FRIEDEMANN, G. Die Unterbindung der Beckenvenen bei der pyamischen Form des Kindbettfiebers. _Munchener Med. Wochensch._, 1906, liii. 1813.

LENDON, A. A. Puerperal Infection, Thrombosis: Ligature of the Right Ovarian Vein. _Australian Medical Journal_, 1907, xxvi. 120.

MICHELS, E. The Surgical Treatment of Puerperal Pyaemia. _Lancet_, 1903, i. 1025.

STEVENS, T. G. The Bacteriological Examination of a Thrombosed Ovarian Vein (following Hysterectomy). _Trans. Path. Soc._, li. 50.

TRENDELENBURG, F. Ueber die chirurgische Behandlung der puerperalen Pyamie. _Munchener Med. Wochensch._, 1902, xlix. 513.

CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS

Injuries of the uterus fall into six groups:--

1. Gynaecological injuries.

2. Obstetric injuries.

3. Injuries to the pregnant uterus.

4. Injuries to the pregnant uterus in the course of abdominal operations.

5. Bullet-wounds of the pregnant uterus.

6. Stab-wounds of the pregnant uterus.

=Gynaecological injuries.= The simplest and certainly the commonest accident is perforation of the uterus with a sound, dilator, or forceps in the operation of curetting. Many cases are known in which the uterus has been perforated by clean instruments of this cla.s.s and the patients have suffered no inconvenience.

On the other hand, when the sound or the uterus is septic, perforation of the uterus has been followed by a rapidly fatal peritonitis; indeed, some of these injuries may prove as lethal as a snake-bite.

Occasionally very serious consequences follow simple perforations by dilators and curettes; this has induced some gynaecologists to urge that if, in the course of dilatation and curettage of the uterus, a rupture or perforation of the uterine wall occurs, it is better to perform a cliotomy and a.s.sure oneself of the safety of the patient than to hope that no untoward result will ensue.

This advice is too sweeping. When the perforating instrument is clean, and there is little or no bleeding, the case may be left to itself; if untoward signs arise, cliotomy should be performed. Sometimes a pelvic abscess occurs as a sequence to the accident, and will require evacuation through the v.a.g.i.n.al fornix, or, perhaps, by means of an incision in the flank. Verco found a piece of a curette, 2-3/4 inches long, in an abscess cavity behind the uterus. The patient had been curetted two weeks previously.

A perforation, or a rent in the uterine wall, in the course of curetting, is a serious accident when the operator is unaware that such has happened, and proceeds to flush out the uterine cavity with poisonous antiseptic solutions, especially perchloride of mercury.

Cases are known in which, under these conditions, the woman has died in the course of a few hours.

Injuries, in the course of instrumentation of the uterus, are not always mere perforations; some are wide rents--and this is an especial danger in removing sessile submucous fibroids (v.a.g.i.n.al myomectomy). _A serious complication of tears or rents of the uterine wall, whether the uterus is gravid or non-gravid, is extrusion or prolapse of the intestine._ It is also remarkable that in several reported cases the pract.i.tioner has mistaken the intestines for 'secundines', even in unimpregnated uteri, and has withdrawn them, and even cut lengths of intestine away, before recognizing his error.

In one case of this kind, where a pract.i.tioner had withdrawn and removed several feet of intestine through a rent in the course of a curettage, I performed cliotomy, closed the hole in the uterus, joined the cut ends of the bowel with sutures, resected the mesentery belonging to the removed bowel, and thus saved the patient's life. In another case, where a pract.i.tioner had torn the uterus during curettage and intestine appeared in the v.a.g.i.n.a, there was such free bleeding that I found it prudent to perform subtotal hysterectomy. This patient also recovered.

Successful operations of this kind have also been performed by Werelius and Nixon Jones.

Palmer Dudley relates that on one occasion, in curetting a recently gravid uterus, he tore the posterior wall without being aware of it, and withdrew eight inches of intestine, thinking it to be secundines; he recognized the error, and pushed the intestine back through the opening in the uterine wall. The patient recovered, and subsequently had two successful pregnancies.

These cases show how impossible it is to recommend any hard and fast lines of treatment. Much depends on the circ.u.mstances of the case, the character of the injury, and above all on the experience and resourcefulness of the pract.i.tioner.

Ruptures or tears of the uterus in the process of instrumental dilatation or curettage are by no means rare, and they have a high mortality. Jakob of Munich collected 141 instances of such injuries, and of these twenty-three died chiefly from septic peritonitis. Among these injuries seventy-three were inflicted with the curette, nineteen with the sound, fourteen with forceps (_Ausraumungszangen_), and six were due to flushing catheters.

=Obstetric injuries.= The uterus is liable, during labour, to be torn, as a result of its own expulsive efforts, especially when the transit of the ftus is hindered or obstructed by narrowness of the pelvic outlet, tumours, or undue size of the child. This form of injury is called _spontaneous rupture_, to distinguish it from the rupture due to midwifery implements. The uterus is frequently torn in the obstetric manuvre known as 'turning'.

