[Reprinted from the Transactions of the Philadelphia County Medical Society.] 
ABDOMINAL SURGERY AT THE KENSINGTON 
HOSPITAL FOR WOMEN. 
CHARLES P. NOBLE, M.D., 
SURGEON IN CHAR&J^ 
[Read April 8,1891.] 
The following report embraces all cases of abdominal section done 
in the Kensington Hospital for Women during my connection with 
it. Cases of hernia, forming a special class, are excluded. The 
number of operations is eighty-five, being the work of three opera- 
tors-Drs. Kelly, Robb, and myself. As it is manifestly impossible to 
report these cases in detail, they will be given in groups, with com- 
ments on the nature of each class. And, to add to the practical 
value of the report, I will give the lessons I have learned and the 
impression I have formed from the study of these cases. 
Selection of Cases for Operation.-Certain definite princi- 
ples have been followed in the selection of cases for operation. 
Operation has been recommended in all cases of ovarian and par- 
ovarian tumors, ovarian abscess, pyosalpinx, hsemato-salpinx, and of 
hydro-salpinx unless organic disease of the vital organs clearly for- 
bade it; also in cases of fibroid tumor of the uterus in which hemor- 
rhage or pressure symptoms demanded it; also in cases of extra- 
uterine pregnancy, both before and after rupture; also in certain 
cases of simple salpingitis and ovaritis in which well-directed 
treatment, long continued, failed of relief, and in which life was made 
burdensome by the continuance of the disease. Operation has been 
refused only in cases of serious kidney disease or of advanced cancer. 
Treatment of Patient Before Operation.-Whenever prac- 
ticable, for a week prior to operation patients have been put upon 
simple food, the bowels gently purged, and the skin made clean and 
active by warm baths given daily or on alternate days. This regimen 
is considered especially important for cachectic women with sluggish 2 
NOBLE, 
emunctories. When time is precious a purge is given, and a thor- 
ough bath. As my experience grows, I become more convinced of 
the advantage of preparatory treatment entending over weeks or 
months in chronic broken-down cases. The nutrition of such cases 
should be improved in every way; and the state of their emunctories 
be carefully studied. 
In acute cases, if operation is to be done, all delay is pernicious. 
Before operation the abdomen is scrubbed with soap and water, alcohol, 
and sublimate solution 1:1000. 
Preparation for Operation.-I believe that the essentials for 
success in abdominal operations are asepsis, rapid, careful, and thor- 
ough operating, thorough irrigation in septic cases, and drainage. 
To secure asepsis an elaborate technique is faithfully followed. The 
doctrine that infection comes by contact is fully believed ; hence every- 
thing coming in contact with the patient is rendered aseptic. 
Treatment of the Hands and Arms.-The hands and arms 
of the surgeon and assistants are washed carefully through three 
waters, a good lather being made with soap, and the nail-brush vigor- 
ously applied; especial attention is given to the subungual spaces. 
Ten minutes are consumed in the process. The hands are them im- 
mersed in a saturated solution of permanganate of potassium, next 
in a saturated solution of oxalic acid to remove the permanganate, 
and, finally, in a 1 :1000 solution of corrosive sublimate, in which 
they remain three minutes. Whenever the skin about the fingers is 
chapped, or the hands have been recently exposed to septic material, 
the fingers are soaked in peroxide of hydrogen solution before the 
sublimate bath is used. 
Dressings.-Gauze is prepared by tearing cheese-cloth in squares 
of one yard, which are boiled in a solution of carbonate of sodium 
two drachms to water one gallon, for twenty minutes; then washed 
through pure boiled water four times; wrung out and soaked in sub- 
limate .solution 1 : 500 for one hour; then preserved in alcohol. 
Before use it is washed in sterilized water. 
Silk is prepared by winding Chinese silk on spools; boiling it for 
twenty minutes; soaking it for three hours in sublimate solution 
1:1000 ; and preserving it in 4 per cent, carbolized alcohol. Before 
each operation it is boiled fifteen minutes. In the future I propose 
to sterilize it in the steam sterilizer. 
Catgut is prepared by heating it in the hot-air sterilizer for four 
hours, gradually increasing the heat to 280° F. The last half-hour 3 
ABDOMINAL SURGERY. 
the heat varies from 250° F. to 280° F. It is then preserved in 
carbolized alcohol 4 per cent. 
Sponges are prepared by-beating to get rid of dust; soaking in 
hydrochloric acid one drachm to water one pint for from twelve to 
twenty-four hours; washing through twelve to sixteen waters, until 
the water ceases to look yellow; soaking in sublimate solution 1:1000 
for twelve hours; when they are transferred to carbolic acid solution, 
4 per cent., for preservation. Varying qualities of sponges are used, 
from the reef sponge to the potter's sponge, the cost varying from 
one to fifty cents each. The coarse sponges are bleached by " White's 
method " before they are washed. Before using them, sponges are 
washed in boiled water, and are used but once. By exercising some 
care the average cost for sponges for each operation will not exceed 
fifteen cents. In comparison with the assurance of always having 
aseptic sponges this is nothing. 
Instruments are kept aseptic. Before each operation they are 
sterilized in an Arnold's steam sterilizer for an hour. Formerly a 
Rohrbeck's dry hot-air oven was used, temperature 250° F. to 300° F., 
for two hours.' This heat spoils the temper of steel instruments. 
After a clean operation the instruments are thoroughly washed and 
scalded, special attention being paid to the French joints and irregu- 
larities. After a septic operation the instruments are sterilized, after 
washing, for one hour, then dried and put away. 
Basins and trays before operation are thoroughly washed with 
soap and water, scalded, and washed with sublimate solution. They 
are then filled with boiling water. After operation the same process 
is repeated, and after septic operations they soak over night in sub- 
limate solution. 
