Critique of Macroscopic Examination of Specimens Removed 
in Thirty-Two Consecutive Laparotomies. 
[With one death]. 
BY F. BYRON ROBINSON, B.S., M.D. 
CHICAGO, ILL. 
PROFESSOR GYNECOLOGY IN CHICAGO POST-GRADUATE MEDICAL SCHOOL; 
GYNECOLOGIST TO WOMAN'S HOSPITAL, TO CHARITY HOSPITAL. 
AND TO POST-GRADUATE HOSPITAL. 
The modern success in abdominal surgery excites 
the admiration of all. It is the outcome of syste- 
matic experiments, observation and reasoning. Its 
success at one time was thought to be due to an- 
tiseptics, i.e., chemic solutions which destroyed a 
vegetable germ. But we know to-day that simple 
cleanliness accomplishes all. We obtain cleanliness 
to-day by heat and water, two simple elements. The 
spray and chemic lotion have passed into oblivion 
with many others found not essential. 
Modern research sifts matters until essentials are 
found and non-essentials are eliminated. The most 
delicate of all surgery is that of the peritoneum, 
which is almost as important to the human economy 
as the brain. The immediate and remote effects of 
surgery on the peritoneum should be always held in 
mind. The greatest of lymph sacs brooks no insults 
without records. The peritoneum surrounds the vis- 
ceral organs which hold body and soul together by 
their wonderfully balanced functions, and pathology 
which impairs this function should be removed. In 
the following cases some of the macroscopic pathol- 
ogy will be given to show etiology, pathologic pro- 
cess and final results. 
Some views will be presented as to the anatomic 
and physiologic nature of reflexes. Some of the log- 
ical reasons for the removal of abdominal tumors 
will be presented. 
Anesthetics.-Chloroform narcosis is such a rapid, 
beautiful and quiet affair that I determined to give 
it a good trial. It acted very nicely in England 
where I saw scarcely any trouble in a large series of 
cases. It acted nearly as well in Germany and Aus- 
tria, where I witnessed a large number of patients 
narcotized. But I found that we could not use it with 2 
the same impunity in this country. Our chloroform 
does not act as safely on patients as in England 
and Europe. I have come to this opinion from prac- 
tical experiments on dogs and careful observation on 
humans. In chloroform the heart fails, and quite a 
number of dangerous scenes for five years have made 
me almost abandon it in laparotomy. 
Again, anesthetizers are, too frequently, untrained 
men who do not realize the terrible significance of 
keeping constantly before them the pulse, pupil and 
respiration. 
Ether, it must be admitted may induce bronchitis 
and nephritis but it is the safer. We frequently 
employ a mixture of alcohol, chloroform and ether. 
It must be borne in mind that the narcosis is a very 
important matter in cases exhausted by the presence 
of tumors, suppuration or worn out by pain. Again, 
I have shown that many women who have tumors 
are afflicted with pathologic hearts, livers, kidneys 
and lung malnutrition. 
The preparation of the patient is very important 
on account of the results. The urine is carefully 
examined for urea which is one of the standards to 
decide whether laparotomy should be performed. 
The kidneys, genitals and peritoneum are very inti- 
mately associated anatomically and physiologically, 
especially by nerves and blood vessels. A disturb- 
ance in one is soon followed by a disturbance in an- 
other. The kidneys and ureters both, come from the 
same organ, the Wolffian body. Sometimes a vagi- 
nal hysterectomy is followed in a week by death from 
nephritis. We examine carefully for urea for several 
days previous to the operation. 
The urea varied from four to twelve grains to the 
ounce. A few days of rest soon brought about a 
more regular quantity of urea. I think it is not safe 
to do laparotomy with less than five grains of urea to 
the ounce. In sudden demands to operate, no time 
was given to find urea, but such cases were generally 
fairly healthy, e.g., rupture of tubal pregnancy or 
sudden invasion of pus. It was shown that a woman 
who would lie in bed for three days previous to the 
operation would fare better in the results, the urea 
would become more regular, her bowels were moved 
from ten to fifteen times-until the bile glistened in 3 
the stool. Her heart stood the operation better. Her 
abdomen was well scrubbed and a compress bound 
on the night before the operation. In regard to 
drain tubes, I used them only where pus was 
found or extensive adhesions were torn up. As expe- 
rience increases with the years, I use less drain tubes 
in laparotomy. The drain tube we employ is one of 
my own device manufactured from aluminium, open 
at the bottom, perforated with round holes for one- 
third of the distance up and flanged at the top. The 
drain tube was employed from ten hours to several 
days. When less than a dram of fluid an hour was 
drawn from the tube it was removed. I believe the 
tube increases the danger of infection and hernia to a 
very considerable extent. 
The patient is not allowed to get up before the 
twenty-first day. The amount of fluid given to the 
patient after the operation, I am inclined to increase. 
I give them an ounce of fluid an hour immediately 
after the operation, and soon increase it to two or 
three ounces an hour. Fluids flush the kidneys. 
The second or third day I use enema and Mg. S O4 
to secure bowel movements and intestinal contrac- 
tions. Distension means intestinal paresis, and ab- 
dominal pain generally means excessive gas accumu- 
lation. The recommendation to use nux vomica to 
stimulate intestinal contraction wras not followed. 
The Trendelenberg position is employed in nearly 
all cases. This position often embarrassed the heart 
by abdominal viscera pressing on the diaphragm. 
Four abdominal fistulae followed which lasted many 
months, and two are not closed yet (six months after 
operation). These fistulse arise in old cases of in- 
fected tumors. 
As most of the principles employed will arise in 
each case, I will give an account of them in the fol- 
lowing cases: 
Case 1.-Miss H. L., age 24. She had had a laparotomy 
about eight months previously and the physician reported 
that the tubes and ovaries were removed. She became in- 
fected and lay in bed some two months with peritonitis. 
Dr. Franklin Martin kindly consented to assist me in the 
operation. On opening the abdomen the intestines were 
found almost a solid mass, held together by exudates. The 
uterus was about six inches long and proportionately en- 
larged. The lower portion of the uterus was so firmly attached to the left pelvic bony wall that I could move the 
whole woman by moving the uterus. Multiple cysts as large 
as a child's head existed on each side of the uterus. After 
careful examination and consultation with Dr. Martin it 
was deemed inadvisable to remove the uterus, tubes or cysts 
on account of the dense adhesions. The large cysts were 
drained with gauze and stitched to the abdominal walls. 
Among hundreds of operations seldom have I witnessed 
such widespread and dense adhesions. A special reason for 
not tearing up the adhesions was that malignancy was sus- 
pected. She recovered quite well. But her subsequent his- 
tory was of great interest. I kept trace of her for one year. 
I made the distinct observation in her case of the repeated 
rupture and formation of cysts without causing peritonitis. 
The abdomen would swell and become tense and then sud- 
denly flatten out. As soon as the abdomen flattened out her 
pain disappeared. But I also noted that she had profuse 
diuresis for several days. This drained the cyst which rup- 
tured into the peritoneum through the kidneys. I had made 
this same observation while experimenting on dogs three 
years previously. While operating on dog's intestines I 
would occasionally fill the dog's abdomen full of warm 
water and then close the abdominal wound. The dog would 
urinate profusely for two to four days. The water was ab- 
sorbed by the peritoneal stomata and eliminated by the kid- 
ney. It is quite rare to observe the repeated formation and 
rupture of cysts in the abdominal cavity, especially when it 
is followed by no peritonitis. I once drew a few quarts of 
fluid from the cysts through the vagina but the cysts quickly 
refilled. At the puncture a dense adhesion formed so I con- 
cluded not to puncture any more but to wait until the fill- 
ing of the cysts gave her such pain that she would seek an- 
other operation. 
I wished to have another operation for two reasons: 
1, it could be noted that the girl would die if not relieved; 
2, also noted that the formation of the cysts had torn the 
uterus from its dense, firm attachment and pushed it up in- 
to the abdomen, so that six months after the operation con- 
vinced me that the uterus and appendages could be removed. 
But I watched her every few weeks for a whole year, and 
her case presented a volume to any gynecologist. The cysts 
would fill until the abdomen stretched like a drum head. 
Such stretching and pushing elevated the whole uterus above 
the pelvic brim although its adhesions were such that they 
would hold 150 pounds. The pain was intense at the climax 
of tension. Suddenly one of the cysts would break and the 
abdomen would flatten. Pain would cease. Profuse diure- 
sis would ensue. No fever arose. Slowly the cysts would 
refill. The greatest volume of information in this case arose 
from the pressure and irritation of the cysts on the viscera 
through reflex action. The effect of irritation and pressure 
on this young woman were : 
1. Kidney disturbance ; the irritation passed from the dis- 
eased location (pelvis) up the hypogastric plexus to the ab- 
dominal brain where it was reorganized and sent over the 
renal plexus to the kidney. 
4 The kidney was forced into three troubles: it secreted 
excessive urine, deficient urine or disproportionate quantities of 
its elements. Every one of these conditions continued with 
this girl. She made large quantities at times, and again 
small quantities of urine loaded with salts and the irregular 
quantities. Thus the kidney was under continual irritation 
from the tumors. The irritation was transmitted to the 
kidney by reflex action by way of the hypogastric plexus, 
abdominal brain and renal plexus, i.e., a distinct anatomic 
route. 
It would not take long to produce diseased kidneys if 
such irritation were long persistent. This effect on the kid- 
ney by reflex action from the cysts induced me to desire 
another operation. But I never requested her to undergo 
another operation. Her own condition (pain and inability 
to work) forced her to ask it. 
