ABDOMINAL and pelvic tumours connected with the female organs of generation be classified in the following may

manner:

OVARIAN TUMOURS

Simple and multilocular cysts-of follicular origin.

Proliferous cysts of epithelial origin. Sarcomatous tumours of connectivetissue origin.

Fibrous tumours-of fibre-cell origin. Hypertrophy-excess of growth of some or all of the tissues.

Malignant tumours-degeneration of one or all of the tissues.

EXTRA-OVARIAN TUMOURS

Cysts of parovarium-of epithelial or tubular origin.

Cysts of broad ligament-origin, connective-tissue cells or ova.

Cysts of Fallopian tubes-origin, ova, epithelium tissues; by occlusion.

Cysts of subperitoneal tissues-con

nective-tissue cells.

subject to as many deviations from natural growth and action, as any other cell structure. Each series of cells may go wrong separately; a few series of cells may go wrong together and entrain the rest, or the whole may go wrong at the same time. It is easy to understand how, by continued development, from a diseased reproductive cell we may have a simple or multilocular cyst; from endothelium, a papilloma; from a group of connective tissue cells, a sarcoma; from fibre cells, a fibroma; and with partial or general degeneration of the tissues, some form of malignant tumour. In the same way, we trace the origin of extra-ovarian cysts and tumours to the histological elements of the tissues in which they appear, the structural characteristics depending upon the nature of the cell point of departure.

MODES OF EXAMINATION OF THE OVARIES

Absence of the ovaries, from their

imperfect development or atrophy, may occasionally be inferred from

of ovarian follicular origin.

versal law of development. It

with a cell. The combined the primitive cell is as

ments of the ovaries requires skill and care. The ovaries may generally be felt in their normal position on either side of the uterus, a little below the brim of the pelvis, between one finger passed upwards in the vagina and another pressed downwards from the abdominal wall. It is only in cases of firm vagina, or very tense or thick abdominal wall, that the ovaries

cannot be made out.

In order that this examination may be done effectually, the patient should be made to lie on her back, with the shoulders and knees raised so as to relax the belly, and both bladder and rectum must be empty. It is only by combined internal and external examinations that a normal ovary, or one only slightly enlarged, can be detected. External examination alone is fruitless. By vaginal examination alone a resisting body may perhaps be felt through the upper part of the vault of the vagina: its mobility may be recognised, but nothing more. Sometimes the ovaries are so easily displaced that they elude internal examination alone. Yet two fingers brought together, one from without and one from within, may fix and feel the ovary between them. It is well first to find the fundus uteri and to steady it by one or two fingers, and then by the combined examination an ovary is found near the uterus, on one side of it. The finger can be passed around it, and it may be pushed from before backwards, and less easily towards and away from the side of the uterus. It has a firm elastic feel, glides easily under the fingers, and unevenness of the surface may often be detected.

A small hard mass of fæces in the bowel, a swollen pelvic gland, a cyst in the broad ligament, a dilatation of the Fallopian tube, or a small pedunculate outgrowth from the uterus might give a similar impression to the examining fingers, but after some practice this will not be mistaken for the characteristic feel of the ovary.

The right ovary is most easily reached by one or two fingers of the right hand in the vagina, the left hand being on the abdomen; the left ovary by the left hand being used for the vagina, and the right for the outside.

Examination by the rectum is in some cases more, in others less, useful than by the vagina. Occasionally, when the rec

both ovaries may be distinctly felt by the rectum and not by the vagina. In some cases, when the ovaries can be readily felt by the vagina they cannot be touched by the rectum. Even in the case where the ovary is abnormally situated in Douglas's space it may be palpable through the posterior wall of the vagina, and the fingers of the hand compressing the abdomen meet a finger in the vagina much more readily than one in the rectum. Examination both by rectum and vagina is necessary when an ovary, not enlarged, is supposed to be in Douglas's space, for Schultze has known a gland behind the rectum to be felt through the vagina and mistaken for an ovary.