Towels used about the patient have been preserved in 4 per cent, 
carbolic acid solution, or have been freshly sterilized with steam. 
The Nurse.-The nurse for the operation is kept away from 
septic cases, should such be in the hospital. She has a bath and a 
fresh suit before entering the room. 
The Operating-room.-Formerly, when the hospital had no 
operating-room, the room selected was scrubbed and aired for twenty- 
four hours. Then the woodwork was wiped with sublimate solution 
1:1000. All tables were likewise wiped with sublimate solution. 
Now, with a model operating-room, having tiled floor and walls, 
abundant light and special ventilation, the walls are wiped, and the 
floor scrubbed and flushed with water, which runs into an open roof- 
spout; thus obviating a sewer connection. After foul operations 4 
NOBLE-, 
sublimate solution will be used. Every facility for obtaining and 
maintaining cleanliness and asepsis is afforded by the apparatus in 
the room. Wash-basins with an abundance of running water for washing 
the hands, and instruments and basins, are very convenient. The 
room, when in use, is protected against sewer-gas by the best modern 
plumbing used throughout the building; while the waste-pipe leading 
from the operating-room is doubly ventilated. Further protection is 
afforded by the modern traps. Between operating days the waste- 
pipe from the operating-room is shut off from the sewer by an air-tight 
valve. Thus a maximum protection is afforded against septic hands, 
instruments and appliances, with a minimum danger of atmospheric 
pollution. Clean water is obtained by the use of the Pasteur filter; 
and this is sterilized in a jacketed kettle heated by steam from the 
boiler. In this way an abundance of sterilized water is assured. 
The room is warmed with steam by the system of indirect radia- 
tion, and is ventilated by a warm ventilating flue. The temperature 
is kept at 75° F. 
Operation. Anaesthetic.-Ether was used formerly for all cases. 
Various bad results have made me believe that chloroform is a better 
anaesthetic for the abdominal surgeon. At the present time I do not 
use ether in old women, nor when bronchitis, nephritis, or organic 
heart disease exists. I have found cachectic subjects, " wrecks," and 
fat women to take ether badly. The anaesthetic is given late, so that 
the operator waits for the patient rather than the patient for the 
operator. I believe anaesthesia in itself to be dangerous, and that the 
danger increases with the duration of the anaesthesia. The Allis 
inhaler is used for ether; the Esmarch inhaler for chloroform. From 
ether I have had " collapse " once; pneumonia once; bronchitis 
twice; uraemia and death twice. From chloroform, "collapse" 
once; uraemia and death once. 
Technique of Operation.-The technique employed is not pecu- 
liar. I believe in rapid, careful, and thorough work. This is shown 
by the fact that only two exploratory operations are found in the list. 
No chemical antiseptics are used during operation. The instru- 
ments and sponges are kept in sterilized water. 
Toilet of Peritoneum.-In non-septic cases, such as simple ovarian 
tumors, the peritoneum is simply sponged dry before closing the 
wound. In these cases the aseptic technique employed completely 
fills every scientific requirement. No sepsis is in the peritoneum 
before operation; none is introduced during operation; hence none is 
present after operation. ABDOMINAL SURGERY. 
5 
In septic operations, including pus accumulations, hsemato- and 
hydro-salpinx, more or less irrigation is used. If the presence of 
sepsis be doubtful, as, for instance, from the escape of some fluid from 
a hydro-salpinx, water is poured into the pelvis, and it is sponged 
dry. If septic matter has escaped into the pelvis in small amount, 
the pelvis is irrigated with sterilized water by means of the Davidson 
syringe-care being taken to protect the general peritoneal cavity. 
When large amounts of septic material are to be removed, I use the 
" flusher " and irrigate the entire peritoneum with gallons of water. 
This process requires time, and entails shock. I do not like it alto- 
gether, yet know of no substitute. In septic cases the scientific 
requirements are not met by an aseptic technique. The flusher may 
disseminate the septic matter throughout the peritoneal cavity. 
Moreover, when plain sterilized water is used, septic foci in the belly 
are not disinfected. Yet, practically, the results obtained in such 
cases by asepsis with free irrigation and drainage are much better 
than by the use of chemical solutions to disinfect the peritoneal 
cavity. Hence, until some disinfectant is discovered which will kill 
germs without irritating the peritoneum, the present plan must be 
adhered to. I only use sublimate solution in the belly to disinfect a 
limited area, such as a pedicle. It should be used on a sponge spar- 
ingly. The peroxide of hydrogen may prove useful for this purpose. 
Ligatures and Sutures.-In abdominal surgery aseptic silk is the 
best material for ligatures and sutures. 
Drainage.-Drainage is necessary for safety in all cases having 
dense adhesions; and I believe it is always of advantage. I use it in 
almost every case. When the drainage-tube is properly cared for, I 
believe that there is no objection which can be urged against it. The 
plea that it favors hernia is apparently an objection; but it only 
favors hernia when left in a long time, and it is only left in a long 
time in cases in which there is excessive drainage; cases which would 
frequently die without it. Such women should be glad to have a 
hernia-it is hernia or death. Of the 85 cases reported, 77 were 
drained, and 8 were not drained. 
Dressing.-After the incision is sutured the abdominal wall is 
washed with sublimate solution, and a wet sublimate gauze dressing is 
applied. A layer of cotton is applied over this; and the whole is 
held in position by a Scultetus bandage. The drainage-tube is 
buried in the cotton, and the bandage is.applied over all. Rubber- 
dam is used about the tube only in cases in which an excessive flow 
is expected. 6 
NOBLE, 
During the operation the patient's legs are wrapped in a blanket, 
and her underclothing is protected by covering with towels. The use 
of the Kelly pad to drain away all fluid is, also, of the greatest assist- 
ance in keeping the clothing dry. After opeiation the patient is 
put in a bed which has been warmed with hot-water cans. The cans 
remain ; care being taken to avoid burning the patient. 
