Volume 4 — DISEASES OF THE GENITO-URINARY SYSTEM. (continued 10)

TREATMENT.—Like hydrocele of Nuck's canal, hydro-salpinx occasionally heals spontaneously, but more frequently it will need aspiration, together with injections of iodine or of carbolic acid. When pus is present, absorption probably never takes place, and an operation will be needed. If the symptoms are grave enough to warrant an exploratory incision, and dropsy of the tubes be discovered, both the tube and its ovary should be extirpated, for in the great majority of cases the corresponding ovary will have undergone follicular or interstitial degeneration. Unless there are very good reasons for adopting a different course, both ovaries and tubes should be removed, because the sound ovary, together with its tube, is liable to become diseased. The incision should always be abdominal, and not larger than to admit two fingers. The broad ligament is transfixed between the tube and the ovarian ligament by a double ligature and tied on either side. The operation is, in fact, analogous to that of öophorectomy. When the tubes contain pus, they are liable to become adherent to the sigmoid flexure, to the rectum, or to the small intestines, making their removal very difficult—sometimes, indeed, impossible. The separation of such adhesions requires the greatest care and delicacy.

Cysts of the Terminal Vesicle of the Oviduct.

A little bladder-like body, not larger than a pea, is often found hanging by a thread-like stalk from one of the fimbriæ of the oviduct. It is a relic of foetal life, being probably the remains of the Wolffian body, and sometimes goes by the name of the hydatid or vesicle of Morgagni. The walls are very thin and covered by peritoneum. What rôle these vesicles play in the economy is uncertain, but they have been found to undergo cystic degeneration. They rarely attain to a size larger than that of an orange, and then either remain stationary or else burst. I have met with several examples of cysts which, after reaching the above size, did not grow any larger. I have also met with one case in which, after attaining the bulk of a small apple, the cyst burst, and immediately refilled, to burst again and again at intervals of from four to six weeks.¹³ The collapse of the sac was attended each time by colicky pains, but of no great severity.

¹³ "Bursting Cysts of the Abdominal Cavity," by Wm. Goodell, Trans. Amer. Gynæcol. Soc., 1881, p. 228.

Other small cysts I have met with which either burst under the pressure of the examining finger or were designedly burst by bimanual pressure. These, I am disposed to think, were cysts of the terminal vesicle of the oviduct. These cysts are of but little surgical importance, as they rarely need operative interference. If such should arise, they are to be treated by aspiration, and if this fails by extirpation.

Solid Tumors of the Round Ligament.

These are occasionally met with, and usually on the right side. They belong to the connective-tissue group, being either myoma, fibroma, or sarcoma. They form at any point of the round ligament, and may therefore be either intra-peritoneal, intra-canalicular—that is, in the inguinal canal—or extra-peritoneal. The symptoms are those arising from pressure, and are not at all diagnostic. The only treatment of these tumors is removal, but, as their growth is very slow, they are not to be touched unless the symptoms become exacting.¹⁴

¹⁴ Medical Times and Gazette, Dec. 1, 1883.

OVARIAN TUMORS.

The morbid growths of the ovary are conveniently divided into the solid and the cystic.

The solid ones are either benign, under the form of fibroma, or malignant, being then either carcinoma or sarcoma.

Fibroid Tumor of the Ovary.

Fibroid degeneration of the ovary is so rare a form of disease as to be denied by excellent authorities, who contend that all the cases reported under that term were pedunculated uterine fibroids, which had so grown around and so involved the corresponding ovary as to be mistaken for an ovarian fibroid. Yet while such mistakes have undoubtedly been made, there can be no question that ovarian fibroid does occasionally present itself as a rare form of disease.¹⁵ Out of 155 cases of ovariotomy thus far performed by myself, I have met with 4 undoubted cases of ovarian fibroid. The tumors weighed respectively 2, 3, 4, and 15 pounds, and in each, with the exception of the first, abdominal dropsy was the prominent symptom. All but one of these cases promptly recovered.

¹⁵ Brit. Med. Journ., March 18, 1882, p. 384.

According to Francis Delafield,¹⁶ "The structure of a fibroid of the ovary resembles that of the ordinary fibroid tumors of the uterus. That is, they are composed of connective tissue and smooth muscular fibre. The tumor, therefore, is a myo-fibroma. There has been some question whether ovarian tumors ever contain smooth muscle, but the best authorities now admit that it does sometimes exist in such tumors."

¹⁶ Boston Med. and Surg. Journ., Nov. 17, 1881, p. 461.

Occasionally these tumors arise not from a general hypertrophy of the whole ovary, but from a nodule or a tumor growing in and from the stroma of the ovary. Solid ovarian fibroids are of slow growth and rarely attain a large size. When, however, they are of the geode variety, with numerous cystic cavities, they grow rapidly and may reach enormous proportions.

DIAGNOSIS.—The only other abdominal tumor for which it is very likely to be mistaken is a pedunculated fibroid tumor on the peritoneal surface of the womb, and with our present knowledge it seems impossible to tell them apart.

When they float about in ascitic fluid they often give the sign of ballottement in a very perfect manner. From carcinoma of the ovary they can generally be told by their smooth surface.

PROGNOSIS.—Fibroid tumors of the ovary grow so slowly that, like pedunculated fibroid tumors of the womb, they ordinarily do not attain a very bulky size. When the climacteric is reached they tend, like the latter, to stop growing and to undergo a calcareous degeneration. More often, however, they cause by their presence a dropsical effusion of the abdominal cavity, which has to be repeatedly drawn off; and it is for this reason that they usually have to be extirpated. They are removed precisely in the same way as an ovarian cyst, and the prognosis is equally good, but they are liable to have short and broad pedicles which need to be tied very carefully in sections.

Malignant Diseases of the Ovary.

These affections are either primary or secondary. When secondary, they follow analogous diseases of the womb or of the pelvic structures. When primary, they appear under different forms, as in other portions of the body, being either encephaloid, scirrhous, melanotic, or papillary. Colloid cancer of the ovary may be practically excluded, because it is of extreme rareness. The term colloid when applied to ovarian cysts refers more to the gluey consistency of the contained fluid than to the question of malignancy. In my experience the most common form is that of papilloma, which, however, like villous growths elsewhere, is not always malignant. I have removed papillary cysts and villous growths of the ovary, yet the subsequent history of the cases proved that the tumors were benign. The only macroscopic distinction between the benign and the malignant form which I have hitherto attempted to make is, that in the malignant form papillary growths will be found in patches upon adjacent structures, or else the womb and the broad ligaments are also involved in one cauliflower-like tumor. But Tait observes that he has had two cases of ovariotomy in which he left large masses of papilloma, fixing the womb, yet in each case these masses wholly disappeared, and the patients are both in perfect health.¹⁷

¹⁷ Diseases of the Ovaries, 4th Am. ed., p. 147.

There is, however, no question that malignancy lurks in many ovarian cystomata which present to the naked eye an innocent appearance.

The patient recovers promptly from the operation for their removal, but dies a few months later from cancer of the peritoneum or of other organs. Every ovariotomist has met with such examples. In one of my own cases, in which not the slightest sign of malignancy was apparent, the patient wholly recovered from the operation. Shortly after her convalescence an effusion took place in the right pleural cavity. The chest was tapped three times before her death, which was due to cancer of the liver and of the broad ligament at the site of the ablated ovary. In my first case of ovariotomy, one in which the clamp was used, menstruation took place regularly for several months from the cicatrix, which within a year became affected with cancer.

Both ovaries are usually involved in cysto-carcinoma, and this fact should be borne in mind in making a diagnosis. From the marvellous changes often produced progressively in the epithelial linings of ovarian cysts, by which they are transformed into tufts of villous cancer, Tait inclines to the opinion that their growth is associated with a tendency toward malignancy. He believes that tapping hastens on this degeneration, and that after an accidental rupture of such a cyst the peritoneum will be found studded with patches of papillary cancer. Hence he argues that ovarian cysts should never be tapped, and that they should be removed in the earlier stages of their existence, before these malignant transformations have taken place.¹⁸

¹⁸ Op. cit., p. 148.

DIAGNOSIS.—Since, as has been shown, this cannot always be made out, even by the eye, after the removal of the cysts, it follows that in a large proportion of cases the malignant character of the degeneration cannot be recognized. There are, however, certain symptoms pointing to malignancy which will often throw much light. These, in the order of their frequency, are—

(a) The presence of ascitic fluid or of oedema of the lower extremities when the tumor is too small to produce such pressure symptoms.

(b) General cachexia, rapid emaciation, and grave constitutional disturbance out of all proportion to the size of the tumor.

(c) The hardness and solidity of the tumor, together with its nodulous and irregular surface.

(d) The concurrent development of two ovarian growths.

(e) The retraction and burying of the cervix in the vaginal vault.

(f) Pain in stabs, starting from the groin and running down the inside of the thigh. But pain is not a trustworthy symptom, as it is often absent, especially in cysto-carcinoma, and may be caused by benign growths as well.

TREATMENT.—Whenever no doubt exists as to the malignancy of an ovarian growth, an operation looking to its removal should not be urged by the physician. On the other hand, since a positive diagnosis on this point is rarely attained, and since cancer of the ovary tends for a long time to remain localized, whenever a suspicion of malignancy exists ovariotomy should be performed early, before adhesions have been contracted with neighboring structures. In such a case I should incline to burn off the pedicle in preference to using the ligature.

In those cases in which, on account of adhesions, no operation is justifiable, palliative treatment can alone be resorted to. This comprises the removal of the ascitic fluid or the contents of the cyst by the aspirator whenever the pressure becomes uncomfortable. Symptoms should be treated, and, that of pain being the most urgent, opium will be needed up to the last in increasing doses.

Dermoid Cyst, or Piliferous Cyst of the Ovary.

