Gifford, G. T.British Medical Journal, 1907, ii. 1042.Kouwer, Prof.Zentralbl. für Gynäk., 1907, xxxi. 1447.MacLaren, A.Annals of Surgery, 1896, xxiv. 365.Neugebauer, F. v.Monatsschriften für Geburtsh. u. Gyn., 1900, Bd. xi, 821, 933.Zentralbl. für Gynäk., 1904, xxviii. 65.Stewart, J. E. F.Australian Medical Gazette, 1906, xxv. 446.Waldo, R. W.American Journal of Obstetrics, 1906, liv. 553.Wilson, H. P. C.Trans. American Gynecological Society, 1884, ix. 94.
Gifford, G. T.British Medical Journal, 1907, ii. 1042.
Kouwer, Prof.Zentralbl. für Gynäk., 1907, xxxi. 1447.
MacLaren, A.Annals of Surgery, 1896, xxiv. 365.
Neugebauer, F. v.Monatsschriften für Geburtsh. u. Gyn., 1900, Bd. xi, 821, 933.Zentralbl. für Gynäk., 1904, xxviii. 65.
Stewart, J. E. F.Australian Medical Gazette, 1906, xxv. 446.
Waldo, R. W.American Journal of Obstetrics, 1906, liv. 553.
Wilson, H. P. C.Trans. American Gynecological Society, 1884, ix. 94.
Tetanus.This dread complication of wounds occasionally occurs after ovariotomy, and during the ‘reign of the clamp’ it was especially frequent in Germany (Olshausen). Cases have been reported in England,and tetanus has been noticed to affect patients who have been ovariotomized in rooms recently plastered.
Since Kitasato demonstrated the bacillary origin of tetanus poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the tetanus bacillus.
Tetanus, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the tetanus bacillus was detected in some wallaby tendon employed to suspend the uterus. Tetanus has also been traced to infected catgut employed in cholecystotomy (1905).
Ed. Martin reported the occurrence of tetanus after vaginal fixation of the uterus and colporrhaphia anterior. Cumol-catgut was employed.
Menzer has recorded a similar case which occurred in Dührssen’s Klinik (1901). The ligatures were of catgut.
Mallet refers to two post-operative deaths from tetanus. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material.
In practice it is important to remember that tetanus arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling.
Tetanus occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind.
Dorsett, W. B.Two fatal cases of Tetanus following Abdominal Section due to Infected Ligatures, &c.Am. Journ. of Obstet., 1902, xlvi. 620.Mallet, G. H.Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.Martin, Ed.Postoperativer Tetanus (with references).Zent. f. Gyn., 1906, xxx. 395.Meinert.Drei gynäkologische Fälle von Wundstarrkrampf.Arch. für Gyn., 1893, xliv. 381.Menzer.Tetanus Infection after Vaginal Fixation of the Uterus.Zeitsch. f. Geb. u. Gyn., 1901, xliv. 517.Olshausen, R.Tetanus nach Ovariotomie Billroth-Lücke’s.Handb. der Frauenkrankheiten, 1877–9, ii. 367.Taylor, H.Tetanus after Hysterectomy.Am. Journ. of Obstet., 1908, lvii. 574.
Dorsett, W. B.Two fatal cases of Tetanus following Abdominal Section due to Infected Ligatures, &c.Am. Journ. of Obstet., 1902, xlvi. 620.
Mallet, G. H.Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.
Martin, Ed.Postoperativer Tetanus (with references).Zent. f. Gyn., 1906, xxx. 395.
Meinert.Drei gynäkologische Fälle von Wundstarrkrampf.Arch. für Gyn., 1893, xliv. 381.
Menzer.Tetanus Infection after Vaginal Fixation of the Uterus.Zeitsch. f. Geb. u. Gyn., 1901, xliv. 517.
Olshausen, R.Tetanus nach Ovariotomie Billroth-Lücke’s.Handb. der Frauenkrankheiten, 1877–9, ii. 367.
Taylor, H.Tetanus after Hysterectomy.Am. Journ. of Obstet., 1908, lvii. 574.
Injury to intestines.Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where cœliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut.
Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the rectum runs a great risk of being damaged.
In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis.
It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed.
In sewing the abdominal incision the intestines have been pricked with a needle, and in some instances the bowel has been accidentally included in the sutures and sewn to the abdominal wall. On one occasion while securing a very long incision with through and through sutures, while passing the needle through the abdominal wall, it broke, and the broken end came with great force against the anterior wall of the stomach and tore a hole in it. This I secured at once with suture and the accident had no bad consequences.
