A System of Operative Surgery Part 17

Lequeu has seen many cases of post-operative parot.i.tis, and at his suggestion Verliac and Morel investigated the condition in the laboratory. They came to the conclusion that this variety of parot.i.tis originates in the ducts of the gland.

When parot.i.tis complicates post-operative convalescence, it is almost entirely confined to septic cases: it may occur within two days of the operation or as late as the thirtieth day. It is more common between the sixth and tenth days, and its advent is accompanied by much disturbance.

The parotid swells and becomes painful and tender; the skin over it is red and often brawny. These signs are accompanied by fever, malaise, and depression of spirits. In mild cases they subside in a few days, but in severe cases rigors occur, with high fever and suppuration.

The mild cases are best treated with warm fomentations, frequently changed. If suppuration occurs, the pus will need to be evacuated by a scalpel, but incisions in a suppurating parotid gland should be carried out with careful regard to the branches of the facial nerve (pes anserinus), and the large vessels intimately a.s.sociated with it.

The surgeon need not be in a great hurry to use the scalpel in these cases, for it seems occasionally as if the skin would slough, and yet when it is incised no pus escapes. This septic parot.i.tis is deceptive in the red and brawny appearance of the skin covering the swollen gland, and the misleading sense of fluctuation. In many instances the inflammatory products escape by way of the parotid duct.

Septic parot.i.tis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases.

=Thrombosis.= After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and dema of the limb. It is noticed most frequently about the twelfth day after operation.

In some patients the thrombosis is confined to the superficial veins of the calf and thigh, but when the femoral and internal iliac veins and the a.s.sociated lymphatics are involved, the dema is of a solid kind.

Apart from the danger which ensues from the detachment of a fragment of clot and its arrest in the pulmonary artery, this complication is often very serious for the patient, for it entails a long confinement to bed, a tedious convalescence, and the dema of the limb will sometimes persist for many weeks or months, in spite of topical applications, careful bandaging, or judicious ma.s.sage.

Post-operative thrombosis was formerly fairly common after hysterectomy for fibroids and in the later stages of malignant disease of the uterus.

Its frequency after operations for fibroids was attributed to the profound anaemia in patients who had severe and exhausting metrorrhagia.

I am convinced that it is due to sepsis. In several instances I have caused the clot found in thrombosed veins to be examined bacteriologically, and pathogenic microscopic organisms have been isolated. I am also satisfied that in some cases of thrombosis of the veins of the thigh, especially those limited to the saphenous veins, the clotting spreads from the superficial veins of the hypogastrium which are infected from the abdominal incision.

=Pulmonary embolism.= In perusing the clinical histories of a series of cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost any surgical operation, here and there a record may be read to this effect: 'The patient appeared to be doing well after the operation, when she sat up, laughed and chatted with the nurse, then suddenly fell back and died in a few minutes.'

Anything more tragic than this it is difficult to conceive, and, as a rule, after such a sad occurrence, the relatives are so distressed that they rarely permit an examination of the body. Death in such circ.u.mstances is usually attributed to embolism of the pulmonary artery.

In some instances this is an a.s.sumption, but there are many in which an embolus has been demonstrated, and a few in which the source has been detected.

Post-operative embolism of the pulmonary artery is an important matter for surgeons interested in the operative treatment of uterine fibroids, for it follows such operations more frequently than any other. In order to afford some notion of the relative liability of patients to this accident after subtotal and total hysterectomy for fibroids, I have gathered the following statistics, which are interesting as showing an extraordinary variation in the practice of different operators:--

Baldy ascertained that among 366 operations for fibroids in the Gynecean Hospital, Philadelphia, there were thirteen sudden deaths attributed to pulmonary embolism.

In the Middles.e.x Hospital between the years 1896 and 1906 (both years inclusive) there were 212 abdominal hysterectomies performed for fibroids. Three of the patients died from pulmonary embolism. Spencer, in eighty-five total hysterectomies, had two deaths from pulmonary embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one sudden death.

