not then sufficiently separate the peritoneum from the abdominal contents, the opening must be carefully enlarged with a blunt-pointed director until a finger can be inserted and any adhesions separated, fluid evacuated, or a swab introduced between the peritoneum and bowel, as the case may be. If the omentum is wounded the bleeding-points must be ligatured OPENING ABDOMINAL CAVITY 283 at once with thin silk, or if the intestine is injured it should be sutured according to the directions given elsewhere. iv. Adherent tumour. — The tumour may be adherent to the parietal peritoneum. In the case of an ovarian cyst which has been inflamed and then become adherent to the parietal peritoneum, there will be at times some difficulty in distinguishing the one from the other. We have known cases where the peritoneum, having been mistaken for the cyst-wall, has been stripped off the parietes nearly up to the diaphragm before the error was discovered, with the result that sloughing took place at a later date. To determine between peritone'um and cyst-wall may test the powers of even the most experienced, and the only way to obviate this danger is to remember that the condition just described may exist, and when, as in this or in any other case, there appears to be difficulty in opening the abdominal cavity, to try again at a higher point of the incision. Size of opening in abdominal wall. — It is important that the opening in the abdominal wall should be sufficiently large to deliver the tumour and to enable one to obtain a good view of the pelvic organs. There is a great tendency for most beginners, and even for many veterans, to make this opening too small. As a result, any complications that present themselves are much more troublesome to deal with, and the operator loses much valuable time niggling about in a confined space, only to be compelled in the end to enlarge the opening. There is no greater tendency to a ventral hernia with a large opening than with a small one, and the operator will be well advised in making his first incision of ample length. The exact length depends upon the circumstances with which he has to deal. In the case of solid tumours the upper end of the incision, as a general rule, should be at least 2 inches above the upper end of the tumour. If, however, the tumour be very large, or there be doubts 28 4 GYNAECOLOGICAL SURGERY as to its removability, or its exact location, it is better to begin with an incision large enough only for adequate examination, and to enlarge it or not as the ascertained nature of the case may demand. Similarly in large fluid tumours, some of which are with advantage tapped before removal, it is advisable to begin with a moderate incision. It is lamentable to see the abdomen split from ensiform to pubis for a tumour which subsequent examination shows could have been properly removed through a wound a third the length. In obese patients the size of the wound must be relatively large, while in those with thin or flaccid abdominal walls a much smaller opening will suffice. In all operations requiring deep dissection at the bottom of the pelvis, such as the radical abdominal operation for carcinoma of the cervix, a free incision of the abdominal wall must be made. If it is necessary to pass the umbilicus when enlarging the wound upwards, it is good practice to carry the incision around and not through this structure. There are three good reasons for this : i. The skin there is with difficulty rendered sterile. 2. The various layers of the abdominal wall fusing at that point, it is impossible to effect there a satisfactory three-tiered suture when closing the abdominal wall. 3. Owing to the thinness of the tissues and the down dip of the skin, buried sutures are more likely to cause suppuration in that situation. This is the more disastrous if a continuous peritoneal suture has been employed, since the wound will suppurate deeply along its whole length. In enlarging the wound downwards, the linea alba may be incised right down to the bone, but the peritoneum should not be divided lower than a point an inch above the pubis. Apart from the possibility of wounding the bladder, such a proceeding has the disadvantage of freeing this viscus to such an extent that it drops down upon the uterus and continually obscures the surgeon's view CLOSING ABDOMINAL WOUND 285 throughout the operation. This is especially baulking in deep operations in fat patients. Closing the abdominal wound. — This is effected in the following stages : — ■ i. Peritoneum. — The peritoneum is united by a con- tinuous suture of No. 2 silk. The assistant should elevate the peritoneal edges by means of two pressure-forceps, one applied at each end of the incision. Fig. 178. — Suturing the peritoneum. After the first stitch is tied., he removes the forceps at that end, and, maintaining his hold of the other, employs his free hand in holding the thread taut, so as to prevent its slipping during the insertion of each stitch. If the bowels are troublesome and bulge into the wound, so that they are in danger of being pricked, a small swab may be placed over them before the suturing is started, care being taken, of course, to leave an opening sufficiently large to remove the swab before the layer is completely sutured. At times, after removal of this suture-swab, much difficulty 286 GYNECOLOGICAL SURGERY may be found in closing the small opening that remains, on account of the intestine bulging through the opening. This difficulty will be successfully surmounted if the cut edges of the peritoneum are lifted as high as possible with two pairs of forceps and the suture is passed during ex- piration, or by passing the forefinger of the left hand into the wound, depressing the gut, and then suturing above the finger and drawing the silk tight as the finger is removed. It is best to commence suturing this layer at the umbilical Fig. 179. — Suturing the fascia. end of the incision, because (i) it is the more difficult end, especially in fat patients ; and (2) if a suture- swab is being used, its withdrawal will not then disturb the omentum (Fig. 178). ii. Fascia. — The fascial edges are united with inter- rupted No. 4 silk sutures on curved needles, beginning at the pubic end of the wound (Fig. 179). As each suture is tied it is handed to the assistant, who pulls it tightly towards the pubis, thus putting the fascial edges on the stretch and defining them. As the following suture is tied he cuts CLOSING ABDOMINAL WOUND 287 the suture he is holding, just above the knot, and then takes hold of the next one. If the abdominal incision has been carried above the navel, it may be found impossible to suture the fascia and peritoneum separately, since the two may be so adherent there as to form practically only one layer. In such cases the peritoneum and fascia above the navel are sutured together with interrupted silk sutures, care being taken when passing the highest sutures that neither the colon nor the stomach is transfixed. In some cases, especially when the sutured peritoneum is loose and falls away markedly from the fascia at the pubic end of the wound, it is a good plan to pass one or two sutures through both peritoneum and fascia, thus bringing the two into apposition and closing the potential space into which blood might ooze and cause a haema- toma. Some surgeons prefer to pass these "haemostatic" sutures through all three layers, including the skin. iii. Skin. — The skin-incision may be closed either by suture or by means of Michel's clips. If suturing is preferred, a simple continuous suture of No. 2 silk on a straight 4-in. needle should be adopted, care being taken to oppose the edges accurately, for otherwise healing may be less perfect (Fig. 180). While suturing the skin a vein may be pricked, and oozing rather more than can be neglected take place. As a rule, this is at once stopped by tightening the suture, but if not, a pair of pressure-forceps should be applied to the oozing spot for a few minutes, or a mattress-suture passed under- neath it. When the incision is carried above the navel, it is often better, if this structure is at all depressed, to approximate the skin-edges in its neighbourhood by one or two inter- rupted sutures of silk, since they can be more easily removed than the continuous stitch. In exceptional circumstances, such as extreme flab- biness of the abdominal wall, or where post-operative 288 GYNECOLOGICAL SURGERY bronchitis is anticipated, it is good practice to reinforce the three-tier suture described by a few through-and- through interrupted silk sutures. Two of these sutures are with advantage inserted on either side of a drainage track, so as to close the planes of the abdominal wall and prevent suppuration from extending along them. By far the better method of closing the skin, in our opinion, is by Michel's clips. The advantages of this clever device may be thus summarized : — (i) It is to be remembered that every suture pene- Fig. 180. — Suturing the skin. trating the skin is, in fact, a seton. Both during its insertion and its removal, particles of epidermis, possibly infected, tend to be implanted in the underlying connective tissue, while during the whole of its tenure a potential track for the downgrowth of organisms is created. We believe that many stitch-abscesses have their origin thus. Michel's clips, since they do not penetrate the thickness of the skin, are free from this objection. (2) Owing to the broad surface of contact effected by the clips, a peculiarly strong union occurs, so that they CLOSING ABDOMINAL WOUND 289 may be safely removed three days after the operation. This is a great relief to the patient. (3) They can be inserted more quickly than the quickest method of suture. (4) The subsequent scar is very narrow and no stitch- hole scars are left. Moreover, the scar does not tend to adhere to the fascia and become depressed. This may seem a small matter in a situa- tion like the ab- domen, but in our experience many women are very sensitive, and na- turally so, of an unsightly seam disfiguring the na- tural curve of the abdominal wall. (5) If there is any bleeding from the wound after the operation is over, the blood escapes between the clips, therefore the troublesome complication of a hematoma is avoided. Since we have used Michel's clips we have seen this com- plication very rarely. Application of Michel's clips.— The pubic angle of the wound is seized with the forceps in the right hand, and the skin edges are approximated with the clip-holder in the left hand, about half an inch above it (Fig. 181). The lower edges of the incision are then pulled taut by making traction with the clip-holder in an upward direction, and T Fig. 181.— Technique of Michel's clips : Approximating the skin-edges. 2Q0 GYNECOLOGICAL SURGERY with the forceps in the right hand the surgeon removes a clip from the holder (Fig. 182), and clips the skin-edges Fig. 182.— Seizing the clip. Fig. 183.— Continuing the approximation. just above the lower angle of the incision (Fig. 183). He now, without letting go of the clip he has inserted, makes traction pubicwards on the forceps holding it, and thus renders taut the ununited skin-edge adjoining, which is again approximated with the clip-holder about half an inch from the clip that has been fixed. Traction is made with the clip-holder in the opposite direc- tion while another clip is removed and fixed, and so on. Fig. 183a. — Method of removing clip. CLOSING ABDOMINAL WOUND 291 Removal of sutures and clips. — Skin-sutures should be removed on the seventh day after the operation, except in the case of through-and-through sutures, which may be left in situ a day or two longer if the surgeon thinks necessary. If Michel's clips have been used, they should be removed on the fourth day. The clips are easily re- moved by means of the special forceps figured on p. 18. The clip having been steadied by forceps held in the left hand, the beak of the removal forceps is inserted under the clip, which is then opened out and removed (Fig. 183a). A narrow strip of gauze along the wound and one or two bands of adhesive strapping are then applied. CHAPTER XIV SUBTOTAL HYSTERECTOMY BY THE ROUTINE CLAMP AND LIGATURE METHODS Indications — This and the method next to be described are the ordinary ways of performing subtotal hysterectomy. The technique is indicated in all conditions in which the body of the uterus is either movable or, being adherent, can be freed ; and in which the broad ligaments and supra- vaginal cervix, beyond being elongated, are not deformed by the presence in them of a tumour. These are not the correct methods of performing subtotal hysterectomy for myomata of the supravaginal cervix or broad ligament, nor for those cases in which the top of the uterus is tethered down by adhesions that cannot readily be divided. For such cases the methods described a ^ PP- 338, 406 and 331 are properly to be employed. I. SUBTOTAL HYSTERECTOMY BY THE CLAMP METHOD Preparation of the patient. — See pp. 82-86. Instruments — See p. 276. Operation. — The following are the steps of the pro- cedure : — i. Opening the abdominal cavity. — See p. 276. ii. Delivering the uterus. — If the uterus is the seat of a tumour, the surgeon slips his left hand into the abdo- minal cavity under it, and while he is lifting it through the wound his right hand assists in retracting the parietes on the right side, the assistant, if necessary, doing likewise on the left. If the uterus is not enlarged, it cannot, except in thin women with very lax tissues, be brought outside 292 Plate III.— Multiple Myomata of the Uterine Body. SUBTOTAL HYSTERECTOMY 293 the abdominal wound. Delivery may be assisted by traction on a volsella fixed on the uterus (Fig. 184). iii. Inserting the large swab. — When the tumour has been delivered, the intestines and omentum are covered, and prevented from protruding through the abdominal opening or into the field of operation, by packing the largest flat swab well up under the abdominal wall, and then turning the lower edge down into Douglas's pouch (Fig. 185). iv. Clamping and divid- ing the ovarian vessels. — Two pressure - forceps are now applied to the upper Fig. 184. — Routine subtotal hysterectomy : Delivering the uterus. Fig. 185. — Inserting the large swab. 294 GYNAECOLOGICAL SURGERY border of the broad ligaments on each side. Their exact position will depend upon whether the ovaries are healthy, and whether they are going to be conserved or not. If the ovaries are healthy, they should always be con- served, and in this case the forceps will be applied between the uterus and the ovary. One pair of forceps on each side clamps the tube, and as much mesometrium as possible, including the ovarian vessels, close to the uterus, while the other pair is applied in a similar manner an inch nearer the ovary (Fig. 186). Fig. 186. — Clamping the top of the broad ligament. It is necessary to clamp a good inch of mesometrium, since the ovarian artery does not run close under the tube. Pressure-forceps with blades half as long again as the ordinary ones will therefore be found best for this purpose, and any oozing will be much better controlled. If, how- ever, it has been decided to remove the ovaries, then the outer pair of forceps is applied to the ovarico-pelvic liga- ment outside the ovary. The forceps being applied, the upper part of the broad ligament and the tube are divided just inside the outer forceps. SUBTOTAL HYSTERECTOMY 295 v. Clamping and dividing the round ligament. — The method of dealing with the round ligament varies. In many cases it will be found possible to secure the round ligament with the same pair of forceps that is clamping the ovarian vessels and tube. In other cases, where the upper portion of the broad ligament is expanded by the growth of the tumour, it will be necessary to clamp the round Fig. 187. — Dividing the top of the broad ligament. ligaments separately. Or it may be found that one forceps will suffice to secure the round ligaments, tubes, and ovarian ligament as they come off the cornu of the uterus, whilst further out, owing to the separation of the broad ligament, separate clamps will be needed. Or, lastly, it may prove to be necessary to clamp the round ligament separately on account of its size, which may have increased pari passu with the hypertrophy of the rest of the uterus. If the precaution of clamping the round ligaments is not 296 GYNECOLOGICAL SURGERY taken, troublesome oozing due to their retraction after division may delay the suturing of the stump at a later period. After being clamped, the round ligaments are divided. vi. Opening up the broad ligaments. — The broad liga- ments are further divided as far as the lower limit of the avascular space which lies beneath the ovarian and round ligaments (Fig. 187), and .are then opened up towards the Fig. 188. — Opening up the broad ligament. uterus by hooking the forefinger of each hand between the cut edges of the peritoneum and abducting them, while the uterus is pulled over to the opposite side by the assistant so as to bring the uterine vessels into view (Fig. 188). vii. Reflecting the anterior flap of peritoneum. — The anterior flap of peritoneum is, as a rule, quite easily dis- sected off the lower part of the uterus or tumour and turned downwards. Exactly how much peritoneum should SUBTOTAL HYSTERECTOMY 297 be deflected is a matter of experience rather than rule, but sufficient must be taken to cover the stump later on. When in doubt, therefore, it is better for the operator to take too much than too little, for it can be trimmed easily, if necessary, and peritoneal flaps always shrink more or less. Before deflecting the anterior flap its upper limit should be delineated by raising the loose peritoneum on Fig. 189. — Demarcating the peritoneal flap. the front surface of the lower segment of the uterus with the finger (Fig. 189). If nothing but peritoneum is raised there will be little or no oozing, but this will not be the case if the anterior flap be fashioned by cutting, for in that case a certain amount of subserous muscle will be included in it. The separation of the peritoneum on the front of the lower uterine segment is effected easily, except along a frsenum-like attachment in the middle line, which may require a touch with the scalpel. 298 GYNECOLOGICAL SURGERY The chief care in dissecting off this flap is to see that the bladder is not injured (Fig. 190). If the operator is in any doubt as to the condition of this organ, he should have a sound passed into it, but to the experienced eye it is usually recognizable as a ridge running across the anterior surface of the peritoneum at the bottom of the utero-vesical pouch. Fig. 190. — Dissecting the anterior peritoneal flap. viii. Clamping the uterine vessels. — After the anterior flap has been separated and the broad ligaments have been opened up, the uterine vessels can often be seen running up the uterine wall, or, if not seen, can be felt pulsating, and at this stage pressure-forceps are applied to them on each side (Fig. 191). In many cases the uterine vessels can be clamped before reflecting the anterior flap, a procedure which has SUBTOTAL HYSTERECTOMY 299 the advantage of minimizing any oozing during the per- formance of the latter (Fig. 190). ix. Dissecting down the posterior flap of peritoneum. — If the full extent of the movable peritoneum on the front of the uterus has been utilized in making the anterior flap, a posterior flap is not, as a rule, necessary. If, how- ever, it is desired to make one, the assistant should drag the uterus forwards, and, the upper limit of the posterior Fig. 191. — Clamping the uterine vessels. flap having been indicated with the scalpel, the peritoneum is deflected downwards. As this membrane is more adherent to the posterior than to the anterior surface of the uterus, greater difficulty will be found in its separation than in the case of the anterior flap, and care must be taken not to button-hole it. Very often it is impossible to limit the flap to peritoneum only, and some of the subjacent tissue has to be dissected off with it, when oozing — which is, however, of little consequence — may be rather marked. 3oo GYNAECOLOGICAL SURGERY x. Removing the uterus and tumour. — The operator now pulls the uterus over towards him with his left hand, and amputates it slightly above the limit of the reflected flaps and just above the point where the uterine vessels are clamped (Fig. 192). The stump of cervix that remains will, if the vessels have been properly occluded, appear white. Fig. 192. — Amputating the uterus. The method of amputating the uterus may be carried out in different ways. Some authorities advocate a wedge- like incision so as to form flaps of cervical tissue, which, when sutured together, obliterate the raw surface of the stump. Other surgeons aim at removing as much as possible of the cervical stump, short of performing total hysterectomy, in order to extirpate any diseased mucous membrane and reduce the bulk of the stump to a minimum. SUBTOTAL HYSTERECTOMY 301 This they effect by a circular movement of the scalpel while strong traction is made on the portion being excised. If this manoeuvre is carried to its extreme, as practised by Bland-Sutton, nothing is left after the excision but a thin shell of cervical tissue. We have practised both these methods, but as a rule we prefer to cut the cervix straight across. Directly the uterus is amputated the stump should Fig. 193. — Passing the ligature to secure the uterine artery. be seized with a volsella and drawn up for inspection. All blood-clots having been cleared away, and any unsecured vessel clamped, the ligature of the vessels is proceeded with. xi. Ligaturing the uterine vessels. — The cervical tissue on each side is transfixed with a curved needle threaded with No. 4 silk, in front of the points of the forceps which are clamping the uterine vessels (Fig. 193). The ligature is then tied below the forceps so as to encircle the vessels, the assistant meanwhile holding the forceps horizontally 302 GYNAECOLOGICAL SURGERY to prevent their points from catching in the grip of the liga- ture (Fig. 194). If when the forceps are removed there is oozing from the uterine vessels, these must be reclamped and another ligature applied. If in spite of such ligatures the stump is not quite dry, the oozing is due to the anasto- mosis between the vessels of the cervix and the vaginal arteries. This oozing can be stopped by one or two mattress- Fig. 194. — Securing the uterine artery. sutures passed through the stump. Additional ligatures may be applied directly around the free ends of the uterine vessels, and thus assurance be rendered doubly sure. xii. Securing the ovarian vessels and round ligaments. — We shall describe four ways of performing this step of the operation : 1. A needle armed with No. 4 silk is passed through that portion of the broad ligament which is internal to SUBTOTAL HYSTERECTOMY 303 the forceps clamping the ovarian vessels and round liga- ment (Fig. 195). The ligature is then brought across the round ligament and outside the forceps over the upper border of the ovarico-uterine ligament so that the ovarian vessels and round ligament are secured with the same ligature (Fig. 196). This is the quickest way to secure these structures, but it has the obvious disadvantage that if the Fig. 195. — Passing the ligature to secure the ovarian artery. round ligament retracts from the grasp of the ligature the latter is of no further use, and the ovarian vessels will bleed. This method may be followed with almost certain security when the round ligaments and ovarian pedicle are very thin and elongated, but only in such cases. The operation is concluded by suturing the peritoneal flaps across the stump by means of a continuous silk suture from left to right (Figs. 197, 198). 2. In the second method, a needle into which is tied a long piece of No. 4 silk, doubled so that the ends are Fig. 197. — Closing the perito- neum over the stump. SUBTOTAL HYSTERECTOMY 305 Fig. 198. — First method of treating the pedicles and flaps. equal, is made to transfix that portion of the broad liga- ment which, is internal to the forceps clamping the vessels but external to the round ligament. The ligature is now divided so that the needle is left attached to the inner half of it. The outer half of the ligature is then used to sur- round the ova- rian vessels and Fallopian tube, while the internal ligature by means of its attached needle is made to re-transfix both layers of the broad ligament internally to the round ligament, this structure being pulled into its grip as it is tied. The advantage of this method, which is the one we have generally employed, is that the ovarian vessels are ren- dered as secure as possible, and that the mattress-suture controlling the round ligament gathers up a great deal of the slack of the broad ligament (Fig. 199). 3. We have devised another method, which appears to us an improve- ment on the one last described, be- cause in it the ligature securing the round liga- ment is also used to close laterally the gap in the broad ligament by attaching the end of the round liga- ment to the angle of the stump, thus reducing the length of the peritoneal suture-line over the stump. This is effected by running the inner half of the ligature along the posterior layer of the broad ligament as a pleating suture, the last pleat including the peritoneum on the Fig. 199. — Second method of treating the pedicles and flaps. 306 GYNECOLOGICAL SURGERY Fig. 200.— Third method of treating the pedicles and flaps. posterior surface of the stump. From this surface of the stump it is carried across the stump and made to transfix the anterior peritoneal flap well internally to the round ligament, so that when tied the broad ligament is puckered up and the round liga- ment pulled in to- wards the middle line (Fig. 200). 4. The last me- thod is identical with the one just described, except that only one ligature is used. The ovarian vessels and tube having been secured as indicated, the free end of the ligature to which the needle is attached is made to follow the same path as that of the inner ligature in Method 3, and is eventually tied to the other free end of the ligature securing the ovarian vessels, the round ligament being pulled into its grip meanwhile. This method (Fig. 201) is the quickest of all, but inferior in point of security to No. 3. xiii. Suturing the broad liga- ments and perito- neal flaps. — The unclosed portion of the peritoneum which intervenes between the ligatures that include the round ligaments is now to be closed. Where this gap is considerable, as occurs in the two methods first described for securing the ovarian vessels and round ligament, closure should be effected by approximating the edges with a continuous Fig. 201. — Fourth method of treating the pedicles and flaps. SUBTOTAL HYSTERECTOMY 307 No. 2 or No. 4 silk suture on a small curved needle. The suture should be started just internally to the point where the left round ligament is tied, and should be carried across to a corresponding suture on the right side (Fig. 197). The result will be neater if the operator adopts a Lem- bert's suture, particularly when passing the needle through the peritoneum on the posterior surface of the stump. This proceeding ensures that the suture-line lies posteriorly, i.e. facing the rectum, instead of along the top of the stump, where it is much more in danger of contracting adhesions to omentum and small intestine. It has been seriously advised to effect, by means of a large posterior flap, a suture which runs along the front of the stump, i.e. along the bottom of the utero-vesical pouch. This is the worst position for the suture-line, because no utero- vesical pouch exists after the proper performance of a subtotal hysterectomy, and the suture-iine is in the same danger of adhesion as when situated along the top of the stump, while the formation of a large posterior flap prolongs the operation, causes more oozing, and is in many cases entirely impracticable. If the third or the fourth method of securing the ovarian vessels and round ligaments has been followed, the peritoneal gap is closed by one or two mattress-sutures (Figs. 200, 201). The operator must bear in mind the position of the bladder, otherwise it may be transfixed when the needle is passed through the anterior flap. xiv. Closing the abdominal cavity. — See p. 285. Difficulties, i. Small incision. — If the primary incision is not of sufficient length, it can easily be enlarged in an upward direction, first placing a swab over the bowels and avoiding the navel by incising round it. If the peri- toneum cannot be further lengthened towards the pubis on account of the bladder, it will often be found that the division of fascia right down to the bone is of great advantage in aiding the delivery of the tumour. ii/Nature of the tumour. — When the uterus is enlarged 3o8 GYNECOLOGICAL SURGERY by tumours, usually myomata, growing in the supravaginal cervix or bulging into the broad ligaments, it cannot be delivered through the abdominal wound, because the stretched peritoneum over the lower uterine segment and broad ligaments fixes the organ. These tumours require special treatment (see pp. 338 and 406). iii. Impaction. — The tumour, or part of it, may be im- pacted in Douglas's pouch and held there by atmospheric pressure. This difficulty may be surmounted by so tilting the tumour that a little air can rush in under it, or by seizing it with the volsella, or by a combination of the two methods (Fig. 184). iv. Adhesions. — The tumour may be held fast by adhesions, so that it cannot be delivered until they are separated. If so, the adhesions must be separated with great care by means of the fingers, dissecting forceps, scissors, scalpel, or swab. If the freed ends of the adhe- sions bleed, they should be carefully ligatured with No. 2 silk. Special care must be taken in separating the intes- tinal adhesions, because wounding the intestine may result in peritonitis with death, or a faecal fistula. It will be found that intestinal adhesions are often best separated by a stroking movement of the swab on the tumour portion of the adhesions ; but if they are so tough that they will not separate without cutting, and the intestine is so close that there is a danger of wounding, it will be safer rather to cut off the superficial layer of the uterine wall to which the adhesions are attached, and leave it tethered to the intestine, or deliberately to resect the involved portion of the gut. If the intestine is wounded, it must be repaired according to the manner described elsewhere. In the case of a firmly adherent portion of omentum it is best to ligature and divide it, afterwards carefully examining the cut end to make sure that it is not oozing. Dressing — See p. 44. The vagina is carefully cleansed with swabs on long forceps, by which means any blood- SUBTOTAL HYSTERECTOMY 309 clot that may have escaped through the cervical canal can be removed, or, if any serious bleeding is taking place from the stump, as rarely happens, it might be detected and dealt with at once. It is a good plan to empty the bladder with a catheter before sending the patient back to bed, so that for some hours she need not be disturbed. A proper amount of urine will be an indication that the ureters are intact, and the absence of blood will show that the urinary tract has not been injured. After-treatment. — See Chapter xxxn. II. BY LIGATURE The great advantage of this method is that, when pro- perly carried out, it is an almost bloodless procedure. It is eminently suitable for cases in which the disease affects the uterine body alone and the latter is freely movable, and in which the patient is already so exsanguinated that every drop of blood is of vital importance to her. We ourselves as a routine practice have abandoned this technique for the method just described, because in cases of difficult hysterectomy, especially where the broad ligaments are shortened, twisted, or otherwise deformed, it is very diffi- cult to ligature the vessels securely prior to the removal of the tumour, and the pedicles had often to be religatured, necessitating the loss of much time and the use of an increased quantity of ligature materials. The method, in spite of these defects, is in straight- forward cases an excellent one, and we think that surgeons who are not used to this class of work will find it the most satisfactory to begin with. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation. — The steps of the operation are the follow- ing :— i. Opening the abdominal cavity- — See p. 276. ii. Inserting the large swab. — See p. 293. 3io GYNECOLOGICAL SURGERY iii. Securing the ovarian vessels. — The operator pulls the uterus over to his side so that the broad ligament on the assistant's side is put upon the stretch. The surgeon, with a pedicle-needle threaded double with No. 4 silk, passes the ligature through the top of the broad ligament just below the ovarian vessels. The loop of silk is then Fig. 202. — Subtotal hysterectomy by ligature method : Passing the ovarian ligature. pulled free of the eye of the pedicle-needle (Fig. 202) and is divided with scissors. Both ends are now freed of the needle, which is withdrawn, leaving two ligatures trans- fixing the broad ligament. Having, by pulling on the two ligatures, found the ends belonging to each, the operator takes the ligature nearest the ovary and by a sawing move- ment separates it from the other ligature, and then ties it close to the ovary (Fig. 203). He ties the other liga- SUBTOTAL HYSTERECTOMY 311 ture in a similar manner, only in this case draws it in towards the uterus and ties it as near that organ as pos- sible. Thus there is a free space left between the tube and ovarian vessels and that portion of the broad liga- ment which lies below them. If the ovary is going to be taken away, the ovarico-pelvic ligament is tied off in the same way. That portion of the broad ligament which has been ligatured is now divided with scissors between the ligatures as shown in Fig. 204. The opposite side is Fig. 203. — Separating the ligatures. next treated in a similar manner by some surgeons ; others prefer to finish off one side first according to the succeeding sections. It is purely a matter of taste and convenience which method is followed, although perhaps less blood is lost if the two ovarian vessels are tied off on each side before proceeding to secure the uterine artery. iv. Securing the round ligament. — If the round liga- ment is near the Fallopian tube, it may be secured by the same ligature which surrounds the ovarian end of the ovarian vessels. If on account of the tumour the round ligament is much displaced, or if it is hypertrophied, then it should be separately secured by passing beneath it a 312 GYNECOLOGICAL SURGERY double ligature of No. 4 silk (Fig. 205), drawing the ligatures apart and tying it off in two places, and dividing it between the ligatures (Fig. 206). It is better to tie the round liga- ment separately under the conditions detailed, because, having a tendency to contract, it may escape from a ligature holding it, and set free the ovarian vessels. v. Opening up the broad ligaments. — See p. 296. vi. Securing the uterine vessels The uterine artery having been brought into view or its position ascertained Fig. 204. — Dividing the ovarian pedicle. by palpation, the operator pulls the uterus upwards and towards his side, and then passes a rectangular curved needle between the uterus and the uterine vessels, being careful not to prick them in so doing (Fig. 207). The uterine vessels are tied (Fig. 208). The assistant then pulls the uterus over towards his side, so that the uterine vessels may be secured in a similar manner on the opposite side, vii. Dissecting down the anterior flap of peritoneum. — See p. 296 and Fig. 209. SUBTOTAL HYSTERECTOMY 313 Fig. 205. — Passing the round-ligament ligature. Fig. 206. — Securing the round ligament. 3i4 GYNECOLOGICAL SURGERY viii. Dissecting down the posterior flap of peritoneum. — See p. 299 and Fig. 210. ix. Removing the uterus and tumour. — See p. 300 and Fig. 192. x. Suturing the peritoneal flaps. — The ovarian vessels and round ligaments being already ligatured, and all oozing from the stump having been stopped, the peritoneal flaps Fig. 207. — -Passing the ligature round the uterine artery. are united from left to right by a continuous No. 2 silk suture (Fig. 197). xi. Closing the abdominal cavity. — See p. 285. Dressing and after-treatment. — See p. 44 and Chapter XXXII. Difficulties in subtotal hysterectomy for disease of the body of the uterus. — The difficulties of this operation vary immensely in different cases. They are least when the patient has had children, the pelvis is shallow, the abdominal wall thin, the enlargement considerable and limited to the upper part of the body of the uterus, Fig. 208. — Securing the uterine artery. Fig. 209. — Dissecting the anterior flap. 3i6 GYNECOLOGICAL SURGERY and the broad ligaments and cervix elongated and thin. Where the opposite obtains, the difficulties may be con- siderable, and especially so where the tumour has invaded the lower segment of the uterus and produced much thick- ening of the cervix. The gravest difficulties are, however, incurred by the operator mistakenly employing the tech- Fig. 210. — Dissecting the posterior flap. nique just described to cases of cervical or broad-ligament myomata. HYSTERECTOMY WITH SALPINGO- OOPHORECTOMY In the description already given of hysterectomy, it has been taken for granted that the ovaries and tubes were healthy, and they have accordingly been conserved. It not infrequently happens, however, that one or both appendages are the seat of disease which may be of a chronic inflammatory nature, with or without dilatation SUBTOTAL HYSTERECTOMY 317 Fig 211. — Hysterectomy and salpingo-obphorectomy Pulling up the appendage. Fig. 212. — Dividing the ovarico-pelvic ligament and round ligament. 3 i8 GYNECOLOGICAL SURGERY of the tube (pyosalpinx or hydrosalpinx). In such circum- stances, the appendages may have to be removed with the uterus. Separation of the appendage — The diseased appen- dage is pulled up and separated from any adjacent structures to which it is adherent. The precise method of doing this and the difficulties encountered are described Fig. 213. — Securing the uterine artery. elsewhere. The appendage having been freed, the ovarico- pelvic ligament is clamped with pressure-forceps externally to the Fallopian tube and ovary (Fig. 211). A further pair of forceps having been applied an inch nearer the uterus, the ligament is divided between the two (Fig. 212). The round ligament separately clamped is then divided. The broad ligament being thus opened up, the uterine artery is exposed and clamped (Fig. 213), and the operator then proceeds on the lines indicated on pp. 298-307. CHAPTER XV ABDOMINAL TOTAL HYSTERECTOMY I. BY THE ROUTINE METHOD This operation may be indicated when the uterus is the seat of myomata, of malignant disease, or of fibrosis, and further under occasional conditions of sepsis, of injury, of congenital deformity, and in certain cases of inflammatory disease of the uterine appendages. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. In addition Fenton's dilator No. 16 will be required. Operation. — i. Directly the patient is put into the Trendelenburg position an assistant should place the largest size Fenton's dilator in the vagina, so that if the operator elects first to cut into the vaginal canal posteriorly, this wall can be clearly defined and steadied by the pressure of the instrument. ii. Opening the abdominal cavity. — See p. 276. iii. Inserting the large swab. — See p. 293. iv. Clamping the ovarian vessels and round ligaments. — The ovarian vessels and round ligaments are clamped with pressure-forceps on each side, as described at pp. 293-96 (Fig. 214). v. Dividing the broad and round ligaments. — See pp. 293-96. vi. Reflecting the bladder. — An incision is made through the peritoneum on the front of the uterus, joining the incision in either broad ligament, in the manner described at p. 296, and the anterior peritoneal flap and subsequently the bladder are then carefully rolled back by pressure ap- plied with a swab until the vaginal wall is reached. This 319 320 GYNECOLOGICAL SURGERY Fig. 214. — Routine abdominal total hysterectomy Dividing the top of the broad ligament. Fig. 215,— Reflecting the bladder, ABDOMINAL TOTAL HYSTERECTOMY 321 is identified by feeling the limit of the vaginal cervix and recognizing the parallel muscle-fibres of the vagina (Fig. 215). vii. Cutting through the posterior vaginal wall. — The uterus is now dragged well forward with a volsella, and an incision made with scissors into the vagina through the posterior vaginal wall (Fig. 216). The position of this structure is first rendered accessible by the assistant thrust- ing the point of the dilator well up the vagina. In per- Fig. 216. — Cutting through the posterior vaginal wall. forming this he should seize the outer end of the dilator through the sterile sheet that covers the thighs of the patient. viii. Cutting through the anterior vaginal wall. — The first and second fingers of the left hand are pushed through the posterior opening into the vagina, and the anterior vaginal wall is stretched over them ; then with the scalpel in his right hand the surgeon cuts through the anterior vaginal wall on to his fingers (Fig, 217) which are slipped through the opening as it is enlarged, v 322 GYNAECOLOGICAL SURGERY ix. Clamping the uterine vessels and removing the uterus. — The uterus is now only held by a couple of lateral folds, each of them consisting of a leash of uterine vessels, some cellular tissue surrounding them, the lateral cervico- pelvic ligament and utero-sacral ligament, and the wall of the lateral vaginal fornix. The uterus being well pulled up, a pair of long pressure- Fig. 217. — Gutting through the anterior vaginal wall. forceps is applied on each side to these folds, which are then divided with scissors close to the cervix, and the organ is removed (Fig. 218). x. Ligature of the uterine vessels and lateral vaginal vessels. — In some cases these can be secured together by a ligature passed through the lateral angles of the vagina, and tied over the uterine artery proximally to the forceps. In other cases, where the mass of tissue held in the grip ABDOMINAL TOTAL HYSTERECTOMY 323 of the forceps is large, it is better to transfix the mass under the uterine artery with a needle into which a double ligature has been tied. The ligature having been cut, one half is tied over the uterine artery, and the other half, to which the needle is attached, is used to mattress the lateral vaginal angle (Figs. 219 and 220). xi. Ligature of the ovarian vessels. — See pp. 302-06. xii. Suture of the broad ligaments and peritoneal flaps. — Any of the methods described on p. 302 may be used to Fig. 218. — Clamping the uterine vessels. close the peritoneum over the operation area. The vagina should be left wide open for drainage (Fig. 221). Its total closure by suture is fraught with danger. xiii. Closing the abdominal cavity. — See p. 285. Difficulties and dangers. — When the vagina is being opened, care must be taken not to injure the rectum, and also not to cut into the plane of cellular tissue between the rectum and the vagina. In the latter case difficulty will be found in opening the vagina, and a large oozing 324 GYNECOLOGICAL SURGERY area will be opened up. These difficulties are overcome by the use of the dilator described. Fig. 219. — Ligature of the uterine artery. Besides the danger of wounding the rectum and bladder, the ureters may be ligatured or cut when the uterine vessels Fig. 220. — Mattressing the lateral vaginal angle. ABDOMINAL TOTAL HYSTERECTOMY 325 are secured, so that the lateral folds should be divided as near the cervix as possible. The operation in thin patients with a uterus merely enlarged but not deformed presents no special difficulties, but it is otherwise in a stout woman with a small uterus and a deep pelvis. Here, from the depth at which the operator is working, the embarrassment of flatus-laden intestines, and the presence of much adipose tissue, the resources of the surgeon may be greatly taxed. Fig. 221. — Closing the peritoneum over the open vagina . Dressing and after-treatment. — See p. 44 and Chapter XXXII. A certain number of cases present some foul discharge and a little fever during the second week, due to infection of the operation area from the vagina. Vaginal douches should be given after the first week. Alternative technique. — In some cases it is better to open the anterior vaginal fornix first, and to push the fingers through on to the posterior vaginal wall, which is then divided on to them from behind ; or the posterior vaginal 326 GYNECOLOGICAL SURGERY wall may be divided through the opening in the anterior. This is facilitated by seizing the vaginal cervix with a vol- sella and drawing it out through the anterior opening in the manner described on p. 333. In easy cases a rapid method of removing the uterus is to transfix both anterior and posterior vaginal walls with the scalpel from the front, and then to cut upwards and outwards on either side, having previously clamped the uterine arteries just before they enter the uterus. Care must be taken not to injure the rectum with the point of the scalpel in doing this. II. BY DOYEN'S METHOD This method of performing total hysterectomy is advo- cated and practised by certain operators. We have per- formed it, but consider it inferior to the usual method, described at pp. 319-26. The technique may have to be modified in different cases. It is often impossible to rotate the uterus sufficiently far forwards to get at the cervix until the upper parts of the broad ligaments are first divided. The method is an easy one in simple cases, but when dealing with cervical tumours it is impossible to carry it out. Preparation of the patient. — See pp. 82-86. Instruments. — See general list (p. 276). Fenton's dilator No. 16 will also be required. Operation. i. Opening the abdominal cavity. — See p. 276. ii. Insertion of large swab. — See p. 293. iii. Opening the vagina posteriorly. — The fundus is seized with a volsella, the uterus is drawn upwards and forwards, and the edge of the cervix is felt as it impinges against the anterior boundary of Douglas's pouch. A longi- tudinal incision of about an inch is now made in the middle line upon the cervix, and the vagina opened posteriorly (Fig. 222). This proceeding is facilitated by placing the large Fenton's dilator in the vagina previously {see p. 319). DOYEN'S HYSTERECTOMY 327 iv. Seizing the cervix. — The index-finger of the left hand is introduced into the vagina through the incision, and the external os having thus been located, another volsella is guided to the cervix, which is seized and its vaginal portion drawn through the opening in the pos- terior vaginal wall into Douglas's pouch, any secretion that is adhering to its surface being swabbed off. Fig. 222. — Doyen's panhysterectomy : Opening the vagina posteriorly. v. Circular incision of the vagina at the cervico- vaginal junction. — After the cervix is pulled through, it is held with the left hand while the surgeon, with a scalpel in his right hand, by means of a circular cut incises the vault of the vagina at its junction with the cervix (Fig. 223). Any free oozing at this stage can be controlled by pressure- forceps. vi. Opening the utero - vesical pouch. — The first and second fingers of the left hand are now passed into the 32t GYNECOLOGICAL SURGERY vagina through the wound in Douglas's pouch, and, working through the anterior part of the circular incision round the cervix, proceed to separate the bladder from the anterior surface of the uterus. This manoeuvre may be assisted with cuts of the scissors and by the assistant strongly pulling the cervix upwards and forwards (Fig. 224). The uterus is now pulled back, the fingers of the left hand distend Fig. 223. — Delivering and circumcising the cervix. the peritoneum at its reflection from the anterior surface of the uterus, and an incision is made on to the fingers through the peritoneum, so that the utero-vesical pouch is opened into the vagina (Fig. 225). vii. Clamping and dividing the broad ligaments. — While the assistant pulls the uterus over to one side, the broad ligament near the cornu of the uterus on the other side is clamped and the ovarian vessels and round ligament are thus secured. The surgeon passes through the posterior opening in the vagina the first and second fingers of his DOYEN'S HYSTERECTOMY 329 Fig. 225. — Opening the utero-vesical pouch. 330 GYNECOLOGICAL SURGERY Fig. 226. — Dividing the base of the right broad ligament. Fig. 227. — Removal of the uterus. BONNEY'S HYSTERECTOMY 331 left hand in front of the undivided portion of the broad ligament, while the thumb makes counter-pressure from behind, thus controlling the uterine artery. The remainder of the broad ligament is now divided with scissors, the uterine artery being clamped. The opposite side is treated similarly and the uterus removed (Figs. 226 and 227). viii. Ligaturing the vessels. — The ovarian and uterine vessels are ligated in the usual way (see pp. 301-06). ix. Suturing the broad ligaments. — See p. 306. x. Closing the abdominal cavity. — See p. 285. Dangers. — See p. 323. Dressing and after-treatment. — See p. 44 and Chapter XXXII. III. BY BONNEY'S METHOD This operation, which may shortly be described as a reversed Doyen, was planned by one of us when dealing with a myoma of the posterior wall of the supravaginal cervix which had burrowed underneath the peritoneal lining of Douglas's pouch, and which was so large that it had stripped the peritoneum off the rectum and had invaded the mesocolon, so that at the first glance the large intestine seemed to be adherent to the fundus of the uterus and the ordinary relations could not be identified. The same operation would serve in a case where the intestines had become so adherent to the fundus of the uterus that they could not be separated from above. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation, i. Opening the abdominal cavity- — See p. 276. ii. Clamping the round ligaments.— The round liga- ments on each side are clamped with pressure-forceps and divided close to their uterine attachment. Hi. Stripping back the bladder. — An incision is made through the peritoneum across the anterior surface of the uterus from round ligament to round ligament (Fig. 228), 332 GYNAECOLOGICAL SURGERY after which the peritoneum is stripped back, together with the bladder, by swab pressure (Fig. 229). Fig. 228. — Bonney's hysterectomy : Incising the peritoneum over the front of the tumour. iv. Incising the anterior vaginal wall. — The bladder being kept out of the way, the anterior vaginal wall is divided with a scalpel or scissors (Fig. 230). Fig. 229. — Separating the bladder. BONNEY'S HYSTERECTOMY 333 v. Delivering the cervix through the incision in the anterior vaginal wall. — A pair of volsella forceps is passed through the opening in the anterior vaginal wall, and the cervix seized with them and drawn upwards and through the opening, after which the rest of the mucous membrane of the vaginal vault at its junction with the cervix is circumcised (Fig. 231). vi. Clamping and dividing the uterine arteries. — The Fig. 230. — Incising the anterior vaginal wall. surgeon pulls the cervix well up and divides the base of the broad ligament in the neighbourhood of the cervix, together with the uterine artery, which is clamped as it comes into view (Fig. 232), first on one side and then on the other. vii. Separating the tumour from the rectum. — After the bases of the broad ligaments have been divided, the surgeon is able to pull the lower pole of the uterus upwards to a much greater extent, and the myoma on the Fig. 231. — Delivering the cervix. Fig. 232. — Clamping the base of the broad ligament. BONNEY'S HYSTERECTOMY 335 posterior wall is gradually separated from the rectum with the fingers and a few judicious cuts of the scalpel (Fig. 233). viii. Clamping the ovarian arteries. — The uterus as it is pulled upwards is dragged well over to one side, and the ovarian artery of the opposite side, together with Fig. 233. — Separating the uterus from the rectum. the upper border of the broad ligament, comes into view and is clamped with pressure-forceps and divided (Fig. 234). ix. Separating the fundus of the uterus. — The fundus of the uterus, which is attached to the intestines by the posterior layer of peritoneum of Douglas's pouch that has been pushed up by the tumour, is freed by dividing this peritoneum close to the uterus across to the other 336 GYNECOLOGICAL SURGERY Fig. 234. — Clamping the left ovarian vessels. Fig. 235. — Separating the fundus of the uterus. BONNEY'S HYSTERECTOMY 337 side when the opposite ovarian vessels are clamped and divided, and the uterus is free (Fig. 235). # x. Ligaturing the uterine arteries and lateral vaginal angles. — See p. 322. xi. Ligaturing the ovarian arteries and the round liga- ments, and suturing the broad ligaments and the cut edges of the peritoneum. — See pp. 302-07. As a very large area of denudation is necessarily left after removal of the uterus such as has been described, as much peritoneum as possible should be saved on its anterior surface. This large anterior flap is sutured directly to the cut peritoneal edge on the anterior surface of the large intestine. xii. Closing the abdominal cavity- — See p. 285. Dangers. — See p. 323. Dressing and after-treatment. — See p. 44 and Chapter XXXII. w CHAPTER XVI HYSTERECTOMY FOR CERVICAL MYOMA General remarks. — A myoma growing from the supra- vaginal cervix is not suitably treated by the classical methods of performing subtotal and total hysterectomy, the former because the amputation would have to take place across the tumour, leaving one-half of it behind, and the latter because in a large cervical myoma the tumour is so impacted in the pelvis and so overhangs the vagina that the wall of this canal cannot be reached until the tumour is much displaced or actually cut away. In order to understand the technique of the removal of these tumours an appreciation of their anatomical relations is necessary. Cervical myomata may be classified as — (i) Anterior, when a tumour springing from the superficial muscle bulges forwards and undermines the bladder. (2) Posterior, when a tumour similarly situated on the posterior surface of the cervix either flattens the pouch of Douglas from before backwards and compresses the rectum against the sacrum, or the rarer form where the tumour undermines the peritoneum at the bottom of Douglas's pouch, and, obliterating this cul-de-sac, lifts the serous membrane off the anterior surface of the rectum and sacrum. (3) Lateral, when the myoma, starting on the side of the cervix, burrows out into the broad ligament and expands it. These tumours in their growth outwards may fill the whole broad ligament and sometimes find their way between the layers of the mesocolon, the bowel lying sessile upon them. Their relation to the ureter is important. Most 338 Plate IV.— Central Cervical Myoma. HYSTERECTOMY FOR CERVICAL MYOMA 339 commonly this structure is underneath the growth and to the outer side. Very rarely when the myoma starts quite low down at the junction with the vagina it may insinuate itself under the ureter and lift it on its upper surface high up out of the pelvis. (4) Central, when the tumour, either of interstitial or of submucous origin, expands the cervix equally in all directions. This variety of tumour may present all the anatomical vagaries mentioned in connexion with the other three varieties. A cervical myoma can at once be recognized on opening the abdominal cavity by noticing that the cavity of the pelvis is more or less filled by a tumour, elevated on which is the body of the uterus, like " the lantern on the dome of St. Paul's " — to use Bland-Sutton's very apposite simile. This characteristic appearance does not occur when there is a second tumour in the body of the uterus itself ; and there is a variety of fundal submucous myoma which, growing along the cavity of the uterus, expands the supravaginal cervix without having any attachment to it. This variety may be termed the pseudo-cervical myoma. (5) Lastly, cervical tumours may be multiple, so that a lateral myoma, may be present on both sides, or an ante- rior myoma may be coexistent with a posterior tumour, or a lateral myoma may complicate either an anterior or a posterior one. The operation for the removal of a cervical myoma is usually difficult, and may at times be an extremely for- midable undertaking. The natural difficulties of the ope- ration are, however, greatly enhanced by a want of knowledge of the technique most suitable to the occa- sion, and ignorance on the operator's part of the altered anatomical relations of the surrounding structures. It is for this reason that we have laid such stress upon the disturbance of the normal relations to one another of the various structures involved. 340 GYNAECOLOGICAL SURGERY I. HYSTERECTOMY FOR A CENTRAL CERVICAL MYOMA, WITH PARTIAL ENUCLEATION OF THE BASE Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation. — The steps of the operation are as follows : — i. Opening the abdominal cavity. — See p. 276. Fig. 236. — Hysterectomy for a central cervical myoma : Dividing the top of the broad ligament. ii. Inserting a large swab. — See p. 293. hi. Clamping and dividing the ovarian vessels and round ligaments. — The upper part of the broad ligament containing the ovarian artery and ligament is preferably clamped and divided in the usual way on each side (pp. 293- 96, and Fig. 236). In many of these cases, however, the uterine vessels are so elevated on the surface of the tumour HYSTERECTOMY FOR CERVICAL MYOMA 341 that they run almost parallel with the ovarian vessels, the result being a formidable vascular leash converging towards the cornu on each side. In such circumstances the separate clamping of the ovarian contingent is almost impossible, and the whole mass must be seized and divided. From the many vessels thus opened up very brisk haemor- rhage may occur, which must be immediately controlled by the application of several pressure-forceps. Fig. 237. — Stripping the peritoneum off the front of the tumour. The clamping of the uterine vessels is merely tem- porary, as these vessels will presently be divided again lower down. In some cases the ovarian vessels can be isolated by first dividing the round ligament and then inserting the finger through the hole in the peritoneum undermining them and lifting them up, when they are easily secured. iv. Dissecting down the anterior flap of peritoneum. — 342 GYNAECOLOGICAL SURGERY An incision is made between the points where the round ligaments have been divided through the upper limit of the loose peritoneum in front of the uterus and well above the level of the bladder reflection (Fig. 237), and the bladder is then separated, together with the anterior flap of peri- toneum, from the surface of the expanded supravaginal cervix (Fig. 238). Special care must be taken to see that Fig. 238.— Pushing back the bladder. the bladder is not injured, as it will probably be very much displaced upwards. v. Incising the capsule of the tumour. — The capsule of the tumour formed by the tissues of the expanded supravaginal cervix is next incised anteriorly with a scalpel for about 2 inches. The index-finger of the right hand is inserted in the incision and the exact plane of separation between the tumour and its capsule is defined (Fig. 239). The incision is now extended across the supravaginal cervix (Fig. 240). If the operator is in any doubt as to the position of the bladder, he should have a sound passed into this organ, since it is when incising the capsule of the tumour that the bladder is most often injured. HYSTERECTOMY FOR CERVICAL MYOMA 343 vi. Partial enucleation of the tumour and amputation of the uterus. — A volsella is fixed in the anterior surface Fig. 239.— Exploring the capsule of the tumour. of the tumour now exposed through the incision in its capsule, and it is then pulled upwards as much as possible Fig. 240. — Enlarging the opening in the capsule of the tumour. 344 GYNECOLOGICAL SURGERY whilst the operator continues the enucleation by passing the fingers of the right hand between the tumour and its bed (Fig. 241). The circular incision in the capsule is extended by successive cuts towards the left, and in the course of this proceeding the uterine vessels on the assist- ant's side are divided and immediately clamped (Fig. 242). The incision is now extended round the back of the expanded supravaginal cervix to meet its beginning in Fig. 241. — Enucleating the base of the tumour. front, the enucleation of the tumour being meanwhile continued. The uterine vessels on the operator's side are the last to be divided, and can usually be secured by the assistant before the uterus and tumour are finally separated (Fig. 243). vii. Ligature of the ovarian and uterine vessels. — See pp. 301-6. viii. Treatment of the stump. — The stump, which in these cases consists of the expanded supravaginal cervix Fig 243. — Final stage of amputation. 346 GYNECOLOGICAL SURGERY surrounding the cavity from which the tumour has been enucleated, is now trimmed up with scissors, all redundant tissue being removed and the cavity obliterated with mattress-sutures (Fig. 244). ix. Suturing the broad ligaments and peritoneal flaps. — See p. 306. x. Closing the abdominal cavity. — See p. 285. xi. Dressing and after-treatment. — See p. 44 and Chapter XXXII. Difficulty. — The surgeon may find some difficulty in enucleating the tumour, and this is nearly always due to Fig. 244. — Securing the stump with mattress-sutures. the fact that his fingers are not within the true capsule. The commonest error is to attempt to peel off the peri- toneum only ; or, again, there may be one or two layers of connective tissue under the peritoneum which, partly separating, are mistaken for the capsule. Lastly, the incision to open up the capsule may be too deep, and the operator unknowingly may be trying to separate the outer layer of the tumour from its deeper parts. If the right plane between the capsule and the tumour is identified, the latter can generally be freed quite easily. HYSTERECTOMY FOR CERVICAL MYOMA 347 If the tumour has been or is inflamed, the capsule may be adherent to it, and the adhesions may have to be cut through. Advantages of the method. — The special method here described in detail has the great advantage that it is applicable to all cases of central cervical myoma, whatever their size. The enucleation being accomplished within the capsule, all danger of wounding such important structures as the ureter, rectum, or bladder is avoided, whereas an attempt to perform total hysterectomy by the usual method will be fraught with a risk to those structures that increases pari passu with the size and fixity of the tumour. Total hysterectomy for a central cervical myoma. — Occasions may, however, arise when it is desirable to remove the whole uterus. In such a case, if the parts are lax, and the tumour is small and rides up after division of the peritoneum so that the vaginal wall becomes accessible, the growth may be successfully removed on the lines pre- viously indicated for the ordinary method of performing panhysterectomy. Where this is not possible and yet the ablation of the whole uterus is desirable, the object is best attained by separately excising the expanded cervical stump after the removal of the tumour and the upper part of the uterus has been carried out by the method already described. The removal of the cervical stump is effected by the same technique as that described under Total Hysterectomy (p. 319), the vagina being first opened either in front or behind, as appears most convenient to the operator. II. HYSTERECTOMY FOR CERVICAL MYOMA, WITH TOTAL ENUCLEATION BY TRANS- VERSE INCISION Indications. — This method may be chosen when the myoma enucleates with great ease and without much haemorrhage. It is also indicated when the myoma has caused great enlargement of the cervix and it is desired 348 GYNECOLOGICAL SURGERY to reduce its bulk before proceeding with the hyster- ectomy. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation, i. Opening the abdominal cavity- — See p. 276. ii. Insertion of the large swab. — See p. 293. iii. Clamping and dividing the ovarian vessels and round ligaments. — See p. 293-96. Fig. 245. — Hysterectomy for cervical myoma, with total enucleation by transverse incision : Enucleating the whole tumour. iv. Dissecting down to the anterior flap of peritoneum. — See pp. 296-98. v. Incising the capsule and enucleating the tumour. — After the anterior flap of peritoneum and the bladder have been turned down, the uterus is pulled up with a volsella, and an incision is made across the anterior surface of the expanded supravaginal cervix through the capsule of the tumour. With the fingers of the right hand the surgeon then gradually enucleates the entire tumour, HYSTERECTOMY FOR CERVICAL MYOMA 349 pulling upon it at the same time with a volsella held in the left hand (Fig. 245). vi. Clamping the uterine arteries and amputation of the uterus. — The uterus with its collapsed supravaginal cervix can now easily be pulled out of the abdominal cavity. The lower edge of the incised capsule being secured with pressure-forceps which the surgeon holds in his left hand, the assistant pulls on the uterus, and the surgeon, having clamped both uterine arteries, amputates the uterus with Fig. 246. — Amputating the uterus. a pair of scissors (Fig. 246). Whether a panhysterectomy or a subtotal is done depends rather upon how much the vagina has been stretched. As the uterus is being ampu- tated the surgeon will find either that he is cutting through the vagina, in which case a panhysterectomy will be per- formed, or that he is cutting through a very dilated supra- vaginal cervix, in which case the hysterectomy is subtotal, for it is often difficult to distinguish between the collapsed cervix and the vagina. In either case, after the uterus is removed two cavities will be seen. One, the expanded supravaginal cervix or the vagina, and the other — which 35o GYNAECOLOGICAL SURGERY may lie in front, behind, or to the side of it — the lower pole of the capsule of the tumour (Fig. 247). The tumour cavity is now closed by a series of mattress-sutures, which should also be made to occlude the cervical canal if the amputation has been subtotal. If the whole uterus has been removed, it is better to leave the vagina open and merely suture the peritoneum over it. vii. Ligaturing the uterine and ovarian arteries and round ligament and suturing the peritoneal flaps. — See pp. 301-07. Fig. 247. — Treatment of the stump. viii. Closing the abdominal cavity- — See p. 285. Dangers. — See p. 323. Dressings and after-treatment. — See p. 44 and Chapter XXXII. III. HYSTERECTOMY FOR A CERVICAL MYOMA BY HEMISECTION OF THE UTERUS General remarks. — Some cervical myomata are best removed by hemisection of the uterus followed by hysterec- tomy. This method is particularly indicated when the tumour, either central or posterior, raises the bladder so that on the abdomen being opened the utero-vesical pouch is found obliterated and the uterus is so covered by the HYSTERECTOMY FOR CERVICAL MYOMA 351 bladder that only its fundus presents. In such cases it is impossible to adopt the method of transverse section of the capsule previously described, as the intervening bladder cannot be sufficiently pushed down. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation. i. Abdominal incision. — The abdominal cavity is opened by the method described at p. 276, particular care being taken not to wound the bladder, which is much raised in these cases. Fig. 248. — Hysterectomy for a cervical myoma by hemisection of the uterus : Separating the bladder. ii. Separation of the bladder. — The round ligaments on each side having been clamped with pressure-forceps, an incision is made from one to the other at the level of the upper limit of the loose attachment of the peritoneum where it is stretched over the tumour and the anterior surface of the uterus. The peritoneum, together with the bladder, is now pushed downwards as far as possible from off trie face of the expanded supravaginal cervix with a swab (Fig. 248). iii. Hemisection of the uterus. — Pressure-forceps are next applied to the upper edges of the broad ligaments so as to control the ovarian vessels. The operator then seizes 352 GYNAECOLOGICAL SURGERY the fundus on each side with volsella forceps ; he hands the left pair of forceps to an assistant, and, grasping the right pair in his left hand, steadies the uterus and divides the body in half with a scalpel, the incision being carried downwards well into the tumour so that the plane of its capsule is easily made out (Fig. 249). iv. Enucleating the tumour. — The capsule having been Fig. 249. — Hemisection of the uterus. defined, the tumour is seized with a volsella and enu- cleated entire by means of the fingers (Fig. 250). v. Amputation of the uterus. — The partially-divided uterus with the collapsed cervix is next removed by the method described at p. 349, the amputation taking place either through the cervix or through the vagina. vi. Closing the abdominal cavity. — See p. 285. Dangers. — Those described at p. 323. Dressing and after-treatment. — See p. 44 and Chapter XXXII. ^Kz-t-^t^/s^jf. Plate V. — Myoma of the Anterior Uterine Wall and Cervix. HYSTERECTOMY FOR CERVICAL MYOMA 353 IV. HYSTERECTOMY FOR AN ANTERIOR CERVICAL MYOMA General remarks. — An anterior cervical myoma takes up one of two positions : either it undermines the bladder and elevates it on its upper surface, or it forces its way up between the peritoneum covering the posterior wall of the bladder and the musculature of the viscus. In the first case, unless the displacement of the bladder is appre- Fig. 250. — Enucleating the tumour ciated, it will stand a good chance of being wounded when the parietal incision is made. In the second case, unless all the loose peritoneum covering the front surface of the expanded supravaginal cervix and uterus is utilised in the formation of the anterior peritoneal flap, it will be found that at the close of the operation there is in- insufficient peritoneum to cover the denuded posterior wall of the bladder and the upper surface of the stump. It should also be borne in mind that the round ligaments, x 354 GYNECOLOGICAL SURGERY especially in the case of the anatomical displacement first mentioned, may be so elevated that they form the highest ridge in the broad ligament, and that by the tumour bulging into the wound and retroverting the body of the uterus the landmarks of the ovary and the Fallopian tubes are hidden from the operator. In these circumstances we have seen the round ligaments mistaken for the fold containing the ovarian vessels, and clamped and divided as such, with the result that this division, being extended too far forwards, has opened the elevated bladder. Fig. 251. — Hysterectomy for anterior cervical myoma : Dividing the peritoneum over the front of the tumour. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. ii. Insertion of large swab. — See p. 293. iii. Clamping the round ligaments. — The round liga- ments, having been very carefully defined and their relation to the bladder made out, are clamped and divided close to their attachment to the uterus (Fig. 251). iv. Incising the peritoneum and capsule over the tumour. — The peritoneum covering the expanded supra- vaginal cervix is now divided at the upper limit of its loose HYSTERECTOMY FOR CERVICAL MYOMA 355 attachment to the uterus, this point being, if necessary, defined beforehand by undermining the peritoneum with the finger. The incision commences on the left-hand side just where the round ligaments are clamped, and extends to a similar point on the other side (Fig. 251). The anterior peritoneal flap is now pushed off the surface of the expanded supravaginal cervix until the reflection of the bladder is Fig. 252. — Enucleating the base of the tumour. reached, and the capsule of the tumour is then divided just above the level of the bladder attachment. v. Enucleation of the base of the tumour. — The peri- toneum and capsule are now together carefully pushed off the face of the tumour, the base of which is gradually enucleated with the first and second fingers of the right hand, care being taken not to injure the bladder. This enucleation is assisted by fixing the volsella to the tumour and pulling on this with the left hand (Fig. 252). vi. Division of the broad ligaments, etc. — When the 356 GYNECOLOGICAL SURGERY base of the tumour is enucleated the volsella is transferred to the uterus, which is pulled up, the ovarian vessels are clamped and the broad ligaments divided (Fig. 253). vii. Clamping the uterine vessels and amputation of the uterus. — The volsella is again fixed to the tumour, which together with the uterus is drawn out of the wound. Fig. 253. — Clamping the ovarian artery. The uterine vessels are then clamped on each side and the uterus amputated through the cervix with a scalpel (Fig. 254). If a total hysterectomy is desired, the anterior vaginal wall should first be opened, as described at p. 332. viii. Ligaturing the vessels. — See pp. 301-06. ix. Treatment of the stump. — See p. 344. x. Suturing the peritoneal flaps. — See p. 306. xi. Closing the abdominal cavity. — See p. 285. Dangers. — Those described on p. 323. Dressing and after-treatment. — See p. 44 and Chapter XXXII. HYSTERECTOMY FOR CERVICAL MYOMA 357 V. HYSTERECTOMY FOR A POSTERIOR CERVICAL MYOMA General remarks. — The methods of dealing with a posterior cervical myoma are two, depending upon its variet}' as described at p. 338. If the rarer form therein Fig. 254. — Clamping the uterine artery. described is present, when the tumour, undermining the peritoneum at the bottom of Douglas's pouch, strips the serous membrane off the anterior face of the sacrum and rectum, the uterus will be found to have been bodily elevated on the myoma in a position of retroversion. In this case the cervix and the upper part of the vagina are the most accessible parts at which to commence the ampu- tation, and it will be found best to adopt the technique 358 GYNECOLOGICAL SURGERY of an operation devised by one of us for such conditions {see p. 331). If the tumour be of the commoner variety, namely, that bulging back into the pouch of Douglas, the method about to be described should be followed. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. Fig. 255. — Hysterectomy for a posterior cervical myoma : Incising the peritoneum and the tumour-capsule. ii. Insertion of large swab. — See p. 293. iii. Clamping and dividing the ovarian vessels and round ligaments. — The ovarian vessels and round ligaments are clamped and divided as described at pp. 293-96. iv. Incising the peritoneum and capsule. — The peri- toneum and capsule at the junction of the tumour with the posterior surface of the uterus are incised and reflected (Fig. 255). v. Enucleation of the base of the tumour. — The fingers being now forced between the capsule and the tumour, the latter is partially enucleated (Fig. 256). HYSTERECTOMY FOR CERVICAL MYOMA 359 Fig. 256.— Enucleating the base of the tumour. Fig. 257.— Clamping the uterine vessels. 360 GYNAECOLOGICAL SURGERY vi. Reflecting the anterior flap of peritoneum. — The peri- toneum over the anterior surface of the supravaginal cervix is next reflected, as described at pp. 296-98. vii. Clamping the uterine vessels and amputating the uterus. — Strong traction is now made on the tumour, which, together with the freed uterus, can be easily pulled up with a volsella so that the uterine vessels on each side are brought into view and then clamped (Fig. 257), after which the uterus is amputated in the usual way described for subtotal hysterectomy, or, if total removal is desired, then by first opening the anterior vaginal vault. viii. Ligaturing the ovarian and uterine vessels. — See pp. 301-06. ix. Treatment of the stump. — If the posterior peritoneal flap and the capsule of the tumour are redundant, as they usually are, they are trimmed up with scissors, after which the stump is sutured in the manner described at p. 344. x. Suturing the peritoneal flaps. — See p. 306. Dangers. — Those described on page 323. Dressing and after-treatment. — See p. 44 and Chapter XXXII. CHAPTER XVII THE RADICAL ABDOMINAL OPERATION FOR CARCINOMA OF THE CERVIX Wertheim's radical operation for cancer of the cervix consists in removing, through an abdominal incision, the uterus and its appendages and, by means of clamps, suffi- cient vagina to form a bag in which the diseased cervix can be encapsuled. In addition, the parametrium and as much connective tissue of the pelvis as possible are dissected out, together with as many regional glands as the operator may deem advisable. W. A. Freund, in 1878, was the first to advocate abdo- minal hysterectomy for cancer of the uterus, but it is to Ries, of Chicago, that we owe the development of the radical operation as it is practised to-day. In 1895, Ries, by operating on dogs and cadavers, satisfied himself and others that it would be possible to remove the uterus and its appendages, the cellular tissue of the pelvis, and the lymphatic glands as far as the bifurcation of the common iliac, without killing the patient. Clark, in 1896, put this suggestion into practice on the living woman at the Johns Hopkins Hospital, and his example was quickly followed by others, among whom may be mentioned Werder, Rump, Mackenrodt, and Wertheim. It is, however, to Wertheim that we owe the present position of this operation, which he has performed as a routine one for a much longer period and in far greater numbers than any other surgeon, and his results are the most interesting we have. It is to be noted, however, that although in England, at any rate, the radical operation is known by Wertheim's name, the only point in its procedure that he invented is the appli- cation of the vaginal clamp. 