I N T E R E S T I N G C O M P L I C A T I O N S O F A N H Y S T E R E C T O M u

B Y A L F R E D S M I T H , F.R.C.S.I.; Professor of M:idwifery, National University of h'eland ;

Gyn~ezologist, St. Vincen~'s tIospital, &c.

[Reacl in the Section of Obste~rics, December 13, 1912.]

IT is not my intention to occupy the attention of this Section for any great length of time. I wish to bring under your notice and place on record an " abdominal sur- prise " which I venture to suggest is in many points quite unique. On September 23rd of this year (1912), I saw in con- sultation with Dr. O'Reilly, of Rato~th, a private patient, whose symptoms, owing to age and unpleasant vaginal discharges, suggested malignancy. Under ether I was able to satisfy myself that the cause of her trouble was multiple fibromata of the uterus without any evidence of malignancy.

A sub-total hysterectomy was advised, and successfully performed by me, assisted by Drs. O'Reilly and Meenan, on September 26th, 1912. The operation over, I pro- ceeded to make the peritoneal toilet, and felt my finger pricked by some sharp instrument. On investigating the cause I found the point of a needle sticking through che wall of a small intestine. To prevent the possibility of leakage a purse-string suture of fine catgut was inserted so as to encircle the needle opening into the intestine, the end being tightened together as the needle was being withdrawn. I searched further, and, to my astonish- ment, I found more needles--some lying in the omentum

236 Interesting Complications of an Hysterectomy.

away from any coil of intestine. Others were found pro- jec~ing through the wall of the intestine, but covered by a smooth covering as if a diverticulum had been made from the intestinal wall (specimen shown). Others had per- forated the intestine, b u t a protective omental adhesion surrounded the needle.

The appendix, which dipped into the pelvis ~lmost to the floor, was, as you see, hypertrophied and markedly congested. On palpation a hard body could be felt. Ir was removed.

Dr. Harry M:eade made an x-ray photograph (here shown) of the appendix showing two needles and one pin lying parallel to each other, the heads being down. The eye of the needle is plainly to be seen, and Dr. T. T. O'Ferrall opened a window in the appendix showing the three metallic bodies in situ. All the needIes, as you see

10 in number--are tarnished by I-I~S. They ~re ex- tremely brittle and of the same size.

Considering the nature of the operation, so:me anxiety was felt as to the subsequent convalescence. Nothing untoward h~ppened until the end of the third week. Preparations were being made for the patient to get up. On the morning of the appointed day, whilst stooling, the patient was seized by an acute pain referred to the anus. The sister in charge, on making ah examination, found needle stuck in the mucous membrane, which she promptIy removed. Some days following this the patient com- plained of abdominal pains, aggravated by pressure over both iliac regions. Palliative measures gave little or no relief. The possibility of more needles being present was considere(t, and Dr. Maurice Hayes kindly skiagraphed the patient for me. (Plates were shown.) Two of the plates locate three needles~one on the right side evi-

By DR. A. SMITH. 237

dently broken in two, another on the left side at pelvic brim, and a third somewhere about the os pubis. I re- opened the abdomen. Ir was felt that although the presence of needles was demonstrated, their precise posi- tion, whether in the intestine of outside ir, could not be determined. My anxiety was soon allayed, as dipping my fingers into the Ieft iliac fossa 1 found at once a needle perforating the sigmoid flexure of the colon, but well protected by omental adhesions. The broken needle which I show you, covered by its fibrous envelope, was removed from a small intestine on the right side. The third needle--that is, the one indicated lying close to the os pubis--was found in the omentum.

Ny " b a g " consisted of ten needles and one pin. In look- ing up references to foreign body appendicitis I find in the September number of the A nnals o/ Surgery ah exhaus- tire article by Royal Itamilton Fowler, M.D. He says sharp-pointed metallic foreign bodies represent a class by themselves. They have rarely been found even in Iarge surgical experiences, and their occurrence repre- sents a surgical curiosity. The common domestic pin is the most frequently encountered body of this nature found in the appendix. 5lcBurney and Park have seen but two cases. A. O. J. Kelly found one instance in a study of 460 cases. Kelly and Hurdon but one in 1,000 cases. Bell two in 1,000 cases. Ewing, Schultze and Wood in exceptionally large pathological experience have observed no cases. Barnes, in a study of 94 cases of true foreign bodies found in the appendix, estimated that more than 52 per cent. were pins. Whist Fowler observed one in- stance in his first series of 50 cases of appendicitis.

As regards the number of metallic bodies found in the appendix, McBurney found two pins lying parallel to each

288 ln~eresting ComplicaLions of an HysŸ

other, and Hirst also found two pins in an appendix which he rem oved.

On Iooking up the references to which I had access I cannot find recorded any case where three sharp-pointed metallic foreign bodies were previously found in the appendix. The presence of two needles is also interesting.

General observa~ions and conclusions.--There can be no doubt, from the positions where the needles were found, that they gained an entrance to their host through ~he alimen~ary tract. Ye~ the pa~ien~ stoutly denies that she ever had the habit of holding needles in her mouth or of swallowing them. She admitted, however, that when a child in her nursery the nurse frequently gave her the work-basket to tidy and play with. That the needles were a long time lost is evident from their extreme brittleness, the well-organised fibrous envelope which covered the perforating needles, and the distance which some of the needles travelled into the omentum. This case then goes to confirm the view that the presence of metallic foreign bodies is more apt to cause chronic than acute appen- dicitis.

Remarkable features.--That so many needles could be swallowed with such apparent impunity. That their per- foration of the intestinal wall gave rise to so little disturb- ance, no evidence whatever of anything approaching peri- tonitis, merely tiny protective fibrous sheets, of a delicate omental adhesion covering the needles. That this is the first recorded instance of three sharp-pointed metallic foreign bodies being found in the appendix.

THE PRESIDENT said diffieuRy of diagnosis.

the case demonst, rat, ed furt, her the I~ had been suggesbed that these

By DR. A. SMITH. 239

needles were probably taken in a packet when the patien~ was a child, so ~ha~ probably all the needles were taken in a~ the same ~ime, and i~ was well known tha~ when a needle entered ~he body ir travelled in the most extraordinary manner to different par~s of the system.

DR. JELLETT referred to a case treated ab the Adelaide Hospital some years ago in which thirty-nine needles were removed from a girl's st~mach, and within two years she re~urned with a furt~her crop.

DR. I:~OWLETTE said that some years ago, in a post- mo,rtem examination at SHeevens' Hospital, he found an inch and a hall pin in the appendix which had given rise to abscess of the liver. He considered tha~ foreign bodies were more common than reports showed as the cause of appendicitis.

Da. A. S~x ,~ on " Interesting Complicgt, ions of an

Hysterectomy."

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Ÿ237 eongo, ining two needles and one. pin.