[Reprinted from the Transactions of the Philadelphia County Medical Society, 
February 22, 1893.] 
CERTAIN PROBLEMS IN ABDOMINAL SURGERY- 
BASED ON ONE HUNDRED CCELIOTOMIES 
DONE AT THE KENSINGTON 
HOSPITAL FOR WOMEN. 
By CHARLES P. NOBLE, M.D., 
SUBGEON IN CHARGE, KENSINGTON"HCMiJAL FOR WOMEN. 
I wish to discuss certain of the very practical problems which 
confront the gynecologist in his daily work, and will use as a basis 
for the discussion the methods employed and the results obtained in 
one hundred consecutive coeliotomies done at the Kensington Hos- 
pital for Women. In April, 1891, I read a paper before this Society 
detailing the technique in abdominal surgery as employed in that 
Hospital. Further experience has served to confirm the value of 
most of the methods then in use; hence I shall refer to technique in 
this paper very briefly. 
The essentials of success in abdominal surgery are : 
1. Early operation. 
2. Careful preparation of the patient; with especial reference to 
stimulating the emunctories and to securing asepsis of the abdominal 
wall. 
3. An aseptic operating-room. 
4. Aseptic hands and instruments for the surgeon. 
5. As great rapidity in operating as is compatible with careful, 
thorough work. 
6. Irrigation and drainage in septic cases. 
7. Careful after-treatment, embracing especially the withholding 
of fluids for about forty-eight hours; early purgation, and at least 
three weeks' confinement to bed. 
The principle of early operation at last has been established in 
ovarian cysts. It is equally applicable to cysts of the tubes, to 
ectopic gestation, to certain fibroid tumors, and to the graver forms 
of salpingitis. Delay is just as dangerous in these cases of coeliotomy 2 
NOBLE, 
as in cases of ovariotomy. Delay in operating is the cause of most 
of the deathsand of most of the failures to cure in this class of cases. 
In ectopic pregnancy delay often means hemorrhage and death- 
perhaps before operation, or shortly after operation-from acute 
anaemia. Twice I have operated where the abdomen was so full of 
blood that it was distended as from ascites. In both these cases the 
hemorrhage had been so large that death resulted from acute anaemia. 
In the inflammatory cases, with collections of serum, blood, or pus in 
the tubes or ovaries, delay means progressive invalidism, with perhaps 
absolute prostration of the centres of life. It means repeated attacks 
of peritonitis, increasing adhesions, matting together of the pelvic and 
abdominal viscera, and even the degeneration of distant organs, 
especially the kidneys and lungs. In this class, especially, delay is 
bad. A cure is next to impossible without a radical operation ; and 
delay renders this more difficult and dangerous, and less certain to 
restore the sufferer to health and strength. The neuralgic pains 
which often distress this class of women for months after the removal 
of the appendages are due almost always to adhesions, the result of 
repeated attacks of peritonitis, together with depraved blood and 
poor general nutrition, the result of long-continued invalidism. With 
reference to this class of cases (hydro-, hsemato-, and pyosalpinx, and 
ahscess of the ovary), I have no doubt that if those who are inclined 
to decry pelvic surgery and to magnify its shortcomings would 
expend their energies in inducing these poor women to submit to 
early operation we would have fewer deaths from operation and far 
fewer cases of post-operation pelvic pain. In other words, most of 
the deaths and most of the relative failures from operation in these 
cases are clearly chargeable to those who advocate what they falsely 
call conservative treatment, and thus deprive their patients of the 
advantages of early operative treatment. These remarks do not 
apply to non-cystic inflammations of the uterine appendages, of 
which I shall speak later. Nor shall I discuss here the peculiarities 
of fibroid tumors which demand early operation. Of the other 
essentials to success I shall say nothing, except concerning drainage. 
DRAINAGE. 
There is a growing tendency among surgeons to restrict the use of 
drainage and to attribute certain dangers to its use. In the hands 
of careful men most excellent results are obtained practically without 
the employment of drainage. This is a fact which merits the closest CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
3 
attention. The results obtained by Kelly, Mann, Baer, Dudley and 
others show conclusively that drainage is neither so necessary nor so 
valuable as has been believed. Nevertheless, I am not prepared to 
believe that it is not of great value in septic operations and in cases 
in which it is necessary to separate many vascular adhesions. I use 
drainage constantly in such cases, and my results have been most 
gratifying-certainly as good as those reported by other surgeons. 
That there is a definite risk of the accumulation and decomposition 
of serum in "septic " operations and in operations dealing with ex- 
tensive vascular adhesions, giving rise to septic peritonitis and death, 
was proved by the work of our elders. To Keith especially do we 
owe a debt for emphasizing this fact and for proving that this risk 
can be lessened greatly by the use of the drainage-tube. Those who 
oppose drainage point to their results as proving that drainage is un- 
necessary, or practically so. I believe that the better results obtained 
at present without drainage, as compared with the results of ten years 
ago, is explained by five facts : 
1. Surgeons do cleaner work ; they are more aseptic than for- 
merly. 
2. They have better means for securing haemostasis. 
3. They do not use irritating chemical antiseptic solutions in the 
peritoneal cavity. 
4. They deprive their patients of water for forty-eight hours after 
operation, thus producing systemic thirst, and bringing about the 
absorption of serum from the peritoneal cavity. 
5. They purge early and freely on the first sign of peritoneal 
irritation. 
These facts and alterations in practice undoubtedly render the 
employment of drainage far less imperative than it was ten years ago ; 
but they do not, in my judgment, do away with its advantage in 
bad cases. 
The opponents of drainage not only deny the beneficent nature of 
the drainage-tube, but they attribute to its use various harmful 
effects : 
1. That it is an open door for the entrance of infection. 
2. That it produces fecal fistula. 
3. That it favors hernia. 
I am inclined to admit the validity of the third objection without 
argument. It is also true that the tube may prove an open door for 
infection. The careful work of Robb and Ghriskey in Kelly's service 
at the Johns Hopkins Hospital proves that it is impossible to prevent 4 
N OBLE, 
infection of the tube by mere cleanliness or by pure asepsis not 
maintained by the use of chemical antiseptics. In these observations 
nothing but cotton or gauze, sterilized by heat and held in an aseptic 
forceps, was passed down the tube. Yet infection of the tube was 
frequent. Robb concludes from these experiments that drainage is 
harmful because it favors post-operative infection. This conclusion 
is logically drawn only with reference to drainage as practised by 
him. His results have only a relative bearing upon the general 
question of drainage. It is probable that the open method of drain- 
age as practised by the disciples of Tait will give an even larger 
percentage of cases of tube-infection than those reported by Robb ; but 
so far as I know, no careful observations on this point have been made. 
By using sterile gauze wet in sublimate solution (1 : 2000) to fill 
the tube, which has previously been drained, by soaking up the fluids 
by means of pledgets of sterile cotton held in a forceps, I believe the 
tube can be kept aseptic. The continual presence of the wet bichloride 
of mercury gauze in the tube kills or inhibits the growth of any 
germs which may make an entrance. I have practised this method 
of managing the tube in nearly 150 cases, and have the utmost confi- 
dence in its efficacy in preventing infection through the tube. In 
addition to using the wet bichloride gauze as a capillary drain and as 
a disinfecting plug for the tube, I have not hesitated to pass cotton 
soaked in bichloride solution to the bottom of Douglas's pouch each 
time I dressed the tube (two or three times in twenty-four hours) as an 
additional means of preventing infection. From long experience I am 
able to maintain that this restricted application of bichloride solu- 
tion is harmless, although I am as firmly persuaded as anyone that 
the extensive use of chemical solutions within the peritoneal cavity is 
harmful, and therefore bad surgery. By this method of managing 
the tube I believe it is possible to prevent infection along the inside 
of the tube. At times infection occurs along the outside of the tube, 
especially when it is in position longer than 36 hours. This is best 
prevented by using a wet bichloride gauze dressing over' the wound 
and around the tube. But when the tube is in position several days 
I frankly admit that infection from the skin can take place along the 
outside of the tube in spite of all we can do. This, in.my experience, 
has invariably been of mild character, without serious results. 
