COLUMBIA LIBRARIES OFFSITE HEALTH ' 11 !!i HX00039624 mtl)fCttpotI^rtng0rk College of ^fJPSiiciansi anb ^urgeong Xibrarp Dr. w. n.B^ii Digitized by the Internet Arcinive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/clinicalpathologOOdora CLINICAL AND PATHOLOGICAL OBSERYATIONS ON TUMOURS OF THE OVARY, FALLOPIAN TUBE, AND BROAD LIGAMENT BY ALBAN H. G. DOEAN, F.E.C.S. ASSISTANT-SURGEON TO THE SAMARITAN FREE HOSPITAL FOEMERLT ANATOMICAL AND PATHOLOGICAL ASSISTANT TO THE MUSEUM OP THE ROYAL COLLEGE OF SURGEONS OF ENGLAND WITH THIRTY-TWO ILLUSTRATIONS BY THE AUTHOR AND C, J. BERJEAU LONDON SMITH, ELDEE, & CO., 15 WATEELOO PLACE 1884 1411 rights reserved] Qv' />• \^ .*- PEEFACE. •Sl^XE I first joined the staff of the Samaritan Free Hospital in the spring of 1877, I have assisted at nearly seven hundred abdominal sections. In Xovemher 1877, I determined thence- forth to take brief notes of every case that came under my notice, either at that institution or elsewhere. In this manner I have succeeded in collecting a considerable amount of material, upon which this work is founded. I have avoided certain sub- jects that have repeatedly been discussed by surgeons who have had frequent opportunities of perfonxdng ovariotomy, such as statistics of mortality, the merits of the antiseptic system, the use of the drainage tube, the weight of tumours, and the nature of their fluid contents. On the other hand, I have dwelt at some length upon other pathological and cHnicai questions in relation to tumours of the uterine appendages. In this wav I have endeavom-ed to utilise the resources of the Samaritan Hospital after the manner of Dr. Henry Savage and the late Dr. C. H. Eitchie ; the ' Surgery of the Female Pelvic Organs ' of the former being based to a great extent upon researches made at that hospital, whilst Dr. Ritchie's ' Ovarian vi FREFACE. Physiology and Pathology ' was the result of the examination of a large series of ovarian tumours removed by Sir Spencer Wells at the same institution. In the chapter on the origin of multilocular ovarian cysts, I have described the result of repeated examinations of human foetal, infantile, and adult ovaries prepared for me after dififerent methods by different experts, and have given my reasons for believing that these tumom-s most probably arise from Graafian follicles that have never developed into corpora lutea. Under natural conditions such follicles undergo atrophy, but under certain morbid influences they develop into cysts. This point cannot be thoroughly settled till the verification or refutation of Dr. Fouhs' theory that the cells lining the follicles arise from the stroma, and not from the germinal epithelium together with the ova. If this theory be perfectly correct, a purely stromal origin for cysts becomes possible. If the stroma normally pro- duces cells to line cavities protectiog ova, it is easy to under- stand that it may, under pathological influences, produce such cells where there are no ova. Under Balfour's theory, that the follicular cells arise with the ova from the germinal epithelium, each collection of such cells in the stroma must be considered to be a follicle, and any morbid growth from such cells would be of essentially follicular origin. The relation of ovarian cysts to the broad ligament, and the true origin and nature of cysts that are found within the layers of that peritoneal fold, are subjects that have particularly interested me, as I have enjoyed favourable opportunities of studying morbid conditions of the broad ligament, when engaged PREFACE. vii in the examination of several hundred cysts and uterine appen- dages immediately after operation. I prepared a large number of specimens illustrating the morbid anatomy of the broad ligament, for the Museum of the Eoyal College of Surgeons of England, a few years since, and some of my views on the subject are published in the archives of metropolitan societies. They will be found, in a collective form, in the third and fourth chapters of this work. I have devoted further chapters to the consideration of other subjects associated with disease of the ovaries and broad ligament. The arrangement of these subjects being, for various reasons, somewhat different from that which is famihar to the reader of ovarian literature, I have added an index to facilitate reference. In describing specimens which I have prepared for the Museum of the College of Surgeons, I have added the number of each specimen as given in the new edition of the Catalogue of the Pathological Series. As the volume of the new Catalogue which includes the series of speci- mens illustrating diseases of the uterine appendages is not yet published, it is possible that some of the numbers may be altered when that volume appears in print, but, on reference to the series in question, there will be little difficulty in identifying the specimens. I have avoided synonyms, in which ovarian literature abounds, as much as possible, and endeavoured to adhere to a nomenclature that is in conformity with general pathology. I have used the terms ' papilloma ' and ' papillary tumour ' indis- criminately for morbid growths the essential feature of which is that they consist of papillary masses, but have avoided the viii PREFACE. former term ' papilloma,' in reference to glandular or adenoma- tous tumours that bear papillary growths on their surfaces, as I have explained at p. 31. As to the term 'glandular growth,' it has so long been employed by writers on ovarian disease, that I have generally made use of it in preference to the more modern expression ' adenoma.' The illustrations are entirely original. Nine, namely figs. 13, 14, 15, 16, 17, 19, 26, 27, and 29, were drawn by Mr. C. J. Berjeau; the remainder were sketched by myself, mostly from recent specimens. The engraving has been exe- cuted by Mr. Danielsson (Lebon and Co.). In fig. 2, 3, p. 10, the appearance of the epithelium is somewhat unnatural, owing to the free border having been inadvertently shaded. I have specially mentioned in the different chapters of this work the names of those colleagues and friends to whom I have been indebted for aid in my pathological researches, and I here take the opportunity of thanking them collectively for their kind assistance. 51 Seymour Street, Londox, W. July 1884. CONTENTS. CHAPTER PAGE I. THE ORIGIN OF THE COilAION MULTILOCULAR OVARIAN CYST 1 II. MULTILOCULAR AND GLANDULAR OVARIAN CYSTS . . 14 III. THE PAROVARIUM AND ITS RELATION TO CYSTIC *DISEASE OF THE BROAD LIGAMENT — SIMPLE BROAD LIGAMENT CYSTS . . . . . . . . .40 IV. PAPILLOMATOUS AND SESSILE OVARIAN CYSTS — PAPILLO- MATOUS DISEASE OF THE BROAD LIGAMENT . . 59 V. DERMOID CYSTS OF THE OVARY . . . . .77 VI. SOLID TUMOURS OF THE OVARY ..... 93 VII. RUPTURE OF OVARIAN CYSTS . . . . .105 VIII. TWISTING OF THE PEDICLE . . . . . .118 IX. THE ABDOMINAL WOUND — NOTES ON ADHESIONS . . 126 X. COMPLETE INTRA-PERITONEAL LIGATURE OP THE PEDICLE '137 XI. MORBID CONDITIONS OF THE KIDNEY ASSOCIATED WITH OVARIAN TUMOURS ...... 152 XII. TUMOURS OF THE FALLOPIAN TUBE . . . .165 LIST OF AUTHORS QUOTED IN THIS WORE . . .177 INDEX ISl ILLUSTEATIONS. Fie. 1. 2. 3, SECTIOX OF THE OVAEY OF A SEVEN-MOlsTHS' FCETUS , CHANGES IX ATKOPHTING FOLLICLES .... AGS 4 10 4. GLANDULAE OE ADEXOirATOUS GEOTVTH FEOM THE INTEEIOE OF A MTJLTILOCULAE CYST 32, 33 DIAGEAM OF THE STErCTUEES IN AND ADJACENT TO THE EEOAD LIGAMENT PAEOVAEIUM, SHOWING CYSTS DEVELOPED FE03I ITS TrBES, AND GAETNEE'S DUCT HYDATIDS OF ilOEGAGNI ABOVE AND BELOTV THE NOEMAL DEGEEE OF DEVEL0P3IENT ........ 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. PEDUNCULATED BEOAD LIGAMENT CYSTS SESSILE BEOAD LIGAMENT CYST OF PAEOVAEIAN OEIGIN DISSECTION OF A BEOAD LIGAMENT CYST DEVELOPED INDEPEN- DENT OF THE PAEOVAEIUM A SIMPLE EEOAD LIGAMENT CYST . A SMALL MULTILOCULAE OVARIAN CYST INCIPIENT CYST OF THE HILUM OF THE OVAEY A LAEGE CYST OF THE HILUM OF THE OVAEY DERMOID CYST OP THE OVARY EOUSD-CELIiED SARCOMA FROM A DERMOID CYST 42 43 45 46 47 47 BEOAD LIGAMENT CYST DEVELOPED ABOVE THE FALLOPIAN TUBE 48 BEOAD LIGAMENT CYST DEVELOPED IN THE PROXIMITY OF THE OVAEIAN FIMBRIA OP THE TUBE 53 54 60 61 62 87 90 xii ILL USTRA TI0N8. FIG. PAGE 19. myoma of the ovaky 97 20. spijStdlk-celled sarcoma of the OVAEY 99 21. round-celled sarcoma developing in an ovary ... 99 22. ALVEOLAR SARCOMA OF THE OVARY 101 23. TUMOUR OP THE OVARY OP UNCERTAIN NATURE .... 102 2'1. THE SAME TUMOUR, MORE HIGHLY MAGNIFIED .... 102 25. CANCER OF THE OVARY 103 26. SECONDARY CYST UNDERGOING EPFAGBMENT 116 27. DERMOID CYST TWISTED OFF ITS PEDICLE 123 28. PEDICLE OP THE SAME CYST 123 29. CYST, TWISTED OFF ITS PEDICLE, RECEIVING VASCULAR SUPPLY PROM ADHESIONS 124 30. DILATED VEIN PROM A TWISTED PEDICLE . . . . j 125 31. CYST AND ADJACENT PARTS AFTER LONG DRAINAGE . . . 131 32. STUMP OP AN OVARIAN PEDICLE : DEATH PROM TETANUS ON THE EIGHTH DAY AFTER OPERATION 141 TUMOUES OF THE OVARY, TUBE AND BROAD LIGAMENT. CHAPTEE I. THE ORIGIN OF THE COMMON MULTILOCULAR OVARIAN CYST. Of all questions connected with ovarian pathology the most unsatisfactory is the origin of the common multilocular ovarian cyst. Where there are many opinions there must also be much error, and careful and competent observers differ strongly from each other as to the development and normal condition of the tissues which are the seat of the most interesting form of disease affecting the ovary. Many seem to have based their chief theories on what are really terms given to appearances. I refer particularly to the so-called tubes of Pfliiger, round which expression the arguments of De Sinety and Malassez may be said to revolve. Others trace ovarian cystic disease to a colloid or mucoid change in the ovarian stroma, but are not agreed among themselves as to the precise nature of the primary change, some believing that it originates within the Grraafian follicles at some stage of their development, others that it is entirely independent of these structures. I have had the opportunity of examining a considerable number of fcetal human ovaries, and also of comparing them with the ovaries of children under puberty. One result of my observations is that I cannot help agreeing with the conclusion of Balfour and Foulis, both of whom I know to have had far greater experience than myself in the study of the develop- B 2 TUMOUHS OF THE OVAHY, ment of the healthy ovary, that the tubes of Pfliiger do not exist as such. A fertile soui'ce of eiTor amongst niicroscopists is the idea that a section represents the natural condition of a structure. It is true that a cell is admitted to be not a flat plate, or a mere smface with a round or fusiform outline, and with, it may be, processes radiating from the outline alone, but a more or less spherical solid body, where processes, when they exist, radiate in all directions from the entii^e periphery. It is not so often remembered that what appear to be networks of filamentous processes, are in reality planes of delicate tissue, intersecting one another, so as not merely to enclose a space, but also to box up solid matter. A section, in such a case, shows what appear to be tubes cut across, but what are really collections of cells smTounded completely by stroma. In short, the microscopist must be ever on the alert lest he take appear- ances for facts. I feel bound to declare that, whilst in no way claiming to discover what Balfour and Foulis have discovered, or advanced as a theory, I ever believed that the ' tubes,' as I saw them in fcetal human ovaries, were simply rows of follicles imbedded in the ovarian stroma. Whether they had imbedded themselves, growing down from the germinal epithelium, or whether the stroma had gro-wn up into the limits of that epithelium I never could decide ; but I saw that the epithelium was in rows deeply imbedded in the stroma, and that the rows were not tubes. Putting aside the main point where Balfour and FouKs differ — the former believing that the follicular epithelium is derived from the germinal epithelial cells, whilst Dr. FouHs contends that it is developed from the connective-tissue cells of the ovarian stroma— I will quote the opinions of these accurate observers on the Pfliiger's tube theory. Balfour considered that the parenchyma of the ovary was made up of thickened germinal epithelium, differing from the original germinal epithelial patch in that it is broken up into a kind of meshwork by ingrowths of the stroma. Hence Pfliiger's tubes are merely trabecule of germinal epithelium. Dr. FouHs says : ' All the ova are derived from the germ- epithelial cells. In the development of the ovary, small and large TUBE AND BROAD LIGAMENT. 3 groups of the germ-epithelial cells become gradually imbedded in the ever-advancing stroma. Germ-epithelial cells do not grow downwards into the substance of the ovary. The ovarian stroma constantly grows outwards, surrounding and imbedding certain of the germ- epithelial cells. As these latter increase in size and as the stroma thickens around them, the whole ovary becomes enlarged. Pfliiger's tubes in the kitten's ovary have no existence as such, but are appearances produced by long groups of germ-epithelial cells, many of which groups are not completely cut off from the germ- epithelial layer by the young ovarian stroma. Such groups of germ-epithelial cells, in various forms, are met with in all ovaries, but have no importance whatever as tubular structures. In the human child's ovary numerous furrows or clefts between irregularities of the surface are met with. Sections through these furrows and clefts produce the appearance as if the germ-epithelium (pseudo-epithelium, Balfour) passed downwards into the ovary in the form of tubular open pits, as was described by Waldeyer and his pre- decessors. No real tubular structures, from which Graafian follicles are formed, exist in the mammalian ovary at any stage of its development. Graafian follicles are formed only in one way from the beginning of the ovary to the end of its exist- ence.' All that I have observed in examining the parenchyma of human foetal ovaries appears to be in accord with the opinions of Balfour and Foulis concerning Pfliiger's tubes. The drawing (fig. 1) represents a section of a portion of the parenchyma of the ovary of a seven months' foetus. The section was prepared for me in the physiological laboratory of St. Bartholomew's Hospital by my friend Dr. Vincent Harris. Here the ova are clearly arranged in the * meshes ' of the stroma. In this speci- men several of the clefts and furrows on the surface existed ; such would have been taken by Waldeyer for tubes. But the germinal epithelium, unchanged in character, covers the entire contour of each cleft. To return to the arrangement of the stroma, it will be seen that the usually circular form of its meshes, enclosing several follicles, implies that when the ovary is solid, and not reduced to a microscopical section, these folli- cles lie in spherical cavities in the stroma. For this stroma, in B 2 TUMOURS OF THE OVARY, growing up around the cells, has enclosed groups of them in all directions, so that these groups lie in cavities of the stroma, and not in meshes. And even if it be the germinal epithelium that grows down into the stroma, the result is the same, the stroma grows around the epithelial cells in all directions so as to enclose them in cavities. A glance at fig. 1 will show that if the cavities were tubes cut across, they must be very large tubes indeed, and, as they are all very similar in shape, they must repre- sent a group of tubes running in the same direc- tion. We would naturally expect then that, if a sec- tion of the ovary were made in a different plane — that is to say, from side to side, and not from its free border towards the hilum — we should see the tubes in longitudinal section giving a very characteristic appearance. But this is just what never has been seen. Again, as the cavities in the section (fig. 1) are of very con- siderable diameter, we should expect to find their orifices on the surface of the ovary at least equally wide. But we find no such orifices, and it is vain to say that the tubes once had openings, but that these openings, and parts of each tube, have become choked off by ingrowths of stroma. This choking-off process is a mere term, a clumsy way of expressing the surrounding of groups of cells by stroma. Fig. 1. — 1. Section of the Ovary of a seven months' Foetus, a. Germinal epithelium. 6. Primitive ova with trabecule of stroma beginning to surround them. c. Graafian follicles with epithelial lining (membrana granulosa) and ovum in the centre. The stroma has forced its way between the follicles. d. A Graafian follicle cut so that only a small segment, not including an ovum, is seen ; there are several others in this condition. At e the contents and lining of the follicles are not drawn, so as to show the arrangement of the stroma, x 250. 2. A primitive ovum (1, 6) surroimded by stroma, 3. A follicle from the deeper part of section 1 (1, c). 4. Section through a Wolffian tube in the hilum of the same ovary, showing very distinct lining of ciUated epithelium and a small thick- walled vessel near the tube, x 400. TUBE AND BROAl) LIGAMENT. 5 As the stroma increases, the cavities lose their circular outline, and become pressed against each other, so that an appearance is produced as though a convoluted tube were cut across in its long axis. The e\ddence that the tubes of Pfliiger have no existence as such must seriously affect the value of the theories of De Sinety and Malassez, which are based to a great extent on the doctrine that elements in the germinal layer invade the ovarian stroma, in process of normal development, or under morbid influences. Their * pathological ingrowths' (enfonce- ments pathologiques) are evidently meant to be on the type of Pfliiger's tubes. Still, I do not deny that these distinguished authorities may have reasoned rightly ^ on wrong premisses, and considering the vast amount of labour which it is known that they have expended in the study of ovarian disease, all their conclusions deserve to be most carefully taken into account. The next question affecting all theories on the origin of ovarian cysts is the nature of ' colloid ' deposits in the ovary. Whatever they may be, they have been described by different pathologists as the product of some form of degeneration com- mencing in the stroma, in the walls of the Grraafian follicles and corpora lutea, and in the walls of the large blood-vessels that are found in the ovary. My observations lead me to believe that the change may begin in any of these structures. The ' colloid ' deposits are exceedingly common in ovaries at certain periods of life ; the observer must be careful when studying this condition to distinguish extra-foUicular from intra-follicular colloid growths, and to be certain that he does not overlook appearances produced by the disintegration of corpora lutea and of Graafian follicles that have atrophied without ever having attained their fullest development. This is no easy task, for, putting aside the intricate histology of each essential element of the ovary in its well-developed form, the pathologist must not forget that changes in the stroma and vessels are very frequent. Still more important is it to remember that an infant's two ovaries contain at birth many thousand ova. Waldeyer computes the number at 300,000. What is to become of all these ova ? They are complicated 6 TUMOURS OF THE OVARY, structures, and include epithelial elements ; but on comparing a good section of an infantile ovary witli another of an adult ovary it will be seen how the former is studded with Grraafian follicles, and how, comparatively, these structures are scarce in the latter. On the other hand, the stroma of the infantile ovary is tolerably uniform in the parenchymatous portion, whilst in the adult singular hazy, gelatinous patches and streaks are often to be detected, scattered over the stroma in all direc- tions. Waldeyer, Beigel, and others declare that the follicles do not lie latent till puberty. They ripen and atrophy, and do really form a kind of corpus luteum. The truth must be so, or else several thousands of the follicles atrophy without ripening ; there is no third way of accounting for the rapid disappearance of a large proportion of these structures between birth and adult life. In comparing a section of the ovary of a seven months' foetus with that of the ovary of a child aged three, both in my possession, I was struck with the great diminu- tion in the number of follicles in the latter specimen, after taking the increase of stroma thoroughly into account. The stroma in the older ovary was far less uniform, its fibres were less distinct, and there were suspicious hazy patches between them at certain points. I cannot see that these patches can be explained in any other way than by the theory that they are the remains of follicles. The development and subsequent retrograde changes in corpora lutea, as distinguished from atrophied follicles, are tolerably well known. The more deeply-seated follicles cer- tainly atrophy in a different manner. The membrana granu- losa falls in, its epithelial cells become detached and collect as a granular mass. I have observed this condition, first described by Hermann Beigel, but am not sm-e that the detach- ment of cells may not be partly caused by the microtome. The stroma always thickens around the collapsed membrana granulosa, and the result is a sinuous ring (fig. 2, i h), semi- opaque and continuous at first, but soon becoming incomplete through ingrowth of stroma, and at length nothing is left but a zigzag line of this semi-opaque substance. On the other hand, the complete sinuous ring may become much thickened, probably from continuance of the changes in the surrounding TUBE AND BROAD LIGAMENT. 7 stroma. Patenko, as well as Beigel and myself, has traced the atrophy of the follicles to the last stage, where a sinuous ring is formed, the ovarian stroma pushing into the sinuosities. The semi-opaque tissue appears to be made of exceedingly fine granules. Patenko describes a further change following atrophy whereby tough, semi-opaque bodies termed corpora fibrosa are formed ; these are familiar to anyone who has had the opportunity of examining a large number of ovaries. These bodies represent a condition that is essentially and extremely atrophic — abnormal atrophy of the undeveloped follicle, in fact. I now turn to the reverse change, abnormal development interrupting the atrophic process. I cannot help thinking that the origin of cystic disease is to be sought from careful and prolonged study of the difi'erent changes which follicles in process of atrophy may imdergo, when influences which it may be impossible to trace prevent the atrophy from ever being completed. Let the epithelial elements of the original folhcle be even but in part preserved, then subsequent changes, the reverse of atrophy, may be readily understood. I have noted the frequency with which the stroma of enlarged ovaries, exhibiting all the traces of cystic disease,. is studded with little semi-opaque patches, just visible to the naked eye and not thin- walled. Such ovaries were the fellows of large multilocular cysts, and were themselves en- larged to the size of a small orange, and bore several cysts containing glairy albuminous fluid like the contents of the tumour of the opposite ovary. I must here refer to a very characteristic specimen already described in a contribution to the ' Journal of Anatomy and Physiology,' by Dr. Vincent Harris and myself, but since then I have very carefully re-examined sections of this specimen. On July 15, 1880, Dr. Bantock removed a large multilocular cyst of the right ovary from a robust young married woman, aged twenty-eight. She had been married nearly two years, and, not having menstruated for several months, believed her- self to be pregnant, which was not the case. The left ovary was nearly three inches in diameter, and almost spherical in form ; its surface was very slightly puckered at certain points. On section, a large number of thin-walled cysts were found, 8 TUMOURS OF THE OVARY, varying from one-twentieth to one-twelfth of an inch in dia- meter. These were mostly Grraafian follicles and contained ova. Between the follicles the stroma was very abundant and succulent. It closely resembled the stroma that often lies below the cyst, that represents, in fact, the remains of ovarian tissue, in a large multilocular ovarian tumour. By ' below ' I mean between the tumour and its pedicle. There was one very recent true corpus luteum, oval, and seven lines by three in diameter; it had a thin yellow margin, and contained a dark red clot. I must here observe that in cases of simple dilatation of Graafian follicles I have generally found the stroma, on the other hand, much condensed ; this favours the view that the dilatation is due to changes which surround the follicles with toughened tissue, preventing rupture for a long time. Simple dilatation of follicles is a very frequent concomitant of ovarian disease, and is not rare independently of that affection. The follicles, in these cases, bulge very freely from the surface of the ovary, whilst in instances where there is evidence that incipient cystic disease exists, the entire parenchyma of the ovary is as a rule uniformly dis- tended. Indeed, dropsy of the follicles differs from common cystic ovarian disease as much as the latter differs from papil-' lary cystic disease of the ovarian hilum. In the first the cysts bulge from the free border of the ovary, in the second the ovary enlarges in a uniform manner, whilst in the third the tissue of the hilum becomes distended, and pushes the parenchyma outwards, the free border of the ovary being long recognisable, until the papillomatous cyst has reached very large proportions. As to the alleged occasional origin of the common form of cystic disease from dilated matm'e follicles, I cannot say that the theory has been ever disproved, but evidence is strongly against it. On microscopic examination of the specimen now under consideration, the normal follicles were very evident, and in the abundant stroma that surrounded them were large numbers of follicles in every stage of degeneration. Some were reduced to a sinuous band, many formed fusiform bodies consisting of radiating cloudy structures, bearing traces of degenerate nuclei. In the centre were broken-down masses of pigment. TUBE AND BROAD LIGAMENT. 9 The bands were very distinctly circumscribed by the surround- ing stroma, which sent in filiform processes of elongated and nucleated cells. Every stage of degeneration of the follicle could be traced, and of the follicular origin of the bands there could be very little doubt. I do not wish to enter here into tedious con- troversy, further than to remark that Dr. H. S. Grabbett has disputed the conclusions of Dr. Harris and myself on the rela- tion of these ' colloid ' changes to cystic disease of the ovaries, and on the intrafollicular origin of the colloid deposit. As to the latter point, I must observe that Beigel and Patenko, working on perfectly different principles from Dr. Harris and myself, have both traced, as we have traced, the intrafollicular origin of the ' colloid ' changes. I do° not deny that a colloid change may occur in the stroma outside the follicles, but this appears to be simply an increase of the intercellular substance, which becomes unusually granular. In regard to the relation of these changes to cystic ovarian disease, I perfectly agree with Dr. Grabbett that they are found independently of that affection ; that they are very frequently seen in healthy ovaries ; and that they are important factors in bringing about atrophy of the . ovary. But I also have reason to believe that ovarian cystic disease, in a large number of cases, originates in some arrest of the downward progress of the normal degeneration of the atrophying follicles. Fig. 2 shows sections of the ovary in question. I have not drawn any of the larger follicles in the earlier stages of de- generation, several of which existed in the same specimen, but I have drawn (fig. 2, i, ci) a degenerate follicle in its most advanced stage, being nearly efiaced, and (6) another, not quite so advanced ; here a part of the sinuous band remains, else- where the stroma has invaded the follicle. These structures bear all the characters which Beigel and Patenko have described and figured as degenerate follicles. On the opposite side of the section was a large cavity (fig. 2, 2) with a similar sinuous border, within which a second well-defined margin was developed. After careful examination, I satisfied myself that this cavity was not a vein, nor an artery, nor a large follicle, nor a degenerate true corpus luteum. It 10 TUMOUitS OF THE OVARY, must be understood that I apply this term, as Beigel and others have done, to the corpus luteum of pregnancy and men- struation as distinguished from that of a follicle that has never developed. It had no resemblance to any of those structures, Fig. 2.— Changes in Atrophying Follicles. 1. (Mag. 2 inch objective.) a. A degenerate follicle nearly effaced. 6. Another not so ^ near complete effacement ; a vein and artery lie close to it. 2. (2 inch objective.) A degenerate follicle from the same ovary, developing into a cyst. Tissue has formed internal to the sinuous border. 3. (J inch objective.) The free border of 2 (at a) showing a distinct epithelial lining. all of which existed in the same ovary, nor did it bear any like- ness to some Wolffian relics in the deep part of the stroma. On examining the inner margin under a ^-inch objective, I could detect a distinct lining of cubical epithelium (fig. 2, 3), and such epithelium lined the free margins of all the cavities that existed within the sinuous bands. The cells were never ciliated, although it must be here remembered that the epithe- lium lining the Wolffian ducts often retains its primitive cubical epithelium, which fail to develop cilia. But the cavi- ties under consideration were far from the tissue of the hilum, and small follicles lay near them. The cells bore a strong resemblance to those of the membrana granulosa in certain stages of its development. I cannot help thinking that it is rational, therefore, to trace the origin of these cavities to changes in follicles. In the monograph by Dr. Harris and myself, an account will be found of several variations, as we believed them to be, of the process of change in atrophied follicles leading to cystic disease, with sketches of the microscopic appearances. They were from two ovaries, the one more than half an ounce in weight, the other weighing exactly one ounce, and each was fellow to a large multilocular cyst, and removed as suspicious. TUBE AND BROAD LIGAMENT. 11 In the one case, opaque bodies, some ^V i^^^ i^ diameter, lay in the stroma, which sent numerous delicate ingrowths between the semi-opaque, sinuous bands of which the body was com- posed. These ingrowths formed what in a section appeared as a meshwork ; but, in the solid body, such a meshwork would rather be formed of planes of stroma intersecting each other, and enclosing more or less completely portions of the semi- opaque material. In the second specimen, where the sus- pected ovary weighed an ounce, several bodies from ^^^^ ^^ i^^ of an inch lay deep in the stroma, below some normal follicles and a corpus luteum. These bodies had well-defined oval borders, and were filled with mucoid tissue, containing, as microscopical examination proved, a great quantity of large branched cells, their processes being connected with the sur- rounding stroma. Further observation has led me to rely less on the evidence of these last two specimens than on that de- scribed above at length, which is very frequent in incipient cystic disease. In the first case, I suspect that the sinuous bands within their meshwork were degenerate vessels. Noeg- gerath describes a similar appearance, and in a large cirrhotic ovary I have seen groups of vessels, with their coats still partially distinguishable, undergoing this colloid change. In the second case, the myxomatous tissue,- occupying the centre of the oval bodies, suggested degeneration of the stroma, as such tissue is not supposed to be derived from epithelium ' ; moreover, the cells were actually connected with the stroma. Yet, in such a case, some epithelial relics from follicles might furnish a lining to the cysts formed by the breaking down of the myxomatous tissue, and, in this case, two such cysts were formed. I did not, I must admit, find any trace of an epi- thelial lining in these cysts, as in fig. 2, 3. As for the forma- tion of epithelium from connective tissue, that involves ques- tions of importance in general pathology, and its possibility is denied by many ; certainly, I could trace no evidence of such a process in this case. I agree with Dr. Grabbett that if the degeneration takes place in Graafian follicles, the process must ' This specimen recalled the invasion of cystic cavities by colloid tissue developed in the stroma, as figured by De Sinety and Malassez, Archives de Physiologic, 2nd Series, vol. vii. 1880, plate xviii. fig. 1. 12 TUMOURS OF THE OVARY, be traced from its early to its latest stages ; this could be done in the specimen first described, but not in that where myxo- matous patches were to be found. I also agree with that pathologist in his opinion that we must not consider every morbid appearance in an ovary to be necessarily connected with cystic disease. The changes in the large blood-vessels of the ovary, from which Noeggerath attempted to trace the origin of cystic disease, are certainly very frequent in ovaries where no such disease need be suspected, and I cannot say that I believe so much in Noeggerath's theory as I did in 1881, for I have searched many ovaries since then, and found that when cystic disease was most reasonably suspected, it was not vascular nor myxomatous changes that prevailed, but distinct alterations in the process of atrophy of undeveloped follicles, resembling, in their early stages, the conditions accurately described by Patenko, Beigel, and Slavjansky. As to the theory of De Sinety and Malassez, although the tubes of Pfliiger do not exist, the pathological ingrowths of which they speak probably represent follicles ill-developed from the very earliest stage, when first they became surrounded by stroma. Foulis's theory, still too theoretical for practical in- ferences, that the follicular epithelium is derived from the connective-tissue cells of the stroma, would seem to imply that the stroma might, in some cases, develop follicular epithelium independent of germinal-epithelial cells which they surround, and which, as nobody now doubts, become ova. In fact, follicles without ova would thus be formed. I have made some reference to this matter in the Preface to this work. It is more likely that the pathological ingrowths are masses of fol- licular cells remaining after the absorption or destruction of ova, and, therefore, very liable to set up disease. In this chapter, however, I have described what I have seen, and it is what I have seen that leads me to believe, for the reasons already given, that the most probable origin of cystic disease of the ovary is an arrest of the normal retrograde metamor- phosis of Graafian follicles that have never become corpora lutea of menstruation or of pregnancy. Within the last twelve months Mr. F. S. Eve has described, TUBE AND BROAD LIGAMENT. 13 in a course of unpublished lectures given at the Eoyal College of Surgeons in 1883, a series of changes within the stroma of ovaries affected with incipient cystic disease, that fully coincide with my researches, though explained in somewhat different terms. I have seen some of the microscopical specimens on which his opinions are founded, and observed collections of follicular epithelium undergoing great extension of area, push- ing inwards towards the follicular cavity, and outwards into the stroma. This is a stage further towards the development of cystic disease than I have been able to trace in my own speci- mens. The epithelium of these altered follicles bore all the characters of that which lines the more primitive follicles in a healthy ovary. The process had evidently commenced very early in the retrogression of the afifefcted follicles. Mr. Eve lays some stress on the formation of follicles and ova after birth. I have no further space for discussing his interesting researches ; I only remark that the most recent labours of em- bryologists and pathologists all point to a follicular origin for cystic disease of the ovary. Lastly, in discussing the development of multilocular cysts, we must not forget the structure of the full-grown cysts them- selves. I will reserve for the next chapter the consideration of the epithelium that lines the cavities of such cysts, an epithe- lium quite unlike that on the surface or in the follicles of the normal ovary at any age, and I will also show that certain appearances taken for colloid changes are essentially epithelial. 14 TUMOURS OF THE OVAET, CHAPTER II. MULTILOCULAR AND GLANDULAR OVARLAN CYSTS. The common multilocular cyst of the ovary has been very often described by pathologists. Some notice of its rarer varieties, where it is sessile, mixed vrith dermoid growths, or presents other peculiarities, will be found in chapters devoted to special subjects; and other sections of this work deal with the changes and accidents which are more or less frequent in the history of a multilocular cyst, and with its origin and its relation to cysts of the hilum and the broad ligament. A multilocular cyst generally presents a smooth surface when felt through the abdominal walls, but may be very irregular, when the secondary cysts project freely from under the main cyst wall. If one cyst contain much more fluid than the rest, and at the same time be not very tense, fluctuation will be evident, and there will be a distinct thrill on percussion. I am referring now to uncomplicated cases. When the abdominal incision is made, the surface of a healthy multilocular cyst appears smooth, glistening and almost silvery, owing to the great amount of fibrous tissue in its walls, especially if those walls be thick. "VMien a simple broad ligament cyst is exposed, the wall is sometimes so thin as to give the tumour a dark appearance, the fluid showing through the wall, or it may look Hke a uterine growth, owing to hyper- trophy of the muscular fibres of the broad ligament. The appearance of a myoma of the uterus is very characteristic. In short, there is no difficulty in recognising a healthy multilo- cular cyst. "When the surface of the exposed tumour is not glossy, this may indicate dermoid contents, twisting of the pedicle, or simple degeneration or inflammatory changes in the walls. Circular patches of thinner and duller, but stiU TUBE AND BROAD LIGAMENT. 15 smooth, tissue indicate the presence of large secondary cysts developed in the main wall of the tumour. On plunging the trocar into the wall of a typical multilo- cular cyst, a quantity of a glairy albuminous fluid escapes, often to the amount of several gallons. It may be almost colourless like clear boiled sago, but is generally of a greyish tint. Very often it appears to be stained of a rich, dark, red- dish-brown hue, sometimes described as * chocolate colour,' but it is only the semi-solid material mixed with fat, often found in the cavities of dermoid cysts, that thoroughly resem- bles chocolate in appearance. In both cases, however, the dark colour is due to changes in extravasated blood. When solid growths spring in abundance from the secondary cysts, the fluid is particularly glairy, and often semi-solid opaque white masses escape from those cysts. True colloid changes produce the characteristic pale-orange jelly-like material that gives great trouble to the operator, as it cannot run through the cannula, and when broken up by the hand much haemor- rhage into the cavity of the tumour is often set up before the pedicle can be reached and secured ; besides, the main wall of the cyst is usually soft in these cases, and easily ruptured by the fingers or knuckles, yet it is particularly advisable not to allow any colloid material to escape into the peritoneal cavity. When perfectly clear fluid, devoid of glairiness, escapes from some of the secondary cysts, these will almost invariably be found to contain papillary growths, readily distinguished from the glandular masses more frequent in true multilocular cysts ; but perfectly smooth-walled secondary cysts may contain clear, non-albuminous fluid. The glairiness and greyish or yellowish-grey colouration of ovarian fluid is a physical characteristic practically sufficient for diagnosis from ascitic fluid. Chemical tests for ovarian fluid are not satisfactory and are of a kind unsuitable for the surgeon who cannot keep up more than a superficial knowledge of the science of chemistry, nor carry spectroscopes and other apparatus about with him ; nor are medico-chemical authorities yet agreed upon a perfect test for ovarian fluid. ' We have no one characteristic that can enable us chemically to distin- guish between the fluid of an ovarian cyst and the contents of 16 TUMOURS OF THE OVARY, a cyst of another organ,' writes Dr. C. H. Ralfe. ' If the solid constituents be above that of ordinary blood serum, we can say positively the fluid is not ascitic, but otherwise we have to depend on an examination of the whole constituents of the fluid before we can venture to form an opinion.' I will pass over the subject of the large vacuolated cells, already described by Foulis and Thornton as characteristic of malignant disease. Their presence is a serious matter as regards prognosis, but I have repeatedly observed them where the solid growths in a cyst were purely glandular. More will be said regarding this subject in Chapter XII., in relation to a case of papilloma of the Fallopian tube, where proliferating and vacuolated cells abounded in the fluid which filled the peritoneum, yet the after-history of the case was conclusive as to the absence of malignant disease. Secondary cysts certainly break through the main cyst wall in many cases, and this will be considered in the chapter on ruptinre of ovarian cysts. Undoubtedly in some cases the pro- truding secondary cyst does not rupture, but merely stretches the main wall, forming a prominence, and other cysts may follow it. Nor can it be doubted that the main wall may rupture, and, its walls undergoing atrophy, the secondary cysts will then form a tumour, in shape resembling a pile of cannoA balls. This is the exogenous cyst, as it is sometimes termed. I certainly believe that true exogenous cysts may exist ; I mean collections of two or more cysts that were independent of each other from the first, never having been included within a common main wall. In a woman forty-five years old, where both ovaries were removed by Mr. Thornton, one was converted into an ordinary multilocular cyst. The other formed an elon- gated tumour a foot long, made up of cysts full of glairy fluid, and completely separated from each other by hypertrophied ovarian tissue. In eight cases where I have assisted at opera- tion, the tumour has been a cluster of cysts, but in all but that just quoted there was no evidence that they were truly exogenous in the sense above indicated. The false exogenous cyst — that is, a collection of secondary cysts that have burst through a main wall — is a serious form of tumour very prone to rupture, often filled with solid growth, and especially liable TUBE ANL BROAD LIGAMENT. 17 to contract adhesions. Omentum and intestine adherent to the deep grooves between the cysts are very troublesome to separate. The false exogenous cyst can often be recognised by the thin and very vascular walls of the secondary cysts of which it is made up. The tendency of secondary cysts to open into each other when in proximity, through simple atrophy of the contiguous portions of their walls, is very marked in most cases, and it is not surprising that multilocular cysts of both ovaries not unfrequently become fused. The main wall of each tumour suffers from pressure in various ways, so as to become thinned, and the secondary cysts of the one can readily burst into the secondary cysts of the other. These double fused ovarian cysts are of great clinical interest, and very troublesome and puzzling to the operator, especially if there be many adhesions in the pelvic region. In the five cases where I have been present at operation the second pedicle, that is, that which was recognised as a pedicle after another had already been detected, was usually taken at first for an adhesion, and one of the two pedicles was always much smaller than the other. It is possible that in other cases a twisted pedicle may have been taken for a pelvic adhesion. For in cases of double cystic disease the pedicle of one tumour may become twisted, and the tumour might then adhere to, and also receive its nutrition from its fellow. Should deep pelvic adhesions exist, the operator might readily separate the twisted pedicle as such, and fearing to handle the pelvic struc- tures in too searching a manner, might be under the impres- sion that he had left behind ' the other ovary, buried in adhesions.' An ovary actually in that condition, or atrophied, is not always easy to recognise. Of the cases of double and fused cysts, which I have seen on the operating table, the most serious was in a woman aged forty-four. On tapping the tumour, and drawing it out of the abdominal wound, a very broad and narrow pedicle was dis- covered ; it included the left FaUopian tube. This pedicle was very hard to secure ; it had to be transfixed in two places by the needle armed with a double stout silk ligature. A long narrow band, resembling a pelvic adhesion, bound down the c IS TUMOVRS OF THE OVARY, lower part of the tumour on the right side. It was found to be a true pedicle, containing the right tube and ovarian ligament. The abdominal walls were very fat, and the patient died with septic symptoms on the fourth day. In another case, the patient was thirty-nine years of age ; the abdomen was much distended, and its integuments cede- matous ; the cyst was very tense, and its surface irregular, so that there was some suspicion that a uterine tumour existed. On vaginal examination the uterus was found to be pushed to the left, and it did not move freely when the sound was intro- duced into its cavity. A very large multilocular cyst was re- moved at the operation, and a short broad pedicle connected it on each side with the uterus ; both were secured, and the patient recovered. The third case was that of a woman aged thirty-five. The tumour had been tapped a few months before its removal by Dr. Bantock. When the abdominal wound was made, the outer wall of the tumour appeared dull, and on removing the fluid a number of small cysts were found, collected into one mass behind the cyst first exposed ; the fluid which they contained was ovarian, and mixed with pus. The cyst nearest to the abdominal wound had leaked considerably since the tapping,, and allowed the escape of a great amount of fluid into the peritoneal cavity, causing inflammatory ascites ; there were also abundant peritoneal and omental adhesions. A distinct pedicle, with the Fallopian tube readily recognisable, and bearing the normal relation to the cyst, was found springing from each side of the uterus. A drainage tube was passed into Douglas's pouch, and the patient made a good recovery. The two next cases, by a curious coincidence of a kind not rare in clinical records, were operated upon within six days of each other at the Samaritan Hospital. One was in a patient under Mr. Thornton's care. The patient was fifty-six years of age. The tumour was large, and composed of but few cysts. There were strong pelvic adhesions ; some lay deep in Douglas's pouch ; another lay close to the common iliac artery. The relation of the Fallopian tube, in each pedicle, to the tumour was very evident in this case. The operation took a hundred and ten minutes, the separation of adhesions proving particu- TUBE AND BROAD LIGAMENT. 19. larly irksome. A drainage-tube was passed into Douglas's pouch, and the patient made a good recovery. The last case was that of a patient in Dr. Bantock's wards ; she was fifty-five years of age. The tumour formed a great mass full of colloid material, which escaped into the peritoneal cavity, the cyst wall being very soft and readily lacerated. There were abundant adhesions to the parietes and intestines, one binding the sigmoid flexure intimately to the back of the cyst ; the left pedicle was easily recognised, the Fallopian tube being distinct ; on the right side the tumour was connected to the uterus by a stout and short pedicle, the different tissues of which could not be distinguished, but no right tube or ovary could be found. Portions of the main cyst wall had to be left, adherent to the parietes, and a drainage tube was employed. The patient recovered. Thus, out of the five cases of double fused ovarian cyst where I have witnessed the operations for that removal, one terminated fatally, and all were very troublesome to the ope- rator. In all, the pedicles were secured by transfixion, the process being invariably difficult. As a rule adhesions existed ; and the uncertainty produced in the minds of the operator and his assistants, when an anomaly of this kind is first inspected, is an element which adds to the tediousness of cases of this description. I must here mention a sixth case, which differed from the others in that the true pathological condition could not be made out during the operation. The patient was about thirty-five years old. A large multilocular cyst was discovered at the operation ; it adhered to the parietes, the omentum, the ileum at several different points, and the vermiform appendix. A capsule, really the outer layer of the main cyst wall, was peeled off the cyst, and the lowest part of the tumour that could be reached was transfixed twice and treated as a pedicle ; some vessels in the portion of the capsule left behind were secured. About two inches of the vermiform appendix had to be cut away, being inseparable from the cyst ; this portion contained a plug of solid fseces. The shock was very severe, and the patient hardly survived the operation one hour ; at the necropsy 1 found that two true pedicles existed ; the}'' passed on to the 20 TUMOURS OF THE OVARY, lower surface of the portion of the tumour that had been left behind and ligatured. Out of 605 cases of ovariotomy, oophorectomy, hysterec- tomy, and other forms of abdominal section where I have been present — this series commencing on November 15, 1877, and ending on March 25, 1884 — I find, on referring to my notes, that 366 were operations for the removal of multilocular ovarian tumours. Out of these at least forty-eight were double, in- cluding the six cases of fused cysts already recorded, and in nearly twenty more cases suspiciously enlarged ovaries were re- moved after the cystic tumour had been cut away, the forty- eight comprising only those cases where the smaller tumour was a multilocular cyst three inches or more in diameter. In the above 366 cases I include all multilocular tumours where the secondary cysts contained no solid contents, or were par- tially or completely filled with colloid or glandular growths, by which last term I mean new formations which the pathologist would describe as adenoma or adeno-sarcoma. I include sessile multilocular cysts, with or without glandular contents — de- scribed in another part of this work — but for pathological reasons, which I will explain elsewhere, I exclude all cases where cysts, however undoubtedly ovarian, contained papillary growths. From the forty-eight cases of double multilocular ovarian cyst, I, of course, exclude cases where one tumour was dermoid or completely solid. Statistics of such cases will be found in other chapters. It is not possible to classify multilocular cysts by the number of their loculi ; indeed, in many cystic tumours that were prac- tically unilocular I have found, not only the characteristic fluid and even glandular growths, but also abundant traces of broken- down septa, whilst in other cases the secondary cysts were countless. I will return presently to this question of cavities. It is likewise impossible to separate multilocular cysts without glandular contents from those that include such growths within their cavities ; at least, this cannot be done with any precision, as, in a small tumour that has been removed within a few months after the patient has first observed an abdominal swelling, a very slight irregularity in the lining membrane of a secondary cyst may represent what would have become in a year or two TUBE AND BROAD LIGAMENT. 