Reprint from TAe Southern Practitioner, January, 1897. 
ABDOMINAL HYSTERECTOMY FOR FIBROMA UTERI. 
BY 
Professor of Obstetrics and Gynecology in the Johns Hopkins 
HOWARD A. KELLY, M.D., 
University, Baltimore. 
CHAS. P. NOBLE, M.D., 
Surgeon-in-Chief, Kensington Hospital for Women, Philadelphia 
HENRY D. FRY, M.D., 
Professor of Obstetrics in the Georgetown University, Washington, I). C, 
AND 
WILLIAM D. HAGGARD, JR., M.D., 
Associate Professor of Gynecology in the University of Tennessee, Nashville 
A Discussion, by invitation, at the Nashville Academy of Medicine, 
November 12,1896. DISCUSSION. 
Dr. Howard A. Kelly, of Baltimore.—Abdominal hys- 
terectomy for fibroma is one of the most important and interest- 
ing topics to every gynecologist. The case at the City Hospital, 
tendered me through the courtesy of Dr. Haggard, Sr., will form 
the text of my remarks. I there made an enucleation in a little 
over seven minutes by a new and simplified technique. 
When I began surgery, in 1883, a fibroid tumor of the 
uterus was a noli me tangere. 
Surgeons opened the abdomen, and, finding a fibroid, at once 
decided that the case was inoperable; when it was mistaken for 
an ovarian growth and removed, the mortality was so frightful 
as to deter others from taking such risks. 
The first important step was taken by Hegar, of Germany, 
when he removed both ovaries and tubes in fibroids, finding, in 
many instances, that the growth shrivelled from the lessened nu- 
trition. This castration was widely practiced; often with dis- 
tinct advantages. At first this operation was adopted with en- 
thusiasm, but it now occupies a very restricted field in gyneco- 
iogy. 
When Schrceder, in Germany, first performed hysterectomies 
for fibroids, he did as Spencer Wells had done in ovariotomy, 
strove for an ideal method, and dropped the stump into the ab- 
domen. The large mortality which followed this plan was due 
we now know to deficiencies in the aseptic technique. 
Another class of operators, with Koeberle, began a plan of 
treatment, by clamping the stump of the exsected fibroid uterus 
externally in the abdominal incision by the serre-noeud, where 
it became mummified in the lower angle and sloughed away, 
leaving a granulating pit in the lower abdomen. 
Schrceder attributed bis mortality to two causes, the shrink- 
age of the stump allowing hemorrhage, and infection from the 
cervical canal extending into the abdominal cavity. In the 
extra-peritoneal clamp method of dealing with the stump, these 
two dangers were avoided, and this plan of operation prevailed 
for awh|l§. Dr. Joseph Price, of Philadelphia, was its most 2 
earnest and successful champion in this country, and succeeded 
in engrafting his views largely in the South and West. 
The next step was taken by Prof. Fritsch, of Bonn, and 
myself, independently, April 1889.* To avoid sepsis the stump 
was sewed together and then stitched or suspended to the perito- 
neum in the lower angle of the abdominal wound; at the same 
time the sutures used in sewing its lips together were left long 
and held by a pair of forceps lying across the wound so that the 
stump could be instantly everted and inspected in case of hem- 
orrhage. The smooth convalescence of patients so treated showed 
that neither hemorrhage nor sepsis from the stump were in re- 
ality such great dangers as the profession at that time believed 
them to be. 
Ths disposal of the dread of hemorrhage and sepsis in this man- 
ner, prepared the way for the next important step in the evolu- 
tion of the subject. Now, under the improved technique, Dr. 
Eastman, Dr. Krug, and Prof. Chrobak began dropping the 
stump, and then covering it completely with the anterior layer 
of peritoneum. 
In 1895 I originated a plan of treating myomatous uteri, 
which I shall now describe. Dr, Pryor, of New York, had 
published prior to my first publication, an account of a similar 
plan of treating intra-ligmentary tumors. 
