My Operative Experience In “Pus Cases.’7 Read in the Section of Obstetrics and Diseases of Women, at the Forty* third Annual meeting of the American Medical Association, held at" Detroit, June, 1892. BY «/ I. S. STONE, M.D., SURGEON TO COLUMBIA HOSPITAL, WASHINGTON, D. C. Reprinted from the “Journal of the American Medical Association July 9, 1892. CHICAGO: PUBLISHED AT THE OFFICE OF THE ASSOCIATION. 1892. MY OPERATIVE EXPERIENCE IN “PUS CASES.” BY I. S. STONE, M.D., SURGEON TO COLUMBIA HOSPITAL, WASHINGTON, D. C. The following brief recital of a personal experience includes only cases selected from those occurring in my service at Columbia Hospital during the past year. In that time twenty-five cases have been re- ferred to me for operation in which pus in varying amounts was found in the pelvis or abdomen. It will be therefore understood that this is not an ac- count of my “year’s work in gynecology,” for I shall not mention other surgery for the present. Of these twenty-five cases three have died. But if I add to these the remainder of my pelvic cases I would have nearly fifty without added mortality. I shall limit myself to the consideration of these pus cases alone and shall not mention oophorectomy, ovariotomy or any other surgery. The organic law of the Columbia Hospital demands that all cases requiring a laparot- omy shall be submitted to a consultation of the vis- iting staff, composed of four surgeons, two of whom are obstetricians and two are gynecologists. It may therefore be taken for granted that only severe cases 4 are treated surgically and unnecessary operations are not performed. In all of my cases a cause was clearly found for the pathological condition. In about two thirds of the cases, sepsis following abortion or delivery at term, proved the cause. The remainder were due to gonorrhoea. In all of my post puerperal cases the acute stage had passed, and it is impossible to say just how many were due to infection by gonorrhoea, or to that from other sources. One of my cases of post puerperal infection followed rupture of the uterus after labor or during after treatment. Five cases were the victims of puerperal septicaemia con- tinuing for four, five, and in one case eight months, following delivery at term. These women looked like victims of phthisis, or malignant disease. Six cases had pelvic abscesses of all sizes to a quart of pus fol- lowing upon gonorrhoea for from one to twelve or more months. One of the most interesting cases was the result of specific infection of a bicornate uterus. Clinical History.—The'account given by the patient of her suffering, is generally sufficient to indicate suppuration within the pelvis. They tell of pain, peritonitis, rigors and sweats, and slow getting up af- ter delivery. These symptoms demand that a care- ful pelvic examination be made which will always clear up the diagnosis. Strange enough it is, yet true, that quite a large proportion of these patients claim that they were treated for neuralgia, malaria, etc., and that no pelvic examination had been made by the attending physician. 5 Of all symptoms pain is the most indefinite. It is always present in varying amount, but is never a pos- itive indication of the extent of disease. Many neu- rotic patients have far greater tenderness in the ovarian region, and complain more of pain than is elicited in the examination of a pelvic abscess. Neither is the temperature an indication of the ex- tent of disease. We may see a temperature of 100° in morning and 102° in afternoon in a patient with pelvic abscess containing a pint of pus, and with ex- tensive bowel adhesions. Per contra, a small pyo- salpinx may cause a rise to 104° p.m. Some of my cases of pyosalpinx with adhesion had no rise of temperature. But we must never underestimate the important information given {jy the thermometer, for continued high temperature in these cases means trouble ahead for both patient and operator. The pulse will furnish much information. A pulse of 140 or above with a continued high temperature means an ill patient. It means a diffi- cult and dangerous surgical operation where all the resources of the well appointed hospital, and the best surgical skill may be required to meet the many pos- sibilities of such surgery as is necessary to save life. The information gained by the pelvic examination of these patients is final and most satisfactory as a rule. My plan is first to examine without, and after- ward with, an an£esthetic. Rarely it is important to learn more than to be sure that pus is, or is not, present—or rather, is an operation demanded or not? I fail to see any benefit to be derived from nice dis- tinctions about diagnosis. Such refinements are ab- 6 surd to the practical surgeon. The preparation of the patient includes tonics, laxatives and good food, cleanliness, cheerful surroundings. I prefer always to give quinine at once after admission, to watch its effect upon the temperature. Not infrequently a rise of temperature during convalescence after operation is promptly reduced by the administration of qui- nine, showing a malarial complication. So much has been said about expedition, and everything else a surgeon must have in mind during an operation, that I shall not refer to this part of my method or opinions. Each one has an individuality peculiar to himself and cannot be a surgeon without this sine qua non. Drainage is just as important as it ever was in many cases, but the glass tube reaches a lim- ited area and I am finding great comfort and satis- faction in the use of the gauze drain. It has done good service in every case, and it is scarcely neces- sary to say that it is used in very severe cases. Haemorrhage has never been difficult to control. Every important vessel can be brought into view by means of the Trendelenburg posture, which I find very useful. Flushing the abdominal cavity is also just as beneficial as Joseph Price claims it to be. I find myself occasionally