21 an extensive mass of solid deposit. Out of the 366 cases, how- ever, in twenty-six the tumours contained much solid growth. In fourteen this growth was distinctly adeno-sarcomatous. In twelve the solid matter was very malignant in appearance ; in one of these it bore the microscopical characters of round-celled sarcoma; in two, at the very least, the growth was colloid cancer ; in most of the nine remaining cases the general naked- eye appearances of colloid cancer were present, but I had no opportunity of examining the specimens microscopically. In over one hundred cases I observed distinct traces of glandular growths ; and as over one hundred more were small and recently developed tumours which would probably have developed such growths, it is evident that the tendency for adeno-sarcoma to develop within the cavities of ovarian cysts is very great. The outer surface of the main wall of a typical pedunculated multilocular cyst, not involved in any inflammatory or degenera- tive process, is, as is well known, and has been before observed, smooth, gKstening, and silvery white in appearance. It varies considerably in thickness, according to its degree of distension from fluid, cystic, and solid contents. When it contains much fluid, even to the extent of many gallons, its coats may still remain strong enough to resist considerable violence without rupture ; distension alone, without softening or degeneration from twisting of the pedicle, producing but little direct effect on the periphery of the tumour. When secondary cysts abound within the main wall, the latter is very liable to become thin, not necessarily from inflammation or degeneration, but from mechanical causes, especially great local distension, a secondary cyst forcing it outwards. The development of cysts of this kind, in the very substance of the main wall, causes it to become particularly thin and soft. In cases where the secondary cysts contain glandular material, the main wall is generally thin and relatively soft from the first, the connective tissue within its substance is more or less embryonic ; as well-formed fibres are not freely developed where such tissue exists, the main wall, in cases of this kind, generally lacks lustre, and, instead of appear- ing silvery, it assumes a greenish grey and semi-transparent appearance. When we also bear in mind the changes which adhesions, inflammation, atrophy from twisting of the pedicle, 23 TUMOURS OF THE OVARY, and from blocking of the vessels within the wall itself, may produce, all altering the appearance of the outer aspect of the entire tumour, we may draw a corollary from the above, and actual observation will bear out this corollary, which is, that the smoother and shinier and the more silvery the cyst wall appears, when exposed by abdominal incision, the better the case will be both for the patient and for the operator. Nevertheless, I have seen one case at least where a multi- locular tumour, bearing all these external appearances, proved, when it had been emptied by means of the trocar, to be very intimately adherent to the brim of the pehis. When the pedicle is unobstructed, and when the adhesions arise from local inflammation, not of the cyst, but of contiguous parietal peritoneum, omentum or intestine, the outer wall of the cyst may remain unaffected except around the seat of adhesion. A dermoid cyst has very seldom a smoothy, shiny, and silvery outer wall, unless a portion distended with clear fluid, and devoid of dense solid deposit, presents towards the ab- dominal wall. As a rule, such a cyst is externally more or less dull green or grey iu hue, with orange or ochreous patches. A simple broad ligament or ' parovarian ' cyst can be recognised by the thinness of its walls, allowing the fluid to be seen thi'ough it ; but sometimes the walls contain great quantities of fibrous tissue, so as to appear silvery and shiny ; in these cases the transparent fluid can be sometimes seen, or rather recognised, where there are gaps between the meshes of fibres. In many cases these cysts cannot be diagnosed from multilocu- lar ovarian cysts by the appearance of the outer wall alone. Cystic uterine tumours have a glossy and pale-red appearance, and the walls are generally thick and resistant. Cysts of the broad ligament with solid contents, many simple broad-liga- ment cysts, and multilocular papillaiy cysts of the hilum of the ovary, as well as ovarian cysts of the more frequent type that have part of the broad ligament reflected over them, have often a reddish surface, the colom" being produced by the plain muscular fibres within the broad ligament. Hence there is often much difficulty in distinguishing them at first sight from cystic uterine tumours. TUBE AND BROAD LIGAMENT. 23 On the surface of otherwise perfectly healthy multilocular ovarian cysts, numerous red patches, made up of collections of dilated vessels, may generally be seen ; also small oval or cir- cular areas bluer and less silvery than the remainder of the surface of the cyst ; these areas are devoid of epithelial or endo- thelial covering. De Sinety and Malassez have minutely described sundry vegetations found on the surface of multilocular ovarian cysts. I have frequently observed both the ' connective-tissue vegeta- tions,' and the ' mixed vegetations ' of which they speak. I agree with them in assigning little clinical importance to these structures ; they, strange to say, bear no relation to the con- tents of the interior of the cyst. In about twenty cases I have found lingular little peduncu- lated growths hanging from the main wall, far from the pedicle. Still more frequently small, thin-walled cysts, lined with endo- thelium, project from the surface of the tumour; they are pathologically homologous to similar cysts developed between the folds of the broad ligament, and described elsewhere. The pedunculated growths to which I refer are masses of connective tissue, sometimes partly cystic. Care must be taken in inves- tigating these growths to make sure that the ovarian cyst is not partially invested with the folds of the broad ligament, or has burrowed under the peritoneum. When this is the case, these structures are more frequent than in typical pedunculated cysts. This might be expected with regard to the thin- walled cysts so frequently developed in connection with serous mem- branes. Yet I have often seen such cysts in typical cystic ovarian tumours bearing long pedicles, and in no way invading the peritoneum. The connective-tissue growths described by De Sinety and Malassez are very frequent ; they may appear as elevated, flat- tened, opaque patches, consisting of dense fibrous tissue, or as small tubercles of young connective tissue mixed with minute thin-walled cysts developed in the new growth. Such growths are not rare on atrophied or on otherwise normal ovaries. In 1879 I found a mass of these growths upon an ovary removed for the cure of menorrhagia, and I also observed a similar col- lection of connective tissue forming a group of papillary out- 24 TUMOURS OF THE OVARY, growths on the surface of the atrophied ovaries of a lunatic, aged thirty-eight, whose uterus was imperfectly developed, and, in the same year, I discovered precisely similar growths on the surface of ovarian cysts. They are, it would therefore appear, essentially ovarian, and not necessarily connected with cystic disease. The ' mixed growths,' described by the same author, are pathological curiosities. They often appear as little red, fleshy wattles or caruncles, sometimes bearing a strong resemblance to Fallopian fimbrise. They bear a covering of low, cubical epithelium. I have found their substance to be entirely nsevoid in some cases. The French pathologists, above quoted, claim to have found ciliated epithelium upon some of these mixed growths. If so, they must surely have been detached from the fimbriae of the Fallopian tube ; it is not rare to find a portion of the ovarian fimbria of the tube completely detached from the rest of that fringe, lying on the surface of an ovarian cyst, and this might become the seat of a growth. None of these growths are identical with the true papil- lomatous masses which spring from hilum cysts and broad- ligament cysts, nor with the glandular, solid contents of the typical multilocular cysts under consideration, for neither of these two forms of intracystic growth tend to develop spon- taneously on the outer surface of a cystic tumour. When true papillomata are found in that situation, they, in my experi- ence, can always be traced to rupture of the cyst wall from rapid growth of intracystic papillomatous masses and sub- sequent dissemination ; or the infection may have spread from the broad ligament. The presence of glandular growths on the surface of a cystic tumour is also invariably to be traced to infection from within, set up by rupture, or to similar infection from a similar tumour of the opposite ovary. In none of the fifteen cases examined by De Sinety and Malassez ' did any internal growths project from the exterior through an opening in the main wall, in the manner so frequently observed within the cyst, between adjacent loculi.' I have twice seen glandular growths projecting through the main wall, and on several more occasions have I observed papil- lomatous growths perforating the main wall ; more will be TUBE AND BROAD LIGAMENT. 25 found on this subject in the chapter on rupture of ovarian cysts. The outer surface of the main wall of a typical multilocular cyst is invested with a layer of low columnar or cubical epithe- lium, according to most authorities, but in a large number of specimens of large cysts which I have examined the cellular covering of the tumour was perfectly endothelial in appearance, nor, after repeated examination, could I detect any cubical or columnar epithelium. De Sinety and Malassez state that the outer or peritoneal surface of these cysts displays an epithelial covering formed of short cylindrical cells, with an incomplete endothelium beneath it. I cannot enter into general histological questions as to the relations of endothe- lium to epithelium, and the alleged existence of the former, in some structures, beneath layers of the latter, nor am I prepared to say that the endothelium is derived from the peritoneum, so as to present a cellular uniformity which does not exist between that serous membrane and the surface of a healthy ovary. On small cystic tumours under six inches in diameter, I have often found cubical epithelium, but this I have only seen as an exception in large cysts. It is most probable, that the change in the epithelium is due to disten- sion and alterations in nutrition. In any. case the outermost lining of the main cyst wall in large tumours bears all the appearances of endothelium. The middle coat, as it may be termed, of the main cyst wall is composed of connective tissue, always well developed in typical cases ; it is often aponeurotic in appearance, white and elastic fibres, especially the former, abounding. Plain muscular fibres are also present, and can be traced to the ovarian ligament, which is almost entirely made up of that tissue ; in its proximity, therefore, fibres of this kind predomi- nate, in the middle coat of the cyst wall, over white and elastic fibres. As in all fibrous structures, this coat may be divided into two, three, or more lamellae by dissection. In its sub- stance run the vessels which supply the tumour ; these are small and regularly distributed in the more typical and inno- cent kinds of cysts, large and irregular when solid intracystic growths exist to any considerable extent. Morbid changes 26 TUMOURS OF THE OVARY, in the vessels are almost invariably present to a limited extent in typical cases. I shall reserve this subject, however, for the chapters on rupture of the cyst and twisting of the pedicle — matters with which vascular disease is intimately related. Within the substance of this coat a process of cyst form- ation is often to be detected ; sometimes small cavities lined with columnar epithelium are to be seen. On the other hand, secondary cysts of large size certainly appear to develop in this coat, and such cysts I have ever found to be lined with endothelium. I shall presently revert to this subject of epi- thelial and endothelial structures developed in proximity. Traces of normal ovarian tissue may often be found in this coat : I have discovered a corpus luteum of some three or four weeks' growth several inches from the pedicle. On the surface of the cyst wall near the pedicle, the peculiar wrinkled appear- ance presented by the tissue of the ovarian hilum may often be observed, and, if developed to any great extent, papilloma- tous growths will almost certainly be found amongst the loculi of the cyst. We now come to the inner lining of the main cyst wall. If secondary cysts be very abundant, which is not the rule, no one loculus predominating greatly in volume over the others, it will be impossible to define a continuous lining to the main wall. As a rule, however, one cyst greatly exceeds the remainder in its capacity. In that case, especially if the large cyst be tense, its lining bears all the characters of endo- thelium. It may have originally been epithelial in character, and have altered through pressure, as in the case of the outer surface of the cyst wall. Mr. F. S. Eve and others have observed a similar change in the process of cyst formation in the testicle. This inner lining in very tense cysts appears smooth and glistening. In May 1879, Mr. Thornton removed a very large cystic tumour of the ovary from a woman aged fifty. There was a main cyst holding several gallons of very clear but viscid ovarian fluid and numerous secondary cysts containing rather thicker fluid. I found, on staining the inner wall of the large cyst, that it was invested with a perfect layer of endothelium, whilst the smaller cysts were lined with long TUBE AND BROAD LIGAMENT. 27 columnar epithelial cells. The difference in the fluid contents, as above noted, is significant. Very frequently, especially if not very tense, the main cyst bears internally a layer of vascular mucous membrane, for so it may fairly be termed. This layer may be freely dissected off the - middle coat, from which it is separated by true sub- mucous tissue containing lymphoid elements and plain mus- cular fibres, and it bears true columnar epithelium ; it is thus transitional between the endothelium of tense cysts and the complicated epithelial structures investing the glandular growths of the secondary cysts. Passing over the singular results due to vascular changes, the ochreous patches and areas of hypersemia, congestion, and atrophy, to be referred to in another chapter, the loculi will now engage our attention. It is impossible to draw a line between multilocular cysts that are literally multilocular and other cysts which contain but few or even no septa, yet in other respects bear all the characters of the typical ovarian cyst. Terms like paucilocular and oligocystic are clumsy and unscientific, especially as they tend to confound small typical cysts with large specimens of dropsical Grraafian follicles. We have at present only to do with the former, and it is best to retain the name multilocular ovarian cyst, as implying a tumour of the ovary, one of th-e most constant characteristics of which is division into several or many compartments. If, as is the case, there be but one cavity within the main wall, and all other characteristics remain the same, the name may, in accordance with scientific principles, be retained. A name is a symbol, a denomination, and not a definition : were it to be attempted to make names serve as definitions, endless confusion would ensue. Biologists do not turn the Thylacinus or Tasmanian ' wolf ' out of the order Marsupialia because that animal has no marsupium. Although a tumour is not quite so distinct a unit as is any species of animal or plant, pathological nomenclature should be applied on the principles adopted in other sciences. When one cavity is so predominant that the tumour appears literally unilocular at operation, careful examination will seldom fail to show secondary cysts projecting under its inner lining 28 TUMOURS OF THE OVARY, membrane, generally towards the site of attackment of the pedicle. In such a case, the predominance of secreting power over secondary cyst and new-growth-producing power has been given as an explanation of the character of the tumour ; but, after all, this is but a pedantic way of describing the tumour under pretence of explaining the cause of its peculiar construction. This predominance of one cyst, with almost complete absence of secondary cysts, is often held to be a sign that the tumour is of the most innocent character possible. It is more correct to say that such a tumour is still in its most innocent stage. I have seen operations on cases where large, tense, and freely movable cysts had pre\'iously been repeatedly tapped, the fluid, as usual, being clear, and only sHghtly glairy at the earher tap- pings, and becoming more glahy, darker and thicker the more frequently paracentesis has been perfoiTaed, thus assuming the characters of fluid found in highly multilocular cysts. In such cases a number of secondary cysts have usually been dis- covered, and there can be little doubt that there would not have been so many secondaiy cysts had ovariotomy been performed before the first paracentesis. The removal of fluid pressure no doubt aided the growth of these cysts. On the other hand, the escape of several pints of clear and moderately glaii'y fluid through the trocar during operation must not lead the operator to suppose that there are few secondary cysts ; on attempting to draw the collapsed tumour out of the abdominal wall, he may be surprised to find that its base is stufi''ed with secondary cysts, filled perhaps with glandular or even sarcomatous matter. As a rule, however, I have found that the predominance of one cvst is a favourable sign, indicating the simplest form of tumour. Indications of the breaking down of septa are extremely common in the cavities of these predominating cysts, and may also be seen within secondary cysts. Several wiiters have taken the pains to discuss whether these septa be in process of forma- tion or in process of destruction, but there can be little or no doubt that they are in the latter condition. I have repeatedly examined multilocular cysts, so as to be able to trace every in- termediate stage between two or three secondary cysts lying on the inner wall of the main cyst to the perfectly multilocular TUBE AND BROAI) LIGAMENT. 29 condition, the cavity of the entire tumour being subdivided into loculi of tolerably equal capacity, loculi lined with the same kind of inner wall, and bearing the same kind of growths as the distinct secondary cysts. Close packing of these cysts must of necessity change their spherical walls into polygonal septa. In some places young connective tissue is freely de- posited in the substance of the septa ; in others the septa become very thin, and then rupture. A thickening of the substance of the septum along the margin of the rent is fre- quently seen, and I have found a secondary growth that had protruded from its parent cavity through a rent in the septum into the neighbouring cavity, tightly nipped, and indeed partly strangulated by a thick ring of tissue formed in this manner. \\Tien a solitary secondary cyst projecting from the inner side of the main wall bursts, its wall appears, some time after rup- ture, as a ring of fibrous tissue lying on the main wall, with a base consisting of its former lining membrane ; this condition has been taken for ulceration. I shall revert to it in speaking of rupture of the cyst (fig. 26). The tendency of a rupture in the septum between two secondary cysts or loculi is not to remain stationary by thicken- ing of the edges of the rent, but rather to increase ; and as the process of rupture often occurs simultiineously in several loculi, a curious appearance is produced — a collection of elevated fibrous structures, with large holes in them, lying on the inner wall of the main cyst. These become, in course of time, mere narrow fibrous bands, interlacing, and ultimately appearing as white, glistening, very wide-meshed elevations on the main wall. Thin- walled cysts lined with endothelium often form on the fibrous relics of broken-down septa, and these relics may par- tially chondrify. Of course it is highly important, pathologically speaking, to determine, when examining an apparently uni- locular cyst, whether such traces of sej)ta exist. If they do, as is generally the case if the tumour has existed for a long time, the significance of the single cavity is evident. If none are found, as in tumours that have not been long in growing, then no doubt the single cavity has been single from the first. In twenty-six out of 366 cases of multilocular cystic dis- ease of the ovary which I have examined, there was a con- 30 TUMOURS OF THE OVARY, spicuous amount of soft solid growth in the secondary cysts or loculi. I have never seen a growth of this kind projecting into the cavities of a tumour consisting of very few large cysts, nor do I expect to see such a case, there being in fact, and under any theory already propounded, a relation between abundance of secondary cysts and abundance of solid growth. That this growth is not found in association with cysts filled with the clearer type of ovarian fluid is also what might be expected, the thicker type being a secretion from the growth, or at least the dense glairy fluid bears some inseparable relation to the succu- lent solid matter. On cutting into a multilocular cyst, with solid matter in its cavities, well-known appearances are produced — a mass of thin but rather opaque-walled and vascular secondary cysts project into the main cyst cavity; these cysts on section show the characteristic masses of glandular matter — semi-transparent and pale greyish green in tint — and the free ca\aties which they still leave in the cysts or loculi which they occupy are filled with a glairy fluid, the colour of egg-albumen, or much more opaque and dead-white ; in some cases this mucous fluid is almost as tenacious as treacle, and oozes from the cut surface of the solid matter. This solid growth is exceedingly soft, and is readily broken down by the hand of the operator, when such a manoeuvre is necessary, before the entire tumour can be drawn through the abdominal wound. Sometimes, in the midst of the most solid part of these growths, masses of thin-walled cysts containing clear fluid are found; they are lined with endothelium, and appear to be connective tissue productions, possibly derived from the endotheHum which is said to line all lymph-spaces in connective tissue. They seem to be homo- logues of the cysts developed in the main wall, as already described. Here, as in the main wall, cysts with endothelium are being developed in proximity to epithelial structures, only here the latter predominate ; in the main wall the smaller cystic cavities appear to have epithelial, the larger endothelial linings. When the latter enlarge, they remain thin-walled ; their lining is still endothelial, and their fluid contents almost free from glairiness. So it is with these thin- walled cysts in the solid glandular intracystic matter. In one tumour I found TUBE AND BROAD LIGAMENT. 31 two or three dozen of these cysts, some over an inch in diameter. Their attachment to the soft tissue which surrounded them was so slight that they almost slipped out of their matrix as the tumour was cut across by the dissecting knife, and they con- trasted strongly with the cavities into which the solid matter projected. On the other hand, the deeper part of the solid matter not unfrequently contains chondrified patches. I found such patches in a multilocular cyst removed by Sir Spencer Wells in 1878 ; the secondary cysts were not very numerous, and few were more than partially filled with the growths, which were essentially glandular, and secreted very glairy fluid ; there was not a trace of any dermoid growth. This chondrification is evidently analogous or identical with the growth of cartilage seen in sarcoma of the parotid gland, testicle, and other organs. The free surface of the glandular growths must be examined with care, and the observer should choose the larger cavities into which they project, as there is then all the more surface to study. The surface is always very irregular, sometimes granular and tuberous ; frequently papillary masses project in all direc- tions. These must never be confounded with the true papillo- matous growths characteristic of hilum cysts. The latter have very little connective tissue behind them ; they form masses of fine, brittle, gritty tags that sprout direct from the wall of their parent cyst, which contains no soft and succulent solid matter, and the fluid contents are always watery. I have had several opportunities of examining mixed cysts, with the typical glan- dular growths in close relation to true papillomata. The glandular papillary growths in these cases showed very dis- tinctly from their true papillomatous neighbours. Where the latter prevailed, clear fluid predominated ; in the direction where the former grew, the free contents of the secondary cysts were glairy. But more will be said of papillomata in another chapter. They have ever appeared to me as utterly distinct from glandular growths. Even when glandular growths are not rich, as usual, in young connective tissue under their epithelium, I have found that they still secrete glairy and not clear fluid. The microscopical features of this glandular material must now be considered. I shall continue to describe what I have seen with full deference to the varied opinions of Wilson Fox, 32 TUMOURS OF THE OVARY, Strieker, Olshausen, De Sinety, and Malassez, and numerous other pathologists, not forgetting the younger Dr. Eitchie, who associated with Sir Spencer Wells early in his career as an ovariotomist, and, examining a large number of cysts removed by that surgeon, was cut short only too soon in labom-s of the same kind as those which I am now recording. In six different samples of advanced glandular growth the appearances were as follows : — Fig. 3, 1, represents the naked-eye appearances of a section of a glandular mass from a secondary cyst. The patient was twenty-seven years of age in June 1880, when Mr. Thornton re- moved a large multilocular cyst of the right ovary, which had a broad pedicle. One cavity predominated ; its inner coat was verv smooth, but had the appearance of mucous membrane, and Fig. 3. — 1. Section of a glandular growth from the Interior of an ovarian cyst, natural size. 2. The part of the same marked a in 1, as seen under a half -inch objective. the fluid contents were glairy. Several secondary cysts pro- jected into its cavity. These cysts were filled with the solid masses, from one of whicli the section here figured was prepared. The cavities are separated by much connective tissue, and small growths may be seen to project into them. In several other sections which I have examined, the connective tissue between the ca\'ities was exceedingly scanty, so that they ap- peared as a network of fibres lined with epithelium. In others the connective tissue was very abundant and embryonic, in- cluding sarcomatous matter. The section under consideration is a fair average specimen of the intracystic growth most fre- quent in a typical multilocular ovarian cyst. On examining the borders of the cystic cavities in these sections under a high power, I found that they were lined with TUBE AND BROAD LIGAMENT. 33 the long columnar epithelial cells so often described in works on ovarian pathology. There were numerous chalice or goblet cells, and diverticula of epithelium projected freely into the surrounding connective tissue. That new cysts may be formed by the coalescence of the free ends of papillary processes of epithelium, as Wilson Fox and others believe, I do not deny, but in this, and in other sections that I examined, I found more certain evidence that some cysts were formed by the closing in of the upper part of epithelial ingrowths, which burrow deeply into the subjacent connective tissue. Some of the cavities in this section were very minute. One of them Jq inch in diameter (fig. 3, i a) appeared, under an inch objective, like one of the patches of colloid change de- scribed by many authors (fig. 3, 2). On examining the same Fig. 4 — 1. The epithelial lining of one of the large cavities in Pig. 3, 1, with broken- down cells lying free above it. 2. A portion of 2, Fig. 3, showing a distinct epithelial lining and collections of cast epithelium, seen in their long and short diameters. At a is an epithelial in- growth, marked a in 2, Fig. 3. (J inch objective.) with an eighth-inch power, the entire cavity was found to be lined with the characteristic long cylindrical epithelial cells (fig. 4, i). The cavity figured in fig. 3, 2 was bisected by an ingrowth of connective tissue, and in the lower segment the epithelial lining had become detached from the surrounding stroma. Under a one-inch objective, minute processes could be seen projecting into the contents of the cavity, especially at certain points (fig. 3, 2 a). The lower of these two indicated in the sketch appeared under an eighth-inch objective as in fig. 4, 2 a. In fact, it was an epithelial process. The contents, even under a low power, were not homogeneous in appearance. On careful examination the greater part appeared as a collec- tion of broken-down epithelium. In fig. 4, i the translucent cast epithelial cells are represented above the free surface of D 34 TUMOVRS OF THE OVARY, the intact epithelial lining of the cavitv. In fig. 4, 2 I have drawn the same appearances as I fonnd them ; towards the right are about a dozen cells lying lengthwise, and not ad- vanced in disintegration ; close to them ai'e a cluster of similar epithelial cells standing on end; these clusters made the dotted appearance observed under a lower power (fig. 3, 2). The greater part of the contents of the cavity appeared to be filled with cast epithelial cells. ^Mlether the homogeneous sub- stance between the cast cells represented a fuither stage of disintegi-ation, or was a dii'ect secretion from the intact epi- thelial lining of the canity, I cannot say ] the relation of epi- thelium to secretion is still, I believe, a disputed question among physiologists. The appearances I have just described have been frequently taken for colloid changes in the stroma, but the epithelial lining shows that the cavities must have had some relation to the larger cysts with similar epithelial investments. I believe that they are developed from obstructed diverticula ; the casting-off of epithelium and the free secretion into the in- terior of these ca^dties causing considerable distension. I have observed true colloid changes in the stroma in these glandular masses, but they were patches of a uniform semi-opaque material, with few or no processes of connective tissue travers- ino- them, and without a trace of any epithelial lining. In other specimens I found that the sohd masses appeared as a meshwork of ca\dties representing cysts, and lined with columnar epithelial cells that were never cihated. The scanty stroma was young connective tissue. I could not find any of the cavities simulating colloid change as in the section above described. These solid gro-^vths, with innumerable cystic cavities in their substance, certainly appear to deserve the naine of glandu- lar growths or adenomata. That the stroma may be sarcomatous in some cases, I can myself testify ; but, as a rule, it is merely young connective tissue without malignant characteristics. The term mucoid epithelioma is open to obvious objections; mucoid adenoma is far more reasonable a term. The long cylindrical ceUs Lining the cysts within these growths differ verv o-reatly from the germinal epithelium of a fcetal ovary, TUBE AND BROAD LIGAMENT. 35 from the epithelial covering of the tunica albuginea in the adult, from the membrana granulosa of the follicles at any stage of their development, and from the epithelium of the traces of the Wolffian ducts in the hilum, extending occasionally to the parenchyma. Hence, if the formation of typical multilocular cysts be traced from any of the above structures, the patholo- gist must depend upon other elements than the epithelium for proof, or else admit that epithelium changes its character com- pletely according to circumstances. This is exceedingly pro- bable, and, in another chapter, I have given my reasons for believing that changes in undeveloped Graafian follicles arrested in their processes of atrophy are the starting-points of multi- locular ovarian cysts. According to the researches of Mr. F. S. Eve, to which I have referred at the conclusion of that chapter, it is easy to connect the primitive extension of folli- cular epithelium with the more minute cavities which I have just described, if only we could be sure that when the former, about Y^ inch in diameter, are in course of development, their epithelium gradually alters till it becomes as in the latter, which are about -^^ inch in diameter. This is possible, but not proven. The question of diagnosis is very familiar to the readers of modem surgical literature, but I will conclude this chapter with a few observations on the subject. To ensure the greatest possible accuracy in diagnosis of a suspected ovarian tumour, several small points must be borne in mind. The patient should of course lie on her back during examination, with the planes of her shoulders and hips parallel with the plane of the couch. The chamber in which she is examined should be warm, and not adjacent to a noisy street, or to a room full of people en- gaged in conversation. A draught causes real danger to the patient ; cold is the source of, not only discomfort, but also great physical irritability, impeding diagnostic manipulations ; noise is disturbing to the surgeon, and a grave impediment when pregnancy is suspected, as in such a case auscultation must be practised in order to find out if the foetal heart-sounds be audible, and perfect silence is then essentially requisite. The surgeon should be particularly careful that his hands are warm. Cold fingers cause contractions of the patient's abdo- D 2 m Tl'MOVRS OF THE OVARY, minal muscles, greatly interfering with diagnosis ; they do not, moreover, possess their most perfect degi'ee of tactile sensi- bility until they are comfortably warm. Tight-fitting gloves, when worn in winter, make the fingers very numb as well as cold ; they should, therefore, be taken off at least ten minutes before the patient is examined. To restore warmth to the hands, the natural temperature of the pockets generally proves more rapidly efficacious than immersion in hot water, but the simplest and best method is to wait for ten minutes before beginning the necessary manipulations in a warm room, for the hands warined by the general rise of the circulation will part with their heat less rapidly than if merely warmed locally. Inspection, palpation, percussion, and auscultation must be carried out on the principles necessary for the diagnosis of any abdominal tumour. The dress of the patient should be so arranged as in no way to touch or compress any part of the abdo- men. Stays only half unlaced and pressing on the epigastrium, or the upper edge of a skirt or petticoat constricting the hips, are most effectual impediments to examination. When from the absence of bulging and dulness on percussion in the flanks, of resonance in the umbilical region, of altered area of dulness on turning the patient on her side, and of certain signs of visceral disease, it is evident that ascites does not exist, or when there is reason to believe that there is more or less free fluid in the peritoneal cavity, then the surgeon must see if a circumscribed tumour can also be detected. The prominence of the front of the abdomen and the great increase of distance between the umbilicus and the pubes are very characteristic in cases of large ovarian and uterine tumours. A distinct thrill on percussion is very marked in cases of true parovarian cysts in thin patients, or in thin-walled ovarian cysts where one cavdty greatly exceeds the others in capacity. In such cases fluctuation is of course e^ddent. On the other hand, when the cyst is multilocular, the contents very colloid, or the abdominal walls thick, fluctuation is often very difiicult to detect. Even after a fair amount of experience, the sm-geon cannot always feel certain that a somewhat firm and very obscurely fluctuating tumour is a multilocular ovarian cyst, and not a soft sarcoma of the ovary, or a soft uterine outgrowth. If the pedicle be short TUBE AND BROAD LIGAMENT. 37 or the outgrowth pedunculated, even the sound will fail to dis- tinguish between uterine and ovarian tumours. The diagnosis of adhesions between the cyst wall and the abdominal parietes will always be attempted by the surgeon, but in these days adhesions of this kind are little dreaded, and, if suspected, must not of themselves be made a bar to operation. The sliding of the abdominal walls over a cyst that is not adherent is very characteristic, especially when the cyst wall is irregular. But when the cyst is very large, tightly stretching the abdominal walls, this movement is often imper- ceptible. Sir Spencer Wells has already shown how bands of adhesion may be stretched when soft, so as to allow free sliding of the abdominal walls during the respiratory movements. I have seen several instances of this condition, and, on the other hand, I once examined, together with several colleagues, a woman, aged fifty,. where a cyst, not very bulky, appeared to be fixed to the abdominal walls, but not a single parietal adhesion was found when the operation was performed, contrary to the expectation of all who had examined the case. Some words must be said on crepitus detected on palpa- tion. When an ovarian cyst attains large proportions the parietal .peritoneum and the omentum are very liable to repeated attacks of inflammation. The patient complains of abdominal pain and tenderness on pressure, often trifling in proportion to the extent of peritoneum involved. The tempera- ture rises, and on placing the hand upon the abdomen, over the cyst, very distinct crepitus can be detected. This is a physical sign of the friction between two inflamed surfaces, and of necessity implies that adhesions do not exist, at least over the area of crepitus. If the general symptoms be not severe, it is most probable that the cyst wall is not involved in the inflammatory process, or at the most only to a limited extent. It must not be forgotten that where crepitus is detected there is presumptive evidence that the inflammatory process may be existent in a more advanced stage behind the cyst, which may have strong visceral and pelvic adhesions. Still more important is it for the smgeon to remember that when crepitus is evident on palpation, it is in his power to check a serious morbid process, and to diminish the risks and 38 TUMOURS OF THE OVARY, difficulties of a future operation. Absolute rest in bed must be enforced on the patient, and the application of large poultices to the abdomen will prove of great benefit ; if this be done there need not be much necessity for preventing the action of the bowels for several days, unless the general symptoms be very severe, for it is after prolonged constipation that the condition in question frequently occurs. In two cases in my own practice where crackling could be felt over the entire surface of the tumour and troublesome costiveness existed, this treatment proved of marked benefit ; at the operation that succeeded traces of peritoneal inflammation were evident, but no adhesions were found. In one of these cases there had been a distinct rigor and a rise of temperature to 101*4°, following the introduction of the uterine sound. The operation was performed three weeks later; no suppurative processes existed. In both cases recovery was rapid. When a cicatrix of a tapping puncture is seen, it is pro- bable that the cyst wall adheres to the abdominal parietes at that point, but the adhesion is not generally very intimate. This question concerns the subject of tapping more than diagnosis. If the cyst has been frequently tapped with an ordinary trocar, without an aspirator, or without antiseptic precautions, the surgeon may reasonably suspect adhesions, not alone through the repetition of the palliative measure, but also from the conditions that rendered that measure needful and that imply the existence of adhesions. After, or rather in the course of examination of the abdomen, pelvic exploration must be undertaken. It is very important that the bowels should have first been well cleared, if the patient be examined by appointment, and if she present herself, unsuspecting the nature of her complaint, to the surgeon, he must be very certain that the middle and upper part of the rectum be not loaded with scybala. A few faecal masses near the anus are readily distinguished ; they pit when pressed upon by the finger applied to the posterior wall of the vagina. But when hard scybala are collected in the bowel at the level of the cervix and body of the uterus they greatly impede diag- nosis. They are often too firm to pit upon pressure, any attempt at which causes tenderness, as it is hard to press on TUBE AND BROAD LIGAMENT. 39 structures high up in the pelvis without the nail touching the vaginal mucous membrane. They here simulate fibroid out- growths from the back of the uterus, especially when pressed downwards and backwards by the cyst and the uterine body ; they also prevent the surgeon from properly estimating the existence or extent of solid deposits in the pelvis. The above observations refer especially to the common multilocular cyst. The other forms of cystic disease of the uterine appendages are as a rule less easily recognised, but some of their clinical features will be considered in other chapters, together with further details of clinical interest in relation to multilocular cysts, especially with regard to adhe- sions, rupture, and the management of the pedicle. 40 TrMOVRS OF THE OVAP.Y, CHAPTER III. THE PAROVARIUM AXD ITS RELATIOX TO CYSTIC DISEASE OF THE BROAD LI GA3IEXT— SIMPLE BROAD LIGAMEXT CYSTS. ly the preceding chapters I have limited my obsen^ations almost entirely to questions bearing on the development and structure of multilocular ovarian cysts, including those that bear glandular or adenomatous contents, but excluding papillo- matous cysts, nor have I yet dwelt on the subject of sessile ovarian tumours. For reasons which will be apparent on perusal of this chapter, it is advisable to consider the histology and pathology of the structures included within the folds of the broad ligament before entering into the pathology and cHnical features of sessile and papillomatous cysts of the ovaiy. Just as Pfliiger's tubes have been a stumbling-block in the way of a coiTect appreciation of the development of the multilocular cyst, so the parovarium is a centre round which much error has revolved. Only it is, unlike Pfliiger's tubes, a real struc- ture and not a misleading term for an appearance seen in microscopic sections. Owing to its somewhat mysterious character, much in the way of cyst development has been attri- buted to it, but the most fi'equent form of broad ligament cyst is at least not invariably of parovarian origin, whilst another and more serious kind of cystic tumom- decidedly develops, in some cases, from the parovarium, whilst in others it as sm-ely springs from the hilum of the ovary. As the parovaiium plays such a prominent part in the pathology of cystic tumom's of the broad ligament, it is better that the organ itself be considered before discussing the origin of minute cysts in its vicinity. Implicit trust must not be placed in diagrams and second-hand information, as sources of TUBE AND BROAD LIGAMENT. 41 knowledge of the anatomy of this structure. It is not sufficient for us to think of the parovarium as something also termed the organ of Eosenmiiller or epioophoron ; some obscure, insigni- ficant structure beautifully figured in two or three foreign works on anatomy. It is equally unscientific to despise it as a ' relic' Every part of the human body is a relic of what once was em- bryonic ; most organs develop, it is true, and increase in functional importance, whilst the parovarium does not normally develop in the adult, and though it may have its functions, they are as yet unknown. It seems strange that so definite a structure should persist into adult life, and yet be good for nothing. The blocking of its efferent duct and .the incomplete character of the epithelial lining of its tubes certainly make it appear to be as useless as the nipples of the male. To the pathologist the parovarium is of great interest, since, from or near it, cysts of the simplest and of the most complicated type may take their origin, and undoubtedly some such cysts actually arise from it, whilst others are merely associated with it by accidental proximity. To procure a good pair of uterine appen- dages suitable for the dissection of the parovarium, it is best to remove the internal organs of a young adult virgin who has not suffered during life from any disease of the pelvic viscera that tends to cause thickening of the broad ligament or long- standing congestion of its vessels. A still more suitable oppor- tunity for examining the parovarium occurs when a multilocular glandular (and not papillary) cyst of the ovary is removed, pro- vided that the operation be uncomplicated ; then, if no local inflammatory processes have existed, the broad ligament will be found lying, with the Fallopian tube, upon the cyst, thin and very much, stretched. The parovarium may then be plainly detected on holding the tube and the ligament up to the light. If, however, the specimen be preserved in spirit, th.e tissues of the ligament become semi-opaque and obscure the view of this structure. It is necessary, therefore, to dissect off the posterior layer of the broad ligament when the specimen is fresh. This can be readily effected if the tube and ligament, with a small portion of ovarian tissue, be pinned on a flat piece of cork and immersed in a saucer filled with water. When the entire outline of the parovarium is exposed, methylated spirit 42 TUMOURS OF THE OVARY, must be added ; in a few hours the tubes of that structure will be sufficiently tough for further dissection. When freed from its attachment to the posterior layer of broad ligament, its tubes shrink up, but it can be readily stretched and fixed to adjacent structures by means of silk threads, so as to show far better than before dissection. Fig. 5 represents, diagrammati- cally, the parovarium and other structures in its vicinity, to which frequent reference will be made throughout this chapter. FiG. 5.— Diagram of the Structures in and adjacent to the Broad Ligament. I. Framework of the parenchyma of the ovary, seat of la, simple or glandular multi- locular cyst. 2. Tissue of hilum, with 3, papillomatous cyst. 4. Broad ligament cyst, independent of parovarium and Fallopian tube. 5. A similar cyst in broad liga- ment above the tube, but not connected with it. 6. A similar cyst developed close to 7, ovarian fimbria of tube. 8. The hydatid of Morgagni. 9. Cyst developed from horizontal tube of iiarovarium. Cysts 4, 0, 6, 8 and 9, are always lined internally with a simple layer of endothelium. 10. The parovarium ; the dotted lines represent the inner portion, always more or less obsolete in the adult. 11. A small cyst developed from a vertical tube ; cysts that have this origin, or that spring from the obsolete portion, have a lining of cubical or ciliated epithelium, and tend to develop papillo- matous gi-owths, as do cysts in 2, tissue of the hilum. 12. The duct of Gartner, often persistent in the adult as a fibrous cord. 13. Track of that duct in the uterine wall; unobliterated portions are, according to Coblenz, the origin of papillomatoiK cysts in the uterus. The vertical tubes of the parovarium and the horizontal canal into which they run, superiorly, are easy to recognise. If one of these tubes be .prepared for the microscope it is most probable that, though patent, nothing will be found within it excepting broken-down epithelium, and, perhaps, small tracts of the inner wall still lined with cubical epithelial cells. The canal or efferent duct can often be traced inwards till it becomes a slender band that runs in the direction of the uterus (fig. 6). This band is the duct of Gartner, more persistent in many of TUBE AND BROAD LIGAMENT. 43 the lower mammalia than in woman. I have found it well- marked in over a iifth of the specimens that I have examined. Fig. 6.