i ■ T r i nr l r l r lrl r i nr l ^ I r l Mr inrlrlrlMrlrlrrrlrlrlrlrlrinrinrirlrlririri i COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS • LOS ANGELES, CALIFORNIA ft®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®! ■^ 2 mmSiJi Of CALIFORNIA CAUFORNIA COLLEGE OF MEDICINE LIBRARY NOV 1 ;:; 19/0 IRVINE, CALIFORNIA 92664 _ATLAS OF OPERATIVE GYN/ECOLOGY BY BARTON COOKE HIRST, M.D. Professor of Obstetrics, University of Pennsylvania 16 Jf PLATES; ^6 FIGURES PHILADELPHIA & LONDON J. B. LIPPINCOTT COMPANY WP I n t7 D ^( ^ H Copyright, 1919, by J. B. Lippinxott Company EUclroty-ped and Printed by J. B. Lippincolt Company The Washington Square Press, Philadelphia, U. S. A. PREFACE The author has attempted the graphic method of describing operations for conditions peculiar to women, by a series of colored illustrations showing the separate steps of each operative procedure. These illustrations have been made, after repeated observation of the operations as they were per- formed, by the artist, Mrs. J. D. Z. Chase. This method enables even the student without previous operative experience to comprehend modern operative technic. The text has been subordinated to the illustrations, saving the reader's time and lightening the burden of obtaining a grasp of the subject. The work has been confined strictly to conditions peculiar to women, leaving the operations common to both sexes to the general surgeon, who is more competent to deal with them. The views expressed and the operative technic advocated are based on many years' experience in dealing with all the conditions peculiar to women — an experience which the author believes is necessarj' to a correct judgment in selecting the operation best suited to a woman's subsequent life history. Barton Cooke Hirst, ^I.D. Philadelphia. June, 1919. 28400 CONTENTS Equipment and Preparation for Gynecological Operations 1 The Operating Room 1 The Operating Tables 4 The Patient 6 Instruments 6 Preparation for Vaginal Operations 10 Preparation for an Abdominal Section 13 Closure of Abdominal Wound 25 Operative Technic 25 A Rational Perineorrhaphy 30 The After-treatment of Perineorrhaphies 31 Operation for Complete Tear of the Perineum Through the Sphincter Ani 46 After-treatment 46 Other Contingencies 47 Repair of Injuries of the Anterior Vaginal Wall Involving the Supports of the Bladder 55 Laceration of Muscle and Fascia of Urogenital Trigonum .... .56 Developed Cystocele 60 Interposition Operation 70 Injuries of the Cervix 85 Fistula of the Urogenital Tract 94 Ureteral Fistul^e 101 The Vaginal Operations for Ureteral Fistulse 101 Operative Treatment for Retroversion of the Uterus 102 Prolapse and Inversion of the Uterus 118 Dilatation of the Cervical Canal 126 Instrumental 126 Anterior Vaginal Hysterotomj' 127 Electrolysis 128 Operation for Enlarging the Vaginal Introitus in Cases of Vaginismus 135 Operations for Gynatresia 140 An Operation for Anus Vestibularis 149 vi CONTENTS Operations on thk \'ulva 153 Exsec'tion of \'ulvar Nerves 153 Dissection of the IiiKiiiiuil ('anal for the Hciiioval of Kilirciiil 'ruiiKirs of tlie Round Ligament 153 Closure of the Inguinal Canal for HcTuia , 153 Removal of the Vulvovaginal or Bartholin's Gland 154 Operations for Hermaphroditism 154 Salpingectomy 158 Operative Procedure 159 Ectopic Gestation 160 Gonorrhceal Infection 160 Drainage 161 Oophorectomy 169 Myomectomy 173 Vaginal Myomectomy 175 Hysterectomy 184 Supravaginal Amputation of the Uterus l)y Abdominal Section 184 Panhysterectomy 197 Extendetl Panhysterectomy for Carcinoma of the Uterus 197 Pregnancy Complicating Cancer of the Uterus 201 Cuneiform Hysterectomy at the Fundus or the Cornua 201 Supravaginal Extraperitoneal Hysterectomy by the Vaginal Route. . . . 207 Vaginal Hysterectomy 217 Cesarean Section 225 Conservative Csesarean Section 225 The Porro Operation 234 Su])ravaginal Amputation of tlie Uterus with Extraperitoneal Fixation of the Cervical Stump 234 Panhysterectomy with Csesarean Section 235 Extraperitoneal Caesarean Section 235 Pubiotomy 246 The After-treatment of Abdominal Section 251 Surgery of the Mammary Gland 253 Surgical Treatment of Mammary Abscess 253 ATLAS OF OPERATIVE GYNAECOLOGY EQUIPMENT AND PREPARATION FOR GYNECOLOGICAL OPERATIONS The preparation for gynaecological operations is in many respects the same as the preparation for any surgical operation. It is not the purpose of the author to repeat what can be fountl in any book on general surgery. There are, however, some peculiar requirements for this special work that deserve consideration. The Operating Room. — In addition to a modern outfit for the best surgical work, including a good architectural plan and all the necessary furniture and equipment, ample horizontal light should be provided for vaginal operations. This is best secured by a continuous cut in the roof and wall for a skylight and window combined. For emergency night work I find the lamp shown in Fig. 1 most convenient. It is cheap, efficient and compact. If the clinic must be used for teaching students, the building plans present problems of great interest. In the operative clinic recently completed for the University Maternity these plans have been worked out, I think, very satisfactorily. (Charts 1 and 2.) As may be seen, there is provision for the students to change their clothes, don their operating suits and shoes, and cleanse their hands and arms. This student dressing-room is furnished complete with receptacles for sterile clothing and with containers to hold sterile gowns and caps, etc. A room is provided for the assembling of patients to be shown in the clinic unansesthetized ; and, adjoining this room, is the anaesthetizing room where the patient can be anaesthetized in private without being seen by other patients awaiting operation. The anaesthetizing room opens into the assem- bly room, which communicates directly with the clinic and also communi- cates with the labor room in which ordinary deliveries are conducted. There is a separate entrance for the class and the students between the assembly room and the clinic room, so that the patients awaiting operation or exhibi- tion do not see the class and the students as they enter and prepare for operative work. The floor space of the clinic room, it may be observed, is unusually large, so that three tables can be accommodated at once. There is direct communication between the operating room and the dispensary, so that out-patients can be exhibited directly from the dispensary service if con- 2 ATLAS OF OPERATHE GYN.EC'OLOGY sidered desirable. There is no .special arrangement for i)atliolo{j;ical work, such as the freezing microtome, etc.; as the pathological and clinical labora- tory work is done in general for all the hospital services. Provision is Fig. 1. — Lanip fur liurizuiital illutiiinutiun. naturallj' made for collecting specimens, pus, etc., which are conveyed directly to the clinical laboratory or to the pathological iaboratorj' for study and examination. EQUIPIMENT AND PREPARATION 3 The class is divided into sections and each man serves in rotation as assistant, anaesthetist, and recorder. Each member of the class has an opportunity to assist a number of times in both pelvic and abdominal surgerj', so that by the end of the final year the man has received as extensive a practical training in the surgical treatment of all affections peculiar to women as it is possible to give him with the clinical service at our command. The records of this service are kept and handed in by the student as part of his final examination, and that part of the class not actively engaged in assisting takes notes of all cases presented both for diagnosis and for operative treatment, these notes being handed in at the end of the year. CHART 1. In the operative clinic not designed for teaching, the problem is natur- ally much simpler. In the new private wing designed for the Howard Hospital, two sets of operating rooms are to be placed at either side of the sterilizing room. At present, a simpler plan is utilized which economizes space to the utmost but at the same time provides all the essential compo- nent parts of an operative clinic— namely, dressing-room, sterilizing room, operating room, anaesthetizing room, and nurses work-room. The anaes- thetizing room is so constructed that it can be made a dark room for cysto- scopic work. The pathological rooms and the cUnical laboratory are within easy reach by an elevator in the basement of the hospital. An ideal arrangement, I think, would be to have a complete equipment for each department of medicine; but as the department of obstetrics and diseases of women is usually only one part of a large general hospital, sep- arate pathological and clinical laboratories, a special X-ray department, 4 ATLAS OF OPERATIVE GYN/ECOLOGY and a department for hycb'otherapeutics would be such an extravagance of spape and equipment, as to make the arrangement impracticable. The modern ))ractice of having a different color in the operating room from the customary glaring wliite of tiles anil white paint is an imjjrovement over the former practice; but I have never experienced any decided disad- vantage from ()i)erating in the white operating room, and would certainly not think it wortli while to ccmvert an oi)erating room, already constructed npcratiiit: laMi- in this manner, into one of a different color. If, however, a new operating room is being constructed, the greenish-blue tint of the new operating rooms of the Brooklyn Hosj^ital appeals to me as the best coloring, instead of the dark slate or brown color seen in some modern operating rooms, with an unpleasant somber effect. The Opekating Tables. — For all ordinary gynaecological operations, I have used for a number of years a simple, light table, reasonable in price, easily moved al)out on large rubber tired wheels, that serves as a stretcher as well as an operating table, saving two movings of the patient from bed BFLOCKIE AMD HASTINGS ARCHITECTS n 13 5AN 50M ST. PH I LA— PA- DI5PEN5AR.Y E NTR.ANCE r EQUIPMENT AND PREPARATION 5 to stretcher and then to operating table (Fig. 2). Three of these tables are in constant use during the clinic: on one a patient is being anaesthetized, on another an operation is performed, and on the third a wound is closed bj- an assistant. This arrangement saves much of the operator's time. For operations requiring deep and difficult work in the pelvis, such as a Wertheim operation, I have one of the complicated and expensive Loewenstein tables (Figs. 3 and 4), which are well worth while for such operations but are too heavy, clumsy, and luiwieldy for routine use. Fig. 3. — Loewenstein operatin& table, most suitable for Wertlieim's operation. An air cushion on t he operating table does much to obviate the distress- ing backache of which the gynaecological patient usually complains after an operation. The instrument tray and stand in gj-naecological work should be pro- \iiled with a screen which is adjusted over the patient's chest in abdominal sections and over the lower abdomen in plastic operations (Fig. 18). This is much more cjuickly adjusted than if the screen were on the operating table; and being fixed to the stand on which the trays rest it is much less likely to get out of order than is the movable screen usually attached to an operating table. 6 ATLAS OF OPERATIVE GYNAECOLOGY The Patient. — It is unnecessary to discuss here the usual preparation for all surgical procedure. Blood studies; blood-pressure estimates; heart, lung, and urinary examinations ; functional tests of the kidneys, and atten- tion to bowel evacuations are the same in this special surgical work as in any other. Instruments. — At a meeting of a Committee on Obstetrics and Gynae- cology summoned by the Committee on National Defense, to prepare a list of instruments essential for modern work in the treatment of all the Fig. 4. — -Loewenstein uperating table Extended with iiietid bar raised for kidney operations on patient in prone position. affections peculiar to women, those shown in Figs. 6-12 were selected. The committee represented the eastern seaboard of the United States and the Middle West. The illu.strations are interesting as showing the collective judgment of different parts of the country as to what is really essential for the surgical treatment of conditions peculiar to women. In addition to these essential instruments, I find myself constantly employing other special implements without which I should find it inconvenient to do my routine work. The Somers clamp is useful for holding the uterus in suspension opera- EQUIPMENT AND PREPARATION 7 tions and in removal of the appendages (Fig. 13). Gelpi's retractor is invaluable in operations on the pelvic floor (Fig. 13, B). It is particularly useful if there is a paucity of assistants. For primary and intermediate operations on lacerations of the genital canal it is extremely convenient, but is also most useful in the secondary operation. Heineberg's pan and sieve (Fig. 14) for catching the endometrium after curettage, when it is desired to preserve the scrapings for microscopic study, Fig. 5. — Separable table for recumbent and rapid conversion into dorsal gynjecological position. is one of the nicest appliances for this purpose that I have seen, and I use it routinely. In removing large fibroid tumors a heavy volsellum forceps is required or else its substitute, the corkscrew (Fig. 15, B). The latter is more conven- ient in tumors of the greatest size, as the handle does not project incon- veniently far from the tumor; but as a rule, I prefer the volsellum forceps. In isolating the round ligaments after opening the inguinal canal, blunt hooks are almost indispensable (Fig. 13, D). I use the kind devised for the approximation of linear wounds. In the Wertheim operation, Wertheim clamps (Fig. 13, E) are extremely ATLAS OF OPERATIVE GYNAECOLOGY useful in preventing the troublesome hemorrhage from the uterovaginal plexuses of veins; and, in order to protect the peritoneal cavity as the can- cerous uterus is removed, the clami) devised by Sigwart (Fig. 15, C) accord- Fla. 6. — a. HBEinoatatic; forceps (Jcmes). straight, o-inch, screw lock. b, Hffimostatic forceps (Halstead- Army), straight. o'2-i"^h, screw lock. c, Hsemoslatic forceps (Kelly-Hopkins), straight, flat shank, screw lock. d. Hemostatic forceps { Kelly-Pean), curved, flat shank, 6!4-inch, screw lock, e, Hsemostatic forceps (Kocher), straight, S's-inch screw lock. /, Htemostatic forceps (Ochsner), heavy, straight, 7'4-inch, screw lock. ing to the suggestion of Bumm is most convenient. In this operation for the blunt dissection of the base of the broad ligament, as well as in a dissection of the anterior vaginal wall, I find GofTe's dissector convenient. EQUIPMENT AND PREP.\RATION 9 Lion-jawed forceps (Fig. 13, C) are useful in the plastic operations in the vagina. In the extra-peritoneal csesarean section, T-shaped hsemostats are essential for holding together the layers of the peritoneum (Fig. 15, D). In dilating the cervix for mechanical dysmenorrhcea and sterility I prefer the two- and four-branched metranoicter to any other appliance (Fig. Fig. 7. — a, Hspniostatic forceps tPean), straight, S'o-inch. screw lock. b, Hsemostatic forceps vPean), curved, S^-inch. screw lock. c. Intestinal forceps (Doyen), straight, 9-irieh, screw lock. i/. Intestinal forceps (Doyen), curved, 9-inch, screw lock. 16, A). I have had a special handle constructed like that of the old Pryor clamps which facilitates both the insertion and the removal of the instru- ment (Figs. 16, D. and 17, B). In addition to the two-branched dilators used for the instrumental dilatation of the cervix, I find it essential to have a four-branched dilator 10 ATLAS OF OPERATIVE GYN^X'OLOGY in addition and I prefer the model named after Dr. Cleveland of New York City (Fig. 17, C). For the pregnant cervix, J. C. Hirst's modification of the (Jau dilator is the most efficient, but occasionally a four-branched dilator for this purpose is convenient. Of the various models on the market, 1 prefer that of Dewees (Fig. 16,:^). Fig. 8. — a. Sponge holder, oval blades, 8J^-inch, screw lock. 6, Tissue forceps ( AUis), tj-inch, 4x5 teelli, screw lock, c. Dressing forceps, straight, 10-inch, with catch, screw lock. d. Dressing forceps (Bozeuian), curved, 10-inch screw lock. Prep.\ration for Vaginal Operations. — The first point to be con- sidered is whether to shave the patient before or after anesthetization. The former saves time and is cleaner. It was compared by the late Dr. Goodell, however, to the toilet of the guillotine. In a verj' nervous and api)rehensive patient, therefore, the latter plan might be preferable. Some patients who object to being shaved would not mind a depilatory. Frequently repeated enemata must be given to empty the rectum; after the last, at least half an EQUIPMENT AND PREPARATION 11 hour before the operation a suppository of 1 grain extract of opium is inserted to prevent defecation during the operation. In cleaning the field of operation I prefer the following plan: A nurse pours from a pitcher, over the vulva, inner thighs, and buttocks, a stream of lysol solution, 1 per cent., an assistant scrubbing the skin with pledgets of absorbent cotton; after the external cleansing, the vulvar orifice is dis- tended with two fingers so that the lysol solution flows into it and the nuicous a Fio. 9 _„. Aneurism needle (Dechanips), blunt point, right, b. Probe, silver, strnight. vvitl. eye, t^.j sizes. 5- and 8-inch, c. Trocar and canula. small, medium, and large sizes, d. Trocar disc and plain canula, two sizes. 5- and iVinch. c. Grooved director, plated, oli-inch. membrane of the vagina is scrubbed with pledgets of cotton; following this the vagina is scrubbed with alcohol and painted with tincture of iodine; a pledget of cotton soaked with a 1-2000 sul:)limate solution is then packed in the \'agina for a coui)le of minutes while thefassistant who does the cleans- ing changes his gloves and the nurses adjust the comliination sheet and drawers. This last is a convenient device for rapidly covering the patient's thighs, legs, buttocks, and public region. By sewing a piece of rubber dam on the inside of the sheet just below the opening which exposes the ATilvar hi ATLAS OF OPERATIVE GYN.^ICOLOGY orifice and clainpiiifj; the sheet tlius protected to the buttocks and the middle of the iierineuni, the patient and operators are protected from possible fecal discharges during the operation. The catheterization of the patient just before ana'sthetization should be done with a short soft rubber catheter, originally made in Paris, l)ut now supplied in this country. The glass catheter frequently used for this WW Fi«. 10. — a, Intestinal needles, taper point, plain eye. half circle, sizes 1, 2, 'i, 4. h. Double-ended retractor, combination of Richardson and Eastman; two sizes, nested: blades ^4x2 inches and 2 x 2f 2 inches, c. Retractor, army type, two sizes nested, 9- and 10-inch, d. Flexible retractor, copper, silver plated, e. Four-prong sharp retractor, steel. /. Self-retaining abdominal retractor (Balfour). purpose should be condemned. The eye is often rough, scratching the urethra: and the glass may crack in boiling water, lireaking off in the bladder when inserted. This hapjiened to one of my jiatients, three-cjuarters of the catheter remaining in the bladder a week before it was discovered, as the frightened nurse was afraid to report what had happened. For special cases some modification of the technic is advisable, as will be noted in the description of certain operations. EQUIPMENT AND PREPARATION 13 Preparation for an Abdominal Section. — In addition to the usual preparation for any major surgical procedure, the question of preparing the skin of the abdomen must be considered. I am opposed to the common 1 rs y _Fiu. 11. — (I. Uterine dourhe (Bozeinan). b, I'terine curette (Martin), steel shank and loop, dull, size 4. h. Uterine curette (Martin), steel, double-ended, blunt blades, c. Uterine curette (Sims), steel !"ops, sharp, sizes 1, 2, and 5. il. Uterine tenaculum, steel, curved and right angle, e, Uterine probe, silver, blunt, with handle. /. Double current female catheter, partition in center, sterling silver, g. Uterine sound (Simpson). practice of smearing tincture of iodine on the skin of the abdomen and then immediately incising it, witli the confident assumption that it is sufficiently sterilized to prevent infection of the wound or of the peritoneal cavity. An expert bacteriologist would be amused at this assumption. In a series of cases prepared in this manner, that I had tested, u ATLAS OF OPERATRE GYN.ECOIXX.Y patliogejiic bacteria were found in every one. The plan that 1 usetl for a number of years, while troublesome to nurses and no doubt to the patient, gives, I believe, a greater security not only against wound infection Init against peritoneal infection; antl 1 feel that it is, therefore, worth while. The jnibis is sluiAed, the skin of the whole abtlomen from ensiform to jiubis and from flank to flank is washed the evening before in lysol solution 1 per cent, with Fig. 12. — a. Obstetrical forceps (Simpson), lonp, hnnd-forpcci blades, h. Pelvimeter (Martin), with centi- meter scale, r. Obstetrical hook (Braiinl, blunt. -*> \> ^ 3V ^::J[ Abdominal incision after a three-minute scrub of abdomen with phenoco solution. PLATE IV. Sterile rubber darn spread smoothly over abdomen. Abdominal sheet adjusted. Operating tray and screen in place. The patient is now protected irom head to knees. PLATE V. Rubber dam incised and sewed to peritoneum. A rubber glove envelopes abdomen, no skin appearing to con- taminate ligatures, instruments, operator's hands or patient's intestines. OPERATIVE TECHNIC 25 CLOSURE OF ABDOMINAL WOUND (Plates VI-IX) The peritoneum is sewed with plain unchromecized number 1 gut by a running; mattress stitch so that peritoneal surfaces and not edges are brought together. This plan limits thelikelihoodofadhesionalong the lineof the wound. If the wound is a long one a few interrupted stitches (chromic gut number 1) unite the split rectus muscle. The fascia is united with a running stitch (number 1 chromic gut), with insertions of the needle somewhat wide of the margin so as to secure o\erlapping. The fat is united with a number stitch of gut in a tier suture so as to eliminate a dead space under the skin. Tension of this stitch is avoided. After a trial of many methods I find an intracutaneous or subcuticular stitch is best for the skin and silkworm gut is the best suture material. It does not stretch, is clean, and secures a permanently narrow, amost invisible scar. The stitch is pulled out on the twelfth day by a strong steady pull downward toward the jnibis. The wound is sealed with inch-wide gauze strips and collodion. In drainage wounds silver foil is used directly over the wound above the drainage tract, made adherent bj' an overlying layer of tissue paper, moistened with alcohol, and then sealed with gauze strips and collodion. OPERATIVE TECHNIC Of the women who consult physicians on account of some pathological condition peculiar to their sex, more than half, or over 50 per cent., will be found to have lacerations of the genital canal. An analysis of over eight thousand patients in my i)rivate case books made some years ago, shows this proportion, and it agrees with the statistics of others. Until the best method of repairing these injuries is agreed upon it would seem useless to proceed farther with a study of the surgical treatment of diseases of women. And yet there is by no means a unanimity of opinion as to the best technic for repairing the commonest of all these injuries, laceration of the pelvic floor. It must be admitted that the ideal to be kept in mind is a knowledge of anatomy, a knowledge of what happens to a woman when she is injured in labor, and a restoration of each structure injured to the condition it was in before the woman had given birth to a child. If this rule is applied to what is seen in most surgical or gyna'cological clinics the observer is amazed at the ignorance of anatomj', the disregard of the nature of the original injury, and the indifference to the woman's subsequent life history, .\fter seeking in vain in visits to the clinics of this country' and Europe to find an ideal operation for the restoration of the pelvic floor and perineum, I was obliged to devise an operation based on these principles: As much knowledge of the anatomj' of the region as is required to understand what hajipcned to it in labor, a comprehension of what did occur in the injuries of labor, and a restoration of the parts to their original condition. PI.ATK VI. Suture of peritoueum so as to evert the edges and bring peritoneal, surfaces in apposition. PLATE VII. Suture of fascia. PI.ATK Vlli Suture of fat with two-tier stitch and gut. PLATE IX. Sub-cuticular stitch of skin. 30 ATLAS OF OPERATI\ E GYNAECOLOGY A RATIONAL PERINEORRHAPHY 'i"he injuries inflicted on the pelvic floor and perineum l)y the child's head are as follows: (1) A laceration of the levator ani, beginning at its upper edge as a rifle and immediately beyond its attachment to the descend- ing ramus of the pubis running downward and inward toward the lower edge of the muscle but stopping short of the median line; if the muscle is only partly torn through, the lower portion is the part injured. (2) A median separation of the deep transversus perina>i and a retraction laterally of the two ends into tlieir sheaths toward the tuber ischii. (3) A sej^aration of this muscle from its attachment near the base of the perineal body. (4) A triangular or rhomboidal laceration in the middle line of the pelvic fascia supei'ticial to the le\'ator antl deep transversus with the apex of the triangle abo\-e and its base below and a secondary triangular extension toward the tiji of the posterior colunui of the vagina. (5) A median tear of the perineal body se\ering the junctions oi the bulbo-ca\"ernosus muscles and of the superficial transversus perinaei. (6) A laceration of CoUes's fascia. The illustrations (Plates X-XXI) show each step of the repair of these various structures and their restoration to the condition they were in before childbirth. The incisions are best made with a knife; the denudation with scissors. The blunt dissection of the vaginal wall i)osteriorly with scissors can l)e done most quickly by inserting the closed scissors in the midline under the vaginal wall and spreading tlie blades aiiart as the scissors are pu.shed upward. Nunfl)er 1 chromic gut is used throughout as the suture matei'ial. Extra hard number 1 is used for the skin of the perineimi. After a trial of Michel's clamps, silkworm gut, linen thread, and heavier gut, this extra hard chromic gut number 1 )iro\ed just what I was looking for, possessing sufficient but not too great durabihty and not requiring removal. If the laceration of the pelvic floor has resulted in a very extensive rectocele with redundant nuicous membrane, and the condition has persisted for some time, a better denudation than that shown in the first set of illus- trations is an extensive triangular denuilation such as is made in the old Hegar operation whicli remo\(>s the redundant nmcous membrane; but the separate junction of the different structures that have been lacerated is accomplished in the manner described (folate XXII). In fact this operation can be performed through any one of the three denudations commonly em- ployed in the pelvic floor — the Hegar, the modified Emmett, or the transverse dissection between vagina and rectum. It is a reproach to medicine that such enormous numbers of women require the secondary repair of the pelvic floor. This regretable fact is due mainly to the unsuccessful practice of imifietliate repair, directly after child-birth, when absence of a special table, insufficient light, lack of assist- ance, a profuse bloody discharge, bruising and distortion of the tissues RATIONAL PERINEORRHAPHY 31 usually prevent an accurate diagnosis and often make an accurate and suc- cessful repair impracticable. The patients I frequently examine (repaired immediately by professed specialists in obstetrics) often present such a sorry spectacle as to convince anyone of the futility of such work. ^ly practice for more than fifteen years in private, ho.spital, and dispensary patients has been to wait at least five days before attempting a repair of the genital canal. Even if it were practicable to repair the pelvic floor immediately with uniform success (which it is notj ample clinical experience in many clinics has demonstrated that the cervix and anterior wall cannot safely be repaired immediately. There seems to be little sense in attempting an imperfect repair of one part of the genital tract and then subjecting the patient to a secondary operation for the repair of the rest of it. Objections to this plan of intermediate operations are that the patient resents an etheri- zation some days after delivery; that the fees are usually too small to com- pensate the physician for the extra trouble; that the physician often lacks the operative training necessary for an intermediate operation ; that infection is promoted by leaving the perineal wound imsutured; and that ansestheti- zation and operation may interfere with milk secretion. These objections have not proved valid in my experience. Another objection is raised that deserves little attention. It has been stated that intermediate operations cannot be done with sucee.ss. This statement is made only by that type of specialist too common in America — the obstetrician with scanty experience in surgery and poor surgical training. In the many hundreds of cases subjected to these operations by my.self and my assistants in tlie last fifteen years the success has been as uniform as in secondary operations; and we have been spared the humiUation, to which the advocates of immediate operation are liable, of hearing that their patients (who have been assured they were repaired immediateh') have been obliged to be operated on subseciuently because the original work was so poorly done. There is no additional danger of infection by waiting, other- wise every wound in the genital canal should be repaired — a procedure that no one advocates or attempts. Besides, ample experience bears out this statement. Indeed, the way the perineum is usually repaired primarily, leaving ununited wounds above the perineum proper, makes the patient more liable to infection than if no sutures had been inserted. The After-treatmext of Perineorrhaphies. — The vagina is sponged out with dry pledgets of gauze when the operation is finished. Irrigation of the wound during and after the operation is avoided. I saw the former practice carried out in Berlin thirty years ago, but it has since been given up. Some operators in this country still persist in its use. The vagina is packed lightly with sterile gauze that remains for twenty-four hours; the patient is encouraged to pass water naturally, if she can; 32 ATLAS OF OPERATIVE (;YN\ECOLO(iY otherwise she is catheterized every eight hours. After the fifth ihiy a sterile water tlouche is o;i\("n every other (hiy. The woman remains in bed twelve to fourteen days. F:a. 19.- -Patient arranged for plastic operation with .\uvard's weighted speculum and Heineberg's funnel and sieve in place and operating tray ovi-r the symphysis. PLATE X. A ratiuiial ptrriiifMiTluipliS". (iaping vulvar oritit-e with urellinx'ele and cystocele. PLATE XI. Incision tlirougli mucous membrane to expose underlying fascia and muscles. PLATE XII. Flaps of mucous membrane to be excised along dotted lines. PLATK XIII Botli layers of triangular ligament cut through to expose levator ani muscle. PLATE XIV. Levators sutured and incision made to expose tlie deep transversiis Levator ani anj subjacent fascia closed; inferior layer of triangular ligament incised to expose the deep trans- versus pcrinsei which is sewed in such a manner as to unite its ends and restore its triangular shape. PLATE XVI. Gap in perineal center and pelvic fascia, through which rectocele protrudes, closed by tier stitch. PLATE XVII. Mucous membrane and subjacent connective.tissue of sulci closed by two-tier stitch. PLATE XVIII. Stitch to restore the' lower tip of posterior column of vagina. PI-ATI-: XIX. Perineal center or body and Colles's fascia united by interrupted stitches. PLA1E XX. Skin sutures; Xo. 1. over-cbromicized gut. PLATE XXI. Operation completed. PLATE XXI Incision for Hegar's denudation of perineum. 