AN ABSTRACT 
OP A 
CLINICAL LECTURE 
ON 
ABDOMINAL SURGERY. . 
BY DONALD MACLEAN, M. D., 
Professor of Surgery and Clinical Surgery in the University of Michigan. 
Reported by WARREN B. SEXTON. 
Gentlemen: Two weeks ago to-day the patient before you 
walked into this amphitheatre and we then made a careful 
examination of an abdominal tumor, which from its appear- 
ance, situation, and history, we supposed or rather suspected to 
be ovarian. 
Two days after that examination, she was operated upon 
here in your presence. It was then found necessary to remove 
her left kidney, and both her ovaries, together with a large mass 
of the great omentum. The tumor which we had supposed to 
be ovarian, proved to be the left kidney, enormously enlarged 
and cystic. Both ovaries were also cystic. In addition to this 
the uterus presented marked evidences of being pregnant.* In 
performing this operation it was found necessary to leave a 
large number of ligatures (cut short) in the peritoneal cavity. 
*Ulterior developments showed that the uterus was not pregnant, 
and that serious complications arose which will be given in the full 
report of the case. 2 
To-day is the fourteenth day and I am very glad to be able 
to present the patient to you in an advanced stage of convales- 
cence; *her wound healed, the stitches removed, the secretions 
natural, the temperature normal, the countenance bright, in 
short, every indication of a speedy and complete recovery. 
You will remember that our patient is a married woman, aged 
twenty-seven, the mother of two living children. 
Before going further let me impresss upon you the fact, that 
a full and precise diagnosis in this case was not possible until 
the abdominal cavity was opened, and even then the difficulties 
were very great indeed. We had to proceed with an unusual 
degree of hesitancy, cautiously feeling our way through an 
intricate tangle of abnormal structures, the precise nature and 
relations of which, it was well nigh impossible to unravel. The 
operation lasted, I am told about thirty minutes, and the 
patient’s appearance now furnishes the most satisfactory evi- 
dence, that all the dangers and risks inherent in such an oper- 
ation must have been safely avoided or provided for. 
Her record shows one serious drawback, which may be met 
in the healing of the wound in any surgical operation. At times 
there were sudden elevations of temperature, and other indica- 
tions that there was absorption of septic material, or that a pus 
cavity was in process of formation. Her tongue was dry, 
rough, and red, and she was restless and uncomfortable. In 
abdominal surgery these are unfavorable indications. The 
cause of this disturbance was carefully sought after, and it was 
found to be due to the formation of small abscesses along the 
incision, at the seat of the silk sutures used to close the wound. 
This occurrence is an unusual one in my experience, in the 
healing process of abdominal incisions. Whether it is due to 
some defect in the mode of preparing the silk used, or to the 
effect of the fluid of the cyst, I cannot say. 
As I have remarked a large number of ligatures were left 
in the peritoneal cavity, but by this time they are all enveloped 
in a thick deposit of inflammatory new-formation. Being thus 
protected they will not be the source of any trouble. I have 
never had any suppuration at the seat of ligatures. All the 
postmortem examinations that I have had the unfortunate 
privilege to make, showed the ligatures covered up and com- 
pletely encysted. 
The other two abdominal operations which you have wit- 
nessed this term were not so desperate. Although the one previous 
to this was in some respects less favorable for recovery. Your 
notes of the case will show her to be a woman aged sixty-eight 
years, feeble and emaciated. The tumor weighed forty-five 
pounds. Moreover, there existed adhesions that necessitated the 
removal of a great portion of the omentum. The haemorrhage 
from surfaces where firm bands were divided was free and obsti- 
nate. A number of ligatures had to be used and there were 3 
in all thirteen silk ligatures left in the peritoneal cavity. The 
operation was on Monday; on the following Saturday the 
patient was brought before you and the sutures removed, and 
one week from that day she left the hospital for her home, 
cured. 
The other case, Mrs. M., aged fifty-three years, was a very 
favorable one. The tumor was a simple ovarian cyst, moderately 
large, and free from adhesions. The peritoneal cavity was not 
open more than eight minutes. She was returned to her room 
in twenty minutes from the time she left it, and returned home 
cured in two weeks from the date of the operation. 
Let our review of this class of operations go back farther. 
