A CASE OF OVARIOTOMY. (UNSUCCESSFUL.) BY EDWARD BORCK, M. D., MEMBER OF THE MEDICAL AND CHIRURG1CAL FACULTY OF MARYLAND AND BALTIMORE MEDICAL ASSOCIATION; ST. LOUIS MEDICAL SOCIETY; MISSOURI STATE MED ASS-; TRI-STATE MED. SOCIETY; FORMERLY ASST. 8 URGE ON TO WEST BUILDING HOSPITAL, BALTIMORE, MD , AND LATE SURG. U. S. VOL8., ETC. [Reprinted from the St. Louis Medical f Surgical Journal, December, 1878.\ SAINT LOUIS: 18 7,9. A CASE OF OVARIOTOMY. The following is the previous history as furnished me by the family physician, Dr. Thomas O’fteilly : “Miss Jessie J. S., accompanied by her mother, called at my office July 14th, 1877. She was a school girl about fourteen years old, and had menstruated regularly for a year and a half. Her general health was good, but in the region of the left ovary there was a diffused swelling, unaccompanied with fluc- tuation or defined border. I informed the mother that the tume- faction was ovarian, but I could not then determine its exact na- ture ; ordered a mild diuretic aperient and iodine paint, and di- rected liei' to call again at my office in a week. On the 21st of J uly she was again examined, when 1 felt satisfied of the pres- ence of fluctuation, which determined me in the opinion that it was an ovarian cyst. From this date until March 16,1878, I saw her occasionally; saw her in consultation with Dr. Hodgen, who confirmed m37 diagnosis. Dr. Gregory, wTho was to have met us on this occasion, being prevented from so doing, saw her some few days later, and fully concurred in the diagnosis. At this time the tumor had become greatly enlarged and more circum- scribed. As there was nothing new’ to suggest, I did not see the patient again until the 6th of October, when the father called up- on me to say that he and his family had fully determined on ovariotomy, and that he had selected Dr.Edw. Borck to operate; 1 visited my patient in conjunction with the Doctor, who will con- tinue the history of the case. Thos. O'R.” Mr. and Mrs. J. S., residing at No. 104 South Fifteenth Street, City, consulted me in the beginning of September, 1878, concern- ing their daughter Jessie, aged fourteen years, ten and a half months—American. She is about five feet four inches high, blue eyes, reddish brown hair, cheerful and lively temperament, of good education. Pulse before examination, 90. afterwards 100; diagnosis ova- rian tumor; gave no opinion. 1 saw her again about two weeks later; pulse before examina- tion 86, soft and regular, afterwards 92; well expressed facia ovariana; face and upper extremities emaciated; skin fair; no oedema of legs and feet; measurement around the umbilicus fifty- two inches ; veins of abdomen prominent; on deep inspiration the abdominal walls could be seen moving over the tumor, and could be lifted up by the hand; respiration rather hurried, 32; men- 2 A Case of Ovariotomy. struation regular but scanty up to a month ago, when it ceased ; no trouble with the urine, bowels tolerably regular, appetite not very good; does not care much for substantial food ; tongue slight ly coated; percussion sound dull ; fluctuation distinct. No exami nation per vagina nor necturn for obvious reasons. The case was a well marked single cystic tumor. The patient’s condition was onerous, still she seemed to carry her misfortune with great fortitude, and desired to be relieved il possible, such being also wish of the parents. Tapping was dis carded, as they rightly understood that the relief would be but temporary, and in her present state it was evident that she could not very long survive, as the cyst was filling up, and, her health rapidly failing, humiliation was more developed than her ap pearanee indicated. The consideration for an operation wasonl ) left then as a last resort, and the only hope of saving her life. I carefully explained the danger of an operation to the family. Though I regarded this case itself rather favorable for an opera tion, 1 avoided giving them any encouragement whatever towards success, and made no promise, except that if they should select me I would operate and give all the attention possible. Advised liberal diet and fresh air. October 6th I saw the patient in consultation with the family physician; no change. After mature consideration and consul- tation on the part of the family, they decided for the operation. The 15th of October, 12 o’clock m., was selected; accordingly all preparations were made