46 ATLAS OF OPERATIVE GYNAECOLOGY OPERATION FOR COMPLETE TEAR OF THE PERINEUM THROUGH THE SPHINCTER ANI The jM-eparatory treatment for this operation (Plate XXIII) should he^in forty-eight hours i^eforehand by purgation and a thorough evacuation of the rectum. I prefer Rochclle salt, 2 drachms the first night, and Epsom salt, 4 drachms the secoiul night, followed on the morning of the operation by repeated irrigations of the rectmn with soap suds and sterile water till it is thoroughly em])tied, and then by an opium suppository. The first stej) in the operation is stretching the sphincter, which is not done in the usual manner, but by catching the retracted ends between the thumb and forefinger and pulling what is really a ribbon and not a ring muscle in the direction of its long fibres (Plate XXIV). Then follow the steps of the operation as shown in Plates XXV-XXIX. The most important detail of the operation is hooking the ends of the muscle into plain view by pulling them out of the pits into which they have retracted as shown in Plate XXVI. An interesting question is the kind of suture material to employ in joining the ends of the muscle. After a trial of catgut and linen thread I find it necessary to use silkworm gut as the only reliable material to hold the ends of the muscle firmly together without danger of premature absorp- tion, stretching, or infection. The rest of the suturing is done with number 1 chromic gut. The sutures in the sphincter may be inserted in such a way as to pull down a flap of rectal wall under the junction of the sphincter, to protect it from fecal contamination (Noble). Usually in a complete tear the perineal body alone is involved in the laceration. The other muscular and fibrous structures of the pelvic floor are spared. But, should they be involved, their repair is effected by the technic already described for perineorrhaphies. After-treatment. — The after-treatment of a complete tear operation is as important as the operation itself. I have tried opening the bowels at all sorts of times, even up to the sixteenth day as proposed by Leopold ; but of late years have adopted one of two plans dependent upon the kind of nursing the patient could afford. If a special nurse is in attendance I prefer the evacuation of the bowels daily or twice daily from the first day. A semi-liquid stool is best secured by Carlsbad water or by Bedford spring water and Sprudel salt, which the patient can take for a couple of weeks or more without irritating the stomach or intestines. One glass of the water with a teaspoonful of the salt twice a day is the average dosage. The line of sutures in the perineum must be thoroughly irrigated after each bowel movement and urination, and then dusted with formic bismuth iodide powder. If the patient is in a ward and cannot secure the undivided attention of a nurse, the bowels are opened on the fifth day with calomel, OPERATION FOR COMPLETE TEAR OF PERINEUM 47 castor oil, and an oil enema given carefully through a rubber catheter. Afterwards the bowels are kept semi-liquid as in the first technic. The two or three silkworm gut sutures in the sphincter are removed in twelve to fourteen days. Other Contingencies. — If the laceration runs far up the recto- vaginal septum I find the sphincter is better brought together and held in position by knotting the silkworm gut sutures in the rectum. Their removal is troublesome. The knee-chest posture, a narrow rectal speculum and an electric head light may be required; but the extra trouble, I think, is well worth while. In the rather common cases in which a sphincter repair has been attempted with an imperfect result and the operator has to do someone else's work over again, there is often a bridge of tissue healed over the perineum and above the anus, but no union of the sphincter muscle; and there is often a recto-vaginal fistula just within the posterior commissure of the vulva. The best plan in such cases is to put one blade of a scissors into the hole communicating with the rectum and with the other on the exterior of the perineum to cut the perineum open from top to bottom and then^'to do the operation again as though the injury were a fresh one. In the very rare cases of central perforation of the perineum, the peri- neum is cut upward from the perforation to the posterior commissure of the vulva and then the pelvic floor and perineum are repaired in the manner already described. If the perforation takes the shape of an oblique slit running diagonally across the perineum, tier sutures of catgut should be employed. After a repair of the sphincter the patient should be cautioned to keep the bowel movements soft for .several months. PLATE XXI il. Complete tear through sphincter ani. J^LATE XXI\'. Stretching sphincter which when torn through is a ribbon and not a ring muscle. PT.ATK \\V. InciMon for Hup splilliiiii cli'iiii.lal inTi PLATE XXVI. Flap splitting denudation completed. Rectovaginal septum sutured. Ends of sphincter caught by sharp hooks and brought out of their pits into plain view. PLATE XXVn. Sutures of ailkworm gut inserted through sphincter muscle and its sheath. PLATE XXVIII. Sphincter joined and perineal body sutured. PLATE XXIX. Skin sutures tied. REPAIR OF INJURIES OF ANTERIOR VAGINAL W.\LL 55 REPAIR OF INJURIES OF THE ANTERIOR VAGINAL WALL INVOLVING THE SUPPORTS OF THE BLADDER Before attempting the repair of these injuries it is necessary, as in the case of injuries to the pelvic floor and perineum, to understand the anatomy of the region, to know what happens to a woman when she is injured in labor, and to devise an efficient operative technic which will either restore the injured parts to their original condition or will so rearrange the anatomi- cal elements as to give the anterior wall and bladder the support which has been impaired by childbirth. The injuries to which the anterior vaginal wall is subject in labor are as follows: (1) A laceration in one or both anterior sulci of the muscle and fascia of the urogenital trigonum — a musculo-fibrous band about an inch wide, stretching across the anterior portion of the pelvic outlet from one ischio-pubic junction to the other one, the only support of the lower third of the anterior vaginal wall, and the only muscle in this region the fibres of which are directly inserted into the vaginal wall (Waldeyer). This muscle lies between the two layers of the triangular ligament: it is continuous with the deep transversus perinsei and is the homologue of the compressor urethra? in the male. (2) A diastasis of the plate of pelvic fascia between the cervix, the anterior vaginal wall, and the bladder by the lateral pressure of the child's head. (3) An elongation of the longitudinal connective tissue fibres between the cervix and the bladder. (4) An injury in the shape of laceration or over-stretching of the cardinal ligaments of the uterus— those strong fibrous bands in the bases of the broad ligaments, extending outward and backward to the pelvic wall; the strongest supports possessed by the uterus, injury to which deprives the upper third of the anterior wall and the anterior vault of the vagina of the support derived from its connection with the cervix. With a weakening of this support, the cervix is allowed to drop downward and forward along the vaginal canal, and to pull the anterior vaginal vault, the upper third of the anterior vaginal wall, and the base of the bladder with it. The commonest cause of this last injury is the premature application of the forceps before full dilatation of the cervix and before the child's head is well descended into the pelvic canal. Another common cause is puUing upon a conical rubber bag like the Voorhees, inserted in an undilated cervical canal. A contributing cause is an overfilled bladder which has not been emptied as it should be before the application of forceps. The most frequent of the injuries to the anterior wall is the laceration of the muscle and fascia of the urogenital trigonum. It stands to the injuries of the pelvic floor in about the proportion of eight to ten— that is, if fifty per cent, of women have distinct damage to the pelvic floor in labor, forty per cent, will show lacerations of the anterior sulci, involving the muscle and fascia. 56 ATLAS OF OPERATIVE GYNAECOLOGY Laceration of Muscle and Fascia of Urogenital Trigonum. — The only one of these injuries which can be corrected shortly after labor is the laceration of the muscle and fascia of the urogenital trigonum. This injury can be corrected at the same time that the i)el\ic floor and cervix are repaired; that is to say, from five to seven days after ialxir in the inter- mediate operation (Plates XXX-XXXII). The injury to the anterior wall is sometimes a frank one; the laceration extends through the nuicous membrane and the triangular ligament underlying it, exposing the muscular fibres, which are torn across ; but often the injury is submucous and concealed so that to expose the injured muscle and fascia it is necessary to incise the superficial fascia or inferior layer of the triangular ligament overlying it as is illustrated in Plate XXX. The muscle being exposed, the fibres can be brought together with a continuous two-tier number 1 catgut suture, the superficial layer of which closes the wound in the superficial fascia. The denuded surface, if a deiui- dation has been necessary, is then repaired; or, if the nuicous membrane is torn, it and the subjacent tissues are united by two-tier stitches. This operation can also be done as a secondary one and is very com- monly required in moderate injuries of the genital canal. The existence of the injury is determined by light pressure upward and outward with the forefinger inserted up to the middle joint; the left hand being used for the left side of the woman's pelvis, the right hand for the right side of the pelvis. If the fascia and nuiscle have been torn, the palmar surface of the finger comes in direct contact with the edge of the pubic bone, nothing intervening except the mucous membrane of the vagina. If, on the contrary, this structure has not been injured there is a distinct resistence felt to the pres- sure upward and outward, and a cushion of musculo-fibrous tissue is dis- tinctly appreciated between the examining finger and the pubic bone. The correction of this injury checks a process which, if not corrected, woiild end eventually in the formation of a cystocele. As the structure injured is the only support possessed by the lower third of the anterior vaginal wall and the corresponding section of bladder and urethra, these latter two structures, unsupported, sag downward and outwartl; and, in course of time, drag the structures above them lower antl lower until event- ually a well-marked cystocele develops. It is all the more certain to do this if there is diastasis of the pelvic fascia and elongation of its longitudinal fibres, as well as injury to the cardinal muscles or ligaments of the uterus; but I believe that, even without these injuries, the damage to the muscle and fascia of the urogenital trigonum alone is sufficient in time to develop a cystocele; and I am firmly con\inced, after some ten years' experience with the repair of this damage, that its earl.y recognition and repair will often jire\ent the formation of a cystocele PLATE XXX. Expoaure of compressor urethrse by incision through interior layer of triangular ligament. pr.\rr: x.wi. Exposed muscle sutured. PLATE XXXII. Sub-mucous connective tissue united over muscle and fascia. Mucous membrane united. 60 ATLAS OF OPERATIVE GYNAECOLOGY later in the woman's life. A longer time, however, than has so far elapsed is necessary to a clear demonstration of this assertion. Developed Cystocele. — In dealing with a cystocele already developed the problem is a more complicated one. The restoration of the muscle and fascia of the urogenital trigonum alone is not sufficient to effect a cure. A more extensive operation is required. The choice of operation depends in great iiart upon the woman's age and her future prospects of child-bearing. If she is approaching middle age or has already reached the menopause there is no question that the interposition operation, introduced into this country by Watkins, of Chicago, is the most efficient means of curing a cystocele (Plates XXXIII-XLI). PLATE XXXIII. Incision and dissection for interposition of uterus. IM.ATK XXXIV. Cutting atL-ru\ faiea,! hgaineut. PLATE XXXV, Opening peritoneal cavity. ri-ATK XXXVI, Extracting corpus uteri with scoop. t'LATE XXXVII. Pulling out the fundus. PLATE XXXVIII. .jf" :r-i:fy^^, A. Stitching the fundus of the corpus uteri to fasi*i;il tdt^en under vagioal mucous membrane. PI.ATK XXXIX. Cutting iit^ supertluous vaginal tlaps. ?I,\TK XT.. I'niting vaginal incision to cervix, PLATE XLI. \'agiiial wound closed. 70 ATLAS OF OPERATIVE GYN^X OLOGY Interposition Operation. — Wat kins gives Diihrssen credit for priority in the interposition operation, which Watkins prefers to call a transposition operation. \Vatkins indejjendently developed this operation in 1898. Wertheini developed the same procedure a year later, with the difference that he left a portion of the uterine surface exposed in the vagina. The next important modification in the operation was by Schauta who sewed the peritoneum, where it was separated from the back wall of the bladder, to the posterior j)eritoneal surface of the uterus at the level of the internal os. In making the vaginal incision and separating the vagina from the bladder, Watkins and most operators exploy a blunt dissection by passing scissors under the vaginal wall in the plane of separation between the vagina and the fascia underlying the bladder. But I teach my students to make a formal dissection, feeling that there is less risk, by this method, of injuring the bladder in the hands of a beginner; although personally I use Watkins's method of dissection, which results in less bleeding and is quicker. Separation of bladder and vagina can be further extended by a piece of gauze over one finger which carries out an extension of the dissection begun with the scissors. In separating the uterus from the bladder, I prefer the discission of the utero-vesical ligament with scissors, rather than by the blunt dissection with the blunt scissors point as Watkins recommends. I believe the latter, except in the hands of the most experienced operators, endangers the bladder too much. After the utero-vesical ligament has been cut, a retractor must be inserted between the bladder and the uterus. In this way, the peritoneal fold between the bladder and the uterus is plainly exposed and can be safely cut through without danger of cutting the bladder wall. For the delivery of the uterus I have had made a scoop which I find very convenient, although occasionally I am obliged to pull the uterus out with a tenaculum forceps — two being used, one above the other, and several grips perhaps being taken of the anterior surface of the uterus by a sort of hand- over-hand procedure before the fundus can be readily extracted. If the cystocele is extreme in degree and associated with considerable prolapse of the uterus, I employ Schauta's modification of the suture of the peri- toneum over the back wall of the bladder to the posterior peritoneal surface of the uterus at the level of the internal os. As the uterus is pushed up by the closure of the vaginal wall under it, and as the cervix is pu.shed backward and upward, this attachment of the uterus to the peritoneal reduplication, as it leaves the bladder, lifts the latter to a higher level in the pelvis than is done by the Watkins or the Wertheim technic. I find it, therefore, of distinct advantage. It is not infrequently necessary to reduce the size of the uterus (Plate XLII). This can readily be done by an excision of a wedge-shaped piece REPAIR OF INJURIES OF ANTERIOR VAGINAL WALL 71 from the anterior uterine wall; and occasionally it is an advantage to unite with this procedure an excision of the uterine mucous membrane. The wound in the uterus is closed by interrupted sutures through the myome- trium and I think with advantage also by a running stitch on the surface of the uterine wound. I have often found it of advantage not to deliver the uterus completely; or rather, after having delivered it, to push it part way back and then to fasten the fundus uteri well forward directly under the urethra to the fascial pillars which diverge at this point, and not to the vaginal mucous membrane. I think by this plan there is less danger of a protrusion of the fundus uteri e\-entually — an experience which Watkins and other operators have had. This procedure also makes it easier to close the vaginal flap over the uterine surface. If, however, there is great relaxation of the anterior vaginal wall, and for a more extensive cystocele than common, this procedure does not do so well. In such cases I follow out the Watkins technic, with Schauta's modification (Plates XLIII-XL\M. It appears from the illustrations (Plates XXXIII-XLI) of Watkins's operation that he depends on a single stitch of catgut to fasten the fundus uteri to the vaginal wall close under the urethra. I find it better to insert each stitch through both the vaginal wall and the uterine body from the fundus downward toward the cervix, using interrupted sutures and not suturing the raw surface of the cervix below the peritoneal co^•ering of the uterus. Watkins's proposition — to close the transverse incision at the cervix longitudinally in order to lengthen the anterior wall and to replace the cervix farther backward — is an excellent one in occasional cases. The advice to excise the redundant mucous membrane over a urethro- cele is also wise. Dependent upon the degree of prolapse associated with the cystocele, the vagina should be sufficiently narrowed by a proper pelvic floor support, the denudation for which, in this case, should be the triangular one of the old Hegar operation, but made more extensively than common. It has seemed to me unnecessary, in my experience, entirely to close the vagina; although in elderly women, if the mucous membrane of the uterus is excised and the cervix is amputated, there is no special objection to this procedure; but the vagina can be narrowed enough, I think to dispense with it. In the preliminary dissection for the operation, hemorrhage should be avoided as carefully as possible and perfect hsemostasis should be secured before suturing the uterus, especially in those structures which will eventually lie above it and cannot, therefore, be properly drained. By carelessness in this particular, I have had some troublesome hsematomata which had to be opened above the sjinphysis. It is quite a common experience to have a 72 ATLAS OF OPERATIVE GYNAECOLOGY hsematoma between the uterus and the vaginal flap, although this can be avoided by careful technic in the operation. Should it occur, however, there is not much harm done. For a while the patient has some fever and pain, but by elevating the head and shoulders or the head of the bed, and applying hot fomentations to the vulva, a spontaneous discharge soon occurs and the symptoms subside. As Wat kins advises, I have avoided gauze drainage in the operation, for which there should be no occasion and which rather predisposes to infection than otherwise. Should a protrusion of the fiuidus uteri develoji, an excision of the protruding part, with suture of the wound, usually removes the symptoms and corrects the physical defect. Too wide a separation of vagina from bladder and of bladder from uterus should be avoided, as such dissection may interfere with the inner- vation of the l)ladder and might possibly explain the occasional cases of incontinence of urine following an interposition. Watkins attributes this incontinence of urine to insufhcient care about fastening the fundus uteri well forward directly under the urethra; but I have seen some cases in which the fundus uteri was carefullj^ anchored in the proper place but in which incontinence of urine developed. I attributed it, in these cases, to an imnecessarily wide isolation of the bladder, which since then I have avoided. There has been in my experience one unavoidable disadvantage of the interposition operation in a considerable number of cases — the bulging of the uterine body into the base of the bladder and distortion of the course of the ureters and their openings, resulting in vesical irritability; but in time, after the tissues become accustomed to the new arrangement, this symptom usually disappears. It has, however, persisted for a discouraging length of time in some of my patients without a true cystitis, cystoscopy showing a normal bladder mucous membrane. PLATE XLII. Incision for diminishing bulk of uterine body. PLATE XLUI. Method of blunt dissection of anterior vaginal wall. PLATE XLIV. Sterilization of patient by resection of the tub? in the interposition operation. PLATE XT A'. Schauta technic of interposition operation with sterilization by section of tubes. REPAIR OF INJURIES OF ANTERIOR VAGINAL WALL 77 Cystocele Alternative Procedures. — If the woman is still young, li\ing with her husband, with prospects of future child-bearing, an interposition is not the suitable operation. What should be selected in such cases is still open to discussion. There is not yet a general agreement upon the subject. My choice is for the operation illustrated in Plates LXVI-LXIX. I am aware, from experience with it, of the advantages of the Goffe operation (Plates L-LII), sewing the base of the bladder to a high le\-el on the anterior face of the uterus and broad ligaments, in cases in which the uterus was well supported in good position; and I have used it with satis- faction, often in combination with the operation illustrated in Plates XLVI- XLIX. I have also on occasion utilized other operations for this purpose — such as the one performed in the ^Ia3'o clinic, which consists in a supra- \'aginal amputation of the uterus and the interposition of the broad ligaments — a useful procedure if there is menorrhagia from a myopathic uterus as well as a cystocele. But I have modified tliis procedure by making three stumps of each broad ligament and interposing these stumps under the l)ladder which gives a firmer sujiport than the outspread broad ligaments of the Alayo operation. But it appears to me that a radical procedure is, as a rule, inappro- priate under the circumstances in the j'oung, child-bearing woman. The operation I employ has the advantages of not opening the peritoneal cavity nor subjecting the woman to any risk, and it alters in no way the anatomical arrangement of the parts. It must be confessed that there is a larger proportion of failures after this procedure than I would like to admit, but the vast majority of cases are satisfactorily cured. Another disadvange is the possible recurrence of the damage in case the woman has another child and the necessity of another operation. The Goffe operation has a decided advantage in this respect, but it requires a perfect position and adequate support of the uterus; which is by no means always present nor can it always be secured in cases requiring an operation for cystocele. If it is decided to interpose the uterus between the bladder and the \agina in women who might afterward concei\'e, the tubes should be re- sected for about an inch, the ends fastened to the back wall of the uterus, and the wound in tlie cornua carefully sewed over with a two-tier stitch so as to close the opening of the interstitial portion of the tube; but, in spite of this technic, conception may occur. It did so in three of my patients the pregnancy, however, in each instance ending in an abortion. PI>ATK XLVI. Blunt dissection of anterior wall to expose the pelvic fascia. PLATE XL\II L'terovesical ligament cut. PLATE XLVIII. The bluddfT, freed from its attachment, pushed upward and autures inserted to pull the fascia together in the midline. PLATE XLIX. Redundant flap of mucous membrane out away. PI.ATK L. Goffe's operation — sutures inserted in the prolapsed bladder. PLATE I.I. Sutures, already inserted in the bladder wall, being now inserted in the anterior face ol the uterus and the anterior layers of the broad ligament. PLATE LII. Sutures tied, bringing tlie prolapsed bladder to a higher level in the pelvis. INJURIES OF THE CERVIX 85 INJURIES OF THE CERVIX These injuries may be a longitudinal or a transverse laceration. In the latter case, the whole cervix or a part of it is torn off at the vaginal junction. If the separation is a partial one, a tab of cervical tissue remains attached to the uterus which must usually be removed by amputation (Plate LIII-LV). If the detachment has been complete, the whole cervi.x in the shape of a ring being torn off from its attachment, no surgical treat- ment, as a rule, is reciuired. There is surprisingly little hemorrhage and the case is, in effect, one of amputation of the cer\ ix, leaving a symmetrical circular scar at the vaginal vault. A longitudinal laceration may be unilateral, bilateral, or multiple, commonly called stellate. The unilateral tear usually requires no surgical attention because there is not, as a rule, an a.ssociated eversion and erosion. A bilateral tear, if moderate in extent and not associated with erosion and eversion, may also be left unrepaired. It is better to have a wide opening of the cervical canal with good drainage than to close the cervical canal too tightly. If, however, there is erosion and eversion or much infiltration of scar tissue at the upper angles of the tear, a repair is indicated by the well-known technic of Emmet, which has never been improved upon in the ordinary uneomphcated bilateral cervical laceration. If the tear is stellate, if there is marked erosion of the whole vaginal portion, if there is extensive cicatricial infiltration, an amputation of the cervix is indicated. As a rule this is best done by a circular incision at the vaginal junction. Other methods have been proposed bj- which a combina- tion of amputation of the two lips separately with Emmet trachelorrhaphy may be employed, or the flap may be made longer on the vaginal surface of the cervix than in the cervical canal, thus turning in health}- squamous epithelium into the canal instead of unhealthy, hj'pertrophied and inflamed columnar epithelium (Plates LVI-LIX). In occasional cases these modifications are obviously indicated; but in most cases in which the Emmet trachelorraphy is not suitable, the pro- cedure usually adopted is the Hegar amputation of the second type which Hegar devised, with sutures inserted in such a manner that the wound is dog-eared on each .side out into the lateral vaginal vault; two sutures are put in, making a lineal wound in this region, on each side. Two other sutures each are usually required to close the wound in the anterior and the pos- terior lip which, as they are amputated, are cut away in such a manner as to leave a wedge-shaped excision so that the two portions of the excised lip may be brought together in nice approximation. A superficial stitch is often required between the two lateral sutures and the sutures in the anterior and posterior lip; but care must be exercised, in inserting these sutures, not to close the cervical canal too tightly. In 86 ATLAS OF OPERATIVE GYN.ECOT>OGY spite of an effort to a\oid this inistake, there are few operators, I think, who have not occasionally made it. One must be on his guard, therefore, to leave a wide canal to insure good drainage, otherwise an acquired stenosis of the cervix will leave the woman in a worse state than she was with the condition for which the cervix was amputated. The suture material in the cervix should be a number 3 size chromic gut. The tissues are tough; there is some strain upon the sutures, so that a smaller size will very likely suffer premature absorbtion and give way, with the certain result of a gaping, unhealed wound and a possibility of quite a severe hemorrhage during convalescence from the operation. PLATE LIII. Amputation of cer\ix. PLATE LIV. Sutures for amputated cervix. PLATE LV. Sutures united. IM,ATK LVI, Trachelorrhaphy. PLATE LVII. Excision of 6aps. PLATE L\'III. tititches inserted. PLATE LIX. Stitches tied. 94 ATLAS OF OPERATIVE GYN.ECOLOGY FISTULiE OF THE UROGENITAL TRACT Vesicovaginal fistulte, a common sequence of labor in the past genera- tion, are now rarely seen as one of the injuries of parturition. The fistula? encountered at present are almost always the result of an operation such as hysterectomy or an anterior vaginal hysterotomy. Their situation and extent, therefore, are quite different from the fistulae usually following labor. The latter are commonly fountl about midway between the x'aginal entrance and the cervix in the center of the anterior vaginal wall. The fistula is usually moderate in size and round in shape. It is easih' accessible and usually easily repaired. The typical operation consists in the separation of the vaginal and bladder walls around the fistulous opening for the space of about one-half inch. The bladder wall is then closed by numl)er 1 catgut sutiires put in transversely in such a manner that they do not include the mucous membrane, but bring together the inner layer of the denuded surface and the outer bladder wall surrounding the opening into the bladder. The vaginal wound is closed at right angles to the one in the bladder or on the bladder wall, the sutures being inserted through the vaginal miicous mem- brane and the subjacent denuded area, usually put in from above downward as there is conunonly some redundance of mucous membrane of the anterior vaginal wall, the slack of which is taken up in this manner (Plates LX, LXI). For these vaginal sutures I prefer fine linen thread following the suggestion of Fritsch of C.ermany, who had the largest experience in the repair of this condition possessed, I believe, by any surgeon, his work l^eing on the eastern border of Prussia, where attendance on labor cases is in large part by ignorant midwives, and where this particular consequence of a neglected labor was unusually conunon. After the closure of the vesical and vaginal wounds the bladder is drained by a mushroom catheter for foiu- days; after that, for a couple of days, the woman should be catheterized every four hours; she then should be allowed to ]:)ass water naturally. While the nmshroom catheter is in place, the nurse attaches a funnel to the catheter twice a day, through which is poured into the bladder two ounces of boracic acid solution, which clears the eye of the catheter and helps to keep the bladder clean. .At other times the mushroom catheter is jointed by a short glass tube to a longer rubber tube, which is led into a jar containing boracic acid solution tied to the side of the woman's bed ; in this the end of the rubber tube is submerged. The linen stitches in the vagina need not be removed for some time after the operation. I am in the habit of letting the woman leave the hospital with directions to return in a couple of weeks or longer, the sutures, therefore, remaining in place some four to six weeks from the time they were in.serted. Fistulae between the vagina and the bladder are not always so easily accessible; nor so moderate in size and regular in contour. Ihey may be FISTUL.E OF THE T ROGENITAL TRACT 95 situated hig:h in the anterior vaginal vault; they may involve almost the whole anterior vaginal wall and base of the bladder with even a portion of the urethra. There is no operation which demands so much individual study or such individual differences in technic. I have been obliged to use the cervix as a plug to till up the hole in the bladder for which it was impos- sible to secure sufficient tissue from the vaginal wall. The fistula was caused by a neglected ring pessary and admitted fourfingers into the bladder. In some cases I have utilized the corpus uteri, pulled out through the anterior \aginal wall, as a plug to close a defect involving the whole base of the blad- der. If the fistula is situated high in the anterior vaginal vault, it may be necessary, as suggested by Ward of New York, to dissect the vaginal^wall free from the bladder beginning directly under the urethra and exteniling the dissection up to the vaginal vault; that is to say, beginning the dissection in the region not affected by scar tissue and approaching the area of injury after the plane of separation between vagina and bladder is plainly outlined by dissection in the uninjured portion of the urogenital septum. Occasion- ally, in order to get access to such a fistula, it is necessary to utilize the Schuchardt incision shown in Plate LXII. It may be sufficient to enlarge the vaginal opening by bilateral incisions not so extensive as those of Schuchardt. In closing fistulse extending a considerable distance transversely, care nuist be exercised to locate the ureteral orifices, which otherwise might be buried in the denuded surface or occluded by a suture. In suturing a denuded area around or a transplanted flap over a vesical fistula, the needle must not penetrate the vesical mucous membrane. If it does, an intravesical hemorrhage will probably result in failure of the operation or the suture tract may develop into another fistula. Acquired atresia of the vagina is a method of spontaneous cure not infrequently seen. If the patient has passed the menopause, she remains comfortable: but if she menstruates into the bladder, there may be severe distress at the periods; and, if the lower portion only of the vaginal canal is closed, a sac exists beneath the level of the fistula in which blood, pus, and decomposed urine collect. It is occasionally impossible to close a serious defect in the posterior wall and base of the bladder. In such cases a colpocleisis is jus- tifiable, if the precaution is taken to close the canal up to the level of the fistula, leaving no vaginal sac below for the retention of decomposed urine and menstrual discharge. Fritsch has closed a fistula by denuding the anterior surface of the pos- terior lip of the cer\ix in a case of defect of the anterior lip and implanting the posterior lip in the \esical opening. The woman menstruated into the bladder, but nevertheless remained comfortable for years. To close the vagina (colpocleisis) a circular denudation is made around S)(i ATLAS OF OPERATIVE (iYN^ECOLOGY the whole canal two ccutinieters l)roa(l, at a 8ufficieut height to preclude the formation of a sac below the level of the fistula; a row of interrupted sutures across the vagina, inserted frpm before backward, closes the canal. In difficult cases of extensive fistula? deep within the vagina, and of fixation of the bladder by cicatricial adhesions, tlie following procedures ha\e been advocated and adopted : Incision into the anterior bladder-wall by suprapubic cystotomy in the Trendelenburg posture and closure of the fistula from above, silk ligatures, if they are used, being left long and led out of the urethra, whence they are removed by traction after they have cut through the tissue; or buried catgut sutures may l)e employed (Trendelenburg). A transverse incision over the pul)is, freeing the bladtler, and closure of the fistula i'roui the vagina (Fritsch). Separation of the \'agina from the bladder around the fistula, closure of the opening in the bladder, and a separate closure of the vaginal wound, as in anterior colporrhaphy (Winternitz, Mackenrodt). Opening Douglas's pouch, retroverting the uterus into the vagina, using its posterior siu'face (which becomes anterior in the complete retro- version) as a plug to fill in a large defect in the vesicovaginal septum, and making an artificial os in the fundus to allow the escape of menstrual dis- charge (Freund). I modified this procedure in one instance by pulling the uterus out through the anterior vaginal vault and fastening it imder the symphysis. If the urethra is absent or partly destroyed, its restoration is always doubtful. The most hopeful plan is to ])rei)are a flap of mucous membrane as thick as possible from one side, to ttu'n it inward so as to bring the nmcous surface within the newly made canal, and to fasten it in a denuded area on the opposite side. The new urethra should be established before the vesical fistula is closed. Fortunately, continence may be established without the presence of a urethra by leaving a narrow orifice at the neck of the bladder. This was accomplished in one of my cases after several futile attempts to construct a new urethra, which was entirely lacking, directly back of the external meatus. If there is such a serious defect of urethra and base of bladder that no plastic operation succeeds in restoring e\-en partial continence, colpocleisis and a rectovaginal fistula may make the i:)atient's condition endurable. But, if there is a cystitis at the time of operation, the result may be fatal from an exacerbation of the inflammation and infection of the ureters and kidneys. Indeed, there is always danger of pyelonephritis after such an oj^eration, though occasionally, as in one of Fritsch's cases, the patient remains com- fortable and well for years. PISTUL.E OF THE UROGENITAL TRACT ^ The rectovaginal fistula, admitting a forefinger, should be made by a transverse incision just abo\e the sphincter ani, the vaginal and rectal mucous membranes being united by interrupted sutures of catgut. The vaginal orifice is then closed. A double rubber drainage-tube is inserted through the fistula, and during the patient's convalescence the vesico- vaginal pouch is frequenth^ irrigated with a boracic acid solution. If a ureter has been included in one of the stitches, there are symptoms of deficient urinary secretion, rapid pulse, pain in the back, a tendency' to somnolence, and sometimes, though rarely, high fever. There are two courses open to the operators: one is to remove the stitches and to do the operating over again; the other is to tru.st to nature to overcome the diffi- culty, which is often done by the stitch cutting through, by the urine under pressure forcing its way through the loop of the ligature, or by the establish- ment of a uretero-vaginal fistida. Occasionally the kidney on the affected side atrophies and the remaining kidney performs the work of two, as after a nephrectomy'. If there is a persistence of incontinence after the operation, the flow of urine may come from a suture track, from a failure of union at some part of the wound, or from a second fistula not detected at the time of operation. The last two conditions reciuire subsequent operations. A small suture- track fistula often closes spontaneously, and some time should be allowed for this result before subjecting the patient to a second operation, which might be unnecessary. Intravesical hemorrhage will not occur after an operation for vesico- vaginal fistula if the sutures are properly placed. If it does, it is an awkward complication. The bladder should be washed out with boracic acid solution every two hours to prevent the formation of a large clot. If a clot does form in the bladder, causing tenesmus, the injection of pepsin solution has been recommended to soften it, but from recent experience with it a citrate of sodium solution 2 per cent, would seem better. Occasionally the fistulous opening between genital and urinary tract is found within the cervical canal. To reach it, it may be necessary to cut the cervix in two bilateralh' and then to separate the anterior lip of the cervix from the vaginal vault and the bladder wall, the hole in the latter being sewed separately by the technic already described. PTvATK LX, Map splitting denutUition for vesicovnginal fistula. Pr.ATK LXI. Stitches in bladder wall and vagina inserted at right angles. 