CHAPTER XI

THE AFTER-TREATMENT. RISKS AND SEQUELÆ OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS

The performance of ovariotomy, hysterectomy, and allied procedures is attended by several risks, immediate and remote, which may spoil the best-planned and most carefully executed operation. Some of these may be avoided by careful attention to the details embraced by the phrase ‘after-treatment’.

THE AFTER-TREATMENT OF ABDOMINAL OPERATIONS

The patient is returned to the bed with gentleness and usually lies on her back, but many anæsthetists prefer to turn the patient on one or other side for an hour, until there is a fair return to consciousness. The patient then lies on her back and a pillow is placed under the knees. Hot-water bottles should not be placed in the bed with the patient until she is completely conscious, and they are rarely needed. The healing of blisters caused by hot-water bottles is a slow process. During the first twelve hours the patient complains of pain, thirst, and vomiting.

The thirst is in a measure relieved by administering six or eight ounces of normal saline solution by the rectum an hour after the patient returns to bed, and repeating it in three or four hours. The patient may wash her mouth out frequently with water, hot or cold, according to her fancy, and if there is no vomiting she may swallow a little hot water from time to time. As a rule, it is better for her to abstain from swallowing anything for the first eighteen hours; the best way to avoid vomiting after an anæsthetic is to keep the stomach empty.

There is always some pain after an abdominal operation, partly due to tension on the sutures, and colic. The injection of normal saline solution (a teaspoonful of salt to a pint of water) by the rectum often controls this, but occasionally the pain is so severe that it is necessary to give a quarter of a grain of morphine hypodermically, or in a suppository, about twelve hours after the operation, in order to procure sleep. The routine use of morphine after these operations is injudicious and rarely necessary.

At the end of twenty-four hours small quantities of barley-water, tea, or milk and water are given, and if retained they may be taken in increasing quantities. On the fourth day an enema is given to clear the bowel, and then the patient will take fish, chicken, &c., and soon get on to convalescent diet.

When vomiting is very troublesome, it is sometimes necessary to keep a patient on rectal feeding two or three days.

When there is abdominal distension, this may be relieved by the passage of a rectal tube at intervals of three hours, and if this fails a turpentine enema should be given.

Patients should always be encouraged to empty their bladder naturally: many are unable to pass water whilst lying on their backs. In these cases the urine is drawn from the bladder by a carefully sterilized glass catheter. Before passing the catheter, the nurse carefully wipes away the mucus from the urethral orifice. Cleanliness and care with the catheter must be enforced: cystitis causes much misery. During the first few days the quantity of urine passed by the patient is measured, and recorded in the notebook.

The temperature should be observed every four hours during the first week and recorded. The first record after the operation is usually subnormal, and in twelve hours it rises to normal or beyond. During the first twenty hours it may rise to 100° without causing alarm; beyond this, if accompanied by a rapid pulse, an anxious face, and distended belly, it will cause anxiety to the surgeon. A temperature of 101° or 102° unaccompanied by other unfavourable symptoms is not a cause for alarm, unless maintained.

The state of the pulse is a valuable guide and more trustworthy than the temperature. When the pulse remains steady and full there is no cause for alarm. When it increases in frequency to 120 or 130 beats per minute, and is thin and thready, then there is danger, even if the temperature is only slightly raised.

On the seventh or eighth day the sutures will require removal. Occasionally a hæmatoma forms in the wound; and in patients in whom the operation has been performed for septic conditions, stitch abscesses will occur. In septic cases the sutures require to remain a few days longer, to allow the wound to unite more securely.

When oöphorectomy, ovariotomy, or hysterectomy is followed by a non-febrile convalescence the patient may be allowed to leave her bed on the fourteenth day, and at the end of another week she may return to her home or go to the seaside according to circumstances. When the wound has healed by primary union, and this is usual where aseptic methods have been followed and buried sutures employed for the fascial and muscular layer, an abdominal belt is unnecessary. When suppuration has taken place in the wound and healing has been retarded, especially in a patient in whom operations have been performed for septic conditions, it is a useful precaution to advise her to wear a well-made belt. This is more necessary for women who have to get their living by hard work.

COMPLICATIONS OF ABDOMINAL GYNÆCOLOGICAL OPERATIONS

=Metrostaxis.= After ovariotomy and oöphorectomy, unilateral or bilateral, blood sometimes escapes from the uterus in the course of the first week, and simulates menstruation: it sometimes occurs within forty-eight hours of the operation, and is usually ushered in with a rise of temperature (100°-101°).

=Bed-sores.= These sometimes give trouble when operations are performed on elderly or enfeebled patients, especially when they are thin and have incontinence of urine. With due watchfulness and care on the part of the nurse a bed-sore ought rarely to occur.

=Post-anæsthetic paralysis.= Paralysis following operations on the pelvic organs occurs in connexion with the upper and lower limbs; it is an awkward and avoidable complication. Some of the simplest cases are those which arise from the pressure upon an individual nerve, such as the ulnar, circumflex, or musculo-spiral, due to the arm coming in contact with the sharp edge of a metal operating table. When the patient’s legs are flexed across the sharp edge of the table and fixed, as in the Trendelenburg position, during a long operation, the external popliteal nerve is liable to be pressed upon by the condyles of the femur. This will lead to paralysis of the muscles supplied by it. In some instances the paralysis is bilateral. Paralyses of this kind are identical with what are known as ‘sleeping palsies’. The more serious paralyses are directly due to the Trendelenburg position, in which there is a great tendency for the arms to be displaced over the head and hang downwards or abducted, as this position causes the clavicle to compress the nerves of the brachial plexus upon the first rib, or the scalenus anticus muscle, and perhaps, as some observers believe, between the clavicle and the transverse processes of the fifth and sixth cervical vertebræ.

Most of the writers on this subject attribute the paralysis more particularly to drawing the head to one side when the patient lies in the Trendelenburg position with abducted upper limbs, as it tends to stretch the lower cervical nerves of the opposite side, especially the fifth. This stretching is probably a greater factor in producing paralysis than pressure.

The form of paralysis produced in this way is that known as Erb’s palsy, and the muscles particularly concerned are the deltoid, brachialis anticus, biceps, and the supinator longus. Sometimes the spinati are involved. Occasionally the paralysis is bilateral. A case has been reported in which there was a total lesion of the brachial plexus, including the muscles of the shoulder girdle.

The following facts serve to show that stretching rather than pressure is responsible for this class of paralyses. A patient had undergone a vaginal operation in the crutch position, when the assistant drew her along the table by means of his fingers hooked in the axillæ over the folds of the pectoral muscles: next morning both upper limbs were found to be paralysed, and they remained in this condition many weeks.

In some of the lighter forms the paralysis passes off in a few days, but cases are known in which it has persisted for many months, and as it renders the limb useless for a time it is a serious matter.

Halstead refers to a case of bilateral peroneal paralysis following salpingectomy in the Trendelenburg posture which disabled a patient for six months.

On the whole prognosis is favourable, and recovery the rule.

Büdinger has described a case in which the upper limb was paralysed after an abdominal operation. The patient died some weeks later, and a clot of blood was found pressing on the surface of the brain at a spot corresponding to the arm centre.

REFERENCES

BÜDINGER. Über Lähmungen nach Chloroformnarkosen. _Archiv f. klin. Chir._, 1894, Bd. xlvii. 121.

COTTON, F. J., and ALLEN, F. W. Brachial Paralysis--Post-narcotic. _Boston Med. and Surg. Journal_, 1903, cxlviii. 499.

HALSTEAD, A. E. Anæsthesia Paralysis. _Surgery, Gynæcology, and Obstetrics_, 1908, vi. 201.

TURNEY. Post-anæsthetic Paralysis. _Clinical Journal_, 1899, xiv. 185.

