Anterior Colpotomy in Pelvic Disease by J. WESLEY BOVEE, M.D. Washington, D. C. REPRINTED FROM The American Journal of Obstetrics Vol. XXXIV, No. 1.1896. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS 1896 ANTERIOR COLPOTOMY IN PELVIC DISEASE.1 So much has been said and written of late concerning the evil results of abdominal section that other avenues for reaching pelvic, intraperitoneal disease have been sought. The objections to abdominal section offered are : the liability to subsequent ventral hernia in the line of the incision ; the subsequent ugly scar that occurs in some cases, particularly when the drainage tube is used or when suppuration occurs in the line of the incision or along stitch holes ; adhesions of omentum or bowel to the line of incision of the peritoneum ; the handling and exposure of the abdominal viscera, consider- able at times, and which endangers the introduction of sepsis and, possibly, bowel paralysis with peritonitis ; the breaking-up of the provisional barrier formed often by the agglutination of intestines, omentum, uterus, bladder, and body wall to limit the extent of invasion of the disease ; and many others of less importance. Many surgeons have adopted the vaginal route as a substi- tute for abdominal section for the greatest variety of conditions. I might say that this is to a large extent due to the progress of vaginal hysterectomy for cancer, in which no minor part of the honor belongs to American gynecology. It was Krug and other Americans who demonstrated the very small mortality rate of this operation when done properly and upon suitable cases. Then the French surgeons began removing uterine fibroids, even intramural and subperitoneal, by the vagina, lauding this method even in cases where the tumors nearly reach the um- bilicus. Americans placed this operation upon trial, Polk and other New York men becoming quite enthusiastic over it. Cases of pelvic abscess, pyosalpinx, ovarian abscess, and other kindred pus accumulations have for years been evacuated 1 Read before the Washington Obstetrical and Gynecological Society, February 7th, 1896. 2 BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. through the vagina, sometimes with complete relief to the patient. Then came attempts, often hazardous, at removing suppu- rating appendages through Douglas' cul-de-sac. This was practised considerably and was followed by the astounding papers of Jacobs and others, who blamed the uterus for all the trouble in pelvic inflammation and that this traitor to pelvic health must be drummed out of camp ; that the uterus must be expelled whether the tubal or ovarian pus sacs were or were not disturbed. They declared the rational treatment of pelvic pus cases was to remove the uterus by vaginal hysterectomy, and that removal of diseased appendages was not necessary ; in fact, simply to drain them through the cavity left by the hysterectomy. This, too, is a French operation that has been adopted by many Americans. Montgomery, Werder, and some New York gentlemen have adopted it, and now Cushing, of Boston, appears on the stage as an enthusiastic player in this drama. No doubt a field for this operation exists, but that it will take the place of abdominal section for the severer pelvic diseases I am not prepared to admit. The operation I wish to offer for your consideration is a vaginal method of reaching the uterus and appendages, but not applicable to the very severe cases. It is known as anterior colpotomy and is done as follows : The patient is put in the dorsal position with the feet raised-the Edebohls table being particularly useful for this purpose-the vagina and vulva carefully cleansed, and a Simon speculum introduced. The cervix uteri is grasped by a volsella, drawn down toward the vulva as far as possible, and held by an assistant. With another volsella the anterior wall of the vagina is grasped just under the urethra and made tense by traction on the two volsellse. An incision beginning at the cervix and extending about an inch toward the ure- thral orifice is made in the vaginal wall between the volselhe. Meeting the cervical end of this incision, another is made which curves around the cervix in front and to the sides to the extent of about an inch, thus making two lateral flaps. These are dissected back laterally from the vagina and cervix. The ute- rus and bladder are now gently separated by the finger, care being necessary to prevent opening the bladder, and the peri- toneum opened. The finger may now be introduced through the opening for exploration or other purposes. I have been closing the wound in the following manner: With catgut or very fine silk suture close the peritoneum first. BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. 