CASE XXI.-Pyo-salpinx.—Extensive peri and para-metritis.--One sac torn out, the other opened and drained.-Mary S., colored, æt. 28 years, admitted to the hospital January 20, 1890, had suffered for the last four weeks with marked distress and pain in the pelvis; this attack had come on suddenly with high temperature and severe pain. The uterus was imbedded in a mass of exudation involving the broad ligaments. This exudation could be felt above the brim of the pelvis, through the abdominal walls, presenting a condition formerly described as perimetritis. She was operated on January 31. The uterus, ovaries, tubes and intestines were so matted together that it was impossible, at first, to outline and determine the relation of the various parts. The finger was pressed into the mass at the point where we should expect the fundus of the uterus, and this used as a land-mark to enucleate the tubes and ovaries from the intestines. A pus-sac was torn out on the right side; the left was situated low down in Douglas's pouch, was a thin walled sac, and closely adherent to the rectum. It was torn open, the cavity curetted with the finger and the drainage tube inserted into it. The parts were so friable that a ligature could not be applied, as there was considerable oozing; the bleeding surfaces were brushed with a sponge wet with a solution of the ferric sub-sulphate. The wound was closed with cat-gut and the cavity of the abdomen kept filled with a solution of boro-glyceride by irrigating it every four hours. The temperature of the patient immediately after the operation was 96.2°. Several times during convalescence the temperature fell below normal; on the twelfth day it was 96.4°. The maximum temperature was 100°, reached on the twenty-first day. The patient has fully recovered her health and expresses herself as feeling well. CASE XXI.-Appendages removed two years ago.-Secondary section.--Extensive intestinal adhesions.--Suture of the intestines.--Catherine M., colored, æt. 36 years, native of Delaware, admitted to the hospital February 8, 1890. She had undergone an operation a year ago for removal of the ovaries and tubes, the indication for which was not definitely known. No infiltration could be determined, but as the patient continually complained of pain in the one region, it was determined to open the abdomen and ascertain the cause. Operation done March 6. There were no adhesions between the intestines and the anterior parieties. A number of bands of adhesions were found between the intestines, uterus and stumps of the pedicles. These bands had been drawn out by the peristaltic action of the intestines, and were the cause of the distress which she suffered; they were torn through with some difficulty, and in one place the gut was torn open, requiring that it should be sutured. A drainage tube was inserted and the cavity treated wet. The temperature following the operation was 96.2°, from which she rallied in a few hours. Maximum temperature was 100°, occurring on the second and fifth days. The patient entirely recovered from the distress she had suffered. CASE XXIII.-Epithelioma uteri.—Vaginal hysterectomy.-Louisa H., æt. 41 years, was sent to the hospital by Dr. Kobler to undergo an operation for the relief of apparent malignant diseases of the uterus. She had been suffering for a number of months from uterine hemorrhage, attended with discharge of small masses of tissue and with considerable pain. The external surface presented a granular appearance; the uterus was freely movable, with no involvement of vagina or broad ligaments. The uterus was removed March 20, 1890. The broad ligaments were secured by clamps. Duration of the operation fifteen minutes. Temperature after operation 96.6°; on the second day reached 101°; from this time continued between normal and 100.2° until the fifteenth day, when it reached 103.2° and continued high for one week. The patient has fully recovered. CASE XXIV.-Pyo-salpinx.—Removal of the appendages.--Fanny R., æt. 30, entered the hospital suffering with pain in the abdomen. A mass could be distinguished passing around the brim of the pelvis to the left side; this, from the history, size and shape, was diagnosed as pyo salpinx. The right tube was adherent throughout Operation in the clinic March 29, 1890. its length and was considerably enlarged. drainage tube inserted. Convalescence normal, but later the patient had a redevelopment of an old lung trouble, which kept her confined for some weeks. She has since fully recovered. This series of cases comprises: Ovariotomy, 1; hysterectomy, supra-vaginal, 2; removal of appendages (both sides), 12; removal of appendages (one side) 2; nephrectomy, 1; section exploratory, 1; section (secondary) volvulus, 1; section (secondary) adhesions, 1; hysterectomy, 2. Four patients died: Nephrectomy, 1; hysterectomy, supra-vaginal, 2; removal of appendages, 1. Eight patients were operated upon in the clinical amphitheatre (1, 2, 3, 13, 14, 16, 17, 24) with two deaths (2 and 16), neither of which could be attributed to that cause. Cases 1 and 3 were done under the spray; the other cases without antiseptic precautions, farther than having the room sprinkled with a sublimate solution the morning of operation. Every precaution as to cleanliness was observed. Hysterectomy, supra-vaginal.-The patients (3 and 4) upon whom this operation was performed were poorly fitted for it; one had calcareous degeneration of the valves of the heart, coats of the vessels and of the tumor; the other, sacculated kidneys, leaving but little of the secreting tissue undestroyed. Much valuable time, however, was lost in case 3 in our efforts to control hemorrhage by the wire. Later experience has demonstrated that these cases are more successfully treated by the use of a clamp and extra peritoneal treatment. Case 5 unfortunately, lived too short a time to fully demonstrate the value of the operation in the treatment of her condition. The improvement, however, was far greater than under any other method of treatment to which she had been subjected. She Case 6 is now confined in the asylum at Norristown. has, I believe, been included upon the list of those who have become insane after this operation; but, as she had been insane for a number of years before with marked exaggeration of all her symptoms with each period, and an uninterrupted lucid interval of one year followed, it seems quite reasonable to judge that