DOUBLE OVARIOTOMY 
PERFORMED FOR THE REMOVAL OF 
SOLID OVARIAN TUMOURS. 
TRANSFUSION OF MM FOUR DAYS AFTER OPERATION. 
BY vX 
T. GAILLARD THOMAS, M.D., 
PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE COLLEGE OP 
PHYSICIANS AND SURGEONS, NEW YORK. 
[Reprinted from the American Journal of the Medical Sciences, for January, 1876.] 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1876. DOUBLE OVARIOTOMY. 
On the ninth of October, 1875, Mrs. S., of Oswego, N. Y., temporarily 
residing in Brooklyn, mt. 30 years, the mother of two children, called upon 
me by the advice of Dr Chauncey L. Mitchell, of the latter city, and gave 
me the following history of her case. 
Seventeen months ago, up to which time she had been in good health, 
she had been safely delivered of a child. Since that time she had been 
slowly but steadily failing in strength, becoming more and more feeble, 
and within the last six months rapidly emaciating. No cause could be 
found for this constitutional depreciation until last May, when Dr. C. C. 
P. Clark, of Oswego, upon making a careful vaginal examination, dis- 
covered a solid tumour connected with one ovary, not larger than an egg. 
Since that time this tumour had gone on steadily increasing in size until 
at the time of her examination by me it was as large as the uterus at the 
sixth and a half or seventh month of pregnancy. 
Besides the marked constitutional depreciation and emaciation which 
had developed during the past six months, no other decided symptoms 
had shown themselves. The menstrual discharge had been absent for 
three months, and some neuralgic pains had existed about the inguinal 
regions and lower part of the abdomen. When asked what her chief suf- 
fering was, the patient would reply that she suffered no absolute pain, but 
that she felt generally wretched and exceedingly feeble. 
Physical examination yielded the following results : the uterus held its 
normal position as to elevation in the pelvis, but was pushed forwards 
towards the symphysis pubis by a round, hard immovable tumour, which 
occupied Douglas’s pouch aud filled the upper part of the sacral con- 
cavity. The uterus measured, from os externum to fundus, three inches, 
and upon rotation of the uterine sound, it could be distinctly, though not 
freely, moved without impressing the movement upon the tumour which 
lay behind it. Upon conjoined manipulation the large hard tumour men- 
tioned as occupying the abdominal cavity could be felt. It extended 
above the umbilicus for about three inches, and filled the false pelvis from 
one iliac crest to the other. Its surface was flat and smooth, the tips of 
the fingers could be inserted under its edge, and the tumour could be easily 
moved in every direction, though only to a limited degree. 
I was somewhat puzzled at finding that movements impressed upon the 
abdominal tumour did not proportionately influence that portion felt 
behind the uterus. This fact was fully explained upon opening the ab- 
dominal cavity at a later period. The uterus moved with the abdominal 
tumour, but not nearly as freely as it would have done had this been 
attached to it by sessile attachment or even by a short pedicle. 
Owing to the enfeebled state of the patient, the physical examination 
was not made as thoroughly as it might have been, and was concluded as 
rapidly as was consistent with clearness of diagnosis. 
Upon this visit Mrs. S. showed me a letter from Dr. W. L. Atlee, who 
had examined the case on the Ist of October, 1875, to her physician, Dr. 2 
Clark, in which he expressed himself in the following words : “ I exam- 
ined your excellent patient, Mrs. S., day before yesterday, at Auburn, and 
find a very unique and interesting specimen of disease. I have never felt 
a tumour that more closely resembled a cirrhosis of the liver, and from that 
circumstance, and from her pallid and rather cachectic appearance, I am 
somewhat apprehensive of a malignant basis.” He also stated his opinion 
that a resort to operation would be a hazardous one. It was under the 
depressing influences of so grave an opinion from so high an authority 
that she sought ray advice. 
The whole history of the case, as well as the physical signs, so closely 
resembled those of two cases of solid ovarian adenoma with which I 
had met, that I ventured to hope that this tumour might partake of that 
nature, and not be true cancer. As the sequel will show, the raicrosco- 
pists to whom specimens were subsequently submitted differ somewhat as 
to their nature. As all, however, agree in the existence of a decided 
adenomatous element in them, it may not be without interest for the 
general reader to give a sketch of the very meagre literature of this form 
of tumour as it occurs in the ovary. 
