[Ill.u.s.tration: FIG. 68. SUBMUCOUS FIBRO-MYOMATA, CAPABLE OF TREATMENT BY MORCELLEMENT. (_From drawings made at time of operation._)]

=v.a.g.i.n.al hysterectomy.= By v.a.g.i.n.al hysterectomy is meant removal of the whole uterus by the v.a.g.i.n.a, with or without the appendages. The advantages that the v.a.g.i.n.al operation possesses over abdominal hysterectomy are, there is less disturbance of peritoneum and intestines, less shock, and no abdominal scar or risk of subsequent hernia. The operation is limited to uteri not exceeding in size the head of a full-time ftus.

=Indications.= (i) Malignant disease of the uterus (fundus or cervix) in an early stage: chorio-epithelioma malignum.

(ii) Certain cases of fibro-myoma of the uterus.

(iii) Certain cases of inflammatory disease of the uterine appendages complicated by recurrent attacks of local perimetritis.

(iv) Other conditions, such as intractable uterine haemorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrha.

It has also been advised for irreducible chronic inversion of the uterus, and for severe procidentia uteri. No case of the former has occurred in the author's experience in which the operation was found necessary. In the latter condition the operation is not to be recommended, the almost certain result of the procedure being prolapse of the v.a.g.i.n.al walls and the intestines (enterocele).

=v.a.g.i.n.al hysterectomy for carcinoma.= The only cases suitable for operation are early ones, in which the disease is still confined to the uterus itself, which should be freely mobile in all directions. No signs of infection of the surrounding cellular tissue and v.a.g.i.n.al walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anaesthesia to settle this point before operation is decided upon. Rectal examination is most important to estimate the condition of the sacro-uterine ligaments, the cervix being pulled down so as to place them on the stretch.

Occasionally, cases of carcinoma of the cervix are seen, in which the cellular tissue immediately surrounding the cervix is apparently free from disease, but if search be made further outwards, a hard, fixed ma.s.s is found plastered, as it were, on to the side of the pelvis, indicating advanced disease of the lymphatic glands, or cellular tissue at the outer part of the broad ligaments. Such cases are hopeless for operation.

If the disease is in the sloughing stage, and there is foul discharge, Paquelin's cautery should be applied to the diseased surface, followed by v.a.g.i.n.al douches of formalin (?j to the pint), or some other efficient antiseptic, given three times a day for three days prior to operation.

The operation consists of three main stages:--

(_a_) Separation of the cervix from the v.a.g.i.n.a, pushing up of the bladder and ureters, and opening the anterior and posterior peritoneal pouches.

(_b_) Removal of the uterus by ligaturing and dividing the broad ligaments.

(_c_) Treatment of the peritoneal and v.a.g.i.n.al flaps thus left.

First of all, the growth, if of the cervix, should receive careful preliminary attention, for it const.i.tutes a continuous source of infection, not only by means of septic organisms, but also of cancer cells, which may become implanted in the wound and cause early recurrence. The cervix is drawn down with a volsella and all visible growth is burnt away with the Paquelin cautery, until apparently healthy tissue only is left. The cervix is then completely closed by the application of a volsella or three or four stout silk sutures, pa.s.sing through both anterior and posterior lips. The ends of the sutures may be left long if preferred and serve as tractors.

After these preliminary measures against infection have been completed, the removal of the uterus is proceeded with. A posterior speculum, Auvard's or Pozzi's, is pa.s.sed, and the cervix is drawn downwards and somewhat backwards by traction on the volsellum or the long ends of the silk sutures. A sound is pa.s.sed into the bladder to define its lower limit. A transverse or T-shaped incision (Fig. 48) is now made through the v.a.g.i.n.a at the level of the cervico-v.a.g.i.n.al junction in front. This const.i.tutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, pa.s.sing through the whole thickness of the v.a.g.i.n.a, but no further.

[Ill.u.s.tration: FIG. 69. GALABIN'S BROAD-LIGAMENT NEEDLE (RIGHT).]

[Ill.u.s.tration: FIG. 70. JESSETT'S BROAD-LIGAMENT NEEDLE.]

The knife is now laid aside, and the operator proceeds to push up the v.a.g.i.n.a and bladder from the anterior aspect of the cervix with the index-finger or a winged director, until the anterior peritoneal pouch is reached. This is at once recognized by its glistening white appearance and by the manner in which its opposing surfaces glide over one another.

This part of the operation must be conducted very cautiously for fear of injury to the bladder: the pulp of the finger only must be used in the separation. The frequent use of the bladder sound is very useful at this stage, as it is quite easy to wound this viscus laterally. Bleeding from the divided twigs of the v.a.g.i.n.al vessels often obscures the field of operation and renders the separation of the bladder troublesome: it well repays the operator to stop all bleeding after making the v.a.g.i.n.al incision.

The peritoneum is next picked up and opened with scissors. The anterior fold of peritoneum may sometimes be more easily reached after the bases of the broad ligaments have been ligatured and divided, thus allowing the uterus to be drawn down more readily, and making the peritoneum more accessible. An anterior retractor is then pa.s.sed to keep the bladder out of the way.

[Ill.u.s.tration: FIG. 71. v.a.g.i.n.aL HYSTERECTOMY. The patient is in the lithotomy position, the v.a.g.i.n.al incisions have been made and the peritoneal cavity opened. The left broad ligament is exposed, and a Galabin's needle threaded with silk is being pa.s.sed from before backwards on to the index-finger of the operator's left hand inserted into the peritoneal cavity. (_Semi-diagrammatic, from a photograph._)

_a, a_{1}, a_{11}_. Retractors.

_c._ Cervix.

_p._ Suprav.a.g.i.n.al cervix denuded of its coverings.