361 362 GYNECOLOGICAL SURGERY What advantages has Wertheim's operation over simple yaginal hysterectomy ? — We must discuss this ques- tion under four headings : — i. The operation from the pathological standpoint. 2. Primary mortality. 3. Percentage operability. 4. Percentage of cures. 1. The operation from a pathological standpoint. — From this point of view we believe that the value of the procedure is manifest. The advance of a carcinomatous growth takes place in two ways : first, by a gradual pressure- destruction of the tissue surrounding it, "infiltration"; and, secondly, by a growth-insinuation along trunk lym- phatic channels, " permeation." The distinction between these two methods of growth has lately been insisted on by Sampson Handley, and is very important. The first is seen at the rnacroscopical growing edge, where a remark- ably abrupt line between the carcinoma and the surrounding tissues is exhibited. The second is evidenced by the car- cinomatous lymphatic glands and secondary nodules occur- ring at a distance from the primary growth. The distinction is exemplified by the clinical course of a rodent ulcer and an epithelioma respectively. In the first we have a growth by infiltration alone ; in the second, both by infiltration and permeation. Had we to deal with a tumour growing solely by infiltration, it would be possible permanently to remove it by an incision just outside its abrupt rnacro- scopical margin ; but growth by permeation requires a wide removal of the entire lymphatic tract to render it successful. Growth by infiltration is occurring around the whole periphery of a carcinoma, but growth by permeation only along certain well-defined lymphatic channels. Applying these general considerations to carcinoma of the cervix, we see that the distinction between these different methods of growth is well preserved. Thus, the bladder, rectum, and vagina are involved by infiltration, a slow process taking many months or a year or two to cross the WERTHEIM'S OPERATION 363 short length of tissue that separates them from the cervix. The pelvic glands, on the other hand, are involved by permeation, a much faster method of extension, by which the many inches of tissue intervening between them and the primary growth may be spanned in a few weeks. Now, the lines of lymphatic conduction in the case of the cervix are few and simple, and run, as we have shown, straight outwards through the parametrium to the external iliac glands. The demands of pathology are therefore satisfied by an excision so planned as to include this tract, while keeping just outside the periphery of the macroscopic growing edge elsewhere. Wertheim's operation does this and more ; and it is, therefore, a rational treatment, even where the edge of the growth is separated from the bladder or rectum by one-twentieth of an inch of uninfiltrated tissue. But growth by permeation does not always occur in these patients, for of all the common sites of carcinoma the cervix is that in which metastases (and therefore growth by permeation) are least common. 2. Primary mortality. — The primary mortality of Wert- heim's operation is undoubtedly high. With increased experience it can be lowered. Wertheim's results are an example of this. In his first 200 cases there were 50 deaths ; in his last 258 cases, 35 deaths. In his first 30 cases the mortality was 40 per cent. ; in his last 30 cases it was 7 per cent. His total mortality to date is i5 - 2 per cent. In a paper read by one of us at the Medical Society of London in 1909 it was shown that the mortality of 243 cases of Wertheim's operation performed by British surgeons was 18*1 per cent. Doderlein publishes a list of 715 operations with a mortality of 14*8 per cent. ; he gives his own primary mortality for 65 cases as 18*7 per cent. Schindler, of Graz, has a mortality of 9 per cent. Bumm had a mortality of 25 per cent., but, having improved his technique, it has fallen to 15 per cent. The mortality of all the cases of radical abdominal operations 364 GYNAECOLOGICAL SURGERY performed in the British Isles that one of us has collected, 313 in number, is 18*5 per cent. The mortality for simple vaginal hysterectomy is naturally lower. Schauta gives the following statistics for vaginal hysterectomy : Waldstein (Schauta), 10-3 per cent. ; Hocheisen (Gusserow), 14-4 per cent. ; Krukenburg (Ols- hausen), 127 per cent. ; Zurhelle (Fritsch), 6*6 per cent. Doderlein reports 4,368 vaginal hysterectomies with a mortality of 9*1 per cent. Hirschmann collected 1,241 cases with a mortality of 8'8 per cent. ; Fehling, 770 cases with a mortality of 0/6 per cent. Percentages smaller than these have been reported — by Leopold, 57 per cent., and by Amann, 4 per cent. In England the experience of some of those who have performed vaginal hysterectomy to a large extent has been more favourable than this, but the operability rate in this country is lower than that on the Continent. The fact that the radical abdominal operation has a higher primary mortality should not of itself deprive any patient of the chance of cure. Moreover, this increased mortality is mostly because cases of a much more advanced or serious nature can be and are treated by this method. It is, therefore, unfair to compare the primary mortality of the radical abdominal operation with that of vaginal hysterectomy, which can only be performed in early cases. If the percentage mortality is reckoned according to whether the case is one of an early, moderate, or advanced nature, we find in 238 of the " Wertheim's " which we have collected the following results : — ■ In 186 advanced cases, 23*1 per cent. In 19 moderate cases, 5 '2 per cent. In 33 early cases, 6*3 per cent. These results bear out our belief that the mortality of this operation is not appreciably higher than that of simple vaginal hysterectomy, if only cases of a similar nature are operated on. WERTHEIM'S OPERATION 365 Although every effort must be made to reduce the primary mortality of Wertheim's operation, still, in a comparison of the merits of these two operations, we are distinctly of the opinion that too much should not be made of the greater mortality. If, after a period of five years, there are appreciably more patients alive out of every hundred operated upon by this method than out of every hundred operated upon by simple vaginal hys- terectomy, then, in spite of the primary mortality, the end justifies the means. 3. Percentage operability. — The percentage operability is greatly increased by the radical abdominal operation because the bladder, rectum, and ureter can be separated from the growth without much risk of injury, whereas in simple vaginal hysterectomy in a large number of cases this is impossible. It has been argued that the percentage operability can be made as large as any operator chooses if he operates upon cases in which there is no chance of cure. Up to a certain point no doubt this criticism is just, but we do not think it entirely meets the case. It is, as we shall see, difficult to determine beforehand in which patients there is a chance of cure. All are agreed that, if only early cases are chosen, the percentage of cures will be much greater and the mortality much less. Still, it is evident that most operators have not limited themselves in this way, with the result that many women have been cured whose chances from a clinical examination might have been thought to be hopeless. According to Doderlein and Kronig, the average percentage operability of ten opera- tors by the radical abdominal method was 68. Wertheim has operated upon 49 per cent, of his cases, Schindler 46 per cent., and Bumm 90 per cent. ; but this latter figure must be due to the fact that Bumm has operated on cases that most other surgeons would refuse — a surmise which is perhaps warranted by his heavy primary mortality. We have noted every case of cancer of the cervix both 366 GYNECOLOGICAL SURGERY in the in- and out-patient departments of the Middlesex and Chelsea Hospitals, and also the private cases that we have seen during 1908 and 1909, and our percentage operability during this period has been 67. The average percentage operability for vaginal hysterectomy is much smaller, and although Gusserow, Olshausen, Kaltenbach, Leopold, Kuestner, and Doderlein return a percentage of 31, that of Chrobak and Schauta is 15, and of Waldstein 147, these last being more in accord with the experience of English operators, which is nearer 12. 4. Percentage of cures. — If the uterus is removed by simple vaginal hysterectomy, practically all the parametrium is left behind ; if by Wertheim's method, all the parame- trium and a large portion of the cellular tissue of the pelvis are taken away. The results of the pathological investiga- tion of the parametrium extending over a large number of cases, and including the microscopical examination of some thousands of sections, prove conclusively to our minds that this structure should always be removed. Schauta found that the parametrium was infected in 69 per cent, of his cases, Wertheim in 60 per cent., Kundrat in 55 per cent., Baisch in 50 per cent. ; and many other observers have similar records. In at least half the cases, therefore, simple vaginal hysterectomy is useless, because cancerous tissue is left behind. These facts do not carry much weight with those who favour vaginal hysterectomy, because they argue that if, on clinical examination, the parametrium is found to be involved, no method of removal is satisfactory ; whereas, if the uterus is quite mobile and the parametrium is felt to be soft, vaginal hysterectomy holds out as good a chance of cure as any other operation. The pathological findings have proved this opinion to be untenable. It is impossible to diagnose clinically the real condition of the parametrium. A hard parametrium may contain no cancer, a soft one may be full of cancer. In 22*5 per cent, of Wertheim's cases, although the parametrium felt quite soft, a marked WERTHEIM'S OPERATION 367 cancer-infection had taken place ; and in 14 per cent, where the parametrium felt quite hard, no infection had occurred, the induration being due to inflammatory reaction. Kundrat likewise found the parametrium infected in 16 per cent, of his cases in which clinically it appeared to be free. It is almost impossible to estimate accurately the per- centage of cures in this country, because of the difficulty in tracing hospital patients. It is much easier abroad to keep in touch with patients, since the police keep a record of where people live and when they change their addresses. The German method of estimating cures is a very strict one, including, as it does by Winter's method, the number of cases per hundred operated upon, added to the number of patients per hundred remaining well, the result, divided by one hundred, being called the " absolute cure " for the number of cases taken. Five years seems to be the period chosen by most authorities, after which the patient may be said to be cured as far as her original disease goes. The statistics we have collected for this country are useless for the purpose under discussion, as nearly all the operations have been performed within the last year or two. On the Continent, however, a large number of cases have accumulated that now fulfil this standard. Wertheim has 138 women alive operated upon more than five years ago, which equals a percentage cure of 62. Polosson has 60 per cent, free of recurrence after five years, Mackenrodt 45 per cent., Bumm 30 per cent. When we compare this with the percentage of cures by vaginal hysterectomy, a very great difference is at once notice- able. With cases of carcinoma of the cervix, we find that Jacobs had 1*2 per cent., Gusserow 2-5 per cent., Olshausen 6-6 per cent., Kustner 0/2 per cent., Kaltenbach 9/2 per cent., Leopold 8*2 per cent., Doderlein and Pozzi 9 per cent., and Polosson 12 per cent, of patients living after five years, so that apparently not one-tenth of the cases operated upon by vaginal hysterectomy are alive after 368 GYNECOLOGICAL SURGERY this period. Frommer had 35*6 per cent, recurrences in the first year, Zweifel 69/8 per cent, in the first six months, and Winter, out of 148 cases, had 115 recurring the first year, 13 in the second, 13 in the third, 5 in the fourth, and 2 in the fifth. Segan, out of 49 cases, had only 2 living after five years ; Bouilly had yj per cent, of recurrences with 17 cases ; Waldstein, out of 274 cases, had only 4 living after five years ; and there are many other records with the same tale. English operators have been more successful than this, as, for instance, Spencer and Lewers with 24 per cent, and 16 per cent, of cures respectively after five years. It must be remem- bered, however, that foreign statistics deal with thousands of cases, whereas our English ones deal with hundreds. In comparison with vaginal hysterectomy, therefore, the percentages of cures in the case of Wertheim's and other radical abdominal operations show a remarkable improvement. This increase in the number of cures by the radical abdominal operation is due entirely to two factors. One we have already discussed, namely, the thorough removal of the parametrium and the adjacent connective tissue. The other is due to the means taken for preventing any part of the wound from being contaminated by the growth — that part of the operation, in fact, with which Wertheim's name is particularly associated, i.e. clamping the vagina well below any growth before dividing it, so that the diseased cervix is removed in a bag of vagina, and the risk of local implantation of cancer cells on the cut edges of this canal is practically eliminated. In the past the recurrence of cancer after the removal of the diseased cervix has nearly always been local, due to cell-implantation on the cut edges of the wound, or to an imperfect removal of the parametrium. Winter reports recurrence in the vaginal scar in 54 out of 58 cases, Mangiagalli in 114 out of 115 cases. Most other operators have had a similar experience to record. On WERTHEIM'S OPERATION 369 the other hand, with Wertheim's operation local recur- rence is a rarity. The standpoint from which any operation must be gauged is its ultimate result with regard to the cure of the greatest number of patients. Even if, therefore, the per- centage of cures with Wertheim's operation were not greater than that by the simple vaginal method, neverthe- less it would be the better operation because of the increased operability, since a greater number of patients would be saved. But, further, the percentage of cures by vaginal hysterectomy is a very low one, whereas that by the radical abdominal methods may, we think, in comparison, be termed high. Archibald Leitch found, from an investigation of 900 cases of carcinoma of the cervix that had not been operated upon, that the average duration of the disease, from the earliest symptoms to death, was one year and nine months.* About six months may be taken as the average period between the first appearance of the symptoms and the report of the patient to her medical man, so that one year and three months is the average life-expectation of these patients if not operated upon. This period in most persons is one of more or less acute mental distress, and it there- fore appears to us that the gain of a period of hopeful life, in any event, to the patient who recovers from the radical operation, is one of the principal justifications for its performance. The only point in favour of simple vaginal hysterectomy is its low mortality, although, as we have pointed out, if we take similar cases the difference between this and Wertheim's operation is not appreciable. Has Wertheim's operation any advantage over para- vaginal section? — By means of Schauta's paravaginal section the scope of vaginal hysterectomy in this disease can be much enlarged. This operator has devised and * Fifth Report of the Middlesex Hospital Cancer Investigation laboratories. Y 370 GYNECOLOGICAL SURGERY practised a radical vaginal operation which will be found described on pp. 260-71. The question of the relative values of extended vaginal hysterectomy and the abdominal operation depends upon whether there is any necessity to remove the regional glands. Theoretically there is nothing to urge against the routine removal of glands ; in fact, all are probably agreed that, if such a procedure were possible, this would be the right and proper course to pursue. As a matter of fact, however, it is impossible to remove from the living woman all the glands that drain the pelvic organs. It is open to anyone to attempt this removal on a cadaver, and he will find that, besides being most difficult, certain structures have to be interfered with, the disturbance of which would kill a living person. Schauta examined the regional glands in 60 bodies dead of cancer of the uterus, and in only 233 per cent, did he find it technically possible to remove them. As, therefore, it is not possible to be certain of removing all infected glands, is it worth while systematically to remove any glands on the off-chance that they are infected and the only ones infected ? One has to consider the subject from a pathological as well as from a clinical point of view. It is only by examining microscopically every gland removed that we can gain any information worth having on the subject. To judge their cancerous nature or otherwise from their size and texture has been proved conclusively to be a useless method of diagnosis, and the wide discrepancy of the gland-statistics issued by different operators is, we think, largely due to the fact that microscopical examina- tion has not been made in each case. Glands which are large and hard have often been found free of cancerous infection on being examined by the microscope. Doderlein reports 18 cases with enlarged glands, and in n of them cancer was absent. On the other hand, glands which are so small and soft that they are perhaps overlooked during the operation, may be found to be full of cancer- WERTHEIM'S OPERATION 371 cells. Then, again, the statistics of glandular infection vary according to whether they have been calculated from glands removed at the operation or post-mortem. Take Schauta's statistics for instance. He examined 1,182 glands by means of 160,000 serial sections, and found that in. 577 per cent, the glands were affected. But most of the glands were removed post-mortem from patients who had died from very advanced cancer, when it would have been unjustifiable to have attempted removal of the growth. Riechelmann found 35 per cent, of the glands infected in 86 bodies dead from carcinoma of the cervix. Archibald Leitch, working in the Middlesex Hospital Cancer Investigation Laboratories, analysed 915 cases of carcinoma of the cervix in which an autopsy had been performed, and found glandular deposits in only 38*36 per cent., whilst no less than 55 per cent, were free of metastatic growths in any situation. MacCormac, working on a new series in the same laboratories, tells us that of 75 cases he has analysed, only 33 per cent, had glandular deposits that cou'd be demonstrated by the microscope ; and that is the general experience of the workers in these laboratories, amongst whom one of us has had the honour to be numbered. Taking operative statistics, Doderlein gives a list of ten operators whose average percentage is 39/9. Wertheim removed carcinomatous glands in 35 per cent, of his cases, and Bumm in 33*3 per cent. In 73 of our own cases the percentage was 31, and in 70 English cases we have collected, where a microscopical examination has been made, it was 47. We think, therefore, we may take it that in at least one-third of the patients who come to us some of the glands are infected. Granted that in one-third of the patients who seek relief the glands are affected, is any advantage gained by systematically endeavouring to remove these glands ? This question may be regarded from several points of view. It can be argued that the systematic removal of the glands 372 GYNAECOLOGICAL SURGERY may in many cases increase the danger of the operation. Large vessels may be wounded during the necessary mani- pulations, resulting in the immediate death of the patient from haemorrhage, and at any rate the time taken over the operation is often increased, sometimes markedly so, and time in these cases is of prime importance. This argu- ment, however, should not, in our opinion, deter surgeons from removing as many of the regional glands as possible. The great object is, of course, to cure as many patients as possible, and if by the systematic removal of these glands a greater number of women are saved, the surgeon should not hold his hand because the primary mortality is thereby increased. Statistics, as far as they show anything, seem to prove that the removal of glands, when definitely carcinomatous, is usually followed by recurrence. This has been the ex- perience, among others, of Wertheim, most of whose cases died within three years ; of Fromme, who states that recurrence has occurred in all of Bumm's cases in 1902 and 1903 in which carcinoma of the glands was detected; and of von Rosthorn, in all of whose cases except one recurrence had occurred where he had removed carcinoma- tous glands. The English records are of too late a date to make them of any value for this purpose. Post-mortem records of patients dying as a result of the operation show that in many cases where carcinomatous glands have been removed, others which could not be removed have also been affected, and, therefore, that it was useless to remove any glands in the first instance. Veit, Pankow, and Wertheim, among others, are of opinion that the routine extirpation of glands does not help the case, and the latter remarks that since in only one-third of the cases are the glands involved, to remove them indiscriminately in every case is to injure the other two-thirds, and that the occa- sional cure of a patient does not counterbalance the extra mortality due to routine extirpation. The condition of the primary growth is no absolute guide, for while, as a rule, WERTHEIM'S OPERATION 373 the glands are only affected at a late stage, often being found quite free in very advanced operable cases, still glands markedly enlarged and infected have been found in the earlier stages of carcinoma of the cervix. The object of removing glands is, of course, to prevent recurrence therein, but recurrence in the glands only is rare. Schauta argues that that only can be considered a real glandular recurrence in which there is no local recurrence, for in the latter condition it may very well be due to the local state. He remarks that facts have arisen which make the spon- taneous cure of cancer more likely. In comparing the percentage of recurrences in the extended vaginal operation in which the glands cannot be removed with the radical abdominal operation in which only local recurrences take place, the difference is not very material, and therefore a question arises which cannot at present be answered : " What becomes of the carcinomatous glands always left in the case of vaginal operations and very frequently in the case of abdominal operations ? " After removal of the primary tumour, carcinomatous masses left behind in the glands may remain latent and only break out very late, and perhaps never, death being due to other causes ; and it is noticeable that, considering the frequency with which infected glands are found at operation, glandular recur- rence should be so rare. Hocheisen had a patient living in 1899, six and a half years after an incomplete opera- tion, without any sign of recurrence. In 35 recurrences, Schauta found only 2 in the glands, and in 12 recurrences Franz found 1. Wertheim, Zweifel, Doderlein, and others only remove glands when enlarged. Bumm, Ries, Amann, von Rosthorn, and Freund are in favour of removing every gland possible, and there are some cases on record which support this practice. Doderlein has 2 patients living four and a half years, and 3 three and a half years after the removal of carcinomatous glands ; Wertheim has 4 patients living three to three and a half years ; Mackenrodt, 1 patient living five years, 3 living four years, and 7 374 GYNAECOLOGICAL SURGERY living three years ; whilst Bumm has 2 patients living three years in each case after carcinomatous glands were extir- pated. In our opinion the importance of the routine removal of glands lies not so much in the extirpation of those obviously enlarged as in the prophylactic excision of those that appear healthy. Our experience is that the glands first affected are almost invariably those in the parametrium and along the external and common iliac vessels. The removal of the glands in these situations does not, we have found, materially add to the length or shock of the opera- tion, and we have, therefore, removed them in every case. The only method by which the regional glands can be removed is through an abdominal incision. They cannot be removed by paravaginal section. The advocates of paravaginal section allow that if all diseased glands could be removed by the abdominal operation, this would be the best treatment, but maintain that as this is impossible, there is no need to operate through the abdomen, since the operation can be carried out in every other particular just as well as by the vaginal method. They contend that just as much parametrium and cellular tissue can be removed, with less shock, less danger of infection, no scar, and no greater danger of injury to the ureters, bladder, rectum, or large vessels. Schauta's percentage mortality for 258 cases works out at I0'8, in comparison with Wertheim's 15 per cent, for 458 cases. The mortality of Schauta's last 45 cases was 8'5 per cent., of Wertheim's last 30 cases 7 per cent. An analysis of Schauta's cases also shows the following : — In 79 early cases the mortality is yy per cent. In 26 moderate cases the mortality is n *i per cent. In 53 advanced cases the mortality is 207 per cent. Paravaginal section shows a great advance in percentage operability on simple vaginal hysterectomy. Schauta's WERTHEIM'S OPERATION 375 percentage is 487 per cent., which is only slightly less than that by the abdominal method. Lastly, with respect to the question of cure, Schauta's operation holds a high position, 53 "3 per cent, of his patients who were operated upon over five years ago being alive. Wertheim and others, on the other hand, maintain that Schauta's operation is more difficult, that the primary mortality is as great, that the percentage operability is less and the percentage of cures less, and that the superiority of the abdominal operation lies not only in the opportunity it affords for the removal of glands, but also in the easier removal of the parametric tissue and the smaller risk of injury to the bladder, ureter, and intestines, in the more reliable hsemostasis, and in the great facility for treating adhesions. Conclusions. — We ourselves prefer the abdominal opera- tion, the percentage operability of which is undoubtedly greater, whilst the mortality is probably about the same. But beyond this there are certain cases in which the vaginal operation is fated to fail. Thus we lately per- formed the radical abdominal operation on a patient with an apparently early growth, whose obesity was such that the question of the vaginal operation had been seriously considered. At the operation, in spite of the fact that the cervical growth was small and the uterus very movable, a carcinomatous gland the size of a walnut was found on the brim of the pelvis. Had the lower route been chosen, it is obvious that the operation would have been better left undone. Further, the abdominal route has these great advan- tages — that it is possible to proceed a certain way on the operation and yet be able to turn back if satisfactory removal of the growth is revealed to be impossible ; whilst, on the other hand, what appears from the vagina to be hopeless fixity of the uterus may, when investigated from the abdomen, turn out to be dependent on conditions not cancerous, the effective treatment of which allows of the 376 GYN/ECOLOGICAL SURGERY operation being satisfactorily performed. Moreover, it is possible at once to ascertain in many cases if carcinomatous involvement of the glands has proceeded so far as to make the operation useless. As we have stated, we systematically practise the removal of the accessible regional glands — namely, those in the broad ligaments, the obturator fossae, and along the external and common iliac arteries — being of opinion that the proceeding does not materially increase the severity of the operation, whilst it certainly lessens the chances of recurrence. Even where some of these glands are car- cinomatous and the chances are against a permanent cure, it is surely better to free the patient of gross evidence of carcinoma rather than perform an operation that may leave big masses of the growth behind. Lastly, in our experience, the convalescence from the radical vaginal operation is much more markedly associated with suppuration, and takes a much longer time. There are, however, two conditions in which we believe that the vaginal route should be chosen : (i) in cases of great obesity, especially in nulliparae ; (2) in cases in which, in addition to the primary growth in the cervix, a meta- static nodule is present in the lower inch of the vaginal wall. Limits of Wertheim's operation. — It is impossible in many cases to decide from vaginal examination whether the removal of the growth is feasible or not. The examination in doubtful cases must be conducted under an anaesthetic. Partial fixity of the uterus is no contra-indication, for, so long as it can be pushed up, the fact that it cannot be pulled down is of no moment. The important point to decide is the nature of the fixation. Rigidity of the broad ligaments appearing to be due to infiltration is often shown on opening the abdomen to be caused by the salpingitis commonly met with in advanced cases. Considerable extension of the growth along the lateral, and particularly the posterior, vaginal wall is com- patible with successful extirpation. Infiltration of the WERTHEIM'S OPERATION 377 rectal wall contra-indicates any operation, but this degree of extension usually occurs so late that the operation is not feasible on other counts as well. Infiltration of the bladder-wall is the most serious drawback to the operation, and when extensive is an absolute bar to any attempt at removal. It is often im- possible to be sure of this until the separation of the bladder is commenced, for the uterus may be movable and yet the growth have involved the bladder, the conjoined organs moving up and down together. The slighter degrees of adhesion, probably inflammatory, may be overcome by swab-pressure and cautious snipping with scissors, but if this is impossible the surgeon has the choice of desisting from further attempts at removal or of excising the adherent piece of bladder. If the patient is young and relatively strong, and the area of adhesion is not extensive and involves only one uretero-vesical junction or neither, and if there are no other bars to the completion of the operation, the portion of bladder should be excised, with, if need be, the adherent segment of ureter on that side. After the extirpation has been completed the hole in the bladder must be closed, and the ureter, if it has been cut, must be implanted in the vesical wall. If, however, the patient is elderly or feeble, and the growth extensive elsewhere, the operation should be ter- minated by suturing up the raw surfaces already made and closing the abdominal wound. These uncompleted cases usually recover well. If a large mass is found in the broad ligament, the question of the propriety of continuing the operation will depend upon the relation to it of the ureter. This structure resists infiltration for a long time, and is often found on the lateral aspect of the mass, having been pushed there in front of the growth. At other times it runs in a sort of canal or groove through the growth, from which it can be dissected out. 37« GYNAECOLOGICAL SURGERY Though excision of portions of the bladder or of the ureter may be successful, yet the likelihood of a fistula is great. Such fistulae cause great distress, and the problem of how to deal with them is itself beset with many diffi- culties and risks. Further, the chance of permanent cure in a case so advanced is slight, while the temporary relief to the patient obtained from the removal of the growth is counterbalanced by the annoyance of continual leakage of urine. Great judgment is therefore required before deciding to proceed to these lengths. Preliminary operation. — If there is any offensive dis- charge, an anaesthetic can be given and the growth scraped away as much as possible, after which the bleeding surface may be cauterized and the vagina washed twice daily with a solution of hydrogen peroxide (10 volumes) till the major operation. This preparatory treatment has certain disadvantages : the cauterized cervix, if many days elapse between the operations, sloughs, and the septic discharge is often worse than that for which the cauteriza- tion was originally undertaken ; the patient, again, is subjected to the risks of a double anaesthetic. If this practice is followed, the radical operation should not be undertaken until the cauterized tissue has entirely sloughed, leaving a clean surface. If cauterization is decided on, we think the best prac- tice is to perform it immediately before undertaking the radical operation ; but latterly we have given it up alto- gether, and contented ourselves in these cases with simple scraping a week or two beforehand. If there is no offensive discharge, preliminary scraping is unnecessary. Great care should be taken not to do this preliminary scraping too thoroughly, for (i) the tissue between the growth and the bladder or the pouch of Douglas may be so thin that either may be opened, and (2) so much of the cervix may be removed that later in the course of the major operation the body of the uterus may tear away from the diseased cervix. WERTHEIM'S OPERATION 379 Preparation of the patient. — See pp. 82-86. As a good many of these patients are in a miserable state of health, they should be kept in hospital ten days or a fortnight prior to the major operation, during which time the im- provement of their general condition must be attempted by good feeding and tonics. Immediately before the operation the vagina should be thoroughly swabbed out with 3 per cent, formalin, and then packed with sterilized gauze. Instruments. — See p. 276. In addition four long angular Kocher's pressure-forceps, four additional ring forceps, a Berkeley-Bonney clamp, an aneurysm-needle, a blunt Worrall's needle, and two pieces of india-rubber sheeting, 14 in. by 12 in., will be required. Operation, i. Opening the abdominal cavity. — See p. 276. One of the serious complications of our earlier cases — and this has happened to many other surgeons — consisted in sloughing of the abdominal wound, due (1) to the bruising of the tissues from their prolonged manipu- lation, (2) to infection of the tissues by some organism from the vagina when this canal was divided. To obviate these dangers we cover the wound in the abdominal wall with red sheet rubber — having tried nearly every other substance in any way suitable, and found the rubber the best. This covering is kept in place with the retractor (Fig. 258). Since we have followed this method not one of our wounds has sloughed. The abdominal incision must be a large one, in all cases extending to the umbilicus, and in fat patients at least an inch above. ; ii. Ligaturing the ovarian vessels.— The ovarian vessels are ligatured on each side by passing a No. 4 silk ligature underneath them just where the ovarico-pelvic ligament reaches the brim of the pelvis, the uterus being pulled over to the opposite side by the assistant, so that this ligament may be put on the stretch (Fig. 259). Before passing the ligature the upper edge of the ligament should be rolled between 38o GYNECOLOGICAL SURGERY the index-finger and thumb to ensure that the ureter, which is very superficial at this point, is not included in it. Fig. 258. — Radical abdominal operation for carcinoma of the cervix : Preparing the abdominal wound. iii. Clamping the ovarico-pelvic ligament. — The ovarian vessels at their uterine end are clamped on each side with a pair of Kocher's forceps applied to the broad Fig. 259. — Ligaturing the ovarian vessels. WERTHEIM'S OPERATION 381 ligament close to the uterus. The forceps will also include part of the round ligaments. iv. Division of the ovarico-pelvic ligaments. — The ovarico- pelvic ligaments are divided, either with the scalpel or scissors, just distaily to the ligatures which have been placed on them (Fig. 260). v. Ligaturing the round ligaments. — A ligature of No. 4 silk is passed under the round ligament on each side, Fig. 260. — Dividing the ovarico-pelvic ligament. and this structure is tied as far away from the uterus as possible and divided (Fig. 261). Two mass ligatures are now placed round the separated appendages at their junc- tion with the uterus. The ends of these, if left long, make a convenient tractor. vi. Reflecting the bladder. — The peritoneum on the anterior surface of the uterus at the upper limits of its loose attachment is incised right across, and together with the bladder is separated from the supravaginal cervix and the upper part of the vagina by pushing it downwards with a swab (Fig. 262). This separation may be aided by a few gentle snips with the scissors, dividing certain of the 382 GYNAECOLOGICAL SURGERY Fig. 261. — Ligaturing the round ligament. Fig. 262. — Pushing back the bladder. WERTHEIM'S OPERATION 383 muscle-fibres of the bladder which adhere to the vagina and tend to tear back into the bladder like a " hang-nail " unless cut free. vii. Identification of the ureters and dissection of their cervical portion. — The ureter on each side has now to be identified. The ease with which this can be done varies. In some cases the ureters can be seen at once and dealt with quite easily, in others the greatest difficulty Fig. 263. — Identifying the ureter. may be experienced in finding them. The best way is to pull up the posterior layer of the broad ligament with pressure-forceps, and on rolling this layer between the finger and thumb, commencing in the region of the ovarian ligature, the ureter will be felt as a cord slipping under the finger, about the size and offering the resistance of a quill toothpick. Often it can be seen through the vascular subperitoneal tissue as a white line. The ureter having been identified, an aneurysm-needle is pushed under it, after which it is traced forwards to where it passes under the uterine artery (Fig. 263). 3§4 GYNECOLOGICAL SURGERY viii. Ligaturing the uterine vessels. — -The uterine ves- sels should he ligatured with No. 4 silk as far out towards the wall of the pelvis as possible. This is best done by first separating these structures from the ureter by pushing the index - finger through the potential space (ureteric canal) which is present in this neighbourhood (Fig. 264), and, having raised them, passing under them a ligature by means of Worrall's needle. The division of the uterine Fig. 264. — Ligaturing the uterine artery. vessels will expose the ureter, so that it can be easily separated up to the bladder. In cases where the parametrium is healthy the uterine vessels quickly come into view, but in others their identifi- cation is very troublesome. If no " ureteric canal " can be found, the vessels should be sought for and ligatured just as they leave the trunk common to them and the superior vesical artery on the side wall of the pelvis. It is necessary to ligature the distal end of the vessel after dividing it, on account of the free anastomosis. ix. Separation of the ureters. — By gently pulling on WERTHEIM'S OPERATION 385 the aneurysm-needle the ureter is raised from its bed of cellular tissue in the base of the broad ligament, and is then carefully dissected free with the points of the dis- secting forceps or with a few slight snips of the scissors. By degrees the cervical portion of the ureter is freed up to its point of entrance into the bladder (Fig. 265). If diffi- culty is found in tracing the ureter after the uterine artery Fig. 265. — Isolating the ureter. has been divided, it is helpful to seize the distal end of the latter with forceps and gently pull it back towards the uterus, when, as it strips, the ureter lying underneath it comes into view. As a rule, the left ureter is the more difficult to isolate. x. Separating the rectum and dividing the utero- sacral ligaments. — The uterus is pulled well forwards by the assistant, and the peritoneum at the bottom of Douglas's pouch is caught with a pair of forceps, pulled up and snipped z 386 GYNECOLOGICAL SURGERY (Fig. 266). The index finger is then pushed through this opening in the peritoneum and separates the rectum from the posterior vaginal wall downwards for over an inch (Fig. 267). The utero-sacral folds are next clamped and divided, care being taken not to include the ureter in the forceps, by keeping that structure out of the way with the finger (Fig. 268). The rectum may be injured during its separation from Fig. 266. — Incising the peritoneum posteriorly. the posterior vaginal wall, or may necrose later, in each case causing a recto-vaginal fistula. Wertheim, in his 458 cases, had one recto-vaginal fistula. We have had one case, and there are two examples in the 291 cases collected by us. xi. Clamping and removing the lateral masses of para- vaginal tissue. — The utero-sacral ligaments having been divided, the mass of cellulo-fibrous tissue forming the lateral cervico-pelvic ligaments in the base of the broad ligament, perhaps infiltrated with growth or inflammatory WERTHEIM'S OPERATION 387 products, will be found stretching out from the side of the cervix to the wall of the pelvis. This mass is clamped Fig. 267. — Separat- ing the rectum from the vagina. on each side with angular Kocher forceps as near the pelvic wall as possible, and is then divided with scissors, so that Fig. 268. — Dividing the utero-sacral ligament. 3 88 GYNECOLOGICAL SURGERY as much as possible of the cellular tissue here is removed (Fig. 269). xii. Final separation of the bladder. — The parts to be removed are now almost isolated, but before proceeding to this step the bladder, especially in the neighbourhood of the ureters, is still further pushed off the anterior vaginal wall, this step being rendered easier by the facility with which the operator can pull up the vagina. Fig. 269. — Dividing the paravaginal tissue. xiii. Clamping the vagina. — The uterus, together with the cellular tissue in its neighbourhood, is now to be removed by cutting across the vagina as low down as pos- sible. This is one of the most important steps of the oper- ation, and when it is properly carried out the diseased cervix is removed in a bag of vagina, the vagina being cut across at a part where it is presumably healthy, so that the risk of cell-implantation is absent. To achieve this, Wertheim places special clamp-forceps across the vagina, above the line of its contemplated division. The application of these forceps is not always easy. WERTHEIM'S OPERATION 589 We have tried several patterns after the models of Wertheim and Howard Kelly, but have found all of them inconvenient in difficult cases and more or less liable to slip and come off at the critical moment of amputation. We have there- fore devised a new pattern, for application in the antero- posterior vertical plane (Fig. 14, p. 15). The blades are joined at a T-angle to shanks sufficiently curved to embrace the mass to be removed, and additional grip is obtained Fig. 270. — Adjusting the vaginal clamp. by serrating them longitudinally, and giving them a " spring " similar to that characterizing Doyen's smaller clamp-forceps. Two pairs of finger rings are provided, of which the lower are used for the purposes of adjustment and the upper to obtain the necessary force when clamping. We have found this instrument superior in every way to the other patterns we have used. It is easy to apply, it cannot slip, and it makes an excellent tractor. The uterus is pulled up out of the pelvis as far as possible by the assistant, and, the vagina having been well cleared J 90 GYN/EGOLOGICAL SURGERY of the bladder in front and the rectum behind, the gauze which was inserted into the vagina just before the operation is removed, after which the vagina is clamped with the Berkeley-Bonney forceps right across and well below the limits of the growth (Fig. 270). Fig. 271.— Dividing the vagina by the cautery- knife. xiv. Division of the vagina. — The clamp having been securely fixed, and a swab having been placed between the rectum and vagina, this canal is divided below the clamp from left to right, either with the actual cautery or with the scalpel (Fig. 271). If the former is used, the parts around must be packed off with moist sterilized gauze. The anterior vaginal wall should be divided across its whole breadth before the posterior wall is incised. WERTHEIM'S OPERATION 59 e xv. Application of ligatures. — Immediately the removal has been effected, ligatures must be applied for permanent control of the vessels divided. The first of these secure the lateral vaginal angle and adjacent paravaginal tissue on each side, from which there is always free bleeding (Fig. 272). Afterwards the clamps upon the stumps of the utero-sacral ligaments and the subureteric masses of tissue are replaced by ligatures, which are most conveniently passed by means Fig. 272. — Ligaturing the lateral vaginal angle. of Worrall's blunt needle. As the operator is working very deep, and close up to the side wall of the pelvis, this is often a troublesome part of the operation. The needle should be passed deeply to the point of the clamp, and the ligature tied behind the clamp. xvi. Further removal of cellular tissue and the regional glands. — All bleeding having been stopped, the surgeon explores for lymphatic glands still remaining on the side- wall of the pelvis. It is important to obtain access to the obturator fossae, and this is effected by isolating a sheet of tissue containing at its upper edge the common trunk of the uterine and superior vesical arteries and its continuation, 392 GYNAECOLOGICAL SURGERY the superior vesical and obliterated hypogastric arteries. This sheet, having been isolated by the finger, is ligatured at its distal end, divided, and stripped back as far as the internal iliac artery, where it is again ligatured and removed. The obturator region is now exposed with the artery and nerve, and the glands and loose cellular tissue are removed therefrom. The peritoneum is next stripped off the external and Fig. 273. — Removing the iliac glands. common iliac arteries by the finger, and the chain of glands lying between the artery and vein is separated by ring forceps at its lower end, and stripped upwards (if possible, as a continuous piece of tissue) to near the bifurcation of the aorta, where a ligature is applied to it, and it is then removed (Fig. 273). Glands are sometimes found adherent to the iliac vein, in which case great care must be taken when removing them not to injure it. If the vein is torn, it would, of course, have to be ligatured, laterally if possible. xvii. Suturing the pelvic peritoneum. — All serious bleed- WERTHEIM'S OPERATION 393 ing having been arrested by further ligatures, and oozing by hot swabs if necessary, the anterior peritoneal flap is sutured to the cut edge of the posterior peritoneum covering the back of the pelvis, with a continuous suture of No. 4 silk from left to right, so that in this manner the peritoneum covering the bladder is sutured to that on the anterior face of the rectum, and eventually the floor of the pelvis Fig. 274. — Suturing the peritoneal flaps. is covered over and the raw-surfaced cavity of the pelvis disappears from view (Fig. 274). The suturing should be commenced at the region of the left ovarian ligature and carried across to a similar point on the right. Any little holes in the line of the peritoneal suture are closed by interrupted sutures so that the saline fluid, if subsequently to be introduced, is prevented from escaping. xviii. Closing the abdominal cavity. — See p. 285. Be- fore closing the abdomen, three pints of saline solution at a temperature of 108 F. may be poured into the abdo- minal cavity to prevent shock. Difficulties and dangers, i. Separation of the bladder. — The ease with which the bladder can be separated depends 394 GYNAECOLOGICAL SURGERY entirely on the extent of the growth. In an early case the bladder strips quite easily and the fibres of the vagina at once come into view, and the separation is carried down till the upper inch of the anterior vaginal wall is exposed. On the other hand, if the growth is extensive, very great difficulty may be experienced in separating the bladder, and this viscus, unless the greatest care be taken, is very likely to be injured. The risk is, of course, all the greater if the bladder itself is found to be infiltrated ; in that case, indeed, it becomes a question whether the opera- tion should be persevered with, since it may be neces- sary to excise that portion of the bladder which is affected. If the wound remains undiscovered, or after suture does not heal, a fistula of course results, as it may after the bladder has been opened deliberately and a piece of it resected. Vesico - vaginal fistula may also be due to necrosis of the bladder -wall from sepsis and sloughing aided by its diminished blood-supply, owing to ligature of the vesical arteries or denudation of its walls when separating it from the vagina. We have no records of Wertheim's for vesico-vaginal fistula. Bumm, in his 108 cases, injured the bladder 5 times ; 2 of the wounds healed with fistula, 3 of the patients died. We have had 3 cases, and the accident occurred 15 times in the 291 British cases collected by us ; in 13 of these the wound closed spontaneously, and in 2 the fistula was closed by operation. On 4 occasions in the same series the bladder was intentionally opened, and in each case the wound healed without a fistula, portions of the bladder being removed in 3 cases. At the Johns Hopkins Hospital, in 157 cases the bladder was injured 19 times = 12 'i per cent. Schindler ha> collected 362 cases (nine operators) with the bladder and ureter wounded 90 times = 24/8 per cent. In comparison with this, Schauta wounded the bladder 11 times (7 accidental injuries, 4 fistulae) ; and Doderlein collected 1,979 cases (90 operators) of simple WERTHEIM'S OPERATION 395 vaginal hysterectomy, and found the bladder wounded 61 times ; whilst Olshausen had 638 cases with the bladder wounded 22 times. In all of Wertheim's cases where a portion of the bladder or ureter has been inten- tionally resected, recurrence has been early. If the bladder has been accidentally injured, or a piece of it purposely resected, it is often a very difficult and lengthy procedure to suture the opening properly, situated as it is at the junction of the posterior wall and trigone. Sepsis, too, frequently occurs in this situation, and after operation the sutures are less likely to hold. Russell Andrews tells us that in three cases he very successfully and rapidly repaired the wound, after he had intentionally resected a portion of the bladder for growth, by suturing the anterior vaginal wall over the opening. During the separation of the bladder there may be troublesome bleeding from the anterior vaginal vessels. These, if possible, should be secured with forceps and tied, or, failing this, the oozing must be temporarily arrested by pressure with a swab. ii. Injury to the ureters. — One of the principal points to remember is not to free more ureter than is necessary, and to be most careful not to injure the peri-ureteral plexus of vessels, since if this is done there is danger of the ureter subsequently necrosing. From what has been said, it will be apparent that the chief danger of this operation is injury to the ureters. They run the risk of injury — (1) When the ovarian ligatures are being applied. (2) When the uterine vessels are being tied. (3) When their cervical portion is being dissected free. (4) When the vaginal clamp is being applied. (5) W T hen the pelvic peritoneum is being sutured. The injury may consist in dividing them, including them in a ligature or suture, damaging the peri-ureteral plexus of vessels (stripping them too clean), or crushing them with forceps. 396 GYNECOLOGICAL SURGERY If they are divided, it is necessary to determine which is the best treatment. The divided ends can be sutured by the method described on p. 544, but it is best if possible to implant the renal end into the bladder (p. 540). The renal end can also be ligatured in the hope that the kidney may atrophy ; if it does not, this organ will have to be removed at a future date. If the accident is not discovered and treated, or if the ureter necroses after it has been sutured or implanted, the urine will escape through the vagina and, if the patient lives, a permanent fistula results. This will have to be dealt with at a later date by transplanting the end into the bladder or removing the kidney. In the latter event, great care must be taken not to remove the wrong kidney. These accidents are more likely to happen when the growth is an extensive one and when infiltration has taken place into the broad ligament, so that the mass forms a great buttress on each side. At times, when the ureter is surrounded by much infiltration, it can be dissected out only with the greatest difficulty, or this may be found altogether impossible, and the involved portion will have to be resected. Sometimes, owing to the ureter apparently lying at a much lower level than usual, great difficulty will be experienced in detecting it as it winds round the cervix, in which case its dissection will have to be commenced much farther back, perhaps even near the ovarian ligature, so that when it is freed it will hang like a clothes-line across the pelvis. This method of dealing with the ureter is to be particularly avoided if possible, because of the injury to its blood-supply, which is largely derived from the vessels of the peritoneum to which it is adherent. The uterine artery may be found running parallel with the course of the ureter and above it ; this distribution is abnormal, and the vessel may be mistaken at first for the ureter. When the posterior layer of peritoneum in the neigh- bourhood of the ovarian vessels is pulled up to pass the WERTHEIM'S OPERATION 397 first stitch of the continuous suture, the ureter may be pulled up with it, and care must be taken not to include this structure. iii. Clamping and dividing the vagina. — Great care must be taken when applying the clamp not to include the ureter or any portion of the bladder in its grip. Also, when the vagina is cut across, any discharge from it may escape into the peritoneal cavity. It is for this reason that the preliminary scraping and disinfection is so im- portant. The danger of soiling the peritoneum is over- come to a certain extent by packing the vagina lightly with gauze just before the operation is commenced, and remov- ing it just before the amputation, as previously described. Great care must be taken also when dividing the vagina not to injure the ureters, bladder, or rectum. The rectum is particularly in danger as it is out of sight, and for this reason a swab should be placed between it and vagina before the latter is divided. Bumm objects to the use of a clamp, on the ground just stated, and also — and this he considers the more important reason — because he finds that its application prevents the perfect removal of the parametrium. Bumm argues that the parametrium and cellular tissue can only be properly separated when the vagina is cut through before the separation commences. For this purpose he packs a swab close up against the cervical growth and then separates the vagina well below this at the junction of its middle and lower third. The " cuff " that is thus fashioned is sewn together over the swab, and the rest of the vaginal wall is thoroughly disinfected. This takes ten minutes. A new set of gloves and instruments having been obtained, the patient is placed in the Trendelenburg position and the operation continued per abdomen. After the ureter has been separated and the uterine artery liga- tured, the rectum is separated from the posterior vaginal wall till the cut end of the vagina is reached. The hand then pulls up the growth encased in the bag of vagina, and 39§ GYNECOLOGICAL SURGERY gradually the uterus, parametrium, and cellular tissue are separated from below upwards and outwards as far as the lateral wall of the pelvis, in one piece. We have tried this technique, but think it inferior to that we have described. iv. Arrest of haemorrhage. — In the course of the opera- tion it may be necessary at frequent intervals to arrest oozing, or even brisk haemorrhage, by means of clamp forceps or ligature. If the bleeding vessel is plainly seen, it can, of course, be picked up with forceps and ligatured, but much trouble is experienced from venous oozing due to the wounding of the plexus of veins in the base of the broad ligament. The bleeding is at times so free that the pelvis rapidly fills up with blood. The excess of blood must be removed quickly with swabs, a clean swab pressed down on the bleeding area by an assistant, and then at a given signal he removes the swab and the operator clamps the bleeding spot. By far the best instruments to use for this purpose are ring forceps (Fig. 5, p. 10), which secure a good grip of the tissue, while their oval ends enable a ligature to be applied over them with ease even in a deep cavity. With the ureters separated and in view, no fear need be felt in applying the forceps, as there are no structures of vital importance which can be injured. If the bleeding is not very brisk, and its source is difficult to locate, pressure with a swab will at times check it. During the dissection of the cellular tissue and removal of the uterus the large iliac vessels will be in view, and injury to them must be avoided. There is usually a certain amount of free haemorrhage from the cut vaginal walls. This stops when a mattress- suture is applied to each lateral angle of the cut surface (Fig. 272). Dressing and after-treatment. — The general lines of after-treatment are indicated at p. 44 and in Chapter xxxn. Paresis of the bladder invariably follows this operation, and regular catheterization is a necessity for some week or two afterwards. The power of micturition always returns. WERTHEIM'S OPERATION 399 Postoperative complications. — There are certain com- plications so frequently following this operation that they require a separate discussion. i. Shock. — The shock is always considerable, and some- times profound. This is due to the time occupied by the operation, the free loss of blood, and the extensive dis- turbance of the parts. Further, in most cases the patient's health is already undermined by pain, haemorrhage, and septic discharges, in addition to which many of the women are over fifty. The value of time in this operation cannot be over-estimated. Up to an hour and a half the patients stand the manipulations well, but after this period every ten minutes increases the amount of shock very materially. A perusal of our personal cases shows that the time taken by the operation in our hands varied from 51 to as much as 165 minutes. These figures show the strik- ing variation in the difficulty of the operation in different cases, a factor which is beyond the control of the operator. The difficulties become enormously enhanced when the patients are fat, or when there is extensive infiltration of the cellular tissue or adhesion to the bladder. We have found that cases presenting extensive infiltration and cancerous hypertrophy of the cervix without ulceration are very much more arduous to deal with than those exhibiting excavation or fungosis. In particular, the surgeon should try to avoid injury to the bladder, for the extra time taken to suture the rent is a great handicap to the patient. In many advanced cases a condition of chronic adhesive sal- pingitis is present which delays the operation and makes the exposure of the ureters more difficult. The amount of oozing from the extensive raw surface left after the extirpa- tion varies greatly. In some cases, particularly in early ones, it is comparatively slight, but where the growth is extensive it may be considerable, and time is unavoidably lost in arresting it. Shock is lessened in these cases by the routine intro- duction into the abdominal cavity of three pints of saline 400 GYNECOLOGICAL SURGERY infusion at a temperature of 108 F., and special care should be taken to keep the patient as warm as possible. ii. Haemorrhage. — Even with the greatest care the operator can exercise, a very considerable amount of blood is always lost, most of it from a continual oozing which it is impossible to control. The operator should secure every vessel that is bleeding even at the commencement of the operation, since it may truly be said that every drop is of value. Some operators have deliberately ligatured both internal iliac arteries as a preliminary to removing the uterus. The dangers of such a proceeding are obvious, and we do not think well of it. Temporary clamping of these arteries has also been suggested, but we have found that, in those cases in which it is most necessary, a sufficient exposure of both internal iliac arteries is an operation involving some time and may in itself cause a good deal of bleeding. iii. Septic infection of the operation area. The bac- teriology of Wertheim's operation. — The value of syste- matic bacteriological examinations in cases of carcinoma of the cervix, both before and during the operation, is insisted upon by Liepmann from Bumm's clinic in Berlin. His procedure is as follows : — Three long-handled sterile swabs are taken and inocu- lated — (i) from the carcinomatous ulcer exposed by Doyen's specula as soon as the external genitals have been disin- fected ; (2) from the peritoneal cavity as soon as it is opened ; (3) from the interior of the growth, the glands, or parametrial tissue — the surface of the masses being first sterilized by a glowing knife, and the tissues being incised by a sterile knife. The three swabs are each placed in a sterile Petri dish as soon as they are taken, and trans- ferred to the laboratory, where the bouillon tubes are inoculated. Liepmann thus gets his " three-swab " test. The first gives the primary bacterial content of the carcinoma, the second that of the peritoneal cavity, and the third that of WERTHEIM'S OPERATION 401 the parametrium and glands. In only one of more than a hundred cases had complete sterility been procured throughout. In this case the operation lasted 130 minutes, the carcinoma was broken into during the separation of the bladder, and the peritoneum was closed without drainage. Nevertheless recovery was non-febrile and uninterrupted, and the patient passed flatus on the first day, showing absence of intestinal paralysis. In all other cases streptococci have been found, either in pure culture, or along with staphylococci and bacilli. Streptococci from carcinoma possess an extremely high virulence, especially for the peritoneum. Where strepto- cocci were found in the peritoneal cavity and drainage was not employed, the fate of the patients was, with few exceptions, sealed. Thus, in one case where the opera- tion was easy and short, lasting only 83 minutes, where streptococci in long chains were found in the carcinoma and in the peritoneal cavity, the patient died from septic infection on the fourth day. Influenced by Liepmann's bacteriological findings, Bumm proceeded to leave the peritoneum open and to employ drainage from below, with the following results : — ■ No. of No. of cases No. of deaths from operated deaths. septic upon. infection. Prior to July, 1907 (peritoneum closed). . 34 16 = 47% 12 = 38% Since July, 1907 (peritoneum open, drainage from below) 40 6 = 15% 2= 5% Liepmann believes that it is not the magnitude of the operative procedures which accounts for the high mortality of Wertheim's operations, but that this is due to operating in a bacteria-laden medium, i.e. to sepsis. As a precaution against sepsis we advise that the sound be passed into the uterus before the operation, in case a pyometra is present. This condition is a very serious complication, as, 2 A 402 GYNAECOLOGICAL SURGERY during the operation, pus may escape through the holes made by the volsella or in some other way. We have had two cases of pyometra, and in 291 cases we have collected there are 7 examples. As a further precaution against sepsis, the vagina may be swabbed out with perchloride of mercury, 1 — 2,000, after the clamp has been applied and the gauze packing withdrawn ; but before the vagina is divided, and during the section of the vagina, the surrounding pelvic tissues should be well protected by swabs. In cases in which the growth is not breaking down, and the patients are free from offensive vaginal discharge, the risk of serious septic infection of the operation area should be slight. A certain amount of infection of the extensive raw surface that is left in the pelvis is perhaps inevitable, and most cases manifest some fever accom- panied by a vaginal discharge during the second week of convalescence. When the cervix is extensively ulcerated, or when a fungating and stinking mass fills the vaginal vault, the probability of serious infection of the operation area becomes much enhanced. The methods taken for the preliminary cleansing of the cervix have been already indicated, but in some cases it is impossible to ensure the discharge being absolutely sweet. In these cases signs of marked septic infection of the operation area usually begin about the fifth day with considerable fever and a foul discharge lasting perhaps for several weeks. iv. Septic infection of the bladder. — As has been said, for a week or two the patients suffer from inability to empty the bladder completely, and this is sufficient in itself to account for the tendency that exists to cystitis. The tendency is in- creased by the extensive denudation of the outer wall of the bladder in the region where it has been separated from the supravaginal cervix, vagina, and parametric tissue, and by the injury done to the bladder-wall from its diminished blood-supply and from damage to its nerves. In regard to WERTHEIM'S OPERATION 403 this, we have pointed out that the area of bladder attach- ment to the cervix, normally about f in., becomes greatly elongated owing to the enlargement of the cervix produced by the carcinoma. In addition, this raw area of the outer bladder-wall directly bounds the large subperitoneal cavity left by the operation, a cavity that in all cases subsequently becomes more or less infected. The appearance of pus in the urine in these circumstances is not surprising. Wertheim states that cystitis occurred in practically all his patients, and was one of the principal causes of their prolonged convalescence. In some instances the infection spread, causing pyelo-nephritis, in one case with fatal results. In the cases we have collected there is a great difference in the frequency with which this complication is noted by the different operators, due, we think, to the care, or otherwise, with which the urine has been tested. We have had the urine tested repeatedly in all our cases, and the case was noted as one of cystitis when any pus was detected. We had this complication in the larger proportion of our patients. The bladder, therefore, should be catheterized twice a day and washed out with a solu- tion of boric acid. If this routine be carried out, cystitis will not occur, or, occurring, will be of short duration. v. Septic infection of the abdominal wound. — One of the most notable things about convalescence from Wertheim's operation is the comparatively large number of cases in which the wound fails to heal by primary intention. There may be a stitch-abscess, a little local suppuration, or sloughing of the whole wound. This latter is a very tire- some complication. We have noted that it has nearly always occurred in those cases in which the odour of the primary growth was markedly offensive. It is due to infec- tion, by an organism from the site of the primary growth, of the tissues whose power of resistance has already been lowered by the bruising caused by prolonged retraction of the wound-edges ; the slough has the same odour and appearance as the sloughing carcinoma. Owing to the long 404 GYNECOLOGICAL SURGERY duration of the operation in some cases, and the degree of manipulation involved, the edges of the abdominal wound may become bruised and devitalized. There is, therefore, a great probability of sloughing or suppuration if during the operation they become infected by septic organisms. Where the cervical growth is breaking down and stinking, and complete cleansing by scraping, cauteriza- tion, and antiseptic applications is not possible, the abdo- minal wound may easily be infected by the vaginal contents after the amputation. In several of our cases this accident appears to have happened. In each of them, on the fourth day after the operation, when the Michel's clips holding the skin-edges together were removed, a foul discharge was noticed oozing from the lower end of the wound. The skin-edges were immediately separated along its whole length, and the cellular tissue, fascia, and muscle-edges were found in a condition of sphacelus. In spite of this, the skin itself was not even reddened, nor was the patient's general condition apparently affected. Dressings soaked in peroxide of hydrogen were immediately applied, and in twenty-four hours the wounds had a clean appearance. In one case, a bacteriological sample was submitted to Messrs. Foulerton and Hillier, and an anaerobic organism was isolated, but the causal relation borne by it to the condition described has to be further investigated. From the facts that the slough had in all the cases exactly the same appearance and odour as that characterizing the breaking-down carcinoma, and that the free opening of the wound to the air and the application of peroxide of hydrogen immediately restored a healthy condition, it would appear almost certain that this peculiar occurrence is due to infection by organisms (probably anaerobic) that pre-existed at the site of the carcinoma. The prevention of wound infection is therefore an important matter. It is to be effected — i. By procuring as complete a cleansing of the cervix and vagina as the case will admit of. WERTHEIM'S OPERATION 405 2. By shortening the operation as much as possible, and so saving the wound-edges from needless exposure and manipulation. 3. By covering those edges with a layer of sterile india-rubber in the manner previously described (p. 379). Less manipulation of the wound-edges is required if a mechanical retractor be used. The presence of wound- sepsis should be looked for on the fourth day, when the Michel's clips are removed, and, if there is any oozing from the lower end of the wound, the skin-edges there should be immediately separated and the condition of the deeper parts investigated. For it is a noteworthy fact that the skin may be apparently normal and the wound-edges well united and yet the cellular tissue, fascia, and muscular edges under them be in a condition of sphacelus. Sloughing or suppuration having been found, the whole length of the skin-incision should be opened up and dressings soaked with peroxide of hydrogen solution (10 volumes) freely applied. This measure and the free access of air to the affected part cause the condition rapidly to improve, and in forty- eight hours the wound may look quite clean. It will, however, take many weeks to heal entirely, and, as a weak scar is certain to result, the patient must be fitted with an abdominal belt. CHAPTER XVIII THE OPERATIONS FOR BROAD-LIGAMENT MYOMATA General remarks. — Broad-ligament myomata are divisible into two classes. The first variety is the true ligament myoma, and springs from the muscle-fibres normally found in the mesometrium. These tumours may, therefore, be found in at least three situations : i. In the round ligament. 2. In the ovarico-uterine ligament. 3. In the connective tissue surrounding the ovarian or uterine vessels. As a rule, tumours growing in the first two situations are of small size, and can be enucleated on ordinary prin- ciples. Tumours growing in the third situation frequently attain a large size ; they distend the broad ligament so that the Fallopian tube is stretched and lies sessile on their upper surface as in a broad-ligament cyst. Having exhausted the capacity of the broad ligament, the tumour pushes its way upwards, stripping the peritoneum off the lateral wall of the pelvis and iliac fossa, and on the left side often in addition burrows between the layers of the sigmoid mesocolon, the bowel itself then lying sessile upon the tumour. If the operator is not familiar with the anatomy of these tumours he may believe that this condition of the bowel is due to adhesions, and may abandon the attempt to remove the tumour, when, as a matter of fact, a plane of easy cleavage lies between the muscularis of the intestine and the surface of the tumour. True tumours of the broad ligament can be distinguished by the fact that they are entirely separate from the uterus, 406 Plate VI. — Myoma of the Right Broad Ligament. BROAD-LIGAMENT MYOMATA 407 which they displace but do not deform. Their relation to the uterine artery should be remembered ; it lies beneath and on the inner side of the tumour, while the ureter is displaced inwards, and will be found running in the posterior peritoneal layer of the broad ligament, after leaving which it courses under the tumour to reach the bladder. There are two methods of dealing with these broad- ligament myomata. If the tumour is small it may be enucleated in the manner described for dealing with broad- ligament cysts (p. 463). If the tumour is very large, vascular or adherent, it may be necessary to remove the uterus in addition, principally as a means of easily con- trolling the haemorrhage. This method will be described in the operation for the second variety of broad-ligament myoma. This second variety may be termed the "false" broad- ligament myoma. In this case the tumour springs from the lateral wall of the uterine body or of the cervix, and bulges outwards between the layers of the broad ligament. The uterus is, therefore, part and parcel of the tumour. These tumours distend the broad ligament, and also at times raise the lateral pelvic peritoneum and invade the mesocolon. Besides their relation to the uterus, they differ from the first variety in that they displace the uterine artery outwards and upwards, so that in extreme cases the uterine and ovarian vessels are approximated and run a parallel course on the top of the tumour. The ureter is displaced outwards to the pelvic wall and, as a rule, lies under the tumour, except in the rare lateral cervical myomata already referred to, when, together with the lateral angle of the bladder, it may be undermined by the tumour and elevated on its upper surface. These tumours, when small, can sometimes be enucleated, but when large they must be dealt with as follows : It is better to begin the removal of the tumours by attacking the healthy side of the uterus. The reasons 408 GYNECOLOGICAL SURGERY for this are, in the first place, that haemorrhage can be better controlled, and, secondly, that the uterus itself constitutes the firmest attachment of the tumour, which is elsewhere surrounded by cellular tissue and peri- toneum. The greatest difficulty in these cases is the control of the uterine vessels on the side of the tumour, and it is often impossible to secure them until the tumour is removed from the field of view. The concluding stage of its removal Fig. 275. — Hysterectomy for a broad-ligament myoma Dividing the peritoneum over the front of the uterus. has, therefore, often to be effected as quickly as possible, and this is materially aided by the previous amputation of the uterus and clamping of the uterine vessels on the healthy side. Preparation of the patient. — See pp. 82-86. Instruments. — See general list, p. 276. Operation. — i. Opening the abdominal cavity. — See p. 276. ii. Clamping and dividing the ovarian vessels and round ligament on the healthy side. — See pp. 293-96. iii. Securing the ovarian vessels and round ligament on the diseased side. — The peritoneum over the front of the BROAD-LIGAMENT MYOMATA 409 uterus is now incised at the upper level of. its loose attach- ment, together with the round ligament on the diseased side, this structure having been previously clamped with forceps (Fig. 275). The index ringer of the surgeon's left hand is then inserted between the cut edges of the peri- toneum and forced under the Fallopian tube and ovarian vessels, which are thus separated from the tumour. Two Fig. 276. — Clamping the ovarian vessels on the side of the tumour. pressure-forceps having been applied to these structures (Fig. 276), they are divided between them. iv. Stripping the anterior peritoneal flap. — The peri- toneum is now stripped from the upper surface of the tumour as far as possible, and the bladder is pushed down (Fig. 277). v. Clamping the uterine vessels on the healthy side. — See p. 298. vi. Amputating the uterus and dividing the uterine vessels on the diseased side. — The uterine vessels on the 4io GYNAECOLOGICAL SURGERY same side as the tumour are secured by drawing the fundus of the uterus over towards the side on which the tumour lies with a volsella, cutting through the uterus at the level of the internal os, and clamping the vessels when they come into view or as they spurt (Fig. 278). vii. Enucleating the tumour. — The assistant pulls the uterus strongly towards the side of the tumour, and Fig. 277. — Stripping the peritoneum over the tumour. the operator, passing the fingers of his left hand between the tumour and the base of the broad ligament, frees its lower surface and thus enucleates it (Fig. 279). viii. Ligaturing the uterine and ovarian vessels. — See pp. 301-6. ix. Obliterating the cavity of the broad ligament. — All redundant peritoneum being removed with the scissors, it will usually be found that the suture of the perito- neal flaps can be immediately proceeded with (p. 306). Where, however, the cavity extends deeply into the broad ligament, and much oozing is present, it may be obli- terated by sutures from the bottom upwards. Care must BROAD-LIGAMENT MYOMATA 4" Fig. 278. — -Amputating the uterus. Fig. 279. — -Completing the enucleation of the tumour. 