PERSONAL EXPERIENCES IN LAPAROTOMY. BY MARY A. DIXON JONES, M.D. NEW YORK Reprint from the Medical Record, August 7, 1897 NEW YORK THE PUBLISHERS’ PRINTING COMPANY 132, 134, 136 West Fourteenth Street 1897 PERSONAL EXPERIENCES IN LAPAROTOMY. BY MARY A. DIXON JONES, M.D. NEW YORK Reprint from the Medical Record, August 7, 1897 NEW YORK THE PUBLISHERS’ PRINTING COMPANY 132, 134, 136 West Fourteenth Street 1897 PERSONAL EXPERIENCES IN LAPAROTOMY. MARY A. DIXON JONES, M.D. NEW YORK. My cases come within the period 1879 to 1889. I will now give my work, all that I have attempted or performed. My first case was that of a patient brought me from Maine by her husband; the tubes and ovaries were wrapped in a mass of disease. At the time it occurred to me that as these organs were incurable, and could be of no possible utility, they should be removed. This was the thought that forced itself upon me. I had not then heard of “Tait’s opera- tion” or of “oophorectomy.” So entirely engrossed had I been with my own practice that my medical journals were unopened, nor did I have time to think of the advance of surgery in any direction; but this procedure seemed so right, so self-evident, that I should have proposed it, had not attention, as I learned, been already called to it. I invited Prof. B, F. Dawson to see this patient with me, and on the day of the operation, imagining she might have a better chance if Professor Dawson performed it, I invited him to do so, and he kindly complied. So now, when it comes to the arithmetic of statistics, I cannot put this, my first patient, on my list. Dr. Dawson reported the case to the New York Obstetrical Society' and before his class in the New York Post-Graduate School, presenting the specimens on each occasion. My first laparotomy was performed October 18, 1884. The patient was brought to me from Connecti- cut by her parents, in June, 1884. She had been an invalid seven or more years—once she did not leave her bed for a period of eighteen months. After ex- amination I informed the parents that I did not be- lieve any amount of treatment would restore the organs to health, and that nothing would cure or relieve the patient but the removal of the hopelessly diseased structures. Still I advised treatment to see if an operation could not be avoided, or at least to get the patient in better condition. Careful and continuous treatment I gave this patient for four months; she may have improved somewhat in general condition, but I believe the organs were growing worse all the time, and in my report of the case I said the operation should have been performed years before; and now I say of her, as I can say of many or most of the pa- tients in this list, that if she had not had the opera- tion. she would long since have been in her grave. My second case of laparotomy was for bleeding myoma. The patient came from Maine to see me, March, 1885, and on May 19th I removed the uterine appendages. She made a most happy recovery. Sub- sequently with the microscope I studied carefully the tubes and ovaries of this patient, to see what path- ological changes might have taken place. In the tubes I found chronic interstitial salpingitis, and the ovaries were in acute and subacute inflammation. It was in the ovaries of this patient that I for the second time recognized diseased ova. In other cases of re- moval of the uterine appendages for myoma, I have made a thorough study of the pathological conditions of the appendages, and in every instance have found in them profound and chronic disease; so that I re- marked, in an article in the New York Medical Jour- nal of September 1, 1888, that in cases of fibroid of the uterus the tubes and ovaries were always so dis- eased that on that account their removal was de- manded; and that probably this disease of the appen- dages caused the development of the myoma. Of this I have, from subsequent research, become more con- vinced. My third case of laparotomy was also for a helpless invalid, who for fifteen years had been suffering and had been refused admission into two hospitals, having been informed at one institution that “the hospital did not receive incurables.” I admitted the patient into my private hospital. She made a most excellent recovery. Every patient in the following list of laparotomies has an interesting history. The cases are from my private practice, from two dispensary clinics, and six patients were sent me by physicians. One of the dis- pensaries referred to had from eight to twenty patients daily, the other had from twenty to forty-five; and, what is a singular circumstance, in the first dispensary I seldom found a case of “pus tubes,” while in the second I had them every day, and have counted in one clinic as many as seventeen patients with this disease. We could not possibly operate on all who needed operation, so for my cases I selected the patients who seemed physically to be in the most serious or dangerous conditions; and thus it trans- pired that I, without understanding the disease, had many cases of endothelioma of the ovary—a disease which I was first to recognize, and which at the time I submitted to the kindly consideration of the medical profession. Few diseases make such serious inroads upon the system, cause more pain, or have more pro- nounced symptoms. There are marked emaciation and, in advanced cases, almost the cadaveric hue of cancer or consumption, and a general cachexy of the system. The first patient in whom I recognized this disease was one on whom I had operated on June 25, 1885. Dr. Charles Heitzmann, in looking at the long protoplasmic masses of this growth, at first pronounced it “ sarcoma,” and subsequently said: “ We shall have to term it either endothelioma or alveolar sarcoma.” The next case in which I found this disease was that of a patient on whom I operated for the removal of the uterine appendages, May 10, 1887 (Case No. 23). This patient was so emaciated, so cadaveric, that I at first thought she had phthisis, or, more likely, can- cer of the liver. I presented the uterine appendages before the New York Pathological Society the same month, and, subsequently, microscopical slides of the growth. Also, Prof. Mitchell Prudden, then president of the society, at my request took a small section from each of the ovaries of this patient, and had them mounted in his laboratory. He wrote me it was “car- cinoma,” also sending a slide so labelled. I sent a microscopical slide of these ovaries, mounted by Dr. Louis Heitzmann, to Professor Waldeyer, of Berlin. He replied, October 18, 1887, that “the growth is carcinoma;” and certainly, in studying the minute anatomy of this growth I could readily believe it might be some form of cancer. I am still more impressed with this when I see the effects of the disease upon the system, as I said in an article in the New York Medical Journal, September, 1889: “When we look at this rapidly growing formation and the great masses of granules, the impression forces itself upon us that it may be malignant. Future investigation may prove it so. The cancer epithelia do not multiply more rap idly, or destroy the tissues more surely, or seem more threatening or monstrous in their appearance and growth.” While in this list I have included all my cases of laparotomy, whether for splenectomy, hysterectomy, or ovariotomy, yet most of the operations were for the removal of “diseased uterine appendages.” Some eminent surgeons, as they have thought proper, have removed the uterine appendages for “ ovaralgia,” “ dvs- menorrhcea,” and various nerve conditions; but I never could accept this idea. I have all the time main- tained that whatever might be the symptoms, local 01 constitutional, the tubes and ovaries should not be re- 1 May 15, 1883. American Journal of Obstetrics, 1883, p. 1,192. PERSONAL EXPERIENCES IN LAPAROTOMY. 