A PLEAFOE THE

Extra-Peritoneal Treatment of the Stumpin Abdominal Hysterectomy

for Fibroids,

BY

A. LAPTHORN SMITH, 8.A., M.D., M.R.C.S., E., F.O.S. L.

Lecturer on Gynecology, in Bishop’s College; Surgeonto the Woman’s Hospital; Gynecologist to the

Montreal Dispensary.

[Reprinted from CanadaLancbt, January,1891. J

TORONTO:Dudley & Burns, 11 Colborne St.,

1891.

A PLEA

FOR THE

Extra-Peritoneal Treatment of the Stumpin Abdominal Hysterectomy

for Fibroids,

BY

A. LAPTHORN SMITH, 8.A., M.D., M.R.C.S., E., F.O.S. L

Lecturer on Gynecology, in Bishop’s College; Surgeonto the Woman’s Hospital; Gynecologist to the

Montreal Dispensary.

[Reprinted from Canada Lancet, January. 1891.]

TORONTO I

Dudley & Burns, 11 Colborne St.,1891.

ABDOMINAL HYSTERECTOMY FOR FI-BROID TUMORS OF THE UTERUS.*

A. LAPTHORN SMITH, B. A , M. D., M. R. C. S., ENG.

At the outset of my paper, I wish to correct apossible misunderstanding which may arise frommy reading a paper at all on the “OperativeTreatment of Fibroids and Myomas.” Because Ido so, I do not wish it to be understood that Ihave in any way lost faith in the electrical treat-ment, used with a definite object in certain par-ticular cases. Neither by reading this paper doI mean to advise that fibroids and myomas shouldbe treated by operation at all, except in certainspecial conditions. Where pain or bleeding, orpressure symptoms are the reasons for the patientconsulting us, I believe still that in the majorityof cases, the careful application of the galvaniccurrent under rigid antiseptic precautions, willrelieve and even permanently cure in most casesall the symptoms. It is only in cases in whichthe tumor has come under observation, after ithas attained enormous dimensions, or in cases inwhich there is some doubt, without an explora-

* Read before Med. Chirurg. Society, Montreal, 21st Nov., 1890.

4

ory incision, whether the tumor is really a fibroidor myoma at all, that I would advise operativetreatment. Seeing that operative treatment issometimes required and that those who operateare in doubt as to what method of operation toadopt, it is the object of ray paper to urge themand those who send patients to them, to adoptthe extra-peritoneal method of treating the stump.

We must remember, as has been said over and over

again, that fibroid tumors rarely if ever cause deathand before exposing the patient to the risk of anoperation, the mortality of which varies ail theway from two or three to fifty per cent., accordingto the method adopted of treating the pedicle, theconscientious adviser must feel sure that he hasexhausted every other and less fatal method ofaffording relief or cure. Supposing that this hasbeen done without avail, and that some form ofoperative procedure, owing to the size of thegrowth, is imperative, the removal of the ap-pendages or Tait’s operation will certainly offerthe least risk, although it must be rememberedthat it, like electricity, is in the majority of cases,only palliative and not curative. Moreover, inundertaking the removal of the appendages, weare never sure whether the operation may notterminate in hysterectomy; for in large fibroids,the appendages are sometimes so difficult to get

5

at and to remove, that the taking out of thewhole tumor with them, offers a greater chance ofsuccess.

The next question of importance which presentsitself for consideration is, that, having decidedupon the advisability of performing abdominalhysterectomy, what method of operating offersthe greatest certainty of success, by success, mean-

ing, of course, recovery from the operation.After having examined carefully the statistics

of the principal operators, and judging also frommy own personal observation of the results ofthese operations in Paris, Berlin, New York,Philadelphia and Montreal, I have come to thevery decided conclusion that there is only onesafe way, that is, with Koeberle’s serre nceud,Tait’s pins, and the extra-peritoneal treatment ofthe stump. ... I have seen several deathsfollowing operations in which the stump, afterhaving been carefully sewed up, was dropped intothe peritoneal cavity ] some of these deathsbeing due to concealed hemorrhage, because thedrainage tube was not used, and others being dueto peritonitis; while I have not seen one deathfollow in any case in which the stump was

brought outside the peritoneal cavity. The timerequired for the completion of the operation ismuch less, and the ease with which the operation

6

Secondly, the intra-peritoneal method requiresthe leaving in the peritoneum or at least in the cututerus, a considerable quantity of animal ligature,which in the process of manufacture has gonethrough putrefaction. Of course this is supposedto have been sterilized, but I am informed by Dr.Marcy, of Boston, that he has had several deathsfrom peritonitis, following his operations for cure

of hernia; and on investigation he found that theso-called sterilized catgut was reeking with thegerms of putrefaction.

