THE 
HISTORY OF NINE CASES 
OF 
OVARIOTOMY. 
BY 
PROFESSOR OF OBSTETRICS AND DISEASES OF "WOMEN AND CHILDREN IN THE COLLEGE 
OF PHYSICIANS AND SURGEONS. NEW YORK ; PHYSICIAN TO BELLEVUE HOSPITAL. 
T. GAILLARD THOMAS, M. D., 
[FROM BELLEVUE AND CHARITY HOSPITAL REPORTS.] 
NEW YORK: 
D. APPLETON AND COMPANY. 
90, 92 & 94 GRAND STREET. 
1869. THE 
HISTORY OF NINE CASES 
OF 
OVARIOTOMY. 
BY 
T. GAILLARD THOMAS, M. D., 
PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE COLLEGE 
OF PHYSICIANS AND SURGEONS, NEW YORK ; PHYSICIAN TO BELLEVUE HOSPITAL. 
\FROM BELLEVUE AND CHARITY HOSPITAL REPORTS.} 
NEW YORK: 
D. APPLETON AND COMPANY, 
90, 92 & 91 GRAND STREET. 
1869. Entered, according to Act of Congress, in the year 1869, by 
D. APPLETON & CO., 
In the Clerk’s Office of the District Court of the United States for the 
Southern District of New York. THE HISTORY OF NINE CASES 
OF 
OVARIOTOMY. 
It is now just sixty years since the operation of ovariotomy 
was first introduced to the medical profession by an American 
surgeon. Dr. Ephraim McDowell, of Kentucky, performed 
this operation in 1809, the patient recovering from it and living 
twenty-five years afterward. Since that period, the most con- 
stant and acrimonious discussion has been, until within a few 
years, kept up, as to the propriety, I may even say the legiti- 
macy, of the procedure. In spite of all opposition, supported 
as it has too often been by unfair argument and absolute mis- 
representation, the operation has steadily advanced, and at 
the present time has reached a position so sure and unassail- 
able in the esteem of the profession, that no one who desires 
to see his name stand in the list of those who favor advance in 
medical science ventures to depreciate it. 
It is true that here and there will be found those who even 
now declare that the procedure is one too hazardous in its steps 
and too fruitless in its results to warrant its adoption. But 
these will almost invariably be found to stand upon the same 
level with the men who systematically vilify the speculum 
and anaesthesia, and depreciate the value of the microscope 
and ophthalmoscope. 
Although this be true, the operation of ovariotomy is as 
yet too recent not to require the light which can be thrown 4 
OVARIOTOMY. 
upon it by honestly reported statistics, and by tbem alone. 
Amputation of tlie thigh has been so often performed, for so 
many years, and in so wide an extent of territory, that the 
surgeon who now performs it is excusable if he does not report 
every case for the critical examination of his peers. All ques- 
tions as to the value and results of the operation are at rest; 
and, although statistics with regard to it will always be of value, 
the profession no longer demands them as essential for its ulti- 
mate position as a surgical resource. With ovariotomy it is 
otherwise. Every case should be carefully and frankly re- 
ported, in order that it may serve to swell the numbers from 
which conclusions, whether favorable or unfavorable to the 
procedure, are to be drawn. 
There are many influences at work at present which tend 
to keep up the mortality attendant upon this operation. Some 
of these are inherent to the operation itself, and will always 
exist; others, as knowledge increases with experience, and the 
basis upon which it rests becomes more stable and assured, will 
greatly diminish or entirely disappear. First among these 
must be mentioned the necessity for cutting into the perito- 
naeum, exposing this delicate and important structure for a 
long time, and often leaving vessels open upon its surface, or 
within its cavity, which pour out blood that serves as mate- 
rial for putrefaction. Second, the difficulty of diagnosis must 
not be lost sight of. It is safe to say that in no pathological 
condition for which surgical procedure is adopted, not except- 
ing that of internal aneurism, is this difficulty equalled. But 
it is not my intention to enumerate all the influences to which 
I have made allusion, and I shall content myself with the men- 
tion of a third. The observation of others may not agree 
with mine, and many may dissent from what I am about to 
advance, but to me it stands forth clearly as an influence 
which has done, and is doing, much to injure the position of 
ovariotomy as a surgical resource. It is this: the operation 
of ovariotomy is at present often performed by men inexperi- 
enced in the diagnosis and treatment of ovarian tumors. The 
statistics of some of the best operators prove that they have 
been progressively successful, as they have advanced in experi- 
ence, and learned to avoid the dangers attendant upon the pro- OVAEIOTOMY. 
5 
cedure, and we must conclude that they who operate for the 
first or second time, must damage the array of reported cases 
and increase the rate of mortality. I know full well that it 
may be objected to this statement, that if inexperienced men 
never operated, where would our supply of new surgeons come 
from ? In reply to this I would remark, that if the profes- 
sional relations of any man make it likely that he will be fre- 
quently called upon to perform this or any other operation, he 
should prepare himself to meet the demand upon him ; but I 
cannot think it incumbent on any practitioner, upon whom 
no such demand is likely to be made, to have performed one or 
two operations of ovariotomy. I sincerely believe, as the re- 
sult of observation, that the third influence which I have stated 
as marring the statistics of the subject, is by no means an 
insignificant one. With these remarks, I proceed to the his- 
tory of, 
Case I.—Large single cyst, with numerous small ones at base, 
of eighteen months' standing ; removal by ovariotomy ; 
recovery. 
Eliza B., native of Ireland, aged thirty-five years, by occu- 
pation a child’s nurse, of perfectly temperate habits, single, and 
previously in good health, consulted me on the 1st of November, 
1863, on account of an abdominal enlargement which she sup- 
posed to be “ dropsy.” About eighteen months before the 
date which I have recorded, she was startled by observing an 
enlargement about the size of a child’s head low down in the 
abdomen on the right side. At first she kept the fact secret, 
but so rapidly did the swelling increase, that she sought the 
advice of her mistress, who requested a neighboring physician 
to see her. The examination of this physician led the patient 
to believe that he suspected pregnancy, although he made no 
such statement, and, being of rather a morbid disposition, she 
subsequently refused to see him or any other physician, until 
she came under my observation. 
When I saw her she was in good health, her color was 
good, appetite moderate, spirits not depressed, and pulse nor- 
mal. She stated, however, that for three months she had been 6 
OVARIOTOMY. 
losing strength and flesh gradually, and that she was becom- 
ing troubled in respiration. 
