peeling off from the peritoneum of plastic deposits, the removal of the
sponges packed into its cavity, and the careful cleansing away of all
fluids and of every blood-clot. In the search for all such foreign
bodies, or, indeed, for obscure oozing-points, the reflector of the
ophthalmoscope or Colin's illuminating lamp will give much aid.
Douglas's pouch and the peritoneal fold between the bladder and the
womb are favorite localities for the collection of blood or of serum,
and should therefore be thoroughly mopped out by small sponges on
holders, otherwise peritonitis or septicæmia may result, which are the
two great factors of death in unsuccessful cases. When this has been
thoroughly done, a clean sponge is placed in Douglas's pouch, another
in the sulcus between the bladder and the womb, and a third, a large
and broad flat one, is laid over the intestines under the wound to
catch the blood that may drop from the needle-tracks. Each needle is
passed from within outward a quarter of an inch away from the
peritoneal edge of the wound, and is made to emerge at the same
distance from its cutaneous edge. If the recti muscles are included in
the sutures, there is said to be a liability to the formation of
abscesses in the suture-tracks. Hence almost every ovariotomist advises
that the peritoneum and skin should be pinched together, and that the
needle should be passed through them alone without perforating the
muscles. Yet I believe that from a too close observance of this rule
come many cases of hernia in the track of the wound, and that were the
recti muscles {330} more closely coaptated they would not recede from
one another and thus aid in the formation of a rupture. My own rule is
to include these muscles in the suture wherever they are exposed to
view. The sutures should lie about one-third of an inch apart. The
needles should be lance-pointed and held by a needle-holder. In fat
women it is not always easy to get the two surfaces of the wound in
exact coaptation; consequently, more or less puckering and eversion of
the edges may take place. To avoid this, it will be well, before
passing the needles, to bring the edges of the wound together, and make
with a fountain-pen transverse lines at proper intervals across the
incision as landmarks for the introduction of the sutures. These
cross-lines are also of advantage whenever the abdominal walls are too
tense for accurate coaptation, as after öophorectomy, after the removal
of a small abdominal tumor, or after an exploratory incision for a
solid tumor which cannot be removed. In these cases, indeed, it would
be well to make the cross-lines the first step of the operation, before
even the abdominal incision has been made.
The reasons why the needle is made to enter the peritoneum first are,
that the stitches are lodged more evenly on that vulnerable surface,
and with less injury to it, such as the stripping of it off from the
abdominal wall; and, further, that a stray knuckle of bowel is not so
likely to be wounded by the upward as by the downward thrust of the
needle. The object of including the peritoneum in the stitches is to
bring in contact two long and narrow ribbon-like surfaces of a
membrane, which will quickly unite--so quickly as to forestall any
formation of pus in the overlying tissues, and to bar the entrance of
this or other septic fluids from the wound in the abdominal wall.
Another advantage is, that this inclusion of the peritoneum by
presenting an uninterrupted surface of parietal peritoneum to the
visceral peritoneum prevents the adhesion of the omentum and of the
intestines to the internal lips of the wound, which otherwise takes
place.
When all the sutures have been passed, their ends on one side are
loosely twisted together into a single strand, which is securely caught
by a pressure-forceps. The same thing is done with the ends on the
other side. A finger of each hand is now passed down into the centre of
the wound, and the middle portion of all the upper sutures and of all
the lower ones are separated from one another by being drawn to
opposite angles of the wound. This permits the removal of the sponges,
and, if they are stained with blood, the further search for some
overlooked bleeding vessel. To guard against twisting of their
convolutions, the bowels, still further disturbed by these final
manipulations, are now restored to their natural position, and the
omentum, after being again examined for some bleeding vessel, is gently
spread out over them. The forceps and sponges are then counted to see
that not one has been left in the abdominal cavity. The importance of
this cannot be too strongly impressed upon the operator, for
distinguished ovariotomists have overlooked these articles, and have
left them behind in the abdominal cavity--a sponge and a bulldog
forceps in one case.[57] Tait has heard of ten such cases.[58] It is
indeed sometimes no easy task to find a missing sponge when lost in the
{331} convolutions of the intestines. The sponges therefore should not
be much smaller than the fist.
