Chapter XVII: Front Matter (17)

TREATMENT.--Whenever the dislocated ovaries are congested or they display signs of chronic inflammation, the same remedies will of course be useful as those for ovaritis. In addition, pessaries are important adjuvants, and especially in those cases in which the womb has a backward displacement. In the simple, uncomplicated cases of ovarian dislocation, in which the womb is in its proper position, a pessary often does more harm than good. To be of service it must be long enough to obliterate Douglas's pouch, and the pressure on the rectum or on the sacral nerves then becomes unbearable. If, on the other hand, it be too short, the ovary slips down behind it and gets badly pinched. These requirements practically exclude the resort to Hodge's pessary or to any of its modifications, with the exception, perhaps, of Fowler's. In the long run, a thick elastic and soft ring-pessary will do the most good, by offering a broad shelf on which the ovaries will sometimes, but not always, lodge. The air-cushion pessary and Gariel's air-bag will often answer the purpose better than any other, but, being of soft rubber, they soon become fetid and soon collapse.

A very excellent way of keeping up the ovaries is the knee-chest posture devised by H. F. Campbell of Georgia. Two or three times a day, or more frequently if needful, the woman unbuttons her dress, unhooks her corset, and loosens her underclothing. She then kneels on her bed with her body bent forward until her chest is brought down to the surface of the bed, while her head is turned to one side and the lower cheek supported in the palm of the corresponding hand. Her knees should be about ten inches apart and the thighs perpendicular to the bed. The trunk of the woman's body is now supported, like a tripod, by her two knees and the upper portion of her thorax. If she now refrains from straining and breathes naturally, a reversal of gravity will be established. With the fingers of her free hand she next opens the vulva. Air will {289} rush in, distending the vagina, and the contents of the abdomen will at once sink toward the diaphragm. This will, of course, draw the womb and the displaced ovaries out of the pelvic basin. As it is rather awkward for a woman while in this posture to free one hand to reach the vulva, Campbell advises that previously to taking this attitude she should insert into the vagina a small glass tube open at each end and long enough to project externally. This will leave an air-way and dispense with the use of the fingers. After staying in this posture for a few minutes, the woman removes the tube and slowly turns over on her side, where she is to lie as long as she can. Such constant replacements are of great service, for they lessen the throbbing and they give the limp ligaments a chance of shrinking and of keeping the truant ovaries at home.

In this intractable disorder an abdominal brace will sometimes do good. It may not cure, but it often blunts the edge of the aches, and thereby gives much comfort. By pressing the abdominal wall upward and inward the brace forms a shelf on which the viscera rest, and thus it takes off a portion of the load from the womb and from its ovaries. By virtually narrowing the pelvic inlet it lessens the space into which the bowels tend to crowd, and to that extent protects the pelvic organs. By swinging the pelvis backward it makes the axis of the superior strait lie more obliquely to the axis of the trunk, and the sum of the visceral pressure now converges, not in the pelvic basin, but on the portion of the abdominal wall lying between the symphysis pubis and the umbilicus.

There is yet another treatment which, combined with the knee-chest posture, I deem the best of all. It is Mitchell's rest-cure, to which I have before referred. After the patient begins to improve and to fatten, as she usually does under this treatment, she is taught how to replace the ovaries by atmospheric pressure, and the result is that in my experience they finally stay up. The explanation is as follows: By this treatment the circulation of nerve-fluid and of blood is equalized, and the ovaries, relieved of their turgescence, grow lighter. Then the increased deposit of fat in the abdominal walls, in the omental apron, and around the viscera, to say nothing of the needful fat-padding in all the pelvic nooks and crannies, increases the retentive power of the abdomen. Finally, by its gravity the now fat-laden and overhanging wall of the abdomen tends to draw toward itself--that is to say, upward--the movable floor of the pelvis. The behavior is like that of a rubber ball half filled with air, in which bulging at one pole causes a corresponding cupping at the other. This explains the ascent of the womb in women who get fat after the climacteric.

In exceptional cases the hypertrophied glands keep heavy and refuse either to go up or to stay up under any treatment whatever. The only known remedy will then be their extirpation--an operation which will be discussed under its appropriate heading.

Hernia of the Ovary.

