The President’s Address: 
Delivered before the American Gyne- 
cological Society, at Washington, 
D. C., September 1885. 
With the Author’s Compliments. 
By W. T. HOWARD, M. D., 
Professor of the Diseases of Children in the 
University of Maryland ; Gynecologist to the Universi- 
ty Hospital; Surgeon to the Hospital for the Women 
of Maryland; Consulting Gynecologist to the Union 
Protestant Infirmary : Consulting Physician to the He- 
brew Hospital and Asylum Association of Baltimore 
City ; Honorary Member of the State Medical Soetety 
of North Carolina, etc. 
REPRINT -PROM VOLUME X 
ffijnecoloflical 
1885. THE PRESIDENT’S ANNUAL ADDRESS: TWO 
RARE CASES IN ABDOMINAL SURGERY. 
BY WILLIAM T. HOWARD, M. D., 
Baltimore. 
Gentlemen, Confreres of the American Gynecolo- 
gical Society : In the profession of medicine, above all, per- 
haps, facts are the things that teach. And the intellect, 
the reason, is the test of truth. The senses are the servants, 
who wait upon the mind, which sits as a judge deciding 
upon impressions, and. detecting the true from the false. 
The judge, who is to discover the truth of complex medical 
facts and phenomena, must be no ignorant, prejudiced parti- 
san, biased by preconceived opinions. He must be richly 
endowed and largely stored with the wisdom of the past 
and the rapidly accumulating information of the present, 
capable of patient induction, and quick to detect the relations 
between seemingly dissimilar things. 
Few minds, it may be said, can attain this standard of 
qualification for the discovery of truth. But if I seem to 
describe the attributes of genius, or rare qualities which can 
be acquired or improved only by a felicitous combination of 
circumstances, and that culture which presumes the posses- 
sion of ample means and large opportunities—qualities illus- 
trated by high achievements distinguishing the gifted few— 
on the other hand it is equally to be remembered that valu- 
able observations may be made, and valuable facts gathered, 
and valuable truths discovered or illustrated, and enforced 
by all. It is not a large number of cases carelessly observed 
and committed only to the treacherous custody of the mem- 2 
ANNUAL ADDRESS OF THE PRESIDENT. 
ory, but the comparatively few that are carefully observed, 
well studied, and honestly recorded, that contribute to estab- 
lish the great principles of scientific medicine. Truth should 
ever be sought in the clear light of patient and unbiased 
observations, and we should listen attentively to the voice of 
Nature, whose testimony, if properly interpreted, is ever to 
be trusted. It is thus that many of the pictures of disease 
drawn by the ancient masters—Aristseus, Hippocrates, and 
Sydenham—even yet, through the dim vista of retreating 
ages, are life-like in the fresh-glowing colors of truth, and 
are distorted or become unnatural only when touched by the 
shadowy hues of conjecture. 
In order that the teachings of Nature, intelligently ob- 
served, may be duly realized and perpetuated, I have ever 
thought that, in the report of cases, it is essential that fail- 
ures as well as successes be included, as the former often 
■teach more than the latter, and both are equally important 
for the elucidation of truth. The student of military science 
who should confine his studies to the manoeuvres of suc- 
cessful battles, and avert his attention from the errors that 
.have led to disaster when victory might have been won, 
would lose half of the lessons taught by experience, and all 
of the wisdom that is born of misfortune. And the medical 
man wTho, through vanity or fear, records only his triumphs 
and omits his failures, their causes and results, deprives his 
fellows of as much knowledge as he bestows. I admire 
and honor the manly way in which Lawson Tait, of splen- 
did genius and iron nerve, spoke of his operation for the 
relief of bleeding myomas before the recent meeting of the 
British Medical Association at Cardiff :1 
“ Adverse critics have been delighted to rake up my early 
cases in which the mortality was nearly 25 per cent. ; but I 
need not say that, as I originated this proceeding, I had to 
bear the burden of the blunders inseparable from ignorance— 
blunders which have helped me not only to mend my own 
wTays, but also to mend the ways of those who came after me, 
-» Brit. Med. Jour., August 15, 1886, p. 288. WILLIAM T. HOWARD. 
3 
and who have forgotten to credit me with the better results 
which my misfortunes provided for them.” 
Impressed -with these views, and because there is too 
often a disposition on the part of many to suppress errors 
of diagnosis and unfortunate results, I reported to this So- 
ciety, just five years ago, three fatal cases of rupture of the 
uterus, and extrusion of the fetus into the abdominal cavity, 
with laparotomy. All occurred in the practice of others. 
The literature of the subject was scanty, widely diffused, 
and, when I was suddenly called to operate, I had little light 
to guide me, as it seldom falls to the lot of one person to 
perform laparotomy, under such circumstances, as many 
times. In looking back now at these cases in the light of 
the experience then acquired, it seems to me that the life of 
one might, with a high degree of certainty, have been saved; 
and that the life of another might probably have been saved. 
The third and last case, when I was called in to operate, was 
already in extremis, and the operation was done as a dernier 
ressort and to relieve intense suffering. But had laparotomy 
been promptly done when the accident occurred, the un- 
fortunate woman might almost certainly have been rescued. 
To-day I propose to present the histories of two rare 
cases of exceptional interest and of great importance, in which 
I was so completely baffled in diagnosis that I declined an 
attempt to make one. And I trust that the lessons they 
teach may be useful to others, as I fain hope they may be to 
myself. 
Case I.—Sarah Hawkins, negress, aged twenty-four years, 
married, presented herself at the dispensary attached to my 
service in the University of Maryland Hospital on April 20, 
1882. She stated to my chief of clinic, Dr. W. P. Chunn, that 
menstruation first occurred at the age of fourteen, and had 
always been regular and normal; that she was the mother of 
five children, and had never had a miscarriage. Her last child 
was born two months before, and, some days afterward, she 
noticed an enlargement of the lower portion of the abdomen, 
which gradually extended in the middle line up to the umbili- 4 
ANNUAL ADDRESS OF THE PRESIDENT. 
cus, attended by beai-ing-down pains and frequent micturition. 
Upon examination by Dr. Chunn, fluctuation was found to be 
well marked all over the abdomen, with decided resonance 
about the umbilical region, and with dullness and bulging in 
both flanks. Six weeks after this date she came to the dis- 
pensary again, and Dr. Chunn found that the umbilical reso- 
nance had entirely disappeared, being supplanted by dullness 
on percussion, and the umbilicus itself was projected forward 
in the form and shape of a spherical tumor. Nearly two weeks 
after this last examination by Dr. Chunn, he brought her be- 
fore my clinical class on clinic day, and I saw her for the first 
time. Noticing at a glance that she was ill, I made a very 
careful examination. The temperature was Fahr., pulse 
120, and respiration 32 to the minute ; auscultation and per- 
cussion quickly revealed the unmistakable signs of pleurisy ; 
dullness on percussion on the left side up to the supra-spinal 
fossa, feeble respiration over the base, a decided broncho- 
vesicular respiration near the upper limit of dullness, and a 
well-marked egophonic twang to the voice. The abdomen was 
enlarged to about the size of a seven months’ pregnancy, was 
remarkably protuberant in the center, and one would say, at a 
glance, it was, in all probability, an ovarian cystoma. There 
were complete dullness over the entire tumor, which remained 
unchanged in any position, and quick and equal fluctuation in 
every direction. The abdominal wall was harder and more 
resistant than natural, but in no place was this better marked 
than another, and there was no evidence whatever of a solid 
tumor. In short, the signs of a simple unilocular cyst seemed 
perfectly developed. Examined per vaginam, the uterus was 
well in front of the tumor ; the sound entered 2f inches, and 
was uninfluenced by an effort to move the tumor, which seemed 
unusually tense and elastic. 
The question, then, was, What is it ? I will not discuss 
all the conditions which might possibly produce the phe- 
nomena in question, but only those which usually and in- 
stinctively suggest themselves. 
1. Was it an ovarian cystoma? The first objection to 
that view of the case is the extreme infrequency of that WILLIAM T. HOWARD. 
5 
affection in the negro race. Indeed, although my entire 
professional life of forty years has been passed in communi- 
ties in which negroes exist in large numbers, and for the past 
eighteen years many hundreds have attended my gynecologi- 
cal clinics, I have yet to see an ovarian cystoma in the negro 
race. The testimony of the late Dr. W. L. Atlee was nearly 
similar. He wrote: “ I may state as a remarkable fact that, 
out of two hundred and fifty-five operations performed by 
me for the removal of the ovary, only one was performed 
on the negro, and that a mulatto, notwithstanding I have 
been frequently consulted by that class for abdominal and 
pelvic tumors. So satisfied am I of the predominance of 
fibroid tumors in the negro that, when consulted, I never an- 
ticipate finding an ovarian tumor.” 1 
Again, the growth of an ovarian tumor is usually slow. 
