CLINICAL CONTRIBUTION 
TO THE 
SUBJECT OF REMOVAL OF THE UTERUS IN WHOLE 
OR IN PART FOR THE EXTIRPATION OF TUMORS 
CONNECTED WITH THAT ORGAN. 
BY 
T. GAILLARD THOMAS, M.D., 
NEW YORK. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA.: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 880. CLINICAL CONTRIBUTION 
TO THE 
SUBJECT OF REMOVAL OF THE UTERUS IN WHOLE 
OR IN PART FOR THE EXTIRPATION OF TUMORS 
CONNECTED WITH THAT ORGAN. 
BY 
T. GAILLARD THOMAS, M.D., 
NEW YORK. 
EXTRACTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1 880. CLINICAL CONTRIBUTION TO THE SUBJECT OP RE- 
MOVAL OP THE UTERUS IN WHOLE OR IN PART 
FOR THE EXTIRPATION OF TUMORS CONNECTED 
WITH THAT ORGAN. 
The exigencies of modern surgery are very great; and instead 
of diminishing in number as unexplored fields are invaded and 
fresh positions conquered, they appear to develop new propor- 
tions. In our day we have seen paracentesis of the gall-bladder, 
the membranes of the brain and the pericardium; extirpation 
of the larynx and rectum ; and ablation of the kidney and 
spleen, placed upon enduring bases as operative procedures; and 
gradually even the most conservative are yielding to the con- 
viction that it has become essential that the uterus should be 
rendered amenable to complete removal. 
There are three circumstances under which complete extirpa- 
tion of the uterus may now he regarded as a legitimate and 
often a necessary procedure: first, where it is, after Freund’s 
method, removed on account of malignant disease; second, 
where, as an addendum to the Ctesarean section, it is practised 
after Porro’s plan; and third, where it is extirpated to render 
practicable the removal of tumors, either of solid or cystic cha- 
racter, which take their origin in its tissues, or, arising in the 
ovaries, form attachments to it too firm to be broken. 
It is with the third and last of these indications that I pro- 
pose to deal to-day. 
I have said that the most conservative must gradually yield 
to the demand of modern surgery for the removal of the entire 
uterus by laparotomy; it is in this class of cases that they must 
first do so. It should not, however, be supposed that even here a 
conservatism, the honesty of which we must all respect, although 
sometimes boldly dissenting from its deductions, has yet been 4 
REMOVAL OF THE UTERUS. 
fully satisfied. That this is by no means the ease the following 
quotations from some of our best authorities will prove. 
Barnes, writing so lately as two years ago, declares that “ the 
time has not yet come for forming a confident opinion upon the 
practice of laparotomy for the removal of uterine fibroids, either 
alone or with the uterus. At present there is little ground for 
enthusiastic advocacy of the practice. The case may best be 
summed up by stating that the question is ad hoc sub judice. We 
must for a while be content with the divided opinions expressed, 
in the Academy of Medicine on the occasion of a report presented 
by Demarquay on memoirs by Kceberle, who advocates the pro- 
ceeding, and by Boinet, who condemns it. Boinet showed that 
the operation had for the most part been performed accidentally 
in cases mistaken for enlarged ovary; that it could not be de- 
fended on the same grounds as ovariotomy ; that it should always 
be rejected when the tumor was not pedunculated, and especially 
when it involves the entire or partial removal of the uterus. 
Demarquay agreed with Boinet. On the other hand, Richet 
cautioned the Academy against pronouncing any summary con- 
demnation of an operation which at present is dreaded as ova- 
riotomy once was.” For myself, let me say that it is truly a sad 
spectacle for the world of surgery to behold the Academy of 
Medicine of Paris, the great deeds of whose founders have in 
times past electrified their contemporaries by their originality 
and brilliancy, to-day restrained by the warning voice of one 
man, Richet, from condemning a procedure which is as sure to 
be demanded by the surgery of the future as ovariotomy was by 
that of the past! 
Emmet, in the second edition of a treatise upon gynaecology, 
of which all his countrymen feel justly proud, says: “To remove 
the uterus when enormously enlarged from a fibrous growth, is 
unquestionably one of the most formidable operations a surgeon 
can be called upon to undertake. The degree of success which 
has so far attended the operation offers but little encouragement 
for the future. M. Pean, of Paris, presented, in 1873, seven 
recoveries out of nine cases where he removed the uterus for 
fibrous growths. As this success has not been equalled by any 
other operator, we must suppose it to have been accidental, and 
that subsequently he himself has not been so fortunate, as already 
six years have elapsed since his last report.” 
I could go on quoting to this effect for any length of time, REMOVAL OP THE UTERUS. 
5 
but I lack incentive to do so; all my hearers know that the 
prevailing opinion goes with the eminent authors whom I have 
just quoted, and that I am to-day giving evidence in favor of a 
young and feeble cause. 