A dermoid cyst is a congenital tumor having a wall composed of elements like true skin, with its appendages of hairs, sebaceous glands, etc., and contains teeth, hair, bone, cartilage, muscle, and a cheesy material very like vernix caseosa. These cysts are solitary, two never being found in the same person, and, further, they are always unilocular. They are either external or internal—that is, they affect either the surface of the body or else the cavities of the body, as "under the tongue, in the pharynx, oesophagus, cranial cavity, peritoneal cavity, lung, ovary, testis, bladder, and kidney."¹⁹ No tumors are more curious, and none are more puzzling to explain. The theories accounting for their origin are very remarkable, and are as follows: Excess of formative nisus. Parthenogenesis, or virgin birth; that is to say, imperfect imitation of transmitted fertility—a property peculiar to many insects, by which, without any renewal of fertilization, successive generations of procreating individuals start from a single ovum. Inclusion of abnormal structures, where there is a dipping in of the epiblast to meet the hypoblast during foetal life, and the pinching off of the same. Foetus in foetu—viz. the inclusion of an imperfectly developed ovum within another which matures perfectly. Hypererchesis; which means that "the ovum has in it the origin-buds of certain tissues, which under exceptional hypererchetic action may go on to the rudimental formation of these tissues without a fusion with the male germ."²⁰ According to Elsner, who has written last on this subject, and to whom I am indebted for much information, "dermoids occur externally and internally in places where the epiblast dips down to meet the hypoblast, and where by processes of grooved involution new bodies are formed, such being, first in order, the testicle and ovary, and that they are therefore all (without exception) embryonal in their first structure."

¹⁹ Elsner, Dublin Journal Medical Sciences, May, 1882, p. 380.

²⁰ Diseases of Ovaries, by L. Tait, 4th ed., p. 177.

SYMPTOMS.—These congenital tumors begin early in life, and usually remain dormant until puberty. Then the periodic congestions of menstruation usually stimulate them into growth. Sometimes they need the increased vascularization of pregnancy. They are more liable than ovarian cysts to inflammation and suppuration, but they grow much more slowly, and very rarely reach the large size of the latter. They are also very liable to contract adhesions to every structure they touch, making their extirpation very difficult and sometimes impossible. Often they create pain out of all proportion to their size. Occasionally, they break and empty their contents through fistulous communications with the intestines, bladder, or the abdominal wall. But collapse of the usually thick walls of the cyst does not take place, and a cure results far less frequently than in pelvic abscesses, which empty themselves through analogous channels. The cyst ordinarily does not lessen in size; suppuration goes on with hectic fever and exhaustion, which finally carry off the patient.

DIAGNOSIS.—Quiescent or slow-growing pelvic tumors, semi-solid to the feel, and first discovered at the age of puberty, are usually dermoid cysts. Their small size is also an aid to diagnosis, for they very rarely reach the bulk of the adult head. On several occasions I have found them in Douglas's pouch, fig-shaped and flattened in their antero-posterior diameter. From its attachments to neighboring structures a dermoid cyst is very liable to be mistaken for the cyst of an extra-uterine foetation. But the exclusion of the history of pregnancy and the slow growth of a dermoid cyst, unless suppuration has taken place, ought to distinguish the one from the other.

TREATMENT.—While quiescent the cyst should not be touched, as it is very vulnerable and liable to resent the slightest injury, even from the slender trocar of the aspirator. If suppuration takes place and the tumor points to the surface, it should be treated, like any other abscess, by a free incision, by the evacuation of its contents, by the introduction of a drainage-tube, and by the injection of antiseptic solutions. Small cysts lying in Douglas's pouch can sometimes be cured by aspiration; at least I have twice succeeded in obliterating them in this way. The operation was, however, followed by suppuration of the cyst, the abscess bursting into the vagina. If after an exploratory incision an abdominal cyst turns out to be dermoid, it should be extirpated. But if extensive adhesions preclude such an operation, the cyst should be opened, evacuated, and thoroughly cleansed. The edges of the opening should then be stitched to those of the abdominal wound and a drainage-tube put in. The after-treatment of such a case will be analogous to that of an ovarian cyst under like conditions, to which the reader is referred.

Cystic Tumors of the Ovary.

These represent by far the most frequent variety of ovarian tumors, and as such demand our best attention. They consist, in probably the majority of cases, in a dropsical enlargement of one ovisac or of more—viz. in a follicular dropsy. Indeed, as Cazeaux has aptly said, the ovisacs, or Graäfian follicles, are ovarian cysts in miniature. These cysts are divided into three classes, which depend wholly upon the number of ovisacs involved. Thus, a single, or barren, cyst, containing merely fluid, is called a monocyst or unilocular cyst. Such a cyst would be due to the dropsical enlargement of but one ovisac. It is extremely rare—so much so that its existence is denied. The probability is that a one-chambered sac does not begin as such, but it becomes so through the breaking of the walls of other contained cysts. A multiple cyst is caused by the simultaneous growth of two or more ovisacs, one of which usually takes the lead in growth and keeps the others dwarfed. This form of cyst is by far the most common. It grows with great rapidity, and may reach a weight of over one hundred pounds. I have successfully removed one weighing one hundred and twelve pounds. A proliferous cyst is a mother-cyst packed with innumerable child-cysts of varying size. These endogenous cysts multiply by exogenous and endogenous growth. The proliferous cyst rarely attains to the size of the multiple cyst, but surgically it is a solid tumor, because it cannot be emptied by tapping, and therefore often needs a long incision for its removal. It also usually possesses a very thin wall, which is liable to be torn during the needful manipulation for its removal. Racemose cysts are occasionally met with. They consist of a number of isolated cysts of varying size attached to one common stalk like a bunch of grapes. I have met with two such examples. Tait thinks that they are "produced by the retention of the ova in the Graäfian follicles, and the distension of their cavities by a continuous secretion of the liquor folliculi."

The pedicle or stalk by which an ovarian cyst is attached to the womb consists of the corresponding broad ligament, oviduct, ovarian ligament, and vessels. The pedicle is sometimes long and slender, at other times short and broad. There is one form of ovarian cyst which has no proper pedicle. It grows between the two layers of the broad ligament, and tends to develop downward into Douglas's pouch. It is called the intra-ligamentous cyst, and needs careful and tedious enucleation for its removal. Sometimes, indeed, extirpation is out of the question, and the cyst has to be treated by the drainage-tube, as will hereafter be shown.

The contents of ovarian cysts vary very greatly in color and in consistency. In monocysts the fluid is often limpid and colorless. In multiple cysts the contents are usually syrupy, thick, and turbid. Sometimes the color is quite dark, as much so as weak coffee. The surface of the fluid, after standing, will be covered with a pellicle of cholesterin crystals, which sparkle in the sunlight. In proliferous cysts the contents are usually viscid, sometimes as much so as jelly, and to this the term colloid is applied. Foulis, who is an authority on this subject, states that he has "never found that an ovarian fluid, however long kept, ever deposited a precipitate spontaneously. Whereas very frequently in the case of an ascitic fluid such a spontaneous precipitate appeared within a period varying from a few hours to a few days."²¹ Again he observes: "After ten years of observation made on fluids withdrawn by the aspirator, I found that ovarian fluids never throw down a precipitate of a fibrinous character. An ovarian fluid was always a pure cellular secretion. An ascitic fluid was always the result of obstruction to the circulation or of inflammatory action in the peritoneum, and ascitic fluids allowed to stand for a short time nearly always showed a precipitate with the character of felted material under the microscope. If they tapped the patient and subjected the fluid to this test, two or three days would suffice to tell in cases in which there was doubt. The deposit in ovarian fluids showed cellular, not fibrinous, elements under the microscope."²²

²¹ Edinburgh Medical Journal, July, 1885, p. 76.

²² Ibid., June, 1885, p. 1131.

Chemically, the contents are mucous and albuminous, the albumen being readily detected by the tests of heat and nitric acid. Microscopically, ovarian fluid is found to contain fat-globules, epithelial, granular, and pus-cells, crystals of cholesterin, blood-corpuscles, and compound granular cells, also called the inflammatory globules of Gluge.

Whether ovarian fluid contains a cell or corpuscle peculiar to itself is yet a moot question. Drysdale contends that it has a characteristic cell. He describes it as "an albuminoid body containing little fatty particles which give it a granular appearance. It resembles in some particulars many other granular cells, but can be distinguished from all other cells found in the abdominal cavity.... The principal test I employ is acetic acid. If the cell is ovarian, the acid changes it but little, perhaps rendering it only a little more transparent. But if it be a white blood-cell, a lymph-corpuscle, or any of those granular cells which resemble them, it will nearly always take on a different appearance, the cells almost vanishing perhaps, and multiple (2-5) nuclei appearing, as in the pus-cell. Then, if the cell be suspected to be fatty, degenerated, or Gluge's cell, ether may be added, by which the fatty materials will be dissolved and disappear. If no fatty degeneration be present, it is sufficient to add acetic acid."²³ Garrigues, on the other hand, contends that the ovarian fluid does not contain a characteristic cell.²⁴

²³ Trans. Amer. Gynæcol. Soc., vol. i. p. 195.

²⁴ Ibid., vol. vi. p. 54.

If I am not mistaken, the opinion of the best microscopists of Philadelphia is that the Drysdale cell, while not characteristic of ovarian fluids, is not found in any other fluid in such large numbers, and to that extent it is of diagnostic value.

CAUSATION.—In probably the very great majority of cases an ovarian cyst is a dropsy of several ovisacs, but the cause of such growths has never yet been ascertained. In the majority of cases it seems to depend upon some sexual disturbance.