Although Lawson Tait affirms,2 in speaking of ovarian tu- 
mors, that “the rate of increase gives no guide,” and, to 
prove his statement, cites an instance in which he removed 
a multilocular tumor of great size from a patient aged sixty- 
six, “ which had grown in four months ” ; still, even if it be 
granted that the history of this wonderful case was not mis- 
leading, the general fact remains that it usually requires from 
one and a half to two years for an ovarian tumor to reach 
the size of the pregnant uterus. We all know how often 
patients tell us that they have only recently become aware 
of the existence of fibroid tumors of the uterus, and, indeed, 
of many other morbid conditions, when universal experience 
nullifies the idea of recent occurrence. 
For these reasons chiefly I rejected the diagnosis of 
ovarian cystoma in the case in question. 
2. Was it a fibro-cystoma of the uterus? The first ques- 
tion to be considered is, What is the relative frequency of this 
affection and of ovarian cystomata? For the infrequency of 
a disease is a matter of great importance in questions of dif- 
ficult diagnosis; and, as Chomel has well insisted, when a 
group of symptoms belongs to two affections, one of which 
1 Ovarian Tumors, p. 192. 2 Diseases of the Ovaries, fourth ed., p. 189. 6 
ANNUAL ADDRESS OF THE PRESIDENT. 
is very frequent and the other as rare, the physician will, and 
naturally should, be led to apply these symptoms to the most 
common disease.1 
Fibro-cysts of the uterus seem much more common in 
this country than abroad. The lamented Peaslee, writing 
in 1872, says:2 “ I have myself met with ten cases in the last 
two years, and have seen not less than fifty since my first 
operation of ovariotomy in 1850.” Dr. Emmet states that, 
in former years, he saw an unusual number of fibro-cystic 
tumors of the uterus, but that now, from more wide-spread 
knowledge of these growths, he sees comparatively few cases.3 
Dr. Thomas’s experience in regard to uterine fibro-cysts 
seems to have been small. He says:4 “ I had recently under 
my care two very large tumors supposed to be of this kind.” 
And I do not find in his work5 that Dr. Byford had seen a 
case. Dr. Atlee has recorded the history of only five fibro- 
cystic uterine tumors, although he did three hundred and 
seventy-eight ovariotomies. On the other side, Lawson Tait, 
writing in 1882, says:6 “ The fibro-cystic tumor of the uterus 
is an extremely rare affection—so rare that, until four months 
ago, I had never seen a case ”; and, in spite of his enormous 
experience and wonderful skill, he mistook that for a unilocu- 
lar parovarian cyst, and removed it wTith a fatal result. In 
respect of Sir Spencer 'Wells’s unequaled experience, Dr. 
Peaslee says: “ He assures me that he meets with not more 
than one fibro-cyst for fifty ovarian cysts.” Perhaps that is 
his reason for not alluding to the subject in the chapter on 
Differential Diagnosis of Ovarian Tumors in his recent 
work,7 although he has done 1,139 ovariotomies. Dr. Thomas 
Keith made his first mistake, in diagnosis of 194 operations,8 
1 Elements of General Pathology, p. 337. 
1 Ovarian Tumors, p. 106. 
8 Gynecology, third ed., p. 678. 
4 Diseases of Women, fifth ed., p. 557. 
B Diseases and Accidents incident to Women, third ed., 1881. 
6 Op. cit., fourth ed., p. 215. 
1 Diagnosis and Surgical Treatment of Abdominal Tumors, 1885. 
8 Contributions to the Surgical Treatment of Tumors of the Abdomen, p. 25. WILLIAM T. HOWARD. 
7 
when he mistook a case of fibrous cystic tumor of the uterus 
for an ovarian tumor; which attests at once his unrivaled 
accuracy in diagnosis and the infrequency of uterine fibro- 
cysts abroad. 
It is clear, then, from the evidence adduced, that, in re- 
spect of frequency of occurrence, whether in this country or 
abroad, a fibro-cystoma of the uterus, in comparison with an 
ovarian cystoma, is a very rare disease. This is all the more 
remarkable in the negro race, among whom fibroids of the 
uterus are met with every day; and uterine fibro-cysts, in 
certainly the majority of cases, are merely extra-uterine 
fibroids that have become softened. I have only once seen 
a uterine fibro-cyst in a negress, aged thirty-two years, which 
was filled with pus, and removed with a fatal result. 
But however important as an element of differential di- 
agnosis infrequency of occurrence of fibro-cysts of the uterus 
may be in the white race in a doubtful case, it avails little 
in the negro race, among whom ovarian cystomata are almost 
unknown. Still, as ovarian and fibro-cystic uterine tumors 
are almost equally among the rarest of all rare things in 
negroes, that fact alone should rather lead the mind away 
from the diagnosis of these affections among them in quest 
of others to account for the phenomena in question. But, 
before that is done, other elements of diagnosis should be 
utilized. What influence has age in the solution of the 
problem in hand ? In a remarkable paper upon the Diag- 
nosis of Ovarian Tumors from Fibro-cystic Tumors of the 
Uterus, by our eminent Fellow, Dr. Charles Carroll Lee,1 
and which has been so generally quoted both at home and 
abroad, he gives the histories of nineteen cases, derived from 
various sources. In eighteen the age is stated, and there 
were only two under 34 years; generally they were from 40 
to 50; one was 26, and one 27. Besides these I have searched 
out and added ten others—five reported by Dr. W. L. At- 
lee, aged, respectively, 36, 40, 40, 56, and 42 years; two 
by Dr. Thomas Keith, 52 and 28 years; one by Sir Spencer 
1 New York Medical Journal, vol. xiv, p. 449. 8 
ANNUAL ADDRESS OF THE PRESIDENT. 
Wells,1 aged 39 years, mistaken for a multilocular ovarian 
cyst; one by Dr. Hunter McGuire,2 aged 24—a negress; and 
one by myself, aged 32 years, also a negress. Thus, of twenty- 
eight cases of fibro-cysts of the uterus, only four were under 
34 years. In view of these facts, it seems to me that the age 
of the patient is a matter of considerable importance in the 
differential diagnosis of two affections often so confessedly 
difficult as to elude the skill of the most accurate experts, 
however matured and sharpened by amplest experience. Of 
the nineteen cases of fibro-cystic tumors of the uterus col- 
lected and analyzed by Dr. Lee, a correct diagnosis was 
made before operation in only one; all the rest were mis- 
taken for ovarian cysts. So far, then, as age lent aid to 
diagnosis, my case, twenty-four years old, was probably not a 
fibro-cyst of the uterus; still, Dr. McGuire’s case was of the 
same age and of the same race—a fact well known to me at 
the time. 
The rate of growth is always to be considered, and there 
can be no question that uterine fibro-cysts, like hard fibroid 
tumors, usually grow much more slowly than ovarian cysts; 
still, we have the authority of W. L. Atlee8 for the state- 
ment that the growth of the former may be as rapid as that 
of the latter; and Peaslee4 makes the same assertion. In all 
such affections, however, the rate of increase must be re- 
ceived with caution and reserve ; and the fact that they may 
remain long unrecognized depreciates the value of this ele- 
ment of differential diagnosis. Hence I was not disposed 
to attach great importance to the statement of my patient, 
of very limited intelligence, that the growth, whatever it 
might be, did not date back farther than three months and a 
half. 
It is generally taught that, in making a diagnosis between 
a uterine fibro-cyst and an ovarian cyst, we must remember 
that in the former the uterine cavity is generally enlarged, 
1 British Med. Jour., 1878, vol. ii, p. 865. 
* Philadelphia Med. Times, vol. ii, p. 244. 
8 Op. cit., p. 262. 4 Op. cit., p. 107. WILLIAM T. HOWARD. 
9 
much exceeds two and a half inches in length, and that menor- 
rhagia and metrorrhagia are generally observed. But the ex- 
ceptions are not infrequent. On the 3d of July, 1880, I suc- 
cessfully performed double ovariotomy on a lady, twenty-eight 
years of age, who had suffered from profuse menorrhagia and 
metrorrhagia for ten years, and who had no fibroids or other 
disease of the uterus. She had metrorrhagia when the oper- 
ation was done ; the hemorrhage promptly ceased, and, two 
years afterward, she had never bled from the uterus again. 
Hear the testimony of our eminent Honorary Fellow, Dr. 
