TWO CASF:S OF ABDOMINAL SECTION: (I) PYOSAL- 
PINX; INTRAPERITONEAL ABSCPLSS; ENCYSTED 
PERITONITIS SIMULATING SO CALLED 
URACHAL CYST; (2) HYDROSALPINX; 
H/EM ATOMA OF OVARY; TUBO- 
OVARIAN CYST. 
CLINICAL LECTURE DELIVERED BEFORE THE POST GRADUATE MEDICAL 
SCHOOL AT THE WOMAN’S HOSPITAL OF CHICAGO. 
By Henry T. Byford, M. D., Chicago. 
Prof, of Gynecology Chicago Post Graduate Medical School; Clinical Prof, of Gynecology 
Woman’s Medical College, Chicago; Gynecologist to the St. Luke’s and the Woman’s 
Hospitals; Consulting Gynecologist to Michael Reese, the Charity, ami the 
Provident Hospitals of Chicago. 
Gentlemen:—The case now being anesthetized is one of great 
interest. Whether we will find a pyosalpinx or tuberculosis of the 
appendages, I cannot positively determine until the abdomen is 
opened. She came to the hospital two weeks ago, with a daily after- 
noon temperature of one hundred to one hundred and one degrees F. 
She was aboijt on her feet, but had considerable pelvic pain, was ex- 
tremely emaciated and haggard looking, and had the physical signs 
of incipient pulmonary phthisis. She is thirty-six years old, married 
twelve years, has three children, youngest six years. She has never 
been bedridden except from an attack of pneumonia one year ago, 
and at her confinements. After the last one she was in bed two 
weeks, and got about rather slowly. In case this should be pyosal- 
pinx, the only cause obtainable in the history, is the birth of the 
last child, since which time she has had pains in the lower abdomen 
before menstruating, and occasional attacks of menorrhagia. 
A vaginal examination revealed a fixation of the uterus in about 
normal position with indurated tissue behind and at both sides. 
Rectal indigitation revealed hard tissue laterally, and a semi-fluc- 
tuating mass over the cul-de-sac of Douglas. In view of the fact 
that there was no history of acute attacks of pelvic trouble, yet a 
constant temperature, and a vague feeling of fullness and fluctua- 
tion in the lower abdomen, together with the general cachectic ap- 
pearance and local pulmonary signs, the possibility of pelvic tuber- 
culosis was entertained. Yet tilte varietv of this form of disease and 2 
the frequency of pyosalpinx always incline me to suspect the latter. 
One thing may be said, however, viz., the condition is serious 
and calls for abdominal section. 
It is remarkable how patients like this will keep on their feet 
and carry their ailments about the house and country, while others 
with much less local trouble will keep the bed. The patient in the 
ward bed next to the one our patient occupied, has been bedridden 
for over a year with retroversion and prolapse of a slightly enlarged 
ovary, which is not even tender. Our patient we have put to bed 
and dieted for two weeks to get her in condition for an operation, 
and the improvement in her looks and local condition under this 
rest treatment, has been surprising. The temperature remains be- 
low ioo degrees K, and she has taken on flesh. The other one is 
also being prepared for operation, but by a diametrically opposite 
course of treatment, viz., by being got out of bed every day, and 
diligently fed. The limbs were like broomsticks, and the circulation 
so feeble that I dared not put her under ether long enough to per- 
form an Alexander operation and perineorrhaphy, until her strength 
should be improved. She is also gaining rapidly by being made to 
get up and take more exercise and more food. 
As everything is ready, we will rapidly open the abdomen. 1 
find the omentum adherent to the abdominal wall from above the 
umbilicus to the pubes. It is as thick as the hand, and looks like 
a piece of placenta. I he peritoneum at the place of adhesion looks 
as if destroyed, and is pinkish gray and granular to the sight and 
touch, and hanging to the edges of the separated omentum are 
thickened friable shreds of it that look like a cyst wall. The serum 
contains some whitish flakes, would measure about a quart, 
and is apparently shut off from the general peritoneal cavity 
by frail adhesions. The pelvis is filled as with a solid mass. 
The peritoneum reflects directly from the fundus uteri to the pubes 
without any indication of any vesical pouch or bladder, although 
the latter must of course be underneath, between the uterus and 
pubic bones. Just in front of the uterus the normal peritoneum is 
replaced by the granular surface just mentioned, from which the 
thickened omentum has been separated. On either side, the upper 
edges of the broad ligaments extend to the skies of the pelvis like 
thick guyropes, projecting a little from the general mass while pos- 
teriorly, the pelvis is full up to the fundus uteri and promontory 
of the sacrum. Thus the appearance is as if the peritoneum never 
had entered the pelvis, and we seem to have quite a typical case of 3 
what Lawson Tait and Robinson call urachal cyst with tuberculous 
appendages. 
Now, how shall we get this pelvis cleared out? I cannot get 
down at the sides pelvis, so I work the finger ends of my left 
hand down between the central mass and the sacrum, and 
suddenly break into a small cavity of fluid, which in similar cases I 
have found to contain serum and flaky matter. As it comes up it 
proves to be pus, so we must exercise great care not to spread this 
about. It has already touched the omentum, uterus and a loop of 
the intestines. I carefully keep my left hand just where it was, with 
the palm transversely, so as to hold the incision open and the in- 
testines out of the way, and carefully sponge out. We will request 
all nurses to stand to one side, and not touch these septic sponges. 