By my plan of operating, from half an hour to an hour is 
saved the patient in the enucleation stage, the most important 
period of the operation, for with the completion of the ablation 
of the tumors the question as to the possibility of operating is 
answered, and all important complications have been met; the 
steps following the enucleation are more or less routine in char- 
acter. An abdominal incision is made and the ovarian vessels 
tied on one side; then the round ligament is tied on the same 
side and the top of the broad ligament opened and the incision 
carried across, separating vesical peritoneum from uterus; the 
bladder is pushed well down with a sponge; next, having in 
this way exposed it, tie the uterine artery near the point where it 
leaves the uterus in the pelvic cellular tissue. Now cut boldly 
across the cervix with the spud while pulling the uterus upward 
and outward. This develops a cellular interspace in the opposite 
broad ligament as soon as the cervix is completely divided, in 
which there is no bleeding and the uterine artery can be distinctly 
seen and clamped. Now pulling the uterus still further up and 
rolling it over, a clamp is applied to the round ligament and then 
to the ovarian vessels, when the fibroid uterus is cut away entirely. 
*Vid. American Journal of Obstetrics, April, 1889, page 375, volume 
22; also Centralblatt f. Gynecology, Nov. 1, 1989, 3 
There is no haste throughout, but an orderly progression of steps, 
and yet Dr. Haggard tells me this uterus with its sixteen tumors 
was removed in four and a half minutes. I have done it at 
home in three minutes. The rest of the operation consists in 
applying ligatures in place of the clamps to the ovarian vessels, 
to the round ligament, and to the uterine artery of both sides. 
The cervical stump “is now closed, and the bladder, peritoneum 
and anterior layer of the broad ligament are sewn to the pos- 
terior layer, when the female plevis is converted into the male 
form. 
Fig. 1. 
Showing line of incision through peritoneum from left to right, through left broad 
ligament, round ligament, utero-vesical peritoneum, right round ligament, and ending with 
right broad ligament near the pelvic brim.—Johns Hopkins Hospital Bulletin. 
There is an occasional interruption in convalenscence. If 
there is hemorrhage into the cellular tissue, causing hematoma 
or pus, divulse the cervix and let it out. If there is extensive 
hemorrhage into the cellular tissue, a small drain should be 
placed in the cervix. 
Fibroid uteri should be treated in this way only when they 
produce symptoms serious enough to justify hysterectomy. If 
there is but moderate discomfort at the menstrual period, don’t 
remove the organs. But, if there is constant hemorrhage, pain, 4 
Severe pressure symptoms, a choked pelvis causing pressure on 
the ureters, or changing the functional activity of bowel and 
bladder, operate at once. 
When asked why he left the ovaries, Dr. Kelly replied that 
it was experimental, with the hope of avoiding the unpleasant 
sequelse from the sudden induction of the menopause. In all 
recent cases he had been leaving one or both ovaries, if not dis- 
placed or diseased, and had some very satisfactory results in 
changing entirely the character of the convalescence and the 
sequelse. It is, however, too early to speak with assurance. 
The next step in the line of progress will be the removal of 
large interstitial myomata or multiple myomata without sacrific- 
ing the uterus or any part of it. Dr. Kelly cited cases in which 
he had removed seven, eight and nine tumors in this way, and 
demonstrated with the specimen before him the removal of six- 
teen myomata without opening the uterine cavity, which he said 
could just as easily be removed from the uterus while in situ as 
he had done on the specimen. 
Dr. Charles P. Noble, of Philadelphia:—My own expe- 
rience with hysterectomy began after the pioneer work of 
Keith and Bantock in England, and of Schroeder in Ger- 
many, had opened this field to the abdominal surgeon. My 
first three hysterectomies for fibroid tumors were performed 
after the method of Bantock, using the serre-noeud. These three 
patients recovered, but the various disadvantages about the 
method were such as to cause me to abandon it. The chief 
objections to the method are: 1. It entails sloughing of the 
stump above the constricting wire. From this point of necrosis, 
infection of the patient may take place. 2. It entails a long 
convalescence, as until the stump separates and the resulting 
wound granulates, the patient must remain in bed—from six to 
ten weeks being the usual time. 3. A large percentage of patients 
operated upon with the “ nceud” suffer from subsequent ventral 
hernia. The three patients operated upon by myself by this 
method, each had a hernia, which required a subsequent opera- 
tion. 4. It is inapplicable to certain tumors, either because of a 
short stump or short vagina, which makes it difficult or impossi- 
ble to bring the stump up into the wound; or because of the 
nature of the tumor, more especially cervical fibroids, which 
render this technique difficult or impossible. 