In a matter of such vital importance, it is wellfor us to take the opinion of men who have hadlarge experience; for, as a rule, experience insurgery is purchased at the price of life. Ban-tock, in the British Medical Journal for May,1890, in discussing the matter, says certain casesof pedunculated fibroid might be treated by liga-ting and dropping the the pedicle, but somepedicles would be insecure and dangerous, nomatter how carefully they were tied. He hadtried both plans, and it was his want of successwith the ligature that had led him to have re-course almost invariably to the extra-peritonealtreatment. He had used the most powerful for-ceps ; had compressed the pedicle to an eighth ofits original volume; had applied the double liga-ture; and had even stitched the peritoneal edges

7

is performed is much greater in the extra-peri-toneal method. This element of time requiredfor an operation is a very important one. I be-lieve the risk of any abdominal operation is, otherthings being equal, in direct ratio to the time re-quired. Part of this danger may be due to anaes-thesia, which itself is a serious matter, and partlyto the more prolonged pressure and manipulationof the intestines. This is so much the case thatone may almost say with certainty that inabdominal operations which can be performedwithout the intestines being seen, with an openingonly large enough to admit one or two fingers,and which only require 10 or 15 minutes for per-formance, the death rate will only be about 2per cent.

In the intra-peritoneal method, the stump mustbe constricted by a rubber band or some other force,while the tedious suturing of the stump is goingon. This constriction of blood vessels, it is wellknown, as in cases where the Esmarch bandage isused on the limbs, is generally followed by paraly-sis of the blood vessels and consequent oozing,probably due to injury of the vaso motor nerves,so that the experience of many operators is thatit is the rule to have oozing from the stump, nomatter how carefully the borders are approxi-mated.

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together, yet before the operation had been com-pleted, oozing had often begun. He insisted onthe fact that patients did not usually die fromthe haemorrhage, as such, but from septicaemia dueto the decomposition of the ooze. That was whythe use of the drainage tube was advised. Hewould be very glad if a method could be devisedto overcome the difficulties and drawbacks, as therecovery took much less time; but he had heardof no method which would give such assuranceagainst haemorrhage as that obtained from theextra-abdominal method.

Lawson Tait, in the same journal, holds thateven the most tempting looking pedicles can notbe relied on, because the uterine tissue is so ladenwith serum, that even if tied ever so tightly, itwould begin to bleed in twenty-four hours. Hehad tied some 6,000 pedicles, and while he hasnever had haemorrhage from ovarian pedicles, ex-

cept in one or two cases, it was quite anotherthing with the pedicles of fibroids. He re-gretted nothing so much as having been inducedto try the intra-peritoneal treatment of the pedi-cle. Even hydraulic pressure would not renderthem secure, and he had employed pressure up tothree tons. At present all that his nurses had todo was to give a turn to the clamp wheneveroozing set in. They were not secure until the

9

lapse of 80 or 90 hours. It was true that certaincases might be safely treated by ligature, butit was impossible to distinguish them prior tooperation.

Joseph Price, of Philadelphia, advocates thedry extra-peritoneal treatment of the pedicle.After the clamp is applied, the stump is cut offand trimmed down so far as seems compatible withsafety. The stump is then drawn down into thelower angle of the incision, and its peritonealcovering above and below the wire, stitched to theabdominal peritoneum, two or three stitches beingall that is required. This shuts out all possiblechance of sepsis. A dry dressing of iodoformgauze is applied. Other antiseptic powdered sub-stances, such as salicylic acid or subnitrate ofbismuth may be used if desired. In case of largesucculent stumps, the bichloride may be directlyapplied. The result of this treatment is that thestump is completely mummified, and in a fewdays, varying according to the progressive tight-ening of the clamp, drops off without odor ordischarge. That absolute safety may be assured,it is of the greatest importance that a reliablewire be used. The daily tightening of the clampkeeps up a constant strain on the metal, while atthe same time it brings the wire into a greatercurvature. The metal must, therefore, be pliable,

10

but strong, and not ductile as copper. For thispurpose he prefers the Delta metal.

Howard Kelley recommends constriction of thepedicle by the elastic ligature, amputation of thetumor so as to leave a cupped surface to thestump, then a careful suture of the raw surfacesof the stump, leaving the ends of the sutures long :

then suturing off the stump into the lower angleof the abdominal wound. In cases of haemorrhageor oozing, the long suture ends allow the stumpto be easily brought into sight. Whether thisimprovement of his has diminished his mortalityor not, I am unable to say, but I see by the lastreports on gynecology of the Johns Hopkins Hos-pital [British Medical Journal, Oct. 11th, 1890,page 848), that of the six hysterectomies forfibroids performed in that hospital between Oc-tober, 1889, and March, 1890, there were threedeaths or a mortality of 50 per cent. On theother hand, at the recent meeting of the Amer-ican Association of Obstericians and Gynecologistsat Philadelphia, Dr. Joseph Price reported thewonderful record of twenty-six consecutive ab-dominal hysterectomies without a death. The me-

thod which he invariably employs, being the extra-peritoneal treatment of the stump with Koeberle’sserre noeud and transfixing pins (Buffalo Medicaland Surgical Journal, Nov. 1890, page 222).