3 moved except for profound disease of the organs them- selves, when they are incapable of being restored to health, and when their remaining becomes a positive injury to the system. I said in 1888,1 and now repeat: “ I have never operated on a case but I had full and substantial reasons to diagnose incurable disease of the appendages;” in the same article declaring: “I would not remove the uterine appendages for mental or neurotic diseases unless I believed the appendages were diseased,” and the disease absolutely demanded their removal. I have even hesitated in some instances to remove the uterine appendages when they were pro- foundly diseased, and when there were indications even apparently necessitating an immediate operation. A patient, twenty-three years old, entered the Woman’s Hospital, July 5, 1887. One ovary was enlarged to the size of a small orange and bound in on all sides by adhesions; the tubes gave evidence of pyosalpin- gitis. But this patient had had a child thirteen months before! If these organs are capable of these functions, why not leave them? Any one might have known that with conditions existing as they were in this woman it was impossible for conception to take place; but I wanted to give her the millionth part of a chance, so sincerely do I congratulate a woman who has chil- dren. The patient was in the hospital forty-six days and everything w as done to improve her condition; she seemed in many respects much better and compara- tively comfortable, so on the 20th of August I dis- missed her from the hospital and sent her home. As soon as she commenced to be on her feet and go around, she realized that her sufferings were just the same, and just as intolerable. She returned to the hospital three days afterward, and again begged that the operation might be performed. In due time it was done. This is Case No. 33. The patient was in a dangerous condition, and should, when first in the hospital, have been operated upon without delay. Not only was there destructive disease of the tubes, but a blood cyst in the left ovary was in immediate danger of rupturing, with possibly fatal results. Be- sides, to show still more plainly how futile was the delay, every ovum in both of her ovaries was in help- less ruin. Another patient to whom I tried in the same way to give the possibility of a chance—subsequent events proving it was quite as useless—entered the Woman’s Hospital of Brooklyn, March 21, 1888. Hoping to save the tubes and ovaries, I gave her special local and constitutional treatment. She improved, and dismissed her April 17, 1888. After returning home she realized that her trouble was still there, and of her own accord she returned to the hospital in four days, and again requested that the diseased organs be removed. This is Case No. 59. In this instance also I realized that it was not only a useless but a dangerous delay. In September, 1888, Dr. B , of Bridgeport, Conn., brought a young woman, twenty-six years old, married three years, and without children. In my report of this case, in the Pittsburg Medical Review,2 October, 1889, I said: “It seemed so extremely sad for one so young and so lately married to be deprived of all chance of the sacred privilege of motherhood, that I suggested to Dr. B that the patient return home and have the cervix dilated and the anteflexion corrected, and thus give her, if possible, a chance.” The patient at once objected to any delay, insisted upon immediate relief, and the physician added: “Treatment has been tried.” This is Case No. 69. There was immediate demand for the operation. The pathological conditions showed that it should have been done without delay, even before the time the patient visited me. In every case that I have operated on I have, in studying the pathological specimens removed, become more impressed that not only was there, in each in- stance, a necessity for the operation, but in each one it should have been done at an earlier period than it was performed. The great danger in these conditions is delay; and this delay is an injustice and a loss to the patient. As to delaying these operations for a possible conception, in every one of these patients, as was subsequently demonstrated, all capability of any physiological functions of the tubes and ovaries was destroyed by the existing disease; and in every one this complete destruction was still further emphasized by finding in the ovaries of each, as far as examined, only diseased and ruined ova. In some, even of young women, I found complete destruction of these important structures, not one egg in either ovary; thus giving new proof of and new insight into what I said in 1886,1 and repeated Sep- tember 28, 1889:2 “The disease that caused the suffering has also produced a profound sterility.” After careful study into the pathology of every speci- men I have removed, I again repeat, as was my im- pression on the first examination of the various pa- tients, that not only was there a necessity for the operation, and that in each case the operation should have been done at an earlier period, but in every in- stance, as I told the patient, there was no capability or possibility of conception. My stereotyped expres- sion, repeated to many, was: “With or without the operation, you can’t have children.” The operations were done to save life, and if possible to restore to health and active usefulness. Of all the cases, there were of pyosalpingitis sev- enty-nine. Not only did the tubes contain pus, but their walls, as I afterward demonstrated, were more or less destroyed by suppurative inflammation. The ovaries were equally diseased. These all involved difficult and dangerous operations. There were two operations for cystoma, or ovarioto- my. Probably these were the least difficult of all the operations in the list; even the removal of a cystoma that contained over sixty pounds of fluid (Case No. 89) was in no way a difficult operation and was performed with great ease and celerity. Yet a writer uses this expression:3 “I have long entertained the opinion that ovariotomy is the most difficult operation in the whole field of surgery.” I must differ from the writer, for I have long maintained the belief that ovariotomy generally is one of the least difficult operations of abdominal surgery. Duncan says:1 “It cannot be too strongly enforced that removal of the appendages for chronic disease is, in most cases, much more diffi- cult than performing ovariotomy.” Dr. G. Bantock says:5 “ Difficulties far exceeding those of nine out of ten of the ordinary run of ovariotomy.” Sir Spen- cer Wells on the same occasion: “It is more difficult than ordinary ovariotomy.” Dr. A. Martin, of Berlin: “ The operation is not only difficult, but dangerous.” Lawson Tait: “It is in almost all instances a difficult operation, sometimes one of exceeding difficulty.” Dr. L. S. McMurtry6 gives his testimony: “To remove pus tubes and adherent ovaries is among the most severe tasks of operative surgery.” And Dr. Thomas Keith, nearly thirty years before, said: “ There is no 1 Medical Record, August 21, 1886, p. 19S. 2 New York Medical Journal, September 28, 1889, p. 337. 