ABDOMINAL SURGERY, SEVEN OASES. Read before the Clinical Society February 27tii, 1885 By E. E. MONTGOMERY, M.D., Late Obstetrician to the Philadelphia Hospital. REPRINT FROM “THE MEDICAL BULLETIN.” PHILADELPHIA: F. A. DAVIS, Att’y, Publisher, 1217 Filbert Street. 1885. ABDOMINAL SURGERY. SEVEN CASES. llKA1) 1JKKORK TilK CLINICAL SOCIETY FEBRUARY 27'1'H. 1S85. By E. E. MONTGOMERY, M.IX, Late Obstetrician to the Philadelphia Hospital REFBINT FROM “THE MEDICAL BULLETIN.” PHILADELPHIA: P. A. DAYIS, Att’y, Publisher, 1217 Filbert Street. 1885. ABDOMINAL SURGERY. SEVEN CASES. By E. E. Montgomery, M.D., Late Obstetrician to the Philadelphia Hospital. [Read before the Clinical Society, February 27th, 1885 ] ALTHOUGH the majority of these cases have been published, we feel that they present points of sufficient interest to permit of their being grouped together, and they thus enable us to discuss more readily the treatment and results. Case I.—Ovarian Tumor ; Ovariotomy ; Recovery.—Mary W., tet. 28 years, married, of irregular habits, entered the Philadelphia Hospital April 23, 1879. Health had never been good, and had a family history of phthisis. Menstruation began at twelve years, and con- tinued until four years before. She had had three miscarriages; the first at five months. A swelling appeared in the left inguinal region four years before, which increased gradually, and during its growth her menses had oc- curred at irregular intervals. Within the last two years she had had occasional retention of urine, requiring catheterization, and had had continual morning sickness. The distress in the back and lower part of the abdomen had been so severe as at one time to lead her to attempt suicide, for which she was confined in the Insane Hospital. She was still irritable, and at times required close watching to prevent attempts at self destruction. The abdomen was nearly symmetrical, slightly more prominent to the left; while recumbent, percussion was now resonant over the superior part of the tumor, and tympanitic in the inguinal region. Fluctuation was quite distinct. The abdominal walls were freely movable, and the tumor could be seen to move up and down during respiration. The uterus was neither enlarged nor connected with the tumor. The tumor was decided to be a left ovarian cyst, and its early 4 removal advised. The patient consenting, four weeks later I performed the operation, assisted by Drs. Walker, Warder, Bell, Heller, and Martin. The spray and other antiseptic precautions were used. An incision three inches long was made to the peritoneum, when, no bleeding occurring, the latter was opened, and the pearly-tinted cyst disclosed. Finding no adhesions, the incision was extended to five inches, the sac punctured with the trocar and drawn out, as its contents were discharged. There were no adhesions. A clamp was temporarily applied to the long pedicle and the tumor removed. The pedicle was treated intra-peritoneally, tied with silk in two sections, and the liga- ture from one side tied around the whole stump. The right ovary was found to contain two small cysts, but, as my principal assistant, Dr. Walker, feared its removal would prejudice the result, it was allowed to remain. The abdominal cavity carefully cleansed, the wound was closed with silver sutures, half an inch apart, and including nearly an inch of the peritoneal surface. The antiseptic dressing was applied, and the patient placed in a bed previously heated by cans of hot water. The operation occupied thirty-two minutes, and was followed by no shock. She had some nausea and vomiting, which was controlled by mustard sinapism and sipping hot water. Later, she was so violent that morph., gr. ss., was given hypodermically, and subsequently chloral, gr. xx, per rectum. The delirium was most marked upon the first, fifth, and eighth days, requiring the nurse at times to hold her in bed. The highest temperature reached was 101.6, occurring on the evening ot May 22d, the second day, and became normal the morning of May 24th. She was able to walk into the clinics two weeks after the oper- ation. She has returned to the hospital at various times since the operation, and was an inmate of the obstetrical ward during the early part of 1884, suffering from the effects of a recent abortion. Case II.— Cancer of the Uterus and Rectum; Colotomy; Sur- vival One Year; Death ; Autopsy.—Louise P., set. 35 years, domestic, of German descent, married, mother of five children, was admitted to Philadelphia Hospital in April, 1880, suffering from cancer of the uterus and rectum, causing stricture of the latter viscus. The trouble began eighteen months before as an uneasiness about the rectum, diffi- culty in defecation, attended with straining and pain. The discharges were slight, liquid, of a muco purulent and occasionally bloody char- acter. This condition continued, better or worse at intervals, until within five months of her admission, when it became permanent. She 5 was treated for several months at St. Mary’s Hospital, with but little relief. She is greatly emaciated, presents a sallow cachectic appearance; complains of want of appetite; nausea, and frequent stools, largely of a muco-purulent and sanguineous character, attended by great straining and severe pain. 