[Footnote 57: _Lancet_, May 26, 1877, p. 783; _British Med. Journ._,
Jan. 28, 1882, p. 115; _Ibid._, Dec. 25, 1880; also, _Ovarian and
Uterine Tumors_, by Spencer Wells, London ed., p. 336.]
[Footnote 58: _Diseases of the Ovaries_, by Lawson Tait, 4th ed., p.
261.]
Before closing the wound the operator removes the pressure-forceps and
catches in one hand all the ends of the sutures on his side, his
assistant does the same thing on the other side, and the edges of the
wound are brought together by a firm pressure, which also chases the
air out of the abdominal cavity. To stop the bleeding from the
needle-tracks as soon as possible, each suture is rapidly tied and by
the surgeon's knot. When the whole wound has been closed, and not till
then, the ends of all the sutures are gathered together in one hand,
and they are cut off about two inches from the knot by one snip of the
scissors. This saves precious time, which would be lost were each
suture by itself to be cut after being tied. At gaping points of the
wound intermediate superficial stitches should be put in. In fat women
several such stitches will usually be needed.
Dressing of the Wound.--After the wound has been closed the rubber
apron is removed and the abdomen cleansed and dried. The wound may now
be dressed according to Lister's plan. This consists, first, of a
narrow protective of prepared oiled silk, moistened by a 1:40 solution
of carbolic acid; next, of one broad layer of antiseptic gauze wetted
with the same solution; and over this eight folds more of the dry
gauze, having a piece of mackintosh interposed between the seventh and
the eighth layer. The lamp is now blown out, and the spray-jet being
directed away from the abdomen, the dressing is secured by an elastic
flannel binder, the rucking of which can be prevented by tapes pinned
to it around each thigh. Most of the leading ovariotomists, however,
employ simpler dressings, which have been found equally antiseptic.
Wells covers the wound with a dry dressing of thymol cotton, kept in
place by long strips of adhesive plaster, going two-thirds of the way
around the body. Over all is pinned a flannel binder. The thymol cotton
is prepared by steeping absorbent cotton wool in a solution of one part
of thymol to one thousand of water, and drying it. Keith dresses the
wound with gauze wrung out of a 1:8 glycerole of carbolic acid. On this
are laid several layers of dry carbolated gauze, next some cotton wool,
and over all a flannel binder. Thornton uses Lister's gauze and the
mackintosh, but without the protective. This dressing is secured by
adhesive straps. On these are laid several folded napkins, and over all
a flannel binder is pinned very tightly. Bantock resorts to dry thymol
gauze. Tait uses nothing but ordinary absorbent cotton. Salicylated
cotton I have found to answer so well that for years I used nothing
else. It is made by steeping two parts of absorbent cotton in a
solution of one part of salicylic acid to two of commercial ether, and
afterward drying the cotton by a low heat. Lately I have been resorting
to Keith's dressing, but it probably possesses no greater advantages.
The flannel binder having been pinned on, the night-dress is pulled
down and the patient put to bed. The opium suppository containing one
grain of the watery extract is slipped into the rectum, the six bottles
of hot water are applied to different portions of the body, and she is
covered with warm blankets. The tables, tubs, and other articles used
in the operation are now removed, the room is darkened, and she is left
alone with her nurse, who has positive instructions to admit no one
besides the physician.
{332} Drainage.--When blood in small quantities is effused into the
peritoneal cavity, coagulation usually takes place, the serum is then
absorbed, the clot becomes organized, and no harm results. But when
blood in large quantities collects in Douglas's pouch, it may behave as
a foreign body and cause mischief. When, also, blood is mixed with
serum, coagulation is not so likely to take place; the blood-corpuscles
then are liable to break down, the fluid to become putrid, and
septicæmia to set in. For these reasons the removal of these fluids by
different modes of drainage has long been put in practice. The best
mode is by a glass tube passed down to the bottom of Douglas's pouch
through the abdominal wound, and not, as has been recommended, through
a special opening made for it in the roof of the vagina. Drainage is at
present very rarely resorted to by those operators who use strict
antiseptic precautions, for they contend that septic changes in the
blood do not then take place. Wells and Thornton have virtually given
it up, while Keith, Tait, and Bantock, who have abandoned Listerism,
are warm advocates of it. This question is a very important one,
because a drainage-tube tends to the formation of a ventral hernia,
and, being a foreign body, is in itself hurtful, and therefore should
not be resorted to unless it will do more good than harm.
