[Extract from Transactions of the Tri-State Medical Association of Mississippi, 
Arkansas and Tennessee.] 
REPORT 
OF 
Sen (©onsegutive (Sases 
OF 
Abdominal Section 
BY 
DR. R. B. MAURY, 
Memphis, Tenn. 
Reprint from the Memphis Medical Monthly, March, 1888. 
Formerly, Mississippi Valley Medical Monthly. 
PRESS OF S. C. TOOF & CO., MEMPHIS. 
1888. Report of Ten Consecutive Cases of Abdominal Section. 
BY DR. R. B. MAURY, 
MEMPHIS, TENN. 
Dr. R. B. Maury being called upon, made the following 
remarks : 
I have not been able to prepare a paper, but will be pleased 
to report, as a contribution to the proceedings of the Society, 
my six months' work in Abdominal Surgery. 
Most of the cases are complete; of others a full history 
cannot now be given, but it will be furnished before the trans- 
actions are ready for publication. 
The first cases which I present come together naturally as 
illustrating a subject which is frequently brought before the 
general practitioner. I allude to the subject of chronic pelvic 
inflammation. 
Until quite recently, this form of disease has been generally 
regarded and spoken of as an inflammation of the pelvic 
cellular tissue. Twenty-five years ago its true nature was 
fully revealed to us by Bernutz; but for some reason or other 
his teachings were not accepted at their real value until the 
knowledge gained from operations inside the abdomen and 
new investigations in the deadhouse have confirmed their 
truth in every detail. 
After very careful study of this subject, I feel prepared to 
state that in the class of cases we are now considering it is 
not the cellular tissue which is involved, but the pelvic peri- 
toneum ; and that pelvic peritonitis is the characteristic fea- 
ture in women who suffer from chronic pelvic inflammation. 
Many of the cases have their origin in endometrial inflam- 
mation, which extends through one or both tubes to the 
peritoneum, and sets up an inflammation in the immediate 
vicinity of the ovaries. 2 
The gonorrhoeal poison does this very frequently, but most 
of the patients whom/l see have never suffered from gonor- 
rhoea. They date theii' sufferings from a miscarriage or from 
labor at term ; and I have repeatedly had opportunities of 
observing the very beginnings of the disease in the puerperal 
woman before she has left her bed. 
The women suffering thus do not generally present those 
grave symptoms which, in their aggregate, are denominated 
puerperal fever. They do have a moderate fever, with some 
soreness and a little pain, for several weeks after delivery, 
but their condition is not such as to give the practitioner 
great anxiety. 
In these cases an exploration of the pelvis shows tender- 
ness of the uterine body; with pain and tenderness upon 
pressure, and exudation of inflammatory products in one or 
both of the postero-lateral regions of the pelvis. 
Other cases are wholly unconnected with parturition ; the 
peritoneum, however, is inflamed, the ovary inflamed, en- 
larged and adherent. 
In a third class the evidences of peritonitis, when the abdo- 
men is opened, are slight, or perhaps absent, but the ovary is 
diseased, is diminished in size, its capsule is thickened and 
puckered, and its stroma evidently damaged in various ways. 
So much for the etiology. 
Now for the treatment. 
An accurate practitioner who gives a fair statement of his 
results is bound to acknowledge that the treatment of these 
cases is unsatisfactory in the extreme ; that it taxes to the 
utmost all the judgment and skill he can bring to bear upon 
them ; that it is most trying to the patience of the woman, 
and that at last a cure is effected in many cases only by an 
operation for removal of the diseased appendages; and I 
may add that in exceptional instances, even after the ovaries 
and tubes are removed, and the resources of medicine and 
surgery have been exhausted, the woman is still an invalid 
and a sufferer. 
As long as we regarded the pathological condition here as 
a chronic inflammation of the cellular tissue of the pelvis, 
there was theoretical ground for the hope that a cure might 3 
be effected by prolonged rest, by counter-irritation over the 
abdomen and the roof of the vagina, and by vaginal tam- 
pons saturated with glycerine, which would deplete and give 
support to the walls of the dilated veins of the connective 
tissue. I say there was theoretical ground for the hope. The 
theory was fallacious and the hope was generally delusive. 