Concerning the second objection to " glass drainage," that it pro- 
duces fecal fistula, I believe that the Scotch verdict of " not proven " 
must be brought in. That a glass tube resting on the bowel for a long 
time, without rotation or elevation, might cause ulceration of the bowel CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
5 
is true; but no one recommends such bad practice; and when the 
bowel has been seriously injured in separating adhesions, so that fecal 
fistula is to be feared, I feel decidedly safer with a tube in position 
to act as a danger signal and to provide a means of exit for fecal 
matter should a fistula form. That the probability of fecal fistula is 
slight in careful hands is indicated by the fact that I have had but 
two such cases. 
I shall now give an analysis of the one hundred consecutive coeli- 
otomies herewith reported. 
These operations have been done for the following conditions: 
Pregnancy in flat pelvis, c. v. 2J in .1 
Ovarian cysts: Treble, 1; double, 2; single, 8; single malignant, 1 . 12 
Ovarian cysts, complicated by: Salpingitis and pelvic adhesions, 4; 
hydro- and haemato-salpinx, 2; double pyosalpinx, 1 . . . 7 
Suppurating ovarian cysts, complicated by: Double salpingitis, 2; 
hydrosalpinx, 1; pyosalpinx, 2 5 
Pyosalpinx: Double, 7; double, with abscess of both ovaries, 1; 
single, 3; single and abscess of ovary, 1 12 
Fibro-cyst of uterus 1 
Fibro-myoma of uterus 9 
Extra-uterine pregnancy : Ruptured, 2; unruptured, 1 ... 3 
Double hydrosalpinx 3 
Hydro- and haemato-salpinx 1 
Tubercular peritonitis with double pyosalpinx (tubercular) . . 1 
Tubercular peritonitis with cancer of pelvis ...... 2 
Tubercular peritonitis 1 
Pelvic abscess 1 
Pelvic cellulitis 1 
Malignant tumor of kidney 1 
Peritoneal carcinoma 1 
Hemorrhage into the pregnant bifid uterus 1 
Cancer of colon 1 
Ventral hernia (post-operative) 3 
Inguinal hernia and femoral hernia, 1 each 2 
Catarrhal appendicitis (recurrent) 1 
Retroflexion of uterus, with adherent appendages .... 2 
Retroflexion of uterus-left ovaritis 1 
Chronic salpingitis and ovaritis: One side, 6; both sides, 2; both sides 
with broad ligament cyst, 1 9 
Chronic salpingo-oophoritis with extensive adhesions . . .10 
Haematoma of right, cirrhosis of left ovary 1 
Hypertrophic, cystic, and cirrhotic degeneration of ovaries-hysteria 
with periods1 ........... 1 
Arrested development of the sexual organs-cystic ovaries-chronic 
peritonitis . • ......... 4 
Menstrual insanity with fibroid tumor and left ovarian cyst . . 1 
Endometritis fungosa (adenoma), salpingitis, cystic ovaries, uterine 
hemorrhage 1 - 100 
1 In this connection., it should, be mentioned that in one case of ovarian cyst hystero- 
epilepsy existed; also in one ease of ovarian cyst with adherent appendages. In the 
three cases a cure has resulted. 6 
NOBLE, 
In the following operations both uterine appendages were removed 
for- 
Uterine fibro-myoma 5 
Ovarian cyst 7 
Ovarian cyst, complicated by suppuration in cyst, or pyo-, hydro-, or 
haemato-salpinx or salpingitis 10 
Chronic salpingo-oophoritis, with extensive adhesions . . .10 
Chronic salpingo-oophoritis, with broad-ligament cyst ... 1 
Pyosalpinx and ovarian abscess 11 
Hydro- and haemato-salpinx ......... 4 
Extra-uterine pregnancy 3 
Arrested development of the sexual organs, with chronic ovaritis, sal- 
pingitis, and peritonitis 4 
Haematoma and cirrhosis of ovaries 1 
Retroflexion of uterus and adherent appendages 1 
Endometritis fungosa, salpingitis, cystic ovaries, metrorrhagia . . 1 
Chronic ovaritis and salpingitis, without adhesions .... 2 
Small uterine fibroid and ovarian cyst-menstrual insanity . . 1 
Hypertrophic, cystic, and cirrhotic degeneration of ovaries: Hysteria 
with periods 1 
62 
One uterine appendage was removed for- 
Ovarian cyst .4 
Ovarian cyst, complicated by pyo- or haemato-salpinx .... 2 
. Pyosalpinx 1 
Pyosalpinx and abscess of ovary 1 
Retroflexion of uterus-left ovaritis 1 
Retroflexion of uterus, with adherent appendages .... 1 
Chronic salpingo-oophoritis 6 
16 
Miscellaneous coeliotomies- 
Hysterectomy for fibro-cyst, 1; for soft fibroid, 2 3 
Exploratory incisions 9 
Tubercular fluid evacuated 3 
Caesarean section 1 
Appendix vermiformis removed 1 
Herniotomy: Post-operative ventral hernia 3 
Herniotomy: Inguinal, 1; femoral, 1 2 
22 
Total-100 
Cases 35, 37, 41, 43, 54, 73 died-6 per cent. 
The diseases for which the abdominal sections were done must be 
divided into thirty-one groups. It would not be profitable, nor is it 
possible in the time at my disposal, to discuss each of these indi- 
cations. 
Happily, it is no longer necessary to discuss the necessity for early 
operation in labor complicated by deformity of the pelvis sufficient 
to prevent delivery per vias naturales, for ovarian and tubal cysts, 7 
CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
for certain fibroid tumors, for extra-uterine pregnancy, and for the 
well-marked cases of chronic salpingo-obphoritis with adhesions. 
Those who are not convinced of the necessity and advantages of 
operation in these cases are either not familiar with the diseases in 
question or are so constituted as not to be convinced by evidence or 
argument. For such conditions there have been 65 operations. 
CHRONIC SALPINGO-OOPHORITIS WITHOUT ADHESIONS. 
The cases in which the necessity for and advisability of operation 
is least certain are cases of chronic salpingitis and ovaritis, with 
trifling adhesions or none at all, and in which the principal symp- 
tom is pain, local and reflex, with various neuroses and disturbances 
of digestion and nutrition as complications. In this class of cases 
there have been 8 operations; in 6 cases one uterine appendage was 
removed, in 2 cases both were removed. If to these we add an 
operation for haematoma of the right ovary and cirrhosis of left, and 
a case of double salpingo-obphoritis, with a small, broad ligament 
cyst; and also a case of hypertrophic cystic and cirrhotic degenera- 
tion of the ovaries, with marked hysterical catalepsy at the menstrual 
periods, we have 11 operations, in 5 of which both uterine appendages 
were removed. Indeed, in 6 cases both were removed, because one 
case was operated on twice. All of these patients recovered from 
the operation, and, speaking in general terms, they have been much 
benefited or entirely cured. One patient (Case 32-63), with cystic 
ovaries, salpingitis, and metrorrhagia, was not benefited by removing 
the worst appendage, but was entirely cured when the second one 
was removed. Case 42, with hypertrophic, cystic, and cirrhotic de- 
generation of the ovaries, and having hysterical cataleptic attacks at 
her periods, was entirely cured. In every case the results obtained 
justified the operation., and in most of them the results were entirely 
satisfactory. 
In my judgment, the indication for operation in this class of cases 
is difficult to define, and too much caution cannot be maintained in 
advising operation. The cases reported were operated upon only 
after the failure of long-continued non-operative treatment. I 
believe that operation is not justifiable in such cases, no matter 
how great the suffering, unless the patient first submits to well- 
directed, long-continued treatment. If this fails to cure, and the 
patient's health is destroyed, her life made miserable, and she her- 
self perhaps pauperized by her condition, operation is indicated. 8 
NOBLE, 
Under such conditions operation and the removal of the offending 
member is a great boon to these sufferers. With careful after-treat- 
ment, tending to improve nutrition, many otherwise hopeless sufferers 
in this way can be cured. These patients were selected for operation 
from a large number, and many of them had been under treatment 
from one to three years without material improvement. 
ARRESTED DEVELOPMENT OF THE SEXUAL ORGANS. 
