of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

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others were cases of gangrenous appendix which on one pretext
or another might have been dallied with had I not suspected
ruptured tubal pregnancy. I have seen so many patients die,
and some of them were in my own practice, from waiting for an
exact diagnosis that I have become bitterly prejudiced against
this excuse for delay. When a woman appears to be dying from
intraabdominal hemorrhage, let us save her life first and make
the diagnosis afterward. Let us open the abdomen to tie the
bleeding vessels, and the diagnosis will be made beyond the
shadow of a doubt almost before we have cut through the
peritoneum. I feel the more justified in taking this stand
•because in many of my cases it would have been impossible to
make a correct diagnosis before the abdomen was opened. I
am, therefore, constantly telling my younger friends, *' Make your-
selves experts in the bimanual palpation of the pelvic contents,
so that nothing abnormal can escape you; and if you find some-
thing which should not be there, get it out before it has time to
become dangerously large." By taking this stand myself I
have been able to do easily what Lawson Tait claimed could
never be done — remove a tubal pregnancy before rupture. I
have had several such, but the most interesting one was a woman
who had been ten years sterile and whom I had been treating
for several weeks for salpingitis. She came one Monday with
an almost cured inflammation of her left tube, and on the
following Thursday that tube was pregnant; the following Monday
it was as big as my little finger; the next week as big as my first
finger; the third Monday it was as big as a sausage, and two days
later it was removed before rupture by vaginal section, and the

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250 smith: two cases of tubal pregnancy.

woman recovered very quickly. This was the only one of the
fifty-one I ever did by this route, feeling as I did that I was
taking fearful chances if a furious hemorrhage should start up.

It must not be supposed from the above remarks that I am
utterly opposed to an exact diagnosis being made. After you
have called the ambulance to take the patient to the hospital or
while you are waiting for the specialist to be rushed to the home
for consultation, you cannot employ the time better than in
trying to make the most exact diagnosis possible. It certainly
is a feather in the young doctor's cap if when the older man
comes the younger one is able to say, ** I suspect a tubal pregnancy
for the following reasons." But what I object to is waiting
until to-morrow or next week to make the diagnosis. When an
open artery is pumping blood into the peritoneal cavity, that
is no time for splitting hairs as to which exact spot the hemor-
rhage is located at.

Moreover, for well-known reasons it is in some cases impossible
to say what it is for at least five times the appendix has been
found buried in adhesions, so that the two doctors who were
called in one of these cases were both right, although they each
said a different thing.

Case I. — Mrs. G., at. thirty-four, began to menstruate at
twelve and continued to do so normally until her marriage at
twenty-two and after, for she has never been pregnant before,
although married twelve years. For the first time she missed
her period due on the fifteenth of July. Ten days later, on the
twenty-fifth of July, she was washing all day, and that night-
she began to bleed and to have terrible cramps in her right side.
Dr. McGovern was sent for, and as she had great tenderness all
over the abdomen, he diagnosed appendicitis, and sent her to the
Hotel Dieu in the ambulance. There she remained nine days,
being treated with ice bags on the abdomen. As the pain was
much better she came home, but continued to flow until the
sevententh of August . when Dr. McGovem sent her to my
service at the Western Hospital. On examining her I found a
large mass on her right side pushing the small uterus over to the
left. I had no hesitation in diagnosing it as tubal pregnancy
with possible appendicitis, basing my opinion on the irregular
hemorrhage lasting twenty-three days. The abdomen was
opened, but before going through the peritoneum, we could all see
the black blood showing through. About two quarts of clots were
removed, as well as the ruptured pregnant right tube, and cystic
ovary and densely adherent appendix. She made a good re-
covery; highest temperature loo®, highest pulse 98; and she
went home on the twenty-first day.

