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I! I 



^= 1^" Second Revised Reprint Edillon. 



4 



Ovarian Tumors, 

AND RElvlARKS ON ^f 

ABDOMINAL SURGERY, 

WITH TIIK RESULT (IP 50 CASES. 

RV 

ElJWARD BoRCK. AM, M. D.. 
PROFiiSSOK OF SURGERY, Etc. 



ST. LOUIS, MO. 



4 



lyi9ifl«Ei 




UiM i0@iEgiMl@Mi!l 



SeGsnd Retlsed Reprinl Edition. 



Ovarian Tumors, 



AND REMARKS ON 



ABDOMINAL SURGERY. 



WITH THE RESULT OF 50 CASES. 



Edward Borck, a. m., m d. 



PROFESSOR OF SURGERY, Etc. 



ST. LOUIS, MO. 



issr. 



WEISS A MACCALLUM, 

PRINTERS, 

3747 * 3749 N. Broadway, St. Louis, mo. 



^ ^ 



• • • 









» • • 

« 4 « 






* 
» » • » 






PREFACE TO FIfiST EDITION. 



These lectores were delirered during \be first three sessions of 1$$:!>S$9 
at the College for Medicml Practitioners, St. Lonis, Mo., and published at 
the request of many professional friends near and distant who werv not 
able to listen to me in person. I prepared the first part for the Cincinnati 
Obstetric Gazette, wherein it appeared in September, 18^. 

This reprint, wil5 additional tables, and mj method of operating is 
dedicated to the dass of Medical Practitioners who attended my lectares 
daring the above named sessions. 

BY THE AUTHOR. 



7 f su 



PREFACE TO SECOND EDITION. 



The first reprint edition as will be seen was published in 1883, the 
applications for the same were very numerous and gratifying, the reprints 
then on hand have long ago given out; however, the inquiries for the re- 
prints continue to be received up to date. 

To supply the demand and thinking it a duty owed to the profession, to 
contribute from time to time whatever experience one may have had, I 
offer and dedicate this revised edition to the Medical Profession in grati- 
tude for the many kind favors received from my professional brethern and 
friends throughout this great valley. 

The first part is a lecture on Diagnosis. The second part, my method 
of operating as lately delivered to my private classes. The third part, 
a paper read before the Mississippi Valley Medical Society. 

I will be obliged to you if after reading this pamphlet you would 
acknowledge the receipt of the same; if this, like previous ones, will 
meet your kind recognition and prove to be a profit to you it will be the 
reward of the author. 

Very truly yours, 





PART I. 
LECTUBB ON DIAGNOSIS OP OVAKIAN TUMORS. 

Fellow Practitioners! 

In our last lecture we considered abdominal tumors in general and 
studied the various modes by which we are enabled to make a correct 
diagnosis, and under that head included also hernias. To-day we will 
take up a class of tumors to which the fair sex, whom we all adore and 
love so much, alone is heir to— Ovarian Tumors. 

And as I speak to men that have had years of experience in their pro- 
fession and love their study, I take it for granted that you are all ac- 
quainted with the pathology — I need not occupy your time with repeating 
what you can read. As usual, you find a roster upon the wall which will 
inform you of the papers and articles lately written upon that subject. 
In addition I call your attention to this little work of Garrigues on Diag- 
nosis, and refer you to the late edition of Sir T. Spencer Wells, on Ovarian 
Tumors. Let us consider the diagnosis and take a simple case of ovarian 
tumor for our guide. It matters not what kind of an ovarian tumor we 
have, so we know it is ovarian and nothing else, and do not mistake it for 
other tumors or swellings, or the reverse. 

For convenience's sake, the development of an ovarian tumor may be 
divided into four stages. -Now let me make a diagram: on the left side 
the tumor begins to grow; as long as it is within the pelvis it is in the 
first stage; if it grows up to the umbilicus, it is in the second stage; from 
here to the epigastrium, it is in the third stage ; and up to its highest 
point. In the fourth stage its prominence and circumference is alone in- 
creased. Between those boundary lines you may make subdivisions again 
if you choose. The reason why these tumors occur more upon the left 
side, is owing to the fact that the left ovarian veins have no valves. 

Now let us reflect ior a moment and sefe what disturbance we may ex- 
pect to be produced by such a growth. 

In the first stage : If the uterus is in a normal position the tumor is 
in front of the uterus and behind the bladder. There is irritation of the 
bladder, dysmenorrhoea, constipation, a feeling of a heaviness in the pelvis 
and hemorrhoids, the latter being frequent with poly cysts. 

In the second stage : What must it do? It must displace the small in- 
testines to the opposite side, and as it has arisen out of the pelvis the 
uterus is therefore placed behind the cyst, and the bladder goes with the 
uterus. The tumor by this time has acquired a pedicle and is movable, 
the patient discovers it rolling about as a ball if no adhesion has been 
formed. There is a desire to urinate, but diminished action of the 
kidneys. 

In the third stage: The small intestines are pushed up, the large 
omentum is only between the tumor and the abdominal walls, it is up to 
the epigastrium, presses upon the stomach and diaphragm, elevates the 
ribs, interferes with respiration and digestion, produces palpitation of the 
heart and the general health fails. We have derangements of menstrua- 
tion, emaciation of face and neck and upper extremities. There is a 
peculiar expression of the countenance, enlargement of the abdominal 
yeins and oedema of the lower extremities. 

In the fourth stage : The tumor extends in all directions where there 
Is no resistance, all the symptoms are aggravated, the pulse runs up to 
120-130. 




T make these preliminary remarks to refresh your memory. Now sup- 
pose a patient comes to us with symptoms like these : — lier abdomen has 
increased gradually in volume, without any sickness; she tells us the 
swelling first appeared in the iliac region and extended upwards; she has 
also observed in the beginning of the growth, by turning quickly in bed, 
a feeling like a ball rolling about in her abdomen. If the swollen abdomen 
appears like an advanced pregnancy, with well and equal fluctuation, if 
there is a dull sound in the anterior abdominal region in every position, 
but on the side a tympanitic sound upon percussion, if by the motions we 
impart to the swelling the uterus moves along but is of normal depth, 
then we can suspect an ovarian cyst. The whole character of the swell- 
mg speaks in favor of a cyst, the passive movements of the uterus along 
with the tumor indicates that the tumor belongs to the internal generative 
organs. The passive movements produced with the uterus and the normal 
size of the same, indicates to us that the swelling does not belong to the 
uterus; it must be an ovarian cyst. And we can prove this positively by 
making examination per rectum — and here I will say to you, make your 
examinations always for healthy organs, do not hunt for an ovarian cyst 
but for two normal ovaries — if you find both in their physiological condi- 
tion exclude disease of the ovary, the swelling must be something else. 
If you find but one ovary normal and the other mentioned symptoms in 
addition, you will not go amiss to say ovarian tumor. 

Aspiration of the fluid and the chemical and microscopical examination 
will clear up any doubt; The chemical character is principally albumen, 
extractive matters, fat and salt united with water, but it contains no fibrin, 
and the fiuid is not spontaneously coagulable. (Here the microscopical 
appearance of what the fiuid reveals, was shpwn, after Drysdale.) Now 
after this you may think it easy to make a correct diagnosis, but be not 
Jeceived, it is sometimes very difficult. Let me relate to you the history 
of a case. An American lady 25 years old, married, had two children, one 
living, 6 years old, she informed me when I first saw her in consultation 
with the physician then in attendance, that three years previously she 
noticed a swelling in her left iliac region which gradually grew larger; 
she felt that something was rolling about in her abdomen. She kept it 
secret and at last she became so large that her friends thought her preg- 
nant with twins or triplets. She had suffered all this time with intermit-, 
tent fever. Six months previous she had gone north, and came home im- 
proved in health. Physicians had recommended tapping, but it was not 
resorted to. She had passed a good deal of water at times, could not tell 
exactly, but believed it came from the bladder, then became more natural 
in size, still a large lump remained. The last three months she grew 
worse, the swelling became hard, every sixth day she would have an attack 
of fever and pain in abdomen — "Inflammatory attack. Peritonitis." 