As the best results of those using the “ nceud” have been 
improved upon by other methods which do not have the disad- 
vantages detailed, in my opinion this method of hysterectomy 
has become obsolete, and the only further function of the serve- 
nceud is to serve as an object of historical interest in medical 
museums. 
Dr. Kelly has referred to Schroeder’s work and outlined the 5 
bearing which it has had upon the subsequent development of 
hysterectomy, Schroeder was the pioneer in dropping the stump 
in hysterectomy, and deserves full credit for the impetus which 
he gave the operation. There are two reasons why his mortality 
was high; 1. He operated in pre-antiseptic days, and many of 
Fig, 2. 
Left ovarian vessels tied, left round ligament tied, vesical peritoneum divided and pushed down 
and left uterine vessels ligated. Cervix amputated and uterus pulled up and out, exposing right 
uterine artery, which is clamped an inch above the cervical stump. The two following steps are 
clamping the right round ligament and right ovarian vessels, when the mass is removed.—Johns Hop- 
kins Hospital Bulletin. 
the patients were infected as a consequence of faulty technique. 
2. He failed to recognize that hemorrhage could be controlled 
simply and safely by the ligation of the two ovarian and the two 6 
uterine arteries. In his work he depended upon a multiplictiy 
of ligatures placed in the cervix itself, rather than upon ligation 
of the trunks of the uterine arteries. No doubt in many cases 
these arteries were ligated, but this was by accident, and not by 
design; as a consequence, a certain number of his patients died 
from hemorrhage. 
Dr. Kelly has treated the development of hysterectomy in his 
own work. It seems to me that the two essentials in the devel- 
opment of the modern operation of hysterectomy are the perfec- 
tion of the aseptic technique, and the recognition of the ease and 
certainty with which hemorrhage can be controlled by ligating 
the trunks of the ovarian and uterine arteries. All our present 
good results rest upon this basis. 
When I began dropping the stump in hysterectomy, for a 
time I placed no ligatures whatever in the cervical tissue, and as 
a rule, this is unnecessary to secure haemostasis, if the uterine 
arteries are well ligated low down on the cervix. In none of the 
cases thus treated was there secondary hemorrhage. More recently 
to ensure against possible infection from the vagina, I have 
stitched up the stump with a few catgut sutures before suturing 
the flap of bladder peritoneum over it. 
Dr, Kelly has described the excellent method of hysterectomy 
which he follows. There is no doubt that by this method the 
tumor can be quickly removed, and that in the hands of an expert, 
such as Dr. Kelly, it gives beautiful results. In certain cases of 
fibroids, notably in those intra ligamentous in development, and 
others complicated by dense adhesions of one uterine appendage, 
this method offers great advantages over any other; but for rou- 
tine work I prefer to ligate and cut down the broad ligament 
upon one side, then upon the other side, and to amputate the 
cervical stump after the blood vessels have been secured. An 
inexperienced operator, in following the method of Dr. Kelly, 
might easily lose his wits from the occurrence of hemorrhage after 
cutting through the stump of the cervix, and in, more or less, 
wildly applying haemostatic forceps to arrest bleeding, enclose 
the ureter in the grasp of the forceps. This accident has hap- 
pened, and resulted in the wounding of the ureter upon one side. 
In the hands of an expert no operation is more simple and 
satisfactory than the modern hysterectomy for fibroid. There are 
some points, however, which might be dwelt upon with advantage. 
