A System of Operative Surgery Part 15

Sir Spencer Wells had removed a large, multilocular ovarian cyst from the left side of the patient, when he felt what was supposed to be a cyst of the right ovary. When tapped it was found to be a gravid uterus, in which pregnancy had advanced to near the fifth month. Caesarean section was at once performed and the patient recovered.

Injuries of this kind are rarely likely to happen now, for the clumsy ovariotomy trocar is pa.s.sing out of use.

[Ill.u.s.tration: FIG. 24. DIAGRAM REPRESENTING A GUNSHOT INJURY OF THE UTERUS. The woman was aged 28, and in the seventh month of pregnancy.

The bullet was extracted from under the skin on the left side, four inches behind the anterior superior spine of the ilium. The line A B represents the track of the bullet. (_British Medical Journal_, 1896, vol. i, p. 332.)]

=Bullet-wounds of the pregnant uterus.= These are very rare, and, like rupture of the uterus, liable to be complicated with injury of the intestines; it is for this reason that the canon of surgery applicable to penetrating wounds of the abdomen should be practised in these circ.u.mstances, and the patient submitted to cliotomy.

When the gravid uterus is penetrated by a bullet there may be little bleeding on account of the contracting property of the uterine tissue.

In some instances amniotic fluid stained with blood escapes. In operating, the anterior as well as the posterior surface of the uterus should be carefully examined in order to determine if the bullet pa.s.sed through this organ. In some instances the ftus has been injured by the bullet. When free bleeding follows a bullet-wound of the gravid uterus the haemorrhage is usually due to damage of blood-vessels connected with the intestines.

The best method of dealing with the uterus in such conditions is undetermined, but a study of the few reported cases indicates that the best results follow cliotomy, with suture of the perforated intestine and the hole or holes in the uterus. The patients usually abort. In Prichard's case (Fig. 24) hysterectomy was performed, but the patient died.

Even in some apparently desperate cases good consequences follow the conservative operation, as the following reports demonstrate:--

In a case under the care of Albarran, the patient was aged nineteen years and in the fifth month of pregnancy when shot. There were four perforations of the small intestines, and the mesenteric artery was wounded. He resected 20 centimetres of small intestine. A loop of umbilical cord protruded through the bullet-hole in the uterus; this was resected and the ends of the cord tied. The patient miscarried a few hours after the operation, but recovered.

Baudet reported a case in which there were four perforations of the small intestine: he sutured the wounds in the uterus and the holes in the bowel; the woman aborted some hours after the operation, but recovered.

In a case under Robinson's care the bullet entered the uterus and penetrated the right shoulder of the ftus. The patient, who was in the eighth month of pregnancy, quickly miscarried. The bullet was found in the debris. The patient not only recovered, but reconceived, and gave birth to another child in the following year.

=Stab-wound of the pregnant uterus.= Examples of this kind of injury are rare, but some of the recorded cases are remarkable. Guelliot has recorded the details of a case in which a pregnant woman was stabbed in the b.u.t.tock. The knife pa.s.sed through the great sciatic notch, and penetrated the uterus and the child's skull. The woman miscarried of a dead ftus next day. The great sciatic nerve was injured, but the woman recovered, though she remained lame.

Steele recorded an example where a woman, six and a half months pregnant, stabbed herself in the lower abdomen with a knife; she was taken to a hospital and kept at rest until the wound healed. Six weeks after the injury the woman was delivered of a live male child, normally developed, but much of the child's large and small intestines protruded through an opening in the abdomen. The jejunum was completely severed as a result of the stab. Steele attempted to deal with this extraordinary lesion surgically, but the child died a few hours later.

REFERENCES

ALBARRAN. Plaies multiples de l'intestin et de l'uterus gravide par balle de revolver. _Bull. et Mem. de la Soc. de Chirurgie de Paris_, 1895, xxi. 243.

BAUDET, R. Plaies de l'intestin et de l'uterus gravide par balle de revolver. _Bull. et Mem. de la Soc. de Chir. de Paris_, 1907, x.x.xiii. 779.

BLAND-SUTTON, J. A Clinical Lecture on the Treatment of Injuries of the Uterus. _The Clinical Journal_, 1908, x.x.xi. 289. On two cases of Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1907, lvi.

BRAUN-FERNWALD, R. VON. uber Uterusperforation. _Zentralbl. f. Gyn._, 1907, x.x.xi. 1161.

CONGDON, C. Abdominal Section for Trauma of the Uterus. _The Am. Journal of Obstetrics_, 1906, liv. 618.

