THE BROOKLYN MEDICAL JOURNAL Published Monthly under the supervision of the Medical Society of the County of Kings. ENTERED AT BROOKLYN, N. Y. POst office AS SECOND CLASS MATTER. No paper published or to be published elsewhere as original will be accepted in this department. PELVIC SURGERY BY VAGINAL SECTION. BY CHARLES JEWETT, M. D., SC. D. Read before the Brooklyn Gynecological Society. The following cases are reported in response to the call for material to help out the evening's program. They represent some recent experience in dealing with pelvic disease through the vaginal incision, and may be of interest in view of the conservative tendencies of the times in pelvic surgery. The method offers advantages in certain conditions as an alternative of abdominal sec-. tion; in others a vaginal section may be done either with diagnostic or therapeutic intent where a laparotomy would scarcely be justified. For exploration, for separation of adhesions, for removal of diseased ovaries and tubes it is frequently a competent and, at the same time, a simpler and less formidable undertaking, at least to the patient, than opening the abdomen from above. The woman suffers less shock, less peritoneal injury, she recovers more rapidly, and is saved the unsightly scar and the possible hernial consequences of the abdominal operation. Attention has been especially called to the possibilities of this method in the treatment of septic disease in the pelvis by the work of Henrotin. While the subject is not new, it has assumed new importance and the method finds new applications. I have usually proceeded as follows: The woman is placed in the lithotomy position under an anesthetic. The antiseptic preparation is the same as for vaginal hysterectomy. If, however, we accept the conclusions of Krönig and Menge the preliminary antisepsis of the vagina, before operation, is unnecessary. The perineum is held back with a short-billed retractor. The cervix is drawn as far forward against the pubic bones as the mobility of the uterus will safely permit. A longitudinal fold of the vaginal wall is caught with a double tenaculum in the median line behind the uterus. This fold is cut with strong blunt-pointed scissors an inch to an inch and a half from the lower border of the cervix, the scissors being held with the points against the posterior wall of the cervix. A similar fold is then seized at the bottom of the incision and clipped. Sometimes the peritoneum is opened at the second clipping. It is better after dividing the vaginal wall to open the peritoneum with the finger. There is generally free bleeding for a moment from the incision, but seldom enough to require a hemostatic suture. The primary opening is small and is well away from the uterine arteries and the ureters. It is readily enlarged if necessary to admit. two or three fingers. Free access is now had to the entire pelvic peritoneum and its contents for exploration or treatment. I have not found it necessary to add a longitudinal incision. The uterus, if movable, is already partially retroverted by the traction of the volsella. With one hand over the abdomen, the ovaries and tubes can, in most cases, easily be pressed down within the grasp of the vaginal fingers and drawn to the vulva. Adhesions can safely be broken up, pus collections in tube or ovary, peritoneum or broad ligament, opened and drained, and even adherent knuckles of intestine may sometimes be brought into view and separated under direct inspection. The wound is left open or is immediately closed according to the indications. CASE I. A neurotic woman about thirty-five years of age, married five years; had one child 3 years old. Cervix lacerated and eroded; profuse muco-purulent discharge from the uterus; pain in region of left ovary. Was disabled from work for a year before operation. She was curetted, the cervix was repaired, and the eft ovary removed through the vagina. The ovary was cirrhotic, but otherwise presented nothing abnormal. Within a few weeks she had resumed her usual duties and, with the exception of occasional prolapse of the uterus after a hard day's work, was in perfect health. CASE II.-Patient married, age, twenty-eight years; one child eight years old, no subsequent pregnancy. Cervix lacerated, chronic endometritis dating from birth of child. Left tube thickened and corresponding ovary enlarged, cystic and painful to the Was curetted, the cervix restored, and the pelvis explored through posterior vaginal incision. The diseased ovary and tube could not be brought into the vagina far enough to be tied off. The ovary was, therefore, returned after puncturing the cysts. Convalescence was free from fever. Left her bed in two weeks. Recovery complete with entire relief of pelvic symptoms and corresponding improvement in general health. CASE III.-Woman, twenty-eight years old, three children, youngest four years, two miscarriages. When first seen was profoundly septic, her temperature having reached 104° daily for several days. The history was that of ruptured ectopic pregnancy, beginning about eleven weeks before. Rupture had occurred into the broad ligament soon after the end of the sixth week. A large fluctuating tumor was found behind the uterus, reaching two inches or more above Poupart's ligament on the left. An opening was made through the vaginal wall an inch or more above and behind the lower border of the cervix. The incision opened into a cavity about the size of a fetal head, filled with thin, fetid blood and pus. The cavity was washed out, its walls partially curetted, cleansed again with peroxid of hydrogen and packed lightly with iodoform gauze. The temperature fell within a few hours to 9910. After three days the gauze packing was removed and replaced with a T-shaped rubber tube. Two months later the woman was in perfect health and had resumed her usual duties. CASE IV. A single woman, aged thirty-two, had suffered from extreme irritability of bladder for fourteen years. The intervals of micturition during the day rarely exceeded fifteen minutes. She had received treatment at the hands of several gynecologists. The left fold of Douglas was thickened, tense, and painful to the touch. Uterus retroverted and held by adhesions of broad ligament. Examination of bladder through a Kelly speculum showed a hyperemic patch at the trigone. Douglas' pouch was opened by an incision through the vagina and the left uterosacral fold freely divided. Adhesions were broken up and the fundus was fixed to the anterior abdominal wall with a single silk suture which was removed method in the treatment of septic disease in the pelvis by the work of Henrotin. While the subject is not new, it has assumed new importance and the method finds new applications. I have usually proceeded as follows: The woman is placed in the lithotomy position under an anesthetic. The antiseptic preparation is the same as for vaginal hysterectomy. If, however, we accept the conclusions of Krönig and Menge the preliminary antisepsis of the vagina, before operation, is unnecessary. The perineum is held back with a short-billed retractor. The cervix is drawn as far forward against the pubic bones as the mobility of the uterus will safely permit. A longitudinal fold of the vaginal wall is caught with a double tenaculum in the median line behind the uterus. This fold is cut with strong blunt-pointed scissors an inch to an inch and a half from the lower border of the cervix, the scissors being held with the points against the posterior wall of the cervix. A similar fold is then seized at the bottom of the incision and clipped. Sometimes the peritoneum is opened at the second clipping. It is better after dividing the vaginal wall to open the peritoneum with the finger. There is generally free bleeding for a moment from the incision, but seldom enough to require a hemostatic suture. The primary opening is small and is well away from the uterine arteries and the ureters. It is readily enlarged if necessary to admit two or three fingers. Free access is now had to the entire pelvic peritoneum and its contents for exploration or treatment. I have not found it necessary to add a longitudinal incision. The uterus, if movable, is already partially retroverted by the traction of the volsella. With one hand over the abdomen, the ovaries and tubes can, in most cases, easily be pressed down within the grasp of the vaginal fingers and drawn to the vulva. Adhesions can safely be broken up, pus collections in tube or ovary, peritoneum or broad ligament, opened and drained, and even adherent knuckles of intestine may sometimes be brought into view and separated under direct inspection. The wound is left open or is immediately closed according to the indications. CASE I. A neurotic woman about thirty-five years of age, married five years; had one child 3 years old. Cervix lacerated and eroded; profuse muco-purulent discharge from the uterus; pain in region of left ovary. Was disabled from work for a year before operation. She was curetted, the cervix was repaired, and the eft ovary removed through the vagina. The ovary was cirrhotic, but otherwise presented nothing abnormal. Within a few weeks |