CASE 
or 
EXTIRPATION OE A BILOCULAR OVARIAN CYST 
THE 
LARGE PERITONEAL SECTION. 
WASHINGTON L. ATLEE, M. D., 
Of Lancaster, Penn., Professor of Medical Chemistry in the Medical Department of 
Pennsylvania College, Philadelphia. 
READ BEFORE “THE LANCASTER CITY AND COUNTY MEDICAL SOCIETY,” 
April 17th, 1844. 
[From the American Journal of the Medical Sciences for July, 1841.] 
PHILADELPHIA: 
T. K. & P. G. COLLINS, PRINTERS, 
NO. 1 LODGE ALLEY. 
1544. CASE 
OF 
EXTIRPATION OF A BILOCULAR OVARIAN CYST 
BT THE 
LARGE PERITONEAL SECTION. 
December 13th, 1843,1 was requested by Dr. Adam Shellar, of Mountjoy, 
to visit Mrs. S., of Chicques, for the purpose of performing paracentesis 
abdominis in “dropsy of the abdomen.” A mere glance at the abdomen 
induced me to doubt the existence of peritoneal dropsy, and upon a close 
examination I was fully satisfied that there was encysted or ovarian dropsy. 
As Dr. Nathaniel Watson, one of the attending physicians, was not present, 
and as the case would probably prove to be of more importance than had 
been anticipated, I proposed to postpone the operation until the 15th, in 
order that both the medical gentlemen might be present at the time of de- 
ciding upon the character of the disease by tapping. 
Accordingly, upon the 15th, I again visited the patient, and received the 
following history from her: 
She was 61 years old on the 26th of last November, never had had any 
children, did not believe she had ever conceived, had menstruated regu- 
larly in early life, and passed through her menstrual period at the age of 40 
years, without any untoward symptoms. For four or five years she felt a 
fulness in the lower part of the abdomen, which has gradually increased 
until the present time. Her attention had first been called to the enlarge- 
ment of the abdomen by a soreness there, which made it painful when 
she came suddenly against any object. Flow long she may have been 
swelled before this she does not know, but believes not long. About this 
period, and since, she frequently complained of pain in her right side, and 
would suddenly press with her open hand just above the hip bone. Before 
noticing the swelling she became very much constipated, and has continued 
so ever since, having recourse to small doses of Epsom salts as a daily laxa- W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
4 
tive. The process of defecation is difficult, and accompanied with the sen- 
sation of a mechanical obstruction. The faeces, however, are round, but 
contracted in size. From the earliest period of constipation there has always 
been, also, a more or less frequent desire to pass urine. About the same 
time her left leg began to swell, the swelling having continued ever since, 
and the right thigh above, and in front, has been affected with neuralgic 
pains. For years she has been troubled with occasional slight attacks of 
hepatic derangement, which were readily relieved by mild mercurials. For 
many years also she had a constant herpetic eruption on her left leg, which 
became better about the time the dropsy commenced, although a scaly con- 
dition of the skin has continued. She was peculiarly susceptible to the 
operation of medicine, and she possessed a constitutional idiosyncrasy to the 
action of mercury, becoming salivated by a single application of a mercurial 
solution to the skin. She can lie better upon her right side than upon the 
left. One day, in the early part of November last, in a certain position of 
her body, she felt something roll or fluctuate in the abdomen, communicating 
the sensation of a fluid. Frequently during exercise her respiration became 
slightly accelerated, only however for a short time. This disturbance of 
the respiration she attributed to flatulency, to which she had been accus- 
tomed for years. Occasionally she felt a slight pain in the region of the 
uterus. Her appetite in general was good, but she required the observance 
of great care in diet, using the mildest nourishment for several years. 
The following notes, which were taken at the bedside of the patient, were 
dictated to Dr. Shellar as the examination was being made by myself. 
Pulse 88,* soft, open and full; skin soft and pleasant to the touch; tempe- 
rature natural and uniform; tongue slightly furred, whitish, soft, moist, and 
spreading, the follicles at its root enlarged; ptyalism, caused by a few doses 
of mercurials during the last week. 
The patient lying on her back. The tumour of the abdomen is very 
prominent and nearly globular. Its greatest diameter extends from the left 
hypochondrium to the right iliac region. Below it is most prominent upon 
the right side, above it is most prominent upon the left, elevating consider- 
ably the cartilages of the ribs on that side. The lower edge of the thorax 
forms the upper boundary of the tumour, and is elevated by the latter. The 
tumour is softest upon the right side, most resisting upon the left. The 
sound, on percussion, is flat over the whole anterior face of the abdomen, 
even in the epigastrium and hypogastrium. By the hand a pulsation can be 
felt throughout the whole body of the tumour; by the stethoscope the 
impulse and sound of the aorta can be recognized over the whole tumour, 
but most strongly over the left side. The integuments of the abdomen are 
smooth and natural in appearance. The size is rather larger than at the full 
period of pregnancy; there is greater width, more prominence above the 
umbilicus, and rather more flatness in the most anterior part of the tumour. 
The patient lying upon her left side. The change of position does not 
alter the appearance and contour of the tumour. The sound is flat in the 
whole lumbar region of the right side; tympanitic in the right hypochondriac 
region. Fluctuation in the right side is tolerably distinct. 
The patient lying on her right side. There is no change in the tumour. 
The elevation of the left side when lying on the right, is greater than that of 
the right side when lying on the left. Tympanitic sound in the left lumbar 
* On the 13th the pulse had been 80; it probably was now excited by the idea of 
paracentesis. W. L. Atlee’s Case of Extirpation of Ovarian Cyst, 
5 
region merely distinguishable, but distinct in the left hypochondriac region. 
Fluctuation perceptible on the left side, but not so distinctly as on the right. 
Examination per vaginara. The vagina is considerably shortened; a 
tumour can be felt through its posterior wall, having an extremely tender 
spot high upon its anterior face when pressed upon with the point of the 
finger backwards. The supposed cervix uteri is thrown forward behind the 
symphysis pubis, puffy, tumefied, but free from tenderness; the os tincse is 
not evident. 
Examination per anum. As soon as the finger enters the sphincter it 
strikes against a tumour, which is felt through the anterior walls of the 
rectum, and appears to be globular and very slightly uneven. It is movable 
and has a sarcomatous feel. 
Previously to paracentesis the abdomen was again examined in reference 
to a proper point to introduce the trocar, the patient being on her back. 
By pressure over the abdomen a resisting body could be discovered parallel 
to the linea alba, about an inch or an inch and a half to the left of it, and 
along its greatest length. In order to detect this it was necessary to make 
very deep pressure, and it felt like a solid tumour dipping down under the 
linea alba towards the right side. Over the right side there was distinct 
fluctuation; over the left and also across the abdomen the fluctuation was 
indistinct. In consequence of these circumstances a point, about two inches 
to the right of the mesian line, and midway between the umbilicus and 
pubis, was selected for tapping. The trocar entered without using much 
force, and seven pints of lemon-coloured, very clear transparent fluid, 
of the consistence of serum, were drawn out. The abdominal tumour, 
however, only diminished on the right side, leaving the intumescence of the 
left side equally as great as it had been before tapping. Now, upon exa- 
mining the abdomen again, the tumour, still existing within the left side, can 
be traced across the linea alba projecting deeply into the right side to the 
extent of three or four inches across the mesian line, having upon its deep 
surface loose longitudinal ridges, supposed to be folds of the flaccid sac just 
emptied. Fluctuation of the left side is now much more distinct than it 
was before, extending even into the deep portion of the tumour upon the 
right side. The aortic impulse is not so evident as before. This tumour 
evidently is a sac, and the appearance of solidity along the left of the linea 
alba, previous to paracentesis, was owing to the right sac having overlaid 
the left sac to a point beyond the linea alba, perhaps about two inches or 
more, thus making a superficial layer of fluid over the body of the left sac, 
through which the latter, upon deep pressure, simulated a deeply seated solid 
tumour. A ridge is also perceptible upon the left side of the linea alba, 
formed, no doubt, by the empty sac being folded upon the septum of the 
two sacs. 
In consequence of this ridge a point, about two inches to the left of the 
linea alba, was selected for paracentesis of the left sac. It required more 
force to introduce the trocar than in the first instance. After making one 
plunge with the trocar, I had to follow it with another before it entered, 
and after it had entered the fluid did not flow freely through the canula; it 
appeared as if a portion of membrane was lying against the inner opening 
acting as a valve. From this circumstance I believe I must have first pene- 
trated the overlapping layer of the right sac before entering the left, and that 
the left was only partially entered by the canula. However, upon intro- 
ducing through the canula a flexible female catheter, which went in without 
opposition, a lemon-coloured slightly cloudy fluid, of the consistence of W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
serum, escaped through the catheter and around it through the canula. It 
amounted to ten pints. The whole extent of the abdomen was now dimi- 
nished in size, and upon handling it an undulating vibrating motion was 
produced, as if some fluid still existed in the cavities, although all the usual 
efforts had been used to remove the whole of it. 
The fluid from both cavities had an adhesive feel between the fingers, and 
when boiled was hardened like the white of an egg, so that the spoon con- 
taining it could be knocked, while inverted, against the table without dis- 
placing it. The fluid of the right sac, when shaken in a vial, formed a very 
adhesive bead, which continued a great length of time, while the fluid in the 
left sac formed a volatile bead, which disappeared directly. It did not affect 
litmus paper. 
The urine, passed before tapping, was not coagulated by heat; it reddened 
litmus paper strongly. 
Half an hour after tapping the pulse was 80, and in other respects the 
patient was the same as before. 
After dinner, at 1 o’clock, when the patient had recovered from the fatigue 
of the operation, the examination was resumed, she lying upon her back. 
Longitudinal ridges can be felt upon the right side of the spine in the lumbar 
region. They are very movable, and supposed to be the folds of the flaccid 
cysts along the posterior part of the septum. The sound, on percussion, is 
distinctly tympanitic in the epigastric, right hypochondriac, umbilical and 
right lumbar regions, less so in the left hypochondrium, rather flat in the left 
lumbar, and flat over the whole lower part of the abdomen. Percussion 
over the ridges on the right side is painful when the pleximeter is accom- 
panied with deep pressure. 