In the first volume of Mr. Spencer Wells’s work upon Diseases of the 
Ovaries, on page 122, will be found the following description of a tumour 
presented at the Pathological Society : 
“ Mr. Spencer Wells exhibited a specimen of ‘ adenoma of the ovary,’ which 
he said he thought the most appropriate designation which occurred to him, 
although it might be called fibro-epithelioma, or alveolar adenoid tumour. It 
is identical in structure with the adenoid growths first described in connection 
with the mammary gland, and it was very interesting that it should now be 
found in connection with the ovary. He had not seen a similar growth in the 
ovary before, nor had he found it described by any author. A drawing of Dr. 
Hughes Bennett’s of the structure of chronic mammary tumour might have 
been taken from one of the sections shown to the society. ’The tumour was 
removed on the third of last September from a single lady about fifty years of 
age, who recovered perfectly after the operation. It consisted in great part of 
an ordinary raultilocular cyst; but one large cyst was filled with semi-solid 
matter, which at first sight looked exactly like soft cancer, but after hardening 
in spirit and examining thin sections the true character was made out, and it 
was seen that the surface of the growth was fringed with papilliform villi, its 
substance showing in vertical sections a delicate fibrous stroma forming round 
or oval alveoli. These alveoli are lined with densely grouped epithelial cells, 
forming a continuous zone, which incloses an area loosely packed with cellular 
elements of similar form. On the margins of most sections the contents of the 
alveoli are frequently seen to protrude, like papillae, through ruptured portions 
of the fibrous septa, or the lining zone of the alveolus has become liberated and 
divided so as to assume the appearance of a long cylindrical band or column 
of the epithelial cells. The tumour, therefore, belongs distinctly to the class 
of fibro-epithelial growths, and from the folliculoid character ot its alveoli 
would, Mr. Wells thought, be most appropriately classed as adenoma.” 
This was in 1862, and Mr. Wells claimed priority in the name. The 
tumour presented was not a solid one, for the patient was twice tapped, 
and on each occasion fourteen pints of fluid were removed. 
Since that period it has become a recognized fact among pathologists 
that a certain degree of adenoid development occurs in every true ovarian 
cystoma. Mr. Wells himself considers, in his recent work upon Diseases 3 
of the Ovaries, under the head of adenoid tumours, all simple, multiple, 
and proliferous cysts; and Delafield1 declares that “in the ovaries most of 
the compound cysts are adenomata, with dilatation of the follicles.77 It is 
only in exceptional cases that solid adenomatous tumours, with few and 
insignificant follicular dilatations, are met with. I have met with two 
instances of this variety. 
In 1864 a tumour of this character was removed by Mr. Baker Brown, 
presented to the Obstetrical Society of London,2 and referred for special 
examination to Drs. Greenhalgh and Braxton Hicks, who made the follow- 
ing report:—- 
“ External Aspect.—The tumour is firm, very lobulated, and somewhat kid- 
ney-shaped, the right lobe constituting about one-third, the left two-thirds of 
the whole mass. In its long axis it measures nearly eight inches. The trans- 
verse circumference of the right lobe is about ten inches, that of the left 
about the same. The investing membrane is everywhere closely adherent, 
from which it is separable with difficulty.” 
In the right lobe of the tumour were numerous cavities, the largest as large 
as a walnut; in the left a larger one. “On the division of the tumour in its 
long axis the right lobe cuts like what has been called sarcomatous tissue ; 
the left, being much softer, recedes before the knife, whilst the other was more 
or less cartilaginous.” 
“The great mass of the tumour is made up of solid pinkish tissue, the left 
lobe possessing delicate bands of lighter tissue radiating from near its centre.” 
After giving the microscopic features of the tumour the committee concludes 
by saying: “ We consider, from the general microscopical examinations of the 
above tumour, that it was a specimen of that form of disease recently desig- 
nated adenoma of the ovary.” 