as in my previous cases. The patient was in good spirits, and seemed confident of recovery. The evening before the operation an enema was administered to evacuate the bowels; a cup of milk and bread allowed. On the morning of the operation, after bathing, she was dressed with a short gown, flannel drawers and stockings. A cup of milk and bread allowed; the patient was then put into an easy chair, kept quiet, wrapped up in blankets, warm water bottles put to her •feet, and room steamed with hot water to keep her moist. This is essential; dry cold skin would be a disadvantage. The operating room being prepared, the assistants all exposed them selves for some time to the spray of a solution of carbolic acid, and washed their ha‘nds in carbolized water. The patient was brought in, and having been placed in her ready made bed, and with the able assistance of Drs. I). V. Dean, Thomas and Robt O’Reilly, Chas. J. S. Digges, PI A. Vogt, Mr. Alex. Heburn and Sister Micheale, of the St. Marien Convent, 1 proceeded : Chloroform was administered, but after a few whits she began to vomit, and sulph. ether was substituted. I made an incision through the skin about two inches long, below the umbili- cus in the linea alba; she vomited again ; dissected down to the peritoneum ; after all hemorrhage ceased, divided it, having satis- fied myself that there were no adhesions, i lengthened the incision about three inches toward the pubis; this exposed well A Case of Ovariotomy. 3 the bluish looking cyst; thrusting my elevator into the sac I intro- duced the trocar ami drew off the contents; none of the abdominal viscera protruded ; the cyst was then entirely lifted out of the abdomen; the pedicle was short and not very thick ; clamp ap- plied ; below this a single and one transfixed catgut ligature ap- plied ; pedicle cut and clamp removed ; the pedicle contracted and part of it slipped from under the ligature; some hemorrhage en- sued, but prevented from running into the pelvic cavity by the quick attention of one of the assistants compressing the lips of the wound around the stump. I then tied a double transfixed silk ligature around the pedicle, arid after all hemorrhage had stopped, flie abdomen was very carefully cleaned of what little blood could be found; the pedicle returned into the abdomen ; the wound closed with four deep seated double well carbolized silk lig- atures and two oiled pasteboard strips, used in the manner of a quilted suture, thereby bringing the internal suriaces of the peri- toneum together in apposition; about eight superficial sutures were next introduced to close the wound completely; the wound measured three and one-half inches after closing; dressed with carbolized glycerine and lint, covered with prepared cotton; a bandage of gauze finished the dressings; the hoops fixed to the bed and patient covered with blankets; one-fifth grain of mor- phine subcutaneously injected into the arm ; lost about one ounce of blood in all. The vomiting was very troublesome and obsti- nate during the operation. The operation had to be suspended several times on account of it, thereby causing considerable delay; at one time it was so severe that it took the hands of three assistants to support the abdomen firmly to prevent the es- capement of the viscera; the occurrence of this unfavorable symptom was much regretted by all present. The operation lasted two hours from the beginning of the pi*eparation until the patient was dressed. Before the operation : Pulse, 80 ; respira- tion, 40 ; after the operation : Pulse, 120 ; tempei’ature, 99.2° ; respiration, 36. 3 p. M.—Administered opium gr. i, followed shortly after by vomiting; ice given at intervals. 6 p. M.— Pulse, 122; respiration, 23; vomited; ice; oxalate cerium gr. i. 9:30p.m.—Vomited once severely; ice; slept 50 minutes; ice; slept again until 11 o’clock; ice; vomited. Oct. 16th, 2 a m.—One-fifth grain of morphine subcutaneously over epigastric region ; slept till half past 5 o’clock; pulse, 100 ; temperature, 100°; no vomiting; passed urine twice naturally. 10 a. m.—Pulse, 120; passed urine again; vomited; ice, beef tea, milk. 2:30 P. M.—One-tenth grain morphine; quiet. 6 p. M.—One-fifth grain morphine; pulse, 130. 7 P. M.—Pulse, 120; respiration, 27. 4 A Case or Ovariotomy. 8:30 p. M.—Pulse, 132; respiration, 28 ; awake. 9 p. m.—Pulse, 125 ; respiration, 27 ; asleep. 12 p. m.—Pulse, 98 while asleep. Oct. 17th, 6 a. m.