=Giving way of the wound.= After cœliotomy the patient runs a risk of the wound being burst open, and this accident seems particularly liable to happen in cases where catgut has been selected for the suture material. Accidents of this kind belong to two categories:--

1. Many cases occur in patients from violent coughing or vomiting, as the straining causes the knots of the sutures to slip.

2. In feeble patients, and those debilitated by anæmia, diabetes, &c., and especially in septic wounds, the union of the edges of the incision unite very slowly; if the sutures are taken out on the eighth day, as is the custom, the wound is liable to burst asunder. This accident is prone to occur in patients whose abdominal wall has been greatly distended by a large tumour, and especially by pregnancy. On the whole the accident is more prone to complicate Cæsarean section than any other operation on the pelvic organs, and cases have been reported in which there has been a repetition of the accident. The largest collection of case-reports in which the wound has burst open after cœliotomy has been made by Madelung; a perusal of his paper shows that it is an accident with a high mortality. It is a fact that cases of this kind are rarely published, and from inquiries I find that it is of common occurrence. It has certainly diminished since surgeons have widely adopted the method of securing the wound with buried suture, but this is not always a preventative. The complication which makes the accident so unfortunate for the patient is the protrusion of the intestines.

In dealing with this condition the surgeon carefully and gently cleans the extruded intestines and omentum with sterilized water, returns them into the abdomen, and resutures the wound.

REFERENCES

MADELUNG, O. Ueber den postoperativen Vorfall von Baucheingeweiden. _Verhandlung. d. Deutschen Gesellsch. f. Chir._, Berlin, 1905, xxxiv, 2. Theil, p. 168.

=Hæmorrhage.= However carefully an operation may be conducted or whatever material may be employed for ligatures, there is a liability of bleeding after the patient has been returned to bed. Severe internal bleeding is usually due to the slipping of a ligature from an ovarian pedicle, or a uterine artery: it may come from a vaginal artery, especially in total hysterectomy, and occasionally from a vessel in an adhesion which has been missed in the course of the operation, for oozing which is scarcely appreciable when a patient is collapsed may become very free when reaction occurs.

Severe internal bleeding is manifested by very obvious signs: pallor, cold skin, rapid but feeble pulse, restlessness, and sighing respiration. When these symptoms are manifested the wound must be reopened, the blood and clot removed, and the bleeding point secured. It often happens, where the bleeding is due to the slipping of a ligature from the uterine or ovarian artery, that by the time the surgeon reopens the wound the patient is so bloodless that there is difficulty in determining the source of the bleeding. In very bad cases it is a wise plan to arrange for an assistant to perform the intravenous infusion whilst the surgeon deals with the bleeding vessel. (See Vol. I, p. 405.)

Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored.

In some instances the subcutaneous injection of normal saline solution may be employed. A suitable region is the loose tissue under and around the breasts. When this method is adopted the skin should be rendered antiseptic, otherwise troublesome abscesses and cellulitis will arise in the subcutaneous tissue at the situation where the saline solution has been injected.

=Intrapelvic hæmorrhage.= For many years I have maintained that two factors which have enabled hysterectomy to vanquish oöphorectomy in the treatment of uterine fibroids are _rigid asepsis_ and _perfect hæmostasis_. In the early days of intrapelvic surgery there used to be much discussion on the subject of free blood in the pelvic cavity: some practical surgeons urged that it was harmful and would induce peritonitis, and others took the opposite view. From my own observations I came to the conclusion that effusions of blood in the abdomen were often quickly absorbed, but that this was not invariable; and that post-operative collections of blood were very liable to become septic, especially when drainage was employed. I also pointed out that the large effusions of blood in the abdomen due to tubal abortion, or to the rupture of a gravid tube, are often attended with fever, and in some instances the temperature rises to 103°. In such cases, when operative interference is undertaken, the deliquescent clot present in the pelvis often gives off a musty odour. Much light has been thrown on this condition by Dudgeon and Sargent, who have specially investigated the bacteriology of intraperitoneal effusions. These observers have isolated from intraperitoneal effusions of blood a white staphylococcus, which makes its appearance in the blood within a few hours of being effused, and they are of opinion that the febrile disturbances so frequently found after effusions of blood into the peritoneal cavity are due to the presence of this organism.

Apart from the pathological importance of these observations there is a point of practical value connected with them. The white staphylococcus will infect sutures and give rise to stitch-abscesses in the wound; in view of this fact it behoves the surgeon who has to deal with a stale effusion of blood in the pelvis and evacuates it by an incision through the abdominal wall, that in closing the incision he should employ through and through sutures, and not attempt to suture it layer by layer. I have noticed the same tendency to stitch-abscess in cases of diffuse pelvic inflammation due to infection by the gonococcus.

=Pneumonia.= This is a serious and not infrequent sequel of cœliotomy, especially when it concerns diseased conditions in the upper half of the abdomen: pneumonia occurs frequently as a sequel to ovariotomy, hysterectomy, and allied operations, and occasionally has a fatal ending. It may arise from inhalation, or may be due to the dorsal position (hypostatic pneumonia), or it may arise from infection.

Inhalation pneumonia is not uncommon, and although it is often attributed to the anæsthetic, especially ether, it is doubtless due to a combination of causes, such as a cold room, undue exposure of the body, septic teeth, the chilling effects of ether on the tissues of the lung, and occasionally to a dirty face-piece belonging to the ether or chloroform apparatus.

Hypostatic congestion of the lungs is liable to occur in the aged and in debilitated patients; it is a complication in such cases always to be guarded against.

Embolic pneumonia is the most serious form, and occurs as a sequel to operations for septic conditions, such as pyosalpinx, suppurating ovarian cysts, septic fibroids, and post-operative sepsis; it is also associated with thrombosis, especially when the pelvic veins contain septic clot.

In the preceding section attention was drawn to the appearance in intra-abdominal blood-effusions of a white staphylococcus: such collections of blood are prone to decompose and cause the temperature to rise.

On several occasions in which blood has been effused freely into the pelvic cavity, either as a consequence of tubal pregnancy, or as a sequel to an operation, such as an abdominal myomectomy, and the blood has been allowed to remain, or it has been inefficiently drained, the patients have died from septic pneumonia.

In cases of septic thrombosis the patients run a definite risk from pulmonary embolism. When the embolus is large the patient sometimes dies in a few minutes (see p. 101); but even in cases where the embolus is too small to promptly destroy the patient’s life, its lodgment in the lungs entails in some instances a very serious illness, and occasionally a fatal termination.

=Parotitis.= Septic parotitis, or, as it is sometimes called, symptomatic or secondary parotitis, to distinguish it from mumps, is an occasional sequel to abdominal operations of all kinds. Careful observations have shown that parotitis is more common after operations for septic conditions, and, although it occasionally occurs after operations which run an afebrile course, the conditions underlying it are mainly septic in character.

Septic parotitis is distinguished from mumps in the following points:--

It occurs as a complication of some other affection, is in itself non-contagious, and occasionally suppurates. There are two views held in regard to its etiology: some hold that it is due to direct infection of the duct (Stenson’s) of the parotid gland by micro-organisms from the mouth, whilst others maintain that the path of infection is mainly by the blood-stream.

Two able investigations have recently been published in regard to this condition, in which one writer (Bucknall) supports the view that it is an ascending affection from the mouth, and the other (Tebbs) brings forward evidence that the elements of infection reach it by the blood-stream.

Lequeu has seen many cases of post-operative parotitis, and at his suggestion Verliac and Morel investigated the condition in the laboratory. They came to the conclusion that this variety of parotitis originates in the ducts of the gland.