An unrecognized wound of the bowel in the course of a pelvic operation is almost certainly fatal. Accidental injuries, such as punctures and cuts, require immediate suture, and I have never known any harm follow. On the other hand, ragged tears in thickened and inflamed bowel require careful consideration in order to spare patients the inconvenience and distress of fæcal fistulæ.
In regard to small intestine a very small opening may occasionally be safely secured with fine silk, but in most cases it is wiser, if the bowel is thickened and inflamed around the hole, to resect well wide of the damaged portion and join the cut ends (circular enterorrhaphy).
Holes low down in the rectum are difficult to suture securely. Theseshould be treated by drainage, using a wide rubber drain; the convalescence will be tedious, but the fistula will close.
It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a fæcal fistula which had followed an oöphorectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube passed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble.
If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or cæcum he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.)
Intestinal obstruction.It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:—
1. Adhesions to the abdominal wound.
2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.
3. Strangulation around an adventitious band.
4. Obstruction due to an overlooked cancer in the colon.
5. Strangulation in a sac formed by a yielding cicatrix.
The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.
The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.
From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking uplike a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the supravaginal cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.
The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or oöphorectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment.
Perforating ulcer of the stomach and small intestine.A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident.2
Injuries to the bladder.This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk.
The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap.
Injuries to the ureter.Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in vaginal hysterectomy, because the vesical segments of these ducts come into close relationship with it.
British surgical and gynæcological periodical literature contains very little that concerns ureteral injuries, but it is only necessary to look into the pages of theZentralblatt für Gynäkologieto find ample evidence that the integrity of the ureters is frequently sacrificed to modern pelvic surgery.
Blau published statistics from Chrobak’s Klinik in Vienna showing that in the interval January, 1900, to January, 1902, the ureters were injured fifteen times. In total hysterectomy seven times; in the course of ovariotomy on three occasions.
Sampson stated that from August, 1889, to January, 1904, the uterus was removed 156 times for cancer of its neck at the Johns Hopkins Hospital, Baltimore, and the ureters were injured nineteen times. The injuries were of various kinds, such as ‘ligating, clamping, cauterizing, cutting.’
In abdominal hysterectomy for fibroids the risk of injuring a ureter is not great. Thus Deaver writes that in the course of 250 abdominal hysterectomies he injured the ureter once, but the accident entailed the death of the patient.
I have performed hysterectomy on 1,000 occasions and injured the ureter once; my patient had a narrow escape for life and lost a kidney.
I have been present on five occasions when a ureter was injured. Four of the operations were for the removal of the uterus on account of fibroids, and one was an ovariotomy. Four of the patients died.
The injuries to which the ureters are liable in the course of hysterectomy are as follows:—
1. One or both ureters have been included in the ligatures applied to the uterine arteries.
2. One or both ureters have been cut or completely divided with scissors, or knife, in removal of the uterus.
3. A segment of a ureter 7 centimetres in length has been accidentally exsected.
4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of vaginal hysterectomy, and subsequently sloughed.
5. Ureters exposed in the course of ‘radical’ operations for cancer of the neck of the uterus often slough.
6. A ureter is sometimes transfixed by a needle and thread when sewingthe layers of the broad ligament together in the course of a subtotal hysterectomy.
The most dangerous injury to the ureters occurs in the course of a subtotal hysterectomy, especially if it is not recognized at the time of the operation. In such circumstances the urine will slowly leak into the connective tissue of the broad ligament and form an extravasation extending into the loin.
In some cases the fluid will leak directly into the pelvis, and a sinus will form in the abdominal wound and allow the urine to escape; this may be the first intimation that a ureter has been injured, whereas when a ureter has sustained damage in the course of a total abdominal or a vaginal hysterectomy, the leakage of urine along the vagina will quickly apprise the surgeon of the accident.
There is another form of injury to the ureter which should be mentioned. Occasionally a fibroid, but more often a cyst or tumour arising from the base of the broad ligament, will involve the corresponding ureter and carry it upwards in such a way that, when the layers of the broad ligament are reflected, the ureter will be found crossing the crown of the tumour like a strap. In such a case the pressure has usually exerted a banal influence on the kidney, and it is often in the condition known as sacculation. In a case under my own care in which I attempted to remove a malignant tumour of the broad ligament, and in which the ureter ran over its upper pole in this way, thinking it was an adhesion, traction was made upon it, and the ureter came away with a portion of the renal pelvis. At the post-mortem examination the kidney was merely a thin-walled sac with purulent contents.