When I first saw this patient and before knowing anything about the 
particulars of the history of the case, I ventured to say to the attending 
physician that I expected to find an ovarian cyst, simply by the charac- 
teristic expression of the face. Upon an examination I found a large 
tumor in the left side, extending up to the umbilicus. Near the umbilicus 
a distinct fluctuation which I recognized as an abscess, or possibly 
nature's effort to open in that region; adhesion only on right side and in 
front of tumor, left lower side none, I could lift up the abdominal muscles 
there. Fluctuation otherwise not distinct, the whole tumor somewhat 
movable, uterus normal and pushed to right side. Per vaginam tumor 
could be felt; per rectum, right ovary plain, left not detectable, but tumor 
distinct. Great irritability of the stomach. She had been seen by a host 
of physicians, some eminent and well known, but no opinion was given ; that 
is no one committed himself to a positive diagnosis. Poultices, liniment 
etc., had been applied externally, also internal medication, all to no pur- 
Only temporary relief was obtained ; she was very weak, no can-^ 



— 7— 

cerous cachexia, no family history of cancer. I diagnosed positively an 
ovarian tumor, but gave a guarded opinion in regard to complications, re- 
commended a tonic regimen to build her up. She recruited nicely. When 
I saw her again ten days later I was informed that she had passed some- 
thing like fluid and matter, amounting to a quart, from her bowels. She 
was anxious to have something done to relieve her suffering. I recom- 
mended an operation, and carefully stated to all concerned that I would 
make an exploratory incision and then if advisable go on with the opera- 
tion, otherwise abandon it. They all gladly consented in good hopes. — 
Now what do you expect? After opening the abdomen, I found a whole 
mass of adhesion, omentum, mesentery, intestines, all adherent together 
to the abdominal walls , the abdominal walls cancerous *, the fluctuation 
we detected near the umbilicus turned out to be an encysted abscess; 
while cutting through the abdomen in the linea alba, a crackling sound 
could be heard; no where could an opening be found, all was one mass 
of adhesion. My assistants all look at me and I felt like I had made a 
mistake, or that I had been deceived in my diagnosis. 1 could not appre- 
hend that I was mistaken, finally I succeeded in getting my fluger between 
the walls of the abdomen and hunted for the left ovary. I assure you I 
felt relieved and confess, a little proud, when I exhibited a plain tumor, 
of that ovary about as large as a French turnip, or a child's head, a 
shriveled up sac without fluid. I could peel it out of the surrounding 
cancerous mass. 

The patient's fate was sealed, but it was an instructive case — an ovarian 
cyst which nature had tried to cure spontaneously and a development of 
malignant growth not from the tumor, but from other parts and from 
other unknown causes, surrounding, or better, enveloping the tumor. 
They are perplexing cases! Not one symptom alone, but all combined 
should be taken into consideration and carefully studied and weighed. 

It is said of Thomas Keith that he did not make a single mistake in his 
diagnosis in 200 successive cases. I cannot say this because my cases 
have not yet run up to that number. But I can say that in all my own 
cases, and in those which I have examined for others up to this time, I 
have been fortunate enough. My diagnosis have always been verified. 

In regard to my success, I prefers other to inform you. 

Pregnancy, encysted dropsy of the peritoneum, uterine, fibroid tumors, 
distended bladder, renal tumor and cysts, cysts of the broad ligament, 
(these by the way are considered as the most difficult to diagnose,) ascites, 
etc., etc., have all been, and may again be mistaken for ovarian tumors. 
When 1 visited Europe three years ago I was fortunate enough to meet 
and make the acquaintance of the best surgeons and had ample oppor- 
tunity to see them operate; I saw one of the. world renowned Ovario- 
tomists make a mistake in his diagnosis; after opening the abdomen there 
was no ovarian tumor. Doctors are human and liable to err. Again, 
ovarian cysts may be complicated with pregnancy, ascites, uterine fibroma 
and second cyst. 

Ascites is mistaken the most frequently for ovarian dropsy, though that 
mistake ought not to be made by any practitioner. 

In ascites the intestine floats upon the fluid, consequently in the re- 
cumbent position of the patient the dull sound must be heard at the 
lowest point, the tympanitic sounds upon the highest point of the abdomen. 
In ovarian cyst the reverse. If the patient changes her position in ascites 
the fluid will always gravitate to the lowest point, the intestine floating 
upon it. In ovarian cyst it remains the same. It is also well to remem- 
ber that oedema of the extremities appears after tumor is developed, 
but often precedes it in ascites. As I have said to you of other surgical 
affections that it is not well nor prudent for the surgeon at once to go to 
work with his hands and feel and twist and pinch the parts injured, but 
should first of all inspect with his eyes and educate them as perfectly as 



—8— 

possible to observe the different outlines, always having in his brain the 
normal contours and position, and then mark the abnormal. Here we can 
learn a good deal to our advantage with the aid of our eyes, look at these 
drawings. 




Fig. 1 is a lateral view of the abdomen affected with ascites. 




Fig. 2 Is a lateral view of the abdomen affected with an ovarian cyst. 

(Albert.) 

We can see at once the difference in the shape and outlines, it needs 
no explanation. Observe the difference between the sternum and the 
umbilicus, and pubis, and look at the umbilicus itself, it may be obliter- 
ated in ovarian dropsy, but never presents an arching like it does in as- 
cites, etc. One point I wish to call your attention to in ovarian cyst, you 
can grasp the abdominal wall between your fingers and lift them up from 
the tumor wherever there is no adhesion ; in ascites you cannot do it. 

The symptoms and signs of pregnancy I need not explain to you, you 
understand them too well, but let us remember that in the patient affected 
with an ovarian cyst the breast may become enlarged, and an areola 
around the nipples maybe present, also morning sickness. 

Of the diagnosis of uterine fibroid tumors we will speak some other 
time. 

In regard to a distended bladder, all I wish to say is this : never under 

any circumstances depend upon the nurse or even the patient herself, they 

may be honest in telling you that she had just passed water, and a good 

^rdeal of it. I lately met with a case and received such information, yet I 

■ntroduced the catheter and drew off a large amount of urine, I do this 

f^eiy time before examining. Recollect the case on record related to you 



, — 9— 

of a child where the urethra was closed and the bladder adhered to the 
umbilicus and at or near that place had a fistulous opening through 
which the urine escaped; she was operated upon at the age of 18 years, 
and a passage made at the natural situation ; the fistulous opening closed 
spontaneously. We meet sometimes with adhesion of the bladder at that 
point as a complication with ovarian cyst. Again, there are cases on record 
where an ovarian cyst became adherent to the umbilicus and formed a 
fistulous opening and a spontaneous cure took place. 

How to diagnose tumors and cysts of the kidney : I have already spoken 
to you in a previous lecture ; do not forget that tumors of the kidneys will 
enlarge from the posterior to the anterior part above and they push the 
intestine in front. The colon here is always in front and can be filled with 
air and be distended thereby and recognized. 

In the cyst of the broad ligament the fluid is always as clear as spring 
water, contains no albumen and a manual examination per rectum under 
chloroform will detect two ovaries. These are the cysts that are cured 
by tapping. 

Now this drawing represents a side view of an abdomen affected with a 
multilocular cyst, and this is a portrait of the characteristic feature (facies 
ovariana, after Wells.) The time of one hour is too short to go into de- 
tails about everything, but to do you and the subject justice I have pre- 
pared these tables you see hanging upon the walls which you may study 
for yourselves. See tables, pages 10, 11 and 12. 

Here you have the differential diagnosis of a mono cyst, a poly cyst and 
a dermoid cyst. 

Then here the chemical consistence of the fluids of an ovarian cyst, cyst 
of the broad ligament, amniotic fluid and ascitic fluid. And here what 
the microscope reveals. 

