Cases of Ovariotomy, with Some Remarks Upon the Operation

This was followed CASES pounds. again by speedy OF OVARIOTOMY, WITH SOME restoration to health. REMARKS UPON THE OPERATION. Having explained to herself and friends By WM. Warren Greene, M.D., Professor of Surgery the nature of her case, and her chances in the Medical School of Maine and in the with and without an she was University of Michigan. operation, left, with the advice that in case she elect- There is no occasion at the present day for ed it, excision should be performed before multiplying reports of ovariotomy, unless the re-accumulation was sufficient to pro- the cases possess some unusual interest. duce much general disturbance. In eight Therefore, in presenting the following cases, weeks, the sac had re-filled sufficiently to which, eight in number, constitute all the disturb the stomach and heart, and she de- operations that I*have performed up to cided upon an operation. This I made in this time, I shall avoid details, except they the presence and with the assistance of be of special value. Drs. H. S. Lucas, A. M. Smith, and F. K. Case I.—Miss-, aged 16. I first saw Paddock. her with her physician, Dr. H. S. Lucas, of Ether being administered, she was placed, Chester, Mass., in December, 1862. She supine, upon a table in a room the tempe- had been a healthy girl until two years be- rature of which was 80° Fahr., and the air fore, at which time menstruation was estab- was kept constantly moist by steam. Stand- lished, and soon after she noticed an abdo- ing upon the patient's right, I made an in- minal enlargement. She could not tell cision, with a common scalpel, in the me- whether it more upon one side than dian from above the umbilicus to the began " line, the other, but thought both alike." This pubes. This was afterwards extended gradually increased, without pain or ten- nearly to the ensiform cartilage. The tu- derness, or any marked impairment of the mor was readily exposed, and the principal general health, until the spring of 1862. cyst, seized and steadied by a tenaculum, At this time it increased rapidly, and even was emptied of its fluid contents, which, before the distention was extreme, her resembled that removed in the former tap- health failed quite suddenly. She lost pings. There remained a ûeshy mass filled strength and appetite, and suffered great with small cysts containing thick albumi- derangement of the digestive organs. A nous jelly, the whole being so large as to marked feature was, also, an unusually require the extension of the first incision rapid pulse, which Dr. Lucas assured me above referred to. Adhesions of moderate was 140 per minute, whereas its normal strength existed over a considerable por- rate was below 80. Dr. L. tapped her at tion of the abdominal parietes, and also to this time, drawing off " about three pailfuls the lower border of the stomach and liver, of syrupy, molasses-colored fluid." The but none were sufficiently firm to prevent a operation was followed by immediate relief ready separation of the tumor. The pedi- of" all unpleasant symptoms, appetite and cle was found to be the right broad liga- strength returned, the pulse fell to its natu- ment. This was transfixed with a needle ral standard, and in a few weeks she was armed with a double ligature, and each half in excellent health. tied in the following manner, which I de- By the following September, the abdo- scribe with some particularity, for a reason men had again enlarged sufficiently to re- which will be apparent further on. I had produce the symptoms above described, turned the mass out of the abdomen towards which were as speedily relieved by para- myself, and while partially supporting it, centesis as in the first instance, a fluid of tied one half of the pedicle. My friend, Dr. similar character, though in less quantity, -, who stood opposite, said, "Let me having been withdrawn. tie the other half, Doctor, I can reach it I found her, in the following December, more easily than you"; and, in violation with all the evidences of a multilocular of a rule from which I have not since de- ovarian cyst, and with the same derange- parted, I reluctantly allowed him to do so. ment of the general health as had preceded As he tightened the knot, I noticed, what the two previous tappings. The heart's always makes me apprehensive, that he did action was very rapid and feeble, and yet so with a wriggling motion of the hands. the enlargement was not nearly as great as This motion is often seen, and is made, I is frequently seen when the action is little suppose, with the idea that thus the knot is if at all affected by the pressure. My notes more effectually tightened, whereas the of the case do not include a statement of the effect, so far as any is produced, is almost quantity of liquid at this time evacuated, invariably to loosen it. I said, " Doctor, but I think the amount was about eighteen are you sure that is tight ?" He assured me

