THE CHARLES EDWARD VAN CLEEF MEMORIAL LIBRARY CORNELL UNIVERSITY THE 3fflflttt0t 5lcteri«arg Kibtratg FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 Cornell University Library RG 104.K29 1902 V.2 Operative gynecology, 3 1924 000 328 462 '/M Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000328462 OPERATIVE GYNECOLOGY VOLUME II OPERATIVE GYNECOLOGY BY HOWARD A. KELLY, A. B., M. D. FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY; PROFESSOR OF GYNECOLOGY AND OBSTETFTCS IN THE JOHNS HOPKINS UNIVERSITY, AND GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE ; FORMERLY ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA; CORRESPONDING MEMBER OF THE SOCI^T^; OBST^TRICALE ET GYN^COLGGIQUE DE PARIS, AND OF THE GESELLSCHAFT fOR GEBURTShOlFE ZU LEIPZIG WITB' TWENTY-FOUR PLATES AND FIVE HUNDRED AND NINETY ORIGINAL ILLUSTRATIONS VOL. II NEW YORK D. APPLETON AND COMPANY 1902 , , ^ . ;,\ "^ 0'VAc|, /6^ /V57 COPYKIGBT, 1898, Bl D. APPLBTON AND COMPANY, CONTENTS. CHAPTER PAGE XX. General principles and complications common to abdominal operations . 1 XXI. Care of wound and patient up to recovery 44 XXII. Complications arising after abdominal operations 56 XXIII. Tuberculous peritonitis ... . .... 134 XXI\^. Suspension of the uterus 149 XXY. Conservative operations on the uterine tubes and ovaries. . . . 163 XXVI. Simple salpingo-oOphorectomv and salpingo-oophorectomy for adherent tubes and ovaries . . ... 193 XXVII. Vaginal drainage and enucleation for pyosalpinx, ovarian abscess, tubo- OVARIAN ABSCESS, AND PELVIC A33SCESS 209 XXVIII. Hysterectomy, with extirpation of ovaries and tubes — abdominal hystero- SALPINGO-OOPHORECT03IV 236 XXIX. Ovariotomy . 246 XXX. Abdominal hysterectomy for carcinoma and sarcoma of the uterus . . 305 XXXI. Myomectomy — hystero-myomectomy . . . 338 XXXII. Operations during pregnancy . . . 403 XXXIII. Cesarean section ... .... 415 XXXIV. Extra-uterine pregnancy . . .... 438 XXXV. The radical cure of hernia . . . . 467 XXXVI. Intestinal complications . . 493 XXXVII. The more remote results of abdominal operations . . . 518 XXXVIII. On the conduct of autopsies, the making of protocols, and the preserva- tion OF tissues for microscopic examination in gynecological practice . 531 V LIST OF ILLUSTEATIONS. PIG. PAGE 316. Stricture of rectum due to pelvic inflammatory disease . . . . , . .20 317. Vermiforta appendix adherent to a large papillary ovarian cyst .... 21 318. Extensive pelvic inflammatory disease with general adhesions .... .33 319. The clear space . . . . 24 320. Encysted silli ligature in the right broad ligament . . 35 321. Closure of the abdominal wound .... .42 323, 323, 324, 325. Showing the average charts, or composite temperatures and pulse rates in ten cases in each group : ... 54 326. Introducing normal salt solution under the breasts in case of extreme anemia . . 70 327. Chart showing convalescence complicated by a high pulse rate 72 328. Normal convalescence interrupted by periodical rises of temperature due to the presence of the Plasmodium malarias .... . . .... 75 329. Chart of a case of septic peritonitis following myomectomy 86 330. Chart of a case of general sepsis following a perineal operation . . . 102 331. Chart of a case of septicemia from a purulent peritonitis 103 332. Chart showing an abdominal operation complicated by pneumonia . . . 108 333. Stitch-hole abscess chart 115 334. Tuberculous left tube with adherent omentum 135 335. Tuberculous right tube, with tubercles over a parovarian cyst 135 336. General tuberculous peritonitis 136 337. Tuberculosis of tubes and ovaries . . 144 338. Tuberculosis of the tube 144 339. Diagram showing the relative advantages of closing or of draining the abdomen in tuberculous peritonitis 146 340. Composite chart, showing course of fever after operation in tuberculous peritonitis, without drainage 146 341. Chart showing recovery after removal of tubes and ovaries in tuberculous peritonitis . 147 342. Suspension of the uterus, seen from above .... 150 343. Steps in the reduction of the uterus in the palliative treatment of retroflexion ; anterior lip of cervix grasped with tenaculum forceps ... 151 344. Same, traction straightening out the angle of flexion 151 345. Same, the finger in rectum induces slight anteflexion 152 346. Same, forceps carrying the cervix back into the pelvis 153 347. Same, the retroflexion reduced 153 348. Production of an extreme anteposition 154 349. Suspension of the uterus within a year after the operation 155 350. Suspension of the uterus, seen a year after the original operation 156 351. Upper elevator 159 352. Lower elevator 159 353. Suspension of the uterus, showing elevation of the uterus with the lower elevator . . 160 354. Suspension of the uterus 160 355. Suspension of the uterus, as seen from above 161 356. Suspension of the uterus ; outline of operation completed . 161 vii vm LIST OF ILLUSTRATIONS. colored plate FIG. 357. Conservative operation on the ovary ... 358. Parovarian cyst removed from left broad ligament 359. Parovarian cyst extirpated without removing either tube or ovary . 860. Hypertrophy of the ovary, with cystic degeneration ... . . 361. Hemorrhagic corpus luteum cyst and cystic Graafian follicle in same ovary . 362. Cyst of the corpus luteum 363. Pedunculate corpus luteum cyst of the left ovary .... 364. Cysts of corpora lutea in both ovaries 365. Velaraentous adhesion of the right uterine tube to itself and to the uterine oornu 366. Angular attachment of the left uterine tube to the cornu of the uterus . 367. Adhesions of the outer free extremities of both uterine tubes to the ovaries . 368. Conservative operation to preserve the right ovary and left tube 369. Diagram of same after removal of the right tube and left ovary 370. Double hydrosalpinx . . 371. Large left hydrosalpinx, with numerous adhesions 373. Double hydrosalpinx, with adhesions .... 373. Hydrosalpinx 374. Hydrosalpinx, with few convolutions ... 375. Same, in longitudinal section 376. Hydrosalpinx containing a nodular S-shaped calculus 377. Hydrosalpinx, with congenital deficiency in the tube 378. Right tubo-ovarian cyst 379. Same, laid open .... 380. Tubq-ovarian cyst, from right side 381. Same, divided ... 383. Outline of the torsion of the pyosalpinx shown in the 383. Large abscess of the right ovary 384. Abscess of the ovary, laid open .... 385. Nodular salpingitis .... 386. Opening a retro-uterine pelvic abscess by puncture 387. Stout curved, saw-toothed traction forceps . 388. Conservative treatment of abscess of both uterine tubes . . ... 389. Same, showing gauze drain behind uterus and extending down into vagina . 390. Ovarian abscess 391. Double pyosalpinx, with carcinoma of the cervix . . 392. Extirpation of myomatous uterus, ovaries, and tubes, with a left ovarian cystoma . 393. Hystero-salpingo-oophoreetomy for large double hydrosalpinx . . ... 394. Outline showing extirpation of the uterus, tubes, and ovaries by a continuous incision . 395. Extirpation of uterus, tubes, and ovaries for pelvic peritonitis 396. Diagram showing the relations of an ovarian cyst to the peritoneum of the pelvic floor and broad ligament 397. Long pedicle of a papillary ovarian adeno-cystoma 398. Diagram showing the relations of an intraligamentary cyst to the anterior and posterior layers of the peritoneum of the broad ligament 399. Adherent cyst of the ovary showing the mimicry of the intraligamentary cyst 400. Parasitic ovarian cyst of left side, with general peritoneal carcinosis .... 401. Left ovarian cyst with a twisted pedicle 402. Same, pedicle untwisted to show its anatomical elements 403. The relations of the parasitic multilooular ovarian cyst shown in inset Pig. 400 404. Ovarian cyst showing natural perforation, with discharge 405. Large multilooular ovarian cyst in a negress .... .... 406. Typical polycystic ovarian tumor, with long twisted pedicle 407. Multilocular ovarian cyst, in which smaller cysts project into the cavity of the large one . 408. Polycystic ovarian tumor and parovarian cyst existing on the same side . . . . 409. Multiple adeno-cystomata of the ovary PAGE 174 175 176 178 179 180 181 181 183 184 185 188 189 200 201 301 202 202 203 303 203 304 205 205 205 209 214 215 215 224 225 328 329 234 235 337 240 341 343 348 249 350 250 250 251 251 251 253 253 259 360 361 362 LIST OF ILLDSTEATIOM'S. a wisp of hair FIG. 410. Wall of a maltilocular ovarian cyst magnified 170 times . 411. Papillomata of both ovaries, seen m siYm from behind 412. Inner surface of a papillo-adeno-cystoma of the left ovary 41.3. Cysto-papilloma of the ovary 414. Solid or fibroid papillary adenoma of the ovary .... 41.'5. Adeno-carcinoma (colloid carcinoma) of the ovary 416. Cysto-carcinoma of the ovary of unusual form 417. Flat carcinomatous metastatic nodules on the intestines . 418. Large adeno-carcinoma (colloid carcinoma) of the omentum 419. Adeno-carcinoma of the omentum, seen in section .... 420. Rudimentary jaw from a dermoid cyst containing molar teeth, and with growing from its extremity 421. Contour of the abdomen in the case of an unusually large dermoid cyst 422. Left dermoid cyst of the ovary with a long pedicle .... 423. Complicated dermoid cyst of the right ovary . ...» 424. Right dermoid cyst with extensive adhesions 425. Parovarian cyst situated between the atnpulla of the tube and the outer end of the ovary . 426. Parovarian cyst, showing its translucency and the uterine tube spread out on its surface . 427. Parovarian cyst, with subsidiary cysts lying beneath the tubo-ovarian fimbria 428. Parovarian cyst bulging out on both sides of the tube .... 429. Cyst of the parovarium 430. Parovarian cyst . . 481. Parovarian cyst with twisted pedicle 432. Subperitoneal cyst developed entirely from the peritoneum 433. The pedicle of the hydatid tied about the free tubal fimbria at its base 434. Same, enlarged, showing appearance of the degenerated fimbria ... , 435. Fibroid tumor of the ovary 436. Calculus of the ovary . . 437. Partially calcified fibroma of the right ovary 438. Angio-sarcoma of the left ovary, with metastasis in the uterus 439. Monooystic tumor of the left broad ligament 440. Suppurating adherent ovarian cyst . . ... 441. Suppurating adherent ovarian cyst 442. Same, cross-section of the intestinal and mesenteric attachment 443. Diagram from a case of intraligamentary cyst, seen from above 444. Same, showing closure of wound after enucleation of cyst 445. Intraligamentary Graafian follicle cysts, in situ .... 446. Same, removed 447. Multiple dermoid cysts of both ovaries 448. Left dermoid cyst and right multilocular ovarian cyst' with twisted pedicle . 449. Fibroma of the left ovary with large myomata of the uterus ... 450. Adeno-carcinoma of the cervix, with hydroureter of both sides ... 451. Carcinoma of the cervix ... 452. Extensive epithelioma of the cervix 453. Inoperable epithelioma of the cervix o • ■ • 454. Adeno-oaroinomatous nodule entirely concealed within the cervix 455. Adeno-carcinoma of the body of the uterus, growth stopped at internal os 456. Adeno-carcinoma of the body of the uterus 457. Same, cut through the anterior wall 458. Adeno-carcinoma of the uterine body, with metastatic nodules in the lymph channels of the left broad ligament 459. Limited area of carcinoma of the fundus of the uterus on the left side . . . . 460. Operation for carcinoma of the uterus 461. Carcinomaiiteri ... 462. Double hydroureter due to advanced cancer of the cervix uteri . . . . PAGE 263 265 268 270 272 274 275 276 276 276 277 277 378 379 280 281 281 281 282 283 284 285 386 287 287 288 388 289 390 396 397 298 298 299 299 300 301 302 303 303 305 307 308 309 310 311 312 313 313 314 316 317 318 X LIST OF ILLUSTEATIOKS. PIG . PAGE 463. Autopsy on a case of carcinoma of the cervix ; hydroureter, with double ureter on the left 319 464. The upper half of a hydroureter, with hydronephrosis from compression due to a can- cerous cervix 320 465. JRelations of the ureter and bladder to the uterus and vagina . . . 323 466. Diagram showing stoppage of bougie in the ureter in the operation for carcinoma of the cervix ......... . .... 324 467. Outline diagram of the steps of the radical operation for cancer of the cervix 325 468. Hysterectomy for carcinoma of the cervix; left broad ligament opened up . . 326 469. Same, the left uterine artery tied and out off . 327 470. Same, bladder freed and vaginal vault opened anteriorly .... 329 471. Same, in sagittal section, showing the left side of the pelvis, with the operation completed. 330 472. Epithelioma of the cervix in grapelike mass . . -331 473. Uterus enucleated per vaginam, in contrast with this method . 332 474. Small sarcoma imithe riglit horn of the uterus ... . 332 475. Sarcoma of the body of the uterus . . . • 333 476. Sarcomatous nodule in the vagina ... . 334 477. Sarcoma of the uterus and right ovary . . . 335 478. Same, uterus cut open in front 336 479. Greatly enlarged right ovary removed with a mj-omatous uterus . . 340 480. Uterus with extensive myomatous involvement • 342 481. Myomatous uterus, showing interstitial and subperitoneal masses . . 343 482. Diagram of Case J. S. S., San. 107 ... . . . . 344 483. Globular myomatous uterus presenting form of pregnant uterus at term . . 345 484. Myomatous uterus, exhibiting a perfect cast of the pelvis 346 485. Large subperitoneal myoma, seen from behind ... . . 347 486. Pedunculated myomata, giving a perfect ballottement ... . 350 487. Large globular myoma choking the pelvis . . 352 488. Same, lifted up into the abdomen . 353 489. Uterus after extirpation of a myomatous tumor, showing great muscular hypertrophy . 356 490. Myomatous uterus, conservative operation . . 358 491. Conservative treatment of the myomatous uterus ... . . 358 492. Same, after removal of the tumors 359 493. CuUen's myoma eniicleator 359 494. Myomatous uterus from which eight myomata were enucleated by seven incisions . . 361 495. Same, showing incisions closed by interrupted catgut sutures 361 496. Large submucous myoma . 363 497. Schematic diagram, showing incision from left to right in extirpating the myomatous uterus . . 369 498. The operation of hystero-myomectoray . . 371 499. The last step in the enucleation of the myomatous uterus ... . 372 500. Complicated hystero-myomectomy (hydrosalpinx and ovarian cyst) . . . 375 501. Complicated hystero-myomectomy (intestinal and omental adhesions) 502. Globular myomatous uterus complicated by dermoid cysts of the left ovary 503. Myoma and carcinoma in a negress 504. Myoma with cystic degeneration 505. Large fibro-eystio tumor of the uterus attached to a multinodular myomatous 506. Torsion of the globular myomatous uterus from left to right . 507. Same, untwisted 508. Pelvis choked by a oup-and-ball myoma 509. Large myomatous uterus filling the lower two thirds of the abdomen 510. Displacement of the bladder due to a large myomatous uterus . 511. Large cystic myoma of the left broad ligament filled with pus. 512. Myomatous uterus weighing thirty-nine pounds . 391 . 391 . 391 394 . 396 513. Complicated hystero-myomectomy, showing extensive subperitoneal development . . 397 376 379 380 . 381 uterus . 382 . 383 LIST OF ILLUSTRATIONS. XI FIG. PAGE 514. Complicated hystero-myomeotomy 399 515. Myomatous uterus presenting an extraordinary mimicry of a child in a transverse po- sition 401 516. Cesarean uterus removed six years after operation .... ... 420 517. Porro-Cesarean section for fibroid uterus at term 425 518. Extra-uterine pregnancy some six or eight months beyond term 428 519. Tubal diverticula forming the two rounded eminences on the upper border of the am- pulla '. 431 520. Triple tubal ostia .... 432 521. Fetus and umbilical cord found lying among clots in abdominal cavity .... 438 522. Extra-uterine pregnancy . 439 523. Ruptured left extra-uterine pregnancy with large, free intraperitoneal hemorrhage 439 524s Extra- uterine pregnancy, showing tube cast 440 525. Extra-uterine tubal mole filling and distending the ampulla .... . 441 526. Extra-uterine pregnancy ; cross section of the tubal wall in the ampulla . . 445 527. Extra-uterine pregnancy ; tubal abortion 450 528. Same, coagulum turned out . 450 529. Extra-uterine pregnancy with tubal abortion 453 530. Operation for ruptured extra-uterine pregnancy .... ... 452 531. Lithopedion lying undisturbed in the abdominal cavity 460 532. Lithopedion removed from the abdominal cavity four years after a false labor . . 461 583. Pregnancy in a rudimentary left uterine horn ; rupture, death 465 584. Hernia of the pregnant uterus in the negress . 467 535. General principles of the radical operation for hernia ; incision made and hernial sac protruding 469 536. Same, with the sac returned and sutures laid . . 470 537. Same, with the silver-wire mattress sutures drawn up, twisted, and the ends turned down . 470 538. Same, the mattress suture tied 471 539. Same, interrupted catgut sutures passed, but not yet tied, in the intervals between the mattress sutures 471 540. Operation for a ventral hernia , 473 541. Tissues grasped by the mattress sutures in closing the hernia .... .473 542. Mattress sutures uniting the recti muscles and their overlying fascife . . . ,473 543. Incarcerated umbilical hernia in a fat woman 474 544. Same, the hernial sac removed .... 475 545. Anatomy of the inguinal canal . . ... .... 476 546. Anatomy of the inguinal canal in its deeper layers .... . 477 547. First step in the operation for inguinal hernia ; the sac exposed ... . 478 548. Second step of same ; the sac drawn out of wound . . . . . 479 549. Third step of same ; the sao incised 480 550. Fourth step of same; closure of neck of sac with mattress sutures 481 551. Fifth step of same ; closure of the inguinal canal with silver-wire mattress sutures . 482 553. Sixth step of same ; the mattress sutures drawn up and twisted, and the wound being closed by a continuous suture 483 553. Operation for the radical cure of a large inguinal hernia where the conjoined tendon is deficient 454 554. Showing the facility with which the rectus muscle, released from its sheath, can be drawn over and attached to Poupart's ligament, covering in the entire inguinal canal . . 485 555. Partial hernia of the left ovary 488 556. Left femoral hernia 49O 557. Method of dealing with intestinal adhesions where an interval can be developed be- tween the bowel and the adherent surface by slight traction . . . . . . 493 558. First step in the operation for appendicitis ... 498 559. Second step in the operation for appendicitis . 499 560. Third step in the operation for appendicitis 500 Xll LIST OF ILLUSTEATIONS. PIG. PAGE 561. Retracted appendioal stump within a cuff of peritoneum 501 562. Closure of the peritoneal cuff over the stump by mattress and interrupted sutures , . 503 563. Inversion and extraperitoneal disposal of the little buttonlike stump beneath the con- tiguous margins of the mesenteriolum 503 564. Curved intestinal needle .... 503 565. Halsted's method of preserving the intestinal needles 503 566. Human small intestine magnified one hundred times to show the relative thickness of the various coats 504 567. A section of the colon magnified one hundred times 504 568. Cross-section of the rectum magnified twenty-five times 505 569. Lateral anastomosis. First step ; ends of bowel closed and mattress sutures introduced on the lower side 506 570. Same, second step ; lower row of sutures tied and the lateral sutures applied . . 506 571. Same, third step ; lateral sutures tied, making a pocket 507 573. Same, fourth step ; remaining sutures in place ready to complete the union on all sides 507 573. Same, completed ; all sutures tied 508 574. End to end anastomosis without artificial aids ; presection sutures in place . . . 508 575. Same ; presection sutures tied 509 576. Same ; mattress sutures in place . . .... . . 509 577. Same ; sutures all tied, accurate approximation of divided ends of bowel . . 509 578. Circular suture of the intestine . . . . 510 579. One of the divided ends of the intestine . . 511 580. The introduction of the collapsed rubber cylinder between the presection sutures . . 511 581. After tying the three presection sutures and inserting the rubber bag a fourth stitch, b, is inserted 511 583. The mesenteric mattress suture devised by Mitchell and Hunner . . . . 511 583. Prom ten to twelve mattress sutures are introduced, and the tying begun with the mesenteric suture a 513 584. Two sutures separated to allow the defiated bag to be withdrawn . 513 585. Sutures all tied, and the anastomosis completed 514 586. Anastomosis of the sigmoid into the ampulla of the rectum . 515 587. Making a sigmoid anus in occlusion of the lower bowel . . , 516 588. Making a sigmoid anus , . 517 589. Post-operative intra-abdominal hernia 518 590. Strangulated hernia in a patient seventy-five years old, due to ovariotomy twenty-seven years before 531 591. A section through the constricted portion of the bowel shown in Fig. 590 . . . 523 593. Showing the ends of the tubes and pieces of the ovary left after an imperfect opera- tion 525 LIST OF PLATES. PLATE PAGE XI. Pig. 1. Hydrosalpinx simplex 199 Fig. 2. Hydrosalpinx foUioularis. XII. Hydrosalpinx simplex .... 199 XIII. Hydrosalpinx follicularis (Fig. 1. Plate XI magniiied) . . 204 XIV, A typical pyosalpinx . 209 XV. Section of a small nodule taken from the inner surface of a cysto-papilloma of the ovary (Fig. 413) ... ... 270 XVI. A papillary ovarian cyst exhibiting a few sai'comatous nodules . . 275 XVII. Epithelioma of the cervix .309 XVIII. Radical operation for cancer of the uterus . . 321 XIX. Injected specimen showing the vascular supply of myomala . 838 XX. Angio-myoma of the uterus, with cystic degeneration . 383 XXI. Benign adeno-myoma of the uterus . . ... . . 385 XXII. Benign adeno-myoma of the uterus; magnified sections of Plate XXI . . 387 XXIII. Diagnosis of extra-uterine pregnancy by microscopic examination .... 448 XXIV. Pregnancy in a rudimentary left uterine horn ; magnified sections of Fig. 583 . . 464 xiii OPERATIVE GYNECOLOGY. OHAPTEK XX. OENERAL PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. 1. Health of the surgeon. 2. Examination of the patient : Lungs, heart and circulation, liver, stomach, family history. 3. Urinalysis. 4. Preliminary preparation of the patient : a. To produce the best possible physical condition. h. To quicken the emunctories. c. To secure aseptic surface of abdomen. 5. Preparation of patient in the operating room. €. Preparation of surgeon and assistants. 7. Proper dress and conduct of visitors. 8. Length -oi incision, and how to find the peritoneum : a. The exploratory incision, h. Cutting through the umbilicus, c. Hemorrhage from the incision. 9. Exposure of the field of operation : a. Elevated pelvis ; advantages and disadvantages. J. Illu- mination. • 10. Methods of dealing with adhesions : a. Adhesions to pelvic walls, floor, and broad ligaments. b. Omental adhesions, c. Uterine adhesions, d. Rectal adhesions, e. Intestinal adhe- sions. /. Appendical adhesions and removal of the vermiform appendix, g. Vesical adhesions. 11. Injuries to the bladder and ureters. 12. Ligation of the pedicle. 13. Hemorrhage : a. Sources of. i. Control of. 14. Irrigation of abdomen with normal salt solution. 15. Drainage. 1. Physiology of drainage: (a) Function of the peritoneum under normal and pathological conditions, (b) Mechanism of absorption of fluids and solid particles in the peritoneal cavity. 2. Clinical studies of the subject. 3. Objections to drainage. 4. The prevention and removal of infection without resorting to drainage : {a) Postural drainage. 5. Cases to be drained. 6. How to put in and take out a gauze drain. 16. Closure of the incision. 17. The abdominal dressing. In order to avoid constant repetition in discussing the various operative pro- cedures as they are taken up, I propose in this chapter to consider certain details common to the technique of all abdominal operations. The Health of the Surgeon. — The surgeon's physical condition has much to do with the success of his work. I would insist that no man in ill health is justified in doing abdominal surgery, because he is not in condition to stand the great and often prolonged strain upon his attention, with the constant appeals to a clear judgment in rapidly deciding questions of vital importance. Moreover, to meet fiuch serious emergencies as may arise, not only judgment is needed, but a well- balanced nervous and muscular system, which are not at the disposal of an invalid. A surgeon who is affected with acute tonsillitis, pharyngitis, ozena, 41 1 2 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPEKATIONS. alveolar abscess, furunculosis, or pulmonary tuberculosis should consider himself absolutely debarred from performing abdominal operations of any sort on ac- count of the danger of direct infection of the patient. It is also improper for any one who has an elevation of temperature to go near the operating table. A suppurating wound of any part of the hand debars the surgeon, assistant, or nurse from operating or assisting until it is healed, so that the part can be thor- oughly scrubbed. Examination of the Patient. — Preceding every abdominal operation a thorough physical examination must be made, including an investigation of every impor- tant organ in the body. It is best to do this by taking the organs up in some systematic order, which should not be deviated from. The lungs must be care- fully examined for tuberculosis, the pleural cavities for fluid, the heart for valvu- lar lesions and evidences of fatty degeneration, the arterial system for sclerosis> the urine for nephritis, pyelitis, or diabetes, and the liver for cirrhosis. Gastric symptoms, indicating ulcer of the stomach or carcinoma, demand attention. Close inquiry must be made into the patient's former history to discover any tendency toward insanity. "Women who have been in an asylum, or those who- have at times appeared mentally unsound, although able to remain at home, are. peculiarly prone to melancholia or even violent insanity after any operation, whether pelvic or abdominal. In one case, in which I simply repaired the peri- neum, the patient, who was markedly emotional, developed a profound melan- cholia which lasted for months. Another woman, a pronounced neurasthenic, three weeks after a suspension operation, attempted suicide by cutting the abdo- men with a broken bottle, although up to that time she had shown no signs of actual insanity ; about two months later she succeeded in cutting her throat with, a razor. Cases might easily be multiplied, but this subject will be discussed more fully in the complications following operations. A careful preliminary study of his cases after this fashion is of paramount, importance to the operator, for unless such a routine examination is followed out. in every case, now and then a life will be lost from some unsuspected associated disease. Disease of an extrapelvic organ, sufficiently advanced to cause death independently in the near future, forbids any but an emergency operation. This, need not, however, prohibit operations for pelvic abscess in patients vsdth pul- monary tuberculosis, where there is reason to believe that the patient may liv& some years in comparative comfort, if the pelvic complication is removed. Old age also forms no barrier, as the results of careful work appear almost as success- ful in the aged as in the young. It is my habit, in referring patients from a consultation or from my private office to a hospital for operation, to fill out one or more of the headings on a chart similar to the following one, printed on a sheet of paper large enough to- file with the patient's history. Under the " preliminary investigation " I write, any notes which may be necessary to call attention to certain features in the general examination to which special attention should be given; as a rule the- history of the patient has brought out some good reason for a particularly care- ful study of some organ or organs, which is emphasized in this way. > UEHiTALYSIS. It is also important to note at once just what surgical procedures appear to be needed, as it is quite possible, now that so many operations are done at one sitting, that a busy surgeon may forget one or more where several are indicated. OUTLINE OF PROPOSED TREATMENT. Name, Date, Prbliminaey Investigation or Opeeations : Chest Upper Abdominal Digestion Pelvic Urine Appendix vermiformis. Kidneys Renal Blood Cervical Rectal Breast TTrinalysis. — No detail in the preparation of a patient for operation is more important than a careful examination of the urine, which must never be omitted. The kidneys are the most important emunctories of the body, and their function is especially taxed after an operation ; it is therefore essential to note particularly the way they acted beforehand, not only as a test of present efficiency and as a guide in determining whether or not to do an operation, but to afford a standard of comparison after the operation, should their activity appear impaired. A con- valescence is often impeded by unsound kidneys ; moreover, every pathologist will attest that renal lesions are commonly brought to light in the autopsies on women dying from gynecological operations. Out of twenty-nine autopsies made upon cases dying in my service at the Johns Hopkins Hospital, nineteen, or 65 per cent, showed some kidney lesion. In eight there was a chronic diffuse nephritis, in eight fatty degeneration and cloudy swelling, in two the ureter was occluded by a ligature, and in one there was atrophy of one kidney. One of the chronic nephritis group had a pyelitis with calcareous incrustation of the papillse of the pyramids, and one of the two cases with an occluded ureter had a hydronephrosis on the occluded side and a pyonephrosis of the other side. The first of these cases died some months after a hysterectomy and removal of both ovaries and tubes for carcinoma uteri and dermoid cyst, by extension of the cancerous dis- ease. Only in the two cases with ligatured ureters was the renal condition the cause of death ; it must be borne in mind that fatty degeneration and cloudy swelling are almost always due to the peritonitis, and are therefore a part of the infec- tion, and secondary to it, and must not be taken into account in explaining the cause of death. 4 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPEBATIONS. In none of my cases was the chronic nephritis far advanced, and in no in- stance could I attribute the death directly to this source, although, as shown by Dr. Simon Flexner in a recent research on terminal infections, lesions of the kidney may impair the powers of resistance, and thus allow certain organ- isms to gain a foothold and cause a fatal termination. A knowledge of the condition of the kidneys is of eminent practical value for the following reasons : First, that we may refuse to operate upon cases presenting advanced renal lesions. Second, that we may delay the operation in less serious cases until these emunctories are brought into the best possible condition by careful preparatory treatment. Third, that we may adopt unusual precautions in the course of operations upon cases complicated by a kidney disease. Fourth, that we may watch such cases carefully throughout their convales- cence, avoiding opiates or other drugs which tend to check the secretion, and that we may assist impaired kidneys by throwing the stress of excretion as much as possible upon the skin and bowels. It is my practice in major operative cases to have several urinalyses made, first, two or three days before operation, then shortly after it to determine whether any disturbance has been produced by the operation, and again when the patient gets out of bed, usually about the twenty -first day, to see if any dis- turbances previously found have disappeared. To avoid contamination by leucorrheal or menstrual discharges, the bladder is catheteriz ed ; this is usually done in the early morning, because the night urine approximates the diurnal average in its physical characteristics. To determine accurately the difference between catheterized and voided specimens of urine, I made a series of thirty analyses of each kind, with the fol- lowing result : E"ine of the voided specimens showed albumin, while the cathe- terized urine from the same patients showed none. In all the nine cases the patients had a leucorrheal discharge, showing the source of contamination. It is evident from this that reliance can only be placed upon catheterized specimens, and no examination revealing the presence of lesser grades of albuminuria can be considered final until it is controlled in this way. The best receptacle for the urine to be examined is a conical glass graduate, which quickly shows the presence of any sediment. The analysis should include a description of the physical characteristics of the urine, its specific gravity and reaction, the presence of sediment, the pres- ence of albumin or sugar, the average daily amount of urine passed, the percent- age of urea, and the microscopical appearances. It is best to record each exami- nation in a book of urinary charts, whose separate leaves can be torn out and filed with the history of the case, leaving a duphcate stub in the book. I give here the chart which I use in my own work. UEINALYSIS. iVo._ Name. ANALYSIS or UEIISTE. Date_ Diagnosis Mixed- Date. Amount. Time. Characteristics. Albumin. Sugar. Urea. Microscope. Color Reaction Spec. grav. Sediment Color Reaction Spec. grav. Sediment Color Reaction Spec. grav. Seditnent The heat test, and Heller's nitric-acid test, are sufficiently delicate and are the best to detect albumin. I used trichloracetic acid at one time extensively, but found it unnecessarily sensitive, giving evidence of percentages of albumin too minute for practical purposes. Fehling's solution is the best for the detection of sugar. I have found sugar in the urine in but three out of a thousand uri- nary examinations in gynecological surgical cases; in two the amount was small and transient and did not prevent an opej'ation ; the third case was one of complete tear of the recto-vaginal septum. Upon discovering the sugar all idea of performing an operation was abandoned, and, in spite of appropriate treatment for the diabetes, the patient died in coma a few weeks later. Out of twelve hundred examinations of the urine I ha^e never seen glyco- suria arise after an operation. From a careful study of five hundred urinary charts of my abdominal cases I deduced the following rules: First, no case of advanced nephritis should be subjected to an abdominal operation of greater gravity than a simple tapping of a cyst or of an ascites. 6 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. Second, women witli a marked amount of albumin in the urine should be carefully watched for a time, and if the albumin persists no serious operation which is not imperative should be performed. Epithelial and blood casts, asso- ciated with the albumin, increase the gravity of the outlook. Third, hyaline and granular casts do not contraindicate operation unless numerous and persistent. Albumin is found in 23 per cent of all cases, and casts in 5 per cent. Fourth, vascular changes, high-tension pulse, and heart hypertrophy must always be looked for. These alterations become serious when associated with casts and albumin in the urine. Fifth, a marked diminution in the excretion of urea in twenty-four hours, associated with a small amount of albumin or a few casts, must be regarded as of serious import. Sixth, pus in the urine, amounting to more than a trace, is of serious signifi- cance, and its source must be determined before operation. This will occasion- ally be found to come from an unsuspected pyelitis or pyelonephritis. Seventh, sugar must always be looked for ; if scant and transient it may be disregarded, but if persistent no major operation should be performed. It will be seen by the third rule that a small amount of albumin and a few granular and hyahne casts need not prevent an operation. On the contrary, such minor renal changes are observed in a large percentage of all gynecological cases, and are often directly dependent upon the presence of a pelvic tumor, in which case the renal complication actually constitutes an im- portant indication for the operation. In cases of large cysto- mata and fibroid tumors I have often seen the albumin disappear entirely within two weeks after the removal of the mass. In sixty-six of my cases with simple albuminuria no untoward renal symptoms were observed after operation. When an operation is determined upon in the presence of renal changes the operator will diminish the tendency to shock and tax the lessened vitality of the patient as little as possible by avoiding all delays, by proceeding promptly with his work as soon as the patient is anesthetized, by taking all possible precau- tions to avoid shock during the operation, by the external application of heat and avoidance of exposure of the viscera, and by calling upon the bowels and skin for active supplemental service as soon as possible after it. There is a definite causal relationship between certain classes of gynecological cases and certain ureteral and renal affections which is in general as follows: Myomata in many instances press upon the ureters, inducing hydroureter and hydronephrosis.' This is particularly the case in subperitoneo-pelvic myo- mata lifting up and displacing the pelvic portions of the ureters into the abdo- men. One patient died in the ward without any operation at all, with a pyelo- nephritis caused by a myomatous uterus choking the pelvis and abdomen. I have seen pelvic abscess associated with a pyelonephritis of the same side causing death. Although constantly looking for it, I have seen but one case of PEELIMINAEX PBEPAKATION OF THE PATIENT. 7 extensive amyloid degeneration associated with pelvic suppuration, and that patient was syphilitic. In view of the impression created by the older litera- ture on this subject, the absence of amyloid degeneration in so large a number of chronic pus cases is certainly noteworthy, and dread of its occurrence ought not to be such a bugbear to gynecologists. Carcinoma of the cervix in its advanced stages compresses the ureters and produces hydronephrosis and death from uremia in a large percentage of eases. Of eight inoperable carcinoma cases in which an autopsy was made, two showed one ureter very greatly enlarged with associated hydronephrosis, while the other cases showed a very great distention of both ureters and kidneys (see Chapter XXX). In five of these cases the patients showed marked symptoms of uremia for days and even weeks before death, and, for the last few days before the end came, were in profound coma. ,,: Preliminary Preparation of the Patient. — The object in view in preparing the patient is threefold : First, to 4)ring her into the best physical condition possible ; second, to quicken her emunctories, and secure a thorough evacuation of the intestinal tract ; and third, to secure as nearly as possible an aseptic condition of the skin of the abdomen adjacent to the line of incision. The exact amount of preparation which it is best to devote to any given case preceding celiotomy will vary with the widely varying conditions of the pa- tients. When the general health is good, but one or two days are needed, de- voted chiefly to the thorough evacuation of the intestinal tract and the disin- fection of the abdominal skin. In urgent eases, such as Cesarean section in an exhausted patient, all preliminary preparations must be dispensed with, and the abdomen cleansed for the first and only time within the few minutes immedi- ately preceding the operation. Cases of ruptured cysts with hemorrhage, ruptured pelvic abscess, ileus, appendicitis, ruptured ectopic gestation sac, in which the general condition is rapidly growing worse, should be operated upon as speedily as possible, utilizing any little intervening time in stimulating the patient with hypodermics of strychnin, doses of brandy, and rectal enemata. In private practice the gravity of the patient's symptoms may even demand a sacrifice of some of the important details in the aseptic technique. The oper- ator, for example, may be obliged under these circumstances to make use of hot water from the spigot, and vessels which have only been scalded out. The preparation of the room will often be imperfect, and it may even be found ne- cessary to cleanse a dirty abdomen just before beginning the operation. Poor women with abdominal tumors, pelvic abscesses, or other inflammatory diseases, who are in a depressed, run-down condition, and who have only laid aside the burden of exacting household duties and family cares just as they entered the hospital, improve remarkably upon being given one or two weeks of preparatory treatment with absolute rest in bed, nutritious diet, tonics, and mild stimulation in the shape of koumiss and malt. Daily baths and rub- bing with alcohol are valuable adjuvants in bringing back much of the lost tone. 8 PEINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. Patients who are greatlj depressed physically by prolonged or chronic ill- ness show a greater susceptibility to infection than the strong and robust. As an instance of this statement, in the last twenty cases of cancer of the uterus operated upon by the abdominal method, 50 per cent have had varying de- grees of local suppuration of the abdominal wound, varying from a slight dis- charge of pus to an extensive breaking down of the wound. The admirable paper of Dr. Simon Flexner, upon terminal infec- tions, bears directly on this point. In an exhaustive analysis of the autop- sy records of cases dying in the Johns Hopkins Hospital, he found that patients- suffering with chronic heart lesions, nephritis, and other long-standing ail- ments were in a great proportion of cases carried ofE by some terminal infec- tion. In other words, the decrease of vital resistance occasioned by the pro- longed illness simply paved the way for a terminal infection which then easily- carried the patient ofE. In the light of this instructive paper all patients with any form of chronic- disease should be brought into the best possible physical condition by appro- priate tonic treatment before being subjected to any serious operation. In the pre-antiseptic days no surgeon felt justified in proceeding with an operation without at least two weeks' to a month's preliminary treatment. When healing fer primam was so exceptional and " laudable pus " so much desired, the practical sense of the early surgeons taught them to first surround their patients with the best possible conditions for increasing their powers of resistance before proceeding with an operation. Extremely nervous patients require peculiar management, and the operation should, as a rule, be performed within one or two days after the announcement of its necessity has been made, in order to lessen the drawbacks of wakeful nights, disturbed digestion, and nervous apprehensions. If the patient can be prepared for operation without suspecting it, I some- times announce it just as I am ready to give the anesthetic. In such a case it is important to have a clear understanding with the relatives or a responsible attending physician. The best general rule is to take four days to make all the necessary immedi- ate preparations. The bowels must be regulated, and there must be a thorough evacua- tion of the whole intestinal tract just before the operation. The presump- tion in all pelvic tumor cases, even though they complain of diarrhea, is that a fecal stasis exists in the large bowel, and the surgeon should not decide to- the contrary before taking the history, making an examination of the rectum through the vagina, and palpating the abdomen to determine the condition of the sigmoid flexure and colon. Tympany is one of the most embarrassing com- plications, and, in an extreme form, even contraindicates operation. It must therefore first be carried off by active purgation, associated with the use of car- minatives and bismuth. The old-fashioned black draught is an efficient saline purge, and the carminative combined with it tends to prevent any griping. The following is the formula : PREPARATIOlir OF THE PATIENT IN THE OPEEATING ROOM. 9 ^ Magnes. sulph § j ; Fol. sennjB 3 ii] ; Mannae 3 ij ; Pulv. cardam. sem 3 j ; Aq. buUient O j. Boil, strain, and give two ounces every two hours. Yaginal douches of a saturated solution of boric acid or a 2 per cent car- bolic-acid solution should be given twice a day before operation if the patient has an offensive or purulent discharge ; otherwise they are omitted. On the preceding evening a general warm bath is given. From twelve to eighteen hours beforehand a purgative dose of citrate of magnesia, castor oil, Epsom salts, licorice powder, or a pill of aloes, strychnin, and belladonna is given, followed early the next morning by a rectal enema. A free pui'gation quickens the absorptive activities of the peritoneum immediately after the opera- tion, and so promotes the speedy removal of blood and debris. After the patient's bowels are thoroughly evacuated, if necessary using a second enema to effect it, she is prepared for the operation. In order that the field of operation may be rendered as aseptic as possible before the patient is taken to the operating room, the most active disinfectant measures are employed. All of the articles necessary to the cleansing of the abdomen are placed in convenient reach. Usually a small stand is placed near the bed, and upon this are placed green soap, flasks of water and of bichloride solution (1-1,000), a package of sterile towels, gauze scrubbing mops, alcohol, and ether. The abdomen is well exposed, the bed and clothing above and at the sides being protected by a rubber sheet. The skin from the ensiform to just above the pubes is lathered with green soap and water, and shaved well out from the median line. If the abdominal incision is to be made in any other locality than the median line the nurse is so instructed, and varies the shaving to suit the site of operation. After shaving, the skin is thoroughly scrubbed with a gauze mop. In the case of a nervous, delicate, refined woman, the shaving had better be done on the operating table when she is unconscious. The nurse now suspends the preparation while she disinfects her own hands, after which the skin is thoroughly rubbed and washed with alcohol, then ether, and finally with a 1-1,000 bichloride of mercury solution. A large sterile gauze shield is tied by conveniently placed tapes over the ab- domen, and the patient's toilet is completed by putting on a clean nightgown. If she is nervous or feels weak, a wine glass of sherry or a small milk punch may be given. Preparation of the Patient in the Operating Room. — The anesthetic should be administered ia a room adjoining the operating room, arranged as much as possible like an ordinary bedroom, so that the patient may not have the dis- tress of witnessing any of the preparations. The most satisfactory anesthetizing couch in a hospital is the carriage upon which she has been brought from the ward. When unconscious she may be transferred to the operating table and 10 PRIKCIPLES AITD GOMPLlCATIOlirS COMMOST TO ABDOMINAL OPERATIONS. placed with her hips resting on the ovariotomy pad, so that its lower border reaches about 15 centimeters (6 inches) below the vulva, and the upper border lies well above the abdomen ; a self -draining table in a hospital does away with the necessity of using the pad. The first step toward disinfection in all abdominal cases, after the patient is put upon the table, is the thorough cleansing of the vagina by raising and sepa- rating the legs and applying soap and warm water vigorously, with a bunch oi sterilized cotton held in the grasp of a pair of long dressing forceps. This step need not be carried out in a young woman with an intact hymen. A large fun- nel or an open speculum may be placed between the thighs close to the body to facilitate drainage of fluids running down from the abdomen onto the pad. The patient's clothes are drawn well above the upper border of the pad, her arms are flexed and folded on the chest, and retained in this position by the undervest being pulled up over them, and by tying the wrists together with a gauze ban- dage. The chest is protected by a blanket with a rubber sheet over it, and the legs warmly wrapped in a blanket and a sheet in like manner. If the operation is to be long, the feet should rest upon a hot-water bag, and another be placed under the knees, and still others about the chest. For feeble patients I use long, narrow, hot-water bags encased in flannel and reaching from the armpits to the knees. Cleansing the Abdomen. — The temporary protective gauze band- age, referred to above, is now removed by the nurse, and an assistant, with sterilized hands, proceeds to scrub the abdomen with sterilized cotton balls en- veloped in gauze, applying soap and water freely for several minutes. Especial care should be observed, both in the preliminary preparation in the ward as well as upon the operating table, in cleansing the folds of the umbilicus, where it is deep, using some absorbent cotton held in forceps. Following the soap and water, the abdomen is scrubbed with ether, and after this with alcohol, and finally with a bichloride solution (1-1,000). Before disinfecting the abdomen of unusually fat women, the creases formed by the overhanging cutaneous folds should be inspected for a slight dermatitis or an eczema, which often exists, and unless the operation is imperatively demanded, these areas should be entirely healed before an incision is made through the abdomen, as such apparently insignificant surface lesions may conceal virulent organisms. In one patient, a woman with thick abdominal walls, upon whom I operated, a superficial eczema was noted at the time, but was not considered dangerous be- cause of the thorough disinfection. Notwithstanding these precautions, the patient died of a virulent infection with suppuration of the abdominal wound, which extended into the peritoneum. When we consider the fact that the staphylococcus epidermidis alb us has its normal habitat in the deeper layers of the corium, it is reasonable to infer that in an eezematous patch in one of the deep folds of the abdomen, which is subjected to constant friction, there may be deeply underlying infected areas uninfluenced by the most radical disinfecting measures. PKOPBR DRESS AND CONDUCT OF VISITORS. 11 Arranging the Field of Operation. — Sterilized towels are now laid upon the rubber sheets on the chest and thighs and on the sides of the ab- domen, completely covering them ; a piece of sterilized gauze, four layei-s thick and 1 meter (1 yard) square, or a sheet made for the purpose with a hole in the middle, is laid over the patient from breast to knees ; finally two sterilized towels are spread above and below over the ends of the cover. A wire bracket resting on the patient's thighs and covered with sterilized towels serves as a con- venient receptacle for the instruments which the operator needs to have close at hand if the operation is done with the patient in the horizontal posture. I provide for this when the pelvis is elevated by turning over the end of a towel stretched across the thighs and clamping it to the sheet so as to make a shallow pocket, in which the instruments rest without slipping down. Preparation of Surgeon and Assistants. — During the preparation of the patient, which is made by a trustworthy assistant, the surgeon cleanses and disinfects his hands according to the method described in Chapter I, page 20. Having completed the disinfection of his hands, the surgeon begins the operation by cutting an opening in the gauze diaphragm, leaving the abdomen and surrounding parts protected by it. After the operation is begun it must be the constant effort of the surgeon and his assistants to prevent the importation of any infectious matter from the outside. To this end contact with unsterilized objects must be rigorously avoided, and should it be necessary to use the cautery or qther instruments which can not be rendered aseptic, the hands are protected by small squares of sterilized gauze, which are thrown away immediately after use. The aseptic field is confined to the sterilized instruments, sponges, and ligatures, and the protected abdomen of the patient, and should" the operator, by accident or un- avoidably, step outside of this field and be contaminated, the error in technique must at once be corrected by scrubbing the hands for a minute and immersing them again in the bichloride-of -mercury solution (1-1,000). Proper Dress and Conduct of Visitors. — Few operations are performed in our large hospitals without the presence of visitors, who often act as a pleasant stimulus to the operator to do his best work and whose presence is in no way detrimental to the patient. To prevent the possible introduction of infectious matter from outside, pro- fessional work, visitors should be required to wear fresh long linen dusters. This precaution not only covers in the street dust upon their garments, but, by putting the visitor in uniform, as it were, serves as a constant reminder of his relation to the operation and the sterilized objects of the operating room. Bystanders should keep their dusters buttoned and their hands at their sides or in their pockets, and under no circumstances should they pick up or touch anything, or attempt to assist in any way unless requested to do so. If allowed to step near enough to inspect the wound closely, they must be cautioned not to let their clothes touch the operating table or the patient, and not to bring their heads directly over the wound, or to breathe into it, or to speak over it. 12 PEINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. Visitors and students also should not use the same wash basins and towels as the operator and his assistants. The Length of the Incision, and how to find the Peritoneum. — As to the length of the incision, the best rule is to make it long enough for the operator to work as rapidly as is consistent with proper attention to details. Too long an incision embarrasses the operator by permitting the escape of the bowels at its upper angle, while one that is too short hampers every movement and prevents a proper inspection of the field as the operation progresses. It was a tendency of some of the earliest operators to make enormous incisions. Sir Spencer Wells shows in his book {On Ovarian and Uterine Tuntors, London, 1882, p. 294) that his percentage of mortality in cases in which the incision did not exceed six inches was 20-65, while the percentage in cases exceeding six inches was 39-43. But with true surgical insight he infers correctly " that the extent of the incision is little less than an indication of the gravity of the ease, as it can not be supposed that two or three inches, more or less, of simple division of the parietes of the abdomen would augment the danger to this amount." In general, an incision 4 centimeters (1^ inches) in length may be called short, and of from 8 to 12 centimeters (3 to 5 inches) medium, and beyond this long. The operator must never allow the shortness of the incision to restrict his manipula- tions within the abdomen. Difficult operations — such as the removal of large ad- herent tumors, pelvic abscesses, and other inflammatory masses — require a longer incision to facilitate inspection of the field as well as the freer use of the hand in the abdomen. Exploratory Incision . — The short incision, made for the evacuation of ascitic fluid and for an exploration of the peritoneal cavity, need not be more than 3 to 4 centimeters in length. After the abdomen is collapsed by the escape of the fluid, one or two fingers may then be introduced for the purpose of ex- ploring the pelvis and neighboring viscera. Ey enlarging the incision upward the whole hand may be inserted and all the important abdominal organs — stom- ach, spleen, liver, gall bladder, pancreas, omentum, mesentery, aorta, kidneys, vermiform appendix, pelvic viscera, etc. — systematically examined. The length of the incision for suspension of the uterus is also not more than 3 or 4 centi- meters. Incision in Fat "Women . — If the abdominal walls are fat the incision must be longer, because the great thickness of the parietes renders more difficult every manipulation within the cavity. In rare cases of enormous accumulation of fat (adiposus, lipomatosus), in which the diagnosis is obscure, great advantage will be gained and danger of suppuration in the convalescence, or of hernia afterward, avoided by making an exploratory incision through the umbilical ring, where the abdominal wall is thinnest from the absence of fat and muscular tissue between the skin and peritoneum. By adopting such a procedure we may avoid making an incision through a fat wall 20 to 30 centimeters (8 to 12 inches) thick. I operated in this way upon a patient of Dr. G. "W. Gruthrie, of Wilkesbarre, Pa., whose weight was consid- erably over three hundred pounds. In order to tap her for an ascitic accumu- THE LENGTH OF THE INCISION, AND HOW TO FIND THE PERITONEUM. 13 lation, Dr. Guthrie had been obliged to have a trocar made 14 inches long, and this barely reached through the fat walls. At the operation I made an incision, 10 centimeters (4 inches) long, through the umbilicus and explored the whole peritonea] cavity, introducing the entire arm. It was fortunate, indeed, that I adopted this plan and did not make the incision lower down, as the patient got out of bed as soon as she regained consciousness and refused to return to it again even at night. In cases in which there is a tumor within the abdomen the length of the incision is determined in the following manner : "When the operator is uncertain as to the exact character of the operation, it is best to begin by making a small incision, beginning about 3 centimeters (1-J- inches) above the symphysis, and then, if necessary, to enlarge it by using the index and middle fingers of the left hand to lift up the abdominal wall from the intestines, while cutting upward in the linea alba with a knife or stout blunt-pointed scissors. A large monocystic ovarian or parovarian tumor may often be evacuated and easily drawn out of a little incision, provided there are no adhesions or secondary masses which can not be reduced in size. An adherent cyst, on the other hand, may call for an extension of the incision up through the umbilicus. Small non-adherent ovarian and tubal enlargements can easily be turned out through an incision 4 to 6 centi- meters (1^ to 2^ inches) long. Pelvic abscesses require a longer incision, 8 to 10 centimeters (3 to 4 inches), to give a better exposure and facilitate the tapping and enucleation of the pus sac and the final inspection and cleansing of the pelvis. In making a long incision I prefer to cut directly through the umbilicus, and then, keeping a little to the left above it, to avoid the suspensory ligament of the liver ; in closing this incision the tissue at the umbilicus should be split on each side to gain a broader surface for approximation. Myomatous uteri and other large solid or semisolid tumors require an inci- sion, in proportion to their size, large enough to permit the mass to be turned out onto the abdominal wall by its small axis without diminution. In making the incision the operator first fixes the median line with his eye from umbilicus to symphysis ; then holding the skin a little tense on either side with thumb and middle finger, he cuts with one sweep, with a sharp, broad- bellied scalpel, through the skin and subcutaneous fat down to the deep fascia covering the muscle. The linea alba is at once seen as a distinct white line, or is felt as a cord between the recti ; if not found in this way, it may be exposed by making a slightly oblique incision through the fascia from above downward, crossing its course. With the linea as a guide, the incision is continued in be- tween the recti muscles. It does no harm if in the search the sheath is opened and the muscle exposed ; when this occurs, the linea is found on that side which yields least upon making gentle traction on the fascia. The operator and his assistant now catch the underlying fat and connective tissue (subperitoneal fat) on either side with a pair of rat-toothed forceps, a little distant apart, and lift it up ; it is then incised and the delicate peri- toneum below picked up in like manner. Immediately above the peritoneum 14 PRINCIPLES AND COHPLIOATIONS COMMON TO ABDOMINAL OPEEATIONS. two veins running vertically are usually found close to the median line, 2 or 3 millimeters apart. They are often 1 or 2 millimeters in diameter, and it is advisable not to cut them when it can be avoided. (See Fig. 19.) At this point, beneath the muscles, the inexperienced operator may become confused and, under the impression that he is gaining access to the abdommal cavity, begin to dissect outward between the muscular and peritoneal layers. 1 have seen this fruitless and embarrassing quest continued for twenty minutes before the peritoneum was opened. Indeed, it was not uncommon for the older operators to consume from ten minutes to half an hour iu making the incision. This error is to be avoided by picking up the tissues on each side of the median line as described and incising them inward, layer by layer, always keeping in the center. The peritoneum must be picked up with great care to avoid catching intestines or omentum in the forceps ; when it is nicked slightly, air rushes in and the abdominal wall balloons out a little, while the intestines fall away. This is particularly noticeable when the pelvis is elevated. The opening is then enlarged sufficiently to admit the index finger, which is swept around to make sure that there are no parietal, intestinal, or omental adhesions, and that the bladder is not close to the incision. With this assurance, the incision in the peritoneum is enlarged to the full size of the cut on the skin surface. Nothing is gained, but much advantage is lost, by making the incision fun- nel-shaped, long on the skin surface and short on the peritoneum. Hemorrhage from the incision is not often troublesome, although the pre- liminary scrubbing of the abdomen may dilate the capillaries and so give rise to a free capillary oozing at first ; as a rule, this ceases within a minute or so, and may be disregarded. In more active bleeding a few artery clamps may be necessary to catch the vessels, which are then tied at once with fine catgut. More care must be taken to prevent the loss of even a small amount of blood in this way if the patient is weak or has had a hemorrhage. By tying all the actively bleeding vessels in the incision at once, the liability of the formation of a hematoma and subsequent suppuration is much lessened. I have followed this plan of making a median abdominal incision through the linea alba in over two thousand celiotomies, and have no reason to distrust it on the ground advocated by some surgeons that the cicatricial union is less firm and secure than in those cases where the incision is made lateral to the median line. Exposure of the Field of Operation. —E levation of the Pelvi s — A d - vantages and Disadvantages.— One of the most important maneuvers in abdominal surgery is the elevation of the pelvis so as to displace the obtrud- ing loops of intestines lying between the incision and the pelvic viscera; by doing this, the field of operation is perfectly exposed to sight and touch. This is especially necessary when numerous adhesions and extensive bleeding areas are to be dealt with, for the work proceeds more rapidly and with greater cer- tainty than without the elevation. BXPOSUKE OF THE FIELD OF OPEEATION. 15 The advantages of this posture were first appreciated by Bardenheuer, of Cologne, as noted by Dr. E. Gushing (see Die Dravnirung der Peritonealhohle, Stuttgart, 1881, p. 276). Before the elevated posture came into general use much dexterity was ac- quired in manipulating the intestines, to keep them out of the field, with fingers and sponges ; this is now unnecessary, because the simple position mechanically throws all the movable viscera up toward the diaphragm and out of the way. In the elevated posture the patient lies upon her back on an inclined plane, with the pelvis laised more or less above the level of the chest. To secure this elevation in a simple manner, a variety of tables, and attachments for tables already in use, have been devised. These differ in general in two ways, one pro- viding for the tilting- of the whole body, the other flexing the back while the shoulders and head lie flat. A number of these tables admirably fulfill the various requirements : such are the Edebohls, Cleveland, and Boldt tables. My own table is provided with a simple rest for the abdomen and hips, which is ele- vated and held iu position by means of a ratchet attachment (see Chapter I). The advantages of the elevated posture are so great that it is indispensable in all pelvic and lower abdominal work ; the parts to be operated upon are per- fectly exposed to view as well as touch, giving the operator a clear knowledge of the condition of the structures throughout the operation. One of the most important advantages is the fact that the intestines are kept out of the way without handling them ; moreover, by causing the blood to gravitate toward the head the danger of shock is diminished, especially in anemic women. I consider it also an important advantage that the operator looks into the pelvis, and handles the pelvic structures without the necessity of bringing his own and his assistant's head directly over the incision. The amount of elevation needed will vary with each case. In stout women, where there is a redundance of fat within the abdomen, it may be necessary to raise the body to an angle of 45°. As a rule, an elevation of from 18° to 30° will be sufficient. When the patient becomes deeply cyan- osed and the breathing stertorous, she must be let down lower. The ob- servant operator will discover, after the intestines have once gravitated toward the diaphragm well out of the way, that he may then let the pelvis down much lower, often quite near the table, and continue his operation without embarrass- ment from obtruding bowels. I would say, as a general rule, that it is best to begin with a high elevation, 40° to 30°, and then to continue the operation at a lower elevation. By elevating the patient for one or two minutes just before beginning the operation, on opening the abdomen the bowels will then be found already well out of the way. In order not to waste time waiting for the intestines to gravitate slowly into the upper abdomen, and to dispose of obtruding coils, it is a great help to use non-absorbent cotton pads covered with gauze to push them out of the way and hold them there. I always have at hand for this purpose a num- ber of little bolsters, about 12 centimeters (5 inches) long and 4 to 6 centimeters (2^ inches) in diameter, made of non-absorbent cotton enclosed in gauze and ster- 16 PEINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPEEATIONS. ilized. The non-absorbent cotton retains its form and elasticity, and is there- fore better than absorbent cotton. The dangers of the elevated position are four: First, it may be the means of carrying septic matter from the pelvis into the upper abdomen. This will be avoided by packmg in gauze and sponges so as to wall ofE the pelvis from the abdominal cavity m all inflammatory cases where pus is found. If the operator expects to open a pelvic abscess, he must let the patient down almost level and do it in that posi- tion. In case of an unexpected rupture of an abscess, or the discovery of free pus in the pelvis on opening the abdomen, the patient must be dropped at once to a level position, and sponges and gauze packed rapidly in to catch the dis- charge. If the pus has become widely distributed, it is better to irrigate the lower abdomen freely at once and then to pack in sponges and gauze while con- cluding the operation, after which it is best to irrigate thoroughly once more. Secondly, the elevated posture tends to check bleeding from vessels, which may become active enough to destroy life when the horizontal posture is resumed. This must always be borne in mind, and will only be avoided by taking unusual care to stop all bleeding, and then by exam- ining the whole field some time after letting the pelvis down, to see if there is any flow. Thirdly, a perforated omentum may cause death by catch- ing and retaining a loop of intestine in one of its holes, and so causing an ileus. I lost one case in this way. Although the abdomen was opened again and some adhesions broken up and the distended bowel relieved, the incar- cerated loop was first discovered at the post-mortem examination. Fourthly, a stout woman may lose her life in the struggle to keep her diaphragm going against the great weight of fat viscera pressing upon it. The danger signs are rapid stertorous breathing, deep cyano- sis, irregular pulse, dilated pupils, and cessation of cardiac pulsation from an overdistended right heart. Retractors . — Flat and scoop-shaped retractors of three sizes are necessary to hold apart the edges of the abdominal incision, converting the linear opening into an oval which gives a perfect view of the parts beneath. After a thorough exposure and study of the field to determine the exact character of the opera- tion, one of the retractors is removed, and the assistant then follows the surgeon as he proceeds with the enucleation and suturing by retracting, first one side, then the lower angle, and then the opposite side, as the operation progresses. One of the most important uses of the retractors is to avoid the constant con- tact of the hands with the abdominal incision, increasing the liability to in- fection. Where much force has been necessary to hold the incision open, its edges are always bruised and infiltrated with blood. Cases which have come to the post- mortem table have invariably shown widespread ecchymoses on both sides ex- tending out under the peritoneum. This will be in some measure prevented by making a longer incision, not so hard to hold open, and by gentleness in METHODS OF DEALING WITH ADHESIONS. 17 retracting. The use of the hand as a retractor, protected by gauze, is an ad- vantage in this respect. Dr. "W. E. Ashton has devised an excellent self-retaining bivalve retractor for use in incisions of medium size. The Illumination of the Field . — The illumination of the field of operation is best obtained through a high window admitting north hght. If this can not be obtained, a diffuse light from a number of windows in a room whose walls are painted of a light color is good. But a dull, cloudy day may so obscure the light in the best-appointed operating room that artiticial means of illumination should always be at hand. Indeed, I constantly resort to artificial light even under ordinary circumstances. An electric light of sixteen or twenty candle power supplied from a street current is the most satisfactory form of illumination. The burner is attached to a short handle and connected by long insulated wires to the socket on the wall. A good tin reflector, painted black on the outside and with white enamel paint on the inside, encloses one half of the lamp and protects the operator's eyes during the illumination of the abdomen. The assistant holds the light and directs it where it is wanted, taking care to keep it far enough away from the wound not to interfere with the operation. After a little experience the operator will find no difficulty in looking in beside the light, and so gaining a perfect view of all parts of the pelvis, at the same time using instruments and sponges and passing ligatures freely without striking the lamp, which should be held about six inches above the incision. Where the electric current from the street is not available a storage battery can be util- ized. The inconveniences of a storage battery are its weight and the uncer- tainty of the light, which may suddenly give out when most wanted. The latter objection, however, has been largely overcome by improved construction, and I find a storage battery a necessary and valuable adjuvant in my private work. The weight of a battery which is not too large to carry around is about twenty pounds, and it measures 8 by 9 by 10 inches ; its working time is about fifteen hours, after which it must be refilled. This may be done from any direct (Edison) street current by interposing a Vetter current adapter, which fits into the ordinary lamp socket and carries a lamp for the necessary resist- ance between the source of current supply and the battery. The head light which goes with the storage battery is a miniature lamp of four candle power, enclosed in a cylinder with a refiector behind and a plano-convex lens in front of it ; it has a ratchet for adjustment, and is attached to a fiexible steel head- band with cords to connect it to the battery. A battery a little larger than this is capable of running a hand light of six-candle power for some hours. In operations conducted in private houses a common candle held in a metal tube with a conical tin reflector will do in case of urgent need. The light from a lamp may even be thrown into the pelvic cavity with a common hand mirror in extreme necessity. Methods of Dealing with Adhesions. — Operations upon pelvic tumors and in- flammatory masses are often complicated by adhesions to the pelvic walls, pelvic floor, omentum, uterus, rectum, small intestines and colon, bladder, and 43 18 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPEEATIONS. vermiform appendix. Adhesions to the pelvic walls and floor vary greatly la character, sometimes being light and easily broken, at other times dense, so as only to be severed by sacrificing a portion of the underlying structure. They can usually be fi-eed by carefully distinguishing a plane of cleavage between the peritoneum of the tumor and the visceral peritoneum, and following this cau- tiously with the fingers as the tumor is stripped off. Omental Adhesions. — One of the offices of the omentum is to re- move foreign materials from the abdominal cavity, or to encapsulate them, and for this reason it is found with extreme frequency adhering to inflammatory masses. If the mass is small the omentum may envelop it completely ; where the whole pelvis is choked, it often acts as a diaphragm to separate the pelvis, from the abdominal cavity by forming adhesions to the pelvic brim on all sides. In other cases it may adhere to one part of the brim or to the uterus or bladder. The pelvic inflammatory diseases are most likely to be accompanied by omental adhesions. In a series of one hundred hystero-salpingo-oophorectomies in my clinic I found that there were forty-seven cases (47 per cent) in which the omentum was adherent. The adhesions varied from light velamentous ones, easily separated, to dense indurated masses covering in and encapsulating puru- lent collections. In five of these cases it was necessary to remove large portions, of the omentum attached to purulent foci. In other instances adherent portions of the omentum were simply ligated and cut, the divided portions remaining attached to the enucleated structures. Adhesions to the anterior abdominal wall are frequent, especially after pelvic operations. An adherent omentum always impedes the operator, and must be released at the outset, either by stripping off light adhesions with the fingers, or by ligat- ing and excising a sufficient portion of a densely adherent omentum to leave a clear field for the pelvic operation. The removal of a portion or all of the omentum does not increase the danger of the operation, and it should be promptly resorted to rather than waste much time in separating adhesions and applying numerous ligatures in trying to save the omentum. Cut or torn omen- tal vessels bleed freely and persistently, and all hemorrhages from this source must be promptly checked. If there are any obscure bleeding points after sepa- ration of a number of omental adhesions, they can be located by drawing the omentum out of the incision and spreading it out on clean white gauze ; the red stains found on the gauze after a few minutes then correspond to bleeding points. It is always preferable to ligate and excise persistently oozing sections of omen- tum rather than to search out individual vessels. Areas of omentum which are densely adherent to pelvic structures can be tied off with fine silk or catgut liga- tures and cut just below, and left in the pelvis with safety. A rapid way of tying off the omentum is to push a finger or an artery forceps through one of the clear spaces, drawing a ligature back, tying it over the free border, and cut- ting it just below. By continuing this across the abdomen, the whole omentum can be tied off in small sections, catching several vessels with each ligature. Uterine Adhesion s.— In all pelvic inflammatory diseases the uterus is usually found attached to the adjacent structures by its lateral or posterior sur- METHODS OF DEALING WITH ADHESIOIfS. 19 faces. These adhesions are usually peeled off without difficulty in the course of the operation, and only demand attention if oozing is persistent. A small quantity of dry sterilized powdered persulphate of iron may be apphed on the tip of the finger or a bit of gauze to fine bleeding points with excellent styptic effect. Sutures may be passed through the uterus with impunity in any number and at any depth, so long as they do not include the mucosa. If the oozing area is limited, a suture threaded directly into a small needle may be passed under the bleeding area a short distance from it. The stitch-hole thus made some- times bleeds more actively than the points which it is designed to control, but on tying the suture the tissue will become blanched and the oozing cease. Care must be taken not to tie the suture too tightly, or it will cut and the hemorrhage be made worse. This accident will be avoided by observing the surface, as the knot is tied, and ceasing further traction as soon as the oozing is checked. Hemorrhage from longer and deeper injuries to the uterus may be con- trolled by a series of interrupted ligatures passed transversely beneath the wound. Oozing on the lateral surfaces of the uterus may occasionally be checked by drawing a part of the broad ligament over against it with sutures. When there is a slight persistent oozing over a wide area of the posterior sur- face of the uterus, which can not be conveniently controlled by the means just described, the uterus may be forced down into retroposition on the pelvic floor without suture. I have found this method effective in a number of cases, and have seen no disadvantage from it. An adherent retroflexed uterus may be freed by simply stripping up the fundus with the fingers, if the adhesions are light. If they are dense, it is better to expose the uterus and pull the fundus forward, putting the adhesions on the stretch and cutting them with scissors under inspection. If the uterus is extensively adherent, it is better to remove it with the lateral structures (hystero- salpingo-oophorectomy). Rectal Adhesions . — Eectal adhesions are the most troublesome as a class, because they are often situated deep down in the pelvis, so as to be almost inaccessible, and because the bowel can not be displaced and brought up into the incision or outside, as with adhesions of the small intestines. In the one hun- dred cases of pelvic infiammatory disease referred to under the previous head- ing, thirty-five had more or less extensive adhesions between the inflamed structures and the rectum. These adhesions are best dealt with by lifting the uterus or adherent tube and ovary carefully upward and forward away from the bowel. If the adhesion is stretched a little by this maneuver, so as to present a little space between the adhering organs, the scissors may be used with good effect to separate them. Often in this way a widely ad- herent area may be released without injury to the bowel. Where the adhesion is flat and the adherent mass can not be raised up from the bowel, the fingers may be tried judiciously, and an effort made to strip off the adhesion by working the fingers in the direction of least resistance, but always keeping the palmar surfaces toward the tumor or the uterus, lifting it off the bowel. A plane of cleavage is almost always found between the old agglutinated peritoneal sur- 20 PEINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. faces, and no injury is sustained in the separation. If this plan does not succeed it is better to leave behind a piece of a tumor, or the outer wall of an abscess sac, where the adhesion is so dense that it can not be separated without imminent risk of opening the lumen of the bowel. Such a piece can afterward be trimmed down and its linino; membrane peeled, scraped, or burned off. When any or all of the coats of the bowel are torn, the edges of the tear must be neatly approximated by sutures. This is usually easy on account of the thickness of its coats, which give the suture a good hold. The cliief difhcu ty in suturing often arises from the brittle- ness of the tissue which is infiltrated with inflammatory products, causing the suture to tear out when the attempt is made to tie it. If a hold can be secured, interrupted mattress sutures or simple in- terrupted sutures of fine silk are applied and tied at frequent intervals. When the torn area is a large one, I have suc- ceeded in a numlier of instances in pro- tecting it by laying the uterus down on it in retroposition so that the posterior surface of the uterus made good the de- fect. In one case, a negress (J. S., 332), operated upon Sept. 2, 1890, there was a long, triangular tear through the muscu- lar coats of the rectum, with its apex just below the promontory of the sacrum. I closed it by suturing the posterior surface of the uterus to the bowel with two continuous sutures, beginning at the pelvic floor on either side and extending up to the apex. This patient made an excellent recovery without any rectal dis- turbance (./"A«.s Hopkins Hospital Report in Gynecology, vol. ii, p. 413). When the bowel has been widely opened, or when the suturing has been unsatisfactory, it is always wiser to put a gauze drain in the pelvis through the vaginal vault to provide for a possil)le infection through the injured bowel. It is better to move the bowels on the third day with a pill. The nurse must be cautioned under no circumstances to give a large enema, distending the bowel. At the utmost nothing more than a little glycerin and oil should be in- jected into the rectum through a syringe with a short nozzle. Other Intestinal Adhesions . — Intestinal adhesions of all kinds must be handled with extreme care, to avoid woundiny; the coats of the bowel and so making an avenue for septic invasion of the peritoneal cavity. In general there are two varieties of these adhesions — the loose membranous or velamentous, and those which are den se and organized — involv- ing one or more of the coats of the intestines. In order to avoid the danger of blindly tearing a hole in the intestines, intestinal adhesions should invariably Fig. .316. — STiiLCTURE of the Rectum due to Pel- vic Inflammatory Disease, seen tiihoiigh THE Proctoscope, 9.-5 Centimeters above THE Anls. Dec. 8, 1896. Natural .Size. METHODS OF DEALING WITH ADHESIONS. 21 be broken up under direct inspection. Velanientons membranous adhesions are readily stripped olf without involving the integrity of the bowel, and, on account of their low organization and poor vascularization, they do not give rise to hem- orrhage. They prove most difficult to handle if they are bunched together, when they acquire strength, like a string of spider's web. This must be avoided by spreading them out and dealing with them separately. The case is different with dense flat adhesions, where the plastic lymph has undergone organization, and the pei'itoneal surfaces are bound intimately to- gether Ijy the newly formed connective tissue, richly supplied with blood vessels. This class of adhesions is most frequently associated with pelvic abscess. On attempting to strip the adjacent loops of intestines loose, the peritoneal coat is torn, and sometimes the external and internal muscular coats are ruptured with it, even into the lumen of the bowel ; if much force is used, the tear will often extend far beyond the point at wliich it started. To prevent this, the whole area must be well exposed and the adherent structures released slowly and gently by dissection, as far as possible with the fingers, using the point of the knife or scissors only when neces- sary to nick strong bands. Adhesions to benign tumors and cysts and to the uterus are more easilj^ dealt with, inasmuch as a portion of the wall of the cyst, or a part of a tumor, or a piece of the uterine wall may be cut off with impunity and left attached to the bowel to avoid opening it. If there is oozing from this surface or from the intestine, it may be checked either by cauterizing it lightly or by bringing together its free edges with sutures. In one hundred cases of pel- vic inflammatory disease in which hystero-salpingo-oophorectomy was performed, the intestines were ad- herent either to the inflammatory Fig. 317.— Veemiform Appendix (App.) ADHERENT TO . ^ ,11' '^ Large Papillakt Ovarian Cyst. Deo. 22, 1894. structures or among themselves m 2/^ Natural Size. fifty-two cases. In twenty -four cases the intestine was injured in the enucleation, varying in degree from a simple laceration of the external coat to complete rupture of all the coats. Appendical Adhesions. — A large percentage of pehdc inflamma- tory diseases and ovarian tumors is associated with adhesions to the vermiform appendix, which is quite often found firmly attached to the mass by its extrem- 22 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. ity or its lateral wall. The cases in which the vermiform appendix is most likely to be involved are those in which its free end hangs down over the pelvic brim close to, or in contact with, an inflamed right tube. An inflammatory affection of the tube will in this way easily involve the appendix, and an appen- dicitis ml], on the other hand, infect the tube ; so that the appendicitis may be either primary or secondary, and the same may be said of the salpingitis. ^^ hen the appendicitis is secondary it is usually limited to the outer coats. In one of my cases in which the disease was primarily in the appendix this organ was perforated, the pelvis was filled with pus, and the tube became in- flamed and the ovary gangrenous, appearing green and black. The patient sur- Fig. 318. — Exten-siye Pelvic iNFLA^rMATiniv I)ist;A^i'; witei Gexkuai. Adhesioxs, due to Tuberculous Endometritis, Pelvic I^eiiitonitis, Tuberculosis of both Tuu.es and of Right Ovary. The right ovary is .5 x 4 x 3 to show the densely adherent centimeters in size, and is tilled with pus. The drawiiiLr is e-sjiecially intended veriniforin apiteiidix. Path, Nn. 1071, Up, Feli. 1.5, IS'.ni, Isatural size. vived the operation for the removal of these structures, and was up and going about when she died suddenl}^ on the twenty-eighth day, suffocated by a large peri-hepatic abscess rupturing into a bronchus. Gentle traction will sometimes suflice to free an adherent appenilix, but it must l»e watched for a time to make sure that it will not continue to bleed if it is dropped without Ijeing removed. Sometimes a fine silk suture at the bleed- ing point will check the flow, but tliis is often not admissible, because the appen- dix tends to tear and bleed more freely after the puncture of a needle. If the hemorrhage persists, amputation of the appendix is best. Where the adliesions are firm it is better not to try to save the appendix, but to remove it with the right tube and ovary (see Chap. XXX YIj. INJURIES TO THE BLADDER AND URETERS. 23 Vesical Adhesions . — The bladder occupies a comparatively isolated position in the anterior part of the pelvis, and for this reason vesical adhesions are rarer than adhesions elsewhere. The omentum is the abdominal organ most liable to contract adhesions with the bladder. In almost all cases the vesical attachments are to the posterior pelvic viscera — that is, to the uterus, rectum, ovaries, and tubes. Sometimes but a few strong bands connect -the bladder with one of the organs behind it, at other times a large part of the vault of the bladder is drawn over the top of the uterus and its lateral structures by the adhesions to the rectum, completely burying them out of sight. In order not to injure the vascular walls of the bladder, delicate manipulation is required to separate it from the adjacent adherent structures. Adhesions may usually be severed with knife or scissors, leaving behind, if necessary, a part of the uterus or the wall of a tumor. All vesical tears should be repaired at once by suture. If the peritoneal coat alone is injured the rent may be approximated by a con- iinuous suture. A deep tear opening the cavity of the bladder is best remedied by a series of interrupted fine silk sutures placed close together, each one enter- ing on the peritoneal surface and penetrating deeply enough to include the mus- cular coats, but not the mucous coat. When these sutures are tied there ought to be a perfect approximation, which of itself checks all hemorrhage. If the "union is neat no fear need be entertained of a leakage of urine. For this reason abdominal drainage will not be necessary. Urine escaping over the peri- toneum during an operation is not harmful, unless it contains septic matter, as in cystitis. In this case too great care can not be taken to avoid any contamina- tion, however slight. Injuries to the Bladder and Ureters. — Injuries to the bladder in the course of •an abdominal operation arise from its displacement either out of the pelvis be- neath the abdominal wall in front of the peritoneum, or from its being lifted up into the abdomen by a subperitoneal tumor. Such accidents most commonly •occur in the case of large fibroid tumors choking the peMs and leaving no room for the expansion of the bladder, which is then forced to distend up under the •cellular tissue of the abdominal wall. For this reason it is important in all oper- ations for large myomata to make the incision slowly and ■with great care, and to cut through into the peritoneum preferably high up toward the umbilicus, so as to keep above the bladder, and then to continue the incision downward, guided by a finger within the peritoneum. I had a case a number of years ago of a suppurating ovarian cyst which had ■contracted adhesions with the bladder and dragged it halfway up to the umbili- cus. In opening the abdomen I unwittingly cut directly through the bladder, whose walls were greatly thickened by inflammation. The result of this acci- dent was a permanent urinary fistula. The bladder is often lifted up into the abdomen by large fibroid tumors, and will inevitably be injured in the process of enucleation if two rules are not observed. 1. The point of reflection of the bladder onto the uterus must be found by making traction on the vesical peritoneum, which is loose and movable, and by noting the line of flrm attachment to the uterus. 24: PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. 2. The anterior incision in removing the uterus must always be made from round ligament across to round ligament, following this line. By neglecting this last rule in extirpating a large subperitoneal fibroid I cut ofE with the tumor a piece of the bladder as large as the palm of my hand, ihe hole was at once closed with interrupted sutures, and healed without leavmg a fistula. . , The ureter is often laid bare from the broad ligament to the pelvic brim by the removal of a subperitpneal fibroid tumor. Eo ill consequence follows the simple exposure. There is great danger of tying or piercing a ureter in the effort to check hemorrhage following the removal of an adherent mass from the pelvic floor. On this account I am extremely cautious about using a needle and suture m this situation. I once pierced a ureter in such a case, and the patient had a drib- bling of urine from the incision lasting several weeks, when it ceased sponta- neously. The ureter, is often tied in removing fibroids or fibrocystic or cancerous uteri, and the only safe rule to avoid such an accident is to trace out the ureter from pelvic brim to vesical ending, making sure of its integrity. It may be accidentally cut when lifted high out of the pelvis on a subperitoneal fibroid. The only way to avoid this is to examine with minute care before tying and cut- ting any distended vessel found running up over the anterior face of the tumor looking like a vein or lymphatic, 1 or 2 centimeters in diameter (see Chapter XXXI). If divided, a uretero-ureteral anastomosis must be performed (see Chapter XIII, p. 466). Ligation of the Pedicle. — Silk is the best ligature material for the pedicle of a pelvic tumor, and if not weakened by the sterilization the intermediate size (see Fig. Y) will be strong enough and less liable to lodge septic matter and produce an abdominal fistula. "Where tissue is ligated en masse, it is best always, as an additional precau- tion, to pick up the exposed mouths of the large vessels separately and pull them out a little and throw an additional fine suture about them. By this plan hemorrhage will be avoided^ even if the pedicle shrinks. If the pedicle is long and thin, a single ligature may suflice to control it. It is then cut off about 2 centimeters beyond the ligature. A thicker pedicle must be transfixed by two ligatures and tied on opposite sides. It is never safe to tie off sessile tumors or tumors with short pedicles in this way, on account of the extreme danger of the slipping of the ligatures. In tying off ovarian and tubal tumors I have long since abandoned the plan of pulling the mass up through the incision and transfixing the broad ligament with two ligatures below and tying in opposite directions. There can be no doubt that this time-honored tie is responsible for almost all the hemorrhages occurring after simple salpingo-oophorectomy. I have not found the Stafford- shire knot one whit more satisfactory, knowing of many cases of hemorrhage following its use, one of which I saw in the hands of its first advocate. The best and safest way to tie off the top of the broad ligament is to tie the Fig. 319.~The Clear Space. ' By lifting up the tube and ovary an area is developed in tlie outer part of the broad ligament where both layers of the ligament come together without any intervening vessels or tissues. In the figure the index linger is seen tlirough the elear space, which it pushes forward. By transllxing with the needle, as shown, and tying over the top of the broad ligament in the direction of the dotted line, all the ovarian ves- sels are secured. LIGATION OF THE PEDICLE. 25 ovarian and uterine vessels separately, leaving- tlie membranous interval free, and without attempting to draw them together. When the structures are removed this leaves two little bunches of tissue holding the vessels, one at the pelvic brim under the cecum or under the sigmoid flexure, and the other at the uterine cornu ; Ijetween these the peritoneal layers of the broad ligament fall together in a narrow line. The ovarian vessels are easily found and tied by transfixing an interval at the outer extremity of the broad ligament which is free from vessels, and then tying over the toj) of the broad ligament near the brim of the pelvis ; in this way all the veins and the artery ai'e included. I have called this interval " the clear space." The clear space is formed by gathering up the broad ligament between Fig. 320. — Encysted Silk Ligatuee in the Eight Broad Ligament. The ligature had been put in six monthe previously to ligate the large varicose veins in the ligament. The left-hand figure shows the relations of the ligature. No. 451. Natural size. the thumb and forefinger, with the thumb in front, just beyond the fimbriated end of the tube and behind the round ligament at the pelvic brim. As the broad ligament is lifted the vessels are raised, and if a light is held behind, the translu- cent tissues are seen to be made up of two layers of peritoneum and entirely free from any vessels. So thin is this clear space that if it is held a little tense, the needle often punctures it with a click, as if it was going through parchment. The fine silk ligatures used in ligating the pedicles become encysted in lymph and remain innocuous. Fig. 320 shows one of them as it was found six months after its introduction for the purpose of ligating the enormously dilated ovarian veins. The knotted portion of the ligature remains unchanged, but the loop, if it is a long one, is often dissected apart into its ultimate fibrils by the leucocytes, when the silk is not absorbed, as it can always be found with a microscope. 26 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. Hemorrhage. — Active persistent hemorrhage is perhaps the commonest com- plication in abdominal surgerj. The usual source of bleeding is, first, the vessels in the abdominal incision ; second, the uterine vein and arteries ; third, the ova- rian veins and arteries ; and fourth, the vessels of adherent structures, such as uterus, pelvic walls and iioor, broad ligaments, rectum, small intestines, vermi- form appendix, and omentum. To avoid hemorrhage as far as possible, the surgeon must tie every actively bleeding vessel in the abdomen as soon as it is severed. When the hemorrhage comes from the ab- dominal walls it is usually enough to clamp the smaHer vessels temporarily, and upon removing the forceps later in the operation, when they are in the way, the bleeding will have ceased. Occasionally it will happen that the source of blood accumulating on the floor of the pelvis will actually be found in a small vessel in the lower angle of the incision, from which point it trickles down unob- served over the bladder. Bleeding omental vessels must be tied at once, for, if they are allowed to slip up into the abdomen out of sight, a large hemorrhage may occur before discovery, especially with an elevated pelvis. If there is obscure bleeding from any part of the pelvic cavity it may be found by putting in a large dry sponge and waiting a while, when, on taking it out, the blood spot will show where the flow is persistent. I adopt the following precautions for controlling hemorrhage and prevent- ing its recurrence : I make it a rule not to rely solely upon the pedicle liga- tures, but in addition to tie the open mouths of all large vessels with a fine ligature, making assurance doubly sure. With a little pa- tience slight bleeding will often cease spontaneously ; small pelvic vessels, which are easily accessible, may be caught for a time in artery forceps, and when the forceps are removed the bleeding does not recur. Oozing areas deep down in the pelvis may sometimes be controlled by the application of hot water with pressure tipon a sponge or gauze pad. The cautery formerly much used for this purpose ought to be given np, as it checks only the smallest vessels, which can be better controlled in other ways. One of the best means of stopping the flow from a small area, whether on intestines or uterus or pelvic floor low down, is the apphcation of sterilized persulphate of iron. A little of the dry powder is made to adhere to the moistened finger-tip, which is pressed firmly against the bleeding spot for a minute or longer, and then cautiously removed. When there is oozing from a broad surface on the posterior lateral surface of the uterus, the easiest way to control it is by suturing tissue from the adjacent broad ligament over the area and tying the sutures tight. Persistent hemorrhage from a number of branches of the upper part of the uterine artery may be controlled by a ligature applied to the trunk of the artery low down near the base of the broad ligament, in the cervical region. The arterial trunk can be found by drawing the body of the uterus to the opposite side, so as to expose the broad ligament better, and then deter- HBMOBRHAGE. 27 mining the position of the artery by feeling its pulsations. A ligature thrown around it at this point will cut off the blood supply above. I was obliged in one case to resort to the ligation of the internal iliac artery just below the bifurcation of the common iliac. In removing a cancerous uterus through the abdomen, I had opened up a diseased area at the base of the right broad ligament near the pelvic wall, and was unable by ligature or pressure to control the free oozing in the already profoundly anemic patient. I fixed upon the position of the internal iliac artery by locating the common iliac and finding its point of bifurcation by touch. A small incision was then made through the peritoneum and torn more widely open with the fingers, lay- ing the artery bare. The ureter seen close by was lifted up out of the way toward the pelvic brim. The artery was now loosened from its bed, so that a ligature could be passed beneath it without injuring the vein. This was done and the ligature tied, the circulation controlled, and the patient recovered. In similar operations the ureter must always be recognized and removed to one side, and the artery carefully isolated from the vein. In another case in which I tied both arteries, hoping to check a cancerous development, I had the mis- fortune to puncture the left common iliac vein. Not knowing that it was the iliac vein, I tied it, and gangrene of the leg followed, necessitating amputation in the middle of the thigh. The patient survived, and died in the natural course of the cancerous affection. If the patient comes onto the operating table in an anemic state and loses blood freely, or if she is rendered anemic and shocked by the loss of blood during an operation, from half a liter to a liter of normal salt solution must be given subcutaneously. In all simple operations upon the uterus, ovaries, and tubes, uncomplicated by adhesions, hemorrhage within the abdomen must arise from one of the four principal vessels, uterine or ovarian. Hemorrhage after the removal of tubes and ovaries, or of an ovarian tumor, is always from one of the extremities of the broad ligament at its pelvic or its uterine end ; if it comes from the outer ex- tremity, the ovarian vessels are bleeding ; if from the inner extremity, at the cornu uteri the uterine vessels furnish the flow. These vessels are all accessi- ble, and can readily be controlled by an additional ligature passed beneath the bleeding point. Hemorrhage from the ovarian vessels occurring during the operation, after they have been ligated, comes from cutting too close to the liga- ture, or from a careless handling of the surrounding tissues which serves to drag the pedicle out from under its ligature. This is especially liable to happen in sponging out the pelvis, and in putting tension upon the broad ligaments to remove an ovary and tube from the opposite side. The bleeding area appears as a long, dark, oval slit on top of the broad ligament extending out over the superior strait. This accident may be corrected by catching the outer extremity of the broad ligament with forceps and lifting it well up from the pelvis in order to pass another ligature beneath the ovarian vessels higher up. The great dan- ger at this point is that of including the ureter in the ligature. This must be 28 PK,IN"CIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. avoided by inspecting the ureter and seeing that it remains in its normal position and is not picked up with the vessels. To avoid displacing the ligatures m sponging out the pelvis, two fingers should be introduced into the wound, the index finger to hold the uterus forward, and the middle finger resting on the promontory of the sacrum ; between these the sponge may be easily carried mto all parts of the posterior pelvis without striking the tops of the broad ligaments and straining the ligatures. In cases of pelvic inflammatory disease, the tearing loose of the ovary from its hilum during enucleation often gives rise to free hemorrhage. The remedy for this accident is to clamp the bleeding vessels with two or more forceps, and then to tie the main trunks at either extremity by pass- ing two or more ligatures through the broad hgament. Hemorrhage from the uterus, bladder, or intestines can usually be controlled by passing a fine ligature beneath the bleeding point with- out penetrating the cavity of the viscus, drawing the knot just tight enough to check the flow. An important principle to be observed in the ligation of a bleeding vessel deep down in the pelvis and difficult of access, or oozing so active as to obscure the field, is to introduce and tie a ligature as near the point as possible. If this does not control the hemorrhage, it will at least be in close proximity to the source, and so serve as a tractor to draw the tissue up into better view while another ligature is applied, followed, if necessary, by a third and a fourth. It is occasionally necessary to pass one ligature below the other in this way halfway down the broad ligament before a dry field is secured. When the hemorrhage is too general to be controlled by the above means, or when the life of a patient is likely to be jeopardized by the length of time necessary to control a number of bleeding points, a gauze drain must be used. If packed tightly, it acts as an efficient hemostatic and removes the blood as well. This method of controlling bleeding will only be necessary in rare in- stances if the foregoing means are faithfully employed. Irrigation. — The best means of cleansing the peritoneum after contamination by septic discharges, blood, or the debris from tumors, is to wash out the abdo- men with a normal salt solution. Pouring the hot solution into the abdomen also serves an excellent purpose as a stimulant. But irrigation, although invalu- able in some cases, should not be resorted to frequently. When there has been moderate hemorrhage, limited to the pelvis, the blood should be gently removed with sponges, and any small amount remaining will be absorbed without diffi- culty. Even the escape of a small quantity of pus does not require irrigation, if it is at once taken up, and if the microscope shows that it is sterile or contains but few germs. When, however, the removal of a large adherent ovarian or myomatous tumor has been accompanied with considerable hemorrhage, or when a large pus sac has ruptured in the pelvis and the pus has been found distributed among the intestines, and when the intestines have been sutured, then thorough irrigation is necessary f oi* the purpose of diluting and removing infectious mate- rial which can not be taken up so well by sponges. Pure water is irritating to the peritoneum, and for this reason the normal salt solution (six tenths of one per cent) is employed as the irrigating fiuid. Before every abdominal operation EXPERIMBIS^TAL STUDY OF DRAINAGE. 29 a flask of the solution should be placed on the sand bath and brought to 43-3° to 44'4° C. (110° to 112° F.), as indicated by a long thermometer standing in it. A more convenient method is to briag one flask to the boiling point and have a second cold one ready to mix with it, reducing it at once to the desired temper- ature. To mix them I use a graduated glass pitcher, devised by Dr. H. Eobb, provided with a flxed thermometer. To use irrigation, the solution is poured into the abdominal cavity by a nurse or assistant. By making a funnel of the palmar surface of the hand, the operator can direct the fluid into the pelvis or up into any part of the abdomen among the intestines. When the infection is limited to the pelvis, care must be exercised not to let the water flow up among the intestines, which serves to distribute more widely the infection. This is done in two ways — by keeping the incision widely open, so that it affords the easiest avenue of escape for the water, and by avoiding the use of too much water at one time. A little is poured in and swabbed about in the pelvis with a sponge and removed, then a little more, and so on. The upper abdominal cavity can be better washed out if the pelvis is elevated when the water is poured ; in this way it will often receive a liter or more before overflowing. By letting the pelvis down, the fluid either escapes or is easily sponged out. This may be re- peated any number of times. I have used as much as 13 liters in this way to wash out the blood from a ruptured extra-uterine pregnancy which had accu- mulated under the liver. In drying out the abdomen the renal fossae must not be forgotten, as a considerable quantity of fluid is liable to accumulate there. In septic cases the sponges must be separated, and those which have been employed in removing pus from a ruptured abscess must be laid aside and not be used later in cleansing out the abdomen. Another efficient method of irri- gating is by means of a long glass douche nozzle connected by rubber tubing with' a large funnel ; in this way the fluid can be directed to any part of the abdomen, and its force increased by raising the funnel. It is a cardinal prin- ciple not to irrigate over a wider area than has been contaminated. Thus the pelvis alone will most frequently need it, next the lower abdomen below the omentum, and last of all the entire abdominal cavity from diaphragm to pelvic floor. Experimental Study of Drainage. — Physiology of Drainage. — When to drain, how to drain, and whether or not to drain at all, are questions of the highest import in abdominal surgery. There is perhaps no topic upon which surgeons are more at variance with one another in their practice; for, while some men drain almost all their oases, even the simplest, others have abandoned drainage in all but the rarest instances. After an extensive experience with all forms of drainage, I have myself been slowly forced to the conclusion that it is rarely of value and often harmful ; for example, in the flrst five hundred abdominal sections performed in my de- partment at the Johns Hopkins Hospital, the glass drainage-tube was extensively employed — seventy -three times in the flrst one hundred cases. The whole subject of drainage is one of such fundamental importance that I deem it necessary to present in some detail the arguments drawn from numer- 30 PEINCIPLBS AlfD COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. ous experimental studies and clinical experience in over two thousand of my cases to form a basis from which to draw correct conclusions. For this purpose I have drawn freely upon the work of my late assistant Dr. J. G. Clark {Johns JIopL Hosp. Bull., Apr., 1897). Function of the Peritoneum under Normal and Patho- logical Conditions.— Gr. Wegner {Verhand. d. dsutsch. Gesell. f. Chir., Berlin, 1877), the first investigator who by experiments upon animals endeav- ored to arrive at some definite conclusion as to the ability of the peritoneum to rid itself of injurious fluids or solid particles, was convinced that a comparatively large quantity of infectious matter could be eliminated or encapsulated by the peritoneal exudate without serious harm to the animal. Grawitz {Ghar. Annal. Jahr., xi, 1886) next took up the experimental study of infection of the peritoneum, pursuing his investigations under improved bacteriological technique, and arrived at the following conclusions : 1. The introduction of non-pyogenic organisms into the abdominal cavity, either in small or large quantity, or mixed with formed particles, produces no harm. 2. Great quantities of organisms which ordinarily produce no symptoms may give rise to a general sepsis if the absorptive function of the peritoneum is impaired. 3. Injection of pyogenic organisms into the peritoneal cavity may be quite as harmless as injections of non -pathogenic varieties. (In these experiments he injected a flocculent emulsion of staphylococcus albus and aureus and the streptococcus pyogenes in 10 cubic centimeters of water without any visible reaction.) 4. The introduction of pus-producing cocci into the normal peritoneal cavity produces a purulent peritonitis, first, if the culture fluid is difficult of absorption, and, second, if irritating materials are present which destroy the tissues of the peritoneum, thus preparing a place for the lodgment of the organisms and the production of an exudate upon which they may grow. Pawlowsky ( Virchmv's Archiv, JSTo. 117, p. 469, 1889), in an excellent experimental study, reviewed Wegner's and Grawitz's work, with whom he agreed in many particulars, but disagreed in others. The main point of differ- ence, however, between Pawlowsky and Grawitz related to the ability of the normal peritoneum to deal with the staphylococcus aureus. Pawlowsky found that the large quantities of staphylococci injected by Grawitz without harm into dogs produced death very rapidly in the animals upon which he experimented, and that only a minimum quantity was harmless. Eeichel {Dewt. Zeit.f. CMr., vol. xxx, 1889) went over the same ground in an experimental research, and in the main agreed with Grawitz. The essen- tial points of value in Eeichel's paper are, that peritonitis usually arises, first, because more organisms gain entrance than can be handled by the peritoneum, and, second, because the stagnation of degenerating fluids in dead spaces favors the growth of the organisms. He also accounts for Grawitz's and Pawlowsky's conflicting results on the EXPERIMENTAL STUDY OE DRAINAGE. 31 ground that some animals are more susceptible to infection than others, and that there are marked differences in the virulence of cultures of the same organ- ism under varying conditions. A carefully conducted experimental research by Waterhouse ( Yirchoio's Archim, vol. cxix, p. 342, 1890), carried out under the oversight of Orth, appears to me to settle satisfactorily the question of the ability of the normal peritoneum to take care of infection. He injected 6 cubic centimeters of a cloudy culture of staphylococcus aureus into the abdominal cavity of dogs, employing both the methods of Grawitz and Pawlowsky, and all of the animals survived. The same results were obtained with the streptococcus, bacillus pyocyaneus, and the intestinal bacteria. Waterhouse then endeavored to simulate the conditions occasionally met with after operations by introducing 8 cubic centimeters of urine and small quantities of blood with the cultures, and again the results were negative. If, however, 15 to 20 cubic centimeters of fresh blood were introduced into the peritoneal cavity, followed in a few minutes by the staphylococcus aureus, severe peritonitis was produced. In these experiments Waterhouse agreed with Pawlowsky and Grawitz that the dangers of peritonitis are increased by tardy absorption of fluids, which in effect leaves a culture medium for the growth of the organisms. After the introduction of blood clots 3 centimeters in size, followed by the staphylococcus aureus, death occurred from peritonitis in twenty-four hours. Waterhouse also found that the purulent exudate from acute abscesses is extremely virulent, 2 cubic centimeters of the staphylococcus aureus and 1 cubic centimeter of the streptococcus from this source causing death in twenty -four hours. If a very small quantity of the pus, however, was introduced with water, the animals frequently survived. After the introduction of turpentine with the organisms, as done in Grawitz's experiments, peritonitis did not follow, which is explained by Water- house on the ground that the organisms are rendered inactive or are killed by the turpentine. He proved this point by injecting the turpentine first and following it in a short time with the infecting germs; in every instance the animal died of peritonitis. Dogs with a strangulation of the intestines were easily infected. In three instances the staphylococcus aureus introduced into the peritoneal cavity of cats suffering from ascites, was quickly followed by death from peritonitis, which resulted, as Waterhouse says, because there was a favorable culture material, a diminished absorption, and an injury to the peritoneal endo- thelium. Burginsky {^Baumgarten' s Jahresbericht, vol. vii, 1891), in a series of ex- periments, also came to the conclusion that the discrepancies in the results of Pawlowsky's and Grawitz's experiments were due to variations in the virulence of the cultures employed. Halsted {Johns Hoph. Hosp. Rep., vol. ii, 1891) confirmed and extended the views of previous observers concerning the resistance of the normal peritoneum 32 PEISrCIPLES AKD COMPLICATIOK-S COMMON TO ABDOMINAL OPBEATIONS. to infection, and called attention to the dangers of introducing pyogenic organ- isms about a ligated or strangulated area, or in conjunction witli insoluble bodies. Pieces of sterile potato introduced into the peritoneal cavity of controlled ani- mals were soon encapsulated and produced no disturbance, but when infected with pyogenic cocci invariably caused peritonitis. A recent paper by Cobbett and Melsome {Journal of Pathology and Bacteriology, 1895), on Local and General Immunity, contains some valuable observations bearing upon the resistance of the peritoneum to infection. Notwithstanding the injection of large quantities of virulent streptococci, a few of their animals survived. They state that " in those animals which suc- cumbed quickest, free cocci were very numerous in the peritoneal exudation, and in those which survived longest they were either absent or contained within phagocytes." These observers, in order to discover how' quickly the organisms disappeared from the peritoneal cavity, killed two rabbits which appeared about to recover. " In the first, which had received 5 cubic centimeters of broth culture thirty hours before, only one chain of streptococci was found after prolonged search, but many cocci were contained in cells, and broth inoculated with this fluid grew a good culture." " The second rabbit having shown no signs of illness after an injection of 6 cubic centimeters of anaerobic broth culture, received next day 10 cubic centi- meters of a similar material swarming with streptococci. When killed five and a half hours later, not only could no streptococci be seen, either free or in cells, but no growth grew on cultures made from the abdominal fluid." From this review of the literature bearing upon infection of the peritoneum I make the following summary : 1. Under normal conditions the peritoneum can dispose of large numbers of pyogenic organisms without producing peritonitis. 2. The less the absorption from the peritoneal cavity the greater the danger of infection. 3. Solid sterile particles, such as fecal matter, potato, etc., are partly ab- sorbed and the remainder are encapsulated without the production of peri- tonitis. 