Within fifteen months previous to the first of these later cases, 
and within the recollection of many of you who are now pres- 
ent as students, there have been four other ovarian tumors 
removed in this amphitheatre, under similar circumstances, 
exposed to the same atmospheric impurities and septic dan- 
gers, as the cases just enumerated. Not one of the four could 
be regarded as a favorable case for operation. Three of the 
patients had reached the age when the reparative processes of 
nature have lost their force and activity. They were debilitated 
and their strength so exhausted and so enfeebled that a sur- 
geon more jealous of his statistics and reputation, than of 
the interests of his patients, would not have operated. Yet 
all three cases got well, making very rapid, and I may sav, 
brilliant recoveries. The other case was quite remarkable 
for several particulars. The patient was a young woman; her 
strength had not yet become impaired; she was strong and full 
of hope and courage. The tumor was large, and was growing 
rapidly, but the one remarkable complication in her case, was 
a large gravid uterus, the patient being in the seventh month 
of pregnancy. In consequence of the rapid increase of the 
tumor and the intense suffering which it occasioned, there was 
no choice but to operate at the earliest possible moment after 
the patient presented herself at this clinique. The operation in 
every particular passed off satisfactorily. It was done rapidly, 
but gently, and safely. The peritoneal cavity was open not 
longer than fifteen minutes. The uterus was handled with the 
utmost gentleness and received the least possible amount of 
manipulation, nevertheless, labor pains came on in a few hours 
and the woman sank under the combined shock of the operation 
and the miscarriage. 
This completes the list of ovariotomies performed in this 
clinique and hospital during the time specified, making seven 
operations; six recoveries and one death. The latter clearly 
independent of anything like septic influences. 
Two weeks ago I operated upon Mrs. 0., at Otisville, in this 
State, in her own house, and amidst surroundings the most 
unfavorable and discouraging that could possibly be imagined 4 
The patient was sixty three years old. The tumor was large, 
multilocular, extensively adherent, had been tapped and the 
cysts contained enormous quantities of purulent fluid and 
masses of inflammatory lympth. I never had the privilege of 
seeing Mrs. 0. until the day of operation (October 16, 1884), 
and then I had only two hours to spend there, before the train 
was due by which I returned home. Having performed the 
operation as carefully and completely as if I had the whole 
day before me, I left her in the care of Dr. J. D. Laing, from 
whom I received daily reports as to her symptoms and condi- 
tion for two weeks, at the end of which time he pronounced 
her cured. Being financially poor, and physically in an ad- 
vanced stage of exhaustion, her removal from her bed or her 
home to anv more com.ortable or healthy surroundings, much 
as that was to he desired, was simply impossible. Not only so, 
hut the patient had remained firm and immovable in her deter- 
mination to be operated upon in her own home or not at all. 
We had, therefore, no choice hut to operate where we did and 
as we did, or else leave the unfortunate patient to her miser- 
able fate. 
Again on the ,80th of October last, I performed ovariotomy 
upon Mrs. W., of Manchester, in this state, under circumstances, 
which, if we except the age of the patient, were more unfavora- 
ble and deplorable than those of the case just described. The 
patient, Mrs. W., is thirty-eight years old. Her tumor had 
grown rapidly, having commenced, so far as could be discov- 
ered, just ten months before I saw her. She also was a poor 
woman, and all her surroundings accordingly unsuitable for 
the safe and satisfactory performance of any surgical proced- 
ure. She was much emaciated and greatly exhausted. Her 
tumor, along with the ascitic fluid withdrawn from the abdom- 
inal cavity at the time of the operation, weighed one hundred 
and three pounds. Owing to the enormous distension of her 
abdominal cavity, and pressure upon the thoracic viscera, she 
was unable to stand on her feet, lie on her back, or turn over 
in bed. Her removal, therefore, to any more favorable place 
for operation, desirable as it might have been, was a physical 
impossibility. Here we had once more to choose between 
operating there and then or abandoning her to her fate. We 
chose the former, and the result has demonstrated the correct- 
ness of our course. The patient has made a rapid and most 
satisfactory recovery. Before leaving this case, I should men- 
tion the fact that the tumor was multilocular, and some of the 
larger cysts were filled with a semi-solid mass presenting a 
striking resemblance to soft soap. I will also mention the fact 
that the case had not been seen bv me before the time of the 
operation, nor have I seen her since. The after-treatment was 
placed in the care of her family physician, Dr. A. C. Taylor, 
of Manchester, assisted by my brother, Dr. A. M. Maclean, and 5 
then by Mr. Julius Noer, a member of this class, who was sent 
from here to remain a few days by the patient’s bedside. 