'Her previous health was good. She denies any syphilitic taint. Her habits are bad, being intemperate, and an inveterate user of snuff. Mother died from “rectal obstruction,” most probably cancer. Men- struation had ceased. The uterus was retroverted, hard, dense, immovable. Posterior wall of vagina rigid. Rectum was obstructed an inch from the anus by a firm annular stricture, which would not admit the little finger. April 14, 1880, the patient was etherized and rectotomy was per- formed, bypassing a probe pointed bistoury through the stricture and cutting toward the sacrum. The rectal walls were infiltrated and con- tracted, so far as the finger could reach. The following day a severe diarrhoea set in. She progressed from bad to worse; stools were then muco-purulent, attended with great straining and agonizing pain. The skin was a dirty-brown color, and emitted an offensive odor. She was weak, without appetite, and suffered from nausea and vomiting. April 28th, 9 A.M., she was brought before the class for colotomy, though her condition was such as to render the efficacy of any oper- ative interference extremely doubtful. Drs. Parish, Musser, and Stryker assisted in the operation. She was placed upon the right side with 4 good-sized pillow under the abdomen. A stain with iodine was made at a point half an inch posterior to the middle of a line drawn from the anterior to the posterior superior spine of the ileum. An incision, midway between the lower rib and crest of the ileum, was made from the erector spinae mass, obliquely forward, four inches, through skin, superficial fascia, and lumbar aponeurosis, to the quadratus muscle, tearing through the fascia covering it anteriorly. The gut protruding into the wound, it was transfixed by two sutures, three-fourths of an inch apart, drawn out, and an opening made between them. The gut was then attached to the skin by six wire sutures. The wound was dressed with oakum, saturated with carbolized oil. She stood the operation badly, and it was only through frequent subcutaneous injections of whiskey by Dr. Parish that she survived it. She, however, rallied from the shock, and recovered without difficulty. The first evacuation through the artificial anus occurred on May 2d, 6 the fourth day after operation, and was painless. By the end of a month she was able to attend to herself and go about the house at will. Oct. 8th. She looked much better than upon her admission; had a marked tendency to diarrhoea, which was controlled by morph, gr. % daily. With the morphia she had two evacuations daily. With each evacuation from the side, there was a muco-purulent discharge from the anus. Death occurred in May, 1881, from exhaustion. Autopsy.—Body greatly emaciated. The intestines were every- where glued together by old bonds of adhesion. The whole of the rectum and part of the sigmoid flexure had undergone malignant degen- eration and softening. The opening of the artificial anus was about five inches above the flexure, and the portion of bowel below it was contracted and empty. Case III.—Multiple Uterine Fibroid Partially Caltified; Re- moval; Death; Autopsy Maria B. (colored), tet. 53 years, single, domestic, was admitted to the Philadelphia Hospital April 21, 1880, with a large abdominal tumor, which had first appeared some seventeen years before. The growth was first noticed in the left inguinal region and gradually grew until it completely filled the abdomen. Her greatest distress had been from the size and weight of the tumor. She had a sister suffering from a similar growth. The menopause had occurred seven years before, after which the tumor had remained unchanged. During her menstrual life the flow was excessive. She was greatly troubled with constipation; appetite variable; di- gestion moderate; pulse soft, compressible. The abdomen was very prominent in the upright position, so that she was obliged to lean back to support it. The superficial veins of the abdomen were distended. The abdomen is quite irregular, more prominent to the right; below and to the left, above and in the centre the umbilicus protrudes like a nipple. The tumor was fully movable, irregular or nodular, and presented a flat surface in the hypogastric region, the pedicle, hardly an inch in diameter, could be distinctly felt. The tumor was very hard, and intestinal resonance could be distinguished at each side. Per vaginam : the hymen was unruptured, the os normal, cervix elongated, apparently attenuated, posteriorly, a large mass filled up the pelvis, and another