of tljeruriter. 
CASES OF 
LAPAROTOMY PRESENTING FEATORES OF 
UNUSUAL INTEREST. 
BY 
CHARLES P. STRONG, M. D., 
Assistant Surgeon, Free Hospital for Women; Physician to Out- 
Patients, Massachusetts General Hospital: Assistant 
in Gynecology, Harvard Medical School. 
Reprinted front the Boston Medical and Surgical Journal 
of April 14, i8q2. 
BOSTON: 
DAMRELL & UPHAM, PUBLISHERS 
No. 283 Washington Street. 
1892. S. J PARKH!LL & CO., PRINTERS 
BOSTON CASES OF LAPAROTOMY PRESENTING FEAT- 
URES OF UNUSUAL INTEREST.1 
BY CHARLES P. STRONG, M.D. 
Assistant Surgeon, Free Hospital for Women, Physician to Out-pa- 
tients, Massachusetts General Hospital, etc. 
Many of the operations performed by me during 
the last eight years, involving opening of the abdomen 
for various reasons, have been reported; but there 
remain others, presenting certain points of inter- 
est, which have not been reported. I wish to empha- 
size and illustrate by some cases the following points : 
The difficulties of diagnosis of abdominal growths. 
Results of removal of the uterine appendages in 
their influence upon menstrual disorders associated 
with reflex symptoms. 
Change, as of senile atrophy, rapidly following the 
removal of diseased ovaries. 
Certain unexplained results; for example, decrease 
in tumors with subsidence of symptoms following 
laparotomies which were but little more than explora- 
tory incisions. 
The difficulties of diagnosis of abdominal growths. 
Mrs. L. S., thirty-eight. Married six years. One 
miscarriage at six months, five years ago, since which 
time menstruation has been more abundant. 
Examination under ether December 10, 1889. The 
patient had previously to this time been under treat- 
ment in the out-patient department for haemorrhages, 
very constant and very profuse, confining her to bed 
for two weeks at a time. During the past three 
months these haemorrhages had been almost without 
iRead before the Obstetrical Society of Boston, February 13,1892. 2 
cessation. She entered with a diagnosis of submucous 
fibroid. A mass the size of a pigeon’s egg, firmly con- 
nected to the uterus, was found on the left. In the 
median line was felt a mass extending up to the um- 
bilicus, the pubic outline of this induration illy defined. 
The fundus of the uterus could not be mapped out. 
On the right side was a firm, movable mass about the 
size of the kidney, at the level of the umbilicus. The 
depth of the uterus was four and one-half inches. 
The curette brought away, through an os that readily 
admitted two fingers, considerable masses of tissue, which 
Dr. W. F. Whitney pronounced hyperplastic uterine 
mucous membrane. The diagnosis of fibroid was ap- 
parently confirmed by this examination, in so far as it 
was possible to make any diagnosis. 
The haemorrhage not being checked by the curetting, 
the patient was operated upon, and the following con- 
dition found: The left tube convoluted and twisted 
upon itself, and glued to the uterus, its cavity distended 
with puriform secretion, formed the mass on the left. 
On the right, the whole broad ligament spread over 
the intestines like the omentum, and was attached at 
the level of the umbilicus. The right tube was very 
much enlarged, holding about four to six ounces of 
puriform material. This kidney-shaped mass, which 
felt like a pediculated fibroid, the omentum and the 
apron-like broad ligament were firmly adherent through- 
out their extent, and the intestines were also matted 
together by both chronic and recent adhesions. The 
case was one of double purulent salpingitis and pelvic 
peritonitis. 
Mrs. H. N. T., thirty-two. Mother of three chil- 
dren. Questionable miscarriage a year and one-half 
ago, at two months. Seen in June. Always been 
well previously until March, when it was supposed 
that she had an attack of malaria, as she had chills 3 
and fever. These were accompanied by very little 
pain on the right side. In bed about half the time. 
In May a swelling was noticed on the right side; co- 
incident with the appearance of this swelling, there 
was pain in the right leg along the course of the 
sciatic nerve, and pain which shot up along the course 
of the right ureter. The pain was so excessive as to 
demand frequent and large doses of morphia. Patient 
much emaciated; general condition very poor; oc- 
casionally a high temperature; most of the time the 
temperature very slightly elevated above normal. Depth 
of uterus between three and three and one-half inches. 
No catamenia since March, that is, three months. 
Had previously been entirely regular. 
Under ether there could be felt an enlarged tube on 
the left side. On the right side there could be felt 
adhesions; and in the median line a mass about the 
size of the fcetal head at term — elastic, not distinctly 
fluctuating, not separated from the uterus, lying to- 
ward the right side, and on the anterior surface of the 
uterus. This tumor had increased somewhat in size 
since it was first discovered, but not rapidly. The 
diagnosis was between a uterine fibroid and salpingitis, 
with the preference rather in favor of the former from 
the relation of the mass to the uterine body. I oper- 
ated the first of August, and found the mass over- 
lying the uterus to be a tubo-ovarian abscess, densely ad- 
herent to the surrounding tissues. The ovary contained 
a cyst the size of a man’s fist, into which the thickened 
tube opened freely; this cyst was filled with some- 
what offensive pus. In consequence of the manipula- 
tions necessary to free it from its adhesions, tears were 
made into the rectum and into the tube, so that the 
pus escaped freely into the cavity of the rectum and 
the abdominal cavity. The rectal tear was stitched 
up by a continuous suture of fine silk. The left tube 4 
was also freed from its adhesions and removed; it was 
enlarged to the size of the little finger and contained 
pus. The abdominal cavity was washed out and the 
patient made a perfect convalescence. 
