Clinical Lecture. 
DYSMENORRHGEA FROM HEMATOMA OF THE OVARY—DOUBLE 
DERMOID CYST OF THE OVARY—TWO CASES OF FIBRO- 
SARCOMA OF THE OVARY-REMARKS ON DRAIN- 
AGE AND THE AFTER-TREATMENT IN 
LAPAROTOMY* 
B. F. BAER, M, D„ 
PROFESSOR OF GYNAECOLOGY IN THE PHILADELPHIA POLYCLINIC. 
Gentlemen:—While our patient is being prepared and etherized, 
I will show you several tumors which I have removed within a short 
time. This will be the more interesting and instructive because T 
fear that our case to-day may prove to be of somewhat similar nature 
to one of the cases I shall relate. 
I have in this bottle a small tumor which is an ovary enlarged to 
about three times its natural size. On the same day on which this 
tumor was removed, I removed from another patient this tumor, 
which you see is large, solid and formidable looking ; it weighs 15 
pounds. Yet the patient with the smaller tumor suffered far more 
than the latter. This disproportion between the size of the tumor 
and the amount of suffering is one of the interesting and important 
circumstances met with in ovarian disease, and teaches the valuable 
lesson that the patient who happens to have a small tumor should 
not for that reason be condemned to a life-time of torture, when we 
know that her disease is as certainly incurable without operation as 
is that of the patient whose tumor happens to be large. 
The patient from whom the small specimen was removed is 31 
years of age, and had one child nine or ten years ago. Since that 
time she has been sterile. So far, therefore, as fertility is concerned, 
her ovarian function has been useless. Puberty occurred at the age 
of 13, and menstruation had been constantly attended with pain in 
the left ovarian region. For this she had been treated in various 
ways and by different methods, but without result so far as cure was 
concerned. Dysmenorrhcea is so often spoken of as resulting from 
one cause only, stenosis of the cervical canal or anteflexion of the 
*Delivered at the Hospital of the Philadelphia Polyclinic. 2 
uterus, and as, therefore, amenable to but one plan of treatment, by 
dilatation, that I can say nothing more important to you than to ask 
you to free your minds from this idea. The term should be used in 
its generic sense only, as expressing a symptom for which there are 
many causes, both general and local. 
The patient had been worse since the birth of her child, and 
recently was almost constantly bid-ridden from pain and exhaustion; 
she could obtain relief only by the use of morphia, to which she 
had become addicted. Two years ago she was treated for retroflex- 
ion of the uterus to which was ascribed all of her sufferings. I 
believe this was an error; the symptoms were not due to the dis- 
placement, but to a diseased left ovary. The trouble was doubtless 
aggravated by the complication, but the mechanical means used (in 
the form of a large pessary) for the retention of the organ, served 
only to increase the symptoms. As was to be expected the patient 
became worse. The diagnosis was wrong and the treatment neces- 
sarily at fault. 
When she entered my private hospital she was emaciated and 
exhausted, and complained of constant pain in the left ovarian 
region. Upon examination lat once detected a tumor to the left 
of the uterus and posterior to the broad ligament, which I knew to 
be an enlarged ovary. It had the peculiar shape of the ovary, only 
somewhat more rounded, and it was excessively tender on pressure, 
and mobile. As the patient approached her menstrual periods the 
tumor became larger and more tender, from congestion of the ovarian 
vessels and the haemorrhage into the Grafflan follicle, which occurs 
during the ovulation excitement. Excruciating pain resulted from 
the swelling and distention, and was described by the patient as 
resembling the sensation which might be produced if the ovary were 
within the grasp of a vise. There was also a sense of numbness 
extending all over the affected side, from the ovarian centre upwards 
to the prsecordial region, even extending to the side of the face and 
head, and downwards along the line of the genito-crural nerve and 
its inosculations, to the labia majora, inside of the thigh and to the 
foot, producing such lameness as to render walking extremely diffi- 
cult and painful at times. These symptoms and physical signs 
pointed conclusively to the condition known as hsematoma of the 
ovary. As indicated above the tumor results from an undue amount 
of haemorrhage into the Grafflan follicle and retention of the blood 
from failure of the outer covering of the ovary to rupture, and dis- 3 
charge its contents into the Fallopian tube to pass off as menstrual 
haemorrhage, as is the case when the function of ovulation and men- 
struation is normally performed. Nature now attempts to repair 
the damage by bringing about an involution of the hsematoma, as 
she does when a normal corpus luteum is formed ; but she often fails, 
and the clot then remains as a small dark body. In some cases the 
ovary is completely riddled with these masses which, becoming hard, 
press upon the nerves, and thus add to the patient’s suffering and 
serve to render constant the pain which at first was only present at 
the menstrual periods. 