above. Per rectum: a large hard tumor in Doug- las’s cul de sac pressed upon the rectum, was as freely movable as the space would admit, and was continuous with the mass above. It had 7 undergone calcareous degeneration, as was shown by the density and cracking of a bony plate during examination. In view of the patient’s hapless condition and her desire for the removal of the tumor, an operation was deemed desirable. After suitable preparatory measures, the patient was etherized and brought before the class May 5th, and the operation performed under carbolic spray. Drs. Warder, Parish, Lynn, Stryker, and Hatfield assisted. An incision four inches long, avoiding large veins, was made to the peritoneum, hemorrhage arrested and the latter opened, when a few ounces of ascitic fluid escaped. Finding the cervix sufficiently long for a pedicle, the abdominal wound was extended above to the umbilicus and below to an inch of the symphysis. The growth was a cluster of fibroids; the largest, situated above to the left, had ex- tensive omental adhesions, which, being very vascular, were tied by a double ligature. ' Considerable difficulty was experienced in bringing this portion through the opening. It was connected with the main tumor by a pedicle the size of the wrist, which was ligated and the mass removed. The cervix and broad ligaments were then ligated in three sections just above the bladder with iron wire, and the remaining portion removed. Two of the tumors were so near the ligatures that the excision had to be made through them, after which’ the remaining portions were enucleated. This loosened the wire, so that it did not entirely control the bleeding; a clamp was temporarily applied, the sur- face seared with a hot iron and the stump encircled by another wire. After arresting all bleeding and carefully cleansing the abdominal cavity, the wound was closed with silver sutures, excepting at the lower angle, where a glass drainage tube was inserted. The complete Lister dressing was applied to the wound, and the patient placed in a well warmed bed in a private room. The operation occupied two hours, and was followed by profound shock, but she rallied under whiskey and digitalis and external heat. 8.30 P.M., T. 1010, P. 116; had pain over the abdomen, nausea and vomiting were marked during the afternoon, but yielded to rectal injection of chloral. May 6th. 4 A.M., T. 101.40, P. 138. 4 P.M., T. 103.8°, P. 152. As the dressing was satuiatfcd with discharge, it was renewed under the spray. yth. 7.30 P.M., T. xoo.6°, P. 140; shows evidence of failure; tongue, dry, parched and tremulous; skin covered with a cold, clammy 8 sweat; abdomen tympanitic, and distended to the size before the oper- ation. Death occurred at 4 F.M. Autopsy twenty hours after death. The peritoneal line of incision was united, excepting at the point of entrance of the drainage tube. The intestines were distended, and the peritoneum injected. The intestines were glued to the pedicle, but nowhere else in the abdomen were there any flakes of lymph or any pus. The pedicle itself was in good condition; lymph had been thrown out, gluing it to the adjacent intestines and encysting the wire. The bladder was in a normal condition, though the wire encircling the pedicle was in close proximity. The remaining cervix measured inches. Kid- neys large, fatty; capsule easily separated. Liver fatty. Heart soft, flabby; aortic valves contained bony plates. The aorta had undergone atheromatous degeneration, and contained numerous plates of calcareous formation. The mass removed weighed twelve pounds, and presented a large number of tumors of the submucous, mural, and subperitoneal varieties, varying in size from a hickory-nut to that of the largest, which weighed seven pounds. Case IV.—Large Uterine Fibroid; Removal; Death from Shock ; Autopsy.—Sarah B., set. 46 years, widow, of temperate habits; entered the Gynaecological Ward in February, 1882, and solicited the removal of a large fibroid tumor. During her early menstrual life she suffered from severe hemorrhages. Her menses ceased, at one time, for five years, and she had not menstruated for two years. The tumor appeared eighteen years before, soon acquired great size, fiilling up the abdomen. She had been treated with ergotine, hypodermatically, and subsequently by the earth treatment; the latter followed by a slight reduction, due possibly to rest in bed. The abdomen was very prominent; its walls thin, and the mass had settled down and forward, so that it encroached but little upon the por- tion above the umbilicus. The tumor was regular in outline and sym- metrically developed. The bladder covered the whole of the lower face of the mass. Above, to the right, a small, loosely-connected mass was discovered, between which and the tumor percussion was resonant. The abdominal walls were freely movable over the tumor, but the latter would admit of