Some Deceptive Abdominal Conditions and the Question of Operation
Authors: A. H. Tubby
Journal: BMJ (1904)

on June 20th, 2903, by Dr. Gray, who was of opinion that she had a pelvic tumour which would prevent the passage of a child by the natural way.Slhe was in fairly good health, and had no symptoms of 4haemorrhage or pressure from the pelvic tumour.The examination of -he abdomen showed the top of the uterus well above the umbilicus.The uterine walls showed prominent nodules at the top and upper part, :and parts of the fetus could be felt in utero.The pelvic examination showed a rounded mass in Douglas's pouch which was firmly wedged .andextended to the pelvic wall, displacing the uterus forwards.Operation.-OnJune 23rd chloroform was administered and the abdo- tuinal wvall divided by a long median incision extending from above the umbilicus almost to the pubes.On exposing the uterus a large fibroid 'tumour was found on its anterior wall, which was pedunculated and 'bled somewhat freely on attempting to bring out the uterus.A thick band of omentum was adherent to the upper part of the uterus.The omentum was first divided between ligatures; the broad ligaments on -each side were tied in two places and divided between the ligatures.'rhe loose tissue on each side of the 'uterus was then separated with ithe finger, and the uterine arteries felt low down on each side.Macewen's needle threaded with tilick silk was passed round the arteries, and on the right side this ligature was tied, but the left ligature was not tightened.The uterus was then drawn out at the -abdominal cavity and packed round with flat sponges and towels.An inelsion was made in its anterior wall about 5 in. in depth, and the :muscular wall torn through to the same extent.The membrane was then carefully opened and the finger passed in, to find the position of 'the placenta.The opening in the membranes was then enlarged, and the child readily withdrawn.Respiration set in at once, and the cord was cut lbetween two pressure forceps.The liquor amnii was drained over the side to avoid soiling the peritoneum.The cord with the forceps was returned, and a flat sponge .placed in the uterine cavity, while the margins in the opening of the uterus were pressed together.The uterus was then drawn forwards, -and with some difficulty the fibroid tumour was drawn out of the pelvis.Both uterine arteries were now tied securely, and the uteras cut through low down, so as to make two flaps of uterine tissue.There was very little haemorrhage from this stump, which was brought together fwith buried catgut sutures and silk sutures through the peritoneum.'The pelvis was then cleared of clots, etc., and a Keith's drainage tube ianserted in the pelvis, with its upper end projecting from the lower part of the wound.The abdominal wall was brouight together with silkworm-gut sutures, the separate layers being united with buried catgut sutures.The operation lasted one hour, and at its termination '&he pulse was 8o and good in character.After-history.-The patient made a good recovery, the only incident to 4be noted was a small collection of pus in the pelvis which necessitated ,the reintroduction of a drainage tube for some days.