Physical examination revealed a large globular tumor fill- 
ing the whole abdomen, and evidently pressing upward against 
the diaphragm. Fluctuation was obtained readily and clearly. 
Over the anterior face of the mass, dulness upon percussion 
existed, and the intestines were found displaced upward and 
laterally. The uterus was elevated, and anterior to the tumor. 
Regarding the case as one of ovarian cyst, I informed the pa- 
tient of my conclusion as to the diagnosis, and advised her at 
once to submit to the operation of ovariotomy. To this she 
readily consented, and all was made ready for its performance. 
A good room was procured for her, as well as a skilful nurse, 
and the 1st of December was appointed for the operation. 
The operation was performed at half-past 12, p. m. ; the 
weather was cool, snow having fallen heavily on the day pre- 
vious, but clear and bracing. 
I was assisted by Drs. T. A. Emmet, George T. Elliot, 
J. S. Thebaud, Foster Swift, and G. S. Winston. Dr. Win- 
ston having produced anaesthesia by Squibb’s ether, the patient 
was placed on a table, and, after evacuation of the bladder, 
the operation commenced with an incision by a bistoury in the 
median line, midway between the umbilicus and symphysis 
pubis, involving the skin and adipose tissue. This incision 
was two and a half inches in length, my intention being to 
prolong it if I found it necessary to do so. 
Having cut down to the fibrous expansion formed by the 
conjoined sheaths of the recti, this was picked up by a tenacu- 
lum, and a very small opening made by scissors into the peri- 
tonaeum, and a grooved director inserted, upon which this 
fibrous sheath and the parietal peritonaeum were slit upward 
by the bistoury. The sac was now exposed, presenting a 
Avhite, shining, fibrous surface. A small amount of straw- 
colored serum escaped from the peritoneal cavity, the result 
of congestion of the vessels compressed by the tumor. The 
hands having been carefully washed in warm water, two fin- 
gers were now passed into the peritonaeum and swept over the 
surface of the tumor, ascertaining the fact that no adhesions 
existed, at least in its upper part. Firm pressure being now OYAEIOTOMY. 
7 
made on the sides of the incision, by the hands of an assist- 
ant, a large trocar and canula were plunged into the cyst. 
Upon the withdrawal of the trocar, there rushed from the 
canula with great violence a little less than six quarts of a fluid 
looking like the rinsings of a vessel which had contained milk, 
and having floating upon its surface some little pellets, like fat. 
The edges of the incision in the cyst were now seized by the 
fingers, and in this way the sac was drawn out of the abdominal 
cavity. It came forth without resistance, no adhesions exist- 
ing. The cyst was a degeneration of the right ovary, and at 
its base the Fallopian tube could be distinctly traced. In ad- 
dition to one large cyst, were discovered, upon inspection, six 
or eight small ones, about the size of pigeons’ eggs, and one 
the size of the foetal head was emptied as the large cyst was 
drawn forth. 
A double thread of strong silver wire was now passed 
through the centre of the pedicle by means of a large needle, 
separated and twisted so as to ligate both sides of the pedicle, 
one of the ligatures encircling the right and the other the left 
portion. Another needle, similarly armed, was then passed at 
right angles to the first, and the two ligatures which it carried 
were disposed of in the same way. After this a strong ligature, 
composed of trout-line, was fastened above the silver ligatures, 
and the sac cut off by the bistoury just above it. 
The abdominal incision was then closed by silver sutures 
one inch distant from each other. The pedicle was placed 
at the inferior angle of the wound, and kept from returning to 
the abdominal cavity by a darning-needle passed through it, 
and left with the point broken off and the extremities guarded 
by cork, at right angles to the pedicle, and flat upon the ab- 
dominal walls. A piece of patent lint, soaked in tepid water, 
was then laid over the wound, the whole abdomen covered 
with warm cotton batting, and an obstetric bandage applied 
with moderate tightness. 
After the operation the pulse was found to be T6 to the 
minute, and as voluminous as before. The patient, who was 
not yet conscious, was then placed in a warm bed, hot bottles 
were put to her feet, she was covered carefully with warm 
blankets, and in fifteen minutes had ten drops of Magendie’s 8 
OVARIOTOMY. 
solution of morphine injected into the areolar tissue of the 
arm by the hypodermic syringe. 
After this she slept quietly for between five and six hours. 
Upon awakening, she suffered slightly from nausea, but this 
soon passed off, the pulse rose to 96, but never went above 
it, and on the fourth day the bladder was emptied without 
the use of the catheter. The diet consisted almost entirely 
of milk for four days, when animal broths and farina-gruel 
were added to this. During the entire convalescence, pain 
and restlessness were quieted by the use of the hypodermic 
syringe ; and pellets of ice, iced champagne and soda-water 
were freely given for the relief of the nausea which it created. 
Seven days after the operation all the stitches wTere re- 
moved, except those immediately in contact with the pedicle, 
and on the eleventh day the patient, contrary to orders, sat 
up out of bed for a little while during the absence of the 
nurse. This produced no evil effect whatever; and on the 
next day the end of the stump was cut off, two remaining su- 
tures removed, the abdominal bandage tightened, and the 
patient allowed to sit up for a short time. This was now re- 
peated every day until she soon walked about the room. 
At the time of writing this, it is six years since the opera- 
tion, and I frequently see my patient in my visits to the chil- 
dren under her charge. She is in perfect health, and has never 
suffered from the operation, the only vestige of which is, a 
cicatricial line on the linea alba that is scarcely visible. 
The fluid discharged from this sac was milky in hue, as I 
have said, and about six quarts in amount. Tested by heat 
and nitric acid, it behaved precisely like highly-albuminous 
urine, and, when rubbed between the fingers, gave the tenacious 
sensation experienced by smearing them with thin syrup and 
water. The specific gravity of this fluid was 1012. 
Case II.—Fibro-cystic tumor, weighing IT lbs., removed by 
abdominal section ; death from shock in forty hours. 
Mary M., a native of Ireland, aged about thirty-two years, 
married eight years, never pregnant, applied to me in Sep- 
tember, 1864, on account of an abdominal tumor accompanied 
by profuse menorrhagia. She stated that she had noticed an OVARIOTOMY. 