The ligature silk should be as fine as possible. The first ligature 
should embrace the ovarian artery upon one side. The second 
ligature, of very fine silk, should embrace the round ligament 
and the small artery and vein which accompany it. A forceps 
applied alongside the uterus guards against reflux hemorrhage, 
and permits the upper portion of the broad ligament down to, 
and including the round ligament, to be cut through. The peri- 7 
toneum in front of the uterus and tumor should then be incised 
from one round ligament to the other, and the bladder stripped 
off from the cervix. It will now be found that very moderate 
pressure upon the open broad ligament with a sponge will push 
the loose connective tissue away from the uterus down to, or 
below the level of the internal os, and will expose the uterine 
artery and vein which run up along the side of the uterus. This 
should now be securely ligated and cut. The same process should 
be repeated upon the opposite side. A very important point is to 
be certain that the ovarian vessels are well secured by their liga- 
tures, and also that the uterine arteries are picked up with for- 
ceps, and a separate ligature of fine silk be placed upon them, in 
addition to the original mass ligature. By observing these points, 
troublesome hemorrhage will be avoided at the time of operation, 
and secondary hemorrhage be reduced to a minimum. So far, 
in my experience, I have never seen a secondary hemorrhage 
after hysterectomy. 
Another method of hysterectomy is to remove the entire 
uterus. This method has several disadvantages over the one 
Hysterectomy Spud. Used instead of a knife for amputating the uterus at the cervix. The 
curved blade enables the operator to work easily in a deep pelvis cupping out the stump.—Johns Hop- 
kins Hospital Bulletin. 
described. It takes longer to do it, because the cervix must be 
cut out, and the bleeding resulting from cutting through the 
vagina requires a certain amount of time for its arrest. Another 
objection, and the more important one, is that the cavity of the 
vagina is opened and brought in communication with that of the 
peritoneum. This greatly increases the risk of septic peritonitis. 
Careful studies of the endometrium in uteri removed by hyster- 
ectomy have shown that the endometrium at the level of the 
internal os is almost, if not constantly, sterile; while it is well 
known that the vagina constantly swarms with germs. Careful 
preparation of the vagina before operation, of course, reduces the 
risk of infection, but does not remove it. As bearing upon the 
relative advantages of the two methods, it is worth recalling that 
most of the American gynecologists who have been the advocates 
of pan-hysterectomy have abandoned abdominal for vaginal hys- 
terectomy whenever the size of the tumor permits. This indi- 
cates that their experience was for some reason unsatisfactory, as 8 
the same is not true of those who have made the supra-vaginal 
amputation. 
The French school of surgeons have applied the method of 
vaginal hysterectomy to the removal of small fibroids, including 
in this classification all those which do not extend above the 
umbilicus. The results which they have obtained have been 
good, but the method seems crude to one who is a master of the 
niceties of abdominal hysterectomy. During the past summer I 
had the pleasure of witnessing a hysterectomy by Segond, of 
Paris, and am sure that none of its advocates can perform the 
operation more skilfully than it was done in this case. The two 
methods may be contrasted as follows: 
When an abdominal hysterectomy is completed in an aseptic 
case, the parts are left in condition for immediate healing. 
Twelve or twenty-four hours suffice to cover over any peritoneal 
wounds, and the patient proceeds at once with her convalescence. 
With the modern method of closing the abdominal wound, by 
buried and intra-cuticular sutures, the entire operative process is 
complete at the conclusion of the operation, and the patient is 
not further disturbed even for the removal of sutures. In the 
vaginal operation, hemorrhage is guarded against by the use of 
heavy clamps, which ensures the sloughing of all tissues included 
in the bite of the forceps. The forceps themselves must remain 
on for twenty-four hours or longer, giving considerable annoy- 
ance to the patient by their presence. As the peritoneal cavity 
is left in open communication with the vagina at the end of the 
operation, it is necessary to pack the wound with gauze to invite 
a localized peritonitis, so as to guard the peritoneal cavity from 
infection from the inevitable sloughing of the stumps. This 
process involves, at the best, a foul-smelling septic discharge, 
which, if it does not infect the particular patient, is a source of 
possible contamination of others operated upon later, as the hands 
of the operator may become infected in the subsequent dressing 
of the patient. At the best, the convalescence of the patient is 
postponed until localized peritonitis has shut off the field of 
operation and until the sloughing process is complete. The con- 
trast in the two classes of cases is so great that I find it difficult to 
understand how the vaginal operation can appeal to one whose 
aim is the highest development of surgery. 
