A System of Operative Surgery Part 18

STEWART, J. E. F. _Australian Medical Gazette_, 1906, xxv. 446.

WALDO, R. W. _American Journal of Obstetrics_, 1906, liv. 553.

WILSON, H. P. C. _Trans. American Gynecological Society_, 1884, ix. 94.

=Teta.n.u.s.= This dread complication of wounds occasionally occurs after ovariotomy, and during the 'reign of the clamp' it was especially frequent in Germany (Olshausen). Cases have been reported in England, and teta.n.u.s has been noticed to affect patients who have been ovariotomized in rooms recently plastered.

Since Kitasato demonstrated the bacillary origin of teta.n.u.s poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the teta.n.u.s bacillus.

Teta.n.u.s, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the teta.n.u.s bacillus was detected in some wallaby tendon employed to suspend the uterus.

Teta.n.u.s has also been traced to infected catgut employed in cholecystotomy (1905).

Ed. Martin reported the occurrence of teta.n.u.s after v.a.g.i.n.al fixation of the uterus and colporrhaphia anterior. c.u.mol-catgut was employed.

Menzer has recorded a similar case which occurred in Duhrssen's Klinik (1901). The ligatures were of catgut.

Mallet refers to two post-operative deaths from teta.n.u.s. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material.

In practice it is important to remember that teta.n.u.s arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling.

Teta.n.u.s occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind.

REFERENCES

DORSETT, W. B. Two fatal cases of Teta.n.u.s following Abdominal Section due to Infected Ligatures, &c. _Am. Journ. of Obstet._, 1902, xlvi.

620.

MALLET, G. H. Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.

MARTIN, ED. Postoperativer Teta.n.u.s (with references). _Zent. f. Gyn._, 1906, x.x.x. 395.

MEINERT. Drei gynakologische Falle von Wundstarrkrampf. _Arch. fur Gyn._, 1893, xliv. 381.

MENZER. Teta.n.u.s Infection after v.a.g.i.n.al Fixation of the Uterus.

_Zeitsch. f. Geb. u. Gyn._, 1901, xliv. 517.

OLSHAUSEN, R. Teta.n.u.s nach Ovariotomie Billroth-Lucke's. _Handb. der Frauenkrankheiten_, 1877-9, ii. 367.

TAYLOR, H. Teta.n.u.s after Hysterectomy. _Am. Journ. of Obstet._, 1908, lvii. 574.

=Injury to intestines.= Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where cliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut.

Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the r.e.c.t.u.m runs a great risk of being damaged.

In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis.

It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed.

In sewing the abdominal incision the intestines have been p.r.i.c.ked with a needle, and in some instances the bowel has been accidentally included in the sutures and sewn to the abdominal wall. On one occasion while securing a very long incision with through and through sutures, while pa.s.sing the needle through the abdominal wall, it broke, and the broken end came with great force against the anterior wall of the stomach and tore a hole in it. This I secured at once with suture and the accident had no bad consequences.

An unrecognized wound of the bowel in the course of a pelvic operation is almost certainly fatal. Accidental injuries, such as punctures and cuts, require immediate suture, and I have never known any harm follow.

On the other hand, ragged tears in thickened and inflamed bowel require careful consideration in order to spare patients the inconvenience and distress of faecal fistulae.

In regard to small intestine a very small opening may occasionally be safely secured with fine silk, but in most cases it is wiser, if the bowel is thickened and inflamed around the hole, to resect well wide of the damaged portion and join the cut ends (circular enterorrhaphy).

Holes low down in the r.e.c.t.u.m are difficult to suture securely. These should be treated by drainage, using a wide rubber drain; the convalescence will be tedious, but the fistula will close.

It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a faecal fistula which had followed an ooph.o.r.ectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube pa.s.sed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble.

If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or caec.u.m he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.)

=Intestinal obstruction.= It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:--

1. Adhesions to the abdominal wound.

2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.

3. Strangulation around an advent.i.tious band.

4. Obstruction due to an overlooked cancer in the colon.

5. Strangulation in a sac formed by a yielding cicatrix.

The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.

The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.

From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up like a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the suprav.a.g.i.n.al cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.

The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or ooph.o.r.ectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment.

=Perforating ulcer of the stomach and small intestine.= A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident.[2]

[2] Bland-Sutton, J. On Perforation of the Stomach and Small Intestine as a Sequel to Ovariotomy and Hysterectomy. _Journ. of Obstet. and Gyn.

of the British Empire_, 1909, xv.

=Injuries to the bladder.= This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk.

The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap.

=Injuries to the ureter.= Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in v.a.g.i.n.al hysterectomy, because the vesical segments of these ducts come into close relationship with it.

British surgical and gynaecological periodical literature contains very little that concerns ureteral injuries, but it is only necessary to look into the pages of the _Zentralblatt fur Gynakologie_ to find ample evidence that the integrity of the ureters is frequently sacrificed to modern pelvic surgery.

Blau published statistics from Chrobak's Klinik in Vienna showing that in the interval January, 1900, to January, 1902, the ureters were injured fifteen times. In total hysterectomy seven times; in the course of ovariotomy on three occasions.