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S. (Samuel Jean) Pozzi.

Treatise on gynæcology : medical and surgical online

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275. Amputation of the Cervix in Uterine Prolapse 497

276. Colpo-perineorrhaphy toy Hegar's Method 498

277. -279. Colpo-perineorrhaphy by Martin's Method 500

280. Colpo-perineorrhaphy by Bischoff's Method 503

281, 285. Colpo-perineorrhaphy by Flap-splitting, Dol^ris' Method 504

286, 287. Anterior Elytrorrhaphy 506

288. Stoltz " Tobacco Pouch " Operations for Cystocele (Mund<5) 508

289, 290. Le Fort's Operation for Closure of Vagina 509

291. Scheme of Inversion of Uterus 520

292. Inversion of Uterus Without Prolapse 521

293. Inversion and Prolapse of the Uterus Caused by a Fibroid Tumor 522

294. Inversion of the Uterus 523

295. Forceps with Semi-annular Jaws Guarded by Rubber for Grasping the

Inverted Uterus (Perier) 528

296. Perier's Ligature Holder 529

297. 300. Cervical Stenosis — Various Forms of Conical Cervix 533

301, b02. Discission of the Cervical Canal 536

303. Hypertrophy of the Supra- vaginal Portion of the Cervix 542

304. Hypertrophy of the Intra-vaginal with Elongation of the Supra-vaginal

Portion of the Cervix 543

305. Hypertrophy of the Intra-vaginal Cervix with a Deep Biateral Laceration, 543



LIST OF PLATES.



Plates I. and II.

Gynecological Operating Room of the Johns Hopkins Hospital. . . . .page 4

Plates III. and IV.

Lacerations of the Cervix (Munde") page 156

Plate V.

Submucous Fibroid Spontaneously Expelled from Uterus and Vagina,

page 244

Plate VI.

Hegar's Extra-peritoneal Treatment of the Pedicle after Supra-vaginal
Hysterectomy page 290



CLINICAL AND OPERATIYE GYNECOLOGY.



CHAPTER I.

ANTISEPSIS IN GYNAECOLOGY.

The general laws of surgical antisepsis are applicable in the main
to gynecology, but there are certain surgical details and technical
processes which it is necessary to emphasize and describe at length.
These details fall naturally into two divisions; the first relating to
operations through the natural passages upon the vagina, cervix uteri,
and uterine cavity; the second to operations through artificial open-
ings involving the peritoneum.

Antisepsis of Operations theough Natural Openings.

A. Of the Operator. — Absolute cleanliness of the hands is of great
importance in general surgery, but is pre-eminently a matter of neces-
sity where there is to be manipulation of the vaginal or uterine cavi-
ties ; for in these situations pathogenic germs find a culture-medium
essentially favorable to their development, and infection is rapidly
initiated. The nails must be carefully cleaned with a smooth-pointed
file ; the hands and arms to the elbow should be scrubbed for three
or four minutes with soap and a stiff brush in hot water. The towels
used should have been rendered aseptic in a sterilizing oven. (Foster's
experiments have shown the difficulties in the way of complete disin-
fection of the hands. Having carefully washed them in soap and
water, then in an antiseptic solution, and having wiped them upon a
towel previously heated to 140°, he plunged them into a sterilized
peptone solution; which then became the seat of colonies of bacteria.)

From researches carried on by Yon Eiselsberg x in Professor Bill-
roth's clinic, upon the various substances used in the hospitals for
cleansing the hands, it would seem that the almond powder so freely
used in obstetric wards, is tainted with germs, cocci, and bacilli in
great variety. Its use should be absolutely forbidden. All soaps are.



