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through a small vagina, without using either, and i seldom use more than one retractor in any kind of vaginal hysterectomy.
When this principle is correctly appreciated, the surgeon will recognize that vaginal speculums or retractors are not usually necessary in these operations, and that he can operate more rapidly and more successfully without them. The only retractor needed in curetting or in operations for cervix lacerations is one or two fingers, by which the entire vagina and the cervix may be exposed and plainly seen with a woman on her back, the vulva being drawn to the edge of the table. With a large vagina I have so thoroughly exposed the vagina and the cervix that the medical students at the Kentucky School of Medicine could see every step of the operation, sitting several rows of seats from me. In these operations, having cleansed the vagina by washing with hot water and soap, using a brush or pledgets of absorbent cotton, we need the following instruments and appliances, viz: For curetting: one or two small Pean forceps for fixation of the cervix; one sharp spoon-shaped curette; a curved bulbous-end forceps for tamponing the uterus with iodoform gauze if we prefer tamponing; one reflux irrigation tube if we prefer irrigating the uterine cavity with hot water or antiseptic solutions.
In operations for cervix lacerations we may add to these: one needle holder and two strong, short, sharply curved needles, with large eyes for catgut; and one small, sharp knife with which the laceration on one side may be denuded in one minute by cutting away the tissue in one piece. The catgut is introduced at the lowest part of the denuded cervix and tied, leaving a long end for another knot when the continuous suture has been carried to the apex of the laceration, reversed and brought back to the point of starting.
The interrupted suture has no advantage over the continuous, and by its use we prolong the operation one hundred per cent, and do not get as perfect coaptation, an essential factor in all plastic operations where aseptic union is desired. When the sutures are tied the pressure should be not only evenly distributed but just firm enough to hold the surfaces in apposition, for a certain amount of swelling of tissue occurs after the use of any sort of suture, and if drawn too tightly there will be tissue necrosis, and union will not be perfect. Before 1890 I often experienced trouble because of this fault; but in January of that year my dear friend, Dr. Thomas Addis Emmet, invited me to see his operations at the Woman's Hospital, that I might learn his methods in gyne
cological plastic surgery; and he then repeatedly impressed the wise lesson that sutures must be tied just tight enough to hold the surfaces together, otherwise strangulation would occur.
This same principle applies in all kinds of plastic surgery; and in 1895 I was surprised at the perfect results in getting union of the abdominal wound in laparotomy in the practice of Dr. Emmet's old pupil, Dr. E. C. Dudley, of Chicago, who tied the deep sutures so loosely that the handle of a scalpel could be pushed through the wound between them without force.
Had Dr. Emmet done no other original work, what he has done to perfect the operation for laceration of the cervix, and in other plastic surgery, would be enough to leave his name in letters of gold on the hearts of suffering woman. The uterus should be curetted and cleansed before the lacerated surfaces are denuded, for in all cases where an operation is indicated the endometrium is diseased, usually septic, and if not removed there is danger of wound infection and failure in getting union. Because of this thorough curetting we should guard against cervical stenosis or atresia, which is easily done by the introduction into the uterus, immediately after the sutures are tied, of a small strip of iodoform gauze, to remain for two or three days; and in two or three weeks after the operation introduce a speculum and then, if needed, enlarge the cervical opening by a uterine sound so as to keep the canal of proper size. If the operation is correctly performed, and the after-treatment properly carried out, union will nearly always be perfect, and in a few months the cervix and the os will often be virginal in appearance, and no one could tell that an operation had been performed.
These patients are allowed to use the commode for passing urine and feces, and while I keep them in bed for about one week I believe they would do about as well were I to permit them to sit up and walk about the room after the first day.
I am going to test this in my hospital work at the College Hospital and the City Hospital, for, if this can be done, the operation for cervix lacerations will be so easily made successful that it can be performed in nearly any home, even upon uneducated and ignorant people. After the removal of the gauze I instruct the nurse to irrigate twice daily with a 1 to 3,000 bichloride of mercury solution; but, if the woman is allowed to sit up immediately after the operation and to walk, then I would not usually advise the irrigation, and especially would I decline
to do so if the woinan were ignorant and uncleanly in her surroundings, for the irrigation might then be an efficient means of conveying sepsis.
While the uterine dilator that I devised is probably the most popular in this country and in Europe, I seldom use it or any other forin, for dilation is not often indicated if we use the small spoon-shaped curette, and begin in the cervix and carefully tunnel through the internal os.
By this means we will find that when the operation is completed, and all the diseased tissue in the cervical canal and in the uterine cavity removed, that the opening at the cervico-uterine junction is one quarter of an inch in diameter, abundantly large for all practical purposes. While I nearly always irrigate the uterine cavity with a i to 3,000 bichloride solution and tampon with iodoform gauze, there are excellent operators and recognized authorities who do neither, and they claiin equally good results. The results following curetting for acute gonorrheal endometritis have not been good, and serious complications have followed this method of treatment; nor is it usually the treatinent to curette in acute septic infection following labor or abortion. If the uterus contains decidual membranes or debris these should be removed, but this can be done with few exceptions by the finger.