The patient lying on her left side, and examination per vaginam. The 
part, previously supposed to be the enlarged cervix uteri, is now considered 
to be the uterus itself in a state of atrophy. It now occupies a position 
nearer to the sacrum than to the symphysis pubis, and more to the left side. 
A hard, globular tumour is felt through the posterior wall of the vagina; 
passing the finger under it I can elevate it above the brim of the pelvis, so 
as to feel it with my other hand placed over the right groin. While poising 
the tumour upon my finger in the vagina, and pressing with the fingers of my 
other hand into the pelvis from above the pubis, I can get beneath the tumour 
so as to elevate it considerably. The attachment to the right side of the 
uterus can be easily distinguished by pressing it between the finger within 
and the hand outside. This attachment is apparently very short, owing 
probably to the tumour being jammed against the uterus. No other attach- 
ments can be recognized. On the left side of the uterus nothing unusual is 
discovered in the pelvis. 
Examination per anura. The finger again meets the tumour immediately 
within the sphincter lying against the anterior wall of the rectum. With the 
finger in this position, and the other hand on the right groin, the tumour can 
be played up and down, and seems less sensitive to pressure than before 
paracentesis. When the tumour is in situ the rectum is pressed flat against 
the curve of the sacrum. Hardened flat faeces are discovered in the rectum. 
The tumour is considered to be an enlargement of the right ovary, asso- 
ciated with ovarian cysts. The left ovary is supposed to be free from 
disease. 
Having now fully satisfied myself of the character of the disease, it 
became my duty to inform the patient of its probable results. I told her 
that the records of medical experience, as well as my own observation, fail W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
7 
to render any assurance of the least prospect of cure by ordinary means— 
that ovarian dropsy is beyond the reach of medicine—that the disease, most 
likely, would never be less burthensome than it is now—that sooner or later 
it would cause death—that persons with the same disease had sometimes 
lived many years, but that at her age, and with her constitution and amount 
of suffering, this most probably would not be the case with her—that tapping 
would afford temporary relief, and that the oftener it was done the oftener 
and sooner it would have to be repeated, and thus by rapidly draining the 
system the sooner it would destroy life—that operations for the entire extir- 
pation of the diseased mass had been performed, some terminating success- 
fully, others fatally—that it was an operation of the greatest magnitude, and 
was not considered a legitimate or justifiable one by many eminent medical 
men—and that death might occur as its immediate or remote effects. On 
the other hand, I informed her, that an operation, although fraught with 
danger, afforded the only means of restoration to health—that, although her 
advanced age lessened, in some degree, the chances of recovery, yet I 
believed she had stamina of constitution sufficient to bear an operation—that 
I desired her and her friends to clearly understand me as not urging it upon 
her, or advising her to it—that after having duly and deliberately viewed the 
matter in all its aspects, she must decide for herself—that if she then deter- 
mined to risk the operation rather than suffer her disease, I would undertake it, 
provided the services of a good nurse could be procured, and an experienced 
surgeon would share the responsibility of the case with me. 
This statement having been made to my patient in the presence of her 
husband, her sister, and the attending physician, with a spirit of candour 
and frankness, I took my leave of her, promising to render ray assistance in 
any way, and at any time it might be desired. 
A letter from Dr. Similar, dated December 22d, states that “Mrs. S. is 
doing quite well, her pulse ranging from 75 to 80, there being no febrile 
excitement. She sits up in bed, has not walked about, says she feels weak 
when on her feet. I measured her day after day, and so far find very little 
difference.” 
March 7th, 1844, I was requested to visit Mrs. S. in order to tap her 
again. She informed me that for six weeks after her first tapping she felt 
pretty comfortable, but the fluid began to accumulate soon after I left her. 
She now feels much worse and much more oppressed than she did before 
the first tapping. She has to make water frequently, and passes only a 
little at a time; has, however, no occasion to rise out of bed at night to 
urinate, and can pass water with greater ease standing than she can in a 
stooping posture. She still has to resort to laxatives to procure stool, and 
defecation is difficult, and accompanied by a sensation of obstruction. Any 
kind of exertion, as getting into bed, overcomes her, and produces difficulty 
of respiration. Her left leg is considerably oedematous, the other less so. 
She complains of a peculiar forcing and pressing uneasiness and pain in the 
left hypochondrium. 
After giving this account of herself she told me that she had concluded to 
have the operation performed, if I believed her capable of living through it, 
as she suffered so much from the disease that she felt satisfied, if not relieved, 
she must soon sink under it. Her friends were surprised at this announce- 
ment, as she had never spoken of the operation to any one until that mo- 
ment, and from her silence all had concluded that she had no idea of it, 
although she had arrived at that determination some time before. I therefore 8 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
conducted the examination with particular care, and reported, as I proceeded 
in it, to Dr. Shellar, who wrote it down as before. 
Soon after my arrival to-day her pulse, while she was sitting, was 100. 
The patient lying upon her back in bed. The abdominal tumour is larger 
than at the first examination; its contour the same, rather more prominence 
in the inferior right side. Admeasurement of the abdomen, taken obliquely 
around it from the left hypochondrium to the right lumbar region, is forty and a 
quarter inches: from the right hypochondrium to the left lumbar region, thirty- 
seven and a half inches; and transversely around the belly above the hips, 
thirty-eight inches. Percussion of the abdomen is accompanied by the same 
sounds as before. A ridge can be felt and seen along the left of the linea 
alba, supposed to be the septum of the sacs. There is less pain on pressure 
around the umbilicus than before the first tapping. The patient says that 
after she was tapped there were pain and tenderness on sneezing or coughing 
along the left side of the mesian line, extending above and below the umbi- 
licus three or four inches. This has continued ever since. 
Examination per vaginam. The cervix uteri is slightly tumefied and 
pushed down nearly in contact with the perineum, and to the left of the 
central line. The pelvis is nearly filled with a resisting substance, the 
greatest resistance being on the right side. A hard globular body can be 
felt through the posterior wall of the vagina, resting against the concavity 
and point of the os coccygis. The uterus is pretty firmly fixed in its posi- 
tion, it being scarcely movable. There is no particular tenderness observable 
in touching the uterus. 
The patient being turned upon her left side it makes no change in the con- 
dition of things. 
Examination per rectum. A hard globular body is felt as soon as the 
finger enters the internal sphincter, pressing against the anterior wall of the 
gut, and carrying the latter before it so as to convert that part of the rectum 
into an inverted sac for its reception: the tumour projects into the rectum as 
if it were a tumour of the gut itself arising from its internal face. The 
point of the finger passed up and around its left border to its anterior face, 
meets an exceedingly tender point, which causes the patient to flinch sud- 
denly and exclaim that the pain flies to her very heart. The tumour presses 
the walls of the rectum together, occupying the hollow of the sacrum and 
coccyx, and pressing pretty firmly against them, and feels like sarcoma. 
High up on the posterior part of the tumour, along the track of the rectum, 
it is very tender to the touch. The patient says she suffers more from this 
examination than from the one before. 
I now punctured the sac on the right side, and took from it twelve and a 
half pints of the same clear, straw-coloured, serum-like fluid as before, 
making the puncture through the old cicatrix. From the left sac, which was 
opened about an inch to the left of the old mark, in order to avoid the over- 
lapping sac, I removed eight and a half pints of fluid similar to the above, it 
being much clearer than the fluid out of the same sac at it» first tapping. 
After paracentesis she measures around the hips transversely thirty and a 
quarter inches; above the hips and umbilicus twenty-six and a half inches. 
In examining the abdomen I can distinctly grasp the aorta and trace it to its 
bifurcation, can feel the projection of the os sacrum, and the folds of the 
flaccid cysts, and also a singular, lobulated, oblong tumour crossing the 
mesian line below the projection of the sacrum, deeply seated, and inclining 
most to the left side. This tumour is supposed to be either the aggregated 
folds of the sacs, the development of other cysts or indurated deposits in W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
9 
in the septum, or hardened faeces in the intestines. It is quite movable, and 
can easily be grasped in the fingers. 
Examination per vaginam. Employing the finger gently, and without 
much pressure, the parts within the vagina appear very much the same as 
before lapping. The uterus is quite movable, can be played up and down 
between the finger in the vagina and the hand above the pubis. The tumour, 
posterior to the vagina, can be dislodged and elevated to the right side 
against the hand over the right iliac region. While keeping the tumour 
thus poised upon the finger in the vagina, and endeavouring, with the other 
hand, to get under the tumour above the brim of the pelvis outside, a very 
tender spot is encountered, which produces the same intense suffering as in 
the examination per rectum, and, no doubt, is owing to the same part of the 
tumour being touched. The tumour is very movable, and can be played up 
and down within the pelvis. While the tumour is elevated the pelvis seems 
empty. I think the tumour has enlarged since the first examination. The 
posterior face of the uterus is slightly tender. No abnormal condition can 
be detected on the left side of the uterus. 
The patient having been turned upon her left side, no change is produced 
in the relative position of things. 
Examination per rectum. The attachment of the tumour to the uterus 
can be pretty distinctly traced with the finger, in the rectum, placed against 
the posterior wall of the broad ligament, and the fingers of the other hand 
outside pressed deeply into the pelvis against its anterior wall, thus grasping, 
between them, the broad ligament. The attachment, thus examined, is sup- 
posed to be more than an inch in extent, and the tumour is quite movable 
upon it. 
From the whole examination, I think that the morbid attachments, if any, 
of the sacs and tumour are very slight. 
After she had recovered from the exhaustion produced by the tapping, 
about one hour having elapsed, her pulse was 88. 
I again reviewed the symptoms and history of the case, and felt confident 
that it was a case of encysted ovarian dropsy; that there was a tumour of 
the right ovary; that the cysts were connected with this tumour, though they 
possibly might originate in the left ovary; but that there was no evidence 
leading to the opinion that the left ovary was diseased. 
As my patient had now determined upon the operation, I emphatically 
repeated to her and her friends all I had before told her, and in addition 
insisted upon having the privilege of selecting a consulting surgeon to 
examine the case, and also share in its responsibility, should he coincide 
with me in opinion. Accordingly, on the 9lh of March I called my brother. 
Dr. John L. Atlee, into consultation, and visited Mrs. S. in company with him 
and Dr. Shellar. 