Very recently the relation of the sexual condition to disease has been made the subject of scientific inquiry. From a careful examination of the registrar's tables for France, M. Bertillon shows that marriage, by giving a comparative immunity from diseases of the sexual organs, prolongs life in both sexes. This statement is confirmed by the statistics of ovarian tumor. Of Lee's 136 cases, 88 were married, 37 were unmarried, and 11 were widows. Of Sir Spencer Wells's first 500 cases, 260 were married, 221 were unmarried, and 19 were widows. Out of 155 completed cases of ovariotomy performed by myself, 91 were married, 48 were single, 16 were widows. Of the married, 24 were sterile, 10 had one child, and 26 had but two children, and several confessed to using preventive measures. Out of a total of 791 cases of ovarian tumor, there are, then, 352 without husbands to 439 with husbands. Now, when one considers how small the proportion of single women and of widows is to married women whose husbands are living, the significance of these figures goes to show that childbearing women, and especially the prolific ones, are less liable to cystic degeneration of the ovaries, and that, unless the cycle of reproduction is completed in a woman, she is plainly violating some law of her being.

SYMPTOMS.—There are no symptoms pathognomonic of this affection, for they are mainly those of pressure, and therefore belong in common to all fluid collections in the abdominal cavity. But in proportion as the abdomen swells there is a marked emaciation of the extremities. The limbs waste away, the face becomes pinched, the eyes are hollow and staring, deep wrinkles and furrows appear on the forehead and around the mouth, and the nostrils are wide open. This facial expression is termed the facies ovariana. Sometimes, when both ovaries are simultaneously affected, hair will grow on the chin and on the upper lip.

THE NATURAL HISTORY.—The natural course of an ovarian cyst is to grow rapidly, and in about two years from the time of its discovery to destroy life by exhaustion through the embarrassing pressure which it makes upon the organs of respiration, circulation, and nutrition. Malignant cysts grow more rapidly than the benign, while the latter will, on the other hand, occasionally remain for years in a state of quiescence. I have kept stationary cysts under observation for ten years, and others have been reported which lasted twenty years without change.

As a cyst develops it is very likely to contract adhesions to the organs with which it lies in contact. The most common adhesion is that of the omentum. Next to this is adhesion to the abdominal walls. Then will happen more rarely adhesions to the bowels, womb, bladder, pelvis, liver, and stomach. A loop of intestine will sometimes be found fastened to the front wall of the cyst, but usually the bowels lie packed behind the tumor.

Rupture of the cyst sometimes takes place, either spontaneously, through over-distension, or through violence, as a kick, a rude fall, or from being run over by a carriage. This accident, if the fluid happens to be bland, may be followed by a cure; but more often a violent peritonitis sets in, which carries the patient off in a few hours. From a study of 257 cases, Aronson²⁵ rates the fatality at 41 per cent.; but without question the very great majority of cases of bursting cysts of the abdomen in which this accident was followed by a cure were cysts of the parovarium, which being thin-walled are likely to burst, and which contain a bland, unirritating fluid. Bursting of the sac can be recognized by more or by less collapse and pain, by the disappearance of the cyst, and by the lessened size of the abdomen. If the patient does not at once succumb, excessive diuresis usually occurs.

²⁵ American Journal of Obstetrics, Nov., 1883, p. 1210.

It happens occasionally that the inner cyst-wall inflames, either spontaneously or in consequence of being tapped or from other injury. Suppuration then takes place, the contained fluid becomes fetid, and offensive gases are generated which give a tympanitic sound on percussion. There will be creeping chills, a red tongue, night-sweats, a frequent pulse, a general rise in the temperature with evening exacerbations: in one word, all the well-known symptoms of blood-poisoning will be present in a greater or less degree. Unless the cyst be at once removed the woman will speedily die.

Ulceration of the cyst, with perforation of its wall, may also occur. The decomposing contents will then be discharged, either into the peritoneal cavity or into any viscus to which the cyst may have contracted adhesions. In this way the purulent contents of an ovarian cyst have been discharged through the bowels, the bladder, the vagina, and even into the womb through the oviducts.

Hemorrhage within the sac is an occasional accident. When it takes place the tumor rapidly enlarges, great abdominal pain is caused by this sudden stretching, the complexion grows pale, the features become pinched; there will be collapse and all the symptoms of internal hemorrhage. If the bleeding does not stop, the patient will die in a few hours. On the other hand, if she survives the immediate danger, she is liable to succumb later to septicæmia, which arises from the decomposition of the now bloody fluid. The immediate removal of the cyst gives the woman, then, her sole chance of life.

Twisting of the pedicle of an ovarian tumor by axial rotation is another serious complication, which leads to its strangulation and gangrene, with consequent fatal peritonitis. The chief factors of this accident are, probably, the filling and emptying of the bladder and rectum, which may rotate an unadherent cyst with a long stalk. The symptoms of axial rotation, as carefully noted by Tait²⁶ and Aronson,²⁷ are sudden accession of severe abdominal pain and tenderness, a rapid increase in size, and incessant vomiting, the matter thrown up soon becoming green. The pulse rises, but the temperature is not always affected, and rigors are absent. Such a train of symptoms should lead at once to the abdominal section.

²⁶ London Obstet. Trans., vol. xxii. p. 97.

²⁷ American Journal of Obstet., Nov., 1883, p. 1211.

DIAGNOSIS.—The diagnosis of ovarian cysts is often beset with so many difficulties that very humiliating blunders have been made by the best surgeons of the day. Lizars of Edinburgh performed laparotomy on a woman in order to remove a suspected ovarian cyst, and found nothing but fat. Others have done the same thing, and to their dismay have discovered merely an accumulation of wind in the intestines. The great Dieffenbach once opened the belly of a woman for supposed extra-uterine pregnancy, and found neither fat nor wind—not even, indeed, a trace of a tumor. Once an enormously distended bag of waters broke just as a deservedly eminent British surgeon had rolled up his sleeves and was about to wheel his patient into an amphitheatre crowded with spectators to witness an ovariotomy. A surgeon of whom Great Britain can well be proud once drove his trocar into the shoulder of a foetus under the idea that he was tapping one of these cysts. These facts show the importance of knowing how to make an examination for a suspected ovarian cyst, and how to distinguish such a cyst from other tumors and other fluid collections in the abdominal cavity.

The usual history of an ovarian cyst is—a tumor first discovered in one groin, rapidly enlarging, without tenderness or soreness, giving no inconvenience save from its bulk. The general health remains good until the tumor begins to distend the abdomen; then emaciation takes place, the strength becomes impaired, and the features begin to assume that pinched expression described on a preceding page as the facies ovariana. By inspection and palpation there will be found an elastic but somewhat irregular tumor, yielding the sense of fluctuation. By percussion a dull sound will be elicited at every point, except in the flanks, which are more or less resonant. If the contents of the tumor are colloid or the tumor is thick-walled or very tense, the sense of fluctuation may be either obscure or wanting. Sometimes a feeling like that of fluctuation is conveyed by a fat-laden wall of the abdomen. To muffle this fat-thrill the ulnar edge of the hand of an assistant is laid along the linea alba while the surgeon percusses the abdomen. The pressure thus exerted acts precisely like the damper-wedge of the piano-tuner, which muffles the sound of one string while its fellow is being tuned. By these means fluctuation can be detected and the diagnosis of a collection of fluid unhesitatingly made out.

By the amount of solid and fluid portions of a cyst correct diagnosis can often be made out, whether it is simple or multiple, compound or proliferous; but this is a matter of comparatively little practical importance, because when once a growing tumor has been ascertained to be ovarian, its removal must follow as a matter of course.

There are, however, certain enlargements or tumors of the abdomen which are very liable to be mistaken for an ovarian cyst, and to these, in the order of their frequency, we shall call attention.

Ascites.—When the fluid is not encysted, but free, as in ascites, it is at liberty to go to the most dependent portions of the body. Hence changes in the posture of the woman will make corresponding changes in the level of the fluid. These level-changes are made evident by percussion. When the woman lies on her back the intestines float up to the surface, and the fluid gravitates to the flanks, making them bulge. In other words, percussion in the dorsal position elicits a clear note in the umbilical region and a dull note in each flank. In this posture the front surface of the abdomen is symmetrical and somewhat flattened. But when the woman sits up the belly becomes convex. Further, ascitic fluid is displaceable by pressure on the abdomen. But even these signs are not always trustworthy, because the intestines, glued down by adhesions, may not float up, and there will be dulness over the front of the abdomen, or a distended colon may make each flank resonant. For instance, I have known a papillary cancer of the omentum attended with dropsy of the abdominal cavity to give such signs of ovarian cyst as dulness in front and resonance in the flanks. When the fluid is ascitic the floating or false ribs are not pushed outward. The womb is usually low down and movable; there will also be more or less of bulging in Douglas's pouch.

On the other hand, in an ovarian cyst the womb is usually not very movable, and it is displaced to one side, generally behind the cyst. While the woman lies on her back the front surface of the abdomen is convex and unchanged in form. The floating ribs bulge out, making the chest conical. There will also be dulness in the front wall over the tumor, but usually more or less resonance in the flanks and over the region of the stomach: this clearness on percussion has been aptly termed coronal resonance. These areas of dulness and of resonance remain constant whatever the posture of the woman. Yet in suppurating cysts or after a careless tapping, or in cysts communicating with the intestine, the sac may contain gas, which will give a tympanitic sound over all the elevated portions of the abdominal surface.

It must, however, be borne in mind that ascites may exist concurrently with an ovarian cyst, and especially if the tumor be malignant in character. This can usually be detected by deep palpation, when the cyst will be reached and recognized by the fingers; or by pressing lightly, and then more firmly during percussion, an upper and a lower stratum of fluctuation will be detected.

Pregnancy.—The question of pregnancy is a very serious one, for it is sometimes a most difficult one to decide, especially when dropsy of the amnion (hydramnios) exists. In making a diagnosis nothing must be taken for granted, not even the woman's statement. She may be mistaken, or, indeed, she may be wilfully deceiving in the hope of having a cheap abortion induced by the examination. She may be pregnant and yet menstruate. On the other hand, an ovarian tumor will sometimes arrest menstruation. A healthy, ruddy complexion coexistent with abdominal enlargement should always excite a suspicion of pregnancy. There is sometimes a jaded look in pregnancy—the facies uterina—but never the facies ovariana.

