Four Cases of Oophorectomy, with Remarks. JOSEPH TABER JOHNSON, A. M., M. D., WASHINGTON, D. C. BY REPRINT PROM VOLUME X ffinnecological 1885. FOUR OASES OF OOPHORECTOMY, WITH REMARKS. BY JOSEPH TABER JOHNSON, A. M., M. D., Washington, D. C. Me. President and Fellows : I received a peremptory order from the President a few days ago, while at my place in the mountains, to write a paper for this meeting, and in complying with this order I shall tax your patience but a few moments. I have simply to add to the statistics of oophorectomy my little quota of four cases, and a few remarks upon early diagnosis and earlier operations in the distressing class of cases which are finally relieved by Battey’s or Tait’s opera- tion. My first case was a Miss H., from Pennsylvania, referred to me by Dr. J. R. Riley, of this city, a fearful sufferer from chronic ovaritis and menstrual epilepsy. She was twenty- nine years of age. Her menses appeared earlier than in the average girl, but, for several months prior to their eruption, convulsions of a severe and prolonged character always oc- curred. When I saw her she had been a victim of these monthly recurring spasms for a period of fourteen years. She had never been trusted to attend school, had grown up without education, and presented the appearance of be- sotted ignorance. She had constant pain in both ovaries, but for several years her sufferings had been limited to the left side. She was not only unable to perform any kind of useful or remunerative labor, but for two weeks out of every month, or just half of her time, she was constantly under 2 FOUR CASES OF OOPHORECTOMY\ WITH REMARKS. tlie care of an attendant. She had been treated by many physicians of all known and many unknown schools, and had been the subject of much experimentation by old women cranks and quacks. She had never received permanent benefit from any kind of treatment, and was constantly growing worse. The ova- rian pain in the inter-menstrual period was greatly aggra- vated by exercise or housework. When I saw her she was a pitiable and revolting spectacle. Her face, with its numer- ous scars and bruises, the effects of falls during her spasms, associated with a total lack of refinement or culture, gave her an almost beastly look. After learning her history, I soon decided that, as every- thing likely to be of service had already been done, over and over again, if a premature change of life could be induced, upon Battey’s theory, by Battey’s operation, I would at- tempt it. Consent having finally been granted, and the relatives subsequently being clamorous for the operation, as offering the only hope of recovery, I performed it on the 17th of August, 1882, removing both ovaries and one Fallopian tube. The patient’s excellent recovery was only retarded by one or two stitch-hole abscesses, and a slight attack of bron- chitis. For several months she had no periods and no spasms, and was greatly improved in her general health and appearance. Gradually her menses returned, and with them convulsions of a mild form, so that now, three years since her operation, she is menstruating with a greater regularity than ever, but with less frequent and much less severe at- tacks than formerly. Her sister informed me, a year after the operation, that it was the family belief that she had been so long accustomed to having these “ spells ” that they had become a habit with her, and that 6he only had them when excited or angry; and it was the general opinion that they were purely hysterical, and that she could control them if she desired. JOSEPH TABER JOHNSON. 3 Her physician wrote me on the 23d of July last: “ My opinion is that the operation was a great relief, and has cer- tainly prolonged her life.” The patient and her friends frequently declared to me their pleasure and satisfaction with the results of the opera- tion. Case II.—Miss W., aged twenty-one, formerly in good circumstances. Her parents both became addicted to strong drink, squandered their property, broke up their home, and finally separated. Miss W. was taken in charge by poor rela- tives, and was compelled to earn what she could by sewing. Over-work, insufficient nourishment, and mental anxiety soon destroyed her health and spirits. She took a severe cold, at the time of a monthly period, about five years ago. The period was suppressed, and she was “ confined to bed for sev- eral weeks with pain and fever.” Since this time she has been a great sufferer from chronic ovaritis and dysmenorrhea. Had been constantly treated, without benefit, and was steadily grow- ing worse. Her only relief was in bed, with hot applications and ano- dynes, during the week of her menses. She had leucorrhea and a displaced uterus, which were constantly treated with varying success, but without helping the ovarian pain. I saw her at the request of Dr. II. E. Leach, and treated her three months, but she grew worse all the time, and