1 tie i'>riii> r must naturally be tied bei" the latter are inserted. TATK r.xn. Schuchardt's incision completed. URETERAL FISTULA 101 URETERAL FISTULA There may be a communication between the ureter and the genital tract in women; the fistulous opening may be into the vagina or into the cervix. The recognition of the ureteral fistula is easy. There is a constant dribbling of urine, while at the same time half the urine is passed naturally by the bladder. By cystoscopy and the catheterization of the ureters there is additional confirmation of the existence of a ureteral fistula. There are three kinds of surgical treatments for these fistulse: nephrectomy, a plastic operation in the vagina, and an abdominal section followed by the junction of the ureter or its implantation in the bladder. Nephrectomy and the abdominal operation to join the ureter by an end-to-end or bilateral implantation may be required in any sort of patient — man, woman, or child. The only operations peculiar to women are those in the vagina. Consequently I confine myself to a description of the opera- tive treatment of ureteral fistulse in a vaginal operation. The Vaginal Operations for Ureteral Fistula. -The first requi- site for a successful plastic operation by the vagina is to find the upper end of the ureter and its orifice, which is not always easy to do. If there is not too much scar tissue the ureter may be dissected out, implanted into an incision made into the bladder, and fastened in place by several inter- rupted sutures of fine catgut. The vaginal wound is closed over the end of the ureter and the opening in the bladder into which it has been implanted (Parvin, Mc Arthur). It has sometimes been possible to sew the mucous membrane of the bladder to the mucous membrane of the ureter and so to fasten the latter in place. The vaginal mucous membrane, dissected back on each side by a flaji-splitting dissection, is united over the ureter and the newly made opening into the bladder. Schede's Operation: — This operation has given, on the whole, the best results: A vesicovaginal fistula is made close by the ureteral fistula, the mucous membrane of the bladder and that of the vagina being united by interrupted sutures of catgut; an oval denudation is made, one centimeter wide, around both the ureteral and the vesical fistulae, leaving a strip of undenuded membrane 0.5 centimeter wide, immediately surrounding both fistulse. The denuded surfaces are united by interrupted sutures, thus directing the stream of urine from the ureter into the bladder. BandVs Operation: — This is only practicable if both ends of the ureter are discoverable and are normally patent. A ureteral catheter is passed into both the lower and the upper segments of the ureter, emerging from the urethra. A denudation is made and united as in Schede's operation, but without making a vesicovaginal fistula. If the catheter is fenestrated the whole bladder is drained by it, or the urethra may be drained by a rubber tube through which the ureteral catheter passes. 102 ATLAS OF OPERATIVE GYNJ^/ OLOGY Mackenrodt's Operation. — A very ingenious procedure, which has been successful in the few cases in which it was tried. A vesicovaginal fistula is made near the ureteral fistula. A semicircular thick flap of vaginal mucosa is dissected ofT, so that it carries the ureteral opening in its center, has its attached base next to the vesicovaginal fistula, and its free edge away from it. By turning this flap over a half circle on its base it closes the vesicovaginal fistula like a lid; it is sewed in place by catgut sutures with the vaginal nuicous membrane directed into the bladder, and so turning the ureteral fistula into the bladder. The raw surfaces left by the removal of the flap and over the vesicovaginal fistula are united with interrupted sutures or are allowed to granulate. Dudley's Operation. ^\s Reynolds says, this is a crude procedure, but it has succeeded when other plans have failed. A sharp-pointed artery or other similar forceps is passed into the urethra; a vesicovaginal opening is made; one blade of the forceps, which is opened for the purpose, is pushed out of the incision in the bladder; the renal end of the ureter is threaded on it ; the handles of the instrument are closed and tied, thus clamping the end of the ureter to the bladder wall. The forceps is lightly pulled upon after eight or ten days. If it does not come away it is opened and extracted. OPERATIVE TREATMENT FOR RETROVERSION OF THE UTERUS Retroversion of the uterus ranks second in frequency after lacerations of the birth canal among the affections peculiar to women — that is, leaving out endometritis or hyperplasia of the endometrium, which accompanies almost all pathological conditions of the pelvic organs, but which as an entity or a disease entirely by itself is very rare. Retrodisplacement of the uterus constitutes 10 per cent, or more of all the diseases of women, so that a .surgeon who learns the best operative treatment for these two conditions is in a position to deal successfully with 60 per cent, or more of the women who apply to him on account of some disease peculiar to their sex. There is considerable difference of opinion as to the necessity for the operative treatment of retrodisplacement of the uterus, but no one can have seen much of the diseases of women without admitting that there are main- cases demanding the relief which can only be afforded the woman by an operation. The alternative, the use of a pessarj-, has so manj- disad- vantages that it is more and more rarely resorted to except as a tem- jjorary measure. The operative treatment of retroversion, however, is a matter of choice for the patient. My practice is to state the relative advantages and disadvantages of the two procedures, pointing out that the pessary must be removed e\-ery six weeks; that it must occasionally be left out altogether on account of ulcerations of the vagina; that it never promises a permanent OPERATIVE TREATMENT FOR RETRO^ ERSION OF UTERUS 103 cure — on the contrary, by stretching the ligaments, it makes the displace- ment more difficult to manage without artificial support than if the pessary had never been employed; and it must be worn indefiniteh'. Some patients, however, insist on the use of a pessarj'. There are women coming to my office now at regular intervals who began this treatment twentj^-five years ago. After a trial of this palliative measure, which many patients demand at first, I find that the vast majority of women deliberately select the operative treatment ; while, if that treatment were urged upon them in the beginning, they would be inclined to become apprehensive and perhaps change their physician ; whereas, if operation is ultimately selected by the patient herself, the original attendant ma}' perform it if he desires to do so. It is true that there are some patients who show surprisingly few symptoms from a retrodisplaced uterus. The young unmarried girl, the woman who has not borne children; even the woman who has borne children and who may have some tendency to prolapse, as well as retrodisplacement, occasionally suffers nothing apparently from the condition of the pelvic organs. But these patients are the exception. Even in the unmarried girl there are often severe symptoms not only localh' but referred, as head- aches, pain in the neck, often coccygeal pain, associated with serious nervous disturbances. I have had several cases of actual epilepsy associated with retro- displacement of the uterus, cured by the operative treatment of that condition. Retrodisplacement of the uterus is also not infrequently a cause of sterility, and the treatment of the woman's sterility must include the per- manent reposition of the uterus and its retention in a normal position. The unsatisfactory result of manj' of the operations performed for retroversion of the uterus have in some quarters created a prejudice against this treatment, but I feel that the improvement in this operation recently secured by a combination of two of the older plans will be found to give such uniformly good results that this source of prejudice against the opera- tive treatment of uterine displacement will be removed by future experience. Another cause of disappointment with the operative treatment of retro- version has been the failure on the part of many operators, especially general surgeons, to take into account the associated injuries of the birth canal. In the vast majority of cases, backward displacement of the uterus follows the process of generation and is very frequently indeed associated with some damage of the genital canal. The discomfort, therefore, which sometimes persists after the operative cure of the backward displacement of the uterus can often be attributed to an imperfect correction of the injuries of child-birth or the total neglect of this feature in a given case. If there is no indication for a repair of the injuries in the genital canal. 104 ATLAS OF OPERATIVE GYNAECOLOGY there is almost invariably a necessity for dilating the cervix and curetting the uterine cavity, so that any operation for retrodisplacenient of the uterus forms only a part of the operative procedure undertaken. In a case of long standing there is ai)t to he also a clironic metritis with enlargement and increase in the weight of the womb, whi(^h may and probably will require treatment subsecjuent to the operation. If all these factors are taken into account, and if the best operative technic is selected, I feel conhdent that what prejudice exists at present against the operative treatment of retroversion will eventually disajij^ear. j\Iy professional life embraces in point of time almost the whole history of the operative treatment of retrodisjilacement, from the susjiension oi)er- ation of Olshausen to the present time. Many of the numerous operations before the profession I have tried in series of cases and have for many years looked for the ideal ojioration that would make the ])atient well and keep her so in s])ite of futuiv childl)('aring. The old suspension operation introduced into this country by Kelly, the operation of Dr. CJilliam with all its modifications, Baldy's ojjeration, Webster's operation, C'cffey's operation, as well as the older operations of Dudley and Mann, have all been tried and given up. It is only during the last four years that I have found the operation which meets my require- ments. While my ex]ierience is necessarily limited with this ]irocedure, in the comparati\'ely short time during which I haA'e utilized it, although the total number of operations is now over two hundred, 1 have had an experience with its component parts over a period of more than twenty years, so that I know well what each one of these operations will do of itself and I ha\'e confidence that the combination of them will give me what I have been long looking for — a procedure that will not only symptomatically cure the patient, but will permit her to bear children in the future without a recurrence of the displacement. In the twenty years that I have been short- ening the roiuid ligaments in the groin, I have not yet seen a patient with a recurrence after a subsequent confinement. It is remarkable to be able to make this statement, but it is a true one. The high percentage of failures reported by some observers is to be explained by an imperfect technic in performing the operation. A disadvantage of the old Alexander operation, however, even as modified by Edebohl was that it did not permit an inspection of the appen- dix and the appendages. I lost a patient once on this account from an appen- dicitis which had been chronic for some time (it probably existed at the time of my operation) ; it suddenly became acute and gangrenous. The jihysician in charge of the case at that time did not believe in the immediate operative treatment and by the time the patient was referred for operation it was too late to save her. OPERATIVE TREATMENT FOR RETROVERSION OF UTERUS 105 The suspension operation is a useful procedure easily and quickly carried out, but it will not stand the strain of the next pregnancy, and has too large a percentage of recurrences. The combination of the two, however, gives me exactly what I have been looking for. The temporary suspension of the uterus with a single strand of number 3 plain gut keeps the uterus in place while the round ligaments are being set in their new position, and takes the i)lace of the pessary it was customary to use while the patient was Fig. 20. — Pfannenstiel incision twelve thiys after the operation. recovering from the old Alexander operation: and while the abdomen is open through the Pfannenstiel incision there is ample opportunity to sever adhesions, inspect the appendix and the appendages, and do what may be required when these structures are exposed to touch and sight (Plates LXIII-LXXIII). Another advantage of this procedure in the young child-bearing woman is the practically unscarred abdomen and the elastic abdominal walls which remain for subsequent child-bearing (Fig. 20). I have foimd this operation 106 ATLAS OF OPERATIVE GYN.^^XOLOdV also peculiarly suitable to those cases of sterility in which the backward displacement of tlie uterus plays a causitive role in the prevention of con- ception. The ojieration not only jierniits the coi-i'ection of the displacement, but also gives an oijjjortunity for the inspection of the ])elvic organs and the detection of some other possible bar to the penetration of spermatozoa, such as closure of the alxlominal orifices of the tubes, adhesions obstructing the calil^er of the tube, and adhesions and plastic exudate burying the ovary. The intra-abdominal work in this (jpci'ation is usually so slight and so speedily perfornunl that there is little chance for subseciuent adhesions in consefiuence of the abdominal section, and the symptomatic relief is de- cidedly greater than is afforded by those operations for retroversion done entirely within the abdominal cavity. The Coffey operation, which at present seems to be most popular in this coimtry, has this disadvantage: I have been obliged twice to reopen an abdomen in order to relie^■e the excessi\-e adhesions sometimes formed anteriorly after this operation. And I do not l)elieve that this operation will stand the strain of subsequent pregnancies. By the follow-up i^lan of writing to the patient a year after the perform- ance of the combination of suspension of the uterus and shortening of the roimd ligaments, I have not yet failed to receive a favorable report from e\'ery patient from whom I have been al)le to secure a reply to my communi- cation, antl so far I ha\'e not found a recurrence of the displacement after this operation. I am encouraged to believe, therefore, that it will prove as satisfactory a procedure as any that has been tried for the operative treatment of retro- version of the uterus. In my experience at least it has been demonstrated to be a much more satisfactory operation than any of the others that have been tested. PLATE LXIII. m^ ' I ■ I J r '. Oferution for rptrovrrsion. Pfaiinenstiel inci^iin. w ■^^ ■f-fiMiit'i-.'^y H 3 v. y. y, ►J w 118 ATLAS OF OPERATIVE GYNAECOLOGY PROLAPSE AND INVERSION OF THE UTERUS The only other displacements of the uterus requiring operative treat- ment are prolapse and inversion. I have never been convinced of the necessity for operating upon cases of antiflexion. Of itself, this displacement is responsible for no symptoms except dysmenorrluEa and sterility. The .former is due more to the ill- development of the uterus of which the antiflexion is a sign than to the dis- placement proper. If sterility is the result, it is due to mechanical inter- ference with the ascension of the spermatozoa in consequence of the stenosis of the cervical canal by angulation, and to the hypoplasia of the genital organs. If operative treatment is reciuired it should usually be a wide dilatation of the cervical canal, which will compensate for the stenosis by angulation. The two operations which might be considered are the Dudley operation for securing a liackward displacement of the external os and the straighten- ing of the cer\ical canal, or the operation proposed bj' Reynolds for elongat- ing the anterior vaginal vault. I have tried the Dudley operation, but do not like it. It leaves a deformed and distorted cervix and I have been able to secure better results in this condition by a wide and permanent dilatation of the cervical canal. The Reynolds operation, consisting of a transverse incision in the anterior vaginal vault and then the insertion of sutures from side to side in such a manner as to elongate this vault might be valuable if the anti- flexion itself produced symptoms — which it really does not. This operation cannot be expected to relieve either dysmenorrhoea or sterility. Prolap.se. — The operative treatment of prolapse of the uterus can also be dismissed in a few words. There are few cases that caiuKjt be perma- nently cured l\v a combination of interposition anteriorly and a proper perineorrhaphy and repair of the pelvic floor posteriorly, combined often with an amputation of the cervix if there is elongation of the supravaginal portion. If these operations are done properly (page 70), it is quite possible to make the exit of the uterus from the l)irth canal a physical impossibility. I have found no occasion, therefore, for the radical procedures recom- mended from time to time for prolapsus uteri, such as vaginal hysterectomy and the anchorage of the vaginal stump to the abdominal wall, or splitting the uterus and burying the two halves in the anterior abdominal wall. Some cases may possibly require such radical treatment, but not for the prolapsus alone. If there is a suspicion of malignancy or a persistent metrorrhagia in a middle-aged woman, I find an operation combining the features of Goffe's mmiber 2 and the Mayo operation most satisfactory. The uterus is completely removed by the vaginal route (page 217) and three stumps of the broad ligament are formed by ligatures on each side. These PROLAPSE AND INVERSION OF THE UTERUS 119 stumps are united in the middle line and by the same stitch are fastened to the fascia directly beneath the anterior vaginal wall, thus interposing these stumps between the bladder and the vagina. Inversion. — Fortunately we possess an operative treatment for inver- sion of the uterus which can always be depended on unless inversion has been associated with some degenerative process of the uterine body, such as partial or total necrosis, demanding the removal of the womb. The proper time to treat inversion of the uterus is immediately after its occurrence. If the physician understands the proper method of taxis, there ought never to be much difficulty in replacing an inverted womb. I have been aisle to do this in at least six cases. The latest one was five days after the woman's delivery. After that time the replacement becomes difficult or impossible, and operative treatment is demanded. In the Spinelli operation we have a procedure that can always be depended upon but it is well to remember that the operation need not always be as extensive as Spinelli recommended. (Plate LXXIV-LXXIX.) In two out of four of these operations which I have performed, I was able to replace the uterus without opening the peritoneal cavity. In undertaking the operation, therefore, this possibility should always be borne in mind. After opening the anterior vaginal vault by a transverse incision and then by a blunt dissection separating the tissues up to the reduiilication of the peritoneum, the anterior lip of the cervix and the lower uterine segment should be severed as shown in the illustration. An attempt should then be made to replace the uterus before proceeding further. This can best be done by beginning the upward pressure against the inverted body of the womb at the upper angle of the wound in the cervix and in the lower uterine segment. If this attempt fails after a justifiable application of force and after the lapse of some little time, in the attempt, the peritoneal cavity must then be opened and the incision extended into the uterine body by reversing the direction of the scissors; but, at each extension of the incision, an attempt to rein vert the womb should be made. It may be necessary to slit practically the whole anterior surface of the uterus in two, but it may easily be possible to reinvert the uterus without such an extensive wound. It is obviously an advantage to avoid a scar running the whole length of the uterus if the woman is ever to become pregnant again. After the reinversion of the uterus is accomplished, the uterine wound is closed by a two-tier catgut suture in the myometrium and then by a continuous up-and-down lace suture in the perimetrium. The opening in the peritoneal ca\ity is then closed and the vaginal A-ault united by interrupted sutures. Drainage is not required. PLATE !>XX!V. Spinelli operation for inversion of uterus. Transverse incision of vagina over the cervix. PLATE LXXV. T-shaped incision to gain more room. PLATE LXXVI. Discission of a ring muscle in cervix begun. PLATE LXXVII. If necessary discission of uterine wall. PLATE I.XXVIII. Uterus re-inverted and wound in the wall closed. PLATE LXXIX. Mucous membrane united. 126 ATLAS OF Ol'KRATIVE GYN^X'OIXK.Y DILATATION OF THE CERVICAL CANAL Dilatation of tlie cervical canal can he effected by instrumental dila- tation, liy the insertion of an intra-nterine stem which is retained in place for a mniilici- of weeks; by an anterior vaginal hysterotomy; by electrolysis; and, in the case of a pregnant uterus, liy rubber bags distended with water. Instrumental. — If the dilatation is jierfornied upon the non-pregnant uterus, my practice is to use three instrumental dilators in succession : the weaker model of the Goodell dilator modified by Bacr; the stronger two- branch dilator devised by Wathen of L()uis\iUe and last the four-branch dilator named after Dr. Cleveland of New York City. Following this I insert my own modification of 8chatz's metranoicter which I have now used for some eight or nine years with great satisfaction. It effects a wide dila- tation of the cervical canal if left in place for twenty-four hours. If the widest possible dilatation is desired, it can be replaced in twenty-four hours by a fresh instrument, which is allowed to remain in place twenty- four hours more. When the instrument is removed the uterus is washed out with Lugol's solution, one drachm to the i)int. Perfornu'd for sterility, this instrument has given me a forty-three per cent, cure in the patients from whom I have secured an answer more than two years after the operation was performed. One of my staff ad- dressed one hundred and sixty-seven letters to these patients some years ago, and from the replies received was able to record a forty-three per cent, cure; and that without a prior examination of the husbantl, which I now insist upon before undertaking an oi)erati()n for sterility. For mechanical dysmenorrhoea, this form of dilatation is not so suc- cessful; it gives temporary but, in the majority of cases, not jiermanent relief. I tried the intra-uterine tube designed by Wylie of New York, the successor of the old intra-uterine stem, and its various modifications for a period of two years, but was obliged to give it up on account of the percent- age of infected tubes and endometrium which result from its use. There is no way of escaping this disadvantage. Any foreign body left in the uterus for a considerable space of time is certain to result, occasionally, in an infection ; and I am now seeing cases of this sort in which my colleagues still use this implement, so that my belief in its danger is confirmed. In some cases, Hcgar's graduated bougies will be found a useful instrimient for the dilatation of the cer\'ix. I find the chief use of this instrument to be after a contraction of the cervix fallowing the more radical instrumental dilatation just described. Hegar's bougies are also useful if it is desired to dilate the cervix prior to the use of the uterine endoscope to avoid obscuring the field of vision by blood. The large sizes of the Hegar's dilators for the pregnant uterus are occasionally useful in multijjarse, but are not so good as rubber bags. DILATATION OF THE CERVICAL CANAL 1-27 For the pregnant uterus, there is a useful two-branch dilator modified from the original instrument of Gau by J. C. Hirst. This instrument secures a dilatation of the pregnant cervix to the extent of seven centimetres in a linear direction. This degree of dilatation is safe. A more powerful dilator for the pregnant cervix is a four-branched instrument such as the Bossi and its modifications, a very good one being the instrument devised by the late Dr. Dewees. They are not so generally used, however, as thej^ were for a time after Leopold of Dresden called the attention of gyna-cologists to Bossi's dilator. These instrumental dilators are too powerful and too likely to inflict serious damage upon the cervix. If used at all the dilatation should never be carried to a diameter of more than four centimetres. For the con- tinuance of the dilatation of the pregnant cer\ix and its extension, rubber bags are used. After trying all the models de\ased, I had one made which I think is superior to the conical bags in general use. The disadvantage of these conical bags is that they elongate the cervix and are apt to dis- place the presenting part. By pulling upon them, as is often recommended to hasten the dilatation, a prolapsus uteri often results. The flattened hour-glass shape of my bags avoids all these disadvantages; they are more difficult to insert accuratelj', but once put in proper position they effect a dilatation of the cervix more satisfactorily and with less disadvantage than any model that I have ever tried. Anterior Y.\gix.\l Hysterotomy. — This is an extremelj- valuable procedure for the exploration and evacuation of the uterine cavity. (Plate LXXX-LXXXV.) It may be utilized for the digital exploration of the uterine cavitj', for the removal of polypoid and submucous tumors, and for the evacuation of the pregnant uterus up to the seventh month. Beyond that time the fetal head is so large that the incision in the anterior uterine wall may be dangerously extended and may possibly involve injury to tl:e bladder, even if the posterior lip is also cut to gain more room. The anterior lip of the cervix is seized bj' two double tenacula; and after making a T-shaped incision in the anterior vaginal wall and dissecting the flap backward, and by a blunt dissection with a piece of gauze separating the bladder from the cervix, the latter up to and beyond the internal os is cut with scissors directly in the middle line, the incision beginning between the two tenacula. It may occasionally be necessary to cut the uterovesical ligament and to separate completely the bladder from the uterus; but ordinarily such a high dissection is not required. Before making the incision in the cervix and lower uterine segment, the bladder is protected by an anterior vaginal retractor. In suturing the uterine wound, a number three strand of chromic catgut and a curved needle are recjuired. It is advisable not to put the fu'st suture in the upper angle of the wound but rather about midway up ; and this suture 128 ATLAS OF OPERATIVE GYN.ECOLOCIY can be used as a tractor to bring into view the upper portion of the wound. Interrupted sutures are then inserted up to the upper angle, care being taken not to close the cervical canal which is protected bj' an instrument such as a uterine two-way catheter placed within the canal. As the sutures are placed in the lower portion of the wound, they are inserted from side to side until the end of the wound in the cervix is reached; when two sutures are inserted at right angles to the othei's. In this way the cleft in the cervix which often follows this operation may be a\-oided. The wound in the cervix being closed in this manner, the vaginal flaps are brought together and united to the cervix by interrupted sutures of number 1 chromic catgut. Electrolysis. — In ill-de\eloped uteri the contraction of the cervical canal after an instrumental tlilatation can be pre\ented by electrolysis. It procures also a wider dilatation than could otherwise be obtained. This treatment has the additional advantage of securing a development of the uterus, and is the only agent which can accomplish this purpose. I have had a number of cases of sterility associated with infantile uteri in which electrical stimulation secured a development of the uterus vuitil a full internal measurement was obtained, followed by impregnation and deli\'ery at term. This treatment is carried out by the insertion into the uterine cavity of a copper electrode, as a negative pole, while a positive pole con- sists of a large sponge placed upon the woman's abdomen. A galvanic current of from nine to twelve milliamperes is applied to the uterine cavity for about ten to fifteen minutes every other day for a jieriod of four to six weeks. If, in addition to the enlargement of the cervical canal, it is desired to procure a further development of the uterus, two faradic currents (the rapid and slow interrupted), and the sinusoidal current are employed in addition, the whole treatment continuing for about twenty minutes. PLATE LXXX. \'aginal incision for anterior vaginal hysterotomy. PI, ATI-: I.XXXI. Pushing up bladder with gauze pad. PLATK LXXXII. Incising cervix and lower uterine segment. PLATE LXXXIII. InciBion completed, exposing pouting membranes. PLATE LXXXIV. Sutures of uterine and cervical wounds. PI.ATK T.XXXV. Vaginal flaps closerl. ENLARGING THE VAGINAL INTROITUS 135 AN OPERATION FOR ENLARGING THE VAGINAL INTROITUS IN CASES OF VAGINISMUS In neurotic women a spasmodic contraction of the muscles around the entrance to the vagina is not at all rare. The levator ani and the constrictor vagintp are the muscles involved. L^sually the physician sees a patient with this condition some time after marriage, as embarrassment prevents her from seeking immediate medical aid. I have had women under my care who have had no marital relations for thirteen and twenty j-ears on this account, and a number of others with a history of a shorter duration of the dyspareunia. It is possible to cure the cases of a minor grade by gradual dilatation with the large-sized graduated Hegar dilators made for the preg- nant uterus; these are given to the woman with instructions to use them gently and carefully after warming and oiling them, and to allow herself plenty of time to effect the desired degree of dilatation. The period usually required is on an average six weeks. If this treatment fails, or in the more exaggerated cases in which gradual dilatation cannot be endured, an operation is indicated; this involves cutting the levator ani in each posterior vaginal sulcus, imitating the lacerations of the genital canal in childbirth. (Plates LXXXM- LXXXVII.) The incision goes through both layers of the triangular liga- ment, separates a sufficient extent of the muscle to allow the insertion of three fingers in the ^■agina, and is extended to a moderate degree downward in the middle line of the perineum through the perineal body. The mucous membrane is then united as shown in Plate LXXXVIII. Packing is placed in the vagina and left undisturbed for two daj's. It is not necessary to repack. I have not yet known this operation to fail. In the two cases quoted, one of thirteen and one of twenty years' duration, there was an immediate success. I have also cured a number of cases of sterility from this cause and from a long experience ^\-ith the operation I have acquired great confidence in it. Attempts at marital relations must be postponed until perfect healing of the wound is .secured, and then the husband must be cautioned against any roughness or violence which might hurt or frighten the patient. PI.ATK T. XXXVI First incision for vaginismua operation. PLATE LXXXVII. Second incision for vaginismus operation. PLATK LXXXVIII. Incision through levators and triangular ligament. PLATE LXXXIX Uniting mucous membrane over incisions so as to let the cut muscles gap apart. 