It cannot be denied that the ligatures which are dropped down with the pedicle have at times set up later disturbances. In those instances in which it is difficult to apply the rubber band, I have followed the method of Wan described above.
It seems ad visible in these operations to remove the ovaries, along with the uterine tumor. These organs are at best useless after so large a por tion of the uterus has been removed. Indeed they may do harm by being allowed to remain. Thus Pean lost a case in consequence of hinmatocele, which took its origin from menstrual congestion of the ovary Boeberle observed extra-uterine pregnancy, after extirpation of the uterus with out the ovaries, the cervical canal having been allowed to remain open. In another case of a similar kind, hemorrhage into Douglas's pouch and rectal bleeding occurred at the next menstrual epoch following the opera tion.
It follows, therefore, that as a rule, the ovaries should be removed in the operation. If it is found, however, that owing to adhesions, or other pathological conditions, this procedure would be difficult, it is best not to prolong the operation by attempts at removal of these organs.
The methods just described presuppose a pediculated tumor, or at least, that the uterus can be made use of for the formation of a pedicle. It was for a long time thought that growths of a certain size invading the cervix, and those projecting into the cellular tissue of the pelvis, were not amenable to surgical treatment. Spiegelberg was the first to devise a method of dealing with tumors of the former variety. In a broadly at tached cysto-fibroma, he performed abdominal section, split the capsule of the growth, enucleated it and then closed by suture the large uterine wound. The patient died. Other cases ' in which the uterine wound was not sewed up, also ended fatally. More recently, aided by antiseptic measures, some successful cases have been recorded. It is always well to use the rubber tube for purposes of constriction, and with the idea of limiting the loss of blood.
Sometimes, in doing this operation, it will be found that the uterine wound is so completely closed by contraction of the organs, that sutures are not necessary. But as a general thing it is advisable to sew up the uterine wound, especially when the uterine canal has been laid open.
Operations of this kind have been performed by Schroeder (Hofmeier 1. c.), Martin (1. c.) eight cases with three deaths), MOricke,' N. Eck,' Olshausen (l. c.), Gusserow (one successful case), and others.
More recently successful enucleations of tumors growing into the pelvic tissues have been recorded by Schroeder, Rose, Olshausen, Kaltenbach, Kiister, Gussenbauer, Breisky and others. In such cases also, whenever possible, " rubber constriction " should be used, in order to control bleed ing. The peritoneal investment of these growths is to be split, and the tumor peeled out by the aid of blunt instruments, or preferably the fingers. Firm bands are to be ligatured and cut. The uterine wound is to be closed by deep sutures. Drainage will be necessary in some cases. Whether the additional performance of amputatio uteri is called for depends of course upon the uterine relations of the growth and its size. Prognosis is naturally made worse by the extent of the surgical interfer ence. Schroeder lost twelve cases out of twenty-one of these complicated enucleations, a mortality of 57 per cent.
Finally, total extirpation of the uterus has been advised and done for difficult cases of this kind. Bardenheuer (1. c.) performed the operation successfully four times. Kottmann' and v. Maudach' have also reported similar cases.
On the whole, it does not seem clear what advantages this extremely difficult operation possesses over other methods of treatment, and, indeed, it has not beeen generally followed.
For completeness sake, we here present Pozzi's (Mc. cit., p. 150) statis tics concerning amputations or extirpations of the uterus, most of which were undertaken on account of an error in diagnosis, occasioned by the development of fibroids at the fundus, and consequent inversion of the uterus. Two of these operations, performed with the knife, resulted favorably. Five amputations of the uterus, with the tumor, finished by means of the ligature, resulted in two recoveries and three deaths. In eight cases both methods were combined. The ligature having been first allowed to remain in situ for some time, so that adhesion between the opposite uterine walls should occur at the point of constriction, the am putation of the fundus uteri and of the tumor was then undertaken.