In four cases of arrested development of the sexual organs, with 
cystic ovaries and some chronic peritonitis, both uterine appendages 
were removed. All that was said concerning caution in advising 
operation in the previous class of cases is even more applicable to this 
class. Each of these women was single, had had delayed puberty, 
with abnormal menstruation, with marked anaemia and various 
neuralgias; and each had been under treatment for a long time 
without avail. Life was a burden to both. The results have been 
all that could be desired in three, and the fourth expresses herself as 
happy at being relieved of her menstrual pains, in the pelvis, mam- 
mary glands, and head. She is still very anaemic, but supports 
herself as a dressmaker. One is now a successful trained nurse, 
another a saleswoman, and the last one is doing general housework 
as a servant. 
POST-OPERATIVE VENTRAL HERNIA. 
There have been three operations for post-operative ventral hernia- 
two in cases previously operated on by. myself. These are the only 
herniotomies I have done on my own cases, although not the only 
hernias which have occurred in my practice. In each of these cases 
the primary section was for pus in the pelvis in women much broken 
in health, and in each suppuration followed the operation, preventing 
primary union of the abdominal wall. All three were poor women, 
who were obliged to do heavy work shortly after their operations 
were done. 
I believe that the causes of post-operative ventral hernia are: 
1. Extreme malnutrition of the patient when operated upon. 
2. Failure to approximate the divided transverse aponeurosis. 
3. Suppuration of the abdominal wound. 
4. Drainage. 
5. Early rising from bed. 
6. Too early return to work. 
7. Failure to wear a bandage (?). CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
9 
A certain low percentage of hernias is unavoidable, but a practice 
based upon a recognition of the preceding facts will greatly restrict 
their number. 
The first case herewith reported was operated upon by dissecting 
out the sac, freeing the intra-peritoneal adhesions, and then by pass- 
ing sutures in the usual way through each lip of the wound. Before 
these were tied the divided aponeurosis was united by a running 
catgut suture. The other two were sutured differently. After the 
sac was carefully dissected out, so that the three layers of the abdom- 
inal wall-skin, aponeurosis and muscle, and peritoneum-were dis- 
tinctly free and visible, silkworm-gut sutures were passed, beginning 
at the aponeurosis and passing through it and the rectus muscle and 
peritoneum upon one side, and in the reverse way upon the opposite 
side of the incision. These were tied and cut off close to the knots, 
to become permanent buried stays or supports to the wound. The 
skin was then united by superficial sutures. This method of sutur- 
ing in hernia is original with myself, but the principle, I believe, is 
to be credited to Edebohls, who devised the method for his ordinary 
coeliotomy wounds. The three cases have done well. 
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 
There was one operation for the radical cure of inguinal hernia 
and one for femoral hernia. In the case of the inguinal hernia, the 
lower end of the sac had shut itself off from the upper portion, and 
in this way a cystic tumor had formed as large as a hen's egg. This 
was removed, and the sac was pulled down, ligated, and returned to 
the peritoneal cavity. The pillars of the ring were whipped together 
with a continuous silkworm suture, which was left as a permanent 
support. 
The femoral hernia contained adherent omentum. The operation 
was done as in the first case. A cure has resulted in both cases. I 
wish to call attention to the use of the continued silkworm buried 
suture, or a number of interrupted buried sutures, for closing the 
peritoneal cavity and the pillars of the ring, in operating for hernia. 
I believe the method will be of service in preventing a return of the 
hernia. 
I was somewhat doubtful about including inguinal and femoral 
herniotomies among abdominal sections. Anatomically the classifica- 
tion is correct, but custom is rather against it. But whether these 
herniotomies be included or rejected in this report is of little impor- 10 
NOBLE, 
tance from the standpoint of results, as eight operations done since 
the date of this report could be added, making 108 in all, with but 
six deaths. Two of the deaths were cases of incomplete ovariotomy, 
one of which was for a malignant growth. 
I shall pass over the three operations for retroflexion of the uterus, 
with ovaritis and with adherent uterine appendages, also the one 
operation for recurrent catarrhal appendicitis, and the three opera- 
tions to evacuate fluid iu tubercular cases, and take up the explora- 
tory sections. 
EXPLORATORY CCELIOTOMIES. 
There were nine exploratory sections. One was made in the groin 
for a supposed abscess following removal of the uterine appendages for 
fibroid of the womb. A cellulitis of the right broad ligament 
(infected pedicle1) was found. The pelvic peritoneum was inflamed, 
but the swelling was in the broad ligament. 
The second case was an operation for fibroid. The bladder was 
anomalous, having the peritoneum reflected upon it just below the 
umbilicus. As this prevented the extra-peritoneal treatment of the 
pedicle, the operation was abandoned. The third patient was a case 
of true pelvic abscess following labor; the section was done to deter- 
mine whether pyosalpinx existed. The abscess was evacuated in the 
groin by a second incision. The fourth patient was supposed to be a 
case of pelvic suppuration (pyosalpinx or abscess of the ovary), but 
proved to be cancer of the colon. The fifth case was operated upon 
as an ovarian tumor. The tumor was intra-ligamentous ; filled the 
pelvis ; was covered with the platysma layer of the broad ligament; 
looked like a pregnant uterus, and as no landmarks could be made 
out, owing to a recent peritonitis, the suspicion of pregnancy was 
entertained, and unfortunately the operation was abandoned. The 
woman died. The seventh case was an operation for fibroid. The 
woman collapsed when the abdomen was opened, so the operation 
was abandoned. The eighth case was thought to have a ruptured 
extra-uterine pregnancy. It proved to be a hemorrhage into one 
horn of a pregnant bifid uterus. The sixth and ninth cases were 
diagnosed as cancer, but at the request of the patient the abdomen 
was opened in the hope of finding the diagnosis a mistake. 
1 Having had a number of infected pedicles, and having seen no haematomas follow- 
ing abdominal sections, it has occurred to me that Tait's post-operative haematomas are 
really infected pedicles. CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
11 
I am thoroughly convinced of the importance and the propriety of 
opening the abdomen in certain cases to complete the diagnosis, but I 
have never yet been obliged to open the abdomen without a very 
definite knowledge of the physical conditions present. The explora- 
tion was to assist in interpreting the physical conditions. I am 
entirely out of sympathy with the theory that it is necessary to open 
the abdomen to find out whether a woman has pelvic or abdominal 
disease. Such a proposition is a confession of too great ignorance of 
the subject of diagnosis. 
I will simply remark, in conclusion, that it is difficult to separate 
strictly exploratory coeliotomies from abandoned operations in making 
classification. 
CYSTIC DEGENERATION OF THE OVARIES AS A CAUSE OF 
METRORRHAGIA. 
In four cases the relation between cystic ovaries and metrorrhagia 
was striking. In two of the cases there is no doubt that it was the 
only cause of the uterine hemorrhage. Of the doubtful cases, No. 
4, aged forty, had been an invalid for fifteen years, with pelvic 
disease originating in childbirth. Prior to her operation she had 
been bleeding almost constantly for three years, during two years of 
which time she was confined to bed. The ovaries were cystic, but 
in addition, chronic salpingitis, with adhesions, existed, so that it is 
only probable that the metrorrhagia was due to the ovarian disease. 
The hemorrhage ceased w.ith the removal of the appendages. Case 
No. 64, age twenty-seven, primipara, is likewise a doubtful illus- 
tration of metrorrhagia from cystic disease of the ovaries. Mrs. 
S. came under my care for supposed miscarriage at the fifth 
week. Hemorrhage continuing, I curetted the uterus, and repeated 
the curetting without anaesthesia, some weeks later. This case was 
my first and last one in which I have attempted to curette the uterus 
without anaesthesia. It proved so painful to the patient and so un- 
satisfactory to myself that I shall not attempt it again. As Mrs. S. 
continued to bleed, I admitted her to the Kensington Hospital for 
Women, and curetted the womb thoroughly, removing a large 
quantity of material with the curette. After a few weeks, bleeding 
recurred and the patient became blanched. From the beginning it 
had been apparent that the left ovary was diseased, and this seemed 
to me to explain the recurring hemorrhages. I explained the situa- 
tion fully to the husband and to the patient, recommended one more 12 
NOBLE, 
curetting, and, that failing, the removal of the appendages. They 
both insisted upon the more radical operation, which, under the cir- 
cumstances, I could not refuse. 