but limited movement per vaginam. The whole uterus is involved in the growth which rests upon the pelvis. The posterior lip of the cervix was thin, and a probe could be passed into the uterine 9 canal, five inches along the posterior surface of the growth, indicating its origin in the anterior wall. Only the urgent desire of the patient led to an attempt at removal of the growth. By way of preparation she was kept in bed one week, and given iron, quinine, and a judicious diet. Dr. Milliken examined the urine, which was alkaline, but contained no albumen. The operation was performed March 17, 1882, under thymol spray. Drs. Duer, Warder, Parish, Musser, and Hatfield assisted. An opening three inches long was made for examination; this was extended above to the umbilicus. The peritoneal covering of the tumor was burned through with Paquelin’s cautery and the bladder stripped off without difficulty. The capsule was raised on either side, allowing ligatures to l>e passed beneath the broad ligaments. The lower part of the cervix was then tied in two sections, both subsequently surrounded by one ligature, and the mass removed. Although the hemorrhage had been slight, the condition of the patient became exceedingly critical. The pulse was scarcely perceptible; breathing infrequent, and sighing. It was only through Dr. Parish’s stimulation of circulation and respiration by frequent hypodermatic injections of whiskey and ammonia, and assiduous applications of hot water over the chest that she survived until the wound could be closed. She was placed in bed, artificial heat applied, ergot and digitalis given hypodermatically, and whiskey by the mouth and rectum, but without counteracting the effects of shock. She died at 4 P.M., two and a half hours after the completion of the operation. Autopsy.—Douglas’s cul de sac contained two ounces of bloody serum. The kidneys were small and sacculated, the right containing pus. The cortical structure in both was greatly decreased. The ureters were un- injured by the dissection, but were dilated to the size of the little finger. An inch and a half of the cervix remained below the ligature. The tumor was a solid mass longer transversely, quite regular in outline, presenting at the right upper surface a smaller growth with an elongated pedicle. The whole mass weighed sixteen pounds. Case V.—Epithelioma of Larynx and (Esophagus ; Gastrostomy ; Death and Autopsy.—Mrs. C., aet. 46 years, married, had been ill for over two years with disease of throat, which Dr. J. Solis-Cohen pro- nounced malignant. It apparently began in the arytenoid cartilages, and finally interfered so much with respiration that Dr. Cohen per- formed tracheotomy in November, 1881, after which, as she lived at a distance from him, he kindly placed her under my care. 10 The disease gradually extended, involving the lymphatic glands. The neck became greatly swollen, making deglutition possible only for liquids, and these frequently ran into the trachea and were coughed out of the tube. Deglutition finally became so difficult as to require the introduction of bougies. A No. io Eng. catheter was at first passed, and the size increased until the French oesophageal bougie was used. Later the swollen glands began to soften, and broke just above the tube, forming a large cavity from which the upper rings of the trachea were discharged necrosed. The extensive ulceration of the throat made it impossible to find the oesophagus, for the introduction of further dilators, and the large opening permitted liquids to escape as fast as taken into the mouth. She was supported for some three weeks on beef blood and whiskey per rectum. December 17, 1882, assisted by Drs. Warder, Walker, Chase, Martin, Mr. Warder, and Miss Wolcott, the patient was anaesthetized with A. C. and E. mixture, and gastrostomy was performed. An in- cision two inches long, parallel to the cartilage of the eighth left rib, was made to the peritoneum, when no bleeding occurring it was opened. The liver was seen moving up and down with each respiration. The stomach, being empty, was reached with difficulty. It was transfixed by two pins at right angles to each other, and stitched to the integument, taking care to pick up the parietal peritoneum with each stitch. Fifteen silk sutures were introduced, three of which were to close the upper angle of the wound. The inclosed portion of the stomach was then opened by a crucial incision. The wound was dressed with cotton satu- rated with a solution of iodoform in collodion ; over this absorbent cotton was applied, held in place by a bandage. After treatment. She was given whiskey 3j, milk siv, per rectum, every three hours. In the first twelve hours two hypodermatic injec- tions of morph, gr. y£ each, were given. 9 P.M. T. 99.8°, P. 100. 18th, 7 A.M. T. 990, P. 104. 10 P.M. T. 98.8°, P. 96. 19th, 7 A.M. T. 98.8°, P. 104. 