4. Death may be produced by general septicemia and not by peritonitis, where large quantities of organisms are taken up by the lymph streams. 5. Irritant chemical substances destroy the tissues of the peritoneum, and prepare a place for the lodgment of organisms which becomes the starting-point for peritonitis. 6. Stagnation of fluids in dead spaces favors the production of peritonitis by furnishing a suitable culture medium for the growth of bacteria. 7. The association of infectious bacteria with blood clots in the peritoneal cavity is especially liable to produce peritonitis. ^ 8. Traumatic injury or strangulation of large areas of tissue are strong etiological factors in the production of peritonitis when associated with in- fectious matter. EXPERIMENTAL STUDY OP DRAINAGE. 33 The accumulated evidence of all these Investigators proves beyond question that the peritoneum, under normal conditions or even when greatly handicapped by disease or artificial conditions, is capable of overcoming the invasion of com- paratively large quantities of pyogenic bacteria. Mechanism of Absorption of Fluids and Solid Particles in the Peritoneal Cavity . — Recent investigations by Muscatello ( Vir- ckow's Archw, 1895) on the histology of the diaphragmatic peritoneum and the mechanism of absorption of substances from the peritoneal cavity, when considered in conjunction with the above conclusions, give ample ground for my suggestion of the elevated posture as a prophylactic measure against post-opera- tive peritonitis. Muscatello accepts Bizzozero's and Gr. Salvioli's classification of the com- ponent parts of the diaphragmatic peritoneum which occur in the following order : Endothelium, membrana limitans, and connective-tissue framework. Up to the time of Muscatello's publication, histologists were equally divided on the question of the presence or absence of stomata between the endothelium. He proved beyond doubt that these openings are optical illusions, due to the defect- ive preparation and staining of the microscopical sections. According to Musca- tello's opinion, minute foreign particles, leucocytes, and fluids pass through open- ings between the endothelium of the diaphragm made by the retraction of the protoplasm of the cells. Beneath the peritoneal endothelium of the diaphragm and between the con- nective-tissue fibers are open spaces 4 to 16 micromillimeters iu diameter, oc- curring in groups of 50 to 60, which communicate with the lymph vessels. A careful search for these spaces failed to reveal them in any other portion of the peritoneum. G. Wegner first proved that the peritoneum was capable of absorbing the most remarkable quantities of fluids, equivalent to 3 to 8 per cent of the bodily weight in one hour, or the animal's entire weight in twenty-four hours. By the injection of foreign particles suspended in a fluid medium into the peritoneal cavities of dogs, Muscatello was able to demonstrate the existence of an intraperitoneal current which carried fluids and small particles toward the diaphragm, regardless of the animal's posture. The rate of transmission of the foreign particles from the peritoneal cavity to their ultimate repository, the lymph glands, could, however, be increased or retarded by the influence of gravity. In those dogs which were suspended with head down, carmine bodies ap- peared in the retrosternal and thoracic lymph glands in from five to seven min- utes, while in animals in which the posture was reversed it was five and a half hours before they could be recovered from these glands. Muscatello proved that small particles were carried from the peritoneal cavity into the lymph spaces of the diaphragm through the openuig made by the re- traction of the endothelium, then into the mediastinal lymphatic vessels and glands, then into the blood current, by which they were transported to the vari- ous organs of the body, from which they were picked up by the lymph vessels 48 34 PKINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. and deposited in the collecting glands of eacli organ. For this reason the large vascular organs, siich as the liver, stomach, spleen, and pancreas, show the par- ticles first and in the greatest numbers, while the lymph glands of the mesen- tery, which gather their vessels from a limited area of the intestine, contam but few of the granules. The function of the leucocyte is of especial importance in the elimination of foreign particles from the peritoneal cavity. Muscatello and other observers find, on examuaing the precipitate in the peritoneal cavity after injecting innocuous foreign particles or bacteria, wander- ing cells interspersed among the particles, some of which are lightly laden with granules, while others are apparently distended to the point of bursting, and still others which have not yet taken up their burdens. In some instances where the granules are too large for one leucocyte to en- compass it, two or more join forces to surround the invader. The leucocytes are found in greatest abundance beneath the omentum. From the peritoneal cavity Muscatello traces the course of the leucocyte through the channels above described, and finally finds them deposited in the lymph glands in various parts of the body. In Muscatello's experiments the leucocytes were able to dispose of the innocu- ous particles rapidly and without apparent ill effect to the animak. In Paw- lowsky's, Cobbett's, and Melsome's experiments, on the other hand, the con- ditions were different, the leucocyte having to meet an antagonistic invader. In those animals which survived the injection the infectious organisms were quickly encompassed by the leucocytes and carried into the general circulation, while in the fatal cases the peritoneal exudate was found swarming with free organisms and only a comparatively few were enclosed in leucocytes. The important conclusions are : 1. Large quantities of fluids may be absorbed by the peritoneum in a re- markably short time. (Wegner.) 2. Minute foreign particles are carried from the peritoneal cavity through the diaphragm into the mediastinal lymph vessels and glands, and thence into the blood, by which they are transmitted to the organs of the body, especially those of the abdomen, and later appear in the collecting lymph glands of these organs. (Muscatello.) 3. The leucocytes are largely the bearers of foreign particles from the peri- toneal cavity. (Muscatello.) 4. There is normally a current in the peritoneal cavity which carries fluids and foreign particles toward the diaphragm, regardless of the posture of the ani- mal, although gravity greatly favors or retards it. (Muscatello.) Historical Development of the Drainage Question in my Clinic. — The clinical study of a number of my cases, as well as several post-mortem examinations, combined with the bacteriological researches of Drs. H. Eobb and A. A. Ghriskey on the infection of the tube tract, convinced me that the glass drainage-tube was often powerless to remove fluids from the pelvis and was a source of grave danger as a channel of infection of clean wounds. EXPERIMENTAL STUDY OF DRAINAGE. 35 In a series of sixteen cases {Johns Hopk. Hosp. Bull., July, 1891), in which the condition of the drainage-tube tract was studied, in nine no cultures were secured, but in six the staphyloccus albus was found, and in one the staphylococcus aureus, and, notwithstanding the most painstaking tech- nique in the care of the drainage-tube, 44 per cent of the cases showed some form of organism. My fears of the transmission of infection through the tube were further increased by one undoubted case in which an infection occurred at the second dressing of the tube, followed by extensive suppuration of the ab- dominal wound. The glass drainage-tube was therefore unconditionally abandoned ; I still, however, felt the necessity of providing some means of eliminating fluids col- lecting in the peritoneal cavity, and so adopted and used the Mikulicz gauze bag in forty cases. This proved no more efficient than the simple gauze drain pro- posed by Fritsch, which was next used ; in January, 1893, following Schauta's observations, but independently, I adopted a new plan, and in order to de- termine whether drainage should or should not be used, I had cover-glass preparations made of all suspicious fluids found during an operation, and if pathogenic organisms were discovered I used a gauze drain. In forty-four cases of pelvic abscess examined for me by Dr. G. B. Miller, gonococci were found in six cover-glass preparations, but did not grow in cultures; the sta- phylococcus epidermidis albus was found once in culture ; the remain- ing thirty-seven cases were negative. These results in general coincide with the investigations of Menge, Schauta, and Reymond and Magill {Annals of Surgery, 1896). In an examination of 144 cases by Schauta, streptococci and staphylococci were found four times ; Menge has observed the staphylococcus once in twenty-six cases, and Morax once in thirty-six cases. From this time drainage was limited to infected cases, and no cases were drained simply because of the numerous adhesions separated and the raw sur- faces left behind. When pus was found and the microscope showed the entire absence of organisms the drain was not used. When the organisms were sparse the drain was not used. When the gonococcus was found the drain was never us,ed under any circumstances. When staphylococci and the colon bacillus were found in moderate numbers the drain was not used. When staphylococci and the colon bacillus were found more abundantly, and when the streptococcus was found in moderate numbers, a drain was used. But a further study of the gauze drains in the few cases in which I was then using them, led me to the conclusion that they also usually became infected after operation, through the opening left in the incision, and that this infection might occasionally give rise to a serious and even a fatal result. Of my last hun- dred cases not one has been drained. Objections to Drainage. — To summarize, the following are the most important objections to drainage : 1. It is unnecessary to provide for the removal of the sero-sanguineous fluid poured oat by the wounded surfaces after an abdominal operation. 36 PBINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPEEATIONS. 2. The very presence of the draia excites a freer flow from the wounded sur- faces than would otherwise take place. 3. The drain is an ineflicient means of removing this fluid, and in some cases it even acts as a plug to insure its retention. 4. Sooner or later the drain is certain to convey an infection down its track, which may either remain localized, and form a suppurating sinus, or may form the focus of a general peritonitis. 5. The mechanical act of removing the drain may be the means of insuring the infection of the entire tract through the infection already existing in its upper part. 6. The removal of a gauze drain is usually attended by intense pain, and it may be the cause of a prolapse of the intestine or of the omentum from the wound. 7. In one case in the hands of an associate, a fatal hemorrhage followed the dislodgment of a ligature at the time of the removal of the drain. 8. Whenever the drain is used largely the mortality is greater than in a group of similar cases which are not drained. 9. With drainage such post-operative sequelae as abnormal elevation of the temperature, persistent vomiting, tympany, vesical irritation, and suppuration of the abdominal wound are nearly three times as frequent as without it. 10. Post-operative obstruction, of the bowel and fecal fistula are more frequent in drained cases. 11. Hernia is a common sequel in the drained cases (8 per cent), while it is rarely ever seen in the cases which are not drained, if the wound does not sup- purate. 12. These remarks refer principally to the gauze drain. Where the glass tube is used, perforation of the intestine and hernia into the openings in the tube occur, the area drained is smaller, and the drainage is ineflicient In order to arrive at a clearer determination of the source and the avenue of the infection in the drained cases, I have divided them into two groups, the first containing tumors, cysts, etc., in which infection previous to operation is rarely present, the second including the inflammatory cases, such as pelvic abscess, pyosalpinx, acute and chronic salpingitis, and peri-oophoritis. In the first class drainage was usually employed to control oozing from adhe- rent surfaces and to remove collecting fluids. Of one hundred of my undrained cases, where there were more or less ex- tensive adhesions, one case was complicated by the formation of a pelvic ab- scess after the operation ; in one hundred similar cases drained, pelvic suppura- tion occurred in eight, showing that the drain was the avenue of infection in a number of cases which would probably have recovered without suppuration if all communication with the exterior had been cut off and the work of absorp- tion intrusted to the peritoneum alone. The Prevention and Eemoval of Infection without Drainage . — It can not be denied but that the greatest advancement along all the lines in abdominal surgery has been made during the same period in which HOW AND WHEN TO DRAIN. 37 the drain has been gradually given up. Each improvement in technique tends to lessen the chances of infection and to minimize the demands upon the elimi- native powers of the peritoneum. Asepsis has been more perfectly attained before operation and maintained throughout its performance ; septic cases are always treated last on operating days, and after treating and examining an acute septic patient, such as in puerperal septicemia, all operative work is aban- doned for three days ; in this I accord with the conclusions reached by Zweif el. The technique of the operation is better in the more perfect control of hem- orrhage, in the better suturing and covering in of raw surfaces, as well as in the protection of the peritoneum from contamination by infected foci, and in the lessened bruising of the tissues either by unnecessary manipulation or by undue traction upon the edges of the abdominal incision. The peritoneal cavity is also no longer washed out in a routine manner merely because of adhesions and hemorrhage ; when seriously contaminated by an infected focas, the washing out is done with a definite purpose and is made thorough. How and When to Drain. — P ostural Drainage . — Following the initia- tive of my assistant Dr. J. G. Clark, and in a practical way utilizing the experi- ments of Muscatello, where there is any serious contamination of the peritoneum and therefore danger of infection, from 500 to 1,000 cubic centimeters of a normal saline solution are left in the peritoneal cavity after ojjeration, and the patient is placed in a bed with the foot elevated eighteen inches, for twenty-four hours. This serves to dilute and promote the rapid absorption of all noxious mate- rial by calling into active play the diaphragmatic lymph spaces. Cases to be Drained . — The drain should be used in abscesses which are walled off from the peritoneal cavity and which can not be enucleated, as in appendicitis or extensive suppuration in the pelvis, where the abscess can not be reached and drained into the vagina. A drain is also called for in cases of widespread peritoneal suppuration, where the patient is too feeble to be treated as proposed by Dr. J. M. T. Finney (see Chapter XXII). A prophylactic drain must also be used when the intestine has been sutured and there is doubt as to the accuracy of the suturing, or of the ability of the tissues to hold the sutures. How to put in and take out a Drain. — The pieces of gauze used for the drain are folded twice and stitched along the edge ; they are 60 centimeters (20 inches) long and 4 to 6 centimeters wide. Gauze is prepared for use according to the formula given in Chapter I ; but before insertion it is im- mersed in water and squeezed out, to remove the excess of iodoform, making a " washed-out iodoform gauze drain " (Sanger). In order to place the drain effectively within the abdomen it is either rolled in a loose coil like a baU of string, so as to pull out from the center, and so laid in the pelvis over the area to be drained, or it is packed in loose layers from side to side so that it can not become tangled in the removal, until the space is 38 PailfCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. filled. This is best done with the pelvis slightly elevated, to keep the intestines out of the way until the gauze is adjusted. The end coming out of the center of the ball lies in the lower angle of the incision. In the rare eases in which it is justifiable to drain for persistent hemorrhage a number of gauze strips may be packed firmly against the bleeding surfaces by folding the gauze upon itself from side to side. The end of each piece must be brought out externally and so marked that the last intro- duced can be recognized and removed first. I had one case in which the end of one piece was not brought out, and in consequence the gauze stayed in the abdomen six weeks, and was only discovered and pulled out as the patient was ready to leave the hospital. If the area needing drainage is extensive, a large quan- tity of gauze should be used without hesitation. I have in this way even filled the whole lower abdominal cavity. In the case of an old woman with an ovarian tumor extensively and densely adherent, where the pulse went up to over two hundred and it was out of the question to take time to stop a general oozing, I tore up large gauze pads and filled the left side and whole lower abdomen with them. There was a free discharge for a few days, when the pack was removed and recovery followed. Where there is a widespread infection and general perito- nitis, drainage through the median line over the pelvis will not sufiice. In this case one or more lateral or posterior openings must be provided as well. I can best demonstrate the value of this way of drain- ing by citing a typical case. I had operated upon a very stout woman with a large extra-uterine sac by opening and draining it jper vaginam. The sac was irrigated daily with a saturated boric-acid solution, and about the fifth day the nurse pushed the point of the glass nozzle through the thin sac wall into the abdominal cavity and forced a liter of the solution into it. This was continued for two days, when the patient developed a violent general peritonitis and J was obliged to open the abdomen hurriedly by night, when I washed out a large quantity of fluid filled with flakes of lymph, and found a universal adhesive peritonitis. The patient was in a low condition and all the steps of the opera- tion had to be hurried to get her off the table with any chance at all of recovery. The abdomen was well washed out and a large pack placed in the pelvis, another pack extending from the incision out toward the right flank, and a third to the left: Free openings for drainage were also made in each flank in front of the erector spinse muscles by pushing out the abdominal wall with a hand in the abdomen and cutting boldly with a knife from without inward through all its layers at once. These incisions were about 6 centimeters (2^ inches) long, and the tendency of their thick walls to drop together was prevented by drawing the peritoneum out over the muscles and suturing it to the skin. A large gauze drain, communicating with the drains above, was stuiled into each flank and brought out at these openings. The patient's life was saved by this extensive free drainage. I have adopted this plan on several other occasions with like success. HOW AND WHEN TO DKAIIT. 39 While the incision must be left well open for the drain to discharge freely out on the surface, too large an opening should not be left, because in vomiting or coughing some coils of intestines may be forced through. On the other hand, it must not be made too small, so as to check the outflow of the discharges. To this end the pieces of gauze coming out on the surface should fit the opening snugly without either being loose or constricted. The point of greatest danger of protrusion is at the upper angle of the opening just above the gauze. If an evident opening remains here after the drain is in place, an additional piece of gauze must be introduced, extending well above the incision and filling the gap. "Where the walls are usually thick there is a tendency to drop together and impede the outflow ; in these cases it is well sometimes to fasten the peritoneum with a few sutures just under the skin, converting the long channel into a nar- rower neck. After two or three days, as the drain is removed, the sutures can be cut and the peritoneum falls back in place. When there is a reasonable prospect at the time of operation that the drain may be removed in two or three days, several silkworm-gut sutures should be placed in the incision through all the layers, and left untied until the drain is taken out, when they are drawn up and the wound completely closed. The wound above the drain may be closed at the completion of the operation in the usual manner, by bringing the peritoneum together with a continuous suture and uniting the fascia and skin with interrupted silkworm-gut sutures. The dressing over the drain consists of layers of absorbent gauze and cotton, covering it well on all sides, and being sufficient in quantity to take up all discharges. These should be removed, as often as they are saturated, by taking them up with steriKzed forceps. Much depends upon the time at which the drain is taken out, for with an early removal and closure of the incision the annoyance of a fistulous tract is avoided. In removing the dressings over the drain, or in (taking it out, extreme anti- septic precautions should always be used, and these should never be intrusted to a nurse. The bedclothes are turned down and the nightgown drawn up ; the bandage is then thrown open and sterilized towels laid on all sides, covering the abdomen. The dressings are then picked up with forceps and removed down to the drain. If there is no infection it is best to remove the drain in thirty -six hours ; in infected cases it may be slowly delivered in the course of four or five days or longer. To remove the drain the end of the gauze is seized and twisted to make it smaller and to loosen it from the edges of the incision ; it is then slowly withdrawn, continuing to twist it all the time. If some free flow follows the removal of the first part, it is well to cut it off and remove the rest later. If the patient suffers much from the attempt to take the drain out it will be wiser to administer a little chloroform. Infection of the drainage tract is to be expected when the pelvis has been the seat of a virulent infection. This is commonest when the staphylococcus aureus and the streptococcus are found in abundance in the pus. With the glass drain- age-tube the case was quite different ; infection of the tract occurred frequently, and often after the simplest operations. In such a case the gauze must be taken 40 PRINCIPLES AND COMPLICATION'S COMMON TO ABDOMINAL OPERATIONS. out slowly and fresh pieces put in to keep the wound from following its natural tendency of closing first in the upper part. After ten days the tract may be irrigated down to the bottom and kept clean with peroxide of hydrogen. A streptococcus wound, and the fistula left by draining a tuberculous peritonitis, are both obstinate affections and may take months to close. If numerous and heavy silk ligatures have been used the fistula will not close until they have all been fished out with a crochet needle. Now that fine silk sutures and catgut sutures have replaced the heavy cable sutures formerly used for pedicles and in ligating large vessels, it is rarely found that a fistulous tract is kept patulous by a bunch of ligatures. Closure of the Incision. — A proper closure of the incision is of the utmost importance, as by an incorrect apposition of its layers the walls may be so weak- ened as to favor the formation of a hernia. It should also be an object in a good closure to leave a fine linear scar, which is neither unsightly nor a source of annoyance to the patient. It must be acknowledged at once that no plan of closure can really restore the parts to their primitive condition, for we have no way of replacing the strong fibrous interlacement of the linea alba. The best method of closure is that which brings the tissues into exact approximation layer by layer in the order they occu- pied before division, and holds them there until firmly united, with the least risk of infection. Experience has shown that the four important layers in the abdominal wall in the median line are the peritoneum, the fascia, the fat, and the skin. A good early union of the peritoneum -pre- vents infection from invading its cavity from without in case of suppuration in the wound. The fascia is the source of strength in holding the two sides together and preventing hernia, and by uniting the fascia the recti muscles in their sheaths are necessarily held also, and therefore need no special suture. The apposition of the fat obliterates the dead space in which blood is likely to accumulate if it is neglected, and thus prevents infection. The union of the skin prevents contamination from without, especially by the white skin staphy- lococcus. The first step in the closure common to all methods is to unite the peri- toneum from top to bottom by a continuous fine catgut suture ; before tying the suture at the lower end, any air in the peritoneal cavity may be expelled by mak- ing pressure with the hands on the sides. The skin and strong fascia overlying the recti muscles are next united in one of two ways. First, by a series of inter- rupted silkworm-gut sutures, each one of which enters on the skin surface half a centimeter from the edge, and then passes through the fat and the fascia of that side ; the suture then crosses the wound and catches up the fascia of the opposite side, and emerges on the skin at a point corresponding to that of en- trance. If the fascia has retracted it maybe drawn out with forceps before transfixing it. It is not necessary to pierce the muscles. All hemorrhage must cease before the sutures are tied. A sponge should be lightly squeezed out in bichloride solution (1-1000) and rubbed well into the interstices of the wound. This should be followed by a hght rinsing with sterile water. Where vessels CLOSURE OF THE INCISION. 41 in the incision continue to bleed, fine ligatures must be applied ; otherwise there will be a collection of blood beneath the skin, which may break down later. These silkworm-gut sutures should be applied about 1 centimeter apart. I generally put them all in first, tying them afterward. Fine superficial catgut sutures between the silkworm gut give accurate approximation throughout. This form of suture, which was at one time extensively used, is not restricted to cases in which it is necessary to close the incision in a hurry, or where there is malignant disease and there is no prospect that the patient will ever subject her abdominal muscles to much strain. The second method is always the best in an aseptic case; after closing the peritoneum with the continuous catgut suture, the retracted fascia is pulled out on both sides with artery forceps and held while it is being united from side to side by mattress silver-wire sutures extending 12 millimeters back of the cut side and embracing about 12 millimeters of the tissue, and placed about 4 or 5 centimeters apart. The suture is drawn snugly up but not too tight, and then twisted five times, caught with the artery forceps, cut off, and the end turned down so as to lie on the fascia horizontally, the end neither projecting upward nor downward. The effect of this row of sutures is to quilt the strong fibrous sheath together in a ridge from top to bottom; between these sutures interrupted catgut sutures are used to insure accurate union throughout ; silkworm gut may be used in place of silver wire. Short wounds, less than 6 centimeters long, may be safely closed with catgut throughout, buried sutures to the peritoneum and fascia, and subcuticular to the skin. The subcutaneous fat is brought into close apposition by a continuous catgut suture. The importance of this can not be insisted upon too strongly. If omitted, a dead space will be left for the collection of blood, which is likely to become infected and cause an abscess. The skin wound is then closed with a continuous subcuticular fine catgut suture, beginning in one end of the wound and ending in the other. Each time the suture is carried from one side to the other it grasps from 2 to 3 milli- meters of the tough corium. This last suture is absorbed in from nine to twelve days, while the silver wire remains buried. The advantages of this plan are a firm closure, freedom from stitch-hole abscess, diminished liability to hernia, and simplicity of after-treatment (see Fig. 321). "When the umbilicus is cut through, it is well to split it on each side before putting in the sutures, to convert the naturally thin surface between the skin and peritoneum into a broader area for better approximation. Hematoma . — If the bleeding vessels in the subcutaneous fat are not all controlled at the time of the operation a hematoma may form under the skin, where it remains for a few days or a week as an indolent tumor, and then either escapes through the incision, or, in the majority of cases, suppurates. The hematoma may form either a slight swelling with a marked discoloration of the adjacent skin area, or it may form a distinct lump, like a marble or a pigeon's egg, under the skin without discoloration. 42 PRINCIPLES AND COMPLICATIONS COMMON TO ABDOMINAL OPERATIONS. The temperature is not affected until infection has occurred. The pain is usually not more than a slight discomfort. The treatment is incision and evacuation ; this may be done by freezmg the surface with ethyl chloride and then making a small incision with a sharp bistoury, either through the original wound or over the most prominent point. -ggg 800^- 5''^ \ ' ,752 \ Pui- >:ative SoftD et 700 740 '720 800 \ \ \ 626> 635^ 654 672^ ^--65 ^\6: V 670 \ 5 6C 15 )5 2- 595 > 591 481 498 The broken line is the composite of 100 cases treated by saline enemata. The unbroken line is the com- posite of 100 cases without the enema. In the table 1,000 cubic centimeters is taken as tlie normal amount of urinary excretion in twenty-four hours. All the cases were abdominal sections for various diseases. The broken line represents the amount of urine excreted when saline enemata were used. The unbroken line represents the amount of urine excreted when the enemata were not used. One liter of the normal saline solution composed each enema. " The first series of one hundred cases shows an average of 752 cubic centi- meters at the end of the first twenty-four hours, while the second shows but 481 cubic centimeters. " Tlie solid line (cases without enemata) drops to its lowest point on the first day, and for three days does not rise nmch above the point, while the broken line (cases with enemata) shows a greater excretion the first day than for seven subsequent days. It is not until the end of the fifth day that the excretion in the two series of cases is of equal amount. " A further study of this composite chart reveals other interesting points. In both series of cases the least amount of urine is excreted during the third day (605 cubic centimeters in one, 498 cubic centimeters in the other), which is readily accounted for by the fact that it is the routine practice to administer a saline purgative on the evening of the second day, which usually acts on the third day. The diminution is therefore a normal physiological one, due to the hydragogue action of the purgative. " Soft diet is begun on the fifth and sixth days, and as a result there is an- other drop in the two lines, as the patient then begins to take more of soft than of Hquid diet. At the end of the fifth day the excretion in both series of cases is equal, and from this time the two lines travel together until they again reach the normal base line on the twelfth to thirteenth day. OATHETBK. 51 " There appears to be a further explanation for the greater excretion of urine in the eases which have the saline enemata than that it is merely due to an in- crease in the amount of water taken into the system. The nausea and vomiting- following anesthesia usually disappear by the end of the first twenty-four hours, after which the imbibition of water has not been restricted in either series. " Notwithstanding the fact that in both series of cases about the same quan- tity of water is taken by the mouth, the excretion in one remains very low for three days, at no time being above 505 cubic centimeters, while the other shows not less than 600 cubic centimeters, or over 100 cubic centimeters more urine passed daily by the patients who have had the enemata. From this observation it would appear that the persistent renal torpidity is due to the irritant or toxic effects of the greatly concentrated urine, and by supplying the body with a liter of salt solution this partial suppression is to a great extent prevented, and the kidney at once resumes its normal function as soon as the patient begins to take water. " The accompanying table of two series of fifty cases, with the record of the daily excretion in each individual case, emphasizes the fact which the composite chart brings out. " In thirty-five of the fifty cases with the enemata the excretion during the first twenty-four hours was greater than it was on the seventh day after opera- tion, while in forty cases without enemata the excretion was less during the first day than during the seventh, the figures in the former being almost exactly re- versed in the latter. The following table, taken from these two series of cases, also shows the same result : Urine excreted. With enemata. Without enemata. 1,000 cubic c sntiraeters u it (( or over Cases. 7 5 3 13 9 11 3 1 Cuei. 1 900 ( 1 800 (. u 700 a a 3 600 (I (I 7 500 11 cc 8 400 u a 14 300 ti u 15 200 (( a 3 100 it Tot a1 50 50 Catheter . — The catheter should only be used to draw the urine, if the patient is unable to pass it naturally after six or eight hoiirs, and then the ut- most care must be taken to pass a clean catheter, through a clean urethral orifice, under inspection. If the catheter has to be used at all, its use must be discon- tinued as soon as possible. If vesical irritability is persistent, it will improve upon taking spirits of nitrous ether, twenty to thirty drops, every two hours, or five drops of copaiba in capsules three times a day. Bowels . — I have often noticed that surgeons grow too anxious, and work 52 CARE OF WOUND AND PATIENT UP TO EECOVEET. too hard to get the bowels moved for the first time. If the patient is doing well in other ways, it need cause no worry should the bowels be sluggish and not respond until as late as the fifth or sixth day. Often after two or three days of active efforts, if the patient is left quite alone they move spontaneously m six or eight hours. As a routine hne of treatment, I give on the evening of the second day something which will move the bowels on the following morning. Calomel will be found to be the most efficacious, and is as a rule best borne by the patient. It can be given in one dose of two or three grains, or one quarter to one sixth of a grain may be given every hour until the same amount is reached, fol- lowed in the morning by six to eight ounces of a solution of citrate of magnesia. About two hours later an enema of 100 cubic centimeters of olive oil with 30 cubic centimeters of glycerin should be injected as high as possible into the rec- tum. If this is not effective, four to six hours may be allowed to elapse before another attempt is made with an injection, consisting of a pint of water at a tem- perature of 110° F. and soapsuds. A satisfactory saline enema much used by Dr. C. P. Noble is the following concentrated solution of the sulphate of magnesia : 9. Magnes. sulph 3 1] ! 01. terebinth 3 ss. ; Glycerinse 3 .1 j Aquse 1- ad ^iv. o' M. and inject in bowel. It is not advisable to use more than three enemata during the third day ; it is better to assist the calomel by castor oil or magnesium sulphate in half -ounce doses, or by a pill of aloin, strychnin, and belladonna. When the bowels are once opened, they should be kept open by a movement at least every other day. Tympany, which often occasions much distress, is usually speedily relieved by the free evacuation of the bowels. Drop doses of tincture of capsicum, or a few drops of tincture of nux vomica in a teaspoonful of hot pepper tea, are valuable adjuvants. A rectal enema of 90 cubic centimeters (3 ounces) of milk of asafetida will also often relieve it. Temperature . — The temperature must always be carefully watched. On the second or third day it is commonly elevated to 100° F., or even 101° F. (37-8° or 38-3° C), but it usually drops with the first free movement of the bowels. This slight rise in temperature appears to be due to the absorption of a fibrin ferment, and it may in exceptional cases be prolonged for several days beyond the usual period. A persistent temperature, however, above 100° is in most cases due to infection either of the wound or in the peritoneum. A sudden rise in temperature, sometimes attended with chill, toward the end of the first week, is often the first indication of suppuration in the abdominal wall. The wound should be inspected immediately for any hard, red, tender areas on one side or the other, the stitch or stitches at that point removed, and the lips of the PULSE. 53 incision slightly separated, to favor the discharge of pus. When the pus has escaped, the temperature falls at once. A chart showing the composite temperature iu ten normal cases for the first week is here given (see Figs. 322-325, p. 54). Pulse . — The pulse is likely to remain quickened 20 or 30 beats or more for three or four days after any severe operation. If the general condition is good, and the pulse full and compressible, this need cause no anxiety. The nor- mal course is a steadily falling pulse after operation, falling less rapidly if there is much pain. A falling pulse is a good sign ; a rising pulse always calls for in- vestigation. In general a pulse from 120 to 130 beats needs watching ; a pulse of 140 beats needs closer watching ; a pulse of 150 beats needs anxious watch- ing ; a pulse of 160 beats does not as a rule recover unless it begins to fall within six to twelve hours after the operation. !N^either the temperature nor the pulse, however, should be studied alone, but always in association. If the pulse is high, from 120 to 140 beats, combined with a high temperature after the first day, when the bowels have been freely moved, infection has probably taken place. The most satisfactory sign of progress is a free evacuation of the bowels, with pulse and temperature dropping together. Facial Expression . — Facial expression is a sign scarcely less signifi- cant than the temperature and pulse, and taken together with these forms a good index of the general condition. A bright natural expression is to be looked for during the normal convalescence ; a flushed, dusky, anxious, haggard, or a laek-luster look are indicative of complications. Wound . — Unless some special cause arises, the wound need not be dressed until the tenth day, when fresh gauze and cotton dressings should be put on with the dressing forceps. The bandage may be changed daily, and the back well rubbed with a solution of alcohol and water, half and half. Boric acid and bismuth powder are also good to rub into the back. This rubbing is the best we can do for the severe pain so constantly felt in the back. Sutures. — The use of the permanent buried silver-wire suture and subcu- itcular catgut sutures has relieved the patients of considerable anxiety, for often the removal of sutures was looked forward to with great dread. The abdominal dressings need not be disturbed until the tenth day except in case of wound in- fection. They should be carefully lifted off and replaced by several layers of fresh sterilized gauze. If they have become adherent to the incision a little sterilized water poured on will rapidly loosen them. The skin about the inci- sion should not be cleansed until about the fourteenth day. Pledgets of cotton wet with dilute alcohol are best for this purpose. The catgut sterilized by the cumol method is usually absorbed by the eighth to the tenth day. Interrupted sutures are removed on the tenth day. First expose the loop by pulling up the suture a httle with forceps, then cut it close to the skin, and draw it out toward the side on which it is cut, to avoid pulling the edges of the wound apart. Adhesive straps across the wound after removing the sutures are not necessary. If the bandage is kept well in place, and put 54 CARE OF WOUU'D AND PATIENT UP TO REOOTEET. DAY OF OPERATION 1 2 3 4 5 6 7 8 9 10 90 UJ !3 80 a. 70 Ul 99 cc 1- < oc 98 UI 0. S UJ o H 97 •«» A A SllsPENSIO UTE Rl •>. > V V \ V '' \ \/ /^ N, -^ ,^ ' .^ A, V A ^^ ^' 1 V \^ -. ^v-- ■^y V ,^-v 1^ / V Fig. 322. 90 Ul !3 80 a. 70 Ul 99° H £ 98° 0. S UJ o K 97 ^ V A ( :ys PEC TO VIY (Sir A S \ > /^ V' A s S^ y V /^ "^ V S, ' ' ^ \ ^ A. V > V /** 'v. "> V ,^^ r ST Fig. 323. PULSE § S 8 HI 100° sr z> H < o oc 99 UJ a S UJ o (- 98 >^ HV ST ;ro -M YO .EC ... TO VIY -■ V r- 1 — ■ -V ^ ^ ^^ •^, / •V V '^•^ "^ ~-^- '>^' .•*■ .i» -=::: -V °^ v. ^r Fig. 324. 100 90 HI to -J ■^ 80 70 o 100 HI o: ^ 99° < HI Q. S 98 UJ 1- 97° ft HV STE ( :ro Foi- -s; Pe .LP VIC NG Infl 5T^ imn )OP ato HO ,EC ise£ ro se.) VIY ^ A \ /\ A A / /^l y / A /\ / \ V ;v < V V V A^ V -^ ^ _ s r<. i \ A. v' -J ■v' S -Temperature Pulse Fig. 325. Fios. 322, 323, 324, 325, showing the Avekage Ciiakts ok Composite Tempeeathees and Pdlse Eates IN Ten CASEa in each Geodp. Cases were selected which appeared to run a smooth course to recovery ■ these were averaged, and the temperature and pulse rates then tabulated, as shown. (See Johns Hopk. Hasp. Sep., 1890, vol. ii, Nos. 3 and 4, p. 177.) COirVALBSCEN"OE. 65 on snugly every time, the wound surfaces will naturally remain in close ap- proximation. In ten or twelve days usually the patient may be propped up with pillows or on a bed rest, and in from seventeen to twenty-one days, according to the rapidity with which strength is regained, she may spend part of the time in a rechning chair or on a sofa. Throughout the convalescence she must avoid straiuing the abdominal muscles. WhUe still abed she must not raise herself to a sitting postm-e or change her position without aid. Later she must not stoop or lift heavy weights. During active vomiting the least strained position is lying on the side with the body shghtly flexed, or on the back with the knees drawn up resting on a pillow. At the end of the fourth or fifth week she should be able to walk around, and perhaps go down stairs. All bodily move- ments should be gentle at first. The patient must not sit up long enough at first to grow tired of the newness of it, and later on she should avoid tiring herself on her feet. It is best not to hasten the getting out of bed, as a pro- longed absolute rest is an important element in securing complete restoration to health. Heavy work and exhaustive exercise of all kinds must be avoided. The convalescence is by no means at an end when the patient is able to re- turn to her home. Disappointment will frequently be avoided if she is warned of this before- hand, and kept under observation for a year or more while regaining her physi- cal and nervous balance and passing the period of any unpleasant sequelae, such as flushes, sweatings, giddiness, and various other nervous manifestations. Sometimes some of the original discomforts persist for some months, only disappearing gradually, so that complete recovery to health does not take place until after a year or a year and a half. Fresh air, rest, diet, and tonic treatment, with encouragement, are the most important aids in the convalescence. Change of air and scene are of the great- est value in bringing about complete restoration to health. The golf field is the best form of moderate exercise I know of, and will prove an invaluable adjuvant as soon as the patient is able to take a little active out-of-door exercise. CHAPTER XXII. COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. 1. Shock. 1. Causes: (a) Anesthesia; (b) loss of blood; (c) enfeeblement by disease; (d) pro- longed exposure of the intestines. 2. Symptoms. 3. Diagnosis: (a) Shock and chloro- form asphyxia; (b) shock and hemorrhage. 4. Prognosis. 5. Preventive treatment: (a) Preliminary tonic treatment ; (6) temperature of operating room ; (c) care of patient on the table, blankets, hot- water bottles, protection of exposed pelvic viscera, etc. ; (d) avoid- ance of hemorrhage. 6. Immediate treatment: (a) Hypodermics; (J) stimulant enemata ; (c) external application of heat ; (d) how to give stimulants and nourishment ; (e) saline infusion. 2. Secondary hemorrhage. 1. Causes. 2. How to avoid hemorrhage by care during operation. 3. Symptoms. 4. Operation. 5. Saline infusion. 8. Peculiarities of the pulse. 4. Variations in temperature : (1) Subnormal temperature ; (2) elevated temperature. 5. Vomiting. 1. Treatment : (a) Medicines to settle the stomach ; (6) lavage ; (c) hot and cold applications ; (d) foods and enemata. 6. Tympanites. 1. Treatment : (a) Turpentine stupes ; (b) rectal tube ; (c) medication ; (d) pur- gation ; (e) Paquelin cautery. 7. Excessive pain. 1. Sparing use of sedatives. 8. Peritonitis. 1. Traumatic or plastic peritonitis : (a) Symptoms ; (b) treatment ; (1) purgation ; (3) diet ; (3) hot and cold stupes. 2. Post-operative septic peritonitis : (a) Sanger's condi- tions of infection ; (1) qualitative; (3) quantitative ; (3) constitutional; (J) kinds of germs (two typical cases) ; (c) modes of origin ; {d) symptoms ; (e) prognosis ; (/) diagnosis ; (g) tabulated symptoms of both traumatic and septic peritonitis; (h) treatment; (1) pro- phylaxis ; (3) medicines ; (3) operative treatment ; (a) methods of operation ; (6) indica- tions for operation ; (c) operation — vaginal ; abdominal. 9. Fermentation and septic fevers : 1. Fermentation fever. 2. Septic intoxication. 3. Septice- mia. 4. Pyemia. 10. Pleurisy: 1. Causes. 2. Symptoms. 3. Treatment. 11. Pneumonia: 1. Causes, (a) Anesthetic ; (J) sepsis. 3. Symptoms. 3. Treatment. 12. Ileus : 1. Causes. 2. Symptoms. 3. Diagnosis. 4. Treatment : (a) Prophylaxis ; (J) enemata and medicines; (c) operative. 13. Stitch-hole abscess and suppuration in the line of the incision. 1. Cause of infection. 2. Symptoms. 3. Diagnosis. 4- Treatment. 14. Nephritis. 1. Relation between abdominal operations and nephritis. 2. Treatment. 15. Suppression of urine. 1. Urinary record. 3. Differentiation of nephritis and ligation of one or both ureters. 3. Treatment. 16. Urinary fistula. 17. Fecal fistula. 1. Causes : (a) Trauma ; (J) necrosis from pressure. 2. Location of fistula. 8. Treatment. 18. Phlebitis: 1. Symptoms. 3. Treatment. 19. Emphysema of the abdominal wall. 20. Sudden death : 1. From embolism. 2. From gas bacillus. Maeked deviations from the course of normal convalescence, as described in Chapter XXI, comprise complications varying in gravity from the simple functional and local disorders which are soon relieved, all the way to the graver systemic manifestations which are often fatal. Every normal convalescence is attended with certain minor discomforts — as a rule, neither excessive nor prolonged— and the patient is usually fairly easy by the third or the fourth day. "When, however, the discomforts persist or be- 56 SHOCK. 5Y come exaggerated, or a variety of other untoward phenomena arise either to retard recovery or to threaten life, the convalescence becomes complicated. Greater skill and acumen are oftener shown in the quick detection of these complications, and a prompt adoption of means to overcome them, than in the performance of a difficult operation ; for this reason skilled surgical attention is quite as important in the convalescent stage as during the operation itself, and it is unwise for the surgeon to consign the care of the case to other hands when it is in any way possible for him to keep a direct personal supervision until com- plete recovery. Shock. — One of the most frequent and alarming effects of an abdominal operation is shock, arising from a profound impression made on the nerve cen- ters, and indicating extreme depression of the patient's vital forces. Shock is usually observed either during or shortly after an operation. Causes. — One of the most frequent causes of shock is prolonged anesthesia. The administration of an anesthetic for two hours, for instance, is always followed by depression of varying degrees, even though the operation has been a minor one. Excessive loss of blood during an operation upon a robust or even plethoric individual, or a moderate hemorrhage in an anemic patient, will speedily produce shock, even though the operation be of short duration. I recall one case in which there was the most profound depression following a' simple oophorectomy in a patient who was extremely anemic before the opera- tion from repeated hemorrhages due to internal hemorrhoids. Little blood was lost during the operation, and the duration of the anesthesia was only twenty- two minutes ; but when she was removed from the operating table the pulse was barely perceptible, respirations were shallow and jerky, and there were no signs of reacting for ten hours afterward. In this case the slight hemorrhage and the depressing effects of the anesthetic acted conjointly. A constitution already enfeebled by disease also predis- poses to shock ; for instance, patients debilitated by advanced carcinoma have scant resisting powers, are often profoundly depressed by the operation, and re- cuperate slowly. Prolonged exposure of the intestines and omentum through a long incision, or when lifted- out of the abdomen, is one of the most prolific causes of shock through the rapid radiation of heat, especially when there has been already considerable hemorrhage before or during the operation, as in the case of a ruptured ectopic pregnancy. While any one of these causes acting alone is sufficient to produce shock, two or more or all of them acting in combination induce a condition of profound depression from which it is difficult for the patient to rally. For example, I would cite a case, of not infrequent occurrence — that of a large fibroid uterus with extensive subperitoneal development, with a history of repeated hemor- rhages ; by pressure on the ureters and interference with the excretion of urine, the tumor has also brought about disease of the kidneys. Such a patient is already greatly weakened by the loss of blood, her resisting powers are lessened 58 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. by the renal affection, and, added to these factors, the size and relations of the tumor necessitate a long incision, exposing the intestines, and a prolonged anes- thesia is necessary to effect the enncleation. "We have here all the elements necessary to produce shock, and if we add to these an extensive hemorrhage during the operation, the shock may speedily prove fatal. Symptoms. — There is often good reason to anticipate shock from the chnical history which reveals some predisposing cause, such as an enfeebled con- dition of the patient from hemorrhage, or from serious organic disease. Increasing rapidity of pulse, from 20 to 40 beats, marked pallor and coldness of the surface of the body during an operation, demand the closest attention of the anesthetizer as the forerunners of shock. Additional evidence of prostration is a slow recovery from the anesthetic. As consciousness returns, the patient lies helpless on her back, unable to move, scarcely able to speak above a whisper ; the surface of the body is palUd and bathed in a cold sweat, the lips appear bloodless, the features are pinched, the eyelids drooping, and the general appear- ance that of dissolution. Yarious associated nervous phenomena, such as hic- cough, twitching, headache, and mild delirium may be present. The special senses are often so blunted that the patient hears and sees and feels with diffi- culty. Eespiration is feeble and gasping, or so weak as barely to be perceptible. The temperature is depressed, falling from one to two degrees below normal. Reaction may not set in for hours, notwithstanding the most vigorous stimulat- ing treatment, and then may be so gradual as to be recognized with difficulty. Occasionally there may be great prostration with a slow, full pulse ; in such cases the shock is usually evanescent, disappearing quickly under appropriate stimu- lants. Recovery from shock is indicated by the general reaction of all the vital functions ; the pulse gradually increases in strength and becomes more regular, the respirations are deeper, the temperature rises, the color improves, the ex- pression of the patient becomes bright, and she loses the listless air so character- istic of shock. But instead of the reaction becoming complete and merging into a normal convalescence, traumatic delirium may supervene. Sometimes the stage of depression may be so short as not to be recognized, and the patient at once becomes dehrious after regaining consciousness, or the delirium may be preceded by prolonged shock. The skin becomes flushed, dry, and hot, the tem- perature rises above normal, the pulse is fuller and more regular, although com- pressible, the tongue is dry and tremulous, the thirst is urgent, and, instead of lying prone, the patient is restless and tosses from one side of the bed to the other. The delirium may be low and muttering or of the wildest character. I know of instances in which the patients have fallen out of bed, torn the bed- clothing to pieces, and walked from one room to the other, so wildly maniacal as to require the closest watching and restraint. This traumatic delirium either gradually subsides and the patient recovers, or it is followed by extreme collapse, the pallor again returns, the pulse becomes weak, thready, and is finally imperceptible, and the patient falls into a profound stupor ending in death. SHOCK. 59 Late Shock. — I have seen several cases of profound shock coining on several hours after an operation for large myomata ; although I must admit that these symptoms may have been due to hemorrhage which was afterward absorbed. The case of M. W., aged forty, No. 3296, operated on Jan. 30, 1895, was a good example of this complication. A hysteromyomectomy was done, lasting forty-three minutes in all, removing a tumor filling the abdomen and adherent to the entire breadth of the omentum ; the patient took ether well, and was put to bed at 11.30 a. m. in excellent condition, with a warm skin and a full, regu- lar pulse, beating 84 to the minute. The facial color and expression were also good. At 2.15 p. M. a decided pallor of the face was noted, the mucous membranes were blue, the nails livid, and the pulse imperceptible at both wrists. The res- pirations were shallow, she had precordial distress, and the voice was weak. The reassuring features were that the extremities were warm, and there was no moist- ure on the forehead and no nausea. She was stimulated with strychnin, and coffee and brandy by enemata, but the improvement was slow, and her condition only became normal after five or six days. Another case exhibiting this alarming complication was that of M. D., 3320, aged twenty-nine, operated on Feb. 8, 1895. She was a woman of ordinary stature, with an abdomen enlarged to a cir- cumference of 99 centimeters (40 inches) by a myomatous uterus, lifting the bladder up to a point just below the umbilicus and displacing the sigmoid fiex- ure above the umbilicus. After a difficult enucleation of this large unusually vascular subserous mass, lasting twenty-three minutes, she was put to bed with a pulse of 88. On the second day the pulse began to go steadily upward, rang- ing between 140 and 150 on the third day, when it was scarcely perceptible. As she showed no blanching and seemed bright, I simply stimulated and watched her. From this time the pulse slowly came down, but did not get below 100 again until the twelfth day. In every other respect the convales- cence was normal. Diagnosis. — It is important to differentiate the predisposing or exciting cause of shock, whether from enfeebled vitality, prolonged operation, hemor- rhage, anesthesia, or exposure of bowel and omentum, as the treatment depends largely upon the cause. Chlorofonn asphyxia must be carefully discriminated from shock. Its onset is sudden, with few or no warning symptoms, the respiration grows shallow, irregular, and finally ceases, the pupils dilate, the face assumes an ashen hue, the pulse becomes weak, entirely disappearing at the radial artery. Upon the prompt withdrawal of the anesthetic, the suspension of the patient with head downward, and the induction of artificial respiration, these symptoms disappear and the patient speedily returns to a normal condition. In shock, the gradual appearance of the symptoms, the absence of precipitate onset, and the slow re- sponse to resuscitative measures are marked differential points. Further, it is of vital importance for the surgeon to differentiate promptly 60 COMPLICATIONS ARISING AFTER ABDOMHiTAL OPERATIONS. between the collapse associated with hemorrhage, and shock from nervous de- pression. Prognosis . — If, after a few hours, the general condition of the patient begins to improve, as indicated by the return of color to the lips, lessening pulse rate, increase in the surface temperature, fuller or deeper respiration, vomiting, and a desire to change from the supine to some other position, the prognosis is favorable. The longer the reaction is delayed, the more serious becomes the prognosis, and if, after twenty -four hours, there is no change for the better, each hour thereafter detracts from the patient's chance of recovery. A temperature which persists at one or two degrees below normal for a num- ber of hours is also a sign of ill omen, and few cases recover in which the tem- perature falls to 96° or below. On the other hand, when the reaction goes so far as to merge into traumatic delirium, and the temperature rises to 103° or above, the prognosis becomes grave. A persistently rapid pulse ranging be- tween 140° and 160° is also unfavorable, although one or two days may elapse in some cases before there is marked circulatory reaction, and still recovery may take place. Preventive Treatment. — It is one of the most important duties of the surgeon so to arrange and conduct his operations that causes predisposing to shock may be avoided. To this end operations upon weak and debilitated patients, or upon those in whom the pelvic disease is complicated by disease of some other organ, must be delayed until the general condition can be improved by tonics, rest, and regu- lated diet ; provided that the advantage derived from this treatment is not over- balanced by the progress of the disease in the same time. Operations should never be performed in a cool room ; the most suitable temperature is from 24° to 27° C. (Y5° to 80° P.). Prolonged exposure of the surface of the body in preparing the patient on the operating table must be avoided, and if during the operation it is necessary to lift the intestines out onto the abdomen, they should be carefully protected with layers of gauze wrung out of a hot salt solution, and a salt solution at a temper- ature of 43-3° C. (110° F.) should be poured over the gauze at frequent inter- vals. The lower extremities and chest are wrapped in warm blankets, and these in turn are protected by rubber sheets to prevent them from getting wet ; a hot- water can should be placed between the feet, and hot- water bags down the sides from armpits to thighs. The anesthetic must be administered for as short a time as possible, and all preparations to operate should be completed and the surgeon ready to begin as soon as the patient is fully anesthetized. Extreme precaution must be taken throughout the operation to avoid loss of blood by the prompt clamping or ligation of actively bleeding vessels, control- ling all possible sources of hemorrhage. Immediate Treatment.— If, in spite of these precautions, shock takes place, a reaction must be set up as quickly as possible. This is best accom- plished by the administration of stimulants and the external application of heat. SECONDARY EBMOERHAGE. 61 As soon as the symptoms of shock appear, whether during or after the operation, a hypodermic of brandy, 3 ss., and sulphate of strychnin, gr. -^, should be given, followed every half hour or every hour with a like quantity of brandy and one half the dose of strychnin (gr. ■^). The intervals between the iajec- tions must be lengthened if muscular twitching or a stiffening of the jaw is ob- served. Hypodermic injections, to be quickly effectual, should not be given into the extremities where the circulation is almost completely suspended, but into the deeper tissues of the chest, the sides of the abdomen, the upper parts of the thighs, and the deltoid muscles. As a rapid cardiac stimulant, nitroglyc- erin in the dose of ^5-5- of a grain, given hypodermically every two hours, is of service. Stimulating and nixtritive enemata should also be re- sorted to at once. The first enema may be given while the patient is on the table, and it may be repeated at intervals of from three to six hours. The best enema is made as follows : Two ounces of brandy, twenty grains of ammo- nium carbonate, vdth sufficient water or beef tea, at a temperature of 37'8° C. (100° F.), to make an eight-ounce mixture. This should be slowly injected into the rectum. Later, when reaction sets in, the brandy and carbonate of ammo- nium may be diminished, and the yolks of two or more eggs added. The patient's bed should be thoroughly heated with hot-water bags or cans enveloped in flannel, placed between the blankets half an hour before the com- pletion of the operation. After the patient is transferred to bed great care should be observed to keep the bags or cans at a safe distance from her body. Extensive burns of the second and third degree have resulted from the careless- ness of the nurse in not watching the hot-water bags closely enough. The patient is placed between blankets with her head low, to prevent nausea and syncope, and if the shock has been associated with much loss of blood, the foot of the bed should be elevated six, eight, or twelve inches. In patients suifering from shock the stomach may tolerate a large amount of fluid administered by the anxious attendant, but this should not deceive the sur- geon, for there is little or no absorption from the stomach. To derive the full benefit of nourishment and stimulants, they should be given in very small quan- tities — not more than two or three ounces in an hour. Gentle friction with alco- hol may be employed later, when reaction has set in. When shock has resulted from exhausting hemorrhage, the salt solution infusion must be resorted to when the radial pulse is much quickened. Secondary Hemorrhage. — One of the most frightful accidents which can occur after an abdominal operation is secondary hemorrhage. The pelvic organs are so richly supplied with blood through large vascular channels that death may occur in a short time if one of the ligatures controlling an important artery or vein slips off after the completion of any major gynecological operation. The occurrence of such a hemorrhage is always due to some error in the technique of the operation, and is therefore especially liable to happen in the hands of an inexperienced surgeon. In my earliest work I met with it as often as once in about every hundred abominal cases, but by adopting certain stringent precautions 62 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. I have been able to eliminate it almost to a certainty as a complication. In 1,800 abdominal sections at the Johns Hopkins Hospital there have been 8 cases of extensive hemorrhage into the peritoneum following operation. One of these died and Y recovered after opening the abdomen and checking the flow. Causes . — The chief causes of secondary hemorrhage are : 1. Defective tying. 2. Cutting too close to a ligature. 3. Undue traction on the ligature after tying. 4. The shrinkage of the tissues within the grasp of the ligature. 6. An extensive capillary oozing. How to avoid Hemorrhage by Care during Operation. — The most dangerous method of securing a pedicle is the simple transfixion with an aneurysmal needle carrying two ligatures and tying the pedicle both ways. This is peculiarly dangerous when the hgature is applied to structures springing from the top of the broad ligament. A ligature applied at this point is practically placed upon the apex of a pyramid, and the marvel is that it does not more frequently slip over the summit, setting free the blood vessels. The risk of such an accident is increased by yielding to the common inclination to amputate the ovary and the tube as close as possible to the ligatures. It is evi- dent also that a slight pressure upon the uterus will now drag the broad liga- ment out of the grasp of one or both ligatures. A careless plunging of the sponge held in a holder down into the pelvis, without taking precautions to avoid striking the top of the uterus or the broad ligaments, becomes especially dangerous in this connection. After the abdomen is closed the straining efforts of vomiting or coughing by forcing the viscera down on the uterus and broad ligaments may produce the same effect. ■Catgut tied in an ordinary square knot and cut close will often swell and soften, and so become untied and give rise to hemorrhage. When tissues are edematous or excessively vascular, the attempt to include a large area in a single ligature is dangerous, because they may shrink soon after the operation and so loosen the ligature. Extensive adhesions to the anterior abdominal wall and to the pelvic walls are sometimes the source of a prolonged capillary oozing ; or bleeding omental vessels, torn in breaking up adhesions, may be overlooked and give rise to profuse hemorrhage in the upper part of the abdomen. The following precautions should be taken during every operation to avoid the risk of hemorrhage : I^one but the long, thin pedicles of ovarian tumors should ever be treated by transfixing and ligating both ways, and then the pedicle should be severed at least a centimeter and a half beyond the ligature. Wherever large blood vessels are tied it is safest to use silk ; catgut alone should not be relied upon. All large vessels, such as the uterine and the ova- rian, should be tied twice, first with silk, then the mouths of the vessels should be caught and tied with catgut. SECONDARY HEMORRHAGE. 63 In the remoTal of ovaries and tubes for pyosalpinx and hydrosalpinx, small tumors and myomata, two or three ligatures should be carried through the broad ligament with needle and carrier, the outermost ones grasping but a small amount of tissue and including the important vessels in the manner described in Chapter XX. In sponging posterior to the uterus and broad ligament, the uterus should be held forward with index and middle fingers of the left hand resting on sacrum and fundus, furnishing a safe guide for the sponge in its holder. Continued capillary oozing from any quarter must be noted and stopped by suture, pucker- ing the tissues together, or by coating the tip of the finger with a thin layer of powdered persulphate of iron and then making firm pressure on the spot for about half a minute ; the finger is then gently and slowly removed, and in most cases the bleeding stops with a single application. The oozing may also sometimes be checked by making pressure upon the part with a sponge wrung out of water so hot that the hands can not be put into it. The sponge is wrung out between layers of gauze and applied for half a minute. In the extensive raw areas left after stripping off intestinal or omental adhe- sions, or after the enucleation of dense inflammatory masses or an adherent tumor, there may be a great many oozing points, the bleeding from any one of which would be infinitesimal, but all taken together may cause a dangerous loss of blood. Some of these oozing areas require skill and patience in order to check the flow. Where the oozing areas are situated on the peritoneal and muscular coats of the intestine, or on the posterior surface of the uterus, the best means of controlling it is to pass numerous fine catgut sutures very super- ficially. A quadrangular or circular suture will usually serve a better purpose in these cases than the simple interrupted stitch ; care, however, must be observed in introducing them not to perforate the bowel nor to include enough tissue to cause a narrowing of the bowel when the suture is tied. When the oozing is free and can not be checked and the patient begins to show decided signs of exhaustion, I desist from further attempts and resort to a gauze drain. If the pulse is good and the general condition fair, I would prefer to close the abdomen and leave a limited amount of oozing, rather than to employ any form of drainage, on account of the risks of infection. In cases where the operation has been extensive and where, as the result of the enucleation, there are extensive raw areas and the patient is in a critical con- dition, it may be necessary to put a firm gauze pack into the pelvis by inserting a long strip packed firmly against the raw surfaces and brought out at the lower angle of the incision. The difficulty in removing the drain in these cases is even greater than in suppurative cases, because the plastic lymph thrown out between the gauze and the raw surfaces is very tenacious and the early removal is attended with intense pain, and the risk of pulling out omentum and intestines, or even of dislodging an important ligature, and so setting up anew a free oozing. This accident has occurred once in the gynecological wards of the Johns Hopkins Hospital. A Q4i COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. large drain had been put in to check the free oozing following the enucleation of dense inflammatory masses from the pelvis. The operation was done on a Saturday morning, and Sunday morning, twenty-four hours later, the patient was doing so well that it was thought best to remove the drain. Considerable force was required to start it, and then it came away easily. At this time the patient's pulse was good and her general condition excellent. An hour later the pulse had increased in rate and was not so full in volume. From this time on her condition grew steadily worse, until the symptoms of an internal hemor- rhage were decided, when the abdomen was reopened and a large amount of free blood found. iNot with standing the most careful search, however, it was impossible to detect the bleeding points, and a second drain was inserted ; under the administration of a saline infusion and cardiac stimulants, the pulse im- proved and the danger seemed to be passed, when, without warning, respirations ceased, and, in spite of vigorous and prolonged attempts at artificial respiration, the patient died in a short time. Bleeding omental vessels may be discovered by laying the omentum on a clean piece of gauze, when the spots of blood will indicate the position of any oozing areas. Hemorrhage from the walls of the abdomen may be detected in the same way by laying a piece of gauze on the intestines under the spot. One of the most important ways of avoiding hemorrhage is the making of a final thorough inspection of every part of the field of operation just before closing the abdomen, when any bad ties are found out and reinforced, and concealed bleeding areas may be discovered. Symptoms. — A secondary hemorrhage may occur at any time within forty-eight hours after the operation is over. It may even begin while the patient is still in the operating room, and go on until the symptoms produced are pronounced enough to draw attention to the patient's condition. These symptoms will appear with a rapidity directly in proportion to the previous good or ill condition of the woman and to tbe activity of the hemorrhage. Bleeding from capillary vessels in areas bared by peeling off adhesions rarely exceeds 60 or 90 centimetei-s (2 or 3 ounces), and does not produce serious symptoms attributable to the loss of blood. The greatest danger from this source is the liabihty to subsequent infection of the unabsorbed mass of blood. Hemorrhage from uterine or ovarian vessels, or from branches of the uterine artery in the substance of the uterus, or from a large omental vessel, is so rapid that within a short time— fifteen minutes or half an hour — ^it gives rise to a defi- nite train of symptoms. The actual amount of blood poured out in a given time from a uterine or an ovarian artery will depend upon its size, varying markedly in different individuals ; the quantity is largest in the case of uterine fibroids, where a bleeding uterine or ovarian vessel may very quickly termi- nate a patient's life before any measure can be employed to save her. An illustration of this statement occurred in my wards at the Johns Hop- kins Hospital. A patient had been operated upon for a large symmetrical myoma ; the vessels were aU securely tied, and she made an uninterrupted con- SECONDARY HEMOEEHAGB. 65 valesence until the eighth day. At noon of that day she suddenly cried out, and when the nurse hurried to her she complained of great pain in the left inguinal region. Her pulse was very rapid, and her expression anxious. A resident at once hurried to the ward, arriving there in fifteen minutes ; but by this time the pulse had become imperceptible, and the patient was in a dying condition. The collapse was so sudden that the diagnosis of pulmonary embolus was made. The autopsy showed that there was a tremendous hemorrhage from the uterine artery from the absorption and rupture of the catgut ligature, which allowed the organizing thrombus to be pushed out of the short stump of the artery. If the bleeding takes place in an abdomen with a gauze drain in it, there will be no diificulty in knowing precisely what has occurred. Something about the patient's condition or expression or color excites attention, and when the bedclothes are thrown down the bandage is found wet through with blood. The dressings are saturated, and on pulling the drain out a little the flow continues actively. The usual train of symptoms in hemorrhage are : 1. Sudden quickening of the pulse and diminution in volume without appa- rent cause, or even an entire loss of the pulse. 2. Quickened sighing respiration, and the use of the extraordinary muscles of respiration. 3. Increasing pallor and a pearly conjunctiva. 4. Cold, clammy skin. 5. Yertigo. 6. Restlessness, throwing the arms and legs from side to side. Y. Desire to be raised in bed (orthopnea). 8. Pain in the abdomen, often severe. 9. Vomiting sometimes. The history is often as follows : The patient begins by complaining of pain in the lower abdomen ; her color seems a little paler, and the pulse somewhat quickened. The pain comes on in paroxysms and is diffused. She wears an anxious expression, and she may insist on seeing the doctor at once, fearful that she is not doing well. The radial pulse quickly becomes diminished in vol- ume, while its rhythm is increased from twenty to thirty or more beats ; the legs and arms become cold as the hemorrhage continues, and the radial pulse finally fails altogether, or becomes so faint that it can be detected with difficulty. The physician arrived at the bedside, feels no pulse at all, unless it is the pulsation in his own finger tips as they are pressed deep into the wrist in his anxiety to dis- cover some faint beats. The face assumes an ashen hue, the conjunctival mu- cosa is no longer injected, the lips are blue and the gums blanched. A cold perspiration breaks out on the face, and the respiration is quickened and labored. The temperature is subnormal. She lies flat on her back with chin elevated to make the breathing less difficult, and, although restless and anxious, remains mo- tionless, except for an occasional tossing of the head from side to side as the dyspnea increases. She knows that her condition is changed, but often does not appreciate the gravity of the situation. 45 66 COMPLICATIONS ARISING APTEE ABDOMINAL OPERATIONS. If the bleeding continues unchecked, death ensues in a period varying from six to twenty-four hours, or even longer, depending upon the size of the vessel and the anemic or plethoric condition at the outset. After attacks of bilious vomiting the dyspnea often increases. The accessory respiratory muscles of the neck come into play toward the last, and she complains of a painful or heavy sensation in the cardiac region. This is apt to signalize the beginning of heart failure. With the increasing dyspnea comes a sense of sufioeation and desire to have the head raised with pillows placed beneath the shoulders. The distress and the half articulated gasping requests of the patient at this time are peculiarly distressing to the by- standers. The heart impulse may still be distinctly felt, regular, but sudden, short, and violent, on placing the hand gently over the precordium. Gradually, as life ebbs ,.away, the pupils dilate and a condition of apparent obliviousness supervenes, although even this state may be occasionally interrupted by a hur- ried gasping ejaculation, showing that some consciousness still remains. Com- plete unconsciousness gradually comes on, the breathing becomes short and gasping, the corners of the mouth are drawn out and expanded in a hideous risus, when at last, after one or two shallow gasping efforts, respiration ceases altogether. The heart continues to beat some time after respiration has ceased, and after the pulsations are no longer felt a slight ticking or faint contraction, more or less rhythmical, may be detected for half a minute or more, and the tragic scene is at an end. This accident may happen in the best hands, but in the great majority of cases the patient can be saved by prompt action. Eight post- operative hemor- rhages have occurred in a series of 1,800 abdominal sections in my service at the Johns Hopkins Hospital with only one death. The two following cases are cited as typical illustrations of the usual course and symptoms of this accident : M. R., 2752, Sept. 8, 1894 ; operation simple salpingo-oophorectomy. Care- ful ligation of uterine and ovarian vessels separately ; suspension of the uterus. The risks of hemorrhage dwelt upon at the operation, and ties carefully made to prevent it. Returned at 12 o'clock to her room in excellent condition. Yomited violently at 3 p. m., when her pulse was 66 ; at 3.40 p. m., the pulse 128, weak, compressible, pallor marked, the lips dry and marbled, and thirst intense ; dyspnea ; extremities cold. Abdomen reopened at 7 p. m. Blood spouted up toward the ceiling on open- ing the peritoneum, which was full of fluid blood ; large clots ladled out of both flanks. At this time the patient was pulseless at the wrist ; 160 beats per minute felt at the heart. The ligature at the left cornu uteri was found loose ; this was reapplied lower down in the course of the artery ; after all the clots were taken out the abdomen was irrigate* with a salt solution, and an infusion was given into the radial artery to the amount of 750 cubic centimeters of normal salt solution ; following this the pulse reappeared at the wrist in two minutes, and the patient recovered and is in good health. C. L., 1926, April 19, 1893, salpingo-oophorectomy, removing hematoma of left ovary. Pulse 92-112, fair volume. SECONDARY HEMOEEHAGE. 67 Six hours later vomiting ; pulse suddenly became irregular and almost im- perceptible, rate 160. Dyspnea marked ; pain in epigastrium, sides of chest, and flanks. Intense thirst, frequent vomiting of dark -green fluid, extreme pallor and restlessness. Operation in patient's room in bed ; abdomen reopened under cocain, found fllled with blood. Ligature at the cornu uteri found loose. Blood removed and abdomen flushed out with salt solution. Infused into radial artery TOO centimeters of normal salt solution. Kecovery. Shock is one of the most important conditions liable to be confused with sec- ondary hemorrhage in making a differential diagnosis. Shock, however, does not come on suddenly some hours after operation, and is gradual in its onset. If the patient has been carefully watched, it will often be evident that her shocked condition is but the continuance of a state existing immediately after operation. Such shock, it is true, is often associated with an excessive loss of blood during the operation. It is more profound when in addition to loss of blood is added the depression of a protracted operation in a feeble subject. The differential diagnosis between hemorrhage and a septic infection may sometimes be impossible if, instead of a gradual onset, the septic symptoms appear suddenly. In either case the treatment by abdominal section is the same. I quote one case as an illustration of the possibility of this confusion : L. F., 2612, March 1, 1894, operation for right extra-uterine pregnancy, walled off by adhesions and choking the pelvis posterior to the uterus in an excessively fat woman ; a vaginal incision was made posterior to the cervix, emptying the sac, followed by irrigation and packing with gauze. After removal of the pack on the third day the irrigations were continued every second day with a 5 per cent boric solution, followed by the introduction of a fresh gauze pack. Nine days after the operation the patient was out of bed " doing excellently." Some pain and pallor were evident on the tenth and twelfth days. On the twelfth day the irrigation fluid did not return freely, and there was a discharge of some matter and shreds of tissue ; she screamed with pain, and the pulse be- came suddenly weak and almost imperceptible. She was bathed in a cold sweat, and hands and nails were white and the respirations rapid. There was pain in the hypogastrium, followed by cyanosis, the pulse kept growing more rapid and weaker, with slight abdominal distention, and no tenderness or tenseness. Within five hours all the symptoms of collapse were pronounced. A diagnosis of secondary hemorrhage was made ; the patient, with a pulse of 170, was taken at once to the operating room and put under chloroform anes- thesia. As soon as the abdomen was opened, about a Hter of thin milky fluid, with shreds of tissue floating in it, escaped. The peritoneum was red and in- jected everywhere, and necrotic areas were found on top of the sac in the pelvis, with a perforation communicating with the sac and so with the vagina. The abdomen was thoroughly washed out with salt solution, and gauze drainage pro- vided at three openings, one at the lower angle of the incision, and one well back in each flank, communicating vsdth the central one. The drains were removed 68 COMPLICATIONS ARISING AFTEE ABDOMINAL OPEEATIONS. on the third day covered with a purulent discharge ; following this there was a rapid improvement and recovery. It is of the utmost importance for the operator, his assistants, and the nurses in every case to note the general appearance and the color of the mucous mem- branes of the patient as she leaves the operating room, in order that they may have a satisfactory standard for comparison in case the question of hemorrhage comes up at a later date. Operation . — Having once arrived at a diagnosis of secondary hemorrhage, no time must be lost in carrying out the boldest measures to check the flow, and in making up for the deficient volume of blood by infusion. To check the hemorrhage, all necessary instruments and accessories should always be within easy access wherever there is a patient upon whom an abdomi- nal operation has been performed. In the hospital it is always best to take the patient back to the conveniences of the operating room if it is safe to move her at all. The preparations are there made for opening and washing out the abdomen and catching and tying the bleeding vessel, and possibly closing the wound with drainage. If the operation is at a private house or the patient is too weak to be taken out of her room, a table padded with a blanket and covered with a sheet should be placed near a window or under the gas jet, and upon this the inflated ovari- otomy cushion is laid. The patient is then lifted upon the table. The nurse in the meantime has given her a hypodermic injection of one sixtieth of a grain of strychnin and a half ounce of brandy. These injections should be repeated every half hour until she has well rallied. Two clean basins are placed on chairs by the table, and the irrigator bag is filled with water, at a temperature of about 4:3-3° to 46° C. (110° to 115° F.), and suspended near the table. The instru- ments are laid on a sterilized towel within convenient reach. While the operation is in progress the servant should prepare hot-water bottles, wrap them in flannel, and lay them in the bed, so that it will be warm when the patient is put back in it. Preparations are also made to give the patient an enema of brandy (2 ounces = 60 cubic centimeters) in beef tea (8 ounces = 240 cubic centimeters), with ammo- nium carbonate (20 grains = 1'25 gramme), as soon as the operation is over. The bladder is catheterized. No time is lost in making elaborate prepara- tions ; rather the operator must incur some risk of contamination for the sake of speed. If a good table is not convenient, or the patient is in an alarming condition, the operation may be done on her bed. A nominal amount of anes- thetic is used, and pushed to tinconsciousness at the moment the incision is re- opened. The operator devotes two or three minutes to scrubbing his hands and arms. The dressing covering the wound is rapidly laid aside and the sutures exposed. Beginning at the lower angle, two or three sutures are cut and re- moved, the lips of the incision separated, and the peritoneum pulled up and cut open with the scissors. If the diagnosis is correct, dark blood at once weUs up and flows out over the surface of the abdomen. No time must be wasted in trying to sponge all the blood out, but the wound must be enlarged and two SECONDAKY HEMOEKHAGE. 69 fingers carried down into the pelvis, to the uterus, and laterally out to the ovarian stumps. The side where the hgature has slipped will feel lax in con- trast to the tight bunching of the ligated pedicle on the other side. If no marked difference is recognized, both pedicles must be brought up and tied over again, taking either indifferently first. The broad hgament is best exposed by carrying a pair of bullet forceps down into the pelvis, into the pool of blood, guided to the cornu simply by the index finger. The forceps are then opened and the cornu grasped and dragged up into the wound and exposed, and the vessels clamped with a stout pair of artery forceps. , The outer extremity of the broad ligament is next exposed, using the sponge rapidly to clear away the blood. This is clamped, too, unless the ligature is evi- dently so tight in place that there can be no question as to the possibility of hemorrhage from that point. The opposite side is dealt with in like manner. Any other areas wounded in the operation are now carefully inspected. If the operation has been a hysterectomy, the uterine stUmp must be grasped at once with bullet forceps and pulled well up into view. If the inspection of the field reveals the point of hemorrhage the operator passes a fresh ligature, so as to control the trunk below the wound, and another to its free end. If the source does not appear at once he loses no time, but proceeds to ligate both ovarian and both uterine arteries and veins at a point beyond the field of operation. The lower abdomen and pelvis are cleansed by thorough repeated irrigations with a warm salt solution, diluting and washing out the blood, and bringing out clots lodged among the intestines. Finally all layers of the abdominal wall are united by silkworm-gut sutures, closing the incision from end to end. The wound is redressed and the fresh bandage applied. In case of excessive loss of blood, the legs and arms should be wrapped tightly with flannel bandages from the extremities up to the body, to keep the blood in the head and trunk ; this is further aided by keeping the foot of the bed elevated on a chair 20 to 30 centimeters (8 or 10 inches) high. The hot rectal enema of 60 to 90 cubic centimeters (2 to 3 ounces) of brandy and 2 grammes of ammonium carbonate in a liter of normal salt solution is now given on the operating table. Hot bottles are put about the chest and abdomen in the bed. It must be remembered that during shock little or nothing is absorbed from the stomach ; and so long as the cold, clammy, shocked condition persists, no amount of fluid ingested will satisfy the thirst. As soon as there is some reaction the best way to satisfy the thirst is to give an enema of a pint of warm beef tea, and to repeat it in two or three hours. The hypodermics of strychnin should be given in or near the trunk, a six- tieth of a grain every hour, or even every half hour ; if muscular twitching is noticed, the dose should be diminished. With this treatment the pulse drops from 160 to 140, and so on, 10 or 20 beats each twenty -four hours, until it is again normal. The profound anemia may last for weeks or months, and is not to be relieved 70 COMPLICATIOKS ARISING A1?TEE ABDOMINAL OPEKATIONS. by a routine use of iron ; but the better course is by hygienic measures com- bined by tonics, the hypophosphites and gentian, with arsenic and strychnin. Infusion . — Infusion of salt solution furnishes the quickest and best means of stimulation we possess, and is called for in all cases of hemorrhage. For a long time I employed infusion of normal salt solution into the radial veins, but gave it up in favor of the arterial infusion, because in the latter the Fio. 326. — Intkodccing Normal Salt Solution undek the Bkeasts in a Case of Extheme Anemia. The form of the breast before the injection is seen on the right side, where the trocar has just been intro- duced beneath the gland; on tlie left side the breast is fully distended by half a liter of the solution. fluid enters the artery and is forced up the vessel until the first branches are reached, whence it flows back through the capillaries and is filtered, by which it is diffused with the blood in a more even mixture than when the entire volume of the infusion is injected into the veins. Infusion against the blood current has also a distinct stimulating effect upon the heart. PECULIARITIES OF THE PULSE. 71 After repeated ill experiences with the arterial infusion I was finally com- pelled to give it up. The force necessary to inject the salt solution against the stream of arterial blood causes a much greater distention of the coats of the ves- sel than is normal, and it is probable that the vessel is permanently injured ; ia my experience serious sloughing around the area of infusion has occurred in four cases ; in one instance the entire hand had to be amputated some months later. The infusion of saline solution into the cellular tissues under the breasts is so free from any sequelae, is so easily given, and affords such prompt relief, that I now use it in all cases of hemorrhage, and even where the patient is but slightly depressed by the loss of blood. The method of giving the infusion is simple. I have had graduated bottles made especially for this purpose, which are filled with 1,000 cubic centimeters of the salt solution (0-6 per cent) at a temperature of 100° F. (37-8° C). A rubber tube six feet long, to which is attached a long, slender, sharp aspirating needle, completes the apparatus. The solution must be free from all organic particles, such as bits of cotton from the plug of the bottle in which it has been sterilized. The skin of the breast is carefully disinfected ; the breast is then grasped and lifted well up from the chest, while the needle with the salt solution flowing is thrust into the cellular tissue well under the glandular substance. The bottle is elevated six feet above the patient in order to give sufficient hydrostatic pressure to force the fluid into the tissues. As a rule it requires about twenty minutes to infuse from 700 to 1,000 cubic centimeters of the solution under both breasts. If the patient's symptoms are urgent, both breasts are infused simultaneously. As the infusion proceeds the gland becomes greatly distended, and not infrequently the salt solution spurts from the nipple in a fine jet. At the completion of the operation a piece of adhesive plaster must be placed over the point of puncture to prevent a reflux of some of the injected fluid. In many cases the relief is so great that the patient is made comparatively comfortable at once and does not even complain of thirst. In about fifty cases in which I have employed this form of repletion of the circulation there has not been the slightest ill effect in. the way of local inflam- mation about the breasts. Peculiarities of the Pulse. — As the pulse affords one of the most important indications of the patient's condition, any deviation from the normal should be noted at once and watched by the surgeon with unusual anxiety. The chief value of the pulse is barometrical, as it were, giving an early indication of ap- proaching trouble. In order that the pulse may act as a guide in forming an intelligent opinion of the case, a previous observation as to its natural character is essential. If the pulse is already quickened before the operation, ranging between 100 and 130 or even higher, a simple steady acceleration may be prop- erly regarded as favorable rather than unfavorable, as this is to be expected. When the operation is prolonged and exhausting the pulse rate may be in- 72 COMPLICATIONS AEISIKG APTEB ABDOMINAL OPERATIONS. creased 20 or 30 beats, and may persist so for some hours, or even one or two days, without causing anxiety, providing it maintains its strength, volume, and rhythm. One of the surest signs of reaction, however, is the gradual decrease in the pulse-rate. There is always cause for anxiety when a pulse, previously regular and quiet and but little quickened, begins after twelve hours or more to go up, rising to 120, then 130 or 140 beats per minute, at the same time becom- ing weaker. If in conjunction with this there is a rise of temperature and the patient assumes a distressed look, complains of pain, is nauseated and vomits occasionally, and the abdomen is tympanitic, septic infection may exist. It is, however, a mistake to consider even the widest variation of the pulse rate as indicating in itself a necessary fatal result. FEB. 13 14 15 16 17 18 19 20 21 22 23 lij 0) -J 0. 190 180 170 160 150 140 130 120 110 100 90 80 DAY OF OPEnATION 1 2 3 4- 5 6 7 8 9 10 II 109° 108° 107° 106° 105° 5 lO* < £ 103 a s HI 102 1- 101° 100° 99° 98° 97° #: ^ / A A / / / V N /> >, c o f \ I \ / J V \' \ \ / ( 1 1 1 to o. O N / V 1 -\ 1 1! •^N \ y "\ V ^, '\ A r y A V' \ \ \ ^ \ J \ 1 V X \ 1 1 I 1 \ V / ,^ J V \, /^ V^ ^ ^v > r\ »' V \J ^ \/ PULSE 118/ lay /lis Hi/ / /Hi my /ibH 118/ /152 ? / /178 108/ /176 181/ /IM 156/ /lU 162/ /160 160/ /150 110/ /111 111/ /m 176/ /160 128/ X28 124/ /in 116/ /120 120/ 100/ X02 116/ /102 108/ /112 STOOLS 3 1 1 1 URINE 520 c. 820 oc. 780 cc. 670 CO. 1200 CC. 560 CC. 430 CO. 570 CC. 590 CC. 450 CC. . Temperature Pulse Fig. 327.— Chaet showino Convalescence Complicated by a High Pulse Rate, followed by Eeoovebt. Operation: cystectomy for multilocular orrhage ; pulse counted on table 200 per Operation: cystectomy for multilocular ovarian cyst, begun under cocain; extensive adhesions, and hcm- rhage ; pulse counted on table 200 per minute. Temperature caused probably by drain and stitch ab- SCGSSG8. IN 0. doUi I have repeatedly seen patients recover whose pulse rate was as high as 140 or 150 for some hours; in one instance the pulse ranged between 150 and 162 for three days, after which the patient made an uninterrupted recovery. TAKIATIONS IN TEMPERATURE. 73 I removed an ovarian cyst from a feeble old woman whose pulse went up to 210 during the operation, and one of my residents, by carefully counting the cardiac impulse over the pericardium, made it at one time 240 per minute, and yet she made a good recovery. (See chart. Fig. 327.) An intermittent pulse is sometimes observed during convalescence when it has been rapid immediately after operation ; indeed, an intermittent pulse occa- sionally occurs after operation without apparent cause. A markedly intermit- tent pulse is also noted in the latter stages of septic infection, and is always a cause for grave apprehension. An abnormally slow pulse (bradycardia) is occasionally noticed, but it usu- ally exists also before operation. I had a patient who recovered with a pulse rate of 30 per minute after cholecystotomy, but this had been the normal rate through life. Variations in Temperatnre.^Subnormal temperature is indicative of pro- found depression arising from shock, hemorrhage, or the gradual retrogression of the vital functions preceding death. The temperature may fall slightly below normal during or immediately after an operation from the refrigerant depressing effect of the anesthetic, especially if ether has been employed, but quickly returns or rises even above the normal upon the application of external heat. A sudden fall of temperature after the patient has recovered from the first effects of an operation, associated with an increase in the pulse rate, is one of the signs of hemorrhage. The gradual depression of temperature preceding natural death is usually coincident with failure in all the other vital functions, and is different from the rapid fall from hemorrhage or severe shock. Some elevation of temperature, known as simple wound fever, is observed in almost all cases, even where the recovery is otherwise perfectly normal. This need occasion no alarm, although calling for increased watchfulness. The composite temperature charts in Chapter XXI demonstrate the normal febrile reaction attending the healing of abdominal wounds. Quite frequently a considerable elevation of temperature occurs, extend- ing over several days, and then subsides without giving any sign of its cause. So far as the progress of these cases is concerned they may be considered normal, yet since we can not reconcile this abnormal elevation of temperature, extending over several days, with a perfect convalescence in a surgical sense, we are constrained for the present to attribute it to the effects of infection, for un- doubtedly mild grades of infection can be combated by the phagocytic action of the leucocytes and the germicidal effects of the blood serum without any other signs than those manifested by these variations of temperature. Even local suppuration, deep in the abdominal wall or about the stump of an ovarian cyst or the cervix, may occur and never be definitely located, the accumulations of pus being gradually absorbed. Looking at these abnormal temperatures from this standpoint, the gyne- cologist must feel anxious about his case until the normal curve is reached. Y4 COMPLICATIOlfS ARISING AFTER ABDOMIIfAL OPBEATIONS. "When malaria is prevalent, or a patient comes from a locality in which it is endemic, a sudden rise of temperature should at once call for a blood examina- tion, and the surgeon may be relieved of grave anxiety by finding the Plas- modium malarias present. During August and December, 1896, my associate, Dr. W. W. Eussell, observed several of these cases (see Johns Hopk. JIosp. Bvl., E"ov., Dec. 1896). In one instance the patient had been operated upon in the hospital one year previously for a large pelvic abscess, and a quantity of pus was evacuated by vaginal incision and drainage ; she remained in perfect health until two weeks before the second admission, when she began again to feel miserable ; in a few days severe chills came on, succeeded by headache, backache, and high fever. Feeling sure that there was a return of her former malady, she hurried at once to the hospital. A vaginal examination revealed some induration at the base of the broad ligament, but there was no sign of any purulent collection. She was then put to bed and watched for several days, when a blood exam- ination was made, the plasmodium found and the diagnosis of malaria made (see malarial chart). By keeping in mind the possibility of malaria as the cause of high tempera- ture grave anxiety and even serious mistakes may be avoided. An instance of a mistake of this kind is that of a gynecologist who performed salpingo- oophorectomy in the belief that the adherent appendages that he removed were the cause of the periodical rise in temperature. A subsequent examination of the blood revealed the plasmodium, and a course of quinin speedily relieved the symptoms. Occasionally the most unaccountable rises of temperature will occur during the convalescence of an abdominal section case. When there is a definite peri- odicity of these rises, or a slight diurnal variation like that seen in septic cases, some point of infection will usually be discovered to account for the abnormal temperature. In rare cases the variations in temperature follow no law, rising to an alarm- ingly high point one day and then abruptly falling to normal, where it may remain for a variable length of time and again show the same excursus. The patient's general condition is usually good, and in no way corresponds with the temperature ; she has no accompanying chills or sweating ; a careful physical examination and microscopic examination of the blood fails to reveal any cause for the thermal disturbance. On careful review of the history of such a case a marked hysteric temperament may be discovered, which may account for the unusual symptoms ; such a diagnosis, however, should only be accepted as a last resort after the most careful exclusion of every other possible source ; it is in just such cases that the greatest injustice is sometimes done the patient. I once operated upon a young woman of neurotic temperament for extensive suppuration of the pelvic organs. The convalescence progressed smoothly, the temperature reaching normal on the seventh day after operation, and continu- ing so until the twelfth day ; then it suddenly rose, between eight and eleven VOMITING. 75 o'clock in tlie morning, to 105-5° F. (40-8° C), and remained at this point until the evening, when it fell abruptly to normal. No further disturbance was noted for six days, when again the same phenomenon occurred. During this time nothing could be detected to account for the rise in temperiture, and it was attributed to hysteria. Two days later the temperature again rose to 105° F. (40-5° C), and for the next nine days showed a typical septic chart, when it again reached the normal and continued so for five days, and again rose to 102° F. (38-9° C), dropped to normal, and the next day made the highest rise of any time during the convalescence, reaching 106-6° F. (41-5° C.) The patient complained of chills and sweating occasionally, but otherwise showed no ill efEects from this hyperpyrexia. For a number of days the chart indicated sep- OCT. AY OP ONTH 19 20 21 22 23 24 25 26 27 28 29 30 1 111 3 0. I40 130 120 110 100 90 80 AY OF ; RATI Of II 12 13 14 15 16 17 18 19 20 21 22 23 lOUR 00 s s ft B ft a s i a ft i g a a a 00- 103° A E \ O \ ini° o / 1 3 O 1 1 '■ IOO° 1 \ L ^ qq' A \ / 1 /^ ,^ y' ' > ^^ A. I A L /v / y \. / 1 ^ ^ 7 \ S^o A ,y A ^, ^/ >^ "N V o 1 > \ r 7 \ .-., "t — - ■- — -^ -•>■ y' ,/ v s ■> / ^^ •^^ \l v' y V "^ J V V 'ULSE y /m y /so SI / SO / y / 84/ / / 80 88 / / 88 / /oo / y / so/ /% so/ /l2 80/ /96 TOOLS 1 4 ' 3 ' 1 1 1 3 2 2 Temperature Pulse Tig. 328. — Normal Convalescence Intebkupted bt Periodical Eises or Tempebatdke due to Pbesenoe of the Plasmodium Malaria. No. 4618. sis, and yet repeated examinations failed to reveal its presence. Since the pa- tient's return home she has had similar attacks, and it has now been more than two years since her operation and she enjoys fairly good health. Vomiting. — Nausea and vomiting follow the administration of an anesthetic in the great majority of cases where the operation is prolonged, but vomiting can only be considered a complication when it is persistent or excessive. The personal peculiarities and idiosyncrasies of a patient are an important factor in the case, and should be inquired into before the operation. Patients frequently volunteer the information that they dread the anesthetic on account of an irritable stomach or a tendency to excessive nausea discovered in some former experience. 1Q COMPIICATIONS ARISING AFTER ABDOMINAL OPERATIONS. Vomiting may invariably follow the ingestion of liquids or food for three or four days after an operation ; indeed, the nausea may be so great as to cause vomiting at the mere sight of food. When this condition is associated with in- crease of pulse rate, elevation of temperature, tympanites, and severe intermit- tent abdominal pain, it may be accepted as a sign of peritonitis. In this case the vomiting becomes more frequent and retching in character, the ejecta con- sisting of a little yellow or black bile, expelled in small quantities. When excessive emesis is associated with severe intermittent pains and a failing pulse, with but slight elevation of temperature, it points strongly to intestinal obstruc- tion, when the vomited matter may soon become feculent in odor. Sometimes the appearance of the ejecta and the severe pain in the epigas- trium suggest gastric ulcer, gastritis, or some other affection of the stomach ; under these circumstances the history aids iu establishing or disproving the supposition. Treatment . — The stomach must have absolute rest so long as it is in an irri- table condition, and nutrition must be maintained largely by rectal alimentation. Internal medication is usually of little service, although occasionally limewater in small quantities seems to allay the excessive irritability. A few drops of the spirits of chloroform may be given at frequent intervals; cocain, 2-per-cent solution, may be given in 10 to 20 minim doses ; bismuth subnitrate or mor- pbin in small doses is also valuable. Iced champagne in 2 or 3 drachm doses fre- quently has a soothing effect. Two or three drops of tincture of capsicum in a teaspoonful of hot water is often valuable. If the bowels have not been moved, relief is often instantaneous upon a thorough evacuation. In intractable cases the greatest relief frequently follows the washing out of the stomach with a weak boric-acid solution, and after lavage two or three times the vomiting vdll often disappear entirely. For this reason I always resort to lavage when doubtful whether or not the vomiting is a sign of an obscure peritonitis or an ileus, and in several instances it has seemed even to save the patient's life. Its happy effect is well illustrated by case E. B., ISTo. 4828. Operation, Nov. 23, 1896. A hysteromyomectomy was performed for an enormous myoma, entirely subperitoneal. All went well until the sixth day, when the patient complained of intense epigastric pains, kept crying out and vomiting violently, and had the appearance of a woman in extreme collapse. It was curious to note that although she was an ignorant woman she persistently declared that her bowels were closed, and if she did not get a passage through she would shortly die. I saw her in this condition on the following day and ordered lavage, which gave immediate and permanent relief. A hot-water bag, ice bag, or a weak mustard plaster, applied to the epigas- trium, usually renders the patient more comfortable, and may bring entire relief from the nausea. As a rule, it is best to withhold all food by the mouth until there are no more active manifestations of the nausea. ISTutrient enemata, if properly pre- pared, are easily assimilated, and may be relied upon exclusively for a few days. TYMPANITES. 77 Among the best formulae are the following : 1. -One egg. A little table salt. Peptonized milk, 60 to 90 cubic centimeters (2 to 3 ounces). Brandy, 30 cubic centimeters ; or, 2. The whites of two eggs. Peptonized milk, 180 to 200 cubic centimeters. To allay excessiTe thirst, a half pint or a pint of water injected high up into the bowel is efficacious. Dr. E. C. Dudley, of Chicago, recommends enemata of beef tea, which I have used with great satisfaction, as they serve the double purpose, if they are retained, of furnishing food and relieving thirst ; and if they are ex- pelled, an early evacuation of the bowels may be secured. The food in these cases when first given by the mouth must be light and digestible, and given in small quantities at frequent intervals. Albumen, as prepared in Chapter XXI, is the least irritating form of nutriment. Meat jellies, light broths, or koumiss are best retained as soon as the condition of the stomach begins to improve. Tympanites. — Excessive tympanites is one of the most distressing complica- tions following celiotomy. The abdomen becomes greatly distended and often markedly sensitive, and the upward pressure on the stomach and diaphragm interferes with digestion and impedes respiration to such an extent as to cause great discomfort. I have seen two instances where death seemed to have been due to the paralysis of the diaphragm caused by an excessive tympanites, as the autopsies revealed no other possible cause. Palpitation of the heart and dis- turbed rhythm are frequently due to this intestinal distenton. Tympanites, like the variation in pulse rate and temperature, may be without serious significance, due simply to intestinal atony or constipation, which is promptly relieved by appropriate measures. If it is associated with increasing pulse rate, fever, con- stipation, and vomiting, it is a symptom of peritonitis. Treatment . — The ''application of turpentine stupes to the abdomen is one of the best of the mild remedies often: effectual in relieving the condition. The stupe is made by wringing a broad piece of flannel out of hot water containing turpentine in the proportion of 60 cubic centimeters to the liter (1 ounce to the pint). The stupes must not be left on too long, or be too frequently repeated, or they will blister the skin. The introduction of a rectal tube high up into the lower bowel permits the escape of flatus and often affords relief at once. "When there is an excessive accumulation of gas it is advisable to leave the tube in the rec- tum for some hours. To facilitate the passage of the tube the index finger should be well oiled and introduced as far up as possible to serve as a guide for the end of the tube as it is pushed through the ampulla into the upper bowel where the gas has accumulated. If this is not done the tube will be almost cer- tain to coil up in the ampulla without reaching the upper rectum at all. Hoffman's anodyne, in the dose of twenty minims to a drachm, given in 78 COMPLICATIONS AEISIlfG AFTER ABDOMINAL OPEEATIONS. cracked ice, is a good internal remedy. Five drops of turpentine in emulsion or on loaf sugar is also of value, stimulating and assisting in the expulsion of the flatus. The evacuation of the bowel by an active purgative — such as magnesium sulphate, citrate of magnesia, or a pill of aloin, strychnin, and belladonna, followed by repeated enemata of oil or soapsuds — ^is the best of all means of permanently relieving tympany, and should be resorted to at once if the mild measures fail after a brief trial. One of the best remedies for a distressing tympany is the light applica- tion of the Paquelin cautery. The platinum tip should be heated to dull redness and lightly drawn over the abdomen, only touching the top of the short hairs, and not actually coming in contact with the epidermis. The manipulation of the cautery requires some little skill, or deep bums may be pro- duced. It is best to practice the movement with the cold point on one's own arm before trying it upon the patient. When the entire abdomen has been gone over in this way the patient is usually greatly relieved, and begins at once to expel great volumes of flatus. The relief has been so great in some cases that I have had patients who were almost paralyzed with fear at the sight of the red-hot tip during the first application request a repetition of the treatment on the slightest return of the tympany. Where there is reason to anticipate a tympanitic condition of the bowel on account of extensive injury to its peritoneal coat or on account of inefficient evacuation of the bowel previous to operation, the cautery can be used with good effect on the slightest indication of distention. In these cases it acts as a prophylactic. In an extreme case I know of no plan so good as that of Dr. L. M. Sweetnam, of Toronto, which consists in the postural treatment of tympany by putting the patient in the knee-breast posture and introducing a rectal tube. As soon as the tube passes beyond the utero- sacral ligaments volumes of gas begin to escape. One of my patients was desperately ill with tympany — the barrel-like abdomen as tense as a drum, and the pelvis was so choked with dis- tended intestines that the rectal tube could not be passed. I gave her com- plete rehef by putting her under chloroform and introducing, in the knee- breast posture, one of my long rectal specula ; the bowel was collapsed until the speculum reached the sigmoid flexure, when the gas began to escape freely, and she recovered. Excessive Pain.— The surgeon, and especially the family, are often unneces- sarily fearful on account of the excessive suffering of the patient after an abdominal operation. The pain is usually referred to the lower abdomen, where it is constant and so severe as to seem almost unendurable. Highly sensitive or nervous women will oftener complain in this way, while others of a phlegmatic temperament, or who are accustomed to exercising self-control, suppress all manifestations of pain and only complain when questioned. The simplest, abdominal operations may be followed by the severest pain, while other cases, where extensive adhesions to adjacent organs have been sepa- rated, cause comparatively little or even no suffering. PERITONITIS. 79 In the absence of other untoward symptoms there is no occasion for alarm, as the pain usually subsides in from twenty-four to forty-eight hours, and the patient suffers but little afterward. Women addicted to the use of morphin complain most bitterly and are the longest in becoming quiet after operation. If sedatives are persistently withheld these patients become exhausted in one or two days, and are not so importunate in their demands for the drug, and al- though they may say they have had absolutely no sleep, an observant nurse will have noted many short naps aggregating in all sufficient rest in twenty-four hours. I know of no better method of breaking the common morphin habit than the absolute prohibition of anodynes in any form during their convales- cence following operation. The suffering for the first two or three days is undeniably of the severest character, but the moral effect produced by triumph- ing over real pain, and the realization that it can be accomplished without resort to morphin, are of the greatest value in restoring the moral stamina of the patient. After having gone through such a struggle the patient will rarely return to its use if she has any moral character left to work upon. In ordinary cases I do not object to the use of one or two hypodermics of morphin in the first twenty-four hours, indeed it is better to use it, but no prac- tice is more pernicious than the repeated administration of sedatives for the relief of pain for several days following abdominal operations. The general tone of the patients who have withstood the pain without anodynes is far better at the end of a week than that of those who have been relieved by morphin. The severe pain complained of by neurotic or acutely sensitive women must be carefully differentiated from the pain of peritonitis, which is most severe on the second, third, or fourth day after operation, and is intermittent in character, associated with tympanites, elevated temperature, quickened pulse, and a bad facial expression ; here, too, mOrphin should be withheld, as it dulls the patient's mind, locks up the secretions, blunts the sensations, and so tends to mask the symptoms at a critical period. Peritonitis. — If we accept the views of Grawitz, Klemperer, and others con- cerning the pathology of peritonitis, we class all forms together as septic or infectious. A number of observers, however, maintain, from the standpoint of experi- mental as well as of clinical observation, that there exists a simple, post-opera- tive, traumatic peritonitis without infection. This view would seem to be supported by the common surgical experience that although cultures taken throughout the course and at the end of an operation frequently show no growths and therefore the absence of an infection, yet for the first two or three days after an operation the patient may exhibit many of the symptoms of peritonitis. The experimental researches of Pawlowsky upon the etiology of peritonitis would seem also to confirm this view ; he injected various chemicals into the peritoneal cavity of animals and found that they produced a _ " simple inflam- mation." In several instances where I have been compelled to reopen the abdomen 80 COMPLICATIONS ARISING AETEE ABDOMINAL OPERATIONS. sooii after the original operation to relieve an obstructed bowel I have found extensive union between adjacent peritoneal surfaces ; these cases failed to show any kind of micro-organisms in the peritoneal cavity, and yet the evidences of the pouring out of a plastic lymph with the subsequent formation of ad- hesions were abundant. The scientific pathologist seriously questions the propriety of denominating as forms of true peritoneal inflammation those processes which are simply associated with the repair of the injured tissues, and are thus of necessity purely localized at the seat of the injury. I think, however, that for the more practical purposes of the surgeon it will be well for the present to preserve the customary nomenclature without ex- pressing a definite judgment as to the strictly scientific question involved, for in the first place it behooves the surgeon to be keenly on the alert to detect peri- tonitis and everything that simulates it, and, in the second place, it is equally certain that if the plastic forms are not themselves true inflammations they do unquestionably often form the basis of an inflammation. Traumatic or Plastic Peritonitis. — The so-called traumatic or plastic peri- tonitis is a regenerative process, and occurs to some degree in every case in which the abdomen is opened ; it is slight and circumscribed after simple opera- tion, and extensive when wide areas of adhesion have been separated, as in the enucleation of adherent tubal and ovarian tumors. The wide area of cellular tissue exposed in some cases gives rise to serous oozing, and the plastic lymph serves to agglutinate adjacent structures to the raw areas, which become vascu- larized, and finally converted into fibrous tissue. A traumatic "peritonitis" may also be induced by prolonged exposure or rough manipulation of the ab- dominal viscera without taking away the peritoneal covering. The character of the adhesions formed varies ; sometimes they are flat and dense and can only be liberated by tearing the bowel or cutting away the adherent surfaces ; or they are long and weblike or velamentous, and can be freed without difiiculty. After some months the most extensive adhesions may disappear spontaneously by absorption. I have opened the abdomen a second time in cases where the adhesions were almost universal at the time of the first operation, and found , only a few delicate bands remaining. S y m p t o ms . — In the milder forms there are no symptoms whatever. The symptoms of the more aggravated forms are vomiting, severe pain in the lower abdomen, tympanites, tenderness on pressure, accelerated pulse, and elevated tem- perature, rising at first to 99°, then to 100°, or even 101°. The pulse is usually only slightly quickened and remains full in volume, and the patient has a good facial expression, lacking the pale, drawn appearance characteristic of sepsis. Yomiting is less frequent and not so persistent and so retching in character as in septic peritonitis. The ejecta consist of the contents of the stomach, but the vomiting is not, as a rule, of the violent biliary character seen in septic peritonitis. Traumatic peritonitis rarely becomes general, although the extreme tympany and general tenderness over the abdomen often lead to such an inference. TRAUMATIC OR PLASTIC PERITONITIS. 