Reprinted from Gaillard's Medical Journal for August, 1887. 
TWO CASES OF OVARIOTOMY; 
WITH REMARKS ON THE IMPORTANCE OF 
POSITION IN THIS OPERATION, 
AND ON THE 
SIMULTANEOUS AND RAPID DEVELOPMENT OF PELVIC AB- 
SCESS AND OVARIAN CYST IN IMMEDIATE PROXIMITY. 
By A. PALMER DUDLEY, M.D., New York, 
Gynaecologist to the Northeastern Dispensary. 
In reporting these cases my object is not so much to swell the 
number of such operations reported as to point out what I now con- 
sider my mistakes in them, and also to call attention to some points 
which might be of benefit to those of the profession who do not have 
the privilege of visiting the institutions of this city where ovariotomy 
is of almost daily occurrence. 
Case I.-The patient was twenty-eight years of age, and first men- 
strated at fourteen. The period was irregular in return and always at- 
tended with some pain. She married at eighteen, and thirteen months 
later was delivered of a still-born child. It was a breach presentation, 
with which she was in labor several days. Instruments were not used, 
and the child had been dead about half an hour when delivered. The 
patient remained an invalid, and was confined to her room for three 
months afterwards. Her menses did not return for four years, and 
then recurred irregularly. At the time she became my patient it was 
her habit to flow moderately for three months, and then cease from 
three to six months. Four years after the birth of her child, and about 
two years before I saw her, she first felt an enlargement in the right 2 
inguinal region. Its growth was gradual, and had been attended with 
very severe headaches, and occasionally nausea and vomiting. It was 
irregular in shape, easily movable, and seemed to be a multilocular 
cyst, with thick walls. To make a correct diagnosis was a difficult 
matter, in consequence of her continued menorrhagia. The latter, 
however, was relieved by thoroughly curetting the uterus, and she 
improved in general health for some months. But the increase of the 
tumor, with its attending constitutional symptoms, soon required sur- 
gical treatment, and an operation was performed for its removal. An 
incision three inches in length was made through the median line of the 
abdomen, and the patient was then turned upon her side and a Spencer 
Wells's trocar introduced. The growth proved to be a multilocular 
ovarian cyst with thick walls. Its colloid contents were so adhesive 
that the trocar was of little use, and I at once opened the sac suffic- 
iently to admit my hand, and with my fingers broke up cyst after cyst 
within the main sac. This occupied considerable time, and as the 
patient failed quite rapidly, she was turned upon her back and the 
operation finished with her in that position. And, notwithstanding the 
extreme care taken to avoid it, some of the contents of the tumor es- 
caped into the abdominal cavity. The growth had no adhesions except 
to the omentum for about half an inch, and this was ligated with cat- 
gut. The pedicle was long and slender, and was quilted with catgut, 
cut short and dropped back. The uterus and opposite ovary were, to 
all appearances, perfectly healthy; and after thoroughly cleansing the 
abdominal cavity, I closed the external incision with interrupted silver 
sutures. The patient did not bear the operation very well, showing 
marked signs of exhaustion, and reacted slowly with the aid of hypo- 
dermic injections of brandy, hot applications, etc. By the next morn- 
ing, however, she had thoroughly reacted, and from that time her re- 
covery was uninterrupted. Peritonitis did not follow, nor was there a 
sufficient rise of temperature to make it worthy of note. Aided by 
Dr. Whitmore, of Boston, under whose care she was subsequently 
placed, I was able to follow her case in its after stages, and will herein 
mention its most prominent features. 
The operation was performed in November, and in the following 
January she was taken with cramp-like pains in the pelvis, extending 
into the thigh. About the same time an induration appeared behind, 
and to the right of the uterus, attended by some fever and increase of 
pulse. This was at first thought to be pelvic cellulitis, but its steady 
increase and attending constitutional symptoms soon evidenced a far 
graver malady. In March, in consultation with Dr. Whitmore, I saw 3 
her again, and, after a careful examination, made the diagnosis of 
malignant disease. Tonics and stimulants, with opiates sufficient to 
relieve pain were given her ; but the disease seemed to involve so much 
of the abdominal viscera that further operative measures were deemed 
unjustifiable. She died the following May, seven months after the 
operation. I made a post mortem examination three hours after her 
death, and found the abdomen very much distended with fluid, of which 
I removed a large pailful. This disclosed the growth to be as large as 
a man's head and involving not only the pelvic viscera but the omen- 
tum and small intestines as well. The latter were so matted together 
that I did not attempt to trace them through the growth. The left 
ovary was about the size of a foetal head at term, and contained a fluid 
of varying consistency, together with several pus cavities. This I re- 
moved and had examined by a specialist in microscopical work, who 
pronounced it sarcoma of the round cell type. 