Dr. White, our second assistant, will squeeze them out and wash 
them. Having sponged out the pus, I wipe a little soft, cheesy 
looking matter from the bottom of the cul-de-sac of Douglas. Now 
Dr. White and I will disinfect our hands and the sponges in a one 
or two thousandth bichloride solution, and sponge out carefully 
again. Now I will dismiss Dr. White, and these sponges as they 
are septic, call for fresh basins, disinfect my own hands again, recall 
the nurses, and take fresh sponges and pack them over the intes- 
tines above the infected area. 
I am now able to loosen up the tubes from the bottom of the 
lateral sacro-peritoneal pouches, but as the broad ligaments are 
fleshy and friable, find it very difficult to get a pedicle. The left 
broad ligament tears- out, and the ligature cuts so that only the 
isolated Fallopian tube remains in it. Yet, strange to say, there is 
but little bleeding. I touch a little strong carbolic acid to the some- 
what dilated section of the tube left on the stump, to forestall in- 
fection. The ligature on the other stump cuts entirely through, so 
that none is left on it; yet, still stranger to say, there is but moderate 
bleeding. Oftentimes, in cases like this, the spermatic or ovarian 
artery will bleed, and require ligaturing. Without removing the 
large sponges that shut off the general peritoneal cavity, we will ir- 
rigate the pelvic cavity with several gallons of water as hot as I can 
bear on my hand as I hold the sponges in place. It is often said 
that hot water checks hemorrhage, but I usually find that even 
when as hot as I dare use it in the peritoneal cavity it either in- 
creases it, or has but little effect. In this case it tends to increase 
it. Now, we have washed out and sponged out, we will pack these 
small sponges firmly in the pelvis, and leave them until the exter- 
nal stitches are put in and ready to tie, then take them out, put a 
glass drainage tube into the cul-de-sac to draw off the subsequent 
oozing, and close up around it. 
Most German operators would in this case enlarge the incision, 
eventrate the intestines and sew up bleeding surfaces, so as to be 
able to close without drainage. I do not like to expose either the 
intestines or the unhealthy tissue to such manipulation, nor do I 
like to leave so many ligatures, for fear they may become directed, 4 
and prove more dangerous than the drainage tube. The discharge 
of infected ligatures, keeping the patient in a state of discomfort 
and anxiety for months and sometimes years, is quite a common 
after result of abdominal section. Their infection may be primary 
at the time of the operation, or secondary from leaving the drainage 
tube in too long. The tube should usually be removed in twenty- 
four or thirty-six hours. Infection is apt to result from leaving it 
longer. 
Our next case is that of a virgin, Miss Florence M., aged thirty 
five years, who had an attack of peritonitis .twelve years ago, and 
has ever since complained of pelvic symptoms. Her health is de- 
stroyed to such a degree, that she is a poor subject for an operation. 
She has scarcely any temperature, and but little tenderness in the 
pelvis, yet she complains of pelvic distress, and h'as hard indurated 
masses on each side of the uterus. Until I saw her, no one ever 
suggested a laparotomy. 
We rapidly cut through the abdominal walls and find large 
masses adherent to the posterior surfaces of the broad ligaments. 
But it is almost impossible to loosen anything. The tubes are cystic, 
and tear the broad ligaments as they are separated. The right mass, 
A'hich I have pulled up, is extremely interesting. It is, as you see 
a hydrosalpinx the size of the thumb, with a tubo-ovarian cyst at 
the fimbriated extremity, the size of a walnut. 
We may have three kinds of tubo-ovarian cysts. In one case 
the fimbriated extremity of the tube adheres to the ovary, and the 
retained serum, blood or pus is retained in a sac made up of the wall 
of the tube and the substance of the ovary. In another case an 
ovarian cyst, cystoma, or abscess, grows into the fimbriated extrem- 
ity of the tube until its walls finally adhere to and coalesce with the 
inner surface of the tube. In the third kind, which may be a more 
advanced stage of the second, the ovarian cyst, cystoma or abscess, 
may burst into the lumen of the adherent tube, so that both tube 
and ovary form a part of the resulting cyst. 
In this case we have both the first and second varieties, viz: P 
hydrosalpinx whose walls are both tubal and ovarian, and an ovarian 
cyst developed into the lumen of the adherent tube. If this ovarian 
cvst had remained until it burst into tne tube, we would have hail 
the third variety. The specimen is quite a rare one. 
The other tube is a simple hydrosalpinx. Under it I find a 
deeply bedded cyst, the size of a hen’s egg, which bursts in my fin- 
gers as I enucleate it, and allows a black bloody fluid to escape. It 
comes up and proves to be an ovarian cyst into which hemorrhage 
has taken place. Although both sides are ligatured, the hemorrhage 
in this case is greater than in the previous one, for the adhesions 
are older and firmer, and have torn the peritoneum from the broad 
and sacro-uterine ligaments. If an operation has to be done lor 
such conditions, it should, therefore, be done as early in the course 
of the ailment as possible, that the adhesions may not be so firm 
and the pelvic disorganization so great. We wash out anil pack the 
pelvis as before, sew up and put in a drainage tube.