10 140 . ATLAS OF OPERATRE GYN.ECOLOC.Y OPERATIONS FOR GYNATRESIA These operations \ary in degree from the l)hnit dissection separating the agglutinated labia of a new-born female infant to the construction of an artificial vagina. The interniediate operations are dissections, sometimes blunt, but usually l)loody, of transverse septa varying in situation and in depth, perhaps including the whole or the greater part t)f the length of the vagina; or, as is usually the case, consisting of transverse septa no thicker than the ordinary hj'men. (Plate XC.) If the atresia affects only the lower i)ortion of the genital canal, while the upper portion is fairly well developed, menstruation occurs without the escape of blood externally; the consequence is an accumulation of blood within the uterus — htcnuitometra, or in the tube — htrmatosalpinx. It is the latter possibility which makes such cases serious. While it is usually easy enough to reach, to e\-acuate, and to wash out with a boracic acid solution the accumulation of blood in the uterus, it is impossible to reach the collection within the tubes, which cannot possibly drain themselves although there is enough of a communication left between tubes and uterine cavity to insure a rapid infection of the accumulated blood in the former. It is a disputed point how the abdominal orifices come to be closed in these cases; the irritation of a foreign body — blood — oozing from the tubes causes, I believe, an inflammation of the peritoneum and an agglutination of the fimbria-. Therefore a jiart of e\'ery operation to evacuate retained blood in the genital tract, in consequence of gynatresia, is an exploratory abdominal section to inspect the tubes. If they are found cUstended they should be removed and the cornua should be carefully closed by sutures. It is then safe to dissect the closed vaginal canal, and if necessary the cervix, in order to reach the accumulation of blood in the uterus; which is evacuated and washed jiersistently with a boracic aciil solution imtil the cavity is com- pletely emptied. If there has been an infection of the uterine contents before the operation, and there is pus in the uterine cavity instead of blood, a hysterectomy must be considered with a complete removal not only of uterus but of tubes also. A pyometra will more often be found in connection with an acquired atresia of the lower genital canal. I have seen such a condition in connection with a vesicovaginal fistula above the point of atresia, and I have been obliged to operate on such a case in which the vagina was deliberately closed by a former operator in order to correct a vesicovaginal fistula which it had been impossible, apparently, to close by the usual operation. Hysterectomy must also be considered in cases of ill-development of the uterus with closure of the vagina. I once operated on an interesting case OPERATIONS FOR G^'NATRESU Ul of this sort in whicli there was a large hsematoinetra and an enormous hsematosalpinx in a uterus unicornus and a single tube. In complete gyna- tresia involving an absence of the vagina and also of the uterus, represented only by a small bundle of muscle fibre without a trace of uterine cavity, it is sometimes necessary to consider the remo\al of the o\aries, as patients with this condition have se\ere menstrual molimina unrelieved by the periodic loss of blood in a menstruation. Fig. 21. — Congenital absence of the vagina. If the genital canal is preserved above the site of the atresia, the vaginal canal can be preserved by uniting the mucous membrane, below the point of occlusion, to the mucous membrane above that point. The raw area left by the dissection of this area is thus covered by mucous membrane (Plate XCI) and a patent continuous vaginal canal is secured. If there is an entire absence of the vagina, but a uterus, uterine cavity, and cervix, flaps of skin may be turned in from the labia or from the external genitalia and united to the cervix. This sort of artificial \agina it is possible to keep PLATE XC. Crucial incision for imperforate hymen or transverse vaginal septum. PLATE XCI. R:iw surfuiTs roverecl by ihucmus meiiibrnne altpr iniisi.jii uf imperforate hyiuen or transverse vaginal septum. (J J ». PLATE XCIII. Lateral anastomosis of ileum and pulling the isolated portion of intestine into the artificial vaginal canal made by blunt dissection. PLATE XCIV. Segment of intestine sutured into the artificially made vaginal canal. PLATE XCV. Point of reduplication in intestinal segment opened so as to establish a canal lined by mucous membrane. I'r,ATE XCVI. Septum between apposed intestinal loops removed. AN OPERATION FOR ANUS VESTIBULARIS 149 open, perhaps with the aid of Sims's plug of glass or haid ruljljcr, or pos- sibly by gauze packing contained within a thin rubber pouch (condom). But even then, and even if the atresia is limited to a small area, precaution must be taken to prevent a cicatricial contraction at the site of the atresia. If there is an absence of the whole genital tract, with the exception perhaps of the tubes and ovaries, the question of making an artificial vagina for purposes of coition must occasionally be considered. As a rule the propriety of this o)ieration is questionable, but occasionally it is justifiable— as in a case recently under my care where coition was accomplished through the urethra without present incontinence but with imminent danger of it and with the constant possibility of a severe cystitis. E\-en in such a case, it might be preferable to avoid the only operation practicable for making an artificial vagina, and to allow marital relations to be continued in the ab- normal manner in wliich they had been begun. The question should cer- tainly l)e ])ut jilainly Ijefore both husband and wife as to whether a major operation in\olving some risk to life shouUl be undertaken for the sole purpose that it could attain. If an operation for an artificial vagina is decided upon, there is no question that the only one which promises a per- manent success is the operation devised by Baldwin with utilization of the intestinal tract as illustrated in Plates XCII-XCVI. I ha^•e used all the plastic operations for an artificial vagina, including the implantation of one woman's vagina in another; but they all failed eventually. I have seen an artificial vagina constructed from a segment of the rectum through an incision alongside the sacrum, which was partially removed as in a Kraske operation ; and I have attempted such an operation myself. But the tech- nical difficulty was so great and the patient's condition became so bad that I gave it up without completing it. I should select the operation which utilizes a section of the small intestine, if I ever undertook such a thing at all; but as yet I ha\'e not seen a case (out of a considerable number of cases of absence of the genital canal under my care) in which such a jirocedure seemed to me justifiable. AN OPERATION FOR ANUS VESTIBULARIS .\n interesting congenital anomaly re([uiring surgical treatment is the opening of the anus into the fossa navicularis, usually described as anus vestibularis, although the fossa navicularis is not, strictly speaking, a part of the vestibule. (Plates XCVII-XCIX.) I have operated on this condition twice with success, once in an infant a year old and once in a girl aged sixteen. The sphincter and lower rectum are dissected loose, anteriorly and to a certain tlegree laterally, after making a longitudinal incision from the posterior edge of the anus to the point on the perineum where the anus is PLATE IXCVIl. Anus vestibularis. PLATE XCVIII. Anus vestibularis dissected loose and an incision below it preparatory to its fixation in a normal posiUon. PLATE XCIX. Anus vestibularis transferred to normal position and'fixed there. OPERATIONS ON THE VULVA 153 normally situated. The anus, sphincter muscle, and a small segment of the rectum are then pulled back to the posterior termination of the longitudinal incision and stitched there with linen thread. The longitudinal incision is then closed in front of the bowel. OPERATIONS ON THE VULVA Operations on the vulva consist of the removal of tumors, cystic or solid, from the labia majora or the labia minora; the removal of cy.'^ts of the vul\-o\-aginal gland; the removal of venereal warts, and operations more or less extensive on the external genitalia varying from the removal of small adenocarcinomata in Skene's glands in the urethra to the amputation of the labia and the extension of the incision into the groins for the removal of the lymphatic glands in that region. If it is necessary to remove large cy.stic or solid tumors from the vulva, the hemorrhage may prove embarrassing; as a rule, however, the operator is not much troubled on this account, as the ve.ssels are easily accessible. ExsECTioN OF Vulvar Nerves. — The most difficult operation in this region is the exsection of the five pairs of vulvar nerves for pruritis ^•ulv£e or nymphomania. I have done five of these operations with success, but the dissection required is extremely difficult and tedious. The most important thing to remember is in the exsection of the ter- minal division of the pudic nerve into the perineal nerve and the nerve of the dorsum of the clitoris. If the exsection of the pudic nerve is made below the origin f)f the nerve which controls the action of the sphincter ani. the latter may be severed, with permanent incontinence of gas and faces as a result. Dissection of the Inguinal Canal for the Removal of Fibroid Tumors of the Round Ligament. — It is convenient to include this among operations on the vulva. I have removed three of these growths, each of considerable size. The operation is easy: the skin, .'superficial fascia, fat, and fascia of the external obliquus are incised over the tumor, which is then enucleated. The rest of the operation is like an extensive herniorrhaphy. Closure of the Inguinal Canal for Hernia. — In the female this procedure presents some features differing from those characterizing the same operation in the male. The round ligament in the female is utilized in the closure of the canal and there is. of course, no vas deferens to avoid. The internal ring should be closed with permanent sutures of linen thread in addition to the obUteration of the canal, thus making the perma- nent success of the operation more certain. Procedure hi Pregnancy. — The question sometimes arises as to the propriety of removing growths of the vulva in pregnant women. This appUes particularly to large cysts and sohd tumors of the labia; to elephan- lot ATLAS OF OPERATIVE GYN-I^.COLOGY tiasis, and to veueroal warts upon the external genitalia. The coninion- sense rule to follow is to jiostpone the operation until after deli\ery or, if the bulk of the tumors constitutes an obstacle to delivery, to attempt no operation in this region until shortly before term, allowing if ])ossil)le two weeks for the healing of the wound before tlic actual onset of labor. Removal of the Vulvovagin.\l ok Bartholin's (Jland. — The commonest operation on the vulva is the removal of a distended and prob- ably suppurating vulvovaginal gland, usually but not always the result of gonorrhoeal infection. If not removed entire, the abscess in the gland will probably recur from time to time. The incision is made on the inner surface of the labium majus, the whole length of the tlistended gland; the gland is dissected out with sharp-pointed scissors cur\ed on the fiat; care must be taken not to incise the capsule of the gland, as it will collapse and its removal is then difficult; this is certain to occur when the efferent duct is cut, but by that time the dissection should be complete. If the abscess opens spontaneously just before the operation, or is prematurely evacuated before the dissection is completed, the cavity of the gland may be filled with sterile paraffin melting at 110° F. which is usually supplied to the nose and throat specialists. The space left after the removal of the gland is closed with two layers of catgut sutures, a horse-hair drain of a few strands of silkworm gut being laid in the deepest jiortion of the wound and emerging from Ijoth extremities of the skin incision. OPERATIONS FOR HERMAPHRODITISM It is a safe rule in all cases of pseudohermaphroditism in which the sex is really doubtful to bring up the individual as a male. This course avoids some of the curious and awkward situations that arc often noted in such cases. I have seen an indi\idual married for twelve years as a wife, who applied for a diagnosis of the cause and for the treatment of sterility, but on examination was foinid to be a male pseudohermaphrodite. I have recently examined an individual about seventeen years of age who was acting as a ladies' maid, and applied for treatment on account of the non- appearance of menstruation. This individual was found to be a male. I once saw a man nineteen years of age don his first pair of trousers and take his position in the world as a male. He had been brought up as a woman until his gruff voice, manly stride, and sprouting beard aroused a suspicion as to his true sex. On the contrary I had the opportunity of examining a female pseudohermaphrodite brought up as a male, perfectly happy in that capacity, keeping a small cigar shop and living in all respects the life of a young man. Many other cases of this kind are collected in that OPERATION FOR HERMAPHRODITISM 155 extraordinary book on licrmaphnxlitism by v. Neugebauer. Ono occasion- ally sees a male hermaphrodite, however, who is exceedingly unhappy as a male. All the secondary external characteristics of sex in such individuals are frecjuently feminine and the tastes and inclinations are all those of a woman. Consequently these creatures are miserably unhappy in their life as males; whereas, if they hved as females, they would be moderately con- tent and would not ha\-e that marked disposition to suicide which is noted in such a large proportion of the cases collected in v. Neugebauer's book. I have examined three such individuals myself and in two of them offered to renio\e by operation the characteristics of the male sex and to con\-ert them as far as jiossible into females by enlarging the rudimentary \agina and by tlie removal of the male sexual glands and the penis. Al- though these creatures applied to me for surgical treatment, none of them finally accepted it. They had the excessive shjTiess which is often seen in these unfortunate individuals and on this account, I think, disappeared from my notice after making arrangements for operative treatment. I should not hesitate, in a case of this kind, to perform such an operation; for I am convincefl that it would contribute markedly to the hai)j)iness of the hermaphrodite, and could in no way be detrimental to the indi\-idual and probably not to those with whom he came in contact. 11 PLATE C. Incision for excision of labia and exposure of inguinal glands. PLATE CI. Suture of wound after removal of labia and inguinal glands. 158 ATLAS OF OPERATIVE GYNAECOLOGY SALPINGECTOMY Salpingectomy is indicated for jiyosalpinx, hsematosaliiinx, tuberculosis of the tubes (Fig. 23), streptococcic infection, carcinoma, and ectopic ges- tation. In hydnisal]Mnx (Fig. 24) I i)refer opening the fimbriated extremity with a luemostat. draining the tube, and preserving it. Fig. 22. — Py()sali)iiix or pus tube. m a:^-- Fig. 23, — Tuberculosis nf the Fallopian tube. SALPINGECTOMY 15!) Operative Procedure. — If salpingectomy is indicated the method of removing the tube is shown in Plates CII-CV. The tube is first cut off from the uterine cornu. A hsemostat is then fastened on the broad ligament under the cut extremity of the tube: another is clamped on the free edge of tlie broad ligament laterally, securing the ovarian artery. The tube is then cut off, traction being made upon it with the hiemostat fastened to its uterine extremity; as the middle of the broad ligament is reached a bleeding vessel must be clamped. The broad ligament is then sewed over with a lock stitch which can usually be dej^ended on to check the hemorrhage that would otherwise require ligation of the vessels separately; the ends of the running stitch are tied around the free edge of the broad ligament securing Fig. 24. — Hydrosalpinx. the ovarian artery. If in spite of this stitch there should be some oozing from the cut surface of the broad ligament, a mattress suture maybe em- ployed, under the ruiming lock stitch, including that portion of the broad ligament from which the hemorrhage comes (Plate CVIII). I canietl out this practice for a number of years without an accident, but have recently had a fatal secondary hemorrhage. In addition to the lock stitch, therefore, I now tie the three arteries separately: namely, the ovarian, round ligament, and uterine. If it is intended to remove the tube alone, witliout the ovary, the forceps on the lateral free edge of the broad ligament is placed abo\e the ovary and includes the ovarian fimbria of the tube. If it is desired to remove the ovary also, the hsemostat is placed below the o\ary. I prefer the long curved Keen hsemostat for this purpose. If the uterine end of the tube is infiltrated as in salpingitis isthmia nodosa, the proposition of Beuttner UiO ATLAS OF OPERATIVE GYN.ECOLOC.Y and Polak to remove the fundus uteri with the interstitial portions of the tube is an excellent pi'actice, avoiding irritation and uterine leucorrhcea in the patient's subsequent life history. An interesting ((uestion arises in many cases of salpingectomy as to the remo\'al of both tubes. If there is gonorrhoeal infection, and only one tube seems to be involved, it is practically certain that the other will be- come infectetl in the near future. I always examine carefully, therefore, to see if there is even a drop of jnis in the ajjparently unaB'ected tube; and if I find any evidences of infection at all both tubes are remo\etl. Even if no such evidence is discovered, it is usually safer to remove the apparently healthy tube, unless the patient or her husband refuses to accept the consequent sterility. Ectopic Gestation. — In the case of ectopic gestation the proposition has recently been advanced for the removal of the unaffected tube for fear that the woman will have an ectopic gestation in that tube in the future. But this would seem a reprehensible procedure, usually unnecessarily steril- izing the woman. One of my staff collected the statistics of my operations for tubal pregnancy during a space of ten years. It was found that in that time I had operated on one hundred sixty-seven tubal gestations. Of this miml)er, there were seven who lunl a repeated gestation sul)se(iuentl}' in the other tube; but, from the reports that we were able to secure, it appeared that thirty children had been born subsequently to women on whom I had operated for ectopic gestation. This seems to me to answer conclusively the question as to whether both tubes should be removed in this condition. Had I followed this practice, at least thirty children in this series would have l)een deprived of the ojiportunity for existence; whereas only seven of the women operated upon had to undergo a .second operation for tubal pregnancy. GoNORRHCEAL INFECTION. — Another important practical question is whether to operate immediately in an acute stage of suppurative salpingitis which may usually be assumed to be gonorrhoeal in origin. As a rule it is better to wait for the subsidence of the acute symptom, but it is not necessary to wait an inordinate length of time. I find that four or five days with an ice-bag over the lower abdomen and two hot douches in the vagina daily, with care to secure free evacuation of the bowels, is usually sufficient. Some operators advocate a delay of weeks; but this, in my experience, is entirely unnecessary, and I do not hesitate to operate at once if the symptoms are very threatening and I fear the occurrence of general sujjpurative peritonitis. In a lunnber of cases I have removed tubes dripping with pus from the fimbriated extremities, where there has been no time for closure of the abdominal orifices. That this may be done with impunity is demonstrated by the fact that in such operations there has been no mortality in my cases; whereas I have seen fatal general suppurative SALPINGECTOMY 161 peritonitis from hesitancy to operate on gonorrho'al pus tubes in an acute stage of inflammation. It is uncjuestionably better to wait for the subsidence of acute inflammation, if this seems practicable; but carrying this practice too far occasionally results in a mortality that might have been avoided. Drainage. — Another question, and one difficult sometimes to answer, is whether or not to drain the pelvis in cases of acute salpingitis. In strepto- coccic infection of the tubes which results in an interstitial salpingitis rather than a pyosalpinx, drainage as a rule is necessary. In gonorrhoeal and tuber- culosis pus tubes, drainage is rarely required. How to drain is another question which the operator must be prepared to answer — whether to drain the pelvic cavity through the vaginal vault, or through the abdominal incision. I ha\e tried both forms of drainage extensively, and am now quite clear that the drainage through the abdominal wound gives the least morbidity and mortality following operation. As to the method of abdominal drainage, my professional career has embraced prevailing methods of different types, so that my experience enables me to judge of their various merits. At first nothing but a glass tube was used. This was subsecjuently replaced b.y gauze alone; but each had its disadvantages: the glass tubes did not protect the abdominal organs from contamination, and often resulted in a new infection after the operation; whereas the gauze drainage of the pelvis did not always drain material which accumulated in Douglas's pouch. I had the opportunity in some post-mortem examinations to find a quarter of a pint of infected bloody and purulent material in Douglas's pouch which the gauze drainage had not disposed of. Since then I have adopted, as a rule, the use of both glass tube and gauze packing, and my results have materially improved. Occasional cases are better treated by the cigarette drain or by a simple rubber tube. But the whole question of drainage will be discussed in a separate section. PLATE CII. Salpingectomy: separation of tube from uterine cnrnu. PLATE cm. Tube cut away. PLATE CIV. JWII ' "IIIIIIHK li. Haw edge of broad ligament with arteries elaiiiped. PLATE CV. Chain stitrh to control hemorrhage terminating by ligating the ovarian artery. PLATE CVII. Salpingo-oophorectomy. PLATE CVIII. Vessels secured by chain or lock-stitch closing upper edge of broad ligament. OOPHORECTOMY 169 OOPHORECTOMY The removal of an ovary is required for a number of indications : neo- plasms, infections, chronic and acute inflammations, degeneration and adhe- sions. Occasionally the removal of healthy ovaries is deinanded but only, in my experience, in those cases of ill-development of the rest of the genital tract in which the menstrual periods are accompanied by severe menstrual molimina which are not relieved by the periodic loss of blood and conse- quent diminution of pelvic congestion. The ovary may be removed entire or only in part — in the latter case for a localized neoplasm, cyst, inflannna- tion, or degeneration. The technic of removal of the entire ovary is illustrated in Plates CIX, ex. If the mesovarium is very broad, three instead of two inter- lacing ligatures may be required; and the raw surface left, after ligation of the mesovarium, may with advantage be sewed over by a running stitch above the catgut ligatures, or it may be implanted in the split posterior layer of the broad ligament which is then sewed over it. In the removal of large ovarian cystic tumors, it may be of advantage to puncture the cyst and thus diminish its bulk, thereby reducing the length of the abdominal incision; but there are quite a number of ovarian cysts which should not be punctured before removal—for example, malignant tumors, dermoid cysts, and large abscesses of the ovaries. The ordinary simple serous cyst, simple glandular cyst, and even the pseudomucin cyst may be punctured with impunity before removal; but in the latter case, if any ovarian contents have spilled into the pelvic or abdominal cavities, care should be taken to remove them for fear of implan- tation metastases and the subsequent development of pseudomyxoma peritonei. The color of the simple serous cyst, the simple glandular cyst, and the pseudomucin cyst indicates as a rule their true character, the first two having comparatively thin walls and showing the clear fluid contents through them; the latter ha\ing a characteristic blue color well described as cerulean blue. If the operator is in doubt as to whether an ovarian tumor should be punctured or not, he should always avoid this procedure and should make an abdominal incision of sufficient length to deliver the ovarian tumor entire, no matter how long this incision may ha\e to Ije. If one ovary is the site of a neoplasm, the condition of the other ovary should always be carefully investigated; for a large proportion of ovarian tumors is bilateral; so that if there is any indication of a beginning tumor in the apparently unaffected ovary, it should be also removed— otherwise a subsequent operation will be demanded and, in the case of malignancy, the second operation may come too late to save the patient. There is a point in the technic of the removal of ovarian tumors which experience has taught me never to neglect. The uterus should always be 170 ATLAS OF OPERATIVE GYNECOLOGY suspended by a single strand of number 3 catgut ; otherwise the weight of the ovarian stump on the posterior surface of the broad Hgament is apt to pull the uterus over backward and to result in an adherent retroversion. Until I learned this lesson, I found it necessary to reopen the abdomeii in quite a number of cases to correct the adhesion of the ovarian stump to the tissues on the posterior wall of the pelvic cavity. In i)artial ocipliorectomy the cyst or diseased area of the ovary should be c()m])letely dissected out. This is particularly important in the former case in order that all the secreting surface of the cystic tumor shall be removed, otherwise there will be a reformation of tlic cyst. The wound loft in the o\ary l)y this operation should })e united by inter- rupted plain number 1 catgut sutures. The two corners of the wound are first sutured and the ends of the sutures are left long. As an assistant hokls these up and apart, the rest of the ovarian wound is easily and conveniently united. The interrupted stitch will be found to give much the best approxi- mation; the running stitch rarely unites the o^'arian wound satisfactorily. In removing intraligamentary cysts without a pedicle, a transverse incision is made in the anterior face of the broad ligament, avoiding import- ant blood vessels ; then with the fingers, or a blunt dissection by closed blunt pointed scissors, the tumor is shelled out of its bed. Sometimes a more convenient place to make the first incision in the broad ligament is in its free lateral border; occasionally it may be found more convenient to make the incision ])()steriorly. This can be judged by an inspection of the tumor after it is exposed to touch and sight. After the enucleation of the tumor, a deep raw bed may be left. As far as })ossible, the upper walls of this bed are cut away. It may then be possible to close the sack by sutures, obliterating the dead spaces within it ; but in doing so it must be remembered that the ureter runs along the base of the sack, so that deep suturing in this region must be avoided unless the ureter is dissected out and exposed to ^■iew, as in the Wertheim operation. If it is impossible successfully to dispose of the bed of an intraliga- mentary cyst otherwise, it may be marsupialized and fastened to the abdom- inal wall, through which it is tlrained by a strip of gauze, a cigarette drain, or a rul)ber tube until its cavitv is obliterated. PLATE CIX. Pedicle clamped f<.>r lh 'plitjiLctLin} . 12 PLATE ex. Interlacing ligatures of stump after oophorectomy. MYOMECTOMY 173 MYOMECTOMY Abdominal. — In the surgical treatment of fibroid tumors one of the most difficult questions to decide is whether to remove the tumor alone or to do a hysterectomy. It is usually impossible to decide this question until the tumor is exposed to sight and touch, and an operation for a fibroid tumor should only be undertaken with the understanding that the surgeon should exercise his judgment as to the proper operation after he has exposed the tumor. Patients are sometimes disposed to exact promises that they shall not be mutilated, and require an assurance that the tumor alone will be removed. It is perfectly proper for the patient to express a wish of this kind; but it must be understood that the surgeon, while bearing in mind the patient's desire, is free to exercise his best judgment during the operation. A number of considerations must be taken into account in coming to a correct decision. In the first place, generally speaking, myomectomy is more dangerous than hysterectomy, except in subperitoneal tumors with a small pedicle. There is no special reason for myomectomy in a woman approaching the menopause who has no hope for child-bearing and in whom the menstrual function will soon cease. If the tubes are so diseased that they must be removed, there is no good reason for myomectomy in prefer- ence to hysterectomy. If the patient is indifferent in regard to conception, a hysterectomy is usually preferable. If there is the sUghtest suspicion as to the character of the tumor, as to a possibility of sarcomatous degeneration, myomectomy is ob\-iously improper. If the patient's physical condition is poor, if her haemoglobin percentage is low, hysterectomy is preferable. If the tumor is situated in the broad ligament it must be remembered that the closure of the tumor bed is much more diflncult than if it were situated in the uterine wall, and there is much greater danger of hjematoma and infection of the tumor bed subsequent to the operation; if the tumor is submucous, either a vaginal myomectomy or an abdominal hysterectomy is preferable to an abdominal mj-omectomy; for it is undesirable to open the uterine cavity during the operation, on account of a possible infection of uterine wound extending to the perimetrium and thus causing fatal perito- nitis. If the tumor is multiple and a number of incisions in the uterine wall are necessary, a hysterectomy is usually- preferred. I have, however, removed five myomata through as many incisions in a woman sterile for thirteen years after marriage, who conceived three months after the operation. As arguments on the other side of the question, the following facts must be considered : If the operation is performed on a comparatively young married woman desirous of maternity, the hkelihood of conception after a myomectomy must be taken into account. Winter's statistics show 18-20 per cent, of 174 ATLAS OF OPERATIVE GYN.I^COLOGY conceptions after myoinectoni}- in women under fort}- years of age. If the tumor is subperitoneal or interstitial, single, and moderate in size; if the patient's physical condition is good and her haemoglobin percentage is fairly high; if there is no suggestion of malignant change in the tumor — mj'omectomy may be the preferable operation. If the tumor is subperito- neal, with a small pedicle, there is no question about the advisability of mjomectomy. These questions must be considered and a rapid decision made after careful inspection and palpation of the tumor, taking into accoinit the patient's contlition and history. Technically, the operation of myomectomy is comparatively easy if the tumor is situated in the uterine wall well above the level of the internal os. A lower situation makes the operation techni- cally difficult and usually undesirable. An incision is made directly over the tiunor long enough to extract it without tearing the uterine wall. When the tumor surface is reached, the uterine wall is stripped back sufficientlj' far to enable a firm grasp to be taken of the tumor by a volsellum forceps; then, with the finger or knife- handle or a dissector, the tumor is easily enucleated from its bed. The most imjiortant featiuT of the operation is an accurate closure of the tumor bed. I have found it easier to accomplish this by successive rows of inter- rupted sutures of a number 3 catgut on a cur\ed, round-pointed needle. After the bed of the tumor is comjiletely closed by the successive layers of sutures, the peritoneal investiture of the uterus is securely closed by a run- ning suture up and down the wound, which, when completed, makes the laced suture look like a shoelace and secures a more accurate closure of the perim(>trium than any kind of stitch. Even with the most accurate closure, however, of the external uterine wound, there is pro\'ocation to extensive adhesions afterward between the uterus and neighboring structures. It is often necessary, therefore, to con- sider the susjiension of the uterus diu'ing the time required for healing of the woimd; this I ha\'e always accomjjlished by a single strand of number 3 gut fastening the uterine fundus to the abdominal peritoneum, which secures a temporary suspension and does much to prevent undesirable adhesions to the uterus during the period of surgical convalescence. The existence of pregnancy sometimes makes the decision between myomectomy and hysterectomy unusually difficult; but it must be remem- bered that myomectomy is quite jiossible during pregnancy without inter- rupting the woman's condition. In common with all operators of experience, I have removed fibroid tumors by myomectomy both from the uterine wall and from the broad ligament without interrupting gestation ; but the oper- ation is more difficult in this condition than otherwise, on account of the vascularity of the tumor bed. IVIYOMECTOMY 175 As a rule, an operation for a fibroid tumor during pregnancy should be a hysterectomy and not a myomectomy, and if possible the operation should be postponed until a date in pregnancy when a coincident csesarean section and hysterectomy will secure at the same time the removal of the tuiiKjr and the birth of a \'iable infant. Vaginal Myomectomy. — This operation is most suitable for cervical myomata and for submucous fibroids; the latter are usually best dealt with by a preparatory anterior vaginal hysterotomy. By this means the surface of the tumor is exposed, and e\en alt hough only a small area is made accessible it is sufficient to grasp the tumor with a volsellum forceps and to begin its removal by morcellation. It is surprising how large a tumor may be removed in this manner; a tumor quite as large as a fetal head can be dealt with successfully by patience and persistence. A small submucous growth can readily be enucleated from under the mucous membrane, which is first incised until the tumor itself ajipears in view, and then, as in the case of abdominal myomectomy, the tumor is enucleated by the finger, a knife handle, or blunt pointed closed scissors. In rare instances the removal of submucous fibroids is made particularly easy by an inversion of the uterus, which has been caused by a fibroid dependent from the fundus. In such a case, enucleation must be followed by Spinelli's operation for inversion of the womb if it cannot be reduced by taxis. In a cervical myoma, vaginal enucleation is almost alwaj's to be pre- ferred. The operation is easy if the tumor is small; but is practicable even in tumors of large size, in which the uterus proper sits upon the top of a growth larger than the fetal head. An incision is made directly o\-er the most prominent portion of the tumor, the incision usually being made upon the vaginal portion of the cervix or through the mucous membrane of a vaginal vault. As soon as the tumor wall proper is exposed it is seized with a \-olsellum forceps and then enucleated if its size is small, or morcel- lated by the excision of piece after piece until finally the remaining small part of the growth can be extracted after enucleation (Plates CXI-C'XVII). A large cavity is left behind, which is packed with gauze; in vaginal myomectomy a closure of the tumor cavity by suture is usually impracticable. The packing is left in place fortj^-eight hours. If there is much oozing on its removal, it may be necessary to irrigate the tumor cavity and to repack; but it is surprising to see how cjuickly large tumor cavities are reduced in size until they are obliterated. It is also surprising to observe how little hemorrhage there is from these large tumor ca\uties after \-aginal myomec- tomy. In exceptional cases, in which hemorrhage maj' be troublesome, it can be controlled by a sufficiently firm pack. In undertaking the removal of a fibroid tmuor by the vagina, the 176 ATLAS OF OPERATIVE GYNECOLOGY operator must be preiiared for unexpected difficulties and may have to resort to an abdominal section to finish the operation. It may be necessary to remove infected and sloughing myomata from the uterine cavity, especially after childbirth, as they are particularly prone to degeneration and infection after that process. In such cases naturally the vaginal operation is to be preferred. But I have been obliged to resort to abdominal hysterectomy in a large submucous fibroid tumor with strep- tococcic infection and the patient in a truly desperate condition; but fortu- nately the operation resulted in her recovery. As a rule it is unwise to open the uterine cavity through an abdominal incision in order to get at the tumor; so that, if the vaginal operation is impracticable, the abdominal operation should be a hysterectomy, although the tumor would ordinarily be a suitable one for myomectomy. In some of these cases the patient's local and general condition is so bad that the surgeon is loath to undertake any operative interference. In one such case of necrotic infected submucous myoma following childbirth, I secured recovery by spraying the uterine ca\ity with dichloramin-T until the whole tumor gradually sloughed away and the patient eventually made a perfect recovery. PLATE CXI. Incision of uterine wall inr niyonn.'