When parotitis complicates post-operative convalescence, it is almost entirely confined to septic cases: it may occur within two days of the operation or as late as the thirtieth day. It is more common between the sixth and tenth days, and its advent is accompanied by much disturbance. The parotid swells and becomes painful and tender; the skin over it is red and often brawny. These signs are accompanied by fever, malaise, and depression of spirits. In mild cases they subside in a few days, but in severe cases rigors occur, with high fever and suppuration.

The mild cases are best treated with warm fomentations, frequently changed. If suppuration occurs, the pus will need to be evacuated by a scalpel, but incisions in a suppurating parotid gland should be carried out with careful regard to the branches of the facial nerve (pes anserinus), and the large vessels intimately associated with it.

The surgeon need not be in a great hurry to use the scalpel in these cases, for it seems occasionally as if the skin would slough, and yet when it is incised no pus escapes. This septic parotitis is deceptive in the red and brawny appearance of the skin covering the swollen gland, and the misleading sense of fluctuation. In many instances the inflammatory products escape by way of the parotid duct.

Septic parotitis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases.

=Thrombosis.= After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and œdema of the limb. It is noticed most frequently about the twelfth day after operation.

In some patients the thrombosis is confined to the superficial veins of the calf and thigh, but when the femoral and internal iliac veins and the associated lymphatics are involved, the œdema is of a solid kind. Apart from the danger which ensues from the detachment of a fragment of clot and its arrest in the pulmonary artery, this complication is often very serious for the patient, for it entails a long confinement to bed, a tedious convalescence, and the œdema of the limb will sometimes persist for many weeks or months, in spite of topical applications, careful bandaging, or judicious massage.

Post-operative thrombosis was formerly fairly common after hysterectomy for fibroids and in the later stages of malignant disease of the uterus. Its frequency after operations for fibroids was attributed to the profound anæmia in patients who had severe and exhausting metrorrhagia. I am convinced that it is due to sepsis. In several instances I have caused the clot found in thrombosed veins to be examined bacteriologically, and pathogenic microscopic organisms have been isolated. I am also satisfied that in some cases of thrombosis of the veins of the thigh, especially those limited to the saphenous veins, the clotting spreads from the superficial veins of the hypogastrium which are infected from the abdominal incision.

=Pulmonary embolism.= In perusing the clinical histories of a series of cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost any surgical operation, here and there a record may be read to this effect: ‘The patient appeared to be doing well after the operation, when she sat up, laughed and chatted with the nurse, then suddenly fell back and died in a few minutes.’

Anything more tragic than this it is difficult to conceive, and, as a rule, after such a sad occurrence, the relatives are so distressed that they rarely permit an examination of the body. Death in such circumstances is usually attributed to embolism of the pulmonary artery. In some instances this is an assumption, but there are many in which an embolus has been demonstrated, and a few in which the source has been detected.

Post-operative embolism of the pulmonary artery is an important matter for surgeons interested in the operative treatment of uterine fibroids, for it follows such operations more frequently than any other. In order to afford some notion of the relative liability of patients to this accident after subtotal and total hysterectomy for fibroids, I have gathered the following statistics, which are interesting as showing an extraordinary variation in the practice of different operators:--

Baldy ascertained that among 366 operations for fibroids in the Gynecean Hospital, Philadelphia, there were thirteen sudden deaths attributed to pulmonary embolism.

In the Middlesex Hospital between the years 1896 and 1906 (both years inclusive) there were 212 abdominal hysterectomies performed for fibroids. Three of the patients died from pulmonary embolism. Spencer, in eighty-five total hysterectomies, had two deaths from pulmonary embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one sudden death.

Mallet collected the records of 1,800 cœliotomies: there were six deaths attributed to embolism, and of these, three followed operations for uterine fibroids. Chas. P. Noble, in forty-two vaginal myomectomies, lost two patients, one from septic endocarditis, the other from embolism; in the latter case the fibroid was gangrenous.

Olshausen, from the year 1896 to the end of 1905, performed 366 hysterectomies for fibroids; twenty-seven of these patients died. Five of the fatal cases were due to embolism.

Since 1894 I have performed more than a thousand operations of various kinds for fibroids, and have lost one patient from pulmonary embolism. This happened in 1900. The woman was forty-five years of age and profoundly anæmic from profuse and long-continued menorrhagia. Twelve days after subtotal hysterectomy she asked to be pillowed up in bed; this was done, when she suddenly slipped down the bed in agony and died in fifteen minutes. At the post-mortem examination the right pulmonary artery was found plugged with a thick clot. No thrombosed vessels were found in the pelvis.

The symptoms of pulmonary embolism may occur at any period from the hour of the operation up to the thirtieth day. In the majority of patients embolism happens about the twelfth day. The symptoms supervene with great suddenness and seem to be preceded by movement, such as sitting up, getting out of bed, and especially straining during defæcation. Withrow tells of a patient who was attacked whilst ‘putting on her clothes to leave the hospital’. She died in twelve hours. Reclus, at a meeting of the Société de Paris, 1897, mentioned that a patient quitting the hospital, apparently convalescent from hysterectomy, fell dead in the courtyard from pulmonary embolism. In one remarkable instance a patient complained of sciatic pain fifteen days after hysterectomy. In order to afford relief the surgeon flexed the patient’s thigh on her abdomen and then suddenly extended it. This dislodged a clot, and the woman was seized with the symptoms of pulmonary embolism and died in forty-seven minutes. At the post-mortem examination the pulmonary artery was found occluded with clot and the ovarian vein contained a thrombus (Byron Robinson).

It is important to note that these fatal cases of pulmonary embolism occur when they are least expected, and it is an unusual sequence in patients with obvious thrombosis of the femoral and saphenous veins.

The most constant symptoms are urgent dyspnœa accompanied by great distress; in some instances the patient becomes pallid and in others cyanotic. Death may follow in a few minutes; in less severe cases it is delayed several hours, the patient remains conscious, but suffers severe mental agony.

A pulmonary embolism is not necessarily fatal, for a woman after a pelvic operation may complain of sudden pain in the chest, urgent dyspnœa, exhibit great mental distress, and in a short time spit up sputum mixed with blood. In a few hours the urgent symptoms subside and in two or three days pass away, and the patient recovers. I have seen five examples of this mild form of pulmonary embolism after hysterectomy. One of the patients appeared to suffer from a succession of small pulmonary emboli.

Somerville Hastings refers to a woman thirty-six years of age, anæmic from profuse, long-continued menorrhagia due to a uterine fibroid, who, whilst waiting in the hospital for hysterectomy, was seized with pulmonary embolism and died three hours later. An embolus occupied the pulmonary artery, resembling a blood-clot found in the left common and internal iliac veins. Hastings also states that in a patient who died from pulmonary embolism, after an operation, a thrombus occupied the right cardiac ventricle, and he thought it possible that this intraventricular clot furnished the embolus (Fig. 25).

We must bear in mind that individuals apparently in good health die suddenly in the street, in the armchair, in a bath, or even during sleep: it is a fair assumption that some of the instances of sudden death occurring during convalescence from surgical operations may be due to failure of the heart absolutely unconnected with the operation. It is, however, undeniable that thrombosis of the pelvic veins after ovariotomy, or hysterectomy, is a source of fatal emboli. At present there is very little evidence available as to the cause of the thrombosis, but it can scarcely be doubted that sepsis, it may be only of a mild type, is responsible for some of the cases.

A careful consideration of the matter reveals beyond any doubt that pulmonary embolism occurs much more frequently after hysterectomy or fibroids than after any other operation, and it is especially liable to happen in women who are profoundly anæmic from profuse and prolonged menorrhagia. This indicates that long-continued and irregular losses of blood induce some change in the composition of this important fluid, which favours its coagulation.