— Left Broad Ligaieext. Its posterior layer has been removed. Parovarinm ■well formed. Duct of Gartner distinct ; the horizontal tube has sunk downwards in process of dissection, so that the duct appears to run upwards as well as Inwards. A cyst is developed from one vertical tube. A large pyriform cyst is continuous, by a thin cord, with the horizontal duct. For several years, the attention of anatomists and surgeons has been frequently directed to a pair of ducts situated one on each side of the female urethra. They appear to be almost, if not quite constant, and, morphologically -speaking, they were hailed on their discovery as positive proofs of the persistence of the inferior portion of the efferent duct of the Wolffian body in woman. Coblenz and other writers have traced Gartner's ducts in woman and in domestic animals, from the parovarium to the walls of the urethra ; Kocks, Kleinwachter, and especially Skene of Brooklyn, all describe the ducts found in the urethra of the human female. The urethral ducts, or ' Skene's tubes,' appear to be subject to a locaKsed catarrhal inflammation. Bohn, of Vienna, and several French surgeons have described this affection, and recommend the introduction of a probe coated with nitrate of silver when the discharge becomes chronic, the ducts being laid open if that treatment fail. Eieder, of Basel, has failed to trace Gartner's ducts as far as the urethra, and recently Dr. Max Schiiller, of Berlin, has published the results of a long series of dissections, and his conclusions tend to sub- vert the theories of Skene and the morphologists, the m-ethral 44 TUMOURS OF THE OVARY, ducts appearing to be the outlets of a pair of very distinct glands. Dr. Schiiller states that, between the longitudinal folds of urethral mucous membrane that converge towards the meatus, numerous pores and depressions may be found. On each side of the middle line, posteriorly, rises a ring of mucous membrane surrounding an orifice, into which a sound of from one to four millimetres in thickness can be passed for from half a centi- metre to two and a half centimetres upwards. This is the duct, and the pair have been found by Dr. Schiiller in subjects of every age, from foetal life to the eightieth year, almost con- stantly. Inflammation of the urethral ducts can be diagnosed, he believes, when discharge from the meatus exists, without scalding pains during micturition. On horizontal section each duct appears as a tube, with a contour the more and more irre- gular from involutions and elevations of its lining membrane the higher up the section is made, until it can be traced to its termination above as a gland made up of a collection of short tubules. The orifice of the duct is lined with a thick layer of squamous epithelium covering erectile tissue ; the rest of the canal is invested with stratified transitional epithelium, covering vascular submucous tissue that contains plain muscular fibres. In old subjects the ducts are much contracted. Dr. Schiiller has traced their origin in the foetus to the same period of em- bryonic life as that wherein the other structures composing the urethral mucous membrane are developed, and he can find no communication between them and the duct of Grartner. I have observed a catarrhal discharge from these ducts in two of my out-patients at the Samaritan Hospital. As for Dr. Schiiller's discovery, it is possible that the gland forms a secondary communication with Gartner's duct very early in foetal life ; this would reconcile the above conflicting theories. The lower ends of the vertical tubes of the parovarium are lost in the hilum of the ovary • this is a matter of great patho- logical importance, as will presently be explained. The inner- most of the tubes are always more or less obliterated as a rule ; about eight or ten are well developed, whilst five or six more remain visible as fibrous threads. When cystic ovarian disease exists, the tubes are always more distinct than in health, and in cases of double cystic disease I have generally found them best TUBE AND BROAD LIGAMENT. 45 marked on the side where the largest tumour has developed. In one such parovarium I counted twenty-four well-developed vertical tubes. In all probability the inner tubes are the seat of origin of those papillary cysts that are sometimes found be- tween the less obliterated part of the parovarium and the uterus. In the normal parovarium the vertical tubes are not parallel to each other, as they converge inferiorly. When a tumour of the ovary exists this is less marked, as the hilum has increased in size and spread out the lower ends of the tubes. Each tube runs a somewhat zigzag course downwards. In most specimens several small cysts may be found in different parts of the broad ligament and its vicinity. The long pedunculated hydatid of Morgagni (fig. 7) is an almost constant pear-shaped cyst hanging from one of fhe lower fimbriae of the Fallopian tube ; it represents the blind extremity of IMiiller's duct, which, in the process of development, breaks open near that extremity, and develops the fimbria along the border of Fig. 7. — A S.-\[ALL Hydatid of iloiiGAGxi (viewed anteriorly) ; it arises above and in front of the ovarian fimbria. The fimbrise of the Fallopian tube are ill developed. 2. An unusually well-developed hydatid of Morgagni (viewed anteriorly). The hydatid arises from the same point as in the upper figure. The fimbrise of the Fallo- pian tube are highly developed, bvit short. the line of dehiscence. The term ' hydatid of Morgagni ' is exclusively employed by some anatomists to signify the pedun- culated cyst found in connection with the testicle ; this cyst is likewise believed to be a vestigial relic of the uppermost ex- tremity of Miiller's duct, the lower portion of which is repre- sented in the adult male by the tissue round the sinus pocularis in the prostatic part of the urethra. The use of the name 46 TUMOURS OF THE OVARY, ' hydatid of Morgagiii ' for Iiomologous bodies in both sexes is to be encouraged, being scientifically coirect. This hydatid is certainlvnot identical with the sessile cyst frequently developed behind the long or ovarian fimbria of the Fallopian tube. I have repeatedly found the cyst and the hydatid co-existent. The pedicle of the hydatid is above and anterior to the root of the ovarian fimbria. At the outer extremity of the horizontal tube or efferent duct of the parovarium a very similar cystic body, also pedun- culated, is frequently developed (figs. 6 and 8). I have found every cyst of this kind to be lined with an inner layer of endo- thelium, and not with the ciliated or columnar epithelial cells which invest the lininsf membrane of a vertical tube. This Fig. 8. — A PEDrxcTXATED Cyst, continuous -nith the horizontal tube of the parovarium. Above it 15 a cyst of similar form, independent both of the Fallopian tube and of the parovarium. Both cysts were lined Tvith endothelium. The cut surface of the ovary displays two corpora lutea. terminal cyst is occasionally non-pedunculated (fig. 9), forcing apart the layers of the broad ligament as it increases in size. As a rule, however, it hangs from the ligament by a pedicle. Since pedicles of this type are poorly supplied with blood, and readily become twisted, neither this terminal cyst, when pedun- culated, nor the hydatid of Morgagni ever attain large dimen- sions. On a vertical tube of the parovarium a minute cyst may often be found (fig. 6), and close to the point of entry of such a tube into the tissue of the hilum of the ovary a similar cyst may sometimes be detected, partly embedded in the ovarian tissue. Far away fi-om the parovarian tubes some minute cysts are often observed, adherent, as a rule, to the anterior layer of TUBE AND BROAD LIGAMENT. 47 the broad ligament (figs. 10 and 12). They are most plainly visible anteriorly, through the ligament, when the specimen is fresh. When developed beneath the reflexion of the peritoneum Fig. 9.— a Sessile, Thix-walled Cyst, developed on the extremity of the horizontal tube of the parovarium, viewed from behind. The outermost vertical tube passes in front of it. The cyst is quite independent of the ovarian fimbria of the Fallopian tube. Fig. 10.— As Ovary with the Tube and Intehmediatb Stettctueks. A part of the posterior layer of the broad ligament has been removed. A large thin- walled cyst lies between the layerg of that ligament ; it is quite independent of the Fallopian tube and the parovarium. The outermost vertical tube of the parovarium crrsses over the cyst and joins the ovarian fimbria, an unusual condition. Two smaller broad-ligament cysts lie internal to the large cyst. over the upper border of the Fallopian tube, they are often pe- dunculated, as they can more readily push the serous membrane upwards than insinuate themselves between its layers below the 48 TUMOrRS OF THE OVABY, tube. Still, even in tKis position, the cyst may be perfectly sessile (fig. 11). In some cases these cysts become peduncu- lated, even when they are developed in the folds of the broad Fig. 1L — ^A Thk-waixed Ctst, developed in the broad ligament at its line of re- flexion over the Fallopian tube. The cyst is perfectly free from the tube, ligament below the tube (fig. 8), and sometimes several such pedunculated cysts hang like tassels from the ligament. As a rule, however, these cysts, when they increase in size, push apart the layers of the broad ligament. I have invariably found that their inner layer is endothelial. It is often from a minute cyst of this kind, free from the parovarian tubes, that is deve- loped the large cyst commonly termed ' parovaidan,' with its thin transparent wall, its single cavity, lined with flat or low columnar epithelium, and its clear watery contents. I have examined over one hundi-ed broad- ligament cysts of this kind, perfectly free from the parovarium and from the tube, and ranging from one-fortieth of an inchi to one inch in diameter. The broad ligament is often studded with minute cysts, some spherical, some oval, and in rarer instances they assume an ovoid form, standing out from the surface of the broad ligament, without possessing a pedicle. I have also observed a cystoid degeneration of the broad ligament apparently produced by local congestion or oedema. It is very frequently seen in cases of myoma of the uterus, where the tumour rises high in the abdomen and drags the ligaments upwards. When the tumour is cut away with the uterine appendages, the mass of small cyst- like projections dis- appear (for that reason I have made use of the term ' cystoid " degeneration), whilst generally a few true cysts can then be detected on the surface of the lisrament. This condition is still TUBE AND BROAD LIGAMENT. 49 more frequent in the connective tissue around the ovarian vessels. This so-called parovarian cyst often arises close to the ovary under the ovarian fimbria of the tube (figs. 10 and 12) ; as it develops it pushes the parovarium inwards, and rises, between the folds of the ligament, as high as the tube, which often be- comes stretched to an indefinite extent. The true relation of the ovarian fimbria to the cyst will be considered further on. The entire parovarium may often be found outside the wall of such a cyst posteriorly (fig. 10). The terminal cyst of the paro- varium, which also bears a layer of endothelium, may, as I have already observed, likewise become enlarged without developing a pedicle. It then forces the layers of the broad ligament apart, and becomes a large unilocular cyst that is truly paro- varian. As it enlarges, it first comes in contact with the ovarian fimbria of the tube, which it stretches, and finally stretches the tube itself. In this stage it cannot be distin- guished, either by its appearance and relations, or by the character of its endothelial lining, from a cyst originating in the manner just described, although when incipient the differ- ence is apparent at a glance (figs. 9 and 12). Hence it is better to use the term ' simple cyst of the broad ligament ' than to employ the term ' parovarian cyst,' when speaking of a large cyst free from the ovary, which has generally been con- sidered to be invariably of parovarian origin. I will now take into further consideration the cysts in con- nection with the vertical tubes of the parovarium. These tubes, when perfectly developed and not degenerate, are lined with ciliated epithelium, as are the walls of certain cysts in the ovary and the broad ligament. Such cysts have a tendency to develop solid papillary growths from their inner walls, and usually contain a clear watery fluid ; when they have grown to a large volume the epithelium generally ceases to be ciliated. Histologically and pathologically they are identical with the papillary cysts described elsewhere that appear in the tissue of the hilum of the ovary where relics of the Wolffian body exist, and do not tend to invade the stroma of the parenchyma, but rapidly grow into the broad ligament, forcing apart its layers. I shall presently refer to the question of mixed papillary 50 TUMOURS OF THE OVARY, and glandular cysts in ovarian tumours. As Wolffian elements extend into the tissue of the parenchyma of the ovary, and, on the other hand, follicles may grow into the tissue of the hilum, these mixed growths are readily accounted for. I have found that even the typical glandular ovarian cysts may, in rare cases, push into the hilum, and force apart the layers of the broad ligament. But histologically it is only the ovarian cysts with papillary contents that need consideration in discussing cysts that spring from the parovarium. Xo case of multilocular cystic disease of the broad ligament, with glandular intracystic growths and no implication of the ovary, has ever been de- scribed, but large papillary cysts of the broad ligament, en- tirely free from the ovary, which remains healthy, yet pre- senting all the characters of similar ovarian cysts, are now well known to pathologists. Incipient cysts of this kind may be seen in some specimens springing from a vertical tube of the parovarium. From the generally obliterated, inner vertical tubes of the parovarium, of which a faint indication may some- times be found on dissection, similar cysts may develop between the parovarium and the uterus, as has already been observed. These cysts with papillary contents spread over the broad ligament with great rapidity. If once a cyst wall bursts, papillary masses sprout freely into the peritoneal cavity and soon grow over the tube, the fundus uteri, and the visceral and parietal peritoneum. In the chapter on the Fallopian tube, I have given my reasons for believing that the masses of papil- lomatous growths that sometimes infest the ovary and broad ligament, and are unaccompanied by any cystic growth, may have their origin in the Fallopian tube itself. I have found perfect cysts, filled with the characteristic gi'owth, on the peri- toneum of Douglas's pouch, far from ovarian or parovarian tissue, in cases of ruptured papillary cyst of the broad ligament. It is, from this fact, easy to understand how similar papillary cysts may also be found between the layers of the broad liga- ment, on the site of the above-described minute cysts of non- parovarian origin ; but whether, in such cases, these minute cysts themselves receive some morbid stimulus which causes their unperforated lining membrane to produce papillary growths, I cannot say, only I doubt this possibility. In mixed TUBE AND BROAD LIGAMENT. 51 glandular and papillary multilocular tumours of the ovary, each loculus generally produces one of the two forms of solid growth alone, excepting when a papillary mass perforates a compart- ment loaded with purely glandular growths. These papillary cysts of the broad ligament are, after all, not very common, whilst the small cysts, bulging from the vertical tubes of the parovarium, are far from rare. This is not to be wondered at, for the chance of any one such minute cyst ever growing large is very slight. The parovarian tubes, and everything associated with them, tend to atrophy and not to enlarge ; it is unusual to find one single tube thoroughly patent in an adult, and its lumen is always more or less choked with broken-down epithelium. The^ cavities of cysts directly connected with the tubes generally become filled with a similar material, and all growth ceases, as a rule, before such cysts attain the size of a pea. It is the presence of papillary growths, springing from the inner walls, that is the essential feature of cysts derived from I the vertical tubes of the parovarium and their prolongation] into the tissue of the ovarian hilum. Too much importance must not be placed on the presence or absence of ciliated epi- thelium. Dr. Fischel, in a paper ' Ueber Parovarialcysten und parovarielle Kystome,' in the fifteenth volume of the ' Archiv flir Grynaekologie,' 'discusses this epithelial question at great length. He admits that on the inner walls of many of these cysts with papillary growths, ciliated cells are absent, or only found in places, and is difiident with regard to Klebs's opinion that the ciliated epithelium may become changed into other forms, nor does he fully accept Spiegelberg's theory that the pressure of the fluid contents can flatten ciliated epithelium till it loses its cilia and becomes pavement epithelium. Dr. Fischel is more inclined to believe that when ciliated epithe- lium is not found under these circumstances, the simpler type that replaces it was never ciliated at all. Waldeyer has shown that the epithelium of the Wolffian body is not originally ciliated ; the simpler non-ciliated, cubical epithelial cells covering the papillae in these cysts represent this earlier type of Wolffian epithelium. On the other hand, it must be clearly understood that the inner lining of all the other cysts described E 2 62 TUMOURS OF THE OVARY, above is endothelial — that is, made up of a single layer of flattened epithelial cells ; this I have repeatedly verified by nitrate of silver staining. The usual condition of a vertical tube of the adult parovarium renders microscopic examination of its epithelium very difficult, but I have far oftener found simple columnar or cubical cells than ciliated epithelium. For the reasons just given, I believe it to be better to trust to the anatomical position of cysts of the broad ligament, as seen by the naked eye in their earliest visible stage, rather than to any blind reliance on the presence or absence of a kind of epithe- lium not always found in the very structure on which the whole question depends. It might be contended that some of the minute non- parovarian cysts are developed from Miiller's duct, which ulti- mately becomes the Fallopian tube. There is no evidence, however, that any true Fallopian cyst has ever been found, excepting such as are developed within its canal from obstruc- tion, papillary growths, or extra-uterine gestation. The minute cysts found on the upper border of the tube, under the serous membrane, are, as has already been observed, quite free from the tube and identical in character with the non-parovarian broad-ligament cysts found below the tube. The cyst, often developed between the layers of the broad ligament close to the ovarian iimbria of the tube, does not appear to be histologically continuous with it. It is lined with endothelium, whilst the ovarian fimbria is invested with a layer of ciliated epithelium. This is not, perhaps, conclusive evidence, as the same applies to the hydatid of Morgagni. On examination of a cyst of this kind, however, I have ever found that the fimbria was distinct from it ; the subdivisions of its fleshy processes being stretched over the capsule of the cyst, just as the entire Fallopian tube is stretched over a larger cyst (fig. 12). The small shreds or tags that often project from the upper border of the tube, and are covered with a layer of serous membrane, are not cysts but abnormal fimbriae. They are the result of an exaggeration of the process of dehiscence which normally takes place near the extremity of Miiller's duct, when the orifice of the tube and its fimbriae are developed. If the split be prolonged backwards, a fringe may be formed some distance behind the normal fimbriae. TUBE AND BROAD LIGAMENT. 53 But a cyst could hardly be developed in the course of this process, excepting the hydatid of Morgagni, which is almost constant, as the dehiscence never extends to the extremity of l}^f% Fig. 12. — A Right Broad Ligajibxt showing a large cyst developed between its layers close under the ovarian fimbria of the Fallopian tube ; the secondary fringes of that fimbria are stretched over the cyst and parted widely from each other, and an incision in the capsule exposes the cyst-wall. The horizontal tube of the parovarium termi- nates in a pedunculated cyst. A small cyst is developed in the broad ligament above the parovarium. The hydatid of Morgagni is replaced by a pedunculated fringe. Miiller's duct, and that extremity always tends to close at the point of dehiscence, so as to become at once a cyst hanging from the fimbrige, the hydatid of Morgagni itself. The pedicle may be very long, or may be replaced by a small fringe mounted on a long pedicle, or may even bear a second fimbria, as a singular specimen that I once examined (fig. 7). It often undergoes hypertrophy and elongation in cases of cystic disease of adjacent structures, or when chronic inflammation of the tube and ovary has existed for a prolonged period. In one case of long- standing suppuration of an ovarian cyst treated by excision, I found, when the entire cyst was ultimately removed, that the pedicle of the hydatid was six inches long, although the hy- datid itself was not a quarter of an inch in diameter ; the case will be described in the chapter on the abdominal wound in ovariotomy. I will • first consider the simple broad ligament cyst more specially, before turning to papillomatous and sessile cysts in connection with the ovary, parovarium, and broad ligament. In its more clinical aspects the simple broad ligament cyst has been for long familiar to the surgeon. In the earlier success- 64 TUMOURS OF THE OVARY, ful cases of ' ovariotomy ' it was, at least as a rule, a cyst of this kind that was removed ; this subject has been discussed by Mr. Tait. The diagnosis of a broad ligament cyst is generally easy ; adhesions are rare, and the results after operation very satisfactory; the operation itself is seldom difficult, although one complication may tax the skill of the operator to the utmost. The beginner naturally prefers to commence with a case of broad ligament cyst. It is significant that, at the Samaritan Free Hospital, this kind of cyst is not often seen, although a few years back it was very frequently removed by operation at that institution. Many such cysts are now operated upon by private practitioners with excellent results. By a process of selection, easy to understand, it is the worst cases of ovarian tumour, or rather those that from external appearance promise to be the worst, that are most frequently sent to special hospitals. The thin wall of a broad ligament cyst, with the tube tightly stretched over it, and the clear, watery contents are well known to surgeons and pathologists. Some good drawings Fig. 13.— a Sbiple Broad Ligament Cyst. of fully developed ' parovarian ' cysts are to be found in a paper by Dr. Bantock in the fifteenth volume of the ' Transactions ' of the Obstetrical Society of London. The ovary generally hangs free and unaffected from the lower part of the cyst (fig. 13). TUBE AND BROAD LIGAMENT. 65 In six cases that I have seen, that organ, on the other hand, was stretched out and flattened, by the extreme size and tenseness of the cyst, which jammed it down into Douglas's pouch or stretched it out, as the capsule became more and more distended, much as the Fallopian fimbriae are stretched, although from the relation of the ligament to the ovary that organ cannot be brought so close into contact with the cyst as can the tube which lies within the folds of the broad ligament. In one case, under the care of IMr. Meredith, the flattening of the ovary was so extreme that it was difficult to find it at all, until some Graafian follicles were discovered on cutting into a thickened area on the capsule. The ovarian ligament is also frequently stretched to the extent of three or four inches. It is not common to find papillomatous growths springing from the inner walls of a tumour that in all other respects bears the appearances of a simple broad ligament cyst, but when they are found this offers the strongest possible evidence that the cyst is truly parovarian, for reasons which I have already given at length. In one case, that died of tetanus, I found a small bunch of papillomatous outgrowths, the ovary was not the least compressed, but the growth of the cyst had been arrested by twisting of its pedicle, and haemorrhage had occurred into the cyst cavity, causing its contents to be very turbid. Had this complication not occurred, the papillary growths would probably have been more exuberant. In another case I found half-a-dozen such outgrowths ; the cyst was of the usual type with very clear fluid contents. The possibility of the existence of papillomatous outgrowths appears to me to be a strong argument against attempting the cure of broad ligament cysts by simple tapping. This often proves to be a permanent remedy, and is, I understand, still advocated by that most distinguished surgeon Dr. Keith. But the removal of a simple broad ligament cyst is a very easy operation, and the mortality exceedingly low ; at the best it appears hardly advisable to leave a large flaccid cyst hanging down into the pelvis, and should there be any papillary growths it is very unsafe to leave them behind, as they may suddenly increase with great rapidity, and invade the peritoneum. Tap- 56 TUMOURS OF THE OVARY, ping is also not unfrequently very inefficacious ; in one instance, a case under the care of Dr. Bantock, the cyst had been tapped seven times. At the operation a few adhesions, rare in cysts of this type, were found. The ovary was much flattened out, so that the cyst must have become very tense and grown rapidly notwithstanding the tappings. Eupture of a simple broad-ligament cyst is not rare ; I have seen two operations where this had previously occurred. In one it had been caused by a fall, in the second it had taken place several years before operation, and a large cicatrix was found in the cyst wall. On account of the nature of the fluid contents, this accident very seldom produces severe peritoneal symptoms. In the two above referred to, the rupture had caused very little inconvenience to the patient. When the abdominal incision, including the division of the peritoneum, is completed, the thin wall of a broad ligament cyst generally presents a very characteristic appearance, differ- ing greatly from the shiny, more or less opaque, silvery-white surface of a true ovarian cyst. In one case, under INir. Thorn- ton's care, the walls of an undoubted broad ligament cyst were much thickened by a great development of fibrous tissue, so as to present the appearance of a thin-walled ovarian cyst. Inflammation of the cyst-wall is uncommon ; I have only observed one case where this condition was marked ; the opera- tion was perfectly simple. On account of the little tendency which these cysts possess to cause peritoneal irritation, adhe- sions are rare. One case is mentioned above, and was clearly the result of tapping. In another case, where I assisted Sir Spencer Wells, the sigmoid flexure was closely adherent to the capsule, but its separation was not difficult. In a third case, under the care of Mr. Meredith, there were deep pelvic adhesions, greatly prolonging the operation. In a fourth, in Mr. Thornton's wards, the adhesions were very troublesome, and the temperature rose to 102° on the second and third day. The only troublesome complication that is frequent in operations on broad ligament cysts arises from the disposition TUBE AND BROAD LIGAMENT. 57 of tlie capsule in some cases. As a rule, the cyst pushes against the tube, the ovarian fimbria, and the ovary, and a good pedicle separates it from the uterus. But in some cases it burrows downwards so as to grow in the direction of the ovarian ligament, and beyond the limits of the broad liga- ment, and its removal becomes a matter of considerable diffi- culty. It is then necessary to shell the cyst out of the ligament, which has afterwards to be, for the greater part, cut away, a portion being treated as a pedicle, and secured by ligature. Exclusive of over fifty cases where incipient broad- ligament cysts were found in connection with ovarian and uterine tumours, I have assisted at thirty-two cases where fully developed broad-ligament cysts were removed, and in six the process of forcible separation of the broad ligament was requisite in order to get at the deepest part of the cyst. In one case, under Dr. Bantock's care, the cyst bmTowed deeply into Douglas's pouch, whence it was shelled out. In another case, under the same surgeon, the process of detach- ment of the capsule was easier, though the cyst was very large, forming a tumour that extended into both flanks ; the ovary was so much flattened as to be hard to recognise, and the tube stretched in a singular manner, its ostium being widely dilated, so that when the elongated fimbriee were held up, it was possible to distend the tube by simply blowing at the ostium, without the aid of a blow-pipe. In both the cases of rupture, above described, the cyst had to be shelled out of its capsule. In another case a large broad ligament cyst existed on both sides, the wall of the right-hand cyst seemed to have become inflamed, the fimbriae of the tube were matted together. The detachment of the capsule proved to be a very difficult task ; a drainage tube was passed into Douglas's pouch, but the patient died on the fom-th day. As a rule, recovery is very rapid and without any consider- able rise of temperature ; in one case, however, that I have seen (a woman of thirty-six years of age), the temperature rose to over 105°, though complete antiseptic precautions had been taken, but the patient had been subject to ague ; she recovered perfectly. 58 TUMOURS OF THE OVARY, In one case the rigtit broad ligament was cystic, whilst the left ovary was converted into a multilocular cyst. In another two cysts existed on one side, one holding several pints, and the other about an ounce of characteristic clear fluid. This specimen, removed by Mr. Thornton, forms a very instructive preparation, now in the Museum of the College of Surgeons (Pathological Series, 4588, new catalogue). The relation of the cysts to the broad ligament is illustrated by dissection. TUBE AND BROAD LIGAMENT. 59 CHAPTER IV. PAPILLOMATOUS AND SESSILE OVARIAN CYSTS— PAPILLO- MATOUS DISEASE OF TEE BROAD LIGAMENT. As papillomatous cystic disease of the uterine appendages, ex- cluding the Fallopian tube, which will be considered further on, appears to be very intimately associated with the relics of the Wolffian body, which are represented in the adult chiefly by the parovarium, the reason why I have entered into the subject of parovarian cysts before turning to papillomatous cysts of the ovary will now be evident. For the elimination of certain errors, I have been compelled to state at length all that I had to say concerning broad ligament cysts in general before returning to the remaining forms of cystic ovarian disease. The ovary is divided into two parts, histologically distinct, and differing in the manner of their development. The essen- tial part is the collection of Graafian follicles, or parenchyma, with its surrounding stroma, and the other part is the tissue of the hilum, close to the broad ligament. From the stroma of the parenchyma (fig. 5, i) arise the ovarian cysts already de- scribed. As the seat of origin of these cysts is in the free part of the ovary, they rapidly absorb the structures in that part, so that when the tumour is only a few inches in diameter, the normal outline of the ovary is lost, and its healthy portion can- not at first be detected (fig. 14). As the hilum remains as a rule free from disease, such cysts have usually a very distinct pedicle. In some cases, presently to be described, the com- mon multilocular ovarian cyst, with or without glandular con- tents, is sessile. From the tissue of the hilum of the ovary arise the multi- locular proliferous cysts, which contain exuberant, firm papillo- matous growths, instead of the succulent glandular material 60 TUMOURS OF THE OVARY, found on the inner walls of many cysts arising from the stroma of the parenchyma. This tissue is very vascular, and contains, as Fig. 14. — ^A Siuxl iIui.TiLOcrL.\E Ovaeiax Cyst, slightly reduced from natural size (ilnseum of tlie Eoyal CoUege of Surgeons, Pathological Series, I^o. 275). has already been observed, traces of the tubes of the Wolffian body (fig. 1, 4). The parovarium, which represents the greater part of that body, appears to the naked eye to run into the hilum of the ovary. The papillomatous growths within these cysts are identical with similar growths found in certain large cysts of the broad Kgament, the origin of which has been traced to relics of the Wolffian body lying between the parovarium and the uterus, as will presently be shown. As the seat of origin of these cysts is not in the free part of the ovary, the normal shape of that portion of the ovary is retained until the tumour has reached a considerable size. On the other hand, such tumours must almost always be more or less sessile, especially when, as is frequently the case, the layers of the broad liga- ment have been parted asunder by the growth, which tends to advance in that dii-ection rather than towai'ds the stroma of the parenchyma. The fluid within these cysts is clear and not glairy. Since remnants of the epithelium of the "Wolffian body ex- TUBE AND BROAD LIGAMENT, 61 tend into the stroma of the parenchyma, it is easy to under- stand how papillary growths are often found in some secondary cysts when the others are filled with glandular material. Mul- tilocular cysts, developed entirely from the tissue of the hilum, appear to contain papillomatous growth alone. The woodcut (fig. 15) represents an ovary removed by Dr. Bantock from a woman aged thirty-one for the relief of uncon- trollable monorrhagia. Its fellow was also removed. This sketch may be instructively compared with fig. 14, the drawing of an ovary affected with incipient multilocular disease of the ordinary kind. From the ovary (fig. 15) projects an oval cyst, from the inner wall of which spring numerous small papillo- matous growths, and one of its extremities is closely connected with the tissue of the hilum. In fig. 15 it will be seen that the ovary itself is not invaded by the cyst, but projects above Fig. 15.— Incipiext Pavillojiatous Cyst of the Hilum. The free portion of the ovary projects above, posteriorly. it somewhat posteriorly. In fig. 1 6 this freedom of the parenchy- matous portion of the ovary is still more plainly marked ; here the tumour was over a foot in diameter before it was emptied of its contents. The large oval cyst in fig. 15 had already forced itself into the broad ligament close to the hilum. In the opposite ovary a similar cyst, only one inch in diameter, sprang from the tissue of the hilum, leaving the parenchyma entirely uninvaded, but already beginning to force itself between the layers of the broad ligament. The larger these papillary cysts grow, the more and more do they invade the ligament, and the more 62 TUMOURS OF THE OVARY, sessile and troublesome to the operator do they become. But the more that a cyst that was originally developed in the Fig. 16. — A Large PAPILLO^L\■l•ous Cyst spriugiiig from the Hilum of the Ovary, the greater part of which organ is not involved in the morbid growth. The cyst has forced its way between the layers of the broad ligament as far as tlie Fallopian tube : this condition has been made more clear by removal of a part of the ligament over the tube and another part over the cyst ; the corresponding portion of the wall of the cyst has also been taken away to expose the cavity. parenchyma grows, the more the ovary loses its normal outline, but the broad ligament remains intact. I shall presently revert to these tumours to consider their clinical peculiarities. A few years since, when examining the internal generative organs of a seven months' foetus, kindly forwarded to me by my friend Dr. Champneys, I found that both ovaries were in out- ward appearance normal. Some microscopic sections were made at the physiological laboratory of St. Bartholomew's Hospital by Dr. Vincent Harris. Each ovary measured two- fifths of an inch in length. The right proved to be perfectly normal. Hundreds of Grraafian vesicles were scattered over the stroma. In the tissue of the hilum, but there only, were thick- walled vessels. It is significant that whilst in the left ovary not one of the smaller cystic cavities presently to be described could be positively identified as an ovisac, in this, its fellow, the follicles forced themselves on the observer's notice at the first glance. Some of the deeper follicles lay close to the thick-walled vessels with which they are so often confounded. TUBE AND BROAD LIGAMENT. 63 The ova were very distinct ; the epithehal lining of the folli- cles was far more prominent than the slender endothelium which bounded the lumen of the thick-walled vessels, but much thinner than the lining of the morbid cysts in the left ovary. The spindle-celled stroma of the parenchyma in this normal ovary contrasted strongly with the fibrous and elastic tissue which replaced it in the same organ on the left side. The left ovary appeared quite flat, like its fellow, and had the sharply-defined, sinuous border characteristic of the ovary in later foetal life. Dr. Harris and myself were much surprised, on examining the sections, to find that the ovary contained three cysts, of almost equal size, lying in a row along its long axis, and plainly visible to the naked eye, which could also detect exuberant vegetations growing from their walls. The cysts were almost perfectly spherical ; the largest measured one-twelfth, the smallest one-sixteenth of an inch in diameter. Examining the sections under the microscope, I found that the cysts, owing to their great relative proportions, encroached equally on the vascular tissue of the hilum, and on the more superficial part of the ovary towards the tunica albuginea. They were surrounded by much condensed fibrous tissue. Into their interior grew an abundance of branched vegetations covered with a stratified layer of columnar epithelium. After repeated examination I could detect cilia on some of the super- ficial epithelial cells. In the narrower processes of the vegeta- tions the stroma appeared purely fibrous, but in the broader tufts there were epithelial bodies in the midst of the stroma. The tissue at the base of these same tufts passed into the sub- stance of the ovary, external to the boundary of the cyst, the epitheloid cells being traceable throughout, from the stroma at the free end of the tuft to the stroma of the ovary. These cells were clearly the same which, found in the deeper parts of normal ovaries, are admitted to be relics of the tubes of the Wolffian bodies. The stroma of the parenchyma of the aff"ected ovary con- tained an unusual amount of elastic fibre and a very scanty supply of the spindle cells seen in normal ovarian tissue — as in the fellow to this ovary. The germinal epithelium had atrophied and become converted into a true condensed, fibrous 64 TUMOUES OF THE OVARY, tunica albuginea. Towards the surface of the ovary -vvere several enlarged vessels, some full of blood-corpuscles, and all recognisable by their thin endothelium and thick muscular coats. Close to them were several cystic bodies not exceeding one-fiftieth of an inch in diameter, and hned with columnar epithelium precisely similar to that which invested the intra- cystic gi'owths. At first these small cysts appeared to be true Graafian vesicles, but on careful examination it could be seen that none contained ova, and that the epithelium on theu' inner walls was made up of much larger cells, aiTanged with greater regularity than in the cellular lining of a true ovisac in any stage of its development. Xo such epithelium could be found within any of the normal follicles which swarmed in the opposite ovary. The stroma around these small cysts contained a great number of the epithelial cells akeady mentioned. In fact, these cysts were most probably an early and younger form "of the larger proliferating cavities. From the above account it will be seen that the vegetations were identical with the papillomatous growths found in cysts after bh'th. The epithelial elements scattered in the stroma of a normal ovary representing a general atrophy of that part of the "S^'olffian body which becomes suiTOunded by ovarian tissue, it is reasonable to suppose that the proliferating cysts in this specimen represented tubes belonging to that body which have, on the other hand, become dilated and cystic. All these changes, normal and morbid, were to be seen in this same specimen. Firstly, the proliferating cysts, then the smaller cystic bodies, one-fiftieth of an inch in diameter, and hardly altered from their original condition as true "Wolfi&an tubes, and, lastly, the epithelial relics of other "SVolffian tubes that have undergone normal atrophy. The absence of Graafian vesicles was so marked in this ovary as to lead to the conclu- sion that the abnormal changes in the Wolffian tubes must have blighted their development at a very early period. A drawing of this diseased foetal ovary will be found in the ' Transactions of the Pathological Society ' for 1881, and in the last edition of Sir Spencer Wells' work, page 34. I think that all must admit that this remarkable case throws a great deal of light on the origin of papillomatous cysts of the ovary. The TUBE AND BROAD LIGAMENT. G5 follicular elements were completely suppressed, and the Wolffian structures had become over-developed, with the result of pro- ducing a row of cysts filled with the most characteristic papil- lomatous growths. I shall refer once more to this particular case when discussing the question of morbid growths within the Fallopian tube. The accidental discovery of the disease in this case is a strong testimony in favour of the value of sys- tematic examination of still-born children, as advocated by Mr. J. B. Sutton in a communication read in March 1884 at a meeting of the Eoyal Medical and Chirurgical Society. As far as ovarian histology and pathology are concerned, it is very desirable that human foetal ovaries should be studied, as the relation of the stroma to the follicles and Wolffian tubes is not the same in many of the lower mammalia as it is in woman. The papillomatous growths, of which so much is being said in these pages, form, wherever they may develop, very luxuriant cauliflower masses, with free tags or villous processes in great abundance. They are sometimes gritty through psammomatous changes, and bleed freely when handled during operation. Their free surface is invested with a layer of cylindrical epithe- lium, the cells of which are never so extremely long as those lining glandular growths, but they generally bear cilia. Each process contains a blood vessel, often obliterated ; the connective tissue basis is scanty, and chondrification or development of sarcomatous matter is rare. I have never detected goblet or chalice cells on the epithelium of these growths. Some patho- logists believe that papillomatous and glandular intracystic ovarian growths are identical, excepting that the epithelial elements predominate in the former, and the connective tissue basis in the latter. But not only is the seat of origin of the two forms of growth quite different, but the epithelium of the glandular growths, so far from being subservient to its con- nective tissue basis, is very active in pushing itself in all directions, forming acini and cysts, and secreting a dense fluid. In papillomatous growths, though vessels abound and in- crease of papillary projections progresses actively, none of these more complicated processes take place, and the fluid contents of the cysts in which they grow is almost devoid of organic products. 66 TUMOURS OF THE OVARY, It is not always easy to decide, in the case of a patient who has undergone and recovered from an operation, whether a papillomatous cyst be of ovarian origin or entirely developed, from the first, from the broad ligament. For reasons already given, papillomata are liable to develop in the parovarium, and also in the tissue of the hilum of the ovary ; and as some of this tissue extends far into the parenchyma, that portion of the ovary may, in rare cases, be involved, and all trace of the normal outline of the organ destroyed. StUl, even when a papillo- matous hilum cyst has reached a very considerable size, the flattened parenchymatous part of the ovary, with its convex border, often projects very distinctly from the back of the tumour, and on section follicles and corpora lutea can be de- tected. In one case, where the tumour was removed by Dr. Bantock, the cyst held several pints of fluid, and was full of papillomatous growths ; still, the free part of the ovary pro- jected freely from its posterior aspect. The follicles were dis- tinct, and the papillomatous growths that had completely replaced the normal tissue of the hilum had invaded the paren- chyma to a very limited extent. More frequently the ovary is concealed, not by destruction of the parenchyma by papillary invasion, but by growth of papillomata on its free surface. This complication generally follows rupture of the cyst. The opposite condition, where, instead of papillomatous hilum cysts invading the broad ligament, cysts of the same kind commence in the Wolffian relics in the folds of that Liga- ment, and grow so rapidly as to bury the ovary in cauliflower masses, is not uncommon. In such cases the papillomatous growths are particularly liable to burst through their cyst-walls and grow over to the exterior of the ovary, as in cases, above referred to, where the growths are ovarian in origin. There is a specimen in the Museum of the Eoyal College of Surgeons where the ovaries are completely concealed in this manner ; the broad ligaments are infested with papillomatous growths, which have burst from their cystic coverings ; and it was only after a prolonged search that I could find the ovaries, deeply buried in the growths. In another case, where papillomatous tumours were entirely of broad ligament origin, I found the ovaries buried in the TUBE AND BROAD LIGAMENT. G7 papillomatous masses, but their surfaces were normal, and not a single papillomatous body could be found upon them. The patient was a young woman aged thirty-three ; an exploratory operation was made by Sir Spencer Wells in November 1877 ; a large cyst was discovered adhering so intimately to the abdo- minal wall that it could not be removed ; it was filled with pax^illomatous masses and clear fluid. The cyst was drained, but the patient died on the eighth day. It must here be observed, as in the chapter on solid tumours, that papillomatous growths are very intolerant of operative interference ; and as far as im- mediate results are concerned, it appears more dangerous to leave them behind than to leave sarcomatous deposits in the abdominal cavity. At the necropsy of this case, I found that the cyst adhered to the parietes, the liver, the diaphragm, the stomach, the great omentum, and the large intestines. The papillomatous masses grew mostly from its lower part. On removing this portion of the cyst, I discovered that the whole pelvic cavity was filled with masses of thin-walled multilocular cysts, containing clear, pale, yellow fluid, and papillomatous outgrowths from their walls. I have ever found that the fluid is clear, and generally colourless, in small papillomatous cysts ; the presence of glairy fluid probably indicates the admixture ef glandular elements, which is easily understood when the tumour is ovarian- — for it must be remembered that the tissues of the hilum and the parenchyma invade each other's limits. In this case, the cysts varied in size from the dimensions of a cob-nut to those of a large orange. They were crowded into Douglas's space, and clustered thickly over the summit of the uterus and bladder. This power of invasion is very characteristic ; even the cystic nature of the growth is reproduced in secondary deposits, as in the case of ruptured glandular cysts of the ovary. After examining the papillary masses carefully, I came upon both ovaries. They were small and red, and there were no papillo- matous growths, either free or encysted, on their surfaces. I have assisted at nine operations for the removal of papil- lomatous cysts where the hilum, at least, of the ovary was in- volved, and the layers of the broad ligament invaded. It is more frequent for hilum cysts to invade that ligament than for broad- F 2 68 TV MOTES OF THE OVABY. ligament cysts to attack the hilum, since cysts in the hilmn meet least resistance in the direction of the cellular tissue betTveen the layers of the broad ligament, whilst broad ligament cvsts meet less resistance \vhere they bulge anteriorly and pos- teriorly fi'om their ligament, and stretch the Fallopian tube, than where they press against the hilum of the ovary. This probably accounts, on the other hand, for the fi'equent immunity of the ovary in cases of papillomatous broad ligament cysts, as in the case above described ; vrhen that organ is invaded in these instances, it is its sm-face, as abeady observed, that is affected. On the other hand, I have been present at four operations ■where ovaries have been removed for papillaiy tumom's which did not invade the broad hgament ; that is to say, the tumours had pedicles. In twenty-fom' cases where I assisted at the operation, sessile cysts infiltrating the broad ligament were re- moved, more or less completely, but their origin coidd not be ascertained ; none of these contained glandular growths, most were multil ocular, but papillomatous growths did not exist. Several, I believe, were multiple simple broad ligament cysts. In fom- other cases I aided my colleagues in the removal of papillomatous sessile cysts, where it was impossible to say whether the hilum or the broad ligament was the primary seat of disease. In another case the cyst was sessile, clearly ovarian, and apparently dennoid, in one respect ; and in another the dermoid character was certain. Lastly, I have seen two cases where a sessile cystic tumom' of the ovary was removed, and this proved to be an undoubted case of glandular cystic disease invading the hilum and the broad ligament. It is easy to understand why this condition should be rare : just as broad- lio-ament cvsts, for reasons above given, do not as a rule invade the hilum, but gi'ow in other directions, so glandular cysts arising in the parenchyma do not tend to grow in the direction of the hilum, but bulge out towai'ds the periphery of the ovary itself, where there is no resistance whatever. All sessile cysts are troublesome to the operator ; and, as they so often contain papillomatous growths, unsatisfactoiy re- sults often occur sooner or later after removal. They are, therefore, of great clinical, as well as pathological importance ; TUBE AND BROAD LIGAMENT. 