An honest conservatism is the bulwark of scientific surgery, 
but there is no virtue so likely to run to dangerous extremes as 
this very one whose merits we are lauding. Let us remember 
how many life-saving procedures have been condemned in times 
past which to-day7 command our highest esteem, and let us be 
cautious how in a laudable effort to avoid recklessness, we repeat 
the errors of our forefathers in attempting to suppress what time 
has now, set its seal upon as valuable contributions to our art. 
Fifty years ago the operation of laparotomy for the removal of 
ovarian cysts was almost universally condemned as a surgical 
temerity for which it was very questionable whether the perpe- 
trators ought not to be held amenable to the law. No epithets 
were regarded as too vile to be hurled as anathemas against the 
men who were regarded as so reckless as to peril human life by 
its performance, and it required a good deal of moral courage 
for one to be willing even to sanction by his presence a procedure 
about the surgical impropriety of which there was so unanimous 
a verdict. And let us not forget that results seemed for a long 
time to uphold the view of the majority. Many died of those 
operated upon, and few recovered ; women suffering from obesity7, 
tympanites, or pregnancy were, through errors of diagnosis, ex- 
posed to the great and uncalled for dangers of laparotomy; and 
even in simple cases intestines were torn, large bloodvessels 
severed, or sponges and instruments sewed up in the devoted 
bodies of the victims of reckless surgery often enough to give 
powerful arguments to the opposition. 
Fifty years have passed away, and what is now the position of 
this “opprobrium chirurgiae?” What the fate of the men who 
bore in its infancy’ the ignominy7 of sustaining it? McDowell, 
its discoverer, has just had a monument erected to his honored 
memory, and the names of At lee, Peaslee, Wells, Keith, Kceberle, 
Dunlap, and Kimball stand high in the annals of surgery. 
It has become rather a favorite mathematical exploit for anni- 
versary orators to calculate how many centuries of life have 
been given to woman by the establishment of the operation of 
ovariotomy upon an enduring basis. We learn of twenty, thirty, 
forty, seventy successive operations without a single death; and 6 
REMOVAL OF THE UTERUS. 
we hear one of the most eminent of ovariotomists declaring it 
to be “ the safest of all the great surgical operations!” 
It is with the desire to put upon record further testimony 
from which may be drawn reliable deductions as to the pro- 
priety of removing solid or cystic tumors by laparotomy, when 
such removal involves the necessity of ablation of the uterus, 
that this clinical contribution is made. 
Case I.—Dora G., single, aged forty-three, entered the Wo- 
man’s Hospital in May, 1874. Six years previous to that time 
she had noticed an abdominal enlargement, which went on 
steadily increasing for three years, when she was told by a 
physician that it was a solid tumor of the womb. Two years 
before admission she was attacked by severe pain, which, from 
her description, was probably due to peritonitis. At the time 
of admission the patient was found to be very much emaciated, 
and the abdomen large and hard. She suffered greatly from 
constipation and from frequent micturition, and could sleep 
only in the sitting posture. The respiration was eighteen to the 
minute, pulse ninety-two, and large veins were found on the 
surface of the abdomen. The uterus could not be touched upon 
digital examination. The largest circumference of the abdo- 
men was found to be fifty-two inches; measurement from pubes 
to umbilicus fourteen inches, and from ensiform cartilage to 
umbilicus thirteen inches. 
The diagnosis of large fibrous tumor of the uterus was made, 
and upon consultation with Drs. Peaslee, Emmet, Metcalfe, 
Markoe, and Peters, operation was decided upon, and performed 
on the 18th of May. 
An incision four inches in length was made from the pubes 
upwards, and the hand being introduced, the tumor was found 
everywhere adherent to the abdominal walls and intestines, 
which were firmly attached to its lateral and upper surfaces. 
The incision was now extended upwards, the adhesions broken, 
many vessels tied, and the tumor lifted from its position in the 
abdomen by two assistants. A temporary clamp was. applied 
at the very lowest portion of the cervix, ligatures passed below 
it at right angles to each other, the pedicle securely tied, the 
clamp removed, and the stump kept between the lips of the 
wound by a long knitting-needle. A drainage tube was then 
introduced, the wound closed by silver suture, and the patient 
put to bed and quieted by opium. REMOVAL OF THE UTERUS. 
7 
The tumor was found to‘weigh exactly fifty pounds, and was 
a good specimen of uterine myoma. 
In thirty hours after the operation it became evident the 
patient was sinking from internal hemorrhage, and I opened 
the abdomen, removed a considerable amount of coagulated 
blood, and tied a large, bleeding vessel. As she did not rally, I 
transfused into her median basilic vein eight ounces of blood. 