In addition to the history already given, she stated that about four years 
ago, while riding on horseback with a basket of marketing before her upon 
her arm, she felt pain of the abdomen from the pressure of the basket. She 
became larger on the right side first, and had several times called the atten- 
tion of her husband to the circumstance. Ever since the first tapping she 
can lie best upon the left side. After both tappings, before much fluid had 
accumulated, she could pass feces without much difficulty. The oedema of 
the lower extremities, which existed before lapping, always diminished after- 
wards. Until recently there had not been much disturbance of the general 
health, although her constitution, for the last fifteen years, had been feeble. 
To-day the abdomen is very much relaxed, and much more tender to 10 
W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
pressure than hitherto, particularly in the right iliac region. From the 
umbilicus downwards it seems to be occupied by a thick membrane or sac, 
which gives a dull sound on percussion, the upper border being occupied by 
a hard tumour about four inches long, and one and a half or two inches wide, 
lying transversely across the abdomen. This tumour is movable, and appears 
to have no connections with the uterus, and is the same tumour much in- 
creased in size, which I observed for the first time day before yesterday. 
Above this point, and also in the right iliac region, the sound is tympanitic. 
Her pulse is 78; the tongue is very slightly coated with a yellowish fur, but 
looks healthy; her appetite is good, and has been rather craving since last 
summer. 
My brother, having made a careful examination per vaginam et anum, 
arrived precisely at the same conclusion that I had done: that the dropsy 
was encysted; that the cysts and tumours were developed in the right ova- 
rium; that the uterus was slightly atrophied, was distinct from the diseased 
ovarium, except by its natural connections; that the pedicle was nearly or 
quite the normal length; and that no important adhesions existed. My 
brother fully concurred with me also in considering the operation a justifi- 
able one, if the patient chose to have it performed. She then informed us 
that she had come to the conclusion herself of having the tumour extirpated; 
that she felt sensibly that her health had recently rapidly declined, and her 
sufferings were increased; that she had considered all the dangers of the 
operation, and desired to have it performed whenever we should deem it 
advisable. The opinion which 1 had previously given to her, was now 
jointly delivered again to her in the presence of her husband and sister, and 
the dangers of the operation fairly stated and fully understood by all the 
parties interested. It was then determined to wait until the cysts should 
become partially filled, so that the distended sacs might in some measure 
afford a guide to us in the operation. In the mean time she was ordered to 
take regular and moderate exercise, and to use nourishing light diet and mild 
laxatives. 
March 23d, my brother and myself again visited Mrs. S., in company 
with Dr. Shellar. For several days after our last visit her health had not 
been good; she had had considerable fever, with great tenderness of the 
abdomen, and there was quite a hardness around the wound made by tap- 
ping, on the right side, from which, after removing the adhesive strip which 
covered it, a good deal of healthy pus was discharged, which afforded her 
great relief. After this the fever left her, the sore began to heal, and her 
health to improve, though the tumours continued tender, and the water 
rapidly accumulated in the sacs. 
The abdomen is already quite prominent, and elevated to the distance of 
two inches above the umbilicus. The tumour which we felt in the inferior 
part of the abdomen, now occupies the left hypochondriac region anteriorly, 
and is tender upon pressure: it appears to be connected with the walls of 
the sacs, and to have become elevated as they became distended. The 
parietes of the abdomen can be pinched up from the sacs, and moved freely 
over their surface, even at the points where the sacs had been punctured, 
indicating freedom from attachments. The abscess spoken of above must 
have been confined to the walls of the abdomen. The patient’s pulse is 90, 
and her health tolerably good. 
We fixed upon Friday following, the 29th inst., for extirpating the dis- 
eased mass. She was ordered to continue her usual diet until Thursday 
morning, then to take a full dose of her laxative medicine, after which she W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
11 
was to take nothing but barley water, and in the evening a few drops of 
elixir of opium, to quiet the peristaltic action of the bowels. 
March 29th. Friday, 10 o’clock, A. M.; the patient’s pulse is 86, soft, 
and compressible; skin soft and natural; tongue slightly red, but moist, and 
having a thin yellowish fur on its middle and posterior part. She had taken a 
dose of Epsom salts yesterday morning, which fully evacuated her bowels, 
after which she took ten drops of M‘Munn’s elixir of opium last evening, and 
slept pretty well nearly all night. After taking the salts she was restricted to 
barley water as her only nourishment. This morning she had a small liquid 
discharge from her bowels resembling barley water. The last time, previ- 
ously to the operation, she passed her water, was between 9 and 10 o’clock, 
A. M., to the amount of a teacupful, which was an unusually large quantity 
for her to make at once. It reddened litmus paper. 
Preparatory to the operation, all who were to be engaged in the manipula- 
tion of the abdomen, carefully trimmed their nails, and washed their hands, 
and every arrangement was made by my brother and myself previously to 
admitting the other medical gentlemen into the room. The patient was very 
comfortably fixed upon an ordinary dining table, with the leaves down, her 
head and shoulders were slightly raised and resting on pillows, and her feet 
supported upon two chairs at the lower end of the table, her hips being near 
the end, and covered by a sheet applied as a child’s diaper; a sheet was 
thrown over her lower extremities, and an ordinary night-gown enveloped 
her body. The hair along the mesian line of the abdomen, and over the 
pubis, was shaved off, and the parts cleanly sponged and dried. The abdo- 
men presented an enlargement equal to that usually found in the seventh 
month of pregnancy, wanting, however, its symmetry, since the tumour 
principally occupied the left side. 
All the preparations being completed, and the patient’s mind being as 
calm and tranquil as could be desired under the circumstances, the medical 
attendants were called into the room, and at the same moment a light cambric 
handkerchief was thrown loosely over the patient’s face. 
I took my position upon the right side of the patient, my brother, as 
principal assistant, being on the left, and in the presence of Professor D. 
Gilbert, Drs. Shellar, Stubbs, Gryder, Carpenter, and Cox, respectable phy- 
sicians, and Messrs. Richards, Rohrer, Hershey, and Franklin, medical 
students, and one female attendant, I commenced the operation at eleven 
minutes past 11 o’clock, A. M., the patient not being in any way secured 
or fastened, excepting her knees and hands supported by the physicians 
present, 
I began the incision with a scalpel, immediately below the umbilicus, and 
carried it down in a straight line to within one inch of the symphysis pubis, 
making a bold section through the skin and subcutaneous tissues, until I 
struck upon the sheath of the recti muscles. The adipose tissue was unusu- 
ally abundant for so lean a patient. In deepening the incision about the 
centre of the section, the inner edge of the right rectus muscle was pene- 
trated, in consequence of having been drawn over towards the left side by 
the greater prominence of the tumour in that direction. A small incision 
was now made through the linea alba and peritoneum, through which I 
introduced the probe-pointed bistoury, and slit them open to the extent of 
the external wound. The patient did not evince any pain until this section 
of the peritoneum was being made, A small branch of the epigastric artery 
was wounded just below the umbilicus, and another just above the pubis, 
requiring no ligature. As soon as the peritoneum was opened, a large white W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
dense sac, studded with dendriform clusters of capillary vessels, rode up 
against the opening. I now introduced my hand into the abdominal cavity 
for the purpose of examining the connections of the tumour, and of lifting 
it out of its bed. The contact of the hand against the internal face of the 
peritoneum produced considerable pain. Carrying my hand up the right 
side of the tumour, and over its fundus, which projected into the epigastric 
region, I discovered no adhesions until I arrived into the lower part of the 
left hypochondriac region, where I came against a ligaraentpus band, which 
could be traced in a continuous sheet along the left side down into the pelvis. 
Now endeavouring, with my hand behind the tumour, to tilt it out of the 
abdomen, I found the opening entirely too small to permit this, and as there 
was no effusion into the cavity of the peritoneum, and as I did not wish the 
contents of the sacs to escape therein, I preferred extending the incision 
both ways to diminishing the size of the tumour by puncturing the cysts, 
and thus also increasing the difficulties by rendering them flaccid. The 
incision below was continued to the bone, and above it was extended about 
three inches, rising above the umbilicus about two inches, and passing it on 
the left side. I was now enabled to seize the tumour with both hands, and 
by careful manipulation succeeded in rolling out the fundus of the tumour. 
The lower part of the tumour still seemed to be engaged in the pelvis, but 
by continuing gradual outward pressure, it suddenly arose from the pelvis 
with a sucking kind of sound distinctly audible. During this time there was 
no protrusion of the intestines, except a very small knuckle at the upper 
and right side of the tumour, which was easily pushed back by my brother’s 
finger. I now carefully drew the tumour forward through the opening, and 
placing it into the hands of Dr. Gilbert, I turned it over upon the left side of 
the patient, in order to have a better opportunity of tying its pedicle, which 
we had supposed had originated from the right side of the uterus. The 
band previously detected upon the left side I considered extensive omental 
attachments, and as it bound down that side of the tumour very closely, I 
determined to secure the pedicle on the right side first, and afterwards evert- 
ing the tumour still more, I could more easily detach the rest. To our great 
disappointment, however, I found no connections whatever with the right side 
of the uterus. I now changed the position of the tumour from the left side 
of the patient over to the right side, thus putting on the stretch and exposing 
to view a broad ligamentous sheet, attaching the tumour to the body of the 
patient by a pedicle five or six inches broad, extending from the left hypo- 
chondrium down into the pelvis. Within this ligament the sigmoid flexure 
of the colon was incorporated, and near its upper border approximated to 
within an inch of the tumour. It was also highly vascular; one vein, as 
large as the largest size goose-quill, ran along the tumour where it was 
attached, and sent out large ramifications throughout its whole extent. 
