April, 1916.] SURGERY AT SECUNDERABAD. i35

% JPkoii of lospitat |i[atfi?.

SOME GYNAECOLOGICAL LAPAROTOMIES.

By C. BKODRIBB,

Major,

Secunderabad.

A period of enforced idleness appeared to me to afford a suitable opportunity to pass in review the work done during two surgically busy years. In doing this I found that out of some 800 major operations 300 involved the opening of the

peritoneal cavity, while of this last number no less than 118 were performed for disease of the uterus and its appendages. Tt is this 118 I wish to discuss as the number seems to me a lar^e

o

enough number of operations on one organ to

draw some conclusions from.

When one remembers that Secunderabad is not

a ^Presidency town, and that besides the Civil

Hospital in which these operations were done

there are two other larger hospitals, one general and one zenana, in the neighbourhood, one

appreciates the fact that the women of India have of recent years gained much greater confidence in Western methods in the treatment of surgical abdominal conditions.

Since to gain that confidence is perhaps our

most important duty these numbers are gratify- ing.

In making remarks upon these cases I have

expressed my opinion as founded on my own

experience in the belief that it may be of some

value to those with less experience than myself, while I hope that it will be treated with indul-

gence by those who have more. Of the 118 cases under review?

107 were discharged cured. 8 died. 2 were discharged relieved. 1 was discharged otherwise and probably

died.

The series includes the following :?

A.?Ovariotomies for ovarian* tumours.

Twenty-three cases, of which 22 were cured, and one died.

These cases call for no special remark. The case that died was an old woman of over

70, who was admitted for dyspnoea; her tumour weighed 03 lbs. and was the biggest of the series. It was very adherent to the transverse colon. She did well until her stitches were

removed, when, fearing pneumonia, she was got up. She developed some rales at the base of the lung and died quite suddenly. P. M. showed

nothing wrong as regards the operation but

advanced hepatic cirrhosis. The other tumours varied in weight, the three

largest being 63, 27, and 20 lbs. One of the cases had a tumour about the size of

a four months' pregnancy. There was no pedicle and the base was absolutely immovable on

the pelvic floor. It was therefore marsupialised. The wall was very friable, and when cut bled* so

freely that the bleeding was only stopped by oversewing. There was a collection of pus at

the bottom of the cyst which accounted for the fever the patient had been suffering from. The case is of interest in that this deep sinus very

rapidly closed, and examined by myself and more

recently by a well known surgeon in London, not the slightest sign of anything abnormal could be

made out in the pelvis, in spite of the fact that

one was obliged to leave the thick wall of a large cyst. In two cases there were stitch abscesses in the abdominal wall, all other caser, healed by first intention. "When in these cases one comes across a very thick pedicle and is afraid of the

ligatures, some very powerful clamp such as Kockers or Miles is an extra safeguard against bleeding, as is oversewing the stump. There

can be few things more horrible for a surgeon than the slipping of a ligature on an ovarian

pedicle a few hours after the patient has been returned to bed. The fact that I have known of thi ee such cases (not mine), all of which died, had perhaps made me unduly cautious.

B.?Hystek ECTOMI ES.

Eleven cases, 9 cured, 2 died. These were all supravaginal hysterectomies by

the abdominal route.

They were mostly done for fibroids, which ill

all cases were large, there being none that did

not reach the umbilicus. One of the deaths was in such a case. The patient in this case was very weak and ancemic and was being kept in hospital to try to improve her condition prior to operation. As she insisted on having the

operation or leaving the hospital, the operation was done earlier than desirable, salines and nutrients being given immediately prior to the

operation. She died from shock in 24 hours. Her uterus contained a large sloughing sub- mucous fibroid of the size of a newly born infant's head.

Two of these cases were lor septic infection of the uterus after labour.

These are most difficult cases, not as regards the operation, but as regards making a decision as to whether to operate or not.

I have seen it stated that septic infection

during labour is almost invariably fatal. That is

certainly not a fact, and could not. I think, be

136 THE 1M.DIAN MEDICAL GAZETTE. [April, 191G.

the unbiassed opinion of anyone who has had

charge of a maternity hospital. A large proportion of cases of septic uterine infection get well

without operative measures of any kind. A small

proportion do badly, and those that do badty, nearly always die.

It has been argued by some people that

hysterectomy should be done almost as soon as

symptoms of septic infection show themselves, on the same ground that probably the best results

are attained in appendicitis if the appendix is

removed as soon as a diagnosis is warranted. But the conditions to my mind are in no way

analogous, especially in India. In the first place the removal of a uterus,

especially a septic puerperal uterus, is a much

graver operation than an appendicectomy, while in the second place the resulting disability is much

greater. This last especially applies to India.

