recent mortality each of only 3 per cent., have abandoned the spray.
The latter claims now "to get as good results without it, and better
results than any one has yet got with it."[45] My own practice is to
adhere {316} to the spray and to every detail of antiseptic surgery;
and I fully agree with Bigelow that "it would be a grave error to
abandon a practice which has achieved brilliant results until something
shall be brought forth which shall be as thoroughly protective, and in
the use of which there may be no possible dangers. Time alone can
demonstrate satisfactorily the relative values of Listerism and of
perfect cleanliness without Listerism. The results of a large number of
cases in which cleanliness and attention to detail have alone been used
are the only criteria upon which we can strike a judicial balance."[46]
[Footnote 45: _Brit. Med. Journ._, May 27, p. 796.]
[Footnote 46: _Am. Journ. of Obstetrics_, July, 1882, p. 651.]
Contraindications for Ovariotomy.--An operation should be declined in
far-advanced tuberculosis, in cancer of the ovary or of any other part
of the body, in grave structural lesions of any of the vital organs, in
ascites if caused by disease of the heart, the liver, or the kidney, in
gastric ulcer, or in any serious disease of the alimentary canal.
Extensive adhesions should not count as a contraindication, nor should
age, since young girls and very old women have been successfully
operated on. Albuminuria is often due to the pressure of the tumor on
the kidneys, and, unless it existed before the appearance of the tumor
or is positively known to be caused by Bright's disease, should not
preclude the operation. Extreme debility dependent upon the ovarian
disease makes the prognosis grave, but it should not prevent a resort
to ovariotomy. I have indeed had several recoveries when the patient
was so reduced in strength as to make it a very anxious and difficult
task to keep her from dying on the table.
Indications for Ovariotomy.--This operation should not, as a rule, be
performed when the cyst has first been discovered, but when it has
grown so large as to distend the belly, and when the woman has become
thin and her health has begun to fail. The reasons for waiting
are--that the woman will have lived longer should the operation turn
out to be a fatal one; that, the abdominal wall having become thinner
both by being overstretched and by the absorption of fat, the incision
will be proportionately shorter and shallower; that, the patient being
now less full-blooded, both hemorrhage and inflammation will not be so
likely to occur; that the bowels are crowded away from the line of
incision; and that the pressure and rubbing to which the peritoneum has
been for some time subjected will make it less vulnerable, and
therefore less likely to take on inflammatory action. When, however, a
woman broods over her condition and is anxious to have the tumor
removed, the operation should be performed much earlier, especially if
the surgeon be experienced.
Again, when an ovarian cyst is complicated with pregnancy it is best to
perform the operation in the first half of the period of gestation; for
in the last half the broad ligaments receive a large supply of blood,
and all the pelvic vessels become varicose. Pregnancy is indeed no bar
to the operation, the prognosis being favorable both to the mother and
to the child. Schroeder and Olshausen performed 21 ovariotomies in
pregnant women, with only 2 deaths.[47]
[Footnote 47: _Brit. Med. Journ._, Dec., 1880, p. 1027.]
When septic peritonitis sets in; when the contents of the sac become
purulent, as they sometimes do either spontaneously or after an
unprotected tapping; when the cyst bursts and serious symptoms arise;
when torsion of the pedicle occurs or when a free hemorrhage into the
sac takes {317} place,--the radical operation should unhesitatingly be
performed, and that without any delay.
Preparation of the Patient for the Operation.--The operation having
been decided upon, every precaution must be taken to ensure a favorable
result. The patient should avoid all exposure to contagious or to
zymotic diseases, and she should be put in the very best condition of
health possible under the circumstances. If the kidneys be inactive and
the urine highly concentrated, depositing mixed urates in abundance, it
will be well for the patient to make use of warm baths and to take
saline cathartics in quantities sufficient to secure a daily action of
the bowels. The alkaline carbonates, largely diluted, will also prove
beneficial, and so will also the effervescent citrate of lithia.
