bjg ? WHAT IT IS AND HOW TO DO IT, BY JULIUS F. MINER, M. D., Professor of Special Surgery in the Buffalo Medical CoLifROE, BUFFALO. NT. Y. [Reprinted from the Buffalo Medical and Surgical Journal, June, 1875.] BUFFALO: Baker, Jon.es & Co., Printers, 330 and 332 Washington Street. 1875. iipfiD wnj|| iixl l-hI-Iid n ♦ T © WHAT IT IS AND HOW TO DO IT. BY JULIUS F. MINER, M. D., Professor of Special Surgery in the Buffalo Medical College, BUFFALO, N. Y. [Reprinted from the Buffalo Medical and Surgical Journal, June, 1S75.] BUFFALO: Baker, Jones & Co., Printers, 220 and 222 Washington Street. I§75- WHAT IT IS AND HOW TO DO IT. JULIUS F. MINER, M. L)„ Professor or Special Surgery isr the Buffalo Medical College. It is now about six years since I first announced to the profes- sion that the Ovarian Tumor could be removed by Enucleation, and invited my professional friends to make trial of the proposed plan, describing as well as I could what I had done, and the con- clusions I had formed. The idea that a tumor having such large arterial supply could be removed without clamp, ligature or cau- tery, though at first startling, was very readily accepted, and both in this country and in Europe, successful trial has led many of the most distinguished operators to not only make trial of it, but to speak of it in high terms of commendation, until now it is one of the established and acknowledged methods of operation. By the numerous reports and papers upon the subject, I discover that the exact manner of enucleation is not yet distinctly understood, some have spoken of clamp after enucleation, others have spoken of cutting, the very thing it is designed to avoid. Others still have limited the detachment of the pedicle to two or three inches above its base, thus showing me that I have never been fully understood in the method of removing ovarian tumors by enucleation, a plan which my experience convinces me, if properly understood and 4 OVARIOTOMY BY ENUCLEATION—MINER. executed, possesses advantages over all others and is of almost uni- versal application. It is well known that the ovarian tumor is surrounded by a peritoneal covering, that the pedicle, proper, usually divides into three or four parts passing up o?er the walls of the tumor in bands of variable width containing vessels often of large size, which with connective tissue, make a band which passes over the walls of the cyst, gradually diminishing in thickness and in the size of the vessels it contains, until finally it is lost in a simple thickened part of peritoneal covering. The peritoneal covering is not closely attached to the cyst, but separates readily the same that the peritoneum separates elsewhere in the pelvic cavity, being im- mediately lined by the sub-serous cellular tissue, thus no vessels of any considerable size enter the cyst. This cyst separates from its attachments with remarkable readiness, so much so that in sev- eral instances it is reported to have escaped the grasp of the opera- tor and fallen spontaneously from the pedicle; Providence, or ac- cident plainly indicating the natural and proper method of removal* The capillary vessels thus broken do not bleed, the band con- tracts and corrugates the larger trunks, while the broken off capil- liary vessels thus separated ooze only a little for a minute or two, a dry napkin applied for a short time is all that is required. The fear of hemorrhage is wholly unfounded, and I now say without hesitation that the danger of bleeding after this mode of proced- ure is vastly less than the danger of slipping of clamp or ligature in the former methods, when the vessels are divided in their trunks. Here they are separated only in their extreme branches and cannot bleed—do not give troublesome hemorrhage; it is rare that any ves- sels are torn large enough to be seen as vessels or points of hemor- rhage, and torsion is all that can be required in almost any case. If care is taken not to wound the vessels with either trocar, knife or scissors, there will be n6 hemorrhage. The tumor being thus removed the operation is completed. There is no clamp to be used, there is nothing to clamp, the pedicle is not to be treated, it requires no attention except careful manipulation and resting back in its original place as near as possible, if the usual conditions are pres- ent no drainage is necessary, the incision may be closed as perfectly as possible. These bands are to be grasped where they commence OVARIOTOMY BY EXTTCLEATIOX—MIXER, to diverge with the hand and raised from the cyst, tracing out the band to its termination often nearly around to the opposite side. The idea is not that the cyst is to be separated from a capsular in- vestment, as some tumors are enucleated. It is only to be sepa- rated from its vascular