After removing the diseased parts and securing the large vessels directly concerned in the pedicles, attention is directed to the oozing from the torn tissues in the floor of the pelvis. Any vessel which is bleeding should be ligatured with thin silk, and then the recesses of the pelvis may be firmly plugged with a dab wrung out of hot water: this is a valuable measure of hæmostasis. This dab is removed in two or three minutes, and any vessel which is bleeding is quickly seen and ligatured.
In cases where the enucleation of adherent and inflamed tubes leaves large raw and slightly oozing surfaces in the pelvis, drainage is a wise precaution. After a trial of a variety of measures for this purpose I find the simplest to be a narrow rubber drainage tube reaching to the bottom of the pelvis and emerging at the lower extremity of the abdominal incision. It is rarely required for more than forty-eight hours. Some surgeons are opposed to drainage, and one writer compares it to ‘defending oneself against the sparks of Vulcan with an umbrella’; his mortality is high.
In simple cases the incision is closed according to the method described on [p. 9]; but after the removal of suppurating ovaries and tubes it is better to unite the wound by a single layer of sutures through all the tissues of the abdominal wall: buried sutures in such conditions nearly always give trouble.
Abdominal hysterectomy after bilateral oöphorectomy and ovariotomy. After the complete removal of the ovaries and tubes the uterus is a useless organ, and when the ‘appendages’ have been removed for inflammatory lesions, acute or chronic, it may become a troublesome organ. In some instances a uterus devoid of its appendages has been attacked by cancer. In a few instances in which patients have undergone bilateral oöphorectomy, or bilateral ovariotomy, successful conception has followed the operation (see [p. 17]).
The most annoying consequences which follow bilateral oöphorectomy for salpingitis, acute or chronic, are hæmorrhage, pain, or a purulent discharge. Every surgeon with an ordinary experience of this class of surgery has probably had to remove the uterus on several occasions as a sequel to bilateral oöphorectomy.
It is advised by many surgeons, when they find the appendages so hopelessly diseased that they must be removed, to perform subtotal hysterectomy at the same time. My own practice in this matter is to perform subtotal hysterectomy when it is necessary to remove the uterus as well as the appendages in chronic disease; and total hysterectomy when it is deemed advisable to remove the uterus with the appendages in acute infective conditions. The reasons for this modification are obvious, because in chronic conditions there is little liability for the stump to become infected, for experience teaches that though the distended tubes contain pus in chronic cases, yet on bacteriological examination this pus is sterile. In the acute cases the pus swarms with micro-organisms—bacillus colli, staphylococcus, and occasionally streptococcus; these infect the stump, set up suppuration, infect the ligatures, and establish a chronic sinus. To cure this condition it is necessary to remove the stump by the vaginal route.
In cases of tuberculous infection of the Fallopian tubes it is not necessary to remove the uterus unless it is obviously implicated by the disease. In several patients I have left an ovary without any subsequent ill consequences.
Mortality. In order to estimate the risks of oöphorectomy it is necessary to classify the heterogenous conditions for which this operation is required. In the majority of cases the chief cause is inflammatory (septic) affections of the Fallopian tubes: other causes are tubal and ovarian pregnancy, and prolapse of the ovary. Tubal pregnancy is considered in a separate chapter, and as prolapse of the ovary is so often associated with retroflexion of the uterus it is dealt with in the chapter on Hysteropexy.
In order to give some notion of the relative frequency of the infective conditions of the tubes and ovaries usually classed in Hospital Reports as ‘diseased uterine appendages’, I chose one hundred consecutive operations from my case-reports at the Chelsea Hospital for Women. They are classed thus:—
| Salpingitis | 49 |
| Pyosalpinx | 31 |
| Hydrosalpinx | 10 |
| Tuberculous | 8 |
| Ovarian abscess | 2 |