[Reprinted from the American Journal of Obstetrics and Diseasess 
of Women and Children, VoI. XXVI.. No. 4, 1892.] 
COMPLICATIONS 
DURING AND AFTER THE OPERATION IN A FEW RECENT 
CASES OF 
ABDOMINAL AND PELVIC SURGERY.1 
BY 
WM. H. WATHEN,_ M.D., 
Professor of Abdominal Surgery and Gynecology in the Kentucky School of Medicine; 
Ex-President of the Section on Obstetrics and Gynecology of the American Medical 
Association; Fellow of the American Gynecological Society, of the American ‘F 
Association of Obstetricians and Gynecologists, and of the SouthernfMgi- 
cal and Gynecological Society; Consulting Gynecologist to 
Louisville City Hospital, etc. 
Louisville, Ky. 
While an experienced gynecologist can usually diagnosti- 
cate pathological conditions in the pelvis or abdomen that 
indicate the necessity for an operation, all successful lapa- 
ratomists are constantly reminded that it is seldom if ever 
possible, until the abdomen has been opened, to know just 
what complications are to be treated in order to complete the 
operation and save the life of the patient. It is then not al- 
ways possible to do so. It is exceptional that we find just what 
we had expected. We anticipate complications that may 
jeopardize the life of the patient, but the operation proves to 
be a simple affair ; again, we open the abdomen expecting to 
complete the operation without difficulty, but conditions are 
met with that make the procedure a dangerous one that se- 
verely taxes the ingenuity of the most experienced laparato- 
mist. Hence the necessity of never attempting such work 
until we are thoroughly prepared, theoretically and practi- 
cally, to treat successfully the various complications that we 
may encounter. If the operator knows how to treat cor- 
rectly every abnormal condition in the abdomen or pelvis 
that surgery can remove, his failure to make an absolutely 
1 Read before the American Gynecological Society, September 21st, 1S92'. 2 
WATIIEN I COMPLICATIONS IN ABDOMINAL 
correct diagnosis is of no serious consequence, if lie does hon- 
est work. But there is too much laparatomy done, and too 
many men are doing it—men who know too little about such 
work and have but few facilities for operating.” The desire 
to be known as an abdominal surgeon and to report a series 
of sections seems to sometimes control the intelligence or the 
honor of the surgeon, and women with comparatively healthy 
ovaries and tubes are mutilated beyond redemption, and 
many of them are made invalids or die, because the operator 
is ignorant of the correct principles and details that every 
successful laparatomist must know. 
The patients who recover from the immediate effect of the 
operation are at once published in advocacy of successful lapa- 
ratomy, but we hear nothing of the incomplete operations or 
the sequelae that are developed later, nor have we always an 
opportunity to know anything about the numerous cases that 
die during or soon after the operation. The operator is too 
enthusiastic and energetic in his efforts to convince other wo- 
men—probably a little nervous, but otherwise comparatively 
healthy, with no pelvic exudates or adhesions—that their ova- 
ries and tubes are useless organs, and dangerous ones too, for, 
if not hurriedly removed, a pus tube mag rupture and cause 
death within a few hours. We are all familiar with such 
cases, and there is probably not a city in the country, where 
several men are doing abdominal surgery, that has not one or 
more operators of which the above is a correct prototype. 
It is no uncommon occurrence for a woman to consult me, 
saying that a physician had advised the removal of her ova- 
ries and tubes because of extensive adhesions, exudates, or 
pus tubes, where an examination showed an entire absence 
of every pathological condition that her pseudo-laparatomist 
had so vividly pictured to her. I have written several pa- 
pers in condemnation of reckless laparatomy, and have re- 
ported many cases in proof of the correctness of the position 
I have assumed, no one of which has been controverted. 
I could report many more, but the evil is so manifest to all 
honest and successful abdominal surgeons that it would be a 
waste of time. 
I am pleased to see that many men, with the courage of 
their convictions, have tried to teach the medical profession AND PELVIC SURGERY. 