It has been suggested that the practice of keeping patients strictly confined to bed for two or three weeks after hysterectomy and allied operations is responsible for the thrombosis which is the source of these fatal emboli. Some American surgeons act on this suggestion and insist on their patients getting out of bed a few days after such operations. This method does not commend itself to British surgeons. In my own practice I make it a rule, even in the most favourable conditions, to keep the patients confined to bed for two weeks. No patient is allowed up until her temperature has been normal for at least three days. The consequences of this practice appear to be justified, for in more than a thousand hysterectomies, only one of my patients lost her life in consequence of pulmonary embolism.

In cases of embolism of the pulmonary artery, death does not always occur immediately, but may be postponed for an hour or more after the lodgment of the embolus.

Trendelenburg is of opinion that it might be possible to remove this clot by direct surgical intervention. After careful consideration of the matter he carried out this operation on a woman aged sixty-three years; he raised an osteoplastic flap on the left side of the thorax, exposed the conus arteriosus, and intended to withdraw the clot, by means of a specially constructed pump, through a slit in its walls. The patient died from excessive bleeding before the clot could be extracted; the operation was hindered by an adherent pericardium.

Trendelenburg has carried out this operation on a man forty-five years of age. This patient was tabetic and sustained a spontaneous fracture of the femur. One month later he was seized with urgent dyspnœa and signs clearly indicating the lodgment of an embolus in the pulmonary artery. Trendelenburg exposed the heart, opened the pulmonary artery, and by means of polypus forceps succeeded in withdrawing 34 centimetres of clot. The incision in the artery was carefully closed with sutures. The man improved considerably as the result of the operation, but died thirty-seven hours later. At the post-mortem examination the left and right branches of the pulmonary artery contained an embolus. From the surgical point of view there are no reasons why such a bold example should not be repeated with success.

When patients who are profoundly anæmic from menorrhagia due to fibroids undergo hysterectomy, it is a useful measure to give them twenty grains of citrate of sodium twice daily in order to diminish the abnormal tendency of the blood to coagulate in the vessels. Certainly this drug should be administered if there is the least evidence of thrombosis.

=Foreign bodies left in the abdomen.= Every writer on ovariotomy and kindred operations insists on the importance of exercising the utmost personal vigilance in counting instruments and dabs before, and immediately after, an abdominal operation in order to avert the dangers which ensue when instruments, dabs, gauze, or drainage tubes are accidentally left in the abdominal cavity. Before the era of antiseptic surgery nearly all the patients in whom foreign bodies were left in the abdominal cavity died. In several instances the surgeon has discovered, on counting the sponges and instruments after the operation, one or more to be missing, and, failing to find them in the room, has reopened the wound and recovered the missing article. In many lucky cases, a sponge or compress has given rise to an abscess, and, the wound reopened, the sponge presented at the opening. Often a compress of cotton-wool or gauze has slowly ulcerated into the rectum and been discharged through the anus.

When things of this kind are left in the abdomen the risks are not so great now as in pre-antiseptic days, but they cause much discomfort and anxiety as well as suffering: moreover, such an accident entails reopening the wound and occasionally a serious operation for the removal of the missing article, and as a recent decision in a Court of Law fixes the responsibility on the operator, there is always the possibility of an action at law with all its vexations and the liability of being mulcted in damages.

The behaviour of foreign bodies left in the abdomen is curious and also interesting from the great length of time which metal instruments will sometimes remain without causing very urgent symptoms, and the tendency they exhibit to penetrate adjacent viscera.

Among the early cases Sir Spencer Wells reported one in which a pair of forceps was found in a patient’s bladder who died a month after ovariotomy. Olshausen mentions that a pair of forceps was passed by the rectum nine months after ovariotomy, and Terrillon tells of a pair of pressure forceps which remained eight months in the belly and came out close to the navel. One of the most remarkable instances is recorded by MacLaren, in which a pair of forceps was left in the abdomen in the course of a hysterectomy. Two years later, a swelling formed in the right iliac region; this was explored through an abdominal incision, and the hæmostatic forceps represented in Fig. 26 was found embedded in the omentum; the forceps had ulcerated into the cæcum and the blades were lodged in the vermiform appendix. The patient recovered.

In order to illustrate the diminished risks run by patients when the instruments and dabs used in operations are thoroughly sterilized, reference may be made to a case recently reported by J. E. F. Stewart (Australia), in which he removed a pair of pressure forceps which had remained in the abdomen for ten years and a half. The patient, who had been more or less an invalid since the primary operation, had suffered from attacks of acute pain, constipation alternating with diarrhœa, and pains in the lower limbs. The instrument, which measured 5 inches long and 2-1/2 across the handles, was lying point downwards in the pelvis, and the ring handles could be felt through the belly-wall before the operation: it had made its way into the small intestine.

The tendency for a foreign body, whether hard like forceps, or soft like gauze pads, to erode its way into the intestine is very remarkable. Thus Gifford operated on a patient with intestinal obstruction; an impacted mass was felt in the ileum, it was extracted through an incision in the gut and proved to be a pad of cotton-wool enveloped in gauze. She recovered. Three months previously this woman had undergone abdominal myomectomy.

Another source of risk to patients is the practice or habit of packing the pelvic recesses with strips of gauze temporarily, either with the hope of controlling oozing, or to serve as a drain. I have long abandoned this habit. The disadvantage of gauze stuffing which needs consideration in this section is the risk that some portion, or the whole of it, is sometimes left in the wound. Examples are known where long strips of ‘gauze stuffing’, sometimes amounting to a yard or more, have been passed through the anus a year after the operation. Many intractable sinuses have had a forgotten piece of gauze as the cause of their persistence.

A woman had cœliotomy performed for peritonitis, the consequence of criminal abortion; she had a long convalescence due to an intractable sinus. Eventually the patient was thought to have tuberculous disease of the appendages, and a mass, formed mainly by the Fallopian tube, was removed. The walls of the tube were intact, but when slit open the tube was found to contain a small gauze tampon (Kouwer).

The isolated records relating to foreign bodies left in the abdomen are very numerous. Thus Wilson in 1884 was able to collect twenty-eight cases from periodical literature and personal reports from friends. An interesting discussion took place on the reading of a paper on this subject before an American gynæcological society, by R. W. Waldo, and the number of cases related by the members is astonishing and refer to such things as sponges, dabs, forceps, a strip of iodoform gauze ‘a yard wide and two yards long’, a pair of spectacles, and ‘an operating-room towel’, which were left in the abdominal cavity.

The most comprehensive collection of records relating to foreign bodies left in wounds of all kinds has been made by F. von Neugebauer; they amount to 195.

REFERENCES

GIFFORD, G. T. _British Medical Journal_, 1907, ii. 1042.

KOUWER, PROF. _Zentralbl. für Gynäk._, 1907, xxxi. 1447.

MACLAREN, A. _Annals of Surgery_, 1896, xxiv. 365.

NEUGEBAUER, F. V. _Monatsschriften für Geburtsh. u. Gyn._, 1900, Bd. xi, 821, 933. _Zentralbl. für Gynäk._, 1904, xxviii. 65.

STEWART, J. E. F. _Australian Medical Gazette_, 1906, xxv. 446.

WALDO, R. W. _American Journal of Obstetrics_, 1906, liv. 553.

WILSON, H. P. C. _Trans. American Gynecological Society_, 1884, ix. 94.

=Tetanus.= This dread complication of wounds occasionally occurs after ovariotomy, and during the ‘reign of the clamp’ it was especially frequent in Germany (Olshausen). Cases have been reported in England, and tetanus has been noticed to affect patients who have been ovariotomized in rooms recently plastered.

Since Kitasato demonstrated the bacillary origin of tetanus poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the tetanus bacillus.

Tetanus, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the tetanus bacillus was detected in some wallaby tendon employed to suspend the uterus. Tetanus has also been traced to infected catgut employed in cholecystotomy (1905).