All this will give you a pretty good idea of the difficulties we may en- 
counter and what is necessary to make a correct diagnosis. In conclu- 
sion I will say to you again : Be systematic in all your doings, only by 
following and carrying out a certain system can we expect to come any 
ways near to perfection. Let me repeat then: 

First take the symptoms into consideration, the history of the case, the 
expression of the face and neck, the activity of the kidneys, the sympa- 
thetic affections of the mammae; then the local signs; then the rational 
signs as detected by the patient; then the physical local signs; exploration, 
such as inspection, measurements, palpitation, percussion, auscultation, 
change of position, vaginal touch, trocar, microscope ; and last of all ex- 
ploratory incision. 

Second ; Ask yourselves the following questions, so beautifully illus- 
trated by the late Dr. Peaslee, and answer each and every one of them 
positively, viz: 

Is there actually an enlargement within the cavity? 

Is there fluctuation, indicating an accumulation of fluid within the ab- 
domen, or a solid tumor? **Me8enteric flbroma or flbro-plastic.** 

Is the fluctuation due to ascites? 

Does the cause of the enlargement arise in the pelvis? 

Is not the tumor a pregnant tumor? 

Is there not still an enlargement of the uterus though it be not gravid? 
**H8Bmatometra, hydrometra, uterine hypertrophy, flbroma, carcinoma of 
fandus, uterine flbro cysts." 

And to what is the fluctuation due? Serous cyst of the broad ligament, 
encysted dropsy of peritoneum, dropsy of fallopian tubes, renal cyst 
hepatic cyst, pelvic abscess, splenic abscess, etc." 

In our next lecture we will take up the treatment, or rather when and 
now to operate, and I will demonstrate to you my method of operating. 



—10— 



OVARIAN DROPSY. 

The tumor is most prominent upon one 
side, save in advanced stages. 

The tumor remains prominent and glob- 
ular in all positions of the body. 

The tumor is locally fluctuant. 

The tumor begins in one iliac fossa. 

The percussion is dull in front when the 
patient lies upon her back, but is tympa- 
nitic, from displaced intestine, at the sides. 

Is constant and not affected by attitude. 

Palpitation detects an oval outline and 
an irregular surface to the tumor. 

The cervix of uterus is normal in posi- 
tion. 

The health is generally good until the 
tumor becomes large. 

If present, oedema of the limbs /o//ows 
the advent of tumor. 

Aortic pulsation may be transmitted. 

No apparent cause exists. 

Normal color and moisture of the skin 
exist. 



ASCITES. 

The tumor is uniform and symmetrical. 

The tumor flattens and increases in its 
breadth on lying down. 

The tumor fluctuates through the entire 
abdomen. 

The tumor begins symmetrically from 
below. 

The percussion is resonant in front of ab- 
domen, when patient lies on the back, as 
the bowel floats ; but is flat at the sides of 
the abdomen. / 

Is variable, and is affected by attitudes of 
patient and by amount of fluid present. 

No circumscribed outline to tumor or ir- 
regularity of surface is discovered. 

The cervix is frequently displaced. 

The health is usually impaired from the 
commencement. 
It often precedes the ascites. 

Aortic pulsation is never present. 

Hepatic, cardiac, or renal disease often \ 
CO -exists. 

The skin is often jaundiced and is fre- 
quently dry like parchment. 

Ranney. 



FI^UED I>RA1¥N BY ASPIRATOR REVEAI^S: 
OVARIAN FI.UII>. ASCITES. 



Microscope may reveal: 

Epithelial cells; oil globules; granular 
matter; cholesterine ; ovarian granular 
cells; blood celU; Pus cells; Gluge's in- 
flammatory corpuscles. 



Microscope reveals: 
Pus cells ; oil globules ; amoeboid bodies ; 
squamous epithelium. 



{Drysdaie.) 



HEALTHY AMNIOTIC 1?XUII> 



Is a thin pale straw-colored fluid, turbid and fiocculent, has a peculiar odor— deposit 
occurs- on standing, its. chemical character is alkaline, specific gravity: loos-ioio— con- 
tains no fibrin; but albumen, acid acet clouds it, becomes opaque on boiling. Micro- 
scope reveals: Epithelial cells; small tesellated cells, with oil globules and fiacculi. 
Ether dissolves the last. 



FLUID DRAWN BY A SPIRATORjl REVEALS: 
OVARIAN. ASCITES. 



Amber or brown color. 
Not spontaneously coagulable. 
Specifjc grsLvity lOiS to 1024. 
■Para/bi/men and metalbumen. 



Light straw-colored. 

Spontaneously coagulable if fibrinous. 

Specific gravity, loio to 1015. 



—11— 



CYST OF BROAD I^IGAMENT. 

Very slow growth, rare, always mono- 

cystic. 
Mostly in young persons. 
Expression natural ; not much emaciation. 
General health slightly impaired — though 

in third stage. 
Abdominal veins less prominent. 
Fluctuation remarkably distinct. 
Uterus lies low, generally. 

Per vaginam, fluctuation very clear. 
Fluid contains no albumen, and is as clea^ 
as spring-water. Specific gravity 1005. 

Scarcely ever fills after tapping. 
Very seldom fatal. 



OVARIAN CYST — THIRD STAG£. 

Commofl*; growth more rapid; tvro forms 

of cystoma. 
Occurs at all ages. • 
Expression changed; emaciation. 
Decidedly impaired. 

Veins more developed. 

Less distinct. 

Not depressed, but behind tumor gener- 
ally. 

Less clear. 

Contains much albumeq, and is not per- 
fectly transparent. Specific gravity 
1015 or more. 

Fills again after tapping. 

Almost always fatal at last. 

{Peas lee.) 



MONOCYST. 

Slower growth. Not com- 
mon. 

Peculiar expression comes 
later. 

General health fails much 
later. 

Abdomen symmetrical ; if 
monocyst salient, point- 
ed. 

Enlargement from 31; to 45 
inches. 

Surface smooth if mono- 
cyst. 

Tumor disappears after 
tapping. 

Oedema of lower extremi- 
ties very rare , abdominal 
veins less enlarged and 
later. 

Adhesions less common 
and less firm. 

Inflammation of cyst-wall 
not common. 

Ulceration of cyst-wall not 
common. 

Spontaneous rupture not 
common. 

Amenorrhoea comes later. 

Fluctuation distinct, and 
throughout if a monocyst ' 
and from any point to all 
others. 

Per vaginam^ uterus is 
higher, and the fluctua- 
tion also. 



POLYCYST. 

Rapid growth. More com - 

mon. 
Comes much earlier. 

Fails early; by end of sec- 
ond stage. 

Not symmetrical; not 
pointed. 

Sometimes to 55 or even 78 

inches. 
Lobulated; irregular. 

Does not disappear. 

Very common. Veins en- 
larged early. 



Adhesions the rule, and 

vascular. 
Not so common. 

More common. 

Far more common. 

Comes much earlier. 
Less distinct, and circum- 
scribed. 



Uterus lower, and the fluc- 
tuation also, or none at 
all. 



DERMOID CYST. 

Congenital. Very slow. 

Very rare. 
Latest of all. 

Very late. 

Not symmetrical. 



Smallest: generally 30 to 

40 inches. 
A monocyst, as a rule. 

Does not completely col- 
lapse. 
Very uncommon. 



Adhesions not very rare. 

Most common, propor- 
tionally. 
Most common of all. 

Very uncommon. 

Very late. 

Fluctuation more obscure. 



Uterus lower : fluctuation 
dull. 






• • • . - * 



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jr5'/m«»r!ili. 



-12— 



f - 1 If 1 1 1 J|r /^» I or ,• r u n! v^no^ai- 
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f.ortf^inq rpith«:lial Hcalea, 
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t M I % of r.holestrine, 
h;iir<i, f.ir., r.tc; a sin- 
ful': hair in patho^nomo- 
mr. 



Ex^^^lion.^ Sr\ tA\f^t,ry^t o1 biif two or \hrtc roniifitu«:nt <:y<t«, with thin partitions, 
mjty jfivc ill! th<r %\%n* of » monorynt* 



PART II. 
KSTHOD OF OPERATING. 