2. The second effect from the cysts, I observed in this 
24-year-old woman was constipation and indigestion. Her 
appetite was poor and capricious and at times wanting. 
The digestion was disturbed by the irritation passing up the 
hypergastric plexus, and being reorganized in the abdominal 
brain and sent out to the digestive tract by way of the 
gastric plexus (to the stomach), by way of the superior mes- 
enteric plexus (to twenty feet of small gut) and by way of 
the inferior mesenteric plexus (to the large bowel). The 
irritation thus reflexed to the digestive tract would disturb 
sensation, motion and secretion of the whole canal. The 
result on the tract was increased, decreased or disproportionate 
secretions. In fact, the indigestion was so persistent that 
malnutrition soon appeared. Malnutrition resulted in some 
eight months in anemia. Curiously enough she never became 
neurotic. If she was allowed more time under such disturb- 
ances, neurosis would finally appear. 
3. The third effect I noted this year of visceral irritation 
from the tumors was cardiac disturbance. The heart per- 
formed its action rapidly and irregularly. The irritation 
from the tumor passed up the hypogastric plexus to the 
abdominal brain where it was reorganized and transmitted up 
thegreatsplanchnicstothe three greatcervical sympathetic 
ganglia, where the forces were reorganized and sent direct 
to the heart. The pneumogastric rules the steady rhythm 
of the heart, while the sympathetic rules the rapidity of the 
heart. So that disturbances of the kidney, digestive tract 
and heart arose from a year's irritation of the tumors. The 
lungs,liver and spleen so far had not manifested any disorder 
perceptible. She was incapacitated from labor a whole 
year until the next operation. 
• Tumors demand removal from reflex irritation through 
the sympathetic nerve. An abdominal tumor will cause 
fatty degeneration of the heart, indigestion, malnutrition, 
anemia, neurosis, fatty degeneration of the liver, irregular 
action of the lungs (asthma) and degeneration of the spleen 
-all through reflex action on the abdominal brain. 
Case 2.-Mrs. M., age 54. She was referred to me by Dr. 
4- R. Martin with a diagnosis of cancer of the cervix. The 
hemorrhage was quite profuse and continuous with a distinct 
5 6 
odor of decomposition. I did vaginal hysterectomy at the 
Woman's Hospital with the kind assistance of Dr. Franklin 
H. Martin. I used the ligature. The patient recovered,but 
I wish to note a peculiar point in regard to temperature. In 
twenty hours her temperature sprang up to 104; pulse 
was about 85. This rapid change of temperature was not due 
to sepsis, but to disturbance in the heat centers (reflex) from 
wounding and constricting the great hypogastric plexus. 
It was a neurotic rise of temperature. It fell suddenly in 
ten to fifteen hours. It may be that the injury inflicted on 
the hypogastric plexus by ligature is reflected to the me- 
dulla or heat center and inhibits the action. At any rate 
the heat center lowers its tone and runs riot until it recov- 
ers from the shock of the ligature. The operation was done 
eighteen months ago. The cancerous mass has returned in 
the stump at present as large as a hazel nut, and she has 
begun to bleed easily again. 
From the clinical and macroscopical manifestation 
I diagnosed cancer of the cervix, with a fibroid tumor 
three-quarters of an inch in diameter situated in 
the cervix in the site of the cancer. This speci- 
men was warmly discussed in the Chicago Path- 
ological Society by Drs. Van Hook, Hektoen and 
Angear. The opinions were divided between sarcoma 
or cancer. This discussion proceeded, even, with ex- 
cellent specimens of the tumor under the microscope 
prepared by Dr. Angear. Dr. Angear has carefully 
worked it out, and I fully agree with him that the 
specimens which he so accurately prepared are 
cancer. 
The manner of return (eighteen months and slow) 
show it to be cancer. If it were sarcoma it would 
return and grow rapidly. Recurring sarcoma grow 
with the rapidity of an avalanche. This shows that 
the microscope can not be relied upon in early diag- 
nosis. In Vienna I have known of a dermatologist, 
a gynecologist and a pathologist in consultation over 
a disease of the labia, but utterly unable to agree as 
to the kind of disease they were examining. Disease 
is simply a change of structure, and there are early 
stages when clinical symptoms or the microscope 
will not decide its nature. Time alone will tell. 
I am opposed to vaginal hysterectomy for cancer 
when the disease is advanced in the broad ligaments 
to any considerable extent. It does not elevate sur- 
gery and only shatters the renewed hopes of a de- 
spairing patient. I believe, also, that many of the 
reported cases of uterine cancer cured by vaginal 7 
hysterectomy were mistaken diagnoses. Cancer is a 
disease which will not be cured, whether in the 
uterus or other location. But with the incipient 
cancer of the uterus-in the early stage of cancer- 
vaginal hysterectomy is eminently proper and highly 
hopeful. It is the proper method of treatment. 
Case 3.-Mrs. P., age 32. Two children, the youngest 6. 
Abortion four years previous. She had been ill since, more or 
less. Examination revealed the uterus fixed with a mass of 
exudation on its left about the size of a cocoanut. She took 
hot douches at home for a month. She then went to the 
Woman's Hospital and lay in bed some ten days. Douches 
and rest cleared up two-thirds of the exudate. I operated 
in September, 1893, removing the tubes and ovaries. She 
had much pain at the monthly. The tubes were very crooked 
and convoluted. She made a good recovery, but she was 
tubercular and it appeared to me that the tubercular lungs 
became slightly worse. However, ten months after the 
operation she is well in the pelvis and fairly well in the 
lungs. 
She became very neurotic from her four years' invalidism, 
and would have hysterical spells. This case was a very good 
lesson as to what preparatory treatment will do. It made 
the exudate less, her recovery smoother, the operation easier 
and sequelse less apt to occur. Dr. Mary Shibley and Dr. 
Marie White assisted me in the operation. 
Case 4.-Miss A., age 22. A history of gonorrhea was fairly 
evident. She was sick in bed for eleven weeks and pus had 
flowed from the rectum for six weeks. The case was referred 
to me by Dr. Chas. Simons and Dr. D.T. Nelson. I operated 
on her at the Charity Hospital, assisted by Dr. Franklin H. 
Martin and Dr. Mary Shibley. Vaginal examination re- 
vealed the whole left half of the pelvis a solid mass. On 
opening the abdomen, a tumor the size of a cocoanut pre- 
sented, lying in a dense mass of exudates and old adhesions. 
By carefully separating the adhesions and enucleating the 
tumor, I finally brought it into the abdominal incision when 
its terribly foul contents burst and flowed among the intes- 
tines. Now, came a very peculiar feature in the case. The 
left tube was about nine inches long and so large and dilated 
that it actually resembled a gut. So near did it resemble a 
gut that we could not decide what it was until it was traced 
right to the uterus. Both appendages were removed. But 
no hole could be found in the gut, rectum, sigmoid or small 
intestine, so I closed the abdomen with much misgiving for 
fbar of leakage from the old fistula which had discharged 
pus for six weeks through rectum. Drainage was employed. 
To my surprise and delight she made a good though not 
rapid recovery. She walked away quite well in a month. 
At present writing she has a small abdominal fistula, ten 
months after the operation. She is in splendid health and 
has gained some twenty-five pounds in weight. 
The specimen was from a slow progressive patho- 8 
logic process. The large tumor I made out to be 
an ovarian abscess which had perforated into the 
rectum. Its contents had a fecal odor. The left 
tube was some nine inches long and looked like a 
piece of small intestine. Its peritoneum showed 
remnants of perisalpingitis, old adhesions, flakes of 
lymph and thickened from inflammatory exudates. 
The reason the tube was so long was because the ovary 
in enlarging had stretched it. The muscular wall of 
the tube was not very much changed except, perhaps, 
the longitudinal muscle layer was increased some. 
The muscular wall was mainly thickened by inflam- 
matory exudates during successive inflammatory ex- 
acerbations. The essential and main changes oc- 
curred in the endosalpinx-the mucous lining of the 
tube. It showed all stages of inflammation. Parts 
were totally destroyed but most, partially. Some 
spots were denuded and some showed the progressive, 
infectious catarrhal process-gonorrhea. 
The tubal lumen was irregularly dilated. The 
method of closure of the fimbriated end was no 
doubt the chief reason of the ovarian abscess. 
In closing, a part of the fimbriae were left outside of 
the tubal lumen, while the remainder were turned 
in. Now those left in the abdominal cavity kept up 
a continual chance for renewing infection of the 
peritoneum. The ovary is nearly always infected by 
the tube, and is, therefore, a secondary disease. This 
ovary was cystically degenerated, i.e.,the gonorrheal 
process had passed from the tubal mucous membrane to 
the germinal epithelium of the ovary, and then passed 
on to the membrana granulosa which lines the graafian 
follicles. The gonorrheal pathologic process had then 
disturbed the normal membrana granulosa, and these 
little cysts had abnormally dilated. The opposite 
tube and ovary were in an incipient stage of salpin- 
gitis and chronic ovaritis. The endosalpingitis had 
sufficiently started and existed long enough to have 
involved the ovary-it was cystically degenerated. 
The muscle of the tube and its perisalpinx or peri- 
toneal covering was almost normal. I removed it 
because the gonorrheal process was well rooted in 
both endosalpinx and ovary. 
