A SUCCESSFUL 
Case of Hysterectomy. 
By Reynold W Wilcox, A. M„ M. D„ 
OF NEW YORK. 
At the present time some apology seems to be necessary 
when one adds, to the already overburdened literature, the re- 
port of another successful case of abdominal section. But since 
this operation has passes out of the hands of the gynecologists, 
since no longer is the privacy of the abdominal cavity respected 
even by the general practitioner, all points connected with the 
operation should be carefully weighed that no one may enter- 
tain the propriety of performing this operation unless he has 
fully considered all contingencies that may arise as well as the 
treatment suitable to meet them. The fact that this operation 
was successful was not the motive for reporting it, but to call 
attention to matters of detail usually lost sight of in the pres- 
ence of other and to the surgeon, more important subjects for 
consideration. 
The patient Mrs. J. E.-came under observation Nov. 1st, 
1883. Her age was forty one, she had borne two children du- 
ring a married life of fifteen years, had had two miscarriages, 
both of them since the birth of the last child, eleven years ago. 
The labors were normal. Her menstruation was regular in 
time, lasting three days, with normal flow, but some pain in the 
back before its appearance. For the last two years she had re- 
marked an increase of size but considered it to be due to an in- 
crease of flesh. The tumor was discovered on examination 
about six months previous. For the last year had noticed some 
emaciation but no very great failure of health until six months 
ago, when she complained of loss of appetite. No other dis- 
Reprinted from the St. Louis Medical and Surgical Journal, Oct., 1885. 2 
ease was detected. Her chief annoyance was caused by the 
bulk of the tumor. 
The operation was performed on Sept. 5th, by Dr. B. F. 
Dawson, assisted by the writer. The tumor was a multilocular, 
papillomatous ovarian cyst, the solid portion weighing five and 
one-fourth, the fluid contents eleven and one half pounds. The 
mass was, in the main; divided into three cysts, each containing 
thick purulent fluid. There were many adhesions to the small 
intestines which were dissected off by the handle of the scalpel. 
There was found also a large surface of firm adhesion to the 
fundus and posterior surface of the uterus f rom which the tumor 
could not be detached. A Dawson clamp was placed around 
the uterus at the cervico-corporeal junction and the mass with 
the body of the uterus cut off. All adhesions were thoroughly 
cauterized with the actual cautery, especially on the left of the 
uterus and on the small intestines, some places also being 
ligated. 
The most scrupulous cleanliness was observed by all concer- 
ned in the operation but no particular attention was paid to anti- 
sepsis. The writers observation in a large number of abdominal 
sections that he has witnessed by almost every prominent ovar- 
iotomist, leads him to believe that each operator should look to 
himself rather than to any particular mode of antisepsis when 
he seaks to exylain his fatal cases. A prominent feature of this 
operation was the use of perfectly clean, but wet towels, not only 
to thoroughly envelope t.hq tumor at the various stages of its ex- 
traction, that none of its contents should enter the abdominal 
cavity, but as well to protect the sides of the incision from con- 
tact with the tumor and, indeed, to prevent any oozing from the 
cut surfaces from entering the peritoneal cavity. As usual, other 
frequently renewed towels were used to keep the surface of the 
abdomen warm. 
The treatment of the peritoneum is very important when 
the pedicle must be retained without the abdominal cavity, and 
when in addition, as in this case, a drainage tube must be used. 
The writer had occasion to examine, post moDm, a number of 
cases of hysterectomy, in which the pedicle had been treated 
extra-peritoneally and in all, so far as be can remember, there 
were collections of either blood or pus between the stump and 
the edges of the incision and sometimes these collections exten- 
ded to a considerable distance laterally, so that had the patients 
recovered, their convalescence would have been protracted by 
mural abscesses, conditions too often lost sight of by the opera- 
tor, their importance being too little appreciated. And, indeed, 
the opportunity for the formation of ventral hernia is thus af- 
forded. In this case the peritoneum was brought up and fas- 
tened to the skin by interrupted sutures, around both the drain- 
age tube and the pedicle. Although, this at first sight might 
seem .to produce a structurally weak abdominal wall vet the 3 
final result would be, as shown, firm parietes. Deep, sutures of 
silver wire were passed through the pedicle and walls and othei* 
sut.ires were used as in an ordinary case. The clamp seems to 
present some advantage when it is intended as a portion of the 
the permanent dressing, since the pedicie is compressed so that 
its longest diameter presents in the line of the wound. The 
jaws are so constructed that the circulation is not entirely ob- 
structed, thus permitting a slow separation by dry gangrene, 
giving less opportunily for septic infection. A glass drainage 
tube was inserted in the lower angle of the wound and the ped- 
icle was touched with pure carbolic acid. 