Wft win now tAk«! up the op<!rAt}on and I will explain to you my method. 
A law (fi you will hflvn an opportunity* to hhh me operate upon the lady 
wm \n th*' houwfi and aw«l«t; If poHHible I will ^Ive you all the same 
cbam;f!. We will take It for granted that before proceeding with the 
operation, you have made a correct dla^noMlM and have prepared the patient 
fn the yt^ry be«t condition, have ^Iven the evening before an enema to clear 
ont the bowelw, and allowed a cup of milk and bread. On the morning of 
the operation have the patient bathed, drcHHed with a short gown, flannel 
drawers and fft<icklngM. Let her rest In an easy-chair, covered with a 
blanket, and If her wkln \n not moist steam lier with some hot water or 
apply hot water bottles to her feet. This Is essential, dry cold skin would 
be a disadvantage, (live her 10 gr. of (]ulnlne and j^ gr. of morphine an 
hotir before the operation. And by all mcmns have her full confidence. 
Never persuade one to be operated on, but let the patient implore you to 
do so. At the same tluu^ your operating room, which should be the best 
room In the house, must have been prepared according to your own direc- 
tions, and It Is best to give them In writing or print as follows: 

The room should be about 80** F. during the operation and kept at about 
70° F afterwards. Kroe circulation of air should be secured. 

All furtilturi», carpets, curtains, etc., are to be removed; the room is to 
be freshly whltewaslied or varnished like my own private operating 
rooms, floor tuid woodwork nil scrubbed with soap and water, and rinsed 
with water ami chlorinated soda, one to two tumblerfuls to a bucketful 
of soft water. Troeure a small, new bed-lounge— mnie are made of iron 
—six feet long and twenty-eight Inches broad, with two squart* blocks of 
wood six Inches high or more, with holes drilled into them to receive the 
rollers of the feet of the bed to make it stand solid and firm and to elevate 
the bed to a proper height to suit tlie operator. Have a good firm mat- 
*rwMi to lit the bct^ It must be nine or ten Inches high; two small tables; 
two yirtl* of India rubber or oil cloth to spread over the 
" doieu «oft towels, tliree or four stone wash-bowls and one 
ttMrmometcr; one clean bucket for water, and one cup; 
r Ittbj tumblf^rs. drinking water, tea spoon: three or four 
ifOa hoopa, and a iHKl-pan, Tlie towels, as well as the 
dt^iittlH must bte wt»ll washed and rinsed In the solution of 
Ji bill iM>t be starched. l>uriiig the operaUon no one is 
I or oilier the it>om. l-tider no circumstances is any per- 

• ♦* :»••* •• : " 




7 



—13— 

son permitted to visit the patient or remain in the room except the nurse 
or the attending physician. 
You should also see that the following is on hand, and give (in writing,) 

THESE DIRECTIONS TO THE FAMILY DRUGGIST: 

R Distilled Water 5 gallons. 

Oil Silk 1 yard. 

Lister's Carbolized Gauze....! piece, 6 yards. 

Alcohol )4 pint. 

Mitchell's Mole Skin Plaster lyard. 

Liq. Ferri. Persulphatis )4 ounce. 

Brandy (French) 1 pint. 

Pure Carbolic Acid 1 ounce. 

Chloroform 1 pound. 

(Mallinckrodt's is preferable.) 

Or Bichloride of Methyline, if the latter is used I prefer Mallinckrodt's. 
I used it in several cases, given through Jounker's apparatus, and it acts 
very nicely. Nevertheless I like the chloroform the best. 

Nitrite of Amyl one drachm, is well to have on hand and a Battery. 

R Iodine gr. ii. 

Pot. lod 3 ss. 

Aquae Dist 5 viii. M. 

Sig. Use to fumigate the room before operation. 

Here is the atomizer (Lister's spray) . I will light it for you and you 
can observe how it works. 

In my earlier operations, I used the carbolized spray during the opera- 
tion. I now discard that plan as not necessary. 

R Acid Carbolic 3 ss. 

Glycerine 5 vii. ss. M. 

Sig. Ready to be mixed with water to wash the hands, instruments and 
sponges. The sponges should be new and of the finest quality, previously 
well washed in a weak solution of Nitric Acid, then kept in carbolized 
water. 

R Acid Carbolic 3 i. 

on OlivsB 5 vi. M. 

or R Bichloride of Mercury 1 part. 

Water ". 2000 parts. 

Sig. Used to pour upon a saucer or plate ; the ligatures and threaded 
needles are laid and kept in this until needed. 

R Chloride of Sodium 3 iv, 

Albumen 3 vi. 

Distilled Water oi. M. 

Sig. Used for dipping in the hands, instruments and sponges, after dis- 
infection, and before using them. This is th6 artificial serum and has to 
be diluted with three parts of warm water, the temperature of blood heat. 
It is also used to syringe out the abdominal cavity, to clean it of any blood 
or. fluid it may contain. I now prefer to use the artificial serum exclu- 
sively, instead of carbolic acid or mercury for hands, instruments and 
ligatures. 

R Pulv. Opii 

Sacc. Albi _ gr. xii. 

Misce etdiv. in Chart No. 12 

Sig. Used as directed or needed. 

R Morph. Sulph gr. i. 

Aquse Dist ^t C. M. 

Sig. For hypodermic injections. 

**Listerine'* may be well substituted for Carbolic Acid. 



— u- 

All prescriptions should be marked in full on every bottle and package.) 

So far your drugs and dressings. Here I like to call your attention to a 
point of interest in regard to chloroform. Chloroform should never be 
kept in large bottles for the reason that very seldom a pound of chloro- 
form is use at any one time, opening and reopening the chloroform spoils 
it — injures its virtue. Water will also spoil it. If you send to the drug- 
store for one or two ounces of chloroform you cannot depend upon it, for 
you do not know how long it has been upon the shelf and how many times 
it has been opened and thereby having absorbed moisture. At any rate it 
is a risk to administer chloroform of which you know nothing. I use 
Mallinci^rodt's special prepared chloroform and as you see here it comes 
in two ounce vials with glass stoppers, hermetically sealed. Whenever I 
use chloroform I open a fresh bottle, whatever is left is never used again 
for inhalation. It would be much wiser for druggists to keep chloroform 
in two ounce bottles, if you need more than two ounces obtain two or 
three or more bottles, if less, the loss is not much. Up to tliis time I 
have not to regret the death of a patient from chloroform ; but nearly 
came losing two healthy patients in my office after administering the 
chloroform left from a pound bottle which had been opened several times. 
My chloroformist Dr. E. Chancellor has kept a patient under the full in- 
fluence of chloroform for me for one hour, until I i)erformed an Ovaria- 
tomy, with but two ounces of Mallinckrodt's special chloroform without 
vomiting or any other unfavorable symptom. You see I still adhere to the 
chloroform, I prefer it instead of any other anesthesia. 

NOW THE INSTRUMENTS. 

I brought my case and will explain to you as I go along. Here is a plain 
trocar, ^-inch calibre about 12 inches long which I employ for tapping 
a cyst without further operation. It seems to be very large but it is not; 
I first cut through the skin and cellular tissue with a scalpel then intro- 
duce the trocar and draw off the fluid. The opening will contract almost 
completely. Here is another trocar like the Dome trocar, used for tap- 
ping a cyst after opening the abdominal cavity ; you see it can be with- 
drawn and has a safety tube and you can do no injury in searching for a 
partition within a cyst. This is a Dawson's Modified Clamp. Two wire 
retractors, three Peaslee's needles, one tooth-edged scissors, one pair 
curved small scissors, one pair straight small scissors, one steel sound 
No. 10, for locating adhesions, one artery forceps slide catch, one female 
catheter, one pair wire cutting forceps, one steel grooved director, one 
large tenaculum, one scalpel— fixed handle, one straight bistoury— fixed 
handle, one probe pointed bistoury — fixed handle, one artery needle— fixed 
hand e, one dozen steel ovariotomy pins, one caigut ligature jar, one gran- 
ite enameled iron tray, for carbolized silk or linen ligature, oil paper, oil 
pasteboard strips, etc. ; with room for needles, beads, iron and silver wire, 
etc. Here are two of my dressing and needle forceps, with slide catch six 
inches long, extra deep serrated. 

