CHAPTER IX

OPERATIONS UPON THE UTERUS DURING PREGNANCY, PARTURIENCY, AND PUERPERY

Pregnancy is apt to be complicated with tumours growing in the walls of the uterus, _e.g._ fibroids, cancer of the neck of the uterus, or cysts and tumours of one or both ovaries; morbid conditions of the Fallopian tubes, _e.g._ pyosalpinx, tubal pregnancy; tumours and cysts in the broad ligament; displaced viscera occupying the pelvis, _e.g._ the spleen or the kidney; tumours arising in the pelvic bones, _e.g._ osteoma, enchondroma, or sarcoma; and echinococcus cysts and colonies growing in the omentum, but occupying the pelvis, or arising in the pelvic tissues.

This is a formidable list, and any one of them may so complicate the pregnancy that it may be necessary to remove the tumour, and in some instances to perform Cæsarean section, or even hysterectomy.

CÆSAREAN SECTION

This signifies the removal of a fœtus and placenta from the uterus through an incision involving the abdominal and uterine walls.

This operation is required when the outlet of the pelvis is too narrow to permit the transit of a viable child, as in rickets and osteomalacia; when the vagina is malformed; when the pelvic outlet is narrowed by tumours growing from the pelvic wall. Occasionally the passage of a fœtus is barred by tumours growing from the uterus, especially a large cervix fibroid, or a fibroid growing from the lower segment of the uterine wall. An ovarian cyst, especially a dermoid incarcerated by the uterus, may render this operation necessary. The rarest causes are cancer of the neck of the uterus and cancer of the rectum.

This operation is advocated by some obstetricians in certain cases of eclampsia and placenta prævia.

=Operation.= When it is known some days beforehand that the patient will be submitted to this operation, she should be prepared as for ovariotomy. Often it happens that the operation is undertaken after labour has commenced, and in circumstances which make time very precious. Even then the abdomen, pubes, and vulva can be shaved and thoroughly washed with warm soap and water, and lightly rubbed with ether and cotton wool.

The instruments required are those given on p. 5.

When the patient is under the influence of ether and the bladder emptied with the catheter, an incision is made in the linea alba from the umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy is very thin, and, unless the surgeon be cautious, the knife will come in contact with the uterus before he is aware of it.

The uterus lies just under the incision, and the operator ascertains that it lies centrally (often the uterus is somewhat rotated to the right or left), and then makes a free incision through the uterine wall and extracts the fœtus and placenta; as the uterus contracts, he slips his left hand behind the fundus, and grasps the uterus near the cervix, and effectually controls the bleeding. The assistant passes a large warm flat dab into the belly to restrain the intestines and omentum. The uterine cavity is sponged out, and the finger passed through the os uteri into the vagina in order to ensure a free passage for blood and serum.

The incision in the uterine wall may be closed either by a double or a single set of silk sutures. When two layers of sutures are employed, the first set involve the mucous and adjacent half of the muscular layer[;] these sutures should be fairly close together, for they not only bring the parts into apposition, but they restrain the bleeding. A second row of silk sutures is now inserted, including the serous coat and adjacent half of the muscular layer. These threads should not be tied too tightly, as the tissues of a gravid uterus are soft and easily tear. In closing the uterine incision the surgeon should not spend time vainly in endeavouring to stanch the bleeding from the edges of the incision; this is best effected by dexterously inserting and securing the sutures.

The recesses of the pelvis are carefully cleaned by gentle sponging, and the parietal incision is closed as after ovariotomy.

The dressing varies with the fancy of the operator; a piece of sterilized gauze and a square of Gamgee tissue held in position by a many-tail of flannel firmly applied is all that is necessary.