69 and I shall now describe some of the cases, as above classified, at length. Firstly come the nine cases where the evidence that the hilum was the primary seat of papillomatous cystic disease was very strong. The first was in a patient aged thirty-eight, in Mr. Thornton's wards. The tumour formed a large multilocular cyst full of papillary growths. A very broad and vascular band, consisting of the broad ligament close to the hilum, and with its layers parted by the advance of the growth, constituted a sort of pedicle, whence the tumour had to be partly shelled out ; the tumour also adhered strongly to Douglas's pouch, by an area of adhesion as extensive as the false pedicle. Drainage was necessary ; the patient recovered. The second, where the patient was thirty-three years of age, and under the care of Dr. Bantock, was a good example of the difficulties attending cases of this kind. A large iiTegular swelling occupied the abdomen ; there was a d*eep cleft on its surface, and the whole felt like one cyst, with intestine lyincr across the middle, but on percussion no vibration could be trans- mitted from one side to the other. On opening the abdominal cavity a pint or two of ascitic fluid escaped ; then a cystic ovary came into view. The false pedicle was extremely broad, and the lower and outer part adhered to-the csecum; internally the tumom' almost reached the uterus. I must observe that by ' pedicle ' alone I mean a true pedicle — that is, the normal tube, broad hgament, and ovarian ligament — whilst by false pedicle I mean the line of structures that the operator cuts through in removing the tumour, after having ligatured the proximal side, either by transfixion or piece by piece, as best he may in cases like those that I am now describing. After that the ovary had been tapped, and much bloody fluid and pa]3illomatous masses removed, the uterus was raised out of the pelvis, and stood well out of the wound, being nearly double its usual size ; small villous growths sprang from its surface. It was then found that the left ovary was also cystic. Its contents were a puriform fluid and papillomatous growths, which studded its interior, and it had forced itself into the folds of the broad ligament as far as the tube, pushing up also the round ligament of the uterus in front. Still, a pedicle could be formed between the cyst anri 70 TUMOURS OF THE OVARY, the uterus, and was secured by transfixion. The base of the right cyst had to be shelled out of its capsule of broad ligament, which was transfixed twice with silk ligatures. The ligament was not very vascular. No drainage tube was inserted; the case made a good recovery. The third was a very bad case. The patient was forty-six years of age ; the cyst had burst, and the bladder, uterus, and pelvic peritoneum were studded with papillary growths. The cyst had forced itself between the layers of the broad ligament, and grown backwards, pushing itself under the peritoneum, till at one point its wall touched the common iliac arteries. It was mostly enucleated. The patient died on the fifth day ; there was thrombosis of the right femoral vein, which accounted for a swollen state of the right lower extremity before the opera- tion. The papillomatous deposits had reached the peritoneal lining of the diaphragm. The fourth was in a woman aged sixty-one. The papillo- matous growths had infiltrations of sarcomatous material at their bases ; the false pedicle was hard to make — for in these cases they literally have to be planned out — and it was still harder to secure the vessels which kept slipping. The opposite ovary was the seat of small simple cysts projecting from its parenchyma. The patient, under Mr. Thornton's care, re- covered. The fifth case, in a woman aged fifty, was like the third, an instance of double papillomatous cystic disease of the ovaries, and also resembled it in terminating fatally. The false pedicle on the right side was hard to secure, and two large arteries were tied separately. The left tumour, though very small, was still more sessile than the right ; it was separated from its base by the thermo-cautery, and then the tissues on the proximal side of the burnt surface were ligatured. The patient died on the tenth day. The left false pedicle adhered by its raw surface to the rectum ; there was septic fluid in Douglas's pouch, and both kidneys were diseased in the manner described in another chapter. The sixth case, occurring in a woman sixty years old, ter- minated favourably. The cyst contained clear watery fluid and incipient papillomatous growths ; it had forced the layers of the TUBE AND BROAD LIGAMENT. 71 broad ligament so far apart that in taking it a\vay the uterine tissue was wounded, and the ther mo-cautery had to be applied. In the seventh case the patient was thirty years old, the peritoneum was full of ascitic fluid, the cyst had a very dull wall, as though partly gangrenous. IVIr. Thornton, who operated, found that it had a sessile and broad attachment to the right side of the uterus ; it was enucleated from its broad ligament capsule, forceps being applied as vessels were severed, the tube and main vessels were then secured by transfixion, and afterwards the base was transfixed several times, and a ' bag- mouth ' ligature applied round the whole false pedicle. There were numerous omental adhesions. The patient recovered. In the eighth case, a patient aged thirty- five, the cyst was so universally adherent that it could not' be removed ; the patient recovered from the operation. The ninth case occurred in a woman aged forty-five, under the care of Dr. Bantock. On opening the abdominal cavity, a small tumour with very large veins on its dull-red surface was exposed. It was tapped, and four pints of a glairy greenish albuminous fluid of high specific gravity escaped. On draw- ing up the collapsed cyst, the parenchyma of the ovary was discovered projecting very distinctly from the lower part of the cyst ; the natural outline of the free border of the ovary was well preserved. A false pedicle was readily formed by trans- fixion, as the cyst had not forced itself quite up to the uterus, and the tumour cut away, with the capsule entire. This capsule, the broad ligament, had given the reddish colour to the surface of the cyst ; in many cases of this kind, but especi- ally in this instance, the tumour at first sight looks like a uterine myoma. I found that the wall of the cyst was con- tinuous with the ovary, and not thin, as is the case in papillary cysts confined to the broad ligament alone, but thick, dull- white, and corrugated, like the surface of the ovary close to the hilum. The patient recovered. I will now make some mention of the four cases where I have witnessed the removal of ovarian tumours that bore papil- lomatous contents, yet had at the same time true pedicles, with no encroachment on the layers of the broad ligament ; in fact, the pedicle was in each case like that of a typical multi- 72 TUMOURS OF TBE OVARY, locular ovarian cyst devoid of solid growths. The first was removed by ]Mr. Thornton from a robust country giii, aged seventeen. The tumom- formed a large cyst with secondary cysts containing papillary growths. The pedicle was of a fair length, and not difficult to secure. There were omental adhesions. In the second case, the patient was forty-seven years old, and under the care of the same sm'geon. The tumour was similar to that in the last case ; the pedicle was long and narrow, and readily secured, '^^^lat makes this case of con- siderable pathological interest is the fact that a small thin- walled cyst lay between the layers of the broad ligament and contained papillary outgrowths. This cyst bulged from the ligament, so that its sides touched the ovarian tumour, but the two growths were not continuous. Some unknown stimulus had caused the simultaneous growth of papillomata in two difiFerent parts where Wolffian relics existed. The third also occurred in a patient of Mr. Thornton's, forty years of age. A year previously a partly solid tumour of the left ovary had been removed by the same operator. The right ovary was found to be convei-ted into a lai'ge unilocular cyst, covered externally with flakes of lymph and ochreous from degeneration. A few papillomatous outgrowths sprang from its inner walls, which were lined with organised fibrine ; the fluid contents were thick and brown. The pedicle was broad and thin, the stump of the opposite ovary healthy. The last case occurred in Dr. Bantock's wards. The patient was middle-aged, and had two tumours, each ovary being con- verted into a large multilocular cyst containing papillomatous growths. There were universal adhesions ; the parietal perito- neum was much thickened, and the omentum thick and indurated. One pedicle was very long and twisted, the other still longer and thinner, consisting of an atrophied tube. The adhesions were, doubtless, an indirect result of the twisting of the pedicle. The separation of the adhesions, and the thinness of the cyst walls, which broke down very readily when handled firml}", caused the operation to be very protracted. A drainage tube was passed into Douglas's pouch. Xone of these four operations ended fatally. It is important to observe that in none of these four cases TUBE AND BROAD LIGAMENT. 73 were the papillomatous intra-cystic growths either numerous or exuberant. Under this condition, it is natural that the growth should not force itself into the layers of the broad ligament, a complication which invariably occurs when the papillary disease is advanced. It is probable that in these cases the disease originated in those Wolffian relics that exist in the parenchymatous part of the ovary, as in the case of mixed glandular and papillomatous cysts. In the chapter on the former type, I observed that glandular growths with papillary elevations on their surfaces must not be taken for papillomatous growths. In twenty- four cases that I have seen submitted to opera- tion the tumour was sessile, the operation very troublesome, and no solid matter could be found in the interior of the cysts. Out of these a very large majority were ordinary multilocular cysts that had pushed apart the layers of the broaa ligament, and often burrowed under the pelvic or even the parietal peri- toneum. This is quite the exception in the case of such cysts, and appears to be the result of a rapid growth of the cystic elements in the parenchyma towards the hilum, but certain pecuHar dispositions of the peritoneum decidedly favour the anomaly. Meredith, Coblenz, and others have described cases where, undoubtedly, these cysts have- burrowed under the parietal layer of the peritoneum, so as to lie directly under the abdominal walls, the operator finding that no peritoneum covers the tumour, and in other cases the tumours have bur- rowed under the peritoneum lining the back of the pelvis, and even the lumbar region, so as to lie against the great vessels, as in the case of papillomatous cyst above described. These cases are authenticated by the competent observers who have described them ; but, as every prosector and demonstrator of anatomy is aware, it is not always easy to trace abnormal dis- positions of the peritoneal folds, even where no tumours exist and the entire abdominal cavity can be exposed to the light in a dissecting-room. It is far more difficult to identify the rela- tions of the peritoneum through the comparatively limited incision which the surgeon makes for the purpose of removing an ovarian tumour. The form, appearance, and constant position of the Fallopian tube renders it very easy to decide 74 TUMOURS OF THE OVARY, whether a cyst has forced itself between the layers of the broad ligament, or confined itself to the ovary. This can be often ascertained at a glance. But the more extensive en- croachments on the peritoneum cannot always be correctly defined at an operation. In several cases I strongly suspected that the multilocular cysts were of broad ligament origin, but I had no opportunity of examining their walls. In four more cases, none of which were fatal, but all very tedious to the operator and his assistants, there was papillomatous disease involving the broad ligament, but it was very uncertain how far the ovary was involved, or whether it was not left behind. In one case the growths concealed the pelvic structures, and could not all be removed. It is tolerably certain that one or more of these cases were examples of primary broad ligament disease, like Sir Spencer "Wells's case described above. In five cases there was little or no doubt that the disease was papillomatous and confined to the broad ligament, whence, in one of the cases, the tumour could be shelled out. In another, a woman aged thirty-six, the ovaries appeared to be separate, but the tumour could not be removed. In the third, a woman aged twenty-five, under the care of Dr. Bantock, a tumour of this kind was enucleated from each broad ligament ; the patient made a good recovery. The fourth case was in a woman thirty-five yeai's of age, under the care of the same surgeon. The tumour formed a fluctuating mass, filling the front of the abdomen and also the left flank. It was universally adherent and papillomatous, and had partly forced its way under the parietal peritoneum. It touched the bladder directly ; this organ was lacerated, but successfully sewn up again, during the operation, which was tedious, even for a case of this kind. Both ovaries were perfectly normal, and the uterus was dis- tinct from the cyst. As the broad ligament had not been forced entirely apart, it is just possible that the tumour originated in some relics of Grartners duct remaining in the vaginal wall. Coblenz believes in this pathological condition. In this case, however, it is remarkable, as the tumour was partly in the broad ligament and touched the ovary, that the uterus was quite uninvolved, if the tumour really originated in the vaginal wall. It seems far more likely, considering its relations, that TUBE AND BROAD LIGAMENT. 75 it arose in the Wolffian relics contained in the folds of the ligament — that is, from the parovarium — and instead of push- ing the layers of the Kgament apart till it touched the Fal- lopian tube, it had grown downwards and forwards. This patient made a good recovery. To the above four cases I may add a somewhat doubtful one : a patient aged thirty-five, where, as in the second, the operation had to be given up. It was probably very like the case now illustrated by the specimen in the Museum of the College of Surgeons, above described, where the ovaries were completely concealed by papillary growths, although their interiors contained none. I must also add Sir Spencer Wells's case already described in this chapter; here the ovaries were entirely distinct from the diseased masses. In one instance, a patient aged forty-seven, ]\ir. Thornton removed a sessile ovarian tumour, where several pints of liquid fat were found in one of its secondary cavities. The opposite (right) Fallopian tube and the vermiform appendix adhered to the cyst, and the construction of a false pedicle gave the operator great trouble ; the patient recovered. This is the only case but one of a sessile ovarian tumour that I have had the opportunity of examining, that appeared to be dermoid. Considering the nature of dermoid structures, it is rather remarkable that they do not more frequently force their way into the broad ligament. A more evident instance of a dermoid cyst invading the broad ligament will be found in the chapter on cysts of that class. In one case, a woman aged forty-four, under the care of Dr. Bantock, a multilocular ovarian cyst had forced itself into the layers of the broad ligament, touching the side of the uterus, and extending deeply into the pelvis. The pelvic portion was first removed, then the uterine attachment was transfixed and cut away. On examining the tumour, I found that the secondary cysts contained masses of solid glandular growths, so often seen in pedunculated multilocular ovarian cysts, but no papillomatous structures. It is evident that glandular cystomata very rarely invade the broad ligament. I have very recently seen a second case of a glandular cyst invading the broad ligament in the wards of the same surgeon. The patient was twenty-four years of age, and a firm, but indis- 76 TUMOURS OF THE OVARY, tinctly fluctuating tumour occupied the lower part of the abdo- men, not reaching to the umbilicus. At the operation the tumour was found to be covered in front by adherent omentum, and, on applying the trocar, a few pints of glairy brownish fluid escaped. The pedicle was narrow, and not difficult to secure. On examining the tumour after its removal, I found that it had invaded the entire outer part of the broad ligament, pushing against the fimbrise of the tube, which were much stretched, and against the outermost portion of the tube itself. The inner part of the broad ligament was not involved, and the parovarian tubes were plainly visible. Eemembering the position of these tubes, it is evident that the cyst had only invaded the most ex- ternal part of the ligament. It had pushed upwards and out- wards towards the ovarian fimbria ; the hilum, the corrugated outer surface of which was very distinct, contained no papillary cysts. A large and very recent corpus luteum, three-quarters of an inch in diameter, projected from the lower part of the cyst ; it contained recent clot, and had a very thin bright yellow border. I have searched for cases like these for several years, but these two examples seem to be a protest against dogmatic pathology. The blank formula, * such and such a disease never does so and so' must not be filled up and applied rashly by the pathologist; yet it should not be forgotten that the reverse principle — 'this specimen is described in order to disprove 's assertion that such and such a disease never does so and so ' — is an equally fertile source of error. To avoid both these vicious methods as far as possible, I have described and noted the relative frequency of the above cases at length — perhaps at tedious length — but they represent what I have seen, and I leave others to draw inferences from them. TUBE AND BROAD LIGAMENT. 77 CHAPTEE V. BERMOIB CYSTS OF THE OVART. Dermoid cysts of the ovary are very frequent, as clinical and pathological records amply indicate. Within seven years I have assisted at thirty-two operations where undoubted dermoid cysts of the ovary were removed, hair and sebaceous glands being present in all, bone in most, teeth in many, and sarco- matous material in a few. In the autumn of 1871, and in the winter, spring, and summer of 1873, when I held the appointment of House Surgeon to St. Bartholomew's Hospital, I had the opportunity of re- moving three congenital dermoid cysts from the outer angle of the orbits of hospital patients, and several thousand patients then passed under my notice in the great City hospital. Be- tween April 1882 and April 1884 I- removed six ovarian tumours, and in two cases these tumours were dermoid. This shows, in a rough manner, how far more frequent dermoid disease is in the ovary than in the part where it is most fre- quently found away from that organ. The relation of congenital dermoid cysts of the orbit to the branchial clefts can hardly bear on the question of dermoid ovarian tumours. The more pertinent question of the cause of the formation of these tumours in the ovary is a very profound one. Arguments must be founded on data, and I cannot see that we are in aay way sure of our data in this case. In science, we must seek how processes begin ; we cannot always hope to find out why they begin. As for the data, I have examined two incipient dermoid cysts, and the cyst cavity ap- peared in each case to be a dilated Grraafian follicle, but fine hairs grew from every point of the lining membrane ; no dis- tinct membrana granulosa could be detected, and I therefore 78 TUMOURS OF THE OVARY, could not prove that it was a follicle. The contents were a few grains of semifluid sebaceous matter. That ova require the agency of spermatozoa before the changes that can produce a perfect foetus can be set in action there can be no doubt. There is no known reason why an ovum should not develop more or less shapeless masses of definite tissues without impregnation. It must be remembered, too, that the membrana granulosa is more than a mere epithelial surface ; perhaps the ovum may influence its cells. All is, however, hypothetical. The dermoid ovarian cyst question appears to me to be closely and in- separably linked with some of the most profound mysteries of organic life. To talk of parthenogenesis or of foetal inclusion is, in reality, not giving an explanation. In MoUere's ' Malade Imaginaire,' Argan, the principal character, undergoes a mock examination, in a scene designed by the dramatist as a satire against medical education in Paris under the rule of Louis XIV. He is asked in dog-Latin the cause and reason why opium sends a man to sleep, and replies : ' I have been asked by the learned Doctor the cause and reason why opium produces sleep, to which I answer : because there is in it a dormitive virtue, the nature of which is to make the senses drowsy.' To explain the growth of hair, bone, teeth, and glands in the ovary of an unimpreg- nated subject by saying that it is due to parthenogenesis is equally unscientific. INir. Pepper, in his ' Elements of Surgical Pathology,' disposes of the fcetal inclusion theory by introducing one of the most forcible arguments that have ever been brought against it — that dermoid cysts ' are not the outcome of so-called foetal inclusions is proved by the fact of their having occasion- ally been found to contain more than a hundred teeth.' These cysts are so remarkable that they have attracted the attention of pathologists very extensively during the past few years, especially since the establishment of ovariotomy as a re- cognised surgical operation. It is more profitable to continue the examination of the tissues included within dermoid cysts than to indulge in speculations as to the origin of tumours of this class. I will now relate my own experience of their histo- logical and clinical peculiarities. In the thirty-one cases I have seen, the ages of the patients / TUBE AND BROAD LIGAMENT. 79 jllows : fourteen years old, 1 case ; seventeen, 1 ; J twenty-one, 2 ; twenty-two, 2 ; twenty-seven, 1 ; _ thirty-one, 1 ; thirty-two, 2 ; thirty-four, 1 ; thirty- lirty-six, 1 ; thirty-seven, 2 ; thirty-eight, 1 ; thirty- forty-one, 2 ; forty-two, 1 ; forty-eight, 1 ; fifty (about), ihree, 1 ; fifty-eight, 1 ; sixty-three, 1 ; age not speci- \otal, 31. c youngest patient, aged fourteen, was a very healthy m a village in Nottinghamshire ; the catamenia had appeared ; the mammary glands were infantile, but the y and pubic hair was developed.^ The oldest, sixty-three of age, had a large multilocular cyst of the left ovary, one 3 loculi containing hair, sebaceous matter, and ossifying age, most of the remainder being filled with dark choco- coloured glairy fluid. The opposite ovary was the size of rge orange, full of hair and sebaceous matter, and contain- ossifying cartilage, but no teeth in its walls. It adhered /ongly to Douglas's pouch. Both these cases were in Dr. Bantock's wards, and recovered from the operation. In eight cases teeth were found ; in one they amounted to over twenty in number ; in some of the remaining twenty-three, solitary teeth might have been overlooked ; in two cases I have not recorded the contents. Nearly all contained hair, but in three I failed to find any. The hair was generally pale ; in one case it was quite black, darker than the patient's hair on ex- ternal parts. In more than half the cases the free contents were, at least in the secondary cysts, chiefly sebaceous, and resembled in ' In Augtist 1883, Dr. Eoemer successfully operated, at the Augusta Hospital, Berlin, on an infant aged 1 year and 8 months, removing a dermoid ovarian tumour 'the size of the child's head.' See London Medical Record, June 1884. This case appears to be the youngest where ovariotomy has been performed. Neville, of Dublin, operated on a patient, aged 2 years and 11 months, with fatal results within two hours. Busch's and Alcott's cases were both 2 years old ; neither recovered. The following five were successful, but the patients were older. Schwartz's case was 4 years old ; Barker's two cases were 7 years old ; Knowsley Thornton's case was also 7 ; Cnpples', Chenowetts' and Spencer Wells's were each 8 years old. A collection of cases of ovariotomy performed on older children will be found in an article by Dr. Chenowetts in the American Journal of Obstetrics, July 1882, p. 625. For a full account of Dr. Eoemer's case, with references to the others above mentioned, see London Medical Record, article 2684. 80 TUMOURS OF THE OVARY, \ every respect tbe pultaceous grease which fills up cysts on the head ; this material was often very \ mixed up with the hairs. In such cases, the operatoi discovered the true nature of the tumour when pluL hand into its cavity, when his fingers became at one with grease and hair. When the secondary cysts w[ with sebaceous matter, the cavity of the main cyst contained a greasy fluid of a chocolate colour ; when gl elements existed, there was a tendency to glairiness ; ' one instance of this kind the fluid was clear and albuif glairy, and almost entirely free from grease. On the^ hand, when dermoid structmres freely grew from the inn^ of the main cyst, the contents sometimes resembled half-li chocolate, and in one case were of the colour of moist c{ powder. When the characteristic greasy and chocolate-colot fluid, which seldom exceeded five or six pints in amount,', lain a few minutes exposed in an open pail or basin, beaut hexagonal patterns, formed by cholesterine crystals, would a^ pear on its surface. The significance of the varieties of the fluid and semifluid contents of these dermoid cysts could be no mystery. The greasiness was due to sebaceous elements, and the colour to alterations in effused blood. In two cases some of the cavities were filled with pellets of sebaceous matter resembling sugar-coated pills, a condition already noted by Rokitansky, Routh, and others. In a case of incipient dermoid disease — the ovary being about three inches in its longest diameter, and the fellow of a large dermoid tumour — two cysts contained, together with hair, a very pure white putty-like material ; it resembled the ' Chinese white ' of colourmen. It was simply pure sebum. In seven instances free fat predominated in the secondary cavities ; it was entirely fluid, and closely resembled olive oil in one of these cases ; in another, it was mixed with glairy secretion from glandular elements in the tumour, so as to appear as a pale yellow glycerine-like fluid ; in the remainder the fat was semi-solid ; it did not appear to trouble the operator as much as the more common sebaceous matter, as it could more readily be washed off the fingers. In another case, under my own care, and de- scribed in the chapter on twisting of the pedicle, there was a TUBE AND BROAD LIGAMENT. 81 quantity of a pomatum-like material in the main cyst, appa- rently due to the admixture of a small amount of sebaceous matter with common fat. In six cases the pedicle was twisted ; and reference to some of these will be found in the chapter on that complication, which, in the case of ordinary multilocular cysts, causes the outer surface of the tumour to lose its natural shiny silvery appearance. The surface of a dermoid cyst is, however, often dull and brownish, even when the pedicle is not twisted. As most dermoid cysts do not fluctuate freely on palpation, but feel elastic — especially if filled with hair and sebaceous material — and as the dull-brown outer surface of the main wall resembles uterine tissue, these cases sometimes puzzle the operator. In one instance there was marked pigraentation around the umbi- Kcus ; here no uterine complication existed. In seven of the cases of dermoid cyst that I have seen, both ovaries were involved. One of these, under my own care, is described in the chapter on twisted pedicle. In one, a patient fifty-three years of age, the rectum ^ and stomach were the seat of malignant disease, in which the omentum was also in- volved. The right ovary was converted into a large dermoid cyst. The left, now in the pathological series of the Museum of the Eoyal College of Surgeons (4506), measured about three inches in its longest diameter. It contained one cystic cavity filled with fat and short hairs, and minute cysts in the stroma filled with liquid oil. The patient sank firom exhaustion thirty-four hours after the operation. One of these cases, under the care of Mr. Thornton, was very remarkable. The patient was thirty-seven years of age, and before operation there was a suspicion that the tumour might be a fibroid outgrowth from the uterus, or a cystic ovary with a twisted pedicle. On opening the abdominal cavity a large tumour of the right ovary was first removed ; it was full of sebaceous matter and spicula of bone, which partly escaped into the peritoneal cavity, and were with difficulty removed. There were numerous peritoneal adhesions. The left ovary ' Microscopical sections of the new growth in this jjart of the intestine bore the appearances of columnar epithelioma. Neither ovarian tumour con- tained a trace of malignant disease. G 82 TUMOURS OF THE OVARY, was converted into a cystic body of very irregular shape. I prepared it for the Museum of the Eoyal College of Surgeons, where it is now preserved (Pathological Series, 4516). It con- sisted of three large cysts from two to three inches in diameter, and arranged in an irregular manner, the middle cyst bulging forwards, whilst the inner and outer cysts projected backwards towards each other. They were divided by more or less com- plete septa, and were filled with sebaceous material. There were pedunculated cysts in the broad ligament, and the fimbrige of the Fallopian tube were abnormally developed ; a small sessile cyst also lay over the site of the parovarium. The dermoid cyst, when fresh, had a most curious appearance, resembling a large sausage twisted in three directions. Its form was probably determined by the pressure of the tumour of the right ovary. The third case of double dermoid cyst has already been referred to above ; pale yellow fat hke poma- tum was found in one cyst ; it is more minutely and clini- cally described in the chapter on twisted pedicle ; the smaller tumour was the right ovary, converted into a heavy oval body three inches in its long diameter ; its pedicle was stretched, twisted, and atrophied, and it contained a dense mass of hair and fat. The fourth case of double dermoid cyst was in a patient fifty-one years of age ; the right was large and strongly ad- herent to the abdominal walls. This, too, was a case of twisted pedicle ; that structure was thin and its vessels obliterated. Here, in fact, is another interesting point in ovarian pathology : the adhesions, very vascular, kept up the vitality of the cyst, and saved it from gangrene. The left tumour was the size of a large orange, and stuffed with hair and fat. The next case, under the care of Mr. Thornton, was that of a woman, aged forty-two. A few years before operation she suffered from a copious vaginal discharge, and she declared that the tumour, which then existed, diminished in size ; at the operation the abdominal walls were flaccid, as in the third of these cases. The tumour was a large dermoid cyst, full of small teeth approaching the type of normal bicuspids. The opposite ovary was below the normal size. It contained a small cyst, from the inner wall of which fine hairs grew. As I have already ob- TUBE AXI) BROAD LIGAMENT. 83 served, all the wall being converted into epidermis, I could not prove that the cyst was a dilated Grraafian follicle. The sixth case was that of a patient under the care of Dr. Bantock, a woman sixty-three years old. This is a great age for the occurrence of dermoid disease in the ovary ; I have been informed that some authorities have denied its existence in middle-aged or old women. In this case an exceedingly irre- gular fluctuating tumour, very freely movable, distended the abdominal walls to above the umbilicus. A large multilocular dermoid cyst of the left ovary was found. One of the loculi contained hair, sebaceous matter, and ossifying cartilage ; most of the remainder were filled with dark chocolate-coloured fluid. Dermoid cysts generally include but few secondary cysts, and these are often mere cavities in the main wall, hardly bulging into the main cavity. The opposite ovary formed a second dermoid cyst about the size of a large orange ; its walls were unusually thin for a tumour of this kind, and one secondary cyst contained cartilage, but no bone nor teeth. On tapping the main cyst much hair and sebaceous material was encountered, giving us, as I was assisting the operator, great trouble. The cyst lay deep in the pelvis with a strong adhesion to Douglas's pouch ; this was secured by a clamp forceps, and divided, then the pedicle was transfixed, ligatured, and cut away. The patient made a very good recovery. In fact, only three out of the large number of cases of removal of dermoid tumours that I have seen ended fatally, and one of these was No. 2 in the series of cases of unfavourable changes in the ligatured pedicle, described in the chapter on that subject. The last case of double dermoid cystic disease was in a patient aged thirty-eight. The relations of one cyst were diffi- cult to trace during the operation ; it was believed by the operator that it was separate from the ovary, and entirely within the folds of the broad ligament ; it was adherent to the uterus, and part of the Fallopian tube was matted on to its wall by adhesions. In the chapter on sessile tumours, I have referred to a case where a growth of this kind was partly dermoid. In this case, now under consideration, there was happily no opportunity for confirming the true relations of the cyst, for the patient made a good recovery. The opposite 84 TUMOURS OF THE OVARY, ovary was about double the normal size, and contained two dermoid cysts filled with the Chinese-white, putty-like material already described. In three cases of dermoid ovarian tumour, the opposite ovary was converted into a multilocular cyst. In the first case the patient was thirty-nine years of age. The left ovary formed a large multilocular cyst with glandular contents, and a broad, short pedicle with very large veins. The right was converted into a small dermoid cyst containing much hair, sebaceous matter, and a pint or more of liquid fat. Its pedicle was also broad and short. The patient died with symptoms of very acute bronchitis on the third day. The second case was in a patient aged thirty-five. Before operation, two fluctuating tumours could be felt in the abdomen, and the fundus of the uterus was plainly to be detected above the pubes, in front of the tumours. The left mass proved to be a small multilocular ovarian cyst with a short and broad pedicle; the^right was a spherical dermoid cyst full of hair and sebaceous material. Its pedicle was twisted and very thin, and the operator. Dr. Bantock, readily secured that structure by simply tying a silk ligature around it. Its vein was plugged and dilated ; this peculiarity is described in the chapter on twisting of the pedicle. The patient made a good recovery. In the third case the patient, under the care of Mr. Thornton, was about fifty years old. I have already referred to the question of age in relation to dermoid ovarian tumours. The right ovary was converted into a small multilocular cyst that had leaked a little ; it contained a glairy, clear fluid, and some of the secondary cysts had tough deposits in their walls, which at other parts were atrophied, and had even given way so that the cavities of the cysts communicated with each other. I examined these deposits and found that they were dense Cicatricial tissue and not cartilage, nor could I find any der- moid elements in this tumour. On the other hand, the left ovary was converted into a dermoid cyst about four inches in diameter ; it contained sebaceous matter and hair. In four cases the tumour was mixed, being partly a multi- locular cyst with glairy fluid contents and glandular solid matter, as a rule, in the secondary cavities, and partly dermoid TUBE AND BROAD LIGAMENT. 85 In the first case the patient, twenty-eight years of age, was under the care of Sir Spencer Wells. On opening the ab- dominal cavity, the main cyst was found to be so strongly adherent to the abdominal walls that it could not safely be removed. A large secondary cyst grew from its interior, springing by a kind of pedicle from its inner wall, and covered with lymph and clots ; the fluid in the main cyst was albu- minous, clear, and glairy. A clamp was applied to the pedicle of the inner cyst, which was then cut away. This cyst con- tained sebaceous matter, hair, and flat bones in great quantity; these latter formed hard plates with irregular margins, re- sembling the facial bones of a teleostean fish. There were no teeth. The patient was pregnant during operation ; she made a good recovery, and was alive four years later. (The case is No. 879 in Sir Spencer Wells's series.) The next case, which was under the care of Dr. Bantock, is that to which reference has been abeady made in speaking of the age of patients subject to dermoid cystic disease, the patient being only fourteen years of age. The tumour was a multi- locular cyst with glairy albuminous fluid in its main and in most of its secondary cavities, but two small secondary cysts contained hair, sebaceous matter, and spicula of bone. There were no adhesions, and its pedicle was broad and thin ; it con- tained large vessels. It was readily secured, and the patient made a rapid recovery. The third case was under the care of the same surgeon. The patient was twenty-two years of age ; the cyst had ruptured, and was much reduced in size compared to what it had been a few weeks before operation. The rup- ture was a circular hole, about an inch in diameter, and com- pletely blocked by an unruptured secondary cyst, that pro- bably was not the cause of the rupture, for the tissue of the main wall was degenerate around the aperture and elsewhere ; it had become approximated to the aperture when the main wall had fallen in after rupture. Keference will be found to cases of this kind in the chapter on rupture of ovarian cysts. In this case the cyst was multilocular and full of glairy fluid ; in some of the smaller cysts were hair, skin, teeth, and bony plates. In one cavity lay a large knob of hyaline cartilage nearly three-quarters of an inch in diameter, also two tuberosi- 86 TUMOURS OF THE OVARY, ties about two inches in diameter, composed of dark-red, firm, fleshy material. More will be said of this material when I come to speak of malignant characters of dermoid tumours. The fourth case of a mixed tumour of this class was operated upon by Mr. Thornton in December 1880. The patient was about forty-eight years of age. The cyst was very large and multilocular ; several gallons of a pale yellow, viscid fluid were withdrawn by the trocar; and the main cyst wall was very thin. Some of the secondary cavities contained hair, teeth, and sebaceous material. Before speaking of malignant characters, and dismissing one case under INIr. Thornton's care, where a dermoid cyst burst into the bladder, and where, after emptying the cyst cavity of foetid sebaceous contents, the edges of the cyst wall were fixed to the edges of the abdominal wound, with satisfactory results, I will revert to the usual histological characters of dermoid cysts. A very fine example is in the Museum of the Eoyal College of Surgeons (Pathological Series, 4512). It is a small denti- gerous cyst of an ovary, removed by Dr. Bantock in 1879. The patient was a young single woman, the tumoui" had been observed for about a year, and had occasionally caused severe pain, as is not rarely the case with small heavy dermoid cysts. There were firm omental adhesions. The cyst contained several pints of thick chocolate-coloured, semi-fluid, material. On preparing the tumour for the College Museum, I found in its inner wall a semilunar plate of porous bone over two inches in length, bearing towards its inner extremity several teeth, well formed, and resembling small molars and bicuspids (fig. 17). The bone was covered by a soft membrane, which could hardly be called a gum, its inner part in contact with the bone resembled periosteum, but its outer aspect bore sebaceous follicles and very short hairs. The fang of one of the teeth grew entirely from this membrane, quite unconnected with the bone by any socket. Indeed, teeth are often found growing in dermoid cysts where no bone exists. On the other hand, I have repeatedly found true sockets, with their teeth firmly fixed in them, in both the kinds of bone that are developed in dermoid cysts, that is in the flat porous plates like the facial bones of certain fishes, and in the TUBE AND BROAD LIGAMENT. 87 heavy tuberculai' masses of ivory-like bone described in Sir Spencer Wells's work. The so-called cavities of reserve are often merely sockets developed very close to other teeth, as in Fig. 17. — Dep.jioid Cyst of the Ovary. No. 261 in the College Museum, which I found in a dermoid cyst removed from a young girl by Mi'. Thornton. It is a piece of bone resembling a portion of the alveolar process of a jaw. It contains a well-formed tooth in a perfect socket, and the crown only of a second tooth in a shallow socket. It was seated, together with a patch of hair, on the inner side of the cyst wall. The second socket has clearly been developed indepen- dently of that which bears the more perfect tooth. I have found that when teeth are numerous the bicuspid type pre- dominates. A\Tien the dental element is scanty the indi^-idual teeth have generally a canine or incisor type. The epidermic structures so abundant in dermoid cysts are well known to pathologists, and have been often described. An abundant development of sebaceous follicles is exceedingly common. In one specimen in my possession sweat glands are conspicuou. -, but they are not always so abundant as the former 88 TUMOURS OF THE OVARY, kind of gland. The epidermic cells are sometimes arranged in a very thin, sometimes in a very thick layer ; often they fonii a smooth, even covering to the subjacent structm'es ; in other cases there are papillae. I have found very deep involutions of epidermis, dipping one-twentieth of an inch or deeper into the subjacent tissues, but Imed with the characteristic flattened cells, even in the deepest part. The rete Maljjighii is often well developed, pigment may be abundant or nearly absent. Lymphoid tissue is frequently present to a very marked extent, and bears some relation to malignant deposits, as will presently be shown. Fat sometimes abounds in the subcutaneous con- nective tissue, which is frequently of an embryonic type, though often quite firm, fibrous, and well developed. This tissue very frequently contains hyaline cartilage and bone; of the latter I have spoken abeady. The cartilage may form small bodies like ivory pegs, liable to be taken at first for teeth, or else may protrude from the rest of the dermoid stmctures as a knob or tubercle, only invested by perichondrium, as though it had forced its way through the epidermis or mucous membrane, under which it had developed. Deep in these dermoid growths numerous cystic and tubular structures are often found, and they present an infinite variety of t}q3e. Some, lined with very large columnar cells, are in every respect similar to small glandular ovarian cysts. Others simulate pharyngeal and other mucous glands. I have seen in one case a considerable collection of nerve tissue, including medullated fibres and ganglion cells of varying sizes, some lai-ge and well formed. Plain muscular fibre is also frequent ; I have never seen the striated variety in a dermoid ovarian growth. Vessels of all kinds often abound, the aiieries have thick walls and do not appear to rupture easUy ; indeed, col- lections of extravasated blood generally denote hsemorrhage within a thin-walled cyst, or the presence of sai'comatous material, as in a case which will presently be related. It is not surprising that so many tissues are found promiscuously in these cysts if they be really developed from an unimpreg- nated ovum, for nobody can doubt that the ovum possesses the germ? of all tissues. The process of impregnation certainly differentiates some of the ovular elements, so that the tissues TUBE AND BROAD LIGAMENT. 89 of the foetus may develop in their right places ; this process does not play a share in the development of dermoid tumours, hence it is not to be wondered at that the natural relation of parts in the foetus is not maintained. Whether a blastoderm develops without dividing into the three layers as in an im- pregnated ovum, I cannot say ; it seems probable that the ovum may partly develop as far as the undivided blastoderm ; if so, this would explain the origin of dermoid tumours. The most interesting question with regard to dermoid cysts, and the most important clinically as well as pathologically, is the occasional occurrence of malignant new growths within their cavities. Mr. Thornton assures me that he has known several cases where malignant deposits have recurred in the pelvis two or three years after the removal of large dermoid cysts containing soft white growths that strongly resemble sar- comata. These growths, as in one case in my own practice, may occur in dermoid tumours where some of the most com- plex structures, as muscle and nerve cells and fibres, exist, as well as epidermis and its appendages. In October 1 883 I removed a dermoid- ovarian tumour from a girl aged seventeen ; the clinical featm-es of this case are related in the chapter on twisting of the pedicle. The tumour was multilocular ; one large cavity was filled with greasy choco- late-coloured fluid mixed with soft clot ; many of the secondary cysts held broad, thin, and flat bony plates, masses of sebaceous material, skin and hair, and some soft, very suspicious-looking substance. Some microscopic specimens of great beauty were prepared for me by Mr. Lyndon and Mr. Francis in the physio- logical laboratory at St. Bartholomew's Hospital. Some of these were from portions of solid growth clearly epidermic, yet including soft white growths ; others were cut through the in- distinct line of demarcation between the epidermic and deeper structures and the soft, almost diffluent, white growth which filled some of the secondary cysts, and which I had suspected to be sarcomatous. This soft growth was full of small prickles, which were in reality very fine bony spicula, and there were numerous haemorrhages into its substance. The epidermic and other structures in the firmer part of the tumour included hair, sebaceous and sudoriparous glands, 90 TUMOURS OF THE OVARY, fat, fibrous tissue, plain muscular fibres, bone, cartilage, and nerve cells. Towards the soft white growth there was abun- dance of connective tissue which passed gradually and without any sharp line of demarcation into the soft material which con- sisted almost entirely of round cells (fig. 18); near the well-formed con- nective tissue many connective tissue ^t^ '— j^-^-""!.-^.— corpuscles passed between the cells, ■ ^^~-'i. ~ -''— ^ but in the deeper and softer part of ^- - J . , :'i- " the growth nothing could be found but ^-'^^ ;" : ' - '_ ■ -^ round cells and a granular, very trans- ^'r{ '^ ' :-: -^.^^l J parent matrix. In fact, this was a '"/go 5 ~ . :,: /, sarcomatous growth; I took care to © Oqq G, liiQpPcr^ distinguish it from collections of leu- ©oo©Go o Q^'o c^ oocytes in other parts of the tumour Fig. 18.- Round-celled sakcojia where hgemorrhage had occurred. FROM A Dermoid Cyst, showing r\ ^ xi i j. t • j. j the transition from the connec- Only OUC mOUth later 1 aSSlstcd tive tissue of the firmer poi-tion x\ "n i. i j. x • T. of the tumour to the collection Dr. Bautock at au Operation where a of round-cells, with a trace of i -j j. i r ' flhrniation of the intercellular dermoid cyst was rcmovcd from a substance in the softer part of „ _ „ j x j. j- rpi the tumour. youug womau aged twenty- two. ihe cyst was multilocular, and the smaller cysts contained much dermoid growth, including hair and teeth ; there were bony spicula and a large knob of cartilage. In the midst of one of these growths were two large tubero- sities the size of small potatoes, and composed of dark-red, firm, fleshy material, not so soft as in my case. Some fine sections of this were prepared by ]\Ir. Lyndon and ]\Ir. Francis. At first, parts of the sections appeared to show abundant lymphoid tissue, but the fibrous network with leucocytes evidently represented the hgemorrhage which had caused the growths to be stained of a deep red colour almost throughout ; indeed, the transition from recent clot to this condition of leucocytes lying in meshes of fibrine could readily be traced. But in the paler portions very abundant connective tissue was found ; it was in parts well developed, but mostly embryonic. Large spindle-cells and collections of round cells abounded. The relation between the connective tissue of a dermoid cyst and sarcomatous growths within the same cyst is, it may reasonably be presumed, the same as the relation between the TUBE AND BROAD LIGAMENT. 91 same tissue and the same forms of morbid growth elsewhere. Considering, however, the abnormal conditions of a dermoid tumom-, it is not wonderful that many of its tissues should exhibit aberrations of histological structure. With regard to growths that are included amongst innocent tumours, growths composed of normal cartilage, bone, fibrous, and even glandular tissue, it is impossible to determine their existence as such within the cavities of a dermoid cyst, for is such a cyst to be described in homologous terms, as regards general pathology, as a mass of enchondromata, exostoses, fibromata, adenomata, and so on ? This appears illogical ; and if such a description be true, we must invent the term^ seboma, sudoriparous-gland-tumour, and employ much more English cut on Greek and Latin Like fustian, heretofore, on satin. The formation of perfect skin, epidermic appendages, and adipose tissue, is clearly something not identical with the forma- tion of tumours. But it cannot be determined where bone or cartilage may grow in the tissues of a- dermoid tumour as a natural part of the peculiar process whereby such tumours form, and where bone or cartilage may grow within a dermoid tumour as an exostosis or enchondroma within such a tumour. Where epithelium should or should not be is also a question well-nigh impossible to solve, when we contemplate the multitude of sebaceous and sudoriparous glands, and structures resembling pharyngeal and other glands, not excluding cysts of the multi- locular ovarian type, all of which may be found in a square inch of solid growth from a dermoid cyst. Hence it is very difficult to venture a decision on any quasi-cancerous tissue in cysts of this kind. With regard, however, to the sarcomata, these growths are considered to be made up of more or less embryonic connective tissue. In dermoid cysts connective tissue exists in all its stages of development, and the last two examples which I have described show that the perfect tissue may be seen passing into less well-developed structures, bearing every resemblance to the new growths known as spindle-celled sarcoma and round-celled sarcoma elsewhere. What is far more serious is the fact that 92 TUMOURS OF THE OVARY, experienced clinical authorities declare that dermoid cysts, with ill-developed tissue of this kind, give rise to all the worst results which follow the development of sarcomata elsewhere, so that it is, pathologically speaking, not illogical to speak of sarcoma of a dermoid cyst as a tumom' of a tumour. The abundant con- nective tissue of a dermoid cyst is a natural and necessary feature in such a cyst, and from it sarcoma may develop, just as that morbid growth may grow from the natural connective tissue of previously healthy parts of the human body. By analogy, then, we may proceed further, and say that some of the large knobs of cartilage which are found, but not as a rule, in dermoid cysts are enchondromata within those cysts. These knobs tend to ossify, and the consequence would be, under the same theory, an osteoma or exostosis of a dermoid cyst; but the large dentigerous plates of bone, whether simulating the alveolar part of the maxillse, or consisting of osseous tissue denser than the petrous portion of a temporal bone, are clearly a result of the primary influence which causes a dermoid tumour to form, for no exostosis away from the jaws has ever been found to develop teeth. I have avoided throughout this chapter the word teratoma, as it is merely a term covering ignorance, and liable to mislead the pathologist. TUBE AND BROAD LIGAMENT. 