9 
enlargement of the abdomen about four or four and a half 
years before, but had paid no attention to it at first, as it gave 
her no inconvenience except mental anxiety on account of its 
presence. As it went on steadily increasing in size, however, 
she began to flow very freely at her menstrual epochs. This 
exhausted her to such a degree, and she had of late suffered 
so constantly from pain, distention, dyspnoea, and vesical irri- 
tation, that she strongly desired operative interference. 
I kept the patient under observation for two months, en- 
deavoring by palliative means to give her relief. At the end 
of this time, she and her husband urgently desired some more 
decided interference, and, as it appeared to me that her life 
would be sacrificed by the continuance of the symptoms which 
existed, I determined upon operating. 
At this time, physical examination revealed a large globular 
mass in the abdomen, which appeared to yield fluctuation very 
perfectly. The intestines were pressed upward and laterally, 
and percussion over the whole anterior face of the abdomen 
yielded dulness. The uterus was normal in size, and to all 
appearance unattached to the tumor, a point which was 
carefully noted. Before operation, the patient was examined 
with me by Drs. Peaslee, Budd, and Loomis, all of whom 
agreed with me, that the case was one of ovarian cyst, that 
operation was legitimate, and that the prospect of recovery 
was ordinarily good. 
The operation was performed in presence of Drs. Peaslee, 
Budd, and Loomis, the house-staff of Bellevue Hospital, and a 
large number of medical students, at 3 p. m., in a ward of Belle- 
vue Hospital which had just undergone complete renovation, 
and which contained no other patients. An incision two inches 
in length was made over the median line, midway between 
the symphysis pubis and umbilicus. When the conjoined 
sheaths of the recti were reached, the operation was arrested 
until all oozing had ceased; then the sheath was caught up 
by a tenaculum, a small opening cut, a grooved director passed, 
and upon it a bistoury slid up so as to open the peritonaeum. 
The anterior wall of the tumor being then exposed to view, a 
steel sound was dipped in warm water and passed around it 
in search of adhesions, but none were discovered. 10 
OVARIOTOMY. 
Palpation of the tumor was now practised by myself and 
the gentlemen who aided me, and, as it appeared to ns all cer- 
tain that it consisted of a sac filled with fluid, I plunged in a 
large trocar and canula. To my surprise, instead of a gush of 
fluid, a free flow of blood occurred, and, withdrawing the trocar, 
I found that the tumor was not a sac filled with fluid, but a 
cystic sarcoma. The flow of blood from the deep wound made 
with the trocar was so free, that it was thought best not to 
abandon the operation, but to extirpate the tumor. Accord- 
ingly, I enlarged the incision to about five inches in length, 
and very readily turned it out of the abdomen. The pedicle 
was soon discovered on the left side; it was small, but very 
short. Ligating this with a strong cord made of silk threads, 
I cut it close off, and returned it to the abdomen. The wound 
was then closed by interrupted silver sutures which involved 
the peritonaeum, and dressed with cold-water dressing, held in 
place by the obstetric bandage. The patient, who had been 
kept under the influence of ether not quite an hour, was now 
put to bed, and warm bottles were applied to her feet, and ten 
drops of Magendie’s solution of morphine were thrown into the 
areolar tissue of the arm by the hypodermic syringe. 
Just after the operation I felt the pulse, found it beating at 
the rate of 160 to the minute, and so feebly as to give me great 
apprehension as to whether the patient would not die on the 
table. After she had slept for an hour, the pulse sank to 
140, and became stronger, but it never became less frequent. 
When consciousness was restored, the patient seemed much 
depressed in mind, declared that she knew she was going to 
die (she had been quite sanguine before the operation), moaned 
constantly, and looked wild and unsettled. Throughout the 
next day this singular condition continued. She took milk- 
punch when urged, but desired no food, and nothing to drink 
except ice water. I saw her at midnight on the second night 
after the operation, and it was then evident that collapse was 
approaching. In spite of continued dry warmth kept up at 
the feet, and as high as the knees, the extremities became cold; 
a clammy perspiration broke out over the whole surface, and 
toward morning the patient died. OYAEIOTOMY. 
11 
A post-mortem examination revealed no trace of perito- 
nitis and no secondary haemorrhage. 
The tumor, when placed upon a table and palpated, was 
so deceptive in its apparent yielding of fluctuation, that it was 
even then declared to contain fluid which had not been 
reached by the trocar, and this view was entertained until it 
was bisected. It was found that it consisted of loose fibrous 
elements, forming numerous loculi, about the size of a hickory- 
nut, which were filled with a honey-like material. After sec- 
tion had allowed what was computed as about three pounds 
of this material to flow away, the tumor weighed a little 
more than fourteen pounds. 
To one not familiar with the difficulties attendant upon the 
diagnosis of these cases, and their differentiation from cystic 
disease, it may appear astonishing that so grave an error 
should have been made in this case. They who have encoun- 
tered them will readily agree that not only is diagnosis very 
difficult, but often impossible, without exposing the patient to 
the risks of paracentesis. In this case I did not resort to this 
explorative procedure, because my mind did not admit a 
doubt as to the true nature of the tumor. On two other occa- 
sions I was, with others, similarly deceived: [one was a case 
that I saw in consultation with Dr. Peaslee, and in which he 
subsequently made an explorative incision that proved fatal; 
the other was removed by a long abdominal incision by Dr. 
O’Reilly, the patient dying on the seventh or eighth day. 
Case III.—Alveolar cancer of left ovary; ascites / removal 
of cancer ; return of pedicle to abdomen ; death of patient 
on eighth day, from septicaemia. 
Mary McC., aged twenty-one years, single, a cook by occu- 
pation, was sent to me by ber employer on account of an ab- 
dominal enlargement. Upon examination I found lier very 
sallow, almost jaundiced in appearance, very large about the 
abdomen, and exceedingly weak. She informed me that just 
one year before that time, she had noticed a slight abdominal 
enlargement, which had steadily and rapidly increased. At 
the same time she had emaciated rapidly, grown very weak 12 
OVARIOTOMY. 
and low-spirited, and now felt tliat, unless relieved very soon, 
she would die from exhaustion. 
Physical exploration revealed a large accumulation of 
fluid in the peritonaeum, and, in addition, a round tumor oc- 
cupying the whole of the left side of the abdomen. 
Although the case was not looked upon as a favorable one 
for operation, it was determined that, since extirpation offered 
the best chance for the saving of life, it should be resorted to. 