<.'toniy. PI>ATE CXII. Enucleation of tunicjr. PLATE CXIII. "X N. X \ \ Closure of tumor bed. PLATE CXIV. Closure of tumor bed by second row of interrupted sutures. PLATE CXV. Closure of uterine wall. PLATE CXVI. Enucleation of fibroid tumor of moderate size by vaginal route. PLATE CXVII. -M Enucleation of fibroid tumor of moderate size by vaginal route. 184 ATLAS OF OPERATIVE (.YN.^XOLOGY HYSTERECTOMY Of all the operations performed upon women, hysterectomy has perhaps the f);reatest variety of indications and of technic. There is the supravaginal amputation of the womb by the abdominal route; panhysterectomy by abdominal section; panhysterectomy with exsection of the parametrium (Wertheim's extended operation) ; partial or cuneiform hysterectomy involving the fundus or one wall; cuneiform hysterectomy involving posterior and anterior walls with exsection of the endometrium; supravaginal extraperitoneal hysterectomy by the vaginal route, and vaginal hysterectomy. Supravaginal Amputation of the Uterus by Abdominal Section. — This is the kind of hysterectomy more frequently performed than all the rest put together. It is the usual method of treating a fibroid tumor. It is often employed when the appendages are removed for inflammatory con- ditions. It may be demanded bj' an infection of the uterus, by suppurative metritis, and by streptococcic necrosis. It is also one of the methods of performing csesarean section. Associated with this form of hysterectomy is usually the removal of a part or all of the appendages. The common practice is to leave one ovary in the abdominal cavity, when the body of the uterus is removed, with the idea of saving the woman the disagreeable symptoms of the precipitate menopause; but the result of this practice has not been altogether satisfactory. It has been too frequently found that the ovary later undergoes cystic or other degeneration and gives rise to such troublesome symptoms that the abdomen must again be opened for its removal. This has been my experience so often that I confess to a prejudice against leaving one ovary behind in performing a supravaginal hysterectomy. Possibly this difficulty will be obviated in the future by leaving the tube and broad ligament with the ovary in order to preserve its normal circulation. The observations of Polak, in the Long Island College Hospital in Brooklyn, would appear to confirm this view ; and I shall, in the future, adopt this procedure in women who are still comparatively young. If they are near the menopause there is no sufficient reason for leaving an ovary behind, and in such women it has been my uniform practice to remove all the append- ages with the body of the uterus. The transplantation of one ovary in the abdominal wall has had a vogue in these cases; but I agree with Graves that the only purpose of this procedure is to comfort the patient's mind with the illusion that she still possessed a sexual gland. Nothing else can be accom- plished by it, as the ovary rapidly degenerates, ceases to ovulate and cannot possibly influence the rest of the body by its internal secretions. The technic of supravaginal hysterectomy varies as one determines to leave an ovary, or an ovary and a tube, or decides upon the removal of all HYSTERECTOMY 185 of the appendages. The patient is raised in a moderate Trendelenburg posi- tion; the tumor is deUvered. The intestines are packed off with a large soft gauze pad. A self-retaining abdominal retractor distends the abdominal wound. The series of illustrations ( Plates C'XVIII-CXX) show an operation in which all of the appendages are removed; but it is easy to vary this technic by placing forceps to control hemorrhage above the ovary and below the tube — in case the former alone is preserved; or by placing the forceps along the broad ligament embracing its entire depth, one being placed next the uterus and the other just beyond it laterally (Plate CXXI). The round ligament is clamped separately (Plate C'XXIII) if a forceps is put on the free edge of the broad ligament. In order to prevent reflux bleeding a clamp is placed along the side of the uterus embracing the tube and the upper portion of the broad ligament to catch the anastomosis of the ovarian and uterine arteries. These clamps being fastened, the broad liga- ment is cut toward the uterus in a direction diagonally inward and down- ward until the lateral wall of the cervix is reached and the uterine artery is exposed. This is clamped (Plate CXXIV) and cut. After the three arteries on each side are severed and the whole broad ligament is cut across, the cervix is encircled by an incision high enough to leave a flap of peritoneum anteriorly and posteriorly ; in the former situation the bladder is at the same time separated from its attachment to the cervix. The cervix is then cut across in such a manner as to leave an inverted wedge. As soon as the uterus is amputated and removed, the cervical canal is burned out with a cautery knife, as it is possible the canal may be infected. Ordi- narily it is sterile, but not invariably so ; therefore the precaution of cauter- izing the canal is a safe one. As soon as this is accomplished, interrupted sutures are passed through the myometrium of the cervix from before back- ward on either side of the canal and one in the middle closing the cervical tissues over the canal ( Plate CXXV) . These ligatures should be of number 3 plain gut. The next step in the operation is the peritonealization of the stump (Plate CXXVI) and the attachment of the infundibulopelvic and round ligaments to the parametrium or to the cervix itself. This can be done by the stitch illustrated in the drawing (Plate CXXM), or this stitch can be modified by putting a single interrupted suture on each side of the cervix, catching in succession the anterior flap of the broad Ugament, the parametrium, the end of the round ligament, the stump of the ovarian artery, the parametrium again, and the posterior flap of the broad ligan:ent. ^^^len this single stitch is tied, as may be seen, the two Hgaments are brought into close contact with the cervix and the upper edge of the broad ligament wound on each side of the cervix is peritoneahzed (Plate C'XXVH). The peritoneum is then stitched over the cervical stump and the operation is concluded (Plate CXXVIII). PLATE CXVIII. Supravaginal hysterectomy for fibromyoma uteri. Uvaiian artery and artery of round ligament clamped. Both broad ligaments clamped to control reflux bleeding. PLATE CXIX. 13 Broad ligament cut and uterine artery on right side clamped "and cut. PLATE CXX. All six Hrteries clamped eeparately. Uterus cut away from cervix. PLATE CXXI. Supravaginal hysterectomy leaving both tubes, broad ligaments, and ovaries; the edges of the broad ligaments can be sewed together in the middle line or the raw edges can be whipped together from side to side. PLATE CXXII. Supravaginal hysterectomy. The three arteries on each side clamped and the right ovarian artery being ligated. PLATE CXXIII Ligation of artery of round ligament by a lit;:tiuM \\ Imh i' i - u t transfix the tissues. PLATE CXXIV. The uterine artery ligated by a ligature passed to its inner side and tied both un the inner and the outer side of the clamp. PLATE CXXV. Cervical stump closed after cauterization of carml. IM.ATK CXXVI. .Suture of peritoiieuru ortion of his blunt dissection. The uterine arteries are then caught as low as possible before they turn upward along the uterine wall. These arteries are severed, and a blunt dissection is made of the tissues lateral to the cervix until the depth of the dissection equals that anteriorly and i)osteriorly. The vaginal wall is then clamped on each side by a Wertheim forceps and the vagina is cut across, leaving a consider- able cuff of it attached to the cervix. Before undertaking this operation, it is naturally essential to disinfect the \'agina thoroughly and to pack it with sterile gauze. If there is anj' doul)t as to the freedom from bacteria of the cervical canal and uterine cavity, the uterus is injected with pure formalin; and the cervix is closed by a running stitch, after the formalin has been allowed amjile time to escape. In addition, the Sigwart clamp may be used to close the vaginal cuff above the site of the transverse incision which separates it and frees the uterus. The peritonealization of the wound is conducted in the same manner as in a supravaginal hysterectomy, except that the round ligament and the infiuulil)uloi)elvic ligaments are fastened to the lateral edges of tlie incision across the vaginal walls, in order to prevent a prolapse of the vagina. Extended Panhysterectomy for Carcinoma of the Uterus. — Panhysterectomy has been gradually develoiJed, since Freund's original operation, by a number of surgeons, including Clark of this country and most particularly Wertheim of Vienna — whose large experience has enabled him to standardize the ojieration and to introduce it to the profession in general, with greater authority than any other single operator in the world. (Plates (CXXIX-CXXXIII.) Whether this extended operation for carcinoma is 198 ATLAS OF OPERATIVE GYNAECOLOGY worth the high primary inortaUty is still questioned by some gynaecologists; but the majority of cxjiorionccd operators will, I think, agree with Peterson, of Ann Arbor, who finds the ultimate result after five years sufficiently satisfactory to justify a cf)ntinuance of the operation. Wertheim's large experience also confirms this view. Although many were originally prejudiced against the operation on account of its technical difficulty and high primary mortality, the large majority of experienced operators are now completely convinced that it is the duty of the surgeon to gi\-e his patient the chance afforded by this opera- tion for permanent cure if there is any possibility of carrying it out with a fair chance of immediate recovery. In the last five years my statistics have been so satisfactory in regard to primary mortality that the prejudice I originally entertained against the operation has completely disappeared. In this time mentioned (five years) I have done forty of these extended operations with only three deaths — a mortality of seven and one-half per cent. The number of operations quoted, it must be confessed, is too small to base an opinion on, but if it is possible to carry out this operation with not much more primary mortality than this, the ultimate result gen- erally justifies the procedure. Unfortunately, in the large American cities, it is impossible to follow up end results after so long a period as five years. But I think that most of us can count upon the end results recorded by Dr. Peterson — namely, sixty-two to sixty-nine per cent, of permanent cures in those who survived the operation; the highest percentage of permanent cures naturally being obtained in cancers of the fundus, while the worst results are shown by cancers of the cervix. As cancers of the fundus have always given a better primary and ulti- mate mortality than cancers of the cervix, the question naturally arises as to whether the extended operation should be done in cancers of the fundus; or whether, on account of its high mortality, one should content himself with the ordinary panhysterectomy without the wide dissection of the broad ligaments or the removal of a largo ]>ortion of the parametrium. Personally, I belie\'e in the extended operation even for cancers of the fundus; it is an easier operation than that for cancer of the cervix, and it would appear from the study of American and European statistics that the chance of permanent recovery in this form of cancer is distinctly increased by the extended operation as compared with the ordinary panhysterectomy. After witnessing a performance of this operation by Wertheim in his own clinic and by Sigwart in Bumm's clinic in Berlin, my choice has been for a combination of the technic of the two medical centres as follows: A long median incision reaching to the symphysis opens the abdomen. HYSTERECTOMY 199 A permanent retractor is adjusted; the patient is raised in the Trendelen- burg position; the intestines are well packed off with gauze pads and the operation proper is begun by a ligation of the ovarian arteries. The catgut ligature used for this purpose is left long and fastened to the sheet covering the woman's abdomen toward her head. Next the round ligaments are ligated; the ligature again is left long, and fastened to the sheet toward the woman's knees. An incision is then made severing the outer lateral edge of the broad ligament, and with it the ovarian artery. The incision is then carried upward on the free edge of the broad ligament toward the mesentery of the large intestine. The incision is then extended downward and inward, severing the anterior face of the broad ligament and separating the blailder from the cervix. The base of the broad ligament is then exposed by blunt dissection, and 1 find the Goffe dissector a useful instrument for this purpose. The dissection is continued until the ureter is well exposed and the uterine artery is seen; the latter is then seized by a hsmostat forceps and elevated, while the forefinger of the operator is passed under it and over the ureter. The artery is then severed to the outer side of the ureter, the whole extent of which is then visible running across the base of the broad ligament and entering the bladder. The posterior face of the broad ligament is then slit from above down- ward and the uterosacral ligaments are se^■ered. An incision through the peritoneum of Douglas's pouch connects the incision severing the ligaments, and is extended outward to meet the incision running downward through the posterior face of the broad ligament. The connective tissue of the pelvis and the parametrium is then completely exposed. Infected glands are carefully felt and looked for. If found, they are naturally renio\ed. The Wertheim clamps are then adjusted so that a considerable portion of the parametrium will be removed with the uterus and a cuff of the \-agina. The Sigwart clamp is then adjusted aliove the Wertheim clamp anil the vagina is severed between the two. The walls of the latter are innr.ediately seized and closed with interrupted sutures of catgut. Then with a curved needle, threaded with number 3 catgut, the lateral fornices of the vagina are transfixed to the inner side of the point of the Wertheim clamps. The ligature is then tied outward, and in this way the uterovaginal plexuses of veins are secured and a bleeding, which was extremely troublesome before the use of the Wertheim clamp became general, is satisfactorily a^■oided. The peritoneum is now united in such a manner that the dead space between the peritoneal fold and the \'aginal wall is obliterated by taking in the upper- most portion of the latter with the needle that sutures the peritoneum. The infundibulopelvic ligament and the round liganient are fastened to the outer edges of the vagina by the kind of stitch shown in the Plate CXXVI. It not only fastens the ends of these ligaments to the vaginal wall in order 200 ATLAS OF OPERATIVE GYNECOLOGY to support them, but when the ligature is tied the stumps of these Ugaments are turned in between the layers of the peritoneum constituting the anterior and posterior layers of the l)road ligament. The sterilization of the vagina, cervix, and uterine cavity, before liegiiming the operation, is of the greatest importance. The vagina is washed out with lysol, one ])er cent.; then with alcohol ; and then painted with iodine. If there is a sloughing cervical cancer it is cauterized, and in any event the interior of the uterus is sterilized by the injection of pure formalin with a Braun intrauterine syringe. If the patient escapes the immediate danger of the operation, the recovery is remarkably smooth and uneventful as a rule. The complete peritonealiza- tion of the i)elvic wound and the cleanly nature of the operation (done with proper asepsis and antiseptic precautions) necessarily contrilnite to an uncomplicated convalescence; but unfortunately tlie operation is a tedious one, and the strain on the patient's heart and ner\()us system is severe. It will be an interesting observation in the future to note a possible improve- ment in mortality by the utilization of gas and oxygen ansesthesia with a limitation of the time the patient is held in the Trendelenburg position. I feel confident that a good many of the tleaths from the Wertheim opera- tion are due to long-continued use of ether or chloroform and to a prolonged elevation of the hii)s; and I believe that the future will show a gratifying reduction in primary' mortality, if gas and oxygen ana-sthesia are substituted for the anaesthetics formerly in more general use, and if the table is lowered as soon as the deeper work in the pelvis is comjileted. The after-treatment is by the Murphy drip of a ([uart of water contain- ing an oimce of bicarbonate of soda and an ounce of glucose. The use of cartliac and general stimulants is more important after this abdominal section than possibly any other. Here again, by a careful attention to the after-treatment of the patient, we may secure a lower mortality. This is cei-tainly a task to which the profession should seriously address attention; for if the primary mortality of the extended operation for car- cinoma of the uterus can be reduced, there is no cjuestion that the operation will receive general favor, and that the proportion of women ultimately and permanently cured of this disease by the ojierative treatment will be materi- ally increased from year to year. The agitation in favor of early diagnosis and operative treatment must still be continued. LTnfortunately, it has not as yet had the effect that we might have expected. In the majority of American clinics the experience, I think, will l)e about that of Reuben Peterson recently in Ann Arbor, where in one hundred and twenty-four cancers of the uterus, seen in four years, ninety-four were inoperable when the i)atient came to the clinic. The operability is in direct proportion to the intelligence and social status of the patient. In a twenty-year service in the Philadelphia Hospital, not a HYSTERECTOMY 201 single operable case was admitted to the ward set aside for such cases, though this ward was constantly filled with incurable cases. Pregnancy Complicating Cancer of the Uterus. — This complica- tion is fortunately rare, for it makes the operation decidedly more difficult. In 57,833 labors it was observed but twenty-six times. If operable, the cancer should be removed by hj'sterectomy without regard for the foetus. If inoperable, csesarean section after the foetus is viable is the proper proced- ure. I have done three panhysterectomies in early pregnancy and one at term, coincident with a csesarean section. The extended operation was done in each instance, but was particularly difficult on account of the extra blood supply and the difficulty of haemostasis. Cuneiform Hysterectomy at the Fundus or the Cornua. — This procedure may be required for localized streptococcic infection, or may be required in interstitial pregnancy; or in cases of salpingitis isthmica nodosa. After excision of the wedge-shaped piece to remove the diseased area, the wound is brought together with interrujited sutures in the myometrium, and the perimetrium is joined by a continuous suture or a lace suture, that is, a continuous suture doubling back on itself. The principle of the operation is naturally to remove only the diseased area and no more. Haemostasis may be difficult, and it may be necessary to ligate the vessels separately; but ordinarily the hemorrhage is controlled by the sutures which unite the wound. With the cuneiform hysterectomy on the posterior uterine wall for the correction of antiflexion, I have had no experience; and the operation has not seemed to me a logical one, the anti- flexion being an expression of undevelopment which the cuneiform hysterec- tomy cannot be expected to correct. A wedge-shaped excision of the anterior wall, ruiming the whole length of the uterine body, is a very useful procedure in cases of interposition, in which the bulk of the uterus is too large to allow it to be placed conveniently below the bladder. Every surgeon with much experience in the interposition operation has had to resort to this form of cuneiform hysterectomy quite frequently. An ingenious procedure proposed, ad\ocated, and extensively performed by Shropshire, of San Antonio, Texas, is to exsect a wedge from the centre of the uterine bodJ^ involving both anterior and posterior wall in such a man- ner as to remove the entire endometrium. There are quite a number of ca.ses in which this procedure is to be recommended — such as nienorrhagia, chronic metritis, and endometritis; and in the case of women in whom there might be a suspicion, not actually confirmed, of beginning malignant degen- eration of the endometrium. In the removal of the tube for pyosalpinx, when it is possible to leave the ovaries behind, this operation might be preferred to supravaginal hysterectomy. PLATE CXXIX. Wertheim or extended panhysterectomy. PLATE CXXX. 14 Self-retaining retractor in place and intestines protected by gauzr pad. PLATE CXXXl. Self-retaining retractor adjusted. Ovarian and round ligament arteries clamped— anterior base of broad ligament incised. PLATE CXXXII. Uterine artery clamped and ureter exposed. PLATE CXXXIII. Wertheim clamps adjusted and vagina severed below the cervix. HYSTERECTOMY 207 Supravaginal Extraperitoneal Hysterectomy by the \'aginal Route. — I have found this an extremely useful procedure, and have utilized it in many cases since first seeing it performed by Doderlein, of Munich. (Plates CXXXIV-CXLII.) In cases of chronic metritis or endometritis near the menopause, this operation has a large field. I find myself often combining it with an interposition, using the stump of the broad ligament tied separately in three sections and then joined in the middle to support the bladder instead of the body of the uterus as is usually done. The technic of this operation, up to the point where the uterus is de- livered through the anterior vaginal vault, is exactly the same as the inter- position operation; but, as soon as the body of the uterus is delivered through the wound, the parietal peritoneum is sutured to the peritoneum of the posterior uterine wall at the le\'el of the internal os. From this moment the operation becomes an extraperitoneal one; the broad ligaments are then seized with clamps in three successive grips and are severed to the level of the internal os. Three ligatures are placed on each broad ligament to the outer side of the clamps, which are then removed. The uterine body is then cut off Ijy an incision across the junction of the body with the cervix; the wound thus left in the latter is united with interrupted sutures and the vaginal wound is then closed over it. For all external appearances the woman remains as she was before the operation, but the corpus uteri has been completely removed, leaving, as a rule, only the appendages and cervix behind. The convalescence of these patients is like that of a plastic operation. It is surprising to see how little reaction follows the removal of the uterine body by this method. PLATE CXXXIV. Supravaginal extraperitoneni liysterectomy. PLATE CXXXV. Uterovesical ligament cut. PLATE CXXXVI. Anterior peritoneal reduplication opencil. PLATE CXXXVII. Uterus extracted — broad ligaments cut and ligated. PLATE. CXXXVin. Peritoneum sewed to posterior wall of uterus. PLATE CXXXIX Uterus amputated. PLATE CXT.. Cervical wound closed. PLATE CXM. Closure ot wound completed. PLATE CXLII. Vaginal mucous membrane united. HYSTERECTOMY -217 Vaginal Hysterectomy. — Finally, this sul:)ject remains to be con- sidered (Plates CXLIII-CXLVIII). This was the operation of choice and the one uniformly selected a generation ago for the removal of the uterus; but it is now comparati\'ely seldom employed. There remains, h()we\-er, a distinct field for it, and every surgeon of nmch experience is resorting to it from time to time. If the surgeon follows Goffe or the Mayos in removing the uterus for prolapse and cystocele, this operation will naturally be frequently employed ; but, personally, I do not see the necessity for the re- moval of the uterus for these conditions. In fact, they can be much better dealt with in another way. Personally, I employ \-aginal hysterectomy for certain unusual cases of malignancy and for fibrosis of the uterus — and for little else, although occasionally it will appear that this method of removing the womb has advantages over the abdominal operation. For example, in very fat women with weak hearts and a decided relaxation of the vaginal outlet and the vagina, vaginal hysterectomy has distinct advantages o\er the abdominal operation; as the risk in such cases is less, and there is decid- edly less danger of heart failure from the prolonged use of the Trendelenburg position. In performing this operation I prefer the bisection of the uterus, after opening both the anterior and the posterior vaginal vault and laterally severing the attachment of the vaginal wall to the cervix. It is much easier to remove one-half the uterus at a time than it is to take out the whole organ at once. This is particularly true of cases in which it is desired to remove the appendages comjiletely with the uterus, and these cases consti- tute the majority in my practice. The extended operation for cancer as practised in Schauta's clinic does not appeal to me. The technical difficulties are great and (in common with most surgeons, I think) I distinctly prefer Wertheim's extended operation l)y the abdominal route. But, occasionally, the Schauta operation is worth bearing in mind. It must be prefaced by a deep Schuchardt incision of the vagina, and this is followed by a dissection of the parametrium until the whole course of the ureter is displayed as it runs across the base of the broad ligament. In this way an expert with this operation is able to remove about as much parametrium as can be done by the Wertheim operation; but this technic does not permit an examination of the pelvic connective tissue, and it might easily result in oA'erlooking infected glands too high to be felt in- seen through the vaginal wound. In securing the broad ligament, in a xaginal hysterectomy, the ligature method is distinctly preferable. In the early part of my practice, almost every surgeon used clamps on the broad ligament, which were allowed to remain in place for about thirty-six hours. This is nmch the quickest and easiest method for performing \aginal hysterectomy; but so many disad- vantages were discovered in it, by extended experience, that \ery few 218 ATLAS OF OPERATIVE GYN.ECOEOGY surgeons to-day resort to it. Infection of the peritoneal cavity, ])rolapse of the intestines, fatal obstruction of the bowel, and occlusion of the ureters were quite conunon complications of the old method of performinji vaginal hysterectomy. In the ligature method, it is convenient to cini)loy tiic clamps (primarily about three in number) on each broad ligament ; and then to ligate the liga- ment in corresponding sections, the ligature being passed through the broad ligament on the lateral side of the clamp; and, as it is tied, the clamp is loosened so as to allow the ligatures to l)ite firmly into the tissues. The .stump is immediately seized again with a clam]! so that it shall not retract out of reach, a very awkward accident in case the ligature has not l)een firmly enough tied and hemorrhage results. After each broad ligament has been ligated in the manner described, the sections are brought downward into the opening of the \-aginal vault and are stitched across in a row by sutures that include the anterior anil ]iosterior vaginal walls at the fornix. In this manner the stumjis are secured in a position where they are reatlily reached, and by their bulk they close the aperture into the peritoneal cavity, thus preventing prolapse and adhesion of the intestinal coils. The parietal peritoneum, both anterior and posterior, is also caught in the sutures run- ning through the vaginal wall and the stumps of the broad ligament. In this manner, the opening from above is satisfactorily and easily peritoneal- ized. Extra sutures are used, when recjuired, to check the hemorrhage from the cut surfaces of the ^'aginal wall, and, at the same time, to close more completely the \aginal wound. At the conclusion of the operation, the vagina is packed with sterile gauze which is allowed to remain in place twenty-four to forty-eight hours. I make it a rule never to attempt a vaginal hysterectomy unless the abdomen is prepared for an immediate section. For, occasionally, insuper- able difficvdties are encountered in the operation. Or else a hemorrhage may occasionally occur which can only be controlled from above through an abdominal incision. A number of years ago, l)efore the necessity for this precaution was universally recognized, I witnessed deaths in the hands of some of my colleagiies on account of the hurried performance of an abdominal section without adequate preparation of the patient. Of late years, however, I have not seen nor heard of such a thing. PLATE CXLIII. 15 Vaginal hysterectomy. PLATE CXLIV. Dividing the uterus. PLATE CXLV. Discission of uterus carried to fundus. PLATE CXLVI. Anterior wall and fundus divided. Posterior vaginal vault opened and vagina separated from cervix. PLATE CXLVII. Arteries and broad ligament clamped and tied. PLATE CXLVIIl. T\vi) linhcji of uterus removed — broad ligaiueiit tied in three segments. Stump to be sutured together. CESAREAN SECTION tus, lij' which it is extracted; and as the head emerges from the uterine wound the assistant, hooking his finger in the upper angle of the wound, pulls the uterus outside the woman's abdominal cavity. Immediately a broad soft gauze pad is tucked behind the uterus, covering the intestines and preventing their escape. The placenta is then separated and great care is exercised to separate com])l(>tely and to extract all of the membrane — which can best be accom- plished by seizing succe.ssive layers or portions of the membrane with a long curved hiemostatic forceps of the Keen model. The uterine cavity being completely evacuated, the suture of the uterine wall is made as follows, by a method which I have adopted after experiment- ing with a number of others and witnessing various kintls of uterine closure in other clinics: Three sutures of fine linen thread are inserted through the myometrium, each end being caught by a hai-mostat and laid aside (Plate C'L). Next a running suture of number 2 chromic catgut begins above the u])per angle of the uterine wound (Plate CLI), then runs down the deeper ])(iition of the myometrium, axoiding the endometrium, and comes up more su]u>rficially, the suture ending ojij^osite whei'e it began with a knot above the upper angle of the uterine wound upon the surface of the uterus. The two sutures of linen thread are then tied as interrupted sutures (Plate CLII) . Finally, a laced suture unites the perimetrium (Plate CLIII), running down as a continuous suture and coming up as a continuous suture with the inser- tion of the needle coming up midway between the insertions made going down; the suture ending in a knot above the upper angle of the wound on the surface of the uterus (Plate CLIV). While the abdominal incision is being made, the patient receives hypo- dermatically a whole ampoule of pituitary extract and an ampoule of ergo- CESAREAN SECTION 227 tine. If there is a tendency to uterine relaxation and to hemorrhage during the operation, a second ampoule of ergotine is administered. The abdominal wound is closed in the usual manner, is sealed by strips of gauze and collo- dium, and the dressing (a gauze pad and a couple of adhesive straps) is applied very lightly over the sealed abdominal wound, in order not to exert any pressure against the uterine body. The patient is not kept rigidly upon her back, but is rather encouraged to turn, with the aid of a nurse, partly on one side and then upon the other — in this way a\'oiding, as a rule, an adhesion of the uterine to the abdominal wall. The after-treatment is the same as after any abdominal section. With this method of uterine suture, in more than three hundred csesarean sections, I have not seen (nor has there been reported to me) a case of rupture of the uterine wound in subse- quent pregnancies and labors, although the percentage of this accident has been found to be about three by some statistical investigators. PLATE CXM\. Size and site of tibduriiiii;il incision. PLATE CL. The infant and plucenta have been extracted. The empty uterus is eventrated. Three sutures of fine linen thread are placed in the myometrium. PLATE CLI, The myometrium is united with a two-tier number 2 chromic catgut suture. PLATE CLII. The two-tier'fluture is finished, but in the drawing the upper layer (in order to show it) is not drawn tight. The lineD threadfl are now tied. PLATE CLIII A laced suture of number 2 chromic catgut unites the perimetrium. PLATE CLIV. The perimetrium stitch complete. 