This patient had suffered so many recurrent attacks 
of pelvic inflammation that her peritoneum was tol- 9 
erant to a severe and dangerous operation. The ope- 
ration absolutely saved her life and she is made a 
useful citizen. 
Case 5.-Operated on Feb. 28,1893, at the Woman's Hos- 
pital. I was assisted by Dr. Mary Shibley and Dr. Marie 
White. She had been an invalid for six years. She was 36 
years old. She aborted once, but had no children. She 
gave ample evidence of gonorrheal and syphilitic infection. 
She had refused operation six years previous, and was now 
a confirmed invalid, unable to earn her own living and de- 
serted by the man who infected her. Examination per 
vaginam revealed old pelvic peritonitis. The roof of the 
pelvis felt like thick, slowly yielding leather. • The uterus 
was fixed and on the left was a tumor the size of a small 
hen's egg. On opening the abdomen the appendages were 
found small and atrophied. The tumor proved to be a broad 
ligament fibroid of a very peculiar nature. It had around 
it a distinct capsule which could be peeled off. The tumor 
was enucleated from the broad ligament with the greatest 
difficulty,shocking the patient considerably. The appendages 
were both tied off. The abdomen irrigated and drained. She 
recovered well for a week, when the temperature rose to 100 
and 101 for some ten days. Pulse about 100. Her abdominal 
wound seemed to have insufficient vitality to heal well. She 
finally recovered with an abdominal fistula which is still 
open and has a suspicious appearance of malignancy. I 
have had cases where a fistula developed in the wound many 
months after operation. 
Six months after the operation she looks fairly well, but 
the wound is not healed. The fistula is surrounded by thick- 
ened and hardened tissues which reach down into the pelvis. 
It may be of a syphilitic nature. It may be observed that 
such old invalids, with ruined nervous system and infected 
venereally, do not make brilliant recoveries, but she is lately 
doing better. 
The tumor is a typical sample of a solid hard 
fibroid. It had no pedicle and was surrounded by a 
firm capsule. It gave the woman much trouble by 
becoming inflamed and tender quite frequently. This 
inflammation and tenderness was difficult to account 
for, as the tumor seemed to be a broad ligament 
fibroid. I mistook it for the ovary on account of its 
tenderness. I still think the tumor did not give the 
tenderness, but that the tube behind it had exacer- 
bations and made the pain appear to be in the 
tumor. This tumor was considered to be an ovary for 
six years of treatment. Both tubes and ovaries were 
mere relics of an inflammatory process. The peri- 
salpinx showed signs of old inflammation. It was 
thick, covered with old adhesions and flakes of lymph. The muscle of the tube had almost entirely disap- 
peared and was replaced by hard, white connective 
tissue. 
The endosalpinx or mucous membrane was nearly 
all gone, except in little patches. The pathologic 
process indicated that the original inflammation 
proceeded from the endosalpinx, and it and the mus- 
cular layer were almost entirely replaced by one- 
fourth of an inch of solid, hard, white, glistening 
connective tissue. The lumen of the tube was oblit- 
erated at intervals in its course, leaving small closed 
cavities with endosalpinx in all stages of disinte- 
gration. The fimbriated tubal ends were closed like 
the fused end of a glass tube. She had not menstru- 
ated for nearly two years. The ovaries were only 
one-third the normal size, shrunken, covered with 
scars, with a few cystically degenerated follicles lying 
in them. One ovary had pieces of calcium salts in 
it the size of a pea, and smaller ones the size of 
wheat kernels. It was a calcified ovary, not ossified. 
These fragments of calcium salts were secreted by 
the membrana granulosa just as an egg is coated by 
its calcium shell as it passes through the ova duct 
of the hen. I have observed calcified ovaries several 
times. The membrana granulosa will not only secrete 
lime salts but will secrete a cheesy matter which I 
have found scores of times in the unruptured Graafian 
follicle. In this woman, gonorrhea had ruined her 
pelvic organs and syphilis was well grounded in her 
system. She visited my office Aug. 3, 1893, and was 
looking well. Her fistula had closed and about all 
infiltration had disappeared from the operative field. 
She was much more fleshy, and ruddy cheeks began 
to appear; pronounced herself as doing well. 
Case 6.-Age 25, puberty at 13. Menstruation regular but 
painful, so she is always in bed for the first two days. The 
flow is profuse for three days. Examination revealed a 
mass on each side of the uterus. She was undefinedly ill 
for several years ; married six years. She gave me a dis- 
tinct history of gonorrheal infection from her husband some 
four years previously. She was an invalid and Dr. Stillians 
sent her to me to operate at the Woman's Hospital, where 
Drs. Shibley and White assisted. She had double pyosal- 
pinx. We irrigated and drained. She made an excellent 
recovery and went home in the fourth week. I saw her six 
months after, and instead of appearing as an invalid she is 
healthy, ruddy and has gained some fifteen to twenty 
10 11 
pounds in weight. Silkworm gut was used for abdominal 
sutures. 
The tubes and ovaries are in a solid mass. The 
only difference in the two specimens is the difference 
in the closure of the abdominal end. One of the 
tubes opens right into the ovary like a clay pipestem 
into the pipe bowl. Its fimbriated mouth never 
closed but simply became glued on the ovary by in- 
flammation. That ovary was smelted with the tube 
into a solid mass. It presented a tubo-ovarian 
abscess. The ovary was infected by the gonococcus 
through the tube-secondarily. The ovary was 
cystically degenerated. 
The endosalpinx was almost entirely obliterated. 
It was smooth as leather; all epithelia had disap- 
peared. The muscle was so much altered that con- 
siderable was crushed out, and the endosalpinx and 
the muscle were replaced by connective tissue. The 
lumen of the tube was irregular and about the size 
of the little finger. 
The perisalpinx was much thickened, covered with 
adhesions and flakes of lymph. The tube was very 
crooked and wound itself around the ovary. The 
other tube and ovary presented an entirely different 
spectacle due to its mode of closure. The fimbriated 
end had all its fimbriae nicely turned back into the 
tubal lumen, and they lay like the petals of a rose, 
neatly coiled up. This mode of closure retained the 
pus entirely in the tubal lumen, and the lumen would 
admit the thumb 
The tube-perisalpinx, musculature and endosal- 
pinx-was similar in all other respects to its fellow 
from the gonorrheal process. But since the pus was 
retained in the closed tubal lumen, the ovary escaped 
the chief brunt of the infection. The ovary is only 
slightly infected, aad now as I write, it lies before 
me in the water, floating almost free from adhesions. 
It escaped the main infection because the ostium 
abdominale closed before infection had passed into 
the ovary, before the ovary became ruined forever. 
This ovary has some four Graafian follicles in a state 
of cystic degeneration, but it is otherwise a fairly 
normal ovary with scarcely any adhesions on it, all 
due to the mode of closure of the fimbriated end of 
the tube. The tubal wall is over one-fourth of an 12 
inch thick of solid connective tissue. The append- 
ages show the typical progress of gonorrhea. 
Case 7.-Mrs. M., age 56. Four children. loperated on 
her six months previous for uterine cancer, removing the 
uterus and leaving the appendages and broad ligament. 
Drs. Shibley and White assisted me at the Woman's Hos- 
pital on Jan. 18, 1893. The lesson which I learned in this 
case was to remove the appendages, always if possible, in a 
woman over 35, along with the uterus, for Mrs. M. developed 
a parovarian cyst in the right broad ligament. If I had 
removed both appendages she would have escaped the sec- 
ond laparotomy. But in a woman under 35 I would gener- 
ally prefer to leave the appendages in the pelvis to prevent 
a too sudden and precipitate menopause, i. e , a premature 
neurosis. The tumor as large as a child's head was easily 
removed and she made a good recovery. I will note here 
that I had used boracic acid sprinkled on the abdominal 
wounds on twenty cases, and four abdominal wounds 
suppurated and we traced it to the impure boracic acid. I 
now use nothing but sterilized gauze, but I would prefer 
boracic acid above all other remedies as it desiccates the 
wound. It prevents the adhesion of the gauze to the wound 
stitches and dries up secretions. Boracic acid is a mere 
common commercial article, is put up by all classes of work- 
men and is apt to be impure. She was drained; pus in 
wound suppurated and attracted our attention, for it was a 
simple laparotomy. Since that time no wound has suppu- 
rated except a case of gonorrheal pyosalpinx. 
The specimen removed was a parovarian cyst con- 
taining about a pint of clear urine-colored fluid. 
We know it is a parovarian cyst for we can enucleate 
it entirely from the broad ligament on account of its 
position. The Fallopian tube, some six inches long, 
is stretched over the superior circumference of the 
cyst. The cyst itself is a fibrous sac; the outside is 
smooth and glistens. Its outer layer is composed of 
fine, visible fibrous strands of white tissue interlac- 
ing in all directions. Its inner layer almost exactly 
resembles a human bladder which had been dilated 
for a long period. The large fibrous strands resem- 
ble a honeycomb meshwork. It looks like the inner 
meshwork of muscles lining the left ventricle of the 
heart. The fibrous strands run in bundles in curved 
directions, making circular depressions surrounded 
by whorls of strands of coarse connective tissue. Of 
course these were hypertrophied by a slow process. 
I would account for the curved bundles and whorls 
of connective tissue by the stretching and displacing 
of the longitudinal and circular layers of tissue sur- 13 
rounding the tubes of the parovarian out of which 
the cyst arose. I could find no trace of the paro- 
varian, except a few small blisters lying just above 
the Fallopian tube where it is usual to find a few, 
viz: close to the abdominal sphincter of the tube. 