412 GYNECOLOGICAL SURGERY be taken to avoid injuring the ureter when doing this (Fig. 280). x. Closing the abdominal cavity- — See p. 285. Difficulties and dangers. — -The difficulties may be some of those which are mentioned under the sections dealing Fig. 280. — Closing the peritoneal flaps. with broad-ligament cysts and cervical myomata. The surgeon must remember the various displacements to which the ureter is liable, and, if he cannot be sure of its exact position, must minimize the danger of wounding it by keeping as close to the tumour as possible whilst enucleating it. Dressing and after-treatment. See p. 44 and Chapter XXXII. CHAPTER XIX ABDOMINAL MYOMECTOMY The operation of abdominal myomectomy has for its object the removal of one or more myomatous tumours from the uterus, with conservation of this organ. This method is the ideal one, but it is often associated with grave disadvantages, so that its performance has many limitations. By myomectomy the necessity of hysterec- tomy is obviated — a point of great importance if the patient specially objects to the removal of the uterus. The chances of future conception are, however, not great, since the majority of women afflicted with myomata are past the child-bearing age. Noble, when investigating a long series of cases, found that only 10 per cent, of the women upon whom myomectomy had been performed subsequently conceived. In regard to the continuance of menstruation, it has to be remembered that operations upon uterine myomata are most often called for on account of excessive monthly bleeding, which it is imperative to cure. The operation of myomectomy undertaken with this object often fails because of the certainty in many cases of leaving small submucous nodules of whose presence the operator was in ignorance. Noble, in the same series of cases, found that in more than 6 per cent, other myomata subsequently developed. The mortality of myomectomy, as estimated from a large number of cases, is higher than that of hyster- ectomy, but in applying such figures to particular cases certain reservations must be borne in mind. Small tumours superficially placed, especially when pedunculated, can be more easily and safely removed than 4*3 4H GYNECOLOGICAL SURGERY the whole uterus ; whilst, on the other hand, interstitial or submucous masses, especially when large, multiple, or situ- ated in the lower segment, present great difficulties and risks. The risks attendant on a difficult abdominal myomec- tomy are due directly or indirectly to haemorrhage. During the operation the bleeding may be so profuse that, after all attempts to check it have failed, hysterectomy may have to be performed as a last resource, or its arrest may entail the application of so many mass ligatures as to leave large areas of tissue in danger of necrosis. Even with the greatest care, there is a likelihood of considerable oozing taking place subsequently to the operation, with the formation of a haematoma of the uterine wall or a localized collection of blood-clot in the peritoneum. In the first event there is a liability to septic infection, whilst in the second the presence of blood in the peritoneum acts as an irritant to the serous membrane and is soon followed by the appearance of organisms. The local peritonitis thus set up is succeeded by fever and pain of some days' duration, and probably always terminates in the form- ation of adhesions to omentum and intestine, result- ing in a few cases in intestinal obstruction and in many cases in postoperative pain. Of course, oozing may occur after hysterectomy, but it is not so likely, and there can be no doubt that the morbidity after diffi- cult myomectomy is greater than that after hysterectomy. The cases in which myomectomy should be performed must therefore be selected. The operator, when faced with the choice of conserving or removing the uterus, must weigh the relative risks and advantages as applied to the particular case. We think that myomectomy is indicated in preference to hysterectomy when the tumour, as far as can be judged, is solitary, when the symptoms com- plained of are those of pressure, of aseptic or non-malignant degeneration, and when the risks involved in its removal are not greater than those of the more radical operations. We would also seriously consider the advisability of ABDOMINAL MYOMECTOMY 4i5 myomectomy in place of hysterectomy, although associated with somewhat greater risk, in the case of a young woman desirous of having a child. In cases, however, where the leading symptom is haemor- rhage, and the patient is past the child-bearing age, or the tumour is the seat of septic or malignant degeneration, hysterectomy is to be performed. Fig. 281. — Abdominal myomectomy for a pedunculated tumour : Incising the capsule at its junction with the pedicle. I. ABDOMINAL MYOMECTOMY FOR A PEDUNCU- LATED SUBPERITONEAL MYOMA By this operation pedunculated subperitoneal fibroids are removed, the uterus being conserved. Preparation of patient. — See pp. 82-86. Instruments. — See p. 276. 4i6 GYNAECOLOGICAL SURGERY Operation, i. Opening the abdominal cavity- — See p. 276. ii. Delivery of the tumour and uterus. — See p. 292. iii. Section of the pedicle. — The pedicle having been clamped with one or more pairs of pressure-forceps, a circular incision is made through the peritoneum distally to the forceps at the base of the pedicle about \ in. from where this structure joins the uterus (Fig. 281). Fig. 282. — Enucleating the tumour. iv. Enucleation of the tumour. — The peritoneum thus incised having been reflected towards the uterus, the tumour is enucleated (Fig. 282). v. Arrest of haemorrhage. — -Any bleeding is controlled by passing two or more silk mattress-sutures through the peritoneum and deeply to the cut surface (Fig. 283). vi. Suture of pedicle-flaps. — The uterine peritoneum is sutured with a continuous No. 2 silk suture (Fig. 284). Alternative methods. — If the pedicle is thin, it can be ABDOMINAL MYOMECTOMY 417 transfixed and tied in the same way as an ovarian pedicle (see p. 456). If the tumour cannot be enucleated and the Fig. 283. — Arresting haemorrhage from the pedicle by mattress-sutures. pedicle is thick, a wedge-shaped incision should be made in the pedicle, which is afterwards closed with mattress- sutures of No. 4 silk. Fig. 284. — Closing the peritoneum over the pedicle. 2B 4i8 GYNECOLOGICAL SURGERY vii. Closing the abdominal cavity. — See p. 285. Dressing and after-treatment. — See p. 44 and Chapter XXXII. II. ABDOMINAL MYOMECTOMY FOR A NON- PEDUNCULATED MYOMA By this operation myomata imbedded in the substance of the uterus are removed, the organ itself being con- served. Preparation of the pa- tient. — See pp. 82-86. Instruments. — See p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. ii. Incision of the cap- sule of the tumour. — The uterus having been de- livered through the ab- dominal incision, the peri- toneum and the capsule covering the tumour are incised, the uterus being steadied meanwhile by the assistant (Fig. 285). iii. Enucleation of the tumour. — -The handle of the scalpel is then passed through the incision, and by its aid, with the assistance of strong traction with a volsella, the tumour is enucleated from its capsule (Fig. 286). iv. Arrest of haemorrhage. — As a rule, all bleeding points are well controlled with mattress-sutures of No. 4 silk, passed deeply to the bleeding surface (Fig. 287). If any spouting vessel is seen, it can be ligatured. Fig. 285. — Abdominal myomectomy for a non-pedunculated tumour : Incising the capsule. ABDOMINAL MYOMECTOMY 419 Fig. 286. — Enucleating the tumour. Fig. 287. — Arresting haemorrhage from the cavity by mattress-sutures. 420 GYNECOLOGICAL SURGERY v. Suturing the uterine incision. — The peritoneal edges of the capsule are approximated with No. 2 silk sutures (Fig. 288). If the cavity is very large, it may be obliterated with buried silk sutures. Fig. 288. — Suturing the uterine incision. vi. Closing the abdominal cavity- — See p. 285. If the haemorrhage cannot be controlled by sutures, hysterectomy must be performed. Dressing and after-treatment. — See p. 44 and Chapter XXXII. CHAPTER XX CESAREAN SECTION Indications.— The indications for Csesarean section may be divided into two classes, absolute and relative. The absolute indications are furnished by conditions in which the child cannot be delivered by any other method, such as extreme pelvic deformity, with a true conjugate of 2\ in. or less, cancer of the cervix, vagina or rectum, uterine myomata, tumours of the ovary, atresia or stenosis of the vagina. These cases require no further discussion. Relative indications are furnished by cases in which there is a choice between this and other operations, as, for instance, in certain cases of eclampsia and severe ante- partum haemorrhage, and in cases of moderate pelvic deformity with a true conjugate above 2 \ in. i. Eclampsia. — In those few and rare examples of this disease where the fits are of great severity and frequency, and where the cervix is rigid, undilatable, and not taken up, Caesarean section is indicated. If it be true that deli- very of the child improves the chances of the mother — an assumption which some are not disposed to maintain — • then, under the conditions stated above, this is the best operation, the alternative one of vaginal Caesarean section being at term more difficult and dangerous, while rapid and forcible dilatation of the long and rigid cervix with Bossi's dilator is inadmissible. ii. Severe antepartum haemorrhage. — As a method of treatment for placenta praevia, the weight of authority is against Caesarean section, although a few obstetricians are in favour of it in very special cases. As Munro Kerr points out, the foetal mortality in placenta praevia is much higher 421 422 GYNECOLOGICAL SURGERY than in Caesarean section — 60 per cent, as against 5 per cent, at the most. On the other hand, the maternal mor- tality of placenta praevia varies from 4 per cent, to 8 per cent., whereas that of Caesarean section (except under very favourable conditions) is higher. In any case, when the bleeding commences before labour has started, and when, because of the relative sizes of the child and the genital canal, labour will be difficult, the mother would have a better chance with Caesarean section, as also she would in cases of central placenta praevia, where the bleeding is serious, and especially when, in addition, the cervix is rigid. In severe cases of concealed accidental haemorrhage the proper treatment is Caesarean section, either by the vaginal or the abdominal route, depending upon the practice of the operator. The abdominal operation is certainly much easier to perform than the vaginal, and there is less risk of damaging the bladder, while subsequent removal of the uterus, if it be indicated, is performed with more advan- tage. On the other hand, by the abdominal route there is more chance of infection and greater shock. iii. Moderate pelvic contraction. — With a true con- jugate below 3 in., Caesarean section is most certainly the operation of election if the child be alive, the patient in good condition, and the circumstances favourable. The exceptions to this rule are when the child is dead or dying (heart-beats sixty per minute or less), when the patient is septic, when repeated attempts at delivery have been made with the forceps or by other methods, when many vaginal examinations have been made, when the patient has been long in labour and the membranes have been ruptured for some time, when the surroundings are unsuit- able, or when the services of a competent surgeon cannot be obtained. Under these conditions the risk to the mother will be less if the child be delivered by craniotomy, for it is in such adverse circumstances that the maternal mor- tality of Caesarean section rises to 8 per cent., or higher. The maternal mortality of craniotomy is not, however, CESAREAN SECTION 423 low, Paul and Bar having reported two series of cases with a death-rate of 11 -5 per cent, and 0/3 per cent, respectively ; and although these figures are high, they more or less agree with the experience of others. With a true conjugate of 3 to 3J in. Caesarean section is, we think, undoubtedly the proper treatment, supposing it can be carried through with strict aseptic precautions, in suitable surroundings, by an operator used to abdo- minal surgery, and before the patient has in any way been interfered with either prior to or at the commencement of labour, the child being alive and well. In the absence of such qualifications an attempt may be made to deliver with forceps ; but not much force must be used, and if the head is movable above the brim this method is contra-indicated. If unsuccessful, craniotomy should be performed. If the child is dead, its head should, of course, be perforated. There is another alternative — namely, pubiotomy — if the child is alive and the disparity between the head and the pelvis is not so great that natural delivery may not be reasonably expected to take place after the pubis has been divided. The induction of premature labour with a conjugate as small as this so seldom results in the birth of a living child, or of one that will survive many weeks, that it has been almost abandoned for such cases. It is true that the maternal mortality with induction is prac- tically nil (and the patient should, of course, be informed of this), yet under the conditions of favourable time, place, and circumstances that may be commanded, and where the patient has early sought advice, Caesarean section is a very safe operation, the mortality being probably under 1 per cent, for such cases in skilled hands. Where the true conjugate is from 3! to 3! in., very careful consideration of all the factors will be necessary. If the woman has previously been through labour, the history will afford most useful information, as, indeed, it will in degrees of contraction greater than those we are now dealing with. There may have been one or 424 GYNECOLOGICAL SURGERY more previous and unsuccessful attempts to procure a living child by the induction of premature labour. Again, the parents may insist upon every precaution being taken to obtain a living child. In such cases it will be best to examine the patient during the last weeks of pregnancy, and, if the child's head can be pressed through the brim of the pelvis, to let labour start, having previously made all preparations for Csesarean section ; then, if the head becomes engaged and is advancing, labour may be allowed to terminate naturally or with the aid of forceps. If the head .does not engage, Caesarean section should be per- formed, after perhaps one or two gentle attempts with the forceps. The patient may not be seen till labour has commenced, and, although the conjugate is over 3^ in., the head may not engage. In these circumstances the obstruction is probably due to the size of the child. Caesarean section is indicated and we have performed it under such conditions, the child weighing I2| lb. At 3! in. the alternative of inducing premature labour is rightly to be considered. The induction of premature labour, if the patient is not less than thirty-six weeks pregnant, will in most cases give a satisfactory result, and, therefore, should be tried if the patient is seen at this time, at any rate for a first pregnancy. If, however, it has previously been tried and failed, this would have an important bearing on the choice of treatment. It must also be remembered that boys' heads are generally larger than girls', and that the first baby is apt to be smaller than those born subsequently. Pubiotomy is successfully performed in cases of this class as an alternative to Caesarean section, particularly in those cases where, the head having engaged, moderate forceps-traction has not succeeded in bringing it down, yet the disparity is not so great but that the extra half- inch added to the conjugate by the operation will allow the head to pass. Forceps-traction, or version alone, will often success- CESAREAN SECTION 425 fully deliver women with contraction of this degree. If they fail (with the reservation mentioned in the last para- graph) the head should be perforated, while for dead children this is the only method of delivery indicated. Preparation of the patient. — See pp. 82-86. Position of the patient. — Lying flat on her back. Instruments. — See p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. The upper limit of the incision should not reach above the umbilicus. It is well to remember that, in cases where Csesarean section is necessary, the bladder will very often be dragged high up into the abdomen, so that there is great danger of wounding it if the incision is carried too low. Some surgeons, before opening the uterus, have de- livered it through the abdominal wound. This method should not be followed except when the uterine contents are septic, in which case there would be less danger of infecting the peritoneal cavity. ii. Opening the uterus. — The uterus, which may have rotated, is so manipulated that the centre of its anterior surface corresponds with the centre of the abdominal wound. The abdominal parietes are then pressed against the uterus by the assistant, so as to prevent, as far as possible, any liquor amnii escaping into the peritoneal cavity. An incision of about 2 in. is now rapidly made through the anterior surface of the uterus in the middle line (Fig. 289). This incision is commonly made through the upper segment of the uterus because of the more vigorous retractility of this portion of the wall. In most cases the parietal incision described will allow of this being easily done, but in some cases, and especially in those where there is an excessive amount of liquor amnii, or where the head is high out of the pelvis, most of the upper segment will be above the superior limit of the parietal incision. In this event, access to the desired site for the uterine incision may be effected by lifting the upper edges of the parietal wound upwards 426 GYNECOLOGICAL SURGERY and outwards, as shown in Fig. 289. This is better than extending the incision above the umbilicus, since it pre- vents extrusions of the bowel when the uterus is delivered through the abdominal wound. There is, however, no Fig. 289. — Caesarean section : Incising the uterus. grave objection, while there are certain advantages, such as accessibility and easy delivery of the child, in making the incision through the lower segment. The uterine wall being divided, the membranes, if not already incised, are ruptured, and the surgeon slips the first and second fingers of his left hand into the uterine cavity and enlarges the uterine incision to about 4 in. (Fig. 290). CESAREAN SECTION 427 The operator must be careful not to injure the child with the scalpel as he is incising the uterus. At times the bleeding is very free when the muscle- wall is being cut through, more especially if the placenta happens to be situated on the anterior wall, and for this reason some operators advise that, if possible, the situation of the placenta should first be determined, and, if neces- Fig. 290. — Enlarging the uterine incision. sary, an effort made to avoid it by incising the uterus in some other place. There is no necessity, however, for this, and no notice should be taken of the bleeding. If the placenta is in the way it should first be rapidly re- moved with the hand. After the delivery of the child the bleeding is, as a rule, arrested by uterine retraction. iii. Delivery of the child.— Having been delivered by traction on a leg (Fig. 291), the child is encouraged to 428 GYNECOLOGICAL SURGERY breathe, and when the umbilical cord has stopped pulsating it is clamped in two places with pressure-forceps, and, the cord being cut between them, the child is freed. In cases where profuse haemorrhage ensues, as, for instance, when the placenta is on the anterior wall, it is impossible to Fig. 291. — Delivering the child. wait so long, and the cord must be at once clamped and divided. iv. Removal of the placenta. — -The placenta and mem- branes are removed with the hand, and, if adherent, care must be taken in peeling them off not to leave any pieces behind (Fig. 292). v. Delivery of the uterus. — After the placenta is removed, the retracted uterus is delivered through the abdominal incision. If the extent of the cut has been CESAREAN SECTION 429 rightly judged, no swab to pack off the intestines is required. If the incision is too large, a swab must be inserted for this purpose. vi. Suturing the uterus. — The wound in the uterus is closed by a series of interrupted sutures of No. 4 silk passed deeply through the peritoneum and muscle on either side, Fig. 292. — Removing the placenta. but not through the mucous membrane (Fig. 293), and tied. A second series should then be introduced between them ; these should be of the Lembert variety, and should, when tied, bury those of the first row. Where the uterine wall is very rigid, Lembert sutures may cut out, in which case ordinary interrupted ones should be used for the second series as for the first (Fig. 294). In all about twelve to fourteen sutures will be required, as a rule. 430 GYNAECOLOGICAL SURGERY vii. Peritoneal toilet. — ■ Any blood or liquor amnii which may have escaped into Douglas's pouch should be removed with a swab, after which the uterus is returned into the abdomen. viii. Closing the abdominal cavity- — See p. 285. Difficulties and dangers, i. Delivering the child. — If Fig. 293. — Inserting the deep sutures. the head of the child has partly entered the brim of the pelvis, some difficulty may be experienced in extracting it. Under these conditions the uterine incision may have to be enlarged and the head disengaged, perhaps by jaw-traction, whilst an assistant forces it up by vaginal manipulation. If the head is impacted in the pelvis, Csesarean section, unless absolutely necessary from inability to deliver the CESAREAN SECTION 43i child by any other method, should never be done, as in the first place the child will certainly be dead by the time it is delivered, and secondly, the uterus may be so injured in the process of delivery that hysterectomy must be performed. Before now it has been found necessary to perforate the head before the child could be extracted from the brim. Fig. 294. — Inserting the superficial sutures. ii. Hsemorrhage. — In most cases all bleeding from the cut uterine wall ceases as the organ retracts, but a few spurting arteries may remain. Hsemorrhage from the wound-edges can always be controlled by the sutures that close the incision in the uterus, and if this is the only bleed- ing that is going on it should be immediately proceeded with. In some cases, however, owing to deficient retrac- tion, free bleeding occurs from the placental site. This must be arrested before the uterus is closed, by massaging the organ, by inserting in it a swab wrung out of boiling 432 GYNECOLOGICAL SURGERY water, and by administering 20 minims of ergotin by intramuscular injection. The loss may be minimized if the assistant grasps the lower uterine segment and com- presses the uterine arteries until the stimulating measures described have time to act. In those rare cases in which the bleeding cannot be controlled by these means the uterus must be amputated by the method described at p. 292. After-treatment. — See p. 44 and Chapter xxxn. The mother should suckle her child unless there is some contra- indication present. Should the patient be sterilized? — This depends upon the condition for which the operation is performed. If the operation is necessary because of obstruction from a tumour of the uterus, this organ should, of course, be removed by hysterectomy after the child has been delivered, unless the tumour can be enucleated. If the operation is done for osteomalacia, improvement or cure of the disease is said to occur if the ovaries are removed, and in this case, as the uterus will be of no further use, it should be removed also. When, however, the operation is performed for obstruction due to other varieties of contracted pelvis, or in some rare cases of accidental and unavoidable haemorrhage, opinions differ very markedly. If Caesarean section is necessary for concealed accidental haemorrhage, it is usually advisable to remove the uterus unless a very firm retraction is secured, rendering the occurrence of post-partum haemor- rhage unlikely. In cases of placenta praevia, where it is necessary to perform ,Caesarean section, the uterus can usually be conserved. When the operation is performed for contracted pelvis, the question of sterilization requires most careful consideration. From the national standpoint, sterilization may be the means of depriving the community of useful citizens ; from the domestic, the life of the Caesarean child obtains thereby an additional importance, as no other children are possible C/ESAREAN SECTION 433 to the woman ; from the point of view of the interests of the patient herself, the sterility thus acquired may, in the case of a widow or an unmarried girl, be a serious handicap to the chance of future marriage, the risk of Cesarean section is not increased by the repetition of its performance, whilst on the other hand sterilization has the advantage of removing the menace from a deformity which in itself is a misfortune. We are of opinion that the pros and cons for steriliza- tion should be fully explained to the patient and her hus- band, and the decision left to them. If they do not express a distinct wish in the matter and the choice is left to the operator, he should decide against sterilization, since, if the domestic aspect of its performance be indifferent to the husband and wife, it behoves him to have regard to the interests of the community at large. If, on the other hand, the patient and her husband wish to avoid the possible repetition of the operation, the woman should be sterilized, but the operator should obtain leave to omit this step if the child is born dead or appears unlikely to survive. In respect to this last point, it is of great importance that the child should be very care- fully examined directly it is born. The rectum in par- ticular should be investigated, since impermeability of this organ has been overlooked. The only efficient method of sterilization, apart from removal of the uterus, is to remove both Fallopian tubes, such procedures as simple ligature or division between ligatures having failed on many occasions. ZQ CHAPTER XXI UTRICULOPLASTY Apart from its reproductive significance it is doubtful whether the monthly flow serves any useful purpose, for it is quite certain that the total absence of menstruation is compatible with perfect health, and even in normal women its presence is always attended with discomfort and often with some degree of pain. In exceptional cases, where a young woman is suffering from intractable and serious haemorrhage not associated with a myoma or other tumour of the uterus, and at the same time has a strong objection on the score of senti- ment to the arrest of menstruation, or is very anxious to bear children, the operation to which we have applied the term utriculoplasty is an alternative to subtotal hysterec- tomy. The operation, first described by Kelly, aims at the formation of a utriculus, which, whilst preserving suf- ficient of the corporeal endometrium to allow of menstrua- tion, is not large enough to permit excessive loss. * We have performed this operation successfully. There are no statistics at present which would enable one to form any definite conclusions as to its value. The cases we have treated thus have all done well, and the object of the operation, viz. to arrest the excessive haemorrhage, was attained in them all. Our first patient became pregnant six months after the operation. The pregnancy proceeded normally until the seventh month, when labour came on naturally. The child was born alive and survived, the patient making a good recovery. This case shows that the diminished uterus is still capable of physiological hypertrophy, and that the risks 434 UTRIGULOPLASTY 435 attending future pregnancy, which might appear formidable, are not so serious as to make it proper to sterilize the patient by resecting the tubes when performing the utriculoplasty. Such sterilization, indeed, would deprive the operation of half its value, and would give it but a sentimental Fig. 295. — Utriculoplasty : Removing a wedge-shaped portion of the uterus. value over subtotal hysterectomy, with which operation the risks are probably about equal when it is performed for the same class of case. Just as the pregnant uterus may rupture at the cicatrix of an old Cesarean wound, so rupture after utriculoplasty is a possibility ; but in the case recorded, at any rate, no such disaster followed. It would be wise, however, to let a year elapse before 436 GYNECOLOGICAL SURGERY permitting the chance of pregnancy, and if pregnancy occurs the patient should be kept under observation. Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. Fig. 296. — Inserting the mattress-sutures. ii. Removal of portion of the uterus.- — A wedge-shaped piece of the uterus is removed as indicated in Fig. 295, having its base at the fundus and its apex at the internal os. The portion resected includes the mucous membrane, but leaves a portion on either side of the V-shaped area of excision. The area of contemplated excision should first be marked out with the point of the scalpel, and should extend above so as to include the entire fundus as far out UTRIGULOPLASTY 437 on either side as a third of an inch from the tubo-uterine junction. iii. Formation of the utriculus. — The raw edges of the cut uterine wall are now approximated by mattress-sutures of silk (Fig. 296) to control bleeding, and the formation of the utriculus is completed by a continuous silk suture along the whole line of junction of the two halves (Fig. 297). Fig. 297. — Completing the utriculus. Dangers. — The bleeding in all our cases has been at /once checked by the sutures. Exceptionally it might be difficult to control, in which case a hysterectomy would be necessary. As there is a large surface of suturing on the uterus, strict asepsis is very important. Dressing and after-treatment. — See p. 44 and Chapter XXXII. CHAPTER XXII OPERATIONS TO REMEDY MALPOSITIONS OF THE UTERUS I. VENTRO-SUSPENSION OF THE UTERUS Ventro-suspension is indicated in cases of retroversion with symptoms in which a pessary is of no use, cannot or will not be tolerated, or is unsuitable by reason of co-existent disease of the appendages. It is an excellent operation for prolapse, but only if combined with a perineoplasty. We have also frequently employed it after the removal of diseased Fallopian tubes or appendages, to prevent the postoperative retroversion and adhesion of the uterus which so commonly follow such an operation. With regard to its application to cases of retroversion uncomplicated by appendage disease, we have for some time in this con- dition shortened the round ligaments intraperitoneally in preference to performing ventro-suspension, as being an operation more anatomically correct. Preparation of patient. — See pp. 82-86. Instruments. — See p. 276. Operation. i. Opening the abdominal cavity- — See p. 276. In this operation the peritoneum should not be divided so low down as the fascia. ii. Raising the uterus. — The uterus which is prolapsed or retroverted, as the case may be, is brought up into the wound by the surgeon passing the first and second fingers of his left hand behind it, and then drawing it forward. If it is fixed by any adhesions, these will, of course, have first to be separated. iii. Passing the sutures. — The lower edge of the parietal peritoneum having been pulled well up over the uterus, a 438 VENTRO-SUSPENSION OF UTERUS 439 No. 4 silk suture is first passed through the parietal peri- toneum and uterine wall on its anterior aspect below the lower angle of the incision in the former (Fig. 298). This suture is tied by the assistant (Fig. 299), and the ends, being left long, are used to keep the uterus forward during Fig. 298. — Ventro-suspension : Inserting the retaining suture. the passage of the subsequent sutures. After this, two or three sutures are passed through the fascia and peritoneum of the left side, then through the peritoneum and muscle of the uterus, and lastly through the peritoneum and fascia of the right side (Fig. 300). These sutures are then tied (Fig. 301). iv. Closing the abdominal cavity. — The rest of the cut edges of the peritoneum, the fascia, and skin are closed in the usual manner (p. 285). 440 GYNECOLOGICAL SURGERY Fig. 299. — Tying the retainin suture. Fig. 300.— Passing the rest of the sutures. VENTRO-SUSPENSION OF UTERUS 441 Dressing and after-treatment. — See p. 44 and Chapter XXXII. Dangers. — In ventro-suspension the object in view is to procure an adhesion between the anterior surface of the uterus and the parietal peritoneum, which will hold up the uterus if prolapsed or keep it in a position of ante- version if it is backwardly displaced. If only the parietal peritoneum is sutured to the uterus, there is no danger of any complication arising during Fig. 301. — Tying the sutures. pregnancy or child-birth which could be rightly attributed to the operation ; but if the parietal fascia is included in addition, there is some risk of such a complication in pro- portion to the area of resulting adhesion. On the other hand, if the fascia is not included in the fixation stitches, the weight of the uterus drags the parietal peritoneum off the anterior abdominal wall and rapidly forms a long ligament, until at length in many cases the displacement returns, with the additional disadvantage of 442 GYNAECOLOGICAL SURGERY a narrow band stretching across the peritoneal cavity, around which intestine may get twisted. The method that we have described aims at steering between the dis- advantages of loose peritoneal suspension and absolute fascial fixation. We have found, as a result of examination when the abdominal cavity has been reopened for some subsequent disease, that at the end of a year or more the technique we follow has resulted in the formation of a short strong ligament about half an inch in length, which is sufficient to hold up the uterus not only in cases in which the operation is undertaken for retroversion, but in those in which there is also prolapse. If the patient subsequently becomes pregnant, there is a danger of some complication arising during pregnancy or child-birth, especially when many fascia sutures have been inserted. We have knowledge of a case in which Csesarean section had to be performed after the uterus had been fixed by ventro-suspension, the pelvis being of normal size and the child in a normal position, and also of a case in which miscarriage occurred twice, and each time the haemorrhage was so severe that the patient nearly died. In our own practice we are unaware of any bad results in these respects. (See also Chapter xli.) It has happened that intestine, slipping undetected between the uterus and parietes, has been wounded when the sutures were passed, or has become adherent there, with resulting obstruction later on, as in two cases we have knowledge of. As the method described has in our experience fulfilled the objects in view, whether the operation was performed for retroversion or prolapse, whether the patient was of fertile age or not, nor has it been followed, as far as we are aware, by any evil results, we have not practised any of the alternative methods of ventro-suspension advocated by certain authorities, such as fundal fixation or posterior fixation, both of which we consider to be greatly inferior, especially in women of the child-bearing age. SHORTENING OF ROUND LIGAMENTS 443 With regard to ventro -fixation, in which the anterior surface of the uterus is first denuded of peritoneum and then sutured to the fascia without the intervention of the parietal peritoneum, we deem it absolutely unjustifiable before the menopause, and at no time more efficacious than the method we practise. This operation, from a careful study of the reported cases, appears in its sequelae to be highly dangerous in the event of pregnancy. II. INTRAPERITONEAL SHORTENING OF THE ROUND LIGAMENTS Indications. — This operation is indicated as an alter- native to ventro-suspension, especially in women of a child-bearing age, in cases of retroversion giving rise to Fig. 302. — Intraperitoneal shortening of the round ligaments : Making the transverse skin-incision. symptoms in which a pessary cannot or will not be borne or does not give relief. It is an ineffective operation for prolapse, because it does not effect a sufficiently direct 444 GYNECOLOGICAL SURGERY pull upwards upon the pelvic floor, and its performance actually tends to make a cystocele much worse by relaxing the anterior wall of the genital canal. It should not, there- fore, be performed for retroversion associated with either of these conditions. Preparation of the patient. — See p. 82. Instruments. — See p. 276. A special pair of forceps (Fig. $a), curved needles, and silk sutures Nos. 2 and 4 will also be required. Operation, i. Open- ing of the abdominal cavity. — See p. 276. In this operation a transverse skin-inci- sion may be made across the upper part of the mons veneris with cosmetic advan- tage, for when the pubic hairs grow again no scar will be visible. If this incision is chosen, the skin will have to be dissected freely from the fascia at its upper edge (Fig. 302). The fascia and peritoneum are then divided in the usual direction, the operator retracting the upper edge of the skin-incision to give more room (Fig. 303). ii. Pulling up the uterus. — A retractor having been inserted into the upper angle of the wound, the uterus is pulled up. iii. Ligature of the round ligaments. — The round Fig. 303. — Incising the fascia vertically. SHORTENING OF ROUND LIGAMENTS 445 ligament on either side is seized just externally to its attach- ment to the uterus with a pair of pressure-forceps, and a double ligature 8 in. long of No. 4 silk is passed round it, and tied about half an inch farther out (Fig. 304). iv. Passing the round-ligament forceps. — The fascia of the rectus is incised about half an inch from the cut Fig. 304. — Placing the guide ligature on the round ligament. edge forming the margin of the abdominal wound, and the round-ligament forceps is then gently forced between the rectus muscle and fascia (Fig. 305), and subsequently between the aponeurosis of the internal oblique and the peritoneum, until the situation of the internal abdo- minal ring is reached, i.e. the point where the round ligament is seen to emerge into the abdominal cavity. The point of the forceps is now directed inwards and is 446 GYNECOLOGICAL SURGERY made to follow a track parallel to the round ligament, immediately in front of it, and under the peritoneum of the broad ligament, until the site of the ligature is reached (Fig. 306). This part of the operation is much facilitated by the assistant making traction on the ligature so that the round ligament becomes taut and apparent. The forceps is now passed through the peritoneum at this spot into the abdo- minal cavity (Fig. 307), the ends of the liga- ture which has been applied to the round liga- ment are seized, and the ligature is pulled back through the path made by the forceps (Fig. 308) until a piece of doubled round ligament presents at the cut in the fas- cia of the rectus about half an inch from the primary incision (Fig. 309). If the points cannot be forced through the peritoneum, the latter must be nicked with the scalpel. The same proceeding is then carried out on the opposite side, v. Anchoring the round ligaments to the fascia of the rectus. — Needles are threaded on the ends of each ligature, and each round ligament is sutured to the edges of the small incision in the fascia, while with the same knot the incision itself is closed (Fig. 310). Fig. 305. — Passing the round-ligament forceps : First stage. SHORTENING OF ROUND LIGAMENTS 447 vi. Closing the abdominal incision. — See p. 285 and Fig. 311. Fig. 306. — Passing the forceps : Second stage. Fig. 307. — Seizing the guide ligature. 448 GYNAECOLOGICAL SURGERY Difficulties. — H the uterus is fixed by adhesions to the pouch of Douglas, these will have to be separated before Fig. 308. — Withdrawal of the guide ligature. Fig. 309. — Appearance of the round ligaments in the abdominal wound, SHORTENING OF ROUND LIGAMENTS 449 the uterus can be brought forward, and diseased tubes or ovaries, or both, will have to be removed in the way de- scribed at p. 476. Dangers. — As the round - ligament forceps is being passed, the uterus is steadied by traction on the ligature Fig. 310. — Anchoring the round ligament to the fascia. that has secured the round ligament, and if too much force is employed the round ligament may be torn away from its uterine attachment, in which case the uterus must be fixed by ventro-suspension. It would be possible when forcing the forceps between the peritoneum and the internal oblique aponeurosis to wound some of the large vessels about the brim of the pelvis, but if the forceps is passed fairly out of the internal abdominal 2D 45o GYNAECOLOGICAL SURGERY ring before it makes the turn into the broad ligament no force is required. The round ligaments should on no account be anchored in the middle line, as this is always followed by pain. Dressing and after-treatment. — See p. 44 and Chapter XXXII. III. INVERSION OF THE UTERUS Chronic inversion is rare. It can generally be cured Fig. 311. — Closing the skin-incision. with the aid of an Aveling's repositor. The failures when this instrument is employed are generally due to the fact that the cup of the repositor does not fit the inverted portion of the uterus. All uteri are not of the same size. It is best, therefore, to take a cast of the inverted portion by scooping out a piece of yellow soap, and then have a boxwood cup turned of the same size and shape. In rare cases Aveling's repositor, in spite of every care, fails, and an operation has to be performed for the cure of the inversion. Many operations have been proposed, both by the abdominal and vaginal route, including hysterectomy. INVERSION OF UTERUS 45* We have not had an opportunity of operating upon an inverted uterus, all the cases we have seen being cured by the repositor. From an examination of the literature of the subject, Haultain's operation, in which he opens the abdominal cavity and incises the posterior wall of the uterus, appears to us to be the most satisfactory. It is pointed out that the abdominal route has three advan- tages over the vaginal, because (i) the incision of the uterus is reduced to a minimum ; (2) traction on the round and broad ligaments may help reposition ; (3) the uterine wall can be more accurately sutured and haemorrhage more efficiently controlled. Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation. i. Opening the abdominal cavity- — See p. 276. On opening the abdominal wall the cup-shaped depression is seen in the uterus. ii. Incising the posterior wall of the uterus. — The uterus is pulled up with a volsella, and the posterior rim of the cup incised through both thicknesses of the inverted wall. iii. Reposition. — The inverted fundus is pressed upon from the vagina, and the incision continued downwards into the cup until the ' inversion is completely reduced from below. iv. Suturing the uterine incision. — The incision into the uterus is carefully sutured with No. 2 silk and all haemorrhage arrested. v. Closing the abdominal cavity- — See p. 285. Dressing and after-treatment.— See p. 44 and Chapter XXXII. CHAPTER XXIII OVARIOTOMY Indications. — Ovariotomy signifies the removal of an ovarian tumour, either cystic or solid, and the presence of an ovarian tumour in a patient is, with few exceptions, an indication for its removal. Unlike the operation of hysterectomy for myomata, concerning which there is still some diversity of opinion among gynaecologists, all are agreed that an ovarian tumour, because of its great liability to complications and the comparative frequency with which it is malignant, should be removed at the earliest convenient opportunity. Ovariotomy is contra- indicated only in cases in which the general condition of the patient is so bad that an operation would in all likelihood cause her death. In these cases, if the size of the cyst is increasing her distress, it should be punc- tured. Also, a small cyst well out of the pelvis discovered at the end of pregnancy may be allowed to remain till the puerperium is well established. Ovariotomy varies very much in difficulty. In many cases it is one of the easiest major operations in surgery; in others the removal may tax the ingenuity of the most experienced surgeon or may be altogether impossible. Preparation of the patient- — See pp. 82-86. Instruments. — See p. 276. If the surgeon intends to tap a cyst before removal, an ovarian trocar may be added to the list given. Operation. i. Opening the abdominal cavity. — See p. 276. The size of the opening will vary according to whether the tumour is cystic or solid, and whether the operator intends, if the tumour is cystic, to tap its contents 452 Plate VII.— Multilocular Ovarian Adeno-Cystoma of the Left Side. OVARIOTOMY 453 before delivering it. In all cases the incision should be large enough to insert the hand, so that the complete exploration of the surface of the tumour can be effected (Fig. 312). The practice of blindly tapping a presenting cyst through a smaller incision than this is a most un- surgical proceeding which is fraught with danger. ii. Tapping ovarian cysts. — The old custom of tapping all ovarian cysts before delivering them through the abdo- minal incision is still practised by many operators, their ar- gument being that, as a rule, a smaller abdominal incision will suffice and the risk of subsequent ventral hernia be minimized. On the other hand, the fol- lowing points may be urged against this practice :■ — • (a) There are no means of diagnosis of the contents of an ovarian cyst until the wall is punctured. The cyst may be a dermoid and the fluid too thick to flow through the trocar. The contents of an ovarian dermoid are very irri- tating to the peritoneum, and extremely liable to cause peritonitis. Or the cyst may be malignant, in which case some of the papillomatous growths escaping may become attached to the viscera or parietes and form secondary nodules. Or, again, the cyst may be glandular and its colloid secretion too thick to flow through the tube, or multilocular, so that the evacuation of all the cavities is impossible. Lastly, the cyst may be inflamed and contain pus. (b) Having once plunged a trocar into a cyst, it is diffi- cult to prevent the fluid from oozing up by the side of it, and, if the fluid is too thick to flow through the trocar, the Fig. 312. — Ovariotomy : Exploring the surface of the cyst. 454 GYNECOLOGICAL SURGERY cyst has to be incised and the contents allowed to escape or scooped out by the hand, as may be, or the attempt to reduce the size before removal has to be abandoned, after the patient has been exposed to all the risk due to escape of the cyst-contents. (c) A further reason for not tapping an ovarian cyst is that if adhesions are present they will be much more diffi- cult to separate from a collapsed cyst-wall than from one tightly stretched. (d) The most important argument against routine tap- ping is the fact, now clearly established, that a much larger number of these tumours are malignant than was formerly believed. Large thin-walled unilocular cysts in young women, if there is no reasonable doubt that they are innocent, should be tapped, so that a long and unsightly scar may be avoided. In all other cases it has been our practice to remove the cyst whole. If the surgeon wishes to tap the cyst, he can do so with one of the many ovarian trocars now on the market, or, if a trocar is not available, the cyst-wall can be incised with a scalpel and a long piece of india-rubber tubing inserted through the hole. As the cyst empties, the collapsed wall may be grasped by a special attachment on the trocar, or, if there is not one, by a pair of ring forceps, and thus gradually drawn up through the opening, while the assistant prevents as far as possible any contents from escaping into the peritoneal cavity by approximating the edges of the wound, and further assists the escape of the fluid and the delivery of the cyst by pressing on the sides of the abdomen (Fig. 313). Precautions. — Before tapping one must be satisfied that the tumour is an ovarian cyst and not a pregnant uterus distended by hydramnios or a cystic fibroid. These mis- takes have been made on occasion with disastrous results. If, from the appearance of the cyst-wall, the operator has reason to suspect that he has to do with a dermoid, a OVARIOTOMY 455 suppurating or a malignant cyst, the tumour should not be tapped. The wall of a benign ovarian cyst resembles mother-of-pearl in appearance ; if, therefore, the tumour is dull, discoloured, bossy, or has papillomatous growths attached to it, it should be delivered whole. Lastly, before tapping a cyst, the operator should Fig 313. — Tapping the cyst. make sure, by passing the fingers over its upper surface, that there are no adhesions in this situation ; if there are, and he taps the cyst before separating them, he will not be able to draw it up out of the wound. When tapping, the operator should push the trocar gently through the cyst-wall while his assistant supports the tumour on each side (Fig. 313). If it is necessary to puncture secondary cysts, care must be taken not to force the point of the instrument through the main cyst-wall. iii. Delivery of the tumour. — Supposing it has been 456 GYNECOLOGICAL SURGERY decided, for the time being at any rate, not to tap the cyst, and always in the case of a solid ovarian tumour, the abdominal incision is extended to a length requisite for the removal of the tumour whole. If free of adhesions, the tumour is gently lifted up in the hollow of the hand, palmar surface uppermost, through the abdominal wound, the cut ends of which are retracted. On its delivery the tumour is handed to the assistant, who will take special care not to drag on the pedi- cle, since in some cases this may be so thin or so rotten that the slightest strain will rupture it, with the re- sult that the distal end will slip down into the pelvis and brisk haemorrhage result before it can be secured as described below. iv. Treatment of the pedicle. — The pedicle of an ovarian tumour consists of the ovarian artery, the pampini- form plexus of veins, the ovarico-pelvic and ovarico-uterine ligaments, with that portion of the broad ligament between these structures, and frequently the Fallopian tube. The operator, holding this pedicle between the fingers and thumb of his left hand, transfixes it above them with a curved needle armed with 24 in. of No. 4 silk, so arranged Fig. 314. — Delivering a multilocular cyst. Plate VIII.— Ovarian Dermoid Cyst. OVARIOTOMY 457 that there are 12 in. on each end of the eye, care being taken to avoid the plexus of veins (Fig. 315). The loop of the ligature is now cut with a pair of scissors so that two ligatures are obtained, and the pedicle can then be firmly secured in two halves by these ligatures, care being exercised to take hold of the corresponding ends of the ligatures when tying them (Fig. 316). A third encircling ligature is lastly Fig. 315. — -Transfixing the pedicle. applied to the whole pedicle in the sulcus made by the other ligatures, thus securing any veins which may have escaped the primary ligatures. During the ligation the assistant must hold the tumour so that the pedicle hangs loose. The tumour is now removed by cutting through the pedicle with scissors at least half an inch above the ligatures, for if the point of severance be too near the ligatures the stump may retract and slip (Fig. 317). The stump is then swabbed, and if it remains blanched, and there is no oozing, the ligatures are cut short and it is allowed to fall back into the abdomen. Variations in treatment of the pedicle. — The method of 458 GYNECOLOGICAL SURGERY Fix 316. — Ligaturing the pedicle in halves. Fig. 317, — Removing the cyst. OVARIOTOMY 459 ligaturing the stump given above is simple, and, when properly carried out, quite satisfactory for thin pedicles, but some of the other methods described elsewhere (pp. 38-41) are equally effective. The pedicle at times is so broad that there would be great danger of its slipping if it were only ligatured in halves, and in these circumstances a Fig. 318. — Ovariotomy : Alternative method of treating the pedicle : Applying the clamps. chain of three, four, or more ligatures may be applied, according to the directions given at p. 41. The pedicle may be so short and the tumour so large that there is a difficulty in properly securing the pedicle before the removal of the tumour. Under these conditions it is best to clamp the pedicle first with a couple of pairs of forceps, remove the tumour, and afterwards ligature it below the forceps (Figs. 318 and 319). After removing an ovarian cyst the other ovary should be examined also, lest it be diseased, and in the case of 460 GYNECOLOGICAL SURGERY papillomatous ovarian cysts many authorities recommend the removal of the opposite ovary, even if it appear healthy, because statistics show that two-thirds of malignant papil- lomatous cysts of the ovary are bilateral. Dressing and after-treatment — See p. 44 and Chapter XXXII. Difficulties, i. Delivering the tumour. — Ovarian cysts Fig. 319. — Ligaturing the pedicle. are very liable to become inflamed owing to torsion of the pedicle, pressure, the nature of their contents (dermoids) or other causes, and as a consequence the cyst may become adherent to intestines, omentum, bladder, rectum, to the large blood-vessels, to the floor of the pelvis or the abdo- minal parietes, and to the diaphragm. If adhesions are present, it will be dangerous and perhaps impossible to deliver the tumour before they are separated, and for this reason great care must be taken that any adhesions on the under-surface are detected, otherwise they may be Plate IX. — Bilateral Papuliferous Ovarian Cysts. OVARIOTOMY 461 torn through, and if attached to veins great haemorrhage may immediately occur. Adhesions can be separated by the hand, swabs, scissors, or scalpel. Parietal adhesions or adhesions to the floor of the pelvis are, as a rule, best sepa- rated by gently insinuating the hand between the cyst- wall and the peritoneum. In tying off omental adhesions the operator must avoid including a portion of the trans- verse colon running in the omentum. When the intestine is adherent to the cyst and an endeavour is being made to dissect it off, the wall of intestine must be clearly identified, since the two are sometimes so intimately attached and the intestine is so spread out that it is quite easy to mistake the tissues and open the bowel. Part of the cyst may also be impacted in Douglas's pouch, in which case care must be taken not to rupture it during its delivery. ii. Restraint of the intestines. — In some cases in which the tumour is very large and the incision in the abdominal parietes extensive, the biggest swab will not be sufficient to keep the bowels in position after the tumour is delivered. This difficulty can be surmounted by drawing together that part of the incision above the umbilicus with one or two temporary silk sutures passing through all the layers of the abdominal wall. iii. Closing the abdominal cavity- — See p. 285. Irremovable ovarian cysts. — It sometimes happens that while the removal of an adherent ovarian tumour at first seemed feasible, the surgeon after a while finds that the successful termination of the operation is hopeless. Under these conditions two courses are open to him : either (a) to empty the cyst of its contents and then stitch the hole to the abdominal opening, thus making the cyst- cavity extraperitoneal and draining it ; or, (b) when the cyst fills a very large portion of the abdominal cavity and is universally and indissolubly adherent, deliberately to sequester the cyst by closing the incision in its wall and the parietes, and, except for the evacuation of its contents, leave the patient in statu quo. 462 GYNAECOLOGICAL SURGERY If the cyst is rendered extraperitoneal and drained, it sometimes happens that, after a period of prolonged dis- charge, the patient recovers owing to the destruction of the secretory surface produced by the inflammation of the cyst-wall that always follows drainage. In other cases, however, great suppuration and necrosis of the cyst-wall ensue, to which the patient succumbs. If the cyst has been sequestered it will gradually "refill and require subsequent tapping. It is most important, therefore, for the surgeon carefully to consider, when dealing with an adherent cyst, whether there is a fair chance of being able to remove it ; if he concludes that there is not, he had better treat it by one of the methods just described than endeavour to remove it, lest in the attempt he inflict such injuries on the mesentery, bowel, or large abdominal veins that the patient succumbs. Nothing requires more experience or wiser judgment in abdominal surgery than to decide when not to interfere with an ovarian cyst. Hysterectomy and ovariotomy. — In cases of papilloma- tous or obviously malignant cysts or solid tumours of both ovaries, or even in cases where malignancy may be reasonably suspected, it is advisable to remove the uterus in addition. Hysterectomy may also be occasionally necessary in order to arrest haemorrhage or to facilitate the removal of adherent ovarian tumours. At times, myomata of the uterus may co-exist with an ovarian cyst or cysts. If only one ovary has to be removed, an endeavour should be made to enu- cleate the myoma, if feasible. If both ovaries have to be removed, the conservation of the uterus is not necessary. CHAPTER XXIV OPERATIONS ON THE BROAD LIGAMENT I. ENUCLEATION OF A BROAD-LIGAMENT CYST General characteristics. — All broad-ligament cysts have certain general characteristics, namely, the Fallopian tube is stretched over them, they are covered with shiny peri- toneum, and, except those growing from the outer third of the mesosalpinx, they have no pedicle. The relations of a broad-ligament cyst are very variable, and depend upon the site of its origin and its size. These cysts may start in three different positions, as follows : — i. In the mesosalpinx. 2. Between the ovarian and uterine arteries in the broad ligament. 3. Under the uterine arteries. 1. When growing from the inner two-thirds of the mesosalpinx the cysts are sessile ; when from the outer third, pedunculated. The ovarian vessels in either case lie on the deep surface of the cyst. Such tumours can, therefore, be removed without wounding the ovarian artery, are accessible, and, except for adventitious adhe- sions, are easily dealt with. 2. If the cyst starts between the ovarian and uterine vessels, it forces its way upwards until the ovarian vessels and Fallopian tube lie sessile on its upper surface and in close relation with each other, the vessels often being spread out. At a later stage the tumour grows backwards, progres- sively stripping the peritoneum and ureter from off the lateral pelvic wall so that the posterior layer of the broad 463 464 GYNECOLOGICAL SURGERY ligament is gradually displaced towards the opposite side and in time the pouch of Douglas is entirely obliterated. When this happens, adhesion occurs between the contiguous peritoneal surfaces covering the cyst, the back of the uterus, and the opposite broad ligament. During this process the cyst makes its way between the layers of the meso-sigmoid and underneath the peritoneum covering the rectum until the bowel comes to lie sessile on its upper and inner surface. The relation of the ureter and the iliac vessels to such a cyst is most important. The ureter lies on its inner surface closely attached to the peritoneum, while the iliac vessels are on its outer side. 3. If the cyst starts below the uterine vessels, these, as well as the ovarians, run across on its upper surface, as does also the ureter. These cysts, if they attain a large size, cross the middle line under the peritoneum at the bottom of Douglas's pouch, which is obliterated from below upwards as the peritoneum is forced off the posterior surface of the uterus. The general displacement of the parts is very similar to that which obtains in the preceding variety, but is distinguishable by the position of the uterine vessels and ureter. The second and third varieties of these cysts at times, by crossing the middle line, give the appear- ance of involving both broad ligaments. The anatomical displacements are so varied and intricate that no two cysts have exactly the same relations, and a very careful inspection of the tumour, with reference to the points we have mentioned, should first be undertaken before its removal is commenced. Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation. i. Opening the abdominal cavity. — See p. 276. On passing the hand into the peritoneal cavity to ascertain the relations of the cyst, the operator will discover that the tumour has no pedicle, and that it cannot be delivered. On examining its upper surface, the capillary vessels of the stretched peritoneum are seen, together with Plate X. — Bilateral Malignant Ovarian Tumour. BROAD-LIGAMENT CYST 465 the Fallopian tube, running across it, and in the case of the second and third varieties the ovarian vessels or ovarian and uterine vessels as well. ii. Incising the broad ligament. — At a spot on the surface of the cyst where blood-vessels appear least numerous, the broad ligament is opened by gently incising with a scalpel the layer of peritoneum covering the cyst (Fig. 320). Fig, 320. — Enucleation of a broad-ligament cyst : Incising the broad ligament. If this incision is made too deeply the cyst-wall will be wounded, the contents escape, and as a result much greater difficulty will be experienced in removing the cyst. iii. Enucleation. — -The opening in the broad ligament is now sufficiently enlarged with the fingers, and by their means, aided by the handle of a scalpel or by scissors, as may be most convenient, the cyst is shelled out. During this 2E 466 GYNECOLOGICAL SURGERY proceeding the path of least resistance should be followed, but keeping as near to the cyst-wall as possible, so as to avoid tearing the broad ligament or damaging any other important structures (Fig. 321). Any bleeding spots are caught with forceps for the time being, and can later be ligatured with No. 4 silk. If the tumour is very large, it may be convenient, having opened the broad ligament, to tap the cyst before attempting its enucleation. Closing the cavity in the broad ligament. — All IV. Fig. 321. — Enucleating the cyst. oozing of blood having been stopped, and all redundant peritoneum having been cut away with scissors, it will often be found that the cavity from which the cyst was removed is so much diminished that its obliteration can be sufficiently effected by a continuous suture approximat- ing the edges of the peritoneum (Fig. 322). Where, how- ever, the cavity extends deeply into the depths of the broad ligament, and much oozing from its walls is taking place, it may be obliterated as follows : A curved needle armed with a long piece of No. 2 silk transfixes the tissue at the bottom of the cavity, and the end of the suture is tied. The cavity is then gradually obliterated from below BROAD-LIGAMENT CYST 467 upwards by suturing the walls together, and so gradually approximating the two layers of the broad ligament till the free edges of this structure are reached, when they are carefully sutured. If a large cavity is left unobliterated there is consider- able risk of postoperative oozing taking place therein, and the hematoma so formed may give rise to much inflamma- tory trouble. The steps of the enucleation just described will be the Fig. 322. — Closing the cavity in the broad ligament. same, mutatis mutandis, when removing any other tumour that has distended the broad ligament, such as a broad- ligament myoma, or the mass formed by a tubal gestation that has ruptured into the broad ligament. v. Closing the abdominal cavity. — See p. 285. Dangers, i. Haemorrhage. — -More blood must of neces- sity be lost during the enucleation of a broad-ligament cyst than in removing a simple ovarian tumour, but, as a rule, the oozing from the walls of the broad ligament is of no serious consequence, although occasionally it may be so severe as to necessitate special treatment. 468 GYNAECOLOGICAL SURGERY If the ovarian vessels are stretched out over the surface of the tumour, it is often better, before enucleating the cyst, to ligature them at their uterine and pelvic ends and divide them. Sometimes the cyst will be easily enu- cleated till the operator gets to its base, when he finds that it is held by some tough structures, generally uterine vessels, which, if cut without previous clamping with forceps, may give rise to troublesome bleeding. Lastly, the bleeding from the bed of the cyst is at times too free to allow of the closure of the cavity, for fear of blood subsequently collecting. If there is any danger of this, the peritoneal capsule of the cyst must be sutured to the abdominal wound so that the cavity becomes extra- peritoneal ; the cavity is then packed with gauze, and drained. ii. Injury to ureter or large veins. — ■ It very often happens that after a cyst has been enucleated the ureter will be seen lying across the base of the broad ligament, and the operator must always have in his mind the danger of wounding this structure when he is enucleating, as the ureter may be displaced from its natural position, and has been found running over the cyst. It can be recognized as a long tube about the size of a slate pencil, and if it is carefully inspected for a few moments lumbricoid muscular contractions may be seen to take place in it. When the cyst is very large it may spread over the brim of the pelvis, in which case the iliac arteries and veins will lie under its base and may be wounded. Dressing and after-treatment. — See p. 44 and Chap. xxxn. Alternative methods of treating broad-ligament cysts. — It is not always possible to enucleate the cyst owing to the adhesions between it and the cellular tissue of the broad ligament. In these circumstances it is sometimes possible to excise the cyst together with the portion of the broad ligament in which it grows, especially when it is one of those growing between the layers of the mesosalpinx. The cyst should be completely emptied by puncture, and the Plate XI. — Broad- Ligament Cyst of the Left Side. BROAD-LIGAMENT CYST 469 collapsed sac, together with that portion of the broad ligament covering it, is then pulled up out of the wound (Fig. 323). The position of the ureter having been defined as far as possible, the ovarico-pelvic ligament is clamped, as is the uterine end of the broad ligament and Fallopian tube, and the tissue between the clamps excised by a wedge- shaped incision. In many cases it is possible to remove the entire cyst in this way, but sometimes a small piece of Fig. 323, — Excision of a broad-ligament cyst : Applying clamps to the base of the collapsed cyst. its lower part is left behind. This, however, in our experience does not give trouble, the sac probably becoming oblite- rated as after a partial excision of the tunica vaginalis for hydrocele. The two ends of the ovarian vessels having been secured, the cut edges of the incision in the broad ligament are united by interrupted mattress-sutures (Fig. 324). The ovary may or may not have to be removed during this operation. If possible, it should, of course, be con- served. In those very formidable broad-ligament cysts which comprise the second and third varieties described, it is frequently impossible to remove the cyst in any way 470 GYNAECOLOGICAL SURGERY without the gravest danger of wounding the ureter, bowel, and large vessels. In these circumstances the cyst-wall Fig. 324. — Ligaturing the cut edges of the broad ligament. must be brought up to the abdominal incision and stitched to it, so that it becomes extraperitoneal. The cyst is then Fig. 325. — Treatment of an irremovable broad-ligament cyst : Stripping the peritoneum off the upper surface of the cyst before partial excision. PSEUDO-BROAD-LIGAMENT CYST 47* packed lightly with gauze and drained, or, after being emptied, the hole may be sewn up and the cyst sequestered (p. 461). In other cases a certain amount of cyst-wall can be removed but not all (Fig. 325). This having been done, the edges of the remaining portion must be sutured to the abdominal wound and the cavity drained (Fig. 326). II. Fig. 326. — Stitching the remainder of the cyst to the abdominal wound. REMOVAL OF A PSEUDO-BROAD-LIGAMENT CYST By a pseudo-broad-ligament cyst we mean an ovarian cyst which, instead of rising up out of the pelvis, has grown downwards and forwards under the posterior layer of the broad ligament, pushing and rotating the anterior layer of 472 GYNECOLOGICAL SURGERY this structure upwards and practically forming a covering to the ovarian cyst, so that on the abdomen being opened the appearance presented resembles, to the inexperienced eye, that of a broad-ligament cyst. Consequently, much time and trouble are expended in trying to enucleate the tumour. These cysts may be identified by noting that the ovary is not separate from the tumour, and that while the anterior surface of the cyst is covered by the stretched peritoneum of the broad ligament, with the Fallopian tube and ovarian vessels running across it, the cephalward and posterior surface present the characteristics of an ordinary ovarian cyst. If the hand is passed down into the pelvis at the back of the cyst, it will in many cases be found possible to scoop it out from under the stretched and rotated broad ligament, and subsequently to deal with it by the method of removal previously described. When it is very tightly incarcerated under the broad ligament, and particularly if it is very adherent, the following method should be adopted : — ■ Operation. i. Opening the abdominal cavity. — See p. 276. ii. Dividing the broad ligament. — The edge of the stretched broad ligament, which can be identified by the Fallopian tube, should be defined and separated from the upper surface of the cyst. A pair of pressure-forceps is now applied in the neighbourhood of the uterus, and another about an inch externally to it ; each of these should include the leash of ovarian vessels which is seen running over the surface of the tumour (Fig. 327). The broad ligament covering the tumour is then divided with scissors as far as the pedicle of the tumour, i.e. the hilum of the ovary, which forms the limit of separable attach- ment between the broad ligament and the upper surface of the tumour (Fig. 328). iii. Delivering the tumour. — The surgeon places his left hand underneath the tumour, now freed from the tethering PSEUDO-BROAD-LIGAMENT CYST 473 broad ligament, and gradually levers it up and delivers it through the abdominal incision (Fig. 329). Fig. 327. — Removal of a pseudo-broad-ligament cyst : Clamping the stretched broad ligament. iv. Tying the ovarian pedicle. — The pedicle is trans- fixed with No. 4 silk, and that portion of it nearest the Fig. 328. — Dividing the stretched broad ligament. uterus is secured, the assistant at the same time pulling into the grasp of the ligature the inner half of the previously 474 GYNAECOLOGICAL SURGERY Fig. 329. — Delivering the cyst. Fig. 330. — Ligaturing the inner half of the pedicle. PSEUDO-BROAD-LIGAMENT CYST 475 divided broad ligament (Fig. 330). After this the cyst is raised right up by the assistant, and the other half of the ligature is tied similarly, including the outer half of the cut broad ligament, and the cyst is then cut away (Fig. 331) Fig. 331. — Ligaturing the outer half of the pedicle. v. Closing the abdominal cavity. — See p. 285. Dangers. — The dangers are similar to those of ordinary ovariotomy (p. 460). It should be remembered that the ureter lies on the outer side of such cysts ; not on the inner, as in a true broad-ligament cyst. Dressing and after-treatment. — See p. 44 and Chapter XXXII. CHAPTER XXV OPERATIONS ON THE FALLOPIAN TUBES AND OVARIES I. SALPINGO-OOPHORECTOMY Indications. — A Fallopian tube and ovary may be excised either through an opening in the abdominal wall or through one in the vaginal wall. In our opinion, the first method is the safer and more satisfactory, and this we shall now proceed to describe. The appendages may be removed for diseases of the tubes and ovaries, such as acute and chronic salpingitis, hydro-salpinx, pyo-salpinx, hsemato- salpinx, tubo-ovarian cyst and abscess, and carcinoma of the tube, or for tubal gestation. They are removed by some to hasten the menopause in bleeding myomata, or to cure dysmenorrhcea, all other means having failed. They have also been removed for epilepsy, and to check the" growth of mammary carcinoma. The operation of salpingo-oophorectomy has in the past been much abused, owing to its being performed in cases in which a salpingectomy would have sufficed. The reasons for and against conserving the ovary will be discussed at the end of this chapter. For the present we limit our- selves to stating that the ablation of a healthy ovary merely to increase the facility of removing a diseased tube is absolutely unjustifiable. The operation is most often indicated in those cases of inflammatory disease of the tube secondarily involving the ovary in which both structures are destroyed beyond the reach of conservative surgery ; in tubal gestation in which the ovary is involved; and in ovarian gestation in which the tube is damaged. The method of treating 476 SALPINGO-OOPHORECTOMY 477 uterine myomata by salpingo-oophorectomy is altogether to be condemned, since it sacrifices healthy organs in the possession of which all the attributes of femininity centre, for one which, in addition to being functionally useless, is a menace to health and life. As a method of treating dysmenorrhcea it is very rarely indicated. It has been advocated in cases of intractable so- called "ovarian" dysmenorrhcea; and undoubtedly, if the pain can be definitely proved to be located in the ovaries, the removal of these organs would be a logical procedure to relieve it. We are, however, unacquainted with any recorded case in which monthly attacks of ovarian pain recurred after the removal of the body of the uterus, and our belief is, therefore, that the pain in all or almost all cases of dysmenorrhcea is of uterine origin. If so, sub- total hysterectomy, not oophorectomy, is the proper opera- tion in cases of this class. We have no experience of the operation as a treatment for epilepsy. Some successful cases have been recorded, but, on the whole, we judge that it has been a failure. Salpingo-oophorectomy has been performed many times with the idea of checking the growth in inoperable mammary carcinoma. While the results on the whole have been disappointing, a certain number of cases of undoubted amelioration or actual disappearance of the growth are on record. It is, therefore, a perfectly justifiable operation if the patient, fully understanding its dubious chances of success, desires it. When the appendages are adherent, the operation may become one of the most difficult in surgery ; in fact, in exceptional cases so firm may the adhesions be that the operation has to be abandoned. Taking a double pyo- salpinx of average size as an example, the operation is performed as follows : — Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation, i. Opening the abdominal cavity. — See p. 276. 