81 Dangerous symptoms may arise from pressure of the distended intestines on the diaphragm, interfering with respiration, or from ileus, or, later, from strangulation of the bowel by bands of adhesions. In the usual course of simple plastic peritonitis, in from two to four days after the operation the tympanites disappears, the pain subsides, the temper- ature gradually falls, the pulse rate decreases, and convalescence becomes estab- lished. While the convalescence usually proceeds in this manner, if the fluid is not promptly absorbed another outcome is possible ; the few germs which always get into the peritoneum, even in the most aseptically conducted oper- ations, find in the stagnating fluid a rich nutriment under precisely the proper conditions of temperature for a rapid nmltiplication, and in this way a septic peritonitis may be produced, which would never have arisen in a dry peritoneum. Treatment . — P rophylaxis plays an important role in the treatment of traumatic peritonitis. At the operation the intestines must be exposed and handled as little as possible, and kept carefully protected with gauze. No other solution than the normal salt solution should come into contact with the peritoneum. Where denudation is necessary its extent should be as limited as possible, and, whenever possible, flaps of peritoneum should be left to cover up the denuded areas. The amount of exudation will be lessened by protecting the denuded areas and by checking all hemorrhage before closure. Free purgation is the sheet anchor in the treatment of traumatic peritonitis, depleting the circulation and actively removing the fluids within the peritoneum. If the stomach is not too unsettled, a hydragogue purgative, such as citrate of magnesia or a concentrated solution of Epsom salts, should be given every hour until the bowels are freely moved. Sometimes, even with considerable nausea, these purgatives may be given by the mouth, and instead of increasing the nausea will often allay it. Calomel in half -grain doses every hour until two grains are adpainistered, followed by a saline cathartic, acts well in many cases. If the irritability of the stomach is so great as to preclude the administration of drugs by the mouth, the evacuation must be secured by an enema, begin- ning with a pint of warm soapsuds containing three or four ounces of sweet oil or one drachm of spirits of turpentine. This should be repeated every two or three hours until the bowels are freely moved and the flatus expelled. By the time the lower bowel is thoroughly evacuated the stomach will usu- ally be settled sufiiciently to tolerate medicine by the mouth. If the enema is expelled as soon as it is injected, the rectal tube must be introduced again, this time high up into the colon, so that the enema may be thrown at once into the sigmoid flexure, or even higher. One is often surprised, notwithstanding the free evacuation of the bowels before the operation, to see the large amount of fecal matter passed at this time. The diet should consist of highly nutritious liquid food, which will leave little or no residuum in the intestinal canal ; plain milk should therefore be dis- carded. To facilitate thorough digestion and to allay nausea the food should be given in small quantities every hour or two. Peptonized milk, beef broth, wine whey, 46 82 COMPLICATIONS AEISINGt AFTER ABDOMINAL OPEEATIONS. and mulled wine are all easily assimilated. Iced champagne or soda water in small quantities is often soothing when the stomach is excessively irritable. If the stomach is intolerant to foods, rectal alimentation must be resorted to according to the method described on page 77. A turpentine stupe or a hot- water bag applied to the abdomen is useful in allaying pain. Patients sometimes experience the greatest relief from the application of iced flannels over the abdomen. Post-operative Septic Peritonitis. — This form of peritonitis is invariably pro- duced by the invasion of pyogenic micro-organisms into the peritoneal cavity. It is due, therefore, to a localized infection extending from a definite point out over the surrounding peritoneum until it is either checked by a wall of in- testinal adhesions or until it has invaded the entire peritoneal cavity. The con- ditions underlying the infection of the peritoneum are the same as those under- lying the infection of all other wounds. The view of older surgeons that the peritoneum was especially susceptible to infection has been disproved by many clinical and experimental observations ; indeed, we have now so far reversed this opinion that we consider the perito- neum one of the most resistant of all the organs to the invasion of micro-organ- isms. We know also that we are constantly testing its powers of resistance, for in spite of every effort we rarely exclude all infectious germs from the peritoneal cavity during an operation. The experiments of Pawlowsky, Grawitz, "Welch, Halsted, "Waterhouse, and others all show that the healthy peritoneum can withstand, without the least visible reaction, great quantities of pyogenic organisms if they are introduced suspended in a fluid culture medium. Sanger has defined three important conditions concerned in infectious pro- cesses: first, qualitative, relating to the pyogenic properties of the infectious germ; second, quantitative, relating to the number of organisms present; and third, the constitutional, referring to the susceptibility of the subject to infec- tion. Dr. Wilham "Welch says : " It is apparent that while there is no reason to doubt that pyogenic cocci are specific agents of infection, the effects which they produce depend upon a variety of conditions, such as the source, the number, and the virulence of the micrococci, the accompanying toxic substances, the part of the body invaded, the readiness of absorption, the presence of foreign bodies and the pathological products, the general state of the patient, and the condition and handling of the wounded tissues." The more we learn of infectious processes the more are we convinced that the vital resistance of the patient plays an important, if not the greatest part, in the resistance to infection. If a patient is much depressed physically, and is subjected to an abdominal operation in which there is extensive traumatism to the peritoneum attended by considerable oozing, the chances for a serious in- fection are much increased. To the individual factor of vital resistance is un- doubtedly ascribable many of the discrepancies as to the apparent varying degrees POST-OPEKATITE SEPTIC PERITONITIS. 83 of virulence of the same infection, when under precisely the same conditions one patient will be infected and another escape. It is a clinical fact, and one which all discriminating physicians have learned to value, that persons suffering from pre-existing chronic cardiac, renal, or he- patic disease are prone to be carried off suddenly by intercurrent acute affections, which it is now recognized are due to pathogenic micro-organisms. If these conditions arise spontaneously, without the aid of traumatism or in consequence of a surgical procedure, it may be regarded as a natural sequence for infection to take place under like circumstances when, as a result of surgical operations, the way is opened for the entrance into the body of pathogenic bacteria ; the gravity of the infectious process will, in a given instance, depend upon the degree of absence of resistance to infection in the individual, the nature of the operation, the perfection of the technique employed, and the virulence of the entering micro-organisms. The pathological and bacteriological study of all the cases of peritonitis which have come to autopsy in the Johns Hopkins Hospital has clearly demonstrated the greater liability to the invasion of bacteria on the part of persons subject to chronic diseases of one or several of the important viscera. It is well established that the streptococcus pyogenes is the most virulent of all the ordinary micro-organisms, and its introduction or escape into the peritoneal cavity is one of the most dangerous accidents that can occur in the course of an operation. I found by a routine examination of all pelvic ab- scesses that the streptococcus was rarely present, and when it did occur the use of drainage was of little or no avail in resisting a further invasion, as a virulent infection of the peritoneum was almost invariably fatal whether the drain was inserted or not. The staphylococcus aureus under favorable conditions may also give rise to an extensive serous inflammation and septicemia. In the five cases of post- operative peritonitis which occurred in the gynecological department of the Johns Hopkins Hospital in 1893 the infecting organism was the staphy- lococcus aureus. The bacillus coli communis under favorable conditions is capable of producing a peritonitis, although its role in this capacity has been questioned. The growth of the bacillus is so vigorous that it would appear to kill the less resistant pyogenic cocci, which are consequently not found by the time the patient is operated upon or on the autopsy table. Other organisms, besides the simple pyogenic cocci, are capable of causing peritonitis. Cases havfe been reported in which the bacillus pyocyaneus, the bacillus proteus, bacillus typhosus, and the micrococcus lanceolatus have been the infecting agents. The gonococcus, while occasionally found in purulent collections in the peri- toneum, seems only in rare instances to possess the power of exciting an active inflammation of the serous membranes. In many hundreds of bacteriological examinations I have never yet been able to demonstrate this micro-organism as the etiological factor in the production of septic peritonitis. In one case which 84 COMPLICATIONS AKISIIirG AFTER ABDOMIN-AL OPERATIONS. came under my observation a pus tube had been ruptured some days previous to operation, giving ample opportunity for the beginning of an inflammation. At the time of operation there was only the slightest local pelvic peritonitis, notwithstanding the fact that a great quantity of pus containing myriads of gonococci was lying free in the pelvis. The patient made an uninterrupted re- covery without even the usual symptoms of traumatic peritonitis. The staphylococcus albus, under favorable circumstances, may produce a local peritonitis, but its pyogenic properties are slight. The group of infectious peritonitic eases may be further subdivided, de- pending upon the virulence of the infection and the resistance of the patient. The most fatal of all forms is that where the micro- organism multiplies so rapidly and its toxic products are taken up so quickly by the blood and lymph vessels that the patient is overwhelmed in a very short time and dies as though suffering from severe shock. In these cases the local reaction is slight, and there may be but little evi- dence of peritonitis, the symptoms being almost entirely constitutional. The peritoneum in these cases is covered with a thin slimy or viscid exudate of fibrin, which, upon microscopical examination, shows myriads of micrococci. The onset of the symptoms is rapid, the pulse showing an abrupt rise, and the general appearance of the patient becoming much worse. The temperature, as a rule, only rises to 99°, 100°, or 101° F. (37-2°, 37-8°, 38-3° C), but it may show a wide excursus above the normal. I cite two cases as examples of this fulminating form of peritonitis, in both of which streptococci were present. Y. W. (3198). The patient was operated upon Nov. 8, 1894, for multiple myomata of the uterus. The tumor was large and lay in an oblique direction in the abdomen from the right ovarian region to the spleen. The operation was done under the usual precautions, and was not especially difiicult. The time of operation from beginning to end was fifty-five minutes. Practically no bleeding occurred, the vessels being securely clamped and tied as the operation progressed. The uterus was amputated just above the cervix, and the uterine cavity appeared normal. The stump was then lightly drawn together with catgut sutures, and over this the peritoneum was sutured. No blood or debris remained in the pelvic cavity at the completion of the opera- tion, and the patient left the operating table in splendid condition and quickly rallied from the efliects of the anesthetic. She was returned to the ward at 10 A. m., and by six o'clock the same day her temperature had reached 101° F. (38-3° C), and her pulse, which had ranged between 80 and 90, suddenly ran up to 120 and 130 and became irregu- lar. Her appearance was bad, the face was covered with cold perspiration, and the expression was drawn. Under strong stimulation in the way of rectal enemata and whiskey and strychnin, the patient appeared to improve a little, but by the next morning the POST-OPEBATIVE SEPTIC PERITONITIS. 86 pulse had almost disappeared. Tlie abdomen was tympanitic and tender to pressure. ' The symptoms were so rapid in their onset that the possibility of a secondary hemorrhage was seriously discussed. At eight o'clock the patient was taken to the operating room and the abdo- men reopened. There was no trace of hemorrhage. As soon as the stitches were removed from the abdominal wall a few drops of thin, yellowish pus ex- uded. On opening the abdomen, the intestines and parietal peritoneum were found covered with a very thin viscid layer of fibrin. The abdomen was irrigated thoroughly and a gauze draiu inserted, and salt solution was infused into the radial artery. Patient regained consciousness, but died within an hour. Her temperature in the early morning hours reached 104-5° F. (40-2° C). Autopsy No. 595. Anatomical diagnosis : Laparotomy wound for hystero- myomectomy ; wound infection ; acute fibrino-purulent peritonitis ; cloudy swelling of organs ; fatty degeneration of heart, liver, and kidneys ; hydrone- phrosis on the right side with early atrophic changes in the right kidney. On cutting through the abdominal wall near the line of incision, yellowish- white pus exudes from the muscles and external to them. Over the parietal peritoneum in the neighborhood of the incision a fine deposit of fibrin is visible. The cellular tissues in front of the bladder are markedly edematous. The serous coat of the intestine is markedly congested, especially at points of contact. Fine and coarse flakes of fibrin are present on both small and large intestine, espe- cially in the lower abdomen. The upper part of the abdomen, the peritoneum covering the stomach, and the liver, are entirely free from exudate. Slight ex- cess of serous fluid in peritoneal cavity. Bacteriological examination : Cover-slips from the pus in the wound and from the peritoneal exudate show cocci, chiefly in pairs. Cultures made from the abdominal wound, the peritoneum, the kidney, the lungs, the spleen, and from the heart's blood show myriads of colonies of streptococci. In such a case as this the vital resistance of the patient was poor and the virulence of the invading micro-organisms marked. The next grade of infection is less rapid in the onset of its symptoms, and the course of the disease is more prolonged. Pawlowsky has designated this as the purulent hemorrhagic type. The following case is a good example of this form : E. E. H., No. 6583, myomectomy, Jan. 23, 1893. An abdominal incision about 14 centimeters long was made, exposing a globular uterus choking the pelvis, with a tumor 8*5 centi- meters in diameter in its anterior wall, and a similar nodule also 8'5 centimeters in diameter in the posterior wall. Incisions were made into these nodules, and they were enucleated from the uterine tissue, the cavities created were obliter- ated by buried and superficial catgut sutures ; several other small nodules were also enucleated, and the abdomen was then closed by four series of buried catgut sutures. The duration of the operation was thirty -four minutes. The next day the patient complained of severe stabbing-like pains over the 86 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. lower part of the left lung ; the pain was increased on deep inspiration, the tongue was moist, slightly coated, and the abdomen was not distended. Two days after tl)e operation the pulse was rapid, 120 to the minute, but fair in volume ; temperature, 104"4°. Her expression, however, was bad, and she was nauseated at intervals during the entire day. The abdomen was now DAY OF aPERATtON 1 2 3 4 190 180 170 160 150 140 UJ U) -1 130 2 120 110 100 90 80 HOUR 8 12 6 12 6 12 6 12 6 12 6 12 6 109° 108° 107 106° 105° a 104 1- < ^ 103° 111 102 101° .00° 99° 98° a 5 IV ter in. iea h / 1 / / / / 1 f r <■ / r- V ; / A \ . J ;\ .^ / A V / / V > \ V V \f- y Temperature Pulse Tia. ! -Chaht of a Case of Septic Pebitonitis following Myomeotomit. Death on the Foueth Day. E. H. H., 6583. tympanitic and sensitive. On reopening the lower angle of the wound I was unable to find any evidence of suppuration. Three days after the operation the temperature rose to 10Y-8° and was quickly followed by death, with the patient conscious to the last. Autopsy . — Anatomical diagnosis : Stitch-hole abscesses ; purulent hem- orrhagic peritonitis following laparotomy for myomectomy ; myomata of uterus ; acute splenic tumor ; embolic lung abscesses ; congestion of lungs ; infection with streptococcus pyogenes and staphylococcus pyogenes aureus. POST-OPEEATIVB SEPTIC PEEITONITIS. 87 In the midline is a linear wound 12 centimeters in length, situated between the umbilicus and pubes ; the lower angle is gaping, but the upper part of the wound is united. On incising the wound, a purulent, sanguineous exudate is found between the skin and the deep muscles, and the muscle wherever ex- posed is very red. On cutting through the stitches which hold the abdominal walls together, small accumulations of pus are found about the sutures, forming foci which can be readily distinguished from the general purulent infiltration of the wound. On removing some of the sutures, they are found covered with pus. The deep layer of sutures is likewise covered with pus. The parietal peritoneum is injected, and on opening it an accumulation of bloody pus is found just beneath the incision. The omentum is adherent to the intestines and to the parietal peritoneum, rolled up, intensely injected, and cov- ered with pus. The peritoneum covering the intestines is vividly injected, and the cavity contains about 500 cubic centimeters of blood. The greatly dis- tended intestines are covered by a layer of fibrin and pus. In the pelvis, cover- ing the superior surface of the uterus and filhng up a large part of the cavity, is a mixture of pus, blood, and flakes of fibrin. Along the superior surface of the uterus a row of sutures can be seen, and on cutting into it there is a globular cavity about 2"5 centimeters in diameter filled with blood. On removing the superficial uterine sutures, pus can be squeezed from the cavities left by them. Both the anterior and posterior culs-de-sao are covered by a fibrinous exudate, which anteriorly is thick and hemorrhagic and can be stripped off from the peritoneum. The cavity of the uterus is normal. The tubes and ovaries are normal. Bacteriological Eeport . — Cover-slips from the catgut suture in the subcutaneous abdominal wound show numerous cocci arranged singly, in pairs or in bunches, and in chains. Some cocci are enclosed in polymorphonuclear leuco- cytes. Cover-slips from the uterus, spleen, liver, and kidneys are negative ; the small purulent abscesses in the lung contain myriads of cocci arranged in bunches and chains. The cultures show the presence of staphylococcus pyogenes aureus in the abdominal wound, in uterine mus- cle, kidneys, spleen, and liver, and also in the small puru- lent areas in the right lung. Cultiires from the fibrin in the pelvis yield two organisms — a coccus and a bacillus. This coccus on agar rolls forms pin-point white circular colonies. Cover-glass preparations show it to be streptococcus pyogenes. On potatoes, bouillon, and agar-slant it gives the typical growth of streptococcus pyogenes. The bacillus proves to be bacillus coli communis; this organism is also found in the kidney. If a patient is more resistant to the invasion of the infection, the character of the exudate assumes a distinctly fibrino-purulent character ; if the case is a pro- longed one, lasting for two to three weeks, the exudate is entirely puruleiit. - The last form is the least virulent of all, but at the best is always a most serious condition. According to Pawlowsky, the first evidence of resistance to micro- organisms on the part of the peritoneum is the throwing out of the exudate. If 88 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. the progress of the disease is slow he states that the lymph spaces become oc- cluded with the pyogenic organisms and inflammatory products, thus prevent- ing the invasion of other organs with the infecting germ. Modes of Origin of Septic Peritonitis. — These pyogenic or- ganisms may iind an entrance into the peritoneum in a variety of ways : First, from the liberation during operation of infected matter, as by the rup- ture of a pelvic abscess which has been walled off by adhesions. Second, from injury to the intestinal coat, which permits the direct escape of pus-producing germs from the bowel. Third, micro-organisms may be imported into the peritoneum from without by the surgeon or his assistants on the hands, sponges, instruments, ligatures, or accessories. Furthermore, several of these factors may co-operate in the same case to produce peritonitis. In a simple operation unattended with traumatism to the pelvic cellular tis- sue or viscera there is little to favor the growth of organisms, whereas in more extensive operations, when there is considerable oozing, or when hemorrhagic or other debris has been left in the peritoneal cavity, there is much greater dan- ger, and this matter serves as a rich pabulum for the growth of even a few or- ganisms which may have gained access. Symptoms . — Septic peritonitis following an operation does not manifest itself until the germs have had time to multiply and excite some systemic reac- tion. The signs of this are both local and general, depending respectively upon the reaction at the point of infection and the absorption of toxic by-products. The local reaction is a conservative effort on the part of K"ature endeavoring to limit the infection, and consists in a gaseous distention of the intestines which produces a marked tympany and so increases the intra- abdominal pressure and opposes a mechanical hindrance to the distribution of the septic fluid. This phenomenon can be readily demonstrated clinically by injecting a colored fluid into a lax peritoneal cavity and also into a tense one ; in the former the fluid will be found generally distributed throughout the cavity, while in the latter it will be localized in close proximity to the point of injection. As a result of the reaction there is an exudate of plastic lymph thrown out at the point of infection, which agglutinates the surrounding vis- cera and so tends further to impede or to limit the extent of the infection. In all cases where the peritonitis is not general its limitation is due to these ad- hesions circumscribing and seahng it off from the general peritoneal cavity. A pus pocket may be formed in this way on the floor of the pelvis, or laterally around the stump of a broad ligament, or on the site of an amputated or enucle- ated myoma, or posterior to the broad ligaments. In the rapidly fatal type of peritonitis the surgeon may hesitate between the diagnosis of hemorrhage, shock, and infection. In a case of virulent septic peritonitis following a sim- ple exploratory incision for carcinoma of the peritoneum the patient died within twenty-four hours in a state of profound depression without one of the local POST- OPERATIVE SEPTIC PEEITONITIS. 89 symptoms of peritonitis. Within five hours the toxic effects of the micro- organisms began to be manifest. The pulse at first rapid, rising from 10 to 20 beats an hour, grew irregular, and finally disappeared. The thermometer indicated only a temperature of 101° F. (38-3° C.) in the mouth, and yet the patient complained of distressing internal heat, which was explained by the rectal temperature of 105° F. (40-5° C). The heart sound was weak and irregular, the skin cold and clammy, and the fingers and hands assumed the typical appearance of the washerwoman's hands. These cases present a picture of the most profound depression of all the vital functions. In the less virulent cases the systemic effects of the absorption of the toxic by-products are indicated usually by a chilly sensation or even a rigor, and the pulse becomes rapid, small, and wiry. The rise in temperature is often abrupt immediately after the chill, reaching 104° or 105° F. (40° or 40-5° C), or it may not rise above 102° or 103° F. (38-9° or 39-5° C). After the first rise the temperature remains above normal, but the subse- quent elevation is moderate, rising higher in the evening than in the morning, although the diurnal variation is not usually more than one or two degrees. There is constant abdominal pain with paroxysms, recurring every few minutes and causing the patient to cry out. The appearance of the patient is characteristic ; her face is pinched and drawn, the eyes are hollow, and the expression anxious ; the skin is often dusky and the forehead is bedewed with sweat. In no surgical disease do we see a more typical Hippocratic facies than in septic peritonitis. Vomiting is one of the earliest symptoms and is fre- quent and persistent, the violent expulsive efforts causing severe pain through- out the lower abdomen, and especially in the line of incision. The contents of the stomach are first ejected, followed by yellowish or greenish bile, and this by a blackish fluid. Later the vomiting becomes more retching in character and only small quantities of flidd are expelled. The patient can no longer main- tain the prone posture on account of the increased pain caused by the tension of the abdominal muscles, and either lies with her shoulders elevated and thighs drawn up or turns on her side with the body curved forward and the thighs flexed on the abdomen. The thirst is often consuming and insatiable, and is not relieved even by the ingestion of large quantities of fluid, which the patient constantly craves, regardless of the fact that drinking makes the vomiting worse. The respiration is costal in type as the diaphragmatic movements greatly in- crease the pain. In the majority of cases the tympanites is extreme, although in some of the most virulent cases the abdomen may be quite lax. Usually the symptoms of septic peritonitis appear on the second or third day after operation, and run a course of from three days to a week, or may even be prolonged to eight or ten days, depending upon the virulence of the infection, the resisting and eliminating powers of the system, and the limitation of the inflammatory process by local barriers. All cases do not run the typical course just described. There may be marked variations in the most important symptoms ; thus the pulse at the outset may continue full and strong and but slightly accelerated, failing only after two or 90 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. three days. Vomiting may only occur at intervals of a few hours, and the stomach may even retain all that is administered by the mouth. Just before death, however, a liter or more of the fluid may be ejected, demonstrating the futility of giving medicine and nutriment by this avenue. Such cases simulate at their outset the simple, frank, non-septic peritonitis. In other instances the first symptom noted will be mild delirium, especially at night, indicated by a slight incoherence in speech, slowness of comprehension, or a peculiar somnolence. The cases in which the abdomen remains flat through- out the course of the disease are the worse forms of peritonitis in which there is no attempt at a local reaction, and the patients quickly succumb. Prognosis . — Diffuse septic peritonitis usually terminates in death. The most virulent form will kill the patient within twenty -four or forty-eight hours, but death occurs usually within four or five days. If the pulse continues rapid and feeble, ranging between 1-iO and 160, and there is no abatement in the fever for two or three days, the prognosis is bad. In such cases the pain is usually se- vere, the vomiting persistent, and the patient finally dies in collapse. In less aggra- vated cases the patient may live for eight or ten days and then die of exhaustion. A falling temperature and steady general improvement in the pulse indicate a favorable termination. In such cases there may be complete resolution, or a circumscribed collection of pus may remain as a sequel of the attack. Diagnosis. — In typical cases the tympanites, the constipation, the fever, the rapid and feeble pulse, the peculiar facial expression, and the vomiting are so characteristic of the affection that a diagnosis can be made without difficulty. A rapid pulse, excessive pain, tympanites, or persisting vomiting, may mislead the surgeon temporarily, but these conditions will be differentiated from a septic peritonitis in the absence of the other symptoms. Tabulated Symptoms of both Traumatic and Septic Peritonitis . — In view of the necessity of recognizing the essential points in the diagnosis of the two forms of peritonitis, I here tabulate the leading symp- toms of each. SIMPLE TRAUMATIC PERITONITIS. SEPTIC PERITONITIS. Symptoms follow directly upon operation. Symptoms often delayed two or three days. Pain often severe. Pain intermittent and excessive. Absent in worse forms. Tympany variable, generally not excessive. Tympany excessive, in bad forms often absent. Tenderness on pressure. Tenderness on pressure excessive. Vomiting occasional, but not as a rule excessive. Vomiting frequent, protracted and retching in character, like that of seasickness. Temperature only slightly elevated. Temperature usually high, remaining elevated, with slight or no tendency to fall. Pulse full and quickened, regular, not often Pulse rapid, feeble, rate increasing, running ^^°''^ 120- from 130 to 140 and above. Facial expression good. Facial expression pinched, anxious. Mind clear. Mind becomes cloudy, muttering in sleep, ten- dency to delirium. General appearance that of a patient not dan- The general appearance that of one extremely gerously ill. i^_ POST-OPEEATIVB SEPTIC PERITONITIS. 91 Treatment of Septic Peritonitis — Prophylaxis. — As the most important developments in surgery of recent years have been directed toward securing aseptic conditions in and about the field of operation, an im- perative obligation rests upon the surgeon to observe the most scrupulous care in keeping infectious material out of the peritoneum. To this end the field of operation, instruments, ligatures, sponges, dressings, and the hands of the sur- geon and assistants must be sterile and must be maintained in this condition. It is only by observing these precautions rigidly that the surgeon is relieved of personal responsibility. Under such conditions all the simpler abdominal opera- tions will run a favorable course. When the operation is directed against encapsulated septic foci within the abdomen, such as pyosalpinx and ovarian abscess, the purulent mass should always, if possible, be removed without rupture ; this can only be done safely when the sac is small and comparatively free. If the sac is large or adherent, it should first be emptied by aspiration and then enucleated. Sponges and gauze which have become contaminated must be discarded, and fresh ones packed in around the mass before finishing the enucleation. After the free pus has been removed, the hole in the sac must be closed by a suture, and the surgeon and assistants must wash their hands. During the evacuation of the pus only the surgeon and one assistant who handles the sponges should come in contact with it, the first and second assistants avoiding contamination as scrupulously as possible. When the collapsed sac is loosened and lifted up I slip a gauze bag over it several folds thick, pull the draw string tight around the neck of the tumor, and hold it protected in this way until it is completely taken out. If any septic matter escapes into the pelvis or gets into the abdomen, the lower or the entire abdominal cavity, according to the extent of the distribution, should be washed out with a normal salt solution at a temperature of 43-3 C. (110 F.). At the completion of the enucleation the peritoneal cavity should again be washed out with two or three liters of salt solution. Many cases are obviated by draining pelvic abscesses into the vault of the vagina instead of attempting a trans-peritoneal enucleation. Intestinal injuries occurring during the course of an operation must be care- fully sutured at once, in order to secure accurate union of the serous and mus- cular coats of the bowel, and so prevent the escape of septic matter from the bowel into the peritoneal cavity. The careful cheeking of all oozing must also be one of the cardinal prin- ciples in all these cases. The danger of fluids in dead spaces in the peritoneal cavity has been recog- nized for many years. Sims believed that it was the serous discharge which developed some toxic principle while stagnating in the peritoneal cavity that caused the frequent occurrence of post- operative peritonitis, and for this reason he devised a cannula for insertion into Douglas' cul-de-sac, to drain the serum and blood as it was discharged from the injured tissues. By the absolute control of all oozing we obviate the necessity for drainage, which is itself a cause of peritonitis. 92 COMPLICATIONS AKISIITG AFTER ABDOMINAL OPERATIONS. Handling the intestines and the parietal peritoneum must be avoided as much as possible, and if the intestines are exposed they should be covered with gauze saturated with warm normal salt solution, which must be renewed as often as it gets cool. The rough retraction of the walls of the abdominal incision with heavy metal retractors must be avoided. If there is the least question as to the thor- ough disinfection of the surgeon's or assistants' hands, rubber gloves boiled in soda solution, as first used by Halsted, must be worn. In all operations where frequent sponging is necessary, especially if reef sponges are used, the assistant in charge of this duty should wear gloves, and it will be safer if all but the operator are similarly protected. Sterilized white cotton gloves used in my clinic for the assistants who handle instruments and ligatures have been abandoned, as they failed to prevent the transference of any particles of matter from the hands to the patient. Kecent experiments show that gross particles may pass through the meshes. In view of the possibility of limiting the infection and arresting traumatic inflammation in its incipiency, the bowels should be thoroughly evacuated, for by this means the pelvic circulation is depleted and the absorption of extrava- sated blood and serum from the peritoneal cavity is promoted. The remedies suggested under the treatment of traumatic peritonitis may be employed at the onset of the symptoms of septic peritonitis, as the indications to be met at this time are the same in both conditions. The severity of the vomiting usually pre- cludes the administration of purgatives by the mouth, and often the enemata are repeatedly expelled only slightly tinged with fecal matter, and the bowels remain unmoved until death. When the distention of the abdomen is not extreme the constant application of ice bags over the lower abdomen during the early stage is of value in limiting the inflammatory process. Strychnin hypodermieally may be given, in the dose of one sixtieth to one fortieth of a grain every hour, to sustain the heart and the nervous sys- tem. Morphin may be used for the relief of extreme suffering or when a fatal issue is unavoidable. "Whenever the temperature rises above 38° C. (101° F.) sponging the body and limbs with cold or iced water will be of material assist- ance in limiting or reducing the temperature. The administration of food by the mouth is rarely of use, as it is usually vomited, or if retained it is not ab- sorbed. If, however, the intervals between the attacks of vomiting are not too short, a half drachm of liquid food, such as milk and limewater, may be given every fifteen minutes with the hope that some of it will be absorbed. The strength of the patient must be maintained by nutritive and stimulating enemata every six or eight hours, according to the tolerance of the rectum. Operative Treatment . — I heartily condemn the general rule of opening the abdomen as soon as a septic peritonitis is suspected. Often there is a mis- take in the diagnosis, and with a little patience untoward symptoms will subside and the patient will recover without operation, and in other cases the operation is hopeless from the outset, and the patient succumbs all the quicker because of it. POST- OPERATIVE SEPTIC PERITONITIS. 93 I know of no class of cases in which it is more difficult to decide when to operate and when not to operate, and, in spite of a wide experience and a careful study of all the clinical signs in each case, I still occasionally make, mistakes and open the abdomen to find no peritonitis where it was believed to be present, or, thinking the symptoms will subside, I wait until it is too late and the disease is beyond control. This liabihty to error is due to the fact that in its early stages a septic peritonitis may simulate a variety of simple complications, making a differential diagnosis absolutely impossible. If any definite rule could be laid down by which we could recognize a septic infection in its incipiency, the rule would be to reopen the abdomen at once and clean out the peritoneum and close up the abdomen, or in most cases clean out and drain, with the exception of a small group in which absolutely all that can be accomphshed has been done at the first operation. Such exceptions, for example, are incomplete operations and operations in which the patient is so ex- hausted that she can not possibly stand any further strain. A septic peritonitis in its earliest stages must be distinguished from excessive tympany, excessive nausea, excessive pain, unusual torpor of the bowels, unduly elevated temperature, and rapid pulse on the one hand, and from hemorrhage and auto -intoxication on the other. That surgeon will best differentiate his cases who unremittingly watches every symptom of the early convalescence and proceeds at once to meet any complication that may arise. Two points must be well weighed in the decision in every doubtful case — in the first place the character of the operation, and in the second place the condi- tions surrounding the operation — that is to say, the character of the technique of the operation. If at the time of operation the condition of the patient was bad and septic foci were opened up and the peritoneum widely contaminated, or if the in- testines required extensive suturing, then the decision that a post-operative septic peritonitis is under way will be more readily adopted than in a case where these complications were absent, for the percentage of septic cases is vastly greater after complicated than after simpler operations. Again, if the operation has been conducted under circumstances which pre- vented the carrying out of a satisfactory technique, as, for example, in an emer- gency case at the home of the patient, or, when the assistance has been poor, a septic peritonitis will be suspected, when in another case with similar symp- toms the absolute assurance that the technique has been perfect in all respects will give the operator courage to persist in a purely palliative line of treat- ment. A sudden severe intraperitoneal hemorrhage is marked by .symptoms of rapid collapse, anemia, small vanishing pulse, and precordial dis- tress with air-hunger. The sudden anemia and the remarkably rapid change in the pulse serve to distinguish this condition from peritonitis ; in either case the treatment, so far as it relates to opening the abdomen promptly and controlling the disease, is the same. 94 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. In the event of a slow hemorrhage the signs become most distinct with the onset of a peritonitis, when the indication is also to open the abdomen and clean out the peritoneum. Auto-intoxication by absorption of toxic elements from the intestinal tract sometimes closely mimics the severe forms of general septic peritonitis. The patient lies listless with a dark skin and sunken eyes, vomiting occasionally, with a quickened pulse, and some elevation of temperature and tympany which may be excessive. The chief differences lie in the fact that the expression lacks the collapsed pinched look of peritonitis, the vomiting is not usually of the persistent and bilious character, and there is no progressive change from bad to worse. Any gases which pass and alvine evacuations are intensely fetid. \ Other complications, such as tympany, nausea, pain, and sluggish bowels, are distinguished by the absence of the train of symptoms of a peritonitis. The onset of a septic peritonitis is usually noticeable within the first thirty- six hours ; the pulse rises 20 or 30 beats, the temperature goes up two or three degrees, tympany increases until the abdomen is distended as tight as a drum, and breathing is embarrassed; the abdominal pains recur at short intervals and vomiting increases in frequency, the stomach pouring out quantities of black bile. The bowels obstinately refuse to respond to every effort to secure a movement. There is soon a notable diminution in the quantity of urine passed, so marked in some cases as to induce the operator to think he may have tied a ureter. The expression of the patient shows that she is desperately ill, and in the later stages the appearance is that of collapse. In the worst cases the septic intoxication is so virulent that none of the reactionary symptoms have time to develop, and she dies without much vomiting, or any tympany at all, or any elevation of temperature. The pulse, quickened at first, breaks down sud- denly and runs up to 150, 160, and on up beyond counting. Whenever the patient is evidently going from bad to worse, and the symptoms point distinctly toward peri- tonitis, it will be best to operate at once. In a doubtful case it is important to begin at once in the effort to evacuate the bowels by giving calomel in a dose of 3 or 4 grains followed by an enema of half a liter of warm water and soapsuds containing about three ounces of sweet oil and half a teaspoonful of turpentine. Castor oil is sometimes a good addition to the enema, or a saturated solution of sulphate of magnesia may be given in a three-ounce mixture. When the pain is excessive small doses of morphin or codein in half -grain doses hypodermically must be used. Preceding an operation for septic peritonitis the abdo- men must be examined with the utmost care to discover any evidences of localized inflammation or suppuration. The vagina also must be examined for evidences of fix- ation of the cervix on one or both sides, or of any fluid accumulation just above the vaginal vault. POST-OPERATIVE SEPTIC PERITONITIS. 95 The discovery of a point of localization of tlie infection gives the operation a definite objective point and may limit its scope. The sthenic type of case, where the infection is still localized, offers the best hope of a recovery after a secondary operation ; in such cases there is evidence of a strong resistance to the infection, revealed principally in the pulse, which remains of good volume and advances in its rate but slowly, and the appearance of collapse is wanting. In suitable eases an examination of the abdomen will often reveal areas of hardness and fluctuation in the pelvis surrounded by tym- panitic bowels. A vaginal and rectal examination shows the presence of hard masses on one or both sides, and sometimes of fluctuation. There are, in general, two methods of procedure in the operative treatment of septic peritonitis— first, the evacuation of pockets of pus or fluid by a vaginal incision ; second, reopening the incision to clean out septic fluids. The flrst method is available in a small percentage of cases only, where an infection is localized on the pelvic floor. In such cases the incision may be made, when distinct fluctuation is felt through the vaginal vault. Prehminary to mak- ing the opening the vagina must be thoroughly cleansed ; the patient is then brought to the edge of the table and a free incision is made posterior to the cervix, opening up the abscess, which is washed out and drained for a few days with iodoform gauze. A finger in the rectum serves to protect the bowel from any injury during the operation. Where the infection is not clearly localized the better plan of procedure is to reopen the incision and so expose the wounded area in the pelvis, which is in almost all cases the focus of the infection. The choice of an anesthetic, indeed the propriety of using any form of anesthesia, is a question of vital import. When the pulse is rapid and feeble — running above 135 — and the patient is greatly depressed, no anesthetic should be given, or, at the utmost, but a few whiffs of chloroform when she begins to struggle after the incision is reopened. The production of complete anesthesia under these circumstances is often followed by heart failure, the pulse running higher and higher until it disappears. If the patient's condition permits the use of an anesthetic, chloroform is to be preferred to ether on account of its speedier action. A further objection to the use of ether is that cardiac failure, in a heart already depressed by septic poison, is more likely to follow the struggling and vomiting attending its administration than it is to occur from the depressing effect of chloroform. At first only the subcutaneous and one buried silver- wire suture are removed from the lower angle of the wound — enough to permit the introduction of the index and middle fingers. The lips of the wound are separated by the finger, or, if too adherent, by introducing scissors, spreading the blades. Especial care must be taken in reopening the incision to keep in the median line, and not to dissect up the tissues on either side. At the bottom of the wound appears the puckered peritoneum, vnth its con- tinuous suture, which should be lifted up with the dressing forceps and cut. Separating the peritoneum, the index finger is inserted, and if it encounters 96 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. adherent intestines, it is carried down under the abdominal wall and over the top of the bladder to the uterus and broad ligaments. Pockets of pus are readily recognized by the finger tips, and the nature of the discharge can be further verified by noting the character of the fluid with- drawn on the fingers. If there is a large quantity of fluid confined under ten- sion, it will gush forth from the incision as soon as it is opened. A small sponge on a holder may be used to remove this, observing the utmost care to avoid separating the coils of intestines adjacent to the purulent focus. A gentle bimanual examination should be made before closing the incision, with one finger in the peritoneal cavity palpating through the adherent intes- tines, and the other, protected by sterilized rubber gloves, introduced into the vagina. Other deposits are easily felt at the sides and broken open so as to discharge into the main cavity first opened. Irrigation should only be employed when the infection is so widespread that it can not be removed in any other way. Drainage is the mainstay in the treatment after operation ; sufficient gauze should be loosely packed in to fill the cavity, leaving one end projecting from the lower angle of the wound. If a generalized peritonitis is found the treatment must be even more radical. A sufficiently long incision to admit of easy access to all parts of the peri- toneum is made. Quickly withdraw the coils of small intestines from the peritoneal cavity, beginning with the worst coils. Remove all or as much as is necessary of the small intestine, and place to one side, covered with gauze or towels, thus practically disemboweling the patient- for the time being. Then thoroughly and systematically wipe out the peritonea] cavity with large pledgets of gauze wrung out of hot salt solution, paying especial attention to the pelvic portion. Next, the small intestine should be systematically gone over loop by loop, while still outside the abdomen, and rendered macroscopically clean by wiping with gauze compresses wrung out of hot salt solution. It is necessary to use a considerable amount of force at times, in order to remove adherent flakes of partly organized lymph. It should be done thoroughly and conscien- tiously, however, as upon this depends, we beheve, in great measure, the success of the operation. It facilitates the cleansing process, as well as lessens the shock of the operation, if the wiping of the intestinal coils is carried on under a con- tinuous irrigation of warm salt solution. After being cleansed macroscopically of all foreign material, pus, blood, lymph, etc., the intestine should be replaced in the abdomen ; if there has been any intestinal suture the worst or sutured coil is returned last, and left most superficial, in order that it may be the better drained by being packed about with gauze if necessary. The abdominal wound should then be sutured in the usual manner, leaving just room enough for the gauze drain. Six cases of general septic peritonitis have been operated upon up to the present time by Dr. J. M. T. Finney, the originator of this method, and five of them recovered. FEEMBNTATIOK AND SEPTIC FEVERS. 97 Fermentation and Septic Fevers. — " It is desirable to distinguish from septic peritonitis certain post-operative pathological and clinical states which arise in- dependently of the invasion, either of the peritoneum or the body at large, by pathogenic micro-organisms ; and it is further necessary to consider some of the more remote consequences of the development in the peritoneal cavity of pyo- genic bacteria." The terms septic intoxication, septicemia, and pyemia are by some employed more or less interchangeably to designate certain symptoms arising from a bacterial infection of the body at large. " Although septic intoxication can be separated more or less readily from septicemia and pyemia, the distinction between the two latter conditions, while important from a surgical standpoint and convenient from pathological grounds, is much more artificial." In septicemia small foci of degenerated cells and necroses of cells are often found within the viscera, and it is therefore not, as it is frequently described, a disease "without demonstrable lesions" in contradistinction to pyemia, which invariably shows foci of suppuration and necroses. Septicemia and pyemia may be but stages of one process, for in some cases pyogenic bacteria may gain entrance to the blood and circulate throughout the tissues, producing the characteristic symptoms of septicemia. The process may be held in check at this point, or it may go on to the formation of focal necroses or suppuration in the viscera at some point remote from the original portal of entrance, with the attendant symptoms of pyemia. Septicemia and pyemia are therefore but the generaUzation through the vascular system of the infection which has first been local ; for example, septicemia often supervenes upon a sep- tic peritonitis in its later stages, and septicemia or pyemia may be the result of an infected peritoneal wound. The organisms which most frequently produce septicemia and pyemia are the streptococcus, the staphylococcus aureus, albus, and cit- reus, the micrococcus lanceolatus, and more rarely the colon bacillus, the gonococcus, the capsulated bacillus of Fried- lander, and the typhoid bacillus. In surgical cases the last two organisms are rarely met with. Any of these organisms may produce either septicemia or pyemia, but the streptococcus is more likely to produce septicemia when it is the infecting organism. That the staphylococci are often present in local lesions without pro- ducing septicemia or pyemia is shown by the fact that they are frequently found in localized infections, such as stitch-hole and intramural abscesses, and rarely produce more than a local reaction, while patients infected with streptococci in the same situations rarely escape so easily. The grave puerperal infections are most frequently produced by the strep- tococcus, and the slow convalescence in these cases with all the accompanying symptoms of general invasion or infection are well known. There seems to be a larger variety of organisms capable of producing sep- ticemia than pyemia, for instance the proteus vulgaris may produce sep- ticemia, but thus far it has not been found in a true pyemia. 47 §8 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. Some of the specific organisms which usually are the etiological factors in inflammation peculiar to them may under certain conditions give rise to septice- mia. Such examples are furnished by the micrococcus lanceolatus and the gonococcus. That we can not take a particular pathogenic organism and say that it will invariably produce pyemia or septicemia is illustrated by the fact that the pneumococcus which produces in man localized inflammations, such as croupous pneumonia, etc., in animals tends to end in septicemia. Sapremia, according to the older conception of the term, implied that at some point in the body there was a focus of putrescent matter containing prod- ucts of decomposition, and the absorption from this area gave rise to the toxic symptoms. In these cases the symptoms were supposed to be due to the absorp- tion of toxines or ptomaines elaborated by the putrefactive bacteria, and not to the entrance of organisms themselves into the blood. More recent investigators have shown that this theory is not tenable because all pathogenic organisms are capable of producing toxic substances of one kind or another which are injurious to life. The by-products of the putrefactive bac- teria closely resemble in poisonous qualities those of the pathogenic bacteria, but in locally infected wounds the former are rarely met with while the latter are uniformly present. This forces us to ascribe the symptoms, frequently attributed to putrefactive intoxication, to the absorption of toxines elaborated by the more common pyogenic organisms. For this reason the terra "septic intoxication" is a better one under which to classify these symptoms, because it is sufficiently broad to include all conditions arising from the absorption of toxines produced by any forms of bac- teria. In surgical cases the chief agents of septic intoxication are the pyo- genic cocci, to which may be added the bacillus pyocyaneus and pro- tons, perhaps the colon bacillus, and among the anaerobic forms, which more closely resemble the putrefactive germs, the bacillus aerogenes capsulatus, the importance of which has not yet been sufficiently appreciated. The study of septic intoxication in human pathology is yet in its infancy, and sufficient discrimination has not been made by surgeons between the so- called sapremia and a form of intoxication which may arise from antiseptically treated wounds. Under the name "fermentation fever," Bergmann, Billroth, and Yolkmann have described certain symptoms due to the resorption of fermenta- tion products or of aseptic tissue necrosis. Yolkmann ascribes the rise of tem- perature after operations in which the wound remains aseptic throughout and after operation to the absorption of dead tissue. Bergmann invented the term fermentation fever for the mild febrile disturbances occurring after operations, believing that they were due to the absorption of fibrin-ferment. Edelberg and Angerer confirmed this theory by injecting blood or its pj-oducts containing fibrin-ferment into animals, and found that it was invariably followed by a rise of temperature. SEPTIC INTOXICATION. 99 When viewed from this standpoint the common rise of temperature follow- ing all operations of any magnitude can be much more easily accounted for than on the ground of septic infection, for it is not probable that under the painstak- ing technique of modern surgery all wounds should be infected sufficiently to cause this increase in temperature, while few operations are so slight as not to cause more or less cell death. The composite temperature and pulse charts which I have constructed of normal convalescence after abdominal operations show this characteristic rise for the first three days. From a clinical standpoint I will classify the febrile disturbances due to fer- mentation and septic products under the following headings : 1. Fermentation fever. 2. Septic intoxication. 3. Septicemia. 4. Pyemia. Fermentation Fever. — The rise in temperature produced by the absorption of fibrin-ferment and the products of aseptic tissue necrosis is usually slight and of but short duration. It is oftenest noted by the evening of the day of operation, and may continue from twenty-four to seventy-six hours. Obvi- ously the febrile disturbances following a simple abdominal operation would be much less than in those cases where extensive traumatism occurs. This slight rise of temperature (see composite charts. Chapter XXI) may be considered normal and need give rise to no anxiety. Septic Intoxication. — This condition, like fermentation fever, may arise shortly after operation or it may occur later when toxic products are pro- duced in the course of a septic infection. In abdominal operations, where pus escapes from abscesses and gains entrance into the blood either through the wounded tissues or through absorption from the peritoneum, the accumulated toxic products which it contains may give rise to a marked febrile reaction. In one case in which I opened a pelvic abscess which contained no living organism, the temperature rose abruptly to 105'5° F. (40'8° C.) in a few hours, remained at this point for about two hours, and then abruptly dropped to the normal. Associated with this febrile reaction are the usual symptoms of all fevers — dry tongue, thirst, scanty high-colored urine, flushed face, headache, and rest- lessness. If the symptoms are due to the temporary absorption of toxic prod- ucts they disappear with the subsidence of the fever. Until a marked amelioration of symptoms occurs, the surgeon will neces- sarily feel considerable anxiety, as these same phenomena occur in acute septice- mia. When the symptoms of septic intoxication arise three or four days after operation, the prognosis is more grave, because it usually indicates an active in- fectious process which has been generated in some part of the wound. The symptoms in these cases are more gradual in their onset, as the accumu- lated toxines are not thrown at once into the system, as occurs when an abscess is ruptured, but by a more gradual process associated with the multiplication of the bacteria. When the septic intoxication is severe the systemic disturbances are usually initiated by a chill. The temperature rises more gradually, and may not reach its acme until three or four days. The patient loses her appe- tite, the tongue becomes furred and dry, the skin is hot and dry, and the tern- 100 COMPLICATIONS AKISING AFTER ABDOMINAL OPERATIONS. perature may reach as high as 105° F. (40'5° C), with slight varying remissions. The urine becomes scanty, high-colored, and ranges in specific gravity from 1025 to 1030. Restlessness, insomnia, and occasionally delirium, may accom- pany the higher rises in temperature. In fatal cases the patient often sinks into a lethargic condition, which shades oflF into coma, while in others the symp- toms of profound shock predominate. The body is covered with a profuse perspiration, the extremities are cold, the pulse is feeble, fluttering, or inter- mittent. The prognosis depends entirely upon the local septic process. If the system overcomes the infection, or its source is ehminated by surgical interference, the symptoms quickly disappear, otherwise a rapidly fatal termination may occur within a few hours. The differentia] diagnosis between septic intoxication and septicemia can often be made by a bacteriological examination of the blood. Blood cultures and cover-slip preparations from the blood should be made ; the presence of bacteria indicates septicemia. The treatment in these cases is largely expectant ; if the patient can retain fluids, pure water should be given in abundance ; the use of the saline enemata, which should be given as a routine procedure after all abdominal operations, is of great service in diluting the poison and in assisting the kidneys to eliminate it rapidly. All remedies in these cases should be directed toward aiding the system to eliminate the poison. Unless there is an active intoxication produced by poisons which are being constantly elaborated at some point and thrown into the system, the symptoms will quickly subside. In all cases where toxic symptoms arise a few days after the operation, the dressings should be removed and the abdominal wound carefully inspected ; if it appears healthy, a vaginal examination should be made to ascertain whether there is a local point of suppuration in the pelvis. In the early stages of the infection the local infectious process may be inferred from an increased tender- ness or acute pain produced by the pelvic examination. Where a gauze drain has been inserted, either through the abdominal in- cision or through the vagina, the toxic symptoms may arise from the backing up of infected fluids, the drain should therefore invariably be withdrawn sufficiently to ascertain whether there is any retained fluid behind it. If nothing distinctive of sepsis is discovered the patient should be watched closely for the succeeding days when some point hitherto concealed may become sufficiently evident to localize it. If suppuration has occurred in the abdominal wall, it should be freely opened and repeatedly and thoroughly cleansed with peroxide of hydrogen. When suppuration is detected about the stump of an amputated uterus, or at the site of a pelvic operation, it may be reached and drained either through wide dilatation of the cervix or through a vaginal open- ing made in the manner described in the treatment of pelvic abscesses. After the abscess has been opened care should be observed to keep the passage patulous until the cavity has filled with healthy granulation tissue. To SEPTICEMIA. 101 this end a douche should be given daily, the curved glass nozzle inserted well into the abscess cavity. The duty should be attended to by the surgeon, and should not be relegated to a nurse. If the pulse shows signs of 'failure, infusions of normal salt solution should be given into the cellular tissue beneath the breasts, employing at least 500 to 1,000 cubic centimeters every twenty-four hours. Sulphate of strychnin in -jig- to -^ grain doses, depending upon the urgency for stimulation, should be given every two or three hours. Liquid diet should be frequently administered. The bowels must not be permitted to become con- stipated. Septicemia. — The same symptoms noted in septic intoxication are present in true septicemia, but in the latter condition they are more marked and may tend much more rapidly to a fatal termination. Septicemia may arise within a few hours after an operation, from a severe form of mycotic peritonitis or virulent infection of the external wound, or it may come on days after from some localized focus of infection, such as an intramural abscess or a suppuration in the peritoneal cavity. In an uncomplicated ease of hystero-myomeetomy, where I had every rea- son to believe that the operation had been properly conducted, the patient died within twenty -four hours of a virulent streptococcus infection. The symptoms were so severe, and so characteristic of profound shock, that the abdomen was re-opened, with the expectation of finding a post-operative hemorrhage. An- other case died almost as quickly from infection of the abdominal wound with virulent streptococci. In both instances the infecting organisms were found in the blood before death. Usually septicemia does not run so rapid a course, but shows more or less variation of the symptoms. The temperature may remain uniformly high with slight morning remission, or it may show wide variations. In some cases the temperature may run a typically septic course for a few days, then drop to nor- mal for a day or longer, and again resume its characteristic course. The following are typical examples of septicemia, in one instance following immediately after operation, in the other some days later. S. "W., 3304, colored, aged forty years. Diagnosis, myoma uteri. Opera- tion, hystero-myomeetomy, ISTov. 28, 1894. The operation was easy and uncomplicated, and the usual technique was carried out in every particular. Day of Operation . — Keturned to ward at twelve o'clock with a good pulse, 80 to the minute. N'o unusual symptoms following anesthesia noted until twelve midnight, when the temperature was 101-8° F. (38"8° C), pulse 120 and weak, and she complained of nausea and great pain. Second Day . — From midnight until morning the pulse steadily failed ; at 4 A. M. it was 138, small, and difficult to. count. At six o'clock, worse, tem- perature subnormal, body covered with cold perspiration, extremities cold, abdo- men slightly distended, marked tenderness on pressure ; the face was pinched and drawn, the tongue dry, and she lay in a profound lethargy. Under vigor- 102 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. ous stimulation and application of external heat the temperature rose to normal and the pulse improved slightly. At ten o'clock the abdominal stitches were loosened, followed by an escape of bloody, purulent fluid ; the stitches were then removed. Free pus extended down between the layers of the abdominal muscles and a small amount was found in the peritoneal cavity. Abdomen irrigated. A half liter of salt solu- tion was infused into the radial artery. She rapidly declined and died at eleven o'clock, twenty-four hours from the time of the secondary operation and three. days after the original operation. Abstract of Autopsy Notes . — Autopsy No. 595. Anatomical Diagnosis: Laparotomy wound for hystero-myomectomy ; wound infection, DEC. 17 18 19 20 21 22 23 24- 25 26 27 CO -J Q. 170 160 150 140 130 120 110 100 90 80 HOUR M c d ■# 5 3 E s 2 S 00 « s p. a a 00 a g S =3 d s a d s a S a oo a d a (3 107° 106 105° ui 104° t '03 < iij ° E. 102 S U o 1- 101 100° 99° 90° c o c o ■o n) a> Q. Q. n / A '\ ^ > ^ a 1 o .f ^ ^ ^ y "•. V, -» / y V- V en / ^ / / >. \ V / -^ -V /•'i J V '\ \ / N /"' y / \ S- / / \ \ A A \ ; / i V \ ^ -^ s ^1 ■>^ A ■^ ;J ^ ' V. .*- ^ ^ PULSE lOo/ X 81 / / 88 88 / /so in/ /8S / 90 92 y /l22 188/ /l3S 136/ /l34 140/' /l60' 152/ /l54 154/ /160' wo/ /158 156/ /l52 148/ /l52 156/ /160 164/' /l5S /164 156/ /^60 162/ /l64 Temperature . Pulse Fig. 330. — General Sepsis ekom a Focus of Infection in the Vagina eeom a Pekineal Operation. Sixth day wound opened up and drained ; death on the twelfth day. J. MoG., 1896. acute fibrino-purulent peritonitis, cloudy swelling of organs, fatty degeneration of heart, liver, and kidneys ; hydronephrosis on right side with early atrophic changes in the right kidney. On cutting through the abdominal wall in the muscles and external to them near the line of incision, yellowish-white pus exudes. On the parietal perito- neum in the neighborhood of the incision a fine deposit of fibrin is visible, and the cellular tissues in front of the bladder are markedly edematous. The serous coat of intestine is markedly congested, especially at points of contact ; fine and coarse flakes of fibrin are present on small and large intestine, especially over the lower abdomen. The upper part of the abdomen and peritoneum covering the SEPTICEMIA. 103 stomach and the hver is entirely free from exudate. The cervical stump and the peritoneum covering it show nothing to suggest this as the portal of entrance of the infectious agent. A small amount of clotted blood ex- ists beneath the peritone- um, which was stitched back over the stump. Bacteriological Examination . — Oover- slips from pus in wound and peritoneal exudate show cocci chiefly in pairs. Cultures from the ab- dominal wound, the peri- toneal cavity, heart's blood, kidney, lungs, spleen, and ureter, all show myriads of streptococci. The following case illus- trates the course of sep- ticemia of gradual onset and prolonged d uration : Gynecological No. 3110. A. M., white, single. Diagnosis. — Pelvic abscess, universal pelvic per- itonitis. Operation April 2, 1894. Enucleation of both ovaries and tubes and abscess sac. Complications, dense adhesions ; escape of large quantity of fetid pus and free hemorrhage dur- ing the operation. Incision 8 centimeters (3|- inches) long ; the intes- tine was raised out of pelvis, exposing the uterus right latero-flexed and a large •convex cystic mass filling 3snnd gi§828°g 'IU"B f ^- * l^O « ■uifii ^- — ■lu-dg N. < ivS in •lud t •V •U2t N \| w •iu-T?8 -^ ■XU"B f ^ ^ 1^ — -g-ei- - ■lUgl < r — ^u _1 ■ui-dg V L. •ui-df > ,> 0- •ugi ^ ^ 1^ ■IU"B 8 < i •IU"B f > { _ =>o to •UI3I • \ ^u •lu-dg -J \ 3 \ ■iu*d f •ej ■*' > •UZX > < o\2 O •tU"BS t- •ur« f "-1 J >^ S ■mzi ^ > ,a •m-dg < 1 1^ - •m"d f ■ s •UST < > ^ ■UI"BS ^ ■lU'l? 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CO _J O UJ z 3 "^ en D O ft* Eh EC H Ph ■< o 104 COMPLICATIONS ARISING AFTEE ABDOMINAL OPERATIONS. the whole posterior quadrant and posterior part of pelvis, between the uterus and the sacrum. The rectum covering mass all but small area — 3 by 1'5 centimeters — was dissected off without injury. The abscess then broke with the escape of 260 cubic centimeters of fetid yellow pus, caught on sponges and gauze. The hole was sewed up and the enucleation continued ; the friable tissue broke down, how- ever, and was removed piecemeal, leaving an extensive bleeding surface on the floor of the pelvis. The ovarian vessels were ligated and the left uterine comu excised and the vessels controlled by transfixion of the broad ligament low down. After checking the hemorrhage the mass was finally enucleated, with the internal iliac artery laid bare throughout its course. A pyosalpinx on the right side was then removed from a bed of dense adhesions. A gauze drain was inserted after thoroughly washing out the pelvis and abdomen with normal salt solution. Second Day . — Dressings removed, covered with a large amount of pale hemorrhagic discharge. When the drain was loosened a copious discharge of brownish-red serum escaped ; no distention of abdomen ; highest pulse 100, and temperature 101-4° F. (38-5° 0.) during the day. Third Day . — About three fourths of the drain removed, followed by a profuse and somewhat offensive purulent discharge. Highest temperature 101-4° F. (38-5° C), pulse 100. Fourth Day. — About eight inches more of the gauze removed, followed by bloody purulent discharge. Temperature and pulse same as preceding day. The general condition remained about the same until the thirteenth day, when the patient had a severe chill lasting half an hour, followed by a tempera- ture of 105-6° F. (40-8° C). The wound, although discharging freely, appeared healthy. ISTothing abnormal detected by vaginal examination, and she com- plained of no pain. Temperature dropped to normal, where it remained until the nineteenth day, when she again had a severe chill with a temperature fol- lowing it of 105-4° F. (40-7° C.) and a pulse of 144. Cold sponging used when the temperature rose. Yaginal douches (1-200) of bichloride of mercury solu- tion. By the afternoon the temperature had fallen to 99-3° F. (37-3° C.) and pulse to 100. Profuse sweating during the pyrexia. Later in the day had some headache. At midnight the temperature had risen to 101-6° F. (38-6° C.) and pulse to 108. Twentieth Da y .—Temperature at 10 A. m. 105-6° F. (40-7° C), pulse 128. Twenty-third Day . — Since last note temperature has ranged between 104-5° and 102° F. (40-2° to 38-9° C.) and pulse from 148 to 116. This varying temperature suddenly dropped to 101° F, (88-3° 0.) and pulse to 116. From the twenty-third to the twenty-eighth day the symptoms gradually subsided, until the pulse and temperature again reached the normal. The patient, who had up to this time presented the classical symptoms of a slow infection, now began to improve, but five days later had another febrile reaction, the temperature rising to 103° F. (39-6° C.) and the pulse to 120. The following day the temperature rose abruptly from normal to 106° F. (41-1° C.) PYEMIA. 105 and tlie pulse from 90 to 150, preceded by a severe chill and followed by pro- fuse sweating, nausea, and vomiting. Three days later the temperature again reached the normal, and continued so until the patient's discharge on the fortieth day after operation. At that time she had regained her appetite and showed all the signs of a rapid return to health. The prognosis in septicemia depends more or less upon the variety of the organism causing it and largely upon the immediate checking of its develop- ment by liberating the localized focus of infection in which it is generated. In cases in which the blood cultures or cover-glass preparations show streptococci the prognosis is exceedingly grave, for patients rarely survive such an infection. The staphylococcus aureus, while usually not dangerous so long as it is confined to a localized point, may prove very virulent when it gains en- trance to the circulation. The bacillus aerogenes capsulatus (Welch) is also a virulent organism, and usually produces death quickly. Under suitable conditions the pneumococcus and colon bacillus may become fatal. The treatment advised in septic intoxication should be carried out in septicemia. The greatest diligence should be observed in making a thorough examiuation of these cases in order to discover early the point of suppuration and to open it freely. Pyemia. — Pyemia is a general infection characterized by the occurrence of metastatic abscesses in parts remote from the original point of infection, and associated with recurrent chills and intermittent fever. Pyemia occurs in the course of suppurative processes and is due to the en- trance of masses of bacteria or of infected emboli into the circulation, which lodge in other parts of the body and produce metastatic abscesses. The symptoms are similar to those of a slow septicemia. The temperature shows a wide daily excursus, rising in some cases from normal up to 103° or 105° F. (39'5° to 40'5° C.) in the afternoon and then falling during the evening ■ to or near the normal. The rise in the temperature is preceded usually by a chill, which is so regular in its periodicity as to give rise to the belief in some cases that it is of malarial origin. I see perhaps no more common mistake than that of ascribing irregular temperature and recurrent chills produced by puru- lent collections to malaria. As the pyemic process increases in severity the chills which may have oc- curred only every two or three days now occur once or oftener daily. Following the cold stage there is a rise of temperature, which in turn gives way with the appearance of more or less profuse sweating. The fever is always of an intermittent or remittent type, and in some cases the temperature may fall below normal in the intervals between the chills. The pulse in its fluctuations corresponds to the rise and fall of the temperature, vary- ing between 100 and 150. 106 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. The patient is frequently nauseated and tlie appetite is poor. In severe cases delirium may be present, and occasionally tlie symptoms of a profoundly ty- phoid state appear toward the end of a fatal ease. As the infection progresses a characteristic yellowish color of the skin appears, due to the destruction of the red blood cells. Albumen and casts usually appear in the urine, and when abundant indicate metastatic abscesses in the kidneys. The symptoms of metastatic suppuration are varied ; when multiple ab- scesses occur in the lungs they may resemble those of a broncho -pneumonia. Suppurative pleuritis, purulent pericarditis, or endocarditis may arise at any time and cause a rapidly fatal termination. In acute pyemia the suppurative process is usually so rapidly fatal that only very small necroses and abscesses are found. As pyemia is not a primary but a secondary infectious process superimposed upon the original localized infection, the prognosis is always exceedingly grave. Cases so affected die with few exceptions. The focal abscesses forming in parts inaccessible to operation sooner or later produce a fatal termination. Treatment . — Under the aseptic treatment of wounds, pyemia has become one of the rarest post- operative complications. The treatment is unsatisfactory, because remedies have little or no effect in staying its progress. Stimulants and carefully regulated diet should be prescribed. The wound from which the pyemic process has arisen should be freely opened, if accessible, and kept as clean as possible by frequent irrigations with an antiseptic solution. Pleurisy.— Pleurisy is comparatively rare after celiotomy, but it does occur either alone or as a part of a septic infection. It is much rarer than pneumonia. One form of pleurisy is the tuberculous, associated with a tuberculous peritoni- tis ; in this case the onset may be insidious and masked by the peritoneal symp- toms so as entirely to escape recognition before operation. Septic pleurisy, contrary to expectation, is associated usually with the milder grades of infection ; it appears four or five days after the onset of the septic symptoms with an abrupt rise in the temperature, preceded by a chill and accel- eration of pulse. I have seen five cases of pleurisy in over twelve hundred sections ; four of them were mild and readily passed off. The fifth followed a difficult operation for the removal of large multinodular, subperitoneal cystic myomata weighing thirty -nine pounds. The patient made a rapid uncomplicated recovery, until she sat up in a chair by the window, when she was seized with severe pain in the left side, accompanied with some quickening of the pulse and a temperature of 102° F. and friction r41es. A week later there was a relapse with effusion. This quickly subsided, and was followed by complete recovery. Symptoms . — The symptoms are usually quite characteristic ; the patient complains of difficult and painful breathing on one side, accompanied by a short hacking cough. A physical examination shows a diminished respiratory move- ment and friction rdles. Treatment. — At the outset the pain may be relieved by a mustard PNEUMONIA. 107 plaster, a turpentine stupe, or a blister. The cautery is a still better counter- irritant, lightly drawn six or eight times over the surface ; great relief follows the application, and often there is no more pain. If the cough continues and respiration is painful, adhesive straps may be used to immobilize the affected side. I have never seen a large effusion needing to be tapped. The best pro- phylaxis is to keep the patient well covered and out of currents of air during her convalescence. Pneumonia. — C a u s e s . — Pneumonia following operations arises from expo- sure of the body during the operation, or from the irritating effects of an anes- thetic, or from the inhalation of foreign matter (inspiration pneumonia), or from the lodgment in the pulmonary capillaries of septic emboli from a focus of in- fection at the seat of operation. Pneumonia is often due to a prolonged and unnecessarily free use of the anesthetic, and is distinguished from the embolic variety by its coming on within the first twenty-four hours. It follows the administration of ether much more frequently than of chloroform. I have only once seen pneumonia after the use of chloroform. I have seen examples of the so-called non-septic pneumonia seven times in seventeen hundred cases ; six times the anesthetic used was ether, and once it was ether followed by chloroform ; in this last case the patient was in good con- dition for four days, when the respiration and pulse became rapid and the tongue dry and brown. Mucous and gurgling rales were heard over the base of the right lung, which was consolidated. The diagnosis was confirmed at the autopsy. In another patient (L. Y., 'No. 2677, March 29, 1894) a right ovary was removed containing pus, and the uterus suspended. On the second day in the evening the rectal temperature was 101'1° F. (38-38° C), the pulse 110, and respirations 30. Bronchial breathing was found over the right base, contrast- ing with normal breathing on the left side. Kesonance was good on both sides. There was no nausea. The temperature rapidly rose until the following morn- ing, when it was 104-2° F. (40-1° C), with the pulse at 140 ; on the even- ing of the same day the thermometer registered 105-4° F. (40-7° C). The res- pirations were now 60, and the patient complained of much pain on inspiration. Three hours later she began to cough and expectorate rusty sputum, and had pain in the chest on deep inspiration. Her temperature continued the next day to 104-5° F. (40-7° C.) ; pulse 144, dicrotic, full and bounding, and respirations 60. The upper part of the right lung now showed typical signs of consolida- tion. There was no distention of abdomen or abdominal pain. On the fifth day she was looking and feeling better, and had little cough ; the lower lobes remained free ; temperature 99-2° F. (37-3° C.) ; pulse 108 and full ; constant improvement from this time on. The temperature was normal and the pulse 104 the next day. There was no abdominal complication throughout. The accompanying temperature and pulse chart shows the characteristic course of the disease. The prognosis of a pneumonia resulting from an anesthetic is favorable ; it usually begins with a bronchitis and runs a typical course, soon reaching a crisis. 108 COMPLICATIONS AKISING AFTER ABDOMINAL OPERATIONS. I have seen two deaths from pneumonia after operation, one the ease of an old woman who had had a severe attack of bronchitis just before the opera- tion, and to whom the ether was given by an inexperienced man who saturated the patient with the drug ; the second followed a hysterectomy for carcinoma, and was severe from its onset, the patient dying on the fifth day from heart failure. MARCH APRIL DAY OF MONTH 29 30 31 1 2 3 4 5 6 7 8 9 u ISO 140 ISO 120 110 100 90 80 DAY OF >PERATIOr 1 2 3 4 5 6 7 8 9 HOUR 8 12 6 12 6 12 6 12 12 G 12 6 12 6 12 6 12 12 6 12 C 12 12 c 12 c 12 12 G 12 12 105° 104° m 103° DC = H 102 S 101° s Li Q H 100 99° 98 A A P I -v r J '\ R r r V ; 1 I 1 \y /^ S- ^ N] / \ / / h 1 V V V X f 1 ^. •| 1 ; I \ A 1 f \ \ V J \ V V <, ) l\ 1 I V /- r -A \, ^ 1 \ \ V iJ ll '^ ->, f- ^ / n/ \! k ^ r ^ ^ 1 PULSE M./ 88 / /80 91/ /120 138/ /l40 142/ /142 /lU. 140/ /112 130/ /123 128/ /l36 132/ 120/ /ll8 104/ /fia 108/ /l21 120/ /120 112/ /l04 100/ /loo 100/ /ioo 98 / /8S / / RESP. 20 20 22 30 60 60 60 58 50 48 50 40 38 28 28 24 22 STOOLS 3 1 1 1 1 1 URINE 150 cc. 700 cc. 800 CO. 100 CC. 610 CO; Lost 860 CO. 61000. 430 CO. .Temperature Pulse Fig. 332. — Chart showing an Abdominal Opekation Complicated by Pneumonia. Initial chill on the third day and cri,sis on the sixth day, with normal temperature on the ninth day. Op., right salpingo-oophorectomy and suspensio uteri. March 27, 1894. L. Y., 9572. In septic cases embolic pneumonia may arise many days after the operation, and, if mild, may terminate as an ordinary pneumonia. It often appears also simply as a concomitant of a general septic infection, when it is only one of the determining factors in producing a fatal issue. Symptoms . — In septic pneumonia the symptoms come on gradually and are so closely associated with those of the general septicemia that they may escape notice. In two cases of pyemia under my observation disseminated patches of septic pneumonia were discovered at the autopsy, although a careful physical examination of the chest had failed to reveal the fact before death. The first symptoms usually appear four or five days or longer after the septic process is under way; there is a slighi hacking cough, followed by muco- purulent expectoration, and more or less dyspnea, at times distressing in its severity. The character of the pulse, as a rule, affords no information as to the ILEUS. 109 thoracic disease, because it is already rapid from the toxemia ; the physical ex- amination is also unsatisfactory, for the isolated pneumonic patches often give no demonstrable signs. The prognosis is grave, as the complication is but an evidence of the general infection. Treatment . — The treatment of the simple lobar pneumonia is expectant and stimulant. At first it is weU to give rehef by controlling the excessive coughing with codein in doses of one fourth to one half a grain ; this allays irritation without checking expectoration. A cotton jacket to protect the chest is essential, and should be applied from the first and worn well into the convalescence. If there is much pain in the chest, the application of turpentine stupes and a mustard plaster will give great relief. The condition of the heart must be watched, and at any sign of failure stimulants must be given freely. A whisky eggnog affords both nutrition and stimulation ; strychnin in the dose of one fortieth of a grain should also be given every two or three hours. On account of the risk of heart failure, abso- lute rest in a recumbent position must be enjoined. In septic pneumonia the treatment should be of a vigorously supporting nature. In addition to strychnin and whisky or brandy, the most nutritious food in concentrated form must be given by mouth or rectum. Quinin in five- grain suppositories may be given night and morning, with apparently good effect in some cases. Ileus. — Ileus arising after operation is the result of an interference with in- testinal peristalsis by one of the following causes : Either by the strangulation of a knuckle of intestine under a band of adhe- sion, or by an adhesion of the bowel to a raw surface, or by adhesions of the bowels among themselves about a septic focus, or by the incarceration of a loop of the intestine through a hole in the omentum, or, finally, by a simple twist of a loop of the bowel on its axis. Symptoms . — The first sign of an ileus is a griping pain more or less local- ized over one area of the abdomen ; it occurs in paroxysms and may recur every two or three minutes, beginning gradually and increasing to a maximum of intensity and then subsiding. At the onset of the paroxysm the patient as- sumes an expression of intense pain, and as the acme is reached she often cries out. The peristaltic wave can be readily seen in patients with very or moderately thin abdominal walls, which are most distended above the obstruction. If the obstruction is partial, fiuids and fiatus are forced through with a gurgling sound, often audible at a distance from the bed. The tense muscular contraction of the peristaltic wave can be felt by the hand, giving at times the sensation of a dense fibrous tumor. After a paroxysm the patient lies prostrated, bedewed with a cold sweat. One of the most important symptoms is the diSiculty of moving the bowels. One or two passages may be secured at first from the lower bowel, but after this there is no further evacuation, and purgatives only increase the vomiting. 110 COMPLICATIONS ARISING AFTEE ABDOMINAL OPERATIONS. The nausea and vomiting are distressing from the beginning. The con- tents of the stomach are first ejected, and later, when the vomiting becomes more frequent and violent, the ejecta consist of small quantities of bile and mucus, followed by dark fluid with a strong stercoraceous odor, and at last by liquid fecal ejecta. The abdomen soon becomes swollen, tympanitic, and tender. The patient is rapidly exhausted, and toward the last the vomiting may cease, but the gynecologist should not be misled by this delusive calm, as it is usually but a precursor of collapse. At the last the. extremities grow cold, the eyes look sunken and the face pinched, while the pulse becomes rapid and shotty. If the ileus is not speedily relieved, the patient may die either from exhaus- tion or from gangrene and peritonitis. Apart from a septic complication, the patient may live many days with an ileus, especially if the strangulation is in- complete. A woman in a weakened condition before the operation succumbs much sooner than one whose vitality is unimpaired. Diagnosis . — That a correct diagnosis should be made at the earliest pos- sible moment is of the utmost importance, as upon this hinges the immediate active treatment. First of all, ileus must not be confused with an aggravated tympanitis, which often gives rise to symptoms like those of intestinal strangu- lation. In these cases we find the abdomen swollen and tender, and the bowels at first resist all efforts to empty them, whether by mouth or by enema, and there may be also persistent nausea and vomiting. If to this we add the intes- tinal tormina common during the first few days after an operation, the picture of an ileus in its early stages seems almost complete. In tympanites, however, the general pain is not often severely paroxysmal in character, the pulse is but little affected, the general condition is not that of profound depression, and there is an entire absence of the characteristic facial expression of ileus ; finally, persistent efforts at evacuation of the bowels are followed by a copious move- ment. Until this is obtained there is sometimes ground for anxiety as to the correctness of the diagnosis. The differentiation between ileus and peritonitis may be easy or it may be diificult, especially since both conditions may be present at once. The ileus in the case of infection arises from the adhesions formed about a septic focus, which represent a conservative effort to limit the spread of the infection. The rise in temperature and quickened pulse are here the most marked evidences of the complication. It must be remembered that an ileus may be incomplete, when the intestinal contents will be forced on in small quantities and the bowels may be slightly moved at intervals. Such a case is the following : Ileus due to incarceration of a loop of small intestine through a hole in the omentum due to the Trendelenburg position. The patient (M. C, 2193) was operated upon Sept. 11, 1893, for pelvic peri- tonitis, with cystic ovary and tubes bound down by dense adhesions. In placing her in the Trendelenburg position a loop of bowel slipped through a hole in the omentum and was not discovered in closing the abdomen. The next day she ILEUS. Ill complained of much pain in tlie abdomen and slight nansea ; pulse, 92. Two days later, pain, distention, and nausea ; bowels slightly moved on this and the following day. Two days later, pain not so bad ; still vomiting. Slight fecal odor of ejecta, intense thirst, less tympany ; general condition improved ; pulse, 100 ; temperature, 100° F. Sixth day, vomiting. Stomach washed out, bringing 1-5 liters blackish fluid ; nausea relieved. Abdomen greatly distended in epigastrium ; tongue red, dry, swollen ; much thirst and griping pains ; small dark fluid movement. Ninth day, distention less ; lavage daily, ofEensive ejecta with fecal odor. Pain not much, but restless ; flatulence marked ; enema effectual yesterday and to-day. Eleventh day, almost constant paia, with frequent paroxysmal attacks not defi- nitely located. Large fluid bowel movement. Thirteenth day, semi-formed in- voluntary movements. Sixteenth day, several movements and frequent vomit- ing, at one time 600 cubic centimeters of fetid liquid ; anxious expression ; much thirst; tongue red and dry. Seventeenth day, abdomen opened above umbilicus, exposing greatly distended small intestines. Tense band found on left side, cutting across bowel and extending down to the left kidney. This was divided and an adherent knuckle of intestine freed from the left lower abdomi- nal wall, with the escape of grumous fluid ; counter-puncture with drainage of this area. The patient died on the twenty -second day after the original operation, and the autopsy revealed a loop of intestine 25 centimeters (10 inches) from the ileo-cecal valve, projecting through an omental hole. The following is a typical case of a late ileus due to adhesions between the small intestine and the uterus about the stump of a myoma : The abdomen was closed vnthout drainage. The patient made an uncom- plicated recovery, and the sutures were removed on the seventh day, but on the twelfth day she began with a moderate tympanites and vomiting at long inter- vals. Peristaltic movements were noticed through the abdominal walls, but there was no pain as yet. There was a copious movement on the eleventh day. The pulse was good, the tongue moist, the temperature normal, and the general condition good. On the next day (the thirteenth) she had pain in lower abdo- men, but seemed otherwise quite well. Fourteenth day, no movement since the eleventh day, in spite of eight grains of calomel, soap and oil and glycerin enemata. As the abdomen became more distended and the pain increased with the constant gurgling, and a marked bulging was felt in the pelvis, she was put in the knee-breast position under anesthesia, and by compression and massage the liquid mass was gradually forced out of the pelvis up into the abdomen. This was followed by an evacuation and great relief until early the following morn- ing, when the symptoms returned with stercoraceous vomiting. I then opened the abdomen and found numerous coils of small intestines densely adherent about the pedicle. The coats appeared gangrenous, and were torn in detaching them, necessitating a resection of 15 centimeters (6 inches) of the bowel ; she died five days later. 112 COMPLICATIONS AEISING AFTER ABDOMINAL OPERATIONS. In uncomplicated ileus the temperature is but slightly or not at all elevated, while in peritonitis there is a definite febrile reaction. In peritonitis a study of the chart will usually show an elevated temperature of longer duration ; the pain is not focal but more diffuse, and lacks the dis- tinctly paroxysmal character. The vomiting is also more continuous, and the pain is the result of the act and not independent of it. Location of the Ileus . — It is important not only to diagnose the ex- istence of an ileus, but as nearly as possible to locate its position. If the stop- page is in the rectum or in the sigmoid flexure, this will be evident by the more uniform distention of the abdomen and the less frequent retching and lessened pain. In most cases, however, the ileus is due to the pinning down of a knuckle of the small intestines to some point in the pelvis. In such a case the s t r i c- ture or the adhesion will be found just below the mass of distended intestines. The seat of the obstruction, therefore, is not to be located in the distended gurgling mass of intestines, but in the flat, quiescent part of the abdomen below them. The prognosis in these cases is always serious, but lessens in gravity the earlier the diagnosis is made. The surgeon is not justified in opening the ab- domen before trying to secure an evacuation of the bowels by mechanical agents unless the symptoms are so pronounced that he can be certain of his diagnosis. In eighteen hundred abdominal-section cases, I have reopened the abdomen four times for ileus ; two of the cases recovered and two died. I attribute the successful results to the early diagnosis and operation. Treatment . — Prophylaxis is the most important point in the treatment, as an ileus can often be prevented by the adoption of certain precautions and rules at the time of the original operation, which I would epitomize as follows : 1. All knuckle adhesions of the small intestine which are found must be released. 2. Adhesions binding the small intestines to the pelvic floor and walls must be freed. 3. All peritoneal bands must be severed. 4. Openings in the omentum must either be closed by suture or excised, or the omentum tucked up close to the colon, taking care at the end of the opera- tion to see that no loop of bowel has slipped through it. 5. As far as possible, all denuded surfaces must be protected by perito- neum. 6. When the intestines have been lifted out they must be replaced carefully, restoring them with their mutual relations undisturbed ; this is best done by float- ing them in water poured into the abdomen. 7. A sound omentum must be drawn down between the intestines and the abdominal incision to protect the former. 8. A loop of intestine twisted on its mesentery must be restored. 9. The pelvis must be filled after an operation as far as possible by rectum and sigmoid, to the exclusion of the small intestines. ILEUS. 113 General adhesions binding loops of intestines together in their normal mutual relations need not be broken up, as the peristalsis is not interfered with, and the extensive dissection serves no good purpose. One way of covering in extensive raw areas on the floor of the pelvis, created by the enucleation of adherent tubes and ovaries, is to put the uterus over them in retroposition, presenting its smooth anterior face to the intestines above. When the elevated pelvic posture is used there is always danger of a loop of intestine dropping into an adventitious opening in the omentum. For this rea- son the relation of the omentum and the bowels must always be looked into at the close of the operation. The last steps before^ closing the abdomen are : First, to lift the small intes- tines out of the pelvis, and place in the pelvis the rectum and any redundant sigmoid flexure, so that if any adhesions form they will neither produce discom- fort nor interfere with function ; and second, to see that the small intestines are arranged in the lower abdomen beneath the omentum without any twisting on the mesentery. Enemata and Medicines . — As soon as the signs of ileus are noted the efforts must at once be directed toward securing a free movement of the bowels by brisk purgation. To this end a large dose of calomel is given by the mouth, and high enemata of soap and water, with a drachm of turpentine to the pint, are given hourly. Eochelle or Epsom salts may be given in half -ounce doses every hour after the calomel. To reheve the paroxysmal pains, turpentine stupes on the abdomen are val- uable. If these measures fail at first it is best to wait a few hours and then try again, in case the patient is in good condition and shows no signs of weakening. If the vomiting is not frequent and the patient can retain and absorb nourish- ment, it is well to wait longer — even two or three days. If, on the other hand, the signs are urgent and there is a marked increase in pulse rate, with parox- ysmal pains and persistent vomiting becoming stercoraceous, the indications are for an immediate operation. Operative Treatment . — Every precaution must be observed to pre- vent shock. Chloroform is the best anesthetic on account of its rapid action, and the patient should be anesthetized on the operating table. Hot blankets niust be wrapped about her and the external heat kept up by hot-water bottles. If the abdominal dressing has not been removed since the first operation, it will not be necessary to cleanse the abdomen again. Having noted as accurately as possible the position of the suspected ileus, two or more stitches are cut and the wound reopened. If adhesions are detected, a larger opening should be made if necessary to facilitate rapid work. The loops of the intestines are drawn out and laid on hot gauze and inspected. The operator must be slow to conclude that the ileus is due to a slight twist in the intestines, only accepting this as a cause after a careful search has failed to reveal more definite causes, such as strangulation under peritoneal bands, and adhesions in the pelvis. All adhe- sions must be handled with the utmost caution for fear of tearing ofl: the coats of the bowel. 48 114 COMPLICATIONS ARISING AFTEB ABDOMINAL OPERATIONS. The site of the obstruction if not at once apparent, must be sought in an orderly way from below upward. The iirst point to inspect is the ileo-cecal valve. If the small intestine is collapsed here the bowel is then passed rapidly through the fingers until the border be- tween the collapsed and the distended portion is reached, where the cause of the stricture will be found. After removing the obstruction between the collapsed and the distended parts of the bowels the abdomen must be closed at once. In one case the obstruction was in the rectum just above the ampulla. When the intestine is adherent to the pedicle of a cyst, to the uterine stump, to the broad ligament, or to the abdominal walls, and there is danger of tearing it in the separation, the former structures to which it adheres must be sacrificed as far as possible and left sticking to the intestine, rather than risk a laceration requiring extensive suturing of the distended thin-walled bowel. Separation of adhesions between loops of intestines should be done with the greatest care, and, in case an unavoidable injury to the muscular coat occurs, it should be repaired with fine silk sutures. The straight round needle threaded with iron -dyed silk is the best for this purpose. If the lumen of the intestiae has been opened, it is usually safer to put in a gauze drain on account of pos- sible sepsis. If at the completion of the operation the patient is much shocked, the ab- dominal wound is best closed rapidly by silkworm-gut sutures, including all the layers, and in urgent cases the superficial sutures between may be omitted. The patient should be put back to bed, stimulated, and kept warm. It is not well to hasten an evacuation of the intestines after such an opera- tion, as this will often occur spontaneously in twelve or twenty-four hours, if the ileus is relieved. If the upper bowel has been sutured, most of the alimentation sfiould be given by rectal enemata for five days after the operation, and only small quanti- ties of liquid food should be given by the mouth. Where the rectum, sigmoid flexure, colon, or lower end of the ileum are involved I prefer to give all the food by the mouth. In any case foods should be selected which are almost wholly assimilated and leave almost no residue, or which do not tend to cause constipation or produce flatus. Nature is our great assistant in these cases, for the adhesions between the peritoneal surfaces are rapidly formed and the injured parts protected. In one case I tried suspending the patient by the heels, hoping that gravita- tion would drag the adherent bowel out of the pelvis. I also powerfully aided the suspension by an active bimanual manipulation of the intestines through the vagina and rectum, and rectum and lower abdomen. The facility with which the adherent coils could be felt and manipulated was remarkable, but the adhesions were so many and so dense that no impression was made upon them. Stitch-hole Abscess and Suppuration in the Line of the Incision. — Suppuration in the line of the abdominal incision and stitch-hole abscesses usually appear within ten days after the operation, as the result of an infection which ends in STITCH-HOLE ABSCESS AND SUPPUEATION IN THE LINE OF INCISIOlf. 115 the formation of an abscess on one side of the incision or causes a separation of the Ups of the wound. The defect in the tissue is healed by a slow process of granulation and cicatrization, and the result in some instances is a broad, stellate, unsightly scar. These abscesses usually form in the superficial layers of fat, to which the in- fection easily gains an entrance by means of the skin sutures. Abscesses located close to the surface become quickly localized, point into the incision, or to one side of it, and discharge. They may give rise to such symptoms as slight local discomfort and slight elevation of temperature (see chart, Fig. 333), but they are often overlooked until a little pus, sometimes not more than a drop or two, is found on the dressing. When, however, the suppuration occurs in the muscular tissues, forming a true mural abscess, the symptoms are usually pronounced and JUNE 10 II 12 13 14 15 16 17 18 19 20 21 111 vt -1 0. 120 110 100 90 80 70 60 DAY OF >PERATIOA 1 2 3 4 5 6 7 , a 9 HOUR G 12 6 12 6 12 Ij 12 c 12 6 12 G 12 G 12 G 12 6 12 6 12 G 12 6 12 G 12 G 12 G 12 G 12 102° 101° 111 a: ^ ^ roo < u 99° a. S m 98 97° o c A \ s ■a 3 'e -o f- V > A N ^ ^ v- -V •^ y y ^ \r V ■^ \ < Q. 3 CC o O / r 1 ,\ ?^ / ^ V A \ / ^ s y -N V y. / \ V A / A \. ^. ^ A V V- — '' \ r ^ — ^ ^ / V \_ J \ / \ j V / PULSE X r 96 / /98 91 / /s8 98/ /l08 100/' /l06 loo/ /94 lot/ /ss 88 / 90/ /so 80 / /88 93 / /ss 88 / /88 90 / /88 88/ 100/ /lOC 118/ /92 96/ /88 92 / /]00 100/ /98 STOOLS 1 5 1 1 URINE 250 cc. 345 cc. 695 CO. 740 CO, 590 CC. 600 CC. 720 00. 800 00. 850 CC. .Temperature Puis Fig. 333.— Stitoh-hole Abscess Chart. The chart shows a practically normal course until the sixth day, when a stitch-hole abscess begins to develop. There is a decided rise of temperature for three days, followed by an abrupt decline when the abscess ruptures on the ninth day. Op., hystero-myomeotomy, complicated by double pyosalpmx. Gyn. No. 4441. progressive, and, if the infectious matter is not liberated early, may even end in death either through the extent of the abscess or by its discharge into the peri- toneal cavity. Grawitz, from experiments upon animals, concluded that a localized collection of pus in the abdominal wall communicating vsdth the peritoneum could produce the most fatal form of peritonitis. Fortunately, however, the abscesses seldom follow this course. In a series of seventeen hundred abdominal sections in the Johns Hopkins Hospital, three deaths from peritonitis were attributed to stitch-hole abscesses communicating with the peritoneal cavity. 116 COMPLICATIOH"S ARISING AFTER ABDOMIlfAL OPERATION'S. Causes . — The limitation of this post-operative complication depends more upon the care observed in preserving the vitality of the tissues in the line of the incision and adjacent to it than upon the mere exclusion of infectious germs. Unnecessary handling of the wound, rough retraction of its edges and prolonged pressure with metal retractors, carelessness in checking bleeding in the incision, strangulation of large bits of tissue by ligatures, and the use of sutures penetrating the skin in closing the incision, all conduce to the formation of stitch abscess. In a prolonged or difficult operation the vital resistance of the skin and underlying tissues is often greatly impaired by the retractors. Every autopsy upon serious operative cases in which prolonged retraction has been made shows marked discoloration of the tissues not only of the abdominal incision, but also of the parietal peritoneum adjacent to the incision. To avoid this bruising as much as possible, the incision should be long enough to permit of the freest manipulation and inspection of the field of operation without making undue pressure to expose it. Every bleeding point in the incision must be checked, as, notwithstanding the greatest care observed in obliterating all dead spaces, small lacuhse are likely to be left behind, where blood may accumulate and offer a focus for infection. It is a good rule to tie every actively bleeding vessel as soon as it is cut. Liga- tures of fine catgut, which are quickly absorbed, are the best, and only enough force should be used in tying them to stop the bleeding. Large areas of tissue must not be included in the ligature. In one hundred and twenty-five cases of suspension of the uterus, only one ease showed even a drop of pus. This is the most favorable of all operations, as all of the conditions requisite for perfect healing are fulfilled, there being a mini- mum of traumatism, no prolonged handling of the tissues, slight bleeding, and little danger of infection. A noteworthy instance of a profound depression of the general system on account of a wasting or chronic disease, and a consequent failure in resistance to infection, is seen in carcinoma of the uterus. In 20 per cent of cases of abdomi- nal hysterectomy for carcinoma in the Johns Hopkins Hospital, the abdominal wounds have showed some degree of suppuration. Pus eases, contrary to the natural supposition of the clinician, are infre- quently followed by a stitch abscess, which may be due to the immunization of the patient by the preceding septic process, but more probably depends upon the fact that most cases contain no living organisms. The active infecting germs in the great majority of stitch abscesses are the staphylococcus epidermidis albus and the staphylococcus aureus. The impossibility of ridding the skin of the staphylococcus albus makes it a constant factor to be feared as a possible source of infection in every case. "While it is normally a feeble pyogenic coccus, under certain conditions it may become more actively pathogenic. STITCH-HOLE ABSCESS AND SUPPURATION IN THE LINE OF INCISION. 117 Symptoms . — The first symptoms are usually observed from four to five days after the operation. The patient complains of abdominal pains, and an ele- vation of temperature follows, while the pulse does not rise in proportion. A severe rigor may be the initial symptom ; the temperature, instead of fall- ing normally, as shown in the composite chart in Chapter XXI, may rise even four or five degrees. The pain becomes more acute and locahzed in a day or so. These symptoms may continue several days, when, if the nature of the trouble has not been suspected, a sudden relief is experienced, and on opening the band- age, pus is found oozing in quantity from the wound or a stitch hole. If the in- fection is widespread, several stitch-hole abscesses are found, from each of which thick creamy pus may be squeezed. If the wound is inspected at the onset of the symptoms, a circumscribed red painful induration will be found at the focus of infection, limited to one side of the incision or about a suture. Later it may involve the entire wound and even occupy an area as large as the open hand. After the pus has escaped the abscess may heal in a few days. In other cases the large wound cavity continues to discharge profusely for weeks. It is possible (and this must always be borne in mind) that the discharge, in- stead of breaking through on the skin surface, may burrow into the peritoneum, where it at once produces a purulent peritonitis, and, on opening the abdomen, pus can be seen oozing out through the stitch-hole onto the peritoneal surface upon pressing on the wall. All infections are not so severe as those just described, for not infrequently there is a small abscess in the superficial part of the wound, forming a shallow pocket not larger than the end of the little finger and containing a drop or two of muco-purulent discharge. These slight areas of infection are of no moment, and give rise to no symptoms. Diagnosis . — The diagnosis is simple ; inspection and palpation of the abdominal wall reveal a localized point of induration sensitive to pressure, ex- hibiting the classical signs of acute inflammation, heat, swelling, and pain. Only a deep-seated abscess between the muscles and peritoneum can confuse the diag- nosis by simulating a localized infection about the pedicle of a pelvic tumor. The superficial induration and the localized pain are sufficient to remove the doubt. As the symptoms may not always definitely indicate the real cause of the pain and elevation of temperature, it is important in all cases of post-operative fever. to search for an abscess in the ab- dominal wall. Treatment . — My experience with various methods of suture has con- vinced me that where it is avoidable a penetrating suture of the skin should not be used. In a series of seven hundred abdominal section cases I employed a continu- ous suture for the peritoneum, and penetrating sutures of silkworm gut for skin, fat, aponeurosis, and muscle. Since the adoption of the method of suture de- scribed in Chapter XX, in which the peritoneum, aponeurosis, subcutaneous tis- sue, and skin are brought together by separate layers of suture, I find by a com- 118 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. parison of an equal number of cases of celiotomy closed in this way that the percentage of suppuration is far less than in the pre\rious series. This improve- ment is no doubt due to the use of the subcutaneous suture and the freedom from strangulation of tissues. Whea the induration about the infected area is first detected, one or two sutures in its immediate vicinity may be cut to relieve the tension and to facili- tate the discharge of the pus. Pain is relieved by the application of dry heat and the administration of Dover's powder. The bowels should be thoroughly opened. If there seems to be any obstruction to the escape of pus, a part of the wound should be separated with the forceps, under cocain. Poultices are not advisable unless the area of suppuration is large, because they tend to break the whole wound down. In cases where there is extensive induration of the tissue lateral to the incision, a flaxseed poultice, made up with 1-1,000 bichloride of mercury solution, may be applied there and kept warm by means of a hot-water bag. When the pus is near the surface, the inflamed area must be freely opened, either under the in- fluence of cocain or of a few whiffs of chloroform. Judicious pressure at the side often materially assists the evacuation of pus. The wound should be washed out with peroxide of hydrogen, followed by a half of one per cent solution of formalin, once or twice daily, and later, if the sides of the incision tend to gape, they should be gently drawn together with adhesive straps, until cicatricial tissue has been formed. Nephritis. — Although acute congestion of the kidneys or acute nephritis are often assigned as the cause of death after surgical operations, I am unable to find a single record of such a case, either in my clinical histories or autopsy records. In many instances a temporary increase in the amount of albumen and in the number of hyaline and granular casts, which have been present before opera- tion, is noted, but in no instance has the patient showed signs of uremia. In many of the fatal cases of peritonitis in which there was coincident kid- ney disease it is quite certain that the renal lesion has been a contributory cause to the death by decreasing the patient's vital force and thus permitting a bac- terial invasion without resistance. This conclusion is brought out clearljr by Dr. S. Plexner's recent researches upon terminal infections (A Statistical and Ex- perimeiital Study of Tenninal Infections. Jour, of Exper. Med., vol. i, No. 3, 1896). His statistics are so striking that we must henceforth consider minutely the question of renal or indeed of any chronic visceral disease as a potent factor in opening the way for the easy invasion of the tissues by micro-organisms. In this manner the renal disease may be indirectly the cause of a fatal issue. Dr. Flexner found in a series of 793 autopsies made in the Johns Hopkins Hospital that 255 were upon cases of chronic heart or kidney disease, or both combined. In 213 of these cases of chronic disease the bacteriological examination yielded positive results, and the infection thus demonstrated was either local or general ; the local infections are much more common than the general, and are SUPPfiESSION OF UKINE. 119 found in a large proportion of all cases of chronic Bright's disease, arterio-scle- rosis, cirrhosis of the liver, and other chronic diseases. Affections of the serous membranes (acute peritonitis, pleuritis, and pericarditis), meninges, and endo- cardium are the most frequent. Out of 29 cases of end-infections in chronic Bright's disease alone, 26 oc- curred in which the bacteria were present in some local situation ; out of 85 cases of combined kidney and heart disease there were 66 of local infection, and out of 51 cases of chronic kidney disease associated with some other form of chronic disease, there were 35 localized terminal infections. In 94 of these cases the iufection was found in the following situations with the frequency shown : Cases. Acute peritonitis 37 Acute pleuritis (without pneumonia) 11 Acute pericarditis 23 Acute endocarditis 19 Acute meningitis 4 In reference to this group, it may be said that the micro-organisms found at the focus of inflammation appeared also in one or more of the organs of the body, but their distribution was not so general as to warrant the classification of the eases among the true septicemias. The varieties of bacteria found in the peritoneum are shown by the follow- ing analysis, which also exhibits the portals of entry of the micro-organisms as far as they could be determined with a fair show of probability : Acute Pbbitonitis. Bacteria. Frequency. Infection atrium. Streptococcus 8 Intestine 13 times. Staphylococcus aureus and albus 9 Laparotomy 13 " Micrococcus lanceolatus 4 Tapping abdomen 2 " Bacillus aerogenes capsulatus 2 Pneumonia 3 " Bacillus coli communis 3 Sloughing myoma uteri 2 " Bacillus pyooyaneus 1 Pyelonephritis 1 time. Bacillus proteus 1 Doubtful 3 times. Bacillus anthracis 1 Staphylococcus cereus flavus 1 Streptococcus and staphylococcus aureus. . . 