93 CHAPTEE VI. SOLID TUMOURS OF THE OVARY. I HAVE been present at twenty operations for the removal of solid tumours of the ovary, and in one case the tumour was evidently a hard cancer. Sarcoma or carcinoma of the ovary involves numerous questions of great cKnical and pathological interest. Firstly comes diagnosis from pregnancy, and from fibroid or rather myomatous tumours of the uterus ; then the justifiability of operations ; then the clinical aspects of the rela- tion of sarcoma of the ovary to cystic ovarian tumours that have become partly solid through intracystic glandular or papillary growths, and to solid or partially solid dermoid tumom-s. Lastly, there are more purely pathological questions, the first of which is the nature of ovarian sarcoma and its relation to the histology of the healthy ovary ; and this leads to general pro- blems concerning the relation of any tumour in any part of the body to its surroundings, especially as regards its origin. The general features of diagnosis need not be dwelt upon, nor discussed in detail, as they are to be found in almost every text-book and standard work on diseases of women. The very frequent presence of ascites and the softness of many sarco- mata, that often contain large cysts, are common sources of difficulty. In suspected pregnancy there is the placental souffle and the foetal heart to be sought, and the other signs of this condition to be noted ; lastly, a little waiting must settle all. The diagnosis of ovarian sarcoma from soft subperitoneal myoma of the uterus is often a matter of very great difficulty, and in some cases — as when a large solid pelvic growth causes ana- sarca of the lower extremities from pressure, emaciation, and other unfavourable symptoms — the truth cannot be learnt till the abdominal walls have been opened by the surgeon. The 94 TUMOURS OF THE OVARY, symptoms of advanced malignant disease of this kind are very evident, and there is now no doubt that the surgeon is justified in removing a solid tumour if he find, in the course of an ex- ploratory operation, that it is ovarian. Dismissing the question of hysterectomy, in case the tumour should prove to be uterine, I may here remark that, as far as my experience extends, the risk of exploratory operations under the above circumstances is very slight, even when removal of the tumour is found to be impracticable. I have witnessed fourteen true exploratory operations where nothing could be removed, in three of which the tumour was found to be uterine — none of these cases died ; in a fourth, pregnancy and cystic ovarian disease were suspected,, but it proved to be a case of cystic myoma of a pregnant uterus ; the patient was afterwards delivered at full term. In one case, sarcoma of the liver was discovered after several quarts of ascitic fluid had been removed ; the patient recovered. In another, several suppurating hydatids, projecting from below the liver, were detected ; they were drained, but the patient died. In another case a singular condition of peritonitic adhesions existed, but no tumour could be found ; the patient recovered. In three there was extensive papillomatous disease of the broad ligament ; one was drained, and died with very acute septic symptoms ; the other two recovered perfectly from the incision. One other case was a broad ligament cyst which could not be removed, owing to deep pelvic connections ; it contained no solid growths. Its main wall was opened and stitched to the edges of the abdominal wound after several pints of fluid had been let out ; the patient made a good recovery. In the three remaining cases disseminated malignant disease of the ovaries was discovered ; the parietal peritoneum was found infected in at least two, but all recovered from the operation ; nor was there any failure of union in the abdominal wound. Thus the risk of an abdominal operation is not great, and a sarcoma of the ovary, even when disseminated, tolerates inter- ference of this kind far better than papillomatous cysts, which bleed very severely at the least touch. Should a solid tumour of the ovary be suspected, it is the duty of the operator, unless there be signs of pelvic deposit and other evidences of dissemi- nation of mahgnant growth, to make an exploratory incision. TUBE AND BROAD LIGAMENT. 95 If the diagnosis prove correct, and a fair pedicle exists, the tumour may safely be removed. A sarcoma of the ovary, if left alone, is certain to cause secondary deposits and death, after months of great misery to the patient. When removed, it cer- tainly does not tend to recur as rapidly as a sarcoma in other parts of the body. Wells and others have had numerous cases where recurrence was delayed for years, or indefinitely. The microscopical appearances of solid tumours of the ovary now demand consideration. The tissues of the normal ovary must be clearly understood, the observer never losing sight of the fact that he must take into account, not only the connective- tissue framework and the unstriped muscular fibres, but also the cellular and tubular relics of the Wolffian body in the hilum, the thick-coated blood-vessels, and the follicles in all their con- ditions, whether as corpora lutea, as structures that have under- gone retrograde changes without ever becoming corpora lutea, or as normal follicles, large or small ; nor must the colloid changes in the stroma be overlooked, whatever may be their nature and origin. Of the follicular and Wolffian element I have spoken else- where ; as to the stroma, it is convenient to quote the words of Dr. Klein in his excellent ' Elements of Histology.' I have italicised the names of structures which are particularly impor- tant for the present question : ' In the part of the ovary next to the hilum there are numerous blood-vessels in a loose ^6rous connective tissue, with numerous longitudinal bundles oi non- striped muscular tissue directly continuous with the same tissues of the ligamentum latum. This portion of the ovary is the zona vasculosa (Wal- deyer). All parts of the zona vasculosa — i.e. the bundles of fibrous connective tissue, the blood-vessels, and the bundles of non-striped muscular tissue — are traceable into the parenchyma. The stroma of this latter, however, is made up of bundles of shorter or longer transparent and spindle-shaped cells, each with an oval nucleus. These bundles of spindle-shaped cells form, by crossing and interlacing, a tolerably dense tissue, in which lie embedded in special arrangements the Grraafian follicles. Around the larger examples of the latter, the sjoindle- shaped cells form more or less concentric layers. In the human 96 TUMOURS OF THE OVARY, ovary bundles oi fibrous tissue are also met with. The spindle- shaped cells are most probably a young state of connective tissue. Between these bundles of spindle-shaped cells occur cylindrical or irregular streaks or groups of polyhedral cells, each with a spherical nucleus ; they correspond to the inter- stitial epithelial cells mentioned (sic) in the testis, and they are also derived from the foetal Wolffian body.' Hence we are assured, on the authority of a distinguished and experienced histologist, that the ovary contains elements in its framework alone, putting aside the follicles and the blood- vessels, whence fibroma, sarcoma, myoma, or cancer may develop. I may add that I have found that the ligament of the ovary is a great conductor of the influence, whatever that may be, which sets up the formation of a myoma in the uterus or in the ovary ; or, to speak more plainly, that ligament is often very much thickened in cases of myoma of the uterus ; and when the same form of tumour attacks the ovary first, I have frequently found hypertrophy of the muscular substance of that ligament, in- volving the portion of the uterine wall that it joins. In old museum specimens of ' fibrous tumours ' of the ovary, I have found, as might be expected, that many were sarcomata, whilst others were clearly myomatous. Klein's ' numerous lon- gitudinal bundles of non-striped muscular tissue ' are not only * directly continuous with the same tissues in the ligamentum latum,' but also with the same tissues in the ovarian ligament ; and when a myoma exists, and the junction of the ligament with the tumour is examined, long lines of muscular fibre-cells may be seen running from the direction of the ligament, and spreading out widely amongst the precisely similar cells in the substance of the tumour. This condition, which is by no means rare, is most successfully to be sought for in cases of multiple myomata of the uterus, where the ovary is tough and slightly enlarged — involved, in fact, in the new growth. The origin of solid ovarian tumours of the type of each tissue is, in all probability, due to the same causes as in other organs, and these causes involve questions too wide and too general for discussion in these pages. I must, however, refer to hsemorrhages within the ovarian substance, whether confined to, or taking place beyond, the limits of a follicle or corpus TUBE AND BROAD LIGAMENT. 97 luteum ; that coagula may become sarcomatous is as probable in the ovary as elsewhere. Here, as in other cases, the patho- logist must be certain that the hsemorrhage is not secondary to a minute deposit of sarcomatous tissue, including the usual thin-walled vessels so liable to rupture. I have never found a solid ovarian tumour to be formed of pure fibrous tissue, and strongly suspect that the ' fibroids ' of the ovary are identical pathologically with ' fibroids ' of the uterus. All the solid tumours that I have seen removed at operations have proved to be sarcomatous or cancerous. But in 1879, when working in the Museum of the Eoyal College of Pig. 19.— Myoma of the Ovaky. Surgeons, I examined and mounted a specimen of a tumour of the ovary which bore the microscopical characters of a myoma. It was presented by Sir Spencer Wells, and is represented in this sketch (fig. 19). It was removed by the donor from a single woman aged sixty-eight ; she had observed it for over eight years. An abdominal incision, ten inches long, was necessary before it could be drawn out of the patient's body ; it had a good pedicle, easily secured, and the ovarian ligament was very thick. The patient made a good recovery, and was quite well in 1884. When first removed, the tumour weighed 1 5 lbs. 2 oz. The Fallopian tube and the broad ligament were perfectly free from disease. The circumference of the tumour 98 TUMOURS OF THE OVARY, was thirty-one inches ; its vertical measurement seven and a half inches ; from right to left it measm-ed nine and a half inches, and antero-posteriorly nine inches. Its anterior sur- face was tolerably regular ; its posterior was divided by a deep depression into two large tubercles, and the ovarian ligament, connecting it with the uterus, was much enlarged. On section, its surface appeared of a uniform white colour, with a pattern produced by innumerable bands of wavy and interlacing fibres ; the substance of the tumour was extremely tough, as resistant as in the firmest uterine 'fibroids.' On microscopical examina- tion, I found that it bore the very closest resemblance to sec- tions from uterine ' fibroids,' and from ovaries involved in uterine disease of that kind. There was very little true con- nective tissue to be found in the entire tumour, and that which existed appeared to be histologically well developed. In spindle-celled sarcoma of the ovary, I have never found . the ovary nearly as firm as in the above case of myoma. There is a very close relation between this kind of sarcoma of the ovary and the hypertrophy of the stroma, not rare in an ovary the fellow of which is involved in cystic disease, also in cases of atrophy of the follicles in healthy young sterile women and in other allied conditions. This true hypertrophy of the stroma must be distinguished from the changes seen in conges- tion and cirrhosis of the ovary, but it is hard to distinguish from true sarcoma. I have sections of a right ovary that was three inches in diameter, two ounces in weight, and very suc- culent in texture ; it contained hardly a trace of any follicles ; its fellow was a large multilocular cyst. These sections closely resemble those taken from the specimen next to be described. The normal spindle-cells were simply further apart than in a healthy ovary, and the intercellular substance was more abundant. The transition from this condition to the commonest form of sarcoma of the ovary is readily understood on microscopic exa- mination of sections of new growths of this kind. The appended drawings illustrate the microscopic appearances of sections of a large solid tumour removed by Sir Spencer Wells from a young woman in May 1880 ; the patient was in good health two years later. It was almost entirely made up of small spindle-cells, very TUBE AND BROAD LIGAMENT. 99 far apart, with abundant intercellular substance, consisting of very fine fibrils and numerous thin-walled vessels. The inter- cellular substance was obscurely fibrillated in the middle and softer parts of the tumour, but near the surface white fibrous Fi&. 20. — Spixdle-Celled Sarcoma of the Ovart, showing the superficial and the more central part of the tumour. tissue was abundant, and the close relation between the cells and the fibres was evident (fig. 20). 'A few round cells were seen, exclusive of spindle-cells cut across transversely ; also some larger cells with large nuclei, probably of Wolffian origin. In this case the tumour may be considered as simply a hyper- plasia of the young connective tissue that naturally exists in the ovary. It is the most frequent form of sarcoma of that organ. Other forms of sarcoma are frequent, and I have seen and examined specimens which differ from the above typical form in greater predominance of the cells, but many more where the intercellular substance was much increased. In a section of an incipient and tolerably firm sarcoma of the right ovary I found that large round cells were very abundant. The opposite ovary was converted into a large solid tumour, and hnfli wprA rAmnvprl frnm n ^^'^- 21.— Eound-Celled Sarcoma DOtn were remOVea, irom a developing in a small Ovary. patient aged forty-five, by Mr. Thornton in December 1881. Fig. 21 represents the right ovary itself; it was hardly of the normal size. The sarcoma- tous substance, though fiLrm for a sarcoma, was much softer than that of a pure spindle-celled sarcoma of the ovary, and bore no resemblance to hypertrophied ovarian stroma. The patient made a good recovery. In another case of sarcoma of both ovaries, under the care H 2 e- 100 TUMOURS OF THE OVARY, of tlie same surgeon, where rupture of a multilocular cyst with , hasmorrhage had been diagnosed, it was found, on opening the abdominal cavity, that several pints of old blood had escaped from the right ovary, which had become an exceedingly soft tumour, the size of a lemon, and closely adherent to the side of the pelvis. The left was about the same size, and so dark that I thought it must be melanotic, but the colouration proved to be due to extravasated blood, not a trace of true melanotic pigment being present. Both tumours were removed, and the patient, a woman aged twenty-six, recovered from the operation. The right tumour was much broken down ; the left was less affected, but was very soft, quite of the ' ericephaloid ' type, and no patches of mucoid tissue were visible to the naked eye. On microscopical examination, it proved to be a mixed sarcoma. The round cells predominated, excepting at a few points where the sections closely resembled those of the case of spindle- celled sarcoma mentioned in this chapter. In the softer parts there were large clusters of round cells, and the microscope revealed several areas of mucoid tissue with characteristic branched cells. In another case, under the care of a colleague, the tumour had all the microscopical characters of alveolar sarcoma. The patient was a married women, jiged twenty-five. A solid elastic tumour of several months' growth filled the hypogastrium ; the uterus was apparently free from it. To the touch it felt like a pedunculated uterine myoma or a dermoid ovarian tumour. At the operation it -proved to be a solid ovarian growth; the pedicle was extremely vascular, but not very hard to secure ; some large veins on its inner limits were ligatured separately, as were the outer vessels, on the usual plan. Transfixion of the entire pedicle was managed without causing haemorrhage, as the large veins could readily be pushed apart by the fingers before the needle was introduced. The left ovary formed a small sarcomatous mass three inches in diameter ; it was re- moved. The patient did well till the twenty-third day, when the temperature rose to 106°, and she died three days later. No necropsy was allowed ; death appeared to be due to acute peritonitis set up by some secondary malignant deposit. TUBE AND BROAD LIGAMENT. 101 Fig. 22. — ^Alveolar Saecojia op the Ovary. Some sections were carefully prepared for me at the Eoyal College of Sm-geons by ]\Ir. F. S. Eve. Fig. 22 shows the appearances of a section. The tumour was made up of large round cells, collected in groups, and lying in the spaces of a network of fibres, with which they appeared to be very in- timately connected ; fibres, too, could be distinctly seen passing between individual cells. This specimen may be in- structively contrasted with a case of scirrhus to be described farther on. Mr. Butlin, Mr. Eve, and my- self, after careful examina- tion of this tumour, have all arrived at the same con- clusion as to its nature. In a case which I saw in August 1882 with Sir Spencer Wells, the nature of the tumour was a little doubtful. The patient was a girl aged sixteen, who had been under the care of Mr. ConoUy, of Wood G-reen. She had never menstruated, and her friends had noticed that she had been growing larger for twelve months ; emaciation was progressing rather rapidly. I found the abdomen distended by an elastic and obscurely fluctuating growth, extending for two inches above the um- bilicus ; there was resonance on percussion both in the flanks and the epigastrium. Two or three stationary hard bodies could be felt on the surface of the tumour. In the following- autumn, the patient grew rapidly worse, and, in January 1883, Sir Spencer Wells removed the tumour with my assistance. Seven pints of fluid were removed, and the solid mass sepa- rated with difficulty from adhesions to the parietes, intes- tines, omentum, and liver. The patient recovered perfectly, and was in excellent health eighteen months after the opera- tion. The tumour was a large soft mass, weighing fourteen and a half pounds. On section it appeared to be chiefly what would once have been termed a ' fibro-cellular growth ' — that is, it was made up of a dense network of white fibres, the interstices between which were filled with semi-opaque material. 102 TUMOURS OF THE OVARY, The microscopical appearances (fig. 23) proved to be rather puzzling. A stout network of connective tissue, bearing scanty but characteristic nuclei, inclosed a great number of oval or circular cavities, which bore traces of a semitransparent material that had for the most part dropped out of these cavities, probably during the process of section. In the midst of the connective-tissue network were many semitransparent patches quite distinct from the ca\'ities. On examining the section under a higher power, I failed to find a trace of any regular epithelial lining to the cavities, but the semitransparent patches contained large cells that were undergoing some form of degeneration 'of a hyaline character, but not that which is so characteristic in colloid cancer (fig. 24). In some the' nuclei \ Vv\ Fig. 23.— Tumoitr of OvAaT, of tmcertain nature. : \^ fi'ijif) Fig. 24. — The same Ttoioub as in Fig. 23, as seen under ^inch objective. were plainly \dsible ; in others the outline was indefinite, so that they appeared as though smudged or blurred over each other. The connective-tissue nuclei in the smrounding stroma were very distinctly seen under a -i-inch objective. Altogether it would seem that this tumour was a simple hypertrophy of the connective tissue of the ovary. The characters • of the epithelium bore no resemblance to any normal epithelial elements of the ovary, but some remote relation may perhaps be traced to those of Grraafian follicles in the strong tendency to degeneration which they exhibited. Probably this tumour was a pecuUar form of adenoma ; the subsequent history of the case, the patient being now (April 1884) in excellent health, is against sarcoma and carcinoma. TUBE AND BROAD LIGAMENT. 103 The following case was undoubtedly an example of cancer of the ovary. Tn March 1881, I was present at an operation where a very large solid tumour was removed by a colleague from a girl aged fifteen.' It was an oval mass cutting, and cupping on section, precisely like a scirrhus of the breast. Its cut surface was dull-yellow and fibrous-looking ; in the centre was a large area of mucoid tissue, and close to it a bright yellow patch, cutting very grittily. The patient sank from exhaustion within forty- eight hours of the opera- tion. On microscopical examination, all the characters of hard cancer were found to be strongly marked (fig. 25). The drawings suflQciently show the nature of the growth, the H\$ p, ,'©©/ ® w Q o ?7) ^' Fig. 25.— Cancer of the Ovary. (2-mch and J-inch objectives.) • intercellular substance was a very dense framework of con- nective tissue with characteristic corpuscles ; the cells were closely packed in the alveoli formed by the framework. This case may instructively be compared with the example of alveolar sarcoma (fig. 22) already described. There, the intercellular substance was delicate and very intimately connected with the cells, amidst which it sent delicate processes. In this case of cancer the intercellular substance was abundant and coarse, and quite separate from the cells which were tightly packed in the alveoli. ' For a full account of the clinical features of this case see ' Solid Ovarian Tumours,' by J. K. Thornton, Medical Times and Gazette, vol. i. 1883, p. 211. 104 TUMOURS OF THE OVARY, I have not since come across a precisely similar case. The malignant deposit, not unfrequent within multilocular cysts, is, as far as I have observed, either true colloid cancer, or else what may vaguely be described as adeno-sarcoma, it being hard to distinguish how far the glandular or the sarcomatous elements prevail. The question of malignant dermoid cysts is discussed in the chapter on dermoid tumours of the ovary. TUBE AND BRGAD LIGAMENT. 105 CHAPTER VII. RUPTURE OF OVARIAN CYSTS. EuPTURE of an ovarian cyst is an important complication, to be considered both from its clinical and its surgical aspects. Its symptoms and prognosis demand careful study ; the treatment often bears upon the question of the justifiability of ovariotomy in cases in a desperate condition, and the allied problem of early operation in cases of ovarian tumour is ever associated with the desire on the part of the surgeon to save the patient from the risks of this comphcation. Prolonged experience in ovarian surgery tends to prove that rupture of the cyst is, as a rule, a mere leakage, producing but a slight amount of discomfort, and very trifling symptoms of peritoneal irritation. A patient will often state, as a part of the history of her illness, that she woke up on one occasion, and found she was much smaller. On the other hand, a clear history of rupture, with no subsequent acute symptoms, may be followed by ascites, cachexia, and other signs of a dissemi- nated new growth in the abdomen. Lastly, we must consider the true acute rupture of an ovarian cyst, followed by fatal haemorrhage or peritonitis. These varieties of the complication depend greatly upon the nature and cause of the rent or aperture in the cyst. The giving way of a secondary cyst through the main wall of a tumour, or the leakage of a large cyst through that wall, pro- duce very mild results, provided that the fluid pom^ed into the peritoneum be free from inflammatory, septic, or malignant elements. Eupture of a cyst wall through the o^'ergrowth of a solid intracystic formation is not likel\' to be immediately followed by serious symptoms, as the effusion is checked by the growth which stops the leak, but the risk of malignant infection 106 TUMOURS OF THE OVARY, of the peritoneum is very great. It is hardly necessary to say that traumatic rupture of a cyst, or spontaneous rupture of an inflamed or gangrenous cyst, is a very grave matter. This latter and best-recognised variety of the complication in ques- tion may be put aside till treatment is considered. Any tightly distended cyst may burst, if struck hard enough, or if it soften through pathological changes. The leakage or less acute rupture of a cyst is an interesting pathological study, which throws much light on certain clinical questions. In a very large proportion of the common multi- locular ovarian cysts which I have examined, I have noticed, as many others must have noticed, how the main wall is thinner at certain points than at others. Putting aside the appearances of thinning through inflammatory degeneration or blocking of vessels, for the present, I will presently dwell for a time on the thinning from mere distension — far more common, by the way. On opening the tumour, the thin, transparent, or semi- transparent patches will be found to correspond with secondary cysts pressing against the main wall. Very often such cysts are seen bulging from that wall, the moment that the abdo- minal cavity is opened by the operator, and not unfrequently they are burst in the process of extraction of the cyst through the abdominal wound. But before discussing pathological details any further, I will speak of the clinical experience on which my observations are founded. In the wards of the Samaritan Hospital, I have seen twenty- nine ovariotomies where the cyst had previously been ruptured. I exclude from this category all cases of rupture of the cyst during operation, a frequent occurrence which includes rents in the main cyst wall produced by dragging on the tumour when collapsed after its fluid contents have been emptied, rupture of weak or gangrenous parts of a cyst wall dming operative manipulations, and the perforation of the posterior part of a cyst by the finger of the operator, an accident that may occur when the solid contents of a tumour are being broken down to facilitate its extraction. All these conditions apper- tain more to purely operative details than to the present subject. When an uninflamed cyst has ruptured or leaked, and the TUBE AND BROAD LIGAMENT. 107 operation is performed a very short time afterwards, the appear- ances seen when the abdominal cavity is first opened are very characteristic, and may puzzle an inexperienced surgeon. The thin stretched peritoneum, with numerous fibrous bands cross- ing it and with its vessels dilated through incipient inflamma- tory changes, sometimes looks like the sm-face of the large intestine. It can generally be pressed against the surface of the cyst, and then a puncture with the point of the scalpel will let out the fluid and expose the cyst. As the opening of the abdominal cavity destroys for the time the mutual pressure of its contents, the ruptured cyst immediately begins to empty itself of the remainder of its contents with considerable rapidity if the rent in its wall cannot be secured in time. I will now relate all that transpired at the operations where a previously ruptured cyst was removed, including the public observations of the operator and the appearances of the struc- tures concerned in the operation. The previous history of the cases, and other details not bearing on the present question, are, of course, the property of the operators. I write this, not only in accordance with the principles on which this work is composed, but also to remind the reader that a previous history of rupture existed in the majority of the twenty-nine cases. In four of the cases, however, the history was remarkably clear and instructive. A woman aged forty-five had been troubled for years with an enlargement of the abdomen, which suddenly disappeared spontaneously, but the patient's size rapidly increased again, the abdomen was tapped, characteristic ovarian fluid was drawn off, and after a few months a large ovarian tumour with one predominating cyst was removed. There were only a few parietal and omental adhesions, and the operation terminated favourably. In another case there was a history, on good authority, of great reduction in the size of a cyst, but no cicatrix could be found ; the tumour was a dermoid cyst with a very irregular outer surface, and the cicatricial tissue might well have been effaced or concealed by thick fibrous tissue which lay in the sulci between the numerous tuberosities on the surface of the cyst. There was very little peritonitis. In a third case a woman, aged thirty-nine, had a 108 TUMOURS OF THE OVARY, fall, and immediately observed a reduction in the size of her abdomen. Very little pain followed, and at the operation the tumour was found to be a simple broad-ligament cyst. The fluid contents of a growth of this kind have long been known to be devoid of irritating qualities, as far as the peritoneum is concerned. In many broad-ligament cysts bearing papillary growths the fluid is very similar, but the results are far different, as will be shown presently. Hence, if rupture of the so-called parovarian cyst (and I retain the conventional name, to avoid confusion, as stated in the chapter on broad-ligament cysts) be diagnosed, operation should not be delayed, for the simplest cyst of this class sometimes contains a few papillomatous growths, which will entirely alter the prognosis. In a fourth case, there was a clear history of ruptirre, a few years before operation. At the operation a large parovarian cyst was removed ; in its walls a very distinct cicatrix was found, with its tissue partly calcified. This forms a preparation now in the Museum of the Eoyal College of Surgeons, to which collection it was presented by the operator, Mr. Thornton. (Pathological Series, IVo. 4505.) Passing to the immediate results of rupture, in four very acute peritonitis existed, and in ten there were objective evidences of chronic peritonitis. In one of these cases acute pleurisy followed rupture, and the pleura was tapped. The peritoneum was intensely injected, but all bad symptoms dis- appeared after the removal of the tumour, which was an almost sessile multilocular cyst. The case bears a certain analogy to the curious example of papilloma of the Fallopian tube, related in another chapter. On the other hand, a sickly and timid young woman, under the care of Dr. Bantock, had consulted that surgeon for abdo- minal swelling and jaimdice. The swelling suddenly diminished in size, but the patient suffered no consequent pain. The tumour was tapped a few weeks before operation. When ovario- tomy was performed the pelvis was found to be full of clear, glairy, ovarian fluid, and there was a rent at the lower part of the cyst three and a half inches in diameter, and its margins were well healed. The tumour was a large multilocular cyst of the right ovary. There was one pelvic adhesion, but none TUBE AND BROAD LIGAMENT. 109 between the cyst and the parietal peritoneum. The abdominal cavity was sponged out with plain warm water, and the patient made a good recovery. In the cases of ruptured colloid cysts which I have observed, peritonitis invariably existed ; the omentum, when bathed by colloid fluid for a prolonged period, becomes very much thickened, and looks like a mass of boiled sago with small blood-vessels running over it. This condition, in particular, gives the peculiar feeling, on palpation, which Olshausen terms coUoidknittern. He considers it as patho- gnomonic of ruptured colloid cysts, but I have found that it is by no means invariably present. One of these colloid cases was very remarkable. The patient was a healthy woman about thirty-five years of age ; a tumour had been observed for several years^ and shortly before operation she had suffered from pains in the pelvis. The tumour was not well defined ; it pressed upon the body of the uterus, which was thus pushed forwards in the pelvis. At the operation, when the peritoneum was exposed, a quantity of free material could be seen through it. On laying open that serous membrane, several pounds of free colloid material escaped, or were removed by the hand of the operator, and the cyst was found to be widely rent, with exceedingly soft walls, and with a deep pelvic ad- hesion. The peritoneum was found to be intensely injected wherever it was exposed ; yet, notwithstanding the extreme degree of extravasation of colloid material and these objective evidences of peritonitis, the clinical symptoms of that disease were absent. The pressnre of a prolongation of the cyst into the pelvis, to which it adhered, was the cause of the pelvic pain. The patient unfortunately died on the tenth day ; there was broken-down malignant deposit in Douglas's pouch. Grangrene and consequent rupture of an ovarian tumour is generally associated with twisting of the pedicle, but I have seen one case where the tumour gave way two days before operation, when it was found to be a large multilocular growth, with a rent in front, through tissue in the outer wall that ap- peared to be in an incipient state of gangrene, but the pedicle was not twisted. Acute peritonitis, without purulent exuda- tion, but intense in degree, existed, and the patient died within twelve hours. It must not be supposed that the abdominal 110 TV MOVES OF THE OVAEY. structures are thrown into relief, and thus made more readily distinguishable from each other by the vascular changes in acute peritonitis ; on the contrary, the surfaces of the intes- tines, bladder, uterus, and parietal peritoneum lose their natural differences of tiut and shininess or dulness of surface, and the matting together of the uterine appendages in the neigh- bom'hood of the csecum, sigmoid flexure, and rectum, greatly embaiTass even experienced operators ; nor is such a case easy when no adhesions or extensive effusion exists, as in the instance fii'st mentioned. A multilooular cyst often bursts posteriorly, secondary cysts projecting, in a manner presently to be described, through the main wall, and rupturing into Douglas's pouch ; frequently in such cases but little peritoneal imtation is set up. I once assisted Dr. Bantock at an operation on a patient aged twenty- one, where a large multilocular cyst was removed ; there was a distinct history of diminution in size, with a sensation of some- thing having given way, but there had been very little extra abdominal pain. On opening the abdominal wall, the thin, stretched peritoneum, with numerous fibrous bands crossing it, and Avith clear blood-stained fluid behind it, looked like a piece of inflamed distended intestine. On punctm-ing the serous membrane, a quantity of the blood-stained fluid escaped, and the shiny white outer wall of the cyst came into view. The cyst was tapped, and, on drawing it through the abdominal wound, its posterior wall was found to be very thin, and it had yielded at one point. The free fluid appeared to be partly ascitic. There was no fuiiiher complication ; the pedicle was not twisted ; a drainage-tube was inserted into Douglas's pouch, and the patient made a good recovery. The staining of the fluid in this case leads to the subject of hsemon-hage, another source of danger after rupture of a cyst. As a rule, haemorrhage is but sHght, especially in the typical instances of rents in thinned parts of the outer walls of cysts, where the degeneration of those parts is often due to blocking of vessels. If a rent or circular aperture communicate with the interior of a large cystic cavity lined with very vascular walls, especially when vascular sohd growths are present, the walls of the vessels lose theu support, and hfemorrhage occurs. This is TUBE AND BROAD LIGAMENT. Ill very often seen when the tumour has been emptied in the course of the operation ; the bleeding is seldom rapid under such circumstances, although, of course, the surgeon should secure the pedicle as quickly as possible. It is evident, on the other hand, that when bleeding is caused by rupture of a cyst, it may in a few hours amount to a serious loss of blood. I assisted a colleague two years ago at an operation upon a woman about thirty-five years of age, who had entered the hospital with an ovarian tumour, and was seized with acute bronchitis in the ward. After a fit of coughing she became reduced in size, and the cyst became flaccid ; the patient then grew more and more anfemic every day. On opening the abdominal cavity, the ap- pearances were much as in the last case, only the free fluid was much more deeply blood-stained. The rent in the cyst was blocked by a secondary cyst in a manner presently to be de- scribed. The tumour was sessile, and extremely difiicult to remove ; the operation — imperative, considering the symptoms — was performed under very unfavourable circumstances, and the patient died on the fourth day. Comparing this with the last case, and both with some other cases in this chapter, where either no other complications, or other complications of the gravest nature, existed, it is evidently futile to attempt to make statistical inferences, and to calculate the proportion of mor- tality in a collection of cases of rupture of ovarian cysts. Cysts containing papillomatous growths are particularly liable to rupture. In another chapter the origin and nature of these growths are discussed at length. When they occur in mixed tumours, alongside of other cysts containing glandular contents — in tumours, that is to say, that arise partly from the parenchymatous stroma, partly from the tissue of the hilum — the walls of the secondary cysts whence they spring are often, at first, thick and tough ; when they grow within true broad- ligament cysts the walls are often exceedingly thin. So rapid, in most cases, is the growth of these papillary structures that they can soon burst any cyst wall, thick or thin ; but from their wedge-like or pyramidal form they tend to stop the leak that they make. This involves a far greater danger to the patient than the escape of fluid contents, especially in these particular cases, for the fluid is often clear and watery; nor when it is 112 TUMOURS OF THE OVARY, mixed with blood from the growths, which are very vascular, does it always set up great peritoneal irritation. The growths themselves are very liable to infect the whole peritoneal cavity, exhibiting the most malignant tendencies. In a patient, aged twenty, where rupture had occurred a few weeks before opera- tion, Mr. Thornton found a multilocular ovarian cyst, perforated at one point by a very large papillomatous mass. A large papillomatous growth had formed in Douglas's pouch, and the broad ligament also contained a papillary mass ; but this latter was evidently part of the original disease, and not the result of the rupture. Cysts containing numerous thin-walled secondary cystic growths, with no solid contents, also tend to rupture, not through the pressure of the growths, but rather from thinning of the main cyst wall. The minute secondary cysts tend, after rupture, to reproduce themselves all over the peritoneum, especially upon the serous coat of the intestines, but do not then appear to be malignant ; indeed, they seem as harmless as the small thin-walled broad-ligament cysts that form indepen- dently of relics of the Wolffian body in the immediate vicinity of the Fallopian tube. I observed this kind of infection of the peritoneum in a case under JNlr. Thornton's care ; the patient made a good recovery, and the disease did not recur. There is apparently some relation between these secondary thin-walled cysts and the papillomatous growths. Into the wards of the same surgeon a patient was admitted in 1878, where a tumour existed with a clear history of rupture one year before operation. There was a hole in the cyst wall the size of a threepenny-piece, blocked up by a large protruding papillomatous mass, and the surface of the main cyst was studded with minute thin-walled cysts. Even the malignancy of the papillomatous gro-^^hs is very uncertain. In Sir Spencer Wells's curious case of papilloma of the Falloj^ian tube, recorded in another chapter, there were several thin-walled pedunculated cysts amongst the papillomatous masses, and the peritoneum was bathed with discharge from the papillomatous growths, yet the patient was in good health four years after the operation. In cases where the disseminated papillary growths are of ovarian or Wolffian origin, the patient is not necessarily doomed ; still, their dissemination over the peritoneum is a grave complication. TUBE AND BROAD LIGAMENT. 113 I liave seen one ease where the contents of a dermoid cyst were discharged into the bladder, and one where the fluid from the interior of a multilocular cyst emptied itself into the rectum, the contents being passed during defsecation. In both cases the operation was successful, but much complicated by adhesions. In these instances, indeed, it is rather a question of adhesion than rupture. An intimate primary adhesion be- tween the cyst wall and the intestine may degenerate in such a manner as to set up a communication between them, or the irritation caused by a slight rupture may be the exciting cause of an adhesion of this class. The tissue which binds the adhe- rent parts forms a conduit or tightly closed channel, through which the ovarian fluid may pass to an indefinite extent, not a minim ever entering the peritoneal cavity ; and the constant irritation increases the production of organised inflammatory products which defend the peritoneum from the fluid. In short, in these cases the difficulty will ever lie in the separation of adhesions. When a communication exists between a cyst and the bladder or intestine, it is most probable that a primary adhesion became the seat of communication. That, as stated above, the irritation caused by a slight rupture may set up an adhesion, followed by an aperture of communication, there can be little doubt, but this is probably the exception. Old adhesions be- tween a cyst wall and the viscera tend to become degenerate, especially in the centre, and hence perforation is very probable. The subject of adhesions secondary to rupture is really a part of the subject of peritonitis from that compKcation. When the surgeon can confidently diagnose rupture, he must be prepared to find adhesions, and often they prove to be very intimate. Almost any complication in ovarian cystic disease increases the chance of adhesions. But, as nothing is certain in ovarian surgery, a very acute case of rupture, subjected to operation after all peritoneal symptoms have subsided, may prove — as in one instance, where I assisted a colleague — to be perfectly un- complicated in all other respects, no adhesions existing. Such cases resemble those where subacute attacks of peritonitis worry the patient. The suffering enforces rest, and resolution of the inflammation takes place without the formation of organised 1 114 TUMOURS OF THE OVARY, inflammatory products. The history alarms the surgeon, and, on opening the abdominal cavity, he is agreeably surprised to find that adhesions are entirely absent. The actual nature of a rupture now remains for considera- tion. It may appear as a long rent, especially when caused by a blow or a fall ; the largest cyst in a multilocular tumour is generally ruptured in such a case, and at the operation its walls are seen lying flaccid on the mass of smaller cysts behind and below it. The perforation caused by a papillomatous or even by a glandular growth is also to a great extent mechanical. The growth protrudes ; its edges growing widely beyond the circumference of the aperture that it has made in the cyst wall. When this kind of perforation occurs in the front of the main cyst, the growth is often kept down for a time, and much flattened by the pressure and the movements of the abdominal walls, so as to appear, as in one case that I have seen, like the head of a nail that has been driven into the tumour. A leak is very frequently blocked up by an unruptured secondary cyst that has had no share in the injury to the main cyst wall, but has become approximated to the rupture, as that wall has fallen in after the escape of the ovarian fluid ; I have seen this con- dition well marked in three cases. In such a case, the secondary cyst may become the largest and fullest cyst in the tumour ; in fact, the same change occurs as after repeated tapping. The pathological formation of a rupture by changes in the main cyst wall must be considered at length. It occurs through certain inflammatory and degenerative changes in the wall, and also from the pressure of secondary cysts developed more or less within the substance of the main wall. Local degeneration of the main cyst wall, independent of all changes resulting from the breaking down of secondary cysts, are very frequent, and the condition must be familiar to all who have read certain well-known British and foreign works on ovarian tumours. Wells describes the appearances of the inner aspect of the cyst wall at the seat of degeneration. This area is often several inches in circumference ; its periphery consists of a zone of very vascular tissue ; the vessels being large, engorged, and ruptured or blocked at certain points, much blood being TUBE AXD BROAI) LIGAMENT. 115 effused around the ruptured vessels. The centre of the area is of a very characteristic ochreous colour, becoming reddish- orange towards the periphery, and the wall is at this part very thin. The pathological significance of this condition is evident ; the engorged vessels have been incapable of carrying nutrition to, or removing effete material from, the affected portion of the cyst, and the blood extravasated from the most distended vessels has undergone changes chiefly affecting its colouring matter, and hence the ochreous patches, which are homologous to the familiar hues of an old bruise on the integuments. The primary cause of the congestion may be inflammation of the wall, which often causes less extreme effects than those above described. Hence, in examining the inner aspect of a cyst that has inflamed, not only may these degenerate areas be ob- served, but also large patches of pure congestion without ruj^- ture or blocking of any vessels, and, on the other hand, small points of very ansemic tissue, where degeneration has ceased to extend, without having ever advanced to any great degree. The breaking-down of one of these degenerate patches causes a rent, the margins of which are, from the very nature of the condition, thin from the first, and they tend to become thinner, the seat of rupture appearing after a week or two as a circular aperture from a quarter of an inch to over one inch in diameter. In some cases the irritation of the outpouring fluid causes inflammatory changes around the aperture, evidenced by hypersemia most marked on the outer aspect of the cyst, or even by effusion and thickening. This condition is frequently taken for ulceration, but I believe the above interpretation to be the truth. I have examined several ovarian cysts, where more than one rupture existed. The most recent always appeared as a simple rent or a very small round hole in de- generate tissue ; the hyperaemia and thickening lay around old apertures, some surrounded by peritoneal adhesions. "^Tien ulceration did exist, it was secondary to rupture. It is clear that when a cyst with an atrophied area becomes highly dis- tended, it is liable to burst at that area without any previous ulceration. What have been repeatedly taken for ulcers on the inner aspect of the main wall of an ovarian cyst are small secondary I 2 116 TUMOURS OF THE OVARY, cysts that have opened inwardly and are in process of effacement. This leads to the most frequent cause of rupture of a cyst, next to degeneration of its walls from vascular changes. In cutting through several inches of any main cyst wall, minute secondary cysts are generally to be found, and their nature has been dis- cussed in Chapter II. These often enlarge indefinitely, and may burst externally ; hence the small flaccid cysts frequently found on the surface of a large cystoma. Far more frequently they burst inwardly, discharging their contents into the main cavity ; hence follows a very characteristic appearance on the inner wall of the main cyst. The ruptured secondary cyst appears at first as a circular depression with an elevated margin (fig. 26). The base is simply the vascular membrane that always Knes the interior of secondary cysts, and it is invested with the usual columnar or cubical epithelium. It is very unlike the granular FIG. se.-EupTURED SEcoxDAHT cyst On the base of an ulcer. I have inner aspect of the main wall of an ovarian coon fVn'o oTM-i/:iQi-o-n/-.a ^r, tumour, in process of effacement. (Museum of ^^®" ^^^^ appeal aUCe in ia 4504!f ^^ °^ Surgeons, Pathological Series, ^U incipient multilocular cyst of the ovary, several secondary cysts already being in course of destruction. The ruptured cyst does not long retain this appearance. Its elevated circular border becomes effaced by degeneration, and, when several secondary cysts have broken down together, as frequently occurs, an elevated, white fibrous patch is seen con- taining curious semicircular rings. This patch is made up of collapsed cyst walls ; it simulates cicatricial tissue, and is very prone to degenerate and become the seat of rupture. But every intervening stage between this condition and immediate internal rupture of a secondary cyst may sometimes be seen in the same tumour. In May 1884, I exhibited at the Obstetrical Society of London a specimen, where an unusual combination of circum- stances had produced a remarkable appearance in the main TUBE AND BROAD LIGAMENT. 117 cyst wall. A secondary cyst had developed in the substance of the main wall distending the latter externally without causing rupture. On the other hand, it had ruptured internally. Hence a thin-walled digital protrusion two inches deep was seen on the outer surface of the tumour, whilst internally the pro- trusion could be seen to communicate with the cavity of the tumour by a circular orifice over an inch in diameter, sur- rounded by a very sharp fibrous ring of the kind usually seen at the seat of rupture of a secondary cyst when it bursts in- wards. The tumour itself had ruptured at a point where another secondary cyst had formed in the main wall. I must here refer to a case described by my friend and colleague, Mr. Meredith, where ai\ ovarian cyst had ruptured repeatedly during a period of nine years before its removal. Copious diuresis followed each spontaneous reduction in the size of the tumour, which rapidly refilled. The patches of tawny or ochreous discolouration, above described, were scat- tered all over the main cyst wall. Mr. Meredith also describes the appearances which I have just noted ; they were simply secondary cysts undergoing effacement ; he wisely speaks of them as ' so-called " ulcerations." ' In both cases — that is, whether an ochreous patch in the main wall, or a protruding secondary cyst breaks down — I have ever found that the changes in the torn tissue are not ulcerative, but atrophic, provided that the rupture be recent. 118 TUMOURS OF THE OVARY. CHAPTER VIII. TWISTIXG OF THE PEDICLE. TwiSTES'G of the pedicle of an ovarian tumour is a subject of gi'eat pathological and clinical interest. Many theories on the mechanism of this complication have been advanced, and its artificial imitation has even been advocated with a view to the induction of atrophy of a cyst, an ingenious idea which it is to be hoped will never again be brought into practice. Some of the latest views on axial rotation of ovarian tumours wiU be found in the last editions of the standard works of Su' Spencer WeUs and ]Mr. Lawson Tait. In 1880 there was an interesting discussion on a paper read before the Obstetrical Society of London by the latter surgeon. Sir Spencer "SVells observed that it was not difficult to understand how an ovarian tumour of moderate size could rotate and twist a pedicle of some length, and the mere alteration from the erect to the recumbent position was, in his opinion, enough to account for half a turn. If a tumour of moderate size be builder on one side, through the deposit of solid matter in a secondary cyst, or through other causes, it seems to me very easy to understand how it may roll over when the patient lies for some time on the opposite side. ]Mr. Tait, in his paper, advanced the theory that the passage of sohd fceces along the rectum may act as a wedge, and thus gi'adually turn ' an ovarian tumour growing on the right side with a free pedicle, and resting with its axis inclined towards the top of the ninth or tenth rib on the left side.' At first sight this appears to be merely an ingenious theory, but at the time that the paper was read it struck me that ]\Ir. Tait's opinion coincided with some of my own convictions grounded upon experiments that I had made when making necropsies on TUBE AND BROAD LIGAMENT. 