3 
the wisdom of conservative gynecology and the evil of reck- 
less and selfish mutilation of women. Among those who 
deserve especial commendation may be mentioned Polk, Em- 
met, Munde, and Coe, of this country, and Wells, Keith, 
Doleris, and Apostoli, of Europe. Just here I wish to em- 
phasize that I am an earnest believer in laparatomy in prop- 
erly selected cases, and E know of no department of surgery 
that has achieved such results or deserves more universal ap- 
proval and praise. 
I am doing a good deal of abdominal surgery, but I ope- 
rate for the removal of disease where no other treatment 
could so certainly cure the patient. And I have probably 
had my share of success, for I have had no death, and prac- 
tically no untoward symptom for about one year, though I 
have operated on women where the conditions indicated an 
unfavorable prognosis. 
“ I do not believe that reported recoveries in simple cases of 
laparatomy always indicate superior or unusual skill in the 
operator ; and such reports are of little value to the medical 
profession, and may indirectly result in the death of many 
women by influencing ignorant men, with no facilities for 
such work, to attempt it because of its apparent simplicity.” 
I will therefore report a few selected cases from my recent 
work where there was some unusual condition, or troublesome 
complication, to contend with during or after the opeiaticn. 
The study of such cases teaches us to do better work by 
learning how to treat complications and prevent accidents. 
Case I.—Miss M., age 2d, was referred to me by a well- 
known surgeon of Missouri, who had diagnosticated pelvic 
abscess on the left side. She was always apparently in ex- 
cellent health until July, 1891, and had never suspected any 
tumor or disease in the pelvis or abdomen. At this time she 
began to suffer severely in the left inguinal region, had ac- 
celerated pulse and several degrees of increased temperature. 
A tumor could be distinctly outlined on the left side of the 
pelvis, extending into the abdomen. The pain and fever 
continued for several wTeeks, but finally subsided, and she 
thought she was well and did not examine to learn if the 
tumor had disappeared. She did not suffer any more and 
was apparently well until July, 1892, when she had a recur- 4 
WATHEN : COMPLICATIONS IN ABDOMINAL 
rence of the pain and fever, and again noticed the tumor. 
She suffered intensely and was confined to bed for four 
weeks, and could not come to Louisville for six weeks. She 
has lost twenty pounds of flesh, is still feeble, hut has no pain 
or fever and is regaining strength. The uterus is nearly im- 
movable, with a tumor in the left broad ligament which seems 
to be fixed and connected with the uterus; it extends as high 
as the umbilicus and over a little to the right of the median 
line. A correct diagnosis is impossible, but the necessity for 
a laparatomy is positive. 
The abdomen was opened August 20tli, 1892. The omen- 
tum was thick, showed signs of extensive chronic peritonitis, 
and was firmly adherent to all the anterior part of the tumor 
and to the upper surface of the pelvic structures. When 
the adhesions were separated the omentum was so torn and 
bruised that I removed it above the level of the umbilicus. 
The tumor was an embedded broad-ligament cyst, which had 
not only unfolded the broad-ligament layers of peritoneum, 
but had stripped this membrane from the posterior pelvic 
wall to a point above the sigmoid flexure of the colon, sepa- 
rating the layers of the meso-colon so that the mesenteric 
surface of the bowel was attached to the thin cyst wall. The 
bowel could be distinctly seen and traced on the anterior sur- 
face of the tumor over to the right side, where it dipped into 
the pelvis and came around behind the womb to the rectum. 
The uterus was enlarged to three times its normal size, and 
the peritoneal covering was separated over a large surface 
from the left side of the body and fundus, thereby exposing 
its muscular layer. There was no shock, and the patient has 
made an uninterrupted recovery from the operation. 
Case II.—Mrs. W., Kentucky, age 40; married and has 
several children, the youngest 3 years old. She is anemic 
and sallow; has complained of some pain and pressure in the 
region of the uterus for six months, but for three months the 
pain on the right side has been so severe that she has been 
most of the time confined to bed and has lost considerable 
flesh. She has not missed her menstrual period until three 
months ago; since then menstruation has been irregular. 
The uterus is fixed and there are hard exudates on each side. 