The fibrous strands of the cyst wall are plain to the 
naked eye and very large under the lens. The cyst 
had a short pedicle which did not open into its 
cavity. The tube of Fallopius is interesting, as it is 
stretched about six inches long and is closed at both 
ends, one end from the ligature six months ago and 
the one fimbriated end was closed by old pathologic 
process. 
The perisalpinx is simply thickened but notes no 
inflammation. The musculature does not show much 
change. But the endosalpinx or mucous membrane 
shows a peculiar change. There is no fluid of any 
kind in the tubal lumen. The tubal plicae look much 
like the wrinkles in an old person's face or in the scro- 
tum. The fine epithelium is all gone, and under the 
high lens the endosalpinx appears like an oiled, clean 
shaven hogskin with many wrinkles in it. The 
tubal plicae are all in perfect parallel rows and fall 
to either side like the ruffles of a linen garment. In 
the middle of the tube there is a break in the plical 
rows as if they ran into a sphincteral opening, and 
here I find the tube has an opening only covered by 
peritoneum. This depression is called a tubal hernia 
by some, but it is simple a deficiency of the tubal 
wall; an attempt at the foundation of a tubal ostium. 
I would call attention to the idea that here is a good 
chance to account for some tubal pregnancies, for 
the ovum may drop down into this little pit and 
there being deficiency of muscle it is not forced on 
by tubal peristaltis and so grows in the depression. 
The lens shows beautifully the perfect endosalpinx 
subjected to senile changes. The tubal lumen is 
slightly wider than normal, but the stretching ac- 
counts for that. The rows of tubal plicae have lost 
all villous appearances; no fringes appear; simply, 
bare wrinkled folds of endosalpinx in perfect order 
under the lens, only now suggestive of their old 
wonderful function of twenty years ago. After the 
parovarian cyst was enucleated a splendid view of 
the broad ligament came to sight. It had developed 14 
in it considerable muscular tissue and connective 
tissue. As I previously noted, after fifteen months 
Mrs. M's cancer is returned in the old stump of the 
extirpated uterus. 
Case 8.-Miss N., age 19. Puberty at 13; menstruation 
regular with some pain; suffers much with frontal headache. 
Has leucorrhea. Has not been strong for four years. She 
is very tender on right side extending in pelvis and lumbar 
region. Bowels regular. She had been ailing for four years 
and at one time she was in bed for several months. She 
was sent to the Woman's Hospital where I repeatedly ex- 
amined her for several weeks. Nothing very definite could 
be diagnosed, but on the right side and in the pelvis a swell- 
ing was felt. Her temperature varied and she was very 
tender. For two weeks 1 refused to operate, but afterwards 
several sudden rises of temperature and severe attacks of 
pain induced me to explore for two reasons: 1, appendicitis ; 
2, disease of the appendages. 
It may be noted that a distinct history of gonorrhea was 
told, viz: sudden acquisition of burning and scalding in 
making water which lasted for several months. Leucorrhea 
was present. Frequent recurrent pelvic attacks occurred. 
I watched her daily for some three weeks and finally con- 
cluded to operate assisted by Drs. Shibley and White. I 
removed both ovaries and tubes also the vermiform appen- 
dix. She did well until the fifth day when a hematocele 
appeared on the right side about the size of a large apple. 
The temperature sprang up to 103. I had about decided to 
cut a couple of stitches in the abdominal wound and intro- 
duce my finger into the swollen mass when she suddenly 
began to recover, i. e., the pulse and temperature went down 
quickly to nearly normal. It is a question in my mind 
whether these swellings occurring after laparotomy on one 
side of the pelvis are not due to infection, i. e., they are exu- 
dates and not hematocele. The tension of this swelling 
gave her much pain by pressure on nerves and that may 
raise temperature. I shall carefully further investigate 
this subject, whether it be exudate from infection or hema- 
tocele which so frequently follows laparotomy. 
In Mr. Tait's work, I think it occurred in about 12 
per cent, while I was a pupil during six months. 
The girl left the hospital well, some six weeks after 
the operation. . 
The specimens, viz: the tubes and ovaries and 
vermiform appendix, I carefully preserved in pure 
alcohol without allowing them to be handled. When 
I wish to examine them they are dropped into clear 
water and become soft and normal again, except in 
color. Both tubes are very similar. They are very 
short, convoluted, with sharp spirally curved angles 
and smaller than normal. The uterine end is very small. The peritoneum does not dip down into the 
angles, but stretches from one tubal convolution to 
another, showing that the tube is quite free in the 
broad ligament or mesosalpinx. It appears to me 
that such a contorted, spirally angled tube in a vir- 
gin is a congenital malformation. If convoluted 
tubes are found in the multipara it is likely a rever- 
sion to the fetal type, due to subinvolution of the 
longitudinal muscular fibers of the tube. These 
fibers are chiefly enlarged in gestation. Several 
years ago I discussed and presented the subject of 
contorted tubes to the profession, noting that it was 
the chief factor in virginal dysmenorrhea. It causes 
tubal colic and is the phenomenon in pre-menstrual 
pain. This woman had quite typical, contorted 
twisted tubes and she suffered much pain at the 
menstrual period. Such tubes are difficult to drive 
menstrual fluid through by reason of so many bends 
and angles in the lumen, and thus is excited tubal 
peristalsis and tubal colic. No changes can be noted 
in the musculature of the tubes, nor does the high 
lens indicate any pathology in the perisalpinx. Any 
pathologic changes under the eye or lens is to be 
found in the endosalpinx. The mucous membrane 
of the tube is swollen, a little edematous and is so 
luxuriant and abundant that it quite fills the lumen. 
In good sunlight under the lens it lies in folded 
wrinkles, not so uniform as it does in the general tube. 
The tubal plicae do not lie in distinct parallel folds, 
but such parallel folds are broken by whorls encir- 
cling depressions in the ampulla; such depressions 
lie as usual on the side of the tube not covered by 
the peritoneum. The depressions or pits appear to 
be embryologic attempts at the formation of accessory 
tubal ostia; for the bottom of the pit is generally 
only covered by peritoneum and where the tube is 
not covered by peritoneum the wall is made of slight 
muscular layers and connective tissue. These pits 
or whorls lying in the ampulla are in my opinion 
ample explanations for ectopic pregnancy. 
The ovum falls in one of these depressions and 
there is no particular force to dislodge it as the mus- 
cular is deficient, so that peristaltis will fail to for- 
ward the ovum toward the uterus. Some of the 
tubal plicae are one-quarter of an inch long. In this 
15 16 
tube the abdominal ostium is very peculiar. The 
tube appeared to attempt to form a double abdominal 
ostium but the septum between the two abdominal 
ostia failed to grow or atrophied, and there is pre- 
sented in this case a large irregular ostium having 
abnormally abundant and luxuriant folds of tubal 
plicae. 
The abdominal ostium is one and one-half inches 
across. The lens shows no break or ulceration in 
the endosalpinx; it is simply in the mild early stage 
of endosalpingitis. In this case the tubal plicae of 
the endosalpinx are so luxuriant, abundant and 
swollen that the tubal lumen was well filled and 
fluids would be difficult to force through. 
To force fluids through at the menstrual time 
would require considerable peristalsis which often 
amounted to tubal colic or pre-menstrua] pain in 
her case. .The ovaries were about normal, but I 
would call attention to the fact that there is a dis- 
tinct corpus luteum in one ovary one-half inch across. 
But observe that she never had an abortion nor a 
child. The conclusions are just what I found sev- 
eral years ago by investigating animals, i. e., that 
the corpus luteum is no sign of pregnancy, and its 
elevation to any legal significance in courts of 
justice is a reliq of false so-called authority. 
The parovarium was normal except the dilatation 
of one of Kobelt's tubes to the size of a pea. Gart- 
ner's duct and the tubules were normal. The 
vermiform appendix was in a catarrhal condition. 
The mouths of its swollen glands were enlarged, red 
and had too much secretion. It had several ulcers 
on its surface which were quite plain under the lens ; 
some of the ulcers had denuded the epithelium and 
some were secreting gray slimy mucus. No doubt 
this was an appendix which had recurrent attacks of 
catarrh; in fact it had an attack as often as some 
irritating substance entered the valve of Gerlach 
and irritated until it became expelled. 
Case 9.-Age 24. Puberty at 11; menstruation regular 
but quite profuse, lasting about seven days. She was very 
pale and anemic. Menstruation was very painful for four 
days and compelled her to be in bed two days. Last period 
flowed for two weeks. Has long had leucorrhea which has 
distinct odor and is yellow. She is tender on pressure in 
pelvis, especially on left side. She was occasionally sick in 17 
bed for two months at a time and had so much pain that 
much morphin was used. Two years ago she had two 
abortions and since that time she has been ill with pelvic 
trouble. I sent her to the Woman's Hospital and under rest 
and hot douches the exudates (size of a large apple on left 
side) nearly all disappeared. A renewed attack of pelvic 
trouble while in the Hospital induced me to operate. The 
recurring exudates were deposited on the left side at each 
attack. The diagnosis was salpingitis of gonorrheal origin ; 
physicians had treated her husband for several years for 
gonorrheal discharge from the urethra. I operated at the 
Woman's Hospital Oct. 4, 1892, with the assistance of Drs. 
White and Shibley, removing both appendages. She made 
a very good recovery. Drainage for two days. 