3A. J. C. Skene: Proceedings of the Medical Society of the County of Kings, June, 1883, p. 222. “ Diseases of Women,” p. 510, 1888. 4 British Medical Journal. 5 Transactions of the International Congress, 1881, p. 294. 6 Southern Surgical and Gynaecological Transactions, 1889, p. 202. 1 American Journal of Obstetrics, February, 1888, p. 158. 2 Page 301. 4 PERSONAL EXPERIENCES IN LAPAROTOMY. mystery in ovariotomy; it is not a difficult opera- tion.” But certainly there is often great difficulty, and mys- tery too, in leading out diseased uterine appendages from a complexity of dense adhesions. So difficult is this that Dr. Thomas Savage, of Birmingham, said 1 that in five of his forty cases he was unable to do any- thing beyond the simple abdominal section, on ac- count of the strength and character of the adhesions; adding: “In others I was obliged to leave behind a part of one ovary at least.” Dr. C. E. Penrose, in reporting eleven cases, remarked: “In one case I found it impossible to remove the left tube and ovary, they were so firmly adherent.” A similar record has been made by many great surgeons. In this list there was one case of cancer, No. 55, carcinoma on the floor of the pelvis,2 and the can- cerous material had infiltrated the tubes and ovaries. At the time of the operation, March 19, 1888, so convinced was I of the malignancy of the disease and the hopelessness of the case, that immediately I in- formed the husband that the patient probably would not live three days. But she did so well and made so good a recovery that I dismissed the idea of malig- nancy until the following December, when, in due course, studying the pathology of this specimen, I found that it was not only cancer, but cancer of the most ma- lignant type. In the specimen there were really three forms of cancer—scirrhous, adenoid, and medullary. Further, in studying this pathological specimen, it was seen for the first time and clearly demonstrated that the indifferent or medullary corpuscles were changing to large polyhedral epithelia, and forming cancer nests. This change of inflammatory corpuscles to cancer epithelia had never before, so far as I know, been observed or mentioned. It was a startling thought. Also in this specimen there was revealed the inter- esting fact that the lymph vessels carry the cancer epi- thelia. This had long been supposed to be the case, but so far as I know had never before been verified or demonstrated. Under high powers of the microscope the lymph vessels were clearly seen to be largely di- lated and carrying their burden of cancer epithelia. It was a revelation!—marvellous!—to see these vessels so crowded and so infinite in number! Another fact to be noted: This patient had suffered for years with the continued distress and irritation of diseased uterine appendages. If, ten years previously, these organs—even then profoundly diseased—had been removed, the unfortunate woman might have been saved not only the infection of her system from the diseased tubes and ovaries, but the subsequent devel- opment of cancer. Dermoid cysts, one case (No. 34). This was one of the most difficult and dangerous of the whole list of operations. The case was reported to and the spec- imens were presented before the New York Pathologi- cal Society, September 28,1887. Dr. William Goodell said:3 “In my experience dermoid cysts are very apt to have firm and extensive attachments, which make their removal far from easy.” Dr. Thomas Keith reports a dermoid cyst;4 so far as I could make out the conditions, they were very similar in every respect to those in my case—ovaries in each universally ad- herent. The operation performed by Dr. Keith lasted three and one-half hours, and the patient died thirty- six hours later. In my case of dermoid cyst the pa- tient made a rapid recovery, and subsequently had good health. The number of cases of abscesses of, or connected with the ovaries was twenty-eight. Dr. Lawson Tait said: “In a majority of instances probably death oc- curs from the rupture of the abscess into the perito- neum.” He reports' one case before the British Gynaecological Society, and says: “Operation ex- tremely difficult, and hemorrhage severe.” Intraligamentous cysts, one case (No. 62). Dr. Goodell says :2 “ Intraligamentous cysts present griev- ous complications, which tax the pluck and skill of the operator to the utmost.” Dr. Paul F. Munde says :3 “ They are to me the most formidable tumors of the uterine appendages; three out of live deaths after lapa- rotomy occurred in intraligamentous cysts.” My pa- tient (No. 62) made a rapid recovery. Endothelioma, twenty-two cases. This is a more frequent and a more serious disease than many imag- ine, not only causing much suffering but being destruc- tive to health. I believe an untold number of women have died from this disease or from the complications arising therefrom. Of haematoma, the outcome of endothelioma, there are ten cases. Dr. Howard Kelly, before the Obstetri- cal Society of Philadelphia,4 exhibited a specimen of haematoma of the ovary with adherent Fallopian tubes, remarking: “The haematoma is about the size and shape of a large Spanish chestnut. The indications for operative interference, after I had made my diag- nosis, were greater than in the case of any large ova- rian cyst I have ever seen, and the prospects ana re- sults of any form of palliation were futile. Almost the whole of this large ovary is filled with a bloody cyst.” Dr. A. P. Dudley reported to the New York Pathological Society6 a haematoma of the ovary, occupy- ing nearly the entire organ, for which previous to its removal he had “for a year adopted every variety of general internal treatment, with external applications, but the woman was not in the least relieved.” Dr. Boldt has reported a rupture of haematoma, or blood cyst, and states that but for immediate operation death would have ensued. Dr. R. H. Reed says:' “Early surgical relief is the only safe and reliable course of treatment.” Dr. R. A. Murray reported a haematoma of both ovaries,7 saying: “There was an extreme amount of adhesions, which rendered the operation most difficult, prolonging it three hours.” Gyromatous cysts, eight cases. Gyroma is another disease which I was first to recognize. These cysts have hard, firm walls, sometimes in waxy degenera- tion, or in intense inflammation, or again are being reduced to firm fibrous connective tissue'—in any state necessarily compressing delicate nerve fibre, and giv- ing rise to various neuroses and reflex irritations.6 As I said in the New York Medical Journal, May 10, 1890: “The irritation of these hard, firm growths amid the delicate tissues of the ovary not only causes pain, but, if anything would produce cancer of the ovary, the continued irritation of these nodular masses would seem to be sufficient.” Blood cysts, also the outcome of endothelioma, twelve in number. From their nature, growth, and mode of development, blood cysts are most serious conditions, constantly causing great pain and distress, and ever there is an increasing danger of their ruptur- ing into the peritoneal cavity, possibly with fatal re- sults. In every case of blood cyst that I have had, I have carefully examined with the microscope all other portions of the ovary, and in every instance have found all profoundly diseased, no normal tissue in 1 British Medical Journal, May 8, 1886, p. 881. 