119 cases of ovarian disease that had proved fatal before any opera- tion could be performed. I had already observed that when a large tumour with an irregular posterior surface lay to the right of the rectum, an accumulation of faeces might press against the pelvic portion of the growth in such a manner as to push the whole tumour about a quarter of a turn round its vertical axis. Should the pedicle be very long, or very short yet inelastic, it would remain twisted after this pressure was removed, and might become still more twisted when the pres- sure was reapplied. In one body I found a large ovarian tumour pressed upon in this manner by the rectum, which was slightly distended owing to a cancerous stricture. A little artificial distension of the intestine caused it to press against the tumour so as to push its left, side backwards, stretching and twisting the pedicle. In examining separately this same pedicle, which had not been twisted, except in the course of my experiment, I found that it was two and a half inches long, and an inch broad, and that some of its veins were completely plugged with old coagula. It may be observed that in many cases of considerable twisting of the pedicle the vessels are not so obstructed from within or without as might be expected. I cannot see that the similar theories propounded by Mr. Tait and myself can be in any way unreasonable, based as they are on actual observations ; still I believe that, as a rule, the twisting of a pedicle is to be explained by the simpler doctrine that the tumour, pressed upon by the viscera and even the costal cartilages above, and by the pelvic structures below, but comparatively free laterally and anteriorly, rotates on its own axis every time that the patient after walking or lying on her back turns round and rests on her side. Most healthy persons lie habitually on one particular side, and in cases of ovarian tumour, as in certain stages of inflammatory diseases of the lungs, such a choice may be due to tenderness in the opposite direction. Whatever theories may prove, the clinical results of twisting of the pedicle are very definite. This complication may cause ruj)ture or sloughing of the tumour, arrest of growth of the tumour through obstruction to the vessels of the pedicle, absolute atrophy of the tumour. 120 TUMOURS OF THE OVARY, and lastly, detachment of the tumour from the pedicle, and subsequent nourishment of its tissues through vascular ad- hesions. So disastrous a catastrophe as gangrene has not failed to attract the attention of experienced operators, and "Wells, Tait, Thornton, Wiltshire, and others have described cases of this complication where immediate operation, an imperative duty, has succeeded or failed in saving life. Sudden and violent pain in the abdomen, with vomiting, is a very suspicious symptom in a patient that bears a large tumour, presenting the characters of an ovarian cyst. For clinical reports of individual cases I must refer the reader to the special writings of the above- named surgeons. The principal features of this condition are too self-evident to need any discussion. Kotation of an ovarian tumour and twisting of its pedicle is a frequent accident, yet consequent gangrene is rare. Arrest of growth is a far more common result. Dull, constant abdo- minal pains in a patient who keeps in good general health and bears a cystic tumour that increases but little or not at all in the course of many months or years is a suspicious symptom. When the abdominal incision is made, the surface of the cyst appears not white and glistening, but dark-brown and destitute of lustre. On plunging the trocar into the cyst, the contents are found to be very thick and dark, for the twisting of the pedicle causes rupture of innumerable small veins in the inner lining membranes of the cyst, and the colouring matter of the blood undergoes alteration in the ovarian fluid. Similar haemorrhages, with consequent discolouration of the contents of the cyst, are very frequent in large, old, highly multilocular tumours where the lining membranes of the secondary cysts are thin, and the vessels provided with very weak walls. On the collapse of the cyst and its withdrawal through the abdo- minal wound, the twisting of the pedicle will be at once detected. A pedicle thus affected is very favourable for the application of the ligature, and when adhesions have not been numerous the prognosis in these cases is very good. I have seen tetanus follow and prove fatal in one case where the pedicle of a parovarian cyst was found to be twisted, and was very readily and safely secured by transfixion and ligature ; but the TVBE AND BROAD LIGAMENT. 121 cause of the fatal complication appeared to be a draught. Of twenty-one cases of operation on ovarian tumours with twisted pedicles at which I have assisted, only two ended fatally, the case just mentioned and one case where very multiple adhesions existed. The obstruction to the vascular supply of a tumour follow- ing twisting of its pedicle not only causes arrest of the growth of the tumour and h£emorrhages into its cavity, but these hgemorrhages may be sufficient to induce marked ansemia, as I once observed in a patient upon whom ]\Ir. Thornton operated. Of necessity such haemorrhages can only be serious when the twisting is slight enough not entirely to obstruct the vessels in the pedicle. In examining a twisted pedicie from a cyst removed in 1882 by Mr. Meredith, I found that the hydatid of Morgagni had undergone a remarkable calcareous degeneration ; the fimbrige of the tube were atrophied. The first case of ovariotomy in my own practice was an example of dermoid cystic disease of both ovaries, with atrophy of the tumour on the right side through twisting of the pedicle. A married woman, aged thirty-two, consulted me in March 1882 for relief from an abdominal swelling, which did not inconve- nience her from its bulk, but caused constant abdominal pain, and a peculiar feeling of irritation referred to the iKac fossae. In the summer of 1881 she noticed an oval lump in the left iliac fossa. She sought advice at a general hospital in London, but it was found that she was pregnant, and she was recom- mended to wait until she had been confined before submitting to operation. This decision was evidently justifiable, as the tumour could not have been large or dangerous at the time, and there was no necessity to put the patient to the risk of an abortion. On January 26, 1882, she was confined, at full term, of her fifth child, which only lived for three weeks. On March 26 the catamenia reappeared. The abdominal pain was particularly severe when the patient coughed. On examination, I found a small tumour occupying the lower part of the abdomen, from the pubes to two inches above the umbilicus ; it was not very tense, and fluctuated in all direc- tions. The uterus was fairly movable and pushed to the left ; 122 TUMOURS OF THE OVARY, the cyst could not be felt in the pelvis, but to the right of the uterus there was some fulness. At the operation I found that the tumour was a dermoid cyst of the left ovary, filled with seven and a half pints of a greasy chocolate-coloured fluid and masses of a half-liquid fat resembling pomatum; there was an epidermic lining on the walls of two secondary cysts, which contained spicules of bone. On searching behind the right broad ligament I drew up a heavy oval body, three inches in its long diameter, which took the place of the right ovary. The pedicle was twisted and atrophied to an extreme degree, resembling a large nerve stretched over the surface of the cyst and connecting it with the back of the uterus. I applied a ligature to the pedicle, as a safeguard, though I doubt whether it would have bled if it had been simply cut across, and its proximal end dropped back into the pelvis. The cyst was stuffed with a very dense mass of coarse, black hair, mixed with yellow fat ; its walls were lined with epidermis. The patient made a very rapid recovery, and on the first day after operation observed that all the abdominal pain and the feeling of irritation in the iliac regions had entirely disappeared. These symptoms were, I believe, mostly due to the remarkable condition of the right ovary. The rapid and early growth of a dense mass of hair and fat in its interior, with little increase in bulk, had made it very heavy. It had hung down in the pelvis and rolled about, so as to become twisted round its own pedicle, a complication that had arrested its further growth. The tumour of the left ovary was neither large nor heavy, and less likely to have been the chief source of irritation than the small but heavy and particularly solid tumour that had been shaking about in the pelvis for months. The twisting process may be continued to a degree yet further than in my case. In 1881 Mr. Thornton operated upon a woman aged 34, who for seven years had presented sym- ptoms of an abdominal tumour. In the interval she had given birth to four children. As in the case just described, the pain was out of proportion to the size of the tumour. At the operation a spherical dermoid cyst the size of a cricket-ball was removed ; it was entirely detached from its pedicle, and adhered to the omentum, which supplied it with blood (fig. 27). The right TUBE AND BROAD LIGAMENT. 123 ovary was then found to be cystic and was removed. The left Fallopian tube was obstructed and slightly dilated ; close to it, *;,^_-r£s^^5^ Fig. 27. — Dermoid Cyst, twisted off its Pedicle, and receiving Its vascular supply from the adherent omentum. (Museum of Royal College of Surgeons, Pathological Series, No. 4549.) Fig. 28.— Stump of Pedicle OF Tumour represented in fig. 27. in the site of the ovarian ligament, lay a short, firm tag of fatty and partly calcareous tissue (fig. 28). Dr. Heywood Smith has described a similar case. It not unfrequently happens that. the cyst becomes so in- timately adherent to the omentum or parietal peritoneum that all its vascular supply is obtained in this manner, as Dr. Eitchie and others have already indicated. The irritation, set up by rotation of a cyst and the twisting of its pedicle, causes, in many cases, such adhesions, and then the pedicle tends to atrophy, and may break off as in Mr. Thornton's case. This sequence of changes accounts for the comparative rarity of gangrene after twisting of the pedicle. In a young girl upon whom I operated in 1883, I found a large, heavy dermoid cyst with a very narrow pedicle just beginning to be twisted from left to right. For some weeks before operation, the patient had suffered from symptoms of peritonitis, and, on placing my hand on the upper part of the tumour, I could for several days feel very marked crepitus. At the operation I could find no adhesions, but the parietal peritoneum and omentum were inflamed. All symptoms of inflammation 124 TUMOURS OF THE OVARY, rapidly subsided after the removal of the tumour. Had the operation been delayed, the twisting would probably have con- tinued, and the peritoneal inflammation increased till adhesions would have been established ; on the other hand, rupture of the cyst, or gangrene of the tumour from occlusion of the vessels in the pedicle, and the failure of vascular supply through adhesions, might have occurred. In 1880 I assisted Dr. Bantock in an operation on a young woman, where a large ovarian cyst was found connected with the parietal peritoneum and the omentum by very abundant, and very vascular, shaggy adhesions (fig. 29). The pedicle was twisted and much ¥S ^ Wo \^h " \^' Fig. 29. — Cyst twisted off its Pedicle, receiving vascular supply through adhesions. (Museum of Royal College of Surgeons, Pathological Series", So. 4551.) atrophied ; its veins were distended and blocked with solid friable clot. In the course of the same year, I assisted the same surgeon in a precisely similar case and operation ; the tumour was twisted one whole turn on its pedicle, and the adhe- sions were very numerous, the vermiform appendix being closely connected to the cyst by a vascular band. A year later I saw INIr. Thornton operate on a case where the tumour was nourished by a very vascular and intimate omental adhesion; in this case the pedicle was but slightly twisted, but its veins were com- TUBE Ayn BROAD LIGAMENT. 125 pletely plugged. I have assisted at several other very tedious cases of the same kind; two, both under ]Mr. Thornton's care, being in pregnant women — these cases recovered. In another case where Dr. Bantock operated, the omental adhesions were very intimate and troublesome to secure, and the ileum ad- hered closely, but was readily separated with little subsequent haemorrhage. In the chapter on dermoid tumours of the ovary, I men- tioned a case of a patient aged 3o, in whom two ovarian tumours were found, the left being a simple multilocular cyst with a short pedicle, whilst the right was a sphe- rical dermoid tumour with a twisted pedicle. The sketch (fig. 30) shows the condition of one of the veins in this pedicle. The vein was dilated at one point into a small, thin-walled spherical cyst, which, when the specimen was fresh, contained fluid blood, and was not impervious, as a small probe from a surgeon's pocket case could be passed' into the vein from its cystic dilatation. The walls of the undilated part of the vein were, thickened. This specimen is preserved in the Museum of the Royal College of Surgeons (Xo. 4552 in the Xew Patho- logical Catalogue). %. ''*^, Fig. 30.— Dilated Veix fbom A TWLSTED Pedicle. 126 TUMOURS OF THE OVARY, CHAPTEE IX. THE ABDOMINAL WOUND— NOTES ON ADHESIONS. Judging from what I have witnessed, I cannot consider that the precise length of the abdominal wound is a matter of great importance. The removal of a large cyst through a small wound looks well, no doubt, but, although I have never seen sloughing, or even suppuration, of a wound caused by bruising in the course of the extraction of a large tumour, a cyst may be ruptured during the process, and the sponging out of the peri- toneum will thereby be rendered more difficult under circum- stances where it is particularly necessary. It is very frequently found in the middle of the operation that the uppermost part of the tumour adheres to the parietal peritoneum by very vas- cular bands of lymph ; their separation causes much haemor- rhage, and, if the abdominal wound be not long enough, the operator will be obliged to prolong it considerably upwards in order to reach the bleeding points. This is to be avoided if possible, but, though the operator may dislike the necessity of compulsory enlargement of the wound, it is his duty to do so under the circumstances, and he may console himself by the reflection that the increased length of the abdominal incision entails in itself no increased risk whatever, as Sir Spencer Wells has shown, whilst a better view of the bleeding vessels on the parietal peritoneum will be of great advantage both to the patient and to the surgeon. To evert the edges of a long wound, and to secure the bleeding vessels, is an easy task ; to have to direct an assistant to raise the upper angle of a short wound, and to ' make shots ' with a pair of forceps at vessels bleeding, half in the dark, on the surface of the peritoneum above the level of the wound, is a troublesome proceeding, especially if the patient be not perfectly under the influence of TUBE AND BROAD LIGAMENT. 127 the anaesthetic, so that the recti take to violent and irregular contraction during the process. In order to bring the knife as directly down on the linea alba as possible, it is best to follow closely the slightly pig- mented line on the integuments, which runs from the umbilicus to the pubes, or to cut straight between those points when the line does not exist. This is highly important, as lateral deviations of the knife may entail abscess, especially if the linea alba be missed altogether, and the sheath and fibres of the recti be dissected up or lacerated. The patient must be kept well imder the influence of whatever anaesthetic is em- ployed when the linea alba is being divided, or else the parietal peritoneum will be forced against the knife, and fluid possibly ejected into the operator's face ; the cyst wall and adherent intestine may also be put into jeopardy. The incision of the peritoneum, and its complete division to the extent of the rest of the wound, is an easy matter if done deliberately, though adhesions may complicate this stage of the operation. I do not attach much importance to the material employed for suture ; silk threads answer very well, and I can speak highly of the silkworm gut advocated by Dr. Bantock ; in six of my own ovariotomies I have found it answer admirably. Care must be taken after gut sutures have been introduced that they are not jerked out of the assistant's hands whilst the operator is introducing or withdrawing the sponges employed for cleansing the peritoneum, an accident likely to happen, as they become slippery when wet. It is best during these manipulations that the ends of the threads should be collected on each side, and held together by compression forceps. As the cut ends of the gut after the wound has been closed are rather stiff, the operator must be careful that some of them do not turn directly upwards or downwards and sink into the wound. The withdrawal of silkworm-gut sutures is a matter of great facility ; the point below the knot where the scissors should be applied can readily be reached by the extreme point of those instruments with the least possible amount of pressure on the integument, and, when cut, the gut slips out smoothly and painlessly on gentle traction with a pair of dressing forceps. 128 TUMOURS OF THE OVARY, I have never seen a case of complete failure of union of the edges of the abdominal wound, although I have seen two abdo- minal sections where it burst open during vomiting, but neither were ovariotomies. Damage to subcutaneous fat or laceration of the fibres of the recti may cause abscess and greatly protract convalescence, but the skin and peritoneum unite with great rapidity, often in the worst cases that die two or three days after operation. This ready union of the wound is one of the great advantages which the advocates of complete intraperitoneal ligature of the pedicle can claim over the clamp method. In- deed, the chief danger in the former case is that the wound heals so rapidly that the patient may be tempted to walk about too soon ; but this ambition must be checked by the surgeon or the nurse, else a hernial dilatation of the cicatrix may occur. This exceedingly troublesome complication is also caused by the operator failing to pass the threads through every layer of the structures on each side of the wound, excepting through the fibres of the recti, and by pulling the sutures too tight when the wound is closed — a common error with beginners which inter- feres with the process of cicatrisation. Mr. Thornton, who has laid great stress on this point, operated in 1879 on a middle- aged patient, removing an ovarian cyst, ovariotomy having been performed by another surgeon fifteen years previously. There was no special difficulty about the second operation, but the integuments of the abdomen around the old cicatrix had be- come distended into a pouch by the gradual yielding of the cicatricial tissue, which was more marked in the peritoneal layer than in the integument. The affected integuments were therefore cut away, with great benefit to the patient, and I made a preparation of the parts removed, which is now preserved in the Museum of the Eoyal College of Surgeons (Pathological Series, No. 4562, New Catalogue). A patient with hernia of the cicatrix once informed this ovariotortiist that the complica- tion gaye her more trouble and pain than had ever been pro- duced by the tumour. A similar case occurred in the hospital practice of the same operator in 1880 ; the first ovariotomy had been performed ten months previously, and at the second, as a small hernial protrusion of the lower part of the old cica- trix existed, the entire line of scar was pared away. I have TUBE AND BROAD LIGAMENT. 129 seen a radical cure of an umbilical hernia attempted on this plan, in the course of an operation for the removal of a mixed sarcoma of the ovary, but the patient died of acute pelvic peri- tonitis. There is no particular risk in such a manoeuvre as far as the abdominal wound is concerned, but the condition of the contents of the hernia may render interference serious. Three preparations which I have made for the College of Surgeons Museum show that the abdominal wound unites well even in cases that die from the operation. One of these (4561, New Pathological Catalogue) shows the integuments around the abdominal wound from a middle-aged woman who died six days after the removal of an ovarian tumour. The edges of the wound are brought together by silkworm gut ; at most points the ap- posed edges of integument are united ; posteriorly the peri- toneal surfaces appear everted, so as to lie against each other ; this was, of course, effected by the usual method of application of the sutures ; they were found to be adherent, in the deeper part of the wound, by recent lymph, easily broken down. It must be remembered when it is necessary to open an abdominal wound, through slipping of the pedicle and other catastrophes, within a few days after operation, that the union of the divided peritoneum, though produced rapidly, is for some time not very firm, and offers no obstacles to the 'operator. Another and similar preparation (No. 54, New Catalogue) is from a case of a girl where death occurred, from tetanus, eight days after ova- riotomy. The contractions of the abdominal muscles had been very severe for thirty hours previous to death, as I can testify, having watched the case for a colleague. The wounded peri- toneum had united very closely throughout ; the integuments adhered uniforml}^, but slightly, and were readily parted by traction at the necropsy. The last preparation (No. 55) is from a patient aged forty- nine, who died twenty days after ovariotomy. Twelve days after operation, facial erysipelas occurred, followed by ostitis and periostitis of the right side of the lower jaw, which was partially necrosed. Abscesses were found in the lungs and kidneys (this point is noticed in reference to the same case in another chapter), and there was pus in the pericardium. A full report of the case, by Dr. Bantock, will be found in the Medical Times K 130 TUMOURS OF THE OVARY, and Gazette^ vol. ii. 1879. The patient was exceedingly corpu- lent, but in the preparation the union of the integument is very perfect, excepting at one point, where a drainage tube had been inserted. The peritoneal borders of the wound were so feebly united by lymph that they came apart on gentle traction at the necropsy. This case shows that the gravest complica- tions have no marked effect on the wound ; though the peri- toneal union had softened, it had not broken down before death. The value of compression forceps is well shown in the rapid healing of the abdominal wound after ovariotomy, as they avoid the necessity for at least four or five ligatures which would certainly interfere with union of the divided structures. I have never seen any bad result from the use of these forceps, but I have seen an abscess where a ligature had been applied. In speaking of the abdominal wound, I must here refer to two remarkable cases, both in the hospital practice of Mr. Thornton, which illustrate the bad effects of incision and drain- age, when undertaken as a substitute for ovariotomy. They form very instructive preparations in the Museum of the Eoyal College of Surgeons. The first was that of a woman aged thirty- five. A surgeon attempted radical cure of an ovarian tumour by making a deep incision into the cyst, which was allowed to discharge through the abdominal wound. For two years and a half, purulent fluid escaped through the wound, and produced hectic symptoms ; the patient also suffered from secondary syphilis, and became much reduced in health. Mr. Thornton removed the remains of the cyst, with tissues around the fistu- lous track, through which the pus escaped. The specimen is here figured (fig. 31). It will be seen that the cyst has been reduced to a small cavity, which, in the specimen, measures hardly two inches in its longest diameter. This cavity, not laid open, is lined with a layer of exuberant granulations, and communicates with the surface of the abdomen by a fistulous track about an inch in length. In the sketch, the puckered in- tegument around the external orifice of the track, cut away with the rest of the tumour at the operation, is represented, and at the opposite extremity of the preparation is a second cyst, spherical, and about half an inch in diameter. It was trans- TUBE AND BROAD LIGAMENT. 131 parent when fresh. Below the larger, and close to the smaller cyst, is the fimbriated extremity of the Fallopian tube, which Fig. 31. — Cy.st axd adjacent part.s after long Drainage. has acquired a communication with the cavity of the larger cyst, which gives the observer the impression that a dilated tube might have been punctured ; from the history, however, there appears to have been a large ovarian cyst at the time when incision was performed. A glass tube has been passed into the mouth of the tube, and close to the fimbriae a long, thin-walled, pedunculated body is represented ; this appears to have been a hypertrophied hydatid of Morgagni. I have re- ferred to this peculiarity in Chapter III. Recovery in this case was complete, but protracted. The specimen is numbered 4553 in the New Pathological Catalogue of the College Museum. A similar specimen is No. 4554 in the same series. The patient was also under the care of Mr. Thornton ; she was forty- nine years of age, and a few years previously another surgeon had endeavoured to cure a cystic ovarian tumour by puncture of the cyst, and insertion of a drainage tube through the abdo- minal wound. Much clear fluid escaped for months, but no suppuration occurred ; and when the tube was removed, the communication between the cyst and the surface of the body rapidly healed up, and the cyst refilled. It was, therefore, re- moved with the adherent portion of integument, and the patient recovered perfectly. The preparation consists of a multilocular ovarian tumour, one cyst greatly exceeding the others in size, measuring six inches in diameter. The entire tumour is adhe- 132 TUMOURS OF THE OVARY, rent to a portion of the abdominal wall which was removed with it at the operation, and shows a puckered cicatrix which has deep connections with a band of tissue that runs to the cyst wall behind. There is no trace of any granulations on the inner lining of the large cyst which had been kept open. These cases show that incision and drainage are bad substi- tutes for ovariotomy ; they also demonstrate that an abdominal wound will bear a great deal of prolonged surgical interference. This is also shown in cases where the drainage tube has to be used after complete ovariotomy, and in the results of hysterec- tomy, when the uterine stump lies for weeks protruding from . the lower angle of the wound. In fact, in itself the abdominal wound is a trifling part of the operation of ovariotomy, and the bad results following long incisions are due to the tumour or to other conditions which made a long wound necessary, and not to the wound itself. Any work on ovarian tumours would be incomplete without some notice of the subject of adhesions. The presence of adhe- sions constitutes one of the most important complications which the operator has to encounter. Hence all the standard works on ovariotomy dwell on this subject at great length. I will confine my remarks chiefly to the question of diagnosis, and to cases where the vermiform appendix adheres to the tumom\ One of the chief difficulties in the diagnosis of adhesions is the uncertainty of the results of peritonitis, so that after severe and repeated attacks of that comphcation, disabling the patient for weeks at a time, no adhesions may form, whilst the most intimate connections between the cyst wall and the parietal and visceral layers of the peritoneum are sometimes found in cases where patients have sufi"ered from very little pain, and have seldom been confined to their beds from the date of the first appearance of the tumour. Age, long-standing ill-health, and repeated tapping, do not by any means imply a greater probability of the existence of adhesions, but are, on the other hand, frequently associated with recurrent peritonitis, and no subsequent organisation of inflammatory effusions, excepting such changes as bring about a simple thickening of portions of the serous membrane. Some constitutional diseases actually tend to prevent the occurrence of adhesive peritonitis, so that TUBE AND BROAD LIGAMENT. 133 the patient is saved from one troublesome complication though exposed to greater risks of another kind. In another chapter I referred to two cases in my own practice where symptoms of peritonitis, checked by medical treatment, were very marked before operation, but no adhesions could be found when the tumour was removed. One of the patients was a woman aged forty-eight ; she had been twice tapped, and three weeks before ovariotomy she had been seized with a rigor, and a rise of tem- perature to 101*4°, after a uterine sound had been introduced. Her general health had been bad for several years, and she had seldom passed one pint of urine in twenty-four hours for six months before operation. Three weeks later I assisted Dr. Bantock at an operation on a patient who was nearly twenty years older, but in very good health ; the cyst had been tapped several times, but symptoms of peritonitis had not been marked. The cyst was found to be universally adherent to the parietal peritoneum, the lower part of the great omentum was inti- mately connected with the tumour, and the anterior surface of that serous fold adhered to the parietal peritoneum. The operation was very tedious, and drainage was found to be neces- sary. In June 1881 I assisted the same surgeon in an ovario- tomy on a patient aged forty-five, who had enjoyed very good health for the two or three years since the discovery of the abdominal tumour. Occasionally she had felt pains in the hypogastrium, attributed to flatulence, but she had never been confined to her bed. At the operation the cyst wall was found to be perfectly free from parietal adhesions anteriorly, but laterally it was strongly adherent, and its separation was a matter of considerable difficulty. It is not necessary for me to enter into further details on the subject; suffice it to say that I have noted over forty-five cases out of five hundred ovariotomies where multiple adhesions existed without any previous history of peritonitis or of other symptoms which would lead the surgeon to suspect their existence. On the other hand, I have found that cases where adhesions have been suspected, but have not been discovered at operation, are yet more frequent. I must once more refer to the crepitus detected on palpation when the omentum is inflamed, or when the inflamed parietal peritoneum rubs 134 TUMOURS OF THE OVARY, against the cyst wall. This signifies that adhesions cannot exist over the area of crepitation, since ' so long as the friction can be felt or heard, movement must be free ; ' such are the words of Sir Spencer Wells, and they must ever be borne in mind. In over six cases that I have seen, the vermiform appendix adhered to the cyst. This is a troublesome kind of adhesion. The branch of the ileo-colic division of the superior mesenteric artery that runs along the appendix bleeds very freely when divided, after retracting to a considerable extent, and if the- appendix itself be cut it must be Hgatured, but some mucous membrane will be left on the distal side, and very possibly, as the ligature is being tightened, a cylindrical cast of the ap- pendix, composed of fgecal matter, will be squeezed out, and will drop into the peritoneal cavity if the operator and assist- ant be not careful. It is therefore advisable to wash the distal end thoroughly with tincture of iodine before returning it into the abdomen. Adhesion of the vermiform appendix appears almost in- variably associated with extensive adhesions between the tumour and other abdominal structures. In a patient aged forty- seven, upon whom Mr. Thornton operated in the spring of 1880, a large cyst of the left ovary was exposed when the abdominal incision was made, abundant parietal and visceral adhesions were found, and the right Fallopian tube and vermiform a]3pendix adhered firmly to the cyst. About half an inch of the appendix was cut away. It may here be observed that it is not very easy to secure the artery separately, after tearing the adherent appendix away from the cyst wall, as is often attempted, with a view of leaving the appendix intact. In this case the separation of adhesions prolonged the operation, which lasted a hundred minutes ; the patient recovered. A few days later a similar operation was performed on a woman aged thirty-five at the same hospital, and adhesions were so universal and the structures adjacent to the tumour were so altered by pathological changes that the true nature of the patient's disease could not be determined till after death, when I found at the necropsy that the tumom* was a fused double ovarian cyst. I have mentioned this case in the chapter on multi- TUBE AND BROAD LIGAMENT. 135 locular cysts. At the operation the vermiform appendix was found to be stretched, and over six inches in length ; three inches of that tube adhered strongly to the wall of the cyst, and some of the adherent portion was absolutely inseparable, so it was cut away, and the remainder of the appendix sepa- rated from the tumour and ligatured, when a plug of solid fgeces, the calibre of a No. ^ English catheter, was squeezed out. "Within a very few days of this operation Mr. Thornton removed a large cystic mixed sarcoma from a woman aged fifty- seven. The pedicle was broad, short, and apparently infiltrated with sarcomatous matter ; it adhered by a band of tissue to the vermiform appendix. There were » no other adhesions in this case, but the surfaces of the tumour and the intestines were covered with shreds of inflammatory lymph. The patient recovered from the operation. Thus three cases of adherent vermiform appendix occurred in the same hospital very close together, the first being on March 17, the last on March 24, 1880. The next case occurred exactly eleven months later. The patient was a woman aged fifty-two. Dr. Bantock had removed the left ovary for cystic disease three years previously, and on this occasion the right ovary, which' had also become cystic, was taken away. The great omentum adhered intimately to the cyst, and the vermiform appendix, very difficult to distin- guish at first, had formed close connections with the tumour. It was torn off the cyst wall and replaced in the abdominal cavity. The patient made a good recovery. In 1884, I saw three cases of adherent appendix, all within the month of March, and all in the 'wards of the Samaritan Hospital. One was a case of uterine myoma ; the second was ovarian. The patient was a young woman with a small multi- locular cyst, the pedicle of which was twisted and atrophied. There were abundant parietal adhesions, and the appendix was firmly bound down to the surface of the cyst. Eight days later, Mr. Thornton operated on a case of ovarian cystic tumour, where the adhesion to the appendix was strong and hard to separate. I once found, when making a necropsy, a detached cyst 136 TUMOURS OF THE OVARY, adherent to the vermiform appendix. A woman aged fifty-five had died in the hospital before any operation could be per- formed. On opening the abdominal cavity I found a large papillomatous cyst of the right ovary universally adherent to the abdominal walls in front. There was also a small multi- locular cyst of the left ovary, with glandular intracystic con- tents and strong adhesions to the surrounding structures. A small cyst, four inches long and one and a half broad, lay in the right iliac fossa. It had no connection with the tumour of the right ovary, and adhered firmly to the vermiform appendix. It contained several cavities which held fluid that was clear, like that in the right ovarian cyst, and smelt distinctly fascal, though I ascertained that no communication existed between it and the canal of the appendix. There could be no doubt that this cyst had sprung from the ovarian tumour on the right side and become detached ; several other cysts with clear con- tents lay in the pelvis. In this same case I found a cyst with a cavity large enough to hold a filbert, in the substance of the left suprarenal body. It contained clear fluid, and is preserved in the Museum of the Eoyal College of Surgeons. Visceral and parietal adhesions have long since been con- sidered at great length by authorities in ovarian surgery. Of the use of adhesions in cases of twisted pedicle, as sources of vascular supply to the cyst, I have already spoken in a former chapter. The shock during and immediately after the separa- tion of extensive adhesions is often very marked, especially if the patient be not thoroughly under the influence of the anaesthetic. TUBE AND BROAD LIGAMENT. 137 CHAPTEK X. COMPLETE IXTRA-PERITOXEAL LIGATURE OF THE PEDICLE. There can be no doubt that at the present day the most usual method of securing the pedicle of a«Ji ovarian tmnour is by com- plete intra-peritoneal ligature. I originally introduced this expression as the title of an article on the subject, pubhshed in the ' St. Bartholomew's Hospital Eeports' for 1877, to avoid the repetition of longer and clumsier modes of indicating the same idea, such as ' ligature of the pedicle followed by cutting the ends of the ligature short, and replacing the stump of the pedi- cle within the peritoneal cavity.' It must be remembered that the adjective ' complete ' refers to the fact that at the comple- tion of the process both the ligature and the stump of the pedicle are entirely within the abdomen. When the clamp is employed, the pedicle is kept out of the peritoneum ; when the cautery is ax^plied, it may be replaced within the cavity of that membrane. Formerly, when the ligature was applied to the pedicle, its extremities were uncut and left dependent from the external wound. Hence the expression, which I endeavoured to introduce in 1877, implied a method essentially different from those just enumerated. In these days, however, the ends of the ligature are always cut short, and the clamp is but seldom used ', hence it is sufficient to speak of ' ligature ' as implying complete intra-peritoneal ligature of the pedicle. It is not at all remarkable that this method was looked upon with great distrust and disfavour, even by many specialists, until a few years since. Judging from pathological and clinical observation, the surgeon has never been off his guard against the mischief likely to arise from foreign bodies remain- ing in the tissues. From time immemorial he has avoided the 138 TUMOURS OF THE OVARY, permanent introduction of such substances into the body, excepting for the distinct object of producing counter-irritation. When necessity has compelled him to pass threads or pins into the tissues for such pm-poses as the arrest of hsemorrhage, he has ever been eager to remove them at the earliest opportunity consistent with safety. The immunity from inflammation, observed when — through accident — certain foreign bodies re- main long in the tissues, though an assm'ed fact, rests never- theless on the evidence of comparatively few cases. Hence the siu'geon has been slow to trust to immunity from bad results aft^r deliberately leaving foreign bodies within the human frame. It is remarkable that the deviation from pre- cedent has at last been estabhshed, not for any minor opera- tion, but for one so beset with dangers, that it is of the highest importance to consider how every individual element of risk may be neutralised or ehminated. Avoiding the polemical aspects of this, as of every other question connected with ovariotomy, I hkewise do not deem it necessary to dwell on the oft-told history of the introduction of complete intra-peritoneal ligatui'e. Long details will be found in the standard works of Wells and Tait, and in my own contri- bution to the annual ' Eeports ' of St. Bartholomew's Hospital. The maimer in which this method was gradually introduced, the supposed and real effects of ligature on the stump of the pedicle, and the true share it has borne in fatal results where it has been employed, are more instructive matters for con- sideration. The introduction of complete intra- peritoneal ligature was not precisely empirical, but rather due to the fact that the surgeon probably considered that it entailed less risk than the practice of leaving the ends of the ligatui'es dependent from the abdominal wound. Dr. Xathan Smith, of Connecticut, was the second ovariotomist ; the first to practise complete intra- peritoneal ligature. The immortal McDowell, of Kentucky, did not cut the ends of the ligatme which he employed in the first ovariotomy. Dr. Xathan Smith in 1821 ligatured two arteries in the pedicle of an ovarian cyst, and secured two vessels in the omentum. The material for ligature was leather cut in strips from a kid-glove. The ends of all the ligatures TUBE AND BROAD LIGAMENT. 139 were cut short, and the external wound closed, the stump of the pedicle having been returned into the abdominal cavity. The patient recovered. The method was continued with varying success, and fluctuations in favour among specialists, till the successes of Sir Spencer Wells, who preferred the clamp, caused it to be discountenanced for many years. When that ovario- tomist began his career as an operator, the clamp appeared to be the simplest and most trustworthy appliance for securing the pedicle ; nor was complete intra-peritoneal ligature tho- roughly understood. Subsequent experience has proved its true value, and it is now almost universally employed even by Sir Spencer Wells himself. One great hindrance to its rapid introduction was a mis- apprehension of the nature of its effects on the stump of the pedicle. There was for long a fixed idea that the stump must slough, or would at the least be very prone to become gan- grenous, and that the ligatures would become encapsuled, yet very liable to cause pelvic abscesses. Experience has shown that the stump does not slough, and that the ligatures do not as a rule cause abscesses; indeed, they actually become absorbed. WTien a finger is tightly constricted by a thin cord or stout piece of twine, the distal part is cut away from all its vascular supply, and lies literally out in the cold, far from the heat- producing organs of the body. The changes in the proximal part of the finger, caused by the constricting cord, are of no avail in saving the distal part ; on the contrary, they aid in its amputation. Surgeons formerly overlooked the fact that the ligatured pedicle is in a different condition. Its need for vascular supply is small from the first moment that the tumour has been cut away. It is literally nursed by the warm perito- neum that surrounds it, and it lies in the human body, a mar- vellous heat-producing apparatus that keeps it in a regular temperature of about 100° Fahrenheit, which is more than any wool, poultice, or ingenious, but complicated, artificial instru- ment could do. True, when fever follows, the pedicle may be made hotter than may be good for it, but the bad effects of fever on a wound or injured part alone are slight. There is yet a more important factor in the agencies that save the pedicle. The bulging of the tissues over each side of the groove, formed by 140 TUMOURS OF THE OVARY, the ligature, brings the strangulated portion of the stump at once into close contact with the unstrangulated proximal part. Through the slight irritation, produced at first by the pressure of the ligatm-e, the proximal part throws out plastic lymph, which conveys nutritive plasma, and, ultimately, capillaries to the distal portion of the stump, which is thus saved from gan- grene. The credit of the practical demonstration of this very important fact must be given to Dr. Bantock, who in 1872 ex- hibited at the Obstetrical Society of London the stump of an ovarian pedicle from a patient who had died of cancer a year after double ovariotomy had been performed upon her. In the Museum of the Eoyal College of Surgeons are a series of specimens, which I have prepared, where the condition of the ligatured pedicle from a few days to six months after operation is shown, and the conditions above described are plainly dis- played. The bulging and approximation of the tissues of the pedicle on each side of the ligature are generally well marked, and the ligature itself is usually buried in lymph, which con- nects the distal and proximal parts of the pedicle. One of these specimens is from a patient aged thirty-seven, who died in the Samaritan Hospital in 1877 from, septicaemia on the sixth day after the removal of a large ovarian cyst. There was no evidence that death was in any way due to this method of treatment. At the present date, when sponging out of the peritoneum and drainage is carried out with far greater efficiency and boldness, owing to increased experience, than in 1877, such a case would, in all jirobability, recover. The stump of the pedicle, now preserved in the College Museum, is an inch broad, and its inner border is a quarter of an inch from the fundus of the uterus. When recent, I found that it was not in a sloughy condition, nor was it congested. It was separated from the uterine appendages by four silk ligatures, none of which had cut into the tissues, but all were covered with bands of lymph, bridging over the constriction which they had produced. The outer extremity of the distal side of the pedicle was already very firmly united to the broad ligament by well-organised lymph ; it had touched the ligament and then acquired adhesions ; this change, however, I have never found in any other specimen that I have examined. In a case that TUBE AND BROAD LIGAMENT. 141 died of tetanus on the eighth day, the adhesion of the bulging tissues over the pedicle was well marked (fig. 32). The Fig. 32.— Stump op an Ovarlvn Pedicle ; death from tetanus on the eighth day after operation. The silk ligatures are completely concealed ; a glass rod is passed between them and the bands of Ijinph passing from the proximal to the distal portion of the stump. severest septic changes in the peritoneal cavity after the separation of multiple adhesions, or inflammation of a portion of sarcomatous tissue or cyst wall left behind, often fail to affect the changes which take place in the pedicle. On April 5, 1876, Dr. Bantock removed a large multilocular tumour from the left ovary of a girl eighteen years of age. The patient made a good recovery^ but in the following October the right ovary became the seat of a sarcoma. An ex- ploratory operation was performed, and, on account of the cha- racter of the tumour, it was not deemed advisable to remove it. The patient died on November 3, 1876. The pedicle had shrunk to a small fleshy knob ; its free upper edge had fallen over and curled inwards, forming an adhesion to its anterior surface. A vascular band ran externally from the atrophied pedicle to the broad ligament, and a still more important adhesion connected the pedicle with a portion of the omentum which had become adherent to the fundus of the uterus. These somewhat unusual adhesions had saved the pedicle from further atrophy. Since 1877 I have seen several such stumps of pedicles in the course of a second operation for the removal of a tumour in the oppo- site ovary. The stumps were as a rule hardly larger than a boiled pea, and entirely free from adhesions. In the specimen just described and preserved in the College Museum, and figured in the paper already quoted, a deep 142 TUMOURS OF THE OVARY, groove marked the position of the hempen ligature, not a trace of which remained. In other cases where silk had been em- ployed, the ligature had also entirely disappeared ; of course I am now referring to pedicles as they appear many months after ovariotomy. The fate of the ligature silk is an interesting question. A pedicle, immediately after ligature, is often a good stout bunch of tissue. The calibre of the loop of silk that encircles it must be considerable. Six months later, a groove round a little fleshy button is all that can be seen of the pedicle and the seat of ligature. It is clear that the silk cannot pull itself tighter, and it becomes bmied in lymph so soon, in favourable cases, and that lymph organises into firm tissue so much more rapidly than the collateral process of shrinking in the distal part of the stump, that the silk can hardly slip off the pedicle, even if transfixion had not been practised at the opera- tion. May it not work its way through the lymph and the atrophied stump, as in the case of a ligatured artery ? I do not deny that this may sometimes occur ; and to search the peritoneum for a small loop of silk, probably buried in organised lymph, would be no easy task. But cannot the silk be absorbed ? Many that still doubt that this can occiu-, once- asserted that a ligatured pedicle would be almost certain to slough. A distinguished London hospital surgeon once observed to me, referring to the advocates of the ligature, and to my own observations in the ' St. Bartholomew's Hospital Eeports : ' ' I have no patience with people who say that silk ligatures can be absorbed by granulations.' It would be interesting if some experiments were made on the chemical action of serum, pus, and other organic fluids upon silk fibre. Then it might be ascertained whether absolute solution of the fibre or simple disintegration by maceration takes place, or whether the fibre resists all destructive processes after prolonged exposure to the action of serum at a tempera- ture of 100°. But the experiments of Spiegelberg and Wal- deyer and Maslowsky, so often quoted by Sir Spencer Wells and other authorities, prove that after intra-peritoneal ligature of the stumps of excised portions of the horns of the uterus in bitches, a communication between the distal and proximal parts of the stump is established by inflammatory plastic efl"u- TUBE AND BROAD LIGAMENT. 143 sion, and the ligatiu-e is unravelled by granulation cells insi- nuating themselves between its fibres. There can be no doubt, in my opinion, about the unravelling, but I have never proved that the silk fibres are actually absorbed. Perhaps disintegra- tion is more probably the cause of the disappearance of the ligature. In concluding this part of the argument, it may be remarked, as a brief summary of what has just been under con- sideration, that the ligatured pedicle does not slough, and that the ligature does not set up any prejudicial local mischief. The question of drawing the silk as tight as possible, and of the significance of the coagulum, which, forms more or less on the free surface of the stump, will be considered farther on. I may here observe that carbolised catgut answers some of the purposes required for ligature of the pedicle, but it is hardly to be relied upon for wide, tough, thick, and short pedicles. I must, however, admit that I have had no experience of its use. The most important question concerning complete intra- peritoneal ligature is the share it has played in leading to fatal results. This subject I treated at length in a second com- munication to the ' St. Bartholomew's Hospital Eeports,' 1878. The mortality is considerably less at the present date — 1884 — than it was six years ago. Before entering into any arguments or general details, I will enumerate the only cases where I found unfavourable changes in the ligatured pedicle itself after death. Cases of Uxfavoueable Chaxges ix the Ligatured Pedicle. 