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Fritsch, at the 10th International Congress(.American Journal ofObstetrics, 1890, page 1166)summed up the whole question, to my mind, veryclearly, when he said :

“The different methods ofoperation are immaterial in view of the questionwhether the mode is to be intra-peritoneal or ex-tra-peritoneal.”

Only three objections to this method, are ofimportance which are :

First, that the dragging of the stump up to thelower angle of the abdominal incision causes, insome cases, obstruction of the rectum, but I havenever seen this occur to such an extent as notto be easily overcome by a turpentine enema,which by distending the rectum, allows the freeescape of gas.

The second objection is that in some cases, thetumor extends so far down in the cervix as torender it impossible to get a pedicle, but even inthis case, the same method holds good, for it isonly necessary to transfix it, no matter how large,with Tait’s pins, or even two knitting needles,and to set a wire around it, when, even if it were

the size of the thigh, it could be greatly com-

pressed. Besides, it is just in these cases inwhich shrinkage is greatest after an operation,that consequently the danger would be great-est of sewing up the stump and dropping it

12

into the abdominal cavity. It can be watched,and as it shrinks, the wire can be occasionallytightened, if rendered necessary by bleeding.

The third objection is that there is sometimesdownward sloughing of the stump ; but this I be-lieve can always be avoided by not tightening thewire more than just barely enough to controlhaemorrhage but leaving the screw always acces-sible, so that it may be tightened if necessary.

Drainage. —One of the greatest secrets of suc-cess in abdominal operations, is without doubt,the realization of the absolute necessity of leavingin a drainage tube in every case in which ad-hesions have been torn, and in which consequently,there will be oozing into the peritoneal cavity.It is quite true that the peritoneum, if left un-

hampered with opium in any shape or form, maybe able to dispose of a large amount of exudation,more especially if it is'drained through the wallsof the intestines, by the passage through thelatter of a denser saline fluid towards which theperitoneal liquids will flow by osmosis. But,nevertheless, the risk of leaving the liquid in theperitoneal cavity to putrefy, is too great for anyone to run. As Tait has recently shown, thereare germs everywhere, even in the peritonealcavity during an operation; but they will be ap-parently harmless if there be nothing there on

13

which to germinate. Germs cannot live on air,they must have dead organic matter to subsiston; so that instead of germicides, Tait and all hisschool depend rather on leaving the abdominalcavity clean, and keeping it so.

Looking over the death rate of abdominal hys-terectomy, we notice that the greatest run of suc-

cessful cases are in the practice of men such as

Joseph Price, who, as I have said, has recentlyreported a run of 26 consecutive cases, without adeath, and who, at a recent meeting of the Amer-ican Association of Gynecologists, stated thatwhen he was in doubt, he always drained, andsignificantly adds he always tried to believe him-self in doubt.

Some objections have been made to the use ofthe drainage tube, but they are mostly theoretical,and easily disposed of, the principal one being therisk of hernia following removal of the tube.This can easily be guarded against, by placing anextra loose suture in the middle of the space to beoccupied by the tube, and which on the removalof the tube can be drawn tight and tied. 1 havenever seen hernia follow a case in which thedrainage tube was used for a few days, while Ihave seen several cases of hernia in cases in whichit was not used at all.

The other objection is, that it may cause injury

to the" intestines, especially the rectum by thepressure upon it, but if care is taken to use a tubejust long enough to dip into Douglas’ cul-de-sacand no more, and to use no compression upon theexternal extremity, but, on the contrary, to leavethe tube floating freely in the cul-de-sac, therewill be no danger from this source. In somecases, I believe, death has followed the removal ofthe drainage tube while oozing was still going on.

The rule to follow is ; As long as the amountof fluid pumped from the tube exceeds one drachmfor four hours, the drainage tube should be leftin.

I see only one possible improvement on theextra peritoneal treatment of the stump, and thatis to have no stump at all. Two or three methodsof attaining this object have been suggested andput in actual practice. One consists in first re-moving the bulk of the tumor by abdominal sec-tion, after having placed an elastic ligature aroundthe cervix j then dropping the stump into thepelvis and temporarily closing the abdominalwound; and then proceeding to remove the stumpby vaginal hysterectomy, which, owing to themuch smaller bulk to be removed, is very mucheasier than vaginal hysterectomy in any othercondition. In doing this, lock compression for-ceps may be used to arrest haemorrhage from the

remains of the broad ligament, and considerablyshorten the duration of the operation. This, Ibelieve, is destined to become the ideal operationfor the removal of large fibroids. It was first ad-vocated, I believe, by Dr. A. Mary Dickson Jones,of Brooklyn, who recently sent a communicationin which she reports several successful cases inwhich this method was followed. The operationhas not been done, however, often enough tospeak so decidedly about it as we can about theextra-peritoneal method, and, therefore, until thecombined method of abdominal and vaginal hys-terectomy has been more thoroughly tried, I urgeupon any who do hysterectomy for fibroids at all,to use the safe and in every way satisfactorymethod of the extra-peritoneal treatment of thestump.