(From the Richmond and Louisville Medical Journal, for April, 1870.) 
Tumor of the Left Ovary; Large Tumor 
from Bight Broad Ligament; Preg- 
nancy Coexisting; Incision; Abortion, 
BR J. TAYLOR BRADFORD, M.D., 
OF AUGUSTA, KY. 
Mr. S., of Boonville, Mo., wrote me, that “his wife 
had ovarian tumor, and during the last two months, the 
tumor had increased so rapidly, that some surgical inter- 
ference would have to be instituted, and that he would 
send her to Paris, Ky., where her parents reside, for me 
to operate on.” In another letter, he says, “I have a 
medical education; (mark the historical connection with 
coming events); have been married three years; my wife 
had been in bad health before we were married; her 
monthly sickness had been irregular, but after taking 
iron, etc., she had become regular; last Spring she caught 
cold; menses ceased, but appeared again, and at such 
times, without pain.” 
When Mrs. S. arrived at Paris, Ky., she wrote me: 
“The tumor is growing so rapidly that I can not lie 
down, and hope you will set an early day for the opera- 
tion. My husband has written you the symptoms of the 468 
Clinical Kecords. 
[April 
case ; there is one thing I must tell you ; for several years 
before I was married I had bad health ; I had been 
treated for chronic disease of the stomach and bowels, 
but had a swelling in the left side, which had not gone 
a\Vay, when I was married; one year after I was married, 
the right side became fuller. My monthlies, both before 
and since I was married, were irregular, but after taking 
iron and tonics, they appeared again, and since that, with- 
out pain.” 
When I visited Mrs. S. in Paris, in company with Dr. 
Ray, the details of her case were much as her letter pur- 
ported, except, that it was then time for her monthly 
sickness, and if not on her then, from her feelings it soon 
would be, and that her husband had written her from Mis- 
souri, that, she must recollect, that was the time for her 
monthlies, and if Dr. Bradford thought best, to postpone 
his coming until it passed off. I postponed, for the pres- 
ent, a minute examination, as I did finally, altogether, for 
a reason yet to be stated. Prior to my visit, Dr. Ray 
wrote me, that he had examined the case, and had diag- 
nosed two tumors, in which, as it turned out, he was 
correct. On account of expected or existing menstrua- 
tion, I postponed the operation two weeks, but examined 
carefully the tumors in the abdomen. Over the entire 
abdomen, fluctuation was distinct, save a space over the 
left side. The patient said to us then, that the disten- 
tion was so great that she could not lie down, and the 
only sleep she got was while sitting up in bed. 
On the left side of the abdomen the tumor was more 
dense, yet a seeming and not to be doubted fluctuation 
was manifest. Pressing down a little to the left of the 
mesian line with a continued and jostling pressue seemed 
to enable you to separate what appeared to be two tumors; 
or otherwise the cyst must be multilocular. My reason for 
believing that Dr. Ray’s opinion was correct, and that 1870.] 
Clinical Records. 
469 
the case was not a mnltilocular tumor, was based upon the 
fact, that when you press steadily and firmly over a multi- 
locular cyst, and you come to the depressions dividing the 
cysts, you feel the elastic resistance at that point, whilst in 
the other, there is no defined point on pressure, if two tu- 
mors exist, and are not adherent. Both from the account 
of the husband and patient, the tumor was increasing rap- 
idly ; fluctuation was unmistakeably distinct over it; 
while there was inability to lie down, and the only sleep 
that was obtained was during the sitting posture, such 
sleep being of short duration. The question naturally 
came up in my mind, if pregnancy does, by mere possi- 
bility, exist, whether is it possible, from the history of 
the case, for it to have existed over two or three months, 
and if so, will the chances of the patient be better to go on 
with the operation in a few days, or take the chances of 
her threatening condition for several months longer. I 
determined at once (no material change occurring), to 
commence the operation in two weeks. In consequence 
of this decision, the digital examination, the use of the 
sound, stethoscope, etc., etc., was dispensed with, but in 
this, as in many such cases, if, not adopting a certain 
routine, any accident happens (whether it could have 
been avoided or not), the public and a few illiterate phys- 
icians look upon it as the result of negligence. To those 
then, who are tender about their reputation, even in the 
face of certain contingencies, it may be well for them to 
go through this often useful routine, whether material to 
the case or not. I returned to Paris, and in two weeks 
there were no further developments, save that the monthly 
sickness did not occur. I further learned from the 
mother, that there was often irregularity of the monthly 
sickness, with fullness in the lower part of the obdomen,. 