The womb was again curetted and the appendages removed February 
15, 1892. lu April the bleeding recurred and continued. I enter- 
tained the diagnosis of malignant adenoma, but concluded to curette 
the uterus and pack it with gauze soaked in 50 per cent, chloride of 
zinc solution. This produced a slough of the inner layers of the 
uterus, about one-fourth of an inch in depth, and also cured the 
bleeding. 
In the other two cases, 28 and 32-63 the relation of the cystic 
disease to the bleeding was unmistakable. Case 28, age twenty- 
three, primipara, had been bleeding two and one-half years, during 
which time she had been treated medically, also by electricity, and 
besides she had had the rest cure. The uterus was enlarged, as was the 
left ovary. Curetting stopped the bleeding for four months, when it 
recurred. The uterine appendages were removed April 23, 1891. 
Each ovary contained a small polycyst. There has been no recur- 
rence of the bleeding. Case 32-63, age twenty-one, had had metror- 
rhagia for eight months, which was increasing in spite of judicious 
treatment on the part of her physicion, Dr. G. G. Faught. Exam- 
ination showed enlarged inflamed ovaries, especially the left one. The 
uterus was curetted, and the left ovary and tube removed. No im- 
provement followed, and in spite of careful treatment the patient's 
condition ran down. Nine months after the first operation the other 
appendage was removed. The ovaries were both markedly cystic, 
and both tubes were the seat of catarrhal salpingitis. The patient 
has made a perfect recovery. 
Six of the coeliotomies were followed by death. Case 35, age 
thirty, Ill-para, was a fat woman in fair condition. She had a sup- 
purating intra-ligamentous cyst of the left ovary. The cyst had 
become inflamed during her last puerperium, some two months prior 
to her operation. The operation was extremely difficult, and lasted 
ninety minutes. The purulent contents of the cyst escaped during the 
operation. Free irrigation and glass-drainage were used. The patient 
went to bed somewhat shocked. She shortly developed hyper- 
pyrexia, and died within twenty-four hours. I was at a loss to 
determine whether the fever was due to virulent sepsis or to nervous 
disturbance. 
Case 37, age fifty-four, X-para, was in extremis when operated 
upon. She was enormously distended, and had had orthopnoea and CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
13 
paralysis of the bowels from pressure for days. A ruptured colloid 
cyst of the right ovary, and two cysts of the left ovary, were re- 
moved. Mrs. J. died in six hours, plainly from filling up of the 
portal vessels, due to the removal of the immense pressure caused 
by the tumors. 
Case 4, age forty-eight, primipara, was prostrated and emaciated. 
A large malignant cyst of the left ovary was removed. The broad 
ligament was infiltrated with cancer. During the operation in 
making traction on the cyst, the entire upper border of the broad liga- 
ment tore away. Instantly the pelvis was flooded with blood which 
ran out of the abdomen in a great stream. I immediately ligated the 
ovarian artery by passing a needle and suture, by touch, through the 
outer end of the broad ligament, and tying it. This controlled the 
bleeding sufficiently to sponge the blood away. The uterine end of 
the broad ligament was then ligated, and a row of interlocking 
sutures passed through the broad ligament. This controlled the 
bleeding completely. It was not possible to remove all the cancer- 
ous material, which fact doubtless explains the patient's death from 
septic peritonitis on the seventh day. Irrigation and glass-drainage 
were used. In such a case I would use the Mikulicz drain now. 
Case 43, primipara, age thirty, in fair condition, was operated on 
for hydro- and hsematosalpiux. Quick operation, irrigation and 
drainage. Hemorrhage into the peritoneal cavity took place during 
the first twenty-four hours-not sufficient, however, I thought to 
necessitate reopening the abdomen. The patient died of septic peri- 
tonitis on the fourth day. 
Case 54, age twenty-eight, primipara, was in poor condition. The 
case has been referred to under the head of exploratory sections. 
Death from peritonitis. 
Case 73, age twenty-four, nullipara, bedridden and markedly 
emaciated. Was operated on for suppurating ovarian tumor and 
double pyosalpinx. She died from exhaustion. No autopsy was 
allowed, but she had no evidence of peritonitis, except vomiting. 
Of the six deaths, four were due to delay. A reasonably early 
operation would have saved them. Of the other two, one might 
have been saved had the abdomen been reopened promptly and the 
blood washed out; the other was a desperate case and would prob- 
ably have died even if the operation had not been abandoned. 
Deaths in abdominal surgery are almost always due to delay in oper- 
ating. The same is true of post-operation pain and invalidism. When 
the profession awakes to this fact the mortality in abdominal surgery 14 
NOBLE, 
will be reduced to one or two per cent, for all cases, and the percentage 
of perfect cures by operation will be improved still more. 
Appended is a list of the coeliotomies, which has been prepared by 
Dr. H. E. Applebach, assistant surgeon to the hospital. 
Case 1.-October 15, 1890. J. W., aged thirty years; single; thin and 
anaemic; fibroid tumor. Removal of uterine appendages; time twenty 
minutes; drainage, two days. Convalescence uncomplicated ; temp, febrile; 
primary union. Recovered (hernia). Discharged December 20, 1890. 
Case 2.-October 15, 1890. Mrs. F., aged twenty-six years; married; 
fairly well nourished ; small right ovarian tumor and large hydrosalpinx, left 
haematosalpinx and atrophied ovary. Adhesions very dense, left ovary could 
not be removed, unless torn from its bed, it was left; time forty minutes; 
drainage, seven days. Convalescence slow; temp, febrile; primary union. 
Recovered. Discharged November 20, 1890. 
Case 3.-October 18, 1890. Mrs. L., aged twenty-seven years ; married; 
healthy appearance; right ovarian tumor, double pyosalpinx. Removal of 
both uterine appendages; time forty minutes ; drainage, four days. Conva- 
lescence slow; temp, febrile; primary union. Recovered. Discharged 
November 15, 1890. 
Case 4.-November 5, 1890. Mrs. W., aged forty-two years; married; 
two pregnancies ; one miscarriage ; condition very poor; chronic invalidism, 
cirrhotic and adherent ovaries, chronic salpingitis, metrorrhagia. Uterus 
dilated and perforated. Abdominal section, with removal of cystic and 
cirrhotic ovaries; time forty-five minutes; drainage, five days. Convales- 
cence slow ; temp, febrile ; primary union. Recovered. Discharged Decem- 
ber 12, 1890. 
Case 5.-November 8, 1890. J. W., aged thirty years; single; anaemic 
cellulitis. Exploratory section over exudate; time twenty-five minutes; 
drainage, iodoform gauze. Convalescence slow; temp, febrile; primary 
union. Recovered. Discharged December 20, 1890. 
Case 6.-November 19, 1890. Mrs. A., aged twenty-four years ; married ; 
two pregnancies; neurasthenic; salpingitis with hypertrophic, cystic, and 
cirrhotic degeneration of the ovaries, with adhesions. Removal of both 
uterine appendages; time thirty minutes; drainage, two days. Convalescence 
unimpaired; temp, afebrile; primary union. Recovered. Discharged De- 
cember 12, 1890. 
Case 7.-November 23, 1890. Miss C., aged twenty-three years; single; 
neurasthenic ; dysmenorrhcea and constant pelvic pain, cirrhotic and cystic 
ovaries, chronic pelvic peritonitis, arrested sexual development. Removal 
of both uterine appendages; time twenty-five minutes; drainage, two days. 
Convalescence uncomplicated; temp, afebrile ; primary union. Recovered. 
Discharged December 19, 1892. 
Case 8.-December 10, 1890. Mrs. M., aged thirty years ; married ; con- 
dition fair; double pyosalpinx. Removal of uterine appendages ; time sixty 
minutes ; drainage four days. Had ether-bronchitis; temp, febrile; primary 
union. Recovered. Discharged January 10, 1891. 
Case 9.-December 19, 1890. Mrs. B., aged thirty-four years; married; 
two pregnancies; three miscarriages; condition bad ; left ovarian cyst and 15 
CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
haematosalpinx. Removal of the left uterine appendage; time thirty min- 
utes ; drainage two days. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged January 25, 1891. 