The various signs of pregnancy should be searched for, especially ballottement and the foetal heart-sounds. The cervical region should be most carefully examined per vaginam. A good broad rule to remember is, that when the womb is gravid the cervix is as soft as one's lips; when it is empty the cervix is as hard as the tip of one's nose. In all doubtful cases any operation should be postponed until time has revealed the true condition of things. Of course the introduction of the sound will settle the question of pregnancy, but this procedure is not to be thought of when any doubt exists, and it is therefore useless as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and may have to be tapped or be extirpated before the delivery of the woman. The history of the case, the unusual size of the abdomen, the sulcus between the two tumors, will generally reveal the condition.

Fibroid Tumors of the Womb.—These tumors often reach a very large size, and if of the soft variety give an obscure sense of fluctuation which so closely resembles that of a colloid ovarian cyst or of a tense thick-walled cyst as to make the differential diagnosis very puzzling. The hard myoma gives no sense of fluctuation, but, on the other hand, if pedunculated it can be very readily taken for a solid ovarian tumor. A fibroid tumor of the womb can very generally be told by the history of menorrhagia, by its slow growth, by the uterine souffles and colics, by the effacement of the cervix, and by the tumor being felt to be continuous with the cervix and inseparable from the womb. Then, again, women burdened with a fibroid tumor so far from losing flesh usually become more fat, and their complexion, like that of many pregnant women, is mottled with patches of brown pigment. Further, the uterine cavity is usually much longer than natural, and when the tumor is moved from side to side the motion is communicated to the sound passed within the cavity. But every rule has its exceptions, for when an ovarian cyst has a close attachment to the womb the latter may become elongated and also follow the movements communicated to the tumor.

The positive diagnosis between an ovarian cyst and a fibro-cystic tumor of the womb is impossible, but, fortunately, the latter disease is exceedingly rare. The existence of the latter may be inferred if the woman's face has a jaded appearance and is disfigured by brown patches—the facies uterina—if the growth of the tumor has been very slow, and if the womb is implicated with it. After tapping there will be a partial collapse of the tumor, and the fluid withdrawn is usually bloody and it coagulates on being cooled. After an exploratory incision the tumor presents to the eye a dark-blue and vascular capsule covered with interlacing fibrous bands.

Renal Cysts.—Cysts of the kidney are very commonly mistaken for ovarian cysts. I have made this mistake, and it was not until after breaking up adhesions and emptying the cyst that I discovered the character of the tumor. It was successfully removed. Renal cysts start from below the floating ribs and extend downward and forward, while an ovarian cyst begins from below and grows upward. The former, being generally caused by impaction of a calculus in the ureter, are usually associated with urinary disturbances. They also push the intestines before them, which give a resonant sound on percussion, while the contrary holds good with an ovarian cyst. Since the transverse colon lies between the cyst and the liver, the line of resonance caused by it will show that the cyst is not hepatic. The fluid withdrawn from a renal cyst contains urea and the other constituents of urine, but the urinous odor will be either very faint, or, as in my case, wholly absent. It may as well be stated here that when renal cysts present great difficulties in the way of their removal, they had better be treated by a large drainage-tube.

A floating kidney may be mistaken for a small ovarian tumor. But the latter has a pelvic attachment and can readily be pushed down into the basin, while the former is kept from being pushed very low downward by an upper attachment. Again, the floating kidney usually keeps its peculiar shape, and it is frequently lost by slipping from under the fingers into its natural bed in the flank.

Spina Bifida.—Strange as it may seem, this spinal cyst, when internal on account of a deficiency in the anterior parietes of the lower vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am cognizant of two such errors of diagnosis made by two distinguished gynecologists. In each the sac was emptied by the aspirator, and the patient perished shortly afterward with the same kind of cerebral symptoms which follow the sudden withdrawal of the fluid from the cavity of an external spina bifida.

Phantom Tumors.—In the diagnosis of an ovarian cyst one must be on guard not to mistake for it a phantom tumor. In this imaginary kind of tumor, which hysterical women have the knack of creating, the whole belly will be uniformly distended to the size of the gravid womb at term. This is caused partly by flatus and fat, and partly by the arching forward of the spinal column, with the recti muscles drawn so tense that they cannot be indented. I have frequently had patients with this kind of abdominal enlargement sent to me from a distance, under the impression that it was due to some kind of tumor. But the diagnosis is easily made from the uniform resonance all over the belly; if, moreover, the patient's attention be engaged by conversation, the rigidity of the recti muscles disappears, the abdomen becomes flaccid, and the hand can be made to sink in so as to feel the spine. In very nervous women it may be needful to administer an anæsthetic, when all the tokens of a tumor will promptly disappear.

Obesity.—A large accumulation of fat on the abdominal wall and in the omentum has frequently given rise to the suspicion of the existence of an ovarian cyst. This condition occurs, usually, at the climacteric, and on percussion the vibratile thrill of the fat-laden wall of the abdomen conveys a very misleading impression of fluctuation. Further, to add to the difficulty, if the layer of fat be a very thick one, the abdomen, instead of being resonant on percussion, yields a dull note. But in obesity the fat is not limited to the abdomen, for the breasts, face, and limbs partake of the general enlargement. The abdominal wall hangs in folds when the sitting posture is assumed, and the umbilicus is indented and not protuberant. My own method of making the diagnosis is to grasp the abdominal wall with both hands and ascertain the amount of fat. When this amount is excluded, there will not be found room enough behind it for a tumor of any size, and the enlargement will thus be satisfactorily accounted for.

A dilated stomach, cystic tumors of the omentum, and encysted abscesses of the peritoneal cavity, and, indeed, of the abdominal wall, have been mistaken for ovarian tumors; but these are very exceptional cases. In all doubtful cases an exploratory incision should be resorted to.

SURGICAL TREATMENT OF OVARIAN CYSTS.—In the consideration of this subject it may be divided into the palliative treatment and the radical treatment.

Palliative Treatment.—Tapping either by the trocar or by the aspirator comprises the only palliative treatment of ovarian cysts; yet, as a broad rule with but few exceptions, an ovarian cyst should not be tapped. The objections to this operation are—that, slight as it may seem, it is by no means devoid of danger. Even when the smallest hollow needle of the aspirator has been used inflammation of the cyst may follow, which will compel the immediate resort to ovariotomy and very greatly compromise the success of this radical operation.²⁸ This has repeatedly happened—once in one of my own cases, in which, however, the removal of the cyst saved my patient's life. Further, the fluid of a polycyst is usually acrid—so much so sometimes as to irritate the hands of the operator—and the escape of a few drops into the cavity of the peritoneum may set up a violent and rapidly fatal peritonitis. Then, again, a fatal hemorrhage may take place from some wounded vessel, either in the cyst-wall, or in the adherent omentum, or in the vascular pedicle which may lie spread out in front of the cyst-wall, or, indeed in the abdominal wall itself, for the vessels here are often varicose from impeded circulation. In the fourth place, adhesions are very likely to form after tapping. Fifthly, innumerable child-cysts, which were very small before the tapping, being now relieved from pressure are liable to take on rapid growth and make the tumor more solid; and the more solid the cyst the longer the incision needed for its removal. Sixthly, in polycysts not only are the dangers attending the operation enhanced, but the cyst rapidly refills, and the woman becomes exhausted by the drain on her system. At the very best, 2 per cent. of cases of tapping in polycysts are fatal, even when performed by the most skilled specialists. Seventhly, a cyst once tapped rapidly refills, and soon needs repetitions of the operation. This drain on the system quickly tells upon the woman, and she is sometimes left too weak to have the radical operation performed. The first tapping, indeed, greatly hastens on this crisis, and it should therefore be put off as long as possible. Eighthly, a cyst emptied by tapping tends to rotate on its axis, and torsion of the pedicle may result, ending in gangrene and peritonitis. Ninthly, repeated tappings tend to convert benign papillary growths into malignant. Finally, Lawson Tait²⁹ draws attention to the fact that "repeated tappings deprive the blood of some element or elements included in the infinite variety of albuminous substances found in ovarian cysts, the deficiency of which predisposes to coagulation of blood." Hence after the removal of the cyst deaths have been "due to the formation of a firm white clot which started from the point of ligature of the pedicle, and slowly traversed the venous system until it reached the heart, death ensuing in from thirty to forty hours after the operation. The symptoms which precede death are swelling of the legs, rapid rise of the pulse, and its disappearance from the extremities some time before death, and breathlessness, ending in suffocation and slight delirium." He has met with several such cases of venous thrombosis starting from the pedicle, and they all occurred in patients who had been previously tapped. There are, however, cases in which tapping cannot be dispensed with; for instance—

1. Many women with ovarian tumors, having heard of cases of abdominal effusion or of cyst in which tapping was followed by a cure, will not submit to the radical operation until repeated tappings have proved to them the futility of the trocar.

2. Cysts of the parovarium and of the broad ligament being often cured by the use of the trocar, it is proper to try the effect of one tapping in slow-growing, unilocular, thinned-walled, and flaccid cysts, which thus exhibit the chief characteristics of these extra-ovarian cysts.

3. When an ovarian cyst develops during the later months of pregnancy, it will often be best to resort to tapping in order to relieve the woman from the pressure of two growing organs and enable her to go to full term. Sometimes labor is made impossible by the presence of a cyst, which will then have to be emptied.

4. In very large tumors which by pressure interfere with the functions of the kidneys, heart, and lungs, thereby causing albuminuria, oedema, or dyspnoea, tapping is a useful prelude to ovariotomy. By the relief from pressure afforded to these organs not only will the liability to shock be lessened, but also to hemorrhage, for vessels previously varicose will now contract to their natural calibre.

