This is sometimes referred to as 'navel delivery', and of this several examples have been recorded. In one such case a ftus was extracted by a butcher: the woman recovered, and the account of this remarkable case ends thus: 'She had a navel rupture, owing to the ignorance of the man in not applying a proper bandage' (_Phil. Trans._, Abridged Edition, 1805, vol. viii, p. 517). This is a good instance of professional bias in the apportioning of blame.

Usually, when pathogenic micro-organisms gain access to the gestation-sac the ftus decomposes, and fistulae form, by which pus, accompanied by fragments of ftal tissue and bones, finds an exit and affords evidence of the nature of the case. These fistulae may open into the r.e.c.t.u.m, bladder, v.a.g.i.n.a, uterus, or some spot on the anterior abdominal wall below or near the umbilicus. The treatment is simple, and consists in dilating the sinus and extracting all the fragments. If this be thoroughly carried out the sinus quickly closes. Partial operations are useless: if but a bit of a bone remain, a troublesome sinus will persist. It is bad practice to attempt to extirpate the sac in such condition; such an operation usually terminates fatally.

In a case of old-standing lithopaedion it is unusual to find any trace of the placenta. J. W. Smith operated on a woman in whom a lithopaedion had caused intestinal obstruction. The ftus had probably been retained 15-1/2 years, and the placenta was represented by a calcified encapsuled ball, with an average diameter of 6 cm.

=Results of operative treatment.= In order to afford some notion of the risks attending the surgical treatment of extra-uterine gestation, as well as to give an idea of its relative frequency in hospital practice, the following figures will serve. From 1896 to 1907, both years inclusive, 116 operations were performed for extra-uterine gestation in the Chelsea Hospital for Women. During this period all the varieties of tubal pregnancy were encountered (ampullary, isthmial, tubo-uterine), including the rare condition of a full-time living ftus free among the intestines, and the more uncommon condition of a full-time cornual pregnancy. There were four deaths in the series, one in 1897, 1902, and two in 1905. Death in the fatal cases was attributed to pulmonary embolism, peritonitis, and in two to heart failure.

A TABLE SHOWING CASES OF CONCURRENT INTRA- AND EXTRA-UTERINE PREGNANCY (COMPOUND PREGNANCY) RUNNING TO TERM, WITH THE FATE OF THE MOTHER AND CHILDREN.

+-----------+-------+---------+--------------+--------------+

_Recorder._

_Year._

_Fate of

_Intra-uterine

_Extra-uterine

Mother._

Child._

Child._

+-----------+-------+---------+--------------+--------------+

Cooke

1863

Died

Died

Died

Sale

1871

Died

Lived

Lived

Wilson

1880

Died

Died

Lived

Galabin

1881

Died

Died

Died

Franklin

1893

Died

Lived

Died

Matthewson

1894

Lived

Lived

Killed[1]

Ludwig

1896

Lived

Lived

Lived

Allardice

1905

Lived

?

Dead[2]

Menge

1907

Lived

Lived

Lived

+-----------+-------+---------+--------------+--------------+

[1] This ftus was killed by means of a stilette pa.s.sed through the abdominal wall of the mother into its thorax. The patient had two subsequent confinements without difficulty. In 1898 the 'lump' had shrunk, but was movable and caused no difficulty. _Pacific Medical Journal_, September, 1898.

[2] Intra-uterine child born naturally at the seventh month.

Extra-uterine ftus died, set up septic changes, and was removed by cliotomy some weeks later.

REFERENCES

LEOPOLD. Ovarialschw.a.n.gerschaft mit Lithopadionbildung von 35-jahriger Dauer. _Arch. f. Gyn., 1882_, Bd. xix. 210.

MENGE. Eine reine Ovarialschw.a.n.gerschaft mit bebendem Kinde. _Vide_ Frankische Gesellschaft fur Geburtshulfe and Frauenheilkunde.

_Munch. med. Wochensch., 1907_, liv. 2452.

SMITH, J. W. _Jour. of Obstet. and Gyn. of the British Empire, 1908_, xiii. 180.

STONHAM, C. Lithopaedion, _Trans. Path. Soc., 1887_, x.x.xviii. 445.