This disease is incurable except by removal of the affected organ 
and lat once advised operation. An incision an inch and a half in 
length, through a rather fat abdominal wall, was sufficient to permit 
me to complete the operation. Upon bringing the ovary up, I 
found as I had expected, the condition here exhibited in the speci- 
men. There was one large hsematoma the size of a walnut, which 
is still unruptured, and at least four or five smaller ones in varying 
stages of subinvolution. At the same time I brought the uterus for- 
ward by shortening the round ligament on the left side. The pro- 
cess of shortening was accomplished by doubling the ligament upon 
itself and including it in the ligature which I used in ligating the 
pedicle. At the patient’s request I removed but one ovary, the 
other being comparatively normal. 
I have met with a good many cases of hsematoma of the ovary, 
and have employed various methods for the relief of the patients, 
but I am more than ever convinced that the proper treatment is the 
removal of the organ. This operation is attended - with but little 
risk when done properly. 
DOUBLE DERMOID CYST OF THE OVARY. 
Two days preceding the operation for the hsematoma I removed 
these specimens. The patient was 32 years old; she had one child 
seven years of age and a second four months ago. Two years ago 
she began to complain of pain in the right ovarian region, which 
had continued ever since with increasing severity. She had become 
pregnant, however, and had given birth to a strong, healthy child 
after a normal labor. Soon after the parturition she left the city, 
but as she was rapidly losing flesh she returned, and then I saw her. 
On examination I found the abdominal wall extremely emaciated 
and quite relaxed, and through it I could detect a jagged mass, very 
irregular, lobulated, and flattened in shape, and at one point quite 4 
tender on pressure. It was very mobile and as large as a child’s 
head. I also found a tumor in the lower pelvis, fully as large as 
the one in the abdominal cavity. The uterus was pushed up and to 
the right. The pelvic tumor was immovably fixed but not tender. 
I expressed the belief that the pelvic tumor was an incarcerated 
ovarian cyst, but I was not certain as to the one occupying the 
abdominal cavity. Its irregular, flattened, lobulated shape and non- 
fluctuating character, together with its extreme mobility and the 
rapid emaciation of the patient, led me to fear that it might be a 
malignant growth, possibly of the kidney, although the urine did 
not show any evidence of disease of the latter organ. I advised 
that the child, which the patient was nursing, should be immedi- 
ately weaned, and that laparotomy be performed as soon as the 
breasts had dried up. 
The operation was performed at the home of the patient. After 
she was anaesthetized and lying upon the table, the abdominal walls 
lay flat and relaxed about the tumor in such a manner as to make 
it look exceedingly malignant in its roughness and irregularity. An 
incision two inches in length was made midway between the umbilicus 
and the pubis, and the tumor exposed to view. To my delight I 
detected the peculiar color of an ovarian cyst. Introducing two 
fingers, I found it to be free from adhesions except at the point cor- 
responding to the tenderness, but I could not at first find that it had 
a pelvic attachment, being apparently free in the abdominal cavity. 
After examining very closely for a pedicle, I discovered what seemed 
to be the broad ligament and Fallopian tube stretched and flattened 
out against the posterior surface of the superior strait, being held 
in this position by the pelvic tumor. Placing my finger under this 
apparent pedicle, I was able to trace it to the tumor, and bringing 
it to the incision made myself sure that it was the Fallopian tube 
and broad ligament. I now punctured the tumor with a trocar, 
although it appeared to be almost solid, when there began to flow 
the peculiar oily substance which is characteristic of dermoid cysts. 
After more than a pint of this semi-fluid substance had been evacu- 
ated the trocar was withdrawn, when the puncture was immediately 
filled and plugged by a mass of hair. Although the tumor was still 
quite large, I was able, by manipulation and some force, to with- 
draw it through the small incision. The pedicle was exceedingly 
vascular, the veins in the broad ligament being as large as my fin- 
ger. After ligating the pedicle and separating the tumor, which was 5 
of the left ovary, the one in the pelvis was with great difficulty dis- 
lodged and brought up to the incision, when it was also punctured. 