2 CLINICAL AND OPEKATIVE GYNAECOLOGY.

good, except the ordinary hard (resin) soap ; in this Eiselsberg has
found many pathogenic spores, whose presence is quite accounted for
by the processes of manufacture — the use of impure fats and the low
temperature of saponification. The scrubbing with soap and water
should be followed by washing in a bichloride solution of 1 : 1,000.
All assistants and nurses should likewise cleanse hands and arms to
the elbow in the same thorough manner. Many operators consider
this method of cleansing insufficient, and prefer to immerse hands
and arms in a solution of. potassium permanganate 4:1,000, which
stains the skin a violet-brown, then removing the color by a concen-
trated solution of oxalic acid, and finally washing in water sterilized
hj means of the Chamberland filter. I believe that this method may
Ibe reserved for the exceptional cases where there has been contact
•with material which is septic or suspected of being so. Fiirbringer 2
-advocates the use of alcohol at 90° as a wash for the hands, in addi-
tion to the soap and bichloride. This process has been accused of
making the fingers stiff and diminishing their tactile sensibility. 3 I
do not use it.

Where one is obliged to handle fetid substances, as in uterine
cancer, etc., the use of deodorizers may well supplement but not
xeplace antiseptics. Without them, the hands become impregnated
with a disagreeable odor which clings in spite of thorough washings.
Poulis, of Edinburgh, finds that anointing them before the operation
with spirits of turpentine is a sufficient protection.

A vessel containing a 1: 1,000 bichloride solution should be placed
at the side of the operator, so that he may from time to time dip his
liands in it.

The operator and his assistants should wear over their ordinary
garments, a blouse, or linen frock, which must be changed and washed
daily. For operations where constant irrigation is used, the surgeon
should further be protected by a large apron of waterproof material
(see Fig. 1 ).

B. Instruments. — As far as practicable, the instruments used
should be of the simplest possible construction, easily taken apart if
composed of several pieces, without cavities or grooves from which
impurities are removed with difficulty. For this reason we should
exclude slides on uterine sounds, canulated suture-needles, needle
holders with springs, and, in spite of their convenience, the ingenious
invention of Jacques Reverdin, needles with movable eyes. Instru-
ments in one piece are the best



ANTISEPSIS IN GYNECOLOGY. 3

The instruments, which immediately after a previous operation
should have been immersed for five minutes in boiling water and care-
fully wiped, must again be boiled just before the next operation, and
then placed in a strong (5$) carbolic solution. Five minutes' immer-
sion in boiling water is sufficient to destroy all germs, as has been
proved by II. Davidson 4 in his culture • experiments. The bichloride
solution cannot be used on account of its destructive action upon
metals. Should the instruments have been previously used upon
septic material (fetid pus, sanious or gangrenous matter, etc.), these
precautions will be insufficient. They must then be immersed for a
half hour in a strong (5#) carbolic solution held at the boiling point,
or kept for an hour in a sterilizing oven at 284° F., or soaked for
twelve hours in a strong cold carbolic solution. These processes have
a deleterious effect upon the instruments, especially the bistouries,
but they are nevertheless indispensable.

C. Surroundings. Operating Boom. Furniture. — It is impor-
tant that the room used be perfectly clean, and free from curtains,
hangings, mats, carpets, etc., which might retain dust. In a private
house, whatever room is used for any important gynaecological op-
eration should be emptied of its furniture and thoroughly cleaned;
in a hospital, it is essential that the floor, walls, and ceiling of the
operating room should be so constructed that they may be washed
daily with the hose. Moreover, it is well to have sterilized water and
antiseptic solutions in jars with long tubes that may be easily reached.
In Fig. 1, I show the arrangement which I have adopted for •this pur-
pose in the hospital of Lourcine-Pascal. It is advantageous to have,
in addition to a high and wide window at the side, free ingress of
light from above. The furniture should be as scanty as practicable,
and exclusively of glass or metal, easily movable and easily cleaned.
Fig. 1 shows several examples of this style of furniture.

D. The Patient. Antisepsis of the External Genitals.— The
patient should have had a complete bath (preferably of bichloride)
the evening before or the morning of the operation. The rectum,
however small a share it has in the operation, should have been
carefully emptied by an enema and afterward washed with a satu-
rated solution of boric acid (50:1,000). The catheter should be used
by the surgeon or an assistant previous to the disinfection of his
hands. In all operations upon the vulva, the pubic hairs must be
shaved, to add to the ease of the operation, as well as to remove a
possible lodging place for septic material.



4 CLINICAL AND OPERATIVE GYNAECOLOGY.

The external genitals should be cleansed first with soap, water, and
a brush, then washed, with a 1: 1,000 bichloride solution. The vagina
may be washed with the same solution diluted one-half with warm
water.