Shock and Collapse.-One patient has " collapsed " from ether, 
and one from chloroform. There was distinct paralysis of respiration 
in each case. The collapse from chloroform was the more profound. 
The lower end of the table wTas elevated immediately; the chin 
drawn forward; artificial respiration by Sylvester's method kept up ; 
and hypodermics of strychnia solution and tincture of digitalis given. 
In the chloroform case, in addition, ether and brandy were given 
hypodermically, and the faradic current was used over the phrenic 
nerve. These methods were used in the order in which I estimate 
their value. I may say that drawing' the chin forward is not 
Howard's method. It has been used in Baltimore for many years, 
and was in constant use from 1882 to 1884. For shock on the 
operating-table strychnia and digitalis have been used; at times 
whiskey. Careful anaesthesia and quick operation are the best 
preventives. 
After-treatment.-In the majority of cases this is simple. 
Nothing is given for twenty-four hours. One drachm of water every 
half-hour is given the second day. Two to four times this amount is 
given the third day, with milk and lime-water of each one drachm, or 
two drachms of beef-tea, every half-hour. These amounts are rapidly 
increased, and the frequency of administration decreased. On the 
sixth day liquid diet practically ad libitum is given, and about the 
eighth day soft diet. The bowels are moved early, especially if there 
is much pain or any fever. Most pain after section comes from 
flatus. The bowels are moved, preferably by enema, or by calomel 
in broken doses, or by citrate of magnesia solution. As an enema 
the following is employed : 
B.-Magnesii sulph ^ij. 
Glycerini ^i. 
01. terebinth. 5ss. 
Aquae q. s. ad giv.-M. 
This is a very satisfactory formula. 
The tube is attended to by myself. It is drained two or three 
times in twenty-four hours; oftener if the drainage is excessive, or if ABDOMINAL SURGERY. 
7 
bleeding is going on. Sterilized cotton is seized by the tube-forceps 
and passed down the tube. In this way all fluid is removed. Then 
a rope of gauze is passed down the tube, and the cotton and bandage 
reapplied. Each time before cleaning the tube the hands are scrubbed, 
and if septic cases are being handled, a sublimate bath is used. 
The tube is removed early ; usually on the second day. It is re- 
moved as soon as the drainage is straw-colored and does not run up 
the gauze into the cotton. After removing it the provisional stitch, 
which has been placed during the operation, is tied. The wound is 
now dusted with a powder containing one part of iodoform to seven of 
boric acid. Fresh gauze and clean cotton are now applied, and, in 
general, the wound is not looked at again until the seventh or eighth 
day, when the deep sutures are taken out and adhesive straps put on. 
This method of dressing I find perfectly satisfactory. I have had but 
one stitch-hole abcess in over a year. 
The catheter is not used if it is possible to avoid it. When neces- 
sary, a glass catheter is employed. This is taken from sublimate 
solution; the vestibule is dried with cotton ; the, catheter properly 
smeared with vaseline, is inserted ; after use it is thoroughly cleaned 
and put back in sublimate solution. Catheter cystitis is rare. 
Patients are kept on their backs for two weeks. The bed-rest is 
used after ten days. After two or three weeks they are allowed to 
get up, and are discharged, in general, after four weeks. I think it 
is best to keep section cases in bed three weeks. Fat women should 
lie fully three weeks ; they are most liable to have hernia. 
Treatment of Complicated Cases.-Shock is met by the use 
of strychnia and digitalis given hypodermically external heat and 
hot coffee, or hot beef-tea and whiskey given by enema. I do not 
like to give more than thirty minims of tincture of digitalis, nor one- 
eighth of a grain of sulphate of strychnia, within six hours. If 
shock gives way to asthenia, strychnia and digitalis are continued. 
In twenty-four hours one drachm of tincture of digitalis, and from 
| to | of a grain of strychnia, are given. For stimulation, enemas 
of beef-tea one pint, whiskey two ounces, are used. For rectal 
alimentation, the following combination is used: 
One egg. 
Milk £viii. 
Peptonize, and add whiskey 
This is given every six hours. 
I have not found rectal injections to relieve thirst. 
When fever occurs, every effort is made to move the bowels. 8 
NOBLE, 
An enema, calomel, or magnesia citrate solution is used. I have 
found the stomachs of those needing purgation too irritable to retain 
Epsom salts or Seidlitz powders. 
Morphia or opium is used scarcely at all. Cases that do well 
do not need it. A little encouragement enables them to bear the 
pain for twenty-four hours, after which time it usually is not severe. 
In very excitable women, and in cases where pain has kept up for 
several days, morphia has been given sparingly. Whether this plan 
is the best in patients that are suffering severely I am not entirely 
convinced, nor that if is best to withhold morphia in all cases, but 
have yielded to the current of modern practice. I intend to try 
phenacetin, antipyrine, chloral, and the bromides for sleeplessness, in 
cases in which the condition of the pulse does not contra-indicate 
depressants. 
Patients requiring stimulation usually have an irritable stomach; 
hence whiskey is given by enema, or champagne by the mouth. 
Less can be done by alimentation and medication after abdominal 
section than after other operations, to combat asthenia; because the 
stomach is not available, as a rule. The fate of the patient is 
decided, in general, when the operation is completed. 
Analysis of Cases.-Of the 85 cases operated on, there were of 
single 5 
double 6 
Pyosalpinx 
Chronic salpingitis and ovaritis 18 
(Of these, 10 were densely adherent.) 
Cirrhotic ovaries 5 
Tubercular peritonitis: cancer of ovaries (same patient 
operated on five times) 5 
Parovarian cysts 2 
Ovarian cysts 14 
11 
Tubal pregnancy 
unruptured 2 
ruptured 2 
4 
Retroflexion-hysterorrhaphy 4 
Hydro-salpinx 4 
Fibroid of uterus (1 myomectomy, with removal of one 
appendage; 3 removals of uterine appendages; 1 
removal of one appendage) 5 
Caesarean section 1 
Bowel adhesions 1 
Mixed cases. 
