LAPAROTOMY PERFORMED FOR THE REMOVAL OF A LARGE QUANTITY OF MENSTRUAL BLOOD FROM ONE HORN OF A BICORN ATE UTERUS. T. OAiLLARD THOMAS, M.D., Surgetm to N. T. State Woman’’* JTosfrital. Reprint from Illustrated MEDICINE « SURGERY, Georoe Henry Fox and Frederic R. Sturgis. Issued Quarterly. $8 Per Annum. Edited by E. B. TREAT, Publisher, 757 Broadway, New York. Copyright, 1882. EDITORIAL NOTICE. The editors of the Illustrated Quarterly solicit from the Profes- sion contributions in the various departments of MEDICINE AND SURGERY. It is desired that every contribution be sent to the Editorial Office, 757 Broadway (care of the publisher), at least six weeks before the appearance of the number fur which it is intended. Every accepted article will be paid for, and the (6x9 inches), photographs, and draiArtrigs will be reproduced without expense to contributors. E. 11. TREAT, Publisher. Illustrated Medicine and Surgery, Contents,, No. il. RESTORATION OF LIP, - Five Illustration*. By Alfrrd C. Post, M.D., LL.D., Emeritus Professor of Surgery iu and President of Medical Department, L nicer si ty of the City of New York. FIBROUS TUMOR OF FACE, - Three Illusiraiiom. By Willard Parker, M.D., Prof. Clinical Surgery, Coll, of Physicians and Surgeons, N. Y. SEPARATION OF THE LOWER EPIPHYSIS OF THE FEMUR. - - Two Illustrations. By JamesXi. Little, M.D., Professor Clinical Surgery, University of the City of N. Y. t LAPAROTOMY FOR REMOVAL OF MENSTRUAL BLOOD, - - Five Illustrations. By T. G. Thomas, M.D., Surgeon to New York State Woman's Hospital. A RARE FORM OF CORNEAL OPACITY, One Illustration. By T. R. Pooley, M.D., Assistant Surgeon N. Y. Ophthalmic and Aural Institute. FACIAL PARALYSIS IN CONNECTION WITH AURAL DISEASE. Four Illustrations. By Sam’l Sexton, M.D., Surgeon to the New York Eye and Ear Infirmary. DISLOCATION OF THE COLUMNAR CARTILAGE OF THE NOSE, - - Om Illustration. By F. IT. Boswortti, M.D., Surgeon to Out door Department, Bellevue Hospital. SUBS EQUEN I' NUMB HR S WILL CONTAIN CONTRIBUTIONS FROM Prof, JAMES R. WOOD, Prof. C. R. A6NEW, Prof, A. L. LOOMIS, Prof. E, L, KEYES, Prof. D. B. ST, JOHN ROOSA, Prof, G. M. LEFFERTS, Prof, AUSTIN FLINT, Prof. F, R. STURGIS, Prof. W, H. VAN BUREN, Dr, V, P, GIBNEY, Prof. F, DELAFIELD, Dr, CHARLES McBURNEY, Prof. E. G, JANEWAY, Dr, M. J, ROBERTS, Dr. BEVERLY ROBINSON, Prof, GEORGE HENRY FOX, Dr. T. E, SATTERTHWAITE, OTUEaCZEIX^JS. LAPAROTOMY PERFORMED FOR THE REMOVAL OF A LARGE QUANTITY OF MENSTRUAL BLOOD FROM ONE HORN OF A BICORNATE UTERUS. T. GrAILLARD THOMAS, M.D, Surgeon to JV. Y. State Woman's Hospital. Mrs. A., a native of France, forty years of age, a widow, who had borne one child, entered my service in the Woman’s Hospital, and gave the following history. For the past sixteen years she had suffered from what a large number of physicians who had examined her had uniformly pronounced to be a fibrous tumor of the uterus. At the commencement of that period she had spent eight months in the hospitals of Paris, and had since consulted many physicians, but without obtaining any relief whatsoever. The three distinguishing features of her case were these: first, since its development the tumor had neither increased nor diminished in size ; second, it was at all times exquisitely sensitive to pressure, and especially so during menstruation; and, third, pain occurred in it during every menstrual act, so severe that nothing gave her relief except a free resort to opium. Her suffering dur- ing menstruation I have never seen surpassed, and she had become so demoralized by it that her object in entering the hospital was to have the growth removed at all hazards. Upon examining her I found the pelvis filled by a tumor about as large as the head of a child a year old, which, as I have already said, was very sensitive to pressure. It was apparently solid, only slightly movable, and by conjoined manipulation appeared to be attached directly to the uterus. I saw no reason to differ from the diagnosis which had been heretofore made in the case, although I was very much puzzled by the existence of the three peculiar features to which I have already referred. I dissuaded the patient from operation, but she was so much distressed at this that I got my colleagues, Dr. T. A. Emmet and Dr. J. B. Hunter to see her with me in consultation; she indulging the hope that they might differ with me in this regard, and declaring that so great were her sufferings that she would infinitely prefer a resort to surgical interference, however great the dangers might be, than to remain exposed to them. Drs. Emmet and Hunter agreed both in the diagnosis and in the propriety of refusing operation. The patient then left the institution, and I did not see her for five or six months, when she returned again urgently demanding operation. I kept her in my service for some time, and then, with regret, again dismissed her without having afforded her any permanent relief. Two months after this she saw me at my office, and so fully described her sufferings, and 19 ILLUSTRATED MEDICINE AND SURGERY\ so earnestly pleaded for relief that I again admitted her to the hospital, promising to remove the ovaries by Battey’s method, in the hope of, in this way, relieving her of at least the greater portion of her troubles. For this operation, she entered my service during the year 1881. I cut down through the abdominal walls, and reached a tumor which looked exactly like a fibroid, I put my fingers upon it, and was surprised to find an obscure and yet distinct sense of fluctu- ation, which had not been recognized through the abdominal walls. Instead, therefore, of going on with the intended operation, I introduced a canula and trocar into the fluctuating tumor, and on withdrawing it there immediately escaped a pint or a pint and a half of menstrual fluid. It had all the characteristics of that fluid, and there could be no mistake with regard to its nature. 