In this case it was impossible to say that the tumor 
felt before the operation was not fibroid. Its location, 
the symptoms caused by its presence, were all indica- 
tive of fibroid rather than salpingitis. The estimated 
contents of the two tubes was a pint in the right side, 
a half a pint in the left. 
Results of removal of the uterine appendages in their 
influence upon menstrual disorders ; reflex symptoms. 
I operated during December, 1890, upon three cases 
to bring about cessation of the menstrual flow, and in- 
volution of the genito-uterine organs. 
Miss G. C., school-teacher. Bed-ridden for two 
years ; intense dysmenorrhoea; probably from the his- 
tory, membranous dysmenorrhoea. Had been dilated, 
curetted, galvanized, undergone the rest cure, and, in 
fact, had every treatment that could be suggested, 
without relief. Removed both tubes and ovaries, 
which were reported by Dr. Whitney to show increase 
of cicatricial tissue in the ovaries ; tubes slightly catar- 
rhal. The patient has entirely recovered. Superin- 
tended and performed a housekeeper’s work on a large 
farm where there were many boarders last summer, and 
is self-supporting in every way, and entirely free from 
abdominal pain at the present time. 
Miss S. B. Associated with the dysmenorrhoea 
was intolerable backache and pain in the side. She 
had been attendant at the out-patient department for 
nearly four years pretty constantly. Uterus was re- 
troflexed and strongly adherent. By one or two 
etherizations and manipulations the adhesions were 
broken up, and the uterus replaced; but it never 5 
stayed long in its position. The shortening of the 
round ligament kept it in place six months; then it 
went backward, due to the traction of the unruptured 
adhesions, uniting the uterus and rectum. Both 
broad ligaments were shortened and thickened. The 
laparotomy showed that the reason for the falling 
backward of the uterus was not due to the stretching 
of the round ligaments, but to the fact that they had 
each ruptured at the uterine attachment, permitting 
the fundus to go backward. The patient is now very 
well; not strong as she will be, but gaining constantly. 
Her weight has increased from ninety-five to one hun- 
dred and fifteen pounds. 
Miss K., thirty years of age. Always had dysmen- 
orrhoea, which, during the past few years, has steadily 
increased, rendering her unable to perform her duties as 
nurse. Headache nearly constant, pain over each 
ovarian region, nausea. The inter-menstrual periods 
too short to permit complete recovery of strength. 
Previous treatment very thorough, including rest, 
galvanism, drainage of uterus. 
Both Fallopian tubes and ovaries removed. Report, 
December, 1890: “The microscopical examination 
showed evidence of a former catarrhal salpingitis with 
cicatricial contraction in both tubes and ovaries.” Con- 
valescence uneventful. Since the operation the pa- 
tient has performed her duties as nurse, and gained 
flesh and strength, suffers from no reflex phenomena 
and considers herself entirely well. 
These three cases represent the favorable results 
which maybe accomplished by this treatment; but, as 
I have always taken occasion to state, I never would 
advise removal of the uterine appendages to overcome 
symptoms on any account, unless these symptoms 
were acutely threatening, without first having the pa- 
tient pass through preliminary palliative treatment of 
suitable duration and character. 6 
Change, as of senile atrophy, rapidly following the re- 
moval of diseased ovaries. 
Mrs. L. Was referred to me last December for 
operation, having a large rectocele and lacerated and 
sub-involuted uterus. On examination, I found in ad- 
dition to these lesions, an ovarian cyst upon either 
side, which I removed by laparotomy, and which 
proved to be dermoid, and occupied, so far as could be 
determined, the entire structure of the ovary, con- 
sequently these must have formed rapidly, as her child 
was only eighteen months old at this time. She made 
a perfectly uninterrupted recovery, and was to report 
six mouths later for the plastic operation first advised. 
At that time there were such marked changes of atrophy 
occurring, that I deemed it best to wait until further 
time had elapsed to see if this operation could be 
avoided. 
January, 1892, one year from the operation, I found 
atrophy of the uterus and the vagina, and a senile- 
vaginitis with its tendency toward adhesive inflamma- 
tion, as marked as though she had normally passed the 
climacteric ten years. 
Certain unexplained results; for example, decrease 
in tumors with subsidence of symptoms following 
laparotomies which were but little more than explora- 
tory incisions. 
Miss M. S., twenty ; single; school-girl. 