One husband when I suggested hysterectomy as the only chance to save his wife's life, replied, " but what is the use of her living if you remove

her uterus ? "

Others again argue that the mortality of

hysterectomy is greater than that of uterine sepsis and therefore hysterectomy should not be done in these cases. This may be true if all cases of

hysterectomy and all cases of sepsis are taken

into account, but if cases are selected and only grave cases of uterine sepsis are submitted to

operation, I believe that lives would be saved. The difficulty is to choose the cases for operation.

Fever always occurs in these cases, generally 011 the third day and generally 48 hours before the

discharge shows any distinctive sign of infec-

tion. Now although one recognises when fever

occurs on the third day of the puerperium there is a tendency to attribute it to any cause rather

than sepsis, the hope being father to the thought, still there can be 110 doubt that in India, the land of fevers and fluxes, there are a considerable number of cases who get fever 011 the third

puerperal day from chronic malaria or other less

well recognised forms of Indian fever." Under these circumstances to submit every

case that gets fever 011 the third or fourth day to intra-uterine disinfection (?) at once would pro- bably do more harm than good. Yet we must

remember that, in sepsis, we are being taught by the war, that, to be effective, antiseptics must be applied within 24 hours of infection.

I must own that 1 am extremely loath to put even a boiled instrument or a gloved finger into a puerperal uterus, approached as it has to be

through ti e vagina, unless 1 am absolutely certain that the uterus is already infected, or that there are retained products of conception.

So one arrives at the conclusion that in India, when fever occurs on the third or fourth day

after labour, without demonstrable changes in the lochial discharge, intra-uterine manipulation is not indicated and hysterectomy is not justified. Now we arrive at the stage generally on the

5tli day, when if infection has taken place there are definite changes in the lochial discharge. The first change is usually that the discharge becomes brownish and has a slightly offensive smell, the condition of the patient being still good. Now for the first time we are sure of uterine

infection, other causes of sepsis further down

having been of course excluded by examina- tion. The difficulty in making a decision now is

that even at this stage many patients get well with the usual methods of drainage and the daily application of intra-uterine antiseptic douches.

It is my impression from two years' experience of an Indian Maternity hospital, though I cannot quote actual numbers, that a larger proportion of these recover with the usual methods than would

be the case if they were all submitted to hyster- ectomy.

But now '"How long to wait?" In three or four more days, that is about the

9th or 10th day after labour, those that are going to get better will show signs of improvement, while those that are going to die will either show no improvement or be worse. Such cases will

invariably die if left alone, and should, it appears to me, be given the chance of a hysterectomy.

it is easy to make the criticism. What chance has a hysterectomy now, with the patient poisoned with sepsis, sometimes no doubt a true septicaemia and not a sapriemia, the broad ligamental veins possibly thrombosed with septic clot, the pulse 130. the patient thirsty with anxious face and

perhaps a few rales appearing at the base of the

lungs. The answer I believe is : A better chance

than if left alone ; many will be lost, but some will recover.

Naturally no surgeon will like operating on such cases. Many will die?no cases could be

worse for his reputation?still 1 think he does

his duty only if he advises the friends to give such patients their only chance.

The final conclusion arrived at then is :?

In fever occurring on the third or fourth day after confinement, in which no other cause of

fever can be demonstrated, and when there are

no lochial changes, neither intra-uterine mani-

pulations nor hysterectomy is advisable. If on

the 4th or 5th day lochial changes become ap-

parent the patient should be placed on the

table, the uterus be cleared out with the gloved hand, and the interior be treated with some

strong antiseptic, such as pure Lysol followed

by spirit, and the uterus be drained, and given a daily intra-uterine douche.

April, 1916.1 PYOSALPINX. HYSTEROPEXY. 13'

If in the next three days there are no signs of improvement or the patient loses ground, a

hysterectomy should be advised. Arguing on

these grounds, I have done two such hysterec- tomies on patients in the condition described above. One lived, the other died. Tn both cases the abdominal wall got infected by the uterus, in neither the peritoneum.

In both cases the examination of the uterus

after removal showed the futility of curetting in such cases, it being impossible even with a sharp curette to remove the slougli from the wall of

the uterus even after it had been laid open.

G.?Pyosalpinx.

Forty cases, of which 38 were discharged cured, and two died. Tt is very rare in India to meet

with a pyosalpinx which is not adherent. In this series T do not remember a single case that was not adherent to surrounding structures, while in all

but a few the adhesions were so dense as to make the removal difficult.