(on the left side) prior to marriage. 
With Drs. Ray, Barnes and Fithean, selected from; Clinical Records. 
[April 
among the physicians by the patient, (and here I desire 
to say, that no one of these physicians is in any way re- 
sponsible for the operation, although no one of them, 
from the facts elicited, had the remotest idea that preg- 
nancy existed, or doubted that the operation was justifia- 
ble), I commenced to operate. 
When the incision was completed down to the tumor, 
a flaccid, watery, and exceedingly thin-walled membran- 
ous tumor was found to he spread out over the firmer one 
on the centre, and to the left. A little manipulation al- 
lowed me to shove this back to the right side, and come 
directly to the more solid part beneath. When this was 
done, it exposed to view an exceedingly vascular tumor 
of about the color of currant jelly, rugous and velvety 
in its external wall. The tumor extended so far up that 
the incision had to be extended some distance above the 
umbilicus, in order to examine its surroundings. The 
tumor| when thus exposed, was still seemingly elastic, 
but it struck me then, (as it has oftem before, in explora- 
tion to complete diagnosis, as certainly fatal in any event), 
that I have never seen one of this kind, where even a 
simple incision was made, if it was punctured, but that it 
proved fatal, whether an attempt was made to remove it 
or not. It is neither a fibrous tumor, nor is it a cystic. 
Sarcoma, a proper name for them, has not been chosen. 
They are peculiarly vascular and bleed, from the punc- 
ture of a needle or the slightest touch, astonishingly. 
The seeming fluctuation, however, was deceptive as 
usual, in this kind of tumor, and the trocar four inches 
in length, was plunged into it. hfot a gill of water es- 
caped, but it continued bleeding, so much so, that I drew 
the orifice, made by the trocar, as closely together as I 
could, by the “shoemaker’s stitch.” 
A tumor like this I recently encountered in Glendale, 
Ohio. Drs. Comegys and Blackman had been in consul- 1870.] 
Clinical Records. 
471 
tation in the case. Capt. Haldeman came to Augusta, 
to have me examine the case, and in connection with 
Prof, Wood, we proceeded to the examination. After 
the usual tests and manipulations by both of us, Dr. Wood 
coincided with Profs. Comegys and Blackman, that it 
was disease of the uterus, but said candidly, that he was 
not quite sure, and nothing but an exploratory incision 
would decide it. I had taken the ground that it was an 
ovarian tumor, but that it could not be removed in all 
probability. I made the incision, Prof. Wood assisting, 
when a tumor like the one I have described, (ovarian), 
but connected and adherent tirmly to the womb, was ex- 
posed. 
From tormer cases of this nature, the fact flashed 
upon me, with a “flesh quake,” such as comes at times, 
that the tumor could not be removed. At once, how- 
ever, I proceeded to examine the surroundings. Run- 
ning the hand around on the left side, I found the base 
of the tumor adherent to the peritoneum and portion of 
the pubis upon its outer wall; then searching for the 
womb, it was found unusually enlarged, and as I thought 
then, the size of a cocoanut, with the left wall of it 
completely adherent to the tumor; making on that side 
a common wall. The womb was immediately under, 
and to the inner side of the tumor, and rising some dis- 
tance out of the pelvis. At this juncture, I directed Dr. 