The tumor is twice the size of a, large orange and reaches on AND PELVIC SURGERY. 
5 
the left side several inches above the pelvic brim. An ex- 
ploratory laparatomy was performed on March 27th, 1892. 
A band of omentum, nearly as wide and thick as the hand, was 
attached to the right broad ligament in the region of the 
severe pain. It was ligated in two places and divided. The 
enlarged uterus and the exudates in the pelvis were united 
in one solid malignant mass. ISlo part of the peritoneal sur- 
face of' the intestines w7as adherent to the tumor, but the 
enlarged uterus, with its neoplastic surroundings, had insinu- 
ated itself under the sigmoid flexure of the colon, which was 
attached by its mesenteric surface across the anterior part of 
the uterus, after the same fashion as in Case I. 
She had no pain after the operation, took no morphia, had 
a normal pulse and temperature, and went home, a distance 
of fifty miles, in two weeks. She has had but little pain since 
and has gained in flesh, but, of course, the growth will con- 
tinue to increase and will eventually cause death. 
Case III.— Mrs. B., Kentucky, age 24; married eight 
months; was well until three years ago, when she was thrown 
from a buggy and probably received some internal injury. 
She recovered from the immediate effects of the fall, but has 
not felt entirely well since. 
Three weeks after marriage she had what was diagnosti- 
cated appendicitis and was very sick for several weeks. She 
had severe pain in the right inguinal region, her bowels could 
not be moved for ten days, and she vomited a great deal of 
matter with a very offensive odor. She finally recovered from 
the immediate effects of the attack, hut has had several re- 
lapses, and at one time the attending and consulting physi- 
cians did not think she could get well. During these attacks 
her pulse became accelerated, though she had but little, if 
any, fever. The uterus is in normal position, with some ad- 
hesions on the right side. No tumor or enlargement can be 
found in the pelvis or abdomen, and firm pressure causes no 
pain. At the earnest request of her husband, a prominent 
physician, who believed she could not live through another 
attack, I performed a laparatomy at St. Joseph’s Infirmary, 
June 12tli, 1892. An incision three inches long was made in 
the right linea semilunaris. The omentum was extensively 
adherent down to the right ovary and tube, and nearly all the 6 
WATHEN : COMPLICATIONS IN ABDOMINAL 
small intestines and some of the cecum and ascending colon 
were held together by tough peritoneal adhesions, as were 
also the right ovary and tube. The pelvic, intestinal, and 
omental adhesions were carefully separated without injury 
to any organ, but the omentum was so torn that it was neces- 
sary to ligate and remove a piece fifteen inches long and sev- 
eral inches wide and to suture an opening above the ligatures. 
There was but little hemorrhage and no shock, and the pa- 
tient was taken from the operating room in thirty minutes. 
A glass drainage tube was used for two days. Before the 
operation her pulse was 100, but it was not over 90 after it, 
and on the second day it was 80 ; it was afterward from 72 to 
80. At no time wras there an untoward symptom, and she 
suffered less after forty-eight hours than at any time since the 
first attack. She returned home, a distance of sixty miles, 
on the sixteenth day. She has gained flesh and says she is 
entirely well. The appendix was adherent, but not enlarged 
or otherwise diseased, and the peritonitis was probably caused 
by the fall from the buggy. 
Case IV.—Miss Ii., Louisville, age 17; single; began to 
suffer severe pain in the region of the appendix vermiformis 
ten days before I saw her in consultation, and had a rapid 
pulse, and high fever that did not intermit. After the fourth 
day a tumor could be felt low down in the right inguinal 
region immediately in contact, and apparently connected, with 
the ileum. The tumor gradually increased in size, and when 
I saw her it had extended to the median line and above the 
umbilicus ; her temperature was 105° and her pulse 110. Her 
bowels moved daily and she had but little tympanites. On 
August 3d an opening two inches long was made in the right 
linea semilunaris and nearly a pint of pus discharged, in which 
was found a fecal concretion, of oval shape, one-tliird of an 
inch in diameter and two-thirds of an inch long. It was hard 
and had a nucleus resembling calcareous matter. The appen- 
dix could not be found, and the peritoneal cavity and intes- 
tines were shut off from the pus cavity, the outer boundary 
of which was formed by the abdominal and pelvic walls. It 
was appendicular in origin, but extraperitoneal. On the sec- 
ond day the pulse and temperature were about normal and 
remained so, The cavity was packed with iodoform gauze, 7 
AND PELVrC SURGERY. 
but in a few days two gum drainage tubes wrere substituted 
and bichloride injections used. 