2 Streptococcus and bacillus coli 1 Streptococcus, staphylococcus aureus, and bacillus coli 1 Streptococcus, staphylococcus aureus, and undetermined bacilli 1 Bacillus pyocyaneus and bacillus coli 1 Unidentified bacilli 1 Suppression of Urine. — Following all operations, especially the graver abdomi- nal ones, there is a marked diminution in the amount of urine passed in twenty- four hours, as has been shown in Chapter XX ; it is, however, of little import and need occasion no alarm, so long as it does not persist and there are no symp- toms of uremia. 120 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. After the first twenty-four or forty-eight hours there is a gradual increase in the quantity up to the normal about the tenth day. In cases of continued suppression the diagnosis lies between nephritis and the ligation of one or both ureters. If nephritis is the cause, the urine shows a large amount of albumen and a greater number of casts than were present before operation, while if it is due to ligation of a ureter, the diminution in the urine will be associated with severe pain on that side radiating up into the kidney, and a microscopic examination of the urine will in some instances show blood cells. It is not practicable, on account of the condition of the patient, to catheterize or to sound the ureters after operation, consequently the symptoms and urinary examination afford the only criteria in making a diagnosis. Acute nephritis rarely follows an operation except where there has been pre- existing disease. The use of the high salt solution enemata immediately after every abdominal operation has assisted very materially in eliminating this complication by increas- ing the volume of urine and so lessening its toxic or irritant effects. Treatment . — If the suppression of urine is due to an exacerbation of a chronic nephritis no time should be lost in beginning active treatment. The saline purgative must be given earlier than usual, and if there is decided or total suppression saline infusions beneath the breasts should be employed. The injection of large quantities of salt solution into the subcutaneous tissues works marvelously well in some cases, because the increased capillary tension of the fluid acting upon the kidney starts the dormant renal function, and the suppression is rapidly overcome. Hot water or steam baths are not practicable in surgical cases, so that remedies must be given by the mouth and endermically. Pilocarpine in one-tenth-grain doses every two hours, and elaterium in one-eighth-grain doses, may be employed in the most serious cases. In suppression due to ligation of the ureter there is but one treatment — re- opening the abdomen and searching out the ligated ureter. Unfortunately, the diagnosis of a ligated ureter is seldom made before autopsy, and consequently the necessary treatment is not applied. In my experience I know that I have ligated the ureters three times, and the accident has occurred in the hands of my assistants twice. Urinary Fistula. — I have only seen two cases of urinary fistula complicating the convalescence from an abdominal operation. In one of these, after the enu- cleation of a densely adherent pelvic mass, it was necessary to pass a number of ligatures with a needle about bleeding points on the pelvic floor. In doing this it is quite certain that the left ureter was punctured, for a constant dribbling of urine began through the drainage-tube which lasted for several weeks without influencing the regular evacuation of the bladder, and finally ceased spontane- ously. In the other ease, in evacuating a large abscess which filled the lower abdomen, I found the bladder fully 5 centimeters above the symphysis and cut through it accidentally. After evacuation of the abscess the thickened bladder walls were sutured together, but the sutures failed to hold in the diseased tissue and a urinary fistula resulted, which was many months in closing. FECAL FISTULA. 121 The occurrence of a fistula complicating the convalescence will be rare if the abdominal operation is skillfully performed and if the operator examines the entire field before closing the wound, when any injury to the urinary organs will be detected and corrected at once. One source of fistula has been due to cutting a ureter the end of which was then brought out in the wound. This ought not to occur any longer with our better knowledge of the relations of the ureters to pelvic tumors and inflamma- tory diseases, coupled with our improved technique in ureteral anastomosis — uretero-ureterostomy and uretero-cystostomy. (See Volume. 1, Chapter XIII.) Fecal Fistula. — Fecal fistula is one of the most annoying complications which can arise after an operation, on account of its disagreeable symptoms and its exhausting nature. Its prevention usually lies within the power of the operator, and when it occurs it is an evidence of defective technique. The two chief causes are injuries to one or two or to all the coats of the bowel during operation, or to necrosis from pressure when a glass drainage-tube is used. A fistula rarely follows injury to the peritoneal layer of the bowel, but when both the muscular coats and the peritoneal layer are involved it will almost invariably follow. Fistulse almost always occur in the rectum or sigmoid flexure, owing to the contact of these portions of the intestine with all pelvic inflammatory masses, and the necessary traumatism in the enucleation of adherent appendages, pus sacs, or tumors. Frequently a pelvic abscess tends to evacuate itself into the rectum, and if an operation is performed for its enucleation at the time when it is on the point of rupturing, there may be only a thin septum between the abscess cavity and the rectum. In such cases a fecal fistula may arise from the breaking down of this septum some days after the operation. In cases in which the fistulous tract has already occurred between an abscess and the bowel it is often almost impos- sible to close it on account of the dense adhesions and the friability of the sur- rounding tissues. AU injuries of the bowel must be sought out and repaired, and if there is the slightest danger of the sutured area breaking down, gauze drainage should be employed. If such an accident occurs after the abdomen is closed without drain- age, there is imminent danger of a rapidly fatal peritonitis being induced. If the injury has not involved the mucous coat, adhesions may form before the fistulous tract opens, thus obviating the dangers of general peritonitis. In all cases where there is danger of a fistula, drainage should be employed. If there is an opening in the intestine which has not been closed, indications of the formation of a fistula will usually be observed within the first twenty-four to forty-eight hours. On changing the dressings the first time, a faint feculent odor may be observed, which becomes marked in character in a few hours, and if the intestinal contents be liquid, feces may escape into the dressings. In this event the dressings should be changed four or five times daily, and the surrounding skin washed with alcohol and anointed 122 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. with zine-oxide ointment. This protection is especially necessary when the fistula communicates with the small intestine, as its discharge is excessively irri- tating. During the next four or five days nothing should be done beyond keeping the parts clean, in order that the local adhesions should not be disturbed until they have securely walled ofE the fistulous tract from the general peritoneal cavity. At the end of five days the first effort should be made to promote the closure of the fistula by washing it out with a warm saline solution (.6 per cent). The fiuid should be injected into the rectum with great gentleness, and the wound watched until the solution wells up through it. At least one liter of fluid should be injected so as to cleanse the entire fistulous area, removing any large particles, and promoting the formation of healthy granulation tissue. These injections must be repeated daily, and often after a few days the discharge will grow less and the fistula gradually close. If the healing of the tract is pre- vented by a silk ligature, this should be sought out with a blunt hook and re- moved at a later date. The fistula gradually contracts until its outer opening presents a puckered, roseate appearance, the purplish red granulation tissue forming a pouting red marginal ring. When the contraction of the tract reaches this point only fluid feces escapes, and when the bowels are constipated nothing but gas escapes. The escape of gas is most distressing to the patient on account of the odor and the possible noise. Frequently as the discharge diminishes the external opening is closed by a thin skin which breaks open again as soon as the intestinal pressure is increased. The deep ligatures occasionally become dislodged and escape, and so there is a temporary closure of the fistula, but, unfortunately, it usually breaks open again. In this way the patient may be disappointed in her hopes of recov- ery from month to month. In cases of a persistent fistula the first effort of the surgeon should be to determine the position of the intestinal opening ; in order to do this, inject water into the rectum ; if it appears quickly in the external wound, the proba- bility is that the rectum is the site of the inner orifice. This diagnosis may be verified by gently passing a probe down through the fistulous tract and then feehng for the end of it by a finger introduced into the rectum. If, on the other hand, the fluid appears slowly after the injection of a half liter or more of water, it is an evidence that the fistulous opening is higher up in the sigmoid flexure. Treatment . — Healing is often promoted by the removal of retained liga- tures, and for this purpose a crochet hook should be employed. When a loop is caught considerable force may be needed to extract it, and if this maneuver fails, delicate pointed scissors may be used to clip the loop. After extracting all of the ligatures no further active treatment should be resorted to so long as there are any signs of improvement. Peroxide of hydro- gen is a very useful agent in cleansing the tract and should be used daily. The use of strong antiseptic and astringent injections is frequently advised, but I have failed to derive any benefit from them. FECAL FISTULA. 123 In the process of formation tlie fistulous tract is at first surrounded by deli- cate adhesions binding the viscera together and walling it off from the peritoneal cavity. Later these adhesions become organized and form a dense fibrous tube 1 to 2 centimeters (f to |- inch) in diameter, and 6 to 10 centimeters (3| to 4 inches) long, with a lumen a few millimeters in diameter and lined with granulation tissue, which often presents the appearance of mucous membrane. The tissue of the fistula is frequently so dense as to give the sensation of cartilage when cut with the knife. If the fistulous tract persists after all local measures have been exhausted, it should be dissected out and the bowel closed by suture. The treatment of an old fistula by the radical operation requires the complete removal of the fistulous channel, and the sever- ance of the tube from its intestinal attachment. Before operation the abdomen should be cleansed with the greatest care, and the intestinal tract should be evacuated thoroughly by purgatives and copious enemata, given two hours before operation, and again immediately before the abdomen is cleansed. Sufficient fluid must be injected to cleanse the bowel so .thoroughly that it returns from the wound perfectly clean. In this way the dan- ger of feces escaping during the operation is largely avoided. But to make assurance doiibly sure, after cleansing the abdomen the fistula is packed with iodoform gauze. A semilunar incision 8 to 10 centimeters (3 to 4 inches) in length is made 2 to 3 centimeters to one side of the fistulous tract. This exposes the intestines, and the extent of their adhesions to each other, and their relation to the fistula may now be studied. If the omentum is adherent above the intestines it should be tied off in small sections and released. The length and direction of the fistulous tube, the density of the adhe- sions, the point of origin, whether high or low in the intestines, must all be determined carefully, as the prognosis in these cases depends much upon these factors. "When the fistulous tract is long and ends in the rectum, and there are dense adhesions surrounding it, the operation is most difficult and often results in failure. Having made a careful examination and determined to continue the oper- ation, a second incision is made on the opposite side, corresponding to and joining the first, thus surrounding the fistula by an oval incision. Two stout silk liga- tures are now passed through the end of the tube and left long, to serve as re- tractors, while the intestinal adhesions are being separated. Bandlike and velamentous adhesions can be severed with the scissors, while those that are dense and flat and bind the fistulous tract closely to the intestine must be dissected off, leaving, if necessary, part of the wall of the fistula adhering to the intestine. By observing the greatest precaution the fistulous tract may be freed down to its point of origin with httle or no injury to the bowels. 124 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. Having broken up the adhesions, the intestines should be packed away from the fistulous tract with gauze pads to expose the site of operation and protect the peritoneal cavity from any intestinal discharge which may escape upon severing the fistula. A transverse oval incision is then made in the gut around the fistulous opening. The transverse incision is preferable to the longitudinal, because it is followed by much less contraction of the bowel, due to the suturing. If the fistulous opening involves a large part of the bowel it may be necessary to resect the bowel and do an end-to-end enterorrhaphy. The opening in the bowel should be closed by sutures, in a similar manner to that described under intestinal injuries (Chapter XXXVI). If the opening is large and the first layer of sutures does not close it with perfect accuracy, a sero-serous suture should be applied over this ; or a loop of intestines, preferably the sigmoid flexure, can be brought down to cover the site of suture if it is in the rectum. The latter maneuver is of the greatest utility, as shown by an autopsy on a patient who had died of purulent peritonitis. The case was one of pelvic ab- scess, which was densely adherent and released with the greatest difliculty. Dur- ing the enucleation the rectum was lacerated, requiring three sutures to close it, and, as an additional precaution, the sigmoid flexure was drawn down over the sutured area. At the time of the autopsy, four days later, it was found that there had not been the slightest leakage from the rectum, notwithstanding the fact that the sutures had not held properly ; for the sigmoid had become ad- herent, and had effectually protected the rectum with its peritoneal covering, and so excluded the contents of the intestine from the peritoneal cavity. In no case should the lowly organized tissues of the wall of the fistula be utilized in closing the gut. At the completion of the operation the peritoneal cavity should be carefully cleansed with salt solution, and a gauze drain laid down to the point of suture in the intestine ; if possible, the drain should be brought out through the vagina. The sphincter ani should then be thoroughly dilated to facilitate opening the bowels as well as to prevent any considerable accumulation in the lower bowel. Drainage may be dispensed with if the fistula is superficially situated and has been easily repaired. Sometimes when the immediate result of the operation is a failure the new granulation tissue forming in the canal will, after a few days, completely close the opening with as good an ultimate result as though the primary suturing had held. The following case illustrates this means of closure : J. H., 2547, oper- ated upon at her home in the country, April 7, 1891, for densely adherent double pyosalpinx. A glass drainage-tube was inserted, and the patient remained in bed two months and a half. About the third week fecal matter was found escaping through the drainage tract. Since then she has had chills off and on up to the present time (Jan. 30, 1894). Following these attacks there was in- tense soreness in the lower abdomen, accompanied by a profuse purulent and fecal discharge through the fistula. FECAL BISTULA. 125 Operation for fecal listula, Feb. 1, 1894. At the lower angle of the abdomi- nal sear is a fistulous tract through which a probe may be passed deep into the pelvis, and above the fistula is a prominent swelling produced by a hernial pro- trusion. The operation consisted in an oval excision of the skin around the fistula, including the hernial sac. The sac and the indurated cicatricial ring around it were dissected out. The fistulous tract was then slowly detached and followed down into the pelvis 10 centimeters (4 inches), where it ended at the rectum. The intestines could not be separated from it at this point on account of the dense adhesions. The fistulous mass then broke off close to its entrance into the gut, where, on account of the dense indurated tissue, it was impossible to suture it satisfactorily ; consequently a large gauze drain was inserted, in the hope that new forming cicatricial tissue would close the fistula. The abdomen was closed with interrupted silkworm-gut sutures down to the drainage tract. For four days subsequent to the operation the patient did well, no gas or fecal fluid escaping from the drainage tract. On the fifth a slight amount of hquid feces appeared ; this discharge persisted for nine days, and then ceased entirely, no flatus even escaping through the fistula, and at the tide of discharge from the hospital the abdominal wound was perfectly healed, and it has re- mained so since. B. W. M., 3108, admitted Oct. 15, 1894, for intestinal fistula following hystero-myomectomy in 1892. Six months after the operation an abscess formed at the lower angle of the incision and ruptured externally, and six months later a silk ligature came away. On June 29, 1893, a number of ligatures were fished out of the fistulous tract with a crochet hook ; in July another bunch was dis- charged. Several times a discharge of fecal matter came through the fistula, and in taking enemata the water escaped through the opening. Operation, Oct. 16, 1894. Excision of the fistulous tract and suture of the bowel. The fistulous orifice was cut out by a large oval excision of the skin and the old scar, opening through into the abdomen. ~So adhesions to the abdominal wall. An adherent loop of the ileum to the fistulous tract was separated by excising part of the wall of the fistula, and leav- ing it on the bowel. The detached outer end of the fistula was now closed by sutures to prevent the escape of fecal contents, and when enveloped in gauze, it served as a tractor ■to draw the fistula up, as it was slowly dissected out of its bed of adhesions. Within the abdomen it hugged the anterior abdominal wall, and then entered the pelvis over the left brim and passed over the bladder to the sigmoid flexure, where the bowel was pinned down to the pelvic wall, bladder, and the old stump by dense adhesions. The fistulous tract was now dissected away from its vesical at- tachments, cutting loose an actively bleeding area on the vault of the bladder 3 by 2 centimeters, but sacrificing the wall of the fistula and not the bladder. After extensive dissection of the sigmoid flexure from its abdominal adhesions poste- riorly, and freeing it back to the point where it crossed the brim of the pelvis, a 126 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. dense knotted mass was brought up and fhought to be dense bladder adhesions. On dissecting this ofE with a view of sacrificing the bladder rather than the bowel, the uterine stump was found to have been separated and not the bladder. The stump was excessively vascular, with a cavity in the center, where one silkworm-gut suture and two or three small silk sutures lay. The fistulous tract was now found to communicate with the rectum by an opening 2 millimeters in diameter, around which for 3 or 4 centimeters a band of dense cicatricial tissue existed. All of the fibrous tissue was trimmed away and the hole in the rectum closed by one mattress and two straight interrupted sutures. The raw area about the fistulous opening was next whipped over with adjacent peritoneum by eight intestinal sutures. The pelvis was then thoroughly irrigated and a gauze drain inserted down to the site of suture, and a complete recovery ensued. After such an operation the bowels should not be disturbed for four or five days, when a small oil enema, 150 to 200 cubic centimeters (5 to 6 ounces), may be given, with a mild purgative pill or cascara sagrada by the mouth, followed by a repetition of the enema in three hours ; this will secure the desired effect without unduly disturbing the bowel and endangering the integrity of the intes- tinal suture by the increased tension. Phlebitis. — Phlebitis in the femoral vein occurs as a post- operative complica- tion in a little less than one per cent of all cases. I have had nine cases in twelve hundred operations, once double, beginning first in the left leg and then appear- ing in the right. It does not occur until two or three weeks after the operation — on the twenty-second day in five of my cases. The latest phlebitis I have seen after operation was on the twenty-sixth day. In all my cases the inflammation was mild in character, and I have never known a death to occur from this cause. The real danger in these cases is the dislodgment of an embolus, which may plug the pulmonary artery. With this phlebitis of the femoral vein I would also associate a group of cases characterized by the same symptoms — pain coming on about two weeks after operation, elevated temperature and tenderness, passing off slowly — in. which, however, the discomforts are felt entirely in the pelvis on one side and there is no evidence of any cellulitis or peritonitis upon making a vaginal exami- nation. I have seen this affection then spread from the pelvic out into the femoral vein of the same side. Symptoms . — The first symptoms are a rise in the temperature and quick- ened pulse, together with a deep-seated pain in the line of the inflamed vessel, and soon the leg becomes slightly edematous. The vein becomes hard, swollen, and cordlike, and has a peculiar knobby feel ; its course may be marked by a dusky red line, especially if the superficial veins are involved. The edema subsides when the collateral circulation is established, often after some weeks. One of the most annoying symptoms is a lameness which may persist for many weeks. Treatment. — The local treatment consists in keeping the limb elevated and in the application of cloths saturated with a warm solution of lead water and laudanum, or merely of warm fomentations. A shght flannel pressure bandage EMPHYSEMA OF THE ABDOMIIfAL WALL. 127 is often of service in relieving pain. The Paquelin cautery lightly touched over the inflamed line often affords great relief. Spontaneous recovery occurs in from three to eight weeks. Emphysema of the Abdominal Wall. — This complication naturally calls for anxious attention until its cause is deiinitely settled, as the prognosis of this condition is grave when the bacillus aerogenes capsulatus is the infecting organism. In two cases occurring in my clinic, reported by Dr. W. W. Eussell, air had evidently been forced from the abdominal cavity shortly after the operation into the tissues adjacent to the wound. Winter and Madalener have reported similar cases ; the latter, beheving that the emphysema is due to the elevation of the pelvis during the operation, recommends lowering the patient to a horizontal position before closing the incision. Heil proved experimentally that when the deeper layers of the ab- dominal wound were imperfectly brought together emphysema might occur. Although usually confined to a small area, the emphysema may involve the entire abdominal wall and chest. The air is forced out into the tissues between the skin and muscle, and never, as Leopold suggests, between the peritoneum and muscle. The following case illustrates this complication : ]Sr. W. W., 377^, aged thirty-three ; operation, Sept. 12, 1895, suspension of the uterus for retroflexion, with the pelvis elevated during the operation. The incision was closed by three tiers of sutures — the peritoneum by a con- tinuous catgut suture, the fascia by silver-wire mattress sutures, and the skin by a continuous subcuticular catgut sutare. For twelve hours after operation the patient was violently nauseated and vomited several times ; the bowels were well moved on the fourth day, and there was but slight pain during the conva- lescence. The highest temperature was 99-8° F. (37"6° C), and the pulse ranged between 65 and 90. The dressings were changed for the first time on the eighth day, when the right side of the abdomen was found sensitive but normal in appear- ance, while the left side was uniformly distended, sensitive, and yielded a dis- tinct crepitus on pressure ; bubbles of gas eonld be felt escaping from beneath the fingers wherever pressure was made ; the union of the wound was perfect, and there was no evidence of infection of any kind. In a few days the emphysema, which was first noticed to the left of the wound, had completely surrounded it, and then it spread in all directions under the skin, upward to the costal margin, downward to the symphysis pubis and Poupart's ligament, and laterally well into the flanks. The skin did not show any change, nor was any indication apparent beneath it. Cultures and cover- slips made from a small incision through the skin proved negative. When the patient left the hospital about five weeks after operation her general condition was excellent and the emphysema had entirely disappeared. Since the discovery of the gas bacillus by Dr. Welch numerous cases of infec- tion from this source have been reported. 128 COMPLICATIONS ARISING AFTER ABDOMINAL OPERATIONS. The notes of a ease furnished me by Dr. Bloodgood, resident surgeon in the Johns Hopkins Hospital, are extremely interesting when compared with the case above, as this is the first time the gas bacillus has been found in the abdomi- nal wound. S. R. Surgical ISTo. 6102. Diagnosis, chronic appendicitis. Operation Feb. lY, 1897 ; removal of the appendix after recurring attacks ; the incision was made through the right rectus muscle, the adherent appendix was dissected free and excised, and the stump closed by suture ; a large gauze drain was packed down to the stump. On the day of operation the patient returned to the ward with a pulse of 100 ; the evening temperature was 99-3° F. (37-3° C.) ; pulse 96. At 9.45 p. m. emphysema was discovered in the wound, extending out on the left side of the abdominal wall, and on the right side into a blood clot cavity. The material in the cavity was chocolate-colored and contained bubbles of gas, and the sur- rounding muscular tissue appeared necrotic. G-reat numbers of gas bacilli were found in the tissues and in the blood-clot. Cover-slips from the clot showed few leucocytes, a few red blood cells, and debris; the field was filled with large capsulated bacilli of three sizes. Numbers one and two were numerous, a few were in chains of five. Second day : Patient noisy and restless aU night. At 4 a. m., sixteen hours after operation, the temperature had risen to 104:-4° F. (40-2° C), pulse 144. At 8 this morning the temperature is 103"5° F. (39'4° C.) ; pulse 128 ; respira- tions 36, now and then intermittent, entirely thoracic. Patient has had no nausea and vomiting since he left the operating room. Small fluid reddish stool ; cover-glass preparations from stool show great numbers of gas baeilH. At 10.30 A. M. the temperature was 104-8° F. (40-5° C.) ; pulse 136 ; respi- rations 50. Wound opened and irrigated ; 11 a. m., pulse 160, respirations 60 ; 12 M., temperature 105-6° F. (40-8° C), pulse 160, respirations 60 ; 1 p. m., rapidly faihng ; died at 1-45 p. m. Blood cultures taken immediately after death negative. Cultures taken at autopsy eight hours after death from all the organs showed myriads of the bacillus capsulatus aerogenes. Whenever emphysematous areas are discovered about an abdominal wound, a small incision should be made in order to obtain cover-glass preparations and cultures. If the bacillus aerogenes capsulatus is found, no time should be lost in opening the wound and irrigating it freely and packing with gauze. In the case above reported the wound was freely drained, but, notwithstand- ing this means of exit, the infection proved rapidly fatal. Sudden Death. — Embolism of the pulmonary arteries stands in close causal relationship to thrombosis of the pelvic and crural veins. Since the work of Mahler in Leopold's clinic has made clear the clinical signs and the underlying pathological conditions of thrombosis and embolism following gynecological operations, numerous cases have been observed and carefully studied post mor- tem, notably by Olshausen, Wyder, and Gessner (see C. Kuge's Festschrift, SUDDEN- DEATH. 129 Ueher totliche LungenemboUe, etc.). A thrombus is formed in one of the pel- vic or femoral veins, is dislodged, and swept with the circulation into the pul- monary artery ; if the thrombus is a small one the attack is characterized by precordial distress, pain, and dyspnea, associated with a quickened pulse ; after one or more of these attacks the patient may recover completely. Lusk saw a case in which the lodgment of such an embolus in the lung was immediately followed by the rapid diminution of a marked edema of the leg {Brii. Med. Jour., 1880, p. 843). With the lodgment of a larger embolus the patient complains of pain in her side or under the shoulder blades, of suffocation and extreme precordial dis- tress ; she sits up in bed with an anxious expression, gasping for breath with all the auxiliary respiratory muscles brought into play, a cold, clammy sweat be- dews the face, she becomes cyanosed, and the mind, at first clear, is clouded, and she may die in a few minutes, or indeed in a few seconds, as in the following case under my care : The patient had been operated upon for a papillomatous ovarian cyst and extensive ascites. The enucleation was a difficult one, and some flat nodules were left scattered over the floor of the pelvis ; she made, however, in every way a most satisfactory recovery until the fourteenth day. She had been propped up in bed during that day, and had felt no ill efliects from it. When my assist- ant made the rounds that night she expressed herself as feeling unusually well, and consequently was in the best of spirits. She went to sleep early and rested well until twelve o'clock, when she awakened, complaining of a numb sensation in the left leg. The nurse, supposing that this came from a cramped position in bed, assisted her to turn over, and rubbed the leg vigorously for a few sec- onds. Suddenly the patient gave a sharp cry, and complained of frightful roaring in the head and a feeling of suffocation. The pulse quickly became weak and intermittent, the breathing spasmodic, and within a few seconds she died. 1^0 autopsy was made, but there can be no doubt but that the cause of death was the lodgment in the pulmonary arteries of a detached embolus from some vessels about the seat of operation. Whatever causes act to produce and to dislodge a thrombus are also effective in forming an embolus. Thrombi — that is to say, potential emboh — are formed by the prolonged pressure of pelvic tumors upon the pelvic veins, by anemia, by marasmus, notably that associated with carcinoma, by changes in the circulation, diminishing its force, particularly when due to heart disease, and by a local infection spreading through the walls of the veins. The immediate cause of the dislodgment of the clot may be found in an act of coughing, in a sudden change of posture, in straining at stool, etc. I am inclined to think with Olshausen that an infection in the proximity of the vein, causing a phlebitis with its attendant thrombus, is the real cause in most cases, and I would attribute less importance to such conditions of the heart as " brown atrophy " and " fatty degeneration," although cases have been ob- served in association with a warty heart or a villous pericardium. 40 130 COMPLICATIONS AEISIKG AFTER ABDOMINAL OPERATIONS. The symptoms in the following case are characteristic of the lodgment of emboli in the lungs, when death is not produced suddenly, but the patient sur- vives one or more attacks. Thrombi formed in the large veins of the broad ligament from which emboli were detached at varying intervals and lodged in the lungs, producing infarcts. The dyspnea was sudden in its appearance, and continued more or less aggravated until the patient's life was finally terminated suddenly by the lodg- ment of a large blood clot in the pulmonary arteries. The autopsy notes bear out the clinical symptoms. Infarcts and tumor metastases of varying ages were found, showing that the emboli were lodged at different times. M. E. H., ISTo. 2225, admitted Sept. 25, 1893. For over a year she had been feeling tired and languid and not able to do as much work as formerly. Seven months before her admission she ceased to work on account of increasing weakness and a heavy, dull, pressing pain in the left ovarian region ; four months later the abdomen began to increase rapidly in size, when pain was felt on the right side as much as on the left. Two weeks ago her feet and ankles began to swell, and about this time great dyspnea devel- oped, and she was unable to lie down. When first seen she was pale and anemic, her complexion sallow, and her eyes sunken ; she had lost flesh rapidly of late. Bowels constipated, defecation painful ; great dyspnea, especially on lying down. Pulse small, quick, and wiry. Locomotion difficult and painful. The abdomen was found greatly distended, most marked to "the left of the umbilicus and between the umbilicus and pubes ; the skin was glossy and the tumor mass irregular ; the largest portion was ovoid, and extended from the left flank down to Poupart's ligament, the second portion was continuous with the first, and extended from the left flank to the median line. Eesonance in either flank, dullness and fluctuation over tumor masses. Marked edema of the legs below the knees. Sept. 28, 1893. — Paracentesis abdominis, one liter of bloody viscid fluid re- moved, and the dyspnea relieved. Oct. 8, 1893. — Patient began to suffer intensely with dyspnea this morn- ing. Pulse quick and irregular, 130 to 140. Face pale and livid. Great pain in the lower abdomen. She can only breathe when propped up in bed, and lies with eyes shut and mouth open ; the extraordinary muscles of respiration are all brought into action in breathing. Oct. 15, 1893. — Abdomen again tapped, removing 360 cubic centimeters of dark coffee-colored fluid. Dyspnea still severe, but not so intense as when last noted. Oct. ^5th. — Twenty -three hundred cubic centimeters of bloody viscid fluid evacuated through a small incision. Jfov. 2d. — Complains of great shortness of breath ; pulse 130, weak and thready. Face livid, expression anxious, dyspnea marked. Nov. 5th. — Since last note she has gradually failed, is restless, and the air- hunger is intense. She died suddenly at T p. m. SUDDEN DEATH. 131 Autopsy 467 . — Anatomical diagnosis : Sarcoma of the uterus, secondary in the lung ; embolism of the pulmonary arteries ; thromboses of the veins in the broad ligaments and the mesosalpinx; acute fibrinous peritonitis, acute fibrinous pleurisy, bronchiectatic cavities. XJ terus . — Cavity 13 centimeters in depth ; on the right side the wall is 2 centimeters in thickness ; the left side is contiauous with a large tumor, which occupies the pelvis and extends 4 centimeters above the umbilicus. Continuous with the large tumor mass is another 12 by 18 centimeters, which occupies the right side of abdomen, beginning at the free border of the ribs and extending down into the pelvis. On section of the tumor, its center is found to be necrotic and sloughing. The upper tumor mass is nodular, and presents on section a grayish-white color. It contains 550 cubic centimeters of brownish fluid in which flakes of necrotic tissue are floating. The inner wall is covered with sloughing masses of tissue. The veins of the broad ligament and mesosalpinx are greatly distended by thromboses which are generally red and not adherent; occasionally partly decolorized thrombi appear. Lungs . — The pleura is covered with a thin layer of fibrin, and over the base of the lung are areas of intense injection or hemorrhage. On section, the lobe presents a granular appearance ; the color is variegated and is predominat- ingly red. Beneath the pleura are a number of areas more selid than the rest and more hemorrhagic in appearance, somewhat wedge-shaped, with the bases toward the pleura. In the upper and middle portion of the lungs is an area more sohd than the rest, distinctly projecting ; on section its center is hemor- rhagic, its borders gray, and on slight pressure a thin puriform fluid escapes. Four centimeters from the base in the middle line is a circumscribed globular area, 2 centimeters in diameter, composed of a grayish-yellow friable tissue beset with hemorrhages. On removing this tissue a tolerably smooth base ap- pears, on which a small amount of connective tissue and vessels are visible. In the base of the upper lobe is a circumscribed area coming to the surface of the pleura, which is covered with flbrin and small hemorrhages. Pus can be squeezed from the consolidated area. The upper lobe is other- wise pale, slightly edematous, and its anterior edge emphysematous. The pul- monary artery supplying the upper lobe is occupied by a thrombus, the outermost parts of which are moderately flrm, yellowish red ; the interior is softer and darker. It is only slightly adherent to the vessel wall and can be followed into the branches for some distance. The branches to the lower lobes are also thrombosed. The branch to the middle lobe contains a simi- lar thrombus, and the smaller branches are likewise plugged. Left lung is collapsed, free from recent adhesions, the apex is retracted, and on section of the retracted portion three cavities separated by septa composed of grayish-red granulation tissue and a firmer tissue apparently containing cartilage. The pleiira over the area is injected and the outermost zone of these cavities is formed by the pleura, whereas beneath them in the lung substance is a dense 132 COMPLICATIONS AEISING AFTEK ABDOMIITAL OPEKATIONS. grayish-white tissue. About the middle of this lobe near the root is another cavity larger than the others. In the lower lobe is a circular consolidated mass the size of a small marble, with sharp, distinct outlines. The pleura over this zone is highly injected, the center opaque. There is a thrombus mass occu- pying the pulmonary artery distributed to the lower lobe similarly to the right side. Death from embohsm has occurred after myomotomy, removal of the tubes and ovaries for myoma, hystero -myomectomy, the extirpation of a carcino- matous uterus, exploratory incision for carcinoma, ovariotomy, ventrofixation of the retroflexed movable uterus, and curettage of the cancerous cervix. Eelatively the greatest number of cases has occurred after myoma opera- tions, which exhibit so large a proportion as eighteen out of a total of forty- three cases (Gessner). Aside from the clinical signs just detailed, Mahler lays great stress upon a persistent frequency of the pulse rate, which is out of all proportion to the ele- vation of the temperature. With the attack and the precordial pain and the dyspnea there is usually a rise in the temperature coincident with a rise in the pulse rate, but the temperature drops speedily while the pulse remains high for some days, due, it would appear, to the increased resistance and the elevation of the blood pressure occasioned by the plugging of one or more of the usual larger circulatory channels in the lesser system. Treatment . — There is no treatment for the severe cases, but for those which are characterized by a succession of attacks and for cases which present any of the signs of thrombi, prophylaxis is of the utmost importance. Wyder even declares that he will no longer undertake serious gynecological operations when edema is present with a high pulse rate and other signs of a recent thrombosis, provided the general condition of the patient will sanction a postponement. The occurrence of such a frightful accident, even after so simple an opera- tion as a ventrofixation, teaches anew the important lesson that the surgeon is never warranted in guaranteeing the recovery of the patient even after a seem- ingly simple operation. Patients whose vitality is depressed, and those who are anemic, should be watched with especial solicitude. The dangers are increased if an edema before the operation has given evi- dence of a thrombosis. The risk increases after the operation when local tenderness and elevation of temperature with a quickened pulse give evidence of the formation of thrombi. All these cases should be guarded with especial care, kept longer in bed, and any active or straining movements rigorously guarded against. The avoidance of an artificial anemia produced by excessive loss of blood during an operation, and the use of the subcutaneous saline infusions when it does occur, must also be looked upon as important prophylactic measures. In case of phlebitis the limb should be kept well bandaged and quiet, and under no circumstances should any vigorous massage movements be made, as was done in the first case cited. DEATH FROM INTESTINAL HEMOERHAGE. 133 Death from Intestinal Hemorrhage. — In three cases of wHch I have cog- nizance death has occurred from the hemorrhage produced by an intestinal ulcer. One of these cases occurred in the practice of Dr. Thad. Eeamy, of Cincinnati, another was related to me by Dr. Bela-"Wala, of Budapest, and the third occurred in my own clinic, following an operation for a left pyosalpinx, containing from 20 to 30 cubic centimeters of pus, produced by a streptococcus infection. The patient was operated upon by Dr. H. Kobb ; the abscess rup- tured in the enncleation, and she died in four days of an extensive intestinal hemorrhage with a septic peritonitis. The autopsy showed the presence of a round ulcer of the duodenum 18 millimeters in diameter, with an erosion of a small vein 1 millimeter in diam- eter, while the large and small intestines contained immense quantities of soft reddish coagula, estimated at about 2 liters. CHAPTEE XXIII. TUBERCULOUS PERITONITIS. 1. Clinical characteristics. 3. Predisposing causes. 3. Symptoms. 4. Diagnosis. 5. Treatment. 1. Abdominal section : a. To remove focus of disease ; h. To remove fluids ; c. To release adhesions. 3. Drainage after operation for tuberculous peritonitis. TuBEECULosis of the peritoneal cavity is one of the most interesting and im- portant affections the gynecologist is called upon to treat ; it is interesting on account of the difficulty of forming an ■ accurate diagnosis ; it is important on account of its frequency as well as of the surprisingly successful results of sur- gical treatment. It owes its specific character to an invasion of the peritoneal cavity by the tubercle bacillus, which has usually gained entrance from some other infected point acting as a focus of distribution. This form of tuberculosis exhibits, more than any other gynecological affec- tion, a remarkable tendency to vary in its morbid manifestations — for example, in one case the disease occurs in the form of a few tubercular nodules scattered over the peritoneal surface of the uterine tube, or even limited to the tubal mucosa, but from this point in more advanced cases it may spread out over the neighboring peritoneum, which then looks as if peppered with little white seeds, most abundant about the mouth of the tube. Spreading farther from such a focus, the whole lower abdomen becomes involved, and both parietal and visceral peritoneum are studded with nodules, single or aggregated, from half a milli- meter to several millimeters in diameter. The appearances on opening the abdomen vary greatly, according as more or less abundant adhesions have been formed, or according to the amount of effu- sion of free or sacculated, bloody or serous fluid accompanying the peritonitis. In miliary peritonitis the whole peritoneal cavity is uniformly studded with discrete nodules. In the acute cases of tuberculous peritonitis there is a noticeable congestion of the peritoneum, with fresh vascularized shreds of lymph hanging from the in- flamed surfaces. The peritoneum is intensely red and thickened, and the neigh- boring circulation markedly affected, as shown by the increased hemorrhage from small vessels in incising the abdominal wall. The thickening of the peritoneum may be uniform, and may amount to several millimeters in chronic cases, so that the organ looks like a gray blanket covering all inequalities. The skin around the umbilicus has been noted to be red and edematous in a few instances. 134 Fia. 335. — Tuberculous Eight Tube with Tueekcle Nodbles distkieuted oveb the Surface of a Parovakian Cyst. The ovary of this side was not removed. San. Jan. 22, 1897. Natural size. O'we'^t"'?? Vi.Ui Fio. 334.— Tuberculous Left Tube with Adherent Omentum. San. Jan. 22, 1897. Natural Size. TUBERCULOSIS. 135 The very fat of the abdominal wall often betrays the nature of the disease, before the peritoneum is opened, by its unhealthy, pale, lusterless, sodden ap- pearance. Large sacculi of clear or turbid serous fluid are sometimes found in the pelvis or in front of the intestines, and smaller sacculi may be found walled off among them. I have seen abscesses of varying size ; one of the largest containing sev- eral liters of pus, was situated just beneath the abdominal -wall, and extended from the symphysis to the umbilicus. The omentum in a mild case may be found simply covering in the pelvis, to which it adheres around the borders of the superior strait, or it may adhere by its free border to the anterior abdominal wall. It undergoes extraordinary changes in some advanced cases, contracting and thickening with the deposit of tuberculous masses, until it tinally forms a thick, solid roll lying across the abdo- men from right to left, attached to the transverse colon. The mass is tympanitic and may seem quite movable. In a case of Dr. "William Gardner, of Montreal, cited by Osier {Johns Ropk. Hosp. Rep., vol. ii. No. 2), a hard tumor felt down in the right iliac and lumbar regions proved at the operation to be the omentum. The intestines often adhere lightly to one another and to the pelvic struc- tures ; at other times the adhesions are so extensive as to present the peculiar appearance of a large sac, which might easily be mistaken for a cyst, and the attempt made to extirpate it. Close inspection of this sac, however, will reveal fine lines where the coils of intestines are agglutinated, often distinctly marked out by a little deposit of lymph, looking like a white thread on the red surface. I have seen this line everywhere parallel to the line of union of the intestinal coils, but a few millimeters distant from it, ■ showing that the intestines had been pulled away by peristaltic movements, after its formation. In event of any uncertainty the true nature of this sac may be revealed upon striking a sharp blow with a finger, which sets up a faint vermicular motion. In a case of extensive tuberculous disease which I saw in 1885, 1 was much em- barrassed upon opening the abdomen and removing the fluid to find a large red sac fiUing the lower abdomen, with its pedicle apparently attached to the poste- rior abdominal wall. A close inspection revealed the sinuous white lines spoken of, on the surface, and on tapping the sac lightly with the finger a distinct peri- staltic wave was started, showing that it consisted of the entire mass of the small intestines. The fluid accumulated in the peritoneal cavity was drained out, and the patient recovered and is living to-day. Tuberculosis of pelvic origin may be associated with a variety of other dis- eases. In one of my cases, for example, there was a miliary tuberculosis of the left tube, and a dermoid cyst of the right ovary 3 centimeters in diameter. In another ease there was an ovarian cyst on the left side about 12 centimeters in diameter (5 inches), and an extensive peritoneal tuberculosis, covering the outer surface of the cyst as well, with effusion. In still another case a tuberculous tubo-ovarian abscess contained gonococci. 136 TUBEKCTLOUS PERITONITIS. Etiology. — The cause in all cases is the invasion of the peritoneum by the tubercle bacillus, which finds in the serous surface a suitable pabulum for germination. The mode of invasion is often diflicult to determine. In the cases seen by the gynecologist the proximal avenue is usually by the uterine tube, and in many instances it is quite clear that the disease has reached the tube by the vagina and uterus, because the tuberculous lesions are also found in these organs. Fig. 33t). — General Tltbekculous Peritonitis. Showing the way in which the uterus, tuhes, broad ligaments, and ovaries are studded with tubercles. There is also a commencing tuberculosis of the tubal mucosa. The case is also complicated by a coincident epithelioma of the cervi.x. July 24, 1895, No. 81.3. % natural size. Cases of dissemination of the tubercles over the peritoneum may also occur from a broken-down mesenteric gland, or by extension from tuberculous intes- tinal ulcers. Miliary tuberculosis involving all the organs of the body may arise from a cheesy thoracic gland opening into a vein and distributing its products through- out the whole system. With this affection we have nothing to do. Predisposing causes are not easy to determine ; in a series of sixteen cases of my own, the family history was good in twelve, tuberculous in two, and can- cerous in two. A previous depressed state of health does not seem to be such an important factor as one would naturally expect, for out of nineteen of my cases, fourteen were well until taken with the present illness, and but five stated that they were previously in ill health. There is also a wide variance in the histories that are presented as to the time of onset. Six patients out of twenty-one definitely dated their illness from a miscarriage or a labor, two others fixed the beginning of their disease at a pe- riod between two and three weeks before applying for relief, six others dated it back some time between three months and a year, and six more from one to seven years ; one could not fix any time. TUBEKCULOSIS. 137 Pregnancy shows a definite causa] relationship which has not been adequately noted. Twenty-eight per cent of my cases definitely dated their ailment from a miscarriage or a labor. Of the married women, 29-41 per cent remained sterile and 11'76 per cent miscarried every time ; 41*17 per cent were sometimes delivered at term and sometimes had miscarriages, while but 17'64 per cent always went to term. To the ten child-bearing women thirty-five children were born — an average of 3"5 each — while nine women had twelve miscarriages; one of the mothers bore eight children. The following history of a patient whom I saw ia consultation with Dr. L. M. Sweetnam, of Toronto, is quite characteristic of this group of cases: A woman in the twenties, previously in perfect health, had a mechanically induced abortion between the second and third months; within a month she went to bed with peritonitis, and remained there four weeks. For a year after this she suffered abdominal pain in walking, and had frequent elevation of temperature while going about, sometimes rising over 105° F. (40° C). When the abdomen was opened the intestines were found extensively and densely adherent, and there were two pus sacs present, itfothing was removed, but 4 grams of iodo- form were introduced and distributed through the abdominal cavity, and for twelve months the temperature remained practically normal. Eight or nine months after this the patient had a subacute left pleuritis, and three months later she died of typical acute tuberculous meningitis. The tendency of the disease is either to run an acute course and subside, leaving behind pelvic adhesions involving tubes, ovaries, and uterus, or to as- sume a chronic phase with exudation or the production of fibroid tissue. The fact must not be lost sight of that some of the cases which reach the surgeon's hands have passed the period of danger from extension of the tuber- culosis, and the relief desired is for the sequelae of the disease. Contrary to expectation, grave tuberculous disease of other organs is not com- mon, not even of the lungs — in fact, the presence of tuberculous peritonitis of pelvic origin seems often to afford an immunity to tuberculosis elsewhere. I have seen but four cases of extensive tuberculous pelvic disease associated with advanced lesions in the lungs, two of them in a series of twenty-two cases, and it was not possible in either case to determine upon the primary focus of inva- sion. In one of my cases I drained an encysted tuberculous peritonitis and the patient recovered, and died a year later of phthisis. I do not here refer to eases of tuberculous peritonitis arising late in the course of pulmonary or intestinal phthisis, for these do not often come into the hands of the gynecologist for treatment. ' Only one patient had pleurisy, although pleurisy with or without effusion has been frequently noted as a common complication. I have never seen either lupus or tuberculous joints or tuberculous rectal disease associated with perito- neal tuberculosis. A markedly predisposing factor is found in the age of the patient. The young and the old are comparatively immune from tuberculous peritonitis of 138 TUBERCULOUS PEEITONITIS. pelvic origin, although it is quite common in young children from other sources. The average age of twenty-nine of my cases was 27"59 years, the oldest being forty-seven, and the youngest a black girl of seventeen; the youngest white woman was thirty. Dr. "William Osier {Johns Hopk. Hosp. Rep., vol. ii, No. 2. p. 70) has ana- lyzed 346 cases, male and female, according to age, with the following result : Under ten, 27 ; between ten and twenty, 75 ; from twenty to thirty, 87 ; be- tween thirty and forty, 71 ; from forty to fifty, 61 ; from fifty to sixty, 19 ; from sixty to seventy, 4 ; above seventy, 2. It still remains a question whether race exerts an influence on the relative frequency of the disease. In my clinic of thirty beds, in which six were occu- pied by blacks, twenty-nine cases are recorded in the course of five years, of which eleven were in the blacks. It would appear from an analysis of my cases that there is some difference in the average age at which the disease attacks the two races : out of my twen- ty-nine cases, the average age of the white women was 29'55 years, while the average age of the blacks was but 25-63. Sixteen of the twenty-nine cases were between twenty and thirty years of age. The general appearance of many of these tuberculous women on admission to the hospital was a striking contradiction of the opinion that a tuberculous patient carries about with her the impress of her disease in a pale, anxious look and an emaciated frame. Quite the contrary may be true. For example, one of the most robust, blooming young women I have ever seen had so extensive a pelvic tuberculosis as to necessitate the removal of uterus, ovaries, and tubes. Dr. Osier has dwelt with especial force upon the latency of the process in some eases when " the eruption takes place so slowly and so painlessly that the patient may not have presented a single symptom of abdominal disease." In one case a man died with a strangulated omental hernia, and an entirely unsuspected exten- sive fibrous tuberculous peritonitis was found on autopsy. A girl died of typhoid fever, and at the autopsy an extensive tuberculous peritonitis was found. One of my own patients (B. M., 14), forty-two years old, had been ill ever since her last child was born, five years before ; for a year she had noted an abdominal tumor growing in the left side. Her poor health was associated with a winter cough and pleurisy on the right side. I operated Oct. 18, 1889, and removed a left ovarian tumor as large as a cocoanut and a right ovarian cyst as large as a lemon. The ovarian tumor and the entire peritoneum were covered with miliary tubercles, the intestines were matted together in places, and there were 500 cubic centimeters of free fluid in the peritoneal cavity. The nodules were firm and hard and some of them pigmented, and a microscopic examination showed that they were tuberculous. She made a com- plete recovery, and died later of a malignant disease in the pedicle of the tumor. Sixteen out of twenty patients, or 80 per cent, are noted to have been in good condition with a good color, while but five, or 20 per cent, were poorly nourished, anemic, and sickly. TUBERCULOSIS. 139 The percentage of ill-nourished patients among the negroes was larger than among the whites, holding a relation of 25 to 16'66. Symptoms . — P a i n is the most constant symptom, and is referred to the back, lower abdomen, and pelvic organs ; it is usually persistent and associated with menstrual exacerbations. It varies all the way from a continuous ache or soreness to intense suffering, compelling the patient to stay abed. One patient will complain of a sharp and shooting pain with a sense of bearing down, in- creased by walking or exertion ; another speaks of a sharp, shooting pain during the monthly period, and at other times a dull soreness extending into the thighs, with giddiness. The abdomen is often distended with wind, and the distention may be per- manent or it may recur at intervals ; there is often also nausea and vomiting. I have been told by some women that they were suffering from " inflammation of the stomach." The blacks complain of a " misery " in the pit of the stomach. Intense pain in the ovarian regions and severe headaches are frequent. With the pain there is always a tenderness of the lower abdomen, so that the patient can not endure deep pressure nor stand erect with comfort. They of necessity adopt the posture and gait which are characteristic of the chronic lower abdominal inflammations. Poor appetite or dyspeptic symptoms were complained of by four fifths of my cases. Fever is sometimes absent and sometimes present, al- though the patients not infrequently complain of " chills and fever," with chilly sensations and sometimes night sweats. A persistent slight elevation of tem- perature between 99° and 100° is often seen, and more rarely a decided eleva- tion from 102° to 104° in the acute cases. Constipation occurs in one half the cases ; 20 per cent complain of pain in defecation, which may be attributed to the disturbance of the inflamed adherent surfaces during the act of straining. Pain in urination is the most characteristic of all the symptoms. Oiit of 20 cases, only 3 were free from it ; 14 complained of burning pain during micturition ; in 8 of these frequency of urination was added ; in 3 others there was incontinence with pain. The menstrual history is noted in 22 cases ; 2 of these had amenorrhea, 2 scanty flow, and in 3 the flow was more profuse than formerly. Dysmenorrhea was specially complained of by but 4 cases, while in 9 no change was noted at all. Leueorrhea was profuse in 8 out of 15 cases ; in 3 it was of an irritating character, and in 3 others the patient complained of the bad odor. There was a continuous blood-stained discharge in one instance. Diagnosis . — In attempting to make a diagnosis of tuberculous peritonitis before operation it is at once evident that those symptoms -most reliable and char- acteristic of tuberculosis of other organs fail us here. In many instances the healthy appearance of the patient and the good fam- ily history disarm any suspicion as to latent tuberculosis in the mind of one not specially familiar with its peculiarities. 14:0 TUBERCULOUS PERITONITIS. In three classes of cases, however, the diagnosis is not difficult to make : First, where extensive pulmonary disease is associated with pelvic inflamma- tory masses the presumptive diagnosis is that the abdominal trouble is similar in character. Second, where a persistent uterine discharge or uterine curettings are found to contain tuberculous foci, the inflammatory disease lateral to the uterus may confidently be asserted to be similar in its origin. Third, where there is pelvic inflammatory disease associated with irregular, ill-defined masses with fluctuation in the lower abdomen, and the latter are noted at subsequent examinations to have changed their relations to some extent, the diagnosis will be tuberculosis. The utility of tuberculin as a means of diagnosis still remains to be deter- mined. In making a diagnosis the surgeon must in many cases be guided by proba- bilities only, as the grounds for a positive assertion may not be found. The chief source of error lies in mistaking a simple pelvic peritonitis, or a pyosalpinx, or carcinoma of the ovary with effusion, or even an ovarian tumor, for tuberculosis. In a case in the hands of Dr. L. M. Sweetnam, with amenor- rhea followed by an irregular flow and severe pain, extra-uterine pregnancy was diagnosed, but the patient died later of tuberculosis. Again, a diagnosis of hysteria or of simple dysmenorrhea has been made where the affection was tuberculous. I made this mistake at the first examination of a large, healthy, florid young woman with many characteristic hysterical traits, who complained of constant pain in the pelvis, exaggerated at each period. She had general marked sensi- tiveness on pressure over the vaginal vault and the lower abdomen, but, on ac- count of the depth of the pelvis, the examination was unsatisfactory and noth- ing was felt. Fortunately, at a later date I made a more thorough examination under anesthesia and found ovaries and tubes still movable, but restricted by long adhesions. An abdominal section showed that ovaries and tubes and uterus were covered with tubercles, and the adhesions were numerous and only separable with difficulty ; the uterus, ovaries, and tubes had to be re- moved. A general practitioner will be peculiarly liable to commit this error in simi- lar cases, and he can only avoid it by insisting on an examination under anes- thesia, by a competent speciahst, in all cases where pelvic pain is persistent. Tuberculosis must be borne in mind in all cases of pelvic inflammatory disease with masses posterior and lateral to the uterus, with marked tenderness on pressure in the vagina or over the lower abdomen ; the probabilities are still greater if encysted accumulations can be felt in the lower abdomen, more espe- cially if a large amount of fluid has existed and been partially absorbed. I think the tenderness in tuberculosis greater and more persistent than in simple inflammation. The history of chills with fever, or the statement by the patient that she has had " malaria " or " dumb chills," must be carefully noted, together with pain TUBERCULOSIS. 141 in walking and pain in the back, and especially painful micturition. A phthis- ical facies will sometimes strongly suggest a diagnosis. One patient presented such a suggestive history as this : She was fir^t taken suddenly ill with high fever and general pains, and a constant painful, dry cough, with rapid breathing ; when these symptoms subsided the abdomen was noticed to be swollen, and by palpation I found distinct masses and loculi of fluid in the lower abdomen. The diagnosis was confirmed by operation. A negress was confined to bed two years before with a severe illness due to a lung disease ; she had had some cough ever since recovery, and caught cold easily. Four months before I saw her she had to go to bed on accoimt of ab- dominal pains and swelling, with fever. After the removal of adherent tubo- ovarian tuberculous masses she recovered her health and gained fifty pounds in weight. In numerous cases I have noted an enlarged uterus, as large even as a two and a half or three months' pregnancy — indeed, the possibility of pregnancy was seriously considered in three eases. The position of the uterus is variable ; it is, as a rule, fixed with the appendages by adhesions to the pelvic walls and floor. The cervix was softened in five of my cases. The lateral masses are often indistinctly outlined. I mistook one case seen for the first time on the operating table for a multi- locular ovarian cyst ; there was a marked prominence, with dullness of the an- terior part of the abdomen due to four liters of fiuid ; on the right side was a firm boss as big as a coeoanut ; the flanks were tympanitic. The pelvis was filled with an elastic mass bulging down the floor and pushing the cervix down and to the left, and the fundus could not be felt. The possibility of an encysted tuberculous peritonitis simulating an ovarian cyst in this way has been carefully considered by Dr. "W". T. Howard, of Balti- more {Trans. Amer. Oynecol. Soc, 1885, p. 41). Dr. Howard's patient was a negress, twenty-four years old. The abdomen was enlarged to the size of a seven month's pregnancy, and presented the appearance of an ovarian cyst. " The signs of a simple unilocular cyst seemed perfectly developed." She was suffering also from a pleurisy. The differential signs between tuberculous peritonitis and an ovarian cyst or a uterine fibro-cyst must rest first upon the history of the rapid growth of the effusion, upon the fact that the anterior part of the abdomen is tympanitic in peritonitis so long as the amount of effusion is small, and becomes dull and tense only when it has increased enough to lift the anterior wall well up from the mutually adherent intestines. The presence of tympany. in the fianks does not help to differentiate a cyst from an effusion in these cases, because the fluid is also encysted by the adhesions. Coincident pleurisy is a most suggestive sign. If the fluid is removed by tapping, the abdominal wall collapses and irregular hard masses are felt within. The most valuable means of arriving at a differ- ential diagnosis is by means of a thorough bimanual examination by the rectum and by the abdomen, at the same time drawing down the cervix so as to bring the pelvic organs within reach. A fibro-cystic tumor will in this way be differ- 142 TUBEKCULOUS PERITONITIS. entiated from a simple sacculated collection by the connection of the former with the uterus, and an ovarian cyst will be recognized by its pedicle. Car- cinomatous disease forming hard masses through the peritoneum, resembling those of tuberculosis, may often be recognized by distinct nodular and papillary masses felt in the pelvis. And in case of tuberculosis the small tubercle knots may sometimes be felt with perfect distinctness through the i-ectal mucosa. The tubercle bacilli are rarely found in the ascitic and encapsulated fluids ; they are found with difficulty in sections of the tubercles, while they may be abundant in cheesy foci and may also be found by crushing a tubercle and ex- amining it fresh on a cover-glass. It is sometimes necessary to make a pains- taking search before the characteristic bacillus is found, but a positive diagnosis may be made from a single typical organism. As pointed out by Dr. J. W. Williams, a large percentage of the adherent tubes and ovaries removed on account of chronic pel vi- peritonitis is in reality tuberculous, but the demonstration can only be made after a most painstaking microscopic investigation ; the diagnosis can not be made either before or at the operation. Tubercle bacilli may be discovered in a vaginal discharge when the uterus is involved, and, as already stated, one of the surest ways of making a diagnosis is by means of uterine scrapings, which exhibit tuberculous foci in a large per- centage of cases where the disease is advanced in the tubes. Sometimes, too, there is a marked affection of the uterus where disease in the tubes is still in its early stages. The peculiarities of these scrapings have been described in Chapter XIY, p. 489. I would briefly recapitulate the important clinical diagnostic points, and they are valuable just in proportion b.s a number of them are associated together, under these thirteen heads : 1. Often a sudden onset of the disease, it may be after pregnancy or a mis- carriage. 2. A history of chills with fever, or " malaria," but without the Plasmo- dium. Sometimes the stage of invasion is put down as " typhoid fever." 3. Gradual increase of swelling, terminating in a marked enlargement of the abdomen. 4. More or less constant abdominal pain increased especially by walking. 5. Pain in urinating. 6. Pelvic masses which can not be distinctly outlined either by palpation or percussion ; there is something puzzling and peculiar about the relations of the masses to the pelvic organs. I. Apparent change in the position of the masses in the abdomen noted at subsequent examinations. 8. Great tenderness on pressure at the vaginal vault and over the lower abdomen. 9. Sometimes an enlarged uterus. 10. Evidences of an encysted peritonitis. II. Emaciation — tuberculous facies. TUBEKOULOSIS. 143 12. Slight persistent evening rise of temperature, often with subnormal morning temperature, lasting for weeks or months. 13. The discovery of tubercle bacilli in vaginal or uterine secretions or in the endometrium after curettage, or more rarely in the fluid obtained by tapping a cyst by the vagina or by the abdomen. Treatment . — There can be no doubt but that many patients suffering from tuberculous peritonitis recover spontaneously, without any assistance what- ever. On the other hand, a large number become chronic invalids, showing but little if any change in their condition from year to year ; others again grow pro- gressively worse, until the whole peritoneum is studded with tubercles, and the intestines become mutually adherent, or effusion increases rapidly in quantity, greatly distending the abdomen, becoming at times purulent, and the neglected patient dies of exhaustion. JS^o treatment other than general hygienic measures is called for where the patient has had aa attack of peritonitis believed to be tuberculous, and is con- stantly improving ; but such a patient ought to be warned of the possibility of a recurrence of the attack and kept under observation. If a tender pelvic mass is found by vaginal examination, and it does not disappear in the course of several months, it should be removed. "When a patient comes under observation with pain, or ascites and pelvic masses, the only proper method of treatment is the removal of as much of the disease as possible by an abdominal section. With timely treatment all cases originating within the pelvis may be cured. Often even advanced and seemingly hopeless cases, apparently in the last stages, will recover after operation. Only those cases should be abandoned as hopeless where the patient seems to be actually dying, or where there is such an extreme state of prostration, without marked "effusion in the abdomen, that the attempt to remove adherent pelvic structures would be manifestly fatal within a short time. The curability of the disease by operation is abundantly demonstrated by my own experience. ISTone of the twenty-two cases cited above died from the operation, though one died a month later with numerous adhesions about the site of some tuberculous intestinal ulcers. One of those not included in this hst operated on in 1886 is now living and well. In a case operated upon by Dr. "W. S. Halsted at the Johns Hopkins Hos- pital, the capsule of the liver was found studded with tuberculous nodules, which were also distributed over the adherent intestines, the diagnosis being confirmed by the microscope. The patient recovered and went out; four months and a half later she returned and died in the hospital ward of pneu- monia. At the autopsy no adhesions were found between intestines, but a number of little withered, scattered, pigmented fibrous nodules proved to be tubercles containing in their center numerous bacilli. There were no tubercles in the chest. Thus the abdominal trouble had steadily retrograded and become 6ft 144 TUBERCULOUS PERITONITIS. innocuous, and the opportunity to examine it was due to the accidental occur- rence of a pneumonia. The object of the operation is threefold : First, to remove, if possible, the focus of the disease. Second, to remove all fluid exudate. Third, to release dangerous adhesions. The abdominal incision should not be more than 4 or 5 centimeters (l^- to 2 inches) long at first, and lengthened afterward according to necessity. In opening the abdomen an unusual vascularity of the walls is often noted, and the fat is frequently of a pale, unhealthy, watery appearance, like the fat which in the market con- demns meat to an experi- enced buyer, and the pa- rietal peritoneum may be 2 to 3 millimeters thick. The operator must in all cases, where the pa- tient's condition is good enoiigh, remove either one or both tubes and ovaries, if they are the seat of tuberculous dis- ease, and it is better tO' do this when it is possi- ble, no matter how much the disease has extend- ed beyond its original focus. It is hotter, too, where the omentum is extensively infiltrated and its utility as an ab- sorbent is lost, to remove it close up to the colon. Where both sides are extensively involved, as shown in Fig. 337, it will be better to remove the uterus too, on account of the probable involvement of the uterine mucosa. If the uterus is so buried that its enucleation presents unusual difiiculties, the tubes and ovaries may he removed separately, as shown in Fig. 338. If the ovary is simply involved in adhesions and the disease seems to be almost confined to the tube, this should l)e removed and the ovary left. This condition is sometimes found in the form of a salpingitis nodosa. Much care must be exercised in the enucleation on ac- count of the rigid friable nature of the structures, which tear widely if injudiciously pulled. In one of my cases the ovary and tube of the left side felt like a mass of bone. The difficulties will be greatly i'la. 83)j. -tueerculosts of the tube, posterior surface of the Left Ovaey and Tube. Note the thickening of the tuVie and the disappearance of the meso- salpinx. The fimbrite liave all disappeared, except a few little blunt budlihe processes. Path. No. 184. Natural size. i i -^ S "- -2 3 "^ pi t- -tJ ^*- O O C '" S " o " i^i c 21 = ^ o rf o o K ■S S X -- o tt ;-4 ■^3 O CD ^ C "■f^-rl ci c.-^ c £^ ^ m 5 i^Crt i£ >'Td ® ^ 'C! >1 a CJ S 13 C C= oj ■ii ;^ is ^ C = tt^ '^ C o ? "g.s o & o 03 CD = 3 t§ t~ r^' C3 £« c ^ 3^ ! ^ 5: ^ o •< ►? S.t ^ '=- i "a-a ° (D H-2 2 ?^ o ~ a> CI . TUBERCULOSIS. 145 lessened by a slow, painstaking enucleation, seeking out the points of vantage generally found beneath the ovary on the pelvic floor, and lifting the ovary and tube up and tying off the pedicle at both ends to include uterine and ovarian vessels. One serious difficulty is that, owing to the rigidity of the broad ligaments, the pedicle can not be brought up into the incision and must be treated down in the pelvis. I tore the rectum in separating dense adhesions in one case, and was obliged to suture it. In another case adherent small intestines were separated by leaving some of the inflammatory mass on the bowel. Sutures were also needed to repair several rents in the bowel. The details of the operation of salpingo-oophorectomy are given in Chapter XXVI. "Where the pelvic structures can not be removed, the operator must content himself with fulfilling the two re- maining indications, which must in any event always be attended to — that is, the removal of all fluid and the re- lief of the complications. The fluid of a tuberculous peritonitis is sometimes almost syrupy in consist- ence, and I have repeatedly noticed its coagulation as soon as it is exposed to the air ; at other times it is opalescent, brown, and full of flakes of lymph, or purulent. The spontaneous coagulability of the fluid resembles that sometimes seen in fibro-cystic tumors and considered pathognomonic of this affection by Dr. W. L. Atlee and others. Several writers have noted this error. Dr. Wil- liam T. Howard among others. All the serous and bloody fluid contained in the abdomen must be thoroughly sponged out after dropping the table to a level, so as to cause the fluid in the upper abdomen to gravitate toward the pelvis. Several liters may be evacuated in this way before the peritoneum is dry. Purulent collections are usually sacculated, and not infrequently in the mid- dle or upper part of the abdomen behind the anterior wall. In evacuating such an abscess care must be exercised not to open an avenue into the general abdominal cavity. Mutiple abscesses among the intestines are apt to be associated with intestinal tuberculosis, and unless easily reached without injury to the bowel, had best be let alone. Adhesions must be separated when a single loop of in- testine is found attached to the abdominal wall or pinned down in the pelvis, but the general adhesions uniting all the small intestines into one big saclike mass ought not to be touched, for, as is evident from the patient's history, the peristaltic function of the bowels is not interfered with by the general obliteration of the peritoneum where the normal mutual relaitions are preserved. Paradoxical as it may seem, a single adhesion of a knuckle of the small bowel or colon holding it down in some abnormal position, as to the pelvis or abdominal wall, is far more dangerous. 146 TUBERCULOUS PERITONITIS. A piece of the thickened parietal peritoneum, or of an afEected omentum, should be removed for microscopic examination, when the ovaries and tubes are not taken out ; one of the most satisfactory ways also of demonstrating the na- WEEK 123456789 ^-^ , -•-^^^ \ ■~~-~.^ .^^^ \ Normal Line ■"---. ^__^ Drainage Cases -Abdomen Closed Fia. 839. — DiAGEAM SHOWIIfG THE EeLATIVE AdvAWTAOES of GLOSING OE of DKAIIfllJG THE AbDOMEH Ilf THE Treatment of a Tubekoulous Peeitonitis. Beginning "with the day of operation the temperature dropped to normal, and recovery ensued in the drained eases by the ninth week ; in those which were not drained the temperature became normal and the convalescence well established before the second week. ture of the disease is by inoculating the peritoneum of a guinea-pig, which will develop tuberculosis and die within the course of two or three weeks. The nodular tuberculous masses may be crushed and examined under the microscope DAY OF DISEASE 1 2 3 4 5 6 7 8 9 10 HOUR E E Q. e' VO E Q. VO E W3 E VO E CO E Q- VO e" VO E a. VO e" pi VO e" d. VO e" VO E VO E VO £ a. VO E VO E Q. VO e VO E VO 102° 111 q: H 101° < LU 1 100° Ul 1- 99° 98° 3 1 I ) 3 c 2. > £ > ) A \y A A 3 i / V V V -^ V /^ V A A A I V V ' \ s/ f ' K / ■¥■ TEMP. 98.8/ /100.8 99.8 / ^00.7 99.5^ ^00.5 99.5/ / 99.9 99.3/^ /99.7 99.1 / / 99.4 98.6/ /99.4 98.7 / /99.I 98.3/ /99.4 98.4/ / 99. PULSE 92 / / 93 94 / / 104 98 / / 98 93 / / 92 88 / / 88 86 / / 90 88 / / S8 82 / / 82 78 / / 80 84 / /so -Temperature Fig. 340. — Composite Chaet showing the Coubse and the Disappeakanoe or Fevek aftek Opeeation IN the Cases of Tubeeoulous Peritonitis which were not Deained. TUBERCULOSIS. 147 during the operation to relieve any doubt existing as to the diagnosis between tuberculosis and peritoneal carcinoma. Drainage . — After completing the operation the abdomen should be closed without drainage, unless this is made necessary by some complication, such as the presence of pus, which can not be completely removed, or such an injury to the bowel as can not be satisfactorily repaired and may give rise to a septic peri- tonitis. It has long been the fashion to attribute the good results of operation in tuberculous peritonitis to drainage. I have abandoned all drainage in these cases for more than five years. FEBRUARY MARCH DAY OF 1 21 MONTH 22 23 24 25 26 27 28 ' 2 111 Q. 120 110 100 90 80 70 DAY OF IPE RATION 1 2 3 4 5 6 7 8 9 10 HOUR ^ 12 13 6 12 G 12 6 12 6 12 c 12 6 12 6 12 C 12 c 12 G 12 G 12 6 12 6 12 6 12 6 12 « 12 6 12 6 12 102° (01° 111 a: = ,00° 4 ae o UJ 99 a. 2 UJ 98 97° c ;jE .< •a Oilf / ^ \ \ fl' -A > E \ 0) ; ^ S' '1 V 7 \ V /•v V ■ft. / / ^ QC \ y f s/ V >• / /" ^J ^ ^^ V V 4 ■\ f \ CO / V 'S \/ i^ / 1 ' \^ < i' 'S V "i k^ A ^ + 'i \ s/ h ^ V ^^ V /^ •» + PULSE /102 124/ /112 108/ /II2 120/ /106 112/ /1I6 /108 104/ /lOO 100/ /lOO 100/ /lOO 96 / /so 110/ /104 / 76 /so 8t/ /84 /02 80/ /8t 76/ / 80 72/ / 76 r STOOLS I 1 1 1 1 1 .1 1 ' 1 1 ' 1 URINE 630 cc. 300 + Caih. 90CC.+ Cath. Lost Lost 280CC.+ Voided Lost Lost Lost _ Temperature Pulse Fig. 341. — Chart showih-o Eeoovekt after Eemoval of both Uterine Tubes and Ovaries in a Case OF Tuberculous Salpingitis and Peri-oophoritis and Tuberculous Peritonitis. No drainage was used, and the oontinuous line shows the speedy defervescence within a week after the operation. IC J., Feb. 17, 1S94. Gyu. No. 2597. Serious objections to drainage are that the track of the drain is liable to remain open indefinitely, much to the annoyance of the patient ; a drain also renders the patient liable to hernia. The following facts, however, are sufficient in themselves to settle this impor- tant question in favor of closing the incision completely. The cases referred to as drained are those in which the drain was inserted with a view of curing the disease, and not of providing for the complications above noted. The average duration of convalescence in six cases up to complete remission of the fever with drainage was 59 days. The average period of convalescence without drainage was 17'3 days. The longest duration of fever in a drained case was 71 days, and the shortest was 10 days. The longest continuance of the fever in a case which was not drained was 54 days, and the shortest 2 days. 148 TUBERCULOUS PBEITONITIS. This matter is so important that I present it here in a diagram, which shows the extraordinary difference in the two groups of cases, in the rapidity of the drop from the average temperature at the time of operation down to the base line of normal temperature. The angle between each of these hnes and the perpendicular might also, well be taken as the measure of the difference in advantage in the two meth- ods ; the smaller the angle the quicker the drop to the normal, and therefore the greater the advantage of the plan. I present here, also, a composite chart of all the cases which were not drained. It is constructed by adding up, in separate columns, the morning and evening temperatures of the group of cases under consideration, and dividing the sum in each column by the number of cases. For example, the composite temperature of the first evening, on the day of operation, in twelve cases, is the sum of all the temperatures for that evening divided by twelve, and so on for each morning and evening thereafter. We can do this with a degree of precision in surgical eases which will not be quite attainable in medical cases, because the operation gives a definite starting point. The great advantage of this method of investi- gating the temperature and pulse record is that it obliterates all individual peculiarities and reveals the average or the true type. In comparison with this I present the chart of a case (K. J., 259Y, Feb. 21, 1894), closely approximating the normal in its defervescence, but still showing individual peculiarities. In the drained cases the temperature curve showed marked daily variations, more like those of a septic fever. In the cases closed without drainage there was a gradual but regular drop down to the normal. CHAPTER XXIV. SUSPENSION OF THE TTTERTTS. 1. Historical review. 2. Simpler methods of treating retroflexion : 1. Manual reduction. 3. Pessaries. 3. Resection of lax outlet. 3. Indications for suspension. 4. Methods of operation. 5. Answer to objections to this method. 6. Operation : 1. First step, the incision. 3. Second step, introduction of index and middle fin- gers to elevate the fundus. 3. Third step, attachment of uterus to anterior abdominal wall. 7. Pinal results. « Historical Review. — Suspension of the nterus, ventrofixation, hysterorrhaphy, and hysteropexy are synonymous terms applied to a number of similar abdominal operations, all of which are employed with a view of permanently overcoming retrodeviations (retroflexions and retrover- sions) of the uterus by the formation of an artificial ligament or ligaments hold- ing the fundus in an anterior position. I first called attention to this mode of relieving retrofiexion in Germany in the spring and summer of 1886, when I also secured notes of unpublished cases similarly treated by Dr. Brennecke of Magdeburg, Prof. "Werth of Kiel, and Prof. Sanger of Leipsic, which were published with an original case of my own. Prof. Olshausen, of Berhn, who had the subject under consideration at the same time, was the first to publish a paper upon it, Oct. 23, 1886, entitled Ueber ventrale Operal/ionen bei Prolapsus und Itetvoversio Uteri {Cenfr. f. Gyn., No. 43, 1886). My own paper, entitled Hysterorrhaphy and describing a case operated upon April 25, 1885, was read before the Philadelphia Obstet- rical Society, Nov. 4, 1886, and published in the Amer. Jour, of Ohst., Jan., 1887. Since these publications the correction of retroflexions of the uterus by an abdominal operation has been widely and fully tested, and has undergone in different hands a series of modifications more or less useful. Simpler Methods of treating Retroflexion. — S uspension of the uterus should be resorted to only in cases of persistent retro- flexion which refuse to yield to simpler plans of treat- ment through the vagina, and then only when the dis- comforts of the retroflexion are sufficient to interfere seriously with health. In many cases the physician will be justified in extending his treatment over some months in the endeavor to bring the uterus into anteposition and keep it 149 150 SUSPENSION OF THE UTEEUS. there. One or more of the following three plans of treatment are serviceable to this end : 1. Manual reduction. 2. Packs and pessaries. 3. Resection of a lax outlet. For manual reduction the vagina should be cleansed and the anterior lip of the cervix caught by a corrugated tenaculum or tenaculum forceps (Fig. Pig. 342.— SuspENfiiON of the Uterus, seen from Above ; from a Case opened over Si.x Months AFTER THE SUSPENSORV OPERATION. Notice the long fibrous bands uniting the posterior surface of the uterus to the anterior abdominal wall. Jan. 6, 1896. 343) and drawn down toward the vagiiial outlet (Fig. 344) ; while it is held in this position the index finger is introduced into the rectum, and used to raise the fundus up into the pelvis, reducing the angle of flexion (Fig. 345). There is sometimes a sensible jump as the body of the uterus escapes from between the utero-sacral folds where it had lain incarcerated, often giving the false im- pression that there is a retroflexion with adhesions. As soon as the fundus is elevated in this way the cervix is carried back into the sacral hollow by means SIMPLER METHODS OF TREATING KETROFLEXIOK. 151 of the forceps, thus rotating the uterine body forward (Fig. 3i6). The rest of the reduction is now effected bimanually through the vagina and the abdominal walls. The fundus is caught with the abdominal hand pressing deep down into the pelvis, drawn forward and held there, while the vaginal finger indents the Fig. 343. — Steps in the Reduction of the Uterus in the Palliative Treatment of Retroflexion. The antei-ior lip of the cervhx is grasped with a tenaculum forceps and drawn in the direction of the arrow. uterus on its anterior surface at the junction of the cervix and body, and so brings it into complete antetlexion (Fig. 34Y). By further pushing the cervix high up toward the promontory of the sacrum and the fundus down behind the symphy- sis, the anterior position is exaggerated (Fig. 348). A Hodge, or a Thomas, or a Munde pessary will in some cases so far alleviate the symptoms of a retro- flexion, even though the flexion is not cured, as to obviate the necessity for an operation. Wool and boroglycer- ide cotton packs, used for a time, will also often tide the patient over a period of discomfort without op- eration. A marked relaxation of the vaginal outlet is often as. sociated with retroflexion where the flexion has followed parturition ; in such patients the discomforts often arise from the tugging upon the broad ligaments of a uterus working its way down to the outlet, and the simple flexion is not the cause of the pain. In a considerable number of these cases an oper- FiG. 344.- The traction straightens out the angle of flexion and brings the body of the uterus within easy reach. 152 SUSPENSION" OF THE UTEEUS. ation restoring the lax outlet relieves both the discomforts and the tendency to prolapse, although the flexion persists. When the patient is not relieved by this, an abdominal operation to correct the flexion may be resorted to later. !t'iG. 345. — The finger is then introduced into the rectum, and by pushing in the direction of the arrow a sliglit autehexion is produced. Indications for Operation. — Suspension of the uterus is not indicated in all cases of persistent retroflexion. The commonest group of symptoms calling for the sus- pension are a sense of weight, discomfort, or bearing down, aggravated by exertion, inability to walk with- out pain, backache, and pain in the lower abdomen and thighs. These symptoms are usually worse at the menstrual period, when the pelvic discomforts may be so great as to put the patient to bed for several days. As a rule, women suffering from re- troflexion are intensely nervous, liable to dyspepsia, palpitation, neuralgias, and headaches. The case is still clearer if all the symp- toms are relieved by rest. Back- ache is the most fallible symptom, and the surgeon must be cautious about promising its relief. Only rarely is the renal function inter- fered with by pressure on the ureters, giving rise to attacks of renal colic. Occa- sionally the pressure of the retroflexed fundus upon the rectum, causing obstinate constipation and great pain in defecation, is the chief indication for operation. Fio. 346. — The forceps are then used to carry the oervi.x well back into the pelvis. INDICATIONS FOE OPERATION". 153 A good way to test the probable effect of an operation for retroflexion is by lifting the uterus and supporting it on a wool pack or a pessary ; if this affords decided relief after a fair trial, the flexion may be con- sidered to be the source of the disturbance. Suspension should always be used in those cases which Dr. B. McMonagle has described as " tied to the physician's office by their ailment," now better and now worse, and so continuing indefi- nitely under treatment. A retroflexed adherent uterus is, as a rule, the result of a pelvic peritonitis primarily involving the tubes and ovaries, and a suspensory operation after freeing these adhesions is not advisable if they are very extensive. It only exposes a raw surface to the formation of intestinal adhesions, and if the tubes and ovaries are so diseased as to be practically useless, there is no advantage in keeping the dis- FiG. 347. — The flexion being in this manner reduced, the fundus is within reach of the hand palpating through the abdominal wall, grasping it and forcing it in the direction of the arrow; a flnger in the vagina at the same time pushes the cervix back into the sacral hollow. eased womb. I have, however, in many cases of general light pelvic adhesions, freed uterus and ovaries and then raised the uterus and attached it to the ab- dominal wall. In one case (E. B., 2701, April 6, 1894) I found the uterus alone adherent and both tubes and ovaries free ; the adhesions were easily severed and the uterus suspended. In prolapse of the uterus, as I have pointed out in Chapter XV, the operations on the cervix and vaginal outlet are generally sufiicient to hold the uterus within the pelvis. But when the vaginal floor is so weak and the vault so relaxed tliat there is doubt as to the sufficiency of the inferior sup- ports to retain the uterus unaided, the abdomen may be opened and the uterus attached to the anterior abdominal wall by its posterior surface, with great me- chanical advantage and a greater assurance of success. 154 SUSPENSIOK OF THE UTERUS. lifting, suffer more from Occupation has much to do in deciding upon an operation. "Women whose occupations require them to be more or less constantly on their feet and a displacement of the uterus than others whose life is less laborious. On the other hand, high- strung neurotic wom- en will suffer in the same way, while a phlegmatic disposition will experience no dis- comfort. I recall in this connection an ex- tremely neurasthenic hysterical woman who had spent four years on her back in a hydropathic establish- ment and recovered perfect health after operation. I once op- erated, unwittingly, on an epileptic patient in the first month of her pregnancy, and, in spite of the fact that she had from six to eight attacks daily, she went to terra. Dr. H. J). Fry, of Washington, operated upon a woman, ten weeks pregnant, with an adherent retroflexed incarcerated uterus ; after freeing and suspending it to the anterior abdominal wall, she went to term. Methods of Operation. — The method at first adopted of suspending the uterus by the fundus or l)y bringing up its anterior face against the abdominal wall I rejected over six years ago, on account of the mechanical disadvantage in which it left the uterus to resist subsequent retrodisplacement ; for a uterus lifted in this way hangs with its whole weight upon its attachments, and the perma- nent correction of the displacement must depend upon the strength of the adhesions binding it to the anterior abdominal wall. When, however, the body is brought into a decided anteflexion and attached to the abdominal wall by its posterior surface, it then lies in a natural position, and the forces of the intra-abdominal pressure are no longer exercised in adding to its weight and tearing it loose from its moorings ; on the contrary, the pres- sure then simply tends to lengthen out the adhesions and to increase the anteflexion, rendering a recurrence of the retrodis- placement less likely. My present operation, therefore, as carried out in over three hundred cases. Fig. 348. — The final step is the pioduction of an extreme anteposition of the fundus, and the insertion of a pack into the upper part ot the v.igina to hold the cervix up. METHODS OF OPERATION". 155 consists in the following steps : An abdominal incision just over the symphysis, the introduction of two fingers and elevation of the retrollexed fundus, bring- ing it into anteflexion, and its retention there by means of sutures through its posterior surface, lifting it up to the abdominal wall. Answer to Objections to this Method. — Three objections may be raised against the suspension of the uterus in this way to the anterior abdomi- nal wall : First, that such an operation substitutes a fixed, unnatui-al anteflexion for a retroflexion, and the suspensory operation is therefore not what it purports to be — a simple correction of the retroflexion with a restoration of the normal condition. Second, that an attachment of the body of the uterus to the abdominal wall behind the symphysis pubis, and resting upon the bladder, must inter- fere with the natural disten- . tion of this organ and so ex- i' ' '/ , '^ ■ •'^ ■.•■.■>-. i^-- \ cite dysuria. \ \ Third, that in the event of pregnancy occurring after suspension the patient's life might be imperiled by inability of the uterus to develop normally. An experience of six years has brought a satis- factory answer to each of these queries in favor of the operation. In the first place, the actual fixation to the abdom- inal wall lasts but a short time ; a few weeks after the operation the utei-us will be found, by a bimanual exami- nation, lying with the fundus behiud the symphysis and in a position of easy anteflexion at a distance from the anteri- or abdominal wall, apparently normal in every resjDect and in no way hindered in its movements until the attempt is made to throw it into retroflexion ; it will then be found limited in its movements in this direction by long adhesions between the fundus and the abdominal wall. In four cases where I have had occasion to open the abdomen at periods varying from one to three years after a suspensory operation the uterus was discovered each time lying in easy anteflexion with its posterior surface 3 to 5 Fig. 349. — Suspension cif the Utekus within a Year after THE (JI'EKATION. Showing the long fibrous bund connecting the fundus of tlie uterus with the anterior abdominal wall. This is continued down in the form of a thin septum over the bladder and ante- rior face of the uterus. May 27, 189(i. 156 SUSPENSION" OF THE UTERUS. centimeters (IJ to 2 inches) distant from the anterior abdominal wall, with which it was connected by a dense, smooth, fibrous band from a few millimeters to 1-| centimeters in breadth. In two cases there were two separate slender bands. In one case these suspensory cords were thicker at the ends and thinned out in the middle, and the suspensory sutures remained imbedded in the abdominal end ; in another case (Fig. 350) one suture lay at the abdominal wall and the other re- mained attached to the uterus. There was no tension on these lax bands, and it was evident from the relationship that the fundus of the uterus gradually sinks 1 . ■ i'lG. .350. — Suspension of the Utekus Seen a Year aftek the Okiginal Operation. Showing the long fibrous bands attaching the fundus to the anterior abdominal wall. One of the suspensory sutures has remained on the fundus, while the other is seen on the abdominal wall. March 2, 1896. % 'natural size. after the operation, drawing out the fibrous tissue connecting it to the anterior abdominal wall, until the womb comes to lie, without any tugging, in a natural, easy posture. Secondly, transient irritability of the bladder is occasionally observed, as after all sorts of abdominal operations, but it is not frequent or persistent or in any way peculiar to this operation. The fact is, that the female bladder expands physiologically, like saddle-bags, most from side to side, and least in an antero- posterior direction, and this method of distention becomes more marked in pregnancy. In answer to this objection it is also only necessary to recall the METHODS OF OPEEATIOK. 157 frequency with which the myomatous uteras was treated a few years ago by pinning the stump in the lower angle of the incision, and yet no untoward bladder symptoms were observed. Thirdly, a critical study of the effects of ventrofixation and of suspension of the uterus on a subsequent pregnancy has been made by Dr. C. P. Noble, of Philadelphia {Trans, of the Amer. Gyn. Soc, 1896). Dr. Noble has found that all the serious difficulties have been met with in the cases having broad adhesions between the uterus and the abdominal wall; but he did not find it possible in the collation of his sta- tistics to distinguish between the results of the various methods of operating. I have heard from forty -nine married women upon whom I have performed my suspensory operation at a date sufficiently remote to form a judgment as to the result ; they reported fourteen cases of pregnancy, and in only one of these was there any complication attributable to the suspensory operation ; that was one of my first Baltimore cases, operated upon Oct. 19, 1889, when the uterus was not suspended by the fundus but by the ovarian ligaments, and the con- valescence was delayed by an infection of the wound and discharge of the ligatures which bound the uterus firmly to the abdominal wall by broad dense adhesions. The patient became pregnant and fell into labor Jan. 16, 1894, under the care of Dr. Helena Goodwin, of Philadelphia (see Amer. Jour. Ohs., 1894, p. 370). Her labor began with a copious discharge of amnion stained with meconium. The breech presented, and the uterine contractions were regular and frequent. The cervix dilated with mechanical aid. She complained bitterly of pain in the left side and in the abdominal incision. The child, a large, well-formed male, was delivered instrumentally, and died of asphyxia ; the placenta came away normally, and a slight perineal tear was repaired. The afterpains were severe and long-continued, associated with ex- treme tenderness over the uterus and in the left side. Puerperal fever set in on the third day with a chill, and on May 7th the abdomen was opened, when the uterus was found firmly fixed to the anterior abdominal wall. There was a large mass of " exudate " on the left side, which explained the fever. The patient recovered. The methods of suspending the uterus generally in vogue produce wide- spread dense attachments of the fundus to the abdominal wall (fixation and not suspension), and are productive of the following serious difficulties in pregnancy and in labor : Difficulties during Pregnancy. — (a) Marked retraction of the scar due to the tugging adherent uterus. (b) Constant pain in the hypogastrium. (c) As pregnancy advances the cervix retracts into the pelvis and may even become displaced posteriorly up into the abdominal cavity. (d) The anterior portion of the uterine body fails to expand and forms a large, fleshy, tumorous mass, obstructing the superior strait. (e) On the other hand, the posterior part of the uterus may become as thin as tissue paper. 51 158 SUSPENSION" OF THE UTEEUS. (f) Abortion or premature labor may come on spontaneously. (g) Persistent excessive nausea may be due to traction on tbe scar (case of Dr. Cameron, of Montreal). Difficulties during Labor. — (a) Labor may be delayed some weeks beyond term. (b) The labor may be powerless, owing to tbe inability of the thinned-out posterior uterine segment to expel the fetus. (c) The labor may be obstructed by the mass of tissue in the anterior uterine wall, as by a tumor. (d) The proper expansion of the cervix is hindered by its abnormal position high up, even in the abdomen. (e) Malpositions, particularly the transverse and? the breech, are more fre- quent than the normal position. (f) The uterus in labor may tear loose from its moorings with the formation of a large hematoma at the point of rupture. In order to relieve these complications, a variety of obstetric operations have been found necessary, such as turning, the use of the forceps high up, crani- otomy, and celiotomy and amputation of the pregnant uterus. The most important practical suggestion, made by Dr. Noble, is to induce labor at the eighth month if the cervix begins to pull up out of the pelvis. I am able to answer the important question as to the behavior of the arti- ficial ligaments during pregnancy and labor by the following observation : J. A. H., San. 332, was operated upon for retroflexion June 26, 1892. She became pregnant and at the calculated time. May 30, 1896, labor pains set in, and she gave birth spontaneously to a male child weighing 9^ pounds, after nine hours of normal labor. The only noticeable peculiarity of the labor was a right obliquity of the uterus and an unusual prominence of the abdominal wall. After the labor was over I could distinctly feel the suspensory band by pushing the finger in through the umbilical ring and at the same time pulling out the scar in the lax abdominal wall ; the long, tense suspensory could be traced in this way from the anterior abdominal wall below, over the top of the uteriis,. to its posterior face, where it was attached a little to the left. Operation. — The bladder is emptied by catheter, and the customary prepa- rations made for opening the abdomen, after which the pelvis is slightly elevated. The first step is the making of an incision 4 to 5 centimeters (1^ to 2 inches) in length through the abdominal wall in the median line, ending at a. point within 2 centimeters of the symphysis. The peritoneum is opened the full length of the skin incision, and caught with artery forceps in the middle on both sides, drawn out, and the forceps laid on the abdomen. This step insures the retention of enough peritoneum to close the peritoneal wound separately at the end of the operation. The second step is the introduction of the index and middle fingers- into the abdominal cavity to elevate the fundus ; they are slipped down behind the symphysis, and over the bladder and the anterior face of the retroflexed uterus, until the fundus is reached on the pelvic floor. If there are any adhe- OPERATION". 159 Bions holding it down, they must be separated by gradually introducing one or two fingers behind the uterus and slowly peehng it up, breaking the adhesions a few at a time, until it is finally freed. Dense adhesions must be severed with knife or scissors under inspection, through a larger incision, carefully drawing Fio. 351. — Upper Eleyatoe. To use in conjunction with the lower elevator in isolating and holding up the uterus during the passage of the lirst suspensory suture. The upper posterior face of the uterus lies in the convexity of the elevator. 3^ ordinary size. the uterus away from the rectum and pelvic fioor so as to make a space large enough to cut between without injuring either organ. "When the ovaries and tubes are so diseased as to require removal, the uterus is taken away too instead of suspending it. Two fingers are hooked under the retroflexed fundus, which is lifted out of its bed and the uterus drawn forward until the fundus lies behind the symphy- sis, with its posterior surface turned up toward the incision. If the intestines crowd into the incision so as to embarrass the fingers in exposing the uterus, a For holding up the uterus for suspension when the pelvis is deep. The anterior face of the uterus rests in the hollow of the elevator. 3^ ordinary size. sponge slipped down behind the fundus usually clears the field. When the pelvis is deep, or the abdominal walls thick, or the uterus from any other cause is difiicult to bring into view, an elevator (see Fig. 352) serves as a temporary artificial point of support, against which the uterine body is held while the first suture is passed through the fun- dus. The elevator used in this way gives a point of sujDport which takes the place of the symphysis under ordinary circumstances. I sometimes use two ele- vators with advantage, one in front and one behind the uterus. The same end may be attained by catching the fundus mth a pair of tenaculum or rat-toothed forceps, drawing it up into the incision, and holding it in view until the first suture is passed. The third step is the attachment of the uterus to the abdominal wall ; this is done by raising one side of the lower angle of the incision with two fin- gers in order to expose the inner surface ; the peritoneiim and subperitoneal tissues parallel to the incision are now transfixed at a point 1 to 1^ centimeters away, including an area 8 to 10 millimeters broad (see Figs. 354 to 356). The fundus uteri is next transfixed by the same needle carried transversely through a part of the posterior surface of the uterus 1 or 2 centimeters below a line con- 160 SUSPENSION OF THE UTERUS. necting the uterine tubes ; the suture takes in uterine tissue about 1 centimeter in breadth and 3 to 4 millimeters in deptli. The needle is next carried through the peritoneum and subperitoneal tissue on the opposite side of the incision at a point corresponding to the first side. The intermediate silk suture is now drawn through and pulled tight, and the three points transfixed by it — that is, the uterus and the peritoneum on both sides — are brought snugly together. A finger is introduced before tying the suture, and a careful examination is made to make sare that no loop of intestine or bit of omentum has been caught between the uterus and the abdominal wall. The first suspensory suture is then tied and the ends cut off close to the knot. A second suture, re-enfor- cing the first, is now introduced with \ 1 1 1 s ^ ^ — " i \i "^d| \ A ■V: I 7" ''' / \ N (-. - C ' "■■ ^'! \ 'i I "'r--. \/y -^. ^ '"-■:. u / '.J v-t^y^J'^-^ ^ JbWSxRfp'^'^ Fig. 3.53. — Suspension of the Uterus, showing Elevation of the Uterus with the Lower Elevator. The uterus is held up in this way while the first suture is passed. greater ease ; it transfixes a corresponding portion of the abdominal wall on both sides about 1 centimeter above the first suture and the uterine tissue 1 centimeter below it; tliis is also drawn up snugly, tied, and cut off close to the knot. The uterus is lifted up and held in anteflexion by the first suture, while the second brings more of its posterior surface into contact with the abdominal Fig. 354. — Suspension" of the Uterus. Showing the two silk suspensory sutures passing through the peritoneum, the movable subperitoneal fat, and connective tissue on both sides, and through the posterior surface of tlie uterus in the middle. The suture nearest the symphysis is always tied before introducing the second suture. OPERATION. 161 ■wall, still further increasing tlie anteflexion. More than two sutures are not needed unless there is an unusual ajnount of dragging. Before closing the abdomen the omentum is drawn down and a final careful examination is made by slipping the finger over the posterior surface of the uterus, around its sides and in front of it, to make sure that no loop of intestine has been caught at any point. The abdominal incision is closed first by uniting the per- itoneum with a continuous su- ture, then the remainder of the abdominal wall is brought together in the usual manner wfith a single buried silver- FiG. 355. — Suspension of the Uterus as seen priim Above. The uterus is attached by a silk suture to the fundus on a line posterior to the uterine tubes, as shown. The cut edges of the peritoneum should be united over this suspensory suture; the fascia is united over this, and the skin over all. wire suture, with catgut above and below it for the fascia, or by using catgut alone for the fascia, and catgut for the fat and the skin. In some cases, in order not to leave any visible scar, I have opened the abdo- men by making a transverse incision in the skin just below the line of growth of the pubic hairs ; the edges of the incision were then drawn up and down and the rest of the in- cision made in a vertical direction. A few months after operation such an incision is entirely concealed from view. During the first four days, if necessary, the bladder should be emptied by catheter or spontane- ously every three or four hours, and after that the interval should not be longer than four to six hours. Dr. C. P. Noble has seen two cases in which the suspensory sutures have been pulled out dur- ing the convalescence by an over- distention of the bladder. His rule is always to use a catheter if Fig. 356. — Suspension or the Uterus. . . , , . .» ^. , . , . . , , . , there is persistent pain, even it Diagram showing the position of the uterus in retro- ■■ _ ^ ' _ flexion in dotted line, and the position of the uterus held the bladder lias jUSt been emptied, in anteflexion by the two suspensory sutures. Mote the ^j.. , , . j yielding of the peritoneum. IhC bOWCJs SllOUld DC mOVCd 162 SUSPENSION OP THE UTERUS. forty-eight hours after operation. It is not necessary for the patient to remain lying in the dorsal position, and she may without risk be gently turned on either side for rest or sleep. The convalescence is managed as after an ordinary ab- dominal operation, with the additional precaution of keeping the patient three weeks in bed and urging the necessity of moderate exercise for three or four weeks longer ; no heavy work or lifting should be done for at least three months. Examinations made some months or even years afterward will show that the cervix lies well back in the pelvis, while the body* lies in anteflexion with the fundus behind the symphysis. The body is separated by an interval of 2 or S centimeters from the abdominal wall by the stretching of the adhesions formed about the suspensory sutures, and there is a free mobility in every direction ex- cept backward. I summarize an analysis of 75 cases, made from one to two years after opera- tion, by Dr. J. E. Stokes, of the Johns Hopkins Hospital : Of these 75 cases, 49 were married and 26 were single. The 49 married women reported 14 pregnancies ; 9 were absolutely normal ; of the remaining 5, one case suffered from the beginning of gestation with abdominal pain ; one patient now pregnant feels wretchedly, with pain over the abdomen ; another case miscarried after " violent dancing " ; in two more cases the " placenta was retained." In general, 27 cases were entirely relieved of their discomforts, 37 were greatly benefited, and 11 were unrelieved. CHAPTEE XXV. CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. 1. What conservatism is. 2. Reasons for conservatism. — 1. The highest aim of surgery. 2. Importance of the conserved structures : a. Mental attitude of the patient, i. Menstruation important, c. Ovulation and pregnancy important, d. Internal secretion. 3. Better knowledge of pelvic diseases. 4. Only the diseased portion of the tube or ovary need be removed. 5. Regeneration of diseased tissues is often possible. 6. Removal of ovary and tube together for purely tech- nical reasons not necessary. 3. Relative importance of ovaries, uterus, tubes. 4. Limits of conservatism. 5. Objections to conservatism. 6. Conservative operations on the ovary : 1. Ovary not removed. — a. For tubal disease, h. In many cases of parovarian cyst. c. In extra-uterine pregnancy, d. In hystero-myomec- tomy. 2. Ovarian adhesions (peri-oophoritis). 3. Multiple and small Graafian cysts. 4. Enlarged cystic Graafian follicles. 5. Cyst of corpus luteum. 6. Hematoma. 7. IDermoid cysts. 8. Ovarian cystoma. 9. Ovarian abscess. 7. Conservative operations on the uterine tubes : 1. Release of adherent tubes. 2. Opening or resection of closed tubes. 3. Emptying, cleansing, or sterilization of inflamed tubes. 4. Amputation of diseased tubes. 5. Exsection of diseased or of strictnred tubes. 6. Drain- age of tubal abscess. 7. Preservation of the tube or closure of the rent in some cases of extra-uterine pregnancy. 8. Results of conservatism. 9. Cases of pregnancy after conservative operations. Gynecological conservatism has come to have a new meaning within the past ten years, and it is now the distinctive attitude of the newer and better surgery as contrasted with the widely prevailing radical methods of the last decade. Conservatism is the effort to spare as much as possible of the pelvic organs during an operation, and to conscientiously avoid the removal of any organ or any portion of an organ that is sound, as well as of organs or parts which, though not sound, are deemed capable of regeneration ; or, if diseased, to avoid remov- ing organs whose presence is not incompatible with life or fair health. Fifteen years ago the statement that an operator was conservative meant that in removing a diseased ovary and tube it was not his habit to remove also the opposite sound ovary and tube, under the assumption that "the disease was liable to recur in the opposite side." Even yet the pernicious practice prevails in some places of removing ovaries for dysmenorrhea, and of removing ovaries exhibiting several or more unrup- tured Graafian follicles under the assumption that they are diseased. It is only a few years since the rule prevailed widely in regard to pyosalpinx of one side that the opposite side must always be removed too. The first telling argument in behalf of conservatism was made by Sir Spen- cer "Wells (Ovariam, and Uterine Tumors, London, 1882, p. 342) in his report of 163 164 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. 1,000 cases of ovariotomy in tabular form, with a note of tlie after-history of each case. An analysis of this table made for me by Dr. J. H. Durkee shows that the ovariotomy was unilateral — that is, that one ovary was left — in 228 women who survived the operation and were under forty years of age ; of these 228 women thus left capable of bearing children, 120 actually did bear 230 children ; to the women in this group who were over forty years of age four children were born. That is to say, there was an average of one child to every young woman with one ovary left in, and there was a recurrence of the disease in the remaining ovary, necessitating operation, without a death, in but six women. The com- parison of the advantage and disadvantage of leaving in an apparently sound ovary is therefore, in each case, the average chance of having one child, as con- trasted with the risks of a recurrence of the disease in 2-6 per cent of the cases. If the mortality of ovariotomy is 5 per cent, then the risk of death is thirteen to one against it even if the disease does recur. C. Schroder {Die Excision von Ovarientumoren mit Erhaltung des Ova- rium. Zeitschrift f. Gel. und Gyn., Bd. xi, 1885, p. 358), by the resection of the ovaries, A. Martin {Ueler partielle Ovarien mid Tvhen Extirpationen. Sarnim. Tdin. Vort., 1889, p. 2481), in the resection of ovaries and in opening closed tubes and by extensive myomectomies, and Dr. W. M. Polk {Are the Tubes cwid Ovaries to he sacrificed in all Cases of Saljnngitis f Trans. Amer. Gyn. Soc, vol. xii, 1887), by his repeated demonstrations and earnest insistence upon the possibility of restoration of function in diseased adherent tubes and ovaries and of the functional value of opened and amputated tubes — have all helped to lay the foundation stones for the important conservative gynecological work in the immediate future. The reasons for Conservatism are : 1. That it is the general attitude of all true surgery. 2. The important uses and relation of the conserved structures to the human organism. 3. The recognition that what were once considered diseases of the tubes and ovaries are in many instances no diseases at all. 4. The recognition that a disease of part of a structure, ovary, tube, or uterus may only demand the removal of that portion which is diseased. 