Ovarian tumors complicated by 
salpingitis 4 
pyosalpinx 4 
hydro-salpinx 1 
haemato-salpinx 2 
11 
Total 85 ABDOMINAL SURGERY. 
9 
Of these abdominal sections, 18 were done by Dr. Kelly, 7 by 
Dr. Robb, and 60 by myself. There have been 7 deaths, in my own 
cases. 
Both uterine appendages* were removed in 60 cases for ovarian 
tumors, or the various forms of salpingitis or tubal pregnancy. 
One uterine appendage was removed in 13 cases-or really in 
12 cases, for in one the other tube and ovary was removed subse- 
quently. This poor woman figures as 5 cases of tubercular perito- 
nitis and cancer of the ovaries. She will be mentioned later. Of 
the women who had but one appendage removed one has had a baby, 
and a second is pregnant. The first was operated on in extremis for 
a huge pyosalpinx and abscess of the ovary ; the other had a myo- 
mectomy and removal of one lightly adherent appendage. 
In 4 cases hysterorrhaphy was done. 
In 1 case the operation was to separate bowel adhesions resulting 
from a previous section. 
There was 1 case of Caesarean section ; a thoroughly unique case, 
which will be reported in full to the College of Physicians. 
There were two exploratory incisions. The first was made to 
determine the nature of an exudate forming after the removal of the 
appendages for fibroid of the uterus. It proved to be a cellulitis of 
the broad ligament, caused by an infected pedicle. This case and two 
similar cases suggest to me that many of the so-called haematomas 
reported by Mr. Tait are cases of infected pedicle. The other ex- 
ploratory incision was an incomplete operation, in the sense that I 
started to remove a fibroid tumor, but, finding an anomaly of the 
bladder, I desisted. The bladder was developed to within one inch 
of the umbilicus, and there was an absence of the vesico-abdominal 
pouch of the peritoneum; that is, the peritoneum simply covered the 
posterior wall of the bladder. As the bladder was three inches wide 
at its upper limit, it would have been necessary to make a lateral inci- 
sion along the outer border of the rectus muscle. To do a hyster- 
ectomy under such circumstances I felt to be unwise. 
Two operations were incomplete. The operation was made for the 
removal of both appendages. In the first case there was a chronic 
salpingitis on the right side, and a pyosalpinx and intra-peritoneal 
abscess on the left side. The right appendage and the left tube 
(pyosalpinx) were removed. The left ovary was imbedded in exu- 
date, and could not be felt. This patient is now the picture of 
blooming health, has gained thirty-five pounds, and menstruates regu- 
larly without pain. 10 
NOBLE, 
The other case was one of defective development of the sexual 
organs ; having, in addition, hydro- and hmmato-salpinx. On opera- 
tion the left ovary was not removed, because it was apparently 
imbedded in the broad ligament near the pelvic wall. To have re- 
moved it would have required violence to tear it from its bed. As 
the operation had been prolonged, I did not think it wise to take the 
time necessary to control free bleeding from a ruptured ovarian 
artery. The woman has not menstruated-which fact shows the 
functional condition of the ovary. 
One broad-ligament cyst was removed from a woman who some 
years before had had the appendages removed for pyosalpinx. The 
exciting cause of the cyst was an infected pedicle. 
Two cases were simple sections for the evacuation of fluid in a case 
of tubercular peritonitis with cancer of the ovaries. 
The case last referred to deserves special notice. She had had 
both breasts removed and axillas cleared out some years ago for 
cancer. Five operations were performed for the primary and secondary 
growths. While my patient, there were a number of nodules about 
the thorax, which were quiescent. She had six abdominal sections ; 
one before the time covered by this report. Four times the fluid was 
removed, and twice in addition one uterine appendage was removed. 
After each operation she filled less rapidly than before. The perito- 
neum was everywhere studded with miliary bodies, supposed to be 
tubercles. The appendages wrere supposed to be tubercular, but 
microscopic examination demonstrated carcinoma. She died eleven 
days after the last section. The autopsy showed cancer of the 
stomach, duodenum, and liver. It was noticed at the last section 
that the tubercular peritonitis was undergoing a cure. The tubercles 
had disappeared, leaving the peritoneum thick and opaque. At the 
autopsy it was noted that the tubercles had disappeared in the pelvis 
and lower abdomen, but that in the upper abdomen they were still 
abundant. 
This fact suggests the query as to whether there is a relation 
between tubercle and cancer in the abdomen; and, again, were the 
miliary bodies really tubercular? Vomiting had been constant for 
nearly two months before the last operation. No pain was complained 
of, and the vomit was not bloody. It was attributed to the presence 
of the accumulating fluid. After operation the vomiting continued, 
everything being rejected. Death occurred from exhaustion on the 
eleventh day. This death is not included in the seven as a death 
from abdominal section, as the operation had nothing to do with it. ABDOMINAL SURGERY. 
11 
Deaths.-Three deaths occurred from suppression of urine. In 
one case albumin was found in the urine, and chloroform was given. 
Death after two days. This woman was a "wreck." She had adhe- 
rent appendages and an intra-ligamentous ovarian tumor adherent to 
the right ureter. The ureter was dissected away from the tumor and 
dropped. Operation was difficult. Autopsy showed right surgical 
kidney and left contracted kidney; no peritonitis. 
In the second case no albumin was found in the urine. Ether was 
given. Operation: Difficult enucleation of appendages imbedded in 
exudate. Death resulted on the fifth day from uraemia. Autopsy showed 
contracted kidneys; no peritonitis. This woman figured in the news- 
papers as having escaped from the hospital in her gown while 
delirious. In jumping from a low second-story window she fractured 
her olecranon, but otherwise I was unable to find any injury. She 
had been sick many years. The third case was a " wreck," having 
been an invalid several years. No albumin was found in the urine. 