Sometimes, and especially when anasarca and oedema of the legs occur,
it will be advisable to relieve the pressure-congestion of the kidneys
by a preliminary tapping. Other organs will also be relieved, and
valuable time for the action of medicines is often gained by emptying
the cyst. Tonics, iron in the form of Basham's mixture, a generous
diet, and fresh air may be needed. A trip to the seashore or to the
country will often do much good in preparing a broken-down patient for
the operation. If the patient comes from a malarial district, from
twenty to thirty grains of quinia should be given during the
twenty-four hours for two or three days before the operation, and ten
grains a few hours before the time of the operation. If this be not
done, a severe explosion of malarial fever after the operation may put
the patient's life in jeopardy.
An operation of election should not be undertaken during a monthly
period. It should be performed either about ten days before one or
about a week after one. The very best time is midway between two
fluxes. When, however, through some lesion or some accident, immediate
relief is demanded, no regard whatever should be paid to the factor of
menstruation. Some surgeons operate, indeed, in any case whether the
woman is menstruating or not, and profess to find no difference in the
result.[48]
[Footnote 48: T. Savage, _Brit. Med. Journ._, April 14, 1883, p. 712.]
For several days before the operation the bowels should be kept open,
and the diet should consist largely of milk, eggs, rice, and of
wholesome and easily-digested food. On the day preceding that of the
operation the upper portion of the pubic hair should be cut off and the
abdomen, if hairy, shaved. In the evening the patient takes a warm
soap-bath, and is washed perfectly clean by her nurse, who must be an
experienced woman, able to pass the catheter and take the temperature.
She then puts on clean clothing and goes to bed, where she stays until
the hour fixed upon for the operation. To ensure sleep, I am in the
habit of giving at bedtime thirty grains of potassium bromide, combined
sometimes with opium. Early next morning a dose of castor oil is
administered, and it is much more easily swallowed if disguised in some
vehicle and brought to the patient without any previous warning. When
oil cannot be taken, I give, at bedtime of the previous evening and in
one dose, two compound cathartic and two Lady Webster pills. To avoid
ether-vomiting, breakfast should consist merely of one piece of dry
toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk,
and afterward she must eat nothing more. To calm the nerves another
thirty-grain dose of {318} potassium bromide may be given, with or
without opium as the case may be, and especially if the woman be at all
agitated.
A very good time for operating is from noon to two o'clock in the
afternoon, for by that time the oil will have acted and the light
breakfast will have been digested. Some surgeons operate as early as
nine and ten o'clock in the morning, in which case the cathartic will
have to be administered in the afternoon of the previous day. At the
hour fixed upon for the operation the woman puts on a flannel sacque,
warm stockings, and drawers, and her nurse then passes the catheter.
The bedstead on which the woman is to lie after the operation should
have a horse-hair mattress, and should be wide enough to permit her
attendants to move her on a draw-sheet from one side of it to the
other. I formerly placed my patients on narrow single bedsteads, so
that they could be reached and be waited upon equally well from either
side; but I found that an unchangeable position on the back soon became
intolerably irksome. Next, indeed, to the thirst following the
operation, my patients complain mostly of the supine posture which they
are compelled to assume.
The room in which the operation is to take place ought to be a separate
one, so that the lady can be etherized in her sleeping-room, and may
not be unnerved by witnessing the needful preparations. Several days
beforehand the carpet of the operating-room should be taken up and the
curtains taken down. Every useless piece of furniture should be
removed, the closets and bureau-drawers emptied, and the whole room
thoroughly cleansed and ventilated. Several hours before the time of
the operation this room ought to be heated to a temperature of 75°, and
the air disinfected and made moist by a solution of carbolic acid kept
boiling in a dish on the stove or over an alcohol lamp. Let me here say
that, if possible, this operation should not be performed within the
walls of a crowded general hospital nor in unhealthy localities, but,
as statistics well show, in private houses or, far preferably, in small
special hospitals.