—Pulse, 111; temperature, 99°; respiration, 28 ; awake ; passed urine. 7:30 a. M.—One-fifth grain morphine; pulse, 125 ; fore part of night quiet, after part restless. 12 m.—Pulse, 110; temperature, 99° ; respiration, 24 ; Vom- ited ; gr. i oxalate cerium; ice, milk. 6:30 p. m.—Pulse, 135 ; respiration, 27. 9:30 p. M.—One-fifth grain morphine. 10:30 p. M.—Pulse, 102; asleep; feels weak; beef tea and brandy, 1 ounce, per rectum. Oct. 18th, A. m.— Beef tea and brandy per rectum; a little nauseated; gr. i oxalate cerium; ice; slept all night tranquilly. 5:30 a. M.—Pulse, 124; respiration, 24; awake. 6 a. m.—Pulse, 102 ; respiration, 21; awake. 7 a. M.—Dressed wound in presence of Dr. Thos. O’Reilly; it looked well; no pus whatever; healed by first intention; no per- itonitis; no tympanitis except over the region of the stomach when full with fluid; thought some of the stitches could be re- moved next day; pulse, 120; -j gr. morphine; sleeps. 12 m.—Pulse, 120; temperature, 100°; respiration, 20. 2 p. m.—Beef tea and quinine per rectum; vomited; patient became irritable and peevish ; no change up to 4 :30 p. M, when 1 left her for a short time, returning at 7 :30 o’clock; 1 was in- formed that she had become worse; the priest had been sent for, also the family physician, and that she was now unconscious; pulse, 158; respiration, 20, and spasmodic; administered 1 oz. of brandy and milk per rectum; repeated it again an hour later; warm water bottles to feet; she revived enough to recognize her parents; swallowing difficult. 10:30 p. M.—Respiration, 11; spasmodic; she gradually sank and expired at 1:30 a. m., October 19. I will state that I operated under the carbolic acid spray. A battery was held in readiness, but not needed. The temperature of the room during operation was 80° F., and was kept at about 70° afterwards. A window was also kept partly open in adjoin- ing room, and the steam atomizer occasionally used to keep the air moist. One-quarter gr. of morphine in granules was tried twice internally, but ejected; afterwards the morphine was always sub-cutaneously administered over the epigastric region; milk, beef tea, gruel and ice cream could not be retained; brandy and water sometimes. After vomiting, the patient always felt relief, but the craving for water and ice was intense, so that she had to be restrained. She would remain quiet until the stomach was again filled with fluid, bloated up and distended; after vom- iting, the stomach would collapse. About one-half hour before death, her stomach being full, a gurgling noise was heard; the fluid seemed to escape into the intestine; no power to vomit. A Case of Ovariotomy. 5 Previous, during the act of vomiting, she would support her ab- domen herself with both hands, and often requested me to lay my hands over the stomach and make a gentle pressure, which was agreeable to her. She was a good, sensible and obedient patient. I remained at the house every night and the greater part of thp day, being relieved in the morning and afternoon, a short time alternately, by Drs. Idggens and Vogt, to whom I am especially indebted for the care bestowed upon the patient dur- ing my absence, and to the family physician for the interest he took in the case, as well as to the other gentlemen and the sister, who admirably and faithfully performed her duty. All the directions were minutely carried out by all the members of the family, for which they deserve great credit. About six gallons of fluid were drawn from the cyst ; clear, like water; specific gravity not quite 1004; contained slight traces of albumen; very slightly acid; cyst itself weighed three and one-half pounds. Microscopic examination not satisfactory; the fluid had spoiled before I had time to examine it; no post mortem. Ovariotomy has been performed a number of times during the past ten years by different surgeons in this city. It would be both instructive and interesting, as well as a valuable contribu- tion towards the statistics, if correct reports of all these cases and their results were at hand. DESCRIPTION OF CYST ELEVATOR. Fig. 1. A, the elevator. B, a cap to protect the|points. This is a simple instrument made of strong steel wire, shaped like a tuning fork, slightly curved, representing a double needle. See fig. 1, A, half size. This is thrust in- to the cyst alter opening the abdomen, linear as shown in Fig. 2. It is then v handed to the first assistant, who holds it upon the fingers of his right hand, as shown in Fig. 3. The trocar is introduced by the operator perpendicularly down into the cyst, and between the prongs ot the elevator and the fingers. The advantage of this method is : no fluid can escape from the cyst, and as the sac empties itself it is gently and very slowly drawn out by the assistant; the trocar is pushed deeper at the same time, the abdominal walls collapsing around the cyst, which are supported by the hands of another assistant, thus pre- Fig. 2. 