After this she rallied and seemed much better. But oozing 
from large numbers of bleeding adhesions was evidently going 
on, and within the next twenty hours she sank rapidly. At 
the end of that time transfusion was again performed, and on 
the evening of the second day, that is, about fifty-one hours 
after the operation, she died. 
The following is a transcript of a report of the autopsy by 
Dr. John H. Beekman, pathologist of the hospital. Autopsy 
made twenty two hours after death:— 
“Body exsanguined, patient having died from hemorrhage. 
Decomposition commenced. Ho single point of hemorrhage 
could be discovered, but there seems to have been an oozing 
where adhesions had been torn through. On examining the 
kidneys the pelvis of the left was found distended with urine, 
and on following the ureter towards the bladder it was found 
sacculated at two places, and was finally discovered to be in- 
cluded in the pedicle, though it had escaped ligation. Both 
kidneys were fiitty and very much softened. Their surrounding 
cellular tissue was infiltrated with blood.” 
Case II.—This case has already appeared in print. I cite it 
here merely to make my experience complete at a glance. Mrs. 
C., a multipara, aged thirty-nine, of spare habit, had enjoyed 
good health until 187H, when, after being violently kicked in 
the lower portion of the abdomen by a child two years of age, 
she suffered severe pain for several hours, which was accompa- 
nied by a profuse leucorrhceal discharge for a few days. Four 
months after this she felt in the hypogastrium a hard mass 
about as large as a walnut. For this she consulted a physician 
of Middletown, who regarded the case as one of anteversion, 
and treated it by replacement twice a week by the uterine 
sound. Great nervous disorder and menorrhagia soon devel- 
oped, and the little mass rapidly grew. A consultation now 
being held, it was thought that pregnancy existed, and an 8 
REMOVAL OF THE UTERUS. 
attempt, at the production of abortion was made. At that time 
the tumor was as large as a three months’ pregnant uterus, was 
movable, and not painful, though tender upon pressure. An- 
other physician was consulted, who made the diagnosis of uterine 
fibroid, but thought that little or nothing could be done in the 
way of treatment. Dr. Mathewson, the present attendant, was 
then employed. Two years after this time pregnancy occurred, 
and advanced to a happy issue. During lactation, after this, 
the tumor could not be felt, but on the recurrence of menstrua- 
tion the mass appeared as large as a three months’ pregnant 
uterus, and, after a ride over a rough road, February ltf, 1678, 
she suffered for some time from severe pains like those of 
colic. The tumor increased in size steadily, and abdominal 
dropsy supervened, which by July, 1878, became so marked, 
and so decidedly interfered with respiration, that she consulted 
a physician of Boston with reference to the practice of electro- 
lysis. lie removed the abdominal fluid by aspiration, lessening 
the patient’s weight thirty-two pounds. From this time to 
November 20, she was tapped or aspirated seven times, and one 
hundred and ninety-five pounds of fluid were thus removed, the 
physician from Boston preferring this course to operation, which 
he thought would prove almost necessarily fatal. Soon after this 
time Mrs. C., acting under the advice of Dr. R. W. Mathewson, 
determined to visit New York and place herself under my care. 
I saw her on the 8th of December, and found her in the following 
condition: The abdomen was somewhat larger than it usually 
is at the end of the ninth month of utero-gestation, and upon 
palpation a large amount of abdominal effusion could readily be 
detected, together with the existence of a hard, rotund mass 
rolling about within it. Conjoined manipulation showed this 
mass to be connected with the uterus, and I decided that it was 
a round fibroid, of subserous character, growing, probably, from 
the fundus. The depth of the uterine cavity I do not remember. 
Although Mrs. C. was much emaciated, and greatly enfeebled 
by repeated losses of serum from tapping, I advised in favor of 
laparotomy, upon the following grounds. First, a solid uterine 
tumor existed, which was beyond the reach of medicine, and 
which, having fully established ascites, would in all probability 
perpetuate this until death closed the scene. Second, the dis- 
comfort resulting from abdominal accumulation would surely 
require repeated tappings, and it needed no power of prophecy REMOVAL OF THE UTERUS. 
9 
to tell what would be the end of such a course; and, third, the 
remainder of her life would be necessarily an existence of suf- 
fering, while laparotomy might possibly result in complete 
recovery. These considerations being laid before Mrs. C., she 
unhesitatingly decided in favor of making one effort for life, 
even although it appeared to be a desperate one. As for myself, 
I never for an instant doubted what the line of duty was, where 
all looked so dark if operation was not decided upon, nor would 
an untoward issue have shaken my conclusion in the least. 
On the 16th of December, at 3 P. M., laparotomy was per- 
formed, with the assistance of Drs. Hunter, Ward, Jones, 
Walker, and E. Mathewson. An incision about six inches in 
length was carried through the median line from a point below 
the umbilicus to one a little above the symphysis pubis. As 
this passed through the peritoneum, a very large amount of fluid 
escaped, and at once a large, round tumor presented itself to 
view. The surface of this presented a very peculiar appearance. 