It must be remembered in judging of the size of an ovary, that if small, and felt through a thick abdominal wall, it will appear to be larger than it is, and that ovaries of the same size felt through walls of different thickness may appear to be of different sizes. A little practice will be sufficient to teach what allowance should be made in face of this source of possible error.

A healthy ovary is generally insensible to moderate pressure. But touch may give pain when there is no reason to suspect inflammation or any other departure from a state of health. The diagnosis can only be made out when the swollen and painful ovary is felt as a circumscribed lump.

Schultze says he has observed that the displacement of the ovary during inflammation may rather be into Douglas's space than to the front of the uterus, and that on regaining its usual volume and sensibility it has returned to its natural position. In other cases after recovery it remains fixed; and once an ovary which had been adherent to the uterus after inflammation was months before it became again movable.

The displacements of the ovary recognised by this mode of double examination are all within the limits of the abdominal cavity; but the whole gland will sometimes find its way through the weak points of the parietes, and we have to deal with it as a form of hernia, either inguinal, crural, ischiatic, umbilical, ventral, or vaginal. Pott's case was one of simple hernia and abscission; but an ovarian cyst has formed outside the inguinal ring, and been the subject of an extra-mural

ovariotomy by a Spanish surgeon. An instance of this kind has not come under my notice, but I do not see that it can offer difficulties to the operator. any

DIAGNOSIS OF THE DIFFERENT KINDS OF OVARIAN TUMOURS AND THEIR ADHESIONS

Many of the signs and symptoms of the tumours classified in this chapter are common to the whole group. There are degrees of hardness and mobility; there are shades of force and sharpness in fluctuation; there are eccentricities of form and variations in relative position which in different cases alter the areas of resonance and dulness. But the physical signs, though often sufficient for diagnosis, are sometimes far from conclusive till we come to test the contents. With them we obtain additional evidence, and are able to declare in certain cases from what sort of cyst they are drawn. The symptoms of the tubercular and malignant tumours are a set apart.

With the cystic enlargements, simple and compound, there are from the first progressive uneasiness running on to diatress, pain from nerve pressure and stretching, irritation from local congestion, and other effects purely arising from mechanical causes. But as the tumour grows bigger and encroaches on the various organs, functions are interfered with and suspended, the lines of innervation are cut or compressed, circulation and absorption are interrupted, nutrition is arrested, and the victim dies atrophied or suffocated. The evidence from mere symptoms is all along more circumstantial than specific, and assists rather in forecasting the end than in identifying any particular kind of cyst.

No time of life is exempt from ovarian tumours. They are found in infancy as well as in old age, though it is seldom that the development begins late. When seen in advanced life they are generally examples of longevity of the tumour no less than of the person. The greater part of my patients have come to me between the ages of 25 and 55, and the average age on my list of 1,000 cases of completed ovariotomy is as near as may be 39. This would seem to show that the condition of the generative function has a great deal to do with the origin of the disease. What Boinet says about childless women, that 'sur 500 femmes atteintes de kystes de

It has been said that the ovary of the right side is more frequently affected than the left. This statement is rather one of impression than of assurance. Both ovaries are often found diseased at the same time in different degrees. With this evidence of sequence, and with our knowledge of the sympathetic morbid action between twin organs, no question can be made as to the rule of practice, as accepted in ophthalmic surgery, to save one by cutting out the other; while it may be as wrong to cut out a sound ovary as a healthy eye.

A long duration of the disease is exceptional. Race and type yield equally to the same etiologic influences. M'Dowell soon fell upon cases among negresses as well as whites. My list is multicolor and cosmopolitan, and, if reports may be trusted, ovariotomists are never anywhere in want of subjects.