Although Cæsarean section is one of the simplest operations that can be performed on the pelvic organs, it formerly had a very high mortality; but since the principles of asepsis have been thoroughly established the death-rate from this operation has been so reduced that it varies from 4 to 10% according to the skill of the operator; indeed the results are so good in the hands of careful and skilful men that on recovery from the operation the patient may reconceive, and there are conditions in which the patient is desirous to produce more children with the knowledge that they must be extricated by Cæsarean section. There are many instances on record of women being submitted to this operation twice, and some thrice; and at least two patients have undergone this operation four times (Sinclair). In view of the fact that a woman after being submitted to Cæsarean section may reconceive, it has been urged (especially by Sinclair) that the anterior surface of the uterus should be attached to the abdominal wall in such a manner as to promote the formation of adhesions, so that when the patient needs to be submitted to ‘repeated Cæsarean section’, the adhesions resulting from the primary operation will so shut off the operation area from the general peritoneal cavity, that the uterus may be opened and the fœtus and placenta extracted by a practically extraperitoneal operation. This question has been discussed in an able and comprehensive paper by Wallace, and also by Sinclair.

There is one great danger which women run by becoming pregnant after Cæsarean section, namely, rupture of the uterus. Some cases illustrating this accident have been reported. This accident has been discussed by Wallace.

Although a few writers, particularly Wallace, consider that all Cæsarean sections should be performed with a view to ulterior pregnancy, this is not the opinion of the majority, for there are many women who, having passed such an ordeal once, have no desire to do so again, and ask for something to be done to prevent its possibility in the future. This involves what is known as ‘sterilization’.

=Sterilization after Cæsarean section.= When Cæsarean section is performed the uterus is preserved, and after convalescence the woman is in a position to reconceive. There are conditions in which she is most anxious to produce more children even with the risk of having them extracted by this operation. On the other hand, some women, knowing the risks, ask that steps may be taken to prevent a recurrence of what they consider a catastrophe. This appears a simple matter, but it is not so in reality, for in many instances in which the operator had been under the impression that he had effected this by ligature of both Fallopian tubes in continuity, he has been surprised when the woman has again come under his notice well advanced in pregnancy.

This has happened even when each tube has been ligatured in two places and a segment of the tube exsected between the ligatures. Bilateral oöphorectomy has been recommended, but on the whole, when the patient and her husband wish that further risks should be avoided, the wisest plan is to perform subtotal hysterectomy instead of Cæsarean section; moreover it is a difficult matter to completely remove healthy ovaries, and _it needs only a small portion to maintain menstruation_ (Fig. 21).

The whole of this matter is one that is really a question of ethics, and the extreme views are represented by Wallace and Sinclair in the papers to which reference has already been made. The difficulty of effectively sterilizing women by simply relying on bilateral oöphorectomy is shown by the well-established cases in which patients have successfully conceived after bilateral ovariotomy and oöphorectomy.

The youngest patient on whom Cæsarean section has been carried out with success to the mother and child was thirteen years of age. The operation was performed by Gache in Buenos Ayres on account of smallness of the pelvis. Women have recovered after a self-inflicted Cæsarean section.

REFERENCES

DORAN, A. Pregnancy after Removal of both Ovaries for Cystic Tumour. _Journal of Obstetrics and Gynæcology of the British Empire_, 1902, 11, i.

GACHE, S. Opération césarienne sur une fille de 13 ans: Guérison. _Annales de Gynécologie_, 1904, p. 601.

HARRIS, R. P. Six self-inflicted Cæsarean Operations with recovery in five cases. _Am. Journ. of the Medical Sciences_, 1888, xcv. 150.

SINCLAIR, SIR WILLIAM. Cæsarean Section successfully performed for the Fourth Time on the same Woman, with remarks on the production of Utero-parietal Adhesions. _Journal of Obstetrics and Gynæcology of the British Empire_, 1907, xii. 335.

WALLACE, ARTHUR J. On Repeated Cæsarean Section. Ibid., 1902, ii. 555.

CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER

It occasionally happens that a woman in whom the course of pregnancy is nearly complete dies suddenly from disease, such as hæmoptysis, hæmatemesis, cardiac trouble, or uterine hæmorrhage in the preliminary stage of labour; or is killed by accident. In some such circumstance attempts are sometimes made to rescue the unborn child, by performing Cæsarean section. It is true that such efforts are rarely attended with success, but in cases where death is very sudden and the surroundings such as to enable the operation to be performed without delay, the child may be extracted from the uterus and survive. Successful cases of this kind are published from time to time.

