A Case OF OVARIOTOMY. BY EDWARD BORCK, M. D., MKMBKK OF THE MEDICAL AND CHIRURGICAL FACULTY OF MARYLAND AND I1ALTIMO RE MEDICAL ASSOCIATION, AND ST. LOUIS MEDICAL SOCIETY, FORMERLY ASST. SURGEON TO WEST BUILDING IIOSPITAL, BALTIMORE. MD., AND LATE SURGEON U. 8. VOL., ETC. \lifprmted from the St. Louis Medical and Surgical Journal, April, 187S.~[ sr LouiSr 1878. THE ST. LOUIS Medical and Surgical Journal. ESTABLISHED IN 1843.—PUBLISHED MONTHLY. Thos. IF. Rumbold, M. I)., Editor and Proprietor; Hiram Christopher, M. D Associate Editor. Each Number will Contain 80 Pages, Making a [Volume of Nearly 1,000 Pages. The St. Louis Medical and Surgical Journal commences its Thirty-Fourth Vol- ume with an Increase of ‘24 pages. As it is now printed in smaller’type, the increase in Its pages nearly doubles its former contents. This has had the effect of greatly increas- ing its popularity and, as a consequence, its circulation. The Journal will be conducted in the interests of the profession, and we look to it for that encouragement and assistance so necessary to success, and to the advance- ment of the Science and Art of Medicine and Surgery. Although it is the lHoneer of the Medical Journals of the West, yet its present en- largement gives good proof that it is not too old, nor too set in its way to keep pace with the progress of the age. 1* Original Contributions. 2, Translations from the German, French and Span- ish. 3, Reports of Medical Societies. 4, Clinical Reports from Private Practice. 5, Clinical Reports from Hospital Practice. «, Selections from Current Medical and Scientific Literature. 7, Editorials. 8, Obituary Notices of Prominent Men. 9, Reviews of Medical and Scientific Books. lO, Notices of Books and Pamphlets Received. 11, News Items. 12, Meteorological Observations taken In St. Louis. 13, Mortality Report of the JCity of St. pjouis. 14, Comparative Mortality Rates of the ten largest cities in the United States. The Translations from the German, French and Spanish Medical and Scientific Journals, will be from those articles which contain the advance views of the Medical and Scientific men living in those countries. The .Journal will contain a full Report of the Proceedings of the St. Louis Med- ical Society, and a Summary of all the Societies in Missouri, and of many in Illinois and other States, thus placing before its readers the latest views and experiences of the profession in all the Departments of Medicine, Practical as well as Theoretical. It will be the aim of the Editors, in all respects, to maintain the high and honor- \ able position it has so long held. No personalities shall ever soil its pages; when dis- cussions cannot be carried on without these, space in its columns will be declined. Contributions of Original Articles on both Medical and Scientific subjects are in- vited from all parts of the country. Articles on the following subjects will appear in the present volume: Contributions on Fractures. By JohnT. Hodges, M. D.. Professor of Surgical Anatomy. Fractures and Dislocations in St. Louis Medical College. Contributions on Syphilis. By Thos. Kennaud, M. I)., of St. Louis. Contributions on Lithotomy. ’ By David Prince, M . D., of Jacksonville, 111. Contributions on Genito-Urethral and Rectal Surgery. By W. Hutson Ford, M. D., of St. Louis. Contributions on the Present State of Pathology of Phthisis Pulmonalis. A Series of Papers byJ. Hilgakd Tyndale, M.D., of New York City. Contributions on Genesis. A Series of Papers. By the Associate Editor. Contributions on Urinary and Renal Diseases. By John Bryson, M. D., of 8t. Louis. Contributions on Medical Experts as Witnesses. By Fred. T. Ledergerbkr, Esq., of St. Louis. Contributions on Nasal, Pharyngeal, Aural, Laryngeal and Bronchial Diseases, By the Editor. From the above it will be seen that it is not the intention of the editors to con- fine The Journal to subjects relating to Medicine and Surgery alone; subjects col- lateral to these will receive attention, and such are invited from the profession. The departments of science are so closely connected as to make it almost impossible for a Physician or Surgeon to be proficient as such, without considerable knowledge of kind- red branches. Communications and all Nnhacriptiouft should be addressed to THE EDITOR, 1225 Washington Avenue, St. Louis, Mo. TERMS:—Three Dollars a year, payable in Advance. Single Numbers Thirty Cents. Postage prepaid in all cases. THE JOURNAL WILL CONTAIN: A CASE OF OVARIOTOMY. The following is the history of this, ease as given to me by Dr. E. A. Vogt, the family physician : Mrs Maria A. Bodeman, residing on St. Charles Rock Road, near Rinckles; married; aged 55; German; tall and slender; mother of five children, three grown and two dead. She is of good constitution. Consulted me on the 19th of January, 1878, on account of an enlargement in her abdomen, which was grad- ually increasing ; her right foot was swollen ; she suffered from constipation and sometimes