A System of Operative Surgery, Volume IV (of 4)

NCY, AND

nditions 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

he pregnancy that it may be necessary to remove the tumour, and in

EAN S

lacenta from the uterus through an incision

wed by tumours growing from the pelvic wall. Occasionally the passage of a f?tus is barred by tumours growing from the uterus, especially a large cervix fibroid, or a fibroid growing from the lower segment

me obstetricians in certain cases

my. Often it happens that the operation is undertaken after labour has commenced, and in circumstances which make time very precious. Even th

required are tho

in the linea alba from the umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy is very thi

extracts the f?tus 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

r, 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

cleaned by gentle sponging, and the parie

terilized gauze and a square of Gamgee tissue held in position b

n which the patient is desirous to produce more children with the knowledge that they must be extricated by C?sarean 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 C?sarean section may reconceive, it has been urged (especially by Sinclair) that the anterior surface of the uterus should be attach

rean section, namely, rupture of the uterus. Some cases illustrating this

ncy, 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

er a supposed complete o?phorectomy had been performed to induce an artificial

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

commended, 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 instea

e papers to which reference has already been made. The difficulty of effectively sterilizing women by simply relying on bilateral o?phor

and child was thirteen years of age. The operation was performed by Gache in Buenos Ayres on a

ere

es for Cystic Tumour. Journal of Obstetrics and

une fille de 13 ans: Guérison. An

erations with recovery in five cases. Am. Jo

ime on the same Woman, with remarks on the production of Utero-parietal Adhesio

epeated C?sarean Sectio

MEDIATELY AFTER THE

or is killed by accident. In some such circumstance attempts are sometimes made to rescue the unborn child, by performing C?sarean section. It is true that such efforts are rarely attended with success, but in cases where

it is to act promptly the fol

s cervix. The uterus with the f?tus 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? minutes, it required

?morrhage, and an asphyxiated f?tus was promptly extracted by c?liotomy. Prolonged efforts at ar

ere

eration immediately after the death o

an der Toten. Münchener med

mortua. Monats. f. Geb.

ERECTOMY DURING PRE

varian 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 f?tus (lithop?dion), or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a C?sarean 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

arovarian 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 increa

urgently indicated during pregnancy

n applying the ligature, as the tissues, being unusually vascular and soft, are easily lacerated. Occasionally the tumour lies in the pelvis below the uterus: i

been performed near the End

n. Res

r. Re

. Ref

lborn Am. J. of Obst

ived Brit. Med. J

rans. Obstet. So

otomy 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 h?morrhage due to the twisting of a pedicle'. The

h 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 Camp

nd 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 incarcera

ere

rian Dermoid Tumour associated wit

Cyst, of or near the Ovary, treated by Abdominal Sect

er's Researches in Female Pelvi

d by Bilateral Ovarian Dermoid Cyst

abdominal section; Dermoid Disease of both Ova

oth Ovaries during Pregnancy. Trans

mour is discovered during labour and it impe

d the uterus by C?sarean 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 sometim

and labour is to find that the cyst has undergone axial rotation and t

umours obstructi

or. Na

r. Re

r. Fa

. Ref

record Trans. Obst

id R. Lived I

oid R. Lived

rmoid R. Lived La

R. Lived Lance

o record Brit. Med. J

perform C?sarean section in order t

f?tus of four months' development. Removed by the sub

ymptoms 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 u

med during puerpery without in any way interfer

ovariotomy was performed during the puerperium, or shortly after abortion. Since this date McKerron has collect

ere

ses of the Ovaries, &c., Lon

gnancy, complicated with Tumours

Labour, and Childbed with O

e 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 operat

erated, he may be able to extract the tumour and ligature the pedicle without disturbing the pregnancy; a big fibroid invading

ing pregnancy shows that the operation had been undertaken on account of a great increase in the size of

rward operation, the subtotal operation being preferable. When it is needed during puerpery it is for septic complications, and there is no greater difficulty in p

ted from the gravid uterus and the pr

es the neck or the lower segment of the uterus so as to offer an impassable

of uterine fibroids has brought to light is a knowledge of that ch

nosis, for red degeneration is especially liable to occur in fibroids lodged in a pregn

ually remarkable is its painfulness and tenderness when in a state of red degeneratio