2 Medical News, January 29, 1887. 3 American Journal of Obstetrics, January, 1888, p. 15. 4 February 4, 1886. 6 October 26, 1887. 6 Cincinnati Lancet-Clinic, January 28, 1890, p. 775. 1 Medical Record, January 18, 1889, p. 79. 8 American Journal of Obstetrics, February, 1888, p. 158. 1 British Medical Journal, October 19, 1878, p. 590. 2 Medical Record, March n, 1893, p. 292. 3 Medical News, March 11, 1885, p. 316. 4 British Medical Journal, October 19, 1878, p. 591. PERSONAL EXPERIENCES IN LAPAROTOMY. 5 Number. ff Name. V be < V B CO Number of Children. Date of Operation. Place. Pathological Conditions. Operation. Who Present. Adhesiops. Result, Recovery or Death. Remarks. Where Reported. 1 Miss A i. Corning. 20 s. O Oct. ix, 1884. Her home. Pyo-interstitial salpingitis. Uterus in extreme retro- version; ovaries enlarged six or eight times their nor- mal size, dislocated downward, and exceedingly tender; intense oophoritis, in many places commencing sup- puration; ova diseased and ruined. Removal of uter- ine appendages. Drs. W. G. Wylie, ’ J. H. H. Burge. C. N. D. Jones, J. Merritt. Yes. R. The patient said she had been sick for seven years; once did not leave her bed for eighteen months. Suffered with extreme pain. It would have been better for the patient if these diseased organs had been removed years before. N. Y. Med. Rkc., April 16 1885; N. Y. Med. Jour. May 10, 1890; Buff. Med andSurg. Jour.,Nov.,1892 2 Mrs. O. 35 M. 2 May 23, 1885. My private hospital. Bleeding myoma. Intramural and two subperitoneal fibroids; salpingitis; ovaries more than three times their normal size, and projecting from each one a cyst the size of a hen’s egg; acute and subacute oophoritis; few ova and these diseased. do. Drs. C. C. Lee, C. N. D. Jones, S. King, E. J. C. Minnard. Yes. R. The patient made a rapid recovery; sixth day, pulse and temperature normal; twenty-fifth day she left the hos- pital. When last heard from she was in excellent health. N. Y. Med. Rec., Aug. 21, 1886. 3 Miss S . McN. 35 S. Q June 2 5, 1885. Private hos- oital. Endothelioma, or alveolar sarcoma of the ovary. Tubes dilated and closed at their fimbriated extremity. For fifteen years the patient had suffered with lacinating pains in the pelvis. do . Drs. W. G. Wylie, C. N.D. Jones, S. King. Slight. R. Many thought the patient would not survive the opera- tion, but after it was performed she gained rapidly in health, strength, and vigor. N. Y. Med. Rec., Aug 21, i88y Buff. Med. anc Surg Jour., Nov., 1892 N. Y. Med. Jour., Sept 28. 1889. N. Y. Med. Rec., Aug. 21, 1886. 4 Mrs. 1 23 j M. O Oct. 3 i , 1885. do. Pyo-interstitial salpingitis. The transparent attenuated walls of the pus tubes seemed ready to burst; they were bound by firm adhesions to the enlarged and dis- eased ovaries. do. Drs. W. G. Wylie, C. N. D. Jones. Yes. R. L The patient had constant pain and soreness in the pelvis; seven years she had suffered; she made an excellent recovery. The husband wrote that “ he could not have imagined she would ever be so well.” Is Mrs. McK. ? M. O Dec. 1 0, 1885. do. Pyo-interstitial salpingitis. Ovaries small, hard, and nodular; almost the whole normal structure was re- placed by cicatricial tissue; endothelioma of the ovary; abscess near the peritoneum. do. Drs. C.N.D. Jones, Carey, E. J. C. Minnard. Yes. R. Epileptic attacks at every monthly period; patient made an excellent recovery, was up and around at the end of the second week, and when last heard from had had no return of the spasms. do. 6 Mrs. D. 21 M. O Jan. 23, 1886. do. Pyo-interstitial salpingitis. In the left ovary an abscess occupying nearly the whole structure; right ovary in a state of intense oophoritis. do. Drs. W. G. Wylie, Jones, Ingalls. Yes. R. Patient wrote March 2, 1886: “ I am feeling perfectly well, never felt better.” do. 7 Mrs. S. 26 i M. 2 Feb. 1 0, 1886. do. Pyo-interstitial salpingitis. Each tube was bifid, and had two distinct sets of fimbria; ovaries atrophied, and in a state of acute and subacute oophoritis. do. Drs. C. N. D. Jones and Ingalls. Yes. R. 1 The patient had suffered five years great pain and dis- tress; not able to atterfd to her household duties; she made an excellent recovery from the operation; third day, pulse and temperature normal, and since she has had excellent health. do. 8 Miss E. S. S. O March 31, 3886. do. Uterus anteflexed and bound down by adhesions; tubes in a state of salpingitis; ovaries in acute inflammation; the right one contained a hsematoma. do. Drs. Jones and In- galls. Yes. R. The patient had been suffering for five years; the oper- ation was attended with great difficulty on account of firm and dense adhesions. do. 9 IO i Miss B. Mrs. C. j' 1 S. M. O O April 6, 1886. June 29, 1886. do. Woman’s Hosp i t a 1 of Brook- lyn. Pyosalpingitis. Abscess in right ovary; oophoritis; waxy degeneration of the arteries. Pyo-interstitial salpingitis. Ovaries enlarged to three and one-half inches in diameter, each one containing a blood cyst, the rest of the tissue in intense inflamma- tion; in many sections no ova, and the few found were in intense inflammation or waxy degeneration. do. do. do. Drs. C. N. D. Jones and Caroline Pease Yes. R‘ For five years patient had suffered with almost constant pain in the pelvis; by operation she was relieved of her suffering and restored to health. The ovaries and tubes were bound down by dense firm adhesions; the patient made an excellent recovery. do, N. Y. Med. Rec., Aug 28, 1885, p. 252. XI Miss G. S. O July, 1886. do. Chronic interstitial salpingitis. Peritonitis; suppurative oophoritis; destruction of the ova. do. Drs. C. N. D. Jones and Samuel King. Yes. R. The patient suffered great pain, was unable to work; after the operation she had excellent health. ?2 Mrs. S. )• M. O July, 1886. do. The patient was brought to the Woman's Hospital with septic peritonitis; the tubes contained pus, and the ovaries were in suppuration. do. Yes. D. There was apparently no hope when she was brought to the hospital; her whole system was septic. *3 Miss S. S. 1 S. O Jan. 22. 1887. do. The right ovary containing an abscess was enlarged to three inches in diameter and dislocated low down in Douglas’ cul-de-sac; ectasia of the lymph vessels; much of the stroma was transformed into a fine globu- lar hyaline mass; ova were destroyed. do. Yes. R. i Before the operation the patient suffered constant and intense pain in the pelvis and was not able to perform her daily duties; after the operation she was well and vigorous; third day, pulse and temperature normal. N. Y. Bath. Soc., March, 1887; Am. Jour. Obst. Feb., 1888. «4 Miss Kattie. S. O Jan. 26, 1887. do. Salpingitis. Gyromatous cysts; intense oophoritis; in the dense walls of the gyromatous cysts were found im- prisoned delicate nerve fibres; all ova were diseased, some in waxy degeneration. do. Yes. R. The patient had been sick for years; after the operation her health was excellent. do. >5 Mrs. L. 36 i i M. P Jan. 28, 1887. do. Interstitial and catarrhal salpingitis. Ovaries enlarged, exceedingly sensitive, and low down in Douglas’ cul- de-sac; endotheliomatous growths extending to the periphery of the ovary; intense oophoritis; no ova; blood-vessels waxy. do. 1 Yes. R. The patient recovered from the operation without a bad symptom; at the end of the third week was able to assume the burdens of her household duties; March 10, 1887, she was the picture of health, suffering no distress, strong, and able to work; in July, 1889, she had so improved that her physicians did not recognize her. The patient made an excellent recovery; said “ she had not been so well for twenty years. ’ ’ N. Y. Med. Jour., May ia and 17, 1890, case 7; Am. Jour. Obst., Feb., 1888. i6 Mrs. M. t • M. I March 9, 1887. do. Bleeding myoma of the uterus. Hemorrhage for the last five months without a day’s intermission, appen- dages diseased; inflammation of the ova and salpin- gitis. do. Yes. R. Am. Jour. Obst., Feb., 1888. 