1. A. F., 61. — Removal of the left ovary for cystic disease ; death on the fourth day. Pedicle of the left ovary very tightly Hgatured by transfixion ; congested and sloughy in parts, but adherent to the broad hgament by recent lymph deposited elong its outer and pos- terior border. Ulceration at several points from pressure of the liga- ture. An adhesion between the tumour and the sigmoid flexure had been separated during the operation ; this adhesion was old and weU- organised and left on the bowel a raw surface the size of a halfpenny, where the muscular coat was exposed. At this spot the cahbre of the intestine was diminished to a diameter of under a quarter of an inch. The walls of the bowel at the seat of obstruction were inflamed and thickened. There was no other morbid appearance in the body. 144 TUMOURS OF THE OVARY, 2. Mrs. J., 41. — Large dermoid cyst of the left ovary. The pedi- cle was secured by complete intraperitoneal ligature, and its outer extremity was drawn up against the abdominal wall through trans- fixion by one of the threads of silkworm gut which closed the external wound ; death on the fifth day. Pedicle secured by eight stout silk ligatures, inflammatory efiusion thrown out between its anterior sur- face and the broad ligament. Free border not sloughy; a small fri- able clot adherent to it. One of the ligatures traversed an abscess cavity in the broad Kgament, and a soft, dark red clot, commencing in the substance of the pedicle, extended into the abscess. The right Fallopian tube was dilated, and contained a drachm or more of foetid reddish fluid. A coil of small intestine was adherent to the stump posteriorly. The abdominal cavity exhibited no traces of peritonitis. The kidneys were diseased : they are described in Chapter XI. No. 15. 3. J. F., 27. — Removal of both ovaries for cystic disease ; numer- ous adhesions to abdominal wall, omentum, intestines, and uterus. Death on the sixth day after distinct pysemic symptoms. There was universal peritonitis, consolidation of the base of the left lung, and disease of the right kidney, described in Chapter XI. No. 25. The pedicle of the right tumour, which alone had contracted adhesions to neighbouring parts, inckided a portion of the cyst wall, which was adherent to the back part of its own pedicle. This remnant of the cyst was partly sloughy and partly suppurating. The left pedicle was capped by dark, soft clot, but had contracted no adhesions, although lymph was thrown over the ligatures. 4. Mrs. S., 39. — Removal of a cystic tumour of the right ovary ; internal hsemorrhage and death within twenty-four hours. The left Fallopian tube, which was dilated, had been opened and some of its vessels secured ; there had been numerous parietal adhesions. The pelvis and lower part of the abdominal cavity were stuffed with about two pints of dark coagula, mostly issuing from the vessels of the left tube, but partly from vessels on the left side of the abdominal parietes. The pedicle on the distal side of the ligature was very small, its free edge being hardly half an inch wide ; it was capped by a dark clot. A large varix, looking like a small sausage, lay over the right common iliac artery. It extended from the level of the lower end of the right kidney to the ligature that secured the pedicle. It was formed by dilatation of the right ovarian vein, and contained solid, dark clot. 5. Mrs. W., 49. — Removal of a cystic tumour of the right ovary. Pygemic symptoms, and death twenty days after operation, from peri- TUBE AND BROAD LIGAMENT. 145 ostitis of the lower jaw. PjEemic changes in several of the viscera. The left ovary, already slightly cystic, had suppurated. The stump of the pedicle of the right ovary was sloughy and covered with a brickdust-coloured exudation. It was firmly secured by ligature ; the contiguous parts adhered over the threads by the medium of sticky lymph easily broken down. 6. S. A., 45. — Removal ofa multilocular cystic tumour of the right ovary, containing papillomatous growths. Peritoneum infected with the papillomatous growths. Death on the fifth day. On the free surface of the pedicle was a mass of papilloma, breaking down and mixed with coagula. The ligatures were buried by the adhesion of the dis- tal and proximal part of the pedicle, and the veios in the proximal portion were plugged, the broad ligament was infiltrated with sarco- matous deposit and adherent to the rectum, which was thereby par- tially obstructed. The right femoral and external iliac vein were completely plugged with clot partly decolourised. 7. A. M., 26. — Ptcmoval of sarcomatous left ovary. High tem- perature and cerebral symptoms, death on fourteenth day. Evidence of slight meningitis ; peritoneum healthy except towards pelvic region. A loop of ileum adhered, by recent lymph, to the parietal peritoneum close to the left iliac fossa ; the same loop adhered inferiorly to another coil. On raising the two loops, an ounce of thick creamy pus welled up. This fluid lay in a cavity formed above and anteriorly by the coils of ileum, postei-iorly by the rectum, and below by the fundus of the uterus and the pedicle. All these structures were adherent continuously, and the cavity, tightly closed, was Kned with a partly sloughy pyogenic membrane. The pedicle, which included the left angle of the fundus of the uterus, projected freely, from below, into the abscess cavity ; it was partially secured by a single stout silk, which was rather loose, but there was no cap of coagulum, and this part seemed sloughy on the distal side. The outer part of the pedicle was secured by another silk ligature ; between the ligatured parts, and internal to the inner and sloughy piece, the pedicle was free and open, no clot covered the two open surfaces, but on peeling ofi" the pyogenic mem- brane which covered them, sarcomatous tissue was exposed. The tumour had been sessile, and had not been transfixed ; the open sur- faces had been caused by a yielding of the structures beneath, evidently some days after the operation, otherwise much hfemorrhage would have ensued. 8. Mrs. S., 40. — Removal of multilocular cystic tumours of both ovaries; death in fifty-seven hours. Purulent peritonitis, lar^e L 146 TUMOURS OF THE OVARY, collections of pus between the liver and diaphragm, Douglas's pouch filled with purulent fluid. Pedicles of both ovaries well secured ; puri- form fluid oozed from the distal end of the left pedicle. 9. Miss D., 40. — Colloid disease of the ovary ; death four days after operation. There was universal pelvic peritonitis, and the pelvic viscera were swimming in pus. The pedicle was infiltrated with colloid, its free border was suppurating but not sloughy. In all the remaining necropsies that I have made on cases of death after ovariotomy and ligature of the pedicle, the ap- pearances of the stump of the pedicle were the same as in the specimens which I have already described as representing the normal changes after ligature ; and no pus, no sloughy tissue, nor any sign of haemorrhage, beyond the amount necessary to form a cap to the free surface of the stump, could be found. An analysis of the nine cases where I discovered a clearly un- favourable condition of the pedicle may prove of some interest. I have described the appearances in full, and will now add my own interpretation of them. In the first, sixth, seventh, and ninth cases, there is strong evidence that the changes in the pedicle represented the primary cause of death. This is very questionable with regard to the fifth, eighth, and especially the second. The third was a remarkable case, bearing rather on incomplete ovariotomy than on the treatment of the pedicle. In the fourth, death was due, on direct proof, to hsemorrhage ; but the plugging of the ovarian vein was a remarkable and unfavourable change, partly involving the pedicle, and therefore necessary to record as an abnormal condition of that structure after ligature. The sixth, seventh, and ninth are the most important, for they illustrate the great danger of leaving portions of new growth or colloid material behind in the stump. In the ninth, the evidence that the pedicle was the primary seat of mischief was strongest, and the advocates of the clamp might reasonably observe that it would have been better had the pedicle been secured outside the peritoneal cavity. This could not have been done in the seventh case, which was exceptional ; the tumour was sessile, and the uterine tissue had been encroached upon ; application of ligatures proved very difficult, and the TUBE AND BROAL LIGAME^'T. 147 unfavourable changes were rather due to the impossibihty of applying the ligature in the usual manner, than to any fault in that method in general. In the sixth case, the pedicle was in a highly unfavourable condition, but the state of the peritoneum must also be considered ; nor is the cause of the plugging of the veins quite e\-ident. It must here be observed that experience proves that the presence of colloid or sarco- matous material in the pedicle is by no means an indication of certain death, after removal of the tumour and complete intra- peritoneal ligature. I have seen the best results in very bad cases. In the first case probably both the changes in the pedicle and the intestinal lesion took a share in the fatal result. It is always possible that the operator may pull the hgature so tightly as to cause sloughing, before the salutary changes already described can save the stump of the pedicle. There was no covering of organised coagulum, so often observed on the cut surface of the stump. On the other hand, the pedicle, not cut so long as to be entirely free at its margin from vascular influence, had become adherent posteriorly to the broad liga- ments This favourable pathological change suggests that the congestion and actual slough of parts of the stump had been secondary. Now the condition of the sigmoid flexm'e of the colon represented morbid influences quite sufficient to destroy a patient sixty-one years of age, and exhausted by sufi'ering, followed by a severe operation. These influences possibly in- duced the sloughing of isolated spots on the pedicle after the, establishment of the favourable adhesive changes. The fifth was a remarkable and obscure case, the cause of the death of which gave rise to a controversy published in the Medical Times and Gazette, vol. ii. 1879, p. 607. The slough- ing of the distal end of the stump of the pedicle was possibly secondary to the pyaemia, whatever may have been the cause of that deadly complication. In the eighth case, also, the su^Dpu- ration of the pedicle was very probably secondary to the puru- lent peritonitis. The second demands much consideration. The thrombus, which was found extending for a considerable distance on both sides of the ligature, had become disorganised, and undergone suppurative changes. The pus mio-ht have X. 2 148 TUMOURS OF THE OVARY, arisen from the sole disorganisation of the clot, excluded by the coats of its veins from the tissues around, or that fluid might have been produced externally, and entered the vein at the free border of the stump of the pedicle : the latter interpretation is more in accordance with modern ideas. The thrombus might have induced phlebitis and suppurative inflammation outside the vein, or the compression of the vein by inflamed or oede- matous tissue around it may have caused thrombosis, after the manner so distinctly noted by Billroth. The coagulum itself, whether primary or secondary, was actually breaking up in the abscess cavity. The diseased state of the kidneys favoured retrograde changes in the thrombus. But putting aside the still unsettled questions respecting thrombosis and pus in veins, it must be remembered, when considering the abscess in this pedicle, that in the same case the right Fallopian tube was dilated, and contained a drachm or more of fcetid reddish fluid ; hence the state of the tube might have been the cause, and not the effect, of the other morbid changes. In ovariotomy, it is always dangerous to leave a dilated tube behind ; the strong tendency to suppuration in an oviduct thus affected is signifi- cantly demonstrated by the surgical experiences of Mr. Lawson Tait. The third case is complex ; the pedicle of the left tumour was in a satisfactory condition ; that of the right included a piece of the cyst wall that could not be removed ; the fragment had suppurated, and partly sloughed. Hence this case shows the risk of leaving portions of cyst wall behind, rather than the dangers of ligature. A\Tien the timaour cannot be completely removed, the operator should aim at securing every bleeding point in the cut edge of the piece of cyst left behind. This is safer than putting all trust in tightly constricting ligatures ap- plied to the broad ligament below the cyst. The vitality of a piece of tumour is less than that of the ordinary tissues of a normal pedicle. The fourth case is a curiosity, as far as the present subject is concerned, but a few words must be said on the plugging and ' haematoceles ' of the veins of the broad ligament. After the ligature is secured, the operator has to devote some time to the cleansing of the peritoneum ; and when he has performed that TUBE AND BROAD LIGAMENT. 1-19 daty, he frequently finds, on taking a last look at the pedicle, that there is a large globular distension immediately below the ligature. The nature of this swelling is evident ; it is a varix, often wrongly termed a haematocele, but its importance, judging from experience, is trifling. I must have observed it over a hundred times, but have never been able to trace bad results from this complication, and the plugging and obliteration of an entire ovarian vein can be of little import when a large tumour whence it received its blood has been cut away. In this case, the emptiness of all other veins in the patient's body made the condition of the ovarian vein all the more prominent. Although I have not seen any bad results that could be directly referred to the varix, which sometimes forms imme- diately on the tightening of the ligature, a reference once more to the second case suggests a possible source of severe risk ; and, without wandering into theories concerning phlebitis, the con- ditions which caused an abscess to form in the pedicle in this case would probably prove more rapidly fatal to life in instances where a varix exists. In this case, however, a vein in the pedicle had been wounded— in fact, the ligature crossed the abscess cavity — whilst a varix arises from the tight constriction, and not from the transfixion of large veins. When assisting Dr. Bantock in removing a large multilocular cyst of over twelve years' duration from a woman aged twenty-nine, I observed that the pedicle was very thick and broad, and its veins were ex- tremely dilated. On applying and tightening the ligature, which transfixed the pedicle in the usual manner, a large varix formed. The operator, objecting to leave matters in this con- dition, secured the open mouths of the vessels on the cut sur- face of the pedicle, loosened the ligature, and turned out a mass of clot from the varix. The pedicle was then transfixed at two points below the level of the first ligature, and secured in that manner by a chain of three ligatures. The case did very well, and more than a year later I observed a similar condition of things, when assisting the same surgeon, in a case where amenor- rhcea, changes in the nipples, and discolouration of the vulva, with the presence of a soft globular mass in the hypogastrium in front of the fluctuating cyst, raised a natural suspicion of pregnancy. This mass proved, at tlie operation, to be simply an 150 TV MOVES OF THE OVARY, outgrowth from the main cyst. The pedicle was broad and short, and the ovarian vein much dilated. They were both secured, the vein being tied separately. A very large varix quickly formed. Dr. Bantock on this occasion did not loosen the ligature that transfixed the pedicle, but simply cut that which had secured the vein. A great mass of coagulum was then turned out of the vein, which was tied once more. The patient recovered. Hence, if the operator dread the idea of leaving a varix behind, there is no difficulty in calmly and deliberately emptying its contents. Such a course is especially advisable when it is evident that a vein has been transfixed in the application of the ligatui'e. In the gTeat majority of cases the transfixed and ligatured pedicle undergoes the favourable changes described at the com- mencement of this chapter ; and, as it is so rare to find un- favourable conditions of that structure after death, matters are still more satisfactory, as regai'ds the pedicle alone, when the patient recovers, and there are none of the disadvantages atten- dant on the separation of the distal end of the stump when the clamp is employed. Much has been written about the cap of clot which covers the raw siu-face of the pedicle in most cases, but I cannot see any reason to attach much importance to it. As might be exjDected, I have generally found a soft dark coagulum on the raw surface of the pedicle in cases where the patient has died within twenty-four hom'S of operation, from causes with which the pedicle has had nothing to do, and in similar instances where the patient has not succumbed till long after ovariotomy I have found a clot undergoing organisation. On the other hand, on examining the body of a woman aged fifty, who was very weak, and died of acute bronchitis seven days after ovariotomy, much prolonged by the presence of numerous adhesions which had to be separated, I found that the free border of the stump of the pedicle was not capped with any clot, but its edges had united through inflammatory changes on the raw surface between them. Much lymph covered the liga- tm'es, so as to establish a communication between the distal and proximal part of the pedicle, in the manner ah-eady noted. The absence of a clot is, however, rare. The significance of the clot on the pedicle has been the TUBE AND BROAD LIGAMENT. 151 subject of some of the numerous disputes between operators that have been so conspicuous in recent medical literature. A very large proportion of patients recover perfectly after liga,ture of the pedicle, and it is reasonable to suppose that in them, as in the fatal cases, that structure may sometimes be capped with a large clot, sometimes with a small clot, and, in rarer instances, with none at all. It is only in the second of the series described above that there was any suspicion of primary decomposition of the clot, though, should septic changes arise elsewhere within the peritoneal cavity, the clot may readily become infected. Mr. Thornton is a strong advocate of the practice of a moderate and not extreme tightening of the ligature. In his experience, the stump, when tied too tightly, frequently becomes painful a few months after operation. He considers that the presence of a cap of clot is a good sign, as it proves that the ligature has been drawn tightly enough to prevent serious haemorrhage, yet not so tightly as to cut off all supply from the distal portion of the stump. I have expressed precisely the same opinion else- where, and in Hegar's practice a tightly ligatured false pedicle of a sessile cyst actually sloughed, and was discharged from the rectum, the patient recovering. In the last edition of Sir Spencer Wells's work, I find the following passage : ' I differ entirely both from Mr. Doran and Mr. Thornton, and, fearing that a loose ligatm-e will become looser as the included tissue shrinks, that bleeding would be probable, and that unless a ligature sinks deeply into, or forms a deep groove in the pedicle, the surfaces of peritoneum on either side of it are less likely to unite, cover up the silk, and maintain the vitality of the stump, I always tie the ligatures as tightly as I can.' The practice of securing the vessels in the outer border of the pedicle separately — a practice attended by the very best results — obviates the necessity of drawing the ligatures of the pedicle to an extreme degree of tightness, and thereby lessens the risk of sloughing. A very sHght degree of tenseness is sufficient to cause the tissues to bulge over the groove formed by the ligatm-e, and thus to insure salutary changes already described. 152 TUMOVES OF THE OVAEY, CHAPTEE XI. MORBID COXDIIIOXS OF THE KIDNEY ASSOCIATED WITH OTARIAX TUMOURS. I>' speaking of the treatment of a patient before ovariotomy is performed, Sir Spencer Wells observes, in his standard work : ' One condition which certainly requires coiTection before the operation is undertaken is that common one where only a small quantity of highly concentrated urine, depositing mixed urates in abundance, is passed. If ovariotomy be performed on a patient in this condition, a serious amount of kidney conges- tion, with symptoms almost amounting to m'semic fever, is almost certain to follow the operation. Before undertaking it, therefore, it may be necessary to gain time by tapping.' The author then recommends that the patient should take alkaline carbonates largely diluted, especially lithia water or other pre- parations of the salts of lithium. The excretion of small quantities of urine loaded with pink mates is very frequent ; it tends, if unchecked, to set up slight cystitis, and renders the bladder very sensitive to the catheter after operation.^ It appears, upon clinical evidence, to be due entirely to the pressure of the tumour, and if that growth be tapped, the urine is at once secreted in greater quantities, less charged with solid constituents. After operation, when no bad results follow, this scanty concentrated mine gives way, pre- cisely as after tapping, to a more copious renal secretion. A far more dangerous symptom is the excretion within twenty- four hours of about a pint to a pint and a half of pale mine of ' The slight, or sometimes severe, cystitis after operation is too often due to carelessness on the part of the nurse, who may introduce the catheter with perfect skill and with sufficient frequency, yet neglect to clean it thoroughly after use. TUBE AND BROAD LIGAMENJ. 153 a low specific gravity, not necessarily containing a single cast, nor yet a trace of albumen. I have observed several such cases in Dr. Bantock's wards, and after operation high temperature, falling with a rise in the excretion of urine, was the rule. Copious secretion of urine of a very low specific gravity is common in young hysterical patients, but is of no importance as regards operations and prognosis ; it is certainly no indica- tion for tapping. Lastly, the presence of a trifling amount of albumen, even up to one-twelfth, is not very serious if about fifty ounces of m'ine or more are passed in twenty-four hours, and if the characteristic symptoms of primary renal disease be absent. In long-standing easels of glandular tumours, almost solid, or in sarcoma of the ovary, scanty concentrated urine and oedema of the lower extremities and abdominal in- teguments are very often met with, and after successful opera- tions they disappear and leave no trace of any suspicion of the existence of visceral disease. I will pass over oases where evidence of primary renal dis- ease was very strong, nor will I dwell on instances of absence of sulphates in the urine, or changes in that fluid attributed to carbolic acid poisoning. I wish to record the fact that in thirty-two out of over forty necropsies that I have made on the bodies of patients who have died, either after ovariotomy, or with large ovarian tumours in the abdomen, I found that the kidneys presented very distinct morbid appearances. The clinical evidence is strong that in the majority of these cases the disease was due to the presence of a tumour ; the dilatation of the ureters immediately above the brim of the pelvis, where the pressure would be most direct, was probably more frequent than what I have represented it to be, as in some cases I may possibly have overlooked a slight degree of dilatation. The appearances of the kidneys I now give at length, having rejected all details that might be fallacious, through being recorded by one who has not had very extensive opportu- nities for the special study of renal disease. I have already subjected the list to the scrutiny of my friend and former col- league. Dr. Goodhart, assistant physician to Guy's Hospital, whose opinion as that of a pathologist of wide experience in the post-mortem room of a great school of medicine, and in the 154 TUMOURS OF THE OVARY, Museum of the Eoyal College of Surgeons, is of the highest value. After perusing my notes he wrote in reply, ' I have gone through your notes carefully and with pleasure, for disease due to pressure has always interested me. I have been in the habit of teaching the students in the post-mortem room that obstruction to the outflow of urine leads to (1) simple atrophy; (2) granular kidney, and (3) scarring of the kidney. I am also very interested to see the large number of cases in which you have found adhesion of the capsule. My impression is, and your facts bear it out, that adhesion of the capsule is one of the earliest and commonest features of backward pressure and of interstitial inflammation. It has always seemed to me that, though pressure is liable to produce granular or contracted kidneys, they are usually, when from this source, of a peculiar pattern, so that, from the look of the organs, you might have a suspicion of their cause ; and one of these peculiarities is con- siderable irregularity of size, one kidney being much larger than the other ; another is the association of deep pucker- ings, or scars which indicate bygone inflammation or sometimes superficial abscess ; and altogether, the granulation of the surface of each kidney is very irregular and diffused. Now, all these points are, I find, illustrated by your notes. Of conges- tion, pallor, softness, toughness, and similar appearances, the original observer can alone gauge the significance. They often mean only the mode of death, rather than any distinct renal disease ; but, of course, in association with any other disease they may mean a good deal.' As for the congestion, I believe that in the cases here recorded it was often due to septic changes. In Dr. Eussell Reynolds's ' System of Medicine ' will be found a valuable contribution by Mr. Marcus Beck on nephritis and pyelitis consecutive to affections of the lower urinary tract. I had not turned my attention to Mr. Beck's researches until quite recently, when the importance of the signification of the marked prevalence of morbid changes in the kidney in ovarian disease became evident as I looked through the records of my own necropsies. I repeat, what I have observed before, that I have never had the opportunity of studying renal disease, ex- cepting, I may add, in 1871, when I held the appointment of TUBE AND BROAD LIGAMENT. 155 house physician to Dr. Southey at St. Bartholomew's Hospital, and then, strangely enough, in relation to later experience, I had under my care an unusually large number of cases of chronic interstitial nephritis, and attended several necropsies on the patients of others, who had died of that disease. Between 1877 and 1882, 1 made a large number of necropsies on patients dying from ovarian and uterine tumours or after ovariotomy, outside as well as within the walls of the Samaritan Hospital. The frequency of changes in the kidneys, resembling those seen in interstitial nephritis, struck me very forcibly ; unfortu- nately, lack of time prevented me fi-om making any micro- scopical preparations of the kidnejs which I examined. In searching through the literature of the subject, Mr. Beck's paper particularly struck me. It refers directly, as its title im- plies, to the results of vesical, prostatic, and urethral pressm'e ; still, much of its contents bears indirectly upon the kind of pressure which may be produced by tumours. I will first re- capitulate my own cases, and then compare my notes with the observations to be found in ]Mr. Beck's paper, employing the classij&cation adopted by that sm-geon. Cases of Diseased Kidxeys found on Post- Mortem ExAiii- NATiox after Death from Ovariax Tumour, Ovario- To^r^, OR Hysterectomy. Death after removal of a multilociilar ovarian cyst occurred in all cases where no other cause is specijied. Series I. — Direct Effects of Pressure Evident. 1, J. S., 26. — Death from acute inflammation of a large multi- locular tumour of the right ovary ; peritonitis and pleurisy ; papilloma of the left ovary, which had become fused to the right, and infil- tration of the broad ligament. Eight kidney 4^ oz., pelvis much dilated at the expense of the cortical poriiion, which was mottled, but mostly pale; the capsule was not adherent. Left kidney 5^ oz., much enlarged, sxirface on section mottled, chiefly pale ; pelvis not dilated. 2. A. H., about 3.5. — Death ten minutes after the removal of a very large fibroid tumour of the uterus. Eight kidney with several puckered depressions on its surface, capsule not adherent. Substance mottled ; cortical portion not narrower than normal. Left kidney 1.56 TUMOURS OF THE OVARY. "v\-ith pelvis dilated to the size of a walnut, surface of glandular portion very irregular under the capsule, "svhicli was not adherent ; cortex very narrow, not tough. 3. S. Gr., 43. — Death on fifth day; purulent peritonitis, old ad- herent pericardium. Right kidney 4^ oz., capsule not adherent, firm, very pale, mottled, stellate veins on surface strongly marked. Left kidney '2\ oz. ; pelvis much dilated at the expense of the glandular sub- stance : C5.psule strongly adherent, cortex mottled, contained one cyst ^ inch in diameter. 4. Mrs. H., 26. — Death in fourteen houi-s, much emphysema. Right kidney 5-g- oz., capsule slightly adherent, substance congested. Left kidney contracted, capsule adherent, pelvis dilated, cortical por- tion granular with several cysts. Left ureter much dilated in its middle third. 5. j\Jj"S. S., 39. — Death in three hom-s, other viscera healthy. Kidneys each 5^ oz., pale, rather tough, capsules perfectly free. Right ureter dilated to calibre of nearly half an inch in diameter above the brim of the pelvis, but not dilated below that point. 6. Mrs. J., 35. — Death on fifth day ; acute peritonitis, liver very large and pale. Right kidney 4 oz., much congested, capsule slightly adherent, tissue healthy, shght dilatation of ureter above the brim of the pelvis. Left kidney 4 oz., congested, capsule free, tissue healthy, ureter not dilated. Series II. — Diffuse Interstitial Sejjhritis} 7. Mrs. A., 35. — Removal of a large sarcomatous ovary ; pregnancy. Death in two days ; aortic incompetency. Right kidney 4 oz., flabby, pale, contracting, capsule adherent. Left kidney 3 oz., less flabby, but pale and contracting, capsule considerably adherent, and surface puckered. Both kidneys smelt offensively urinous. 8. K. C, 37. — Death on tenth day; purulent peritonitis; other viscera normal. Right kidney 3 oz., contracted capsule intimately adherent, cortical jooi'tion very narrow, substance tough. Vessels be- tween bases of pyramids visibly engorged. Left kidney 5^^ oz., capsule strongly adherent, glandular portion as on right side. In this case both ovaries were cystic and pressvire must have been very great. 9. A. M. T., 39. — Death on fifth day ; hjemorrhage from lacera- tion of broad ligament, right pleura universally adherent, slight dila- ' The cases are here arranged, as far as was found practicable, in the order of their severity, the least diseased being placed last. TUBE AND BROAD LIGAMENT. 157 tation of right ventricle. Right kidney 4^ oz., capsule entirely adherent, substance pale and tough, no infarcts. Left kidneys 5 oz., capsule entirely and strongly adherent, substance pale, much softer than in right kidney. A cystic dilatation ^ inch in diameter lay in the base of one pyramid, filled with clear fluid. In another pyramid, near the base, was a white mass the size of a millet seed and soft on section. 10. Mrs. B., 63.— Death on fifth day; emphysema and dilated right ventricle. Right kidney 5 oz., deeply congested, capsule uni- versally adherent, substance tough, several small thin- walled cysts under capsules tilled with slightly turbid fluid. Left kidney 4^ oz., a cyst one quarter of an inch in diameter under the capsule, otherwise appearances as on right side. Strong urinous odour from both kidneys. 11. Mrs. B., 41. — Death on third day. Slight emphysema, coronary arteries calcified, no valvular disease. Right kidney 5 oz., very soft, recently congested, capsules strongly adherent, stellate veins engorged, cortical portion very narrow. Left kidney 4^ oz., less con- gested, capsule only partially adherent. 12. M. 0., 58. — Death on third day; mitral constriction, no marked cardiac symptoms before death. Right kidney 4^ oz., left 4 oz., both pale, capsules adherent, cortex much diminished in breadth, tissue very tough, most probably true chronic atrophy of granular kidneys. 13. Mrs. K., 26. — Case of twisted and completely obstructed pedicle ; cyst very large, multilocular and entirely nourished by multi- ple adhesions. (See Chapter VIII.) There was severe shock following the separation of the adhesions, and the patient sank on the third day. The other viscera were healthy. Right kidney 4 oz., pale, stellate veins on surface marked, capsule slightly adherent, substance tough, pyramids congested. Left kidney 3^ oz., pale, much contracted, cap- sule strongly adherent, substance tough, cortical portion very narrow, pyramids deeply congested. 14. Mrs. S., 48. — Death on seventh day ; chronic emphysema. Right kidney 4 oz., left 4^ oz., both much congested, capsules lai'gely adherent, siiperficial stellate veins deeply injected. Cortex not nar- rowed, bases of pyramids much frayed out. 15. Mrs. J., 41. — Death on fifth day; abscess in pedicle. Right kidney 5^ oz., capsule adherent, cortex pale and diminished in area. Left kidney 5^ oz., capsule not adherent, other appearances as on right side. The ovarian cyst was large, but the renal disease was only incipient. 158 TUMOURS OF THE OVARY, 16. Miss D., 40. — Death on third day; suppuration of pedicle, which was infiltrated with colloid material. Other viscera healthy. Both kidneys pale, capsules adherent, cortex much diminished in breadth. The tumour was a multilocular cyst containing colloid material and very large. The patient was much emaciated. 17. Mrs. A., 42. — Death on fifteenth day; pharyngeal abscess, old pleural adhesions on right side. Right kidney 5 oz., left 4^, cap- sules of both adherent, cortex rather narrow. 18. INIrs. F., 35. — Death a few minutes after operation. Eight kidney 4 oz., left 5 oz., both exceedingly pale, capsules slightly ad- herent, substance not abnormally tough nor soft, cortex narrow. The other viscera were healthy, except that the left pleura was almost universally adherent. 19. S. A., 45. — Ovariotomy, malignant infection of peritoneum, acute peritonitis; death on fifth day. Right kidney 3-| oz., very tough, capsule adherent, cortical portion very narrow. Left 4 oz., similar morbid appearances. 20. Mr. B. — Death on fifth day; purulent peritonitis. Right kidney 6^ oz., left 5 oz. Capsules adherent, cortex tough, deeply congested. 21. A. B., 54. — Death on second day; purulent peritonitis,. Right kidney 5 oz., capsule slightly but universally adherent, sub- stance tough, pale, cortex narrow. Left kidney 4 oz., similar appear- ances. 22. Mrs. 0., 32. — Death on eleventh day; pyaemia, no disease of other viscera. Right kidney 5 oz., left 4-|- oz., capsules not adherent, substance rather pale, stellate veins much dilated at certain points, cortex very nari'ow. 23. Mrs. G., 49. — Death on fifth day; acute peritonitis, obstruc- tion of ileum. Right kidney 4 oz., left 3 oz., capsules slightly ad- herent, glandular substance deeply congested. The other viscera were healthy. 24. F. H., 33. — Death in twenty-eight hours, acute congestion and oedema of lung. Right kidney 5^ oz., left 4z\ oz., capsules not adherent, glandular substance very pale, slight mottling of outer surface under capsule. 25. Mrs. B., 42. — Dermoid cyst of both ovaries, cancer of the rectum, no operation. Right kidney 4 oz., left kidney 5 oz., both much mottled, capsules not adherent, stellate veins on surface much distended. TUBE A^^D BROAD LIGAMENT. 159 Series III. — Acute Interstitial Ke/pliritis. 26. J. F., 27. — Removal of two large ovarian cysts, purulent peritonitis ; death on sixth day. Right kidney much enlarged, cap- sule not adherent, numerous small abscesses on surface of gland and a few in its substance, also several puckered cicatrices. Pelvis and ureter dilated. 27. Mrs. W., 49. — Death three weeks after operation; periosteal abscess in left angle of lower jaw-bone ; pysemic changes in lungs. Right kidney 10|- oz., left 8 oz., both deeply congested, capsules slightly adherent, numerous metastatic abscesses on the surface, and several, nearly a line in diameter, in the cortex. Series IY. — Cicatricial Kidney. 28. Mrs. H., 42.— Death on twelfth day. Right kidney 4^ oz., contracted, very tough, capsule closely adherent, large white cicatrices on surface, vdth extensive embolic infarcts. Section pale, slightly granular, pyramids normal. Left kidney 4 oz., much contracted, very tough, capsules adherent, no cicatrices nor infarcts, but surface highly granular on section ; cortex narrow, pyramids engorged. Strong urinous odour from both kidneys. 29. Mrs. S., 34. — Removal of a very large multilocular cyst ; death three minutes after the operation. Other viscera healthy. Riaht kidney 3^ oz., very pale, capsule not adherent, surface much puckered, cortex very narrow. Left kidney 6^ oz., deeply congested, appear- ances otherwise normal. It had evidently undergone compensatory hypertrophy. Series V. — Recent Congestion. 30. E. B., 54. — Removal of a very large multilocular cyst after its rupture ; acute peritonitis existed ; death in twenty-four hours. Right kidney 5 oz., left 5 oz. ; both highly congested, capsules quite free ; Malpighian bodies markedly prominent. Series YI. — Renal Disease p-ohahly Priraary. 3L Mrs. S., about 40. — Removal of right ovary and pedunculated fibroid tumour of uterus, sloughing of pedicle of fibroid ; death on fourth day. Other viscera normal. Right kidney 3 oz., left 3^ oz., both congested, capsules slightly adherent, tissue soft. The small size of the kidneys suggested atrophy from long-standing disease. 160 TUMOURS OF THE OVARY, 32. E. H., 54. — Removal of a large multilobular ovarian cyst; much, ascites ; death on third day. Large fatty heart and nutmeg liver. Right kidney 7 oz., much congested, capsule quite fi-pe, sub- stance very flabby. Left kidney r)\ oz.. congested, capsule quite free; substance firmer than on right side, minute cysts all over the cortex. 33. E. S., .56. — Death on fourth day : mitral and aortic incom- petence. Right kidney 3^ oz., capsule adherent, siurface much puckered. Cortex very narrow, of tough consistence, and full of small cysts. Left kidney 1^ oz. ; capsule strongly adherent, surface less puckered than on right side ■ cortex not very narrow, but full of cysts. Thei'e must have been old disease of uncertain origin to explain the condition of the right kidney, and the apparent compensatory hyper- trophy of the left. As already stated, these appearances accord with what has been observed by Dr. Groodhart in cases of death from large abdominal tumours of every variety. I will now compare my notes with the remarks of ]\Ir. Marcus Beck in the monograph already quoted, which must be generally familiar to the medical public, and refers to one cause of pressure not quite identical with that which existed in my own cases. The differences and points of resemblance in cause and effects may here advan- tageously be studied. ]Mi'. Beck first considers the eff"ects of pressure on the kidney in the com'se of vesical and urethral disease. He re- jects the old doctrine that in chi'onic stricture and calculus the vahiilar vesical orifice of the ui-eter becomes deranged, so as to allow mine to be forced back up that duct dming attempts at micturition, and in that manner to distend its walls. The real cause of obstruction is stricture of the orifice of the ureter by the thick bundles of muscular tissue in the walls of the hyper- trophied bladder, and by the thickening and induration of its mucous membrane. Hence, so far, obstruction from vesical changes and obstruction from pressure of a tumour on the ureter are very similar. In both cases, as far as the kidney is concerned, the mischief arises fi-om obstruction of the ureter. In the case, however, of a tumom-, there can be no question of the extension of decomposition of the urine fi'om the bladder to the pelvis of the kidney, which ]Mr. Beck believes may occur in chronic vesical affections, thouarh he denies the regurgitation TUBE AND BROAD LIGAMENT. 161 theory as a cause of dilatation of tlie ureter. The effects on the kidney which that surgeon has observed in cases of pressure ou the ureter from without are very similar to those which I have described. It must be borne in mind, however, that in Mr. Beck's cases the obstruction appears to have been always more or less acute. In my own, the pressure was seldom very severe, and must always have varied in severity according to the patient's position. I have seen the m-eter adherent to the back of a large ovarian timiour, yet not much dilated nor ob- structed. Hence dilatation of the pelvis is often trifling or imperceptible in ovarian cases, and hence Series I. contains but few cases. In Case 2, where a very large fibroid uterine tumom- was removed, the dilatation was most' marked, and here pressui'e was particularly evident. In most of the cases, however, there was practically no dilatation at all. The ureters were constantly pressed upon by large tumours, and hence arose a constant, gentle, yet prejudicial pressm^e on the glandular substance of the kidney, as shown in Series II. In these cases, as the secretion of urine is to a great extent dependent upon the difference between the pressure of blood in th-e Malpighian tufts and that of the mine in the tubules, it would be, as Mr. Beck observes, diminished to a dangerous degree, were not the pressure in the Malpighian tufts somewhat increased by the slight obstruction to the venous circulation caused by the great overgrowth of the inter-tubular connective tissue. Hence, in such cases the secretion of urine is increased, but its specific gravity is lowered ; acute congestion may, how- ever, choke the renal vessels, and cause complete cessation of the secretion of urine. In cases of ovarian tumour the sup- pression is rarely complete, but the abundant excretion of urine of low density is replaced for a time by a very scanty secretion of uriiae of a high specific gravity. This is the condition which Sir Spencer Wells has found so mischievous. I believe, how- ever, that it does not represent acute congestion of healthy kidneys, but rather congestion of kidneys damaged by pressure. For, when a sickly middle-aged subject of ovarian disease passes scanty concentrated urine before operation, I have often noticed that, within a day or two after, that secretion becomes copious, and of a low specific gravity. During convalescence, the M 162 TUMOmS OF TEE OVARY, density increases. But -^hen an ovarian tumour is removed before it has attained lai'ge proportions, from a healthy young woman passing urine of the normal density, and without any deposit, the urine usually deposits urates very fi'eely for two or thi'ee days, and then returns at once to the normal standard. The elimination of tissue waste should be rapid after a severe operation, but this cannot be effectively carried out when the kidnev is damaged by pressui'e, but after the congestion ceases its more chi-onic morbid condition becomes displayed. The healthy kidney, on the other hand, eliminates effete products with gTeat rapidity : hence the abundance of m-ates. As to the cicatricial processes, they may bear some relation to tapping, as they are said to bear to regidar catheterism. But I cannot bring forward sufficient evidence to support this state- ment. It must be remembered that the diseased kidneys which I have described here at length ai'e, of necessity, from fatal cases, and I strongly believe, as I have asserted already in the course of discussions at societies on ovariotomy mortality, that their diseased condition was the chief cause of death. This consi- deration especially applies to the form of renal disease observed where pressure exists, but less evidently as a direct result of pressm'e. This fonn of secondary renal inflammation, termed by 3Ir. Beck and others diffuse interstitial nephritis, is very frequent in conjunction with ovarian disease ; and. on reference to Series II. in my list, it wiH be seen that a large proportion present all the characteristics ascribed to that disease. The adherent capsule, prominence of the stellate veins, fr-equent mottling of the glandular substance, and occasional presence of putrid mine, gi^ing a strong odomrto the gland, are all frequent characters of the kidneys which I examined. I cannot say that it is alwavs easv to decide upon the exact natm-e of the pres- sure. From the position of the kidney it is well sheltered from anv tumom- that might press on its pelvis, at least fr'om any ovarian or uterine tumour, x^s for congestion from altered blood pressm-e. or fr-om causes similar to those that produce certain forms of nephritis in pregnancy, those are questions which I do not feel competent to decide. I believe that this diffuse interstitial nephritis is a result of a more prolonged, TUBE AND BROAD LIGAMENT. 163 but less extreme degree of pressure of the tumour on the ureter as it crosses the brim of the pelvis, than that which causes the more direct effects of pressure on the glandular structure of the kidney. I have already noted the case of true dilatation of the pelvis from pressure on the ureter by a heavy uterine growth. In an average, but chronic case of multilocular ovarian cyst, the pressure on the ureters is slight, but constant, and in such a case is difiuse interstitial nephritis most frequently found after death. This affection is far more symmetrical than the more mechanical type, and its symptoms more obscure ; hence the surgeon may find before operation that the patient's urine is ' normal.' The temporary presence of urates may cause the secretion to be of the ' normal ' specific gravity. The operation is performed; it may be perfectly simple, but too often death follows within three or four days, to the dismay of the surgeon, who then considers his case to be ' most extra- ordinary, as there were no symptoms of peritonitis, and every- thing went well, but I could not get the kidneys to act.' Then when the necropsy is made, the kidneys appear as in Case 7. I must here observe that a disaster of this kind is quite under- stood -by my own colleagues, but many general surgeons appear still to expect that nothing can destroy life after ovariotomy but septicaemia or peritonitis. The more acute form of interstitial nephritis, ' with scattered points of suppuration,' as described by Mr. Beck, and illustrated by Series III., is not frequent after ovariotomy. In Case 27, there were numerous abscesses, but it was an instance of very characteristic pyaemia, with metastatic abscesses in the lungs, and under the periosteum of the lower jaw. Hence the precise pathological nature of the renal abscesses must remain obscure. It is very possible, however, that chronic nephritis already existed ; acute changes followed operation, and the kidneys became a focus of pygemic infection. The great weight of the right kidney indicated old-standing disease. Lastly, in some cases out of my series, the kidneys were merely acutely congested from other complications, and pre- sented no chronic changes. Before dismissing these patho- logical questions, I must add that it is just possible that chronic nephritis independent of ovarian disease existed in some of M 2 164 TUMOURS OF THE OVARY, these cases. Several of the patients were of intemperate habits, or subjected to constant exposure to cold and wet ; in Series VI. I have reason to believe that this was especially the case. Considering the brilKant statistics of certain specialists, and the frequency of renal disease in cases of ovarian tumour, it appears reasonable to suppose that removal of the tumour is frequently followed by complete recovery from the complica- tion. There is a great difference between a subject that has recovered from ovariotomy, and has no constitutional tendency to chronic nephritis, and a gouty or cachectic indi\'idual who has granular kidneys, and, at the samie time, cannot or will not refrain from diet and from habits that aggravate his disease and cause it to be so intractable. TUBE AND BROAD LIGAMENT. 166 CHAPTER XII. TUMOURS OF THE FALLOPIAN TUBE. In works on anatomy, it has long been the custom to display the Fallopian tube as though it ran directly outwards from the uterus, with its fimbrise floating freely apart from each other, as though they naturally floated in some fluid, the ovarian fimbria running directly downwards to the outer border of the ovary. This method of depicting the tube is well adapted for the simultaneous display of the other uterine appendages ; and in this work I have been forced to represent them displayed in that manner, for otherwise it would be impossible to show the parovarium and the broad ligament cysts which are not par- ovarian. It must, however, be borne in mind that the Fallopian tube never lies in the position above described, in the li\dng subject. Were that the case, then, before the ovum could enter the tube, it must either be ejected by the ovary into the ostium of the tube above it, which is a theory nobody would care to advance, or else the fimbrise, under the influence of menstrual or sexual excitement, must descend and grasp the ovary, so that, as the ripe Grraafian folHcle ruptures, the ovum may fall into the tangles of the tubal fimbriae. This is the morsus diaboli theory. The term just employed has been a fertile source of physiological error, just as the conventional manner of depict- ing the tube has led to anatomical misunderstanding. Professor Hyrtl has shown, in his Onoviatologia AnatoTnica, that the term morsus diaboli was given to the fimbriae of the tube, by anatomical teachers of a past age, on account of their resem- blance to the root of the Devil's-bit scabious (Scabiosa succisa, Linn.), so called because there was once a widespread belief amongst the peasantry of Europe that the root of that plant appeared to be nibbled off — ' prsemorse,' as the botanists would 166 TUMOURS OF THE OVARY, say — because the arch-fiend was in the habit of biting at it from below, in parts of the earth so saintly in those days that he had no more congenial employment. In an edition of ' Grerarde's Herbal,' in my own library, dated 1598, I find the following observation on the name of this plant: 'It is commonly called Morsiis Diaboli, or Divels (sic) bit, of the root (as it seemeth) that is bitten off. For the superstitious people hold o]Dinion, that the divell {sic) for the envie that he beareth to mankind bit it off, bicause it woulde be otherwise good for many uses : it is called of Fuchsius, Succisa : in high Dutch (that is, Grerman) Teuffels Ahhisz ; in lowe Dutch, Duyvelles beet ; in French, Mors du Diahle ; in English, Divels bit, and Fore bit.' The truncated root axis and the radiating fibrils bear a resemblance, as near as are most other anatomical resemblances, to the expanded fimbrise of the tube. To my own eyes, the flower of a Devil's-bit scabious, though it is purple and not red, looks far more like the fimbrias as seen when expanded in water, and I cannot help thinking that the term morsus diaboli was first based on the latter simile. In any case, it was never originally intended to imply that the fimbriae could grip the ovary under the influence of sexual orgasm. It is singular that a botanical simile, connected, on the one hand, with a medieval superstition, and, on the other, with the fact that many anatomical teachers, from the dawn of modern history until a very recent date, were also lecturers on botany, should tend to keep up a gross physiological error. Professor His demonstrated in 1881, in the Archiv fur Anatomie und Physiologie, the true position of the uterine appendages, through a series of observations made on the pelvic organs of healthy young women killed by accident or suicide. The uterus was never found to lie symmetrically in the middle of the pelvic cavity ; it inclined to the right in two cases, to the left in thi-ee. In subjects where the uterus inclined to the right, the right ovary lay with its long axis completely vertical, and with one side closely applied to the bony wall of the pelvis ; but the left ovary, being dragged upon by the uterus, lay obliquely in the pelvis, traction being effected by the ovarian ligament, which pulled the anterior part of the ovary away from the wall of the TUBE AND BROAD LIGAMENT. 