H. R. Spencer
1923 BMJ (Clinical Research Edition)  
OVARIOTOMY on women over 70 years of age is so uncommon as to justify tlle publication of a complete series of cases, The advanced aae of the patients introduces pathological,. clirical,: and therapeutical features which are worthy of consideration. The following ten cases have been met with amongst 625 ovariotomies I have performed. CASE I. M. A. F., aged 82t years. This' case was published in the BRITISH MEDICAL JOURNAL in 1893 (ii, 1271). 'The 'patient was, so far as I know, the oldest upon
more » ... w, the oldest upon whom ovariotomy bad been performed up to that time, except Homans's patient, who was apparently a few weeks older. The tumour was a multilocular cyst of the size and shape of a cottage loaf. There was some mental wandering, bronchitis, and loss of control of faeces and urine during cohvalescence; but a good r'ecovery ebsued and the patient was in excellent health elevenmonthslater. The patient's mother died at the age of 76, two sisters at 70, and one was still living at the ace of 79. CASE IT. E. F., a widow aged 71 who had had fifteen children, two miscarriages, was admitted to University College Hospital on May 10th, 1898, complaining of enlargement of the abdomen and prolapse of the womb for four years, and of a dirty vaginal discharge sometimes tinged with blood, which had been' present for some months. For six months she had had difficulty and frequency in passing water; sometimes there wag n, aching pain in the lower abdomen and back; the bowels were confined. Menstruation began at 17, was regular, not excessive, and lasted for three or four days; it ceased at 50., The patient's father and mother' died at the age of 78. The abdomen was greatly distended, the half-girth being 221 inches on each side, while the measurement from ensiform cartilage to pubes was 201 inches. A large, evldently multilocular, ovarian tumour distended the abdomen. The vagina was inverted and had a large ulcer on it. The Os wa hiealthy. Under treatment by boric acid douches the ulcer gr,adnally heiled by July 1st. On July 11th, 1898, ovariotomy was performed'. Ventro-fixation was also performed by means of the ligature:on the -right pedicle and a second silk ligature passed under the left rouind ligament tying the left side of the uterus to the abdomiinal wall; this liga-" ture was removed on the seventh day. The abdominal"'incision was closed with silkworm gut passed through the 'abdominal wall', buried silk for the fascia, and horsehair for the skin. The operation lasted thirty-four minutes. The tumour was a multilocular ovarian cyst without papilloms. or solid growth, and contained 151 pints of fluid. There was very little shcck after the operation; a little sickness occurred at 5 p.m. and 11 p.m. The patient slept a good deal in the evening, was comfortable except for a slight pain in the back, and passed urine spontaneously. Some pain next day was due to pressure of a too tight bandage, and was at once releved on relaxing the bandage. Flatus was passed on the second day. The recovery was simple, the temperature only once reaching 1000 after the operation. The wound healed by first intention, and the patient left the hospital on August 13th. Seen on October 25th the scar was sound, but there was still procidentia of -the vagina and cervix. For a few days after the operation the patient was rather sullen, at a time when she slept badly; but later her spirits became normal. CASE IIr. L.-B., a married woman aged 70, who had had two children naturally, was admitted to University College Hospital on May 19th, 193, complaining of a tumour in the abdomen which she had noticed for six months, increasing in size and accompanied by pain In the lower part of the back; she also had pain on passing a motion except wheu the bowels were relaxed with medicine. Menstruation had always been regular. The patient was rather feeble. The abdomen was irsegularly distended, chiefly below the umbilicus and on the right side by a cystic tumour which reached up to within one inch of the urmbilicus and projected into Douglas's pouch, displacing the small atrophied uterus slightly forwards and to the left. The tumour fluctuated and was evidently a multilocular ovarian cyst. Ovariotomy was performed on May 25th, the pedicle being tied with silk and the surface of the stump turned in and stitched over with fine silk. The abdominal wall was closed with throughand-through stitches of silkwQrm gut and buried continuous silk for the peritoneum and sheath of rectus. The operation lasted fourteen minutes. There was no abdominal discomfort or shock, and very little vomiting afterwards. The, wound united by first intention. The temperature rose daily to 1000 for the first five days, and in the second week on two occasions reached 101.20; but after the oixteenth day it did not rise above 99.50 and was normal -when she wvas discharged well on June 30th. -The tumour was a multilocular cyst of the left ovary with no solid growth or papilloma; it weighed 2 lb. 7i oz. The right ovary was normal and was not removed. No cause for the rise of temperature was discoverel; there were no rA!es in the chest, and no pain or mental disturbance. CASE IV. Mrs. B., aged 74 (two children, 'no miscarriage), was seen by me at New Barnet, in consultation with Dr. Elam, in May, 1914. She had lost a good deal at the menstrual