Accordingly, in the presence of Drs. Otis, Swift, Reynolds, 
Finnell, and Hull, I undertook the operation. 
The patient having been anaesthetized with ether, I cut 
down slowly through the abdominal walls into the perito- 
naeum. Instantly a large amount of peritoneal fluid escaped, 
a much larger amount, indeed, than had been computed in 
the diagnosis. After its escape, I found in the left side of the 
abdomen a solid mass about the size of a large cabbage, 
and resembling in feel and appearance an ordinary cauli- 
flower. This was attached to the broad ligament at about the 
point ordinarily occupied by the ovary. It was too large for 
removal through the small opening which I had made, but 
this being enlarged, it was readily turned out. Securing the 
pedicle, which was short, by two strong hempen ligatures 
passed through its centre, it was returned, after removal of the 
growth, to the abdomen, and the abdominal incision closed by 
interrupted silver sutures. 
The patient rallied well after the operation. She was kept 
upon beet-tea, milk, and gruels, and quieted by administration 
of opium. Tier pulse kept up to about 100, respiration was 
normal, and nothing existed to excite alarm except the ex- 
treme nervous depression of the patient. She asserted that 
she would certainly die, and really seemed convinced that 
such would be the case. With the exception of this symptom 
she appeared to be progressing favorably until the seventh 
night. Then she seemed more than usually nervous and ex- 
citable, and desired to see the priest, who was accordingly 
sent for. 
On visiting her early on the morning of the eighth day, 
I found that a great change had come over her during the 
night. Her eyes were wild and haggard, her face maniacal, OVARIOTOMY. 
13 
her tongue red and dry, and she constantly talked in an inco- 
herent and violent manner, as is so often found to be the case 
in puerperal mania. As I entered the room, she covered her 
head with the bedclothes, and screamed out that I had 
leagued with the priest to murder her. Nothing would pacify 
her, or dissuade her from this view. After soothing her for 
some time, I succeeded in getting near enough to her to find 
that the pulse was beating at 160 to the minute, and that the 
breath yielded a sweetish odor like sugar-cane. I was now 
convinced that she was suffering from septicaemia, and that the 
mania which had supervened was due to it. But, even with 
this knowledge, nothing could be done in the excited state of 
the patient. She remained in the maniacal state which I 
have described till evening, when she sunk into coma and 
died. No post-mortem examination could be obtained. 
Case IY.—Multilocular ovarian cyst; removal by short in- 
cision ; pedicle ligated with silk, and returned to the ab- 
dominal cavity / recovery. History recorded by Dr. Jas. 
L. Brown. 
MissC. AY., twenty-two years of age, consulted Dr. Thomas 
in tlie early part of December, 1867, with reference to an ab- 
dominal tumor which she had first noticed nearly a year pre- 
viously, and which had been growing rapidly during the past 
six or seven months. 
She stated that her general health had been excellent until 
September, 1866, when there began to be some irregularity in 
her menses. The periods became more frequent, occurring at 
intervals varying from eight days to a fortnight, the duration 
and quantity of the flow being about the same as before. In 
a short time her general health began to be impaired, and 
medical advice was sought on account of the menorrhagia 
which was supposed to be the cause of her ill health. Failing 
to receive any benefit from the physician first consulted, other 
advice was sought, and no less than twelve physicians, nearly 
all of them homoeopathic practitioners, were consulted with- 
out avail, before Dr. Thomas was asked to see the case. No 
vaginal or other physical examination was ever made or pro- 
posed by any of these gentlemen. The existence of the tu- 14 
OVAKIOTOMY. 
mor in the abdomen was first noticed by Miss W. some three 
or four months after the disturbance of the menses. At first 
she merely observed a hardness, which seemed to make its ap- 
pearance with the menstrual flow and subside with its cessation. 
In a few weeks, however, this hardness was found to be persist- 
ent and to be steadily increasing in area. With the growth of 
the tumor there was a corresponding depreciation of the pa- 
tient’s health, which had become very greatly impaired when she 
first was seen by Dr. Thomas. The menorrhagia was persistent 
during the whole of this period, the intervals never exceeding 
two weeks, and rarely extending beyond ten or twelve days. On 
examining the case, Dr. Thomas found no difficulty in recog- 
nizing the presence of a cystic tumor of the ovary, and recom- 
mended its removal by ovariotomy. The recommendation 
was accepted by the patient and her friends, and the opera- 
tion performed December 15,1867, by Dr. Thomas, with the 
assistance of Drs. E. R. Peaslee, J. B. Reynolds, Mintzer (of 
Philadelphia), and J. L. Brown. The external incision through 
the integuments was about three and a half inches in length, 
the internal incision through the peritonaeum being about half 
an inch less. The tumor was found to be multilocular, and 
the main cyst on being tapped discharged a chocolate-colored 
fluid of about the consistence of cream. A second cyst about 
half as large contained a clear gelatinous fluid of much greater 
consistency. After evacuating these and several smaller cysts, 
the sac was readily removed through the opening, no adhesions 
existing anywhere. The pedicle, which sprang from the 
right side, was transfixed by a needle armed with a double 
silk ligature and tied in segments, each ligature including one- 
half of it. The actual cautery was then applied to the cut 
edge, and the charred portions pared off with a scalpel, after 
which the pedicle was returned to the abdomen. 
A small quantity of blood which had found its way into 
the pelvic cavity was then carefully sponged out, and the 
wound was closed with six wire sutures, between which were 
inserted five pins after the manner practised in operations for 
harelip. A layer of soft cotton was placed over the wound, 
and an ordinary obstetrical bandage around the abdomen. 
The patient was then placed in bed, and ten drops of Magen- OVARIOTOMY. 
15 
die’s solution of morphine administered. The whole dura- 
tion of the operation, including the anaesthetizing, was just 
two hours. 
8 p. m.—Patient entirely recovered from the effects of the 
ether. No pain or nausea. Pulse 84, and tolerably full. 
16th, 9 a. m.—Passed a comfortable night, but did not 
sleep much. Pulse 86. No pain or nausea. Used catheter. 
8£ p. m.—Begins to he troubled with flatus. Otherwise com- 
fortable. Pulse 108. No nourishment except two tumbler- 
fuls of milk. Has been kept moderately under the influence 
of morphine. Used catheter. 
