A System of Operative Surgery Part 11

[Ill.u.s.tration: FIG. 21. PORTION OF OVARY AND FALLOPIAN TUBE. The parts were removed a year after a supposed complete ooph.o.r.ectomy had been performed to induce an artificial menopause. This fragment of ovary maintained menstruation regularly. Full size.]

Although a few writers, particularly Wallace, consider that all Caesarean sections should be performed with a view to ulterior pregnancy, this is not the opinion of the majority, for there are many women who, having pa.s.sed such an ordeal once, have no desire to do so again, and ask for something to be done to prevent its possibility in the future. This involves what is known as 'sterilization'.

=Sterilization after Caesarean section.= When Caesarean section is performed the uterus is preserved, and after convalescence the woman is in a position to reconceive. There are conditions in which she is most anxious to produce more children even with the risk of having them extracted by this operation. On the other hand, some women, knowing the risks, ask that steps may be taken to prevent a recurrence of what they consider a catastrophe. This appears a simple matter, but it is not so in reality, for in many instances in which the operator had been under the impression that he had effected this by ligature of both Fallopian tubes in continuity, he has been surprised when the woman has again come under his notice well advanced in pregnancy.

This has happened even when each tube has been ligatured in two places and a segment of the tube exsected between the ligatures. Bilateral ooph.o.r.ectomy has been recommended, but on the whole, when the patient and her husband wish that further risks should be avoided, the wisest plan is to perform subtotal hysterectomy instead of Caesarean section; moreover it is a difficult matter to completely remove healthy ovaries, and _it needs only a small portion to maintain menstruation_ (Fig. 21).

The whole of this matter is one that is really a question of ethics, and the extreme views are represented by Wallace and Sinclair in the papers to which reference has already been made. The difficulty of effectively sterilizing women by simply relying on bilateral ooph.o.r.ectomy is shown by the well-established cases in which patients have successfully conceived after bilateral ovariotomy and ooph.o.r.ectomy.

The youngest patient on whom Caesarean section has been carried out with success to the mother and child was thirteen years of age. The operation was performed by Gache in Buenos Ayres on account of smallness of the pelvis. Women have recovered after a self-inflicted Caesarean section.

REFERENCES

DORAN, A. Pregnancy after Removal of both Ovaries for Cystic Tumour.

_Journal of Obstetrics and Gynaecology of the British Empire_, 1902, 11, i.

GACHE, S. Operation cesarienne sur une fille de 13 ans: Guerison.

_Annales de Gynecologie_, 1904, p. 601.

HARRIS, R. P. Six self-inflicted Caesarean Operations with recovery in five cases. _Am. Journ. of the Medical Sciences_, 1888, xcv. 150.

SINCLAIR, SIR WILLIAM. Caesarean Section successfully performed for the Fourth Time on the same Woman, with remarks on the production of Utero-parietal Adhesions. _Journal of Obstetrics and Gynaecology of the British Empire_, 1907, xii. 335.

WALLACE, ARTHUR J. On Repeated Caesarean Section. Ibid., 1902, ii. 555.

CaeSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER

It occasionally happens that a woman in whom the course of pregnancy is nearly complete dies suddenly from disease, such as haemoptysis, haematemesis, cardiac trouble, or uterine haemorrhage in the preliminary stage of labour; or is killed by accident. In some such circ.u.mstance attempts are sometimes made to rescue the unborn child, by performing Caesarean section. It is true that such efforts are rarely attended with success, but in cases where death is very sudden and the surroundings such as to enable the operation to be performed without delay, the child may be extracted from the uterus and survive. Successful cases of this kind are published from time to time.

In order to show how necessary it is to act promptly the following case may be mentioned:--

A woman in the eighth month of pregnancy was found to be suffering from cancer of the neck of the uterus. The child was alive. I decided to perform hysterectomy. The uterus was exposed through a free incision in the abdominal wall and quickly detached from its cervix. The uterus with the ftus inside was handed to an a.s.sistant, who quickly extracted the child. Although the time which elapsed from the complete etherization of the mother until the extraction of the child from the uterus was 2-1/2 minutes, it required the display of some energy to induce the child to breathe. This is the first record as far as I know of a child being delivered alive from a uterus detached from its mother. The woman died on the fourth day after the operation, and the child on the fourteenth.

Moglich had a successful case. A patient aged forty-one years, with placenta praevia, died from haemorrhage, and an asphyxiated ftus was promptly extracted by cliotomy. Prolonged efforts at artificial respiration were successful, and the child was well five weeks later (see also Sippel).

REFERENCES

HUGIER, M., and MONOD, M. Caesarean Operation immediately after the death of the Mother. _Lancet_, 1829-30, i. 899.

MoGLICH. Ueber Kaiserschnitt an der Toten. _Munchener med. Wochensch._, 1908, lv. 202.

SIPPEL. Sectio Caesarea in mortua. _Monats. f. Geb. u. Gyn._, 1907, xxvi.

618.

OVARIOTOMY AND HYSTERECTOMY DURING PREGNANCY AND IN LABOUR

Although the directions in surgical writings are clearly laid down concerning the course to be pursued when pregnancy and labour are complicated by an ovarian tumour, the difficulty which often confronts the operator when he is face to face with the actual case is uncertainty regarding the nature of the tumour. Although he may begin the operation under the impression that he has to deal with an ovarian tumour, it may turn out to be a fibroid, a tumour of the pelvic wall, a misplaced spleen or kidney, a tubal pregnancy, a sequestered extra-uterine ftus (lithopaedion), or a calcified hydatid cyst. Thus an expected ovariotomy may terminate as a Caesarean section, or as a hysterectomy. In many cases the surgeon must rely on his own judgment and experience, but it may be useful to furnish some directions which may help him. It may be useful also to mention what unexpected conditions are sometimes found. Thus an experienced gynaecologist like Prof. Olshausen once removed a gravid uterus under the impression that it contained a cystic fibroid which would obstruct delivery. When it was examined after removal, the suspected fibroid proved to be a large sacral teratoma growing from the ftus.