Although, as I have just shown, in 1862 and ’64 this variety of tumour 
was formally introduced into the list of ovarian tumours by high authority, 
it has not been admitted to a recognized position at the hands of syste- 
matic writers. Thus Peaslee,3 writing in 1872, says: “It should have been 
stated that adenoma of the ovary has more recently been asserted. But 
since this term is rightly applied only to an hypertrophic development of 
the epithelial element of a gland, the subject needs further investigation.’7 
He says no more than this upon adenoma. In Atlee’s4 work, published in 
the same year, no allusion to this form of tumour appears. Barnes is 
equally silent upon the subject, and in the most recent of the works upon 
gynaecology, by Prof. Schroeder,5 of Erlangen, it passes likewise without 
mention. The latter author alludes to papilloma, sarcoma, fibroids, and 
carcinoma of the ovary, but nowhere does adenoma receive even a mention. 
When the large experience of Atleeand Peaslee is borne in mind, with the 
additional fact that Barnes writes in the very city in which Wells first 
drew attention to this form of tumour, it becomes very evident that ova- 
rian adenoma, as a tumour in the main of solid character, has not been 
admitted to a recognized position. 
1 Post-mortem Examinations and Morbid Anatomy. 
2 Transactions, vol. vi. p. 181* 
3 Ovarian Tumours. 4 Ovarian Tumours. 
5 Diseases of Female Sexual Organs.—Ziemsscn's Cyclop. 4 
From this digression I now return to the case which forms the subject 
of this paper. 
As the patient was already greatly enfeebled, and was steadily becoming 
more and more exhausted, I readily assented to her own desire and that 
of her friends, and agreed to perform ovariotomy without much delay. 
On the 14th of October, at o’clock P. M., I proceeded to operate in 
the presence of Dr. C. C. P. Clark, of Oswego, Drs. Mitchell and Skene, 
of Brooklyn, and Drs. Hunter, Walker, and Jones, of New York. The 
patient having been etherized by Dr. Skene, and placed upon her back 
upon a table, I made an incision through the peritoneum extending from 
a point two inches above the umbilicus to the symphysis pubis. Through 
this the tumour, which was unattached, was removed. The pedicle, con- 
sisting of the right ovarian ligament, Fallopian tube, and extension of the 
round ligament, was secured in a clamp, but upon subsequent examination 
it was found to be so tense that I ligated and returned it to the pelvis. 
Upon examining the uterus it was found to be perfectly normal, but the 
left ovary was as large as a bullock’s kidney and lay behind the uterus, 
distending and occupying Douglas’s pouch. This was removed like the 
right, and the abdominal incision rapidly closed. 
The w'hole operation occupied thirty-six minutes. At its conclusion 
the patient was removed to a warm bed, hot bricks put to her feet, the 
room darkened, and perfect quiet enjoined. 
The patient was left under the care of Dr. S. B. Jones, who, on account 
of her very enfeebled condition, remained with her constantly for the next 
five days, and to his watchfulness and care 1 cannot but feel that the 
subsequent recovery of the patient was in great part due. 
She was kept entirely upon the milk diet, taking this in very small 
amounts, and at intervals of three or four hours, and was quieted by small 
doses of morphia. 
During the next thirty-six hours all went well, the temperature did not 
rise above 102°, and the only anxiety which was felt in reference to her 
during this period was created by the fact that she could take very little 
food without vomiting, and that her pulse, the rate of which was 130 to 
the minute, was exceedingly small, feeble, and flickering. On Friday [ 
saw her in consultation with Drs. Mitchell and Jones. On Saturday 
morning, just thirty-six hours after the operation, I received a telegram 
stating that a rather profuse uterine hemorrhage had come on, and that 
the patient had lost ground decidedly in consequence. At ten that morn- 
ing I saw her, and the condition of affairs looked decidedly unpromising. 
The pulse was so rapid and weak that at times it could scarcely be felt, 
and the patient began to vomit everything that was put into the stomach, 
even small pellets of ice. The foot of the bedstead was elevated twelve 
inches, cold was applied to the vulva, and the patient kept perfectly quiet. 
From this time nourishment was given by the rectum alone. 