Case II (for the accurate history of this case I am indebted

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smith: two cases of tubal pregnancy. 251

to Dr. J. Heagherty, of Montreal). — Mrs. F., set. thirty, was
admitted to the Gynecological Ward of the Western Hospital on
the eleventh of September, 1909. She had first menstruated
at sixteen, and was always regular and normal. She was
married at twenty-four; had one child bom dead two years ago,
and one miscarriage last New Year's day. On August 15, 1909,
when, as she thought, she was one month pregnant, she was taJcen
with a sharp pain in the abdomen, followed by a slight bloody
discharge, both of which she attributed to an abortion, although
the pain was different from her other miscarriages. Dr. Heagherty
found her with a temperature of 100 1/5® and a pulse of 100, and
gave her a hypodermic of morphia. Next day she was nearly
well again, but on the twenty-sixth of August she called at his
oflSce saying that the bloody discharge had never completely
stopped. She was feeling very weak. As Dr. Heagherty was
away on his holidays, he did not see her again until the eleventh
of September, when she told him that on the fourth of September
she had been taken with a sudden sharp stabbing pain on the
left side radiating to the back, with hemorrhage and weakness.
The physician who saw her in his absence gave her ergot and
applied a fly blister over left ovary, after which the pain and
hemorrhage ceased for a week. But as they returned on the
eleventh, Dr. Heagherty sent her into the hospital.

Unfortunately, that was a Saturday afternoon and I was in
the country for the week end, so the chief house surgeon
exercised his privilege and curretted her. On my return, on
Monday morning, I examined her and, finding a mass the size
of an orange in the left vaginal fornix, I told him that I feared he
had been curetting a tubal pregnancy, I let her go home on the
eighteenth after fully explaining to her what a tubal pregnancy
was and urging her to tell everybody in the house that should
she be taken with a sudden unconsciousness, they were to call the
ambulance and send her back to me for immediate operation.
On the twenty-first of September Dr. Heagherty was again
called for pain and hemorrhage and inability to urinate owing to
distention. He passed the catheter and then he examined her
and felt a large mass on left side. Hot fomentations and saline
purgatives relieved the distention. He saw her daily, her tem-
perature being around 99 1/2** and pulse 80, and she felt well
apart from occasional sweating and abdominal distention.
However, he thought it better that she should be operated on and
sent her to me at the Samaritan Hospital for Women on the
eleventh of October, and next day, the twelfth, the abdomen was
opened, and this specimen was removed together with a full
quart of clots; I also removed the left ovary, and the vermiform
appendix, as it was very swollen and adherent. But I left the
right ovary and tube intact. Highest temperature, 100°. She
made a good recovery and went home in twenty-eight days.

338 Bishop Street.

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K. I. SANES, M. D.,

Pittsburgh, Pa.

In pelvic surgery both the abdominal and vaginal routes have
their distinct fields of usefulness; a gynecologist, therefore, must
be both a ventroceliotomist and colpoceliotomist.

Shortcomings of the Abdominal Route. — While the general ap-
plications of asepsis and the development of abdominal operative
technic has greatly reduced the mortality in ventroceliotomy,
we still meet in pelvic surgery postoperative complications
directly attributable to the use of the abdominal route.

Sepsis in ventroceliotomies is a complication occurring oc-
casionally even in the hands of most careful gynecologists.
The reason for it is not difficult to find. The abdominal cavity is
exposed to air, which may be septic; the clean abdominal viscera
must be handled while operating in the pelvic cavity; the pelvic
organs must be brought up into the general peritoneal cavity
for their correction or removal, and the accumulated wound
secretions as well as contents of accidentally ruptured septic
tumors must be carried off through the abdominal incision.
Such procedures, of course, favor peritoneal infection, and,
while with perfect technic, it should seldom occur, it does occur
nevertheless, because, while we always strive at perfect technic
we do not always attain it.

Not only does the ventroceliotomy expose the patient to the
danger of peritoneal infection, but it also adds a great deal to the
degree of operative shock. The exposure to air of the peritoneal
cavity, the disturbance of its viscera by hands, sponges, and in-
struments, together with the deep anesthesia necessary for
complete relaxation of the abdominal wall, are additional danger-
ous shock-factors peculiar to ventroceliotomy.

Among the other serious disadvantages of ventroceliotomy
are the gastrointestinal complications. As results of the ex-
posure and handling of the abdominal viscera, intestinal paresis,
ileus, acute gastric dilatation, and intestinal adhesions occur

* Read before the College of Physicians of Pittsburgh, Pa., Oct. 14, 1909, .