Case 10.-January 10, 1891. Mrs. L., aged thirty-seven years; married; 
three pregnancies; condition very good; double salpingitis with adhesions, 
extra-uterine pregnancy on right side unruptured. Removal of both uterine 
appendages (diagnosis confirmed by Dr. Piersoll, of the University of Pennsyl- 
vania) ; time twenty-five minutes ; drainage, thirty-two hours. Convalescence 
uninterrupted; temp, afebrile; primary union. Recovered. Discharged 
February 10, 1891. 
Case 11.-January 17, 1891. Mrs. H., aged forty-one years; married; 
five pregnancies; debilitated; salpingitis, cystic ovaries, and chronic peri- 
tonitis. Removal of both uterine appendages; time twenty-five minutes; 
oozing hemorrhage began six hours after the operation and continued twelve 
hours ; temp, afebrile ; primary union. Recovered. Discharged March 20, 
1891. 
Case 12.-January 17, 1891. Mrs. H., aged thirty-eight years; married ; 
four pregnancies; condition good; fibroid tumor of uterus, left ovarian cyst, 
menstrual insanity. Removal of both uterine appendages; drainage, one 
day. Convalescence uninterrupted; temp, afebrile; primary union. Re- 
covered. Discharged February 18, 1891. 
Case 13.-January 22, 1891. Mrs. F., aged twenty-eight years ; married; 
nullipara; condition good; chronic salpingitis and ovaritis, extensive peri- 
tonitis, universal adhesions. Removal of both uterine appendages (owing to 
extensive and dense adhesions the operation was not a clean one); time fifty- 
five minutes; drainage, two and a half days. Stitch-hole abscess during the 
second week; temp, afebrile. Recovered. Discharged February 27, 1891. 
Case 14.-January 28, 1891. Mrs. C., aged forty-one years; married; 
nullipara; condition very poor; tubercular peritonitis, cancer of liver, 
stomach, and duodenum. Abdominal section and evacuation of four gallons 
of fluid, it was the sixth section; apparently the tubercular nodules were 
undergoing cicatrization ; time twenty-five minutes ; drainage eighty hours. 
Continual vomiting resulting from cancer; temp, afebrile; primary union. 
Recovered. Death from exhaustion, caused by constant vomiting excited by 
cancer of stomach, occurred shortly afterward. Had been vomiting for two 
months. 
Case 15.-February 5, 1891. Mrs. M., aged twenty-six years; married; 
nullipara; condition good; pyosalpinx on right side, salpingitis on left side. 
Removal of both uterine appendages, the abscess had perforated the mus- 
cular coat of colon, was curetted and sutured; time forty minutes ; drainage, 
two days. Convalescence uninterrupted; temp, afebrile; primary union. 
Recovered. Discharged February 25, 1891. 
Case 16.-March 11, 1891. Mrs. P., aged thirty-three years; married; 
one pregnancy; one miscarriage; condition fair ; ovarian tumor on right side; 
salpingitis on left side. Removal of both uterine appendages; time thirty 
minutes; drainage, two days. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged April 8, 1891. 
Case 17.-March 11, 1891. Mrs. H., aged thirty-three years; married; 
one pregnancy ; condition good ; retroflexion, salpingitis on both sides, uterus 16 
'NOBLE, 
adherent. Removal of both uterine appendages, ligature placed under round 
ligaments; time twenty-five minutes; drainage, five days. Convalescence 
uninterrupted: temp, afebrile; primary union. Recovered. Discharged 
April 16, 1891. 
Case 18.-March 16, 1891. Mrs. H., aged thirty-eight years; married; 
two pregnancies ; one miscarriage; condition fair; double hydrosalpingitis. 
Removal of both uterine appendages; time thirty minutes; drainage, four 
days. Convalescence uninterrupted; temp, afebrile; primary union. Re- 
covery. Discharged April 14, 1891. 
Case 19.-March 16,1891. Mrs. A., aged thirty-six years; married; three 
pregnancies; two miscarriages ; condition good ; double hydrosalpinx. Re- 
moval of both uterine appendages, very dense adhesions, collapse from 
chloroform ; time fifty minutes; drainage, two days. Convalescence uninter- 
rupted; temp, afebrile; primary union. Recovered. Discharged April 14, 
1891. 
Case 20.-March 23, 1891. Miss T., aged seventeen years; condition 
good; fibroid of uterus. Exploratory section, bladder anomalous, extending 
to within one inch of umbilicus; time thirty minutes, drainage, none. Con- 
valescence uninterrupted ; temp, afebrile ; primary union. Recovered. Dis- 
charged April 27, 1891. 
Case 21.-March 23, 1891. Miss S-, aged thirty-four years; single; con- 
dition worn; rudimentary appendages, neurasthenia, cystic ovaries. Re- 
moval of both uterine appendages; time thirty minutes; drainage, two days. 
Convalescence uninterrupted; temp, afebrile; primary union. Recovered. 
Discharged May 3, 1891. 
Case 22.-March 26, 1891. Mrs. McG., aged forty years; married; three 
pregnancies; condition worn; tubercular peritonitis and cancer of append- 
ages. Abdominal section and evacuation of fluid; time twenty minutes; 
drainage, six days. Convalescence uninterrupted; temp. 100.5°, slightly 
febrile; primary union. Recovered. Discharged March 21, 1890. 
Case 23.-April 2, 1891. Mrs. H., aged thirty-four years ; married; three 
pregnancies; condition very poor; retroflexion, large tender left ovary. Re- 
moval of left uterine appendage, ligature under round ligament; time thirty 
minutes; drainage, one day. Bronchitis; temp, afebrile; primary union. 
Recovered. Discharged May 10, 1891. 
Case 24.April 10, 1891. Miss McC., aged twenty-four years; single; 
condition fair; salpingitis on left side. Removal of left uterine appendage; 
time twenty minutes; drainage, one day. Convalescence uninterrupted; 
temp, afebrile; primary union. Recovered. Discharged May 2, 1891. 
Case 25.-April 12,1891. Mrs. P., aged twenty-four years; married; two 
pregnancies; condition bad ; true pelvic abscess. Exploratory section ; time 
fifteen minutes; drainage, none. Pelvic abscess evacuated on twelfth day; 
temp, febrile; primary union. Recovered. Discharged May 2, 1891. 
Case 26.-April 16,1891. Mrs. B.,aged twenty-five years; married; nulli- 
para ; condition very good; double salpingitis with dense adhesions. Re- 
moval of both uterine appendages, some of left ovary was not removed ; time 
thirty minutes; drainage, three days. Convalescence uninterrupted; temp, 
afebrile; primary union. Recovered. Discharged May 14, 1891. 
Case 27.-April 23, 1891. Mrs. R., aged thirty-four years; married; two 17 
CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
pregnancies; condition good; post-operative ventral hernia. Cicatrix dis- 
sected out, aponeurosis sutured with continuous catgut sutures; time one 
hour; drainage, none. Convalescence uninterrupted; temp, afebrile; pri- 
mary union. Recovered. Discharged May 29, 1891. 
Case 28.-April 22, 1891. B. B., aged twenty-three years; single; one 
pregnancy; very anaemic; double ovarian cystoma (small), long-continued 
metrorrhagia. Removal of both uterine appendages; time twenty-five minutes; 
drainage, one day. Convalescence uninterrupted ; temp, afebrile; primary 
union Recovered. Discharged May 19, 1891. 
Case 29.-April 27,1891. Mrs. C., aged thirty-five years ; married; nulli- 
para ; condition very bad; double ovarian, thin-walled cystomata. Re- 
moval of both cysts and tubes; time forty minutes; drainage, one day. 
Convalescence uninterrupted; temp, afebrile; primary union. Recovered. 
Discharged May 25, 1891. 
Case 30.-May 11, 1891. Mrs. H., aged thirty-four years; married; nine 
pregnancies; two miscarriages; condition poor; suppurating left ovarian 
cyst, double salpingitis, universal adhesions. Incomplete removal of both 
appendages, thorough irrigation, pus had burrowed between vagina 
and rectum; time ninety minutes; drainage, seven days. Convalescence 
uninterrupted; temp, afebrile; primary union. Recovered. Discharged 
June 17, 1891. 