This is probably due to the fact that the Indian woman of the lower classes will not come to

hospital until the pain has been prolonged and severe, while to the accompanying fever she

often pays but little heed.

As one gains experience however, it is surpris- ing what ragged adherent pus tubes can be

separated with patience without harming sur-

rounding structures. I notice that in the first six cases of this

series there were three in which the tube was

not removed but opened and drained, and there

was also one case in which the pelvis was drained because the tube burst during removal. With

increasing experience one found that with

patience nearly all these tubes could be got away, so that in the last 3G cases there was only one in which the tube was not removed. T think

that if it is possible to remove the tube it is

better to do so than drain it. as if it is removed

the abdomen can be sewn up and healing by first intention be obtained ; this saving a prolong- ed convalescence, a potential ventral hernia, and, one suspects, a certain amount of postoperative invalidism in cases in which the tube is left.

Another thing that one learns is that there is

very rarely any occasion to drain these cases, even though they burst during removal and

the peritoneum as high up as the packing off towels becomes bathed in pus.

The pelvis in such cases can be cleansed with swabs and entirely closed without anxiety, the

patient being nursed in the Fowler position and

given continous saline for the first 24 hours. The only exception to this is probabty in cases

secondary to a recent puerperium that are

acute in nature, but as such cases will rarely 'shew..dense adhesions, their removal is easy, so

that they do not burst during removal and thus do not require drainage.

' '

The majority are chronic cases secondary to

gonorrhoea and these if they do burst do not

infect the peritoneum. In the last 3G cases I have only drained three,

one because the tube could not be removed, the other two for reasons given below.

In one of these cases a prolonged and deter-

mined effort was made to get away a very tough old tube. This was at last successful, but it was then seen that "a hole that would take one's thumb had been made in the anterior rectal wall. The sides of this hole were too friable to hold

stitches, so a large piece of the omentum was

excised and the hole plugged with this which was lightly sutured in place with catgut and a drain

placed in the pelvis. The bowels were opened 011 the fourth day and.the tube removed on the

sixth, and the provisional stitches tied. The case

healed by first intention without untoward result.

In another similar case the ureter was cut. To anastomose it or implant it into the bladder was

not practicable. I, therefore, knowing the urine was normal, ligatured the cut end of the ureter

as I had seen successfully done in a case in which the ureteric orifice in the bladder had to., be

removed in a case of carcinoma of the base of

the bladder. However 48 hours later a profuse flow of urine came through the tube that had

been placed against the ligatured ureter. The case was taken to the theatre and the kidney and upper part of the ureter was rapidly removed ('25 mins.). The wounds now rapidly healed and the patient made an uninterrupted recovery.

Of the two cases that died, one beside a

double pyosalpinx had double cystic ovaries and

below all this a large abscess in the pouch of

Douglas. She did well for 36 hours, then got a rapidly increasing pulse without signs of general parietal involvement. Fearing bleeding the abdo- men was opened again, but nothing could be found to account for the symptoms. The other case did well for three days and then

developed the most intense jaundice with uncon- trollable vomiting. This was perhaps a case of

delayed chloroform poisoning. There was no case of sepsis acquired during operation in this series.

D.?I Iysteropexy,

Cases 19, of which 18 were discharged cured, and one died. Under this heading are included both fixations and suspensions, suspensions being used in cases of pure retroversion in the parturient, and fixations in cases of prolapse and in those

past the menaupause. ? In suspensions.a thirty-day catgut is used and

only the peritoneum and subperitoneal tissues are

138 THE IN 1)1 AN MEDICAL GAZETTE. [April, 1916.

sewn to the uterus and in fixations a non-absorb-

able suture is used and the apponeurosis is also

included.

Two of these cases have returned to hospital to have easy labours. All cases, except one, healed

by first intention, have left hospital relieved of

their symptoms, nnd none have returned with any complaint.

The exception to these results was the case

that died. This death was due to peritonitis, and is the only case of acquired peritoneal sepsis in the series of 300 abdominal sections. The fatal

complication was the result of a mistake that

was made in the counting of the towels used

for packing off the intestines. The abdomen was

re-opened and the towel removed, but as usually happens in such cases the patient died.

After this all towels had 18 ins. of tape attached to them. They were stitched in threes for sterilisa-

tion, and all artery forceps are sterilised in batches of six tied together, to make a miscount more difficult.

Several of these cases had prolapse with bulging of vaginal walls, and for such a colporrhaphy and perinneorhapy was done at the same time as the fixation.

In others the operation was done as part of an abdominal section for other conditions, such as

pyosalpinx where a large heavy retroverted uterus was found.