Fluid, in quantity and character similar to that described above, 
flowed out, when the tumor slipped through the incision. A pedi- 
cle of like character as to vascularity and length was ligated and 
severed. The abdomen was now thoroughly cleansed and the incis- 
ion closed, neither irrigation nor drainage being used. 
The after history was without event, except in a decided evidence 
of heart failure on the second day. This was controlled by active 
stimulation kept up during the night. She sat up on the eighteenth 
day after the operation, and is rapidly regaining her lost weight and 
strength. 
This case has an added interest, apart from the mere presence 
and removal of the double dermoid disease, in the gestation and 
parturition during the existence of the tumors. It not only shows 
the wonderful struggle and persistence of the procreating function, 
but also furnishes food for thought as to what should be done with 
these tumors when they are found to complicate pregnancy. There 
is a growing disposition to operate early in gestation when preg- 
nancy is found to be complicated by ovarian tumor. This individual 
case went to full term and was safely delivered, but that does not 
prove that the rule is not a good one. 
The next specimen is of peculiar interest to us, because I believe 
the case I shall operate upon to-day is of like character. The 
patient from whom this large, solid tumor was removed from is 39 
years old, and had one child 16 years ago. Nine years ago she was 
operated upon for laceration of the cervix uteri. The account given 
me by her physician was as follows : 
FIBROSARCOMA OF THE OVARY. 
Supposing herself to be pregnant, she engaged the physician for 
the approaching labor, which, however, did not come on at the 
expected time. When a month beyond the appointed time had 
passed, her physician called upon her and found her still waiting 
for the commencement of the labor, presenting the appearance of a 
woman at full term, ruddy and healthy looking. She said she could 
feel the active movements of the child. Another month passed, and 
then suspecting something wrong the physican questioned her more 
carefully, and found that she had been menstruating regularly, and 
that there had not been any mammary changes or other rational 6 
signs of pregnancy, excepting the abdominal enlargement and the 
supposed foetal movements. Examination showed that the cervix 
was hard, and that the pelvis was occupied by a mass closely resem- 
bling the head of a child. The tumor could be felt high up in the 
abdomen. The doctor therefore properly excluded gestation. 
Shortly after this I first saw the patient, and examination informed 
me that the womb was retroverted and somewhat prolapsed, but 
movable. When the tumor was moved the womb moved also, which 
is one of the diagnostic signs of uterine fibroid, or at least that the 
growth is uterine, and yet from the position of the tumor I believed 
it was external to, and not connected with the womb. I could not 
detect any fluctuation. The tumor was smooth and entirely mobile. 
It was with difficulty I convinced the patient that she was not preg- 
nant. She was positive that she could feel the foetal movements. 
This was due probably to the mobile condition of the growth, which 
moved to accommodate itself to the movements of the intestines; 
and then the imagination furnished the rest. I made a diagnosis of 
probable sarcoma of the ovary and advised its removal. A fibroid 
tumor of the womb would not have attained such size in nine 
months or a year, a point which aided me not a little in my diagno- 
sis. After a few weeks of hesitation and doubt on the part of the 
patient, she consented to the operation, and it was performed at her 
home. 
When I reached the growth, I found it to be so extremely vascu- 
lar that I believed I had to deal with a fibroid tumor of the womb. 
I was compelled to make a seven inch incision before I could get the 
tumor out of the abdomen, and not till then did I learn that the 
womb was below and independent of the growth. It had no rela- 
tion whatever with the uterus, except through the ovarian and broad 
ligaments. These I now clamped and then cut the tumor away, 
leaving a very large pedicle. I next transfixed and ligated the ped- 
icle and removed the clamps. After cleansing the abdominal cavity 
the incision was closed without drainage. As the other ovary was 
healthy I did not remove it. The stitches were removed on the 
seventh day and she made a good recovery. The tumor weighed 
fifteen pounds. 