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 9, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. I have that it was, and I divided the pedicle and äcalpel between it and the pedicle. removed the tumor, which woighed, con- the specimen. Not a sign of peritonitis tents included, forty pounds. The ligatures . appeared. The ligature of the other half were then carried through an opening made was separating kindly, the stump looking in the posterior cul de sac of the vagina healthy. down through that canal, and fastened to Case II.—Mrs. -, aged 30. Was al- the thigh with adhesive plaster. During ways healthy previous to her confinement, the entire operation, steady and even com- which was natural, in the spring of 1-864. pression of the abdominal walls had been . Soon thereafter, 6ho noticed an enlargement maintained by assistants, and my hands.and of the hypogastrium, most marked on the sponges kept constantly moist with artifi- right side. This had very rapidly increas- cial serum at blood-heat. After the cavity ed within the three months previous to my was cleansed, a considerable quantity of this visit, at which time, in January, 1865, .I fluid was poured in and allowed to drain off found her with an amount of abdominal dis- through the vagina. The external wound tention sufficient to cause much interference was then closed by interrupted sutures of with the functions of the viscera, and a silver wire, which included the entire thick- careful examination revealed an ovarian ness of the parietes, except the peritone- cyst. She had been rapidly failing in um. These were placed half an inch apart. strength and flesh for several weeks, and A light compress being placed along the was now entirely confined to the bed, and line of the wound, a swathe was applied so weak as to require assistance in chang- and she placed in bed wrapped in warm ing her position. Her pulse was very rapid blankets, with bottles of hot water around .and feeble,.and her general expression such the extremities. as to give very little encouragement for an The patient recovered readily from the operation. She had suffered from several anaesthesia, and was in excellent condition. attacks of peritonitis, no one of which was •She took a moderate dose of morphia, which very severe. was repeated pro re nata, but a very small She decided to take the forlorn chance of amount being required to control pain. an operation, which I made with the assist- I saw her the next day (Friday) at noon, ance of Drs. Talbot and Pettee, of Wil- and found her still in good condition, no | mington, Vt., and Drs. Charles Bliss and symptoms of peritonitis presenting. She Frank S. Abbott, then my students. The had slept quietly the greater part of the mode of procedure was similar to that night, and was very cheerful and hopeful. adopted in Case I. The tumor, which was On Saturday evening, I received a telegram multilocular, was firmly adherent in many from Dr. Lucas, saying, "- is doing points to the abdominal walls, intestines, splendidly ; she will get well." On Sabbath stomach and liver. The pedicle (right evening, I received another despatch, ask- broad ligament) was transfixed, and each ing me to visit the lady as soon as possible. half tied with a suitable ligature, after A drive of twenty miles over terrible roads which I carried an additional one around .was not very rapidly accomplished, and the whole, carrying the three down through when I arrived, at 3 o'clock, Monday morn- the vagina, as in the first instance. ing, the patient had been dead two hours. She sustained very little shock, and we I learned that she remained entirely comfor- left her, three hours after, comfortable, table till late Sunday afternoon, when she though very feeble. She now got anodynes began to be restless and anxious, complain- pro re nata, requiring only moderate doses, ing of slight abdominal uneasiness ; from and was carefully supported from the first this time she grew gradually weak, pale, with concentrated nourishment—quinine, complained of faintness, sank and .died. wine and muriated tincture of iron. As Dr. Lucas and myself were both of the we feared, her recovery was very slow and opinion that she had died of haemorrhage, tedious. So low was her vitality that the ex- and Dr. L. remarked that he had not " felt ternal wound united slowly, the lower angle easy about the ligature that Dr.-tied." at one time re-opening, through which, as We examined the body, Dr. Paddock, then well as through the vagina, much ichorous, medical student, assisting. The external foetid discharge issued. Such was the con- wound had united by first intention through- dition of her blood, that her mouth and out. The abdomen was filled with blood, throat became aphthous, and ulcérations of which, upon examination, was found to the mucous surfaces occurred in various bave issued from the half of the pedicle places. The septum nasi was attacked and that we had suspected, the ligature having perforated, the opening now remaining ad- loosened, so as to admit the handle of the 1 mitting the little finger. The tonics and