10 P.M., T. 101.80, P. 144. The wound was dressed during the day; the upper angle had completely united. An attempt was made to inject some milk, but unsuccessfully; the opening was filled with glairy mucus. She desired to lie upon the left side, but it was followed by severe pain. Morphia gr. % was given hypodermatically. 11 2oth, 8 A.M. Pulse could not be counted. Stupor and mental wandering. Attendant had discontinued stimulant. Ordered whiskey f.3j, tr. digitalis gtt. xx every two hours. 5 P.M. T. xoi°, P. 132. 21 st, 7 A.M. T. 1010; pulse very feeble and compressible, coun- tenance pale and pinched; sank gradually until 2 P.M., when she died. Autopsy, twenty-seven hours after death. The abdominal wound had united above the point at which the stomach was attached. The stomach had been opened about the centre of the anterior surface and was well glued to the wound without any extravasation of its contents having occurred. The peritoneum was injected, but no serous effusion or flakes of lymph were present. Case VI.—Menstrual Epilepsy ; Oophorectomy ; Recovery.— Sarah H., set. 17 years, became an inmate of the Philadelphia Hospital in April, 18S4. Excepting an attack of inflammatory rheumatism, she was well until her thirteenth year, when she began to have epileptic seizures. These attacks occurred monthly, increasing in number and virulence until her admission. She was unconscious from ten days to two weeks out of each month. She was warned of an approaching attack, by fullness in the head, tingling sensations over various parts of the body, and pain in the back. There had been, but once, a trace of menstrual discharge, and that but for a single day. Family history good. She was pale, flabby, anaemic, poorly devel- oped, and quite hysterical. Extremities were cold, clammy; appetite good, without abnormal cravings; bowels constipated, urine normal. There was a mitral regurgitant murmur. The epileptic attacks varied; some resembled the epilepsia gravior; others, the petit mal. In the former, there was a sudden scream, foaming at the mouth, general con- vulsions, followed by profound stupor for several hours; tongue was bitten; urine and feces voided in bed. In the lighter attacks, she utters a piercing scream, falls from her chair, lies motionless for a few minutes, and recovers without any knowledge of what has occurred. Her falls from bed were so frequent that her mattress was placed upon the floor during the epileptic period. She was given a generous diet, cod-liver oil, quinine, iron, with various remedies to control the convulsions, as assafeetida, valerian, bro- mides, chloral, nitrite of amyl and nitro-glycerine; other means, as galvanism and massage, were tried with the hope of establishing the men- strual function. Under this treatment her general condition was greatly 12 improved, but there was no indication of the menses, nor any abatement of the epileptic seizures. After some months it was decided to remove the uterine appendages. By the courtesy of Dr. Stryker, the writer was permitted to perform the operation. The operation was performed, on September 13th. Dr. Hearn administered ether, and Dr. Stryker assisted the operator. The instruments and sponges had been placed in hot water; no other anti- septic was used. An incision two inches long was made, midway be- tween umbilicus and symphysis, through the abdominal walls, the fundus uteri found by the finger, and from it first the right ovary and tube, then the left brought up, ligated with black silk and removed. In the effort to effect the complete removal of the tissue of the left ovary, the pedicle was cut too short, and the ligature slipped, permitting the ovarian artery to bleed. The stump was quickly seized with haemos- tatic forceps and re-ligated. The abdominal cavity was washed out with warm water. Five silk sutures were used to close the wound. Th6 wound was dressed with a thick layer of absorbent cotton, held in place by adhesive strips and a flannel bandage. The operation required thirty- five minutes, and was followed by slight shock. She recovered from the operation without developing symptoms of special interest. The highest temperature, 1020, was reached at 12 M. on the 17th. She was returned to her ward upon the 26th, and that night a severe convulsion occurred. She had a number of convulsions before November 1st, but none so severe as those previous to the operation. In none of them did she fall out of bed, and was perfectly conscious during the intervals. Subsequent to the above date five weeks elapsed in which she was perfectly free of epileptic seizures. Case VII.