6 PERSONAL EXPERIENCES IN LAPAROTOMY. | Number. II Name. •a8y State. | N umber of 1 Children. Date of Operation. Place. Pathological Conditions. Operation. Who Present. Adhesions. Result, Recovery or Death- Remarks. Where Reported. 17 Mrs. N. M. 3 March 14, 1887. Woman’s Hosp i t a 1 of Brook- lyn. Suppurative parenchymatous salpingitis. Ovaries in in- tense inflammation; in some places commencing sup- puration; large gyromatous cysts; endotheliomatous growths; ova diseased and ruined. Removal of uter- ine appendages. Yes. R. The uterus retroverted; the appendages enlarged, sensi- tive; and low down in Douglas’ cul-de-sac; the patient made an excellent recovery; the temperature the sec- ond day after the operation was three-fourths degree better than the day before, and the third day it was normal, which it had not previously been for months. Am. Jour. Obst., Feb., 188& 18 Mrs. M. M. 1 April 6, 1887. do. Chronic interstitial salpingitis. Peritonitis; acute and subacute oophoritis. do. Yes. R. Her whole system was becoming septic; she made an ex- cellent recovery. do. *9 Miss C. 28 S. O April 11, 1887. do. Each ovary enlarged into a blood cyst. Endothelioma changing to angioma and haematoma; remaining tissue of the ovary was in intense inflammation; only two ova were found, and they were in waxy degeneration. do. Yes. R. The patient suffered for years with intense pain in the pelvis; after the operation she gained in strength, health, and flesh, and wrote, June 4, 1889: “ I am in perfect health, after fifteen years of suffering.” N. Y. Med. Jour., Sept. 28 1889; Buff. Med. Jour, Nov., 1892. 20 Mrs. F. M. O April, 15, 1887. Pyo-interstitial salpingitis. Suppurative oophoritis; tubes were enlarged and contained pus; small abscess in the walls of the tubes; tubes and ovaries bound down by dense adhesions. do. Dense and thick. D. The patient had been sick twenty years; had had re- peated attacks of peritonitis, and specific constitutional disease rendered her whole system septic. 21 Mrs. F. M. 2 April 1 5, 1887. do. Blood cyst in the ovary. Endothelioma; intense oopho- ritis; waxy degeneration of the ova; mental disturb- ance. do. Dr. C. N. D. Jones. Adhesions. R. The patient had suffered for some years, was unable to attend to her household duties; after the operation she regained her health and improved in mental condition. 22 Mrs. F. M. 2 April 2 s, 1887. do. Pyo-interstitial salpingitis. Pelvic peritonitis; right ovary and tube were high up and adherent; left ovary and tube also fixed by firm adhesions, and in some places bound to the colon and to the appendix vermiformis. In the ovary, endotheliomatous growths, gyromatous cysts; intense oophoritis; ova m waxy degeneration. do. do. Dense. R. For five years the patient had suffered intense pain in the pelvis; she was emaciated, feeble, and not able to go around; after the operation she gained rapidly in strength and vigor, and was able to attend to her daily vocations. N. Y. Path. Soc. 23 Mary L . Webster. M. O May 10, 1887. do. Both ovaries were enlarged, prolapsed and painful to the slightest touch. Each contained a forming blood cyst; endothelioma changing to haematoma; portions of both ovaries were in a state of myxomatous degen- eration, some portions showing intense oophoritis; ova were all diseased and ruined, not a normal one in either ovary; salpingitis of the tubes. do. do. Slight. R. The patient came with her mother to consult me, March 30, 1887; she was pale, emaciated, cachectic, and had apparently tuberculous consumption; she said she had constant pain on each side of the pelvis, severe, sharp, and lacinating, and that she had suffered for years. N. Y. Path. Soc., May, 1887; Dec. 12, 1888; N. Y. Med. Jour., Sept. 28, 1889; Buff. Med. and Surg. Jour., Nov., 1892. 34 Mrs. Mar- garet Gun- ther. M. 8 May 21, 1887. do. Left ovary enlarged into a blood cyst. Right ovary, cavernous angioma; small lakes of blood, or endothe- lioma changed to haematoma. Other portions of the ovary were intensely inflamed. do. do. Adhesions. R. The patient was emaciated, cachectic, and had all the ap- pearance of phthisis; after the operation she was re- lieved of pain, gained flesh and strength, and was able to do the household work and washing for a fam- ily of eight persons; hernia was developed. N. V. Path. Soc., Sept.,1887; N. Y. Med. Jour., Sept. 28,1889; N.Y. Med. Rec., Sept. 6. 1890; Buff. Med. Jour., Nov., 1892. 25 c6 27 28 Mrs. B. Mrs. S. Mrs. V. Mrs. E. M. M. M. M. 3 0 3 0 May 20, 1887. June 1 , 1887. June 2, 1887. June 10, 1887. June 20, 1887. do do. do. do. Both ovaries enlarged, prolapsed, and extremely sensi- tive; the right, pear shaped, measured two inches in diameter, and both were filled with an endothelioma- tous growth in a far-advanced stage; lakes of blood corpuscles; the ova in both ovaries were ruined. The uterine appendages were bound down in dense ad- hesions from repeated attacks of peritonitis. Pyo- salpingitis and oophoritis. Suppurative oophoritis and gyroma. The rest of the ovarian structure was in intense inflammation. Ovarian cystoma. do. do. do. do. do. do. do. do. do. Dense. Adhesions. do. R. R. R. R. Before the operation the patient complained of distress and cramps, and extreme pain in the pelvis; not able to be around; she made an excellent recovery, and wrote: “ I am able to work and am entirely well.” The patient had been sick twenty years; after the oper- ation her condition greatly improved. The patient was weak and feeble, and suffered with con- stant pain in the pelvis; after the operation she gave every indication of good health, both of body and mind. The patient made a good recovery. N. Y. Med. Jour., Sept. 28, 1889; N. Y. Path. Soc. 29 M«*s H. S. 0 do. Pyo-interstitial salpingitis. Tubes full of pus; adhe- sions so large and firm that many had to be ligated and cut. In the walls of the tubes and in the peri- toneum were many miliary abscesses; ovaries in in- tense inflammation; large gyromatous cysts; walls waxy; no ova. do. Dr. A. M. Jacobus. Very dense. R. The patient complained of constant pain in the pelvis, sometimes agonizing; unable to perform any kind of labor; fourth day after the operation, pulse and tem- perature normal. N. Y. Path. Soc., Sept. 28, 1887. 3° Mrs. T. M. 0 July, 1887. do. Pyo-interstitial salpingitis. Ovaries enlarged, extremely sensitive, and with the adherent tubes dislocated low down behind a retroverted uterus; intense acute and subacute oophoritis; gyromatous formations; diseased ova. do. do. Dense. R. The patient complained of constant pain and distress in the pelvis; was not able to be out of bed; pulse, 120; temperature, ioi° F.; weighed seventy pounds; hadin- dications of insanity, talked of self-destruction; after the operation her mental and nervous conditions im- N. Y. Med. Jour., May 10 and 17, 1890, case it; Buff. Med. and Surg. Jour., Nov., 1892. 