passing hare-lip pins through the whole thickness of the abdominal wall at intervals of an inch. Each pin perforated the skin about an inch, and the peritoneum about half an inch, from the incision on either side; so that when the two opposed surfaces were pressed together upon the pin, two layers of the peritoneum were in contact with each other. But I soon began to prefer sutures to pins, and tried different materials for this purpose. After repeated trials I found thin strong Chinese silk superior to other materials for closing the wound, as I had for tying the pedicle. For some years I have soaked the silk in a 5 per cent. solution of carbolic acid before using it, and Billroth's experience proves that it may be safer to boil the silk. The most couvenient manner of applying the sutures is the following: Silk about eighteen inches in length is threaded at each end on a strong straight needle. Each needle is introduced by a holder from within outwards, through the peritoneum and the whole thickness of the abdominal wall, at about one-third of an inch from the cut edges of peritoneum and skin on either side-pinching up peritoneum and skin together, so that the silk may be carried through both without perforation of the recti muscles. The ends of the sutures are held by the assistant, who draws up the lips of the wound until all the deep sutures have been applied. Then the lips of the wound are held apart again, in order that the operator may convince himself that no further bleeding has taken place within the abdominal cavity, which, if required, has to be sponged again, and the protecting sponge removed. This done, the sutures are tied, carefully adapting the edges of the skin to each other without inversion or eversion, and the ends of the threads are cut off. If the abdominal wall is very thick, superficial sutures may be required between the deep ones. If the pedicle has been secured by the clamp, a suture should be passed close to the latter, in order to bring the lips of the wound so accurately around the pedicle that the peritoneal cavity is perfectly closed. DRESSING AND BANDAGE After the closure of the wound, the bdomen is carefully cleaned and dried, the india-rubber cloth removed, and the wound covered with some non-irritating antiseptic gauze, or salicylic or boracic wool, and supported by long strips of adhesive plaster. In many cases the false ribs have been pressed outwards by the tumour, and after its removal a deep hollow is left. This must be filled up with pads of cotton-wool. A flannel belt is fastened around her abdomen by pins, and the patient is then gently removed to her bed. She is kept on her back, her knees supported by a pillow, is covered with light but warm blankets, and provided with hot-water bottles, if she is at all chilly. The room is darkened, and she is left alone with her nurse. After ovariotomy and other serious operations, patients rally much more rapidly if the head be kept warm, covered up with a shawl or flannel. When we reflect how tempera- | is well established may be very advanture is lowered by cooling the head, it tageous. If reaction is slow, the head is not difficult to understand that warm- should not be raised by pillows, but kept ing the head until reaction after shock low. CHAPTER VIII ACCIDENTS DURING OVARIOTOMY Fainting is an accident which may happen | responds very nearly with the results of in any operation, and before the use of anaesthetics was not uncommon. I have, however, never been embarrassed in my ovariotomies by this condition. And only in one case has the methylene caused any trouble. Then the pulse became for a while imperceptible, and we were obliged to give brandy. The woman rallied. She had some thoracic complication, and though the cyst only contained about 16 pints of fluid, yet, as the removal was very quickly over, it is possible that the enfeebled heart and lungs were unable to accommodate themselves to the sudden change of pressure. Keith's practice, in which there are very few deaths recorded as from secondary causes; while in my own experience in private cases and since adopting Listerian details, I have had only 3 immediate deaths, 2 from cardiac embolism in about 20 hours, and one from hæmorrhage almost immediately after the patient was in bed. But this was not a case of ovariotomy only. It occurred since the completion of the 1,000 cases, and I unwisely, after removing an ovarian tumour, attempted to remove a cyst of the liver. In one case of secondary bleeding which came on shortly after the operation was Out of the 127 deaths which followed finished, I reopened the wound, put my first 500 operations, 20 were put another ligature on the pedicle in lieu of down as the effect of exhaustion, and the one which had slipped, and left the none from hæmorrhage; while in the patient not the worse for the accident. She second series of 105 deaths there were got rapidly well. In