Instead of looking like an ordinary fibroid, it was covered over 
thickly by a network of bloodvessels as large as the radial 
artery. These vessels did not belong to the tumor itself, but 
draped over it, and were slightly attached to its upper surface. 
They extended from the pelvic cavity upwards towards the omen- 
tum. I was at a loss to account for them, and can only offer, 
by way of explanation, the. suggestion that they developed in 
some false membranous expansion, which, being absorbed, had 
left them in the position just described. These vessels were tied 
with silk ligatures, not separately, but three or four together, 
on each side of the tumor, and then they were cut in two. The 
tumor was then lifted up by my assistants, and was found to be 
attached to the whole fundus uteri ; indeed, it seemed to be an 
expansion upwards of the uterus. 
Estimating as well as I could the point at which the tumor 
began, and the uterus ended—for of this I could not be certain 
—I passed a large mattress needle through, and left it in place. 
Then passing a double ligature of twisted silk through, just 
above this, I tied the two halves of the penetrated uterine 
fundus very firmly, and cut the tumor off. How much of the 
uterine tissue was cut away I cannot say, hut my impression is 
that as much was removed as could be taken, without opening 
into the uterine cavity. The abdominal wound was then closed 
by silver suture; the uterus, which was penetrated by the large 10 
REMOVAL OF THE UTERUS. 
needle, being held as a pedicle between the lips of the wound, 
and an antiseptic dressing was applied. All pain was quieted 
by morphia, the patient ordered milk diet, and perfect quie- 
tude enjoined. At 7 P. M., on the day of the operation, hemor- 
rhage occurred from the stump, but tightening the ligatures 
readily controlled this, and the patient went on to rapid and 
complete recovery. The operation being performed on Decem- 
ber 16, on the 3d of January the patient was sitting up out of 
bed. At the end of a month she went to her home in Connec- 
ticut. Dr. Mathewson, writing on May 7, says, “Mrs. C. remains 
well.” The tumor was a good specimen of the uterine fibroid, 
or myoma. It was as large as the head of a child of two years 
of age, and weighed three and a half pounds. Its tissue was 
not very dense, but no cystic formations existed in it. 
Case III.—E. A., aged thirty-four, married fifteen years, and 
mother of three children, the youngest of which was ten years 
old, had nine years previously suffered from certain irregulari- 
ties of menstruation, which led to the belief that she was preg- 
nant. This opinion proved to be erroneous, however, and it soon 
became evident that the abdominal enlargement, attributed to 
utero-gestation, was due to a tumor in the lower part of the 
abdomen, a little to the right of the median line. When first 
noticed, this was as large as a child’s head at birth, of which size 
it remained for four years; then it commenced to increase grad- 
ually until one year previous to admission to the hospital, when 
it developed very rapidly. 
Three years previous she was confined to bed for five weeks 
by a violent attack of peritonitis. Until three weeks before 
entering the hospital, she had suffered but little pain ; since that 
time she had experienced a great deal, and had been much an- 
noyed by pressure of the tumor against the stomach and dia- 
phragm, which caused indigestion and dyspnoea. During this 
time she had become rapidly emaciated, suffered greatly from 
night-sweats, and was unable to bear even the slightest exertion. 
The measurements of the tumor were the following: — 
Largest circumference 45 inches. 
Pubes to umbilicus 13 “ 
Ensiform cartilage to umbilicus 11 “ 
Some doubt existed as to whether the tumor was uterine or 
ovarian; but gradually I became convinced that it was of the REMOVAL OF THE UTERUS. 
11 
former variety, and that its removal would involve ablation of 
a part or the whole of the uterus. 
The patient’scondition soon became so wretched that I thought 
that very little hope would attend operation, and I delayed a 
resort to surgical interference during January, February, March, 
and half of April. By that time her condition had somewhat 
improved from rest, the most nutritious diet, malt, and vege- 
table and mineral tonics; and as the only hope of saving her 
life evidently existed in the removal of the tumor, I operated. 
An incision, four inches in length, was made from the pubes 
upwards, and a hard, solid tumor was found to occupy the ab- 
dominal cavity. In the hope of diminishing the size of this by 
the evacuation of fluid contents, I passed a long, slender trocar and 
canula into it, but without result. The incision was, therefore, 
prolonged upwards, so as to admit of the escape of the growth. 
On the right side very powerful adhesions were found to con- 
nect the tumor with the brim of the pelvis, which had to be 
broken very cautiously, as they were very vascular, and con- 
tained many arteries of considerable size, requiring ligation. In 
spite of every precaution, a good deal of blood was lost. On 
the same side the small intestines were very firmly adherent to 
the tumor, and were separated with considerable difficulty. 