I have had the opportunity of seeing a large number of these operations performed, as well as many of their after results. And both when I was House Surgeon to Dr. A. E. G-iles, in 1902, and again when on study leave in 1912 I acted as his clinical assistant, I formed the opinion that this simple operation properly performed is most

effective and free from any bad after results and

that no more complicated procedure is either

necessary or desirable. In this opinion T am

confirmed by my own cases.

E.?Pelvic Abscess.

Six cases, of which 4 were cured, one died, and one was discharged otherwise.

In all cases of pelvic abscess the abdominal route has been used.

In one case the abscess was discharging into the rectum on admission. This rapidly healed with abdominal drainage. In one or two cases a counter drain Was placed in the vagina. In such cases a T. shaped drain made as described, I think, in Binny's Surgery is very useful as it does not tend to come out until it is taken out.

The case discharged otherwise probably died. She had also to have a rib excised for an empyema and 'was very ill when removed from hospital by her friends;

F.?Extrauterine Gestation.

Of the four cases, one died, the others were cured. The case that died was brought in too

late. She was pulseless on arrival. I saw her in the cart in which she was brought just as I was

leaving hospital. She was taken straight into the theatre so that her tube was removed within half an hour of her arrival. Her abdomen was full of blood and she never rallied.

One case was interesting, in that the sac had burst and placenta had become engrafted on the bowel and omentum forming a gestation sac,

reaching nearly to the umbilicus. The clot was cleared out, and the whole cavity plugged with rolls of gauze to control the bleeding. She did

quite well and left the hospital quite healed up. All other cases healed by first intention.

G.?Cesarean Sections.

Of seven cases, three recovered and one died. The case that died presented no difficulty, the whole operation lasted 28 minutes and there was

no excessive loss of blood. She recovered from the shock and then died quite suddenly, the

cause being probably an embolus. One case got a stitch infection of the abdominal wall ; others healed by first intention. In doing this operation there are certain details on which it seems to me sufficient stress is not laid in text book accounts ; for a knowledge of these I am indebted to

Dr. Grow.

In the first place it is a good thing to explain to your assistant exactly what you are going to do and his part in the operation, also to have a second assistant to take charge of the baby, who understands how to resuscitate it.

The thing that makes this operation simple is

that, with the exception of the placental site, you know beforehand exactly what is in front

of you and in this it differs from nearly all other abdominal sections.

There is no need to make the incision above the umbilicus and its length need not exceed 4 to 5 inches.

In making the incision into the uterus, this is rapidl}T done in one cut; it will be found that if the finger is then run along this incision it

divides the remaining muscular fibres and comes down on the membranes of placenta as the case

may be.

The Assistant now hooks up the abdominal

wall with his finger and the uterine incision is

rapidly enlarged upwards as high as is required. If the placenta is in front the hand rapidly

separates it, seizes it, and pulls it out. This does

not take five seconds. As soon as the child is removed the Assistant

takes his finger from the abdominal wound and placing it in the upper angle of the uterine

wound brings the uterus which has already

April, 1916.J SARCOMA OF THE DURA MATER. 139

contracted out of the abdominal wound, and

places a towel behind it. He also puts one hand behind it. Should now any bleeding take place he only has to give the uterus a little rub between his two hands to keep it contracted and dry.

There is no necessity at any time to try to control bleeding by pressure on the uterus or

vessels.

The thing for the beginner to remember is

that if you go straight on, neither being slow nor hurried, there will never be serious bleeding although there may appear to be when there is

Liquor Arnnii mixed with the blood. I have described these details because this is

an operation that any one in India ma}- be called upon to do at any time at very short notice.

There is one other case of interest.

A woman of 45 was admitted with a history of three days vomiting, five days absolute con- stipation. a distended abdomen, and a feeble, rapid pulse.

She had prolapse of the uterus which was

months pregnant but which was not retroverted. The uterus could not be pushed up in the ordinary way, though no great force was tried as the abdomen was much distended, and it was thought that it was kept down by the intra-abdominal

pressure due to intestinal obstruction from some other cause. The abdomen was opened to find that the pregnant uterus was incarcerated in the

pelvis and no other cause of obstruction could

be found. There was no retroversion. All

attempts of getting the uterus up out. of the

pelvis failed, so the abdomen was sewn up and

the uterus emptied per vaginam. She was

relieved of all her symptoms and got quite well,

but still the uterus remained fixed and prolapsed. She unfortunately refused any further operation. I had not before heard or read of a fixed prolapsed uterus without retroversion as a cause of in-

testinal obstruction. / /

....