—Cyst of Broad Ligament; Laparotomy; Recovery. —Emily A., ret. 30, married, never pregnant, suffered for seven years from an enlargement of the abdomen, which, beginning soon after marriage, was at first attributed to pregnancy. Her menses, however, were never suppressed, and now occur every three weeks. The only dis- tress, excepting pain at catamenia, is the sensation of weight. After coming to this country she was informed that she had an ovarian tumor, in which the adhesions were too extensive to permit of removal. Para- centesis was then performed, and some six times subsequently in as many years. The largest quantity removed at any one time was forty pounds. She at one time suffered from an attack of peritonitis, which kept her in bed three months. October 1, 1884, her abdomen was distended by a 13 nearly symmetrical tumor, which was slightly more prominent on the right side. Fluctuation was distinct over the whole surface. In cough- ing, the whole mass would be propelled forward and downward. Her general condition was good. The tumor was diagnosed a parovarian cyst, and she was advised to submit to an exploratory incision, with a view of complete removal if the adhesions would permit, otherwise stitch the sac to the integument and insert a drainage tube. The operation was performed October gth, Dr. Warder assisting, and Dr. Joseph Martin giving ether. An incision two inches long was made to the sac, which, being easily dissected, the incision was extended to four inches, and the tumor emptied by the trocar of nearly two gallons of pale, straw-colored liquid. The opening into the sac was increased to admit two fingers to ascertain its character. It was everywhere adherent, but was enucleated without difficulty and without ligating a vessel. The previous attack of peritonitis had glued the peritoneal surface of the tumor to the parietal peritoneum, so that the viscera were shut off above. On the right side was a small globular mass, from whose surface there was considerable oozing. It proved to be an enlarged ovary. By its re- moval the first opening was made into the peritoneal cavity. The ab- domen was packed with sponges, while seven silk sutures were intro- duced, the sponges removed, a glass drainage-tube inserted, and the wound closed and dressed with salicylated cotton, held in place by plaster and bandage. As in the former case, boiled water was the only antiseptic. The operation occupied forty-five minutes, and was well borne. She suffered pain during the afternoon, for which morph., gr. was given hypodermatically. This was followed by severe vomiting, which was relieved by a rectal injection of chloral. The temperature did not exceed ioi° until the evening of the seventh day, when it was 102.6°. The drainage-tube discharged about three ounces of bloody serum daily. It was removed the fourth day and a rubber tube substituted. With the elevation of the temperature there was a change in the discharge, it became offensive and the ab- domen tympanitic. Under quinine, whiskey, and cleansing of the cavity with carbolized solutions, the temperature became normal on the morn- ing of the nth day. The rubber tube was removed at the end of three weeks, but the sinus did not close for some weeks later. An abscess then formed beneath the cicatrice and opened through it, leaving a sinus an inch long, which has not yet healed. Remarks.—Case I. being a simple cyst, without adhesions, the 14 operation should have been completed through the first three-inch-long incision. The removal of the remaining degenerated ovary in this case would, probably, have been justifiable from a humanitarian standpoint, but the occurrence of pregnancy and the absence of any further de- velopment of the cysts, demonstrate the importance of desisting from such removal in cases where reproduction is desirable. Cases III. and IV. were very unpromising ones for operation. The latter, in the light of the autopsy, was absolutely hopeless, as from the loss of kidney structure, it is questionable whether she would have sur- vived the etherization, had no incision been made. The chances for the former would have been enhanced had we been properly provided with haemostatic forceps and the spray dispensed with. The results of oper- ations without antiseptics, by men of large experience, depending upon the most scrupulous cleanliness, lead us to question the value of antiseptics in the above cases, particularly in the prolonged operations. The peril of the patient is increased by the prolonged chilling of the peritoneum, by the absorption of a deleterious agent, and by the increased organic matter washed into the wound from the impure air of the room. Case II. is another exemplification of the value of colotomy in pro- longing life and increasing comfort in malignant disease of the rectum. In Case V. the operation was postponed too long. In Case VI. the convulsions have been much less frequent, nearly three months interval occurring between the last epileptic periods. She has just undergone a severe attack of inflammatory rheumatism. Case VII. demonstrates the importance of making an exploratory incision before pronouncing against the removal of an intra-abdominal tumor. 1305 North Broad Street.