In all cases in the course of an abdominal hysterectomy it is useful for the surgeon to inform himself of the condition of the kidneys. Whilst performing a subtotal hysterectomy, one of the fibroids burrowed deeply between the layers of the left broad ligament; when all the bleeding was checked, I looked carefully to determine that the ureter was safe, and found it kinked by the ligature applied to the corresponding uterine artery; it was at once removed. On palpating the kidneys I found the right kidney small, and shrunken, and useless. Fortunately the woman recovered.
The method of treating an injured ureter varies greatly and will depend not only on the extent of the damage, but also on the time at which it is recognized. For example, if the surgeon recognizes the injury in the course of the operation, he will be able to deal with it at once. This we may termimmediatetreatment. The more difficult cases are those in which the injury is unrecognized at the time of the operation and only becomes obvious in the course of convalescence; the treatment in such circumstances may be calledsecondary.
The primary treatment of an injury to a ureter in the course of a pelvic operation will depend in a large measure on the ability, judgment, and experience of the surgeon, as well as on the extent of the injury. For example, if the ureter be partially divided, the opening may be closed with sutures of thin silk; when the duct is completely divided, the cut ends may be invaginated, the upper into the lower, and retained in position by suture. When five or more centimetres of the ureter have been accidentally exsected, none of these methods is applicable; in such circumstances several plans have been tried. Of these the simplest is ligature of the proximal end with the hope of inducing atrophy of the kidney; in several recorded instances this has proved successful. The surgeon who adopts this method should satisfy himself that the patient has another kidney, and that it is, as far as he can ascertain at the time, healthy. Some surgeons who have divided a ureter have promptly removed the corresponding kidney; others have secured the proximal end in the upper angle of the abdominal incision and removed the kidney subsequently.
The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomyFig. 27. The Relation of Parts after Ricard’s Operation of Uretero-cysto-neostomy(after Lutaud). A, the proximal end of the ureter with the mucous membrane reflected. B, the walls of the bladder, showing the mode of fixing the ureter to its walls. 1 and 2, sutures.
It has been suggested that when a portion of a ureter has been resected and the proximal end cannot be engrafted into the wall of the bladder, it should be turned into the cæcum or the sigmoid flexure, according to its position, and thus preserve to the patient the kidney and save her the distress of a urinary fistula. This method has not found favour with practical surgeons. The most promising procedure consists in engrafting the proximal end of the cut ureter into the bladder. This is known as uretero-cysto-neostomy, an operation which has been made the subject of a valuable thesis by Dr. Lutaud. This thesis appears to have been inspired as a result of two successful operations performed by Ricard. The principle of this method is as follows:—
The abdomen is opened by the usual median subumbilical incision, and the peritoneum covering the damaged duct is incised and its proximal end exposed: the mucous membrane of the ureter is reflected like a cuff. An opening is made in the bladder wall in a situation convenient for making the junction, and two centimetres of the ureter are allowed to project freely into the vesical cavity, ‘à la façon d’un battant de cloche.’ The ureter is secured by sutures to the vesical mucous membrane, and to the muscular coat of the bladder. The sutures should be of thin catgut and must not perforate the bladder or the ureteral walls. The bladder itself near the junction should be attached by sutures to the adjacent peritoneum to prevent dragging (Fig. 27).
Lutaud significantly points out that we know little of the subsequent fate of ureters which have been engrafted into the bladder. The immediate results have been successful, but there is good reason to believe that when a ureter has been engrafted into the bladder, its walls become sclerosed by a chronic ureteritis, and its lumen is gradually stenosed. These changes take place slowly and cause little or no discomfort in connexion with the kidney or the bladder, so that they pass unnoticed.
If the opinion expressed by Lutaud, that the ureter becomes stenosed after uretero-cysto-neostomy, is found to be a constant, or even a frequent, sequel to the transplantation of a ureter into the bladder, it will cause surgeons to be careful, and not follow too literally the advice given by some writers to the effect that in performing the ‘radical operation’ for cancer of the cervix, if the ureters are implicated these ducts may be divided and their proximal ends engrafted into the bladder.