I have had a large experience in the treatment of these 
cases in a private hospital where they were situated most 
advantageously for recovery; where they had rest, the hot 
water douche, the vaginal tampon of cotton and wool, applied 
daily for months. The strictest attention was paid to diges- 
tion, to the selection of food, to the securing of the beneficial 
influences of light and sunshine and cheerful surroundings. 
Of course they improve under such treatment, and some of 
them get well, entirely and permanently well. Many are 
only partially or temporarily benefited. 
If there has been any cellulitis, it is removed, and peri- 
toneal inflammation subsides, but adhesions, I am sure, un- 
dergo very little change. This treatment accomplishes but 
little where there is a deep-seated disease of the tubes in the 
way of a chronic salpingitis, with thickening of the walls, 
with or without pus ; and I think it does nothing for organ- 
ically diseased ovaries. 
In addition to the treatment above mentioned, I have made 
use of the galvanic current, faithfully following the teach- 
ings of Apostoli and Engelmann, but up to the present time 
with doubtful results. 
In no case have I resorted to abdominal section and removal 
of the appendages, until other means had been tried, at least 
for many weeks, and in most cases, months. 
I will now present my cases. 
Case I. Pyosalpinx with Cystic Ovaries-Removal of Ap- 
pendages-Recovery. 
Mrs. II. This patient, twenty-seven years of age, and mar- 
ried, with one child, dated her sufferings from her confine- 
ment three years before. Her symptoms were frequent 
headaches, derangement of digestion, extreme nervousness, 4 
constant pelvic pain, irregular and painful menstruation, and 
the morphine habit. 
There were the usual evidences of pelvic peritonitis, with 
tumor on each side of the uterus, especially the left. 
She was under my treatment and observation for one year 
and steadily grew worse. Her condition was pitiable in the 
extreme. 
The appendages were removed March 9th. The operation 
was difficult. Adhesions were firm and extensive. The left 
ovary was the size of a hen's egg, and was converted into a 
cyst, which ruptured in detaching the adhesions. The left 
ovary was largely cystic. Both tubes contained pus; they were 
not dilated, but their walls were thickened, and they felt like 
fibrous cords ; the fimbriae were destroyed and their external 
orifices occluded. 
She left me in four weeks restored to health, and has contin- 
ued well in every way. 
I used a small Keith's drainage tube for six days with this 
case, and on removing it found that the omentum had insin- 
uated itself through one of the small openings in the tube. 
Its removal was difficult and was followed by a sharp peri- 
tonitis. This was the only trouble encountered in the man- 
agement of this case. 
Case II. Chronic Ovaritis - Appendages Removed -Re- 
covery. 
Mrs. R. Four years before the operation this lady had 
come to me for the relief of dysmenorrhoea and vaginismus. 
She had then been married one year, but sexual intercourse 
had been impossible. Sim's operation for vaginismus was 
performed and she went home. Her husband then had inter- 
course with her once, and this was followed by conception. 
After that intercourse was impossible. Her child was born 
in due time. She passed through the puerperium satisfac- 
torily, but her condition was in no respect improved. The 
vaginismus continued as bad as ever and menstruation as 
painful. Suffering thus for three years, she was brought to 
me last June a bed-ridden invalid. 5 
An exploration of the pelvic organs without ether was im- 
possible. She suffered constant pain in the pelvis, especially 
on the right side, and the pain was greatly aggravated by 
assuming the erect position. 
She was in no sense hysterical, nor did she use opium. 
The abdomen was opened on June 10th. I remarked at 
the time that I would remove the appendages, even though 
they might seem healthy, because of the woman's intense 
sufferings. The operation was very simple. There were no 
adhesions. The Staffordshire knot was usecl, and the incis- 
ion, two inches in length, was closed. 
The temperature never rose above the normal,-and conval- 
escence was rapid. 
The tubes were free from disease, but both ovaries were 
small, shriveled and cartilaginous in feel, with wrinkled and 
thickened capsules, and presented a condition which I would 
say was one of chronic ovaritis. 
Notwithstanding the simplicity of the operation and the 
favorable convalescence, this lady has not been restored to 
health. She has not menstruated since the operation; the 
vaginismus has been cured, and she has been relieved of the 
old pain, but she remains feeble, is unable to walk, and when 
she gets out of bed suffers a pain in the left groin. 
