Cceliotomy for Bilateral Pyosalpinx, followed Four Days later by Appendicitis. OPERATION. RECOVERY. A Case of Bilateral Ovarian Fibro- sarcoma. BY FREDERICK HOLME WIGGIN, M.D., President of the Society of Alumni of Bel levue Hospital ; Visiting Surgeon to the City Hospital, Gynaecological Division. REPRINTED FROM THE Neto York fUetocal journal for February 10 and April 7, 1891/.. Reprinted front, the New York Medical Journal for February 10 and April 7, CCELIOTOMY FOR BILATERAL PYOSALPINX, FOLLOWED FOUR DAYS LATER BY APPENDICITIS. OPERATION. RECOVERY* A CASE OF BILATERAL OVARIAN FIBRO-SARCOMA. By FREDERICK HOLME WIGGIN, M. D., PRESIDENT OF THE SOCIETY OF ALUMNI OF KBYleVUE HOSPITAL ; VISITING SURGEON TO THE CITY HOSPITAL, GYNAECOLOGICAL DIVISION. A. D., nineteen years of age, an unmarried woman, was ad- mitted to the uterine service of the City Hospital in November, 1893. The family history was bad. 'The patient began to menstruate at twelve years of age; it was of the regular monthly type. She had pain at the beginning of the period, which ceased when the flow was established. She was deliv- ered in August at the Maternity Hospital. Regarding her pres- ent trouble, she stated that she had had severe abdominal pains with marked tenderness over both ovaries, associated with backache and headache. Her temperature ranged from 101° to 102°. Examination per vaginam revealed an enlarged and. tender uterus, retroplaced and fixed; also a laceration of the cervix. Both tubes were enlarged, especially the left. A diag- nosis was made of endometritis and double pyosalpinx, and. * Read before the Society of the Alumni of Bellevue Hospital, Feb- ruary 7, 1894. Copyright, 1894, by D. Appleton and Company. 2 CaiLIOTOMY FOR BILATERAL PYOSALP1NX. curetting and coeliotomy for removal of the diseased tubes were advised. On November 27th, her general condition having im- proved, and her temperature having fallen to 99'5°, the opera- tion was performed. The uterus was first curetted and packed with iodoform gauze, after which the abdomen was opened. The uterus and tubes were found firmly bound down by strong adhesions, the breaking up of which caused very free haemor- rhage, which was controlled, after removal of both tubes ami ovaries, by the liberal use of hydrogen dioxide. Both tubes were found to contain pus. The ovaries were degenerated and cystic. The abdominal cavity was filled with hot salt solution (0'6 per cent.) and the wound closed without drainage. The patient did well, had little nausea, and took nourishment; the bowels moved satisfactorily, and the temperature ranged from 99° to 100 4° from the time of the operation till December 1st, when she had a chill, and a rise of temperature to 104°. Her pulse rose to 160 at this time, and she complained of pain in the abdomen, and was restless and irritable, and had nausea and diarrhoea. The wound showed no sign of infection, and had closed by primary intention. Five grains of acetanilide and one grain of citrate of caffeine reduced the temperature to 101 '2°; the nausea passed off and the patient had a good night. On December 2d there was marked tenderness and pain over the appendix. There was still no appearance of infection of tLe wound, but to make sure of this the sutures were removed. No pus was found, an l examination per raginam was negative. The temperature varied from 100'6° to 103°, the pulse from 140 to 180, and the diarrhoea continued. Her condition was the same on December 4th-the temperature, 101° to 102'8° ; pulse, 126 to 140. The following day she had incontinence of urine and faeces; the temperature was 101'4° to 103'8°, and the pulse 124 to 142 ; there was also marked tympanites. On De- cember 6th, as the patient was going from bad to worse, and tenderness and fullness on the right side were more marked, it was determined to open the abdominal cavity over the site of the appendix. The patient was anaesthetized and the perito- naeum opened, when five or six ounces of foetid pus escaped at once. Examination showed the abscess cavity to be shut off CCELIOTOMY FOR BILATERAL PYOSALPINX. 3 from the general cavity by adhesions, which were not disturbed. The cavity was washed out with hydrogen dioxide and lightly packed with iodoform gauze. There was no connection be- tween the abscess and the original incision. Eight hours after the operation her temperature had fallen to 99'4°, and the pulse to 128. The next day she was doing well. The abscess was washed out with hydrogen dioxide and an iodoform-gauze drain inserted, and this treatment was continued daily till December 10th, when, as there was no pus, the drain was omitted and the cavity was allowed to collapse, the wound being gradually drawn together by adhesive strips. It was noted on December 20th that the patient was rapidly gaining in strength, and that the cicatrization of the wound was nearly complete. This case teaches the folly of delaying reopening the abdominal cavity if a coeliotomy is followed by evidence of septic infection, because we may be afraid that the infec- tion is general and that the operation is therefore almost hopeless. In the second place, it shows that we should not be deterred because the patient's general condition is bad. In the case just reported the operation should have been performed four days before it was, but the pulse of 180 made me hesitate, as I was afraid that the patient would not bear the anaesthetic. With the patient's condi- tion not improved by the delay, the anaesthesia, which lasted only ten minutes, was well borne, her pulse improv- ing while under its influence, and her hopeless condition was relieved by my finding and removing the cause of her sepsis. It is reasonable to believe that in breaking up the adhesions in the primary coeliotomy, the appendix had been injured, and that this may be oftener the cause of sepsis after these operations than we are at present aware. It is not uncommon to find in the dead-house or dissecting room the appendix adherent to the right ovary. In conclusion, I hope that this case will lead others to have the courage of their convictions. 