The literature relating to this accident is abundant, and the reports issued from lying-in inst.i.tutions deal with extensive figures, but unfortunately the reporters are not in harmony on the principles of treatment.

There are three methods of dealing with rupture of the uterus:--

1. Treating the patient conservatively, which means at most lightly packing the part with antiseptic gauze.

2. Performing cliotomy and st.i.tching up the rent in the uterus.

3. Hysterectomy, preferably by the abdominal route, as this enables the peritoneal cavity to be cleared of clot.

The only point in which there is any semblance of agreement among obstetricians is this: in cases of complete rupture, in which the ftus and membranes are extruded from the uterus into the belly, cliotomy is clearly indicated.

Admirable reports have been published by Walla, Klien, Ivanoff, and Munro Kerr.

Klien's is a critical and very valuable study, based upon 347 cases of rupture of the uterus published in the preceding twenty years. Of these cases 149 were operated upon, with a mortality of 44 per cent.; 198 were not operated upon, 96 recovered and 102 died--a mortality of 52 per cent. Among the unoperated cases some were not treated in any way, and in these the mortality was 73 per cent., whilst in those treated by drainage, plugging and irrigation, the mortality was only 37.5 per cent.

When there is dangerous bleeding Klien advises immediate operation.

Lacerations of the v.a.g.i.n.a make the prognosis unfavourable, and especially injury of the bladder.

During the last ten years hysterectomy has been so much improved and the technique so simplified, that the operative treatment of complete rupture of the gravid uterus will be more frequently undertaken in the future than it has in the past, and with every prospect of reducing the heavy bill of mortality at present a.s.sociated with this grave accident.

Donaldson (1908) reports a remarkable case in which the uterus ruptured during forceps delivery; 12-1/2 feet of small intestine, detached from the mesentery, were extruded with the ftus. Cliotomy was performed, the detached intestine cut away, and the proximal end of the bowel anastomosed into the caec.u.m. A long rent in the posterior wall of the uterus was closed with sutures. The patient survived the accident ten days, and died from sepsis; 'the entire uterus seemed to be a sloughing ma.s.s.' Donaldson states that, had he removed the uterus at the time he operated on the intestine, the patient would probably have survived.

=Injuries to the pregnant uterus.= Some of the most remarkable injuries inflicted on the gravid uterus are the consequences of attempts to induce what is technically called criminal abortion, especially when the abortion is self-induced. Kehr has recorded an example of a desperate effort of this kind:--A widow, twenty-nine years of age, when in the fifth month of an illicit pregnancy, fired a revolver bullet into the uterus through the anterior abdominal wall. Cliotomy was performed, and the wound in the uterus closed by suture. The woman aborted on the fourteenth day, but recovered.

A gravid uterus in the later months of pregnancy is a big organ, and, like the abdominal viscera generally, may be severely damaged by blows, kicks from horses or brutal men, b.u.t.ts from animals, such as a calf or a goat, falls upon the belly, or a fall downstairs, or the woman may be run over. The treatment to be adopted in these conditions varies widely with the circ.u.mstances. As a general rule it may be stated that the most satisfactory mode of treatment is cliotomy; this permits a thorough examination of the organ, and facilitates removal of effused blood. In the late stages of pregnancy accidents of this kind entail Caesarean section.

Among the most curious injuries of this group are those known as horn-rips: these are cases in which the pregnant uterus is torn open by the horn of a bull. An interesting collection of cases ill.u.s.trating this accident has been made by Robert P. Harris. Even after very severe injuries, in some of which the intestines protruded, women have recovered, and several children survived this terrible mode of delivery.

=Injury to a gravid uterus in the course of an abdominal operation.= In spite of every care it has happened on many occasions that a pregnant uterus has been mistaken for an ovarian cyst, the abdomen has been opened and a trocar plunged into the uterus. In some instances a uterus in which the pregnancy has advanced as far as the sixth month has been removed under the impression that it was a large ovarian cyst, and this accident has happened with a pregnant uterus greatly enlarged in the somewhat rare condition known as hydramnios. A pregnant uterus is also liable to be stabbed by an ovariotomy trocar when the condition is complicated with unilateral or bilateral ovarian cysts. The gravid uterus has very thin walls and, occasionally, resembles so very closely an ovarian cyst as to deceive an inexperienced operator.

When the surgeon finds that he has injured a pregnant uterus in the course of an abdominal operation three courses are open to him, each of which has been practised with success by surgeons of renown:--

1. Sew up the incision in the uterus.

2. Perform Caesarean section.

3. Remove the uterus (subtotal hysterectomy).

Several cases have been reported in which injury to a gravid uterus during ovariotomy has terminated fatally, especially when the surgeon followed the plan of sewing up the wound in the uterus.

A careful consideration of the reported cases indicates that the best results follow for the patient when the surgeon performs Caesarean section, as the following record shows:--