finally entered my service at the Providence Hospital, where, after another month spent in preparatory treatment, with oophorec- tomy in view, I removed the ovaries and tubes. She made a perfect recovery. Was sitting up in two weeks, and in less than a month left the hospital a new creature—no pains, no menses, happy in mind and well in body. In a letter received from her about two years after leaving the hospital she used the following words : “ No pen can write the sufferings I endured in the five years previous to my opera- tion. At times I became almost desperate enough to take my life and end my sufferings. . . . My life now seems a new one, 4 FOUR CASES OF OOPHORECTOMY, WITH REMARKS. and I am getting along splendidly. ... I am now a well, hap- py, and cheerful girl, and do not feel like the same person at all.” She closes by recommending oophorectomy “ to anybody suffering as she did,” and reasserts that “ it has been a sure cure to her.” Case III.—Miss S., aged twenty-four, a young lady of agreeable looks and refined manners, evidently from a family of education and former wealth, was sent me by Dr. Mary Parsons. She had been for some years a great sufferer from dysmenorrhea and reflex disturbances in the stomach and nerv- ous system. Ovarian pain, vomiting, backache and headache, and insomnia were more or less constant. I quote from the Garfield Hospital report, where she was for several weeks my private patient. “ She was brought up in the midst of excitement, and her nervous system was constantly strained to its utmost. She was healthy until at the age of fourteen, when her menses began. At once a change came over her. ‘ A cloud seemed to have settled on her brain.’ She began to lose health and strength. Each period was pre- ceded by about ten days of violent pain in the abdomen and head, accompanied with nausea and vomiting.” For the last seven years she has been under the care of nu- merous doctors, at home and in hospitals, without relief. At present, and for many months, she states that, while the men- strual molimen has been regular, there is no flow. The period is accompanied by all her former distressing symptoms, but the discharge has been growing less and less, until now it amounts to a few stains upon a single napkin. She became my patient subsequently in the Providence Hospital, through the kindness of Dr. J. R. Bromwell. After four months of fruitless effort I declined to spend further time upon her unless she submitted to oophorectomy. She had sev- eral times exhibited decided evidence of insanity, and her rela- tives desired the operation as much to preserve the soundness of her mind as her body. Accordingly, on the 15th of Febru- ary last, I removed both ovaries and tubes. Her convalescence was somewhat retarded by the formation of abscesses, but she made an excellent recovery, and continues to this day to be a marvel to herself and friends. The ova- JOSEPH TABER JOHNSON. 5 rian pains and reflex symptoms have disappeared, and she returned to her duties as a clerk in one of the Government departments, where she performed her duties to the entire satisfaction of her superiors, and is now in the country doing well. She lost her place August 30, 1885. She writes me as follows in a letter just received : “ I have suffered for years almost constantly with severe throbbing pain in my side and back, greatly aggravated by exercise, and at times accompanied with intense nausea, entire loss of appetite, sleeplessness, and a nervousness which can not be described, which would often continue for ten days, only to be alleviated by large doses of morphine. I was in Hospital No. 4, with Dr. No. 26, confined to my bed for four months, and more or less for two years, growing rapidly worse, and my suffering so great that I felt I could endure it no longer. When I resigned myself to the operation I believed and hoped that it would end my life. I am now relieved of the old pain, and am better in every way than I have been for ten years, . . . and I can not express what I feel for my noble, untiring, and skillful physician. I feel that I owe more than my life to him, for I fear I would have been insane with the suffering there was no respite from until I fell into his kind hands.” Case IV.