There remains the question of the relative frequency with 
which the operation for fibroids should be done. My work in the 
past has been in very close agreement with the principles laid 
down by Dr. Kelly, but the more I see of fibroid tumors the more 
lam inclined to broaden the field of operative treatment. This 
tendency is due to my experience in dealing with degenerated 
fibroids, and because I have been obliged to operate a large 
number of times in women of advanced age because of complica- 9 
tions due to the degeneration of fibroids, or on account of sec- 
ondary diseases arising from their presence. The old theory that 
the menopause is curative of fibroids of the uterus is very far 
from correct. It has no influence whatever upon soft fibroids, 
and but little influence upon many of the hard variety. Its 
influence is most marked in multinodular fibroids of small,size. 
As I have been obliged to operate numerous times in women of 
advanced age because of necrotic, calcareous, or myxomatous 
degeneration, and in a smaller number of cases in younger women 
on account of sarcomatous degeneration, I am led to question the 
advisability of permitting fibroids to run their natural course, 
even though producing minor symptoms when they come under 
observation. The question may well be asked, what does it profit 
a woman to retain a fibroid tumor in her economy? Not to go 
into this question too much at length, I will say that while I 
would not maintain the position that every fibroid should be 
removed so soon as a diagnosis is made, I believe the next ad- 
vance in dealing with this subject will be the more general advo- 
cacy of operation early in the course of the disease, with the 
definite object of conserving the sexual organs. Operations done 
early, when the patient is in good condition, will permit of the 
more frequent adoption of myomectomy, which will cure the 
patient, and at the same time leave the sexual organs intact. 
This, I repeat, will be the next advance in the field of gynecology. 
Dk. Henry D. Fry, of Washington City:—The subject has 
been so ably and exhaustively treated by the speakers who have 
preceded me that very little remains to be said concerning the 
technique of the operation for the removal of fibroma uteri. 
Personally, I have had no experience with the method of free- 
ing and cutting away one side first, and then amputating the 
uterus, and, finally, cutting away the remaining broad liga- 
ment. I entered the field about the time when the extra-perito- 
neal treatment of the stump was being abandoned. Excluding 
the comparatively small number of cases in which complete hys- 
terectomy was indicated, I have followed the plan of cutting both 
broad ligaments and amputating the uterus at the internal os. 
To introduce another phase of the subject I would ask, what 
is to be done with the mass of women who have fibroids and ap- 
ply for relief? Are they all to be subjected to the radical opera- 
tion? Few of them may be able to obtain the skill of the 
masters of the profession, and must they submit to the increased 
risks of an operation at less skilled hands? It is true that cer- 
tain dangers are run by the presence of fibroids after the meno- 
pause; they may undergo malignant degeneration; they may be- 
come cystic; they may continue to grow; but will they kill as 
many as the knife if promiscuously used? 
It is a far more common experience that they become quies- 
cent or diminish after the climacteric. 10 
I do not wish it understood that I deprecate hysterectomy for 
fibroids. I only desire to emphasize the point, that we must select 
cases for operation, and not look upon every woman having a 
tumor as a necessary candidate for our surgical enthusiasm. 
Now, the principal symptoms which bring these cases to us are 
hemorrhage and pressure effects. A certain proportion can be 
relieved by paliative treatment, while in a large number of those 
suffering from metrorrhagia complete relief is obtained by re- 
moval of the tubes and ovaries in selected cases. In my experi- 
ence, this method has given perfect satisfaction. It is certainly 
less dangerous than the radical operation, except in skilled hands. 
I wish to say a word in regard to the method mentioned to- 
night of leaving one ovary, or both, when performing hysterec- 
tomy; and that word is a protest. 
Formerly it was advised to take out the ovaries and leave the 
tumor, now it is proposed to talce out the tumor and leave the 
ovaries. The only argument advanced in support is, to prevent 
the artificial production of the menopause and consequent re- 
flex phenomena. Now, these phenomena are the same in kind 
and quantity as accompany the natural change of life, and if the 
woman survives the operation she will go through with them at 
that time. She does not escape, therefore, why not do a com- 
plete operation and let her have it all over? Removal of the 
uterus removes the physiological importance of the ovaries. 
There are objections, on the other hand, to the practice of leav- 
ing one or both. Degenerative changes may take place, ovarian 
tumors may develop. The woman may have an abdominal 
pregnancy. Some women will have a baby even after the uterus 
is removed, as in the case reported by Koeberle, where the sper- 
raatozoids passed through a fistulous tract left after vaginal hys- 
terectomy. 