3 Then, with coarser silk, catgut, or kangaroo tendon, insert the first suture into one vaginal flap near its urethral end, taking care to not penetrate the vaginal mucous membrane ; carry it through the cellular tissue at the base of the bladder, slightly into the body of the uterus on the same side, superficially through the uterus, bringing it out on the opposite side of that organ at a point corresponding to that of its entrance, back through the cellular tissue, and into the other flap at a point opposite to its first insertion. The next suture passes into one flap, half-way from last suture to cervix, through the cervix, and back into the other flap at a point opposite its insertion. Another suture is passed into one flap at junction of incisions near cervix, slightly into that portion of the uterus, and back into the opposite flap. These sutures are now tied, and a more complete closure of the wound is made by a few fine, superficial sutures or by a buried one. The patient is now put to bed and the urine drawn or voided every few hours. If animal sutures are used no further treatment is necessary, and the patients may sit out of bed after twelve to twenty-five days, according to the severity of the condition of the pelvic organs. I have done the operation but seven times, with seven recov- eries, and presume the result would have been the same in these cases had abdominal section been done, but that such section is more dangerous than anterior colpotomy cannot be doubted. The value of any operation cannot be tested by a few applications, but enough has been done to merit the fur- ther trial of anterior colpotomy. The histories of my cases are as follows : Case I. Double Salpingitis.-Miss S. was admitted to Co- lumbia Hospital October 9th, 1895. She was 23 years old, white; had one abortion in November, 1894, two or three attacks of gonorrhea, and was an inveterate masturbator ; had severe cutting pains in both sides of the pelvis, was neurotic, and had profuse and painful menstrual flow. An examination revealed a very capacious vagina, a tender uterus, and small lateral pelvic masses. A few days later curettement was done. This, with other remedies, had not improved her by November 7th, 1895, when by anterior colpotomy the enlarged, inflamed, and adherent tubes were removed with cystic ovaries. She did nicely for a week, when localized pain and fever ensued. This I believe was due to masturbation, as she soon after felt well and has continued so. The Fallopian tubes were examined by Surgeon Walter Reed, U. S. A., Curator Army Medical Mu- 4 BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. seum, who kindly reported that no gonococci were found in them. Case II. Mental Aberration.-Mrs. R., white, 37 years old, multipara; seen in July, 1895. She was very nervous, begged for free professional service, and gave this history : She had a nice home and children, an indulgent husband, and a devoted mother. Previous to six months ago was a mastur- bator ; was curetted for endometritis two years ago. Two months ago consulted a woman homeopathist of this city and received a severe lecture for masturbating, and was assured in- sanity would ensue if the practice was at any time resumed. As she had considerable vulvar irritation, she was in constant fear that she would rub or in some other way handle her geni- tals, masturbate, and become crazy. She visited other physi- cians, giving the same history and imploring relief from this dreaded future. She had considerable pelvic pain and consti- pation. Examination.-The uterus was normal in size and position ; right appendages large and fixed. Later she com- plained of such a constant irritation in the region of the clitoris that her terror was extreme. Her husband told me that her fear of insanity from this cause was ever present and that many physicians had advised removal of the ovaries. Tonics and sedatives for six weeks failed to relieve her, and castration was advised as a dernier ressort. This was done November 5th, 1895, by anterior colpotomy, and a right cystic ovary with a thickened and degenerated tube was removed. The left atrophied ovary and normal tube were also taken out. Rapid recovery followed and a notable composure has continued since, though she still fears the same result. Case III. Multiple Fibroids and Adherent Appendages.- Mrs. R., white, widow, 38 years old, was treated by me in Columbia Hospital during the winter of 1894-95 for pain in the right side, probably due to small multiple fibroids and an en- larged uterus. Relief was afforded without operation and she was discharged. In October, 1895, she was admitted to my service in Providence Hospital, and, her complaint being worse, the adherent appendages were removed by anterior colpotomy, after curettement, November 17th, 1895. Her recovery was excellent and her relief complete. Case IV. Uterine Retroflexion with Adhesions and Pyo- salpingitis.-Mrs. N., white, IVpara, 28 years old, admitted to Columbia Hospital November 21st, 1895, complaining of severe pain in the back, rectum, and inguinal regions. Her last labor BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. 