On the evening of that day I was forced to go to Rhinebeck, from 
whence I could not return before the evening of the following day. At 
eleven o’clock that night I received a telegram from Dr. Jones, stating 
that the uterine hemorrhage had recurred so violently that with the assent 
of Dr. Mitchell he had used a vaginal tampon, and that the patient was 
sinking so rapidly that she would die before morning. Reaching home 
late on Sunday night I found that death had not occurred, and early on 
Monday morning I went to Brooklyn to see her. 
On this visit I found everything looking very badly. Both stomach 5 
and rectum rejected all nourishment; the temperature was only 102°, 
but the pulse was small, flickering, and beating at 140 to the minute. 
It was agreed that very small amounts of fluid food should be cautiously 
tried by stomach and rectum, and, as the patient appeared to be dying 
from sheer exhaustion, the result of previous enfeeblement by the disease, 
and more recent starvation and loss of blood, that, in case Drs. Mitchell 
and Jones should towards night feel convinced that death would occur, I 
should be summoned to perform transfusion. 
At six that evening (Monday, four days after operation), I received a 
telegram urging ray immediate attendance on Mrs. S., who appeared to 
be rapidly sinking. When I saw her I found her bathed in cold sweat, 
with a temperature of 101°, a pulse of 150, and a facies expressive of 
approaching dissolution. It was decided at once to try the effect of trans- 
fusion. 
Three experiments with the transfusion of blood rendered me very 
averse to the employment of this fluid, and with the consent of ray col- 
leagues I decided to employ instead perfectly pure, fresh milk. This 
idea suggested itself to ray mind from the recollection of some cases in 
which it was employed twenty years ago by Dr. Edward M. Hodder, 
of Toronto, Canada. In 1850 Dr. Hodder injected this fluid into the 
veins of three patients moribund from Asiatic cholera, which was at 
that time epidemic in Canada. In a communication from him he informs 
me that he injected as much as fourteen ounces at one sitting; that no 
alarming symptoms occurred; that good results manifested themselves 
from the first; and that two recoveries had taken place in patients who 
appeared moribund when the operation was resorted to. He was encour- 
aged to try the method from the fact that Donne had injected milk into 
the veins of dogs and rabbits without injury to them. Since the cases 
reported by Dr. Hodder, I know of no one who has repeated this experi- 
ment in the human being until a year ago, when Dr. Joseph W. Howe, of 
this city, injected six ounces of warm goat’s milk into the cephalic vein of 
a patient suffering from tubercular disease, and who appeared to be dying 
from starvation in consequence of an inability to retain nutritious material 
by either stomach or rectum. Dr. Howe declares that— 
“When nearly two ounces had been thrown into the circulation, he com- 
plained of pain in the head and vertigo. The eyes twitched from side to 
side (nystagmus), and he said he could not see. The same symptoms 
recurred when the next ounce was thrown in, and ceased when the injection 
was suspended. The third repetition of the same quantity produced pain 
in the chest and dyspnoea, and no brain symptoms. His pulse seemed to 
be fuller after the operation, and he said he felt better, Death took place 
four days afterwards, A post-mortem examination showed that there 
were no clots in the veins of the arm or in the lungs. The brain was 
normal. I don’t think the operation improved his condition, notwith- 
standing the fact that the patient himself and the house surgeon thought it 
did.” 
Having decided to inject milk into the veins of my patient, a young and 
healthy cow was driven into the yard, a pitcher with gauze tied over its 6 
top was placed in a bucket of warm water, the vein was exposed and the 
cow milked at the moment the fluid was needed. By means of the very per- 
fect and safe transfusion apparatus of M. Colin of Paris, I slowly injected 
eight and a half ounces into the median basilic vein. The first effect 
which evidenced itself did so after about three ounces had been injected. 
Then the pulse became so rapid and weak that Dr. Mitchell, who kept it 
under his finger during the operation, could scarcely detect it. The patient 
declared that she felt as if her head would burst, and seemed greatly over- 
come. I went on slowly, however, transfusing the fluid until the amount 
mentioned had been reached ; she was then left perfectly quiet. 
In an hour from this time she had a decided rigor, the pulse was found 
beating between 150 and 160 to the minute, and the temperature rose to 
104°. This high rate of temperature, however, soon passed off, and 
towards midnight the patient fell into a quiet sleep, from which she did 
not awake until morning. 