This is usually a congenital displacement, and, according to Englisch,[3] is, when double, almost always so. The ovary is then found either in {290} the inguinal canal or outside of this canal in the corresponding labium majus. The oviduct then accompanies it. When the hernia is acquired, the ovary, with or without the oviduct, makes one of the contents of the sac of an inguinal, a crural, a ventral, or an ischiatic hernia. Of these, the inguinal is by far the most common. Thus, out of 67 cases observed in 9 years by Langlon at the Truss Society, all were inguinal with 1 doubtful exception. Of these 67, 42 were congenital, 25 acquired.

[Footnote 3: _New Sydenham Soc.'s Biennial Retrospect_, 1871-72, p. 291.]

The character of the lesion is told by the peculiar tenderness and nausea following pressure, and by the swelling of the tumor just before the menstrual flux. In one case mentioned by Routh[4] pressure on the tumor produced distressing sexual excitement; but this is an unusual symptom, although I have seen it produced by the pressure of hardened feces.[5] It is not always easy to decide whether the displaced glands are ovaries or testicles; and repeated mistakes in regard to sex have thus been made.[6] So difficult, indeed, is it sometimes that the microscope can alone settle the question.

[Footnote 4: _Trans. Royal Medical and Chir. Soc., Lancet_, Jan. 28, 1882.]

[Footnote 5: Goodell, _Lessons in Gynæcology_, 2d ed., chap. xxvi. p. 332.]

[Footnote 6: Chambers, _Trans. London Obstet. Soc._, 1881.]

TREATMENT.--In a reducible hernia, taxis and an appropriate truss comprise the treatment. If irreducible, a truss with a concave pad may be used to protect the ovary from injury. If the ovary be fixed by adhesions and it give much discomfort, it should be removed by operation.

Öophorectomy; Battey's Operation.

There are certain forms of diseases of women peculiar to the menstrual period of life. The attendant lesions are found either in the reproductive organs themselves or outside of them in remote organs, but with such monthly exacerbations as show their participation in the catamenial excitement. They are always very hard to cure, and often prove to be wholly unmanageable until the climacteric has been established.

In this category may be classed fibroid tumors of the womb, chronic pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia, ovarian insanity, ovarian epilepsy, and, in short, all those phenomena or those lesions which are embraced under the term of pernicious menstruation.

Fibroid tumors of the womb are, fortunately, pretty manageable. Usually, the womb, like a generous host, hospitably entertains them; but once in a while an unwelcome one presents itself which arouses all the resentment of that organ. If, then, it stubbornly resists all treatment, it slowly but surely destroys life by the pain which it evokes and by the loss of blood it gives rise to. In such a case the woman is virtually bed-ridden from her floodings and sufferings, and she looks forward to the climacteric as her only hope. But the change of life is then always postponed for several years beyond the natural term--oftentimes so many years as to be overtaken by the death of the patient.

Then, again, there are those cases in which, despite all treatment, the ovaries remain turgid with blood, acutely neuralgic, and to the last degree sensitive. They become dislocated and lie in Douglas's pouch, or irremediable tissue-changes take place, attended by follicular or by {291} interstitial degeneration. A woman with such a lesion is usually a helpless invalid, racked with atrocious pains, weakened by exhausting menorrhagia, and wholly unable to fulfil her duties as wife or as mother. Usually she seeks relief in anodynes and becomes a confirmed opium-eater.

There are also many distressing cases of salpingitis or of pelvic peritonitis and pelvic cellulitis which cripple a woman past all hope by monthly exacerbations. Such cases are by no means rare, and the woman, reduced to skin and bone, finally dies, because in spite of all treatment the inflammation is rekindled at every monthly period.

Further, there are cases of epilepsy which seem to come wholly from the sexual organs--cases with an ovarian aura, so to speak. The fits begin at puberty, very generally last through life, and end in impairment of the mind. Often the first convulsion is ushered in by the first menstruation, and ever after it is around ovulation as a storm-centre that future eclamptic attacks revolve. Such an epileptic is the terror of her family and a valueless member of society. Generally she dies insane or with enfeebled mind, and if she marries she is very likely to transmit her infirmities to her children, either in the same form as her own or in kind.

Finally, what insane asylum does not hold incurable women whose mental infirmities seem to depend wholly upon the act of ovulation? Some there are who, indeed, never exhibit symptoms of insanity excepting during the monthly flux.