You will note that we have now described five cases oper- 
ated upon within the month of October last. Three here in 
your presence, including the case of extirpation of kidney , and 
two in remote country villages. All have made rapid recoveries. 
Going three or four months farther back in the retrospect, 
I have to record three cases operated upon by myself in the 
public amphitheatre of Harper Hospital, Detroit, during a 
time when, to my certain knowledge, erysipelas, diffuse suppu- 
ration and diphtheria existed in the institution. Three cases, 
which as regards the character and relations of the tumors, and 
the general health of the patients, might be truthfully described 
as desperate. Of these three two were dismissed cured Jnside 
of three weeks from the date of their operations. The third, 
the most desperate of all, a case which my professional breth- 
ren, who were present at the operation, without a dissenting 
voice, regarded as* practically beyond the reach of hope, was 
dismissed cured, after eight weeks of the most careful and 
devoted after-treatment. 
In the latter part of July I performed ovariotomy upon a 
lady, aged sixty years, in delicate health, at Midland City, this 
State. Owing to a very large adhesion, which was broad, thick, 
and short, and very vascular, the operation was made difficult 
and tedious. Every effort was made and all possible care taken 
to prevent and oontrol haemorrhage from this peculiar structure. 
When the cavity was closed it seemed that every vessel had 
been secured and all oozing stopped. But at the end of twenty- 
four hours, without a previous bad symptom, she began to sink 
rapidly, and in a few hours life yielded to an easy, painless 
death. No postmortem was allowed, but the mode of death 
suggests internal haemorrhage as the cause. 
A short time prior to the operations in Harper Hospital, I 
had two cases in the city of Detroit. Both operations were 
performed in private residences. The hygienic surroundings, 
in both instances were as bad as it is possible to imagine; one 
being a third-rate boarding house in a cheap back street of the 
city. In this case both ovaries were removed. The other, a 
small room about twelve feet by fourteen feet, one door of the 
room opening on a damp, foul street, and another into the 
kitchen. These cases were dismissed cured within two weeks 
from the date of operation. 
But our list is not yet completed. On the 15th day of Jan- 
uary, 1884, I went to the city of Kalamazoo, in this State, for 
the purpose of performing ovariotomy on a young lady eighteen 
vears of age, who insisted upon having her operation done in 
her own home. But for the existence of glycosuria, the case 
was in all respects a favorable one for operation. The patient 
was not on the operating table more than fifteen minutes, 6 
The recovery in this case was rapid, uneventful, and complete. 
Immediately upon the completion of this operation, I was 
asked to see another patient suffering from ovarian disease. 
This proved to be a very different and much more unfavorable 
case. The tumor was large and multilocular, the general 
health of the patient much broken down, and her spirits very 
greatly depressed. Her lower extremities were swollen to their 
utmost capacity by dropsical fluid. Notwithstanding the unfa- 
vorable nature of the case, and the no less unfavorable con- 
dition of her hygienic surroundings, I proposed to afford her 
at once, the only chance of life which remained, namely, the 
removal of her disease by operation. This proposal having 
been considered and accepted, I proceeded without further 
ceremony or delay to carry it into execution. Both ovaries and 
a large mass of adherent omentum were removed. For some 
hours after the operation the patient suffered severely from 
shock, but in due time rallied and recovered without a bad 
symptom, and is now in the enjoyment of robust health. Even 
the habit of using large doses of morphia, acquired during the 
period of her ovarian trouble has been completely abandoned. 
The last case about which I will speak now was operated upon 
in the city of Pontiac, this state, Mrs. S., aged thirty-five. Her 
tumor was large and had been allowed to go on until the 
vitality of the patient was about exhausted; she was reduced 
to such an extent that even hope itself was gone. The opera- 
tion was not a difficult one, but the patient never recovered 
from the shock, and gradually sank. 
Here are eighteen cases, all that I have operated upon 
during eighteen months, with fifteen recoveries and three deaths. 
I have reviewed these cases for a double purpose; to show 
the folly and the danger of neglecting an early operation; 
and to criticise some ideas that have been recently advanced, 
regarding the place of operation and the qualifications of the 
operator; and at the same time to protest against making 
figures the basis for estimating the value of such results as 
are here shown; the intrinsic merits, the difficulties and pecul- 
iarities should he the points considered. . The eighteen cases 
here mentioned, represent the sum total of all cases of ovarian 
tumors that have applied to me during the time specified. 