retention of urine; her appetite was good and she slept wel . She stated that seventeen years ago she perceived a small hard lump in her right side and at the same time her menses ceased to appear. Her abdomen grad- ually enlarged and she believed herself pregnant. Not feeling very well she consulted Dr. Heitzig, who informed her that she was not enciente; he gave her a prescription. After she took the medicine the swelling disappeared, leaving a small hard lump in her right side. This was not iollowed by any deteriora- tion of her health until within the last two months, when her abdomen began rapidly to increase in size. On palpation 1 per- ceived a partly hard and partly soft elastic tumor in her right iliac region, extending somewhat to the left of the median line, very slightly movable ; no pain on pressure. Per vaginam ex- amination revealed uterus of normal depth, moveable, and fun- dus drawn a little to the right side; ordered four grain doses of iodide of potassium every two hours; the compound iodine ointment with extract of belladonna to be applied externally morning and night. Gave my opinion as to the presence of an ovarian tumor, which unless diminished by the medicine, would require extirpation to save her life. Under this treatment the patient for the first few weeks thought that she was improving and the tumor diminishing. On the 18th of February I saw her again, the tumor now was much enlarged; called Dr. Hall in consultation, who /confirmed m}r diagnosis, and told her that an early operation would be all that could relieve her. E. A. V. This case then came into my hand. A close examination was made and a multilocular tumor diagnosed with several hard tumors attached, which we thought might possibly be fibroids with adhesions. Uterus moveable; the tumor had increased very much in the last two months; the patient being very tran- quil, having a calm, resolute appearance, but not exactly the facia ovariana (after Wells) and willing to undergo anything for relief. The danger of the operation having been fully explained to 4 OVARIOTOMY. her and husband, she decided in favor of the operation for the 4th of March. In the interval the triends of the patient being desirous of the opinion of another surgeon, it was agreed to consult Prof. John T. Hodgen ; accordingly vve met the Doctor at his office. He examined the patient very care- fully, and gave it as his opinion that the case was one of a mul- ti locular tumor with adhesion, probably very short and broad pedicle; thought the case not very favorable for an operation; advised to still wait a while longer, unless the tumor grew rap- idly, and not to operate as long as the patient was comfortable. Upon this decision the patient was sent home to remain under the care of the family physician for observation. However, the tumor grew rapidly; the patient feeling very uncomfortable, suffering from difficulty of breathing, constipation and pain. I was informed by the family physician that the patient had de- termined to have the operation performed and requested me to be ready by Tuedav morning, March 19th. Under these circum- stances I agreed to operate. I may here take opportunity to state that I, as well as the above named gentleman and the pa- tient, was exceecingly sorry that Dr. John T. Hodgen could not possibly he present during the operation. The next choico was Dr. Louis Bauer, whom I accordingly invited. Everything was well prepared for the operation ; the room was whitewashed, the floor well scrubbed with chloriate of soda and water; towels and bed sheets rinsed in a like solution; all furniture removed; clean wash basins, etc.; a single bed with a new mattress, ready made, and the whole covered with a rubber cloth. Previous to the operation the patient took one grain of opium at 9 o'clock and one grain at 10 o’clock; she was wrapped in flannel blank- ets, with warm water bottles to her feet. Dr. Louis Bauer, who saw the patient for the first time, examined her very carefully, and thought the case was not unfavorable. This decision for the operation was confirmed by the concurrence of all concerned. The patient was then placed in bed and Dr. Charles J. S. Digges administered the chloroform, the patient taking it very kindly. Dr. Hiram Christopher took charge of the sponges which I had previously prepared by washing in a weak solution of nitric acid, and then in a solution of soda, then soaked well in carbolic acid water. During the operation the sponges were washed in carbolic acid water and* then dipped in artificial serum1 before being used again. The Doctor rendered admirable assistance. Dr. E. A. Vogt took position on the right of the patient, sup- fmrting the abdominal walls, which office he performed excel- ently. No intestines or omentum protruded. Mr. Alex. Heb- 1. Artificial serum made as follows : Chloride of Sodium 3 jv. Albumin.. 3 jv. Water Ojv. 31. This was made the temperature of blood heat. Ovariotomy. 