In my opinion, there is no objection to the 1 : 1,000 bichloride solu-
tion as a vaginal injection, providing that it is administered under the
conditions, and according to the directions, to be given below. The
biniodide of mercury has been recommended, but it does not seem to
offer any great advantages. 5 Pinard and Bernardy use a solution of
biniodide 1 : 4,000 instead of a sublimate solution 1 : 1,000. The use
of bichloride in gynecology and especially in obstetrics has been
much decried of late. Certainly at first it was used in too strong
solutions and with too little care, but the reaction has reached the
other extreme. The papers published upon this subject have not
always taken into account the radical difference between injections
given immediately after labor, and those administered under other
conditions. In the woman recently delivered, the vaginal and uterine
cavities communicate through a more or less gaping and softened
cervix. Fluid injected into the vagina, especially if one be not care-
ful to separate its walls with the fingers, flows readily into the uterus r
accumulates and remains there, and is perhaps absorbed by the re-
laxed mucosa, or its desquamated surface. Hence the accidents noted
after simple vaginal injections, 6 which have been observed not only
after the use of bichloride, but after carbolic solutions. I would here
point out a danger attending the use of aqueous solutions prepared
upon the spot by diluting concentrated solutions of carbolic acid;
more especially if the preparation be impure, small oily drops may
form which dissolve with difficulty, and, as a consequence, the injec-
tion, instead of being a perfect solution, is in reality a toxic mixture.
This is the explanation of cases observed by Briggs, 7 serious accidents
resulting from the administration of an injection of a teaspoonful of
the alcoholic solution of carbolic acid in a pint of water, to women
recently delivered. It is equally certain that the intra-uterine injec-
tion of a too powerful bichloride solution (1: 1,000) may be dangerous
even in non-puerperal patients, as in the case quoted by Mijalieff,
where such an injection, given daily for twenty-six days, for simple
metritis, resulted in a mercurial nephritis with hematuria. I pur-
posely omit allusion to the experiments upon the vagine of female
rabbits and Guinea-pigs, which do not seem to me to have a bearing
upon this special point. Moreover, one should keep in mind the fact



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ANTISEPSIS IN GYNECOLOGY.




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6 CLINICAL AND OPERATIVE GYNAECOLOGY.

that the bichloride solutions commonly employed are very rapidly
neutralized by contact with abundant secretions, leucorrhcea, cancer-
ous ichor, etc., and lose both their toxic and disinfecting power.
Ernest Laplace 8 has recently shown the instability of this antiseptic,
and has investigated the cause and its remedies. The mercurial salt
is precipitated by albuminoid matter, forming albuminates, whence
the rapid loss of antiseptic power. The following are a few of his
experiments : To an open tube containing a little less than an ounce
(25 cc.) of natural serum, is added about a drachm (5 cc.) of sublimate
solution 1:1,000; the development of germs is not prevented; with 7
minims of serum bacteria are present. In a tube containing a drachm
of sublimate solution 1 : 1,000, with about 12 minims of putrefied human
blood containing bacteria, the microbes multiply ; if a few drops of
this mixture are cultivated on gelatin according to Esmarch's method,
at the end of five days we shall find large colonies of the staphylo-
coccus aureus. Laplace has found that the addition of 5:1,000 of
tartaric acid to the solution is sufficient to prevent the formation of
the albuminates of mercury, without impairing its power to destroy
every germ present. This discovery, most valuable for general sur-
gery, may also be utilized in gynaecology. From my own experi-
ments, I have nothing but praise to award it.