Lockyer, in removing a burrowing fibroid, wounded the bladder and divided the right ureter; he sutured the vesical incision and removed the right kidney. During the twenty-four hours following the operation there was anuria. The abdomen was reopened and then it was found that the left ureter had also been divided. The proximal end of this ureter was engrafted into the bladder through the wound which had been already sutured. Convalescence was disturbed by a urinary fistula. The woman recovered and reported herself in good health three years later.
It has happened that after nephrectomy for the cure of a ureteral fistula, the sequel of a ‘radical operation’, the remaining ureter became thoroughly blocked by recurrent growth and the patient died from anuria.
In the cases where the injury to a ureter has been overlooked in the course of the operation many difficulties arise before the true conditions are appreciated. In some instances they soon become obvious; for example, Purcell in 1898 performed an abdominal hysterectomy, next day the patient had complete anuria. The abdomen was reopened fifty-eight hours later; a distended ureter was easily recognized behind the ligaturesapplied to the right and left uterine artery respectively. The ligatures were removed, the swelling quickly subsided, and urine reached the bladder. The woman recovered.
When a ureter is injured in the performance of total hysterectomy, urine escapes by the vagina, and at first there may be some doubt whether the leak is due to an injury to the bladder or to the ureter. In such conditions the quantity of urine voided from the bladder is compared with that which escapes from the vagina; if the quantities are equal, or nearly equal, the leak is in a ureter. A more reliable method is to inject a solution of methylene blue into the bladder through the urethra. If the coloured fluid escapes from the vagina, the leak is in the bladder; if not, it is in the ureter. When a vaginal leakage occurs a few days after a vaginal hysterectomy, it is probably due to necrosis and sloughing of a ureter, or the duct may have been included in a ligature which has separated by sloughing.
Noble, in 1902, published an interesting series of injuries to the ureter. One of these is of great value, because it proves that a ureter may be accidentally ligatured and give rise to no symptoms.
A woman of thirty-three years of age was submitted to vaginal hysterectomy for cancer of the neck of the uterus, complicated with pregnancy. She died four days after the operation, and at the post-mortem examination the left ureter was found occluded with a ligature. The ureter and pelvis of the kidney were distended with urine.
The urine voided during the four days amounted on the first day to 480 c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48 oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull suspicion in regard to any patient, but the facts of the case are sufficient to raise suspicions of another kind, namely, that it is possible and probable that a ureter has been ligatured in the course of an operation, and the patient has recovered without any one having any suspicion that such an accident has happened.
As soon as the surgeon clearly establishes the existence of a ureteral fistula he is beset with the necessity of deciding which duct is the seat of damage. Some years ago, when it was the practice to remove the kidney for a persistent ureteral fistula, the decision involved the surgeon in a grave responsibility, for the removal of the wrong kidney could only be regarded as a catastrophe for the patient. Morris has recorded a case in which this actually happened. A woman had total hysterectomy performed for a cervix fibroid by a gynæcologist; in the course of the convalescence a ureteral fistula was recognized, and as this failed to close spontaneously, a surgical colleague performed nephrectomy, and next day found to his chagrin that he had removed the kidney belonging tothe uninjured ureter. Serious accidents of this kind are less likely to happen now, because the surgeon can avail himself of the cystoscope and ureteral catheter; with these instruments it is possible, not only to decide with certainty which ureter is injured, but also to determine the position and extent of the damage. See also Vol. III.
It is important to remember that every ureteral fistula does not require an operation. It is always advisable, when it has been clearly established that a woman has a leaking ureter, to wait a little, certainly six weeks, for many fistulæ of this kind will gradually close. In describing such a case, Jonas draws attention to a cystoscopic sign of some value. He performed a total hysterectomy for fibroids, and on the tenth day the nurse reported the escape of urine by the vagina. The daily output of urine from the bladder, which had averaged 50 ounces, fell to 25 ounces. On cystoscopic examination, urine could be seen issuing from the right ureteral orifice; at first the left orifice could not be seen, but on careful watching a movement was detected similar to the contraction of a ureter discharging urine, but no fluid came from the opening. This is known asleergehen(empty contraction), and it indicates that there is a lateral opening, but not complete interruption in the continuity of the ureter. Such a case should have an opportunity of healing spontaneously. This happened in Jonas’s patient.