Ed. Martin reported the occurrence of tetanus after vaginal fixation of the uterus and colporrhaphia anterior. Cumol-catgut was employed.

Menzer has recorded a similar case which occurred in Dührssen’s Klinik (1901). The ligatures were of catgut.

Mallet refers to two post-operative deaths from tetanus. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material.

In practice it is important to remember that tetanus arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling.

Tetanus occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind.

REFERENCES

DORSETT, W. B. Two fatal cases of Tetanus following Abdominal Section due to Infected Ligatures, &c. _Am. Journ. of Obstet._, 1902, xlvi. 620.

MALLET, G. H. Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.

MARTIN, ED. Postoperativer Tetanus (with references). _Zent. f. Gyn._, 1906, xxx. 395.

MEINERT. Drei gynäkologische Fälle von Wundstarrkrampf. _Arch. für Gyn._, 1893, xliv. 381.

MENZER. Tetanus Infection after Vaginal Fixation of the Uterus. _Zeitsch. f. Geb. u. Gyn._, 1901, xliv. 517.

OLSHAUSEN, R. Tetanus nach Ovariotomie Billroth-Lücke’s. _Handb. der Frauenkrankheiten_, 1877-9, ii. 367.

TAYLOR, H. Tetanus after Hysterectomy. _Am. Journ. of Obstet._, 1908, lvii. 574.

=Injury to intestines.= Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where cœliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut.

Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the rectum runs a great risk of being damaged.

In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis.

It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed.

In sewing the abdominal incision the intestines have been pricked with a needle, and in some instances the bowel has been accidentally included in the sutures and sewn to the abdominal wall. On one occasion while securing a very long incision with through and through sutures, while passing the needle through the abdominal wall, it broke, and the broken end came with great force against the anterior wall of the stomach and tore a hole in it. This I secured at once with suture and the accident had no bad consequences.

An unrecognized wound of the bowel in the course of a pelvic operation is almost certainly fatal. Accidental injuries, such as punctures and cuts, require immediate suture, and I have never known any harm follow. On the other hand, ragged tears in thickened and inflamed bowel require careful consideration in order to spare patients the inconvenience and distress of fæcal fistulæ.

In regard to small intestine a very small opening may occasionally be safely secured with fine silk, but in most cases it is wiser, if the bowel is thickened and inflamed around the hole, to resect well wide of the damaged portion and join the cut ends (circular enterorrhaphy).

Holes low down in the rectum are difficult to suture securely. These should be treated by drainage, using a wide rubber drain; the convalescence will be tedious, but the fistula will close.

It is useful to remember that if the rubber tube be too long it may enter the hole in the bowel and thus maintain the fistula. On one occasion I was asked to close a fæcal fistula which had followed an oöphorectomy. This fistula persisted five years. At the operation I found a hole in the sigmoid flexure with its margins adherent to the opening in the parietes, so that the tube passed directly into the bowel. The gut was detached and the opening closed with sutures, and it gave no further trouble.

If, in the course of an ovariotomy or hysterectomy, the surgeon discovers a cancerous stricture in the colon or cæcum he should resect the affected section, if it permits of this treatment; otherwise lateral anastomosis should be performed. (See Vol. II.)

=Intestinal obstruction.= It is difficult to estimate with any approach to accuracy the relative frequency of intestinal obstruction after operations on the uterus and its appendages; nevertheless the danger is real. The obstruction may be acute or chronic: it may occur within thirty hours of the operation or be delayed for months or years. The causes may be arranged under five headings:--

1. Adhesions to the abdominal wound.

2. Adhesions to the pedicle, stump, or a raw surface in the pelvis.

3. Strangulation around an adventitious band.

4. Obstruction due to an overlooked cancer in the colon.

5. Strangulation in a sac formed by a yielding cicatrix.

The form of intestinal obstruction with which we are most concerned here arises shortly after the operation and in the course of convalescence; it may be caused by adhesions to the abdominal incision, the pedicles, raw surfaces in the pelvis left after the removal of adherent cysts and tumours, and the cervical stump of a subtotal hysterectomy.

The subject is one of importance, for the complication is fairly common in the practice of some surgeons, and is one which it is very necessary to recognize, for, unless measures of relief are undertaken promptly, the patient surely dies.

From a careful study of the matter I have come to the conclusion that acute intestinal obstruction is more frequent after ovariotomy than after hysterectomy, and this is due to the fact that the stump or pedicle left after the removal of an ovarian tumour lies higher in the pelvis, and in closer relation to ileum and jejunum, than the cervical stump left after the removal of the uterus. This view also receives support from the fact that acute intestinal obstruction following hysterectomy is more frequent in the practice of those surgeons who perform subtotal hysterectomy improperly, and leave a large piece of the neck of the uterus sticking up like a median post in the floor of the pelvis. As far as I can judge from the scanty records relating to this complication after hysterectomy, it is the sigmoid flexure of the colon which is most commonly adherent to the cervical stump. The best way of avoiding this accident is to remove the supravaginal cervix so freely that, when the peritoneum is closed over the incision in the floor of the pelvis, there is nothing visible except a narrow thin line of suture at the base of the bladder.

The only rational method of treating acute intestinal obstruction following operations in the pelvis, is to promptly reopen the abdomen and set free the adherent coil of gut. Operations of this kind after hysterectomy are more often successful than when they are a sequel to ovariotomy, and this is, I think, due to the fact already mentioned, that when intestinal obstruction follows ovariotomy or oöphorectomy, the obstruction arises in the small intestine and is usually very acute and more dangerous; whereas after hysterectomy the obstruction affects, as a rule, the sigmoid flexure of the colon, and though it may be fairly acute, is not nearly so dangerous, and gives far better results to operative treatment.

=Perforating ulcer of the stomach and small intestine.= A rare cause of death after ovariotomy or hysterectomy is a perforating ulcer of the stomach or jejunum. Since 1887 I have seen three cases. In each instance the patient died from septic peritonitis. Rosthorn lost a patient from perforating ulcer of the stomach after hysterectomy. Olshausen states that he has seen at least four examples of this accident.[2]

[2] Bland-Sutton, J. On Perforation of the Stomach and Small Intestine as a Sequel to Ovariotomy and Hysterectomy. _Journ. of Obstet. and Gyn. of the British Empire_, 1909, xv.

=Injuries to the bladder.= This viscus has been injured in a variety of ways during operations on the pelvic organs. An overfull bladder has been mistaken for an ovarian cyst and been punctured with a trocar before the mistake was discovered. When tumours are impacted in the pelvis the bladder is often pushed up into the hypogastrium; this happens with bilateral ovarian tumours, incarcerated fibroids, and especially with large cervix fibroids. When the bladder is pushed up, care should be exercised in making the abdominal incision, or it will be cut. Punctures and incisions in the bladder should be immediately closed with sutures of fine silk.

The bladder is liable to be injured in the performance of subtotal and total hysterectomy, especially in the latter operation when separating it from the neck of the uterus. In the subtotal operation the risk arises chiefly in suturing the peritoneal flaps over the cervical stump, for the bladder is liable to be punctured with the needle as it lies close to the anterior flap.

=Injuries to the ureter.= Since the vulgarization of hysterectomy, injuries of the ureters have become common; nearly all are inflicted in cases where the neck of the uterus is removed, as in total abdominal hysterectomy, and in vaginal hysterectomy, because the vesical segments of these ducts come into close relationship with it.

British surgical and gynæcological periodical literature contains very little that concerns ureteral injuries, but it is only necessary to look into the pages of the _Zentralblatt für Gynäkologie_ to find ample evidence that the integrity of the ureters is frequently sacrificed to modern pelvic surgery.

