_a,p._ Anterior and posterior lip of cervix before exsection.

_e.o.u._ External os uteri.

_i.o.u._ Internal os uteri.

_s,s'._ Sutures.

[Ill.u.s.tration: FIG. 63. HEGAR'S OPERATION FOR SUPRAv.a.g.i.n.aL ELONGATION OF CERVIX. The cervix has been removed and four sutures pa.s.sed but not tied.

_c.m.m._ Cervical mucous membrane.

_s._ One of the sutures.

_sp._ Speculum.

_v.m.m._ v.a.g.i.n.al mucous membrane.

TRACHELORRHAPHY.

=Indications.= This operation is performed for the repair of certain forms of laceration of the cervix. It was formerly practised in every case in which a laceration occurred: it is now only permissible in cases in which there is extroversion of the mucous membrane with certain symptoms, such as haemorrhage or free leucorrhal discharge accompanied by backache on exertion and general ill health. It was formerly considered that there was a direct relation between cervical laceration and cancer, but further inquiry has failed to corroborate this view.

The instruments required are: a Sims's or Auvard's speculum; long-handled, angular-bladed knives (right and left); Emmett's scissors (right and left) (Fig. 64); toothed dissecting forceps; short stout needles with sharp triangular points, straight or very slightly curved.

=Operation.= As it is usually found that subinvolution is present and kept up by the laceration, it is best to perform a preliminary curettage (see p. 154) before proceeding to the operation proper.

[Ill.u.s.tration: FIG. 64. EMMETT'S SCISSORS (LEFT) FOR TRACHELORRHAPHY.]

The patient is placed in the lithotomy position and an Auvard's speculum is inserted. A piece of stout silver wire or a tenaculum is pa.s.sed deeply through the anterior and posterior lips of the cervix; steady traction can be made through these and the uterus kept fixed while denudation and suturing are carried out. Should marked extroversion be present, with hypertrophy of the cervical glands, the curette should be freely applied to the diseased surface.

The uterine sound is pa.s.sed to mark the situation of the internal os uteri, and an antero-posterior linear piece of lining membrane, about a quarter of an inch in breadth, must be allowed to remain untouched. This is necessary to prevent total occlusion of the cervical ca.n.a.l when the denuded flaps are sutured (Fig. 65).

_Denudation._ The right half of the anterior and posterior lips of the cervix (upper and lower from the operator's point of view) are first pared by means of the angular knives and scissors, great care being taken to see that the deep angle of the reflexion is not overlooked. The other side is then treated in a similar manner. The tissues will be found extremely hard and resistant, especially if there be much cicatrization about the angle of the laceration.

_The pa.s.sage of the sutures_ (Fig. 65). The short stout, triangular-pointed needle is first doubly threaded with silk or stout chromicized catgut so that a loop of three to four inches in length is produced. The needle and the silk suture are pa.s.sed as in Fig. 65, two on either side.

[Ill.u.s.tration: FIG. 65. TRACHELORRHAPHY. The patient is in the lithotomy position. The left half of the cervix has been denuded and two sutures, _a_, _a'_ and _b_, _b'_, pa.s.sed. The right half is intact, but the method of pa.s.sing the needle _n_ is indicated.

_ant._ Anterior lip of cervix.

_post._ Posterior lip of cervix.

_t,t._ Tenacula.

_o.u.i._ Os uteri internum.

_sp._ Speculum.

_w._ Wire.

The triangular-pointed needle must be held in Schauta's specially strong holder (Fig. 73), and should be made to pierce the cervix near the raw surface on one lip, and pushed through the tissues immediately below this to emerge on the strip of unpared cervix already mentioned. It is then carried across the sulcus and is made to emerge through the opposite lip of the cervix. A stout wire is now hooked into the loop and pulled through the needle track. When the two wire sutures are inserted on either side, the flaps are brought together and the wires twisted together.

=Results.= Primary union is the rule, and the wire sutures may be removed at the end of the tenth or twelfth day. The cervix has the appearance observed in the nullipara, and may lead to complications in any ensuing labour from difficulty of dilatation.

Duhrssen modifies Emmett's operation by a flap-splitting procedure which, however, does not appear to possess sufficient advantages to warrant its general introduction.

v.a.g.i.n.aL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri in an anteverted position, by suturing it to the anterior v.a.g.i.n.al cul-de-sac.

=Indications.= These are somewhat uncertain, and the field of utility of the operation is rapidly becoming more limited. Advocates of this procedure recommend it for backward displacement of the uterus with or without adhesions. It is considered specially applicable to cases in which slight retroversion is complicated by moderate prolapsus. The results which have so far obtained do not appear to be so good as those resulting from the use of a well-fitting pessary.