Articles Needed for the Operation.--The following articles should be
provided by some member of the patient's family. Following the example
of the late Washington L. Atlee, I have a printed list of them, which
is sent to the family physician some days before the operation:
One yard of rubber plaster; two rolls of raw cotton, made aseptic by
being baked in the range-oven just before the operation; two yards and
a half of fine white flannel, for two binders; six one-grain rectal
suppositories of the watery extract of opium; two pounds of the best
ether; two gallons of a 5 per cent. solution of the best carbolic acid,
made at least two days beforehand; four ounces of Monsel's solution of
iron; twelve ounces of undiluted alcohol for the spray-producer; some
old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap;
a pin-cushion, with large pins; two kitchen tables, or two
dressing-tables; one small stand for the spray-producer; one small
table for the basins and sponges; one chair without a back for a bucket
of hot water; two new tin basins and one tin cup; a new bucket and a
jug of hot water; a kettle of boiling water, ready on the range; a
small tub and an empty bucket; six bottles filled with hot water and
tightly corked; an empty wine-bottle for the aspirator; a rubber
ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard
and a quarter square, with an oval hole in the centre six inches wide
and eight long; one kitchen apron for the operator; one {319} clean
blanket for the patient's lower extremities; two large platters or two
meat-dishes, to be used as trays for the instruments;[49] clean towels,
clean sheets, clean blankets, clean comfortables, and clean pillows.
[Footnote 49: These platters are usually too shallow to hold a solution
of carbolic acid deep enough to cover the bulkier instruments. It would
therefore be well to have a tin tray made especially for the purpose,
measuring nineteen inches long, twelve wide, and three deep; or a nest
of smaller trays can be carried in the operator's bag.]
Instruments.--In simple cases very few instruments are needed; but as
one never knows beforehand what complications may be met with, it is
best to be always prepared for every emergency. One must therefore have
on hand every instrument likely to be wanted in the most formidable
operation. The following list comprises all the instruments and other
articles that I carry with me in my operating-bag, but it will not suit
every surgeon, who will after a few operations choose his own favorite
instruments:
One steam spray-producer, which will work two hours; assorted silk
ligatures on spools; Lister's antiseptic gauze or salicylated cotton;
two dozen straight surgeon's needles; assorted needles with varying
curves; two large needles for transfixing pedicles; an aneurismal
needle; one needle-holder; one hypodermic syringe; two dozen assorted
pressure-forceps; one uterine tenaculum; assorted hair-lip pins and
acupressure needles; one grooved director; two scalpels; Baker-Brown's
cautery clamp; ten fine surgeon's sponges of different sizes; two long
and flat sponges; one wire écraseur; one wire clamp or Koeberle's
serre-noeud; Paquelin's cautery or three cautery-irons; one Wells's
trocar with rubber tubing; one aspirator; two Nélaton's cyst-forceps;
one straight pair of scissors; one pair of scissors curved on the flat;
one right-angled pair of scissors; Allis's improved ether-inhaler; one
flexible male catheter; three glass drainage-tubes of different sizes
and lengths, together with the rubber sheeting and the sponge used with
them.
The twenty-four needles should be threaded, two on one thread of fine
silk eighteen inches long--viz. No. 1 or 2, of an excellent quality
furnished by Messrs. J. H. Gemrig & Son of Philadelphia. To keep these
threads from becoming snarled they are rolled up in a strip of muslin
gauze, each pair of two needles with their thread being covered up by
one fold of the gauze. The two pedicle-needles should also be threaded,
but with stouter thread (No. 4), fully two feet long. All these armed
needles should be put into a 5 per cent. solution of carbolic acid for
several hours before the operation. Assorted needles of varying curves
come occasionally into use, and it is always well to have several very
fine needles on hand, together with the finest Chinese silk, in order
to close a wounded viscus, such as the bladder or the bowels.
As an aid to the memory it is well to have invariably at every
operation the same number of sponges and the same number of
pressure-forceps, for these are the only articles likely to be left
behind and closed up in the abdominal cavity. The cautery-irons should
be wedge-shaped; the iron spreader used by apothecaries in making
plasters forms an excellent substitute. In my hands the best
pressure-forceps is Koeberle's. Its pointed beak catches the tissues
far better than that of Wells's forceps, which looks like a crocodile's
muzzle. The ordinary hæmostatic bulldog clips, or the serres-fines,
must on no account be used, because if {320} they should lose their
hold and drop into the abdominal cavity they would be too small to be
readily discovered, and might indeed be hopelessly lost in the coils of
the bowels. Long strings attached to each one would, however, overcome
this objection.