doing without it, since I use the Trendelenburg posture for difficult cases. I quite agree with those who claim that it rarely if ever does harm. It is also occasionally necessary to use aristol as suggested by Dr. Robert T. Morris of New York. After separating formidable adhesions it is very desirable to prevent the reforming of these dangerous impediments to the peristaltic action of 7 the intestines. Aristol may be freely sifted over these surfaces without fear of harmful result. In the after- treatment my method is to sustain all the cases of laparotomy for pelvic abscess by giving food and stimulants by rectum at once, and by the mouth just as soon as they can be borne. Patients must not be allowed to remain the usual twenty-four hours without nourishment. In the treatment of nausea, if persistent, I resort to lavage in any case. It is the most potent agent for good I have ever seen tried. Of course the usual sip of hot water, and even creasote may be tried, but when these fail it seems unkind to try every drug with a reputation as a composer of sick stomachs. A clean stomach is often in my experience the fore- runner of an appetite. With soap and water for the hands, clean dressings, instruments, sutures, etc., all suppuration can generally be avoided in the abdom- inal wound. Chemical antiseptics, I do not find essential. The only use these agents have in my laparotomies,is where thehandsof assistantor operator need to be quickly cleansed during an operation, and where the usual time and care cannot be given them. Clean boiled water is used without any chemical whatever. Suppuration may generally be avoided in all cases where the abdominal wound is not infected by pus or serum removed. The greatest care bestowed upon hands, and instruments, will not prevent infec- tion of the wound, if fetid pus from a suppurating ermoid cyst, or even that from certain pelvic ab- scesses, comes in contact with it. It has never been my misfortune to have a ventral hernia follow 8 a laparotomy. All operations done for pelvic ab- scess or pyosalpinx have been completed. In one or two cases very small ovaries were not found even af- ter careful search. They were, if present, too small to have any pus in them. No exploratory operation for pus has been undertaken by me. The following case is reported to show how fatal an attack of gonorrhoea may prove. Case 15.—Mrs. had contracted gonorrhoea from her husband and came to my office for treatment. She was at once sent to the hospital where in a short time the vagini- tis was cured. But in two weeks she had cystitis, then nephritis. An ovarian abscess on left side holding a pint of pus rapidly formed. Operation was refused at first and was only done as a last resort. Patient did well for three days, then came suppression of urine, uraemia and death on fifth day. The autopsy showed a perfect condition of the pedi- cles and peritoneum. No peritonitis. Death due to nephri- tis in less than five weeks after infection from gonorrhoea. The next case, also fatal, is cited to show how easily some patients succumb to shock. Also how sepsis following abortion may continue indefinitely and not recover. Case 26.—Miss , age 19, had an induced abortion one year previous to her admission to the hospital. History of pain in pelvis, gonorrhoea, inflammation of bowels, purulent vaginal discharge, large mass in right and smaller one in left ovarian region ; uterus fixed and low down in the pel- vis. Operation difficult, and bowel much injured in one place but returned hoping for good results. Patient did bad- ly from the start. Bowels refused to respond to salines. Distension. Again resorted to irrigation. Pulse did not recover its tone. Death on third day. I am unable to say why this patient could not stand the shock of operation. She had the very best care during the after treatment. The next case (No. 18), I report to show that a perfectly satisfactory operation may fail of its object, partly owing to lack of care in after treatment. Mrs. had puerperal septictemia followed in by a large pelvic abscess extending to umbilicus at time of sec- 9 tion. High temperature to 104. Pulse 130. Everything fixed in pelvis and lower abdomen. During the two weeks she remained in the hospital prior to operation she grew steadily worse and a bad result was not altogether surpris- ing. The difficulty of the undertaking can only be known to those who have wrestled with these formidable cases. The operation required about an hour,and very much pus escaped and was washed out of the cavity. Although the operation was well done, as shown at autopsy, she had severe shock, and in absence of nurse for a few moments from the room the night after the operation, arose from her bed with the glass drainage tube in position. I consider this case a sacri- fice to the unfortunate theory of some of our leading sur- geons who say starve these cases for 24 hours. This patient needed food and stimulants from the start which she did not get until too late. The next case (No. 17), in many respects like the last, only following gonorrhoea instead of puerperal septicaemia. A woman, age and married, had symptoms of pelvic abscess for before admission to the hospital. After admission her condition grew rapidly worse and a tumor now reaching nearly to the umbilicus was of uncertain character. Her temperature and pulse gave evidence of the severity of the disease and of the necessity for operative treatment. I pause here to remark that to have aspirated any of these cases through the vagina, would have reached only a small area of the disease, and would have evacuated very little of the accumulated pus. In opening the abdomi- nal cavity the omentum was, as is so often the case, adher- ent to everything in its reach. It was difficult to find an opening or crevice anywhere to even begin the work of separation and enucleation. Many visitors present, among others the hospital staff and Professor Lovejoy of the