These veins were very much engorged with dark-coloured blood. This 
pedicle consisted of a double fold of peritoneum arising out of the broad 
ligament of the uterus, having a triangular form; its lower edge, running 
from the uterus to the left side of the pelvis, was several inches long; its 
upper edge, running from the tumour to the uplifted sigmoid flexure, was 
one inch in length; and the distance along the tumour, between these two 
edges, as above stated, five or six inches long, having the fallopian tube very 
much elongated and somewhat attenuated, stretched up to the top of the 
tumour. A surgeon’s needle, armed with a waxed single strand of saddler’s 
silk, was now passed through so as to include about one inch of the lower 
border of the pedicle, and firmly tied. This portion of the pedicle was then W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
13 
divided near the tumour. This exposed some of the large veins upon its 
surface, which ruptured as soon as they were deprived of their peritoneal sup- 
port, and most of the blood lost in the operation was poured out at this stage 
of the dissection. A second single ligature was introduced about an inch 
above the first, embracing several large veins and the fallopian tube, but in 
endeavouring to tie it the ligature broke twice, after which I substituted a 
double strand of saddler’s silk, and secured it well. About one-half of the 
pedicle remaining above, through which several engorged veins inosculated, 
it was transfixed in the centre with a needle doubly armed with a double 
strand of silk, wffiich being secured belowr and above, the last being very 
near the tumour in order to avoid the intestine, the whole connection was 
then separated and the tumour removed. The amount of blood lost was 
not more than five or six ounces, which was found in the cavity of the 
pelvis. This was carefully removed, and the cavity well cleansed from all 
coagula and fluid blood, by soft sponges pressed out of warm water. The 
cut ends of the pedicle were carefully examined, and there was no oozing of 
blood. The ligatures, four in number, having been brought out at the lower 
end of the wound, the latter wras now carefully closed by nine harelip sutures, 
and intervening adhesive strips, covered with patent lint, and a soft compress, 
and the whole secured by a broad towel, extending from the thorax to the 
trochanters, around the abdomen; and the patient was comfortably placed in 
bed at five minutes before 12 o’clock. 
During the operation the patient evinced comparatively little pain ar suf- 
fering; indeed, at no time were there any manifestations of pain, except 
when the peritoneal lining of the abdominal parietes was touched. There 
was also some uneasiness noticed whenever the support to the tumour, after 
being dislodged, was in any way relaxed, so as to cause traction upon its 
attachment to the pedicle. By the time the tumour was removed the patient’s 
pulse had fallen to 60. The respiration was not complained of, but seemed 
to be performed without the aid of the abdominal muscles. 
In consequence of the previous judicious treatment and regimen, the intes- 
tines lay in a perfectly collapsed or quiescent state, quite free from any 
peristaltic action, thereby enabling the operation to proceed without embar- 
rassment or difficulty being experienced from them. The intestines, how- 
ever, presented a darker pinkish appearance than in Miss R.’s case, owing 
to considerable venous congestion, as was evinced by an engorged state of 
the veins of the mesentery. The very favourable condition of the stomach 
from the same cause was also pre-eminently exemplified, by the complete 
absence, during the operation, of all gastric irritability'—no nausea, vomiting, 
or other uneasiness being complained of, except a slight feeling of flatulent 
distension, unaccompanied by eructation, a small sense of thirst, and a feel- 
ing of weakness in the first stage of the operation, which last, however, soon 
passed away. 
There was no chilliness or sinking complained of, but the hands became 
somewhat cool and relaxed. 
The omentum was crowded down into the left side of the pelvis, had quite 
a healthy aspect, and formed no attachments to the tumour. It was lifted 
from the pelvis, and before closing the wound, spread over the anterior face 
of the small intestines. The uterus was quite healthy in appearance, but 
considered to be slightly hypertrophied, and the right ovary was entirely 
free from disease. There were no attachments at the points where para- 
centesis had been performed; indeed, there were no connections whatever, 
excepting to the pedicle. 14 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
While engaged in dressing the wound, the patient gave directions to the 
persons about her in a clear and strong voice. 
The operation, previously to dislocating the tumour, occupied six minutes, 
and eight minutes more until the tumour was removed, making fourteen 
minutes from the time the knife was laid upon the abdomen until the tumour 
was carried from the patient. 
At the commencement of the operation the temperature of the room was 
81°, and arose as the operation progressed to 86°. The out-door tempera- 
ture at 2 o’clock, P. M., was 61°. Wind N. W. in the morning, and changed 
to the E. afterwards. 
Before she was placed upon the table there were several eructations of 
wind from the stomach, and after she was placed upon the table, in raising 
her up to fix the pillows there was a slight eructation. 
Fifteen minutes after 12 o’clock her pulse was 56; her countenance 
slightly pale, but not sunken; the temperature of the skin very little lower 
than natural; voice clear and strong; she complains of dull, deep-seated pain 
in the lower and internal part of the abdomen, near the seat of the ligatures. 
Ten minutes after the pulse rose to 66. The patient is to be restricted to 
cold water, no nourishment. I|, P. M, Pulse 66; skin warmer, quite 
natural; tongue the same as before the operation; pain somewhat dimi- 
nished; no flatulence, hiccough, or nausea. 2 o’clock, P. M. Pulse 68; 
the patient complains of slight sickness of the stomach, which she attributes 
to flatulency, and can relieve herself by eructation. 2 hours 45 minutes. 
Wind more troublesome, a little belching, and feeling of sickness; describes 
the feeling as water-brash. 3P. M. Pulse 70; stomach more settled, skin 
soft and of good temperature, and the patient quite comfortable. 3j, P. M. 
In a natural sleep. 4, P. M. Pulse 77, heat of skin increased, patient com- 
fortable. 7, P. M. Pulse 82, continues soft and compressible. Wind blow- 
ing very strong from the east, and raining hard. 10, P. M. Pulse 84, rather 
more full and resisting; skin warmer, and she complains of the hands being 
too warm. The tongue has not altered in appearance, but becomes dry, 
which is usual with her while in a recumbent posture. 115, P. M. Drew 
off a half pint of urine with the catheter, in order to prevent any action of 
the abdominal muscles by any voluntary effort. It reddened litmus. 
From this time until 3 o’clock of Saturday morning, the 30th, her pulse 
ranged from 78 to 84, and was soft and compressible. At this time the pulse 
had very slight quickness and some fulness; she had a transient flatulent 
pain, producing a little sickness. 6, A. M. The patient passed a very com- 
fortable night; had no symptoms requiring attention; took a few spoonsful of 
water occasionally, and dozed a good deal; complained only of dryness of 
the mouth and heat of the hands. Wiped her hands with a wet cloth, which 
was very grateful to her. Felt a desire to have her bowels moved, which 
passed off again. 9, A. M. Pulse has not risen above 84, Used the 
catheter; removed a half pint of healthy urine. Allowed the patient thin 
barley water. 2£, P. M. Pulse 85; a little quickness. Complains of her 
position; feels fatigued and sore. Had her shifted in a moderate degree; 
felt pain over the abdomen on being moved. Some gastric disturbance from 
wind. 3, P. M. Pulse 86, moderately hard; skin quite natural. Had a 
smart thunder gust with hail. 5, P. M. Pulse 84; complains of pain after 
drinking cold water. 6, P. M. Pulse 90 to 94, rather quick and full, but 
not hard; palms and soles warm and rather dry; tongue slightly furred, 
somewhat dry, but not glazed; general surface of skin about natural; has 
passed no wind per rectum ; has had no real nausea, but a feeling of wind in W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
15 
the stomach, and a desire to raise it. Removed eight ounces of deep straw- 
coloured urine. Moderate pressure on the abdomen—gives no pain except in 
the left iliac region, and that is more soreness than sharp pain. 9, P. M. 
Pulse 98, harder ; tongue dry and furred; thirst increased; skin hotter than 
natural; tenderness on pressure over the whole abdomen, greater at the lower 
part. Dr. Cox, who remained with her at this time, bled her to the amount 
of about ten ounces, after which the pulse rose to 100, and became soft. 
10, P. M. Pulse 98, soft and much less quick; skin natural temperature; 
abdominal tenderness diminished ; stomach calm ; the patient prefers mode- 
rately cool water to barley water. 
Sunday, 31st, 1 o’clock, A. M. Pulse 95 ; upper part of abdomen slightly 
painful, lower part painful on pressure; inclined to doze; thirst not great. 
7, A. M. Pulse 100; has not exceeded this. Dr. Shellar removed ten 
ounces of highly coloured acid urine, after which the pulse sunk to 90, soft; 
skin natural; slight pain in the abdomen on coughing. Passed a pretty com- 
fortable night, and had some natural sleep, and dozed a good deal. The 
thermometer sunk to 22° last night, and the wind changed to the N. W. 
2, P. M. Pulse 102, soft, compressible; skin natural; tongue dry, but soft; 
no unusual fur; it appears perfectly natural after drinking; abdomen slightly 
distended, sound tympanitic; no tenderness on pressure, except over the left 
groin; drew off about four ounces of highly coloured urine. The patient 
was shifted from one side of the bed to the other without any manifestation 
of pain ; a disposition to rift up wind. As barley water sickens her, ordered 
her to take the water off of scalded bread or toast, and seasoned with salt. 
Took a teaspoonful of salts. 5, P. M. Pulse 105, harder; skin warmer, 
soft, and moderately moist; slight tenderness over the whole abdomen; the 
patient moans, relishes toast and water, and takes it freely, and it lies well on 
the stomach ; slight borborygmi. 7, P. M. Administered injection of flax- 
seed tea; tenderness of the abdomen diminished; pulse 106, compressible. 
8, P. M. Pulse 105, softer; injection operated about five minutes ago, had 
a fetid smell, and was accompanied with much wind; less heat of skin ; 
scarcely any pain on pressure, except in the lower part of the abdomen. 
10, P. M. Pulse 103; has had quite a refreshing sleep; drew off five 
ounces of highly coloured urine. ll£, P. M. Pulse 102; has been sleeping; 
Dr. Shellar administered another injection of flaxseed tea, with five drops of 
elixir of opium in it; complains of water-brash directly after drinking; 
tosses about the arms, and draws up her knees occasionally. 12 o’clock. 
Pulse 100, soft; skin soft and natural; less dryness of hands; lies perfectly 
easy; is in a perfectly natural sleep; very little tenderness of the abdomen. 
2 o’clock, A. M. Monday, April Ist. Pulse 100; gave a teaspoonful of 
salts. 5, A. M. Pulse 98; has been rather restless since 3, A. M. 6, A. M. 