The ten sponges must be of the best quality and about the size of one's
fist. Two of them should be flat, long, and thin, such as are called by
the trade potter's sponges. When first bought, sponges almost always
contain sand. To rid them of this they are beaten, then soaked for
twenty-four hours in a 3 per cent. solution of muriatic acid, and
afterward washed out in clear running water. Sponges should never be
put into boiling water, which destroys their elasticity, shrivels them
up, and spoils them. After every operation the sponges should be
thoroughly cleansed in cold water and immersed for forty-eight hours in
a solution of washing soda (sodii carbonas) containing four ounces to
the gallon of water. They are then rinsed out in running water, and
placed in a 5 per cent. solution of carbolic acid. At the end of a week
they are to be taken out and hung up in a bag. Instead of a solution of
soda, some prefer an 8 per cent. solution of sulphurous acid, in which
the sponges are soaked for from two to four hours. This bleaches the
sponges, but does not cleanse them so well as the alkaline solution.
Only three assistants are needed--two are enough if they are
experienced--and they and the surgeon should take a soap-bath, and not
see on that morning any patient ill from a zymotic or a contagious
disease. Their clothes should also be scrupulously clean. To ensure
still further protection, each one takes off his coat, waistcoat, and
neck-tie if they are of a material which cannot be washed. The nurse
must also wear clean clothing which can be washed. A few bystanders may
be permitted, but they should wear clean clothing and take off their
overcoats. They should also be cautioned not to visit before the
operation any case of contagious disease.
Upon arriving at the patient's house the surgeon, together with his
assistants and the nurse, proceeds at once to get everything in
readiness. The two tables may be arranged in the form of a T, covered
with several thicknesses of quilts, and with a pillow on the
cross-table. When the tables are thus arranged a third one will be
needed for the instruments and the spray-producer. In order to
economize room and furniture, I am in the habit of putting one table at
right angles to the other--viz. with its short arm to the left instead
of to the right, thus: _|. The woman lies on the long arm of the _|,
with her feet directed to the short arm, and on the projecting and free
portion of the table forming the short arm are placed the tray of
instruments and the spray-producer. As it takes time to get up steam in
the necessarily large spray-producer, hot water should be poured into
the boiler, and it should be one of the first things attended to. In
order not to chill the patient, the spray solution of carbolic acid
should also be heated before it is used. The edges of the oval hole in
the rubber cloth are next smeared with some adhesive preparation, but a
plaster suitable for all seasons of the year is not easy to devise.
Keith's formula is the following, but it will not always stick:
Rx. Emplastri saponis, ounce iv;
Emplastri resinæ, ounce iij;
Olei olivæ opt., ounce i. M.
{321} After many trials, W. D. Robinson of Philadelphia has succeeded
in making for me a very good plaster according to the following
formula:
Rx. Emplastri saponis, ounce ij;
Resinæ, drachm vi;
Terebinthinæ albæ, drachm ij. M.
I must, however, add that I now very rarely use this rubber cloth.
Not all the instruments in one's bag, but only those likely to be
needed, are now placed in the tray or in the platters, and covered over
with boiling water, to which in a few minutes is added the same
quantity of a 5 per cent. solution of carbolic acid. The best plan
would perhaps be to pour into the tray a boiling 2.5 per cent. solution
of carbolic acid. Into the same tray is also laid the roll of gauze
containing the threaded needles. By its side on the table, and within
easy reach, is placed a small bottle filled with a 5 per cent.
carbolated solution in which are kept two small spools of Nos. 1 and 2
silk. The adhesive or rubber plaster is cut into strips of appropriate
length, and the antiseptic dressing put in readiness. The trocar with
tubing attached is hung on a nail near by. The sponges are carefully
counted and placed in one of two basins arranged side by side on a
table to the left of the patient. The other basin is one-third filled
with a 5 per cent. solution of carbolic acid, which later on is reduced
by the addition of pure hot water to a strength of 2.5 per cent. On a
chair is placed a bucket of clean warm water.
