THREE 
PERITONEAL SECTIONS 
PERFORMED UPON THE SAME PATIENT WITHIN NINE MONTHS 
VAGINAL SECTION, VENTRAL SECTION AND 
INGUINAL SECTION. 
By Henry T. Byfqrd, M.D. 
PROFESSOR Ob' DISEASES Ob' WOMEN, POST-GRADUATE MEDICAL SCHOOL; 
GYNECOLOGIST TO ST. LUKE'S HOSPITAL; SURGEON TO 
THE WOMAN'S HOSPITAL OF CHICAGO. 
Reprinted from the North American Practitioner, of 
January, 1890. THREE PERITONEAL SECTIONS 
PERFORMED UPON THE SAME PATIENT WITHIN NINE MONTHS : VAGINAL SEC- 
TION, VENTRAL SECTION AND INGUINAL SECTION. 
By HENRY T. BYFORD, M.D., 
PROFESSOR OF DISEASES OF WOMEN, POST-GRADUATE MEDICAL SCHOOL; GYNECOLOGIST TO ST. LUKE'S 
HOSPITAL; SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO. 
J HAVE thought this case interesting because of the number of peri- 
* toiieal sections performed upon the same person, because it included 
the first removal of an ovary from within the pelvic cavity by way 
of the inguinal canal,* and from its illustration of the characteristic 
results of too much conservatism. 
The patient, Sophie N , a servant 28 years old, was admitted 
to St. Luke's Hospital May 14, 1888, and received local treatment for 
an enlarged right ovary and retroversion of uterus, with a temperature 
constantly above 99' F., even when she was kept in bed for two weeks. 
Uterus could not be kept in position by a pessary. On account of the 
continued pain and desire of the patient to become able to again work 
for her living, I consented to remove the enlarged ovary. This I did by 
*A11 other inguinal oophorectomies have been, as far as I know, for ovaries within or at the 
entrance of the inguinal canal. 2 
BYFORD, THREE PERITONEAL SECTIONS. 
vaginal section, Aug. 15, 1888. The left ovary was drawn down in 
sight and, appearing healthy, was not taken out. After closing the 
vaginal incision I introduced a stem into the flabby uterus, and tamponed 
it in position with iodoform-gauze. The patient made a good recovery, 
but the uterus again became retro verted when the patient got up from 
her bed. The temperature became normal, but the backache, and par- 
ticularly the pain in the left side, was still so severe upon any attempt 
at active exercise that, after several months' treatment at the dispensary, 
the patient returned to have the other ovary removed. Her general 
health was becoming more impaired, and her mental condition one of 
anxiety and despondency. 
I opened the abdomen over the symphysis Jan. 9, 1889, before the 
regular clinical class of St. Luke's Hospital,* examined the left ovary 
again by sight and touch, and, finding it healthy, dropped it back into 
the abdominal cavity. I pulled up the old stump, from which the liga- 
tures (braided silk, No. 10) had become absorbed, and stitched it to the 
peritoneum and fascia, to the right of the supra pubic region, by one fine 
silk suture. I then introduced a thread through the left broad ligament 
near the uterus, so as to include the round ligament, and sutured this 
part to the peritoneum on the left side, using only one stitch. Patient 
recovered without a bad symptom, except that the temperature went to 
100Q F. three weeks later, at her first subsequent menstrual period. 
When, at the end of four weeks, she was allowed to get up, she still 
complained of her back. As the cervix as well as the fundus was for- 
ward I introduced one of my barrier pessaries to hold the cervix back, 
and turned her over to the outdoor department for local treatment. 
In about three months she returned with her left side worse than 
ever. She had tried to work, but was unable to do so, and now de- 
manded that all of her pelvic organs be taken out. Local treatment 
had failed to help her. 
By examination I found the uterus still hung up behind the pubes, 
and the left ovary very tender and drawn forward so as to lie behind the. 
inguinal canal. 
Accordingly, on the 13th of May, 1889, in the presence of the 
post-graduate class, I cut down upon the left external inguinal ring, 
opened the canal a short distance, cut through its posterior wall into the 
peritoneal cavity, and came directly upon the ovary. I was able with 
forceps to draw forth the ovary through an opening in the peritoneum 
that would not freely admit two lingers. The broad ligament was very 
firmly attached to the peritoneum anteriorly, just as it had been sewed, 
♦North American Practitioner, February, 1889. BYFOR1), THREE PERITONEAL SECTIONS. 
3 
but the ovary was now enlarged and adherent to the posterior surface 
•of the broad ligament. The tube was adherent to the abdominal wall 
and to the omentum. I ligated the tube and ovarian ligament and their 
vessels with one thread, and the infundibulo-pelvic ligament and ovarian 
artery with another. I then put a temporary clamp upon the pedicle, 
cut off the ovary and tube, and sewed up the edges of the unligated 
middle portion of the broad ligament with fine silk. The pedicle was 
thus flat and over an inch wide, and traction of the infundibulo-pelvic 
portion of the pedicle upon the uterus avoided. The patient recovered 
promptly, with only one bad symptom, viz.: suppuration of the drainage 
hole, lasting five months (although the discharge was slight after the 
first month) before finally closing. I attributed this to the abundant 
and loose character of the fatty connective tissue in front of and under 
the paravesical pouch, and would counsel any one who may enter the 
peritoneal cavity by this route, to work a little upwards as he goes 
through the posterior wall of the inguinal canal-for fear of getting under 
instead of into the pouch. 
By way of criticism I may say that it would have been better to 
have removed both ovaries at the first operation, viz.: the vaginal sec- 
tion. The displacement could then probably have been cured, as it has 
been in other cases of mine, by being tamponed in position until the ex- 
udates and adhesions about both stumps and the recto-uterine pouch 
had formed. But I believed, and still believe, that the left ovary would 
not have become diseased through the first operation. Hence my con- 
servatism seems not entirely unjustifiable, particularly as she was 
rather an attractive looking girl and might have had a chance to marry 
and bear children. The cause of the disease of the remaining ovary 
was the stitching of the sound side to the abdominal walls, an observa- 
tion which has led me to suspect that the broad ligament structures 
should not be sutured unless the ovary be at the same time removed. 
It were better, I think, either to remove the ovaries or else pass the 
thread through the uterine wall. In case only one ovary were removed 
it would usually be sufficient for a case of retroversion to suture the side 
<of the stump only. Either Alexander's operation or posterior fixation by 
;suturing the sacro-uterine ligament is preferable to stitching the sound 
;side. As to the un justifiability of opening the abdominal cavity so of- 
ten in one patient, we have come to a point in which we can say that 
it is about as safe to open the abdominal cavity as to open deep into 
•cellular tissue. The danger lies not so much in opening the cavity as 
in the diseased condition we find and interfere with. Exploration, 
hysterorrhaphy and the removal of ovaries without adhesions or devel- 4 
BYFORD, THREE PERITONEAL SECTIONS. 
opment into tumors, give very slight mortalities in the hands of the ex- 
pert, and will soon be, in fact are now, performed in cases in which life 
is not at stake. 
As to this particular case, operations upon the peritoneum did not 
seem to affect the patient any more seriously than minor operations do 
the majority of patients. She is completely cured of her symptoms,, 
and is content to retain the rest of her organs.