The tumor and the uterus, from which it grew, were now 
lifted well out of the pelvis, and a steel clamp, nine inches in 
length, was fixed around the uterus, at the internal os. The 
tumor was cut away, the stump thoroughly charred with the 
actual cautery, a glass drainage-tube passed down into Douglas’s 
pouch, and the abdominal cavity, after having been thoroughly 
cleansed, was closed by silver suture. The operation, which was 
performed under the antiseptic method, lasted fifty-two minutes, 
and the tumor was found to weigh twenty-four pounds. 
The patient was put upon the usual sustaining treatment 
adopted after ovariotomy, the temperature was kept at about 
100° by affusion practised after Kibbee’s method, but the pulse, 
which at the termination of the operation was 140, never came 
down to the normal standard, and on the third day became very 
rapid and feeble, and the patient died. 
Case IV.—S. D., aged twenty-four, single, entered the Wo- 
man’s Hospital, January, 1879. Three years before admission the 
patient had noticed an abdominal enlargement, which had gone 12 
REMOVAL OF THE UTERUS. 
on slowly increasing until three months previous, when the in- 
crease became very rapid, and she sent for a physician, who told 
her that she had an abdominal tumor. 
Uuring these three years the patient had suffered little pain, 
but within the last year had steadily emaciated, so that on 
admission the arms, legs, and neck were greatly attenuated, the 
expression of her face anxious, and the complexion sallow and 
unhealthy. 
At this time the abdominal measurements were the follow- 
ing: — 
Greatest circumference 37£ inches. 
Pubes to umbilicus “ 
Ensiform cartilage to umbilicus 9 “ 
Right anterior superior spinous process to umbilicus . 9£ “ 
Left “ “ “ “ “ 9£ “ 
Up to two weeks before admission to the hospital the patient 
had been comparatively well, but at that time she had slipped 
in going down stairs, had struck violently upon the buttocks, 
and had since suffered from general malaise, feverishness, and 
pain over the whole abdomen. Upon examination the tumor, 
which was recognized as a uterine fibroid, was found to be 
exquisitely tender over its whole surface. The temperature 
of the patient was found to vary from 102° to 103°; and the 
pulse to range from 110 to 120. Some years ago I saw, in con- 
sultation with Ur. Hoeggerath, the wife of an eminent physi- 
cian of this city, who presented a history very similar to that just 
given. The patient had suffered for ten years from a large 
uterine fibroid, and felt comparatively well until one day she 
slipped upon the ice and fell heavily upon the buttocks. After 
this uterine hemorrhage came on, septicsemic symptoms devel- 
oped themselves, and the patient died. Autopsy revealed the 
existence of a clot of blood as large as a cocoanut in the centre 
of the tumor. It was a true hematocele, which had taken place 
in the tumor in consequence of the rupture of a blood-vessel pro- 
duced bjT the fall, and had given rise to septicaemia. Ur. Noeg- 
geratli very cleverly made a diagnosis of this previous to death. 
I ventured to make a similar diagnosis in the patient whose 
case I am now relating, and on account of it hastened operation. 
The tumor was removed by abdominal incision, and a large 
clamp placed around the uterus about its middle. The opera- 
tion was performed under the antiseptic method, lasted thirty- REMOVAL OF THE UTERUS. 
13 
seven minutes, and the tumor weighed twenty pounds. An 
incision through the centre of this revealed the existence of 
a mass of grumous blood about equal in size to a coeoanut. This 
had evidently been the focus from which septicaemia had taken 
its origin. 
The patient was sustained after the operation by nutritious 
enemata, hypodermic injections ot' brandy, and small amounts 
of food and stimulants by the mouth. Pain was quieted by 
opiates used by rectum and hypodermically, and the tempera- 
ture, which showed a marked tendency to rise, kept at about 
100° by affusion after Kibbee’s method; but the pulse steadily 
increased in rapidity and diminished in force, and on the fifth 
day the patient died. 
Autopsy showed a small amount of peritonitis only. 
Thus far my experience in removing tumors involving re- 
moval of the uterus had been by no means flattering. Out 
of four cases three had died and one had recovered! But I was 
encouraged to persevere by the facts that I saw several points 
in which I could improve my patients’ chances, and that I had 
thus far operated solely upon cases in which the only possible 
chance which could be offered the patient was a resort to sur- 
gery. I felt conscientiously that to deprive the patients of this, 
even although it were not a very bright one, when the alterna- 
tive was certain death, was not in accord either with the dictates 
of true surgery or of enlightened humanity. 