Georgetown Medical College, were invited to inspect the tumor after the abdomen was well opened and omentum removed,but without any definite conclusion. It is well to be frank, and hence I cheerfully admit that I was unable to say with my hands upon the mass just what was within. The separation proceeding,however, soon revealed abundant pus, which gushed out freely, and although the operation was difficult, was well done, and after much anxiety for a few days she made a perfect recovery. The temperature and pulse chart of this case is very interesting. Both were high before section, and very gradually recovered afterwards. A striking feature of these pelvic abscesses is the very smajj 10 amount of debris found and removed. The remains of this woman’s tubes and ovaries give no conception of the kind of surgery required to complete the operation. The separation of adhesions in this case was done without tearing the bowel, and the abdominal wound healed nicely and without suppuration. Septic Disease in Uterus Bicornus. — Another interesting case, No. 22, occurred in a young negress following gonor- rhoea. When first admitted she appeared to have a fibroid tumor reaching the umbilicus, with suppurating tubes and ovaries. High temperature, quick pulse and other signs of pelvic disease present. The case was considered by the visiting staff so undesirable a subject for operation, that she was allowed to remain for several weeks under observa- tion, during which time she gained somewhat, and a favor- able time was selected after her condition had improved. The operation was nearly completed before the discovery was made that I had really removed the tube, ovary and a portion of the bicornate uterus. This was not extremely difficult save for the broad pedicle, which was very deep down in the pelvis, and so closely attached to the uterus as to cause some delay. When the left side was undertaken the real nature of the case was understood, and fortunately no serious disease existed, and operation was not required upon that side. The sac contained very thick and peculiar, ill-smelling pus. uneventful save for a slight dementia which continued a few days only, and was of the happy or ecstatic variety. She proved quite entertaining to her nurse, and discoursed tuneful melodies without number. Another interesting case recently treated deserves mention. Had septic metritis, high temperature, etc. A month or six weeks previously had child at term, followed by septicsemia. A mass in right ovarian region supposed to be Fallopian tube. Temperature 102°, pulse 120. Patient and consultant refused to assent to an operation until several weeks had passed, during which time she steadily grew worse. Opera- tion difficult from the start. Omentum glued to everything, and dipping down over right appendages, was inserted in the wall of the uterus just above the attachment of the bladder. When scooped out, a large opening was found into the uterine cavity, through which the index finger was freely passed. Infection had entered the pelvis and abdomen through this channel. The intestines were badly torn in separating adhesions, requiring many sutures before they could be returned. I was anxious about the patient until her bowels acted, for fear that I had closed the bowels too tightly. Her convalescence was uninterrupted after her bowels acted, fifty-two hours after section. I should have 11 remarked that I packed this patient’s pelvis with gauze, and dusted aristol over intestines where previously adherent. Gauze wyas used all around the uterus, for fear of infection through the uterine wound, as it could not be entirely closed with sutures, owing to the friable nature of the tissues. Still more gauze was passed down in the vicinity of the right broad ligament, where the intestines had been very adhe- rent. The glass drain discharged but little fluid, while the gauze poured out an abundance. These formidable cases are fortunately, as a rule, safe for full and complete recovery, after the danger incident to the operation has passed. Thus far, I have more satisfaction with this surgery than any other. It is always best to complete the work well, when once undertaken. Otherwise the old method of puncture through the vagina will be again heard from. In this connection I wish to say that I have seen at least four cases where puncture through vagina reached pus in the bro'ad ligament, and was followed by an apparent cure. But if any practi- tioner will witness one of these sections, and see how perfectly thin and healthy the broad ligament re- mains -after all adhesions and disease have been removed, he must indeed be hard to convince if he still believes in the old theory of “ cellulitis ” as explaining these pelvic masses. Finally, and in conclusion, I must refer to the minor cases whick have been operated upon, and which are abroad in the land by scores, without rec- ognition. One case, No. 20. W. had been married sixteen years; one conception; pelvic disease ever since. Pain, retroflexion, sterility. Treated for months at a time by various physicians. Finally, after nearly two months more of treatment under my own supervision without result, section. Two 12 large pus tubes like sausages. No trouble whatever in convalescence. Another patient (Case 12), unmarried, had gonor- rhoea some months before admission to hospital. Vaginitis treated. Pain in both ovarian regions, rap- idly growing worse. Section. Plenty of pus in ova- ries and tubes. Perfect recovery. Another (Case 34) contracted gonorrhoea from hus- band. In four weeks pyosalpingitis of right side, in- volving intestine. At time of section free pus poured out of left tube. Fimbria of right tube implanted upon intestine like a placenta; ovarian and tubal abscess. Bowel gave much anxiety, as it was badly necrosed. Gauze packing and drainage after flush- ing. Perfect recovery. The length of this article forbids further mention of these very interesting cases.