For these menstrual affections there is a remedy which, while yet in its infancy, promises much--one first proposed and performed by R. Battey of Rome, Georgia. This able surgeon reasoned that, since these disorders are kept up by the monthly afflux of blood to the sexual apparatus, and therefore incurable during menstrual life, the only chance of immediate relief lies in the establishment of an artificial menopause. To bring about this change of life he advocated the extirpation of both the ovaries, and labeled the operation normal ovariotomy. With this name fault has been found, because it does not cover the whole ground, for often the ovaries themselves, together with the oviducts, are found diseased. Now, since it is important to distinguish this operation from that of ovariotomy proper, and since the term spaying, which technically defines the character of the operation, is obnoxious from its association with the lower animals, the terms öophorectomy, or Battey's operation, have been adopted.

In well-selected cases this operation has been followed by wonderful results; but it has been greatly abused. By it I have restored to perfect health cases of otherwise incurable fibroid tumors of the womb, cases of dysmenorrhoea and of menorrhagia, and cases of pernicious menstruation in which the sufferers were reduced to the last degree of emaciation and feebleness. Out of 5 cases of ovarian insanity I have also cured 4; the fifth, while not wholly restored, is yet very much better.

This operation has been performed both by the vaginal and the abdominal section. For some years I was a warm advocate of the vaginal method, but I have wholly given it up, because by this method of operation adherent ovaries cannot be safely dislodged, the ovaries cannot always be reached, the vaginal wound cannot be dressed antiseptically, {292} and because the abdominal mode is more simple and less dangerous. Only when the ovaries are dislocated and low down in Douglas's pouch would I possibly resort to the vaginal incision.

If the abdominal operation be performed, the incision should be made between the navel and the pubes in the median line, and not over each ovary, as advised by some authors. One great caution must, however, be observed, and that is not to wound the intestines. In ovariotomy the cyst is in front of the intestines, and there is very little danger of injuring the latter. But in cases of öophorectomy, no tumor being present, the bowels lie in contact with the wall of the abdomen, and are very likely to be wounded by the knife when the peritoneum is incised. The incision should be long enough to admit two fingers. These, being passed behind the womb, are conducted to the ovary by gliding along the oviduct as a guide. Each ovary, together with its oviduct, is in turn brought up to the opening. It is then seized by a fenestrated polypus-forceps and its stalk transfixed, tied on either side with fine silk, cut off, and dropped back into the abdominal cavity. Should the stalk be so short that ovarian tissue is left behind in the button of the stump, it should be destroyed by Paquelin's cautery, for it is astonishing how small an amount of this tissue will keep up not only menstruation, but even menorrhagia. On the other hand, it will not answer merely to ligate the pedicles without removing the ovaries. This has been tried, and not only did menstruation continue, but in one instance pregnancy took place.[7]

[Footnote 7: Murphy, _British Medical Journal_, April 18, 1885, p. 787.]

The dressing is precisely the same as in ovariotomy, and, like it, the operation should be performed with every detail of antiseptic surgery.

In the vaginal operation the vagina first should be thoroughly cleansed with a solution of carbolic acid, and the patient placed on her back and not on her side. I am convinced from experience that the usual left-lateral position is a dangerous one, for as soon as the peritoneum is opened the air rushes out and in during every inspiration and expiration--an untoward circumstance which cannot happen in the dorsal position. A duckbill speculum is introduced, and the perineum pulled downward. The cervix uteri is transfixed by a strong thread, by which the womb is drawn downward and forward. The post-cervical mucous membrane is next caught up by a uterine tenaculum and snipped open for about an inch. The index finger of the left hand is then passed in, and each ovary brought down to the incision by the finger-tip hooked into the sling made by the oviduct. The ovary is seized by a fenestrated forceps and brought into the vagina, where its stalk is transfixed by passing a needle armed with a double thread between the ovarian ligament and the oviduct, and each half is securely tied. The ovary and the fimbriated end of the oviduct are then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. To close the vaginal opening one or two stitches will be needed, and finally the wound is covered with iodoform and the vagina gently packed with pads of carbolated or salicylated cotton.

It is a fact worthy of note that during the week following the ablation of the uterine appendages a sanguineous discharge from the womb usually takes place. This is in no wise a menstruation, but a metrostaxis {293} set up by the irritation of the ovarian nerves, caused by the means adopted to secure the pedicles. Candor, however, compels me to say that for some inexplicable reason the removal of the uterine appendages--viz. ovaries and oviducts--does not always bring about the change of life. These cases are exceptional, and they are supposed to be due to either the presence of a third ovary or to some small portion of ovarian stroma left behind.