5 run, of the firm of A. M. Leslie & Co., surgical instrument maker, took charge of the steam atomizer, which he handled well.2 The room’s temperature was 75° to 80° Fahrenheit. A solu- tion of iodide of potassium and iodine in water was placed on the stove to fumigate the room.3 All the assistants washed their hands in carbolic acid and rinsed them in artificial serum. Dis- tilled water, warm and cold, only was used. The instruments before being used were dipped in carbolic acid water. Having thus everything ivcil prepared and ready, with the kind assistance and skillful precept of Dr. Louis Bauer on the left of the patient and opposite me, I proceeded and made an incision in the linea alba from the umbilicus to within half an inch of the pubis. The cellular tissue was a little oedematous. I divided layer after layer down to the peritoneum, waited till all bleeding, which was remarkably little, had ceased, the patient not losing more than a teaspoonful of blood during the whole operation ; no artery needed tying. I opened the peritoneum and exposed the tumor. There was no adhesion with the ex- ception of three small ribbon-like connections with the perito- neum on the right side, very vascular, which were tied each by carbolized linen thread, cut short. I introduced a trocar into the cyst and drew off nearly a bucket full of dark fluid of a .greenish brown color, very tenacious and gelatinous.4 There was only this one largo cyst to be emptied of fluid, besides which it contained hard masses of lobulatcd degenerated sub- stances. The pedicle was long and thin. I applied a Dawson’s clamp, below this a double catgut ligature, removed the tumor with a pair of serrated scissors, then removed the clamp—there was no bleeding—dropped the pedicle into the pelvic cavity, which needed very little sponging. The wound, which on account of the contraction of the ab- dominal parietes, now measured only four inches, was closed with four deep doubled silk ligatures; a strip of pasteboard, previously w7cll soaked in carbolized oil and dried, was used after the manner of the quilled suture. Seven superficial silk ligatures were next put in, all being well carbolized and waxed. The wound was dressed with lint and carbolized glycerine, cot- 2. The strength of the carbolized solution used for the steam atomizer was carbolic acid, 1 part, alcohol, 1 part, glycerine, 1 part, and distilled water, 5 parts. 3. The iodine fumigation was of the strength of \ gr. iodine, 4 grs. iod. potassium, to g i distilled water. 4. The liquid contained in the cyst coagulated on the application of heat .and nitric acid. On microscopic examination of the fluid it was found to .contain abundance of blood corpuscles :md degenerative tissue. 6 Ovariotomy. ton prepared with salicylic acid was used as a cover;5 then tlie- abdomen was surrounded by a carbolized gauze bandage. One- half of a grain of morphine was subcutaneously injected, the rubber blanket removed, and four hoops fixed to the bed to keep cover from abdomen. The patient rallied admirably from the anaesthesia; no vomit- ing. The tumor and its contents weighed 18 pounds and ounces; the cyst alone 4 lb. 3 oz.; there probably escaped in addition to this 7 to 10 lbs. ot fluid on the floor. The operation lasted 45 minutes from the beginning till the dressing was com- pleted. No one was allowed to enter or leave the room during the operation. Afterwards no one except the nurse was allowed in the room. Carbolic acid spray was used every few hours afterwards. Pulse before operation, 76; after operation, 87; temperature, 95|°; respiration 80. Immediately after opera- tion I gr. morphia, subcutaneously. One hour after this three grains of opium per mouth, and followed by one grain every two hpurs. 1 remained with my patient till 4 o’clock p. m. She was quiet and in good spirits; skin moist; gave her- a little cold milk porridge and water. Was relieved by Dr. Vogt, who remained till 11 o’clock p.m. Pulse 98; temp. 101°; resp. 30. I then took charge again, remaining up all night till 8 o’clock the next morning. Drew half a pint of clear urine by catheter. Patient slept three hours during the night. Pulse 95; temp. 103£°; resp. 28. Takes milk and ice. Lett her in charge of Sister Franzisca of the St. Marien Convent. Noonr pulse 90; temp. 102°. Evening, pulse 100; temp. 105°; respira- tion 30. Slept a little during the day. Passed a gallon of urine. Va- gina and neck of uterus is hot but not tender. During night, pulse 90. 21st.—Morning, pulse 100; temp. 104°; resp., 28. Noon, pulse 90; temp. 1021°. There was no pain ; no symptoms of peritonitis. Introduced two fingers into the rectum to let flatus pass. Evening, pulse 110; temp. 104°; resp. hurried; ene- meta of inf. of mentha viridus; flatus passed well. The excite- ment was produced by mental emotion, from domestic causes and not from her condition. Her tongue was dry; thirst quenched by ice and cold milk. During the night the pulse was 89 ; temp. 100° ; passed urine. 22nd.