REMARKS ON ABDOMINAL SURGERY. Cyst of Broad. Ligament. Laparotomy, Recovery. BY F. J. LUTZ, A.M , M.D. ST. LOUIS, MO. Keprint from Transactions Missouri State Medical Society. 1880. REMARKS ON Abdominal Surgery. CYST OF BROAD LIGAMENT. LAPAROTOMY, RECOVERY. - BY BY F. J. LUTZ, A.M., M.D Reprinted from the Transactions of the Missouri State Medical Society, 1880. ST. LOUIS : Davis & Freegard, Printers, 417 North Third St. 1880. ABDOMINAL SURGERY. CYST OF BROAD LIGAMENT-LAPAROTOMY, RECOVERY. It is difficult, I dare say impossible, to utilize medical associa- tions for purposes of scientific investigation, but by a proper ex- change of experience and views they can be made efficient agents in the dissemination of scientific results ; and it is with this object in view that I penned the following remarks upon a subject so full of interest and so very important, which is as yet barely emerging from that first epoch in the history of every great advance in sur- gery. The deplorable fatality which formerly attended wounds of the peritonium was a sufficient reason for the older surgeons to dread this class of injuries more than all others, and we are therefore not surprised to hear from John Bell the terse observation: " Hence it comes to pass that in one short sentence we announce the general principles of such wounds, and in one short and general prognostic we declare them to be fatal." Nor is it difficult to picture to our- selves the despair of Abernethy, to whom is attributed the quaint remark that Nature would have nothing to do with these cases, but stood by and shook her head and left the patient to his hopeless fate. How very different is the opinion held by surgeons of our day ! We are told, and the assertion is strengthened by an array of suc- cessful results which seems to defy contradiction, that wounds of the peritoneum are not at all dangerous ; that the peritoneum may 4 Lutz : Remarks on be subjected to insults of all kinds with impunity ; that it may be pierced, cut, torn, bruised and burned without danger-provided only a watchful eye be kept upon infection. (Schroeder.) In our day feats are accomplished in abdominal surgery of which the older surgeons never dreamed in their most fanciful reveries : tumors weighing fifty and sixty pounds are removed from the cavity of the perito- neum and the patients recover without any great rise of tempera- ture or an alarming increase in the frequency of the pulse ; and 1 need only remind you of the many lives which have been saved by enterotomy, which, under the old regime, were consigned to a pre- mature grave, and to the great alleviation of suffering by the timely performance of gastrotomy. Hence the idea at once suggests itself that the older surgeons were certainly very much mistaken when they considered injuries of the abdomen so exceedingly dangerous, whereas they have proved themselves comparatively harmless. The audacity of this view we shall presently show and at the very outset, we will say, that in spite of our increased knowledge of the causes which effect their great mortality and therefore our increased success in com- bating them-for an enemy whose strength and position is known is easily conquered-abdominal injuries are and always will be dan- gerous lesions. What then are the dangers attending these injuries and how may we avoid or at least combat them? The first great danger which arises on opening the abdominal cavity consists in the exposure of the peritoneum to a lower tem- perature. The peritoneum as you know is a very large serous sac, the surfaces of which are continually moist and glide smoothly over each other. A sudden cooling of this immense surface may re- sult in reflex paralytic conditions of the heart and in death. In the next place, the power of absorption of the peritoneum is so great, that any exudation which may have undergone putre- factive changes, and which will be most rapidly absorbed, will pro- duce rapid and serious septicaemia. Add to this the peristaltic motion of the bowels, by which everything which enters the peritoneal cavity is carried over the en- tire surface, and the descent of the diaphram and the small intestines Abdominal Surgery. 