These are my cyst elevators, made of strong steel wire, shaped like a 

tuning-fork, or lady's 
hair-pin, slightly curved, 
a double needle ; and here 
is a cautery iron, and two 
pieces of rubber tubing 
about four feet long, one 

Fio. 3.-Hal£ the smallest size. ?^ ^}^^ ^^ fastened tO 

^ ^2,e E:iovator. B-A cap to protect the points. ^}^ ^^O^f- ^Iso twenty- 
-^^^^ K *- f ^^g Qj. ijijipty flue needles 

i>a^ ^^jreaded with fine linen ligatures, in case you should need them to 
^r ^^ZlcP *^y openings in the intestines or bladder that may happen to 





Fig. 4. 



—16— 

give way. Instead of the ordinary surgeon's needle I use the Fig. 4. They 
are made of sewing machine needles. The eye is in the anterior instead of 

the posterior 
part as you 
see in the 
drawing and 
perfectly 
smooth, one 
long ligature 
is all that is 
required. I 
had little 
handles put 
on mine, 

saves the trouble and annoyance of a needle holder. Mess. A. M. Leslie 
& Co., No. 204 North Broadway, of this city, manufacture and keep the 
various sizes on hand. 

These are the instruments necessary for the operation. Have them all 
arranged conveniently upon a small table; see yourself that everthing is 
in perfect order and nothing missing, keep everything out of sight of the 
patient. Before your patient is brought in, arrange and designate the 
duties of each of j^our assistants, tell each of them what you expect him 
to do, and to do that and nothing else; place your main assistant on the 
left of the patient; one for the chloroform, who must be aware of his re- 
sponsible duty. Intrust your sponges but to one person only, count them 
out to him, and before closing the abdomen, demand them all; see also 
that none of the instruments are missing, and allow no one to do anything, 
especially to put his hand into the abdomen, except you ask him to 
do so. One ready for any emergency that may happen. 

Do not talk, keep quiet and tranquill; have no lookers-on. And let me 
tell you, see that you have the very best of assistants, one superior to 
yourself is preferable, at least equal; your main assistant should never be 
inferior to yourself if possible. For one who knows and is acquainted 
with the operation will render you better service; be not afraid of him 
who has had the experience for he was once there where you now begin, 
and he will act forbearingly with you. But avoid the one who is selfish, 
one who thinks he knows it all. An operator who for his own vanity's 
sake never employs any but ignorant nurses or young student's or others 
whom he can blindfold, and who will not be aware of and are not able to 
observe his mistakes so that he may shine and appear to be a great light, 
will never gain a great success. Another point of great importance is to 
pay your assistants and pay them as liberal as you possibly can; cases of 
charity excepted; you occupy their time, their time is as valuable as yours. 
Only by paying your assistants you can obtain good and skilled ones; you 
are then under no obligations to them and they like to assist you and are 
always ready, and hardly ever disappoint you. 

I can obtain scores of Doctors to come and assist me, many come that 
are anxious to see me operate. But what good will it do me and my 
patient to be annoyed by idle lookers on who will ask a hundred and one 
questions to no purpose. What good are those that offer their assistance 
without compensation, telling you they will come, but when the time 
arrives they put in no appearance, excuse is, **an Obstetric case on hand," 
or they come in a hurry half-an-hour behind time, the operation hardly 
completed off they start, one after another. I know of a surgeon in this 
city who operated with such assistants, and before the operation was com- 
pleted, he and the nurse were the only ones left to take care of the 
patient, to ligature the blood-vessels and finish the toilet. 




-Pw whMi j^ou will neetM a aashjie of f.... 

Providing that yo^ ham not been in a dissealing room or engaged at an 
outopsy, and have not sxen or attended or have been in contact wUh any 
>joruagious or m/ectiow diaeaaea whatsoever, for the last 24 hotira previ- 
ow« to date of operation. 

Taking due precautioita of having handi and body ai well as garments 
moroughly surgicaltg deo». OperaUng gown laitl be famished. 
,,^^ ^''^cfuai, as no one will be admitted to the operating room after the 
operation has begun, nor WUI anyone be permitUd to lenue the room itntil 
ifte operation and toilet is completed. Truly yours, 

EDW. BORCK, M. D. 

'■'-E*BE UNSWEB. Cur. Ninth & S^il!sbury Sts, 



Eliarity exteiiipdl 
"I will lie "■■ I..- 
thank thy I 



iLtnount ol fee yuu will pay cash, (cases of 

wyr you receive wlii almost invariably read 

1 iiiiiiu, ■ jinii mev are on hand and will remain until you 

for their service iind right and justice will prevail on both. 

NoLtber nefjluct to invite and select the family physician or the 

you the case to be one of your assistants . 



side! „^, 

PayBlclan who kindly acm, juu mc i^imn LU UD uiic ui juui a»B in uji 111.0 . 

Everything being ready, the patient is brought in, laid upon the bed, 
covered and chloroformed. The iisslstant will gently support the abdo- 
nieil with his eipanded hands. You begin your incision through the skin 
a little below the umbilicus In the Unea alba and carry it down to the 
pubis, then divide the cellular and adipose tissue, using your groove 
director, liiyer after layer, until you come to the peritoneal covering; if 
you miss tbe median line move your direutor from slile to side and you 
Will find it again. However, I think there is no harm, perhaps an advun- 
''^ge, in cutting ihrough the rectus muscle. Having reached the perito- 
neum, atop and wait until all hemorrhage has ceased. Then pick up the 
peritoneal layer with a forceps, nick with the knife and divide It the 
whole length. The cyst will now be exposed. Ton can recognize It by its 
bluish appearance; if you are nut sure examine It closely, you will see 
Whether there are any adhesions and may use the sound for that purpose. 
" yon have not room enough lengthen your incision. Having aatisfled 
yourself about that, the next step will be to empty the cyst. 

Let us suppose this bladder which lies be- 
fore Q8 and wlilch is filled with water, to be 
H cyst. You take the elevator and Intro- 
auce It thus: see Fig. 5. Now take the trocar, 
Oiraat it Into the cyst, between the prongs i-.^, ;, 

»nd fingers. See Fig. a. The advantage of 
Uda method is : no fluid can escape from the cyst and the sack empties 




Itself; It Is gently and very 
slowly drawn ont, the trocar 
is pusbed gently deeper at 
the same time; the abdom- 
inal walls collapsing around 
the cyst, which are support- 
ed by the hands of an assist- 
ant thus preventing any of 
the viscera from protruding, 
and by the time the cyst is 
nearly empty, it is also al- 
most drawn out from its 
bed; the hold is flrm and 
nimecessary traction and 
manipulation is avoided and 
no air can enter. If needed 
a ligature can be applied 
around the cyst and trocar 
below the piongs of the ele- 
vator. With a little care all 
soiling of clothes and bed- 
ding can be prevented. This 
elevator may also be conven- 
iently employed to transfls the pedicle, used with the ligature; with the 
cap in its place the pedicle can be fixed in lower part of wound, tlie ele- 
vator resting transversely upon the outside of the abdomen, and no clamp 
at all IB needed. 

Yon see how nicely it works, it acts like a siphon, the thinnest cyst can 
' be held In this way without tearing; the patient may be turned over on 
her side to facilitate matters. I have employed this method in all my 
operations except the first, this idea struck niethen and this little instru- 
ment has given me a great deal of pleasure, for a description of the same 
has appeared in many medical journals here and abroad and has been 
translated in almost all of the modem languages, I may say it travelled 
around the globe, and I aro pleased to notice that many American, English 
and French surgeons now prefer to employ this elevator or needle. 

The cyat now being emptied, adhesion if there be any separated, and 
blood-vessels tied, the whole mass lifted out of the abdomen, you take 
this clamp and secure the pedicle and cut it off above the clamp with the 
serrated scissors. Now you must tie and secure the pedicle, do this by 
transfixion, thus : Take one of these Peaslee needles armed with a strong 
ligature, secured into a handle, pushed through the middle of the pedicle, 
llien slip in nut less than four single strong silk threads, never roll them 
■np rope-like yon cannot secure a safe knot in that way. Now withdraw 
the needle wiUi the silk, you have four ends on each side. Tie each half 
with two of the ligatures and the whole again with the other two, cut the 
ends short, now remove your clamps slowly, be sure that all bleeding has 
stopped, or suspend with the clamp and transllxed the 'pedicle with an 
elevator " which is a double ueedle;" ligate the pedicle alrapiy below the 
needle. I often prefer this method; the following steps are the same. 