3* Mrs. Kate Helms. M. 0 July 18. 18S7. do. Pyo-interstitial salpingitis. The uterine appendages wrapped in a dense mass of adhesions, and adherent to the alimentary canal and to the appendix; tubes contained pus, and the pseudomembranous adhesions were in intense inflammation; in many places abscess formations; each ovary contained a blood cyst, fibroma, and waxy ova; diseased blood-vessels. do. Dr. Brush. Very dense. D. proved. The patient said she had suffered for nine years, and so much that she had often rolled on the floor in agony; the pus formations with the specific constitutional disease produced a septic condition of the system. N. Y. Med Jour., May 6, 1890, case 6. PERSONAL EXPERIENCES IN LAPAROTOMY. 32 Mis. R. 34 M. O August Woman’s The uterine appendages were wrapped in a dense mass Removal of uter- Dr. C. N. D. Jones. Very dense. R. Constant distress, not able to attend to her daily duties; N. Y. Path. Soc. 13,1887. Hospital. of adhesions, and in the adhesions were many points of suppuration; tubes contained pus, closed at the fimbriated extremity, scarce a trace of the fimbria left; ovaries were in a state of acute inflammation and ine appendages. after the operation she was free from pain and able to work. contained gyromatous formations, some of them waxy, some breaking down into endothelioma; there were no 33 Mrs. D. , , M. 2 Sept. 5, do. Pyo-interstitial salpingitis. The tubes closed and con- do. do do. R. Suffered constant pain and distress in the pelvis; not able to attend to her household duties; after the oper- 1887. tained pus; muscle fibres of the wall reduced to in- flammatory corpuscles, in many places approaching ation she was free from pain, and able to work; her Jour., Sept. 28, 1889, case 7. suppuration; miliary abscesses, especially near the health excellent. periphery; ovaries enlarged, one the size of a goose egg, and each one contained a blood cyst. One formed part of the wall of an abscess cavity. Some of the bands of adhesions were % inch wide; ova in colloid degeneration. 34 Hultine. M. 2 August do. Dermoid cyst in the right ovary. Ovary tightly Removal of der- do. do. R. The patient said she had been sick for fifteen years; N. Y. Path. Soc., Sept. 28, 1887. 19, 1887. wedged deep into the pelvis, and bound on all sides by moid cyst. after the operation she regained her strength and was firm adhesions; the right tube size of a lemon, full of pus, all traces of fimbria gone, and adherent on all sides, especially by old dense adhesions to the pos- terior part of the uterus; a large blood cyst in left ovary; also bound to the uterus and to the pelvic wall by firm adhesions. The left tube enlarged as the right and filled with pus, and the tube firmly bound to the uterus and to the walls of the pelvis. able to work; said she scrubbed and washed and so produced hernia. 35 Mrs. H. M. O Sept. 5, do. Pyo-interstitial salpingitis. Intense oophoritis; inflam- Removal of uter- do. Dense. R. Patient suffered, not able to do anything; after her 1887. mation of the left ovary approaching an abscess; in the right ovary, haematoma and intense inflammation; ine appendages. operation she was free from pain, strong, and well. very few ova and these ruined by disease. 3« Mrs. J. M. 2 Oct. 5, do. The uterus in extreme retroversion, dragged down by enlarged ovaries so sensitive that the slightest touch do. do. Slight. R. Patient made an excellent recovery, gained strength, and N. 1. Med. Jour., May 10 1887. was able to work. gave distress, and increased pressure caused fainting and convulsions; intense oophoritis, gyroma, waxy do. degeneration of the ova. 37 Mrs. L. M. n O Oct. 1 5 , Chronic salpingitis. The tubes and ovaries wrapped in do. do. Thick. R. The patient was emaciated and feeble, and complained of constant distress in the pelvis; after the operation N. Y. Path. Soc., Nov. 9, yrs. 1887. a mass of dense adhesions. Some were 4 inches in 1887. length and 1% inches wide. Ovaries were atrophied to less than one-third their normal size; destruction of the ova; the menstrual periods ceased at the age of twenty-five. she greatly improved in strength and vigor; left the hospital comfortable and in good condition. 38 Mrs. R i d- M. 5 2 Oct. 2 4, do. Uterus retroflexed and retroverted. Ovaries enlarged, do. Dr. Willie Douglas. Adhesions. R. Patient said she had been sick for six years, had con- dinger. yrs. 1887. prolapsed, and extremely sensitive; one, size of a small orange, contained a blood cyst; the other contained a stant pain in the pelvis, the distress increasing; after the operation she spoke of her improved condition, that she was well, able to work, and glad that she had 1889, case 9. large endotheliomatous growth which extended to the periphery; there were few ova, and they were dis- eased. Pyo-interstitial salpingitis. Intense oophoritis; ovaries had the operation. 39 Mrs. E. M. 8 Oct. 2 4, do. do. do. Dense. R. The patient suffered with pain, weakness, and constant 1887. enlarged, prolapsed below the fundus of the retro- distress in the pelvis; since the operation she says her verted uterus. health has never been better. 40 Mrs. B. M. O Oct. 2 5, do. Hsematoma or blood cyst in each ovary. Intense do. do. do. R. Patient suffered intense pain, was weak and emaciated: 1887. oophoritis; both ovaries bound in with adhesions; peri- by the operation she was relieved of her suffering, and do. tonitis; peritoneal salpingitis. gradually gained health and strength. 41 Ma rgaret M. 3 Oct. 2 9, Both ovaries enlarged, prolapsed, and exceedingly sen- do. Dr. C. N. D. Jones. Adhesions. R. The patient said she had pain in the pelvis all the N. Y. Med. Jour., May 10 Fisher. 1887. sitive; tubes swollen to more than an inch in diameter, full of blood, and in a state of interstitial and catarrhal salpingitis; ovaries in intense inflammation, and con- tained fibromatous formations; ova diseased. time, so severe that she could not attend to her household duties; after the operation she repeatedly spoke as to “how improved were her conditions,” and “how glad she was that she had had the opera- tion.” The patient complained of intense pain in the pelvis, and 17, 1890 (?), case 2. 42 Mrs. E. 28 M. 2 Nov. 15, do. Pyo-interstitial salpingitis. Ovaries in intense inflam- do. do* Dense. N. Y. Path. Soc. 1887. mation; tubes and ovaries in the midst of inflammatory was sick and not able to work; after the operation adhesions, in some places forming abscesses; some ad- she said she was free from pain, able to work, and had hesions Y inch wide. excellent health. Mrs. J. M. 20 yrs. Nov. 15, 1887. do. Bleeding intramural myoma; weight, nine pounds. Chronic salpingitis, atrophy of the tubes; inflamma- tion of the peritoneal membrane; oophoritis; gyroma- Hysterectomy. do. R. Patient had severe pain, was prostrated, weak, and in- capable of any kind of labor; after operation she said N. Y. Path Soc., Nov. 23, 1887; N. Y. Med. Jour., J she was better and more comfortable than she had Aug. 25, 1888; Am. Jour. tous formations; blood-vessels diseased; ova in waxy degeneration. been for twenty years. Obst., vol. cxxxiii,, No. 3, 1896. 44 Mrs. H. M. 3 Nov. 1 9 , do. Peritonitis, salpingitis, and oophoritis. Removal of uter- Dr. C. N. D. Jones. Adhesions. R. Complained of pain in the pelvis, and not able to work; 1887. ine appendages. after the operation, patient said her health was re- stored. 