Case V.—Mrs. E., aged fifty-four, native of Dover Plains, New 
York, the mother of one child twenty-seven years of age, was 
admitted to the Woman’s Hospital, December 18, 1879. The 
patient had noticed a hard lump fourteen years before, and 
twelve years previous to admission had consulted Dr. Emmet, 
who pronounced it a fibrous tumor. Since that time it had 
steadily increased until it had reached very large dimensions. 
During the patient’s stay in the hospital prior to operation, 
she suffered very much from indigestion, constipation, and 
dyspnoea. Her expression was anxious and her limbs much 
emaciated. Upon physical examination the uterus could nowhere 
be touched, so completely was it drawn up out of the pelvis. 
On the 3d of January the tumor was removed. An incision 
four inches long being made from the pubes upwards in the 
median line, a very large tumor was exposed, which was half 14 
REMOVAL OF THE UTERUS. 
solid and half fluid in character, and which was fortunately 
found but slightly adherent to the abdominal walls. The fluid 
portions of the tumor, constituting probably a little more than 
half of its bulk, were evacuated by a long, slender trocar, and 
the incision being then prolonged the solid portions of the tumor 
within reach were removed from the abdominal cavity. It was 
found that the tumor had drawn the uterus high up out of 
the pelvis, and that that organ was so thoroughly united to it, 
that uterus, ovaries, and tumor would have to be removed toge- 
ther. The bladder was stripped away from its attachment to the 
anterior wall of the cervix, the vagina just below the os externum 
was transfixed by Peaslee’s needle, a strong, double carbolized 
silk ligature was drawn into position, the mass cut away removed, 
and the abdominal cavity, after having been thoroughly cleansed, 
closed by silver suture. 
The patient was put upon the customary treatment after 
ovariotomy, all pain quieted by opium, nutrition kept up by 
enemata, and the temperature kept at about 100° by Ivibbee’s 
method. 
On the 29th of March, eighty-five days after operation, the 
patient returned to her home well. 
I have heard from her within the past month, and she tells 
me that she lias entirely recovered. 
The tumor was carefully examined by Dr. W. H. Welch, 
pathologist of the hospital, and was at first thought by him to 
be a uterine fibro-cyst. Upon more careful examination, how- 
ever, he found it to be an ovarian tumor of composite form, 
which had developed between the layers of the broad ligament 
and forced the uterus out of the pelvic cavity. 
The tumor and uterus were upon his examination found to 
be entirely inseparable. 
Case VI.—Mrs. J. E., aged fifty-nine, the mother of six chil- 
dren, was admitted to the Woman’s Hospital, January 26,1880. 
Three years ago she noticed a small tumor in the right side of 
the abdomen. For two years this had grown slowly, but during 
the last year had developed very rapidly indeed. During that 
time she had become very much emaciated, and upon my first 
examination had an anxious facies, a reddish tongue, and slight 
oedema of the feet. Physical examination revealed a very large 
abdominal tumor, the uterus much elevated in the pelvis, sur- REMOVAL OF THE UTERUS. 
15 
face of tumor irregular, and the growth evidently consisting of 
a mixture of solid and fluid elements. 
The following was the result of abdominal measurements:— 
Greatest circumference 44 inches. 
Pubes to umbilicus 9 “ 
Eusiform cartilage to umbilicus 9 “ 
Right anterior superior spinous process to umbilicus .11 “ 
Left “ “ “ “ “ 121 “ 
On the 22d of February I removed the tumor through an in- 
cision in the median line five inches in length. By means of a 
trocar I evacuated a large number of cysts, and by powerful 
traction drew out the solid masses of the tumor, to which I 
found the uterus so firmly attached that its separation was out 
of the question. A portion of the sac dipped into the pelvis 
behind the uterus, and was so adherent there that it was im- 
possible to remove it. Drawing this up as far as possible, I sur- 
rounded it, the remaining portion of the sac, and the uterine 
neck at as low a point as I could without compressing the 
bladder with a large clamp, and cut away uterus and sac. I 
then cauterized the stump thoroughly with a hot iron. 
The patient was put upon the usual treatment, and the sac 
syringed out with carbolized water every fifth hour. A day to 
day record of the progress of the case would be as unnecessary 
as it would be wearisome. It suffices to say that the patient 
entirely recovered, and was discharged from the hospital on the 
19th of May, three months after the operation. 
The portion of uterus within and below the clamp, which was 
removed on the fourteenth day, entirely sloughed out; the open- 
ing which was left by its removal being slowly filled up by 
granulations. 
The tumor examined by Dr. Welch was found to be a com- 
posite ovarian cyst, very similar to that last described. 
Case VII.—Mrs. E. B., age uncertain, but probably about 
forty, a native of Oldtown, Maine, married eight years, and 
mother of one child seven years old, entered the hospital in 
February, 1880. 