—The patient is cheerful. Morning, pulse 88; temp. 100°; resp. 25. Evening, pulse 95; tempt. 101°. During night, pulse 90; temp. 101°. 23rd.—Morning, pulse 88; temp. 991°. Uterus and vagina 5. The cotton was prepared as follows : Salicylic acid 3 i, dissolve in sulp. ether g ij. This was sprinkled over the cotton and allowed to evap- orate, which left the acid on the cotton according to Dr. Prince’s method. Ovariotomy. 7 not hot nor tender to touch. The patient took raw egg and iced milk. Noon, pulse 88; temp. 100°. Evening, pulse 96; temp. 100°; resp. 23. Increased the opium to two grains ev- ery three hours. Looked at the wound which was healed with- out any suppuration. 24tii.—Evening, pulse 86; temp. 99°; resp. 22. Patient rested well and complained of not having enough to eat. 25th.—Afternoon, pulse 80; temp. 99; resp., quiet; tongue moist. Removed the four deep seated sutures and two superfi- cial sutures. Not a drop of matter, but a little induration round wound; some gas in the intestine. Treatment continued, 26th.—Pulse 80; temp. 99at noon; sleeps well; passes urine freely; is tranquil. 27th.—At noon, pulse 86; temp. 99°; resp. 22. Removed .all stitches, wound healed and not a drop of pus; dressed with vaseline, enemeta of soap water and ol. ricine ; had a good evac- uation and flatus passed; skin moist; treatment continued; al- lowed pigeon broth. 28th.—Pulse 90; temp. 100°; resp., L8. An evacuation of the bowels followed an enema. Slept well; skin and tongue moist. 29th.—Pulse 86; temp. 98£°; resp. normal. Slept well; had three natural evacuations of the bowels. 30th.—Pulse 86; respiration and temperature normal. Slept well; passed water. Ordered chocolate. Wound looks well; no suppuration; abdomen natural and soft; skin and tongue moist. She is left in the care of the family physician, Dr. Vogt. Will not visit her until next Thursday, unless called to •do so. From the above daily report, it is seen that the patient is do- ing well. She has taken in all 102 grains of opium and one- half grain of morphine—the latter hypodermically. She may now be considered as having passed the most dangerous time. The farther history of the case will be given in the next number of The Journal. The success of this case may be attributed to the favorable circumstances surrounding the patient. She was in good health and spirits, feeling confident that she would survive the opera- tion, and I think that the time for operation was well selected, for had this been delayed—had her health began to fail, and had the tumor grown larger, the prospect might not have been as good as it is now. The weather also was very favorable, the temperature being mild. Sbe had excellent nursing. Although her room was on the lower floor, yet it had windows to the east and west, and doors on the north and south. She had the bene- Continuation of the History of the Case Reported on Page 309 of the April No. of The Journal. April 4th.—Saw patient for the last time with the family physician. She was able to sit up in bed; pulse, respiration, temperature and secretions normal; ordered a dose of quinine of gr. v., to be taken every day for a few days. Nurse dis- charged. Her husband informed me, on the 11th of April, that she had been walking in the garden for two days. The family physician writes me, on April 20th, as follows : “Saw Mrs. Bodeman April 6th; she was in every respect doing well. April 15th found her working in her garden; says she feels now like one having new life.” From the above report it will be seen that the patient made a quick and uninterrupted recovery, being able to walk about on the 21st day after the operation. 1 may, in addition, state that I have subjected the fluid again to examination. The reaction was alkaline; the degenerated tissue was perhaps fatty degenerated epithelial cells; but I could not find a single distinct epithelial, nor pus cell. Errata in the last number:—Read that the incision was made from the umbillicus to within one and one-half inches of the pubis. E. B. 8 Ovariotomy fit of country air. Undoubtedly a part of the credit must bo given to the careful and scrupulous preparations, and although some surgeons do not put much faith in Lister’s Antiseptic method, yet one thing is certain, that to follow it enforces dis- cipline and care, which is essential to success. The walls of the cyst were thick and dense. The peritoneum lining the abdominal wall, was remarkarbly thick and so dense that it was with difficulty that I could thrust a needle through it. In conclusion I wish to express my sincere thanks to Ur. Louis Bauer for the promptitude with which he rendered me his valuable assistance; and to Dr. E. A. Vogt for carrying out so carefully all directions given him in the preparation of the pa- tient, and for his prudence and good judgment in the after treat- ment. Also to the other gentlemen for their assistance, and Sister Franzisca for her faithful discharge of her arduous and responsible duty. 3613 North Ninth St.