1 was very much puzzled by this, for the woman had been carefully examined, she had menstruated regularly, the uterus had been repeatedly measured, and Avas found to be two inches and a half in length. Taking hold of the tumor with two strong tenacula and drawing it up into the abdominal wound, I passed my hand down and discovered its relations, when at once it flashed across my mind that this was a uterus binomial; that the canal in the left horn was free, and allowed the escape of the menstrual fluid from that side, while the canal in the right horn was not open throughout its entire length, and consequently obstructed the menstrual discharge from that side. The original condition of the parts was probably that represented in Fig. 9 or Fig. 10, one cervix being pervious, and the other impervious, if the uterus were originally bicornate as represented in Fig. 9, or else no cervix existing if the organ were originally unicornate as represented in Fig. 10. Fig. 9.—Bicorn Uterus. Fig. 10. —Unicorn Uterus. Under such circumstances, one uterus, or rather one horn, discharges menstrual blood; in the other, that fluid, secreted by the endometrium, accummulates and creates a tumor presenting many of the features of a fibroid. When this thought suggested itself I was able to account for all the peculiarities of the case: First, the fact that the tumor had the appearances of a fibroid, and gave such agonizing pain at each menstrual period ; second, the fact that the tumor remained at about the same size, not growing larger, as a fibroid would do, -although it was not at all impossible for a tumor of this character to have become larger by gradual distension ; and, lastly, the fact that the patient had comparative immunity from pain between the menstrual periods. I now found myself in an unfortunate dilemma, for had I proceeded to remove the ovaries, blood would have escaped from the wound into the abdominal cavity, and would very likely have set up fatal peritonitis or septicaemia. Hence, I adopted a course which struck me, as under the circumstances, the only one which would meet the emergency. 20 LAPAROTOMY. The following diagram, Fig. 11, will show the condition of affairs at this stage of the operation I caught hold of the uterus on one side, and Dr. Ward on the other, each with a strong tenaculum, and dragged it firmly up into the abdominal wound, and passed two strong knitting-needles through the tumor and laid them on the ab- dominal walls above and below the point of puncture. i then passed two sutures deep down, and fastened the tumor in the abdominal wound, and left a tube in for drainage and irrigation, I remarked to the spec- tators present, that the woman would almost surely suffer from septicaemia, and this prediction was fully verified ; but by having the cavity constantly irrigated with carbolized water, and controlling the temperature by Kib- bee’s method of affusion, she re- covered. A day-to-day history would accomplish nothing in increasing the interest of the case, hence, I spare the reader a recapitulation of it. It suffices to say that the uterine cavity was thoroughly washed out with carbolized water every four or five hours ; the tem- perature, which rose to 100°, kept in the neighborhood of 100° by affusion ; and quinine and opium used freely; and the patient treated in all respects as she would have been after ovariotomy. D% c E 0 /I H Fid. 11. A. B. Abdominal Walls._ C. Section in median line. D. Canula. E. One uterine body distended by retained menstrual blood. F Urine uteri, impervious on one side. G. Uterus with pervious cervical canal. H. Vagina. At the next period, menstrual blood escaped simultaneously from the vagina and the abdom- inal wound, the drainage tube not having been removed from the latter. Never have I known more complete relief ensue from any operation than from this one. The patient constantly expressed her- self as entirely relieved, and is so well satisfied with her present condition that she is entirely unwilling to consider a procedure to which I shall soon allude for improving it. lor her, however, to continue in her present state of comfort, it is evidently essential that the abdominal opening shall be kept free until the menopause. To accomplish this, as soon as the menstrual period was over, I had constructed a solid glass rod represented in actual size by Fig. 12. Fig. la. 21 ILLUSTRATED MEDICINE AND SURGERY. This, the patient wears constantly, except at menstrual periods, keeping