For these reasons, that further complications may ensue by 
leaving an ovary, I do not endorse the suggestions unless some 
good ground could be advanced to support it. 
Dr. William D. Haggard, Jr., of Nashville:—l have been 
very much impressed with the method of hysterectomy devised 
and employed by Dr. Kelly, The case which he has referred 
to, and in which I had the pleasure of assisting him, I regard as 
one of the most masterful pieces of surgery it has ever been my 
privilege to witness. All my later training has been in total 
hysterectomy, and the cases I have done have all been by that 
method. I admire the beauty and perfection of the technique 
described to us to-night, but I must object to the strictures 
placed upon total hysterectomy by Dr. Noble, In seventy- 
three abdominal hysterectomies occurring in the Woman’s Hos- 
pital last year, I am positive quite seventy of them were total. Ithas been alleged that it takes longer. “ Cutting the cervix 
out” is not a separate step, but only requires stripping the peri- 
toneum down a trifle further than when amputating at the inter- 
nal os. Ligating the uterine arteries is required in both, after 
which amputation is made at the vaginal vault rather than above 
it. The cut end of the vagina rarely requires ligature. When 
the tumor is removed, hemostasis is complete, and there are no 
vessels, stump, or peritoneal flaps requiring ligature or suture, 
and the operation is concluded. What is gained in the rapidity 
of enucleation by the other method is equalized by the stages of 
ligaturing and suturing. Hence a contrast of time from the be- 
ginning to the completion of both will not show a gain where 
supra-vaginal amputation is made. 
The danger of opening into the vagina seems more theoretical 
than real. Careful preparation of the vagina, although it con- 
stantly swarms with germs, appears to be effectual in curettage, 
where the uterine mucosa is denuded and lymph channels left 
open; suppuration is rare in extensive plastic operations on the 
vagina itself; infection is almost unknown in explorative vagi- 
nal section, where the vagina and peritoneum are in continuous 
and practically unobstructed communication; and the advocates 
of vaginal ovariotomy and hysterectomy per vaginam base their 
very low mortality on the immunity from sepsis by this method. 
Moreover, germs in the vagina were evidently not the determin- 
ing factor that induced certain American gynecologists to aban- 
don total abdominal hysterectomy for total hystectomy per 
vaginam, as now they deliberately choose the vagina as their 
avenue of approach. I regard Krug as the chief exponent of 
pan-hystectomy in this country, and I believe his allegiance to 
the abdominal route is still unshaken. 
Personally, I am not prepared to champion the vaginal 
method in fibroma with the same assurance that I have favored 
that route in septic pelvic conditions. With this element elimi- 
nated, I believe pelvic surgery is easiest done through the abdo- 
men, in Trendelenburg’s posture. This is typically true of fibroid 
disease, and if total hysterectomy is contemplated, the technique 
of Krug is very satisfactory. 
The use of strong silk-loops, fixed in opposite sides of the 
abdominal incision, and at its lower angle, are superior to instru- 
mental retractors. Silk is likewise employed as a temporary 
hemostatic to the uterine end of the tube, while the other portion 
of the double ligature is pulled out near to the infundibulo-pel- 
vic ligament and made to secure the ovarian artery. The oppo-' 
site side is treated similarly. Section of both broad ligaments 
is made with scissors close to the uterus until the vicinity of the 
uterine artery is reached. The lower extremities of these incis- 
ions are connected by an incision through the peritoneum cover- 12 
ing the anterior face of the uterus. The peritoneum is pushed 
down until the vagina is reached and opened with scissors. A 
finger introduced through the opening impinges on the posterior 
vaginal fornix which is opened behind on the finger directly. 
The uterus is then moored only by the lower segments of the 
broad ligaments containing the uterine arteries. A double trans- 
fixion ligature is applied to this portion. The upper half tied 
and the superior end of the other ligature passed under the unse- 
vered ligament containing the uterine artery and tied. It is then 
cut near the cervix and the corresponding side secured in like- 
manner, and when severed completes both enunciation and hem- 
ostasis with safety and celerity, The vagina is then filled iodo- 
form gauze, and when the patient is lowered into the horizontal 
position the peritoneum falls into neat approximation over the 
cut end of the vagina. The results are entirely satisfactory. 