Case 31.-May 28, 1891. Mrs. B., aged forty-six years; married; two 
pregnancies; condition good; large oedematous myoma, larger than full- 
term pregnancy. Hysterectomy, broad ligament tied off, Koeberl&'s nceud; 
time two and a half hours ; drainage, twenty-four hours. Stump clipped off 
on tenth day; temp, afebrile; union primary. Recovered. Discharged July 
15, 1891. 
Case 32.-May 28, 1891. Miss W., aged twenty-one years; single; con- 
dition fair; salpingitis and ovaritis on left side, metrorrhagia. Left uterine 
appendage removed ; time twenty minutes; drainage two days. Convalescence 
uninterrupted; temp, afebrile; primary union. Recovered. Discharged 
June 25, 1891. 
Case 33.-June 15, 1891. Mrs. W., aged forty years; married; three 
pregnancies; condition poor; double salpingitis, broad ligament cyst on 
right side, adherent appendages. Removal of both uterine appendages; 
time forty minutes ; drainage, one day. Convalescence uninterrupted ; temp. 
101°, febrile ; primary union. Recovered. Discharged July 12, 1891. 
Case 34.-June 18, 1891. L. C., aged twenty-three years; married; one 
pregnancy; condition fair; ovarian tumor on right side, salpingitis and 
ovaritis on left side. Removal of both uterine appendages; time twenty-five 
minutes; drainage, two days. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged July 14, 1891. 
Case 35.-June 25, 1891. Mrs. R., aged thirty-years; married; three 
pregnancies; had peritonitis; intra-ligamentous cyst (suppurating) of left 
ovary. Enucleation of cyst, removal of appendage, free irrigation ; time 
ninety minutes. Died within twenty-four hours in hyperpyrexia; temp, 
febrile. 
Case 36.-June 29, 1891. Mrs. L., aged thirty-four years ; married; one 
pregnancy ; condition poor ; adherent appendages, gumma beneath omentum 18 
NOBLE, 
and Fallopian tube. Removal of both uterine appendages; time forty- 
minutes ; drainage, twenty-six days. Abdomen reopened on fifth day and 
flushed; temp, febrile. Recovered. Discharged July 12, 1891. 
Case 37.-July 2, 1891. Mrs. J., aged fifty-four years; married; seven 
pregnancies; three miscarriages; condition very bad, orthopnoea, paresis of 
bowels; immense right ovarian colloid cyst, two left ovarian cysts, uterine 
myoma as large as a foetal head. Removal of ovarian tumors ; right tumor 
having burst, the colloid material was free in the peritoneal cavity; time 
forty minutes; drainage. Death in six hours from shock, pressure removed 
from portal vessels. 
Case 38.-July 25, 1891. Mrs. B., aged thirty-five years; married; two 
pregnancies ; condition fair ; right ovarian cyst, left tube and ovary inflamed 
and adherent. Removal of both uterine appendages; time forty minutes; 
drainage, two days. Abdomen reopened during third week, owing to an infec- 
tion of the left pedicle; temp, febrile. Two sinuses. Recovered. Discharged 
August 15, 1891. 
Case 39.-July 27, 1891. Mrs. F., aged thirty years ; married ; nullipara; 
condition poor, bedridden for months; cancer of colon. Exploratory section ; 
time twenty-five minutes; drainage, none. Convalescence uninterrupted; 
temp, afebrile; primary union. Recovered. Discharged August 22, 1891. 
Case 40.-July 30, 1891. Miss R., aged thirty years; single; anaemia and 
neurasthenia; imperfect development of uterine appendages. Removal of 
uterine appendages; time thirty minutes. Convalescence uninterrupted; 
temp, afebrile; primary union. Recovered. Discharged August 22, 1891. 
Case 41.-July 30, 1891. Mrs. R., aged forty-eight years; married; one 
pregnancy; condition very bad; large ovarian cyst with cancer in broad 
ligament. Removal of cyst and uterine appendage, very difficult enuclea- 
tion, profuse hemorrhage; ligation of ovarian and uterine arteries; time one 
hour; drainage. Peritonitis set in on third day, died on seventh day; temp, 
febrile. 
Case 42.-August 3, 1891. Mrs. D., aged twenty-four years ; married; one 
pregnancy; condition fair; chronic ovaritis, with hypertrophic, cystic, and 
cirrhotic degeneration, hysteria with periods ; catalepsy. Removal of both 
uterine appendages; time twenty-five minutes ; drainage, one day. Conva- 
lescence uninterrupted ; temp, afebrile ; primary union. Recovered. Dis- 
charged August 27, 1891. 
Case 43.-August 8, 1891. Mrs. B., aged thirty years; married; one 
pregnancy; condition fair; hydrosalpinx on right side, hsematosalpinx on 
left side. Removal of both uterine appendages ; time thirty minutes ; drain- 
age. Hemorrhage after operation, died of septic peritonitis on fourth day; 
temp, febrile. 
Case 44.-August 27, 1891. Mrs. C., aged thirty years; married; one 
pregnancy ; one miscarriage ; condition poor; left ovarian suppurating cyst. 
Removal of left uterine appendage; time twenty-five minutes; drainage, 
three days. Infection of pedicle ; temp, febrile ; primary union. Recovered. 
Discharged September 21, 1891. 
Case 45.-September 3, 1891. Mrs. P., aged forty-two years; married; 
three pregnancies; condition poor; gonorrhoeal salpingitis with extensive 
adhesions. Removal of both uterine appendages ; time thirty-five minutes; CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
19 
drainage, two days. Infection of pedicle; temp, febrile; suppurating wound. 
Recovered. Discharged October 15, 1891. 
Case 46.-September 4, 1891. Mrs. S., aged twenty-seven years ; married; 
two pregnancies; anaemic; ovaritis on left side. Removal of left uterine 
appendage; time twenty-five minutes; drainage, two days. Stitch-hole 
abscess; temp, febrile; primary union. Recovered. Discharged October 
4, 1891. 
Case 47.-September 5, 1891. Miss M., aged thirty-three years; single; 
condition fair ; uterine fibroid with cysts of ovaries. Removal of both uterine 
appendages. Convalescence uninterrupted; temp, afebrile; primary union. 
Recovered. Discharged October 3, 1891. 
Case 48.-September 7, 1891.-Miss W., aged nineteen years; single; 
anaemic; ovarian cyst on right side. Removal of right uterine appendage 
(left appendage removed by Dr. Kelly); time twenty-five minutes; drainage, 
two days. Cellulitis in abdominal wound ; temp, febrile; wound suppurated. 
Recovered. Discharged October 14, 1891. 
Case 49.-September 21, 1891. Mrs. A., aged twenty-two years; married; 
one pregnancy ; one miscarriage; very sick; temp. 104, pulse 140; pyosalpinx 
and abscess on the left side. Removal of left uterine appendages; time 
thirty-five minutes; drainage, two days. Abscess of peritoneum, high up; 
temp, febrile ; wound suppurated. Recovered. Discharged October 28, 1892. 
Case 50.-September 28, 1891. Miss M., aged twenty-four years ; single ; 
condition poor; chronic ovaritis, arrested development, one ovary adherent. 
Removal of both uterine appendages; time twenty-five minutes; drainage, 
thirty-four hours. Convalescence uninterrupted ; temp, afebrile; primary 
union. Recovered. Discharged November 5, 1891. • 
Case 51.-October 4, 1891. Miss H., aged twenty-four years; single; 
condition good; intra-ligamentous ovarian cyst, with extensive adhesions on 
left side. Cyst enucleated and both uterine appendages removed; time 
seventy minutes; drainage, twenty-four hours. Convalescence uninterrupted; 
temp, febrile; primary union. Recovered. Discharged November 11, 1891. 
Case 52.-October 8, 1891. Mrs. H., aged thirty-five years ; married; two 
pregnancies; condition bad; ruptured tubal pregnancy on left side, right 
tube adherent. Both uterine appendages removed; time forty-five minutes; 
drainage, one and a half days. Convalescence uninterrupted; temp, febrile ; 
primary union. Recovered. Discharged November 6, 1891. 