5 was seven years ago ; has had no abortions ; cries with pain when bowels move and severe bleeding follows ; is an invalid. Examination.-Fundus uteri bound down in Douglas' cul- de-sac ; a mass was felt on either side ; endometritis and a bi- laterally lacerated cervix were found ; large hemorrhoids and numerous ulcers, quite large, within and without the sphincter ani muscle, were also found. November 25th curettement and trachelorrhaphy were done, and then, by anterior colpotomy, the uterus was freed and the enlarged and adherent appen- dages, containing pus, were removed. They were nearly un- recognizable. The sphincter ani was then dilated, the hemor- rhoids removed, the ulcers excised, and all the raw surfaces covered by means of buried catgut sutures. She made a good recovery, leaving the hospital in three weeks. Case V. Cystic Ovaries and Adherent Appendages with Retroversion of the Uterus.-B. H., white, widow, 26 years old, was admitted to Columbia Hospital January 20th, 1896, where she had been treated a few months earlier. About one year before, I had done curettement and a trachelorrhaphy on her. She had had two children, the last four years ago after tedious labor, and two abortions, the last of which occurred five years ago. Complaint, pain in both inguinal regions and back and deficient, irregular, and painful menstruation. An exami- nation revealed a small, retro verted uterus that could be easily replaced but fell back, and enlarged and cystic ovaries that were adherent. The appendages were removed by anterior col- potomy January 23d, 1896, with good result so far as now known. Case VI. Multiple Fibromata Uteri and Adherent, Cys- tic Ovaries.-E. C., colored, 29 years old, married, was ad- mitted to Columbia Hospital January 22d, 1896, complaining of pain in lower abdomen and numbness in the vulva ; profuse, painful, and almost constant flow. Examination.-Uterus the seat of a number of fibroids and the ovaries adherent. By anterior colpotomy, January 27th, the uterus, fully three times its normal size, was carefully examined, its fundus with the appendages brought into the vagina, and hysterectomy found to be advisable. This was done, ligating from top of the broad ligaments downward and leaving considerable of the vaginal portion of the cervix for closure of the wound. The whole of the wound was closed by buried sutures. The ovaries were both cystic and removed. She is doing nicely and will prob- ably fully recover. 6 BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. Case VII. Retroversion and Metritis with Adhesions t and Double Hydrosalpinx with Cystic Ovaries.-Lucy B., colored, 26 years old, married, was admitted to Columbia Hos- pital January 16th, 1896, complaining of pain in the back and prolapse of the uterus of two years' standing. Had one child six years ago after normal labor. Three abortions preceded that birth. Menses very profuse and last occurred two weeks before. The examination showed a very large uterus, retroverted and adherent, and appendages enlarged, tender, and fixed. On January 30th, 1896, the uterus was curetted and in its cavity was placed a small strip of iodoform gauze. Then by anterior colpotomy the adhesions to the posterior surface of the uterus were broken and the appendages liberated and removed. The ovaries were both cystic, but I managed to leave nearly half of the left one, stitching over the cut surface. Both tubes, however, were beyond repair, as they were distended by clear fluid, the fimbriae, after opening that end of each, being un- recognizable. Then by the use of kangaroo tendon the uterus was still further fixed forward to the vagina, after the plan of Mackenrodt and others, except that I used buried suture. This patient is doing well, although it is too early to say that complete recovery is assured. This operation is not represented as being an unqualified sub- stitute for abdominal section, even in the treatment of gyne- cological diseases that are limited to the pelvic cavity. But, recognizing there are disadvantages in abdominal section, as above mentioned, though unwilling to believe they are as im- portant as some would have us think, and knowing that by anterior colpotomy they may be avoided, was my reason for employing this method and for bringing it to your attention. Diihrssen, of Berlin, is said to have been its originator. August Martin, of that city, began to perform the operation with great success, and published in the Annals of Gynecology and Pedi- atry, Boston, 1895, lx., 1, an interesting article on the subject, in which he reports one hundred and nine operations with no deaths. Among his cases were seventeen for myomata uteri, two for tubal pregnancy, and forty-nine for uterine adhesions. Diihrssen has operated twice and Kossmann once, by this method, for ruptured tubal pregnancy (Martin). Its principal application is in exploration of the intraperitoneal portion of the pelvis, but other conditions, as will be later mentioned, are amenable to treatment by it. Adhesions of the uterus, if not dense, may be easily separated, and an imprisoned uterus held BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. 