1897 BMJ (Clinical Research Edition)  
TUDILBOUVRMA made to open the os with a sound, the uterus being steadied from above and pressed down towards the pelvis. This expedient apparently succeeded, and first the tip, then the whole of the forefinger, was passed; but it was soon evident that an entrance had been made, not within the cervix, but behind it into the peritoneal cavity. In this emergency it was decided that the safety of the patient would be best consulted by Caesarean section, and she was carefully moved for this purpose
more » ... d for this purpose to the Jessop Hospital (a distance of four miles). Consent of patient and husband being given, the operation was commenced. The abdominal and uterine incisions were made in the usual way. Both child and placenta were extracted without difficulty; haemorrhage at this moment was free, but scarcely excessive. The cavity of the cervix was then opened into the vagina, and the ovaries excised. Up to this point, Caesarean section only had been contemplated, but the atony of the uterus was so marked, and the continuous oozing of blood so great, that it was thought better to complete by Porro's method. After securing the remainder of the broad ligament on each side and ligaturing the cervix, the uterus was cut away obliquely so as to form a front and back flap, the bottom of the cupshaped wound scraped, iodoform freely applied, and the flaps sewn together. The stump was then drawn into the lower angle of the wound, and secured by ligatures left for the purpose; these were passed through the parietal peritoneum, but not through the skin. An additional stitclh between parietal peritoneum and stump was inserted on each side, and in closing the abdominal wound the lowest silkworm suture was also made to take a hold of the peritoneum, closing the stump. The rest of the abdominal wound was closed as in ovariotomy. No drainage was used at first, but a gauze drain was found useful at a later stage. Rigid antiseptic precautions were observed throughout. For a few hours after the operation, the condition of the patient was very critical. She then rallied, and afterwards made an excellent recovery. The temperature never rose higher than 101.20, and by the eleventh day it had fallen to normal. Two ligatures from the broad ligament (each with a small slough) came away, one on the twenty-first, the other on the twenty-sixth day after operation. The thick ligature round the cervix was not again heard of. The deep sinus at the lower angle of the wound had comnpletely closed seven weeks after the operation, and the patient left hospital a fortnight later. There was at present no sign of hernial protrusion. Mother and child are quite well. Dr. Keeling briefly discussed the questions of complete occlusion of thte os externum in labour, the justifiability of the operation which had been undertaken, the respective merits and applicability of Siinger's Cusarean section, Porro's operation, and laparo-elytrotomy, and defended the method of dealing with the stump which had been employed in the case cited. The PRESIDENT and Mr. PYE-SMITH made remarks. NOTTINGHAM MEDICO-CHIR-URGTCAL SOCIETY.-At a meeting on February 17th, Dr. MUTCH, Vice-President, in the chair, a discussion was opened on the Indications for and Results of Removal of the Uterine Appendages by Mr. CHICKEN, who said the conditions under which this operation might be performed were: (i) When-,ever such coarse disease exists in ovary or tube as to destroy entirely their function; (2) when affected with malignant disease; (3) to induce an artificial menopause in certain cases; (4) as a means of preventing conception when the pelvis is contracted; (5) in certain cases of fibroids of the uterus the operation should not be performed for simple inflammation of tube or ovary, and he expressed strong disapproval of Tait's dictum that both ovaries should be removed when only one was diseased. He thought hernia not infrequently followed the operation because the abdomen was opened through the linea alba; he recommended an incision not median,but through the rectus muscle. Dr. MICHIE advised the operation for all those cases where tlle tubes contained pus, as in this event resolution did not take place. Also in hydrosalpinx and hiematosalpinx or in tubal gestation the operation should be performed without delay. It might be done for the arrest of the growth of myoma of the uterus, but in these cases care must be taken to remove all the ovarian tissue. He had undertaken this method of treatment for uterine myomata in about 50 cases, and in all except two had had a favourable result. For some forms of infantile uterus. where intense pain had occurred at the menstrual periods Dr. Michie further drew attention to the frequent presence of thealcoholic habit in persons who suffer from uterine disease,. and thought that this habit was responsible for some of thefailures which were often attributed to the operation.-Mr. TRESIDDER thought that when the operation was done for nervous affections, such as hystero-epilepsy, little good resulted; even for uterine fibroids he thought it was still an open question what the nature of the result was. He certainly thought the results generally obtained were not so good as. those of Dr. Michie, which gave 96 per cent. favourable. He differed from Dr. Michie that the menopause artificially produced presented no material distinction from that occurring physiologically, as he thought the nervous disturbance ir artificial menopause was much more profound, dread of impending evil being a marked feature. Miss GRAY drew attention to the fact that the effect of the operation was not immediate either in the production of the menopause, or in its. curative effect. Dr. BLURTON also emphasised this fact. Dr. ROTHERA related a case where the beneficial effects of waiting before resorting early to operation were exemplified, the fibroid sloughing and being expelled. He further related two cases where the operation was a failure: in one thepatient was now bedridden; in the other, performed for menorrhagia, no benefit followed. He further thought that the induced menopause differed vastly in its nervous effects from the physiological. Dr. O'MULLANE and Dr. BOLTON relateW cases. Dr. MUTCH agreed with Dr. Michie that alcoholism was responsible for some of the failures of this operation. Mr. CHICKEN and Dr. MICHIE replied.-Dr. MICHIE showed a Pregnant Uterus which he had removed ten days before affected with myoma ; it had become impacted in the pelvis. Thepatient made a good recovery. The operation was performed by the abdominal method, and the entire organ was removed..
doi:10.1136/bmj.1.1887.532 fatcat:j5wddi7uz5h6dcuwzrsfmnht34