periods, which ceased at the age of 50. At the age of 71 she had a grave attack of hemiplegia, for which Sir Thomas Barlow saw her in consultation. For nearly a year it was thought sbe would not recover. She gradually aot about, but had since suffered'from phlebitis in the veins of the arms and legs. Early in 1914 she began to complain of pain in thd lower abdomen and of difficulty in micturition and defaecation. A tumour was discovered reaching up nearly to the umbilicus, most mark'ed on the left side. It was. fixed, was diagnosed as an adherent ovarian tumour, and was removed (at the patient's house) with -some' difficuilty, 'on'accoun't of 'the' strong adhesions,' on May 4th, 1914. In cutting the tumour free the bladder was opened for about two inches and the hole was closed with silk sutures, not involving the mucous membrane. A drainage tube was inserted. The wound healed by first intention, except the track of the drainage tube, which closed quickly by granulation. There wat no trouble'after the operation. The tumour was a multilocular ovarian cyst, with no solid growth or papilloma, the cyst having' the usual columnar epithelial lining. .The patient remained well for more than six years after the operation, but died of haematemesis, thought to be due to gastric ulcer, when over 80 years of age, on October 15th, 1920. CASE V. C. G., a virgin aged 71, was sent to me by Dr. Goullet on February 17th, 1916, complaining of swelling of the abdomen ai'd aching pain for the past six months. Menstruation had ceased at 50. It had not been very regular at first, butUbecame more so6 later on, and was always attended with a good deal of paiu. The patient had lately suffered on most days from vomitilng. On six occasionB she had had to have a'catheter passed for retention'of urine. The bowels were confined. She had really had pretty good health; but when a young woman, having a "displacemeint"I of the womb, she was kept in' a recumbent position for twenty years, always being carried if she left her room; she suffered much from sickness during this time. The legs were not swollen and she had been getting thinner. A slight cough sometimes troubled her, but there was no expectoration. The tumour had been discovered by the doctor a fortnight before I saw her. The abdomen was greatly .distended by a multilocular ovarian tumour,considerably larger than a uterus at term. The uterus was small and freely movable, and the lower end of the tumour could be felt in front of the body and movable apart from it. . A multilocular ovarian tumour of the left side which contained neither new growth'-n-or papilloma was removed in a'nursing home on; February 20th', 1916. The right ovary, 'atrophied, was not removed. 'The patient made a simple recovery. The wound. healed by first intention. She was in fairly good health in February, 1923, seven years after the operation. A sister is living at the age of 86. CASE VI. C. D., aged 701 years (four children, no miscarriage), was admitted to University College Hospital on July 18th"1918. Her last-child was born thirty years ago. Slle complained of being suddenly. seized with pain in the abdomen when.out walking reqently. A doctor whom she consulted found an abdominal tumour, 4which had greatly increased in size during the lastmonth. Menstruation began at 17 and ceased at 5+. It had been regular every four weeks, lasting seven days', unaccompanied by pain. The flow was rather free, fifteen diapers being used; micturition was frequent; the bowels regular. The patient had lost a good deal of flesh lately. On examination an abdominal (evidently multilocular ovarian) tumour, as big as the uterus at term, reached up to the ensiform cartilage. The uterus was atrophied and movable. Behind and to the left side was a hard tumour, as big as a hen's egg, wh-ich appeared to be an, ovarian fibroid. The large abdominal tumour could not be felt per vaginam. The case was diagnosed as an ovarian fibroid on the left side and a multiloculur ovarian cyst on the right. The' large tumour was found to affect the left ovary when removed on July 20tb, 1918, tbrough a four-inch median abdominal incision;. on tapping this cyst about agallon of straw-coloured flaid escaped. The pecdicle was tVed and stitched over with silk. A small-cyst was found in the right ovary, which was also removed. The hard tumour proved to be a' subperitoneal calcified fibroid ol the tuterus and was not removed. The abdominal wound was closed with through-and-through stitches -of silkworm gut, continuous silk for the peritoneum, interrupted silk for the sheath of the rectus, and silkworm gut for the skin. The patient was a little sick after the operation and required the use of the catheter. She made an uninterrupted recovery, and left the hospital on August 12th, -1918. The tumour was a multilocular -cyst, quite smooth on the outer surface and free from adhesions, and showed a few. dilated lympha,tics; an accessory ostium was present in the Fallbpian tube. The inner surface was irregular and covered in places with pigment and thin patches of papilloma up to the si2e of a sixpence, and in a few places with little solid white growths not bigger than a grain of wheat or a pin's head. There w1as n1o ei2tensive mass of papilloma and no other solid growth. The right ovary measured rTw ZBa z M IEDIL JOUUMAS '& a z
doi:10.1136/bmj.1.3249.582 fatcat:ursck3trubbnvl4fazcw5zleai