—Mrs. X., aged forty, mother of three children, had suffered a constant burning pain in the left ovary for twenty years, and for the past few years in the right ovary also. She had, in addition, a lacerated cervix and perineum, both of which had been restored by operations. She had been under treatment for many years, and had spent, she told me, over $10,000 to obtain relief from this constant gnawing, burn- ing pain, without success. She was practically bedridden three weeks out of every month, and had little if any enjoyment in life. Her pains all culminated about the time of her period. Constant nausea and neuralgia, both reflex, made her life a burden which she refused longer to bear. A lady friend, in about her condition, had been operated on and cured, and she calmly and deliberately made up her mind to have her offending organs removed. I demurred, and begged her to stand it five years longer, until nature would come to her rescue in the change of life. She replied that she had stood 6 FOUR CASES OF OOPHORECTOMY, WITH REMARKS. it just as long as she could, and that, unless she obtained relief, she would be in her grave or an insane asylum in less than a year. Finally, after she told me that she had arranged to be oper- ated on in New York in a week, unless I operated within that time, upon the advice and with the consent of her husband I removed the ovaries and tubes in a private room in the Provi- dence Hospital, on the 16th of last February, the day after the operation on Case III. She rallied well, and, with the excep- tion of vomiting, seemed to do well for three days ; but the vomiting could not be controlled, and she died, exhausted, on the morning of the sixth day. The autopsy gave little evi- dence of the cause of death. Her constant retching and vom- iting had set up some slight peritonitis about the vicinity of the sutures. One small sponge readily absorbed all the fluid in the abdominal cavity, which was inodorous. An abscess about the size of a chestnut was found in the abdominal wall, in the track of one of the stitches. I have three patients now upon whom I think of oper- ating this fall, who have been well treated by various physi- cians for several years, with varying results, but no per- manent benefit. One lady had the measles four years ago. The characteristic eruption never fully declared itself, and during her convalescence she took cold at a period, and has ever since been a great sufferer. Her flow gradually became less and less, and her pain greater and greater, until within the past year it is the exception for her to have any at all. She is about twenty-three years old. During her menstrual week she is subject to fainting spells, and fre- quently remains unconscious for hours at a time. During the intervals between her periods she is constantly tormented with severe pains in the ovaries, head, and back of the neck. She is a clerk in a Government department, and when these attacks occur during office-hours she has to be taken home in a carriage and watched over by her friends for several days until she can be trusted to go out again alone. During the remainder of the month she does work enough JOSEPH TABER JOHNSON. 7 to retain her place, but with the-greatest physical and men- tal strain. She is constantly growing worse, and is ready to be operated on whenever I say the time has come. Two wTeeks ago she had the worst attack she has ever had. In addition to her dysmenorrheal pains, she had par- oxysms of dental neuralgia, and a part of the time it required the strength of three men to control her. She made several attempts to commit suicide by drink- ing laudanum and trying to jump out of the window. In another case a lady, the wife of a prominent Govern- ment official, aged thirty, married nine years, and without children, is a great mental and physical sufferer at the time of her periods. She is compelled to remain in her room, and most of the time in bed, from seven to ten days out of every month. Her ovaries are enlarged, very tender, and give her the most exquisite pains if she oversteps the narrow boundaries which she has found by many sad and distressing experiences hem her in upon all sides. One ovary is badly adherent, and the other, about the size of a hen’s egg, is now quite movable. This is one of the most anxious women I have met to have children. She has, however, never been pregnant. She has been more or less under treatment for ten years, and everything seems to have been done, and w-ell done, to overcome her dysmenorrhea and cure her sterility which gynecologists could do or invent, but, with the exception of some relief to her monthly pains, gained as much by experi- ence in taking better care of herself as by treatment, she is worse off, taking the case as a whole, now than she was five years ago, with no prospects of being any better until the change of life inaugurates those changes and brings that mysterious quiet to the sexual apparatus of the female which we are powerless to hasten by treatment or to fully understand. The sad termination of my last case causes flie to hesi- tate before subjecting this charming lady to the dangers 8 FOUR CASES OF OOPHORECTOMY, WITH REMARKS. of Battey’s or Tait’s operation, and yet I am fully convinced that it is the only thing left to do. She has repeatedly begged for some operation which held out the least prospect even of making it possible for her to have a child of her own. Her maternal instinct is so strong as to lead her to court any suffering which might bring this glad fruition to hopes so long deferred. When told that she wais hopelessly