supply which is contained in these bands. Any other attachments are to be separated in the usual manner. Care is necessary not to wound or divide the vessels in their trunks, and although the attachment will sometimes he found very strong at points, it can be forced off, or even with care a small piece of The above cut hastily drawn by Dr. Brush, who has assisted me in operating several times •will give a very fair idea of the procedure. The fingers of the operator are represented be- neath a vascular portion of the pedicle, separating it from the walls of the tumor. Tnis sep- aration is to be carefully made until the vessels are traced to their termination. To make the illustration plainer, the tumor is represented as raised from the abdominal cavity. Of course where extensive adhesions are present this is impossible, and the risks of removal are very great. Formerly these cases were abandoned. The adhesions are to be separated and the process continued to the pedicle. OVARIOTOMY BY EXUCLEATIOX—MIXEIi. the cyst may be left attached to the pedicle, and no harm can result from it, it has vascular supply, and is living tissue, like all the rest of the pedicle which is left. Nothing remains to suppu- rate, become encysted or to be absorbed or otherwise provided for. Again this plan may be tried first and no harm result from it. If for any reason it should be deemed impracticable, a clamp, the most unsurgical appliance in the world, can be equally well applied. The pedicle can subsequently be burned or tied with ligature equally well as if enucleation had not been tried, for I am going to say that few rules in surgery but have exceptions, and though I believe all ovarian tumors can be, and should be removed by this simple method, supplemented when necessary, by torsion or silver ligature to small vessels which bleed, still I desire to provide for all possible contingencies, and give the operator the assurance that he can try enucleation, and being dissatisfied with it he is yet at liberty to adopt any other plan he may prefer, so that while everything may be gained, nothing can be lost. There is no reason for pointing out the advantages of the plan. Those who have studied the history of ovariotomy and are iamiliar with the difficulties and objections which may fairly be urged against all former methods of procedure, will at once apprehend that if enucleation is successful he has no pedicle keeping open the lower angle of the incision, or dragging upou the parts; no unfa- vorable adhesions of the pedicle, no wires to be discharged, by sup- puration, no crusts of burned tissue to be provided for. The ab- dominal cavity has been opened and ihe diseased part removed. All that is left is capable of life. It has been supposed that enu- cleation was designed to apply to cases of extensive adhesions or short pedicle, where no other plan could be adopted, thus lessen- ing the number of incompleted operations. Most clearly it is capable of this, but instead of its being reserved as a dernier ressort it is to be chosen first, and the case regarded as most favorable when it can be successfully accomplished. My surgical friends who have seen the operation unite in regarding it as the most nat- ural surgical procedure possible. To see it is to be convinced of its entire feasibility and safety, while its advantages are too appar- ent to require a moments consideration. OVARIOTOMY BY ENUCLEATION MINER. Since writing the above, two cases, illustrating every point con- nected with Enucleation, have fallen under notice. Prof. James P. White operated by enucleation in Oneida county, and desires me to say, he has now adopted the method in four cases, and thinks “this method to be chosen first, and if vessels bleed, or any conditions are found, making it necessity to employ former methods, to do so after trial of enucleation.” Wednesday, June 23, I had also opportunity to satisfactorily demonstrate every position taken in this paper, to nearly the entire profession of Buffalo, by au operation upon a private patient, Mrs. Cobb, from Penn., removing by the above method au ovarian cyst of great size, without any vessel requiring even torsion, and without any haemorrhage at all. It was one of those cases formerly abandoned by surgeons as immovable, on account of adhesions, being closely adherent to the walls of the abdomen on all sides. After cutting- down upon the cyst proper, it was easily pulled out of its bed; no pedicle being found which would make it impossible to remove it by any of the former methods. Mrs. Cobb died the third day in con- vulsions. But enucleation is not for these desperate cases alone; it is applicable to all cases, and as Dr. White fairly states, is to be chosen first, other plans adopted, after trial of this.