WORRALL. Ectopic Gestation complicating Normal Pregnancy. Abdominal section. Recovery. _Med. Press and Circular, 1891_, i. 296.

CHAPTER V

HYSTERECTOMY AND MYOMECTOMY

_Hysterectomy is the name applied to the surgical operation for the removal of the uterus._

=Indications.= Hysterectomy is mainly required in the radical treatment of fibroids and malignant disease (carcinoma, sarcoma, and chorion-epithelioma). It is occasionally required for injury, and certain morbid states due to acute and chronic sepsis; and for a condition but little understood, termed generically fibrosis.

Hysterectomy is also carried out for such conditions as diffuse adenomyoma of the uterus, haemato-metra, tuberculous endometritis, and on rare occasions for chronic inversion of the uterus and inveterate dysmenorrha.

The presence of fibroids in the uterus is a common cause for which hysterectomy is required, and the history of this operation is full of interest.

The uterus may be removed by two methods. In one, access is obtained to the uterus through an incision in the belly-wall; this is termed abdominal hysterectomy. In the other, the whole uterus is extirpated through the v.a.g.i.n.a, and on this account it is termed v.a.g.i.n.al hysterectomy or colpo-hysterectomy.

The abdominal method of removing the uterus may be performed in two ways:--

In one the body of the uterus and a portion of its neck is removed; this is called subtotal hysterectomy (or suprav.a.g.i.n.al hysterectomy). In the other the body of the uterus and the whole of its neck are excised: this is total hysterectomy (or panhysterectomy). The ovaries and Fallopian tubes may, or may not, be removed, according to the disease for which the operation is undertaken. This is a matter which will receive ample consideration later on (see p. 56).

For the satisfactory performance of abdominal hysterectomy the Trendelenburg position is necessary.

SUBTOTAL HYSTERECTOMY

The abdomen is opened by the median sub.u.mbilical incision; but when the operation is performed for the removal of large tumours it will frequently require extension above the umbilicus. The operator should never allow himself to be embarra.s.sed by a small incision. As soon as the peritoneal cavity is reached, the surgeon introduces his hand and carefully makes out the nature of the case, the presence or otherwise of adhesions, other tumours, and the relation of the fibroid to the uterus, and determines whether it is impacted in the pelvis. The uterus is then carefully lifted out through the incision, or drawn out with the a.s.sistance of a volsella; the intestines and omentum are isolated from the pelvis with a large warm dab.

[Ill.u.s.tration: FIG. 9. A DIAGRAM TO SHOW THE ARTERIAL SUPPLY OF THE UTERUS.]

In a simple case the broad ligaments are seized with haemostatic forceps; if the ovaries and tubes are healthy and the surgeon wishes to preserve them, the forceps are applied between the ovary and the uterus; but if they are obviously diseased and must be sacrificed, the forceps are applied to the broad ligaments near the brim of the pelvis beyond the outer pole of the ovary. In some instances the round ligament of the uterus can be seized with the same forceps, but in many cases it is necessary to clip it separately. It is an advantage to secure the round ligament at this stage, for the forceps controls its artery and prevents the stump of the ligament unduly retracting the peritoneum. The broad and round ligament on each side are divided, and the uterine artery is exposed on each side of the uterus and caught with forceps: a peritoneal flap is then fashioned on the anterior wall of the uterus at its junction with the neck, taking care not to injure the bladder; and a similar flap is cut on the posterior wall. The uterus is then detached at a point well below the junction of the cervix with the body of the uterus: if the forceps are correctly applied to the vessels the detachment of the uterus is an almost bloodless proceeding: a small vessel here and there will perhaps require the application of a pair of forceps.