Ether was given. An ovarian and a parovarian tumor were removed; 
rapid, simple operation. Death after three days from uraemia. 
Autopsy showed contracted kidneys; no peritonitis. 
These cases taught me the necessity of having the urine examined 
microscopically-even repeatedly in the cases having arterio-capillary 
fibrosis. With the knowledge of the kidney disease I would not 
operate now on such cases as the first and second. Women with con- 
tracted kidneys will not stand difficult operations. In such a case as 
the third I would try in every way to improve nutrition and to assist 
the kidneys, and then operate under chloroform. 
One death occurred on the third day from intestinal obstruction. 
At the autopsy it was found that an organic stricture of the colon 
existed, which had resulted from a long-standing adhesion of the colon 
to the broad ligament. 
Two deaths occurred from peritonitis-one on the fifth day from 
septic peritonitis, after the removal of double hydro-salpinx. The 
drainage-tube was used, but it did not empty the pelvis. This death 
is the only one after operation in my experience in which death would 
not have occurred without operation. 
The other occurred on the second day after the removal of double 
pyosalpinx and a right ovarian tumor. Free irrigation and drainage. 
Peritonitis developed the first day. The abdomen was again opened 
and flushed. Death within forty-eight hours. These are the only 
deaths which have occurred in my practice, except after the gravest 12 
NOBLE, 
operations, or when the patients have been extremely prostrated by 
acute or chronic disease. Both of these women were feeble. 
One death occurred thirty-six hours after operation for ruptured 
tubal pregnancy. The abdomen was full of blood. Fever shortly 
developed, and the patient died within thirty-six hours in hyper- 
pyrexia. This death was attributed to sepsis, but I do not feel clear 
as to its cause. It was more probably due to acute anaemia. 
Results.-After all, the important question is, What good was 
accomplished by these operations ? It is gratifying to be able to say 
that the results have been good. I do not know a single patient who 
is not distinctly better than before operation. Because of the fact 
that all these patients are not under under my care at present it is 
not possible to give the exact percentage of those cured, improved, 
etc. Many become immediately and permanently cured after con- 
valescence from the operation. More are improved after operation, 
and their cure is delayed six or more months. Some will never be 
well women, although the operation accomplished all that was ex- 
pected. The menopause with its nervous manifestations annoys some 
patients, but in none have serious symptoms been found. 
Finally, those patients became well quickly who were operated on 
early, before the general health and nutrition were impaired. The 
operation removed all disease. Depending upon the chronicity of the 
disease and the local complications, and upon the impairment of the 
general health, the restoration to health has been rapid or slow. The 
" wrecks " have improved, but none of them are robust women. The 
question of prompt, early operation for grave pelvic disease is now 
the most important one in gynecology, and results can only improve 
when the profession becomes convinced of this fact, and women are 
sent to the gynecologist while it is yet possible to cure them.1 
1 The technique employed is based on that introduced by Dr. Kelly. I am under 
many obligations to him, and to Drs. Robb and Boyd, for advice and assistance. ABDOMINAL SURGERY. 
13 
No. 
Name, and 
date of 
operation. 
Age 
Disease. 
Operation. 
Drainage 
Result. 
Operator. 
1 
Mrs. McG., 
Jane 8,1889 
30 
Pyosalpinx. 
Abdominal sec- 
tion ; removal of 
uterine append- 
ages. 
1^ days 
Recovered. 
Dr. H. A. Kelly. 
2 
Mrs. H., 
June 24 
27 
Double pyosal- 
pinx. 
Removal of uterine 
appendages. 
36 hours 
Recovered. 
Dr. H. Robb. 
3 
Mrs. S., 
July 5 
18 
Large cirrhotic 
ovaries. 
Removal of uterine 
appendages. 
10 hours 
Recovered. 
Dr. H. Robb. 
4 
Miss E., 
July 24 
23 
Double pyosal- 
pinx. 
Removal of uterine 
appendages. 
2% days 
Recovered. 
Dr. H Robb. 
5 
Mrs. N., 
July 29 
23 
Salpingitis and 
ovaritis. 
Removal of uterine 
appendages. 
None 
Recovered. 
Dr. H. Robb. 
6 
Mrs. 0., 
July 31 
40 
Tuberculous peri- 
tonitis. 
Abdominal section. 
12 hours 
Recovered. 
Dr. H. Robb. 
7 
Mrs. K., 
Aug. 5 
30 
Salpingitis and 
ovaritis. 
Removal of uterine 
appendages. 
12 hours 
Recovered. 
Dr. H. Robb. 
8 
Mrs. J., 
Aug. 14 
31 
Cirrhotic ovaries. 
Removal of uterine 
appendages. 
None 
Recovered. 
Dr. H. Robb. 
9 
Mrs. X., 
Aug. 19 
36 
left, pyosalpinx; 
right,salpingitis. 
Removal of uterine 
appendages. 
48 hours 
Recovered. 
(Stitch-hole 
abscess.) 
Dr. C. P. Noble. 
10 
Mrs. J., 
Aug. 22 
20 
Double salpin- 
gitis ; cheesy 
tubes; dense 
adhesions. 
Removal of uterine 
appendages. 
24 hours 
Recovered. 
(Sinus.) 
Dr. C. P. froble. 
11 
Mrs. P., 
Sept. 10 
30 
Pyosalpinx, 
double. 
Removal of uterine 
appendages. 
Yes 
Recovered. 
Dr. H. A. Kelly. 
12 
Mrs. W., 
Sept. 12 
31 
Parovarian. 
Removal of one 
appendage. 
None 
Recovered. 