After a careful consideration of the subject I am forced from
experience to believe that between the two extremes there lies a golden
mean, and that drainage, even when the spray is used, is needed under
the following conditions:
(_a_) Whenever a purulent or a colloid cyst has burst, and its
contents have escaped into the cavity of the abdomen, either
during the operation or some days beforehand.
(_b_) Whenever the contents of the cyst are putrid or purulent, and
septic symptoms or those of peritonitis are present.
(_c_) Whenever a large amount of ascitic fluid is found in the
abdominal cavity.
(_d_) Whenever four drachms or more of pure blood, or especially of a
sero-sanguinolent fluid, can be squeezed out of the sponge in
Douglas's pouch when removed just before the closure of the
wound.
(_e_) Whenever the operator is in doubt what to do.
Should it be deemed needful for some of the above reasons to make use
of drainage, a glass tube, open at both ends and about six inches in
length, is passed through the salicylated cotton or other dressing,
then between the two lowest stitches, down to the bottom of Douglas's
pouch. A wire suture is first introduced between these sutures and left
untwisted, its object being to close firmly the opening left by the
removal of the tube and to hasten its union. Otherwise, a weak cicatrix
results, tending to the subsequent formation of hernia. Keith's
drainage-tube of three sizes is the one that I prefer. Its lower end is
perforated with holes, and its upper end has a shoulder which keeps it
from slipping into the abdominal cavity, and also enables it to hold a
piece of thin rubber sheeting about eighteen inches square. In the
centre of this a small circular hole is made, which, by stretching, is
sprung over the tube. The mouth of the tube is covered by a cup-shaped
sponge wrung out of a 5 per cent. solution of carbolic acid, and over
this the sheeting is folded four times. The flannel binder may either
be pinned over the drainage-tube, or else {333} it may be slit at the
site of the tube and passed on each side of it, leaving the sponge and
rubber sheeting outside of the dressing. They are then best held in
place by a narrow strip of flannel, so as to permit inspection without
interfering with the main dressing. Several times a day the sponge is
removed, squeezed out, cleansed in a 5 per cent. solution of carbolic
acid, and replaced. This in a hospital had better be done under the
spray. Bloody serum collecting in this tube is sucked out either by a
fine rubber tube attached to a syringe, or else by the long nozzle
itself of the ordinary uterine syringe.
To prevent injurious pressure on the rectum, the tube must be lifted up
occasionally about half an inch, and allowed to slip back of its own
accord. It can be removed whenever the discharge has been reduced to
not more than one or two drachms, and this usually happens within the
first forty-eight hours. After its removal the opening left in the
wound is closed by twisting the free ends of the wire suture placed
there for this purpose.
AFTER-TREATMENT.--The subsequent treatment needs the greatest
attention. The first care is to establish reaction. This is best done
by stimulants, such as brandy and whiskey given in iced soda-water.
Enemata of beef-tea and brandy or of milk and brandy will also be of
advantage, while artificial heat is kept up. For the vomiting, which
comes partly from the anæsthetic and partly from shock, repeated deep
inspirations should be tried. They help by getting the blood rid of the
anæsthetic as soon as possible. Chloral may also be given, or small
lumps of ice may be swallowed. Sips of very hot water, or a
tablespoonful every hour of a mixture containing equal parts of
lime-water and of cinnamon-water, may also do good. A hypodermic of
morphia will often allay vomiting, and I have seen it yield to small
doses of atropia, and also to two grains of pure pepsin given every two
hours in a tablespoonful of raw-beef juice. Twenty drops of ether given
by the mouth will sometimes relieve it, and so also will a few drops of
chloroform confined by a watch-glass over the pit of the stomach. In
some cases I have tried, with the best results, the following
effervescent mixture, recommended by Chèron:[59]
Rx. Potassii bicarb. |
Potassii bromidi. aa | gr. xxxij;
Aquæ, fluidounce ij. M.
Rx. Acidi citrici, drachm j;
Syrupi, fluidounce j;
Aquæ, fluidounce iv. M.