7 forward by a proper insertion of sutures anteriorly; adherent appendages inay be liberated and removed. I have, though with trepidation, removed in this manner tubes containing pus. Mackenrodt, of Berlin, and Vineberg 1 and Wiggin,2 of New York, have employed the method for vaginal fixation of the uterus. Vineberg does not consider opening the peritoneal cavity necessary, as he used the method only for vaginal fixa- tion. It is an easy matter to pull the normal uterine body through the opening thus made, and following it will come the normal tubes and ovaries. This can all be done by one index finger, if the tension on the cervix by the tenaculum be relieved. If the uterus be partially fixed posteriorly, gentle traction on a tenaculum forceps, or a volsella fastened into the anterior wall of the fundus, will permit the index finger to be passed over and behind that organ and its liberation effected. Adhesions of the appendages, if slight or moderate, can be easily separated. Tumors having a diameter of two inches or less may be removed through this anterior opening. Particu- larly is this method applicable if the growth be in or upon the anterior wall of the uterus. There is no doubt in my mind but that for malignant disease of the uterus in which the organ is not very much enlarged, hysterectomy can be best performed by this method-pulling the uterus and its appendages into the vagina and thus facilitate ligation and removal of these organs with a large portion of the broad ligaments. In doing this we work from the ovarian artery, near the pelvic wall, toward the uterine artery at the cervix, leaving it until the last to open the cul-de-sac of Douglas. We have in this the advantage of the abdominal method, removal of appendages and a large portion of the broad ligaments, without its disadvantage of conveying the malignant disease up through the peritoneal cavity in re- moving the diseased tissue. It has the advantage of the vagi- nal route as well, without some of the disadvantages of that method as usually practised. Martin says: " Myomata may be removed wherever they may be situated-subserous ones simply by excision, after ligating the pedicle; intramural ones through an incision into the anterior uterine wall which has been exposed, even if we have to enter the cavity itself. By morcellement we can in time remove very large tumors, but should avoid those which extend too near the umbilicus. The special advantage of this method is to fix the anterior surface 1 New York Medical Journal, 1894. lx., 516. 2 New England Medical Monthly, October, 1895. 8 BOVEE : ANTERIOR COLPOTOMY IN PELVIC DISEASE. of the uterus to the vaginal wall and so control the bleeding, if any. Should all the uterine tissue capable of function be removed, total extirpation can be carried out at once." By this safer method we can do more conservative work in dealing with tubal and ovarian troubles. Resecting those organs, emptying tubes containing non-purulent fluids and leaving them, and many other like operations may be done, for the danger is not great, and, if necessary, subsequent operation by the same route or through the abdomen may be done. Free displacements of the uterus or of the appendages are easily treated and relieved in this way, if the suturing to vagina and bladder be modified by the individual case. I would not, how- ever, be understood that it is a simple operation, that can be done as easily as an exploratory laparatomy, for such is not the case. Martin's enthusiasm for the operation exceeds mine, as does his experience. I am not willing to attack large fibroids by this method, nor have I the courage to employ it where much pus is present or where adhesions are severe and involv- ing intestinal loops, or perhaps the vermiform appendix, or the bladder. Nor would I employ it in cases in which drainage of the cul-de-sac of Douglas would be necessary. With Joseph Price I believe in section and drainage by the abdomen, and will continue to employ them in cases too severe for anterior colpotomy. I have very little faith in treating pelvic pus cases through the vagina, except as a temporary relief from imme- diate danger to life and when the collections may be easily reached by that route. Nor do I believe the uterus should be usually removed with the appendages when these latter organs are changed into abscesses. I do think, however, that abdom- inal section and anterior colpotomy are the two best methods of reaching and treating diseases of the periphery of the uterine body and of the appendages. From the foregoing it will be noted that I have endeavored to outline the legitimate field for this new operation. I am much pleased with it thus far, but great care must be exercised in selecting cases for its employ- ment rather than resorting to abdominal section. 1404 H STREET.