Pulse 96 ; no operation on the bowels ; gave another injection, which ope- 
rated soon; stools liquid, and very fetid ; mouth more moist; thirst still 
considerable. 9, A. M. Pulse 96; skin cooler; bowels continued open 
during the last hour. 101, A. M. Pulse 97 and soft; drew off’ half a pint of 
highly coloured urine; skin soft and pleasant; inclined the patient towards 
the left side. 7, P. M. Pulse 100; the patient moans; thirst; abdomen 
tympanitic; complains of slight pain on pressure ; sickness of the stomach 
after drinking; palms and soles dry; administered an injection of flaxseed 
tea; drew off four ounces of urine highly coloured. 85, P. M. Injection 
passed with a good deal of wind of a fetid smell. 10, P. M. Pulse 98, soft; 
has had a good sleep; gave an injection. 11, P. M. Pulse 96; skin moist; 16 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
passed injection with considerable wind and some natural stool, and less 
fetid. 
Tuesday, April 2d, 2, A. M. Dr. Shellar gave her a teaspoonful of weak 
mint tea, which relieved her stomach of wind, and made her quite easy; 
pulse 96. 6, A. M. Pulse 97; passed urine herself with griping pain; bor- 
borygmi with frequent discharges of wind per anum. Slept a good deal 
during the night. 8, A. M. Pulse 95; skin moist; had two black stools 
since 6 o’clock, of a sour disagreeable smell. 9, A. M. Pulse 96; griping 
of the bowels ; palms and soles dry and hot; no pain on pressure over the 
stomach. 105 A. M. Griping and frequent moaning since 9 o’clock; dis- 
charged urine of a very disagreeable smell. P. M. Administered half 
a teaspoonful of oil. 15, P. M. Pulse 96, compressible; a fluid of a brick 
dust colour, and of a very disagreeable smell, works up occasionally from 
the stomach ; discharged per anum a good deal of wind of a very disagree- 
able smell. 3, P. M. Pulse 95; urinated an hour since; gave a half spoon- 
ful of oil, which was followed in half an hour by a stool of the natural colour, 
and in half an hour afterwards another of the same kind. 4s, P. M. The 
patient visited by Dr. J. L. Atlee. The general symptoms favourable ; pulse 
100; skin natural, nose warm, cheeks cool, palms rather warmer than the 
rest of the body; wound dry; frequent eructations of wind, with ejections 
from the stomach of a yellowish offensive fluid, possessing a smell similar 
to that of the stools, but more faint and less fetid; has had two small yel- 
lowish stools, evidently bile; says the eructations are bitter, not sour; no 
general tenderness of the abdomen, but from the left side upwards there is 
some tenderness, diminishing as we ascend; there is considerable distension 
along the whole track of the colon. 8, P. M. Pulse 100, small and weak; 
skin as before; has thrown off the water occasionally which she takes for 
several hours past; distension continues. Gave a flaxseed injection with a 
tablespoonful of the aqueous solution of assafcetida. 9, P. M. Dr. Shellar 
has the patient in charge to-night. She has had a half an hour of sound 
sleep; pulse 100; skin of the natural temperature; still troubled with eruc- 
tations of the same nature as during the afternoon, though not so frequently ; 
some of the injection discharged with some flatus; not much tenderness of 
the abdomen, still distended. Repeated the assafcetida injection, which 
brought away a great deal of wind, but no feculent discharge. Passed urine 
voluntarily, being very highly coloured and having a strong smell. 10|, 
P. M. Symptoms the same, hands cool; gave 01. ricini et spirits tereb. 
aa Iss. 11, P. M. Pulse 102 ; ejected some of the medicine. 
15, A. M. Wednesday, April 3d. Pulse 102; hands warm; othersymp- 
toms the same; discharged a large quantity of wind; then fell asleep soundly 
for three quarters of an hour ; complains of a burning in the throat and sto- 
mach, caused by the medicine; eructations not so frequent, 2, A. M. Pulse 
102, compressible; symptoms the same, excepting that she feels easier and 
can sleep; gave an injection. 3, A. M. Pulse 104; tenderness of the epi- 
gastrium and general uneasiness; discharges wind per rectum. 4|, A. M. 
Pulse 124 ; abstracted from the arm about three ounces of blood, after which 
the pulse sunk to 114; hands and face cool; eructations returned; dis- 
charged urine. 6, A. M. Pulse 120; hands getting warmer by the applica- 
tion of warm cloths ; sickness and eructations of the stomach continue. An 
express was sent off at 4£, A. M. from Mr. S., distance 10 miles, by Dr. 
Shellar, to Lancaster, desiring our immediate attendance, and intimating the 
most unfavourable turn to the patient’s symptoms. I arrived at 82, A. M., W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
17 
but found the patient rapidly sinking-, the pulse being almost imperceptible, 
and too frequent to be counted ; the hands and wrists cold and clammy; and 
very great distension along both sides and in the epigastrium, the abdomen 
less elevated along the track of the wound. Fearing some intestinal obstruc- 
tion, perhaps incarceration of a portion of the intestine in the track of the 
wound, as in one of Mr. Walne's cases, I examined the wound carefully, 
withdrew all the needles, but could discover no cause existing there. Fearing 
that the ligature near the sigmoid flexure might have strangulated that part of 
the colon, I endeavoured to introduce a rectum tube, but could not succeed in 
passing it in more than four or five inches. In surveying the obstruction in 
the rectum with my finger, I struck again against the same tumour which 
ive had encounter e.d in all our examinations before the operation, but thought 
it might be nothing more than a knuckle of intestine very much distended, 
and occupying the same location. I now administered injections of turpen- 
tine and gave brandy and water, but without avail, and the patient sank into 
the arms of death at three-quarters past 9, A. M. 
Autopsy one hour after death.—The abdomen externally was found sunk 
along the track of the wound, particularly about the umbilicus ; it was promi- 
nent along both sides, most so on the right, and was marked by very great 
fulness of the epigastrium ; a depression existed between the epigastrium and 
each side. 
The whole wound was united excepting a quarter of an inch at the umbili- 
cus, and half an inch where the ligatures came out. The adhesions could 
be easily overcome by separating the edges with the fingers. Opposite the 
umbilicus, where the point of non-adhesion was, there was a small collection 
of bloody matter outside of the omentum, and also a small deposit of coagu- 
lated blood at the same place. The muscular or internal lips of the wound 
were slightly separated, between which the omentum was moderately ele- 
vated, but had no appearance of strangulation. Very slight adhesions existed 
between the anterior walls of the abdomen and the great omentum, this latter 
being spread over the intestines very much as we had placed it at the lime of 
the operation. It was somewhat injected with arterial blood, and slightly 
inflamed, and its veins were congested. In endeavouring to raise the omen- 
tum from the small intestines, it was found to be attached to them, particu- 
larly at its lower extremity, and it appeared to dip down into the left side of 
the pelvis. In detaching it a considerable gush of serum rose up out of the 
left side of the pelvis. By raising the omentum the convolutions of the small 
intestines were discovered to be inflated, and suffused with a bright vermi- 
lion tint, particularly those most adjacent to the pelvis, and they were agglu- 
tinated by a soft albuminous exudation. The small intestines also adhered 
to the peritoneum lining the parietes of the abdomen at those points where the 
omentum did not intervene. The ileum was the most intensely inflamed, 
particularly near the valve of Bauhin, and a thick coat of lymph was depo- 
sited between its folds, and so bound down its convolutions as effectually to 
strangulate the bowel; there was also considerable distension of it, but the 
greatest distension was in the jejunum and duodenum. The stomach was 
greatly distended, but not much injected. The caecum was moderately dis- 
tended, but the ascending, transverse, and upper part of the descending colon 
was empty and very much contracted. A small quantity of flatus was in the 
lower part of the descending colon, but the sigmoid flexure was very much 
contracted and inflamed; the rectum being less so. The transverse colon 
particularly, was very firmly contracted and inflamed, having a bloody spot- 
ted appearance, and the omentum attached to it was very much injected. A 18 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
dense deposit of dull-white lymph was found about the intestines in the left 
lumbar region. On separating the folds of the intestines, a large quantity of 
sero-purulent fluid escaped, particularly from the iliac and pelvic fossae. In 
some of the interspaces there was actual pus, appearing like small abscesses. 
The pelvic viscera were glued together. The right ovary was seen in the 
same condition as at the time of the operation, excepting that it had formed 
loose attachments to the parts around. The womb was considered somewhat 
hypertrophied for a person at her age. 
We now determined to remove the womb, right ovary, rectum, sigmoid 
flexure, and the remains of the pedicle, with the ligatures attached. After 
relieving the viscera of all their surrounding attachments, and passing the 
hand deeply into the pelvis to raise them out, a globular cyst, about the size 
of an orange, was lifted up from the deepest part of the pelvis, and was 
found to be pendulous from the right ovary. The uterus was severed just 
below its cervix before its removal, and there issued from its cavity, at the 
points of section, a yellowish thick gelatinous fluid. 
On examining the parts after their removal, the first ligature was found to 
be attached to the posterior wall of the broad ligament, including the round 
ligament, near the body of the uterus, and about a quarter of an inch beneath 
the fallopian tube. The second enveloped the fallopian tube and large ves- 
sels about two inches from the uterus. The third also enclosed the fallopian 
tube and vessels about half an inch further on. And the fourth included the 
sheet of membrane and vessels between the tumour and sigmoid flexure, 
about half an inch distance from the latter. The examination of the parts 
on the right side of the uterus was exceedingly interesting and satisfactory; 
the right ovary was healthy, there being no cystic degeneration within it or 
the fallopian tube, and having no immediate connection with the cyst which 
had occupied the pelvis on the right side. The cyst had its origin exclu- 
sively in the broad ligament, projecting from its posterior walls, had a 
pedicle about two inches broad, was suspended at a distance of one inch at 
least from the fallopian tube and ovary, the latter being entirely free, and its 
distance from the body of the uterus was about one inch and a quarter, it 
being supported on that part of its pedicle by the round ligament. The cyst 
must have occupied the recto-vaginal cul de sac of the peritoneum, and must 
have been driven down against the coccyx by the distended cysts of the left 
ovarium. Its very low position in the pelvis may be understood when it is 
mentioned that the anterior duplicature of the peritoneum was reflected off 
from the broad ligament to the pubic portion of the pelvis, about half an inch 
above the highest portion of the cyst, and that the same point of the latter 
was at least two and a half inches below the fundus of the uterus. The 
uterus was lined with a beautiful velvety scarlet membrane; the orificium 
internum was studded with diaphanous papillary vesicles, which, on being 
cut, effused a gelatinous kind of fluid; the dilated part of the cavity, corre- 
sponding with the cervix, was plainly marked by the ridges denominated 
arbor vitae uterinus. The uterus was about three inches long, two inches 
wide, and its walls about half an inch thick, being perfectly healthy in struc- 
ture. The sigmoid flexure attached to the detached parts was contracted 
in size, and very much inflamed, particularly near the ligature around the 
pedicle. This very interesting specimen I have carefully preserved. 
