Five Cases of Ovariotomy in Women over Seventy Years of Age BY HOWARD A. KELLY, M.D. Professor of Gynecology and Obstetrics in tbe Johns Hopkins University, Baltimore, Md. Thu American Journal of Obstetrics REPRINTED FROM V..i, XXXH-. No 2.1890. NEW YORK WILLIAM WOOD & COMPANY, PUBLISHERS 1896 FIVE CASES OF OVARIOTOMY IN WOMEN OVER SEVENTY YEARS OF AGE.1 In the Johns Hopkins Hospital Reports, vol. iii., Balti- more, 1894, page 509, I collated and tabulated, with Dr. Mary Sherwood, one hundred and fifteen cases of ovariotomy in wo- men over 70 years old. I then reported in full two of my cases, aged respectively 75 and ?3 years. The first was one of a rapidly growing right ovarian multilocular cyst with elongation of the adherent uterus up into the abdominal cavity (ascensus uteri). The tumor was removed June 18th, 1890, and the patient made an uncompli- cated recovery. She died nine months later after an attack of grippe. The second case was a left ovarian cystoma with areas of adeno-carcinoma. The tumor was removed July 11th, 1892, and the patient recovered rapidly. The three cases which I now add to the list are as yet unre- ported. Case 111.—Mrs. N., patient of Dr. Fenby, aged 74-J years ; menopause between 45 and 50 years. She had noticed the pre- sence of a tenseness of the abdomen for one year past; there was no pain, but a constant languor, and a bearing-down in the pelvic region. The distension grew and she lost flesh apace, and for several months there had been nausea and indigestion. 1 Read before the Gynecological and Obstetrical Society of Baltimore, May 12th, 1896. _ 2 KELLY : FIVE CASES OF OVARIOTOMY I found a large multilocular ovarian cyst filling the abdo men, which was 102 centimetres in circumference and measured 42 centimetres from pubis to ensiform. The tumor was uni- form in its outlines, but I diagnosed a multilocular cyst by noting the marked difference in tension between the fluids contained in the upper and lower poles while palpating it bi- manually. Operation August 28th, 1895. A long incision was made through fat abdominal walls, exposing the nacreous surface of the cystoma, which was tapped, evacuating 2,600 cubic centi- metres of dark, bloody fluid, specific gravity 1020. There was an area of omental adhesions on top of the tumor, covering a surface 6by 4 centimetres. The cyst was turned out, and its very vascular pedicle, 5 centimetres broad, on the left side, was tied off. The uterus lay in anteflexion. The opposite ovary was not diseased. The incision was closed with four layers of sutures, using continuous catgut for the peritoneum, silver wire through the fascia, and continuous catgut for the fat and sub- cuticular layers. The cyst was peculiar in that the mesosalpinx was obliterated, spreading the tube out flat on its surface. The patient recovered rapidly, sitting up on the eighteenth day. The incision at the time of her discharge, twenty-five days after the operation, looked like a fine hair line. Pathologist’s Report.—Specimen consists of ovarian cyst 23 by 23 by 15 centimetres in size. The upper part of anterior surface presents area of omental adhesions 8 by 4 centimetres. Remainder of surface smooth, glistening, and traversed by deli- cate, branching blood vessels. Fallopian tube, 12 centimetres long, is attached to the cyst by mesosalpinx, and the fimbriated extremity is stretched out over its surface, covering an area 13 by 4 centimetres. The cyst contains a large cavity, 14 centime- tres in diameter, and numerous smaller ones divided by fibrous septa. Its walls average 1 millimetre, in one or two places, however, reaching 2.5 centimetres. These thickened portions consist of a honeycombed network of fibres containing small cyst cavities. Cyst contained dark brownish-red, hemorrhagic fluid. Histologically the cyst walls are composed of fibrous tissue lined by one layer of cylindrical epithelium. Many por- tions contain necrotic areas; there is also evidence of old hem- orrhages into the tissue, especially surrounding the necrosis. Fallopian tube is normal. Diagnosis, multilocular adeno-cys- toma of ovary. IN WOMEN OVER SEVENTY YEARS OF AGE. 3 Case IV.