A System of Operative Surgery Part 13

Doran 39 ? R. 1904, xlv. 119.

Doran 30 4th month R. Ibid.

Doran 30 ? R. Ibid.

Boyd 42 8th month D. Ibid., 106 Boyd 40 3rd month R. Ibid.

Fairbairn 22 5th week post partum R. Ibid., 194.

Doran 38 4th week post partum R. 1904, xlvi. 274.

Taylor 33 3rd month R. 1905, xlvii. 333.

Andrews ? 3rd day post partum R. Ibid., 4.

Lea 39 7th week post partum R. Ibid., 1 Boyd 42 4th month, total R. 1907, xlix. 49.

Bland-Sutton 39 4-1/2 months R. 1907.

Dauber 31 3rd month R. 1908.

McCann 25 4-1/2 months R. Ibid.

Spanton 33 2-1/2 months D. Ibid.

TABLE OF CASES IN WHICH ABDOMINAL MYOMECTOMY WAS PERFORMED DURING PREGNANCY

From the _Transactions of the Obstetrical Society_, 1900-8, both years inclusive.

-----------+---------+--------------------+---------+----------------- _Age of _Stage of _Recorder._ Patient._ Pregnancy._ _Result._ _Reference._ -----------+---------+--------------------+---------+----------------- Donald 31 3rd month R. 1901, xliii. 194.

Walls ? ? R. Ibid., 195.

Routh ? 5th month R. 1904, xlvi. 279.

Spencer 41 9th month R. Ibid., 122.

Malcolm 32 7th week post partum R. Ibid., 15.

Doran 28 2nd month R. 1905, xlvii, 426.

Vaughan ? 4th month R. Ibid., 427.

Vaughan ? 3-1/2 months R. Ibid.

Swayne 40 5th month R. 1908, l.

Swayne 35 4-1/2 months R. Ibid.

Williamson 32 7th month R. Ibid., 73.

Scharlieb 37 4-1/2 months R. Ibid.

Scharlieb 39 3-1/2 months R. Ibid.

=Pregnancy complicated with cancer of the cervix.= When a pregnant woman comes under observation with cancer of the neck of the uterus in an operative stage in the early months, hysterectomy should be performed: in some instances the cervix has been amputated without disturbing the pregnancy.

In the later stages good consequences follow the induction of labour and the immediate performance of hysterectomy. Surprising as it may seem, a uterus immediately after labour can be safely extirpated through the v.a.g.i.n.a.

When the cancer is so advanced as to be inoperable, the pregnancy should be allowed to go to term, and if the cancerous ma.s.s offer an impa.s.sable barrier to delivery, Caesarean section should be performed. This operation has been found necessary to extract a dead ftus.

Most surgeons in dealing with operable cases of this complication of pregnancy remove the parts through the v.a.g.i.n.a, because in the abdominal operation the septic cervix is withdrawn through the abdomen; this makes it extremely difficult to avoid soiling the pelvic peritoneum.

=Concurrent uterine and tubal pregnancy.= This condition may require operation in three different circ.u.mstances:--

1. _Tubal and uterine pregnancy occur simultaneously and the complication is recognized in the early months._ Here the operation would be that of ooph.o.r.ectomy, and the uterine pregnancy may continue undisturbed to term.

2. _Intra- and extra-uterine gestation with living ftuses runs concurrently to term._ This is an exceedingly dangerous, though a rare, combination. The table on p. 35 shows how deadly a compound pregnancy is to the mother: it sets forth also the fate of the children.

3. _Uterine pregnancy is complicated by the presence of a quiescent (sequestered) extra-uterine ftus._ Many cases have been reported in which a ftus of this character has occupied the pelvis, yet the woman conceived and the child was safely delivered at term; but a sequestered ftus may const.i.tute an impa.s.sable barrier and require removal (Operations for Compound Pregnancy, see p. 33).

=Pregnancy complicated by tumours growing from the pelvic walls.= When the pelvis is occupied by a chondroma, osteoma, or a sarcoma growing from the innominate bones or the sacrum, or from the fascia of the pelvis and displacing the gravid uterus, the proper course is to perform subtotal hysterectomy. If the obstruction is not detected until the child is viable, and there is no especial call for urgency, interference should be postponed until near term; the child can then be saved by Caesarean section, and the uterus removed.

The operation in such circ.u.mstances calls for the exercise of judgment, but it is rarely difficult. Among interesting tumours complicating labour and obstructing delivery, special mention may be made of dermoids and teratomata lying in the hollow of the sacrum. Skutsch has collected the chief German records.

Echinococcus cysts (hydatids) have grown in the pelvic connective tissue and obstructed labour. Cases have been reported by Knowsley Thornton, Kustner, Blacker, and others.