another case I feared only 8 from exhaustion and 2 from that the patient was dying of internal hæmorrhage. The probability is that bleeding, but the father and brother, both some of the first series of deaths were medical men, were opposed to the reopenalso partly due to bleeding, but the fact ing of the wound, and would not permit was not established by examination. The an examination after death, so that I am deaths from exhaustion were mostly at not quite sure how far my fear was well the end of 2 or 3 days, but in 1 as early founded. In 1882 secondary bleeding as 13 hours. No case of collapse after occurred a few hours after operation on a the operation happened in the second lady aged 62. I opened the wound, found series, but in the first there were 6 cases that the ligature had slipped, transfixed -the time being from 2 hours to about and tied the pedicle, sponged out the 40 hours. No death has ever occurred peritoneal cavity, and reclosed the wound during the operation either from shock-assisted by Mr. Fuller of Piccadilly. alone or the anaesthetic. The patient did not seem much the worse for the accident, but she died on the 5th day. Thus out of the 232 deaths after 1,000 operations only 36 are immediately attributable to shock and hæmorrhage, a proportion lessened by increased experience. The remaining mortality of 196 was due to other causes; and, considering the large proportion of septic disease which proved fatal during the earlier years, was to a great extent avoidable. The mortality of 3.6 per cent. from shock and hæmorrhage cor Burst cysts and suppurating cysts do not seem to have lowered the success of my operations. There have been 15 such cases, 12 burst cysts and 3 suppurating cysts, among my 1,000 operations, and only 1 death resulted. My experience of 139 cases since the 1,000 gives 6 cases where the cysts had burst; of these 3 recovered and 3 died. H Injuries to viscera.-Several cases are on record, and I have heard of others not recorded, where the bladder has been injured either in making the first incision or in separating adhesions between the cyst and the bladder. Should the bladder be injured, the opening should be very carefully closed by suture, and a catheter maintained in the bladder for several days. As a rule the effects have not been serious, although in some cases the urine has drained through the wound for several days. In one case where I had cut into a patent urachus from which urine escaped, I closed the opening by one of the sutures which closed the incision in the abdominal wall, and no inconvenience followed. In 1881 Professor Billroth, in making a double ovariotomy, was obliged to resect part of the bladder and some inches of small intestine on account of adhesions between these parts. And in another double ovariotomy, done at the Salpêtrière by Professor Pozzi in December 1882, though all due precautions had been taken to empty the bladder, there was found, after opening the peritoneum, a layer of what appeared to be a membranous expansion, the product of some old inflammation. An incision of at least 10 centimetres, corresponding with that in the peritoneum, was made through this. After removing the two ovaries, and when preparing to close the abdominal wound, the supposed membrane, on being examined, proved to be the bladder. It had in no way contracted after the use of the catheter, and the hand could be easily passed into it through the wound. Professor Pozzi had therefore to deal with a wound of both the anterior and posterior coats. The posterior one he closed completely with sutures. That in front was partially sewn up, and the opening left was made to correspond exactly with a part of that in the abdominal wall. A siphon-tube was arranged to drain away the urine, and the bladder was, from time to time, washed out with a solution of boracic acid. By the end of January the urine began to pass naturally; in March the fistula was closed, and the woman entirely recovered. The rectum has been torn or divided during the separation of adhesions, in some cases with fatal consequences; in others, where accurate closing has been effected by suture, recovery has followed without any fæcal fistula. In a patient on whom I operated in July 1876, removing a tumour of the right ovary, the left having been removed 3 years before, the cyst was drawn out with a coil of adherent intestine. This was carefully separated, but not without a tear, leaving an opening sufficiently large to admit one finger. I inverted the edges of the opening so as to bring two surfaces of the peritoneum in apposition, united them by a continuous silk suture, and the patient recovered without any ill effect from the accident. In another case operated on in the Samaritan Hospital in June 1875, in removing a malignant growth weighing 41 pounds, I also detached and cut away about 3 inches of small intestine, the coats of which were involved in the