4 CCELIOTOMY FOR BILATERAL PYOSALPINX. DISCUSSION. Dr. W Evelyn Poster said that he bad had a similar case in which perityphlitis and pyosalpinx had coexisted, but the circumstances had been such that the operation had been done for both conditions at the same time. The abscess had been on the left side, the appendix had contained a faecal concretion, and the abscess had been attached to the left tube and ovary, the appendix being so elongated as to wind around the abscess mass to the opposite side of the abdomen. Dr. C. C. Barrows thought that Dr. Wiggin deserved much credit for his skill in diagnosis and boldness in operating on this case, for he thought very few surgeons would have done the operation. With a patient in the Trendelenburg posture, one could both see and feel the appendix through a median in- cision. In many cases of pyosalpinx he had found the appen- dix adherent, and in three cases he had found pus in the appen- dix, which had apparently communicated with the pus in the right Falloppian tube. He thought it should be a cardinal rule for every abdominal surgeon to carefully examine the appendix everytime the abdomen was opened, with a view to its removal unless entirely healthy. It was quite probable there had been a pathological condition in the appendix before the primary laparotomy in Dr. Wiggin's case, and the necessary injury done by disturbance of adhesions might have brought on an acute inflammation of the organ. Dr. R. A. Murray also thought the operator should be con- gratulated on his success in this case. He had seen quite a number of septic cases where the surgeon had refused to reopen the abdomen because the result was so commonly fatal. A case had been reported, he believed by Dr. Coe, of late fever in a parturient woman. About two weeks after confinement there had been a rise of temperature, associated with a swelling on .one side of the abdomen. There had been no explanation of the rise of temperature until about a week later, when a con- sulting surgeon had decided it was due to a pyosalpinx. The abdomen had been opened, and it had been found that there was a pyosalpinx and also an appendicitis. The appendix had BILATERAL OVARIAN FIBRO-SARCOMA. 5 contained pus, which had ruptured into the ovarian tissue, pro- ducing an ovarian abscess and also an involvement of the tube. The trauma of pregnancy had apparently stirred up a latent appendicitis. When we recalled the amount of trauma incident to the Crede expulsion of the placenta, or similar manipulation of the uterus during labor, it was not surprising that such an accident should occur. Dr. Goldthwaite said that he had operated for appendicitis only a few times, and with not very flattering success. In two of his cases the appendix had been adherent to the ovary. In one case there had been ulceration through the appendix, but the abscess cavity had been shut off from the general ab- dominal cavity. He had been surprised in several cases at the extreme length of the appendix. He would also congratu- late the operator most heartily on his great success in this case. Dr. Parker Syms said that he had seen a good many cases where infection had occurred after laparotomy, but he could recall no instances where he had seen the abdomen reopened, although he thought it would have been desirable in several of the cases. No one could say that a curable condition might not be discovered in this way. A CASE OF BILATERAL OVARIAN FIBRO-SARCOMA* The comparative rarity of ovarian fibro-sarcoma (Schro- der finding but ten out of six hundred, and Olshausen twelve out of two hundred and ninety-three ovarian growths) makes the specimens to which I desire to call your attention of interest. * Read before the Society of the Alumni of Bellevue Hospital, De- cember 6, 1893. 6 BILATERAL OVARIAN FIBRO-SARCOMA. On November 5th I was asked to see Mrs. J. R., forty five years of age, whose history was as follows: She began to men- struate at ten years of age; it was painless and regular, of the monthly type. It diminished in quantity slightly before it ceased entirely last January. She has had three children, all of whom are alive, the youngest being twenty-one years of age. She has had two miscarriages-one sixteen years ago, the last three years ago. Previous History.-Her health has always been good. Her present illness commenced with the cessation of menstruation last January. At that time she felt a fullness in her abdomen, and by that her attention was called to a tumor low down in the abdomen, of about the size of a ben's egg. This tumor has increased in size regularly, and of late rapidly. Four months ago she noticed the second tumor, which also increased in size gradually till within a short time. During the last few weeks she has lost flesh and strength rapidly, the urine has been scanty, and breathing has begun to be affected. Physical Examination.-The patient is extremely emaciated ; her breathing is short and shallow; her abdomen is enormously distended. Palpation reveals marked ascites. The lower part of her abdomen, as high as the umbilicus, is filled by a nodular tumor, divided into two parts by a deep sulcus. Vaginal ex- amination reveals a bard, nodular tumor completely filling the pelvic roof; the cervix and uterine cavity are normal; the uterus is anteverted and crowded over to the left side. An operation was advised, and performed with the assistance of Dr. W. S. McLaren, of Litchfield, Conn., and Dr. Karrman, of North Woodbury, Conn. On opening the abdomen, a large amount of fluid escaped; the tumors immediately presented, and were found to be free from adhesions. They were removed without difficulty. The patient made a good recovery, her tem- perature and pulse becoming normal within forty-eight hours. I am indebted for the microscopical examination and report to Dr. E. K. Dunham, of the Carnegie Laboratory. 55 West Thirty-sixth Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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