It is possible she may in time entirely recover, but I am 
not very hopeful. I fear the operation was performed too late. 
Case Ill. Chronic Ovaritis with Rigid, Unyielding Broad 
Ligaments-Appendages Removed-Recovery. 
Mrs. McP., twenty-eight years old. refers her ill-health to 
her confinement three years ago. There was history of pelvic 
inflammation at that time, and since then I have had oppor- 
tunity to examine her on three separate occasions. Uterine 
mobility was impaired, and there was great tenderness on 
pressure in the culs de sac, especially the right. 
There was great mental depression, and her countenance 
indicated suffering. Digestion was deranged, and she had 
frequent headaches. The least exertion aggravated the pain 
in the ovaries. Menstruation was scant, prolonged and pain- 6 
ful. She was treated for one month in the usual way, and 
the glycerine tampon applied nearly every day. Finding 
that the treatment was followed by no improvement, and hav- 
ing known her condition for three years, I advised operation. 
The appendages were removed with much difficulty on 
December 3rd. Adhesions were easily detached, but the 
broad ligaments were so rigid and unyielding and contracted 
that it was very difficult to apply the ligature, which was 
done through a two-and-a-half-inch incision, rather by touch 
than by sight. 
It would have been better done if I had made the incision 
four inches. 
There was free hemorrhage, which was not stopped by hot 
water irrigation or sponge packing, and I then relied on Mr. 
Lawson Tait's plan by drainage, having the nurse to empty 
the tube every thirty minutes. 
There was not enough blood lost to affect the patient un- 
pleasantly, but it continued to come, so that the tube could 
not be dispensed with, and at the expiration of ten days there 
was bloody purulent discharge. After this, pure pus in 
abundance. No unfavorable symptoms arose. The pulse 
and temperature remained normal, and the patient rapidly 
improved in flesh and strength, being relieved of her dyspep- 
sia and headaches and pelvic pains. 
At the end of two and a half months, she is up and doing 
well, but has a small sinus at the lower end of the incision 
where the tube was. 
The ovaries presented the appearance of chronic inflam- 
mation. Upon their surfaces were numerous cicatricial con- 
tractions, the capsule was thickened, and they were rather 
under size. In the left were many cysts ; in the right there 
was hemorrhage into the stroma in two places. 
The two cases which follow were pus cases, and their con- 
dition was very critical. 7 
Case, IV. Ovarian Abscess - Hematoma of Ovary - Re- 
moval of Appendages - Recovery. 
Mrs. S. was brought to me by Dr. Fawcett, of Idaville, 
who fully appreciated the gravity of her condition and had 
diagnosed suppuration. She was thirty-four years old, and 
dated her ill-health from the birth of her first child, twelve 
years ago. She has had three children ; the last was born 
three years ago. 
For a year past she has menstruated every two or three 
weeks, and has repeatedly had profuse floodings lasting for 
ten or twelve days. 
She suffers constant pain in the right hypogastrium, which 
extends down the limb to the toes. She is unable to walk. 
Of late her mental condition has been so unsettled that her 
family were anxious in regard to it. 
She came to me November 26th, after having flooded nearly 
all the time since September 21st. She was put to bed and 
opiates administered every two or three days when the pelvic 
pain became severe. One week after admission the hemor- 
rhage returned and was so profuse that the tampon was 
required night and morning for four days. 
The uterus was found to be fixed in a position of retrover- 
sion. There was a tumor on each side of it, much larger 
on the right than on the left. Pulse and temperature normal. 
The abdomen was opened December 27th. 
The pelvic viscera were so matted together that their in- 
dividuality was lost. After an hour's patient work, the 
appendages were removed. 
The left ovary was three times its natural size and contained 
fluid. The right had to be aspirated before the ligature could 
be applied. Four ounces of pus and old blood clots were 
removed from it. Its stroma was entirely destroyed and its 
thickened capsule converted into a pus sac. 
This case has been of great interest to me, because it 
throw's light upon the causation of ovarian abscess. I refer 
to abscess of the ovary unconnected with the puerperal state. 
Nothing very satisfactory has been written on this subject so 
far as I have seen. 8 
Henry Morris* after alluding to the rarity of ovarian 
abscess, says : " Apart altogether from pregnancy and par- 
turition, it may be excited by any chronic source of ovarian 
irritation, and may be preceded by many years of ovarian, 
uterine or other pelvic trouble." 
