Page images
PDF
EPUB

of sufficient length was gently pushed through by the thumb and finger. This incision was closed by two rows of continuous catgut sutures; first by the approximation of the mucous and muscular layers and secondly the peritoneal layer. The opening at the fundus was closed by inverting it and then by puckering and tying the purse-string suture, whereby there was a direct approximation of the serous surfaces. Gauze drainage with rubber tissue covering it was introduced and the wound approximated with interrupted silkworm-gut sutures. Until January 19 the temperature varied from normal up to 100°, when it rose to 1024 and continued about the same until January 29, when it returned to normal. The other symptoms during these ten days were profuse sweating and a slight chilliness at times. At first I was unable to account for the sudden rise

of temperature as all other evidences of septic wound were absent. The source was quickly ascertained by urinalysis, when quantities of pus were found with scant secretion of urine. Diuretin in ten grain doses gradually changed this condition. Yellow stools were first observed on January 21; the yellow green color gradually began to fade. February 10, the date she left the hospital, she was able to walk the halls of the hospital. She sleeps well, appetite good, stools normal and no trace of albumin. At this writing she is nearly at her former weight and has an extraordinary appetite.

Remarks. It will be observed that I did not stitch the gall-bladder to the abdominal parieties, but closed the opening and let it drop back. Experience

[merged small][merged small][graphic]

the gall-bladder and then a secondary operation would be much preferable to leaving it to close by granulation.

Specimen III-Sixty-eight Gall-Stones (Figure III) removed February 24, 1898, from J. C., aged thirty-nine years, weight one hundred and sixty-five pounds, referred to me by DocTOR C. BONNING, of Detroit. Family history good.

Patient's History.-Has been the victim of so-called bilious attacks for the last twelve or fifteen years, lasting from two to four months; confined most of the time to his house. No pain, simply distress, in the region of the liver, gallbladder and stomach, rarely any rise of temperature. These attacks occurred two or three times a year with partial jaundice. Three years ago he had the first attack of severe pain lasting three hours, with vomiting of blood, relieved by a hypodermic injection of morphia. One year later another attack occurred of longer duration, followed by others at more frequent intervals. About a year ago, in the absence of his family physician, DOCTOR BONNING was called, diagnosed gall-stones and advised an operation, but his physician disagreed with the opinion and attributed these paroxysms to the passage of " thickened bile." After this numerous gall-stones were found in the stools at various times. The

last attack occurred two weeks ago when DOCTOR BONNING was again called and reiterated his previous opinion and advice. I saw him with DOCTOR BONNING February 22 and concurred in the opinion, following which he went to Harper Hospital February 23.

Present Condition.-The extreme jaundice and constant pain in region of gall-bladder is rapidly disappearing and his recovery seems assured.

Remarks.-Histories like the above, in our present state of knowledge, should indicate the condition and the necessity for surgical interference long before the paroxysms of pain occurred. In this case the prognosis would have been grave without an operation. The unfortunate presence of sepsis in the gallbladder obviated the advisability of closing the incision.

HYSTERECTOMY BY ABDOMINAL SECTION FOR FIBROMA OF THE UTERUS.

Specimen IV.-Uterus with Ovaries (Figure IV), weight eight pounds. MRS.

B., aged fifty-two years, entered Saint Mary's Hospital February 4, 1898, having been sent to me by DOCTOR A. R. INGRAM, of Fenton, Michigan.

Previous History.-Mother of four children. Has been conscious for the last six years of a gradually growing tumor in the pelvis. Treated by several physicians, one of whom used some sort of electrical treatment without benefit. For the last year uterine hemorrhage has been frequent and profuse.

Present Condition.-Walks with great difficulty. Very much emaciated and anemic. Rapid pulse. Difficult defecation and frequent micturition.

Physical Examination.-By vagina the tumor is found to fill the pelvic cavity, pressing on the rectum and bladder. Tumor can be seen projecting above the umbilicus and felt mostly to the right. By abdominal manipulation the tumor is but slightly movable. The urine has a specific gravity of 1026, acid, no albumin or sugar. Preparation.-Copious draughts of water were given as soon as she entered the hospital and continued until the time of operation, the better to meet the postoperative thirst. General bath, soap poultice on abdomen over night, scrubbing on the morning of operation with soap and water and bichloride dressings applied. Mild cathartic (saline), enemas and carbolated vaginal douche given.

[graphic]

FIGURE III.

Operation.-January 5, 1898. Incision to right of median line through inner border of right rectus muscle, extending from two inches above symphysis to two inches above the umbilicus. Section revealed extensive adhesions to omentum, rectum and bladder, traversed with many large blood-vessels.