17th, 8|- a. m.—Passed a good night. No morphine since 
9 last evening. Pulse 84. Skin cool and comfortable. Mind 
bright and cheerful.—12 p. m. Condition about the same as 
in the morning. Has thus far taken no nourishment but 
milk, of which she drank about a quart to-day. No trouble 
from flatus since yesterday. Still obliged to use catheter. 
9 a. m.—Passed a good night. Pulse 84. Condition 
about the same as yesterday morning.—11 p. m. Has taken 
no morphine in twenty-four hours. Begins to suffer from irri- 
tability of the bladder; otherwise quite comfortable. Pulse 
88. Milk diet only. 
19th.—Suffering some distress from irritability of the blad- 
der ; otherwise comfortable. In the evening was able to evac- 
uate the bladder without the catheter for the first time since 
the operation. All the pins were removed to-day. Pulse 90. 
20th.—Pulse 96. All the sutures taken out to-day. Pa- 
tient comfortable, but quite weak. Ordered egg-nogg, sherry 
wine, and quinine. Pulse rose in evening to 108. 
21st.—Better in every respect. Pulse 86, and full. 
The convalescence of the patient was now uninterrupted 
until the 31st of December, wdien she was taken with an at- 
tack of peritonitis, which was confined to the right iliac region, 
and which, although it assumed quite a threatening aspect for 
two or three days, finally yielded to treatment, and the patient 
made a good recovery. The menstrual function was reestab- 
lished about two months after the operation, and has since 
been perfectly regular in every respect. 16 
OVARIOTOMY. 
P. S.—Since the foregoing account was written, the patient 
has been married. 
Case V.—Multilocular ovarian tumor ; removal l)y short in- 
cision / pedicle treated by clamp ; recovery. 
Mrs. Y., aged forty years, a native of Yew Jersey, married, 
and tlie mother of a large family, consulted me in the month 
of March, 1869, by advice of Dr. Van Riper, of Passaic, under 
whose care she had been. The patient was a thin, wiry, and 
enduring woman, who had enjoyed good health up to one year 
before the time at which I saw her. At that time she noticed 
an abdominal enlargement. This gave her no anxiety, as she 
supposed it to be due to pregnancy. She was somewhat sur- 
prised, however, to find that, in spite of its steady increase, 
she still menstruated, and as her periods occurred every two 
weeks after the sixth month was passed, she became alarmed 
and sought medical advice. For about six weeks before the 
operation which I am about to describe, she suffered from 
abdominal pain, but until that time she had not done so. 
About the same time she lost appetite, became somewhat de- 
pressed in spirits, and failure in strength and flesh was ob- 
served. 
When I saw the patient in March, I found an irregular 
nodulated tumor filling the abdomen. Toward the left 
lateral surface of the mass a protuberance, equal in size to the 
head of a newly-born infant, was formed, and below this 
others of less size could be discovered. Percussion over the 
abdominal surface yielded dulness, and palpation gave fluctu- 
ation distinctly. Vaginal touch revealed the uterus pressed 
forward and upward, and discovered no protrusion in Doug- 
las’s cul-de-sac. 
I looked upon the case as one of multilocular ovarian cyst, 
and advised operation, which was determined upon, and ac- 
cordingly performed on the 26th of April, 1869, in presence of 
Drs. Willard Parker, C. Van Piper, Pobert Stewart, W. J. 
Cadmus, J. II. Kenworthy, Garnet Terliune, P. A. Terhune, 
James L. Brown, and W. Linsley. 
The day was clear and the weather very comfortable. The 
patient being placed upon her back, on a firm table, before a OVAEIOTOMY. 
17 
window admitting a good light, ether was administered by 
Dr. Stewart. I then made an incision of two inches in 
length in the median line, exposed the tumor, and plunged in 
a large trocar and canula. There instantly gushed forth an 
albuminous looking fluid, which flowed until the largest cyst 
wTas emptied. Then turning the canula so as to plunge it into 
two others, which were quite large, I emptied these, and easily 
withdrew the sac, which was free from adhesions. The pedicle 
was then secured by a clamp, and the wound closed by inter- 
rupted silver sutures. 
The time occupied in the operation was forty-five minutes ; 
the weight of the tumor twenty pounds; and the amount of 
fluid removed from it a little over two gallons. 
Subsequent to the operation the case was carefully watched 
by Drs. Van Riper and Stewart, and the details which follow 
are taken from notes by the latter gentleman. 
“ Three hours after the operation, pulse 60, slightly inter- 
mittent ; surface cold; expression natural; no pain; says she 
feels happy; urine voided naturally; slight nausea. One 
grain of opium was given in pill. 
“April 27/4.—Rested well; expression good; no pain; 
pulse 70 ; tongue clean; urine voided naturally; respirations 
20 to the minute. She was given to-day beef-tea and milk, 
and just enough opium to quiet restlessness. 
“ April 28/4.—Called to patient on account of great pain 
down left thigh ; drew off urine with catheter, and gave one 
grain of opium, which relieved her. Pulse 60; respiration 20. 
“ April 29th.—Pulse 72; respiration 20; stump dressed 
with carbolic acid.” 
From this time onward the notes vary so little from those 
just given that it is useless to state them. The patient went 
on to recovery without an unfavorable symptom. On the 
seventh day after the operation the clamp was removed and 
the sutures withdrawn. The whole abdominal wound was 
found closed by first intention, except just around the pedicle. 
In a fortnight after removal of the tumor, the patient sat up in 
bed. How, six months after the operation, she declares her- 
self to be in better health than she has experienced for many 
years. 18 
OVARIOTOMY. 
Case VI.—Multilocular ovarian tumor; firm adhesions ; 
pedicle treated by damp ; recovery. Notes by Dr. Benja- 
min Riggs. 
Jolianna Murphy, aged forty, born in Ireland, a widow, 
was admitted to Bellevue Hospital, April 29, 1869. 
The patient states that she has borne three children ; that 
all her confinements were natural, and without bad results. 
She menstruated regularly till September, 1868, when she 
was seized with flooding two weeks before the proper time of 
menstruation. During the three months following she did not 
menstruate at all. In October, 1868, she first noticed a swell- 
ing of the abdomen, which since that time has steadily in- 
creased, but she does not know that it commenced on either 
side. From January to March, 1869, she menstruated regu- 
larly. In March she had a second attack of flooding, lasting 
six days, and leaving her very weak. Two weeks before ad- 
mission was flooding for about a week, and was much reduced 
in strength. 
