GASTROTOMY. LARGE ABDOMINAL-UTERINE TUMOR, EXTIRPATED BY JOHN O'REILLY, M.D., F.R.C.S.I. Reported bv RICHARD J. HALTOX. L.R.C.S.I. NEW YORK: PRINTED BY llOBERT CKAIGIIEAl), Sl, 83, AM) 85 C'ENTKE STHEKT. 186;f. ^V .T -TfcTxV J GASTROTOMY. LARGE ABDOMINAL-UTERINE TUMOR, EXTIRPATED BY JOHN O'REILLY, M.D., F.R.C.S.I. Reported by RICHARD J. HALTON, L.R.C.S.I. NEW YORK: PRINTED BY ROBERT CRAIGHEAD, 81, 83, AND 85 CENTRE STREET. 1863. GASTROTOMY. LARGE ABDOMINAL-UTERINE TUMOR, EXTIRPATED by JOHN O'REILLY, M.D., F.R.C.S.I. [Reported by RICHARD J. HALTON, L.E.C.S.I.] Mrs. L., the subject of the present report, was a married woman about 55 years old, the mother of several children. Seven years ago the tumor first made its appearance, at that time .causing little or no inconvenience; but as time passed it increased in size, and finally filled up the whole front of the abdomen, distending the parts so as to produce great deformity, while the pain became considerable, and latterly the constitu- tion began to give way altogether. There was a good deal of emaciation, and the lower extremities showed considerable oedema. On examination, the tumor was found to be firmly fixed, but the parietes were movable slightly upon it. There was no evidence of fluctuation, but it was supposed, from its great elasticity before the operation, that it contained a num- ber of cysts. As the patient was evidently sinking, Dr. O'Reilly determined to give her the chance the operation affords, a middling one, according to the general opinion of the profession ; but by his theory of the physiological action of the orgamc nervous glands, and the effect of opium thereon, he calculated on being able to prevent peritonitis, which is so often fatal after these operations. With this intention, there- fore, he prepared the patient, and the night before the opera- tion gave her forty drops of laudanum to keep her bowels quiet and contracted during the operation. She slept well, and in the morning, just before the operation, her pulse was 144. She was cheerful, perfectly easy, and very hopeful as to the re- sult. On the first of July, at 12£ o'clock p.m., chloroform being 4 administered by Mr. James O'Dowd, Dr. O'Reilly, in presence of Drs. Nelson, T. G. Thomas, and myself, commenced the operation. The first incision was carried from the umbilicus to the pubes, and the integuments, muscles, and peritoneum, being divided, the tumor was brought into view, and Dr. O'Reilly made an attempt to introduce a trocar, but without success: he tried in another spot with the like result. Indeed, from its feel, it was evidently solid.; so he prolonged the incision almost to the ensiform cartilage, and now the parietes, contracted at each side, left the tumor exposed. It hid the viscera altogether, and when it came to be lifted out it was found to be attached to the uterus, or rather the uterus was attached to it behind, and the fallopian tubes embraced it on either side. The lateral ligaments were closely attached to it; in fact they formed an all but complete investment, for they stretched out on it apparent- ly as the tumor increased. There was a great deal of difficulty in finding the exact attachments of the tumor, but the principal ones appeared to be from the third to the fourth lumbar verte- bra, and then extending along the sacro-iliac synchondrosis of the right side—how far down in the pelvis may be imagined when I mention the fact that I tied a vessel low down in the recto-uterine space: the attachments were partly torn through with the hand, partly cut. The principal vessel entered the tumor opposite the third lumbar vertebra, and was of con- siderable size ; there were about six smaller ones : each was tied as it was divided ; nevertheless, haemorrhage from the numerous oozing-points was considerable. When the tumor was removed, the abdominal cavity (the lower part of it) was sponged out several times to remove the blood. The edges of the wound were brought together first by a deep me- tallic suture, twisted, embracing the soft parts external to the peritoneum ; and by a common interrupted suture securing the integuments, sticking-plaster being applied in the intervals be- tween the sutures; and finally a towel folded flat, a pad of tow, and a many-tailed bandage, completed the dressing, the two last tails of the bandage being brought down under the thighs, up in front of the groin, and fastened there to guard against any slipping; and then the patient being thoroughly washed, and all traces of blood removed, was carried to