Mallet collected the records of 1,800 cliotomies: there were six deaths attributed to embolism, and of these, three followed operations for uterine fibroids. Chas. P. n.o.ble, in forty-two v.a.g.i.n.al myomectomies, lost two patients, one from septic endocarditis, the other from embolism; in the latter case the fibroid was gangrenous.

Olshausen, from the year 1896 to the end of 1905, performed 366 hysterectomies for fibroids; twenty-seven of these patients died. Five of the fatal cases were due to embolism.

Since 1894 I have performed more than a thousand operations of various kinds for fibroids, and have lost one patient from pulmonary embolism.

This happened in 1900. The woman was forty-five years of age and profoundly anaemic from profuse and long-continued menorrhagia. Twelve days after subtotal hysterectomy she asked to be pillowed up in bed; this was done, when she suddenly slipped down the bed in agony and died in fifteen minutes. At the post-mortem examination the right pulmonary artery was found plugged with a thick clot. No thrombosed vessels were found in the pelvis.

The symptoms of pulmonary embolism may occur at any period from the hour of the operation up to the thirtieth day. In the majority of patients embolism happens about the twelfth day. The symptoms supervene with great suddenness and seem to be preceded by movement, such as sitting up, getting out of bed, and especially straining during defaecation.

Withrow tells of a patient who was attacked whilst 'putting on her clothes to leave the hospital'. She died in twelve hours. Reclus, at a meeting of the Societe de Paris, 1897, mentioned that a patient quitting the hospital, apparently convalescent from hysterectomy, fell dead in the courtyard from pulmonary embolism. In one remarkable instance a patient complained of sciatic pain fifteen days after hysterectomy. In order to afford relief the surgeon flexed the patient's thigh on her abdomen and then suddenly extended it. This dislodged a clot, and the woman was seized with the symptoms of pulmonary embolism and died in forty-seven minutes. At the post-mortem examination the pulmonary artery was found occluded with clot and the ovarian vein contained a thrombus (Byron Robinson).

It is important to note that these fatal cases of pulmonary embolism occur when they are least expected, and it is an unusual sequence in patients with obvious thrombosis of the femoral and saphenous veins.

The most constant symptoms are urgent dyspna accompanied by great distress; in some instances the patient becomes pallid and in others cyanotic. Death may follow in a few minutes; in less severe cases it is delayed several hours, the patient remains conscious, but suffers severe mental agony.

A pulmonary embolism is not necessarily fatal, for a woman after a pelvic operation may complain of sudden pain in the chest, urgent dyspna, exhibit great mental distress, and in a short time spit up sputum mixed with blood. In a few hours the urgent symptoms subside and in two or three days pa.s.s away, and the patient recovers. I have seen five examples of this mild form of pulmonary embolism after hysterectomy. One of the patients appeared to suffer from a succession of small pulmonary emboli.

[Ill.u.s.tration: FIG. 25. THE PULMONARY ARTERY AND ADJACENT PART OF THE LUNG AND TRACHEA. The artery is completely occluded by a clot derived from a thrombus in the right auricle. (_Museum of the Middles.e.x Hospital._) Three-quarter size.]

Somerville Hastings refers to a woman thirty-six years of age, anaemic from profuse, long-continued menorrhagia due to a uterine fibroid, who, whilst waiting in the hospital for hysterectomy, was seized with pulmonary embolism and died three hours later. An embolus occupied the pulmonary artery, resembling a blood-clot found in the left common and internal iliac veins. Hastings also states that in a patient who died from pulmonary embolism, after an operation, a thrombus occupied the right cardiac ventricle, and he thought it possible that this intraventricular clot furnished the embolus (Fig. 25).

We must bear in mind that individuals apparently in good health die suddenly in the street, in the armchair, in a bath, or even during sleep: it is a fair a.s.sumption that some of the instances of sudden death occurring during convalescence from surgical operations may be due to failure of the heart absolutely unconnected with the operation. It is, however, undeniable that thrombosis of the pelvic veins after ovariotomy, or hysterectomy, is a source of fatal emboli. At present there is very little evidence available as to the cause of the thrombosis, but it can scarcely be doubted that sepsis, it may be only of a mild type, is responsible for some of the cases.