5. In cases of doubtful diagnosis or in those in which from malignancy, from formidable adhesions, or from other circumstances the radical operation is deemed impracticable, tapping in the first case may clear up the diagnosis, and in the latter ones will prolong the patient's life. But it must always be borne in mind that in a few weeks the fluid will reaccumulate, and the operation will have to be repeated, rapidly exhausting the patient by the drain on her system. It is well, therefore, to put off the first tapping as long as possible.

²⁸ American Journal of Obstetrics, Nov., 1883, pp. 1169 and 1189; also Transactions American Gynæcological Society, vol. ii., 1877, p. 270.

²⁹ Midland Medical Society, Lancet, Feb. 18, 1882.

Tapping may be performed through the abdominal wall, through the vagina, or through the rectum, but, for reasons which will presently be given, the first mode is decidedly the best.

Tapping through the Abdominal Wall.—For this operation either the aspirator may be used or else Wells's trocar with a long rubber tube attachment. Of the two, I much prefer the former. In aspiration, after the bladder has been emptied, the woman lies on her back close to the side of the bedstead with her abdomen exposed. The preferable site of puncture is in the linea alba midway between the navel and the symphysis pubis; that is to say, at a point where the tissues, being tendinous, are most free from blood-vessels, and where the omentum is most out of the way. But if at this point the tumor feels solid, or an underlying knuckle of intestine is discovered by percussion, or the vessels look varicose, any other place in the abdominal wall may be selected where fluctuation is most manifest, provided it lies below the level of the navel. The reason for choosing a low site for the puncture is, that if the hollow needle be plunged in at any point above the navel it will slip out of the cyst as the latter collapses and before it is wholly emptied. The skin is now thoroughly cleansed with soap and water and washed with a 5 per cent. solution of carbolic acid. The painful part of the operation being the penetration of the skin, the selected place for puncture should either be frozen with the ether spray or be benumbed by a lump of ice dipped into some table-salt. After the aspirator-jar has been exhausted of air the hollow needle or canula, armed with its stilette, is lubricated with carbolated oil or vaseline, and rapidly plunged deeply into the cyst. Should the cyst not wholly collapse, the canula has probably become obstructed, and it should be cleared out by one of the blunt stilettes which are made of different sizes to fit the different canulas. Sometimes the flaccid walls of the sac as it becomes empty are sucked up into the end of the canula, and the flow of fluid is suddenly arrested. This accident is recognized by a peculiar valve-like vibration communicated to the instrument, and is overcome by raising up the end of the canula or by directing it to another part of the cyst. Should, on the other hand, other cysts present themselves, they can be emptied without withdrawing the canula by reintroducing the stilette, and by directing its point to each cyst in succession. When the fluid ceases to flow the fore finger and thumb firmly compress the fold of the abdominal wall behind the canula as it is withdrawn, so as to avoid the entrance of air, and the small puncture is covered by a piece of adhesive plaster. A pad of cotton wool is now laid over the scaphoid abdomen and a flannel binder applied. These afford a grateful feeling of support and take away that sense of goneness which is likely to occur. To avoid all risks of inflammation the patient must keep her bed for three or four days and eat sparingly.

When Wells's or any other large trocar is used, the operation should be performed under the spray and with every antiseptic precaution. The skin should be previously incised with a lancet, and, lest air should be sucked up into the sac, the free end of the rubber tubing should touch the bottom of the bucket, so as to be always immersed in the escaping fluid. This rubber tubing acts as a syphon with great suction power, and the cyst is more rapidly emptied by Wells's trocar than by the aspirator. Yet I cannot help believing that the latter by its small size is by far the safer instrument, and I always use it when a simple tapping is aimed at. Should any stubborn bleeding follow the removal of the canula, a harelip pin may be passed across the wound deeply enough to get below the wounded vessel, and compression made by a turn or two of silk ligature around the pin. The same means are to be adopted to stop the oozing of fluid which sometimes takes place when a cyst with colloid contents cannot be wholly emptied by the trocar. For it is highly prudent under such circumstances to stop the oozing, as some of the fluid is sure to get into the cavity of the peritoneum, with very generally fatal effects. In such a case the pin ought to include the lips of the wound in the cyst. To avoid as much as possible the escape of irritating ovarian fluid into the cavity of the abdomen, the cyst when tapped should always, if possible, be wholly emptied. This is a rule without an exception. It is therefore very bad practice to remove even with the hypodermic syringe a few drops of the fluid for microscopic examination. Several cases of death from this cause have been reported.³⁰ I lay stress on this point because in my Lessons in Gynæcology I advocate the practice.

³⁰ American Journal of Obstetrics, April, 1876, p. 146.

Tapping through the Vagina.—This operation is sometimes a very tempting one to perform when one of the cysts of a polycyst is pressing downward behind the bladder and causing dysuria. But it is by no means so safe as the supra-pubic mode of tapping. The reasons for this are—(a) The vessels are larger and lie closer together in the lower wall of the cyst near the stalk; (b) in a polycyst the larger cysts, growing where they have most room, usually develop in the abdominal cavity, while the more solid portion remains below in the pelvic region; (c) other organs, such as the bladder, womb, and rectum, are liable to become dislocated and lie in the track of the trocar; (d) the roof of the vagina responds to every respiratory movement of the diaphragm, and a cyst low down is not, from pelvic adhesions, so likely to collapse when tapped as one higher up: hence the cyst is liable to act as a pair of bellows, sucking in air and forcing it out. This inevitably causes suppurative inflammation with all its attendant evils. For these reasons this mode of tapping is never resorted to, except in cases of pelvic adhesion or in those in which the cyst starts from the lower side of the broad ligament and grows downward. Even then it is done only to relieve the distress caused by the double pressure upon bladder and rectum. In such cases the aspirator should be used, as it lessens all the risks. Should suppurative inflammation set in, the sac must be again emptied, the wound kept open by a drainage-tube, and the cavity thoroughly cleansed by daily injections of antiseptic fluids.

Tapping through the rectum has long ago been abandoned by the profession, as it ought to be, except in some very rare cases of atresia vaginæ. It was at one time supposed to possess advantages over the vaginal method, because the subsequent offensive discharges could be retained at will like the other contents of the bowel. But the cavity of the sac always became distended with fecal gas, and fatal septicæmia was pretty sure to set in.

Radical Treatment.—Tapping, followed by the injection of iodine into these cysts, has sometimes been rewarded with a cure, and at one time this mode of treatment had very warm advocates. After the cyst is wholly emptied by aspiration the action of the instrument is reversed, and from two to ten ounces of the officinal tincture of iodine are thrown in. The tincture is used of full strength, because the residual fluid in the cyst will be enough to dilute it. The cyst-wall is next kneaded, and the patient made to turn from side to side and from back to chest, so that the tincture may come in contact with every portion of the secreting surface of the cyst. The fluid is then pumped out, but all cannot be brought away; enough usually remains behind to produce some slight constitutional disturbance. While the canula is being withdrawn, in order to prevent the escape of any of the irritating injection into the abdominal cavity the thumb and fore finger are made to grasp the fold of abdominal wall at the puncture-site and to press it firmly down on to the collapsed cyst-wall. Good and lasting cures have followed such a treatment; but since they can happen only in monocysts, which are almost always parovarian, and not ovarian, it is probable that the mere emptying of the cyst would have done as much. In polycysts such a treatment is not to be thought of, for it would be attended with far more hazard than even the operation of ovariotomy. At the present day injections of iodine are practised only by physicians who do not operate; ovariotomists never resort to them.

Tapping, followed by enlarging the wound in the cyst, stitching its edges to those of the abdominal wound, and permanently keeping it open by tents or by a large drainage-tube, has frequently been attended with success. But since extensive and prolonged suppuration must inevitably ensue, this operation has proved to be a far more dangerous one than that of ovariotomy. It should, therefore, not be resorted to excepting in cases of cysts which are too adherent to be removed. The after-treatment consists in treating the case precisely as if it were an abscess. The cyst is kept empty by draining, and sweet by such deodorizing agents as solutions of iodine, carbolic acid, potassium permanganate, and the liquor sodæ chloratæ. Early this year I had one such case, a patient of C. A. Currie, in which the cyst was wholly adherent to all the pelvic organs and structures, and had besides a communication with the bladder. Not daring, under such circumstances, to remove it, I treated it successfully by incision, drainage, and disinfecting injections; but it was a long time before the drainage-tube could be removed and the woman be released from her bed. Cases, indeed, have occurred in which six months elapsed before the drainage-tube could be taken out and the woman pronounced well.

Another exception in favor of this operation may be made in the case of small cysts growing downward and bulging out the hind wall of the vagina. It may then be advisable to follow Noeggerath's plan. He snips open the vagina transversely behind the cervix to the length of one inch, and makes a corresponding incision in the cyst-wall. The edges of the two incisions are then stitched together and a drainage-tube put in. Thus, the cyst is left with a free and permanent opening into the vagina, through which such antiseptic solutions as have been noted above are thrown up. In time the collapsed cyst-walls adhere to one another and cease to secrete.

Electrolysis has of late also been lauded as a sure and harmless remedy for these cysts. But a careful examination of the subject made by Mundé shows that this agent has been greatly overrated as a specific, and that it "can in no wise supplant ovariotomy."³¹

³¹ Transactions American Gynæcological Society, vol. ii. p. 435.

Rupture of ovarian cysts has occasionally taken place, either through over-distension or through such violence as a rude fall or an upset from a carriage. This accident, if the tumor were a monocyst or if the fluid happened to be bland, sometimes ended in a lasting cure. The hint was not thrown away, and several surgeons cut circular openings into the cyst to establish a permanent communication with it and the abdominal cavity. But this practice was soon given up, because it was found that the intrusion of ovarian fluid into the serous cavity usually set up a violent and rapidly fatal peritonitis. For such an accident, when followed by inflammation, there is but one remedy—the immediate removal of the cyst by ovariotomy. Desperate as this remedy seems, it has repeatedly been followed by success. The only cyst in which it might be held warrantable to establish a communication with the abdominal cavity is that of a cyst of the parovarium recurring after repeated tappings, and so bound down by adhesions or so covered by the broad ligament as to be irremovable. The fluid it contains is so limpid and bland as not ordinarily to inflame the peritoneum.