Description of the extirpated tumour. The tumour, immediately after 
the operation, weighed ten and a quarter pounds; it lost three-quarters of a 
pound weight in twelve days, being suspended in diluted alcohol, after 
which the following observations were made. The greatest circumference W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
19 
of the tumour is two feet nine inches, the smallest two feet. Its shape is 
irregularly pyriform, with a cordiform indentation at its narrowest end. The 
marks of the trocar are plainly visible, and, when placed in a horizontal 
line, indicate very accurately the position of the tumour within the abdomen 
at the time of tapping. The cordiform indentation, with its bulging lips on 
each side, occupied the pelvis, and most probably received within it the 
fundus uteri. The larger end of the tumour occupied the epigastrium, and 
the septum between the cysts, two of which constituted the entire tumour, 
run obliquely down on the left of the linea alba, gradually approaching it in 
its descent. It was very evident, from comparing the old with the recent 
marks of the trocar, that the tumour had changed its position to a small 
extent after the first tapping, and that the upper portion was thrown over 
more to the left, and the lower to the right side. The pedicle had a most 
extensive attachment to the tumour. Starting at the inferior portion of the 
septum, by the insertion of the round ligament, it sweeps around the bulging 
part of the left side of the tumour, and returning again to the septum termi- 
nates in the fundus of the tumour, making an attachment of thirteen and a 
half inches in length, even in this state of the sacs, they being only half 
filled with fluid. This measurement includes several inches of the pedicle 
which were not touched by the knife. The length of the cut portion, 
measured on the tumour, is nine and a half inches, and the part of the fal- 
lopian tube, attached to the tumour, is five and a half inches in length, which, 
added to the uterine portion, gives the great length of eight or nine inches. 
The fallopian tube terminates in a dense mass in the fundus of the tumour, 
which appears to be the ovary disintegrated and diffused through the struc- 
ture of the cyst in that part, and the fimbriated extremity is stretched over a 
considerable space on the posterior wall of the fundus. This is much the 
most dense part of the cysts, excepting the septum, which forms dense 
ridges upon the surface of the tumour, and plainly points out its own loca- 
tion. The right sac is the largest. The walls of the cysts are a very dense 
white structure, interspersed with a few transparent spots. 
From the position of the sigmoid flexure, and its connection with the 
pedicle, I have no doubt that as the cysts became developed, they elevated 
the posterior fold of the broad ligament as it is reflected off to the sigmoid 
flexure, and stretching it as they enlarged, thus elevated the intestine and 
involved it in the pedicle. Indeed, from the circumstance of the round 
ligament being inserted in the lower part of the septum, and the fimbriated 
extremity of the fallopian tube being spread upon its upper part, with the 
whole tube swinging entirely free of the tumour, there is every reason to 
believe that it originated, like the other cyst, in the posterior walls of the 
broad ligament, and in this way more readily involved this intestine. 
Remarks.—I have given this unfortunate case in full detail, in a con- 
scious spirit of truth and candour, because it is an unsuccessful one. It 
is not so much to avoid the censure of “keeping studiously and carefully 
from the public eye the unsuccessful cases of the operation,” (Mr. Law- 
rence,) which is a species of dishonesty and empiricism deserving unqualified 
condemnation, as to do an act of professional duty peremptorily required 
by the unsettled position of this operation in the minds of the most eminent 
surgeons, that induces me to its publication. I have carefully avoided 
giving* any colour to the case, save what its symptoms have expressed, and 20 
W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
I am perfectly willing to furnish it as one of the numerical arguments 
against ovariotomy. Still, candidly admitting the case to be fairly one of 
unsuccess, notwithstanding the mitigating circumstances of age, constitu- 
tion, and insidious inflammation, I as confidently as ever consider the ope- 
ration justifiable in appropriate cases of a disease otherwise desperate and 
incurable, and where it “secures the only remaining chance of life."— 
(Blundel, Medical Examiner.) 
In reviewing the history and symptoms of this case, it must be admitted 
that every thing led to the opinion of the right ovary alone being diseased: 
pain in the right side, neuralgia of the right thigh, tumour in the right side 
of the pelvis crowding the uterus to the left, pressure elevating this tumour 
into the right groin, evident attachments of the tumour to the right side of 
the uterus, nothing abnormal occupying the left side of uterus—each, singly, 
drew attention to the right ovary, and, collectively, almost indubitably indi- 
cated the location of the disease. On the other hand, the swelling of the 
left leg, and the flat sound over the left lumbar region after tapping, were the 
only symptoms which could draw attention to the left ovary. The first 
symptom could be explained by the peculiar anatomical arrangement of the 
iliac vessels; for, according to my observation, it is a fact, only explicable, in 
my opinion, by the anatomy of certain parts, that the left leg is more liable 
to oedema, varicose veins, &c., resulting from pressure within the abdomen, 
as in pregnancy, &c., than the right leg. The right common iliac artery, 
traversing the left common iliac vein, just below its termination in the 
ascending cava, and where it lies upon the resisting prominence of the fifth 
lumbar vertebra, must necessarily obstruct the circulation in the inelastic 
vein whenever subjected to the insistent pressure of a tumour, and thus 
impeding the whole venous circulation of the left leg, while the supply of 
blood would be continued through the elastic resisting artery, lead to an 
osdematous or a varicose state of this limb sooner than the other. The 
second symptom, or dulness of sound, could be explained by supposing that 
the flaccid cyst might be retained in the left lumbar region by omental 
adhesions, a circumstance not at all unusual in ovarian tumour. With this 
explanation, the conclusion, that the disease was in the right ovary was 
irresistible. 
The operation, therefore, was commenced with every confidence of find- 
ing the pedicle of the tumour attached to the right side of the uterus, and 
our astonishment was great in discovering the tumour, at this point, entirely 
free, and its pedicle, which was the only attachment, arising out of the oppo- 
site side. Although this circumstance could not affect the course or the 
result of the operation, it yet so conflicted with the diagnosis as to convince 
us of the truth of the antecedent of the enthymeme, assumed by those un- 
favourable to gastrotomy, that the “ very impossibility of knowing beforehand 
the exact condition of the organs which it is proposed to extirpate forms one 
of the strongest arguments against the operation,” (The British and Foreign W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
21 
Medical Review,) without establishing the consequent deduced from it. De- 
siring, however, to explain the contradiction, we considered that the lower 
end of the cysts, which had been wedged into the pelvis, had been tilted 
over upon the right side of the uterus, and dipping deeply down had simu- 
lated the tumour, which we had previously felt in that location, and that that 
portion of the cysts contained an indurated portion of the ovary, which had 
continued in situ after the fluid had been removed. In order, however, fully 
to satisfy ourselves that the right ovary was not diseased, I took it up in my 
Angers, with the fallopian tube, and a considerable portion of broad liga- 
ment, examined it carefully, and exhibited it to the gentlemen around. We 
all considered it healthy, and so it was pronounced. Had our patient re- 
covered after the operation, the true state of things could never have been 
known, and the case would have been reported in accordance with the above 
state of facts. The consequence would have been, that her disease would have 
returned, and its return would have been attributed to a subsequent develop- 
ment of diseased action in the right ovary, which had been perfectly healthy 
at the time of the operation. Here then would have been another blow to 
the advocates of gastrotomy, so that living or dead the case would have 
been used against them. In order, therefore, to make the operation doubly 
sure, the extirpation of both ovaria, the healthy as well as diseased, would 
have to be resorted to—a course which I had previously contemplated in 
patients who had passed the climacteric period of life. The patient, how- 
ever, died, and was subjected to a post-mortem examination. This revealed a 
state of things which was equally as astonishing, and which, although appa- 
rently contradicting the unanimous opinion expressed at the time of the 
operation, essentially confirmed the diagnosis: there was a tumour attached 
to the right side of the uterus. It was this very tumour that had been felt 
previously to the operation, and also after it while employing the rectum 
tube when the patient was moribund. It was only discoverable per vaginam 
vel per rectum, and was entirely out of view when the abdomen was opened 
and the pelvis examined through its superior strait, both during the opera- 
tion and the autopsy. Now it is such cases as this that often leads to the 
most important precautions in practice, and in a similar case 1 would not 
close the wound until I had fully satisfied myself hxj a vaginal examination. 
The publication of this case, therefore, may produce this, if no other good 
in ovariotomy: establish the rule never to finish the operation without such 
an examination. It must be very evident that the mere survey of the ovary 
is by no means sufficient, and that the cases of return of this disease on 
record may be accounted for in this way. An examination of this kind, in 
addition, is thorough, is the only way to avoid difficulty, and to clear up all 
doubt. 
In reference to the cause of death, peritonitis, there were none of the 
ordinary indications of this disease, nor any symptoms requiring particular 
treatment, until the evening of the fifth day. Indeed, it was a matter of 22 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
general surprise, how little disturbance so great a wound had produced, and 
that not a single unfavourable symptom arose during or for several days after 
the operation. I have no doubt, from the post-mortem appearances, that 
inflammation supervened before the fifth day, and that this was one of those 
anomalous cases of peritonitis, which steals on insidiously, where the bowels 
act without impediment, where vomiting and unusual gastric irritation do not 
exist, where the pulse seldom exceeds 100, and where the state of the skin 
continues natural, and even where tenderness of the abdomen is not remark- 
able. There had been no rigors; no acute pain, nor great distress from pressure, 
nor feeling of incumbrance from the bed-clothes; no obstinate constipation; 
no nausea and vomiting until the last evening; no dry and hot skin; no 
rapid, small, and hard pulse; no white furred tongue and dry lips; nothing 
indicating inflammation of the peritoneum. The tenderness of the abdomen 
and flatulency, the only symptoms, were not at all remarkable, and not greater 
than would be likely to arise from the healthy inflammation of such a wound. 
