Polypoid or sessile intra-uterine growths smaller than a child's head at term can he removed through the dilated cervix, by morcellation. The uterus usually contracts readily after the re moval, but, if not, a tight packing with gauze, which should be removed during the second twenty-four hours, and ergot internally, will prevent heemorrhage.
Small subserous or intramural growths palpable on the anterior or posterior uterine walls can be enucleated and the bed sutured through an incision in the anterior or posterior vaginal fornix (ante rior or posterior colpotomy). Such tu mors, when larger than an egg, require abdominal section for their enucleation. Polypoid and submucous tumors larger than a foetal head at term can be enu cleated by abdominal section and in cision through the uterine wall. The uterus can then be sutured with catgut, and, if the bed cannot be obliterated by eutures, it can be packed with gauze that extends out through the vagina, and the peritoneal side be closed. When many intramural myomas are present the uterus may be amputated at the internal os (supravaginal hysterectomy) or be moved with the cervix (total extirpa tion, panhystercctomy). Multiple small fibroids with symptoms may he treated by vaginal hysterectomy.
The health of a woman during her sexual period of life suffers less from the loss of her uterus than from the complete removal of the ovaries. Close observation and study of clinical reports show that continued menstruation after oliphorectomy occurs under two distinct conditions: (1) when oophorectomy has been performed for inflammatory lesions of the tubes and ovaries; (2) when the operation has been carried out to antici pate the menopause in patients with uterine myomata. The operative disad vantages of abdominal enucleation of myomata compared with hysterectomy are many. A careful consideration of all the facts makes it clear that the uterus can only be considered as a re ceptacle or reservoir wherein oh-perms may develop. It is secondary, and cer tainly subservient, to the ovaries. It is not a vital organ, and its removal en tails two physiological sequelaa in women during the sexual period of life, namely: amenorrhaxt and sterility. J. Bland Sutton (Brit. Med. Jour., April S, '99).
It is a very important matter to pre serve ovaries to avoid the symptoms which removal brings, besides the moral suffering. In removing the uterus or a fibroid tumor an ovary should be left behind. Gynaecologists usually limit enueleation of fibroid tumors to solitary growths. Twenty-seven enucleations per sonally performed. The indications for enucleation should he so enlarged as to embrace cases in which several myomata are present. Olshausen (German Surg. Conp..; Brit. Gynme. Jour., Aug., I9001.
_Enucleation.—This is accomplished by making an incision across the tumor, catching hold of it with a vulsellum or a hook passed between the separated edges of the incision. enucleating with the fingers or blunt-edged instrument, and sewing up the bed with formalde hyde or formalin catgut.
Abdominal supravaginal hysterectomy is performed about as follows: Trendel enburg's position. Incision in median line extending from above pubes to below umbilicus. Separation of adhesions. In cision of capsule of any tumor that may be held down in pelvis, and enucleation of the tumor from its broad-ligament bed. Separation of the bladder from the tore of anterior peritoneal flap over the stumps of broad ligaments and uterus.
An operation practiced at the Johns Hopkins Hospital, and demonstrated in upward of two hundred eases within the past two years, consists in the fol lowing steps: 1. Opening the abdomen.
2. Ligation of the ovarian vessels near the pelvic brim, either on the right or on the left side, clamping them toward the uterus, and cutting between.
3. Ligating the round ligament of the same side near the uterus, cutting it uterus. Ligature of the ovarian and uterine arteries, or of the broad liga ments down to the internal os, clamp ing next to the uterus. Section of broad ligaments between ligatures. Am putation of cervix at the internal os. Disinfection of cervix. Excision of a transverse, wedge-shaped piece from cer vix, leaving an anterior and posterior flap. Paring out the cervical mucous membrane. Suture of the two cervical flaps with superficial catgut sutures. Su free, and connecting the two incisions, in order to open up the top of the broad ligament.