George Granville Bantock. In writing about hysterectomy 
he states:1 “If any one were asked to name the most charac- 
teristic symptom of uterine fibroid, he would probably an- 
swer ‘ hemorrhage.’ But it is a remarkable fact that in only 
four of twenty-one cases in which I have operated was this a 
prominent symptom at the time of operation.” There are so 
many affections of the uterus which may co-exist with an 
ovarian cystoma and produce profuse uterine hemorrhages, 
and, on the other hand, uterine fibro-cysts are so generally 
extra-uterine, with slight involvement of the uterine wall, 
that the presence or absence of uterine hemorrhages ought 
not, in a doubtful differential diagnosis, to receive great 
weight. And this is all the more apparent wrhen we con- 
sider that diseases of the ovaries themselves produce copious 
uterine hemorrhages. Thus, a few years back, I lost a patient 
in the Maryland University Hospital from incessant metror- 
rhagia which nothing could control; and the autopsy re- 
vealed the existence of carcinomatous degeneration of the 
right ovary as the sole lesion. On the 21st of May, 1881, 1 
performed oophorectomy on a married and sterile lady, aged 
twenty-five, who had no uterine disease, and had long suf- 
fered from metrorrhagia. Both ovaries were nearly three 
times their normal size, hard, nodulated, and undergoing 
cystic degeneration. And Lawson Tait has emphasized the 
close association of uncontrollable menorrhagia with small 
cystic ovaries.2 
1 British Med. Jour., August 26, 1882, p. 364. 5 Op. cit., p 190. 10 
ANNUAL ADDRESS OF THE PRESIDENT. 
In the case which forms the text of these remarks there 
were no menstrual irregularities whatever. Having rejected 
the diagnosis of uterine fibro-cyst, I next considered— 
3. Was it a 'parovarian cyst ? Dr. Atlee says:1 
“There is no condition of the female abdomen that imi- 
tates ovarian dropsy as much as this. It may be safely as- 
serted that its external appearances, when the disease is fully 
developed, are identical with those of unilocular ovarian 
dropsy at a similar stage of development.” 
My case, like a parovarian cyst, presented to palpation a 
uniform and rapid wave in every diameter of the tumor; 
and, according to Peaslee, a parovarian cyst “ occurs most 
usually in young women,” and my case was twenty-four years 
of age. On the other hand, parovarian cysts are usually 
of very slow development, and generally so flaccid that, 
although they may fill the abdomen and even reach to the 
sternum, they may be compressed to the umbilicus, while an 
ovarian cyst is hard and incompressible—clinical data espe- 
cially emphasized by Goodell,2 who affirms that exceptions 
to this rule are very rare; that is, either a tense parovarian 
cyst or a flaccid ovarian one. I have seen only two well- 
marked exceptions—a tense parovarian cyst in the practice 
of Dr. Alan P. Smith, of Baltimore, and quite recently, in 
my own practice, a large flaccid ovarian cyst, of which I 
will speak farther on. In the case I am discussing, as al- 
ready stated, the cyst was hard, tense, and elastic. In re- 
spect to the value of age as an element of diagnosis, Dr. 
Atlee’s experience does not seem to bear out Dr. Peaslee’s 
statement. Of seven cases reported by Atlee, the ages were, 
respectively, 25, two 29,30,40, and two 44 years old. Slowness 
of development is more characteristic. Goodell removed a 
parovarian cyst which had existed ten years, and Lawson 
Tait one which had been in existence more than ten years. 
Still, these cysts occasionally grow rapidly. Tait says that 
he has “removed a very large parovarian cyst, when the 
1 Op. at., p. 107. 
* Amer. Jour, of Obstel., vol. xvii, p. 391. WILLIAM T. HOWARD. 
11 
fact was fully ascertained that the tumor grew in less than 
six weeks ” ; and in another place (presumably, from the 
connection, speaking of these cysts) that he has “removed 
two unilocular tumors, one of which grew so as to completely 
distend the abdomen in seven weeks, and another, almost as 
large, which had not been noticed for more than live 
weeks.” 1 But parovarian cysts are comparatively rare, do 
not seriously affect the general health, and almost always 
impart to the palpating hand the sensation of a very thin 
liquid. And I readily excluded a parovarian cyst in my 
case. 
4. Was it a case of simple ascites ? When I saw the 
case, pure ascites was out of the question. The lines and 
limits of dullness and fluctuation corresponded exactly in all 
positions ; the percussion-note was resonant at the sides over 
the ascending and descending colon; and the abdomen was 
not sufficiently distended to prevent the buoyant intestines 
from floating to the surface, as occurs exceptionally in ex- 
cessively large accumulations of free fluid in the peritoneal 
cavity, and thus mimicking encysted fluid. 
5, and lastly. Was it a case of so-called encysted dropsy 
of the peritoneum, the result of simple peritonitis ? This is 
admitted on all hands to be an extremely rare affection, and, 
according to Peaslee, it occurs more seldom in women than 
in men. The intestines may be strapped down to the back 
by adhesions and large deposits of lymph, or held down by a 
thickened and shortened omentum, and plastic exudations 
so disposed as to form a cystdike cavity in which serum is 
imprisoned ; so that the areas of dullness and resonance re- 
main the same on changing the patient’s position. In Octo- 
ber, 1875, I was kindly invited by Prof. Erich, of Baltimore, 
to witness an ovariotomy in a negress, aged twenty, who was 
supposed to present all the physical signs of a large ovarian cyst, 
and the diagnosis had been sustained by the character of the 
fluid drawn by tapping, which was positively stated, by an 
experienced microscopist, to reveal the presence of the so- 
1 Op. citpp. 167 and 189. 12 
ANNUAL ADDRESS OF TIIE PRESIDENT. 
called ovarian cell.1 It turned ont to be, however, “ encysted 
ascites simulating ovarian dropsy,” and was followed by an un- 
fortunate result. Dr. J. Ewing Mears has reported a similar 
case, aged forty, wdiich he mistook for a multilocular cyst of 
the ovary, and for which he operated with a fortunate issue.2 
But, according to Peaslee and Barnes,3 in encysted dropsy 
of the peritoneum fluctuation is weak and limited ; the abdo- 
men is not prominent, but flat, at points even depressed; the 
health is not bad, and the increase of the affection slow, 
while in my case all this was reversed. In the cases in 
question, however, the inflammatory exudations in the ab- 
dominal cavity are attended, especially in their earlier stages, 
by symptoms of constitutional disturbance much more acute 
and grave than those which usually herald the earlier peri- 
ods of ovarian cystomata, which, according to Atlee, only ex- 
ceptionally exhibit, then, violent symptoms. But, as my case 
was attended with acute pleurisy and marked constitutional 
disturbance, and the abdominal enlargement revealed no ten- 
derness upon pressure, there seemed no reason why the 
acuteness of the phenomena present should be referred to en- 
cysted dropsy of the peritoneum, and it wras excluded. 
And now, gentlemen, those of you who may have hon- 
ored me thus far in listening to this address are ready, I 
fancy, to say : “ You have been speaking long enough 
already, if not too long; why do you not tell us at once 
what the thing was?” Well, I will anticipate enough to 
say it was not any one of the morbid states I have been dis- 
cussing. 
The case was transferred to my gynecological in 
the hospital, and on the 20th of June, having thought it over, 
I considered what was best to be done. Would it be best to 
aspirate the pleuritic effusion, and thus relieve the oppressed 
breathing? In a bad case of multilocular ovarian cystoma I 
had given prompt relief, August 15,1878, to a lady aged fifty, 
1 Boston Med. and Surg. Jour., vol. ciii, p. 318. 
* Trans. College Phys., Philadelphia, vol. i, p. 111. 
3 Med. and Surg. Bis. of Women, second edition, p. 3GG. WILLIAM T. HOWARD. 
13 
by aspirating the left pleural sac, which wras filled to repletion 
by an acute pleuritic effusion, and which did not return. In 
this case, however, I determined to aspirate the abdominal 
cyst, as I was anxious to ascertain the character of the con- 
tained fluid. This I preferred to making an exploratory in- 
cision, which might lead, of necessity, to a completed opera- 
tion, for which, should it be subsequently required, I hoped 
to have the poor woman in better condition. And this I 
proceeded to do, with every antiseptic precaution. As the 
fluid, which was of a light straw-color, was pumped into a 
large pitcher, it began to coagulate as speedily as blood ; and, 
an hour afterward, I never saw a firmer clot and more abun- 
dant serum in the by-gone days when medical men were not 
afraid to bleed. After all the fluid was removed, large, hard 
masses were easily felt through the abdominal wall, resem- 
bling those felt after tapping in the walls of a multilocular 
ovarian cyst. According to Dr. Atlee’s teaching, as we all 
know, I had before me a fibro-cyst of the uterus. He said:1 
“I consider the fluid removed from a fibro-cystic uterine 
tumor to be blood minus the corpuscles, or true liquor san- 
guinis, which rapidly coagulates on exposure to the atmosphere, 
and after a reasonable time separates into fibrin and serum. So 
far as my experience goes, I have met with no other fluid, re- 
moved from the abdominal cavity, that undergoes such 
changes ; nor have I met with any other form of tumor that 
furnishes such a fluid. It may, therefore, be pronounced not 
only diagnostic, but pathognomonic.” 
But my experience had furnished me two cases before 
this which clearly seemed to negative Dr. Atlee’s experience. 