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frequently enough to be important causes of postoperative dis-
comfort, morbidity, and even death.

To these most important postoperative complications of the
ventroceliotomy should be added the ventral hernia. It is true
that with careful closure and primary union, ventral hernia
should not occur, but we sometimes fail to get primary union and
even in cases in which we do get primary union, postoperative
hernias occur (in spite of careful closure of the incision). This
is especially noticed in women with weak abdominal walls, and in
the poorer classes of patients that are compelled to resume hard
work early after operation.

With such disadvantages of ventroceliotomy is it any wonder
that colpoceliotomy should have been proposed to the pro-
fession and that it should have found many followers among the

Now let us take up the colpoceliotomy, investigate its ad-
vantages and disadvantages, and then define, if possible, its in-
dications in pelvic surgery.

Advantages of Colpoceliotomy, — Colpoceliotomy does away to a
very large degree with the above cited disadvantages of ventro-
celiotomy. It reduces greatly the risk of peritoneal infection
because the general peritoneal cavity and its viscera are neither
exposed to the air nor disturbed; because during the operation
the wound secretions and septic contents of the pelvis are safely
carried off through the vaginal incision, and because post-
operative drainage if required can be easily and safely established
in a most natural and most effective manner.

Nor is the severe shock, the other cause of postoperative
mortality in ventroceliotomy, common in colpoceliotomy. The
reasons for this are easily understood. The general peritoneal
cavity is not entered, and therefore is not disturbed nor cooled;
the anesthesia need not be profound, because the exposure of the
pelvic organs through the vaginal incision does not require com-
plete muscular relaxation; the time of the operation in a large
number of cases is shorter, because the incision consumes but
little time and because both the preliminary extraperitoneal
operations, such as curettement, and the intraperitoneal opera-
tions proper, are performed in one field, thus saving the time re-
quired for changing the patient's position, preparing the ab-
dominal field, etc.

The other important complication of ventroceliotomy, the
postoperative hernia, is not met with in colpoceliotomy, there

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being no ventral incision, and the vaginal incision not favoring
any hernia formation.

Not only does the colpoceliotomy avoid the serious disadvan-
tages of ventroceliotomy, but it gives us a smoother and shorter
convalescence. A patient after a colpoceliotomy does not
sufiFer as much as she does after a ventroceliotomy, because the
postoperative discomforts common after ventroceliotomy,
such as pains and gastrointestinal disturbances, are either mild
or entirely absent. Nor does the patient need to be confined to
bed as long as she does after a ventroceliotomy. Even drainage
cases may with advantage be allowed out of bed early, because
better pelvic drainage can be obtained in the sitting or standing,
than in the recumbent posture. It is true that quite a number
of surgeons allow favorable ventroceliotomies out of bed early,
but the profession at large has not adapted this practice, and in
abdominal drainage cases such practice is out of question.

Again, the ability of the patient to resume her usual duties is
regained earlier after colpoceliotomy than after ventroceliotomy —
an advantage which is of great economic value to the poorer
classes of patients.

There is another advantage of colpoceliotomy that may be
mentioned here, though this advantage is purely "psychical."
People have a horror for abdominal section; if a choice is possible
they always prefer the vaginal route. In fact, it is not uncom-
mon to meet patients who readily consent to a colpoceliotomy,
but who absolutely refuse to undergo a ventroceliotomy.

We can see from the above that the colpoceliotomy reduces
the postoperative shock, lessens the chances of sepsis, shortens
and lightens the convalescence, avoids danger of traumatic ad-
hesions, and does away with postoperative hernias.

Disadvantages of Colpoceliotomy, — Having such advantages
over the ventroceliotomy, why is the colpoceliotomy not gen-
erally practised in pelvic surgery The answer to this question
is found in the limited accessibility of intraperitoneal lesions
through the vaginal route.

The vaginal incision is for anatomical reasons more limited
than abdominal. While the length of the abdominal incision
can be made in accordance with the needs of the operation, the
vaginal incision cannot.