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 9, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. stimulants were increased until heroic doses made through the ulcer down to the ilium ; were given, to which she responded well. these flaps being reflected, a sinus was In addition, the abdominal cavity was tho- found leading through the bone to the in- roughly washed out once or twice daily, ac- side of the pelvis. A probe introduced cording to indications, with artificial serum through this cloaca detected diseased bone at blood heat. This was accomplished by on the inside of the ilium, anterior to using a long pipe (a large catheter answers the point of entrance. Two disks of bone, nicely) attached to. an elastic syringe and one half an inch in diameter, were removed inserted into the opening in Douglass's cul by the trephine—one involving the cloaca de sac, through which the ligatures passed, and the other three fourths of an inch ante- which allowed the fluid ready exit after it rior to it. The intervening bone was then was injected, although for a part of the removed by a chisel. time a portion of it escaped through the The inner surface of the removed bone lower angle of the external wound. was found roughened and a portion of its I advised Dr. Talbot, the attending phy- substance wanting. There was but slight sician, to consider symptoms of peritonitis haemorrhage, and this stopped spontane- indications for this washing out of the ab- ously. dominal cavity, and it invariably had the im- 2. Blepharoplasty. Dr. H. J. Bigelow.— mediate effect to relieve local distress, allay Male, aged 19. In September, 1865, this fever and restlessness, and in every way patient received a gun-shot wound. The improve the condition of the patient. While explosion carried away the surface of the the discharges were of an acrid or offensive right upper lid and frontal region, leaving character, solutions of chlorine were added. a considerable indentation of the bone, but After a tedious illness, this lady made a without injuring the eye. On recovery, the a good recovery, and is now in perfect upper lid was everted and fastened to the health. The tumor weighed 38 pounds. eyebrow, with entire loss of skin and outer Too much praise cannot be awarded to two thirds of the ciliary border. The in- my friend Dr. J. H. Talbot for his faithful, terval between the eyeball and the eyebrow skilful care of this case ; and to his ready was occupied by a red, granulating surface. appreciation of the varying indications and At the first operation, the margin of the the prompt, energetic and skilful manner lid had been brought down from the eye- in which he met them, does this patient owe brow and a large flap, two and one half her recovery. inches long and one wide, had been taken [To be continued.] from the temple as far back as the hair. This was now cicatrized and smoothed, the pedicle having been at a previous time ad- justed. Now, on the outer half of the ciliary margin the mucous membrane is still everted to the extent of one third of an inch. Operation.—The everted edge was MASSACHUSETTS GENERAL HOSPITAL. carefully dissected and brought down, and Surgical Operations for the week ending March 28th. a flap one half an inch wide and two inches Reported by Messrs. Thomas Waterman, Jr., and three fourths was taken, like the and H. H. A. Beach. long last, from the temple, on a line horizontal 1. Necrosis of Ilium. Dr. R. M. Hodges. with the eye. This was secured in the dis- —Female, aged 19. Two years ago, this sected interval by fine sutures. patient received a bruise over her right hip Since the above was written, the whole from a rod. Soreness alone followed, last- flap has united, and the wound in the tem- ing about three weeks. One year later, a ple also, by the first intention. small abscess pointed at this spot, and, 3. Ligation of Eœmorrhoids. Dr. H. G. evacuating itself, continued to discharge Clark.—Patient has had external haemor- for two months, when it closed and remain- rhoids for about a year. Operation, with ed so till two months ago, when the abscess ether. Three double ligatures were passed repeated itself. There has been no pain through the external folds, and the skin and no lameness. On examination, there was cut with a scalpel between the points was found an irregular ulcer, about half an of entrance. The ligatures were then tied inch in diameter, and two inches back of in the grooves (to save time and pain in the anterior superior spinous process of the the ulcération), and the mass strangulated. right ilium ; a probe introduced into this, 4. Tumor of Leg ; Amputation of Thigh. after a little manipulation, reached diseased Dr. R. M. Hodges.—Patient, an Irish boy, bone beneath. A free crucial incision was aged 13. Last August, while bathing,