6 A Case of Ovariotomv. v mting any of the viscera from protruding, and by the time the cy it is nearly empty it is also almost drawn out from its bed, the hold is firm, and necessary traction and manipulating is avoided, and no air can enter; if needed, a ligatu -e can be applied around ihe cyst and trocar below the prongs of the elevator; with a lit- tle care all soiling of clothes and bedding can be pi evented. Fig. 3. C, right hand of assistant. E, the Cyst. D, right hand of operator. F, abdomen. A fall description of all the instruments that I employ, and which should not he used, tor any other purpose, can be obtained in pamphlet form from A.'M. Leslie & Co., St. Louis, Mo. Directions for patient, always to be given in writing: The best room in the house is always to be selected. All furniture, carpets, curtains, etc., are to be removed; the room is to be fresh- ly whitewashed, floor and woodwork well scrubbed with soap and water, and rinsed with water and chlorinated soda, one to two tumblerfuls to a bucketful of soft water. Procure a small, new bed-lounge six feet long and twenty-eight inches broad, with two square blocks of wood six inches high, or more, with holes drilled into them to receive the rollers of the feet of the bed, to make it stand solid and Arm, and to elevate the bed to a proper height to suit the operator, and a good firm mattress to fit the bed must be nine or ten inches high; two small tables; one chair; two yards of Indian rubber or oil cloth to spread over the bed; one-half dozen soft towels, three or four stone wash-bowls, and one pitcher; one thermometer; one clean bucket for water, and' one cup; one old bucket or tub; tumblers, drinking water, tea spoon; three or four wooden clean hoops, and bed-pan. The towels, as well as the bed clothes and dresses, must be well washed and rinsed in the solution of chlorinated soda; must not be starched. During the operation no one is allowed to leave or A Case of Ovariotomy. 7 enter the room, and after the operation, under no circumstance is any person permitted to visit the patient or remain in the room,' excepting the nurse or the attending physician. DIRECTIONS TO THE DRUGGIST. It. Distilled Water 5 gallons. Oil Silk 1 yard. Lister’s Carbolized Gauze, (for bandage) 1 piece. Alcohol 1 pint. Liq. Ferri. Persulphatis J ounce. Brandy (French) !..l pint. Chloroform and Sulph. Ether 1 -■ (Squibb’s or MaJinkrodt’s best) f aa 1 Pouna- Carbolized Acid, pure 1 ounce. IJ. Iodine grs. ii. Pot. Iod 3 ss. Aquae Dist g viii. M. Sig. Used to fumigate the room before operation. 9-. Acid Carbolic g i. Glycerine g vii. M. Sig. Used to mix with water to wash the hands, instruments and sponges; the latter should be new, and of the fittest quality; previ- ously well washed in a weak solution of nitric acid, then kept "in a solu- tion of carbolic acid. lit. Acid Carbolic 3 i. Glycerine g iv. M. Sig. Used for dressing the wound. It. Acid Carbolic 1 3 i. 01. Olive g vi. M. Sig. Used to pour upon a saucer or plate ; the ligatures and threaded needles are laid and kept in this until needed. Ijt. Chloride Sodium 3 iv. Albumen 3 vi. Dist. Water O i. M. Sig. Used for dipping the hands, instruments and sponges in after disinfection, and before using them (this is the artificial serum), and has to be diluted with three parts of warm water, the temperature of blood heat. Misce. et div. in Chart. No. 12. Sig. Used as directed. II. Opii Pulv Sacc. Alb aa gr. xii. It. Acid Carbolic..... Alcohol Glycerine aa g i. Aqua Dist g v. M. Sig. This lias to be diluted with three parts of water, and used for the steam atomizer as a spray during operatipn. All prescriptions should be marked, in full on the bottle or package. 3G13N. Ninth St. THE ST. LOUIS Medical and Surgical Journal. ESTABLISHED IN 1843-PUBLISHED MONTHLY. THE PIONEER MEDICAL JOURNAL OF THE WEST. 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