I saw her about ten the next day, when Drs. Mitchell and Jones gave 
me a very encouraging account of her. As I entered her room she said in 
a feeble voice, “ I feel that lam going to get well.” This I was particu- 
larly glad to hear, as during the previous day she had given up all hope 
and was utterly despondent. The pulse was beating at 116 to the minute, 
the temperature was 99|°, the tendency to sweating had disappeared, and 
the facies had much improved. 
During the day very small amounts of iced milk and lime-water were 
given by the mouth and retained. From this time onwards it would be 
needless to mark the daily changes which occurred. The patient steadily 
progressed to complete recovery, and on the twenty-first day after the ope- 
ration, upon a visit made by Dr. Jones, she walked down stairs to meet 
him. The notes taken by him on this occasion declare that “the appetite 
is excellent, the patient growing stout, sleeping well, and gaining every 
day.” Six weeks have now elapsed since the operation, and the patient 
is entirely well. 
The general appearance of the tumours is as follows : The larger re- 
sembles closely in aspect a cirrhosed liver. It measures in its longer cir- 
cumference 19 inches; in its shorter inches ; and weighs 4?r pounds. 
The smaller tumour resembles a large fatty kidney ; measures in its long 
circumference 12 inches ;in its shorter inches ; and weighs ljf pounds. 
Upon section a number of cysts were found in the larger tumour about 
the size of a chestnut, and filled with colloid material. In the smaller 
tumour no cysts appear except upon the circumference, where a few small 
ones, the largest about the size of a marble, exist. 
Four gentlemen have examined these growths by the microscope, and 
as their reports differ somewhat I give them in their own words. They 
are presented in the order in which they were handed in.1 
Report of Dr. E. Gr. Janeway:— 
“The microscopic examination of the tumour of ovary shows— 
“ Ist. More, at the periphery, fibroid tissue with normal or some excess 
of cellular elements. In some spots I noticed an accumulation of lym- 
phoid cells in this. 
“ 2d. More central, sarcoma tissue, numbers of spindle cells arranged in 
1 These tumours are preserved in alcohol, and I shall be happy to forward sec- 
tions of them to any mioroscopist who would like to examiue them. 7 
groups with but little intermediate tissue in parts. In some places the 
section had divided these transversely, giving the appearance of groups of 
round cells. 
“3d. Rounded spaces lined by epithelium, mostly of polygonal character, 
in some approaching a little to the cylindrical. 
“4th. Occasionally smooth muscular fibre cells. 
“ The name properly would be sarcoma. I think that in part these fol- 
licular spaces are of new formation, and that perhaps adeno-sarcoma 
would be a better name. 
“Here and there I observed spaces from which a part of the fluid noticed 
on section escaped. These showed little spaces between the cells which 
assumed more of a stellate character.” 
Report of Dr F. H. Chapman:— 
“The tumour is ‘ adenoid.’ 
“Thin sections of the alcohol-preserved preparation presented simply a 
dense fibrous tissue ; but treatment by water, and afterwards by acetic acid, 
enabled me to obtain beautifully reticulated connective tissue, the meshes 
of which were filled with colloid globules, oil-globules, and granulations. 
No cells could be found; cells iii the strict pathological sense, although 
the ‘nuclei’ and ‘cells’ of Spencer Wells were abundant. 
“In order to verify the diagnosis, other methods were adopted. With 
caustic potash the connective tissue was dissolved, leaving as a residue the 
globules of different kinds which are not readily acted upon by this agent. 
Thin sections were also tinged with carmine and coloured in gold, the 
former of which methods produced fine specimens of connective tissue 
reticulation, and the latter, by colouring the globules and so-called cells, 
enabled me to judge more accurately of the proportion of globules to the 
tissue. 
“Vessels were not numerous. The nerves were not studied, as for this 
portion of the structure fresh specimens are necessary.” 
Report of Dr. J. Adler:— 
“The portion of tumour presented for examination appeared as a whitish, 
tolerably firm substance of apparently fibrous structure, and containing a 
number of small cysts of about the size of a pin’s head. Most of these 
little cysts contained clear colloid matter. But very little material could 
be scraped away with a knife, and this consisted mainly of small epithe- 
lioid cells. These transparent sections examined under the microscope 
showed somewhat different structure in different localities of the tumour. 