Barnes, who was standing near me, to examine the con- 
nections of the womb; he did so, and was, I believe, the 
only one of the physicians who did. Extending the ex- 
amination to the flaccid and watery tumor, I found the 
tumor to be from the broad ligament, and not from the 
ovary. This tumor was very large, and would have 
probably yielded, in weight of fluid, pounds. 
Prof. Simpson, Dr. Wilson Fox and Mr. Spencer Weils, 
with their large experience, are not correct in asserting, 472 
Clinical Records. 
[April 
that such tumors rarely attain the size of the human 
head; I have a tumor in my office of twenty-four pounds 
weight, removed in Bracken county, Ky., (Brs. Moore 
and McMillen present), with the ovaria removed in the 
normal state. 
I did not tap the flaccid tumor, from the fact, that I 
believed the tumor would prove fatal in any event, and 
if the patient recovered, it could be tapped, with appro- 
priate remedies for its subsequent removal. I closed up 
the wound and in two days after, abortion ensued. The 
poor woman died some twenty-four hours after. I re- 
gret for the better satisfaction of the profession, that no 
post-mortem was allowed. The incision, however, was 
of such extent, as to establish beyond a doubt, its true 
character, etc., etc. I confess, that whilst I should like 
to have done better, I did not know how I could (surgi- 
cally) have done less. 
For the past ten years I have had but little inclination 
to make a display of my cases of ovariotomy, much as 
I have had to do with this subject, and much as I have 
been interested in it. Of the last nineteen completed 
operations, I have not published one; the success of 
these, and the former ten, I leave for the present, to the 
limited area in which they were performed. But now, 
that I have had one marked case and one shrouded in 
the peculiar mystery, in which this branch of surgery is 
occasionally involved, dubious perhaps, as to proper sur- 
gical procedure, I hasten to give a faithful account of it. 
Br. Thomas, in his recent and able work on “Diseases 
of Women/’ says in regard to ovariotomy: “It is not 
only difficult but utterly impossible, even for the most 
capable and accomplished diagnostician to arrive at a 
certain conclusion. Experienced operators have opened 
the abdomen under erroneous impression as to the na- 
ture of the tumor, and absolutely removed the morbid 1870.] 
Clinical Kecords. 
473 
growth and the womb from which it grew, before a diag- 
nosis was made.” 
When the distinguished Sir Astley Cooper and Dr, 
Highton, of London, fixed a day to tap a patient for 
ovariotomy; the day before the tapping, the patient gave 
birth to a child. (Brown’s Surgical Diseases of Women, 
p. 170), It was looked upon then as wonderful negli- 
gence; but now that similar mistakes have occurred to 
the best operators, and that such unpublished cases, are 
in numbers, legion, it has become an acknowledged fact, 
that he who has followed the routine of ovarian tumor, 
diagnostics, with their varied and often complicated 
phases, and has not met with deceptive occurrences in di- 
agnosis, however well “winnowed his thoughts,” search- 
ing his scrutiny or strong his apprehension, is some 
Messiah, whose history is yet to be written. 
Lizars, of England, assisted by the ablest men of Lon- 
don, made an incision for ovarian tumor; no tumor was 
found, but obesity the only result. (Edin. Med. and 
Surg. Jour., 1824, vol. xxii.) 
King, of England, made an incision of eight inches for 
ovarian tumor. After minutes search in the ab- 
domen ;no tumor could be found. (London Lancet, J an. 
1837.) 
Prinel diagnosed a case of ovarian tumor; operation; 
fifth day patient died. The post-mortem revealed a pe- 
diunculated tumor of the spleen. (Am. Jour. Med. ScL 
for October, 1852.) 
Dr. Henry Smith relates a case, where an incision of 
eight inches in length was made for ovarian tumor; 
both ovaries were found to be sound, and indurated 
omentum found to be the source of the error. (Phila. 
Med. Exp., Jan., 1855.) 
Smith and McDowell; patient tapped ninety times; 
diagnosis considered certain, as to ovarian tumor; no 474 
Clinical Records. 
[April 
tumor found, but a mass of intestines matted together, 
with fluid. 