This operation in no wise unsexes a woman or changes her appearance or character. It simply brings on the change of life with its attendant phenomena. Her instincts and affections remain the same, her sexual organs continue excitable, her breasts do not wither up, and she is no less a mother or a wife.[8]

[Footnote 8: _Lessons in Gynæcology_, by Wm. Goodell, M.D., chap. xxvi.]

Extra-Ovarian Cysts.

There is a class of tumors which, while not ovarian, lie so near to the ovary as often to involve it, and usually need precisely the same treatment as cysts of that organ. In their extirpation the ovary is almost always also involved. This close anatomical relationship makes it needful to describe them in conjunction with ovarian tumors. They comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called the Hydatid or Vesicle of Morgagni.

Cysts of the Parovarium.

These are formed from the dropsical distension of one of the tubules of the parovarium, or organ of Rosenmüller, which lies between the folds of the broad ligament and between the ovary and the oviduct. Usually, one tubule alone is affected, and the cyst is then unilocular; but exceptional cases have been met with in which several of the tubules have become dilated, and the cyst is then bilocular or even multilocular.[9] These cysts are often called cysts of the broad ligament.

[Footnote 9: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans. American Gynæc. Soc._, 1881, p. 231.]

By examining cysts in their early stage Albert Doran has demonstrated that "the vertical tubes of the parovarium are lined with epithelium, sometimes ciliated, but oftener cubical, the original, primitive form of the tubes of the Wolffian body. From these tubes and from the hilum of the ovary, full of Wolffian relics, spring the multilocular papillary cysts which give so much trouble to the operator. At the outer end of the horizontal tube of the parovarium is a cystic dilatation which is lined with a structure resembling endothelium. Apart from the parovarium, between the folds of the broad ligament, minute cysts are frequent. It is from these and from the terminal cyst of the parovarium that the simple unilocular so-called parovarian cyst arises. The terminal cyst of the Fallopian tube never attains a large size, and no true cysts of the broad ligament appear, when young and minute, to arise from that tube."[10]

[Footnote 10: _British Med. Journal_, Oct. 21, 1882, p. 792.]

{294} These cysts are more commonly found in young women. From the thinness of their walls and the limpid character of their fluid, they yield very marked waves of fluctuation which are equally distinct at every point. They can usually be distinguished from ovarian cysts either by a lack of that tenseness so characteristic of the latter or by varying conditions of tenseness and flaccidity, as if the fluid were sometimes absorbed more quickly than at other times. They also grow more slowly than the ovarian cyst, and do not exert the same profound constitutional impression. The facies ovariana is absent, and the health of the woman may in no wise be disturbed. They, indeed, in the majority of cases, seem to do no harm, and are merely annoying from their bulk. The fluid they contain is with rare exceptions as limpid and clear as spring-water, but with refractive powers so high as to magnify the fibres of the wooden pail into which it has been drawn off.

Owing to their very thin walls and delicate structure these cysts on very slight provocation are liable to burst. On account of the blandness of the contained fluid this accident is rarely followed by collapse or by peritonitis. The rent heals up and the cyst usually refills; but in a large proportion of cases it does not, and the woman remains permanently healed.[11] Sometimes they are pedunculated, but often they lie between the two folds of the broad ligament, having no proper stalk.

[Footnote 11: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans. American Gynæcological Society_, 1881, p. 226.]