It is

The discovery of a tumour in the abdomen is generally made by the patient herself. The question, What is it? is one for the surgeon. Having satisfied himself that he has an ovarian tumour to deal with, and putting aside, the tuberculous and cancerous degenerations which are indicated by the general conditions, to him the points of primary importance are its seat, solidity, and relative freedom. He has to make out, if possible, the basic origin of this tumour, and what sort of pedicle it has, on which side it is attached, and whether it be single or double. possible that there may be a cyst of both ovaries. This I saw for the first time in a young lady whom I attended with Dr. Priestley. There was a distinct sulcus between the two cysts near the median line, and it became a question whether this was owing to disease on both sides or to the peculiar shape of a cyst on one side. It was supposed that the latter opinion was more probably true, because the catamenia were regular; but at the operation two free simple ovarian cysts were removed without difficulty. In one case the appearance leading to suspicion of both ovaries being diseased, depended on a deep sulcus in the cyst caused by the rotation of the tumour and the pull on the Fallopian tube. If the resonance of

between two cysts, the probability of disease on both sides is strong.

The next questions are, whether the tumour is cystic or solid, or whether it is free or adherent; and if adherent, whether the adhesions are of such a character that they may be separated without risk, or so extensive and intimate that separation would be almost certainly fatal. On their solution depends the decision whether tapping should or should not be recommended; whether drainage should be tried, or whether ovariotomy would be the best practice; whether this operation could be done with more or less than the average chances of a good result; or whether the difficulties would be so great that it should not be attempted, even if the patient were herself anxious thereby to escape from her sufferings whatever the risk might be.

Solid tumours of the ovary are excessively rare. In two of the cases which I have seen, the tumours were surrounded by fluid in the peritoneal cavity, and it was only after removal of this fluid that the size and consistence of the body could be made out. Solid portions of large tumours which fluctuate in other parts are common enough, but general hardness and irregularity of form, with nodular masses cartilaginous or bony to the touch, almost indicate the dermoid character of the growth, especially in a fair and young patient.

When by internal and external examinations the outline of the tumour can be traced smooth and elastic over its whole extent, when the wave of fluctuation is equally perceptible in all directions and limited by the line of dulness on percussion, and the want of resonance is circumscribed, the inference is pretty clear not only that the tumour is cystic, but that it is practically unilocular.

This simple cyst, however, may be either ovarian or extra-ovarian. If in a young person it is either flaccid and of long duration, or excessively tense and of recent formation, the inference is almost equally clear that the cyst is extra-ovarian and the contents limpid. As this kind of cyst especially may be not only temporarily emptied, but emptied with some probability that the fluid will not collect again, it is interesting to ascertain if possible whether it is really single, or whether there may be one large cyst with smaller ones

cepted as proof that an extra-ovarian cyst is simple: first, that it has lasted for years with little damage to the health; or secondly, that it has formed with such rapidity as to be mistaken for ascites. In the first of these two conditions the cyst is generally flaccid, and there is little or no suffering beyond the inconvenience arising from its bulk. In the second, the cyst is tense, and there is the suffering which accompanies undue and sudden abdominal distension. Both are likely to be mistaken for ascites, but may be distinguished by the signs of the inclosure of the fluid in a cyst, enumerated in the next chapter.

With these simple cysts, whether of the ovary or not, the health is for some time but little affected. The first appearance is in much the same spot, the advance is similar, the form of the abdomen and the effect of change of position are not different. The fluctuation in both is limited, but to the touch the shock is not the same. It is as distinct in the one as in the other, but from the character of the fluid and the thinness of the walls in the broad-ligament cysts, the wave impression under percussion in them is more defined. Scarcely a trace of these tumours can be felt after tapping, so completely do the walls collapse. The fluid itself, in contrast with that from a true ovarian cyst, is thin, clear, odourless, and any coagulum formed by boiling is redissolved by boiling acetic acid. On this test the practitioner may mostly rely with safety, and found a reasonable hope that further proceedings will be unnecessary.

