tically the same whether the condition is pelvic peritonitis, cellulitis, ovaritis, or salpingitis. Celiotomy will be required if suppuration has occurred, and in cases of tubercular peritonitis the abdomen should be opened and flushed with hot water freely. Rarely is it advisable to remove the products of suppuration or effusion by an incision from the vagina or by tapping.

1311 CONNECTICUT AVE., N. W.

TRANSACTIONS OF THE CHICAGO

GYNECOLOGICAL SOCIETY.

Meeting of March 16th, 1894.

The President, FERNAND HENROTIN, M.D., in the Chair.

REPORT OF DEATH FROM LAPARATOMY ON THE TWENTY-FIFTH DAY, WITH EXHIBITION OF SPECIMEN.

DR. J. H. ETHERIDGE. This is a case of death occurring in almost a tragical manner on the twenty-fifth day after laparatomy. The patient had diseased tubes and ovaries which required removal. She went through convalescence without a symptom, and was up and around. She was eating well and had every promise of making entirely satisfactory progress and going home. One morning she was suddenly seized, while asleep, with a very severe pain about the umbilicus, getting the interne up about 5 o'clock, who gave her a hypodermic injection to relieve her. I saw her at 9 o'clock, and she was in a state of apparently approaching collapse. Vaginal examination revealed tenderness to the right of the uterus. Nothing that was done was of any avail. The symptoms intensified during the day and night, and she grew gradually worse, the original symptoms being confined exclusively to the abdomen. Her pulse increased so that it could not be counted. Her temperature went up a little beyond normal, then dropped to subnormal; and as the ratio of the pulse and temperature changed, she grew worse of course, and finally died the next morning. Her death was so mysterious that we held an autopsy. On opening the abdomen there immediately gushed out a large amount of feces in solution, the contents of the intestine. We then commenced a systematic examination of the intestine, and found a rupture of the intestine about four feet from the ileo-cecal valve. The last two feet of the small intestine were contracted, and so small that at one place the intestine was not as large as my little finger. Above the ileo-cecal valve the intestine was of normal size and everything appeared all right, except that the intestinal walls

up to the point of rupture seemed to be very thin. The intestine about a foot and a half below the point of rupture had become attached to the broad ligament. I have brought the uterus and remnant of the broad ligament to exhibit to the Society. The ligature with which the tube and ovary were tied off was not involved in the adhesions and had become encysted. The intestine was firmly adherent to the right broad ligament for about three inches. The strange part about the case is that the intestine was apparently not occluded at the point of adhesion, but there must have been some twist in the intestine that caused complete occlusion, and peristalsis, together with the thin wall, was sufficient to rupture the intestine. The cause of death was acute septic peritonitis.

At the time of operation no adhesions existed; both the anterior and posterior surfaces of the broad ligament were free. These adhesions apparently took place in cold blood upon the normal surface of the broad ligament.

DR. FRANKLIN H. MARTIN.-It seems to me that a mistake in this case was that the abdomen was not opened before death. The symptoms given-profound shock, pain, and all the symptoms of a ruptured intestine or an organ discharging infected contents into the peritoneal cavity-would have led many operators to reopen the abdomen. No harm could have arisen from so doing, and if it had been opened early, in a case making such good progress, an operator with the skill of Dr. Etheridge might have separated these adhesions, found the difficulty, and treated it on general surgical principles. I do not agree with Dr. Etheridge's statement that adhesions of the intestines" took place in cold blood." I believe there is always a reason why an adhesion of the intestine occurs after laparatomy. Either there is a large denuded surface left upon which attachment is formed, or if one intestine adheres to another it is because that intestine has been denuded of its peritoneal epithelium. Such adhesions occur in the surgical experience of all operators, and the fact that they occurred in this case should not subject the operator to criticism.

DR. F. BYRON ROBINSON.-I am much interested in this specimen of adhesion of the gut to the broad ligament; not because of the rarity of the specimen, for I have seen similar adhesions a hundred times in autopsies of human beings and dogs, but on account of Dr. Etheridge's interpretation of the case.

I do not think a twisting or volvulus of the gut caused the bowel obstruction. It was due to peritonitis, which produced intestinal paralysis, which causes tympanites. The wall of the intestine being paralyzed, the fermenting secretions form gases which dilate it. Meissner's plexus is so disordered by the infection that the secretion is either excessive, deficient, or disproportionate. It is my opinion that the chief pain after laparatomy is due to tympanites; the bowel is distended and forms strong adhesions to distant organs by plastic peritonitis. In

fected bowels will not act; they remain quiescent; but if they are stimulated by cathartics they contract and expel their contents.

My experience from autopsies is that in the first week of peritonitis absorption is very slow; in the second week it begins to progress rapidly; and in the third week the exudates are chiefly absorbed and form organized bands and adhesions. The specimen exhibited by Dr. Etheridge is in the fourth week and shows a well-organized adhesion, no doubt containing new nerves, blood vessels, lymphatic vessels, and connective tissue. It is likely the distended gut became infected from the cut end of the FaÏlopian tube.

As a result of extensive studies on the cadaver, I believe the apparent stricture in the specimen exhibited by Dr. Etheridge to be due to post-mortem changes-that is, rigor mortis, whereby the circular muscles of the gut are firmly contracted. We may find the gut in a spasmodic contraction of anemia.

Dr. Martin and I are of the same opinion and do not hesitate to reopen the abdomen after laparatomy when grave symptoms persist. I have saved life by this procedure. I think, however, that Dr. Martin is more sanguine than I am in regard to recovery after feces have escaped into the general abdominal cavity. It is likely that the adhesion of the gut to the broad ligament, in the specimen which Dr. Etheridge presents, had nothing to do with the patient's death. The patient died from perforation of the bowel, which allowed the escape of feces. The perforation occurred from pathological con itions unconnected with the operation-that is, from mucous ulcer or tubercular or glandular degeneration.