The points in this case to which I desire to call attention are: 
First, the slow, steady development of the tumor, covering a period of 
nearly five years ; also its long, slender pedicle, absence of adhesion, 
and its apparently benign contents. (I say benign, because, although 
I did not have the contents microscopically examined, I have since 
seen many of the same character that had been examined by the 
Pathologist of the Woman's Hospital and pronounced benign.) Also 
that the uterus, opposite ovary, and Douglas's cul-de-sac were perfectly 
normal at the time of the operation. 
Nevertheless, within two months, malignant disease developed in 
the cul-de-sac and to the right of the uterus, in consequence of which 
this question presented itself to my mind: How much might I, by my 
method of operation, have been to blame for this unfortunate result ? 
The patient had been turned upon her back before the tumor was 
entirely removed, and some of the contents had escaped into the 
abdominal cavity. This could and should have been prevented by 
keeping the patient upon her side until the sac had been completely 
drawn through the abdominal incision, a temporary ligature applied to 
the pedicle, and the wound cleansed with antiseptic solution. So far 
as I am able to learn, Dr. T. G. Thomas was the first to practice this 
method in this country. It is true that surgeons now frequently oper- 
ate for the removal of ovarian growths with the patient upon her back 
during the whole time occupied. This practice, however, should be 
condemned, since it does not give the patient the best chance for 
recovery. It is next to impossible to drain and remove a cyst (and 
particularly a multilocular cyst) with the patient in that position, with- 4 
out some of the fluid making its way into the abdominal cavity. While 
this fluid might appear to be of a non-malignant character, it might, 
when brought in contact with a freshly-congested peritoneum, trans- 
plant itself and reproduce disease of a malignant, type. The surgeon s 
duty, therefore, should be to pay the utmost attention to the minor 
points in these operations. One*of the most important of these should 
be to prevent even the smallest possible quantity of the contents of any 
growth from entering the peritoneal cavity. This may be accom- 
plished by keeping the patient upon her side until the tumor is re- 
moved, the pedicle temporarily ligated, and the external wound thor- 
oughly cleansed with carbolized water. Until then the patient cannot, 
with safety, be turned upon her back for the purpose of completing the 
operation. 
Case II.-The patient was thirty-nine years of age when she first 
came under my care; at which time she gave the following history : 
She matured at the age of thirteen, with regular returns every three 
weeks, lasting from two to seven days. The flow was scanty and un- 
accompanied by pain. She had been married eleven years, but had 
never been pregnant. About six weeks before she came to me she 
had strained her back, she thought, while lifting a heavy tub, as she had 
experienced pain at the time. One week later she had taken a severe 
cold, and suffered with general neuralgic pains seemingly all over the 
body. Soon after her physician had been called in, and discovered a 
slight enlargement on the right side, which had rapidly increased in 
size until she came to me, three weeks later, at which time she pre- 
sented the following symptoms : General health, poor ; no appetite ; a 
pale, anxious expression; some elevation of temperature and pulse, 
and pain in the right side. Local examination revealed an enlarge- 
ment in the right side, low down, the size of a foetal head. Vaginal 
roof hard and tender, uterus fixed. Her surroundings were such that 
she could not have proper care at home, and she was sent to the hos- 
pital. Further examination after admittance showed the enlargement 
to be, apparently, a simple cyst of the right ovary, with some form of 
pelvic complication. She was put upon tonic treatment, with hot vagi- 
nal injections, and applications of compound tincture of iodine to the 
pelvic roof, daily. These applications were made as she lay upon her 
back in bed, with Sims's speculum used over the pubes. I avoided, as 
far as possible, causing any traction upon the pelvic organs or giving 
her pain. Eight days after entering the hospital she was taken with vio- 
lent cramp-like pains in the lower part of the abdomen, accompanied 
by a severe chill, which lasted half an hour. She recovered slowly 5 
from the chill, but still continued to have the pain, for the relief of 
which morphia had to be given. From that time till the day of the 
operation she failed, having constant elevation of temperature and 
pulse, loss of appetite, and sleeplessness, except under opiates. She 
could take but little nourishment and had become very weak. The 
abdominal growth had rapidly increased in size, and the vaginal roof 
still remained very tender to the touch. Her condition had become so 
grave, and she showed such evident signs of suppuration either in the 
cyst or pelvic tissue, that I brought her to the operating room for the 
purpose of exploring the vaginal roof with an aspirating needle. After 
further examination both by Dr. Scott and myself, I decided to wait a 
few days more, hoping for some improvement in her condition in the 
meantime. None occurred, but rather the reverse became apparent, 
and she was prepared for operation. She was placed under the in- 
fluence of an anaesthetic and an incision was made through the ex- 
ternal abdominal walls. The growth proved to be a simple cyst of the 
right ovary, without attachment anteriorly, but it was so attached in 
the pelvis that it had pushed the uterus over against the left pelvic 
brim. The uterus had several small sub-peritoneal fibroids on its su- 
perior and posterior surfaces. 