Dr. H. A. Kelly. 
13 
Mrs. G., 
Sept. 23 
27 
Left tubal preg- 
nancy ; right 
ovarian cyst. 
Removal of ap- 
pendages. 
48 hours 
Recovered. 
Dr. C. P. Noble. 
14 
Mrs. S.( 
Sept. 26 
39 
Ovarian cyst. 
Removal of ap- 
pendages. 
36 hours 
Recovered. 
Dr. C. P. Noble. 
15 
Mrs. B., 
Oct. 14, 
26 
Ovaritis; varico- 
cele of broad 
ligament. 
Removal of ap- 
pendages. 
None 
Recovered 
Dr. C. P. Noble. 
16 
Mrs. M., 
Oct. 19 
43 
Retroflexion. 
Hysterorrhaphy. 
None 
Recovered. 
Dr. H. A. Kelly. 
17 
Mrs. C., 
Oct. 24 
40 
Pyosalpinx; 
intra-peritoneal 
abscess. 
Removal of ap- 
pendages. 
33 hours 
Recovered. 
(Sinus.) 
Dr. C. P. Noble. 
18 
Mrs. L., 
Oct. 26 
30 
Gonorrhoeal sal- 
pingitis. 
Removal of ap- 
pendages. 
29 hours 
Recovered. 
Dr. C. P. Noble. 
19 
Mrs H., 
Nov. 30 
33 
Hydrosalpinx. 
Removal of ap- 
pendages. 
3 days 
Recovered. 
Dr. H. A. Kelly. 
20 
Mrs. P-., 
Jan. 3, 1890 
23 
Pyosalpinx and 
abscess of ovary. 
Removal of one 
uterine appendage. 
48 hours 
Recovered. 
Dr. 0. P. Noble. 
21 
Mrs. 0., 
Jan. 4 
28 
Ovarian tumor. 
Removal of uterine 
appendages. 
48 hours 
Recovered. 
Dr. H. A. Kelly; 
22 
Mrs. 0., 
Jan. 28 
35 
Fibroid of uterus. 
Removal of left 
uterine appendage; 
right, inaccessible. 
48 hours 
Recovered. 
Dr. C. P. Noble. 
23 
Mrs. J., 
Jan. 30 
29 
Double pyosal- 
pinx ; abscess of 
left ovary. 
Removal of both 
appendages; % 
pint of pus. 
72 hours 
Recovered. 
Dr. C. P. Noble. 
24 
Miss 0., 
Feb. 1 
22 
Retroflexion. 
Hysterorrhaphy. 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
25 
Mrs. S., 
Feb. 1 
28 
Ovarian tumor on 
right side; cystic 
ovary on left. 
Removal of uterine 
appendages. 
5 days 
Recovered. 
Dr. H. A. Kelly. 
26 
Mrs. 0., 
Feb. 4 
28 
Salpingitis and 
cystic ovaries. 
Removal of ap- 
pendages. 
16 days 
Hemor- 
rhage. 
Recovered. 
Dr. C. P. Noble. 
27 
Miss B., 
Feb. 8 
19 
Dermoid cyst of 
left ovary. 
Removal of left 
appendage; very 
dense adhesions. 
22 days 
Recovered.1 
Dr. C. P. Noble. 
28 
Mrs. Y., 
Feb. 27 
40 
Ovarian tumor on 
right side; sal- 
pingitis on left. 
Removal of tumor 
and appendage 
on left side. 
58 hours 
Recovered. 
Dr. C. P. Noble. 
29 
Mrs. S., 
March 1 
32 
Salpingitis, 
double. 
Removal of uterine 
appendages. 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
1 Fecal fistula discovered after 48 hours. After third week fecal fistula closed, and after eight weeks 
sinus entirely closed up. 14 
NOBLE, 
No. 
Name, and 
date of 
operation. 
Age 
Disease. 
Operation. 
Drainage 
Result. 
Operator. 
30 
Mrs. R., 
March 7 
29 
Right, intraliga- 
mentary ovarian 
cyst adherent to 
ureter; left,tube 
and ovary ad- 
herent ; chronic 
nephritis. 
Removal of uterine 
appendages ; 
chloroform. 
Yes 
Death 3d 
day. Sup- 
pression of 
urine after 
24 hours. 
Post-mort. 
Dr. C. P. Noble. 
31 
Mrs. Z., 
March 13 
31 
Double hydrosal- 
pinx, size of 
orange, on right 
side. 
Removal of uterine 
appendages. 
Yes 
Death third 
day from 
intestinal 
obstruction 
coming on 
after 24 hrs. 
Organic 
stricture of 
colon. 
Post-mort. 
Dr. C. P. Noble. 
32 
Mrs. MeV., 
March 15 
42 
Retroflexion of 
uterus. 
Hysterorrhaphy. 
None 
Recovered. 
Dr. H. A. Kelly. 
33 
* 
Mrs. N., 
■March 20 
28 
Unruptured tubal 
pregnancy on 
right side ; sal- 
pingitis on left. 
Removal of preg- 
nant tube and 
ovary, also left 
appendage. 
48 hours 
Recovered. 
Dr. C. P. Noble. 
34 
Miss V., 
March 29 
21 
Ovarian cyst on 
right side. 
Removal of right 
uterine appendage 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
35 
Mrs. X., 
April 3 
24 
Cystic degenera- 
tion of ovaries; 
double salpin- 
gitis. 
Removal of uterine 
appendages. 
50 hours 
Recovered. 
Dr. C. P. Noble. 
36 
Mrs. 0., 
April 5 
40 
Tuberculosis peri- 
tonei ; cancer of 
ovaries. 
Evacuation of fluid 
and removal of 
left uterine ap- 
pendage. 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
37 
Miss R., 
April 7 
23 
Gonorrhoeal sal- 
pingitis. 