Case 53.-October 19, 1891. Mrs. K., aged thirty-six years; married; 
nullipara; condition very bad, chronic bronchitis ; fibro-cyst of uterus. Hys- 
terectomy ; time two hours; drainage, none. Stump clipped off on eleventh 
day; temp, afebrile; primary union except about pedicle. Recovered. Dis- 
charged December 4, 1891. 
Case 54.-October 22, 1891. Mrs. A., aged twenty-eight years; married; 
one pregnancy; condition poor ; suppurating ovarian cyst, intra-ligamentous. 
Exploratory section, operation abandoned because the diagnosis of pregnancy 
was adopted; time thirty minutes; drainage. Peritonitis; temp, febrile. 
Died. 
Case 55.-November 5, 1891. Miss N., aged thirty years; single; con- 
dition fair ; ovarian cyst on left side and uterine myoma. Removal of both 
uterine appendages; time thirty-five minutes; drainage, none. Convalescence 20 
NOBLE, 
uninterrupted; temp, afebrile; primary union. Recovered. Discharged 
November 20, 1891. 
Case 56.-November 9, 1891. Mrs. B., aged twenty-two years; married ; 
one pregnancy; one miscarriage; condition fair; pyosalpinx and intra-peri- 
toneal abscess. Removal of both uterine appendages; time forty minutes; 
drainage, three days. Convalescence uninterrupted; temp, febrile; primary 
union. Recovered. Discharged December 7, 1891. 
Case 57.-December 3, 1891. Mrs. McG., married; nullipara; condition 
fair; uterine myoma. Removal of both uterine appendages; time thirty-five 
minutes; drainage, none. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged January 11, 1892. 
Case 58.-December 6, 1891. Mrs. A., aged thirty-two years; married; 
nullipara; condition fair; femoral hernia. Radical operation; time forty- 
five minutes; drainage, none. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged January 27, 1892. 
Case 59.-December 19, 1891. Mrs. H., aged forty years; married; 
nullipara; condition good; double pyosalpinx. Removal of both uterine 
appendages; time twenty-five minutes; drainage, one day. Good conva- 
lescence; temp, afebrile; primary union. Recovered. Discharged January 
20, 1892. 
Case 60.-January 21, 1892. Mrs. S., aged forty-eight years; married; 
nullipara; condition poor; carcinoma peritonei. Exploratory abdominal 
section; time twenty-five minutes; drainage, none; temp, febrile; primary 
union. Recovered. Discharged February 2, 1892. 
Case 61.-January 29, 1892. Mrs. V., aged thirty years ; married ; three 
pregnancies; condition fair; haematoma of right ovary, the left cirrhotic. Re- 
moval of both uterine appendages ; time thirty-five minutes ; drainage, none. 
Suppression of urine; temp, febrile; primary union. Recovered. Discharged 
February 20, 1892. 
Case 62.-February 2, 1892. Mrs. H., aged twenty-six years; married; 
nullipara; condition poor; suppurating right intra-ligamentous ovarian cyst, 
left hydrosalpinx. Removal of both uterine appendages, ovarian cyst held 
one quart of pus; time one hour; drainage, nine days. Convalescence slow; 
temp, febrile. Recovered. Discharged March 10, 1892. 
Case 63.-February 4, 1892. Miss W., aged twenty-two years; single; 
condition fair; cystic right ovary, salpingitis, menorrhagia. Removal of 
right uterine appendage, left appendage previously removed for same trouble; 
time twenty minutes; drainage, none. Convalescence good; temp, afebrile ; 
primary union. Recovered. Discharged February 24, 1892. 
Case 64.-February 15,1892. Mrs. S., aged twenty-seven years ; married; 
one pregnancy; condition poor ; endometritis fungosa, cystic ovaries, uncon- 
trollable hemorrhages. Curetting and removal of both uterine appendages ; 
time forty minutes; drainage, one day. Convalescence good; temp, afebrile; 
primary union. Recovered. Discharged March 6, 1892. 
Case 65.-February 17, 1892.-Mrs. I., aged forty years ; married ; nulli- 
para ; anaemic ; fibroma uteri. Exploratory abdominal section ; time twenty- 
five minutes; drainage, none. Double lobar pneumonia; temp, febrile; 
primary union. Recovered. Discharged April 4, 1892, 
Case 66.-February 23, 1892. Mrs. A., aged thirty years; married ; CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
21 
nullipara; condition fair; left pyosalpinx, and suppurating intra-ligamentous 
ovarian cyst. Removal of left tube and cyst; time two and a half hours ; 
drainage, three days. Convalescence uncomplicated ; temp, febrile ; primary 
union. Recovered. Discharged March 6, 1892. 
Case 67.-February 25, 1892. Mrs. G., aged thirty-five years; married; 
five pregnancies; six miscarriages; condition poor; double pyosalpinx. Re- 
moval of both uterine appendages; time fifty minutes ; drainage, three days. 
Convalescence slow; temp, febrile; suppurating wound. Recovered. Dis- 
charged March 25, 1892. 
Case 68.-March 7, 1892. Mrs. R., aged forty-two years; married; nulli- 
para; condition poor; right ovarian cyst, containing one gallon of fluid. 
Removal of both uterine appendages; time forty minutes; drainage, none. 
Convalescence uninterrupted; temp, afebrile; stitch-hole abscess. Recovered. 
Discharged April 7, 1892. 
Case 69.-April 4, 1892. Mrs. A., aged thirty years; married ; nullipara ; 
condition fair; right pyosalpinx. Removal of right tube; time one hour; 
drainage, two days. Convalescence uncomplicated ; temp, afebrile; primary 
union. Recovered. Discharged May 3, 1892. 
Case 70.-Miss G., aged twenty-one years; single; one pregnancy; condi- 
tion good; double ovaritis, salpingitis, with extensive adhesions. Removal 
of both uterine appendages; time thirty-five minutes; drainage, two days. 
Convalescence uncomplicated; temp, afebrile; primary union. Recovered, 
Discharged May 17, 1892. 
Case 71.-May 5, 1892. Mrs. T., aged twenty-two years; married ; one 
pregnancy; condition good; right ovarian tumor, left cystic degenerate ovary 
and adherent tubes. Removal of tumor and both uterine appendages ; time 
forty minutes; drainage, one day. Convalescence uncomplicated; temp, 
afebrile; primary union. Recovered. Discharged June 2, 1892. 
Case 72.-May 16, 1892. Mrs. O., aged twenty years; married; two preg- 
nancies; condition fair; right ovarian cyst, left degenerate ovary. Removal 
of the tumor and both uterine appendages; time thirty minutes; drainage, 
none. Convalescence uninterrupted; temp, afebrile; primary union. Re- 
covered. Discharged June 12, 1892. 
Case 73.-May 19, 1892. Miss M., aged twenty-four years; single; con- 
dition very bad; suppurating ovarian tumor, double pyosalpinx. Removal 
of tumor and both uterine appendages; time one and a quarter hours ; drain- 
age. Patient died from exhaustion, no sign of peritonitis except vomiting; 
temp, afebrile. 
Case 74.-May 26, 1892. Mrs. T., aged twenty-nine years; married; 
nullipara; condition fair; ovaritis. Removal of left uterine appendage; time 
twenty-five minutes; drainage, none. Convalescence uncomplicated ; temp, 
afebrile; primary union. Recovered. Discharged June 26, 1892. 
Case 75.-June 16, 1892. Mrs. C., aged thirty-five years; married; five 
pregnancies; six miscarriages ; condition poor; ventral hernia. Herniotomy; 
time thirty-five minutes; drainage, none. Convalescence uncomplicated; 
temp, afebrile ; primary union. Recovered. Discharged August 12, 1892. 
Case 76.-June 30, 1892. Mrs. C., aged thirty-two years; married; one 
miscarriage; anaemic; chronic salpingitis with marked adhesions, ovaritis. 
Removal of both uterine appendages; time forty minutes; drainage, none. 22 
NOBLE, 
Convalescence uncomplicated; temp, afebrile ; primary union. Recovered. 
Discharged August 18, 1892. 
Case 77.-June 20, 1892. Mrs. N., aged forty years ; married; two preg- 
nancies; condition poor; chronic ovaritis, salpingitis, dense adhesions, retro- 
flexion. Removal of both uterine appendages, hysterorrhaphy; time forty- 
five minutes; drainage, two days. Convalescence uninterrupted; temp, 
afebrile; primary union. Recovered. Discharged July 27, 1892. 