I must say a few words about a new antiseptic, creolin, which has
recently appeared, and has been experimented with in gynaecology
and obstetrics by Baumm and Born 9 in the Maternity and Obstetrical
Clinic of Breslau. As a result of their researches, it would seem that
creolin possesses certain decided advantages, but also certain draw-
backs which tend to greatly limit its usefulness. It is extremely diffi-
cult to obtain a fixed product, its exact chemical composition not
having as yet been determined. It is used in solution of i: 100 in
treating ruptured perineum, fissured nipples, etc. If more concen-
trated, it may produce erythema, or eschars, so that as an antiseptic
it would seem to be inferior to a 1 : 8,000 bichloride solution (Baumm).
For intra-uterine injections Born has used a 1 : 100 solution, for vaginal
irrigations 2:100, with no resulting accident due to absorption. Be-
sides its undoubted antiseptic power, creolin possesses the great ad-
vantage of leaving the vagina soft and flexible, and even of imparting
to it a degree of oiliness which is of decided advantage in obstetrical
operations, and in certain gynaecological manipulations when several
fingers have to be introduced into the vagina, or where a large tumor
is to be extracted through it (enucleation of fibroid bodies, vaginal



ANTISEPSIS IN GYN/ECOLOGT. 7

hysterectomy). We know that solutions of the bichloride of mercury
and even those of carbolic acid have the opposite effect of stiffening
and roughening the vaginal mucosa, leading often to serious incon-
venience. This is, I believe, the only useful application of creolin.
The opacity of the solution renders it unfit for the immersion of in-
struments.

Naphthol /?, used by Bouchard for intestinal antisepsis, has been
recently extolled for surgical dressings, either in solution or as a
saturated gauze. 10 It has the advantage of being very slightly poi-





Fig. 2. — Vaginal Irrigator for Suspension.



Fig. 3.— Portable Vaginal Irrigator.



sonous, and seems destined to render real service. The aqueous solu-
tion contains only two parts in a thousand.

Vaginal injections, to be truly cleansing, should be given accord-
ing to certain definite rules. A jjortable cylindrical can, to which is
attached a long tube ending in the nozzle (Figs. 2 and 3), should be
fixed at a slight height above the operator, or held up by an assistant.
The person who gives the injection places the canula in the vagina,
introducing by its side the index and middle fingers, which are gently
pushed up to the cul-de-sac, then firmly pressed in every direction to
open out the folds of the vagina and permit of their thorough cleans-
ing. If this procedure be neglected, some cause of infection will



s



CLINICAL AND OPERATIVE GYNECOLOGY.

1



surely remain. The surgeon or his assistant should himself give such
an injection before an operation ; it is what I call rinsing the vagina.

All canulse to be used by the surgeon should be of strong glass
with one terminal orifice, for the water should be directed toward the
cul-de-sac and the cervix, cleaning the vagina upon its return only.




Fig. 4.— Fenestrated Speculum for Vaginal Irrigation.

For injections to be administered by the patient herself, it is best, to
avoid all possibility of introducing the tube into the os uteri, to have
a canula with several openings on the side of a terminal enlargement.
It is also a convenience to use a wire speculum, which accurately fits
the canula, and which opens out the vagina and permits of thorough
irrigation (Fig. 4). The patient should lie upon a pan or a rubber
sheet arranged to carry the fluids into a pail (Figs. 5 and 6).




Fig. 5.— French Bedpan with Exit-tube.



The accidents liable to occur from vaginal injections and the dan-
ger of wounding the cervix or allowing liquid to enter through it,
have been greatly exaggerated. Some physicians have even gone so
far as to forbid the use of the canula. This is, I think, a grave error.
You should simply instruct the patient to insert the instrument to a
depth of six to eight centimetres (three inches) only, or about a fin-
ger's length.



ANTISEPSIS IN" GYNECOLOGY.



9



Rubber carmine, which are not easily cleaned and disinfected,
should be discarded.

Curved canulre possess no advantage over straight ones.

During the week preceding the operation, the x>atient should take
an antiseptic injection (sublimate solution, 1:2,000) morning and
evening; after which a small pad of iodoform gauze is to be inserted in
the vagina. On the day of the operation three injections are to be
given, the first two at intervals of an hour, the third at the very
moment of the operation ; I will point out later the reason for this
method of procedure.

After a vaginal injection, especially of corrosive sublimate, one
should be careful to press down upon the fourchette in such a manner
as to insure the escape of all the fluid. In many women, the terminal




Fig. 6. — Hospital Bed-pan (or Baker's Bed-pan).



portions of the vagina and tbe vulva are of so firm a quality that
much fluid may remain imprisoned in the upper part of the canal, and
give rise to the various accidents due to absorption. I have myself
witnessed several minor casualties due to this cause.