Removal of uterine 
appendages. 
36 hours 
Recovered. 
Dr. C. P. Noble. 
38 
Mrs. X., 
April 12 
30 
Salpingitis with 
extensive adhe- 
Removal of uterine 
appendages. 
77 hours 
Recovered. 
Dr. C. P. Noble. 
39 
Mrs. McC., 
April 12 
sions. 
Myoma uteri. 
Myomectomy; re- 
moval of right 
ovary and tube 
Yes 
Recovered. 
Dr. H. A. Kelly. 
40 
Miss C., 
April 12 
30 
Large cystic ova- 
ries ; menstrual 
epilepsy. 
Removal of uterine 
appendages. 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
41 
Mrs. J., 
April 15 
44 
Fibroid of uterus 
and double sal- 
pingitis. 
Removal of uterine 
appendages. 
50 hours 
Recovered. 
Dr. C. P. Noble. 
42 
Mrs. R., 
April 15 
33 
Salpingitis with 
adhesions. 
Removal of ap- 
pendages ; right 
tube rudiment- 
ary with ovary 
separated from 
pelvis and at- 
tached to omen- 
tum. 
67 hours 
Recovered. 
Dr. C. P. Noble. 
43 
Mrs. W., 
April 19 
39 
Intraligamentous 
cyst right side. 
Removal of cyst. 
48 hours 
Recovered. 
Dr. H. A. Kelly. 
44 
Miss J., 
April 19 
23 
Double ovarian 
tumor. 
Removal of tumors; 
pedicle to right 
tumor very 
fleshy. 
72 hours 
Recovered. 
Hemorrhage 
-reopened 
belly next 
day and 
flushed ; 
sutured 
broad liga- 
ment. 
Dr. C. P. Noble. 
45 
Mrs. R., 
April 22 
27 
Small ovarian 
cyst. 
Removal of uterine 
appendages. 
48 hours 
Recovered. 
Dr. C. P. Noble. 
46 
Mrs. B., 
April 22 
20 
Double salpin- 
gitis, with ova- 
rian cyst on left 
side. 
Removal of uterine 
appendages. 
78 hours 
Recovered. 
Ether pneu- 
monia. 
Dr. C. P. Noble. ABDOMINAL SURGERY. 
15 
No. 
Name, and 
date of 
operation. 
Age 
Disease. 
Operation. 
Drainage 
Result. 
Operator. 
47 
Mrs. R., 
April 26 
29 
Dense adhesion of 
small intestines 
and rectum to 
pedicle of left 
tube and ovary 
resulting from 
operation one 
year ago. 
Adhesions broken 
up. 
55 hours 
Recovered. 
Dr. C. P. Noble. 
48 
Mrs. J., 
April 27 
28 
Pregnancy com- 
plicated by con- 
tracted pelvis. 
Caesarean section. 
None 
Recovered. 
Dr. C. P. Noble. 
49 
Miss X., 
May 3 
22 
Ovaritis; large 
left ovary. 
Removal of left 
uterine append- 
age. 
43 hours 
Recovered. 
Dr. C. P. Noble. 
50 
Mrs. M., 
May 7 
34 
Specific tubo-ova- 
rian inflamma- 
tion. 
Ether: removal of 
both tubes and 
ovaries with dif- 
ficulty. 
42 hours 
Death from 
uraemic 
poisoning. 
Post-mort.: 
chronic 
nephritis. 
Dr. C. P. Noble. 
51 
Mrs. K.( 
May 10 
37 
Double ovarian 
cyst. 
Tumors removed; 
4 gals, pus eva- 
cuated from right 
cyst; ligated 
fleshy pedicle 7 
or 8 inches wide 
30 hours 
Recovered. 
Dr C. P. Noble. 
52 
Mrs. C., 
May 13 
35 
Double hydrosal- 
pinx, with ad- 
hesions. 
Removal of uterine 
appendages. 
Yes 
Death from 
septic perito- 
nitis on fifth 
day. 
Recovered. 
Dr. C. P. Noble. 
53 
Mrs. A., 
May 31 
54 
Ruptured colloid 
cyst of right 
ovary. 
Removal of cyst 
and free colloid 
material in peri- 
toneum. 
2 weeks 
Dr. C. P. Noble. 
54 
Mrs. A., 
June 2 
40 
Extra-uterine 
pregnancy. 
Ruptured tube. 
Belly filled with 
fluid and clotted 
blood to diaph- 
ragm ; append- 
age tied off. 
Yes 
Death from 
acute sepsis 
within 36 
hours? hy- 
perpyrexia ; 
no other 
symptom. 
Dr. C. P. Noble. 
55 
Mrs. L., 
June 4 
22 
Right ovarian 
cyst; double 
pyosalpinx. 
Removal of uterine 
appendages. 
Yes 
Belly re- 
opened 
and 
flushed. 
Death from 
acute septic 
peritonitis. 
Dr. C. P. Noble. 
56 
Mrs. B., 
June 11 
27 
Double salpin- 
gitis. 
Removal of uterine 
appendages 
65 hours 
Recovered. 
Dr. C. P. Noble. 
57 
Mrs. T., 
June 19 
Salpingitis and 
extensive adhe- 
sions. 
Removal of uterine 
appendages. 
10 days 
Slight 
hemor- 
rhage. 
Recovered. 
Dr. C. P. Noble. 
58 
Mrs. W., 
Sept. 4 
40 
Ovarian tumor on 
right side; par- 
ovarian on left 
side. 
Removal of uterine 
appendages; 
ether. 
Yes 
Death from 
uraemia on 
third day. 
Post-mort.: 
contracted 
kidneys. 
Dr. C. P. Noble. 
59 
Mrs. S., 
Sept. 4 
30 
Parovarian cyst 
on left side. 
Removal of cyst. 
72 hours 
Recovered. 
Dr. C. P. Noble. 