it in position by a girdle which presses upon its head, and at the same time sustains the parts about the incision. She has now left the hospital, but reports to me occasionally, and has been instructed how to allow the free escape of menstrual blood by the genu-pectoral position, and how to wash out the cavity with carbolized water, in case of any septic symptoms attending upon or following menstruation. This last maneuvre she has frequently practiced, and perfectly understands. Fig. 13, although a rough diagram, represents very accurately, I think, the present state of affairs. c rp> !!lTjjx m IE When this operation was adopted, I felt that it had helped my patient and myself out of a very difficult dilem- ma, but at the present time I do not feel at all satisfied with the status rerum. Should the patient not become pregnant, it is highly probable that all will go well with her until the menopause, but should pregnancy occur in the left horn, the right will assuredly be torn away from its abdominal moorings, and a fatal issue would occur. F A. B. Abdominal walls. C. Glass plug. D. Uterine body fastened to the abdo- minal walls. E. Uterus with pervious cervical canal. F. Vagina. Fig. 13. At the moment of operation, and since that time, the propriety of penetrating the impervious cervical canal of the right horn, keeping it permanently open, closing the upper opening, dropping this horn into the pelvic cavity, and then closing the abdominal wound, has been carefully considered. As is so often the fact, under similar circumstances, the advisability of this course will very likely be immediately determined upon by many who have not had an opportunity of observing the case. To those who have watched it with keen anxiety, through its various phases, much more difficulty will attend the decision. The patient is past forty; should conception occur the propriety of checking utero-gestation would be quite evident ; the patient, who has gone through with a great deal of suffering, strenuously objects to interference with a condition which is perfectly satisfactory to her and the dangers attendant upon the steps referred to would be very considerable. So many years have elapsed since pregnancy occurred with her, that I think it highly improb- able that it will now take place after the fortieth year. Should it do so, I should feel myself called upon under present circumstances to put a stop to its progress. This, however, I should feel justi- fied in doing only once ; having once resorted to it as a therapeutic resource, I should feel it my duty to urge upon her a resort to those further surgical steps which I have mentioned. 22 To tKe JMedtcciZ IPr'ofzsstort: The undersigned respectfully announces, that in compliance with repeated solicitations from the medical profession, he has undertaken the publication of an IstraM Quarterly of Medici id Surra, EDITED GEORGE HENRY FOX, g FREDERIC R. STURGIS. To every one familiar with foreign Hospital Reports and Society Transactions, the value of illustrated articles is evident. While in this country there is no dearth of medical literature, it must be admitted that many interesting cases, especially of a surgical or pathological nature, are imperfectly reported, or remain unrecorded, for lack of the means of suitable representation. It is the object of the proposed “ Illustrated Quarterly ” to meet this defect. It is hoped that by means of photographs from life, chromo-lithographs, and engravings of the highest artistic excel- lence, much valuable and instructive material may be brought within the reach of the Profession, which has. heretofore been inaccessible. It is intended to offer nothing to the reader but original matter, and no space will be allotted to translations, extracts, digests, or material with which the profession is already well supplied. In order to command the best talent, all contributions which are accepted will be liberally paid for. The names of the editors and the eminent gentlemen whose co-operation has been secured, are such as to ensure a publication of the highest character, and one which it is hoped will be wel- comed by the profession, and prove a valued addition to American Medical Literature. The,arnple experience of the publisher in the production of lithographic and photographic work has been such, as to guarantee the prompt and satisfactory appearance of the proposed “ Quarterly ;” in this connection it is only necessary to mention, that a former work of somewhat similar character (“ Photographic Illustrations of Skin Diseases”) appeared monthly, during two years, without interruption or delay. Each number of the “Quarterly” will consist of four quarto plates, printed on fine quality of cardboard, 10 x 12 inches, with twenty-four dr more quarto pages of accompanying text, printed on superfine paper. The text will contain descriptions of the cases represented by the plates, and other papers, illustrated when necessary, by means of wood engravings. Served by mail or carrier to Yearly Subscribers only. Price, $B. Payable, if de- sired, in Quarterly payments of $2. No subscription received for less than a year. E. B. 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