A dessertspoonful of the former is added to a tablespoonful of the
latter, and given every hour. For vomiting, especially of the bilious
variety, Lawson Tait recommends Monson's pepsin wine, given every ten
minutes in drachm doses with a little ice-water.
[Footnote 59: _Archives de Tocologie_, Février, 1883, p. 122.]
Flatus is another annoying symptom, which, however, can very generally
be dispelled by turning the patient over on her side and inserting a
flexible catheter high up in the rectum. If this fails to relieve it,
enemata of turpentine may be tried, or five-drop doses of the tincture
of nux vomica may be given every two hours. Should the abdomen become
painfully bloated, the binder must be loosened and the adhesive straps
{334} nicked in several places. The painful tension on the stitches can
be relieved by drawing the knees up and supporting them over a pillow
doubled on itself. Should the flatus not yield, and symptoms of
obstruction set in, the bowels must be opened at all hazards. Castor
oil and Epsom salts are good cathartics for this purpose. When vomiting
accompanies obstruction, calomel answers best, because it is not so
liable to be rejected.
For the first thirty-six to forty-eight hours after the operation
nothing whatever should be given to the patient excepting cracked ice,
sips of hot tea or of barley-water, and an occasional teaspoonful of
old whiskey. After that time tablespoonful doses of milk, of beef-tea,
of thin oatmeal gruel, or of barley-water can be given every hour or
two. The diet may then be cautiously increased, and especially after
wind begins to escape from the rectum, the patient being enjoined not
to hold it back from motives of delicacy. If the condition of the
patient is such as to demand more nourishment, it had better be taken
by the rectum. For a week the urine should be drawn off by the nurse,
and the bowels kept quiet by a morning and an evening suppository. No
other anodyne need be given unless called for by pain, wakefulness, or
restlessness. Should the body-heat indicate a temperature of 101° or
over, a bladder filled with broken ice, or, what is far better, a
rubber ice-cap, should be kept on the head of the patient as long as it
feels comfortable and does not chill her. If the temperature does not
fall, and peritonitis or other septic symptoms set in, ice should also
be applied to the pit of the stomach. Quinia and morphia must then be
given in very large doses, preferably by the rectum, together with ten
drops of the tincture of digitalis every hour until the pulse-rate is
lessened and the temperature falls.
When a full week has elapsed the bowels should be opened; and, as this
is a matter of importance, and is occasionally attended with symptoms
of obstruction and with a good deal of constitutional disturbance, a
few words will not come amiss. If the hardened feces can be softened
down and dislodged by enemata, this is perhaps the best plan, clysters
of ox-gall and water or of glycerin and water being the most efficient.
But in my experience enemata have so often failed that I rarely resort
to them in the first instance. If the woman's stomach is not irritable,
I prefer to give her an ounce of castor oil. This is disguised in the
compound syrup of sarsaparilla or in some other suitable vehicle, as
warm milk, and is brought to her without any previous warning early on
the morning of the eighth day. Should it be deemed unwise to try the
oil, two Lady Webster pills and two compound cathartic pills can be
given at bedtime of the seventh day, or a pill containing three grains
of the compound extract of colocynth with one grain of the extract of
hyoscyamus may be swallowed every four hours. The compound licorice
powder of the German Pharmacopoeia, to which has been added potassium
bitartrate, also answers well, provided the patient's stomach will bear
teaspoonful doses every four hours. Should these remedies fail to act,
they must be supplemented by enemata.
Fatal obstruction of the bowels from matting or from constricting bands
of organized lymph has been frequently reported. Thus far, I have met
with one fatal case, which, however, passed out of my hands after the
operation. But occasionally I see cases of obstinate {335} constipation
which give me great uneasiness and put me to my wits' ends. In one
case, after the failure of other remedies the obstruction was overcome
by broken doses of calomel combined with sodium bicarbonate, and by the
distension of the lower bowel with very large enemata slowly given.
Another desperate case yielded to repeated doses of tincture of
belladonna. A third case, complicated by obstinate vomiting, was saved
by ten grains of calomel given every two hours until the bowels were
moved. Seventy grains were thus administered before the desired effect
was attained, yet salivation did not occur.