Our patient being now about ready for operation, I will give you 
a brief history of the case before beginning. She is a single 
woman, 30 years of age ; she entered puberty at 18 ; the menstrual 
FIBROSARCOMA OF THE OVARY. 7 
function has always been performed with difficulty, hut otherwise 
she enjoyed good health until about a year ago. At that time she 
discovered a lump about the size of her fist in the left iliac region, 
and she remembers that it was hard and quite mobile. She says 
she could move it to either side and up and down, as though it were 
loose in her abdomen. From this time the mass increased rapidly 
in size. Six months ago she had an attack of la grippe, and this 
was accompanied with great soreness all over the abdomen extend- 
ing around to the lumbo-sacral regions. Since this illness she has 
been going down hill rapidly, and the abdomen as you see, has 
increased to the size of the full term of gestation ; she has become 
emaciated and is quite cachectic in appearance. She suffers consid- 
erable pain in the lumbo-sacral regions, and has great irritability of 
the bladder. There is also some oedema of the feet and legs. Her 
catamenia are regular in time and quantity. As you observe, the 
abdomen is symmetrical and smooth in contour. On palpation a 
round, firm mass of the size and somewhat the shape of the preg- 
nant uterus at full term is outlined. This mass is not movable 
within the abdominal cavity, but seems to be firmly adherent to the 
abdominal walls. The veins are distended and there is a purplish 
hue of the surface, showing a decided interference with the circula- 
tion. There is only a faint suspicion of fluctuation. There is dull- 
ness all over the anterior surface of the abdomen with resonance in 
the line of the colon. Pervaginam, yesterday, the uterus was found 
to be slightly above the normal in size and seemed to be free from 
the tumor. It occupies a position below and to the right of the 
mass. The diagnosis as to the exact character of this growth is 
obscure, but I believe it to be ovarian, and hope it may prove to be 
a thick-walled cyst, for I know it is not thin-walled. I fear, how- 
ever, that it may be a solid tumor of the ovary. Its very rapid 
development, peculiar conformation, and its relation to the uterus, 
together with the marked effect it has had on the patient’s health, 
render it almost certain that it is not a uterine fibroid. But, what- 
ever it is the indications are clear for its removal. 
I now begin by making an incision two inches in length and 
expose the tumor to view. lam sorry to say that it has the pecu- 
liar purplish color and vascularity common to fibroid tumor of the 
uterus; but it is firmly adherent to the abdominal wall, and this 
causes me to hope that it may still prove to be ovarian, for fibroids 
of the womb, as a rule are not adherent to the abdominal wall. It 8 
will be necessary to increase the length of the incision, so that I 
may safely separate adhesions and introduce my hand to learn if 
possible where it is attached. lam glad to say that I can trace its 
pedicle, which is small, to the region of the left ovary, but I also 
learn that it is universally adherent to the peritoneal surface and 
that there are a number of strong intestinal and omental adhesions. 
I begin the separation of the adhesions by tying off the omentum, 
when I find that it will be necessary to still further increase the 
length of the incision to fully six inches. Now you can see how 
extensive and firm the intestinal attachments are, and what care 
will be necessary in their separation. As I proceed with the dissec- 
tion I find it necessary to leave a portion of the outer wall of the 
tumor in contact with the intestine, for fear of tearing the latter. 
