When all the sutures have been passed, their ends on one side are loosely twisted together into a single strand, which is securely caught by a pressure-forceps. The same thing is done with the ends on the other side. A finger of each hand is now passed down into the centre of the wound, and the middle portion of all the upper sutures and of all the lower ones are separated from one another by being drawn to opposite angles of the wound. This permits the removal of the sponges, and, if they are stained with blood, the further search for some overlooked bleeding vessel. To guard against twisting of their convolutions, the bowels, still further disturbed by these final manipulations, are now restored to their natural position, and the omentum, after being again examined for some bleeding vessel, is gently spread out over them. The forceps and sponges are then counted to see that not one has been left in the abdominal cavity. The importance of this cannot be too strongly impressed upon the operator, for distinguished ovariotomists have overlooked these articles, and have left them behind in the abdominal cavity—a sponge and a bulldog forceps in one case.57 Tait has heard of ten such cases.58 It is indeed sometimes no easy task to find a missing sponge when lost in the convolutions of the intestines. The sponges therefore should not be much smaller than the fist.
57 Lancet, May 26, 1877, p. 783; British Med. Journ., Jan. 28, 1882, p. 115; Ibid., Dec. 25, 1880; also, Ovarian and Uterine Tumors, by Spencer Wells, London ed., p. 336.
58 Diseases of the Ovaries, by Lawson Tait, 4th ed., p. 261.
Before closing the wound the operator removes the pressure-forceps and catches in one hand all the ends of the sutures on his side, his assistant does the same thing on the other side, and the edges of the wound are brought together by a firm pressure, which also chases the air out of the abdominal cavity. To stop the bleeding from the needle-tracks as soon as possible, each suture is rapidly tied and by the surgeon's knot. When the whole wound has been closed, and not till then, the ends of all the sutures are gathered together in one hand, and they are cut off about two inches from the knot by one snip of the scissors. This saves precious time, which would be lost were each suture by itself to be cut after being tied. At gaping points of the wound intermediate superficial stitches should be put in. In fat women several such stitches will usually be needed.
Dressing of the Wound.—After the wound has been closed the rubber apron is removed and the abdomen cleansed and dried. The wound may now be dressed according to Lister's plan. This consists, first, of a narrow protective of prepared oiled silk, moistened by a 1:40 solution of carbolic acid; next, of one broad layer of antiseptic gauze wetted with the same solution; and over this eight folds more of the dry gauze, having a piece of mackintosh interposed between the seventh and the eighth layer. The lamp is now blown out, and the spray-jet being directed away from the abdomen, the dressing is secured by an elastic flannel binder, the rucking of which can be prevented by tapes pinned to it around each thigh. Most of the leading ovariotomists, however, employ simpler dressings, which have been found equally antiseptic. Wells covers the wound with a dry dressing of thymol cotton, kept in place by long strips of adhesive plaster, going two-thirds of the way around the body. Over all is pinned a flannel binder. The thymol cotton is prepared by steeping absorbent cotton wool in a solution of one part of thymol to one thousand of water, and drying it. Keith dresses the wound with gauze wrung out of a 1:8 glycerole of carbolic acid. On this are laid several layers of dry carbolated gauze, next some cotton wool, and over all a flannel binder. Thornton uses Lister's gauze and the mackintosh, but without the protective. This dressing is secured by adhesive straps. On these are laid several folded napkins, and over all a flannel binder is pinned very tightly. Bantock resorts to dry thymol gauze. Tait uses nothing but ordinary absorbent cotton. Salicylated cotton I have found to answer so well that for years I used nothing else. It is made by steeping two parts of absorbent cotton in a solution of one part of salicylic acid to two of commercial ether, and afterward drying the cotton by a low heat. Lately I have been resorting to Keith's dressing, but it probably possesses no greater advantages.
The flannel binder having been pinned on, the night-dress is pulled down and the patient put to bed. The opium suppository containing one grain of the watery extract is slipped into the rectum, the six bottles of hot water are applied to different portions of the body, and she is covered with warm blankets. The tables, tubs, and other articles used in the operation are now removed, the room is darkened, and she is left alone with her nurse, who has positive instructions to admit no one besides the physician.
Drainage.—When blood in small quantities is effused into the peritoneal cavity, coagulation usually takes place, the serum is then absorbed, the clot becomes organized, and no harm results. But when blood in large quantities collects in Douglas's pouch, it may behave as a foreign body and cause mischief. When, also, blood is mixed with serum, coagulation is not so likely to take place; the blood-corpuscles then are liable to break down, the fluid to become putrid, and septicæmia to set in. For these reasons the removal of these fluids by different modes of drainage has long been put in practice. The best mode is by a glass tube passed down to the bottom of Douglas's pouch through the abdominal wound, and not, as has been recommended, through a special opening made for it in the roof of the vagina. Drainage is at present very rarely resorted to by those operators who use strict antiseptic precautions, for they contend that septic changes in the blood do not then take place. Wells and Thornton have virtually given it up, while Keith, Tait, and Bantock, who have abandoned Listerism, are warm advocates of it. This question is a very important one, because a drainage-tube tends to the formation of a ventral hernia, and, being a foreign body, is in itself hurtful, and therefore should not be resorted to unless it will do more good than harm.
After a careful consideration of the subject I am forced from experience to believe that between the two extremes there lies a golden mean, and that drainage, even when the spray is used, is needed under the following conditions:
| (a) | Whenever a purulent or a colloid cyst has burst, and its contents have escaped into the cavity of the abdomen, either during the operation or some days beforehand. |
| (b) | Whenever the contents of the cyst are putrid or purulent, and septic symptoms or those of peritonitis are present. |
| (c) | Whenever a large amount of ascitic fluid is found in the abdominal cavity. |
| (d) | Whenever four drachms or more of pure blood, or especially of a sero-sanguinolent fluid, can be squeezed out of the sponge in Douglas's pouch when removed just before the closure of the wound. |
| (e) | Whenever the operator is in doubt what to do. |