Blau published statistics from Chrobak’s Klinik in Vienna showing that in the interval January, 1900, to January, 1902, the ureters were injured fifteen times. In total hysterectomy seven times; in the course of ovariotomy on three occasions.

Sampson stated that from August, 1889, to January, 1904, the uterus was removed 156 times for cancer of its neck at the Johns Hopkins Hospital, Baltimore, and the ureters were injured nineteen times. The injuries were of various kinds, such as ‘ligating, clamping, cauterizing, cutting.’

In abdominal hysterectomy for fibroids the risk of injuring a ureter is not great. Thus Deaver writes that in the course of 250 abdominal hysterectomies he injured the ureter once, but the accident entailed the death of the patient.

I have performed hysterectomy on 1,000 occasions and injured the ureter once; my patient had a narrow escape for life and lost a kidney.

I have been present on five occasions when a ureter was injured. Four of the operations were for the removal of the uterus on account of fibroids, and one was an ovariotomy. Four of the patients died.

The injuries to which the ureters are liable in the course of hysterectomy are as follows:--

1. One or both ureters have been included in the ligatures applied to the uterine arteries.

2. One or both ureters have been cut or completely divided with scissors, or knife, in removal of the uterus.

3. A segment of a ureter 7 centimetres in length has been accidentally exsected.

4. One or both ureters have been compressed by clamps applied to restrain bleeding in the course of vaginal hysterectomy, and subsequently sloughed.

5. Ureters exposed in the course of ‘radical’ operations for cancer of the neck of the uterus often slough.

6. A ureter is sometimes transfixed by a needle and thread when sewing the layers of the broad ligament together in the course of a subtotal hysterectomy.

The most dangerous injury to the ureters occurs in the course of a subtotal hysterectomy, especially if it is not recognized at the time of the operation. In such circumstances the urine will slowly leak into the connective tissue of the broad ligament and form an extravasation extending into the loin.

In some cases the fluid will leak directly into the pelvis, and a sinus will form in the abdominal wound and allow the urine to escape; this may be the first intimation that a ureter has been injured, whereas when a ureter has sustained damage in the course of a total abdominal or a vaginal hysterectomy, the leakage of urine along the vagina will quickly apprise the surgeon of the accident.

There is another form of injury to the ureter which should be mentioned. Occasionally a fibroid, but more often a cyst or tumour arising from the base of the broad ligament, will involve the corresponding ureter and carry it upwards in such a way that, when the layers of the broad ligament are reflected, the ureter will be found crossing the crown of the tumour like a strap. In such a case the pressure has usually exerted a banal influence on the kidney, and it is often in the condition known as sacculation. In a case under my own care in which I attempted to remove a malignant tumour of the broad ligament, and in which the ureter ran over its upper pole in this way, thinking it was an adhesion, traction was made upon it, and the ureter came away with a portion of the renal pelvis. At the post-mortem examination the kidney was merely a thin-walled sac with purulent contents.

In all cases in the course of an abdominal hysterectomy it is useful for the surgeon to inform himself of the condition of the kidneys. Whilst performing a subtotal hysterectomy, one of the fibroids burrowed deeply between the layers of the left broad ligament; when all the bleeding was checked, I looked carefully to determine that the ureter was safe, and found it kinked by the ligature applied to the corresponding uterine artery; it was at once removed. On palpating the kidneys I found the right kidney small, and shrunken, and useless. Fortunately the woman recovered.

The method of treating an injured ureter varies greatly and will depend not only on the extent of the damage, but also on the time at which it is recognized. For example, if the surgeon recognizes the injury in the course of the operation, he will be able to deal with it at once. This we may term _immediate_ treatment. The more difficult cases are those in which the injury is unrecognized at the time of the operation and only becomes obvious in the course of convalescence; the treatment in such circumstances may be called _secondary_.

The primary treatment of an injury to a ureter in the course of a pelvic operation will depend in a large measure on the ability, judgment, and experience of the surgeon, as well as on the extent of the injury. For example, if the ureter be partially divided, the opening may be closed with sutures of thin silk; when the duct is completely divided, the cut ends may be invaginated, the upper into the lower, and retained in position by suture. When five or more centimetres of the ureter have been accidentally exsected, none of these methods is applicable; in such circumstances several plans have been tried. Of these the simplest is ligature of the proximal end with the hope of inducing atrophy of the kidney; in several recorded instances this has proved successful. The surgeon who adopts this method should satisfy himself that the patient has another kidney, and that it is, as far as he can ascertain at the time, healthy. Some surgeons who have divided a ureter have promptly removed the corresponding kidney; others have secured the proximal end in the upper angle of the abdominal incision and removed the kidney subsequently.

It has been suggested that when a portion of a ureter has been resected and the proximal end cannot be engrafted into the wall of the bladder, it should be turned into the cæcum or the sigmoid flexure, according to its position, and thus preserve to the patient the kidney and save her the distress of a urinary fistula. This method has not found favour with practical surgeons. The most promising procedure consists in engrafting the proximal end of the cut ureter into the bladder. This is known as uretero-cysto-neostomy, an operation which has been made the subject of a valuable thesis by Dr. Lutaud. This thesis appears to have been inspired as a result of two successful operations performed by Ricard. The principle of this method is as follows:--

The abdomen is opened by the usual median subumbilical incision, and the peritoneum covering the damaged duct is incised and its proximal end exposed: the mucous membrane of the ureter is reflected like a cuff. An opening is made in the bladder wall in a situation convenient for making the junction, and two centimetres of the ureter are allowed to project freely into the vesical cavity, ‘à la façon d’un battant de cloche.’ The ureter is secured by sutures to the vesical mucous membrane, and to the muscular coat of the bladder. The sutures should be of thin catgut and must not perforate the bladder or the ureteral walls. The bladder itself near the junction should be attached by sutures to the adjacent peritoneum to prevent dragging (Fig. 27).

Lutaud significantly points out that we know little of the subsequent fate of ureters which have been engrafted into the bladder. The immediate results have been successful, but there is good reason to believe that when a ureter has been engrafted into the bladder, its walls become sclerosed by a chronic ureteritis, and its lumen is gradually stenosed. These changes take place slowly and cause little or no discomfort in connexion with the kidney or the bladder, so that they pass unnoticed.

If the opinion expressed by Lutaud, that the ureter becomes stenosed after uretero-cysto-neostomy, is found to be a constant, or even a frequent, sequel to the transplantation of a ureter into the bladder, it will cause surgeons to be careful, and not follow too literally the advice given by some writers to the effect that in performing the ‘radical operation’ for cancer of the cervix, if the ureters are implicated these ducts may be divided and their proximal ends engrafted into the bladder.

Lockyer, in removing a burrowing fibroid, wounded the bladder and divided the right ureter; he sutured the vesical incision and removed the right kidney. During the twenty-four hours following the operation there was anuria. The abdomen was reopened and then it was found that the left ureter had also been divided. The proximal end of this ureter was engrafted into the bladder through the wound which had been already sutured. Convalescence was disturbed by a urinary fistula. The woman recovered and reported herself in good health three years later.

It has happened that after nephrectomy for the cure of a ureteral fistula, the sequel of a ‘radical operation’, the remaining ureter became thoroughly blocked by recurrent growth and the patient died from anuria.

In the cases where the injury to a ureter has been overlooked in the course of the operation many difficulties arise before the true conditions are appreciated. In some instances they soon become obvious; for example, Purcell in 1898 performed an abdominal hysterectomy, next day the patient had complete anuria. The abdomen was reopened fifty-eight hours later; a distended ureter was easily recognized behind the ligatures applied to the right and left uterine artery respectively. The ligatures were removed, the swelling quickly subsided, and urine reached the bladder. The woman recovered.