Perfected technique in any method is the sesame to success. 
INTESTINAL OBSTRUCTION FOLLOWING ABDOMINAL HYSTEREC- 
TOMY; operation; recovery.* 
The patient operated upon by Prof. Kellyf did well until 
the ninth day. Highest temperature 100° F. On the evening 
of the ninth day she had an attack of colic immediately after 
a semi-solid supper, inaugurated by vomiting. The pulse rose 
from 72 to 100. 
She was given mercurials and aromatic spirits of ammonia by 
the resident physician, followed by salines in the morning. Con- 
stipation being unrelieved and pain continuing, she was given 
more salines and a high enema, which moved the lower bowel 
only. 
Pulse being high, an explanation of her symptoms was sought 
in the abdominal incision and the cervical stump. The former 
had healed throughout by early and clean union; the latter was 
perfectly free from induration and tenderness. 
On the eleventh day pain continued unabated, with vomit- 
ing; pulse remained high, and obstipation was complete in spite 
of all attempts to overcome it. By night her pulse was 140, 
distention marked, and the diagnosis of intestinal obstruction 
was apparent. I favored immediate operation, but ray consult- 
ants insisted on waiting until morning, meanwhile giving a large 
dose of castor-oil and a high saline enema. Both were inef- 
fectual. 
The next morning at 8 o’clock—the twelfth day after opera- 
* Reported to the Nashville Academy of Medicine at its meeting on 
Thursday, November 26, 1896. 
f Yid. Page 1, first paragraph of remarks of Dr. Howard A. 
Kelly. 13 
tion and sixty-two hours after onset of symptoms—I opened the 
abdomen. Pulse 156, weak and thready. The pain, distention 
and vomiting were all increased, but the latter was not stercoral. 
Coils of distended gut could be seen in peristalsis outlined 
through the abdominal wall. There was a point of tenderness 
in the left iliac region. 
Section was made through the left linea semilunaris. Slight 
adhesions of the intestines to the line of previous incision were 
found, which were easily broken and the gut drawn out. A dis- 
tinct adhesion flexure was found and separated. As this entire 
segment was collapsed, it was obviously below the real point of 
constriction. Continuing the search, loops of the red, angry, 
enormously distended gut were drawn into the incision, the 
proximal end being returned as it was drawn up from below. A 
slight transverse tear in the peritoneal coat from traction warned 
me that the point of anchorage was reached. Slipping my hand 
alongside, I found a dense adhesion, which was carefully freed 
and brought into view. There was a denuded area on the gut 
about four inches long and one inch wide. It was too extensive 
for peritoneal plastic operation, and the patient’s condition 
would have hardly warranted a resection. It was dusted with 
iodoform in lieu of aristol. 
At the site of constriction, though not participating in it, 
was found a long tubular band about the size of a small lead 
pencil and three inches long, both ends of which were attached 
It was snipped with scissors. It was non-inflammatory. It may 
have been Meckel’s diverticulum. 
The rent in the peritoneal coat of the gut was closed by a 
continuous Lembert suture of silk, the gut returned, and the 
abdomen hurridly cloeed with interrupted sutures of silkworm 
gut. A high enema of brandy and normal salt solution (one 
pint) was given on the table to prevent shock. Purgative saline 
enemas were given in four and eight hours. Bowels moved after 
twelve hours, fourteen times in first twenty-four hours. Gas 
was not passed until the next day. Convalescence was undis- 
turbed, except for a slight sinus in the hastily closed incision. 
In a recent communication, Dr. Kelly thought the obstruc- 
tion due to a mild septic peritonitis with its accompanying adhe- 
sions. He further said: “ There was a great deal of fingering 
done to release the uterus and tubes from a mass of velamentous 
adhesions, but I said very little about the matter as I was strip- 
ping them up, as I wanted to concentrate the attention of the 
class on the steps of the enucleation.” 
In the twenty-eight cases of intestinal obstruction in adults 
collected in Sajous’ Annual for 1895 for the preceding year, the 
average time of operation was days. There were six deaths, 
or a mortality of 21.4 per cent.