Adhesions were carefully separated and ligatures applied as necessary, first isolating ovarian and uterine arteries and ligating them separately. The entire uterus was removed by circular amputation of vagina at its upper end; the cut edges of walls of vagina were approximated with two rows of catgut sutures, and afterward as far as possible the cut edges of peritoneum. Glass drainage

FIGURE IV.

through abdomen but none through vagina. Abdominal incision was closed by interrupted silkworm-gut sutures. Although very weak from acute anemia she made a good recovery and left the hospital for her home on the thirtythird day.

Specimen V-Fibroma of Uterus-Interstitial-(Figure V). Weight seven pounds. MISS L. L., aged twenty-eight years. I first saw her January 19, 1898, in consultation with DOCTOR F. B. WALKER.

Previous History.-Had knowledge of growing tumor for three years, with persistent headaches at times and several severe hemorrhages. Anemia was a prominent symptom. Mother and aunt died from some form of malignant growth. Has been operated upon twice within the last year per vaginam for removal of growth.

Present Condition. - Very anemic, temperature 100° and pulse 100. Examination reveals tumor filling pelvis,

[graphic]

immovable and markedly apparent by the prominence of the abdomen. Urine normal. The preparations were made as in the preceding case.

Operation made January 25, 1898, by DOCTOR FRANK B. WALKER and myself. While liberating adhesions which were more extensive than in the preceding case, we inadvertently rent the bladder on the posterior part of fundus transversely for three inches, which was closed with two rows of continuous catgut sutures. The tumor was cut off just below the utero-vaginal junction. and the wounds treated in the same manner as the case just reported. Shock was profound after the operation and necessitated prompt and copious cellular infusion of saline solution under the breasts. The rapid pulse kept up for several days. She, however, rallied gradually and made a good recovery leav

ing the hospital February 21, 1898. No inconvenience followed the rent in the bladder and the headaches have ceased.

[ocr errors]

Remarks. My reason for not making a median incision through the abdominal wall is that experience has taught me that there is less liability to a ventral hernia when the incision is made through the belly of the muscle. A much firmer union is the result. I am also convinced that there is less liability to stitch abscesses with a removable suture than when it is buried. Hysterectomy for removal of intramural fibromata of the uterus is a justifiable operation. The earlier it is done the less the mortality. Anemia and degeneration of the organs is of a less degree and is conducive to better results. Low mortality is

[graphic][merged small]

largely due to our improved knowledge of operative technique and aseptic precautions. This fact makes it a justifiable procedure and one that the surgeon can conscientiously recommend. How much better that a woman should have a bleeding uterine fibroma removed than go through a life of chronic invalidism accompanied with suffering and an early death. Small tumors may be removed through the vagina, all other things being equal.

OOPHORECTOMY.

Specimen VI-Ovaries and Rudimentary Uterus removed from Miss M. G., aged twenty-three years, January 13, 1898.

Previous History.-Patient was brought to me about six years ago by her married sister for the relief of amenorrhea. For a year or more she has suffered with pains peculiar to the appearance of the menstrual function, but there was no further evidence. Her sister stated that she had been examined by several physicians, one of them informing her that there was an abnormality of some kind. I found by examination that the labia were normal, and on separating them but one opening was apparent and that much smaller than a normal ostium vaginæ yet much larger than a normal urethra. I was unable to introduce even my little finger. On introducing a catheter a quantity of urine was withdrawn. A sound was then introduced and full-sized bladder explored. Further examination failed to find any evidence of vagina whatever. Subsequently I made a bimanual (finger in the rectum) examination and found what seemed to be a rudimentary body together with ovaries. She would occasionally have incontinence of urine. Since I first saw her she has had a

[graphic][merged small]

varied train of symptoms-severe pelvic and abdominal pains and dyspepsia. Has worn abdominal bands, spent several months at a sanitarium and received the usual treatment given at such places. She taught school until the early part of last year when the condition of her health was such that she had to give it up. Two months ago she returned to me willing to submit to a laparotomy that I had suggested to her several times.

Present Condition.-DOCTOR W. P. MANTON examined her with me under the influence of an anesthetic January 7, 1898, and fully corroborated my diagnosis and concurred in my advice as to the necessity of a laparotomy. She entered Harper Hospital January 11, 1898, and underwent the usual preparations for the operation.

Operation January 12, assisted by DOCTOR W. P. MANTON. After making the median incision she was placed in the Trendelenberg position which gave us a fine view of the contents of the pelvic cavity. The ovaries and Fallopian tubes were normal in appearance. The tubes attached on either side to a solid rudimentary body, the bodies widely separated from each other converging and joining together below into a thin sickle-shaped band. In this band we felt two flat button-shaped bodies. There was no evidence in the least of a vagina. The ovaries, tubes and bodies were removed as seen in Figure VI. She made an uninterrupted recovery and left the hospital February 3. She

« PreviousContinue »