In briefly considering these different methods, it may be premised that all those precautions characterizing " strictest antisepsis," are invariably to be taken.
In dealing with the pediculated variety of sub-serous fibroid, the opera tion will resemble simple ovariotomy. The pedicle is transfixed, secured by ligature near the uterus, and cut. If the pedicle is very broad, or very vascular, it is advisable to ligate each bleeding vessel, or to secure it by suture.
If it becomes necessary to cut a part of the tumor out of the substance of the uterus, owing to a very broad attachment, the uterine wound is to be sewed up.
These operations being comparatively simple, justify a favorable prog nosis. Thus out of 21 cases Schroeder only lost 2, a mortality of 9.5 per cent.
The cases mentioned under the second and third categories entail much more difficult and complicated methods of operation. In performing either partial or supra-vaginal amputation of the uterus, it is necessary to secure both the round and broad ligaments by double ligatures. When the uterus and the tumors that grow from it are thus made freely mov able, it is best to place a rubber tube around the cervix, or at a point corresponding to the site selected for amputation. (Kleeberg.') The uterus and tumor are then removed by ablation. If by this procedure the cavity of the uterus has not been opened, the wound is closed by suture, just as in simple myomotomy. In supra-vaginal amputation, the uterine cavity is of course always laid open, which constitutes a serious complication. The question in such cases is what to do with the pedicle, consisting of the cervix or the stump of the amputated uterus. At first, just as in ovariotomy, it was deemed advisable to use the extra-peritoneal method. But later the intra-peritoneal method was more generally adopted. Nevertheless, even at the present day, this point is still in dispute.
In my opinion the intra-peritoneal method is to be preferred, as doing all that the others can do, but being in addition more simple and always possible of execution. Still, it is not to be denied that, in certain cases, the extra-peritoneal treatment of the pedicle may be almost a necessity.
Two objects must be kept in view in treating the pedicle. The first is to obviate bleeding, and the second is to prevent infection. The older method, as practised by Wan, lioeberle and Rose,' consists in carrying through the region of the internal os a large needle armed with a double ligature of silk or wire, and then to tie the ends laterally. This prevents bleeding from the uterine arteries, and also shuts off the cervical canal. The stump can be secured by clamp in the lower margin of the abdominal incision, and kept, so far as possible, in an aseptic condition.
But to carry out systematically the extra-peritoneal method of treating the pedicle, Hegar's plan is to be preferred to the others. This author stitches the pedicle to the abdominal walls in such a way that the parietal peritoneum is carefully sewed to the pedicular peritoneum. In this way the cervical wound is kept altogether without the cavity of the peri toneum.
For intra-peritoneal treatment Schroeder's plan is the simplest. After ablation of the tumor and while the rubber tube is still in position, the stump is trimmed in such a way that two opposing flaps are formed. These are secured by sutures placed in rows at different levels (Elven Wilde). The edges of the peritoneal investment are finally closed by a series of very fine sutures.
Olshausen excises a part of the mucous membrane of the cervix, closes the opening by stitches of catgut, but does not use the Schroeder sutures at different levels. He also catches the peritoneum as he goes along, in place of employing a series of separate stitches for that membrane. I have also always employed the latter method. I have simply closed the wound in the stump by very deep sutures, and have then introduced a tampon of iodoform from the vagina.
Olshausen has, under certain conditions, allowed the constricting rubber band to remain in situ, without untoward effects, barring the formation of a fistula in one case. I have not deemed this necessary, always, like Schroeder, removing the rubber after application of the sutures.