OVARIOTOMY.—The term ovariotomy comes from [Greek: ôarion], ovary, and [Greek: tomê], an incision. It is a barbarous compound of Latin and Greek, which is forced into meaning the operation for the extirpation of an ovary on account of some disease of its own structures which causes it to increase in bulk. A fibroid or a sarcomatous degeneration of this organ, as has been shown, will sometimes happen, but cystic degeneration is by far the most common form of disease to which the ovary is liable. When both ovaries are enlarged and removed the operation is called double ovariotomy. The terms ovariotomy and öophorectomy ([Greek: ôophoron] and [Greek: echtemnô], to cut out the ovary) really mean the same thing, the latter word, indeed, being the more appropriate. But by modern usage the former is limited to the operation for the removal of an ovary greatly enlarged by some intrinsic disorder. By öophorectomy is now meant the operation for the removal of both ovaries for the purpose of bringing on the menopause, and thus curing diseases kept up or caused by the functional existence of those organs, while they themselves may or may not be diseased.

Before the eighteenth century the operation of ovariotomy as a radical cure had been suggested by a number of physicians, but had never been put into practice. Later, John Hunter and John Bell both advocated the operation, but neither ventured to perform it. This honor was reserved for Ephraim McDowell, a Virginian practising in Kentucky, who had attended Bell's course of lectures delivered in Edinburgh in 1794, and had imbibed the opinions of his teacher. He returned to Kentucky in 1795, and began at once to practise his profession, but it was not until 1809 that he first met with the opportunity for performing ovariotomy. The operation was successful, his patient having lived thirty-two years longer and having died at the end of her seventy-eighth year. Before his own death, which occurred June 25, 1830, in the fifty-ninth year of his age, McDowell had performed 13 ovariotomies, with 8 recoveries.

In spite of McDowell's success, and in spite of a large and growing percentage of recoveries reported by Atlee, Clay, and Spencer Wells, this operation was condemned so violently by the profession that its advocates were fairly ostracised, and fifteen years have hardly elapsed since it has been put upon as firm a basis as any other capital operation in surgery. "In 1843, Dieffenbach, the boldest of all surgeons then living, wrote that ovariotomy was murder, and that every one who performed it should be put into the dock. Now," writes Nussbaum, "we save lives with it by the hundred, and the omission of its performance in a proper case would in these days be looked upon as culpable negligence."³²

³² British Medical Journal, Oct. 26, 1878, p. 617.

The most common causes of death after ovariotomy are septicæmia or septic peritonitis, traumatic or frank peritonitis, shock, exhaustion, and hemorrhage; and it is against these foes that the operator must from the first aim all his efforts. In no other operation does the issue depend so largely on the experience of the surgeon. Every ovariotomist finds that his success grows with the number of his cases. Of 1000 successive ovariotomies, Wells lost 34 out of the first group of 100 cases, and but 11 out of the last group of 100. Out of his first 50 ovariotomies, Lawson Tait had 19 deaths.³³ The mortality of his last 313 cases was as low as 4.76 per cent.³⁴ Keith, who began with a mortality of about 20 per cent., lately had a series of 100 cases with 97 recoveries; 70 of these were successive. Schroeder had in the first 100 of his Berlin cases 17 deaths; in the second 100, 18; and in his third 100, 8 deaths.³⁵ Of my own first cases, I lost about 1 in every 3. Out of my last 22 cases there was but 1 death, and that occurred in a lady operated on at her home, too distant for me to see her again. In July, 1884, Peruzzi collected statistics up to date of Italian ovariotomists. Out of the first series of 100 cases, they lost 61. In the second 100 there were 36 deaths, but in the third series only 26 died.³⁶

³³ Medical Record, Jan. 3, 1885, No. 2, and British Medical Journal, April 15, 1882, p. 544.

³⁴ Medical Record, Jan. 3, 1885, p. 2, and American Journal of Obstetrics, July, 1882, p. 547.

³⁵ Maryland Medical Journal, July 1, 1882, p. 110.

³⁶ British Medical Journal, Sept. 16, 1882, p. 528.

The statistics of the leading ovariotomists up to January, 1883, are as follows:³⁷

Cases. Recovered. Died. Mortality, per cent.

Clay 93 64 29 31.11

Sir Spencer Wells 1088 847 241 22.15

Keith 381 340 41 10.76

Knowsley Thornton 328 293 35 10.67

Lawson Tait 226 199 27 11.94

³⁷ Medical News, Jan. 27, 1883, p. 117.

The statistics of general hospitals are by no means so good. In the Vienna General Hospital during the year 1881 "ovariotomy was performed 64 times, with 38 complete recoveries, 25 deaths, and 1 woman was discharged with marasmus."³⁸ Taking the profession at large, out of 5153 cases of ovariotomy collected by Baum, there was a mortality of 29.13 per cent.³⁹ Out of 2023 cases collected by Younkin, the mortality was 27 per cent.⁴⁰ By operative skill, by cleanliness, by wise hygienic measures, and probably by the use of antiseptic precautions, the fatality may be said to have been reduced by skilled specialists to about 10 per cent.; which, considering the size of the wound, the importance of the parts involved, and the delicacy of the exposed structures, is a remarkably low average. The average is indeed better than that of amputations. Before 1869, Sir James Y. Simpson stated that the average mortality of amputations of the extremities was 39.1 per cent. In the Glasgow Royal Infirmary the average mortality has been 25.5 per cent.—viz. of thigh cases there were 380 cases, with 113 deaths = 29.7 per cent.; of the leg, 182 cases, with 54 deaths = 29.6 per cent.; of arm cases, 167, with 33 deaths = 19.7 per cent.; of forearm cases, 93, with 12 deaths: mortality = 12.9 per cent.⁴¹

³⁸ Medical News, Dec. 30, 1882, p. 745.

³⁹ Agnew's Surgery, vol. ii. p. 811.

⁴⁰ The New York Medical Record, Nov. 11, 1882, p. 560.

⁴¹ Lancet, Sept., 1882.

This brings up the question of simple or of aseptic ovariotomy—a very important question and one not yet fully settled. The objections to Listerism are—that it is very troublesome; that it is liable to poison the patient fatally, as well as to injure the health of the operator; that it is useless, indeed merely a surgical craze; and that it is not the carbolic acid which does good, but the cleanliness enforced by this system. But there is no doubt that since the introduction of antiseptic surgery the mortality has been much lessened in every land. For instance, "in Germany, where the success of ovariotomy has not been so good as in other countries, the mortality by means of the antiseptic treatment has been reduced from 90 to 20 per cent."⁴² From an analysis of all the cases of ovariotomies performed by American surgeons, "the percentage of recoveries is overwhelmingly in favor of Listerism."⁴³ During the year 1881 in the Samaritan Hospital two of the surgeons used the carbolated spray of a strength of 1 in 40, and followed out every detail of antiseptic surgery. They had a mortality of 7 per cent. A third surgeon of that institution, after gradually lessening the strength of the spray until water was alone used, finally gave even it up altogether. He, however, for purposes of cleanliness always covered the instruments in the tray with water. The mortality of his operations showed the high rate of 30 per cent. The house committee, a body of laymen, thereupon "expressed a strong opinion against the performance of ovariotomy for the future without full antiseptic precautions."⁴⁴

⁴² Agnew's Surgery, vol. ii. p. 800.

⁴³ H. C. Bigelow, American Journal of Obstetrics, July, 1882, p. 651.

⁴⁴ British Medical Journal, May 20, 1882, p. 747.

On the other hand, Tait of Birmingham and Keith of Edinburgh, with a recent mortality each of only 3 per cent., have abandoned the spray. The latter claims now "to get as good results without it, and better results than any one has yet got with it."⁴⁵ My own practice is to adhere to the spray and to every detail of antiseptic surgery; and I fully agree with Bigelow that "it would be a grave error to abandon a practice which has achieved brilliant results until something shall be brought forth which shall be as thoroughly protective, and in the use of which there may be no possible dangers. Time alone can demonstrate satisfactorily the relative values of Listerism and of perfect cleanliness without Listerism. The results of a large number of cases in which cleanliness and attention to detail have alone been used are the only criteria upon which we can strike a judicial balance."⁴⁶

⁴⁵ Brit. Med. Journ., May 27, p. 796.

⁴⁶ Am. Journ. of Obstetrics, July, 1882, p. 651.

Contraindications for Ovariotomy.—An operation should be declined in far-advanced tuberculosis, in cancer of the ovary or of any other part of the body, in grave structural lesions of any of the vital organs, in ascites if caused by disease of the heart, the liver, or the kidney, in gastric ulcer, or in any serious disease of the alimentary canal. Extensive adhesions should not count as a contraindication, nor should age, since young girls and very old women have been successfully operated on. Albuminuria is often due to the pressure of the tumor on the kidneys, and, unless it existed before the appearance of the tumor or is positively known to be caused by Bright's disease, should not preclude the operation. Extreme debility dependent upon the ovarian disease makes the prognosis grave, but it should not prevent a resort to ovariotomy. I have indeed had several recoveries when the patient was so reduced in strength as to make it a very anxious and difficult task to keep her from dying on the table.

Indications for Ovariotomy.—This operation should not, as a rule, be performed when the cyst has first been discovered, but when it has grown so large as to distend the belly, and when the woman has become thin and her health has begun to fail. The reasons for waiting are—that the woman will have lived longer should the operation turn out to be a fatal one; that, the abdominal wall having become thinner both by being overstretched and by the absorption of fat, the incision will be proportionately shorter and shallower; that, the patient being now less full-blooded, both hemorrhage and inflammation will not be so likely to occur; that the bowels are crowded away from the line of incision; and that the pressure and rubbing to which the peritoneum has been for some time subjected will make it less vulnerable, and therefore less likely to take on inflammatory action. When, however, a woman broods over her condition and is anxious to have the tumor removed, the operation should be performed much earlier, especially if the surgeon be experienced.

