Gastrotomy—(fl case of Ovarian Dropsy, removal of sac and
fatal termination.') By A. H. Grimshaw, M. D., of Wilmington,
Del., Member of the American Medical Association.
I consider that a man does not perform his duty to his fellow
practitioners when he only publishes his*successful cases, and, al-
though I should have preferred to report this as a successful case,
nevertheless, acting honestly and conscientiously, I give it as it oc-
curred.
Edith Borkman, set. 37 years, who has borne several children,
one since the commencement of her dropsy, came into the Alms
House of this county, Nov. 16th, 1848. She was then in bad
health, cachectic, emaciated, and with great distension of the ab-
domen ; there was also an immense ulcer occupying the umbilical
region, and destroying all traces of umbilicus. Her case being di-
agnosticated ovarian dropsy, to relieve urgent symptoms she was
tapped by the attending physician. The ulcer healed almost im-
mediately after this tapping, in consequence of the removal of the
distension ; her health also improved. After this, she menstruated
once, and left the house, remaining out till March 12th, 1849,
since which time, till the day of her death, she continued in the
house, and was tapped eight times; at each tapping, about four
gallons and a half of fluid were drawn off, sometimes straw color-
ed, at others, chocolate-like.
She came under my care in July, and I performed the last tap-
ping about ten days previously to the operation about to be describ-
ed, and drew off five gallons of fluid. The operations of tapping
were only resorted to when the woman’s comfort and health began
to suffer from the distension. Between the first two tappings, eight
months elapsed; after this, about four weeks was the average. Her
health was good, appetite excellent, and spirits cheerful. Before
coming under my care, I had mentioned to her that such tumours had
been extracted, and as soon as I took charge, she requested me to per-
form an operation for her relief. Her case was one upon which I
deliberated seriously, and one which was inspected by my medical
friends of this city, both before and after the tappings. Before
the last, she measured 52 inches around the hips, and 39 from the
scrobiculus cordis to the pubis.
Upon looking into all the authorities within my reach, and, as
the patient herself expressed it, knowing that she must inevitably
die, and that within a comparatively short time, if an operation
would not prolong her life, I deemed an operation for extraction to
be justifiable. I shall not attempt to prolong this article by argu-
ing this point. Dr. Atlee has demonstrated the feasibility and
justifiability of the operation, in the “ Amer. Med. Journal,” but
let me give one quotation from Chelius’ Surgery. “If the operation
is to become established, of which I have the strongest doubts, it
must be confined to examples of the malady where tapping has
been already so often performed as to preclude, from the experi-
ence of similar cases, any idea that it can ever be dispensed with,
and when we are confident that great suffering must lead to early
death.” Again, “ In such cases, if the diagnosis excludes the be-
lief that there are serious adhesions, or malignant and solid
growths complicating the tumour, and if the patient strongly de-
sires it, the operation is defensible.”
Late reports prove that it is defensible even when we have
“ serious adhesions,” even when “solid growths” exist. In this
case there was ovarian dropsy ; we did not fear, but expected to
meet serious adhesions; the patient “strongly desired it,” even
after I had told her that one half die under the opera-
tion.
On Wednesday, Sept. 4th, 1850, at 12 M., the pulse being 80
per minute, I commenced the operation. Present, Drs. Thomson,
Askew, Bush, Porter, Baker, Barstow, and my colleague, Dr.
Wilson, together with several medical students. The patient was
under the influence of ether. I made an incision about 12 inches
long, from a point about three inches to the right of the umbili-
cus, (to avoid the cicatrix) to the linea alba, above the pubis.
This cut allowed a considerable quantity of water to escape. The
parietes of the abdomen, I should mention, were cedematous,
and the fluid had separated the fascia from the integuments to a con-
siderable extent; there was also a thick layer of fat over the
whole abdomen. In attempting to penetrate the fibrous layer,
now exposed to viewr, my knife punctured the sac, which was
adherent at this point and quite tense ; this allowed the contents
of the sac to escape. I then attempted to find the point of junc-
tion of sac and fascia, and imagining I had done this, separated the
fascia on each side of the incision, before detecting the error. There
was no appearance of muscular fibre. At last when I had almost des-
paired of succeeding in extracting the sac, on account of these
difficulties, upon deepening my incision near the pubis, a thin
layer of muscular fibres was severed, the remains of the pyra-
midalis. Penetrating at this point, I was enabled to detach the
sac, with comparative ease, the adhesions all being round the
point at which I had first entered, being an extension of the
disease of the integuments, involving all the subjacent struc-
tures.
The tumour always had retained a position on the right side ;
after tapping, small tumours could be detected attached to the
sac. It was in reality a dropsy of the left ovary, the
sac, when unattached had fallen over to the right side, twisting
the pedicle, or broad ligament. I applied three ligatures to this
and cut it off. The Fallopian tube appeared to be healthy. The
uterus to all appearance healthy, confirming our opinion formed
by an examination per vaginam. The right ovary was larger
than natural, more solid and whitish coloured. We closed up the
wound; the patient was exceedingly feeble, and still under the in-
fluence of ether, and refused to take stimulants. She had lost a large
quantity of blood, part from the wound in integuments, and part
from several small vessels wounded in attempting to separate the
fascia; torsion was used to each vessel as soon as it was wounded.
The wound was dressed and the patient put to bed. There was
great restlessness and complaint of heat of body, also great thirst,
pulse feeble and apparently rising; stimulants were administered
freely, with an anodyne. Until 4 P. M., although the case pre-
sented a decidedly unfavorable appearance, we had hope. After 4
o’clock she sank fast, and died at 5 o’clock 10 minutes.
The next morning, upon examining the cavity of the abdomen,
we found that about four ounces of blood had escaped into the
cavity of the peritoneum, and was mixed with some of the fluid
from the sac. The right ovary, upon cutting it open, was found
to contain several small cysts.
Notwithstanding the sudden and unfortunate termination of this
case, I should give my voice for the operation. I would beg the
medical gentlemen who dread the knife, and shudder at the unfor-
tunate termination of a surgical case, to take the scalpel and ope-
rate on their dead patients ; let them, after dissection has revealed to
them mistakes in diagnosis, hidden maladies not “ dreamed of in
their philosophy,” be disposed to be charitable, and acknowledge
that they have not only failed to relieve their patients but sometimes
have not applied the correct treatment. Rather attribute the fatal
issue of this operation to my want of skill, than to the unjustifi-
ability of the operation. I consider it more proper than tying the
primitive carotid for the cure of erectile tumors on the head and
face, and I shall under like circumstances, if my patient will con-
sent, operate again.
[We commend the honesty and moral courage of our correspond-
ent in thus reporting his unsuccessful case, although we regret its
termination. If all were equally fearless, this, as well as
some other heroic operations, would lose much of their eclat, a great
portion of which is to be traced to the fact that the whole truth is
not divulged.—Ed. Exam.]