—E. J., 71 years old, and thirty-one years past the menopause, was sent into the hospital from the dispensary by Dr. W, W. Russell, complaining of an “abdominal tumor.” She had first noticed an enlargement in the abdomen four or five months before, which increased steadily up to the time of her admission ; she had constant pain and cramps at times and was very sore to the touch. Her feet and ankles were more or less swollen, especially the left foot and ankle. Micturition for several months past had been difficult, and there was a constant irritability of the bladder. She had lost much flesh, was ane- mic and sallow, and had a bad cough. Examination.—The abdomen was distended by a dome-like tumor, most prominent on the left side between the umbilicus and symphysis. The pelvic organs were senile and the uterus crowded down on the floor under the tumor. Operation for left ovarian adeno-cystoma, April 35th, 1896. As the tumor was adherent to the entire lower anterior abdominal wall, the incision was made from symphysis to umbilicus and the abdominal cavity first opened above. The tumor was punctured and 3,500 cubic centimetres of yellowish, mucoid contents evacuated. The adhesions to the abdominal wall were then stripped off with the fingers and the tumor turned out, its broad pedicle clamped and divided, freeing the growth. After ligating the vessels at each end of the pedicle, a large hematoma was found dissecting its way up along the ovarian vessels above the sigmoid flexure. The vessels were completely hidden in this, so I drew the descending colon toward the median line and incised its mesocolon 6 centimetres above the brim on the outer side and exposed the ovarian ves- sels there, well above the hematoma, and tied them, preventing further hemorrhage. It was then easy to squeeze out the blood below and catch the vessels at that point also. The edges of the incision into the mesocolon lay in such good apposition that I did not suture them. In seeking out the ureter above and below the brim I was confused for a while by finding a calca- reous, spindle-shaped enlargement of the internal iliac artery just below the bifurcation, feeling like a stone in a ureter ; the common and external iliac above this were soft and pliable. The abdomen was closed without a drain and the patient made a good recovery. She is still in the hospital. Pathologist’s Report.—Specimen (not examined microscopi- cally) consists of a multilocular ovarian cyst approximately 17 4 KELLY : FIVE CASES OF OVARIOTOMY centimetres in size ; for the most part smooth and glistening, but presenting a few adhesions. Numerous small blood vessels radiate from attachment of pedicle over its surface. Springing from the cyst on outer side of pedicle is a pedunculated cystic nodule 9 by 6 by 5 centimetres, consisting of delicate-walled cysts which contain transparent yellow fluid. The pedicle also contains small cyst cavities, on the inner surface of which calca- reous material has been deposited. This nodule is encircled by Fallopian tube. The large cyst walls average 2 millimetres in diameter ; large areas, however, vary from 0.5 to 3 centimetres. These thickened portions on their inner surface present delicate cysts ; more deeply are composed of a dense fibrous network, the interstices containing thick, creamy fluid, also small amount of calcareous material. Springing into the cyst from these portions are large, irregular, exceedingly friable masses, also consisting of a fibrillated network in the meshes of which is a thick, creamy substance. The remaining portion of the inner surface of the cyst is covered by yellow, friable material, removed with difficulty, leaving roughened surface beneath Fallopian tube 10 centimetres long. Fimbriated extremity free, patent. Case Y.—Mrs. B. A. W., a patient of Dr. Snively, of Waynesboro, Pa. She was 72 years old and twenty-two years past the menopause. She had always had good health. Be- tween two and three weeks before my examination, while tak- ing a bath, she had noticed a hard lump in her side, low down. She had no pain or other discomfort than frequent micturition. I found on examination that the pelvis was choked with cys- tic tumors firmly wedged in and adherent; the mass extended up into the lower abdomen and was made up of a number of thin-walled cysts. May 2d, 1896, operation for papillary ovarian tumors ex- tending on to the peritoneum. A median abdominal incision was made and the pelvis and lower abdomen found choked by the growths, mostly with thin walls, and everywhere below densely adherent. There were some papillary masses on the peritoneum, and one on the tumor, just under the incision, was removed for examination. Enucleation was out of the question on account of the adhe- sions and the invasion of the papillary elements into the gene- ral peritoneum, and the abdomen was closed. The patient has recovered from the exploratory operation. IN WOMEN OVER SEVENTY YEARS OF AGE. 5 RECAPITULATION OF FIVE CASES. | Case. 1 Age. Tumor first observed. Character of tumor. Past menopause. Operation. Result. 