45 Mrs. H. M. O Nov., 1887 do. Uterus misplaced; tubes contained pus; ovaries enlarged, do. do. Dense. ' R. Patient suffered great distress; after the operation she N. Y. Path. Soc. prolapsed, and in acute inflammation. had excellent health. 46 Mrs. Hoff- M. O Jan. 4, do. Spleen considerably larger than the ninth month of Splenectomy. do. '* Adhesions. D. The patient was extremely weak; the operation was man. 1888. pregnancy; abscess of the left kidney perforating into the left colon descendens; pus, granular, and waxy only an effort to save her. casts in the urine. 7 8 PERSONAL EXPERIENCES IN LAPAROTOMY. u Jj Name b g ■§2 s’ 0.2 Place. Pathological Conditions. Operation. Who Present. Adhesions. Results, Recovery or Death. Remarks. Where Reported. e p z d t>0 < 4-* 3 cn pJS zo 58. 0 47 Miss T. s. O Jan. io, Home. Salpingitis, oophoritis, endothelioma for left side. Removal of uter- Dr. C. N. D. Jones. Adhesions. R. Her condition was depreciating more and more her gen- 1887. ine appendages. eral health. 48 Mrs. A. M. Q Jan rj Pyo-interstitial salpingitis. Peritonitis; peritoneal ab- scess; tubes larger than the ovaries, and full of pus ; Removal of uter- Dense. R. Patient suffered intense pain, not able to be out of her bed; after operation she was free from pain and N. Y. Med. Jour., Sept. 28, 1889, case 5. 1888. Hospital. ine appendages. abscess in the cortex of the left ovary ; both ovaries in intense inflammation, and in many places ap- proaching an abscess; ova broken up into medullary and colloid corpuscles. do. D. health restored. 49 Mrs. E c - M. 3 Jan. 27, do. The uterus, tubes, and ovaries were bound in one solid Dr. C. N. D. Jones. Very dense. Her whole system was septic from the large pus for- hardt. 1888. mass six inches in diameter and fixed in the pelvis mation and the repeated attacks of suppurative by dense adhesions ; some portions of this mass gave evident fluctuation, which proved to be a large pelvic i peritonitis. abscess and near by a number of smaller abscesses. The left tube measured ten inches in length, and some portions four inches in diameter, was bound by extensive and firm adhesions to the rectum and pel- vie wall; ovaries were in intense acute inflammation; large portions of the normal structure destroyed by an endotheliomatous growth. Mrs. E. M. 2 Feb. 2, 1888. do. Parovarian cyst. do. Slight. R. Patient relieved of distress, and able to attend to her R. daily duties. 51 Mrs. H. M. O Feb. 7, do. Pyo-interstitial salpingitis. Peritoneal abscess, and an Dr. C. N, D. Jones. Dense. The patient was pale, feeble, and cachectic, not able 1888. abscess in the cortex of the ovary; ovaries enlarged to work, suffered so that she sometimes rolled on and prolapsed; intense oophoritis; haematoma, gy- the floor in agony; after the operation she fully re- roma, and waxy degeneration of the ova. R. gained her health. 52 Mrs. Han- 40 M. O Feb. 16, do. Intramural fibroid tumor, fourteen pounds, with sub- Panhysterectomy. do. Very dense. Patient said she had such constant torment that she N. Y. Path. Soc., N. Y. nah Strome. 1888. peritoneal fibroids weighing over seventeen pounds; felt she must kill herself; after operation, she was Med. Jour., Aug. 25 and right tube 10 inches long, 4% inches in circumference, relieved of distress and was able to be up on the Sept. 1, 1888; Ann.Gynae., and filled with bloody serum; left tube 5 inches long, twelfth day. Am. Jour, of Obst., vol. and filled with pus; both ovaries in acute and sub- acute inflammation; ova ruined. xxxiii., No. 3. 1896. S3 Miss M. S. O March 7, do. Pyo-interstitial salpingitis and oophoritis. j Removal of uter- do. Adhesions. R. After the operation she was free from pain and able to Pittsburg Medical Review, 1888. ine appendages. work. Oct., 1889, case 1. 54 Mrs. U. M. O March 7, do. Salpingitis. Endothelioma of the ovary extending to do. do. I )ense. R. Patient suffered intensely; after operation free from 1888. the periphery; a forming hsematoma; no ova. pain and regained her health. 55 Mrs. Miller. M. 2 March 19, do. Cancer on the floor of the pelvis. The uterus and ap- Removal of do. do. R. 1 he patient made an excellent recovery from the Pitt. Med. Rev., Oct., 1889; 1888. pendages fixed by adhesions on the extreme right; cancer and uter- operation, but at the end of thirteen months there N. Y. Med. Rkc. , March tubes and ovaries chronically diseased, and now in- filtrated with cancer. ine appendages. was a return of the malignant disease. 11, 1890, case 2. 56 Miss B. S. 0 March 28, do. Salpingitis and oophoritis, with myxomatous degenera- Removal of uter- do. Adhesions. R. The patient suffered intensely, not able to attend 1888. tion of the ovary; no ova. ine appendages. to daily duties; after operation she regained her health. 57 Mrs. Hoch. M. 9 March 28, do. The left tube was enlarged to a blood cyst, size of an Removal of blood do. Dense. R. The patient was weak, prostrated, and in great dis- ! 1888. orange, adherent to the retroverted and retrofiexed cyst. tress; the pains in the back and pelvis were increasing uterus, and to its accompanying ovary, and to the and unbearable; she was able to leave the hospital in walls of the pelvis. three weeks, relieved of distress, and since has been perfectly well. 58 Miss Emma S. 0 May 2 4 , do. Uterus in extreme retroversion; in front of it, and ad- Removal of uter- do. Adhesions. R. Before the operation the patient wrote: “ In five years N. Y. Path. Soc., April 25, Memmen. 1888. herent to the pelvis, was a large sensitive mass three ine appendages. I have not had a well day, and the pain makes me so 1888; Pitt. Med. Rev., inches in diameter, which proved to be a growing ovarian cyst; it was the right ovary. The left ovary was low down in Douglas’ cul-de-sac, in a state of weak I cannot work.” After the operation she was able to work, and wrote: “ I am glad the diseased Oct., 1889, case 7; IN. Y. Med. Jour., May 10 and i ovaries are removed.” 17, 1890, case 9. acute and subacute inflammation; the ova of both ova- ries were diseased and ruined; suppurative salpingitis of the mucosa and interstitial salpingitis of the tube wall. Pyo-interstitial salpingitis. Peritonitis; oophoritis. 59 Mrs. L. j M. 0 May 2 4 , do. do. do. do. R. The patient was an invalid for many years from dis- 1888. eased uterine appendages; after their removal she had excellent health and was able to attend to her household duties. 60 Mrs. Ofeldt. M. 7 May 2 8 , do. The uterus was retrofiexed and retroverted, and boun(d do. do. do. R. The patient said she had constant distress, that her sufferings were so great she could not stand it; after Pitt. Med. Rev., Oct., 1889, 1888. down by firm adhesions and by adherent uterine ap- case 3. pendages. The right ovary, in intense inflamma- the operation she was relieved from pain and gradu- tion; it with the tube formed part of the wall of an abscess which extended into the adjoining pelvic aponeurosis; salpingitis; repeated attacks of peri- tonitis; the ova were ruined. i i ally regained her strength and vigor. PERSONAL EXPERIENCES IN LAPAROTOMY. 