Weibel states that a ureteral fistula due to necrosis after a radical operation for cancer of the uterus usually occurs in the second week. The earliest day is the seventh, and the latest the eighteenth day after operation. The majority of these fistulæ heal in from three to twelve weeks. If a fistula persist for more than three months spontaneous healing is not to be expected. A ureteral fistula is a serious matter for the patient. Blacker has had three cases after total hysterectomy. In one the kidney was removed on account of septic changes. The second had an attack of suppression of urine lasting twenty-four hours; it passed off, the patient recovered and the fistula healed. The third died eight weeks after the hysterectomy with symptoms of pyæmia; a small abscess had formed near the site of the fistula.
The fate of ligatures.When a ligature is satisfactorily applied to a pedicle the tissue on the distal side of the ligature is isolated from the circulation. The fate of this tissue and of the ligature has been the subject of much speculation.
It is a matter of common observation that when animal tissues are cut off from the circulation, they atrophy; but if pathogenic micro-organisms gain access to such parts, suppuration ensues. In due course, through the activity of the living cells, the dead tissues are detached from the living, a process termed sloughing.
When a piece of healthy tissue is removed from the body and immersed in a sterile solution, and absolutely isolated from the atmosphere, decomposition is indefinitely postponed, but as soon as unsterilized air is allowed access to it, putrefactive changes ensue. The pedicle after ovariotomy is in an air-tight chamber, and if the tissues included by the ligature are healthy, and the silk employed for the purpose is absolutely aseptic, this pedicle, when returned into the abdomen, resembles the piece of tissue isolated from contact with the atmosphere. No septic changes occur, but aggressive leucocytes attack the silk and may, in course of time, effect its removal, even the knots. For this desirable result three conditions require to be fulfilled: (1) the ligatured tissue must be aseptic; (2) the ligature should be absolutely sterile; and (3) air or intestinal contents must be excluded.
These conditions may be prevented in many ways. The tissues included in the ligature are not always free from infective organisms, especially the Fallopian tube, which is usually included in the ligature, and this structure, especially in cases where oöphorectomy is performed for inflammatory diseases, often contains septic microbes; this endangers the ligature and leads to the formation of pus, with its complications, sloughing of the pedicle and abscess. The tissues may be healthy and aseptic, but the ligature may have been imperfectly sterilized, or become contaminated by assistants, or even by the hands of the surgeon during its application.
The operation may have been conducted aseptically and the tissues be healthy, but the ligature becomes infected by the admission of air as a result of drainage, or implication of the bowel or bladder.
I made a careful study of the fate of silk sutures employed in pelvic surgery extending over many years, and came to the conclusion that, even under favourable conditions, silk ligatures disappear very slowly. The silk used to secure an ovarian pedicle may, in very favourable circumstances, disappear in twelve months, but the knots require nearly double that time. The piece of silk which encircles the Fallopian tube is apt to behave in a curious way; in 1898 I removed an ovarian cyst the size of a fist, and tied its slender pedicle with thin silk. Although the recovery was uneventful, the patient complained during many weeks of cramp-like pains on the side from which the cyst was removed. These pains gradually subsided, and ten months later, during menstruation, the patient noticed on the napkin a tiny loop of silk, which she saved. This was the loop of silk which secured the Fallopian tube; it had ulcerated into the tube and been conducted into the uterus and escaped. I have since had a like condition, the loop making its appearance three weeks after an ovariotomy. It has been established by experiments onthe long uterine cornu of rabbits, that an encircling ligature will ulcerate through, leaving the lumen of the cornu intact. Clinical observations regarding ligatures applied to Fallopian tubes in the performance of Cæsarean section for the purpose of preventing pregnancy prove that this is a useless measure (seep. 71), for these tubes in many instances have recovered their patency, and pregnancy has recurred. It is a fair inference that the ligature ulcerates into the lumen of the tube, which then heals behind it, without stricture of the canal. A similar condition of things sometimes arises after Cæsarean section, especially when the uterine incision is closed by two layers of sutures. Those sutures which involve the endometrium will ulcerate into the uterine cavity and cause irregular slight losses of blood until they escape.
A Uterus in Sagittal SectionFig. 28. A Uterus in Sagittal Section.Showing silk ligatures which had been introduced in the operation of Cæsarean section four years previously. (Museum, Royal College of Surgeons.) Full size.