A careful consideration of the matter reveals beyond any doubt that pulmonary embolism occurs much more frequently after hysterectomy or fibroids than after any other operation, and it is especially liable to happen in women who are profoundly anaemic from profuse and prolonged menorrhagia. This indicates that long-continued and irregular losses of blood induce some change in the composition of this important fluid, which favours its coagulation.

It has been suggested that the practice of keeping patients strictly confined to bed for two or three weeks after hysterectomy and allied operations is responsible for the thrombosis which is the source of these fatal emboli. Some American surgeons act on this suggestion and insist on their patients getting out of bed a few days after such operations. This method does not commend itself to British surgeons. In my own practice I make it a rule, even in the most favourable conditions, to keep the patients confined to bed for two weeks. No patient is allowed up until her temperature has been normal for at least three days. The consequences of this practice appear to be justified, for in more than a thousand hysterectomies, only one of my patients lost her life in consequence of pulmonary embolism.

In cases of embolism of the pulmonary artery, death does not always occur immediately, but may be postponed for an hour or more after the lodgment of the embolus.

Trendelenburg is of opinion that it might be possible to remove this clot by direct surgical intervention. After careful consideration of the matter he carried out this operation on a woman aged sixty-three years; he raised an osteoplastic flap on the left side of the thorax, exposed the conus arteriosus, and intended to withdraw the clot, by means of a specially constructed pump, through a slit in its walls. The patient died from excessive bleeding before the clot could be extracted; the operation was hindered by an adherent pericardium.

Trendelenburg has carried out this operation on a man forty-five years of age. This patient was tabetic and sustained a spontaneous fracture of the femur. One month later he was seized with urgent dyspna and signs clearly indicating the lodgment of an embolus in the pulmonary artery.

Trendelenburg exposed the heart, opened the pulmonary artery, and by means of polypus forceps succeeded in withdrawing 34 centimetres of clot. The incision in the artery was carefully closed with sutures. The man improved considerably as the result of the operation, but died thirty-seven hours later. At the post-mortem examination the left and right branches of the pulmonary artery contained an embolus. From the surgical point of view there are no reasons why such a bold example should not be repeated with success.

When patients who are profoundly anaemic from menorrhagia due to fibroids undergo hysterectomy, it is a useful measure to give them twenty grains of citrate of sodium twice daily in order to diminish the abnormal tendency of the blood to coagulate in the vessels. Certainly this drug should be administered if there is the least evidence of thrombosis.

=Foreign bodies left in the abdomen.= Every writer on ovariotomy and kindred operations insists on the importance of exercising the utmost personal vigilance in counting instruments and dabs before, and immediately after, an abdominal operation in order to avert the dangers which ensue when instruments, dabs, gauze, or drainage tubes are accidentally left in the abdominal cavity. Before the era of antiseptic surgery nearly all the patients in whom foreign bodies were left in the abdominal cavity died. In several instances the surgeon has discovered, on counting the sponges and instruments after the operation, one or more to be missing, and, failing to find them in the room, has reopened the wound and recovered the missing article. In many lucky cases, a sponge or compress has given rise to an abscess, and, the wound reopened, the sponge presented at the opening. Often a compress of cotton-wool or gauze has slowly ulcerated into the r.e.c.t.u.m and been discharged through the a.n.u.s.

When things of this kind are left in the abdomen the risks are not so great now as in pre-antiseptic days, but they cause much discomfort and anxiety as well as suffering: moreover, such an accident entails reopening the wound and occasionally a serious operation for the removal of the missing article, and as a recent decision in a Court of Law fixes the responsibility on the operator, there is always the possibility of an action at law with all its vexations and the liability of being mulcted in damages.

The behaviour of foreign bodies left in the abdomen is curious and also interesting from the great length of time which metal instruments will sometimes remain without causing very urgent symptoms, and the tendency they exhibit to penetrate adjacent viscera.

