TWO LAPAROTOMIES ON SAME PATIENT—REMOVAL 
OF BOTH OVARIES FOB CYSTIC DISEASE, AND 
ALSO A LARGE TUMOR OF THE MESENTERY 
—SILK LIGATURE PASSES INTO THE 
BLADDER AND SERVES AS THE NU- 
CLEUS OF A CALCULUS. 
BY tt. A. KINLOCH, M. D., OF CHARLESTON, S. C. 
On the seventh of January, 188(5, I operated at the St. Fran- 
cis Xavier Infirmary, upon Mrs. O’N., aged twenty-eight years, 
for the removal of a very large cystoma of the left ovary. She 
had been confined some three months before, at Port Royal, S. 
C., and had been ill with what was called puerperal fever, or 
peritonitis, following labor. Upon reaching this City she came 
under my care. I found the abdomen largely distended with 
fluid, flic patient emaciated and enfeebled, and having fever of 
an asthenic type. After a few days’ rest, careful regulation of 
diet, and a few doses of quinine and opium, her general condi- 
tion improved. I now aspirated the abdomen, or rather the 
cyst as it proved to be, and drew off several gallons of fluid of 
a turbid, dirty straw-color. I supposed from the history that 
the fluid occupied the peritoneal cavity. After its withdrawal, 
I discovered by manipulation, that there existed a large mova- 
ble tumor, and by further investigation, 1 made the diagnosis 
of ovarian cystoma. The tumor had likely been growing for 
more than a year, and had complicated the pregnancy.* 
Her labor had been tedious and painful, but she had given 
birth to a healthy and well developed infant. Patient was, by 
diet and medication, with quinine and iron, prepared for oper- 
ation. As before stated, the operation was done on the seventh 
of January, 188(5. There were several extensive parietal and 
intestinal adhesions, and at one point, to the right side of the 
abdomen and above the umbilicus, a portion of the mesentery 
was attached to the tumor. This was resected after applying to 
the tissue several silk ligatures. A solution of Hyd. Bichl., 
1-8000, was used in cleansing out the cavity A glass drainage 
tube was inserted, and the external wound dressed with iodo- 
form and cotton. I regarded the case as an unpromising one. 
To my surprise, the patient never had a serious symptom, and 
recovered so rapidly that in three weeks she was walking about 
her room. The only annoyance experienced was from the for- 
♦From the pressure of the uterus the tumor had been divided in such a 
way as to feel like a saddle-bag—full on each side and thin in the middle line. 2 
Two Laparotomies on Same Patient—R. A. Kinloch, M. D. 
mation of hard feculent masses in the colon and rectum, be- 
cause of a too exclusive milk diet. In the early part of July, 
six months after this operation, patient called at my office and 
complained of symptoms of cystitis, or irritable bladder. T 
was about leaving the city for a summer vacation. I prescribed 
for her an alkaline mixture, and anodyne suppositories when 
necessary. Upon my return home in October, patient visited 
me and gave the following history: The remedies given for the 
cystitis had afforded very little relief, but about a month pre- 
vious, while urinating, she experienced great difficulty and 
pain, and suddenly there fell into the chamber this foreign 
body (calculus exhibited), which she presented to me. 
It is conical in shape, and at its apex can be seen the ends 
of the braided silk ligature which I used for tying the pedicle 
of the tumor at the time of the operation ; curious enough it 
forms the nucleus of the phosphatie calculus. It most cer- 
tainly passed from the abdominal cavity into the cavity of the 
bladder, how and by what means may be a matter for 
speculation.* 
The history of this lady is further interesting. When pre- 
senting me with the calculus, she seemed to be in perfect health, 
but said she would like me to examine her abdomen, as there 
was a small depression or opening in the deep abdominal pari- 
eties, just where the drainage tube had been. A few daj78 after 
this, I visited her at her residence, to examine the condition 
referred to.. I found a deficiency in the deep abdominal struc- 
tures, at the lower end of the cicatrix, into which I could put 
the end of my index finger. It was of no consequence ; there 
was no hernial protrusion. But, to my surprise, I found the 
abdominal cavity occupied by another tumor, compact, semi- 
fluctuating and with diameters respectively of about eight and 
twelve inches. The patient had not been aware of its exist- 
ence. She had attributed her enlargement to fat and improved 
health. On the twentieth of November, 1886, I operated for 
the removal of this second tumor, which I then presumed was 
a cystoma of the right ovary. Upon opening the abdomen, 
through the line of the old incision, I began my search for ad- 
hesions. I soon found a portion of the mesentery attached 
to the surface of the tumor, just about where I had ligated this 
structure at my previous operation. These supposed adhesions 
were spread out, fan-like, upon the outer cyst wall, and when 
traced backwards were resolvable into three very large veins, 
round and fully distended. I applied two silk ligatures, by 
transfixing the tissue, to each vein, and then encircled the three 
veins, together with the mesenteric tissue en masse, with the 
free ends of one of the proximal ligatures ; the other ligatures 
*Prof. T. G. Thomas, of New York, informs me that in one of his cases 
of ovariotomy, as he learned from the physician in charge, the ligature was 
discharged from the bladder. Two Laparotomies on Same Patient—R. A. Kinloch, M. I). 
3 
were cut clone to the loops. The vascular mesenteric structure 
was cut between the ligatures, and a portion left attached to 
the cyst walls. I next punctured the cystic growth with Em- 
met's large trocar, to try and reduce its size. This availed hut 
little, as the interior cysts were small and their contents quite 
viscid. Patient was turned upon the side and the tumor freely 
cut into with a scalpel. This enabled me to begin its delivery 
through the abdominal wound, which was altogether below the 
umbilicus. As the tumor began to emerge, I passed my hand 
deep into the pelvic cavity to get at the supposed pedicle, still 
believing the growth to be a cystoma of the right ovary. Sud- 
denly, and to 1113' great surprise, the whole mass tumbled out 
on to the table. The tumor was of the mesentery, and the 
tissue, which I had in the beginning ligated and divided, con- 
stituted the sole attachment. The right ovary was now brought 
into view, and, as it presented evidences of beginning cystic 
disease, was removed. In bringing together the parietal wound 
with sutures of silk worm gut. I thought it best to include 
the pedicle, which I have described as made up of enlarged 
veins and mesenteric structure, in the wound. I transfixed 
this with a large steel needle, wrapped the ends of the needle 
in iodoformed cotton, and dressed the wound with the same 
material. Patient progressed favorably, experiencing only1 
slight rise of temperature for two or three days, attributable to 
a small parietal abscess. I adopted Tait’s plan, and acted on 
the bowels on the third day with salines. In withdrawing the 
needle from the pedicle, which never presented any evidence 
of gangrene, the stump retreated towards the cavity, and was 
lost in the deep part of the parietal wound. I felt somewhat 
uneasy at this occurrence, hut no trouble ensued. Patient was 
about in three weeks and was soon after this time discharged. 
My friend, I)r. John Guiteras, kindty examined the growth and 
reported as follows: 
“ It presented no evidence of malignity. The numerous cysts 
were lined with columnar epithelium, some of the cells being 
ciliated. The fibrous tissue stroma very vascular. There are 
innumerable minute cysts in the fibrous tissue walls. In all of 
these the columnar epithelium preserves its perfectly regular 
arrangement.” At this date, April 8th, 1887, patient is in per- 
fect health. There has been no menstruation since last 
operation.