47 8 GYNAECOLOGICAL SURGERY ii. Defining the appendages. — The left hand of the operator is passed through the incision and the condition of the pelvis explored. In this proceeding the fundus of the uterus should be first identified. After the peritoneal cavity has been opened, instead of the intestines slipping back so as to disclose the pelvic organs, all that the operator sees is either the omentum with its lower edge fixed in the region of the pubes, forming a lid to the pelvic cavity, or coils of Fig. 332. — Salpingo-oophorectomy : Separating adherent omentum. intestine matted together and fixed in the same position. On passing his hand into the abdominal cavity, he will perhaps find that the omentum or intestine is adherent to the abdominal parietes or to the fundus of the bladder, or that some coils of small intestine are adherent to the anterior surface of the uterus or to the Fallopian tubes. The pelvic colon is almost invariably adherent by its appendices epiploic^ to the diseased appendages, par- ticularly on the left side. If any omental bands are present, these should first be clamped with forceps, divided and tied (Fig. 332). The more superficial of the intestinal adhesions are then care- fully separated (Fig. 333). Plate XII. — Bilateral Hydro- Salpinx. SALP1NGO-OOPHOREGTOMY 479 In many cases the appendix will be found adherent to the Fallopian tube on the right side, in which case it should be carefully separated, and if its condition warrants removal this may be carried out as described elsewhere (P- 524)- iii. Insertion of the large swab. — The large swab is now to be inserted (p. 293), and the separation of the deeper and more formidable adhesions may then be proceeded Fig. 333. — Separating adherent intestine. with, without fear of infection of the general peritoneal cavity in the event of the tube rupturing. iv. Separation of the appendages. — This, of course, is carried out first on one side and then on the other. Which appendage is first removed may be a matter of little consequence, but if that of one side is obviously easier to remove than that of the other, then it should be dealt with first, in order that additional room may be available for the removal of the more adherent one. The dilated tubes are always found curled downwards and backwards, adherent to the posterior surface of the uterus, the floor of the pelvis, the posterior surface of the broad ligament, and not seldom to the anterior surface 480 GYNECOLOGICAL SURGERY of the rectum ; whilst on many occasions the operator will find that both tubes have in addition become adherent to each other, thus entirely filling Douglas's pouch and surrounding the uterus behind. On account of the important structures which may be adherent to the diseased appendages, the separation must be most cautiously proceeded with, and every care also Fig. 334. — Elevating the appendage. should be taken to prevent rupture of the tube and the escape of pus. It is best and easiest, therefore, to commence the process of separation by passing the fingers of the left hand down to the floor of the pelvis, and then to insinuate their tips, with the palmar surfaces forwards, under the lowest part of the swelling, below the spot where the ovarian ligament joins the uterus. By carefully flexing and unflex- ing the fingers, the adhesions are gradually separated from below upwards ; and it may be necessary, although it is best avoided if possible, to help this separation by clamping SALPINGO-OOPHOREGTOMY 481 some portion of the appendage with ring forceps and pulling it up with the right hand during the manipulations of the left hand (Fig. 334). The facility with which the separation is performed depends largely on an appreciation of the anatomical deformity which the parts have undergone in consequence of the disease, and on the educated sense of tissue-appre- ciation which guides the manipulating fingers in the right plane of cleavage. Fig. 335. — Clamping and dividing the ovarico-pelvic ligament. The appendages having eventually been delivered through the abdominal opening, each is removed as follows : — ■ v. Clamping the ovarian vessels. — - With a pair of pressure-forceps the ovarico-pelvic ligament is clamped near the pelvic brim and the ovarian artery and vein are thus temporarily secured (Fig. 335). The ligament is now severed with scissors, distally to the clamp, and the outer attach- ment of the appendage is thus freed. This incision should extend more than an inch along the edge of the broad ligament. The remaining attachment of the appendage, consisting of the tube, the ovarico-uterine ligament, and the 2 F 482 GYNECOLOGICAL SURGERY undivided portion of the broad ligament, is now transfixed by a needle armed with silk (Fig. 336) and tied in two halves, the loop of the outer section of the ligature fall- ing into the angle at the end of the incision through the ovarico-pelvic ligament (Fig. 337). Care should be taken, Fig. 336. — Transfixing the undivided portion of the pedicle. in transfixing this portion of the pedicle, not to perforate the uterine end of the ovarian vessels contained within it. vi. Removal of the appendage.- — The appendage is separated, distally to the transfixion ligature, with scissors (Fig. 338). vii. Ligature of the ovarian vessels. — The proximal ends of the ovarian vessels are permanently secured by passing a No. 4 silk ligature under each ovarico-pelvic ligament above the clamp by which it is temporarily held (Figs. 339 and 340). viii. Closure of the broad ligaments. — The raw surface SALPINGO-OOPHOREGTOMY 483 Fig. 337. — Ligaturing the undivided portion of the pedicle. Fig. 338. — Removing the appendage. 4§4 GYNECOLOGICAL SURGERY left at the top of each broad ligament is usually obliterated sufficiently by the ligatures described. If, however, the Fig. 339. — Passing the ligature to secure the ovarico-pelvic ligament. incision through the ovarico-pelvic ligament has been carried too far inwards, several small vessels may have Fig. 340. — Securing the ovarico-pelvic ligament. been opened up which will require separate control by means of mattress-sutures. Plate XIII.— Bilateral Pyo-Salpinx. BISECTION OF UTERUS 485 ix. Closing the abdominal cavity. — See p. 285. Dressing and after-treatment. — See p. 44 and Chapter XXXII. Difficulties. — The chief difficulty of the operation is entirely due to the number and strength of the adhesions, and to deal with these the skill and ingenuity of the surgeon may be taxed to the utmost. If the adhesions are recent they will be soft and may be separated quite easily, but if the peritonitis is of old standing, then the adhesions will be tough, and their separation may even be impossible. In advanced cases scissors may be necessary to divide adhesions, more especially those in the neighbourhood of the ovarico-uterine ligament, which, on account of inflam- matory thickening and contraction, may anchor the diseased structures to the side of the uterus, and may have to be separately divided to set the mass free. II. BISECTION OF THE UTERUS In very difficult cases of double pyo-salpinx, when the dilated Fallopian tubes are adherent to one another and to the floor of the pelvis, the apparent impossibility of separating the diseased structures can be surmounted by dividing the uterus down the middle and removing each half with its corresponding appendages, a method devised by Faure and described in the following paragraphs. Operation. — The round ligaments having been ligatured and divided about an inch from the uterus, the incisions dividing them are joined across the middle line, and the peri- toneum and bladder pushed off the supravaginal cervix. A volsella is then fixed to each corner of the uterus, which is divided by an incision down the middle line as far as the internal os (Fig. 341). One half of the uterus is now divided transversely with a pair of scissors, the uterine artery being clamped as it comes into view (Fig. 342). The half of the uterus being thus freed, the fingers of the left hand can lift it up some- what and so get under the pyo-salpinx, which it will be 486 GYNECOLOGICAL SURGERY found can now be very much more easily separated from the structures to which it is adherent. As the mass composed of the conjoined uterus and appendage is raised out of the pelvic cavity, the ovarico- pelvic ligament is put on the stretch and clamped, and the pyo-salpinx and its corresponding half of the uterus are then cut away (Fig. 343). Fig. 341. — Salpingo-oophorectomy with hysterectomy by bisection : Bisecting the uterus. The diseased appendage and the half of the uterus on the other side are now similarly treated. The uterine and ovarian vessels on either side, already clamped, are now ligatured in the manner described at pp. 301-07 (Fig- 344)- The hysterectomy in this case is subtotal. If it is desired to remove the whole of the uterus, the bladder must be separated entirely from the supravaginal cervix after the preliminary incision of the peritoneum across BISECTION OF UTERUS Fig. 343. — Removing the left half of the uterus. 488 GYNAECOLOGICAL SURGERY the front of the uterus has been made. The splitting incision is then carried right down the posterior wall until the vagina is opened, and, the fingers of the left hand having been inserted therein, the anterior wall is divided to the same extent. Each half of the cervix is cut free from its lateral attachment to the vagina and gradually separated from the broad ligament from below upwards, the uterine artery being seized as it presents or spurts. Where the removal of the uterus is carried out to facili- tate the extirpation of the diseased appendages the subtotal Fig. 344. — -Appearance of the stumps after removal of the uterus and appendages. operation will suffice, but where it is undertaken because the uterus is also diseased the hysterectomy should be total. In such circumstances preliminary splitting of the uterus should not be done unless it facilitates the operation, but the technique described at pp. 319-26 should be followed. Finally, there are those cases in which after the removal of the appendages the uterus is left so lacerated and oozing as to forbid its being conserved. In such circumstances the subtotal operation is generally the best. Hysterectomy in cases of double appendage disease. — Many authorities maintain that in cases of diseased BISECTION OF UTERUS 489 appendages the uterus should always be removed as well, because it is sure to be diseased, can be of no further use, and may be a source of future trouble. There can be no doubt that a conserved uterus after bilateral salpingo-oophorectomy for pyo-salpinx may be a source of a chronic purulent discharge, especially in gonococcal cases, whilst in some instances severe haemorrhages may periodi- cally occur from it. On the other hand, the uterus frequently is apparently healthy, in spite of the presence of a double pyo-salpinx, especially in old-standing cases not of venereal origin. Further, the removal of the uterus, especially when total, increases the severity of the operation, and opens up planes of healthy connective tissue to probable infection. We therefore think that the routine performance of hysterectomy in these cases is to be deprecated. If any portion of the ovary can be conserved it is well to leave the uterus, if possible. In chronic cases of double pyo- salpinx not due to gonorrhoea, we should also content ourselves with removing the appendages only. In acute septic cases, again, in which the patient is very ill, we believe that it is the best practice to let the uterus alone, i.e. to do as little as is necessary, firstly for fear of opening up healthy pelvic tissues to acute infection, and, secondly, because these patients stand extensive operative procedures very badly. The cases most suitable for entire ablation of the uterus and adnexa are those of gonorrhoeal pyo- salpinx with chronic gonorrhoeal metritis, evidenced by a purulent cervical discharge and a swollen, soft, vascular condi- tion of the uterus as viewed through the abdominal incision. Dangers of salpingo-oophorectomy. — In separating the adhesions — i. The intestines may be wounded. ii. Pus may escape. hi. Large vessels may be opened. iv. Bleeding from the raw surfaces may be severe. v. The bladder may be injured. vi. The broad ligament may be opened up. 4Q0 GYNECOLOGICAL SURGERY i. Wounding intestine. ■ — The rectum may be wounded, also the colon or the small intestine — most commonly the rectum. The wound may extend through the peri- toneal coat only, or through the muscular coat, or the lumen of the bowel may be opened. Generally it is the peritoneal covering alone that is injured, when, as a rule, no harm results, although a path is thus left for the Bacillus coli to escape and perhaps set up peritonitis. Or the injured wall may slough and a faecal fistula result. Both of these complications are more likely if the muscular coat is dam- aged. If the lumen of the bowel is opened and escapes de- tection, a fatal peritonitis results, or, at least, a faecal fistula. The treatment depends on the amount of injury. If the peritoneal coat is simply abraded, it had better be let alone, since it is usually impossible satisfactorily to suture it. Of course, all bleeding points must be tied. If the muscular coat is injured or the bowel opened, the wound must be repaired according to the directions given at p. 545. In any case, a small india-rubber drainage-tube must be left in for three days at least. ii. Escape of pus. — If a pyo-salpinx or tubo-ovarian abscess is ruptured during the manipulations, the contents will escape, and it is then advisable to lower the patient into a more horizontal position to obviate the risk of any pus escaping past the swabs. The pus should be carefully removed with swabs, and the swabs which have been previously packed round the diseased area in case of this accident occurring should not be removed until it is time to close the abdominal incision, for fear of soiling the rest of the abdominal contents. The old-fashioned method of irrigating the pelvic cavity in these cases is to be condemned. It does no good, and may do harm by distributing pus over the abdominal cavity. If pus escapes, the result will depend upon its nature. In recent cases, as, for instance, an acute pyo- salpinx following abortion, the pus is very infective, and drainage is a necessity. SALPINGO-OOPHORECTOMY 491 In a very large majority of chronic cases the pus is sterile ; no harm results from its escape, and many operators do not consider it advisable to drain. On nearly every occasion, both at the Middlesex Hospital and at the Chelsea Hospital for Women, in which the pus from chronic cases has been examined bacteriologically, organisms have been absent ; and this experience is confirmed by that of most other observers. We think, however, that it is best that at the end of the operation, before the abdominal incision is closed, a small drainage-tube should be passed down into the pelvis and left in situ for twenty-four to forty-eight hours, so that if suppuration takes place a path may be available for the escape of the pus. iii. Injury to vessels. — It occasionally happens that the pyo-salpinx is adherent to the brim of the pelvis, and in separating the adhesions great caution is necessary lest the iliac vein be injured. This accident is fortunately rare. If it occurs, a swab must be at once pressed over the bleed- ing area to prevent the escape of blood, and then, as it is raised, the operator secures the opening with a pair of pressure-forceps, after which the vein must be ligatured. As ligature of the iliac vein is such a serious matter, a lateral ligature should be applied if possible. In cases where the broad ligament is contracted from inflammation so that it cannot be drawn up, the iliac vein may be transfixed by the needle while securing the ovarian vessels. A retro- peritoneal hsematoma will at once occur, and must be dealt with (p. 42). iv. Serious oozing. — After the removal of the diseased structures, raw oozing surfaces, where the adhesions have been separated, will come into view. The positions where these are most marked are the floor of the pelvis, the anterior surface of the rectum, and the posterior surfaces of the uterus and broad ligament. In most cases the oozing of blood soon stops, and no particular treatment is neces- sary, but in some the_ bleeding is free, blood welling up 492 GYNAECOLOGICAL SURGERY into the pelvic cavity as soon as the swab is removed. A careful search, aided perhaps by a hand-lamp, must now be made to ascertain if there is any particular point where the bleeding is coming from, and if such a one is discovered it should be secured with a ligature of No. 2 silk tied over the forceps or with a mattress-suture. At times the bleeding due to the separation of the adhesions on the posterior surface of the uterus may be so severe that it can only be arrested by a hysterectomy. If the bleeding- point happens to be on the rectum, care will, of course, be taken not to include more of the bowel-wall in the silk ligature than can possibly be avoided. If the condition is one of general oozing rather than of bleeding from definite points, the bleeding may often be stopped by the applica- tion of swabs wrung out of boiling water. If this is not sufficient, it only remains to pack the bleeding area with sterile gauze, which is removed in twenty-four hours. The oozing may be stopped by swabbing the area with adrenalin, but we are of opinion that this should not be employed, since it affords an additional channel of infection and its effect on diseased vessels is very slight and at the most temporary. v. Injury to the bladder. — ■ In some cases of pyo- salpinx the inflammatory mass may actually raise the whole bladder out of the pelvis, so that it runs some risk of being wounded on the peritoneal cavity being opened. Where a large mass can be felt jutting up above the pubes, this is particularly to be borne in mind. In other cases the bladder may be adherent over the top of the uterus to the omentum, intestine, or the diseased tubes themselves, and may be torn in the process of separation. In either event the wound must be immediately closed by the method described at p. 539. vi. Wounding the broad ligament. — Occasionally the diseased appendages are so adherent to the back of the broad ligament that in separating them the peritoneum is torn away and a hole is left, exposing the cellular tissue, SALPINGO-OOPHOREGTOMY 493 from which marked bleeding may take place. This hole must be closed by one or more mattress-sutures of silk. Besides the dangers connected with separation of the adhesions, there is the risk of — ■ Ligaturing the ureter. — -Just where the ovarico-pelvic ligament is in relation with the brim of the pelvis the ureter is very superficial, and can be felt quite easily by rubbing the tissues between the finger and thumb. Care must therefore be taken, when ligating the ovarian vessels in this situation, not to include the ureter. It is also to be remembered, when closing rents in the broad ligament, that the ureter is closely adherent to the posterior peritoneal layer, and is in danger of being trans- fixed by the needle or included in the ligature. Alternative methods of removing diseased appendages. — When there are no adhesions, and no inflammatory contraction of the broad ligament, and the Fallopian tubes are not dilated to any extent, a simple method of removing the appendages consists in pulling the tube up with the ovum forceps, transfixing the broad ligament, dividing the ligature, and tying it on both sides, as described at p. 456. This was the original method of removing the diseased tube in all cases, but it has two grave disadvan- tages in cases where the broad ligament is at all thickened : (1) the ligature is subjected to much lateral tension, owing to the two halves of the pedicle straining in opposite direc- tions, with the danger of one of them pulling out of its grip and the whole ligature becoming useless in conse- quence ; (2) the stump left is bulky, and apt subsequently to contract adhesions and become a chronic source of pain. We have, therefore, given up this method of treating the pedicle. If total removal of the tube, as well as of the ovary, is desired, the operation described must be so modified as to include the excision of a wedge-shaped portion of the uterine cornu (see Total Salpingectomy, p. 498). 494 GYNECOLOGICAL SURGERY III. TUBO-OVARIAN CYSTS AND ABSCESS These two conditions often give rise to a displacement very similar to that of the pseudo-broad-ligament cyst (p. 470), i.e. the enlarged ovary tends to under-burrow the broad ligament, which is rotated and stretched over its upper (cephalward) and anterior surface. The edge of the stretched broad ligament is, of course, formed by the distended Fallopian tube. In many cases the ovarian part of the mass is easily displaced from under the broad ligament, but not infrequently, especially in tubo- ovarian abscess, it may be so firmly fixed as to neces- sitate division of the broad ligament before it can be freed. The technique described for pseudo-broad-ligament cysts is then to be followed, except that the division of this structure and the tube must be carried out right up at the uterine cornu, that is across the non-dilated isthmic portion of the tube just as it leaves the uterus. Special care must be taken securely to clamp the distal end of the tube at its point of division, for otherwise the whole contents of the swelling will escape therefrom. For the rest, the steps are similar to those described for salpingo- oophorectomy (pp. 476 and 493). IV. OVARIAN SUSPENSION Indications.- — Suspension of the ovaries is indicated in cases of ovarian prolapse causing dyspareunia, the uterus being in its normal position. It is also indicated where the uterus is in addition retroverted and the ovaries remain in the pouch of Douglas in spite of rectification of the retroversion. Lastly, it is a useful method to pursue where, after salpingectomy or salpingostomy for salpingitis, it is desired to lift the ovaries out of the bed of the adherent appendages. Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. 1 _ k ^ 1 Iff J H|^^^^ ipp :3P | 1 :Y:";J fe K "^■v-- ■'-^m***^' Sv y fY^'i ^^s^ ' *~4 Plate XIV,— Right Tubo-Ovarian Cyst OVARIAN SUSPENSION Operation, i. Opening the abdominal cavity .- 495 —See p. 276. ii. Pleating the ovarico-uterine ligament.— Whilst an assistant pulls the uterus over to the left side, the operator holds the right ovary in his left hand and puts the ovarico- uterine ligament on the stretch. With a small curved needle, armed with No. 2 silk, the operator next trans- fixes the ligament at its insertion into the uterus and ties Fig. 345. — Ovarian suspension : First step in the insertion of the pleating suture. a knot there (Fig. 345), after which he passes the portion of the suture attached to the needle backwards and forwards through the ovarico-uterine ligament till the inner pole of the ovary is reached (Fig. 346). The needle being cut away, the two ends of the suture are tied together, with the result that the ligament is thrown into pleats and the ovary assumes more or less its normal position (Fig. 347). iii. Closing the abdominal cavity- — See p. 285. Dressing and after-treatment. — See p. 44 and Chapter XXXII. 496 GYNAECOLOGICAL SURGERY Fig. 346. — The pleating suture applied. Fig. 347.— Shortening the ovarian ligament. Plate XV.— Large Ovarian Abscess of the Left Side. SALPINGECTOMY 497 V. RESECTION OF A PORTION OF THE OVARY When operating on a patient for disease of the uterine appendages, the surgeon often discovers that only a small portion of the ovary is implicated and that the greater portion of it is apparently healthy. In these circumstances we think that the treatment should be as conservative as possible, only the diseased portion being resected. Operation. — ■ There are three methods of resecting portions of the ovary : i. In the case of a single cyst of small size it may be simply punctured, or a portion of the cyst-wall is excised. 2. The diseased portion of the ovary may be removed from the healthy by a wedge-shaped incision, the edges of which are subsequently approximated with fine silk sutures. 3. A transfixion-ligature may be made to constrict the ovary above the diseased portion, which is then removed. This method of placing the ligature is often employed while removing a diseased appendage or an ovarian cyst when it is desired to conserve a portion of the ovary. VI. SALPINGECTOMY Salpingectomy is indicated when the Fallopian tube is hopelessly diseased but the ovary apparently healthy. It is contra-indicated in cases of malignant disease of the tube, in which the internal genital organs of the patient should be removed, whilst in certain cases of hydro-salpinx and haemato-salpinx the more conservative operation of salpingostomy is preferable. Subtotal Salpingectomy Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation, i. Opening of the abdomen. — See p. 276. ii. Separation and amputation of the Fallopian tube. — The ampullary end of the Fallopian tube is now caught in 2G 49 8 GYNAECOLOGICAL SURGERY pressure-forceps and pulled a little outwards and upwards so as to put it on the stretch, and a pair of pressure-forceps is applied to the ovarian fimbria and outer edge of the mesosalpinx parallel to the course of the tube and about a quarter of an inch from it. The tube is now dissected off the mesosalpinx as far as its uterine end, then a pair of pressure-forceps is applied at its junction with the uterus and the tube is cut free (Fig. 348). Fig. 348. — Subtotal salpingectomy : Removing the tube. iii. Ligaturing the mesosalpinx. — The cut edge of the mesosalpinx, with any bleeding vessels therein, is secured by several mattress-sutures of No. 2 silk, and the uterine stump of the tube is finally ligatured with the same material (Fig. 349). iv. Closing the abdomen. — See p. 285. Dressing and after-treatment. — See p. 44 and Chapter XXXII. Total Salpingectomy This operation is indicated especially in acute tubal infections and pyo-salpinx, and it has for its object SALPINGOSTOMY 499 the removal of the entire tube as far as the uterine ostium. Operation. — -The steps of the operation are those pre- viously described under partial salpingectomy, but, instead of clamping and amputating the tube at its junction with the uterine wall, a wedge-shaped portion of this latter, containing the interstitial part of the tube, is excised Fig. 349. — -Ligaturing the stump of the tube. (Fig. 35°) . and the wound united with mattress-sutures of No. 4 silk (Fig. 351). A continuous suture is then applied, beginning at the outer point of the cut edge of the meso- salpinx and ending at the uterine end of the incision in the cornu (Fig. 352). VII. SALPINGOSTOMY In certain cases of hydro-salpinx, and haemato-salpinx not due to tubal gestation, in which the tube-wall, though thinned by distension, is otherwise healthy, the operation of salpingostomy is indicated in preference to salpingectomy. 500 GYNECOLOGICAL SURGERY Fig. 350. — Total salpingectomy : Excising the uterine cornu. Fig. 351. — Passing the mattress-sutures. SALPINGOSTOMY 501 Fig. 352. — Applying the continuous suture. Fig. 353.— Salpingostomy : Slitting the Fallopian tube. 502 GYNAECOLOGICAL SURGERY Preparation of the patient. — See pp. 82-86. Instruments. — See p. 276. Operation, i. Opening the abdomen. — See p. 276. ii. Delivery of the Fallopian tube. — See p. 479. iii. Slitting the Fallopian tube. — The tube is slit up for about an inch along its free border, care being taken not to ex- tend the incision to the junction of the ampulla with the isthmus (Fig. 353)- iv. Formation of the new os- tium. — The con- tents of the tube having been evacuated, the mucous m e m- brane on each side of the inci- sion is everted and stitched to the peritoneum covering the tube on its lateral as- pect with inter- rupted No. 1 silk sutures (Fig. 354). v. Closing the abdominal wound. — See p. 285. Dangers. — The bleeding from the divided tube-wall is at times quite free. If it is not arrested by the inter- rupted sutures, a hematoma may form which will invali- date the operation. Dressing and after-treatment — See p. 44 and Chap. xxxn. Fig. 354. — Forming the new ostium. CHAPTER XXVI OPERATIONS FOR EXTRA-UTERINE GESTATION The operative treatment of extra-uterine gestation depends upon the period of pregnancy. FIRST THREE MONTHS The operations that may be indicated in the first three months are salpingectomy, oophorectomy, salpingo-oopho- rectomy, hystero-salpingectomy, salpingectomy with partial hysterectomy. In our opinion, every case of extra-uterine gestation diagnosed in the first three months should be operated upon. The non-observance of this rule is based upon the assumption that the ovum is dead and that the blood al- ready effused will be absorbed without further trouble. Both these assumptions are frequently found to be wrong. It is impossible to diagnose with certainty the death of the extra-uterine foetus, and even if the foetus be dead the trophoblast in the wall of the gestation-sac may continue to grow, and, invading the tube-wall, lead to a further haemorrhage. The second contention, that the blood will be absorbed without further trouble, is equally untenable, because, quite apart from the fact that in many of the cases the patients are ill in bed for weeks and perhaps there is sup- puration in the end, there remains the danger, which is very real, that in the process of absorption of the blood- clot, adhesions may form which may permanently occlude the healthy tube, may fix and retrovert the uterus, or may cause intestinal obstruction. We would draw particular attention to the frequency with which the opposite tube is 503 504 GYNECOLOGICAL SURGERY found occluded and distended in operations for hematocele, whereas in those for acute tubal rupture it is almost in- variably found to be healthy. To our minds, one of the strongest reasons for immediate operation on an early tubal gestation is the preservation of the unaffected tube. Lastly, it has been shown by Hamilton Bell and others that the mortality, to say nothing of the morbidity, of cases left to take their own course is higher than of those treated by operation. It is always desirable to save the ovary if possible, and this can usually be done in the cases of acute tubal rupture, and especially when pregnancy is very early. Where, however, a haematocele has formed, or the distension of the tube is very great, the ovary may be so adherent or dis- integrated that its removal with the tube becomes necessary. In ovarian pregnancy the same holds good, but the ovary alone may be removed in early cases of acute rupture. The operative technique in any of these cases is similar to that already described under Salpingectomy (p. 497), Salpingo-oophorectomy (p. 476), and Oophorectomy (ovari- otomy) (p. 453), but we draw attention to a few additional points. Acute rupture of the gestation-sac with hsemo-peri- toneum. — There is no class of case in which the symptoms supervene with more dramatic suddenness and intensity than in acute tubal rupture, nor any in which prompt and determined surgical measures are rewarded with more pleasurable success. The primary object of controlling the bleeding tube should be carried out as quickly as possible. This effected, the surgeon may proceed with the rest of the opera- tion with such deliberation as the state of the patient admits. Directly the abdominal muscles are separated, the peritoneum will be seen to have a bluish tinge, due to the blood beneath it. The abdomen being opened, no time should be wasted in clearing out the effused blood, but Plate XVI — Ruptured Tubal Pregnancy. EXTRA-UTERINE GESTATION 505 the hand should be passed down to the uterus, and with this as a guide the ruptured tube is discovered, grasped, pulled out of the wound, and clamped. The appendage is now examined, and the whole of it, if diseased, or the tube or the ovary only if conservation be possible, is removed. The opposite tube having been examined and found healthy, the effused blood in the pelvis is rapidly cleared out, and swabs on forceps are passed up into the loin pouches to remove any accumulation there. Where, however, the patient's condition is very bad, it is a mistake to waste time in trying to remove all the blood, as this involves a great deal of handling of the intestines. In such cases, while the surgeon is securing the bleeding-point, an assistant exposes the median cephalic or basilic vein, and directly the haemorrhage is under control he begins saline venous infusion. Rupture of the gestation-sac with hematocele. — In these cases the omentum will be found adherent to the fundus of the uterus and the appendage on the diseased side. The omentum, which is often discoloured, is separated (Fig. 355), and the collection of black blood-clot forming the hsematocele is exposed and scooped out with the left hand (Fig. 356). It will be found that the haemato-salpinx is buried in this blood-clot at the bottom of the pelvis, from which it is displaced in the manner described at p. 479. The appendage, being raised, is dealt with by complete removal (p. 476) or by salpingectomy (p. 497). The opposite tube is next examined. It will frequently be found to be in a condition of hydro-salpinx or hemato- salpinx. If so, it should be opened, emptied, and salpingostomy carried out (p. 494). Not seldom from the bed of the separated tube there will be troublesome oozing, which can generally be arrested with hot sponges. The question of drainage depends mostly on the previous temperature of the patient. If it has been considerable, and irregular in type, suggesting septic infection, a drainage- 5o6 GYNECOLOGICAL SURGERY Fig. 355. — Operation for hematocele Separating adherent omentum. tube should certainly be inserted ; in other cases this is not necessary. Rupture of the gestation-sac with a broad-ligament Fig. 356. — Removing the blood-clot. EXTRA-UTERINE GESTATION 507 hsematoma. — The treatment of this class of case is con- ducted on lines similar to those described for rupture with hematocele, the only difference being in the treatment of the sac left after the evacuation of the haematoma. When the effused blood is limited to the mesosalpinx, it is generally Fig. 357. — Enucleating the haemato-salpinx. possible to remove it en masse with the tube ; if, however, it has extended into the broad ligament proper and, as in bad cases, has also lifted the peritoneum off the lateral pelvic wall and iliac fossa and on the left side made its way into the mesentery of the colon, it is best, having removed the tube and evacuated the blood from the sac in the broad ligament, to stitch the opening in the sac to 5o8 GYNECOLOGICAL SURGLRY the parietal wound, pack it lightly with gauze, and allow it to granulate up. In very bad cases, especially where there is difficulty in controlling the bleeding from the wall of the sac, the uterus and upper part of the broad ligament may be removed, and the anterior peritoneal flap thus ob- tained used to cover over the raw surface or base of the sac. Ruptured interstitial gestation. — Hysterectomy, or par- tial hystero-salpingectomy, is indicated in the rare con- dition of ruptured interstitial gestation. In most of the recorded cases the former operation has been performed. An alternative proceeding is to remove the wedge-shaped portion of the uterine tissue containing the gestation-sac alone. We have performed this operation with success. Its merit lies in the conservation of the uterus ; but in respect of time and rapidity of hsemostasis this procedure is inferior to the former operation. FOURTH AND FIFTH MONTHS As after the third month the gestation can no longer be confined to the tube, but is either intraperitoneal or intraligamentous, and as with the advance of pregnancy the placental surface becomes increasingly large and the vascularity of the parts increasingly greater, these cases present features peculiar to themselves. It is a fact that, having passed the limit of the third month safely, the gestation sometimes proceeds to term without further trouble, but at other times the surgeon will be called upon to interfere because some acute symptoms have arisen. In these cases the whole crux of the situation is the treatment of the placenta. If the child is dead, the placenta, can in most cases be removed without serious risk. If the child is alive, the position of the placenta requires consideration. If the sac is intraperitoneal, the placenta is most commonly adherent to the back and fundus of the uterus, the affected tube, the back of the broad ligament, and the omentum — positions in which it is possible to control the vessels before attempting its removal. In other cases, however, it is EXTRAUTERINE GESTATION 509 adherent to the intestine or the iliac fossa, in which event it is not possible to follow this procedure. If the sac is intraligamentous the case is more serious still, for in this situation nearly the whole of the chorion is placental, and it may be impossible to remove the child without incising it, while the vessels cannot be controlled beforehand. On opening the abdomen, therefore, the surgeon should very carefully study the problem that lies before him, and avoid the premature separation of any adhesions before he has settled upon his plan of action. If the gestation-sac is intraperitoneal, and the pregnancy has not advanced more than five months, we think that it is better in all cases to attempt its complete extirpation. Before starting upon this, as many tributary vessels as possible in the omentum, the ovarico-pelvic ligament, and, if necessary, on the opposite side of the uterus, should be ligatured. This done, the gestation-sac must be opened, the foetus removed, and the placenta rapidly peeled off. If the sac is intraligamentous, the course to be pursued is more difficult of decision. Where the gestation has not advanced beyond the fourth month, or in any case where the sac is so situated that its entire removal appears feasible, we believe it is best to do this. The haemorrhage, which is bound to be free, may be minimized by removing the uterus as well, beginning the operation on the side opposite to the gestation-sac and securing the uterine artery on the same side as the supravaginal cervix is cut across, and before the extirpation of the sac. Where, however, the gestation has advanced to the fifth month, or the sac is deeply embedded between the layers of the broad ligament, the safest course is to open the sac and membranes, remove the child, and then deli- berately sequester the placenta by closing the aperture in the peritoneum of the broad ligament with sutures. The closed sac should then be fixed to the parietal incision, so that in case it has subsequently to be reopened for sepsis or haemorrhage the operation may be extraperitoneal. 5io GYNECOLOGICAL SURGERY The rationale of sequestration of the placenta is founded on the good results obtained by nature in cases of spon- taneously sequestered extra-uterine gestation. It goes without saying that the operation must be conducted with the greatest asepsis. Sometimes it is impossible to incise the intraligamentous sac without cutting through the placenta. In such an event sequestration may still be proceeded with if the bleeding from the cut edges of the placenta can be arrested by sutures. Where it cannot, or where part of the placenta is definitely separated, it will be necessary at all costs to extirpate it in the manner described above. Instead of sequestering the placenta, the old plan of stitching the sac to the abdominal wound (marsupialization) and draining it may be adopted ; but this is a very fatal proceeding, as the placenta nearly always sloughs, and the patient dies either of secondary haemorrhage as it separates or of acute sepsis. SIXTH, SEVENTH, EIGHTH AND NINTH MONTHS Where extra-uterine gestation has advanced to or beyond the sixth month without causing urgent symptoms, it has been conclusively shown that the safest course to pursue is to let the patient alone, in the good hope that the death of the child will sooner or later occur, after which it can be removed with the placenta in comparative safety. When urgent symptoms arise, the surgeon must interfere, and the difficulties that face him are those detailed in the preceding section, magnified in proportion to the further advance of the pregnancy. If the placenta is below the child, the best course is to remove the latter and then close the sac and sequester the placenta. Where the placenta is already much separated, the haemorrhage may compel its removal, in which event the surgeon must control the bleeding by forceps and ligatures applied as rapidly as possible, or, if these do not suffice, the sac must be tightly plugged with gauze. Marsupialization of the sac EXTRA-UTERINE GESTATION 511 and drainage are to be avoided, if possible, on account of the risks already mentioned. If the placenta is above the child and delivery cannot be effected without cutting through it, the bleeding resulting may necessitate its removal, but an attempt should first be made to arrest the haemorrhage by ligatures. In some cases, however, the child can be delivered without interfering with the placenta, and after the child's removal it is found that its extirpation is possible, as, for instance, if its main blood-supply is derived from the omental vessels. In such circumstances it should be extirpated or else treated by sequestration of the sac. Lastly, in some intraligamentous cases, where a quick placenta lies above the child and has to be incised in order to get it out, the best that can be done is to control the bleeding in the cut edges with mattress-sutures, close the sac, and fix it to the abdominal wound, which is sutured over it. The whole question of the operative treatment of advanced extra-uterine gestation is beset with great diffi- culties, the more so since these cases are so rare that no individual surgeon has had sufficient experience to en- able him to generalize, while the conditions found are so different in their anatomy that no two cases are alike. Treatment must be founded on a careful consideration of the anatomical peculiarities of each case, with due regard to the general rules given above. EXTRA-UTERINE GESTATION AFTER TERM .\ These cases present, as a rule, no special difficulties. The child and placenta, being dead, can be removed with comparative safety. The operation should be postponed for three months except when the signs of fever and pain show that the fcetal sac has become infected. Where suppuration has occurred in the sac, the case must, of course, be at once operated upon. No general rules can be laid down. Some of these cases are easily dealt with, but in others, where fistulous tracks have formed into the intes- tine and bladder, the operation may be very formidable. CHAPTER XXVII OVARIAN TUMOURS COMPLICATING PREG- NANCY, LABOUR, AND THE PUERPERIUM The well-recognized rule that if a woman has an ovarian tumour the sooner it is removed the better it will be for her, holds good with but few exceptions, be she pregnant, in labour, or lying-in. An ovarian tumour is more liable to rupture, inflame, undergo axial rotation, or bleed when any of the above-named conditions are present than in their absence. OVARIAN TUMOUR AND PREGNANCY The tumour, on account of the greater blood-supply, will grow more rapidly, and on this account the resulting pressure may cause troublesome vomiting or serious oedema. Again, the patient is more likely to miscarry on account of the presence of the tumour, and the tumour itself is particularly liable to undergo axial rotation. When, in addition, it is remembered that she has to go through the perils of labour, it is evident that the tumour should be removed with the least possible delay. As a rule, the results of removal are particularly gratifying, the pregnancy in the majority of cases continuing to term without further trouble. It must be remembered, however, that the risk of miscarriage after the enucleation of a broad-ligament cyst is greater than after a simple ovariotomy. Great care must be exercised, when operating upon ovarian tumour complicating pregnancy, not to injure the uterus. If the uterus is injured it may be necessary to open it and remove the ovum after the manner of a Csesarean section, or if the wound is slight its suture may suffice. 512 OVARIAN TUMOURS AND LABOUR 513 There are three exceptions to the rule that the tumour should be removed : one, when a small cyst well out of the pelvis is discovered at the end of pregnancy, in which event it may be allowed to remain till the puerperium is well established ; a second, when the patient is very ill, perhaps with oedema of the lungs from the over-distension, in which case the pressure may be temporarily relieved by tapping the cyst, and its removal undertaken later ; and a third, when the tumour has been inflamed and the adhe- sions are so numerous that separation of them would cause death from haemorrhage. This condition cannot be well diagnosed until the abdominal cavity is opened ; and the ex- perienced operator will rest satisfied with simple drainage or with closing the abdomen and subsequently tapping the cyst. Whilst, as has been said, the performance of ovariotomy on a pregnant woman does not as a rule induce miscarriage or premature labour, yet a liability to do so is present more or less in all cases. For this reason it is our practice, in such cases, to administer morphia (I gr.) hypodermically before recovery from the anaesthetic, and to keep the patient under the influence of the drug for forty-eight hours by repeated small doses. Further, the surgeon has to remember the tension that will be thrown upon the scar if the pregnancy proceeds, and the strain upon the stitches uniting the wound if labour comes on before it has united strongly. For these reasons special care must be taken to suture the wound as strongly as possible, and the ordinary three-tier method should be supplemented by through-and- through sutures. OVARIAN TUMOUR AND LABOUR The accidents that are liable to occur when an ovarian tumour complicates labour depend upon the position of the tumour, as also in some respects does the treatment. If the tumour is above the presenting part, it may rupture, its pedicle may become twisted, or it may be injured so that later it inflames. 2 H 514 GYNECOLOGICAL SURGERY If the tumour is below the presenting part, it will obstruct labour, leading to rupture of the uterus, of the vagina, or of the rectum. On occasions the tumour itself ruptures, or is so bruised that it subsequently in- flames. Lastly, after the passage of the child its sudden elevation may result in torsion of its pedicle. Treatment. — -When the tumour is above the presenting part it is rare for obstruction to occur, and labour may be allowed to terminate, the growth being removed as soon as the patient is convalescent or directly any untoward symptoms arise. When the tumour is below the presenting part obstruc- tion will result. This is usually absolute, but occasionally the uterine contractions may eventually rupture the cyst and allow the child to escape. Very rarely it has happened that the tumour has been forced down by the advancing child and expelled through a ruptured rectum or vagina via the anus or the vulva. As a permanent obstruction would lead to the rupture of the uterus, and as the alternatives of the cyst being ruptured or expelled are highly dangerous, if the obstruc- tion cannot be relieved by pushing up the tumour past the presenting part, under an anaesthetic, and delivering the child with forceps, all are agreed that, with one excep- tion, the proper treatment is to remove it either through the abdomen or through the vagina, the better route being the abdominal one. After removal of the tumour, the child should be delivered with forceps to prevent the labour- pains from straining the sutures. The remarks on page 513 concerning the necessity for firm closure of the abdominal wound should be read in this connexion. The exception referred to is when the attendant is not skilled in abdominal surgery and cannot obtain the services of one who is. In that case, the tumour will have to be tapped per vaginam, and the child delivered with forceps OVARIAN TUMOURS AND LABOUR 515 or by craniotomy. This entails the risk of peritonitis from escape of some of the cyst-fluid into the pelvic cavity, while the cyst-wall may subsequently slough from bruising during delivery. It is therefore advisable, if the attendant has been forced to tap the cyst, that the tumour should be removed as soon as possible after the termination of labour. OVARIAN TUMOUR AND THE PUERPERIUM The tumour may inflame from the bruising it has received during the birth of the child or from extension of intra-uterine sepsis, and its pedicle is especially liable to twist owing to the laxity of the abdominal wall and the mobility of the abdominal contents. Treatment. — As a rule, if the patient has gone through labour safely, there is no necessity to interfere with the tumour until she is convalescent, but if during the lying-in any of the above complications arise, the tumour must be removed as soon as possible. Solid tumours. — The foregoing remarks deal with solid and cystic tumours of the ovary as a whole, but it is evident that those which are especially concerned with rupture and tapping need not be considered if the tumour should be a solid one. CHAPTER XXVIII UTERINE MYOMATA COMPLICATING PREG- NANCY, LABOUR, AND THE PUERPERIUM MYOMA AND PREGNANCY The fact that a myomatous uterus has become pregnant is, considered by itself, a contra-indication for the removal of the tumour, because (i) the life of the child has to be considered, and (2) the operation would probably involve the removal of a functional organ. Myomata in pregnancy should, therefore, not be operated upon except for urgent symptoms, or at term in reasonable anticipation of obstruc- tion to delivery or trouble during the puerperium. There can be no doubt that the urgent need for the removal of myomata during pregnancy rarely arises, since (1) the commonest reason for the removal of myomata, namely menorrhagia, is absent ; (2) the myomata are usually subserous, and the least likely of all the varieties to undergo degenerative changes ; (3) the elevation of the tumour out of the pelvis due to pregnancy lessens the risk of pelvic pressure symptoms. Myomata complicating pregnancy, however, sometimes need operative treatment on account of symptoms produced by degeneration, by torsion, by pressure, or because their situation or size would imperil delivery. There is one form of degeneration of a myoma, namely, red necrobiosis, which is frequently associated with preg- nancy. In this condition the tumour becomes very tender and painful, the temperature rises, and there is distinct enlargement of the growth. Torsion of a myoma is uncommon. It occurs more often in connexion with pregnancy or puerpery than at any other time, because of the softness of the uterine tissue. 5i6 MYOMA AND PREGNANCY 517 The twist usually affects the pedicle only, but exceptionally the whole uterus may be rotated. Myomata, particularly of the posterior wall, may retro- vert the pregnant uterus and incarcerate it in the pelvis. Pedunculated myomata may also fall into the pelvis and impact, whilst the hypertrophy of the muscle-tissue sur- rounding a cervical myoma may so enlarge the mass as to cause dangerous pressure symptoms. Lastly, although the tumour may be situated above the pelvic brim, its size, together with that of the gravid uterus, may be sufficient to produce such a degree of abdo- minal distension that relief becomes urgent. It is well known that myomata situated by the side of or even below the head may during labour be displaced upwards by the retracting uterine muscle, so that the delivery is terminated in safety, but we are of opinion that it is very unwise to await this event, for, even though it happen, the tumour may be so bruised in the process that septic necrosis will subsequently occur. If, then, at term the tumour is in the pelvis, operative treatment should be undertaken. Treatment. i. Degeneration. — -If urgent symptoms of degeneration appear, the abdominal cavity must be opened. Except on the rare occasions in which it is found possible safely to enucleate or ligature the degenerating tumour, the uterus should be removed by a subtotal hys- terectomy, the child, if viable, being first delivered by Csesarean section. ii. Pressure. — The pressure may be due either to the pelvic environment of the tumour or to its mere bulk. If the pressure symptoms are due to the incarceration of a retro verted gravid myomatous uterus, and can be relieved by rectifying the displacement under an anaesthetic, this should be done. But in all other cases of pelvic impaction, and in all cases of myomata situated in the abdomen and giving rise to pressure symptoms, the abdomen should be opened and the tumour removed, with or without the uterus. In such instances there is a better chance of 518 GYNECOLOGICAL SURGERY conserving the uterus than when the symptoms are due to degeneration, because in a good number of these cases the tumours are pedunculated. iii. Torsion. — The abdominal cavity must be opened, and if the torsion merely involves the pedicle, the surgeon should be able to remove the tumour and leave the uterus ; but if the latter itself is twisted, it will probably have to be removed as well, Caesarean section being first performed if the child is viable. iv. Anticipation at term of obstruction to delivery, or of trouble in the puerperium. — Choosing a date a few days before labour is expected, the abdomen should be opened and the condition investigated. If the tumour is pedunculated, and if it is solitary or there are no others of importance present, it should be possible to displace it from the pelvis and ligate it off, the abdominal wound then being closed and pregnancy allowed to terminate naturally. If, on the other hand, the tumour is so situ- ated that it is impossible to carry out this treatment, or if, being pedunculated, there are yet- other large tumours present, Caesarean section is indicated, followed by hystero- myomectomy. Myomectomy or hysterectomy — The ideal treatment is to remove the myoma only, and allow the pregnancy to continue. This is usually possible with pedunculated subperitoneal tumours. The enucleation of sessile tumours is commonly followed by such haemorrhage as compels the removal of the uterus ; while in the event of its being able to be controlled by ligatures the likelihood of miscarriage or premature labour is very great. It is particularly to be remembered that owing to the softness of the wall of the pregnant uterus a sessile tumour may give the impression of being pedunculated before the abdomen is opened. Where myomectomy has been performed the patient should be kept under the influence of morphia as described on p. 513. The remarks there made on the necessity for MYOMA AND LABOUR 519 firm closure of the abdominal wound are equally applicable here. MYOMA AND LABOUR For operating upon a myoma in labour the indications are obstruction and haemorrhage. Obstruction. — This may be due to — i. A submucous myoma situated below the presenting part, ii. A subperitoneal myoma below the presenting part. hi. Interstitial and cervical myomata. iv. A broad-ligament myoma. Treatment, i. Submucous myoma. — If this is poly- poid in form and protruding below the head of the child, the stalk should be cut through and the tumour removed, after which the labour may be allowed to proceed. If the tumour is sessile and small and projecting into the cervical canal below the child's head, its capsule should be incised and it should be enucleated. If the tumour is too large safely to follow this procedure, Caesarean section followed by hystero-myomectomy is the proper course. ii. Subperitoneal myoma. — If, the patient being under anaesthesia, the tumour is pedunculated, one may be able to push it above the presenting part at once and without difficulty. If so, this should be done, and the child delivered with forceps. It cannot be denied that there is a certain element of danger in this treatment. We remember a case in which the tumour was displaced with ease, and yet, becoming necrosed, killed the patient within a week. Further, the tumour may be an ovarian cyst, and may be ruptured in the process. These risks, however, are much less than those of performing an abdominal section, and perhaps a Caesarean delivery, in a patient unprepared, and who probably has been already subjected to prolonged efforts at delivery. In following the treatment recommended, the medical attendant should keep a very careful watch on the patient, and if the tumour subsequently causes any bad symptoms 520 GYNAECOLOGICAL SURGERY it should be at once removed ; otherwise it may be left to be dealt with when the patient is convalescent. If the tumour cannot be pushed up, the abdomen must be opened and Csesarean hysterectomy performed. iii. and iv. Interstitial, cervical and broad-ligament myo- mata. — The abdomen must be opened, Csesarean section per- formed, and the tumour removed with or without the uterus. Haemorrhage. — Cases are on record where intraperi- toneal bleeding has occurred during labour from omentum having been torn off the surface of a uterine myoma to which it was previously adherent. In such circumstances abdominal section would at once be indicated. MYOMA AND THE PUERPERIUM After labour or miscarriage, uterine myomata may imperil life on account of infection, degeneration, pressure, torsion, or extrusion. Infection may result from bruising during delivery or the introduction of septic organisms into the cavity of the uterus. Of the various forms of degeneration that may occur, red necrobiosis is the commonest. Pressure may be due to the sinking down of the tumour into the pelvis after the uterus has emptied itself. Torsion occa- sionally occurs owing to the alteration of its intra-abdominal relations following retraction of the uterus. Extrusion is probably primarily due to intra-uterine sepsis causing ulceration of the capsule of the tumour. Treatments — Infection, degeneration, pressure, torsion, must all be dealt with by abdominal section. In the first, total hysterectomy will be needed, with drainage of the pelvic cavity. In the second, subtotal hysterectomy will probably suffice. In pressure or torsion, it is likely that subtotal hysterectomy will be required, but on occasion it may be possible to save the uterus whilst removing the tumour. Extrusion, being always a septic process, should be dealt with by vaginal enucleation. CHAPTER XXIX CANCER OF THE CERVIX UTERI COMPLICAT- ING PREGNANCY AND LABOUR COMPLICATING PREGNANCY The treatment may be divided into four classes : i. When the cancer is operable and the child is not viable. 2. When the cancer is operable and the child is viable. 3. When the cancer is inoperable and the child is not viable. 4. When the cancer is inoperable and the child is viable. 1. Cancer operable and child not viable. — The best treatment is the radical extirpation after Wertheim's method. An alternative but not so good a method is to remove the uterus by vaginal hysterectomy, and to evacuate its contents during the operation, if necessary. 2. Cancer operable and child viable. — The proper treatment is a Csesarean section, followed by radical ab- dominal extirpation, which in these circumstances is easier than usual. An alternative but much inferior method of treatment is to induce labour and remove the uterus subsequently, either by the radical method or by vaginal hysterectomy. 3. Cancer inoperable and child not viable. — It is very difficult to give a decided opinion as to the correct treat- ment in this case. Various factors have to be taken into consideration. If abdominal examination disclosed that the patient was not more than three months pregnant, un- doubtedly the proper treatment would be to evacuate the uterus and thoroughly scrape and cauterize the growth. 521 522 GYNAECOLOGICAL SURGERY We think this to be the proper treatment, because — (i) It is unlikely that the patient will live to the practical viability of the child if the case, when it comes under treatment, is already inoperable by the modern standard (pp. 376-78). (2) The presence of the pregnancy accelerates the growth and makes the haemorrhage much worse. (3) Pregnancy itself means the supervention of a good deal of additional distress. (4) Scraping and cauterization, which have undoubtedly a retarding effect on many cases of carcinoma of the cervix, cannot be done till the uterus is evacuated. If the pregnancy is not discovered until after the third month, we think it should be allowed to go on till the child is viable, (1) because the evacuation of the uterus would be a much more difficult and dangerous or even impossible proceeding, and (2) because there is a better chance of the child surviving to viability. 4. Cancer inoperable and child viable. — The child must be delivered by Cesarean section, after which it is better, in the mother's interest, to remove the body of the uterus because of its liability to infection during the puer- perium. The hysterectomy is therefore subtotal, and some surgeons have suggested that the best treatment, so as to avoid peritoneal infection, would be to fix the stump in the abdominal wound after the method of Porro, but without the gross method of clamping en masse origin- ally used in this proceeding. COMPLICATING LABOUR The treatment may be divided into three classes : 1. Cancer operable. 2. Cancer inoperable, child alive. 3. Cancer inoperable, child dead. 1. Cancer operable. — If the patient is in the first stage of labour, that is when the os is not yet fully dilated and the presenting part is still in the uterus, the proper treatment is a Csesarean section, followed by radical extir- CANCER OF CERVIX AND LABOUR 523 pation. An alternative but inferior treatment would be to allow the labour to terminate naturally, and subsequently to remove the uterus by vaginal hysterectomy. If the presenting part has come through the cervix and is in the vagina, then the labour must be allowed to terminate and the uterus be subsequently removed by a radical extirpation, or, failing this, a vaginal hysterectomy. 2. Cancer inoperable, child alive. — The treatment of this condition is the same as that indicated in the para- graph dealing with a similar state of things in the later months of pregnancy, p. 522. 3. Cancer inoperable, child dead. — The difficulty in this case is to secure enough dilatation of the cervix to deliver the child, craniotomy having first been performed. Owing to the injury caused to the parts during delivery, sloughing may take place, the patient subsequently dying of septicaemia. If, therefore, it is obvious that sufficient dilatation of the cervix cannot be secured to allow the crushed head to pass without great bruising and laceration, it will be safer to remove the child by Csesarean section and the body of the uterus by a supravaginal hysterectomy, as previously described. CHAPTER XXX OPERATIONS ON THE INTESTINAL CANAL I. APPENDICEGTOMY Sometimes, when the abdominal cavity is opened prepara- tory to the removal of a diseased Fallopian tube, ovary, or uterus, the appendix is found to be so diseased or so adherent to the diseased structure that its removal is imperative. At other times the appendix may be found to be the sole cause of the symptoms previously supposed to be due to some disease of the genital organs. Instruments. — Among the instruments prepared for the primary operation will be found those necessary for remov- ing the appendix. Operation, i. Opening the abdominal cavity- — In most cases a middle-line incision has been employed, and, as a rule, the appendix can be removed very well through such an opening. It may be necessary in some cases to make an additional opening over the appendix. ii. Clamping and dividing the meso-appendix. — Any adhesions present having been separated, and the appendix having been pulled up and steadied, its mesentery is clamped by pressure-forceps, the vessels being thus temporarily secured. The mesentery is then divided throughout its whole length up to the caecum, and the appendix is set free (Fig. 358)- iii. Amputating the appendix. — A ligature of No. 2 silk is passed round the appendix at its junction with the caecum. The ligature having been tied, the appendix is amputated about one-eighth of an inch above the ligature (Fig. 359). The stump is then touched with pure carbolic acid. 524 APPENDIGEGTOMY 525 iv. Burying the stump. — -A purse-string suture passed through the serous and muscular coats of the caecum is made to surround the stump of the appendix, and as this is pulled tight, the latter is invaginated by an assistant with the aid of the forceps, so that it is entirely buried. The vessels in the mesentery are secured with ligatures of No. 2 silk (Fig. 360). Dangers. — When amputating the appendix, faecal or Fig. 358. — Appendicectomy : Dividing the meso-appendix. purulent matter may escape, so that the field of operation should always be carefully packed off with swabs. Dressing and after-treatment. — See Chapter xxxn. In cases of chronic appendicitis, no drainage is necessary, but where a pyo-appendix has been removed and the sur- rounding peritoneum has possibly been contaminated with pus, it is better to leave a very small drainage-tube down to the stump for forty-eight hours. Where a local peritoneal abscess is present it should always be evacuated and drained by a large tube through an iliac incision, the median 526 GYNAECOLOGICAL SURGERY abdominal incision having been previously closed, unless the pus has extended into the pelvis, in which case the incision should be utilized to drain the pelvic cavity separately. Lastly, if diffuse peritonitis is present, the appendix should be removed by means of a right iliac incision, through which a large tube is subsequently inserted down to the site of the stump. The pel- vis should then be drained through the median inci- sion, and in most cases a third open- ing is also made into the right lum- bar pouch, so as to obviate the ex- tension of pus be- hind the ascending colon and the for- mation of a sub- phrenic abscess. Finally, in a few cases of complete general peritonitis, drainage incision should also be made into the left iliac and left lumbar pouches. The patient should be propped well up as soon as possible after the operation. II. ENTERECTOMY During the course of an operation on the female genital organs it may be found necessary to excise a portion of Fig. 359. — Ligaturing the base of the appendix. ENTERECTOMY 527 the intestine, owing to its adhesion to some growth and the impossibility of freeing it. Again, an operation may be started on the assumption that a growth felt per abdomen or per vaginam is gynae- Fig. 360. — Invaginating the stump. cological in nature, but when the abdominal cavity is opened it is found that the mass represents malignant disease of the bowel, and that the only proper treatment is enterectomy. We shall only describe the method of end- to-end anastomosis, which, in our opinion, is the best in the large majority of cases. 528 GYNAECOLOGICAL SURGERY Operation, i. Excising the bowel. — The loop of bowel containing the growth having been drawn well up into the wound, the abdominal contents are carefully packed off with gauze and two pairs of bowel clamps and two pairs of ring forceps are applied as follows : one pair of ring forceps on each side of the growth but well free of it, and one pair of bowel clamps 3 in. farther from the growth on Fig. 361. — Enterectomy : Excision of the diseased segment of bowel. either side of the others. The mesentery should not be in- cluded in the clamps. The bowel is then divided with scissors between the ring forceps and the clamp on each side of the growth (Fig. 361) (the contents of the excised portion being thus prevented from escaping), together with a V-shaped portion of the mesentery corresponding to the portion of bowel excised. ii. Ligaturing the mesenteric vessels and emptying the proximal portion of the bowel. — All bleeding-points in the mesentery are secured with pressure-forceps and liga- tured with No. 2 silk. If the portion of bowel resected is ENTEREGTOMY 529 distal to the hepatic flexure of the colon, it will usually be found that the bowel above it is loaded with retained scybala, and it is most essential that these should be removed before the anastomosis is proceeded with, or their passage will subsequently endanger the integrity of the suture-line. Having, therefore, most carefully covered up OPT — - : Fig. 362. — Emptying the upper bowel. everything with sterilized cloths except the proximal portion of bowel, the surgeon proceeds to remove the clamp securing its cut end and " milks " the intestinal contents into a porringer (Fig. 362). The clamp is then reapplied to this portion of intestine about 2 in. from its cut end, and the parts are carefully washed with sterile saline solution. iii. Trimming the cut ends of the intestine. — The mucous coat of the cut ends will be found somewhat ragged and excessive, and this should be trimmed up so that it is flush with the muscular coat (Fig. 363). 2 1 530 GYNECOLOGICAL SURGERY iv. Anchoring the cut ends. — A suture of No. I silk is passed through the mesentery of each piece of intestine just at the point where it joins the bowel, and tied (Fig. 364), the ends of the suture being left long. v. Applying the first row of sutures. — The bowel-ends are approximated as nearly as possible. The mucous mem- brane and the muscular coats of the cut ends of the intestine are joined with a continuous suture of No. 1 silk, beginning 1 1 Fig. 363. — Trimming the edges of the bowel. at the middle point of the lateral margin of the cut lumen on the side opposite to the operator, and being carried towards him across the situation of the mesenteric attach- ment to a similar point on his own side (Fig. 365). The integrity of the mesenteric half of the bowel lumen being thus restored, the suture is carried round its remaining half. In order to do this the needle, after having been passed through the operator's right-hand edge of the bowel from within outwards, is reversed in the forceps and pene- trates the edge to the left hand of the operator from without inwards, and is so continued until it meets with the loose ENTEREGTOMY 53i Fig. 364. — Tying the anchoring suture. Fig. 365. — Applying the first half of the first-row suture, 532 GYNAECOLOGICAL SURGERY end of the suture at the point where the stitching was first begun, i.e. at the middle point of the lateral wall farthest from the operator (Fig. 366). The two ends of the suture are then tied. By adopting this method the first-row suture is more securely finished off than if it were begun at the point of mesenteric attachment. vi. Second row of sutures. — One of the ends of the Fig. 366. — Applying the second half of the first-row suture. suture that anchored the two pieces of mesentery together is threaded on a needle, and the peritoneum is continuously stitched by Lembert's method right round the lumen of the bowel till the other end of the suture is reached, to which it is tied (Fig. 367). vii. Third row of sutures. — Some operators are satis- fied in any case with two rows of sutures, but it has always been our practice, when dealing with these cases, to insert a third row of interrupted Lembert sutures of No. 1 silk, which, when tied, completely bury the second row of sutures (Fig. 368). ENTERECTOMY 533 Fig. 367. — Applying the second-row suture. Fig. 368. — Applying the third-row suture. 534 GYNECOLOGICAL SURGERY The gap in the mesentery is closed with two or three interrupted silk sutures. Care must be taken not to include a vessel in them, especially in the small intestine, for fear of injuring the blood-supply to the bowel. viii. Closing the abdominal wound. — The anastomosis should now be carefully examined for any gaps or loose sutures, and, none being found, it should be freely washed with warm saline solution, after which the abdominal wound should be closed after the method described on p. 285. Where there is any doubt as to the suture-line holding, a very small tube should be inserted down to the involved coil for two or three days. After-treatment. — It has been our practice to treat these cases by abstention from food of any sort for a week, maintaining the strength and alleviating the thirst by four- hourly rectal injections of from 6 to 10 ounces of warm saline solution. Our colleagues on the medical side at the Middlesex Hospital have conclusively shown that it is possible to maintain patients on this treatment, and this alone, for several weeks, and our cases of intestinal resection have amply confirmed it. After the first forty-eight hours we allow water to be given by the mouth in moderate quan- tities as well. At the end of a week, mouth-feeding is begun, and after a couple of days the bowels are opened by an enema. This treatment has proved very successful, and all our patients have recovered most satisfactorily. In other respects the general lines of the after-treatment of these cases are the same as those described at p. 44 and Chapter xxxn. Difficulties. — The operation of intestinal anastomosis is, as a rule, extremely simple and, when not performed in conditions of acute intestinal obstruction, very success- ful. On occasions, however, its performance is difficult, as when the loop of gut cannot be brought out of the wound owing to shortness of the mesentery. In other cases the lumens of the upper and lower ends of intes- GOLOTOMY 535 tine are of different size, as, for instance, after resection of the caecum. In these circumstances the larger end may be partly closed with sutures until the aperture approximates to that of the smaller end, when the anastomosis may be proceeded with on the lines indicated. Or it may be pre- ferred to close the bowel-ends and perform lateral anasto- mosis. Or, lastly, the larger end only may be closed and the smaller end be laterally implanted. In all cases when possible the anastomosed coil should be left immediately under the abdominal wound, and where from any reason the suture-line is likely to yield a drainage- tube should be inserted as previously advised. III. COLOTOMY The gynaecological surgeon finds himself occasionally called upon to perform colotomy in such circumstances as an irremovable pelvic tumour with intestinal obstruction. The various methods of performing this operation are described at length in text-books devoted to general sur- gery. We shall here content ourselves with a description of the method we ourselves employ. Preparation of the patient. — See pp. 82-86. Position. — ■ The patient should lie in the horizontal position. Instruments. — See p. 276. In addition a Paul's tube will be required if the bowel is to be immediately opened. Operation, i. Opening the abdominal cavity. — As in most cases the abdomen will have already been opened in the middle line, it will be necessary to make an additional / opening over that portion of the bowel which it is intended to bring to the surface. In the ordinary left inguinal colotomy this will be parallel with Poupart's ligament, and the upper end will be at a point at the junction of the outer and middle third of a line joining the anterior superior spine and the umbilicus. ii. Anchoring the loop of intestine. — The large intestine 536 GYNAECOLOGICAL SURGERY Fig. 369.— Golotomy : Anchoring the mesentery. of interrupted silk sutures wound and the peri- toneal and muscular coats of the intestine, iv. Insertion of purse -string suture in the bowel. ■ — • If immediate opening of the bowel is neces- sary, a purse-string suture is applied well outside the area of the contemplated aperture, and the bowel is incised with a scalpel for about three-quarters of an inch (Fig. 371). presents at the wound, and a piece of it is pulled up and anchored to the fascia by pass- ing a mattress - suture through the mesentery and the fascia on both sides (Fig. 369), after which the intestine is tethered to the upper and lower angles of the wound by silk sutures passed through the fascia and muscular coat of the bowel (Fig. 370). iii. Suture of the bowel to the skin. — The bowel is sutured to the skin all round by a series that includes the skin of the Fig. 370.— Anchor- ing the bowel. GOLOTOMY 537 v. Insertion of Paul's tube.— Paul's tube, with a long piece of india-rubber tubing affixed, is rapidly inserted through the hole made by the scalpel, and the purse-string su- ture is then drawn tight, so that the tube is fixed securely in the bowel (Fig. 372). Dressing. — Large pads of ab- sorbent wool are placed over the wound, and are kept in place by a bandage. The india-rubber tube is led away into a recep- tacle under the bed. After-treatment. — See Chap- ter xxxii. The tube is re- moved about the fourth day, after which the wound is dressed often as the action of the as bowels may render necessary. The skin should be carefully Fig. 371.— Open- ing the bowel. Fig. 372.— In- serting Paul's tube. 538 GYNAECOLOGICAL SURGERY washed with soap and water whenever this is done, and should be protected by smearing it with a mixture of zinc ointment and vaseline. The skin sutures should be removed at the end of a week. IV. C.ECOSTOMY This operation is occasionally called for in conditions of acute intestinal obstruction where the exact site of the obstruction is unknown except that it is somewhere in the large intestine, and where the condition of the patient is such that an exploratory cceliotomy is not advisable. In these circumstances the operation is remarkably successful and can be performed very quickly. Preparation of the patient. — See pp. 82-86. As the operation has usually to be performed in emergency, the opportunity for preoperative preparation is limited to the short period on the table before operation. Position. — The patient will be in the dorsal position. Instruments. — -A scalpel, a dissecting forceps, two pres- sure-forceps, and a couple of curved needles No. 7. Operation, i. Opening the abdominal cavity. — The incision, unlike that of colotomy, should be made close to the right anterior superior iliac spine. It should be short, have its centre at this point, and lie parallel to the direction of the fibres of the external oblique. ii. Suturing the bowel. — In such a case as we describe, the distended caecum immediately protrudes through the parietal wound, to each end of which it should be secured by a suture of No. 4 silk passed through the skin and fascia on both sides of the wound and the muscular and serous coats of the bowel. Two lateral mattress-sutures should be applied, one on each side, picking up the skin and fascia and serous and muscular coats of the bowel. A small opening should then be made in the bowel by stabbing it with the point of a scalpel. After-treatment. — As for colotomy. The sutures should 6e removed at the end of ten days. CHAPTER XXXI OPERATION-WOUNDS OF THE BLADDER, URETER, AND BOWEL I. WOUNDS OF THE BLADDER During operations on the pelvic organs, and more parti- cularly those having for their object the removal of the uterus, the bladder may be wounded. Wounds of the bladder may be divided into three classes : i. The peritoneal covering only is injured. 