By this time your cautery iron Is ready heated to a black heat, clean it 
and scorch the end of the pedicle carefully, that is to say amalgamate it. 
Done I drop it into the pelvic cavity. The pedicle may also be treated 
Without the cautery. It seems to me that instead of dividing the pedicle 
■it would be just as well to cut through the cyst close to the pedicle, leav- 
b^ a part of the cyst upon the stump for protection, of course removing , 
12ie internal secreting membrane of the cyst. This would be a natural 
protection and 1 think that even the ligature can be dispensed with. 
Wliy? ' If the cyst Is broadly adherent to the peritoneum or intestine, or 



—18— 

bladder, no one would cut through those parts to separate the cyst, but 
he would cut through the cyst wall, as I have done before myself, leaving 
that piece of the cyst which is attached to the other organ, remove the 
secreting membrane ; often without any hemorrhage and without any bad 
consequences. This I will put into practice as soon as I have the proper 
chance. 

I have up to this time employed the intra- peritoneal method in every 
case. Now comes the most important duty; namely, to take time and 
search for every bleeding vessel, secure them by fine linen carbolized 
ligatures, cut short. You may have to use one only, you may have to em- 
ploy 50 or 100, no matter how many stop the bleeding, wash out the ab- 
dominal cavity with the artificial serum, after this is done thoroughly you 
are ready lo close the wound. This you can do in different ways. Some- 
times I take one of these large pins, put two of these beads upon it, then 
thrust it into the one «ide of the abdominal wall an inch from the edge 
of the wound and be careful to embrace skin, muscular and other tissues 
and the peritoneum, then let it run out through the other side from within, 
using three or four of these pins; then bring the lips of the wound 
together so that the peritoneal surfaces will meet (for this is important.) 
They unite within the first 24 hours. Then put two more beads upon each 
of the other side of the pins and fasten with thread or small pieces of lead, 
(these are deep seated sutures,) then I put in as many superficial linen 
sutures as may be needed to close the wound completely. Or I use strong 
silk or linen sutures for the deep seated ones instead of the pin. A 
double ligature is introduced as described, then insert through the loops 
on either side a strip of strong pasteboard, previously well satu- 
rated in carbolized oil, and use like a quill suture. Oiled paper or glass 
is the only material I know of that does not irritate the skin. However, 
the pin and beads are preferable, for the reason, if any swelling takes 
place, one or more of the beads may be brokeu and the tension relieved. 
I never use cat-gut it is absorbed too quickly and is not safe. You may 
also employ the method I adopted in one of my cases that is to close the peri- 
toneum with fine ligatures in the manner I showed you previously in in- 
testinal sutures, the rest is closed as usual not inclosing the peritoneum. 
In my last eight cases [ did not suture the peritoneum at all merely thrust- 
ing the needle through the skin and muscles, leaving the peritoneum 
untouched. 

I mentioned before, that it might be an advantage to cut through the 
rectus muscle half or an inch beyond the linea alba instead of directly 
through it in the median line, and why? If the peritoneum is euclosed 
, like an apron between the aponeurosis of the rectus muscle it might pre- 
vent the perfect union of the same and the patient is in danger ol a ventral 
hernia afterwards. It never happened in any of my cases, but ventral 
hernia has been the sequel after ovariotomy and it strikes me that this 
may be the cause. To avoid this the method last described may be 
employed. But if the incision is made through the muscles and union 
takes place there can be no such danger. 

The wound being closed, everything cleaned, now comes the dressing. 
I use several layers of antiseptic gauze over this a large layer of salicylic 
cotton, then a flannel bandage snugly applied. However, where the ab- 
domen is flabby it is well to support the abdomen with one or two pieces 
of adhesive plaster, "mole skin'* before applying the dressing. Then I 
generally give a hypodermic injection of }^ gr. of morphine. 

Have all instruments and utensils brought out of the room before the 
patieut rallies, leave her on the operating bed. 

The after treatment depends upon circumstances and must be adapted 
accordingly. 

In regard to the proper time for operating see my article in the Cincin- 
nati Obstetric Gazette ^ March 1880. 




PART III. 

TiBMARKS ON ABDOMINAL SURGERY, WITH TlIK 
XtJi^jMXJ^ RESULT OP 50 CASES.* 




aurec witu mi; nr> iaj cm v^"*-.! vi^v.i.t*uiv#ii — iifi ui*iii*v(>(i III Miu wjunii^ pian: 
let the patient live as long as she possibly can and resort to extirpation 

/Milv ns A hist chance. He bad lost at lonat 4-ur«t1v» nnflnnta III BUCGt^uufrkii 



leL till- p.xuiuiiu iiTx. «.o ix,.-o -w «..^. K^^'nnniiy uiiu and ri*-?»"H' »<" *"^»"» iiauciii 
only as a last chance. He had lost at least twelve patients In Buccesslou. 
Auotlier surgeon held the same view buc acknowledged, and to bU 
credit may it be said, that he had lost thirteen patients In 8UCC08a\on and 

*Read before the Mississippi Valley Medical Society, at ita meeting in lt^im«wUlft 
Ind., September, 1885. 



—20— 

was almost afraid to touch another case ; there were others also of the 
same opinion. There was but one surgeon who stated that he always 
operated as early as he had made a diagnosis if his patient would let him ; 
he saved about sixty-six per ceni. of his cases. 

My paper was published in the Cincinnati Obstetric Gazette^ March, 
1880, but the report of the discussion was omitted. 

I still adhere to the v^ews then expressed in favor of an early operation, 
and to-day I am able to sustain my former theory by my own practice. 

In March, 1878, I had my first case of ovariotomy. The patient was a 
lady fifty-five years of age, suffering from a multilocular tumor. She 
lived in the country and was recommended to me by my neighbor and 
friend Dr. G. W. Hall, and I shall be ever thankful to him for his kindness; 
for if he had not sent me this case I might never have had the others. 
Previous to this time I knew nothing about the operation and very little of 
the disease, having had but little opportunity to observe such cases, and 
never having seen the operation performed. My surgical practice ran in 
another direction. However, I studied the operation as well as I had time 
to do while the patient was under observation and made all the necessary 
preparations. I tried to find a work on ovarian tumors by either Peaslee, 
Atlee or Wells, but none of my acquaintances in St. Louis had either one 
of them in their library. Dr. Hall advised me to operate under the 
guidance and with the assistance of one who had had experience in such 
cases, which wise suggestion I followed and called upon Dr. Louis Bauer, 
who cheerfully agreed to aid me with his counsel. Under his precept I 
operated upon this patient, notwithstanding that all the other iSurgeons 
who were consulted advised against the operation and favored the expect- 
ant plan. The cyst was only of a few months' duration, in the third stage. 
I conducted the after-treatment myself; my patient recovered. 

Here allow me to relate some of the tribulations I had to endure during 
the progress of my case; and I will first state that, at that time, the 
opinion of the profession of my city was almost unanimously for the wait- 
ing — the last#moment — plan. 

The surgeons in St. Louis prior to 1878 had not been very successful 
with ovariotomy. The bad results were attributed to the atmosphere — 
they said that malaria in our climate acted so verv detrimentally upon 
these cases. It was taken for granted that every patient operated upon 
would die, and every doctor even those connected with the case expected 
that mine would also succumb, and that is the reason why every doctor 
whom I met would put the polite questions : Is your patient dead? Will 
she die? How long do you think she will live? Questions framed in that 
style were the interrogations of all, except of Dr. AUeyne, who in his kind 
and big heart said: *'I hope she will recover;" well, she did and it was a 
wonder. Being called an enthusiast, it was said that the success would 
drive me crazy. 