In order to show how necessary it is to act promptly the following case may be mentioned:--

A woman in the eighth month of pregnancy was found to be suffering from cancer of the neck of the uterus. The child was alive. I decided to perform hysterectomy. The uterus was exposed through a free incision in the abdominal wall and quickly detached from its cervix. The uterus with the fœtus inside was handed to an assistant, who quickly extracted the child. Although the time which elapsed from the complete etherization of the mother until the extraction of the child from the uterus was 2-1/2 minutes, it required the display of some energy to induce the child to breathe. This is the first record as far as I know of a child being delivered alive from a uterus detached from its mother. The woman died on the fourth day after the operation, and the child on the fourteenth.

Möglich had a successful case. A patient aged forty-one years, with placenta prævia, died from hæmorrhage, and an asphyxiated fœtus was promptly extracted by cœliotomy. Prolonged efforts at artificial respiration were successful, and the child was well five weeks later (see also Sippel).

REFERENCES

HUGIER, M., and MONOD, M. Cæsarean Operation immediately after the death of the Mother. _Lancet_, 1829-30, i. 899.

MÖGLICH. Ueber Kaiserschnitt an der Toten. _Münchener med. Wochensch._, 1908, lv. 202.

SIPPEL. Sectio Cæsarea in mortua. _Monats. f. Geb. u. Gyn._, 1907, xxvi. 618.

OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOUR

Although the directions in surgical writings are clearly laid down concerning the course to be pursued when pregnancy and labour are complicated by an ovarian tumour, the difficulty which often confronts the operator when he is face to face with the actual case is uncertainty regarding the nature of the tumour. Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine fœtus (lithopædion), or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a Cæsarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. It may be useful also to mention what unexpected conditions are sometimes found. Thus an experienced gynæcologist like Prof. Olshausen once removed a gravid uterus under the impression that it contained a cystic fibroid which would obstruct delivery. When it was examined after removal, the suspected fibroid proved to be a large sacral teratoma growing from the fœtus.

=Ovarian tumours and pregnancy.= Before the fourth month of pregnancy, single and double ovariotomy is attended with a low rate of mortality, and the risk of disturbing the pregnancy is small. The removal of a parovarian cyst during pregnancy is more liable to be followed by abortion than single or double ovariotomy. After the fourth month the risk is that of an ordinary ovariotomy, but the chances of abortion increase with each month. It is also a fact that ovariotomy may be safely carried out between the eighth and ninth months of gestation without precipitating labour, even when the tumour is incarcerated in the pelvis.

In many cases in which ovariotomy is urgently indicated during pregnancy, the pedicle will be found twisted.

When the tumour is situated above the uterus there is rarely any difficulty in dealing with it, as the pedicle is usually long, but it will require extra care in applying the ligature, as the tissues, being unusually vascular and soft, are easily lacerated. Occasionally the tumour lies in the pelvis below the uterus: in this case the surgeon carefully insinuates his hand between the pelvic wall and the uterus, and then gently withdraws the tumour from its incarcerated position.

CASES IN WHICH OVARIOTOMY HAS BEEN PERFORMED NEAR THE END OF THE NINTH MONTH OF PREGNANCY

+------------+--------+---------+------------------------------------+ | |_Result |_Result | | | _Surgeon._ | to | to | _Reference._ | | |Mother._| Child._ | | +------------+--------+---------+------------------------------------+ |Pippingsköld| R. |Stillborn|_Am. J. of Obstet._, 1880 xiii. 308.| |Bland-Sutton| R. | Lived |_Brit. Med. Jour._, 1895, i. 461. | |Morse | R. | Lived |_Trans. Obstet. Soc._, xxxviii. 221.| +------------+--------+---------+------------------------------------+

In operating for ovarian cysts complicating pregnancy, the surgeon should, after removing the cyst, carefully examine the other ovary, for twin tumours may be present. Berry Hart performed ovariotomy on a woman in the fifth month of pregnancy, and removed a dermoid of the left ovary ‘enlarged to about the size of a man’s brain by recent hæmorrhage due to the twisting of a pedicle’. The patient died on the ninth day. A frozen section was made of the pelvis, and on inspecting the cut surface the right ovary, converted into a dermoid, was found incarcerated by the gravid uterus.