Two years ago patient noticed a hard lump in the left iliac 
fossa. This continued to grow for a year, when it suddenly 
disappeared with great pain and prostration, and her physicians 
declared that the tumor had burst. After a month, however, 16 
REMOVAL OF THE UTERUS. 
it reappeared, and for the past year has increased very rapidly. 
She suffered from occasional pain through the pelvis and a sense 
of weight and pressure from the tumor. 
The abdominal measurements were the following:— 
Greatest circumference 34£ inches. 
Pubes to umbilicus 8 “ 
Ensiform cartilage to umbilicus 8 “ 
Right anterior superior spinous process to umbilicus . 9 “ 
Left “ “ “ “ “ .8 “ 
On the 23d of March the tumor was removed through an in- 
cision live inches in length through the median line. By means 
of a trocar a large amount of thick, bloody fluid was evacuated, 
hut on the right side there was a hard mass the size of a seven- 
year old child’s head, which had to he dragged through the 
opening. To this the uterus was firmly adherent. 
The lower portion of the sac, that within the pelvis, was so 
completely adherent to large folds of small intestines, that sepa- 
ration could not be thought of. Lifting the uterus, solid mass, 
and liberated portion of the sac high out of the pelvis, I now ap- 
plied my large steel clamp as low down on the cervix anteriorly 
as the vesical attachment would permit, and as low down poste- 
riorly as the point at which the intestines were attached, I in- 
serted a drainage tube, tightened the clamp around the whole, 
and cut away the uterus and the tumor. 
The pedicle was then prevented from slipping by being trans- 
fixed just above the clamp by four knitting-needles, passed at 
right angles to each other, the stump was thoroughly seared by 
the actual cautery, the abdominal cavity cleansed and the wound 
closed by silver suture. 
The operation was performed under the antiseptic method, 
and lasted forty minutes. The tumor weighed twenty pounds 
and a half. 
The patient was put upon the usual treatment after ovariot- 
omy, and the retained sac syringed out with carbolized water 
every five hours. 
The patient developed no bad symptoms and went on to com- 
plete recovery, being discharged May 17th, a little less than two 
months after the operation. 
The portion of the uterus in and below the clamp entirely 
sloughed out; the cavity which was left healing by granula- 
tions, so that no trace of the organ remained. REMOVAL OF THE UTERUS. 
17 
Dr. Welch, who pronounced the tumor to be a very peculiar 
form of uterine fibro-cyst, or cysto-myoma, has very kindly 
handed me a very elaborate report of it, which I here append. 
Dr. WTelch’s report of Mrs. B.’s case. 
“ CYSTIC MYOMA. 
In connection with the part of the tumor extirpated, there 
were removed both ovaries, the fundus and upper part of cor- 
pus uteri, the left Fallopian tube entire, a part of the right 
tube, the left parovarium, and portions of the broad ligaments. 
The portion of the cyst wall removed (apparently its upper 
and anterior portion) measures 24 centimetres in breadth 
(laterally), and 18 centimetres in height (vertically). Its median 
surface is in close apposition with the portion of uterus removed, 
hut is separated from it by a little lax connective tissue. The 
cyst wall is furthermore adherent to fundus uteri by old 
fibrous adhesions. The portion of uterus removed measures 6 
centimetres in breadth at fundus, 4 centimetres in length, and 
3 centimetres in antero-posterior diameter. A probe passes 
2| centimetres into the uterine cavity. The left Fallopian 
tube, with its fimbriated extremity, has been removed entire. 
It measures 11 centimetres in length, is pervious, and appears 
normal. It is separated from the outer surface of the tumor by 
the upper portion of the broad ligament (mesentericus tubal), in 
which can be distinctly seen the normal contours of the paro- 
varian tubules. The right Fallopian tube has been severed close 
to the uterus ; but a detached portion, measuring 10 centime- 
tres in length, and not including the fimbriated extremity, has 
been removed, and remains attached to the tumor by a short 
mesenterium tubal. With this exception, none of the right 
broad ligament was removed, it having been cut close to the 
uterine wall. 
The right ovary was removed, and is present in a separate 
piece. It is of normal dimensions and appearance. It contains 
two corpora lutea, one small and yellow, the other large, with 
gray convoluted walls and bloody contents. (These were proven 
to be corpora lutea by microscopic examination.) The left ovary 
has also been removed, and lies at the line of junction of left 
mesenterium tubal, with cyst walls. Although preserving the 18 
REMOVAL OF THE UTERUS. 
contours of a normal ovary, it is much flattened out by the pres- 
sure of the tumor. It measures 5 by 4 centimetres. It pre- 
sented under the microscope the normal ovarian stroma, 
containing even ova, but no large G-raafian follicles, and showed 
clearly the parenchymatous and vascular zones. The left ova- 
rian ligament is very much thickened, and for a portion of its 
extent is incorporated with the cyst wall. The right ovarian 
ligament was cut off close to the uterus. With the exception 
of a subserous myoma, about the size of an almond, near the 
left cornu, the uterus appears essentially normal. The tumor, 
as far as can be judged from the portion removed, is a unilocular 
cyst. Its external surface is smooth and glistening, and pre- 
sents numerous fibrous adhesions. The peritoneum passes con- 
tinuously from the uterus and the upper portion of the broad 
ligament upon the outer surface of the tumor. The tumor seems 
to have grown between the layers of the lower part of the left 
broad ligament, and into the pelvic and surrounding connective 
tissue, displacing the uterus forwards and upwards, and con- 
tracting adhesions with the right ovary and Fallopian tube. 