bed. She got 0 immediately a draught containing two grains of opium, and after half an hour, that having produced no apparent effect, she got two grains more. She was ordered to take nothing but a small piece of ice, sucked occasionally, and to take two grains of opium every third hour, making in all eight grains between the hours of one p.m, and nine p.m . She slept about three hours after the last dose of the opium, and had no pain of any kind. The opium t6 be continued during the night every third hour. It is worthy of remark that, during the operation, all rules laid down in books on the subject were entirely disregard- ed. The window was kept open, admitting a free draught. The intestines were allowed to come out, and they were never touched until the operation being over, when they were all lifted in again, Dr. Nelson well remarking that " the flannel usually employed to keep them in was as rough to the delicate covering of the intestines as a clothes-brush would be to the skin." Vomiting having occurred, the stomach was thrown for- wards out of the abdominal cavity, as it were : its contractions and dilatations could be plainly observed. The liver was quite healthy. The tumor, which might be called fatty fibro-cellular, displayed on section two large lobes of fat, intersected with fibrous bands, large sinuses (venou>), connected by cellular tissue; it presented very much the appearance of a cow's ud- der, and weighed over thirty pounds. After the patient was got into bed, she expressed herself as being quite easy. She had suffered no pain ; pulse 100 ; voice pretty strong. July 2d, five o'clock a.m.—Pulse 112, very nice aud soft; had no pain, but she slept none, and has thrown up the draughts since last night. She got now the two grains of opium in two pills instead of the draught every third hour. The parts around the wound not covered with the dressing are soft and nice. She has taken nothing since the operation but a little ice sucked occasionally. Two o'clock p.m.—Pulse 104 ; had a little pain in right iliac region, which increased and also attacked the umbilical region. At 2£ o'clock, the pain increasing, she began to take the qpium at shorter intervals, and between that hour and S£ f.m. she took fourteen grains. The pain being now relieved, the usual doses were resumed. 6 July 3d, five o'clock a.m.—Passed a good night; pulse and tongue as before ; to continue the opium. Having complained of acidity of the stomach, she was directed to take three parts of sweet milk mixed with one of lime-water, in half-ounce doses occasionally. 2 o'clock p.m.—-Same report as morning.* Continue treatment. Si o'clock p.m.—Suffered in the interim a great deal of severe spasmodic pain in the umbilical and right iliac regions, so that she took eighteen grains of opium at short intervals to afford relief, and that failing to do so, Dr. O'lt. administered a four grain dose at once, upon which the pain ceased entirely, thus making twenty-two grains of opium between 2 j o'clock and S£ o'clock. To go on with the opium every third hour during the night. It is to be remarked she drank in the course of the day a quart of the milk and lime-water, and sucked one orange. July 4th, 5 o'clock a.m.—There was a copious discharge of urine during the night; she slept well, pulse 120, tongue moist but slightly furred; she has no pain, and expresses herself much better; her voice is stronger, and her face looks well. 2 o'clock p.m.—The same as morning; continue treatment. 8 o'clock p.m—She eat a few teaspoonfuls of beef jelly to-day, and she still goes on with the opium; iced sweet milk mixed with lime-water as before. July 5th.—Pulse and tongue as before. She took some cof- fee to-day, which caused slight flatulence, and she also drank cream of tartar and lemonade against orders, both of which were vomited almost immediately; with this exception she feels well; eat a little jelly. Take the opium every sixth hour. July 6th.—Pulse 130 ; tongue moist, exhibiting a patch of dirty white fur with red intervals between ; she took no opium since morning; she had a very slight pain in the right iliac region, but it was very trifling; she looks well, and is cheerful; has no pain about the wound ; drank a pint of chicken-tea and eat a little jelly; the epigastrium was slightly swollen, as if the stomach was flatulent. Pulse and tongue both good to- day ; the bowels were well moved, and there was a large quan- tity of flatus discharged; a great deal of* urine passed; she feels a great deal better; directed to take two grains of opium if she be restless. 