In the case I am here describing the right ovary, after hav- 
ing been aspirated, removed and laid open, was found to con- 
tain still some pus and disintegrated blood clots. The left 
ovary was the seat of an haematoma. Quite four-fifths of its 
structure was destroyed by a blood clot, which, together with 
a reddish fluid, was surrounded by a firm wall of connective 
tissue. In a short period it is probable that disintegration of 
the clot and suppuration would have occurred in this as it 
had already done in its fellow. 
I would, then, point out that haematoma must be one of 
the causes of ovarian abscess. 
The Fallopian tubes were immensely hypertrophied; their 
walls were thickened and their lumen enlarged so as easily to 
admit a common grooved director. They contained no pus 
or other fluid. 
During the operation hemorrhage was free, but by sponge 
packing and irrigation with warm water the patient was put 
to bed with a clean and dry peritoneum. 
Pulse and temperature never rose above the normal, and 
she was out of bed on the nineteenth day. 
I might say that this woman was restored to health just as 
soon as the effects of the operation were over with. She is 
in perfect health today, two months afterward. 
Case V. Chronic Peritonitis with Ovarian Abscess-Ab- 
dominal Section and Drainage - Recovery. 
This patient, thirty-two years old, the mother of two chil- 
dren, came to me from Stormville, Miss. She has been an 
invalid for five years ; has suffered pain in left ovarian region 
for many months, and during the past year has been having 
a bloody discharge from the uterus nearly all the time. Com- 
ing to me November 8th, she was very anaemic, had constant 
* International Encyclopaedia of Surgery, Vol. V. 9 
fever, with night sweats, and a spleen which came down below 
the crest of the ilium. Exploration of the pelvis revealed a 
retroverted, fixed uterus, with a swelling on the left side of 
it, and more or less exudation on all sides. There was also 
a stellated laceration of the cervix. 
On December 29th the abdomen was opened. I had diag- 
nosed pyosalpinx and proposed to remove the appendages. 
In this I was mistaken. The pelvic organs were so completely 
and firmly bound together by old adhesions that separation 
and removal were impossible Douglas' pouch was obliter- 
ated. The uterus could not be distinguished from the other 
structures. The pelvic cavity was filled up by a confused 
mass of diseased organs, and all was roofed over by intestines 
firmly adherent around the circumference of the superior 
strait. In this roof there was an opening which exposed the 
abscess wall. * This abscess occupied the left two-thirds of 
the pelvis. It was aspirated and four ounces of pus removed. 
Its wall was quite a half inch in thickness and so firmly bound 
by adhesions that the edges of the incision made in it could 
not be brought into the abdominal wall incision. 
One of Keith's large glass drainage tubes was carried to 
the bottom of the abscess cavity, and parallel drainage of the 
peritoneum was established by a rubber tube, separated from 
the glass tube by a single stitch. 
This was apparently a rather unsatisfactory state of affairs, 
but everything went well. The pulse and temperature sank 
to the normal, though for months she had not been free from 
fever. She ate well from the start, laid aside her hypodermics 
of morphia in ten days, gained rapidly in flesh, and in four 
days the rubber tube was removed. 
Not so with the glass tube. It was soon exchanged for 
the rubber, and this was dispensed with in a month's time. 
Two months after the operation she returned home with a 
small tube sinus, having gained flesh and strength, and being 
in excellent health. 
At this time there were but few evidences left in the pelvic 
roof of inflammation, though the uterus was immovable. 
Menstruation appeared about six weeks after the operation. 
It was scant and painless. 10 
In the two cases which follow, the abdomen was opened 
for the relief of peritonitis. 
Case VI. Intra-Peritoneal Hematocele Resulting in Sup- 
puration and Septicemia-Abdominal Section and Drainage- 
Recovery. 
I was asked to see this case in consultation, by Dr. R. B. 
Nall, from whom the following history was obtained: 
The patient was thirty-two years old and the mother of 
one child. She had had several miscarriages, and from time 
to time had suffered from hemorrhage. 