The operation lasted two and one-half hours, the patient's con- 
dition calling for several hypodermic injections of brandy during 
it. She reacted well. During the evening considerable bloody 
serum was removed from the drainage tube. 
Second day: The temperature varied from 101° to 102% the 
pulse 118 to 132, very week. Enough opium was given to 
relieve pain and the patient was nourished and stimulated by rec- 
tal enemata. Both the head and abdominal Lister coils were 
kept on. Quinine also was administered by enemfc. The urine 
contained many granular, large and small, some hyaline casts, a 
small amount of albumen, some puss. On account of the weak- 
ness of the pulse, it was thought best to increase the brandy to 
three ounces daily. Marked tympanitis was present. Still con- 
siderable discharge removed from the tube. 
Third day: Some improvement in the character . of the 
pulse, urine unchanged, except less pus, temperature 1004° to 
1014°, pulse 118 to 122. Less serum in tube. 
Fourth day: The temperature had fallen to 99-|°, pulse to 
106. Both coils were, removed, to be replaced when the temper- 
ature should again rise. Some quinine deafness, so that quinine 
was diminished one-half and salicylic acid substituted for it. 
F/fth day: Milk and lime water by the mouth, seltzer. 
Sixth day: Temperature 100-|-0, pulse 94, patient very com- 
fortable. 
Seventh day: Temperature is steadily rising. The discharge 
from the tube is slightly yellow7, turbid, no especial odor. On 
microscopical examination many leucocytes are found. The 
patient complains of pressure about the heart, numbness of left 
leg and arm. Some difficulty of speech, no deviation of tongue, 
pupils were normal. Suppuration was evidently taking place 
under the clamp and the pus was finding its way into the abdom- 
inal cavity along the side of the tube. The clamp was removed 
and a support devised to prevent the pedicle from falling down- 
wards into the abdominal cavity ami rupturing the adhesions 
betw'.een it and the sides of the wound. 
This support is due to the ingenuity of Dr. Dawson and this 
w7as the second case in which it was employed. An Albert 
Smith retroversion passary of the largest size was moulded into 4 
the form of a Graiky-Hcwitt anteversion pessary as modified by 
Thomas, except, </f course, the transverse bar is wanting. A 
strong doubled silver wire is passed under the damp, around the 
pedicle and twised. The clamp being removed, the passary, 
moulded as described, is placed over the pedicle, the two ends 
resting upon the abdominal walls on either side of the line of 
incision and the four ends of the wires carried over and around 
the highest of the sides of the passary, or, if a lar. e sized Grail/y- 
Ilewitt be employed, over the bar, and secured by twisting/the 
ends together. Thus the pedicle is held firmly and easy access 
is permitted for dressing. 
From observation of this and other cases it seems that it may 
happen that the clamp is left in- position too long, so that the 
wound secretions may be retained under it. Naturally the clamps 
that entirely shut off the blood supply in the pedicle fall off ear- 
lier, it may be too early for a firm union of pedicle to the ab- 
dominal wall. 
The temperature gradually diminished, reaching 1001° the 
palse to 92. 
Eighth day: Some sutures removed, patient comfortable. 
Ninth day: Salicylic acid omitted. An impervious wall of 
lymph having probably formed about the drainage tube so that 
the general peritoneal cavity is shut off and no serum having 
been found in the tube of two days, it is removed. A roll of 
iodoformized cotton being substituted and twice removed. 
Tenth day: Some elevation of temperature caused, presuma- 
bly, by a mural abscess. 
Twelfth day: Solid food. The place in which the tube was 
situated has entirely closed. Some discharge of mucus from 
the vagina. Ordered douch to be given. Temperature 994-°. 
Fourteenth day, To be nourished entirely by the mouth. 
Nineteenth day: The pessary support removed. The mum- 
ified portion of pedicle retained in the grasp of the silver wire 
separated dy the cautery. 
Thirtieth day: Is sitt/ng up. Wound practically healed. 
Fortieth day: Discharged from observation, perfect recovery. 
The patient now weighs as much as before the operation. Ab- 
dominal wall firm. 
Eighteen months after the operation, the patient reported her- 
self without an ache or a pain, in perfect health. 
New York City. September, 1885.