When symptoms of obstruction once present themselves, they are likely
to recur. The contents of the bowel should therefore be kept fluid, and
for this purpose I know nothing better than the German compound
licorice powder, given in teaspoonful doses at bedtime.
Suppression of urine sometimes follows ovariotomy, and in cases of
diseased kidney is an alarming complication for this condition. For
this symptom digitalis and the acetate of potassium should be given.
Thornton treats it by baring the arms and packing them in towels which
are kept wet with ice-water.
Tetanus may destroy the life of a patient while convalescing from the
operation of ovariotomy. J. M. Bennett reports such a case.[60] The
symptoms first showed themselves on the sixteenth day, and the woman
died two days later. Chloral in drachm doses, administered by the bowel
in the yolk of an egg, is perhaps the only remedy from which any good
can be expected.
[Footnote 60: _Lancet_, Dec. 3, 1881.]
Occasionally, a few days after the operation, without any septic
symptoms whatever or without any marked rise in the temperature, the
parotid glands grow tender, swell up, and run through a course
precisely like mumps, ending in resolution. This complication has been
met with so frequently by myself and others that it cannot be a mere
coincidence, but must be due to a reverse sympathy between the ovaries
and these glands. It does not appear to increase the risk of the
patient, for recovery took place in all the reported cases, of which
three occurred in my own practice.[61] Parotid bubo may also take place
after ovariotomy, but this sign of blood-poisoning, being a general
one, happens as well after other grave surgical operations and during
the course of specific fevers. Yet from the sympathetic relation
between the parotid glands and the sexual organs it seems to occur more
frequently in the septicæmia following ovariotomy.
[Footnote 61: Wm. Goodell, _Transactions of American Gynæcological
Society_, 1885.]
Acute mania sometimes follows ovariotomy, especially when both ovaries
have been removed. The attack is usually temporary, but it sometimes
ends in insanity, and even in death, as in one of my own patients.
Keith, Thornton, Tait, and other leading ovariotomists report analogous
cases.[62]
[Footnote 62: _The British Medical Journal_, March 21, 1885, p. 597.]
SURGICAL TREATMENT.--The dressings, being antiseptic, need not, as a
rule, be removed until the day following that on which the bowels are
moved. Every other stitch may then be removed, and especially all that
are loose or are cutting the tissues. The wound is then washed with a
2.5 per cent. solution of carbolic acid, and dressed anew with
salicylated {336} cotton. I usually find the first dressing so sweet
that I am able to reapply the unsoiled portion of it for a second
dressing. A clean binder is now pinned on and the woman's clothing
changed. Three or four days later all the stitches should be removed,
the wound secured by narrow adhesive strips, and dressed as before. For
fear of a weak cicatrix and the formation of a hernia at the site of
the wound, the patient should not get out of bed until fully three
weeks have elapsed, and should for as many months wear some kind of
close-fitting gored binder or abdominal supporter.
If, before the week is over, the dressings become soiled or give out a
bad odor, they should be at once renewed. They should also be removed
whenever a high temperature, without being accompanied by tympanites,
leads to the suspicion of cutaneous abscesses.
THE ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY.--When by the breaking up
of adhesions to it the liver is wounded, the bleeding surface can
usually be stanched, as Koeberle has shown, by the ferric subsulphate
applied to the raw surface by the finger. If this fails the actual
cautery at a dull heat should be used.
If, unfortunately, an adherent portion of the bowel is torn open, the
wound should be carefully closed with very fine silk by the continuous
suture. The sutured portion is then fastened to the lower angle of the
abdominal wound as a safeguard in case of the subsequent formation of
stercoral fistula.[63] Should the intestine be injured to any extent,
the wound must be closed by two sets of fine silk sutures, the first
set uniting the mucous edges of the wound by the continuous suture, the
other set uniting one serous coat to the other at a line about one
quarter of an inch distant from the wound. An ordinary cambric needle
with fine sewing-silk will answer admirably for this purpose. In small
wounds one continuous suture, carried through all the coats but the
mucous, will suffice. A mere puncture can be closed by hooking it up
and surrounding it by a single fine ligature.
[Footnote 63: "Discussion on a Paper by Garrigues," _Am. Gynæcol. Soc.
Trans._, 1881.]