This results in so much haemorrhage that I am compelled to ligate on 
the surface of the bowel as we advance. There is considerable 
haemorrhage from the torn surface of the tumor, and it will be 
impossible to check this because of the broad surface denuded, and 
the impossibility of ligating on the solid mass. With the hope that 
the tumor is not entirely solid, and that I may reduce its size and 
thus facilitate the separation of the adhesions and check the bleed- 
ing, I will now plunge a trocar into it. But you see this was a mis- 
take, for the tumor proves to be solid and we are compelled to pro- 
ceed as we were doing at first. This large surface which I havejust 
now separated is bleeding so profusely because I have wounded the 
muscular wall of the intestine; it is necessary to double it upon 
itself and ligate it, and this makes a decided knuckle; even this 
does not stop the bleeding, I will therefore pass a ligature in a 
needle and ligate it in the form of a suture. This controls the 
bleeding and will also serve to unite the torn muscular coat. I now 
continue the separation and ligation from point to point until we 
have the tumor entirely free except an attachment to the colon 
which I next separate, placing here several ligatures. I will now 
lift the tumor from the abdominal cavity, and am glad to say the 
pedicle is small and that the tumor is of the ovary. I next quickly 
grasp the pedicle with a clamp forceps, and cut the tumor away, 
placing a warm towel immediately over the intestines, while an 
assistant closes the incision by placing a hand on either side. Before 
ligating the pedicle I will look carefully for bleeding points that 
may have been missed, and I find it necessary to place several addi- 
tional sutures along the line of the intestine. I next transfix the 9 
broad ,ligament with this pointed forceps which has in its grasp a 
single ligature, with which I tie, first towards the uterus, and then 
towards the outer surface of the ligament, bringing it back again to 
the point first tied, making three knots. Removing now the clamp 
forceps, I find the bleeding entirely controlled. I therefore cut the 
ends of the ligature close to the knot and drop the pedicle. The 
right ovary is in a healthy condition and I will therefore not remove 
it, since the patient requested me to leave it if not diseased, 
although in view of the character of the tumor I believe it would 
be wise to remove it. You observe that the patient is very weak, 
being pulseless at the wrist, and I will ask a nurse to administer a 
stimulating enema, which I always have in readiness, while I make 
the toilette of the peritoneum and finish the operation as rapidly as 
possible. But I will first place the sutures for the closure of the 
incision. These are of Chinese silk, as all my ligatures are, and I 
carry the'needle from without inwards, including the peritoneum 
and then from within outwards on the opposite side, about three to 
the inch, until they are all placed. Now carefully removing all 
clots and fluid and being sure that no bleeding is taking place, I 
close the abdomen without irrigation or drainage. The dressing will 
consist of first dusting the line of incision with aristol as a desic- 
cant, covering it with a strip of sterilized gauze and a thick pad of 
cotton which is surrounded with sterilized gauze, all of which are 
strapped firmly with adhesive plaster. The patient is now returned 
to bed, a bag of hot water placed to her feet and a hypodermic 
injection of morphia and atropia at once administered. 
REMARKS ON DRAINAGE, AND THE AFTER-TREATMENT 
IN LAPAROTOMY. 
I think you will agree with me that this was a formidable operation, 
and that the outlook for the recovery of the patient, in view of the 
extensive ligation along the line of the intestinal track, is anything 
but favorable. But we have done our best and must trust the result, 
not alone to kind nature, but to vigilance and care in the after- 
treatment. One of the gentlemen has just asked me why I did not 
irrigate and drain in this case? This, therefore, is a very appropri- 
ate place for a few words on the technique of the operation and the 
after management. You observed that I was careful to remove all 
foreign material from the abdominal cavity, and, as I succeeded in 
doing so, I believe that irrigation would have been an unnecessary 
and meddlesome procedure. On precisely the same principle, I did 10 
not drain. As there was nothing to drain it would have been unsci- 
entific and meddlesome practice to have placed a drainage tube. 
Now, it is self-evident that if the patient recovers as well without it, 
drainage was unnecessary, and that she was therefore better olf than 
if I had left a drainage tube projecting into the abdominal cavity, 
to serve as a certain means of irritation and a possible source of 
infection and fistula, to say nothing of a predisposition to hernia by 
weakening the lower end of the cicatrix. Some time ago, while I 
was operating for the removal of several fibroid tumors, I was hon- 
ored with the presence of a prominent surgeon who has had a large 
experience in abdominal work. Considerable hemorrhage occurred. 
When I was ready to close the incision and he found I was doing so 
without irrigation or drainage, he remarked that he could not resist 
the criticism that I was taking great risk and that he would not 
himself have the courage to close the wound without first flushing 
the abdominal cavity and inserting a drainage tube. I replied that 
I would have more fear of a drainage tube in a case where I consid- 
ered it unnecessary, than in closing the wound without it; that I 
felt confident my patient was better without the tube. My friend 
said he would watch the case with great trepidation, and if she did 
well it would be a revelation to him. lam glad to say the patient 
recovered without a bad symptom. Some of you recall the case. 