About four years before this date I had a case under care in 
which I was greatly puzzled in making the diagnosis between 
an ovarian cyst and a fibro-cystic tumor of the uterus. I as- 
pirated the tumor and drew off nearly two pints of a reddish 
fluid (all that would flow through the tube) which did not 
coagulate during the twenty-eight days that I kept a portion 
1 Op. cil., p. 289. 14 
ANNUAL ADDRESS OF THE PRESIDENT. 
of it in a bottle; and, relying npon Dr. Atlee’s test of the 
speedy coagulability of fibro-cystic fluid, I decided in favor 
of ovarian cystoma. But, when I subsequently opened the 
abdomen, I encountered a large fibroid of the uterus grow- 
ing from the right side of the organ by a pedicle about the 
size of a man’s wrist, and undergoing cystic degeneration. 
This case proved that the fluid from a fibro-cystic uterine 
tumor does not always rapidly coagulate on exposure to the 
atmosphere. Again, on the 20th of December, 1878, I was 
consulted by a gentleman, aged forty-nine, from Raleigh, 
N. C., who had been suffering for some months from 
apparently simple ascites or hydro-peritoneum. Remedies 
made no impression on the disease; and, from frequently 
getting out of bed at night and sitting up to relieve, in some 
degree, urgent dyspnea, he contracted a croupous pneu- 
monia which involved the entire right lung, which is twice 
as fatal as pneumonia of the left. Dyspnea became so 
alarming that, on the 3d of January succeeding, assisted by 
Prof. George W. Miltenberger, I tapped the abdomen. The 
ordinary trocars used in this little operation were too short to 
penetrate entirely through the abdominal wall, and I used an 
aspirating tube which entered four inches and a quarter before 
the lemon-yellow fluid began to flow. It soon began to coagu- 
late, and the clot formed was nearly as large, in proportion to 
quantity, as occurs in venesection. Perhaps there was a 
chronic diffuse peritonitis, which sometimes arises in the 
course of old-standing ascites, particularly if the latter be 
dependent on stasis in the portal vein, and more especially 
when an atrophic nutmeg liver is developed as a result of 
the stasis,1 as was altogether probable in the case in question. 
In ordinary simple ascites there is generally some spontane- 
ous coagulation, but nothing like what took place in this 
case, which proved that there is another fluid removed from 
the abdominal cavity, other than uterine fibro-cystic fluid, 
which speedily coagulates on atmospheric exposure. Thus, 
to resume: An analysis of these three cases proves (1) that 
1 Bauer, in Ziemssen's Cyc., vol. viii, p. 296. WILLIAM T. HOWARD. 
15 
the fluid from a fibro-cystic uterine tumor does not always 
rapidly coagulate on exposure to the atmosphere; (2) that 
fluid simply from the abdominal cavity may rapidly coagu- 
late on atmospheric exposure; and (3) that fluid removed 
from an abdominal cyst, not a fibro-uterine cyst, may do so 
likewise. 
After the cyst was aspirated the patient seemed to do well 
until the third day, when she had a chill and rapid rise of 
fever, and all the signs and symptoms of acute peritonitis 
quickly supervened. On the seventh day she died, and, at 
my request, the autopsy was kindly made by my colleague, 
Dr. I. E. Atkinson, professor of pathology in the University 
of Maryland: 
“ Body emaciated and of medium size. A tumor-like promi- 
nence was visible in the epigastric and umbilical regions. The 
presence of fluid was not evident to palpation. Upon opening 
the abdominal cavity, a mass as large as a child’s head at term 
presented at the opening. This proved to be composed of 
omentum, transverse colon, and small intestines bound to- 
gether and made smooth and continuous by inflammatory exu- 
dation. As the masses of lymph were gently separated, the 
thickened and inflamed peritoneum was seen to be everywhere 
invaded by fine miliary tubercles. Recently formed visceral 
peritoneal adhesions were found throughout the abdominal 
cavity, and tubercle was sprinkled over both parietal and vis- 
ceral surfaces. There was but little fluid in the abdominal 
cavity of a pale straw-color. There was no sign of ovarian or 
uterine disease. There was some tubercular ulceration in the 
small intestine. The other abdominal organs remained unaf- 
fected. 
“Upon opening the thorax, a large quantity of clear serum, 
of the color of brown sherry, escaped from the left pleural 
cavity. Both costal and visceral pleurae were invaded by scat- 
tered miliary gray tubercles. The pericardial sac also con- 
tained some fluid of a straw color, and had a few miliary tu- 
bercles on its surface toward the base. In both lungs were 
scattered miliary gray tubercles, but no softening or case- 
ation.” 16 
ANNUAL ADDRESS OF THE PRESIDENT. 
It is thus seen that this was a case of encysted tubercular 
peritonitis, which presented the characteristic phenomena of 
a unilocular ovarian or parovarian cyst. The small amount 
of fluid found is obviously accounted for by the recent attack 
of adhesive peritonitis, w'hicli nearly obliterated the tubercu- 
lar cyst, and by the large amount drawn ofl by aspiration. 
Now, it may well be asked, As you correctly reasoned out 
what the case was not, wdiy did you not reason out what it 
was ? The answer is near at hand. I was so engrossed with 
the phenomena before me that I strangely failed to remember 
the clinical history recorded by my intelligent chief of clinic, 
Dr. Chunn, and to attach due importance to commemorative 
events. We all know how prone wre are not to give great 
weight to the past observations of others when they are in 
complete and obvious contrast with what wTe immediately 
observe ourselves. The history of the case evinced the pres- 
ence of a fluid evidently free in the peritoneal cavity when 
the patient first presented herself to Dr. Chunn; and when 
I saw her, about seven weeks later, there was obviously 
fluid imprisoned in an abdominal cyst. Now, this was evi- 
dently the result of a simple or tubercular peritonitis, or else 
cancer of the peritoneum. And, as the latter would, in all 
probability, be excluded by the absence of its concomitant 
circumstances, the diagnosis would be narrowed down to the 
two former. But, as tubercular peritonitis is usually associ- 
ated with a tuberculous process distributed throughout the 
body, and notably in the lungs, the presence of pleurisy in 
my case ought to have been strikingly significant; and, by 
the familiar process of exclusion, a simple inflammatory cyst 
ought to have been rejected and a tubercular peritonitic 
cyst accepted. This is the important lesson which my case 
teaches. But, if I failed to read it aright, while I have no 
disposition to dodge behind the ample shield of great names, 
it is some consolation to know that some of the ablest and 
most experienced gynecological diagnosticians have failed 
likewise, as will presently appear. * 
The literature of encysted tubercular peritonitis, simulat- WILLIAM T. HOWARD. 
17 
ing ovarian cysts, is very scanty. No illustrative cases are 
given in our standard gynecological works; indeed, the sub- 
ject does not seem to have received even the cold respect of 
a passing recognition. Nor in works on the general practice 
of medicine, save in a perfunctory and dimly shadowed way 
of no practical utility, unless the following, cited by Bauer,1 
be a slight exception: 
“ In Kaulick’s work a case is recorded in which the partial 
sacculation of fluid by means of firm membranes produced phe- 
nomena which gave rise to a similarity to an ovarian cyst.” 
In works consecrated to diseases of the ovaries and ovari- 
otomy we do not find much on the subject in hand. In his 
great work, Peaslee2 simply says: “ Acute tubercular perito- 
nitis may simulate an ovarian or other form of abdominal 
tumor.” Sir Spencer Wells enlightens us with a single illus- 
trative case. Called, in 1862, to see an unmarried lady, aged 
twenty-two, whose abdomen was as large as that of a woman 
near the full term of pregnancy, and filled with free fluid, 
which gravitated to the lowest point with all changes of po- 
sition, and looking at her appearance and to the fact that 
she had occasional pain, he diagnosticated a subacute form of 
tubercular peritonitis. Some months afterward, however, a 
remarkable change had taken place. The abdomen was much 
more prominent and arched than before; it was dull in all 
positions of the body, and clear in both flanks as she lay on 
her back; fluctuation was evident in all directions; and, on 
taking a deep inspiration, a cyst appeared to move downward 
from the epigastrium beneath the parietes. He now doubted 
the accuracy of his first opinion, and she was tapped. Seven 
days later he became rather impressed with the belief that 
he was dealing with a thin, non-adherent, unilocular ovarian 
cyst, and made an exploratory incision. No cyst appeared, 
but a large quantity of opalescent fluid escaped, and the 
whole of the peritoneum was seen to be studded with myriads 
1 Op. cit., p. 336. 
a Op. cit., p. 165. 18 
ANNUAL ADDRESS OF THE PRESIDENT. 
of tubercles.1 So that, although he had the advantage of a 
personal examination when the diagnosis of an abdominal 
cyst was clearly out of the question, and sagaciously made a 
correct diagnosis, subsequently, when the conditions were 
radically changed, he doubted its accuracy, and thought he 
had before him an ovarian cyst. But the most remarkable 
part of the history of this lucky lady remains to be told. She 
got well, married, and, in 1881—twenty-two years afterward 
—wras still well! 