The principle involved in this part of the operation may be explained by reference to the diagram (Fig. 9). The blood-supply of the uterus follows four routes; two of these are the ovarian arteries which traverse the broad ligaments to reach the cornua of the uterus, where they anastomose with the terminations of the uterine arteries; the latter come into relation with the uterus near the junction of the body and cervix, and then ascend the sides of the uterus to the cornua. No large vessels are found on the anterior or posterior surface of the uterus. An arterial twig runs along the round ligament, bringing the ovarian artery into relation with the deep epigastric artery. If the surgeon thoroughly appreciates the distribution of the ovarian and uterine vessels he will at once perceive that if the four forceps are properly applied to the vessels the blood-supply is under absolute control: indeed, in many cases a subtotal hysterectomy can be performed without the loss of more than an ounce of blood. When the broad ligament is clamped and detached there is a spurt of blood from the uterine cornu which lasts until the corresponding uterine artery is caught with the forceps, and the cessation of the bleeding at the uterine cornu is a sign that the artery is securely clipped. It must be remembered that with a small tumour in the uterus the vessels follow their normal courses and can be easily found, but when the uterus is deformed by huge tumours, the vessels are not so easily seen, and they are of large size and give rise to furious bleeding when divided. In dealing with large and vascular uterine fibroids another factor has to be reckoned with, namely, the enormous veins in the pampiniform plexus, interspersed with lymphatics which in some cases are as thick as the index-finger; it is not an uncommon thing to meet with lymphatics in this situation a centimetre in diameter and filled with straw-coloured lymph.

[Ill.u.s.tration: FIG. 10. A FIBROID GROWING NEAR THE RIGHT UTERINE CORNU.

It separates the ovarian ligament, Fallopian tube, and round ligament of the uterus from each other. Full size.]

The surgeon now secures the vessels. The ovarian pedicles are transfixed and ligatured with silk as in ovariotomy: the round ligament is usually included in the ovarian pedicle. It occasionally happens that a fibroid situated near the uterine cornu will grow in such a manner that it widely separates the ovarian ligament, the Fallopian tube, and the round ligament from each other as shown in Fig. 10. In such a condition it is impossible to save the ovary without risk, and also inadvisable to attempt the inclusion of the round ligament in the pedicle containing the ovarian vessels. In these circ.u.mstances the round ligament is easily secured by a mattress suture, which should include both layers of the corresponding broad ligament.

[Ill.u.s.tration: FIG. 11. THE MATTRESS SUTURE. A diagram to show the method of applying it.]

When the surgeon decides to leave an ovary and the corresponding Fallopian tube, these structures are carefully examined to determine if they are healthy and free from any suspicious fluid. _When the endometrium is septic or cancerous both ovaries and tubes should be removed._ When the surgeon decides to leave an ovary and its corresponding Fallopian tube, he should take care in securing the ligatures to include the ligament of the ovary: it is very liable to slip out of the encircling loop of silk. It is often convenient to include the round ligament of the uterus in the pedicle, but it is not a disadvantage when it is tied separately.

[Ill.u.s.tration: FIG. 12. THE STUMP AFTER SUBTOTAL HYSTERECTOMY. To show the method of applying the continuous suture.]

The uterine arteries are ligatured with thin silk; these vessels as they run up the sides of the uterus are accompanied by veins, so that there is a vascular tract at the point where the cervix is divided. If after the uterine vessels are secured there is oozing from these veins, it is easily controlled by a mattress suture. This kind of suture is so useful that the mode of inserting it may be given in more detail. In the diagram (Fig. 11) the silk is represented in position before it is tied, and in that particular instance it is represented as being pa.s.sed through the peritoneal flaps from before backwards, and this is usually the most convenient route; occasionally the reverse direction is easier. It will be noticed in the diagram that this suture not only controls oozing from the tissue in the immediate neighbourhood of the uterine vessels, but it also embraces the main vessels, and thus serves as an additional security against haemorrhage; it also brings the peritoneal flaps into apposition.

As soon as the oozing of blood has been controlled, the cervical ca.n.a.l is examined to ascertain if it be free from polypi or cancer. Should the condition of the cervix be in the least degree suspicious of cancer it must be extirpated. When it is healthy, then the flaps are brought together by one or two interrupted sutures, and the edges more carefully approximated by a continuous suture of thin silk. In suturing the flaps it is necessary to avoid puncturing the bladder, which is quite close to, and often forms part of, the anterior flap. Care must also be taken in pa.s.sing the needle (especially when it has sharp edges) in the neighbourhood of the stumps of the uterine arteries, or they will be p.r.i.c.ked, and then free bleeding will cause delay in the operation.

When this operation is properly performed, there should be no projecting stump on the floor of the pelvis; the sutured edges of the peritoneum merely appear as a thin line below the base of the bladder.