By this apparently very favourable condition of the patient we were lulled 
into inaction, and at the very time we were congratulating her and ourselves 
upon her having passed the lime of greatest danger so well, the disease, no 
doubt, was quietly making the most dreadful havoc. Had the usual evi- 
dences of peritonitis existed, we were prepared and watching to meet them 
in their onset, and thus met they most probably would have succumbed to 
our measures. The question may here be asked,—had age, or the shock 
from the operation, or both together, any agency in so diminishing the sus- 
ceptibility of the system as to render it incapable of noticing this stale of 
things? The nervous shock was certainly not great, and gradual and appa- 
rently wholesome reaction supervened in good time. Her age, therefore, 
conjoined with a feeble and debilitated constitution, may perhaps account for 
the want of the necessary elasticity of fibre. 
The extreme sensitiveness of the peritoneum, and the congested state of 
the mesenteric veins at the time of the operation, may have had considerable 
influence in causing peritonitis. The section of the peritoneum, and the fric- 
tion of the hand against it, produced infinitely greater manifestations of suffer- 
ing than any other part of the operation. This did not exist in my brother’s 
case, and it is not stated as having occurred in any other that I have seen 
reported. It was, however, remarkable in this instance, and excited the 
attention of all present.* 
* Another instance of extensive exposure of the peritoneum, occurred in my practice 
in June, 1830. I was called to sec Master D. L., a lad about ten years old, who had been 
attacked by a furious cow, which had just calved. She threw him down into the corner 
of a worm-fcnce, and gored him most dreadfully. The most serious wound was in the 
walls of the abdomen : the point of the horn entered at the superior spinous process of 
the ilium on one side, crossed the abdomen transversely, and came out at the same point 
on the opposite side, ripping open the whole intermediate space. The wound gaped at 
least three inches, owing to the retraction of the divided muscular fibres. Fortunately 
the peritoneum was not wounded. The point of the horn appeared to have insinuated W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
23 
Another circumstance, which I believe is unique in this case, is the impli- 
cation of the intestine within the pedicle of the tumour. In Professor Lizar’s 
third case, and in Dr. Chrysmar’s first case, both of which proved fatal, the 
former in 53, the latter in 36 hours, there were adhesions of the colon to the 
tumour, (The British and Foreign Medical Review,) but in neither of these 
cases was it involved within the pedicle. In this case it was, and so closely 
approximated the tumour, that only one inch of pedicle existed between the 
two, upon which to apply the ligature. At this point on the intestine, and 
in the adjacent small intestines, the marks of inflammation were intense. 
Did the inflammation originate here and radiate to the parts contiguous ? 
Pathologists inform us that the effect of contact in propagating serous inflam- 
mation, is more obvious than that of continuity. 
This case would seem to show that tapping, either as an aid to diagnosis, 
or prospective to an operation, is not objectionable as inducing adhesions. 
Dr. Frederick Bird is of the same opinion. (Bi aithwaite’s Retrospect.) Dr. 
Charles Clay, however, is “averse to puncturing, because at the places punc- 
tured adhesions are effected, and by the alternate distension and collapse of the 
sac, fresh adhesions -are also formed in other parts.” [lbid.) In my case 
not the least adhesions existed, notwithstanding suppurative inflammation 
supervened in the abdominal walls after one of the tappings, a circumstance 
highly calculated to produce them. 
It must have been observed in the report of this case, that before the opera- 
tion the uterus was considered atrophied, and that during the operation, and 
also at the autopsy, it was considered hypertrophied for the age of the patient. 
Its exact measurement is given, and it corresponds with the size of a healthy 
womb in the child-bearing period of life. Could both conditions have existed 
at the several periods of observation ? The query is of no moment excepting 
as connected with the diagnosis, and may, I think, reasonably be answered 
in the affirmative. It possibly was in a state of atrophy, and may have 
become hypertrophied by subsequently increased action within itself, as was 
itself between the peritoneum lining the parietes and the fascia transversalis, and the con- 
vex body of the horn skated upon the peritoneum without tearing it; every thing anterior 
to it was ripped asunder, and a clean, even, incised-like wound remained. The convolu- 
tions of the bowels were plainly visible through the semi-transparent peritoneum, which 
was the only thing that prevented their escape, being placed like a glass in front of them* 
In riding hastily to the place I lost my case of instruments, and had nothing but a roll of 
adhesive plaster with which to dress this extensive wound. I, however, brought the lips 
of the wound carefully together, and secured them with very long straps of plaster, with- 
out the aid of a single ligature. Then placing the patient on his back with the shoulders 
and hips elevated, I gave a dose of laudanum to keep the bowels quiet, placed him on 
absolute diet, and had him watched night and day to prevent motion of the body. Con- 
tinuing rigidly this let-alone treatment for several days, the whole wound healed up by 
the first intention. The bowels were acted on for the first time by oil on the fifth day, 
anfl the patient recovered without a bad symptom. In this case also, no tenderness of 
the peritoneum was evinced by handling. 24 
W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
indicated by an augmentation of tenderness at and after the second tapping. 
The relative position of the tumour and the womb, the top of the former, 
after the removal of the parts, being two and a half inches below the fundus 
of the latter, may perhaps have misled us in regard to its atrophied state, as 
the cervix uteri corresponded with the body of the tumour, and may have 
been mistaken for the womb itself. 
Aiding in the diagnosis of our case, there was one very prominent symp- 
tom, which I do not remember of having seen noticed by writers in any other, 
but which I think would generally obtain in encysted dropsy: the pulsations 
of the abdominal tumour, and the impulse of the aorta. In great abdominal 
enlargement, under the very circumstances when the difficulty of distinguish- 
ing between peritoneal and ovarian dropsies arises, I think that this would be 
a pathognomonic feature of great value. The impulse of the aorta upon the 
resisting walls of a distended cyst, would communicate fluctuation in all 
directions, in the same way that the impulsion of the fingers upon the walls 
of the abdomen produces a corresponding motion in ascites, while at the 
same time the aortic impulse in the latter, for apparent reasons, would be 
exceedingly feeble or not at all recognizable. In Miss R.’s case, the only 
thing in dispute between my brother and myself remaining unsettled until 
the operation, was in relation to the character of the dropsy. It was ovarian 
tumour and peritoneal dropsy, a case entirely unique in the medical records 
accessible at the time. Taking all the diagnostic indications collectively, it 
was admitted on both sides, that its character was obscure. In that case the 
abdominal pulsation was absent. 
It is worthy of being observed that the fluid drawn from these cysts, was 
different from that which we find in the majority of cases, and as this is 
esteemed one of the most valuable diagnostic signs, I desire to refer to it here. 
Dr. Alexander Kilgour, who furnishes some valuable hirils on the diagnosis 
of ovarian disease, observes that “in most cases of encysted ovarian dropsy 
the fluid is thicker than serum, flowing through the canula of the consistence 
of train oil, of a greenish or dark colour, and of a saponaceous feel. Some- 
times it is gruraous, like drained honey, or like jelly; or it assumes these 
characters as the sac becomes emptied. Nitric acid added to it produces 
a thick coagulum, and so also does boiling. When these characters are pre- 
sent, there can be no doubt as to the nature of the dropsy.” [Am. Journ. Med. 
Sci., Oct. 1843, p. 489.) This is true, and such a fluid unfailingly distin- 
guishes ovarian dropsy from every thing else. But there are cases of ovarian 
dropsy, not alone “unilocular,” where the fluid is not so easily distinguished 
from that of ascites, and where, if we possessed no collateral aid in diagnosis, 
it could not serve us in deciding upon the nature of the disease. Such was 
this case. The physical characters of the fluid corresponded in density* 
colour, and transparency, with ascitic; and its chemical character, as testqd 
by heat and nitric acid, exhibited similar evidence to that of ascites, tested in W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
25 
two instances since. The only difference discoverable between the two fluids 
was in the amount of albumen, the ovarian containing more, and therefore 
being more densely coagulable than the peritoneal. This property, therefore, 
not being exclusive, will not always be available as a characteristic sign, and 
it being only relative in degree, must prove uncertain in inexperienced hands, 
particularly when not associated with distinguishing physical characters. 
I would also call attention to the condition of the cysts after tapping. 
They were collapsed into folds and ridges, which could be felt plainly 
within the cavity, and entirely distinct from the walls of the abdomen. 
How far the position of the cysts after paracentesis will diagnosticate adhe- 
sions may be presumed from this case, in which none existed. The effect 
of attachments between the cyst and walls of the abdomen would no doubt 
be a proportionate augmentation in the thickness of these walls, with a feel- 
ing of double folds in pinching them up between the fingers. Where the 
sac has receded from the walls of the abdomen, and forms rugae within, 
there is strong presumption, if not absolute certainty, of the absence of 
adhesions, at least to the abdominal parietes. This state of the cysts also 
affords very strong pathognomonic evidence, for in ascites nothing of this 
kind would be presented. 
The fact of the tumour having been composed of only two large cysts, 
free from adhesions, and independent of any great amount of solid deposit 
within its walls, would appear to render it a case peculiarly adapted to Jeaf- 
freson’s operation, but the great extent of the pedicle, its investment of the 
colon, and the proximity of the latter to the cysts, would plainly have ren- 
dered it equally, if not more immediately hazardous. Jeaffreson’s operation, 
particularly as modified by Dr. Frederick Bird, is certainly worthy of imita- 
tion, but in many cases must necessarily yield to the large peritoneal section. 
In peritoneal sections for the extirpation of ovaria I have thought that 
there might be less liability to inflammation than in wounds where such or 
similar disease does not exist. The constant friction of the tumour, and the 
distension of the peritoneum, may tend towards obtunding its sensibility, and 
rendering it less liable to react upon the application of irritants. In the 
above case, however, there evidently Avas a morbid state of irritability, a 
state of hyperemia existing in this membrane at the time of the operation, 
unusual in other cases, rendering it more liable to inflammatory action. With 
this view of the case, I doubt whether we “should be justified in making 
extensive incisions into the abdominal cavity for other objects than the one 
here related,” (Dr. Charles Clay, Braithivaite's Retrospect,) basing the pro- 
priety of such operations merely upon the success of ovarian cases. 