“One set of sections showed the following : 
“ A stroma consisting of fibrous tissue mostly wavy, often denser and 
firmer, containing but few puriform or small round cells. In this stroma 
are imbedded follicles, evidently Graafian vesicles, with all peculiarities of 
structure with this exception, that in many the ovum cannot be detected, 
but the cavity is filled up by a mass of proliferating epithelial cells. We 
find further, follicular cysts retaining mostly the lining of short cylindrical 
epithelium and filled with colloid. And lastly, irregular epithelial masses 
of considerable size, involving usually a number of follicles from which 
they seem to originate; frequently these masses are strikingly similar to 
the ‘epithelial-tubes’ (Epithel-Schlanche) of Pfliiger and Waldeyer. A 
second set of sections representing the main portion of the piece of tumour 
under examination showed the following : Fibrous tissue, mostly firm and 
dense, containing but few cells, arranged so as to interlace in various 
directions and form an extensive network. The bands of fibrous tissue are 8 
sometimes very broad, sometimes but very thin and delicate. The meshes 
thus formed vary in size, being sometimes hardly perceptible between the 
masses of fibrous tissue, as a rule, however, tolerably large, and through a 
large tract of tumour nearly equal in size, thus presenting an appearance 
of great regularity. These spaces between the bands of fibrous tissue are 
filled up with epithelioid cells, showing a large nucleus and an irregular 
usually flat protoplasmatic body. The size of these cells varies somewhat, 
on the average they do not exceed the size of the epithelium of Graafian 
vesicles. These latter occur also in this set of sections usually filled up 
with epithelium. 
“A third set of sections from but one or two spots of the piece under 
examination seem to consist, at first view, mainly of fibrous matter in 
which a higher power shows numbers of spindle-shaped cells arranged in 
bands, and here and there particles of large granulated round cells. Here, 
too, a closer examination detects, everywhere, filling up the interstices 
between the fibrous matter, epithelioid cells similar to those described 
above. Besides these three sets of sections a number of others can be ob- 
tained which exhibit combinations of all the structures described above. 
The tumour is moderately vascularized. Bloodvessels show no abnormi- 
ties. 
“The first set of sections described ranges, as regards diagnosis, undoubt- 
edly under the head of Adenoma in the sense used by modern authors and 
especially Klebs {Handbuch der Patholog. Anatomic, p. 796). Taking 
its origin from this adenomatous growth, the bulk of the tumour seems 
made up, as shown by second set of sections, of tissues moderately carcino- 
matous. This form of carcinoma, originating in adenoma of ovary, has 
often been described (Klebs, loc. cit. p. 809, as fibrous carcinoma ; Virchow, 
Die Krankhaften Gesclnvulske, vol. ii. 370). A certain amount of 
sarcomatous tissue seems to enter into the composition of the tumour as 
shown by the last set of sections. The sarcomatous tissue has evidently 
developed from the fibrous stroma, and as, nearly always, in sarcoma of 
ovary, degenerates into carcinoma (sarcoma carcinornatosa, Virchow, 100. 
oil.), altogether the tumour may be classified as adenoma carcinomatosa.” 
Report of Dr. Francis Delafield ; 
“Specimens were examined from both the large and small tumours. In 
both the structure is essentially the same. 
“The tumours are conjoint in their structure. We can distinguish— 
“l. Large rounded and tubular follicles lined with epithelium. Some 
of them are dilated so as to form cysts. They look like the follicles found 
in adenomata of the ovaries. 
“2. Long rows of polygonal nucleated cells looking like true cancer. 
“3. A reticulated arrangement of connective tissue, the spaces large and 
small. The small spaces containing cells, the larger colloid matter. These 
larger spaces do not resemble the dilated follicles spoken of under (1), 
although these also contain colloid matter. This stimulated tissue 
resembles exactly colloid cancer. 
“4. The stroma in ordinary fibrillated connective tissue, in some places 
infiltrated with round cells. 
“Classing the tumour according to its more important elements, I should 
call it a carcinoma, partly simple, partly colloid complicated by the growth 
of glandular follicles such as are seen in ordinary ovarian adenomata.” PROSPECTUS FOR 1876. 
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