Part 14 (1/2)

FRIEDEMANN, G. Die Unterbindung der Beckenvenen bei der pyamischen Form des Kindbettfiebers. _Munchener Med. Wochensch._, 1906, liii. 1813.

LENDON, A. A. Puerperal Infection, Thrombosis: Ligature of the Right Ovarian Vein. _Australian Medical Journal_, 1907, xxvi. 120.

MICHELS, E. The Surgical Treatment of Puerperal Pyaemia. _Lancet_, 1903, i. 1025.

STEVENS, T. G. The Bacteriological Examination of a Thrombosed Ovarian Vein (following Hysterectomy). _Trans. Path. Soc._, li. 50.

TRENDELENBURG, F. Ueber die chirurgische Behandlung der puerperalen Pyamie. _Munchener Med. Wochensch._, 1902, xlix. 513.

CHAPTER X

OPERATIONS FOR INJURIES OF THE UTERUS

Injuries of the uterus fall into six groups:--

1. Gynaecological injuries.

2. Obstetric injuries.

3. Injuries to the pregnant uterus.

4. Injuries to the pregnant uterus in the course of abdominal operations.

5. Bullet-wounds of the pregnant uterus.

6. Stab-wounds of the pregnant uterus.

=Gynaecological injuries.= The simplest and certainly the commonest accident is perforation of the uterus with a sound, dilator, or forceps in the operation of curetting. Many cases are known in which the uterus has been perforated by clean instruments of this cla.s.s and the patients have suffered no inconvenience.

On the other hand, when the sound or the uterus is septic, perforation of the uterus has been followed by a rapidly fatal peritonitis; indeed, some of these injuries may prove as lethal as a snake-bite.

Occasionally very serious consequences follow simple perforations by dilators and curettes; this has induced some gynaecologists to urge that if, in the course of dilatation and curettage of the uterus, a rupture or perforation of the uterine wall occurs, it is better to perform a cliotomy and a.s.sure oneself of the safety of the patient than to hope that no untoward result will ensue.

This advice is too sweeping. When the perforating instrument is clean, and there is little or no bleeding, the case may be left to itself; if untoward signs arise, cliotomy should be performed. Sometimes a pelvic abscess occurs as a sequence to the accident, and will require evacuation through the v.a.g.i.n.al fornix, or, perhaps, by means of an incision in the flank. Verco found a piece of a curette, 2-3/4 inches long, in an abscess cavity behind the uterus. The patient had been curetted two weeks previously.

A perforation, or a rent in the uterine wall, in the course of curetting, is a serious accident when the operator is unaware that such has happened, and proceeds to flush out the uterine cavity with poisonous antiseptic solutions, especially perchloride of mercury.

Cases are known in which, under these conditions, the woman has died in the course of a few hours.

Injuries, in the course of instrumentation of the uterus, are not always mere perforations; some are wide rents--and this is an especial danger in removing sessile submucous fibroids (v.a.g.i.n.al myomectomy). _A serious complication of tears or rents of the uterine wall, whether the uterus is gravid or non-gravid, is extrusion or prolapse of the intestine._ It is also remarkable that in several reported cases the pract.i.tioner has mistaken the intestines for 'secundines', even in unimpregnated uteri, and has withdrawn them, and even cut lengths of intestine away, before recognizing his error.

In one case of this kind, where a pract.i.tioner had withdrawn and removed several feet of intestine through a rent in the course of a curettage, I performed cliotomy, closed the hole in the uterus, joined the cut ends of the bowel with sutures, resected the mesentery belonging to the removed bowel, and thus saved the patient's life. In another case, where a pract.i.tioner had torn the uterus during curettage and intestine appeared in the v.a.g.i.n.a, there was such free bleeding that I found it prudent to perform subtotal hysterectomy. This patient also recovered.

Successful operations of this kind have also been performed by Werelius and Nixon Jones.

Palmer Dudley relates that on one occasion, in curetting a recently gravid uterus, he tore the posterior wall without being aware of it, and withdrew eight inches of intestine, thinking it to be secundines; he recognized the error, and pushed the intestine back through the opening in the uterine wall. The patient recovered, and subsequently had two successful pregnancies.

These cases show how impossible it is to recommend any hard and fast lines of treatment. Much depends on the circ.u.mstances of the case, the character of the injury, and above all on the experience and resourcefulness of the pract.i.tioner.