REFERENCES

BLACKER, G. F. Clinical Lecture on Uterine Fibroids complicating Pregnancy. _The Clinical Journal_, 1908, x.x.xi. 309.

KuSTNER. Kaiserschnitt wegen eines Echinokokkus im Becken. _Zentralbl.

f. Gynak._, 1907, x.x.xi. 1390.

SKUTSCH, F. Ueber die Dermoidcysten des Beckenbindegewebes. _Zeitsch. f.

Geburts. and Gynak._, 1899, xl. 353.

THORNTON, J. K. Removal of Hydatids of the Omentum and from the Pelvis.

_Medical Times and Gazette_, 1878, ii. 565.

OPERATIONS FOR PUERPERAL SEPSIS (METASTATIC BACTERIaeMIA)

Acute septic infection (puerperal) of the uterus, too frequent even in this antiseptic epoch, is a desperate condition, but attempts have been made to deal with it by two methods--either hysterectomy, or the ligature and excision of the thrombosed ovarian veins.

So far as hysterectomy for this condition is concerned, it may be stated that it has been tried, but with no encouraging measure of success; it is a very desperate proceeding, and has been occasionally successful by the abdominal, as well as by the v.a.g.i.n.al route. It is possible that v.a.g.i.n.al hysterectomy may now and then be a wise operation in acute puerperal infection, but better results have been attained by ligature of the thrombosed pelvic veins, and by drainage of the pelvic cavity. Some interesting operations, with brilliant results, have been published by Trendelenburg, Michels, Cuff, b.u.mm, and others.

In some cases of puerperal pyaemia a careful examination of the patient's abdomen has enabled the surgeon to feel the thrombosed ovarian vein, and in others the vein has been exposed by an incision running from the tip of the eleventh rib to the spine of the p.u.b.es, parallel with Poupart's ligament. The muscles are divided and the peritoneum reached; this is reflected until the thrombosed ovarian vein is exposed and separated from the ureter. About half an inch below its junction with the renal vein or the vena cava, as the case may be, it is securely ligatured and divided; the vein is then slit up and the clot turned out. The operation, when carried out in this way, is extraperitoneal. In some instances successful ligature of the thrombosed ovarian vein has been effected by the usual median incision into the peritoneal cavity.

The object of ligaturing the thrombosed ovarian vein is to prevent the pathogenic micro-organisms in the clot from entering the circulation.

b.u.mm reported five cases in which he ligatured these veins. Three of the patients recovered.

It is more than probable that if operative interference be carried out on thrombosed ovarian veins before the condition of the patients become desperate, more of them might be rescued. Success has been attained even in desperate conditions; for example, Friedemann ligatured these veins in a woman whose general condition was not only bad, but who also had extensive bed-sores. She recovered.

T. G. Stevens reported the details concerning a woman who died, of acute septicaemia, eleven days after a subtotal hysterectomy (by Galabin) for fibroids. The right ovarian vein was thrombosed from the ligature in the pelvis to its entrance into the vena cava, and he isolated from the clot and produced in cultures the _bacillus pyocyaneus_. He also stated that 'the vein could have been easily dissected out, and possibly the fatal result might have been averted'.

This operation rests on sound principles, for the ligature of the ovarian veins prevents the septic blood entering the circulation, thereby setting up, among other things, endocarditis and pulmonary embolism.

The great difficulty in dealing with this condition is the selection of suitable cases. Experience teaches that acute cases are unsuitable. The best results have been attained in the chronic forms of the disease where the thrombosis was limited. There is great uncertainty in a given case as to the extent of the thrombosis and the number of veins implicated. As has already been mentioned, there are two routes for gaining access to the thrombosed vessels--the extraperitoneal and the intraperitoneal. I prefer the intraperitoneal route (cliotomy), for it enables the surgeon to deal with the vessels, iliac or ovarian, of both sides, as well as allowing a thorough examination of the pelvic organs, and it permits the drainage of any collection of serum or pus found in the pelvis. From a study of the reported cases it is clear that the best results are obtained by cliotomy. The ligature of thrombosed ovarian veins in chronic puerperal pyaemia promises good results for the future, but it needs further experience to teach us the kind of case in which it is likely to be successful.

REFERENCES

b.u.mM, E. Zur operativen Behandlung der puerperalen Pyamie. _Berliner Klin. Wochensch._, 1905, xlii. 829.

CUFF, A. A Contribution to the Operative Treatment of Puerperal Pyaemia.

_Journ. of Obstet. and Gyn. of the British Empire_, 1906, ix. 517.

FERGUSON, J. HAIG. Abdominal Hysterectomy for Acute Puerperal Metritis and Acute Salpingitis. _Obstet. Transactions_, Edin., 1906, x.x.xi.

123.