My next case was a lady forty-three years old. I removed a large right 
ovarian cyst in the last stage and also removed the uterus; she died. 
Seventeen years before Dr. Pope had extirpated a cyst of the left side from 
this patient. 

The next case was a young girl, fourteen years old, who suffered from 
a single cyst of the left side in the last stage; she died. 

But we learn something from the cases we lose, and you may rest as- 
sured I devoted all my spare time to the study of such cases. 

I then had eight successful cases in succession. The next case, one of 
ovarian cyst complicated with cancer, I lost. 

The twelve succeeding cases recovered. Then I lost two cases, both of 
simple cyst in the last stage of the disease. 

Out of my following twenty-five cases I lost but one, a colored woman ; 
I diagnosed a cyst of broad ligament, last stage, and recommended tap- 
ping; however, it was agreed to operate and she died. 



—21 — 

This gives me fifty cases from March, 1878 to May, 1884, with five 
deaths, as follows : Simple cysts, 8 ; cyst of broad ligament, 2 ; ovarian 
cyst with cancer, 1, ovarian cyst with removal of uterus, 1; persistent 
pain of ovary, found on removal to be due to cystic degeneration, 1; 
dbro-cystic tumors, 6; oligo- and poiy-cysts, etc., 31.* 

These cases were all from private practice, as I am not directly con- 
nected with any hospital, nor have or had charge of any hospital where 
such cases present themselves or could be sent to ; they were all, with the 
exception of one case, operated upon at their own homes, and were distri- 
buted over several States. The cases were all with exceptions of those 
that died, early operations— from six to twenty-four months' duration ; 
the youngest patient was fourteen years, the oldest sixty years. Twice I 
used drainage-tubes through the abdomen, and once drainage through the 
vagina, in cases in which there were many adhesions and consequent sur- 
face bleeding. In all the other cases the Abdomen was closed ; the pedicle 
was dropped into the abdomen in every case. In one case, a simple cyst, 
I had to open the abdomen again on the third day as my patient was sink- 
ing from internal hemorrhage; I washed but the clotted blood and closed 
the wound again. She recovered. In this case I had been induced to em- 
ploy the catgut ligature. I will never use it again. 

After my first case I adopted one mode of operating, which, with the 
exception of lately discarding the spray, I have strictly adhered to in 
every instance, and with which you are all acquainted. 

I remain with my patients until they are out of danger — sometimes from 
three to six days. 

What influence the atmosphere and the malaria of Missouri and vicinity 
have liad upon such patients I am not able to say at present, for other 
surgeons of my city and elsewhere have also had brilliant success of late. 
It may be that the air, so detrimental previous to 1878, has since changed 
for the better. 

Now, when we know that the average life of a patient afflicted with 
ovarian tumor is four years ; that polycysts terminate fatally in twelve- ^ 
months, oligocysts in twenty- four months, after the third state has begun' 
— what conclusions can be drawn from my own cases? 

1. That those cases operated upon in the very last stage died. 

2. That the comparatively early operations were successful. 

3. That there is no absolute need to send your patient off to a hospital 
or private institution if she is moderately comfortable at home. I always 
advise those gentlemen who attend my lectures, as well as others, to do as 
I do — take care of their own patients, if they have the confidence in them- 
selves to do so ; but If you do, by all means give your patient all your 
time and attention and be well prepared for all emergencies. 

For one class of patients the hospital may be indicated ; for another 
class of patients a piivate institution may be preferable or more conveni- 
ent for the surgeon; nay, it may become a necessity for him who has more 
than one case — it saves time and labor; for I know what it is to travel fifty, 
one hundred or five hundred miles to see your patient, and prepare for an 
operation and give her your exclusive time. It has been intimated to me 
more than once that I must pick my patients. I will freely and openly 
admit that I do and I will tell you how I do it. If a case of fibrous tumor 
of the uterus presents itself and the patient is fairly comfortable, age 
about forty-three or forty-five, I advise her to wait and not interfere by 
operation — such are cases for the waiting plan ; for we know that if she 
passes her menstrual period she has a chance to recover ; at least her 
misery will cease, and if the tumor does not shrink, it will at least cease 
growing. If she still insists upon the operation, I refuse, and advise her 



*Duriiij^ the year, JS85, I operated upon five cases with one death. Duiinj<^ iSS<>, I 
operated but on three cases wliicli all recovered. 



—22— 

to obtain the opinion of some one else. I know tliat some of snch refased 
patients have been operated npon by others and they have died. If others 
present themselves with cnmors in the last stage, with broken-down con- 
stitutions and with the chances all against them, I give them no encour- 
agement whatsoever and they will of their own accord seek other advice. 

The favorable cases, of course, I encourage, but I never urge the opera- 
ation. I leave that to the patient to do. Again I see a patient where a 
certain something (call it if you will, the faculty of presaging) tells me 
that the result will or may be fatal; then I had rather not have the patient. 
I must feel that my patient will survive, and so must shfc— there must be 
the utmost confidence on both sides. 

I am never anxious for a case ; I am never anxious to operate for the 
sake of the operation. On the other hand I would not refuse a case, even 
the most desperate one, if the operation offered the only, even the slighest 
chance of saving her life. Moral duty would commend the surgeon to 
run any amount of risk. 

I will relate a case which I saw in Illinois some time ago, one of ovarian 
cyst in the last stage, complicated with extra-uterine pregnancy. The 
woman suffered dreadfully, she was a pitiful object to look at and certainly 
doomed to death. Had I been prepared I would have operated at once as 
she was willing; the next day was Sunday and she would not be operated 
upon on that day. It was put off until Monday morning; but the patient 
did not live until then. Sunday the tumor broke through the vagina, and 
she died at once. In such a case I think it would have been perfectly 
justifiable, at least to try and give relief. 

My intention was to relate all my cases in detail, but I think now that 
such is not necessary; for, even after one has gone through the labor of 
preparing a long list of cases and their histories, very few will read them, 
far less study them. We are well enough supplied with the reports of iso- 
lated successful cases. You can hardly take up a journal, wherever pub- 
lished, that does not contain the report of a case. They are of no value 
in a statistical sense, but it speaks well for the American profession that 
there are men, even in the smallest towns capable of performing any 
operation and ready to do their duty. In the near future this will be con- 
sidered a minor operation. It is reasonable to suppose that wherever 
there are successful cases there may also have been failures. How few 
of those isolated fatal cases do we see reported? 

I have seen many operations abroad and at home. Of the home cases 
in which I have seen others operate the majority died. Not a single one 
of these fatal cases has been reported up to the present time. Well, my 
friends may say I picked my cases, I would call it a judicious selection or 
discrimination between cases and recommend all who begin to do the 
same. One thing my friends cannot say: that I hide my fatal cases. 
Every one of my fatal cases has been published at once and in detail, and 
I will publish every other case I happen to lose in the future, for the 
benefit of all. I keep full records of all my cases, and some day, when 
their number has doubled I may have them published. 

Since 1878 I have seen and examined on an average about twenty-five 
cases per year for abdominal enlargement, and in not a single instance 
have I made an exploratory incision for the purpose of making a diagnosis, 
though it is justifiable in very doubtful cases, and as a rule, safe. 

I do not believe in the practice of opening every woman's abdomen be- 
cause it is easier to make a diagnosis. I prefer the more difficult manner — 
without the knife ; but whenever I might be in doubt and should have to 
resort to an exploratory incision, it would be with the distinct under- 
standing to go on with the operation at once if such were indicated. 



MEMORANDUM OF 

DR. EDWARD BORCK'S 

CONTRIBUTIONS TOWARDS 

Medical and Surgical Literature, 

TO DATE 

SO?. XiOTJIS, 3^0-, 1887. 



1871 

On tine Use of Bromide of Potassium in Malarial Diseases. — The Medical 

Archives. St. Louis, Julv, 1 87 1. 
Sll1)Clltaneoils Infeciions of Ergotine in Affections of the Uterus. — 

The Medical Archives, St. Louis, August, 1871. 
Hypodermic Infections. — The Medical Archives, St. Louis, October, 

1871. 