167 pelvis, the posterior extremity being still held against the brim of the pelvis by the fold of peritoneum which invests the ovarian vessels — the infundibulo-pelvic ligament of certain anatomists. When the uterus inclined to the left, the relative positions of the ovaries, as just described, were reversed. Each Fallopian tube forms a loop around its ovary, the anterior half of the loop ascending sharply over the ovary, the posterior loop, which in- cludes the dilated part of the tube close to the fimbrise, descend- ing and bulging freely behind the ovary. Both sides of the loop cover a great part of the ovary like a curtain. The ovarian fimbria runs backwards and upwards on to the ovary, that organ being, as the above description shows, closely embraced by the free end of the tube. I have repeatedly verified this discovery made by Professor His, finding that the healthy ovary hangs from its ovarian liga- ment obliquely downwards, embraced above by the tube, the fimbriee of which lie on its surface externally, and, to a certain extent, inferiorly. The appearance of the ovarian fimbria run- ning upwards on the ovary is very characteristic. To verify this description of the relations of the ovary to the tube, the intestines must be raised very gently, lest the uterine appen- dages be displaced. It is evident that the ripe ova can, by this arrangement, drop into the tube, and may fall at once among spermatozoa. When a slight attack of pelvic peritonitis causes the fimbrias to adhere to the ovary, the obstructed tube becomes dilated, and, instead of rising high above the ovary, as would be the case were the conventional ideas concerning the relative position of these structures true, half the dilated tube coils round the outer side and lower part of the ovary. For the same reason tubo-ovarian cysts lie outside or below the ovary, and never above it ; and, in cases of foetation within the outer third of the tube, the ovary lies above the fcetal sac, between it and the inner third of the tube. This morbid condition is frequently taken for ovarian fcstation, simply because the foetus lies below the ovary, which would seem, to those who had not accurately studied the question, to be far out of the range of the Fallopian tube. The relations of the Fallopian tube to ovarian and broad 168 TUMOURS OF THE OVARY, ligament cysts have been already described in previous chapters. In large simple broad ligament cysts the tube becomes ex- tremely stretched, as do the fimbriae ; in multilocular ovarian cysts the stretching is less marked, as the tumour does not press directly on the tube. I have seen true hypertrophy of the tube, however, in more than one case of this kind, and one specimen I have prepared and mounted in the Museum of the Eoyal College of Surgeons (Pathological Series, No. 4563, New Catalogue). The patient was a single woman, aged thirty-five. She suffered much from a large multilocular ovarian cyst, which had twice become inflamed, delaying operation. When the cyst was removed by Dr. Bantock, it was found to be universally adherent to the intestines and abdominal wall ; but the tube hung free from its surface, measuring six inches in length, and with walls not only stretched, but also much hypertrophied. The tube was unobstructed, and the fimbriae shared in the pro- cess of hypertrophy; shreds of lymph hung from some of them. I have never been present at an operation where a tubo- ovarian cyst was discovered. A preparation in the College of Surgeons Museum (No. 4574, New Catalogue) shows this con- dition very plainly ; it was taken in 1876 by Dr. Gfoodhart from the body of an intemperate woman, aged thirty-eight, who died from gangrene of one leg after a fall. Both Fallopian tubes are much dilated, especially the right, which has formed a com- munication with the corresponding ovary, that organ being dilated into a cyst over two inches in diameter. The ovarian ligament can be traced on to the surface of the cyst. There are numerous adhesions on the surface of the uterus, the result of chronic perimetritis. I have repeatedly examined this speci- men, and have clearly traced the communication between the cavity of the dilated tube and the cavity of the ovarian cyst. True tumours of the Fallopian tube are not common. The small thin-walled cysts that often stud its surface are really developed in the cellular tissue under the portion of the broad ligament that is reflected over the tube, as I have already demonstrated in another chapter. Tubal gestation is beyond the scope of this work. I may here remark, however, that I once saw a patient who was supposed, by several surgeons, to TUBE AM) BROAD LIGAMENT. 169 be suffering from a large ovarian tumour, a ' thin-walled secon- dary cyst ' projecting into Douglas's pouch. Menstruation had been absent for over a year. A long and tedious railway journey, with subsequent exaniination by several medical attendants, brought on very severe abdominal pains, rapidly followed by collapse and death. I performed the necropsy, and found that the ' cyst ' was an eight months' fcetus, evidently developed in a dilated right Fallopian tube, the ' thin-walled secondary cyst ' in Douglas's pouch being its head. The dilated tube had rup- tured, and the consequent haemorrhage had proved fatal. It is not my intention to speak at length of dilatation of the Fallopian tube from simple obstruction — the condition known as hydrosalpinx when the fluid contents of the tube are clear, and pyosalpinx when they are pm'ulent. Certain opera- tive measures, practised and advocated by jNIr. Lawson Tait and others, have thrown great light on these pathological conditions. In 1877, I prepared for the College of Surgeons Museum (Xo. 4571, New Catalogue) a remarkable specimen presented by Sir Spencer Wells. It consisted of two Fallopian tubes dilated to such an extent as to constitute cystic tumours of considerable magnitude. The right weighed, on removal, 4 lbs. 11 oz. ; the left, 1 lb. 6 oz. Both contained a fluid like thin mucus. The left tube was removed with a portion of the ovary ; several pedunculated cysts sprang from the broad ligament. Some of the cysts contained vegetations similar, microscopically, to the papillomatous growth from the interior of the Fallopian tube, which will shortly be described. The patient was a single woman, aged twenty-three. Nine months before operation she noticed a lump in her left iliac fossa ; this enlarged and filled the lower part of the abdomen . The patient married nine months after the tubes were removed, and menstruation continued with per- fect regularity for two years and a half, when she last wrote to the operator. In over six cases of multilocular ovarian tumour I have seen dilatation of the Fallopian tube from obstruction ; inflammation of the peritoneum or the cyst wall extending to the fimbriae, which become matted together, so that the ostium is soon completely blocked. In these cases the fimbriae, soldered toge- ther laterally, often share in the dilatation, and give a singular 170 TUMOURS OF THE OVARY, , appearance to the end of the tube, resembling a cluster of buds, or forming a kind of Maltese cross. When the ostium is blocked higher up, the fimbrise, of necessity, cannot be involved in the dilatation ; this is also the case when the obstruction is caused by pressure of bands of adhesion on the tube, or through kink- ing at any point internal to the attachment of the fimbriae. In any case, when the dilatation has increased to a marked extent, the fimbriae are generally obliterated altogether. A series of examples of hydro- and pyosalpinx, discovered in the post- mortem theatre of the Middlesex Hospital, formed the subject of an interesting communication recently read by Dr. J. Kingston Fowler before the Medical Society. There can now be no doubt that some of the more intractable cases of constant pain in the pelvic and iliac regions, often attributed to other causes, are really due to disease of the tube. I have had the opportunity of examining one remarkable specimen of a true morbid growth affecting the Fallopian tube. The clinical history presents several features of considerable interest. In October 1877, a maiden lady, aged fifty, thin and ema- ciated, came under the care of Mr. Bickersteth, of Liverpool. Four weeks previously she had experienced a severe attack of menorrhagia following amenorrhoea, which had lasted several months. There were now symptoms attributed to inflammation of the right ovary and surrounding cellular tissue. The local pain was severe, and there was vomiting, constipation, difficulty in micturition, general tumefaction of the abdomen, and high fever. She recovered perfectly after remaining in bed for six weeks. But in March 1878, she had an attack of pleural effu- sion on the right side. One hundred and twenty ounces of clear fluid were removed by tapping ;. then the abdomen began to swell, and on July 30 paracentesis was performed, and nine pints of fluid were drawn off; thirteen pints more had to be removed in September. In October, the right pleura again re- quired tapping, by which means one hundred ounces of fluid were removed. In January 1879, the abdomen having again become swollen, sixteen pints were drawn off by the trocar and cannula. Ever since the subsidence of the symptoms of pelvic inflammation, throughout the period of recurrent pleural and TUBE AND BROAD LIGAMENT. 171 peritoneal effusion, there had been neither acute disturbance of the system, nor even so little as the solitary objective symptom of rise of temperature, and after each tapping recovery appeared to be for a time complete ; nor was there any evidence of cardiac or hepatic disease. In March 1879, two months after the third tapping of the abdomen, the patient was referred to Sir Spencer Wells for consultation, as the nature of the abdominal lesion remained very uncertain. During the first enlargement of the abdomen, Mr. Bickersteth detected a clear percussion note persistently in front of the abdomen, and a dull note in both flanks, most marked on the right side, slowly and slightly altered by change of position. Sir Spencer Wells recommended an exploratory incision, to which the patient at first objected ; so the abdo- men was simply tapped. Dr. Caton examined the fluid, which amounted to twenty-two pints. Its specific gravity was 1022, and it coagulated almost entirely under the action of heat and nitric acid. Its scanty flocculent deposit was found to consist of large cells, mostly grouped in clusters, and apparently pro- liferating ; many were distinctly vacuolated, being of the kind described by Foulis and Thornton ; indeed, the latter surgeon examined some of the fluid removed- from this same case during the subsequent operation, and observed the same vacuolated, proliferating cells, which he kindly pointed out to me under the microscope. Sir Spencer Wells, on examining the patient shortly after the final tapping, detected a hard, nodular mass behind the uterus, which organ was freely movable, and so low in the pelvis that the cervix lay close to the vulva. Dr. W. PI. Day, at the same time, examined the thorax, and found evidence of the presence of a small quantity of fluid in the right pleural cavity, without any sign of disease of the lungs themselves. On account of the tendency to pleural effusion, he considered an operation imperative. Clusters of proHferating cells had been found in the pleural as well as in the peritoneal fluid. On April 28, 1879, Sir Spencer Wells operated on the patient, employing strict antiseptic precautions. Wlien the peritoneal cavity was laid open by the usual incision through the linea alba, seventeen pints of amber-coloured, opalescent 272 TUMOURS OF THE OVARY, fluid escaped. The left ovary was noiinal ; to the right of the uterus, which was of the usual dimensions, a tumoui" was found the size of a large orange, and consisting of the gi'eater part of the right Fallopian tube ; the ovary coidd be distinctly felt be- hind it. The tube and ovarian ligament behind the growth were secured by silk ligatures, and the tumour, and the ovary, which could not be separated from it, were cut away. The peritoneum was carefully examined for secondary deposits, but none could be found. The patient made a very rapid recovery. On laying the tumour open, it was found to be filled with cauliflower excrescences, covered with a mucoid secretion, which issued fi'om the open fimbriated extremity. About an inch of the innermiost portion of the tube remained undilated and quite pervious. The remainder formed an elongated oval tumour three and a half inches long. Its upper, anterior, and posterior sm'faces were uniformly smooth and white. On the inferior aspect, the abdominal orifice was plainly visible; it readily ad- mitted a stout bristle, which entered directly into the cavity of the tube. The fimbrise, although thickened and shortened, re- mained quite distinct. The ovary was an inch and a half long, and somewhat flattened. Its outer portion adhered to the tube, and contained three menstrual corpora lutea, one apparently quite recent. No cystic nor papillary bodies could be found within the ovary, but a small, transparent, thin-walled cyst projected from its surface. The broad ligament between the ovary and the undilated portion of the tube was much thickened, but contained no new growths. The cauliflower excrescences grew from all parts of the niueous membrane of the dilated portion of the tube. Several cysts, with smooth exteriors and thin walls, rose by narrow pedicles from amidst the excrescences, and contained papillary outgrowths ; other cysts had their walls roughened externally by similar new formations, also springing from their interiors. On microscopical examination, the cauliflower growths were found to be covered with countless secondary offshoots. The free surfaces of the growths were invested throughout with a single layer of columnar epithelium ; some, but only few, of the cells in this layer were cihated. The stroma was almost universally made up of small fusiform connective-tissue cells, TUBE AND BROAD LIGAMENT. 173 and was but poorly supplied with blood-vessels. I found that, at some points, chondrification had taken place. An engraving of the tube, with drawings of the microscopical appearances^ of sections of the cauliflower growths, will be found in the Trans- actions of the Pathological Society, vol. xxxi. 1880. In August 1879, the patient had an attack of pleurisy ; in September, Mr. Bickersteth reported ' dulness and deficient respiration, with feeble sounds over the right side of the chest, indicating thickening of the pleura from recent inflammation.' A few weeks previously Dr. Cameron had detected friction sounds over the same side. During her illness, the patient menstruated four times, at irregular intervals. The last period was about six or eight weeks before operation ; the catamenia have never reappeared since the tumour was removed. The absolute limitation of the epithelium to free surfaces in this specimen was sufficient to show that the growth was not cancerous ; moreover, the patient, operated upon in 1879, was quite well in the spring of 1884. That the cells found free in the fluid were derived from the epithelium, there can be little doubt ; that these free bodies might infect the peritoneum is also highly probable, but Sir Spencer Wells failed to find any secondary growths on the contents of the abdominal cavity which came within his reach during the operation. This is neither the first nor the last case where fluid with cells of this kind has failed to cause secondary malignant deposits, or even to indicate the presence of malignant disease ; and, according to experienced operators, secondary deposits from ovarian cysts are by no means constantly malignant, as after histories have proved. The excrescences of which this tumour was made up re- sembled a broad ligament papilloma, rather than a glandular ovarian growth ; but, though the epithelial lining was partly ciliated, and the stroma relatively scanty, there was a distinct, thick, mucoid secretion, and the chondrification in the stroma resembled what is seen in intracystic adenoid growths. As far as development is concerned, tube, ovary, and parovarium are very distinct structures, and that there should be dififerences in the morbid growths that attack each of them is quite in accord- ance with the general laws of pathology. 174 TUMOURS OF THE OVARY, Kokitansky states that new growths developed from minute papillae, seen on the mucous membranes of diseased Fallopian tubes, are rare, and seldom exceed the size of a pea or a bean. Hennig has found that hyperplasia of the tubal mucous mem- brane passes into polypoid growth through the successive stages of warty and papillary tumours, these transitional forms being often found side by side in dropsical tubes. In a case of stric- ture of the tube by a band of lymph, this author found a warty outgrowth one centimetre broad, close to the seat of constric- tion, which growth he considered to be the result of chronic catarrh. The specimen now under consideration was evidently an unusually large example of the outgrowth recognised by Rokitansky and Hennig. The excrescences were, perhaps, not so much tumours as hyperplasise produced by chronic inflam- mation. They closely resembled the condylomata around the labia in venereal patients, especially frequent in cases where the external parts are irritated by copious and chronic dis- charges, or by want of cleanliness. Dropsy of the Fallopian tubes is nearly always preceded by catarrh of the mucous mem- brane. This case of papilloma of the tube began by symptoms attributed to inflammation of the right ovary, that is to say, the tube in reality was inflamed. The discharge of secretion through the abdominal aperture irritated the peritoneum, and produced ascites, for the abundance of the fluid, removed by tapping, shows that the peritoneal cavity was filled chiefly by its own secretion, and not by that thrown off from the growths in the tube. The open condition of the fimbriated extremity of the Fallopian tube was a very unusual feature ; indeed, Cruveilhier states that in dropsical distension, obliteration of that extremity is constant. The continuous flow of free mucous discharge from the earliest stage of disease probably accounts for the patency of the abdominal aperture in this ease. Had the dis- charge been scantier and intermittent, the fimbriae might have adhered to each other, and sealed up the tube; then the tumour would have attained a great size, but ascites would less probably have supervened, since no discharge could escape into the peritoneum so as to irritate that serous membrane, and spread a morbid influence as far as to the right pleura. TUBE AND BROAD LIGAMENT. 175 In February 1882, I assisted Mr. Thornton in an operation for the removal of a large broad ligament cyst, over which the Fallopian tube was stretched. The opposite tube was dilated, and bound down to its ovary by adhesions. On its upper surface was a thin-walled broad ligament cyst nearly an inch in diameter. The mucous membrane of the tube was studded with papillomatous outgrowths. In conclusion, I must observe that it is possible that some of the papillomatous masses that infest the surface of the ovary and broad ligament may originate from the Fallopian tube, especially in those cases where no cysts can be found. The ovarian fimbria of the tube run^, it must be remembered, on to the surface of the ovary. In another chapter, I described a case of papillomatous cysts found in a fcetal ovary. In one of the sections, a mass of vegetations sprouted, without any cap- sule, from the outer end of the ovary. The epithelial lining- was far more regular than in the intra-cystic gi'owths, and, on examining a section of the fimbriated extremity of the Fallo- pian tube connected with this ovary, the identity of its epithe- lium and subepithelial stroma with the epithelium and stroma in the free vegetations outside the ovary became self-evident. In fact, these free growths very probably developed from the ovarian fimbria of the tube. The same morbid influence that set up papillomatous disease in the Wolffian tubes produced the same pathological condition in the adjacent fimbrise. In several cases of ovarian cysts I have seen a firm adhesion of the tube on the affected side to the opposite tube ; the latter may also adhere to that part of the wall of the cyst that pjrojects in its direction. These cases may greatly puzzle the operator ; and when the patient recovers from the operation, it is difficult to feel sure what was the true meaning of the unusual position of the tubes. '\i\'Tien, however, both tubes lie on the surface of a large cystic tumour, each with a distinct ' mesosalpinx ' con- taining the parovarium — the tumour having a pedicle on both sides of the uterus — the surgeon may feel sure that he has to deal with a fused double ovarian cyst, a subject which I have already discussed at some length. LIST OF AUTHOES QUOTED IN THIS WORK. Balfour. — On the Structure and Development of the Vertebrate Ovary : Quarterly Journal of Microscopical Science, vol. xviii., 1878. Bantock. — On the Pathology of Certain so-called Unilocular Ovarian Cysts : Transactions of the Obstetrical Society of London, vol. xv. First Series of Twenty-five Cases of Completed Ovariotomy ; - British Medical Journal, vol. i., 1879 (contains observations on the use of silkworm-gut). Specimen illustrating the Changes in the Pedicle of an Ovarian Cyst when treated by Ligature : Trans- actions of the Obstetrical Society of London, vol. xiv., 1872. Case of Ovariotomy ■; Recovery from the Operation ; Otitis ; Death : Medical Times and Gazette, vol. ii., 1879, p. 607. Beck (Marcus, M. B.). — Nephritis and Pyelitis subsequent to the Affections of the Lower Urinary Tract : Russell Reynolds's System of Medicine, vol. v., 1879. Beigel. — Zur Naturgeschichte des Corpus Luteum : Archiv fiir Gyndkologie, Band xiii., 1878. CoBLENz. — Zur Genese und Entwickelung von Kystomen im Bereich der inneren weiblichen Sexualorgane : Virchow's Archiv, Band Ixxxiv. Das Ovarialpapillom : Ld., Band Ixxxii. Die ' papil- laren ' Adenokystenformen im Bereiche der inneren weiblichen Sexualorgane und ihre Behandlung : Zeitschrift filr Geburtshillfe und Gyndkologie, Band vii., Heft 1, Zur Ovariotomie : Archiv fiir Gyndkologie, Band xviii., Heft 2. [An excellent series of monographs on an important subject in rela- tion to ovarian pathology, especially as regards the origin of papillomata. N 178 LIST OF AUTHORS QUOTED IN THIS WORK. I have made an abstract, in English, of Dr. Coblenz's works, which will be found in the London Medical Record, vol. x.,p. 81. The mono- graph which stands first in the above list is particularly worthy of the attention of surgeons as well as pathologists. Agreeing almost entirely with Dr. Ooblenz on the nature of papillomata of the ovary and broad ligament, I attach more importance to the entirely non-parovarian origin of the many thin-walled broad-ligament cysts.] Cruveilhier. — Traite cV Anatomie Pathologique Generale. For Ms notes on effects of closure of the Fallopian tube see vol. iii., p. 371. De Sinety and Malassez, — Sur la Structure, I'Origine et le Developpe- ment des Kystes de I'Ovaire : Archives de Physiologie, deuxi^me serie, tomes v., vi., vii. DoRAN. — Papilloma of the Fallopian Tube, associated with Ascites and Pleuritic Effusion : Transactions of the Pathological Society of London, Yo\. xxxi., 1880. Proliferating cystsin the Ovary of a Seven Months' Foetus : Id., vol. xxxii., 1881. Papillary Cysts of the Ovary: Id., vol. xxxiii., 1882. Incipient Cystic Disease of the Parovarium and Broad Ligament : Id. vol. xxxiv. , 1883. Coblenz on the Embryological Origin of Ovarian, Uterine, and Vaginal Cysts : London Medical Record, vol. x., 1882. Microscopic Sections of a Dermoid Ovarian Cyst : Transactions of the Obstetrical Society of London, vol. xxiii. On Complete Intraperitoneal Ligature of the Pedicle in Ovariotomy : St. Bar- tholomew's Hospital Reports, vol. xiii. Further Remarks on Complete Intraperitoneal Ligature of the Pedicle in Ovariotomy : Id., vol. xiv. FisCHEL. — Ueber Parovarialcysten und parovarielle Kystome : Archiv fiir Gyndkologie, Band xv. FouLis. — The Development of the Ovary and the Structure of the Ova in Man and other Mammalia ; with special reference to the Origin and Development of the Follicular Epithelial Cells : Journal of Anatomy and Physiology, vol. xiii., part 3, p. 353. Fowler (Dr. J. Kingston). — A Contribution to the Pathology of Hydro- and Pyosalpinx. A Paper read before the Medical Society of London, April 28, 1884. It is published, complete, in the Medical Times and Gazette, May 3, 1884. Fox (Wilson, M.D.). — On the Origin, Structure, and Mode of Develop- ment of the Cystic Tumours of the Ovary : Medico-Chirurgical Transactions, vol. xlvii. LIST OF AUTHORS QUOTED IN THIS WORK. 179 Gabbett. — Colloid Degeneration of the Non-Cystic Ovary, with asso- ciated Vascular Changes : Journal of Anatomy and Physiology ^ vol. xvi. Gerarde. — The Herball, or Historic of Plantes, London, 1598. GooDHART. — On Erysipelas of the Kidney and Urinary Tract, with some Remarks on the Disease generally called Surgical Kidney : Guy's Hospital Reports, third series, vol. xix,, 1874. Harris (Vincent D., M.D.) and Doran. — The Ovary in incipient Cystic Disease : Journal of Anatomy and Physiology, vol. xv. Spinal Cord from a Case of Tetanus following Ovariotomy : Transactions of the Pathological Society of London, vol. xxxi., 1880. Hennig. — Die Krankheiten der Eileiter und die Tubenschwanger- schaft, Stuttgart, 1876. His. — Die Lage der Eierstocke in der weiblichen Leiche : Archiv filr Anatomie und Physiologie, Anat. Abtheilung, 1881. Hyrtl. — Onomatologia Anatomica, Geschichte und Kritik der anatomischen Sprache der Gegenwai't, mit besonderer Beriick- sichtigung ihrer Barbarismen, Widei'sinnigkeiten, Tropen und grammatikalischen Fehler : Vienna, 1880. Klein. — Elements of Histology (Manuals for Students of Medicine : Cassell & Co., 1883). Malassez. — See De Sinety and Malassez. Meredith. — Ovarian Cyst which had ruptured repeatedly during a period of nine years prior to its removal : Transactions of the. Pathological Society, vol. xxxi., 1880. Extraperitoneal Ovario- tomy : Lancet, vol. ii., 1880, p. 297. Noeggerath. — The Diseases of the Blood- Vessels of the Ovary in Relation to the Genesis of Ovarian Cysts : American Journal of Obstetrics, vol. xiii., 1880. Patenko. — Ueber die Entwickelung der Corpora Fibrosa in Ovarien, Virchow's Archiv, Ba,nd Ixxxiv., 1881. Pepper. — Elements of Surgical Pathology (Manuals for Students of Medicine : Cassell & Co., 1883). Olshausen. — Die Krankheiten der Ovarien : Pitha und Billroth, Handhuch der allgemeinen und sjyeciellen Chirurgie, Band iv., 6 Lieferung. N 2 180 LIST OF AUTHORS QUOTED IN THIS WORK. Ralfe (C. H., M.D.). — Clinical Chemistry (Manuals for Students of Medicine: Cassell & Co., 1883). RiEDER. — Ueber die Gartner'schen (Wolff'schen) Kanale beim menschliclien Weibe : Yirchow's Archiv, Band xcvi., Heft 1. Ritchie. — Contribution to assist the Study of Ovarian Physiology and Pathology: 1865. RoEMER. — Ovariotomie bei einem 1 Jahr 8 Monate alten Kinde : Heilung : Deutsche Medicinische Wochenschrift, Dec. 26, 1883. RoKiTANSKY. — Lehrbuch der pathologischen Anatomie, vol. iii. ScHULLER (Max, M.D.). — Ein Beitrag zur Anatomie der weiblichen Harnrohre. Festschrift fiir Professor Schultze, Jena : Berlin, 1883. Slavjansky. — Zur normalen und pathologischen Histologie des Graaf 'schen Blaschens des Menschen : Virchow's Archiv, Band li., 1870. Stricker. — Manual of Human and Comparative Histology : Trans- lated by Henry Power, M.B., New Sydenham Society, 1872. Sutton (J. B.). — On the Value of Systematic Examination of Still- born Children. A Paper read before the Royal Medical and Chirurgical Society on March 11, 1884. (Before the annual publications of the Society are available, an abstract in the British Medical Journal, Lancet, and Medical Times, for March 15, 1884, will supply information as to the nature of this valuable paper.) Tait (Lawson, F.R.C.S.). — Three Cases of Axial Rotation of Ovarian Tumours : Transactions of the Obstetrical Society of London, vol. xxii., 1880. The Pathology and Treatment of Diseases of the Ovaries, fovirth edition, 1883. Thornton and Doran. — Case of Ovarian Tumour complicated by Cardiac and Renal Disease : Obstetrical Joiirnal, 1878. [Many of Mr. Knowsley Thornton's cases, described in this work in reference only to special features of interest, as observed by myself during operations and subsequent examinations of tumours, are included in the statistical tables published by that surgeon in the Medico-Chirur- gical Transactioyis, vol. xlvi., liSBl, and in London medical newspapers during the past eight years.] Wells (Sir T. Spencer, Bart.). — On Ovarian and Uterine Tumours, their Diagnosis and Treatment : 1882. INDEX. ABD ABDOMINAL wound, abscess in, causes of, 127, 128; danger of dissecting up tissues whilst making, 127 ; hernia of cicatrix of, 128 ; keeping of, open for drainage of cysts, 130 ; length of, not a matter of great impor- tance, 126, 132 ; prolonging of, during operation often necessary and not difficult or dangerous, 126 ; suture of, materials for, 127 ; union of, often perfect in fatal cases, 129 Abscess, in abdominal wound, 127, 128, 180 ; in pedicle, from liga- ture, 147 Adenoma, adeno-sarcoma of ovary, 84 ; suspected case, of unusual character, 102. (See Glandu- lar growths in ovarian cysts) Adhesions, 37, 88, 132; in cases of exogenous cysts, often very troublesome, 17 ; prevention of, by medical treatment, 37 ; in cases of twisted pedicle, carry- ing on the functions of the pedicle, 123 ; of sigmoid flexure to cyst, 19; of vermiform ap- pendix, 19, 124, 132 Alveolar sarcoma of ovary, 100 Ascites, in cases of solid ovarian tumours, 93 Axial rotation. (See Tivisting r,/ 2>edich') BRO BALFOUR, Professor, on ' Pflii- ger's tubes,' 2 Bantock (Dr. Gr. Granville), on parovarian C3'sts, 54 ; on changes in pedicle after ligature, 140. (See also clinical repoits passim) Beck (Mr. Marcus), on nephritis and pyelitis, 1.54, 160 Beigel (Dr. H.), on atrophy of Graafian follicles, 6 Bickersteth (Mr.), case of papil- loma of Fallopian t-.ube, 170 Bilateral ovarian disease. (See Lonhle ovarian cijsts and Fused, douhle ovarian cysts) Bladder, discharge of contents of cyst into, 86, 113 Broad ligament, multilocui'ar cyat invading layers of, 68, 73; ditto, with glandular contents invading layers of, 6S-, 75 ; cystoid degeneration of, 48 Broad ligament cyst, simple, 49, 53; often considered to be par- ovarian, 48 ; reasons why this theory must be modified, 49; often distinct from the first, from the Fallopian tube and broad ligament, 47 ; relation to broad ligament, 57; wall of, as distinguished from wall of ovarian cyst, 22 ; inner lining is endothelial, 48 ; sometimes de- veloped close to ovarian fimbria 182 INDEX. BOH of tube, 48, 52 ; papillary growths in, indicate true parovarian origin, 55 (see Papillomatous cyxts, Parovanxim, and Sessile cysts) ; rupture of, 56, 57, 108 ; cicatrix in ruptured wall of, 108 ; inflammation of wall of, 56 ; adhesions, 56 ; tapping, cure of, by, not advisable, 55 ; opera- tion, results very favourable, 54, 57 ; clinical aspects of, 53 ; flattening of ovary by growth of, 55 Bohn, on inflammation of urethral ducts, 43 Bone in dermoid cysts, 86 Bone, necrosis of, after ovariotomy, ]29, 163 CANCER of ovary, colloid, 20, 21, 104 ; hard or scirrhous, 103 Cells, proliferating and vacuolated in ovarian and ascitic fluid, 16 Childhood, ovarian cysts and ova- riotomy in, 79, note Chondrification, in glandular or adenomatous growths, 31 ; in a papillomatous growth within the Fallopian tube, 173 ; in septa of loculi in cysts, 29 Cicatrix, of abdominal incision, hernia of, causes of and cases, 128; of cyst wall, 108 Coblenz (Dr. H.), on Gartner's and the iirethral ducts, 43, 74 ; on burrowing of ovarian cysts under the peritoneum, 73 Colloid, cancer of ovary, 20, 21 ; changes in ovarian tissues, 5 ; cysts, rupture of, 109 ; in relation to epithelial changes, 33, 34 ; in cysts, 15, 109 ; rupture of cysts with colloid contents, 109 Compression forceps, their value in treatment of abdominal wound, 130 Crepitus on palpation, 37, 133 DER Cruveilhier, on distension and ob- struction of the Fallopian tubes, 174 Cyst. (See Broad ligament cyst. Dermoid cyst. Exogenous cyst, Fused double ovarian cysts, Multilocular ovarian cyst, Pup- ture of ovarian cysts, Secondary cysts, &c.) Cystoid degeneration of broad ligament, 48 "TVEF^CATION, contents of -»-' ovarian cyst discharged dur- ing, 113 ; sloughmg pedicle dis- charged during, 151 Dermoid cyst, age of patients with, 79 ; bone in, 86 ; cartilage in, 85, 88 ; cases of double, 81, 121 ; case of, in an infant, operation, 79, note; case of, complicated by malignant disease of stomach, rectum, and omentum, 81 ; cases of, with multilocular cyst of opposite ovary, 84 ; cases of, mixed with glandular or simple tQultUocular cystic structure, 84 ; case of, in patient aged sixtj'-three, 79, 83 ; epidermic structures in, 87 ; fat in, 80, 88 ; glandular and cystic structures in, 88 ; hair in, 79 ; incipient, 77, 82 ; muscle, nerve, and lymphoid tissue in, 88 ; pigmen- tation of umbilicus in case of, 81 ; pill-like bodies in, 80 ; plug- ging of vessels of pedicle in, 84 ; pregnancy in case of, 85 ; rup- ture of, into bladder, 86, 113 ; rupture of, into peritoneal cavity, 85, 107; sessile, 68, 75, 83; statistics of, 79 ; sarcomatous growths in, 89 ; teeth and bone in, 79, 86 ; theories on origin of, 77; twisting of pedicle of, 81, 89 (see T^visting of Pedicle) ; unilocular or almost unilocular as a rule, 83; variations in fluid INDEX. 183 DES and solid contents, 80 ; wall of, distinguished from multilocolar cyst, 22 De Sinety and Malassez, on origin of ovarian cysts, 5, 12 ; on vege- tations on outer surface of cysts, 23 Diagnosis, observations on, in cases of ovarian tumour, 35 Double ovarian cysts, 20 ; fusion of, 17. (See Fused double ovarian cysts') Drainage, after incision of cysts, a bad substitute for ovariotomy, 130 ENDOTHELIUM, on outer wall of multilocular cysts, 25 ; within tense cysts, 26 ; in thin- walled cysts found within glan- dular growths, 30 Epithelium, change of character of, in development of multi- - locular glandular cysts, 34 ; of glandular intracystic growths, 33 ; of inner wall of multilocu- lar cysts, 26, 27 ; of outer wall, 25 Eve (Mr. F. S.), on changes in intracystic epithelium from pressure, 26 ; on incipient cystic disease of the ovary, 14, 35 S Exogenous cyst, 16 ; false variety of, caused by rupture of main wall, exposing secondary cysts, 16 Exploratory' operations, not dan- gerous when performed in cases of suspected solid ovarian tu- mours, 94 ; statistics of, 94 Extra-uterine pregnancy, case of tubal type, diagnosed as ovarian tumour, 168 FALLOPIAN tube, dilated, case of, 160 ; position of dilated, in relation to ovary, 167 ; h>-pcr- GAN trophy of, 168 ; morsus diaboli of, meaning and origin of the term, 165; obstruction of, in ovarian disease, 169 ; ovarian fimbria of, cysts developed in broad ligament close to, 52 ; its true position during life, 167 ; its relation to free papillomatous outgrowths, 175 ; its secondary fringes often found on surface of multilocular cj'st, 24 ; papil- loma of, remarkable case of, 170; papillomata on mucous membrane of, 175 ; position of, during life, 165 ; stretching of, in cystic disease of broad liga- ment, 168 Fallopian tube cysts, 52. (See Morgagni, Hydatid of) Fibroid tumours of ovary, gene- rally sarcomatous or myomatous, 96 Fischel, on the epithelium of the parovarium, 51 Fluid, ovarian, chemical characters of. Dr. Ralfe on, 15 ; in dermoid cysts, 80 ; in multilocular cysts, 15 ; in papillomatous cysts, 49, 60 ; not highly irritant to peri- toneum, 105 ; passed by the rec- tum, 113 ; vacuolated cells in, 16 Foetus, papillomatous cysts in, 62 Follicles. (See Graafian Fol- licles) Forceps, compression, their value in treatment of abdominal wound, 130 Foulis, on ' Pfliiger's tubes,' 3 ; on proliferating vacuolated cells in ovarian fluid, 16 Fowler (Dr. J. K.), on hydro- and pyosalpinx, 170 r\ ABBETT (Dr. H. S.), on colloid ^ changes in the ovary, 9 Gangrene of cyst, followed by rupture, 109 ; a result of twist- ing of the pedicle, 1 20 184 INDEX. Gartner, duct of, 42 ; papilloma of, 74 ; relation to urethral duct disputed, 43 Glandular or adenomatous growths in ovarian cysts, 20, 21 ; chon- drification in, 31 ; cysts contain- ing, may be sessile, 68, 75 ; cysts, thin-walled, in substance of, 30 ; epithelium of, 33 ; micro- scopic appearances of, 31 ; pa- pillary form not identical with papillomatous growths, 31 ; rup- ture of main cyst wall by, 24 ; sarcomatous characters in, 21 ; statistics of, 29 Goodhart (Dr. J. F.), on kidney disease in cases of abdominal tumour, 153 Graafian follicles, atrophy of, 6 ; Beigel and Patenko on atrophy of, 6, 7 ; dropsy of, 8 ; number at birth, 5. (See Origin of viultilociilar ovarian cysts) Gut, silkworm, 127 HEMORRHAGE, into ovary, in relation to the origin of sar- coma, 96 ; after rupture of cyst, 1 10 ; in cases of twisted pedicle, 121 ; into sarcoma of ovary, 100 Harris (Dr. Vincent D.), and author, on origin of multilocular ovarian cysts, 7, 11 Hegar, his case of sloughing pedi- cle passed by the rectum, 151 Hennig, on new growths of the Fallopian tube, 174 Hernia, of cicatrix of abdominal wound, 128 ; cause of, id. ; re- moval of distended cicatrix, id. ; umbilical, attempted radical cnre of, in course of an ovario- tomy, 129 Hilum cysts, 59 ; cases of, 67, 69 ; may be pedunculated, cases, 68, 71 ; sessile, as a rule, 60. (See Painllomatous cysts) LIG His, on the position of the Fallo- pian tubes, 166 Hj'datid of Morgagni. (See 3Ior- ga.gni, hydatid of) Hydrosalpinx, 169 Hypertrophy of Fallopian tube, 168 Hypertrophy of ovarian stroma, its histological resemblance to sarcoma of ovary, 98 Hyrtl (Professor Josef), on the term morsus diaboli, 165 TNCISION. of cyst, followed by J- drainage, two cases demon- strating its futility, 130 Incomplete operations, not spe- cially dangerous when a malig- nant ovarian tumour is dis- covered, 94 Infancy, ovarian cysts and ova- riotomy in, 79, Tiote. See also Foetits Infundibulo-pelvic ligament, its influence on the position of the ovary, 167 JAW-BONE, necrosis of, after ovariotomy, 129, 163 KEITH (Dr. T.), on the tapping of simple broad ligament cysts, 55 Kidney, cases of diseased, found after death from ovarian disease, ovariotomy, or hysterectomy, 155 ; relation of disease of, to ovariotomy and its results, 152 Klein, on tissues found in the healthy ovary, 95 Kleinwachter, on the urethral ducts, 43 Kocks, on the urethral ducts, 43 T IGAMENT of the ovary. (See -*-^ Ovarian ligavient) INDEX. 185 LIG Ligatui'e of pedicle, complete in- traperitoneal, significance of the term, 137; advantages of, as regards abdominal wound, 128 ; advantages of, over clamp, as regards after-results, 150 ; cases of unfavourable changes in the pedicle after, 143 ; clot on stump of pedicle after, 151 ; conserva- tive changes in ligatured pedicle after, 140 ; history of its intro- duction, 138; material used for, changes in, 142 ; museum speci- mens illustrating changes after, 140 ; Smith, Dr. Nathan, first to employ, 138 ; sloughing not pro- duced by, 139 ; tightening of the ligatures in, different opi- nions of Wells, Thornton, and author concerning, 151 ; varix or hjematocele following, 148 ; Wells, Sir T. Spencer on, 139, 151 Linea alba, how to divide it accu- rately, 127 Lung, abscess in, after ovariotomy, 129 Tl/FALASSEZ. See Be Slmiy and -»-'-'- Malassez Maxillary bone, inferior, necrosis of, after ovariotomy, 129, 163 Melanosis, simulated by hsemor- rhage into sarcomatous ovarian growth, 100 Meredith, on cysts burrowing under the peritoneum, 73 ; on rupture of cysts, 117 Morgagni, hydatid of, 45 ; calca- reous degeneration of, 121 ; de- velopment of, from Mi'iller's duct, 58 ; hypertrophy of, 53, 131 ; its significance, 45 Morsus duiboli, erroneous theor\' concerning, 165; true meaning and derivation of term, 166 MiiUer, duct of, 52. (See 3Ior- ff'^jni, liijilatifl nf) OPE Multilocular ovarian cyst, appear- ance of its outer waU ; distinc- tion from other tumours, 14, 22 ; contents, fluid, 15 ; epi- thelium of outer wall of, 25 : exogenous type (see Exogeyious cystn) ; fusion of, of both ovaries into one tumour (see Fused dovMe avarian ci/sts') : glan- dular growths in (see Glandu- lar growths in ovarian cysts') ; middle coat of main wall of, 25 ; inner coat, 26 ; origin of (see Origin of vudtilocular ovarian cysts) ; rupture of feepta of, 28 ; secondary cysts in (see Secondary cysts) ; septa within, 27 ; sessile or non-pedunculated, 68, 73 ; statistics of author's experience of, 20 Myoma of ovary, 96 ; often taken for fibroma, 96 NECROSIS of jaw after ovario- tomy, 129, 163 Nephritis in ovarian disease, 155 Nerve tissues in dermoid cysts, 88 New growths in ovary (see Cancer of ovary, Glandular groivths in ovarian cysts and Sa/rcoma of ovary) Noeggerath, on oritin of cystic disease of ovary from diseased blood-vessels, 12 Non-pedunculated cysts (see Ses- sile cystic tumours) OLIGOCYSTIC, objection to the term, 27 Omentum, adherent, suppljdng cyst with blood in case of twisted pedicle, 122; cancer of, 81; colloid material, effect of, upon. 109 Operations, incomplete and ex- 186 INDEX. ORI ploratory (see Exjjloratory ope- rations) Origin of multilocular cysts, atro- phy of fo]licles in relation to, 7 ; colloid changes in relation to, 5 ; changes in vessels, in re- lation to, 12 ; De Sinety and Malassez on, 1, 13 ; Eve on, 13 ; Pfliiger's tubQs in relation to (see PJiilgeT's tules) Ovarian fimbria of Fallopian tube, cysts developed in broad liga- ment, close to, 52 ; position of, during lifetime, 167 ; papillo- matous outgrowths, its relation to, 175 Ovarian ligament, an essential part of a true pedicle, 69 ; its relation to myoma of uterus and ovary, 96 Ovariotomjr m infancy, 79, note PAPILLARY growths in glandu- lar tumours, their distinction from true papilloma ta, 31 Papilloma of Fallopian tube, cases of, 170, 175 Papillomatous cysts, cases of, de- veloped in hilum of ovary, 67 ; case of, independent of ovary, 74 ; development of, from hilum of ovary, 59 ; from parovarium, 49 ; diagnosis of origin of (from hilum or parovarium), often dif- ficult, 65 ; foetus, case of, in, 62 ; sessile as a rule, 59 ; may be pedunculated when arising from hilum, 68, 71 (see Broad liga- ment cyst, simple, Hilum cysts, and Parovarivvi) Papillomatous growths, characters and microscopic appearances of, 65 ; development of, from par- ovarium, 49 ; free or unencysted variety of, infesting broad liga- ment, surface of ovary, &c., 66, 175; rupture of cysts containing, 111 PER Paracentesis, in relation to adhe- sions, 38 Parovarian cyst, true, really papil- lomatous, 49 ; may be developed from terminal part of horizontal duct of parovarium, 49 (see Broad ligament cyst, simple^ Parovarium, 40 — Efferent duct of (duct of Gart- ner), 42 ; its epithelium not al- ways ciliated, 51 ; papilloma of, 74 ; relation to urethi'al duct disputed, 43 — Horizontal tube or canal of, 42 ; terminal cyst of, 46 ; resem- blance of terminal cyst of, to simple broad ligament cyst, 49 — Vertical tubes of, 42 ; cysts developed from, 46 ; tendency of cysts developed from, to be- come the seat of papillomatous growths, 49, 51 ; number of, 44 ; obliteration of most internal constant, 44 ; cases of papilloma of broad ligament probably de- veloped from, 74 Patenko, on atrophy of Graafian follicles, 7 Paucilocular, objection to term, 27 Pedicle, absence of (see Sessile cysts) ; double, in fused double ovarian cysts, 17; in hilum cysts bearing papillomatous contents, 68, 71 ; true and false, distinc- tion between, 69 ; vein in, dila- tation of, 125 (see also Ligature of pedicle and Twisting of pe- dicle^ Pelvic examination, 38 Pericarditis, purulent, after ovario- tomy, 129 Periostitis of jaw after ovariotomy, 129 Peritonitis, absence of clinical symptoms of, in case of, 109 ; efi'ects of, as seen during opera- tion, 110 ; after rupture of cyst, 108 (see also cases passim') mDEX. 187 PIG Pigmentation of umbilicus, in case of dermoid cyst, 81 Pill-like bodies in dermoid cyst, 80 Pfluger's tubes, their existence doubted, 2 ; author's observa- tions on, 3, 4 ; Balfour on, 2 ; De Sinety and Malassez theory on origin of multilocular cysts based on belief in existence of, ■ 5 ; Foulis on, 2 Pleurisy after rupture of cyst, 108 ; in case of papilloma of Fallo- pian tube, 170 Pregnancy, co-existent with cystic myoma of uterus, 94 ; diagnosis from solid ovarian tumour, 98 ; tubal, 168 Proliferating and vacuolated cells, in ovarian and ascitic fluid, 16, 171 Psammomatous changes in papillo- matous cysts, 65 Pyelitis in ovarian disease (see Cases), 155-160 Pyo-pericarditis after ovariotomy, 129 Pyosalpinx, 169 "pALFE (Dr. C. H.), on chemical -Lt characteristics of ovarian fluid, 16 Rectum, ovarian fluid passed by, 113; sloughing pedicle passed by, 151 Eectus abdominis muscle, dangers of womiding, in making abdo- minal incision, 127, 128 Rieder, on the urethral ducts, 43 Ritchie (Dr. C. G.), on cysts re- ceiving their blood-supply from adhesions, 123 ; his labours in ovarian pathology, 32 Rokitansky on new growths within the Fallopian tube, 174 Round-celled sarcoma of ovary, 99 ; in cystic disease, 21 Rupture of ovarian cysts, 16, 105 : SES bad results after, when colloid material is eflrused, 109 ; block- ing of, by secondary cyst, or papillomatous growth, 85, 114 ; changes in cyst wall, causing, 114 ; danger of, when cyst con- tains papillomatous growths, 111 ; general considerations on, 105, 114 ; haemorrhage following, 110; histories of, 107; imme- diate results of, 108 ; natm-e and appearances of, 114; statistics of, 106 ; traumatic, generally a long rent, 114 Rupture into bladder, 113; in pos- terior part of cyst, 110; of der- moid cyst, 107, 113 ; into rectum, 113; of septa and secondary cysts, 28, 116; of simple broad ligament cysts, 56, 57, 108 QAECOilA of ovary, alveolar, '^ 100 ; hemorrhage into, 100 ; melanosis simulated by hsemor- " rhage into, 100; mixed, 100; round-celled, 99 ; spindle-celled, its histological resemblance to simple hypertrophy of ovarian stroma, 98 Schiiller (Dr. Max), on the urethral ducts, 43 Scirrhus of ovary, 103 Scybala, impede pelvic examina- tion, 38 Secondary cysts, may fill up rup- ture in wall of main cj'St, 16, 114 ; in relation to predominat- ing or largest cavity within main wall of tumour, 27 ; rela- tion to septa within ovarian tumours, 29 ; in substance of main cyst wall, 26 ; thin-walled tj-pe, in glandular growths, 30 -Septa, in multilocular cysts, 27 Sessile cystic tximours, dermoid, 68, 75 ; cases of,,of multilocular and glandular type, 68, 73, 75 ; hilum cysts generally of this 188 INDEX. class, 60 ; operations on, diffi- culty of, 68 Sigmoid flexure, adhesion of, to cyst, 19 Silkworm gut, its value as a mate- rial for suture of abdominal wound, 127 Skene's tubes, 43 Solid tumours of the ovary, nor- mal ovarian structures in rela- tion to, 95 (see Cancer of ovary, 3Iyoma, Sarcoma) Spindle-celled sarcoma of ovary, 98 Supra-renal body, cyst of, 136 Sutures, of abdominal wound, material for, 127 ; bad results after drawing them too tightly, 128 Symmetrical ovarian cystic dis- ease (see Douile ovarian cysta and Fused double ovarian cysts) rpAIT (Mr. Lawson), on the ear- -■- lier ovariotomies, 54 ; on twisting or axial rotation of the pedicle, 118 ; on hydro- and pyosalpinx, 169 Tapping, in relation to adhesions, 38 Teeth in dermoid cysts, 79, 86 Teratoma, the term objectionable, 92 Tetanus after ovariotomy, 120, 141 Thornton (Mr. J. Knowsley), on recurrent dermoid tumours, 89 ; on tightening of ligature of ovarian pedicle, 151 ; on bad results of drawing the abdo- minal sutures too tightly, 128 ; on proliferating cells in ovarian fluid, 16, 171 (see also clinical reports, passim) Thrombosis of femoral vein after ovariotomy, 70 Tubal gestation, case of, simulat- UTE ing ovarian tumour, death after manipulation, 169. Relation of foetal sac to ovary in, 167 Tubo-ovarian cyst, specimen of, 168 Tumours of Ovary (see Cancer of ovary, Dermoid cyst. Glandular growths in ovarian cysts, Slnl- tilocvlar ovarian cyst, Sarcoma of ovary, &c.) Twisting of pedicle, cases of, 121; cyst completely separated from its normal attachment, in case of, 122 ; dermoid cysts, cases of this complication in, 81, 121 ; dilatation of vein in pedicle in case of, 125 ; gangrene of cyst following, 120; hsemorrhage into cavity of cyst causing anfemia, in case of, 121 ; opinion of Wells, Tait, and author on cause of, 118 ; symptoms of, in chronic cases, 120 ; tetanus after opera- tion in case of, 120 ; vascular supply of cyst maintained through adhesions, in cases of, 123 ULCERATION of cyst wall, in relation to rupture of cysts, 115 Umbilical hernia, radical cure of, attempted in course of an ovario- tomy, 129 Umbilicus, pigmentation of, in case of dermoid cyst, 81 Unilocular cyst, often a mere variety of the multilocular form, 20,27 Urethral ducts, 48 ; alleged rela- tion of, to duct of Gartner, 43 ; catarrh of, 44 ; said to be ducts of a special urethral gland, 44 Urine, in cases of ovarian tumour, 152 Uterine cyst, outer wall of, dis- tinguished from that of an ovarian cyst, 23 INDEX. 189 UTE Uterine myoma and myoma of ovary, 96 Utero-ovarian ligament (see Ova- rian ligament') YACUOLATED cells, in ovarian and ascitic fluid, 16, 171 Vein, dilated, in a twisted pedicle, 125 ; plugging of femoral, after ovariotomy, 70 Vermiform appendix, adherent to ovarian cyst, 19, 132 ; detached cyst adherent to, 135, 136 birth, 5 ; Foulis on his ' tubes,' 3 (see also PJluger's tubes') Wells (Sir T. 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