The British Medical Journals, in reviewing the cases of Dr. Charles Clay, 
and others, speak decidedly against the operation of gastrotoray. As the 
subject has become one of vital importance, and as this has been styled an 
American operation, I propose concluding my paper by noticing one or two 
points in the English Journals. 26 
W. L. Allee’s Case of Extirpation of Ovarian Cyst. 
One writer, in the general scope of his paper, takes a candid and fair view 
of Clay’s and other operations, and very properly corrects some of the sta- 
tistical errors which Dr. Clay permitted himself to embrace in his report. 
However much it must be regretted that any member of the profession, as 
distinguished as Dr. Clay, should attempt to establish an operation by unfair 
means, or by disparaging and misrepresenting the manner of operating and 
success of other surgeons, still it must be equally regretted that his reviewers 
should place the merits of the major operation in juxtaposition with the errors 
of Dr. Clay, and thus condemn together what are essentially disconnected, 
and decry the value of the one with the same breath used in combating the 
other. 
One of the principal objections brought forward by the British writers is 
the difficulty of forming a diagnosis in cases of ovarian diseases. “ The 
impossibility of ascertaining either the existence of any disease of the ovaries, 
the real character of such disease, or the adhesions or connections which it 
may have originally held, or have formed during the progress of its growth, 
has been freely granted by every experienced physician and surgeon who has 
directed his attention to the subject, and is also made abundantly manifest by 
the cases of extirpation which have been recently recorded.” (The London 
and Edinburgh Monthly Journal of Medical Sciences.) The “very im- 
possibility of knowing beforehand the exact condition of the organs which it 
is proposed to extirpate, forms, in our opinion, one of the strongest argu- 
ments against the operation; and will always do so until we are furnished 
with some unerring means of distinguishing between simple ovarian tumours 
and cases in which ovarian cysts are associated with other diseases of those 
organs.” (The British and Foreign Medical Review.) That there is a 
difficulty in diagnosis in some cases must be admitted, and in such the whole 
force of the argument ought peremptorily to operate. Some of the fatal 
cases referred to by the writers, I think would be obnoxious to this charge, 
and ought to exhibit more the temerity of the surgeon in undertaking ovari- 
otomy where the diagnosis was obscure, or the malignancy of the tumour, 
and other circumstances, contraindicated it, than to undervalue a well-judged 
and well-timed operation in cases where nothing objectionable obtains. 
While, however, admitting the position in some cases, we do consider it 
untenable in others, and cannot admit that there is an impossibility of know- 
ing the condition of things beforehand in all cases. The possibility of correct 
diagnosis, at least as to the existence of ovarian disease, and in reference to 
the propriety of an operation, I consider has been sufficiently proved by the 
many successful, and even unsuccessful cases of peritoneal section, and also 
by post-mortem observations where no such operation had been performed. 
And although errors may have occurred in certain cases, nothing less has 
happened in other kinds of surgery, where operations are acknowledged to 
be legitimate and proper. If, then, cases do occur, where doubt does not 
exist, ought the operation to be performed? The several successful cases. W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
both of the minor and major operation, and the character of the disease to 
be remedied, speak sufficiently in the affirmative, and the writers themselves, 
in such cases, would not raise an objection, if a fair inference may be drawn 
from the above quotations. 
Another objection is the danger of hemorrhage. “The extent to which 
the incisions must be carried, and the adhesions which must be destroyed in 
many cases before the tumours can be removed, would lead us, a priori, to 
dread the consequences of loss of blood.” [The London and Edinburgh 
Monthly Journal.) It is rather surprising that this should have been offered 
as a serious objection against the operation, when we consider how rare 
hemorrhage has been in these cases, and how perfectly easy it is to control 
it by the careful application of ligatures. Is there one case on record where 
the cause of death could be legitimately traced to hemorrhage? Even in 
Mr. M‘Dowell’s third case, and in Mr. Lizar’s second case, where hemor- 
rhage was profuse, death did not occur, and in Mr. Clay’s fifth case, where 
death did occur, the hemorrhage, apart from other violence, was not so great 
as solely to account for the result. And whence is the great fear of hemor- 
rhage a priori? Large and important vessels seldom exist in the pedicle of 
ovarian cysts and tumours, and the attachments, which the latter may have 
formed with the surrounding parts, when organized, are supplied with the 
smaller class of vessels, while the extensive incisions through the skin 
involve no arteries worthy of notice. 
After giving details of several successful cases, it is observed : “All must, 
we think, agree with us in the opinion that the mere announcement that these 
thirteen persons recovered from the operation, would by no means suffice to 
enable us to estimate it aright. The sufferings endured during its perform- 
ance, the pains of a protracted convalescence, and the imminent danger in 
which life was placed in some instances, ought all to be taken into account. 
The sufferings and the danger too, in these cases, were neither few nor 
small.” (The British and Foreign Medical Review.) The fact, I fear, 
has been overlooked that in other capital operations, legitimated by time and 
results, all the above circumstances occur, and that suffering, pain, and dan- 
ger, are necessary accompaniments. To balance this, look at the ovarian 
patient condemned, by the opponents to extirpation, to uninterrupted misery, 
to interminable sufferings, to all the agony and inconvenience of obstructed 
circulation, respiration, defecation and the functions of all the pelvic, abdomi- 
nal and thoracic viscera ; condemned to certain death by a protracted, incura- 
ble, burlhensome disease, draining her system of its usual pabulum, depriv- 
ing her of exercise and the pure air and light of heaven, and oppressing her 
with a loathsome enormous mass too great for her enfeebled, emaciated frame 
to carry. Thus metamorphosed, in the depth of her agony and affliction, 
she appeals to us for assistance, and though life may be the forfeiture, she 
stakes it willingly. What is to be done? Take every thing into the esti- 28 
W. L. Alice’s Case of Extirpation of Ovarian Cyst. 
mate, and is not the operation not only justifiable, but sometimes criminally 
omitted ? 
It is also observed, that “ there are objections, however, to the operations, 
far more conclusive than any which can be deduced from the inadequate 
nature of the testimony in its favour. Not only did six of the persons, 
whose ovaries were extirpated, die from the effects of the operation, but in 
eight instances, after the abdominal cavity had been laid open, the removal of 
the tumour wasfound impracticable, and the lives of three of these patients were 
sacrificed to the fruitless and ill-judged interference of the surgeon.” {lbid.) 
What capital operation, I would ask, is exempt from such a charge? The 
victims of the knife have been numberless in almost every branch of opera- 
tive surgery: bladders have been cut for stone without finding any, legs have 
been amputated that ought to have been saved, hatfuls of eyes have been 
destroyed without restoring vision, aneurisms have been opened believing 
them to be abscesses, and a variety of other malpractice must occur to the 
mind of every surgeon. Does it follow from this that the operations of litho- 
tomy, amputation, cataract, and the lancing of abscesses ought to be con- 
demned? Is fruitless, ill-judged, or ill-directed surgery in a few instances, 
to be adduced in condemnation of any operation ? I apprehend not. Why 
then not place gastrotoray upon the same footing ? As a new operation, 
undergoing a course of probation, it is perhaps equally as successful at this 
age of its history, as some other operations, now established, were in their 
early infancy, and which, even now, occasionally illustrate the improper and 
fruitless interference of the surgeon. Upon this principle, operative surgery 
would become obsolete. 
Certain writers also throw out some very improper insinuations upon the 
motives of the younger members of the profession, who undertake what 
older surgeons “ are reluctant to attempt.” After representing this operation 
as exceedingly hazardous and fatal, and then accusing the young surgeon of 
endeavouring to advance his reputation by “exciting the astonishment of the 
vulgar,” they must have forgotten the self-contradiction of their position, and 
the danger of young surgeons seeking professional eclat where censure only 
was to be encountered. And why thus assail the junior members of the pro- 
fession? Where is the time-honoured surgeon, bending under the weight of 
years, and enjoying the full fruition of a successful career, that has not laid 
the foundation of his fame before time has begun to mark his temples with 
the frosts of age? Whence have sprung the great improvements of our art? 
Have they not mainly originated with men in the prime and vigour of life, 
before age began to enervate the mind, or routine to fix the habit? Then let 
it not be said that because the “aged and the timorous are reluctant to 
attempt” an operation, that the younger man, emboldened by assiduous 
investigation and new discoveries, should be censured for the innovation. 
The oath, “ Nullius unquam hominis vitam ancipiti tentaturum experimento,” W. L. Atlee’s Case of Extirpation of Ovarian Cyst. 
29 
fortunately for gastrotomy, does not include the whole of medical morality; 
the principle will be more complete by adding, in English, and the life of no 
one should ever be sacrificed to a necessarily fated disease when art can pre- 
vent it. On this point the beautiful language of Hufeland is quoted : “ Thine 
is a high and holy office, see that thou exercise it purely, not for thine own 
advancement, not for thine own honour, but for the glory of God, and the 
good of thy neighbour. Hereafter thou wilt have to give an account of it.” 
There are sins of omission as well as of commission. The good of our 
neighbour, and our professional duty, always obligate us to risk our reputa- 
tion in contributing to the one, and in properly exercising the other; and if, 
when relief can be afforded in a horrible and fatal disease, we are unwilling 
to hazard our fame, or take responsibility in consequence of danger, then 
indeed we prostitute a high and holy office, fail to exercise it purely, and 
will have to give an account of it hereafter. The same German author elo- 
quently observes: “ Der wahre Arzt soil kein anderes Interesse haben, als 
Gesundheit und Leben seines Kranken. Jedes andere fuehrt ihm vom 
wahren Wege ab, und kann fuer den Kranken die nachtheiligsten Folgen 
haben. Er brancht nur in irgsnd einen Collisionsfall zu gerathen, wobey 
seine Reputation pder sein Beutel in Gefahr kommt, wenn er etwas zur 
Erhaltung des Kranken wagt, under wird zuverlaessig lieber den Kranken 
sterben lassen, als seine Reputation verlieren.”* (Makrobiotik, von Dr. 
Hufeland.) 
* The honest physician should have no other interest than the health and life of his 
patient. Every other leads him from the true path, and may result in the most injurious 
consequences to the sick. Should a case of difficulty7 arise, in which, by hazarding any 
thing for his patient’s preservation, he might endanger either his character or his purse, 
he would unfailingly rather let him die than sacrifice his own reputation.