Physical Signs on Admission.—The patient has a tumor 
of the abdomen, fluctuating at all points, dull on percussion, 
excepting tympanitic resonance on the left side, extending from, 
the ensifonn-cartilage to the pubes. Measurement between 
anterior-superior spinous process through the umbilicus twenty 
and a half inches, largest girth thirty-five and a half inches. 
On vaginal examination, the uterus is found movable, and 
no fluid seems to fill the cul-de-sac. The tumor does not seem 
to sag much in the flanks when the patient lies down. Some 
abdominal pain is complained of, and the patient is low-spirit- 
ed, wanting in appetite, and somewhat emaciated, though al 
ways of spare habit. There seems to be some mental derange- 
ment : she attributes her tumor to a rattlesnake which she sup- 
poses she swallowed while drinking from a pool some time 
ago. 
In May diuretics were tried without effect upon the tu- 
mor, which increased steadily though very slowly. During the 
early part of June a tonic treatment was adopted, and a gen- 
erous diet with some stimulants allowed, preparatory to an 
operation. In May and June there were several irregular 
and small discharges of blood from the uterus. OVAKIOTOMY. 
19 
On the 18th of June, the patient was in fair condition and 
spirits, and Dr. Thomas decided to operate. An anaesthetic 
being given, an incision about two inches long was made in 
the median line between the umbilicus and the pubes. On 
reaching the sac, a trocar was introduced with a canula of such 
construction that the sac and external coverings were clamped 
together, and leakage into the peritonaeum prevented. Sev- 
eral cysts wTere now discovered and successively emptied. The 
large one, which was first reached, contained clear, viscid fluid 
in large quantity. Two others contained grumous fluid full of 
flocculent lymph. The whole tumor was but slightly adherent 
in front, more strongly attached behind and below. 
After evacuating all fluid contents and separating the at- 
tachments, the mass wras withdrawn through the original open- 
ing, which was slightly enlarged before this could be done. 
The pedicle, of considerable length, was cut and retained by a 
clamp outside the wound, which was sewu up so as to grasp it 
tightly. Immediately after the operation there was consider- 
able shock. About thirty minims of Magendie’s solution of 
morphine wrere given hypodermically through the night, and 
eight ounces of whiskey by the mouth. Next day the pulse was 
full and under 100, no pain or restlessness. Urine drawn 
off every four hours. Wound dressed with wTeak solution 
of carbolic acid. In the evening there were restlessness and 
some vomiting; skin hot and pulse rapid. Fifteen minims of 
Magendie’s solution of morphine were given as before. 
June 20th, a. m.—Slept badly. Stomach irritable all 
night. Fifteen minims of the morphine solution were given 
hypodermically. 
June 21st.—Better, pulse about 80. Has some appetite. 
June 22d.—Pulse 80. Scarcely any pain. Condition im- 
proving. 
June 23d and 21th.—Pulse about 100. Appetite and gen- 
eral condition still improving. 
June 25th.—A week, less five hours, after the operation, 
the clamp was removed. A small abscess in the abdominal 
walls opening into the wound, treated by charcoal poultices. 
June 26th.—Bowels moved twice spontaneously. From 
this time convalescence went on rapidly without a bad symp- 20 
OVARIOTOMY. 
tom, and the patient was discharged perfectly well about the 
end of July. No abnormal increase in the size of the abdo- 
men occurred from the time of operation until that of dis- 
charge. 
Case YII.—Multilocular ovarian cyst; removal of four- 
fifths of the sac ; pedicle and ligatures left in the vagina / 
death from peritonitis. 
Mrs. Yan T., a native of Holland, forty-five years old, 
married, mother of one child; was seen by me in consultation 
with Dr. 1ST. S. Drake, of Brooklyn, in June, 1869. 
The tumor had been first observed about eighteen months 
before I saw her, and had steadily increased in spite of a va- 
riety of plans of local and general treatment which had been 
pursued under the advice of physicians whom she had con- 
sulted before calling upon Dr. Drake. Ho diagnosis had 
been made before Dr. Drake saw her. lie at once recognized 
the nature of the case, and requested me to see her in reference 
to operation. 
The patient, at the time I first saw her, was in good gen- 
eral condition, not emaciated, and quite hopeful as to the issue. 
The abdominal surface yielded dulness on percussion, and the 
sense of fluctuation could be readily appreciated. As there 
were no obscure points to be settled by paracentesis, I pro- 
posed operation at an early day. This was gladly acceded to, 
and accordingly on Sunday, June 27tli, ovariotomy was per- 
formed in presence of Drs. Drake, Hutchison, G. K. Smith, 
Turner, Simmes, and Mulhallan, of Brooklyn; and Drs. Peas- 
lee, Sands, and Jas. L. Brown, of Hew York. 
The patient having been brought fully under the influence 
of ether, an incision three inches long was made over the me- 
dian line between the symphysis pubis and the umbilicus. The 
peritonaeum being reached, a steel sound was swept over the 
circumference of the tumor, and by it universal, though very 
delicate, adhesions were found to exist. These were readily 
broken down, and a large trocar and canula were plunged into 
the cyst. A clear fluid like spring-water flowed away, and the 
cyst collapsed. This fluid was found to be slightly albumi- 
nous by the tests of heat and nitric acid. It resembled pre- OVAKIOTOMY. 
21 
cisely that wdiieh flows from cysts of the broad ligaments, al- 
though this cyst was certainly one of ovarian character. 
Traction being made upon the emptied sac, it came forth 
for about four-fifths of its extent, but farther than this it 
could not be drawn. I then enlarged the abdominal opening, 
and found that from the pelvis sprang extensive and powerful 
adhesions which bound down the whole base of the sac. I 
strove to break these, but it was slow and painful work, and in 
the end I was forced to leave in the abdomen about one-fifth of 
the sac. The pedicle was so short that I could not employ a 
clamp, and so large that I dared not leave it in the abdomen. 
I therefore secured it with a strong hempen cord, cut an open- 
ing into the vagina through Douglas’s cul-de-sac, and left cord 
and pedicle in the vagina. 
The peritoneal cavity was now so filled with clots of blood, 
that I did not wish to keep the patient anaesthetized for so 
long a time as sponging them out would require, so I intro- 
duced through the abdominal opening the long nozzle of a 
Davidson’s syringe, and cleansed the abdomen by a stream of 
warm water which swept all accumulations before it as it es- 
caped into the vagina. 