5. The discovery that in certain diseases an entire regeneration may take place and badly diseased tubes may again become normal in their functions. 6. On account of the value of the structures involved, ovary and tube are no longer removed en masse for purely technical reasons, but a diseased tube or part of a tube, a diseased ovary or part of an ovary, is removed by itself, each without interfering with the other. 1. Conservatism the highest aim of surgery. It is almost an aphorism in general surgery that exsective surgery is its op- probrium, and no conscientious surgeon removes a limb or part of the body which could be restored to its usefulness by a careful conservative treatment. I shall never forget the impression made upon me, as a hospital resident in 1882, EEASOiTS FOR CONSERVATISM. 165 "wlien I saw a boy brought in with a clean compound fracture of one forearm and simple fractures of the radius, ulna, and humerus of the other arm, and the surgeon amputated both arms ! If the traditions of surgery and its best principles all point toward conserva- tism as its highest goal, there is no reason for making any exceptions to these rules in the special field of gynecological surgery. 2. The importance of the conserved structures to the wel- fare of the patient. The pelvic organs are indelibly associated in a woman's mind with those fundamental difPerences between the sexes which impress upon the female or- ganism all that is distinctive and peculiar in her attitude toward the world at large ; and with the healthy performance of her functions in the recurring monthly fluxes, ovulation, and the possibility of conception, lie, though the woman may be unconscious of it, some of the deepest wellsprings of her hap- piness. The effect of the removal of the sexual organs in woman is, in many in- stances, entirely analogous to the corresponding operation upon a man, disturb- ing her psychical and physical balance, and bringing on a state of wretched confusion in the new and anomalous relationship in which she finds herself. Menstruation has often been denounced as a useless, troublesome function, entailing discomforts and impeding woman's progress ia all competitive work, but we are now beginning to realize that so long as its cyclical changes persist, they hold most important fundamental relations to the well-being of the body at large ; and while we are as yet unable to state what is definitely accomplished by the act in the way of excretion, or its influence on metabolism, we do know that the sudden artificial induction of the menopause is often a source of ex- treme and lasting discomforts (see Chapter XXVI). It is still a matter for future demonstration whether or not these sequelae are in all cases obviated by leaving in one or both ovaries when the uterus and tubes are removed and men- struation so checked. Ovulation and pregnancy under suitable conditions are, to a degree utterly unappreciable to the male mind, essential elements of woman's happiness. To dwell upon this point would be but to reiterate what any attentive surgeon may gather from his daily experience in the consulting room, and to rehearse well- known facts in the history of womankind. C. Schroder stated that one of his reasons for the preservation of part of an ovary was to preserve the function of ovulation, even if it were ac- companied by but a theoretical possibility of concep- tion. I have dwelt in another chapter on the profound psychic changes and melancholia often brought on by the surgical, forcibly induced meno- pause. Internal Secretion . — There is a growing conviction that the ovary belongs to the same group of organs as the thyroid, thymus, and pineal glands, and that, in addition to its function of ovulation, it secretes a substance which is absorbed and consumed in the animal economy, and which is necessary to it in 166 CONSEEVATIVE OPERATION'S ON THE TUBES AND OVARIES. retaining its physiological balance (see C. H. F. Eouth, Brit. Gyn. Jour., May, 1894). The argument in behalf of the existence of this substance, which we might call " ovarine " were it not for the illegitimate trade uses for which this term has been appropriated, does not yet rest upon the basis of an absolute demonstra- tion, but rather upon the strong analogy which may be drawn between the ovary and the internal secretive glands named, and as evidenced by the disastrous con- sequences following its removal during the period of its functional activity. C. Martin says {Brit. Gyn. Jour., Nov. 1893, p. 273): "It is probable that the ovaries, like the liver and thyroid gland, modify the blood circulating through them, and add to the blood some peculiar product of their metabolism. It may be that some of the climacteric symptoms are due to the loss of this substance from the system." An active principle called " spermin," found in sperm by Schreiner in 1878, has been found in the thyroid and thymus glands, and in the spleen, ovaries, testes, and blood, from all of which it has been extracted in the form of an in- soluble spermin phosphate. A. Poehl (Z. Erhl. d. Wirk. d. Spermins als. physiol. Tonicum aiif die Aiotointoxicationen. Berl. Tdin. Woch., Sept. 4, 1893, p. 873) has elaborately studied this product, and found it in both the male and the female reproductive organs, and as a normal physiological constituent of the prostate, testicles, ova- ries, thyroid, thymus, pancreas, and spleen, as well as in the blood. The crystals of spermin were separated from the semen in a form similar to the Charcot-Leyden crystals of Boettcher, with which they were for a long time confused. Spermin is, as A. Gautier has declared, a leukomain believed until recently to be a product of the retrogressive metamorphosis of an albumen, either injurious or indifferent to the organism ; evidences now in hand, how- ever, go to show that spermin possesses most valuable functions in connection with the activities of living beings, and the spermin secreting and elaborating organs may be called the " apothecaries " of the body, secreting many impor- tant medicaments much more active and more accurately representing its true wants under varying conditions than any artificially administered drugs. Spermin is an active oxidizing agent, assisting by its catalytic action in restoring the oxidizing power of the blood without having recourse to the oxygen derived from the air ; this action is remarkably illustrated by the introduction of a small quantity of spermin with metallic magnesium into a watery solution of the chlorides of the noble metals, and some others (AuCljjCuCl^, etc.), when the metal is converted into magnesium oxjde, the needed oxygen being taken from the water. Spermin has shown a favorable action when given to patients suffering from diabetes, scurvy, etc., in which auto-intoxications are manifestly the result of an accumulation of retrograde products ; injected subcutaneously, it acts as a physiological tonic in all kinds of depressed conditions, such as neurasthenia, anemia, etc. Poehl declares that it increases the nitrogenous excreta of the kidneys. Its action is enhanced by the alkaline condition of the blood. REASONS FOR CONSEKVATISM. le*; More positive evidences for an internal secretion of the ovary are furnished by the experiments upon bitches made by G. E. Curatulo and L. Tarulli {La 8ecrezione Interna delle Ovale, Rome, 1896). These authors, after regulating the diet of the animals until a certain average quantity of nitrogenous materials and phosphates were excreted daily, removed the ovaries. In each experiment they found the phosphates (PjOJ in the urine greatly and permanently reduced in quantity. In one case, where the nitrogenous materials averaged 9'93 grammes and the phosphates 1"5 gramme, a series of daily observations was continued over three months, and demonstrated the fact that, while the nitrogen remained about the same in quantity, the phosphates decreased down to 0'6 gramme. These data are of such great importance as affording one of the most tangible evidences as yet offered of the existence of this third secretive ovarian function that I present here three of the tables taken from their book, in condensed form. The upper line of figures in each case shows the condition of the bitch before operation ; following this are given the dates of the succeeding observa- tions and the condition of the animal at each date ; the last line shows what may be considered as the average effect of the castration upon the urine some months after operation. Table showing the Effect of Castration upon the Composition of Urine. November 14 December 14. January 14 . . Pebrnary 14 . March 9 April 24 Mav 5 June 23 July 13 March 9 April 9 May 8 June 9 July 6 April 1.5 May 15 June 15 Weight of animal, Urine in 24 hours, Azote elim- inated, gr. PaOe emitted, gr. I Dog A, both ovaries taken out November 1.5. 9,500 7,520 8,720 9,750 10,260 9,220 10,200 10,170 11,900 795 740 910 960 860 960 1,065 680 700 9-230 9-870 10-310 10-870 10-790 9-060 10-600 9-100 10-690 1-710 0-740 0-700 0-665 0-650 0-.576 0-860 0-460 0-560 Dog B, both ovaries removed March 10. 11,160 12,800 13,900 1,500 16,459 840 870 900 700 620 13-64 18-40 14-20 12-93 13-20 1-51 1-04 0-86 0-98 0-93 Dog C. uterus and ovaries removed April 24. 5,250 5,650 6,300 470 530 500 -13 -18 •86 0-65 0-32 0-27 These experiments also explain the utility of castration for the relief of osteomalacia, in permanently diminishing to such a- marked degree the excretion of the lime salts which go to form the solid elements of the bones. Associating Ouratulo's results with the evidence given by Poehl of the high oxidizing power of " spermin," we may attribute the effects of castration in de- 168 CONSBETATIVE OPERATIONS ON THE TUBES AND OVARIES. creasing the phosphates in the urine, not to the lessened quantity taken in the food, but to a diminished oxidation of the organic phosphates contained in the tissues, which, combined with earthy bases, are finally deposited in the bones in the form of calcium and magnesium phosphates. Eouth (ut sup.) gives further important evidence of the existence of an in- ternal ovarian secretion in citing Dr. AirstofE's investigations, which show that when one ovary is removed in a rabbit the other under- goes a compensatory hypertrophy increasing both in size and weight, the follicles mature and wither more quickly, and the medullary por- tion increases. These changes begin within two months after the operation, and in three or four months the remaining ovary has become nearly double its ori- ginal size. Since the ill effects of castration in women, whether the structures are diseased or not, are often so disastrous, it becomes a question of paramount importance to determine whether we can in any way substitute the lost ovarian tissue, and to this end two natural lines of experiments have been tried. E. Knauer (Cen. f. Gyn., No. 20, May 16, 1896, in a communication entitled Einige Versuche iiber Ova- rientransj)lantation bei Kaninchen) has shown that the ovaries may be completely severed from their normal surroundings and successfully transplanted either to a part of the broad ligament or between the muscles of the abdominal wall. In one of the rabbits experimented upon and examined six months after the transplantation, one ovary excised and implanted in the broad ligament was found as big as a lentil and abundantly nourished, with a normal stroma and numerous follicles of all sizes containing ovules ; a number of degenerated follicles was also found, perhaps more than usual. An ovary implanted in the fascia of the abdominal wall was only about a third its original size, but was in other respects normal. The important conclusion may therefore be drawn that the ovaries may be transplanted even to a distant point differing widely from their normal habitat, where they will not only grow, but will also continue to develop normal Graafian follicles. It still remains to be shown whether these follicles rupture, and of what use transplanted ovaries may be to the animal economy. The second line of experimental substitution of the lost ovarian tissue is that of feeding to the women deprived of their ovaries one of the various organic juices. This has been tried by R. Chrobak {Centr. f. Oijn., No. 20, May 16,, 1896) in a few cases with distinctly encouraging results. The ovaries of cows, washed in ether and alcohol and dried at a temperature of 45 to 50° C. with an air pump, and then pulverized and made into tablets con- taining 0'2 gram of ovarian substance each, were used. Two, three, or even four of these tablets were given daily to women suffering from the severe symp- toms of an ii^duced climacteric ; in one case, after taking two or three tablets daily, the attacks of giddiness, flushes, and sweatings, which the patient had been REASON'S FOR CONSERVATISM. 169 having on an average of ten times daily, were reduced to three, and disap- peared entirely at night ; another patient was entirely relieved of attacks which had been distressing her five or six times a day ; in another case, with frequent attacks, as many as twenty a day, they were reduced one half. If the ovary and thyroid gland both secrete a similar principle, spermin, or if the ovary secretes a principle which is then elaborated for use by the thyroid gland, it is manifest that good results might be expected by the administration of the thyroid gland, or of the thyroid extract, for it shows such remarkable powers of retaining its identity, even in the presence of mineral acids, that it might well be expected to withstand also the chemistry of digestion. A valuable contribution to this line of observation has been made by Dr. H. B. Stehman, of Chicago {Amer. Oyn. and Ohs. Jour., Feb., 189Y), who gave thyroid tablets to a series of patients, suffering from various forms of mental and other disturbances, such as excessive flow, amenorrhea, extreme nervousness, and ovarian pains, all of which might, under the present hypothesis of the func- tion of the internal secretions, be attribiited to deficient ovarian secretion. Each tablet given three times daily represented about one sixth of a sheep's thyroid. In each of the six cases such a remarkable improvement was observed within several weeks that the conclusion seems well-founded that " in those cases of neurasthenia, with poor nutrition, and in consequence disordered pelvic func- tion, ovarian tissue is indicated. The extract not only modifies the nutrition of the ovary, but also general nutrition, and this return to the normal makes physiologic processes possible." There exists probably " an intimate nutritive relation between the pelvic generative organs and the thyroid, and the ovary shares, too, in some mysterious manner in the processes of general metabolism." 3. A further reason for the advance made in conservatism is the more intelligent discrimination exercised in regard to pelvic diseases, the result of broader clinical observations, associated with careful microscopic examinations of tissues removed. This has had the effect of com- pelling gynecologists in general to abandon all enucleations of " cystic ovaries," except in rare cases where the ovary is so greatly hypertrophied as to be con- verted simply into an aggregation of cysts with the albuginea greatly thick- ened. A few prominent cysts with clear walls often exhibited in the past as evidences of a "cystic degeneration" are now considered as either entirely nor- mal, or so near normal as never of themselves to justify the removal of the ovary. " Cirrhosis of the ovary " is still another much-abused term, used even yet to describe the product of a chronic infiammation of the ovary which does not exist as a pathological entity. The so-called cirrhotic ovaries are simply contracted hard bodies, for the most part the result of a protracted malnutrition of the organ, often due to displacement and surrounding adhesions binding it down and cutting off its circulation. Adhesions of the uterus and adhesions surrounding the tubes and ovaries are often but the evidences of an old attack of pelvic peritonitis due to an infection starting in the mucous surface of the uteras and propagated through the uterine tube ; the original disease has, in many instances, long since run its course, and 170 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. the lymph bands and adhesions left behind uniting the peritoneal surfaces of the pelvic viscera do not signify any existing disease of the organs themselves. If these adhesions are severed and the accidentally imprisoned organs released, there is no reason, in many instances, why their normal functions should not be re-established and the symptoms relieved without extirpation. In this connection C. C. Burrows (Amer^ Jour. Ohst., vol. xxviii, No. 6, 1893) furnishes us with a most instructive case of regeneration. A patient was operated upon and a purulent tube and ovary were removed from the right side ; adhesions about the left tube and ovary were broken up, the closed end of the tube was opened, and the cystic ovary was resected, about one third of it being removed. On opening the abdomen a year later to cure a ventral hernia, the tube and the ovary were found free from adhesions and perfectly healtliy, the fimbriated extremity was open, and no evidences of the ovarian resection could be found ; the health of the patient was perfect except for the hernia. The general rule may then be laid down that adhesions of the ovaries and tubes to the pelvic floor, pelvic walls, or to the broad ligaments, uterus, and intestines, never constitute per se a valid reason for the removal of these structures, and if these organs are removed the reason for the extirpation must be grounded in the actual con- dition of the organ itself. 4. When the disease affects only a portion of a struc- ture, the rule is that the diseased portion should be re- moved and as much as possible of the sound tissue left. For example, if the outer extremity of the uterine tube is extensively altered by cicatricial changes the end of the tube may be amputated with a good hope of restoring its function ; this procedure will be illustrated in discussing the technique of conservative operations. If an ovary shows cystic degeneration, the cyst, whether Graafian or corpus luteum follicle, may be exsected and the sound tissue left. Even in the case of small ovarian abscesses, 2 to 4 centimeters in diameter, I should advocate open- ing the abscess, removing its lining membrane or curetting it, and sewing up and saving the ovary. There is the best clinical evidence to show that even a small bit of ova- rian tissue left behind, or the stump of an amputated tube, may not only per- form its ordinary functions, but may even contribute and carry an ovum to be lodged in the uterus, and go through the evolutions of a normal pregnancy. 5. The regeneration of inflamed tissues has also been abun- dantly demonstrated by the best clinical evidences ; after draining large pelvic abscesses, the pelvic organs have at a later date been found perfectly restored ; uterine tubes presenting a parenchymatous salpingitis have been dropped back and later found healthy, and the best evidence of their perfect function given by the occurrence of pregnancy. In hydrosalpinx, although distended and thinned by the pressure of the accumulated fluid, the tubal walls preserve their normal epithelial covering, and LIMITATIONS OF CONSERVATISM. lYl after opening the ostium or cutting ofE the ampullar end the tubes may resume their functions perfectly. 6. The sacrifice of the tube and ovary is often due to purely technical reasons on account of the habit among operators of clinging to a traditional method of removing the tube and the ovary, pulling them up together, and transfixing and tying them off in a bunch. By the exercise of a more intelligent judgment and with better skill the op- erator will no longer be embarrassed in removing either tube or ovary alone, or a piece of the tube, or a portion of the ovary. For the same unintelligent technical reason both tube and ovary have been extirpated in removing parovarian cysts in which it is frequently possible by a simple carefully conducted dissection to extirpate the cyst, leaving behind the otherwise unaffected structures. Relative Importance of Ovaries, Uterus, Tubes. — In all intelligent conservative efforts the various important objects of the conservatism must be borne in mind, and these are, first, the complete restoration of all the functions without pain ; second, to preserve menstruation and ovulation ; third, to put the organs in con- dition to make pregnancy possible ; fourth, to preserve ovulation and the in- ternal ovarian secretion, even though the menstruation and possible conception have to be sacrificed. In each of these four categories the ovaries are essential, for, with the re- moval of the ovaries, ovulation, internal secretion, and menstruation cease ; the ovaries are therefore the organs of paramount importance, and without them both uterine tubes and uterus are useless. So extremely important are the ovaries that, if the circumstances justify it, even a small piece of sound ovarian tissue should be preserved. j^ext in importance to the ovaries comes the uterus, for with the ovaries and the uterus ovulation, internal secretion, and menstruation may continue with due regularity. There is no reason to believe that the tubes without the uterus and ovaries are of any use ; their value is, however, enhanced by the presence of even a small bit of ovarian tissue with the uterus to such a degree that one or both tubes, even when mutilated, may often be preserved with advantage under these circum- stances, and pregnancy occur. Limitations of Conservatism. — Both Nature and disease impose upon our con- servative efforts several easily definable limitations. After a woman has reached the forties, when reparative processes in disease are not so active, and when age makes pregnancy less likely, even under normal conditions, and especially after the menopause, one important reason for con- servatism — namely, a chance of conception — loses its force. This limitation, however, affects only the uterine tubes, whose sole function is to act as transmitters of the ova. The ovaries and the uterus, on the other hand, are of value so long as menstruation persists, for severe nervous disturb- ances may arise from the removal of both these organs even in the forties. ISTo age limit can be set upon the utility of the ovaries until it has been demonstrated that the internal secretion also ceases with the menopause, a con- 53 1Y2 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. elusion which is, for the present at least, apparently at variance with the clinical- facts. Inasmuch, however, a6 the ovary has lost at least two of its important uses (ovulation and menstruation), less hesitation should be felt in saeriiicing it in the presence of disease. Malignant disease of an ovary has been generally recognized not only as con- stituting the strongest possible indication for its removal, but for the removal of its fellow as well, whether apparently diseased or not. I can not concur in this sweeping conclusion, and in the event of discovering such a disease as a super- ficial papilloma of one ovary at the very beginning, if the other ovary appeared perfectly normal, I should without hesitation save it in a young woman, with the expectation of carefully watching the patient for several years, and of operat- ing at once upon detecting the slightest evidence of disease. Tumors of the ovaries of the connective-tissue group usually forbid any con- servative eiforts, as they commonly involve the entii-e organ. Objections to Conservatism. — Among the objections urged against conserva- tism, that of the liability of the disease to recur in the opposite side or in the parts left behind is the most important. When the disease is not of a serious nature, as in the case of Graafian or corpus luteum cysts, there is no evidence to show that the remaining parts are in any way jDecuiiarly liable to disease, and the burden of proof still rests upon those who object to conservatism. In unilateral inflammatory disease, which is for the most part propagated from the uterus, it is true that the opposite side may subsequently go through the same changes, but there is no more reason for extirpating apparently sound organs than there is for recommending the removal of all infected uteri, unless it is that the open abdomen makes the operation a convenient one. "When both tubes exhibit different stages of the same disease, and one is choked with pus and the other only thickened and inflamed, the question of conservatism is a more difficult one, because the chances of the disease progress- ing in the healthier side are greater. If, however, the patient has expressed willingness to run the risk of a second operation, the surgeon should be glad, upon removing the worst side, to release all adhesions and to squeeze out and wash out the other tube, and then to dilate, curette, and drain the uterus, in hopes of cutting short the process in this way. The olijection that adherent and inflamed structures are either so far de- stroyed or crippled by the disease as to be beyond Nature's reparative processes is not borne out by the facts now abundantly laid before the profession. It has also been stated that the risks of an extra uterine pregnancy were a serious ob- jection to conservative operations upon organs either in themselves diseased or else implicated in neighboring disease, but while this argument demanded careful consideration at first, the fact that no case has ever yet been reported is a sufficient answer to it. There is no risk of infection, sepsis, and death in operations upon non-infiammatory cases, such as resection of the ovary, etc. In inflammatory cases the risk is not increased in the absence of pus, but in some forms of pelvic abscess the risk may be very great. The history of the case and the severity of the inflammatory process asso- CONSERVATIVE OPBRATIOXS ON THE OVARY. 173 ciated with a microscopic examination of the pus during the operation will often guide the operator as to the advisability of opening up and washing out and leaving the pus tube or an ovarian abscess. In the presence of numerous cocci, presumably streptococci, I should not attempt to preserve the structure in which they were found, but I should not hesitate to treat abscesses showing gonococci, or sparse cocci or bacilli of any other sort, by carefully cleansing them and restoring the organs with or without a vaginal drain, according to the extent of the disease. The published records so far do not show any increase in the mortality from conservatism of this sort. The risk to life from a second operation is not often increased by the first operation ; the abdominal scar may be easily excised, and if a considerable part of the disease has been removed, the second operation is, as a rule, much easier than the first. It is true that the pain, often to the patient the one prominent symptom, may persist and prove the conservatism in any particular case to have been ill-advised ; but, to refer again to recorded cases, the patients who have continued to complain constitute a small minority — much smaller than the per- centage complaining after the exsective operations of a few years ago. In general the best reply to all these objections is the assertion of the pa- tient's inalienable right in all cases to decide that her pelvic organs shall not be sacrificed under any possible complication of conditions which may exist, and the conscientious surgeon will always abet her in her willingness to take some risks in order to preserve her natural functions. In case the patient commits her case entirely to the hands of the surgeon to use his best judgment, he should act in all cases as he would do if she were his nearest relative, and try hard to avoid mutilation. CONSERVATIVE OPERATIONS ON THE OVARY. The removal of the opposite ovary in disease of one side was the habitual practice of some of the earlier gynecologists, and still continues, as I know by experience, to be the routine custom of men not well trained in their special work. In so far as the question relates to unilateral ovarian cystomata, I have given an unanswerable argument in the early part of this chapter, elaborated from the statistics of Sir Spencer "Wells's one thousand cases of ovariotomy. The question is, however, quite a difEerent one when one ovary is affected 'with papilloma, sarcoma, or carcinoma ; these diseases are so frequently bilateral that there appears at first sight to be a marked liability on the part of both organs to become affected independently of each other, in which case the second ovary, if left behind, will be so liable to require operation at a later date that complete extirpation of both sides is the rule. I can not, however, assent to this theory, as yet unproved, and so have adopted the following rules : When the opposite ovary appears perfectly sound and norma] in size, con- sistence, color, and outlines, I in all cases leave it in a young woman. 174 CO]SrSEEVATIVB OPERATION'S ON" THE TUBES AND OVARIES. If it is enlarged and there is reason to suspect disease, I remove it. In a case in which it is extremely important to retain one ovary and I am not quite sure of its condition, I excise a wedge of the ovarian tissue and harden and examine it immediately, during the operation, under the microscope, and if the piece is found diseased I remove the entire organ ; if no disease is found I spare the organ and keep the patient under careful observation for several years. In a case (L. K. W.) of superficial papilloma of the right ovary in a young woman twenty-seven years old, operated upon Feb. 10, 1892, the left ovary, which appeared sound, was left in ; she has since married and continues now, five years after the operation, in good health, without recurrence, as I have assured myself by examination. In another case (A. W., 5069, March 6, 1897) of papillomatous masses of the right ovary sprouting out between enlarged Graafian cysts, I removed the entire ovary ; the left ovary was sound except at its outer pole, where there were three large Graafian cysts, without any evidence of papilloma ; these were cut out and the sound portion closed by a continuous catgut suture. In the case of a large fibroma of the right ovary (A. S. W., 5061, March 10, 1897), attached by a distinct pedicle, 2'5 centimeters long and 1'5 centimeter wide at the inner pole of the ovary, my assistant. Dr. Cullen, exsected the pedicle, cutting deeply down into the ovary, and removed the mass ; about three fifths of the ovary remained and the wound was closed by a continuous cat- gut suture. The following are the various conditions for which conservative operations may be practiced upon the ovary : 1. The ovary is not removed for purely technical reasons and through adher- ence to a purely traditional style of operating — (a) For tubal disease, (b) In many cases of parovarian cysts, (c) In extra-uterine pregnancy, (d) In hys- tero-myomectomy. 2. Ovarian adhesions (peri-oophoritis). 3. Multiple Graafian cysts. 4. Single large Graafian cyst. 5. Cyst of the corpus luteum. 6. Hematoma. 7. Dermoid cyst. 8. Ovarian cystoma. 9. Ovarian. abscess. The conservative principles applied to the treatment of the ovary under these various conditions involve the puncture of some cysts, the exsection of other cysts and sewing together the parts which are left, and the amputation of a greater or lesser part of the ovary with suture of the remainder. Whenever it is possible, the ovary with the uterine tube should be lifted outsid e the body and i sol ated by surround- ing it with gauze pads ; a large cystic ovary may be emptied first by aspiration and then lifted out, to avoid making a large abdominal incision. The ovarian tissue does not usually bleed freely, but if there is much oozing it may be con- %^^ Fig. 357. — Conservative Upkeation on the Ovary, % Natural Size. On the right side the entire ovary has been removed for papilloma ; on t)ie left, two cystic Graafian folli- cles have been removed and the ovary sutured and left, as shown. The parts removed are shown in the lower part of the figure. Op., March 6, lti'J7. OVAKY NOT REMOVED FOK TECHNICAL REASONS. 175 -trolled readily by digital compression of the vessels at the poles. The diseased ovarian tissue may be removed either -with a knife and forceps or with the fingers when it is friable. As the ovary is but a small organ, and the simple diseases treated conservatively are not liable to recur at the site of extirpation, the dis- section should aim simply at shelling out the affected portion with the least j^os- sible sacrifice of good tissue. A wedge-shaped excision, whether in the length or the breadth of the ovary or at one of the poles, is easier to bring together by B u t n r e . A small needle threaded with a fine catgut suture is the best means of approximation. Each suture is passed well down into the tissue, entering and emerging 2 to 3 millimeters from the edges of the cut and tied tightly enough to control any hemorrhage ; when all are in place the ■ovary is dropped back into the pelvis. If there is but little tendency to bleed a -continuous suture may be used with advantage. 1. Ovary not Removed for Technical Reasons. — The ovary should never be re- moved simply because the tube of the same side is taken out, and as a matter of convenionce. The diseased tube can be removed alone after releasing it from its adhesions by cutting it off at the uterine cornu, or by making an incision into the mesosalpinx, just under the fimbriated end, and then cutting or stripping it loose along the mesosalpinx, keeping close beneath the tube, until the detach- ment is complete. In this way only small vessels are divided and the bleeding is slight and easily controlled by a few fine catgut ligatures ; the layers of the mesosalpinx may then be drawn together with a continuous cat- gut suture. In all cases of parovarian <3ysts where the ovary can be traced by means of the utero- ovarian ligament and clearly distinguished from the tumor, there is no need to sacrifice •either the ovary or the tube in removing the cyst. Parovarian cysts with clear walls and of lesser size may be removed by incising the meso- salpinx at a point where there are the fewest vessels, and draw- ing back the peritoneum on both sides as the cyst is shelled out from its bed ; another plan of removal, useful when the peritoneum stretched out over the cyst is redundant, is to make an oval incision into the peritoneum, removing a suificiently large piece to permit the remainder to be drawn neatly together after the extirpation. In large parovarian cysts where the tube is greatly elongated, after tapping Fig. 358. — Parovarian Cyst in the Left Broad Ligament removed by incising the mesosalpinx and without SACKIFICING EITHER OvAKY OK TuBE. SaN. Nov 21, 1895. Natural Size. 176 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. the cyst and bringing it outside and carefully distinguishing the position of the tube and the ovaiy, the opening into the mesosalpinx is enlarged, the cyst with- drawn, bleeding vessels secured and the peritoneal opening approximated, and the whole dropped back again minus the tumor. In extra-uterine pregnancy there is no reason whatever for the sacrifice of the ovary in removing a mutilated tube ; Dr. J. G. Clark has allowed the ovary to remain without any apparent disadvantage in a case operated upon at my clinic. In hystero-myoniectomy, by tying ofE the uterine tube at the uterine cornu instead of near the pelvic brim, the tube and ovary are both pushed down into the pelvis and out of the way as soon as the top of the broad ligament is opened, when the rest of the enucleation is conducted as before. Fig. 359. — Parovarian Cyst extirpated without removing either Tube or Ovart. Tlie cap of peritoneum was left on by cuttine through it on all sides and then shelling the tumor out of its cellular investment. Note the additional cysts attached to the tumor on the right. San. Isov. "Jl, 1S95. Natural size. 2. Adherent Ovaries. — Ovarian adhesions (peri -oophoritis) may vary all the way from a delicate web between the ovary and the pelvic wall, scarcely appre- ciable to the touch, to a dense mass of lymph imbedding the ovary so com- pletely out of sight that it appears to be actually within the broad ligament (pseudo-intraligamentary). The lighter weblike and velamentous adhesions are easily broken up with the fingers, or by exposing the adhesions and using the points of the scissors in conducting a careful dissection until the ovary is freed. In detaching a more firmly adherent ovary the best plan of procedure is to try to work the fingers in beneath it and so secure a purchase under its free ENLARGED CYSTIC GRAAFIAN FOLLICLES. 177 border for rolling it on its hilum, as an axis, from below up toward the brim of the pelvis. Any attempt to free it by working in a direction from above downward will only result in tearing the tissues. If the ovary hangs low down in the pelvis, after freeing it, the ovarian ligament should be shortened by taking a plait in it, so as to lift the ovary closer up beside the uterus. I have even stitched the ovary directly to the uterine cornu. After controlling any hemorrhage from the pelvic floor and walls the abdomen is closed without a drain. I would not be understood to recommend opening the abdomen to release any but dense ovarian adhesions, for all others which can be broken up with a moderate amount of force may just as well be handled bimanually and set free through the rectum and abdominal wall. This is done by securing a thorough evacuation of the bowels and placing the patient under anesthesia ; the index finger of one hand is then carried well above the ampulla behind the uterus by pushing the uterus a little back into retroflexion with the other hand ; then the index finger, passing along toward the cornu, readily distinguishes the prominent utero-ovarian ligament, and by tracing this out to ward the pelvic wall the ovary is found. After determining its size and outlining any irregularities of its surface, the next effort made is to test its mobility, and this is done, not by pushing it up as a whole, but by introducing the finger, or if need be two fingers, under its lower border and lifting it ; if it is free, it will go up easily, rotating on its hilum as an axis ; if it is adherent, the adhesions will be felt giving way and snapping one after another as the pressure is increased until the whole surface is freed. The greatest difficulty will be found in completely freeing the pole next to the pelvic wall ; after the ovary is entirely free, the finger can be carried around it on every side, above and below and around both poles, and it responds readily to every touch. 3. Multiple and Small Graafian Cysts. — It is not yet decided whether any clinical symptoms arise from the cystic follicles often seen, from the size of a pea to that of a cherry. It has been my habit, as well as that of many other operators, to bring out tne ovary and puncture these cysts with a knife point or a needle, and to emj)ty them by pressure. P. Miiller and Pozzi use the thermo- cautery in opening them, to prevent reclosure. Until we know just how far an aggregation of cystic follicles may be a departure from the normal, we shall not be in a position to decide this important question. One thing, however, is quite certain for the present, and that is that they never of themselves justify removal of an ovary or even of a piece of an ovary. 4. Enlarged Cystic Graafian Follicles. — Graafian follicle cysts form a definite group of tumors of the ovary, and are, as indicated in the name, simply enlarge- ments of structures which normally remain small and rupture or disappear. Such cysts are single or multiple and vary in diameter from 6 to 8 milli- meters to 6 or 8 centimeters or even more. The smaller cysts can only be reckoned as pathological when they occur in large numbers in an enlarged ovary, as shown in Fig. 360, and must be care- 178 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. fully distinguished from the few small cysts normally found in ovaries which are not enlarged ; they appear as numerous pealike projections over the surface of a large ovoid ovary with a dense coat. The single cysts increase to the size of a walnut or an orange, occupying a part of the ovary, with translucent walls easily raptured. Pathologically these are nothing more than dilated cystic f olhcles ; if they are adherent in the pelvis their surface, instead of being smooth, is roughened by the attachments. The walls, varying in thickness from 1-5 to 2 or 3 millimeters, are thinnest at the most prominent part. The fluid within re- sembles serum or clear water, or it may be made turbid by hem- orrhage. It contains desquamated and fatty epithelial cells. Ova are often found with- in demonstrating their origin. The cyst wall ex- hibits the layers of the Graafian follicle with a single layer of Round hyaline masses correspond to de- FiG. 360 — Hypertrophy of the Ovary^, with Cystic Degeneration. Over twenty follicles are visible on the surface, projecting from beneath the thick capsule. I'ath. No. 282. cuboidal or flat epithelium within, generate epithelial cells. I have had one case in which a dilated Graafian follicle and a cystic corpus luteum existed side hj side in the same ovary. The partition wall broke down and the two coalesced, forming a single cyst with the characteristics of each in different places. The symptoms produced are generally more or less constant discomfort or pain on the side on which the tumor is situated, increasing at the menstrual period. The physical signs presented by such cysts are usually definite enough to enable the examiner to make a correct diagnosis. Such follicles may rupture spontaneously through the increasing tension of the thin walls and the patient experiences a sudden relief, or they are often ruptured accidentally, as I have seen, in making a bimanual examination. In several cases, upon opening the abdomen at once, I have found from 20 to 50 cubic centimeters of blood-tinged serum in the pelvis with the torn edges of the cyst floating in it. If a positive diagnosis could be made in every case it would never be necessary to open the abdomen for the sole purpose of treating these cysts, for EXLARGED CYSTIC GRAAFIAN FOLLICLES. 179 the plan of rupturing them by pressure made by a finger in tlie vagina or rectum would be perfectly safe, and probably in most instances just as etScient in curing tlie affection as an extirpation by celiotomy. While they can be recognized with certainty in most cases by a well-trained touch, they may be confused with a corpus luteum cyst, an ovarian or tubal abscess, or encysted pelvic perito- nitis, or a hydrosalpinx. The diiferential points are these : the Graafian cyst has usu- ally such thin, delicate walls that they seem almost ready to rupture on making the gentlest ^Jressure ; it is more or less spherical in out- line, and at its base connected with the ovary, and as a rule it is not adherent. Abscess cases and en- cysted peritonitis show evidences of surrounding inflammation in the hardening of the incasing tissues ; the hydrosalpinx is elongated and not so circumscribed. Wherever there is any doubt in the diagnosis, the safe rule is not to rupture the cyst, but to take it out by the ab- domen or by a vaginal incision. The cyst may be deliberately ruptured by grasping it between the fingers through the abdomen and rectum and gradually increasing the pressure until it breaks suddenly, and in a moment all trace of the tumor is gone. I have twice opened the abdomen for other causes within two or three days after the unintentional rupture of one of these cysts in the course of a preliminary examination, and found but a few cubic centimeters of blood and serum, and a flaccid collapsed cyst with a wide rent in its wall. If the sac does not yield to a moderately firm pressure, the effort should be abandoned and the cyst tapped through the vagina. Before tapping, the vagina must be cleansed thoroughly with soap and water ; then a long trocar and can- nula attached to an aspirator is introduced guided by the finger, which rests on the tumor at the vault of the vagina ; an assistant, by making pressure above, brings the cyst firmly down onto the vaginal finger, while the operator pushes the trocar and cannula into the now prominent convex surface close to and a little behind the cervix, in a direction upward and slightly backward. The trocar is withdrawn and the fiuid evacuated through the cannula. After evacuation the cannula is withdrawn and the vagina loosely packed with iodoform gauze. There is no reaction following so slight an operation. Fig. 36L — Hemorrhagic Corpus Luteum Cyst (C) and Cystic Graafian Follicle ( (t) in the Same Ovary. The cysts are buckled toi:retLer and were developed from the outer extremity of the ovary ( O) on both sides of the tubo-ovariun liinljria. The tube is held ri^id, stretched out in the sulcus between the cvsts. May 16, 1896. Natural size. 180 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. When such a cyst is ruptured or evacuated in this way it does not, as a rule, refill. After rupture the patient should be kept in bed two or three days and have the bowels freely opened. The operation for the removal of the cyst by celiotomy is a simple one. If it is small and can be easily brought out of the incision without rupture, this may be done, but if it is large it is better to tap the cyst and empty it and draw it out in a collapsed condition, rather than to enlarge a small incision. Laying the ovary with the cyst on a small pad, the cyst is then exsected, and as it usually lies attached to the superficial free portion of the ovary, this again need not be cut into deeply. Souietimes it is attached to one of the poles or to the free border, and is almost pedimculate ; in this case, an oval incision is made around its base and a careful dissection suflices to peel it out of its bed, and the wound in the ovarian tissue is then closed with a few interrupted catgut sutures, or with a continuous suture, if the wound is a long one. Multiple large cysts, either connected or isolated, should be treated in the same way. 5. Cysts of the Corpus Luteum. — These are corpora lutea which have not ruptured and which have reached abnormal dimensions. The average size is that of a walnut, but they may reach 6 centimeters or more in diameter. If small they are seen as cysts springing from the ovary, but if large they may occupy the greater part of the ovarian tissue. Their walls may be gray, bright red, bluish red, or almost black, but shining through the peritoneal cover- ing, usually there is a yellowish red or golden yellow tissue similar to that seen in a tyjjical corpus luteum. Beneath the peritoneal covering numorous fine branching blood-vessels can be seen. The cyst walls vary from 1 to 2 milli- meters in thickness. The inner surface is covered by a reddish yellow mem- brane to which a few clots may be at- tached. The cavity is partially or com- pletely filled with blood, which may have undergone retrogressive changes, and accordingly be of a dark chocolate or inky black color. Tliese cysts are but loosely connected with the tissue of the ovary, and are sometimes even shelled out accidentally while handling the ovary. Histologically tlie cyst walls are composed of ovarian stroma, which may contain ova. Graafian follicles, or corpora fibrosa. The inner surface is lined { Fig. 362. — CvsT of the Cokpus Ll-teum. The uterine tube lies on the cyst above. 173. Natural size. No. DERMOID CYSTS OF THE OVARY. 181 by several layers of corpus luteum cells, some of which maybe swollen and filled with brown granular pigment, or present a vacuolated appearance. Passing in- ward from the ovarian stroma are spindle-shaped cells, which divide the corpus luteum cells into rows. Numerous new-formed blood capillaries may accompany these spindle-shaped cells. The cyst cavity contains red blood-corpuscles ; degenerate cells, polymorphonuclear leucocytes, and granular material may also be present. These cysts do not differ in any way clinically from the Graafian cysts just described, unless it be that the wall of the cyst is some- times thicker and the contents jelly- like and discolored with blood. The operation is in all respects similar to that described above. The figures in the text show well how easily such a cyst may be re- moved, often leaving the ovary al- most intact. 6. Hematoma of the Ovary. — The surgical treatment of hematoma will vary with the extent of the disease. From our present standpoint the hematoma must be reckoned among the be- nign tumors, and the conservative course of treatment is a proper one whenever it can be of any use. When the entire ovary appears to be taken up by a large hematoma, and no sound ovarian tissue can be found about its hilum, the better plan will be to extirpate the ovary. When, on the other hand, but a portion of the ovary is involved, the affected part should be cut away and tlie sound por- tion left. This will often demand a more extensive dissection of the tissvie than in cystic disease, on account of the more intimate relation of the hematoma to the ovary ; but the suturing and the rest of the treatment is the same. 7. Dermoid Cysts of the Ovary. — Quite another field for conservatism is opened up in the treatment of dermoid tumors and ovarian cystomata. The iirst case operated upon in this way was by C. Schroder {Zeitschr. f. Oeb. u. Gyn., Bd. xi, p. 360). The patient, twenty-five years old, had had one child, which had died, and she was intensely anxious for another. Celiotomy was performed Nov. 30, 1882. The tumor on the right side was of a mixed nature — both cystoma and dermoid — and was so developed as to leave intact and sound a considerable part of the ovary, from which the tumor was ex- cised and the wound closed by suture. The left ovary was about three times enlarged by a small dermoid cyst, which was removed by a wedge-shaped ex- cision, and the surfaces united by fourteen sutures. Examination over a year later showed an exudate behind the uterus. Fig. 363. — Pedtnculate Corpus Luteum Cyst of the Left Ovary, in which the Tumor is attache!* TO THE (JVARY BY A BrOAD PeDICLE OF OvARIAX Tissue. Upon removal of the cyst, sound ovarian tissue i& left. Jan. 4, 1893. Natural size. 182 COU"SBRVATIVE OPERATIONS ON THE TUBES AND OVARIES. This initial experiment has been most successfully repeated by F. Matthaei {Zeitsohr.f. Gel. u. Oyn., Bd. xxxi, 1895, p. 351). In four cases of dermoid cysts involving both ovaries, the tumor on one side beinp- large and on the other side small — " about the size of a walnut " — the large tumor was extirpated with the ovary, while the small one was exsected from the sound ovarian tissue, and the wound sewed up with a continuous cat- gut suture. In each one of these instances the patient either became pregnant or bore a living child within two years after the operation. 8. Ovarian Cystoma. — While an ovarian cystoma commonly involves the en- tire ovary in such a manner as to prevent the isolation of any definite portion of normal ovarian tissue, in exceptional cases a part, and it may be even the greater part, of the ovary may be found unafEected by cystic degeneration at the base of the tumor ; the best guide to discover such a portion of sound tissue is the utero-ovarian ligament, which can always be found. "When it has been necessary to remove the other ovary, or when the opposite tube or ovary is extensively diseased, it will be justifiable to remove the cystic portion alone and to leave behind that portion of the ovary which macroscopically appears to be sound. The figure in the text shows a case (Gr. H. K., 4224) operated upon, March 21, 1896, for multilocular ovarian cystoma with twisted pedicle. Had it been important to preserve this ovary, an examination of the drawing will show how readily the greater part of it could have been left after removing the tumor. In cases of ovarian sarcoma resembling an ordinary cystoma, the second ovary, if it has presented any suspicious appearances, ought to be removed as soon as the diagnosis is made by the microscopic examination. In an unfortunate case of Hegar's {Verhand. d. Deutsoh. Gesellsch.f. Gyn., 1892, p. 255) a right-sided cystoma was removed, and a left ovary which looked suspicious was left ; the microscopic examination showed that the tumor was sarcomatous. The woman went home, became pregnant, and bore a miserable deformed child, and returned to the clinic with a tumor of the opposite ovary, which was inoperable, and from which she died. 9. Ovarian Abscess.^In some cases of ovarian abscess the ovary may be saved by a carefully applied conservatism. In the rare instances in which the abscess is located down in the center of the ovary and surrounded by a thick capsule the ovary may be brought up, laid freely open, the pus evacuated, and the lining membrane of the cavity scraped or dissected out, after which the ovary may be closed by suture and dropped again into the pelvis. While it is not my intention to speak here in detail of the conservative treat- ment of pelvic abscesses (see Chapter XXYII), it is important to refer to those cases of pelvic abscess involving both ovary and tube which have recovered by drainage through the vault of the vagina without the extirpation of either ovary or tube. In three instances of this kind in my practice pregnancy has occurred after the healing of the abscess. CONSERVATIVE OPERATION'S ON THE UTERINE TUBES. 183 CONSERVATIVE OPERATIONS ON THE UTERINE TCBES. Although the tube is a more delicate structure than tlie ovary, and its function as a carrier of tlie ovum is more easily disturbed tlian is that of the maturation and discliarge of ever, marvelously amenable to conserv- of afEeetions. The following are the may be practiced upon the uterine (X'<^'^"^ the ova from the ovary, it is, how- -, ative treatment in a variety / commonest operations which tubes : J'lO. 365.- -Velamentous Adhesion of the Kight Uterine Tube to Itself and to the Uterine Cornu. April 1, 1SS7. Natural Size. 1. The release of adherent tubes. 2. The opening or resection of closed tubes. 3. The emptying, cleansing, and sterilization of inflamed tubes. 4. The amputation of diseased tubes. 5. The exseetion of diseased or of strictured tubes. 6. The drainage of tubal abscesses. 7. Preservation of the tube in extra-uterine pregnancy. 1. Adherent Tubes. — Adhesions binding the tubes down in the pelvis may ■often be released by running the fingers down under the tube and breaking them up one after another, or by exposing the uterine end of the tube and making traction upon it, and so tracing the tube down toward the pelvic floor. Adhesions which can not be broken easily with the fingers should be exposed 53 18i CONSERVATIVE OPEKATIONS ON" THE TUBES AN"D OVARIES. and divided with the scissors; too great traction or too rough manipulation must not be made as it is liable to rupture the tube. It is not only important to set free an imprisoned tube in this way, but to divide every adhesion found in any way connected with its peritoneal surface. To set a tube free from its pelvic wall adhesions and leave it kinked is to risk an extra-uterine pregnancy afterward. The figure in the text shows an example of a tube flexed at an acute angle by an adhesion upon itself, stretching from the ampulla to its uterine end ; the simple division of such a band of adhesions set& the tube free and restores its normal mobility. The tubo-ovarian fimltria is one of the most important parts of the tube, because it is the hinge or arm by which the tube is enabled to apply itself to all parts of the ovary and so to take up the discharged ova, which are then trans- mitted to the uterus. I find three kinds of adhesions affecting this important tubal structure, two of which are figured. One is a simple shortening due to adhesions, which restricts the area to which the tube may apply itself to a short radius about the Vt \ Flo. 3t)(j. — Anuulak Attachment of the Left Uterine Tube to the Coknu of the Uterus. Deo. is, 1806. outer pole ; in another the tube is contracted down to the ovary by an oblitera- tion of the outer portion of the mesosalpinx, so that it lies with its orifice directed away from the ovary ; in the third the tube is flexed about the ovary with its lumen still open nn 1 turned toward one small area, to which it may be closely applied. The treatment of these adhesions simply requires a careful dissection with a EMPTYING, CLEANSING, AND STERILIZATION OF INFLAMED TUBES. 185 scalpel, detacliing the tube from the ovary until the mesosalpinx and the tubo- ovarian fimbria are restored to their normal length. 2. Closed Tubes. — When adhesions form about the fimbriated extremity of the uterine tube on its peritoneal surface the tendency of the contracting lymph is to roll in the mucous surfaces, and so to gradually obliterate the Fig. 367. — Adhesions of the (Duteb Free Extremities of both Uterine Tubes to the Ovaries. Showing the method of cUvkliiit!: the adliesions with the scalpel and so freeing the tubes. On the right side the tube is attaclied in such a manner that its open extremity loolvs away from tlie ovary ; on the left side the tube is fastened down with its oriiice facing the ovary. i'"eb. 1, 18a6. % natural size. lumen of the tube. In an earlier form these adhesions may be seen just back of the fimbrige surrounding the tulie like a collar, forming a white fil>rous band encircling it from 2 to 4 millimeters in diameter ; in a more advanced form the lumen may be closed down to a little orifice, out of which pouts one or more conge.sted fimbrige ; in its most advanced form the orifice is completely obliterated and replaced by a depressed scar radiating out over the knobbed end. This collar may be divided in several places, releasing the fimbriae. The closed tube may be opened best by cutting through the scar and up along its dorsum for from 1 to 1^ centimeters, and so laying bare the lumen of the tube and forming a new orifice. The mucous lining should then be drawn out and attached to the peritoneum by fine catgut sutures. Any contents of the tube must be carefully taken up on gauze, and if they are other than a clear limpid fluid, the tube must be washed out as described in the following section. 3. Emptying, Cleansing, and Sterilization of Inflamed Tubes. — Sometimes a catarrhal or a parenchymatous salpingitis is found vdth a greatly congested and thickened tube, whose orifice is open, and a little milking easily forces out a drop or so of bloody serum or of mixed blood and pus. 186 CONSERVATIVE OPEKATIONS ON THE TUBES AND OVARIES. Under such circumstances the decision will often be difficult whether it will be safe or not to attempt to save the tube. The surgeon will be guided princi- pally by the intensity of the local reaction already produced on the pelvic peri- toneum by the infection, as well as by the character and abundance of the cocci found by an immediate microscopic examination, coupled with such facts as have been elucidated from the history. Associated with these data, due weight must be given to the urgency of saving the tube in the particular case in hand. This urgency will naturally be greater if the other tube must be sacrificed, as is often the case when the grade of the inflammatory infection varies on the two sides ; the age of the woman and the number of children she has, as well as her condition in life, must also be considered. The most favorable cases are those where no organisms are found at all, or where the gonocoeci appear alone. To cleanse a tube, it is lifted out of the abdomen, if possible, and laid on a gauze pad and gently squeezed empty a few times by stroking it from the uter- ine toward the fimbriated end ; the fluid discharged should be used for cover- slip and culture experiments. The tube is then washed out with normal salt solution by a syringe attached to a flne silver cannula with a rounded end per- forated with holes ; the end of the syringe is introduced as far as it will go easily, and the fluid forced in and collected as it flows out from the fimbriated end. After washing it clean in this way the tubal mucosa is sterilized with a 1-5,000 bichloride of mercury solution, emptied, wiped dry, and dropped back into the pelvis. 4. Amputation of Diseased Tubes. — If the outer extremity only of a tube is diseased, an amputation may be done so as to remove the disease and leave whatever part is sound. In this way the end only may be cut off, or half, or even the whole ampulla removed. It is of manifest advantage to leave, if possible, a little of the distal end of the tube in order to secure an open orifice to take up any ova which might by chance fall into it or be drawn into it by the pelvic current which sets toward the orifices of patent tubes. C. C. Burrows has practiced amputation in cases of pyosalpinx in five in- stances, as recommended by Polk {Trans. Amer. Gyn. Soc, vol. xviii, p. 182). He says that in some cases there is a healthy patulous portion of the tube next to the uterus, which is shut off from the outer diseased end, and " in such cases where the ovary is healthy and the fimbriated end of the pus tube is not adher- ent to it," he has amputated the tube at the outer end of the healthy portion, washed it out, slit it up a short distance, and united its serous and mucous coats by fine catgut sutures, forming an artificial abdominal ostium. Five cases treated in this way made perfectly good recoveries. When the whole ampulla is removed, then even the stump of the isthmus may be serviceable with its small orifice. In amputating a tube, a ligature is never thrown about its lumen, but it is simply cut off with a scalpel, the bleeding checked, and the permanency of the opening secured by uniting the mucous and peritoneal surfaces by suture. EXTBA-UTERINE PEEGITANCT. 187 5. Exsection of Diseased or Strictured Tubes. — In uodular disease of the tubes, or in tlie case of a stricture of the tube, or in event of the entire division of the tube into two parts, the diseased portion may be excised and the ends brought together by an end-to-end anastomosis (salpingo-salpingostomy). If there are several nodes feeling like httle hard, ovoid lumps in the tube, often of a yellowish color, it will be better not to try to save the tube, except for stringent reasons, as this is one of the forms in which tuberculosis of the tube is often locahzed. After cutting out the disease, the ends of the tube may be united by fine cat- gut sutures penetrating the peritoneal and muscular coats and introduced at in- tervals of about 2 millimeters. In order to graft the isthmus on to the ampulla, it must be slit open on its dorsum to make a lumen corresponding in size to that of the ampulla to which it is to be attached. 6. Drainage of Tubal Abscesses. — The treatment of tubal abscesses (pyosalpinx) as ordinarily found walled off by a blanket of adhesions from the rest of the peritoneal cavity, is fully discussed in the chapter on pelvic abscess. I desire here to speak more particularly of the treatment of those tubes full of pus which are found free, or comparatively free, in the pelvis and without any at- tachments to the vaginal vault. When one tube is diseased in this way and the other is in better condition, I would sacrifice the tube containing pus and direct my efforts toward saving the one least affected. When both tubes are distended by pus, or when the tube containing pus is the only one remaining, and conservatism is desirable, the fol- lowing plan may be tried : After bringing the tubes up onto a piece of gauze and opening them on the dorsum at the outer end and washing them out, they are then dropped back into the pelvis and a free opening made in the vaginal vault by puncturing it with scissors introduced into the vagina by an assistant and pushed through into the pelvic cavity under the guidance of the operator's hand within the abdomen ; the opening thus made behind the cervix is then enlarged with a dilator, and an iodoform gauze pack introduced so as to fill the lower part of the pelvis loosely and drain into the vagina. The ends of the , tubes are loosely imbedded between the folds of this pack ; it is removed in five to seven days and the opening allowed to close. The figures in the text are taken directly from a case treated successfully in this way. 7. Extra-uterine Pregnancy. — The radical exsective method of treating extra- uterine pregnancy can only be justified when the identity of the tube is so dis- torted or when the tube is so far destroyed that its regeneration is impossible. In many cases where the hemorrhage has long since stopped, and where there is a tubal abortion with an intact tube or a small rent, there is no reason why the tube should not be freed from its adhesions, cleansed as far as possible of all clots, the rent sutured, and the tube, together with its ovary, preserved. Particular care must be taken to make sure that the lumen of such a tube will admit a probe all the way through to the uterus. 188 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. PREGNANCY FOLLOWING CONSERVATISM. Out of a series of eighty cases treated conservatively by Dr. W. M. Polk, and most of them seen at intervals varying from six months to two years after the operation, all but seven gave excellent results, and four out'of the eighty bore children (JV. Y. Jour. Gyn. and Obs., Aug., 1893). A. Martin, in a series of forty-five eases — twenty-one of resection of the ova- ries and twenty-four of operations upon the tubes — lost two, one in each group ; and of the twenty women surviving the ovarian conservative operations, five became pregnant. One of his patients, operated upon in Oct., 1888, had the right adnexa re- moved and the left tube resected for hydrosalpinx, became pregnant, and aborted in April, 1889. Pregnancy after an Operation leaving One Tube and the Opposite Ovary. — Pregnancy can only take place in the presence of a delicate adi'ustnient of the pelvic organs in their mutual relations, and therefore furnishes perhaps the best test of the success of any conservative I'IG. 868. — CONSEKVATIVE OPERATION TO PRESERVE THE ElGHT <)\VR-i AND Tlir LfH J UU The right tube, rigid and closed with a bulbous end, was removed. The left ovary, converted into a large hematoma, was also removed. Mrs. B. Op., March 2, 1895. operation. It must be borne in mind, however, that there are other causes than the disease of the adnexa which conspire to keep down the percentage of pregnancies, as, for example, the fact that many of these patients are single, or, if married, the husband has gonorrhea (Martin). PEEGISrAN-CT FOLLOWING CONSERVATISII. 189 In order to secure pregnancy it is not necessary to preserve the ovaries and the uterine tubes in pairs, as the following instance will show : M. B., 3346, came to me in Feb., Ib95, invahded by a constant dull pain in the lower abdomen, with severe exacerbations. On opening the abdomen (March 27, 1895), I removed a left ovary converted into a large hematoma, and Fig. 3b'J. — Diagram of the Condition after Eemoval of the Kight TnsE and Left Ovaet. Showing the distance separating the remaining tube and ovary. a little, withered right tube with a knobbed, closed end covered with lymph. The left tube was normal, and the right ovary was also normal, except for numerous shreds of lymph attached to it and covering also the posterior surface of the retroflexed uterus. The uterus was held forward by picking up a plica of the vesical peritoneum near the symphysis and attaching it to the fundus on both sides. The left tube and the right ovary were left hanging down into the pelvis, with the fimbriated end of the tube 4 centimeters distant from the ovary (see Figs. 368 and 369). Pregnancy occurred in September of the same year, and the patient had her first child in June, 1896. In Nov., 189Y, I had to re- move the left tube for a ruptured extra-uterine pregnancy. Uterus Retroflexed; Appendages firmly Adherent; Ovarian Cysts Opened; Pregnancy within Four Months. — Dr. A. P. Dudley (Amer. Gyn. and Ohs. Jour.^ Feb., 1897) relates a case of a woman, twenty-five years old, operated upon by him in Dec, 1889. The uterus was retroverted, and with the appendages firmly fixed in the pelvic floor ; the adhesions were broken up and numerous cysts in the ovaries punctured and evacuated, and the lining capsule scratched to cause it to fill with a blood clot ; 190 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. the tubes were probed and found patent. The uterus was held forward by an intraperitoneal shortening of the round ligaments. The patient left the hospital in three weeks feeling well, and in four months reported herself pregnant;, later she induced abortion by injecting hot water into the uterus. Extensive Inflammatory Disease involving Right and Left Ovary; Left Tube Normal, Ovary Atrophied; Preg- nancy. — In another patient of Dr. Dudley's, forty years old, the uterus and appendages were firmly fixed in the pelvis by an inflammatory mass. The right appendages, hopelessly diseased and involved in adhesions, were removed, but the left tube was sound with an atrophic ovary ; sixteen months later, in her forty-second year, she gave birtli to a healthy boy weighing seven pounds. Left Pyosalpinx and Imbedded Ovary removed; Right Adherent Tube freed and Cystic, Ovary punctured; Ad- herent Uterus elevated and suspended; Pregnancy. — This patient of Dr. B. MacMonagle is an interesting example of successful conserva- tism and an extraordinary success after suspension of the uterus ; she was thirty- four years old and had had one child ; the abdomen was opened for extensive pelvic peritonitis and retroflexion with adhesions. A left pyosalpinx with a densely adherent ovary was removed, and on the right side the tube was freed from adhesions binding it down to the pelvic floor, and several large cystic folli- cles were punctured ; the uterus, adherent by its posterior surface, was elevated and suspended by two sutures. Within a year she became pregnant and was confined at term, attended by a neighbor who acted as midwife ; three children were born, all lived, and they are now two years old. Normal involution went on, and the uterus remains in anteposition. Retroflexed Uterus and Appendages Imbedded in Adhe- sions; Left Ovary and Tube removed Piecemeal; Right Ovary and Tube badly torn. Tube broken off 5 Centimeters from Uterus; Pregnancy in Six Months. — Dr. B. F. Baer {An- nals of Gyn. and Ped., Jan., 1894, p. 232) reports a case of pregnancy under the most unusual circumstances. The patient, thirty-two years of age, who had a large retroflexed adherent uterus with hard masses on both sides, submitted to an operation, with the express proviso that one ovary or a part of one should at least be left, that she might not be deprived of the possibility of offspring. The abdomen was opened in Feb., 1891, and the retroflexed uterus and appendages were found so covered by organized false membranes as to be completely out of sight. After breaking through the false membranes with great effort, the uterus was dissected loose and brought forward, covered with shreds of broken adhe- sions ; the left ovary and tube were so firmly bound down to the posterior sur- face of the broad ligament that they were taken away piecemeal, and a calcare- ous mass was also removed from the bed of adhesions. The right side was similarly diseased and dissected loose in shreds, the tube being torn off 5 centi- meters from the uterus. As Dr. Baer was about to remove the appendages of this side too, he received a positive injunction from the brother of the patient^ PEEGN'ANCY FOLLOWING CONSERVATISM. 191 who was a physician and was present, not to proceed, as he preferred to aSsume any risk rather than deprive his sister absolutely of all hope of oiispring. The abdomen was therefore closed, an excellent recovery followed, and in fifteen months a child was born. Extensive Pelvic Inflammatory Disease; Kight Tube and Ovary removed; Pus Sac in Left Tube opening into Bowel; Left Tube amputated; Pregnancy. — One of the worst cases for the complications it presents is that of Dr. B. MacMonagle (see Polk, Trans. Congr. Amer. Phys. and Surg., 1894, p. 193). The patient, twenty-four years old, had been married three years without pregnancy. She had a pelvic abscess discharging at intervals through the rec- tum, and following a dilatation of the cervix at the hands of another specialist. "When seen by Dr. MacMonagle in Oct., 1888, she was emaciated, sallow, had con- stipation, frequent urination, and night sweats ; the abdomen was scarred and discolored by blisters and poultices ; the temperature varied from 99° to 101° ; a bad-smelling yellowish discharge issued from the uterus and vagina, and pus and blood appeared in the stool every few days ; the uterus was fixed, and there was thickening and tenderness over both ovaries and uterine tubes. The abdomen was opened and the omentum found adherent to the uterus and the neighboring parts ; there was a small cyst over the right tube and ovary, and extensive adhesions of the tube and ovary to the bowel and broad hgament, with the fimbriated end of the tube bound down to the ovary. The cyst, ovary, and tube were removed close to the uterus. " On the left side, in attempting to enucleate the tube and ovary, a pus sac in the pelvis opening into the bowel was broken iuto and there was a sharp hemor- rhage ; the attempt was made to check this by putting a ligature (Staffordshire knot) deep down in the broad ligament, passing the loops on one side close to the horn of the uterus and on the other outside the ovary ; when this was drawn tight it was found to include the ovary and adherent fimbriated extremity of the tube to such an extent that it was impossible to remove these structures and still leave enough tissue distally to prevent the ligature from slipping ; only the free portion of the tube was then cut out, and the incision closed with a glass tube drain inserted. Two years later she became pregnant and gave birth to a child. Ovarian Cysts of Both Ovaries; Eight Ovary and Tube extirpated; Left Cyst removed, leaving a Piece of the Ovary and the Tube; Pregnancy . — A woman thirty years old was operated upon in May, 1890, by Dr. A. Sipple {Central, f. Gyn., 1893, No. 3, p. 43) for double ovarian tumors ; on the right side no sound tissue was found, and the ovary, about the size of a child's head, was removed with the tube ; on the left side the ovary was about as large as a goose's egg, and at its base a strip of macroscopically normal ovarian tissue was found ; the tumor was therefore cut away, leaving a piece of ovarian tissue at the hilum 4 centimeters long and 3 or 4 millimeters in thickness, which was sutured and dropped. This patient became pregnant in Aug., 1891, and was normally delivered in due time. 192 CONSERVATIVE OPERATIONS ON THE TUBES AND OVARIES. Left Ovarian Cyst and Adherent Uterus; Half of the Eight Ovary removed; Tube not removed; Pregnancy. — In another patient of Dr. Dudley's, twenty-nine years old, an ovarian cyst, firmly attached to the posterior uterine surface, was removed, leaving the uterus denuded ; one half of the left ovary was taken away, but the tube, though much enlarged, was allowed to remain, and the uterus fastened forward. Drainage was used through the vaginal cul-de-sac. Pregnancy occurred, and she miscarried at four months. Hematoma of Both Ovaries; Removal of Left Ovary and Tube; Pesection of the Eight Ovary; Pregnancy. Operation by "W. M. Polk, Dec, 1892. — The left ovary, converted into a hematoma 5 cen- timeters in diameter, was removed with its tube ; two thirds of the right ovary, containing a hematoma, was resected and the remainder brought together by suture ; the right tube was not diseased. The patient recovered her health, and when seen on June 5, 1893, was four and a half months' pregnant. A. Martin reported a case of pregnancy {German Gyn. Soc, 4th meeting, at Bonn, May, 1891) in a woman forty-two years old, operated upon in Oct., 1888, from whom the right adnexa had been removed and the left tube resected for hydrosalpinx. She miscarried in the third month. Dr. Polk presents further a remarkable example of the possibility of re- juvenation in a case of double hematosalpinx. The patient, twenty-two years old, was operated upon in Oct., 1890. The right ovary, the seat of an extensive hematoma, was removed with the right tube ; on the left side the ovary was normal, but the tube, the seat of a hemato- salpinx, was cut off just inside the dilated portion, about an inch from the uterus, and the stump attached close to the ovary.. There were extensive adhesions on both sides. Two years after the operation the patient was dehvered of a healthy male child. CHAPTER XXVI. SIMPLE SALPINGO-OOPHORECTOMY AND SAIiPINGO-OOPHORECTOMY FOB ADHEBENT TUBES AND OV ABIES. A. Simple salpingo-oophoreetoray. 1. Indications and contra-indieations for operation: 1. For myoma of the uterus. 3. For osteomalacia. 3. For incomplete development of the genitals. 4. For extreme dysmen- orrhea. 3. Pour typical cases of castration for extreme dysmenorrhea (out of five hundred abdominal sections). 3. Operation : 1. The incision and delivery of the tube and ovary. 8. Ligation of the pedicle and removal of the ovary and tube. 3. Inspection of the field and closure of the incision. B. Salpingo-oophoreotomy for hydrosalpinx and adherent ovaries and tubes. 1. Hydrosalpinx: (1) Hydrosalpinx simplex. (3) Hydrops tubas profluens. (3) Hydrosalpinx follicularis. (4) Tubo-ovarian cysts. 3. Cause. 3. Symptoms. 4. Treatment: (1) Conservative, a. Breaking up adhesions, h. Jlaking a new ostium in a closed tube. c. Resecting a diseased tube. (8) Radical. SIMPLE SALPINGO-OOPHORECTOMY. Tpie simplest form of abdominal operation, next to the purely exploratory incision and to the suspension operation for retroflexion of the uterus, is the removal of tubes and ovaries not adherent, and not in any way or but slightly altered by disease — that is, salpingo-oophorectomy. The removal of the normal ovaries and tubes forms, as it were, the type of all extirpative operations upon the uterine tubes and the ovaries, even the most complicated, for after the various complications are met and put aside the final steps in the enucleation remain the same. The object of a simple salpingo-oophorectomy is an ar- tificial and premature induction of the menopause for one of several indications — either to secure the effect upon the uterine circulation, as in checking the growth of myoma t a, to check the prog- ress of an osteomalacia, or to relieve the menstrual molimina in cases of incomplete development of the genitals with functionally perfect ovaries, and, in the rarest instances, for excessive dysmenorrhea. The operation has also been performed as the concluding step of a Cesarean section to prevent future conception, but the same end may be obtained here by simply ligating the uterine tubes. The various neuroses, such as menstrual epilepsy, hysteria and hystero-epi- lepsy, and insanity, do not of themselves justify the removal of the uterine tubes and the ovaries. It has long been fondly held by gynecologists that in major epilepsy of a distinctly menstrual type — that is to say, occurring always 193 194 SIMPLE SALPINGO-OOPHORECTOMT FOR ADHERENT TUBES AND OVARIES. during, just before, or immediately after the menstrual period — the expectation of a radical cure from the suppression of the periodical function was fully justified, but the facts of the case do not so far bear out this assumption. I have myself operated for epilepsy in but one case, that of a feeble- minded girl whose attacks were greatly aggravated at the monthly periods ; she improved, but was by no means cured by the operation. Dr. S. Weir Mitchell, our greatest authority, says ( Unvo. Med. Mag., March, 189Y, p. 389) : " In no case seen by me had ablation of ovaries and termination of menstruation cured an epilepsy. I have never sanctioned such operations where the appendages were sound. I have agreed thrice to these operations in epilepsy with such pelvic disease as of itself would justify o5phorectomy. In all three, after some delay, the fits returned and were in no way permanently aided. ... I recall as an illustration a case in which there were epileptic attacks of great severity only at the menstrual epoch. The ovaries were apparently sound, but, as two physicians and a surgeon were against me, my opinion was not regarded and ovariotomy was performed. The attacks, which had been daily, stopped for seven weeks after the operation, and the case was hastily spoken of as a great triumph. The patient, however, then became worse, and perma- nent loss of mind resulted. . . . The ease of operation, the freedom from mor- tality, makes that seem of little moment which should in every ease receive the gravest consideration. ... In all my fife I have met with but four reflex epi- lepsies ; none were from uterine or ovarian or tubal disease." I can not do better than cite the opinion of the same eminent neurologist regarding the value of oophorectomy in insanity. " Because an insane woman is usually worse at her period, it is no reason why the flow should be stopped by operation. That the climacteric puts an end to these disorders is an old delusion ; in fact, the change of life, so-called, is quite as likely to make them worse as to better them." Out of but four cases of neuroses recalled by Dr. Mitchell, one became worse and three were improved by operation. One woman of forty years, after long years of aggravated hysteria, suffered so much from melancholia at her men- strua] period that she besought relief, and finally reluctant consent to operation was given. This resulted in a remarkably improved physical condition, but the insanity became abruptly worse, and has now lasted twelve years. In a case of aggravated hysteria of the type so common in France but rare in this country, the patient finally became violently homicidal at the menstrual epoch. Normal pelvic structures were removed and a gradual im- provement followed, until perfect health was regained. The third, a case of nymphomania with furious sexual dreams at the menstrual period, was similarly treated and relieved, but it must be borne in mind that there were also enlarged ovaries and serious tubal disease. The fourth, a case of menstrual melancholia and maddening head- aches, was also slowly relieved of the melancholia, but the periodical headaches persisted ; in this case, too, there was grave disease of the tubes and ovaries, so that we rightly exclude this and the preceding from our category. SIMPLE SALPINGO-OOPHORECTOMT. 195 It is a question for investigation whetlier the operation is justifiable under any circumstances in feeble-minded girls with uncontrollable sexual pro- clivities, or for incurable masturbation. Salpingo-oophorectomy has been frequently performed in the past for the sake of its efEect in permanently diminishing the blood supply to the uterus where the latter contains myomata which could not be removed without undue risk, but this treatment is now no longer resorted to by the best operators on account of its uncertainty, as well as on account of the improved technique of myomectomy and hysteromyomectomy. Extreme dysmenorrhea is an indication which I accept with great hesitation, even when the suffering is sufficient to impair the patient's health seriously, and all other simpler plans of treatment have been faithfully tried and have failed. Of all operations connected with gynecology, salpingo-oophorectomy per- formed upon this indication and for hysteria has been most abused, either through a want of good judgment on the part of the surgeon in recommending unsuitable eases for operation, or through his being misled by a hysterical woman into imagining her pelvic condition worse than it actually was. In all these cases the advice of the neurologist and the general practi- tioner, as well as that of a conscientious skilled gynecologist, must be sought before deciding upon a radical operation the benefits of which are at best ■doubtful. Dysmenorrhea is but a symptom which may arise from so many other causes than disease of the ovaries, that while the removal of these organs may pos- sibly relieve the periodical monthly pain, it may at the same time leave in its place a great number of nervous symptoms infinitely more distressing than the menstrual discomforts. In younger women the removal of the ovaries is fol- lowed by more pronounced nervous disturbance than in those who are older. The patient herself can never be the right judge as to the necessity of remo%'ing the ovaries. I have seen young women who suffered so severely at ihe menstrual periods that they were importunate in their demands for radical relief, and were wilhng to submit to any operation ; removal of the ovaries sup- pressed the function, but in place of the pain, a train of nervous symptoms ap- peared, along with the realization that they were unsexed and could not morally assume the relationship of marriage with the hope of maternity, and profound mental depression supervened. My attitude with regard to the removal of the ovaries for dysmenorrhea will be seen by the fact that in a recent series of five hundred abdominal sections at the Johns Hopkins Hospital only four cases were operated upon for this reason, and in three of these the relief was not what was looked for. One case, a woman of thirty-eight years (M. H., 4183), who had borne four children, suffered intense agony during the menstrual period. She was not neurotic, and after seeing her through a period there could be no question as to the reality of her sufferings. For four or five days before the flow appeared she had dull headache and bearing-down pain in the lower abdomen, and when 196 SIMPLE SALPINGO-OOPHORECTOMY FOR ADHERENT TUBES AND OVARIES. the flow was once established, instead of relieving her symptoms, it only aggra- vated them. The pain then became sharp and paroxysmal, and the headache was so intense that she could stand no light in her room. These symptoms always persisted for a week, during which time she was bedridden. The uterus was dilated and curetted. At first the retroflexed uterus was sus- pended. Both ovaries and tubes were found normal. For one or two periods subsequent to this operation she was somewhat better, but soon the old pains re- turned with renewed severity, and for the next year she was a constant sufferer. She then returned to the hospital and I explained the effects of the radical operation and my reluctance to perform it. Both husband and wife, however, insisted upon it, and I extirpated ovaries, tubes, and uterus (March 2, 1896). The patient was well for a year after the operation, and then began again to complain of a variety of nervous symptoms, so that the success of the operation was only partial. A second case was that of a nurse (E. D., 3391, March 23, 1895), thirty-six years old, totally incapacitated for one week in every month by severe menstrual cramps. Total extirpation of ovaries and tubes was followed by complete relief, and she has since been able to work without interruption. In the two other cases the patients had enlarged ovaries in which the numer- ous dilated Graafian cysts were distributed underneath the thick tunica al- buginea of the ovary. One woman was twenty-two years old, and her relief from her pelvic symp- toms has been complete, while her subsequent history (J. S., 3333, Feb. 25, 1895) serves well to show that the dysmenorrhea is often only the local expression of a constitutional tendency, and that when the pelvic pain is relieved nervous out- breaks in various other parts of the body are prone to occur. Soon after the operation she suffered from a severe facial neuralgia for which she had all her teeth extracted. She next had an attack of sneezing which lasted almost con- tinually for three days, ^veakening her so that she nearly died. She is now so weak that she can work but little, and suffers from constant shortness of breath. Defecation is extremely painful, and there is an obstinate constipation, necessi- tating the constant use of medicines. The second patient, also a young woman of twenty-two, had suffered since menstruation began with almost a continuous bloody discharge. The menstrual periods were irregular and very painful, and she had long been a confirmed invalid. All forms of treatment, including the tonics, exercise, and diet, had been instituted without relief ; instead of improving, she gradually lost ground. I studied the case carefully, and somewhat reluctantly consented to operate. The patient ceased to menstruate after the operation, and has had no flow for eighteen months ; she has gained flesh and strength, and her color is better, but the nervous symptoms are distressing, the flushes and sweatings and a variety of bizarre sensations keeping her constantly miserable. Her depression at times verges onto melancholia. Since the term " cystic ovary " has been used so frequently, as though it Were a pathological condition, to justify many operations for dysmenorrhea, it OPERATION. 197 should be distinctly understood that the presence of several large Graafian fol- licles is not pathological, except in rare instances in which the ovary is often twice as large as normal, the tunica albuginea is thick and dense, and multiple cysts may be seen shining through it. On section, the capsule is seen as a thick, white, non-vascular area, and there is only occasional evidence of rup- tured follicles. In the light of our present knowledge of the pathology of the ovary, the attempt to justify the removal of small "cystic ovaries'' must be denounced as both unscientific and immoral. Operation. — The operation is an epitome of all the operations for the re- removal of diseased appendages, for the eifort of the operator in the most dif- ficult cases is usually to reduce them to the type of the simple enucleation of the tubes and ovaries by first eliminating the complications and then completing the operation as a simple salpingo-oophorectomy. The Incision and Delivery of the Ovary and Tube . — The patient should be placed upon the table with the pelvis elevated, and an incision from 4 to 6 centimeters (1^ to 2^ inches) long — longer if the abdominal walls are unusually thick — should be made through the linea alba, beginning 3 or 3 centimeters above the symphysis pubis. As soon as the abdomen is opened, the index and middle fingers are intro- duced and conducted along the under surface of the abdominal wall to the sym- physis pubis, and from the symphysis down over the bladder onto the uterus, and out over the cornu uteri to the broad ligament, behind which the tube and ovary are ordinarily found and picked up. Futile efforts to pick up the ovary and tube and draw them through the small incision often embarrass the beginner. The best way is to carry the fin- gers to the outer extremity of the broad ligament, and then, turning the palmar surfaces astride the broad ligament toward the uterus, to carry them down into the pelvis, and bring them up toward the cornu uteri, so as to hook lap both ovary and tube together, which may now be drawn easily out through the incision and tied ofl:. The Ligation of the Pedicle and Removal of the Tube and Ovary . — The structures to be removed are the entire length of the tube, the ovary with its hiltim and a portion of the utero-ovarian ligament, together with their blood vessels, lymphatics, and nerves. The chief risk of the opera- tion lies in the liability to hemorrhage from improper control of the blood vessels. The uterine and ovarian vessels must now be tied separately, while the non- vascular portion of the broad ligament between them is left free. This avoids the tension of the broad ligament produced by binding its pelvic and uterine extremities together by interlocking ligatures, and so obviates the imminent risk of hemorrhage as soon as any tension is put upon the ligament by retching, straining, etc. (see Scmxe Sources of Hemm'rhage in Abdominal Pelvic Opera- tions. Johns Hoph. Hosp. Hep., iii, 1894, p. 419). 198 SIMPLE SALPINGO-OOPHOKECTOMY FOE ADHERENT TUBES AND OVARIES. It is best to use fine silk ligatures in all cases when large vessels are to be controlled. The first ligature includes the ovarian veins and artery, and is passed through the clear space in the broad ligament and tied near the pelvic brim over the top of the infundibulo-pelvic ligament well beyond the fimbriated extremity of the tube. A second ligature of catgut is applied to the utero-ovarian liga- ment posteriorly. A third ligature is passed over the top of the broad ligament at the cornu uteri, embracing the uterine vessels which are visible and the isthmus of the tube. In order to fix the ligatures so that there shall be no danger from slipping over the top of the pedicle when the ovary and tube are removed, the free Hga- ture may be carried over the top of the ligament, or over the cornu, and made to transfix a small portion of the tissue in a reverse direction from that in which it passed through the broad ligament the first time. The clear space is a triangular surface near the upper outer extremity of the broad ligament free from vessels, bounded by the ovarian vessels above, the pelvic wall on the outer side, and the round ligament below and on the inside. It is developed, or made larger, by pulling up the top of the broad ligament. If the finger is pushed into this space from behind forward, the anterior and posterior layers of the broad ligament are brought together, and the furrows in the skin of the finger are often clearly visible through them. I utilize the clear space in the following manner in passing the ligatures : The structures to be removed are drawn well up, and the finger is passed down behind the broad ligament under the ovarian vessels and pushed forward into the clear space. A careful observation is then made to be sure that all the large ovarian veins lie above and none of them lie below the end of the finger. A silk suture of intermediate size is then drawn through the clear space from before backward by means of a needle and carrier, and tied tightly over the top of the vessels. After the ligation the ovary and tube are removed by cutting the pedicle at least 1 centimeter from the ligatures. Particular attention must be given to the removal of the entire ovary, cut- ting through a point in the ovarian ligament well away from the ovary, and then cutting under the hilum well away from the ovarian tissue. As the outer extremity of the broad ligament is severed, its stump, with the ovarian vessels, retracts up to or over the brim of the pelvis, and between this and the cornu uteri there is only the thin falciform edge of the anterior and posterior peritoneal layers of the brOad ligament. If any small bleeding points are noted in this area they must be caught with forceps and controlled with fine catgut ligatures. Inspection of the Field and Closure of the Incision. — Finally, after both appendages have been removed, a careful inspection should be made before closure, in order to determine whether there is any bleeding and whether the stumps are well tied, so as to lessen the likelihood of hemorrhaffe after closure of the incision. If any one of the uterine ligatures or of the PLATE XI 'MM'T-^^. / A X Id Fia X8 -ig. 2. ■IBrodei.fe IjlliLPranS.i'CoBosIo!i,U5,A, DESCRIPTION OF PLATE XI. Fig. 1. — Hydrosalpinx simplex (xl6). Cross-section through the middle of the tube, showing the teatlike and branching folds projecting into the lumen. The smaller folds present marked constrictions at then* bases. '^''"= '-^^t . ni . Fig. 2. — Hydrosalpinx foUicularis ( x 8). Crosfe-s^tion from a point at the junction of the middle and outer third of the tube. Surrounding the central lumen are many large and small round or irregularly shaped cavities. j^The dilatation is greater on the free convex upper surface than below. SALPINGO-OOPHORECTOMY FOR HYDROSALPINX. 199 ovarian arteries appear insecure or doubtful, a second ligature should be thrown around the pedicle to make it secure. It is not necessary to wash out the abdomen or the pelvis, and drainage ought never to be used. The patient is now let down from the elevated position, and the omentum is then drawn down over the small intestines as they drop into the pelvis and in- spected to see that no loop of intestines has slipped through one of its accidental openings. The operation is completed by closing the incision with the three or four layers of sutures, catgut to the peritoneal layer, silver wire or silkworm gut to the fascia and muscle, and catgut to the fat if the walls are thick, and finally a subcuticular suture of catgut or silver wire — all as described in Chapter XXI, on the technique of abdominal operations. salpixgo-oOphorectomy for hydrosalpinx and for adherent tubes and ovaries. The name "hydrosalpinx" is applied to a uterine tube which contains a watery accumulation ; the term is therefore not scientifically accurate. It does not in any way define the morbid process that brings about such an accumu- lation ; it sunply describes a prominent clinical feature. This accumulation of fluid is due to an occlusion of the tube, forming a retention cyst. For clinical convenience the various forms of hydrosalpinx may be grouped as — 1. Hydrosalpinx simplex. 2. Hydrops tubse profluens. 3. Hydrosalpinx follicularis. 4. Tubo-ovarian cysts. 1. Hydrosalpinx Simplex. — In simple hydrosalpinx there is a conical disten- tion of the tube, which is greatest at the fimbriated and least at the uterine end. On opening the abdomen (see Fig. 3Y0), the tube looks like a transparent thin- walled sac beside or behind the uterus ; if both sides are involved, the tubes hang back over the uterus like saddle-bags. The uterine end of the tube is usually on a level with the superior strait, while the dilated extremity dips down toward the pelvic floor. If the tube is only moderately distended, the fluid may all be lodged in that portion which offers the least resistance to expansion — that is, in the ampulla ; when it is excessively enlarged so as to hold half a liter, a liter, or more of fluid, it rises up, filling the lower abdomen and partaking of many of the clinical characteristics of a parovarian cyst (see Figs. 371, 372). Feaslee cites an extraordinary case, if his interpretation is to be credited, which contained 18 pounds of fluid {Ovarian Tumors and Ovariotomy, 1872, p. 105). One or more kinks are commonly found in the tube before its removal, due to the flexures necessary to accommodate its posture to the more resisting sur- rounding structures. Adhesions are uniformly found at the fimbriated end, and 54 200 SIMPLE SA.LPINGO-Or)PHOKECTOMY FOR ADHERENT TUBES AXD OVARIES. these commonly hold the tube down to the pelvic floor ; adhesions to the ovary and to the contiguous i:)elvic wall are also common. The dorsum of the tube is, however, usually free. In rare instances the ampulla is simply closed and there are no pelvic adhesions. When the tubal walls are thin and unruptured, s t r i se may often be seen on the inside, parallel to its lor.g axis ; these are folds in the mucosa. The inner surface is glistening and pinkish in color. Microscopically, the muscular layers Fig. SVO. — Duuijle Hydrosalpinx, drawn from Nature, showing the Relations between the Large Tubes dilated with Clear Fluid and the Uterus and the Posterior Pelvis. Note the flexions of the right tube and the adhesions from tlie uterine oornu to tlie ampulla. in the wall of the tube, in the cases with the least distention, may appear nor- mal ; in other cases they are thinned out until they may be nearly all gone. Be- tween the muscular bundles a connective-tissue-cell proliferation is often found, and the intermuscular connective tissue may be loose and edematous. Hyper- trophy of the muscular coat does not occur. The mucous lining of the tube presents the most remarkable and character- istic changes. The folds, normally so luxuriant and complicated in their branch- DESCRIPTION OF PLATE XII. Hydrosalpinx simplex (x 70). A small portion of Plate XI, Fig. 1, magnified. The peritoneal coat is here free from adhesions and the muscularis is normal. The tube is lined by a single layer of cylindrical epithelium and the stroma of the folds is normal. PLATE XII. % ", j'^^r,., ^^.-v*' c'"-*- ■"-■. ." t"*"' V'-: : V '".". '.-=>^ ■ ■ ■ ■ X 70 ''44'- M.Brodel.fec, i.llh.LPrans&Co,Bosloii, HYDKOSALPIXX SIMPLEX. 201 ing^, are separated from one another as a result of the distension ; they are recos nized as branched folds and iingerlike projections. _L I . , -. L Fig. 371. — Large Left Hydeosalpin.x with Numerous Adhesions; Normal CIvaries, VIight Tube, and Uterus. Drawn to scale below. March 30, 189.5. The epithelium may retain its cilia even in a tube which is markedly dis- tended ; it always occurs in a single layer, cylindrical and cnboidal. -p gY2 Double HYDEOSALrmx, with Adhesions bridging thu Angles in the Tube.s and bindino ' DOWN the Uterus by its fosTERioK Surface. May 21, ISUo. Natural Size. 202 SIMPLE SALPINGO-OOPHORECTOMT FOR ADHEEEN"! TUBES AND OVARIES. Ill some cases calcified plates are found, and in one of my patients I found a long irregular calculus fastened by one end to the isthmus and projecting into the lumen of the dilated tube. In another instance I found a large hydrosalpinx associated with a congenita] deficiency in the tube, dividing its ampulla into two parts, of which the outer end was entirely disconnected with the uterine end and the isthmus (see Fig. 377). ^ t'DROSALPINS. The large bulbous dilated tube is filled with seruinliive tluid and is entirely free from any adhesions to the ovary. The opposite tube and ovary were densely matted together. No. 447. Natural size. 2. Hydrops Tubae Profluens. — This form of hydrosalpinx is characterized by the remarkable clinical sign of a periodical outflow from the tube into the uterus, the vagina, and so out over the person. Martin found four cases out Fia. 374. — Hydeosalpinx with Few Convolutions. The left tube is intimately adherent to the ovary be- low on the right. Three glistening subperitoneal cysts are seen where the tube joins the ovary. C. M., No. 223. Natural size. liG. .37u. — Hydrosalpin.x shown in Figure 874, SEEN IN Longitudinal Section. The ampulla of the tube is marliiedly dilated throughout and ends in a large bulbous extrem- ity. The ovary is seen flattened out below the cyst. Note the parallel folds of the tubal muco- sa, ending abruptly in little bulbous extremities. of five hundred cases of tubal disease. Landau states that the muscular walls of the tube are hypertrophied. The manner of discharge of the fluid varies, occur- ring either constantly with periods of exacerbation, or at intervals of hours or of several days. After the formation of a definite painful t.umor the tube is evacu- ated spontaneously with pain, and the tumor disappears ; one of my cases, a large, HYDROSALPINX FOLLICULARIS. 203 stout woman, was made miserable by the recurring paroxysms of pain. The amount of discharge may be as much as half a liter in twenty-four hours ; when Fio. 376. — Hyukosalfin.x containing a Noddlar S-shaped Calculus lyino in the Lumen of the Tube, WHICH is Adherent to the Ovary. The calculus is shown in detiiil in the outline figure to the right. Cambridge, July, 1894. it accumulates in the vagina, as during the night, on rising it may escape like a gush of warm water, much as if the bladder had suddenly emptied itself. C o d e i n sometimes has a marked effect in controlling the flow, but it does not give permanent relief. Removal of one or both tubes alone will cure the disease. Fig. S??. — Hy'drosalpin.x, with Congenital Deficiency in the Tube. The tube ends in a group of three cysts, and these are connected with the isolated subperitoneal cyst on the right by a thin hand of peritoneum in which there is no portion of a tube. The fimbriated end of the tube lies beyond the single cyst. 3. Hydrosalpinx Follicularis. — In follicular dropsy the tube is usually of small size — not more than 3 centimeters in diameter — and appears externally like the simple dropsical tube just described. On cross-section, however, the lumen of the tube is often diminished or altogether displaced by an open network of 204 SIMPLE SALPINGO-OOPHORECTOMY FOB ADHERENT TUBES AN^D OVABIES. tissues developed in its inner wall and forming oval spaces varying in size from a pin-point to 8 millimeters in diameter (see PI. XI, Fig. 2, and PI. XIII). These cavities are filled with fluid, and apparently comnianicate with one another. The muscular coat shows little alteration, with the exception of some con- nective tissue cell proliferation between the bundles. The folds of the mucosa are sparse or absent, and the mucosa itself is occu- pied by alveoli which are variously subdivided by partitions ; the large alveoli are lined by cuboidal epithelium and the smaller ones liy cylindrical cells. This may be the outcome of an endosalpingitis follicularis described by A. Martin ; Orth states that the alveoli or glandlike spaces may become cystic. Out of eleven cases of hydrosalpinx, four were follicular and two of them were bilateral. One case presented a follicular hydrosalpinx on the left and a sim])le hydrosalpinx on the right, tending to show the close genetic relation- ship between the two varieties. 4. Tubo-ovarian Cysts. — A tubo-ovarian cyst is formed by a communication between a tube and a cyst of the ovary, so that fluid may pass freely from one to the other. The dropsical tube in these cases ends in a Ijulbous enlargement as big as a thumb or a child's head. "What is most remarkable in these cases is the fact that the fimbriated end of the tube is often found spread out over the inner surface of the cyst. J. Bland Sutton {Surg. Dim. of Ov. and Fal. Tubes^ London, 189(), p. 102), who has made an admirable study of this condition, Fig. 378. — Kight Tl'bo-ovakian Cyst. The tube above ends in a bulbous extremity, fused with the ovary, witli only a sli^rht sulcus between them. The ovarian ligament is shown below, leading out to the cystic ovary. By cutting the cyst open in the direction of the dotted line, the interior of the cyst is seen as in Fig. 379. Patli. No. 665. Natural size. bringing his wide acquaintance with comparative pathology to his aid, considers that these tumors are due to the presence of a tunic of the peritoneum, which occasionally invests the human ovary in the same way that the funiciilar pouch clothes the testicle, and similar to the peritoneal pouches in some animals, and for this reason he calls the condition an " ovarian hydrocele." One of my cases of tubo-ovarian cyst, of small size, is seen in Figs. 378 and 379 ; I have also had one case in which the tumor in the left side was as big as a man's head and filled with a limpid fluid ; the valvelike opening out DESCRIPTION OF PLATE XIII. Hydrosalpinx follicularis ( x 70). The peritoneum shows a few recent adhesions ; the muscularis has alniost disappeared and its place is occupied by connective tissue. The small " alveoli " are lined with cylindrical epithelium, the larger ones with cuboidal epithelium, cylindrical in protected areas. The lumina contain some desquamated epi- thelium ; the stroma is almost normal. PLATE X!l X 70 LiihLPrangiCoBoa'.iiJJS.A MBrodel.fec, Fig. 380. — Tl'bo-ovarian Cyst from the Right Side. The uterine tute crosses the cyst in the form of an lo ; at its right extremity it is kinked and adherent to a piece of the uterine cornu which has heen excised with the tumor. The tube ends in the domelike prominence above and to the left. A small, clear subperitoneal cyst marks the border line between the ovarian cyst and the tube. March 8, 1894. -1/5 natural size. Fig. 381. — Tueo-ovarian Cyst divided so as to show the Lakgk OvARiA>f Cyst with the Uv.-vky Flattened Out on its Surface Below. Above, the tube iw seen divided twice ; the smaller dark opening on the outer side shows the rcticulated_ appearance of the tube, while the larifcr opening on the inner side snows the dilated ampulla with its sickle- shaped opening, through which the tube communicates freely with the ovarian cyst below. TUBO-OVARIAN CYSTS. 205 of the tube was partly surrounded by a fringe of finabrise spread out on the inner wall. Bland Sutton says these cysts occasionally suppurate, but this I have never seen. The inner surface in one of my cases was lined by flat epithelium and in another by cuboidal. The fluid is clear and watery and does not contain any pseudo-mucin. Etiology . — The etiology of hydrosalpinx is not yet clear. One thing, however, is quite certain, and that is that it may be produced by any cause 9. — TuBO-OVARIAN CyST LAID OpEN. Showing the orifice and fimbriated extremity of the tube and the distribution of the fimbriae over the interior of the cyst, forming a so-called " ovarian hydrocele." which closes the fimbriated extremity of the tube without destroying its lumen. In this way an infection traveling out through the uterus and the tube into the peritoneum causes a hydrosalpinx by drawing together the peritoneal sur- faces of the tube until it is closed. If the infection is a violent one and produces a catarrhal or a suppurative salpingitis, the sealing up of the tube is Is^ature's best way of protecting the peritoneal cavity from a general infection ; then with the cessation of the sup- purative process a hydrosalpinx may develop. Landau states that a pyosalpinx may terminate in a hydrosalpinx by the pus cells undergoing fatty degenera- tion and leaving the watery elements behind. ' Bland Sutton (ibid., p. 220) holds that hydrosalpinx is often a late stage of pyosalpinx for these reasons : (1) Hydrosalpinx is not found in acute cases ; (2) in many chronic cases hydrosalpinx is found on one side of the uterus and a progressive pyosalpinx on the other ; (3) the ampulla of a tube may be dilated into a hydrosalpinx, and the isthmus contain pus ; (4) the fluid contained in a hydrosalpinx will sometimes be colorless, but the recesses of the tube contain caseous material and cholesterin ; (5) the dilated portion of the tube in hydro- salpinx may, as in pyosalpinx, communicate with an enlarged ovarian follicle to form a tubo-ovarian cyst. It is a remarkable fact that both the tubal mucosa and the muscular walls usually show little or no evidences of any previous inflammatory process. I do not, therefore, believe that the disease is often a sequel of a pyosalpinx. That the process may be a slow one is evident from the numerous cases in which the fimbriated end of the tube is found in all stages of closure ; in one the ends are being turned slightly in and the movements restricted by a band or 206 SIMPLE SALPINGO-OOPHORECTOMY FOB ADHBBENT TUBES AND OVARIES. a collar of lymph just back of the fimbriae ; in another the end of the tube is rounded ofE and bulbous, but from the center a rosette of fimbriae still projects ; a little later a little red bud hangs out of a minute orifice ; finally this disappears within and the closure is complete. At the point of completed closure there is a mass of scar tissue, and the tube often presents a marked depression from which bands of connective tissue radiate out to the periphery. The turning in of the fimbriae is to be accounted for in the following way : The inflamed peritoneum is the only surface to which the lymph can become attached, and every time a contraction is made a gain is effected and more mu- cosa is turned in. There is nothing, on the other hand, to evert the mucosa again, except the swelling from an inflammation which tends to subside after the initial stages of the disease have passed. Symptoms. — The symptoms of hydrosalpinx are variable. When there is much pain and soreness in the pelvis, this is usually due to the coincident pelvic peritonitis and the adhesions formed. The pain is lateral, on one or both sides, and there is marked tenderness developed on pressure, especially if the tube is squeezed bimanually. Upon handling the tube in this way, the patient is often able to locate precisely the focus of her discomforts. Backache, bearing-down, radiating pains, and painful defecation are symp- toms common to pelvic inflammatory disease in general. Menstruation is painful in over 50 per cent of the cases, but in the remainder it is in no way affected. When both tubes are occluded the woman, of course, remains sterile; about 25 per cent of my cases in married women were never pregnant at all. When one tube remains patulous, pregnancy may occur, but there is apt to be an early miscarriage as soon as the enlarging uterus begins to make traction on the unyielding diseased structure. Two of my patients who had no children became pregnant nine and five times respectively and miscarried every time. It must be borne in mind in studying the relationship of hydrosalpinx to pregnancy that the disease often makes its first appearance after the woman has had one or more children. Diagnosis . — The diagnosis will usually be made best by emptying the bowel thoroughly and putting the patient under an anesthetic. Then if the bowel is inflated with air by placing the patient for a short time in the knee- breast posture and letting air in through the anus, a minute examination of the tubes and ovaries can be made and any abnormality detected. Two things must then be determined : first, that there exists a cystic enlarge- ment lateral to the uterus, but not directly connected with it ; and second, that the ovary is not the seat of the enlargement. A hydrosalpinx is always found lateral to, or lateral and posterior to, the uterus, and is usually elongate, differing in this respect from small ovarian cysts. If its curved course can be traced and one or more kinks made out, a diagnosis may be made. The diagnosis is still more certain when the ovary is carefully TUBO-OVAEIAX CYSTS. 'M}7 outlined at the same time and tlie fact made sure that it is not enlarged. When the tube and the ovary are involved in much surrounding inflammation, a diag- nosis will be difficult and often quite impossible. The distinction between hydrosalpinx and pyosalpinx rests upon the tliick- ness of the tubal walls and the dense, often boardlike, feeling of the surround- ing peritoneal and cellular tissue engendered by the suppuration. Treatment . — The treatment of hydrosalpinx and its associated pelvic in- flammation consists in the adoption of measures either conservative or radical. The conservative plan of treatment must always be given the precedence in young women ; this has been dwelt upon in detail in Chapter XXY, and in brief consists in breaking up adhesions, either by the rectum or through an abdominal or vaginal incision ; in opening and making a new ostium in a closed tube ; or in resecting a diseased tube. It must be remembered that no matter how extensive the surrounding in- flammation and how intimately the ovary is involved in it, or how completely the ovary is buried in adhesions, this organ is itself rarely diseased and rarely requires removal. A chronic ovaritis does not exist, and the cirrhotic condition found is due to malnutrition from interference with the circulation. The only possible reason for removing the ovary is the necessity of cutting short the menstrual function. Hadical Treatment . — When a radical plan is adopted this must not be done as a routine procedure, but only after deUberation and duly weighing the chances of conservatism and formulating sufficient reasons for the extir- pation. The radical course is justified in a young woman only where conservatism has already been tried and has failed, and in older women who are condemned by the pelvic disease to a life of suffering and of more or less invalidism. If the woman is married it must not be forgotten that even after forty, women have borne children under the most discouraging conditions. (See Chapter XXV.) The operation consists in — 1. The removal of a diseased tube alone, or 2. The removal of both tubes and the uterus, leaving the ovaries, or 3. The removal of the tube and the ovary together, or 4. The removal of uterus, ovaries, and tubes. The adhesions, the result of a surrounding pelvic peritonitis, vary from Hght bands easily severed all the way to dense inflammatory masses burying the uterus and its adnexa ; these must be carefully and deliberately severed under direct inspection until the pelvic organs are set perfectly free. When one side is affected the best plan is to sever all adhesions and to remove the tube, leaving the ovary. This may be done by lifting up the tube with its mesosalpinx and viewing it by transmitted light, by which the vessels are plainly seen grouped principally at both ends. The catgut ligatures may then be passed through the mesosalpinx and tied at both ends so as to include the main vessels ; the tube is then stripped off by cutting close under its peritoneal attachment. The edges of the mesosalpinx may then be whipped together by a 208 SIMPLE SALPINGO- OOPHORECTOMY FOR ADHERENT TUBES AND OVARIES. fine catgut suture. A large hydrosalpinx should be tapped and evacuated before attempting to remove the tube. The removal of a tube and an ovary, or of both tubes and ovaries, is only done in order to check menstruation where its continuance is deemed incom- patible with complete recovery ; this operation is the same as that of simple salpingo-oophorectomy, which is fully described in the first section of this chapter. When the uterus is adherent and buried in the inilammatory disease sur- rounding the tubes and ovaries, it will be better to remove this organ too, in the manner described in Chapter XXVIII, always remembering to preserve the ovaries in young women, if possible. PLATE XIV 1 BMel. fer ,iih [J'Mn?iCo.rnK-,i<:ii/.'.^ A DESCRIPTION OF PL^-TE XIV. A typical pyosalpinx. The specimen consists of a ^peply injected uterus with four small subserous myomata, and a distended convoluted characteristically yellow and injected club-shaped pyosalpinx of the left tube. Note the injection of the vessels in marked contrast to the yellowish appearance of the tube. '^^'*'' The right side, in precisely similar condition, was removed a few weeks before, and the left tube, thickened and inflamed, but without suppuration, was preserved in hope that it would recover. The inflammatory process advanced, however, steadily to the condition found on the right side, and the tube and the uterus were extirpated at the second operation. CHAPTEE XXVII. ■VAGINAL DRAINAGE AND ENUCLEATION FOR PYOSALPINX, OVARIAN ABSCESS, TUBO-OVARIAN ABSCESS, AND PELVIC ABSCESS. 1. Forms of abscess. 2. Causes of suppuration : 1. G-onoooccus. 2. Streptococcus. 3. Staphylococcus aureus and albus. 4. Micrococcus laneeolatus. 5. Bacillus lactis aerogenes. 6. Proteus Zenkeri. 7. Tubercle bacillus. 