Mr. Lawson Tait states that his book on Diseases of the 
Ovaries includes all the conditions which simulate ovarian 
tumors that have occurred in his practice; and I find no ac- 
count of tubercular peritonitic cysts simulating ovarian cysts 
among them. 
But Dr. Atlee has reported2 three cases of tubercular 
peritonitis which produced conditions similar to those char- 
acteristic of unilocular ovarian cysts, aged ten, twenty-nine, 
and forty-nine years. All were fatal, and not one seems to 
have been correctly diagnosticated before death. All were 
tapped, and in all the fluid, in that respect like ovarian fluid, 
“ firmly coagulated by heat,” but not, as in my case, rapidly 
on exposure to the atmosphere. 
In journalistic literature I have met with only twro cases. 
One, Maggie C., black, aged twelve years, reported8 by 
our distinguished Fellow, Dr. Samuel C. Busey, u as a case 
of tuberculosis of the peritoneum, with the formation of a 
sac simulating an ovarian cyst.” The author says: 
“ During the examination at the time of admission the pos- 
sibility of the presence of an ovarian cyst was considered, but 
was excluded by the facts elicited at the time. A few days’ 
observation and examination of the pulse-rate and temperature 
chart confirmed the diagnosis of tubercular peritonitis. The 
probability of the formation of a cyst in cases of tubercular 
peritonitis simulating ovarian dropsy is very remote. I have 
1 Op. cit., p. 20, and Ovarian and Uterine Tumors, London, 1882, p. 100. 
1 Op. cit., pp. 72, 73, and 78. 
8 GaillarcTs Med. Jour., May, 1880. WILLIAM T. HOWARD. 
19 
not examined the literature of the subject, and can only refer 
to the one case observed by Kaulick.” 
The other case has been recently reported by Prof. 
William Gardner, M. D., of Montreal.1 This was an un- 
married domestic servant, aged twenty-three, who admitted 
a pregnancy, terminating at six or seven months, a year and 
a half previous. The abdominal enlargement had only been 
noticed three or four months previous. Her general health 
had declined, and she was emaciated : 
“Examination.—Well-marked fluctuation over the whole 
of the anterior and antero-lateral aspects of the abdomen. 
Dullness on percussion over the same area. In the lumbar re- 
gion (flanks) and epigastrium the bowel note present. No 
firm or solid part to be felt anywhere. The anterior aspect of 
the abdomen quite uniform. The uterus, measuring two inches, 
pressed upward and forward, lay immediately behind the 
pubes. The patient was admitted to the Montreal General 
Hospital and kept under observation for a few days, when it 
was found that she had fever of septic type, the temperature 
at times running very high, with profuse sweating and occa- 
sional attacks of vomiting. During this interval she was seen by 
Drs. Fenwick, Ross, Roddick, Shepherd, and J. C. Cameron, 
who concurred in my diagnosis of suppurating ovarian cyst. 
Another symptom—red blush and edema of the central anterior 
part of the abdominal wall—seemed to support the view. Oper- 
ation : The ordinary incision for ovariotomy was made, but, on 
reaching the peritoneum, no separation of parietal from visceral 
layer could be made ; the knife entered the collection of fluid, 
passing through what seemed to be a thickened, closely adher- 
ent cyst-wall. 
“ Drainage was practiced in this case, and irrigations of 
carbolized water, then corrosive sublimate solutions, and finally 
solutions of iodine, were used. But death occurred from ex- 
haustion six weeks after the operation. The autopsy revealed 
the anterior peritoneal cavity converted into a suppurating 
cyst, extending from the liver into the true pelvis, which was 
1 Canada Med. and Surg. Jour., June, 1885. 20 
ANNUAL ADDRESS OF THE PRESIDENT. 
nearly filled by the mass, and which consisted of all the intes- 
tines, except the transverse colon, closely matted together by 
recent adhesions and studded with miliary tubercles. The 
lungs were universally adherent, and studded with gray granu- 
lations.” 
Prof. Gardner states that a similar case occurred some 
years ago in the practice of his colleague, Dr. Fenwick, 
in which the same error of diagnosis wras made by all who 
saw it, and that the patient died some months after oper- 
ation. 
I have endeavored to present a fair statement of the 
meager literature of this subject as I have found it. It can 
scarcely be said that a correct diagnosis was made in any of 
the eight cases previous to death ; for if, at first, Sir Spencer 
"Wells made a correct diagnosis of a subacute form of tuber- 
cular peritonitis, he subsequently doubted its accuracy, and 
inclined to believe that he had in hand a thin, non-adherent, 
unilocular ovarian cyst, and operated for it. Dr. Busey cer- 
tainly, in his case, made a correct diagnosis of the tubercular 
process invading the peritoneum and the lungs, and excluded 
the presence of an ovarian cyst; indeed, he even believed 
“ that the wTalls of the sac or abscess were formed in front 
by the parietal peritoneum and posteriorly by the aggluti- 
nated intestines ” ; still, from his stating that the formation 
of a cyst in tubercular peritonitis, simulating ovarian drop- 
sy, is very remote, and his reference to the one case observed 
by Kaulick, in which there was a partial sacculation of fluid 
presenting a similarity to an ovarian cyst, I infer that Dr. 
Busey did not recognize before death that the sac was caused 
by tuberculosis of the peritoneum. It does not appear that 
Dr. Atlee recognized the true character of any one of his 
three cases before death; and Drs. Gardner and Fenwick 
completely failed in the diagnosis of their cases. As for my 
own case, if I did not make a mistake in diagnosis, it was 
only because I made no diagnosis at all; for it is certain that 
I did not even suspect its true character. WILLIAM T. HOWARD. 
21 
The cases adduced are too few to formulate any absolute 
rules for guidance in diagnosis; still, if they are scanned a 
little closely, they furnish some lessons not wholly destitute 
of clinical value. 
1. As regards age. Of seven cases in which this was 
noted, the ages were ten, twelve, twenty-two, twenty-three, 
twenty-four, twenty-nine, and forty-nine years. So that all 
were under thirty except one, and, of the six others, all but 
one were under twenty-five years. And this is in accordance 
with the etiology of tubercular peritonitis when unaccompa- 
nied by the formation of cysts that simulate ovarian or 
other forms of abdominal cysts. Thus Loomis says:1 “ Tu- 
bercular peritonitis is met with most frequently in early 
life.” And Bauer says:a “ In the later periods of life tuber- 
cular peritonitis rarely occurs.” It is clear, then, that age is 
an important element of diagnosis in the cases in question. 
2. Rate of growth. In all the cases under consideration, 
as far as can be ascertained, this was rapid, and varied from 
six weeks to eight months; indeed, only one seems to have 
reached the latter limit. In Dr. Atlee’s cases, from the be- 
ginning until they presented the characteristics of an ovarian 
cyst, in one case less than three months had elapsed, in an- 
other about six weeks, and in the third only a short time, as 
the patient had been suffering from acute pain in the abdo- 
men, followed by sudden enlargement from an accumulation 
of fluid. In my case only three and a half months had 
passed, and in Prof. Gardner’s three or four, when they of- 
fered the conditions pertaining to unilocular ovarian cysts. 
Certainly, then, rapidity of development specially character- 
izes the formation of tubercular peritonitic cysts. 
3. As tubercular peritonitis is only in very rare instances 
a local affection, we should look for the evidences of the 
tuberculous process in other parts of the body, and especially 
note the temperature variations, which were markedly em- 
phasized in Dr. Busey’s and Dr. Gardner’s cases. 
4. And lastly. Prof. Gardner noticed “ red llush and 
1 Practical Medicine, p. 325. 
2 Op. tit., p. 325. 22 
ANNUAL ADDRESS OF THE PRESIDENT. 
edema of the central anterior part of the abdominal wall ” 
in his case, and says that it seemed to support his diagnosis 
of suppurating ovarian cysts. Dr. Loomis, on the other 
hand, states that “ redness and edema about the umbilicus 
are regarded as characteristic of tubercular peritonitis” And 
Bauer also says: 
“ Among the changes in the abdominal parietes which may 
be observed, considerable stress has been repeatedly laid on 
the inflammatory redness and edema which are sometimes de- 
veloped in the neighborhood of the umbilicus in the course of 
tuberculosis of the peritoneum. Yallin has particularly urged 
the importance of this symptom in peritoneal tuberculosis.” 
And in a remarkable paper On Suppurating Ovarian 
Cysts, by Dr. Thomas Keith,1 I find no mention of the 
symptom in question in any of his cases, although full his- 
tories are given of seven acute cases of the ten on which he 
operated. 