2. The muscular coat is injured. 3. All the coats are injured and the bladder is opened. 1. Peritoneal injury — The cut edges of the peritoneum should be approximated with a continuous Lembert's suture of No. 1 silk. 2. Muscular injury. — -The divided muscle should be united with interrupted sutures of No. 1 silk, and the peritoneal wound then closed with a continuous Lembert's suture of No. 1 silk. 3. The bladder is opened. — -The mucous membrane should first be united with a continuous suture of No. 1 silk. The muscular coat should then be united by inter- rupted sutures of No. 1 silk, and, lastly, the peritoneum is closed with a continuous Lembert's suture of No. 1 silk. In some cases of total hysterectomy, especially in the radical operation for carcinoma of the cervix, the bladder may be wounded below the point of peritoneal reflection. Very often in these circumstances the bladder- wall is so thin that tier sutures are impracticable. In such a case a good result may be obtained by suturing the upper edge of the wound in the bladder to the cut lower edge and the edge of the anterior vaginal wall inclusively. 539 540 GYNECOLOGICAL SURGERY After-treatment. — A catheter may either be tied in and left in situ for a week, or it may be passed every two hours during this period. Urotropin or salol, 5 grains three times a day, should be given by the mouth. II. IMPLANTATION OF THE CUT URETER INTO THE BLADDER During some operations on the uterus or broad liga- ment the ureter may be cut, or a piece of it may have to be excised on account of malignant disease implicating it. One method of treating this complication is by implant- ing the end of the cut ureter into the bladder. It is all-important to leave intact the blood-supply to the ureter derived from the peritoneal vessels. No loose end of ureter free of peritoneal attachment should there- fore be utilized for the implantation, but sufficient of the tube should be deliberately resected as far as its lowest point of adhesion to the peritoneum. The implantation having been performed, the cut peri- toneal edge of the posterior layer of the broad ligament should be sutured to the bladder inside the point of anas- tomosis. By this means the ureter is left covered over entirely by peritoneum, and no denuded portion is running unsupported across the pelvis like a clothes-line. The method about to be described accomplishes this object. i. Preparation of the ureter. — The proximal cut end of the ureter is ligated with No. 4 silk, the ends of the ligature being left long to act as a guide. If the distal end of the cut ureter can be seen, it also should be ligated and the silk cut short (Fig. 373). ii. Preparation of the bladder. — -An opening is now made into the bladder through its peritoneal surface (Fig. 374), and, the index finger having been inserted, a second small opening, only just large enough to pass the ureter through, is made just above the original uretero-vesical junction. This should be effected by cutting down on the tip of the index ringer in the bladder with the point of a OPERATION- WOUNDS 54i scalpel. This opening is through the portion of the vesical wall not covered with peritoneum (Fig. 375), Fig. 373. — Placing the guide ligature on the proximal cut end of the ureter. iii. Implanting the ureter. — The proximal end of the cut ureter is now pulled into the bladder by threading the Fig. 374. — Making the upper opening into the bladder. 542 GYNAECOLOGICAL SURGERY guide ligature through the lower opening and out through the upper opening (Fig. 376). iv. Ensheathing the new uretero-vesical junction. — The cut edge of the lateral pelvic peritoneum to which the ureter is adherent is now sutured to the cut edge of the peritoneum covering the bladder, and below this directly to the vesical wall. With a little ingenuity a complete Fig. 375. — Making the lower opening into the bladder. sheath for the ureter at its new junction with the bladder can be effected (Fig. 377). v. Anchoring the ureter. — The ureter projecting into the bladder is prevented from retracting by the previous suture of the peritoneum to which it is attached ; but to ensure against this mishap two No. 1 silk sutures are now made to secure it to the vesical mucosa just as it enters the cavity of the bladder. These pick up the ureteral wall on either side, but do not enter its lumen. The redun- dant portion of the ureter together with the guide ligature OPERATION-WOUNDS 543 is now cut off, leaving about \ in. of the tube projecting into the bladder (Fig. 378). ^ Fig. 376. — Threading the ureter into the bladder. Fig. 377. — Ensheathing the ureterovesical junction with peritoneum. 544 GYNAECOLOGICAL SURGERY vi. Closure of the upper opening in the bladder. — The upper opening in the bladder is closed by tier sutures in the manner described at p. 538. Difficulties. — The smallness of the ureter and the diffi- culty of getting access to the lower part of the posterior wall of the bladder. Dangers. — (1) The junction may not remain water- Fig. 378. — Anchoring the ureter to the vesical mucosa : the redundant portion with the guide-ligature has been cut away. tight, and (2) the implanted end of the ureter may slough. The first of these dangers is not likely to arise if the opera- tion is carefully carried out. The second danger is a very definite one, and is due to the fact that one channel of blood-supply to the ureter, namely the anastomosis between the ureteral and vesical vessels, is cut off by the section of the ureter. Uretero -ureteral anastomosis. — Where the ureter is OPERATION-WOUNDS OF THE BOWEL 545 divided high up in its course, i.e. above the pelvis, it may be necessary to perform an anastomosis of the cut ends. There are various methods of doing this, the best-known being that in which the lower end is enlarged by splitting and the upper end is drawn into it by traction on two guide-sutures and then fixed by other sutures. Where the ureter is dilated this may be fairly easy, but in the natural state of the conduit it is very difficult to perform, and being performed is very likely to result in stenosis or complete blockage. For these reasons we think that whenever it is possible to pull down the upper end suffi- ciently to effect implantation into the bladder, this course is to be preferred. III. WOUNDS OF THE BOWEL During an operation upon the genital organs the bowel may be injured. It may be injured during the primary incision when opening the abdominal cavity if sufficient care is not taken when incising the peritoneum ; the rectum may be incised when removing the body of the uterus in subtotal hysterectomy, and more particularly in a total hysterectomy, especially by Wertheim's method, if care is not taken to place a swab behind the cervix ; whilst various parts of the intestine, and the rectum especially, may be wounded during the separation of adhesions in the opera- tion for pyo-salpinx. Wounds of the intestine are of three degrees : i. The peritoneal coat only may be injured. 2. The peritoneal and muscular coats are divided. 3. The bowel is opened. The wound may be clean cut, or, in the case of the peri- toneum, a portion of this tissue of varying size may be torn off when separating the bowel from some other struc- ture to which it has become adherent. Treatment. — 1. If only the peritoneal coat is injured, the cut peritoneal edges should be carefully sutured with a continuous No. 1 silk on a No. 13 needle. 2J 546 GYNAECOLOGICAL SURGERY If a piece of peritoneum is torn off owing to the separation of a dense adhesion, it may be difficult to approximate the torn edges of the peritoneum on account of its thickened and rigid condition, due to the adhesion. In this case it will be necessary to obliterate the raw and often badly oozing surface by a series of interrupted silk sutures. These, on account of the friable nature of the tissue, will be found readily to tear out, so that great care must be taken in their application, and it is better to use a some- what thicker silk, say No. 2, as being less liable to this accident. Also, the suture must be passed somewhat deeper than the peritoneum to get a good hold of the tissues. It may happen that the surface of bowel denuded of peri- toneum is so large that if the interrupted sutures were applied the lumen would be dangerously narrowed, in which case either the raw surface must be left uncovered or perhaps a piece of omentum can be stitched over it. 2. If the muscular coat also is wounded, the cut edges of the muscle must be approximated by a continuous No. 1 silk suture, after which the peritoneal coat is care- fully sutured in a similar manner. 3. If all three coats are injured and the lumen of the bowel is exposed, the muscular and mucous coats are sutured with a continuous No. 1 silk, after which the peritoneal coat is treated similarly, and in addition a few fine Lembert's sutures can be inserted in the peritoneal coat to cover in the continuous suture already applied to this membrane. If the sutures continually cut out, the injured portion may be fixed to the parietes, or resected. When the muscular or muscular and mucous coats have been wounded, or when there is a raw surface left on the bowel which cannot be covered in, it is advisable to insert a drainage-tube down to the wounded area so that if there is any leakage there may be an avenue of escape. CHAPTER XXXII POSTOPERATIVE TREATMENT i. Immediate. i. The room. — If the operation has been performed in a private house or nursing-home, the room should be properly ventilated, the window being opened at the top ; but care must be taken that the patient is not in any draught, and, if necessary, screens must be arranged to prevent this. The temperature of the room should be kept from 65 F. to 70 F. The room should be darkened by pulling down the blinds or covering the artificial light so that it does not shine directly on the patient's face, and the house should be kept as quiet as possible, no one being allowed in the room whose presence is not absolutely necessary. The nurse will see that the room is tidied up and that all un- necessary articles of furniture are removed before the patient recovers from the anaesthetic. The nurse will require an arm-chair to sit in, a book to write her report in, and a pen. She should not leave the room to summon help or get any article she requires, but should ring the bell. The fire in the room can be made up without causing an appreciable noise, by having small pieces of coal done up in paper bags, or by the nurse putting on the coal with a gloved hand. There is no necessity to use the poker ; rattling with fire-irons, etc., distresses many patients exceedingly. ii. Instruments. — If the surgeon wishes the nurse to clean his instruments, he should give her proper directions. Instruments should be well washed and scrubbed with lysol to remove the blood-stains, all the joints and ridges 547 548 GYNECOLOGICAL SURGERY being carefully examined to see that no debris is adhering to them, after which they can be rinsed in clean water and dried. The flushing curette should have a fine wire passed through it (a long hat-pin will do very well), to make sure that no blood is left behind. The surgeon, when he gets his instruments home, should have them polished with plate-powder, scrubbed with hot water, and then boiled for half an hour, after which they should be polished with a dry clean cloth. The curette, after it has been boiled, should have a little absolute alcohol run through it, which will dry it and so prevent it from rusting. iii. Attention to patient. — Immediately the patient is returned to bed she should be covered with a hot blanket, and, if there is much shock, hot bottles should be packed round her, care being taken that they are efficiently covered with flannel, more especially the metal stoppers, for, being unconscious, she will be unable to feel if she is being burnt. Hot-water bottles should always be placed outside the blanket covering the patient, when this accident, which may very well have disastrous results, cannot occur. The patient's head must be kept low and on one side, a pillow should be placed under her knees, and, if the opera- tion has been serious and prolonged, the recovery from any shock present may be assisted by tilting the foot of the bed with wooden blocks, or books, about 12 in. The pillow should be replaced under her head on recovery from the anaesthetic. If she commences to retch, the nurse, if the operation has been an abdominal one, should hold the patient's abdomen on both sides to prevent as far as possible any strain on the stitches. A small porringer should be adjusted so that it will collect any ejected mate- rial, and a towel should be fastened round the patient's neck, so that her nightgown and the sheets may not be soiled. After the sickness is over, the mouth should be cleared AFTER-TREATMENT 549 with glyco-thymoline or glycerine and borax, applied with wool held in a pair of forceps. It sometimes happens that patients are extremely noisy and hysterical when recovering from an anaesthetic, and on occasion it is difficult to prevent them from throwing themselves out of bed. It is more common for patients to act thus after minor operations, the shock of a major operation being often so great that the patient lies per- fectly quiet. In these very hysterical cases a severe scolding, accompanied by a gentle slap or two on the face with a wet towel, is sufficient, as a rule, to bring the patient to her senses. Surgeons and nurses will, of course, regard whatever the patient says under the influence of the anaesthetic as sacred, not to be mentioned to anyone, even to the patient herself. The patient, if anything she has said is repeated to her, will not believe she has been told all, and will fear that she may have said things that would better have been left un- said. Every doctor knows of cases in which nurses have repeated to their patients remarks that escaped from them while unconscious, and have been surprised to find that what was intended to interest caused mental distress. 2. The pulse. — The most useful and most reliable guide to the patient's condition after an operation is the character and rate of her pulse, but as these vary so much in different individuals, even in apparent health, it is most important that the pulse should have been carefully noted and charted during the days prior to the operation, so that its pre- operative condition may be taken into account when estimating its postoperative characters. The pulse should be taken every four hours and charted. It is impossible to overestimate the value of the pulse as a guide to the diagnosis, prognosis, and treatment of the complications following abdomino-pelvic surgery. The aphorism that the patient varies with the pulse is applicable to these cases without exception. To put it broadly, the pulse-rate 550 GYNECOLOGICAL SURGERY should be highest during the first twelve hours after opera- tion, but should not even then much exceed ioo. After this, if all is going well the rate should certainly have fallen, for a rising pulse after the first twenty-four hours is of the gravest possible import. In the larger number of cases of hysterectomy for myoma in the Middlesex Hospital and the Chelsea Hospital for Women, the pulse- rate never exceeds 80 or 90 at any time. In estimating the pulse, the peculiarities of the patient, the nature and length of an operation, and the amount of blood lost must always be taken into account. As an example, washing out the peritoneal cavity is nearly always followed by a quick pulse for a day or two, while mental excitement in a neurotic individual may cause an alarmingly rapid heart- action. A gradually rising pulse combined with distension of the abdomen and increasing fever makes it practically certain that peritonitis is supervening. The pulse-rate increases to 140 or over with the com- plications of shock or haemorrhage. A quite temporary rise invariably occurs as the patient is coming out of the anaesthetic. 3. Respiration. — A rapid respiration-rate is a most ominous sign after abdominal section. Occurring soon afterwards it points to shock or haemorrhage, whilst its presence later on is associated with such grave complica- tions as peritonitis, pneumonia, and intestinal obstruction. 4. Temperature. — It is just as important to take the patient's temperature as long as possible before the opera- tion as to take the pulse. This, therefore, should be done twice daily and charted. After the operation the tempera- ture should be charted every four hours. The thermo- meter — which should have been properly tested, for cheap thermometers are unreliable — is placed under the patient's tongue, and she is told to close her mouth and breathe through her nose. A hot drink, for a short time after it is taken, will raise the temperature locally in the mouth as much as a degree. Care, therefore, must be taken to AFTER-TREATMENT 55 1 choose a suitable time to use the thermometer. If there is any doubt as to the correctness of the temperature when taken in the mouth, the thermometer should be placed in the axilla or between the legs ; and if there is any suspicion that the instrument is at fault, another should be used as a control. It is an excellent rule on the first visit after an operation to lay the back of one's hand on the patient's face. A warm face is incompatible either with shock or with haemorrhage ; thus the presence of this simple sign assures one that these two complications, so important and so necessary to diagnose at once, are absent. In an average case the temperature rises pretty abruptly to 99 - 5° or ioo° F. within the first six or eight hours. During the next twelve hours it frequently rises half a degree higher. It then begins to fall, and should reach the normal in from one to three days. Many cases, however, never exceed 99'5° F. at any time, whilst others maintain a tem- perature of 99 F. to ioo° F. for a week without assignable cause or obvious ill-effects. A subnormal temperature is indicative of shock or haemorrhage. A rapidly rising tem- perature is bad at any time, but it is especially so on the second or third day, when peritonitis may be feared as a likely cause. A persistently high temperature after opera- tion, without anything obvious to account for it, should always lead to an examination of the abdominal wound for stitch-abscess and of the pelvis for hematocele. Fever occurring in the second week is often due to an inflamma- tory effusion around a ligature, or is the herald of femoral thrombosis. Violent nervous disturbance may lead to a very marked and sudden elevation of temperature, which, however, is not maintained. It is accompanied by a full though rapid pulse, and there is an absence of local ab- dominal and pelvic signs. These points will allay anxiety. Ether-bronchitis will maintain fever for some days. 5. Tongue. — The tongue, after the first twenty-four hours, in abdominal section should be moist. It is generally whitish in colour so long as the patient is not taking solid 552 GYNAECOLOGICAL SURGERY food. In such grave conditions as peritonitis and intes- tinal obstruction it is dry, brown, and cracked, or glazed, red, and ulcerated ; such appearances are of very bad prognosis. The greatest pains should be taken with the mouth after all cases of abdominal section, as indicated at p. 568. Glyco-thymoline and listerine both make admirable mouth- washes. 6. Thirst. — One of the bitterest complaints of a patient during the twenty-four hours succeeding a severe opera- tion is of thirst. The best way to relieve this is to inject 6 ounces of saline solution (a teaspoonful of chloride of sodium to a pint of water) into the rectum every four hours. Other remedies consist in rinsing the mouth out with warm water, or with a weak solution of Condy's fluid. Ice should not be given ; it causes flatulence, and only relieves thirst until it has melted. 7. The bladder, (a) Minor operations. — After most of the minor operations described in this book there is no necessity to use the catheter, unless there be retention of urine. But in excision of the vulva and such cases, where urine passing over the surfaces would be a disadvantage, the catheter may be used for the first few days, though it is not our practice to do so. Where it has been necessary to pack the vagina tightly the catheter will have to be used. Many patients after perineoplasty are unable to pass urine, and the catheter will have to be used for some days. In operations involving the bladder it is advisable to catheterize the patient for some little time (see p. 147). (b) Major operations. — In vaginal hysterectomy and abdominal section the catheter is passed six hours after the operation, and unless the patient is troubled with retention its further use is not indicated. It is passed in order to estimate the quality and character of the urine. Exceptions to this rule must, however, be made when pressure-forceps have been left on to stop haemorrhage in AFTER-TREATMENT 553 vaginal hysterectomy, in which case the urine must be drawn off every eight hours until they are removed, and during the manipulations necessary for this object the greatest care must be taken not to disturb the forceps. Likewise, after hysterectomy the catheter may be used for twenty-four hours to prevent traction on the stump by distension of the bladder. In the radical operation for carcinoma of the cervix, the urine should be regularly drawn off for several days, as there is practically in all cases an ounce or two of residual urine, due to bruising, injury, or altered relations of the bladder. The amount of urine passed each time should be carefully measured, and any abnormality in its appearance, such as the presence of blood, noted. The quantity first passed or drawn off after operation amounts, as a rule, to 4 to 7 ounces, but in very severe cases, especially the radical procedures above referred to, no urine is secreted at all for several hours, and then only in small quantities. If the quantity is less than 4 ounces, one naturally thinks of shock, haemorrhage, suppression, or injury to the ureter. In the case last mentioned the urine may be mixed with blood, but it is not necessarily so. Catheterization. — By the careless use of the catheter a patient may sustain damage, due to the introduction of micro-organisms into her bladder, which will cause many weeks of misery, even if it is not the immediate cause of her death, for the cystitis thus set up may spread by way of the ureters to both kidneys and kill the patient, or to one kidney, which may become so disorganized that nothing short of its removal will save her. The nurse, therefore, has to remember three important and absolute rules when using a catheter : (1) to make her hands as aseptic as she possibly can ; (2) to sterilize the catheter ; and (3) to swab the vulva, more especially that part where the orifice of the urethra is situated, with a solution of biniodide of mercury, 1 — 1,000. A glass catheter should always be used, except when 554 GYNECOLOGICAL SURGERY the instrument has to be left in, in which case a soft rubber catheter is indicated. Before its use, and afterwards, the catheter should be boiled, and when not in use it must be kept in a solution of carbolic acid, I — 20. Catheters are cleaned after use by holding them under a tap and allowing a stream of water to run through them, or by driving water through them with a syringe ; and in addition, as the soft rubber catheter has an eye, attention must be particularly directed towards the cleansing of this part. Having thoroughly washed and scrubbed her hands with soap and water, the nurse dips them for a few minutes in a solution of biniodide of mercury, 1 — 1,000, after which she proceeds to clean the patient's vulva. The patient lies on her back with her legs drawn up and separated, and the nurse then separates the labia with the first and second fingers of the left hand, her wrist resting meanwhile on the pubes of the patient. The vestibule now comes into view, and is freely swabbed with a solution of biniodide of mercury, 1 — 1,000, which will effectually get rid of any •septic matter in this neighbourhood, and so prevent its introduction into the bladder by the catheter. The catheter should, of course, be passed by sight. A porringer having been placed between the patient's legs for the urine to run into, the catheter should be held in the right hand and gently passed along the urethra until the escape of urine denotes that it has entered the bladder. With the labia still separated, the catheter is held in position, and somewhat depressed, until the stream of urine becomes smaller and almost stops, when the instrument should be withdrawn for a short distance and, as a rule, the stream of urine will be augmented, after which it will gradually decrease until it stops, which is the signal that the bladder is empty. On withdrawal of the catheter, the thumb should be kept over its external orifice to prevent the urine that remains in it from being spilt on the patient or AFTER-TREATMENT 555 bedclothes. An inexperienced nurse may have some diffi- culty in identifying the urethral orifice, and as a consequence may pass the catheter into the vagina. Should this happen, the catheter must be re-sterilized before any further attempt is made to pass it. Some nurses make sure of avoiding this mistake by putting a swab of absorbent wool in the vaginal orifice before passing the catheter. A real difficulty may present itself when a tumour is pressing against the neck of the bladder or urethra, in which case the surgeon will have to pass the catheter. If the case should be a septic one a special catheter must be kept for it, and this, if made of india-rubber, should be destroyed when not further needed. 9. The bowels, (a) Minor operations. — On the second night after most minor operations the patient is given an aperient, and the following morning an enema, if neces- sary, after which the bowels are kept acting regularly. The exact form of aperient is not a matter of much import- ance, and the patient, may be ordered any drug she is in the habit of taking. When the operation has been of a plastic nature in the neighbourhood of the rectum, such as a perineoplasty, pos- terior colporrhaphy, or recto-vaginal fistula, the manage- ment of the bowels is a matter of great importance, since distension of the rectum may tend to prevent union, and faecal contamination may produce sepsis. On account of these drawbacks, some surgeons prefer to keep the bowels of the patient confined for four days until union is firm and granulations have formed which will prevent infection. The chief objection to this method of treatment is that scybala passed at the end of this period may by their size cause the wound to break down, although this can gener- ally be prevented by injecting 4 ounces of warm olive oil into the rectum two hours before the soap-and-water enema is administered. Another method in these cases is to keep the bowels acting by drugs from the first, and direct the nurse to use scrupulous care in keeping the parts as clean 556 GYNECOLOGICAL SURGERY as possible. Of the two methods we prefer the first. If drugs are being used the following prescription will suffice : — $) Mag. carb. lev. gr. x. Mag. sulph. 3i- Aq. menth. pip. ad §i. This should be given at 2 a.m. the following day and repeated every four hours until the bowels are opened, and then as often as is necessary to secure an action. Another admirable aperient in gynaecological cases is the following : — Ijc Ext. cascar. liq. 3i- Mag. sulph. 3i- Tr. hyoscyami 3ss. Aq. menth. pip. ad §i. Dose, from two teaspoonfuls to two tablespoonfuls. (b) Major operations. — In abdominal section and vaginal hysterectomy an enema of olive oil, 4 ounces, is adminis- tered at 4 a.m. on the fourth day following the operation, and three hours later a pint of soap-and-water is injected, after which the bowels are kept acting once daily by suit- able aperients. Rectal tube. — ■ The rectal tube (Fig. 379) is first passed twelve hours after the operation, and it should then be used every four hours as long as may be necessary. If saline injec- tions are being administered, it should be passed prior to their introduction. In passing the rectal tube great care must be taken to see that it does not become kinked, as this will necessitate its being withdrawn and again introduced. The distance the nurse will be able to pass the tube varies in different patients, but at any rate, whilst using every care, it must be pushed in as far as it will go, and on an average a tube of 31 in., which is the correct length, will Fig. 379.— Rectal tube. AFTER-TREATMENT 557 pass 21 in. Some rectal tubes are made with a hole in the side of that portion which goes into the rectum, and in others the hole is at the end ; the latter is the better pattern. If the end is well smeared with vaseline very little discomfort will be caused by passing the tube, while the relief to the patient is often very marked. If the patient suffers from haemorrhoids, the passage of the tube may cause great pain, which can be obviated in some degree by introducing into the rectum a cocaine suppository shortly before. The tube is left in position as long as any flatus passes ; in the absence of flatus it should be left in situ from five to ten minutes. The flatus should be made to pass into fluid by holding the free end of the tube under boric acid or mercury solution contained in a porringer. As a rule very little, if any, flatus passes by the tube for the first twenty-four hours, but if its expulsion is delayed much longer than this the patient will commence to experi- ence some discomfort, in which case a rectal wash-out or an enema of rue or turpentine is indicated and usually affords great relief. The methods of administration are described on pp. 587-88. 10. Diet, (a) Minor operations. — Six hours after most minor operations the patient is given 4 ounces of tea and milk, or of hot milk-and-water, and then, as soon as she is able to take it, ordinary diet is allowed. (b) Major operations. — The patient has to be fed most carefully, and a note of all she takes is entered in a special book by the nurse, the total quantities being added up every twelve hours so that the surgeon may see how much the patient is taking. It is useful in feeble patients to add half an ounce of brandy to the routine rectal saline injections during the first twenty-four hours. The following tables form a guide as to how the patient should be treated, supposing she is progressing normally : — 558 GYNECOLOGICAL SURGERY NURSING CHART USED BY THE AUTHORS FOR ALL CASES OF ABDOMINAL SECTION First Day 6 a.m. 8 a.m. 9 a.m. IO a.m. I 30 p.m. I. 45 p.m 2 p.m., Operation 6 p.m. 10 p.m. 12 midnt. 1 a.m. 2 a.m. Directions Simple enema Oi Fresh resh compress of 1 — 4,000 perchloride of mercury applied Douche of perchloride of mercury, 1 — 4,000 Catheter. Injection of liquor strych- ninae 7t]iii Put patient to bed, covered with a blan- ket, head low, pillow under knees, and packed with hot-water bottles well protected ; cradle to keep off weight of clothes When patient recovers consciousness, if she is sick or retching the abdo- men should be held at both sides of wound to protect stitches Take pulse, respiration, and tempera- ture. Saline solution §vi per rectum. Liquor strychninse TT|iii First Night Take pulse, respiration, and temperature Inject liquor strychninas Tl\iii. Pass catheter (measure the urine). Pass rectal tube and afterwards inject per rectum warm saline solution §vi. Patient may have a pillow. See that water bottles are hot and protected Pulse, respiration, and temperature. Pass rectal tube and then inject warm saline solution §vi per rectum Nourishment Tea §iv, milk §ii, two slices bread & butter Beef tea or chicken broth Hot water 3i 3i 3i AFTER-TREATMENT First Night {continued) 559 i 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. s a.m. 9 a.m. io a.m. ii a.m. 12 noon p.m. 3 P-m. Directions If patient is very collapsed, surgeon may order brandy §ss, beef -tea §iii per rectum Pulse, respiration, and temperature. Rectal tube. Saline solution §vi per rectum. Injection liquor strychnine TT|ni Brush, comb, and plait hair. Wash patient's hands and face, shoulders, lower part of back, after which rub eau-de-Cologne and boric powder into the shoulders and back. Cleanse mouth. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during the night, and enter in report book If patient is able to pass her urine naturally and of sufficient quantity, omit the catheter in the following directions. If, however, when patient passes urine naturally it is of small amount, the catheter must be passed immediately after the urine is evac- uated in order to ascertain if the bladder empties itself, and if it does not, the catheter must be continued as below Second Day Pulse, respiration, and temperature. Strychnine n\hi. Rectal tube. Saline solution §vi per rectum. Cleanse mouth Pulse, respiration, temperature, hands and face. Rectal Catheter. Saline solution | rectum. Mouth cleansed Wash tube. per VI Nourishment Hot water 3* 3i 3i §i Hot water 3] 51 Tea, §i, milk §i Milk 3 iv, lime- water 3 ii, hot water 3'-i 56o GYNAECOLOGICAL SURGERY Second Day {continued) 4 p.m. 5 P-m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. io p.m. ii p.m. 12 midnt. 2 a.m. 3 a.m. 4 a.m. 5 a.m. 6 a.m. 7 a.m. Directions Pulse, respiration, temperature. Injec- tion liquor strychnine H|iii. Rectal tube. Saline solution §x per rectum Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during the day, and enter in report book Second Night Pulse, respiration, temperature. Rectal tube. Catheter. Saline solution §x per rectum. Mouth cleansed Pulse, respiration, temperature. Injec- tion liquor strychninae H\iii. Rectal tube. Saline solution §vi per rectum. Mouth cleansed Pulse, respiration, temperature. Rectal tube. Catheter if necessary. Saline solution §vi per rectum Brush, comb and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during night, and enter in report book Nourishment Milk3iv, lime- water 3 ii, hot water 3ii Hot water 3 ii Milk 3 iv, lime- water 3 ii, hot water 3h Milk 3 iv, lime- water 3 h\ hot water 3h Milk §i, lime- water 3 ii, hot water 3 n ' Hot water §ii Milk §i, lime- water 3 ii, hot water 3ii Tea gii, milk 3>i 8 a.m. 9 a.m. IO a.m. ii a.m. 12 noon 2 p.m. 3 P-m- 4 p.m. 6 p.m. 7 p.m. 8 p.m. 9 p.m. io p.m. 12 midnt. AFTER-TREATMENT Third Day 56i Directions Pulse, respiration, temperature. Rectal tube. Mouth cleansed. Omit saline injections Pulse, respiration, temperature. Wash hands and face. Rectal tube. Mouth cleansed Pulse, respiration, temperature Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during the day, and enter in report book Third Night Pulse, respiration, temperature, tube. Mouth cleansed Rectal Pulse, respiration, temperature. Rectal- tube. Mouth cleansed Nourishment Milk § iiss, lime-water 3 ii, hot water 3ii Tea §ii, milk §ii Milk § iiss, lime-water 3ii, water 3h Millagiii, lime- water 3ii, water 3 U ' Barley - water giii Milkg hi, lime- water 3ii, water 3 U Barley - water §iii Milk § hi, lime- water 3h, water 3h 2K 562 GYNAECOLOGICAL SURGERY Third Night (continued) Directions Nourishment 6 a.m. Pulse, respiration, temperature Tea §ii, milk §ii 7 a.m. Brush, comb and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed, and enter in report book Fourth Day 8 a.m. Milk §iv, lime- water 3h, water 3h 9 a.m. Oil and soap enema 10 a.m. Pulse, respiration, temperature. Mouth cleansed. Omit rectal tube „ 12 noon Chicken-broth §iv and jun- ket or boiled custard 2 p.m. Pulse, respiration, temperature. Wash Milk §iv, soda- hands and face water §ii 4 p.m. Tea gii, milk §ii, one slice of bread and butter, no crust 6 p.m. Pulse, respiration, temperature. Injec- Chicken-broth tion liquor strychninas Tl\iii or beef-tea and toast giv 7 p.m. Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw - sheet and top and bottom sheet. Add up amount of nourishment, sleep, and urine passed during the day, and enter in report book Fourth Night 8 p.m. Mild aperient given Milk § iv, soda- water § ii io p.m. Pulse, respiration, temperature. Mouth cleansed Egg and milk 12 midnt. Barley - water ^iv AFTER-TREATMENT Fourth Night {continued) 563 4 a.m. 6 a.m. 7 a.m. 10 a.m. 12 noon 2 p.m. 4 p.m. 6 p.m. 7 p.m. 8 p.m. 10 p.m. Directions Pulse, respiration, temperature Pulse, respiration, temperature Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top and bottom sheets. Add up amount of nourishment, sleep, and urine passed during the night, and enter in report book Fifth Day Pulse, respiration, temperature Wash hands and face Pulse, respiration, temperature Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during the day, and enter in report book Fifth Night Pulse, respiration, temperature Nourishment Milkgiv, soda- water 5ii Tea §iv& milk §ii, or coffee giii and milk giii, steamed egg, two slices of bread and butter Chicken-broth or beef-tea & toast §iv Fish and light pudding Tea §iv, milk § ii, bread and butter Milk gvi Chicken-broth or beef-tea and toast § iv Milk 5 vi, water 564 GYNECOLOGICAL SURGERY Fifth Night (continued) 12 midnt. 2 a.m. 6 a.m. 7 a.m. 8 a.m. IO a.m. 12 noon 2 p.m. 4 p.m. 6 p.m. 7 p.m. 8 p.m. io p.m. 7 a.m. Directions Pulse, respiration, temperature Pulse, respiration, temperature Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet. Add up amount of nourishment, sleep, and urine passed during the night, and enter in report book Sixth Day Pulse, respiration, temperature Wash hands and face Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet Sixth Night Pulse, temperature, respiration Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet Nourishment Barley - water Tea §iv, milk §ii, or coffee | hi and milk giii Chicken-broth or beef-tea §iv and one slice toast Chicken and lightpudding Tea §iv, milk §ii, two slices bread and butter Milk 5vi Chicken-broth or beef-tea §iv and one slice toast Milkgvi, water ^ii AFTER-TREATMENT Seventh Day 565 8 a.m. 10 a.m. 12 noon 2 p.m. 4 p.m. 2 p.m. 7 p.m. 8 p.m. 10 p.m. 7 a.m. Directions Pulse, respiration, temperature Nourishment Wash hands and face Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top and bottom sheets Seventh Night Pulse, respiration, temperature Brush, comb, and plait hair. Wash patient as before. Mouth cleansed. Change draw-sheet and top sheet Fifteenth Day Patient is lifted on to couch Twenty-first Day Patient goes home Tea §iv, milk §ii, or coffee §iii and milk giii Chicken-broth or beef - tea §iv and one slice toast Mutton and light pudding Tea §iv, milk §ii, two slices bread and butter Milk ?vi Chicken-broth or beef-tea giv and one slice toast Milkgvi, water 11. Dressing, (a) Minor operations. — The greatest difficulty is experienced after perineoplasty in keeping the wound aseptic owing to its situation, since it is liable to become contaminated with fseces, urine, the menstrual flow, 566 GYNAECOLOGICAL SURGERY or vaginal discharge, and nearly all the failures of this operation are due to the wound becoming septic. For- tunately, even when this occurs, although the convalescence is delayed and the pain and discomfort to the patient are enhanced, a fair result is generally obtained, the wound healing by granulation. Occasionally it sloughs and totally breaks down, and after a long illness the patient finds to her chagrin that she is no better and that the operation will have to be repeated. Since the result depends so much on the care of the wound, this, whenever soiled, should be dressed by douching it with a solution of biniodide of mercury, i — 2,000. A vaginal douche of boric acid should be given twice a day. Mercury should not be used, as there is danger of some of the solution remaining in the vagina in consequence of the narrowing of the orifice produced by the perineoplasty. The legs should be tied together for the first forty-eight hours. The stitches should be removed from the seventh to the tenth day unless the tension on them is too great or they have cut through, when they should be taken out earlier. Colporrhaphy. — A vaginal douche of boric acid is given twice a day, and otherwise the wound is treated in a similar manner to that described for perineoplasty. Curetting. — The tampons are removed the morning after the curetting, and then a vaginal douche consisting of a quart of a solution of biniodide of mercury, 1 — 4,000, is given, and repeated night and morning. If the uterus has been packed with gauze, this should be removed in twenty-four hours according to the directions given, and its withdrawal must be carried out very gently to minimize the pain and ensure that the gauze is not broken off short, with the result that a piece is left in the uterus. Vulval operations. — The parts should be kept scrupulously clean by changing the dressings whenever they are soiled and douching the parts with mercurial solution, 1 — 2,000. The stitches should be taken out on the eighth day. AFTER-TREATMENT 567 Operations on the vagina. — If gauze has been left in the vagina it is removed the morning following the operation, after which the vagina is douched twice daily with mercurial solution, 1 — -4,000. Cervical operations are treated in a similar way. (b) Major operations. — After vaginal hysterectomy the gauze is removed in thirty-six hours, and then the lower part of the vagina should be swabbed with pellets of wool held with forceps and moistened in a solution of mercury, 1 — 2,000, twice daily for some days. If, because of haemorrhage, forceps have been left on, they may be disturbed by the patient while she is recovering from the anaesthetic, and the nurse must take particular care to prevent this. There is also some danger of the nurse detaching the forceps when attending to the patient, unless she uses great care. The injured parts sometimes slough and the ligatures commence to separate, usually about the tenth day, with the result that there may be a most offensive vaginal discharge, and in this case a vaginal douche of iodine solution, 5i — Oi, will be indicated, but in no circum- stances should a douche be given until a week after the operation. The douche must be given with very little pressure, the can being held only just a little higher than the bed. Abdominal section. — The stitches are taken out on the seventh day, and the wound is then re-dressed. If Michel's clips are used, these should be taken out on the fourth day. When a drain has been left in, the dressings will have to be changed as often as they are soiled. If gauze has been inserted to check haemorrhage, it is removed in twenty- four hours, and the hole may then be closed by an inter- rupted stitch that has been purposely left untied at the operation. If a drain has been used because pus has soiled the peritoneal cavity, or because the bowel has been injured, it should be left in situ for forty-eight hours. After this it should be removed and cleansed daily, being allowed 568 GYNECOLOGICAL SURGERY to remain in as long as there is much discharge ; it should be slightly shortened every day. Further information on the management of drainage-tubes will be found on p. 46. 12. Position of the patient in bed. (a) Minor opera- tions. — In most of the minor operations the position assumed by the patient in bed is of no particular import, After perineoplasty, owing to the local swelling and tender- ness the patient will be more comfortable on her side. (b) Major operations. — As soon as the shock of the operation has passed off, the patient may be allowed to turn on to her side, being kept in that position by pillows placed under her shoulder and hip. In twenty-four hours or less her shoulders should be well raised on pillows and she should be nursed in the semi-reclined posture. This has the great advantage that it encourages the gravitation of peritoneal fluid into the pelvis and minimizes any risk of general peritonitis. The patient may be allowed to sit up in bed of herself on the thirteenth day. Exceptions. — If the patient is very anaemic from haemor- rhage before or during the operation, the above directions must be somewhat modified. She must be kept as quiet as possible for a longer period and must not be allowed to exert herself in any way, as the danger of a sudden syncope is always present for some days. Again, if she is elderly, or is subject to bronchitis, or if bronchitis or broncho- pneumonia supervenes on the anaesthetic, she must be propped up on pillows as soon as possible ; and the same practice must be pursued in cases of sepsis when drainage is being employed. The best apparatus for maintaining a patient in the sitting posture is a bolster placed across the bed immediately below her buttocks. The bolster is kept in position by means of two pieces of bandage, one end of each being sewn to the end of the bolster, and the other tied to the bedposts at the head-end of the bed. 13. Toilet of patient. Mouth. — Every four hours until the patient is strong enough to use her toothbrush, the AFTER-TREATMENT 5&9 mouth and teeth should be cleansed with pledgets ot absorbent wool soaked in glyco-thymoline. False teeth should not be replaced till the morning following the operation, and not then if the patient is attacked with sickness. Hair. — The hair should be brushed, combed, and plaited twice daily. Hands and face. — The hands and face should be washed with warm water and soap thrice daily, at 7 a.m., 2 p.m., and 7 p.m. At the end of a week after major operations, if she so desires, the patient may be allowed to wash her hands and face herself. Body- — The body should be sponged once daily with warm water, and special care must be taken to cleanse the perineal region each time after the patient has defalcated or passed water. Back. — On the morning after the operation the shoulders and back of the patient must be specially treated. With the help of another nurse the patient is gently turned on her side. The shoulders and back, which now come into view, are first sponged with warm water, then washed with eau-de-Cologne or methylated spirit, and lastly dried with oxide of zinc and starch powder mixed in equal proportions. This should be done twice daily, at 7 a.m. and 7 p.m. Dress. — The patient should be dressed in a nightgown which opens down the back. There should be two night- gowns in use, one for the day and one for the night. She should have a clean nightgown every day, and oftener if necessary, and these may be so arranged that the clean nightgown of one day will do for the night but one following. A woollen dressing- jacket must also be worn, and, to save disturbing the patient, it can quite well be put on with the back to the front. The front of her chest should be kept covered with wool or Gamgee tissue if the room is draughty or the patient inclined to bronchitis, and when the operation has been very severe it is best to let the patient 570 GYNECOLOGICAL SURGERY keep on her drawers and stockings for the first twenty - four hours or more. 14. Bed-clothes. — The patient has a blanket next to her for the first few days after major operations, unless the weather is very hot and she can dispense with it. It is very useful when there is much shock. The draw-sheet is changed, as a routine, twice daily, at 7 a.m. and 7 p.m., when the patient's back is being washed, and at any other time when it is soiled. The bottom sheet is changed once a week unless soiled, or the patient desires and can afford a more frequent change. The top sheet may be changed according to the pleasure and the pocket of the patient ; if there are sufficient sheets, a clean one can be used daily, and it is best to have two in use, one for day and one for night, the day sheet being used for the following night. 15. Medicine, etc. — As a rule, no medicinal treatment is prescribed for patients for the first fortnight after an operation, apart from aperients or any other drugs which the surgeon may order for some particular complications. After a fortnight, a tonic may be indicated. We have found a hypodermic injection of the liquor strychninae, n\iii. twice daily for the first week after severe major operations, to be very beneficial, and have seen nothing but good from its use. 16. Belts. — We are not in the habit of ordering abdo- minal belts for our patients after cceliotomy, except in cases where, owing to suppuration of the wound, a ventral hernia is to be feared. If the patient can afford it, it will be best that she should be fitted with new corsets, as the shape of the abdomen is always temporarily altered after abdominal section. The corsets should be made long in front and fastened at the lower edge by a strap to keep the busks flat on the abdominal wall. 17. Visitors. — It is so necessary that the patient should be kept quiet after a major operation, that ordinary visitors should not be allowed to see her for the first week, AFTER-TREATMENT 571 and if possible the husband or parents should be kept away for the first three days. To satisfy the nearest rela- tives, one of them may be allowed to see the patient for a few seconds after the operation, when she is back in bed, and most probably still under the influence of the anaesthetic. 18. Postoperative rest in bed. — Under this head the surgeon will, of course, have to take into consideration the general condition of the patient. If she has been ill for many weeks before the operation, she will have to keep to her bed longer than is usual for the particular operation that she has undergone, and if any complications arise the time must obviously be prolonged. In the majority of instances, however, the patient or her friends may be given a fair idea as to the time necessary for convalescence ; and this, in some cases, is a matter of much importance, as when the expenses of a nursing-home have to be taken into consideration. (a) Minor operations. — ■ In perineoplasty and colpor- rhaphy cases the patient gets up on the fourteenth day. Curetting, vulval, vaginal, and cervical operations.— -The patient rises on the tenth day if all loss and discharge has stopped. (b) Major operations. — Surgeons differ as to when they allow their patients to go home after these operations, the time varying from seventeen to twenty-eight days. As the result of our experience, twenty-one days seems to be the best time in the majority of cases. 19. Resumption of usual occupation. — After the majority of minor operations, patients are soon able to resume their normal avocations. When the operation has been performed for some variety of prolapse of the genital organs, the patient should be warned not to undertake for some time any work or exercise which will necessitate straining of the pelvic floor. It is very advisable that, after a major operation, every patient, on getting up, should be sent away for at least three weeks for a change of air, and, if a hospital patient, 572 GYNECOLOGICAL SURGERY she should be sent to a convalescent-home, since there she will obtain adequate nursing. After a major operation the patient will not have entirely recovered from its effects for at least six months, during which time she should take things as quietly as her circumstances will permit. On the resumption of active exercise, she should be careful for some months longer, whenever possible, to avoid any procedure that will throw much strain on the abdominal muscles. CHAPTER XXXIII METHODS OF ADMINISTERING SALINE SOLUTION Indications. — The administration of saline solution may be indicated in patients suffering from haemorrhage, from shock, from peritonitis, or from suppression of urine. Composition and temperature of solution. — Normal saline solution is made by adding a teaspoonful of sodium chloride (table salt) to a pint of boiled water. The tem- perature at which it should be introduced into the body should be about ioo° F., and, as it loses some heat in its passage to the body, the temperature of the solution in the container from which it is administered should be 105 F.* METHODS OF ADMINISTRATION The channels through which the solution can be intro- duced into the body are — • 1. The veins. 2. The subcutaneous tissue. 3. The rectum. 4. The peritoneal cavity. 1. Intravenous Injection By injecting the solution into the veins, the fluid which the body needs is at once added to the circulation, and this is, therefore, the best method in urgent cases. Preparation of the patient. — Any vein may be chosen, but as a matter of practice one of the veins at the bend of the elbow, the median-basilic or the median-cephalic, * Lazarus Barlow, on experimental grounds, recommends a glucose solu- tion (Arch. Middx. Hosp., xvi. 23). 573 574 GYNECOLOGICAL SURGERY whichever is the more prominent, is generally chosen. The skin covering this region is rendered as aseptic as time will admit of by vigorous scrubbing with soap and water, and afterwards with biniodide of mercury solution, i — 2,000. Instruments.— A scalpel, dissecting forceps, pair of pressure-forceps, aneurysm-needle, No. 2 silk ligatures, and some sort of a bandage to constrict the upper arm are required, in addition to some form of transfusion apparatus, which must consist of a receptacle for the solution, an india-rub- ber tube, a cannula with the opening at the end — not in the side — to insert into the vein, and a thermometer. An irrigating porringer will do very well as a receptacle if the surgeon has a cannula. The injection apparatus devised by one of us (Fig. 22), which contains all that is necessary, will be found very useful for private work. Soloids of chemi- cally pure sodium chloride can be obtained of a sufficient strength for one to a pint of water to make a normal saline solution. The solution must be mixed in a jug, from which it is poured into the receptacle. Operation, i. Isolating the vein. — The arm having been sufficiently bandaged 4 in. above the elbow to stop the return of the venous blood, and so make the veins stand out, and the most prominent vein having been chosen, Fig. 380. — Intravenous saline infusion Isolating the vein. ADMINISTERING SALINE SOLUTION 575 the skin over it is incised in the line of the vein, which is then separated from the tissues surrounding it (Fig. 380). ii. Ligaturing the lower end of the vein. — Three ligatures of silk are passed under the vein by means of an aneurysm- needle or, what will do equally well, a Bonney's needle used with the blunt end first. One ligature is tied at the distal end of the separated vein, the second is used for tying- in the cannula, and the third is reserved to ligature the prox- imal end of the vein at the end of the operation (Fig. 381) iii. Opening the vein. — The vein is picked up with the Fig. 381. — Ligaturing the lower end of the vein. Fig. 382. — Opening the vein. dissecting forceps, and, a longitudinal opening having been made in it with the point of the scalpel (Fig. 382), the 5?b GYNECOLOGICAL SURGERY cannula is inserted into its lumen. A little of the saline injection should be allowed to flow through while it is being introduced, so that all air-bubbles may be expelled, Fig. 383. — Inserting the cannula. and, the blood having been washed away, the opening in the vein is easily seen (Fig. 383). iv. Securing the cannula. — When the cannula is in the vein the second ligature is tied tightly to keep it in position, after which the bandage round the arm is re- moved and the saline solution allowed to run into the vein (Fig. 384). The amount of fluid run in will de- pend upon what the injection is being used for, and will vary from two to five pints. The receptacle containing the solution must not be al- lowed to become empty. If by chance this should occur, Fig. 384. — The cannula secured. ADMINISTERING SALINE SOLUTION 577 the tube must be at once pressed with the finger and thumb to prevent air from entering the vein. The ligature securing the cannula is cut when sufficient solution has been injected, and the third ligature is tied as the cannula is withdrawn, after which one or two interrupted silk sutures unite the skin-wound. Difficulties. — Although this operation is apparently so simple, we have not infrequently seen the attempt to introduce the cannula into the vein utterly fail. This is owing to the trying circumstances in which it has most often to be performed, the surgeon in his hurry omitting the careful performance of the technique we have just described. Frequently the skin-incision made is too small, and time is wasted in identifying the vein. The vein, instead of being freed, may be merely exposed and opened without the previous application of the distal ligature. The free flow of blood that then occurs prevents the operator from seeing the hole through which he must pass the cannula, and he is further unable to lift the vein out of the wound so as to see clearly what he is doing. The result is that he more often than not passes the cannula into the perivenous sheath instead of into the vein itself. In other cases the preliminary bandage round the upper arm may be forgotten, so that if the patient be much exsanguinated the vein merely presents as a flat white strap which it is very difficult properly to open, or into which, being opened, it is difficult to get the cannula. If in spite of every precaution the fluid cannot be introduced into the vein chosen, some other vein must be tried. It may be remarked that if the patient is much collapsed the fluid at first flows very slowly; as the circulation improves, the rate will increase. Dangers. — -The most important fact to remember in connection with intravenous injection is that in cases of haemorrhage it should never be given until the bleeding-spot has been secured. We have several times seen cases in 2 L 578 GYNAECOLOGICAL SURGERY which nearly all the blood of the body had been washed into the peritoneal cavity for this reason. Great care, of course, must be taken that no air is injected with the solution, on account of the danger of an air-embolism. The solution and the instruments should all be aseptic. If too much solution is injected the patient may get cedema of the lungs. Lastly, the solution must be of a proper temperature, and the nurse must keep testing the fluid in the re- ceptacle with a thermometer, and adding hot solution as required. Dressings. — Some gauze, wool, and a bandage. After-treatment.- — The skin-stitches are taken out at the end of a week. 2. Subcutaneous Injection With this method the solution is introduced into the cellular tissue of the body, and is thence absorbed into the circulation. It is a slower method than intravenous injec- tion, and the solution should be hotter — at a temperature of about 108 F. Site of injection. — The most usual place to run in the saline solution is under the breasts ; it can also be run in under the axillae, or just above the crest of the ilium. Preparation of the patient. — The skin over the site of injection is prepared as for intravenous injection. Instruments. — A receptacle for the solution, an aspirat- ing needle attached to a glass funnel by a 4-ft. length of india-rubber tubing, and a thermometer are required. Operation. — At the spot chosen the aspirating needle is introduced, allowing a little of the solution to run out during its insertion. About a pint can be run in under each breast, and the dose can be repeated, if necessary, after the first lot has absorbed. Dressing. — Some collodion and gauze over the point of insertion of the needle. ADMINISTERING SALINE SOLUTION 579 CONTINUOUS SALINE INFUSION This is an extension of the method just described. The fluid is run in by syphon action from a large receptacle through an india-rubber tube to which is attached an aspirating needle, or, better still, a T-piece of glass with two tubes, each furnished with a needle (Fig. 385). Fig. 385. — Continuous infusion into the cellular tissue. The sides of the chest or the thighs are the sites usually selected. The needles should be run well into the cellular tissue and retained there by strips of adhesive strapping. The receptacle should be but slightly raised above the level of the patient so that the inflow is slow, from about half a pint to a pint an hour, a faster rate than this usually soon producing much oedema. If the apparatus works satisfactorily, from 10 to 20 pints may be introduced in 580 GYNECOLOGICAL SURGERY twenty-four hours. It is necessary to have a nurse con- stantly in attendance to see that the temperature of the fluid in the receptacle does not fall below 108 F. Where two needles are employed it is an admirable plan to apply a stopcock or a pressure-forceps to each of the tubes connecting them with the T-piece. Each needle can then be used alternately, the inflow being cut off directly the tissues in the neighbourhood begin to get cedematous. It is very important to sterilize the skin as carefully as possible before introducing the needles ; and the water with which the saline solution is made should, of course, be boiled. This method of administering saline solution is highly praised in the treatment of peritonitis and conditions in which administration of fluid by the mouth or the rectum is impossible. 3. Peritoneal Administration Some surgeons make a point after every abdominal operation, and before closing the abdomen, of pouring into the peritoneal cavity two or three pints of saline solution. Others employ this method only if there has been much haemorrhage. It is certainly an excellent method to adopt if the abdominal cavity has had to be reopened for secondary hsemorrhage, or if the operation has been a prolonged one involving much shock, as, for instance, the radical abdominal operation for cancer of the cervix. Instruments. — A jug to contain the solution, and a thermometer. Injection. — -Three pints of salt-solution at a tempera- ture of 105 F. are mixed in the jug, and the fluid is then poured straight into the abdominal cavity just before the last two inches of abdominal peritoneum is sutured. The patient should be tilted a little so that the solution may not escape before the wound is closed. 4. Rectal Injection Rectal injections of saline solution are used as a routine measure to relieve the thirst after an abdominal section. ADMINISTERING SALINE SOLUTION 581 They are also used as a means of introducing fluid in cases where there has been considerable hsemorrhage during the operation, but not sufficient to indicate venous infusion, and in cases of prolonged operation involving shock. This method may also be employed as an additional means of supply after intravenous injection has been per- formed. It is a most useful method, and as a routine performance after severe operations gives admirable results. In cases where much loss of blood during the operation is anticipated, it is good practice to administer a high rectal injection of a pint of saline solution one hour before the operation. Instruments. — The glass funnel attached to a No. 12 india-rubber catheter and a receptacle to hold the solution, which should be administered at a temperature of ioo° F. Injection. — Before the return of consciousness a pint or more can be introduced into the bowel, but after the effect of the anaesthetic has worn off the rectum will only tolerate 6 ounces. More than this can be injected by introducing a long rectal tube as high up as it will go, and running the solution into the colon, but this is seldom indicated in pelvic surgery, since distension of the sigmoid colon may adversely affect the operation area. As a rule, 6 ounces are injected every two hours for the first few hours, then every four hours for the next twenty-four, unless the condition of the patient demands a more frequent administration. The best time for the injection is after the rectal tube has been passed to relieve flatus, when the tube, without withdrawal, may be used to administer the injection. If the patient's condition indicates stimu- lants, brandy may with advantage be added to the saline solution. Continuous administration can be effected by a modification of the syphon apparatus described in the section dealing with infusion into the cellular tissue (p. 579). Where the bowel low down has been injured in the course of the operation, rectal injections should not be given, for fear of rupturing it. CHAPTER XXXIV POSTOPERATIVE COMPLICATIONS VOMITING Postoperative vomiting may be considered under the following headings : — 1. Anaesthetic vomiting. 2. Irritative vomiting. 3. Neurotic vomiting. 4. Peritonitic vomiting. 5. Obstructive vomiting. 6. Vomiting due to acute dilatation of the stomach. 7. Vomiting due to pylephlebitis. 1. Anaesthetic yomiting. — This occurs soon after the patient has been put back to bed. It is partly dependent on the patient, partly on the nature of the anaesthetic used, partly on the experience of the anaesthetist, and partly on the method of preparation of the patient. Some patients vomit at the least provocation, such as a bad smell, a bad taste, the sight of anything objectionable, or slight pain. Chloroform will suit one patient, and ether another. It is a matter of everyday observation that patients vomit much less when the anaesthetic is administered by one experienced in this class of work, and also that if an anaes- thetic is administered before the stomach is empty vomit- ing will most likely ensue. Anaesthetic vomiting, as a rule, does not last more than a few hours, and the vomited matter consists of bile-stained fluid. The nurse should stay by the patient and keep her from being soiled by any ejected material. The patient should be placed on her side in minor operations, and in major cases the head must be turned to one side. 582 POSTOPERATIVE COMPLICATIONS 583 2. Irritative vomiting. — This is due to a gastritis set up by the anaesthetic. The contents of the stomach are persistently ejected, but vomiting is not so likely to occur if the viscus be left alone and not continually worried by milk or beef -tea being poured into it. Irritative vomiting is often combined with flatulent gastric distension, and pain referred to the left thorax. Large quantities of bile may be brought up — the so-called " bilious " vomiting. There is no abdominal tenderness, fever, or undue rapidity of the pulse. The treatment is to add lime-water to the milk or to peptonize it. This prescription will be found useful : — ty Sodse bicarb. 3*- Ess. menth. pip. Tl\y. Aq. calid, ad §iii. To be administered half an hour before the next feed. This draught, which at times makes the patient very sick, and so effectually washes out the stomach, often gives great relief. The following also may be tried : — ty Bismuthi carb. gr. v. Mag. carb. levis gr. x. Soda^ bicarb, gr. xv. Aq. destil. ad §j. The draught to be taken every three hours if necessary. If the vomiting prove obstinate, feeding by the mouth should be stopped for a few hours, and rectal injections (p. 581) meanwhile administered. There is one remedy which rarely or never fails to stop this form of vomiting, and that is a soap-and-water enema. A certain degree of " polarity " doubtless exists between the two ends of the intestinal tract, and, without doubt, the surest way to check irritative vomiting is to open the bowels. Irritative vomiting does not, as a rule, last more than twenty-four hours. It is not at all uncommon in the more 584 GYNAECOLOGICAL SURGERY severe classes of irritative vomiting for the ejected material to be " coffee-coloured " from the presence in it of altered blood, derived probably from the congested stomach-wall. In the absence of unfavourable abdominal symptoms, this occurrence need not give alarm. 3. Neurotic vomiting. — This is often combined with the foregoing, but when due to neurosis pure and simple it may be very troublesome. The patient is continually retching, whether food be in the stomach or not — she is obviously trying to be sick. There are no other signs suggesting anything amiss : the pulse is not quickened to any marked degree, there is no abdominal distension, and the quantity of the fluid evacuated does not increase ; in fact, the presence of neurotic vomiting is usually noticed in those in whom there is the least likelihood of any grave lesion of the bowel or peritoneum. A good " talking-to " will often act as a cure, if everything else fails. We have found that the addition of a little brandy to the food often tempts the patient to retain it, as in these cases there may be a craving for alcohol or morphia. Neurotic vomiting can be troublesome for several days, and if not relieved the patient may be much exhausted. The remedies men- tioned under "irritative vomiting" (p. 583) may be tried, and in addition relief may sometimes be obtained by counter- irritants, such as an ice-bag, mustard-plaster, or blister over the epigastrium. Drop-doses of tincture of iodine in a teaspoonful of hot water every half-hour, iced champagne, very strong coffee without milk, an enema of 20 grains of chloral hydrate in 3 ounces of water, all these may relieve the patient, or, on the other . hand, may not be of the slightest use. If the condition becomes very troublesome, relief will only be obtained by stopping all food by the mouth, washing out the stomach, and opening the bowels by a simple enema of soap-and- water. If the patient is very excitable, half a grain of morphia will very often change the aspect of affairs entirely, and POSTOPERATIVE COMPLICATIONS 585 the patient will wake up relieved of this troublesome symptom. 4. Peritonitic vomiting. — This comes on during the second or third day following the operation. The vomiting is at first infrequent and the amount small, while the ejected material is pale-brown in colour. Later it is a darker brown or green, and sometimes slightly offensive, while the amount may be very considerable, the patient vomiting as much as half a pint at a time ; but there is no feeling of sickness nor effort to eject the fluid as in the case of irritative vomiting ; the fluid simply wells up and flows out of the mouth. The other signs and symptoms which accompany peritonitis are, as a rule, so evident that the cause of the vomiting cannot be mistaken. The treatment will be described under Peritonitis (p. 601). 5. Obstructive vomiting. — If a portion of the intestinal canal becomes occluded, as the result, immediate or remote, of the operation, obstructive vomiting supervenes. This may be due to many causes, of which a list is given at p. 606, but, whatever the cause, the result is the same. Obstructive vomiting comes on quite gradually, so that for the first two or three days the patient may apparently be progressing quite satisfactorily. Later the vomiting, which at first is only intermittent, gradually increases in frequency, till at last it is practically continuous. Although faecal vomiting is said to be diagnostic of obstruction, the ejected material often does not become faecal in character until the end is at hand, unless the obstruction is very high up, and in many instances it does not become faecal at all. Obstructive vomiting is always accompanied by dis- tension, which gradually becomes more and more marked, commencing, as a rule, over the left abdomen, the seat of the obstruction being usually in the region of the sigmoid flexure. The remaining signs and symptoms of obstruction are described at pp. 608 and 613. 586 GYNECOLOGICAL SURGERY In peritonitic and obstructive vomiting it is most important to note that the large amount vomited is out of all proportion to any fluid that may have been introduced into the stomach by the mouth, whilst its character shows that it is not the normal secretion of the stomach and upper part of the duodenum. It is, in fact, due to an acute bacterial invasion of the stomach and intestinal wall, resulting in a copious watery secretion therefrom. The fseculent odour of obstructive vomiting is due to acute infection of the upper intestinal tract by the Bacillus coli communis and other intestinal bacteria. 6. Vomiting due to acute dilatation of the stomach. — See p. 622. 7. Vomiting due to pylephlebitis. — See p. 619. DISTENSION Abdominal distension after operation is either (1) epi- gastric, (2) flatulent, (3) paretic, (4) obstructive, or (5) peritonitic. 1. Epigastric distension. — This is often associated with irritative vomiting and owns the same cause. It is obviously gastric, and the treatment suggested for irritative vomiting may be tried. If these measures fail, the remedies recom- mended under neurotic vomiting may be used. A distended transverse colon may be mistaken for the stomach if the abdomen be examined without the bandage being unfastened. This would be a serious error, since a distended colon has a very different significance. 2. Flatulent distension. — For forty-eight hours after all abdominal sections, more or less flatulent distension of the intestine occurs. It begins in the stomach (epigastric dis- tension) and gradually works its way downwards, being accompanied in the earlier hours by intermittent explosions per os, and later on per anum. It is probably due to the altered relations and pressure-changes obtaining in the abdominal cavity as the result of the operation. The patient is made unpleasantly aware of its presence by POSTOPERATIVE COMPLICATIONS 587 painful borborygmi, and relief is not obtained until the gas freely escapes from, the rectum. Such passage of flatus rarely occurs naturally until forty-eight hours after the operation, but its passage by the rectal tube should be evident after twenty-four hours. A certain amount of discomfort is to be expected after all abdominal operations, but it is minimized considerably by the regular use of the rectal tube as described at p. 556. 3. Paretic distension. — This in its lesser degrees is a not uncommon condition, especially when the operation has been at all prolonged and there has been much handling of the intestines. The distension is uniform and soft ; there is no rigidity or tenderness of the abdominal walls, and it is a general distension not markedly beginning in or localized to one section of the gut. Although a degree of irritative vomiting not uncommonly accompanies it at first, the pulse and temperature are not unfavourable. Its danger chiefly lies in the possibility of the distension causing a kink in some portion of the bowel tethered by adhesion or shortening of its mesentery, and thus producing a real obstruction. Exceptionally, however, the degree of para- lysis of the gut may be such that complete obstruction results. This important complication is fully dealt with under the head of Intestinal Obstruction (p. 613). In true paretic distension there is a complete absence of painful intestinal movements and borborygmi. Paretic distension is to be treated by frequent applica- tion of the rectal tube, by a turpentine or rue enema, or by a rectal wash-out. Enemata. — A turpentine enema consists of turpentine §ss, olei ricini §i, soap-and-water Oi, and is made either by mixing the turpentine in a porringer with a piece of soft soap as large as a hen's egg, then stirring in the oil, and lastly adding the remaining ingredients, or by beating up the turpentine with the white of an egg and then stirring in the other ingredients. The enema should be injected at a temperature of 102 F. 5S8 GYNECOLOGICAL SURGERY A rue enema consists of olei rutae n\xx, mucilag. acacise 3ii, soap-and-water ad 3vi. In either case, if the enema is not returned the rectal tube should be passed to draw it off. Rectal wash-out. — To wash out the rectum a special tube is passed (p. 536), with a glass funnel fitted to its free end. Two pints of soap-and-water at a temperature of 105 F. should have been mixed with one ounce of turpen- tine, and ten ounces of this solution is poured into the funnel, which is held as high as possible. The fluid is then allowed to remain in the rectum for a few minutes, after which the funnel is lowered into a basin of boric-acid solution and the injection allowed to run out with a consequent aspiration of flatus from the intestine. Another ten ounces is run in until the two pints is used up. As a rule this method of treating the distension is very successful. It has the advantage over an enema that it does not exhaust the patient so much. If the distension is due to simple paresis of the intestinal walls, treatment by one or other of these methods will nearly always relieve it, and we have found the most useful of them to be the rectal tube and rectal wash-out. Eserine and strychnine.— A useful adjunct to the fore- going methods is the hypodermic injection of eserine and strychnine, the first of which has certainly a specific action in restoring tone to the intestinal wall. For this purpose it should be given in doses of T J grain combined with ^ - grain of strychnine every four hours. Pituitary extract is said to produce the same result. 4. Obstructive distension. — In this variety the abdomen is hard and, when due to an organic cause, tender, while the condition is accompanied by persistent vomiting, and after a while an increasing pulse-rate and a rise of tempera- ture. In pelvic surgery the site of the obstruction is most commonly at the sigmoid flexure, and it is important to realize that it is most often a partial, not a complete obstruction. The symptoms, therefore, are subacute, and POSTOPERATIVE COMPLICATIONS 589 perhaps it may be a week or even more before a fatal termination is reached. The distension usually, there- fore, commences and is most marked in the descending colon and sigmoid, and over the latter there are invariably some rigidity and tenderness. It is a slow progressive distension first of the large and then of the small bowel. The distension is at first slight, and flatus and even some small bits of faecal matter may be passed if the obstruction is incomplete. In spite of this, however, the symptoms in- crease, the vomiting, which at first occurred only at long intervals, increases in frequency until it becomes continu- ous, while the ejected matter, which at the commence- ment consisted only of food, towards the close may be stercoraceous, although this is by no means always the case. For a further discussion of the symptoms of intestinal obstruction and its treatment, see p. 606. 