The patient was under the influence of ether from 3 to 5 
o’clock. The pulse, which was 80 to the minute at the com- 
mencement of the operation, remained so until the evening of 
the next day, about twenty-four hours, when it rose to 112. 
Symptoms of peritonitis then developed themselves, and she 
died on Wednesday at 5 r. m., precisely seventy-two hours after 
the operation. Subsequent to the operation she was fed on 
beef-tea and milk, pain relieved by opium, and the bladder 
kept empty by the catheter. 
Case YIII.—Alveolar cancer of both ovaries/ removal 
by ovariotomy y pedicles treated by actual cautery y death 
from peritonitis. Notes by Dr.Benjamin Riggs. 
“ Elizabeth Harrison, aged twenty-seven, born in New York, 
married, was admitted into Bellevue Hospital, April 28, 1869. 
u Patient is a remarkably robust woman. Has been married 
for two years, but has never been pregnant. She menstruated 
regularly every three weeks till January, 1869. Since January 22 
OVARIOTOMY. 
menstruation lias been irregular and painful, occurring, on an 
average, about once in two weeks, with a greatly increased 
loss of blood. In January slie first noticed a swelling in the 
left iliac fossa. Pain in the same region commenced about a 
week later. This swelling has rapidly increased, accompanied 
by a good deal of pain. The tumor is pyriform ; no sagging 
in the flanks. Obscure fluctuation only can be felt. June 9th, 
the abdomen is very full and tense, and there is excessive pain. 
The fluctuation is very obscure, and Dr. Thomas thinks the 
tumor may be colloid cancer. An exploratory trocar brought 
away fluid. Tapping was at once resorted to, and from four to 
five gallons of clear fluid were evacuated, to the patient’s great 
relief. The fluid was alkaline, viscid, and highly albuminous. 
For four days the patient was kept quiet by opiates, some 
soreness being complained of in left iliac fossa. This had dis- 
appeared on the fifth day, and the bowels were moved by enema. 
It was determined, with patient’s consent, to perform an oper- 
ation for the removal of the tumor, now presumed to be an 
ovarian cyst. 
“ June 2Qth.—Bowels thoroughly moved. June 27th, one 
grain of opium night and morning. June 28th, a. m., one grain 
of opium. 2f p. m., after freezing the parts, an incision was 
made down to the sheath of the rectus muscle, extending in the 
median line from an inch below the umbilicus nearly to the 
pubes. The fat through which the incision was made was fully 
three inches thick. By p. m. all oozing from the wound hav- 
ing ceased, the patient was anaesthetized, and the incision car- 
ried down to the peritonaeum, which since the tapping had par- 
tially refilled, but the abdominal walls were by no means tense. 
On opening this membrane, there was a gush of clear yellow 
fluid, and exploration showed that no ovarian cyst existed ; the 
fluid present being contained in the peritoneal sac. Attached 
to each ovary were found soft fungous growths—these were re- 
moved, and the parts from which they sprang seared with a 
red-hot iron. The peritonaeum was washed with a weak so- 
lution of common salt, and, all haemorrhage having apparently 
ceased, the wound was closed. Deep quill sutures wrere used, 
and the superficial edges of the wound were held together by 
pins and twisted silk at some points, at others by ordinary in- OVAKIOTOMY. 
23 
terrupted wire sutures. Anaesthesia was continued, in all, one 
hour and a half. Immediately before the administration of 
the anaesthetic, ten minims of Magendie’s solution of mor- 
phine were given hypodermically. 
“ After the operation, the patient slept through the after- 
noon and evening till about midnight, when there was some 
vomiting. Toward morning there was recurrence of vomit- 
ing, and she suffered pain in the abdomen. Her pulse was 105, 
About half a grain of morphine was given during the night. 
“ June 29th, 10 a. m.—Abdominal pain is complained of. 
Pulse 120; quarter-grain, of morphine given ; 2 p. m., vomits 
considerably. Later in the afternoon febrile excitement ran 
high, but she complained less of pain. During the night mor- 
phine was given. 
“ June 30th, a. m.—Pulse diminished in frequency and hard- 
ness ; skin cooler. At night she grew worse again, pulse 140 ; 
skin hot and dry. Toward midnight she became quieter, and 
slept. 
“ July 1st.—Vomits a good deal this morning ; p. m., vom- 
iting persistent; pulse 120. She takes nothing but a wine- 
glassful of champagne every half hour, followed by a little 
carbonic-acid water. 
“ July 2d.—Vomiting persisted, and pulse remained about 
120 till 3 a. m., when the patient began to fail in strength, 
the pulse increasing in frequency. The extremities became 
cold, and her face was covered with a clammy sweat. At 
noon the pulse was 140, and irregular; at 2 p. m., 165; at 
4 p. m., she died. 
“ Autopsy, July 3d.—Brain not examined. Heart 11 oz. in 
weight; flabby; valves normal. Lungs—hypostatic conges- 
tion at their bases; the right lung adherent. Liver, 3 lb. 
10 oz. in weight; adherent to diaphragm and stomach by old 
false membrane. Kidneys—nothing noticeable; weight 10 oz. 
Spleen, 3 oz. Bladder—mucous membrane congested. 
“ An incision ?-§■ inches long, extended through the abdomi- 
nal walls and peritonaeum. Peritonaeum separated from rectus 
muscle at its lower portion, and the cellular tissue at this point 
partly gangrenous. All the intestines adherent to each other 
and to the abdominal walls by recent lymph. Peritoneal cavity 24 
OVARIOTOMY. 
contains about 8 oz. of dirty-brownish sero-pnrulent fluid. 
There is considerable injection of peritoneal vessels. 
“ The organs in the pelvis adherent to one another by old 
false membranes. Left ovary gone, its site marked by lacerated 
tissue. Right ovary lacerated at one point, the major part of 
it remains in situ, it is swollen and vascular, and its vesicles 
for the most part contain small clots of blood. 
“Fallopian tubes, convoluted, dilated, adherent; the left 
contains bloody muco-pus. Uterus contains nothing but a 
small mucous polypus in its body.” 