If the infection is caused by the germs of putrefaction-sapremiathe dead tissue must be carefully removed so as to prevent further formation of chemical poisons in the uterine laboratory; but, as the infection in such cases is very often a mixed infection, a sharp curette might cause serious trouble, in view of the fact that nature may have thrown around and under the septic endometrium a granulation layer that prevents the further ingress or invasion of germs; but, this being destroyed by the sharpe curette, the invading enemy has but little resistance to overcome, and immediately enters the system through the open mouths of the torn veins and lymphatics. So it may be clearly seen that curetting can usually do no good, and may do much harm, in puerperal infection caused by the germs of suppuration, such as the streptococcus, staphylococcus, etc.; for if they have gone beyond the endometrium they can not be removed by curetting, and if perchance they are still confined to the endometrium, the granulation layer may prevent further entrance, but this protection would be destroyed by curetting. In most of these cases frequent intra-uterine irrigation with hot water, or with a 1 to 10,000 hot bichloride solution, etc., is not contra-indicated, and may be followed by excellent results.
As septic infection of the endometrium, of the uterine parenchyma, of the fallopian tubes, of the pelvic peritoneum, of the general peritoneum, or of the entire system through the veins and lymphatics, is a frequent result of retained membranes following abortion, and as these membranes may be removed immediately after the delivery of the embryo or fetus, I wish to insist upon doing so in every case. If the vagina is small, and in cases where the woman is very nervous, it may be necessary to give an anesthetic.
By bimanual manipulations the uterus may be brought down and held immediately behind the pubes, and by one or more fingers the cavity may be dilatated and explored to the fundus and all membranes removed without the use of any sort of an instrument. If we observe aseptic precautions, there is no immediate or subsequent danger in removing these membranes, but if left in the uterus they may cause hemorrhage, possibly fatal, or any degree of septic infection. My experience and observation afford many instances in proof of this statement, and most of my operations for pus tubes or pelvic abscesses, where I perform laparotomy or hysterectomy, are upon women who have had an abortion or gonorrhea. The doctor should be very guarded in giving his consent for a man who has had gonorrhea to marry, for in many of these cases that appear to be well there remains a stricture where latent gonococci are lodged, but the active congestion incident to the too frequent coition in early married life causes these apparently harmless germs to become actively virulent, so that the young wife is infected, but, being ignorant of the nature of her trouble, does not consult her physician, and after the subsidence of the acute stage of the disease she is left with severe pains in the pelvis, etc., and finally the gynecologist is compelled to remove her tubes and ovaries, and may be her uterus, for pus in the tubes or for pelvic abscesses.
Discussion. Dr. C. J. Walton, of Munfordsville: Dr. Wathen's address upon the subject of curetting the uterus and the operation for lacerations of the cervix uteri is highly instructive, and if we should judge by the attention given him it is fully appreciated by this society and shows he is master of the situation. His method of commanding the cavity of the uterus and his ability to control uterine hemorrhage in abortion in the early months of pregnancy is certainly very commendable, as it is accomplished with the finger alone. Most of us who have practiced obstetrics for thirty or
forty years have been compelled, after unavailing efforts to remove the retained placenta to apply the tampon from time to time to control the hemorrhage until the placenta could be removed, and in the early part of my practice I tamponed a patient from day to day for a week. I think, Mr. President, that you will bear me out in this statement, and that we finally succeeded. I shall go away from this meeting with the most implicit confidence in my ability to relieve my patients in every instance at once with my finger as a curette.
Prof. Henry Miller was a great advocate for the use of the finger in obstetric practice, and said, “May my finger never forget its cunning."
Now in regard to his operation for lacerated cervix uteri: in the simplicity and the dexterity of his manipulations Dr. Wathen is so far ahead of any teacher and lecturer upon the subject that I have heard or read after that I regard him as one of the most expert operators living.
[Other discussions could not be procured in time for publication.]
THE EARLY SIGNS OF CONCEPTION.*
BY W. SYMINGTON BROWN, M. D.
None of the early signs of pregnancy are positively reliable. But they are sufficiently so to put the physician on his guard against interference, and in primiparæ some of these signs approach as near certainty as we usually attain in diagnosis.
Reckoning human gestation to last nine calendar months, the signs which occur during the first three months may be called early. They are: (1) Cessation of the menses; (2) Nausea and vomiting; (3) Coloration of the vagina; (4) Changes in the breasts; (5) Softening of the cervix uteri; (6) Hegar's sign; (7) Enlargement and fuctuation of the corpus uteri.
Cessation of the Menses. This is the symptom most relied upon by the laity; but it is really one of the least reliable signs of pregnancy. Amenorrhea may result from so many different causes, such as phthisis, chlorosis, overwork, gluttony, mental impressions, or a premature menopause, that its occurrence proves of little value in diagnosis.
** Read before the Middlesex-East District Society and the Gynecological Society of Boston,
December 8-9, 1897.