9 6i Miss A Memmen. s. O 1 line, 1888 Woman’s Hospital. interstitial salpingitis. Abscess in the wall of the tube; ovaries in intense inflammation, and contained an endotheliomatous growth; in many sections of the right ovary no ova were found; in the left ovary, the ova were waxy and contained medullary cor- puscles. Removal of uter- ine appendages. Dr. C. N. D. Jones. Adhesions. R. Before the operation she said her life was a misery; after the operation she seemed to be in excellent health, and wrote, July 1, 1888: “I am very thank- ful that the diseased organs are removed.” 62 Mrs. Schultz M. O June 4, 1888. do. Intraligamentous cyst, 9 to 12 inches in diameter, oc- cupying the centre of the abdomen; uterus pushed far to the right, and to it attached this cyst by firm fibrous adhesions; chronic peritonitis; tubes and ovaries gave evidence of long existing disease and repeated attacks of inflammation. Removal of intra- ligamentous cyst. do. do. R. The patient said she had been sick for many years, the last five incapable of any kind of employment; said the tumor was increasing in size, and her health failing more and more; fifth day after the operation, pulse and temperature normal; patient up the tenth day. 1 63 Mrs. Sarah Bates. 49 M. 26 yrs. O J une. 29, 1888. do. Pyo-interstitial salpingitis. Uterus retroverted and fixed by a dense mass of inflammatory adhesions. From long existing disease, and repeated attacks of peritonitis, the ovaries and tubes were buried in firm, thick, well-organized adhesions. The left uterine appendages were especially enlarged and formed a tumor size of an orange; right so completely covered that they could not be removed. Removal of uter- ine appendages on one side. do. Dense. D. Patient said she had been married twenty-six years, had been an invalid for more than twenty years; constant and severe pain in the pelvis rendered life a misery; she said she was unable to work, and that the marital relations were most distressing. 64 Miss M. 35 S. O June 27, 1888. do. I ntense pyo-interstitial salpingitis, terminating in atro- phy of the tube wall; uterus acutely anteflexed and retroverted; both ovaries and tubes were found bound down by dense adhesions, and forming with the pelvic wall on the left side an abscess. The open- ing into the wall of the left ovary by an abscess was ij<3 inches in diameter; the ova were scanty, and those found were broken up in medullary corpuscles. Interstitial salpingitis. Ovaries enlarged, prolapsed, and exceedingly tender; both ovaries and tubes wrapped in dense adhesions; the ovarian stroma de- stroyed by endotheliomatous growths; haematoma, gyromatous cysts; the ova in waxy degeneration. Removal of uter- ine appendages. do. do. R. The patient said she had suffered for years with intense soreness and burning in the pelvis, that rendered her unfit for the active duties of life; she made a rapid recovery from the operation, and subsequently was in the enjoyment of excellent health. Pitt. Med. Rev., Oct., 1889, case 1. 65 Mrs. L. 39 M. 8 June 2 8, 1888. do. do. do. Adhesions. R. The patient said she suffered with such pain in the pelvis that she could not attend to her household duties; she made an excellent recovery and repeat- edly expressed her thanks that she was relieved of suffering and distress. . 66 Mrs. R. 27 M. 6 yrs. 0 July i 8 , 1888. do. Uterus in extreme retroversion, held down by large diseased and adherent ovaries, the slightest touch giving pain and causing nausea; ovaries were in in- tense inflammation, and contained large gyromatous cysts and waxy ova; salpingitis. Almost the entire left ovary was converted into and bordered on an abscess cavity, the walls of which cavity were completed by the floor of the pelvis; right ovary in myxomatous degeneration; both ova- ries and tubes bound in with adhesions; salpingitis; ova in waxy and fatty degeneration. do. do. do. R. Patient said her whole married life was a period of in- validism, not able to walk or be out of bed. The husband wrote, May 9, 1889: “I believe the opera- tion and treatment have saved my wife’s life;” “she enjoys better health than at any time since marriage. ” Pitt. Med. Rev., Oct., 1889, case 8; N. Y. Med. Jour., May 10 and 17, 1890, case 4. 67 Miss H. 35 S. 0 July 19. 1888. do. do. do. do. R. Patient said she had constant pain, burning heat, and bearing down in the pelvis; that at times she was not able to walk, and could not even draw a long breath without causing her pain and distress; she made an excellent recovery, and was entirely relieved of the old pain and suffering. Pitt. Med. Rev., Oct., 1889, case 6. 68 Mrs. Brug- geman. 47 M. 24 yrs. 0 August 2, 1888. do. Intramural myoma, subperitoneal fibroids. The pa- tient was apparently doing well, and everything seemed satisfactory, when some hours afterward the heart’s action became irregular; the patient had for eight years suffered with heart disease; her husband said, “sometimes she could hardly breathe.” Hysterectomy. do. Dense. D. An acute attack of peritonitis. The patient had had uterine tumors for years, but suffered only the last few months, after she had had electrical treatment. N. Y. Path. Soc. 69 Mrs. C. 26 M. 0 Sept. 22, 1888. do. Pyosalpingitis. The anteflexed uterus fixed on the right by dense adhesions, which adhesions covered in the right tube and ovary, and enclosed a large ab- scess cavity filled with pus; destruction of the ova. Removal of uter- ine appendages. do. do. R. The patient said she had constant pain and distress in the pelvis, so severe that she had to go bent over and not able to attend to her household duties; after the operation she was relieved of pain and was strong and vigorous. Pitt. Med. Rev., Oct., 1889, case 5. 70 Mrs. W. 45 M. 8 Sept. 2 9, 1888. do. Uterus fixed on the right by repeated attacks of peri- tonitis; right ovary enlarged by fibroid growths; left ovary, acute and subacute oophoritis, chronic salpin- gitis. do. do. do. R. The patient had been sick nine years; was pale, feeble, and emaciated; she had constant distress in the pel- vis; after the operation she was relieved of pain and regained her health and vigor. N. Y. Path. Soc., Sept. 9, 1887, Dec. 12, 1888; N. Y. Med. Jour., Sept. 28,1889, case 7; Buff. Med. and Surg. Jour., Nov., 1892; N. Y. Med. Jour., May 10 and 17, 1890. 71 Mrs. S. M. 1 Nov. 10, 1888. do. Pyo-interstitial salpingitis. Oophoritis; much of the ovarian tissue destroyed by endothelioma and gy- do. do. Adhesions. R. Patient said she suffered most distressing pain, so in- cessant that she could not attend to her daily duties. 72 Mrs. A. M. 0 Nov., 1888 do. Pyosalpingitis. Uterus anteflexed and retroverted; ovaries enlarged and prolapsed; in each were endo- theliomatous growths and gyromatous cysts; ova in waxy and colloid degeneration. do. do. do. R. Patient made an excellent recovery, was free from pain, and able to work. 72 Miss W. S. 0 Nov., 1888 do. Both ovaries enlarged to blood cyst from endotheli- omatous growths. do. do. 1 do. R. The patient was feeble, emaciated, and cachectic; said she had been sick for more than a dozen years and continued to grow worse; she made an excellent re- covery, and subsequently wrote that she was regain- ing her health, strength, and flesh. 7H Miss G. S. 0 Nov.,1888 do. Bleeding intramural myoma, as large as a foetus at the fourth month, and several small subperitoneal fibroids. Ovaries and tubes in chronic inflammation. do. do. do. R. The patient said she had been an invalid for many years, and was exhausted by repeated uterine hem- orrhages; she made an excellent recovery, and has since written that she “ is in excellent health.” PERSONAL EXPERIENCES IN LAPAROTOMY. £ 3 Name.