Again, when an ovarian cyst is complicated with pregnancy it is best to perform the operation in the first half of the period of gestation; for in the last half the broad ligaments receive a large supply of blood, and all the pelvic vessels become varicose. Pregnancy is indeed no bar to the operation, the prognosis being favorable both to the mother and to the child. Schroeder and Olshausen performed 21 ovariotomies in pregnant women, with only 2 deaths.⁴⁷

⁴⁷ Brit. Med. Journ., Dec., 1880, p. 1027.

When septic peritonitis sets in; when the contents of the sac become purulent, as they sometimes do either spontaneously or after an unprotected tapping; when the cyst bursts and serious symptoms arise; when torsion of the pedicle occurs or when a free hemorrhage into the sac takes place,—the radical operation should unhesitatingly be performed, and that without any delay.

Preparation of the Patient for the Operation.—The operation having been decided upon, every precaution must be taken to ensure a favorable result. The patient should avoid all exposure to contagious or to zymotic diseases, and she should be put in the very best condition of health possible under the circumstances. If the kidneys be inactive and the urine highly concentrated, depositing mixed urates in abundance, it will be well for the patient to make use of warm baths and to take saline cathartics in quantities sufficient to secure a daily action of the bowels. The alkaline carbonates, largely diluted, will also prove beneficial, and so will also the effervescent citrate of lithia. Sometimes, and especially when anasarca and oedema of the legs occur, it will be advisable to relieve the pressure-congestion of the kidneys by a preliminary tapping. Other organs will also be relieved, and valuable time for the action of medicines is often gained by emptying the cyst. Tonics, iron in the form of Basham's mixture, a generous diet, and fresh air may be needed. A trip to the seashore or to the country will often do much good in preparing a broken-down patient for the operation. If the patient comes from a malarial district, from twenty to thirty grains of quinia should be given during the twenty-four hours for two or three days before the operation, and ten grains a few hours before the time of the operation. If this be not done, a severe explosion of malarial fever after the operation may put the patient's life in jeopardy.

An operation of election should not be undertaken during a monthly period. It should be performed either about ten days before one or about a week after one. The very best time is midway between two fluxes. When, however, through some lesion or some accident, immediate relief is demanded, no regard whatever should be paid to the factor of menstruation. Some surgeons operate, indeed, in any case whether the woman is menstruating or not, and profess to find no difference in the result.⁴⁸

⁴⁸ T. Savage, Brit. Med. Journ., April 14, 1883, p. 712.

For several days before the operation the bowels should be kept open, and the diet should consist largely of milk, eggs, rice, and of wholesome and easily-digested food. On the day preceding that of the operation the upper portion of the pubic hair should be cut off and the abdomen, if hairy, shaved. In the evening the patient takes a warm soap-bath, and is washed perfectly clean by her nurse, who must be an experienced woman, able to pass the catheter and take the temperature. She then puts on clean clothing and goes to bed, where she stays until the hour fixed upon for the operation. To ensure sleep, I am in the habit of giving at bedtime thirty grains of potassium bromide, combined sometimes with opium. Early next morning a dose of castor oil is administered, and it is much more easily swallowed if disguised in some vehicle and brought to the patient without any previous warning. When oil cannot be taken, I give, at bedtime of the previous evening and in one dose, two compound cathartic and two Lady Webster pills. To avoid ether-vomiting, breakfast should consist merely of one piece of dry toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk, and afterward she must eat nothing more. To calm the nerves another thirty-grain dose of potassium bromide may be given, with or without opium as the case may be, and especially if the woman be at all agitated.

A very good time for operating is from noon to two o'clock in the afternoon, for by that time the oil will have acted and the light breakfast will have been digested. Some surgeons operate as early as nine and ten o'clock in the morning, in which case the cathartic will have to be administered in the afternoon of the previous day. At the hour fixed upon for the operation the woman puts on a flannel sacque, warm stockings, and drawers, and her nurse then passes the catheter.

The bedstead on which the woman is to lie after the operation should have a horse-hair mattress, and should be wide enough to permit her attendants to move her on a draw-sheet from one side of it to the other. I formerly placed my patients on narrow single bedsteads, so that they could be reached and be waited upon equally well from either side; but I found that an unchangeable position on the back soon became intolerably irksome. Next, indeed, to the thirst following the operation, my patients complain mostly of the supine posture which they are compelled to assume.

The room in which the operation is to take place ought to be a separate one, so that the lady can be etherized in her sleeping-room, and may not be unnerved by witnessing the needful preparations. Several days beforehand the carpet of the operating-room should be taken up and the curtains taken down. Every useless piece of furniture should be removed, the closets and bureau-drawers emptied, and the whole room thoroughly cleansed and ventilated. Several hours before the time of the operation this room ought to be heated to a temperature of 75°, and the air disinfected and made moist by a solution of carbolic acid kept boiling in a dish on the stove or over an alcohol lamp. Let me here say that, if possible, this operation should not be performed within the walls of a crowded general hospital nor in unhealthy localities, but, as statistics well show, in private houses or, far preferably, in small special hospitals.

Articles Needed for the Operation.—The following articles should be provided by some member of the patient's family. Following the example of the late Washington L. Atlee, I have a printed list of them, which is sent to the family physician some days before the operation:

One yard of rubber plaster; two rolls of raw cotton, made aseptic by being baked in the range-oven just before the operation; two yards and a half of fine white flannel, for two binders; six one-grain rectal suppositories of the watery extract of opium; two pounds of the best ether; two gallons of a 5 per cent. solution of the best carbolic acid, made at least two days beforehand; four ounces of Monsel's solution of iron; twelve ounces of undiluted alcohol for the spray-producer; some old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap; a pin-cushion, with large pins; two kitchen tables, or two dressing-tables; one small stand for the spray-producer; one small table for the basins and sponges; one chair without a back for a bucket of hot water; two new tin basins and one tin cup; a new bucket and a jug of hot water; a kettle of boiling water, ready on the range; a small tub and an empty bucket; six bottles filled with hot water and tightly corked; an empty wine-bottle for the aspirator; a rubber ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard and a quarter square, with an oval hole in the centre six inches wide and eight long; one kitchen apron for the operator; one clean blanket for the patient's lower extremities; two large platters or two meat-dishes, to be used as trays for the instruments;⁴⁹ clean towels, clean sheets, clean blankets, clean comfortables, and clean pillows.

⁴⁹ These platters are usually too shallow to hold a solution of carbolic acid deep enough to cover the bulkier instruments. It would therefore be well to have a tin tray made especially for the purpose, measuring nineteen inches long, twelve wide, and three deep; or a nest of smaller trays can be carried in the operator's bag.

Instruments.—In simple cases very few instruments are needed; but as one never knows beforehand what complications may be met with, it is best to be always prepared for every emergency. One must therefore have on hand every instrument likely to be wanted in the most formidable operation. The following list comprises all the instruments and other articles that I carry with me in my operating-bag, but it will not suit every surgeon, who will after a few operations choose his own favorite instruments:

One steam spray-producer, which will work two hours; assorted silk ligatures on spools; Lister's antiseptic gauze or salicylated cotton; two dozen straight surgeon's needles; assorted needles with varying curves; two large needles for transfixing pedicles; an aneurismal needle; one needle-holder; one hypodermic syringe; two dozen assorted pressure-forceps; one uterine tenaculum; assorted hair-lip pins and acupressure needles; one grooved director; two scalpels; Baker-Brown's cautery clamp; ten fine surgeon's sponges of different sizes; two long and flat sponges; one wire écraseur; one wire clamp or Koeberle's serre-noeud; Paquelin's cautery or three cautery-irons; one Wells's trocar with rubber tubing; one aspirator; two Nélaton's cyst-forceps; one straight pair of scissors; one pair of scissors curved on the flat; one right-angled pair of scissors; Allis's improved ether-inhaler; one flexible male catheter; three glass drainage-tubes of different sizes and lengths, together with the rubber sheeting and the sponge used with them.

The twenty-four needles should be threaded, two on one thread of fine silk eighteen inches long—viz. No. 1 or 2, of an excellent quality furnished by Messrs. J. H. Gemrig & Son of Philadelphia. To keep these threads from becoming snarled they are rolled up in a strip of muslin gauze, each pair of two needles with their thread being covered up by one fold of the gauze. The two pedicle-needles should also be threaded, but with stouter thread (No. 4), fully two feet long. All these armed needles should be put into a 5 per cent. solution of carbolic acid for several hours before the operation. Assorted needles of varying curves come occasionally into use, and it is always well to have several very fine needles on hand, together with the finest Chinese silk, in order to close a wounded viscus, such as the bladder or the bowels.

As an aid to the memory it is well to have invariably at every operation the same number of sponges and the same number of pressure-forceps, for these are the only articles likely to be left behind and closed up in the abdominal cavity. The cautery-irons should be wedge-shaped; the iron spreader used by apothecaries in making plasters forms an excellent substitute. In my hands the best pressure-forceps is Koeberle's. Its pointed beak catches the tissues far better than that of Wells's forceps, which looks like a crocodile's muzzle. The ordinary hæmostatic bulldog clips, or the serres-fines, must on no account be used, because if they should lose their hold and drop into the abdominal cavity they would be too small to be readily discovered, and might indeed be hopelessly lost in the coils of the bowels. Long strings attached to each one would, however, overcome this objection.