The pelvis is now cleared of blood and clot; the dabs and instruments are counted, and it is also useful to examine the condition of the vermiform appendix, and if grossly diseased it should be removed.

The abdominal incision is then sutured in the way described on p. 9.

TOTAL HYSTERECTOMY

This operation differs from the preceding in the fact that the neck of the uterus is removed as well as its body. The abdomen is opened in the usual way and the uterus is withdrawn from the abdomen and the arteries controlled by forceps, and the broad ligaments divided exactly as in the case of the subtotal operation. Unless the uterus be very big it is drawn well out of the abdomen and the bladder peeled off its anterior aspect. The surgeon then feels for the extremity of the cervix and opens the v.a.g.i.n.a with the scalpel and carefully detaches it from the neck of the uterus, taking great care to keep close to the cervix in order to avoid wounding the bladder or the ureters. As soon as the uterus is detached, the cut edge of the v.a.g.i.n.a is seized with the volsella to prevent it retracting. In some instances the body of the uterus may be removed as in the subtotal operation, and the cervix detached separately; occasionally the surgeon begins his operation with the intention of performing the subtotal operation, but finds the cervix unhealthy or cancerous, and removes it.

As soon as the uterus is removed and all bleeding under control, then the blood-vessels are secured with ligatures; the ovarian artery and vein are secured on each side in the usual manner. The chief point in this operation is the method of dealing with the v.a.g.i.n.al opening. In the subtotal operation the vessels concerned in the stump are the uterine arteries, but in the total operation the territory of the v.a.g.i.n.al arteries is invaded, and these vessels are apt to bleed when the patient is returned to bed, unless care is taken to secure them in the course of the operation. The parts which require most attention are the lateral angles in the immediate neighbourhood of the uterine arteries; these angles may be secured by a mattress suture involving the anterior and posterior wall of the v.a.g.i.n.a; any oozing on the anterior or posterior wall is commanded by a mattress suture involving these walls separately, so as not to completely close the v.a.g.i.n.al opening. Bleeding from the cut edges of the v.a.g.i.n.a may also be readily controlled by means of a continuous suture of thin silk. The peritoneum is sutured over the cut ends of the v.a.g.i.n.a, so that when the operation is completed a thin seam is seen lying under the base of the bladder.

In cases where the uterus is removed for septic conditions, such, for example, as an infected or gangrenous fibroid, or when cancer of the corporeal endometrium and a submucous fibroid coexist, I modify the last stages of the operation. After the ovarian and uterine arteries are ligatured, the cut edges of the v.a.g.i.n.a are secured in the following way: the cut edge of the peritoneum covering the bladder is st.i.tched to the cut edge of the anterior wall of the v.a.g.i.n.a, and in the same way the peritoneum in relation with the posterior v.a.g.i.n.al wall is st.i.tched to the corresponding cut edge of the v.a.g.i.n.a. The flaps at the lateral angles of the v.a.g.i.n.al opening are drawn together with a suture and the intervening segment is left with merely the cut edges in apposition: this affords a route for the escape of pus if required.

Whether the peritoneum is sutured over the v.a.g.i.n.al opening, or whether the edges are merely left in apposition, the recesses of the pelvis are thoroughly cleared of fluid and clot. The dabs and instruments are counted, and the wound sutured as recommended on p. 9. In septic conditions the abdominal incision should be closed with a single row of through and through sutures. Before the patient leaves the operating table it is useful to examine the v.a.g.i.n.a and mop out any blood which has found its way there in the course of the operation. It is also useful to pa.s.s a gla.s.s catheter and withdraw any urine that has acc.u.mulated during the operation.

If there is evidence of free oozing it is most likely to come from the cut edges of the v.a.g.i.n.al wall in a case of total hysterectomy: under such conditions it is easy to apply a pair of fenestrated forceps to the oozing area and leave them on for thirty-six hours. They will cause the patient trifling inconvenience. Care must be taken not to fix the blade too far on the anterior flap, or it will lead to subsequent sloughing of the bladder.

When there is free oozing of blood from the cervical ca.n.a.l after subtotal hysterectomy, it is easily and safely controlled by applying a pair of fenestrated forceps on each side of the cervix, but not too deeply, or the ureters may be nipped. These should be left on for thirty-six hours.