It is important to emphasize the fact that silk sutures in uterine tissue will, in some instances, remain unabsorbed for many years. A patient who had been submitted to Cæsarean section in 1903 came under my care four years afterwards for the removal of the tumour which caused obstruction; the sutures used to close the uterine incision were visible, and a microscopic examination showed that each silk suture was enclosed in a fibrous tissue sheath (Fig. 28).
The fact that silk sutures will resist absorption for such a long period has an important practical bearing, because so long as pathogenic micro-organisms are denied access they remain inert, but if any septic condition arises in their neighbourhood, and these sutures become involved, they will give rise to abscesses and sinuses as surely as if they had been buried but a few days.
Patients often suffer great distress and annoyance on account of abscesses and sinuses due to septic ligatures, and a sinus will persist as long as the ligature remains. Abscesses and sinuses resulting from troublesome ligatures may escape in many directions; the most common spot is at the lower angle of the abdominal incision; the rectum is another channel of escape, and also the bladder. When a ligature makes its way into the bladder it will set up cystitis and serve as a nucleus for a vesical calculus. In an unusual case recorded by Edebohls, double oöphorectomy was performed for uterine fibroids; a year later the ligature on the left side escaped through the vagina; six months later he performed abdominal hysterectomy. The vermiform appendix was adherent to thestump on the right side; it was removed, and a silk ligature tied in a complicated knot was found in it, making its way towards the cæcum.
On one occasion a woman, who had been submitted to subtotal hysterectomy in the Antipodes, suffered from frequent micturition and fœtid urine; she came under my care. On dilating the urethra, it was found that the cervical stump had ulcerated through the posterior wall of the bladder and projected freely into the vesical cavity, bristling with thick silk ligatures encrusted with phosphatic deposit. The ligatures were removed, the urine soon became acid, and the vesical discomfort quickly subsided, in spite of the anomalous position of the cervical stump.
Until surgeons fully realized the importance of thoroughly sterilizing the silk employed for the pedicles in ovariotomy, it was quite common for the silk loops to ulcerate through the bladder wall and set up cystitis.
Many cases have been reported in which a loop of silk, effecting an entrance into the bladder in this fashion, has formed the nucleus of a phosphatic calculus.
Post-operative kraurosis.In a small proportion of patients (perhaps not more than one per cent.) who have undergone bilateral ovariotomy, oöphorectomy, or hysterectomy, the vulva undergoes the peculiar atrophic changes which are characteristic of the condition known askraurosis vulvæ. This change, so far as my observations go, is chiefly seen in patients who have been submitted to these operations after the fortieth year of life. The cause of these changes is unknown. The condition is troublesome and inconvenient in married women, but spinsters rarely complain of it. Post-operative kraurosis is as rebellious to treatment, and its causation as inexplicable, as kraurosis occurring independently of operation.
The cicatrix.Although the employment of buried sutures has made abdominal incisions more secure in the process of healing, and renders them firmer after union, and thus reduces the chances of a yielding scar, and saves the patient the inconvenience of an abdominal hernia or the annoyance of wearing an abdominal belt, it renders the patient liable to another discomfort, namely, stitch-abscess. This complication arises from a variety of causes—for example, imperfect sterilization of the suture material, or of the patient’s skin preceding the operation. The sutures may be soiled by the hands of nurses and assistants, or the fingers of the surgeon. All these things may be safeguarded, but the operation may have been required for the removal of infected cysts, or pelvic peritonitis: in these cases it is wise not to bury sutures.
Troublesome buried sutures should be removed. In many instances this is easy of accomplishment, and in others it requires patience andoften perseverance, even when the patient is under an anæsthetic. The simplest implement for removing a buried suture is a crochet-hook.
The disadvantage of stitch-abscesses, apart from the inconvenience they cause patients during their convalescence, is that they often cause the scar to yield at that spot, and necessitate the wearing of an abdominal belt. If the hernia is of small extent, and especially when it is situated near the lower angle of the scar, it is difficult to fit a belt which will restrain it without the use of perineal bands or straps. In such cases a truss, on the principle of those employed for inguinal hernia, is more satisfactory than a belt.
Occasionally a scar forms a raised hard red keloid band, and causes some anxiety to the patient. These keloid scars shrink and whiten in the course of a year or eighteen months.
Cancer of the cicatrix.Several cases have been recorded in which, after the removal of an ovarian adenoma, a new growth, described as ‘cancer of the cicatrix’, has formed in the scar. These growths are probably due to the soiling of the wound at the time of operation with epithelial fragments from the tumours.