3. Table showing bacteriological examination of pus from ovaries and tubes. 4. Course of an inflammatory process. 5. Symptoms : 1. Natural terminations of an abscess by : (a) Discharge through uterus ; (J) dis- charge through rectum, vagina, bladder, abdominal wall, or into peritoneum ; (c) becoming encysted ; (d) absorption and disappearance of pus. 6. Prognosis. 7. Diagnosis. 8. Treatment : 1. Expectant. 2. Emptying the sac by massage. 3. Vaginal incision and drain- age. 4. Evacuation through the rectum. 5. Evacuation by the vagina aided by an abdomi- nal incision. 6. Enucleation of pyosalpinx and ovarian abscess (salpingo-oophorectomy). Forms of Abscess. — The term "pelvic abscess" as used in gynecology is somewhat vague, for while it literally includes all forms of pus accumulations found in any part of the pelvis, from the tip of the vermiform appendix to the ischio-rec- tal fossa, common usage has restricted it to intrapelvic suppurations in the neighborhood of the uterus. Considerable confusion exist- ed for many years as to the actual site of these abscesses ; it was long supposed that they were all alike located in the cellular tissue, and were the outcome of a cellulitis. As a matter of fact, demonstrations made from hundreds of cases minutely observed during the last decade prove that the seat of the abscess, as a rule, is located in the uterine tube or the ovary, and that it is rarely found in the cellular tissue. I have found accumulations of pus — 1. Encapsulated in one or both uterine tubes — pyosalpinx, single and double. 2. Within the ovary — ovarian abscess. 3. In tube and ovary separately — tubal and ovarian abscess. ■i. In tube and ovary combined into a common abscess cavity — a tubo-ovarian abscess. 5. In the cornu uteri — cornual abscess. 209 Fig. 382. — Outline of the Torsion of THE Pyosalpinx shown in the Col- ored Plate. The axis is shown by a clotted line which is heavier or lighter according as its plane lies nearer or farther from the observer. Nov. 9, 1894. 210 VAGINAL DRAINAGE AND ENUCLEATION FOB PTOSALPINX, ETC. 6. On the floor of the pelvis below the utero-sacral folds — abscess of Doug- las' cul-de-sao. 7. Anterior to the uterus in the cellular tissue, as well as in the uterine tube. 8. In and about a vermiform appendix hanging down into the jDelvis — sup- purative appendicitis. 9. About the vermiform appendix and in the uterine tube at the same time. 10. Between adherent coils of intestine in the pelvis. 11. About the pedicle left after an abdominal operation. 12. In suppurating ovarian and dermoid cysts. Abscesses are also found (13) in the uterine walls and (14) in the cellular tis- sue at the bases of the broad ligaments. Causes of Suppuration. — Suppurative aifections of the pelvic organs are due to any of the pus-producing micro-organisms which usually find their entrance through the vagina into the uterus, and then into the pelvis, either by way of the uterine tube or by the lymphatics through the uterine wall and parametrium. The route of extension from the uterus depends largely upon the variety of the organism ; the gonococcus almost always travels along the mucous membrane into the tube, where its further extension may be arrested and the reactionary inflammation confined to the tube, or it may escape onto the pelvic peritoneum, setting up a localized peritonitis. In gonococcal infection the inflammatory process is almost invari- ably confined to the pelvic organs and their immediate environment, rarely caus- ing more than a local reaction, and never giving rise to a general infection. In a number of cases I have been able to trace the course of the progressive steps of the invasion of the gonococcus all the way from the external genitals to the pelvic organs. In one instance where a patulous fimbriated extremity of a tube was seen with the pus containing gonococci escaping into the pelvic cavity, at the time of operation for the removal of the tubal abscess, gonococci were also demon- strated in the free pus in the abdomen, in the uterine tube, in the uterus, the vagina, in Bartholin's glands, in Skene's tubules, and in the urethra, making the chain of the infection complete. Besides the extension of gonococcus infection along the mucosa, it has been shown (Wertheim) that it may also pass into the submucous connective tissue and even enter the circulation. Many writers, and especially E. Noeggerath, Sanger, and A. v. Eosthorn, lay great stress upon the frequency of pyosalpinx due to the gonococcus. The two latter found tubal disease in 33 per cent of all women afl:ected with gonorrhea. While the cultures taken from the pus in these cases frequently do not show its presence, I am constrained to attrib- ute this failure to defective culture methods rather than to the absence of this germ, because cover-glass preparations frequently show diplococci which resemble gonococci, and the clinical history of the cases points strongly in this direction. Gronococci have been found in ovarian abscesses by Wertheim, Sanger, and Zweifel. CAUSES OF SXJPPUEATION-. 211 The history of a streptococcus infection is different from that of the gonococcus, both in its chnieal course and in the route of its extension. Infection from this organism usually occurs during a badly conducted puerperium, or after an abortion, or is introduced into the uterus by dirty instruments in the hands of the physician. Intra-uterine applications, and the introduction of sounds and dilators without proper antiseptic precautions, are among the commonest means of conveying the infection from patient to patient. When streptococci gain entrance to the uterus they may invade the pelvis by the same route as the gonococci, or they may penetrate the uterine wall, setting up an endometritis or metritis, and then a parametritis, forming a more or less dense swelling, occurs which usually terminates in an indurated phlegmon or a pelvic cellular abscess. The tube and ovary may then be involved by continuity or by blood infec- tion, or they may escape infection and lie upon the top of the abscess intact. The staphylococcus, while comparatively rare, is occasionally obtained from pelvic abscesses. E. Eaymond and W. S. Magill, in a careful bacteriological study of salpingo- oophoritis, while not denying the possibility of staphylococcus infection, say that they have never seen it. K. Menge reports one case in a series of twenty-six bac- teriological examinations, Y. Morax one in thirty-three cases, while F. Schauta has only seen the streptococcus and the staphylococcus four times in one hundred and forty-four cases. Wertheim found in 116 cases of pyosalpinx that 72 times there were no bac- teria at all, 32 times there were gonococci, 6 times streptococci, and once staphy- lococci. In twenty-iive cases of pelvic abscess opened through the vagina in my clinic. Dr. G. B. Miller found the staphylococcus aureus twice and the a 1 b u s twice. In a series of forty -three cases of purulent conditions of the ovaries and tubes one case showed a mixed infection, consisting of the staphylococcus albus and aureus and the streptococcus. Pelvic abscesses may also be due to a colon bacillus infection. Among the rarer organisms found are the micrococcus lanceolatus, the bacillus laetis aerogenes, and the proteus Zenkeri. Tu- bercle bacilli are occasionally found in the walls of pelvic abscesses. In the twenty -five cases of pelvic abscess evacuated ^er vaginam in my clinic the cultures were negative in twelve cases, streptococci were found in three cases, the colon bacillus four times, staphylococcus pyogenes aureus in two cases, staphylococcus pyogenes albus in two cases, and the gonococcus in four cases. In two cases only were the gonococci grown on culture, the other two being determined from cover-glass preparations. In a careful bacteriological examination of forty-three cases of pyosalpinx, ovarian abscess, and pelvic abscess, removed through the abdominal incision, or- ganisms were found much less frequently than in the above-mentioned cases, which gives ground for the suspicion that the cultures taken by the vaginal 212 VAGIKAL DRAINAGE AND ENUCLEATION" FOE PYOSALPINX, ETC. puncture may have been contaminated. The results of the examination of these forty -three cases are summarized in the following table : Table shoivmg Bacteriological Examination of Pus from Ovaries and Tubes. Diagnosis. Cover-glass. Agar. Glycerin agar. Acid gelatin. Blood serum. Bacteria. 1 Pyosalpinx. . Negative. Negative. Negative. Negative. 2 " Diplococoi in cells. Diplococci free (( Gonococci. 3 " " .. 1 and in pns cells. 4 5 6 Pelvic ab- Negative. U N egative. " '• '• scess. 7 8 9 Pyosalpinx. " " U " " " " Nega- " tive. 10 " " '• Do. Nega- " tive. 11 a ([ " (. Do. Do. a 12 Salpingitis. " (i " Do. Do. " lb Pyosalpinx. u " " Do. Do. '■ 14 Pink yeast. Pink yeast. Pink yeast. Pink yeast, con- tamination of culture tubes. 15 Ovarian ab- scess. Negative. Negative. Negative. 16 Pyosalpinx. " Nega- tive. Nega- tive. 17 Pelvic ab- scess. " Do. Do. " 18 Pvosalpinx. " " " " 19 " '• it " 20 *' Diplococci in cells. Negative. '' (( Gonococci. 31 " , " 1 Negative. 2a Diplococci in cells. Gonococci. 23 Negative. " " Nega- tive. Nega- tive. Negative. 24 " " „ Do. Do. " 25 '• " Do. Do. " 26 " " " " Do. Do. " 27 " " Do. Do. " 28 " " " " Do. Do. 29 " " a Do. Do. 30 Ovarian ab- scess.* Resembling colon bacillus. '■ A white colony. Undiagnosed 31 Pyosalpinx. Negative. " Negative. Negative. 33 Negative. " a4 " '• " *' 35 " " " " " 36 S7 „ Gonococci. Negative. jj ^j Nega- tive. Do. Gonococci. Negative. 38 QQ '* '• «( '* " 40 " Gonococci. u Gonococci. 41 " Negative. " " * On lactose agar, a white growth resembling that in glycerin agar. No gas fermentation ; also a delicate granular growth which liquefies gelatin. COURSE OF AN INPLAMMATOEY PROCESS. 213 42 43 Diagnosis. Pyosalpinx. Cover-glass. Many cocci in pairs and chains. Diplococoi in pairs ; extra- and intra-cellular. Agar. Staphylo. pyog. aure- us and albus, strepto. Glycerin agar. Gonococci. Acid gelatin. Blood serum. Bacteria. Staphylococcus albus and aure- us, strepto- coccus. Gonococci. Total. 1. Negative 33 oases. 3. Gonococcus 7 " 3. Colon bacillus 4. Mixed infection, staphylococcus albus and aureus and streptococcus 1 case. 5. Undiagnosed 1 " 6. Contaminated 1 " On account of the close proximity of the pelvic organs to the rectum, vermi- form appendix, and sigmoid flexure, pyogenic bacteria may escape from one to the other and set up a purulent inflammation. Dr. Hunter E.obb has reported a case in which the pus of a pyosalpinx of one side gave negative results on bac- ieriological examination, while an inflamed tube on the other side, adherent to an -acutely inflamed vermiform appendix, contained streptococci. Mixed infections of two or more different micro-organisms are rarely found. An organism may develop a pelvic abscess and die and pave the way for the ■secondary invasion by bacteria of another form. Course of an Inflammatory Process. — The first efEect of the entrance of the infecting organism into the uterine tube is to set up a reactionary inflammation which, as a rule, tends to close the fimbriated end. In mild cases the inflamma- tory condition may pass off without the production of a pyosalpinx ; when the infection is more severe, pus forms in the tube and may discharge into the uterus, or the fimbriated end may rupture and permit the escape of pus into the pelvis over the ovary, producing peri-oophoritis and pelvic peritonitis, if it is a gonococcal infection ; or a general peritonitis, if more virulent pus-producing organisms are present. The inflammatory condition may be arrested in the uterine tube, but if the infection is persistent it may involve the intraligamentary ■cellular tissue. The ovary is usually involved in the surrounding inflammatory condition {peri-oophoritis), and only rarely is the seat of an ovarian abscess. Infection of the ovary, when it does occur, probably takes place through a ruptured Graafian follicle. In one of my cases (see Fig. 384), like one described by Sanger, the abscess was situated deep in the substance of the ovary, and there was no coincident tubal infection. The initial stages of salpingitis are associated with a more or less violent local reaction, in which the tubes become thickened and edematous and fall back in the pelvis down toward the pelvic floor. The mucosa becomes congested and swells, and is bathed in a mucoid, semi-purulent, or purulent secretion. 55 21i VAGINAL DRAINAGE AND ENUCLEATION FOR PYOSALPINX, ETC. The reactionary inflammation from contiguity of tissues causes the tubes to become adherent by hght adhesions to the adjacent organs. As the inflamma- tory process progresses the adhesions become more dense, and flnally the tube becomes closely attached to the posterior surface of the broad hgament, to the Mf Fig. 383. — Large Akscess of the Kigi-it Ovary, ■without Participation of the Tube, due to Staphylo- coccus Aureus Infection. The areas of denser adhesir.ns are indieiited by the bits of tissue attaelied to the abscess. The tube is- buckled on itself and li.xed by an isthniio-ampuUar adhesion. View from behind. June 1, 1S'J4. No. 317. Natural size. uterus, the pelvic wall and floor, and covers in the ovary with its mesosalpinx. The rectum is more especially lialile to be involved in the adhesions when the inflammation is in the left tube. The pus varies in appearance from a thin puriform fluid to thick yellow matter ; it may be greenish and streaked with blood ; sometimes it is intensely fetid, with a strong odor of garlic. This is apt to be the case when the ab- scess lies in close proximity to the rectum. Both tubes and ovaries may con- tain pus and only one of them smell badly. As a rule, both sides are affected, but the abscess on one side is usually larger than on the other. Occasionally, however, one side presents an advanced pyosalpinx and its fellow is sound. This liability of both sides to share in the SYMPTOMS. 215 disease shows that there is a definite tendency in the progression of the disease from without inward. The term sactosalpinx is applied to closed tnbes, and according as the contents are watery, bloody, or purulent, the disease is denominated as a sactosalpinx serosa, hemorrhag- ica, or purulent a. "When the tube pre- sents a nodular appearance from separate accumulations in the isthmus, the affection is termed a salpingitis isthniica no- dosa. This form of salpingitis is most fre- quently seen in gonorrheal affections (see Fig. 385). Symptoms. — The symptoms produced by the presence of pus in the ovaries, tubes, and surrounding pelvic tissues vary widely according to the stage of the disease and to the variety of infecting organisms. During the acute stage, lasting a week or longer, the patient often suffers intense pain ; she lies in bed with knees drawn up and an anxious expression of face. The elevated temperature, quickened pulse, and local tenderness all point to an inflammation localized in the pelvis. From the general tenderness and tympany often present, the physician, however, is apt to draw the erroneous conclusion that there is a general peritonitis. In gonorrheal cases the pelvic inilammation may be preceded by an acute inflammation of the urethra, vulva, and vagina, which may then be Fig. 384. — Abscess oy tub Ovary Deep DOWN IN THE CENTER, CoRPUS jSlGKUM AND Corpus Luteum and Corpora Fi- brosa IN THE Surrounding Capsule of Ovarian Substance. March 29, 1894. Natural Size. Fig. 385. — Nodular Salpingitis, Salpingitis Isthmica Nodosa. Found often in gonorrheal salpingitis, and in some tuberculous forms. Feb. 24, 1894. Natural .size. quickly followed by pelvic pains and high fever ; the pelvic symptoms, on the other hand, may be deferred for several days or months after the primary infection, when the causal relation is not so evident. The onset may then be gradual, beginning with the acute pain in the ovarian regions, a slight rise of 216 VAGINAL DRAINAGE AND ENUCLEATION BOK PTOSALPINX, ETC. temperature, and painful micturition and defecation. After pus has formed the patient may have rigors, but this is not so frequent as in the graver types of in- fection. The pulse is good, there is httle or no vomiting, the expression is that of a person suffering with pain, but the general condition is excellent. In a streptococcus infection the attack often dates from a con- finement, an abortion, or local treatment of the uterus. The onset is rapid and attended by a chill, high fever, and a rapid pulse. The effect of the septic ab- sorption is soon shown in the general depression ; the expression is bad, the pulse becomes more rapid, and the abdominal distention and tenderness is marked. In the streptococcus cases the patient is bedridden from the begin- ning of the attack, while the patient with a gonorrheal infection may only be bedridden a week or ten days or not at all. After the acute attack has passed in both the gonorrheal and streptococcus infections the patient may get out of bed, continuing to suffer, but in the strep- tococcus cases she usually has a septic temperature and the peculiar anemic look of a grave infection. The attacks of pain and of localized peritonitis tend to recur at variable in- tervals, and are attended each time with the same symptoms, which may con- tinue until a large abscess has formed behind the uterus on one or both sides, completely filling the posterior pelvis. Obstinate constipation is sometimes found as a result of the pain on straining at stool, or due to a stricture of the rectum produced by the in- flammatory mass bridging its lumen. In cases of long standing the stricture may even become so narrow as to form a serious obstacle in securing the evacu- ations. This condition was found five times in sixty-five cases of pelvic in- flammatory disease treated by vaginal incison in my clinic. Frequent urination is often distressing and may arise from impli- cation of the bladder and of one or both ureters in the inflammatory mass. Sometimes there is an actual cystitis from an infection of the bladder similar to that existing in the tubes and ovaries. After the more acute symptoms have subsided the patient is left weak, wan, and sallow, looking as if she had survived a severe illness ; she is relaxed, perspires profusely upon slight exertion, and can not walk without distress. The tempera- ture drops a little, but often does not fall to normal for some days or weeks, rising to 99° or 100° F. in the evening. There is often also a persistent fixed pain in the lower abdomen. Sometimes the symptoms gradually abate, and the patient finally regains complete health. In such cases there is often Httle or no evidence of the previ- ous inflammatory disease found on a careful examination, or again the append- ages may be found adherent but without any evidence of suppuration. If the pelvic suppuration persists, the symptoms, although less severe than in the acute process, are always present ; the patient complains of bearing-down pain, backache, painful defecation and micturition, and often of a purulent vaginal discharge. The gonococcal infection is most likely to subside in this way. SYMPTOMS. 217 A sudden elevation of the temperature during an attack is always a serious symptom, denoting an extension of tlie inflammatory trouble, a grave septicemia, or a general peritonitis. In chronic cases the patients may suffer for twenty years or more from such recurring attacks. If the abscess is not interfered with, one of four modes of termination maybe observed: 1. It may discharge intermittently through the uterus. 2. It may rupture and evacuate itself by the rectum, by the vagina, by the bladder or by the abdominal wall, or it may discharge into the peritoneal cavity. 3. The pus may remain encysted for an indeiinite period and small accumu- lations may become inspissated. 4. It may entirely disappear, leaving behind a hydrosalpinx, or contracted tubes and ovaries bound down and enveloped in adhesions. In a pelvic abscess which goes on to rupture the process is usually an acute one throughout, running its course with high fever, nmch pain, and tym- pany, and ending in the formation of a large pus sac which points into the vagi- nal vault posterior to the cervix, or into the rectum, or works its way up under the lateral wall of the pelvis, appearing on the anterior abdominal wall above Poupart's ligament. Occasionally the bladder is perforated and a large amount of pus suddenly escapes by the urethra. In rare cases the abscess ruptures through the vaulted free surface of the sac and the pus is poured into the abdominal cavity, escaping among the free intestines and bathing the whole abdomen. It may, however, be limited in its distribution by the coils of distended intestines which adhere to the sac so as to shut it off from the general peritoneal cavity. The symptoms following this accident will depend upon the character of the pus. In the more virulent cases the patient will at once fall into a condition of collapse, with rapid, thready pulse, which fails to respond to any stimulation ; she lies apathetic, with a lack luster look, and dies in two or three days. In another class of cases, on the other hand, the discharge of even 250 cubic centi- meters a pint) of pus into the abdomen may be followed by a slowly developing peritonitis, with elevation of temperature, and a pulse rising slowly to 120, 140, and 160. Abscesses which open into the vagina may discharge their contents com- pletely and the cavity collapse and heal, and the patient regain perfect health. If the opening is minute through a fistulous tract the discharge only takes place when there is sufficient pressure within to overcome the resistance, and it may continue in this way for months or years, each reaccumulation being char- acterized by a return of pain, fever, and distention. In some cases the hole cicatrizes over and breaks open afresh each time. When the abscess opens into the rectum, if the opening is direct and large enough and lies at the bottom of the sac, a rapid and complete recovery may take place. If, on the other hand, the abscess empties into the bowel by a long sinus or by a minute orifice, or if the opening is in the upper part of the ab- 218 VAGINAL DKAINAGE AND ENUCLEATION" FOR PYOSALPINX, ETC. scess, SO that the pus only discharges when the sac is full, the discharge may go on indefinitely. A pelvic abscess opening into the bladder or onto the abdominal wall rarely closes, because the opening lies at a higher level than the sac, and pus can there- fore only escape as an overflow or in certain positions of the body ; these open- ings are also always indirectly connected with the sac by a sinus which may pursue a long, tortuous course before reaching the abdominal wall. Prognosis. — The symptoms, course, and termination of these pelvic inflam- ■ matory affections depend upon the species and the virulence of the infecting organisms. Gonorrheal pyosalpinx usually expends its force upon the uterine tube, and beyond the peri-oophoritis and pelvic peritonitis produced by the irritant effects of the toxic products elaborated by the organisms no more extensive damage occurs. The inflammatory condition, however, may be chronic, lasting for years, and is often characterized by exacerbations. In streptococcus or staphylococcus infections the course of the disease is more rapid, tending to produce a general peritonitis or septicemia. While a consid- erable percentage of streptococcus cases die, many survive, but are often inca- pacitated by the accumulation of pus or by the extensive and widespread adhe- sions remaining after the inflammatory condition has subsided. In about half the chronic cases the organisms die and the pus becomes sterile. The prognosis is always serious, and a patient with a pelvic abscess is never out of danger, but lives literally over a mine which may explode at any time, when only the most prompt interference can save life. Diagnosis. — The diagnosis of an abscess involving the uterine tubes or the ovaries, or both, is often easy to make. One of the chief points in establishing it maybe the history of an attack of gonorrhea, a septic labor, or miscarriage, since which time the patient has never enjoyed good health ; many patients will recall a confinement to bed for one or more weeks with peritonitis. Many others date their ill health from the first or second month after mar- riage, even going back to the very week of the marriage, and recalling a more or less profuse irritating leueorrheal discharge with swelling of the internal genitals and dysuria. The outbreak of pelvic peritonitis may then take place at the first menstrual period after marriage. Careful questioning of the husband in these cases will often elicit the information that he was suffering from a slight gleety discharge at the time. The husband of one of my patients actually had a swelled testicle on his wedding day. It is Noeggerath's opinion that no man who has had gonorrhea is ever cured of it. In other cases there is no such definite history of an initial attack and no sharp line of demarkation between health and disease ; the onset is gradual, the pains growing worse and worse with each menstrual period, until a status of invalidism is finally reached. Following the initial symptoms, the most characteristic features in the natu- ral history of the disease are attacks of peritonitis, confining the patient to bed for days, weeks, or months, often referred to as "infiammation of the DIAGNOSIS. 219 stomach." The patient will often recall that her life was even despaired of at this time. The general appearance of a patient suffering from an abscess of the appendages varies from a look of complete health to marked emaciation, a sallow complexion, and an expression of constant suffering. Her attitude and gait as she enters the room are often significant ; there is a slight bending of the body over the pelvis, a cautious gait, and a habit ■of placing the hands on the lower abdomen, keeping up an even pressure on the pelvic viscera to avoid jarring them. This effort is especially marked in step- ping over a gutter in crossing the street. I have known a woman to wear a fihawl whenever she went out to hide these efforts and the position of her hands. The differential points in the diagnosis between gonorrheal and streptococcus cases may be summarized as follows : Gonorrheal Infection. Streptococcus Infection. Slow in its onset, often preceded by inflamma- Onset abrupt, following miscarriage, normal tion of the external genitals and urethra. labor, or topical treatments. Pain localized in one or both ovarian regions. Pain more general and severe in the lower abdo- men. No signs of general peritonitis. Usually signs of peritonitis. Suffers more or less constantly, but may have Suffers constantly, and usually has a septic fever, no fever. Temperature 98-5° to 103° F. (38-9° C). Temperature 101° to 105° F. (38-3° to 40-5° C). Pulse accelerated, but of good quality and vol- Pulse feebler and more rapid, ume. Attack lasts five to fifteen days. Attack seldom lasts less than a month, and may continue three months or more. Often presents the appearance of good health. Anemic and weak. Oonococoi usually found in cover-slip prepara- Gonococci not found in the secretions, tions from the cervical, urethral, or vulvo- vaginal glandular secretions. History of marital gonorrhea. Husband sound. A vaginal examination shows that the uterus has lost its natural mobility , sometimes it is solidly wedged in between masses which are felt on one or both sides of the cervix as dense, hard, shapeless, resisting bodies. A stony hard- ness of the vaginal vault is one of the most characteristic signs of the presence of pus. The position of the fundus often can not be located amid these masses. The bimanual examination does not at first definitely outline any diseased organs, but simply confirms the discovery made by the vaginal hand, that the pelvic peritoneal fioor has become dense and resisting, and that the posterior pelvis is choked with irregular masses. A continued car efuh palpation by a trained hand, however, will soon succeed in differentiating several groups of bodies in the pelvis by their location and rela- tive mobility. The first landmark to be established is the body of the womb. This is done by pushing upon the cervix with the vaginal finger and making deep pressure from above until an impulse is felt at the cervix ; in this way the fundus can be traced by its direct continuity with the cervix, either in front of it or behind it. The limit of motion in the fixed uterus is small, sometimes only 220 VAGHiTAL DRAINAGE AND ENUCLEATION FOR PYOSALPINX, ETC. a few millimeters, but it can be detected by a patient persistence. Masses are now recognized on either side of the uterus and posterior to it, and occasionally straddling it behind, like saddle-bags. Each mass is examined in turn and found filling the posteriur half or two thirds of the pelvis on one side, more or less rounded, with a slight mobility of its own quite distinct from that of the uterus and from the fixed pelvic walls, and it is usually possible to rock it up and down for at least a centimeter. If the tumor contains pus, a sense of fluctuation may often be best felt by means of the examining finger in the rectum ; but if there is but little pus in a thick sac, such as a uterine tube, or a sac surrounded by a dense cellulitis, fluctuation is entirely absent. Sometimes the pelvic abscess is so large as to form a visible tumor above the symphysis, and a bulging red area in the groin may be due to an imminent rupture. Occasionally an accumulation of pus on one side presents nothing more than the physical signs of a small ovarian tumor with slight lax adhesions allowing a wide range of mobility, and the absence of all the characteristic evidences of inflammatory reaction may confuse the diagnosis. In a few instances, however, the diagnosis will be verified in a surprising manner by a free discharge of pus through the cervix, which can be kept up or increased by gentle pressure upon the mass, emptying the abscess more or less completely through the tube, the uterus, and the vagina. Such a gush of pus frequently takes place from the vagina when the abscess sac is grasped and squeezed in the open abdomen during the enucleation. By the rectal examination in pelvic abscess or densely adherent pyosalpinx the narrow part of the bowel above the ampulla behind the cervix often feels- like an auger hole in a board, with rounded edges ; above this the tubes and ovaries are felt as more or less fluctuant, bossed, immovable masses, on either side, walling in the rectum. The temperature is significant where there is a large accumulation of pus, reaching as high as 38-9° to 40° C. (102° F. to 104° F.) or more ; in these cases- the physical signs also are so distinct as to leave no doubt as to the diagnosis. The treatment of tubal, ovarian, and tubo-ovarian abscesses is either palliative and expectant, emptying the sac by massage, vaginal incision, and drainage, or enucleation. In general, the indications establishing the special lines of treatment are as follows : An expectant line of action must be pursued in all cases which are rapidly improving. "When there is no manifest improvement, or the change is progressively worse, immediate active interference is the only safe rule. A sac which empties spontaneously through the uterus, or one which can be easily emptied in this way by manipulation, may be treated by massage with a reason- able hope of ultimate complete recovery. Active surgical interference is the rule in ninety-nine out of every one hun- dred cases, and this consists either in letting out the pus through the vaginal vault, or in opening the abdomen and removing the sac with or without the EMPTYING THE SAC BT MASSAGE. 221 uterus. Wherever it is possible to reach the abscess through the vaginal vault, with or without the aid of an abdominal incision, the patient should first be given the advantage of a trial of this safer method of treatment, by which her pelvic organs are spared. Cases which continue to suffer may afterward submit to the more radical procedure. In patients who are extremely ill, the rapid vaginal operation is often the only one possible under the circumstances. The urgent indication is always to evacuate the pus ; when that is effectively done, the adhesions which are always found are either absorbed or may give rise to no further discomforts. If the patient continues to suffer, an easier and a safer operation may be done at a later date in the absence of pus. Expectant treatment is limited to a careful observation of the disease, asso- ciated with rest and regulation of the bodily functions, and is only applicable in the acute stages of the disease. In rare cases the pus is wholly discharged through the tubes spontaneously, and complete recovery takes place. Expectancy is necessary in the acute stages of the disease, or one of its exacerbations, on account of the increased danger from a radical operation at this period. While waiting, Nature lierself may establish an aveniie of discharge at a point favorable for complete evacuation and good drainage. It is a grave error to hold that as soon as the diagnosis of pelvic abscess is established the next step should be an immediate radical operation. During the acute stages of the formation of a pelvic abscess the patient must be kept absolutely at rest, the bowels freely open, and ice poultices applied to the abdomen ; diaphoretics should be given, and prolonged hot vaginal douches used. Some morphine is necessary to allay the pain. When, under such a regime, the abscess points into the vagina or rectum and breaks of itself, a rapid recovery may follow. I have several times ruptured large abscesses in this way simply with the finger while examining the case. Dilatation of the cervix and curettage have been vaunted as successful in cases of well-defined abscesses to promote the discharge through the uterus, but I have had no experience to enable me to form an opinion. Evacuation, next to expectancy, is the simplest plan of treatment, and one involving few risks to life in suitable cases. It is accomplished by one of three avenues — the uterus, the vagina, or the rectum. Evacuation through the uterus without operation may be systematically carried out in cases in which it has been found possible in a bimanual examination to squeeze pus out of the sac through the uterus and when the symptoms are not urgent. Evacuation by incision is the proper mode of treatment in cases pointing into the vagina or rectum. Simple evacuation by the vagina without enucleation is also indi- cated even where the abdomen has been opened, and the removal of the adherent tubes and ovaries involves unusual risks to life. Emptying the Sac by Massage. — Emptying the sac by bimanual compression is particularly adapted to those cases in which the abscess forms a well-defined more or less spherical mass, without much tenderness, and the dense hardness of 222 VAGINAL DEAINAGB AND ENUCLEATION FOE PYOSALPINX, ETC. the vaginal vault is absent. Success by this form of treatment may be antici- pated in cases presenting a history of discharges of pus per vagmam. Sur- rounded by the proper safeguards, this plan of treatment is free from risk, while ■without due care in avoiding rough handling, and in the absence of a proper selection of cases, there is imminent danger of rupturing the sac into the peri- toneal cavity, and so exciting a fresh and even fatal attack of peritonitis. The relations of the pus sac should first be thoroughly investigated under anesthesia in order to know just where to make the most efiicient pressure. Before each massage treatment the vagina must be thoroughly cleansed. The legs are then brought well up and the chest inclined toward the abdomen, pro- ducing the most marked relaxation of the abdominal muscles possible. With one hand the abdominal walls are deeply invaginated into the pelvis. When the walls are thin the invagination may be made at any convenient point, but in thick or rigid walls either the linea alba or the linea semilunaris form the most yielding points. The vaginal finger, or the index and middle fingers, now push the vagi- nal vault behind the cervix, high up and into the back part of the pelvis toward the middle of the sacral hollow. Both hands are thus brought as nearly as pos- sible together behind the tumor ; then with a little relaxation of each the strain is relieved, the tactile sense becomes more acute, and the sac is palpated, picked up as it were, by the hands, while a gentle pressure is begun and steadily in- creased until the sac is squeezed in a direction toward the uterus. The pressure is then relaxed for a moment, and the sac caught again and squeezed in the same direction by a gentle graduated pressure ; this process is repeated at intervals for from five to ten minutes, until the contents are milked out through the uterus into the vagina. The success of the maneuver will often be indicated by a free flow of pus out of the vagina over the hand. In case there is no such free discharge, retraction and inspection of the posterior vaginal wall may reveal the presence of the pus. Such an evacuation should be made once or twice weekly, and the patient kept in bed afterward for several hours or longer if there is any pain or sign of inflammation. In order to test the value of this treatment as a curative procedure it must be kept up for several months, with rest at the menstrual periods, and the effects judged by the general condition of the patient, together with signs of local im- provement, such as relief from pain, and the most important evidence of all, the fact that the sac fills more slowly, or fails at last to fill at all. Vaginal Incision and Drainage. — The first cases in which I resorted to vagi- nal puncture were those which came to me in such a critical condition that a radical operation was impossible, and the evacuation of the pus through the vagina was done simply as a temporizing measure with the view of performing a more radical operation later, when the patient had sufliciently recovered to permit it with safety. The records of the first cases treated in this way showed the most unexpected and gratifying results. Of fifteen cases, eight were permanently relieved vnth- out further operation. VAGINAL INCISION' AND DRAINAGE. 223 Three of these patients were young women (one aged twenty years, another nineteen years, and a third seventeen years) in whom the preservation of the function of the ovaries was of the greatest importance to future health and hap- piness. Two of these cases were examined two years after operation ; in one no evidence of the former disease could be discovered ; in the other the appendages were adherent but could be distinctly outlined. In all of the relieved cases the menstrual flow became regular and was unattended by pain. AVith these highly satisfactory results as a basis, I extended this method of treatment to a much wider field. At first only abscesses in which fluctuation could be detected at the vault of the vagina were evacuated by puncture ; then cases of dense inflammatory dis- ease, lateral or posterior to the uterus in contact with the vaginal fornix, or walled off from the general peritoneal cavity by adhesions, and finally cases of encysted peritonitis and pyosalpinx, were frequently treated by this means with good results. Of sixty-five cases treated by vaginal puncture up to Sept., 1896, there were fifty -five cases of pelvic abscess and ten of clearly defined pyosalpinx ; in some of these cases there was a pyosalpinx on one side and a hydrosalpinx on the other. In twelve cases there was encysted peritonitis and dense cellulitis. The results in these cases were satisfactory as compared with the higher mortality and slower convalescence in similar cases treated by radical operative measures. Of the sixty-five cases, thirty-two were cured and two died ; of the remain- der, some were greatly relieved, while a small proportion were no better. In five cases operation for the enucleation of the diseased structures was per- formed after the vaginal puncture, when it was found that the patient was only temporarily relieved by this procedure. The following are the steps of the operation: 1. Cleansing the vagina and cervix. 2. Fixing the point in the vaginal vault for the evacuation. 3. Pressing the vaginal wall well up against this point with the index finger, while the middle finger is introduced into the rectum to protect it from injury. 4. Introduction of a long pair of sharp-pointed scissors on the index finger up to the point of puncture, and plunging the scissors into the abscess in a curved direction following the axis of the pelvis. 5. Withdrawal of the scissors with blades open, to enlarge the puncture, fol- lowed by the introduction and withdrawal of a larger pair of blunt scissors or large uterine dilators, making an opening from 2^ to 3 centimeters (1 to 1^ inches) wide. 6. Introduction of the finger, and careful bimanual palpation of the sac wall and surrounding structures, with the finger inside the sac, with a view of discov- ering and breaking down into any secondary abscesses. 7. Curetting, loosening, and removing the lining membrane of the sac wall. S. Irrigation of the cavity. 9. Packing the cavity loosely with washed-out iodoform gauze. 10. The after care, consisting in keeping the cavity well open, so as to drain freely and clean by daily irrigations. 224 YAGINAL DRAINAGE AND ENUCLEATION FOR PTOSALPINX, ETC. The proper point for puncture of the abscess is posterior to the cervix and in the median line or just to the right or left of it. By the side of the cervix there is danger of wounding the uterine vessels or the ureter. The artery can usually be located by careful palpation against the resisting wall of the sac. The handle of the scissors affords a good grip, by which the sharp points can be pushed up into the sac in a curved direction toward the second sacral vertebra, or toward the sacral promontory. The operator must take care not to puncture too low down, in the direction of the lower sacral ver- FiG. 386. — Opening a Retro-Uterine Peltio Abscess (Pus) by puncturing the Posterior Fornix" WITH A Pair of Sharp-Pointed Scissors. The points of the scissors are conducted in the direction of tlie ai-row. middle finger into the rectum to protect it from injury. It is usually best to insert the tebrse, or he may simply transfix the bottom of the cyst and penetrate the rectum. If the cyst is a little above the vault and too much to the right or the left, this may be corrected by a well-directed pressure made by the hand of an assist- ant on the lower abdominal wall. The opening should not be made too much to one side for fear of wounding a ureter. The position of the uterine artery can always be determined by palpation at the vaginal vault; it is usually felt quite prominently, pulsating against the anterior wall of the sac ; knowing its exact position it is safe to enter the sac quite clos3 to it if necessary. As soon as the sac is entered the blades are easily separated, being now in a free space. If there is much pus present it commonly begins to flow at once. By withdrawing the scissors, keeping the blades open, the hole is torn wider. Stout dilators with parallel blades may next be introduced, or a large pair of blunt scissors may be used as a dilator and withdrawn open as before. The orifice can thus be made fully as broad as Douglas' cul-de-sac — from 2|- to 3 VAGINAL INCISION AND DRAINAGE. 225 centimeters (1 to IJ inch) — and the pus quickly empties itself through such a wide dependent opening. The index finger is now easily introduced through this hole, and the size and position and irregularities of the sac explored. The presence of other collections of pus is readily determined by making pressure with the external hand ou any doubtful structures, holding them steadily, while they are carefully palpated by the finger inside the sac. As soon as a well-defined fluctuating mass is felt, if there is no doubt of its being an encysted accumulation, its wall may be broken through with the finger and its contents evacuated through the main abscess cavity. Two or three sepa- rate deposits of pus may be released in this way. Great care must be taken not to overlook any such collections, because complete recovery will only follow the evacuation of all the pus in the pelvis. The empty sac or sacs are now thoroughly irrigated with sterile water, bring- ing away all the pus and loose tissue debris, and a loose pack of washed-out iodoform gauze inserted into the cavity ; finally a teaspoonful or more of the iodoform and boric-acid powder (1-7) should be thrown into the vault of the vagina and a loose vaginal gauze pack inserted. In the case of a large abscess, and especially when it is situated at a distance from the floor of the pelvis, a larger and freer drainage opening is secured by exposing the vaginal vault with specula and making an elliptical incision around and behind the cervix, so as to excise a crescentic piece of the vaginal vault ex- tending up into the peritoneum, as suggested by Dr. G. M. Edebohls. If the edges of the peritoneum are then drawn down and attached to the vaginal tissue, 'im,^/^' Fig. 3SV. — Stout CnEVED Saw-Toothed Traction Foegeps eoe eemovino THE Gauze Pack. }4. Size. The jaws shown full size below. a perfectly free drain, in which there is no tendency of the edges to drop together, is secured. The first efi^ect of the operation may be a sharp rise in the tempera- ture, as high as 103° to 105° F., which subsides in twenty-four hours. After establishing free drainage great relief is usually felt at once. If the condition of the patient remains good, the gauze pack in the sac need not be disturbed for three or four days, or longer, when she is brought to the edge of 226 VAGIKAL DEAIKAGB AND ENUCLEATION FOE PYOSALPINX, ETC. the bed or table, the posterior vaginal wall retracted, all the gauze removed with a suitable pair of forceps, and the cavity well cleansed with peroxide of hydro- gen or boric-acid solution and a fresh pack applied. This cleansing and dressing must be renewed daily, always using speculum and dressing forceps instead of fingers, and carefully avoiding any contamination of the sac wall, for the fact that it has contained pus does not warrant any carelessness as to infection in the after-treatment. Another way of treating the drain is to withdraw the gauze slowly, taking out 3 or 4 inches every day, and not washing out the sac until it is all removed by about the tenth day. The patient may rise from her bed and go about the room in eight or ten days if her general condition warrants it. There is little danger of a free hemorrhage if the operator uses some care in first locating the uterine artery by vaginal touch. In the sixty-five eases 1 have referred to, hemorrhage, beyond that expected from wounding the vas- cular vaginal wall, only occurred in two cases, and in both cases it was easily controlled by a firm pack. Evacuation of the pus into the abdominal cavity must be guarded against as far as possible ; but since we have learned that the pus from these cases is so frequently sterile, this appears as a much less serious complication. In nine of the sixty -five cases punctured ^e/' vaginam, the free peritoneal cavity was opened, and in none of them was there any evidence of this accident in the after-symp- toms of the patient. When, however, the peritoneal cavity is opened the pus must be most thoroughly removed and the cavity wiped out and packed, and irrigation must be used in small quantities and with the utmost care. The making of a fecal fistula must be avoided by first examining the rectum to discover its exact relation to the abscess sac, and by keeping one finger in the rectum during the operation to protect it from injury. Notwithstanding these precautions, a small opening may be made, but it will usually heal quickly if the cavity is well packed with gauze, so as to prevent the ingress of fecal matter into the abscess sac. The gauze should be i-emoved daily and the sac well irri- gated, followed by the firm application of a fresh pack, with the patient in the knee-breast posture. The cases most likely to be entirely relieved by vaginal drainage are those where there is a single well-defined collection of pus which can be evacuated completely. When the cellular tissue is more or less honeycombed with mul- tiple abscesses the progress of the case will be slow, and may require repeated puncture on account of the development of the smaller abscesses after the cen- tral cavity has been evacuated. In one case five such operations were required before the patient was finally relieved. Cases not likely to be benefited are those in which there is dense inflam- matory tissue without fluctuation, surrounding the rectum, bladder, and ureters. Here the symptoms do not come from the collection of pus, but from the effects of the chronic inflammatory disease. Of the sixty-five cases punc- tured per vaginam, ten were of this class, and beyond the slight relief produced EVACUATION BY THE VAGINA AIDED BY AN ABDOMINAL INCISION. 227 by the evacuation of a small quantity of pus, the patient experienced no other benefits from the operation. The cavity contracts day by day in favorable cases, until in a surprisingly short time, sometimes not more than two weeks, a little pit at the vault of the vagina is all that remains. This is finally reduced to a scar, which it may be hard to find at a later date. Vaginal Incision and Drainage in Acute Cases of Pel- vic Inflammation . — A novel plan, proposed by Dr. F. Henrotin {Trans. Amer. Gyn. Soc, 1895, vol. xx, p. 223), on the basis of his experience in twenty-seven cases of acute posterior pelvic infiammatory affections, deserves careful attention. In the absence of further confirmatory evidences it is still impossible to form a satisfactory conclusion and to give this procedure its due position among the other methods of treating suppurating affections. The pa- tient who is suffering from an acute recent infection in its earliest stages is treated by making a semicircular incision posterior to the cervix opening the peritoneum, after which the finger is introduced into the pelvis and used in all further manipulations. With the finger the adherent infiammatory mass is reached, punctured, evacuated, and explored ; in the majority of cases an ab- scess cavity is found. Other foci of inflammation are sought out and opened, and the cavities are then packed with gauze, which is not removed for three, four, or five days, unless the patient's general condition indicates a retention of the secretions. Following such treatment, the pains and malaise all disappear, and the patients, in the majority of instances, make a rapid recovery. The author of this plan of treatment also earnestly advocates a thorough curettage of the uterus at the same sitting. In so far as the pain, tenderness, and elevated pulse and temperature indi- cate the presence of pus, the general rule may be safely followed and evacuation practiced. "Whether it will prove an advantage in the presuppurative stages is still to be determined. Evacuation through the Rectum.— Evacuation through the rectum is only ad- missible when there is such a marked area of softening that spontaneous rup- ture is imminent, and then the opening must be made as low down as possible to secure constant perfect drainage. Under no circumstances is it allowable to make an opening high up above the constriction between the utero-sacral folds. If Nature makes an opening in such a position, the gases and fecal matter enter the sac and the discharge is kept up for an indefinite period. Where the pointing is high up, or even where an opening already exists at this point, a wide counter-opening should be made through the vaginal vault behind the cervix. The free drainage at this point prevents any accumulation within the sac and allows the higher orifice to close. Evacuation by the Vagina aided by an Abdominal Incision. — Evacuation of pelvic abscesses by the vagina, controlled by the hand introduced within the abdominal cavity, is called for when the abscess is not so clearly defined as to 228 VAGINAL DRAINAGE AND ENUCLEATION FOE PYOSALPINX, ETC. admit of ojjeration by the vagina alone, or when wpon opening the abdomen the adhesions are found so dense and widespread that an enucleation of the whole mass would be attended with imminent risk to life, or again when the ex- tremely weakened condition of the patient renders drainage safer than enuclea- tion. In the sixty-five cases of pelvic inflammatory disease treated by vaginal puncture an exploratory abdominal section was done in twenty-one. It is also a better plan of treatment in atypical accumulations of pus, such as deposits around the ligatures and the stump of a previous operation, or where pus pockets are walled in by intestines, or in all cases where the anatomical rela- tions of the septic focus forbid enucleation. Under such conditions if the in- fected tissues lie in contact with the pelvic floor, a wide opening may be made through the vaginal vault, giving abundant drainage below, and at the same time avoiding injury to the peritoneum by controlling the operation through the hand introduced within the abdomen. Similarly, if an abscess can not be enucleated after carefully studying its rela- tions through the abdominal incision, the peritoneal cavity is guarded mth one hand, while the other carries the sharp-pointed scissors up to the vaginal vault, which is perforated behhid the cervix in the direction indicated by the hand within the abdomen. The opening in the vaginal vault is then enlarged, the finger thrust in, and the whole abscess area rapidly broken open into one sac, under the guidance of the hand within. On account of the con- tamination of the hand hold- ing the scissors, the operator now leaves the patient to the assistant, who closes the ab- dominal incision and packs the cavity with washed-out iodoform gauze, with the ends brought out into the vagina. The further treatment of the abscess cavity is to leave the gauze in for several days, when it is removed and the cavity washed out daily ; enough gauze is put back after each washing to keep the opening into the vagina from closing before the cav- , ^CBv 1 \Sfrs 1 ^^^F ^Sp w ""''■"" -Fig. 38S.— Abscess of both Uterine Tubes treated through AN Abdominal Incision by releasing, opening, and wash- ing out the Tubes, and then dropping them "with the Ova- ries ONTO a Gauze Drain leading through the Posterior Fornix into the Vagina. March 4, ISOC. ity above has contracted. One of the worst cases I have ever seen was successfully treated in this way. The patient was in a low typhoid unconscious condition, with a parched brown tongue and pulse at 140. On opening the abdomen the pelvis was found choked EVACUATION" BY THE VAGINA AIDED BY AN" ABDOMINAL INCISION". 229 hj densely adherent masses "whicli could not be differentiated. It was evident that life could not be saved if the operation -was prolonged, so I made a free vaginal opening, and evacuated about 350 cubic centimeters of thick fetid pus. ■She slowly recovered after several "weeks of delirium, and is now, three years after, in good health, "wathout any evidence of peMc disease. Fig. 389. — Showing the Gauze Deain filling the Cul-de-sac behind the Uterus and leading DOWN into the Vagina. "When a pyosalpinx is situated high up in the pe]"vis and is not in contact vrith the vaginal vault it may be necessary to free the adhesions and push the pus sac or sacs down into Douglas' cul-de-sac, where they may be more easily and safely reached by the vaginal puncture. The following case well illustrates this plan of treatment : A. C, 4186, March 4, 1896. Chief complaint, severe lower abdominal pains^ vpith recurrent attacks of fever and chills. She had been married sixteen years and had one child, born eleven years ago '•after a difficult natural labor. Complete rupture of the recto-vaginal septum occurred, and she was confined to bed for two months with puerperal fever ; she ias had four operations since in the endeavor to cure the tear, and each timo 5fi 230 VAGINAL DEAIiq-AGB AND ENUCLEATION" FOR PYOSALPINX, ETC. infection caused a failure. In 1889 she was operated upon for the fifth time successfully. In Jan., 1896, after exposure to cold she began to have an oiiensive hemor- rhagic discharge, accompanied by chills and fever, and her abdomen became swollen and tender, bowels constipated, defecation very painful. At the begin- ning of the attack her fever was high and she vomited much bilious matter. This attack continued throughout February, becoming less and less severe until the present time. The point of greatest tenderness is now in the right iliac region, extending across the abdomen. There is no tympanites, but the abdomen is tender. Micturition is painful, and the urine is loaded with mucus. Her general condition is one of extreme debility, her tongue is coated, appe- tite poor, and she is anemic. Examination. — Vaginal outlet relaxed, uterus anteflexed, cervix bilat- erally lacerated. On both sides of the uterus adherent fluctuating fusiform masses. Diagnosis . — Right ovarian abscess and pyosalpinx ; left pyosalpinx and cystic ovary ; general pelvi-peritonitis with fresh adhesions to rectum, pelvic walls, broad ligaments, uterus, and pelvic floor. Complications. — Fresh plastic lymph gluing all organs together and causing free oozing on separating adhesions. Operation . — Abdominal incision for the purpose of accurately locating the masses which were situated high up in the pelvis, and not in contact with the vaginal fornix, followed by an opening in the posterior wall of the vagina, evacuation of pus, and drainage. The pelvis was choked with the uterus, pyosalpinx, cystic ovary, and ovarian abscess, adhering to all contiguous structures, and the interspaces were filled with plastic lymph. The adherent organs were detached with difiiculty, but without tearing the rectum. An abscess of the ovary,! centimeters (1^ inches) in diameter, ruptured during the separation of the adhesions, discharging pus onto the surrounding gauze ; the distended tube was separated from its adhesions to- the ovary, and its fimbriated end was split open and necrotic material and some pus squeezed out. The left tube was brought up and treated in the same way, but there was no pus in the left ovary. After freeing the tube from its adhesions the closed extremity was split open and a small amount of pus squeezed out. The vagi- nal vault posterior to the cervix was then opened and a gauze drain was pulled through from above downward. The tubes and ovaries embraced the uterus be- hind, touching each other, and filling in the posterior pelvis, with the fimbriated extremities lying in Douglas' cul-de-sac resting on the gauze drain. The patient recovered slowly but steadily. The vaginal drain was removed with little difficulty, moistened with a slightly offensive yellowish discharge ; after the removal there was no discharge. The post-operative temperature at no time rose above 100° F. (37-8° C). She left the hospital five weeks after the operation, and was seen several months later perfectly well and hard at work as a canvassing agent. ENUCLEATION" OF PYOSALPINX AND OVARIAN ABSCESSES. 231 Enucleation of Pyosalpinx and Ovarian Abscesses (Salpingo-oophorectomy). — In enucleating a pyosaJpinx or an ovarian abscess the first step after opening tlie abdomen is to make a careful inspection of the relations of all the pelvic viscera. If omental adhesions interfere with the examination they must be separated by catching the omentum close to the adhesion and tearing them loose from their adhering surface with gentle force, or by tying them off. If the fundus uteri is found at or near its normal position, the fingers then readily glide over the cornua from one side to the other, and palpate the more or less hard nodular masses filling the pelvis on both sides posterior to the broad ligaments. It is by no means rare for the operator not to be able to discover the uterus at all, because it is so covered over with its diseased lateral structures and inflam- matory products, even uniting the bladder to the rectum. As soon as the diseased tubes or ovaries are located, the relations of each to all the structures with which it lies in contact must be studied separately by sight and by touch, pushing a little here and there to determine the amount of mobility, and noting with care any dense, hard, unyielding attachments, and especially all bowel adhesions. As a result of this thorough preliminary inspection the operator concludes whether he will or will not be able to make a satisfactory enucleation. It is im- possible here to lay down such precise rules as will serve to guide the inexpe- rienced surgeon in all cases, but it is undoubtedly true that operations of this character which appear at first sight, and to a beginner, impossible, are readily performed by a more experienced gynecologist. If the structures can be out- lined, and are found to be slightly movable, an enucleation will always be possi- sible ; if, on the other hand, they are densely wedged in the posterior pelvis and adhere to the pelvic walls as if frozen there, an enucleation ought never to be attempted ; the abscesses must then be evacuated by the vaginal route, aided by one hand in the open abdomen. If the masses are to be removed, evidences of fluctuation are sought for and the aspirator inserted, so as to draw off the pus into a sterile bottle ; cultures should then be taken, and cover-glass preparations made for immediate micro- scopic examination. The puncture hole should be closed with a single mattress suture. Any pus that escapes accidentally should be taken up at once, and pieces of gauze and sponges should be stuffed down into the pelvis and on all sides above the pelvic brim, so as to protect the adjacent parts from contamina- tion. The sides of the abdominal incision should also be protected throughout the operation by several layers of gauze. When a large abscess ruptures during an operation, with the pelvis elevated, the patient must at once be let down to a level to prevent the extensive contami- nation of the intestines. All intestinal adhesions should be separated under the eye; velamentous adhesions can be pinched off close to the sac, but flat, dense cicatricial adhesions must be dissected off with the knife or scissors, even leaving a part of the outer wall of the abscess adhering to the iatestine. If any of the 233 VAGINAL DRAINAGE AND ENUCLEATION FOR PYOSALPINX, ETC. pyogenic lining membrane of the cyst is left behind, this can be disinfected either by touching it with pure carbolic acid or by destroying the surface with the cautery, or by scraping it ofE with a scalpel. The successful enucleation of the diseased tube and ovary depends upon two factors : A good tactile sense, which constantly difEerentiates the structures under the fingers and readily recognizes the lines of cleavage between the dis- eased organs and the adherent peritoneal surfaces, and a knowledge of the usual topographical relations of ovarian and tubal abscesses. The natural points of cleavage are opposite to the normal ana- tomical attachments of the tube, along the dorsal and dorso-lateral pelvic walls, and between the two abscess sacs where they touch behind the uterus. When the cysts are completely covered with dense organized tissue an en- trance must sometimef) be effected by dissection with the knife, after which the further separation is not so difficult. By palpating around the dorsal wall of the pelvis a weak spot will usually be found, and then by working one or two fingers down here the split is widened and the cyst may be peeled off from side to side, while the fingers continue to advance on down toward the pelvic floor, at first behind and then under the mass. As the fingers advance, the separation from side to side is kept up until the mass, freed from the dorsal pelvic wall and the pelvic floor is grasped by the fingers and rolled forward and upward toward the incision, using the upper part of the broad ligament as an axis. This completes the separation of adhe- sions to the broad ligament. Adhesions at the outer pole of the mass to the rectum or pelvic wall, and at the inner pole to the uterus, are now looked for and separated under inspection. The whole mass, sometimes as large as the fist, but made up only of tube and ovary, is now brought out of the incision, still retaining its normal attach- ments to the ovarian hilum and ligament, to the mesosalpinx and c o r n u uteri, and to the infundibulo -pelvic ligament. As soon as these structures are brought outside, a sponge or loose piece of gauze is packed down into the incision behind the broad ligament to protect and hold back the intestines. The mass to be amputated should be enclosed in a gauze bag several folds thick the moment it is liberated; this affords a good grasp and protects the hand and the surrounding tissues from the contamination of any escaping pus. The method of ligation and excision of the tube is the same as that described in Chapter XXVI, p. 207. It will usually be found that the ovary is not diseased itself, but is merely involved in adhesions due to the accident of its position in the pelvis in prox- imity to the tube ; under these circumstances the ovaries should be left in women under forty. When the disease is bilateral the opposite side is similarly treated. If persistent oozing is noticed after the enucleation, its source must be sought out and inspected by packing away the intestines with fingers and sponges. A slight, constant oozing from a flat surface on the pelvic floor ENUCLEATION OF PYOSALPINX AND OVARIAN ABSCESSES. 233 may be controlled by a little dried persulphate of iron applied on the finger tip, or the cautery may be used ; bleeding from a large vessel must be controlled by ligatures introduced by the needle and carrier. Hemorrhage from a uterine adhesion, or from the side of the uterus where it joins the broad ligament, or from the ovarian hilum, nmst be controlled by the free use of ligatures through the uterine tissue and through the broad ligament. Persistent active oozing will occasionally be found to proceed from the outer end of a tube which has been torn in two in the enucleation, or from an ad- herent piece of the abscess wall left behind. These may be easily removed with ' forceps or fingers, and the bleeding will cease. Irrigation is indicated where pus has escaped during the operation and there is some probability that the in- testines have been more or less contaminated. If the cyst is aspirated before enucleation the liability to contamination is greatly reduced. The pelvis should now be cleansed with sponges, and then the sides of the incision may be pulled up and as much hot salt solution poured in as the pelvis will hold. The hot salt solution should be stirred about in the pelvis with the hand or with a sponge on a holder, and the water then sponged out and more poured in ; this may be repeated several times, until the surgeon is satisfied that the pus has been well diluted and removed. After drying out the abdomen the last step is a minute, deliberate inspection of the whole field of the operation to see if the ligatures are all in place and holding well, if all bleeding is checked, and if any intestinal adhesions have been overlooked. It is most important to examine minutely the rectum from the pelvic brim to the pelvic floor in search of a fistulous opening or a rent in the outer coats of the bowel. The employment of a drain in these cases is of no value and may give rise to serious harm, and it is therefore much better to close the abdomen without drainage unless a septic focus or a much injured bowel has been left behind, when a vaginal drain should be inserted behind the cervix. In order to prevent the accumulation of fluids in the raw areas left after dif- ficult enucleation of diseased appendages, 500 cubic centimeters of salt solution should be left in the abdominal cavity after operation, and when the patient is returned to her room the foot of the bed should be elevated about twenty de- grees in order to facilitate the rapid absorption by the lymph channels of the fluids and accumulating serum. The addition of the salt solution dilutes any infectious matter present, and not only hastens its absorption, but also lessens the irritant effects of the toxic products of the bacteria. When the abdomen is opened for a pelvic abscess and a widespread or a general purulent peritonitis is found, the course pursued by the operator will depend upon the condition of the patient. If she is so weak that she can pre- sumably only stand an operation of the shortest duration, the best plan will be to irrigate rapidly, cleaning out all the accessible pus with a sponge, paying spe- cial attention to the pelvic cavity and the renal fossae. If the time is too short to permit the enucleation of the pelvic abscess, this should at least be squeezed 23i VAGIXAL DRAINAGE AND ENUCLEATION FOE PYOSALPINX, ETC. empty and a free drainage opening made into the vagina back of tlie cervix and the abdomen closed. When, however, the patient's condition will permit it, the entire abdominal cavity should be washed out and the separate coils of intestines drawn up in an orderly manner and wiped ofE, and the mesentery cleansed, so that, as far as pos- sible, every trace of pus is removed. It must be remembered that only one third of the intestinal canal Hes in contact with the abdominal wall and that there is OvAEiAN Abscess. (A) Densely adherent to the rectum, with retroflexed adherent uterus ( V) ; general pelvic peritonitis of the severest form, involving both tubes and ovaries. Omental adhesions ( 0) 48 centimeters around the border. Pus in abscess sterile. Enucleation of uterus, tubes, and ovaries. Recovery. Gyn. No. 2825. M. v., June 13, 1894. an enormous extent of peritoneal surface distributed over the mesentery, so that after simply washing off what is exposed to view through an abdominal incision, much more is left behind which still more urgently demands attention. Liberal gauze drains should then be inserted in the median line leading down into the pelvis and out onto the coils of intestines. The flanks should also be opened and gauze drains put in there to catch any fluids gravitating in that direction. In this way several yards of gauze may be employed and gradually removed in ENUCLEATIOiq" OF PYOSALPINX AND OVARIAN" ABSCESSES. 235 a few days. When the uterus is extensively diseased eitlier by a chronic endo- metritis or contains numerous myomata, or is cancerous at the same time, as Fig. 391. — Double Pyosalpinx with Carcinoma of the Cervix. Showing a case of not unoommon occurrence in which it is necessary to enucleate both tubes and the ■entire uterus. The pus in both tubes was sterile. No. 308. % natural .size. shown in Fig. 391 and Plate XIY, the enucleation should then include the body ■or the entire uterus with the infected tubes, and the operation should be per- formed as described in Chapter XXVIII. CHAPTER XXVIII. HYSTERECTOMY, WITH EXTIRPATION OF OVARIES AND TUBES- ABDOMINAL HYSTERO-SALPINGO-OOPHORECTOMY. 1. Indications for operation and analysis of one hundred cases. 2. Reasons for removing the uterus. 3. Operation. 4. Complications in one hundred cases. 5. Mortality. Indications for Operation. — The removal of the uterus with diseased ovaries and tubes by the abdominal route is indicated — 1. "Where previous efforts at conservatism have failed. 2. Where the uterus is involved in inflammatory products, buried beneath masses of adhesions, or beneath bladder and rectum adherent together over the- top of the uterus. 3. Where, in addition to the extensive lateral disease, the uterus is subinvo- luted or there is a chronic metritis. 4. Where the incurable disease of the tubes and ovaries is complicated by a. uterus containing myomata. 5. In general, vrhere the enucleation en masse is technically much easier and, therefore safer than the removal of the lateral structures alone. 6. In cancer of the body of the uterus. 7. When both ovaries are the seat of papillary, dermoid, or multilocular cysts. The diseases of the ovaries and tubes most likely to be found with such a. uterus are double pyosalpinx, or pyosalpinx of one side and hydrosalpinx of the other, or double hydrosalpinx, or general posterior pelvic peritonitis binding- down the uterus, ovaries, and tubes. I have found it necessary to remove the uterus, tubes, and ovaries in one= hundred cases for the following reasons : For pyosalpinx in 38 ; for ovarian- abscess, 2 ; for pelvic abscess, involving both tubes and ovaries, 18 ; for salpin- gitis and perioophoritis, 22 ; for hydrosalpinx and pelvic peritonitis, 15 (once with dermoid cyst) ; endometritis, pain, and hemorrhages not relieved by a pre- vious salpingo-oophorectomy, 2 ; tuberculosis of ovaries and tubes, 3. Out of sixty-five cases of pelvic abscess treated by a free vaginal incision and drainage I found it necessary at a later date to resort to the radical plan of ex- tirpating uterus, tubes, and ovaries in five cases. This most radical procedure must be carefully guarded by operating only upon suitable and stringent indica-^ 236 INDICATIONS FOR OPERATION. 237 t i n s . In young women, when the ovaries are not diseased, they must be left in the pelvis, confining the enucleation to the tubes and the uterus. The removal of the uterus with the tubes and ovaries is to be recommended, because without the ovaries it is a useless organ, which may of itself, at a later date, become the source of such serious disturbances as to require its removal. In almost all pelvic inflammatory cases the uterus is traceable as the avenue of Fig. 392. — Extirpation of Myomatous Uterus, Ovaries, a>T) Tubes "svith a Left Ovarian Cystoma. The uterus is filled with myomata, and the left ovary is converted into a lartre ovarian cyst. C\ cervix ; F^ fundus. The dotted line is the median line of the body. No. 44-3. % natural size. infection, and the retention of an infected subinvoluted uterus often in.sures the persistence of a leucorrheal discharge, protracted hemorrhages, and a sense of weight and pelvic discomfort, which seriously mar the result of the operation. In addition to these reasons, many of the uteri operated upon for these con- ditions are lifted out of beds of adhesions, and when freed present, on the ab- dominal side, an extensive raw surface which is liable to contract adhesions with contiguous intestines. In a large percentage of cases, too, not only the tubes and the ovaries are infected, but the uterine cornua as well, necessitating at least a partial amputation if the uterus is left behind. The backward displacement of the uterus onto the pelvic floor when robbed of its adnexa may also cause much distress, and obstruction of the rectum. If the uterus is not taken out, the pedicles at the top of the broad ligaments are exposed to the right and to the left of it, which is avoided by amputating the uterus in the cervical portion and covering in the whole wound with peri- toneum, so as to leave no exposed raw surfaces to contract adhesions. Para- doxical as it may seem, it is easier to take out the uterus with its adnexa than to extirpate densely adherent tubes and ovaries alone. The complete extirpation affords a better view of the entire pelvis, the ligation of the uterine artery gives a better control of hemorrhage, fewer raw areas are left, the operation may be actually of shorter duration, and better drainage is secured if it is called for. 238 HYSTERECTOMY, WITH EXTIRPATION" OF OVARIES AND TUBES. For these important reasons hystero-salpingo-oopliorectomy is to be preferred to double salpingo-oophorectomy. I would only except those cases in which the patient emphatically expresses a desire not to have the uterus removed, and in which there is a small mobile uterine body not involved in the disease. There exists among surgeons a wide divergence of views regarding the rela- tive advantages of the abdominal and vaginal routes iu the extirpation of the uterus and its appendages. I have always held that the abdomen was the best avenue for the following reasons : First and foremost, the operator, upon open- ing the abdomen, has a chance to inspect the condition of the structures lateral to the uterus and to decide whether or not a conservative course may be safely followed; the abdominal route allows the entire operation to be done under the constant supervision and criticism of the clearest inspection of the entire field ; complications such as intestinal adhesions, and particularly adhesion or abscess about the vermiform appendix (attached in twenty-seven out of one hundred of my cases), can be seen and safely dealt with ; hgatures are applied with certainty, and hemorrhage is seen and easily controlled ; the ureter and bladder are not so liable to injury ; and finally the quick, clean recovery follow- ing an aljdominal operation is far preferable to the sloughing and protracted suppuration and slow healing so common after removing the uterus through the vagina and using clamps on the broad ligaments. Operation. — The incision is made in the linea alba from 10 to 15 centimeters (4 to 6 inches) long — a shorter cut if the walls are thin, a longer one if they are thick. If the omentum is adherent it is first released, bleeding points tied, and any free fluid carefully removed by means of sponges. If the intestines do not fall out of the way into the upper part of the abdo- men the pelvis should then be further elevated 30 or more centimeters (12 inches) above the horizontal plane, and the small intestines and any redundant sigmoid lifted out of the pelvic cavity and kept packed away by non-absorbent cotton- gauze pads. The pelvis, thus fully opened to view, is now carefully inspected to determine the extent of the disease on both sides, which side is the worse, a,nd the exact position and relations of the uterus to the inflammatory disease, and whether or not it will be advisable to do a conservative operation. It has become a mere habit with many operators to exhibit surgical skill (sic) by removing uterus, tubes, and ovaries upon various trifling indications, such as a mild pelvic peritonitis with adhesions, a one-sided suppurative salpingitis, etc. The mere mention of such practices carries its own condemnation ; the true surgeon will exercise a far higher skill in wisely selecting certain cases for con- servatism, and sparing all or as much of the pelvic organs as he deems sound or capable of regeneration and a restored functional activity. To this end an un- usual effort should be made in the case of young women by breaking up adhe- sions, by plastic operations, by resections, and by the liberal use of drainage, counting upon the remarkable restorative powers of youth to preserve to them the possibility of conception and motherhood ; or if that is impossible and the tubes must be sacrificed, to preserve menstruation by leaving the uterus and " OPERATION. 239 ovaries ; or if the uterus too must be removed, to preserve the ovaries, or one ovary or a piece of an ovary, to obviate as far as possible the distressing sequelse of the artificial menopause. The older the patient the less these reasons will have weight ; often, too, after long years of invalidism and suffering the patient will insist that she desires above all other things to be rid of her pelvic complaint at all costs ; in this case the surgeon will not assume the same risks to save structures he would other- wise feel fully justified in doing. In all cases and at all times the natural bias of the surgeon's mind should be toward a healthy conservatism. If it is a case of extensive posterior pelvic peritonitis, with long, veil-like adhesions, binding down uterus, ovaries, and tubes, I begin the enucleation by grasping the body of the uterus with a pair of museau for- ceps and drawing it up toward the lower angle of the incision, putting the adhe- sions on the stretch. They may yield readily, and if they do I simply strip the whole posterior surface of the uterus free with my fingers, catching up and breaking the bands one by one, as near to the uterus as possible. JSText, by pulling the uterus to the right and forward, the adhesions on the left are made tense, so that the tube and ovary may easily be stripped loose and lifted up, free- ing the broad ligament; the right side is freed by reversing the movements. If the adhesions of the posterior surface of the womb do not yield readily to the fingers the scissors must be used. Expose the adhesions by pulling the uterus forward and holding the rectum back by means of a sponge held in the forceps or with the fingers, and then cut them, one after the other, close to the uterus. Adhesions of the ovary and tube to the rectum and pelvic wall may also be severed in this way. When the adhesions are universal, dense, and close, the surgeon must carefully inspect the whole field before beginning the enucleation at all, in order to effect an entrance at the point of least resistance. This will often be found at the place where the tubes dip down into the posterior pelvis and are lost among the adhesions. By working in first one finger and then two, and stripping from side to side, a purchase is secured upon the adherent uterus and the under surface of the ovary and tube of that side. In this way dense adhesions frequently yield in a direction from below upward, where it seemed impossible to break through them at the pelvic brim. In severing particularly dense adhesions the principle must always be fol- lowed of cutting closer to the organ which is to be removed. Thus, in freeing the uterus from the rectum in a hysterectomy, a piece of the uterus should be left on the bowel rather than risk wounding the rectum by trying to cut exactly between the two. In another group of cases the uterus, ovaries, and tubes lie completely buried beneath a dense mass of adhesions. Here the uterus may be located by first fixing the position of the rectum and then pass- ing a sound into the bladder to determine its posterior limit, and dissecting care- fully with knife and forceps and scissors between these two points. Below the 240 HYSTERECTOMY, WITH EXTIKPATION OF OVARIES AND TUBES. surface the adhesions often become less dense and can be separated by the fingers, thus opening up a wide area in which the uterus may be found. The dissection is continued until the whole organ with its ovaries and tubes has been freed and elevated out of its bed. In still another class of cases the rectum is adherent to the bladder, covering in uterus, ovaries, and tubes. This Fig. 393. — IlYSTERO-SALPINGO-OdPHOKECTOMY FOR LaRGE DoUELE HYDROSALPINX "WITH EXTENSIVE AD- HESIONS. U^ uterus ; /", fundus ; R Z, round ligaments ; T^ uterine tubes ; (7, ovaries. No. 504. ^e natural size. adhesion may also be broken up and the structures below freed by dissection between the two, pulling the bladder forward and pushing the rectum back so as to make the interval between the two as wide as possible. If a portion of either viscus is to be sacrificed to make the separation, it must be the bladder. If, on account of their density, it is impossible with safety to break up all the adhesions from above, it is best to proceed at once with the first two steps in enucleation by seeking out the ovarian vessels, which can always be found at the outer extremity of the broad ligament upon lifting up the sigmoid flexure. When these are isolated they should be clamped on the uterine side and ligated on the pelvic side and cut between, the incision being continued in an oblique direction across to the insertion of the round ligament into the uterus. The round ligament is now ligated about 2 centimeters away from the uterus and clamped close to it and divided. By this means the top of the broad ligament is now cut completely through and the adherent tube and ovary may be reached from the front and freed. This is done by first severing them from the broad ligament and working down toward the pelvic floor in front of them, afterward dealing with the adhesions to the pelvic wall by working from below upward. OPERATION. 241 When in any of these groups of cases the adhesions are all broken up and the uterus with ovaries and tubes set free, I complete the enucleation by the following steps. Beginning, say, on the left side, these will be : 1. Left ovarian vessels ligated and severed. 2. Left round ligament ligated and severed. 3. Vesico-uterine peritoneum freed from left to right and pushed well down with the bladder, exposing the left uterine artery. 4. Left uterine artery and veins tied in the cervical portion. 5. Uterus amputated across cervical portion. 6. Eight uterine vessels clamped above the stump. 7. Uterus pulled up and out and right round ligament and ovarian vessels clamped and uterus removed. S. Ligatures applied in place of the clamps on the right side. y. Cervical stump closed. ir». Anterior layers of both broad ligaments and vesical peritoneum drawn over the stump and sutured there. I begin the separation by seeking out the left ovarian vessels at the outer extremity of the broad ligament under the sigmoid flexure. The sigmoid is often found dropped over into the outer extremity of the broad liga- ment and united to it by numer- ous adhesions. These may be sep- arated by lifting up the sigmoid, ( ^ riY'Z ^^ \ stretching them a little, and sever- ing with scissors. When the vessels are exposed I clamp them on the uterine side and ligate them with a silk ligature passed through the "clear space" on the pelvic side Fig. 394. — Outline showing Extirpation of the Ute- Kua, Tubes, and Ovaeies by a Continuous Incision IN THE DiEEOTION OF THE AeROWS, OE THE KeVEESE. In case the ovaries are left, as they must he in a young woman if they are sound, the ligation begins at the tubo- ovarian fimbria, between the tube and the ovary. and cut between in an oblique di- rection across to the round liga- ment attachment of the uterus. The incision must be far enough from the ligature (at least 1 centi- meter) to avoid the risk of its slipping off the stump that is left. I next ligate the round ligament about 2 centimeters (f inch) from the uterus and clamp it close to the uterus and sever it too. By these two incisions the top of the broad ligament is laid open. The line of reflection of the vesical peritoneum on to the uterus begins just below the round ligament and dips down into the pelvis and extends in a con- cave line across to the opposite side. If not distinguished at once by the marked contrast between the dark-red color of the uterus and the whiter vesical perito- neum, it will be found by lifting up the bladder with forceps and noting the line which marks the limit between the movable portion on the bladder and the fixed portion on the uterus. 242 HYSTERECTOMY, WITH EXTIRPATION OF OVARIES AND TUBES. There is often found a false line of apparent reflection of the vesical perito- neinn high up on the fundus formed bj^ peritoneal adhesions ; when this is dis- sected away from the uterus the real line of reflection is evident. I now detach the vesical peritoneum along this line, beginning at the left concave line down across the Then, grasping uterus, ovary, and tube in the left hand, or with museau forceps, I draw them strongly upward, outward, and toward the opposite side, while with the right hand I push the vesical peritoneum down oft' the cervix with a firm sponge held in a j)air of forceps. The force of the push and peeling movement with tlie sponge must fall upon the uterus and not on the bladder. The separation of the blad- der from the cervix is easily effected in this way, exposing the uterine arteries round ligament and continuing the incision in front of the uterus around to the right round ligament. and veins low down in the angle between vagina and cervix. After baring the Fig 395 — E\tii i rrioN of Oteru.s, Tubes, and Ovaries for Pelvic Peritonitis. The right ovary contains two sniiill Graafian follicle cysts. The left tube and ovary are converted into ;d mass by the adhesions. % natural size. a ragged mass by the adhesions. % natural size. cervix for about 3 centimeters I take it up between the thumb and the fore- finger in front and behind and seek out its lower end, which can be readily dis- tinguished through the vaginal vault. In the same way, palpating at the side of the cervix, I easily recognize the uterine artery by its pulsations. This I now ligate by a medium-sized silk suture, carried beneath the vessels from before backward, low down and close to the cervix. Having now placed all the uterine vessels on the left side under control, I proceed to amputate the cervix with a hysterectomy spud or a sharp scalpel, cupping it slightly and angling the cut off on the right side to a little higher level. While this is being done the uterus is drawn strongly upward, grasped by a gauze pad or museau forceps, keeping the tissues to be ciit always under ten- sion, so that as soon as the division of the cervix is completed the two parts OPERATION'. 24:3 begin to separate until an interval of two or three centimeters exists between them, in which the right uterine vessel may be seen. These are now clamjDed and controlled a centimeter or more above the cervical stump, and the uterus pulled still farther up until the round ligament is clamped and divided near the fundus ; last of all, the ovarian vessels in the ligament near the pelvic brim are clamped and cut, when the enucleation is complete. As soon as the cervix is cut across it is best to wipe out the canal below with gauze or to push a small piece of iodoform gauze through the canal into the vagina in order to cleanse it ; the uterine cavity must also be prevented from emptying its contents over the wound by laying a thick piece of gauze under it. In dealing with pus cases it is my habit to tie a thick gauze bag over the tube and ovary as soon as they ar.e freed and lifted up, so as to avoid the constant handHng and possible distribution of any of their escaping contents over the pelvic peritoneum during the operation. One of the most signal advantages secured by this method of extirpation is the increased ease with which the enu- cleation can often be effected by attacking the adherent masses from below instead of in the usual way from above, an advan- tage similar to that claimed by the operation of vaginal hystero-salpingo-oopho- rectomy. In order to gain this advantage the enucleation must be begun on the side, right or left, which is least adherent, and the opposite side is not touched until the cervix is divided and its vessels clamped ; then the enucleation of this side too is effected by beginning behind the broad ligament, but in front of the mass, low down near the pelvic floor, and so working it free from below upward. It is often astonishing how easy it is to roll an adherent mass up and out of the abdominal incision in this way, though the same mass may present grave difliculties with intestinal and other adhe- sions when attacked from above. Any cystic masses in ovaries or uterine tubes should always be evacuated with an aspirator before freeing them, both in order to protect the peritoneum from their contents as well as to afford more room in deahng with them. With the removal of the uterus and its attached organs, the cervical stump drops back to the floor of the pelvis. The right uterine and ovarian vessels are tied with silk and the round liga- ment with catgut and the forceps removed. In applying the ligature to the uterine vessels care must be taken not to carry the loop deep down beside the cervix, so as to avoid including the ureter. The vessels which are clamped above the cervix can be seen and tied at a safe level above the base of the broad ligament. There is now seen on the pelvic floor a creseentic denudation, broad in the middle, and tapering to its horns at either pelvic brim, at the stump of the ovarian vessels. In the center lies the cervical stump. I do not in any way disinfect or burn out the cervical • canal or the surface of the stump unless 244 HYSTERECTOMY, WITH EXTIRPATION OF OVARIES AKD TUBES. there has been a purulent uterine discharge. It is suificient simply to wipe the stump out clean with gauze. I now approximate the surface of the stump for two purposes — to shut off communication with the vagina through the canal, and to check any slight hemorrhage. For this purpose I use from four to six catgut sutures, entering the first suture in the middle of the anterior lip, not including the reflected vesical peritoneum, and bringing it out near the cervical canal, to re-enter be- hind the canal, and come out again on the posterior peritoneal surface of the stump. This suture is tied tight at once, and brings the lips of the stump together in the middle; it should be left long, to serve as a tractor, to hold the stump within easy reach, while the remaining sutures are introduced on either side of it. If any bleeding vessels are seen on the surface of the stump, sutures should be passed through the lips in such a manner as to catch and control them when tied. Two or three sutures on each side make an accurate approximation, like the lips of a purse. All the sutures are now cut short and the stump dropped back. The whole raw crescent-shaped area between the peritoneal folds must now be inspected under a good illumination to see if there is any bleeding. If there is, it must be checked, catching the point up with forceps and applying a ligature. Finally, I unite the anterior peritoneal layers of the broad ligaments and the reflected vesical peritoneum to the posterior peritoneum by a continuous catgut suture, so as to cover in the whole raw area, together with the cervical stump. This suture begins by turning in the ovarian stumps, and pierces the peritoneum at points about 1 centimeter apart. Upon reaching the cervical stump the vesical peritoneum is attached to its posterior peritoneal surface. If this long suture is snugly drawn up each time it is passed, it lifts the peri- toneum up in the pelvis, and tends to stop any slight oozing from the edges of the wound. It is essential, before closing the wound by uniting anterior to posterior peritoneum, to stop all bleeding ; if this is not done a hematoma may form which may give rise to an abscess and necessitate the dilatation of the cervix by the vagina to secure its evacuation and drainage. If there is a wide area of cellular tissue exposed, and it tends to ooze, it will be better to close the peri- toneum with mattress sutures, so as to let the blood and serum escape and be absorbed. The pelvis after the extirpation is completed presents to view only the bladder and the rectum with a line of accurately united peritoneum stretching in a concave line between them. The incision in the abdomen is completely closed and the dressing ap- plied. Complications. — The complications met with in the inflammatory group of cases of this class are probably more serious than in any other group in ab- dominal surgery ; out of the histories of my one hundred cases the following have been collated : COMPLICATIONS. 245 Cases. Omental adhesions in 45 Intestinal adhesions in 53 Adhesions of the vermiform appendix in 27 Sigmoid flexure adhesions in 32 Bladder adhesions in 31 The rupture of a pus sac with the escape of jjus into the peritoneal cavity occurred in 27 The intestines were injured in varying degrees from a laceration of the external coat to a complete rupture of all the coats in 24 Old fistulous tracts were found opening into the intestine and requiring suture to close them in 4 A partial obstruction of the intestine existed in 3 It was the fashion to use drainage during the period in which most of these operations were performed, and I must therefore note thirty-one cases drained through the abdominal wound and fifteen drained through the cervix. The mortality in this entire series amounted to four per cent ; one of the deaths was due to an infection entering along the drainage tract, another was caused by peritonitis from the rupture of the intestine at the site of the suture, another was due to a purulent peritonitis, and the fourth came from an intestinal obstruction at the site of an old dense annular cicatrix in the sigmoid flexure. CHAPTER XXIX. OVARIOTOMY. 1. Ovarian tumors in general. 1. Kinds of ovarian tumors. 3. Relative frequency. 3. Benign and malignant tumors. 4. The pedicle: (a) Long pedicle, (b) No pedicle at all. (c) Ro- tation of pedicle. 5. Rupture of a cyst. 6. Clinical course. 7. Diagiusis: (a) Is a tumor present ? (6) Is it an ovarian tumor 1 (c) Of what kind f 2. Multilocular ovarian cyst-adenoma. 1. Pathology : (a) Contained iluid. (b) Pseudomucin. 3. Development. 3. Cause. 4. Symptoms. 8. Papillary tumors of the ovary. 1. Introductory: (a) Forms, (b) Relative malignancy of papil- lomata and carcinomata! (c) Clinical characteristics, (d) Histology, (e) Diagnosis. 3. Papillary parovarian cyst. 3. Papillary cystic Graafian follicle. 4. Pseudomucinous papillary adenoma. 5. Simple papillary adenoma. 6. Papillary adeno-oarcinoma. 7. Papillary cyst-adeno-sarcoma. 4. Carcinomata of the ovary. 5. Dermoid cysts of the ovary. 6. Parovarian cysts. Hydatid of Morgagni. 7. Fibroid tumors of the ovary. 8. Sarcomata of the ovary. 9. Treatment of ovarian tumors. 1. Contraindications to operation. 3. Steps of operation : (a) Median abdominal incision. (J) Evacuation and withdrawal of the cyst, (c) Liberation of all adhesions, (d) Ligation of pedicle, (e) Intraligamentary cysts. (/) Examination of opposite ovary, (g) Cleansing peritoneum, if soiled, (h) Closure of incision. Ovarian Tumors in General. — The ovary, altliougli but a diminutive organ, is peculiarly rich in cellular elements of various kinds which may give rise to a great variety of tumors ; it is difficult also to dissociate mentally the wonderful function of the ovary as a reproductive organ from its marvelous activity as an atypical tissue producer when once its activities have become perverted. We find, therefore, in the ovary retention cysts, epitheliomata (using the word broadly to include adenomata as well), connective-tissue tumors, fetal in- clusion cysts, and parovarian cysts, though the last are not, strictly speaking, ovarian. The first group, the retention cysts, include : Cystic Graafian follicles of large size, Cystic corpora lutea, and Multiple cystic follicles, usually small in size. The epithelial group of tumors include : The cyst-adenomata, which are the classical ovarian tumors, Papillary ovarian tumors, and Adeno-carcinomata. The connective-tissue group is made up of : Fibroid tumors of the ovary, Myomata, and Sarcomata. 346 OVARIAN- TUIIOES IK GENERAL. 247 Dermoid tumors stand aloiie as a peculiar group formed by inclusions of a part of the ectoderm during the development of the ovary. Parovarian cysts, while not strictly belonging to the group of ovarian tumors, are most naturally associated with them for important clinical reasons. Ketention cysts of the ovary are not considered in this chapter, as they have been placed among those affections which are best treated by conservatism. I would also exclude here all of the small and all of the clear-walled parovarian cysts found associated with a sound ovary ; these will be found in the chapter on conservatism. The relative frequency of the different kinds of ovarian tumors varies greatly. Taking 141 cases of large tumors of the ovary differen- tiated macroscopically in the operating room, they were grouped as follows : Multilooular ovarian cysts 38 Unilocular ovarian cysts 36 Parovarian cysts 22 Papillary tumors 20 Dermoid cysts 25 A thorough sifting of this material, however, in the pathological laboratory has served to demonstrate the necessity of a careful microscopical examination in every case; by doing this, small dermoid cysts were discovered where none were suspected on account of their diminutive size, and inflammatory masses were sometimes found to be due to dermoids which had discharged their contents and which only revealed their true character when the minute cell elements were studied. The group of papillary cysts was also enlarged by a microscopic examina- tion at the expense of the multilocular and the unilocular cysts. The group of unilocular cysts of the ovary, when more carefully studied, was diminished by the discovery of small cysts in the walls ; these tumors were therefore in most instances reclassified among the multilocular cysts ; such a reclassification was also made necessary by the frequent discovery of trabeculse on the inner cyst wall. These were clearly the remains of partitions between originally separate cysts which later become fused by pressure and atrophy of the septa or by spontaneous rupture from tension. In marked contrast, therefore, to the group of tumors classified by their purely macroscopic appearances, I present another group of 138 cases of large ovarian tumors, every one of which was examined microscopically; they were found to be distributed as folloM's : Multilocular adeno-cystoma 57 Unilocular adeno-cystoma 3 Adeno-papilloma 87 Adeno-carcinoma. ._ 9 Sarcoma 2 Fibroma , 4 Dermoid cysts 26 Parovarian cysts 10 248 OVAEIOTOMY. It is only necessary to contrast these two lists to demonstrate the necessity of a searching miscroscopic examination in every case in order to establish the diagnosis on a scientific footing. A further most important clinical classification of the ovarian tumors is into benign, malignant, and semi-malig- nant. It must always be borne in mind that these terms are only clinical ex- pressions and are therefore vague ; by a benign tumor is meant one which does not tend to recur when extirpated, as well as one which does not tend to implant itself elsewhere or to invade the tissues ; by a malignant tumor is meant one which tends to destroy life by invasion of the surrounding and subjacent tissues, as well as one which distributes its elements by metastases to other parts of the body ; a semi-malignant tumor is one which may extend to the adjacent parts by implantation, and then may or may not continue to grow after the removal of the parent tumor. In general, the multilocular cyst-adenomata, the dermoids, the fibroids, and the parovarian cysts are classified as benign, the papillary tumors as semi-malig- nant, and the carcinomata and the sarcomata as malignant. The essential Weakness of such a clinical classification is shown histologically by the recognition that many of the cyst-adenomata are in reality papillary tu- mors, and many of the papillomata belong to the carcinomata, and sometimes even to the sarcomata. From a practical stand- point all ovarian tumors must be considered as ma- lignant until removed and proved otherwise. Pedicle. — Ovarian tumors are at- tached to the broad ligament by the same anatomical structures by which the normal ovary is found attached to it. The base of attachment of the tu- mor is called its pedicle, and in this pedicle the various anatomical ele- ments differ greatly in their mutual relations, according to the mode of growth of the tumor, whether up into the abdomen or down toward the pel- vic floor, according to its length, and according as it has a broad or a nar- row insertion. The anatomical structures con- cerned are the mesovarium, the utero-ovarian ligament, the mesosalpinx, the uterine tube, and the broad ligament; they deserve careful consideration in each case, because the correct diagnosis in any given case depends upon the recognition of the relationship between the tumor and the broad ligament and TelvJ Fig. 396. — Diagram showing the Kelations of AN Ovarian Cvst to the Peritoneum of the Pelvic Floor and Broad Ligament. FT, the uterine tube, with its intact mesosalpinx {Ms). The red line (P, 1>) is the peritoneum, which extends to the hilum of the ovary, but does not cover it. PEDICLE. 249 the uterus as established by means of the pedicle ; the treatment, also, is sim- plified or rendered difficult according to the character of the pedicle and the relations of its component structures. In some instances the mesovarium is pulled out witli the utero-ovarian liga- ment in the form of a long band to form a pedicle 6 or 8 or more centimeters V .J i. Fig. 397. — LoNfi Pedicle of a Papillary (Jvarian Adeno-cystoma. The tube is above, with a cyst (hydatid of Morgagni) under its fimbriated extremity. March 8, 1894. No. 202. % natural size. in length (see Fig. 397). At other times the tumor (usually parovarian) de- velops in the outer part of the mesosaljjinx, and the ampullar part of the tube is spread out on its surface. When the whole mesosalpinx is spread apart by the growing tumor, the entire tube is also stretched out on its surface from cornu uteri to fimbriated end, and may be greatly lengthened (see Fig. 398). Continued development in this direction opens up the lower part of the broad hgament, and then raises the pelvic and sometimes the abdominal peritoneum, even as high up as the celiac axis. In broad ligament tumors of this kind the uterus is found lying closely attached on one side. In marked contrast to these tumors which lie between the layers of the broad ligament, a pseudo-intraligamentary tumor may be found when an ovarian tumor the size of a fist or a child's head is caught in the pelvis under the tube and mesosalpinx which it pushes up before it, so that the mesosalpinx covers the tumor in like a hood; the same effect may also be produced by 250 OVARIOTOMY. adhesions to the broad ligament and mesosalpinx covering in the tumor (Paw- lik). (See Fig. 399.) Eotation of the Pedicle . — Spherical non-adherent cysts with a long pedicle are peculiarly liable to an accidental rotation and strangulation of the pedicle, checking the venous outiiow from the tumor and causing hemorrhage into its interior, sometimes large enough to cause the sudden collapse and death of the patient. If the woman survives such an accident and the rotation contin- ues, the entire blood supply may be cut Ms ofE and the cyst become gangrenous. J.7. Pelv. Floor Fig. 398. — Diagram showing the Relations of an Intraligamentary Cyst to the Anterior and Posterior Layers oe the Peritoneum of the Broad Ligament. The red line (P, P) is the peritoneum, of which Ms, Ms is the mesosalpinx, whose layers are widely separated, while the uterine tube {FT) is spread out flat on its surface. P, F - Fig. 399. — Adherent Cyst of the Ovary show- ing the Mimicry of the Intraligamentary Cyst. The uterine tube {F 2"), the mesosalpinx (Ms), and the pelvic peritoneom (P, PF, P) are adherent to the cyst on all sides. The dotted line and the arrow indicate the level of the pelvic brim. The symptoms of strangulation are sudden pain, pallor, and sometimes faint- ing with sudden enlargement of the tumor, which becomes tense and painful. If the woman survives the first attack the symptoms may be progressive and she is confined to bed, and peritonitis supervenes ; later, the cyst, originally free, is found invested on all sides with adhesions. Suppuration may follow, marked by chills and high temperature. With the cutting off of the blood supply and the pouring out of a hemor- rhage into the interior of the cyst, the tumor assumes more the nature of a foreign body, exciting a violent reactive inflammation in all contiguous parts of the peritoneum, and becoming attached to it by vascular adhesions, which in time more or less replace the normal blood supply. In rare cases the pedicle may atrophy and become detached, leaving the tumor to continue a para- sitic existence. A remarkable instance of this sort is shown in Fig. 400, in the inset, and in Fig. 403 in the text. There was ascites in the abdomen and extensive peritoneal carcinosis, and the cyst, which could not be removed on this account, was aspirated. In one of my cases of hemorrhage, figured in the text, there was a large accu- mulation of blood just above the twisted pedicle and in the walls of the adjacent Tlj toe Fig. 400. — Pabasttic Ovarian Cyst of Left Side "with General Peritoneal Carcinosis. The cyst is rolled upward, showing its under surface and the atrophied pedicle with the tube. In the place of the left appendage in the pelvis is seen the uterine end of the pedicle of the cyst. Observe the oval opening in the broad ligament; the upper border of this opening is formed by the uterine end of the tube, while the stump of the ovarian ligament is visible through the opening; both stumps merge into the peri- toneal covering. The external iliac vessels, right ovary, and tube adherent. Nov. 6, 1897. Fig. 401. — Left Ovarian Cyst with a Twisted Pedicle, inoludtito the Uterine Tube, the Ovarian Ligament, and the Round Ligament. The area of hemorrhagie infarction is well shown in tlie pedicle and the adjacent cyst wall. July 16, 1894. Ko. i:iJli.i. % natural size. Round ■ Pedicle , untwisted, Jij^ Fig. 402. — Pedicle tntwisted to show its Anatomical Elements, the Extent to which the KonNi> Ligament is Involved, and the Hemorriiagio Infarct. % Natural Size. PEDICLE. 251 part of the cyst. In this case the short pedicle in twisting occluded the uterine tube and, what is quite rare, the round ligament was drawn up into the twist. AdV carcinomatous OTTientLiTn . / AcHiTTiesenfeTy of , small intest. Airophiei pedicle of cyst FiQ. 403. — The Relations of the Parasitic Moltilooulak Ovarian Cyst shown in Inset Fig. 400. The uterus lies below the cyst in the pelvis and totally diseoiinected from it ; the atrophied detached pedicle lies above the bladder. The cyst is, as shown, extensively adherent to the posterior peritoneum, mesentery, colon, and omentum. Nov, 6, 1897. (Autopsy.) Prof. O. Kiistner {Centralh. f. Gyn., 3 891, No. 11) believes that the tu- mors of the right side, as a rule, rotate from left to right, while left ovarian tumors turn from right to left. In four tumors of the right ovary he found the 252 OVARIOTOMY. twisting in every ease following tins rule, and in six left-sided tumors he found the rule to hold in five cases. I iind two causes for the rotation of cysts. In the first place, large multi- locular cysts exhibit a notable tendency to the formation of one large cyst cavity, wdth a number of subsidiary ones, and the tumor will invariably turn until the convex surface of the large cyst comes to lie in relation to the con- cavity of the distended anterior abdominal wall; this produces a partial rotation which does not tend to increase. I tliink the cases in which the rotation amounts to or exceeds one turn, found in the spherical tumors the size of a man's head, are for the most part due to the alternate relaxations and contrac- tions of the anterior abdominal walls acting most decidedly on the part of the tumor which is nearest the median line. Eupture of a Cyst. — Rupture of an ovarian cyst occurs when its walls have been distended and thinned out, or when sufficient force is applied by a blow or by the powerful contraction of tlie abdominal muscles. In the polycystic tumors the rupture of one cyst into another is a matter of regular occurrence, and in this way many smaller loculi fuse to form the main cyst cavities so commonly found ; the cyst walls are delicate and either rupture by the increased tension of their contents or by absorption of their septa from mutual pressure. Kupture into the abdominal cavity is most apt to occur in the thin-walled cysts, such as some cyst-adenomata and parovarian cysts ; be- cause of their thick walls, dermoid tumors are but rarely ruptured unless from a violent blow. As a result of the severe accidents to which women with large tumors seem peculiarly liable, such as falling down stairs or from a chair, etc., any sort of a cystic tumor may rupture. The rupture is commonly found as a rent in the capsule, and if this happens to open a large blood vessel, death from intraperitoneal hemorrhage may shortly take place. Fortunate- ly, such an occurrence is rare, and the only effect produced is to pour the cyst contents into the abdominal cavity, where, if it is of a bland nature, as in the case of most parovarian cysts, it is rapidly absorbed and thrown off with an enormous polyuria lasting one or more days. If the fiuid is of an ir- ritating nature, a sharp attack of peritonitis with adhesions may result ; when the cyst contains papillary elements, these are disseminated all over the j:)eritoneum, where they con- FiG. 40-t. — i.U'AiuAfj Cyst showino Natukal Perforation AND a Tenacious Pseudomucinous Secretion pouring OUT into the Abdominal Cavity. Dec. 23, Ib'Jo. Nat- ural Size. Fig. 405. — Large Moltiloculak Otabian Cyst in a Negress. Aspiration. Death without operation. Autopsy. DIAGNOSIS. 253 tinue to grow and an ascites forms, and ultimately the patient dies of ex- haustion. After a time the walls of the ruptured cyst retract, forming dense cicatricial bands and exposing and everting any secondary cysts contained ^vithin the cavity. A rare form of rupture is a little pinched-out hole from which the tough pseudo-mucinous fluid slowly oozes out in a tenacious rope. In one of my cases the hole was plugged from within by a little flaccid cyst seen lianging from the outer surface of the tumor. Clinical Course. — The tendency of all ovarian tumors is to grow larger, filling first the posterior quadrant of the pelvis of tlie side from which they spring, then filling the whole pelvis, and finally rising up into the abdomen and gradually encroaching upon its cavity in a direction from below upward. Tumors weighing over fifty pounds are rare, but well-authenticated cases are recorded in which the weight has exceeded one hundred and fifty pounds. The smaller tumors displace the uterus at first by pushing it to the opposite side, then by traction on the pedicle they draw it toward the side to which the tumor is attached (see Vol. I, Figs. 73 and 74) ; if the uterus is adherent it may be drawn up into the abdomen as the tumor enlarges (ascensus uteri). The bladder is displaced, at first becoming gibbous and next expanding up- ward into the abdomen ; when small tumors are adherent or when larger ones press on the pelvic floor and on the brim, the iireters are often compressed, pro- ducing a hydroureter of low grade. The rectum is also compressed, and in the large tumors the other intestines are crowded up under the ribs and out at the sides, and digestion is much inter- fered with. The largest tumors also find room for their contents by pushing out the abdominal wall until it hangs pendulous, even covering the knees, and by spread- ing out the margins of the ribs like great wings (a late chest). Patients thus afflicted often have marked edema of the legs, and suffer so from the weight and from dyspnea that they rarely leave their bedroom, and are often compelled to live in a chair so as to be able to breathe (see Fig. 405). Diagnosis. — In making a diagnosis of an ovarian tumor, three questions must be answered when possible : (a) Is there a tumor present ? (b) Does it occupy the place of the ovary ? (c) What kind of an ovarian tumor is it ? (a) Is there a tumor present? It is usually easy by a vaginal ex- amination to feel the tumor lateral to or behind the uterus, or, if it is large, to see it, to palpate it and to outline it by percussion. Patients often mistake tympany for a tumor and appeal to the physician for a decision, usually adding to their complaint the statement that the tumor increases remarkably at times and goes down again. Some cases of tympany do simulate in an extraordinary manner the configuration of an abdo- men containing a cystic ovarian tumor ; but a little palpation — demonstrating the uniformity of the resistance in all parts of the abdomen, and a few percussion taps over the tumor bringing out the note of resonance all over its surface — serves at once to dispel the illusion. 254 OVAEIOTOMY. In the rare case of an ovarian tumor which contains gas and is therefore tympanitic a discrimination between this and intestinal tympany will be made by the fact that the condition of the patient shows that some grave disease exists ; an examination also shows that the abdominal enlargement is tympanitic over its most prominent part, but flat at the sides where the resistant areas can be palpated ; vaginal examination also reveals the presence of the firm cyst wall and its relations to the uterus. The greatest difficulty in detecting the presence of a tumor is met with in fat women, and here the embarrassment is twofold, for in the first place the examiner may think that he finds a tumor when there is nothing pi'esent but a mass of fat, and in the second place a tumor of medium size may readily escape observation. The best rule to observe in such cases is never to decide that there is a tumor present until indisputable evidence of its existence is secured and it is clearly felt by palpation and outlined by percussion, and above all until its connection with the broad ligament, and so, indirectly, with the uterus, is made manifest by a careful pelvic examination, if need be, under anesthesia. It is always a good rule where the slightest doubt exists not to give an opinion based upon a single obser- vation, but to see the patient two or more times. It is equally hazardous when a woman is excessively fat to decide hastily that there is no tumor present, for experience teaches us that obesity in no way hin- ders the growth of an ovarian cyst. In such a case a doubtful ovarian tumor felt by the abdomen may be felt distinctly by the vagina and by the rectum. The clearest evidence that the patient is not suffering from an ovarian tumor is obtained by giving an anesthetic and then examining the uterus and broad liga- ments thoroughly through the emptied rectum, and by palpating and outlining bothovaries. When an ovarian, tumor as large as one or two fists has a long pedicle and slips up into the flank, it may entirely escape observation, unless it is system- atically sought for in this position by palpating both flanks between the hands, one placed in front and one behind. This lodgment of a tumor in a flank is most apt to occur and' most likely to escape observation when there are two tumors present and the larger one lies prominently under the abdominal wall, easy of access and diagnosis. (b)Is the tumor ovarian? The differential diagnosis of an ovarian tumor from all the other tumors which may be found in the abdominal cavity must be made by discovering in the particular case the presence of certain features characteristic of ovarian tumors, as well as by noting the absence of those features which are peculiar to other kinds of tumors. The methods of making the diagnosis will also vary according as the tumor is small and still confined to the pelvis, or larger, from the size of a child's head to that of a pregnant uterus at term, or from the size of the uterus at term up to the largest tumors observed. In order to diif erentiate an ovarian tumor from abdominal tumors of other DIAGNOSIS. 