5 occurring during respiration, and which are augmented by the pres- sure of the abdominal parietes-and you have additional important factors to increase the power of absorption of the peritoneum. Again, the numerous convolutions of the intestines and their relation to each other and to the other abdominal viscera, result in numerous lacunae in which secretions may lodge and be unable to escape, thereby offering the most favorable opportunity for their decomposition and subsequent absorption. The fact that intestinal gases impart their peculiar odor to ad- jacent collections of pus and secretions is so well known, that I need only remind you of the sickening smell of abscesses in the neighborhood of the bowels, the cavity of which does not commu- nicate with the intestines, to bring this danger of septicaemia home to your minds. And in cases of severe injury to the intestines in which the process of exosmpsis has been paralyzed, so to speak, not only the gases, but also the fluid contents of the bowels find their way through the intestinal walls. These then are the dangers-the knowledge of their nature suggests their remedies, and it is to this knowledge that modern surgery owes its triumphs in abdominal surgery. To meet the first danger we perform our operations in an at- mosphere of about 80° ; we wrap our patients warmly, and have everything that is to come in contact with them, before and after the operation, of a proper temperature. The shock to the peritoneum, and through it to the system at large, is thereby greatly diminished. The efficacy of the noxious ingredients of the atmos- phere which are said to cause the putrefactive changes in wounds we attempt to destroy by saturating the atmosphere of the room with antiseptics, whereas the operation itself should be performed under what are termed antiseptic precautions. The power of ab- sorption, which the peritoneum possesses to so great a degree, can, of course, not be destroyed, but we can remove, with scrupulous care, everything which could possibly be the source of irritation, or which could possibly be absorbed, and therefore too much time cannot be spent upon the toilet of the peritoneum. On the other hand the peristaltic action of .the peritoneal or- gans should be diminished by large doses of opium before the per- 6 Lutz : Remarks on formance of an operation, and afterwards it is our sheet-anchor. The flrm, large bandage which is used after operations about the abdomen assists in no small measure in diminishing abdominal and dia- phragmatic respiration, whereas the insertion of drainage tubes in proper localities prevents the lodging of secretions in the numerous lacunae for a sufficient length of time to undergo putrefactive changes. Even the intestinal gases can be counteracted to a certain extent by a proper dietetic- preparation of our patient for the operation, and by the administration of large and frequent doses of potass, chloras. I have thus briefly, and, as I am aware, most imperfectly, sketched the dangers of abdominal wounds and their antidotes, not because I do not deem them of great importance, but because I wished only to suggest the discussion of this important subject; and, in conclusion, I will report, with your permission, a case of laparotomy for the removal of a cyst of the left broad ligament. Cystic tumors of the broad ligament so closely resemble uni- locular ovarian cysts as to be diagnosticable only by a chemical and microscopical examination of their contents, obtained by aspiration, and they rarely attain so large a size as this one. They form be- tween the layers of peritoneum which envelop the broad ligaments, and are supposed to arise from an increased secretion from the walls of the numerous tubes which compose the parovarium. Tillie H., the young lady from whom the tumor was removed, consulted me for the first time on the 12th of January, 1880. She is seventeen years old, single, but remarkably well developed for her age, and presents the appearance of a woman in the ninth month of pregnancy. At the age of thirteen she began to men- struate and has always had a regular, although somewhat copious menstrual flow. She has always enjoyed good health except dur- ing the last year of her attendance at school, when she suffered from chlorosis. About two years ago she noticed a hardening and gradual swelling of her abdomen which has since continued to en- large but annoys her only by its size. She is not perceptibly ema- ciated nor is her general health implicated. Axillary temperature 99°, no glandular enlargements, no varicose veins and no oede- ma of the lower extremities, nor have any perceptible changes been wrought in the mammae or the areolae. Mensuration from the Abdominal Surgery. 