I have spoken of this case and of Case III., as instances of 
alveolar cancer, not because I regard them as being true car- 
cinomatous disease, but because the question of their pathology 
is not settled, and I prefer rather to abide by the old nomen- 
clature than to discuss the matter. From a clinical stand-point, 
they certainly do not appear to belong to the family of true 
cancer. The appearance of the patient, the hue of the com- 
plexion, and the constitutional condition of those who are 
affected by them, seem to contradict such a supposition. To 
the touch and sight they resemble very closely cauliflower 
growths of the cervix uteri, and seem to belong to the family of 
vegetating epithelioma. My colleague, Dr. IT. B. Sands, kindly 
examined for me a portion of the growth taken from Case VIII., 
and thus describes its appearance under the microscope. 
“ Sections of the tumor, when examined under the micro- 
scope, exhibited the following elements: 1. Connective tis- 
sue, slightly vascular, arranged in the form of villi, either club- 
shaped or conical. 2. Flat epithelium, in several layers, 
covering the villi, but not present in their interior. The ap- 
pearances observed -were those commonly seen in epithelial or 
cauliflower growth.” 
Case IX.—Multilocular cyst, containing numerous large 
cysts • removed by short incision’ pedicle treated by 
clamp ; recovery. Notes by Dr. C. S. Ward. 
Annie Farrell, aged fifteen years, single, presented lierself 
at the clinic at the College of Physicians and Surgeons, Octo- 
ber 15, 1869, on account of an abnormal enlargement, which OVARIOTOMY. 
25 
she first noticed about one year and a half before, and which 
had been steadily increasing until it had now attained a size 
exceeding that of the uterus at full term of pregnancy. At 
the age of thirteen she menstruated once, since which time 
there has been no menstrual flow. Owing to this circumstance 
she had been led to believe that her increased size might be 
due to retention of the menses ; in fact, she stated that this 
opinion had been expressed by some physician whom she had 
consulted. She first noticed the tumor in the left iliac region ; 
it appeared to be smooth, and globular in shape. Five or six 
months later she noticed that it began to be irregular in out- 
line and nodulated. Within the last three months her general 
health had begun to fail, and she became much reduced both 
in flesh and strength. Her face was pale and sallow, and her 
general appearance cachectic. On physical examination the 
abdomen was found distended with a fluctuating tumor, im- 
bedded in which could be felt three smaller tumors of firm 
consistence. These were on the left side, and conveyed the 
impression of being solid masses. With a view to facilitate 
diagnosis as well as to afford temporary relief to the patient, 
Dr. Thomas tapped the tumor on the following day; about a 
gallon of clear fluid, of the consistence of thick mucilage, was 
discharged, which greatly relieved the patient. The seem- 
ingly solid tumors could now be felt more distinctly, and con- 
veyed the feeling of obscure fluctuation. 
The girl’s general condition became much improved, al- 
though the tumor began to refill, and at the end of three weeks 
was again as large as before. Ovariotomy now being the only 
resource, this operation was resorted to on the 4th of Novem- 
ber, 1869, in the presence of Drs. Peaslee, Budd, Norcom (of 
N. C.), Burgess, Howe, James L. Brown, H. F. Walker, and 
C. S. Ward. The patient being fully anaesthetized, an incision 
three inches in length wTas made in the median line, midway 
between the umbilicus and symphysis pubis, down to the peri- 
tonaeum ; after all haemorrhage had ceased, this was lifted, 
snipped, and slit upon a director, allowing a slight flow of 
serum, and exposing the tumor. A sound was swept around 
the tumor, and only one or two slight adhesions found, which 
were gently broken. A trocar was then plunged into the 
3' 26 
OVARIOTOMY. 
principal sac, which discharged a clear fluid like that drawn 
off at the previous tapping, and through this sac about a dozen 
other cysts of various sizes were punctured and the contents 
evacuated. The fluid in all these sacs was clear and limpid, 
but in some of much greater consistence than in others. All 
the cysts being emptied, the sac was readily drawn out and the 
pedicle secured by a clamp ; the tumor was then separated and 
the actual cautery applied to the cut surface of the pedicle. 
The other ovary was examined and found normal. The peri- 
toneal cavity was carefully cleansed by soft sponges squeezed 
out of warm water. The wound was closed by five sutures of 
iron wire passed through the skin and peritonaeum, the pedicle 
being left at the lower angle of the incision ; a pledget of lint 
soaked in a carbolic-acid solution was laid over it, and a binder 
applied, as after parturition. Five minims of Magendie’s solu- 
tion were injected subcutaneously and the patient placed in 
bed. Time of operation forty minutes. 
Progress of Case.—November Ath.—At 4.30 (immediately 
after operation) pulse 88 ; 10.30 p. m., 104; f gr. morphia given. 
November 5th.—9 a. m., pulse 100 ; rested well during the 
night; 6 r. m., pulse 122 ; skin moist, sleeping quietly, has had 
no pain. 
November (Sth.—9 a. m., pulse 120 ; took gr. morphia last 
night and rested well; 6 p. m., pulse 104; patient cheerful 
and comfortable, has taken three pints of milk and six ounces 
of beef-tea to-day. 
November 7th.—-10 a. m., pulse 102; rested well during 
the night; no morphia given ; 6 p. m., pulse 100; patient in 
fine spirits ; has taken milk, toast, beef-tea and steak. 
The patient has complained of no pain since the operation, 
no tenderness on pressure, no tympanites, wound looking well. 
Subsequent to this period the patient has gone on steadily im- 
proving until the date at which this manuscript goes to press, 
November 15. 
In this report are embodied nine cases of ovariotomy. Five 
of them resulted favorably and four unfavorably. Out of the 
four unfavorable cases, two were instances of so called alveolar 
cancer, one a solid tumor, and one a cyst, the whole of which 
could not be removed. Six cysts were operated upon. Of OVAKIOTOMY. 
27 
these, five recovered, and that which ended fatally was a case 
in which one-fifth of the sac had to be left in the abdomen. 
The operation of ovariotomy was only in two cases preceded 
by that of paracentesis. This was due to my desire to avoid 
an additional risk to my patients. I believe, however, that, in 
thus avoiding paracentesis, I committed a grave error. A 
more frequent resort to it would have cleared up many obscuri- 
ties as to diagnosis, and thus prevented resort being had to 
ovariotomy in at least one of my fatal cases. My experience 
thus far will induce me, in the future, to resort to it much 
more generally than I have done in the past. Case IX. recovered without an unfavorable symptom. 
The clamp was removed and sutures withdrawn on the eighth 
day.