234 ATLAS OF OPERATIVE GYNAECOLOGY The Porro Operation. — (Supravaginal Amputation of the Uterus with Peritonealizalion and Sinking of the Cervical Stump.) The only indica- tion that I have found for this operation, of late years, is the existence of fibroinyomata as an obstruction in labor, or as a complication of pregnancy or labor recjuiring cesarean section and infiltration of the myometrium with blood in premature detachment of the placenta. In the earlier part of my practice I performed more amputations of the uterus in caesarean sections than I did Saenger operations. The technic of this operation is the same, up to the point where the uterus is evacuated; except that the abdominal incision is made somewhat lower, in order to facilitate the closure of the cervical stump. The uterus is then amputated as in any supravaginal amputation — for instance, one for a fibroid tumor; the vessels are clamped and cut and the stump and broad ligaments sewed over in the manner already described. If it is desired to leave the ovaries, the tubes should also remain to les.sen the danger of degeneration of the ovaries; in this case, the broad ligaments are sewed together in the midline over the cervical stump, instead of being sewed from one side of the pelvic ca\-ity to the other. Particular care must he exercised to close the cerv'ical stump itself by interrupted anteroposterior catgut .sutures; otherwise there will be trouble- some oozing — the formation of a hsematoma under the peritoneal flap, with possible infection, and \\ith a distinct increase of danger to the patient. Supravaginal Amput.\tion of the Uteris with Extraperitoneal Fixation of the Cervical Sti mp. — This form of operation I have found most useful in the severest infections, which are brought into the hospital after repeated attempts at forceps delivery and a number of examinations made without aseptic precaution. As an example, a case was admitted to my ser\-ice in which, after several days of labor, three physicians in succession had applied forceps, and in the intervals between their tractive efforts had laid the forceps on a wooden floor covered with dust and then had inserted them in the uterus without an}' attempt to cleanse them. The odor from the genital tract was horribly putrid. In the course of the operation a slight wound that I made in one of mj- fingers laid me up for several weeks with severe infection. After the removal of the uterus, the stench was so intolerable that it was immediately taken out of the operating room. This woman recovered. The technic of such an operation is as follows: The uterus is delivered unopened out of the woman's abdomen through a long abdominal incision. The intestines are then carefully packed ofT with gauze pads; the broad ligaments are clamped, cut, and ligated to the uterine arteries, which are then clamped and ligated separately. The cut edges of the broad ligaments are united. The parietal peritoneum is then sewed closely around the cervix. CESAREAN SECTION 235 and the uterus is amputated with a cautery knife without being opened at all. Should the baby be alive, the operation is conducted as quickly as possible, and the child is extracted immediately from the uterus as soon as it is ampu- tated; but in almost all of these cases the child is dead before the operation is attempted. After the amputation of the uterus, the myometrium of the cervix is carefully sutured by interrupted catgut sutures to prevent oozing; the peritoneum is closed over it, and the stump is then allowed to drop back as far as its peritoneal investiture will permit. The sinus remaining after the abdominal wall is closed above the retracted cervix is packed lightly with a strip of gauze. This operative technic is I think easier, quicker, and safer than a pan- hysterectomy. The amputation of the cervix with a cautery knife and the immediate closure of the cervical myometrium avoids opening an infected vagina into the peritoneal cavity; and I feel convinced that it will give in a series of cases a better result than the total removal of the uterus. This has certainly been my experience; as, in the limited nmnber of cavses in which I have carried out this technic, there has been a uniform maternal recovery. Panhysterectomy w^th Cesarean Section. — The only indication which I have found for this operation is a coincident cancer of the cervix with delivery by ca'sarean section at term. The operation is not a particu- larly difficult one, except for the difficulty of controling hemorrhage deep in the pelvis at the angles of the vaginal wound. The operation is conducted pretty much in the same manner as the Wertheim or extended panhysterec- tomy for cancer in the non-pregnant uterus. With the much hj-pertrophied blood-vessels and IjTnphatics it would seem likely that recurrence is more probable than after a panhysterectomy in a non-pregnant uterus. In an operation of this sort successfully performed within a year there was a recurrence at the vaginal vault within six months which is now being treated by radium, but 1 fear unsuccessfully. Extraperitoneal Cesarean Section. — Since the revival by Frank of the old idea of extraperitoneal ca?sarean section in presumably infected cases, the operation has received an extensive enough trial to warrant definite conclusions as to its worth. If one studies the statistics collected by Routh, in Great Britain, of the results of cesarean section in presumably infected cases, and compares these results \\i{\\ those of extraperitoneal csesarean section in Germany, in the same class of cases, there can be no doubt of the superiority of the latter operation over the conservative intra-abdominal or intraperitoneal operation. The Routh statistics show a mortality of more than seventeen per cent., while the average statistics of the German operators give a mortality of but six per cent, in the same class of cases. It should be apparent, there- fore, that a patient must receive the added chance for hfe wliich an extra- 16 >;?6 ATLAS OF OPERATIVE G\'N.ECOLOGY peritoneal caesarean section assures her, if the surgeon is to do his full duty to her. There has been a strange indisposition on the part of American special- ists in obstetrics to take up extraperitoneal csesarean section — explained, I think, by the fact that too many professed experts in olistetrics in America are not well trained as surgeons. The technical difficulties of the operation as compared with the older method has, I believe, deterred many a specialist from attempting it; and there has been a disposition to excuse this disinclination to attempt a new operation on the .ground that it did not yield sufficiently good results to justify it; but this assumption is unwarranted. Everyone who has gi\en extraperitoneal c:esarean section a fair trial remains convinced, I am sure, of its applicability to the kind of case for which it was devised. In my own experience, thirty extraperitoneal csesar- ean sections ha^•e been performed without any maternal mortality, although the operation has been reserved in my hospital services for cases which come to me almost certainly infected — cases examined repeatedly outside without careful aseptic technic, and cases in which futile attempts have been made to deliver with forcejis. After trying several methods, I have for the last four years resorted to a technic which I had at first thought to be original, but which I subse- quently discovered to have been devised by Veit and Fromme. This method is comparatively simple; and the result has proved (in my experi- ence) that it is reliable, jtreventing infection of the peritoneal cavity — especially during puerperal convalescence, which is the chief danger of caesarean section performed upon the presumably infected woman, the infection of the endometrium in such cases spreading directly through the uterine wound to the peritoneal surface and rapidly causing a general septic peritonitis. The technic I have fovmd most satisfactory, after trying other plans, is as follows : An incision through the abdonunal wall is made from a short distance below the umbilicus down to the symphysis pubis (Plates CLV-CVII). The parietal peritoneum is severed to the fundus of the bladder. The loose peritoneum over the lower uterine segment is then lifted with hsemostats and incised with a short incision; closed scissors are inserted in the incision and pushed upward as far as the peritoneum can be detached from the uter- ine wall. The incision in the uterine peritoneum is then lengthened to this extent upward. It is then carried downward to its reduplication over the bladder, opening the uterovesical space; an abdominal retractor is then inserted over the symphysis pubis in such a manner as to crowd the bladder downward and forward. The uterine wall is then incised; the incision CESAREAN SECTION 237 beginning at the upper angle of the incision in the uterine peritoneum; it is carried downward then in the middle hne with scissors, as low as possible, extending a considerable distance below the uterovesical reduplication of the ]ieritoneum. ^leanwhile an assistant clamps the peritoneum of the uterus to the peritoneum of the abdominal wall with T-shaped hannostats in order to close off the peritoneal ca\aty (Plate CLVIII). If the fetal head is presenting, it now comes plainly into view. It is seized with a Simpson obstetrical forceps inserted through the uterine incision, and is turned out of the uterine cavity by a lever-like action of the forceps handles (Plate CLIX). Sellheim has devised a special scoop for this purpose which he uses very skilfully; but after one or two trials of it I have discarded it, finding the forceps much more satisfactory. The placenta is then detached and extracted; the membranes are next carefully detached so that none shall be left behind. During this part of the operation there may be some troublesome hemorrhage from the placental site. There is rarely much hemorrhage from the uterine incision. If the labor has been much delayed and the lower uterine segment is much distended, it is surprising to see how little bleeding occurs from the thinned-out uterine wall. After the extraction of the placenta and mem- brane, the uterine incision is sutured by a two-layer continuous catgut suture, number 2 chromic gut being preferred. The suture runs down the deeper portion of the myometrium, a\'oiding the endometrium, and returns superficially, one knot being tied above the upper angle of the uterine wound. It is usually necessary to insert a few interrupted catgut sutures superficial to the two-tier continued suture, in order to secure perfect appo- sition of the superficial layer of the uterine musculature. The space behind and below the bladder is then carefully cleansed with gauze pads. Next the two layers of peritoneum are closed with a continuous catgut suture (Plate C'LXI) and finally the conjoined layers of peritoneum are joined together in the middle line by three or four interrupted catgut sutures. In this way the uterine wound is kept completely out of the peritoneal cavity and there is a complete extraperitoneal convalescence — the most important object to be secured by this operation. It is easy enough to make any kind of a csesarean section extraperi- toneal during its performance by eventrating the uterine body; but it is in the first few hours after the performance of the operation that infection through the uterine wound from an infected endometrium is most dangerous to the patient. In my early operations I sutured the two layers of peritoneum together before incising the ut-erus; but I found that the peritoneum was so freX. llnldiiit; tilt; infant face (!■ iwnwanl for a few nionients to let tlio liquor aninii out nf the tnnntli aiul hint PLATE CLXI. Sewing the two layers of peritoneum together to make the convalesrenre eitrsperitoneal. PLATE CI.XII. The suture of the uterine muscular wall. ,>46 ATLAS OF OPERATIVE GYNAECOLOGY peritoneum, and meanwhile there was danger of contaminating the peri- toneal cavity. It is much better, therefore, to close off the peritoneal cavity securely by clamps during the operation and then to secure a perfect closure by sutures after the uterine wound is closed and after the uterus has con- tracted subsequent tcj its evacuation. Injections of pituitary extract and ergotine are given at this operation, as in the conservative csesarean section; but they are not administered until the uterine wound ha.s been made and the child's head is extracted, for fear of premature rupture of the distended lower uterine segment. PUBIOTOMY Pubiotomy was designed by the Italian surgeon, Gigli, to supplant symphysiotomy; which, after a checkered career of more than a century, is now scarcely ever heard of. According to its advocates, pubiotomy is superior to symphysiotomy for two reasons: (1) is does not interfere with the supports of the bladder or urethra, and (2) the section is made through bone instead of cartilage and is therefore, it is claimed, more likely to heal readily. The advocates of pubiotomy are, as a rule, obstetricians who have not yet had extensive experi- ence in abdominal surgery. Even those who most enthusiastically endorse it acknowledge that it is not an operation for the occasional operator; that it should be performed only in women who show no signs (jf infec- tion; and that it is best done in a well-equipped hospital. Even under all these circumstances the several varieties of cesarean section are, to my mind, much superior. In an uninfected case no surgeon of large experience with both opera- tions would hesitate to make a choice in favor of an abdominal ca>sarean section. The best statistics of the latter operation are quite equal or superior to the best statistics of pubiotomy and there is no comparison between the convalescence of the two operations. In csesarean section, also, there is entire freedom from the disagreeable complications which not infrequently occur in pubiotomy — injury of the bladder; lacerations of the vagina; making a compound fracture of the pelvis ; communicating with the vaginal canal, with impossibility of preventing infection of the pelvic bones. There is rarely a bony union after pubiotomy and there is a possibility, therefore, of disability in the patient's future life history. Occasionally the pelvis may be found slightly enlarged by the filjrous union which usually takes place between the severed ends of the pubic bone ; and it is possible that subsequent labors, on this account, may be spontane- ous, but this result is not to be looked for and only rarely occurs. Personally I am convinced that pubiotomy in the near future will go PUBIOTOMY 247 the way of symphysiotomy, from which it differs very little and over which it has few advantages. If, however, a surgeon should feel mchned to resort to this operation, the best method of performing it is Dcederlem s modifica- tion of the original operation; which consists in makmg a small mcision above the upper edge of the pubic bone, selecting the region of tbe pubic spine toward which the occiput of the child is directed. ^^ hen he upper edge of the bone has been exposed, the periosteum is incised and hen he needle devised by Dcederlein is inserted directly behind the bone and guided downward by a forefinger until its tip can be made to project under the bone (Plates CLXIII, CLXIV). At this point the skin of the corresponding labium is drawn toward the middle Une so that the puncture which allows the escape of the point of the needle shall be as far removed from the vulvar orifice as possible. The point of the needle being now pressed outward so as to make a projection of the skin over it, a small incision is made so hat the needle can emerge; the end of a Gigli saw is then attached to it, and he needle is withdrawn upward so that the saw is placed directly behind the pubic bone; a few to-and-fro movements of the saw, to which theJiancUe is now attached, severs the bone. There is often quite free hemorrhage from both upper and lower wounds, but it can usually be controlled by pressure (altlK.ugh a fatal bleeding is recorded). After the bone is severed, a choice must be made between the immediate extraction of the child or allowing it to be spontaneously expelled. The latter course seems to me o be he safer one; for the application of forceps, or the extraction of a child by the foot in a breech presentation is much more likely to lacerate the vagina than would be the case in a spontaneous delivery. x,,j w„ In the Heidelberg clinic I was told that the expectant plan had been pursued- and if I remember correctly with something like eighty uninter- rupted recoveries, so far as primary mortality is concernecl. The morbiditv after pubiotomy is always high, much higher than in convalescence from ca^sarean section, and the care of the patient during convalescence is extremely troublesome. , . „ • , , The hips should be supported by a broad band of adhesive p aster or by a firm bandage which buckles together; the patient shoul.l he on a Bradford frame. It is exceedingly difficult, on this apparatus, and with the constrained posture of the woman, to keep her clean, to cathetenze he if required, and to give her the attention demanded by the average puei pel a convalescent. If it is desired to secure Ix.ny union ot the pelvis, the patient must be kept rigidly quiet for two or three weeks but it the operator is satisfied with the average cartilaginous union and the chance o disakli in the patient's future life history, movement can be allowed attei ^^o oi three days. If the vagina is extensively torn in deli^;ery and the lacera- tion coninunicates with the severed ends of the pelvic bone, the most 248 ATLAS OF OPERATIVE GYNAECOLOGY unfavorable kind of compound fracture of the pelvis results. One of my patients died from this cause, and I do not see how such an accident can always be prevented. Another exceedingly disagreeable possibility which I once encountered when I was doing symphysiotomy, but which might also confront the oper- ator in pubiotomy, is an inability to extract the child after severing the pelvic bones on account of the miscalculation of pelvic size or of the size of the fetal head. It is stated by the advocates of pubiotomy that it is practicable with a pelvis having a conjugate diameter down to 7 cm. ; Imt everyone knows how difficult it is to make an absolutely accurate diagnosis of pelvic size, even with instruments of precision recently devised for this jiurpose. ^Moreover, pelvic measurements are only relative and it is absolutely impossible by any of the methods of antepartum foetometry to make an accurate estimate of the size of the fetal head. Antepartum foetometry enables us to make a fairly accurate estimate of the size of the infant, but a miscalculation is always perfectly possible and no one can be certain of avoiding it. \Miile the specialists who practice pubiotomy have recommended that it should be performed only by experts and under the most favorable con- ditions, I feel that the operation is more suitable to the occasional operator who has no training in abdominal surgery; for such an individual it is a much easier oiH-ration than ca^sarean section, reciuiriug fewer implements and not demanding such expert assistance. But with the excellent training that students are now .securing in the principles of abdominal surgery, and with the ample opportunity afforded at present for acciuiring skill in this kind of work, even for the occasional operator, I believe, ciesarean section in the future will ]irove the safer and more desirable procedure, and that pubiotomy in the near future will be regarded in the same light in which symphysiotomy is regarded to-day — as an operation with an interesting history, but for which the need has disappeared. In the hands of the few specialists of this country who still perform it, it is claimed to be an alternative to cicsarean section in the second stage of labor, and to be superior to that operation on accont of its lower mortality; but since the development of the extraperitoneal cesarean section in these cases, the need for inibiotomy, to escape the dangers of caesarean section in patients either exhausted or presumably infected, has disappeared, the extraperitoneal cesarean section giving results, in the hands of experts who are trained in abdominal surgery, that are ciuite equal to those obtained by pubiotomy in primary- mortality, and better results in the patient's convalescence after the operation and in her subsequent life history. PLATE CLXIII. Doederleins' needle passed behind the pubic bone and emergmg through the skm to the outer side of the labium. PLATE CLXIV. The Gigli saw adjusted. AFTER-TREATMENT OF ABDOMINAL SECTION 251 THE AFTER-TREATMENT OF ABDOMINAL SECTION The routine followed in my services is to give the patient a 'Murphy drip proctoclysis of a ciuart of water containing an ounce each of glucose and bicarbonate of soda, so timed as to take an hour to administer. Manj' surgeons at present claim that it is better to give this injection perhaps in smaller amount as an enema, on account of the discomfort of the proctocly- sis; but, if administered as soon as the patient is put to bed it is finished before complete recovery from ansesthesia, and my patients make no com- plaint about it — in fact are usualh' unaware that it has been given. For the first twenty-four hours suppositories of five grains of asafoetida every three hours are useful to control tympanites. If there is much nausea the patient is given a full glass of water with a teaspoonful of bicar- bonate of soda in it, which is usually at once rejected, washing the stomach out, whereupon the stomach usually becomes retentive. A moderate Fowler's position helps to drain the stomach into the duodenum, which also aids in the control of nausea. Water is given in sips as soon as the patient can retain it. At the end of the first twenty-four hours the patient receives an enema of six ounces milk of asafoetida, six ounces water, one drachm of turpentine and one drachm of Hoffmann's anodyne; this is to expel the gas from the intestines. A rectal tube is inserted occasionally to facilitate the expulsion of gas. During the second twenty-four hours, albumen water, l)arley water, clear broth, and whey are administered as food, at three-hour intervals in four-ounce quantities. At the end of the second twenty-four hours, a course of calomel is given: one-fourth grain every hour for eight doses, followed by two ounces of citrate of magnesia every two hours for three doses; or, if the patient objects to the taste of the citrate, a solution of Rochelle salt is substituted. The administration of the calomel makes the patient uncomfortable for the time being, but she is so much better for it the folliiwing day that I still continue it. Several substitutes have been tried from time to time, but they have not been found so satisfactory. After the bowels have been moved, the patient is put on a soft diet. The exaggeration of the distention and of the nausea following sections must occasionally l^e combated. Of all the abdominal operations in gynaecology, the classical csesarean section is most apt to be followed by tJ^npanites. Therefore, eserine salicylate and strychnia are given hypodennically directly after the opera- tion at four-hour intervals, one-sixtieth and one-twentieth grain respec- tively. Should excessive tympanites develop after any section, these rem- edies are employed, with a single hypodermic injection of an ampoule of surgical pituitrin. If the medicinal treatment alone is not sufficient, the following enemata in succession are given at three-hour mtervals : an ounce of alum in a pint 17 SS-J ATLAS OF OPERATIVE GYN/ECOLOGY of water; the enema of milk of asafoetida, etc., already described; an ounce of glycerine, half an ounce of turpentine, half an ounce of Epsom salt, two ounces of water; two and one-half drachms bisulphate of quinine, and a quart of water. A spice poultice is put over the upper abdomen, and in extreme cases, after injecting the rectum with salt solution, an anal elec- trode is inserted; a sponge pad electrode is laid on the abdomen and as strong a galvanic current as the patient can stand (20-40 milliamperes) is turned on. The abdomen and rectum are then shocked by a rapid alter- nation of the poles, by suddenly switching the indicator on the .switch board from negative to positive. In this manner it is possible to relieve tym- panites that would appear to demand re-opening the abdomen for an appar- ent obstniction. While the enemata are being used it is a useful adjuvant if the stomach will retain it to administer two drachms of a fifty per cent, emulsion of castor oil at hourly intervals for eight doses. On the failure of all these measures, re-opening the abdomen may be called for, to relieve an actual obstruction. Occasionally an explanation for persistent and extreme tympanites is found in a thrombosis of the mesenteric veins — usually a fatal complication, but in one instance I witnessed recovery in a typical case. As is well known, nothing relieves excessive vomiting so well as gastric lavage. A spice poultice over the abdomen, the Fowler jiosition and cocaine internally in full doses, are aids; but if the vomiting is due to infection, acute dilatation of the stomach, or obstruction, no treatment directed to the stomach alone will be of any use. //; the after-treatment of plastic operations the dusting of the external wound with formic bisnuith iodide, avoidance of douches till after the first week, and if possible spontaneous urination are the main principles to be observed. In secondary hemorrhages, washing out the vagina with hot water, putting the patient on an operating table and packing the vagina by the aid of a very narrow Sims speculum, firmly but not too forcibly controls the bleeding without tearing the vaginal wounds open. The differential diagnosis of internal bleeding and shock after an ab- dominal operation was at one time an anxious matter; but, with the improved technic of abdominal surgery, secondary hemorrhage into the abdominal cavity after the wound is closed is so rare that it scarcely ever has to be considered. In my two hospital services there has been but one intra- peritoneal hemorrhage during recovery from an abdominal operation in the course of many years. If the question must be considered, Polak's observations would have great walue. The low pulse pressure and the leuco- cytosis of hemorrhage are the main distinguishing features. For shock, a good routine treatment is artificial heat by the electric canopy; enemata AFTER-TREATMENT OF ABDOMINAL SECTION 253 every four hours of one ounce predigested beef; twenty grains carbonate of ammonia, one-half ounce whiskey, and four ounces water; alternating with the enemata, hypodermics of a digitalis preparation and strychnia. For the acute anaemia following an operation which has been preceded or accompanied by severe hemorrhage, intravenous salt solution injections are first tried during or immediately after the operation. There is almost always a response. But if there is not, or if some hours later the patient's pulse fails again, actual transfusion by the citrate of sodium method, five hundred to seven hundred cubic centimeters, is employed. For this purpose a donor is kept in readiness and the tests for haemolysis are made, in a case of need. SURGERY OF THE MAMMARY GLAND It is unusual to devote to the breast a section of a book on the operative treatment of the diseases of women; but there is no class of physicians who see a larger number of pathological conditions of all kinds in the breast than those who are especially interested in diseases peculiar to women. In the practice of such a specialist there is a constant necessity for the diagnosis and recommendation for treatment of various pathological con- ditions in the female breast — from the minor inflammatory and congestive conditions to the most serious pathological new formations. It would appear, therefore, that it is desirable, for any special worker in conditions peculiar to women, to familiarize himself with all the pathological conditions in the breast, and to cultivate skill in their necessary operative treatment. Surgery of the breast is not difficult to anyone who specializes in pelvic and abdominal surgery. There is no reason, therefore, why the g>Tia?cologist should not include operative treatment for conditions of the breast in his special work. It appears to the author an advantage to patients if this is done. The patient is more likely to consult someone known to be interested in female diseases, if she develops an abnormaUty in the breast, than she is to consult any other kind of specialist: and there is always a necessity for differentiating the minor conditions, incitlental to functional activity in the child-bearing process, from more serious conditions. Anyone in control of a large service in obstetrics and gj'nsecology has a better opportunity to familiarize himself with the diagnosis and treatment of all breast condi- tions than the general surgeon. For all these reasons, therefore, it would seem that, in the future, the pathology and treatment of the mammarj^ gland should be a part of every gyngecologist's work. Surgical Treatment of ^^Iammary Abscess. — The author has for a number of years adopted the following plan of treatment, after experience with others that were not so satisfactory : 254 ATLAS OF OPERATIVE GYN.E( OLOGY The area of suppuration is first carefully mapped out; then a small incision is made in the most dependent point of the suppurative area, or a trifle below it, as the woman lies on her back. At this point a small incision through the skin and sujiraficial fascia is made; through this a long Pean forceps is inserted and plunged through the deeper portion of the sup]:)urative area until the point of the instiimient makes a projection under the skin, opposite to the point where the first incision is made. A small incision is now made upon the projecting point of the instrument, which is inished further through until it appears plainly in view. A rubl)er drainage tube with only one fenestra in the middle of it is seized by the forceps and pulled back until it appears through the original incision. The drainage tube traverses the whole extent of the infected area. At a point midway between the first two incisions and in the lowest margin toward the pectoral surface, another incision is made, through which a Pean forceps is forced until it appears at a point opposite, traversing the whole extent of the involved breast. A drainage tube is pulled through as before, with one fenestra in it, in the middle. In a case of extensive suppuration two or three more tubes may be required, until it is obvious that every suppurative area is tapped and well counter-drained. Safety pins are then inserted through the projecting ends of the drainage tube and they are cut ofT above the safety pins so as not to leave too much tube projecting to be pressed upon by the dressing. By a device invented by Dr. Edmund B. Piper, while in the American Ambulance Service in Paris, fluid may be injected into both ends of the drainage tube and is consequently forced out through the single fenestra in the middle, in this way flushing the abscess cavity and the drainage tract efficiently; whereas, by the older plan of injecting fluids into the drainage tube, the inner surface of the tube was kept clean without much influence on the drainage tract or the abscess cavity (Fig. 25). As an irrigating fluid Dakin's fluid may be employed ; but I have found it better to use this only occasionally, employing in the interval a mild antiseptic solution, like one to six thousand, permanganate of potash or a boracic acid solution, the breast being irrigated every three hours, but only once or twice a day by the Dakin fluid. The advantages of this plan of dealing with a mammary abscess are that there is the minimum of disfigure- ment of the breast ; the least possible sacrifice of secreting glandular material ; the earliest possible cure of the abscess, with the least amount of suffering to the patient. The alternative plan of making a large incision, or of making an incision sufficiently great to insert the finger, does not so surely .secure these results. The large incision through the whole extent of the suppurative area makes a SURGERY OF THE MAMMARY GLAND 255 regrettable disfigurement of the breast, and sacrifices an unnecessary amount of gland; it also entails on the woman a greater risk of lacteal fistula. The other plan of using the finger to break up septa between suppurating areas Fia. -Piper's niethod of irrigating infected sinuses and drainage tracts; devised by Majnr E. B. Piper, of the American Ambulance Service in Paris and subsequently adopted by Dakin and Carrel. can never be depended on; it is often impossible to reach with the finger so deep or so far as may be required, and by using the digital method unneces- sary trauma and destruction of tissue sometimes ensue. Between the irrigations the breast is covered with an ample cjuantity of absorbent gauze, which is kept in place by an ordinary Murphy breast binder; the corresponding arm being .supported in a sling. 