Let me here say, once for all, that throughout the operation the
assistant who looks after the sponges attends to them in the following
way: Every soiled sponge returned to him is first cleaned in the bucket
of warm water, next rinsed in the carbolated solution, then squeezed
out and placed in the empty basin. This sequence must be rigidly
observed, because, if the soiled sponge be plunged first in the
carbolated water, the blood and serum which it contains will at once
coagulate in its meshes, and become liable to be dislodged in the
abdominal cavity as foreign bodies.
Meantime, the woman, in another room, has been inhaling the
anæsthetic--the best being, in my opinion, the ether fortior of our
leading manufacturing druggists. It should be administered by Allis's
inhaler, which largely dilutes it with air. Wells and Thornton employ
the bichloride of methylene; Keith uses pure ether; Bantock resorts to
chloroform, and Tait to a mixture of two parts of ether and one of
chloroform, given by means of Clover's apparatus.[50] When the patient
is wholly unconscious her water is drawn off, and she is carried into
the operating-room and laid on the table. To this table she is strapped
down by a belt over her thighs, and her hands are also secured to the
same belt. Her legs are wrapped in warm blankets, and her clothes are
drawn up out of the way. Her chest and body are then covered by the
rubber sheet, but the edges of its oval opening are made to adhere to
the skin from just above the navel to the pubic hair, thus exposing
only a limited portion of the abdomen. After this the spray is turned
on, and the 5 per cent. solution of carbolic acid in the tray and in
the basins is diluted with hot water down to 2.5 per cent. The operator
and his assistants now take off their rings and cleanse their hands
very carefully with carbolated soap and a nail-brush. They may clean
and pare their nails with a penknife {322} before the use of the
nail-brush, but not after, because the knife not only does not remove
all dirt, but it loosens up that which remains. Arranging themselves in
their places, the operator stands to the right of the woman, his chief
assistant to her left, the one who gives the ether at her head, while
the other, who attends to the sponges, takes his place near the basins
at the side of the chief assistant. The nurse holds herself in
readiness to hand towels when called for, and especially to see that a
third basin always contains warm water, so that at any stage of the
operation the surgeon can wash his hands without delay.
[Footnote 50: _The Medical Record_, Jan. 3, 1885, p. 2.]
When everything is ready the door is locked, and the exposed portion of
the abdomen washed with the solution of carbolic acid. An incision
about three inches in length is made with a free hand, and not by
nicks, in the median line below the navel, where the blood-vessels are
few in number. It should end about one inch and a half above the pubes;
that is to say, low enough for the pedicle to be easily reached, but
high enough to avoid cutting the fold of peritoneum reflected from the
bladder to the abdominal wall. The brown line running below the navel
is the surface guide, but after cutting through the skin and fat one
cannot always hit the linea alba beneath. When the cyst is large the
recti muscles have become separated from one another, and there is no
difficulty in keeping within the wide tendinous interspace. But when
the cyst is small the linea alba is, as its name indicates, a mere
line, and the knife will often go astray into the anterior sheath of
one of the recti muscles. The red muscular fibres pouting out of the
opening will be the danger-signal of one's having got off the track
into more vascular regions. To recover it a probe is passed in across
the muscle to the right and to the left, and the nearest point of
arrest will note the linea alba. The disadvantages arising from the
wandering from the linea alba are--that the sheath of the rectus muscle
being cut open, or the muscle itself being wounded, there results
hemorrhage; that the wound is more jagged, and therefore less easily
coaptated; that suppuration in the suture-tracts is more liable to take
place; and, finally, that in cases of small cysts with but little
abdominal enlargement a spasmodic contraction of the wounded muscle is
very likely to embarrass the operator both in removing the cyst and in
introducing the sutures.