In anæmic cases Thornton ties the arterial side of the pedicle first, but in young and vigorous women he ties the venous side first, so as to deplete the woman by gorging the tumor with blood. While cutting off the cysts the abdominal cavity must be so protected by sponges that not a drop of blood shall fall into it. A dilated oviduct in the pedicle tends to suppurate; hence in such a case the ligature should be applied as close to the womb as possible, so as to get below the expanded portion. Before the cyst is cut away the pedicle should be seized on one side by a pressure-forceps, and kept more or less in sight until the wound is ready to be closed up. This will also prevent the ligatures from being rubbed off by the sponges while the abdominal cavity is being cleansed.
Sometimes the cyst has no stalk, but lies between two folds of the broad ligament, or else it is bound to the bladder, womb, and the pelvic tissues by intimate adhesions which cannot be safely severed. Formerly, under such circumstances the abdominal wound was hastily closed up and the case abandoned. Now, thanks to Miner of Buffalo, New York, we can fall back on enucleation, and need rarely be foiled.53 This operation is performed by slitting open the peritoneal capsule of the sac at points close to its attachments, by introducing one finger or more into the opening, and by stripping off this serous and vascular envelope up to where the vessels enter the cyst-wall and become capillary. The artificial stalk thus made is to be treated precisely like a natural one—that is to say, by clamp, ligature, and cautery, or, if it does not bleed, by nothing whatever. This operation I have repeatedly performed, but it is seldom easy, and is always anxious work. Should the cyst be so wholly adherent to the viscera as not to be even enucleated, an incision is made into it. It is then emptied, thoroughly cleansed, and the child-cysts are also crushed by the hand. The edges of the opening thus made in the sac are now included in the stitches of the abdominal wound, but the latter is kept open either by a large cloth tent at the lower angle or by two glass drainage-tubes, one at each angle running down into the sac. Sometimes it may be needful to tie the adherent portion in sections and to cut the free portion away. A drainage-tube must then be inserted at the lower angle of the wound. This expedient has the sanction of Atlee and Olshausen, who have reported successful cases thus treated.54 My own practice in such cases would be, after breaking up the child-cysts, to gather together the free portion of the cyst and bring it out at the lower angle of the wound. A short nickel-plated steel drainage-tube of large bore is inserted, the sac firmly clamped to it by a small wire écraseur, and the redundant portion cut away. Into this metal tube is passed a glass drainage-tube long enough to touch the lowest portion of the sac.
53 Transactions International Med. Congress, 1876, p. 801.
54 Monthly Abstract, July, 1877, p. 334.
In such cases, when feasible, I think it would also be well to adopt Freund's plan of tying the pedicle and severing it, in order to lessen the blood-supply to the cyst.55
55 Boston Med. and Surg. Journal, Aug. 24, 1876, p. 219.
The sac having been removed, the other ovary should be examined, and, if diseased, be tied and cut off. From the sundered bands of adhesion more or less bleeding has been taking place, which must now be attended to. It can usually be stopped by pressure with a sponge or with a finger, or with sponges wrung out of very hot carbolated water. For single vessels torsion will usually succeed, but if it does not, fine carbolated silk or gut ligatures must be used; and it is wonderful how many can be applied without materially compromising the safety of the woman. I once tied over thirty vessels in a lady sixty-eight years of age, who recovered without any symptoms of peritonitis. The free ends of the ligatures should always be cut off close to the knot. Stubborn oozing surfaces can very generally be stanched by searing them with Paquelin's thermo-cautery, or by passing a needle armed with fine silk under and ligating any vessel that may be detected leading up to the seat of the oozing. In some cases nothing answers so well as the pressure of the finger moistened with alcohol or with a drop or two of the ferric subsulphate or of the tincture of iodine. In oozing from inaccessible points in the pelvis a sponge dipped in the undiluted solution of iodine or in Monsel's solution of iron, and afterward well squeezed out, may be pressed firmly down for a few moments into Douglas's pouch. When the oozing comes from a large surface of the abdominal wall, it may finally be arrested by the doubling of the raw surface on itself. The fold thus made is then secured either by a long acupressure needle or by cobbler's stitches passed through from skin to skin. Forty-eight hours after, this needle or these stitches should be removed. For this ingenious device we are indebted to the late Kimball of Lowell, Mass. Should all these measures fail, put in a drainage-tube, close up the abdomen in the manner about to be described, and temporarily lay over the dressings some heavy weights, such as bags of sand or of shot. This plan I have not been obliged to resort to, but it has the sanction of Nussbaum, who uses two large bricks, and it is worthy of being borne in mind.56 In my hands an elastic flannel binder pinned very tightly over a large roll of cotton wool has made pressure enough to check the hemorrhage.