When a ureter is injured in the performance of total hysterectomy, urine escapes by the vagina, and at first there may be some doubt whether the leak is due to an injury to the bladder or to the ureter. In such conditions the quantity of urine voided from the bladder is compared with that which escapes from the vagina; if the quantities are equal, or nearly equal, the leak is in a ureter. A more reliable method is to inject a solution of methylene blue into the bladder through the urethra. If the coloured fluid escapes from the vagina, the leak is in the bladder; if not, it is in the ureter. When a vaginal leakage occurs a few days after a vaginal hysterectomy, it is probably due to necrosis and sloughing of a ureter, or the duct may have been included in a ligature which has separated by sloughing.

Noble, in 1902, published an interesting series of injuries to the ureter. One of these is of great value, because it proves that a ureter may be accidentally ligatured and give rise to no symptoms.

A woman of thirty-three years of age was submitted to vaginal hysterectomy for cancer of the neck of the uterus, complicated with pregnancy. She died four days after the operation, and at the post-mortem examination the left ureter was found occluded with a ligature. The ureter and pelvis of the kidney were distended with urine.

The urine voided during the four days amounted on the first day to 480 c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48 oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull suspicion in regard to any patient, but the facts of the case are sufficient to raise suspicions of another kind, namely, that it is possible and probable that a ureter has been ligatured in the course of an operation, and the patient has recovered without any one having any suspicion that such an accident has happened.

As soon as the surgeon clearly establishes the existence of a ureteral fistula he is beset with the necessity of deciding which duct is the seat of damage. Some years ago, when it was the practice to remove the kidney for a persistent ureteral fistula, the decision involved the surgeon in a grave responsibility, for the removal of the wrong kidney could only be regarded as a catastrophe for the patient. Morris has recorded a case in which this actually happened. A woman had total hysterectomy performed for a cervix fibroid by a gynæcologist; in the course of the convalescence a ureteral fistula was recognized, and as this failed to close spontaneously, a surgical colleague performed nephrectomy, and next day found to his chagrin that he had removed the kidney belonging to the uninjured ureter. Serious accidents of this kind are less likely to happen now, because the surgeon can avail himself of the cystoscope and ureteral catheter; with these instruments it is possible, not only to decide with certainty which ureter is injured, but also to determine the position and extent of the damage. See also Vol. III.

It is important to remember that every ureteral fistula does not require an operation. It is always advisable, when it has been clearly established that a woman has a leaking ureter, to wait a little, certainly six weeks, for many fistulæ of this kind will gradually close. In describing such a case, Jonas draws attention to a cystoscopic sign of some value. He performed a total hysterectomy for fibroids, and on the tenth day the nurse reported the escape of urine by the vagina. The daily output of urine from the bladder, which had averaged 50 ounces, fell to 25 ounces. On cystoscopic examination, urine could be seen issuing from the right ureteral orifice; at first the left orifice could not be seen, but on careful watching a movement was detected similar to the contraction of a ureter discharging urine, but no fluid came from the opening. This is known as _leergehen_ (empty contraction), and it indicates that there is a lateral opening, but not complete interruption in the continuity of the ureter. Such a case should have an opportunity of healing spontaneously. This happened in Jonas’s patient.

Weibel states that a ureteral fistula due to necrosis after a radical operation for cancer of the uterus usually occurs in the second week. The earliest day is the seventh, and the latest the eighteenth day after operation. The majority of these fistulæ heal in from three to twelve weeks. If a fistula persist for more than three months spontaneous healing is not to be expected. A ureteral fistula is a serious matter for the patient. Blacker has had three cases after total hysterectomy. In one the kidney was removed on account of septic changes. The second had an attack of suppression of urine lasting twenty-four hours; it passed off, the patient recovered and the fistula healed. The third died eight weeks after the hysterectomy with symptoms of pyæmia; a small abscess had formed near the site of the fistula.

=The fate of ligatures.= When a ligature is satisfactorily applied to a pedicle the tissue on the distal side of the ligature is isolated from the circulation. The fate of this tissue and of the ligature has been the subject of much speculation.

It is a matter of common observation that when animal tissues are cut off from the circulation, they atrophy; but if pathogenic micro-organisms gain access to such parts, suppuration ensues. In due course, through the activity of the living cells, the dead tissues are detached from the living, a process termed sloughing.

When a piece of healthy tissue is removed from the body and immersed in a sterile solution, and absolutely isolated from the atmosphere, decomposition is indefinitely postponed, but as soon as unsterilized air is allowed access to it, putrefactive changes ensue. The pedicle after ovariotomy is in an air-tight chamber, and if the tissues included by the ligature are healthy, and the silk employed for the purpose is absolutely aseptic, this pedicle, when returned into the abdomen, resembles the piece of tissue isolated from contact with the atmosphere. No septic changes occur, but aggressive leucocytes attack the silk and may, in course of time, effect its removal, even the knots. For this desirable result three conditions require to be fulfilled: (1) the ligatured tissue must be aseptic; (2) the ligature should be absolutely sterile; and (3) air or intestinal contents must be excluded.

These conditions may be prevented in many ways. The tissues included in the ligature are not always free from infective organisms, especially the Fallopian tube, which is usually included in the ligature, and this structure, especially in cases where oöphorectomy is performed for inflammatory diseases, often contains septic microbes; this endangers the ligature and leads to the formation of pus, with its complications, sloughing of the pedicle and abscess. The tissues may be healthy and aseptic, but the ligature may have been imperfectly sterilized, or become contaminated by assistants, or even by the hands of the surgeon during its application.

The operation may have been conducted aseptically and the tissues be healthy, but the ligature becomes infected by the admission of air as a result of drainage, or implication of the bowel or bladder.

I made a careful study of the fate of silk sutures employed in pelvic surgery extending over many years, and came to the conclusion that, even under favourable conditions, silk ligatures disappear very slowly. The silk used to secure an ovarian pedicle may, in very favourable circumstances, disappear in twelve months, but the knots require nearly double that time. The piece of silk which encircles the Fallopian tube is apt to behave in a curious way; in 1898 I removed an ovarian cyst the size of a fist, and tied its slender pedicle with thin silk. Although the recovery was uneventful, the patient complained during many weeks of cramp-like pains on the side from which the cyst was removed. These pains gradually subsided, and ten months later, during menstruation, the patient noticed on the napkin a tiny loop of silk, which she saved. This was the loop of silk which secured the Fallopian tube; it had ulcerated into the tube and been conducted into the uterus and escaped. I have since had a like condition, the loop making its appearance three weeks after an ovariotomy. It has been established by experiments on the long uterine cornu of rabbits, that an encircling ligature will ulcerate through, leaving the lumen of the cornu intact. Clinical observations regarding ligatures applied to Fallopian tubes in the performance of Cæsarean section for the purpose of preventing pregnancy prove that this is a useless measure (see p. 71), for these tubes in many instances have recovered their patency, and pregnancy has recurred. It is a fair inference that the ligature ulcerates into the lumen of the tube, which then heals behind it, without stricture of the canal. A similar condition of things sometimes arises after Cæsarean section, especially when the uterine incision is closed by two layers of sutures. Those sutures which involve the endometrium will ulcerate into the uterine cavity and cause irregular slight losses of blood until they escape.

It is important to emphasize the fact that silk sutures in uterine tissue will, in some instances, remain unabsorbed for many years. A patient who had been submitted to Cæsarean section in 1903 came under my care four years afterwards for the removal of the tumour which caused obstruction; the sutures used to close the uterine incision were visible, and a microscopic examination showed that each silk suture was enclosed in a fibrous tissue sheath (Fig. 28).

The fact that silk sutures will resist absorption for such a long period has an important practical bearing, because so long as pathogenic micro-organisms are denied access they remain inert, but if any septic condition arises in their neighbourhood, and these sutures become involved, they will give rise to abscesses and sinuses as surely as if they had been buried but a few days.