The specimens were of peculiar interest, as pus 
was found in the interior of one ovary on cutting it 
open, so that gonorrheal virus had infected the 
ovaries. Both ovaries were cystically degenerated; 
some of the cysts were three-quarters of an inch in 
diameter. The tubes had carried the infection to 
the ovaries and infected them. The ovaries were 
covered with marks of old and recent inflammation. 
The tubes were both similar. The perisalpinx was 
richly covered with flakes of lymph, and organized 
exudates, old and recent. The peritoneum covering 
the tubes was slightly thickened. The musculature 
was not visibly changed. The endosalpinx showed 
the chief attraction. Its folds were swollen and 
very abundant. The lens showed no break in the 
mucous membrane. The swollen, edematous tubal 
plicse were so large and numerous that the tubal 
lumen was packed quite full and she had a good 
deal of menstrual pain. It would be difficult to force 
the menstrua] fluid through the tube, and the irrita- 
tion would induce considerable tubal peristalsis or 
tubal colic. In this case the gonorrhea had advanced 
through endometrium and endosalpinx where it 
makes a distinct home in the cylindrical epithelium 
of those two membranes. Now since the home of the 
gonococcus is in (glandular) cylindrical epithelium, 
it can easily affect the ovary, for the ovary is cov- 
ered by germinal epithelium (glandular), and then 
the gonococcus advances to the membrana granulosa 
which is typical glandular cylindrical epithelium. 
The membrana granulosa thus becomes infected by 
the gonococcus and soon becomes cystically degene- 
rated. The Graafian follicle then becomes patho- 18 
logical. Again, to show that the infection went out 
at the tubal ends the parovarian in each broad liga- 
ment was distended. Kobelt's tubes were enlarged 
the size of peas. Five pedicled stalks existed in 
one parovarian. 
Then, in general, ovarian and parovarian cystic 
degeneration is a secondary disease and derived 
from infection carried to them by the tubes. The 
pathologic condition removed from this woman has 
restored her to usefulness and health. 
Case 10.-Mrs. S., age 40. Four children. Ill two years, 
since birth of last child. This woman came to the Woman's 
Hospital, sent by Dr. Miller. She had incontinence of 
urine and I treated her for two months with bladder 
douches and drugs. She did not improve. I dilated the 
urethra and explored with the finger but found nothing and 
it did not help her. The whole nervous system was exam- 
ined but no defect discovered. The uterus was bound to 
the left pelvic wall and she had salpingitis. I finally con- 
cluded, after two months of treatment, that the incon- 
tinence of urine was reflex from the old pelvic disease. On 
Jan. 18, 1893, I removed the appendages assisted by Drs. 
White and Shibley. The pelvis on the left side was found 
full of exudate and the uterus was held down in Douglas' 
pouch by about twenty organized bands. The uterus was 
freed. No drain was employed. She recovered quite well 
and the bladder improved. The old organized exudates 
accounted for the bladder paralysis by undue pressure on the 
sacral nerves, especially those which supply the bladder. 
The specimens show that around the abdominal 
tubal ostii, inflammation had spread very wide. 
The tubes were extraordinarily long with wide lumen. 
The perisalpinx had also recent adhesions on it. The 
musculature of the tube was slightly atrophied. The 
endosalpinx showed the chief lesion of disease. It 
was extremely atrophic. The lens revealed in the 
ampulla three large tubal plicae which extended 
right to the tubal ostium abdominale. All the endo- 
salpinx except these three plicae was atrophied. 
The folds had sunk down two-thirds of their orig- 
inal size. No solution of continuity could be found 
in the endosalpinx. This atrophy and some dilata- 
tion of the tubal lumen made the tube appear un- 
naturally large in caliber. No doubt the large tubal 
lumen enabled the infection to pass easily into the 
peritoneal cavity and to infect the ovaries. 
This case confirms a discovery I made in investi- 
gating tubes of man and animals, which was that the 19 
lumen of the left tube is greater than the right, and 
that accounts for the fact that women are ill seven 
times out of ten on the left side. These tubes show 
very small abdominal ostii. The ovaries were cys- 
tically degenerated. The parovarian was normal 
and contained some fourteen vertical tubules. The 
trouble arose from septic matter passing through 
the tubes at the last puerperium, two years prev- 
iously. It was not gonorrheal as it had fairly recov- 
ered, and only left solid adhesions which require 
many years to absorb. 
Case 11.-Mrs. M. No children ; age about 36. This woman 
had severe pain at menstruation and lost so much blood 
that she was a neurotic wreck. She had salpingitis. I 
operated on her May 1, 1893, at the Woman's Hospital 
assisted by Dr. Stillians, whose patient she was. She 
made a good recovery. No drainage. 
The tubes have the most typical appearance of 
convoluted, contorted or spiral angulation I ever 
saw. They are both alike and so twisted and rolled 
that at points they look double. The perisalpinx is 
considerably thickened. The peritoneum does not dip 
down into the depressions between the kinks of the 
tube. The musculature of the tube is slightly atro- 
phied. The endosalpinx is considerably shrunken 
and atrophied. No solution of the continuity exists, 
and the lens in excellent light reveals no epithelial 
denudation. I wish here to call attention to a band 
running along the upper border of the perisalpinx. 
I never saw it described in any book, nor have I ever 
heard any one mention it. The only way to observe 
it well, is to put a typical specimen of convoluted 
tubes in pure alcohol, and as the alcohol shrinks the 
specimen, the band will show itself plainly running 
along the upper border of the tube in the perisalpinx. 
The band resembles exactly the taenia coli; or one 
of the bands which run along the colon, which give 
the colon its sacculated appearance. It is also 
shorter than the colon. The band running along to 
top of the tube is shorter than the tube by about the 
same proportion as it is on the colon. Now this 
band has a share in convoluting and twisting the 
tube; I will call it the taenia tubae. Under the lens 
the band is composed of connective tissue. 
I have observed this band (taenia tubae) previously, 
but on searching anatomy I can not find it described. 20 
I have always found the taenia tubse well made in 
the most typically convoluted tubes. It appears to 
shorten the tube in some cases one-sixth of its 
length and to throw the tube into convolutions. 
These spiral tubes are quite frequently found in 
women with tubal colic or pre-menstrual pain. By 
applying a powerful lens on the endosalpinx in 
bright sunlight another point is revealed, to explain 
pre-menstrual pain or tubal colic. For at the vari- 
ous angles of the bent tube the tubal plicae lose their 
parallel appearance and are thrown into whorls, so 
that the ordinary current of fluid passing through 
the tube at the menstruation will be retarded and 
obstructed. In these whorls of tubal plicae a secure 
nest may be obtained for ectopic gestation. The 
cilia all bend toward the uterus and the tubal peris- 
talsis is also toward the uterus, and thus the cilia 
and peristalsis induce a current of fluid toward the 
uterus at every monthly. The fluid arises from a 
congested endosalpinx. The spots of denuded epi- 
thelium, the tubal hernia, the depressions in the 
endosalpinx and the tubal plicae whorls all may 
have a share in lumen ectopic pregnancy. 
So far, ectopic gestation has not been demon- 
strated in animals below man. The parovarian was 
cystic; as many as twelve cysts could be counted in 
one; nearly all were dilatations of Kobelt's tubes. 
Fifteen vertical tubes were counted. The ovaries 
were normal, with the exception of three to five path- 
ologic Graafian follicles found in each ovary, filled 
with cheesy matter. In this woman the old gyneco- 
logic fad of "ovaritis " did not exist, in fact, but the 
tubes were thecause of her sickness. The diagnosis 
in her case was salpingitis, pain (excessive peristal- 
sis), hemorrhage. 
Case 12.-Mrs. H., age 38. Two children; four miscar- 
riages. Date of last pregnancy nine years ago. Menstrua- 
tion regular, no pain, lasting four days. Married at 16 
years. Four years ago had pain in right side, and one and 
one-half years ago noticed a swelling in right side. She had 
a myoma which had worked down between the bladder and 
vagina. It was the size of a hen's egg. I extirpated it per 
vaginam after the laparotomy, which I did at the Woman's 
Hospital, assisted by Drs. Shibley and White. Drain tube 
was used. She made a good recovery but a slow one, and 
left in four weeks. 21 
The tumor found in the right side was a dermoid, 
size of a cocoanut. It had no pedicle, but was rotated 
off its axis and lodged and nourished in the lower 
border of the omentum. This accounts for her at- 
tack four years ago when, no doubt, the dermoid 
twisted off its axis which likely lay in the ovary, as 
nearly all dermoids arise in the ovary. When it twist- 
ed off its axis it did not become gangrenous because it 
was excluded from air. It nourished from surround- 
ing organs because its twisting off created an irrita- 
tion (mechanical), and that caused an exudate which 
re-organized and produced blood vessels, lymphatics 
and nerves around the circumference of the tumor. 
The formation of this new " nourishing pedicle " is 
of fine, delicate structure having a bluish tint. The 
dermoid contained hair, fat (sebum), and the products 
of the skin. In the cavity of the tumor was found 
one-half of the jawbone, containing one tooth of.per- 
fect form and composition as large as the adult tooth 
behind the canine, and another tooth of half its size, 
of perfect form and composition. The enamel is 
perfect. The jawbone is more porous than*normal. 
Over the top of this bone lay a distinct membrane 
which I took to be the dura mater of the brain. These 
dermoids and their skeleton remains are no doubt the 
vain attempts of the germinal epithelium, which par- 
tially comes from the epiblast, to form complete 
structures. There was so much old adhesion that the 
right tube and ovary were not found. They may 
have been torn away with the dermoid and atrophied. 
