(iv) Other conditions, such as intractable uterine hæmorrhage, usually due to uterine myo-fibrosis, and, as a last resort, severe dysmenorrhœa.
It has also been advised for irreducible chronic inversion of the uterus, and for severe procidentia uteri. No case of the former has occurred in the author’s experience in which the operation was found necessary. In the latter condition the operation is not to be recommended, the almost certain result of the procedure being prolapse of the vaginal walls and the intestines (enterocele).
Vaginal hysterectomy for carcinoma. The only cases suitable for operation are early ones, in which the disease is still confined to the uterus itself, which should be freely mobile in all directions. No signs of infection of the surrounding cellular tissue and vaginal walls should be present. It cannot be too strongly insisted that all cases should be thoroughly examined under anæsthesia to settle this point before operation is decided upon. Rectal examination is most important to estimate the condition of the sacro-uterine ligaments, the cervix being pulled down so as to place them on the stretch.
Occasionally, cases of carcinoma of the cervix are seen, in which the cellular tissue immediately surrounding the cervix is apparently free from disease, but if search be made further outwards, a hard, fixed mass is found plastered, as it were, on to the side of the pelvis, indicating advanced disease of the lymphatic glands, or cellular tissue at the outer part of the broad ligaments. Such cases are hopeless for operation.
If the disease is in the sloughing stage, and there is foul discharge, Paquelin’s cautery should be applied to the diseased surface, followed by vaginal douches of formalin (ʒj to the pint), or some other efficient antiseptic, given three times a day for three days prior to operation. The operation consists of three main stages:—
| (a) | Separation of the cervix from the vagina, pushing up of the bladder and ureters, and opening the anterior and posterior peritoneal pouches. |
| (b) | Removal of the uterus by ligaturing and dividing the broad ligaments. |
| (c) | Treatment of the peritoneal and vaginal flaps thus left. |
First of all, the growth, if of the cervix, should receive careful preliminary attention, for it constitutes a continuous source of infection, not only by means of septic organisms, but also of cancer cells, which may become implanted in the wound and cause early recurrence. The cervix is drawn down with a volsella and all visible growth is burnt away with the Paquelin cautery, until apparently healthy tissue only is left. The cervix is then completely closed by the application of a volsella or three or four stout silk sutures, passing through both anterior and posterior lips. The ends of the sutures may be left long if preferred and serve as tractors.
After these preliminary measures against infection have been completed, the removal of the uterus is proceeded with. A posterior speculum, Auvard’s or Pozzi’s, is passed, and the cervix is drawn downwards and somewhat backwards by traction on the volsellum or the long ends of the silk sutures. A sound is passed into the bladder to define its lower limit. A transverse or T-shaped incision ([Fig. 48]) is now made through the vagina at the level of the cervico-vaginal junction in front. This constitutes the anterior incision, and the transverse portion should extend completely across the anterior aspect of the cervix, passing through the whole thickness of the vagina, but no further.
The knife is now laid aside, and the operator proceeds to push up the vagina and bladder from the anterior aspect of the cervix with the index-finger or a winged director, until the anterior peritoneal pouch is reached. This is at once recognized by its glistening white appearance and by the manner in which its opposing surfaces glide over one another.