There is a wide-spread opinion that an antiseptic injection should
follow and not precede minor gynaecological procedures — as examina-
tion, catheterization, dilatation, etc. This is a grave error. Antisep-
sis is most needed before any such manipulation. The observations
of Kaltenbach n upon the auto-infection of parturient women might
have caused a suspicion of the existence of a condition of latent in-
fection, so to speak, of the female genital organs, especially during
the puerperal period. The researches of Winter 12 have recently
placed this fact beyond dispute. The genital tract, vagina, and
cervix uteri of a healthy woman, contain pathogenic germs ; the
Staphylococcus pyogenes aureus, citreus, albus, and streptococci of



10 CLINICAL AND OPERATIVE GYNAECOLOGY.

three varieties have been recognized by their several distinct charac-
teristics and methods of culture. But, and most important, thfir
virulence seems to be attenuated and latent, since the inoculation of
animals with these germs and their cultures has been without result..
Notwithstanding this, they are a perpetual menace, for these inert
organisms may, at the slightest septic impulse from without, germinate
and fructify with the most terrible consequences. Moreover, there is
no proof that these germs, innocuous so long as they remain in their
ordinary habitat below the orifice of the internal os uteri, may not
reacquire virulent properties if they are suddenly carried beyond this
boundary. That germs may be carried into the uterus by the use of
the sound and by manual touch has been proved beyond a doubt
by Winter's examinations of specimens removed by hysterectomy
shortly after these operations. The consequences of these remarkable
experiments are important. As regards the disinfection of the vagina
prior to operation, they make its necessity apparent. Is it possible,
by means of the most carefully administered injection, to get entirely
rid of the micro-organisms quartered in the cervix ? Steffeck 13 has
made a particular study of this subject, from which he draws the
following instructive conclusions:

1. After a vaginal injection of one litre of a 1 : 3,000 sublimate
solution, as many germs as before are found in the cervix; only the
vagina has been cleansed :

2. After the same injection, in which the vaginal washing has been,
done with the aid of one finger as described above, if some of the
vaginal mucus be inoculated upon agar-agar, a number of colonies
will develop, less numerous, however, than in the first case.

3. After the same performance aided by two fingers, two of every
three cultures will remain sterile.

4. As a final experiment, the injection of the vagina and the
cleansing of the cervix are accomplished in the following manner:
One finger is pushed as deeply as possible into the cervix ; another
ringer opens and permits a thorough washing of the anterior cul-de-sac
— then the two fingers are changed* about in such a way as to cleanse
the posterior cul-de-sac; finally the stream of water is sent directly
into the os externum. After so thorough a washing as this, all cul-
ture experiments have been without result, while before this disinfec-
tion, the tube cultures showed from 50 to 100 colonies. As might
be expected, tiiis disinfection is of short duration, as more germs
come from the supra-vaginal portion of the cervix through the os



ANTISEPSIS IX GYNAECOLOGY. 11

uteri, and at the end of an hour may be found in the lower portion of
the cervix. By repeating the injection for a second, and then a third
time at intervals of an hour, the germs may be destroyed for a longer
time; Steffeck having found that in such a case the mucus was free
from germs for live days.

This process of successive sterilizations is somewhat tedious, but it
reduces to a minimum the chances of auto-infection. This is the rea-
son why I recommend the administration of three consecutive injec-
tions at intervals of an hour, previous to every operation. No sound
or dilator should ever be introduced into the uterus, without this
thrice repeated disinfection of the vagina and cervix.

To the omission of this precaution may be traced the numerous
accidents following these operations even when they are apparently
done under strict antisepsis. If we have to do with a disease causing
a foul odor, as cancer, sloughing fibroid, etc., the antiseptic should be
preceded by a deodorizing injection (which is at the same time in itself
slightly antiseptic) of a quart of hot water to which are added two or
three teasrjoonfuls of Labarraque's solution of chlorinated lime or
Pennes' vinegar. To wash the rectum and the bladder, use either a
solution of boric acid (30 : 1,000) or of salicylic acid (1:1,000), both of



Online LibraryS. (Samuel Jean) PozziTreatise on gynæcology : medical and surgical → online text (page 3 of 53)