The left tube had salpingitis. The endosalpinx 
was in various stages of atrophy, as the lens would 
plainly reveal patches where the tubal plicae were 
four times as small as normal, and other patches with 
abundant tubal plicae. The tumor from the vagina 
proved to be a myoma about the size of an egg. It 
no doubt had traveled from the uterus down into the 
space between the bladder and vagina from the uterine 
rhythm during menstruation. The ovary was normal. 
Case 13.-Mrs. D., age 30. One child ; one miscarriage. Pain 
in pelvis and cystic tumor diagnosed. Laparotomy Dec. 22, 
1893, at Woman's Hospital, assisted by Drs. Shibley and 
White. I drained one day. I removed both appendages 
on account of a distinct history of gonorrhea and pelvic 
suffering. The tubes are normal in their perisalpinx and 
musculature. There is endosalpingitis with sero-pus float- ing over the mucous membrane. The endosalpinx looks 
unhealthy. It is edematous and friable. It is swollen in 
one place and atrophied in another. One tube is stretched 
over the parovarian cyst until it is seven inches long. The 
ovaries are normal. The cyst proved to be parovarian. It is 
five by four inches in diameter. Four gynecologists,including 
myself, diagnosed it a tubal cyst. It can be stripped entirely 
out of the broad ligament. The other parovarian is nor- 
mal, containing twelve vertical tubules. The hydatid of 
Morgagni is as large as a hazel nut, with a pedicle one inch 
long. 
Several small cysts in the region of Kobelt's tubes are as 
large as a pea, and as usual a little cyst nearly always exists 
on the upper border of the perisalpinx just over the abdom- 
inal sphincter of the tube, vestigial remains of the Wolffian 
body. 
Case 14.-Mrs. H., age 22; one child, age 3 years. Puberty 
at 13; menstruation regular, lasts three days and stops a 
day and then reappears. She has painful menstruation, at 
the same time headache and backache. The pain is located 
in pelvis, but radiates into limbs and body. 
She has a yellow, bloody leucorrhea with considerable 
odor. She has considerable pain, indigestion and water- 
brash. Bowels regular. , 
The diagnosis was a tumor in the pelvis, and we knew she 
had gonorrhea contracted two years previously from her 
husband. I operated on her at the Woman's Hospital, Jan. 
31, 1892, assisted by Drs. Shibley and White. Two ovarian 
tumors were removed about the size of a turkey egg. Drain- 
age and irrigation, and the abdomen closed by silkworm gut. 
In this operation, large numbers of organized bands ex- 
isted in the pelvis, reaching far up among the intestines. 
Some of the bands were a foot long. Loops of the intestines 
passed between the bands as loops of rope would pass 
between the fingers of the hand. The bands held the 
uterus, appendages and intestines in a solid mass. The 
wonder was that none of the intestinal loops were obstructed 
or strangulated. I generally break up all such adhesions, 
and scarcely ever ligate any, as hemorrhage soon ceases in 
a band, especially if it be broken in its middle where the 
circulation is quite feeble. 
The specimen showed double pyosalpinx. The 
left had nearly lost all its pus by absorption, while 
the right contained a dram. The endosalpinx was 
in various stages of disease from catarrh to destruc- 
tion. 
The musculature of the tube showed only the alter- 
ation produced by thinning of its wall. However, 
the tubal wall was thick, but that was due to inflam- 
matory exudates. The perisalpinx was thickened 
from ancient and recent peritonitis. Bands and 
exudates of various ages lay on and around the 
22 appendages. Both ovaries had become thoroughly- 
infected by two years of gonorrhea, and cystic degen- 
eration of the Graafian follicle had proceeded until 
the ovaries were the size of turkey eggs; some of the 
degenerated cysts contained pus. The gonorrhea had 
passed from the cylindrical epithelium of the tubes 
to the germinal epithelium of the ovary (glandular 
epithelium) to the cylindrical and glandular epithe- 
lium of the Graafian follicle. The reason of the dis- 
astrous infection of both ovaries was due to the 
method of the closure of the abdominal end of the 
Fallopian tube, i.e., some of the fimbriae were left in 
the peritoneal cavity after the peritoneum around 
the mouth of the tube had contracted. These few 
fimbriae had instigated a continual recurrence at 
menstrual and other times, when the mucous mem- 
brane on the fimbriae was congested, and started anew 
the old (gonorrheal) infection. Ovarian infection is 
seen to perfection in this case. 
The tubes carried the infection to the ovaries, and 
this gives more evidence that ovarian disease is nearly 
always secondary to tubal disease and caused by in- 
fection. This patient left the Hospital seven weeks 
after the operation. She was then well. She had a 
small fistula which frequently occurs after gonorrheal 
pyosalpinx, as one can not remove all the diseased 
tissue and the ligature became infected. Six months 
following the operation she had the fistula. No fecal 
matter ever came through it. Eight weeks after the 
operation, about the time the patient removed home, 
she began to vomit and vomited steadily for three 
weeks, and she has vomited about once weekly the 
following four months. 
Aug. 1, 1893, she returned from her home in Indi- 
ana for treatment at the Woman's Hospital. I found 
a tender spot in the region of the gall bladder and 
pylorus. She has lost over thirty pounds, and is of 
a pale saffron color. She has periods of terrible pain 
and sometimes vomits. Her appetite when not in 
pain is good. The trouble seems to have no connec- 
tion with the laparotomy. The diagnosis by Dr. 
Franklin H. Martin and myself is thought to be a 
gall stone or malignant disease of the pylorus. We 
are now waiting developments for a coming operation. 
Stools move about every two days and are fairly 
23 24 
natural. It appears to me that her second trouble 
has nothing to do with the laparotomy. (Seven 
weeks later this lady has gained about fifteen pounds 
and is looking well.) 
Case 15.-Man, age 24. Ill for several weeks. Tempera- 
ture varied up to 102. Pain and swelling on right side from 
iliac region toward lower rib. A distinct boggy tumor could 
be felt. It had an elongated form and distinct crepitation 
could be perceived by manipulating it. 
The diagnosis was appendicitis. Operation evacuated 
several drachms of pus. The appendix was not searched 
for, but a drain tube and gauze were inserted. The tube was 
shortly after withdrawn. He made a good, easy recovery. 
Case 16.-Ectopic pregnancy. Mrs. B., age 22, was married 
in July, 1892. In December, 1892, a practitioner produced 
an abortion on her of probably a three months pregnancy. 
From December until the last week in February, 1893, she 
was very ill in bed with much fever. In the last week in 
February Drs. Simon and Abel were called to attend her. 
At this time she had a severe chill and her temperature rose 
to 104. On February 26,1 was called in consultation to see 
her, and I found the pelvis absolutely full of a hard, boggy 
mass, which extended out of the pelvis into the right side 
of the abdomen, in the iliac region. Aspiration per vaginam 
was suggested, but I did not think it best, and urged that 
the woman be sent immediately to the Woman's Hospital. 
She was in the Hospital one day and a night when I noticed 
the temperature was rising up to 103. On February 28 I 
diagnosed rupture of the pelvic cyst and infectious invasion. 
One hour after my leaving the hospital she had a severe 
chill, and the temperature rose rapidly to 106.2. Immediate 
preparations for an operation were made. Assisted by Drs. 
Shibley and White, I operated in the presence of Drs. Simons, 
Lucy Waite and Millman. On opening the abdomen the 
pelvis was found full of a hard mass, which was closely 
covered over by adherent omentum. Fortunately, the 
omentum could be stripped off the mass. The mass proved 
to be the fimbriated end of the tube, containing about a 
pint of stinking pus. The whole mass had to be literally 
torn out of the pelvis. After removing both appendages, 
the abdomen was irrigated with some eight quarts of hot 
boiled water and closed with silkworm gut sutures. Drain- 
age was employed. The tube on the right side proved to 
have the large abscess in the fimbriated end, while in the 
isthmus of the tube was found the placental remains of a 
fetus. 
The placenta was about one and one-half inches long and 
one inch thick. No fetus could be found. 
The history of this case may be interpreted as fol- 
lows : the woman first became pregnant in the tube 
where the fetus died. She then shortly afterward 
became pregnant in the uterus. Three months after, 
she was criminally aborted, and this abortion dis- tributed infection anew along the right tube, which 
induced the tubal abscess. 
The tubal disturbance at the time of death of the 
fetus would, no doubt, have subsided but for its 
exacerbation at the time of the criminal abortion 
and, as the os is never prepared for an abortionist, 
soon closed and retained the infected material, which 
overflowed in the direction of least resistance along 
the Fallopian tube. The opposite tube was healthy 
as far as the eye could detect. 
This is a typical case to show that prompt surgical 
interference may save the dying. We are well aware 
that surgical operations on the dying are very un- 
satisfactory. Very often the subsequent wish arises 
that no operation had been done on a patient who 
expired almost with the completion of the operation. 
But this woman, who was only 22 years old, though 
dying, showed a hopeful vigor that we thought might 
rally. 
She did rally and the next day the temperature 
had fallen 5 degrees, and the pulse from 130 and 
140 had fallen to 110. I have never known a patient 
to get well after a temperature of 106.2 with abdom- 
inal section. 
Dr. Byford who had noted the height of temper- 
ature, said he had not known one to recover after 
operation with such a temperature. At the operation 
we took the liberty of removing the apparently 
normal appendage, for it may be noted that when a 
woman has pyosalpinx on one side that, sooner or 
later, the tube on the other side becomes involved. 