=Operation.= The technique recommended by Duhrssen appears to be the most satisfactory, and is as follows: The patient is anaesthetized and placed in the dorsal position with the knees supported by a Clover's crutch. After purification of the parts (see p. 126) the cervix is pulled down as far as possible by means of a volsella: a curettage is then carried out as a preliminary measure (see p. 154). If cervical hypertrophy is present, amputation by Marckwald's method (see p. 160) should be performed, as an elongated cervix acts as a preventive to satisfactory anteversion of the uterus. A transverse or T-shaped incision is now made as in v.a.g.i.n.al hysterectomy (see p. 169), and the cellular tissue pushed up by the index-finger until the peritoneum is reached. The peritoneum is now seized with a volsella and cut through, and the edges sutured to the lips of the v.a.g.i.n.al wound. The uterine fundus is then anteverted by means of a sound: by pressing the handle of the instrument towards the perineum the fundus is brought into the wound. By means of a rectangular curved needle a stout silk suture is pa.s.sed through the anterior wall of the fundus as high up as possible: the v.a.g.i.n.al flaps are not included, as the suture is to be used for traction only. The uterus is now forcibly pulled down and two other sutures are introduced in the same manner higher up. Three sutures of catgut are pa.s.sed through the uterine wall, including the v.a.g.i.n.al and peritoneal flaps. The silk traction sutures are now withdrawn and the permanent ones tied. The v.a.g.i.n.al wound is carefully sutured by means of fine silk.

=Difficulties and dangers.= The risks of the operation are peritonitis and wounding of one or both ureters or the bladder wall. Absolute rest for fourteen days is necessary and no local after-treatment is called for.

CHAPTER XVI

OPERATIONS FOR NEW GROWTHS OF THE UTERUS

Uterine growths include primary malignant disease and fibro-myomata; the former should be treated by exploration and subsequent v.a.g.i.n.al hysterectomy (see p. 168), while the latter should be dealt with according to their relations and attachments to the uterine wall.

[Ill.u.s.tration: FIG. 66. PEDUNCULATED FIBROID POLYPI IN VARIOUS STAGES OF EXTRUSION. (_From drawings made at time of operation._)]

OPERATIONS FOR UTERINE FIBRO-MYOMATA

Fibro-myomata may present themselves to the operator in one of the following forms:--

1. As a fibroid polypus still intra-uterine or presenting through a naturally dilated and thinned-out cervix (submucous pedunculated).

2. As sessile growths presenting by their lower segments at the os uteri, which may be closed, or may be in varying degrees of dilatation (submucous sessile).

3. As tumours incorporated in the uterine wall (interst.i.tial).

=Operations for pedunculated tumours.= _If a fibroid polypus be still intra-uterine_ (Fig. 66) the proper treatment is to dilate the cervix (see p. 156), and, if the pedicle be sufficiently thin, to seize the growth with a pair of stout polypus forceps and twist it off by a slow rotary movement of the handles. Should the pedicle be thicker than the finger, the use of the wire ecraseur is advisable. This is a scientific snare, with a loop of pianoforte wire and a handle or wheel by which it can gradually be tightened, causing the wire to slowly cut through the stalk of the growth (Fig. 67).

[Ill.u.s.tration: FIG. 67. WIRE eCRASEUR.]

The cervix is steadied with a volsella and the loop of the ecraseur is shaped and bent to the size and position of the fibroid. The instrument is then pa.s.sed into the uterine cavity and the noose pushed over the tumour up along the pedicle. The wire loop is then tightened up by means of the handle or wheel, and the wire cuts its way through and separates the growth from the uterine wall. It is somewhat dangerous to put any traction on the tumour before its separation, as is recommended by some writers, as the uterine wall itself may become somewhat inverted and the wire loop may cut through into the peritoneal cavity.

_If the fibroid polypus has pa.s.sed through the external os uteri_, treatment is more simple. Slight traction may be made upon it by means of forceps, and the pedicle severed with scissors; no haemorrhage takes place, owing to the retraction of the stump.

=Operations for sessile tumours.= In submucous sessile fibroids (Fig.

68) in which the lower segment of the uterus is somewhat thinned out and dilated, operative interference may be as follows: Preliminary dilatation of the cervix by bougies may be necessary. The capsule of the tumour is then incised with a sickle-shaped knife and the growth is enucleated by means of the finger or a blunt spoon. In some cases mere incision of the capsule is sufficient, and the uterus expels the growth later on.

Another method of treating these cases is by the operation of _morcellement_, which consists in removing the tumour piecemeal by means of specially made forceps.

The instrument used by the author consists of a strong pair of forceps somewhat like those used in lithotomy, with the two distal ends notched with sharp teeth like a volsella. A portion of the tumour is seized between these two blades, and partly cut and partly twisted off. With patience and care the whole tumour may be thus removed. In one case the author was enabled to remove two large growths, each filling a pint measure. This operation is specially suitable in women in whom an abdominal operation is to be avoided.

=Operations for interst.i.tial tumours.= Interst.i.tial fibroid tumours, if not above the size of a small ftal head, should be treated by v.a.g.i.n.al hysterectomy (_vide infra_); if large, by hysterectomy by the abdominal route (see p. 36).