255 kinds, therefore, the following facts must be borne in mind in making the examination : The ovarian tumor is dull to percussion over its convexity, and is surrounded by an area of resonance above and at the sides ; it is dull also below, on the side toward the pelvis ; tliis dull area below points out, as it were, its natural habitat, and may be compared to the trunk of a tree, showing the place from which it has its origin. The ovarian tumor is attached to the broad ligament by a pedicle which can be felt by the rectum. It replaces the normal ovary of the side from which it springs. By finding a normal ovary on one side and none on the other, but in its place a tumor, the diagnosis is made certain. The conclusion is often easily reached that a tumor is pelvic in its origin, but the more exact nature of the pelvic tumor may'not be so easy to determine. The differential diagnosis must here be made between the ovarian and the various uterine and retroperitoneal tumors and an overdistended bladder. I have seen a patient brought a long distance for operation where there was nothing but a distended bladder, relieved at once by passing a catheter. In another case preparations were made for operation upon a parovarian cyst which proved just before the operation to be nothing but a distended bladder. There is some- thing characteristic about the very appearance of an over-full bladder which forms an elongate ovoid in the median line, more prominent just above the symphysis than any ovarian tumor of like size. The invariable custom of pass- ing a catheter just before operation will prevent mortifying mistakes. Retroperitoneal tumors are usually firm and fixed by a broad base, and their nature becomes evident when the rectum is found lying in front of the tumor. Pregnancy and uterine tumors are most liable to be confused with ovarian tumors, but such mistakes can occur but rarely if in every instance the examination is properly conducted through the inferior strait and the entire uterus is outlined by vaginal or rectal examination, and if the rule is persisted iii of giving an anesthetic and making a minute examination in all doubtful cases. Tuberculosis and- en cysted peritonitis may easily be confused with an ovarian tumor, but in both these conditions the enlargement usually exhibits some indefiniteness of. outline and peculiar irregular areas of tympany and dullness, the mobility is slight, and the areas of dullness are apt to change from week to week. Tubercles may sometimes be distinctly felt through the thin wall of the rectum. A large cystic kidney may extend from the diaphragm to the pelvic floor, closely resembling an ovarian tumor, but the fact must ever be borne in mind that the kidney has a tympanitic area in front of it, due to the displaced colon. , . ; i A small ovarian tumor must be differentiated from small uterine tumors, tubal tumors,', and,. fecal 'masses. The ovarian tumor possesses these characteristics : it lies to one side of or behind the uterus, it is usually evidently 256 OVARIOTOMY. cystic from the more or less distinct sense of fluctuation, and is always movable as distinct from the uterus, with which its connection may often be traced by the utero-ovarian ligament on one side. By recognizing these peculiarities in any given case the possibility of the tumor being uterine is excluded. The greatest difliculty is met with when the small ovarian tumor is adherent to the uterus ; the tumor is then usually lateral to the uterus, it is fluctuant, and, in addition, the firm uterine body can be outhned independent of the tumor; a careful palpation also shows a slight independent mobility. A tubal tumor is thin- walled, elongate, sausage-shaped, and often con- voluted, and in addition the normal ovary may be felt close by. Fecal masses, although liable to confuse at the first examination, will not do so when the bowels have been thoroughly evacuated and a high rectal examination is made. Ovarian tumors of medium size, from that of a child's head to a uterus at term, may best be differentiated, first, by outlining the other abdomi- nal and pelvic organs by palpation and percussion, and so excluding their par- ticipation, and then by grasping the cervix with a tenaculum forceps and pulling it down, by which means perceptible traction is made upon the tumor ; or by g;rasping the cervix and pulling it down and then pulling the tumor up in the abdomen, when the hand holding the forceps is seen to respond to the traction. If a rectal examination is made at this time the tense pedicle may be felt, showing on which side the tumor arises. Ovarian tumors filling the abdomen need to be distinguished from all other large abdominal tumors, and here the diflSculties are greater, because the surrounding area of tympany is not always easily outlined, and the tumor has no free space left in which it can be moved about ; it is impossible also either to demonstrate the existence of a pedicle or its position. The following points will usually be decisive in such cases : There is a vast dull area over the tumor and at the sides and extending •down into the pelvis, but by taking particular pains, tympany may be found far back in the flanks and up under the ribs. The vaginal examination further shows that the uterus is displaced and the pelvis is choked by the tumor. The surface of the tumor may present characteristic bosses, with evident fluctuation at points ; the uterus is intact and displaced, crowded down onto the pelvic floor, or elevated out of the pelvis in front of the tumor, where it may often be felt above the symphysis. Ascites is sometimes taken for an ovarian tumor, and a mistake is often made when, with the ascites, cystic tumors exist in the pelvis. If the woman has borne children or has relaxed abdominal walls, a form of abdo- men may be developed which is almost peculiar to ascites ; as the patient lies on her back the walls belly out at the sides and the top is flattened, like a bladder half full of water ; this appearance is rarely simulated by a flaccid parovarian cyst. The area of dullness and tympany in ascites is one of its most important characteristics ; the intestines float in the fluid and yield a tympanitic note over DIAGNOSIS. 257 the highest point, while the fluid gravitates downward, giving a dull note in whatever position the patient is placed. This valuable sign is wanting under two conditions : When there is a small amount of ascitic fluid and the colon is distended with gas, we may find tympany in the flanks ; and, on the other hand, when the abdomen contains so much fluid that the anterior abdominal wall is pushed out so that the intestines held back by the mesentery can not reach it, the tympanitic note is wanting above. In the first case a mistake will be avoided if careful attention is given to the peculiar sense of free fluid conveyed upon palpation, and if the changes in the areas of dullness upon change of position of the patient are also noted. When a large ascitic accumulation is present a mis- take may still be made, even after careful study of the case, especially when the patient is so ill that a thorough examination is impossible. I made such an erroneous diagnosis in the case of a colored woman, who was so feeble that she could not lie down, and a vaginal examination had to be omitted. On tapping, what appeared to be a straw-colored ascitic fluid escaped and the abdomen collapsed; no trace of a tumor could be felt (see Fig. 405). She died later of exhaustion, and a multilocular ovarian cyst was found with one enormous sac in front of it. When the ascites is due to a pelvic tumor this will be felt jper vaginam, while the ascites gives the usual signs at the abdominal examination. In order to get rid of the unsatisfactory regional terms in common use in our descriptions, I have for the past six years in my teaching designated ab- dominal tumors as follows : Those descending into the cavity from beneath the ribs I call anatropic; those ascending from the pelvis, orthotropic; and those pushing out into the abdomen from the flanks as amphitropic, borrowing the terms from the botanic description of the ovule ; those which are in the middle of the abdomen, surrounded by an area of resonance on all sides, may be designated mesotropic. Eight or left orthotropic, amphitropic, or anatropic serve further to desig- nate tumors in the right or left iliac fossae, the right or left loin, or coming from under the right or left ribs. (c)What kind of an ovarian tumor is present may some- times be a diflicult question to answer. In general, the cystic tumors can be easily separated from the solid ones by the marked difference in the resistance, the smaller size of the solid growths, and their frequent association with ascites. Among the cystic tumors we have to distinguish the adeno-cystomata (the common multilocular ovarian cysts), cystic papillomata, dermoid cysts, paro- varian cysts, cysto-carcinomata, and cysto-sarcomata. A multilocular cyst may sometimes be distinguished by the eye alone, espe- cially when it consists of a number of cysts with well-defined depressions be- tween them, and when the abdominal walls are thin enough to reveal the con- tour of the growth. The chief difiiculty in differentiating a polycyst is its tendency to form one large cyst which, owing to its spherical form, rotates and adapts itself to the 58 258 OVARIOTOMY. concavity of the anterior abdominal walls, and so, to palpation, closely resembles a nniloeular parovarian cyst. The distinction may often be made by observing that the wall of a poly cyst appears thick on palpation and its contents seem to be of more than watery consistence; if a careful search is made in the flanks, irregular bosses may be felt there or high up under the ribs; sometimes a large cyst fills the abdomen, and a careful palpation by the pelvis reveals the presence of a conglomeration of cysts budding off in this direction from the main cyst above. Where the furrows between the separate cysts can not be distinctly made out, a marked difference in the tension between two or more cysts may be discovered by palpation of the tumor in all pos- sible directions. The fact that a large abdominal tumor fills the pelvis also and possesses an irregular form does not prove that it is polycystic, for these characteristics may be observed in parovarian cysts. Papillomata can not be diagnosticated when the outgrowths are confined to the interior of cystic tumors. Small superficial papillomata may, however, some- times be recognized as excrescences plainly felt by the vagina or rectum, and the association of ascites with a small tumor which is often fixed in the pelvis, ta the absence of any grave constitutional disturbances, should arouse the suspicion of papillomata. When the disease is more extensive, the pelvis choked, and im- plantation masses with much ascites are found on the abdominal walls and in the omentum, the diagnosis may be made without difiiculty, particularly after tap- ping, when the contents are much more plainly palpable. In making a differential diagnosis between dermoids and other tumors these facts must be borne in mind. Kiister has shown that the dermoid cyst tends to float up in front of the uterus ; it is also a tumor of slow growth, oftenest found in children and young women, and is frequently painful. The dermoid is usually monocystic, single, not often larger than a man's head, and the fluid fat, on palpation, feels like water or of the consistency of mush. Parovarian cysts convey the impression, both by the touch and by the uni- formity of the abdominal enlargement, that they are unilocular and thin -walled, and although they may have well-defined pedicles, usually they fill out the meso- salpinx at least, and so have a broad base of origin. Cysto-carcinomata and cysto-sarcomata convey the impression of unilocular cysts often with thick resilient walls ; in their earliest stages they present no characteristic features, but later there is ascites, emaciation, and cachexia, and, it may be, metastases. Among the hard tumors we have to distinguish the solid carcinomata, the fibromata, and some sarcomata. The fibroid is usually a dense tumor accompanied by ascites and unaccompanied by any serious constitutional depression, in marked contrast to the loss of appe- tite and strength, the emaciation, cachexia, and edema of the malignant growths. The carcinoma often involves both ovaries, is hard and nodular, and is found in much younger patients than the fibroma ; metastases are, of course, pathog- nomonic. iffwr f J|rf«/i/ J'ir#" ^ "*»>* ^j^^ ^^\ Fig. 406. — Typk \.l PoL"sr\sTic {>\arian Tumok, "ftiTii Long Twisted Pedicle. The larger portion of the ovary {Oo) is intact, and the tumor occupies its outer extremity. The abdominal end of the uterine tube lies below the ovary. Jan. 23, 18'J7. y^ natural size. MULTILOCULAE OVARIAN CYST-ADENOJIA. 259 Multilocular Ovarian Cyst-adenoma. — The multilocular ovarian cyst-adenoma is the classical tumor of the gynecologist, recognized and operated upon for many years before any clear distinctions as to the microscopical or clinical characters of other ovarian tumors obtained recognition (see Fig. 406). Pathology . — The ovarian cyst-adenoma owes its origin to a multiplica- tion of the glandular elements of the ovary ; these glands become distended with secretion, the fluid accumulating with varying degrees of rapidity to form cysts of all sizes. The cysts are usually unilateral, occurring somewhat more often on the right side than on the left, but they may occur in both ovaries at the same time ; six per cent of my cases have been double. They vary greatly in size, some being not larger than an orange, while others appear as huge masses weighing upward of one hundred pounds ; such large tumors, however, are rarely met with any longer, because the patient pre- sents herself for treatment before the cyst can reach such a size and cause much discomfort. The entire tumor usually lies free in the abdominal cavity and appears as a round or oval mass, with a smooth and glistening surface, irregular in outline, presenting many large or small bosses. These bosses represent the individual cysts, whose walls are pearly white or slightly bluish or pinkish in color ; be- neath the peritoneum numerous branching blood vessels can be seen radiating out from the main trunks at the pedicle. On section, the appearance usually seen is that of one or more large cysts surrounded by numerous small ones, many of the smaller ones being situated in the walls of the larger ones, for as the cysts enlarge their walls come in contact, and when by the increasing pres- sure the partitions between them are so thinned as to mpture, the adjoining cysts unite (see Fig. 407). In a recent rupture the remainder of the septum is seen as a perforated diaphragm, later it forms a falciform edge on the cyst wall, and still later appears simply as a ridge or band. More rarely the greater portion of the tumor is formed of masses of small cysts, which, on section, give a honey- combed appearance to the cut surface. The cyst walls vary from 4 to 5 millimeters in thickness. They are com- posed of a dense tissue, which here and there may contain areas of calcification and occasionally a dilated Graafian folHcle, or a corpus luteum can be demon- strated in a thickened portion of the wall, or irregular, brown, slightly raised patches may be seen which represent the site of old hemorrhages. The cysts are separated from one another by delicate partitions, and have smooth, glistening inner surfaces which are of a bluish or pinkish hue. Fre- quently in the largest cysts trabeculse will be seen extending from one side of the cyst wall to the other ; these are the remains of old cyst walls. On histo- logical examination, the surface of the tumor may show no epithelial covering, or may be covered by one layer of flat cells. The cyst walls are composed of con- nective tissue which is arranged in layers parallel to the outer surface, and near the inner surface the tissue is rich in cell elements. The blood supply varies greatly, being sometimes abundant and at other times scanty. There is fre- quently hemorrhage into the cyst wall, the brown patches seen on the inner sur- 260 OVARIOTOMY. face being the sites of old hemorrhages which have been invaded by connective- tissue cells from the cyst wall, and over which the epithelium is wanting. The cyst walls are also often edematous and may be necrotic in places. Occasionally such ovarian elements as Graafian follicles, corpora lutea, and corpora fibrosa are found scattered throughout the walls. In the vicinity of the pedicle non-striped muscle fibers may sometimes be demonstrated. The partitions between the smaller cysts are also composed of connective tis- sue richer in cell elements than that which forms the outer cyst wall, and in this tissue numerous convoluted glands are seen which are the rudimentary cysts. The inner surfaces of both the small and large cysts are lined by a single layer of cylindrical epithelium which is often ciliated. The nuclei of these cells are oval or almost fiat, and are usually situated immediately on the base- ment membrane. Some of the cells are swollen and filled with clear contents, resembling goblet cells, and nuclear figures are also occasionally seen. In some of the larger cysts, but more especially in the smaller ones, the walls present a scalloped or convoluted appearance resembling acinous glands. Calcified areas are common, appearing either as small scales in the fibrous tissue of the walls, or as little granules, which are usually calcified epithelial cells. An ovarian cyst is not infrequently associated with a dermoid cyst of the opposite side or a parovarian cyst (see Fig. 408). Contained Fluid . — The fluid in the larger cysts is thinner than that in the smaller ones. It may be grayish yellow, gray, reddish brown, or dark brown in color, the coloring depending to a great extent on the hemorrhages which have taken place in the cyst cavity ; the blood is usually distributed equally through the cyst fluid, and clots are rarely found. The specific gravity of the fiuid varies from 1010 to 1030. It contains much albumin, and the microscopical examination reveals desquamated fatty epithe- lium, and also large cells which are filled with yellowish pigment and which probably have the same origin. Some of the smaller cysts contain a yellowish- white, semi-transparent viscid fluid ; others a yellowish transparent, jellyhke material, which is but slightly tenacious. The fluid from the smaller cysts, as in the larger ones, contains desquamated epithelium, fat droplets, and detritus. Occasionally a few needle-shaped crystals are seen scattered through the fluid. The fluid which is present in these cysts has three sources of origin : the secretion from the epithelial cells, the transudation of serum from the blood vessels, and the destruction of cells. Pseudo mucin . — Pseudomucin is one of the most important of the con- stituents of the glandular ovarian cystomata, and is almost characteristic. In the days when ovariotomy was exceedingly dangerous great importance was attached to the microscopic and the chemical examination of portions of the cyst fluid removed for diagnostic purposes, and the discovery in this way of the " ovarian cell," the " compound granular cell," and of paralbumin and metal- bumin (Scherer), were looked upon as decisive in determining the presence of an ovarian cyst. Pig. 407. — Mxjltilocular Ovarian Cyst, in which the Smaller Cysts project into the Cavity of the Large One, which in this Way presents Externally the Appearance of a MoNOCYriTic Tumor. The utero-ovarian ligament aud tlie uterine tube are seen cut across below. No. 880. % natural size. MULTILOCULAE OVARIAN" CYST-ADEJiOilA. 261 The " ovarian cell " has long since disappeared, but paralbumin and metalbu- min have kept their place with an identity which has been altered by O. Hammar- stein {Ein Beitr. z. Chemie d. Kijstom Flilssigkeiten. Zeits. f. Pliys. Chem., 1882), who has shown that they do not belong to the alljumin group, as at first supposed. While parallnimin is not a chemically pure body, metalbumin, on the other hand, is closely allied to mucin, and to avoid confusion he has given it the name " p s e u d o m u c i n ." Chemical examination of metalbumin — that is to say, pseudomucin — showed that its chief characteristic was a liability upon boiling with acids to separate a Ji. 3sc.. "^^ ^^16 next group, with ciliated epithelium, and to the papillary careinomata. In seven cases im- plantations on the peritoneum were found but once, in spite of the presence of papillary excrescences on the surface of the tumor in a number of instances. In the case in which the implantations were found they appeared as little glassy nodules which were not papillary, but resemljled those sometimes found with the ordinary ovarian cystoniata. Simple Papillary Adenoma. — These tumors are often called cil- iated papillary tumors, but, as ]3ointed out by Williams, the pres- ence or absence of cilia does not appear to be important, and the same tumors are often ciliated in some places and not in others. Over one third of the papillary tumors examined by Pfannenstiel lielonged to this group, and in about half of them the tumors were bilateral ; in three Fig. 414. — Solip or Fibroid I'apillary THE (j^'ARV. Adenoma On section the tumor consists of fibrous stroma euolos- iu£r alveolar spaces from 0-3 to 1 centimeter in diameter, ■which are completely filled with branching- papillary masses. Color, pinkish gray. Numerous adhesions. Spec. 12Go. Natural size. PAPILLARY ADENO-CAECI2SrOMA. 273 instances the tumor of one ovary was superficial while the other side presented a papillary cyst-adenoma. The superficial form attains the average maximum size of a man's fist, and the cystoma, mostly multilocular, grows larger, rarely reaching, however, the size of the pregnant uterus at term. The contents of the tumors are usually a cloudy, thin serous fluid, never pseudomucinous. Necrosis and the exfoliation of the epithelial cells may pro- duce a yellowish mixture. The epithelium, ciliated or not, is like that of the normal uterine mucosa. About half of these tumors have well-defined pedicles, while the other half grow down between the folds of the broad ligament, and, as a rule, do not pro- ject free into the j^eritoneal cavity. There can be no relapse after complete extirpation, and implanted colonies grow slowly. Papillary Adeno-carcinoma. — In this group are classed all those tumors which microscopically show a departure from the type in the size, form, and arrange- ment of the epithelial cells, whether upon the papilte, or on the inner surfaces of the cyst walls, or in the walls of the tumor itself. Pfannenstiel found that almost half of his cases were papillary adeno- carcinomata, while in twenty-seven of my own cases I found but two of this kind, a difference which it is difficult to explain. These tumors are almost exclusively cystic. In one case there was a cysto- carcinoma of one side and a superficial papilloma of the other. In half the cases the proliferations were found both in the cysts and on the surface, without any evidence of perforation or rupture ; hard carcinomatous nodules are often evident in the cyst wall. In half the cases the tumors were monocystic and more or less spherical, and in the other half they were polycystic. The picture under the microscope is usually that of an adeno-carcinoma; medullary carcinoma is sometimes seen. True metastases were observed in six out of twenty cases, in the retroperito- neal and inguinal glands, in the tube, the uterine wall, the stomach, the liver, and the periosteum of the ribs. In one case there were double ovarian papillary cysto-carcinomata, with car- cinoma of the cervix, in a uterus containing numerous myomata. Peritoneal implantations were found in 30 per cent of the cases — more than twice as often as in the pseudomucinous tumors, and in still further remarkable contrast to the latter group these implantations from the adeno-carcinomata partake of the nature of the mother tumor, and are markedly malignant, dis- tributing themselves widely, and rapidly penetrating into the subjacent tissues. True cachexia is often seen. Implantations occur only when the papillomata are found in the outer surface of the tumor, or when, as in one case, some of the contents of the tumor escaped into the abdomen during the oi^eration. In this case the patient died a few months later of the peritoneal infection. 274 OTAEIOTOMY. About 82 per cent of the patients died of relapse on an average of eight and a half months after the operation, in sharp contrast to the simple adeno- mata where papiliomata were left in the peritoneum, and where the average length of life was three and a half years. Papillary Cyst-adeao-sarcoma. — Only two cases of this kind are recorded, one by Pfannenstiel (p. 551) and one of my own. The iirst case was that of a single woman of forty-seven, from wliom was removed an extensive subperitoneal tumor, the size of a man's head. She died four months later, but it could not be ascertained whether she bad a relapse. The tumor removed was a unilocular cyst, with a wall in one place 2 centimeters thick, at which point the surface was covered with numerous sepa- rate papillary excrescences. On section the tissue appeared homogeneous with some irregular cavities with a smooth wall. The tumor was made up of a vascular connective tissue interpenetrated with round and spindle cells. The papiliomata were purely adenomatous in form, delicately constructed and covered with a simple cylindrical epithelium in a single layer, which also sent numerous glandular extensions into the underlying tissue. There was no trace- able connection between the papiliomata and the sarcoma. Fi». 415.— Adeno-carcinoma (Colloid Carcinoma) of the Ovary, with Numekods Carcinomatous KouuLES on the External Surface of the Unruptured Cysts ; Secondary Growths in the (,)mentum. No. 328. % Natural Size. In a rare case occurring in my own clinic a multilocular adeno-papilloma was found associated with sarcomatous nodules in the inner surface of one of the cysts. (See Dr. T. S. Cullen, Ainer. Jour, of Ohs., vol. xxxiv, 1S96.) PLATE XVI. Fig,: siS^?''^*?;* if®*»ind Gi/n., xv, p. 354) shows the remarkable possibility of a metastasis di- rect from a carcinomatous uterus to the ovary in •cases in which the protracted uterine hemorrhages gave satisfactory evidence of the existence of the uterine carcinoma prior to that of the ovary. He further urges that such a combination is more frequent than is generally believed, and tiiat it should always be borne iu mind and looked for in all cases of ovarian carcinoma. Note the tendem^v the lymphatic vessels, ml size. to a circular arrangement alon? Autopsy Jan. 9, 1897. % natu- FlG. 419. — AllENO-CAllClNOMA OF THE (Xm1':NTI:M, seen IN SECTION. No. 328. Natukal Size. See Fig. 418. Fig. 418. — Large Adeno-carcinoma (Colloid Carcinoma) of the Omentum, Secondary to Carcinoma of the Ovary; i Free Border of the Omentum is ]3elow. Optration removing omental mass. Kecovery. Death some months later. No. 328. }4. natural size. i: lu. 420. — KuriMKNTART Jaw from a Dermoid Cyst containing Molar Teeth^ and with a wisp of Brown Hair growing from one ExTRE:MiTr. On the right is another small piece of dentigerous bone loaded with molar teeth. Case of Dr. Weist. Natural size. DERMOID CYSTS OF THE OVARY. 277 On the other hand, in carcinoma of the body of the uterus the ovaries should be removed too, on account of the possibihty of an early metastasis, not yet recognizable to the naked eye. Dermoid Cysts of the Ovary. — A dermoid ovarian cyst is an ovarian tumor containing some or all of the elements of skin tissue, bones, nerves, and mucous membrane ; it is usually unilocular, and exhibits more or less perfectly the epi- thelial layers of the skin, with sebaceous and sweat glands and hair. Teeth are often found imbedded in the cyst wall, sometimes attached to bone structure, with a well-defined alveolar process closely resembling a part of the lower jaw. Cartilage, nerves, and brain tissue have been found in these cysts, and in one instance nail tissue. A mamma with well-developed nipple has been observed. The outer covering of the tumor is like that of an ordinary ovarian cyst, and in its general relationships the dermoid cyst is in all respects similar to a uni- locular ovarian tumor. The walls of the cyst are lined by many layers of squamous epithelium, and vary from a thin membrane, almost transparent, to one that is thick and leathery, and the contents are oily, thick, and greasy, sometimes cheesy, due to the FlO. 421.— CONTODE OF THE ABDOMEN IN THE CaSE OF AN DnUSUALLY LaKGE DeEMOID CysT. No. 2766, secretions of the sebaceous glands and fatty degeneration of the epithelial cells. The color of the hair may be either light or dark, and bears no relation to that of the surface of the body. It may be found in large quantities, rolled up loosely in a ball, immersed in fat. Hairs of various lengths are also found growing from the cyst wall, usually not exceeding two feet. In a case reported by Dr. P. F. Munde, of ISTew York, the hair was five feet long. After removing a dermoid cyst, if the tumor stands in a cool place it be- 278 OVARIOTOMY. comes hard and deep yellow in color ; if the contents of a large cyst are allowed to stand, the surface shortly becomes covered with fine feathery flakes of choles- terin crystals. Dermoid tumors of the ovary are usually limited to one side. In twenty-one cases I had one in which both right and left ovaries were involved, and one in which there were two cysts on the same side. In operating for a dermoid cyst, if the opposite ovary is at all enlarged it must be incised to determine whether a small dermoid may not be concealed within it. The size of the tumor varies from a little nodule not larger than a distended Graafian follicle to a mass filling the abdomen. One of my cases was but 2 centimeters in diameter, while another contained 10 liters (20 pints) of fluid; they are, however, not often seen much larger than a man's head. The cause of dermoid tumors has not been satisfactorily explained ; the most plausible theory is that of Cohnheim, who attributes their origin to an inclusion of parts of the outer skin layer (ectoderm) in the ovary during its formation in early fetal life. These misplaced skin elements then naturally begin to grow during the period of greatest ovarian activity, and develop the various skin tissues after an atypical fashion. In the examination of the clinical his- tory of nineteen of my cases, I find that fourteen women were married and five sin- gle. Of the fourteen married women, six were childless, but three of these had had miscarriages. The ages of the patients varied from twenty-one to sixty years, the average being thirty-five years. The growth of the tumor in most cases was slow ; one woman had noticed hers for ten years before opera- tion, and others for six or seven years, while another had only known of its presence for three months. Observations as to the slow development can of course only be applied to cases in which the tumor had already at- tained a size sufficient to produce distention and be felt through the lower abdominal wall. "Where the tumor lying in the pelvis was small the patients were unconscious of the existence of any tumor. Out of seventeen cases the tumors were found eight times on the left side and eight times on the right, and once occupying both left and right sides. The pedicle varies as in ovarian multilocular tumors. Eight cases were distinctly pediculated, seven had no pedicle at all, and one had a long twisted pedicle turned one and a half times upon itself. There can be no doubt that dermoid cysts are peculiarly prone to induce attacks of localized peritonitis. This tendency is difficult to explain, Fig. 422.^-Left Dermoid Cyst of the Ovary with a Long Pedicle. The cyst (D) lay in the median line and could easily be pulled high up in the abdomen or displaced into eiflier flank in the position of the dotted lines. No. 2554. DERMOID CYSTS OF THE OVARY. 2Y9 and seems inherent even in the smallest cysts, which are often found matted in a dense mass of adhesions ; on the contrary, however, I have seen a cyst as large as a man's head entirely free from adhesions. I found eight out of nineteen cases not at all adherent, while the other eleven were more or less fixed by adhesions varying from the slight velamentous attachment to the densest fibrous union. Owing to this liability to provoke attacks of peritonitis involving the im- mediately surrounding structures, infiammatory disease involving the other ovary and tube is frequently found. This generally consists in adhesions binding down the tube and ovary, often associated with hydrosalpinx (see Fig. 423). h-/-^^ --!. J^' ■";■■ \ '■^'y^^'-'^i'^'i \ . f^ff s 'y \ -^ Fig. 423. — Complicated Dermoid Cyst of the Kight Ovary, with Dense Adhesions to the Entire Breadth of the Omentum and Displacement of the Right Tube and Round Ligament. The uterus is dragged up (asoensus uteri), and on the left side there is a large hydrosalpinx. No. 8120. Like the ovarian cystoma, the dermoid cyst may become almost completely detached from its natural vascular supply and depend for its existence upon the adhesions formed between it and other organs (see Fig. 424). I have not been able to note anything characteristic in the menstrual history beyond the fact that sixteen of the nineteen cases complained of pain, generally severe. In three non-adherent cases there was no pain at all, but a distressing bearing-down sensation in the lower abdomen. About half of all the cases complained of vesical distress varying from a frequent micturition to a severe tenesmus. A marked emaciation is often apparent. One woman lost 40 pounds in six months, and during this time the abdomen reached a circumference of 92 centimeters (36'8 inches). The prognosis if the tumor is left to grow is bad ; in the absence of complications the growth advances until the abdomen is so distended that th& 280 OVARIOTOMY. functions of the abdominal, and later of the thoracic, organs are impaired by pressure. Far more than in the case of ordinary ovarian cysts are these patients liable to attacks of peritonitis resulting in adhesions to all contiguous structures. Sup- puration of the cyst is also not uncommon, followed by perforation into bladder (see Vol. I, p. 355, Fig. 225) or bowel. On account of the adenoid elements which they contain, the liability to cancerous degeneration is also great. Hydro- nephrosis and pyelitis may be caused by the pressure of the cyst on one or both ureters. For one or more of these cogent reasons the patient who at first de- fers an operation will sooner or later be forced to seek surgical relief. The diagnosis is usually difficult to make. The chief difficulty is in distinguishing a tumor of this sort from an ordinary ovarian tumor. The difference in consistence is of no aid, as the contents of a der- moid cyst are so frequently liquid that they appear on palpation to have about the same consistence as water. The following points may be borne in mind in making the diagnosis : The dermoid tumor is more or less spheri- cal, usually unilateral, giving the im- pression of being a monocyst ; if large, its growth has been slow. If the pa- tient is young, the chances are in favor of a dermoid. Where attended with inflammatory sequelse the dermoid is apt to be extremely painful on pres- sure. The tendency to emaciation must also have its weight in making the di- agnosis. Kiistner's rule that the der- moid tumor has a remarkable tendency to float out in front of the uterus and lie just behind the abdominal wall was found in five out of twelve of my cases, and is therefore a valuable diagnostic point. In one case the diagnosis was unexpectedly made by a vaginal puncture under the impression that the fluctuating sac choking the pelvis and bulging into the vagina was a pelvic abscess. The discharge of fatty matter at once revealed the true nature of the case. In small monocystic tumors not rising out of the pelvis the dermoid tumor must always enter into the list for a differential diagnosis. When the tumor is adherent and there is a history of pelvic pains lasting some years, and the walls Pio. 424.- -KiGHT Dermoid Cyst [D) "with Exten- sive Adhesions. Note the displacement and atrophy of the riiicht tube, and the adhesion to and anffiilation of the left tube. Feb. 2, 1893. No. 584. % natural size. 60 Fig. 425. — Parovarian Cyst situated between the Ampulla of the Tube and the Outer End of the Ovary, The rest of the mesohalpinx is intact. The ovary shows a recently ruptured corpus nigrum. Oct. 16, 1895. Natural size. Fig. 426. — Parovarian Cyst, showing its Translucency and the Characteristic Relations of the XJterinb Tube, which is Greatly Lengthened and Spread Out on the Surface of the Cyst. There is no mesosalpinx, and the fimbriated end is pulled out lonf^er than the tube itself, and describes an arc sweeping around toward the uterine end of the tube. Note the double set of vessels, superficial and deep. The pedicle is at the area uncovered by peritoneum on the right upper surface. The slightly irregular surface seen on the outline juBt to the right of the pedicle is the ovary spread out on the surface of the tumor. July 31, 1895. i^ natural size. PAROVARIAN" CYSTS. 281 of the tumor are evidently thicker than those of a thin Graafian follicle cyst, a probable diagnosis may be made. Parovarian Cysts. — A parovarian cyst is one originating in the tubular remains of the embryonic "Wolffian body, in the layers of the mesosalpinx (see Vol. I, p. 61, Fig. 32), between the uterine tube and ovary; as the cyst continues to grow it either enlarges as a free tumor up into the abdominal cavity, or first down between the layers of the broad ligament and then wp into the abdomen, or it may lie altogether behind the peritoneum. The tubules of the parovarium are one millimeter in diameter or less, and are readily seen by holding the mesosalpinx up to the light while separating the tube from the ovary. Histologically, the tubules are surrounded by several layers of spindle cells, which appear to be non-striped muscular fibers, and they are lined by a single layer of cuboidal or low cylindrical epithelium which is often ciliated. Parovarian cysts vary in size from a few millimeters to 20 or more centi- meters in diameter. If small they may be multiple, but when large they are almost invariably single. These cysts are usually transparent, and are smooth and glistening. As the peritoneum is but loose- ly connected with the cyst wall by a delicate stroma, it can be readi- ly slid over the surface of the tumor. This is due to the fact that the tubules are situated be- tween the layers of the broad ligament and are Fig. 427. — Parovarian Cyst, with Subsidiary Cysts lying beneath , -J -J J U "TH^ TUEO-OVAEIAN FlMBRIA, WEIGHING DOWN THE FIMBRIATED EnD but JOOSely COVereCi oy of the Tube and separating it from the Ovary, which is seen -r^Qi-U^-nQniTv. TT.o Vvl^rirl 01* THE ElGHT, UNDER THE IsTHMDS OF THE TuBE. JuLY 3, 1895. peritoneum. j_uc oioou natural Size. vessels of the peritone- um have a different direction from those of the tumor, so that the two well- defined vascular networks are seen crossing each other. The cyst walls are usually thin, and may contain calcareous plates ; the inner surface is whitish or pinkish in color, smooth, and glistening ; rarely papillary masses spring from the inner wall. The cyst fluid, poor in albumin, is pale and limpid like water, and its specific gravity varies from 1001 to 1006. In those cases, however, where there are papillary masses, or in which hemorrhage has taken place into the cyst, the specific gravity is higher and the color brown, blackish, or yellow. Orth says that he has almost invariably been able to find cilia at some point or other, whether the cyst is large or small. The tumors as they grow tend to separate the layers of the broad ligament more and more and to extend down to the pelvic floor, out toward the rectum or cecum, and up into the abdomen behind the peritoneum. The relations of the tube and the ovary to the cyst are charac- teristic. The tube is arched over the upper surface of the tumor, and may reach 282 OVARIOTOMY. 4(_t or more centimeters in length. Its fimbriated extremity often adheres to the cyst, but becomes lengthened out and spread apart. The ovary is found as a small flattened prominence on the under or anterior surface of the cyst. It may, however, be included in the cyst walls. The tube and ovary, apart from the flattening, are histo- logically normal. Out of one hundred and fifty cases of cystic tumors of the ovary of all kinds in my own clinic, thirty (20 per cent), including all broad ligament cysts, were parovarian. The aver- age age was thirty-nine years, the oldest women being seventy-five and seventy - three, and the youngest eighteen. The majority were about thirty - five. The aver- age number of children to the married women was 3-5. The commonest place for the occurrence of parovarian cysts is un- der the outer extremity of the tube, separating the fimbriated end from the ovary as the tumor increases in size, and thus acting as an efficient cause of sterility. In one case (P. T., I^o. 604, March 14, 1891) there were two cysts, 2t2- centi- meters in diameter, in front of the tubo-ovarian fimbria, and a third, 3 centi- meters in diameter, at the uterine end of the tube. These small cysts are almost always sessile and situated plainly between the folds of the broad ligament. In one case, however (L. W., 1171, Jan. 27, 1892), the tumor, about 3 centimeters in diameter, had a pedicle 1"5 centimeters long under the fimbriated end. The utero-ovarian ligament and the uterine end of the tube are never widely separated, although the tulje itself may be lengthened out, in one case 43 cen- timeters (17'2 inches). It always describes a curved course circling around toward the ovary, which can be found on the surface of the tumor close to the pedicle by means of this ligament. The fact that the parovarian cyst is most likely to spring from the outer part of the parovarium can be shown, even in a large tumor, by lifting up the uterine end of the tube, and exposing this part of Fig. 428. — Parovarian Cyst bulging Out on Both Sides of the Tube and attached to the Isthmus by Bands of Adhesions. The tubo-ovarian fimbria is splinted over the surface of the eyst, and on its upper surface stands out an accessory tube witli two pedicles. The hydatid is well shown, and the ovary lies intact beneath the tumor. March" 16, 1895. Natural size. HYDATID OF MOKGAGNI. 283 the mesosalpinx, when a part of the parovarinm can be seen in it. The simple pediculated parovarian cyst develops from its point of origin up into the ai)do- men without spreading apai-t the layers of the broad ligament. The tumor is slow in attaining a large size, and is usually more flaccid than the ovarian monocysts. The pedicle may be several centimeters long and occupy the breadth of the broad ligament. The ovary is found in the under surface near the uterine end of the tube. Sometimes there is no pedicle, but the tube and the mesosalj^inx lie flat on the surface of the cyst, and the ovary near by. The cyst takes often a somewhat cylindrical form, giving the abdomen the appearance of ascites. A long pedicle may un- dergo torsion, as in the case of other ovarian tumors. A remarkable instance of tor- sion of the pedicle, involv- ing the tube and producing a hemorrhagic infarct of both tube and cyst, is shown in Fig. 431. The most prominent symj)toms in my cases ne- cessitating operation were the size of the tumor, and pain in all but three cases, described as dull and bear- ing down, or paroxysmal and sharp. Adhesions were found in all but four cases. The diagnosis may often be made by recalling the fact that the tumor is one of slow growth, has a smooth surface presenting no bosses or evidence of secondary cysts, is apt to be flaccid in contrast to the tense ovarian cyst, and when large is symmetrically disposed in the abdomen, which is more flattened or cylindroid than in the case of a tense globular ova- rian cyst. The percussion wave is less sharp than in a tensely filled sac, and conveys the impression of a single sac with thin walls. On opening the abdomen the clear monocystic accumulation of serum due to an encysted peritonitis must not be mistaken for parovarian or other cysts. These tumors are oftenest found in cases of extensive pelvic peritonitis. An unusually large bleb of this sort is figured in the text (see Fig. 432). Hydatid of Morgagni (Appendix Vesicularis, Kossmann). — I have seen a variety of interesting affections of the little pediculated vesicular or- gan which hangs from the anterior surface of the broad ligament at the end of the longitudinal canal of the parovarium, and is sometimes known as the hydatid of Morgagni (see Fig. 428). In no case, however, have I observed any Fig. 429. — Cyst of the Parovarium separating the Ampullar End of the Tube from the Ovary. April 6, 1895. Natu- ral Size. 28J: OVARIOTOMY. condition which could interfere with health. The little organ in question, sometimes ovoid, sometimes spherical, is about 8 millimeters in diameter ; at other times it looks like two vesicles fused together with a slight constriction between them, in which lie the vessels and some of the tissue of the pedicle. The length of the pedicle varies from nothing at all, when the vesicle is ses- sile on the broad ligament, to 10 or 12 centimeters ; the average length is about 3 centimeters, when the pedicle is about 2 millimeters in thickness and expanded at the base. Tlie long pedicles are often almost threadlike. The Fig. 430. — Paeovaman Cyst. Showing the mesosalpinx spread out on both sides of the tumor, wliioh Is developed more in its outer part, widely separating the tubal ostium from the ovary. T)ie hydatid is seen above. The pedicle lies above the isthmial end of the tube. Path. No. 240. '/s natural size. little vessels can always be seen ascending the pedicle md clistributed over the pellucid surface of the diminutive cyst. When the pedicle is long enough it will often be found hanging over the tubo-ovarian fimbria, between the tubal orifice and the ovary, into the posterior part of the pelvis ; this tendency ex- plains the following affection, which I have seen twice : The fimbriated end of the tube had adhered to the tubo-ovarian fimbria, except at a point close up under the tubal orifice, where the pedicle of the hydatid passed under it ; by pulling on this pedicle it could be drawn to and fro for a distance of about a centimeter, exhibiting a movement resembling that of the trochlear muscle of the eye, but, owing to a loose investment of adhesions, it could not be moved beyond this distance ; the vesicle hung free on the other side. FIBROID TUMORS OF THE OVARY. 285 1 have several times found the pedicle tied in a single knot about its middle "without interfering with the circulation. In one iateresting case, an ovarian cyst, figured in the text (Figs. 433 and 434), what was undoubted- ly the pedicle of the hyda- tid was found tied around one of the fimbriae of the uterine tube ; the fimbria presented a dead white ap- pearance, there were a few adhesions around the pedi- cle at the point of con- striction, and the hydatid vesicle itself was wanting (Fig. 434). I made a care- ful drawing of the knot a.bout the fimbria enlarged under a low power, but when the specimen reached the laboratory the knot had pulled out and there re- mained only a loop with adhesions. I explain the condition found in the fol- lowing way : A loose knot was formed in the pedicle of the vesicle, which proba- bly hung over the back of the broad ligament ; then one of the fimbrise slipped in, was caught in the tie and strangulated, and the vesicle and distal portion of the pedicle, also strangulated, dropped off, leaving the knot fixed by a little adhesive peritonitis, as I found it. In one case there was a hemorrhagic infarct of the large left hydatid, due to a pedicle several times twisted and almost severed. In another instance the long pediculated left hydatid was adherent to the sigmoid flexure above the pelvic brim, forming a large loop like a long band of lymph. Fibroid Tumors of the Ovary. — These are among the rarest of the pelvic tumors, and are characterized by a multiplication of the connective-tissue ele- ments of the ovary at the expense of all the other histological constituents. The entire organ is usually involved, becoming converted into a "fibroid ovary," which may rarely contain degeneration cysts, dilated blood spaces, and lymph spaces. Fig. 431. — Parovarian Cyst with Twisted Pedicle, with Hem- orrhagic Infarction of the Uterine Tube. The ovary is intact, together with a small portion of the uterine end of the tube. Gyn. No. 1659. Natural size. 286 OVABIOTOMT. The tumor is densely hard, often almost bony in consistence, pinkish or white in color, covered with smooth peritoneum, but divided into lobes by deep and shallow furrows (Fig. 435). The fibrous growth is never disposed like a uterine fibroid in a bed from which it can be shelled out ; the connection with the ovarian stroma is direct and shows no line of demarcation. Calcification of fibroid tumors of the ovary occurs in rare instances, forming masses usually small in volume, consisting of the phosphates and carbonates of calcium. The largest mass I have seen was shown to me by Dr. Copeland in Milwaukee, who at my request sent it to Baltimore, where it was care- fully examined and described by Dr. J. W. Williams in a valuable monograph mm Fig. 432. — Subperitoneal Cyst developed entirely from the Peritoneum. A type of oyst frequently met with in pelvic inflammatory cases. Natural size. upon this subject (see Trans, of the Amer. Gyn. Soc, vol. xviii, 1893). The tumor of the right ovary was Y X 6 X 5 centimeters in diameter, weighed 220 grammes, and was like ivory in consistence. I have also seen a calcified corpus luteum in the ovary of an old negress on the dissecting table ; the little mass imbedded in the ovary was spherical, white, about 1 centimeter in diameter, covered with little aliort spicules, and when the shell, about 1 milli- meter thick, was broken, the interior was found smooth and filled with a watery fluid. The specimen figured in the text (Fig. 436), given me by Dr. G. S. Peck, of Youngstown, O., is an almond-shaped ovarian " calculus," partly enveloped in a thin fibrous capsule, which microscopically consists of fibrillated tissue poor in nuclei FIBKOID TUMORS OF THE OVARY. 287 and containing calcareous particles scattered through it. The stone itself is made up of chalklike material, which Dr. Aldrich upon analysis found to contain a Fig. 433. — The Pedicle of the Hydatid (Appendi.x Vesicularis, Kossmann) tied about the Free Tubal Fimbria at its Ba.se, close to the TuBo-ovAiiiAN Fold. The white thickened fimbria is in marked contrast to the normal red folds above. McGovern, Aug. 23, 1897. Natural size. large amount of calcium phosphate, with traces of the oxalate and carbonate of calcium, together with traces of magnesium phosphate and organic matter. Ov. fimb. (fatly o!egener-ate. Fig. 444. — Diagram showing the Manner of closing up the Deficit left by the Enucleation of AN Intraligaiuentary Cyst ey a Continuous Catgut Suture from Pelvic Wall to Uterine CoRNu. Jan. 5. 1894. 800 OVARIOTOMY. througli the clear spaces so as to include the vessels which are usually grouped at either border. These should be placed well off from the tumor so as to allow plenty of room to cut the tumor away without shaving it too closely. The utero-ovarian ligament should be ligated separately. -„f^' Fig. 445. — Intraligamentart Graafian Follicle Ctsts, seen in situ. Nov. 24, 1894. In a young woman it is not necessary to remove the uterine tube unless it is spread out over the surface of the tumor. It is a good plan to V)urn the pedicle off with a thermo-cautery so as to avoid leaving a raw space behind ; the burnt pedicle is much less liable to contract post-operative adhesions with the contiguous structures. Dr. Skene, of Brooklyn, has devised an electro-cautery which mummifies the stump so that hemorrhage can not take place, and there is no need of using a ligatu re. Intraligamentary Cysts. — When the ovarian tumor grows partly free into the abdominal cavity and partly down between the layers of the broad ligament, there is no real pedicle, but the separation may often be easily effected, after ligating the vessels on the side of the pelvic brim and on the uterine side, TREATMENT OF OVARIAN" TUMORS. 301 by splitting the peritoneum on a line at a level with the pelvic brim and then simply drawing or shelling the tiunor out of the loose cellular attachments which still hold it in the pelvis. These investing tissues are, as a rule, not vascular, and ligatures may be generally dispensed with. The top of the broad ligament is then closed in by a continuous catgut suture (see Figs. 44:3 and 444). When the entire mass lies beneath the peritoneum tlie enucleation is more difficult and the difficiilties increase in direct ratio with the size of the tumor. On opening the abdomen in the case of a large retroperitoneal tumor, the posterior and the visceral layers of the peritoneum may be found lying in direct contact with the anterior wall, the pelvic peritoneum is lifted up, the rectum is displaced, and the sigmoid or the colon pushed forward. The ureter is usually behind the growth, and if injured, the injury comes from detaching it from an adherent tumor. The uterus is displaced by an intraligamentary tumor toward the opposite side, or if there are intraligamentary tumors on both sides, it is crowded between them into the front part of the pelvis. Fig. 446. — Intkaliijamentaey Graafian Follicle Cysts. Nov. 24, 1S94. If both sides are affected, it will be easier and better to operate by removing the uterus and tumors together, by ligating the ovarian vessels first on one side, and so opening up the broad ligament and peeling out and rolling one of the 302 OVAKIOTOMT. tumors with the uterus up and out of the incision, and controlling the uterine vessels of that side. The uterus is then amputated in its cervical portion, the Fig. 447. — Multiple Dermoid Cysts of Both Ovaries, with Extensive Felvi-peritonitis involving Uterus, Tubes, and Ovaries, seen from Above and Anteriorly. FJJ is the fundus uteri. The left ovary consists of a number of cysts ('/>, 7), Z>) covered witli adliesions. The left tube is ri^id, and distended with pus. The right ovary {!)) is also covered with adhesions; and the right tube ha,s been amputated by bands of adhesions, so that it consists of three separate portions. Feb. 2, 1895. Vs natural size. uterine vessels of the opposite side controlled, and the second tumor shelled out easily from below upward ; the ovarian vessels are then clamped and the r --. ,0 j"\ --, — 'i I /.■ ; hV h'^ f I III Fig. 448. — Left Dermoid Cyst and Eight Multilooulak Ovakian Cyst with Twisted I^edicle. Elevation of the uterus. Wo. 2766. TREATMENT OF OVARIAN" TUMORS. 303 whole mass removed, following, in general, the technique used in hystero-myo- mectomy. In removing an intraligamentary tumor of one side, it is important to bear in mind that its blood supply continues to be derived from the same channels from which it came while the tumor was still small — that is to say, the ovarian and the terminal branches of the uterine vessels ; and if these are patiently sought out and secured at once, there need be but little hemorrhage throughout the operation. If the tumor is cystic and is made up of one or two larger cysts, the evacuation of the fluid will give the operator more room for his manipulations and the collapsed sac can be pulled on with greater advantage in drawing the tumor out. In shelling out intralig- amentary tumors it is best to avoid using the naked fingers, using in their stead a firm sponge on a handle, with rubber finger stalls covering the finger tips. After such a tumor is removed the floor of the pelvis is laid bare, and it is a wise and comforting plan always to inspect the ureter throughout its pelvic course, so as to be perfectly sure of its integrity. Complicated Cases . — In cases com- plicated by disease of both ovaries, as in the case' of multiple der- moids shown in the text (Fig. 447), or where a dermoid of one side com- plicates an ovarian cyst of the other (Fig. 448), or where there is an ex- tensive fibroid degeneration of the uterus (Fig. 449) associated with a fibroid ovary, it is better to do a hysterectomy with an ovariotomy, removing the uterus, tubes, and ovaries in one mass as described above. The Ojiposite Ovary . — The opposite ovary ought always to be in- spected and a note as to its condition entered in the history. If it is evidently Fig. 449. — Fibroma of the Left Ovary (MO)^ "with Lakge Mto- MATA (J/, M) OF THE UtERUS (U). Note the smooth surface and coarse exaggeration of the form of the ovary, the large vessels and the dense band of adhesion {F") stretch- ing down under its hilum, attaching it to the broad ligament. Jan. 30, 1895. 3^ natural size. 304 OVAEIOTOMT. diseased it should be removed, too; in a young woman conservatism should always be the ruling principle, and whenever it may be safely applied, a tube or a sound piece of ovary should be retained, even if it be but one tube and the opposite ovary. Resection of the ovary may be practiced in the case of der- moid cysts, and where there is an ovarian cystoma, like that shown in Fig. 406, it would be perfectly proper, if the patient was a young woman, and it was neces- sary to remove the opposite ovary, to resect the one affected with the cystoma, leaving the portion which appeared macroscopically sound, provided the patient consented to remain under observation for several years (see Chapter XXV). The methods of cleansing the peritoneum, the question of drainage, and the closure of the incision are discussed in other chapters. YiQ. 450. — Adeno-cakoinoma ok the Cervix with Rydroureter of Both Sides. The disease stops above abruptly at the junction of the body with the cervix; below, it extends well out into the vaginal vault and the rifjlit broad litraiiietit, and involves the entire tliickness of the cervix. The riii^ht ureter, seen cut across, is uonvertod into a lar^je liydroureter. On the left side two uretei"s are seen, which are also cnnverted intu liydruurctcrs of lesser degree. Autopsy, Jiuie 22, IS'JG. CHAPTEK XXX. ABDOMINAL HYSTERECTOMY FOB CARCINOMA AND SARCOMA OF THE UTERUS. 1. Causes. 2. Epithelioma of the cervix. Three stages: 1. Induration. 2. Sloughing. 3. Disappearance. 4. Mode of extension. 3. Adeno-carcinoma of the cervix. 4. Adeno-oarcinoraa of the body of the uterus. 5. Cancer of the uterus with myoma or tuberculosis. €. Symptoms. 7. Diagnosis: ]. From subjective symptoms. 3. From touch and inspection. 3. Prom micro- scopic examination of scrapings. 8. Treatment: 1. Prevention — rules for. 2. Manner of examining for cancer. 3. The radical operation, a. Preparatory treatment, b. Technique, c. Steps in the operation. ■9. Sarcoma of the uterus. Canoe? of the uterus is a malignant disease cliaracterized by an atypical pro- liferation of the epithelial elements. It is one of the common causes of death among women ; according to a computation of W. K. "Williams, made in 1896, at least eight thousand women were suffering from cancer of the uterus in Eng- land and "Wales at the date of writing. Age. — In fifty-two of my cases of epithelioma of the cervix the following ages were noted : Between 31 and 35 years 5 cases. 35 " 40 " 40 " 45 " 19 45 " 50 " ; 6 50 " 55 55 " 60 60 " 62 Total 52 oases. It is clear from this table that epithelioma of the cervix is most common near the menopause, and this induction coincides with the experience of most investigators. In thirteen of my cases of adeno-carcinoma of the cervix the ages were : Between 30 and 35 years 2 cases. 2 " 35 ' ' 40 ' 40 ' ' 45 ' 45 ' 50 ' 50 ' 55 ' 55 ' 60 ' 60 ' ' 65 65 ' ' 70 1 case. 4 cases. 1 case. " 2 cases. 1 case. The commonest period of occurrence was between 45 and 50. 805 306 ABDOMINAL HYSTERECTOMY FOR CARCINOMA OF THE UTERUS. In estimating the age of patients with adeno-carcinoma of the body, some allowance must be made, as it is impossible to determine with ac- curacy just when the disease commenced. In thirteen cases the patients' ages were as follows : 30 years 1 case. Between 35 and 40 " 1 " 40 " 50 " 1 " "' 50 " 55 ■' 5 oases. 55 " 60 " 3 " 60 " 65 " 3 " Total 13 cases. The period of most frequency was between fifty and sixty. The average adeno-carcinoma of the body, therefore, occurs (or perhaps it would be better to say makes itself evident) at a later period than either epithelioma or adeno- carcinoma of the cervix. Causes. — The etiology of cancer is obscure ; it has, however, been shown that there is a direct causal relation between cancer of the cervix and the traumatisms of childbirth. Cancer of the cervix in unmarried and nuUiparoas women is ex- tremely rare. In fifty of the cases of epithelioma of the cervix with accurate data as to marriage and the number of pregnancies, in every instance the pa- tient was married, forty-nine out of the fifty had borne children, and at least half of the patients had had five or more children. Twelve of the thirteen patients suffering with adeno-carcinoma of the cervix had been pregnant. The thirteenth was unmarried, and gave no history of impregnation. In eleven cases of adeno-carcinoma of the body it was found that ten were married and one single. From the accompanying tabulation it will be seen that four of them, although married for many years, had never been pregnant. In no case did a woman have more than four children. Para. Mis. A. married 7 years D. " 13 " A. " 31 " 1 Q. single M. married 24 " 3 A. " 33 " 3 5 G. " — " 4 A. " 32 " P. " 13 " 1 S. 1 P. " 31 " I recall only three cases of cancer of the cervix in nulliparous women m my entire experience, and in one of these the cervix had been forcibly dilated. Dr. T. A. Emmet told me that the only case of cancer of the cervix he had ever seen in a nullipara was also one where forcible dilatation had been practiced. CAUSES. 307 From a histological standpoint the parasitic origin of the disease has been repeatedly asserted, but this is iinproven ; indeed, many of these so-called para- sites have been found to be nothing more than degenerative forms of epithelial cells. It has been repeatedly asserted that there exists a remarkable racial dif- ference between the negroes and the whites in respect to the liability to cancer, and the statement has even been made that the negro is practically immune. This is clearly erroneous according to my statistics, which show a proportion of eight negresses to ninety-one white women. Cancer or carcinoma of the uterus begins to grow primarily either in or on the cervix or in the body of the organ. This distinction between cancer of the cervix and of the body can always be clearly made with the naked eye in the early stages of the disease, and even remains clear in the most advanced stages in the majority of cases ; occasion- ally, however, in the latest stages, the body is affect- ed in cervical cancer, and, what is rarer, the cervix becomes affected in cancer of the body. There are three varie- ties of cancer found in the uterus, each one depend- ing upon the special form of epithelium involved in forming the growth. The vaginal jDortion of the cer- vix is covered by squa- mous epithelium, and from this springs first the epithehoma, the squamous, or flat-celled variety of car- cinoma, which preserves this type of growth through- out its entire history and through all its extensions, whatever part of the body it may invade ; secondly, the cervical canal and the cervical glands are lined by one layer of very high cylindrical epithelium from which arise the adeno-carcinomata of the cervix, as the name indicates, cancers which preserve Fig. i^\. — Cxv.^.^,.lIA ^t tll Li-..\..\. No carcinomatous tissue can be seen at the vaginal vault, and the vaginal tissue has a normal appearance, but the carcinomatous infiltration has extended like a plate of cartilage beneath the vagina over the area included within the dotted lines. Dec. 9, 1S96. Nat- ural size. \ ^ 308 ABDOMINAL HYSTEKECTOMY FOR CARCIKOMA OF THE UTERUS. in their structure, wherever they penetrate, the glandular type ; thirdly, the uterine mucous membrane and its glands are lined by a single layer of cylin- drical ciliated epithelium; this gives rise to the adeno-carcinomata of the body of the uterus. Epithelioma of the Cervix. — The clinical picture of cancer of the uterus varies greatly both with the location of the disease and with the stage of ad- vancement. Epithelioma of the vaginal portion of the ceivix may be conveniently di- vided into three stages ; in the earliest of these the cervix shows an area of induration and infiltration with increased vascularity and a glazed appearance, or the tissue may present a slight granular appearance due to small fingerlike projections. The diseased tissiie may begin to break down soon and present an excavated area, or it may go on until both lips of the cervix are involved and a mass is formed which fills the whole vagina, and appears to be attached to the vault by a pedicle, closely simulating a pedunculated myoma. The commoner appearance, however, is that of a caulifiower growth with numer- ous fissures and excrescences, as described by Clark in 1824. Fio. 452. — Extensive Epithelioma of the Cervix extending up toward the Fundus, the Upper Part OF which is Free. Four Phleboliths in the Left Broad Lig.\ment. Bunches of Vesicles on THE Dorsum of the Kight Tube. Gtn. Path. No. 625. V, Natural Size. In the second stage the growth breaks down, bits of tissue slough off, and a portion of the cervix may be wanting, leaving an excavated ulcer with infiltrated edges. With further advance in the third stage, the entire cervix disap- pears, leaving in its place a craterous cavity in the vaginal vault covered by necrotic material with hard, irregular walls. With this extension the disease may open up the bladder, the rectum, or the peritoneal cavity, although in the case of the peritoneum the general cavity is almost invariably shut off by a plastic peritonitis. Beginning with the earliest stages of the disease, the cancer cells may invade the lymphatics, traveling as far as the glands, which then enlarge and in turn become foci for further extension. I am, however, convinced, on the basis of the thorough investigations of all my cases by my associate Dr. T. S. Cullen, PLA7" E XVII. X5 f',l^^' vaginam with great ease. In inoperable cases, Csesarean section at or near term offers the best chance for the child, and for the mother it is better to continue the operation by ampu- tating the uterus at the cervix ; in other words, by performing the Porro-Cgesa- rean operation. Symptoms. — The chief symptoms of carcinoma are hemorrhage, watery or purulent discharges, and pain. Hemorrhage is a regular concomitant of some period of the history of the disease, but is not often noted in the early stages ; it increases in frequency and sevei'ity as time goes on. It will not be necessary to en- ter into a disquisition upon the differential clinical signs in all these cases, as the one important difference upon which the diag- nosis of cancer depends rests upon the revelation of the cancerous tis- sue under the microscope. One of my cases (J. H. A., San., 260, Dec. 13, 1895) was cu- retted for uterine hemorrhages and an adeno-carcinoma found ; as the bimanual examination showed that the body of the uterus was not en- larged while the cervix was great- ly thickened, the conclusion was drawn that the disease was local- ized in the cervix. On removing the uterus, however, the fundus was found to be the seat of the neoplasm, while the cervix was extraordinarily enlarged by a cys- tic degeneration extending from the internal to the external os, but not visible from the vaginal side. The age at which this disease usually appears renders the patient unsuspicious, for she attributes it to an irregularity of the menojDause, or to a return of the monthly periods, as a sort of a rejuvenation. Pain, too, is apt to be a late symptom, and is sometimes entirely wanting throughout the disease. The typical distress is a boring, bearing-down, tearing or stabbing pain, which is referred to the lumbar and sacral region, and I'adiates down the legs and forward into the iowei- abdomen. Fig. 459. — Limited Aiiea of Cakcinoma of the Fundus OF THE LfTEltUS ON THE LeFT SiDE. ' The cervix was greatly enlarged, and was thought from the bimanual examination to be the seat of the dis- ease, on aceount of the thickening due to numerous cysts in its substance, none of which were visible in the normal vaginal portion. San. Nov. 21, 1895. Natural size. DIAGNOSIS. 315 The watery disclia^ge and leucorrhea are regular occurrences. The thin ichorous, watery discharge is one of the most characteristic of all the signs of the disease, and sometimes forms the only complaint. Later the discharge becomes purulent, or mnco -purulent, or sanguino-purulent, with an offensive odor, when, as a rule, the case is beyond operative interference. Cachexia and emaciation are not always present, but when found, especially in disease of the cervix, they are almost positive signs that the case is beyond relief. Diagnosis. — The diagnosis of cancer of the uterus is made from the subjective symptoms, from touch, inspection, and from the microscopic examination of curettings or small pieces of tissue excised from the cervix. In the later stages of disease the diagnosis is easily made from the symptoms, and by touch and inspection, but in the majority of such cases the affection is too far advanced to admit of a radical cure. In the earliest stages a diagnosis positive enough to justify a radical opera- tion can not be made without a microscopical examination. In my early expe- riences, I removed the uterus in four cases where a suspected malignant disease did not exist. It is interesting to note that the first vaginal hysterectomy for cancer in 1814 has been proved by recent study to have been an error of this kind. The conditions simulating cancer of the uterus are : 1. Hypertrophy of the mucosa with ectropium and induratictti. 2. Ulceration of the mucous membrane (erosion). 3. Cystic cervical glands. 4. Polypi, which should always be excised and examined microscopically to exclude malignant changes. 5. Submucous myomata. 6. Glandular hypertrophy of the mucous membrane. Y. Endometritis with hemorrhage. In the later stages of cancer of the cervix the disease forms either a large fungoid, friable mass at the vaginal vault with fetid discharges and frequent hemorrhages, or it forms a craterous opening in the position of the cervix filled vrith friable material, bleeding on touch. In such cases there can be no doubt as to the diagnosis. In the case of " eroded," " ulcerated," infiltrated cervices in which the prac- titioner is in doubt, he must either secure the advice of a competent gynecolo- gist or excise a wedge of the suspected area, put it in a five-per- cent solution of formahn, and send it to a reliable pathologist for investi- gation. In cancer of the body the only reliable method of mak- ing the diagnosis is by the microscopic examination of portions of the endometrium removed by curettage. Treatment.— The treatment of carcinoma of the uterus is either radical or palliative ; a radical plan of treatment is adopted in all eases in which the dis- ease is still clearly limited to the uterus and its immediate surroundings, and in 316 ABDOMINAL HYSTEEECTOMY FOR CARCINOMA OF THE UTERUS. which there is a reasonable hope that it may he completly extirpated. Palliative treatment is adopted for those cases which are beyond radical relief. One of the most important objects to be attained in the immediate future is an etRcient prophylaxis in avoidhig the later inoperable stages of the disease. i "^ y f 1 ^^'"'^'^^^^^ V W-' -''iaKSM P \ 1 ■£ ' '"^^rSil k |, ''''wB^m l^aS^^.-r-; :i^^9 B ;■ W °^ '^BeHH il ■B^^ ' - 'T^^^^S^M K '1 I . .:'~,^;«H P^'-''-". ■-.' • ^ ^uunn^^H li/l-^ 11 hBB^^I^^ ,v:A '''^^i^^l ^■^^^^j^ w^^S^^^^^hI N. "n i" Mip^^Jj^ m M ■ftk W^^* ' ^^m/j JH^'M V |w "''' y''. yi 1^^^ / ^Bk ^n^^ 1 . r^ 'wfm s fep ^^^v^^^^BBi [^■w /.^tg^jaWaMiMH gl^^t, , m |ri 'M '^^fl" 5^ wKf'j^r^ hI m pi 7 -J 1 ■=''■ ^^"^^HHi ^ ,1 1 Fig. 4(10.^Opehatton for Carcinoivia of tiik Uterus. Tlie uj'cters are both oathcterized in order to make them stand out prominently during the enucleation. On the right side the puritoneum has been removed luid the bladder divided so as to 8ho\v the relations of the ureter to the uterine and pelvic vessels. A part of the pubic rami have also been removed, to expose the structures better to view. We are not j^et in a position to realize anything positive bj any j)rocess of hygiene or of medication ; there is, however, one snggestive fact in the his- tory of carcinoma, and that is its occurrence with such frequency in parous women. This points clearly to a direct relation between the trauma of child- birth and cancerous affections of the cervix, and suggests the need of some Fig. 4tn. — Oakuinoma Uteri. Carcinoma limited to the posterior cervlcnl and tlie posterior vai^inal walls. It has apparently been en- tirely removed, a narrow band of vaginal mucosa surrounding the margin of advancement downward. The paramttrium is apparently free on either side. The right and left pelvic glands with lymph channels re moved and shown above. The small nodules in anterior uterine wall are myomata. No extension of car- cinoma to the body. Dec. 23, 1895. Anterior view. Yt natural size. TREATMENT. 317 such rules as the following in medical practice (see New York Med. Jour., Oct. 14, 1893) : Kules for the Prevention of Cancer . — 1. It is the duty of the obstetrician to see each of his patients at his office from two to three months after confinement, and to examine and carefully record the exact condition of the various pelvic structures, stating accurately just what lesions have been pro- duced by the childbirth. 2. Cervical lacerations should be described with especial care, noting the position and depth of tears and the appearance of the lips. These lacerations requii-e no treatment when the lips are thin, uninfiltrated, and lying together. Thick, infiltrated, and everted lips, associated with endoeervical catarrh, call for depletory treatment followed by repair of the laceration or amputation. 3. Every child-bearing woman who has passed thirty years of age, and whose condition has not been carefully noted in this way, should consult a competent physician. If the cervical lips do not appear sound, she should be kept under observation and be treated, if necessary, or examined at intervals of six or eight months. 4. Every woman of thirty-three or over who has a cervical tear should be examined at least once a year for ten years or longer if the lacerated cervix does not present a perfectly healthy appearance. 5. The community at large should be so trained by the profession that any woman who suffers from an unusual or an atypical uterine liemorrhage, or from any unusual discharge, should at once seek competent advice as to its cause, and the physician should not rest until he has definitely ascertained its source. This rule holds with increased force in the case of women in the forties, when both patients and doctors are so often deluded into a blind waiting for ]!^ature to reheve that which in time proves to be beyond the resources of both Nature and art. 6. These rules apply with special force to patients whose family history shows a liability to cancerous disease. If these rules were conscientiously observed there can be no doubt but that thousands of lives would be saved yearly in this country alone, for cancer of the uterus is a disease markedly local, and accessible and eradicable in its earliest stages. I feel that while we are searching for the cause and cure for cancer in all its grades, the line of progress in the immediate future for the gynecologist clearly lies in the direction of prophylaxis and anticipation, either preventing the malady or discovering it in time to eradicate it. The radical plan of treatment consists in the removal of the entire uterine body, whether the carcinoma is located at the fundal or at the cervical end. The determination that a case is suitable for radical treatment is made after a careful examination of the pelvic organs conducted in the following manner : A digital examination of the vagina is made, and if the vagiual cervix is found apparently normal to the touch and the supravaginal cervix does not seem to be infiltrated and enlarged, the carcinoma is then confined to the fundus, the most 318 ABDOMIN"AL HYSTEBEOTOMY FOR CAKOINOMA OP THE UTERUS. favorable site for permanent relief after enucleation. The fundus is tlien care- fully examined bimanually, and if it is found without any adhesions and freely movable the outlook is a good one, in spite of the fact that the body of the uterus may be several times its normal size, and even present nodules of the dis- ease which can be felt on its surface. If the body is adherent and, in particular, if there are strong intestinal adhe- sions, and this is associated with cachexia and marked emaciation, the liability of an extension of the disease beyond the uterus is much increased. Even under these circumstances, however, if the patient's general condition will permit it, she should have the benefit of an exploratory incision to determiae the character of the adhesions and whether the disease has extended beyond the possibility of extirpation. "When the cervix is affected the determination is somewhat more difficult, as the disease may extend in such a way that its outermost limits can not be accu- rately determined by the most careful examination. In investigating a case of cervical carcinoma the various modes of extension of the disease must be borne in mind and each avenue examined in turn ; these are : 1. Extension out into the right or the left broad ligaments or into both at once. 2. Extension downward into the vagina. 3. Extension forward into the bladder. 4. Extension backward into the utero -sacral folds and so into the rectum. 5. Extension up into the body of the uterus in rare instances. 6. Metastases into the pelvic glands, rare. 7. Metastases or implantation into the vagina below the focus of the disease, rare. In the early stages, when the cervix is not much enlarged and the uterus is probably movable, and a rectal examination shows that the broad ligaments are probably clear, the operation may be undertaken without any further investi- gation. Later, when the cervix is more extensively diseased, the minutest possible examination should be made before proceeding to operation ; if the uterus is fixed in the pelvis and the broad ligaments, one or both, are found hard, thick, and unyielding, pinning the uterus to the pelvic wall, the case may be rejected without further treatment. Whenever this fixation is not found, then a minute categorical investigation should be made, and it is always my own preference, to do this by putting the patient under the influence of an anesthetic. I then inspect the vagina for any evidences of an implantation of the disease low down, or for evidence of the extension of the disease over the vaginal wall in such a superficial form that it might escape the tactile sense if not first recog- nized by the increased injection shading off into the normal vagina below. In looking into the bladder, the evidences of an early extension in this direction are often evident in the form of a hyperemic area of the base with tits of ede- matous tissue. KiG. 462. — Double Hydkuueetkb due to Advanced Cancek of the Cervix Uteri. The atrophic and inflammatory changes due to the cancer are plainly visible in the adhesions of tlie bladder to the uterus, and in the cicatricial tissue and adhetions between tlie ureters and about tJie kidneys. Autopsy, March 2, 1896. ^ natural size. Pig. 463. — Autopsy on a case of carcinoma of the cervix with compression of the ureters, producing hydroureter ; double ureter on the left and single on the right (faintly seen). The peritoneum is opened and the uterus and bladder pulled to the right, to show the double ureter compressed and kinked at the pelvic floor. Autopsy, June 22, 1896. TREATIIEXT. 319 By touch, however, the most important information is secured ; wlien the disease is advanced in the vaginal direction the vagina feels shortened and the fornices are obliterated. If the anterior lip alone is involved, the extension may- be evident down the anterior vaginal wall, and the hard cervical mass often seems fastened to the bladder. An extension posteriorly toward the rectum is recognized by the want of mobility of the posterior cervical lip, which seems fastened to the sacrum to which it is sometimes drawn up, and examination through the rectum will show the extent of the disease in this direction. An extension of the disease upward into the uterine cavity is rare, and usually only occurs in cases so far advanced in other directions that enucleation is impos- sible ; further* than this it has no significance, as the entire uterus is removed at the operation. Extension out into the broad ligaments can only be suitably investigated through the rectum by carrying the index finger well above the ampulla and back of the uterus. The base of each broad ligament must be carefully studied from its cervical to its pelvic attachment ; a thick, round, hard mass attached to- the cervix and extending out to the pelvic wall in all cases represents the exten- sion of the disease ; a slight thickening, and a condition feeling like strings in the broad ligament, scarcely impairing its mobility while probably indicating also extension of the disease, is in some cases due to inflammatory deposits which clear up after the removal of the uterus. In these cases the patient should be given the benefit of doubt. Enlarged glands may sometimes he felt just posterior to the broad ligaments or at the pelvic brim, especially in the bifurcation of the common iliac artery. A glandular metastasis is one of the late sequelae in car- cinoma of the uterus, and such a discovery in no way contra-indicates a radical plan of treatment. I have repeatedly taken out enlarged glands in the course of an operation, and in but one instance was any evidence of carcinoma found in them. In one case of advanced carcinoma of the body I dissected out a hard gland in the right side on the pelvic brim, about 2 centimeters in diameter, which was- unhesitatingly pronounced carcinomatous from its macroscopic appearances, but the microscope showed that it was simply a hypertrophy. In concluding whether or not to operate, the patient should in all cases have the benefit of any reasonable doubt, and the operator must not be too exacting- in restricting his indications. I have operated several times where the disease was found so advanced that there could be no reasonable question but that some portion of it was left behind, and this was confirmed by a microscopic examination of the specimen, which showed cancer cells right up to the cut edge of the broad ligament, and yet one of these patients enjoyed perfect health for five years, when the disease reappeared in the glands of the neck ; another had a local return after three years of good health, and two others are living, appar- ently in perfect health, three and four years after the operation. I am even willing to extend the limit of the scope of the radical operation to cases which manifestly can not be permanently cured, but in which the uterus 320 ABDOMINAL HYSTERECTOMY FOR CARCINOMA OF THE UTERUS. can be removed -without great difficulty. This may be demanded by the insist- ence of a jjatient who is utterly demoralized by the knowledge that she has a cancer and insists upon active measures for her rehef, as well as for the purpose of relieving septic symptoms, pyometra, and the risks of hemorrhage. The disease will often then return in the pelvis without pain, without hemorrhage, and with- out any extensive breaking down of the tissues ; and a tranquil end may be secured either through death from exhaustion or by uremia. Radical Operation. — The radical operation contem- plates the removal of the entire uterus in the hope of eradicat- ing the disease ; it is done either by the vaginal or the abdominal routes. The abdominal route allows a wide dissection of the broad ligaments, with the removal of all the pelvic connective tissue out to the bony walls, as well as the removal of any enlarged glands found in the pelvis or about its brim ; it is therefore to be preferred in all cases to the vaginal route where the ex- tirpation is limited to the uterus, and the tissues in its immediate vicinity. Two objections to the abdom- inal extirpation are, that it con- sumes more time, lasting from an hour to an hour and a half, or even two hours, and that it is far more difficult to do than the vaginal operation ; the first objection, however, is outweighed by the great advantage of a wider extirpation, and the second will be overcome by practice, developing the requisite technical skill. Preparatory Treatment . — In addition to rest in bed and such build- ing-up measures as are adopted in all cases where there is a depressed physical condition, it is especially important to secure thorough evacuation of the bowels before proceeding to operation. Fig. 464.^The Upper Half of a IIvdroureter, and Hv- DKONEPIIROS13 FROM COMPRESSION OF THE RiGHT UreTER EY A Cancerous Cervix. The kidney (A') is einbe<_Ulo(.l in adljcsioas. The kinked ureter is eompressed or strietnred by the ovarian vessels which cross it at the level of the lower border of the kid- ney. Autopsy, March 2, 1896. Natural size. PLATE XVII!. MBmdeLfe^ L;ih [..Pran?£.rci.Bo.'.lm.U^.A OPERATION" FOE ABDOMINAL HTSTEEECTOMT FOE CANCER. 321 If the disease occupies the cervix, a thorough curettage should be done, as described in Chapter XIV, as a rule, a week or ten days before extirpating the uterus, at the time the examination is made to determine the extent of the disease. Where there are good reasons for not giving the anesthetic twice, the curettage may be done as a preliminary step immediately before the extir- pation. A preliminary curettage a week or two before operation has the following advantages : The field of operation is freed of the necrotic tissue, reducing the risks of infection and lessening the danger of implantation of the cancer cells into the healthy tissue during the operation. Tissue for microscopic examination is secured, and sometimes an operation which had previously seemed feasible is abandoned on account of the extent of the disease discovered at this time. Operation for Abdominal Hysterectomy for Cancer. — It is not many years since W. A. Freund ( Yolk. Samm. klim,. Vortr,, No. 133, 1878) described a method of removing the cancerous uterus through the abdomen ; the mortality following this procedure was, however, so great that few imitators were found. In a case upon which I operated in 1889 I was discouraged from further attempts by the excessive hemorrhage during the operation, and the ligation of a ureter with a fatal result. A most important step was taken by K. Pawlik {InUrnat. Min. Rundschau, Wien, 1889), who introduced bougies into the ureters so as to mark them out during the removal of the uterus and adjacent pelvic cellular tissue. My own method of exposing the ureteral orifices by an atmospheric distention of the bladder, and so introducing the bougies under direct inspection, has made Pawlik's plan easily available. Another advance in the technique of hysterectomy for carcinoma of the uterus was made by A. Mackenrodt {Beit/r. z. Yerhess. d. Dauerresultate d. Total- extirpation hei Carcinoma Uteri. Zeits.f. Gebui't. u. Gynak., 1894, p. 15Y) in the removal of both broad ligaments with the uterus. The last important step has been taken simultaneously and independently by three operators, J. G. Clark {Johns Hopkvns Hospital Bulletin, July-Aug., 1895, and Feb.-March, 1896 ; E. Eies, Zeitschr.f. Geburts. u. Gynak., Bd. xxxii, 1895, p. 266, and Eumpf, Zeitschr. f. Geburts. u. Gynak., Bd. xxxiii, 1895, p. 212). Each of these operators, wishing to establish a parallel between the wide extirpative operations upon cancerous breasts associated with the removal of the axillary glands and the cancer of the uterus, proposed as far as possible to re- move the pelvic glands, and in this way to make the operation more thorough and to reduce the percentage of relapses. Hies dwelt especially upon the importance of removing the uterus, broad liga- ments, and the iliac glands found in the bifurcation of the common iliac artery and in varying number on both sides of and along the iliac vessels. Kumpf, who was the first to operate upon the human being, conducted an extensive dissec- tion, removing the broad ligainents, the parametric tissues, dissecting out the ureters and much of the pelvic connective tissue below them ; in addition, 322 ABDOMIN-AL HYSTERECTOMY FOE CARCINOMA OF THE UTERUS. Douglas' folds with their neighboring tissues and the floor of Douglas' pouch were also removed with the upper part of the vagina. The facility and success of the Kies-Kumpf-Clark operation as developed in my clinic has been greatly enhanced by the passage of catheters into the ureters previous to the operation as before mentioned, converting them for the time into rigid cords, splinted out against the pelvic wall and yet within easy touch, and relieving the operator of the embarrassment arising from any doubt as to their location during the application of the ligatures. These are the steps in the operation : (a) Catheterization of the ureters. (b) Closing the cervix in carcinoma of the body, or of the vaginal vault in carcinoma of the cervix. (c) Thorough disinfection of the vagina, which is then filled with a loose iodo- form gauze tampon. (d) Elevation of the pelvis and abdominal incision, exposing the field of operation. (e) Ligation of the upper parts of both broad ligaments, including the round ligaments. (f) Detachment of the vesical peritoneum and of the bladder down to the vaginal vault. (g) Ligation of the right and left uterine arteries at their origin at the inter- nal iliac arteries. (h) The dissection and freeing of the uterine arteries with all ihe adjacent cellular tissue from the pelvic wall in toward the vault of the vagina. (i) Setting free the ureters which are lifted up and away from the field of operation. (j) Ligation of the large uterine veins above and below the ureter out near the pelvic wall. (k) Enlarged glands found on the pelvic floor must be taken up with the cellular tissue. (1) The uterus, with broad wings of connective tissue, is freed down to its vaginal attachment, and the vagina opened at least 2 centimeters below the low- est limit of the disease, anterior to the cervix, with a thermo-cautery. (m) The opening in the vaginal vault is continued around to the right and to the left, clamping any actively bleeding vessels until the uterus is entirely freed. (n) As soon as the vagina is incised anteriorly a loose iodoform gauze pack is pushed in, and as soon as the opening is large enough to permit it, the lower part of the uterus and the vaginal vault are enveloped in gauze, so as to prevent any discharge from contaminating the wound area ; the gauze wrap affords an excel- lent hold for the operator in making traction upon the uterus as it is gradually delivered. (o) Bleeding vaginal vessels are controlled by catgut ligatures passed through the vaginal walls but not including the mucosa. (p) The entire wound surface is minutely inspected, all oozing vessels con- OPEEATION FOR ABD0JII2SrAL HYSTERECTOMY FOR CANCER. 323 trolled by catgut ligatures, and remforeing ligatures applied to any important vessels where the first ligation seems insecure. (q) The vesical peritoneum and the peritoneum of the anterior layers of the broad ligaments is drawn back and united by continuous suture to the perito- neum of the posterior layers of the broad ligaments and Douglas' cul-de-sac. (r) If there has been no contamination the abdomen may be closed at once. If, however, there has been some escape of the uterine contents over the wound and into the peritoneum, the pelvic cavity should be thoroughly washed out after letting the patient down to a horizontal position before closing the abdomen. (s) The vaginal gauze is changed, and a piece of washed-out iodoform gauze passed loosely up between the lips of the wound to give a little support to the sutured peritoneum above, and to avoid any accumu- lation of fluids within the wound area. The catheterization of the ureters constitutes one of the most important steps, as by means of the catheters or bougies two valuable objects are attained, as already men- tioned : First, the elasticity of the catheter tends to push the ureter out close to the pelvic wall, out of the way of the operation, and second, by means of the catheter, the ureter is converted into a hard cord which can be felt at all times during the enu- cleation, so insuring its safe- ty from injury. The best plan is to intro- duce the catheters before giv- ing the patient the anesthetic, so as to shorten the time of the anesthesia and to avoid the additional shock incident to placing her in the knee-breast position and catheter- izing while under the anesthetic. I have several times catlieterized the ureters before doing a hysterectomy, without elevating the pelvis at all, by simply directing the speculum down to that part of the bladder where the ureteral ori- fices would naturally be looked for, and sliding it over the mucous surface until first one orifice was seen and catheterized ; then the speculum was withdrawn and re-inserted beside the catheter, and the opposite orifice was sought out and catheterized. Fig. 465. — The Kelations of the Ureter and Bladder to the Uteeus and Vagina. The right ureter is seen crossing under the uterine artery at a little dista'nce from the cervix and entering the collapsed Vjladder in front. The uterus is above and to the left. The lower part of the figure is made up of vagina on the left and urethra on the right, with a slight sulcus between. 32i ABDOMINAL HYSTEKECTOMY FOR CARCINOilA OF THE UTERUS. When the broad ligaments are much involved it ^vill sometimes be found im- possible to pass the end of the catheter more than 3 or 4 centimeters into the ureter. This would seem to be due to the fact that one of the prime conditions necessary to the passage of the catheter is a certain amount of mobility on the part of the ureter, and when this is impaired by fixation in an inflammatory mass the end of the catlieter butts up against the mass and is unable to turn the sharp angle formed and so to find the lumen. This condition is diagram- matically ref)rosented in Fig. 466. The closure of the cervix by means of stout silk ligatures passed through both lips in the form of mattress sutures is the first step in operation and should never be omit- ted, as it forms the best means of preventing the escape of cancerous material from the uterus over the wound surface during the enuclea- tion. After tightly tying the liga- tures they are cut short, the abdo- men is cleansed, the pelvis elevated, and a free abdominal incision made, varying in its length according to the thickness of the abdominal wall and the depth of the pelvis. As a rule, the incision should extend one third or one half way up to the lun- Ijilicus, in order to give a perfect ex- posure of the pelvic viscera and to allow the operator to use his hands with entire freedom in all the man- ipulations neeessaiy throughout the operation. The enucleation is begun by grasping the uterus and one tube and ovary and drawing them up- ward and out of the abdomen when possible, and ligating the ovarian vessels near the brim of the pelvis ; the round ligament is next ligated and clamps applied to the ovarian vessels and round ligaments on the uterine side, after which the top of the broad ligament is opened by an incision made between the ligatures and clamps. If the case is one of cancer of the cervix the ligatures may lie safely applied at a point nearer to the uterus : in advanced can-^ cer of the body, however, it is better to apply them well away from the uterus. Fig. 466. — I)i.\gkam showixg wiiv the Bougie Some- times REFUSES TO Pass on Up the Ureter in Car- cinoma OF THE Cer\'ix. The ureter ordinarily yields a little as the hougie passes upward toward the kidney; this movement, hy which it accommodates itself to the elasticity of the bougie, is prevented when the ureter is embedded in a carcinomatous mass, and, as a consequence, an angle is formed just at the entrance of the tixed portion, beyond which it is difficult to coax the instrument. Sometimes the ureter is markedly kinked in the neighborhood of the diseased area (see Fig. 463). It is still important, however, to insert the bougie as far as possible, as the position of the point serves to locate the ureter. OPERATION FOE ABDOMINAL HYSTEKECTOMY FOE CANCEE. 325 on account of the possibility of cancerous elements being contained in the Ijm- phatics of the upper broad ligament or in the round ligaments. Such a con- dition is well shown in Fig. 458. After opening the broad ligament in this way the incision should then be continued on around in front of the uterus to the opposite round ligament, sepa- rating the vesical peritoneum from its uterine attachment. The operator then in a similar manner ligates and opens uj) the other Ijroad ligament, and pulls up the uterus, while at the same time with a sponge held in the grasp of a pair of forceps he pushes down the vesical peritoneum still fur- ther, detaches the bladder, dissecting it loose with a scalpel when it adheres tightly, until it is quite free from the uterus and vaginal vault. Any bleeding vesical vessels may be clamped temjDorarily or tied with catgut. Fig. 467. — Outline Diagram of the Steps of the Eadical Oper.ytion for Cancer of the Cervix. The incisions are made in the directions indicated by the arrows, following the black lines. The loops indicate the po.sitions of three important lisraturea on either side. The vagina ( Va) may be opened from either side, from within out, as indicated, or from without in. Ur is the ureter, behind which the uterine artery is tied. The succeeding steps in the operation are the most difficult and the most critical, for the operator has now to ligate the uterine arteries at a point distant from the uterus, to free the ureter from its relations to the pelvic connective tis- sue, to ligate the large uterine veins, and to dissect out, with the lower segment of the uterus, the entire mass of pelvic connective tissue between the cervix and the pelvic walls, sometimes including a chain of large glands. The best place to ligate the uterine artery is well back in the pelvis at its origin from the anterior branch of the internal iliac ; at this point, although not far from the ureter, it lies more parallel to it and is not so difficult to isolate as it is in the neighborhood of the cervix, where it is surrounded by large veins, 326 ABDOHINAL HYSTERECTOMY FOR CARCINOMA OF THE UTERUS. and where the ureter crosses beneath it at a right angle. The artery is exposed by retracting the anterior and posterior layers of the broad ligament and sepa- rating the cellular tissue by a blunt dissection, which is very conveniently done by a three-pronge-l instrument like a small pitchfork, all the way down to the Fig. 468. — Hysterectomy for Carcinoma of the CEiivi.K. The ab'loiiien i^s incised and the left broad liirament opened up. Tlie stump of the left ovarian vessels is seen at the pelvic brim, and that of the round lijjainent in front, by the bladder. The uterus is ijraspcd by museau forceps and drawn forcibly to the ricrht, while a blunt dissection is carried on down to thq base of the left broad litrament, exposing: the uterine artery and traciiii;^ it back to its origin in the loose pelvic .cellular tissue. The ureter, .splinted by a bougie. i.s plainly seen and felt on the pelvic floor just beneath the uterine arterv. pelvic floor posteriorly, where the artery may be distinctly felt pulsating. The artery may now be easily isolated, lifted up, and ligated with a fine silk ligature passed by means of an aneurism needle ; the artery is cut about half a centimeter beyond the ligature and the dissection continued in toward the cervix. The operator is aljle to assure himself of the position of the ureter before ligating the uterine artery, either by means of the bougie, or when it has not been possible to introduce the bougie, by simply gathering up the uterine artery and the tissues parallel to it between the thumb and forefinger and letting them slip between tlie fingers ; the flat cordlike sensation of the ureter caught in this way is perfectly characteristic, and it is not necessary to see it to know where it is and to feel assured that it is out of the way of harm. The uterine artery, tied and divided as described, is now caught by a pair of artery forceps and drawn up, and the dissection of the cellular tissue continued down toward the uterus, at first keeping close to the pelvic wall, so as to leave OPERATION FOR ABDOMINAL HYSTERECTOMY FOR CANCER. 327 HO tissue between it and the cervix ; during this enucleation the course of the ureter is kept constantly in view, and wherever the dissection encroaches upon it, it is freed without injury. It is especially important not to bruise the coats of the ureter, and not to cut the little tortuous artery on its external surface, in order to avoid the risk of the sloughing of its coats subsequent to the operation -and the formation of a uretero-vaginal fistula. As the dissection is continued on down toward the vaginal vault below the ■cervix, the detached tissue, which began in a point with the uterine artery, widens out into a broad-based cone, attached to the cervix like a wing. Down on the floor of the pelvis two or three large veins, often a centimeter in diameter, are exposed and tied ; one of these veins is usually found lying below the ureter at a point where it would not be expected, and is therefore more liable to injury before ligation. Care should be taken to ligate the veins both distally and proximally, or at least to clamp them on their distal side. Fig. 469.— The uterus (F) is pulled farther to the rijjht, and the uterine artery tied, cut off, and dissected away from the ureter ( Ur) with a mass of pelvic cellular tissue and glands (not shown). P, posterior layer of the peritoneum ; i?, bladder ; C, cervix ; K, vagina. This extensive detachment of the cellular tissue should be completed on both ^ides before proceeding with the final steps of the enucleation. Enlarged glands should always be looked for on the pelvic floor and close to 63 328 ABDOMINAL HYSTERECTOMY FOE CARCINOMA OF THE UTERUS. the pelvic wall ; they can best be recognized as hard nodules in the soft cellular tissue by the sense of touch ; if any are found, they can be dissected out in chains along with the cellular tissue. The next step is the final one in the enucleation — the amputation of the vaginal vault and the removal of the uterus and as much of the vagina as it is necessary to extirpate with it. When the carcinoma affects the body of the uterus alone the vaginal vault may be opened at any convenient point near the cervix. But when the disease affects the cervix, then the point of amputation of the vagina must be determined with great care at the examination made be- fore the operation ; under all circumstances the amputation must be made at least 2 centimeters below the lower margin of the disease. The danger of leav- ing a considerable portion of a carcinoma extending downward into the vaginal epithelium is well shown in Fig. 451. Before opening the vagina the posterior pelvis must be packed with gauze in such a way as to take up at once any dis- charges escaping from the wound. It is my plan always to determine the exact position and the limits of the vagina by percussing it lightly with the forefinger, when it is easily recognized by the tympanic sound. The vagina is best opened first in front with a thermo-cautery knife at a dull heat, because this checks the bleeding from all but the largest vessels, and so saves a great deal of time which must otherwise be spent in encircling the vagina with ligatures. As rapidly as the vagina is cut through with the cautery its edges are grasped by artery forceps, which serve at the same time to control any hemorrhage. As soon as a free opening is made into the vagina a loose iodoform-gauze pack is stuffed into it to take up any secretions, and when the separation be- tween the uterus and vagina is carried a little farther still, a gauze pad is bound around the cervical end of the uterus to prevent anv contamination of the wound from that source. Should there, however, be contamination, in spite of these precautions, the operator must instantly take a sponge or piece of gauze and wipe off the surface very carefully and thoroughly. Any knife or other instru- ment used in cutting carcinomatous tissue should be put aside and not used again until sterilized. The specimen removed should be put into a hardening solution at once and carefully studied, devoting particular attention to the cut surfaces. If the disease extends right out to the edge, the probability of a rapid return will, of course, be much greater. The operator then washes his hands thoroughly, and proceeds to control the vaginal vessels by passing as many catgut ligatures as are needed for the purpose through the outer tissues of the vagina in a direction perpendicular to its long axis. The pelvis is now carefully examined for other enlarged glands either lying on or under the iliac vessels, at the bifurcation of the common iliac artery, or just above it. Wherever these are found they should be removed. Enlarged glands lying upon the internal or external iliac -^eins can often be removed only with extreme care and by painstaking dissection. In one instance I found the gland semilunar in form and closely pressing upon the external iliac vein whose OPEKATIOI^ FOR ABDOMISTAL HYSTETECTOMY FOR CANCER. 329 form it had taken ; it was only detaclied by a niiniite slow dissection, but the separation was finally satisfactorily made. If a vein is torn oii at its point of entrance into the external or common iliac veins the opening should be closed Fig. 47(). — After freeing the bladder and dissecting out the left broad ligament, the vaginal vault is opened anteriorly and all hemorrhage controlled by a series of sutures placed as shown in the figure. The bladder and ureters, with bougies, are shown in dotted outlines. by a fine suture with a fine needle, folding the wall of the vein upon itself, in this way avoiding the necessity of ligating the large trunk with the attendant risk of gangrene below it. A thorough inspection of the whole area exposed and of all the ligatures applied to important vessels is now made as a distinct and most important step in the operation ; in this inspection the operator should assure himself as far as possible as to the thoroughness with which the disease has been extirpated, he should discover any persistently bleeding points and control them with liga- tures, and, above all, he should see that all the large vessels are secure!}' tied and should reinforce any doubtful ligatures. The anterior and posterior semilunar lines of peritoneum which border the wound area in front and behind are now brought together by a continuous cat- gut suture, beginning at the pelvic brim on one side and extending down across the pelvic floor and up to the brim on the opposite side, where the suture is tied. If the possibility of contamination has been excluded throughout the opera- tion the abdominal incision may now be closed by the three layers of sutures, to the peritoneum, fascia, and skin ; but whenever there has been any contamina- 330 ABDOMIN^AL HYSTERECTOMY FOE CAECINOJIA OF THE UTERUS. tion from the uterus or vagina the operation should not be concluded without first thoroughly washing out the pelvis with normal salt solution with the pa- tient in a horizontal position. A loose gauze pack is now pushed up through the vagina and through the opening at its vault to give support to the peritoneum and to drain the wound ; at the same time the vagina should be loosely filled with a similar pack. Fig. 471. — Sagittal Section, showing the Left Side of the Pelvis, with the Operation Completed. The anterior and posterior peritoneum is united by a continuous catgut suture. The stump containing the ovarian vessels is seen at the pelvic brim, this is usually turned under and concealed ; the sutured peri- toneum above this has been opened in order to dissect out the enlarged iliac glands. The vaginal vault is not closed, hut a gauze puck is placed in the vagina and up under the iicritoneum. Shock from the prolonged operation must be sedulously guarded against by keeping the patient well wrapped in woolens, and with hot-water bottles about her during its performance, by giving hypodermics of strychnin at suitable intervals, by avoiding all unnecessary delay, so as to make the anesthesia as short as possible, and by giving a hot stimulating rectal enema just before she goes off the table. For anemia and hemorrhage it will be best to infuse from 500 to 800 cubic centimeters of normal salt sol ution into the cellular tissue under the breast, dur- ing or at the close of the operation. OPERATION FOR ABDOMIITAL HYSTERECTOMY FOR CANCER. 331 "When the operation is complicated by an extension of the disease down the anterior vaginal wall or into the base of the bladder, this may be met by a wider excision at this point, even cutting ont, if need be, a large part of the base of the bladder. After completing the enucleation the clean-edged wound in the bladder may then be brought readily together by interrupted sutures of fine silk, j)assing through all its walls except the mucosa. Care must of course be taken not to injure the ureters at their entrance into the bladder. When the disease extends out laterally or posteriorly onto the rectum farther than the oper- ator has anticipated, the extirpation sometimes becomes a very difficult one. It is particularly hard to make any satisfactory dissection in thickened tissues about the rectum, unless the patient happens to be thin and the pelvis shallow. When Fig. 472. — EriTHELioMA of the Cervix in Grapelike Mass. Showing the extensive removal of the uterus and broad ligaments by the abdominal method. No. 741. % natural size. there is much lateral infiltration the embarrassment from the hemorrhage in cutting through the infiltrated tissue is sometimes so great that the opei-ator has to abandon all idea of radical relief, and finish the operation the best way he can. I operated upon a case of this kind Oct. 16, 1893. The patient (S. L., 2248) had a large friable carcinoma of the cervix, but no infiltration of the broad ligaments could be felt. On opening the abdomen, strong velamentous adhesions from the sigmoid flexure to the posterior surface of the uterus were freed by dissection with the knife, the left ovary and tube were then dug out of a bed of dense adhesions, and the ovarian vessels ligated and the enucleation begun. The right ovary was also dissected out of a bed of adhesions, and the rectum freed from adhesions binding it over the internal iliac artery. As the operation proceeded, it was found impossible to extirpate the disease in the broad hgaments and to check the free oozing from the diseased tissue which was cut ; in order, therefore, to control the entire blood supply going to the part, I ligated both internal iliac arteries at a point 1 centimeter below the bifurcation of the common iliacs. After the ligation all pulsation in the pelvis on both sides 3-32 ABDOMII^AL HYSTERECTOxMT FOE CARCI]SrOMA OF THE UTERUS. ceased below the ligatures. On the left side the ureter was first located and drawn up and out of the way while the ligature was being passed. On the right side there was a marked hydroureter, but I nicked the peritoneum over the ureter and drew it out toward the median line while the artery was being tied ; on con- FiG. 473. — Uterus Enucleatep Per ^^agtnam, TO Contrast with the Uterus Enucle- ated FROM Above, Fig. 47^. Showing the ^reat difference in the amount of tissue removed. Fig. 474.- -Small Sarcoma in the Right Horn of the Uterus. Diagnosis made by curettage ; hysterectomy, the patient living without recurrence five years after operation. tinuino: the dissection of the diseased mass this ureter was liberated from a bed of cancerous tissue, involving its course for 5 centimeters. The patient made a good recovery and suffered in no way from the artificial pelvic anemia, and the disease returned so slowly that she lived over two years after the operation. Sarcoma of the Uterus. — Sarcoma of the uterus is a connective tissue growth of malignant type occurring at all ages. For clinical convenience, sarcoma of the uterus may be divided into sarcoma originating in the cervix and sarcoma commencing in the body. Sarcoma of the Cervix. — In rare instances this disease appears like bunches of grapes springing from the cervix, as first described by Spiegell)erg in 1879, who reported the case of a girl seventeen years of age. The anterior cervical lip was thickened and enlarged, and covering its margins and surface were oval, yel- lowish-brown outgrowths, 1 or 2 centimeters in length. These looked like transparent cysts, were easily crushed, and contained a thick, sticky fiuid. The girl returned nine months later with the entire vagina filled by the growth, which resembled a hydatidiform mole. Weigert, who examined the tissue micro- scopically, found these cystlike masses covered by a single layer of cylindrical SARCOMA OF THE CERVIX. 333 •epithelium, and their interior composed of large, round, spindle-shaped and branching cells, separated from one another by clear spaces. I have seen but one similar case, in a woman about thirty years of age, where, springing from the cervix and hanging down into and filling the vagina, was a growth resembling a bunch of grapes. In my case amputation of the cervix was followed by a speedy recurrence, invasion of the surroi^nding tissues, and death. Dr. J. W. "Williams, who has collected these cases, says that in the majority of instances this variety of the disease manifests itself before the twentieth year ■or after the menopause. In only three cases did it occur between these periods. Sarcoma of the Body of the Utekus. The upper two thirds of the uterine body is distended with mulberry-sliaped tumor masses resembling "brain tissue, and quite vascular. The line of junction "with the uterine wall appears sharply defined, but ■under the microscope metastatic nodules were found in the lymphatics of the left uterine cornu. San. 204, -Operation, April 30, 1895. No recurrence, Feb., 1898. J^ natural size. Spindle-cel led Sarcoma of the Cervix . — Only one case of this variety has come under my notice. The patient was thirty-eight years of age, had been married twenty-one years, and was the mother of eight children. Four months before admission she suddenly began to have copious uterine hem- orrhages, which gradually ceased, but a watery discharge persisted. On vaginal examination, the cervix was found to be the seat of a new growth, which was hard, nodular, and filled the entire vaginal vault. The dis- ease was clearly ineradicable, but the excess of tissue was curetted away. His- tological examination showed that it was a large spindle-celled sarcoma. Endothelioma of the Cervix. — This is an exceedingly rare condi- tion, not more than five or six cases having been recorded. In all of our cases of malignant growths of the cervix only one has belonged to this group. The ■cervix in this case measured 4"5 X 3.5 centimeters, and was markedly indurated, 334 ABDOMINAL HYSTERECTOMY FOB CARCINOMA OF THE UTERUS. while the external os was represented by a craterlike excavation 2'5 X 2 X 2^ centimeters. The floor of the excavation was roughened, but there was no evi- dence of softening or friability until the upper part of the cavity was reached. On histological examination, the typical picture of an endothelioma was found. Sarcoma of the Body of the Uterus . — This is a rare disease when compared with adeno-carcinoma of the uterus, as shown by "Williams, who in 1894 was able to collect but one hundred and forty -four cases from the litera- ture, including both those arising from the cervix and the body. These sarco- mata may be divided into two groups, those affecting the mucosa and those arising in the parenchyma. The growth usually springs from the upper part of the uterine cavity, and although it may be diffuse in character, is usually sharply defined. If detected in the early stage (see Fig. 474) it may con- sist of one rounded or oval nodule, but if larger it may be lobulated, as is well shown in Fig. 47.5. On cutting the sarcomatous, nodule it usually presents a smooth, homo- geneous surface not often traversed by broad trabeculse, as seen in adeno-carci- noma. During the last four years there have been three cases of sarcoma of the body occurring in my clinic, two round-celled and one spindle-celled sarcoma. Histologically the attention is at once- drawn to the large areas of the growth showing jjractically no necrosis and per- fectly preserved. The tissue is composed of a homogeneous mass of cells with lit- tle intervening stroma ; the cells have round vesicular nuclei and are remark- ably uniform in size ; traversing the growth are many delicate blood capillaries which ramify in all directions, dividing the tissue^ up into alveoli. If necrosis takes place it is usually along one margin, the underly- ing growth remaining intact. Secondary Sarcoma of the Uterus. — The uterus is occasionally secondarily involved by a sarcoma of the ovary. In 1894 I operated on a patient where there was a large friable tumor occupying the right side of the pelvis ; it penetrated the uterus and formed a large mass in the uterine^ cavity, while a portion of the growth projected through the external os. Dr. Cullen examined this case and found that it was an angio-sarcoma of the ovary Fig. 476. — Sarcomatous Nodule in the Vagina. Secondtiry to anrcoma of the nterus and right ovary. Op. Feb. 5, 18116. % natural Bize. SARCOMA OF THE UTERUS. 