Many cases have been published in which ovariotomy has been undertaken during the late months of pregnancy, or shortly after delivery, and the surgeons have been astonished to find both ovaries converted into tumours; in very many instances they were dermoids. Cases of this kind have been recorded by Knowsley Thornton, F. Page, Cullingworth, Berry Hart, Malcolm Campbell, and others, including myself. These observations demonstrate that a woman may have both her ovaries occupied by dermoids, yet the glands are capable of yielding fertilizable ova.

Campbell relates that Brewis, in performing an ovariotomy during pregnancy, attempted to conserve some ovarian tissue by resecting the dermoids; this proved impracticable, and both ovaries were excised. Miss Ivens records a case in which a woman thirty-five years of age was five months pregnant and required ovariotomy on account of an incarcerated ovarian dermoid. In the course of the operation both ovaries were found to contain dermoids. A tumour was successfully excised from each. Pregnancy continued undisturbed.

REFERENCES

CAMPBELL, M. Case of Bilateral Ovarian Dermoid Tumour associated with Pregnancy. _Lancet_, 1907, ii. 1760.

CULLINGWORTH, C. J. Three cases of Suppurating Dermoid Cyst, of or near the Ovary, treated by Abdominal Section. _St. Thomas’s Hospital Reports_, 1887-9, xvii. 139.

HART, BERRY. See Clarence Webster’s _Researches in Female Pelvic Anatomy_, Edin., 1892, p. 124.

IVENS, MISS F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts. _Brit. Med. Journal_, 1908, i. 625.

PAGE, F. Acute Peritonitis after Confinement; abdominal section; Dermoid Disease of both Ovaries; removal; recovery. _Lancet_, 1893, ii. 250.

THORNTON, K. A case of removal of both Ovaries during Pregnancy. _Trans. Obstet. Soc._, London, xxviii. 41.

=Ovariotomy during labour.= When an ovarian tumour is discovered during labour and it impedes delivery, ovariotomy should be performed.

In this condition it follows that the tumour lies in the pelvis; when the tumour is tightly impacted by the contracting uterus it has happened that the surgeon has been unable to reach the tumour until he has emptied the uterus by Cæsarean section. Several operators have had this difficulty, myself among them. I have added a list of reported cases drawn from British sources. For this I hope not to be accused of what is sometimes perhaps facetiously called ‘insularity’. The enormous population of these islands should furnish material enough to settle the principles of treatment which should govern these terrible cases of obstructed labour.

One of the commonest conditions met with in ovariotomy during pregnancy and labour is to find that the cyst has undergone axial rotation and twisted its pedicle. The technique in these circumstances is very simple.

OVARIOTOMY FOR TUMOURS OBSTRUCTING LABOUR AT TERM

-----------+--------+--------+---------+------------------------------ |_Nature |_Result |_Fate | _Operator._| of | to | of | _Reference._ |Tumour._|Mother._| Child._ | -----------+--------+--------+---------+------------------------------ Williams |Cyst | R. |No record|_Trans. Obstet. Soc._, xxvi. | | | | 203. Spencer |Dermoid | R. | Lived |Ibid., xl. 14. Boxall[1] |Dermoid | R. | Lived |Ibid., xl. 25. Bland- |Dermoid | R. | Lived |_Lancet_, 1901, i. 382. Sutton[1]| | | | Sinclair[1]|Cyst | R. | Lived |_Lancet_, 1901, i. 158. Favell[1] |Dermoid | R. |No record|_Brit. Med. Journal_, 1901, i. | | | | 894. -----------+--------+--------+---------+------------------------------ [1] In these cases it was necessary to perform Cæsarean section in order to extract the tumour from the pelvis.