She had been under the care of an irregular practitioner, 
who treated her by intra-uterine injections of cod-liver oil 
and tannin. The injections caused much pain. On the night 
after the fourth injection she became very ill ; had severe 
abdominal pain, was pulseless, apparently bloodless, and 
looked as though she would die at once. Dr. Nall saw her 
in this condition and diagnosed haematocele. After a severe 
struggle for forty-eight hours she rallied, and then peritonitis 
set in. 
It was five weeks after she was taken down when I saw 
her. Then the symptoms of septic poisoning were marked. 
She was having chills; her temperature ranged from 103 to 
104, her pulse from 130 to 140. 
. There was a large fluctuating abdominal tumor, extending 
upward from the pelvis above the umbilicus and spreading 
laterally to the hip bones. On exploring this with a hypo- 
dermic syringe it was found to contain bloody pus. 
Under such circumstances surgical interference was clearly 
demanded. The roof of the vagina was carefully explored, 
to see if an opening could be made there. The cavity was 
so filled up with inflammatory deposits that an operation 
through the pelvic roof seemed impracticable. No point 
could be found through which even an aspirator could be 
intelligently thrust. 
On the 26th June, the day after my first visit, I opened the 
abdomen with Dr. Nail's assistance, and removed upwards of 
two quarts of coagulated blood and pus. The cavity was 11 
carefully washed out with warm water, by means of a David- 
son syringe, and a glass drainage tube inserted. 
Within twelve hours after this procedure the temperature 
became natural, and the pulse fell from 130 to 100; and dur- 
ing the convalescence there was no increase of pulse or tem- 
perature. 
The principal difficulty encountered in the subsequent 
management of the case, was to get rid of blood clots which 
could not be removed during the operation, and which 
mained adherent to the walls of the sac formed by the peri- 
tonitis. These clots decomposed, became very fetid, and were 
difficult to remove through the drainage tube. The cavity 
was washed out twice in twenty-four hours with plain warm 
water. Drainage tubes were dispensed with entirely after 
five weeks. The opening entirely closed, and the patient has 
been restored to health. 
Case VII. Chronic -Peritonitis with Effusion of Sero- 
pus-Abdominal Section and Drainage-Recovery. 
This young lady, twenty-three years of age, came before 
me early in October. The history of her case threw but 
little light upon its real nature. Indulging in all the gaieties 
of social life she found last April that she was losing appetite 
and suffering with nausea. For these symptoms she con- 
sulted her physician. Medicine gave no relief. She failed 
in flesh and strength ; went from home for mountain air and 
mineral water, and in pursuit of health had spent the entire 
summer. 
When I saw her she was emaciated to an extreme degree, 
was unable to walk without assistance, and presented the 
appearance of one in advanced phthisis. Menstruation had 
ceased in July. The pulse was 110, the temperature 991 in 
the afternoon. The lungs were free from disease. The abdo- 
men was < nlarged, the swelling was symmetrical, fluctuation 
was distinct. The abdominal walls were sore and tender on 
pressure. The heart, liver and kidneys were free from dis- 
ease, as far as I could ascertain. 
My diagnosis was chronic peritonitis, probably tubercular. 12 
The abdomen was opened on 5th October, three days after 
my first visit. The fluid removed was serum of a deep yellow 
color, in which floated large flocculent masses of lymph ; under 
the microscope, inflammation corpuscles were found in large 
numbers. The pelvic organs were carefully examined and 
found to be free from all appearances of disease. The peri- 
toneum was thickened and hyperaemic, but no signs of tuber- 
cle were discovered. 
The cavity was simply emptied, not irrigated. A glass 
drainage tube of small size was introduced. 
For some weeks the result was very doubtful. It was ex- 
ceedingly difficult to feed the patient, and she sank very low. 
At her earnest request the drainage tube was removed, and 
sooner than it should have been. Some fluid was retained, 
purulent in character and sacculated on the left side, between 
the tube-opening and the ilium. The patient then began to 
improve, and a small tube was re-inserted. For weeks there 
was an area of induration on the left side, but this gradually 
disappeared. The patient has steadily improved, and at this 
(Lite, February 15th, is entirely restored to health. The diges- 
tive functions are absolutely perfect. She has now grown fat, 
and the abdomen presents no signs of disease. She has men- 
struated once. The nature of this case I do not pretend to 
understand. 