disease. The upper and lower ends of the gut were brought together and united by peritoneal suture, but the patient died on the 11th day. Although some fæcal fluid had escaped from the wound in the abdominal wall, the bowels had acted freely in a natural manner, and it appeared that the wound in the intestine had but little to do with the fatal result. The practical lesson from this is to be extremely careful when separating adhesions between the cyst and intestine, and if the intestine is either accidentally wounded, or a diseased portion is intentionally removed, union of the peritoneal edges by fine sutures must be very accurately completed. the The liver has been injured during the separation of adhesions. In one case, in an insane patient under the care of Mr. Archer, of St. John's Wood, I removed some ounces of the lower edge and under surface of both lobes of a large liver. I had considerable trouble in stopping the bleeding, and applied perchloride of iron freely. The ovarian cyst for which I was operating was a very large one, and the patient in an extremely feeble condition after repeated tappings, yet she recovered rapidly and completely as in the most simple case, is still alive, and has regained her soundness of mind as well as body. In one other case, already alluded to, I lost a patient from hæmorrhage after opening a cyst which projected from the under surface of the liver, the walls of which poured out blood with extreme rapidity in spite of all efforts to check it. I have never met with a case in which the spleen has been injured during ovariotomy; but an enlarged spleen has If a kidney should be unavoidably or accidentally removed with, or instead of, an ovarian tumour, as much care would be called for in securing the blood-vessels as in a case of nephrectomy planned beforehand. One or both ureters are known to have been divided or tied accidentally. In Simon's famous case, where a urinary fistula remained after injury to the right ureter, Simon removed the right kidney, and I saw the woman some months afterwards in excellent health. In a similar case Nussbaum, instead of removing the kidney, re-established communication between the kidney and the bladder. It is remarkable that in cases of adhesions low down in the pelvis the ureters should escape injury so often as they do. I suspect that their condition has been overlooked in some post-mortem examinations, and it is probable that in some of the cases where suppression of urine has been a prominent symptom, one or both ureters may have been injured. I have heard of one case where after death one ureter was found tied. sponge might be within the abdomen at the end of the operation, but could not find it, and on counting the sponges the number was complete. It afterwards appeared that one had been torn into two by one of the nurses. No one who has not tried it can understand how difficult it may be sometimes to find a lost sponge. In my lectures as Hunterian Professor at the Royal College of Surgeons in June 1878, I gave the following account of a case in which I left a pair of forceps in the abdomen. 'Not very long ago I removed both ovaries, and a great many forceps were used. After removing one ovary and securing the pedicle, the other ovary had to be removed. It had a very short pedicle, and 5 or 6 of my torsionforceps were put on in order to secure the bleeding vessels, while I was tying them separately. I took off, as I thought, every pair of forceps, closed the wound, and everything seemed quite as it should be. But about 2 hours after the operation I received a message from a friend who was putting up the instruments for me, to say there was a pair of forceps missing. We knew exactly the number of forceps. If we had not known that, one pair would not have been missed. This shows how necessary it is always to know how many forceps are taken. It was about 5 in the afternoon when I had this message: 'There was a pair of forceps missing, proAfter passing the sutures which are to bably they might be in the patient.' Imaclose the opening in the abdominal wall, gine the sort of feeling with which one and before tying them, the sponges and would receive that intimation. I at once forceps should be counted. It is a good went to the patient. She seemed so well plan to take a fixed number of sponges that I did not like to disturb her. There and forceps to every operation. By for- was some doubt where the forceps might ceps I mean the torsion or pressure-for-be, so I thought I would wait a little ceps, the use of which has been already described. Of these I always take 12, of sponges 20. If any other than the usual fixed number be taken, some doubt is almost certain to arise when the nurse is told to count the sponges. Very small sponges are so easily lost, that it is advisable not to use any which when wet are smaller than an ordinary fist. Even then it may not be easy to find one when wet in