December 9, 1890. Previous history and family 
history both good. Three months ago had pain in 
both ovaries and lumbar region, coincidental with a 
profuse, greenish discharge from the vagina ; frequent 
and painful micturition. The menstrual history is of 
interest. Before this, for a number of years, she had 
been regular, flow lasting four days, and requiring six 7 
to eight towels. The first menstruation after this pain 
began lasted but one day and she used but one towel. 
The second appeared two weeks late, and then was 
brought on by medicine which her medical attendant 
gave her. The third was similarly late, but had ap- 
peared without the use of medicine or treatment. 
The pains at first lasted about an hour, occurring 
only two or three times daily, without abdominal ten- 
derness on pressure. These pains grew steadily 
worse, both in frequency and severity. Ten weeks 
ago these attacks were followed by fever, intense pain 
and abdominal soreness, necessitating confinement to 
bed, with indefinite, but large doses of morphia ; a tem- 
perature varying from 102° to 104°, and very consider- 
able bladder irritability. 
I first saw the patient December 9, 1890. She had 
then been in bed ten weeks, and was more or less 
completely narcotized. Her temperature was 102°, 
abdomen very sore, slightly enlarged. The following 
day, under ether, I found by examination, that there 
was atresia of the vagina about two inches withiu the 
vulva, through which I could not insert an ordinary 
sound. Combined rectal and abdominal palpation 
showed a mass upon either side of the pelvis, dense, 
elastic, non-fluctuating, indistinct in its outlines, but 
extending, apparently, across the whole pelvis. I 
made a diagnosis of salpingitis and peritoneal adhe- 
sions. There was no vaginal discharge of moment, so 
that I restored the vagina, by curetting and dilating, 
to its normal dimensions. The posterior cul-de-sac 
was lacking, the cervix terminating abruptly the upper 
end of the vagina. 
Rest in bed, and the employment of hot douches 
produced little effect upon the temperature, which 
continued fluctuating daily between 100° and 102°, 
with regularity. The patient’s general condition 
seemed quite good, with this exception. 8 
I operated January 2d. Through an incision of two 
inches it was found that the omentum was glued 
everywhere to the surface of the abdominal walls. 
The perineum was much thickened, and everywhere 
there were light, fresh adhesions which were easily 
separated. Deflecting the omentum upward and 
backward, there occurred a discharge of six to eight 
ounces of clear, serous fluid. There was no evidence 
of any cyst haviug been opened, but everywhere, as 
the finger was swept about, it encountered matted 
masses of intestines, which in part were easily separated, 
and the interstices of which were tilled with fluid of 
encysted peritonitis. This line of pelvic peritonitis 
terminated sharply at the brim of the pelvis, above 
which were all the intestines except the rectum and 
some few matted and adherent coils of the smaller in- 
testine. 
The adhesions which bound these parts together 
were, as a rule, well organized and very strong. Many 
of them existed as long bands, notably one or two 
which seemed to stretch entirely from one side to the 
other of the pelvis like a piece of twine. These long 
bands were, as a rule, about as large as a lead pencil. 
The largest cavity that was opened, contained perhaps, 
about six ounces of serum. Multitudes of smaller 
cysts contained amounts varying from a few drops to 
an ounce or two. 
There were two especially distinct masses to which 
the tubes could be traced, and which probably con- 
tained the ovaries, but an attempt to dissect these out 
to remove them, showed that the ureter on either side 
was also implicated in these masses, consequently, I 
terminated the operation by breaking down all the 
adhesions possible, by sponging out and rupturing all 
the cysts, and by replacing, as far as possible, the in- 
testines in their normal position. Convalescence was 9 
uninterrupted. Pain ceased from the time of the 
operation ; temperature fell to normal, and remained 
there. Examination under ether, one month after the 
operation, showed that there was present two distinct 
masses; one on the right, about the size of a pigeon’s 
egg, and one on the left, about the size of a hen’s egg. 
The patient has reported from time to time, is per- 
fectly well, going to school again, and menstruation 
has resumed its normal course. 
Miss M., nineteen. Referred to me by Dr. Marion. 
Gives history of having passed through two severe 
attacks of pelvic inflammation, accompanied by high 
fever. It was supposed at that time that she had 
salpingitis. The last attack had been about two months 
before I saw her. There was a firm, dense, resisting 
mass to be felt, filling the left side of the pelvis, crowd- 
ing the uterus to the right, v.ery tender. The ex- 
ploratory incision showed this to be a fibroid growth 
beneath the front of the broad ligament: its seat of 
attachment to the uterus occupying about two-thirds of 
the lateral surface of that organ; non-pediculated 
intramural. The broad ligament and uterus were so 
matted together, as the result of previous peritoneal 
attacks, that it seemed unwise to attempt the enuclea- 
tion of the fibroid. The patient made a good recovery 
from the exploratory incision, has been able to resume 
her work, has declared that there is a noticeable de- 
crease in the size of the mass, aud that she is entirely 
free from pain, unless after very prolonged exercise, 
when she finds that the left side tires more easily than 
any other part. Exactly what local change, if any, 
has taken place here beyond that of freeing the adhe- 
sions, I am unable to say, but certainly the patient has 
practically received great benefit. • Two Volumes yearly, ‘beginning with the first Nos. in January and July. But 
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