The three cases which now follow were abdominal tumors : 
Case VIII. Small Ovarian Monocyst with Twisted 1'edicle 
and Extensive Omental Adhesions-Ovariotomy-Recovery. 
This patient came to me through the courtesy of Dr. Quinn 
of Vicksburg. She was a lady about forty-five years of age, 
and weighed two hundred pounds. She had a small abdom- 
inal tumor on the right side chiefly, and her history indicated 
that it had been there for several years. For a year or more 
she had suffered pain in the right side of the abdomen. Of 
late this pain had rendered her life very mi-erable, and at 
times the use of morphia had become necessary. 
The abdomen was opened on 17th October. The appear- 
ance of the tumor showed that its circulation was obstructed, 13 
the pedicle was twisted twice upon itself. There were no 
adhesions except to the omentum. A large portion of the 
omentum was removed. I presumed that the condition of 
the pedicle accounted for the pain from which she suffered. 
There was no marked elevation of temperature, and con- 
valescence was uninterrupted until the third week. She then 
complained of nervousness and sleeplessness, and had a coated 
tongue. 
Iler evening temperature for two days,rose to 100°. Quin- 
ine was given and these symptoms passed away, and she was 
out of bed by the twenty-first day. 
On November 20th slw went home, as I thought, entirely 
restored to health ; but soon afterward the old pains returned 
and she again suffered very much. What her condition is 
now I do not know. 
Case IX. Uterine Fibroid - Pelvic Abscess - Hysterec- 
tomy - Recovery. 
Mrs. J., of Plummersville, Ark., came to me October 15th, 
upon the advice of Dr. Algood, of that place. She had not 
been in good health for a year, and stated that in July last 
her physician discovered an abdominal tumor Symptoms of 
inflammation were present to a marked degree, and in August 
there was a discharge of pus from the bowels. 
She and her husband concurred in stating that the amount 
of pus discharged was enormous, and that during the twenty- 
four hours which followed the rupture of the abscess, the 
quantity could not have been less than a gallon. 
Since July she had taken large quantities of opium to relieve 
abdominal pain, which was chiefly on the right side, and ex- 
tended downward into the pelvis. 
The bowels were constipated, and were seldom moved, ex- 
cept by medicine, which caused great pain. The foecal dis- 
charges always contained pus, and at times the pus alone w'as 
discharged. 
I found her much emaciated, very feeble and hardly able 
to walk. Her pulse and temperature were normal. 
In the abdomen there was a fluctuating tumor extending 
upward from the pelvis nearly into the right hypochondriac 14 
region. The left upper portion of the abdomen was not 
occupied by the tumor. The tumor was not movable, and 
did not extend deeply into the pelvis. I took it to be an 
ovarian cyst. 
The lower segment of the uterus was clear. The location 
of the former abscess cavity could not be ascertained. 
The abdomen was opened October 18th. 
The tumor was found to be not ovarian, but a soft fibroid. 
An attempt to remove the ovaries failed. The left ovary 
could not be discovered, being bound down by inflammatory 
deposits. The right ovary and tube were spread out upon 
the tumor, high up. The incision was then extended above 
the navel and the tumor turned out. 
Following the plan taught me by Dr. Keith of Edinburg, 
I applied locking forceps close to the uterus on the right side 
and then ligated the broad ligament from above downward. 
The ligament was then divided down to a level with the os 
internum uteri, and the serre noeud applied. 
In closing the abdominal wound, care was taken to stitch 
the peritoneum closely around the pedicle. 
Bantock's plan of dealing with the pedicle was followed. 
It was trimmed as closely as possible to the pedicle needles 
and then stitched. After this, pieces of dry, absorbent lint 
were packed around it. 
The patient was put to bed with a pulse of ninety. 
In a few hours some bleeding was found from the pedicle 
and the wire was tightened. The next day bleeding was dis- 
covered to come from a vessel in the pedicle, which tighten- 
ing the wire did not control. This was promptly stopped by 
ligation en masse. 
The patient did well. The pulse and temperature ranged, 
the one from 86 to 100, the other 98J to 100. 
On the tenth day there was pus around the stump. This 
was profuse on the twelfth and thirteenth days, and the tem- 
perature rose to 101 in the evening for two days. 