56 British Med. Journal, Oct. 26, 1878, p. 617.
The toilet of the peritoneum next comes in order. By this is meant the peeling off from the peritoneum of plastic deposits, the removal of the sponges packed into its cavity, and the careful cleansing away of all fluids and of every blood-clot. In the search for all such foreign bodies, or, indeed, for obscure oozing-points, the reflector of the ophthalmoscope or Colin's illuminating lamp will give much aid. Douglas's pouch and the peritoneal fold between the bladder and the womb are favorite localities for the collection of blood or of serum, and should therefore be thoroughly mopped out by small sponges on holders, otherwise peritonitis or septicæmia may result, which are the two great factors of death in unsuccessful cases. When this has been thoroughly done, a clean sponge is placed in Douglas's pouch, another in the sulcus between the bladder and the womb, and a third, a large and broad flat one, is laid over the intestines under the wound to catch the blood that may drop from the needle-tracks. Each needle is passed from within outward a quarter of an inch away from the peritoneal edge of the wound, and is made to emerge at the same distance from its cutaneous edge. If the recti muscles are included in the sutures, there is said to be a liability to the formation of abscesses in the suture-tracks. Hence almost every ovariotomist advises that the peritoneum and skin should be pinched together, and that the needle should be passed through them alone without perforating the muscles. Yet I believe that from a too close observance of this rule come many cases of hernia in the track of the wound, and that were the recti muscles more closely coaptated they would not recede from one another and thus aid in the formation of a rupture. My own rule is to include these muscles in the suture wherever they are exposed to view. The sutures should lie about one-third of an inch apart. The needles should be lance-pointed and held by a needle-holder. In fat women it is not always easy to get the two surfaces of the wound in exact coaptation; consequently, more or less puckering and eversion of the edges may take place. To avoid this, it will be well, before passing the needles, to bring the edges of the wound together, and make with a fountain-pen transverse lines at proper intervals across the incision as landmarks for the introduction of the sutures. These cross-lines are also of advantage whenever the abdominal walls are too tense for accurate coaptation, as after öophorectomy, after the removal of a small abdominal tumor, or after an exploratory incision for a solid tumor which cannot be removed. In these cases, indeed, it would be well to make the cross-lines the first step of the operation, before even the abdominal incision has been made.
The reasons why the needle is made to enter the peritoneum first are, that the stitches are lodged more evenly on that vulnerable surface, and with less injury to it, such as the stripping of it off from the abdominal wall; and, further, that a stray knuckle of bowel is not so likely to be wounded by the upward as by the downward thrust of the needle. The object of including the peritoneum in the stitches is to bring in contact two long and narrow ribbon-like surfaces of a membrane, which will quickly unite—so quickly as to forestall any formation of pus in the overlying tissues, and to bar the entrance of this or other septic fluids from the wound in the abdominal wall. Another advantage is, that this inclusion of the peritoneum by presenting an uninterrupted surface of parietal peritoneum to the visceral peritoneum prevents the adhesion of the omentum and of the intestines to the internal lips of the wound, which otherwise takes place.