5. Peritonitic distension.- — This form of distension, when the peritonitis causing it is acute and general, is diagnosed with greater ease, accompanied as it is by marked pain, rigidity, and early collapse. The treatment is most hope- less when the symptoms are marked, and we look upon the late Mr. Lawson Tait's plan of administering sulphate of magnesia every hour until the bowels are opened as quite useless, not to say impracticable, since the patient will not retain it in her stomach, and her torments are increased by the vomiting which is instantly induced by putting anything into that viscus. Washing out the stomach, as advised by some authorities for the persistent vomiting accompanying this condition, is worse than useless, since it merely further exhausts the unfortunate patient. Rectal feeding, together with frequent rectal wash-outs and the administration of eserine to reduce if possible the distension, in addition to the treatment described in the section dealing with peri- tonitis (p. 598), is the proper course to pursue. In conclusion, we should like to direct special attention to the value of rectal saline injections in the treatment of vomiting and distension. After giving an extended 590 GYNECOLOGICAL SURGERY trial to all other methods, we have found that there is no procedure that is so generally useful as this. If the vomit- ing be simply irritative, rectal saline injections rest the stomach ; if it be due to partial obstruction, paretic or otherwise, the bowel has time to recover itself ; if to peri- tonitis, peristalsis is minimized, and thereby assists in keep- ing the inflammatory process localized to the operation- site ; and the same advantages apply to cases of obstinate distension. We resort to this method of treatment early in any case of vomiting or distension that does not rapidly improve under the other measures we have indicated. Its applica- tion is also of considerable diagnostic value, since vomiting which continues in spite of the rigid exclusion of everything from the stomach is of very bad import. PAIN After all abdominal sections, patients complain more or less of pain in the back and abdomen for a period of at least twenty-four hours. The pain should then rapidly subside, so that at the end of forty-eight hours the patient is much easier. Pain in the back can be greatly relieved by putting a pillow under the legs, which causes the back to lie flat on the bed, and not arched as is otherwise the case. In cases where this fails, an air-cushion put under the back often gives relief. Pain in the abdomen is most marked in operations where tension on the stitches is likely to be present, such as ventro-suspension, or where, after the enucleation of a broad-ligament cyst, the sac is stitched to the anterior abdominal wall and drained. The single-layer method of closing the abdominal wound results in more pain than the three-layer method, and an incision through the abdominal muscles is followed by more pain than one through the linca alba. A discussion of this symptom centres round the advis- ability of giving morphia after abdominal section. It is POSTOPERATIVE COMPLICATIONS 591 better, if possible, to avoid giving morphia, as this drug may irritate the stomach, and many patients are very sick after its administration, whilst it also tends to increase the thirst from which the patient suffers. If morphia is to be given at all, it should be given on the first night, for three reasons : (1) because the pain is at its worst ; (2) because distension, which morphia directly favours, never comes on until twenty-four hours after operation ; and (3) because peritonitis and obstruction, which are masked by morphia, do not, as a rule, declare them- selves until the second day. Therefore, if morphia is indicated, it should be given on the first night in the form of a suppository or hypodermic injection. Its routine use is to be condemned. In cases where the patient is very neurotic, throwing herself about and complaining of the greatest pain, there being no sickness and an examination showing the tempera- ture and pulse to be normal and distension absent, one- third of a grain of morphia is of the greatest possible value, and will quiet her at once. In appraising the significance of pain after an abdominal operation, its nature and the character of the patient must both be taken into account. Where within the first twenty-four hours the pain is out of proportion to these and is accompanied by undue rapidity of the pulse, some disaster at the operation-site is to be suspected, such as recurrent haemorrhage, which is always associated with severe pain, or the escape of intestinal contents through an unnoticed perforation of the bowel. If the pain appears after twenty-four hours, it is probably due to flatulence, peritonitis, or obstruction, and its treatment will be discussed at pp. 586, 598, 606. INSOMNIA After the first twenty-four hours a patient who is doing well should sleep, at first in short snatches and subse- quently for longer periods. 592 GYNECOLOGICAL SURGERY Persistent insomnia is of bad import. Where peri- tonitis, intestinal obstruction, or similar causes of pain are present, sleep is impossible. In the absence of pain, insomnia is seen in highly nervous patients, especially when exposed to the necessary disturbances that occur in a hospital ward. It is also seen, of course, as a precursor of postoperative insanity. Most characteristically of all, however, it occurs in conditions of toxic absorption, as, for instance, a subacute inflammation round the ligatures at the operation-site. In such cases, also, sleep, though not absent, may be rendered distressing by nightmare-like dreams. Such occurrences are most suggestive of some- thing amiss in the operation-area. As regards treatment, morphia is often not satisfactory, but is to be tried when pain is present. In the absence of pain, trianol, veronal, sulphonal, and bromidia are the best drugs. Bromidia, in particular, has proved useful in our hands. SHOCK AND HEMORRHAGE We consider these two formidable complications to- gether because the distinction between them forms the most important problem in all the after-treatment of abdominal sections. Shock is often a post-haemorrhagic condition following a severe loss of blood during a pro- longed operation ; these are the cases so difficult to dis- tinguish from postoperative haemorrhage. At other times it is a condition of true nervous shock, such as follows upon a blow in the abdomen. Lastly, both causes may be in operation at the same time. It is necessary that post- operative haemorrhage should be distinguished from shock, because the treatment of the two conditions is essentially different. With respect to the blood lost during an operation, we have made a very careful investigation in 123 cases to ascertain its amount. A separate tin of swabs was kept for each patient, and a few hours after this had been ste- POSTOPERATIVE COMPLICATIONS 593 rilized it was weighed. At the conclusion of the operation the tin with the unused swabs was weighed, the difference in weight between this and that before the tin was opened indicating the weight of the swabs removed from the tin before they were used. The used swabs were then weighed, and the difference between this weight and that estimated for the unused swabs removed from the tin gave us the weight of blood lost at the operation. We always use dry swabs. The weight lost by evaporation from the swabs, even after many hours, was negligible. One fluid ounce of blood weighs one ounce avoirdupois. The following table shows the maximum, minimum, and average loss of blood in some of the principal gynaecological operations : — - Number Maximum Minimum A verage Operation. of amount amount amount cases. lost. lost. lost. Total abdominal hyster- ectomy 9 15 oz. 7 oz. II \ oz. Subtotal abdominal hys- terectomy . 31 59 „ 2 ,, II Abdominal hystero-vag- inectomy . 23 39 „ 15 .. 29 „ Ovariotomy . 19 9 „ 1 ,, 5 .. Salpingo-oophorectomy . 15 23 .. 1 ,, 8 „ Intraperitoneal shorten- ing of the round liga- ments 12 5 .. 1 ,, 3 „ Ventro-suspension 14 4 .. 1 ,, 2i ^2 •> The largest quantity of blood lost, 59 oz., was in a very difficult case of hysterectomy for a cervical fibroid which weighed nearly 26 lb. Omitting this case the average amount lost in 30 subtotal hysterectomies was 9 oz. Dullness in the iliac fossa is a fallacious sign of haemor- rhage, for the bowels float up against the parietes, while the colour of the blood oozing through a gauze drain is always pale because the corpuscles become entangled in the meshes of the gauze and it is principally serum which 2M 594 GYNECOLOGICAL SURGERY escapes. The fact, therefore, that the fluid which is escap- ing is pale in colour should not lead the observer to think that haemorrhage is absent. The necessity for a correct diagnosis between shock and haemorrhage is of vital import- ance, and it will be better, therefore, to set out in parallel columns the signs and symptoms of the two conditions. Shock Signs date from the operation Signs tend to get better Face may be blanched Skin is cold and damp Pulse feeble, fast or slow, but the cord of the radial artery can be felt A blush can be squeezed into the finger-tips The superficial veins are full of blood, especially noted when the veins are exposed for in- fusion Patient is quiet, lying on her back The longer the operation and the more severe its nature, the more likely is shock to supervene Abdominal pain absent Patient is listless, apathetic, and takes no interest in her sur- roundings Respirations are quick and shallow Temperature may be subnormal Faintness not commonly com- plained of Brandy enemata improve shock HEMORRHAGE Signs develop after the operation Signs tend to get worse Face and lips are markedly blanched Skin is cold and damp Pulse feeble, nearly always fast, and the cord of the artery cannot be felt A blush cannot be squeezed into the finger-tips The superficial veins are col- lapsed Patient is very restless Duration and severity of the ope- ration are of no significance Severe abdominal pain Patient is anxious, alert, and per- haps fearful of death Respirations are laboured, deep, and gasping Temperature commonly sub- normal Faintness complained of in all cases, and often a feeling of sinking through the bed Brandy enemata increase hae- morrhage In certain cases where the haemorrhage takes the form of a slow continuous oozing, many of the classical symptoms may be modified ; thus, we have seen several cases of POSTOPERATIVE COMPLICATIONS 595 severe intraperitoneal bleeding where the temperature was well above normal, up to ioo° F. and even more, and others in which restlessness and air-hunger were quite absent. Occasionally, also, the pulse-rate may be low. 7. Treatment. — If shock be diagnosed, the foot of the bed should be raised and an ounce of brandy per rectum given at once, together with 10 ounces of saline solution at a temperature of 102 F., and repeated every two or three hours. A hypodermic injection of 5 minims of strychnine is also indicated, and may be repeated as often as is considered necessary. The patient should be wrapped in blankets, and hot-water bottles used to maintain heat. If the condition is serious and the patient does not react to these measures, two or three pints of saline solution should be run into the veins, or continuous saline infusion can be administered. The administration of adrenalin and pituitary extract has been much lauded in shock. Our experience is against the use of vaso-constrictants. They have been advised theoretically on the assumption that by producing arterial contraction the blood-pressure will be beneficially raised. We are, however, of opinion that where the heart is already beating so feebly as to be in momentary danger of stopping altogether, the handicap of increased resistance frequently precipitates that catas- trophe. The most useful drugs in cases of shock are alcohol and strychnine. Digitalin should not be employed ; it raises the blood-pressure and has no beneficial action on the heart in these cases, and in our experience makes matters worse. If hemorrhage, however, be diagnosed, there is but one thing to do, and that is to secure the bleeding vessel. We are most strongly of opinion that infusion should never be practised until the bleeding-point has been secured, no matter how tempting the treatment appears to be. Such treatment is more futile than trying to fill a bottle with a hole in its bottom, and it prevents Nature from checking the haemorrhage by her own method, namely, by the formation 596 GYNECOLOGICAL SURGERY of a clot in the bleeding vessel when, by reason of the haemorrhage, the circulation through it is sufficiently feeble to allow of thrombosis taking place. That this is so is proved by the fact that where, in these cases, death has followed venous infusion, the peritoneal cavity is found to be filled with a mixture of blood and saline solu- tion ; the vessels, in short, have been flushed out with salt-and-water. It is important to remember that when the wound is reopened no bleeding-point may be found if the haemorrhage has been severe, the bleeding having temporarily stopped of its own accord. In this case a careful search must be made for a slipped ligature at the various points where ligatures have been applied, an assistant meanwhile administering a saline venous infusion. As the blood-pressure rises, the bleeding-point will probably become evident. Very little or no anaesthetic is required for these manipulations, and it is marvellous how nearly moribund a person may be and yet recover after a saline infusion. Instead of venous infusion a pint of warm saline solution may be injected under each breast by means of an aspirating trocar, a tube, and a glass funnel ; or large rectal injections of the same fluid may be given (see p. 578). For our part, as mentioned earlier, we prefer venous infusion. In both haemorrhage and shock the head is to be kept as the lowest part of the body and every effort made to maintain warmth. Anxious uncertainty will often be the lot of the watcher in these cases, but it is better to reopen a wound and make sure that the condition is only due to shock than to infuse a patient who has a vessel patent. Here we would again emphasize the extreme importance of frequent and careful observation of the pulse-rate after abdominal operations. We have known cases where the diagnosis of haemorrhage and its successful treatment have been solely founded upon a rapid and otherwise unexplainable rise in the pulse- rate, and there is nothing in which a house-surgeon may take such legitimate pride as the knowledge that his careful POSTOPERATIVE COMPLICATIONS 597 observation and accuracy of judgment have been the means of saving a patient's life. REMOTE SHOCK We have applied this term, for want of a better, to a condition which will be familiar to all who have experience of abdomino-pelvic surgery. The patient is elderly, she is enfeebled, and she is the subject of cardio-vascular degenera- tion. The operation has been severe, and usually accom- panied by considerable loss of blood ; shock immediate, and presenting the symptoms just described, has followed on it ; and the patient under appropriate treatment has rallied. On the morning following the operation she presents a very typical picture. The pulse is fast, strong, and throbbing, the eyes are glistening, and the mental condition is very active. The patient expresses herself as feeling " quite well," " never better," and so forth. All these symptoms become accentuated as the day goes by, and there is great restlessness and a total absence of sleep. On the next day the pulse is still faster but softer and more running, and the apex-beat of the heart will be found to have moved outwards beyond the nipple-line. Mental excitement remains, but the patient has a difficulty in recognizing those about her and she rambles in her speech. There is a progressive loss of strength, and the skin becomes cold, the pulse imperceptible, and the respirations fast. Death ensues in from two to four days after operation. Stimu- lating treatment is indicated, but in our experience nearly all the cases in which these symptoms have typically developed have ended fatally. Post-mortem examination discloses no local abdominal cause for death, the site of the operation, the intestine, and the peritoneum being satisfactory ; but the heart in all the cases is fatty and dilated, and it is to the acute dilatation and failure of this organ that the fatal termination must be ascribed. CHAPTER XXXV POSTOPERATIVE COMPLICATIONS (Continued) PERITONITIS Causes. — Septic peritonitis is due to infection of the peritoneum from — (i) Some instrument, ligature, suture, swab or towel. (2) The hands or breath of the operator or of his assistants. (3) Pus or faecal matter which has escaped during the process of the operation, as, for instance, when an ovarian cyst or pyo-salpinx is being removed or adherent intestines are being separated. (4) The skin of the patient. (5) The patient's vagina. (6) An effusion of blood. It has been shown by Sargent and Dudgeon that the presence of blood in the peritoneal cavity is shortly followed by the appearance of a staphy- lococcus, and it is a matter of common experience that haematoceles are soon followed by signs of local peri- tonitis. (7) Auto-infection of damaged tissue. It is obvious that the more the patient's tissues are bruised by rough handling, the greater the liability to infection. Further, there are certain conditions of tissue-damage that peculiarly favour bacterial activity. It is a remarkable fact that areas of complete vascular stasis (white infarction) , whether produced by an embolus or due to an occluding ligature, are not associated with inflammatory phenomena, whereas those of partial vascular stasis, and especially of venous stasis such as is found in the tissue distal to the twist of an ovarian pedicle or the constriction at the neck of a hernial 598 POSTOPERATIVE COMPLICATIONS 599 sac, rapidly become the seat of an intense bacterial invasion. The absence of any symptoms following the application of a surgical ligature to a piece of omentum, as compared with the violent results when the same tissue becomes strangulated in a hernial sac, may be cited in support of the above statements. Tissues so damaged, and lying in close proximity to the bacteria-laden intestine, readily become the seat of auto-infection therefrom (see p. 41). Septic peritonitis is most commonly due to some flaw in the aseptic technique. The greater the care that is taken with the preparation of the patient, instruments, swabs, ligatures, and the hands of the surgeon and nurses, the fewer will be the number of cases occurring in the surgeon's practice. As a proof of this, one has only to examine the statistics of different hospitals, or of different surgeons in the same hospital. Granted a certain amount of opera- tive ability, a surgeon's results will depend not so much on the difficulties of the case or the rapidity of his mani- pulations as on careful and minute attention to secure a perfect asepsis, or an asepsis as nearly perfect as may be. Wherever the greatest precautions are taken to keep the operation and its field aseptic, there will the best results be found. Further, from a study of the causes of peritonitis, it is evident that the more perfect the haemostasis the less likelihood will there be of peritoneal infection, other things being equal. Thus, the surgeon who, to attain rapidity, is content to take the chance of capillary oozing occurring after he has closed the wound, may be chagrined to find that his case does not run the same apyrexial course as that of a colleague at whose slow and laborious workman- ship he is apt to scoff. Lastly, from our remarks on the auto-infection of damaged tissue, it will be seen how necessary it is for the surgeon to handle as lightly as possible the tissues with which he is dealing, and to remember when applying ligatures that nothing is so likely to become infected as 6oo GYNECOLOGICAL SURGERY a mass of tissue whose vascular mechanism is gravely interfered with but not entirely occluded. General Peritonitis Symptoms and signs. — The first symptoms of peri- tonitis appear, as a rule, about the third day. In cases infected before the operation, they may appear earlier ; in fact, the patient may never have been quite satisfac- tory. Lastly, and more rarely, this complication may only declare itself towards the end of the first week. Pulse.— Instead of the pulse-rate falling, as it should do, and usually does, within twelve hours of the operation, it gradually increases in frequency to 120 and upwards. It is at first quick, small, and hard, but as the fatal termination draws nigh its strength decreases, and at the last it cannot be felt. Temperature. — -This, as a rule, is above normal from the first, and continues to rise until it reaches 104 F., or even higher. A rapidly rising temperature on the second day is a symptom of serious import. The temperature, how- ever, is not so good a guide as some of the other signs, for even in very acute cases the rise may not be marked, and in some of the worst cases, especially when of a suppurating character, the temperature may be subnormal. Vomiting. — See p. 585. Distension. — See p. 589. Exceptionally there may be no distension, the belly being retracted and hard. Pain.— Abdominal pain is one of the first symptoms complained of, and may be frightful in its intensity, though rarely, in some of the worst cases, and especially those associated with a purulent effusion, pain is absent. We have noted as a very bad prognosis the complaint of pain felt under the ribs and through to the back. Respiration. — The breathing is purely thoracic and very rapid ; and it may here be noted that while a rapid pulse following abdominal section is a bad sign, its conjunction with rapid respiration is peculiarly ominous. POSTOPERATIVE COMPLICATIONS 601 Abdominal tenderness. — As a rule, abdominal tender- ness is very marked, and universal. The patient cannot bear the least pressure on the abdomen. In those rarer cases where the temperature is subnormal, the distension not marked, and the pain but slight, the abdominal tender- ness may be absent. Defalcation. — -The bowels are very inert, neither flatus nor faeces passing, and aperients or enemata having no effect. Micturition. ■ — ■ Pain on micturition is present, and is due to the movement of the inflamed peritoneum covering the bladder as this organ contracts. The dread of this pain is such that at times retention results. General signs. — The patient is restless, she has an anxious expression, her. face becomes drawn and her com- plexion grey ; the features are pinched and shrunken, her tongue is dry and brown, the body is bathed in a cold perspiration, the extremities are cold ; mental activity may be maintained almost to the last, but occasionally delirium and coma end the scene. The duration of the symptoms from start to finish is rarely over three days. Treatment. — ■ General peritonitis is an extremely fatal disease. That, however, is no reason why all treatment should be abandoned when it is diagnosed, since there is always the possibility of the condition being due to a localized infection with severe general symptoms, and on occasions patients recover even after general peritonitis. The chief point is to " keep the patient going " as long as possible in the hope that she may be able to withstand the infection. There are five lines of treatment having this object in view. They are — i. Injection of antitoxic serum. 2. Vaccine treatment. 3. Injection of saline solution. 4. Multiple drainage and posture. 5. Stimulants, etc. 602 GYNAECOLOGICAL SURGERY 1. Injection of antitoxic serum. — The most commonly found organisms in general peritonitis are the colon bacillus and streptococci. In a small proportion of cases staphy- lococci are present. It is impossible, in most cases of peritonitis, to be sure as to the nature of the infecting organism, but in view of these general findings it is advis- able to administer an anti-colon and an anti-streptococcic serum together until definite bacteriological indications are obtained. The results of this treatment are disappointing, but it does no harm if it does no good. A dose of 25 c.c. of each serum should be injected in the skin over the side of the chest, and should be repeated in six hours, and again six hours after that. If no result has then been produced, it is useless to continue the injections. If the patient reacts favourably, 10 c.c. of each serum should be given twice a day. If serum is going to be used at all, it should be ex- hibited directly the surgeon forms the opinion that the case is one of general infection, and not, as generally happens, as a last resort when the case is practically hopeless. 2. Vaccines. — When the causative organism is known, a vaccine may be prepared and administered. To obtain a vaccine in this way takes 48 — 72 hours. Stock vaccines are now sold by all the leading druggists which can be used after the bacteriological diagnosis has been made, and pending the obtaining of the special vaccine. Since, however, the patient is already absorbing over- whelming quantities of bacterial toxin, the logic of intro- ducing a minute quantity of the material with a view to cure appears questionable. 3. Continuous injection of saline solution. — This method consists in injecting large quantities of saline solution into the cellular tissue. The technique is fully described at p. 579. The rationale of the treatment is as follows : — (1) The body is short of water because of the incessant vomiting and inability to drink. In the absence of sum- POSTOPERATIVE COMPLICATIONS 603 cient water the leucocytes are unable to resist the infecting micro-organisms . (2) If the blood is deficient in water the infected peri- toneal exudation tends to pass into the blood-current. If an excess of water is introduced into the blood the process is reversed. (3) The saline solution by diluting the toxins renders them less harmful. We have seen marked benefit result from this treat- ment, but in some cases there is difficulty in maintaining the flow of the fluid.* 4. Multiple drainage and posture. — The value of multiple drainage is very great. Unfortunately, in post- operative general peritonitis the patient is so bad by the time the diagnosis is made that the surgeon is chary of any further operative treatment, and the patient is unable to bear even the necessary anaesthetic ; but where the condition is discovered at the operation this treatment should be adopted. Incisions should be made over and drainage-tubes inserted into the pelvis in the middle line, both iliac fossae, and both lumbar pouches. Such measures must be aided by maintaining the patient in the raised posture or, best of all, in Fowler's position (i.e. a reversed Trendelenburg) if the necessary apparatus is at hand. 5. Stimulants. — Apart from the four methods of treat- ment already dealt with, the surgeon can only combat heart-failure by brandy and strychnine, and treat com- plications such as vomiting and distension by the methods indicated at pp. 583-90. When this treatment has failed and death approaches, injections of morphia should be given in such doses as to establish euthanasia. Local Peritonitis Symptoms and signs. — As a rule, for some days the patient appears to be progressing satisfactorily. Then the * The credit of introducing this treatment to English surgeons is due to the late Harold Barnard. 6o4 GYNECOLOGICAL SURGERY pulse-rate and temperature commence to rise, but in neither case to any extreme, the pulse being generally under 120 and the temperature fluctuating between ioo° F. and 103 F. ; the abdomen is slightly distended, and there are pain and tenderness, most often of a localized character. In other cases the general symptoms may be more marked : the temperature is higher, the pulse-rate quicker, the tongue may become dry and brown, vomiting may be troublesome, pain may be intense ; and if together with all these the local disease cannot be distinguished, the case may be mistaken for one of general peritonitis. In local peritonitis, however, a tumour sooner or later appears, con- sisting of adherent and thickened omentum, bowel, and peritoneal exudate. Diagnosis. — On any symptom of sepsis appearing, the surgeon should carefully examine the patient to ascertain if there is a local cause. The abdominal wound should be inspected, the iliac regions palpated, and a vaginal examination made. If local peritonitis is present, a hard and very tender swelling may be found in the region of the pedicle, or an inflam- matory mass can be made out filling up the pelvis and extending towards the abdominal wound. The symptoms are often those of partial intestinal ob- struction with vomiting, fever, and wasting. These cases usually terminate by a copious discharge of pus, often stinking, from the lower end of the abdominal wound, followed by instant relief. Fetor is no indication of a communication with the bowel unless it is accompanied by gas and faecal matter, but the establishment of a faecal fistula is commonly pre- ceded by these symptoms of local suppurative peritonitis. The possibility of this complication is the strongest argu- ment in favour of draining the operation-site by a small tube in all those cases in which the asepticity of that site cannot, by reason of the previous condition, be ensured. POSTOPERATIVE COMPLICATIONS 605 The tube, which should be removed in forty-eight hours, establishes a track along which the pus, if it forms, can readily make its way to the surface. Results. — As a rule, cases of localized postoperative peritonitis recover in the end, although convalescence may be delayed several weeks. In a few days adhesions are formed round the infected area which prevent any general absorption, and a certain number of cases recover without suppuration. Rarely, a general septic peritonitis starts from the local focus. Treatment. — If pus is diagnosed it must be evacuated. If the swelling presents in the neighbourhood of the wound, this should be reopened. If there is a marked swelling in Douglas's pouch, of a fluid nature, an incision should be made into it from the vagina, and after it is evacuated the cavity should be drained with a tube. If an abscess appears in the iliac region it should be opened there. Any further complications should be treated as they arise. For the pain, hot fomentations with glycerine and belladonna or laudanum may be applied to the abdomen and morphia may be given internally, whilst vaginal injections of some antiseptic solution at no F. often give much relief and seem at times to cause absorption. If the heart is weak it should be treated with strychnine and brandy. The bowels must be regulated with enemata, and the patient fed per rectum if the vomiting and distension are marked. PELVIC CELLULITIS Inflammation of the cellular tissue of the pelvis, and more especially that of the broad ligament, may follow a dilatation of the cervix, where the cervical tissue has been lacerated ; a curetting of the uterus ; or some operation involving the broad ligament. For instance, infection may spread from a septic stump after the, removal of a pyo- salpinx, or subtotal hysterectomy ; or after the enucleation of a broad-ligament tumour a vessel may ooze, causing 606 GYNECOLOGICAL SURGERY a hematoma, which later may become infected from the bowel. The patient complains of fever, headache, nausea, thirst, anorexia, and of pain in one or other side of the lower abdomen. An examination will show her pulse to be quickened, her temperature to be raised, the lower abdomen on the affected side markedly tender, and per vaginam a tender swelling can be felt in one or other lateral fornix, somewhat depressing it. The uterus, if present, will be fixed and pushed over somewhat towards the opposite side. As a rule, after a few days the condition subsides, and the patient rapidly recovers. Much more rarely it becomes worse, pus forms, and this, if not evacuated, points in one of several places, among which may be men- tioned the ' abdomen just above the groin, the buttock through the sciatic foramen, the vagina, the bladder, or the rectum. Treatment. — Before suppuration has taken place, the general condition of the patient must be treated with quin- ine and sedatives (if the pain warrants their exhibition), the local disease with vaginal douches of a temperature of no F. and abdominal fomentations. If pus forms, it should be let out by an incision before it has time to point, the best way to get at it being through the vaginal fornix. The swelling should be stabbed with a scalpel, after which a pair of pressure-forceps is inserted, their points separated and withdrawn in this position, and a drainage-tube passed into the opening— and kept in position, if necessary, by suturing it to the cut edge of the vagina. Hot douches should then be given twice daily. INTESTINAL OBSTRUCTION Intestinal obstruction is due either to organic occlusion of the lumen of the intestine in some part of its course, or to a complete paralysis of the intestinal wall affecting its whole length or limited to some particular segment. The former, as the commoner variety, will be first con- sidered. POSTOPERATIVE COMPLICATIONS 607 Organic Obstruction This form of obstruction is due — 1. To adhesions of intestine to other parts. 2. To escape of intestine through some orifice. 3. To inclusion of intestine in a ligature. 4. To strangulation by bands. 1. Adhesions of intestine to other parts. — The intes- tine may become adherent to the pedicle left after the removal of an ovarian cyst or a diseased tube, to the stump or suture-line after a subtotal hysterectomy, to the suture- line after total hysterectomy, to another piece of intestine, to the back of the uterus, the broad ligament, or the floor of the pelvis rough from adhesions, especially after opera- tions for salpingitis, or to the parietal wound. As a result of the adhesion, the lumen of the bowel becomes narrowed and gradual obstruction results. 2. Escape of intestine through some orifice. — The intestine may slip through a hole in the mesentery, a hole formed by an adhesion or by another piece of intestine becoming adherent to some other organ, the pelvic wall or abdominal parietes. Also, in cases where the abdominal wound has been insecurely fastened, or where great straining and vomiting has caused a stitch in the wound to give, a knuckle of intestine has slipped through between the cut edges of the fascia and become nipped. This accident has happened, too, during the closure of the abdominal wound, a piece of gut projecting between the cut edges of the incision and remaining undetected. 3. Inclusion in a ligature.— If the operator is careless, a piece of bowel can easily be included in a pedicle-ligature. In cases where a tumour of the left side has distended the mesosigmoid, care must specially be taken to avoid including a piece of the colon in the ligature that secures the ovarian artery, for owing to the very close proximity of the sigmoid to the left broad ligament this danger is 608 GYNAECOLOGICAL SURGERY a very definite one. It may, however, be avoided by deliberately incising the peritoneal frsenum that unites the colon to the ligament, before applying the ligature. 4. Strangulation by bands. — As a result of inflam- matory processes in the abdomen or pelvis, bands may form, attached to different structures, and the intestine, slipping underneath, may become strangulated. In other cases the omentum becomes adherent in the pelvis and exercises injurious traction on the transverse colon. Where the ovarico-pelvic ligament is thickened and shortened as the result of chronic inflammation, ligatures applied to it may so shorten this structure as to pull upon the sigmoid mesocolon at the brim of the pelvis and kink the bowel. Lastly, appendices epiploicae are peculiarly liable to contract adhesions, thus anchoring a loop of the colon in the pelvis by a narrow pedicle around which the bowel may rotate and strangulate. In themselves the conditions mentioned are compar- atively rarely the determining cause of the obstruction ; it is the supervention on them of flatulent distension which as a rule actually produces the kink. Onset and signs. — -These may supervene at any time from the second day onwards. In most cases they declare themselves by the end of the week, but we have known instances in which obstruction was delayed for over a year. The time when the obstruction declares itself depends entirely on the cause. If a knuckle of intestine is included in a pedicle-ligature, the symptoms supervene early. Those cases that occur after many months are due to contraction of bands. If a piece of bowel becomes adherent to a stump or pedicle, it will be eight or ten days, perhaps, before any alarming symptoms arise. Symptoms and diagnosis — Intestinal obstruction has to be diagnosed from peritonitis and paresis of the bowel. The distinction is so important that it is necessary to consider it in detail under the following heads : — 1. Pain. — The pain of intestinal obstruction is an POSTOPERATIVE COMPLICATIONS 609 intermittent colic of great intensity, which is excited by taking food into the stomach or by abdominal palpation. When the obstruction is situated, as it most often is, in the pelvic colon, the patient when describing the course of the pain correctly indicates the surface-marking of the large intestines from right to left. The pain of peritonitis is continuous, whilst in paresis of the bowel colicky pain, or the sensation of intestinal movement, is absent, though the patient may complain of a distressing feeling of dis- tension. 2. Abdomen. — -The distension of intestinal obstruction is always local to begin with, and, even when general, is more marked at one spot ; thus in sigmoid obstruction the most striking tumidity is in the left iliac region, whilst in that due to adhesion of the intestine to the abdominal wound a very characteristic swelling can be felt round this area. The abdomen is rigid, but not markedly tender, but palpation may excite movements of the bowel, accom- panied by audible borborygmi. When the obstruction has become profound, the distension is so great that the skin is shiny. In peritonitis, on the other hand, the distension is general from the first, there is marked tenderness and rigidity, but no intestinal movements can be felt or heard, nor does the distension become so extreme. In paresis of the bowel, the abdomen, though universally distended, is not painful, and there is a complete absence of intestinal movement. 3. Fever. — In intestinal obstruction, fever as a rule is absent, and towards the close the temperature may be subnormal ; whereas, in peritonitis, fever is commonly present, whilst in paresis of the bowel the temperature is normal. 4. Flatus and results of enemata. — In the early stages of intestinal obstruction some flatus is nearly always passed with the rectal tube, but the amount becomes progressively less, in spite of the increasing gaseous distension. In 2 N 6io GYNECOLOGICAL SURGERY peritonitis, flatus is not obtained by the rectal tube, whilst in paresis a copious discharge with the tube is common though none is passed naturally. When the site of obstruction is low down, as it commonly is, it may be found impossible to introduce the rectal tube more than a short distance, and enemata or large wash- outs cannot be retained. In peritonitis and paresis no such obstruction exists, and enemata are apt to be retained. 5. Vomiting. — ■ The vomiting of obstruction is truly spontaneous, and quite irrespective of the introduction of fluid into the stomach. A very characteristic feature is that the patient, after retaining all that has been given her for several hours, suddenly and without warning ejects a large quantity of fluid containing, undigested, all the food she has taken. As the case advances, the vomit becomes brown in colour, and at last in some instances definitely faecal. In peritonitis, on the other hand, the amount vomited is less in comparison, and as a rule immediately follows the reception of food into the stomach. It does not become faecal. In paresis, vomiting may be absent at first, but later on it becomes copious in quantity and brown in colour. In extreme cases it is faecal at the close. 6. Facies. — In obstruction the aspect of the patient is one of acute distress during the spasms of pain, succeeded by a period of comparative calm in their interval. In peritonitis the patient wears a look of constant agony. In paresis the face is distressed in proportion to the amount of distension, but does not bear that look of apprehension which is seen in organic obstruction. Treatment, i. Prophylactic. — It is impossible entirely to avoid the risk of intestinal obstruction after pelvic operations, but it may be diminished by attention to the following points : — One of the disadvantages which attend the use of catgut for ligatures or sutures is the risk of intestinal POSTOPERATIVE COMPLICATIONS 611 obstruction owing to its yielding, or its too rapid absorption, with the result that oozing occurs, or the edges of a peri- toneal suture-line gape and leave a raw surface. In either case the intestine is very likely to contract adhesions. We remember three cases in particular in which the patients died from this cause. Intestine and omentum are peculiarly liable to adhere to surfaces covered by a film of blood-clot, and it is impor- tant in this regard to ensure as perfect an hsemostasis as possible. Inflamed omentum is a frequent source of adhesions. It is a matter of common observation that when an abdomen has to be reopened, some months or perhaps years after an abdominal section for pelvic disease, the omentum will quite commonly be found adherent to some portion of the pelvis or pelvic organs, whereas the bowel is only rarely so. This marked tendency of the omentum to contract adhesions appears to us to be a strong argument against the routine practice of -some surgeons who tuck the free edge of the omentum down into the pelvis at the close of the operation, for where the omentum is inflamed or the pelvis the seat of peritonitis such a proceeding invites the formation of adhesions. If the omentum is inflamed or adherent, we always remove the affected portion, and at such a level that the new edge is well above the brim of the pelvis. Great care must be taken in suturing the peritoneal layer of the parietal wound, for if gaps be left in it, or the sutures prematurely give way, the intestine rapidly contracts a firm adhesion to the under-surface of the fascia or actually forces itself as an interstitial hernia between the layers of the abdo- minal wall. ii. Curative. — On the diagnosis of organic obstruction several courses are open to the surgeon. The ideal treat- ment, namely, to reopen the abdomen and relieve the obstruction, should always be adopted when the patient is in a state to bear the operation. In this connexion it 612 GYNECOLOGICAL SURGERY is to be remembered that the operation may be both difficult and lengthy from the distension, the diffuse adhe- sions which may be present, and the difficulty of identifying the collapsed portion of the bowel and the position of the obstruction. The extroversion of the distended intestines, which results from the large incision usually necessary, besides considerably increasing the shock, adds yet another difficulty to the operation, namely, that of returning the bowel and closing the wound ; in fact, this is sometimes impossible until the gas in the bowel has been aspirated. In advanced acute obstruction the mere release of the imprisoned gut is not sufficient unless the intestine be at the same time emptied of the noxious faecal matter which it contains. We think that where the obstruction, though acute, is diagnosed early, or where it is subacute or chronic in character and the patient's condition good, and where its location can be gauged with fair accuracy, and par- ticularly if it is in the small intestine, an attempt should be made to deal with the actual cause. But if the patient is very ill, the distension very great, the seat of the obstruction unknown, or its nature sur- mised to be such that it cannot be readily rectified, it is best to perform a caecostomy or colotomy, and to await a more favourable time for dealing with the origin of the trouble. With respect to these two operations, caecostomy is the one of choice because it affords a greater chance of success where the actual site of the obstruction is unknown except that it is somewhere in the large intestine. Moreover, the aperture of a caecostomy is more easily closed, either by nature or by art, after the obstruction has been overcome. Colotomy should be performed in those cases where a subsequent attempt to overcome the obstruction is not in immediate anticipation, or where this may have been attempted and has failed. In obstruction of the small intestine every effort must be made to free the involved portion of bowel, because the POSTOPERATIVE COMPLICATIONS 613 only other resource is the formation of an enteric fistula, the results of which, if a portion of jejunum is opened, are likely to be disastrous. If the existence of a slight partial obstruction be surmised and the patient be not materially ill, expectant treatment may be adopted in the hope that the bowel may right itself. Such treatment consists in witholding food or fluid by the mouth so as to minimize peristalsis, and in combining rectal feeding with the regular use every four hours of high rectal wash-outs. It is most important that, in his endeavours to avoid a second operation, the surgeon should not miss the favourable opportunity for relieving the obstruction. Paretic Obstruction The full explanation of this remarkable condition is not apparent. The occurrence is fortunately not common nowadays, owing probably to improved technique and quicker methods. It is seen almost entirely after pro- longed operations involving much manipulation of the intestines. The paralysis is usually limited to one par- ticular section of the intestine, and in the cases we have operated upon this has usually proved to be the lower end of the small intestine. Symptoms and signs. — The symptoms and signs are very similar to those of organic obstruction, but there is an absence of colicky pain and intestinal movement. The condition supervenes during the first week, with increasing distension and pulse-rapidity. There is no vomiting at first, and flatus, or even faecal matter, is brought away by the rectal tube. In spite of this, however, the distension increases, the shape of the abdomen indicating, as a rule, that it is the small intestine that is becoming distended. Vomiting occurs, first in small quantities, but later copi- ously, the ejecta being a dark-brown, sour-smelling fluid. At the close it may be actually faecal. In some cases the symptoms of acute dilatation of the stomach eventually supervene. Judging from those cases we have operated 614 GYNECOLOGICAL SURGERY upon, the condition is as follows : The paralysed portion of the intestine is collapsed and shrunken ; above this is a section greatly distended with gas but containing no fluid contents, while the yet more proximal portion of the gut (the jejunum in most cases) is distended with brown, sour- smelling or faeculent fluid identical with that vomited. It is most important to realize this condition, because incision of the lower, gas-distended portion of the intestine is quite useless, the paralysis being such that very little or no relief to the distension is afforded. Whatever the cause, there can be little doubt that the patient actually dies from the presence in the upper intestine of the bacteria-laden fluid described, and unless this can be evacuated a fatal termination is a practical certainty. Diagnosis — The diagnosis of paretic obstruction from that due to organic occlusion of the bowel has already been discussed. The distinction is often difficult, but the absence of colicky pain and intestinal movements in the former condition is to be remembered. Treatment, i. Prophylactic. — Care should be taken when operating not to handle the intestines more than is necessary, and particularly to avoid prolonged traction on the mesenteries, for the condition is probably due to injury to the splanchnic nerves contained therein. Particularly should excessive packing of swabs or gauze for the purpose of restraining the intestines be avoided. The forcing of the intestines into the upper abdominal cavity stretches the mesenteries and is liable to injure them. ii. Curative. — On the appearance of the symptoms the methods described under the heading of paretic distension (p. 587) should be vigorously applied. If this is done early the condition is usually overcome. Where they fail to reduce the distension, and particularly where brown, sour- smelling fluid is beginning to be vomited, operative inter- ference holds out the only chance. The abdominal wound should be reopened and the state of affairs explored, par- ticularly in regard to the possibility of an organic cause POSTOPERATIVE COMPLICATIONS 615 for the obstruction. In its absence the bowel should be opened after being stitched into the wound. The exact site of this will depend upon the case, but in general, and particularly where brown vomit is being ejected, it is most necessary to tap that part of the intestine which forms the reservoir containing it. It will therefore be best to open the upper part of the ileum, or even the jejunum, and insert a Paul's tube. If the operation is successful, large quantities of the brown intestinal contents will be evacuated for a day or two, and the vomiting will immediately cease. If the patient survive, normal small-intestine contents will then begin to escape, and emaciation rapidly follows. The closing of the artificial opening should be postponed as long as is safe, but eventually it must be undertaken. The best method, we think, is to resect the attached portion of gut and perform an end-to-end anastomosis. No fear need be entertained that the intestine below will not have recovered its power and that the condition will return. The measures indicated are of course severe, but we have successfully applied them when all the ordinary means of overcoming paretic distension had failed. CHAPTER XXXVI POSTOPERATIVE COMPLICATIONS (Continued) HEART-FAILURE As mentioned elsewhere, the commonest cause of death after an abdominal operation in these days is a primary cardiac failure, the autopsy disclosing no cause of death other than the condition of the heart. Many of the most serious operations have to be performed on elderly and enfeebled patients, and it is in such that the special risk of cardiac failure, quite apart from some other causative condition such as sepsis, is to be encountered. Primary car- diac failure usually occurs in persons with fatty hearts as a result of the operation imposing on the cardiac muscle a relatively too severe strain. It is just this class of patient in whom the stamina of the cardio-vascular system is so difficult to gauge. The preoperative duties of the surgeon in this connexion have already been referred to. Symptoms. — -The chief symptom is a progressively rapid heart-action, associated with an increased respiration-rate, a feeble, flapping first sound, and the gradual progress outwards of the apex-beat beyond the nipple -line, while the condition of the abdomen and the temperature negative any disaster at the operation-site. Treatment. — The sheet-anchors of the surgeon in this condition Mall be strychnine and brandy, 3 minims of the former given hypodermically every four hours, and 4 to 8 ounces daily of the latter by the mouth or rectum. Cham- pagne may also be usefully employed. Digitalis should never be given, since it not only always fails to lower the pulse-rate, but makes it irregular. As 616 POSTOPERATIVE COMPLICATIONS 617 much nourishment should be given to the patient as she is able to take. HYPERPYREXIA Temperatures above 104 F. after abdominal section are of the very gravest import, especially if the rise be con- tinuous. It usually indicates peritonitis or some profound toxaemia, and the patient is almost certain to die. Treatment. — ■ The primary cause must be treated, if possible, and for the fever itself tepid sponging, or an ice- cradle, may be tried. SEPTICAEMIA AND PYEMIA These very serious and usually fatal complications are most likely to happen in the first week, and may occur after any operation. Symptoms and signs. — The patient will present the symptoms of fever ; the temperature will be high and re- mittent, the pulse rapid, and the respirations quick. The skin may be jaundiced or covered with a scarlatinal eruption, and the bowels, which at first are constipated, will become loose. The spleen may become enlarged, and secondary inflammatory foci, such as septic pneumonia, pleurisy, pericarditis, or arthritis, may appear. The face is haggard but flushed, and the mind till the very end is exceptionally clear. There is usually a complete want of perception of the imminence of death. In pyaemia, with the above signs and symptoms, local abscesses form in the pleura, lungs, joints, or liver. Treatment. — The patient must be supported by every means as long as possible, and every attempt made to increase the natural resistance. To this end, if the causative organism is known, a vaccine may be prepared and ad- ministered. It has most chance of success in the more chronic cases, and, pending a definite bacteriological diag- nosis, antistreptococcic serum should be given in large doses. All secondary abscesses should be opened where possible. 6i8 GYNECOLOGICAL SURGERY If the wound is suppurating it must be freely opened up, irrigated and drained. TETANUS In this country postoperative tetanus is almost invari- ably due to the use of imperfectly sterilized catgut. The matter has already been discussed when dealing with that suture material. Treatment. — In such a disastrous event the patient, if not in a single ward, should be removed to one, which must be darkened, and no one except the nurse and doctor allowed to enter it. Every endeavour must be made to " keep the patient going," since if the disease lasts over four days the prognosis is much more favourable. Up to the present no medicine has been found to cure the disease. All the surgeon can do is to see that as much nourishment as possible is taken, to prescribe drugs which will relieve the spasms, and to inject antitetanic serum to neutralize the toxin. With regard to nourishment : when the spasms pre- vent the patient taking food in the ordinary way, she should be fed with a stomach-tube if possible, or with a catheter passed through the nose. Rectal feeding is unsatisfactory. For the spasms the patient may be kept under the influence of morphia ; chloral or chloroform may be administered, the latter not being without danger owing to the risk of syncope supervening on a respiratory spasm. Antitetanic serum has proved disappointing in the acute cases, though in the subacute it has met with more success, and at any rate it should always be used. An injection of 30 c.c. should be given under the skin of the abdomen, followed by one of 15 c.c. twice daily. Injections of 2*5 c.c. of the dried serum in 5 c.c. of distilled water into the frontal lobes of the brain every few days have also proved successful. In the absence of antitetanic serum, Baccelli has had success with injections of 15 minims of a 2 per cent, solution of carbolic acid three times daily till the symptoms disappear. POSTOPERATIVE COMPLICATIONS 619 PYLEPHLEBITIS Pylephlebitis is a rare cause of death after opera- tions on the pelvic organs. When it occurs, it is due to embolic extension from septic thrombosis in some of the veins of the portal area. Thus, in some cases of acute sal- pingitis, or of suppurating or gangrenous tumours, portions of the bowel, mesentery, or omentum may become involved in the process, and the infection, extending to the veins of those parts, may be the starting-point of the disaster. Symptoms. — At first nothing beyond an undue rapidity of the pulse may be noted, not explainable by the condition of the operation-area. Within forty-eight hours jaundice appears. Vomiting becomes persistent, the ejecta con- taining blood in variable quantity, and the patient rapidly sinks, coma supervening before death. The temperature is not necessarily raised. Treatment. — Continuous saline infusion into the cellular tissue may be tried (p. 579), and antitoxic serum may be administered, but we are not aware of any reported re covery after the symptoms noted have been established. PAROTITIS The cause of this complication is not surely known, though some cases may be due to oral sepsis. It probably forms part of a general sepsis, especially when bilateral. It is a remarkable fact that, whereas some years ago instances of this complication were not uncommon in our experience, for a long time we have rarely seen a case, probably owing to the improvement in the technique of aseptic surgery- It is more common where, for some reason, mouth-feeding has been prohibited. Symptoms. — The condition usually supervenes within the first three weeks, and, as a rule, only one gland is affected. The gland is swollen and tender, the temperature and the pulse-rate are raised ; the patient is unable to take her food properly, and feels very ill. Occasionally the 620 GYNECOLOGICAL SURGERY gland suppurates, and especially is this likely to occur in those patients who are cachectic and enfeebled. If suppuration takes place there is much constitutional depression with great pain. If the abscess is not opened it may burst into the auditory meatus, or on the cheek or neck ; it may track down in the tissues of the neck or ulcerate into the external carotid artery. The gland sloughs, and more or less facial paralysis may exist, and even remain permanently after the inflammatory process has subsided. Treatment. — ■ In the milder cases, painting with bella- donna and glycerine and the application of a wool pad are all that is required. When the skin becomes dusky these measures should be changed for fomentations, and cautious incisions in lines corresponding to the important vessels and nerves of this region. Plenty of stimulants and a liberal diet are necessary. If ulceration takes place into the external carotid artery it will probably be necessary to ligature the common carotid, as the oedema and swelling extend too far down the neck to render it possible to reach the external carotid through healthy tissues. THROMBOSIS OF FEMORAL VEIN This most interesting complication appears late. On referring to a considerable number of the cases, we find that in the great majority of them the symptoms de- veloped between the eleventh and thirteenth day after the operation. Symptoms and signs. — The complication is usually ushered in by fever, a sallow face, and marked malaise, the condition of the patient before this having perhaps been quite satisfactory. The leg is very tender when first swollen, and the pain usually precedes the swelling, and is variously localized, sometimes in the course of the inflamed vein, but not uncommonly on the outer side of the leg. The swelling may be limited to an enlargement of the thigh, POSTOPERATIVE COMPLICATIONS 621 which does not pit on pressure, or there may be oedema of the whole or part of the leg. After being acutely tender and painful for a few days, the leg gradually improves. A relapse may occur, and a tendency to swelling of the leg is left for many months. The most striking thing about this complication is the varied nature of the operations preceding it. Thus, we have seen it occur after abdominal hysterectomy, after vaginal hysterectomy, and after simple incision of the abdominal wall ; and we have known a left femoral thrombosis follow on the removal of a right ovarian cyst through an abdominal incision. Its occurrence after vaginal hysterectomy shows that it is not necessarily due to a spreading thrombosis of the superficial epigastric veins secondary to some infection through the cut edges of the abdominal wound, for, though this may be one channel of infection, it is evident from its occurrence without an abdominal wound that there must be others. There is no direct communication between the veins in the broad ligaments and the external iliac vein, and, even if there were, it would not explain left thrombosis after right ovari- otomy. That it has followed on simple abdominal incision without interference with the pelvic organs is remarkable. Again, it is nearly always the left leg which is affected, though the right, or both, may suffer. In some cases the popliteal or deep tibial veins would appear to be primarily thrombosed. In these cases the infecting agent must have travelled against both venous-blood and lymph-stream. The whole subject is involved in mystery, and it well merits careful investigation. It appears to us that the balance of evidence is in favour of a general systemic infection with a local spot of " least resistance." It is more especially liable to occur in anaemic women. Treatment. — The leg must be kept absolutely at rest ; it should be elevated by placing the foot on a pillow, and kept fixed by sand-bags, a cradle being used to keep off the pressure of the bedclothes. Locally, glycerine and belladonna may be applied with or without superimposed 622 GYNECOLOGICAL SURGERY hot fomentations, after which the leg should be firmly but gently bandaged. A high temperature must be treated with quinine or sponging, if necessary, and the pain may be so severe that morphia is required for its alleviation. There is always a danger of the clot becoming displaced, with resulting pulmonary embolism, and the patient must therefore be warned to keep her leg still. The leg must not be lowered until all pain and fever and most of the swelling have disappeared ; it should then be firmly bandaged. EMBOLISM OF THE FEMORAL ARTERY We have seen one case following hysterectomy. On the eighth day the left leg became suddenly white and cold ; a week after the right leg was similarly affected. A line of demarcation formed in the middle of the thighs three days later, and gangrene began two days after that. The com- plication was presumably due to septic endocarditis. THROMBOSIS OF THE INFERIOR VENA CAVA We have seen two examples following hysterectomy. The first patient died suddenly after three days fever. The cava and ovarian veins were thrombosed. In the second the symptoms were slower with oedema of both legs, a peculiar bronzing of the skin and, later, vomiting. The cava con- tained organised clot, and eighteen inches of ileum were gan- grenous from thrombosis of mesenteric veins. ACUTE DILATATION OF THE STOMACH This is a very rare complication. Of 44 cases collected by Campbell Thomson in his book on the subject, no less than 12 were associated with surgical operations, but of these 12 only 4 followed an abdominal section. In severe cases, acute dilatation of the stomach is one of the most dangerous complications. The symptoms are usually sudden. The patient com- POSTOPERATIVE COMPLICATIONS 623 plains of discomfort and fullness in the abdomen, the tem- perature falls, the pulse-rate rises, the urine becomes scanty or suppressed, and death occurs in a few hours. An examination of the abdomen shows that it is distended, and a sense of fluctuation and a succussion splash may often be obtained. The onset is soon followed by the vomiting of large quantities of a fluid of a greenish colour. Usually the condition is primarily a paralytic one, due probably, as Campbell Thomson says, to the circulation of poisons derived from the alimentary canal or some acute infection. It may, as we have pointed out, be the terminal result of paretic obstruction. With regard to treatment, rectal feeding should be ordered, and the stomach-tube should be passed at regular intervals and the contents of the stomach drawn off. Strychnine should be given hypodermically. We have had one example of this complication. It followed the removal of a double pyo-salpinx, in the wall of which Dr. Taylor, the obstetrical registrar, found the gonococcus. The operation was a very difficult one, and pus escaped during the necessary manoeuvres. The patient seemed to progress quite satisfactorily for two days, when she was suddenly seized with acute abdominal pain, due to what she described as "a fullness of the stomach." An examination showed the abdomen to be very distended but not tender, and the stomach very dilated. The temperature was just above normal, the pulse considerably faster than the temperature warranted. In a few hours the patient had vomited nine pints of a greenish fluid. The stomach-tube was used and three pints of this fluid was drawn off. For a few days the stomach-tube was used every four hours, the amount withdrawn being gradually less, and the distension subsiding, till at length the stomach became normal. Strych- nine was also given. Unfortunately, as the patient was convalescing, bronchitis supervened and terminated fatally. At the post-mortem examination the stomach was found the natural size, and there was no peritonitis. 624 GYNECOLOGICAL SURGERY HICCOUGH Hiccough may be due to some inflammatory condition of the abdomen, such as peritonitis, appendicitis, or intes- tinal obstruction. It may be due to gastritis, flatulent dyspepsia, or an overloaded stomach ; or it may be an indication of some general disease, such as diabetes or chronic nephritis. It occasionally complicates cardiac fail- ure, pneumonia, and pleurisy ; whilst sometimes it is present with cerebral tumour. Often no cause can be discovered. In the old days the occurrence of hiccough was con- sidered to be of the gravest import. Probably it gained this sinister reputation from the fact that it not infrequently accompanies general peritonitis. We have, however, fre- quently seen it more or less marked, quite apart from any grave abdominal complication, and it is generally in these cases due to some gastric disturbance. In one case we remember hiccough continuing for three days and nights before it was relieved. Treatment — ■ Many remedies may have to be tried before relief is obtained. Among these we may mention warm applications to the abdomen, freezing the skin in the epigastric region, or along the neck in the course of the phrenic nerve, with the ether spray. Holding the breath, strong traction on the tongue, taking a little snuff to induce sneezing, are remedies which at times are suc- cessful. Drinking water from a glass with the mouth applied to the distal part of its circumference, thus necessi- tating flexion of the trunk, will at times succeed where other measures have failed. Of drugs, aromatic spirits of ammonia, a little neat brandy, morphia, nitro-glycerine, ergot, or turpentine may be prescribed ; and Foot cured a boy, who hiccoughed on an average 840 times an hour for twenty-six weeks (except when asleep), with a pill of iodo- form, extract of Indian hemp, and extract of hemlock. If hiccough is due to gastric disturbance, the stomach may be washed out or an emetic given if other remedies fail. POSTOPERATIVE COMPLICATIONS 625 HEMORRHAGE FROM THE STOMACH Slight degrees of haematemesis not infrequently occur after abdominal section for pelvic disease. The vomit resembles coffee-grounds in colour and appearance, and the blood is probably due to capillary oozing from the con- gested stomach-wall. No particular treatment is required for this (see p. 584). Occasionally severe haemorrhage may occur, which in some cases is certainly due to ulceration of the stomach, for gastric ulcers have been found post-mortem. In a good number of cases on record a perfora- tion of the ulcer has occurred. Both these complications in a patient suffering from gastric ulcer are probably brought about either by (a) congestion of the stomach-wall produced by the anaesthetic ; (b) the effort of vomiting ; or (c) the flatulent gastric distension that so often occurs after abdo- minal section. Treatment. — The treatment is that of haemorrhage from or perforation of a gastric ulcer in circumstances un- connected with abdominal section. HEMORRHAGE FROM THE BOWEL The passage of blood from the bowel after abdominal section is a rare occurrence. When it occurs it is due either to some local injury of the bowel, gangrene of the bowel, ulcerative colitis, or an ulcer of the duodenum or stomach. The subject of operative injury to the bowel has already been dealt with (p. 545). Of ulcerative haemorrhagic colitis we have met with one example. The symptoms came on some days after the operation, and were those of a foul- smelling diarrhoea, mixed with increasing quantities of blood and sloughs, which no treatment alleviated. At the post-mortem examination the whole of the large intestine was found to be the seat of deep multiple ulceration. Should we encounter another case of this description we should perform caecostomy. The treatment of gastric ulcer has been discussed. Should a duodenal ulcer be 2 o 626 GYNAECOLOGICAL SURGERY diagnosed, a gastro-enterostomy should be performed if the patient is in a fit state to bear it. The subject of gan- grene of the bowel demands a separate section. GANGRENE OF THE BOWEL It sometimes happens that in the course of an opera- tion a portion of the mesentery may be so damaged that the blood-supply to a certain length of the bowel is interfered with. This is much more likely to happen when the mesentery of the small intestine is injured, because the vascular anastomosis there is much less free than in the case of the mesocolon. It is also liable to occur at the point where an end-to-end anastomosis has been performed. The symptoms are those of progressive disten- sion and peritonitis, and in some cases its presence is made clear by the passage of large quantities of blood per anum. Treatment. — ■ The surgeon should be careful, when resecting intestine, not to interfere with the mesenteric blood-supply of the cut ends. Also, when intramesenteric tumours have been removed, the corresponding portion of the bowel must be closely inspected for that purplish hue which indicates that its blood-supply is interfered with, in which case it must be resected. If, subsequently to the operation, the surgeon diagnoses gangrene of the bowel, and on opening the abdomen finds his diagnosis correct, he must either resect the gangrenous portion and perform an anastomosis, or bring the whole coil outside, cut off the gangrenous portion, and stitch the open ends into the wound. CONSTIPATION Almost all patients after abdominal section have more or less constipational trouble. This is probably due to the altered relations of the parts, the altered pressure con- ditions obtained in the abdomen, the reclining posture, and the deviation from the natural diet. During con- valescence it thus happens that patients who never before POSTOPERATIVE COMPLICATIONS 627 had any trouble with their bowels are now the subjects of constipation. Treatment. — Constipation in the first week is best re- lieved by an enema of soap-and-water ; after this a daily action may be secured by such purgatives as the patient is usually accustomed to take. In obstinate cases the following prescription will be found very serviceable : — J£ Ext. cascar. sagrad. liq. 5*- Mag. sulph. 5L Tinct. hyoscyami 5 SS - Aq. menth. pip. ad 51. Dose, two teaspoonfuls to two tablespoonfuls. When there is the slightest suspicion that there exists some interference with the free action of the bowel by kinking, pres- sure, or any other cause of intestinal obstruction, no purga- tives by the mouth should be administered. In such cases we know of nothing better than large injections of from 16 to 20 ounces of warm olive oil slowly introduced high up into the bowel by a long rectal tube and retained as long as possible. DIARRHOEA Diarrhoea after abdominal section is not a common complication, and when it occurs is of bad omen. Causes. — Diarrhoea may be due to the following causes : — i. Intestinal obstruction. — When the large intestine is partially obstructed, especially in its pelvic course, diarrhoea frequently occurs, due to the stercoral colitis set up above the seat of stricture. This sign is a very important one, and its significance is apt to be overlooked. The motions passed, always liquid, are small in amount, though the actions are frequent. In deciding whether the diarrhoea is due to obstruction, the surgeon must take into account the relation borne by the amount of material passed per anum to that taken per os, together with the presence or absence of those other signs of intestinal obstruc- tion which will be found detailed at p. 608. 628 GYNECOLOGICAL SURGERY ii. Pelvic inflammation. —When the pelvic colon is surrounded by an inflammatory mass, such as occurs in pelvic peritonitis or cellulitis following an operation, diarrhoea frequently occurs, and the supervention of this complication, accompanied by temperature and pelvic pain, should lead one to make a vaginal examination. iii. Acute ulcerative colitis. — See p. 625. iv. Sepsis.- — -Persons dying from generalized sepsis usually exhibit more or less diarrhoea ; the motions are almost unconsciously passed, although the intellect appears active. It is a sure sign of impending death. INJURIES RESULTING FROM RECTAL INJECTIONS The following injuries may result from rectal injec- tions : — 1. The injection may be too hot, and the bowel con- sequently scalded. 2. The nozzle of the Higginson's syringe, if this instru- ment is used, has been pushed through the bowel-wall and the enema delivered into the peritoneal cavity. 3. The bowel- wall may be so attenuated after separation from tumours, inflammatory masses, etc., that, though not perforated at the time, it may subsequently give way under the pressure of a large rectal injection. 