The patient was placed upon her right side, a large Emmet's trocar 
introduced into the sac, and the contents-a clear, limpid fluid-drawn 
off. I incised the sac sufficiently to admit my hand, and on passing 
the latter into the pelvis, my fingers at once came into contact with 
the pelvic roof. This, instead of being concave, presented an exten- 
sive convex surface, which gave a sensation of fluctuation. The apex 
of this convex surface seemed to be directly beneath the cyst pedicle, 
which had become somewhat spread out by distention from below. I 
selected this as the most favorable point for tapping, and passing a 
long curved trocar into the cyst sac, and guiding it by my fingers (I 
could not see the parts), I plunged it into the roof of the pelvis, and 
drew off through the canula fully a quart of extremely fetid pus. Still 
keeping the patient upon her side and the canula in position, I 
injected and reinjected the pus cavity with a warm solution of bichlo- 
ride of mercury, I to 3,000, until it came back clear. I then withdrew 
the canula, and enlarged the opening sufficiently to admit my finger, 
with which I could feel several bands of necrotic tissue stretching in 
different directions across the pus cavity. These were easily broken 
up, and the cavity again washed out. The ovarian sac was then drawn 
through the external abdominal opening, and the patient placed upon 
her back. 6 
None of the contents of either the cyst or abscess had escaped 
into the abdominal cavity. (The pelvic peritoneum was not inflamed.) 
The pedicle of the sac was, as I have already mentioned, spread out, 
and was attached to the pelvic floor. Under the circumstances 
this was very fortunate, for through it I was able to drain the ab- 
scess, without danger of the pus getting into the general peritoneal 
cavity. I made the drainage by drawing the pedicle up, and without 
ligating it. I cut away all the sac (except enough to make a funnel 
for the drainage of the abscess), and stitched the cyst walls to each 
side of the external abdominal incision with catgut sutures. A Tait's 
drainage-tube was inserted into the pus cavity, the external wound 
closed with silk sutures and dressed antiseptically, and the patient was 
put to bed. The operation lasted sixty-five minutes, during which 
time half an ounce of brandy was given hypodermically. The reac- 
tion was very slow, but her recovery was uninterrupted. Her temper- 
ature, which was 99.2° at the time of the operation, did not rise above 
ioo.2q ; and the pulse, which was 120, came down to normal in a few 
days. 
The pus cavity was washed out every six hours with a solution 
of bichloride of mercury, 1 to 3,000. The drainage-tube was re- 
moved on the fifth day, having remained long enough to prevent a 
too early closure of the opening between the two cavities. The 
sutures were removed on the eighth day. Union by first intention 
had taken place, with the exception of the part where the drainage- 
tube had been inserted. Twenty days after the operation the patient 
sat up, the sinus still remaining open. (A probe could be passed to a 
depth of three and one-half inches.) This was then injected with a 
solution of equal parts of tincture of iodine and alcohol, repeated as 
often as required, until the sinus healed. The patient remained in the 
hospital forty days after the operation, and was then discharged cured. 
She was requested to report occasionally at the out-door department, 
and eighteen months after the operation reported herself well; since 
which time nothing has been heard from her. 
The most important point in the interesting features of this case is 
the simultaneous, rapid development of an ovarian cyst and a pelvic 
abscess, so closely united that, although all the symptoms indicated 
the formation of pus, it was almost impossible to tell whether it pro- 
ceeded from the ovarian sac or pelvic cellular tissue, for both the cyst 
sac and the abscess were so tense, and the pelvic roof so hard and un- 
yielding, that, although a sense of fluctuation could be easily detected 
over the tumor, none could be obtained by bimanual examination. 7 
Again, as the woman had never been pregnant, the abdominal walls 
were tense, and as the abscess was behind and below the uterus, the 
latter being pressed up against the left pelvic brim, the spreading out 
of the pedicle of the tumor by the upward pressure of the abscess 
afforded an otherwise almost impossible medium for safe drainage. 
Considering the condition she was in at the time of the operation, to 
have subjected her to along-continued drainage per vaginam would 
have been hazarding grave chances for her recovery. 
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