DONALDSON, H. J. An unusual Obstetric Complication, causing the removal of 126 inches of Small Intestine. _Surgery, Gynaecology, and Obstetrics_, 1908, vi. 417.

DUDLEY, P. Discussion on Accidental Rupture of the Non-parturient Uterus. _Trans. Am. Gyn. Soc._, 1905, x.x.x. 21.

GUELLIOT. Coup de couteau ayant penetre a travers l'echancrure sciatique jusqu'a l'uterus gravide et jusqu'au ftus, &c. _Societe de Chirurgie_, 1886, xii, 337.

HARRIS, R. P. Cattle-horn Lacerations of the Abdomen and Uterus of Pregnant Women. _The Am. Journal of Obstetrics_, 1887, xx. 673.

IVANOFF, N. De l'etiologie, de la prophylaxie et du traitement des ruptures de l'uterus pendant l'accouchement. _Annales de Gynecologie_, 1904, 449.

JAKOB, J. Gefahren der intra-uterinen instrumentalen Behandlungen.

_Zentralbl. fur Gyn._, 1906, x.x.x, No. 19, 561.

JARMAN, G. W. Accidental Rupture of the Non-parturient Uterus, with report of cases. _Trans. of the Am. Gyn. Society_, 1905, x.x.x. 15.

KEHR, H. uber einen Fall von Schussverletzung des graviden Uterus.

_Centralbl. fur Chir._, 1893, xx. 636.

KERR, MUNRO. On Rupture of the Uterus. _Brit. Med. Journal_, 1907, ii.

445.

KLIEN. Die operative and nichtoperative Behandlung der Uterusruptur.

_Arch. f. Gyn._, 1901, lxii. 193.

PRICHARD, A. W. A case of Bullet-wound of the Pregnant Uterus. _Brit.

Med. Journal_, 1896, i. 332.

ROBINSON, W. S. Death of Ftus _in utero_ from Gunshot-wound: Recovery of the Mother. _Lancet_, 1897, ii. 1045.

STEELE, D. A. K. Stab-wound of Ftus _in utero_. _Surgery, Gynaecology, and Obstetrics_, 1908, vi. 293.

VERCO, W. A. _The Australian Med. Gazette_, 1908, 681.

WALLA, A. VON. Ruptura uteri completa, abdominale Totalextirpation.

Heilung. _Centralb. fur Gynak._, 1900, xxiv. 497.

CHAPTER XI

THE AFTER-TREATMENT. RISKS AND SEQUELae OF ABDOMINAL GYNaeCOLOGICAL OPERATIONS

The performance of ovariotomy, hysterectomy, and allied procedures is attended by several risks, immediate and remote, which may spoil the best-planned and most carefully executed operation. Some of these may be avoided by careful attention to the details embraced by the phrase 'after-treatment'.

THE AFTER-TREATMENT OF ABDOMINAL OPERATIONS

The patient is returned to the bed with gentleness and usually lies on her back, but many anaesthetists prefer to turn the patient on one or other side for an hour, until there is a fair return to consciousness.

The patient then lies on her back and a pillow is placed under the knees. Hot-water bottles should not be placed in the bed with the patient until she is completely conscious, and they are rarely needed.

The healing of blisters caused by hot-water bottles is a slow process.

During the first twelve hours the patient complains of pain, thirst, and vomiting.

The thirst is in a measure relieved by administering six or eight ounces of normal saline solution by the r.e.c.t.u.m an hour after the patient returns to bed, and repeating it in three or four hours. The patient may wash her mouth out frequently with water, hot or cold, according to her fancy, and if there is no vomiting she may swallow a little hot water from time to time. As a rule, it is better for her to abstain from swallowing anything for the first eighteen hours; the best way to avoid vomiting after an anaesthetic is to keep the stomach empty.

There is always some pain after an abdominal operation, partly due to tension on the sutures, and colic. The injection of normal saline solution (a teaspoonful of salt to a pint of water) by the r.e.c.t.u.m often controls this, but occasionally the pain is so severe that it is necessary to give a quarter of a grain of morphine hypodermically, or in a suppository, about twelve hours after the operation, in order to procure sleep. The routine use of morphine after these operations is injudicious and rarely necessary.

At the end of twenty-four hours small quant.i.ties of barley-water, tea, or milk and water are given, and if retained they may be taken in increasing quant.i.ties. On the fourth day an enema is given to clear the bowel, and then the patient will take fish, chicken, &c., and soon get on to convalescent diet.

When vomiting is very troublesome, it is sometimes necessary to keep a patient on rectal feeding two or three days.