335 with secondary involvement of the uterus. See Johns Hopk. IIosp. Bui Dec 189i. A second most instructive case occurred in 1896. As seen from an exami- nation of Fig. 476, a lobulated and smooth mass projected from the cervical canal, and Fig. 478 shows that the uterine cavity was also filled with large and small lobules of a new growth. Keference to Fig. 477 shows that the growth Fig. 477. — Sarcoma of the Uterus ( U) and Right Ovary. The left ovary ( Ov) and tube { T) are intact. The right ovary is couverted into a mass of lar^'e nodules, chokincr the pelvis, covered by adhesions, and attached to the omentum, part of which is left on it. Feb. 5, 1896. No. 10.94. J^ natural size. commenced outside of the uterus, and that this organ was secondarily involved. The microscopical examination demonstrated that the growth was a spindle- celled sarcoma, originating in the ovary. The disease extends by contiguity of tissue, by the veins, and by the lym- phatics ; the extension is often found in the direction of the vagina, which then contains a number of bluish or reddish nodules of various sizes. 336 ABDOMINAL HYSTERECTOMY FOR CAKCINOMA OF THE CERVIX. The tendency is to break down late and to discharge blood and watery fluid with the cell debris. The diagnosis is made from a microscopic examination of scrapmgs or of a piece cut out of the tumor. The patient complains of discomfort and some- times of hemorrhages, and on examination a uterine tumor is found which under the microscope proves to be a sarcoma. Hemorrhage is by no means a constant symptom; in one of my cases, too far gone for any operation, there had never been any hemorrhage at all. Cachexia and pain are usually well marked when the growth is large. Fig. 478. — Sarcoma of the Uterus (Seconuvry to Sa];coma of the Ovary) cut open in Front. Tilt; sarcoma forms a smootli lobulated mass completely "tilling the uterine cavity. Over many of the nodules the mucosa is still preserved, Feb. 5, 1896. Path. No. 1054. Natural size. In another case, operated upon in 1893 and still living, the patient had frequent hemorrhages, and a diagnosis of sarcoma was made from curetted specimens ; on removal, a little tumor, 12 millimeters in diameter, was found in the right uterine cornu (Fig. 4Y1). While the naked-eye appearances are often characteristic they may also prove so deceiving that the microscope must be looked upon as the one certain means of making a diagnosis. In one instance, for example, I was in serious doubt whether the tumor, situated on an inverted fundus, was a myoma or a sarcoma. In general ap- pearance the tumor was slightly lobulated, edematous, friable, and without any SARCOMA OF THE UTERUS. 337 capsule at all ; and on detaching it from the fundus an irregular ragged base was left behind. The tissue was pale and waxy and tore in parallel striae ; in short, the tumor to the naked eye closely resembled a sarcoma, but the micro- scope showed that it was an edematous myoma. The operation for the extirpation of a sarcomatous uterus consists in a wide enucleation, the same as that for carcinoma iust described. CHAPTEE XXXI. MYOMECTOUry— HYSTERO-MYOMECTOMY. 1. Definition. 2. Clinical characters of fibroid tumors. 3. Kinds and sites of myomata. 1. Submucous. 2. Interstitial, or intramural. 3. Subserous, or subperitoneal. 4. Fibro-cystic tumors. 4. FoEm peculiarities. 5. Diagnosis. Examination, under anesthesia, if the tumor is small ; sounding the length of the uterine cavity. 6. Palliative treatment. 1. Relief of pressure symptoms. 2. Hemorrhage : a. Curettage, h. Galvanism. 7. Indications for abdominal operations upon the myomatous uterus. 8. Myomectomy. 1. Definition. 2. Cases suitable for. a. In general, always the operation of election in young women, in the absence of other complications. J. In particular. (1) All pedunculate myomata, where the removal of the tumor will leave a normal uterus. (2) All subserous or interstitial tumors which are well defined in relation to the body of the uterus, whether single or multiple. (3) Multiple small myoma. (4) Broad ligament my- omata where the tubes and ovaries are not diseased. (5) Cornual myomata. (6) Submucous myomata too large to take out per vaginam. 3. Operation : a. Exposure of tumor, b. Incision of capsule or pedicle, c. Temporary control of hemorrhage, d. Enucleation, e. Permanent control of hemorrhage — ligature and suture. /. Closure of incision, suturing the angles, g. Closure of abdominal incision without a drain, h. Dangers of the opera- tion — hemorrhage and sepsis. 4. Pedunculate myomata. 5. Subserous, sessile, and inter- stitial myomata. a. Removal of large interstitial myoma without sacrificing any uterine tissue. 0. Eight subserous and interstitial myoma removed by seven separate incisions, c. Cornual myoma. 6. Extirpation of submucous myomata per abdomen. 9. Hystero-myomectomy. 1. Indications for. 2. Operation : a. Preliminary preparation. 5. Opening abdomen, c. Delivering tumor, d. Ligation of left ovarian vessels and left round ligament, e. Detachment of the vesico-uterine fold from side to side, and pushing it down, separating bladder from cervix. /. Ligation of left uterine vessels, g. Amputa- tion of uterus in cervical portion, leaving a cup-shaped pedicle, h. Clamping uterine artery of right side, clamping right round ligament, clamping right ovarian vessels, fol- lowed by removal of tumors, i. Application of ligatures in place of forceps, j. Suturing the stump, k. Covering wound area with vesical peritoneum. I. Cleansing peritoneal cavity, m. Closure of abdomen without drain. 10. Complications of hystero-myomectomy. 1. Complications due to adhesions and affections of surrounding structures, a. Inflammatory. (1) Simple adhesions of tubes and ovaries. (2) Hydrosalpinx. (3) Pyosalpinx and abscess of ovary. (4) Encysted peritonitis. (5) Omental adhesions. (6) Parietal adhesions. (7) Adhesions to rectum, sigmoid, colon, and small in- testines. (8) Adhesions to vermiform appendix. (9) Adhesions to liver and suspensory ligament, h. Tumors of the ovary. (10) Ovarian cystomata. (11) Dei-moid cysts. (12) Fi- broid ovary. (13) Ovarian hydrocele. (14) Ovarian hematoma. (1.5) Carcinoma of the ovary, c. Diseases of the cervix and uterine mucosa. (16) Cancer of the cervix. (17) Can- cer of the uterus associated with myoma. (18) Tuberculosis of the endometrium. 2. Com- ' plications due to changes in the tumors themselves. (19) Cysto-myoraa. (20) Telangiectatic myoma. (21) Suppurating myoma. (22) Cystic myoma, with twisted pedicle. (28) Adeno- myoma uteri diffusum benignum. 3.' Complications due to location of tumors. (24) Ele- vation of tubes and ovaries high out of pelvis. (25) Globular myoma filling pelvis. (26) Myomata wedged in pelvis. (27) Myoma below vesical peritoneum. (28) Myoma below pos- terior pelvic peritoneum. (29) Myoma in upper part of broad ligament. (30) Myoma in' broad ligament proper. (31) Myoma developed antero-laterally, twisting uterus. (82) Myoma developed postero-laterally. (33) Myomata developing under the pelvic peritoneum in several of these positions at once. (34) Myomata displacing the ureters upward. 4. Complications due to pregnancy, ascites, and other causes. (85) Myoma with pregnancy. (86) Myoma simulating pregnancy. (87) Myoma and ascites, feeble "heart, nephritis, etc. Definition . — Myoma of the uterus, fibroid tumor or fibro-myoma of the uterus, is an atypical nodular growth springing from some portion of the uterine 338 DESCRIPTION OF PLATE XIX. INJECTED SPECIMEN SHOWING THE VASCULAR SUPPLY OF MYOMATA — BUBMUOOUS, INTERSTITIAL, AND SUBSEROUS. The tumors are embedded in a vascular hypertropliied uterus which is deeply injected. The pedunculate subserous tumor above, which has been divided, shows a tessellated arrangement of the large injected vessels surrounding its base; on the left side the vessels are s6en penetrating the substance of the turaor between its lobules ; the distal portion is anemic. The large interstitial tumor is seen everywhere pene- trated by small capillaries, and there are a few large vessels near the outer margin and the center. There is a remarkable contrast between the vascular supply of the uterus and that of the tumor which is partially submucous. The uterine cavity is further occupied by sessile and pedunculate submucous tumors, each of which shows a beau- tiful vascular corona ; on ike free ^Urface of the upper tumor there is a leash of large vessels. The fitrophy of the mucous membrane over these growths is in contrast with the unaltered mucosa of theirest of the uterus. Specimen injected by Dr. J. G. Clark to demonstrate the source of hemorrhages from the uterine mucosa. PLATE XIX. K Becker fef Ul LVVaugiCoBoiiD^.lliA. CLIlsriCAL CHARACTERS OF FIBROID TUMORS. 339 tody, usually above the cervix, varying in size from a microscopic node to that of a mass or masses choking the -whole abdominal cavity. The tmnor is made up of a disorderly interlacement of muscular and connective-tissue fibres, in the larger masses grouped into more or less well-defined spherical nodules. Between the groups of fibres run arteries, veins, and lymph channels derived from the normal vessels of the uterus, ramifying at first beneath the capsule of the tumor and then plunging directly into its interior. Isolated tumors within the uterine walls are well circumscribed and surrounded by the normal muscular fibres ; tumors projecting through the muscular wall become covered on the uterine side by the mucosa, and on the abdominal side by peritoneum. Clinical Characters of Fibroid Tumors. — Although all myomata probably exist in fetal life in diminutive form, they rarely give evidence of their presence until menstruation has been established for some years. Marked indications of their existence usually occur about middle life, from thirty -five, with increasing fre- quency, up to forty-five years of age. The earliest clinical signs are painful menstruation, excessive at the men- strual period, and in married women sterility, and repeated early miscarriages. The tumors, at first occupying the pelvis, as they grow extend toward the abdomen, and growing slowly do not as a rule attract attention by their size until they have exceeded the capacity of the pelvis, and occasion a symmetrical or nodular enlargement of the lower abdomen evident upon inspection, and still more upon palpation. The rate of growth is variable ; it is sometimes so slow as to require ten, fifteen, and twenty years before the tumor attains the size of a uterus at term. Some of the more vascular myomata, however, may even develop per- ceptibly within a few months. With the development of the tumors there is often an enormous hypertro- phy of the enveloping uterine muscle; for example, in one case the tumors weighed 1,950 grams and the uterus alone, after they were removed, weighed 625 grams. Profuse menstrual hemorrhage is the commonest as well as the most striking symptom, and occurs in about fifty per cent of the cases. At the beginning it is apt to be confined to an excessive flow at the period, which lasts from five to eight days ; although this weakens the patient at the time, it is readily compensated for in the interim ; later, as the tumor enlarges, the flow is of longer duration and becomes more excessive in quantity. By this time menstruation, which has been regular although excessive, becomes more frequent, appearing every three or even every two weeks, and leaves the patient prostrated from exces- sive loss of blood. The most profound anemia from this cause is not uncommon ; the patient's skin becomes pecuharly transparent, of a waxy yellow hue, and she suffers from dyspnea, epistaxis, and palpitation, with a sense of utter weakness. A distinct anemic heart murmur marks the profound changes in the condition of the blood. Pain is a variable symptom ; it is most marked when the uterus contains a number of smaller myomatous masses distributed throughout its walls, when 340 MYOMECTOMY — HYSTEEO-MYOMECTOMY. it is nsiially menstrual in type and of a distressing, grinding, bearing-down character, often likened to severe protracted labor pains. Disease of the ovaries and tubes is frequently associated with myoma of the uterus, and both ovaries and tubes are often found bound down in the pelvis by old inflannnatory adhesions ; in this way hydrosalpinx and pyo- salpinx are found. This associated inflannnatory disease is often present in con- nection with small tumors, when the pain is doubtless due more to the iniiamma- tion and the tugging on the adhesions than to the presence of the tumors. Fig. 47'J. — Grkatly Enlakged Eifiirr Ovaky removed with a Myomatous Uterus which was the Size OF A Man's Head. At both poles are some large unruptured cysts, and in between a mass of tliiok cirrhotic ovarian tissue. B., Deo. 6, 1897. Natural size. The ovaries found in connection with large myomatous uteri often utulergo remarkable changes which can scarcely be called disease, although considered by Virchow and others as examples of interstitial oophoritis and cys- tic degeneration. These ovaries are for the most part larger than normal, sometimes peculiarly long and flat ; a part of the increase in size is often due to the presence of a number of large unruptured follicles. There is an increase in the number of KINDS AND SITES OP MTOMATA. 341 the corpora albican tia, with increase in the vascularity and thickening of the vessel walls. Popow has shown that the changes affect the albuginea (surface of the ovary), the interstitial tissue of the ovary, and the paranchyma (follicles). The inter- stitial tissue undergoes a marked proliferation, evident in the coarse hypertrophy of the ovary ; the follicles are most numerous in some cases and then atrophy (oophoritis f ollicularis). A typical example of these changes seen in an advanced form is shown in Fig. 4Y9, removed with a large myomatous uterus. Pressure symptoms do not often occur until the tumors are large enough to choke the pelvis, when frequent urination and difficult defecation are common. When a growing tumor becomes incarcerated under the promontory of the sacrum, preventing its escape into the abdomen, these pressure symptoms often become extremely urgent. The examiner must, however, always be on his guard against drawing hasty conclusions from the size and position of the tumor, for it is remarkable how well the rectum is able to maintain a patulous chan- nel under these circumstances. The bladder preserves its function by displace- ment expanding upward into the lower abdomen, and becoming an abdominal organ. One of the serious dangers arising from the presence of the larger myomata. filling the abdomen, more particularly if they are developed under the pelvic peritoneum, is the production of a hydroureter by pressure at the brim, impairing the function of the kidneys, and inducing hydronephrosis. In a series of one hundred hystero-myomectomies in my clinic, two cases were operated upon on account of periodical attacks of urinary suppression due to pressure on the ureters. I have seen three cases of pyelonephrosis associated with myomatous uteri where the disease was probably grafted onto a hydronephrosis produced by pressure. Cancer of the uterus complicating myoma is rare, the malignant dis- ease starting on the uterine mucosa and extending from that point into the myo- matous mass. The malignant growth may start either in the cervical or in the corporeal part of the uterus. Kinds and Sites of Myomata. — One of the most striking and characteristic dif- ferences among myomata is the variation in size. All gradations are found, from one the size of a pin head to a mass weighing over a hundred pounds. The terms large and small may be used in a purely relative sense with re- gard to the environment of the tumor ; for example, we may speak of a uterus not larger than a fist as a small myomatous uterus, but when it is big enough to choke the pelvis and gets wedged in there it is relatively large ; if the same uterus escapes into the abdomen it is small in relation to its surroundings, until it attains the size of a seven or eight months' pregnancy, and begins to encroach upon the abdominal viscera. The mechanical symptoms produced by the smaller tumors are due to pres- sure on various pelvic organs, while the large tumors often become inconvenient 34:2 MYOMECTOMY— HYSTERO-MTOMECTOMY. from their size and weight alone, and in addition derange digestion, deform the thorax, cause difiiculty in respiration, and interference with tlie circulation. According to the site of the tumor relative to the uterine wall, myomata have long heen classified as submucous, interstitial or intramural, subserous or subperitoneal. From a practical standpoint it is important to distinguish these forms, because each is suscex^tible of a different mode of treatment. Submucous myomata project into the uterine cavity and are covered over the greater part of their periphery with the uterine mucous membrane. As a result of the growth of the tumor in this direction the uterine cavity be- comes proportionately enlarged either in its transverse or in its long axis. Fig. 48'"'. — Uterus with E.vten-sm'e Myomatdl's Involvement chiefly Interstitial and Submucous. Note the e.x'trcme distortion of tlie uterine cavity. Ilystero-inyomoetoaiy. Keeovery. H. G., March 21, 1894. 3^ natural size. Interstitial or intramural tumors, situated entirely within the uterine wall, are enveloped on all sides by normal uterine fibers. This form is most aj^t to become subperitoneal as it grows. Subserous or subperitoneal tnmors develop in the direction of the abdominal cavity and are enveloped for the most part by the pertoneum. Both the subserous and the submucous myomata grow toward tlie surface and tend to become more polypoid. The submucous tumors may be finally cast off through the cervix into the vagina, while the subserous narrow their attach- ments down to a thin pedicle and often derive their nutriment from adhesions to other organs. KINDS AND SITES OF MYOMATA. 343 Fibro- cystic tumors are cliaracterized by an excess of fluid elements, rendering them soft or even fluctuant. This fluid, analogous to serum, is held in enormously dilated lymph channels within the tumor. It coagulates spon- taneously on exposure to the air, a clinical feature recognized by the older writers, and considered by them pathognomonic of this variety. This fact, how- ever, is unrehable, because the fluid of a tuberculous peritonitis or of a cystic Graafian foUicle may also coagulate on exposure. If not extirpated early these tumors often attain an enormous size, larger than any other abdominal growth- In one case reported the mass reached the enormous weight of 195 pounds. Usually the outer covering of the tumor, or of each of the individual compo- nent masses, is formed of dense myomatous tissue. Fro. 481. — Mtomatol's Uterus, showing Interstitial and Subperitoneal Masses. The subperitoneal tumor is half concealed behind tlie opened cervix. Note the larixe uterine cavity with a smooth surface presenting a numbei- of translucent vesicles in the lower portion, and on the lower border of the mucous polyp lying within the uterine cavity. Note also the large vessels laid open opposite the inter- nal OS uteri. l*ath. No. 32.5. ^7 natural size. The life history of a myomatous tumor is well illustrated by a case which was followed for twenty-seven years, from the time it was first ob- served to the operation which I j^erformed in May, 1894. The patient (J. S. S., San. lOY), the daughter of a prominent physician, dis- covered an abdominal tumor in 186*7 when in her twenty-seventh year. Two years later she was examined by Dr. Washington L. Atlee, who left the follow- ing notes and drawing of the relations of the tumor to the uterus, for which I am indebted to his son-in-law, Dr. J. M. Drysdale, of Philadelphia. " To-day I examined Miss Norfolk, Va., June 24, 1869. She is as large as a lady seven months advanced, shape uniform, tumor round and prominent, hard, non-elastic, mov- able, not sensitive, extends across both hip bones and upward to the hypochon- 04 344 MYOMECTOMY — HYSTERO-MYOMECTOMY. dria. The superior strait of the pelvis is occupied by the same tumor, and in the posterior part the cervix uteri is felt. It is shortened in length, folded against the tumor in front, soft. The sound enters to the distance of eight or nine inches. " The following diagrams will explain things " (see Fig. 482) : When I saw the patient in May, 1894, twenty-five years later, the abdomen was enormously distended by a great symmetrically disposed tumor, the top of which was 48 centimeters (19 inches) from the level of the bed as she lay on her back. Her circumference at the umbilicus was 128 centi- meters (51 inches) and she measured 114 centimeters (45 inches) from umbilicus to en- siform cartilage. Ascitic fluid was felt in the flanks. She had an umbilical hernia with an opening 6 by 7 centimeters (2J by 3 inches), and a tender, round mass under the right ribs which was a distended gall bladder. She was suffer- ing acutely with renal colic due to suppression of the urine from pressure on the ureters. At the operation, May 12, the small uterus was found crowded down on the pelvic floor, and the enormous fibroid mass, weighing 59 pounds, was attached to the anterior uterine wall by a pedicle 1 centimeter long and 3 by 2 centimeters broad, nourished by three enormous arteries ^ centimeter in diameter, coursing super- ficially over the anterior part of the fundus. The tumor was extirpated after a long and difiicult operation, on account of the numerous vascular ventral adhesions. The gall bladder was also opened and a quantity of pus evacuated. She made an uninterrupted recovery and is now living in perfect health. The great interest attached to this case is the entire change in position assumed by a tumor already of great size. Dr. Atlee's record shows that in 1869 the tumor involved the whole body of the uterus, lengthening out its cavity 9 inches. When I examined it, twenty - five years after, in spite of its immense size, it had become extruded from the grasp of the uterine muscular tissue, and was so far detached from its broad base as to be left with a comparatively small pedicle. Broad-ligament myomata develop from the lateral wall of the uterus out between the anterior and posterior layers of the broad ligament and Fig. 482. — These diagrams are copies of sketches made by Dr. Washington L. Atlee in 1869. It is important to note the length of the uterine cavity and the intimate relations of the myoma with the uterine walls. When seen by me twenty-five years later, the uterus was of normal size, and the enormous tumor was attached to the fundus by a pedicle 1 centimeter long. KINDS AND SITES OF MYOMATA. 345 extend down toward the pelvic floor, and are in reality a variety of the sub- serous form. When pedunculated, the myomata vary in size from small polyps all the way to huge tumor masses, either submucous or subserous. The pedicle may even be several inches long, but in the subserous form it is rarely over half an inch in length. Sessile tumors have a broad flat base, often with more than half the growth projecting into the uterine or into the peritoneal cavity. The number of myomata found in one uterus varies from a single one or several to an indefinite number, when the uterine tissue is converted into a myomatous mass, consisting of a great number of small nodules. From a practical standpoint the exact location of single tumors, whether cervical or corporeal, is important. With few exceptions it is the fleshy body of the uterus above the neck alone which is involved. When both body and Fig. 483,— Globular Myomatous Uterus presentino Form of pregnant Uterus at Term, with Adap- tation OF THE Lo-ER Part of its Form to that of the Telvic Cavity. . The lower part of the tumor is subperitoneal, and the cervix is displaced up to the level of the pelvic brun. Iwo peritoneal adhesions are shown above the cervical opening. Seen from behind. Hystero-mvo- mectomy. Eecovery. Path. No. 325. i^ natural size. i- e .) .-e o uijo cervix are involved, the vaginal portion of the cervix is distorted and partially or even entirely obliterated, being represented by a mere dimple on the vagi- nal wall. Parasitic myomata are usually pedunculated and depend for a part or the whole of their blood supply upon adventitious vessels of the adjacent 346 MYOMECTOMY — HYSTEEO-MYOMECTOMY. organs. Such tumors are generally large abdominal growths, either entirely detached from the uterus, or connected with it by a small pedicle only, while they are intimately attached to the abdominal walls, intestines, or omentum. Tumors with omental attacliments present the most striking characteristics of this group ; the omentum forms a fringe around the upper border of the mass, and its congested and tortuous blood vessels are enlarged to the size of goose quills, looking like a cluster of whip cords or a collection of angleworms in the space between the tumor and the transverse colon. Form Peculiarities . — When unrestrained in its growth a single myoma will assume a more or less spherical form, and retain it until outside influences compel a change. Various I'cstricting influences frequently impress other than a spherical form upon these tumors. Two sets of external forces come into play in this molding process, the hard and the soft parts. Irregular tumor outlines arising from forces within the tumor itself are found when there is a coincident development of a number of these tumors, and when fresh Fig. 484.— Myomatous Uterus, exhibiting a Teiu'eot Cast or the Telvis. A rubber ligature has been thrown around the neck of tlie mass and tied to control the circulation, a pro- cedure no lonjrer employed. The uppermost part of the mass in the picture lay in contact with the pelvic floor, the tumor has therefore been inverted in lifting it out. It is evid'Mt that the large upper tumor forms a perfect cast of tlie sacral curve and the posterior pelvis. Note the irreirular masses, in contact with the ab- flomen just above the rul)ber tube, which projected out of the pelvis into tlie abdomen. Hystero-myomec- touiy. Kecovery. (Jet. 12, 1^02. nodules bud out on the surface of a tumor, in which case the tumor presents a lobulated or bo.ssed appearance. The most striking instances of the plastic influence of repeated impacts of the soft parts is represented by the vertical furrows on large tumors due to the pressure of the linea alba. The persistence with which the rectum preserves a patulous channel when the pelvis appears to be completely choked is an exam- KINDS AND SITES OF MTOJIATA. 347 pie of the power of a weak force acting with persistent regularity on a more or less resisting body. A myoma is occasionally detained within tlie bony pelvis until its cavity is choked with the tumor, which then presents a perfect cast of the posterior part 5. — Large Subperitoneal Myoma, seen from Behind. Showing remarkable adaptation of form to the vertebral column. FU^ the fundus of the uterus lay on the sacral promontory, and the mass, T, below, lay on the pelvic floor, while T, above, lay on the lumbar vertebrae.. From T to FU, to T, the form of the tumor is concave, exactly following the vertebral column down to the pelvic Hoor. The large tumor is also exactly adapted in its form to the lumbar vertebrae from side to side ; its concavity thus presents a perfect cast of the lumbar vertebral bodies and the sacral promon- tory. Hystero-myomectomy. Kecovery. Path. No. 498. ^/t natural size. of the pelvis, showing exquisitely the sacral curve and the breadth of the pelvis. The surface appears smooth, but, if examined minutely, slight irregularities due to suppressed budding tumors are evident. This explanation is borne out by the fact that clusters of large spherical nodules often bud out through the supe- rior straight from the main body of the tumor. Another remarkable evidence of the conformation of myomatous tumors to their environment is seen in the adaptation of some of the larger tumors to the sacral promontory and the projecting bodies of the lumbar vertebrae (see Fig. 485). 348 MYOMECTOMY — HYSTERO-MYOMECTOMY. Diagnosis. — When a patient complains of painful menstruation, becoming profuse and protracted, and has a history of sterility or early miscarriages, myoma may be suspected. A direct examina- tion to determine the size and shape of the uterus is, however, the only reliable means of deciding the nature of the disease, and in order to detect and locate accu- rately small tumors, it is necessary to examine the pa- tient under an anesthetic. The inferior lip of the cervix is caught with a corrugated tenaculum or with bullet forceps, and while making traction to draw the uterus down toward the outlet the index finger is carried high up in the rectum above the ampulla. Tumors of small size are felt as little nodules or distinct rounded elevations on the ventral or dorsal surfaces of the womb. I have thus repeatedly detected myomata of less than a half centimeter in diam- eter high up on the fundus. I recall one case which had been treated symptomatically twenty-five years for dysmenorrhea and nothing abnormal was detected ; when, however, the examination was made under anesthesia per rectum, the uterus was foimd to be full of little myomata. When the tumor occupies the lower abdomen or fills a large part of the abdominal cavity, more distinct diagnostic signs are observed. The abdomen may have an irregular nodular appearance which is quite charac- teristic (see Vol. I, Fig. 5Y), or if the tumor is a symmetrical spherical mass, it often closely simulates a pregnant uterus (see Fig. 483 ; also Vol. I, Fig. 55). In such a case the history of the long continuance of the growth, often over a period of many years, must be considered in connection with the digital exami- nation in making a diagnosis. One strong peculiarity often present in these myomata is the sharp contour made by the upper border of the tumor as it drops to the chest level with the patient in the dorsal position. The resistance of most myomata to palpation is characteristic — they give the sensation of dense hard unyielding masses ; in exceptional cases, however, all the gradations are found from the puttylike through the soft vascular to the fluctuating cystic myomata. The crucial point in establishing the diagnosis is to determine the relation of the tumor mass to the body of the uterus. This is arrived at by an examination through the vagina in order to determine the position, size, and relations of the cervix to the tumor, and the relations of the tumor to the pelvic cavity. In some cases the cervix projects into the vagina as a rounded knob, and can be traced up to a point where it enters directly into the tumor ; in others, the cervix is either completely involved, and is I'epresented simply by a little orifice in the tumor, often drawn high up into the abdominal cavity, or one of its lips remains as a ridge over this orifice, which may be widened into a slit. In cases which present such charac- teristic signs of myoma, the diagnosis may be made unhesitatingly from the vaginal examination alone. Sometimes the cervix can be traced well above the vaginal vault, and appears to be more or less movable on the surface of the mass DIAGNOSIS. 349 to which it seems to be bound by adhesions. In such cases a rectal examination is required to decide whether the body felt above the vaginal vault and con- tinuous with the vaginal cervix is a small uterus on top of a tumor, or whether it is simply the supravaginal portion of the cervix and the tumor is the enlarged body of the uterus. In order to make the rectal examination satisfactory, the lower bowel must be emptied by a purgative the night before examination, and by an enema in the morning. The finger introduced into the rectum is assisted by the other hand pressing down through the abdominal walls to determine the size and position of the supravaginal cervix. Particular attention is next given to a study of the relation of the cervix to the tumor by slowly and carefully carrying the finger along the posterior surface of the cervix up to the tumor ; this settles the question whether the cervix enters into the tumor or is simply attached to its surface. It must be borne in mind that the distinction between cervix and body is sometimes remarkably emphasized, the body being occupied by the growths, while the cervix remains unaffected and seems to be independent of the tumor. When the cervix is elongated and doubt exists as to whether it is simply a part or the whole of the uterus, the introduction of a flexi- ble sound will settle the doubt by passing directly through the cervical canal and on into the body of the growth. By grasping the cervix with bullet forceps and drawing it down toward the vaginal outlet, while bimanual palpation is made through the rectum and the abdominal walls, the nature of the connection between the upper limit of the cervix and the mass may be still further determined. A cervix going into the mass will be felt to make a direct pull upon it at the point of entrance, while if the small body above the vagina comprises the whole uterus, it will be drawn down and palpated over its fundus and shown to be attached to the mass simply by adhesions. Large myomata, except those which are subserous and pedunculate, distort and increase the length of the uterine cavity, and this alteration often constitutes an important factor in establishing the diagnosis. When the fundus of the uterus can be felt high up on the tumor, or one of the round ligaments is distinguished as a tense cord extending from the main body of the mass down to the inguinal ring, or an enlarged ovary rotated high up and to the front can be distinctly palpated, ^vhile the vaginal cervix is felt below, the existence of an elongated uterine cavity is perfectly evident. When none of these landmarks can be recognized with certainty, the length and direc- tion of the cavity can be measured with a flexible hard rubber uterine sound. If the sound does not enter easily under the guidance of the finger, its introduction may be facilitated by catching the cervix and holding it with a pair of bullet forceps. It is essential during these examinations to observe all the individual peculiarities of the case, which may have an im- portant bearing upon operative treatment or for future comparison to determine whether any changes have occurred ; for example, the size of the tumor and the 350 MYOMECTOMY — HYSTEEO-MYOMECTOMY. extent to which it fills the pelvis, whether in one or all directions, should be noted, as well as the condition and size of the cervix and its position, whether in Omeut.ves. Fig. 486. — Pedunculated Myomata, giving a Perfect Ballottement. Antekior View. The uterus contains numerous interstitial and sessile myoniata, and on its fundus are two pedunculated tumors about the size of a child's head at seven months. The abdomen was filled with ascitic fluid just sufficient to raise the anterior wall 2 or 3 centimeters away from the tumor on the left. On giving the tumor a slight blow, it disappeared at once, to return again immediately and strike the finger a gentle blow back, perfectly imitating the ballottemcnt of pregnancy. Note the manner in which the enlarged omental vessels plunge directly into the tumor. ^ natural size. the pelvis or drawn upward into the alxlomen. In large tumors the abdominal enlargement should be recorded from the circular measurements of the patient's PALLIATIVE TREATMENT. 351 body, and a good contour may be made witb a flexible leaden tape ; the position and size of prominent bosses are also to be described. A sound passed into the bladder will show whether it has suflEered any displacement along with the tumor. The degree of mobility of the tumor may be tested by rocking it from side to side and pushing it up from below. One of the most remarkable myomata I have ever seen exhibited distinctly the sign of ballottement, hitherto considered pathognomonic of preg- nancy. The abdomen was prominently distended, much in the form of a preg- nancy of about eight months, and the uterus was enlarged by two fibroid masses which reached almost to the umbilicus. There was enough ascitic fluid to fill the flanks and occupy the space between the tumors and the abdominal wall. On palpating the abdomen at a point 5 or 6 centimeters above the symphysis noth- ing was felt, but on making sudden deep pressure through about 4 centimeters of fluid a hard body was encountered which instantly disappeared from touch and returned again one or two seconds later, striking the fingers with a decided blow as it came back. An accurate means of recording changes in the form of the abdomen, which can be seen but are diflicult to describe, is by photography. Two pictures should be taken as the patient lies on the table, a side view and a quartering one, on 4 by 5 plates. It is of assistance in judging the size and relations of the tumor if the umbilicus is shown in the pictures. A picture taken from below looking up toward the chest shows the elevation of the tumor and any asymmetry be- tween right and left sides. A photograph of the tumor after its removal com- pletes the record. Palliative Treatment. — The treatment of myomata is either expectant, pallia- tive, abortive, or radical. The great majority of myomatous uteri require no treatment whatever ; many of the smaller growths produce no symptoms, and their discovery is often purely accidental. Frequently the patient herself is the first to notice a small abdominal tumor, although I have seen women with a tumor as large as a seven months' pregnancy who did not know it existed. When it is not larger than a three or four months' pregnancy and produces no subjective symptoms no treatment of any kind is called for. A careful examination, however, should be made and the observa- tions recorded, and the patient advised to return for examination at long intervals, so that any changes and the rate of growth may be watched. No surgical treat- ment should be instituted when a myomatous uterus is complicated by an ad- vanced nephritis, a double pyelonephrosis, or a persistent glycosuria. I mention each of these complications because I have met them. Kelief of Pressure Symptoms. — Discomfort in walking, backache, and a sense of pressure will often be relieved in a small myomatous uterus, where the fundus is retroflexed, by packing the vagina with cotton or wool tampons, or by the use of a pessary, which may even be inserted without replac- ing the uterus and still do good. When the tumor is large enough to choke the pelvis and does not rise into the abdomen, but is held beneath the sacral promontory, sometimes great reUef follows its elevation into the abdomen under 352 MYOMECTOMY — HYSTERO-MYOMECTOMY. an anesthetic. Care must be taken not to force the displacement unless the mass seems free from adhesions. There is a decided risk in doing this, because the large vessels at the point of attachment of the tumor to the uterus are liable to rupture when the pedicle is friable. Hemorrhage. — Profuse menstrual hemorrhages with prolonged periods, lasting one, two, or three weeks, often accompany submucous myomata and large myomatous uteri in association with a hypertrophy of the uterine mucosa ; this may often be relieved for a long period, or even permanently, by dilata- tion of the cervix and a thorough curettage (see Chapter XIV). Fig. 4S7. — Large Globular Myoma choking the Pelvis, compressing Kectuai and Bladder, and FORCING THE BlaDDER UP INTO THE ABDOMEN. Note the retrofle.xion of the uterus. About half size. Autopsy, Jan. 15, 1897. There should be no relaxation in the preparatory details, as described in Chapter XIV, as curettage may be followed by a fatal termination, if great care is not observed in rendering the vagina and cervix as sterile as possible. The posterior vaginal wall is retracted with a Sims or Simon speculum, the anterior lip of the cervix is caught by a pair of bullet forceps, and the uter- ine sound passed in to determine the length, the direction, and the size of the PALLIATIVE TREATMENT. 353 uterine cavity. Guided by this information, the smallest uterine dilator is in- troduced, and the cervix equably stretched in all directions as described. The evidence of the thoroughness of the operation will be shown by the large Fig. 488. — The same myoma lifted up into tiie abdomen out of its bed, showing the hypertrophy of the anterior uterine wall, and the complete detachment of the bladder from the uterus and the upper vagina. Note also the compression of the rectum. amount of tissue discharged through the os in the form of pale shreds and strips of mucous membrane. If the cervix is displaced upward it will often be more readily exposed by placing the patient in the left lateral position. In some of these cases, however, the displacement is so great and the uterine canal so distorted that neither sound nor dilator can be introduced, and curettage is utterly impracticable. 354 MYOMECTOMY— HYSTEEO-MYOMECTOMT. Curettage performed under aseptic conditions is free from danger and worthy of a more general use, as it often gives great temporary relief and does not prevent a subsequent radical treatment. The galvanic electric current, used for the same purpose, is prob- ably the most efficient means of controlling hemorrhage, and producing such permanent surface changes in the uterine mucosa as will tend to prevent its re- turn. The current is applied by introducing a long positive platinum or carbon electrode high up in the uterus, and placing a broad wet cotton or clay negative electrode over the tumor on the abdominal wall. In this way from 50 to 150 milliamperes are used, the limit being deter- mined by the sensitiveness of the patient. The sittings last from five to ten minutes, and after each the patient should remain an hour or more in bed. The application may be repeated every five or seven days, and usually in the course of two or three months the tendency to hemorrhage entirely disappears. Drugs are, as a rule, of little or no service in checking hemorrhage. In rare instances an inhibiting effect is exerted by ergotin, in the dose of 1 to 2 grains four times daily. ABBOMHSTAL OPERATIONS UPON THE MYOMATOUS UTERUS. 1. General indications for operation. 2. Removal of ovaries and tubes without the tumoi'. 3. Enucleation of the myomata — myomectomy. 4. Removal of the myomatous uterus, leaving the cervix — hystero-myomec- tomy. 5. Removal of the myomata with the whole uterus — pan-hystero myomec- tomy. The indications for radical treatment by attacking the myomata directly are absolute and relative. Operation is imperative when the tumor chokes the pelvis and is producing serious symptoms from pressure upon the rec- tum, bladder, or ureters, or when the tumor occupying the abdomen has reached the size of a seven months' pregnancy or larger, and continues to grow. Here pressure upon the bladder, ureters, intestines, stomach, and diaphragm usually produce their characteristic symptoms, which increase until they are so distress- ing as to force the removal of the tumor. The extirpation of the tumor is also indicated when the size is great enough to interfere with the patient's occu- pation. Exhausting hemorrhages also demand radical treatment if curettage and electricity have failed to check the flow. Relative indications are pain, more or less persistent, causing partial or complete invalidism ; this, if not relieved by minor measures, may be so dis- tressing as to necessitate operation. The pain of these cases is often due to a pelvic peritonitis and the associated lesions of the tubes and ovaries. Troublesome hemorrhages and discomforts of all kinds, reducing the patient to a semi-invalided condition, may also be classed among the relative indications, which must be well weighed before deciding to resort to an operation. MYOMECTOMY. 355 In some patients the constant distress of mind from knowing that they have a tumor forms a vahd indication for operation. Abdominal operations for myomata are contra-indicated when there is grave organic disease of other organs, which will probably within a short time prove fatal. Advanced heart or kidney disease, phthisis, emphysema, and asthma all contra-indicate operation. In every case the urine should be examined with extreme care to exclude nephritis, pyelonephrosis, and diabetes. Myomectomy. — Myomectomy is the enucleation of a myoma or fibroid tu- mor without the sacrifice of any material portion of the uterus ; it is thus con- trasted with hystero-myomectomy, which is the removal of the uterine body together with the tumor, and with pan-hystero-myomectomy, which is the re- moval of the entire uterus with its myomata. The defect created by the re- moval of the tumor is closed in by interrupted sutures uniting the base and the edges of the wound, and leaving a normal uterus functionally perfect. Ab- dominal myomectomy is one of the most actively conservative of all operative procedures, and is the counterpart of the vaginal extirpation of submucous myomata. (See Chapter XVIII.) Myomectomy is especially adapted to the treatment of single or of isolated tumors, so disposed that they can be readily excised or shelled out of their beds without undue injury to or loss of the uterine tissue. It should therefore be elected as the proper mode of treatment of all isolated pedunculate, and of many isolated sessile, interstitial, or broad-ligament growths. I have treated in this way a uterus containing as many as nine myomata, each one of which was removed by a separate incision, as well as another containing twelve myomata. ISTo more important advance can be made by the gynecologist in the immediate future than by extending the indications for myomectomy and narrowing the field of hystero-myomectomy, and so saving the uterus wherever possible. Myomectomy should always be preferred to hystero- myomectomy in a young woman, provided there are no comphcat- ing conditions, such as an extreme anemia, in which case the prime indications are to check the hemorrhages and to avoid a protracted operation. Another contra- indication to myomectomy is the presence of any extensive pelvic inflammatory disease, particularly of pelvic abscesses, or the presence of ovarian or dermoid cysts. Myomectomy also should not be performed when there exists any grave dis- ease of other abdominal organs or of the thoracic viscera. "When the uterus is larger than a six months' pregnancy the diflSculties of closing the wounds made by the removal of the large tumors is so great that for the present the indications for myomectomy have not been extended beyond this limit. With these few plain limitations, myomectomy, within the proper age limit, must always be the operation of election, and if hystero-myomectomy is performed, definite reasons must be given why the radical instead of the conservative plan of treatment is selected. 356 MYOMECTOMY — HYSTEKO-MYOMECTOMY. Myomatous tumors may be enucleated from the size of a pea up to that of an adult head or larger, in any number, and wherever and however situated or attached. Categorically stated, cases suitable for abdominal myomectomy are, in general, all single and discrete tumors which can be clearly isolated, and in particular — (a) All pedunculate myomata, where the removal of the tumor will leave a normal uterus. (b) All, even the largest, subse- rous or interstitial myomata which are well defined in relation to the body of the uterus, whether single or multiple. (c) Multiple small myomata in any number. (d) Broad-ligament myomata. (e) A myoma locaHzed at one cornu of the uterus. (f) Submucous myomata too large to be taken out by the vagiua. In careful hands, with the best technique possible, myomectomy is a safe operation, but an inexperi- enced, indifferent operator, and one whose technique is slipshod, will in- evitably lose many cases from hem- orrhage and from sepsis. Under such circumstances the conservative myomectomy is a far more danger- ous operation than the more radical hystero -myomectomy. Much can be done before the operation to determine whether a myomectomy or a hystero-myomectomy should be performed, by making a thorough examination. Where, for example, the rectal, vaginal, and abdominal examinations show that the tumor springs from the uterus by a well-defined pedicle, and that there are no other tumors in the uterus, the surgeon will be able to assure the patient beforehand that at the operation he will merely remove the tumor, and that there will be no mutila- tion. Also, when a careful bimanual examination has shown that the uterus is occupied by several well-defined tumors from the size of a walnut to that of a hen's egg, the operator may then anticipate that a myomectomy will be possible, and the same may be said regarding any number of small myomata. The expectation that a myomectomy will be performed may also be cher- ished whenever a single myoma is found either laterally, or before or behind the uterus, and the uterine canal is shown by measurement not to be much R.rJ l;g Fig. 489. — Uterus after Extirpation of the Myoma- tous Tumor. Showing great muscular hypertrophy, measuring, whcu returned to the abdomen, 14 x 17 centimeters. A row of twenty-nine sutures used in closing the incision in the uterine wall. Jan. 9, 1897. % natural size. MYOMECTOMY. 357 lengthened out, for such an examination demonstrates the fact that the tumor springs more from the upper part of the body, where enucleation is always easier. Whenever a mass of myomata, however large, springs from the fundus, and the examination shows that the uterine canal is not at all, or not much length- ened, and the ovaries are low down on the pelvis beside the body of the uterus, the operator may then also expect to remove the mass alone from the fundus by a myomectomy. With increasing experience in performing myomectomies, after eliminating the possibility of any grave extra-pelvic complications, and assuring himself that there is no extensive pelvic inflammation, the skillful operator will be able to assure all young patients with myomatous uteri which do not rise above the umbilicus that he will in all human probability be able to extirpate the tumors and leave the uterus, ovaries, and oviducts. The election of an abdominal instead of a vaginal myomectomy for a large submucous tumor is made after determining its size and relations by a vaginal examination, and then estimating the difficulties and dangers of the vagi- nal route as greater than the abdominal, on account of a contracted cervix and a vaginal outlet, often quite narrow, making it exceedingly awkward to get at the entire mass and bring it away piecemeal. Operation. — The general principles governing the operation are : (a) A good exposure of the tumors and the uterus through a free abdominal incision with an elevated pelvis. (b) The isolation of the tumor (brought outside if possible) by surrounding it with gauze. (c) The incision around the pedicle or through the capsule, exposing the tumor. (d) The temporary control of hemorrhage by clamps and compression of the main vascular trunks, as, for example, by placing a ligature around the cer- vical portion of the uterus. (e) The enucleation of the tumor from its bed. (f) The permanent control of hemorrhage by ligatures and buried sutures, and sometimes by ligating the uterine arteries. (g) The closure of the iiterine incisions, giving careful attention to the angles, and seeing that no hemorrhage continues between the sutures. (h) Closure of the abdominal incision without a drain. The great danger after the operation is hemorrhage which can only be pre- vented by a most careful attention to the steps detailed. It is an important rule always to inspect the wounds for hemorrhage, with the table dropped level, be- fore closing the abdomen. Pedunculate Myomata . — The abdominal incision must be made large enough to get the tumor out by its smallest axis, together with the fundus of the uterus ; the intestines are then protected by gauze and an assistant grasps and compresses the uterus tightly just below the pedicle to control the hemorrhage, while the operator rapidly makes an incision around the tumor up on its pedicle from 2 to 3 centimeters from the uterine attachment, closer to the 358 MYOMECTOMY — H YSTERO-MYOMECTOMY. uterus at the ends, and the mass is removed. Actively bleeding vessels are at once caught by artery forceps. The freest oozing will usually be found at the Fig. 4110. — Myomatous I hi i- < )iNsek\'ative Oi'ekation. Removing three large myomata (J/, J/, M) without saeriticing the uterus. May 11, 1S06. periphery or in the center of the stump, and, owing to the nature of the tissue, it is not possible to pick up l)leeding points and throAV a ligature about them in Fig. 491. — Conservativk Treat.ment of the Myomatous Uterus. Showing the method of grasping the large posterior tumor and making traction while an oval incision is made not far from its base through the enveloping uterine wall down to the tumor, which is shelled out of its base by traetion and dissection. MYOMECTOMY. 359 the ordinary way. The best plan is to control actively bleeding areas down the middle of the pedicle by passing a mattress suture around each one, including the adjacent tissues, and tying it tight. Large vessels at the periphery are best controlled by passing a liga- ture under the vessel in the uterine tissue a short dis- tance from the edge of the incision. The opposite sides of the incision are next firmly ap- proximated by a series of interrupted deep catgut su- tures. The sutures must be laid so as to inake the most pressure on the bleeding points and thus aid in con trolling the hemorrhage. Every particle of bleeding must be checked before closing the abdomen. Subserous Sessile and Interstitial My- oma t a . — Sessile and inter- stitial tumors vary in size from masses as large as a uterus five months preg- nant down to peaHke nodules on the surface or buried in the uterine wall. The larger tumors when interstitial lie encapsulated in a mass of hypertrophied uterine tissue. The operation for their removal consists in a linear incision through the capsule of peritoneum or uterine tissue, down into the white fibrous tissue of the tumor, grasping the exposed tumor with a pair of stout claw forceps, and elevat- ing it, as it is gradually shelled out of its bed by the fingers, or preferably by some flat blunt instrument, like the handle of a scalpel or closed scissors. Fig. 402. — Same uterus after removal of the tumors, showing the broad bases of uterine tissue now about to be brought together by buried and interrupted eatgut sutures, drawing the lips of the wounds as indieated by the crossed arrows. Kelly's Myoma Enuclka If the uterine cavity is opened it must at once be wiped clean and dry and care taken not to spread its contents over the wound. In- terrupted catgut ligatures should be used in closing the cavity. In passing the deep sutures they should reach down to the mucosa, but should not pene- trate it. In one ease I tore up the entire uterine mucosa of the anterior wall from cervix to fundus, in the form of a triangular flap ; this was closed with a delicate 360 MYOMECTOMY — HYSTEEO-MYOMECTOMY. continuous catgut suture and the rest of the uterine wound, made by the extir- pation of a large tumor, was closed in by buried and interrupted sutures. Per- fect recovery followed. In another case I found it necessary to resect at least a third of the uterine cavity. It may be necessary, if the tumors are large, to control temporarily the uterine circulation by an elastic ligature or a gauze rope twisted around the body of the uterus below the tumor. When the cervical portion of the uterus can be grasped the assistant is able to control the circulation for a while by squeezing it with two hands. The sutures should be laid with a large curved needle armed with a carrier, which is boldly carried deep down through the uterine tissue from one side of the incision across to the other. Numerous sutures and tight hgation will con- trol the bleeding in all cases. The cavity produced by the enucleation of the tumor must always be closed perfectly from bottom to top, to avoid leaving a dead space with the formation of a blood clot which is liable to become septic. Interrupted buried sutures in one, two, or three tiers will serve to approximate the wound below the surface. Wherever there is bleeding a suture is passed and tied tightly. After the wound is well brought together in this way the elastic ligature or the gauze rope is cut to restore the circulation, and additional deep sutures are passed wherever there is any bleeding. At least one tight suture should be placed at each angle of the wound, and, if necessary, beyond the angle, as that is the point most liable to continue bleeding after the abdo- men is closed. The utmost pains must be taken not to handle the structures which are to be left behind any more than is absolutely possible. The hands of the operator and assistants should, in all cases, be protected by sterilized rubber gloves. The uterus should be surrounded with gauze and then laid open. As soon as the overlying tissue is incised and the tumor exposed and caught with forceps, the lips of the incision should be grasped with gauze pads and worked back off from the tumor as it is being drawn forward. When the tumor is removed it will lessen the risks of sepsis if the operator will tie all the hgatures and sutures with lingers protected by rubber linger stalls. It will be possible in this way to conduct an extensive myomectomy from beginning to end without once coming into direct contact with the structures which are to be returned to the abdominal cavity. An interesting example of what may be done by myomectomy to conserve the uterus is afforded by the case of M. A. (No. 1576), operated upon Nov. 5, 1892. An incision 10 centimeters long was made through the abdominal walls, and eight subserous and interstitial myomata were removed from the uterus by seven separate incisions. The duration of the operation down to the closure of the abdominal incision was thirty minutes. The following case shows further what may be done in the ^vay of conserva- tism : F. E. S., 4055, operated upon Jan. 6, 1896, had a myomatous uterus filling the pelvis and rising well above the brim, about as large as a four and a MYOMECTOMY. 361 half months' pregnancy. Per vaginam the cervix seemed to be attached directly at the central portion of the mass, and the fundus could not be felt. The abdomen was opened, and the tumor, which just iilled out the pelvis, brought up and out of the incision. The fundus, with tubes and ovaiies, lay --jrr -=^^g^SSD2Sj Fig. 494 — Myomatous Uterus from wpiich Eight Myomata were enucleated by Seven Incisions. May 11, 1896. in front of the tumor, which was developed in the lower posterior portion of the uterus. I split the capsule 1 to 2 centimeters thick, and rapidly enucleated a fibroid mass 12 x 10 x 10 centimeters in size, without exposing the uterine cavity at all. The bleeding was free but not excessive, and was controlled by eight to ten pairs of forceps. Several vessels were tied with catgut, and the en- tire bed of the tumor obliterated by continu- ous catgut sutures. The edges of the wound were united by intermpted catgut su- tures, and extended, when closed, 15 centi- meters from a point be- neath the left utero-ova- rian ligament downward in the middle line to the pelvic floor. A small myoma, 1-5 by 1'5 centimeters, was also taken out in front of the left cornu. (See also Figs. 494 and 495.) Cornual Myoma . — When a myoma is situated deep in the uterine tissue at one of the cornua, lifting up the uterine tube, the uterus may be saved by Fig. 495. — Uteei-s FROM "WHICH EtGJIT MyOMATA WEBE REMOVED BY Seven Incisions. Showing incisions closed bj interrupted catgut sutures. 362 MYOMECTOMY — HYSTERO-MYOMEOTOMY. removing the tumor with the tube, and, if need be, the ovary of that side. The circulation of the uterus is controlled either by an elastic ligature around the cervical end, or, better, by tying the uterine artery of that side well below the cornu and iigating the ovarian vessels out near the brim of the pelvis. A small oval incision is then made, to include tlie uterine end of the tube, exposing the tumor in its bed ; the growth is then enucleated, as in a case (S. L., 2500) oper- ated on Jan. 15, 1894, where the tube and ovary of the side where the tumor lay were involved in peritoneal adhesions. The uterine cavity was opened periton. Fig. 496. — L.\roE Sibmicous M-^ova. Adapted to removal by abdominal section by splitting open the uterus and enucleating then sewing up the uterine incision. % natural size. the tumor, and The wedge-shaped flaps left after the enucleation were brought firmly and neatly together and the whole drojjped, and the abdomen closed without a drain. Extirpation of S u 1) m u c o u s M y o m a t a per Abdomen . — We owe to Prof. A. Martin, of Berlin, the extension of the field of abdominal myomectomy to the removal of submucous myomata. (See Cent.f. Gyn., July 31, 1886.) MYOSIECTOMT. 363 This operation is indicated when the myoma is the size of a child's head or larger, and the entire cervical canal is undilated, or when a part of a krge; myoma has been extruded through the cervix, leaving a large intra-uterine mass which can not be reached readily through the vagina. Whenever the tumor can be reached by the vagina it should be removed by morcellation. Before the operation it is necessary to disinfect the vagina and the uterine cavity by irrigation with a five-per-cent solution of creolin, and then to pack the uterus, if it can be reached, with iodoform or sterilized gauze, to prevent the escape of secretions over the wound surface and into the peritoneal cavity when the uterus is opened from above. If there is a foul uterine discharge, it wiU be wiser to delay operation until by douches and drainage its character is changed ; if an immediate operation is imperative, it will be safest to sew the cervix up tight and remove the entire uterus when the abdomen is opened. The operation consists in the following steps : 1. Opening the abdomen. 2. Lifting out the uterus onto a gauze napkin, and packing gauze into the posterior pelvis all around the uterus. 3. A temporary rubber ligature around the cervical portion of the uterus to control hemorrhage. 4. Opening the uterine cavity and shelling out the tumor. 5. Closing the uterus by suture and returning it to the abdominal cavity. 6. Closing the abdominal incision. An incision in the lijiea a 1 b a is made large enough to bring the uterus out onto the abdomen. A thick gauze pad is placed beneath it, and tow- els or gauze are packed close around its lower portion and down into the inci- sion, to prevent any possible contamination in case any of its contents should escape when it is opened. A provisional rubber or gauze ligature is thrown about the uterus below the tumor and tied before the uterine incision is made. The position of the pedicle may sometimes be discovered by sliding the uterine walls over the tumor inside of it ; the pedicle will be found at the fixed point which refuses to slide. The incision should be made by preference on the anterior wall, or it may be made across the fundus, away from the pedicle, in the long axis of the uterus, just below the fundus, and it should extend down to the cervix. A few strokes, of the knife lay the uterus open from top to bottom, exposing the tumor. The gauze in the uterus is then taken out with forceps, and a piece of fresh sterilized gauze packed in to protect the margins of the incision, while the tumor is grasped with a sterilized towel or a piece of gauze and peeled from its base by torsion or removed by incising its capsule and peeling it out. The utmost care must be constantly exercised not to let the tumor or any of the contents of the uterine cavity touch the edges of the incision. In a suppurating myoma such a procedure is rarely if ever justifiable. The uterine incision is closed by catgut sutures about 1 centimeter apart, entering and emerging about half a centimeter from the margins of the inci- 364 MYOMECTOMY — HYSTEEO-MYOMECTOMY. sion, and carried down to the mucosa, but not entering it. The sutures should be tied as rapidly as possible until all active bleeding is checked. After the deep sutures are tied, any remaining areas of imperfect approximation may be corrected by half -deep sutures of catgut, passing 5 to 8 millimeters into the tis- sue, as in the Cesarean operation. I prefer to use chromicized catgut at those points which include large vessels. Infective material having been carefully excluded, the abdominal cavity re- quires no cleansing. The gauze pads supporting the uterus are removed and the uterus replaced in the pelvic cavity in anteflexion, so as to keep the intes- tines from coming in contact with the line of incision. The abdominal cavity is then closed, and the after-treatment conducted as usual. Hystero-myomectomy. — Hystero-myomectomy is the correct name of the oper- ation commonly described at length as " supravaginal hysterectomy for fibroid tumors." It consists in the removal of a part or the whole body of the uterus with its tumor masses, usually amputated through the cervix. The history of the evolution of our present methods of treating fibroid tumors of the uterus is deeply interesting, particularly to an American, on ac- count of the important part played by our own surgeons in developing the methods which are now recognized as the best. This subject has commanded the careful attention of Dr. E. ~W. Gushing, of Boston {Ann. of Gyn. and Pediatry, 1895, p. 5Y3), and more recently of Dr. C. P. Noble, of Philadelphia, to whose painstaking studies I am particularly indebted for the historical information which follows. In April, 1845, Dr. W. L. Atlee published a paper in the Amer. Jour, of the Med. Sci. entitled Case of Successful Extirpation of a Fibrous Tumor of the Peritoneal Surface of the Uterus ly the Large Peritoneal Section. The opera- tion was performed in Aug., 1844. From this time on Atlee continued to operate upon fibroid tumors, and he contributed to the literature of the subject throughout his long professional career. He generally operated for the removal of the tumor only, either by the vagina or by abdominal section ; but he occasion- ally did hysterectomy. One of his most important papers was a prize essay published in the Trans, of the Amer. Med. Assoc, 1853, p. 547, and entitled The Surgical ' Treatment of Certain Fibrous Tumors of the Uterus, heretofore considered beyond the Resources of Art. Dr. Walter Burnham, of Lowell, Mass., operated upon a patient June 26, 1853, with the expectation of removing an ovarian cyst, but the tumor proved to be a fibroid which was extruded from the wound by the act of vomiting and could not be replaced. Burnham therefore had to remove it ; he did this by first taking away two pedunculated fibroids to reduce the size, and then passing " a strong double ligature through the neck of the uterus, which was tied on each side ; then to make doubly sure against hemorrhage, a ligature was placed around the whole neck." After this the broad ligaments and cervix were divided and no bleeding followed. The ovaries, which were diseased, were also removed. The cervix was dropped, and the ligatures, brought out at the lower angle of the wound, after the fashion of the day, came away during the fifth HTSTERO-MYOMBCTOMT. 365 week, and the patient recovered. This was the first recovery after hysterectomy for fibroid tumor. Burnham performed altogether fifteen hysterectomies with three recoveries ; the second and third operations were done in 1854 and 1857 (see Dr. J. C. Irish, Hysterectomy for the Treatnnent of Fibroid Tumors, Trans, of the Amer. Med. Assoc, 1878, p. 447). Dr. G. Kimball, of Lowell, was the first to perform a deliberate hysterectomy for fibroid tumors of the uterus, having previously made a correct diagnosis. He operated Sept. 1, 1853, upon a patient in a bad condition from protracted uterine hemorrhages. At the operation the cervix was transfixed, each half ligated, and the uterus amputated in the supravaginal portion ; the cervix was dropped and the ligatures brought out at the lower angle of the wound. The woman was well eight months later, but the ligatures were still attached (see G. Kimball, Suooessful Case of Extirpation, of the Uterus, Boston Med. and Surg. Jour., May, 1855). According to Bigelow, in 1883, Kimball had per- formed eleven hysterectomies with six recoveries and five deaths. Dr. Marcy was one of the first to devote particular attention to the method of treating the cervix, and described an improved way of dealing with the pedi- cle by sewing it across with the cobbler's stitch {Trams, of the Amer. Med. Assoc, 1882, p. 203). Dr. T. A. Emmet in 1884 {Principles and Practice of Gynecology, p. 612) ntilized the peritoneum anterior to the uterus to cover the cervical stump in a hysterectomy done for a dermoid cyst of the ovary and a fibro-cystic uterus. In discussing the principles of the operation the important advance thus made in the retroperitoneal treatment of the stump is clearly pointed out. Dr. M. A. D. Jones, Feb. 16, 1888, performed the first American pan- hysterectomy for uterine fibroid {New York Med. Jowr., Aug. 25 and Sept. 1, 1888), originatiug this form of operation independently of Bardenheuer, whose work was not known at that time in America. Dr. J. Eastman has indelibly associated his name with the operation of pan-hysterectomy by his pioneer work, and by the invention of new instruments facilitating the operation. His first operation was performed Sept. 21, 1889 {Indiana Med. Jour., 1890, also Med. Fortnightly, Jan. 15, 1896). One of the most revolutionary changes was that devised by Dr. L. A. Stim- son, of New York, who proposed and practiced the systematic ligation of the ovarian and uterine arteries in their course as a proper preliminary to hysterec- tomy {New York Med. Jour., March 9, 1889, and Med. News, July 27, 1889). By this simple improvement in the technique the dangerous mass ligatures applied to the broad ligaments were done away with and the risks of sepsis and hemorrhage greatly reduced. Dr. J. K. Goffe {Am,er. Jour. Obs., April, 1890, vol. xxiii, p. 372) originated and carried out a well-defined enucleation followed by the complete covering of the cervical stump, with peritoneal flaps, which he called " an intra-abdominal but extraperitoneal method of disposing of the ped- icle." The first operation was done May 29, 1888, and repeated three times, and then presented before the Obstetric Section of the Academy of Medicine in March, 1890. 366 MYOMECTOMY — HYSTERO-MYOMECTOMY. While in this way citing and giving credit to American work, I would not slight the admirable work done in France and Germany by such well-known men as Velpeau, Amussat, Bardenheuer, Schroder, Martin, Zweifel, Chrobak, Siinger, Fritsch, and finally, Olshausen (see Veit's Handhuch, 1897). In Eng- land the names of Keith, Thornton, Bantock, Milton, of Cairo, and Heywood Smith are indelibly associated with hysterectomy. The indications for hystero- myomectomy are, in gen- eral — (a) Discomfort or ill health produced by the tumor, interfering with occupa- tion or comfortable getting about. (b) All myomata filling the lower abdomen from the size of a six or seven months' pregnancy upward. (c) Smaller tumors choking the pelvis and pressing injuriously on the rectum or bladder. (d) Kapid growth of the tumor. (e) Repeated hemorrhages, which are exhausting to the patient and can not be controlled by simpler means. (f) Persistent intense dysmenorrhea, seriously affecting the general health, an indication to be accepted only with great caution. (g) Severe pain, often associated with attacks of peritonitis, and usually due to pelvic peritonitis, tubal and ovarian inflammatory disease, and pelvic abscess. (h) Myomata complicated by cancer of the uterus, ovarian cysts, dermoid cysts, ovarian fibroids. I feel it my duty to utter an urgent warning against accept- ing the simple fact of the presence of a tumor as a suffi- cient indication for operation. The conscientious operator should always be able to show either that the continued presence of the tumor in some way is a menace to life, or that its presence is incompatible with a comfortable existence. I have, however, operated two or three times solely on account of the dis- tressed mental condition of the patient, induced by the knowl- edge that there was a tumor which she could feel in the abdomen. Until the operation was done it was impossible to allay the fears or to persuade the patient to think of anything else but the tumor, and no reasoning had any effect. The one indication most generally accepted is the large size of the tumor which fills the lower abdomen. Here, on making the incision and exposing the growth, we find the small intestines forced up under the diaphragm and out into the flanks, accounting for the interference with circulation, respiration, and digestion ; frequently, too, thft ureters are so pressed upon as to cause hydro- ureter and hydronephrosis, and a careful examination of the urine before opera- tion may reveal albuminuria, with hyaline and granular casts. A pyelonephrosis may readily supervene upon the hydronephrosis. Hyaline degeneration of the heart muscle and arterio-sclerosis are sometimes seen in old cases and appear to be caused by the stasis in the circulation due to pressure. When the pressure HTSTERO-MYOMECTOMT. 367 is relieved the Mdneys often recover, judging by the fact that the albuminuria soon disappears. Persistent discomfort and protracted severe pains at the menstnial period only become valid indications for an operation when general treatment, such as mild sedatives and hygienic measures, rest, massage, etc., have been faithfully tried, and sufficient time has elapsed to demonstrate the fact that spontaneous relief can not be expected. Hemorrhages in smaller tumors may often be controlled by curettage or by galvanism ; but in the largest tumors the vaginal cervix is often so small and displaced so high into the abdomen that an intra-uterine application of the elec- trode is dangerous or impossible. A firm vaginal pack will also often check hemorrhage at once, and by this means the patient's strength may be husbanded from month to month. When a soft myoma has been discovered and every subsequent examination at intervals of a few months shows that it is growing rapidly and has reached the size of a four or five months' pregnancy, the operator has valid ground for its removal. I would call especial attention to the fact that those myomata which are con- stantly associated vrith great pain almost invariably belong to the class of com- plicated cases in which a tubal and ovarian inflammatory disease will also be found. Even pyosalpinx is not an uncommon addition. The best time to operate is when the patient has been piit in the best possible condition her disease will admit of. Women who are enfeebled and worn out should be put to bed and built up for a time. When the monthly period produces great disturbances, the best time to operate is just before an ex- pected period. I have even operated in several instances without disadvantage a day or two after the period had begun. In operating upon anemic patients unusual precautions must be taken against further loss of blood, to the extent of clamping all the small bleeding vessels in the abdominal walls and controlling at once all oozing from the cellular tissues in the pelvis during the operation. The loss of a few ounces of blood, ordi- narily insignificant, sufiices in these cases to add to the shock easily induced in the patient's weakened condition. Wherever a free hemorrhage has occurred in the course of a hystero-myo- mectomy, enough to give rise to any marked degree of depression, there should be no hesitation in infusing under the breasts a half liter or a liter of normal salt solution (see Chapter XXII, p. 70). The loss of bodily heat must be avoided in every way by keeping the intes- tines vri-thin the body if possible, or by covering with hot gauze any coils that may be exposed to the air. The body and limbs should be wrapped in blankets and a hot-water bag placed at the feet. If the pulse begins to run up during the operation it is best to give hypo- dermics of strychnin, one fortieth of a grain, repeated in doses of one sixtieth of a grain at intervals of half an hour. A stimulant rectal enema of brandy (spiritus vini gaUici, ^ ij ; ammoniae carbonas, gr. xx ; and hot salt solution, q. s. ad f § vj) 368 MYOMECTOMY — HYSTERO-MYOMECTOMT. should be given, with the pelvis well elevated, before the patient is lifted from the operating table. The duration of the entire operation varies from twenty to thirty minutes in easy eases, and from sixty to eighty minutes in the difficult. Operations extending over an hour are apt to produce a decided depression. The duration down to the complete enucleation of the uterus with the tumors lasts from three in the easiest to fifteen or twenty minutes in the most difficult cases ; the rest of the time is taken up in the details of the treatment of the wound made by the excision, covering it in with the peritoneum and closing the abdominal incision. The principal causes of the high rate of mortality following hysterectomy as done by our immediate predecessors were hemorrhage and sepsis. These dangers may now be avoided by following the improved technique recently elaborated. The technique of hystero-myomectomy includes : (a) Preliminary preparation of the field, including the skin and the vagina. (b) Opening the abdomen. (c) Delivering the tumor if possible. (d) Ligation of the ovarian vessels and the round ligament of one side, usu- ally the left, and opening the top of the broad ligament. (e) Detachment of the vesieo -uterine fold of peritoneum from side to side, and pushing it well down so as to separate the bladder from the cervix. (f) Ligation of the uterine vessels of the same side. (g) The amputation of the uterus in the cervical portion, leaving a cup- shaped pedicle. (h) Clamping the uterine artery of the opposite side, clamping the round ligament, and clamping the uterus with the ovarian vessels, followed by removal of the tumors. (i) Applications of ligatures in place of the forceps. (j) Suturing the cervical stump. (k) Covering the wound area vsdth peritoneum. (1) Cleansing the peritoneal cavity. (m) Closure of the abdominal incision without a drain. Hystero-myomectomy without Complications. — Preliminary Prepara- tion . — If the patient is in a reduced condition the operation should be post- poned imtil a maximum improvement has been secured. The preparations im- mediately preceding the operation have been fully detailed in Chapter XX, p. 9. Especial care must be taken to disinfect the vagina thoroughly. Opening the Abdomen . — The patient is placed on the table with her pelvis elevated, and an incision from 6 to 20 centimeters (2^ to 8 inches) long is made over the most prominent part of the tumor, taking care to cut slowly and deliberately, so as not to incise the tumor on opening the peritoneum. I have seen a large vein cut in this way bleed profusely and cause the loss of much valuable time in checking the unnecessary hemorrhage. It is best to open the peritoneum first in the upper part of the incision, so as to avoid the risk of cut- ting the bladder, which is often raised several inches out of the pelvis. The HTSTEKO-MTOMECTOMY WITHOUT COMPLICATIONS. 369 exact position of the fundus of the bladder should be determined beforehand with a sound. The hand is then introduced within the abdomen and passed over the tumor on all sides, making an examination which gives an experienced operator in a few seconds an accurate idea as to the character of the operation, and enables him to estimate the mobility and relations of the uterus with its tu- mors, the presence or absence of adhesions, and particularly the relations of the pedicle to the pelvis, whether broad or narrow, and whether there is any upward displacement of the sigmoid flexure or the bladder. If the tumor is now found to be too large to be delivered, the incision is lengthened by raising its upper angle on two fingers and protecting the peritoneum with a sponge while cut- ting boldly upward with a knife. Stout angled scissors may be used for the same purpose when the abdominal walls are thin. Delivering the Tumor . — Tumors limited to the body of the uterus can be readily lifted out of the abdominal cavity at once, and for this reason they constitute a more favorable class for operation, as a natural pedi- cle is offered by the unaffected cer- vical part below the mass. As soon as the tumor escapes, a warm gauze pad should be slipped in under the incision covering the intestines. In some large multilocular fibro- cysts a succession of deliveries of single tumors is necessary before the entire mass lies without the abdomen. Sometimes after a group of large tumors have been lifted out in this way the pelvis will still be found choked by a tumor which is only dislodged after a prolonged effort. If moderate direct traction fails, an assist- ant should introduce two fingers into the vagina and make strong upward pres- sure in the axis of the superior strait, setting the mass free. Care must be taken not to make such traction on a pedunculate tumor as will result in tearing its pedicle and causing a hemorrhage which might prove troublesome. A large tumor, the size of a child's head, may sometimes be deliv- ered with advantage with obstetrical forceps. Ligation of the Ovarian Vessels and Round Ligament of One Side . — A fine silk ligature (No. 2) may be used to ligate the ovarian vessels, however large. The outer pelvic extremity of the broad ligament, often swollen by a congeries of large purple veins which cross the pelvic brim under the caput coli on the right side and under the sigmoid flexure on the left, is now gathered up between the thumb and forefinger, and the clear space below the vessels sought for, through which a ligature is passed and tied tightly controlling the vessels. It is always surprising to see a bunch of vessels as large as three or four fingers contract dovra. to a mere strand in the bite of a ligature. A second Fig. 497. — Schematic Diaobam. Showing the line of incision, beginning with the left ovarian vessels and ending with the right, in the extirpa- tion of the myomatous uterus. 370 MYOMECTOMY — HYSTBKO-MYOMECTOMY. ligature or a clamp is applied 4 or 6 centimeters away, toward the uterus, aud the vessels cut between the two, at a good distance from the first ligature. In a woman under forty years of age it is better to leave both ovaries in the pelvis, with or without the uterine tubes ; by doing this, although menstruation ceases, the disagreeable symptoms of the artificially induced menopause are avoided. In this case the first and the last ligatures are applied near the horn of the uterus. The round ligament, often enlarged and vascular, is now lifted up near the uterus and tied with catgut and cut through, and the uterine end clamped. The top of the broad ligament is opened up by these incisions. Detaching the Vesico- uterine Peritoneum. — The uterus is now drawn back and the anterior loose peritoneal fold along the curved line of the utero-vesical reflection is cut through from round ligament to round liga- ment. As the bladder is raised, the loose cellular tissue beneath it is exposed, and it may be still further freed by a rapid dissection vsdth knife or scissors. In ordinary cases there is no bleeding of any moment. The uterus is now pulled well up, while the operator completes the separation of the bladder by taking a sponge, firmly compressed and held in a sponge forceps, and pushing the bladder down with it on all sides, baring the cervical end of the uterus almost or quite down to the vaginal junction. This also brings into view the uterine arteries and veins on the same side of the uterus. Sometimes, when these vessels are not exposed quite clearly enough, they may be brought into better view by drawing the uterus forward and nicking the sharp posterior peritoneal margin behind the cervix. Ligation of the Uterine Yessels. — The large uterine veins on the side of the uterus are recognized by their dark color, and the smaller cord- like artery can be plainly felt pulsating. These vessels are now securely ligated close to the side of the cervix by a silk ligature, introduced on a large curved needle, passed close to the cervical tissue but not entering it. The uterus is now drawn over toward the other side, and the operator takes a spud and begins the amputation by cutting through the uterine vessels from 6 to 10 millimeters above the ligature. The assistant stands with open artery forceps in hand ready to grasp any bleeding vessel by chance left out of the ligature. The cut vessels above on the tumor side are better clamped or tied in mass to keep the blood from constantly oozing out and obscuring the field of the operation. The uterus is now completely divided in its cervical portion, at a point just above the vaginal junction, by cutting deliberately through the tissue with a spud or knife, with successive strokes. The cervical canal is usually found about the middle and is recognized by the presence of a little glairy mucus. As soon as this canal is cut across, a pad of gauze several folds thick is laid beneath the upper cut surface to keep any intra-uterine secretions from escaping onto the wound, and the canal below is wiped out. The cutting is now continued across toward the opposite side more slowly, as the little remaining bridge of tissue shows the severance is nearly completed. The bleeding from the cut siir- HYSTEKO-MYOMECTOMY WITHOUT COMPLICATIONS. 371 face is usually so slight tliat it may be neglected, or at most one or two forceps only need be applied. It is a good plan when tlie cervix is nearly divided to cut upward for 1 or 2 centimeters so as to leave behind a thin shell of cervical tissue and expose the opposite uterine vessels at a higher level, where it is much easier to tie them without risk of including the ureter. Clamping the Opposite Uterine Vessels. — When the last strands of uterine tissue are severed or break, as the uterus is drawn up and out and rolls over more onto its side, the opposite uterine veins and artei-y come into view. The beginner ■will expect to find these vessels hugging the Ov.vas. .ound \ig. Fig. 49S. — Thk Opeeatiun of Hysteko-myomectomy. By a continuous incision from left to right, ligating or clamping at the points indicated by tlie arrows; first, the left ovarian vessels ( Ov. ves.) ; next, the round ligament, and then the left uterine artery ( Ft. Art.). Finally the cervix is cut across, and the uterus pulled away until the right uterine vessels are exposed. uterus tightly, and will be surprised to note the considerable cellular interval which often separates them as they are exposed in this way. It is best not to clamp them as soon as seen, but to pull the uterus up fur- ther until the separation between the cut surfaces amounts to several centime- ters. At this higher level the artery, at first not so plainly seen, comes clearly into view and may be clamped by itself, the uterus rolled still more over on its side, and the round ligament clamped close to it and divided, and finally, with a little more traction, the ovarian vessels are seen and clamped and cut, and the whole mass is finally freed and taken away. 372 MYOMECTOMY — HYSTEKO-MYOMBCTOMY. The uterine veins often do not bleed when severed in this way ; if they do, it is easy to control them with one or two pairs of forceps. Ligating the Vessels controlled by Forceps . — As soon as the uterus, with the tumor, is lifted away the operator looks over the whole field to see that there is no active hemorrhage going on. '»10-T1 ^-T- Fio. 409. — The Last Step in the Enucleation of the Myomatous Uterus. The mass is rolled out of the abdomen and is now attached only by tlie round ligament, ovary, and tube. He then proceeds to tie the vessels on the side controlled by forceps, taking up first the round ligament which is encircled with a catgut ligature ; next the ovarian vessels are controlled by transfixing the clear space and tying them with a fine silk ligature. The uterine artery is now drawn up and tied at a point well above the cupped stump. This avoids any risk of tying the ureter. By grasping the cervical stump with a pair of tenaculum forceps it can be pulled up into the abdominal incision within easier reach, bringing with it the uterine vessels, which are then also under better control. Two ligatures should be placed ujjon every important vessel, the first tied in the course of the enucleation and the second when the enucleation is completed. Suturing the Stump. — The next step is to close the stump, but be- fore doing this the operator must look minutely and patiently over the whole field and pick up any minute bleeding points with forceps and tie them with fine catgut. The stump is now closed over the cervical canal by passing from three to five or more catgut sutures in an antero-posterior direction and tjdng each one as it is passed. If the stump is inclined to ooze at places, this may be .1 COMPLICATIOKS OF HYSTBEO-MTOMECTOMT. 373 checked by making one of the sutures include that point and tying it tight. In passing these sutures the mucous membrane of the canal must not be included. By this suturing the cup -shaped pedicle is changed into a transverse linear wound. I do not disinfect the cervical canal any more, unless there is such evi- dence of infection as a discharge of pus from the uterus or a muco-purulent plug in the canal. In this ease the canal should be wiped out with gauze as soon as cut across, and afterward dissected out with a narrow sharp knife and forceps. Covering in the Whole "Wound Area with Vesical Peri- toneum . — The large loose flap of peritoneum which lies in front of the pedicle and the broad ligaments is now picked up with long rat-tooth forceps and drawn over the stump and attached to the posterior peritoneum from side to side by a continuous intermediate catgut suture ; the round ligaments and the pedicles of the ovarian vessels are tiirned in between the layers of peri- toneum, and all that is left of the large wound is a fine line of approximation across the middle of the pelvis, practically converting the pelvis into the male form by the removal of the organs between the rectum and the bladder. This is done by starting the suture at the stump of the ovarian vessels at the brim of the pelvis,, and continuing it down across the pelvis and up to the opposite ova- rian vessels, as described in Chapter XXVIII. If there is a large space left in the cellnlar tissue it will be best to nnite the peritoneum with interrupted or mattress sutures, so that any blood which escapes from capillaries will run into the peritoneum .and be absorbed instead of forming a hematocele. Cleansing the Peritoneum. — If the peritoneum has been much soiled by blood in the course of the operation, one or two hters of normal salt solution (0'6 of one per cent) at a temperature of 43'3 C. (110 F.) should be poured into the pelvis and abdominal cavity, and rapidly sponged out until, all foreign material has been removed. Closing the Incision . — The small intestines are drawn into the lower part of the abdomen, and the omentum is sought out and spread between them and the anterior wall. The abdomen is finally completely closed, without drainage, and dressed as described in Chapter XX, the salt solution enema given, and the patient put to bed. Mortality. — In one hundred consecutive abdominal hysterectomies, in- cluding all kinds of complications, I have lost two cases. Complications of Hystero-myomeetomy. — The operation of hystero-myomectomy varies all the way from the -simplest to one of the most complicated and difficult procedures in gynecology. Cases like those just described as the type are for the most part easy of operation, and, as a rule, make a prompt undisturbed recovery. A long list of complications is, however, added when we analyze one hundred consecutive cases, and enumerate all the difficulties encountered. Some of these complications add but slightly, others more, and still others enormously, to the difficulty of enucleation ; and when several or more complications of various 374 MYOMECTOMY — HYSTERO-MYOMBCTOMY. sorts exist in the same case, the diificulties are enhanced to an even greater degree. This matter has grown to one of such great importance that I deem it necessary to speak in detail of each of these compKcating conditions, first giving a cate- gorical list of all those which are most important. They are in general of four classes : 1. Complications due to adhesions to and affections of the surrounding struc- tures. 2. Complications brought about by changes in the tumors themselves. 3. Complications due to the positions of the myomatous masses. 4. Complications due to pregnancy, ascites, and other causes in particular. Complications due to Adhesions and Affections of the Surrounding Structures. — (a) Inflammatory: 1. Simple adhesions of tubes and ovaries. 2. Hydrosalpinx. 3. Pyosalpinx and abscess of the ovary. 4. Encysted peritonitis. 5. Omental adhesions. 6. Parietal adhesions. 7. Ad- hesions to rectum, sigmoid, colon, and small intestines. 8. Adhesions to vermi- form appendix. 9. Adhesions to liver and suspensory ligament. (b) Tumors of the ovary : 10. Ovarian cystoma. 11. Dermoid cyst. 12. Fibroid ovary. 13. Ovarian hydrocele. 14. Ovarian hematoma. 15. Carci- noma of the ovary. (c) Diseases of cervix and uterine mucosa : 16. Cancer of the cervix. 17. Cancer of the uterus associated with myoma. 18. Tuberculosis of the endome- trium. Complications due to Changes in the Tumors Them- selves. — 19. Cysto-myoma. 20. Telangiectatic myoma. 21. Cystic myoma with twisted pedicle. 22. Suppurating myoma. 23. Adeno-myoma uteri dif- fusum benignum. Complications due to the Location of the Tumors. — 24. Elevation of tubes and ovaries high out of the pelvis. 25. Globular myoma filling pelvis. 26. Myomata wedged in pelvis. 27. Myoma below the vesical peritoneum. 28. Myoma below posterior pelvic peritoneum. 29. Myoma in upper part of broad ligament. 30. Myoma in broad ligament proper. 31. Myoma developed antero-laterally, twisting uterus. 32. Myoma developed postero-laterally. 33. Myomata developing under the pelvic peritoneum in several of these positions at once. 34. Myomata displacing the ureters upward. Complications due to Pregnancy, Ascites, and Other Causes. — 35. Myoma with pregnancy. 36. Myoma simulating pregnancy. 37. Myoma and ascites, feeble heart, nephritis, pyelonephrosis, etc. Several other conditions may be enumerated, too, which add to the gravity, but, except the last, are beyond the possibility of direct treatment at the time of operation ; such are the cases with extreme anemia, rapid feeble heart, valvular heart disease, nephritis, and pyelonephrosis. 1,2,3. Adherent Tubes and Ovaries; Hydrosalpinx; Pyo- salpinx. — The complications due to inflammatory lesions and adhesions in the surrounding structures must in general be dealt with like similar adhesions under other circumstances, as described in Chapter XX COMPLICATIOJTS OF HYSTERO-MYOMECTOMY. 375 ■on General Principles. It is only necessary to speak here first of the frequency with which myomata are complicated by pelvic peritonitis, and, second, of the difficulties of releasing inflamed ovaries and tubes, from the fact that they are often so completely buried behind the tumors, or wedged down into the pelvis, that they are hard to reach without injuring some of the great vascular sinuses in their immediate neighborhood. When they can be got at without special difficulty, an adherent tube and ovary, or a hydrosalpinx, or even a pyosalpinx, may be gently released by gradually working the fingers down between the in- flamed structures and the posterior pelvic wall until their under surface is reached, when they are carefully freed from their adhesions to the pelvic floor and walls, and as they are brought up and out of the pelvis, detached also from flieir broad-ligament adhesions. Fia. 500. — Complicated IItstero-myomectomy. Myomatous uterus with hydrosalpinx on the right side, and a large ovarian cyst on the left side. Ilystero- myomectomy. Recovery. Path. No. 24.5. 3^ natural size. It frequently happens on the left side that these inflamed structures are cov- ■ered in by an adherent sigmoid flexure, and in order to reach them tliis must be dissected off by pulling it away from the tumor, so as to expose the cellular interval which is cut with scissors. When the inflamed tube and ■ovary are hard to reach, either because they are sheltered by the tumor or because they are wedged down in the pelvis, or when the adhesions are so dense that it is dan- gerous to break them up by touch without the controlling aid of sight, it is best to begin the enucleation by seeking out the ovarian vessels at the outer extremity of the broad ligament and tying them at two points and cutting them between, and ihen tying off the round ligament in the same way. By this means the top of the broad ligament is opened up and the uterus so far freed that it can be lifted up and out enough to allow free access to the inflamed structures, which ■can now often be better attacked from the exposed front of the broad ligament. Where pus is present unusual care must be taken to diminish the risks of infection by aspirating and taking away as much of it as possible, and then pro- tecting the infected structures by abundant gauze until they are removed. The risk of an infection is greater here than in almost any other abdominal opera- tion on account of the wide area of cellular tissue bared between the broad liga- ments by the enucleation of the uterus and tumors. 66 376 MYOMECTOMY — HYSTERO-MYOMECTOMY. Adhesions, hydrosalpinx, and pelvic abscesses in the right side are best dealt with toward the end of the enu- cleation; as the utei'us is rolled up and out of the pelvis after clamping the right uterine artery, the right adnexa can be easily reached and freed from adhe- sions under inspection by attacking them from the front. One of the most complicated cases is shown in Fig. 501. The patient had a large umbilical hernia, containing a portion of the omen- tum, which adhered to the edges of the ring ; the omentum was also closely 6Tria\l Otitest,- Fig. 501. — Complicated ilvRTERo-MYOMECToMv. The abdomen is filled with a large myomatous uterus with intestinal and omental adhesions. There is- an umbilical hernia, and on the right side of the pelvis a large abscess opening into the small intestine. In front of the abscess lies the uterine tube full of pus. Enucleation. Recovery." E. L. Operation, March 24^ 1897. adherent to the whole front of the large myomatous uterus, which extended from the pelvic floor well above the umbilicus. The adherent bladder was drawn high up out of the pelvis, and over it lay a large thickened uterine tube distended with pus, while on the right side there was a suppurating COMPLICATIONS OF HYSTERO-M YOMECTOMT. 377 ovarian cyst communicating by a fistulous opening with a loop of the small intestine. The proper plan of procedure in such a case is to work with great deliberation until the adhesions are separated sufficiently to allow the myoma- tous uterus to be handled and to expose the left broad ligament. Gauze should be packed around on all sides to protect the peritoneum and the in- testines from contamination, and any accessible sacs of pus should be tapped so that they will collapse, affording more room and obviating the risks of rupture and extensive contamination. After the enucleation the hernia and the intestinal fistula are treated. If the fistula is well closed a drain is not necessary. 4. Encysted Peritonitis . — In two cases I have encountered an exten- sive encysted peritonitis filling the posterior pelvis ; in one instance this was not discovered until the adhesions at the brim of the pelvis were broken through and the clear serous fiuid gushed out of a pocket lined by peritoneum and extending as far down as the floor of the pelvis. In the other case the fluctuation was so clearly ieltper vaginam that the diagnosis between an ovarian cystoma and a fibroid uterus remained doubtful, until the abdomen was opened and the myo- matous masses were exposed, "when the fiuctuation was found to be due to the sac of fiuid pent up behind the uterus. 5. Omental Adhesions . — The omentum often adheres to the larger fibroid uteri, and in many instances its entire free border is attached like a corona to the anterior and upper convex surface of the tumor. The omental vessels in these cases may be greatly enlarged, standing out like whipcords or looking like great bunches of earthworms. These vessels, instead of ramifying on the surface of the tumor, seem to plunge vertically into the substance, and I have shown by injection that while they do contribute some small vessels to the capsule, for the most part they communicate directly with the deeper portions of the mass. Sometimes all the tissue between the omental vessels disappears, and they stand out like so many separate whipcords from 6 to 10 or 12 centimeters long. Ordinarily this complication is easily met by tying off the whole omentum with eight or ten fine silk ligatures, taking care not to' bunch too many large vessels in one ligature. The difficulties are increased when the distance between the tumor and the transverse colon is so short that there is but little room to work between the two. In one case the whole omentum had disappeared, leav- ing the colon spread out flat on the surface of the tumor, and sending a number of large vessels into its substance. This difficulty was met by cutting ofE a thin shell of the capsule of the tumor circumscribing the vascular area, and then fold- ing it in upon itself, and sewing the edges of the strip together. 6. Parietal Adhesions . — Adhesions to the abdominal walls are not common, and when they do occur, usually form an unimportant complication. The worst adhesions I have ever seen of this kind were in a case of a large fibroid, in which electricity had been used for a long time. Just under the places where the electric pads had been applied on the right and left sides the adhe- sions over areas about 10 by 12 centimeters were the densest I have ever seen : 378 MYOMECTOMY — HYSTEKO-MYOMBCTOMY. two enormous arteries from 3 to 4 millimeters in diameter coursed prominently under the peritoneum from the lower abdomen to the adherent areas. The difficulty of detaching the tumor, which at first bid fair to be serious, from the constant extensive capillary oozing, was overcome by ligating these arteries in their course low down in the abdomen, and by obliterating with buried sutures the raw areas left after detaching the tumor. In rare instances the myoma filling the pelvis forms adhesions to the pelvic floor, and the chief difficulties in the operation may arise from the constant ooz- ing from numerous small vessels in the thickened pelvic peritoneum at a point quite remote from the surface. The best way to control the bleeding is to lift up the peritoneiim so as to make a fold and then to suture one fold to another until the bleeding points are all under control. Y. Intestinal Adhesions . — The sigmoid flexure is more likely to ad- here to a tumor than any other part of the intestine, and it is commonly found attached to the top of the broad Hgament and the tumor adjacent to it. Its separation is easily effected by lifting it up and dissecting it carefully off from the vessels below, which are plainly seen. The rectum rarely gives any trouble from adhering directly to the tumor ; it is more apt to become attached to the inflamed lateral structures. Adhesions to the rectum low down in the pelvis may, as a rule, be safely left undisturbed. The colon and small intestines do not often adhere. When they do, if the separation can not be made easily by drawing up the bowel and forming a httle interval in the connective tissue binding the structures together, which can be safely cut through, then the important principle is to sacrifice the cap- sule of the tumor to the bowel by dissecting off a piece around the attached area. There is, however, one kind of myomatous uterus of which I have seen two examples, where the pelvic adhesions are universal, and the small intestines wherever they touch it are so firmly agglutinated that separation is entirely out of the question. I opened the abdomen in one of these cases four years ago, and concluded, from the red vascular appearance of the softish mass covered with lymph and adherent bowels, that the tumors were malignant ; the patient recovered from the exploratory incision and is in fair health to-day. I know of no way of reaching these cases. 8. Adhesions to the Vermiform Appendix. — When the appen- dix adheres to the tumor, a light adhesion may be peeled off, but if the adhesion is dense, or if there is evidence of a coexisting appendicitis, the best plan is to free the tumor on the left side, cut across the cervix, clamp the right uterine artery and roll the tumor out, and then when the right round ligament and ovarian vessels are secured, to clamp off the appendix near the colon, leaving it attached to the tumor. The stump of the appendix is then dealt mth as de- scribed in Chapter XXXYI. 9. Adhesions to the Liver and its Suspensory Ligament. — This complication existed in one of my cases — a large nodular fibroid uterus filling the abdomen. The suspensory ligament bled freely, but the flow was COMPLICATIONS OF HYSTEEO-31 YOMECTOMY. 79 easily controlled by gathering the bleeding areas together by a catgut suture. Liver adhesions may be treated by passing sutures below the bleeding points and tying tlieni carefully, tight enough to stop the flow, but not tight enougii to cut into the liver tissue. Tumors of the Ovary complicating Fibroid Uteri. — 10. Ovarian cystoma. 11. Dermoid cyst. 12. Fibroid ovary. 13. Ovarian hydro- cele. 14. Hematoma of the ovary. I have met eacli of these conditions as complications of hystero-myomectomy. The first three are rare and merely accidental complications ; the fourth is, I believe, unique. The fifth conrlition is frequently met with, eitlier one or Ijoth ovaries containing a large hematoma developing from tlie corpus luteum. The best plan of operating is to remove the ovarian tumor and the fil)roid uterus together. If the ovarian tumor has a long pedicle, this may be simply clamped and the cyst taken away first ; and if it is so large as to be unwieldy, it may be emptied before tailing it out together with the uterus. The picture shows a large ovoid fibroid uterus with large dermoid cysts of the left ovary in a patient (J. Q., 3250) operated on Dec. 29, 1894 ; the whole was removed in one large mass. These operations are difficult only on account of the awk- wardness of handling the tumors ; their percentage of mortality ought not to be greater than that of simple hystero-mj'omectomy. '/"■ X''0'"' Fig. 502. — Globular Myomatous Uterus complicated by Dermoid Cysts of the Left Ovary. Hystero-myomectomy. Kecovery. Dec. 12, 1894. Longest diameter 32 centimeters. % natural size. 15. Carcinoma of the Ovary. — I have seen three cases of a cancer of the ovary complicating a large fibroid tumor of the uterus. In one of these cases the pelvic peritoneum was the seat of numerous little sprouting cancerous areas, disseminated from the ovaries. The myomatous uterus was as large as a five months' pregnancy. I took out both ovaries and uterus and evacuated a large amount of ascitic fluid. The patient recovered, but died six months later with ascites and large carcinomatous masses filling the abdomen. 380 MYOMECTOMY — HYSTERO-MYOMECTOMY. Another case was that of a colored woman (E. M., Path. JSTo. 1009, operated upon Dec. 11, 1895), with a large myoma filling the lower abdomen and rising abore the umbilicus, with ascites. The bladder was adherent high up on the anterior face, and on the right side there was a large carcinomatous mass filling the right posterior quadrant and extending back behind the rectum. The ex- tirpation was made from left to right in the usual way, and after exposing the cancerous mass from the front of the right broad ligament it was shelled out of its bed and the enucleation continued up behind the rectum, taking away a good handful of carcinomatous tissue in all. A number of enlarged glands were felt behind the rectum and the lower part of the sigmoid flexure, making a perma- nent recovery hopeless. Diseases of the Cervix and Uterine Mucosa. 16. Cancer of the Cervix complicating Myoma . — In rare instances cancer of the cervix, cancer of the uterine mucosa, sarcoma, and tuber- culosis of the endometrium have been found complicating myoma of the uterus. When the myomata are insignificant in size and the tuberculosis or the neoplasm is found in an advanced stage, the myoma may be looked upon simply as a com- plication of the latter. I refer here, however, to instances in which the promi- nent clinical symptoms are due, or have seemed to be due, to the myomatous condition and the neoplasm has not progressed far. Cancer of the cervix may be discovered upon making a vaginal examination to determine the size and I'e- lations of the enlarged uterus ; the other conditions, however, are not apt to be suspected unless the uterine mucosa is curetted and a microscopic examination is made. As a rule, cancer cells are found only when the specimens removed are sub- jected to a thorough examination. In all such instances panhysterectomy is indi- cated ; in the event of the discovery after the operation, the cervix should be taken out by the vaginal route when the patient has recovered from her first operation. 17. Cancer of the Uterus associated with Myomata. — ■ "When we recall the large number of cases of myomata we are called upon to treat, and of the fi-equency of cancer of the uterus, it would be surprising if the one were not at times associated with the other. The liability of myomatous uteri to cancer is, however, manifestly lessened by the fact that the patient is often sterile and the cervix is spared the traumata of parturition which afford an anatomical basis for the cancer. For the sake of conciseness I divide these cases into three groups : (1) Epithelioma of the cervix associated with myoma. (2) Adeno-earcinoma of the cervix and myoma. (3) Adeno-carcinoma of the body of the uterus with myoma. In a review of one hundred cases of carcinoma of the uterus, occurring in my wards at the Johns Hopkins Hospital, eight cases were associated with myomata, one case with epithelioma, one case with adeno-carcinoma of the cer- vix, and six cases with adeno-carcinoma of the body. In the patient with the epithelioma of the cervix the myoma was small and was not discovered until after removal of the organ. 503. — Myoma and Carcinoma in a Negress. Showing the zones occupied by preference by the two forms of disease. The fundus is converted into a mass of myomatous nodules while the entire lower segment of the uterus hai:^ been replaced by carcinomatous vegetations. There are metastases in the inguinal glands as large as an egg. The disease extends through the broad ligaments to the bladder; metastases also exist in the mesenteric, retro-peritoneal, and bronchial glands, as well as in the lungs, pleura, and serosa of the intestines. There is an anemia of all the organs and 3. fatty degeneration of the liver. Hydroureter. The myoniata are not involved in the carcinomatous process. JNo. 9:36. ^Autopsy, March 29, 1897. Vt natural size. COMPLICATIONS OF HYSTEE0-MT03IECT0MY. 381 In the adeno-carcinoma of the cervix there were multiple myomata scattered throughout the uterus. The majority of the cases, six out of eight, where the carcinoma was present with myoma, were adeno-carcinomata of the body. The myomata were in some instances subperitoneal, in others interstitial, while in one case a small submucous nodule was present. Probably one of the most in- teresting cases was one of primary carcinoma of the ovary. The uterus was secondarily involved, and not only was the muscle penetrated in all directions by the new growth, but a large and degenerate myoma showed carcinomatous invasion in numerous places. Although, as has been seen, carcinoma of the uterus is at times associated with myomata, the two diseases represent two dis- FiG. 504. — Myoma -with CrsTic Degeneration. . J'^^.^r cavity, 6x4-5 x 5 centimeters, iilled with liquid resemblinc; melted butter. The tumor is hnbedded in 7 millimeters ot the uterine muscular tissue, and its walls are made up of interlacing non-striated muscu- lar hi)re.s. JNo inflammatory changes found. Hystero-myomeetomy. Kecovery. Path. No 347 6/ natu- tmct processes, in no way dependent the one upon the other, and the presence of the one does not appear to alter the characteristic course of the other. 18. Tuberculosis of the End om etrium .—Tuberculosis of the endometrium is exceedingly rare as a complication in the large myomatous uterus. I have met with but one case, and in this the disease was not recogniz- able to the naked eye, but was readily shown by a microscopic examination occu- pying the entire mucosa ; it extended out into both tubes, which were nodular and caseous but showed no breaking down. A piece removed from this case 382 MYOMECTOMY — HYSTERO-MYOMECTOMY. was used for the plate illustrating tuberculosis of the endometrium, Yol. I, p. 489. Complications due to Changes in the Tumors Them- selves. — There are three principal complications due to alterations in the tumors ; these are cystic, vascular, and suppurative changes. 19. C y s t o - m y m a . — The cystic change, as a rule, does not in any way add to the difficulties of operating. Cystic fibroids may be perfectly free and are as easily extirpated as a solid tumor, as will be seen by looking at the fig- ures ; some cases, on the other hand, show a tendency to form intimate attach- ments on all sides, and here the difficulties arise from the adhesions. I had one case of this kind where the cystic tumor choked the pelvis and was everywhere so densely adherent that I was unable to remove it ; I tapped the cysts through the vagina several times, removing 3 or 4 liters at each tapping ; the patient finally died of exhaustion from the pressure on the viscera. 505.— Large Fibko-i. i '.tic Tumor or the Uterus attached by a Broad Pedicle to a Multi- nodular Myomatous Uterus. Tlie right uterine tube is seen in the angle above between the fibro-cyst and the uterus. The hyper- trophied ovary is seen on the left side. Hystcro-myomectoniy. Eecovery. Jan., 1895. }{ natural size! 20. Telangiectatic Myoma .—The telangiectatic myoma is awkward to handle on account of the great venous sinuses leading out of it, as well as the enormous venous tracts within, any one of which if wounded would immediately deluge the field of operation with blood. A beautiful example of this kind of myoma is shown in section in the colored Plate XX, where the dark vascular areas and the mouths of the cut vessels, which are mostly arteries, are plainly seen in patches. At other places lymph is seen coagulated in the tissues between the myomatous nodules. A tumor of this class often resembles, on section, a large vascular sponge. 21. Suppurating Myoma. — I refer under this head to certain rare cases in which the myomatous tumor forms a shell filled with pus. I do not in- clude here those sloughing submucous tumors which discharge pei^ va^inam. DESCRIPTION OF PLATE XX. ANGIOMYOMA OF THK UTERUS, WITH CYSTIC DEGENERATION. The tumor has been divided lengthwise, and the picture shows one side of the cut surfaces ; the uterine muscle is seen retracted on the right side, and the myomatous nodules stand out prominently. The groups of cysts scattered throughout the tissue are those usually seen in myo- mata undergoing cystic changes. The bluish areas are the most important and strik- ing features of the picture ; they are cross-sections of groups of blood vessels, some of which consist of as many as one hundred vessels. Histologically, they are found to be arteries. The rest of the myoma is divided into innumerable lobules and presents the usual appearance. PLATE. XX. Lnh UPn.n5iCo.Bosin",'.'S'. COMPLICATIONS OF HTSTERO-IIYOMECTOMY. 383 Such a case (A. S., 3216, Dec. 3, 1894) is figured in the text ; the patient had a large intraligamentary mass on the right side with septicemia, and came to the cHnic exceedingly prostrated. (See Fig. 511.) The tumor had formed dense parietal adhesions and the omentum was at- tached by its entire free border, together with the cecum, colon, and small intestines on the right side. R.ov. vesb R.TdligUl^^ Fig. 506. — Torsion of the Gloeulae Myomatous Uterus from Left to Right, bringing the Fundus to THE Front and the Right Tube and Ovary around to the Left Side. The tumor occupies the entire anterior uterine wall. Operation. Recovery. % natural size. Jan. 9, 1897. An incision into the abdomen was made 16 centimeters (6 inches) long, the fluctuating myoma tapped, and 4,700 cubic centimeters of yellow pus removed. The great difficulties on the right side were met by first cutting through the left broad ligament and amputating the uterus, and then clamping the right uterine artery just as described in the typical operation. As the uterus and the big col- 38i MYOMECTOMY — HYSTEKO-MYOMECTOMY. lapsed tumor were rolled up and out, the adherent intestines were approached from below and easily separated. The omentum was tied off, and the dense ahdomi- nal-wall adhesions treated by leaving- on a plaque dissected from the outside of the tumor. The patient recovered and was in good health a year later. These cases are also quite distinct from those in which there is a suppurative endometritis ; I have seen one case in which there existed a pyometra, the uter- ine cavity containing about 40 cubic centimeters of pus. It is on account of this complication that it is so important to cover up the uterine cavity as soon ae it is incised to avoid contamination of the wound. 22. Cystic Myoma Uteri with Twisted Pedicle . — Myo- matous tumors stand in remarkable contrast to ovarian tumors as regards the rarity with which a twisted pedicle is found. Either the myoma may be pedun- ParC oT* ^ erv X that w(ii> twisted Fig. 507. — Torrion of the Myomatots Uterl's. The Uterus seen in Fia. 506 UNT'n'isTED. Showing tlie knoblike ccrvi.x and the thinned-out suprtivaginal cervix. Seen from above and from be- hind the uterus. eulate and twist and contract adhesions, or the body of the uterus with a large myoma of the spherical sort may be revolved on the thinned-out cervix and the broad ligament as a pedicle, as shown in the accompanying illusti-ations (see Figs. 506 and 507). Lesser degrees of torsion, as, for example, a quarter of a turn, are not infre- quently seen, and are due to slight movements of accommodation of the con- tained body, the uterus with its tumors, to the containing body, the lower PLATE :KX1. M BroG^^i,f&- Jfek'fI*^ jy "^T-f ^ f '•^ • 'x^'^f / 1 •■•' > ^_ ,S' N .iS-' > ^^-»<::^ ^ / Z' \^' 'j'* .IIP' f o '^^ T'terini" Mucosa. X4 Tumiir ronsisthig of myoir.;it