In the Appendix to Cooper’s Surgical Dictionary, 
Lyman relates the case of Boinett, where the best sur- 
geons were unable to decide as to the character of the 
tumor. The consultation being among the most event- 
ful of the age; consisting of Roux, Blondin, Montaine, 
of Lyons, Recamier, Jobert, Martin, Solin, and others; 
opinions were divided as to ovarian tumor, uterine dis- 
ease and pregnancy. The tumor disappeared after an 
attack of diarrhoea. 
Harvey presented a case to the London Medical Soci- 
ety, where ovariotomy was determined on; patient died 
suddenly; no tumor found, but an hydatid cyst connected 
with the liver. (Am. Jour. Med. Sci., October, 1852.) 
Dr. Philip Buckner, (originally from Kentucky, and 
to whom I am indebted for my first sight of ovarian 
tumor, 1845), diagnosed a case as ovarian tumor; made 
an incision of nine inches ; no ovarian tumor found, but 
a tumor situated in the mesentery. The tumor was dis- 
sected out; the superior mesenteric artery and other 
small arteries were tied. Patient recovered. This, says 
Mr. Brown, of Edinburg, is the most hazardous feat of 
operative procedure lam acquainted with; in which our 
transatlantic brother has surpassed us. 
Dr, T. Q-aillard Thomas says, “on one occasion I had 
a patient presenting all the usual signs of fluid ovarian 
tumor so perfectly that Dr. Peaslee, Loomis, Budd and 
myself had no doubt as to the fact; upon incision and 
tapping, no fluid was found; upon removing the tumor, 
no one could be convinced that its contents were not fluid, 
except by sections of the mass.” 
Dr. Peaslee and Dr. John O’Riley have had similar 
cases. (Thomas’ Diseases of Women, p. 588.) 
Dr. Burd; patient had a tumor of twelve and a half 1870. J 
Clinical Records. 
475 
months growth; swelling irregular and apparently solid; 
health good; no signs of pregnancy; cyst removed; 
womb found to be three or four months pregnant; abor- 
tion ensued the second day; the placenta gave evidence 
of their having been haemorrhage, and this was mistaken 
for menstruation, in deciding upon the operation. (Lon- 
don Lancet, 1847—Lyman.) 
Dr. Frederick Bird cites the case of a tumor of six- 
teen years standing. Seven years of that time, menses 
did not occur ; pressing necessity required the operation; 
no pregnancy ; recovered. London Med. Gaz., vol. 32.) 
Galenzowski; patient had a tumor of two years growth; 
not removed; seven months pregnant; abortion; lin- 
gered some time; ultimate result not known. (Med. Ga- 
zette, vol. v., 1829.) 
Dr. Twofford ; two tumors; one adherent to the womb, 
the other extra-uterine; the latter containing the limbs 
and trunk of a child ; the head and upper extremities 
having passed into the general cavity ; patient recovered; 
nothing said of menstruation. (Rankin’s Abstract, vol. 
ix., p. 279—Atlee.) 
Dr. Washington Atlee, of Philadelphia, operated for 
ovarian tumor; patient was two months pregnant; no 
miscarriage; died of starvation. (Transactions Am. 
Med. Asso., 1851.) 
Dr. Frederick Bird operated for ovarian tumor; no 
signs of pregnancy; abortion second day; recovered and 
had a child subsequently. (Medico-Chir. Trans., vol. 30.) 
From a hasty reference to my case-book, I give these 
exceptions to correct diagnosis in ovarian tumor. With 
a little time, their number might be increased to a small 
sized volume. They are sufficient, however, to illustrate 
how difficult it is at times, under circumstances of such 
complicated contingencies as may arise, to arrive at the 
undisputed result of accuracy. The best of surgeons, in 476 
Clinical Records. 
[April 
this class of diseases, as all surgical history teaches, must 
learn, that “he that thinketh he standeth, take heed lest 
he fall.” 
