Annual Meeting of the American Surgical Association

1897 Boston Medical and Surgical Journal  
seven headings: (1) iu intractable, often-recurring hemorrhage without discovered fibroid, or malignant disease when all the usual remedies including curetting have failed ; (2) in all cases of malignant disease wheu the operation is possible without permanent injury to the bladder or bowels ; (3) under certain circumstances in cases of fibroid tumor ; (4) iu cases of uncontrollable complete prolapse, particularly after the change of life, when pessaries and all the usuul operations have failed
more » ... rations have failed ; (5) in cases of incurable chronic inversion ; (6) iu cases of infection when the removal of the Fallopian tubes affected with salpingitis has not cured the patient ; (7) to cure puerperal sepsis where the diagnosis is as certain as it can be. Dr. Homans then described two cases iu detail, as examples of the first class. The first case was one of chronic hyperplastic endometritis, and the other one was where an undiscovered fibroid exiBted in the right cornu aud gave rise from time to time to severe hemorrhage. He then described in detail the technique of hysterectomy, and stated that the technique for malignant fibroid disease of the uterus, by the vaginal route is the same as for the removal of the nou-malignant uterus, while the technique of tho removal of the uterus on account of cancer will vary according to the type of the disease. Hysterectomy is indicated in cases of fibroid tumor which cannot be enucleated either from the inside or from tho outside of the uterus. He then fully described the technique of abdominal hysterectomy, where it was decided to leave the neck and ob. The author objected to the expression " the uterus, and its appendages," and suggested instead, " the ovar-ieB and their appendages," the ovaries being the reigning powers in the generative organs. The vagina may be wanting or the uterus may be wanting in cases of imperfect development, but their absence does not imply that of the ovaries, while if the latter are wanting, the other organs always are. In complete hysterectomy the os and the ueck are separated from the vaginal wall before the abdominal dissection is begun. The author then mentioned two cases illustrative of his sixth heading, both of which made good recoveries after operation. He advised the vaginal route in operation for the cure of puerperal sepsis, aud suggi'Sted that a Jacques' self-retaining catheter should be put into the bladder for a few days after every hysterectomy. in discussing this paper, said that the technique of hysterectomy for fibroid tumors varied with the special indications of oach case, and he considered that this operation for suppurative peri-uterine inflammations should be restricted to a very narrow field. The extension of carcinoma of the os occurs in two ways : first, along the vaginal tissue; and, second, into the broad ligament. Abdominal hysterectomy is probably the best iu cases where the malignant growth begins in the body of the uterus. Most cases of malignant disease requiring hysterectomy originate iu the os, and may be removed by the vaginal route when seen early. The author prefers to have the patient anesthetized upon the operating-table, so that as much time as possible may be saved. He is iu favor of the Trendelenburg position, and advises that the abdominal incision be sufficiently large for rapid and accurate work. When the growth is soft and pliable, he suggests that it should be cleansed with a curette and sterilized water and wiped off with a gauze sponge; the firmer margins should be approximated by sutures. He described in detail the steps in the operation, and recommended that silk be used iu securing the ovarian artery. He has discarded the use of iodoform gauze where it is brought in relatiou with the peritoneum, considering it dangerous. Dr. F. E. Lange, of New York, stated that all working iu the dark in these operations should be avoided, and considered hemorrhage and sepsis the two most important dangers. In some cases he has employed a vaginal incision, and in others a crucial incision above the symphysis pubis. But in some cases the fleshy portions do not offer sufficient resistance when brought together, particularly where the patient becomes pregnant after the operation, and has not been so previously. Sometimes it is necessary to use the apron of the large omenlum to prevent the agglutination of the intestine. The para-vaginal and para-rectal incisions consist of the separation of all the soft parts alongside of the rectum, which the author has employed in some cases. The advantage is that the floor of the pelvis is more accessible and provision against infection is also greater, because the drainage takes place away from the peritoneal cavity. Dr. Dudley P. Allen described an operation which he has found to work very well in a number of those cases. Dr. Albert Vander Veer, of Albany, agreed with Dr. Homans as to the places where hysterectomy was advisable. He was in favor of the supra-vaginal or abdominal method in cases where the vagina was comparatively normal, and the cervix in a healthy condition. It gave the operator an opportunity to remove adhesions and to thoroughly explore the pelvis and its contents. He preferred the vaginal route if a cyBtocele or rectocele or prolapse of the ovaries be present. He laid great stress upon the fact that much more could be done for these cases if they were only seen much earlier and promptly diagnosed and treated. In cases of carcinoma confined to the uterus where microscopical examination confirms the suspected symptoms and indications, he advised operation. The surgical route should be by way of the vagina when the uterus is not too large from invasion of the body by the disease, and when no pregnancy beyond the third month complicates it; but he was not iu favor of operation iu all cases of fibroid, as
doi:10.1056/nejm189705271362106 fatcat:2tc63fzphbdvdhrcmjxbdzjeau