60 
Mrs. B., 
Sept. 6 
34 
Pyosalpinx with 
ovarian cyst on 
right side ; left 
salpingitis. 
Removal of ap- 
pendages. 
10 days 
Recovered. 
Belly re- 
opened for 
peritonitis; 
flushed. 
Dr. 0. P. Noble. 
61 
Mrs. M., 
Sept. 13 
58 
Intra-ligamentous 
ovarian cyst on 
left side. 
Removal of cyst 
containing 8 qts. 
of fluid material. 
40 hours 
Recovered. 
Dr. C. P. Noble. 
62 
Miss W., 
Oct 15 
30 
Fibroid tumor. 
Removal of ap- 
pendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
63 
Mrs. Y., 
Oct. 15 
26 
Small ovarian tu- 
mor and large 
hydrosalpinx on 
.right side; hae- 
mato-salpinx on 
left. 
Removal of ap- 
pendages ; left 
ovary not re- 
moved. 
4 days 
Recovered. 
Dr. 0. P. Noble. 16 
ABDOMINAL SURGERY. 
No. 
Name, and 
date of 
operation. 
Age 
Disease. 
Operation. 
Drainage 
Result. 
Operator. 
64 
Mrs. X., 
Oct. 18 
27 
Double pyosal- 
pinx; ovarian 
tumor on right 
side. 
Removal of tumor 
and appendages. 
4 days 
2 tubes. 
Recovered. 
Dr. C. P. Noble. 
65 
Mrs. W., 
Nov. 5 
42 
Chronic invalid- 
ism ; adherent 
cirrhotic ovaries. 
Removal of appen- 
dages. 
5 days 
Recovered. 
Dr. C. P. Noble. 
66 
Miss W., 
Nov. 8 
30 
Cellulitis right 
broad ligament. 
Exploratory in- 
cision. 
Yes 
Recovered. 
Dr. C. P. Noble. 
67 
Mrs. P., 
Nov. 19 
24 
Cheesy tubes with 
cystic ovaries. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
68 
Miss 0., 
Nov. 23 
23 
Dysmenorrhoea; 
constant pelvic 
pain; cystic and 
cirrhotic ovaries; 
neurasthenia. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
69 
Mrs. X., 
Dec. 10 
30 
Double pyosal- 
pinx. 
Removal of uterine 
appendages. 
4 days 
Recovered. 
Ether bron- 
chitis. 
Dr. C. P. Noble. 
70 
Mrs. J., 
Dec. 17 
24 
Ovarian cyst and 
hsemato-salpinx 
on left side. 
Removal of left 
uterine append- 
age. 
2 days 
Recovered. 
Dr. C. P. Noble. 
71 
Mrs. 0., 
Jan. 10,1891 
37 
Double salpin- 
gitis; unruptur- 
ed tubal preg- 
nancy on left 
side. 
Removal of uterine 
appendages. 
32 hours 
Recovered. 
Dr. 0. P. Noble. 
72 
Mrs. A., 
Jan. 17 
41 
Cystic ovaries and 
chronic salpin- 
gitis. 
Removal of uterine 
appendages. 
4 weeks 
Hemor- 
rhage. 
Recovered. 
Dr. C. P. Noble. 
73 
Mrs. H., 
Jan. 17 
38 
Ovarian cyst on 
left side ; fibroid 
of uterus; mens- 
trual insanity. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
74 
Mrs. Y ., 
Jan. 22 
28 
Chronic salpin- 
gitis and ova- 
ritis ; very dense 
adhesions. 
Removal of uterine 
appendages. 
2% days 
Recovered. 
Dr. C. P. Noble. 
75 
Mrs. 0., 
Jan. 28 
42 
Tubercular peri- 
tonitis and can- 
cer of stomach. 
Evacuation of 
fluid. 
80 hours 
Recovered.1 
Dr. 0. P. Noble. 
76 
Mrs. M., 
Feb. 5 
26 
Pyosalpinx on 
right side ; sal- 
pingitis on left. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
77 
Mrs. P., 
March 11 
33 
Ovarian tumor on 
right side; sal- 
pingitis on left. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
78 
Mrs. H., 
March 11 
33 
Retroflexion; ad- 
herent append- 
Removal of uterine 
appendages 
5 days 
Recovered. 
Dr. 0. P. Noble. 
79 
Mrs. K , 
March 16 
38 
S • 
Double hydrosal- 
pinx. 
Removal of ap- 
pendages. 
4 days 
Recovered. 
Dr. C. P. Noble. 
80 
Mrs. A., 
March 16 
36 
Double hydrosal- 
pinx. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P. Noble. 
81 
Miss T., 
March 23 
17 
Fibroid of uterus. 
Exploratory sec- 
tion. 
None 
Recovered. 
Dr. C. P. Noble. 
82 
Miss S., 
March 23 
34 
Rudimentary ap- 
pendages ; neur- 
asthenia. 
Removal of uterine 
appendages. 
2 days 
Recovered. 
Dr. C. P..Noble. 
83 
Mrs. N., 
Sept.27, 1890 
34 
Ovarian cystoma 
on left side. 
Removal of one 
appendage. 
12 hours 
Recovered. 
Dr. H. A..Kelly. 
84 
Mrs. 0 , 
Sept. 27 
40 
Tuberculous peri- 
tonitis. 
Removal of right 
uterine append- 
Yes 
Recovered. 
Dr. H. A. Kelly. 
85 
Mrs. M., 
Sept. 28 
30 
Right, ovarian 
cystoma; left, 
adherent ovary 
and tube. 
age. . 
Removal of uterine 
appendages. 
Yes 
Recovered. 
Dr. H. A. Kelly. 
1 Death from exhaustion on the 11th day caused by constant vomiting excited by cancer of stomach. 
Had been vomiting for two months. Post-mortem.