Greig Smith, in his classical work on Abdominal Surgery, has 
advanced the proposition, “ When in doubt, drain,” and this has 
become an axiom for operators. Some abdominal surgeons apply 
drainage in almost every case. But I believe the time is not far off* 
when the technique of abdominal work will have been so perfected 
that the use of the drainage tube will be the exception instead of the 
rule. (I am now speaking of cases in which extensive peritoneal 
and cellular suppuration is not present.) I have added two words 
to Smith’s dictum so that it reads for .me, “ When in doubt, do not 
drain.” This is the principle upon which I have been working for 
several years and lam convinced of its soundness. If I use a drain- 
age tube I must feel sure that it is necessary; if lam in doubt Ido 
not drain. This method is not founded upon theory alone, for I 
have demonstrated beyond question that the practice is correct. I 
have now reached the ninety-sixth of my last series of one hundred 
completed ovariotomies. Of these ninety-six cases there has not 
been a death from the operation, and I have used a drainage tube 
only in three, and they were early in the series. In many of the 11 
cases adhesions were universal and organized, and some were pus 
cases. The patients recovered more quickly and are better in every 
way than those of the series immmediately preceding this one, in 
which I used the drainage tube more frequently. But more of this 
again. 
Regarding the after-treatment. The patient has already had one 
hypodermic injection of morphia and atropia, and this will be 
repeated if necessary during the afternoon or night; and if required 
will he repeated again, especially if she is emotional or there is a 
tendency to vomiting. Of the series just referred to Ido not believe 
there have been six cases that have not had one or more hypoder- 
mics during the after-treatment, and I have nothing but good to say 
of the practice. The diet will be liberal and will be commenced at 
once in the form of stimulating enemata. It will consist of half an 
ounce of whiskey and six ounces of warm water through a fountain 
syringe, every four hours, until to-morrow at 4A. M. She will then 
get barley water by the mouth in teaspoonful doses every hour. If 
this is well borne, after several doses have been taken, beef juice in 
similar quantity will be substituted. Ido not mean beef tea, but 
beef juice which is obtained by pressing fresh beef after it has been 
broiled slightly on one side. If the digestion proves good, the beef 
juice will be increased to a tablespoonful every two hours, and the 
patient may then have barley water or plain water ad libitum. 
When feeding by the mouth begins, the enemas are discontinued. 
When flatus has passed per anus, which usually occurs within forty- 
eight hours, if the patient is hungry she will get a small cup of tea 
or coffee with soft toast and probably a soft egg. I rarely give milk 
in any form, never until the bowels have moved. Since I have dis- 
continued the use of milk and do not use the drainage tube, I have no 
occasion to treat tympanites. If the bowels do not move spontane- 
ously within three days, a Lady-Webster pill or Epsom salts will be 
administered as a laxative. The patient will be turned on her side 
within twenty-four hours, and earlier if she desires. The custom of 
compelling the patient who has undergone laparotomy to remain in 
the dorsal position is a barbarous one. It is not only unnecessary 
but, positively injurious. Two of the most important factors in the 
after-treatment of these cases are stimulation of intestinal peristal- 
sis, and rest of body. By compelling the patient to occupy the dor- 
sal position, this order is reversed, the result being arrest of intesti- 
nal peristalsis and physical exhaustion from the constant and strained 12 
position. I believe the practice has contributed not a little to the 
mortality, and am sure it has caused a great amount of unnecessary 
suffering. 
Examination of the specimen shows the Fallopian tube and some 
large vessels spread out over the tumor. On section it is found to 
be quite solid and fibrous in appearance, except at one point where 
a small cavity is seen. This contains a semi-fluid, yellowish sub- 
stance which somewhat resembles the fluid found in fibro-cysts of 
the uterus. Placing this tumor by the side of the other solid one 
shown you just before the operation, we see how much alike they are 
in size, shape and consistency. Although they have not yet been 
examined microscopically, I think they are fibro-sarcomas. Solid 
tumor of the ovary, of the size of these growths, is very rarely met 
with, and, although these tumors look very like true fibroids, I 
think it will be shown that they contain sarcomatous elements. 
In that event what will be the future history of the patients ? 
Will the disease return ? If, as in these cases, the development is 
purely local, I think experience teaches that it does not recur. But 
much, if not everything, depends upon the time of operation. The 
longer the delay the greater the danger. 
[The patient was shown to the class three weeks after the opera- 
tion. She had made a good recovery.]* 
*Since this lecture was delivered, Dr. Baer has completed his last series of one 
hundred ovariotomies. Two of the last four were of that class of neglected cases 
in which recovery is always doubtful. In one, a universally adherent 50 pound 
poly-cyst, the patient was so weak that the radial pulse could not be felt. The 
patients are doing well.