The important question now arises : When a correct diag- 
nosis is made of tubercular peritonitic cysts, that simulate 
ovarian cysts, how are they to be treated ? Sir Spencer 
Wells’s case was twice tapped, then was incised as in ovari- 
otomy, and recovered. Dr. Atlee tapped all of his three 
cases, and all died. Drs. Gardner and Fenwdck operated on 
their cases as in ovariotomy, and both died; and I aspirated my 
case with a fatal result. Thus, of six cases treated by opera- 
tive interference, five died—a deplorable exhibition. Hence, 
it may well be asked, Would not a rational therapeutical and 
hygienical management promise better results ? Dr. Busey’s 
case was under care from August 8,1879, till November 5th 
succeeding. It was regarded as hopeless from the date of 
admission; and yet, under his skillful treatment, which con- 
sisted in rest, a nutritious and easily digested diet, tonics, 
1 Edinburgh Med. Jour., February, 1875. This great surgeon says: “ Of the 
ten more or less acute cases operated on, eight recovered, while the two chronic 
cases got well easily.” I do not know that any one has equaled this wonderful 
success in the removal of suppurating ovarian cysts. WILLIAM T. HOWARD. 
23 
cod-liver oil, the syrup of iodide of iron, and iodide of po- 
tassium, a marked diuresis ensued, which relieved the dis- 
tention from fluid accumulation in the abdominal cavity. 
And Dr. McCall Anderson, Professor of Clinical Medicine 
in the University of Glasgow, has published1 three cases 
illustrative of the curability of tubercular peritonitis, the 
diagnosis of which seems to have been justified by their 
clinical histories: 
Case I.—Helen G., aged ten years, was admitted into the 
hospital complaining of swelling of the abdomen of three 
months’ duration, and occasional pains in the epigastrium. Has 
never had much cough ; temperature is usually from 99° to 
100° Fahr., pulse 104, and respiration 36 ; tongue slightly 
furred, appetite fair, bowels loose ; there is evidently free fluid 
in the peritoneal cavity in considerable quantity ; the circum- 
ference at the umbilicus is twenty-six inches. Heart and kid- 
neys healthy, and there is no evidence of liver disease or of 
portal obstruction. The fluid in the peritoneal sac evidently 
results from peritonitis of a tubercular nature, for these rea- 
sons : 1. The girl’s brother died of “ decline of the bowels.” 
2. She is only ten years of age—a time of life when tubercle 
of the peritoneum is common. 3. She has a slight, dry cough, 
dullness on percussion at the left apex, and, in the same situa- 
tion, wavy respiration, with a snoring rale. Under a careful 
regulation of the diet and bowels, and anti-tuberculous treat- 
ment (cod-liver oil and syrup of iodide of iron), toward the 
end of the month not a trace of fluid could be discovered in 
the peritoneal cavity, all pain had disappeared, and she was 
dismissed well, excepting slight dullness at the apex of the left 
lung. 
Case II.—A lad, aged twelve years, had a most violent at- 
tack of tubercular peritonitis ; family strongly scrofulous ; 
father is dying of strumous cervical adenitis ; his mother has 
phthisis, and also two of his brothers ; and a brother died of 
tubercular disease of the bowels. The lad’s disease began 
with pain in the hypogastric region, attended by high fever, 
great emaciation, diarrhea, vomiting, but without serous effu- 
1 London Lancet, March 3, 1877, p. 303. 24 
ANNUAL ADDRESS OF THE PRESIDENT. 
sion in the peritoneal cavity. During his illness of five weeks 
an abscess formed in the neck, and discharged about a cupful 
of pus. His case appeared nearly hopeless, but he was assidu- 
ously nursed, fed, and stimulated ; iced cloths were applied 
to the abdomen for half an hour every second hour, and opi- 
um was given in full doses (a quarter- to a half-grain every 
four hours), with a grain of quinine in each dose. At the date 
of report he was sitting up in his arm-chair, cheerful and well, 
although weak and thin. 
Case III.—This was a little girl, with symptoms very simi- 
lar to those of the first patient, with fluid in the peritoneal 
cavity and consolidation of one apex. She was treated with 
cod-liver oil and syrup of iodide of iron, and a large quantity 
of fluid was twice removed by tapping, which the microscope 
showed to be inflammatory exudation. She made a perfect re- 
covery.” 
Prof. Anderson says to his students in regard to cases of 
tubercular peritonitis : “ I would have you enter upon their 
treatment with a hope that your efforts may be crowned with 
success, especially where the inflammation is accompanied 
by fluid effusionP And this is all the more encouraging 
when we consider the language of Prof. Alfred Loomis, of 
New York city, one of the most acute and accurate auscul- 
tators of which any country can boast, in respect of chronic 
pulmonary phthisis:1 “ Recovery has occurred in one sixth of 
my recorded cases during the past ten years.” Let all this 
be well pondered before the restless surgery of our day, 
always impatient to try its hand, essays operative interference 
in tubercular peritonitic cysts. 
Having detained the Society so long with the history and 
discussion of one case, it is with reluctance that I refer to an- 
other. But, as a whole, it is so extremely rare, interesting, 
and important, that I can not forbear the temptation to bring 
it before you. 
Case II.—Frances R., aged twenty-four, was admitted to 
the Hospital for the Women of Maryland, July 10, 1883. She 
1 Op. cit., p. 197. WILLIAM T. HOWARD. 
25 
seemed to belong to the white race, from her fair, white skin, 
long, straight, auburn hair, and somewhat ruddy cheeks. But 
it was subsequently ascertained, from the visits of her associ- 
ates, that she claimed to be of the colored race. She had been 
married only one year, and had never been pregnant. Her 
general health was good in every respect ; bowels regular, 
appetite excellent, uterine functions normal, and there was no 
evidence of cardiac or renal trouble. She complained only of 
the immense weight she had to carry, and from which she de- 
sired to be freed. 
The abdomen measured : from ensiform cartilage to umbili- 
cus, 10\ inches ; from umbilicus to symphysis pubis, 9| inches ; 
from umbilicus to right anterior superior spinous process of 
ilium, 12 inches; from umbilicus to left anterior superior 
spinous process of ilium, 12£ inches ; circumference at umbili- 
cus, 46£ inches ; circumference below umbilicus, 47 inches. 
Examined per vaginam, the uterus seemed pressed forward 
by a large sac containing fluid, and the sound entered two and 
a half inches. Over the abdomen everywhere there were devel- 
oped the physical signs of a large unilocular sac. The woman 
stated that she commenced enlarging between seven and eight 
years before, and that the increase of size had been very grad- 
ual and free from notable pain or uneasiness, save what seemed 
due to a sense of weight, fullness, and distention. Now, what 
was it ? 
1. Was it ascites, as a physician of large experience, who 
was present, supposed, from the superficial wave responding 
to palpation, the umbilicus retaining its normal position an 
inch nearer to the pubes than the sternum, and its normal 
depression effaced, while the intestines, anchored to the mes- 
entery, could not float to the top of the liquid and elicit 
resonance in front ? This view was quickly dismissed. Un- 
complicated ascites is the result of intra-abdominal disease, 
and, in an immense majority of cases, of cirrhosis of the 
liver. This is the legitimate offspring of alcoholic excesses, 
betokened by its long train of broken health and usually 
tliin-visaged aspect. In this case the conditions were all 26 
ANNUAL ADDRESS OF THE PRESIDENT. 
wanting, to say nothing of its protracted duration and steady 
march, never once relieved in its course by the trocar. 
2. "Was it a large unilocular ovarian cyst ? It is well 
known that multilocular ovarian cysts develop more rapidly 
than unilocular; and it may be safely stated, after Peaslee, 
that, as a rule, the former demand surgical relief within a 
year, and the latter within eighteen months or two years 
from the time they are first recognized by the patient, which 
usually occurs when the cystoma is approaching the level of 
the umbilicus, or about the size of the uterus at the end of 
four and a half to five months of gestation. So that when a 
woman tells us that she has observed a well-marked abdomi- 
nal enlargement for between seven and eight years, which, 
upon examination, is evidently a cystoma, that fact alone is 
strongprima facie evidence against its being of ovarian ori- 
gin. Indeed, before three years have elapsed, women are 
usually greatly exhausted, and the features are characteristic- 
ally chiseled by anxiety, apprehension, and suffering, so as to 
present, even to superficial observation, the model facies 
ovariana. The exceptions are certainly not numerous, still 
they do occur. Thus, on the 29th of August, 1870,1 was con- 
sulted by Mrs. A. E. H., aged thirty-four, a widow with two 
children. In regard to the diagnosis, I wrote her physician 
as follows: 
“ I find the uterus completely retroflexed, somewhat en- 
larged, with marked cervical metritis, and uterine catarrh in- 
volving the entire uterine canal. The malposition of the uterus 
is caused by the tumor. This tumor is, I suspect, of ovarian ori- 
gin. It may be, however, a large extra-uterine fibroid pressing 
the uterus backward. Time will show.” 
And time did show. This patient consulted me again on 
the 15tli of May, 1883. She stated that after her visit to me 
her abdomen gradually enlarged for about eight years, and 
was so immense that she could not walk about, and that she 
had great difficulty in breathing. Then, after a sensation of 
something bursting inside the abdomen, soon followed by WILLIAM T. HOWARD. 