had the operation been performed earlier she would have been permanently cured. Case 11, the abdomen was closed without removal of the appendages, because the operation of tearing up the adhesions seemed a formidable task. Later experience has demonstrated to me its feasibility, and that, in such cases, the removal of the organs is the only certain method of removing the unfavorable symptoms. Case 13 demonstrates the importance, in all cases, but particularly in specific cases, of exercising the greatest care in the management of the bladder. When possible, the use of the catheter should be avoided; when used, the vestibule should be carefully cleansed; the instrument should be scalded out, be in good condition, and in the intervals be kept in antiseptic solution. In cases 18, 21 and 22, the abdominal cavity was kept filled through frequent irrigation with a solution of boro-glyceride. This fluid keeps the coils of intestines separated; favors peristaltic action; decreases the danger of unpleasant adhesions, and favors the reformation of peritoneum by granulation. In the earlier operations internal ligation was done with silk, while silk, silk-worm, gut or wire was used for sutures. In all the cases of the last year chromaticized cat-gut has been used, both for internal ligation and external suturing. The silk ligature in pus cases or where drainage is used is liable to become infected, and then a fistula remains until the ligature is discharged. The early absorption of the cat-gut precludes this. A REPORT OF TWENTY-ONE LAPAROTOMIES IN THE PHILADELPHIA HOSPITAL. BY BARTON COOKE HIRST, M.D. The laparotomies performed were of the following nature: One was for a large intraligamentary cyst; six were oöphorectomies; two were for varices in the broad ligament; one was an omphalectomy; two were exploratory incisions; two were for diseased tubes; two for an abdominal fistula; one for septic peritonitis; one was a myomectomy; one was for pelvic peritonitis; one for pelvic abscess; and one for double ovarian abscess. Among these patients there was but one death, and that not due to the operation. It was in the midst of the influenza epidemic of last year. The woman had had quite a severe attack of the prevailing disease, with a high temperature and a severe bronchitis. At the time of the operation there had been no fever for three days, and she seemed perfectly well except for a slight cough, but the ether undoubtedly determined an attack of pneumonia, which manifested itself on the day after the operation; involved, finally, both lungs with the pleura and proved fatal on the tenth day. The provision for abdominal surgery in the gynæcological department of the Philadelphia Hospital is excellent. A large room on the gynæcological floor is set aside for the purpose, which can be quite isolated; has excellent light, is bare of fixed furniture, and has such ample supply of steam heat pipes that the temperature even in winter can be raised to a high point. I usually endeavor to have it over 85° Fahrenheit, for I know by experience, that a prolonged abdominal operation may be done at this temperature without serious shock, which, done at the ordinary temperature of a room, would be followed by dangerous if not fatal depression. The results of laparotomies done in the special operating room have been much better than in the cases operated upon in clinic; and, notwithstanding the rather general movement at present in favor of doing these operations in a general clinic room, individually, I never would consent to subject a patient to the added risk which is undoubtedly entailed by the surroundings of a clinic amphitheatre, especially in the Philadelphia Hospital. I have seen a young woman, after an operation in the clinic room for removal of tubes and ovaries, without adhesions or any complications, die of septic peritonitis, which I am certain would not have occurred had the environment of the operation permitted of asepsis. One fatal case of this sort must of course outweigh any number of successes. A brief record of the twenty-one abdominal sections may be of interest to those engaged in this work. Abdominal section for intraligamentary cyst.—A young girl of twenty, with an abdominal tumor as large as a pregnant uterus at term; had been growing for a year; appeared first on the right side, but now occupies the median line. Fluctuation apparent on abdominal and vaginal examination; the latter reveals the uterus, not much enlarged, pushed to the left and crowded down in the pelvic cavity. Diagnosis ovarian cyst on 1ight side. Operation showed the cyst to be intraligamentary and unilocular. Its removal was difficult; indeed, a portion was left behind deep down in the pelvis, but the secretory surface was well seared. The patient left the hospital in three weeks, went home to the country, and, was told, led a fast life. Almost a year later she died of pelvic abscess, which I have no doubt was the indirect result of the operation. I endeavored to persuade her to return to Philadelphia for another operation, but without success. Oophorectomies.-Three of the operations were done for fibroid tumors. One of these was exceedingly difficult, so much so that hysterectomy would have been easier; the operation, however, was concluded and the result was good. The remaining three operations were done for pain, and, much as this indication has been abused, these operations, I believe, were justifiable. The first of them was performed on a young woman who had been delivered in the Maternity Hospital three months before. She had ever since her transfer from that institution to the Philadelphia Hospital been confined to bed on occount of great pelvic pain, located mainly in the left ovarian region. The girl was in the medical wards, where she had been sent on account of incipient phthisis. The lung disease was rapidly growing worse from her close confinement to bed. With the idea of relieving the girl's pelvic pain, and allowing her to leave her bed and go out in the open air, an exploratory incision was undertaken at the request of the physician who had her case in charge. On opening the abdomen the left ovary was found enlarged; a fact which could not be demonstrated by the vaginal examination. On the other side the uterine appendages were healthy. The left ovary was removed along with the tube, and the girl made a good recovery from the operation. She was entirely relieved of all |