=Ovariotomy during the puerperium.= It occasionally happens that a woman may go through her pregnancy and labour with an unrecognized ovarian tumour in her abdomen; during the puerperal period it may cause symptoms which lead to its recognition, because in the course of the labour the cyst may burst, undergo axial rotation, or suppurate. When a puerperal woman possesses an ovarian tumour which gives rise to unfavourable signs, ovariotomy should be resorted to without delay. The operation in these circumstances is comparatively simple, and such adhesions as may be present are usually recent and easily overcome.

Single and even double ovariotomy can be performed during puerpery without in any way interfering with involution of the uterus or lactation.

In 1896 I was able to collect fifteen recorded cases of double ovariotomy during pregnancy, and sixteen in which ovariotomy was performed during the puerperium, or shortly after abortion. Since this date McKerron has collected the statistics relating to the whole question of pregnancy and ovarian tumours in a very comprehensive manner.

REFERENCES

BLAND-SUTTON. _Surgical Diseases of the Ovaries, &c._, London, 1896, 2nd Ed. pp. 180-91.

---- The Surgery of Labour and Pregnancy, complicated with Tumours, _Lancet_, 1901, i. 382, 452, 529.

MCKERRON, R. G. _Pregnancy, Labour, and Childbed with Ovarian Tumour_, London, 1903.

=Fibroids and pregnancy.= In a large number of instances in which operations have been undertaken when fibroids complicate pregnancy, they have been performed on an erroneous diagnosis. The tumours when small and placed laterally simulate ovarian cysts; when large and lying high in the abdomen they have been mistaken for renal tumours, and when low in the pelvis they have been regarded as incarcerated ovarian cysts. The variety of fibroid most likely to lead to operation, under the impression that it is an ovarian cyst, is an interstitial fibroid which becomes painful in consequence of undergoing red degeneration. The difficulty which faces the surgeon in this condition is to decide on a safe course.

When the tumour is not likely to cause difficulty it may be wise to close the abdomen. If the tumour is pedunculated and incarcerated, he may be able to extract the tumour and ligature the pedicle without disturbing the pregnancy; a big fibroid invading the broad ligament may be enucleated; a large cervix fibroid will render delivery impossible, and will necessitate hysterectomy.

A study of many recorded cases in which hysterectomy has been performed on account of fibroids complicating pregnancy shows that the operation had been undertaken on account of a great increase in the size of the tumours, the concurrent pregnancy not being discovered until the parts were examined after removal.

Hysterectomy may be necessary at any time during pregnancy; after labour has begun; and during puerpery on account of fibroids. During pregnancy it is a straightforward operation, the subtotal operation being preferable. When it is needed during puerpery it is for septic complications, and there is no greater difficulty in performing hysterectomy then than during pregnancy, but the risk to the patient from sepsis is much greater: therefore total hysterectomy with drainage is advisable.

Fibroids have many times been enucleated from the gravid uterus and the pregnancy has gone successfully to term.

When pregnancy complicated with fibroids goes to term and the tumour occupies the neck or the lower segment of the uterus so as to offer an impassable barrier to the passage of the fœtus, abdominal hysterectomy is a necessity.

=Red Degeneration.= Among the new things which the surgical treatment of uterine fibroids has brought to light is a knowledge of that change to which these tumours are liable, known as ‘red degeneration’.

This increase in our knowledge of the pathology of fibroids is extremely useful in diagnosis, for red degeneration is especially liable to occur in fibroids lodged in a pregnant uterus, and, as I pointed out in 1904, it has the effect of rendering them painful.

One of the most striking features of a uterine fibroid is its insensitiveness, and equally remarkable is its painfulness and tenderness when in a state of red degeneration, but these signs are only exhibited by such fibroids when associated with pregnancy.

Red degeneration, even in an extreme degree, in fibroids occupying the walls of a non-gravid uterus is, as a rule, painless. It is also curious that a gravid uterus may contain four or five fibroids, the size of large potatoes, in its walls, yet only one will exhibit this red degeneration and become acutely painful, whilst its companions remain as insensitive as apples. In the early stages of this change the fibroid exhibits the colour in streaks, but as the pregnancy advances it permeates the whole tumour. Occasionally in the mid-period of pregnancy this necrotic change may be so extreme that the central part (sometimes the whole) of the tumour is reduced to a red pulp.