It is a very notable feature in these old cases of pel- 
vic inflammations how the peritoneum of such 
women becomes tolerant to manipulation, and it also 
resists the invasion of infection to a powerful degree. 
We will note a feature in diagnosis of some troubles 
in the peritoneum. It may be observed that so long 
as the inflammatory masses remain in the pelvis, or 
closely connected with structures mainly supplied 
by the sympathetic nerve, the pain is dull and not 
of a cutting or short character. But as soon as the 
inflammation encroaches on the abdominal wall 
where the peripheral ends of the spinal nerves are in 
close proximity, then pain is much more manifest, 
and one can diagnose with fair certainty a localized 
25 peritonitis of the abdominal parietes. The diagnosis 
of this case could not be made as to whether it was 
ectopic or not, for we did not know that she had had 
an abortion produce'd until after the operation, as it 
was naturally kept a secret. This is a typical case 
to show that one of the great landmarks in gyneco- 
logic practice is abortion. In teaching students 
and practitioners, we have frequently called atten- 
tion to the idea that in gynecology there are six 
great landmarks worth knowing, viz.: 
1. Anatomy. 2. Menstruation. 3. Labor. 
4. Abortion. 5. Gonorrhea. 6. Tumors. 
Each one of these landmarks presents centers 
around which the diagnosis will turn. Around these 
landmarks, as principals, must cluster the details of 
diagnostic conclusions. 
In this case the prompt application of modern 
surgery saved the woman from certain and speedy 
death, and restored her to her family as a useful 
member. Time and experience strikingly confirm 
exploratory and confirmatory sections in cases of 
doubtful diagnosis-and many are doubtful. This 
patient came to my office seven months after the 
operation and she reports herself as perfectly well. 
She has gained some twenty-five pounds in flesh and 
is as robust as woman could appear. 
Case 17.-Age 30. One child 11 years old. One miscar- 
riage. Puberty at 13. Menstruation painful and irregular. 
Married eleven years. She has backache and headache. Leu- 
corrhea yellow, green or bad odor. Has been ill eight years. 
Has had temperature varying up to 104 for many months. 
Some six gynecologists examined this patient, but none 
could give sufficient reasons for any diagnosis. Finally, in 
consultation with Drs. Byford and Martin, it was decided to 
operate. On Feb. 28, 1893, assisted by Drs. Shibley and 
White, I operated at the Woman's Hospital. 
The tumor filled the pelvis and abdomen up to the navel, 
and lying in front of the tumor to the left was the uterus 
with highly diseased appendages. The tumor proved to be 
a large infected dermoid universally adherent. It developed 
in the broad ligament and raised it up to a level with the 
umbilicus. It proved to be the most difficult of operations 
and lasted an hour and a half. She collapsed at the last, 
and her pulse was not perceptible in the wrist for many 
hours. She was bathed in cold perspiration. The foot of 
the bed was elevated. Hot salt enema were given per rec- 
tum. Considerable whisky was given by mouth, hypodermi- 
cally and by rectum. For three days her pulse was over 
140. I could frequently count it up to 180. But her temper- 
26 27 
ature for those three days was about 100 and 101 per rectum. 
The pulse slowly went down for ten days when it was 110 
and temperature 98. During all the time the drain tube 
did good work. The recovery of this woman is one of the 
most miraculous I ever witnessed and much of it is due to 
trained nursing. 
She came to my office six months after the operation, a 
large, robust, healthy looking woman. She still had a small 
abdominal fistula which secreted a few drops daily. 
The specimen is remarkable as showing pathologic 
progress for some ten years. The Fallopian tube 
has a wall of solid connective tissue half an inch 
thick. The mesosalpinx and perisalpinx present the 
thickened and roughened appearance of repeated 
inflammations. Bands, adhesions, exudates and 
flocculent deposits tell the story. The musculature 
is fully one-half an inch thick but nearly all of this 
is hard white connective tissue, and muscle in it is 
very scarce. The endosalpinx shows only fragments 
of its original. It is disorganized in places and 
atrophied in other places. A few widely separated 
tubal plicae present themselves under the lens as fairly 
normal but nearly all atrophied. The dermoid ap- 
pears to be developed out of the ovary. It has on 
its surface quite a number of small cysts similar to 
the Graafian follicles, and its wall for a large part 
seems to be ovarian tissue -with some very small 
ovarian follicles growing in it. Inside the dermoid 
cyst a thick membrane can be peeled out which I take 
to be the old original membrana granulosa. Parts 
of this membrane are one-quarter of an inch thick 
and its line of demarkation from the ovarian tissue 
is complete. This dermoid has a history like almost 
all dermoids and that is that they grow out of the 
ovary ; they are ovarian dermoids. The broad liga- 
ment over the dermoid was enormously hypertro- 
phied. The dermoid was filled with sebum-a kind 
of oily substance of a white color and of the con- 
sistency of lard. It contained hairs and many other 
skin products. A dermoid is a tumor containing skin 
and some of its appendages as hair, teeth, nails-in 
fact almost any portion of the body may be found 
in it, that is in the region of the epiblast. I have 
found the skull and the cranial nerves. 
Case 75.-Mrs. H. Sent to me by Dr. J. F. Percy of Gales- 
burg, Ill. She was 48; puberty at 17. Menstruation regular 
and painless, lasting two days.. Has had ten children, ages 27 to 12. It is eleven years since last child. She has back- 
ache and slight leucorrhea. She has been compelled to be 
quiet for the last few years from simply pressure of the 
tumor. The abdominal swelling has increased for two years 
and rapidly for ten months. She was treated but not tapped. 
In examination a little fluctuation was detected but nothing 
definite could be elicited, and it was impossible to tell what 
kind of a tumor was before us. I could not map out the 
uterus. So with careful examination with inability to diag- 
nose, it was decided to explore. At the Woman's Hospital 
Dec. 12, 1892, assisted by Drs. Shibley, White and Percy I 
operated. The tumor proved to be ovarian with some ad- 
hesions. But only a part of it contained fluid. The solid 
part was divided into many compartments with walls varying 
from one-half inch to three inches thick of fibrous tissue. 
The cavities contained semi-solid jelly which was probably 
mucus and other matter secreted by the membrana gran- 
ulosa. The tumor weighed seventeen pounds. A drain tube 
was employed and the abdomen closed with silkworm gut. 
She left the Hospital well on January 6, 1893. 
Right here is an example to show the effect of pres- 
sure on the abdominal brain by large tumors. I have 
noted that pressure of tumors disturbs rhythm of 
viscera. This lady had distressing attacks of a kind 
of asthma. The rhythm of the lungs was disturbed. 
She had hypertrophy of the heart, due to reflex action 
transmitted to it by way of the splanchnics from the 
abdominal brain to the cervical sympathetic ganglia, 
where the irritation was reorganized and sent to the 
heart on account of the pressure of the tumor on the 
abdominal brain causing the heart to move irregu- 
larly and rapidly. The result was overfeeding and 
consequent hypertrophy. Besides disturbance in 
the heart, this woman had constipation and indiges- 
tion due to pressure of the tumor on the abdominal 
brain. She had gas in the bowels. The reason of 
this was that irritation of the abdominal brain was 
emitted over the gastric plexus to the stomach, the 
superior mesenteric plexus to the small intestine and 
the inferior mesenteric plexus to the large bowel. 
This irritation induced : 1, excessive secretion; 2, 
deficient secretion; 3, disproportionate secretion of 
digestive juices-result indigestion and constipation. 
She had gas in the bowels from fermentation. She 
had liver disease and was pigmented on the skin be- 
cause the rhythm and secretion of the liver was dis- 
turbed. The hepatic plexus carried the irritation 
from the compressed abdominal brain to the liver 
28 and induced excessive, deficient or disproportionate 
secretion. The spleen also was disturbed in its rhythm 
and suffered from pigmentation. Thus through 
reflex action on the sympathetic nerve due to pressure 
of the abdominal brain, the patient suffered in every 
viscus. Since removal of the tumor, so far as I 
could find, all these "reflexes" have disappeared. In 
her requested annual letter to me she reports herself 
well and happy. 
Case 19.-Miss H., sent to me by Drs. R. Zeit and Nyson 
from Medford, Wis. Age 15. Puberty had begun but was 
very irregular. She had a tumor in the middle line of ab- 
domen and the cervix was elongated. Assisted by Drs. 
White and Shibley I operated at the Woman's Hospital. 
The tumor proved to be a very rare specimen of the ovary, 
the size of an apple holding locks of hair. It also had an 
ovarian follicle containing about a pint of clear fluid. Be- 
sides these, a large solid mass about the size of a child's 
head was found at the end of the ovary. This solid mass 
was considered to be sarcoma. Hence a dermoid, an ovarian 
cyst and a sarcoma were all found in the ovary of a girl of 
fifteen. The other ovary was somewhat enlarged and dis- 
tinctly cystic so it was removed. She made a very easy re- 
covery. 
Case 20.-Mrs. G., age 48, sent me by Drs. Washburn and 
Jackson of Indiana. She was enormously distended in the 
abdomen. I operated with the kind assistance of Dr. 
Franklin H. Martin and Drs. Shibley and White. It proved 
to be a very severe operation. We removed a sixty pound 
ovarian tumor, part solid and part fluid. Drainage was em- 
ployed and she did well until twenty-four hours after, when 
the pulse rose steadily higher with a viscous spring to it. 