sterile, and that Tait’s operation would make it for ever impossible for her to conceive, she wanted to die. Her most absorbing hope is taken out of life, and she has no further interest in living. She is desirous now, to quote her words, to be “ killed or cured ” of her pain. If she can live on, and do her duty in her home and to society, free from pain, she would be will- ing ; but, while anxious, for the sake of her friends, to get well and strong once more, I feel assured that her ardent hope is that she may perish in the attempt. Her husband and intimate friends fear that she will, in some attack of pain and mental despondency, end her own life by some rash act, or do some other dreadful deed. I think she is a proper subject for the operation, or at least the enlarged, movable, but most painful ovary should be removed, and the other if possible. Indeed, I now think the operation should have been done years ago. Our means of diagnosis in these sad cases need improving. Of course we hesitate, as in duty bound, to sub- ject these patients to the risks of abdominal section until all other means have been exhausted and have failed to relieve. In the trial of these fruitless means of cure much time and money are spent and suffering endured, and the operation finally becomes a necessity upon a bedridden patient, who is thus reduced to the worst possible condition for a serious operation. Dr. Gill Wylie has recently published a list of twenty-five oophorectomies. “ In every instance,” he says, “ the patients were bedridden invalids, or were totally unfitted to do ordi- JOSEPH TABER JOHNSON. 9 nary work and keep out of the hospital or poor-house. With the exception of three or four, all had extensive adhe- sions, and only one of the twenty-five had no adhesions. The three lost cases were hospital patients, and, on account of the extensive adhesions, the abdominal cavity was exposed. All died of septic poison on the fifth or sixth day.” To illustrate and emphasize my point that our means of early diagnosis need improving, and also the environment of the patient, I have introduced the above quotation from Dr. Wylie’s admirable paper published in the Medical Record of August 29 th last. So far as human foresight would aid us, if these three cases out of his twenty-five had been or could have been diagnosed as fit subjects for oophorectomy, and had consented to it before the adhesions became so numerous and powerful as to require the exposure and manipulation of the abdomi- nal viscera referred to, and that in patients who had en- dured their sufferings for years and had finally become ex- hausted and bedridden, it is altogether probable that they would not have died, especially if operated on in the best surroundings, instead of in the poison-laden air of Bellevue Hospital. His nine cases in private practice, who enjoyed the ad- vantages I mention, all recovered. For the sake of my argument, I maintain that if Dr. Wylie had had the oppor- tunity to make an earlier diagnosis and been allowed to op- erate in advance of the formation of these powerful and extensive adhesions, in as perfect an environment as that enjoyed by the nine successful cases, they would all have been successful in his experienced and skillful hands. We have been upon the defensive in this operation long enough, only doing it when everything else had failed, and long years of mental and physical suffering were closely men- acing our patient with the grave or the lunatic asylum, and finally operating on a bed-ridden wreck, in defiance of well- known surgical laws. Even under these discouraging circumstances the opera- 10 FOUR CASES OF OOPHORECTOMY, WITH REMARKS. tion, when skillfully done, is one of the most successful of the capital operations in surgery, and marvelous in its re- sults. I think the wonderful success of Mr. Lawson Tait is largely owing to the fact that he makes his diagnosis early, before his patients are exhausted, and operates when their powers of recuperation are yet good, and under circum- stances free from any possible septic infection. This appears to be the case, judging from the histories narrated in his recent paper upon his “ Modern Treatment of Uterine Myoma,” a copy of which he kindly sent me about two weeks ago. In this remarkable paper he gives the subsequent history of fifty-eight cases in which he removed the uterine append- ages for the relief of these tumors, with no mortality what- ever ; and, still better, with success in staying the growth or causing the absorption of the tumor in every case but one. Tait says: “In the series published up to the end of 1883 there were fifty cases of the removal of the uterine appendages for myoma, with two deaths, so that my modern experience gives a series of one hundred and eight cases with two deaths; and my belief is that the real mortality of the operation, in experienced hands, is not more than one per cent.” A distinguished Fellow of this Society published a series of “three difficult and fatal operations” several years ago. The adhesions were so great and so extensive in one case that it was necessary, in order to get at the ovaries, to make a large incision, draw out the intestines, and to continue manipulation in the pelvic cavity for nearly two hours be- fore the operation could be completed, and this by a skillful surgeon and aided by skillful assistants. The other cases were similar. For the sake of my argument, again, and in no spirit of criticism of any operator, I beg to suggest that if our means of diagnosis of the cases requiring this operation were so perfected as to give us medical as well as the moral courage JOSEPH TABER JOHNSON. 