Patients often suffer great distress and annoyance on account of abscesses and sinuses due to septic ligatures, and a sinus will persist as long as the ligature remains. Abscesses and sinuses resulting from troublesome ligatures may escape in many directions; the most common spot is at the lower angle of the abdominal incision; the rectum is another channel of escape, and also the bladder. When a ligature makes its way into the bladder it will set up cystitis and serve as a nucleus for a vesical calculus. In an unusual case recorded by Edebohls, double oöphorectomy was performed for uterine fibroids; a year later the ligature on the left side escaped through the vagina; six months later he performed abdominal hysterectomy. The vermiform appendix was adherent to the stump on the right side; it was removed, and a silk ligature tied in a complicated knot was found in it, making its way towards the cæcum.

On one occasion a woman, who had been submitted to subtotal hysterectomy in the Antipodes, suffered from frequent micturition and fœtid urine; she came under my care. On dilating the urethra, it was found that the cervical stump had ulcerated through the posterior wall of the bladder and projected freely into the vesical cavity, bristling with thick silk ligatures encrusted with phosphatic deposit. The ligatures were removed, the urine soon became acid, and the vesical discomfort quickly subsided, in spite of the anomalous position of the cervical stump.

Until surgeons fully realized the importance of thoroughly sterilizing the silk employed for the pedicles in ovariotomy, it was quite common for the silk loops to ulcerate through the bladder wall and set up cystitis.

Many cases have been reported in which a loop of silk, effecting an entrance into the bladder in this fashion, has formed the nucleus of a phosphatic calculus.

=Post-operative kraurosis.= In a small proportion of patients (perhaps not more than one per cent.) who have undergone bilateral ovariotomy, oöphorectomy, or hysterectomy, the vulva undergoes the peculiar atrophic changes which are characteristic of the condition known as _kraurosis vulvæ_. This change, so far as my observations go, is chiefly seen in patients who have been submitted to these operations after the fortieth year of life. The cause of these changes is unknown. The condition is troublesome and inconvenient in married women, but spinsters rarely complain of it. Post-operative kraurosis is as rebellious to treatment, and its causation as inexplicable, as kraurosis occurring independently of operation.

=The cicatrix.= Although the employment of buried sutures has made abdominal incisions more secure in the process of healing, and renders them firmer after union, and thus reduces the chances of a yielding scar, and saves the patient the inconvenience of an abdominal hernia or the annoyance of wearing an abdominal belt, it renders the patient liable to another discomfort, namely, stitch-abscess. This complication arises from a variety of causes--for example, imperfect sterilization of the suture material, or of the patient’s skin preceding the operation. The sutures may be soiled by the hands of nurses and assistants, or the fingers of the surgeon. All these things may be safeguarded, but the operation may have been required for the removal of infected cysts, or pelvic peritonitis: in these cases it is wise not to bury sutures.

Troublesome buried sutures should be removed. In many instances this is easy of accomplishment, and in others it requires patience and often perseverance, even when the patient is under an anæsthetic. The simplest implement for removing a buried suture is a crochet-hook.

The disadvantage of stitch-abscesses, apart from the inconvenience they cause patients during their convalescence, is that they often cause the scar to yield at that spot, and necessitate the wearing of an abdominal belt. If the hernia is of small extent, and especially when it is situated near the lower angle of the scar, it is difficult to fit a belt which will restrain it without the use of perineal bands or straps. In such cases a truss, on the principle of those employed for inguinal hernia, is more satisfactory than a belt.

Occasionally a scar forms a raised hard red keloid band, and causes some anxiety to the patient. These keloid scars shrink and whiten in the course of a year or eighteen months.

=Cancer of the cicatrix.= Several cases have been recorded in which, after the removal of an ovarian adenoma, a new growth, described as ‘cancer of the cicatrix’, has formed in the scar. These growths are probably due to the soiling of the wound at the time of operation with epithelial fragments from the tumours.

After abdominal hysterectomy for cancer of the body of the uterus, or its cervix, the abdominal wound may become infected with this disease, and in cases where exploratory cœliotomy has been performed for diffuse cancerous disease of the peritoneum the cicatrix is liable to become permeated by malignant disease also.

REFERENCES

BALDY, J. M. The Mortality in Operations for Fibroid Tumour of the Uterus. _Trans. Am. Gynæcological Association_, 1905, xxx. 450.

BARTLETT, W., AND THOMPSON, R. L. Occluding Pulmonary Embolism. _Annals of Surgery_, 1908, xlvii. 717.

BLACKER, G. F. _Lancet_, 1909, i. 395.

BLAND-SUTTON, J. Hunterian Lecture on Thrombosis and Embolism after Operations on the Female Pelvic Organs. _Lancet_, 1909, i. 147.

BLAU, A. Ueber die in der Klinik Chrobak bei gynäkologischen Operationen beobachteten Nebenverletzungen. _Beiträge f. Geb. u. Gyn._, 1903, Bd. vii. 53.

BUCKNALL, R. The Pathology and Prevention of Secondary Parotitis (with Literature). _Med.-Chir. Trans._, 1905, lxxxviii. 1.

DEAVER, J. B. Hysterectomy for Fibroids of the Uterus. _Am. Journ. of Obstetrics_, 1905, lii. 858-74.

HASTINGS, S. A Preliminary Note on Embolism in Surgical Cases. _Archives of the Middlesex Hospital_, 1907, xi. 78.

JONAS, E. Temporary Uretero-vaginal Fistula after Panhysterectomy for Fibroid of the Uterus. _Am. Journ. of Obstetrics_, 1907, lvi. 731.

LEQUEU. Sur les parotidites post-opératoires. _Bull. et Mém. de la Soc. de Chir. de Paris_, 1907, T. xxxiii. 1044.

LUTAUD, P. _Sur un procédé d’urétéro-cysto-néostomie dans le traiment des fistules urétéro-vaginales et urétéro-cervicales._ Paris, 1907.

LYLE, RANKEN. A Series of Fifty Consecutive Abdominal Sections. _Journal of the British Gynæcological Society_, 1906-7, xxii. 120.

MALLET, G. H. _Am. Journ. of Obstetrics_, 1905, li. 516.

MORRIS, H. Lectures on the Surgery of the Kidney. _British Medical Journal_, 1898, i. 1039.

NOBLE, C. P. Clinical Report upon Ureteral Surgery. _American Medicine_, 1902, iv. 501.

---- Myomectomy. _New York Medical Journal_, 1906, lxxxviii. 1008.

OLSHAUSEN, R. Veit’s _Handbuch der Gynäkologie_, 1907, 2nd Ed., Bd. i. 715.

PURCELL, F. A. The Risks to the Ureters when performing Hysterectomy, &c. _Journ. Brit. Gyn. Soc._, 1898-9, xiv. 174.

ROBINSON, B. Sudden Death, especially from Embolism, following Surgical Intervention. _Medical Record_, 1905, lvii. 47.

SPENCER, H. R. Discussion at Exeter on Uterine Fibroids, &c. _British Medical Journal_, 1907, ii. 452.

TEBBS, B. N. Symptomatic Parotitis. _Med.-Chir. Trans._, 1905, lxxxviii. 35.

TRENDELENBURG, F. Zur Herzchirurgie. _Zentralbl. für Chir._, 1907, No. 44, 1302.

---- Ueber die chirurgische Behandlung der puerperalen Pyämie. _Münchener Med. Wochenschr._, 1907, xxxiv. 1302.

WEIBEL, W. Das Verhalten der Ureteren nach der erweiterten abdominalen Operation des Uteruskarzinoms. _Zeitsch. f. Geb. u. Gyn._, 1908, lxii. 184.

SECTION I

OPERATIONS UPON THE FEMALE GENITAL ORGANS