With this exception, there was no trouble. The discharge 
of pus declined slowly. It ceased to appear in the stools, 
and I inferred that the old abscess was discharging by this 
channel. The pedicle separated on the eighteenth day. 15 
The patient went home at the end of the fourth week. The 
tumor weighed ten pounds. 
On February 8th she wrote me : " I am in as good health 
'as I ever was in my life. The abscess quit discharging about 
December 15th. My monthly periods returned on me all 
right, and I am getting along just as well as I can." 
I will add that the body of the uterus was cut through a 
short distance above the os internum. 
Case X. Tubal Pregnancy to Full Term without Rup- 
ture-Removal of Dead Fcetus by Abdominal Section-Re- 
covery from Operation-Death from Phthisis. 
A few weeks ago Dr. Black called my attention to a woman 
under his care at the city hospital, and very kindly offered 
her for clinical purposes at the College. 
She had been admitted August 5th, and the resident physi- 
cian, Dr. Clark, had kept a careful daily record of her pulse 
and temperature for nearly three months. Ilis record showed 
that during August the pulse was about 105 and temperature 
101. During September the pulse had increased to 115 and 
the temperature, in the evenings, to 103. During October 
the pulse had reached 130 and the temperature 103 and 103J. 
And yet she was up and going about most of the day. 
She stated that she had had four children. Something over 
one year ago she thought she became pregnant. She had 
all the rational symptoms of pregnancy - the abdomen en- 
larged; the movements of the child were distinct, and in 
June last they ceased, and she had felt no movements since. 
She declared that nothing unusual had occurred during the 
pregnancy; there had been no symptoms of peritonitis; no 
pains or colics, or hemorrhagic discharges. 
In June the impairment of health began ; fever appeared, 
and a cough which she had before grew worse. 
Examination of the abdomen revealed a symmetrical tumor 
reaching the epigastrium. This was firm and elastic and not 
movable. The uterus was five inches in depth, and the sound 
moved freely in its cavity. 
An effort was made to introduce the finger into it for ex- 
ploration, the patient having been etherized, but dilatation 16 
with steel dilators was unsuccessful ; the cervix tore and was 
closed by a silver wire suture ; the uterus was high up and 
not very movable. The patient stated that there had been 
three slight menstrua] returns since June. 
There was well-marked tubercular deposit at the apex of 
the left lung in front, and less distinct evidences of disease 
in the right apex behind. 
Feeling quite sure that the uterus was empty and that we 
had a case of abdominal pregnancy to deal with, the woman 
was submitted to abdominal section in one of the private 
rooms of the Hospital on October 22nd. She was anxious 
for the operation. Drs. Black, Edward Mitchell and Taylor 
assisted me, and a number of students were present. 
The woman was very amemic, as might be imagined, from 
having had fever for four months. Her pulse was 140 and 
temperature 103, as it usually was in the afternoon. 
The abdominal wall was very thin, not thicker than my 
little finger. The tumor, on being exposed, was plainly cov- 
ered with peritoneum. An effort was made to withdraw its 
fluid contents, but nothing flowed through the trocar. In- 
serting my finger into the opening made by the trocar, I 
found a fleshy mass, which proved to be the placenta. The 
placenta was symmetrically implanted across the median line, 
adherent to the anterior wall of the sac. 
An incision being now made through the thick sac wall, 
and through the placenta also, the placenta was stripped oft 
and removed. Then the removal of the foetus was easily 
effected. Bleeding from the walls of the sac was controlled 
by pressure forceps. 
There was but little fluid in the sac, and this resembled 
muddy water and was free from unpleasant odor. It was 
carefully removed by sponging, and the sac was cleansed 
with a solution of bichloride of mercury. 
It became evident upon inspection, as much so as could be 
without a post mortem examination, that this pregnancy had 
occurred in the Fallopian tube; that the tube had not rup- 
tured into the peritoneum in the early months; and that the 
foetal sac had developed at the expense of both layers of the 
broad ligament. 17 
The removal of the sac was considered, but found to be 
impossible ; its pelvic attachments were firm and extensive. 
The opening made in it was therefore closed and stitched 
between the edges of the abdominal incision. A glass drain- 
age tube was passed at the lower angle of the wound to the 
bottom of the sac. 
The foetus was a full developed male child, with abundance 
of hair and perfect nails. It weighed five pounds, and there 
were no signs of decomposition. It had evidently shriveled. 