4. The bowel may have been accidentally opened during an operation, and the sutures closing such openings may burst from the pressure of the rectal injection. Treatment. — The treatment of these disasters is prin- cipally prophylactic. If the nurse take sufficient care, and nothing more solid than the soft rectal tube be used, the injuries noted under 1 and 2 should not occur. In cases where the bowel has been damaged, rectal injections should be avoided, except under great necessity. If the bowel has been ruptured, the proper course to pursue is immediately to open the abdominal wound, suture the rent if possible, wash out the pelvic cavity, and drain with the patient in the sitting posture. CHAPTER XXXVII POSTOPERATIVE COMPLICATIONS (Continued) COMPLICATIONS IN THE ABDOMINAL WOUND The complications that may occur in the abdominal wound are hematoma, abscess, sloughing, sinus, faecal fistula, bursting, scar-hernia, emphysema, etc. HEMATOMA This condition is very likely to arise if trouble is not taken to stop any sharp oozing at the skin-edge or from the subcutaneous tissues. Also, when suturing the fascial or skin-layer, a vessel may be pricked with the needle, and, escaping notice at the time, give rise to a haematoma. Haematoma of the abdominal wound is generally discovered when the skin-stitches are removed at the end of a week, but since an irregular temperature, as a rule, accompanies this condition, it should be detected sooner. The best treatment is to open up the cavity and scrape out the clot, and, if the cavity be small, to powder it thickly with aristol and let it granulate up, which it does rapidly when kept dry. If the cavity be large, it had better be closed anew with silkworm-gut sutures. Abscess Abscess of the abdominal wound may be due to the insertion of an infected suture, or to infection of the wound from the organisms in the patient's skin or abdominal cavity, or to want of surgical cleanliness of the surgeon's or his assistants' hands, or to a haematoma which has sub- sequently become invaded by organisms. The abscess may declare itself any time from a few days following the 629 630 GYNECOLOGICAL SURGERY operation to (in the case of some stitch-abscesses) months afterwards. Abscess most commonly affects one of the interrupted sutures of the fascial layer, and we believe that the usual route of infection is along the track formed by the sutures uniting the skin. We think that this complication will be seen less often if Michel's clips are used. Fever with nothing to account for it should always awaken suspicion of sup- puration round a buried suture. The pulse may increase a little in rapidity, pain in the neighbourhood of the wound will be complained of, and if this be examined an indurated or fluctuating swelling will be felt. When the suppuration affects the continuous suture used for the peritoneum it causes much trouble, for there is a diffuse deep-seated induration along the whole length of the wound and multiple sinuses are formed. Treatment. — The pus must be let out as soon as it is detected, and if it is thought to be due to a stitch, this should also be removed, if possible. In most cases the suppuration takes place just beneath the skin, and slightly opening the wound will allow the pus to escape, after which the cavity should be packed with gauze and the wound allowed to granulate up. The most troublesome cases are those of deep-seated suppuration along the suture uniting the peritoneum, especially in fat patients. In such circumstances the pus does not readily come to the surface, the area of induration is diffuse, and in many cases a degree of local peritonitis is present as well, with symptoms of a certain amount of interference with the intestine. Such a condition may at first be temporized with, hot fomentations being applied meanwhile in the hope that the inflammatory effusion may subside. In the event of incision being necessary, the greatest care should be taken, for omentum always, and intestine commonly, will be found densely adherent to the parietal wound. POSTOPERATIVE COMPLICATIONS 631 Where extensive stitch-suppuration has occurred there is a risk of subsequent ventral hernia, and the patient should be made to wear an abdominal belt for a year or two. Sloughing of the Abdominal Wound In operations of a prolonged nature the cut edges of the abdominal parietes become seriously bruised from traction with instruments or fingers. The resisting power of these parts is therefore markedly lowered, and con- sequently they are very liable to infection. In such cir- cumstances more or less sloughing of the wound may occur. This complication is particularly likely to arise in patients whose resisting power has been diminished by the cachexia of cancer or the debility of old age. Symptoms and signs. — Owing to the severe nature of the operation in these cases, it must be expected that the patient's pulse and temperature will be raised, but with this complication the temperature will be higher and more irregular than the mere operation gives warrant for. Pain in the wound may be complained of, and the wound, when examined, may be found to be tender, red, and swollen. In other cases, however, the skin looks normal in spite of the serious condition of the underlying tissues. In a few days it breaks down along its whole length and a fearfully offensive discharge flows from it. The fascial and muscular edges may be found in a state of black sphacelus. It will take weeks for such a wound to granu- late up, which it will not do till every buried suture is discharged. Treatment. — • In all operations performed in the cir- cumstances and under the conditions just detailed, the edges of the wound must be dragged on as little as possible and the operation must be performed as speedily as its nature permits of. The plan, devised by us and described on p. 379, of covering the wound-edges with sheet rubber, is the best method of preventing this complication. If sloughing has taken place the wound must be opened up 632 GYNAECOLOGICAL SURGERY and peroxide of hydrogen, 10 volumes, should be used to irrigate it frequently. Gauze soaked in the same drug will be found the most useful dressing until the necrosed tissue has separated. Fomentations may then be applied for a few days, and when the area is clean it should be kept covered with lint smeared with boric-acid ointment. When granulation is fairly established, dry dressings and insuffla- tion with aristol should be substituted. If the abdominal wound has suppurated or sloughed, it will be found to heal better if the separated edges are drawn together as much as possible. This cannot be done satisfactorily by means of strapping applied right across the wound, for the pus fouls it and necessitates its frequent replacement, a process which very soon sets up an ecze- matous condition of the skin. The object in view may be accomplished quite satisfactorily by sewing a tape \ in. in breadth to a piece of strapping 5 in. long by 1 in. broad, the end to which the tape is sewn having been previously overfolded for at least an inch. Two or three such pieces of strapping, as may be required, are prepared for each side. The strapping is then fixed so that the end to which the tape is attached lies at least 1 in. from the edge of the wound. After the wound has been dressed, each tape is drawn taut and tied to the corresponding tape on the opposite side, the edges of the wound being thus approximated (Fig. 386). The scar which results after this complication is always a weak one, and the patient must wear an abdominal belt Abdominal Sinus Sinuses can be roughly divided into four classes : — 1. Superficial, due to infection of fascial sutures. These are usually single, but on occasion a series may occur, which may trouble the patient for three or four years. 2. Those connected with suppuration along the con- tinuous peritoneal suture. These are multiple, and can be made to communicate with each other by a probe. POSTOPERATIVE COMPLICATIONS 633 3. Those connected with the ligatures of pedicles in the pelvis. These are characterized by their great length, and are of a very intractable character. They are usually single, and affect the lower end of the wound. 4. Those occurring along the site of an old drain-track, and dependent on some area of necrosed tissue or chronic suppurating surface, such as an imperfectly removed pyo- Fig. 386. — Method of applying strapping to a suppurating wound. salpinx. They not infrequently mark the site of an old faecal fistula. Treatment. — In the first variety it is sometimes easy to pass down a director, feel the suture, and then, after cutting it with a pair of scissors, remove it. At other times, although it can be felt, it is very difficult to remove. One of the best instruments for the purpose is a crochet- hook, and it is surprising how successful this little instru- ment may be after other methods have failed. Lastly, in many cases the ligature or suture cannot be felt at all. In these cases, unless the condition is causing much distress, the patient should be advised to wait at least a year for natural separation. 634 GYNECOLOGICAL SURGERY In the second variety, the length of the suture involved renders its removal difficult unless the whole length of the wound be opened up, though on occasions it is pos- sible to pull it up with a crochet-hook or forceps intro- duced through one of the sinuses. It is better in most cases to wait a while before opening up the wound, because this is an operation involving a certain amount of danger. In the third case, if the ligature cannot be pulled up with the crochet-hook, it is better to counsel patience, in the hope that it will spontaneously separate, which it invariably does after a considerable time (perhaps some years). Exceptionally it may be justifiable to cut down upon it. This is often an operation attended by great difficulty and distinct dangers, and should be avoided if possible. In the fourth case there is, as a rule, no definite exciting cause of the suppuration which is removable by opera- tion. It should therefore be let alone, especially in those cases where a faecal fistula has previously existed, as there would be a great danger of reopening the intestine, and in any event the operation is most unlikely to be successful. Fistula of the Large Intestine Cause. — The large intestine may be torn when separating it from a tumour to which it is adherent. If the tear be not recognized, faecal extravasation takes place, and, if the patient survives, a faecal fistula results. Faecal fistulae are more commonly due to sloughing of a portion of the intestinal wall which has been damaged, but not opened, at the time of the operation. An attenuated rectal wall has ruptured as the result of saline injection into the bowel. Lastly, if the rent in the wall has been detected and sewn up, a fistula may appear later from the stitches giving way. The majority of faecal fistulae occur after operations POSTOPERATIVE COMPLICATIONS 635 for pyo-salpinx or tubo-ovarian abscess where the gut was extremely adherent. Treatment. — As a rule, faecal fistulae close spontaneously in a week or two, although they may be as long as twelve months or more in doing so. Beyond keeping the parts clean, no treatment is indicated. Before any operative attempt is made to close the fistula it should be given at least twelve months to heal. It is our experience that, no matter how desperate the case appears to be, the patient almost invariably recovers who has faecal fistula. Fistula of the Small Intestine Fistulae of the small intestine are not nearly so common as those of the large, because this portion of the gut is much less commonly adherent to pelvic tumours. On the other hand, it is more often adherent to old abdominal scars, the reopening of which may damage it. A fistula of the small intestine is a more serious matter than one of the large, because there is not the same tendency to spontaneous closure ; the contents are liquid and very irritating to the skin ; and, lastly, if the fistula affects the upper portion of the small intestine, a progressive emacia- tion results. Treatment. — If a wound is discovered at the operation, it must be carefully sewn up. If a fistula forms, an attempt must be made to close it as soon as the patient's condition warrants such a procedure. Three courses are open to the surgeon. The first is to reopen the wound, separate and resect the involved coil of intestine, and perform an end-to-end anastomosis. The second course is to form a lateral anastomosis between the proximal and distal portions of the involved coil through a separate ab- dominal incision. Thirdly, if the fistula is very small, the edges of the fistula may be rawed and the wound closed by sutures. In most instances the first course is the best. 636 GYNECOLOGICAL SURGERY Bursting Cause. — In former days, when the abdominal wound was closed with one layer of sutures, it occasionally happened that during a severe fit of retching, vomiting, or coughing the wound gave way and the intestines protruded. Now- adays, with the method of uniting the abdominal wound in three layers, this accident is much rarer, but it still occasionally happens, though, as a rule, only a limited portion of the wound gives way. Symptoms and signs. — Where the entire wound has burst, the patient is seized with a sudden sharp pain, complains of something having given way, and shows signs of collapse. In partial bursting no complaint may be made at first, though later increasing rapidity of the pulse and pain in the region of the wound will be noticed. A valuable sign indicating this disaster is the sudden appear- ance of blood soaking through the dressings over the lower end of the wound at a period when ordinary postoperative oozing should have ceased. On lifting up the bandage, more or less of the intestine is found protruding through the separated edges of the abdominal incision. If the accident is discovered early, the gut merely looks dry and is patchily covered with yellowish lymph. If it has been long protruded, definite peritonitis will be present. When tier sutures have been employed it sometimes happens that the burst does not affect the skin-layer. In such a case the diagnosis must be founded upon the discovery of a resonant tumidity along the area of the wound, or, in the absence of this, bursting may be suspected where, the patient's condition being unsatisfactory, and unusual pain in the wound being complained of, a steady trickle of blood, or a copious discharge of serum, is found to be escaping between the skin-sutures. The possibility of this accident should always be borne in mind, since in most of the cases with which we are acquainted its occurrence was at first overlooked. POSTOPERATIVE COMPLICATIONS 637 Prognosis. — -The patient generally recovers ; rarely acute general peritonitis supervenes with a fatal result. Treatment. — The patient should be anaesthetized, and the protruding intestines, having been carefully cleaned with warm sterile saline solution, should be replaced and the wound closed with every aseptic precaution. Scar-Hernia Scar-hernia has become a less common complication than it was before the method of closing the abdominal cavity with three layers of suture came into use. There can be no doubt that the strength of a median abdominal scar depends entirely on the proper union of the fascia. Scar-hernias occur with increasing frequency towards the pubis ; they are very rare above the umbilicus. This is due to the fact that the pressure on the anterior abdominal wall increases from above downwards owing to the weight of the intestines. Thinning of the abdominal wall is also a potent factor, but it must be combined with increased abdominal pressure, for very firm scars are often obtained in patients with attenuated parietes. It is sometimes remarked that scar-hernias more frequently affect medium- sized wounds than very large ones, and this is doubtless due to the fact that the large incision has been necessary to remove a large tumour, with the result that the abdominal tension is very low during the healing of the scar. Increased abdominal tension is found with obesity, flatulence, chronic cough, or pregnancy, and where one of these conditions exists before an abdominal section, it will predispose to the formation of a scar-hernia. Causes. — Scar-hernia may be due to either of the following causes : — 1. One or more sutures may become loose shortly after the operation owing to the knots giving way, the suture tearing out or breaking, or, if of catgut, being absorbed too soon. The occurrence of such a hernia is soon manifest as a swelling under the skin, resonant on percussion. 638 GYNAECOLOGICAL SURGERY 2. Suppuration may take place round one or more stitches soon after the operation, in which case the fascia in their neighbourhood, not having had time to unite, may separate. Again, the whole wound may suppurate, and the fascial edges throughout its whole length separate, the abdominal contents, after the skin has given way, being covered merely by the underlying peritoneum. Such wounds take many weeks to cicatrize, and always leave an extremely weak and papery scar. 3. A large number of cases of scar-hernia occur at the site of a drain-track, especially when this is situated, as it usually is, at the lower end of the wound. 4. The scar may give way many months after an opera- tion, owing to the rapid abdominal distension associated with pregnancy or ascites. 5. As we have pointed out elsewhere, women who have had an abdominal section should not undertake any duties necessitating heavy strain for several months, as this is liable to cause the scar to stretch. It is among the poor, to whom this advice is more or less a counsel of perfection, that scar-hernias are most common. 6. There can be no doubt that the ill-fitting corsets worn by women of the lower classes, which leave the hypogastrium destitute of all support, force the intestine downwards and raise the pressure at the lower point of the scar. Prophylaxis. — The more careful the surgeon is when suturing the abdominal wound, and the more perfect his asepsis, the less risk will there be of a scar -hernia. The fascial layer should be closed with interrupted sutures, because a continuous suture has the great disadvantage that if any part of it gives way the whole is useless. Silk is to be preferred to catgut for suturing, because the latter is absorbed and its knot is less secure. The sutures should be sufficiently numerous to leave no button-holes between them, and especially must care be taken to ensure that muscle does not project between the fascial edges and POSTOPERATIVE COMPLICATIONS 639 interfere with their union. The silk should not be too thin, No. 4 being the proper size to use, one smaller than this increasing the liability of the suture to cut out. The question of the routine use of belts has already been discussed (p. 570). Treatment. — The anatomy of scar-hernias has an important bearing on the treatment. There are certain cases in which the hernia consists of a diffuse relaxation of the whole breadth of the abdominal wall, and no definite sac is present. The best treatment for these cases is a well-fitting belt, because of the impossibility by operative measures of securing fascial edges sufficiently thick to make a strong scar. If an operation is undertaken, one of two methods may be adopted : (a) that in which the fascial layers are overfolded, either from side to side or from above downwards ; (b) the introduction of a silver filigree as advised by Lawrie McGavin. If a sac is present it may consist of peritoneum and skin, or of skin only, according to whether the former layer has held or not. In the latter case the bowel or omentum will always be found extensively adherent. Scar- hernias with a definite sac are best treated by operation, which should be undertaken as soon as possible, because it is then much easier. In a few cases, when the patient is very feeble and the hernia very large, it is better not to operate but to use a belt. Preparation of the patient.— See pp. 82-86. Instruments. — See general list, p. 276. Operation, i. Opening the abdominal cavity. — Very special care has to be taken when opening the abdominal cavity in these cases. It must be remembered that intestine or omentum is very likely to be adherent to the sac of the hernia, and to cut right down through the skin covering it is only to court disaster. The skin-incision should begin well above the hernia, and should be carried round its lateral limit on either side to the bottom of the scar (Fig. 387). The fascia is next incised well above the 640 GYNAECOLOGICAL SURGERY site of the hernia, and the peritoneum is seized with two pairs of pressure-forceps and incised between them (Fig. 388). ii. Excision of the hernial sac. — The operator next passes his index finger through the hole made into the peritoneal cavity (Fig. 389), and, using it as a guide to Fig. 387. — Operation for ventral hernia Making the skin incision. ensure that the intestines be not wounded, divides the sac at its outer limit on one side (Fig. 390). iii. Separation of adhesions. — The sac being now raised and partially turned over, it may be seen that the omentum or intestines are adherent to it, in which case they must be separated, ligatures being applied where necessary. It is better to resect massive portions of adherent omentum POSTOPERATIVE COMPLICATIONS 641 Fig 389. — -Exploring the interior of the sac. 2 P 642 GYNECOLOGICAL SURGERY by clamping them with pressure-forceps, dividing them, and ligaturing with No. 4 silk (Fig. 391). iv. Removal of the sac. — The sac is now completely excised with scissors, after which the raw edges of the wound are trimmed (Fig. 392) until the edge of the rectus Fig. 390. — Beginning the excision of the sac. muscle on each side is clearly defined and the three layers of peritoneum, fascia, and skin are properly demarcated, v. Closing the abdominal wound. — The wound should be closed if possible in three layers, after the manner described elsewhere (p. 285). It may, however, be impos- sible to suture the peritoneum separately owing to its firm attachment to the fascia, in which case only two layers of sutures can be used, a deep interrupted layer of silk for the peritoneum and fascia, and a superficial continuous layer for the skin, unless clips are used. Where the parietes POSTOPERATIVE COMPLICATIONS 643 are very attenuated or the patient very stout, a series of through-and -through sutures should also be applied. Difficulties and dangers. — • Some operations for scar- hernia are extremely difficult owing to the dense adhesions which are present. The greatest care must be exercised, especially when beginning to in- cise the sac, lest the bowel be wounded. It should be remem- bered that inter- stitial prolonga- tions of the sac between the fascia and muscle, or fascia and skin, are often present, and bowel con- tained in them may be easily wounded whilst making the lateral incision. Before closing the wound a very careful ex- amination should be made of the underlying intes- tine, in case a hole should have been made in it. Death has followed failure to recognize such an accident. Finally, when the sac is very large, great difficulty may be found in approximating the edges of the wound, and through and-through ^sutures of strong silk, applied at least half Fig. 391. -Separating adherent omentum. 644 GYNAECOLOGICAL SURGERY an inch from them, may have to be used to sustain the tension. Emphysema of the Abdominal Wall Causes — This condition may be due to air let into the peritoneal cavity at the time of the operation being Fig. 392. — Trimming the edges of the wound. forced thence into the tissues in the neighbourhood of the abdominal incision. It may also be due to entry of atmospheric air between the skin-sutures into a cavity that has been left between the peritoneum and the fascia at the bottom of the wound ; and we have seen it occur POSTOPERATIVE COMPLICATIONS 645 where, after a wound in the bladder had been sewn up and the bladder continuously drained, the nurse had for- gotten to keep the external end of the catheter submerged in water. Lastly, it may be due to infection with the Bacillus aerogenes capsulatus. Symptoms and signs. — The patient may complain of slight pain, but, as a rule, nothing is noticed till the wound is dressed, when a swelling which crackles on pressure is seen in its neighbourhood. Prognosis. — -In the commoner forms the patient recovers in a week or two without any bad symptoms. When, how- ever, the condition is due to B. aerogenes capsulatus, the outlook is serious, the wound sloughing. Treatment. — No treatment is required, as a rule, but if there is evidence that infection has taken place, the swelling must be incised and the sloughing tissues irri- gated and dressed with a solution of peroxide of hydrogen, 10 volumes. Foreign Bodies left in the Abdomen The object most frequently left in the abdomen is a sponge or swab. This accident is more likely to happen when the operation has been performed for some sudden emergency. In similar circumstances, instruments, large pieces of gauze packing, and other things have been left behind. Needles, from their small size, are easily over- looked, while drainage-tubes have not infrequently slipped back into the abdominal cavity subsequently to the operation. A study of recorded cases shows that although the immediate risks, if the object was sterile, are not great, the final results of this accident are very grave, a large number terminating fatally. Symptoms. — The symptoms are usually those of a definitely local pain and tenderness, and a generally un- satisfactory progress, which the nature of the case does not explain. Not infrequently the real cause has been finally 646 GYNECOLOGICAL SURGERY demonstrated by the pointing of an abscess and the dis- charge of the foreign body through the abdominal or vaginal wound. In less satisfactory cases the sequestrated object has been passed by the bowel or retrieved from the bladder. Cases are on record in which such terminations have been postponed for many months or years, the patient mean- while being in continuous suffering. Treatment. — This accident will never occur if the surgeon himself takes the trouble not only to count all the swabs and instruments before and after the operation, but also to make out a list of them beforehand, which can be verified prior to the closing of the peritoneal cavity. In hospital practice it is not fair to burden the surgeon with the responsibility of actually counting the swabs and instruments, and such duties should be delegated to some responsible person such as the theatre-sister or the house-surgeon, but the surgeon at least should never forget to make inquiry concerning them before suturing up the parietal wound. Before leaving the subject there are two or three points to which we would draw attention. It is obvious that the more swabs are used the greater will be the danger of their being left behind ; the operator should therefore endeavour to work with as few as possible, and always to begin with the same number. If the operator is not having his swabs washed, he should use the original ones as long as possible by squeezing out the blood into a bowl ; and if it is necessary to open a second packet, this should contain the same number as the first. Swabs should never be cut in halves, this being one of the commonest causes of the accident under discussion. And they should never be thrown away until the operation is over and their number verified. The waste-hole of all sinks in operating-theatres should be so guarded as to render it impossible for a swab to get washed down a waste-pipe. In Caesarean section, if a hot swab is put into the cavity of the uterus to encourage retraction, and this chances to POSTOPERATIVE COMPLICATIONS 647 slip into the lower uterine segment during the suturing of the wall, it may not be missed until the swabs are counted prior to closing the abdomen, when much valuable time may be wasted in hunting for it in the peritoneal cavity. If the swab is left in the uterus it gives rise to sepsis, and the operator, having previously emptied the uterus com- pletely of placenta and membranes, may not again examine the interior of this organ, and the nature of the disaster may only be disclosed at the post-mortem. Many a swab has been left behind owing to the operator, after they had been counted, having reintroduced one as a stitch-swab to keep back the intestines while he was securing the abdominal wall. On a swab or instrument being missed, the surgeon, before he searches the abdominal cavity, should have the tumour and the basin containing it examined, lest it be attached to the one or contained in the other. In addition, the wrappings surrounding the patient, and any dirty towels that have been removed, should be carefully in- spected. The nurse at times may report that a swab is missing ; the surgeon will carefully examine the abdominal cavity and fail to discover it. A recount will show the number to be correct ; the nurse has made a mistake- In such a case the surgeon will be well advised not to scold the nurse, whatever irritation he may feel, lest on another occasion when a swab is really missing she may fear to warn him of the accident. If at some time subsequent to the operation suspicion arises that a metal instrument has been left in the abdomen, the question can be settled by examination with X-rays. COMPLICATIONS IN THE VAGINAL WOUND VAGINAL DISCHARGE Causes. — Troublesome vaginal discharge following a pelvic operation is chiefly seen after total hysterectomy, and is due to suppuration round the buried ligatures in M GYNECOLOGICAL SURGERY the operation-site. It may date from soon after the opera- tion, or may only appear after the lapse of some months. The infected ligatures gradually separate and the discharge then ceases, but the process may take some while. A very intractable form of discharge is often seen from the uterus after operations for gonorrhceal pyo-salpinx. This subject has already been referred to (p. 489). Vaginal sinuses exuding pus frequently follow the removal of suppurating tubes or ovaries by the vaginal route, and may originate in a ligature or a portion of the diseased structure that has been left behind — an accident particularly liable to follow these operations. Occasionally curettage may initiate a chronic purulent discharge, whilst the sutures used in plastic vaginal opera- tions, such as colporrhaphy, may be responsible for the same thing. Treatment. — Infected sutures after total hysterectomy may be left to separate spontaneously, as a rule, the vagina being douched twice daily with boric-acid solution. Where, however, the discharge is profuse and distressing to the patient, they should be removed. In most cases they are easily accessible, and can be felt and seen projecting from the granulation-covered scar in the vaginal vault. They can usually be removed without an anaesthetic by the aid of a speculum and a long pair of scissors and forceps. If the patient is intolerant of manipulation, an anaesthetic should be given. Chronic purulent metritis after operations for gonor- rhceal pus -tubes is a very troublesome condition. Douching should first be tried, but, if the discharge persists, thorough curettage and the application of a strong chemical anti- septic to the interior of the organ can be performed if the uterus is fairly movable. If it is fixed, or if previous curettage has failed, as it often does, and the discharge is a serious disabihty to the patient, removal of the uterus by the abdominal route is the proper treatment. A vaginal sinus following operation on the adnexa by POSTOPERATIVE COMPLICATIONS 649 posterior colpotomy had better be allowed a good chance of clearing up of itself. If it refuses, and the discharge is making the patient miserable, the condition should be dealt with by abdominal section if there is any suspicion that unremoved portions of the diseased mass are main- taining the condition. If a ligature is held to be the cause, an attempt to remove it by enlarging the vaginal sinus is admissible. Purulent discharges following minor uterine or vag- inal operations should be dealt with according to their cause — e.g. a repetition of the curettage or the removal of an irritating suture. Prolapse of a Fallopian Tube Rarely after vaginal hysterectomy the end of a Fallo- pian tube has prolapsed into the vagina through the wound in the vaginal vault, and on the wound healing has become fixed in this position. The slight hydrorrhcea which may result has led to an examination and diagnosis of granu- lation tissue or carcinoma. The condition requires no treatment. CHAPTER XXXVIII POSTOPERATIVE COMPLICATIONS (Continued) PULMONARY COMPLICATIONS After operation the following diseases of the lungs and pleura may occur, namely, bronchitis, broncho-pneumonia, lobar pneumonia, septic pneumonia, pleurisy, embolism, etc. Bronchitis This may be, and very often is, due to the ether adminis- tered at the operation, and is then known as ether-bron- chitis. It is not always due to ether, however, since it often comes on three or four days after the operation, whereas ether-bronchitis supervenes at once. When not due to ether it is in some cases possibly caused by undue exposure during the operation. In most cases the patients have already been subject to bronchitis. It is sometimes due to infection from the mouth-pieces or bags of the anaesthetic apparatus. All competent anaesthetists nowa- days wash the face-piece and ether-bag as a routine prac- tice, but where a separate bag is used for the preliminary administration of gas there is sometimes a risk that the anaesthetist may forget to wash it. Broncho-Pneumonia This is either primary or secondary to a spreading bronchitis. It is characterized by rapid breathing, cyanosis, and absence of air-entrance to the bases of the lungs, over which numerous slight rales are heard. Marked inspira- tory retraction of the lower intercostal spaces is noticed. The prognosis is bad. 650 POSTOPERATIVE COMPLICATIONS 651 Lobar Pneumonia Lobar pneumonia sometimes complicates recovery, and the classical signs and symptoms are present. The prog- nosis differs in no way from that of pneumonia in other circumstances. Septic Pneumonia This is a blood-borne infection of the lung, and is usually the result of breaking-down thrombi in some of the pelvic veins. The disease begins with rapid breathing and pleural pain, and in most cases a pleural effusion rapidly forms, at times purulent in nature. Elsewhere multiple slight dry rales are heard. At first there is no expectoration, whilst later a little rusty sputum may be coughed up. The prognosis is very bad indeed. Gangrene of the Lung This rare complication is due either to a septic embolus or to some food being inhaled as a result of vomiting under the anaesthetic. Acute Phthisis Rarely, acute phthisis will follow an operation. We have seen one such case. It is nearly always due to qui- escent disease becoming acute from the irritation of the anaesthetic . Pleurisy On examination of the records of a number of cases of postoperative pulmonary troubles, pleurisy is found to form an appreciable percentage of the total. It may be either primary, or due to extension from a lobar or septic pneumonia. Effusion may or may not occur. Pulmonary Embolism Pulmonary embolism is the most tragic disaster of all postoperative complications. It most commonly occurs 652 GYNAECOLOGICAL SURGERY from the tenth day onwards, and in most cases follows upon a convalescence which till then had been regarded as satisfactory. We have found on a careful perusal of the temperatures in these patients that in almost all cases a little unexplained fever preceded the disaster and that the pulse-rate was a little fast. It is a remarkable fact that embolism rarely follows on a definite attack of phle- bitis and thrombosis, probably because in these cases the clot is so firmly attached to the vein-wall that it cannot readily shift. The postoperative embolus is probably derived from a vein in which thrombosis has occurred from so slight a degree of inflammation as to leave the wall almost intact and the clot very loosely attached. It is this phlebitis which probably gives rise to the trifling fever and increased pulse-rate we have noted. Such slight phlebitis and throm- bosis are particularly apt to occur in patients who have been bleeding seriously for some time prior to the operation, as, for instance, in exsanguinated myoma cases. The actual catastrophe is always precipitated by some movement, such as sitting up in bed or endeavouring to rise from a chair ; it thus commonly affects patients just about to leave the hospital or nursing-home. The patient is seized with great and sudden pain in the chest, has a sensation of choking, and commences to struggle violently for breath. She quickly becomes blue in the face, unconsciousness rapidly supervenes, and respiration stops, but, though the pulse is so fast and feeble that it cannot be counted, the heart usually continues to beat for some minutes longer. When the embolus is so large that it entirely blocks the pulmonary circulation, the heart may immediately stop, in which case there is sudden pallor instead of cyanosis, and the patient may be said to die instantaneously. We have, however, seen cases in which, with sudden pain and dyspnoea, a large area of consolidation of the lung rapidly appeared ; and we regard these as examples of pulmonary embolism on a scale not incompatible with life. POSTOPERATIVE COMPLICATIONS 653 Treatment of pulmonary complications. — In bronchitis and broncho-pneumonia secondary to it, the patient should at once be placed in a steam-tent and given some such mixture as the following, which we have found very useful : — ■ jy Sodse bicarb, gr. xx. Spirit, ammon. aromat. Tl\xv. Spirit, chlorof. H\x. Aq. camph. ad gi. To be taken every four hours. The treatment of lobar pneumonia should be carried out on the recognized lines. Septic pneumonia must be treated by stimulants and aspiration of the thorax if neces- sary, and the injection of a suitable antitoxic serum or vaccine. Pleurisy and acute phthisis require the usual treatment. In pulmonary embolism the patient must be placed on her back, given stimulants such as brandy, ether, and strychnine by the mouth or hypodermically, and if breath- ing ceases artificial respiration may be performed so long as the heart continues to beat. If oxygen is available it should certainly be administered, and venesection may be tried if there is marked cyanosis. If the patient recovers, morphia should be given later to quiet the circulation. As regards prevention, aseptic operative technique is the most important. Where a patient continuously exhibits a pulse-rate and temperature slightly above the normal without any ascertainable local cause, subacute pelvic phlebitis and thrombosis should be suspected. Such patients, especially if anaemic, should be kept very quiet and not allowed to get out of bed or make any unnecessary exertion. But even with the greatest care this terrible catastrophe is not altogether to be avoided. FAT-EMBOLISM This as a complication after abdominal section is very rare, and we have never seen a case. The symptoms and 654 GYNECOLOGICAL SURGERY signs described as attending such a condition are cardiac distress and jaundice, followed by hyperesthesia of the skin on the abdomen and legs, involuntary spasms of the face-muscles, coma, and pleurisy with effusion. On the fifth day following the operation, fat appeared in the urine, and on the seventh day in the blood. The cardiac distress disappeared in forty-eight hours, and the fat from the urine on the fourteenth day. BLADDER COMPLICATIONS The following complications may occur, namely, reten- tion, painful micturition, cystitis, suppression, incontinence, fistulae. Retention Causes. — -Retention is due to inhibition of the micturi- tion centre in the lumbar region of the spinal cord, caused by the shock following severe operations, or reflexly, from the anticipation of painful micturition, especially after operations dealing with the parts in the neighbourhood of the vaginal outlet. Retention may also be due to the unaccustomed posi- tion ; and further, if the patient has been catheterized once or twice, she may, so to speak, get used to the procedure and be unable to pass water normally. In cases where it has been necessary to pack the vagina, the pressure of the tampons may be so great that the urethra is' thereby occluded. Lastly, in those operations where the bladder has to be extensively separated and its relations much altered, as in the radical abdominal operation for carcinoma of the cervix, absolute retention, as a rule, occurs for several days, and partial retention for a week or two longer. Treatment. — If retention occurs after minor opera- tions, hot fomentations to the abdomen, placing a bed-pan containing very hot water under the patient so that steam shall bathe the parts, bathing the vulva with warm water, a smart purge, or a dose of opium may succeed in different POSTOPERATIVE COMPLICATIONS 655 cases. In the event of their failure, the catheter must be used. If retention occurs after major operations, the catheter must be used at once, because a distended bladder may injuriously affect the operation-site. It is to be re- membered that a patient may be able to pass some urine naturally, and yet not empty her bladder, and that where the relations of the bladder have been much altered by the operation, it is possible to get considerable distension of the viscus without any tumour being palpable through the abdominal wall. Painful Micturition This may be due to the urine flowing over the injured parts after operations upon or in the neighbourhood of the urethra. It may also accompany perivesical inflammation either in the peritoneum or the connective tissue. Lastly, it may be due to cystitis. It is not an uncommon occurrence for pain on micturition to develop about the commence- ment of the second week after abdominal section, cystitis or pericystitis being in most cases the cause. Cystitis Two forms of cystitis may appear after abdominal section. One is common, the other rare. The common variety is an inflammation of the bladder- wall due to infection from the site of the operation with Bacillus coli communis. The patient complains of pain about the commencement of the second week, and an ex- amination of the urine shows it to be acid and to contain a little pus. Probably, at first, the mucous coat of the blad- der escapes, and so the urine is unaffected ; subsequently, when it inflames, pus appears in an acid urine. More rarely the primary infection may be staphylococcal, in which case the urine is alkaline from the first ; or, beginning as a colon infection, the cystitis may terminate as a staphylo- coccic, in which case the urine is first acid and then alkaline, 656 GYNECOLOGICAL SURGERY The less common variety is due to careless catheteriza- tion, in which case the urine soon becomes alkaline and ammoniacal. Treatment. — If the urine remains acid, salol in 15-grain doses, taken three times daily, or urotropin in 10-grain doses, acts as a specific. If the urine becomes alkaline and ammoniacal, the bladder should be washed out twice daily. The method of doing this is as follows : Six ounces of boric-acid solution (a drachm to the pint), at a temperature of ioo°, is run into the bladder by means of a soft rubber catheter with a glass funnel attached. After a short interval the fluid is allowed to escape by lowering the funnel, and this is repeated until the fluid comes away clear. For intractable cases the bladder may be washed out with a 1 per cent, solution of protargol once a day, and we have seen success follow the use of a vaccine prepared from an organism isolated from the urine. Suppression of Urine This condition is due either to ureteral obstruction or to renal shock. In obstruction, both ureters may be included in ligatures or clamps ; one ureter may be caught and the opposite kidney fail from sympathetic shock, or the ureter involved may be the only one that is functional. This accident, unless care be taken, is especially liable to occur in vaginal hysterectomy, in abdominal total hysterectomy, during the enucleation of broad-ligament tumours, and in the removal of cervical myomata. If the only functional ureter or both ureters are occkfded , no urine at all will be passed, nor will any be passed in suppression due to primary shock. In the case of sympathetic shock there is a gradual diminution in the quantity of urine passed, blood may appear, and eventually there is complete suppression These cases are due to an acute toxic degeneration of the kidney. The course of such cases is very characteristic. POSTOPERATIVE COMPLICATIONS 657 For several days there may be no symptoms at all — the so-called tolerant period ; this is followed by a condition of high mental distress and nervous irritability, in which the patient may complain of strange and terrible sensa- tions ; the pulse is much quickened though the tempera- ture may be subnormal. Finally, the patient becomes comatose and dies. Treatment. ■ — ■ The urine, after all operations in the neighbourhood of the ureters, should be examined. Clear urine shows that in all probability the ureters are intact. The quantity of urine should always be measured after such operations, although it must be remembered that the amount excreted for the first two days following an operation may be very much less than normal. Clamp forceps which have been left on the broad liga- ments in vaginal hysterectomy should be removed at the end of twenty-four hours in case they include the ureter. If the ureter is obstructed the surgeon must, of course, at once adopt such measures as the case indicates. The abdomen has been opened ten days after an operation, and the ureter freed from the ligature in which it had been included, with successful results. When the condition is due to " shock," or in the obstruc- tive cases after the ureter has been freed, the ordinary measures for suppression must be adopted. The patient should be given large draughts of water, and copious injections of saline solution by the bowel may be tried. If these methods fail to stimulate the kidney, the loins should be dry-cupped, the patient placed in a hot-air bath, and pilocarpin, gr. |, administered hypodermically every four hours. In addition, an injection of saline solu- tion into the veins or under the breasts until an improve- ment is shown may be tried. Lastly, when these measures have failed, the kidney may be exposed from the loin and nephrostomy or decap- sulation performed, according to whether the suppression is due to obstruction or renal " shock," 2Q 658 GYNAECOLOGICAL SURGERY Incontinence Incontinence of urine is most usually due to retention, but it may also be caused by a wounded bladder or an injury to the ureters. If retention is the cause, then there must have been carelessness on the part of the nurse in not recognizing or reporting the retention, and on the part of the surgeon in not making himself acquainted with the quantity of urine that was being passed. The bladder is most commonly wounded in operations on the anterior vaginal wall, such as colporrhaphy, enuclea- tion of a cyst or solid tumour, and during a vaginal or total abdominal hysterectomy. This accident should, of course, be detected at the time of the operation and the rent sewn up, but the stitches may give way, leading to incontinence a few days later. A ureter may be wounded in an abdominal or vaginal hysterectomy or other operation in its immediate neigh- bourhood in which the vagina is opened. In this case its cut end may become engrafted in the vaginal wound, and the urine will then continuously trickle out of the vagina. The same result occurs in the event of an unsuccessful uretero-vesical anastomosis. In all cases of ureteral fistula there is a great likelihood of sepsis travelling up the ureter and setting up pyelo-nephritis. Treatment. — If the incontinence is due to retention, the treatment is obvious. If to injury of the bladder, a catheter should be tied in this organ, which should then be washed out daily with a solution of boric acid. If the bladder and fistula can be kept aseptic, the latter after a while may heal ; if it does not, it must be closed in one of the ways described at p. 145. When the ureter has been divided, the treatment consists (a) in opening the abdomen, freeing the ureter, and transplanting it into the bladder (p. 540) ; (b) in attempting a plastic operation through the vagina to unite the ureter POSTOPERATIVE COMPLICATIONS 659 and bladder ; or (c) in removing the kidney. The last measure should never be performed until ample time for spontaneous closure has elapsed. Further, it is absolutely necessary to be sure that the opposite kidney is healthy. The operator, again, must be most careful, by a cystoscopic examination, to ascertain which ureter is damaged, other- wise he may have the mortification of removing the kidney which is connected with the healthy ureter. If the operator cannot obtain a cystoscope, and in any case as a control of the accuracy of the cystoscopic examination, the following plan, practised by us, will be found very useful : The suspected kidney having been exposed in the loin, 10 c.c. of a strong solution of methylene blue is injected into its pelvis with a serum syringe. The kidney is then returned within the wound, which is temporarily plugged, and the vagina is plugged with a swab. In about 15 minutes the bladder is catheterized, and the tint of the withdrawn urine is compared with that of the fluid squeezed from the vaginal swab. If the kidney exposed corresponds to the faulty ureter, the urine in the vaginal swab will be blue, while that drawn from the bladder will be normal in colour. The removal of the kidney is then proceeded with. Vesicoabdominal and Uretero-Abdominal Fistula Where the bladder or the ureter has been injured in the course of an abdominal operation and the wound has been drained, a fistulous track opening at its lower end may subsequently form, if the patient escapes the imme- diate danger of general peritonitis. _, The treatment, if the fistula is quite recent and un- associated with septic signs, would be to reopen the wound and either close the wound in the bladder or implant the ureter. Where, on the other hand, the fistula is some weeks old, or is the seat of suppuration, it had better be treated expectantly. Many fistulas so treated close spon- taneously after a while. 660 GYNAECOLOGICAL SURGERY KIDNEY COMPLICATIONS Acute Nephritis After an operation on the pelvic organs, acute nephritis may complicate the convalescence. It is in some cases, perhaps, due to the anaesthetic, in others to sepsis. The usual symptoms and signs will be present, the patient complaining of headache, dimness of vision, and nausea ; the temperature will be raised to 102 or over ; the pulse- rate will be increased ; there will be oedema of the body, more especially in the hands, face, and feet ; and an examination of the urine will disclose a large quantity of albumin, hyaline and cellular casts, while the amount of the secretion will be diminished. Treatment. — The patient must be treated on the usual lines of purgation and diaphoresis. The diet must be strictly limited to milk, and a large quantity of water should be drunk. Pyelitis, Pyelo-Nephritis Causes. — Pyelitis and pyelo-nephritis are due to an ascending infection along the ureter following cystitis, when they may be bilateral, to suppuration in the neigh- bourhood of a ureter or some damage to a ureter or to the bladder in its neighbourhood, when they are unilateral. The ureter may be ligatured or clamped during the per- formance of a straightforward hysterectomy, either abdo- minal or vaginal. It is more likely to be injured during the enucleation of a broad-ligament cyst or the removal of a broad-ligament myoma, and most likely of all during the radical operation for carcinoma of the cervix. More rarely, the ureter may be compressed by an inflammatory exudation in the broad ligament following some operation which has interfered with that structure. We have also seen a case in which the disease was due to the compression of the lower end of the ureter by blood which had oozed from some small vessel in the broad POSTOPERATIVE COMPLICATIONS 661 ligament after the removal of a broad-ligament myoma, and had then clotted round the ureter. This, as far as we know, is the only case of its kind ever reported. The presence of a ureteral fistula in most cases eventually results in pyelitis and pyelo-nephritis. Symptoms. — The patient complains of pain in the region of the affected kidney, and perhaps along the course of the ureter. This pain may be more or less continuous or colicky in nature. It is often so severe that morphia has to be administered. The general condition also denotes that fever is present. Signs. — The kidney is found to be enlarged and tender. The quantity of urine is, as a rule, diminished, and a large amount of albumin will be found in it. The degree of pyuria will depend upon whether the disease mostly affects the pelvis or the substance of the kidney. In the first case there may be sufficient pus to form a well-marked sediment in the urine-glass ; in the second case the pus may only just cloud the urine, and its presence will be determined by microscopical examination. A bacterio- logical examination usually reveals a bacilluria due to B. coli communis. Again, the amount of pus present will de- pend upon whether the ureter is compressed or not, and may vary from day to day accordingly. The temperature is, as a rule, fairly high, varying between ioi° and 103 , more especially if much pyelitis is present. If the kidney substance is more particularly affected, the temperature may keep at a lower level. The pulse-rate will be increased and the tongue dry and brown. Rigors may occur. In the case, previously referred to, due to a blood-clot, an examination under an anaesthetic revealed a hard swelling in the neighbourhood of the left ureter, about the size of an unshelled walnut, spreading upwards along the course of the ureter and giving the sensation of a thickened pipe. On cystoscopic examination the left ureteral orifice and the bladder in its neighbourhood showed great ecchy- mosis. The orifice of the ureter was also narrowed and no 662 GYNECOLOGICAL SURGERY urine was escaping from it during the examination, although some obviously did during the twenty-four hours, from the large quantity of albumin present and the condition of the left kidney. Prognosis. — The prognosis depends a good deal upon the cause. In cases of cystitis, when the bladder trouble is cured the disease of the kidney may settle down. Where the ureter has been damaged the prognosis is more grave. Treatment. — If the condition is due to a cystitis, the patient may be treated on the lines indicated at p. 655. If due to pressure from inflammatory exudation or blood- clot, time must be given for these to be absorbed. If pus forms in the broad ligament, it should be evacuated by the vaginal route and the area drained. If the pyelo-nephritis is found to be due to B. coli infec- tion, large doses of citrate and acetate of potash or sodium (gr. xxx every three hours) will sometimes quickly relieve the condition. Treatment by vaccine has often proved successful, and in one case of ours complicating pregnancy we cured the disease by washing out the renal pelvis through a ureteral catheter — a recent method of treatment that has proved successful in the hands of others. If the kidney disease becomes worse, the question of nephrectomy, or at any rate of nephrotomy, will have to be seriously considered. Before the kidney is operated upon, however, it is most essential that a cystoscopic examination should be made in order that the condition of the urine escaping from the ureters may be observed, as it is not always easy to ascertain the state of the kidney from palpation, and it may be that both kidneys are involved. Hydronephrosis, Pyo-Nephrosis Hydro-nephrosis is due to a partial blocking of the ureter from growth, ligation, or compression of inflamma- tory products. The blockage is probably not complete, but intermittent, since, if the ureter is completely clamped POSTOPERATIVE COMPLICATIONS 663 or ligated, atrophy of the kidney results. The patient complains of pain in the affected kidney and along the course of the ureter of that side ; there is an alteration in the quantity of urine, so that at one time the amount will be diminished, and at another markedly increased owing to the escape of urine from the distended kidney. If a local examination of the kidney is made after the passage of the increased quantity of urine, its size will be found to be much diminished, and the patient will suffer less pain and tenderness. As time goes on, if the condi- tion is not dealt with, the patient shows symptoms which are attributable to renal insufficiency. Pyo-nephrosis is due to the ascending infection of a hydro-nephrosis, and, in addition to the signs and symp- toms already mentioned, the patient has high fever and large quantities of pus in the urine. Treatment. — If there is reason to believe that a liga- ture has been placed round the ureter, an attempt should be made to remove it. If an inflammatory mass occupies the broad ligament, this must be drained in the hope that the ureteral condition will be relieved. Pyo-nephrosis must be met by nephrotomy and drainage, or, in the last resort, nephrectomy. Diabetic Coma We have on p. 74 noted the appropriate treatment for diabetes preparatory to operative treatment. After the operation the urine should be frequently examined for diacetic acid, a derivative of #-oxybutyric acid, and even for the latter itself, since diabetic coma is always preceded by the appearance of diacetic and /3-oxy- butyric acids in the urine. A simple test for diacetic acid is that on adding to a specimen of fresh urine a solution of chloride of iron the mixture becomes a claret colour. It must be remembered that formic, carbolic, and salicylic acids in the urine give the same reaction ; but whereas diacetic acid will not give this reaction if the urine is boiled, 664 GYNAECOLOGICAL SURGERY the other acids will. In fermented urine, on polariscopic examination, /3-oxybutyric acid is lsevorotatory. We have met with one case of diabetic coma, and this, in spite of all treatment, terminated fatally. If from the urine it is evident that diabetic coma may be imminent, the amount of bicarbonate of soda given by the mouth should be increased up to as much as 3 ounces a day, or until the urine becomes alkaline. If coma supervenes, the patient should be treated by oxygen-inhalation and intravenous injections of a drachm of bicarbonate of soda in a pint of normal saline solution or sterilized water every few hours, if the maximum dose of this drug has not already been reached. COMPLICATIONS AFTER SALINE INJECTION We have seen one case of thrombosis of the brachial vein follow intravenous injection, and two cases of submammary abscess after subcutaneous injection under the breasts. In all three cases the usual steps had been taken to render the skin-area as aseptic as time would permit. On the two occasions when the submammary abscesses formed it was interesting to note that the condition appeared to cause no discomfort until a large amount of pus had accumulated. The temperature was raised, but the com- plete absence of most symptoms caused the condition to be overlooked for some time. CHAPTER XXXIX POSTOPERATIVE COMPLICATIONS (Concluded) EMBOLISM AND THROMBOSIS OF THE SUPERIOR MESENTERIC ARTERIES These are rare complications after gynaecological opera- tions. The results depend upon the size of the vessel affected. If a small vessel is affected, the signs and symptoms will be those of ulcerative enteritis or colitis as set out at p. 625. If a large vessel is involved, the patient is des- perately ill, complaining of great pain and tenderness in the abdomen. Hgematemesis and profuse loss of blood per anum are present, and there are signs of intestinal obstruction and general peritonitis. Treatment. — The predominant symptoms must be alle- viated, but the condition is practically hopeless. INSANITY The mental balance of a woman may be disturbed after operations on her genital organs, as after operations on other parts of her body. This is not, however, peculiar to females, for males sometimes become insane after opera- tions. In fact, any shock may be responsible for this condition in a mind weak from inheritance or from some prolonged illness. In the early days of ovariotomy and salpingo-cophorec- tomy it used to be the fashion for medical men who were antagonistic to these operations to tell women that if they subjected themselves to such they would in all probability become insane ; and, in fact, such statements 665 666 GYNAECOLOGICAL SURGERY are still occasionally made by well-meaning but ill-informed persons. As we have indicated, it is not because the patient is a woman, nor because certain of her genital organs have been removed, that her mental balance is disturbed. The exciting cause is the shock of a severe operation, comparable, for instance, to the shock of child- birth, acting on an ill-balanced mind and predisposed to by anxiety concerning the approaching operation, and, in cases where the ovaries have been removed, by the succeeding menopause. The natural menopause itself is responsible for many more cases of disturbance of mental balance than any operation. When insanity follows soon after an operation, it usually takes the form of acute mania. Treatment. — ■ These patients are very difficult to treat, on account of the wound. They must be gently restrained, and two nurses must be in constant attendance day and night. Feeding is often a matter of difficulty, the patient refusing nourishment. She must be persuaded, if possible, and, this failing, the nasal tube must be used. Various drugs may be exhibited, such as sulphonal, paraldehyde, and the bromides, the first two being the most satis- factory. Opium and morphia, as a rule, are contra- indicated. Hospital patients must be removed to an asylum as soon as is convenient. Whether or not private patients,, who can afford to pay for the services of properly-trained asylum nurses, should be sent to a private asylum, is a matter for careful consideration. If they are so sent, the stigma of having been in an asylum is incurred. On the other hand, if the patient is treated at home she is apt on recovery to insist on leaving the place which is associated with such unpleasant reminiscences ; and also it must be remembered that these patients take astonishing likes and dislikes to their nurses, so that the latter may have to be frequently changed, which can only be conveniently done in an asylum. POSTOPERATIVE COMPLICATIONS 667 CEREBRAL THROMBOSIS, CEREBRAL HEMORRHAGE These complications have rarely been noticed to follow a gynaecological operation. If the condition arises during the administration of the anaesthetic, the patient does not recover consciousness after the termination of the opera- tion. On the other hand, the disease may not arise till some little time after the operation, in which case the patient, suddenly or gradually, will become unconscious. The cerebral haemorrhage may take place during severe straining or violent sickness. The usual symptoms and signs associated with the above conditions will be present, and need not be further detailed. JAUNDICE This condition sometimes occurs after abdominal sec- tion, and, as a rule, it is of serious prognosis, since it is generally the result of septicaemia or pylephlebitis (p. 619). CUTANEOUS ERUPTIONS Various urticarial manifestations may be met with after abdominal section, the commonest of which is an enema rash. This is scarlatiniform in character, is irritable, and appears first on the buttocks and the abdomen. It follows in a few hours the administration of a soap-and-water enema. Diffuse urticarial patches are sometimes found on the abdomen under the dressing, especially if this is medicated. As a result of shaving the pubes, the hair-follicles may become inflamed, giving rise to sycosis, a troublesome con- dition which may take a long time to settle down. The use of strong mercurial dressings at times provokes a regular dermatitis of the abdomen, as may the use of strong antiseptics (especially iodine) to sterilize the skin, while the adhesive strapping across the abdominal wound, especially if it is frequently removed and reapplied, may provoke 668 GYNECOLOGICAL SURGERY similar trouble (p. 634). Septic rashes when they appear are usually scarlatiniform in character, but they may be haemorrhagic. The general state of the patient will point to their nature. DRUG-POISONING In the course of gynaecological surgery it may be neces- sary to administer various drugs, internally as mixtures, pills, douches, and injections, and externally in the form of fomentations or compresses. If care is not taken when prescribing drugs in these circumstances, too strong a dose may be ordered, with the result that well-marked symptoms arise. Certain people, too, have idiosyncrasies for particular kinds of drugs, and even a small dose in them will produce symptoms and signs which may be puzzling or even alarming. Mercury. — When applied to the skin in the form of a compress, this drug may cause an erythematous rash with the formation of vesicles which at times develop into pustules. According to Malcolm Morris, mercury, when taken internally, may produce almost any kind of skin-lesion, and the effect of the drug may simulate urticaria, herpes, impetigo, or furuncle. Sometimes it produces extensive ulceration. The condition, which may last six months or more, has to be diagnosed from measles and the other eczematous fevers. If the case is one of mercurial poisoning the patient will complain of a metallic taste, soreness of the gums, nausea, and perhaps a severe colic, while an examination will show that there is a red line on the gums, the teeth may be loose, there is much salivation, the breath is very fetid, diarrhoea is present with perhaps melaena, the pulse is small and rapid, the countenance anxious, and the skin cold and clammy. Fatal cases of mercurial poisoning have occurred after an intra-uterine douche of perchloride of mercury, 1 — 2,000. Carbolic acid. — This substance will cause an erythe- POSTOPERATIVE COMPLICATIONS 669 matous rash, and if the patient is poisoned she will have headache, vomiting, the quantity of urine will be diminished and it will be dark-green or blackish in colour. Belladonna. • — ■ The rash of belladonna or atropin re- sembles that of scarlet fever. As a rule, it affects the face, neck, and trunk, and is accompanied by severe itching of the skin. In addition, the patient may complain of being very thirsty and having a very dry throat and mouth. The pupils will be dilated, and in severe cases of poisoning there will be delirium. Bromides and iodides. — A large number of people are unable to take the bromides of potassium, ammonium, or sodium without a resulting skin-eruption, which may be in the form of papules, vesicles, or pustules. The rash is acneiform, and the part affected is generally the forehead, nose, and back of shoulders. The eruptions due to the iodides resemble more or less those due to bromides. They are, however, quicker in development and more painful. Chloral hydrate. — Chloral hydrate sometimes causes a diffuse erythematous rash on the skin, especially the head and face. The rash is unattended with constitutional symptoms, and quickly fades. The taking of food and the drinking of tea or alcohol has a marked effect in increas- ing the severity of the rash. Quinine. — Quinine may cause skin-lesions of various types. Erythema, papules, vesicles, bullae, pustules, and petechias may result. The mucous membrane of the throat may be affected, and consequently the condition may be mistaken for scarlet fever. As a rule, however, there is no fever. The quinine can be detected in the urine. Some patients, as is well known, are unable to take quinine owing to severe headache or noises in the head following its administration. Opium. — Opium sometimes causes a scarlatiniform rash, and sometimes a rash resembling measles. The face and neck are the usual seats of the eruption, which is generally preceded by heat and severe itching. Medicinal doses of 670 GYNECOLOGICAL SURGERY opium may give rise to severe nausea and vomiting in some patients, and in those who are very susceptible to its influence a small dose will cause one or other of the well- known signs of opium-poisoning. Strychnine. — It is our custom, as has been mentioned, to administer strychnine twice a day some few days before a serious operation. If this treatment is followed, a careful watch must be kept to make sure that signs of strychnine- poisoning are not developing, some persons being much more susceptible to the drug than others. If the patient commences to complain of the neck and face muscles being stiff, or if the hands twitch, and the reflexes are found markedly increased, it is time to discontinue the use of the drug. MISCARRIAGE AFTER OPERATIONS The liability to miscarriage after operations on the genital organs varies markedly in different patients, and also according to the nature of the operation that has been performed. If it has been necessary to operate upon a pregnant woman and the pregnant uterus itself has not been removed, we always keep the patient under the in- fluence of morphia after the operation for at least forty- eight hours. The exact amount to be given must be judged by circumstances. The hypodermic injection of one-third of a grain may be given as soon as the patient has recovered from the anaesthetic, and subsequent doses of a quarter of a grain may be administered to keep the pupils slightly contracted, but not oftener than every six hours. If mis- carriage does occur, it must be treated on ordinary principles. In cases of premature labour, the natural efforts after full dilatation of the os must be assisted by chloroform and the use of forceps. BEDSORES Bedsores are generally the result of careless nursing, and should not occur if the back of the patient is attended to as described at p. 569. They are particularly liable to POSTOPERATIVE COMPLICATIONS 67 r occur in ill-nourished, debilitated persons, or where the parts are kept constantly wet by the incontinent flow of urine or faeces. If a bedsore should form, the conval- escence may be prolonged for many weeks. The severity of the lesions varies from a mere breaking of the skin to deep sloughing. They should be treated by relieving the pressure by means of a ring cushion or a water-bed, and by the application of zinc ointment spread on pieces of lint. If there is definite sloughing, peroxide of hydrogen should be used until the surface is healthy. The surround- ing skin must be kept scrupulously clean and dry. COMPLICATIONS DUE TO THE ANESTHETIC Posture paralysis. — As the result of faulty posture on the operation-table, or ill-adjusted retention apparatus, certain muscles of the arms or legs may become paralysed. Arm. — i. The commonest injury to the arm is due to its having been allowed to hang over the edge of the table during a prolonged operation. The musculo-spiral nerve is thus damaged, resulting in paralysis more or less complete of the muscles supplied by it. If the pressure is above the point where the branches to the triceps are given off, the patient will be unable to extend her forearm, wrist, or fingers. If the pressure is below this, the triceps escapes and the muscles at the back of the forearm are alone affected. Anaesthesia is variable in amount, but it may occur along the outer side and back of the forearm, the outer half of the back of the hand, the back of the thumb, index and middle fingers, and the outer half of the ring finger. ii. The brachial plexus may be injured by the shoulder- straps that are sometimes used to support the patient in the Trendelenburg position. As a result, all or some of the muscles of the shoulder and the upper extremity may be paralysed. The patient will be unable to use her arm, and for weeks may be unable to do her hair. Leg. — i. The crutch used for maintaining the patient in 672 GYNECOLOGICAL SURGERY the lithotomy position is sometimes responsible for injury to the peroneal nerve, owing to the pressure of the stirrup which holds the leg. This accident is due to not flexing the thigh sufficiently so as to prevent the weight of the leg from pulling against the stirrup. It is also likely to occur if the leg is not protected by a stocking. The result is foot-drop. ii. The Trendelenburg tilt may be the cause of a similar injury to the popliteal nerve if the popliteal space is com- pressed against the bottom edge of the operating-table. This accident is due to the leg being insufficiently flexed on the thigh, an accident which may occur either from the patient being too far up the table at the time the legs are first strapped to the foot-pieces, or because, although she is correctly strapped (i.e. with the leg at right angles to the thigh), the foot-pieces, being hinged, have from lack of proper clamping subsequently extended. Crushes and dislocations. — Unless great care be taken when the patient is being lowered from the tilted to the horizontal position, the hands or arms may be caught between the top of the table and the frame, resulting in severe bruising, fracture, laceration, or injury to the nerves. The shoulder may be easily dislocated when the patient is under the influence of an anaesthetic unless care be taken, when moving the arms, to avoid over-extension of the shoulder-joint. The accident is most likely to occur when the nightgown, having become soiled, is being changed while the patient is on the table before, being put back to bed. Conjunctivitis. — It occasionally happens that the surgeon, on visiting his patient the day following the opera- tion, finds the eyelids red and swollen. On examination, conjunctivitis is discovered, which is usually due either to a drop of the anaesthetic having been allowed to fall into the eye, or to the bad habit some anaesthetists have of continually touching the eyeball to ascertain the condition of the patient's reflexes. Conjunctivitis, though very pain- ful and annoying, always clears up in a few days. It POSTOPERATIVE COMPLICATIONS 673 should be treated by irrigation with boric-acid solution, cold pads to the eye, and boric ointment between the lids to prevent them sticking. Burns, i. Anaesthetic burns. — If the cheeks, lips, and nose are not covered with a thin layer of grease before chloroform is administered, they may be burnt by the drug coming in contact with the skin, and an annoying dermatitis results, disfiguring the patient for a few days. This condition is best treated by boric-acid ointment. ii. Hot-water bottles. — As we have already pointed out, hot-water bottles must be used with the greatest care, for a bad hot-water bottle burn is a disaster of the first magnitude, entailing expense and physical suffering to the patient, mental distress to the surgeon, and liability to legal proceedings against the nurse. The worst burns have been those caused on the table, due (1) to the hot-water bottle which was placed on the table to warm it having been forgotten when the patient was placed in position ; (2) to unprotected bottles having been placed against the patient's side throughout the opera- tion, or on the chest in cases of sudden heart-failure ; or (3) to contact of the patient with the unguarded metal of an operating-table intentionally heated by hot water. Very serious burns may also result from placing unprotected hot bottles against the patient in bed while she is recovering from the anaesthetic. There is nothing which it behoves the surgeon to be more careful to oversee than the use of hot-water bottles. With modern highly-trained nurses these burns are most likely to occur as the result of over-zeal in an emergency, when, in the immediate necessity for reviving a collapsed patient, the danger of using unprotected bottles is forgotten. We think that hot-water bottles should never be placed on the operating-table, nor do we see any advantage in the use of tables that are artificially warmed. A properly heated room is the best method of avoiding shock in this connexion. The proper way to apply hot-water bottles 2R 674 GYN/ECOLOGICAL SURGERY after the patient has been returned to bed is described at p. 548. The burn caused by a hot-water bottle is peculiarly destructive, owing to the length of time the heat acts and the depth to which the tissues are consequently involved. When first examined, nothing but an area varying in tint from a bright pink to a rusty purple is seen. Later on, vesicles appear, and in bad cases the whole of the affected area for a thickness of an inch or more may slough out and an extensive disfiguring scar result. Treatment. — When the burn is discovered, it should be at once covered with lint spread with boric-acid ointment. If vesication takes place the blister may be pricked. In the event of sloughing, the boric-ointment lint should be exchanged for repeated warm boric-acid fomentations until the surface has become clean, when, if small, it may be allowed to granulate up, with the aid of red lotion if necessary, but if large it should be skin- grafted. Injuries to teeth and gums. — When, during the ad- ministration of the anaesthetic, it is necessary, on account of the patient's tongue falling back and interfering with respiration, to open the mouth with a gag and pull the tongue forwards with forceps, the gag has been known to force out a tooth or lacerate the gums, and if the forceps is used for any length of time the tongue is always bruised and excoriated. As a rule, these accidents can be prevented by gentleness in manipulation. The soreness which the patient has to endure for some days must be treated with antiseptic month-washes. Chloroform introduced into the stomach. — This acci- dent can only happen with a Junker's apparatus that has been wrongly put together — i.e. when the bulb-tube occu- pies the position of the delivery-tube, the result being that, instead of chloroform vapour, the drug itself is pumped into the patient's throat. If this accident occurs the patient will probably die. POSTOPERATIVE COMPLICATIONS 675 Circulatory failure. — According to Hewitt,* this com- plication is predisposed to by (1) any impairment of general health, such as that dependent on anaemia, jaundice, renal disease, shock from injury or loss of blood, and particularly any grave respiratory or cardiac affection ; (2) profound mental disturbance ; (3) the presence of food or fluid within the stomach. It is excited by (1) embarrassed or arrested breathing ; (2) the toxic effects of the anaesthetic itself upon the cardio-vascular system ; (3) the surgical procedure ; (4) vomiting. The condition should be treated by lowering the patient's head and by the maintenance of artificial respiration. Injections of strychnine may be given and ammonia held to the nose. The heart may be directly massaged through the abdominal opening if the operation is an abdominal one, and if it is vaginal the abdomen may be opened for the purpose. Cases are on record in which the cardiac contraction was restarted by this means. If the circulatory failure is due to shock from haemor- rhage, the head should be lowered, brandy enemata given, and saline infusion performed. Respiratory failure. — Respiratory failure is due to obstruction, paralysis, or reflex inhibition. Obstruction is caused by the tongue falling back or by muscular spasm, or by foreign substances being sucked into the upper air- passages. Paralysis is due to an overdose of the anaesthetic. Reflex inhibition, causing stoppage of respiration, is spe cially liable to occur where much traction is being made on the abdominal contents, as, for instance, during the enucleation of a cervical myoma. It may also be caused /by the sudden change of posture occasioned by the assump- tion of the Trendelenburg position or the packing off the intestines with the big swab. Obstruction is treated by removal of the cause. If paralysis threatens, the complexion becoming cyanotic, the pulse small and irregular, and the pupil reflex insensitive, * " Anaesthetics and their Administration." 676 GYNECOLOGICAL SURGERY the administration should at once be stopped, the lips rubbed with a towel, and expiration assisted by pressure on the chest. If this fails, no time should be lost in applying artificial respiration and administering strychnine hypo- dermically. Oxygen, if available, should be administered. Reflex inhibition is similarly treated. The surgeon when performing manoeuvres involving much traction on the abdominal contents will be well advised to ask the anaes- thetist how the patient is bearing it, and, in the event of an unfavourable answer, to desist from his efforts until the breathing is again satisfactory, or to get over the operative difficulty in some other way. Late anaesthetic poisoning.