11 to operate in advance of the growth of these dangerous and fatal adhesions, our percentage of mortality in this country would be greatly reduced. I feel, now, if my fatal case had been operated on earlier, when she was stronger, her chances for recovery would have been vastly improved. I am well aware that if early operation should become the rule, some unwise and rash men would be likely to ex- pose patients to dangerous operations which might, perhaps, be avoided by prolonged and appropriate treatment. I thought last year that I had a case fit for immediate operation. I admitted her to my service in the Providence Hospital, with the understanding that, if she did not show signs of improvement after three months’ treatment, I should remove the uterine appendages. She was a poor girl, with a history of years of dysmenorrhea, and so constant ovarian pains as to prevent her doing any work wThich would pay her way. Suffice it to say that I cured her by appropriate treatment, and she has since remained well, and is now engaged to be married on the first of the coming month. Dr. Baker, in February last, published an admirable paper in the Boston Medical and Surgical Journal upon “ The Use and Abuse of Battey’s and Tait’s Operations,” in which he gives the histories of cases referred to him for operation, which he finally cured by other treatment. Many operators could probably relate a similar experience. So they could in regard to ovariotomy. All kinds of abdomi- nal tumors, including pregnancy, have been mistaken for ova- rian tumors, and too many operations begun under the inspi- ration of a mistaken diagnosis. But no one thinks of using this as an argument against early diagnosis and early opera- tion in cases of ovarian tumors. Dr. Dawson, in discussing a fatal case of oophorectomy in this month’s Journal of Obstetrics, page 944, says of it, that, “ had an operation been allowed when he urged it, six months ago, the patient would have stood a better chance of recovery, and would have been spared months of extreme suffering.” 12 FOUR CASES OF OOPHORECTOMY,\ WITH REMARKS. I saw a skillful and experienced gynecologist remove the uterine appendages last spring from a patient who had been many years a great sufferer. He had urged the operation at a consultation two years previously, and again after the ex- piration of another year of ineffectual treatment and con- tinued agony. Finally objections were withdrawn and the operation agreed to, after all other hopes of relief had de- parted and her strength was well-nigh exhausted. The operation lasted fully an hour and a half, the adhe- sions were strong and numerous, the tubes were enlarged to the size of the small intestine, and for a time were mistaken for intestine. The patient died, I am informed, of peritonitis and internal hemorrhage from torn surfaces on the fifth day. The probabilities are all in favor of the recovery of this patient if she had been operated on two or three years sooner, and she wTould have been saved untold misery in either event. Tait operates early, and finds few adhesions. The time consumed in most of his oophorectomies is from ten to twenty minutes, and the patients all, or nearly all, recover. Two deaths in one hundred and eight cases, according to his latest reports! Is not this the great secret of his success ? Ilis pa- tients are yet in good condition, but surely tending, he thinks, toward a fatal issue. In some instances he removed the ap- pendages where the myoma was no larger than an orange or fetal head, and had yet produced none of the effects of press- ure and displacement, but was rapidly growing and causing great loss of blood, and likely in time to cause death. While I do not venture to make suggestions to this So- ciety, as to any special points or symptoms which would render earlier operations more justifiable, I think I may ex- press the hope that some authoritative means may be soon developed and published whereby we may be able to operate earlier, before the patient drifts into that exhausted and bed- ridden condition, after years of unrelieved suffering, when strong and numerous adhesions add so largely to the diffi- culties and dangers of the operation.