7 July 7th.—She took four grains of opium during the night. The dressings were removed to-day, as well as the pins and sutures ; the whole wound was healed by the first intention, with the ex- ception of the lower part where the ligatures came out; there is not the slightest pain on pressure over any part of the abdomen, which is soft and relaxed ; she expresses a wish to get a beef- steak ; she wants to know when she can get up and go home (she occupied a room at her sister's residence). REMARKS BY DR. O'REILLY. This case fully establishes the fact that the operation known as Ovariotomy may be had recourse to with every prospect of a successful issue in suitable cases; it also unquestionably de- monstrates the efficacy of opium in preventing the occurrence of inflammation of the peritoneum after the operation of ovari- otomy or gastrotomy. It is evident peritonitis would have set in on the second and third days after the operation had not the opium been" freely and promptly administered. Further com- ment on this point is unnecessary, further than to observe Providence has conferred no greater blessing on suffering humanity than opium when judiciously exhibited. In performing the operation care should be taken not to stretch, lacerate, or injure the peritoneum by passing the pins or interrupted sutures through it. I must observe that the operators who employ the clamp cannot help stretching as well as stran- gulating the peritoneum. Sir A. Cooper, in a case where he tied the neck of the sac of a hernia, with a view to obliterate it and effect a radical cure of the hernia, was obliged to untie the ligature in consequence of the vomiting that ensued; it fol- lows, therefore, that strangulation of any part of the peritoneum must be attended with bad consequences, as it induces mortifica- tion of the part implicated. Fine silk ligatures should be used in tying the vessels, and good care should be taken to dissect the peritoneum from the vessels before the ligatures are applied. Dr. Robert Nelson follows these rules—their importance can- not be overrated in a physiological and practical point of view. I will now state what happened soon after Dr. Nelson and I left the patient on the 7th July :—Mrs. L. being in the 8 habit of taking large doses of cream of tartar (about two ounces) " to cure the dropsy" by its purgative action on the bowels, sent for six cents' worth of cream of tartar, which she had dissolved in some cold water and drank off. Not relishing this cream of tartar, she sent for three cents' worth of cream of tartar to another store, dissolved it in some water, and drank it almost all off at a single draught. Towards evening the bowels were violently acted on by the medicine, producing copious discharges, which continued on tuesday night, leaving her alarmingly prostrated and collapsed on Wednesday. The discharges continued from the bowels on Wednesday, Wednes- day night, and almost up to 2^- o'clock p.m. on thursday (9th July), when she died. Opium, stimulants, and restoratives were freely had recourse to, without effect. The hypercatharsis could not be arrested, or the debility and exhaustion conse- quent thereon averted. It will be remarked Mrs. L., although cautioned not to take the cream of tartar, acted on her own responsibility, and caused the action of the bowels to take place by taking the cream of tartar, which I intended should not take place by administering the opium. She could not have taken a more deadly poison than cream of tartar under the circumstances in which she .was placed. She took about three ounces of cream of tartar on tuesday evening, an ex- traordinary dose, when it is recollected half an ounce of cream of tartar will act as a purgative; an ounce as a hydragogue. I believe three ounces of cream of tartar, unless rejected by the stomach, are sufficient to cause the death of a healthy per- son. I am satisfied Mrs. L. might have lived some years had. she obeyed my orders, and not, in violation of her promise, taken the cream of tartar. It will be recollected that the fact of the cream of tartar acting as a -purgative, proved the non-existence of peritonitis. I cannot conclude these remarks without acknowledging my indebtedness to Dr. R. Nelson, of this city, for his able assist- ance and advice. I followed the course which he had so suc- cessfully pursued as an ovariotomist in San Francisco and this city. P.S. No post-mortem examination could be obtained. 230 Washington Square South, K. Y., July 14, 1863.