the peritoneal cavity. It is a good rule for the surgeon strictly to forbid either of his assistants to put a sponge within the abdominal cavity. No one should be allowed to divide a sponge. One of my friends abroad writes that in one of his fatal cases a sponge was found in the peritoneal cavity. He had suspected that a longer. I waited till night; she still seemed pretty well, and I thought I would wait till the morning; but in the morning the nurse told me the lady had been very restless. I then made a very careful examination, by the vagina, and rectum, and abdominal wall, to see if I could feel the forceps, but there was nothing to be felt at all. Still I was uneasy, and I thought I had better open the wound. So I gave her methylene, removed the dressing, and took out two stitches. I put one finger in, but at first could not feel the forceps. At last I found something hard, put another finger in, and found the forceps wrapped up in the omentum. From the way in which the omentum had insinuated itself into the ring handles of the forceps, it was easy to understand how difficult it was to find and remove the instrument; but I did it, returned the omentum, closed the wound, and the patient was none the worse. She got well, and to this day does not know that anything unusual occurred.' I purposely avoid relating a case where a pair of forceps was found in the bladder of a patient a month after recovery from ovariotomy, as the occurrence is still to me inexplicable. It did impress upon me, however, what I had often before told others, that the surgeon should take all the instruments and sponges-not allow assistants or nurses to supply either-and never to neglect counting both. I ought to have added that this should be done before closing the wound, and thus avoid such an unpleasant accident as happened to me last year in a case where I was operating without either of my usual assistants. The patient was in bed before the forceps were counted. One pair was missed before she had quite recovered from the anæsthetic; a little more was given. I took out two stitches, and found the forceps without much difficulty. The patient made a good recovery. I repeat the caution, always to count both sponges and forceps before closing the opening in the abdominal wall. CHAPTER IX ON THE REMOVAL OF BOTH OVARIES AT ONE OPERATION SOME writers on ovarian disease have diseased. In 99 cases of ovarian disease asserted that the right ovary is much more frequently diseased than the left, and that coexisting disease of both ovaries is extremely rare. But, on examining the grounds for these assertions, we find that they are principally based upon examination of patients during life, or patients who have not been submitted to ovariotomy. When we come to examine the result of post-mortem examinations we find that, as there is no anatomical or physiological reason why the right ovary should be more frequently affected than the left, so, in fact, one ovary is found to be diseased as often as the other. Of 80 cases collected by West from Scanzoni, Lee, and his own notes of post-mortem examinations, in 28 the disease was on the right side, in 26 on the left side, and in 26 both ovaries were diseased so that in about one-third of the cases both ovaries were diseased. In 1865 Scanzoni again drew attention to this subject in a paper On the Relation of Disease of both Ovaries to the Ovariotomy Question.' He gives the result of an examination of the reports of postmortem examinations for the previous 14 years by Virchow and Förster. These records were examined with the sole object of ascertaining in how many cases one or both ovaries were Of 52 it was found that in 48 one, and in 51 both ovaries were diseased- -so that in more than half the disease was on both sides. The tendency to disease of both ovaries appears to be greater before the age of 50 than in older women. women under 50, both ovaries were diseased in 31; 1 ovary only in 21 (59 per cent. to 40). Of 44 women above 50, both ovaries were diseased in 17 only, while 1 ovary was diseased in 27. Thus, under 50, we had both ovaries diseased in 59 per cent.; above 50, only in 38 per cent. But it must be remembered that any conclusion drawn from post-mortem examinations would in all probability differ very widely from results observed in ovariotomy. The first series of facts shows what may be expected when ovarian disease has proceeded to its natural termination, or has only been modified by palliative treatment. The other series shows what may be expected when the patient is subjected to radical treatment before the disease has advanced to its last stages. All observation tends to the conclusion that disease begins in one ovary and advances to a considerable extent in that ovary before the other is affected, and that in about half of the cases it proceeds even to its fatal termination without any disease occurring in the opposite ovary. |