There are many cysts which, although practically unilocular, have on some part of the wall of the mother cyst, most commonly near the base, a group or groups of secondary cysts, which negative the supposition that the tumour is extra-ovarian, and the contents instead of being limpid will in many instances prove to be viscid. Multilocular cysts are sometimes as uniform in outline as simple cysts, but as a rule their surface is more or less irregular from the unequal development of their component parts; and the projection of the different compartments can be both felt and seen. These projections vary in hardness, and when the resistance of the cyst wall to pressure is considerable, when the fluctuation is limited by the divisions between the cavities, and its wave is slow

and doubtful, the probability is that the cyst wall is thick and the contents colloid. A septum must be very thin which does not intercept the wave of fluctuation, but in some cases of colloid tumours, where the septa are imperfect, the impulse of the percussed fluid is almost as distinct and instantaneous as in a true unilocular cyst.

Boinet believes that the colour and consistence of the contents of multilocular cysts may be predicted before tapping. The progress of the disease, the signs of inflammation more or less acute and repeated, and the state of the health, will be sufficient to indicate if the contents are serous or purulent, and what their colour may probably be. When abdominal pains have been frequent, and the abdomen is tender on pressure, it is probable that, whether the cyst is unilocular or multilocular, the contents will be sero-sanguinolent. When the temperature ranges from 100° or 101° in the morning to 103° or 104° at night, and emaciation is progressive, appetite lost, thirst troublesome, sleep disturbed, nausea or vomiting distressing, and the abdomen tender on pressure, with hurried pulse and respiration, it is probable that one or more of the cysts may contain pus; and that, when these symptoms are present in an extreme degree, or have lasted for a considerable period, the pus has become fetid. Blood may be found in one or more of the cysts, either as an immediate result of twisting of the pedicle, or as a more slow and gradual oozing from degenerative changes.

When any considerable amount of blood has been poured into the cavity of an ovarian cyst, all the well-known signs of internal hæmorrhage are observed. I have twice seen sudden death occur in this way. In one case five pounds of blood and clot were removed from the cyst into which they had been suddenly poured from a large vein. In the second case the blood passed into the peritoneal cavity. Another patient died, but not immediately, of bleeding through the Fallopian tube and uterus from a large cyst of the left

Ovary.

ADHESIONS

In the early days of ovariotomy great pains were taken to ascertain whether a tumour was free or adherent, and if extensive adhesions to the abdominal wall were believed to exist, ovariotomy was

considered to be improper or impracticable. Mr. Walne, in 1843, began his operations with a small incision just large enough to enable him to ascertain with his finger whether the cyst were free or not. Dr. Frederick Bird published a great number of cases in which he made an exploratory incision, and abandoned the operation as soon as he found that the adhesions were intimate. He was SO anxious to ascertain the presence or absence of adhesions that, even before making an exploratory incision, he used to insert needles through different parts of the abdominal walls into the cyst, believing that by watching the movements of these needles, as the patient inspired and expired, he could make out whether the cyst shifted its place beneath the abdominal wall or not. Others marked the deviations of the cannula after tapping, with the same intention and belief, only to find that all these signs were fallacious.

Before I had operated on any considerable number of cases, I began to doubt whether adhesions seriously affected the result of the operation, and on analysing the first 500 cases, arrived at certain conclusions, to be found in the fifth chapter. The experience of the second 500, and of my first 1,000, as a whole, afterwards modified these conclusions, and proves that it is a matter of some interest to know what are the signs by which a free or an adherent cyst may be recognised. To make this examination the patient should be placed in a good light, lying on her back, with the shoulders and knees somewhat raised, and the whole abdomen uncovered. By watching the abdominal movements during deep inspiration and full expiration, a free ovarian cyst may be seen, providing the abdominal wall is not too thick, moving upwards and downwards with every breath. Irregular elevations and depressions on the surface of the cyst make its free mobility perfectly manifest and indubitable; but when the surface is uniform it is only the upper border of the cyst which can be seen to move, and to avoid deception it may be necessary to ascertain by percussion how high the outline extends above the umbilicus; because the transverse colon, following the respiratory movements, may be easily mistaken for a moving cyst. A thick abdominal wall may obscure the movements of the cyst during inspiration and expiration, but it is quite easy to follow them by the varying position of the