After abdominal hysterectomy for cancer of the body of the uterus, or its cervix, the abdominal wound may become infected with this disease, and in cases where exploratory cœliotomy has been performed for diffuse cancerous disease of the peritoneum the cicatrix is liable to become permeated by malignant disease also.
Baldy, J. M.The Mortality in Operations for Fibroid Tumour of the Uterus.Trans. Am. Gynæcological Association, 1905, xxx. 450.Bartlett, W., and Thompson, R. L.Occluding Pulmonary Embolism.Annals of Surgery, 1908, xlvii. 717.Blacker, G. F.Lancet, 1909, i. 395.Bland-Sutton, J.Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs.Lancet, 1909, i. 147.Blau, A.Ueber die in der Klinik Chrobak bei gynäkologischen Operationen beobachteten Nebenverletzungen.Beiträge f. Geb. u. Gyn., 1903, Bd. vii. 53.Bucknall, R.The Pathology and Prevention of Secondary Parotitis (with Literature).Med.-Chir. Trans., 1905, lxxxviii. 1.Deaver, J. B.Hysterectomy for Fibroids of the Uterus.Am. Journ. of Obstetrics, 1905, lii. 858–74.Hastings, S.A Preliminary Note on Embolism in Surgical Cases.Archives of the Middlesex Hospital, 1907, xi. 78.Jonas, E.Temporary Uretero-vaginal Fistula after Panhysterectomy for Fibroid of the Uterus.Am. Journ. of Obstetrics, 1907, lvi. 731.Lequeu.Sur les parotidites post-opératoires.Bull. et Mém. de la Soc. de Chir. de Paris, 1907, T. xxxiii. 1044.Lutaud, P.Sur un procédé d’urétéro-cysto-néostomie dans le traiment des fistules urétéro-vaginales et urétéro-cervicales.Paris, 1907.Lyle, Ranken.A Series of Fifty Consecutive Abdominal Sections.Journal of the British Gynæcological Society, 1906–7, xxii. 120.Mallet, G. H.Am. Journ. of Obstetrics, 1905, li. 516.Morris, H.Lectures on the Surgery of the Kidney.British Medical Journal, 1898, i. 1039.Noble, C. P.Clinical Report upon Ureteral Surgery.American Medicine, 1902, iv. 501.—— Myomectomy.New York Medical Journal, 1906, lxxxviii. 1008.Olshausen, R.Veit’sHandbuch der Gynäkologie, 1907, 2nd Ed., Bd. i. 715.Purcell, F. A.The Risks to the Ureters when performing Hysterectomy, &c.Journ. Brit. Gyn. Soc., 1898–9, xiv. 174.Robinson, B.Sudden Death, especially from Embolism, following Surgical Intervention.Medical Record, 1905, lvii. 47.Spencer, H. R.Discussion at Exeter on Uterine Fibroids, &c.British Medical Journal, 1907, ii. 452.Tebbs, B. N.Symptomatic Parotitis.Med.-Chir. Trans., 1905, lxxxviii. 35.Trendelenburg, F.Zur Herzchirurgie.Zentralbl. für Chir., 1907, No. 44, 1302.—— Ueber die chirurgische Behandlung der puerperalen Pyämie.Münchener Med. Wochenschr., 1907, xxxiv. 1302.Weibel, W.Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms.Zeitsch. f. Geb. u. Gyn., 1908, lxii. 184.
Baldy, J. M.The Mortality in Operations for Fibroid Tumour of the Uterus.Trans. Am. Gynæcological Association, 1905, xxx. 450.
Bartlett, W., and Thompson, R. L.Occluding Pulmonary Embolism.Annals of Surgery, 1908, xlvii. 717.
Blacker, G. F.Lancet, 1909, i. 395.
Bland-Sutton, J.Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs.Lancet, 1909, i. 147.
Blau, A.Ueber die in der Klinik Chrobak bei gynäkologischen Operationen beobachteten Nebenverletzungen.Beiträge f. Geb. u. Gyn., 1903, Bd. vii. 53.
Bucknall, R.The Pathology and Prevention of Secondary Parotitis (with Literature).Med.-Chir. Trans., 1905, lxxxviii. 1.
Deaver, J. B.Hysterectomy for Fibroids of the Uterus.Am. Journ. of Obstetrics, 1905, lii. 858–74.