Among the early cases Sir Spencer Wells reported one in which a pair of forceps was found in a patient's bladder who died a month after ovariotomy. Olshausen mentions that a pair of forceps was pa.s.sed by the r.e.c.t.u.m nine months after ovariotomy, and Terrillon tells of a pair of pressure forceps which remained eight months in the belly and came out close to the navel. One of the most remarkable instances is recorded by MacLaren, in which a pair of forceps was left in the abdomen in the course of a hysterectomy. Two years later, a swelling formed in the right iliac region; this was explored through an abdominal incision, and the haemostatic forceps represented in Fig. 26 was found embedded in the omentum; the forceps had ulcerated into the caec.u.m and the blades were lodged in the vermiform appendix. The patient recovered.

In order to ill.u.s.trate the diminished risks run by patients when the instruments and dabs used in operations are thoroughly sterilized, reference may be made to a case recently reported by J. E. F. Stewart (Australia), in which he removed a pair of pressure forceps which had remained in the abdomen for ten years and a half. The patient, who had been more or less an invalid since the primary operation, had suffered from attacks of acute pain, constipation alternating with diarrha, and pains in the lower limbs. The instrument, which measured 5 inches long and 2-1/2 across the handles, was lying point downwards in the pelvis, and the ring handles could be felt through the belly-wall before the operation: it had made its way into the small intestine.

[Ill.u.s.tration: FIG. 26. A PAIR OF PRESSURE FORCEPS: this instrument had remained in the abdomen two years after hysterectomy. The forceps had ulcerated into the caec.u.m and the blades had lodged in the vermiform appendix. (_After MacLaren._)]

The tendency for a foreign body, whether hard like forceps, or soft like gauze pads, to erode its way into the intestine is very remarkable. Thus Gifford operated on a patient with intestinal obstruction; an impacted ma.s.s was felt in the ileum, it was extracted through an incision in the gut and proved to be a pad of cotton-wool enveloped in gauze. She recovered. Three months previously this woman had undergone abdominal myomectomy.

Another source of risk to patients is the practice or habit of packing the pelvic recesses with strips of gauze temporarily, either with the hope of controlling oozing, or to serve as a drain. I have long abandoned this habit. The disadvantage of gauze stuffing which needs consideration in this section is the risk that some portion, or the whole of it, is sometimes left in the wound. Examples are known where long strips of 'gauze stuffing', sometimes amounting to a yard or more, have been pa.s.sed through the a.n.u.s a year after the operation. Many intractable sinuses have had a forgotten piece of gauze as the cause of their persistence.

A woman had cliotomy performed for peritonitis, the consequence of criminal abortion; she had a long convalescence due to an intractable sinus. Eventually the patient was thought to have tuberculous disease of the appendages, and a ma.s.s, formed mainly by the Fallopian tube, was removed. The walls of the tube were intact, but when slit open the tube was found to contain a small gauze tampon (Kouwer).

The isolated records relating to foreign bodies left in the abdomen are very numerous. Thus Wilson in 1884 was able to collect twenty-eight cases from periodical literature and personal reports from friends. An interesting discussion took place on the reading of a paper on this subject before an American gynaecological society, by R. W. Waldo, and the number of cases related by the members is astonishing and refer to such things as sponges, dabs, forceps, a strip of iodoform gauze 'a yard wide and two yards long', a pair of spectacles, and 'an operating-room towel', which were left in the abdominal cavity.

The most comprehensive collection of records relating to foreign bodies left in wounds of all kinds has been made by F. von Neugebauer; they amount to 195.

REFERENCES

GIFFORD, G. T. _British Medical Journal_, 1907, ii. 1042.

KOUWER, PROF. _Zentralbl. fur Gynak._, 1907, x.x.xi. 1447.

MACLAREN, A. _Annals of Surgery_, 1896, xxiv. 365.

NEUGEBAUER, F. V. _Monatsschriften fur Geburtsh. u. Gyn._, 1900, Bd. xi, 821, 933. _Zentralbl. fur Gynak._, 1904, xxviii. 65.