Case 78.-June 25, 1892. Mrs. T., aged twenty-six years ; married; three 
pregnancies; condition fair; ruptured left tubal pregnancy. Removal of 
both uterine appendages ; time thirty-five minutes ; drainage; none. Conva- 
lescence uncomplicated ; temp, afebrile ; primary union. Recovered. Dis- 
charged July 22, 1892. 
Case 79.-July 4, 1892. Miss W., aged thirty years; single; condition 
fair; retroflexion, chronic salpingitis, dense adhesions. Removal of left 
uterine appendages, hysterorrhaphy ; time thirty-five minutes ; drainage, one 
day. Convalescence uncomplicated; temp, afebrile; primary union. Re- 
covered. Discharged August 3, 1892. 
Case 80.-July 4, 1892. Mrs. B., aged forty years; married; four preg- 
nancies; six miscarriages; condition poor; double hydrosalpinx, with small 
ovarian cyst. Removal of both uterine appendages; time forty minutes; 
drainage, five days. Convalescence uncomplicated; temp, afebrile ; primary 
union. Recovered. Discharged July 30, 1892. 
Case 81.-July 9, 1892. Mrs. B., aged forty years; married; four preg- 
nancies ; condition worn; large soft fibroid. Abdominal section, hysterec- 
tomy ; time one and a quarter hours ; drainage, none. Convalescence slow; 
temp, afebrile; primary union. Recovered. Discharged August 17, 1892. 
Case 82.-July 13, 1892. Miss S, aged twenty-five years; single; con- 
dition bad; tubercular peritonitis, large effusion. Abdominal section and 
evacuation of fluid ; time thirty minutes; drainage, none. Convalescence 
slow; temp, febrile; primary union. Recovered. Discharged August 19, 
1892, 
Case 83.-July 20, 1892. Mrs. L., aged fifty-two years; married; nulli- 
para; condition fair; left femoral hernia, sacculation of sac forming cyst. 
Herniotomy, removal of sac and cyst, radical operation; time one hour; 
drainage, none. Convalescence uncomplicated; temp, afebrile; primary 
union. Recovered. Discharged August 6, 1892. 
Case 84.-July 24, 1892. Mrs. T., aged thirty years; married; three 
pregnancies; condition fair; chronic ovaritis and salpingitis, dense adhesions. 
Removal of both uterine appendages; time forty minutes; drainage, none. 
Convalescence uncomplicated; temp, afebrile; primary union. Recovered. 
Discharged August 3, 1892. 
Case 85.-July 26, 1892. Miss H., aged eighteen years; single; condition 
good; catarrhal appendicitis. Abdominal section, vermiform appendix 
removed; time thirty-five minutes ; drainage, none. Convalescence uncom- 
plicated; temp, febrile first day; primary union. Recovered. Discharged 
August 23, 1892. 
Case 86.-August 1, 1892. Miss M., aged twenty years; single; condition 
fair; right ovarian cyst, double salpingitis with adhesions, hystero-epilepsy. 
Removal of both uterine appendages; time thirty-five minutes; drainage, one CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
23 
day. Convalescence uncomplicated; temp, afebrile; primary union. Re- 
covered. Discharged September 30, 1892. 
Case 87.-September 7, 1892. Mrs. 0., aged twenty years ; married; one 
miscarriage; condition poor; large hemorrhage in left horn of bifid pregnant 
uterus. Exploratory section, hemorrhage supposed to be in peritoneal 
cavity; time thirty minutes ; drainage none. Abortion followed operation ; 
temp, febrile; primary union. Recovered. Discharged September 19, 1892. 
Case 88.-September 7, 1892. Miss T., aged nineteen years; single; con- 
dition worn, has been in bed seven weeks; double salpingitis, left ovarian 
cyst suppurating. Removal of both uterine appendages; time fifty minutes. 
Convalescence slow; temp, febrile; suppurated. Recovered. Discharged 
October 7, 1892. 
Case 89.-September 14, 1892. Mrs. D., aged forty-two years ; married ; 
eight pregnancies; three miscarriages ; condition fair ; tumor of right kidney, 
malignant. Exploratory section ; time twenty-five minutes ; drainage, none. 
Convalescence uninterrupted; temp, afebrile; primary union. Recovered. 
Discharged October 4, 1892. 
Case 90.-September 28, 1892. Mrs. C., aged twenty-six years ; married ; 
nullipara; condition good; pregnancy, flat pelvis. Elective Caesarean sec- 
tion ; time one hour; drainage, none. Convalescence uninterrupted ; temp, 
afebrile; primary union. Recovered. Discharged October 26, 1892. 
Case 91.-October 3,1892. Miss 0., aged twenty-three years; single; con- 
dition poor; double pyosalpinx. Removal of both uterine appendages; time 
thirty-five minutes; drainage, three days. Wound sloughed ; temp, febrile ; 
suppurated. Recovered. Discharged November 30, 1892. 
Case 92.-October 6, 1892. Mrs. W., aged forty-two ; married; four preg- 
nancies ; condition fair; tubercular peritonitis, double tubercular pyosalpinx. 
Removal of both uterine appendages; time forty minutes; drainage, one day. 
Convalescence slow; temp, febrile; suppurated. Recovered. Discharged 
November 5, 1892. 
Case 93.-October 10, 1892. Miss R., aged twenty-eight years; single ; 
condition fair; double pyosalpinx. Removal of both uterine appendages; 
time thirty-five minutes; drainage, one day. Convalescence uninterrupted; 
temp, afebrile; primary union. Recovered. Discharged November 22, 1892. 
Case 94.-October 21, 1892. Miss E., aged twenty-six years ; single ; con- 
dition fair; ventral hernia. Abdominal section, excision of ring, buried 
silkworm-gut sutures; time forty-five minutes; drainage, none. Conva- 
lescence uninterrupted ; temp, afebrile ; primary union. Recovered. Dis- 
charged November 22, 1892. 
Case 95.-October 27, 1892. Mrs. B., aged thirty-three years; married; 
one pregnancy ; condition fair; small fibroid, right ovarian cyst, left ovaritis. 
Removal of both uterine appendages ; time thirty-five minutes; drainage, 
none. Convalescence uninterrupted; temp, afebrile; primary union. Re- 
covered. Discharged November 27, 1892. 
Case 96.-October 27, 1892. Mrs. H., aged twenty-four years; married; 
two pregnancies ; condition fair; ventral hernia. Herniotomy ; time forty 
minutes; drainage, none. Convalescence uninterrupted; temp, afebrile; 
primary union. Recovered. Discharged November 30, 1892. 
Case 97.-November 3, 1892. Mrs. DeM., aged twenty-eight years; mar- 24 
CERTAIN PROBLEMS IN ABDOMINAL SURGERY. 
ried ; three pregnancies; condition worn; right ovaritis and salpingitis, reflex 
dyspepsia. Removal of right tube and ovary; time thirty-five minutes; 
drainage, none. Convalescence uninterrupted ; temp, afebrile; primary 
union. Recovered. Discharged December 22, 1892. 
Case 98.-November 10, 1892. Mrs. G., aged forty-five years; married; 
three pregnancies ; condition worn; chronic ovaritis and salpingitis, chronic 
invalidism. Removal of both uterine appendages; time thirty minutes ; 
drainage, none. Convalescence uninterrupted; temp, afebrile; primary 
union. Recovered. Discharged December 7, 1892. 
Case 99.-November 10, 1892. Mrs. H., aged thirty-five years; married ; 
nullipara; condition worn; double pyosalpinx. Removal of both uterine 
appendages; time forty-five minutes; drainage, one day. Suppuration of 
pelvis after first week; temp, febrile; primary union. Recovered. Dis- 
charged December 13, 1892. 
Case 100.-December 6, 1892. Miss Q., aged twenty-five years; single; 
condition good; double pyosalpinx, abscess of both ovaries, universal adhe- 
sions. Removal of both uterine appendages; drainage, seventeen days. 
Suppuration in pelvis; temp, febrile. Recovered. Discharged February 2, 
1893.