Her recovery was uninterrupted, and the cavity and abdo- 
minal wound have closed. 
Case Y.—-Mrs. II., Indiana, age 44; married and has three 
children; has been well, with the exception of indigestion, 
until a year ago. She then began to have leucorrhea, the dis- 
charge often being, in appearance like the menstrual flow. 
Six months afterward her husband, an excellent surgeon, made 
an examination and diagnosticated incipient epithelioma, 
limited mainly to the posterior lip of the cervix uteri. Her 
condition gradually grew worse, and she was referred to me 
the 1st of August, 1892. Her general appearance indicates 
perfect health. Her uterus is retroverted, but not adherent. 
The epithelioma has extended to part of the anterior lip, and 
on the posterior vaginal wall down to nearly the bottom of 
the pouch of Douglas. There is no appearance of systemic 
infection, or that the disease has involved the uterine adnexa 
or pelvic glands. The uterus was removed August 15th by 
vaginal hysterectomy, the broad ligament being clamped with 
my hysterectomy forceps, which were removed in forty-eight 
hours. There was no untoward symptom for two weeks, and 
the patient wras sitting up and walking about the room and 
hall of the Infirmary. She had dismissed her nurse, and on 
the morning of the fifteenth day another nurse, in charge 
of convalescing patients, gave her a vaginal douche of two 
quarts of hot 1 : 2,000 bichloride solution. But little of the 
water returned, and she immediately suffered intense pain 
in the pelvis, which in severity was intermittent like labor 
pains, and at each exacerbation some of the water, which had 
been forced into the peritoneal cavity, came awTay. She ceased 
passing urine through the urethra, and on the morning of the 
sixteenth day the discharge was nearly all urine, most of 
which came away during the severe pains. A little urine 
passed through a retained catheter, the quantity gradually 
increasing, and after ten days none passed from the vagina, 
showdng that the opening had closed. It was necessary to 
give morphine hypodermatically every four hours for several 
days, and occasionally for a week. She had no fever or accele- 
ration of pulse and no symptom of peritonitis. 8 
WATHEN! COMPLICATIONS IN ABDOMIN AX AND PELVIC SURGERY. 
I will offer no explanation tosliowliow tlie injection caused 
an opening in the bladder and peritoneal cavity, and report 
this case mainly to justify an opinion expressed by me three 
years ago, that the douche after vaginal hysterectomy is no 
prevention against septic peritonitis, but may convey patho- 
genic germs and irritants to the peritoneum by forcing the 
chemical germicide with necrosed tissue into the pelvic and 
abdominal cavities. 
Case VI.—Mrs. H., Louisville, age 34 ; married, but has 
never been pregnant; has for several years suffered such in- 
tense and constant pain deep in the pelvis and in the rectum 
that she has been unable to attend to her domestic affairs. 
She has been treated by several excellent physicians, none of 
whom diagnosticated her trouble, or gave relief. There is no 
disease in the rectum or the uterus, but a tumor of more than 
fibrous hardness, the size of a turkey egg and movable, can 
be felt deep in the pouch of Douglas and pressing upon the 
rectum. A laparatomy was performed August 1st, 1892, and 
the tumor removed from the folds of the left broad ligament 
with no connection with the ovary or tube. Recovery was 
uninterrupted, and she says she is perfectly relieved. By ex- 
amining the specimen you will see that it is fibroid with ex- 
tensive calcareous degeneration. While a fibroid tumor with 
calcareous degeneration in the folds of the broad ligament, 
having no connection with the uterus, ovaries, or tubes, is not 
unique, it is so rarely observed that but few laparatomists 
have probably seen such a case.