27 
severe intra-abdominal pain and a protracted illness, the 
swelling subsided almost entirely. For a long time there 
was no evidence of swelling up again; then, but very grad- 
ually, the abdomen began to enlarge until the present time. 
She was now greatly distended, presented the typical facies 
ovariana, had lost her appetite completely, and could only 
retain a little lime-water and milk, from long-standing gastric 
irritability. On the 26th of May I operated for ovariotomy 
at the Union Protestant Infirmary, assisted by Drs. Charles 
II. Riley, Charles O’Donovan, Jr., and Robert T. Wilson. 
There were strong and numerous adhesions in every direc- 
tion, and I removed a large multilocular ovarian cyst. She 
succumbed on the fourth day from exhaustion, not having 
been able to retain any kind of nourishment on her stomach, 
and sustained only by rectal food. Now, here was a case of 
a multilocular ovarian cyst which burst, and nearly proved 
fatal, about eight years after I had diagnosticated an ovarian 
cystoma, and which I removed nearly five years after that 
accident occurred. And in a clinical lecture our distin- 
guished Fellow, Dr. T. Gaillard Thomas, makes the follow- 
ing statement:1 
“Three months ago I operated at the Woman’s Hospital 
for a tumor which Dr. Sims had twenty-four years ago de- 
clared to be an ovarian tumor of the size of a cocoanut. When 
I removed it it weighed sixty pounds, and the woman got per- 
fectly well after the operation. This tumor had unquestion- 
ably been growing for at least twenty-four years. ... I have 
frequently removed such tumors after they have been growing 
for nine or ten years.” 
As ovarian cystomata are not remarkable for either dor- 
mancy or sluggishness of growth, Dr. Thomas’s experience 
seems to have been somewhat unique, if he was reported 
correctly. But the testimony of so accurate and experienced 
a gynecologist as to the fact that ovarian cystomata may 
prolong, by some years, the regular normal periods of their 
1 New York Med. Jour., vol, xxxix, p. 88. ANNUAL ADDRESS OF THE PRESIDENT. 
growth is not to be ignored in a case of doubtful differential 
diagnosis. So that the fact that the case in band bad existed 
for between seven and eight years did not, of necessity, 
preclude the possibility of its being an ovarian cystoma. 
Nor did the apparent unimpairment of the general health of 
necessity exclude it; for Lawson Tait1 assures us: “ The 
largest ovarian tumor which I have removed, somewhere 
over one hundred pounds in weight, gave rise to no other 
symptoms than the inability of the patient to get about from 
its immense weight.” 
3. Was it a parovarian cyst f The patient was young, the 
affection had existed between seven and eight years with the 
general health unimpaired, fluctuation was superficial and 
distinct in every diameter of the cystoma, the walls seemed 
very thin, and it did not seem filled to repletion; indeed, 
one could not help thinking that the cyst could easily contain 
three or four quarts more of fluid. All this appeared to be 
much more in unison with the clinical history of a parovarian 
than an ovarian cyst. But there was one phenomenon 
which did not harmonize with the usual behavior of a par- 
ovarian cyst. Although the cystoma seemed to fill the ab- 
dominal cavity and was quite flaccid, it could not be com- 
pressed down near the level of the umbilicus. In this re- 
spect, it more closely resembled an ovarian cyst, which is 
usually tense and can not be compressed like a parovarian 
cyst, as has been already stated in another connection. But 
ovarian cysts are not always tense. On the 9tli of January, 
1885, I operated for ovariotomy on Mrs. A. E. P., white, 
from North Carolina, at the Hospital for the Women of 
Maryland. She was twenty-seven years old, married, had two 
children; no miscarriages. Her last child was born eight 
months before. She had noticed that her abdomen was 
enlarging for the past twenty-two months; that is, five 
months before the beginning of her last pregnancy. The 
tumor had grown very slowly, and was not then at all tense ; 
indeed, it rather presented the appearance of ascites than an 
1 Op. cit., p. 191. WILLIAM T. HOWARD. 
29 
ovarian cyst. She had never been tapped. The uterus was 
retroverted, and the sound entered three inches. I was 
assisted in the operation by the house staff—Drs. Charles 
II. Riley, Charles O’Donovan, Jr., W. P. Chunn, and R. T. 
Wilson. A large unilocular ovarian cyst was successfully 
removed, with unusually strong adhesions in front nearly up 
to the ensiform cartilage. But for these strong anterior 
adhesions, the cyst might easily have been compressed like 
a parovarian cyst. It is rather remarkable that this woman 
did not need ovariotomy for eight months after the termina- 
tion of her pregnancy, the cystoma having been large enough 
to attract her attention five months before she became preg- 
nant. But Dr. Keith states, in his paper On Suppurating 
Ovarian Cysts that in one of his cases a large ovarian cyst 
had existed with at least two of her pregnancies. 
4. Was it a fibro-cystic tumor of the uterus f Although 
Lawson Tait affirms that a differential diagnosis of a fibro- 
cystic tumor is such a very difficult thing, “ that it is possible 
only in the hands of a surgeon who has made two or three 
previous mistakes,” yet in the case in hand, as it seems to 
me, one would incur small risk of mistake in excluding it. 
Dr. McGuire’s case, already mentioned, is the only one on 
record, so far as I know, at the early age of twenty-four 
years; and its clinical history was widely variant from that 
in this case. Moreover, in all the fibro-cystic tumors of the 
uterus that I have seen, the cyst was remarkably tense, while 
in the case under review the cyst was quite flaccid. 
5. Was it a case of tubercular cyst, or one of a simple 
encysted peritonitis f The history and commemorative 
events excluded both. Only a short time before, I had seen 
a case of the latter in the service of my friend and colleague, 
Prof. S. C. Chew, in the wards of the Maryland University 
Hospital, of which he has kindly furnished me the following 
account: 
“ Mrs. X., about fifty-five years of age. A uniform fluctu- 
ating tumor occupied the whole of the abdominal region, giv- 
ing a dull sound on percussion, both in the flanks and in the ANNUAL ADDRESS OF THE PRESIDENT. 
30 
center. She stated that it had commenced as a tumor in the 
right ovarian region, and had gradually extended over the 
abdomen. An examination per vaginam proved that the 
tumor did not project into the pelvis. Dyspnea being urgent, 
she was tapped, and a large bucketful of straw-colored fluid 
was drawn off. This was followed by great relief, so that she 
was able to walk about the ward. In about two weeks the 
distention was again very great, when she was tapped again 
by the resident physician, Dr. Frank West, but without 
relief, and in a few days she died. On post-mortem examina- 
tion there were the signs of a diffused peritonitis, coagulated 
lymph overspreading the intestines and the abdominal wall.” 
In this case diagnosis was not difficult. Vaginal touch 
excluded ovarian and fibro-uterine cysts, and the physical 
signs elicited by palpation excluded ascites. And as a tuber- 
cular peritonitic cyst could not be admitted, and the history 
rejected a renal cyst, which I have once seen mistaken for 
an ovarian cyst, so-called encysted dropsy of the peritoneum 
almost of necessity followed as the diagnosis by exclusion, as 
the result verified. 
Returning to the case under review, it will be seen that 
I have rejected all the affections considered excepting ovari- 
an and parovarian cysts. With the evidence before me, I 
could not decide between the two; and it will be presently 
seen that my hesitation was, perhaps, not injudicious. 
I have not referred hitherto to the microscope as an in- 
strument ex fumo dare lucem. The reason is that, while I 
do not doubt that in the hands of such able and experienced 
experts as Drs. Garrigues and Drysdale, whose memorable 
discussion is fresh in the minds of us all, the microscope will 
often elucidate and render positive a doubtful diagnosis when 
used in connection with the character of the fluid, the clinical 
history and physical examination of patients, yet, in the hands 
of the average microscopist, it is misleading and untrust- 
worthy. 
Let us now see what was the result of the operation, 
which was done on the 13th of July—the third day after the WILLIAM T. MO WALL. 
31 
patient’s admission into tlie hospital. I was assisted by the 
house staff', Dr. Biley acting as my chief assistant; and there 
were present, also, our worthy Fellow, Dr. B. B. Browne, and 
Drs. James Carey Thomas, L. Ernest Neale, J. H. Patterson, 
and W. E. Moseley, who kindly gave the ether. Our emi- 
nent Fellow, and my colleague in the hospital, Dr. II. P. C. 
"Wilson, did not arrive until the operation was far advanced. 