_ut._ Uterine artery.

_b.lig._ Broad ligament.

_n._ Galabin's needle.

_v._ Volsella.

A second incision similar to the first is now made across the posterior aspect of the cervix at the level of the cervico-v.a.g.i.n.al junction, more or less cellular tissue is traversed, and the posterior peritoneal pouch is opened. By joining the ends of these two incisions the cervix is completely separated from the v.a.g.i.n.a.

The uterus is now suspended in the pelvis by the attachments of the broad ligaments only; the next step consists in ligaturing and dividing these. The cervix is drawn over towards the patient's right side by an a.s.sistant, so as to expose the base of the left broad ligament.

Additional s.p.a.ce is gained by drawing aside the left wall of the v.a.g.i.n.a by means of a retractor. By pa.s.sing the left index-finger behind the broad ligament the tube and ovary can be easily felt, and if necessary the bent finger can pull them down for inspection; the finger is then placed beside the cervix below and behind the base of the broad ligament. A Galabin's or Jessett's (Fig. 70) needle, carrying a stout silk suture, is pa.s.sed through the ligament from before backwards, on to the tip of the finger (Fig. 71).

[Ill.u.s.tration: FIG. 72. v.a.g.i.n.aL HYSTERECTOMY. _Final stage._ The uterus has been removed, and the peritoneal flaps are in process of suture.

_a, a_{1}, a_{11}, a_{111}._ Retractors.

_f, f'._ Spencer Wells forceps attached to the anterior and posterior v.a.g.i.n.al flaps.

_p._ Circular orifice left open in the peritoneal flaps for insertion of gauze drain.

_sp._ Stump of left broad ligament with bundle of ligatures (_l_).

_cl._ c.l.i.toris.

_l.m._ Labium majus.

_u._ Urethra.

The ligature should be pa.s.sed about one-third of an inch up the broad ligament. It is then tied tightly and the ends left long and drawn aside. The segment of broad ligament included in the ligature is divided as near the uterus as is justifiable; in carcinoma of the cervix at least half an inch from the disease should be allowed. Care must be taken at this stage to avoid injury to the ureters; these lie about one inch distant from the cervix; consequently all ligatures must be pa.s.sed as near the cervix as possible compatible with being clear of the disease.

A second ligature is now pa.s.sed through the broad ligament above the first and then a third, and more if necessary. The second generally includes the uterine artery, which can always be recognized by its strong pulsation under the finger; the third ligature will control the Fallopian and ovarian arteries. After the arteries on the left side have been secured and divided, attention is directed to the right broad ligament. The cervix is drawn over to the left side, the fundus delivered, and the upper portion of the right broad ligament is dealt with in a similar manner, but from above downwards. If the ovaries and tubes are diseased, they can now be removed by piercing the pedicle and tying the stump in the usual way.

[Ill.u.s.tration: FIG. 73. SCHAUTA'S NEEDLE-HOLDER.]

The uterus having been extirpated, the next step consists in dealing with the wound. First, all bleeding is stopped, and the wound is swabbed clean and dry. The ligatures on either side are tied in two bunches and the ends cut off just within the v.a.g.i.n.a (Fig. 72). The anterior and posterior flaps of peritoneum are united with a few catgut sutures pa.s.sed by means of Schauta's needle-holder (Fig. 73); the walls of the v.a.g.i.n.al vault are treated in a similar fashion, leaving a circular orifice in the median line into which gauze can be inserted for the purpose of drainage.

Some operators prefer to control the vessels in the broad ligaments by means of haemostatic forceps instead of ligatures. Each broad ligament is clamped in three or more portions and the tissue between them and the uterus cut through. They must be allowed to remain in position for at least forty-eight hours, as recurrent haemorrhage is possible if they are removed earlier. The only advantages of the forceps appear to be the rapidity with which the operation can be carried out, and the good drainage. The disadvantages are, that it is a somewhat unsurgical proceeding; there is often much pain from the nipping of the broad ligaments, and inconvenience from the presence of the handles between the l.a.b.i.a; the intestines may be damaged; sloughing and risk of sepsis must be reckoned with.

=After-treatment.= The catheter should be used at first four times daily; the author recommends that the gauze should be removed at the end of twenty-four hours, but some operators retain it longer. The ligatures should be pulled upon a little daily after the seventh day, and they gradually cut their way through the tissues in their grasp. No v.a.g.i.n.al douching should be administered until after the expiration of a week.

=v.a.g.i.n.al hysterectomy for fibroids.= This is not often called for. The operation is necessarily limited to fibroid uteri not exceeding in size a ftal head. Uterine fibroids of such a size can usually be treated in other ways, either temporarily by curetting, or, if submucous, permanently by enucleation through the v.a.g.i.n.a. The operation is most suitable for uteri containing many small fibroids causing severe haemorrhage which cannot be controlled by more palliative measures.

The v.a.g.i.n.a must be large enough to admit of delivery of the uterus through its lumen. Therefore, in virgins and nulliparae, the abdominal operation is always to be preferred. In any case, if the v.a.g.i.n.a be too narrow, additional room may be gained by lateral v.a.g.i.n.al section (see p.

148) or episiotomy.

The operation does not differ in technique from the removal of the uterus for carcinoma, already described. In some cases it may be preferable to bisect the uterus in the sagittal plane before removing it, after the cervico-v.a.g.i.n.al attachments have been separated and the peritoneal pouches opened.

SECTION II

OPHTHALMIC OPERATIONS

BY

M. S. MAYOU, F.R.C.S. (Eng.)

a.s.sistant Surgeon, Central London Ophthalmic Hospital; Surgeon, The Children's Hospital, Paddington Green