The vagina itself, if small, as in some nulliparae, or atrophied
and unyielding, as in some women past menopause, narrows the

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Operative field to such an extent as to make access to the
pelvic organs difiScult and sometimes impossible.

And even with a roomy vagina and with an incision large
enough for the pelvic lesion, colpoceliotomy is frequently
impracticable. To remove or correct a pathological condition
in the uterus or its adnexa, it is necessary to bring the diseased
parts out into the vagina. When, therefore, the uterus and
adnexa are found completely or partially fixed by firm adhesions
or by contracted ligaments, their delivery through the vaginal
incision is either impossible or unsafe.

Again the frequency with which we meet in pelvic cases con-
comitant diseases of abdominal organs, especially those of the
appendix, gall-bladder and bowels, makes it imperative to
examine these organs during our pelvic operations. Through
the vaginal incision these organs can* neither be inspected nor
reached, therefore the pelvic work through the vagina must at
times be incomplete.

While the objection based on the difl5culties met with in inac-
cessible cases is seemingly well founded, it can have no weight
with the great majority of those favoring the colpoceliotomies,
who exclude these inaccessible cases from the vaginal route.
Such operators do not attack through the vagina cases which
have a suspicious history of coexisting appendix or gall-blad-
der diseases, unless the pelvic condition demands immediate at-
tention and a ventroceliotomy is at the time contraindicated;
they do not use the vaginal route for badly adherent pelvic
organs unless they feel reasonably sure that the adhesions can be
safely and easily severed; they do not perform colpoceliotomies
for tumors that are too large to be delivered through a vaginal
incision, unless they can, prior to their delivery, safely reduce
their size.

It is true that cases to all appearances favorable for colpoce-
liotomy may occasionally turn out unfavorable during the
operation, but careful preoperative study and examination of
cases make such occurrences exceedingly rare, and if the operator
takes the precaution to have all his colpoceliotomy cases pre-
pared at the same time for ventroceliotomy and to obtain from
such patients consent to be ventroceliotomized, should it, con-
trary to all reasonable expectations, be found unavoidable, the
occasional failure can be of no serious consequence. The
operation can be finished by ventroceliotomy and the vaginal in-
cision may be either closed or used for drainage purposes, de-

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pending on the character of the lesions and the kind of the

But we hear frequently objections to colpoceliotomy, even in
the accessible cases; such objections being the uncertainty of
hemostasis, the necessity of working in the dark, and the diffi-
culty of disinfecting of vaginal field.

So far as the " uncertainty of hemostasis '* is concerned, we can
easily overcome it by ordinary care. It is true that in col-
poceliotomy, on account of the greater traction on tissues dur-
ing ligation, the liability for tissue retraction with consequent
hemorrhage is greater than in ventroceliotomy, but if we relax
the hold on the tissue while we ligate, if we avoid including
too much tissue in the grasp of one ligature, if we divide the
ligated part at a distance from and parallel with the ligature, if
we avoid pulling on the ligature during the operation and
examine all the stumps at the end of the operation; if we take all
these ordinary precautions there should be no fear about the

As to the objection of '* working in the dark*' is concerned it does
not hold good in cases in which the diseased parts can be brought
out into the vagina, because in such cases a good exposure is
easily obtained. The objection is only applicable to cases in
which, on account of excessive size of the lesion, extensive ad-
hesions, or contracted ligaments, the diseased parts cannot be
delivered into the vagina, but such cases belong to the inacces-
sible class and should therefore be taken care of by the abdominal

The objection based on the " difficulty of disinfecting the vagi-
nal canal " is not well founded. The best proof that the canal can
be made satisfactorily aseptic lies in the well-known fact that
stitch abscesses are by far not as common in the vaginal as they
are in the abdominal incision.

Indications for Colpoceliotomy. — ^The colpoceliotomy, therefore,
can safely and with great advantage be adapted in cases whose
lesions are accessible through the vaginal route. But to get all
its advantages and make it as widely applicable as possible,
both the anterior and posterior colpoceliotomy must be made
use of, as each has its own special advantages and limitations
and therefore each has its own field of usefulness.