, 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,

ery was obstructed by a cervical fibroid. The parts were removed by total hysterectomy. The sm

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

diagnosis. In some the acute pain and tenderness of which the patients complained led the surgeons to believe that the trou

hen a pregnant woman, who has also fibroids in the uterus, complains of sudden

associated with pregnancy, believe that the change is due to thrombosis of the vessels of the fibroid. In two tumours they isola

ults 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

d degeneration of fibroids are founded on an

ere

of Pregnancy and Uterine Fibroids

rieties of Necrotic Changes in Fibro-myomata of the Uterus. J

e Pathology of the Red Degeneration

on Patients in Labour in which t

tor.

er.

e of Operati

Subtotal Hyst. Trans. Ob

Hyst. See Fig. 23. Trans.

l Hyst. Northumberland and Dur

. and Subtotal Hyst.

Total Hyst. Trans. Obste

ct., Total Hyst. Tran

t., Subtotal Hyst. Tra

the child is extracted by C?sarean section. Then in the majority of cases total or subtotal hysterectomy is performed. This is sometimes clumsily termed C?

ed 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 wom

l Hysterectomy was performed for P

ansactions of the Obstetrical Soci

der.

t. Per

ncy. R

eference

h month ? 190

3 weeks R.

month R. 1901

month R. 190

4th mont

4th mont

4th mont

onths R. 190

? R. 1904,

4th month

30 ??

h month D.

3rd mont

week post partu

k post partum R.

month R. 190

day post partu

ek post partu

nth, total R.

n 39 4? mon

3rd mont

4? month

3 2? mont

bdominal Myomectomy was p

he Obstetrical Society, 19

der.

of Pregnancy. R

month R. 190

?? R. Ib

month R. 190

9th month R

week post partu

month R. 1905

th month R.

3? month

5th month

4? month

2 7th month

37 4? mont

39 3? mont

th cancer of the neck of the uterus in an operative stage in the early months, hysterectomy shoul

the immediate performance of hysterectomy. Surprising as it may seem, a u

to term, and if the cancerous mass offer an impassable barrier to delivery, C?sarean sec

rts through the vagina, because in the abdominal operation the septic cervix is withdrawn th

y. This condition may require operati

is recognized in the early months. Here the operation would be that of

s is an exceedingly dangerous, though a rare, combination. The table on p. 35 shows how

ed in which a f?tus of this character has occupied the pelvis, yet the woman conceived and the child was safely delivered at term

m, 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

ng interesting tumours complicating labour and obstructing delivery, special mention may be made of der

nnective tissue and obstructed labour. Cases have been re

ere

rine Fibroids complicating Pregnancy.

es Echinokokkus im Becken. Zentr

des Beckenbindegewebes. Zeitsch. f

f the Omentum and from the Pelvis. Me

RPERAL SEPSIS (MET

epoch, is a desperate condition, but attempts have been made to deal with it by two met

cessful 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

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 li

enic micro-organisms in the clot from entering the circulation. Bumm reported

ients become desperate, more of them might be rescued. Success has been attained even in desperate conditions; for example, Friede

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 cu

rian veins prevents the septic blood entering the circulation, thereb

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 (c?liotomy), 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 drai

ere

der puerperalen Py?mie. Berliner

tment of Puerperal Py?mia. Journ. of Obstet.

Acute Puerperal Metritis and Acute Salpingitis

en bei der py?mischen Form des Kindbettfieber

sis: Ligature of the Right Ovarian Vein. A

reatment of Puerperal Py?m

tion of a Thrombosed Ovarian Vein (followi

e Behandlung der puerperalen Py?mie. Mü