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 assumption 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 anæmic 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 dyspnœa 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 anæmic 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 rectum and been discharged through the anus.
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.