1 75 Two years Right side : Three large cysts, Twenty-five Cystectomy Recovery. before. bloody fluid in largest; part- ly intraligamentary. Ascen- sus uteri. Uterus 21 centi- metres long. Circumference of abdomen 103.5 centime- tres. years. June 18th, 1890. Died of grippe and heart dis- ease nine months later. 2 73 One year be- fore. Left ovarian cystoma with Twenty-five areas of adeno-carcinoma. 1 years. Contents 4,000 cubic centi- metres chocolate-colored1 fluid. Monocyst with septa. 1 Cystectomy July 11th, 1892. Recovery. 3 74 One year be- fore. Left bilocular cyst containing Twenty-five 2,600 cubic centimetres of i to thirty dark, bloody fluid. ! years. Cystectomy August 28th, 1895 Recovery. 4 71 Four to five months be- fore. Left adeno-cystoma of ovary containing 3,500 cubic centi- metres of mucoid contents; partly intraligamentary; mesosalpinx obliterated. Thirty-one years. Cystectomy August 25th, 1896. Recovery. 5 72 Two to three weeks be- fore. Papillary ovarian cysts chok- ing pelvis, spreading on to peritoneum. Twenty-two years. Exploratory operation May 2d, 1896. Recovery. These 5 cases have occurred in a series of 1,700 abdominal operations—that is, in a proportion of 1 to 340. During the same period of time I have operated upon about 150 ovarian cysts, making the proportion in old age about 1 to 30. Out of the 115 cases reported in women over 70 years, 8 tumors weighed over 50 pounds. These were the patients of Dr. L. J. Cooker, 55 pounds ; Dr. Joseph Eastman, 50 pounds ; Dr. R. B. Hall, 59 pounds ; Dr. John Homans (3 cases), 75, 72, 61 pounds; Dr. Peugnet, 55 pounds; Dr. J, M. Sims, 58 pounds. Thirty cases out of 44 were reported in our list as still living from one to seven years after operation. The interest of this subject is due to the extreme age of the patients, and the fact that the tumors had developed in organs long past their period of functional activity, averaging twenty- six years after the menopause in my 5 cases. Women over 60 years of age are apt to look upon an opera- tion for an ovarian cyst as far more dangerous than a like operation in a younger woman, and for this reason they will even postpone any radical procedure indefinitely. My statistics show that this hesitation on account of age is not well grounded and that the risk is little if any greater at the advanced period of life. This is well shown by the fact that out of a total of 115 cases in the tables, in the hands of 6 KELLY : FIVE CASES OF OVARIOTOMY. sixty-six different operators, only 15 died. I think this record would hardly be improved, if indeed it could be equalled, in a list of younger women with the same number of operators. The risk in the aged closely approximates that in children. Bland Sutton states that out of 35 non-sarcomatous ovarian tumors operated upon in young children, 31 recovered, a mor- tality of 11.4 per cent. Three of the patients who were over 80 years of age all recovered. In the Lancet for 1895 Matthew Owens reports a successful ovariotomy in a woman 87 years old. MEDICAL JOURNALS PUBLISHED BY WILLIAM WOOD & COMPANY. MEDICAL RECORD. A WEEKLY JOURNAL OF MEDICINE AND SURGERY. The Medical Record has for years been the leading organ of the medical profession in America, and has gained a world wide reputation as Hie recog- nized medium of intercommunication between the profe.-sion throughout the world. It is intended to be in every respect a medical newspaper, and contains among its Original Articles many of the most important contributions to medical literature. The busy practitioner will find among the Therapeutic Hints and in the Clinical Department a large fund of practical matter, care- fully condensed and exceedingly interesting. 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