=Ovarian tumours and pregnancy.= Before the fourth month of pregnancy, single and double ovariotomy is attended with a low rate of mortality, and the risk of disturbing the pregnancy is small. The removal of a parovarian cyst during pregnancy is more liable to be followed by abortion than single or double ovariotomy. After the fourth month the risk is that of an ordinary ovariotomy, but the chances of abortion increase with each month. It is also a fact that ovariotomy may be safely carried out between the eighth and ninth months of gestation without precipitating labour, even when the tumour is incarcerated in the pelvis.

In many cases in which ovariotomy is urgently indicated during pregnancy, the pedicle will be found twisted.

When the tumour is situated above the uterus there is rarely any difficulty in dealing with it, as the pedicle is usually long, but it will require extra care in applying the ligature, as the tissues, being unusually vascular and soft, are easily lacerated. Occasionally the tumour lies in the pelvis below the uterus: in this case the surgeon carefully insinuates his hand between the pelvic wall and the uterus, and then gently withdraws the tumour from its incarcerated position.

CASES IN WHICH OVARIOTOMY HAS BEEN PERFORMED NEAR THE END OF THE NINTH MONTH OF PREGNANCY

+------------+--------+---------+------------------------------------+ _Result _Result _Surgeon._ to to _Reference._ Mother._ Child._ +------------+--------+---------+------------------------------------+ Pippingskold R. Stillborn _Am. J. of Obstet._, 1880 xiii. 308. Bland-Sutton R. Lived _Brit. Med. Jour._, 1895, i. 461. Morse R. Lived _Trans. Obstet. Soc._, x.x.xviii. 221. +------------+--------+---------+------------------------------------+

In operating for ovarian cysts complicating pregnancy, the surgeon should, after removing the cyst, carefully examine the other ovary, for twin tumours may be present. Berry Hart performed ovariotomy on a woman in the fifth month of pregnancy, and removed a dermoid of the left ovary 'enlarged to about the size of a man's brain by recent haemorrhage due to the twisting of a pedicle'. The patient died on the ninth day. A frozen section was made of the pelvis, and on inspecting the cut surface the right ovary, converted into a dermoid, was found incarcerated by the gravid uterus.

Many cases have been published in which ovariotomy has been undertaken during the late months of pregnancy, or shortly after delivery, and the surgeons have been astonished to find both ovaries converted into tumours; in very many instances they were dermoids. Cases of this kind have been recorded by Knowsley Thornton, F. Page, Cullingworth, Berry Hart, Malcolm Campbell, and others, including myself. These observations demonstrate that a woman may have both her ovaries occupied by dermoids, yet the glands are capable of yielding fertilizable ova.

Campbell relates that Brewis, in performing an ovariotomy during pregnancy, attempted to conserve some ovarian tissue by resecting the dermoids; this proved impracticable, and both ovaries were excised. Miss Ivens records a case in which a woman thirty-five years of age was five months pregnant and required ovariotomy on account of an incarcerated ovarian dermoid. In the course of the operation both ovaries were found to contain dermoids. A tumour was successfully excised from each.

Pregnancy continued undisturbed.

REFERENCES

CAMPBELL, M. Case of Bilateral Ovarian Dermoid Tumour a.s.sociated with Pregnancy. _Lancet_, 1907, ii. 1760.

CULLINGWORTH, C. J. Three cases of Suppurating Dermoid Cyst, of or near the Ovary, treated by Abdominal Section. _St. Thomas's Hospital Reports_, 1887-9, xvii. 139.

HART, BERRY. See Clarence Webster's _Researches in Female Pelvic Anatomy_, Edin., 1892, p. 124.

IVENS, MISS F. Pregnancy complicated by Bilateral Ovarian Dermoid Cysts.

_Brit. Med. Journal_, 1908, i. 625.

PAGE, F. Acute Peritonitis after Confinement; abdominal section; Dermoid Disease of both Ovaries; removal; recovery. _Lancet_, 1893, ii. 250.

THORNTON, K. A case of removal of both Ovaries during Pregnancy. _Trans.

Obstet. Soc._, London, xxviii. 41.

=Ovariotomy during labour.= When an ovarian tumour is discovered during labour and it impedes delivery, ovariotomy should be performed.

In this condition it follows that the tumour lies in the pelvis; when the tumour is tightly impacted by the contracting uterus it has happened that the surgeon has been unable to reach the tumour until he has emptied the uterus by Caesarean section. Several operators have had this difficulty, myself among them. I have added a list of reported cases drawn from British sources. For this I hope not to be accused of what is sometimes perhaps facetiously called 'insularity'. The enormous population of these islands should furnish material enough to settle the principles of treatment which should govern these terrible cases of obstructed labour.

One of the commonest conditions met with in ovariotomy during pregnancy and labour is to find that the cyst has undergone axial rotation and twisted its pedicle. The technique in these circ.u.mstances is very simple.

OVARIOTOMY FOR TUMOURS OBSTRUCTING LABOUR AT TERM

-----------+--------+--------+---------+------------------------------ _Nature _Result _Fate _Operator._ of to of _Reference._ Tumour._ Mother._ Child._ -----------+--------+--------+---------+------------------------------ Williams Cyst R. No record _Trans. Obstet. Soc._, xxvi.

203.

Spencer Dermoid R. Lived Ibid., xl. 14.

Boxall[1] Dermoid R. Lived Ibid., xl. 25.

Bland- Dermoid R. Lived _Lancet_, 1901, i. 382.