— We have seen one case in which death was attributed to this cause. The symptoms were those of peculiar mental lethargy, broken by fits of excitement. Vomiting was persistent, and the pulse-rate progressively rose. Continuous saline infusion would appear to hold out some chance of success in this rare condition. CHAPTER XL IMMEDIATE RESULTS OF OPERATIONS ON THE FEMALE GENITAL ORGANS For the proper appreciation of the value of any statistics relating to a particular operation, one must be careful to take into consideration the class of patient dealt with and the conditions under which the operation was performed. Authors when discussing their personal experience of an operation are very apt to base their final judgment on its relative value from a consideration of the results to all the patients upon whom they have performed it, quite irrespectively of whether it was performed in a hospital or in private. Whilst it is true that in a well-appointed hospital theatre, with highly trained assistants, an opera- tion is performed in circumstances the best calculated to bring it to a successful conclusion, nevertheless this advan- tage is more than counterbalanced by the fact that a large proportion of the patients of a hospital are in a miser- ably ill-nourished and debilitated state as regards their general condition and of neglect as regards the disease for which they are admitted. The physique of private patients is, on the whole, markedly superior, and because they can command efficient medical advice they present themselves to the surgeon while the disease is in a much earlier stage. We have commented elsewhere upon the importance of recognizing this difference in the class of patient operated upon, and need not further discuss it. In this chapter we propose to deal with the immediate results of gynaecological operations and have taken for this purpose all that have been performed during the six- teen years from January, 1895, to August, 1910, inclusive, 677 678 GYNECOLOGICAL SURGERY at the Chelsea Hospital for Women, and all those of a similar nature performed during the same period at the Middlesex Hospital by ourselves and our colleagues there who are also on the staff of the Chelsea Hospital. In these statistics we have not included any cases operated upon privately, in order that the results, as already pointed out, may convey a proper impression of the relative danger of operations performed upon a similar class of patient by the same operators under similar conditions for sixteen years. One point that should perhaps be mentioned is that the patients treated at the Middlesex Hospital are some- what lower in the social scale, not so well nourished, and more often the seat of some general disease, than those treated at the Chelsea Hospital for Women, which was founded for the relief of poor gentlewomen. The Middlesex statistics, as a consequence, if taken by themselves, show a higher mortality and those of Chelsea a lower mortality than the combined mortality here given. Nevertheless, we have thought it right to include both hospitals since the work at Chelsea Hospital is by no means limited to the class for which it was founded. These statistics are, we hope, made more interesting and useful by setting out, in fatal cases, the cause of death where it was verified by post-mortem examination. In the following classification of the causes of death, " shock " has been taken to signify cases in which death took place from a few hours to three days or so after the operation, and in which the post-mortem examination dis- closed no definite cause of death. In reports, such cases are often entered up as cardiac failure, cardiac dilatation, syncope, and so forth. We have also included under " shock " those cases in which the patient was practically dying before admission, and an operation was only per- formed as a last desperate resource. It must be -particularly remembered when examining the statistics that they represent the work of eleven operators, cover- ing a period of nearly sixteen years. During that time the RESULTS-IMMEDIATE 679 surgery of the female genital organs has undergone a vast change, and while in many respects the net results of the whole sixteen years are very gratifying, the mortality from year to year during the period under discussion shows, as in all other institutions, a gradual improvement, in spite of the fact that much more formidable cases are now dealt with than formerly ; and taking the last five years the mortality is considerably lower than in the first ten, whilst in statistics more recent than these the mortality is still less. To illustrate this improvement we have added tables of the gynaecological operations performed at the Chelsea Hospital from January, 1905, to August, 1910, inclusive. We would point out further that some of our colleagues have had a series of over a hundred consecutive abdominal sections without a death, but it is our object to show what results may reasonably be expected from the work of various operators, operating under similar conditions, but with slight modifications of technique peculiar to them- selves. An average mortality-rate cannot, of course, be rigidly applied to individual cases, each of which, in view of its peculiar conditions and circumstances, is " a law unto itself." MAJOR OPERATIONS TOTAL ABDOMINAL HYSTERECTOMY Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Uncomplicated myomata .... Myomata complicated with other pelvic disease Intractable haemorrhage (fibrosis, adeno-myoma) Bilateral salpingitis .... Procidentia uteri ..... Puerperal sepsis ..... Carcinoma and sarcoma of the corpus uteri Carcinoma of the cervix uteri 51 33 8 6 1 1 45 9 154 5 1 o o o I 5 1 13 68o GYNAECOLOGICAL SURGERY Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease I Cases Deaths Uncomplicated myomata .... Myomata complicated with other pelvic disease Intractable haemorrhage (fibrosis, adeno-myoma) Bilateral salpingitis ..... Carcinoma and sarcoma of the corpus uteri . Carcinoma of the cervix uteri 12 1 27 1 3 ° 1 18 1 6 1 67 4 CAUSES OF DEATH Intestinal obstruction by an old band Postoperative haemorrhage Pulmonary embolism Organic heart-disease Shock Preoperative sepsis Peritonitis No post-mortem . 13 Remarks. — The other pelvic conditions with which the myomata were complicated were diseased appendages, ovarian cysts, and pregnancy. The cause of death in two of the cases in which no post-mortem examination was held was thought to be " shock " ; in the third, though no symptoms or signs other than heart-failure were noted, it was probably due to septic intoxication, the case being com- plicated by a perimetric abscess. In the case of puerperal sepsis the uterus was riddled with abscesses. It has not been the practice, either at the Middlesex Hospital or the Chelsea Hospital for Women, to perform total abdo- minal hysterectomy for myomata except in special circum- stances. This fact accounts for the small number of cases and the relatively high percentage-mortality. RESULTS-IMMEDIATE 681 SUBTOTAL ABDOMINAL HYSTERECTOMY Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Uncomplicated myomata .... Myomata complicated by other pelvic disease . Intractable haemorrhage (fibrosis, adeno-myoma) Salpingitis ....... Carcinoma of the corpus uteri Uterine prolapse ...... 873 360 60 43 3 4 47 15 1 2 i,343 65 Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Uncomplicated myomata .... Myomata complicated by other pelvic disease . Intractable haemorrhage (fibrosis, adeno-myoma) Salpingitis ....... Carcinoma of the corpus uteri Uterine prolapse ...... 1 97 186 37 3* 1 4 3 3 1 2 456 9 causes of death Peritonitis Pulmonary embolism Postoperative haemorrhage Intestinal obstruction Organic heart-disease Shock Broncho-pneumonia Preoperative sepsis Hyperpyrexia . Syncope Delirium tremens Thrombosis of inferior vena cava Psoas abscess Acute delirious mania No post-mortem 4 7 8 12 1 1 1 1 1 2 1 1 7 65 682 GYNAECOLOGICAL SURGERY Remarks. — The pelvic complications of the myomata included diseased appendages, simple and malignant ova- rian tumour, broad-ligament cysts, extra-uterine gestation, uterus bicornis, and diseased appendix. Among the cases of intestinal obstruction was one in which the patient died of broncho-pneumonia after a second operation had success- fully relieved the obstruction. In another case the obstruc- tion was due to the intestine becoming adherent to some blood which, on account of a suboccluding ligature, had oozed from the stump and clotted. There were two cases of that very rare condition, thrombosis of the inferior vena cava, in one of which the patient died nine weeks after the operation. The case of syncope occurred in a patient who was just ready to leave the hospital. The patient next to her in the ward suddenly became delirious and frightened her. She died almost immediately afterwards. There was no evidence of pulmonary embolism. In the cases in which no post-mortem examination was made, one patient died apparently of heart-failure eighteen days after the opera- tion ; one was most seriously ill before admission, and her death was attributed to cachexia ; two patients died with the symptoms of peritonitis ; for the remaining deaths no adequate cause could be assigned. VAGINAL HYSTERECTOMY Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Deaths Carcinoma of the corpus uteri Carcinoma of the cervix uteri Uterine prolapse ...... Intractable haemorrhage (fibrosis, adeno-myoma) Myomata ....... Pyometra ....... Uterus bicornis ...... Chorion-epithelioma ..... RESULTS-IMMEDIATE 683 Chelsea Hospital for Women, January, 1905— August, i9io, inclusive Disease Cases Deaths Carcinoma of the corpus uteri Carcinoma of the cervix uteri Uterine prolapse ...... Intractable haemorrhage (fibrosis, adeno-myoma) Pyometra ....... Uterus bicornis . . • Chorion-epithelioma ..... 4 9 5 2 1 2 1 1 1 24 CAUSES OF DEATH Peritonitis Shock Secondary growths Iodoform poisoning No post-mortem Remarks. — In the case in which no post-mortem was held the patient died with the symptoms of peritonitis. RADICAL OPERATION FOR CARCINOMA OF THE CERVIX UTERI Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Operation 1 Cases Deaths Abdominal hystero- vaginectomy (Wertheim) . Vaginal hystero-vaginectomy (Schauta) . 74 2 15 7 6 15 684 GYNECOLOGICAL SURGERY Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Operation Cases Deaths Abdominal hystero- vaginectomy (Wertheim) . 32 4 32 4 CAUSES OF DEATH Fatty degeneration of heart, liver, pancreas (shock) Atheroma of the aorta (shock) Peritonitis, empyema Postoperative haemorrhage . Intestinal obstruction Pulmonary embolism, thrombosis of common iliac vein Paretic obstruction Shock .... No post-mortem 1 1 1 1 1 1 1 1 7 15 Remarks. — Of the cases in which no post - mortem examination was held, one died of double pneumonia ; one of intestinal obstruction (due to bands of adhesion) which was relieved by a second operation, but the operation failed to save the patient ; one of bronchitis and cardiac failure ; one apparently of toxaemia, the wound sloughing ; the remaining three apparently of shock. This operation has only been performed since 1907. Most of these patients, when they are operated upon, are in a very unhealthy and debilitated condition from the dis- charge and haemorrhage, and it is not surprising therefore that the majority of the deaths are due to " shock." The intestinal obstruction was due to a part of the fascial layer opening up some days after the operation, when the patient was recovering satisfactorily, and a piece of intes- tine slipping between the fascial edges and being partially nipped. The indifferent healing properties of the abdo- RESULTS-IMMEDIATE 685 minal wound in these cases have been noted in an earlier chapter. ABDOMINAL MYOMECTOMY Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Uncomplicated myomata .... Myomata complicated by other pelvic disease 79 3i 2 4 no 6 Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Uncomplicated myomata .... Myomata complicated by other pelvic disease 22 14 2 36 2 CAUSES OF DEATH Postoperative haemorrhage Intestinal obstruction Shock .... Anaesthetic poisoning Fatty degeneration of the heart No post-mortem Remarks. — The complications associated with myomec- tomy consisted of pregnancy, diseased appendages, ovarian tumours, retroversion, and prolapse. The intestinal obstruction was due to blood-clot, and was relieved by a second operation, but the patient died subsequently of pulmonary disease. The cause of death in the case where -there was no post-mortem examination could only be diagnosed as shock. 686 GYNECOLOGICAL SURGERY OVARIOTOMY (INCLUDING BROAD-LIGAMENT CYSTS AND SOLID TUMOURS OF THE OVARY) Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Uncomplicated unilateral innocent cysts and tumours ...... Uncomplicated bilateral innocent cysts and tumours ...... Innocent cysts and tumours complicated by other pelvic disease .... Malignant ovarian cysts and tumours Cases Deaths 7i3 23 145 9 53 57 14 46 Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Uncomplicated unilateral innocent cysts and tumours ...... Uncomplicated bilateral innocent cysts and tumours ...... Innocent cysts and tumours complicated by other pelvic disease .... Malignant ovarian cysts and tumours 187 34 23 13 5 1 1 1 257 8 CAUSES OF DEATH Peritonitis . . . . . 15 Intestinal obstruction 8 Pulmonary embolism 1 Shock 5 Postoperative haemorrhage 3 Perforated gastric ulcer 1 Cerebral embolism . , . 1 Organic heart-disease 3 Cerebral haemorrhage 1 Carcinoma of pylorus 1 Bronchitis 1 Diabetic coma . • 1 No post-mortem 5 46 RESULTS-IMMEDIATE 687 Remarks. — The other conditions which complicated this operation were pregnancy, diseased appendages, and resection of intestine. It is interesting to note — and this has been pointed out by other observers — the high mortality associated with malignant ovarian disease. Two cases of intestinal obstruction were preoperative in nature and the patients were practically dying when admitted. Another death was due to a secondary growth in the rectum overlooked at the primary operation, and in a fourth case the obstruction was found to be multiple and due to old peritonitic adhesions from preoperative inflammation of the tumour. Of the cases in which no post- mortem examination was held, one patient died with the signs of pneumonia, another had general suppurative peri- tonitis and subphrenic abscess at the time of the operation, and the others died with the symptoms of shock. Comparing the results of ovariotomy with those of abdo- minal hysterectomy, it is interesting to note that over the sixteen years' period the mortality is much the same (about 5 per cent.), whilst in the last five years the death-rate of the latter operation has fallen much below that of the former. SALPINGO-OOPHORECTOMY AND SALPINGECTOMY Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Unilateral salpingitis ..... Unilateral salpingitis complicated by other pelvic disease ....... Bilateral salpingitis ..... Bilateral salpingitis complicated by other pelvic disease ....... Myomata ....... Carcinoma of Fallopian tube 377 37 333 21 1 11 1 21 1 783 34 688 GYNECOLOGICAL SURGERY Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Unilateral salpingitis ..... Unilateral salpingitis complicated by other pelvic disease ....... Bilateral salpingitis ..... Bilateral salpingitis complicated by other pelvic disease ....... 112 47 147 12 2 1 1 318 4 CAUSES OF DEATH Peritonitis ..... 21 Intestinal obstruction 2 Shock ...... 4 Postoperative haemorrhage 1 Gangrene of bowel .... 2 No post-mortem .... 4 34 Remarks. — The complicating conditions were disease of the appendix and necrotic lymphatic glands. Among the cases of peritonitis was one in which acute peritonitis was present before the patient entered the hospital. In one case in which there was no post-mortem examination the patient died with the symptoms of peri- tonitis, in two the symptoms of shock were present, and in the remaining one the patient died of peritonitis seventeen hours after the first operation, the abdomen being reopened and several pints of fluid evacuated. The intestine was probably injured, but there was no sign of this at either operation. The frequency with which, in the above table, peritonitis is the cause of death will be noticed. This is due, of course, to the fact that a large number of these cases are infected jb before the operation. RESULTS-IMMEDIATE 689 INTRAPERITONEAL SHORTENING OF THE ROUND LIGAMENTS Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases \ Deaths Retroversion ...... 64 64 Remarks. — This operation, which we have performed during the last two years, has given us satisfaction. We have used the Noble-Barrett method as described on p. 443. Twenty-seven of these sixty-four cases were operated upon at the Chelsea Hospital. VENTRO-SUSPENSION Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Uncomplicated retroversion or prolapse . Retroversion or prolapse complicated by other pelvic disease ...... 5io 197 1 2 707 3 Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Uncomplicated retroversion or prolapse . Retroversion or prolapse complicated by other pelvic disease ...... 239 139 1 378 1 2 S 690 GYNECOLOGICAL SURGERY CAUSES OF DEATH Broncho-pneumonia . Pulmonary embolism No post-mortem Remarks. — The other conditions complicating the uterine displacement have been diseased appendages, ruptured perineum, ovarian prolapse, diseased appendix, movable kidney, endometritis, and myomata. The patient on whom no post-mortem examination was held died of diabetic coma. She had no symptoms of diabetes, and the disease was only discovered after the operation. The patient progressed apparently well for a week, and then the abdominal wound sloughed, as did also the wound resulting from a colpo-perineoplasty, and on the twelfth day she suddenly became comatose and died. EXTRA-UTERINE GESTATION Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Disease Cases Deaths Tubal gestation ...... Tubal gestation complicated with other disease 223 2 Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Disease Cases Deaths Tubal gestation ...... 65 3 Tubal gestation complicated with other disease 2 1 67 RESULTS-IMMEDIATE CAUSES OF DEATH Peritonitis ..... i Pulmonary embolism i Intestinal obstruction I Shock ...... 2 Septicaemia ..... I No post-mortem .... 2 691 Remarks. — The patient who died from sepsis was suffer- ing from septicaemia on admission ; in the two cases of " shock " the patients were nearly dead from preopera- tive haemorrhage before admission ; one patient upon whom no post-mortem examination was held was suffering on admission from acute Bright's disease and died of heart -failure, and the other died of intestinal obstruction. In this last case the gestation was of four months' duration and was further complicated by an inflamed myoma the size of a grape-fruit, for which subtotal hyster- ectomy had to be performed. The operation had to be completed quickly, as towards the end the patient's con- dition became alarming. There was no time to suture the peritoneum over the stump of the cervix, and some days later intestinal obstruction slowly supervened from the gut becoming adherent to the stump ; and although this was relieved by a second operation, the patient died. CESAREAN SECTION Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Nature of operation Cases Deaths Conservative, for contracted pelvis Caesarean hysterectomy for contracted pelvis . For dermoid of the ovary .... For congenital malformation of the cervix For carcinoma of the rectum For malignant peritonitis .... 10 6 1 1 1 1 1 20 1 6g2 GYNECOLOGICAL SURGERY Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Nature of operation Cases Deaths Conservative, for contracted pelvis For congenital atresia of cervix For malignant peritoneal growth . 6 1 1 8 Remarks. — In the one fatal case the cause of death was shock. The patient, who was very stout, was admitted into hospital on the third day of obstructed labour. She was at that time in a desperate condition, and did not rally from the operation. At the post-mortem examina- tion the heart was found to be the seat of marked fatty degeneration. MINOR OPERATIONS Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Nature of operation Cases Deaths Dilatation of cervix — For sterility and dysmenorrhoea Dilatation of cervix and curetting — 498 For endometritis, retained products and bleeding 2,614 1 cancer of cervix J 55 2 Vaginal myomectomy For myomatous polyp us 32 159 1 ,, mucous Perineoplasty Colpo-perineoplasty Colporrhaphy Trachelorrhaphy . For dyspareunia and vaginisi nus 155 447 84 90 69 5° 3 1 Carried forw ard 4.353 8 RESULTS-IMMEDIATE 6 93 MINOR OPERATIONS {continued) Nature of operation Cases Deaths Brought forward . 4,353 8 Amputation of cervix ..... 24 Excision of vaginal cyst .... 14 ,, ,, „ tumour .... M ,, Bartholinian cyst 67 abscess 15 ,, „ vulva for cancer and leucoplakia . 45 ,, papilloma 11 Urethral caruncle ..... 213 Excision of urethral mucous membrane 3 Vesico-vaginal fistula .... 13 Vesico-uterine fistula 1 Recto-vaginal fistula 4 Periurethral abscess 2 Haematocolpos 4 Pyocolpos • 1 Haematometra 1 For prolapse (Wertheim) . 2 Pyometra I 4,788 8 CAUSES OF DEATH Pulmonary embolism Pyaemia .... Septicaemia Alcoholic neuritis Bronchitis and pneumonia Remarks. — In the cases of perineoplasty, one patient died of pulmonary embolism, one of alcoholic neuritis several weeks after the operation, and one of pyaemia, the source of which was not traced. The three cases of curet- ting died of bronchitis and broncho-pneumonia. That opera- tions on the perineum should have furnished one-half of the deaths following minor operations is noteworthy. This operation involves opening up a large number of veins. 694 GYNECOLOGICAL SURGERY RESULTS OF ALL MAJOR OPERATIONS Middlesex Hospital and Chelsea Hospital for Women, January, 1895 — August, 1910, inclusive Number of cases Number of deaths Mortality-rate 4,534 199 4-3 % Chelsea Hospital for Women, January, 1905 — August, 1910, inclusive Number of cases Number of deaths Mortality-rate 1,670 38 2-2 % CAUSES OF DEATH Peritonitis .... ■ 52 Shock ..... 33 Intestinal obstruction 22 Pulmonary embolism 13 Organic heart-disease 13 Postoperative haemorrhage 12 Preoperative sepsis . 3 Broncho-pneumonia 3 Thrombosis of inferior vena cava 2 Gangrene of the bowel 2 Hyperpyrexia 1 Syncope .... 1 Delirium tremens 1 Acute delirious mania 1 Secondary growths . 1 Iodoform poisoning 1 Anaesthetic poisoning 1 Perforated gastric ulcer 1 Carcinoma of the pylorus 1 Cerebral embolism . 1 Cerebral haemorrhage 1 Diabetic coma 1 Psoas abscess 1 No post-mon em 3i 199 CHAPTER XLI REMOTE RESULTS OF OPERATIONS ON THE FEMALE GENITAL ORGANS While the remote results of gynaecological surgery are often brilliant and commonly admirable, in a small minority of cases they are disappointing, and that not from any fault in the technique or failure of the patient to recover immediately from the operation with a satisfactory con- valescence. It must be remembered that the patient may be the subject of some disease in addition to that present in the pelvic organs, and that an operation, though successful as far as the pelvic condition is concerned, may not entirely alleviate all the symptoms of which she complains. It is the possibility of this failure to cure, much more than the actual risk of the operation, that at times deters the experienced surgeon from advocating strongly what he feels is the best treatment. j The surgeon, with the rest of mankind, tends to mag- nify his successes and minimize his failures. This, after all, is only human nature, and yet a report by a surgeon of his failures would often be of much more use than a whole string of striking successes. The young and enthusiastic surgeon undertakes a case in the almost certain belief of a perfect ultimate result ; and if the patient recovers, convalesces, and disappears from his notice, he accounts the case one of his successes. Work in an out-patient department for a few years will lessen such confidence. We do not mean for an instant to question the splendid work and brilliant results of surgeons at the present time, but we do wish to insist on the fact 695 696 GYNECOLOGICAL SURGERY that the mere performance of an operation, although apparently successful, is not always followed by the relief which might reasonably have been anticipated. Although, as we shall see from the reports of Arthur Giles about to be quoted, the surgeon is, in the main, justified in his contention that in the majority of cases a cure results, and in most of the remainder marked relief is obtained from very distressing symptoms, the following may be accounted as some of the failures which occasionally occur in the practice of pelvic surgery in the female : — Scar - hernia. — Hernia due to the stretching of an abdominal wound may be the cause of much suffering, and may appear first after several years. This condition has been fully referred to in Chapter xxxvu., p. 637. We think it is probable that the majority of those patients who suffer from a scar-hernia will return to the institution where the operation was performed. A few will put up with the condition, a few may seek advice elsewhere, but most will return. We find that during the last fifteen years 72 patients have been admitted to the Chelsea Hospital for Women for an operation necessi- tated by scar-hernia, and during this time 3,786 patients have recovered from an abdominal operation. Keloid of the scar. — Very rarely there may be a keloid development in the scar. We have seen one such case. The keloid is, as a rule, not very excessive, and, apart from a slight pruritus, causes no trouble. Carcinoma of the scar. — Implantation - metastases rarely occur in the abdominal wound. We have seen few cases. The condition has generally followed the removal of a malignant ovarian tumour. Pain. — Patients, after the abdomen has been opened, will at times complain of pain in an apparently healthy scar, more particularly if silkworm-gut sutures have been used ; whilst chronic abdominal pain, due to intestinal adhesions or to irritation by the ligature in the stump of the pedicle after an ovariotomy, hysterectomy, or removal RESULTS-REMOTE 697 of diseased appendages, is an occasional sequela of these operations. Constipation and flatulence. — These occasionally give rise to great discomfort, and are often due to adhesions between the intestines, omentum, and parietes. There can also be no doubt that the opening of the peritoneal cavity alters, perhaps permanently, the pressure conditions that have previously obtained there, and it is probable that the flatulence and unpleasant consciousness of intestinal peri- stalsis that affect all patients more or less for a time after abdominal operations are due to this cause. Painful micturition. — It is a well-known fact that many women who have had the catheter passed even once after an operation will complain for a long while subse- quently of pain at the end of micturition, and this quite apart from cystitis. In other cases, adhesions between the bladder and neighbouring parts or displacement of that viscus are the cause of this discomfort. Dyspareunia. — After panhysterectomy, and more espe- cially after the radical operation for cancer of the cervix, dyspareunia may occur from shrinkage or shortening of the vagina. Where extensive pelvic peritonitis has existed before the operation, or arises after it, permanently tender adhesions in the pelvis may be responsible for the same complaint. Dyspareunia may also be due to the atrophic condition of the vulva associated with stenosis of the vaginal orifice known as kraurosis vulvae, which occasionally follows re- moval of the ovaries. We have seen one such case. Retroversion of the uterus after the removal of the diseased appendages. — It sometimes happens that, some months after an operation for the removal of diseased Fallopian tubes, and more especially if the operation was of a severe nature necessitating the separation of many adhesions and the consequent formation of a raw surface in Douglas's pouch, the patient will return and state that she feels quite as bad as ever. She has pain on defalcation, 698 GYNECOLOGICAL SURGERY dysmenorrhoea, dyspareunia, backache, and perhaps inter- ference with micturition. A vaginal examination dis- closes the fact that the uterus is retroverted, tender, and fixed. This could have been obviated by ventro-suspen- sion of the uterus at the first operation, a procedure we now almost invariably follow when dealing with this class of case. This matter is referred to at p. 438. Failure to cure symptoms. — 1. The commonest opera- tion for leucorrhcea or menorrhagia is curettage ; but it is sometimes a disappointing operation, especially when carried out for excessive menstrual loss. It is a mistake, therefore, to hold out too strong hopes with this opera- tion ; rather should the patient be warned that, although it is the treatment most suitable to her case, yet the results are sometimes disappointing. 2. Virginal dysmenorrhoea is usually cured by dilat- ing the cervix, but in a certain number of cases it fails to be thus relieved. It may be that it will be cured at a second attempt, or, on the other hand, it may be incur- able by any method short of inducing the menopause by subtotal hysterectomy. It is most necessary, when advis- ing these patients to undergo dilatation of the cervix, to inform them of the possibility of failure. 3. An extensive acquaintance with the operation of ventro-suspension for the condition of prolapse of the uterus, as performed by others as well as ourselves, led us long ago to discard it for the relief of the symptoms com- plained of, unless combined with perineoplasty. Attend- ance in the out-patient department will disclose women, upon whom this operation has been performed, returning with the statement that they are no better, and an examina- tion will show the cause of their complaint ; for whereas the uterus is fixed in good position, the prolapse of the vaginal walls, with which the original condition was associated, remains. Ventro-suspension for prolapse should only be performed in combination with perineoplasty, and, if need be, colporrhaphy as well. RESULTS— REMOTE 699 The return of symptoms — After a successful operation the symptoms for which it was performed may recur. The following are examples of this misfortune : — 1. The fact that when performing a myomectomy no other myoma could be seen or felt is no assurance that none others will appear later on. 2. Many a woman has failed to get permanent relief after the removal of a diseased Fallopian tube or ovary on one side, owing to that on the opposite side becoming disorganized later. 3. That a woman has had tubal gestation on one side is no reason why the other side should not be similarly affected later on. In about 5 per cent, of the cases the disease occurs on both sides sooner or later. 4. Both the ovaries of a woman may grow tumours, and that at different times. 5. Occasionally the adhesion between the uterus and abdominal parietes due to a ventro-suspension breaks or so stretches that the operation is a failure. 6. Dilatation of the cervix for virginal dysmenorrhea, though at first successful, may not be permanently so, the pain returning after the lapse of some months or more. The dilatation should then be repeated. Menopausal symptoms. — If the ovaries are removed, such symptoms as headache, weakness, flushings of heat, sensation of cold; dimness of vision, nausea, etc., may be very troublesome and last for quite a long while. These symptoms may come on acutely or gently, the former being the most troublesome. The treatment of these menopausal symptoms is usually difficult. We have found potassium bromide and nux vomica to be the most generally useful combination of drugs. Ovarian extract has in our hands been an absolute failure. Neurosis. — Every surgeon has had experience of the neuroses following operations. Their manifestations are protean ; nothing abnormal can be detected, and no treat- ment is for long of any avail. Tonics, bromides, change 700 GYNECOLOGICAL SURGERY of air and scene, high-frequency currents, massage, and Weir-Mitchell treatment should be severally tried accord- ing to the peculiarities of the case. The question of sanity and mental instability has already been discussed (p. 665). Convalescence. — The more ill a patient has been before a successful operation, the sooner, other things being equal, will she be gratified with its results. But after any major operation it is well to impress upon the patient that, even if she makes what is considered a normal con- valescence, she will not appreciate its full benefit until the best part of twelve months has elapsed. It takes, roughly, three months to recover her physical and mental balance, six months to begin to feel the improvement wrought by the operation, and twelve months before the new lease of life and health is fully entered on and the recollection of the illness fades away into the past like the memory of an evil dream. The above remarks on the " remote results " of opera- tions are the outcome of our personal experience, much of which has been gained from work in the out-patient department, where we had opportunities from time to time of examining patients upon whom some operation had previously been performed. It is evident that the knowledge thus obtained is only partial, because, in the first place, the average out-patient, when cured, takes no further interest in the hospital or surgeon ; secondly, even if she wished to report herself, the expense and trouble of doing so act as a sufficient deterrent ; thirdly, the only patients one is likely to see are those who have not received all the benefits they anticipated ; and, finally, a certain percentage even of these, failing to obtain relief at one hospital, will seek advice at another in the hope of better success. Our colleague at the Chelsea Hospital for Women, Arthur Giles, has, however, published* a paper * Journal of Obstetrics and Gynecology of the British Empire, xvii., Nos. 3 to 6, and xviii., No. 1. The papers have since been published in RESULTS— REMOTE 701 on remote results, far more complete than anything that had previously appeared in print. He most kindly placed his results at our disposal, and we are thus able to give the conclusions he arrived at after his very exhaustive and critical investigation into the " after-results of abdo- minal operations on the pelvic organs, based on a series of 1,000 consecutive cases." For this purpose printed forms, comprising a large number of questions dealing with the health and condition of the patient after her operation, were sent to each patient ; and in addition, where possible, the patient was examined, or, if this was impossible, the medical attendant was asked to fill up " the present condi- tion." The reports have been collected for over ten years, and form the most important contribution to this subject that has yet appeared. This report is particularly interesting to us since a large portion of it deals with the after-results to patients who have been operated upon at the Chelsea Hospital for Women, at which institution we have gained much of the experience that has encouraged us to write this book. The following are Giles's conclusions, as set out by him under the various operations : — ■ After-Results of Operations for the Removal of Appendages of One Side Number of cases, 284. Percentage of cases traced, 80 "6. 1. Speaking generally, operations for the removal of the appendages of one side have no detrimental effect on the general health, the cases where ill-health could be traced to the operation numbering not more than 5 per cent. About 90 per cent, of cases were actually better after the operation than they were before. 2. The relief of symptoms is well marked after these operations ; about 8y per cent, of patients were free from pain afterwards, or experienced less pain than before the book form under the title of " A Study of the After-Results of Abdominal Operations." (Bailliere, Tindall and Cox.) 702 GYNECOLOGICAL SURGERY operation, whilst a further 5 per cent, were free from pain for a time and developed pain later from other causes. Dyspareunia, dysmenorrhcea, menorrhagia, and leucor- rhcea were relieved in a number of cases. 3. The removal of the appendages of one side was followed by irregularity, diminution, or cessation of men- struation in a small number of cases (8), and in 6 cases there followed a diminution of the sex-instinct. 4. The chances of the disease developing in the remain- ing ovary and tube are not very great ; such a recurrence took place in about 10 per cent, of cases. Consequently, in view of the definite value of the remaining ovary and tube, it is always worth while preserving them when they appear to be healthy. Soiling of the peritoneal cavity with the contents of an ovarian cyst favours the occur- rence of later disease, and therefore the interests of the patients are safeguarded by the removal of these cysts (however large) intact without tapping. 5. The remaining tube and ovary have a considerable value from the point of view of subsequent pregnancy ; 33 patients, or 25 per cent., of the married women under 40 became pregnant. Of these 19 had full-time deliveries (some repeated), 5 had miscarriages, and 7 had extra-uterine pregnancy, while 2 were pregnant when seen. It would appear that after the removal of appendages of one side there is a greater liability to the occurrence of extra-uterine pregnancy than is the case with normal women. The 19 women who had full-time pregnancies bore between them 25 children, and 4 more children were born at full time when ovariotomy was undertaken during pregnancy. A study of the sex of these children in relation to the side on which the remaining or active ovary was situated definitely refutes the theory that right ovaries produce boys and left ovaries produce girls ; it shows clearly that there is no relation between the side from which the ovum is derived and the sex of the child. RESULTS— REMOTE 703 After-Results of the Removal of Both Appendages Number of cases, 277. Percentage of cases traced, 76*6. 1. The removal of both ovaries and tubes has no marked detrimental effect on the subsequent health, for 78 per cent, of the patients were in very good health afterwards, and a further 13 per cent., though suffering in different ways, were better than before the operation, making in all 91 per cent, who were quite well or at least improved. The condition of the general health is even better than it is after unilateral salpingo-oophorectomy. 2. The likelihood of later trouble developing in con- nexion with the uterus when the organ is left is relatively small, as such an occurrence took place in only 7 cases out of 105. It is therefore worth while leaving the uterus in all cases where it appears to be healthy. The removal of the uterus seems to increase the immediate risk of the operation in inflammatory cases. 3. Menstruation continued after these operations in about 40 per cent, of the cases, the proportion being largest in cases where the operation was done for inflammatory disease. When menstruation persisted after ovariotomy for tumours it was mostly in cases where the tumours were parovarian or intraligamentary. The inference is that some portion of ovarian tissue had remained behind in these cases. 4. The characteristics of the artificial menopause pro- duced by the complete removal of both ovaries are as follows : — (1) Flushes of heat come on within three months of the operation in 80 per cent, of the cases, and within a month in 55 per cent. (2) These flushes commonly last for several years, and may go on as long as ten years. Probably the average duration would be three or four years. (3) The majority of patients retain their bodily 704 GYNECOLOGICAL SURGERY vigour and energy, namely, about 72 per cent. ; 28 per cent, are easily tired, or complain of lack of energy. This may be partly due to the fact of an abdominal operation, as distinct from the influence of the meno- pause. (4) The influence of the artificial menopause in causing mental depression is relatively small, amount- ing to about 10 per cent, of the cases. (5) In a large proportion of cases the sex-instincts are not affected ; in 68 per cent, they were either un- affected or increased, in 16 per cent, they were diminished, and in a further 16 per cent, they were lost. (6) The artificial, like the natural menopause, is followed by some atrophy of the uterus and vagina, but not in all cases ; 62 per cent, showed some change within two years, 73 per cent, within five years, and 82 per cent, when more than five years had elapsed. Many patients showed a tendency to obesity, but this effect is not so marked as after the natural menopause. There is no foundation for the view that the removal of the ovaries leads to the development of masculine characteristics, such as growth of hair on the face, atrophy of the breasts, and a deepening of the voice, except, perhaps, in cases where the operation is done before or about the age of puberty. After-Results of Hysterectomy for Uterine Myomata and Fibrosis Number of cases, 228. Percentage of cases traced, 85*3. 1. The effect on the general health of hysterectomy for myomata is very satisfactory, inasmuch as 70 per cent, of the patients were in very good health after the opera- tion, and as many as 96 per cent, were better than before the operation. 2. The fate of the cervical stump after supravaginal hysterectomy need cause no apprehension ; in 180 cases RESULTS— REMOTE 7°5 there was not one that showed any sign of malignancy, and in 98*3 per cent, there was no trouble of any kind. In cases of fibrosis, however, it is important either to do a panhysterectomy, or at least to make sure that the whole of the body of the uterus is removed, as a small portion of it may keep up haemorrhage. 3. After supravaginal hysterectomy, menstruation, or at least a monthly discharge of blood, may take place if only a small portion of the body of the uterus has been left behind. 4. The cessation of menstruation after hysterectomy, with preservation of one or both ovaries, is an" apparent " menopause ; the constitutional changes incidental to the true menopause, as indicated by heat flushes, are delayed from one to several years in these cases. Nevertheless, the removal of the uterus brings about the true menopause a good deal earlier than the usual time. 5. After hysterectomy, with preservation of the ovaries, there is some diminution of the sex-instinct in about 20 per cent, of the cases ; but the sex-instinct is practically never lost altogether. After-Results of Hysterectomy for Carcinoma Number of cases, 21. Percentage of cases traced, 79. 1. The results of hysterectomy for carcinoma of the body of the uterus are very good, as all 6 cases traced showed no sign of recurrence after periods varying from 8 months to 3 years. The results of hysterectomy for carcinoma of the cervix are satisfactory, as far as the recent character of most of the cases allows of deductions, since 7 out of 9 cases showed no recurrence after periods varying from 6 months to 2\ years. 2. The effects on the general health are very good, as all the patients were better after the operation, and 8 out of 13 were in very good health. 2 T 7o6 GYNECOLOGICAL SURGERY After-Results of Abdominal Myomectomy Number of cases, 51. Percentage of cases traced, 81 '6. The following deductions are permissible as to the value and scope of myomectomy versus hysterectomy for fibroids. It may be laid down as a general rule that hysterectomy is preferable to myomectomy — (a) In the case of multiple myomata. (b) In the case of cervical myomata. (c) In the case of a single large interstitial or intra-uterine myoma in women over 40. (d) When interstitial or subperitoneal myomata are associated with haemorrhage, making it probable that intra-uterine myomata are also present. Myomectomy is permissible from the operative point of view in the case of — ■ (a) Pedunculated subperitoneal myomata. (b) Small interstitial myomata when they are not more than three or four in number. (c) A solitary intra-uterine myoma, or a fair-sized solitary interstitial myoma, in women under 40, and more particularly in young married women. Summing up the conclusions of this section, it is shown that— 1. The general health after myomectomy is very good, 85 per cent, of patients being in quite good health, or at least better than before the operation. 2. The likelihood of recurrence of myomata is relatively small, the cases amounting to under 10 per cent. ; 90 per cent, were free from recurrence after periods varying from one to seven years. 3. The menstrual loss is moderate, or even scanty, in about 85 per cent, of cases, many of the patients stating that the loss was less than before the opera- tion. RESULTS-REMOTE 707 4. The uterus from which myomata have been removed may be ' serviceable for child-bearing, 3 patients out of 15 married women under 45 having become pregnant subsequently to the operation. The uterus bears the strain of pregnancy and labour with- out difficulty. After-Results of Operations for Uterine Displacement Number of cases, 309. Percentage of cases traced, 81-5. 1. The effect of ventro-suspension on general health is very good, as 90 per cent, of the patients were better than before the operation, as many as 75 per cent, being in quite good health ; whilst of the 10 per cent, who were not better, in one-half of them the cause had nothing to do with the operation. 2. Symptoms are markedly relieved : 90 per cent, of the patients either had no pain afterwards or had less pain than before the operation ; 14 patients were relieved of dysmenorrhcea ; 21 of dyspareunia ; and 16 of head- aches ; 22 patients got relief from menorrhagia, and 13 from excessive leucorrhcea ; 13 patients found their con- stipation improved. 3. As regards the effect of ventro-suspension on the bladder, 18 per cent, of patients experienced frequency of micturition, and 77 per cent, had no trouble, or no more than before the operation. 4. The position of the uterus remains permanently good in about 95 per cent, of cases ; about 5 per cent, suffer from partial or complete return of displacement. The results in cases of procidentia are not quite so good as in cases of retroversion or prolapse, but 88 per cent, of cases of procidentia show permanent good results. To obtain the best results in procidentia, combined operations are usually necessary. 5. In the event of pregnancy following ventro-suspension, 708 GYNECOLOGICAL SURGERY there is a slightly increased tendency to miscarriage if pregnancy follows too soon after the operation. Ventro- suspension causes no subsequent complications of labour, as out of 44 cases of full-time delivery, 40 had normal con- finements and the remaining 4 had complications which were independent of the operation. 6. When pregnancy follows ventro-suspension the position of the uterus is not disturbed thereby, as the results after pregnancy were just as good as in cases where no preg- nancy followed, and the cases of full-time delivery showed only one instance of partial return of displacement out of 29. Among these cases, therefore, the uterus kept in good position in o,6'6 per cent., as against 947 per cent, in patients who did not become pregnant. AFTER-RESULTS OF ABDOMINAL OPERATIONS IN GENERAL ON THE FEMALE GENERATIVE ORGANS Number of cases, 1,000. Percentage of cases traced, 80. This section constitutes in some measure a summary of those preceding, but there are one or two points to consider that have not been touched upon. 1. With regard to the general health after abdominal operations, it was found that 90 per cent, of the patients were better than they were before the operation, 72 per cent, being in quite good health ; about 6 per cent, were either worse, or at least no better, in many cases from causes quite independent of the operation ; and a further 4 per cent, had been much better for a time, and had suffered lately from ill-health due to local or general causes. 2. The period of invalidism after abdominal operations is limited to about three months in 60 per cent, of the cases ; a further 10 per cent, of the patients cease to be invalids by the end of the first year ; while 30 per cent, are still invalids or semi-invalids at the expiration of that RESULTS-REMOTE 709 period, though two-thirds of these eventually get quite well. Age has a marked influence ; the younger the patient, other things being equal, the quicker the convalescence. 3. The memory appears to be affected in about 25 per cent, of cases after abdominal operations. Further, the deterioration of memory appears to be directly propor- tioned to the duration of the operation, as in cases of long operations for uterine carcinoma the memory was affected in 50 per cent, of the cases ; in short operations for hysteropexy the proportion dropped to 18 per cent. ; and operations of intermediate duration showed proportionate percentages. 4. In 64 cases out of 770 (8*3 per cent.) further abdominal operations were required. About 3 per cent, were necessi- tated by direct sequelae of the operation, and of these the cases of inflammatory disease of the appendages supplied the largest proportion ; 6 cases were necessitated by recur- rence of uterine displacements ; and 34 (4*4 per cent.) were required for conditions independent of the first operation. The risk of subsequent independent condi- tions requiring operation is greatest after unilateral salpingo-oophorectomies, where it amounted to 0/5 per cent. 5. The probabilities of pregnancy following unilateral salpingo-oophorectomy and conservative operations on the uterus are good, as 33 per cent, of married women under 40 among these cases became pregnant afterwards ; 73 per cent, of the completed pregnancies went to the full term, there were 8 cases of extra-uterine pregnancy, and 7 patients were pregnant when they were last seen. Of 60 labours, 55 were normal, and 5 had complications that had no reference to the operation. The chances of labour being normal after these operations are, therefore, just as good as in the case of patients who have had no such operations. 6. Eighty-eight per cent, of the patients had no trouble at all afterwards with the scar; 77 per cent, had stitch- 7 io GYNECOLOGICAL SURGERY abscesses, and 3 "6 per cent, developed a hernia of the scar. The tendency to both complications is markedly greater after operations for inflammatory disease of the appendages ; 90 to 93 per cent, of the " clean " cases had no subsequent trouble. The tendency to stitch-abscess has been dimin- ished by modern improved methods, and particularly by the use of sterilized rubber gloves during operations. INDEX Abdominal and vaginal hysterectomy compared, 222 cavity, closing, 285 opening, 276 difficulties and dan- gers of, 280 hysterectomy {see Hysterectomy, abdominal) myomectomy, 413 after-results of, 706 — causes of death after, 685 — immediate results of, 685 operations in general on the female genital organs, after-results of, 708 preparation of patients for, 82, 85 swabs for, 25 section, dressing after, 567 dressings for, 44 sinus, 632 wound, abscess of, 629 bursting of, 636 complications in, 629 hematoma of, 629 size of, 283 sloughing of, 631 strapping of, 632 Abscess of abdominal wound, 629 of Bartholin's gland, 96 After-results of abdominal myomec- tomy, 706 of abdominal operations in general on the female genital organs, 708 of hysterectomy for carcinoma, 705 of hysterectomy for uterine myo- mata and fibrosis, 704 of operations for uterine displace- ment, 707 of removal of appendages on one side, 701 of removal of both appendages, 703 After-treatment routine, 547 Alcohol in sterilization, 33 Amputation of cervix, 177, 181 immediate results of, 693 Anaesthetic, complications due to, 671 room, 55 where to administer, 86 Anaesthetist, duties of, 60 Aneurysm-needle, 17 Anterior colporrhaphy, 139 Antiseptics, 31 general remarks on, 33 Appendicectomy, 524 Aseptic surgery, 31 Atresia of cervix, 153 Auvard's speculum, 13 Baldwin's method of making an arti- ficial vagina, 129 Barlow, Lazarus, 573 (note) Bartholinian cyst, excision of, 96 Bartholin's gland, abscess of, 96 Basins, 54 Bearing of the surgeon, 1 Bed-clothes during convalescence, 570 Bedsores, 670 Belts, 570 Berkeley-Bonney vaginal clamp, 14 Berkeley's infusion apparatus, 19 portable operating table, 22 retractor, 12 scalpel carrier, 8 Biniodide of mercury, 32 Bladder, attention to after operations, 552 complications, postoperative, 654 hydrostatic dilatation of, 94 implantation of cut ureter into, 540 wounds of, 538 Bland-Sutton, J., 301 Blanket suture, 36 Blood lost during operation, 592 Bonney's clip retractor, 14 dissecting forceps, 8 hysterectomy, 331 needles, 17 Bowel, postoperative gangrene of, 625 haemorrhage from, 625 wounds of, 545 Bowels, treatment of, after major operations, 556 after minor operations, 555 Bowls, 54 Broad-ligament cyst (see Enucleation) myoma, operation for, 406 Bronchitis, postoperative, 650 Broncho-pneumonia, postoperative, 650 Burns, anaesthetic, 673 due to hot-water bottle, 673 Bursting of abdominal wound, 636 711 712 INDEX Ca?costomy, 538 Cesarean section, difficulties and dan- gers of, 430 immediate results of, 691 — indications for, 421 sterilization after, 432 technique of, 425 Canal of Nuck, operation for hydrocele of, 1 01 Carbolic acid, 32 Carcinoma, after-results of hysterec- tomy for, 705 of cervix and labour, 522 of cervix and pregnancy, 521 of cervix, causes of death after radical operation for, 684 of cervix, immediate results of radical operation for, 683 of cervix, Wertheim's radical abdominal operation for, 361 of scar, 696 Cardiac disease and operation, 73 Catgut ligatures, 23 dangers of, 23 Causes of death after major operations, 694 Cauterization for urethral caruncle, 87 Cautery, Paquelin's, 21 Cellulitis after cervical dilatation, 168 postoperative, 605 Cerebral haemorrhage, postoperative, 667 thrombosis, postoperative, 667 Cervical carcinoma (see Carcinoma of cervix) myoma, anterior, hysterectomy for, 353 central, hysterectomy for, 340 general remarks on, 338 hysterectomy for, by hemi- section, 350 hysterectomy for, with enu- cleation, 347 posterior, hysterectomy for, 357 operations, dressing after, 567 Cervico-vesical fistula, 183 Cervix, atresia of, 153 dilatation of (see Dilatation of cervix) dressings for operations on, 45 laceration of, whilst dilating, 160. supra-vaginal amputation of, 181 vaginal, amputation of, 177 Chelsea Hospital for Women, statistics of gynaecological operations at, 678 Chloroform introduced into stomach during anaesthesia, 674 Circulatory failure under anaesthetic, 675 Clamp, intestinal, 16 vaginal, 14 Clip, retractor, 14 Clips, Michel's, 18 Clitoridectomy, 109 Clitoris, removal of, 109 Clover's crutch, 20 Coccyx, removal of, 125 Colon tube, use of , after operations, 556 Colotomy, 535 Colpo-perincoplasty, immediate results of, 692 Colporrhaphy, anterior, 139 — dressing after, 566 immediate results of, 692 posterior, r42 Confinement to bed after operation, 571 Consent of patient in writing, 77 Constipation as after-result of opera- tion, 697 postoperative, 626 Continuous sutures, 36 Convalescence, 700 Costume of operator and staff, 62 Counting of swabs, 27 Cross-suture, 36 Crutch, Clover's, 20 Curette, 20 Curetting, 185 dangers of, 189 dressing after, 566 Cushing's suture, 37 Cutaneous eruptions, postoperative, 667 Cystitis, postoperative, 655 Cysts of broad ligament (see Enuclea- tion) of vagina, 137 — pseudo-broad-ligament, 471 Death after operations (see Results, immediate) Diabetes and operation, 74 Diabetic coma, postoperative, 663 Diarrhoea, postoperative, 627 Diet after operations, 557 Dilatation of cervix, 154 of cervix and curetting, im- mediate results of, 692 of cervix, immediate results of, 692 of stomach, postoperative, 622 Dilators, Fenton's, 19 Directions to nurse after major opera- tions, 558 Discharge, vaginal, 33 Disrobing-room, 56 Dissecting forceps, 8 Distension, epigastric, after operation, 586 flatulent, after operation, 586 paretic, 587 peritonitic, 589 — postoperative, 586 Douche-pan, 54 Douching, vaginal, 33 Doyen's hysterectomy, 326 Drainage, abdominal or vaginal, 47 management of, 48 — material for, 48 — when to employ, 46 INDEX 7*3 Dressings, 565 for abdominal section, 44 for vaginal operations, 45 Drug-poisoning, postoperative, 668 Drugs after operation, 570 Dry heat, sterilization by, 27 Dyspareunia and vaginismus, imme- diate results of operations for, 692 as after -result of operation, 697 Embolism of femoral artery, 622 of mesenteric arteries, postopera- tive, 665 pulmonary, postoperative, 651 Emphysema of abdominal wall, 644 Enemata, turpentine, 587 Enterectomy, 526 Enucleation of broad-ligament cyst, 463 of broad-ligament cyst, alterna- tives to, 468 of broad-ligament cyst, dangers of, 407 Eserine, use of, for intestinal distension, 588 Excision of Bartholinian abscess, im- mediate results of, 693 — of Bartholinian cyst, immediate results of, 693 — of urethral mucous membrane, 693 of vaginal cyst, immediate results of, 693 — of vaginal tumour, immediate re- sults of, 693 of vulva, 103 immediate results of, 693 Extra-uterine gestation after term, 511 causes of death after opera- tion for, 691 immediate results of opera- tion for, 690 in first three months, 503 in fourth and fifth months, 508 in later months, 508 Failure of operation to cure symptoms, 698 Fallopian tube, postoperative prolapse of, 649 / tubes, removal of, in vaginal hysterectomy, 252 Fat-embolism, postoperative, 653 Femoral artery, embolism of, 622 vein, thrombosis of, 620 Fenton's dilators, 19 operation for vaginismus, 132 volsella forceps, 11 Figure-of-8 suture, 36 Fistula, cervico-vesical, 183 large intestinal, 634 recto-vaginal, 152 small intestinal, 635 Fistula, uretero-abdominal, 659 urethro- vaginal, 144 utero -vesical, 184 vesico-abdominal, postoperative, 659 vesico- vaginal, 145 Fixation of tissues, 49 - Flatulence as after-result of operation, 697 Forceps, dissecting, 8 Kocher's, 9 ring, 10 round-ligament, n shot-and-coil, 11 Spencer Wells', 9 volsella, 11 Foreign bodies left in abdomen after operation, 645 Freund, W. A., 361 Friends of patient, communications to, 76 General nurse at operations, duties of, 61 operative considerations, 1 Glove-box, 18 Glover's stitch suture, 37 Gloves, 63 sterilization of, 30 Granny knot, 38 Haematocolpos, immediate results of operations for, 693 Haematoma of vulva, operation for, 102 retroperitoneal, 43 Haematometra, 129, 130 immediate results of operations for, 693 Haemorrhage, postoperative, 592 from bowel, 625 from stomach, 624 Handle) 7 , Sampson, 362 Hands, sterilization of, 34 Haultain's operation for inverted uterus, 450 Health of operating staff, 61 Heart failure, postoperative, 616 Hernia of scars, 637 Hiccough, postoperative, 623 Hot-water bottle, burns due to, 673 Hydrocele of canal of Nuck, excision of, 1 01 Hydrogen, peroxide, 33 Hydronephrosis, postoperative, 662 Hydrostatic dilatation of bladder, 94 Hymen, imperforate, operation for, 94 Hyperpyrexia, postoperative, 617 Hysterectomy, abdominal and vaginal, compared, 222 subtotal, causes of death after, 681 immediate results of, 7H INDEX Hysterectomy, abdominal total, by Bonney's method, 33i ; by Doyen's method, 326 by routine method, 319 by routine method, difficulties and dan- gers, 323 causes of death after, 680 immediate results of, 679 and ovariotomy, 462 by hemisection for cervical myoma, 350 for anterior cervical myoma, 353 for broad-ligament myoma, 406 for central cervical myoma, 340 total, 347 for posterior cervical myoma, 357 for uterine myomata and fibrosis, after-results of, 704 general considerations, 212 in double appendage disease, 488 indications for, 212 or myomectomy, 5 1 8 subtotal and total, compared, 218 by routine clamp method, 292 by routine ligature method, 309 by routine ligature method, difficulties of, 314 difficulties of, 307, 314 vaginal, by clamp method, 259 by clamp and ligature method, 253 by ligature method, 227 by ligature method, dangers of, 248 by ligature method, diffi- culties of, 241 — causes of death after, 683 dressing after, 567 — immediate results of, 682 with enucleation for cervical myoma, 347 with salpingo-oophorectomy, 316 Hystero-vaginectomy by paravaginal section, dangers and difficulties of, 270 radical, 26: Immediate-preparation room, 55 Immediate results {see Results, imme- diate) Imperforate hymen, operation for, 94 Incontinence of urine, postoperative, 658 Infusion apparatus, 19 Insanity after operation, 665 and operation, 75 Insomnia alter operation, 591 Instrument nurse, duties of, 60 Instruments, 7 care of, after operations, 547 for abdominal section, 276 simplicity in, 7 Interrupted sutures, 35 Intervesico-vaginal fixation of uterus, 207 Intestinal clamp, 16 obstruction, postoperative, 606 organic, 607 paretic, 613 Intraperitoneal shortening of round ligaments, 443 of round ligaments, dangers of, 449 of round ligaments, im- mediate results of, 689 Intra-uterine packing, 45 Intravenous saline injection, 573 Invaginating suture, 37 Inversion of uterus, 450 Iodine for skin sterilization, 33 Irremovable ovarian cysts, treatment of, 461 Jaundice, postoperative, 667 Keloid of scar, 696 Kidney complications, postoperative 660 Knots, 38 security of, 23 Kocher's forceps, 9 Leitch, Archibald, 369, 371 Lembert's continuous suture, 36 interrupted suture, 36 Ligature material, 23 shot-and-coil, n Ligatures, absorbability of, 23 occluding and suboccluding, 41 Local antisepsis in major operations, 83 Lock wood's spirit solution, 32 Lung, postoperative gangrene of, 651 Lysol, 33 MacCormac on glandular deposits, 371 Major operations, causes of death after, 694 dressing after, 567 immediate results of, 679- 92, 694 preparation of patient for, 82 Manipulation, operative, 5 Masks, 63 Mattress suture, 36 Mayo's scissors, n Menopausal symptoms after operation, 699 Mercury biniodide, 32 perchloride, 32 Michel's clips, 18 INDEX 7i5 Michel's clips, advantages of, 288 application of, 289 removal of, 291 Micturition, painful, postoperative, 655 Middlesex Hospital, statistics of gynae- cological operations at, 678 Minor operations, causes of death after, 693 dressing after, 565 immediate results of, 692, 693 preparation of patient for, 78 Miscarriage after operations, 670 ■ after ovariotomy, 513 Morphia, use of, after operation, 513, 518, 590, 592 Mucous polypus, immediate results of operations for, 692 of body, 195 of cervix, 195 Myoma and labour, 518 and pregnancy, 516 and puerpery, 519 — broad-ligament, 406 — injury to capsule of, in dilatation of cervix, 168 of vagina, 135 submucous, enucleation of, 203 morcellation of, 206 Myomatous polypus, immediate results of operations for, 159, 692 — of body, 199 of cervix, 197 Myomectomy, abdominal, 413 or hysterectomy, 518 Needle, aneurysm, 17 box, 17 Worrall's, 17 Needles, Bonney's, 17 curved, 17 straight, 17 Nephritis, postoperative acute, 660 Neurosis as after-result of operation, 699 Non.-pedunculated myoma, 418 Nurse, directions to, 75 Nurses, preparation of, at operation, 85 Nurses' store-room, 56 Nursing chart for cases of abdominal section, 558 Occupation, resumption of, after opera- tion, 571 Operating, speed in, 4 suite, 51 tables, 21, 52 theatre, 51 plan of, 52 Operation for absence of vagina, 127, 129 for anterior cervical myoma, 353 for atresia of cervix, 153 for atresia of vagina, 127 Operation for Bartholinian abscess, 96 for Bartholinian cyst, 96 for bleeding myoma, 476 for broad-ligament cyst, 463, 468 for broad-ligament cyst and myoma, 218 for broad-ligament myoma, 406 for cancer of vulva, 103 for carcinoma of cervix, 361 fol carcinoma of tube, 217 for central cervical myoma, 340 for cervical carcinoma, 261 for cervical myoma, 340, 347, 353> 357 for cervicitis, 185 for cervico-vesical fistula, 183 for congenital elongation of cer- vix, 177 for cystocele, 109, 139, 142 for defects of uterus, 212 for deformity of uterus, 319 for delivery of foetus, 421 for dysmenorrhoea, 476 for extra-uterine gestation, 503 for fibrosis, 319 for hasmatoma of vulva, 102 for hamatometra, 129, 130 for hsemato-salpinx, 476, 499 for hydrocele of canal of Nuck, 101 for hydro-salpinx, 476, 499 — for hydrostatic dilatation of blad- der, 94 for hypertrophic elongation of cervix, 177 for hypertrophied clitoris or vulva, 103, 109 for imperforate hymen, 94 — — for inflammation of uterine ap- pendages, 319 for inflammation of uterus, 212 for injury to uterus, 319 for inverted uterus, 450 — ■ — for lacerated cervix, 169, 177 for leucoplakic vulvitis, 103 for leucorrhcea with severe erosion, 177 for malignant disease of vagina, 138 for mucous polypus, 195 for myomata of uterus, 413 for myomatous polypus, 197, 199 for new growths in uterus, 212, 319 for ovarian abscess, 217 for ovarian cysts and tumours, 217 for ovarian prolapse, 494 for ovarian tumours, 452 for pain due to coccyx, 125 for pelvic deformity, 421 for placental polypus, 202 for posterior cervical myoma, 357 for prolapse of anterior vaginal wall, 139 716 INDEX Operation for prolapse of posterior vaginal wall, 142 for prolapse of urethra, 90 for pseudo-broad-ligament cyst, 47i for pyo-salpinx, 476 for rectocele, 109 for relaxed vaginal outlet, 109 for retained products of concep- tion, 191 for retroverted uterus, 438, 443 for rupture of uterus, 212 for ruptured perineum, 109 for salpingitis, 217, 476 for scar-hernia, 639 for septic uterus, 319 for submucous myomata, 203, 206 for suburethral abscess, 92 for transverse septum of vagina, 127 for tubal carcinoma, 476 for tubal gestation, 216, 476 for tubo-ovarian abscess, 476, 494 for tubo-ovarian cysts, 476, 494 for urethral caruncle, 87 for urethrocele, 93 for urethro-vaginal fistula, 144 for utero-vesical fistula, 184 for vaginal cysts, 137 for vaginal myoma, 135 for vaginal septum, 129, 130 for vaginismus, 131 for varicose veins of vulva, 102 for vesico-vaginal fistula, 145 for warts of vulva, 103 tables, 52 — wounds of bladder, 539, 540 of bowel, 545 of ureter, 540 Operations, results of (see Results, immediate, and After -results) in private houses, 65 major (see Major operations) minor (see Minor operations) Operative manipulation, 5 Ovarian cysts, irremovable, 461 suspension, 494 tumours and labour, 513 and pregnancy, 512 and puerpery, 515 Ovaries, conservation of, 225 removal of, in vaginal hysterec- tomy, 252 Ovariotomy, after - results of, 701, 703 and hysterectomy, 462 — causes of death after, 686 difficulties of, 460 immediate results of, 686 indications for, 452 premature labour after, 513 technique of, 452 Ovary, partial resection of, 497 Overalls, 62 Packing, intra-uterine, 45 vaginal, 45 Pain after operation, 590 as after -result of operation, 696 Painful micturition as after-result of operation, 697 Paquelin's cautery, 21 Paravaginal section, 245, 263 compared with Wertheim's operation, 369 Parotitis, postoperative, 619 Patient, communications to, 76 Pedicles, tying, 38 Pedunculated subperitoneal myoma, 4i5 Perchloride of mercury, 32 Perforation of uterus in curetting, 191 of uterus in enucleation of myo- mata, 205 Perineoplasty, dangers of, 122 dressing after, 565 for complete rupture, 117 for incomplete rupture, 109 immediate results of, 692 Peritoneal saline solution, 580 Peritonitis after cervical dilatation, 167 postoperative, 598 general, 600 local, 603 Periurethral abscess, immediate results of operations for, 693 Peroxide of hydrogen, 33 Phthisis, postoperative, 651 Placental polypus, 202 Pleating suture, 37 Pleurisy, postoperative, 651 Pneumonia, postoperative lobar, 651 postoperative septic, 651 Polypus of body, mucous, 195 of body, myomatous, 199 of cervix, mucous, 195 of cervix, myomatous, 197 placental, 202 Position of patient after operation, 568 Posterior colporrhaphy, 142 Postoperative abdominal sinus, 632 abscess of abdominal wound, 629 acute nephritis, 660 phthisis, 651 bedsores, 670 bronchitis, 650 broncho-pneumonia, 650 burns, 673 bursting of abdominal wound, 636 cellulitis, 605 cerebral hemorrhage, 667 thrombosis, 667 conjunctivitis, 672 constipation, 626 crushes and dislocations, 672 cutaneous eruptions, 667 cystitis, 655 diabetic coma, 663 diarrhoea, 627 dilatation of stomach, 622 dislocations and crushes, 672 INDEX 717 Postoperative distension, 586 drug-poisoning, 668 embolism of femoral artery, 622 emphysema of abdominal wall, 644 fat-embolism, 653 fistula of large intestine, 634 of small intestine, 635 gangrene of bowel, 625 of lung, 651 haematoma of abdominal wound, 629 haemorrhage and shock, 592 from bowel, 625 — from stomach, 624 heart-failure, 616 hiccough, 623 hydro-nephrosis, 662 hyperpyrexia, 617 incontinence of urine, 658 insanity, 665 insomnia, 591 jaundice, 667 mesenteric embolism, 665 thrombosis, 665 miscarriage, 670 obstruction, 606 pain, 590 painful micturition, 655 parotitis, 619 peritonitis, 598 pleurisy, 651 pneumonia, 651 posture paralysis, 671 prolapse of Fallopian tube, 649 pulmonary embolism, 651 pyaemia and septicaemia, 617 pyelitis, 660 pyelo-nephritis, 660 pylephlebitis, 619 pyo-nephrosis, 662 retention of urine, 654 scar-hernia, 637 septicaemia and pyaemia, 617 shock and haemorrhage, 592 sloughing of abdominal wound, 631 suppression of urine, 656 temperature, 550 tetanus, 618 — — thirst, 552 thrombosis of femoral vein, 620 of inferior vena cava, 622 treatment, 347 vaginal discharge, 647 vesico-abdominal and uretero- abdominal fistulas, 659 vomiting, 582 Posture paralysis, 671 Pregnancy and operation, 75 Premature labour after ovariotomy, 513 Preoperative examination, 71 Preparation of patient at operation, 85 of patient for major operations, 82 of patient for minor operations, 78 of room for private operations, 66 Preparation of staff at operation, 84 Preservation of specimens, 150 Private operations, nurse's duties at, 65 outfit for, 65 sterilized outfit for, 30 Products of conception, removal of, 191 Prolapse, immediate results of opera- tions for, 693 of urethra, 90 Pseudo-broad-ligament cysts, 471 Pulmonary complications, postopera- tive, 650 disease and operation, 73 — embolism, postoperative, 651 Pulse after operations, 549 Purse-string suture, 37 Pyaemia, postoperative, 617 Pyelitis, postoperative, 660 Pyelo-nephritis, postoperative, 660 Pylephlebitis, postoperative, 619 Pyocolpos, immediate results of opera- tions for, 693 Pyometra, immediate results of opera- tions for, 693 Pyo-nephrosis, postoperative, 662 Pyo-salpinx, rupture of, in dilatation of cervix, 166 Radical abdominal operation (see Wert- heim's operation) — hystero-vaginectomy (see Hystero- vaginectomy) Rectal injections, injuries from, 627 saline injection, 580 tube, use of, after operations, 556 wash-out for distension, 588 Recto-vaginal fistula, immediate results of operations for, 693 Reef knot, 38 Remote results (see After-results) Removal of appendage on one side, after-results of, 701 of both appendages, after-results of, 703 of pseudo -broad-ligament cyst, 47i Renal disease and operation, 74 Resection of ovary, partial, 497 Respiration after operation, 550 Respiratory failure under anaesthetic 675 Results, immediate, of abdominal myo mectomy, 685 of abdominal subtotal hys- terectomy, 681 of abdominal total hysterec- tomy, 679, 680 of amputation of cervix, 693 of Caesarean section, 691 of colpo-perineoplasty, 692 of colporrhaphy, 692 of dilatation of cervix, 692 of dilatation of cervix and curetting, 692 7i8 INDEX Results, immediate, of excision of Bartholinian abscess, 693 of excision of Bartholinian cyst, 693 of excision of urethral mu- cous membrane, 693 ■ of. excision of vaginal cyst, 693 of excision of vaginal tumour, 693 ■ of excision of vulva, 693 ■ of gynaecological operations in general, 677 of intraperitoneal shorten- ing of round ligaments, 689 — of major operations, 679-92 of minor operations, 692, 693 of operations for dyspareu- nia, 692 of operations for extra- uterine gestation, 690 of operations for hsemato- colpos, 693 of operations for haemato- metra, 693 of operations for mucous polypus, 692 of operations for myoma- tous polypus, 692 of operations for periure- thral abscess, 693 — of operations for prolapse, 693 of operations for pyocolpos, 693 of operations for pyometra, 693 of operations for recto- vaginal fistula, 693 of operations for urethral caruncle, 693 of operations for vaginis- mus, 692 of operations for vesico- uterine fistula, 693 of operations for vesico- vaginal fistula, 693 of ovariotomy, 686 of perineoplasty, 692 of radical operation for cer- vical carcinoma, 683, 684 of salpingo-oophorectomy and salpingectomy, 687, 688 of trachelorrhaphy, 692 of vaginal hysterectomy, 682, 683 of vaginal myomectomy, 692 of ventro-suspension, 689 of all major operations, 694 remote (see After-results) Retention of urine, postoperative, 654 Retractor, clip, 14 Retractors, 12 vaginal, 14 Retroperitoneal haimatoma, 43 Retroversion of uterus after removal of diseased appendages, 697 Ries, of Chicago, 361 Ring forceps, 10 Round-ligament forceps, 11 Round ligaments, intraperitoneal, shortening of, 443 Saline solution, composition of, 573 methods of administering, 573 Salpingectomy, subtotal, 497 total, 498 Salpingitis after cervical dilatation, 166 Salpingo - oophorectomy, alternative technique for, 493 bisection of uterus in, 485 causes of death after, 688 dangers of, 489 difficulties of, 485- immediate results of, 687 indications for, 476 technique of, 477 ■ with hysterectomy, 316 Salpingostomy, 499 Sanitas, 33 Scalpel, 8 carrier, Berkeley's, 8 Scalpels, sterilization of, 8, 33 Scar-hernia, 637, 696 operation for, 639 Schauta's paravaginal section, 369 Scissors, 1 1 Septicaemia, postoperative, 617 Septum, longitudinal, of vagina, 130 Sharp spoon, 20 Shock, postoperative, 592 remote, 597 Shot-and-coil forceps, n ligature, 11 Silk-box, 18 Silk ligatures, 23 sterilization of, 30 Silkworm-gut ligatures, 23 Simple continuous suture, 36 interrupted suture, 35 Sinus, abdominal, 632 Skin, sterilization of, 33, 34 Sloughing of abdominal wound, 631 Sound, 19 Specimens, fixation and preservation of, 49 Speculum, Auvard's, 13 Speed in operating, 4 Spencer's operating table, 21 Spencer Wells' forceps, 9 Spirit solution, Lockwood's, 32 Staff of operating theatre, 57 of operating theatre, duties "of, 58 Steam sterilization, 28 Sterilization by boiling, 31 INDEX 719 Sterilization by chemicals, 31 by dry heat, 27 by steam, 28 methods of, 27 of gloves, 30 of hands, 34 of scalpels, 8 of silk, 30 of skin, 33, 34 of swabs, 25 Sterilized outfit for private operations, 30 Sterilizer-drum for emergency opera- tions, 31 Sterilizing-room, 56 Stomach, postoperative acute dilata- tion of, 622 haemorrhage from, 624 Strapping of abdominal wound, 632 Strychnine, use of, before serious opera- tions, 670 Subcutaneous saline injection, 578 Submucous myomata, 203, 206 Subtotal and total hysterectomy com- pared, 218 hysterectomy by routine clamp method (see Hysterec- tomy) by routine ligature method (see Hysterectomy) Suburethral abscess, 91 Suppression of urine, postoperative 656 Surgeon, bearing of, 1 Surgeon's dressing-room, 55 knot, 38 Surgery, aseptic, 31 Surgical technique, 7 Suspension of ovary, 494 Suture of abdominal wound, 513, 518 material, 23 Sutures, varieties of, 35-37 Swab nurse, duties of, 60 Swabs, counting of, 27 for abdominal operations, 25 for vaginal operations, 25 — : — material for, 25 method of making, 25 number required, 26 sterilization of, 25 Symptoms, menopausal, after opera- tion, 699 persistence of, after operation, 699 return of, after operation, 699 Tables, operating, 21, 52 Technique, surgical, 7 Temperature, postoperative, 550 Tetanus, postoperative, 618 Thirst, postoperative, 552 Thread ligatures, 23 Thrombosis of femoral vein, post- operative, 620 — of inferior vena cava, postopera- tive, 622 Thrombosis of mesenteric arteries, postoperative, 665 Thyroid tumours and operation, 75 Tissues, fixation of, 49 Toilet of patient after operation, 568 Tongue after operation, 551 Total and subtotal hysterectomy com- pared, 218 hysterectomy (see Hysterectomy, abdominal, total) Tracheoplasty, 173 Trachelorrhaphy, 169 immediate results of, 692 Tubal gestation (see Extra-uterine ges- tation) Tubo-ovarian abscess, 494 — cyst, 494 Ureter, cut, implantation of, into bladder, 540 injuries to, 251, 395, 468, 540, 658, 659 Uretero-ureteral anastomosis, 544 Uretero-vesical anastomosis, 540 Urethral caruncle, immediate results of operations for, 693 operations for, 87 prolapse, operation for, 90 Urethrocele, operation for, 93 Urethro-vaginal fistula, 144 Uterine artery, rupture of, in dilatation of cervix, 161 displacement, after-results of operations for, 707 myomata and labour, 518 and pregnancy, 516 and puerpery, 519 Utero-vesical fistula, 184 Uterus, perforation of, in dilatation of cervix, 162 Utriculoplasty, 434 Vagina, absence of, 128 atresia of, 127 cysts of, 137 dressings for operations on, 45 longitudinal septum of, 130 myoma of, 135 packing of, 45 removal of, 138 transverse septum of, 127 Vaginal and abdominal hysterectomy compared, 222 clamp, 14 discharge, 33, 647 douching, 34 hysterectomy (see Hysterectomy, vaginal) irrigation, 33 myomectomy, immediate results of, 692 — operations, dressing after, 567 preparation of patient for, 78 720 INDEX Vaginal operations, swabs for, 25 retractors, 14 section, dressing for, 45 Vaginectomy, partial, 138 Vaginismus and dyspareunia, imme- diate results of operations for, 692 plastic operation for, 132 stretching orifice for, 131 Varicose veins of vulva, 101 Vena cava, inferior, postoperative thrombosis of, 620 Ventro-fixation, 443 Ventro -suspension of uterus, 438 of uterus, causes of death after, 690 of uterus, dangers of, 441 of uterus, immediate results of, 689 Vesico-uterine fistula, immediate results of operations for, 693 Vesico-vaginal fistula, 145 immediate results of opera- tions for, 693 Visitors after operation, 570 at operations, 56 Volsella forceps, n Vomiting, anaesthetic, 582 irritative, 583 neurotic, 584 Vomiting, obstructive, 585 peritonitic, 585 Vulva, dressings for operations on, 45 excision of, 103 operation for hasmatoma of, 102 varicose veins of, 101 warts of, 103 Vulval operations, dressing after, 566 Warts of vulva, 103 Wash-out, rectal, for distension, 588 Wertheim's operation, 361 ■ compared with paravaginal section, 369 complications of, 399 difficulties and dangers of, 393 limits of, 376 mortality of, 363 operability rate of, 365 percentage of cures in, 366 technique of, 378 vaginal clamp for, 14 Worrall's needle, 17 Wounds, application of antiseptics to, 33 Printed by Cassell & Company, Limited, La Belle Sauvage, London, E.C. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE ■ C28 (747, MIOO FG104 B45 1911 Berkeley A text-book of gynaecological RQ 10? 19 j I