1874 

Stapliyloma* — Missouri Clinical Record, September, 1874. 



1875- 



On BronCllOCele. — St, Louis Medical and Surgical Journal, March, 
1875. I Inquiry.* 

1878 

Fracture of tlie Femur.— ^/. Louis Medical and Surgical Journal, 

January, 1878. 

RCTienv on tlie Treatment of Fracture of the Femur. Three Wood- 
cuts. — St, Louis Medical and Surgical Journal, March, 1878. 

OTariotomy : Reported Cases of. — The St, Louis Medical and Surgical 
Journal, April, 1878; July, 1878; and December, 1878. 



1879 



Cyst KlCTator : Description of, and Method of Operating. Three Illustra- 
tions. — Cincinnati Obstetric Gazette, February, 1879. 

Fracture of tlie Femur. Compound Comminuted. — Proceedings of the 
St. Louis Medical Society, May, 31, 1879. 

Compound Comminuted Fracture of the Right Fore-arm.— Pr^^- 

ceedings of the St, Louis Medical Society, June 28, 1879. 
Reflections upon tlie History and Progress of the Surgical Treat- 
ment of Wounds and Inflammations. (Report on Progress of Surgery.) 
Transactions of the Medical Association ofthe State of Missouri, June, 1879. 

Monograpli on Fracture of tlie Femur, with fourteen handsome 

Illustrations. Second Edition. Published by Rumbold & Co., St. Louis, Mo. 

Price 50 cents. Out of Print. Third Edition in preparation. Nearly 2,000 

copies were sold. 

1880 

Operations for Harelip. — Proceedings of the St, Louis Med, Society, 

February 21, 1880. 
Ovarian Tumors : At what Stage of the Disease is it the Proper Time to 

Operate? — Cincinnati Obstetric Gazette, March, 1880. loi Inquiries. 
Diseases of tlie Maxillary Sinus. — Indiana Medical Reporter ^ 

Evansville, Ind., April, 1880. (Reprints.) 3 Inquiries. 
Compound Dislocation of tlie Wrist.— Reprint from Transac- 

a<tions of St, Louis Medical Society^ j88o. Four Wooa-cuts. 63 Inquiries. 

I98I 



Simple IHetliods to stop Accidental Hemorrliage. With four 
Wood-cuts. — Indiana Med, Reporter, April, 1881. Reprints. 198 Inquiries. 

* By the number of Inquiries is understood the letters and postals received by the author, 
trom physicians in different parts of the country, asking for reprints, or inquirine^ 
where the said article could oe found or obtainea — after it had oeen published and 
noticed by the Medical Press. 



— 1>4— 

1882 

Surgery in Cllildren. — SL Louis Med, and Sur, Journal, June, 1882. 
Cases from Prof. Borck's Clinic: Amputation in Children. 

Webbed Fingers, Club-foot, Bow-legs, Spinal Curvature, etc. St, Louis 

Medical and Surgical Journal, December, 1882. 

1883 

Clinical Lectures : Extracts from. Fracture of Femur, and other 

Fractures. — St, Louis Med, and Surg, Journal, February, 1883. 
Paralysis in Cliildren^ and Paralytic Contractions. Clinical Lecture — 

Philadelphia Med, and Surg. Reporter, August 25. 1883. 209 Inquiries. 
Spons^e Graf tinsf : Observations on. — St, Louis Weekly Medical Review, 

November 3, 1883. Vol. VIII, No. 18. 96 Inquiries. 
Ovarian Tumors (Two Lectures): Diagnosis of, and Operation. Part I. 

— Cincinnati Obstetric Gazette, September, 1883. 



1884- 



Congenital CIu1)-f OOt : Clinical \.^qX.\xx^.— Archives of Pediatrics. 

February number, 1884. 21 Inquiries. 

On Permanent Wound Dressing.—^/. Louis Weekly Medical 
Review. March 22, 1884. Vol. IX, No. 12. 103 Inquiries. 

ForeiSfn l«etters— to Archives of Pediatrics, October, 1884; and to 
St, Louis Weekly Medical Review ^ July 26, August 2, 23 and 30^ 1884* 
Also Report, to St. Louis Medical Society, of the International Medical Con- 
gress at Copenhagen, September 13, 1884 — same Journal. 

tHome Again! A Svnopsis of a Tour Abroad. The first part consists of the 
report made, as a delegate to and a member of the 8th International Medical 
Congress, Copenhagen, Denmark, August, 1884, to the Medical Society, 
with such additions as may be of interest to the medical profession. The 
second part consists of general sight-seeing, and other information of the 
trip. (Through the kind notices and comments from the Editors of almost 
every Medical Journal here, and several abroad, the applications for 
**Home Again" were over 1,300 from all parts of the U.S. A., and Canada, 
and over 100 from Europe.) 

1885 

fAlinormal Positions of tlie Head. — Med, and Surgical Reporter, 
Philadelphia, Pa., January 31, 1885. Vol. LII, No. 5. Reprints. 

fLittle TllinSfS : i Wood-cut. New England Medical Monthly Journal. 
A Farewell to private class of Medical Practitioners. Reprints. 

fRemarlLS on Alidominal Surs^ery iivitli 50 Cases. Read be- 
fore the Mississippi Valley Medical Society, Evansville, Ind., September, 1885. 
In full in the Medical Record, September 26, 1885, Vol. 28, No. 13, whole 
No. 777. Editor Geo. Schrady, A. M., M. D. W. Wood & Co., Publishers, 
56 & 58 Lafayette Place, N. Y. City. Abstract from same in Journal of the 
American Medical Association, Vol. V, No. 14, October 3, 1885. 65 Ran- 
dolph St., Chicago, Ills. Medical and Surgical Reporter, November 28, 
1885, Vol. LIII, No. 22. D. G. Brinton, M. D.. Editor, 115 S. Seventh St., 
Philadelphia, Pa. 

Extracts of Clinical Lectures. Exsudative Pleuritis. — Archives of 
Pediatrics, Vol. II, No. 9, September 15, 1885. Editor W. P.Watson, A. M., 
M. D. John E. Potter & Co., Publishers, 617 Samson St., Philadelphia, Pa. 

Dislocations and Fractures of the Wrist, Simple and Compound. 
With 8 handsome Illustrations. — LeonharcTs Illustrated Medical Journal, 
Vol. VI, No. 4, October, 1885. l^etroit, Mich. 

1887 

fOTariau Tumors. Diagnosis and Operation. Second and Revised 
Edition with Six Wood-cuts. 



On Hand: Will be sent gratis to any Physician who will send his address and- a 
postage stamp to the Author. 



SURGICAL AND CHILDREN'S CLINIC, 



-AT THE- 



"SURGICAL HOME" 

NORTH ST. LOUIS. 

MONDAYS, WEDNESDAYS tP SATURDAYS, 

Beginning at 1 o'clock and Ending at 2:30 o'clock P.M. 

OPEN THROUGHOUT THE YEAR. 



This Clinic is held under the Direction and Protection of the 
St. Louis Hospital Association for the Surgical Treatnnent 

of Children and Wonnen. 



PLEASE TAKE NOTICE. 

"While we would not refuse to help and treat any actually poor patient sent 
to us, we do not encourage nor sanction any gratuitous treatment and private 
free dispensaries. 

We wish the profession distinctly to understand that this Clinic is NOT A 
FREE ONE, where advice and treatment can be obtained gratis. It is intended 
for that class of our worthy citizens, that are not in the circumstances to pay a 
full or liberal fee, who nevertheless are able and willing to pay something and 
would feel themselves offei.ded to obtain professional skill without giving 
some compensaiion. 

For sucli the above days and hours are set apart The fee is at their own 
pleasure according to their purse, but never less than $i.oo, and paying for their 
own apparatuses if such should be required." 




LANE MEDICAL UBEARY 



ures, 



g tH^in features of these Lectures are Practical Demon- 

r Classes are Limited to 10 Members, 
EACH COURSE S3O.0O, Including: Certificate. 



N561 Borok, E. 
B7E Ovarian tumors. 

1 1R R7 yotlJr? I