Let us now consider separately the indications for the anterior
and posterior colpoceliotomy, as by doing so the indications
of colpoceliotomy can be more clearly defined.

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Posterior Colpocelioiomy, — ^The posterior incision admitting us
to the most dependent part of the pelvic cavity is best adapted
for cases demanding pelvic drainage. It is, therefore, applicable
to any operation on the uterus and the adnexa that requires
postoperative drainage, but is especially applicable to cases in
which the pelvic drainage is the only surgical procedure de-
manded, whether the drainage be extraperitoneal, such as
walled off pelvic exudates, hematomas, abscesses, sactosal-
pinges and broad ligament cysts, or intraperitoneal, such as
septic pelvic peritonitis, tubercular peritonitis and early acute

Because of the easy access to the lower segment of the posterior
uterine wall and to tumors situated low in the pelvis, the poste-
rior incision is well adapted for the subserous or sessile fibroids
of the lower uterine segment, for the accessible pedunculated
fibroids, for the accessible ovarian cysts, hydrosalpinges and un-
ruptured extrauterine pregnancies.

The perfect exposure of the lower pelvis through the posterior
incision obtained easily with patient in Trendelenburg's position
makes the posterior incision especially adapted for pelvic ex-
ploration. So safe, quick, easy and free from discomfort is this
incision, that for exploratory purposes it finds a wide application
in pelvic surgery. While its value as an exploratory incision is
great in many pelvic diseases, its greatest value is found in cases
of suspected unruptured ectopic pregnancy, because of the im-
portance of early diagnosis in such cases.

Anterior Colpoceliotomy, — ^The anterior incision, on the other
hand, while unfavorable for drainage purposes, admits us easily
to the upper and anterior part of the pelvis, thus giving us a
good access to the round ligaments, a satisfactory control over
the infundibulo-pelvic ligaments and a perfect exposure of the
uterus and adnexa.

Such incision, therefore, is not adapted to septic cases requiring
drainage; but to clean cases requiring operative procedures on
the round ligaments, on the fundus uteri, and on the adnexa, the
anterior incision is excellently adapted. Through it we can cor-
rect favorable cases of retro-displacements of the uterus by
shortening of round ligaments, if the patients are of child-bearing
period, or by high vaginal fixation, when future pregnancies can
be excluded; we can correct a prolapsus uteri with pronounced
cystocele by intravaginal implantation of the uterus (Schauta-
Wertheim operation); we can enucleate small fibroids in the

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anterior and fundal part of uterus; we can remove small ovarian
cysts; we can perform oophorectomies for induction of menopause
and salpingectomies for induction of sterility.

Thus we readily see from the above how wide a field we cover
in pelvic surgery by colpoceliotomy, utilizing the anterior or
posterior incision as the case may require. This field is still en-
larged by the vaginal hysterectomy where both the anterior and
posterior incisions are made. The vaginal hysterectomy for
uterine fibroids with extensive adhesions can be perfoimed with
the aid of bisection or morcellation. The vaginal hysterectomy
with dissection of the ureters (Schuchardt's operation) finds a
most ideal application in operable cases of carcinoma of cervix
because it not only permits most extensive removal of the
parametria but allows also continuous downward drainage dur-
ing the operation.

Conclusion. — We called attention to the advantages of col-
poceliotomy, showing that it lessens the danger of sepsis and
shock, avoids postoperative adhesions and hernia, lightens the
burden of convalescence, and permits earlier resumption of work.
We discussed the limitations of colpoceliotomy and admitted its
impracticability in cases of narrow vaginal canal, with pathologi-
cal parts too large or too firmly fixed for delivery through a
vaginal incision, and in cases complicated by abdominal lesions
inaccessible through the vagina. We called attention also to the
necessity of utilizing both the anterior and posterior route:
the posterior for removal or drainage of pathological conditions
low in the pelvis; the anterior route for operation on the round
ligaments, on the anterior and fundal portions of the uterus, and
on nonadherent or slightly adherent adnexa.

We did not intend in this paper to enter into a detailed dis-
cussion of the advantages of individual vaginal operations, nor
did we intend to cite our statistics here. Our only aim was to

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 26 of 109)