I stated that I intended to make only an exploratory incision 
to clear up the diagnosis, which I declined to announce, and 
to be governed by circumstances. All the usual antiseptic 
precautions were adopted, of course. I made an incision, 
about two inches long, in the median line, below the umbili- 
cus. When I had cut down to what seemed to be the sac, 
which did not present the lovely pearl-like conjunctival blue 
of most ovarian cysts, I found the peritoneum very much 
thickened—to apparently about one eighth of an inch—and 
closely adherent to the cyst. I separated the peritoneum, 
for about two inches around the line of incision, from the 
cyst, which then seemed to be ovarian, and introduced the 
trocar. About forty pints of a slightly viscid, greenish 
fluid escaped, which contained many flakes of fibrin, and I 
then extended the incision in the lined alba for about three 
inches, and endeavored to enucleate the cyst. The peri- 
toneum was separated from the cyst for about five inches in 
every direction, and, as the adhesions seemed interminable, 
I made an incision in the cyst to the extent of that in the 
linea alba. When all the fluid was removed, I looked into 
an immense unilocular cyst, which seemed to occupy the en- 
tire abdominal cavity and to be tightly stretched over the 
spinal column, and even the pelvic brim down nearly to the 
ilio-pectineal line. It appeared as if all the intra-abdominal 
organs had been removed, excepting that there were no signs 
of where they had been attached. On the right side the 
peritoneum was removed from the cyst so far that a small 
portion of intestine became visible, apparently the right arch 
of the transverse colon. 
Concluding that it would be impossible to enucleate the ANNUAL ADDRESS OF THE PRESIDENT. 
32 
entire cyst, I removed a few inches of it, which seemed 
redundant, closed the incision along the linea alba with 
silver sutures, and inserted a large drainage-tube. The pa- 
tient rallied well from the operation, but, after twenty-four 
hours, peritonitis set in, and she died on the third day. I 
requested two competent young physicians to make the au- 
topsy, at which I could not be present, as I was then in at- 
tendance upon an obstetrical case, the labor not being termi- 
nated. 
And now, with the exception of the poor woman’s death, 
comes the saddest part of all. The weather was hot, and my 
young friends—prepossessed with the idea, which one of them 
had suggested during the operation, that the case was one of 
encysted dropsy of the peritoneum—contented themselves 
with demonstrating only what had been revealed at the 
operation! The pelvic viscera were not examined at all! 
So that we can only reason about the true nature of the case. 
Dr. Bantock affirms “ that there is no such thing as a true 
unilocular or unifollicular disease of the ovary except in its 
early stages,” and “ that the true ovarian tumor, of size suf- 
ficient to be diagnosed during life, is always multiple.” And 
Lawson Tait affirms : “ The result of all my observations has 
been that, in every unilocular tumor, I have found the ovary 
unaffected, though on several occasions I have seen it stretched 
over the cyst-wall.” 
Now, if these eminent surgeons are correct in their views, 
the case in question was a parovarian cyst. Not that all par- 
ovarian cysts are unilocular, exceptionally, as has been proved 
by Thornton, Gillette, Ledegauck, Olshauser, and Atthill; 
they may be binocular, or even multilocular; but these are 
not so rare as a unilocular ovarian cyst.1 
But the walls of parovarian cysts are almost always very 
thin, and the fluid limpid and opalescent, while in this case 
the cyst-wall was at least an eighth of an inch thick and of 
almost leathery consistency, and the fluid distinctly viscid 
and greenish. In regard to the character of the fluid, how- 
1 Goodell, Trans. Atncr. Gyn. Soc., vol. vi, p. 231. WILLIAM T. HOWARD. 
33 
ever, in parovarian cysts, Lawson Tait declares tliat, while 
it is “ often limpid,” yet this “ is by no means always the 
case, for I have removed many parovarian cysts which con- 
tained thick, gelatinous, grumous, or bloody fluid.” And 
Dr. Garrigues states,1 in writing of parovarian cysts: “ This 
fluid was so like that found in two cases of ovarian cysts with 
watery fluid that it would be impossible to base any differ- 
ential diagnosis between cysts of the broad ligament and 
ovarian cysts on its properties.” 
It is obvious now why it was impossible to compress the 
flaccid cyst down near the level of the umbilicus. The strong 
adhesions effectually precluded that element of diagnosis, so 
generally available in parovarian cysts. But are parovarian 
cysts ever accompanied by strong adhesions? Dr. Mont- 
gomery, of Philadelphia, has recently reported2 an instance 
in which a parovarian cyst was universally adherent. 
I have met with only one case that resembled the one in 
question very closely, and I regret that it has no clinical 
history: 
“A few years ago I opened the body of an elderly woman 
who died with an immense collection of water in the abdomen. 
The fluid amounted to many gallons, and, after it had been re- 
moved, I continued the incision from the sternum to the pubis ; 
and when I had finished the incision and, with the medical 
friend (Dr. Bond) who was with me, looked into the cavity, we 
were both for some time very much astonished to behold only 
a smooth mucous-serous surface in the cavity, and looked for 
some time in vain to find any liver, or stomach, or alimentary 
canal. It seemed that we were examining an abdomen from 
which all the viscera had been carefully removed. I was 
greatly astonished, and quite at a loss what to think of the 
case, or imagine what had become of the abdominal viscera, 
since the line of the spinal column was strongly drawn at the 
back of the great cavity we were inspecting, and we seemed to 
look quite up into the empty concave of the diaphragm. At 
1 Trans. Amer. Gyn. Soc., vol. vi, p. 60. 
8 Medical News, September 19, 1885, p. 330. 34 
ANNUAL ADDRESS OF THE PRESIDENT. 
length, in examining the cut edge of the incision, I saw that 
we were looking into an empty cyst, whose edge was there to 
be seen, and the outer superficies of which was adherent to the 
peritoneum. The cyst adhered pretty firmly everywhere, but 
was cleavable. I detached it completely, discovering the atro- 
phied organs behind and below it firmly compressed against 
the back part of the abdomen. I have no doubt this cyst held 
more than a thousand ounces of serum ; probably twelve hun- 
dred. There was, at the lower part of it, a small solid or hard- 
ened portion, which was the altered remnant of the left ovary, 
all the rest of the cyst having been developed out of that body. 
I gave the specimen to Dr. Horner, who preserves it still, I be- 
lieve, in the museum of the University of Pennsylvania. It 
was the largest single cyst I ever met with.” 1 
It will be seen at once how strikingly Dr. Meigs’s case 
resembles my case; indeed, his description equally applies to 
mine, in so far as I have been able to give it. If he wras 
correct in stating that the cyst in his case was developed out 
of the remnant of the left ovary, it was, of course, an 
ovarian cyst. But may it not have been, according to Ban- 
tock’s view, a cyst originating in one of the tubules of the 
parovary, which grew toward or involved the ovary, separat- 
ing the layers of the peritoneal fold in which it lay im- 
bedded?2 The walls of parovarian cysts are not always 
thin. Lawson Tait says:8 “I have removed a parovarian 
cyst with walls more than half an inch thick, the greater part 
of which was composed of fusiform muscular cells.” 
Gentlemen, I have already detained you much longer 
than I intended. I thank you heartily for the courtesy and 
patience which you have manifested in listening to my dis- 
course, as well as for the high honor your too partial suffrages 
have conferred upon me in electing me to preside over the 
tenth annual meeting of our beloved Society. 
If there be in American medicine anything that is dis- 
1 Woman: her Diseases and Remedies, by Charles D. Meigs, M. D., fourth 
ed., p. 364. 
3 Trans. Obstet. Soc., London, vol. xv. 
s Op. cit., p. 169. WILLIAM T. HOWARD. 
35 
tinctive, it is its gynecology ; and I deem it not inappropri- 
ate, in this onr first meeting in the national capital, to make 
a brief allusion to the peerless father of American gynecolo- 
gy—J. Marion Sims. It was in this city he hoped to pass 
his declining years. lie had already made the purchase of a 
house here for that purpose ; and only six days before his 
sudden demise he wrote me : “ I feel very well satisfied 
with the idea of getting a home for my old age in Washing- 
ton.” Of world-wide fame, it would have been meet that 
in this beautiful city, the capital of his country, his sun, 
having filled the earth with its rays, should have calmly sunk 
to rest. But Providence otherwise ordered it. 
If all that Sims did for gynecological science, and all 
that has, in consequence of his achievements and discoveries, 
of necessity followed, should be suddenly blotted out, what 
an eclipse would suddenly come over our daily life-work and 
toils ! Were I to attempt to speak of him, and the priceless 
boon he conferred on our science and art, I should feel op- 
pressed by the emotions which thrilled the bosom of Bos- 
suet when, with faltering words, he began his eloquent eulo- 
gy on a great warrior: 
“ At the moment I open my lips to celebrate the immortal 
glory of the Prince of Conde I find myself equally over- 
whelmed by the greatness of the theme and the needleness 
of the task. What part of the habitable world has not heard 
of his victories and the wonders of his life ? Everywhere 
they are rehearsed. His own countrymen, in extolling them, 
can give no information even to the stranger. And although 
I may remind you of them, yet everything I could say 
would be anticipated by your thoughts, and I should suffer 
the reproach of falling far below them.”