The placenta weighed one and a half pounds, and was un- 
usually thick. Its Mood vessels were nearly obliterated. Very 
little bleeding occurred when it was detached. 
The operation was followed by no shock. The patient did 
well. The pul se and temperature were better than before the 
operation, and less antipyrin was required. She took food 
unusually well. The cough though was very harassing, and 
opiates were given io relieve it. 
On eighth day the abdominal wound was found to have 
united well. The discharge from the drainage tube was 
moderate, and a rubber tube had been substituted for the 
glass one. The stitches were therefore removed and adhesive 
strips applied. 
About midnight, after a severe paroxysm of coughing, the 
upper part of the abdominal incision was torn open and a 
portion of small intestine protruded. 
This was at once replaced and sutures of silver wire 
introduced. 
The patient's equilibrium did not seem to be materially 
disturbed by this procedure. Everything connected with the 
operation was satisfactory, except the strain on the sutures 
from the harassing cough. 
The pulse and temperature continued nearly as they were 
before the operation, but the woman died from exhaustion 
on November 19, just twenty-eight days after the operation. 
A few days before death a small intestinal fistula was dis- 
covered in the upper portion of the incision, probably pro- 
duced by injury from one of the wire sutures, which had 
been dislocated by the cough. 18 
At the autopsy both lungs were found extensively adherent 
to the chest walls. In the right lung there were cavities in 
the upper and middle lobes. There was a cavity in the apex 
of the left lung. On opening the abdomen there were evi- 
dences of a moderate adhesive peritonitis. 
The abdominal incision had entirely healed on its peritoneal 
aspect, but not completely on its cutaneous surface. The 
small foecal fistula at the upper angle of the wound seemed 
to have arisen from injury sustained by a dislocated wire 
suture. 
The foetal sac was completely drained, and was not larger 
than the fist. It was effectually cut off from the peritoneal 
cavity. 
The pelvic organs were carefully removed, and it was then 
seen beyond all possibility of doubt that the foetal sac was 
entirely extra-peritoneal, that the gestation had originated 
in the right Fallopian tube, and had developed between the 
folds of the broad ligament, downward to the pelvic floor, 
laterally to the pelvic wall, and upward into the abdomen. 
The ovum in its development had lifted the peritoneum oft 
from the bladder and the anterior surface of the uterus, while 
the relations of the peritoneum to the posterior uterine wall 
and to Douglas' pouch were not altered. 
The sac extended quite to the pelvic and abdominal wall 
on the right side, but did not go beyond the left cornu of the 
uterus on the left. 
At the time of the operation it was observed to be covered 
by peritoneum, and this was clearly shown after death. 
The gestation was therefore entirely extra-peritoneal, and 
belonged to the variety, intra-ligamentous of Werth, or sub- 
peritoneo-pelvic of De Zeimeris. 
No trace of the ovary was discoverable in the structures 
belonging to the sac, but on the left side the ovary was found 
much shriveled and otherwise changed in appearance. 
This autopsy corroborates the view taught by Mr. Lawson 
Tait, that in extra-uterine pregnancy, no matter where the 
foetus may be found, its development begins in the Fallopian 
tube, " and that it may become intra-peritoneal or extra- 
peritoneal, just as the tube happens to burst." 19 
Dr. Berry Hart, in a valuable paper read before the EdinT 
burgh Obstetric Society, July 13, 1887, presented drawings 
taken from frozen sections in two cases of advanced extra- 
uterine gestation. Of one ot them he remarked: "The 
second case shows that abdominal gestation can be extra- 
peritoneal, a fact never hitherto demonstrated, although 
strongly contended for by Tait." 
I am unable to present the results of a frozen section, as 
was done so beautifully by the Edinburgh professor ; but my 
autopsy has certainly demonstrated another case of extra-perito- 
neal gestation. 
In thus presenting results nearly free from mortality, as I 
have done here and in other reports to this Society, I would 
say that they are due, not to any special skill in operating, 
but to careful study and observation of the methods of those 
men, who. in this country and abroad, have done so much to 
perfect abdominal surgery. 
Drs. K. W. and E. D. Mitchell, and Dr. W. W. Taylor, 
have, in every way, rendered me valuable assistance in the 
cases here reported.