The ten sponges must be of the best quality and about the size of one's fist. Two of them should be flat, long, and thin, such as are called by the trade potter's sponges. When first bought, sponges almost always contain sand. To rid them of this they are beaten, then soaked for twenty-four hours in a 3 per cent. solution of muriatic acid, and afterward washed out in clear running water. Sponges should never be put into boiling water, which destroys their elasticity, shrivels them up, and spoils them. After every operation the sponges should be thoroughly cleansed in cold water and immersed for forty-eight hours in a solution of washing soda (sodii carbonas) containing four ounces to the gallon of water. They are then rinsed out in running water, and placed in a 5 per cent. solution of carbolic acid. At the end of a week they are to be taken out and hung up in a bag. Instead of a solution of soda, some prefer an 8 per cent. solution of sulphurous acid, in which the sponges are soaked for from two to four hours. This bleaches the sponges, but does not cleanse them so well as the alkaline solution.

Only three assistants are needed—two are enough if they are experienced—and they and the surgeon should take a soap-bath, and not see on that morning any patient ill from a zymotic or a contagious disease. Their clothes should also be scrupulously clean. To ensure still further protection, each one takes off his coat, waistcoat, and neck-tie if they are of a material which cannot be washed. The nurse must also wear clean clothing which can be washed. A few bystanders may be permitted, but they should wear clean clothing and take off their overcoats. They should also be cautioned not to visit before the operation any case of contagious disease.

Upon arriving at the patient's house the surgeon, together with his assistants and the nurse, proceeds at once to get everything in readiness. The two tables may be arranged in the form of a T, covered with several thicknesses of quilts, and with a pillow on the cross-table. When the tables are thus arranged a third one will be needed for the instruments and the spray-producer. In order to economize room and furniture, I am in the habit of putting one table at right angles to the other—viz. with its short arm to the left instead of to the right, thus: _|. The woman lies on the long arm of the _|, with her feet directed to the short arm, and on the projecting and free portion of the table forming the short arm are placed the tray of instruments and the spray-producer. As it takes time to get up steam in the necessarily large spray-producer, hot water should be poured into the boiler, and it should be one of the first things attended to. In order not to chill the patient, the spray solution of carbolic acid should also be heated before it is used. The edges of the oval hole in the rubber cloth are next smeared with some adhesive preparation, but a plaster suitable for all seasons of the year is not easy to devise. Keith's formula is the following, but it will not always stick:

Rx. Emplastri saponis, ounce iv;

Emplastri resinæ, ounce iij;

Olei olivæ opt., ounce i. M.

After many trials, W. D. Robinson of Philadelphia has succeeded in making for me a very good plaster according to the following formula:

Rx. Emplastri saponis, ounce ij;

Resinæ, drachm vi;

Terebinthinæ albæ, drachm ij. M.

I must, however, add that I now very rarely use this rubber cloth.

Not all the instruments in one's bag, but only those likely to be needed, are now placed in the tray or in the platters, and covered over with boiling water, to which in a few minutes is added the same quantity of a 5 per cent. solution of carbolic acid. The best plan would perhaps be to pour into the tray a boiling 2.5 per cent. solution of carbolic acid. Into the same tray is also laid the roll of gauze containing the threaded needles. By its side on the table, and within easy reach, is placed a small bottle filled with a 5 per cent. carbolated solution in which are kept two small spools of Nos. 1 and 2 silk. The adhesive or rubber plaster is cut into strips of appropriate length, and the antiseptic dressing put in readiness. The trocar with tubing attached is hung on a nail near by. The sponges are carefully counted and placed in one of two basins arranged side by side on a table to the left of the patient. The other basin is one-third filled with a 5 per cent. solution of carbolic acid, which later on is reduced by the addition of pure hot water to a strength of 2.5 per cent. On a chair is placed a bucket of clean warm water.

Let me here say, once for all, that throughout the operation the assistant who looks after the sponges attends to them in the following way: Every soiled sponge returned to him is first cleaned in the bucket of warm water, next rinsed in the carbolated solution, then squeezed out and placed in the empty basin. This sequence must be rigidly observed, because, if the soiled sponge be plunged first in the carbolated water, the blood and serum which it contains will at once coagulate in its meshes, and become liable to be dislodged in the abdominal cavity as foreign bodies.

Meantime, the woman, in another room, has been inhaling the anæsthetic—the best being, in my opinion, the ether fortior of our leading manufacturing druggists. It should be administered by Allis's inhaler, which largely dilutes it with air. Wells and Thornton employ the bichloride of methylene; Keith uses pure ether; Bantock resorts to chloroform, and Tait to a mixture of two parts of ether and one of chloroform, given by means of Clover's apparatus.⁵⁰ When the patient is wholly unconscious her water is drawn off, and she is carried into the operating-room and laid on the table. To this table she is strapped down by a belt over her thighs, and her hands are also secured to the same belt. Her legs are wrapped in warm blankets, and her clothes are drawn up out of the way. Her chest and body are then covered by the rubber sheet, but the edges of its oval opening are made to adhere to the skin from just above the navel to the pubic hair, thus exposing only a limited portion of the abdomen. After this the spray is turned on, and the 5 per cent. solution of carbolic acid in the tray and in the basins is diluted with hot water down to 2.5 per cent. The operator and his assistants now take off their rings and cleanse their hands very carefully with carbolated soap and a nail-brush. They may clean and pare their nails with a penknife before the use of the nail-brush, but not after, because the knife not only does not remove all dirt, but it loosens up that which remains. Arranging themselves in their places, the operator stands to the right of the woman, his chief assistant to her left, the one who gives the ether at her head, while the other, who attends to the sponges, takes his place near the basins at the side of the chief assistant. The nurse holds herself in readiness to hand towels when called for, and especially to see that a third basin always contains warm water, so that at any stage of the operation the surgeon can wash his hands without delay.

⁵⁰ The Medical Record, Jan. 3, 1885, p. 2.

When everything is ready the door is locked, and the exposed portion of the abdomen washed with the solution of carbolic acid. An incision about three inches in length is made with a free hand, and not by nicks, in the median line below the navel, where the blood-vessels are few in number. It should end about one inch and a half above the pubes; that is to say, low enough for the pedicle to be easily reached, but high enough to avoid cutting the fold of peritoneum reflected from the bladder to the abdominal wall. The brown line running below the navel is the surface guide, but after cutting through the skin and fat one cannot always hit the linea alba beneath. When the cyst is large the recti muscles have become separated from one another, and there is no difficulty in keeping within the wide tendinous interspace. But when the cyst is small the linea alba is, as its name indicates, a mere line, and the knife will often go astray into the anterior sheath of one of the recti muscles. The red muscular fibres pouting out of the opening will be the danger-signal of one's having got off the track into more vascular regions. To recover it a probe is passed in across the muscle to the right and to the left, and the nearest point of arrest will note the linea alba. The disadvantages arising from the wandering from the linea alba are—that the sheath of the rectus muscle being cut open, or the muscle itself being wounded, there results hemorrhage; that the wound is more jagged, and therefore less easily coaptated; that suppuration in the suture-tracts is more liable to take place; and, finally, that in cases of small cysts with but little abdominal enlargement a spasmodic contraction of the wounded muscle is very likely to embarrass the operator both in removing the cyst and in introducing the sutures.

Again, one cannot on a grooved director cut canonically through the different layers of tissue described with so much precision in the textbooks. On the contrary, all that one needs is to know when the knife is approaching the peritoneum. An excellent landmark is the thin layer of fat overlying the peritoneum. So, after pinching up the abdominal wall to estimate its thickness, the surgeon can boldly cut down through the skin and its underlying fat, but somewhat cautiously through the aponeurotic structures until the second layer of fat is reached. Practically, therefore, he need regard but the following layers: skin with its underlying fat, the intermediate tendinous or muscular structures, the supra-peritoneal fat, and the peritoneum.

Before the abdominal cavity is opened all bleeding is stopped by the use of pressure-forceps, of which one dozen will sometimes dangle from the wound. When the hemorrhage has been wholly stayed, and not until then, the peritoneum is hooked up by a delicate uterine tenaculum and nicked open. On a broad grooved director or on the finger this opening is slit up for a distance of about two inches, either by a right-angled pair of scissors or by a probe-pointed bistoury. A little serum usually escapes and the nacreous wall of the cyst comes into view. This is called an exploratory incision, for by it the diagnosis is confirmed, the presence of adhesions ascertained, and the possibility of completing the operation determined. When it has been decided to go on with the operation, more working room will be needed, and the wound is therefore enlarged by the scissors, the finger being used as a guide to prevent injury to the omentum or to any chance knuckle of bowel that may lie in the way. The size of the incision will depend upon the character of the cyst and on the number of its adhesions. Hence it may range from a length of three inches to the distance from ensiform cartilage to symphysis pubis. An incision contained between the umbilicus and symphysis pubis is technically called a short incision, and one extended above the umbilicus a long incision. Should it be found needful to prolong the wound to a point above the umbilicus, the incision is usually carried to the left of the navel and brought back in a curved line to the linea alba. This is done to avoid the round ligament of the liver and its vessels, which come in there from the right side. Keith, however, cuts directly through the navel; and I find this straight incision to be superior in every respect to the curved one. Other things being equal, the short incision is safer than the long one; but it is a good rule to have an opening large enough for easy manipulation and for the easy withdrawal of the cyst. For instance, a large monocyst without adhesions after being emptied can, like a wet rag, be pulled out, hand over hand, through a very small opening, whereas a much smaller polycyst, which cannot be wholly emptied, and which is more or less adherent, will need a long incision. I once removed an oligo-cyst weighing one hundred and twelve pounds through an incision barely admitting my hand; while I had to open the abdominal cavity from ensiform cartilage to symphysis pubis in order to remove a solid ovarian fibroid tumor weighing but eighteen pounds. Both patients recovered, but the chances were, of course, more against the woman with the long incision. To avoid the escape into the abdominal cavity of any blood from the wound, and to prevent the soiling of the operator's hands, a clean napkin wetted with the carbolated water is doubled over each edge of the incision.