The suddenness with which this pain comes on may be illustrated briefly by the following case:--A primigravida, aged 30, two months pregnant, was seized with sudden pain during a railway journey. Her condition became so alarming that she left the train at an intermediate station and placed herself under the care of a doctor whom she knew. A large, tender, and increasing swelling was found in the abdomen. The doctor regarded the patient’s trouble as being due to rupture of a tubal pregnancy. He asked me to see the patient, and I found a large swelling on the right side of the abdomen reaching as high as the liver. I considered that some change had taken place in this tumour consequent on the pregnancy: it was also probable that it might be an ovarian cyst which had twisted its pedicle. The swelling was very tender. On opening the abdomen the tumour proved to be a large subserous fibroid undergoing red degeneration. The gravid uterus contained several fibroids of the interstitial variety: it was removed. These fibroids exhibited the red change in streaks.

It is a curious and noteworthy fact that many of the operations tabulated on pp. 81 and 82 were undertaken on an erroneous diagnosis. In some the acute pain and tenderness of which the patients complained led the surgeons to believe that the troubles were due to an ovarian cyst which had twisted its pedicle, or to the bursting (or abortion) of a gravid Fallopian tube.

Practitioners and obstetricians are now becoming familiar with the fact that when a pregnant woman, who has also fibroids in the uterus, complains of sudden acute pain, it may be due to one of the fibroids undergoing red degeneration.

The cause of this change is unknown. Lorrain Smith and Fletcher Shaw, after an examination of four specimens, three of which were associated with pregnancy, believe that the change is due to thrombosis of the vessels of the fibroid. In two tumours they isolated micro-organisms, _e.g._ _staphylococci_ in one and _diplococci_ in another: the patients with these tumours exhibited toxic symptoms.

In my early investigations of this disease I often took the tumours to the bacteriological laboratory with the hope of finding some micro-organism which would account for the degeneration. The results were so persistently negative that the search was abandoned. Since learning that Smith and Shaw had found micro-organisms in two cases I had the next specimen which came to hand examined, and it happened to be the fibroid obtained from the acute case described on p. 79. From the softened parts Mr. Somerville Hastings succeeded in obtaining _staphylococcus pyogenes aureus_ in pure culture.

The views here expressed in regard to the red degeneration of fibroids are founded on an examination of thirty-four recent examples.

REFERENCES

BLAND-SUTTON, J. The Inimicality of Pregnancy and Uterine Fibroids. _Essays on Hysterectomy_, 1905, 76.

FAIRBAIRN, J. S. A Contribution to the Study of one of the Varieties of Necrotic Changes in Fibro-myomata of the Uterus. _Journ. of Obstet. and Gyn. of the British Empire_, 1903, iv. 119.

SMITH, J. L., and SHAW, W. F. On the Pathology of the Red Degeneration of Fibroids. _Lancet_, 1909, i. 242.

CASES OF HYSTERECTOMY PERFORMED ON PATIENTS IN LABOUR IN WHICH THE OBSTRUCTION WAS DUE TO FIBROIDS

-----------+--------+-------+----------------+----------------------- |_Result |_Fate | _Nature | _Operator._| to | of | of | _Reference._ |Mother._|Child._| Operation._ | -----------+--------+-------+----------------+----------------------- Spencer | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._, | | | Subtotal Hyst.| xxxviii. 389. Bland- | R. | D. |Total Hyst. |_Trans. Obstet. Soc._, Sutton | | | See Fig. 23. | xlvi. 238. Morison | R. | D. |Cæs. Sect., |_Northumberland and | | | Total Hyst. | Durham Medical | | | | Journal_, July, 1904. Acland | R. | ? |Cæs. Sect. and |_Lancet_, 1904, ii. | | | Subtotal Hyst.| 948. Spencer | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._, | | | Total Hyst. | 1906, xlviii. 240. Spencer | R. | D. |Cæs. Sect., |_Trans. Obstet. Soc._, | | | Total Hyst. | 1908. Pollock | R. | L. |Cæs. Sect., |_Trans. Obstet. Soc._, | | | Subtotal Hyst.| 1908. -----------+--------+-------+----------------+-----------------------

