CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS

Injuries of the uterus fall into six groups:--

1. Gynæcological 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.

=Gynæcological 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 class 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 gynæcologists 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 cœliotomy and assure 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, cœliotomy should be performed. Sometimes a pelvic abscess occurs as a sequence to the accident, and will require evacuation through the vaginal 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 (vaginal 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 practitioner 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 practitioner had withdrawn and removed several feet of intestine through a rent in the course of a curettage, I performed cœliotomy, 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 practitioner had torn the uterus during curettage and intestine appeared in the vagina, 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 circumstances of the case, the character of the injury, and above all on the experience and resourcefulness of the practitioner.

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 (_Ausräumungszangen_), 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 fœtus 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 manœuvre known as ‘turning’.

The literature relating to this accident is abundant, and the reports issued from lying-in institutions 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 cœliotomy and stitching 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 fœtus and membranes are extruded from the uterus into the belly, cœliotomy 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 vagina 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 associated 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 fœtus. Cœliotomy was performed, the detached intestine cut away, and the proximal end of the bowel anastomosed into the cæcum. 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 mass.’ 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. Cœliotomy 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, butts 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 circumstances. As a general rule it may be stated that the most satisfactory mode of treatment is cœliotomy; 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 Cæsarean 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 illustrating 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 Cæsarean 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 Cæsarean section, as the following record shows:--

Sir Spencer Wells had removed a large, multilocular ovarian cyst from the left side of the patient, when he felt what was supposed to be a cyst of the right ovary. When tapped it was found to be a gravid uterus, in which pregnancy had advanced to near the fifth month. Cæsarean section was at once performed and the patient recovered.

Injuries of this kind are rarely likely to happen now, for the clumsy ovariotomy trocar is passing out of use.

=Bullet-wounds of the pregnant uterus.= These are very rare, and, like rupture of the uterus, liable to be complicated with injury of the intestines; it is for this reason that the canon of surgery applicable to penetrating wounds of the abdomen should be practised in these circumstances, and the patient submitted to cœliotomy.

When the gravid uterus is penetrated by a bullet there may be little bleeding on account of the contracting property of the uterine tissue. In some instances amniotic fluid stained with blood escapes. In operating, the anterior as well as the posterior surface of the uterus should be carefully examined in order to determine if the bullet passed through this organ. In some instances the fœtus has been injured by the bullet. When free bleeding follows a bullet-wound of the gravid uterus the hæmorrhage is usually due to damage of blood-vessels connected with the intestines.

The best method of dealing with the uterus in such conditions is undetermined, but a study of the few reported cases indicates that the best results follow cœliotomy, with suture of the perforated intestine and the hole or holes in the uterus. The patients usually abort. In Prichard’s case (Fig. 24) hysterectomy was performed, but the patient died.

Even in some apparently desperate cases good consequences follow the conservative operation, as the following reports demonstrate:--

In a case under the care of Albarran, the patient was aged nineteen years and in the fifth month of pregnancy when shot. There were four perforations of the small intestines, and the mesenteric artery was wounded. He resected 20 centimetres of small intestine. A loop of umbilical cord protruded through the bullet-hole in the uterus; this was resected and the ends of the cord tied. The patient miscarried a few hours after the operation, but recovered.

Baudet reported a case in which there were four perforations of the small intestine: he sutured the wounds in the uterus and the holes in the bowel; the woman aborted some hours after the operation, but recovered.

In a case under Robinson’s care the bullet entered the uterus and penetrated the right shoulder of the fœtus. The patient, who was in the eighth month of pregnancy, quickly miscarried. The bullet was found in the débris. The patient not only recovered, but reconceived, and gave birth to another child in the following year.

=Stab-wound of the pregnant uterus.= Examples of this kind of injury are rare, but some of the recorded cases are remarkable. Guelliot has recorded the details of a case in which a pregnant woman was stabbed in the buttock. The knife passed through the great sciatic notch, and penetrated the uterus and the child’s skull. The woman miscarried of a dead fœtus next day. The great sciatic nerve was injured, but the woman recovered, though she remained lame.

Steele recorded an example where a woman, six and a half months pregnant, stabbed herself in the lower abdomen with a knife; she was taken to a hospital and kept at rest until the wound healed. Six weeks after the injury the woman was delivered of a live male child, normally developed, but much of the child’s large and small intestines protruded through an opening in the abdomen. The jejunum was completely severed as a result of the stab. Steele attempted to deal with this extraordinary lesion surgically, but the child died a few hours later.

REFERENCES

ALBARRAN. Plaies multiples de l’intestin et de l’utérus gravide par balle de revolver. _Bull. et Mém. de la Soc. de Chirurgie de Paris_, 1895, xxi. 243.

BAUDET, R. Plaies de l’intestin et de l’utérus gravide par balle de revolver. _Bull. et Mém. de la Soc. de Chir. de Paris_, 1907, xxxiii. 779.

BLAND-SUTTON, J. A Clinical Lecture on the Treatment of Injuries of the Uterus. _The Clinical Journal_, 1908, xxxi. 289. On two cases of Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1907, lvi.

BRAUN-FERNWALD, R. VON. Über Uterusperforation. _Zentralbl. f. Gyn._, 1907, xxxi. 1161.

CONGDON, C. Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1906, liv. 618.

DONALDSON, H. J. An unusual Obstetric Complication, causing the removal of 126 inches of Small Intestine. _Surgery, Gynæcology, and Obstetrics_, 1908, vi. 417.

DUDLEY, P. Discussion on Accidental Rupture of the Non-parturient Uterus. _Trans. Am. Gyn. Soc._, 1905, xxx. 21.

GUELLIOT. Coup de couteau ayant pénétré à travers l’échancrure sciatique jusqu’à l’utérus gravide et jusqu’au fœtus, &c. _Société de Chirurgie_, 1886, xii, 337.

HARRIS, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of Pregnant Women. _The Am. Journal of Obstetrics_, 1887, xx. 673.

IVANOFF, N. De l’étiologie, de la prophylaxie et du traitement des ruptures de l’utérus pendant l’accouchement. _Annales de Gynécologie_, 1904, 449.

JAKOB, J. Gefahren der intra-uterinen instrumentalen Behandlungen. _Zentralbl. für Gyn._, 1906, xxx, No. 19, 561.

JARMAN, G. W. Accidental Rupture of the Non-parturient Uterus, with report of cases. _Trans. of the Am. Gyn. Society_, 1905, xxx. 15.

KEHR, H. Über einen Fall von Schussverletzung des graviden Uterus. _Centralbl. für Chir._, 1893, xx. 636.

KERR, MUNRO. On Rupture of the Uterus. _Brit. Med. Journal_, 1907, ii. 445.

KLIEN. Die operative and nichtoperative Behandlung der Uterusruptur. _Arch. f. Gyn._, 1901, lxii. 193.

PRICHARD, A. W. A case of Bullet-wound of the Pregnant Uterus. _Brit. Med. Journal_, 1896, i. 332.

ROBINSON, W. S. Death of Fœtus _in utero_ from Gunshot-wound: Recovery of the Mother. _Lancet_, 1897, ii. 1045.

STEELE, D. A. K. Stab-wound of Fœtus _in utero_. _Surgery, Gynæcology, and Obstetrics_, 1908, vi. 293.

VERCO, W. A. _The Australian Med. Gazette_, 1908, 681.

WALLA, A. VON. Ruptura uteri completa, abdominale Totalextirpation. Heilung. _Centralb. für Gynäk._, 1900, xxiv. 497.