256 ATLAS OF OPERATIVE GYNAECOLOGY As soon as the systemic symptoms subside — that is, as soon as the temperatui'e becomes normal — the patient is allowed out of bed and is given the maximum of good air and bright sunlight, with a generous support- ing diet and mild stimulant in the shape of a moderate qauntity of red wine with the principal meal. It is possible to continue mu'sing with the vmaf- fected breast; but as a rule it is better not to do so, as the stimulus of lacta- tion continues the congestion and engorgement of the infected breast. The average length of time required for convalescence is about two weeks; the drainage tubes are usually removed within ten days, a small strip of gauze being inserted in the drainage opening for two or three days afterward. These are then removed; small squares of surgeon's lint with zinc ointment are put over the raw surface of the exit orifices of the drainage tracts, and the breast is then subjected to compression by layers of rubber adhesive plaster put on in squares from the base of the breast toward the nipple. An application occasionally of weak nitrate of silver solution to the granulating area, around the openings of the drainage tracts, hastens their cicatrization and the restoration of skin over them. If the suppurative area is quite limited and superficial, a single small incision into it, with the application afterward of a Bier cup may suffice, or it may be necessary to insert only a single drainage tube for a compara- tively short time. If the abscess is under the breast — the so-called post- mammary abscess, between the breast and the pectoral fascia, lifting the breast from the chest and giving a peculiar elastic sensation to the whole breast when palpated — the drainage should be conducted as described in the treatment of an ordinary extensive mamary abscess, except that the incisions and the drainage tubes are between the breast proper and the pectoral surface. In the course of some twenty-five or thirty years' experience with mammary abscesses it has been twice necessary to amputate the breast for a mammary abscess which had been long neglected before proper treat- ment was api)lied, and in which it was impossible to secure a cessation of suppurative discharge and a healing of the drainage sinuses. In such cases, some unusual infection must be suspected — not the ordinary staphylococcic or streptococcic infection, but tuberculosis, syphilis, or an infection by some of the fungi. In rare instances, and in long neglected cases, the suppu- ration may extend quite far beyond the breast itself, into the axilla or even on to the upper and posterior aspects of the shoulder. The systemic symp- toms in such cases are severe, and it may be necessary to resort to vaccine and serum treatment in addition to the surgical inter\'ention. In young infants the pus may burrow through the thoracic walls into the pleura, but personally I have never seen this in an adult. It might, however, occur in a long neglected and extremely severe infection. SURGERY OF THE MAMMARY GLAND 257 The sooner mammary abscesses are opened the better. It is not wise to wait for the classical symptoms of suppuration elsewhere, if the symptoms of mastitis continue unabated for three or four days ; if there is persistent fever, leucocytosis, redness of the skin or a dusky red hue, and some oedema, an incision or incisions are always required. It is often possible to abort suppuration by an early incision into an inflammed area before actual pus formation has occurred. Inefficient and too long postponed surgical treatment result in almost indefinite inflammation and suppuration. I have .seen cases of puerperal insanity develop in the course of a mammary abscess which had lasted for more than six weeks, with one or two insufficient incisions and inadecjuate drainage. Ill-success in the treatment of mammary abscess often brings unnecessary discredit to the general physician, with loss of reputation and practice. If speedy success, therefore, does not follow treatment, it is good policy to refer such cases, without unnecessary delay, to a specialist, who can usuallj' secure a good result in a moderate length of time or who can, at any rate, better bear the responsibility of a long continued and delayed convalescence. If this is not done, it is often a difficult task for the con- sultant to reconcile the family and the original medical attendant. In addition to the operative treatment for mammary abscess, the following operations are required for pathological conditions of the breast: (1) Excision of Cystic or Solid Tumors by an Incision Directly over the Growths and Their Enucleation. Removal of Supernumerary Glands. Removal of Sm-face Growths (Papillomata). (2) Excision of a Growth or Portion of the Breast Tissue by the Thomas-Warren Incision which is Invisible Afterward in the Erect Posture. Plastic Resection. (3) Amputation of the Breast for Non-MaUgnant Conditions which do not Necessitate the Dissection of the Axilla and the Removal of the Subjacent Tissues, as the Pectoral Muscles and Fascia. (4) Subcutaneous Amputation of the Breast with Preservation of the Nipple. (5) Amputation of the Breast for Malignant Disease Including a Dis- section of the Axilla; Removal of Glands and Fatty Tissue and Removal of Pectoral Muscles and Fascia. (6) Plastic Operations on the Breast: A, for Inverted Nipple (UmbiU- cation of Nipple) ; B, for Hypertrophy ; C, for Pendulous Breast — Mastopexy. (1) Excision of Cystic or Solid Tumors by .\n Incision Directly Over the Growths and Their Enucleation. Removal of Super- numerary' Glands. Removal of Surf.\ce Growths (Papillom.\ta) (Fig. 26). — If no attention need be paid to the disfigurement of a scar on the breast, it is always more convenient to make an incision directly over non- -i5H ATLAS OF OPERATn E (iVX.KCOLOCiY malignant fjrowths and to effect their removal either by enucleation or excision. This is almost alwaj's done in the removal of sniiernunierary glands, which may cause much annoyance to the patient by their situation or by their discharge of secretions, or may be subject to such irritation that there is danger of the development in them of malignant conditions. If the patient belongs to a class of life in which distiguronient wouUl be a great disadvantage, every effort must be made to a\()id it, by the Thomas-Warren incision to be subse(iuentl3' described. The most inijiortant point to decide, before attemjiting the excision or enucleation of a cystic or solid tumor in the breast, is its possible malignancy. Contraction of the nipple, adhesion of the skin, the peculiar pig-skin appearance, extreme hardness of a malignant growth, idceration of the skin, the age of the jiatient — all have to be considered; l)ut there will always be a ]iossil)ility of doul^t. It is therefore advantageous, to a greater degree in tliis than perhaps in any other branch of surgery, to have prepared a rai)id freezing microtome and a microscope, so that a competent pathologist can make an inuuediate diagnosis as to the true nature of the tumor. With the possibility of malignancy in mind, any direct incision into the tumor should be carefully avoided; and it is often a distinct ad\antage to excise a portion of the breast tissue a little wide of the tumor, to be removed with it without coming in direct contact with the growth itself. Moreover it is impossible to enucleate some growths, and the excision of surrovnuling tissue is a necessity. The possibility of a lacteal fistula must also be borne in mind; so that the incisions in the breast, to gain access to the tumor and to effect its removal, should always be made parallel with the milk ducts. A disadvan- tage of the direct incision is that it maj' not permit a sufficiently wide explo- ration of the breast, so that most operators (including the author) prefer the Thomas-Warren incision — which avoids disfigurement, permits the removal of a tumor from any portion of the manmiary gland and also enables the operator to conduct as wide an exploration of the l)reast as he desires. In closing the wound after direct incision over a mammary growth, care must be taken to obliterate by tier sutures of catgut the cavity left behind; otherwise the skin over the cavity will show a depression more disfiguring than the wound in the breast, and moreover there is a likeli- hood of haematoma formation, infection of the wound, and a comjjlication by a mammary abscess after what should be a trifling operation with an immediate recovery. It .should be a rule of practice to remove all tumors in the breast. Malignant degeneration is always possible. The nature of the tumor can never be certainly determined without microscopic examination; future growth demanding amputation of the breast is not unlikely, and as the Fig. 26. — PapiUunia of breast. 260 ATLAS OF OPERATIVE GYNECOLOGY operation is a simple and easy one, usually possible under local anesthesia, there can be no objection to it unless the patient is the subject of some grave systemic disease. If operation is declined the patient should be urged to report at frequent intervals for examination. (2) Excision of a Growth or Portion of the Breast Tissue AND Exploration of the Mammary Gland by the Thomas-Warren Incision which is Invisible Afterward in the Erect Posture. Plastic Resection. — There are many conditions in the mammary gland requiring surgical treatment which can be dealt with by an operation leaving no disfigurement, obviously an important consideration with many women. Tumors of moderate size can thus be removed, the breast can be explored for possible malignant growths, portions of it may be excised for conditions such as imperfect involution and cystic formation; or areas of the breast can be reached and drained in this manner, better than by direct incision in certain cases. The o])eration is not applicable to tumors in a situation most difficult to reach by an incision under the breast and to its outer side. As Deaver points out, growths on the inner, upper quadrant of the breast are usually more conveniently reached by the direct incision over them. But even in this situation it is possible to deal with the conditions by the Thomas-Warren incision, if there is a cogent reason for avoiding the slightest disfigurement. Many women will consent to this operation who might decline operative treatment which would leave a visible scar in evening dress; but if this consideration need not be taken into account, in women of a class who need not concern themselves about evening dress, or in women approaching middle age and the termination of the child-bearing period, an amputation of the breast in extensive invohement, or for removal of a tumor of considerable size, may be better than plastic resection or the removal of the growth by direct incision over it. The Thomas- Warren operation is usually referred to as plastic resection of the breast, and is here described by its author as first performed, with later modifications by the operator: "The patient standing erect and the mamma being completely exposed, a semicircular line is drawn with pen and ink exactly in the fold which is created by the fall of the organ upon the thorax. This line encircles the lower half of the breast at its juncture with the trunk. As soon as it has dried the patient is anaesthetized, and with the bistoury the skin and areolar tissue are cut through, the knife exactly following the ink line just men- tioned until the thoracic muscles are reached (Fig. 27). From these the mamma is now dissected away until the line of dissection represents the chord of an arc extending from extremity to extremity of the semicircular incision. The lower half of the mamma which is now dissected off is, after ligation of all bleeding points, turned upward by an assistant and laid upon the chest wall just below the clavicle. SURGERY OF THE MAMMARY GLAND 261 "An incision is then made upon the tumor from imdemeath bj' the bistoury, a pair of short \'olselhuii forcei)s is firmly fixed into it, and, while traction is made by these, its connections are snipped by scissors — the body of the tumor being closely adhered to in this process — and the growth is removed. All hemorrhage is then checked and the breast is put back into its original position. "Its outer or cutaneous surface is entirely uninjured, and the only alteration which has been effected in the organ is the leaving of a cavity which was formerly occupied by the tumor. A glass tube with small holes I'lu 27 — Priiiia]> iiiL-isioii f(M' the TliMiiKis-Wuneii uperatioli (.Denvciuiid McFarlando 1 ).>. l;nast"; courtesy P. Blakiston's Son & Co.) at its upper extremity and along its sides, about three inches in lengtli, and of about the size of a number 10 urethral sound, is then passed into the cavity between the lips of the incision, and its lower extremity is fixed to the thoracic walls by adhesive plaster. The incision is closed with silk and covered with collodion. The tube is removed in nine days." The operation is designed to take the place of those exploratory incisions which are often inadequate for the purpose, or are so situatetl as to leave a cicatrix in a part of the integument frequently exposed to view. It is also so planned as to expose freely every part of ihe gland, and, therefore, to accomplish all that an amputation would do in doubtful cases. An opera- tion that can relieve the mind of the patient from all uncertainty as to diag- iGi ATLAS OF OPERATIVE GYNAECOLOGY nosis, produces no subsequent deformity, and entails but little discomfort and sacrifice of time, seems well indicated as a substitute for the various forms of treatment which have from time to time been suggested — such as puncture, aspiration, or small exploratory incisions. It is also well adapted to overcome the fears of those who shrink from any operative interference whatever. In early operations I began with an incision similar to that described by Thomas, but have changed it to coincide with the edge of the outer hemisphere; as this incision gives a freer access to the upper hemisphere. Flo. 28. — Conservalive amputation of breast. Primary skin incision. (Deaver and McKarland's "The Breast"; Courtesy P. Blakistou's Son & Co.) Fk;. 29. — Conservative amputation of the breast, tikin flaps reflected. ( Deaver and McFarland's "The Breast"; P. Blakiston's Son & Co. ) and at the same time to the outer hemisphere of the gland — regions more frequently the seat of tumors than the inner quadrants. By prolonging the incision slightly along the anterior axillary border, the breast can be thrown over toward the sternum, and the most remote regions of the gland freely exposed. As the breast falls not only downwards but outward, when the patient is in the upright position, this incision is concealed from view (Fig. 27). The dissection should be carried down to the outer edge of the pectoralis major muscle; when fibers of this muscle have been exposed, the knife will have passed through the deep layer of the superficial pectoral fascia, a fascia which covers the posterior surface of the gland. This layer is sepa- rated from the deep pectoral fascia covering the pectoralis major muscle by a loose layer of connective tissue. The loose connective tissue enables the SURGERY OF THE MAMMARY GLAND 263 dissection to be carried easily between the gland and the muscle, so that they are quickly separated from each other. The left hand of the operator can now manipulate the breast so as to expose the entire posterior surface of the gland. The gland tissue is covered by the posterior layer of the pectoral fascia, but is readily recognized beneath it, as are also any cysts or tumors that may be present. An incision radiating from the center to the periphery of the gland should be made through the fascia, to expose the subjacent growth. The segment of the gland containing the tumor should now be removed by two radiating incisions which, meeting at the center of the gland, include a V-shaped portion of its tissue. The knife should make a clean cut through the gland tissue down to the loose adipose tissue which lies in front of the gland. This adipose layer should not be removed, as its presence is important in preventing a subse- quent depression at this point. No attempt should be made to dissect out the tumor, whether it be solid or cystic. Solid tumors, such as the peri- ductal fibroma, or a cystadenoma, are so intimately associated with the gland tissue that they cannot be "shelled." The fibers of the capsule seem to be continuous with those of the stroma of the gland. Any attempt, therefore, at a dissection of the tumor is followed by a considerable lacera- tion of the surrounding tissues. It is desirable to avoid cutting into cyst cavities, one or two of which are usually found in the same quadrant. In the case of a single solid tumor, the V-shaped wound should be care- fully approximated with a double row of sutures, one adjusting the anterior edges of the wound and the other its posterior lips. The full thickness of the gland at each side will thus be brought into contact, and no gap left to cause a depression on the surface of the breast. In the case of the presence of cysts (in abnormal involution of the breast) a further exploration of the gland tissue is necessary, for although the group of larger cysts forming the tumor, for which the operation has been performed, are usually clustered together in one quadrant, there are also numerous minute cysts in other parts of the gland which have escaped detection. If these are left undisturbed, they may grow later and involve a second operation. After the removal of the cluster of large cysts by the V-incision, the remaining segments of the gland can be explored by a series of radiating incisions. In this way all the smaller cysts are laid open, a procedure which is sufficient to insure their permanent disappearance. Cysts the size of a pea can be snipped out with scissors. Smaller cysts can be left after being laid open. The number of these radiating incisions may vary from three or or four to double that number. It depends largely upon the amount of gland tissue present. Many breasts consist of but little else than adipose 264 ATLAS OF OPERATIVE GYN^XOLOGY tissue interspersed with bands of connective tissue. Usually two or three such incisions are sufficient to satisfy one that the gland has been thoroughly explored. In case an operation has been jierfornied for the purpose of settling a doubtful diagnosis of malignant disease, the breast may be sliced as freely as a brain is at autopsy, provided the radiating method is adopted, without danger of interfering with its vitality. It is usually unnecessary to close these incisions with sutures, as their lips drop together naturally when the organ is folded back on to the pectoral muscle. If, however, any tissue has been dissected out from the sides of one of these incisions it is well to catch the edges together with a single suture. In some operations a very large amount of tissue has to be removed, as in the case of larger cysts; and then it is difficult, if not impossible, to adhere to the radiating system of cutting. Keeping, however, in mind that nothing must be removed excej^t acinous tissue, a great deal of the cortical portion of the gland can be saved as well as considerable portions of the stroma, and all the surrounding adipose tissue of the breast. The somewhat jumbled mass of tissue which remains behind may be so brought together by buried sutures, by the quilting or purse-string methods of sewing, that a well- formed breast may be built up from what is left behind. A second V-.shaped incision is occasionally necessary for large cysts in other quadrants, but I have rarely been obliged to resort to it. All hemor- rhage should now be arrested. This can be done partly by pressure and partly by ligature. Catgut is the only material that should be used for this purpose, as silk leaves a more or less permanent knot behind which may act as a source of irritation. The V-shaped openings should next be sutured in the way above de- scribed, and the gland is now released from the hand of the operator and dropped back on the pectoral muscle. It will be found that the various incised portions of the gland resume their natural positions, and fit accurately together. The gland should next be anchored to the outer edge of the fascia of the pectoral muscle. This holds the gland firmly in its place. A second row of sutures should be taken through the deep layer of the superficial fascia before closing the outer edges of the wound with silk-worm gut. This last row of buried sutures is useful in removing strain from the surface sutures. It is not an uncommon occurrence to find a folding in or inversion of the nipple, particularly in a case of abnormal involution. This condition should be distinguished from retraction of the nipple, seen in carcinoma. This deformity can easily be remedied during the operation by dissec- tion from Ix^hind, so as to lay bare the base of the nipple, where a purse- string suture can be applied in such a way as to force the nipple outward. SURGERY OF THE MAMMARY GLAND 265 In cases of doubtful tumor, where cancer is suspected, the disease can be approached through the incision made for plastic resection. It is well, however, to carry the incision so as to separate the primary nodule from the lymphatic circulation by extending it a little farther along the axillary border. WTien the breast is freed from the pectoral muscle, all danger of forcing cancerous juices through the lymphatic channels is averted. If the nodule proves to be cancer, the small cut which has laid it open should be immediately closed by a suture, and the major operation proceeded with immediately. The dressing (after plastic resection) should be applied so as to produce lateral compression of the lower and upper hemispheres, as the ordinary swathe tends toflatten out the gland and put a strainupon the buried sutures. For this purpose I have devised the "empire" bandage. The material of the bandage should be of compress cloth or cheviot about five inches wide, and long enough to encircle the chest and cross diagonally in front. At the point of crossing it should be caught with a safety pin, and pinned like a diaper. The ends which cross each other at right angles are then folded longitudinally so as to form a "box plait" and are attached to suspenders crossing over the shoulders. (3) Amputation of the Breast for Non-Malignant Conditions which do not necessitate the dissection of the axilla and the Removal of Subjacent Tissues, as the Pectoral Muscles and Fascia. — This operation is often required for a number of conditions — tumors of considerable size and of a non-malignant nature, such as fibro-adenomata; imperfect involution of the breast, with cystic formation; intracystic papil- loma (Fig. 30) ; tuberculous sinuses of the breast; such extensive suppuration and inflammation as completely to destroy the breast as a secreting organ ; rarer forms of infection, such as actinomycosis, Paget's disease of the nipple in its precancerous stage, etc. The decision as to amputation, plastic resection, or direct incision is governed by several considerations — justifiable doubt as to malignancy, the advancing age of the patient, her social status, and her feeling in regard to multilation. In case of doubt as to the selection, it is better, as a rule, to incline to amputation. The operation is easy, simple, and safe. An elliptical incision is made through the skin, beginning on the inner periphery of the gland and ending at the outer periphery, having the nipple as the mid-point of the skin between the incisions. The incision is carried through the skin, fat, and superficial fascia, which are then dissected back so as to expose the upper and lower peripheries of the breast (Figs. 28,29). The incision is then carried through the deep layer of the superficial fascia, when it is easy to strip the breast off by pulling it loose from the connective tissue between the deep layer ■266 ATLAS OF OPERATIVE GYNJ^X'OLOGY of the superficial fascia and the fascia over the pectoraHs major muscle. Bleeclinjv jioiuts are tlien secured; the deeper portion of tli(> tissue is brought together with Intel rupted sutures of catgut and the skin is miited by what- ever form of suture the surgeon prefers. Interrupted sufm-es of silkworm Fig. 30. — Intracystic papilloma of breast removed, with surr'>iiinlin^ breast tissue, throvigh Thomas-Warren incision. gut at wide intervals, with catgut sutures intervening, so as to secure accu- rate apposition of the skin wound, is the method preferred by the author; but any other of the skin sutures is applicable to the case, the union almost always being primary and leaving a narrow, non-disfiguring scar. In the preparation for the operation I am using the same method employed for abdominal section — namely, cleansing the skin with a 2 per cent, soap solution, wiping it off, using ether to remove the sebaceous material and to further dry the skin; and then rubbing the skin at and in SURGERY OF THE MAMMARY GLAM) 267 the neighburhood of the incisions about to be made witli phenoco solution. After the operation the wound is covered with a gauze dressing kept in place by a six-inch-wide gauze bandage, put on in the ordinary manner for a breast bandage. The corresponding arm is sujiported in a sling, and the patient is allowed to get out of bed on the second day. (ieneral ansesthesia, preferably gas and oxygen, is desirable for tins operation. Local anaesthesia would have to be applied over too extensive an area and reciuires too nuich time; but there are certain systemic conditions of the patient which might make the local anaesthesia preferable. In the vast majority of cases, however, the gas and oxygen anaesthesia will be found itleal. The operation is a brief one; and the consecjuent convalescence of the patient, with early rising from bed, is facilitated by the avoidance of ether or chloro- form. It is most important, in this operation, to make a rapid macroscopic and microscopic examination of the breast before closing the wound, to determine the possibility of malignancy in the condition for which the oper- ation is perfoi'ined. In a certain percentage of cases reciuiring amputation of the breast, it is necessary to extend the operation into the axilla for the removal of sympathetically affected lymphatic glands, not involved in malignancy but enlarged, hardened, and pos.sibly painful on account of lymph-adenitis. It is also quite possible to find, in the axilla, growths similar to those removed with the breast, particularly fibro-adenomata. (4) Subcutaneous Amputation of the Breast with Preservation OF the Nipple. — This operation is sometimes indicated tV)r such conditions as extensi\'e imperfect involution and cystic formation, or for some large tumors of a non-malignant variety in\-()lving the greater jiortion of the breast tissue. The operation is designed mainly to reconcile some people to an ampu- tation of the breast without the disfigurement of the coincident removal of the nijiple, a patient sometimes consenting to this form of operation who otherwise might decline the ordinary amputation of the breast. The Thomas-Warren incision is utilized as already described, except that after reaching the loose connective tissue between the deep layer of the superficial fascia and the fascia covering the pectoral muscle, there is a total .separation of the base of the breast from its attachment. It is then comparatively easy to remove the breast from its connection with tlie sub- cutaneous fatty tissue which lies between the manmiary gland antl the skin. If the patient has a considerable amount of fat under the skin, there may be a surprising absence of deformity after the removal of the breast, especially if subcutaneous fat is somewhat quilted by internipted sutures so as to make a projection under the skin to take the place of the gland which has been removed. In a very thin person it is ciuestionable whether there is anything to choose between removal of the breast, leaving the nipple, or the 18 ^268 ATLAS OF OPERATRE GYN^XOLOGY total reini)\'al of the jihmd with the skin over the central portion of it, containing the nipple. Even in sucli people, however, the prejudice against the obvious amputation of the breast by the removal of the nipple with it may be so great as to lead them to refuse operation altogether. Naturally the question is one for the judgment of the patient and physician in each individual case. Obviously this operation lias no place whate\'er in dealing with growths that are malignant or that might possibly be so. The concluding steps of the operation are exactly the same as in the Fig. 31. — Retraction of nipple in carcinoma of tlie breast. plastic resection, except that, if perfect hsemostasis be secured, drainage may not be necessary. If the latter is required, the author's preference is for a slender rubber drainage tube instead of the glass tube advocated by Warren. There is a difference in the dressing after the operation. The support of the breast — or the breast region, rather, from which the mammary gland has been removed — by a special binder, according to the proposition of Warren, is unnecessary; so that the ordinary gauze dressing and six-inch surgical bandage is a sufficient dressing after this operation. SURGERY OF THE MAMMARY GLAND '269 (5) Amputation of the Breast for Malignant Disease Including A Dissection of the Axilla, Removal of Glands and Fatty Tissue and Removal of Pectoral Muscles and Fascia (Figs. 31-33). — The feeling of hopelessness with regard to the success of operation on a mammary Fig. 32. — Pig.skin appearance of breast in cancer. cancer which was felt in the last generation has changed to one decidedly hopeful at present: Halstead's forty-nine cured cases out of one hundred and ninty-one operations, at the expiration of five years, is sufficient cause for the optimistic feeling entertained by the profession to-day. 270 ATLAS OF OPERATIM-: (IVN. ECOLOGY We owe the improved results to the work of .Moore, Lister, Kuster, Gross, Halstead, Willy Meyer, ^'olknl:um, and W. Watson C'heyne; com- bined with the exjieriniental and lal)oratory work on which practical pro- cedure was based and develoiicd. On tliis cooperative plan, nuidcrn oper- ators have perfected a technic which f^ives promise of even better results in the future, in cases .susceptible of a possible operative cure. Not only has improved operative technic achieved this result, but iinproxcmcnl Fig, 33. — Cancer of breast, ulcerative stage. has been further effected by a standardization of the lules in regard to inoperal)ility and the greater care exercised in differential diagnosis. The rules laid down by Handley in regard to inoperability are expressed as clearly as possible. The condition is inoperable: (A) When the primary growth has become attached to the bony thoiax. (B) In the ])resence of cancer en ciiirassc, or of subcutaneous notlules or skin infiltration situated more than two inches from the primary growth. (C) If there is a fixed mass of growth in the axilla, evidently adherent to its walls. (D) If there is marked oedema of the arm. (E) If the supraclavicular glands are enlarged, hard, and fixed. (F) If there is evidence of visceral or bone metastases. SURGERY OF THE MAMMARY GL.\XD •271 (G) If there is incurable constitutional disease — tuberculosis or dia- betes for example— likely to be fatal in a few years at most, or to lead to a post-operative fatality. ■(H) In the acute forms of carcinoma. Patients suffering with mammary cancer, when referred foi- operation. are divisiljle into five more or less clearly defined classes, viz: (A) Inoperable cases presenting absolute contra-indications to any form of operation. Fig. 34, — .lackson's incision for amputation of the breast. {B) Inoperable, but presenting the indications for some palliative operation. (C) Clinically malignant, but apparently operal)le. (D) Clinically uncertain, but apparently malignant. (E) Clinically benign, but found at the time of operation to be malig- nant — either by gross examinations of the cut surface of the tumor, or by the microscopic appearance of tissue sections. All modern ojierators adoj^t the technical principles laid tlown by Halstead. but there are many minor modifications of the incision and of the manner in which the tissues are removed and the wound is closed. Incisions are made differently by Halstead, Handley, Kocher, Rodman, il'i ATLAS OF OPERATIVE GYNECOLOGY Stewart, Murphy, Dawboru, jMeyer, Tansini, Warren and Jackson (Figs. 34,35). The author prefers, however, and has almost always adopted the oper- ative technic employed by John B. Deaver, which he describes as follows: "The incision is begun on the arm at a point opposite the insertion of the i)ectoralis major nuiscle at the level of the anterior edge of the deltoid muscle (Fig. 3G). It is carried upward and inward well on to the shoulder to a point about two inches beyond the line of the anterior axillary margin; Fig. 35. — Jackson's incision for amputation of the breast. Operation completed. and then is continued in a gradual curve (the concavity of which is outward) to within two inches of the upper margin of the breast. This incision is placed well within the line of the anterior axillary margin so that the result- ing scar will not cross the axilla obliciuely and act as a band binding the arm to the side of the chest wall. "Two incisions are made to diverge from the lower end of that just described; these together form an inverted V, the limbs of which are made to encircle the upper segment of the breast. The remaining portions of the incision are marked out, without cutting through the whole thickness of the skin as is done with the upper portions of the incision, the knife being merely SURGERY OF THE MAMMARY GLAND 273 permitted to cut through the epidermis. These superficial markings simply continue the upjier incisions around the breast, and are made to converge at a point about two inches below its lower margin; whence a single incision is carried downward and inward in the midline of the rectus abdominis / f f Fio 36.— Showing the skin incision. The dotted lines indicate that part of the skin incision that is made after the axilliary dissection has been completed. (Deaver and McFarland's "The Breast": courtesy of P. Blakiston s Son & Co.) muscle to a point midway between the tip of the xiphoid cartilage and the umbilicus. The portions of the incision above the breast are deepened until the fascia covering the pectoralis major muscle is exposed. The skin flaps outUned in this manner are then reflected (Fig. 37), the median one being dissected well beyond the edge of the sternum and in an upward direction as high as the upper border of the clavicle. The anterior portion ••274 A'1'I.AS OF OPKHA'rnE GYNiECOLUGV of the deltoid iimsele is exposed in this dissection. The hiteral flaj) is (Hs- sected outward and backward well bej'ond the anterior edge of the lutissinius dorsi muscle. "Having reflected the flaps, the exposure of the axillary space is begun Fio. .'!7. — The upper piirtinn c,f tin .-kin flnp- lii.\ i 1.. . i. i . II. . I r.l :rii.l I li. Imniri :il ,1 1 ;m liunnt of the peotnralis major muscle has heen freed, allowing the musric to retrad tiowiiward and iiiwanl. It will he observed that tfie insertion of both tlie elavicular and sternal lieads of llie peetoralis major niusek- }iave been freed from the htimerus. The cephalic vein is .seen in its norni.al pesition in the deltoper-toral grottve. (Deaver and McFarland's "The Hreast": courtesy of P. Fiiakiston's .Son & Co.) by cutting the tendon of the peetoralis major muscle close to its humeral attachment. "The muscle is removed in toto. When the muscle is freed from its insertion on the humerus, the sternal fibers recede downward and inward; the clavicular head, on the contrary, continues to obscure, to a slight extent, the infraclavicular region. The next step in the operation is to separate SURGERY OF THE MAMMARY GLAND rhe the latter portion of the muscle from its line of origin on the clavicle, cephalic vein is in danger of injury at this stage of the dissection. "The second layer of the anterior axillary wall consisting of the pecto- ralis minor muscle and costocoracoid membrane is now completely exposed. "The index finger is pushed through the costocoracoid membrane FiQ 3S— The pectoralis minor muscle has been elevated on the finger: the cephalic vein is seen above the tin of the finKCr. The cephalic vein and the acromiothoracic vessels are seen piercing the costocoracoid mem- Zne. which^has been pie'iced by the finger in elevating the nmsde The l°n\«''°^»'''^^^°d, .