The great majority being difficult, dangerous, and unpromis- 
ing cases. In view of the fact that in each case the operation 
was done with a full understanding that the patient had 
everything to gain and nothing to lose, and that it was done 
for the purpose of giving her the benefit of any possible chance 
remaining, I feel that saving fifteen lives out of a possible 
eighteen is a result which satisfies my conscience, and as a 
surgeon I can be tried before no higher or more severe tribunal. 
Claim has been made in certain quarters for the exclusive 
performance of ovariotomy in special hospitals set apart for 7 
that purpose and by special operators, who confine themselves 
to abdominal surgery. A claim which it must be admitted 
possesses some theoretical foundation. Unfortunately there 
are practical difficulties in the way which are sufficient to 
render this claim cruel and selfish and worse than absurd. 
No stronger argument could be made against this new doctrine 
than is found in such a retrospect as we have now taken. An 
ostentatious advocate for special abdominal hospitals and spe- 
cial abdominal operators, he himself being a representative of 
the latter, at the late meeting of the American Medical Associa- 
tion, argued that for an operator to open the abdominal cavity, 
anywhere else than in a private abdominal hospital, and espe- 
cially in a public amphitheatre, amounted almost if not quite 
to the crime of manslaughter. The same speaker, on the same 
occasion used the following language: 
“If he,” [the operator] “chooses to do an ovariotomy in 
the amphitheatre, in the presence of one hundred medical stu- 
dents with dust flying with zymotic influences of the dissecting 
room, I say that, if that woman gets well in spite of all that, 
the Almighty is to be given more credit than the operator.” 
You are well aware I have always believed and taught that 
the functions performed by the surgeon, with all his skill, and 
care, and experience, as compared with those performed by 
nature are impotent and insignificant. While, therefore, we 
modestly refrain from, and repudiate any such comparison, we 
do claim on the strength of the statistics now presented, to be 
deserving of more credit, than the man who would deliberately 
consign to lingering and miserable death, all the unfortunate 
sufferers of ovarian tumors, who cannot avail themselves of 
the advantages of his special hospital and of his alleged mar- 
velous power as an abdominal operator. 
The ovarian operator should always select the best possible 
hygienic surroundings for his patient, but at the same time 
there are other matters of no less importance to be considered. 
Among these are tenderness and delicacy in all his manipula- 
tions: thorough cleanliness on the part of the surgeon himself, 
his assistants and his appliances, the cleansing of the peritoneal 
cavity of all fluids and foreign matter of all kinds, the perfect 
control of haemorrhage, the accurate closure of the abdominal 
wound, efficient drainage, the application of dressings such as 
you have seen us use, which are simple and comfortable, and 
efficient as a means of protection not only to the wound but to 
the abdominal cavity and its contents. This, you have noticed, 
consists of a piece of carbolized oil silk to cover the wound, and 
over this a thick padding of clean white cotton wadding, held 
in place by a flannel bandage snugly applied and secured by 
safety pins. 
The diet, nursing, and after-treatment will furnish a subject 
for a future hour. 8 
Since the above was printed it has been thought advis- 
able to refer to an article published in the Physician and Sur- 
geon December, 1881, under the heading: “Practical Observa- 
tions on Ovariotomy,” containing views which are yet firmly 
maintained by the author, and to make the following quota- 
tion : “ First of all I desire to say that in m v opinion the ope- 
ration in question, requires for its successful performance, s<> 
much surgical experience and dexterity, carefully arranged sur- 
roundings, so many appliances and such perfect preparation in 
all respects, that its practice should be confined to a compara- 
tively limited number of surgeons who should be in the truest 
and best sense of the term specialists.” 
Of late years I am sure that the operation has been notori- 
ously abused in this and other states. It would be an easy 
matter to collate a long list of unpublished cases operated upon 
under circumstances which rendered success an exceedingly 
remote possibility, and in which, as a matter of fact, the rate 
of mortality is almost one hundred per cent. Unless a surgeon 
is so situated as to give him in point of experience, surround- 
ings and equipments, special advantages for performing ovari- 
otomy, justice, to all concerned, demands that he should refrain 
from recklessly attempting to gratify his personal ambition at 
so great a risk to his patient’s life. 
The remarkable success of certain celebrated ovariotomists, 
has been attributed to the cautious manner in which they have 
selected their cases, declining to operate whenever the difficul- 
ties and complications of the cases have seemed to endanger the 
chances of success. Mv own conviction is, that the care and 
thoroughness with which they prepare themselves and their 
patients, in each and every instance, furnish the true explana- 
tion of their success, and I am sure that their example has not 
been followed as universally as it ought to have been.