The aim of the surgeon is to save the life of the child as well as that of the mother. To this end, when the operation is carried out and the uterus exposed the child is extracted by Cæsarean section. Then in the majority of cases total or subtotal hysterectomy is performed. This is sometimes clumsily termed Cæsarean hysterectomy. In some instances the operator has been content merely to perform Cæsarean section in the hope that the patient may wish to reconceive.

In order to afford some notion of the frequency with which fibroids cause trouble to pregnant and parturient women, I have collected thirty-six cases which have been reported to the London Obstetrical Society from 1900 to 1908 (both years inclusive), and arranged them in the subjoined tables: they show in an unmistakable way that pregnant women with fibroids do often require aid from surgery, and that such efforts are rewarded with success. There is no condition which simplifies hysterectomy so much as pregnancy.

A TABLE OF CASES IN WHICH ABDOMINAL HYSTERECTOMY WAS PERFORMED FOR PREGNANCY COMPLICATED WITH FIBROIDS

These cases are recorded in the _Transactions of the Obstetrical Society_, 1900-8, both years inclusive.

------------+---------+--------------------+--------+----------------- | _Age | _Period |_Result | _Reference _Recorder._| of | of | to | to |Patient._| Pregnancy._ |Mother._| Volume._ ------------+---------+--------------------+--------+----------------- Horrocks | ? |5th month | ? |1900, xlii. 242. Routh | 33 |33 weeks | R. |Ibid., 244. Doran | 40 |5th month | R. |1901, xliii. 178. Donald | 43 |9th month | R. |1901, xliii. 180. Donald | 34 |4th month | R. |Ibid. Donald | 34 |4th month | R. |Ibid. Donald | 41 |4th month | R. |Ibid. Routh | ? |8-1/2 months | R. |1902, xliv. 41. 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 vagina.

When the cancer is so advanced as to be inoperable, the pregnancy should be allowed to go to term, and if the cancerous mass offer an impassable barrier to delivery, Cæsarean section should be performed. This operation has been found necessary to extract a dead fœtus.

Most surgeons in dealing with operable cases of this complication of pregnancy remove the parts through the vagina, 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 circumstances:--

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

2. _Intra- and extra-uterine gestation with living fœtuses 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 fœtus._ Many cases have been reported in which a fœtus of this character has occupied the pelvis, yet the woman conceived and the child was safely delivered at term; but a sequestered fœtus may constitute an impassable 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 Cæsarean section, and the uterus removed.

The operation in such circumstances 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, Küstner, Blacker, and others.

REFERENCES

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

KÜSTNER. Kaiserschnitt wegen eines Echinokokkus im Becken. _Zentralbl. f. Gynäk._, 1907, xxxi. 1390.

SKUTSCH, F. Ueber die Dermoidcysten des Beckenbindegewebes. _Zeitsch. f. Geburts. and Gynäk._, 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 BACTERIÆMIA)

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 vaginal route. It is possible that vaginal 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, Bumm, and others.

In some cases of puerperal pyæmia 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 pubes, 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. Bumm 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 septicæmia, 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 (cœliotomy), 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 cœliotomy. The ligature of thrombosed ovarian veins in chronic puerperal pyæmia 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

BUMM, E. Zur operativen Behandlung der puerperalen Pyämie. _Berliner Klin. Wochensch._, 1905, xlii. 829.

CUFF, A. A Contribution to the Operative Treatment of Puerperal Pyæmia. _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, xxxi. 123.

FRIEDEMANN, G. Die Unterbindung der Beckenvenen bei der pyämischen Form des Kindbettfiebers. _Münchener 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 Pyæmia. _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 Pyämie. _Münchener Med. Wochensch._, 1902, xlix. 513.