Our own distinguished operator, l)r. Washington Atlee, 
with the leading operators of Europe, have actually 
operated, not only where supposed pregnancy did exist, 
(deciding between the lesser or the greater risk), but 
where, after careful investigation, they felt sure in the 
beliet that pregnancy did not exist. In the statistical 
reports of Sir Robert Lee, Atlee, Lyman, J. Clay and 
Peaslee, the cases of pregnancy complicated with the 
ovarian tumors are numerous, and operations for ovarian 
tumor, (with the undisputed accuracy of leading opera- 
tors and diagnosticians), have resulted in discovering of 
the complication of pregnancy, after the operation was 
commenced. These facts should comfort all surgeons 
who may have the misfortune to make a faulty diagnosis. 
It is said by the historian, Macaulay, that the “history 
of the errors and maladministration of governments, 
are essential to the generation which follows so it is 
with ovariotomy ; but whether the present case will re- 
ceive that charitable deduction incident to its eventful 
history and peculiar collateral concomitants at the time 
of the operation, it nevertheless, must have its instructive 
lesson, of increased caution and diligence for the future. 
An examination, per vaginam, is by no means a sure 
test of pregnancy, and if an operator has decided, as has 
often been done, to go on with an operation from the 
contingencies which may have arisen, whether pregnancy 
existed or not, why the necessity for this or other tests? 
The medical jurisprudence of the age teaches us how 
difficult it is sometimes to determine pregnancy, even 
where there are no tumor complications. I know of an 
unpublished instance, in this State, where a young lady 
of respectable family, had swelling of the abdomen, with 1870.] 
Clinical Records. 
477 
such health as to confine her to the bed. A shrewd 
old lady, who was in the habit ot visiting her, unguard- 
edly said, “there is something living inside.” The re- 
port was thus commenced, and during its gossiping 
rounds, a grave and able medical board was summoned ; 
on this was a prominent man of this State; after several 
hours consultation and examination, the verdict was—“a 
foul slander.” The result was, that in three months 
more, with all the blistering, hot fomentations and poul- 
tices, that the genius and skill of this medical board 
could bring to bear upon the swelling, it would not 
“down,” until nine calandar months had duly passed, 
since the period of its commencement. It then subsided? 
and when the doctors examined the cause of this sub- 
sidence, it proved to be the birth of a—male child. 
For the past fifteen years I have devoted much time 
to this branch of surgery. Reading all that I could find, 
which pertained to it, and avoiding, as far as possible iu 
my operations the “quick sands,” which encumber it; 
but I confess, sincerely, that no case (within my knowl- 
edge) which has occurred in any country, has developed 
the same peculiarity, or is more instructive to the diag- 
nostician. Wejhave here, from patient, husband and ex- 
amining physician, not a symptom or vistage of preg- 
nancy—menstruation declining and occurring, and reoc- 
curring closely, if not up to the time of the operation ; 
a flaccid, floating tumor from the broad ligament of the 
right side, spreading over the tumor ot the left side, as 
well as the womb ; with fluctuation over almost the en- 
tire abdomen, distinct and unmistakeable, and yet, preg- 
nancy existed. 
I make the following deductions from this case ; that 
the peculiar condition of the patient, (leaving out her 
singular history) justified the commencement of the ope- 
ration, with or without the possibility of pregnancy. 478 
Clinical Records. 
[April 
That in no event could the life of that patient have been 
saved, and only in one, could it have been prolonged, 
even for a time. Mmenstruation occurred for some time 
before the operation, it occurred at regular periods, as is 
evinced by the expectant period when I first visited the 
patient, and if the discharge was from the placenta, how 
strange, that it should have occurred at given periodical 
periods. 
From the relative position of the tumors and the 
womb, could the most delicately applied tests (taking 
into account the history of the case), have detected preg- 
nancy ; and if detected, by the merest possibility, what 
should have been done ? Leave the patient to the emer- 
gency of the encroaching tumors and growing womb, 
or take the remote chances of the possibility of preg- 
r,,Tifh its results ?