Hastings, S.A Preliminary Note on Embolism in Surgical Cases.Archives of the Middlesex Hospital, 1907, xi. 78.
Jonas, E.Temporary Uretero-vaginal Fistula after Panhysterectomy for Fibroid of the Uterus.Am. Journ. of Obstetrics, 1907, lvi. 731.
Lequeu.Sur les parotidites post-opératoires.Bull. et Mém. de la Soc. de Chir. de Paris, 1907, T. xxxiii. 1044.
Lutaud, P.Sur un procédé d’urétéro-cysto-néostomie dans le traiment des fistules urétéro-vaginales et urétéro-cervicales.Paris, 1907.
Lyle, Ranken.A Series of Fifty Consecutive Abdominal Sections.Journal of the British Gynæcological Society, 1906–7, xxii. 120.
Mallet, G. H.Am. Journ. of Obstetrics, 1905, li. 516.
Morris, H.Lectures on the Surgery of the Kidney.British Medical Journal, 1898, i. 1039.
Noble, C. P.Clinical Report upon Ureteral Surgery.American Medicine, 1902, iv. 501.
—— Myomectomy.New York Medical Journal, 1906, lxxxviii. 1008.
Olshausen, R.Veit’sHandbuch der Gynäkologie, 1907, 2nd Ed., Bd. i. 715.
Purcell, F. A.The Risks to the Ureters when performing Hysterectomy, &c.Journ. Brit. Gyn. Soc., 1898–9, xiv. 174.
Robinson, B.Sudden Death, especially from Embolism, following Surgical Intervention.Medical Record, 1905, lvii. 47.
Spencer, H. R.Discussion at Exeter on Uterine Fibroids, &c.British Medical Journal, 1907, ii. 452.
Tebbs, B. N.Symptomatic Parotitis.Med.-Chir. Trans., 1905, lxxxviii. 35.
Trendelenburg, F.Zur Herzchirurgie.Zentralbl. für Chir., 1907, No. 44, 1302.
—— Ueber die chirurgische Behandlung der puerperalen Pyämie.Münchener Med. Wochenschr., 1907, xxxiv. 1302.
Weibel, W.Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms.Zeitsch. f. Geb. u. Gyn., 1908, lxii. 184.
SECTION IOPERATIONS UPON THE FEMALE GENITAL ORGANSPART IIVAGINAL GYNÆCOLOGICAL OPERATIONSBYJOHN PHILLIPS, M.A., M.D. (Cantab.), F.R.C.P.Professor of Obstetric Medicine, King’s College, London Obstetric Physician and Gynæcologist to King’s College Hospital
In operations upon the perineum and vagina, the same scrupulous precautions against sepsis should be taken as in abdominal section. Before proceeding to practical details, it will be useful to consider a few points regarding the distribution of bacteria in these parts. Not only the ordinary bacteria of the skin, but also those from the rectum, and, under certain conditions, from the urine and the vaginal secretion abound on the perineal and vulval surfaces. The healthy virgin vagina may be considered free from pathogenic organisms, harbouring only the harmless vaginal bacillus of Döderlein. After sexual congress the vagina contains pathogenic organisms, and in conditions such as carcinoma of the cervix and body of the uterus, and in all forms of vaginitis, many varieties of bacteria are present in great numbers.
The normal uterus is germ-free; in fact the external os uteri may be said to divide the bacteria-free from the bacteria-containing area of the genital canal. But in carcinoma and in the various forms of septic endometritis, the uterus not only contains many pathogenic bacteria, but acts also as a continual source of infection to the vagina and external genital organs. It follows, therefore, that this area may be exceedingly difficult to render sterile, and in certain conditions this is indeed impossible. None the less, every effort should be made to attain this object; for even if the organisms cannot be entirely removed, yet their numbers can be considerably reduced, and it must be remembered that the action of septic organisms is, to a great extent, directly proportionate to their numbers.
The same general principles apply to the preparation of patients for operations on the perineum and vagina as for operations on other parts of the body. Very particular attention, however, must be paid to the bowels; nothing is more prejudicial to the success of an operation, or more annoying to the operator, than to have the area of operation soiledby an escape of fæcal matter from an imperfectly emptied lower bowel. The aperient should be given at least 24 hours before the time of operation. A copious soap-and-water enema should follow after the usual interval, and, an hour or two beforehand, the lower bowel should be thoroughly washed out with a gentle stream of warm water.