=!""^''°''!,°;^^1J arteries lie posterior to the finger, so that there is little danger of wounding them when 'hepeetoralisininor muscle is detached from the coracoid process of the scapula. (Deaverand McFarland s The Breast . courtesy P. Blakiston's Son & Co.) between the pectoralis minor muscle and the acromiothoracic artery, and close to the coracoid process of the scapula (Fig. 38). The tendon of in- sertion of the muscle is then raised on the finger, care being taken to exclude the long thoracic artery which arises behind it. and the tendon severed with a jjair of blunt scissors. 276 ATLAS OF OPERATIVE GYNECOLOGY "WTiile strong traction is made to lift the muscle away from these structures, the tendon of the muscle is grasped with a jiair of ha'mostats to catch the veins which traverse its substance, and a branch of the long thoracic artery which frecjucntly enters it near its scapular attachment. All danger of wounding the adjacent vessels is obviated by using the finger as a guide in cutting the muscle. The axillary space is now fully exposed. "Dissection of the axilla is the next step in the operation; this begins at the apex. The costocoracoid membrane is cut near to the cla\'icle, thus exposing the subclavius muscle and the deep infraclavicular triangle. "The axillary sheath is opened with a sharp knife, as near to the apex of the axilla as possible, and is stripped from the subclavius muscle and the axillary vessels from above downward. This is best accomjilished by gauze dissection, wiping the areolar tissue and the contained h'mphatics away from the vessels and nerves. "Every vestige of fibrous and fatty tissue must be removed, especially from the upper inner portion of the axillary space. This dissection exposes the branches of the axillary artery at their points of origin, the termination of the tributaries to theaxillary vein, and the terminal portion of the cephalic vein (Fig. 39). "The arteries encountered from within outward are the superior thoracic, the alar thoracic, acromiothoracic, long thoracic, and subscapular. The superior thoracic, usually a small vessel, arises high in the axilla, so that it is usually bej'ond the area of dissection. "The other vessels named, with the exception of the acromiothoracic and the subscapular, are to be ligated and cut. As a rule, we preser\e the latter vessel, although its sacrifice may be necessary in order that the tissues surrounding it may be removed. "The veins accompanying these arteries, except the cephalic vein, are tied near their terminations and cut. The anterior thoracic (external and internal) nerves have been severed in reflecting the pectoral muscles. "With the completion of the foregoing tlissection as far outward as the origin of the subscapular artery, it remains to remove the fascia and fat surrounding this vessel and its branches. The dissection begins above the teres minor muscle, is carried downward removing the fascial covering of the muscle, the teres major, subscapularis, latissimus dorsi, and serratus magnus muscles. In cleansing the latter, care must be taken to preserve the external thoracic nerve (nerve of Bell) which runs over it in the line of the mid-axilla. The middle or long subscapular nerve which supplies the latissimus dorsi muscle must be preserved. This is not difficult to do if gauze dissection is adhered to in cleansing the costal surface of the muscle. "The dissection of the axilla being finished, the lower part of the field of operation is exposed by continuing the reflection of the skin flaps (Fig. SURGERY OF THE MAMMARY GLAND 277 40). The incisions outlined on the skin in the manner described above are deepened until the deep pectoral fascia is exposed. Dissection of the lateral flap is made fifst, and exposes the lower digitations of the serratus mag- FiG. 39. — The pectoralis minor muscle has been freed from the coracoid process of the scapula. The apex of the axilla has been cleansed, and the contents are seen reflected downward and outward. In the upper portion of the wound the clavicle and subelavius muscle are visible and emerging from beneath them are the axillary vessels and nerves. iDeaver and McFarland's "The Breast"; courtesv P. Blakiston's ."^on & Co.l nus muscle and some of the upper digitations of the external oblique muscle; as well as the outer half of the upper portion of the sheath of the rectus abdominis muscle. A slight amount of bleeding, from the lateral -278 ATLAS OF OPERATIVE GYNiECOLOC.Y branches of the intercostal arteries is encountered (hiring the reflection of the hiteral thip. "The median flap is now dissected well beyond the edge of the sternum. No attention is paid to the bleeding that results, at this time, from the i Fig. 40. — The axilliary dis.^erti(in is conipletoil with the exception of that portion in tlie region of the lower posterior axilliary fold. The skin flaps have been roinpletely reflected. (Deaver and MeFarland's "The Breast": courtesy P. Blakiston's Son & Co.) perforating branches of the internal mammary artery, as these branches will be cut a second time when the pectoralis major muscle is removed. The breast is now grasped in the left hand and traction is exerted, putting the pectoral muscles on the stretch; they can then easily be freed from their attachments to the chest wall. The axillary contents, the i:iectoral muscles, and the breast are removed as one mass (Fig. 41). SURGERY OF THE MAM.MAItY GLAND 279 "In cases in which the carcinoma involves the lower outer quadrant of the breast, the sixth, seventh, and eighth digitations of the serratus magnus muscle must be reni()\ed. lie. 41. — Ihc breast and pectciriil jiiiisilcs an- jij the grasp of the left haiui ami arc bciag dissecteil from the chest wall. It will be observed that the upper portion of the rectus abdominis sheath has been removed. The long thoracic nerve remains intact, (Deaver and McFarlami's "The Rreast ": courtcsv P. Blakiston's Srtn i!t Co.) "Removal of the fascia covering the upper digitations of the external oblique muscle, together with the upper part of the anterior rectus sheath, completes the dissection (Fig. 42). 280 ATLAS OF OPERATI\'E GYNECOLOGY "The few bloeding points are ligatcd with catgiit. A counter incision is made in the ]iosteri<)i' Hap, in sucli position that with the patient lying Fig. 42. — Dissection completed. The long thoracic and long subscapular nerves are well shown The serra- tus magnus muscle has in part been removed. The illustration shows that the subscapular vessels have been re- moved; this is unnecessary in the majority of instances. The fascial sheaths covering the external oblique and rec- tus abdominis muscles have been in part removed. (Deaver and McFarland's "The Breast"; courtesy P. Blakis- lon's Son & Co.) on her back the opening will be in a dependent position and just in front of the free edge of the latissimus dorsi muscles; in some instances the opening is carried through the muscle. SURGERY OF THE MAMMARY GLAND 281 "A fenestrated drainage tube, one-(iuarter inch in diameter, is placed in the axillary space, care being taken that it does not come in contact with the axillary vessels and nerves. Having determined the proper position of the tube, it is anchored to the skin edges of the counter-opening with a single suture of silkworm gut. "Before closing the wound, a final examination is made for bleeding points, and hot compresses are applied to arrest the slight oozing that occurs in all cases. The transudation of serum incident to the healing process, together with the slight oozing of blood, justifies the employment of drain- age during the first twenty-four hours after operation. A free exit for the material that collects in the axilla minimizes the danger of infection, hastens the healing process, and also minimizes the strength of atlhesions that form in the axilla. "The arm is now adducted and the flaps approximated with three or more interrupted sutures of silkworm gut, the number depending upon the amount of traction necessary to bring the incisional edges together. The wound can be closed primarily in the great majority of instances without over-stretching, if the flaps are sufficiently undermined." The margins of the skin are united with interrupted sutures of fine silkworm gut, at rather wide intervals, catgut stitches intervening. Sterile pads, made of non-absorbent cotton covered with several thick- nesses of gauze, are placed in the axilla in sufficient number to hold the arm at an angle of approximately 70 degrees. The incision is covered with sterile gauze and a figure-of-eight bandage is applied to include the shoulder of the affected side, the axilla, and the chest. This bandage, which should be six inches in width, is composed of eight thicknesses of gauze. The preparation of the field of operation is conducted on the same jirin- ciples as the preparation of the abdomen for a section. The patient receives a full bath the night before operation, is clatl in clean night clothes, and put into a bed with clean sheets. Directly before the operation the skin is cleansed by a soap solution and soft pledgets of absorbent cotton, rubbing away from the site of the incision. The axilla is shaved. This is followed by ether and then by phenoco solution along the area to be incised. This material is lightly wiped off before the incisions are made, in order to prevent excessive irritation of the edges of the skin wound after the conclusion of the operation. The author prefers a dissecting board for the corresponding arm, padded and covered with a sterile gauze bandage, the wrist being bound to it by a light gauze bandage. The field of operation is jM-otected in the usual manner by sterile towels surrounding it; extra towels are so arranged as to jirotect the patient's mouth and nose and the anaesthetist is prepared like one of the surgical assistants with sterile cap, gown, and gloves. 0S2 ATl.AS OF OPERATIVE GYN.ECOUXiV On acrount of the long; exposure of the unprotected chest, the operat- ing room should be unusually warm, and as the patient is transported from the operating room to her bed special precautions must be taken to ]ire\ent a chill. The after-treatment of the operation may have to Ijc that of any serious surgical procedure— artificial heat under an electrical cabinet, stimulating drugs, and possibly intra venus salt solution. The anaesthesia should be general, and the liest residts have been secured by the drop ether method. As soon as the patient recovers from tlie anaes- thetic, she is arranged in l)ed in a semi-recumbent posture with tlie arm corresponding to the operated side supported on jiillows. The dressing of the woimd is renewed in twenty-four hours; the drainage tube remo\ed in one to three days, dependent on the amount of ilischarge. The removal of the stitches is begun on the fom-th or fifth day and completed within seven to ten days. The patient should be able to get out of bed by the end of a week and often sooner, with the arm sujjported by a sling. Early movement of the arm should be encouraged to avoid disability as much as possible. It is astonishing to see what mobility the arm possesses after the removal of the pectoral muscles. CEilema which may occur shortly after the operation is apt to disappear; but, if it makes its appearance only later on, it is possibly a sign of recurrence. As soon as the wound is healed, the patient should be subjected to X-ray treatment at the hands of a specialist, as a preventive treatment. Local recurrences should be carefully watched for and, if small in area, might be aborted by the use of the actual cautery. The operative treatment of recurrent growths is hoi)eless, and should be avoided unless the removal of sloughing masses may contribute somewhat to the patient's comfort. Recurrence or extension in the supraclavicular gland cannot be dealt with successfully by operation, unless the glands are small in size, few in number, and easily removed. The only hope for extensive regional recurrences (and that is a forlorn one) is the use of X-ray and radium. If there is not recurrence within a year, there is great hope of permanent cure ; for usually recurrence manifests itself within the first six months. If the patient shows no sign of recurrence in three years, perma- nent cure is pretty certain. It is not so necessary to observe the five-year interval as it is in cancer of the uterus, but late recurrences beyond the five-year period have been recorded, both regionally and as metastases to distant organs. (6) Pl.\stic Operations on the Breast. — A, Operative Treatment for Inverted Nipple {Umbilication of Nipple). — The term "inverted nipple" SURGERY OF THE MAMMARY GLAND 283 is employed when the nipple is represented by a sort of crater-like depres- sion; the word "umbilication" is used when the nipple projects some- what in the center of a depression below the level of the skin over the rest of the breast. Operations for these conditions have been devised by Axford, Kehrer, and Williams. The principle of these operations is the same. It consists of excising crescentic-shaped flaps of skin and fat down to the fascia, around the nipple outside the areola, and then either puckering the fascia by a circular purse-string suture as in Axford's technic, or in uniting the skin, after excision of crescentic flaps around the nipple, so as to exert traction Fig. 43 — Virginial hypertrophy of the breasts. (Deaver and McFarland's "The Breast' '; courtesy P. Blakiston's Son & Co.) upon the depressed nipple and to build up a wedge of cicatrix and exudate around its base. In both kinds of operation, the nipple is seized by a vol- sellum forceps and pulled out before the sutures are inserted. For true inversion of the nipple these operations are not always success- ful, and for umbilication of the nipple they are very rarely necessary. If a persistent effort is made to draw out the nipple by suction with a breast pump for several weeks before the woman's expected confinement, a plastic operation on the nipples — a so-called mamillaplasty — is almost never necessary. I have never seen a case myself in which operation was required, in order to enable the woman to nurse her baby: which is the only purpose for which such operations should be considered. There is no occasion for surgical interference with the nipples for purely aesthetic reasons, as this 19 384 ATLAS OF OPERATIVE GYNECOLOGY portion of the breast is not exposed to the public gaze. If operative treat- ment is decided upon, it can be performed under local anaesthesia. Fio. 44. — Bilateral hypertrophy of breasts. (Dr, \V. T,. Clark.) Fig. 45.— Hypertrophy of the brea.^t. (Dr \V. I,. Clark.1 In these days, however, of successful artificial feeding of an infant, it must be a rare case indeed in which surgical treatment of nipples that do not respond to persistent traction is really necessary or desirable. SURGERY OF THE MAM.MARY GLAM) -285 B. Operative Treatment of Mammary Hypertrophy (Figs. 43-46). — A degree of mammary hypertrophy demanding operati\e treatment is rare. Deaver and MacFarland were able to collect only one hundred and eighty- two cases. Before resorting to operation, several facts must be carefully considered: (1) The disease often affects young women from puberty, and the mutilation and the disability as regards lactation must be taken into account. (2) The disease not infrequently undergoes a spontaneous cure, as mj^sterious as its occurrence. (3) Lactation sometimes results in invo- lution of the hypertrophied gland. All these considerations must be care- full}' weighed. In exceptional cases, however, there is no room for doubt as to the nec- essary treatment — if the size and weight are so enormous as to make loco- Flu. 40. — Hypertrophy of the breast after operation, (Dr. W. L Clark.) motion imijossible; or if the drain on the woman's s^ystem, for the nutrition of the huge mass of tissue constituting the breasts, results in extreme weak- ness and emaciation of the individual; or if the patient demands the removal of the hypertr()]:)hied breast, or breasts, irrespective of the possibility of spontaneous cure or of future lactation, the surgeon need not hesitate to perform the operation. The usual surgical treatment is amputation, but it is possible to get rid of the superfluous size and weight of the breast without disfigurement to the patient and with a possibility of preserving enough breast tissue perhaps to permit lactation. This can be accomplished ])y making a double ellii)tical incision, through the skin, lea\'ing the nipple intact in the middle of the area ^286 ATLAS OF OPERATIVE GYNECOLOGY marked out. If the median upper bar of this eUiptical incision comes close to the nijijile and curves quite sharply downward both to the inner and the outer sides, and if all the superfluous skin above that jjoint is removed, it is possible to remove a large flap of the enormously stretched skin over the upper, outer surface of the breast, and to imite the woimd in such a manner that the sear is not visible in ordinary evening dress. The bulk of the breast is removed as in the Warren operation, but a large area of skin is necessarily taken away below the nipple with the superfluous portion of the breast. If both breasts must be operated upon, which is necessary in the major- ity of cases, it may be advisable to remo\e or to ojjerate upon one at a time, in order to lessen the severity of the operation ; also because sometimes the removal of one breast results in the involution of the other one. C Operalion for Pendulous Breast; Mastopexy. — Pendulous breasts without hypertrophy almost never require operati\'e treatment. A properly made brassiere will suffice for their support, but there have been recorded cases in which an operation seemed necessary. The easiest way to dispose of the difficulty is by amputation, but operations have been devised for the correction of the pendulous breasts without mutilation. These operations consist in fixation of the mammary gland to the deep fascia of the ]iect oralis major or to the costal cartilages, as in the operation described by Ciirard. The operation is begun by the Thomas-\^'arren incision. The breast is then dissected off from the fascia of the pectorahs major for something like half the extent of its base. Having been displaced upward as far as desired, and possibly reduced somewhat in size by the removal of a portion of the breast tissue, the fixa- tion is accomplished by either silk or chromic gut sutures, fastening the breast to the costal cartilages or cartilage as high as necessary, and utilizing the fascia of the i)ectoralis major for the outer segment of the breast. Suc- cessive rows of interrupted sutures would seem to me the most efficient way of fixing the breast in its new position, although I have no personal expe- rience with the operation and do not know any of my colleagues who have. After the operation it would obviously be necessary to support the breast by a broad bandage encircling the chest below the mammary gland, and supported by straps over the shoulder. INDEX Abdominal section, after-treatment of, 251 for acute ana-mia, 253 for nausea, 251 for shock, 252 for tympanites, 251 galvanization, 252 re-opening of abdomen, 252 for vomiting, 252 internal bleeding, diagnosis of, 252 Murphy drip proctoclysis, 251 preparation for, 13 catheterization, 19 cleansing the skin, 13 Hirst's method, 14 MacDonald's method, 18 Martin's method, 18 thrombosis of mesenteric veins complicat- ing, 252 wound, closure of, 25 Abscess, mammar>', surgical treatment of, 253 After-treatment of abdominal section, 251 of complete tear operation of perineum, 46 of plastic operations, 252 Air-cushion for operating table, 5 Alexander operation for retroversion of uterus, disadvantage of, 104 Anipmia, acute, treatment of, following opera- tion, 253 AnEBSthetics, 19 Antepartum fcetonietry, 248 Anterior vaginal hysterotomy, 127 Anus vestibularLs, operation for, 149 Bandl's operation for ureteral fistula, 101 Bartholin's gland, removal of, 154 Bleeding, internal, after-abdominal section, diagnosis of, 252 Breast, amputation of, for hypertrophy, 285 for malignant disease, 269 after-treatment, 282 X-ray, 282 anaesthesia, 282 Deaver's technic, 272 closure of wound, 281 dissection of axilla, 276 dressing over wound, 281 incision, the, 272 insertion of drainage tube, 2S0 removal of breast, 278 of pectoralis major muscle, 274 Breast, amputation of for malignant disease, Handley's rules regarding inopera- bility, 270 oedema, occurrence of, after, 282 preparation of patient for, 281 recurrent growths, 282 for non-malignant conditions, 265 anaesthesia in, 267 dressing and after-treatment, 267 preparation for operation, 266 technic of, 265 subcutaneous, with preservation of nipple, 267 dressing after operation, 268 Thomas-Warren incision, 267 pathological conditions of,operations for,cys- tic or sohd tumors, 257 papillomata, 257 possibility of lacteal fistula, 257 of malignancy, 257 supernumerary glands, 257 surface growths, 257 Thomas-Warren incision, 258, 260 pendulous, operation for, 286 technic of, 286 plastic operations on, 282 for hypertrophy, 285 for inverted nipple, 282 for pendulous breast, 286 resection of, 260 Cesarean section, 225 conservative, 225 hypodermics of pituitary extract and ergot ine during, 226 removing the feet us, 226 separating the placenta, 228 suture of uterine wall, '226 technic, 225 extraperitoneal, 235 danger of infection, 237 injections of pituitary extract and ergo- tine, 246 mortality statistics, comparative, 235 panhysterectomy with, 235 Sellheim's scoop, 237 technic, 236 delivery of head, 237 of placenta, 237 suturing, 237 iS7 '288 INDKX Csesarean section, Form's, 234 in severe infection, 234 supravaginal amputation of uterus with extraperitoneal fixation of cer- vical stump, 234 with peritonealization anil sinking of cervical stum|), 234 Saenger's, 22r) superiority of, to imlnotomy, 246 tympanites following, treatment of, 2.')1 Cancer of breast, Handley's rules regarding inoiKMability of, 270 operation for, 209 Carcinoma of uterus, importance of early diag- nosis and treatment, 200 panhysterectomy for, 197 Catheter for abdominal section, 19 for vaginal o|H'rations, 12 C'atheterization following operation for vesico- vaginal fistula', 94 in vaginal operations, 12 Cervical canal, dilatation of, 120 anterior vaginal hysterotomy, 127 electrolysis in, 128 instrumental, 126 for mechanical dysmenorrluva, 120 for sterility, 120 in pregnancy, 127 Cervix, injuries of, 85 oijerations for, 85 amputation, 85 Hegar's, 85 caution in inserting sutures, 85 Emmet trachelorrhaphy, 85 suture material in, 80 Clamp, ISigwart, S Somers, Wertheim, 7 Cleveland's dilator, 10 (.'losure of abdominal wound, 25 Coffey operation for retroversion of uterus, dis- advantages of, 106 Colpodeisis, 95 Continence, establishing of, without a urethra, 96 (Cystic or solid tumors of breast, excision of, 257 Cystoeele, avoidance of, 5() operation for, 70 alterative procedures, 77 avoidance of hemorrhage, 71 deUvery of uterus, 70 gauze drainage avoided, 72 ha>matomata follow'ing, 71 in young women, 77 Goffe's, 77 Cystoeele, operation for, in young women, Hirst's, 77 Mayo Clinic method, 77 narrowing of vagina, 71 protrusion of fundus uteri, 72 separation of bladder and vagina, 70 Watkins', 71 Dakin's irrigating lluid in iiiMinmary abscess, 254 Deaver's oi)cration for amiml.-ition of breast in malignant disease, 272 Dewees' dilator, U) Dilatation of cervical canal, 120 Dilators, 9 Cleveland's, 10 Dewees', 10 for dilatation of cervical canal, I'JO, 127 J. C. Hirst's, 10 Drainage in salpingectomy, 101 wounds, closure of, 25 Dudley operation for anteflexion of uterus, US for ureteral fistula, 102 Dysmenorrhiea, mechanical, dilatation of cer- vical canal for, r20 Ectopic gestation, salpingectomy in, 1()0 Electrolysis in dilatation of cervical canal, 128 for development of uterus, 1*28 Emmet trachelorrhaphy, 85 Equipment and preparation for operations, 1 air cushion, 5 Heineberg's pan and sieve, 7 instrument tray and stand, 5 instruments, (J clamjjs, 7 Somers', dilators, 9 forceps, 7, 8 Gelpi's retractor, 7 hooks, 7 metranoicter, 9 operating room, 1 patient, the, 6 tables, 4 Exsection of vulvar nerves, 153 Fibroid tumors of rountl ligament, dissection of inguinal canal for removal of, 153 Fistula", rectovaginal, 97 ureteral, 101 operation for, 101 Bandl's, 101 Dudley s, 102 Mackenrodt's, 102 Schede's, 101 INDEX 289 Fistulae, ureteral, vaginal operation for, 101 of urogenital tract, 94 operations for, 94 vesicovaginal, 94 between vagina and bladder, 94 following labor, 94 operation for, 94 accidental stitching of ureter in, 97 catheterization following, 94 colpocleisis, 95 incision into anterior bladiler-wall, 96 intravesical hemorrhage after, 97 opening Douglas's pouch, 96 persistence of incontinence after, 97 rectovaginal fistula, 97 restoration of urethra, 96 separation of vagina from bladder, 96 transverse incision over pubis, 96 within cervical canal, 97 Foetometrj', antepartum, 248 Forceps, 7 lion-jawed, 9 Fundus uteri, protrusion of, following inter- position operation, 72 Galvanic current for tympanites after abdomi- nal section, 252 Gelpi's retractor, 7 Gland, vulvovaginal or Bartholin's, removal of, 154 Glands of breast, supernumerary, removal of, 257 Goffe's dissector, 8 Gonorrhoeal infection, salpingectomy in, 160 GjTiatresia, operations for, 140 making of artificial vagina, 149 with absence of vagina and uterus, 141 with genital canal preserved above site of atresia, 141 with retained blood in genital tract, 140 Haemostats, T-shaped, 9 Hand cleansing before operation, 19 Handley's rules regarding inoperability of cancer of breast, 270 Heineberg's pan and sieve, 7 Hemorrhage, avoidance of, in operation for cystocele, 71 intravesical, following operation for vesico- vaginal fistula, 97 Hermaphroditism, operations for, 154 Hernia, closure of inguinal canal for, 153 Hirst's dilator, 10 operating table, 4 Hooks, blunt, 7 Hypertrophy, mammary, o|ierative treatment of, 285 conditions necessitating, 285 Hysterectomy, 184 cuneiform, at fundus of cornua, 201 for carcinoma of uterus, 197 for fibroid tumors, 173 for removal of malignant growths, 197 supravaginal, 184 extraperitoneal, by vaginal route, 207. technic of, 207 removal of both ovaries, 184 technic of, 184 vaginal, 217 extended, for cancer, 217 ligature method of securing broad liga- ment, 217 preparations for abdominal section in, 218 Hysterotomy, anterior vaginal, for digital ex- ploration of uterine cavity, 127 Incontinence of urine following interposition operation, 72 Inguinal canal, closure of, for hernia, 153 dissection of, for removal of fibroid tu- mors of round hgament, 153 Injuries to pelvic floor and perineum, immedi- ate repair objectionable, 30 objections to intermediate operation not valid, 31 repair of, 30 Instrument tray and stand, 5 Instruments, 6 catheters, 12 clamps, 7 dilators, 9 forceps, 7 lion-jawed, 9 Gelpi's retractor, 7 ha>mostats, T-shaped, 9 Heineberg's pan and sieve, 7 hooks, 7 listed by National Defense Committee, 6 metranoicter, 9 Somers' clamp, 6 Interposition, cuneiform hysterectomy in cases of, 201 operation, 70 avoidance of hemorrhage, 71 delivery of uterus, 72 fastening of fundus uteri to vaginal wall, 71 incontinence of urine following, 72 narrowing of vagina, 71 separation of bladder and vagina, 72 Inversion of uterus, 1 18 •290 INDEX Inverted nipple, operative treatment for, 282 Lacerations of genital canal, operation for, 25 Lamp for emergency night work, 1 Loewenstein tables, 5 Mackenrodt's operation for ureteral fistula, 102 Mammary abscess, i)leural involvement in, 2,56 surgical treatment of, 2.53 amputation, 2.5(5 Dakin's irrigating fluid for, 2.54 digital method, 254 early operation advised, 256 in convalescence, 256 irrigation method, 254 gland, hypertrophy of, operative treatment of, 285 surgery of, 25.3 Mastopexy, 286 Metranoicter, 9 Murphy drip proctoclysis, 251 Myoma, cervical, myomectomy for, 175 Myomectomy, 173 abdominal, 173 adhesions following, 174 arguments for and against, 173 iluring pregnancy, 174 for infected myomata, 176 technic of operation, 174 vaginal, 175 treatment of tumor cavity after, 175 Nausea, treatment of, after abdominal section, 251 Nerves, vulvar, excision of, 153 Nipple, inverted, operative treatment for, 264, 282 Nymphomania, operaticm for, 1.53 Oophorectomy, 169 partial, 170 union of wound in, 170 Operating room, 1 color or walls, 4 designed for teaching, 1 emergency night work, 1 not designed for teacliing, 3 University maternity clinic, 1 tables, 4 air cushion for, 5 for Wertheim operation, 5 Hirst's, 4 Loewenstein 's, 5 technic, 25 Ovarian cystic tumors, removal of, 169 intrahgamentary cysts without pedi- cle, 170 involvement of both ovaries, 169 suspension of uterus, 170 Ovary, removal of, 169 Panhysterectomy, 197 disinfection of vagina before, 197, 200 extended, for carcinoma of uterus, 197 after-treatment, 200 during pregnancy, 201 Hirst's technic, 199 importance of early diagnosis, 200 mortality from, 198 technic of, 197 Wertheim, 197 with ca'Sarean .section, 235 Papillomata of breast, removal of, 257 Patient, prejmration of, 6 Pendulous breast, operation for, 286 Perineorrhaphy, after-treatment of, 31 rational, 30 Perineum, central perforation of, operation for, 47 complete tear of, operation for, thniugh sphincter ani, 46 after-treatment, 46 contingencies, 47 following failure of previous attempt, 47 preparation for, 46 steps of operation, 46 suture material, 46 with involvement of other structures, 46 Piper's method of irrigating infected .sinuses and drainage tracts, 2.54 Plastic operations, after-treatment of, 2.52 on breast, 282 resection (see Thomas-Warren operation), of breast, 260 Porro's cesarean .section, 234 Pregnancy complicating cancer of uterus, 201 Preparation for operations, 1 abdominal section, 13 anaesthesia, 19 hand cleansing, 19 of vagina, 10 Proctoclysis, Murphy drip, 251 Prolapse of uterus, 118 Pruritis vulvae, operation for, 153 Pubiotomy, "246 advocated only for occasional operator, 248 after-treatment in, 247 danger of compound fracture of pelvis, 248 INDEX 291 Pubiotomy, inability to extract child after, 248 inferiority of to caesarean section, 246 morbidity after, 247 superiority of to sjinphysiotomy, 246 technic of, 247 treatment during convalescence after, 247 Rectocele, operation for, 30 Rectovaginal fistula, 97 Retractor, Melpi's, 7 Retroversion of uterus, operative treatment of, 102 Reynolds operation for anteflexion of uterus, 118 Room for operations, 1 Round ligament, dissection of inguinal canal for removal of fibroid tumors of, 153 S^enger's conservative cesarean section, 225 Salpingectomy, 158 drainage in, 161 in ectopic gestation, 160 in gonorrha'al infection, 160 operative procedui-e, 159 Salpingitis, acute, abdominal drainage in, 161 Schauta's extended hysterectomy for cancer, 217 Schede's operation for ureteral fLstula, 101 Section, ca?sarean, 225 SeUheim scoop in ca?sarean section, 237 Shock, treatment of, after abdominal section, 252 Sigwart clamp, S Somers' clamp, 6 SpinelU operation for inversion of uterus, 119 Sterility, dilatation of cervical canal for, 126 Sterihzing of sheets and covers, 19 Supravaginal amputation of uterus by abdomi- nal section, 184 extraperitoneal hysterectomy by vaginal route, 207 Suspension operation for retroversion of uterus, disadvantages of, 105 Suture material in abdominal section, 25 in operation for complete tear of perineum, 46 for vesicovaginal fistulae, 94 on cervix, 86 in perineorrhaphy, 30 Suturing after anterior vaginal hysterotomy, 127 after Tliomas-Warren operation, 264 Tables for operation, 4 Hirst, 4 Tables for operation, Loewenstein, 5 Technic, operative, 25 Thomas-Warren operation, 257, 260 advantages of, 261 dressing after, 265 for exploration of mammary gland, 260 for subcutaneous amputation of breast, 267 in suspected cancer, 265 inversion of n'pple, correction of, dur- ing, 264 suturing after, 264 technic, 260 Thrombosis of mesenteric veins following ab- dominal section, 252 Trachelorrhaphy, Emmet, in injuries of cervix, . 85 Transposition operation (see Interposition oper- ation), 70 Tray and stand for instruments, 5 Tumor, fibroid, hysterectomy for, 173, 184 infected, spraying uterine cavity with dichloramin-T for, 176 surgical treatment of, 173 myomectomy, abdominal, 173 vaginal, 175 Tumors, forceps for removal of, 7 of breast, cystic or sohd, excision of, 257 closing the wound, 257 Thomas-\\'arren incision, 257, 260 possibility of lacteal fistula, 257 of malignancj-, 257 removal always advisable, 257 ovarian cystic, removal of, 169 Tympanites, treatment of, after abdominal section, 251 galvanic current. 252 I'mbilication of nipple, operative treatment for, 282 I'reteral fistulip, 101 Urogenital tract, fistulae of, 94 trigonum, laceration of muscle and fascia of. 55 ojieration for, 56 I'terus, anteflexion of, 118 Dudley operation for, 118 Reynold's operation for. 118 carcinoma of, importance of early diagnosis and treatment, "200 panhj-sterectomy for, 197 pregnancy complicating, 201 ill-developed, electrolysis for. 128 inversion of, 119 operative treatment of, 119 idi INDEX I'terus, operative treatment of inversion of, proper time for. 119 Spinelli operation, 119 laceration or over-stretching of pigments of, causes of, 55 prolapse of, 118 operative treatment of, 118 retroversion of, epilepsy associated with, 103 operative treatment of, 102 Alexander oi)eration, 104 causes of failure in, 103 Coffey operation, lOG Hirst's method, 105 advantages of, 105 success of, 104, 10(j relative advantages of, over pessaries, 102 suspension operation, 105 sterility due to, 103 symptoms of, 103 supravaginal amputation of, by abdominal section, 184 with extraperitoneal fixation of cervical stump, 234 with peritonealization and sinking of cervical stump, 234 suspension of, in myomectomy, 174 in oophorectomy, 170 Vagina, artificial, operations for, 149 closure of, operation for, 95 Vaginal operations for ureteral fistula, 101 Vaginal operations for ureteral fistula, Bandl's, 101 Dudley's, 102 Mackenrodt's, 102 Schede's, 101 preparation for, 10 catheterization, 12 cleaning the field of operation, 11 Vaginal wall, anterior, injuries of, due to labor, 55 repair of, interposition operation, 70 delivery of uterus, 70 separation of bladder and vag- ina, 70 involving supports of bladder, 55 Vaginismus, dilatation with Hegar dilators for, 135 operation for enlarging the vaginal introitus in, 135 Vesicovaginal fistulse, 94 Vulva, operations on, 153 in pregnancy, 153 X'ulvar nerves, excision of, 153 Vulvovaginal gland, removal of, 154 Wertheim clamps, 7 operation, 197 clamps for, 7 table for, 5 panhysterectomy, 197 Woimds, abdominal closure of, 25 drainage after closure of, 25 «, Date Due JA^ ; Fes : I 1977 J AN 3:, REC'O ■ (^ CAT. NO. 23 233 PRINTED IN U.S.A. »»'«'^"' 000 630 525 a Hirst. Atlas of operative gynecology WP17 H669a 1919 CALIFORNIA COLLEGE OF MEDICINE LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664