7 umbilicus to the right and left ant. sup. spinous processes of the ilia respectively, shows one inch and a half in favor of the left side. On palpation a movable, regular but somewhat dense tumor is discovered over which the abdominal walls roll freely ; the ab- dominal parietes are not cedematous nor are the abdominal veins en- larged. Fluctuation of the tumor is very distinct and superficial. Percussion elicits a dull sound, upwards to the epigastric region on the right side to about middle of lumbar region and inguinal, below to the symphisis and over the whole left side. The uterus is of normal depth and freely movable. Occasionally she suffers from a frequent desire to micturate, but this annoys her only for a few hours. A chemical and microscopic examination of the urine fur- nishes only negative results. Her tongue is clean, appetite good and bowels regular. She sleeps well. Her respiration is frequent but not embarrassed ; the respiratory murmur and heart sounds are normal ; pulse 120 per minute ; aspiration was not permitted ; Uni- locular cyst-probably of leftovary was diagnosticated. As the patient was comfortable and her general health not in- volved she was advised to wait. From time to time she was seen, but no marked change occurred until the latter part of February, when she experienced some difficulty in ascending stairs, and her health began to fail as evinced by a loss of appetite and emaciation. At her urgent request, and I may here say in parenthesis, that a more heroic and confiding patient cannot be imagined, she was pre- pared for the operation which T performed on the 9th of March, assisted by Drs. Gregory, Wesseler, Bernays, Atwood, Hickman, DeCail hoi, and Fuhrmann. Listerism with all its numerous details was carefully observed. Dr. Atwood kindly took charge of the anaesthetic. At first ether was administered, but it was found that the time required to produce anaesthesia was too much prolonged, and chloroform was substituted. The chloroform narcosis was, however, attended with that much dreaded symptom-vomiting, and during the operation it became necessary a number of times to cease all further proceedings until the vomiting was controlled, which was always successfully done by pushing the chloroform. After the patient had been placed on the table a pint of clear straw colored urine was drawn off and an incision was made in the linea 8 Lutz : Remarks on alba, under the spray, about four inches in length. Before the per- itoneum was reached two veins were ligatured and one small artery was tortioned. When all hemorrhage had ceased the peritoneal cavity was opened and the large cyst, which had all the appearan- ces of the bladder, at once completely closed the abdominal incis- ion. Adhesions were sought for with a sound and as none were discovered the cyst was transfixed by Dr. Borck's ingenious cyst elevator which was entrusted to Dr. Hickman, whilst Dr. Bernays gently yet firmly pressed the abdominal parietes against the tumor. The trocar was then introduced between the prongs of the eleva- tor and as the contents of the cyst, a clear straw colored, albumin- ous liquid to the amount of thirty pints escaped, the cyst was gradually drawn from the abdominal cavity by Dr. Hickman. When the long broad pedicle came outside of the parietes, it was found that the cyst grew from the broad ligament. The pedicle was secured by a clamp, two carbolized silk ligatures were made to transfix it under the clamp and then the cyst was removed with the knife above the clamp. During the whole procedure neither the hand nor an instrument, except the sound, nor a spoiige were in the abdominal cavity, nor, were the intestines or ovaries seen. The pedicle, which was very long was sewed into the middle of the ab- dominal wound. The wound, after being united with deep and superficial silk sutures was dressed antiseptically. Slight vomiting occurred during the afternoon, but the patient slept well during the first night, and next morning I found her with a temperature of 99°, pulse 108, and not complaining of pain. Drew off half a pint of urine. I consider it unnecessary to detail to you the various ranges of the temperature and pulse, suffice it to say that the highest tem- perature 100$°, occurred on the evening of the third day after the operation. On this day there was a slight show of the catamenia. On the fifth day an injection of lukewarm water was followed by a copious evacuation. The dressings were removed for the first time on the fifth day, under the spray, and the wound above and below the insertion of the pedicle was found united by first intention. The superficial and two deep sutures were removed. Four days afterward the wound was again dressed and all the sutures were Abdomincd Surgery. 9 removed. A small abscess had formed in the left abdominal wall, it contained abbut a drachm of laudable pus. One of the ligatures of the pedicles was by mishap cut off near the knot and will no doubt become encysted. The wound is entirely closed. The patient is entirely well. Six weeks after the operation she men- struated. P. S.-Contrary to my expectations, tlie ligature which remained in the abdo- men did not become encysted, but the wound opened and suppurated for a few days, after which the patient extracted the projecting ligature witli her fingers. The wound is again healed. The patient is growing perceptibly stronger. July 15, 1880.