Dr. Martin thinks the adhesion was due to trauma or denuding the gut of its peritoneum; I think it was infection. In many of the dogs in which I had not touched the intestines, on post-mortem, a week after laparatomy, the intestines would be plastered over with adhesions and bound together. I have invariably observed the same condition in autopsies on the human subject. I therefore believe that adhesions of the intestines are chiefly due to infection. I believe an operator can traumatize the gut and do a great deal of manipulation, if the hands are clean, without causing adhesions.

DR. H. P. MERRIMAN.-As thirty-six hours elapsed from the time of the first symptoms until death, I would ask Dr. Robinson at what time he thought the intestines ruptured. The The paralysis must have occurred some little time before this, while the woman was walking around and feeling comparatively well.

DR. J. T. BINKLEY, JR.-Dr. Etheridge's case is almost parallel with one I had a couple of weeks ago, and I certainly feel called upon to defend the position taken by Dr. Etheridge, for a good many reasons. Every one here who has had experience in general practice knows that we have just such symptoms as he describes arising in a great many instances from indigestion,

or from causes we cannot determine. Irritation in the abdomen very frequently produces localized pain. A case under my care in the Chicago Hospital progressed beautifully for three or four weeks after abdominal section. An abscess then formed in the abdominal wall, which left a large sinus that closed slowly by granulation. About two weeks ago the patient was ready to go home, when in the middle of the night she was taken with symptoms such as Dr. Etheridge has described, but I did not feel that I ought to reopen the abdomen. The patient recovered and has gone home. She had indigestion, which was relieved by a hypodermic of morphine followed by saline cathartics. Dr. Martin and Dr. Robinson say they would reopen immediately. Dr. Robinson has recently written an article in which he condemns the immediate opening of the abdomen, especially in appendicitis. As he is careful to state that we must have the symptoms of pain, vomiting, localized induration, etc., before operating, I do not see how he can conclude so quickly that because this patient had pain he would immediately open the abdomen.

DR. W. W. JAGGARD.-I was very much interested in Dr. Etheridge's report and the inspection of the specimen. I do not think that the clinical history or the specimen furnishes facts sufficient to make any very exact etiological diagnosis as to the condition, nor to warrant any very dogmatic statements as to what ought to have been done under the circumstances. It looks to me as though the infection spread from the ligature to the intestine, and that there might either have been, and probably was, an actual ileus from obstruction, or there might have been simply a paralytic ileus, as indicated by Dr. Robinson. In either condition the rupture of the intestine seems to me to have been secondary to the general infection of the peritoneal cavity. In either event abdominal section, as suggested by Dr. Martin, seems to me to have been most strongly contra-indicated. It is an anachronism at the present time to open the abdomen for general peritonitis when the patient is in the article of death.

The case points an important moral as regards the operation of removal of the appendages. Unfortunately it is not an isolated nor is it a unique case. You put a silk ligature into an infected cavity, and the ligature is bound to become infected from the contents of the tube, and sooner or later, in a certain proportion of cases, there is bound to be trouble. A case recently came under my observation in which the tubes and ovaries had been removed and the woman was in a very much worse condition after the operation than before as regards the pain. She is bedridden. An abscess formed, and twelve months after operation a ligature was discharged through the bladder.

During the last year I have seen two cases of acute intestinal obstruction originating from a ligatured extremity of a tube that required operation, and these operations were performed by

no tyro, but by one of the most expert abdominal surgeons in this or any other city.

The prognosis in this operation can be made better, and one way of doing this is to use some form of suture that cannot be infected and that will ultimately be absorbed. Recent experiments with chromic-acid catgut indicate that in the following two respects it is preferable to silk: first, it is not so liable to infection when properly prepared; and, second, after a time it is completely absorbed. All the power in the human body cannot overcome germs once located in a silk ligature.

I think Dr. Etheridge is to be commiserated; he deserves, and certainly has, the sympathy of the Society. It is an accident that is liable to happen to any one who is obliged to use silk ligatures in an infected cavity.

DR. HENRY P. NEWMAN.-It is easy to criticise a method of treatment on the living subject, and to tell what we would have done under the circumstances, when we come to examine the post-mortem specimen. I think, with the indications as they existed in this case and the time and conditions as they were, secondary laparatomy was certainly not as strongly indicated as some of our Fellows insist. Čases where adhesions have occurred are subject to frequent attacks of colic or severe abdominal pain for protracted periods, and many of these cases survive for years with just such a history as that related by Dr. Etheridge. A patient recently came under my observation who had had two operations for the removal of tubes and ovaries. During the third laparatomy extensive adhesions to the old stumps were found. This case had suffered agonizing pains many times. She was brought here from Montana in a very critical condition. The adhesions were broken up, and two.. infected sutures, which were the cause of her suffering, removed. The woman was relieved, and went home cured, as we supposed; but I have since learned that she is subject to attacks of "cholera morbus." These adhesions may have returned. Some cases where adhesions have occurred certainly require operative treatment; in others it is questionable whether they should be subjected to repeated laparatomy.

I am under the impression, as Dr. Jaggard has outlined, that infection occurred in this case from the stump. It is possible, too, that there was some fraying-out of the broad ligament by the ligature at its point of constriction, resulting in a raw surface, to which this firm adhesion took place. As a rule adhesions are not firm in acute sepsis; they break down readily and are easily separated; but this is firm, adherent tissue, which cannot be separated, and its close continuity with the old stump, as well as some other manifestations, would lead me to suppose that infection took place at that point.

DR. F. BYRON ROBINSON.-I must have been misunderstood; I had not the slightest idea of criticising Dr. Etheridge. It was