The wall of the cyst varies considerably in thickness in differ- 
ent parts. Its average is 4-6 millimetres in thickness; but in 
some places it is very thin, measuring only 1 millimetre; in 
others very thick, 4-5 centimetres. The thickest part of the wall 
corresponds to an ill-defined myomatous growth, in its anterior 
wall. There are several smaller myomatous nodules in the cyst 
wall, some distinctly circumscribed. In most places, two layers 
can be distinguished, of about equal thickness, in the wall, 
firmly united, an outer, laxer and paler, and inner firm and 
gray. 
The microscopical examination shows the chief constituent of 
the cyst wall to be smooth muscular tissue, in the form of in- 
terlacing bundles and fibres. These muscular fibres have no 
more regularity in their arrangement than in an ordinary ute- 
rine myoma, appearing now as longitudinal, and now as trans- 
verse or oblique sections. The smooth muscular tissue is mixed 
with a considerable amount of connective tissue, which in many 
places, especially in the outer wall, is distinctly mucoid in 
structure. The inner layers are in many places rich in round 
and flat cells, and contain considerable yellowish blood pigment. 
There is no epithelial lining to the cyst, although the inner sur- 
face is comparatively smooth ; in many places quite as smooth as REMOVAL OF THE U T ERUS. 
19 
in ordinary parovarian cysts. Careful search was made both 
upon the fresh and hardened specimens for an epithelial lining. 
In most places the smooth muscle-fibres closely compacted, and 
in parallel arrangement, constitute the inner lining. In some 
places the inner border is hyaline and structureless. There are 
numerous lymph-spaces (interstices) in the cyst wall, but they 
are of microscopic dimensions, and not notably dilated. It is 
not apparent in what way the cyst-cavity was formed, or what 
metamorphosis the muscular tissue has undergone in its devel- 
opment. 
The fluid contained in the cyst is thin, dark-brown in color, 
neutral in reaction, and of a specific gravity of 1012. It contains 
mucin in small amount, and also gives the reactions of alkali- 
albumen, with acetic acid and its alcoholic precipitate (so-called 
paralbuminous reactions). It contains a large amount of serum- 
albumen. It has no tendency to coagulate spontaneously. A 
considerable sediment settles at the bottom, consisting in greatest 
part of red blood-corpuscles (to which the fluid owes its color), 
some white blood-corpuscles, and granular corpuscles, most of 
which contain a nucleus. There are in addition some free fat 
molecules, brownish pigment, and a few corpora ainylacea.” 
It will be seen that this paper embodies the results of seven 
cases, in one of which the whole fundus, in one the whole body, 
and in five the entire uterus were removed. Four of the tumors 
demanding the operation were large solid fibroids, with no 
cystic elements; one was a fibro-cyst, partly solid, and partly 
fluid; and two were peculiar ovarian tumors, which, develop- 
ing between the layers of the broad ligaments, lifted the uterus 
entirely out of the pelvis, and made it a mere addendum to 
their walls. 
Out of the seven cases four recovered, and three died. The 
three fatal cases were all operated on for large solid tumors. Of 
the four successful ones, one was a case of solid uterine fibroid, 
one a case of large fibro-cyst, and two were cases of ovarian cysts, 
with large amounts of solid material in their walls. In recog- 
nizing this fact, it must be borne in mind that a tumor suscep- 
tible of diminution of size by tapping does not render the ope- 
ration of laparotomy as dangerous as one which, being entirely 
solid, involves the necessity for a long abdominal incision. 
As far as my knowledge extends, no one in our country has 20 
had so large an experience in this formidable operation as our 
distinguished Fellow, Dr. Gilman Kimball, of Massachusetts. 
He informs me that he has removed the uterus fourteen times, 
nine times for solid, and five times for fibro-cystic tumors, with 
the excellent result of six recoveries and eight deaths. In some 
of his cases the whole, in others a part only, of the uterus was 
removed. 
Let us hope that the next decade will give us even better 
results than these, and that an operation ad hoc sub judice may 
by the end of that time have achieved for itself a firm and en~ 
during position. 
REMOVAL OF THE UTERUS.