Cysts of the broad ligament must not be confounded with those ovarian cysts which, instead of growing free in the peritoneal cavity, develop between the two layers of the peritoneum--intra-ligamentous ovarian cysts, as Garrigues very aptly calls them in his paper on the "Diagnosis of Ovarian Cysts."[12] In this excellent paper, from which I have gleaned much, he says that sometimes the anatomical relations are so lost that nothing short of a microscopic examination of the outer epithelium can determine the character of the cyst. Thus, "a tumor covered with columnar epithelium is ovarian, and cannot be anything else; while the cyst of the broad ligament, being covered with peritoneum, has flat peritoneal endothelium. In cases of intra-ligamentous development of an ovarian cyst the lower portion is covered by peritoneum, but the upper part has the columnar epithelium characteristic of the ovary." There are, however, certain macroscopic characteristics which will generally tell the nature of the cyst. For instance: usually by a careful examination the corresponding ovary will be found either stretched out and spread out in the wall of the sac, or, what in my experience is more common, elongated and forming a part of the stalk. These cysts are in the vast majority of cases monocysts, while unilocular ovarian cysts are very rarely if ever met with. Their walls are thin, of a conjunctival blue, and fretted with a delicate network of blood-vessels. The oviduct is usually imbedded in the cyst, and by transmitted light its fimbriæ can be traced out in the cyst-walls in long fronds as delicate as those of dried and pressed seaweed. Then, again, the peritoneal coat is readily stripped off. On the other hand, in an ovarian tumor the oviduct is not ordinarily incorporated in the cyst-wall; in fact, a meso-salpinx usually exists; and, further, the peritoneal coat, being nailed down to the cyst-wall proper by the cicatrices of ovulation, is not capable of being stripped off.

[Footnote 12: _Am. Journ. of Obstetrics_, April, 1882, p. 394.]

{295} TREATMENT.--Since these cysts do not ordinarily affect the general health or grow to a very large size, they should, as a rule, be let alone. Whenever grounds for interference arise the cyst should be aspirated, for sometimes after being wholly emptied it does not refill. Should, however, the fluid return, the cyst must be extirpated in precisely the same way as an ovarian tumor. When it is without a pedicle it will have to be carefully enucleated from between the folds of the broad ligament, which then cover it. If this cannot be done, all of the cyst possible should be removed, the edges stitched to the abdominal wound, and a drainage-tube put in. This is the advice ordinarily given, but I have not yet met with a cyst of this variety which could not be removed. Were such a one to occur in my practice I should be tempted to remove all of the cyst possible, and to close up the adherent portion in the cavity of the abdomen without resorting to a drainage-tube. The fluid secreted by a parovarian cyst is so bland that I believe no mischief would arise. The late Washington L. Atlee was accustomed to make merely a large circular opening in the cyst, without attempting to remove it.

Cysts of the Oviducts, or Fallopian Dropsy.

These tumors may contain either fluid or pus. In the former case the cyst is called hydro-salpinx; in the latter, pyo-salpinx. They are caused by salpingitis, or inflammation of the oviduct, which exists rarely per se, unless of gonorrhoeal origin, but is one of the sequels of pelvic peritonitis. The distension of the tube is due to the occlusion of each of its ends. Thus by pelvic inflammation the fimbriæ become glued to the ovary, sealing up the ovarian end, while an endometritis closes the uterine opening. In addition to the dropsy of the tube, I have repeatedly met with small cysts, or bladder-like bodies outside of the tube proper, very analogous to those found on the umbilical cord.

This affection is by no means an uncommon one, every age being liable to it, and it is often the unrecognized cause of ill-health. Since Tait first called the attention of the profession to the frequency of the disease and the means for its cure, many cases have been reported in which obscure pelvic symptoms were cured by the removal of the ovaries and of the oviducts--the uterine appendages, as they are called.

DIAGNOSIS.--This is difficult, because the symptoms are those of pelvic peritonitis or of pelvic cellulitis, the disease of the oviduct being usually associated with that of the broad ligament. In some cases the womb will be found movable, with a sausage-like tumor behind it; the diagnosis is then easy. Usually, the symptoms are negative, and the diagnosis is based upon constant groin-pains and recurring attacks of pelvic inflammation.

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 {296} 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.

[Footnote 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]

[Footnote 14: _Medical Times and Gazette_, Dec. 1, 1883.]

{297} 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.

[Footnote 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."

[Footnote 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 {298} 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]

[Footnote 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]

[Footnote 18: _Op. cit._, p. 148.]

DIAGNOSIS.--Since, as has been shown, this cannot always be made {299} 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, {300} 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."

[Footnote 19: Elsner, _Dublin Journal Medical Sciences_, May, 1882, p. 380.]

[Footnote 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 {301} 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 {302} 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]

[Footnote 21: _Edinburgh Medical Journal_, July, 1885, p. 76.]

[Footnote 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]

[Footnote 23: _Trans. Amer. Gynæcol. Soc._, vol. i. p. 195.]

[Footnote 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 {303} 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, Aronson[25] 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 {304} 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.

[Footnote 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.