The temperature went stealthily and steadily up. Her mind, 
from an active practical character, became slowly but per- 
ceptibly less alert to the world. She grew slowly more stupid 
and died fifty-three hours after the operation from,probably, 
acute sepsis. This was the only death in the series of thirty- 
two cases from the operation and they presented very severe 
pathology. 
Case 21.-Age 56, single. This lady had a laparotomy per- 
formed on her about a year previous, for what I could not 
learn. The abdominal wound did not heal and I suspected 
malignant disease. She was narcotized and the wound 
thoroughly curetted. The wound led to the bottom of 
Douglas' sac. No ligation was found. The two following 
months clearly showed it to be a malignant growth in the 
abdominal wound subsequent to laparotomy. It was con- 
sidered to be cancer. As the growth increased it obstructed 
the bowels. Dr. Joseph B. Bacon and myself performed 
lumbar colotomy on her from which she recovered. She 
died subsequently from the malignant affection. It is 
very rare to see malignancy spring up in an abdominal 
wound following laparotomy. 
29 30 
Case 22.-Mrs. R., age 39. Puberty at 11 years. Menstru- 
ation regular. She was never pregnant. She had myoma 
of the fundus of the uterus and bled profusely for some 
three years and has lost great quantities of blood for the 
past eight months. She was almost bloodless on entrance 
to the Woman's Hospital. Her tumor was a solid mass 
which entirely filled the whole pelvis up to its brim. I 
operated, assisted by Drs. Shibley and White. The mass was 
so dense and extensive that it was considered unwise to 
attempt to remove the uterus, but I carefully dug through 
the mass and put three ligatures around each tube, occlud- 
ing the ovarian artery, and the ligature would render the 
tubes functionless. In November, 1892, this operation was 
performed. It was the first in which I ligated the ovarian 
artery and the uterine as it courses along the side of the 
uterus. Drainage was employed. She recovered. Ten 
months afterward she visited my office and the uterus 
had shrunk to less than one-third its original size; nearly 
every trace of exudate was gone. She menstruated or lost 
blood a few times. She calls herself well and strong. 
Case 23.-Mrs. V., sent to me by Dr. Mary Jackson of Ham- 
mond, Ind. Age 33; seven children. She was taken sud- 
denly ill six weeks before entering Hospital. She grew 
steadily worse. The abdomen enlarged. Drs. White and 
Shibley assisted me to operate. The pelvis was found filled 
with a tumor which was composed of concentric layers of 
blood. It appeared to come from the right Fallopian tube, 
as a distinct ragged aperture was found in the walls of that 
tube. The tumor and appendages were removed. Drainage 
was employed. She recovered and left the Hospital. 
This was considered to be a case of ectopic preg- 
nancy from a careful examination of the specimen. 
The gestation was in the right tube which showed 
the point of rupture. No fetus could be found, but 
the state of the tube indicated such. 
Case 24.-Mrs. A., age 33, sent to me by Dr. Eilertson of 
Chicago. Ill two years ; had three children, ages 13,11 and 
7 years. Has noticed enlargement for two years. One year 
ago the swelling suddenly subsided and then gradually in- 
creased for a year. Dr. Eilertson assisted me to operate six 
months ago. The tumor proved to be an ovarian cyst. The 
other ovary was also as large as a hen's egg. It was removed. 
The sudden decrease of the tumor was made plain on its 
removal. It had on its wall an old scar about the size of a 
silver dollar. This cicatrix represented the point of rupture 
one year before. She recovered and left the Hospital well. 
Case 25.-Age 28. Hl for about one year with pelvic trouble ; 
very ill for five months. The operation was done at Charity 
Hospital by Dr. Geer and myself. It proved to be a case of 
very severe pyosalpinx. The adhesions were extensive and 
dense. The enucleation demanded the tearing up of vast 
areas of old and recent pelvic adhesions. The bowel was 
wounded several times, but not sufficient to tear through 
the mucous membrane. Thorough irrigation and drainage 31 
were employed and the abdomen closed with silkworm gut. 
She did well until about the eleventh day when the temper- 
ature began to rise and for five days it wavered ; on the six- 
teenth day jumped up to 104. Dr. Geer and I then agreed 
to re-open the abdomen. She was anesthetized and the finger 
followed the place where the drain tube had been. As the 
finger entered the wound about three inches, just below the 
pelvic brim, some two ounces of yellow pus rolled out. The 
wound was irrigated, drained and the woman made an excel- 
lent recovery. She has now, seven months after the opera- 
tion, a small fistula in the abdominal wall, but she is ruddy 
and gaining flesh and is well. In this case a re-opening of 
the abdomen absolutely saved the patient's life. 
The following seven cases of laparotomy were per- 
formed by Dr. Lucy Waite at the Charity Hospital 
in my service. I assisted her in each case so that a 
synopsis of them will be included in this series: 
Case 26.-Removal of the appendages for double pyosal- 
pinx and hematoma of left ovary resulting from gonorrhea. 
Patient was 25 years of age and gave a history of gonorrhea 
for three years past and a produced abortion. She was 
almost totally incapacitated for labor. Both tubes and 
ovaries were bound down in massive exudates from which 
the Doctor literally dug them out. Every element in the 
tube and ovary was diseased ; perisalpinx, musculature and 
endosalpinx all had widespread pathologic conditions. Con- 
siderable pus wTas found in the pelvis. The abdominal cavity 
was thoroughly irrigated and. the wound closed with silk- 
worm gut. Drainage was used. Recovery was good. Eight 
months after the operation she is nursing and is practically 
well. The reasons which justified and demanded laparotomy 
in this case were exactly what Dr. Waite and myself had 
repeatedly observed during our four months' treatment of 
the patient viz: periodic exacerbations of pelvic peritonitis, 
pain, gonorrhea, pelvic exudates, rise of temperature, con- 
stant suffering and incapacity for labor and the downward 
course of the patient. 
Case 27.-Removal of the tubes and ovaries for a general 
myoma of the uterus. The patient had had a tumor the size 
of a cocoanut for three years with severe hemorrhage for 
one year. She had three children. She recovered from the 
operation and has had one hemorrhage since, so far as re- 
ported, in six months. 
Ten months after the operation I saw her. She 
appears perfectly well, and says she is now healthy 
and hemorrhage has almost entirely stopped. Dr. 
Waite ligated the upper end of the uterine artery, 
which accounts for the almost complete arrest of 
bleeding. 
Case 28.-Laparotomy for chronic salpingitis and ovaritis. 
Age 36. She was ill seven years and a neurotic wreck. The 
operation proved difficult,as the old organized exudates were 32 
very dense. She made a good recovery and is now very 
well seven months after the operation. She has improved 
in all nervous symptoms. 
Case 29.-Removal of the appendages in a girl of 20 for 
hystero-epileptic convulsions of six years duration. She 
recovered without an untoward event. Six months after the 
operation the guardian of the girl writes to Dr. Waite the 
following: " Your patient is doing nicely and we believe she 
will come out all right." It seems to me that the word, 
epilepsy, should be excluded from this disease, as it is a re- 
flex menstrual disturbance and is not true epilepsy. True 
epilepsy does not recover from removing ovaries or testicles. 
It is true that this girl was a total wreck, that she could not 
even care for herself and that an extra attendant was re- 
quired for at least a week every month to supervise her 
during dozens of convulsions at each period. She is recov- 
ering from a nrtzrost's but not epilepsy. 
Case 30.-Removal of the appendages for double pyosal- 
pinx and abscess of uterine wall, following five weeks after 
delivery. 
The pelvic organs were imbedded in a mass of exudates 
and the abscess contained about a tablespoonful of yellow 
pus. The peritoneum was well irrigated; the mouth of the 
abscess was clamped to the abdominal wound for thirty-six 
hours. Drainage was employed and the patient made a 
good recovery. Five months after the operation she is 
well. 
Case 31.-Age 52; one child 10 years old. Ill since last 
child was born. Laparotomy showed the uterus and ap- 
pendages consolidated into a mass. Dr. Waite separated 
these old dense adhesions with much difficulty. The proof 
of the age of the adhesions was profuse hemorrhage from 
newly formed blood vessels. She recovered well, and left 
the Hospital improved in every respect. A significant fact 
is that her extreme neurosis almost magically disappeared. 
Case 32.-Age 22. Ill two years with pelvic trouble. She 
was a miserable neurotic, incapacitated for labor. She had 
severe attacks of pelvic peritonitis. The menstruation was 
becoming more and more severe with increasing pain. She 
reports a sudden flow of pus through the vagina besides 
leucorrhea. The diagnosis was gonorrheal salpingitis with 
pyosalpinx. Dr. Waite enucleated and tied off both the 
appendages which were in severe pathologic conditions. 
Abdomen irrigated, drained and closed with silkworm gut 
sutures. The patient recovered well, and left the Hospital 
a different looking woman. 
The foregoing thirty-two cases of laparotomy were performed just 
as they came in order. No selection was made, no picking of cases was 
done. The one case of death was from acute sepsis (due to what cause 
I know not) in a woman with a sixty pound ovariah tumor. At present 
(ten months after the above operations), I know of two abdominal 
flstulse existing. So far as .1 know all other flstulee have closed. One 
patient died six months after the operation from acute rheumatism; one 
died a year after the operation from pulmonary tuberculosis. 
Reprinted from the Journal of the American Medical 
Association, January 13 and 20, 1894.